Pediatrics

1 Notes by MedSN
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GENERAL PRINCIPLES .........................................................................................................................1

ROUTINE SCREENINGS .............................................................................................................................2

HPV VACCINE .......................................................................................................................................2
TOILET TRAINING ...................................................................................................................................2
ISOLATED SPEECH DELAY ..........................................................................................................................3
INTRAOSSEOUS CANNULATION ..................................................................................................................3
ARTERIAL LINE PLACEMENT ......................................................................................................................3
INFANT’S WEIGHT & HEIGHT IN 1ST YEAR .....................................................................................................4
HEAD CIRCUMFERENCE ............................................................................................................................4
MOTOR VEHICLE RESTRAINTS ...................................................................................................................5
INJURY PROTECTION IN CHILDREN ..............................................................................................................6
STRENGTH TRAINING IN CHILDREN .............................................................................................................6
INFANT NUTRITION POINTS ......................................................................................................................7
DOWN SYNDROME .................................................................................................................................7
LESCH-NYHAN SYNDROME: ......................................................................................................................8
PRIMITIVE REFLEXES END-PERIOD ..............................................................................................................8
NIEMANN-PICK DISEASE: .........................................................................................................................9
STORAGE DISEASES............................................................................................................................... 10
GALACTOSEMIA ................................................................................................................................... 10
EVALUATION FOR NEONATAL HYDRATION .................................................................................................. 11
OVERDOSE MANAGEMENTS ................................................................................................................... 12
CHOKING HAZARD IN CHILDREN ............................................................................................................... 12

ALLERGY & IMMUNOLOGY ............................................................................................................... 13

HUMORAL IMMUNODEFICIENCY SYNDROMES ............................................................................................. 14

BRUTON AGAMMAGLOBULINEMIA: .......................................................................................................... 15
TRANSIENT HYPOGAMMAGLOBULINEMIA OF INFANCY: .................................................................................. 15
C1 INHIBITOR DEFICIENCY ...................................................................................................................... 16
CHRONIC GRANULOMATOUS DISEASE ....................................................................................................... 18
SEVERE COMBINED IMMUNODEFICIENCY ................................................................................................... 19
SELECTIVE IGA DEFICIENCY ..................................................................................................................... 20
COMMON VARIABLE IMMUNODEFICIENCY.................................................................................................. 20
LEUKOCYTE ADHESION DEFICIENCY ........................................................................................................... 21
HYPER-IGE SYNDROME ......................................................................................................................... 21
ANAPHYLACTIC VS URTICARIAL TRANSFUSION REACTIONS .............................................................................. 21
STANDARD IMMUNIZATIONS................................................................................................................... 22
DTAP VACCINATION ............................................................................................................................. 23
MENINGOCOCCAL VACCINATION.............................................................................................................. 23

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CENTRAL NERVOUS SYSTEM ............................................................................................................. 24

FRAGILE X SYNDROME........................................................................................................................... 25
COMMON CAUSES OF INTELLECTUAL DISABILITY........................................................................................... 26
FRIEDRICH ATAXIA................................................................................................................................ 27
SEIZURE ............................................................................................................................................. 29
FOCAL SEIZURES .................................................................................................................................. 30
ABSENCE SEIZURES ............................................................................................................................... 31
SIMPLE FEBRILE SEIZURES....................................................................................................................... 32
FEBRILE SEIZURES VS MENINGITIS ............................................................................................................ 33
LANDAU-KLEFFNER SYNDROME: .............................................................................................................. 33
LENNOX-GASTAUT SYNDROME ................................................................................................................ 33
TODD PARALYSIS ................................................................................................................................. 34
BREATH-HOLDING SPELL ........................................................................................................................ 34
HOMOCYSTINURIA ............................................................................................................................... 35
STURGE WEBER SYNDROME ................................................................................................................... 37
KLIPPEL-TRENAUNAY SYNDROME ............................................................................................................. 37
NF1.................................................................................................................................................. 38
NF1 OPTIC GLIOMA: ............................................................................................................................ 39
TUBEROUS SCLEROSIS ........................................................................................................................... 41
INCREASED ICP .................................................................................................................................... 42
DURAL VENOUS SINUS .......................................................................................................................... 43
FLOW OF CSF ...................................................................................................................................... 44
HYDROCEPHALUS ................................................................................................................................. 45
VENTRICULOPERITONEAL SHUNT .............................................................................................................. 47
TRAUMATIC BRAIN INJURY ..................................................................................................................... 48
PECARN RULE .................................................................................................................................... 50
CONCUSSION ...................................................................................................................................... 51
POSTCONCUSSION SYNDROME ................................................................................................................ 51
INTRAVENTRICULAR HEMORRHAGE .......................................................................................................... 52
INTRACRANIAL HEMORRHAGE DUE TO VITAMIN K DEFICIENCY ........................................................................ 54
INFANT BOTULISM................................................................................................................................ 55
GUILLAIN-BARRE SYNDROME: ................................................................................................................. 56
PHENYLKETONURIA............................................................................................................................... 58
MYOTONIC MUSCULAR DYSTROPHY ......................................................................................................... 59
BRAIN ABSCESS ................................................................................................................................... 61
MIGRAINES ........................................................................................................................................ 62
MECHANISM OF ACTION OF TRIPTANS....................................................................................................... 63
INDICATIONS FOR NEUROIMAGING IN A CHILD WITH A HEADACHE ................................................................... 63
CEREBRAL PALSY .................................................................................................................................. 64
CEPHALOHEMATOMA ............................................................................................................................ 65

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SUBGALEAL HEMORRHAGE ..................................................................................................................... 65

NONACCIDENTAL TRAUMA ..................................................................................................................... 66
BASILAR SKULL FRACTURE ...................................................................................................................... 66
SUDDEN INFANT DEATH SYNDROME ......................................................................................................... 67
RING ENHANCING LESIONS ..................................................................................................................... 67
MANIFESTATIONS OF INTRACEREBRAL TUMORS ........................................................................................... 68
MEDULLOBLASTOMA ............................................................................................................................ 69
CHOROID PLEXUS PAPILLOMA ................................................................................................................. 70
CRANIOPHARYNGIOMA.......................................................................................................................... 71
PINEAL GLAND TUMOR ......................................................................................................................... 72
TRAUMATIC CAROTID INJURIES................................................................................................................ 73
BACTERIAL MENINGITIS IN CHILDREN IN AGE >1 MONTH ............................................................................... 74
SENSORINEURAL HEARING LOSS AFTER BACTERIAL MENINGITIS ....................................................................... 74
RISK FACTORS FOR COMPLICATIONS OF BACTERIAL MENINGITIS ...................................................................... 74
HSV ENCEPHALITIS ............................................................................................................................... 75
MASTOIDITIS ...................................................................................................................................... 76
LESIONS ON FACES................................................................................................................................ 77
FETAL HYDANTOIN SYNDROME ................................................................................................................ 77
MYELOMENINGOCELE ........................................................................................................................... 78
KALLMANN SYNDROME ......................................................................................................................... 79
PARINAUD SYNDROME .......................................................................................................................... 79

CARDIOVASCULAR SYSTEM .............................................................................................................. 80

BENIGN VS PATHOLOGICAL MURMURS ...................................................................................................... 81

ECG FINDINGS IN HYPERTROPHIC CARDIOMYOPATHY ................................................................................... 82
MAJOR CAUSES OF SUDDEN CARDIAC DEATH.............................................................................................. 82
KAWASAKI DISEASE .............................................................................................................................. 83
VIRAL MYOCARDITIS ............................................................................................................................. 85
COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT ........................................................................................... 86
COARCTATION OF AORTA ....................................................................................................................... 87
VSD ................................................................................................................................................. 88
QT PROLONGATION.............................................................................................................................. 89
TRICUSPID ATRESIA .............................................................................................................................. 90
CONGENITAL HEART DISEASE ROUTINE SCREENING ...................................................................................... 92
APGAR SCORE ..................................................................................................................................... 93
POSTPERICARDIOTOMY SYNDROME .......................................................................................................... 93
VASCULAR RINGS ................................................................................................................................. 94
VENTRICULAR SEPTAL DEFECT ................................................................................................................. 96
TETRALOGY OF FALLOT .......................................................................................................................... 96
RHEUMATIC HEART DISEASE ................................................................................................................... 97

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EFFECT OF MANEUVERS ON HCM ............................................................................................................ 98

PHYSICAL EXAMINATION OF HCM............................................................................................................ 98
CYANOTIC HEART DISEASES .................................................................................................................... 99
AUSCULTATION OF HEART MURMURS ..................................................................................................... 100
DIGEORGE SYNDROME ........................................................................................................................ 101

DERMATOLOGY ............................................................................................................................. 102

CONGENITAL DERMAL MELANOCYTOSIS .................................................................................................. 103

CONGENITAL MELANOCYTIC NEVUS ........................................................................................................ 103
SCALD INJURIES IN CHILD ABUSE ............................................................................................................ 104
TINEA VERSICOLOR ............................................................................................................................. 105
ERYTHRODERMA ................................................................................................................................ 105
ERYTHEMA TOXICUM NEONATORUM ...................................................................................................... 105
TINEA CAPITIS ................................................................................................................................... 106
ALOPECIA AREATA.............................................................................................................................. 107
TINEA CORPORIS ................................................................................................................................ 108
TINEA PEDIS ..................................................................................................................................... 109
PHOTO-PROTECTION ........................................................................................................................... 109
KERATOSIS PILARIS ............................................................................................................................. 110
FOLLICULITIS ..................................................................................................................................... 110
MILIARIA ......................................................................................................................................... 111
PITYRIASIS ROSACEA ........................................................................................................................... 112
ERYTHEMA MULTIFORME..................................................................................................................... 113
NUMMULAR ECZEMA .......................................................................................................................... 113
INFANTILE HEMANGIOMA .................................................................................................................... 114
ATOPIC DERMATITIS ........................................................................................................................... 115
SEBORRHEIC DERMATITIS ..................................................................................................................... 117
PERIANAL DERMATOSES ...................................................................................................................... 118
STREPTOCOCCAL PERIANAL DERMATITIS .................................................................................................. 119
NEONATAL RASHES ............................................................................................................................ 119
COMMON INSECT BITES ....................................................................................................................... 120
CHIGGERS BITE .................................................................................................................................. 120
SUNBURN......................................................................................................................................... 121
HYPERSENSITIVITY REACTIONS............................................................................................................... 122

ENDOCRINE SYSTEM ...................................................................................................................... 123

PRECOCIOUS PUBERTY......................................................................................................................... 124

CONSTITUTIONAL GROWTH DELAY ......................................................................................................... 126
REFEEDING SYNDROME ....................................................................................................................... 127

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VON GIERKE DISEASE .......................................................................................................................... 128

GAUCHER DISEASE ............................................................................................................................. 128
CONGENITAL HYPOTHYROIDISM ............................................................................................................ 129
DIABETIC KETOACIDOSIS ...................................................................................................................... 130

ENT................................................................................................................................................ 132

DIFFERENTIALS OF STRIDOR .................................................................................................................. 133

LARYNGOMALACIA ............................................................................................................................. 134
MID-INSPIRATORY STRIDOR IN LARYNGOMALACIA ..................................................................................... 135
TRACHEOMALACIA ............................................................................................................................. 136
LARYNGEAL PAPILLOMAS ..................................................................................................................... 137
OTITIS EXTERNA ................................................................................................................................ 138
CANDIDA OTITIS EXTERNA .................................................................................................................... 138
ACUTE OTITIS MEDIA .......................................................................................................................... 139
OTITIS MEDIA WITH EFFUSION .............................................................................................................. 141
SUPPURATIVE COMPLICATIONS OF OTITIS MEDIA....................................................................................... 142
RINNE & WEBER TEST ......................................................................................................................... 143
WEBER TEST ..................................................................................................................................... 143
EUSTACHIAN TUBE DYSFUNCTION .......................................................................................................... 144
CHOLESTEATOMA ............................................................................................................................... 145
ACUTE RHINOSINUSITIS IN CHILDREN ...................................................................................................... 146
ACUTE BACTERIAL RHINOSINUSITIS......................................................................................................... 146
NASAL FOREIGN BODY ........................................................................................................................ 147
THYROGLOSSAL DUCT CYST (TDC) ......................................................................................................... 148
THYROID MIGRATION ......................................................................................................................... 149
PHARYNGITIS .................................................................................................................................... 150
SINUSITIS TITBITS ............................................................................................................................... 151
FUNGAL SINUSITIS PRESENTATION.......................................................................................................... 151
PEDIATRIC OBSTRUCTIVE SLEEP APNEA.................................................................................................... 152

GASTROINTESTINAL SYSTEM .......................................................................................................... 153

BILIRUBIN METABOLISM ...................................................................................................................... 154

NORMAL VALUES FOR INFANTS ............................................................................................................. 155
MANAGEMENT OF FOREIGN BODY INGESTION........................................................................................... 156
BATTERY INGESTION ........................................................................................................................... 156
TREATMENT OF COIN IN ESOPHAGUS ...................................................................................................... 157
MANAGEMENT OF MAGNET INGESTION .................................................................................................. 157
SUPPLEMENTATIONS IN EXCLUSIVELY BREASTFED INFANTS ........................................................................... 158
CAUSES OF PHYSIOLOGIC JAUNDICE ........................................................................................................ 158

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PHYSIOLOGIC GASTROESOPHAGEAL REFLUX .............................................................................................. 159

BREASTFEEDING JAUNDICE ................................................................................................................... 160
CELIAC DISEASE ................................................................................................................................. 161
INTUSSUSCEPTION .............................................................................................................................. 162
WHEN TO SUSPECT PATHOLOGICAL LEAD POINT ........................................................................................ 164
EOSINOPHILIC ESOPHAGITIS .................................................................................................................. 165
BECKWITH-WIEDEMANN SYNDROME ...................................................................................................... 166
MILK OR SOY PROTEIN-INDUCED PROCTOCOLITIS....................................................................................... 167
COLIC .............................................................................................................................................. 168
PYLORIC STENOSIS.............................................................................................................................. 169
CYCLIC VOMITING SYNDROME ............................................................................................................... 171
MICROCOLON ................................................................................................................................... 172
PEDIATRIC CONSTIPATION .................................................................................................................... 173
PELLAGRA ........................................................................................................................................ 174
PRUNE BELLY SYNDROME..................................................................................................................... 175
GASTROSCHISIS ................................................................................................................................. 175
REYE SYNDROME ............................................................................................................................... 176
EVALUATION OF BILIARY EMESIS ............................................................................................................ 177
MIDGUT VOLVULUS ............................................................................................................................ 178
JEJUNAL ATRESIA ............................................................................................................................... 179
CHOANAL ATRESIA ............................................................................................................................. 180
CHARGE SYNDROME ........................................................................................................................... 181
TRACHEO-ESOPHAGEAL FISTULA ............................................................................................................ 182
BILIARY ATRESIA ................................................................................................................................ 183
LIVER EDGE IN NEONATES .................................................................................................................... 184
NECROTIZING ENTEROCOLITIS: .............................................................................................................. 185
DEHYDRATION................................................................................................................................... 186
MECKEL DIVERTICULUM ...................................................................................................................... 187
BILIARY CYST .................................................................................................................................... 188
WILSON DISEASE ............................................................................................................................... 189
PROPER BREASTFEEDING TECHNIQUE ...................................................................................................... 190
BREASTFEEDING ADVANTAGES AND CONTRAINDICATIONS ............................................................................ 191
WATER SOLUBLE VITAMINS .................................................................................................................. 192

HEMATOLOGY & ONCOLOGY.......................................................................................................... 193

IRON DEFICIENCY ANEMIA.................................................................................................................... 194

IRON STUDIES IN MICROCYTIC ANEMIA ................................................................................................... 195
IRON DEFICIENCY ANEMIA SCREENING .................................................................................................... 196
HEREDITARY SPHEROCYTOSIS ................................................................................................................ 196
DRUG-INDUCED HEMOLYTIC ANEMIA ..................................................................................................... 197

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PEDIATRIC STROKE ............................................................................................................................. 198

HEMORRHAGIC STROKE IN CHILDREN ...................................................................................................... 198
RUPTURED ARTERIOVENOUS MALFORMATION .......................................................................................... 199
ALL ................................................................................................................................................ 200
AVASCULAR NECROSIS ........................................................................................................................ 201
HEMOPHILIC ARTHROPATHY ................................................................................................................. 202
WISKOTT-ALDRICH SYNDROME ............................................................................................................. 203
IMMUNE THROMBOCYTOPENIA ............................................................................................................. 204
FANCONI ANEMIA .............................................................................................................................. 206
ALPHA THALASSEMIA .......................................................................................................................... 207
THALASSEMIA MINOR ......................................................................................................................... 207
SICKLE CELL DISEASE ........................................................................................................................... 208
CRISIS IN SICKLE CELL DISEASE ............................................................................................................... 208
SPLENIC SEQUESTRATION CRISIS ............................................................................................................ 209
APLASTIC CRISIS................................................................................................................................. 210
COMPLICATIONS OF SICKLE CELL TRAIT .................................................................................................... 210
SICKLE CELL MANAGEMENT .................................................................................................................. 210
DIFFERENTIAL DIAGNOSIS OF BONE PAIN IN SICKLE CELL DISEASE .................................................................. 210
MEDICATIONS THAT TRIGGER HEMOLYSIS IN G6PD DEFICIENCY .................................................................... 211
NEONATAL POLYCYTHEMIA................................................................................................................... 212
DIAMOND-BLACKFAN ANEMIA .............................................................................................................. 213
INHIBITOR DEVELOPMENT IN FACTOR VIII DEFICIENCY: ............................................................................... 214
TRANSIENT ERYTHROBLASTOPENIA OF CHILDHOOD..................................................................................... 214
SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS............................................................................................... 214
ANEMIA OF PREMATURITY ................................................................................................................... 215
VITAMIN K DEFICIENCY........................................................................................................................ 216
HEMOGLOBIN ELECTROPHORESIS FINDINGS IN SICKLE CELL AND THALASSEMIA:................................................. 216
HEMOGLOBIN CHAINS: ........................................................................................................................ 217
FOLATE DEFICIENCY ANEMIA................................................................................................................. 218
HEMOLYTIC UREMIC SYNDROME ........................................................................................................... 218
APLASTIC ANEMIA .............................................................................................................................. 219
TRANSFUSION REACTIONS .................................................................................................................... 220
TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD ................................................................................. 221

INFECTIOUS DISEASES .................................................................................................................... 222

INFECTION CONTROL ISOLATION PRECAUTIONS ......................................................................................... 223

MEASLES ......................................................................................................................................... 224
IMPETIGO......................................................................................................................................... 226
LOCALIZED NON-BULLOUS IMPETIGO ...................................................................................................... 227
BULLOUS IMPETIGO ............................................................................................................................ 228

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TETROLOGY OF FALLOT & BRAIN ABSCESS ................................................................................................ 229

RESPIRATORY TRACT INFECTIONS IN CHILDREN .......................................................................................... 230
PERTUSSIS ........................................................................................................................................ 231
PERTUSSIS PROPHYLAXIS OF CLOSE CONTACTS .......................................................................................... 232
PRIMARY TUBERCULOSIS...................................................................................................................... 233
NONSPECIFIC SYMPTOMS IN CONGENITAL INFECTIONS ................................................................................ 234
RUBELLA .......................................................................................................................................... 235
NEONATAL TETANUS........................................................................................................................... 236
HERPANGINA VS HERPETIC GINGIVOSTOMATITIS........................................................................................ 237
SEPTIC ARTHRITIS IN INFANTS................................................................................................................ 238
SEPTIC ARTHRITIS IN CHILDREN .............................................................................................................. 240
VZV ............................................................................................................................................... 241
NEONATAL VZV INFECTION .................................................................................................................. 242
VZV VACCINATION ............................................................................................................................. 243
VACCINE STRAIN VZV VS WILD STRAIN VZV ............................................................................................ 243
HERPES ZOSTER OTICUS....................................................................................................................... 244
PRESEPTAL VS ORBITAL CELLULITIS ......................................................................................................... 245
RETROPHARYNGEAL ABSCESS ................................................................................................................ 246
HIV IN INFANCY ................................................................................................................................. 248
INFECTIOUS MONONUCLEOSIS............................................................................................................... 249
OSTEOMYELITIS ................................................................................................................................. 250
ACUTE BACTERIAL GASTROENTERITIS ...................................................................................................... 252
SHIGELLA GASTROENTERITIS ................................................................................................................. 253
CAMPYLOBACTER GASTROENTERITIS ....................................................................................................... 253
E COLI DIARRHEA ............................................................................................................................... 254
SALMONELLA GASTROENTERITIS ............................................................................................................ 254
GIARDIASIS ....................................................................................................................................... 255
VIRAL GASTROENTERITIS ...................................................................................................................... 256
NOROVIRUS GASTROENTERITIS .............................................................................................................. 256
DIFFERENTIALS OF TRAVEL-ASSOCIATED DIARRHEA ..................................................................................... 257
CONGENITAL SYPHILIS ......................................................................................................................... 258
CMV .............................................................................................................................................. 259
TREATMENT OF LYME DISEASE .............................................................................................................. 260
NEONATAL SEPSIS .............................................................................................................................. 261
NEONATAL SEPSIS WITH GROUP B STREPTOCOCCUS ................................................................................... 262
VIBRIO VULNIFICUS ............................................................................................................................. 263
PINWORM ........................................................................................................................................ 263
CONGENITAL TOXOPLASMOSIS .............................................................................................................. 264
UNILATERAL LYMPHADENITIS ................................................................................................................ 265
NORMAL VS ABNORMAL LYMPH NODES .................................................................................................. 267
ECZEMA ........................................................................................................................................... 267

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BACTERIAL MENINGITIS ....................................................................................................................... 268

NEISSERIA MENINGITIDIS POSTEXPOSURE PROPHYLAXIS .............................................................................. 270
STREPTOCOCCUS PNEUMONIA SEPSIS IN SICKLE CELL DISEASE ....................................................................... 271
SCARLET FEVER .................................................................................................................................. 272
SCALDED SKIN SYNDROME ................................................................................................................... 273
BACTERIAL SINUSITIS .......................................................................................................................... 274
MUMPS ........................................................................................................................................... 275
ACUTE RHEUMATIC FEVER .................................................................................................................... 276
CAT SCRATCH DISEASE ........................................................................................................................ 277
SCABIES ........................................................................................................................................... 278
RABIES ............................................................................................................................................ 279
NEONATAL HEPATITIS B ....................................................................................................................... 280
FOODBORNE DISEASES ........................................................................................................................ 281
MALARIA ......................................................................................................................................... 282
PERITONSILLAR ABSCESS ...................................................................................................................... 283
NEONATAL CONJUNCTIVITIS.................................................................................................................. 283
JOINT FLUID CHARACTERISTICS .............................................................................................................. 284

MULTISYSTEM ............................................................................................................................... 285

STD SCREENING ................................................................................................................................ 286

UNIVERSAL SCREENING FOR DYSLIPIDEMIA ............................................................................................... 286
MCCUNE-ALBRIGHT SYNDROME ............................................................................................................ 287
DUCHENNE MUSCULAR DYSTROPHY ....................................................................................................... 289
EDWARD’S SYNDROME ........................................................................................................................ 291
PATAU SYNDROME ............................................................................................................................. 292
CRI-DU-CHAT .................................................................................................................................... 292
MARFAN SYNDROME .......................................................................................................................... 293
PRADER-WILLI SYNDROME ................................................................................................................... 295
HEMOLYTIC UREMIC SYNDROME ........................................................................................................... 295

MUSCULOSKELETAL SYSTEM .......................................................................................................... 296

SUPRACONDYLAR HUMERUS FRACTURE ................................................................................................... 297

TODDLER’S FRACTURES........................................................................................................................ 298
FRACTURE COMPLICATIONS .................................................................................................................. 298
OSGOOD-SCHLATTER SYNDROME........................................................................................................... 299
RADIAL HEAD SUBLUXATION ................................................................................................................. 299
PHYSIOLOGIC GENU VARUM ................................................................................................................. 300
OSTEOID OSTEOMA ............................................................................................................................ 302
EWING SARCOMA .............................................................................................................................. 303

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DEVELOPMENTAL DYSPLASIA OF HIP ....................................................................................................... 305

SLIPPED CAPITAL FEMORAL EPIPHYSIS ..................................................................................................... 308
PANNER DISEASE ............................................................................................................................... 309
SERUM SICKNESS-LIKE REACTION ........................................................................................................... 309
LYME DISEASE ................................................................................................................................... 310
RESTLESS LEG SYNDROME .................................................................................................................... 311
GROWING PAINS ............................................................................................................................... 311
TRANSIENT SYNOVITIS ......................................................................................................................... 312
TRANSIENT SYNOVITIS VS SEPTIC ARTHRITIS ............................................................................................. 313
LEGG CALVE PERTHES .......................................................................................................................... 314
ATLANTOAXIAL INSTABILITY IN DOWN SYNDROME ..................................................................................... 315
TETHERED CORD SYNDROME ................................................................................................................ 316
VITAMIN D DEFICIENCY RICKETS ............................................................................................................ 317
LANGERHANS CELL HISTIOCYTOSIS.......................................................................................................... 319
JUVENILE IDIOPATHIC ARTHRITIS ............................................................................................................ 320
TYPES OF JUVENILE IDIOPATHIC ARTHRITIS ............................................................................................... 321
SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS............................................................................................... 321
DIFFERENTIAL DIAGNOSIS FOR NONTRAUMATIC JOINT SWELLING .................................................................. 322
OSTEOGENESIS IMPERFECTA ................................................................................................................. 322
SPONDYLOLISTHESIS ........................................................................................................................... 323
ANKYLOSING SPONDYLITIS ................................................................................................................... 324
METARSUS ADDUCTUS ........................................................................................................................ 324
CALCANEAL APOPHYSITIS ..................................................................................................................... 325
CONGENITAL MUSCULAR TORTICOLLIS: ................................................................................................... 326
UNICAMERAL BONE CYST ..................................................................................................................... 326

OPHTHALMOLOGY ......................................................................................................................... 327

NEONATAL BACTERIAL CONJUNCTIVITIS ................................................................................................... 328

GLAUCOMA IN CHILDREN ..................................................................................................................... 329
RETINOBLASTOMA.............................................................................................................................. 331
PAPILLEDEMA.................................................................................................................................... 332
TRACHOMA ...................................................................................................................................... 333
CHLAMYDIAL CONJUNCTIVITIS ............................................................................................................... 333
STRABISMUS ..................................................................................................................................... 334
AMBLYOPIA ...................................................................................................................................... 335
ALLERGIC CONJUNCTIVITIS.................................................................................................................... 336
VISUAL ACUITY TESTING ...................................................................................................................... 337
MYOPIA........................................................................................................................................... 337
DACRYOSTENOSIS............................................................................................................................... 338
ORBITAL CELLULITIS ............................................................................................................................ 338

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ORBITAL COMPARTMENT SYNDROME ..................................................................................................... 339

OPTIC NERVE INJURY .......................................................................................................................... 339
RETINITIS PIGMENTOSA ....................................................................................................................... 340

POISONING & ENVIRONMENTAL EXPOSURE ................................................................................... 342

METHEMOGLOBINEMIA ....................................................................................................................... 343

LEAD POISONING ............................................................................................................................... 345
CAUSTIC INGESTION ............................................................................................................................ 346
IRON POISONING ............................................................................................................................... 347
INFANT BOTULISM.............................................................................................................................. 347
HEAT EXHAUSTION ............................................................................................................................. 348

PSYCHIATRY ................................................................................................................................... 349

SEXUAL BEHAVIOR IN A CHILD ............................................................................................................... 350

SELECTIVE MUTISM ............................................................................................................................ 350
ADHD ............................................................................................................................................ 351
REACTIVE ATTACHMENT DISORDER ........................................................................................................ 351
DISINHIBITED SOCIAL ENGAGEMENT DISORDER ......................................................................................... 352
TOURETTE SYNDROME ........................................................................................................................ 353
TRICHOTILLOMANIA ............................................................................................................................ 354
STRANGER ANXIETY ............................................................................................................................ 354
SOCIAL (PRAGMATIC) COMMUNICATION DISORDER .................................................................................... 354
LANGUAGE DISORDER ......................................................................................................................... 354
CHILDHOOD-ONSET FLUENCY DISORDER .................................................................................................. 355
RETT SYNDROME ............................................................................................................................... 355
LANDAU KLEFFNER SYNDROME.............................................................................................................. 355
IMAGINARY FRIENDS ........................................................................................................................... 355
NEONATAL ABSTINENCE SYNDROME ....................................................................................................... 356
PRENATAL EXPOSURE TO COCAINE ......................................................................................................... 356
AUTISM ........................................................................................................................................... 357
PYROMANIA ..................................................................................................................................... 358
OCD ............................................................................................................................................... 358
FIREARM INJURY ................................................................................................................................ 358
DEVELOPMENTAL MILESTONES .............................................................................................................. 359
DEVELOPMENTAL MILESTONES DURING FIRST YEAR ................................................................................... 360
FEATURES OF CHILD ABUSE................................................................................................................... 361
MINOR CONSENT ............................................................................................................................... 361
MEDICAL CAUSES OF PSYCHOSIS: ........................................................................................................... 362

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RENAL SYSTEM .............................................................................................................................. 363

HYPERNATREMIA ............................................................................................................................... 364

MINIMAL CHANGE DISEASE .................................................................................................................. 365
POSTSTREPTOCOCCAL GLOMERULONEPHRITIS ........................................................................................... 366
HENOCH-SCHONLEIN PURPURA ............................................................................................................. 367
TIME OF PRESENTATION OF IGA NEPHROPATHY VS PSGN............................................................................ 368
ALPORT SYNDROME............................................................................................................................ 369
RENAL COMPLICATIONS OF SICKLE CELL TRAIT ........................................................................................... 370
HYPOSTHENURIA AS A COMPLICATION OF SICKLE CELL TRAIT ......................................................................... 370
WATER DEPRIVATION TEST .................................................................................................................. 371
ENURESIS ......................................................................................................................................... 372
PRIMARY ENURESIS ............................................................................................................................ 372
DIABETES MELLITUS TYPE 1 .................................................................................................................. 373
EXERCISE-INDUCED HYPOGLYCEMIA ........................................................................................................ 374
CYSTITIS VS PYELONEPHRITIS ................................................................................................................. 375
UTIS IN INFANTS ................................................................................................................................ 375
UTIS IN CHILDREN .............................................................................................................................. 376
INDICATIONS FOR RENAL & BLADDER ULTRASOUND ................................................................................... 377
VESICOURETERAL REFLUX ..................................................................................................................... 378
PEDIATRIC CONSTIPATION LEADING TO CYSTITIS ........................................................................................ 379
POSTERIOR URETHRAL VALVES ............................................................................................................... 381
HEPATITIS B VIRUS-ASSOCIATED MEMBRANOUS NEPHROPATHY (HBVMN) .................................................... 382
RENAL TUBULAR ACIDOSIS ................................................................................................................... 383
NEPHROTIC VS NEPHRITIC SYNDROME ..................................................................................................... 384
WILMS TUMOR ................................................................................................................................. 385
WAGR SYNDROME ............................................................................................................................ 386
NEUROBLASTOMA .............................................................................................................................. 387
VON HIPPEL-LINDAU SYNDROME ........................................................................................................... 388
PROTEINURIA IN ADOLESCENTS .............................................................................................................. 388

REPRODUCTIVE SYSTEM ................................................................................................................. 390

PUBERTAL GYNECOMASTIA................................................................................................................... 391

PRIMARY AMENORRHEA ...................................................................................................................... 392
TURNER SYNDROME ........................................................................................................................... 393
SMALL FOR GESTATIONAL AGE INFANTS: ................................................................................................. 394
ADRENAL HYPERPLASIA ....................................................................................................................... 395
CLASSIC ADRENAL HYPERPLASIA ............................................................................................................ 396
NONCLASSIC ADRENAL HYPERPLASIA ...................................................................................................... 397
ABNORMAL UTERINE BLEEDING DUE TO ANOVULATORY CYCLE ..................................................................... 397

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CLAVICULAR FRACTURE........................................................................................................................ 398

EMERGENCY CONTRACEPTION ............................................................................................................... 399
ROUTINE NEWBORN RESUSCITATION ...................................................................................................... 400
ECTOPIC PREGNANCY .......................................................................................................................... 401
DISSEMINATED GONOCOCCAL INFECTION ................................................................................................. 402
NEONATAL HSV INFECTION .................................................................................................................. 403
ANDROGEN INSENSITIVITY SYNDROME .................................................................................................... 404
MULLERIAN AGENESIS ......................................................................................................................... 404
VWF DEFICIENCY ............................................................................................................................... 405
PRIMARY DYSMENORRHEA ................................................................................................................... 406
PREPUBERTAL VAGINAL BLEEDING.......................................................................................................... 407
INFANT OF DIABETIC MOTHER- COMPLICATIONS........................................................................................ 408
HYDROCELE ...................................................................................................................................... 409
VARICOCELE ...................................................................................................................................... 410
CRYPTORCHIDISM............................................................................................................................... 411
HYPOSPADIAS ................................................................................................................................... 412
FIBROADENOMA ................................................................................................................................ 413

RESPIRATORY SYSTEM ................................................................................................................... 414

ANAPHYLAXIS ................................................................................................................................... 415

FOREIGN BODY ASPIRATION ................................................................................................................. 417
DROWNING ...................................................................................................................................... 418
RESPIRATORY FAILURE IN ASTHMA ......................................................................................................... 419
CYSTIC FIBROSIS................................................................................................................................. 420
CYSTIC FIBROSIS EMPIRIC MANAGEMENT................................................................................................. 421
PRIMARY CILIARY DYSKINESIA ............................................................................................................... 422
RESPIRATORY DISTRESS SYNDROME........................................................................................................ 423
BRONCHOPULMONARY DYSPLASIA ......................................................................................................... 426
PARAPNEUMONIC PLEURAL EFFUSION ..................................................................................................... 427
TRANSIENT TACHYPNEA OF NEWBORN .................................................................................................... 428
BRONCHIOLITIS .................................................................................................................................. 429
EPIGLOTTITIS..................................................................................................................................... 431
CHYLOTHORAX .................................................................................................................................. 433
THYMUS .......................................................................................................................................... 434
CONGENITAL DIAPHRAGMATIC HERNIA ................................................................................................... 435
CROUP ............................................................................................................................................ 437

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General Principles

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ROUTINE SCREENINGS Uric Acid Crystals in

Diapers:
1. Autism screening is performed at ages 18 months and 2 years
1. “Pink stains” or “brick
2. Depression screening starts at age 12 years (repeated annually)
dust” in neonatal
3. Visual acuity screening is routinely done at age 4 years
diapers represent uric
acid crystals
2. Uric acid excretion is
high at birth and
decreases until
adolescence

HPV VACCINE
1. Age ≥15:
a. 3 doses of HPV vaccine
2. Age <15:
a. 2 doses of HPV vaccine 6 months apart
3. This difference is because at age <15, the immune system is weak and
leads to increased antibody production

TOILET TRAINING
1. Most children begin toilet training at age 2-4 years
a. Boys complete training later than girls
2. Bedwetting is normal before age 5

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 PEDIATRICS

ISOLATED SPEECH DELAY

1. It is characterized by problems with following:
a. Articulation (eg, mispronunciation)
b. Fluency (eg, stuttering)
c. Vocal quality (eg, abnormal volume or pitch)
2. Speech should be 100% intelligible by age 4
3. The first step in evaluation of all patients with a speech or language disorder is a hearing test

INTRAOSSEOUS CANNULATION
1. It is carried out in emergency fluid resuscitation when peripheral intravenous access cannot be
obtained
a. It is easy to carry out and takes less time
2. The most common site is proximal tibia
3. Contraindications
a. Infection (eg, cellulitis) over the access site
b. Fracture
c. Previous IO attempts in the chosen extremity
d. Bone fragility (eg, osteogenesis imperfect)

ARTERIAL LINE PLACEMENT

1. It is placed for:
a. Continuous BP monitoring
b. Drawing laboratory studies
2. They SHOULD NOT be used for fluid resuscitation
a. In fact, arterial line for other purposes should be placed after the patient has been
resuscitated because it takes time and great skills

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INFANT’S WEIGHT & HEIGHT IN 1ST YEAR

1. Weight
a. Doubles by 4 months
b. Triples by 1 year
c. Neonates normally lose up to 7% of birth weight in the first 5 days of life
i. Neonate regains the birth weight by age 10-14 days
2. Height
a. Increases by 50% by 1 year

HEAD CIRCUMFERENCE
1. It is an important marker for growth and is routinely measured from birth to age 2-3 because
brain growth is greatest during this period
2. Macrocephaly is considered when head circumference is >97 percentile
a. Benign macrocephaly is considered in following cases:
i. Normal development
ii. No syndromic features
iii. No signs of ↑ ICP
iv. No signs of infection
3. Microcephaly is considered when head circumference is <3 percentile

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MOTOR VEHICLE RESTRAINTS

5
 PEDIATRICS

INJURY PROTECTION IN CHILDREN

STRENGTH TRAINING IN CHILDREN

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INFANT NUTRITION POINTS

1. Breast milk fortified with infant formula may be used in following infants:
a. Failure to thrive infants
b. Preterm infants
2. Formula supplementation can be considered in infants who have lost >7% of birth weight
despite optimization of breastfeeding
3. NEVER give plain water to an infant age <6 months because they have immature kidneys and
will lead to dilution of blood

DOWN SYNDROME
1. Patients with down syndrome often have low birth weight (<2.5 kg)
2. Hypotonia is a prominent feature which presents with:
a. Poor feeding with weak suck
b. Protruding tongue
3. Differentials
a. Fragile X Syndrome can present with hypotonia in infancy but do not have low birth
weight

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LESCH-NYHAN SYNDROME:
Presentation:

1. Early infancy
a. Delayed milestones
b. Hypotonia
2. Early childhood (by age 3)
a. Extrapyramidal symptoms: dystonia, chorea
b. Pyramidal symptoms: spasticity, hyperreflexia
c. Self-mutilation
d. Intellectual disability
3. Untreated, late disease:
a. Gouty arthritis
b. Obstructive nephropathy

PRIMITIVE REFLEXES END-PERIOD

1. Most primitive reflexes end by age 6 months
2. Babinski sign can persist up to 2 years but disappears as early as age 12 months

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NIEMANN-PICK DISEASE:
1. Three types:
a. Type A: most severe
i. Child dies by age 3 years
b. Type B: Mild
c. Type C: Mild
2. Type A and Type B are due to sphingomyelinase deficiency.
3. Autosomal recessive
4. Onset is 2-6 months of age
5. Findings:
a. Cherry red macula
b. Hepatosplenomegaly
c. Hypo/areflexia
d. Loss of motor milestones

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STORAGE DISEASES
1. Tay Sachs= Hexosaminidase A deficiency
a. Same as Niemann Pick, except NO hepatosplenomegaly and hyperreflexia (not areflexia)
2. Krabbe Disease= Galactocerebrosidase deficiency
a. Same as Niemann Pick WITHOUT cherry red macula and hepatosplenomegaly
3. Gaucher= Glucocerebrosidase deficiency
a. Anemia
b. Thrombocytopenia
c. Hepatosplenomegaly
4. Hurler Syndrome= Lysosomal Hydrolase deficiency
a. Inguinal or Umbilical hernia
b. Corneal clouding
c. Coarse facial features

GALACTOSEMIA

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EVALUATION FOR NEONATAL HYDRATION

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OVERDOSE MANAGEMENTS
1. Iron overdose
a. Pre-natal vitamins have high iron content and appear as radiopaque tablets seen on
abdominal x-ray
b. Systemic manifestations:
i. Abdominal pain
ii. Hematemesis
iii. Hypovolemic shock
iv. Metabolic acidosis
c. Management
i. IV saline to treat hypovolemia
ii. IV deferoxamine
2. TCA and aspirin overdose
a. Treat with Sodium Bicarbonate
3. Torsades de pointes
a. Magnesium sulfate is treatment
4. Lithium toxicity
a. Hemodialysis is the treatment because it is the most dialyzable toxin
5. Lead poisoning
a. Use calcium EDTA in moderate or severe poisoning
b. Use oral succimer in mild or moderate lead poisoning
6. Hyperkalemia
a. Use calcium gluconate
7. Acetaminophen toxicity
a. Use N-acetylcysteine

CHOKING HAZARD IN CHILDREN

1. Foods that are choking hazard should be avoided in children age <4
2. A few examples of such foods are:
a. Whole grapes
b. Raw vegetables
c. Uncut hot dogs
d. Hard candy
e. Nuts
f. Seeds
g. Popcorn
3. While eating, make sure of following:
a. Child is supervised
b. Child is sitting upright
c. Child is not running or playing

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Allergy & Immunology

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 PEDIATRICS

HUMORAL IMMUNODEFICIENCY SYNDROMES

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 PEDIATRICS

BRUTON AGAMMAGLOBULINEMIA:
CVID:
1. Similar to Bruton’s, but
patients present with
less severe symptoms
after adolescence.
2. Serum immunoglobulin
concentrations are
decreased but B
lymphocytes levels are
normal

Immunodeficiency tips:
1. Recurrent
sinopulmonary
1. Recurrent sinopulmonary and GIT infections infections mean a B cell
2. Markedly low serum immunoglobulins and B lymphocytes dysfunction
a. Total lymphocytes – T lymphocytes = B lymphocytes 2. Recurrent GIT infections
3. Underdeveloped lymphoid tissues in older children (children under the + sinopulmonary
age of 2 years normally don’t have prominent lymphoid tissue) infections mean IgA
4. Absent lymphoid tissue is also seen in Bruton agammaglobulinemia dysfunction
5. Treatment: 3. Recurrent viral, fungal
a. Monthly IV Immunoglobulin and opportunistic
b. Prophylactic antibiotics infections mean a T cell
c. Live vaccines are contraindicated; other vaccines are not dysfunction
contraindicated but they’re unable to generate an antibody
response.

TRANSIENT HYPOGAMMAGLOBULINEMIA OF INFANCY:

1. Features:
a. Decreased IgG
b. Variable IgM
c. Normal IgA and B and T cell concentrations
2. Sinopulmonary and GIT infections which are relatively mild
3. Immunoglobulin levels normalize after 9-15 months

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 PEDIATRICS

C1 INHIBITOR DEFICIENCY
Contraindications to
Rotavirus Vaccine:
1. Anaphylaxis to vaccine
ingredients
2. History of
intussusception
3. History of uncorrected
malformation of GIT (eg,
Meckel’s diverticulum)
4. SCID

*Note: Rotavirus causes

watery osmotic diarrhea*
1. Autosomal dominant inheritance
2. RECURRENT edema without pruritis or urticarial Vaccination of Premie:
a. This edema is because of elevated bradykinin 1. Vaccinate according to
b. Edema with pruritis and urticarial (along with anaphylaxis) is most chronological age (age
probably IgE mediated, not C1 inhibitor deficiency since birth)
3. Presentation 2. Only Hepatitis B vaccine
a. After dental procedure is administered when
b. After stress patient weighs >2 kg
c. After trauma
d. Multiple areas are involved:
i. Face, limbs and genitalia are most commonly affected
ii. Bowel wall edema
1. Colicky abdominal pain
2. Vomiting
3. Diarrhea
iii. Laryngeal edema
1. Most severe (can cause laryngospasm and airway
obstruction)
4. Diagnosis
a. Exaggerated cleavage of C4 by C1 complex leads to depressed C4
levels
b. Low levels of C1 inhibitor protein or C1 inhibitor function
5. Treatment:
a. C1 inhibitor concentrate
b. Bradykinin antagonist
i. Icatibant In resistant cases
c. Kallikrein inhibitor
i. Ecallantide

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PEDIATRICS

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 PEDIATRICS

CHRONIC GRANULOMATOUS DISEASE

1. X-linked recessive (common in boys)
2. Look for recurrent infections in following by Catalase positive organisms:
a. Skin/soft tissue (RECURRENT ABSCESSES)
b. Pulmonary system (pneumonia or empyema)
3. Diagnosis
a. Test neutrophil function
i. Dihydrorhodamine 123
ii. NBT test
b. Gram stain shows phagocytic cells filled with bacteria
c. Leukocyte, platelet, and B and T cell concentrations are NORMAL in CGD.
4. Treatment
a. Prophylaxis
i. TMP-SMX
ii. Itraconazole
b. Interferon-gamma injections
i. In severe cases

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 PEDIATRICS

SEVERE COMBINED IMMUNODEFICIENCY

1. Main problem is with T cell development
a. Gene defect causes its failure
2. B-cell dysfunction is not primary
a. It is due to absent T cells
3. Hence, the bigger picture shows ABSENT T cells and DYSFUNCTIONAL B cells
4. Inheritance pattern
a. X linked recessive
b. Autosomal recessive
5. Presentation
a. Chronic diarrhea
b. Failure to thrive
c. Absence of lymphoid tissue
d. Lymphopenia
e. Hypogammaglobulinemia
6. Clinical features
a. Recurrent viral, fungal and opportunistic infections
b. Failure to thrive
c. Chronic diarrhea
7. Treatment
a. Stem cell transplant

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SELECTIVE IGA DEFICIENCY

1. Most common primary immunodeficiency
2. Look for:
a. RECURRENT sinopulmonary and GIT infections
b. Autoimmune diseases (eg, celiac, SLE)
c. Atopy (eg, asthma and eczema)
d. Anaphylaxis during blood transfusion
i. Due to IgE antibodies against IgA
3. Diagnosis
a. Low or absent IgA
b. Normal IgG, IgM and B cells
4. Treatment
a. Supportive care
b. Medical alert bracelets for transfusion reactions (for severe deficiency)

COMMON VARIABLE IMMUNODEFICIENCY

1. Age of presentation:
a. Around puberty
b. Adulthood (age 20-40)
i. More common
2. Presentation
a. Recurrent sinopulmonary & GIT infections
b. Autoimmune diseases
c. Chronic lung diseases (eg, bronchiectasis)
d. GIT disorders (chronic diarrhea, IBD-like conditions)
3. Diagnosis
a. Decreased immunoglobulins
b. Normal B cells
c. No response to vaccines
4. Management
a. IV Immunoglobulin infusion
5. CVID patients have increased risk of autoimmune diseases and certain malignancies regardless
of treatment.

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 PEDIATRICS

LEUKOCYTE ADHESION DEFICIENCY

1. Recurrent SKIN & MUCOSAL bacterial infections (e.g. omphalitis, periodontitis)
2. No pus (lack of neutrophils at inflammation site)
3. Poor wound healing
4. Delayed cord separation (>21 days)
5. MARKED peripheral leukocytosis with neutrophilia
6. Biopsy of infected tissue shows lack of neutrophils
7. Culture shows mostly staph aureus and gram – bacilli

HYPER-IGE SYNDROME
1. Also called Job syndrome
2. Inheritance pattern: Autosomal Dominant
3. Presentation:
a. Recurrent skin abscesses
b. Recurrent pulmonary infections
c. Recurrent S aureus infections
d. Characteristic facial features (eg, broad nose)
e. Bony abnormalities (eg, scoliosis)

ANAPHYLACTIC VS URTICARIAL TRANSFUSION REACTIONS

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STANDARD IMMUNIZATIONS

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 PEDIATRICS

DTAP VACCINATION
1. Schedule
a. 5 doses given at ages:
i. 2, 4 & 6 months
ii. 15-18 months
iii. 4-6 years
2. Complications
a. Seizures
i. Not a contraindication if they are uncomplicated i.e, short (<5 minutes) and self-
limiting. Give future DTaP according to schedule
ii. Only observe the patient in case a seizure occurs
b. Anaphylaxis
i. Hold all vaccines containing diphtheria, tetanus or pertussis components
c. Unstable neurological disorders (eg, infantile spasms and uncontrolled epilepsy) and
encephalopathy (ie, coma, decreased level of consciousness, prolonged seizure)
i. Give only diphtheria and tetanus toxoids without pertussis
3. Postexposure antibiotic prophylaxis is required for close contacts of anyone with pertussis
within the last 21 days

MENINGOCOCCAL VACCINATION
1. Routinely administered at age 11 or 12
2. Children with asplenia, HIV or complement deficiency may be vaccinated as early as age 2 years

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Central Nervous System

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 PEDIATRICS

FRAGILE X SYNDROME
1. Most common inherited form of intellectual disability
2. X-linked disorder
3. Trinucleotide CGG repeat expansion → hypermethylation of FMR1 gene
a. C: Prominent chin
b. GG: Giant Gonads (after age 8 years)
4. Other features include:
a. Long face
b. Protruding ears
c. Prominent forehead
d. Speech and motor delay
i. Begins walking and talking around age 20 months
5. Associated with
a. ADHD
b. Autism

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 PEDIATRICS

COMMON CAUSES OF INTELLECTUAL DISABILITY

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 PEDIATRICS

FRIEDRICH ATAXIA

1. Autosomal recessive
2. Progressive ataxia
3. Presentation in adolescence
4. Caused by trinucleotide expansion (most commonly GAA) in the frataxin gene
5. Presentation:
a. Neurologic dysfunction
b. Cardiomyopathy
c. Diabetes mellitus
6. Neurological findings are related to part of spinal cord affected:
a. Corticospinal tract
i. Dysarthria
ii. Limb weakness
b. Spinocerebellar tract
i. Ataxia
c. Dorsal column tract
i. Loss of proprioception and vibration sense

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d. Dorsal root ganglion

i. Loss of deep tendon reflex
7. Skeletal findings:
a. Pes cavus (high-arched feet)
b. Kyphoscoliosis
8. Hypertrophic cardiomyopathy is also seen
9. Diagnosis
a. Imaging: cervical spinal atrophy
b. Confirmation: genetic testing

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SEIZURE
1. Think of seizure when:
a. Sudden loss of consciousness
b. Loss of postural tone
c. DELAYED return to baseline mental status (in contrast to syncope)
2. Some patients may experience:
a. Aura
b. Lateral tongue lacerations
c. Urinary incontinence
d. Perioral cyanosis

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FOCAL SEIZURES

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 PEDIATRICS

ABSENCE SEIZURES

1. Brief
a. <20 seconds long
2. Associated with simple automatisms
a. Eyelid fluttering
b. Lip smacking
3. No postictal state
4. They can be provoked by hyperventilation
5. Diagnosis
a. EEG → 3-Hz spike-wave
6. Treatment: ethosuximide

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SIMPLE FEBRILE SEIZURES

1. Common features are:
a. Generalized
b. <15 minutes
c. Do not recur within 24 hours
2. Treatment
a. Just give acetaminophen and discharge
i. Antipyretics can make the child more comfortable but do not reduce the risk of
future febrile seizures

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FEBRILE SEIZURES VS MENINGITIS

1. Children with following alarming examination findings require immediate lumbar puncture:
a. Signs of ↑ ICP
b. Meningeal signs
c. Prolonged altered mental status (ie, postictal period >10 minutes)
d. Petechial rash

LANDAU-KLEFFNER SYNDROME:
1. It is an epileptic condition that presents with regression in language milestones after normal
development

LENNOX-GASTAUT SYNDROME
1. Age of Presentation: 3-5 years
a. Intellectual disability
b. Severe seizures
2. EEG: Interictal EED demonstrates slow spike-and-wave pattern

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TODD PARALYSIS
1. Hemiparesis or complete hemiplegia involving extremities on one side of body, occurring after a
focal or generalized seizure in the postictal stage
2. It is self-limiting
a. Typically resolves within 36 hours

BREATH-HOLDING SPELL
1. Occurs most commonly in children age 6 months to 2 years
2. Presents with cyanosis or pallor
a. Cyanotic: presents after crying
b. Pallid: presents after minor trauma
i. Loss of consciousness followed by breath-holding, pallor and diaphoresis
ii. This episode lasts <1 minute with subsequent confusion and sleepiness for a few
minutes
3. Follows minor injury or an upsetting event
a. Leads to loss of consciousness
4. Patients typically recover without postictal period
5. Some patients experience recurrent episodes that usually stop by age 5
6. Some patients develop vasovagal syncope later in life

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HOMOCYSTINURIA

1. Autosomal recessive
a. Cystathionine deficiency
2. Clinical features resemble Marfan syndrome (marfinoid habitus), except the following:
a. Fair hair and eyes
b. Fair complexion
c. Developmental delay
d. Cerebrovascular accidents because of thromboembolic events
e. Downward lens dislocation
3. Diagnosis
a. ↑ Homocysteine
b. ↑Methionine
4. Treatment
a. Vitamin B6, folate and vitamin B12
i. Lowers homocysteine levels
b. Antiplatelets/anticoagulants
i. Prevention of stroke, coronary heart disease and venous thromboembolic
disease

35
PEDIATRICS

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 PEDIATRICS

STURGE WEBER SYNDROME

1. Facial port wine stain
2. Leptomeningeal capillary-venous malformation
3. Intellectual disability
4. Seizures
a. Originate focally and then become generalized
5. Glaucoma
6. Visual field defects (eg, homonymous hemianopia)
7. Diagnosis
a. MRI of brain with contrast
i. Detects intracranial vascular malformations

KLIPPEL-TRENAUNAY SYNDROME
1. Malformations
a. Capillary
b. Venous
c. Lymphatic
2. Limb overgrowth
3. Port wine stain
a. Involve the lower extremity rather than the face (as seen in sturge weber)
4. No neurological abnormalities

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NF1 • Conversion disorder

occurs in presence of
witnesses

NF1 skin examination:

Should be carried out yearly

Macrosomia associated
hemorrhages:
Macrosomia is associated
with traumatic or device-
assisted delivery → leads to
1. Autosomal dominant intraparenchymal or
2. Features subdural hemorrhage.
a. Café-au-lait macules These hemorrhages
b. Axillary and inguinal freckling are usually small and do not
c. Lisch Nodules (iris hamartomas) require intervention.
d. Neurofibromas
Seizures as complication
3. Associated with of bacterial meningitis:
a. Neurologic disorders They are focal, instead of
i. Cognitive defects generalized
ii. Learning disabilities
iii. Seizures
b. Optic glioma
4. Yearly ophthalmologic examinations screen for optic gliomas • Nocturnal headaches
a. MRI of brain and orbits is required for any vision changes and morning vomiting
are red flags for
intracranial pathology

LP in Neonates
Neonates don’t experience
herniation after LP as their
open fontanelles relieve ICP

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NF1 OPTIC GLIOMA:

1. 15% of patients with age <6 develop low-grade optic gliomas

a. Mostly asymptomatic but can grow large enough to cause symptoms, such as:
i. Decreased visual acuity
ii. Alterations in color vision
iii. Optic nerve atrophy (looks as optic disk pallor)
iv. Proptosis (this also occurs in retinoblastoma but in retinoblastoma, age of
presentation is <2yo and also there are no skin findings)

39
PEDIATRICS

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 PEDIATRICS

TUBEROUS SCLEROSIS

41
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INCREASED ICP

42
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DURAL VENOUS SINUS

43
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FLOW OF CSF

44
 PEDIATRICS

HYDROCEPHALUS

1. Symptoms
a. Poor feeding
b. Irritability
c. Decreased activity
d. Vomiting
2. Physical examination
a. Tense and bulging fontanelle
b. Prominent scalp veins
c. Widely spaced cranial sutures
d. Rapidly increasing head circumference
3. Diagnosis
a. Acutely symptomatic patient
i. CT scan
b. Stable and asymptomatic patient
i. Sedated MRI
c. Ultrasound
i. Requires widely open anterior fontanelle
ii. Most useful in infants age <6 months
4. Treatment
a. Shunt placement

45
PEDIATRICS

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VENTRICULOPERITONEAL SHUNT

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 PEDIATRICS

TRAUMATIC BRAIN INJURY

Glasgow coma scale = 13-15

Loss of consciousness <5 minutes

Headache
Mild
Traumatic Brain Injury Amnesia before/after injury for <24 hours

Vomiting

Alteration in mental status at time of injury

Focal neurological deficits

Skull fracture

Severe Seizure

Loss of consciousness >5 minutes

Persistent altered mental status

Diagnosis:

1. Mild traumatic brain injury

a. Observe for 4-6 hours
b. Head CT without contrast
c. Improvement during observation or normal CT scan is an indication to discharge the
patient with clear written instruction with return precautions
2. Severe brain injury
a. CT without contrast
b. Close inpatient monitoring
c. Neurosurgical consultation

48
PEDIATRICS

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PECARN RULE

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CONCUSSION

POSTCONCUSSION SYNDROME

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INTRAVENTRICULAR HEMORRHAGE

1. Acute changes in blood flow through germinal matrix leads to hemorrhage either within
germinal matrix or into the lateral ventricle
2. Risk factors
a. Prematurity:
i. Neonates born at <32 weeks are at highest risk because the germinal matrix
involutes by week 32
b. Very low birth weight (<1500 g)
c. Acute changes in cerebral perfusion
i. Hypotension
ii. Hypoventilation
iii. Hyperventilation
3. Presents within 3-4 days of birth
4. Features
a. Mostly asymptomatic
b. In symptomatic patients:
i. Neurologic changes (eg, lethargy, hypotonia, apnea or seizures)
ii. Bulging fontanelle
iii. ↑ head circumference
iv. Anemia
v. Tachycardia (due to hemorrhage)
5. Diagnosis

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a. Cranial ultrasound of all neonates born at <32 weeks gestation at age 1-2 weeks
i. Hyperechoic material (blood) within germinal matrix ± extension to ventricles or
parenchyma
6. Treatment:
a. Symptomatic treatment (eg, blood pressure stabilization, antiseizure medication)

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INTRACRANIAL HEMORRHAGE DUE TO VITAMIN K DEFICIENCY

1. Newborns are vitamin K deficient due to following reasons:
a. Poor placental transfer
b. Absent gut flora to synthesize vitamin K
c. Immature liver function (ie, poor vitamin K utilization)
2. Early-onset Vitamin K deficiency presents within 1 week with following:
a. Early bruising
b. Mucosal bleeding
c. Gastrointestinal hemorrhage
3. Late-onset Vitamin K deficiency presents between age 2 weeks and 6 months with intracranial
hemorrhage
a. Layered hyperdense fluid collection within enlarged ventricles is suggestive
4. Prevention:
a. Intramuscular vitamin K at birth

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INFANT BOTULISM
1. Causes
a. Raw honey ingestion
b. Ingestion of inhaled environmental spores of C botulinum
i. Incidence is highest in California, Pennsylvania and Utah
ii. These areas have greatest soil botulism spores.
2. Clinical features
a. Bilateral bulbar palsies
i. Ptosis
ii. Sluggish pupillary response to light
iii. Poor suck and gag reflexes
b. Followed by symmetric descending flaccid paralysis (hypotonia)
c. Constipation
d. Drooling
3. Treatment
a. Respiratory support
b. NG tube feeding
c. IV human-derived botulism immune globulin
i. Administer it even before diagnostic confirmation of stool spores or toxin

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GUILLAIN-BARRE SYNDROME:

1. Demyelination of peripheral nerves

a. Ascending paralysis
i. Symmetric weakness
b. Weak or absent deep tendon reflexes
c. Respiratory failure
d. Autonomic symptoms
i. BP/HR instability (arrhythmias)
ii. Ileus
2. Preceding respiratory or GIT infection
3. Management
a. If Guillain-Barre is suspected in a stable patient, the very next step is to assess
pulmonary function with spirometry
i. FVC and negative inspiratory force monitor respiratory muscle strength
ii. A decline in FVC (≤20 mL/kg) indicates impending respiratory failure → do
endotracheal intubation
iii. Additional indications for elective intubation are: respiratory distress, severe
dysautonomia (eg, HR and BP instability) or widened pulse pressure
b. Treatment
i. IV immunoglobulin
ii. Plasmapheresis

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PHENYLKETONURIA
1. Diagnosis
a. Newborn screening
i. Tandem mass spectrometry
b. Later in life
i. Quantitative amino acid analysis
2. Treatment
a. Low-phenylalanine diet
i. Cerelas, starches, fruits, vegetables and phenylalanine-free milk is
recommended
ii. High protein foods are contraindicated

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MYOTONIC MUSCULAR DYSTROPHY

1. Autosomal dominant
2. Physical examination
a. Ptosis
b. Temporal wasting
c. Thin cheeks
d. Emaciated extremities
e. Atrophy of thenar and hypothenar eminences
f. Inverted V-shaped upper lip
g. Testicular atrophy
h. Delayed relaxation
3. All muscles are affected:
a. Skeletal muscles
i. Prominent in face, forearms, hands and ankle dorsiflexors (eg, bilateral foot
drop)
b. Smooth muscles
i. Dysphagia → ↑risk of aspiration pneumonia
c. Cardiac muscle
i. Conduction problems → arrhythmia
4. Other manifestations are:
a. Cataract
b. Testicular atrophy/infertility
c. Frontal baldness
d. Insulin resistance

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BRAIN ABSCESS

1. Presents with severe headache which is not relieved by NSAIDs

a. Worse at night because ICP naturally increases in supine position due to gravity
b. Associated with morning vomiting
2. Diagnosis
a. Contrast-enhanced CT scan
b. MRI of brain
c. Neuroimaging shows ring-enhancing lesions and surrounding edema

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MIGRAINES
1. Unlike migraines in adults, migraines in children are
a. Bifrontal
b. Shorter duration
2. If occipital headache is presented, it should raise concerns for a structural lesion
3. Treatment
a. First line
i. Supportive
1. Lying in a dark, quiet room
2. Cool cloth on forehead
ii. Acetaminophen or NSAID
b. Second line:
i. Triptans
1. Oral
2. Intranasal
3. Injectable

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MECHANISM OF ACTION OF TRIPTANS

INDICATIONS FOR NEUROIMAGING IN A CHILD WITH A HEADACHE

1. History of coordination difficulties
2. Presence of numbness or tingling
3. Focal neurological signs
4. History of headache that causes awakening from sleep
5. History of increasing headache frequency

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CEREBRAL PALSY
1. Nonprogressive motor dysfunction
2. Prematurity is the greatest risk factor
3. Spastic cerebral palsy is the most common type
a. Hyperreflexia
b. Hypertonia
c. Equinovarus deformity (feet point down and inward)
4. “Commando crawl” (child pulls itself with arms while dragging the legs behind) is often seen due
to contractures of lower limbs
5. Brain MRI may show periventricular leukomalacia and basal ganglia lesions

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CEPHALOHEMATOMA
1. Subperiosteal hemorrhage
2. Clinical features
a. Firm
b. Nontender
c. Does not cross suture lines
d. No skin discoloration
3. Most cases resolve spontaneously

SUBGALEAL HEMORRHAGE
1. It is caused by the rupture of emissary veins upon scalp traction during delivery
a. It leads to massive blood accumulation between periosteum and galea aponeurotica
2. Physical examination:
a. Diffuse, fluctuant scalp swelling that extends beyond suture lines and potentially
beyond the skull to the neck
b. The swelling shifts with movement and expands over 2-3 days
3. Complications:
a. Hypovolemic shock
b. DIC
c. Death
4. Treatment:
a. Supportive treatment (eg, volume resuscitation, correction of coagulopathy)

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NONACCIDENTAL TRAUMA

BASILAR SKULL FRACTURE

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SUDDEN INFANT DEATH SYNDROME

RING ENHANCING LESIONS

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MANIFESTATIONS OF INTRACEREBRAL TUMORS

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MEDULLOBLASTOMA
1. Occurs in cerebellar VERMIS
a. Hence, it leads to truncal ataxia
2. Pilocytic astrocytoma occurs in lateral cerebellar hemispheres, unlike medulloblastoma
a. Hence, it causes dysdiadochokinesia, dysmetria and intention tremor
th
3. 4 ventricle is close to cerebellum
a. Hence medulloblastoma can also cause obstructive hydrocephalus
i. This leads to increased ICP (which causes headache, papilledema and vomiting)

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CHOROID PLEXUS PAPILLOMA

1. Choroid plexus normally produces CSF

2. Choroid plexus papilloma leads to ↑ production of CSF
3. Presentation:
a. Hydrocephalus (ie, enlarging head)
b. Signs of ↑ ICP:
i. Bulging fontanelle
ii. Vomiting on waking
iii. Poor feeding
c. Developmental delay in infants
d. Headaches in older children or adults
4. Diagnosis:
a. Ultrasound:
i. Shows enlarged ventricles
b. MRI (confirmatory)
5. Treatment:
a. Resection of tumor

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CRANIOPHARYNGIOMA
1. Occur in the suprasellar region adjacent to optic chiasm
2. Compression of:
a. Optic chiasm
i. Leads to bitemporal hemianopsia
b. Pituitary stalk
i. Leads to endocrinopathies
1. GH deficiency
2. Diabetes insipidus
3. Can present with headache or obstructive hydrocephalus

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PINEAL GLAND TUMOR

1. Pineal gland
a. Location: quadrigeminal cistern
b. Function: melatonin production
2. Complications from mass effect
a. Parinaud syndrome
b. Obstructive hydrocephalus
i. Can block CSF flow in aqueduct of Sylvius
3. Trilateral retinoblastoma consists of:
a. Bilateral retinoblastoma
b. Pineal gland tumor

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TRAUMATIC CAROTID INJURIES

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BACTERIAL MENINGITIS IN CHILDREN IN AGE >1 MONTH

SENSORINEURAL HEARING LOSS AFTER BACTERIAL MENINGITIS

1. This complication is most common after streptococcus pneumonia meningitis
a. Infection or inflammation of:
i. CN VIII
ii. Cochlea
iii. Labyrinth
2. Regardless of the organism, all the patients with bacterial meningitis should undergo audiologic
testing

RISK FACTORS FOR COMPLICATIONS OF BACTERIAL MENINGITIS

1. Younger age
2. Delayed time to treatment
3. Prolonged seizures
4. High bacterial load
5. Low CSF glucose at diagnosis

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HSV ENCEPHALITIS

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MASTOIDITIS

1. Causative organisms:
a. Streptococcus pneumoniae
b. Streptococcus pyogenes
c. Staphylococcus aureus
d. Pseudomonas aeruginosa (in patients with recurrent infections or recent antibiotic use)
2. It is most commonly seen in children age ≤2 years

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LESIONS ON FACES

FETAL HYDANTOIN SYNDROME

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MYELOMENINGOCELE

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KALLMANN SYNDROME

PARINAUD SYNDROME
1. Pressure on pretectal region of midbrain, which leads to:
a. Bilateral eyelid retraction
b. Downward gaze preference
c. Light-near dissociation
2. Associated with pineal tumors

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Cardiovascular System

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BENIGN VS PATHOLOGICAL MURMURS

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ECG FINDINGS IN HYPERTROPHIC CARDIOMYOPATHY

Commotio Cordis:
1. Occurs in athletes with
no preexisting cardiac
disease
2. Occurs due to fatal
ventricular fibrillation
after sudden blunt chest
wall trauma
3. Most commonly occurs
in baseball

Cardiothoracic Ratio:
1. In children age <1 year =
≤60%
2. In children age >1 year
and in adults = ≤50%

PDA-Dependent
Congenital Heart Defects:
MAJOR CAUSES OF SUDDEN CARDIAC DEATH 1. Coarctation of aorta
1. Coronary Artery Disease 2. Hypoplastic left heart
2. Cardiomyopathy syndrome
a. Dilated cardiomyopathy 3. Transposition of great
b. Hypertrophic cardiomyopathy arteries
3. Arrhythmia 4. Total anomalous
a. Long QT syndrome pulmonary venous
4. Congenital Heart Defects connection
5. Tricuspid atresia

First two defects require

PDA for systemic circulation.
The rest require it for
pulmonary circulation.

Effects of PDA closure:

1. If pulmonary blood flow
is obstructed: cyanosis
2. If systemic blood flow is
obstructed: hypotension

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KAWASAKI DISEASE

1. Fever for ≥5 days, in addition to ≥4 of the following mucocutaneous findings: “COREL”

a. Conjunctivitis
i. Bilateral
ii. Nonexudative
iii. Spares the limbus
b. Oral mucosal changes
i. Erythema
ii. Fissured lips
iii. Strawberry tongue
c. Rash
i. Blanching maculopapular
d. Extremity changes
i. Erythema
ii. Edema
iii. Desquamation of hands and feet
e. Lymphadenopathy

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i. Cervical
ii. >1.5cm node
2. Irritability is also a common feature
3. Labs:
a. Leukocytosis
b. Thrombocytosis
c. ↑ ESR
d. Sterile pyuria
4. Treatment:
a. IVIG
i. Start within 10 days of fever onset to prevent coronary artery aneurysm
b. Aspirin
5. Assess cardiac complications by echocardiography
6. Risk factors for cardiac complications:
a. Prolonged fever (>10 days)
b. Delayed treatment with IVIG
c. Age <1 year

Disease
Adenovirus • Purulent conjunctivitis
Scarlet Fever • Exudative pharyngitis
• Sandpaper-textured rash
that spares palms and soles
Kawasaki
• Nonpurulent conjunctivitis
• Nonexudative tonsils
• Blanching maculopapular
rash

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VIRAL MYOCARDITIS
1. Etiology
a. Coxsackievirus B
b. Adenovirus
2. Clinical features: divided as pathology in left heart, lungs and right heart.
a. Left heart
i. S3 gallop
ii. Holosystolic murmur
b. Lungs
i. Pulmonary edema
ii. Dyspnea, tachypnea, wheezing, crackled (due to left heart failure)
c. Right heart
i. Hepatosplenomegaly
3. Viral prodrome (e.g, URTI) often precedes the illness
4. Diagnosis
a. Initial workup
i. CXR
1. Cardiomegaly (cardiothoracic ratio >50%)
2. Pulmonary edema
ii. ECG
1. Sinus tachycardia
iii. Echocardiogram
1. Global hypokinesis with decreased ejection fraction
b. Gold standard
i. Biopsy
1. Inflammation and necrosis
5. Treatment
a. Supportive
i. Diuretics
ii. Inotropes
b. IVIG
c. Monitor patients in ICU due to risk of shock and fatal arrhythmia
6. Treatment should be started based on clinical suspicion alone

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COMPLETE ATRIOVENTRICULAR SEPTAL DEFECT

1. Most common congenital heart defect in patients with Down Syndrome

2. Failure of endocardial cushions to merge results in:
a. VSD
b. ASD
c. Common atrioventricular valve due to poor mitral and tricuspid valve development
3. Pulmonary vascular resistance falls around age 6 weeks when the symptoms become evident
4. Auscultation findings are peculiar of the specific heart defects:
a. ASD: fixed split S2
b. VSD: Holosystolic murmur of VSD
c. AV valve: Holosystolic apical murmur
d. Increased flow across pulmonary valve: Systolic ejection murmur

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COARCTATION OF AORTA Congenital Heart Defects

1. Results from thickening of tunica media near the junction of ductus Associations:
arteriosus and the aortic arch 1. Coarctation of aorta:
2. Clinical Features: Turner Syndrome
a. Hypertension in upper extremities 2. Ebstein Anomaly:
b. Lower extremities have following features: Lithium toxicity
i. Hypotension 3. PDA: Congenital Rubella
ii. Hypoxia Syndrome
iii. Decreased oxygen saturation 4. Tetralogy of Fallot:
iv. Decreased femoral pulses Sporadic (more
v. Claudication (adults) common) or DiGeorge
c. Heart failure 5. Transposition of the
i. Irritability great arteries: DiGeorge
ii. Poor feeding Syndrome, infant of
iii. Diaphoresis diabetic mother
d. Cardiogenic shock (infants) 6. Truncus arteriosus:
i. Metabolic acidosis DiGeorge Syndrome
ii. Decreased urine output because of decreased renal HCM Epidemiology:
perfusion More common in African
iii. Prolonged capillary refill time (>3seconds) American population. It is
e. Palpable pulsations of intercostal vessels (adults) autosomal dominant.
3. Auscultation
a. Systolic murmur heard at the left paravertebral interscapular Cyanosis within 24 hours
area of birth:
4. Treatment Think transposition of great
a. Surgical repair vessels or truncus arteriosus,
especially if there is a single
S2. Single S2 is heard in:

• Tetralogy
• Transposition
• Tricuspid atresia
• Truncus arteriosus
• Hypoplastic left
heart syndrome

All of the above also present

with central cyanosis

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VSD
1. Small VSDs close spontaneously by age 2 years with no long-term sequelae
a. They present with a harsh murmur
2. Large VSDs present with a soft murmur due to less turbulence across a larger defect
3. Regardless of the size of the VSD, get an echocardiography to determine the location and size of
the defect and to rule out other defects

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QT PROLONGATION

1. Normal QT interval:
a. In males: <440 ms
b. In females: <460 ms
2. Treatment:
a. Refraining from vigorous exercise
b. Avoiding medications that prolong QT interval
c. Maintaining normal levels of:
i. Calcium
ii. Potassium
iii. Magnesium
d. Treatment of choice is:
i. Beta-blockers (except sotalol)
ii. For symptomatic patients or patients with a history of syncope: Beta blockers +
pacemaker

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TRICUSPID ATRESIA

1. It should be suspected in cyanotic kids with:

a. Left axis deviation
b. Small or absent R waves in the precordial leads
c. Tall, peaked P waves
2. Clinical features
a. Hypoplastic right ventricle
b. Underdevelopment of the pulmonary valve and artery (because of lack of blood flow to
the pulmonary outflow tract)
i. This leads to decreased pulmonary vascular markings on chest X-ray
c. Associated ASD and VSD are necessary for survival
d. No cardiomegaly
3. Risk factors
a. Congenital rubella syndrome
b. Down syndrome
c. Maternal diabetes
d. Family history of congenital heart disease
4. Treatment
a. Surgical repair
5. Differentials
a. Complete atrioventricular canal defect
i. INCREASED pulmonary markings
ii. Cardiomegaly

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b. Ebstein’s anomaly
i. Tall P waves
ii. Right axis deviation
iii. Cardiomegaly
c. Tetrology of Fallot
i. Decreased pulmonary markings due to pulmonary outflow obstruction
ii. Right axis deviation
iii. Boot-shaped heart in later stages
d. TAPVR
i. Right axis deviation
e. Truncus arteriosus
i. ECG is normal in neonates
ii. Cardiomegaly
iii. Increased pulmonary vascular markings

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CONGENITAL HEART DISEASE ROUTINE SCREENING

1. It is done by pre-ductal and post-ductal pulse oximetry
2. Echocardiogram is indicated for a positive screen, which is:
a. <90% in either extremity
b. <95% in both upper and lower extremities
c. >3% difference between upper and lower extremities
3. Remember: acrocyanosis (blue extremities, pink body) is a benign finding in the first days of life
due to initial vasoconstriction
4. Indications for other screening tests:
a. Chest X-ray: If patient has tachypnea (>60/min) or increased work of breathing (eg,
retractions)
b. Echocardiogram: if positive pulse oximetry test or central cyanosis
c. Electrocardiogram: if patient has bradycardia or suspected to have neonatal heart block
d. Hyperoxia test (administering 100% oxygen): when it is required to distinguish the cause
of central cyanosis
i. Pulmonary cause improves with oxygen
ii. Cardiac cause does not improve with oxygen

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APGAR SCORE

POSTPERICARDIOTOMY SYNDROME
1. It is a pleuropericardial disease that occurs day or months after cardiac surgery or injury
2. Inflammation from surgical intervention can lead to:
a. Pericarditis
b. Pericardial effusion
c. Cardiac tamponade
3. Progression to tamponade is characterized by Beck’s triad:
a. Distant heart sounds
b. Distended jugular veins (or scalp veins in infants)
c. Hypotension
4. Chest X-ray shows cardiomegaly
5. Treatment
a. Pericardiocentesis
b. Pericardiectomy

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VASCULAR RINGS

1. Result from abnormal development of aortic arch causing tracheal, bronchial and/or esophageal
compression
2. Two types:
a. Complete (eg, circumferential around
trachea and esophagus)
b. Incomplete (eg, pulmonary artery
sling)
3. Up to 50% of patients also have a cardiac
anomaly
4. Presentation
a. Age <1
b. Respiratory symptoms
i. Biphasic stridor which gets
better with neck extension
ii. Wheezing
iii. Coughing
c. Esophageal symptoms
i. Solid-food dysphagia
ii. Vomiting
5. Diagnosis:
a. Barium swallow to find indentations
b. MRI with angiography to confirm

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6. Differentials
a. Asthma: No stridor (stridor is a symptom of upper airway obstruction)
b. Croup: Presents with fever, rhinorrhea and acute inspiratory stridor. Responds to
nebulized racemic epinephrine
c. Laryngomalacia: Inspiratory stridor. Gets better with prone position
d. Epiglottitis: life-threatening. Inspiratory stridor. Drooling
e. Foreign Body Aspiration: acute onset. History of choking or gagging

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VENTRICULAR SEPTAL DEFECT

1. Murmur
a. Holosystolic at left lower sternal border
b. Diastolic rumble at apex
i. Due to increased flow of blood across the mitral valve
ii. The increased blood is because of left-to-right shunt
c. Prominent S2 because of increased pressure to close pulmonary valve
2. VSD’s may be:
a. Small or moderate
i. They produce II-VI/VI holosystolic murmur because of turbulence
ii. Resolve spontaneously in most cases by age 2 years
b. Large
i. They produce I/VI or quieter murmurs
3. Treatment is a combination of medications (e.g, diuretics) and surgical closure.

TETRALOGY OF FALLOT
1. The murmur is because of pulmonary artery stenosis
a. Harsh systolic murmur heard over the left upper sternal border
b. Single S2 comprises the normal aortic and the inaudible pulmonary component
2. Presentation depends on Right ventricle outflow tract obstruction
a. Increases with exertion, feeding, crying and agitation.
3. Treatment
a. Acute management is knee-chest positioning
b. Inhaled oxygen stimulates pulmonary vasodilation and decreases pulmonary resistance
c. IV fluids improve right ventricle filling and pulmonary flow

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RHEUMATIC HEART DISEASE

1. Suspect rheumatic heart disease if the patient has a history of polyarthritis after a febrile illness
and presence of mitral regurgitation on echocardiogram.
2. Prophylaxis of benzathine penicillin G every 4 weeks is needed to prevent recurrence.
3. The patient should be monitored ever 6-12 months for signs of left ventricular dysfunction

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EFFECT OF MANEUVERS ON HCM

PHYSICAL EXAMINATION OF HCM

1. Dual upstroke carotid pulse due to midsystolic obstruction during cardiac contraction
2. Systolic ejection murmur along the left sternal border with a strong apical impulse

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CYANOTIC HEART DISEASES

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AUSCULTATION OF HEART MURMURS

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DIGEORGE SYNDROME

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Dermatology

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CONGENITAL DERMAL MELANOCYTOSIS

1. Previously known as Mongolian spots
2. Presents as benign, flat, blue-gray patches that are found in infants over the lower back and
buttocks
a. Due to presence of melanocytes in skin’s dermis
3. Common in Africans, Asians and Hispanics
4. Hyperpigmentation fades spontaneously

CONGENITAL MELANOCYTIC NEVUS

1. Benign proliferation of melanocyte cells
a. Solitary
b. Hyperpigmented
c. Overlying dark, coarse hairs
2. Risk of transformation to melanoma increases up to 5% with increasing size of a congenital
melanocytic nevus
a. Remove surgically if large to ↓ risk of transformation to melanoma
b. Small lesions can also be removed for cosmetic reasons

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SCALD INJURIES IN CHILD ABUSE

1. Red flags
a. Sparing of flexural creases
i. Due to flexion of knees, ankles and hip at the time of forced immersion
b. Sharp line of demarcation
c. Uniform burn depth
d. Absence of burn in the distribution of splash marks

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TINEA VERSICOLOR
1. It is most noticeable after sun exposure as the surrounding skin becomes darker
2. Distribution
a. In adults: trunk and upper extremities
b. In children: face

ERYTHRODERMA
1. It is exfoliative dermatitis
2. Symptoms
a. Erythema and scaling in >90% of the body
b. Bright red patches coalesce and gradually peel

ERYTHEMA TOXICUM NEONATORUM

1. Asymptomatic
2. Scattered, blanching, erythematous papules and pustules that spare the palms and soles
3. Pustules are sterile and contain eosinophils
4. It is common in full-term neonates in the first 2 weeks of life
5. Resolves spontaneously

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TINEA CAPITIS
1. Caused by trichophyton tonsurans
2. Most common form in USA is black dot tinea capitis
a. Most common in African Americans
3. Patchy alopecia with residual black dot (broken hair)
a. Pruritis
b. Inflammation
c. Ocular or postauricular lymphadenopathy
4. Differentials of alopecia
a. Alopecia areata
i. Autoimmune
ii. Smooth circular areas of hair loss without scaling
b. Discoid lupus erythematosus
i. Well-demarcated inflammatory plaques
ii. Hypo- or hyperpigmented lesions
iii. Scarring
iv. Photosensitivity
c. Seborrheic Dermatitis
i. Involves scalp as well as eyebrows or nasolabial folds
ii. Greasy

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ALOPECIA AREATA

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TINEA CORPORIS
1. Caused by Trichophyton rubrum
2. Diffuse spread and refractory causes of tinea corporis should be treated with oral antifungals as
second-line treatment
3. Tinea capitis (dermatophyte infection of scalp) ALWAYS requires an oral antifungal as first line
treatment

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TINEA PEDIS

PHOTO-PROTECTION
1. Best method is sun avoidance
2. If you really want to go outdoors, use broad-spectrum sunscreens with sun protection factor 15-
30 or higher
a. It should be applied 15-30 minutes before exposure
b. Reapply every 2 hours (even if the product says “water resistant”)
3. It should be noted that cloud coverage DOES NOT block UV rays
4. Sunscreen is avoided in infants age <6 months because of thin skin and ↑ surface-to-body
weight ratio, which increases exposure to sunscreen chemicals.
a. However small amount of sunscreen can be used if sun exposure is unavoidable and
additional protection is necessary

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KERATOSIS PILARIS

1. It is a benign condition characterized by retained keratin plugs in the hair follicles

2. Presentation:
a. Small, painless papules
b. Roughened skin texture
c. Mottled perifollicular erythema
d. Exacerbations are common in cold, dry weather
3. It can occur anywhere in the body but is most common on the posterior surface of the upper
arm
4. It can occur alone or in association with following:
a. Atopic dermatitis
b. Ichthyosis vulgaris (an inherited disorder characterized by chronically rough, scaly skin)
5. Treatment:
a. Emollients
b. Topical keratolytics (eg, salicylic acid, urea)

FOLLICULITIS
1. It is due to inflamed hair follicles
2. Presentation:
a. Acute, erythematous, pustular eruption

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MILIARIA

1. It is also called heat rash

2. Pathogenesis:
a. Blockage of eccrine sweat ducts in the setting of increased heat or humidity
3. It is most common in newborns and young children
4. Presentation:
a. It can range from small, thin-walled vesicles to patches of erythematous papules or
pustules

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PITYRIASIS ROSACEA

1. The oval lesions that come after the herald patch are distributed obliquely along the lines of
tension, most noticeable on the back

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ERYTHEMA MULTIFORME
1. Erythematous target lesions with a dusky center
2. Precipitated by infection or medication

NUMMULAR ECZEMA
1. Chronic rash
2. Symptoms
a. Dry, erythematous, and INTENSELY pruritic patches on the extremities

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INFANTILE HEMANGIOMA

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ATOPIC DERMATITIS

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Eczema Herpeticum

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SEBORRHEIC DERMATITIS

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PERIANAL DERMATOSES

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STREPTOCOCCAL PERIANAL DERMATITIS

1. Bright, sharply demarcated, confluent erythema in the perianal or perineal region
2. Symptoms
a. Perianal pruritus
b. Pain, particularly with stooling
i. Patient withholds because of pain → constipation
c. Perirectal fissures
d. Blood-streaked stools
3. It is not necessary that the patient also gets streptococcal pharyngitis but there may be a close
contact with recent streptococcal infection (eg, cellulitis, pharyngitis)

NEONATAL RASHES

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COMMON INSECT BITES

CHIGGERS BITE
1. Chiggers are small mites that cause intensely pruritic, erythematous papules on exposed areas
(eg, ankles, waistline)
2. Chiggers are found outdoors (eg, grassy fields)

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SUNBURN

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HYPERSENSITIVITY REACTIONS

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Endocrine System

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PRECOCIOUS PUBERTY

1. It is defined as secondary sexual characteristics appearing in:

a. Girl age <8 years
b. Boy age <9 years
2. Precocious puberty may be:
a. Benign
i. Benign thelarche
ii. Benign adrenarch
1. Risk factor for PCOS, DM-2 and metabolic syndrome, especially in obese
patients
b. Central precocious puberty
c. Peripheral precocious puberty
3. Secondary sexual characteristics may be:
a. Estrogen stimulated
i. Breast tissue
b. Androgen stimulated
i. Pubic and axillary hair
ii. Adult body odor
iii. Acne

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4. Management:
a. Initial management includes bone age evaluation TSH and precocious
b. If advanced bone age, check basal FSH and LH levels and puberty:
levels with pulsatile GnRH Chronic hypothyroidism can
c. If they are increased, the patient has central precocious cause precocious puberty
puberty because TSH can
i. Do MRI inappropriately stimulate
1. Positive in case of hypothalamic or pituitary FSH receptor. This will cause
tumor increase in estrogen and will
2. Negative in case of idiopathic precocious lead to breast development
puberty or vaginal bleeding.
a. Give GnRH therapy
Euthyroid
Hypothyroxinemia:
Patients with anorexia
nervosa have euthyroid
thyroxinemia, which is
characterized by:

• Normal TSH
• Normal to decreased
thyroxine and
triiodothyronine

Obesity and Precocious

Puberty
Obesity → increased
adiposity → ↑insulin
production → stimulation of
adrenal glands to produce
sex hormones → precocious
puberty.

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CONSTITUTIONAL GROWTH DELAY

1. Most common cause of short stature and pubertal delay in adolescents
2. Clinical features
a. Normal birth weight and height
b. Height growth velocity slows between age 6 months to 3 years
c. Normal growth velocity regained after 3 years of age
d. This leads to puberty and adolescent growth spurt delay but it occurs eventually.
3. Bone age radiographs show bone age that is delayed compared to the chronological age

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REFEEDING SYNDROME

1. Occurs when starvation is acutely treated

a. Causes insulin secretion, which leads to:
i. Hypophosphatemia (primary deficit electrolyte as it is required for ATP energy)
ii. Hypokalemia → cardiac arrythmia
iii. Hypomagnesemia → cardiac arrythmia
iv. Decrease in thiamine in serum → Wernicke encephalopathy
b. This leads to cardiopulmonary failure

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VON GIERKE DISEASE

1. Glucose 6 phosphatase deficiency in liver, kidney and intestinal mucosa
a. Glycogen accumulation
2. Presentation
a. At age 3-4 months
b. Hypoglycemia (often resulting in seizures)
c. Lactic acidosis (due to buildup in liver)
d. Hyperuricemia
e. Hyperlipidemia
3. Urine dipstick is positive for ketones
4. Physical examination:
a. Doll-like face
b. Rounded cheeks
c. Thin extremities
d. Short stature
e. Hepatomegaly (protuberant abdomen)

GAUCHER DISEASE

1. Clinical Features:
a. Bone marrow infiltration
i. Anemia and thrombocytopenia
b. Hepatosplenomegaly
i. Splenomegaly is more prominent than hepatomegaly
c. Bony pain
d. Failure to thrive (low weight and height)
e. Delayed puberty

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CONGENITAL HYPOTHYROIDISM

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DIABETIC KETOACIDOSIS

1. Look for:
a. Polyuria
b. Polydipsia
c. Abdominal pain
d. Fatigue
e. Dehydration
f. Kussmaul breathing
g. High glucose in serum
h. Ketones in urine
2. Infections precipitate DKA by:
a. Increased catecholamine
b. Increased cortisol
c. Increased glucagon
3. INsulin keeps potassium INside the cells
a. Hence in DM-1, potassium comes out of the cells and the serum studies may show
normal or increased potassium in the serum but OVERALL BODY STORES OF POTASSIUM
STAY DEPLETED.
4. Treatment
a. Gradual fluid repletion
b. Insulin administration
i. Also supplement with potassium since insulin will cause hypokalemia

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ENT

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DIFFERENTIALS OF STRIDOR

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LARYNGOMALACIA
1. Causes chronic stridor
2. Pathogenesis: caused by “floppy” supraglottic structures that collapse during inspiration
3. Time period
a. Begins in neonatal period
b. Loudest at 4-8 months
4. Presentation
a. Inspiratory stridor
i. Worse in supine position
ii. Exacerbated by feeding or upper respiratory illnesses
iii. Prone position improves the symptoms
5. Diagnosis
a. Clinical
b. Confirmed with
i. Direct laryngoscopy
ii. Flexible fiber-optic laryngoscopy
6. Findings
a. Omega-shaped epiglottis
b. Collapse of supraglottic structures during inspiration
7. Management
a. Spontaneous resolution by age 18 months
b. Treat those patients accordingly who have GERD (give antireflux therapy)
c. Patients with feeding difficulties, cyanosis, or failure to thrive should be referred for
surgical consultation

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MID-INSPIRATORY STRIDOR IN LARYNGOMALACIA

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TRACHEOMALACIA

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LARYNGEAL PAPILLOMAS

1. Causative organism: HPV subtypes 6 and 11

2. Presentation:
a. Hoarseness
b. Airway obstruction
c. Repeated operative interventions
3. Appearance of lesions:
a. Finger-shaped
b. Warty
c. Grapelike
d. Dark-red punctate areas (corresponding to blood vessels)
4. Treatment:
a. Surgical debridement

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OTITIS EXTERNA
1. More common in children and adolescents
2. Also called “swimmers’ ear”
a. Occurs after swimming in outdoor water sources
3. Cerumen is acidic and protective against infection
a. Clearing of cerumen by swimming or excessive cleaning can lead to otitis externa
4. Tympanic membrane is spared (clear, not inflamed, no middle ear fluid)
5. Consider wick placement to facilitate medication delivery

CANDIDA OTITIS EXTERNA

It is seen in otitis associated with a foreign body (eg, hearing aid)

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ACUTE OTITIS MEDIA

1. Age of presentation
a. 6-18 months
b. 5 years
2. Risk factors
a. Lack of breastfeeding
b. Day care attendance
c. Cigarette smoke exposure
d. Recent URTI
3. Otoscopic findings
a. Decreased mobility on pneumatic insufflation
i. This indicates middle ear effusion
b. Bulging of tympanic membrane
i. This indicates middle ear inflammation
4. Fever, hearing loss and tympanic membrane erythema are also present but not required to
make the diagnosis

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5. Management:
a. Age <6 months: amoxicillin
b. Age > 6 months
i. High fever, severe pain or bilateral disease: amoxicillin
ii. Low fever, mild or no pain, and unilateral disease: analgesia and observation
c. ≥3 episodes in 6 months and ≥ 4 episodes in 12 months:
i. Tympanocentesis and culture during myringotomy with tympanostomy tube
placement
6. Differentials
a. CSOM
i. >6-week history
ii. Otorrhea
b. Serous otitis media
i. Lack of acute inflammatory signs (eg, fever, tympanic membrane bulging)

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OTITIS MEDIA WITH EFFUSION

1. It is defined by middle ear fluid without tympanic membrane inflammation
2. Distribution:
a. Young children age 6-24 months are predisposed to fluid accumulation within middle
ear due to narrow, straight eustachian tubes that drain poorly
3. Most effusions develop in setting of a viral infection or following an episode of acute otitis
media
4. Presentation:
a. Ear tugging
b. No fever or severe ear pain
5. Examination:
a. Air-fluid levels posterior to tympanic membrane
b. Poor tympanic membrane mobility on pneumatic insufflation
c. Tympanic membrane is NOT bulging or erythematous
d. Effusion is nonpurulent (in contrast to acute otitis media in which effusion is purulent
and tympanic membrane is bulging or erythematous)
6. Management:
a. Resolution within weeks and no treatment is required
7. Follow-up:
a. Patients should be followed up because chronic otitis media with effusion (>3 months)
can cause speech delay and long-term hearing loss
i. Tympanostomy tube placement can be used to manage chronic otitis media
with effusion

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SUPPURATIVE COMPLICATIONS OF OTITIS MEDIA

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RINNE & WEBER TEST

WEBER TEST

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EUSTACHIAN TUBE DYSFUNCTION

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CHOLESTEATOMA

1. It is a benign growth of the squamous epithelium and accumulation of keratin debris within the
middle ear
2. Risk factors:
a. History of recurrent acute otitis media
b. Chronic middle ear effusion
c. Tympanostomy tube placement
3. Presentation:
a. Chronic otorrhea
b. Conductive hearing loss
4. Examination:
a. Pearly white mass (most commonly in the anterosuperior quadrant of tympanic
membrane)
b. Visible retraction pocket with draining debris
5. Treatment:
a. Surgical excision

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ACUTE RHINOSINUSITIS IN CHILDREN

ACUTE BACTERIAL RHINOSINUSITIS

1. Most common cause is Nontypeable Hemophilus influenza.
a. The other causes are Streptococcus pneumoniae and Moraxella catarrhalis
2. Most common presentation is NASAL discharge and COUGH for 10 DAYS or more WITHOUT
improvement.
a. In contrast, viral rhinosinusitis improves by days 7-10
3. Criteria for diagnosing acute bacterial rhinosinusitis (any 1 of the following 3):
a. Symptoms persist for ≥10 days
b. Symptoms severe in onset (≥39 C [102.2] + drainage) for ≥3 days
c. Symptoms worsen following initial improvement (ie, biphasic illness). Fever may be
absent
4. Treatment:
a. Severe symptoms or worsening: amoxicillin +/- clavulanate
b. Mild symptoms or persistent with no worsening: 3-day period of observation or oral
antibiotics
5. Complications:
a. Periorbital/orbital cellulitis
b. Meningitis
c. Brain abscess

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6. Differentials:
a. Acute Viral Rhinosinusitis:
i. Symptoms typically resolve by day 10
ii. Symptoms are mild (eg, no fever or early resolution of fever, mild pain)
iii. Management: Nasal saline and irrigation, NSAIDs

NASAL FOREIGN BODY

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THYROGLOSSAL DUCT CYST (TDC)

1. Pathophysiology:
a. Thyroid gland is formed as an outpouching from the pharyngeal epithelium at the base
of the tongue. It then descends to the base of the anterior neck via the thyroglossal
duct.
b. If the duct fails to atrophy normally, a TDC can develop from the epithelial remnants
within the duct, forming a midline, cystic mass.
i. Since the tract connects to the base of the tongue, protrusion of the tongue or
swallowing causes the TDC to move superiorly
2. TDC is often detected when it becomes secondarily infected after an upper respiratory tract
infection
3. Treatment:
a. Surgical removal
i. TDC is often associated with ectopic thyroid tissue and may be the only source
of functioning thyroid tissue, thyroid imaging is required preoperatively

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THYROID MIGRATION

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PHARYNGITIS
1. Can be:
a. Viral
i. More common
ii. In age <5yo
b. Bacterial
i. Tonsillar erythema and exudates
ii. Tender anterior cervical nodes
iii. Palatal petechiae
2. If rapid streptococcal antigen test is positive, give amoxicillin ASAP
a. If it’s negative, get a throat culture before prescribing the Abx

3. Centor criteria is reliable for adults, not for children

a. For children, look for symptoms
i. Viral symptoms: cough, rhinorrhea, conjunctivitis, oral ulcers
ii. Bacterial symptoms: exudates, edema, palatal petechiae, absence of viral
symptoms
4. ASO titers can be obtained after 1 MONTH because ASO antibodies peak after a month

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SINUSITIS TITBITS
1. Staph aureus causes chronic sinusitis with inflammation for >12 wks.
2. Strep pyogenes RARELY causes sinusitis. It causes pharyngitis WITHOUT cough or nasal discharge,
whereas in acute bacterial rhinosinusitis by H influenzae both of these symptoms are present.

FUNGAL SINUSITIS PRESENTATION

1. Occurs only in case of impaired host defenses (DM or malignancy)
2. Signs and symptoms:
a. Epistaxis
b. Turbinate destruction
c. Palatal eschars
d. Maxillary cyanosis

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PEDIATRIC OBSTRUCTIVE SLEEP APNEA

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Gastrointestinal System

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BILIRUBIN METABOLISM

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NORMAL VALUES FOR INFANTS

1. They should feed ≥10-20 minutes every 2-3 hours
2. During the first week of life, the number of wet diapers should be the age of the infant in days
3. Healthy infants lose up to 7% of weight in first 5 days of life due to excretion of excess fluid
acquired in utero and during labor

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MANAGEMENT OF FOREIGN BODY INGESTION

BATTERY INGESTION
1. If it is impacted in esophagus, immediate endoscopic removal is necessary to prevent
esophageal mucosal damage and ulceration
2. If it is located distal to esophagus in GIT tract, just observe to confirm battery excretion by:
a. Stool examination
b. Radiographic follow-up

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TREATMENT OF COIN IN ESOPHAGUS

1. Indications for treatment
a. If patient is symptomatic
i. If patient is asymptomatic, he can be observed up to 24 hours after ingestion
b. If time of ingestion is unknown
2. Flexible endoscopy
a. Treatment of choice
b. Less risk of esophageal abrasion
3. Rigid endoscopy
a. Higher risk of esophageal abrasion
b. Reserved for impacted sharp objects in the proximal esophagus

MANAGEMENT OF MAGNET INGESTION

1. Ingestion of ≥2 magnets, especially if swallowed separately, can entrap bowel via attraction
across varying intestinal segments and lead to necrosis, fistulae, or perforation
a. Therefore, magnets visualized in esophagus or stomach on X-ray require immediate
endoscopic removal even if patients are asymptomatic
2. Management of magnets identified beyond stomach:
a. Removal by colonoscopy OR
b. Serial X-rays (every 4-6 hours)
i. If symptoms develop or if the magnets do not progress in the gastrointestinal
tract, surgical removal is indicated

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SUPPLEMENTATIONS IN EXCLUSIVELY BREASTFED INFANTS

1. Depends if child is preterm or term baby
2. Term babies
a. They should be supplemented with 400 IU of vitamin D daily
3. Preterm babies
a. They should be supplemented with vitamin D + iron
b. Iron supplementation should be continued until 1 year
4. Vitamin B12 supplementation is recommended for exclusively breastfed infants born to strict
vegetarian mothers

CAUSES OF PHYSIOLOGIC JAUNDICE

1. ↑ hemoglobin turnover and bilirubin production
a. At birth, RBC concentration is increased (hematocrit 50%-60%) with short life span (90
days)
2. ↓ activity of UGT enzyme
a. Its levels do not reach adult levels until 2 weeks
b. Asian newborns have ↓ UGT activity as compared to other ethnicities
3. Sterile newborn gut
a. ↓ conversion of bilirubin to urobilinogen and hence ↓ excretion

*Note: physiologic jaundice resolves on its own by age 1-2 weeks*

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PHYSIOLOGIC GASTROESOPHAGEAL REFLUX

1. Extremely common Sandifer Syndrome:
GERD + intermittent
2. Children experience frequent postprandial regurgitation as compared to
opisthotonic posturing
adults because:
a. Shorter esophagus Threshold for
b. Incomplete closure of the LES Phototherapy:
c. ↓ angle between esophagus and stomach • Total bilirubin level ≥20
d. Greater time spent in supine position mg/dl
3. Examination, growth and development are normal (in contrast to GERD
→ failure to thrive) and infants are often asymptomatic (“happy spitter”) Criteria for Exchange
4. Management Transfusion:
a. Reassurance • Total bilirubin level ≥25
b. Advise frequent, small-volume feeds mg/dl
c. Hold infant upright for 20-30 minutes after feeds • Evidence of bilirubin-
d. Place the infant prone when awake induced neurologic
e. Avoid activities that increase intraabdominal pressure dysfunction
5. Regurgitation improves when infant can sit upright (approx. 6 months)
Herniorrhaphy for
and resolves by 1 year
Umbilical Hernias:
Many umbilical hernias close
in first few years of life and
they are seldom
symptomatic. Hence, their
repair is rarely
recommended until age 5
years

Introduction of fruit
juices
• They should not increase
from 4-6 ounces per day
• They should never be
given in a bottle because
of extremely increased
risk of dental carries

C. difficile colitis in
children age <2 years:
C. difficile colitis does not
occur in children age <2
years due to lack of
intestinal receptor to
offending toxins until 2 years
of age
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BREASTFEEDING JAUNDICE
1. Exaggerated unconjugated bilirubin in the first week of life that is caused by insufficient intake
of breast milk
2. Pathogenesis
a. Decreased intake of breast milk → delayed stooling → decreased bilirubin elimination →
increased enterohepatic circulation → hyperbilirubinemia
b. Poor intake of breast milk → dehydration → decreased bilirubin delivery to the liver →
decreased conjugation → increased unconjugated bilirubin
3. Look for:
a. Presentation in first week of life
b. Jaundice
c. Exaggerated unconjugated hyperbilirubinemia
d. Signs of dehydration
i. Excessive weight loss (greater than the physiologic 7%)
ii. ↓ voiding
4. Treatment
a. ↑ frequency of breastfeeding
b. Maintain adequate hydration
c. Promote bilirubin excretion
d. If bilirubin still continues to rise, formula supplementation may be necessary but
breastfeeding should NOT be discontinued
e. Reevaluate within 1-2 days

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CELIAC DISEASE
1. Immune-mediated hypersensitivity to gluten → destruction of Most common indication
proximal intestine villi → impaired nutrition absorption for pediatric liver
transplant:
a. GIT symptoms
Biliary atresia
b. Weight loss
c. Iron-deficiency anemia (because of impaired iron absorption
from duodenum)
d. Dermatitis herpetiformis Age of presentation of
i. Vesicular rash with clear fluid biliary atresia
ii. Itchy and burning By age 2 months (1-8 weeks)
iii. Present on extensor surfaces of arms and legs (knees,
elbows, forearms and buttocks)
2. Look for history of autoimmune conditions Lactose Intolerance
3. Diagnosis • Lactose intolerance is
a. Anti-tissue transglutaminase antibody IgA uncommon in children
b. Followed by endoscopic duodenal biopsy for confirmation age <6yo

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INTUSSUSCEPTION

1. Most common cause of intestinal obstruction in children age 6-36 months

2. Ileocolic junction is most commonly involved
3. 75% of children have no identifiable lead points
4. The remaining 25% are due to
a. Meckel’s diverticulum
b. Polyps
c. Henoch-Schonlein purpura (ileoileal intussusception)
d. Tumor
e. Celiac disease
5. Generally, idiopathic intussusception CLASSICALLY presents at age 6-36 months
6. Clinical features
a. Periodic pain
i. Associated with drawing up of legs
b. Emesis
i. Initially nonbilious but becomes bilious as obstruction persists
c. Mucosal ischemia → occult bleeding
i. Becomes grossly bloody “currant jelly” stools if left untreated
d. Lethargy
e. Altered mental status
7. Physical examination
a. Sausage-shaped mass in right upper quadrant
b. Tenderness in right upper and lower quadrants

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8. Management
a. Ultrasound (most sensitive and specific)
i. Do air enema if positive (target sign)

b. Laparotomy
i. If enema reduction fails
ii. If pathological lead point is identified
iii. If patient presents with signs of perforation
1. Free air on x-ray
2. Rigid abdomen

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WHEN TO SUSPECT PATHOLOGICAL LEAD POINT

1. A pathological lead point should be suspected in following:
a. Recurrent intussusception
b. Atypical age for intussusception
c. Atypical location of intussusception (eg, small bowel into small bowel)
d. Persistent rectal bleeding despite reduction of intussusception

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EOSINOPHILIC ESOPHAGITIS
1. Immune-mediated inflammation of esophagus
a. Triggered by food allergens
2. Associated with eczema and allergic conditions (eg, asthma, rhinitis)
3. Presentation
a. Dysphagia
b. Mid-chest and epigastric pain
c. Vomiting
d. Food impaction
i. Food refusal or preference to soft foods is common in children
4. This disease does not respond to acid suppression by PPIs
a. 2-month trial of PPI is considered as part of diagnosis
b. If there is no improvement after 2 months, an endoscopy with esophageal biopsy is
carried out
i. ≥15 eosinophils/hpf
5. Treatment
a. Dietary modifications to avoid food triggers
b. Topical (eg, swallowed) fluticasone

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BECKWITH-WIEDEMANN SYNDROME
1. Sporadic or inherited alteration of chromosome 11p15
a. ↑ insulin-like growth factor 2
i. Newborns must be closely monitored for hypoglycemia
ii. Hypoglycemia is transient and older asymptomatic patients usually do not
require ongoing glucose monitoring
2. Physical findings
a. Macrosomia
b. Macroglossia
c. Hemihyperplasia
d. Medial abdominal wall defects (umbilical hernia, omphalocele)
e. Visceromegaly in some patients
3. Complications
a. Wilms tumor
b. Hepatoblastoma
4. Surveillance
a. Every 3 months from birth to age 4 years = abdominal ultrasound + alpha-fetoprotein
levels
b. Every 3 months from age 4-8 years = abdominal ultrasound
c. Age 8 years to adolescence = renal ultrasound

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MILK OR SOY PROTEIN-INDUCED PROCTOCOLITIS

1. Allergy to proteins in milk

2. It is a non-IgE mediated immunologic response to proteins in formula or breast milk
a. Causes rectal and colonic inflammation
3. Resolves by 1 year of age
4. Clinical Features:
a. Eczema
b. Regurgitation
c. Vomiting
d. Painless bloody stools
5. Diagnosis is clinical and confirmed when bleeding ceases with dietary modifications
6. Treatment
a. In breastfed babies
i. Mother should eliminate all dairy and soy from her diet
b. In formula fed babies
i. Switch to hydrolyzed formula
7. Resolution
a. Visible bleeding resolves within 3 days
b. Complete resolution of occult blood takes up to 2 weeks

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COLIC
1. Excessive crying for ≥3 hours a day, ≥3 days a week, over a period of ≥3 weeks in an otherwise
healthy infant
2. Crying usually occurs at the same time of the day
a. Typically, early in evening
3. It resolves spontaneously by age 4 months
4. Management
a. Discuss calming techniques
b. Review feeding patterns

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PYLORIC STENOSIS

1. Presentation
a. Age 3-5 weeks
b. Signs of dehydration
c. Nonbilious, projectile emesis
2. Hypochloremic hypokalemic metabolic alkalosis
3. Thick, elongated pylorus on abdominal ultrasound
4. Treatment
a. First correct the electrolyte imbalance
i. It has shown to decrease postoperative apnea
b. Then do pyloromyotomy

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CYCLIC VOMITING SYNDROME

1. Treatment
a. Abortive
i. Triptans
b. Supportive
i. Antiemetics
ii. Rehydration
2. Children have gradual resolution of symptoms during adolescence

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MICROCOLON
1. Pathognomonic for Cystic fibrosis
2. Viscous meconium → obstruction of terminal ileum → underused and contracted colon
3. Administration of hyperosmolar enema (eg, Gastrografin) can break up inspissated meconium
and dissolve the obstruction
4. Surgery is required if therapeutic enema fails

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PEDIATRIC CONSTIPATION
1. Treatment
a. Behavioral modification
i. ↑ water intake
ii. ↑ dietary fiber intake
iii. Limiting cow’s milk to <24 oz per day
iv. Sitting on toilet after each meal
b. Oral Laxative (if behavioral modification fails)
i. Polyethylene glycol
ii. Mineral oil
c. Suppositories or enema (if oral laxatives fail)

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PELLAGRA
1. 4 Ds:
a. Diarrhea
b. Dermatitis
i. Photosensitive dermatitis
ii. Resembles sunburn
1. Erythematous
2. Well-demarcated
iii. Over time, the affected skin becomes hyperpigmented and thickened
c. Dementia, depression, distraction
d. Death
2. It is also associated with atrophic glossitis.
3. Treatment is niacin replacement

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PRUNE BELLY SYNDROME

1. Defect in abdominal musculature
2. Intestinal loops seen through thin abdominal wall
3. Intestines covered by skin

GASTROSCHISIS
1. Isolated defect
2. Herniation of uncovered bowel lateral to umbilicus
3. Features
a. Free-floating intestines in amniotic sac seen in prenatal ultrasound
b. Oligohydramnios
c. Continued exposure of intestines to amniotic fluid →chronic inflammation → intestinal
thickening
i. This leads to ↑ risk of necrotizing enterocolitis and bowel obstruction → short
bowel syndrome
4. Treatment
a. Cover with sterile saline dressings
b. Plastic wrap them to minimize heat and fluid losses
c. Decompress stomach by placing NG tube
d. Administer antibiotics
e. Surgical repair

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REYE SYNDROME
1. Due to aspirin ingestion in children
2. Features
a. Encephalopathy
b. Hepatic dysfunction
c. Cerebral edema
d. ↑ ICP

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EVALUATION OF BILIARY EMESIS

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MIDGUT VOLVULUS
1. Primary predisposing factor is malrotation of midgut in early fetal development
2. Presentation
a. Age <1 month
b. Initially abdomen is soft and not distended
c. If ischemia is present:
i. Bloody stools
ii. Bowel perforation
iii. Abdominal distension
iv. Peritonitis
d. Signs of ischemia or systemic decompensation (ie, shock) are an indication for
emergency laparotomy
3. Upper GI series findings
a. “Corkscrew” pattern → volvulus
4. Treatment is surgery (Ladd procedure)

Coffee Bean Sign

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JEJUNAL ATRESIA
1. Atresia of jejunum or ileum is because of a vascular accident in utero that causes necrosis and
resorption of fetal intestines
2. Risk Factors include poor fetal gut perfusion from maternal use of vasoconstrictive medications
such as cocaine and tobacco.
3. Bilious emesis is seen
4. Imaging
a. Triple bubble sign
b. Gasless colon
5. Treatment
a. First resuscitate and stabilize the patient
b. Then do surgical correction

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CHOANAL ATRESIA

1. Failure of posterior nasal passage to canalize completely

2. Cyanosis aggravated by feeding and relieved by crying
3. Condition may be:
a. Isolated
b. Associated with CHARGE syndrome
i. C: Coloboma
ii. H: Heart Defects
iii. A: Atresia Choanae
iv. R: Retardation of growth/development
v. G: Genitourinary anomalies
vi. E: Ear abnormalities/deafness
4. Bilateral choanal atresia present with cyclic cyanosis
5. Unilateral choanal atresia present with symptoms after first URTI.
6. Diagnosis
a. Failure to pass catheter
b. Confirmation is done by CT scan
7. Management
a. Place oropharyngeal airway and orogastric tube feeding
b. Definite treatment is treating the defect with surgery or endoscopy

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CHARGE SYNDROME

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TRACHEO-ESOPHAGEAL FISTULA
1. Presentation is immediately after birth
a. Excessive drooling
b. Choking
c. Coughing
d. Regurgitation with initial feeding attempts
e. Distended abdomen
2. Diagnosis
a. Prenatal ultrasound = polyhydramnios
b. Presence of enteric tube in the proximal esophagus on x-ray and inability to pass the
feeding tube into the stomach
3. Complication
a. Aspiration pneumonia
4. Workup for VACTERL association should be considered
a. V: Vertebral (Ultrasound sacrum)
b. A: Anal atresia (X-ray)
c. C: Cardiac defects (Echocardiogram)
d. T, E: TEF (Catheter X-ray)
e. R: Renal (VCUG)
f. L: Limbs (X-ray wrist)

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BILIARY ATRESIA

1. Presentation
a. Presentation is in first 2 months of life
b. Initially asymptomatic
c. Jaundice (↑ direct bilirubin)
d. Acholic stools (eg, light yellow, clay-colored, white)
e. Dark urine
f. Hepatomegaly
2. Labs:
a. ↑ direct bilirubin
b. Normal or mildly elevated AST and ALT
3. Diagnosis
a. First step → abdominal ultrasound
i. Findings: abnormal/absent gallbladder; absent bile duct; triangular cord
sign (fibrous remnants seen above the porta hepatis)
b. Liver biopsy → plugging and proliferation of bile ducts as well as portal tract edema
and hepatic fibrosis

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c. Gold Standard → cholangiogram

4. Treatment
a. Hepatoportoenterostomy (Kasai procedure)
i. Creation of path for bile to flow from liver to small bowel
b. Liver transplant

LIVER EDGE IN NEONATES

1. Liver edge >3.5 cm is abnormal in neonates.
2. Liver edge ≤3.5 cm is normal

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NECROTIZING ENTEROCOLITIS:
1. Can be caused by:
a. Prematurity
b. When there is reduced mesenteric perfusion, such as:
i. Congenital heart disease
ii. Hypotension
iii. Low birth weight (<1.5 kg)
iv. Enteral feeding (formula > breast milk)
2. Symptoms:
a. Feeding intolerance
b. Abdominal distension
c. Bloody stools
d. Bilious vomiting
e. HYPOTHERMIA (<36.5 C [97.7 F])
f. Leukocytosis
g. Metabolic acidosis
3. Radiology:
a. Pneumatosis intestinalis
b. Air in portal system
4. Complications
a. Perforation
b. Pneumoperitoneum (air is seen under the diaphragm)

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DEHYDRATION
1. Mild dehydration (3-5% volume loss). Presents with:
a. ↓ intake of fluid
b. ↑ fluid loss
c. Minimal or no clinical symptoms
2. Moderate dehydration (6-9% volume loss). Presents with:
a. ↓ skin turgor
b. Dry mucus membranes
c. Tachycardia
d. Irritability
e. Delayed capillary refill (2-3 seconds)
f. ↓ urine output
3. Severe dehydration (10-15% volume loss). Presents with:
a. Cool, clammy skin
b. Delayed capillary refill (>3 seconds)
c. Cracked lips
d. Dry mucus membranes
e. Sunken eyes
f. Sunken fontanelle
g. Tachycardia
h. Lethargy
i. Minimal or no urine output
j. Hypotension
k. Signs of shock

Treatment of dehydration:

1. Mild to moderate dehydration

a. Oral rehydration therapy
2. Moderate to severe dehydration
a. IV fluids (isotonic crystalloid)

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MECKEL DIVERTICULUM

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BILIARY CYST

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WILSON DISEASE

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PROPER BREASTFEEDING TECHNIQUE

1. Advantages:
a. Promotes maternal comfort
b. Ensures adequate infant nutritional intake
c. Facilitates long-term breastfeeding
2. Most breastfeeding patients experience nipple pain in the immediate postpartum period as they
become accustomed to nursing 8-12 times/day or more
a. This pain typically resolves after a few weeks
3. Nipple pain that worsens and persists between feedings is commonly due to nipple injury
caused by poor infant positioning and improper latch-on technique
4. Physical examination:
a. Bloody-appearing nipple discharge
b. Bruising, cracking, and blistering of nipple
c. Breast engorgement
i. This occurs because nipple pain limits breastfeeding, which eventually leads to
breast engorgement
5. Management:
a. Observation of breastfeeding and patient education
6. Differentials:
a. Intraductal papilloma
i. Unilateral breast involvement
ii. There is bloody nipple discharge but no nipple pain

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BREASTFEEDING ADVANTAGES AND CONTRAINDICATIONS

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WATER SOLUBLE VITAMINS

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Hematology & Oncology

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IRON DEFICIENCY ANEMIA Iron Studies in

Sideroblastic Anemia
• Increased serum iron
• Normal TIBC

Corrected Reticulocyte
Count Formula:
Corrected reticulocyte count
= % reticulocyte x
(Hematocrit/45%)

Risk factors for Lead

Poisoning:
1. Houses built before
1978
2. Eating dirt/paint chips
1. Microcytic anemia
2. Look for history of prolonged bleeding or poor dietary intake of iron in
older children
3. Risk factors for iron deficiency in infants: Bone marrow evaluation
a. Prematurity Consider bone marrow
b. Maternal iron deficiency evaluation only when
c. Early introduction of cow’s milk before age 1 year multiple cell lines are
4. In children, it is often caused by excessive cow’s milk intake (>700 ml depressed
[24 oz] daily)
a. <1 year age should NOT be started on cow’s milk
b. >1 year age should not consume excessive amount of cow’s
milk (i.e, >24 oz)
5. Lab findings
a. Decreased erythrocyte count
b. Reactive thrombocytosis (>400,000/mm3)
i. This occurs in response to low RBC
ii. RBC and platelets share a common progenitor cell
c. Increased RDW
d. Low reticulocyte count
e. Mentzer index >13 (due to decline in RBC count)
6. Diagnosis
a. Universal screening is recommended by age 1 year
b. Peripheral smear is NOT needed in initial workup

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c. Iron studies
i. Should not be needed in children with classic presentation
ii. Correct iron deficiency before evaluating for thalassemia with electrophoresis
because iron deficiency can lower hemoglobin A2 and mask the diagnosis
7. Treatment
a. Empiric oral iron therapy
i. Recheck in 4 weeks
ii. If hemoglobin has risen 1 g/dl, the oral therapy should be continued for 2-3
months after the hemoglobin normalizes to replete iron stores

IRON STUDIES IN MICROCYTIC ANEMIA

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IRON DEFICIENCY ANEMIA SCREENING

1. It is done at age 1 and can be considered once in adolescent girls due Hydroxyurea therapy:
It is given in sickle cell
to blood loss from menses
patients, not thalassemia
patients. It increases HbF
HEREDITARY SPHEROCYTOSIS >15% but may cause
myelosuppression

Hyperhemolytic crisis in
Sickle cell:
1. Severe, acute
normocytic hemolytic
anemia
2. Increased reticulocytosis

Anti-D immunoglobulin
in treatment of ITP:
It binds to Rh(D)-positive
erythrocytes and is thought
to saturate Fc receptors on
macrophages within the
reticuloendothelial system,
thereby limiting the ability
of reticuloendothelial
system to clear platelets.
1. Triad
a. Hemolytic anemia Spherocytes:
b. Jaundice Apart from hereditary
c. Splenomegaly spherocytosis, spherocytes
2. Coombs negative are also seen in autoimmune
3. Classic lab finding is elevated MCHC hemolytic anemia
4. Extravascular hemolysis
Burr Cells
5. Patients present with jaundice on the first day of life and this jaundice
Seen in ESRD and pyruvate
is refractory to standard management (eg, phototherapy)
kinase deficiency
6. Diagnosis
a. Eosin-5-maleimide binding test (flow cytometry) Factor XIII Deficiency:
b. Acidified glycerol lysis test Presents in neonatal period
with bleeding from the
umbilical stump

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DRUG-INDUCED HEMOLYTIC ANEMIA

1. Triggers:
a. NSAIDs
b. Cephalosporins
c. Penicillins
2. Mechanisms:
a. Most drugs cause hemolysis through a variety of mechanisms, for example:
i. Oxidative injury
ii. Complement-mediated lysis
b. Penicillins and cephalosporins trigger hemolysis when the drug binds directly to the
surface of erythrocytes and creates a hapten for IgG attachment
i. IgG-coated erythrocytes are then identified by the Fc receptor on splenic
macrophages, leading to partial or whole erythrocyte phagocytosis
(extravascular hemolysis).
ii. Intravascular hemolysis may also occur due to activation of complement
cascade

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PEDIATRIC STROKE
1. Common etiologies are:
a. Sickle cell disease (most common)
b. Prethrombotic disorders
c. Congenital cardiac disease
d. Bacterial meningitis
e. Vasculitis
f. Focal cerebral arteriopathy
g. Head/neck trauma
2. Patient presenting with acute, focal neurologic deficits should raise concerns for stroke

HEMORRHAGIC STROKE IN CHILDREN

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RUPTURED ARTERIOVENOUS MALFORMATION

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ALL

1. Most common cancer in children

2. Labs show bone marrow failure
3. Features
a. Anemia
b. Thrombocytopenia
c. Leukopenia (absolute neutrophil count <500/mm3)
d. Bone pain
i. Due to leukemic infiltration of bone marrow, especially of long bones
ii. Worse at night
e. Lymphadenopathy
f. Hepatosplenomegaly (occurs with extramedullary leukemic spread)
4. Presence of >25% lymphoblasts is diagnostic of ALL
5. Immunophenotyping of these cells with flow cytometry can determine the type of leukemia
6. Treatment involves multidrug chemotherapy

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AVASCULAR NECROSIS
1. Chronic, noninflammatory process
a. No erythema of joint
b. No warmth of joint
c. No leukocytosis
d. No elevated inflammatory markers
2. Most common site
a. Humeral head
b. Femoral head
3. Clinical features
a. Chronic groin, buttock or thigh pain
b. Initially occurs with weight bearing
c. Eventually progresses to occurring at rest
4. X rays of the hip
a. Normal in early stage
b. Crescent sign in advanced stage
5. MRI is the most sensitive test

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HEMOPHILIC ARTHROPATHY

1. It occurs due to recurrent hemarthroses

2. Hemosiderin deposition in the joint • Initial screening
a. Triggers synovial inflammation test for
b. Inflammation leads to fibrosis hemophilia is
c. Destruction of cartilage and bone Coagulation
3. Diagnosis studies and CBC
a. Severe hemophilic arthropathy can be visualized on X-ray
b. Earlier detection can be done by MRI
4. Prophylaxis
a. Factor concentrates

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WISKOTT-ALDRICH SYNDROME
1. Triad
a. Eczema
b. Microthrombocytopenia (small and low number of platelets)
c. Recurrent infections

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IMMUNE THROMBOCYTOPENIA
1. Preceded by viral infection
2. Presents with
a. Petechiae
b. Purpura
c. Mucosal bleeding
i. Epistaxis
ii. Hematuria
iii. GIT bleeding
3. Most cases resolve within 3 months
a. Adolescents with mild initial presentation and NO PRECEDING viral trigger are more
likely to develop chronic ITP
4. Labs
a. Isolated thrombocytopenia
i. Normal to large platelets present on peripheral smear due to increased platelet
turnover
5. Evaluation
a. Chronic ITP
i. Bone marrow examination
ii. Blood tests for:
1. Infection (eg, HIV, Hep C, CMV)
2. Autoimmune disorder (eg, SLE, thyroid disease)
b. If these evaluations are negative, manage chronic ITP along the same course as acute
ITP

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6. Management:

Immune
thrombocytop
enia

Children Adults

Cutaneous Mucosal
Cutaneous Mucosal
symptoms and bleeding or
symptoms bleeding
platelets >30k platelets <30k

Glucocorticoids Glucocorticoids,
Observe Observe
IVIG or Anti-D IVIG or anti-D

Note: give anti-D if Rh-positive and Coombs-negative

7. Second-line treatments (splenectomy, rituximab and thrombopoeitin receptor agonists) are

reserved for
a. Catastrophic bleeding
b. Chronic ITP refractory to intravenous immunoglobulin and glucocorticoids
8. Platelet transfusion is considered in very severe cases of ITP (e.g, intracranial bleeding) but it is
typically avoided as it can lead to further platelet destruction
a. Transfusion is the treatment for congenital platelet abnormalities which present with
very large platelets on smear

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FANCONI ANEMIA
1. Most common congenital cause of aplastic anemia
a. Presents at age 4-12 years
2. It is a DNA repair defect
3. Clinical Features:
a. Pancytopenia
i. Macrocytic anemia
ii. Leukopenia
iii. Thrombocytopenia
b. Short stature
c. Hyper/hypo-pigmentation
d. Hypoplastic thumbs with flattened thenar eminences or polydactyly
4. Diagnosis
a. Positive chromosomal breakage following DNA exposure to interstrand crosslinking
agents
5. Differentials
a. Benzene exposure
i. It can cause chromosomal breakage and aplastic anemia but no thumb and skin
findings are there
b. Diamond Blackfan Anemia
i. Triphalangeal thumb
ii. Pure red cell aplasia

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ALPHA THALASSEMIA

THALASSEMIA MINOR
1. Patients with thalassemia minor are most often diagnosed by universal screening for anemia
around age 1
2. Features
a. Low MCV
b. Normal-to-elevated total RBCs
c. Mentzer index (MCV/RBC) <13
d. Elevated reticulocyte count

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SICKLE CELL DISEASE

CRISIS IN SICKLE CELL DISEASE

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SPLENIC SEQUESTRATION CRISIS

1. Common finding in patients with Sickle cell who have not yet experienced autosplenectomy
a. Diagnose by looking for splenomegaly and signs of shock
2. Leads to splenomegaly and splenic sequestration of
a. RBC
i. Pallor
ii. Acute normocytic anemia
iii. Hypovolemic shock (as majority of blood is trapped in spleen)
iv. Compensatory reticulocytosis
b. Platelets
i. Thrombocytopenia
3. Treatment
a. Correction of hypovolemia with isotonic fluids
b. Small-volume transfusions
c. Eventual splenectomy

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APLASTIC CRISIS
1. Transient arrest of erythropoiesis
a. Leads to SEVERE anemia (<6 g/dl)
b. Occurs before age 15 because parvovirus outbreaks are most common in school-age
children
2. Decrease in RBC
a. Reticulocyte count is low
3. Platelets and WBC are normal
4. Secondary to Parvovirus B19
a. Although B19 symptoms are typical, aplastic crisis can occur without any preceding B19
symptoms
5. Findings
a. Pallor
b. Fatigue
c. Functional systolic murmur (due to hyperdynamic blood flow)
6. Treatment is blood transfusion

COMPLICATIONS OF SICKLE CELL TRAIT

1. Hematuria
2. Splenic infarction at high elevations
3. Sudden death with significant exercise

SICKLE CELL MANAGEMENT

1. Vaccine
a. Conjugate capsular polysaccharide vaccine against S pneumoniae
2. Penicillin
a. Twice daily administration until age 5 years.

DIFFERENTIAL DIAGNOSIS OF BONE PAIN IN SICKLE CELL DISEASE

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MEDICATIONS THAT TRIGGER HEMOLYSIS IN G6PD DEFICIENCY

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NEONATAL POLYCYTHEMIA

1. Increased RBC mass leads to increased uptake of glucose and calcium, hence causing:
a. Hypoglycemia
b. Hypocalcemia
2. Treatment
a. Hydration by oral feeds
b. Glucose-containing parenteral fluids

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DIAMOND-BLACKFAN ANEMIA
1. Clinical features
a. Macrocytic anemia
i. Reticulocytopenia
b. Craniofacial abnormalities
i. Mild hypertelorism
ii. Flat nasal bridge
c. Triphalangeal thumbs
2. Other features include:
a. Short stature
b. Webbed neck
c. Cleft palate
3. Normal platelets and WBC
4. Treatment
a. Mainly corticosteroids
b. RBC transfusion in refractory cases

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INHIBITOR DEVELOPMENT IN FACTOR VIII DEFICIENCY:

1. Approximately 25% of patients with severe hemophilia undergo inhibitor development
a. Suspect inhibitor development in case of:
i. Increased bleeding frequency
ii. Hemorrhage refractory to treatment
2. Regular screening for inhibitor development is performed when:
a. Patients with hemophilia receive factor infusions
b. When inhibitor is clinically suspected
3. Treatment
a. Bypassing products
i. In case of factor VIII inhibitor, give recombinant activated factor VII, activated
prothrombin complex concentrates
ii. These agents work downstream of coagulation cascade

TRANSIENT ERYTHROBLASTOPENIA OF CHILDHOOD

1. Presentation: 6 months to 5 years
2. Features
a. Normocytic normochromic anemia
i. Hb level 3-8 g/dl
b. Extremely low reticulocyte count
c. Normal WBC and platelets

SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS

1. Presents in early childhood
2. Look for:
a. Large joint pain with rash and high fever
3. Treatment
a. Aspirin

*Note: aspirin in children can only be given in Kawasaki Disease and Juvenile Idiopathic Arthritis*

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ANEMIA OF PREMATURITY

1. Normally when a baby is born, EPO concentration decreases in the blood because of high
oxygen supply to tissues
a. Hence, RBC count decrease occurs at age 2-3 months (according to RBC age)
2. But if a baby is born preterm, it gets anemia of prematurity because:
a. Short RBC life span (40-50 days)
b. Frequent phlebotomy in NICU
3. Most cases are asymptomatic
4. Anemia of prematurity is a diagnosis of exclusion
5. Normocytic normochromic anemia
6. Treatment
a. Minimize blood draws
b. Iron supplementation
c. RBC transfusion
i. In symptomatic babies
ii. It will further suppress EPO levels and delay recovery
iii. Supplemental EPO is not effective

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VITAMIN K DEFICIENCY

HEMOGLOBIN ELECTROPHORESIS FINDINGS IN SICKLE CELL AND THALASSEMIA:

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HEMOGLOBIN CHAINS:

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 PEDIATRICS

FOLATE DEFICIENCY ANEMIA

HEMOLYTIC UREMIC SYNDROME

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APLASTIC ANEMIA

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TRANSFUSION REACTIONS

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 PEDIATRICS

TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD

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Infectious Diseases

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INFECTION CONTROL ISOLATION PRECAUTIONS

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MEASLES

1. Maculopapular rash along with

a. Cough
b. Coryza
c. Conjunctivitis
d. Koplik spots
2. Symptoms manifest 1-3 weeks after inhalation of infectious respiratory particles
3. Prevention
a. Airborne precaution
i. Negative pressure room

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ii. N95 face mask

4. Prophylaxis
a. 2 doses of live attenuated measles vaccine at:
i. Age 1
ii. Age 4
b. For planned international travel, an additional dose between age 6 and 11 months is
also recommended

5. Measles due to vaccine administration can also occur

a. It is self-limiting
b. It can spread to other people. Hence, a patient with a rash after MMR vaccine should
avoid contact with immunocompromised patients

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IMPETIGO
1. Features
a. Pustular
b. Painful
c. Non-itchy
d. Honey-crusted lesion
2. Systemic symptoms are absent
3. Increased risk in patients with underlying skin problems such as
a. Eczema
b. Abrasion
c. Insect bite
4. Treatment
a. Oral Clindamycin
5. Differentials
a. Chicken pox
i. Vesicular
ii. Pruritic
b. Eczema Herpeticum
i. Superinfection of HSV in areas of severe eczema
ii. Rash progresses rapidly
1. Vesicular
iii. Associated with fever

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LOCALIZED NON-BULLOUS IMPETIGO

1. Risk factors for impetigo
a. Warm and humid climate
b. Poverty/crowding
c. Poor personal hygiene
d. Pre-existing skin trauma/inflammation
i. Insect bite
ii. Eczema
2. Features
a. Multiple painful pustules
b. Pustules rupture → golden-yellow “honey” crust
c. Local lymphadenopathy
d. Fever is unusual
3. Treatment
a. Topical antibiotics (eg, mupirocin)
b. Oral antibiotics (eg, cephalexin, dicloxacillin, clindamycin) are indicated when topical
therapy is impractical because of widespread involvement
4. Diagnosis
a. Clinical
b. Antistreptolysin O is not helpful because it takes weeks to get results. It is helpful in
complications (eg, PSGN)

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BULLOUS IMPETIGO

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TETROLOGY OF FALLOT & BRAIN ABSCESS

1. Right to left shunt allows bacteria to bypass pulmonary circulation where they are normally
phagocytosed → ↑risk for hematogenous spread of bacteria → brain abscess
2. Symptoms
a. Headache that is severe and nonresponsive to OTC pain medications is the most
common presenting symptom
b. Vomiting early in the morning
c. Fever
d. Focal neurologic changes
e. Seizures
3. Diagnosis
a. Brain imaging

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RESPIRATORY TRACT INFECTIONS IN CHILDREN

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PERTUSSIS
1. Clinical phases
a. Catarrhal
i. 1-2 weeks
ii. Mild cough
iii. Rhinitis
b. Paroxysmal
i. 2-6 weeks
ii. Cough with inspiratory “whoop”
iii. Subconjunctival hemorrhage due to pressure
iv. Facial petechiae
v. Posttussive emesis
c. Convalescent
i. Weeks to months
ii. Symptoms resolve gradually
2. Patients appear remarkably well between coughing episodes but infants age <6 months are at
high risk for life-threatening apnea and death
3. Diagnosis:
a. Lymphocytosis
b. Pertussis culture
c. PCR
4. Treatment is macrolide
a. Should be initiated based on clinical suspicion, without waiting for confirmatory
diagnosis
5. Prevention:
a. Vaccination at following schedule:
i. Age 2, 4, 6, and 12-15 months and 4-6 years

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PERTUSSIS PROPHYLAXIS OF CLOSE CONTACTS

1. Antimicrobial prophylaxis
a. Macrolides
i. Age ≥1 month: azithromycin, clarithromycin or erythromycin
ii. Age <1 month: only azithromycin
1. Erythromycin use is associated with pyloric stenosis
2. Clarithromycin safety data is not available
2. Give vaccination according to immunization schedule to those who are not fully immunized
3. Respiratory isolation is necessary only during first 5 days of antibiotic therapy
a. Hospitalization is indicated in:
i. Infants <3 months due to high risk of apnea
ii. Any patient with severe paroxysms that impair feeding or are complicated by
pneumonia, seizures or other comorbidities

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PRIMARY TUBERCULOSIS

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NONSPECIFIC SYMPTOMS IN CONGENITAL INFECTIONS

1. Jaundice and hepatosplenomegaly
a. Due to fetal reticuloendothelial activation
2. Blueberry muffin rash
a. Due to extramedullary hematopoiesis
3. Growth restriction
a. Due to fetal inflammation

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RUBELLA

1. Some patients also have petechiae or erythematous papules, known as Forchheimer spots, on
the soft palate

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NEONATAL TETANUS

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HERPANGINA VS HERPETIC GINGIVOSTOMATITIS

1. Ulcers in the back of mouth → herpangina
2. Ulcers in the front of mouth → herpetic gingivostomatitis

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SEPTIC ARTHRITIS IN INFANTS

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PEDIATRICS

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 PEDIATRICS

SEPTIC ARTHRITIS IN CHILDREN

1. Don’t give empiric antibiotics BEFORE blood culture or synovial fluid culture because it might
lead to false-negative results.
2. If patient fails to improve with arthrocentesis and 48 hours of antibiotic therapy, do an MRI to
evaluate for concomitant osteomyelitis
3. Do an emergency surgical drainage to prevent permanent joint destruction
4. Debridement and irrigation of the joint space is the most important intervention in preventing
long term disability.
5. There may be joint effusion seen on ultrasound or MRI which can make you confuse it with
transient synovitis. But remember, there is no fever in transient synovitis and it has a short
course. Also, age group is typical (3-8 years)

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VZV

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 PEDIATRICS

NEONATAL VZV INFECTION

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 PEDIATRICS

VZV VACCINATION
1. Infants <1 year (outside of neonatal period) are not eligible for VZV vaccine or immunoglobulin
because they are at lower risk than neonates or older children
2. VZV vaccine is for immunocompetent
3. VZV immunoglobulin is for immunocompromised (including neonates whose mothers developed
infection 5 days before to 2 days after delivery)
a. Viral culture at 24 hours isn’t helpful in neonates with suspected VZV infection because
incubation period for varicella is 2-3 weeks and viral testing at 24 hours is likely to be
negative

VACCINE STRAIN VZV VS WILD STRAIN VZV

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HERPES ZOSTER OTICUS

1. Also called Ramsay Hunt Syndrome
2. Classic triad:
a. Ear pain
b. Facial weakness
c. Vesicular rash in the external auditory canal
3. Reactivation of latent VZV in the geniculate ganglion can lead to facial nerve dysfunction
4. Subsequent spread to the vestibulocochlear nerve (CN VIII) can lead to following problems:
a. Auditory disturbances:
i. Hearing loss
ii. Hyperacusis
iii. Tinnitus
b. Vestibular disturbances:
i. Vertigo
ii. Nausea/vomiting
5. Treatment:
a. Corticosteroids + antivirals

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PRESEPTAL VS ORBITAL CELLULITIS

• Give clindamycin for preseptal orbital cellulitis

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RETROPHARYNGEAL ABSCESS

1. Occurs as a complication of URTI

2. Clinical features
a. Dysphagia
b. Odynophagia
c. Neck pain with extension
d. Muffled voice with no uvular deviation
3. Presentation common in 6 months to 6 years of age
4. Diagnosis
a. Lateral neck x-ray → widening of prevertebral space
b. CT with contrast confirms the diagnosis

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HIV IN INFANCY
1. It presents with
a. Normal absolute lymphocyte count
b. ↓ CD4+ T lymphocyte count
2. Persistence of HIV antibody after age 18 months is confirmatory of infection

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INFECTIOUS MONONUCLEOSIS
1. Prolonged fever and fatigue in the setting of pharyngitis, splenomegaly and posterior cervical
lymphadenopathy
2. Severe tonsillar enlargement → acute airway obstruction
3. Treatment includes corticosteroids to ↓airway edema
4. Rash forms after amoxicillin or ampicillin administration
a. Rash is polymorphous or maculopapular
b. Rash typically spares extremities and occurs on trunk
c. Rash is NOT considered a true drug allergy as patient can receive the same antibiotic in
future
5. Complications:
a. Acute airway obstruction
b. Autoimmune hemolytic anemia & thrombocytopenia
c. Splenic rupture

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OSTEOMYELITIS
Organism Etiology
Group B Streptococcus, E. coli • Neonatal osteomyelitis (age < 2 months)
Staphylococcus aureus • Most common overall
Pseudomonas aeruginosa • Osteomyelitis of foot after a puncture wound
of the plantar surface
• IV drug abuse
Salmonella • Osteomyelitis in patients with sickle cell
disease

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ACUTE BACTERIAL GASTROENTERITIS

1. Management:
a. DO NOT give antibiotics if the patient has mild disease, and only do close follow-up
i. In addition, empiric antibiotics increase the risk of life-threatening hemolytic
uremic syndrome in patients with bloody diarrhea due to E coli O157:H7
b. Give antibiotics if patients are severely ill (eg, extraintestinal disease,
worsening/prolonged symptoms, hospitalized)

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SHIGELLA GASTROENTERITIS
1. Seizures in the setting of an acute bacterial gastroenteritis are most closely associated with
Shigella. Seizures resolve spontaneously
a. It most commonly causes mucoid diarrhea if often but NOT ALWAYS bloody
2. Seizures can also occur due to hypovolemic hyponatremia but they won’t resolve on their own
until hyponatremia is corrected

CAMPYLOBACTER GASTROENTERITIS

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E COLI DIARRHEA

SALMONELLA GASTROENTERITIS

1. Another cause of spread of salmonella in USA is inadequate refrigeration of food as warm

temperatures are ideal for Salmonella growth

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GIARDIASIS

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VIRAL GASTROENTERITIS

NOROVIRUS GASTROENTERITIS
2. It is the most common cause of gastroenteritis in USA
3. Symptoms begin 1-2 days after viral exposure:
a. Nonbloody, nonbilious emesis
b. Watery diarrhea
c. Abdominal pain
4. Treatment:
a. Supportive treatment
b. Symptoms resolve within 2-3 days
5. Differentials:
a. Bacillus cereus and Staph aureus:
i. Vomiting is the predominant feature
ii. Symptoms begin within 6 hours

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DIFFERENTIALS OF TRAVEL-ASSOCIATED DIARRHEA

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CONGENITAL SYPHILIS
1. Symptoms
a. Rhinorrhea (snuffles)
b. Diffuse maculopapular rash that involves palms and soles
i. It can desquamate or become bullous
c. Abnormal long-bone radiographs (eg, metaphyseal lucencies)

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CMV
1. CMV infection is common among children age 1-4 years
a. Transmission in the day care or preschool → major risk factor for infection of pregnant
mothers
2. Transmission: bodily fluids
a. Urine
b. Saliva
3. Precautions: standard precautions
a. Hand hygiene
b. Glove use
4. Congenital CMV
a. Microcephaly
b. Periventricular calcifications
c. Hydrocephalus ex vacuo
d. IUGR
e. Hepatosplenomegaly
f. Jaundice
g. Thrombocytopenia
h. Sensorineural hearing loss (Congenital CMV is the most common cause of nonhereditary
sensorineural hearing loss in children)
5. Differentials
a. Toxoplasmosis
i. Macrocephaly
ii. Diffuse parenchymal calcifications

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TREATMENT OF LYME DISEASE

1. Early localized Lyme disease
a. Oral doxycycline
i. Drug of choice
ii. Treats coexisting Anaplasma phagocytophilum
iii. Shouldn’t be given to children age <8 years
b. Oral cefuroxime or amoxicillin
i. For children age <8 years
ii. For pregnant women
2. Lyme meningitis and heart block (early disseminated)
a. IV ceftriaxone
3. Lyme disease prevention
a. Tick repellant
b. Protective clothing
c. Tick checks
d. Bathing
4. Prophylaxis with doxycycline is reserved for patients who have tick attachment for >36 hours

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NEONATAL SEPSIS
1. Findings
a. Hypothermia
b. Lethargy
c. ↓ WBCs with left shift
2. Risk factors
a. Maternal colonization with Group B streptococcus
b. Prolonged rupture of membranes
c. Chorioamnionitis
3. Decreases activity or poor feeding can be the earliest signs of serious infection
4. Neonates can have fever or hypothermia in sepsis
5. Meningitis symptoms are different in neonates
a. Irritable
b. Lethargy
c. Hypotonic

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NEONATAL SEPSIS WITH GROUP B STREPTOCOCCUS

1. Most common cause of both early onset (age ≤7 days) and late onset neonatal sepsis as well as
meningitis
2. Early-onset GBS disease (≤7 days)
a. Due to vertical transmission
b. Can be prevented by intrapartum antibiotic prophylaxis
i. Prophylaxis is not necessary in case of C-section
3. Late-onset GBS disease
a. Due to horizontal transmission (eg, person to person)

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VIBRIO VULNIFICUS
1. Exposure is due to swimming in brackish water off the New England coast
2. Symptoms
a. Contact: cellulitis
b. Ingestion: sepsis with hypotension and bullous skin lesions

PINWORM
1. Features
a. Nocturnal perianal pruritis
2. Other symptoms are:
a. Abdominal pain
b. Nausea
c. Vomiting
d. Vulvovaginitis

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CONGENITAL TOXOPLASMOSIS

1. Chorioretinitis is seen in adulthood due to reactivation of infection

2. Diagnosis
a. Serology = presence of infant IgM or IgA is confirmatory
3. Treatment
a. Pyrimethamine, sulfadiazine and folate for 1 year
4. Differentials
a. Zika virus
i. Microcephaly
b. Congenital CMV
i. Microcephaly
ii. Periventricular calcifications

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UNILATERAL LYMPHADENITIS
1. Most common causes of acute unilateral lymphadenitis in children are:
a. Staph aureus
b. Strep pyogenes
2. Submandibular nodes are most commonly affected
3. Features
a. Staph aureus
i. Age <5 years
ii. Nontoxic appearing patient
iii. Node is 3-6 cm in size
b. M. avium intracellulare
i. Age <5 years
ii. Nontender lymphadenopathy
iii. Size <4 cm
iv. Skin over the lymph node thins → violaceous color

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NORMAL VS ABNORMAL LYMPH NODES

ECZEMA
1. Dry
2. Scaly
3. Erythematous
4. Pruritic
5. Not associated with fever

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BACTERIAL MENINGITIS

1. Most common cause of bacterial meningitis in children age >1 month:

a. Strep pneumo
b. Neisseria meningitidis
2. Lymphocytic predominance is seen in following bacterial meningitis
a. TB = differentiate by VERY LOW glucose in CSF
b. Syphilis
3. Do CBC, Blood cultures and then LP before prescribing empiric antibiotics.
a. This is because giving antibiotics before LP will sterilize CSF and we can’t make a definite
diagnosis and child will have prolonged antibiotic exposure
b. However, if it is a critical situation (eg, hypotension or status epilepticus) or the patient
cannot receive LP immediately should receive antibiotics first.

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NEISSERIA MENINGITIDIS POSTEXPOSURE PROPHYLAXIS

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STREPTOCOCCUS PNEUMONIA SEPSIS IN SICKLE CELL DISEASE

1. It is the MOST COMMON cause of sepsis in patients with sickle cell disease
2. Even in case of immunization, sepsis is likely because of infection from non-vaccine serotypes
3. Therefore, patients should take penicillin until age 5

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SCARLET FEVER

1. Occurs in children who have pharyngitis due to Group A streptococcus

2. Features
a. Preceding Symptoms: these precede the rash
i. Fever (duh!)
ii. Sore throat
iii. Headache
b. Rash
i. Finely papular “sandpaper” rash
ii. Spreads across the trunk, groin and axillae
iii. More pronounced in SKIN FOLDS
iv. Desquamation of rash once illness resolves → peeling of hands and feet
c. Oral findings
i. Tonsillar exudates
ii. Palatal petechiae
iii. Strawberry tongue
iv. Circumoral pallor

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d. Tender, shotty, anterior cervical lymphadenopathy is also another finding

1. Differentials
a. Scalded skin syndrome
i. Superficial flaccid bullae are seen which are followed by exfoliation of skin
ii. Most common in infancy and rarely occurs after age 5 years

SCALDED SKIN SYNDROME

1. Progress of disease:
a. Prodrome
i. Fever
ii. Irritability
iii. Skin Tenderness
b. Generalized erythema
c. Flaccid blisters/bullae
i. Located in flexural areas exposed to mechanical pressure (eg, axilla, groin)
ii. Nikolsky sign +
iii. Epidermal shedding +
2. Mortality rate in children is low and resolves in 1-2 weeks
3. There is no mucosal involvement generally
4. Differentials:
a. Scarlet Fever: Nikolsky sign (-)
b. Toxic Epidermal Necrolysis
i. Greater than 30% body involved
ii. Mucosal involvement
iii. After taking medication
c. Bullous impetigo
i. Localized
ii. When ruptured, blisters leave honey crusted lesions

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BACTERIAL SINUSITIS
1. Presents with
a. Persistent symptoms of nasal discharge, congestion and cough
b. Symptoms last 10-30 days
c. High fever
d. Purulent nasal drainage for at least 3 days
2. Most common predisposing factor is viral URTI
3. Diagnosis
a. Clinical
b. CT is done to evaluate complications such as orbital cellulitis or intracranial extension
i. Sinus opacification
ii. Mucosal thickening
iii. Air fluid levels
4. Treatment
a. Amoxicillin + clavulanic acid

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MUMPS
1. Symptoms
a. Parotitis
i. Unilateral or bilateral
b. Orchitis
i. Can lead to infertility
c. Pancreatitis
d. Aseptic meningitis
i. Usually benign
e. Sensorineural hearing loss
i. Often transient but can lead to deafness

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ACUTE RHEUMATIC FEVER

1. It can present with carditis:

a. Friction rub
b. Prolonged PR interval
c. Diffuse ST elevations
2. Also look for continuous hand wringing (rapid, irregular jerks) → chorea
a. Sydenham chorea has the longest latency period
i. 1-8 months
3. Diagnosis is based on clinical or laboratory evidence of a preceding event of group A
streptococcus infection along with one of the following:
a. 2 major Jones criteria
b. 1 major and 2 minor criteria
4. Erythema marginatum (annular pink rash with sharp, raised edges and central clearing)
5. ↑acute phase reactants

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CAT SCRATCH DISEASE

1. Look for:
a. NONTENDER papule at scratch site
b. TENDER regional lymphadenopathy
i. Lymphadenopathy takes 1-2 months to resolve
2. Treatment
a. Usually self-resolving
b. Azithromycin may be needed

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SCABIES
1. Intensely pruritic rash
2. Small, erythematous papules or vesicles, as well as burrows
3. Incubation period: 3-6 weeks
4. Prevention:
a. Treating household contacts
b. Decontaminating linens (hot water washing of clothing and bedsheets)
5. Treatment:
a. Topical 5% permethrin
b. Oral ivermectin

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RABIES
1. Incubation period is 1-3 months
2. Postexposure prophylaxis
a. Rabies immune globulin
b. Rabies vaccine

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NEONATAL HEPATITIS B

1. 90% of patients with vertical transmission progress to chronic HBV infection which leads to:
a. Cirrhosis
b. HCC
c. Liver failure
2. Prevention includes HBV vaccine and HBIG
a. Give HBIG first and then give HBV vaccine
b. These should be administered WITHIN 12 HOURS of birth, regardless of birth weight or
clinical condition
c. Don’t do serology or LFTs before administering prophylaxis
i. Do serology after prophylaxis to check if they have been infected or not
ii. If they are infected, do LFTs to check for liver function
3. HBV is not a contraindication for breastfeeding (only HIV is the absolute contraindication in the
developed world. Contraindications for direct breastfeeding include herpetic breast lesions and
peripartum varicella infection)

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FOODBORNE DISEASES

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MALARIA

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PERITONSILLAR ABSCESS

NEONATAL CONJUNCTIVITIS

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JOINT FLUID CHARACTERISTICS

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Multisystem

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STD SCREENING
1. It tests for Chlamydia and Neisseria
2. It should be done in following:
a. All sexually active women age ≤24 years
b. Any person with a new partner in past 2 months
c. Any person with multiple partners
d. Any person with history of STIs
e. Any person with illicit drug use
f. Any person who is incarcerated
g. Any person who has contact with a sex worker
3. Undetected and untreated infections can lead to PID
4. Best screening test is nucleic acid amplification test
a. Patients diagnosed with infection should receive antibiotics IMMEDIATELY and should
refrain from sex until treatment is completed
b. All sexual partners from the preceding 2 months should also be tested and treated for
infection

UNIVERSAL SCREENING FOR DYSLIPIDEMIA

1. Recommended at following ages in normal individuals:
a. Age 9-11
b. Age 17-21
c. The reason is that lipid levels are most stable before and after puberty
2. Screening outside these periods should occur in patients with high risk for cardiovascular
diseases, which includes:
a. History of obesity
b. History of diabetes
c. History of tobacco exposure
d. Family history of premature coronary disease
e. Men age ≥35

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MCCUNE-ALBRIGHT SYNDROME
1. Mutation in GNAS gene → constant G
protein activation → overproduction
of pituitary hormones
2. This leads to:
a. Precocious puberty (FSH, LH)
i. It is GnRH-
independent (ie,
peripheral)
b. Thyrotoxicosis (TH)
c. Acromegaly (GH)
d. Cushing Syndrome (ACTH)
3. Patient also presents with café-au-lait
macules which are:
a. Unilateral
b. Irregular
c. Typically less in number
4. Patient can also have Polyostotic
Fibrous Dysplasia
a. Can lead to fractures
5. Differentials
a. NF1
i. Café-au-lait macules
are REGULAR and
NUMEROUS (≥6)
ii. Axillary freckling is
present

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DUCHENNE MUSCULAR DYSTROPHY

1. Should be suspected in boys age <5 with proximal muscle weakness

2. Signs
a. Gower sign positive
b. Bilateral calf pseudohypertrophy
3. Lab findings
a. ↑ Creatine phosphokinase
b. ↑ aldolase levels
c. These are elevated even before clinical manifestation
d. As disease progresses and more muscle is replaced by fat and fibrosis, these levels
eventually drop
4. Diagnosis
a. Genetic testing: absent dystrophin gene
i. Best test to confirm
b. Muscle biopsy: replacement by fat and fibrosis
c. Immunochemistry staining: absent dystrophin protein
5. Duchene muscular dystrophy can lead to dilated cardiomyopathy and conduction
abnormalities due to progressive fibrosis of cardiac muscles
a. Hence, echocardiogram and ECG are done at the time of diagnosis to screen for these
heart pathologies

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EDWARD’S SYNDROME
1. Trisomy 18
2. Symptoms
a. IUGR
b. Microcephaly
c. Cardiac defects (eg, VSD)
d. Closed fist with overlapping fingers
e. Micrognathia
f. Prominent occiput
g. Rocker-bottom feet
h. Severe intellectual disability

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PATAU SYNDROME

CRI-DU-CHAT
1. 5p deletion
2. Cat-like cry is heard
3. Appearance
a. Protruding metopic suture (classic finding)
b. Hypotonia
c. Short stature
d. Hypertelorism
e. Wide and flat nasal bridge
f. Intellectual disability

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MARFAN SYNDROME
1. Autosomal dominant condition
2. Mutation of the fibrillin-1 gene
3. Signs & Symptoms
a. Joint hypermobility
b. Skin hyperelasticity
c. Long fingers (thumb sign +)
d. Pectus excavatum
e. Scoliosis/kyphosis
f. Long face
g. High arched palate
h. Crowded teeth
i. Ectopia lentis (upward dislocation)
j. Iridodonesis (a rapid contraction and
dilation of the iris)
k. Myopia (from elongation of the globe)
l. Aortic root dilation
i. Most life-threatening finding
ii. Requires close monitoring with
echocardiography for the
development of aneurysms and
aortic arch dissection
m. Mitral valve prolapse
4. Differentials
a. Homocystinuria
i. Downward lens dislocation
ii. Fair complexion
iii. Intellectual disability
iv. Thromboembolic events
b. Congenital contractural arachnodactyly
i. Autosomal dominant
ii. Mutations of fibrillin-2 gene
iii. Symptoms
1. Tall stature
2. Arachnodactyly
3. Multiple contractures involving large joints

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PRADER-WILLI SYNDROME
1. Signs & Symptoms
a. Excessive eating
b. Hypogonadism
c. Almond-shaped eyes
2. Loss of paternal copy of chromosome
15q11-q13
a. Leads to Maternal Uniparental
Disomy
3. Management
a. Karyotype → methylation
studies → FISH → Microsatellite
Probe →Genetic testing
(confirmatory)
b. Management revolves around
obesity and its complications

HEMOLYTIC UREMIC SYNDROME

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Musculoskeletal System

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SUPRACONDYLAR HUMERUS FRACTURE

1. Most common type of pediatric elbow fracture
a. Occurs in age 2-7 years
2. History is significant for a high-impact fall onto an outstretched arm with elbow hyperextended
3. There may be a fracture line and displacement or an occult fracture
4. Occult Fracture
a. Inflammation surrounding the fracture displaces the synovial fat
b. X-ray:
i. Wide anterior fat pad (normally narrow or absent)
ii. Posterior fat pad (normally absent)
5. Complications
a. Neurovascular Injury
b. Compartment Syndrome
i. Results from ↑ pressure (i.e. swelling) within an anatomic space
ii. ↑ risk is seen in:
1. Displaced fractures
2. Patients with concomitant forearm fracture
iii. It should be suspected in a patient with INCREASING swelling and pain which is
unresponsive to escalating analgesics
iv. Additional red flags for compartment syndrome are “4 Ps”
1. Pallor
2. Paresthesia
3. Pulselessness
4. Paralysis
v. Initial management
1. Removal of bandages
2. Measuring compartment pressure
3. Emergency fasciotomy

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TODDLER’S FRACTURES
1. These are the spiral fractures of the distal tibia and can be seen
in ambulatory children age ≤3
2. Presentation:
a. Pain
b. Limp
c. Refusal to bear weight
d. Fracture site tenderness and leg swelling
3. Examination:
a. Pain elicited with ankle dorsiflexion or twisting of knee
and ankle in opposite directions is characteristic
4. Diagnosis:
a. Anteroposterior and lateral radiographs:
i. May be normal initially but usually show a
hairline fracture
5. Treatment:
a. Immobilization and pain control

FRACTURE COMPLICATIONS
FRACTURE COMPLICATIONS
Fracture that interrupts blood supply (eg, femoral head Avascular Necrosis
fracture)
Open fracture Chronic osteomyelitis
Growth plate (physis) fracture Limb length discrepency
Severely displaced radial fracture Limited range of supination and
pronation
Greenstick fracture No long-term complications

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OSGOOD-SCHLATTER SYNDROME
1. Benign cause of knee pain caused by overuse in
young adolescents
2. Periods of rapid growth in children → quadriceps
muscles pull on insertion site of patellar tendon
→ leads to traction apophysitis → leads to
elevation and chronic avulsion of tibial tubercle
3. Features include PROGRESSIVE PAIN
a. ↑ with activity
b. ↓ with rest
c. More often unilateral
d. Prominence and tenderness over the
tibial tubercle
e. Pain can be reproduced by squatting or
extending knee against resistance
4. Differentials

Disease Differentiating Point from OSS

Patellar tendinitis
Patellofemoral Pain
Prepatellar Bursitis
Tibial osteomyelitis
Point tenderness is present at the inferior pole of
patella, instead of tibial tuberosity
Pain localized to the patella, associated with
sensation of instability or “buckling” of knee
History of direct, chronic trauma of anterior knee.
Pain with direct pressure and superficial swelling
over the patella
Systemic symptoms are present alongwith local
symptoms and refusal to bear weight on affected
extremity
Pain does not improve with rest

RADIAL HEAD SUBLUXATION

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PHYSIOLOGIC GENU VARUM

1. Normal bowing of legs from birth to age 2 years

a. Especially noticeable when child begins to walk around age 12-15 months
2. Features
a. Symmetric bowing
b. Normal stature
c. No leg length discrepancy
d. No lateral thrust when walking

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OSTEOID OSTEOMA

1. X-ray:
a. Small, round lucency with sclerotic margins and central ossification
2. Surgical resection is reserved for patients with refractory symptoms

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EWING SARCOMA

1. Second most common malignant bone tumor of childhood after osteosarcoma

2. Location:
a. Pelvis
b. Diaphyses of long bones
3. Clinical Presentation:
a. Localized
i. Subacute or chronic pain and swelling
ii. Pain is worse at night and with activity
iii. Local erythema and warmth are common findings
b. Systemic: occur with metastatic disease
i. Fever
ii. Weight Loss
iii. Leukocytosis
iv. Elevated inflammatory markers
4. Imaging
a. Onion skinning (central lytic lesion with cortical layering)
b. Moth-eaten appearance with extension into soft tissue
5. Treatment
a. Chemo
b. Radiation
c. Surgery

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DEVELOPMENTAL DYSPLASIA OF HIP

1. Treatment
a. Pavlik Harness
i. A splint that holds the hip in flexion and abduction while preventing extension
and adduction

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SLIPPED CAPITAL FEMORAL EPIPHYSIS

1. Commonly seen in obese adolescents
2. Patient presents with:
a. Groin pain
b. Knee pain
c. Limping
d. Loss of abduction and
internal rotation of the hip
e. External rotation of the thigh
when the hip is flexed
3. Look for knee pain with restricted hip
movements
4. Diagnosis
a. Frog-leg lateral-view X-ray of
the hip is diagnostic
5. Treatment
a. Surgical pinning of the slipped epiphyses where it lies
i. Lessens the risk of avascular necrosis of the femoral head and chondrolysis

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PANNER DISEASE
1. Osteochondrosis of the capitellum
2. Seen in adolescents who are actively engaged in sports that involve throwing
3. Features
a. Chronic dull pain
b. Crepitation
c. Loss of pronation and supination

SERUM SICKNESS-LIKE REACTION

1. Symptoms occur 1-2 weeks after exposure
2. Etiology includes:
a. Immune complex formation
b. Antibiotics
i. Beta lactam drugs
ii. Sulfa drugs e.g. TMP-SMX
c. Acute hepatitis B
3. Clinical features
a. Fever
b. Urticarial
c. Polyarthralgia with NO MUCOSAL INVOLVEMENT
d. Lymphadenopathy
4. Lab findings
a. Nonspecific hypocomplementemia
b. ↑ inflammatory markers (ESR, CRP)

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LYME DISEASE

1. Due to B burgdorferi
2. Diagnosis can be confirmed by
a. ELISA
b. Western Blot Testing

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RESTLESS LEG SYNDROME

1. Associated with Iron Deficiency Anemia
2. Characterized by strong urge to move the leg

GROWING PAINS

1. Children with growing pains often have LOWER PAIN THRESHOLD and MORE DEPRESSIVE
SYMPTOMS when compared to other children

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TRANSIENT SYNOVITIS
1. Common cause of HIP PAIN in age 3-8 years
2. Symptoms develop days to weeks after mild viral illness or posttraumatic
a. Pain
b. ↓ range of motion
c. Limp
3. Examination
a. Well appearing
b. Afebrile
c. Affected hip is flexed, slightly abducted and externally rotated to relieve pressure in the
joint space
4. Labs
a. Normal or slightly elevated WBC
b. Normal or slightly elevated inflammatory markers
5. Diagnosis
a. Ultrasound of hip joints may show small bilateral effusions even if symptoms are
unilateral
i. If ultrasound shows unilateral effusion, arthrocentesis is required to evaluate
for septic arthritis
6. Treatment
a. Rest
b. NSAIDs
c. Children recover within 1-4 weeks
7. Differentials:
a. Iliopsoas bursitis:
i. It is an inflammation within the bursa posterior to the iliopsoas muscle due to
overuse or trauma
ii. A palpable click with manipulation of hip is typically present
b. Slipped capital femoral epiphysis:
i. It has chronic symptoms and does not resolve within weeks
ii. It occurs in adolescents, while transient synovitis occurs in age 3-8 years

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TRANSIENT SYNOVITIS VS SEPTIC ARTHRITIS

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LEGG CALVE PERTHES

1. Age of presentation can be between 3-12 years but peak incidence is at 6 years
2. Examination of progressive disease:
a. Limited internal rotation and abduction of the hip
b. Proximal thigh atrophy
c. Trendelenburg sign positive
3. Initial X-rays may be normal
4. Subsequent X-rays and/or MRI are indicated in case of persistent and worsening symptoms

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ATLANTOAXIAL INSTABILITY IN DOWN SYNDROME

1. Excessive laxity in the posterior transverse ligament → ↑mobility between C1 and C2 →
compression of the spinal cord
2. Symptoms
a. Weakness
b. Gait changes
c. Urinary/fecal incontinence
d. Vertebrobasilar symptoms
i. Dizziness
ii. Vertigo
iii. Diplopia
iv. Imbalance
e. Upper motor neuron lesion symptoms
i. Hyperreflexia
ii. Spasticity (patients with Down syndrome are normally hypotonic)
iii. Positive Babinski sign
3. Diagnosis
a. Lateral X-rays of cervical spine in flexion, extension and neutral position
b. Open mouth X-ray: to visualize odontoid
4. Treatment
a. Surgical fusion of C1 and C2

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TETHERED CORD SYNDROME

1. Tissue attachments that limit the movement of spinal cord within spinal column
2. Spinal cord is affected below T12/L1
3. Symptoms
a. Weakness
b. ↓ sensation
c. Urinary incontinence
d. Hyporeflexia
4. Associated with spina bifida

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VITAMIN D DEFICIENCY RICKETS

1. Patients who do not ingest fortified baby food or formula should receive vitamin D
supplementation of 400 IU daily to prevent rickets
2. If they do get rickets then the treatment is Vitamin D repletion with 1000-2000 IU daily. Also,
add calcium supplements

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LANGERHANS CELL HISTIOCYTOSIS

1. Histiocytes (macrophages within tissues) proliferate and infiltrate one or more organ systems
a. Bone: single small, well-defined, lytic lesion
i. Most commonly in skull
ii. Femur, vertebrae and other bones can
also be affected
b. Skin: eczematous rash
c. Lymph nodes: lymphadenopathy
d. Lungs: cough, pulmonary nodules/cysts
e. Liver: hepatomegaly
f. Spleen: Splenomegaly
g. CNS: central DI
2. Diagnosis
a. X-ray: punched-out lytic lesion
b. Biopsy for confirmation
3. Differentials
a. Multiple myeloma: multiple lytic lesions instead
of one. Uncommon in children

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JUVENILE IDIOPATHIC ARTHRITIS

1. Autoimmune disorder of childhood marked by SYMMETRIC arthritis of ≥1 JOINTS within first 6

months of symptom onset
2. Presentation:
a. Joint swelling
b. Minimal pain
3. Large joints (eg, knees, ankles) are most commonly affected; however, hip involvement is rare
4. Anemia is seen due to chronic inflammation and iron deficiency
a. Improves with anti-inflammatories (eg, methotrexate)
5. Uveitis is also a serious complication:
a. Ophthalmologic screening is performed regularly because untreated uveitis is often
asymptomatic and can lead to irreversible vision loss
6. Treatment:
a. NSAIDs (first-line)
b. Intraarticular glucocorticoids
c. DMARDs (eg, methotrexate)

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TYPES OF JUVENILE IDIOPATHIC ARTHRITIS

SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS

1. Clinical features
a. Chronic oligoarthritis
i. Joint pain worse in morning
b. Daily fever
c. Rash
2. Look for:
a. ≥2 weeks of fever occurring once a day (quotidian fever)
b. Arthritis of ≥1 joint
c. Pink macular rash that worsens during fever
3. Lab findings
a. Leukocytosis
b. Thrombocytosis
c. ↑inflammatory markers
d. Anemia
4. Treatment
a. NSAIDs
b. Glucocorticoids
c. Anti-inflammatory Biologic agents

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DIFFERENTIAL DIAGNOSIS FOR NONTRAUMATIC JOINT SWELLING

OSTEOGENESIS IMPERFECTA

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SPONDYLOLISTHESIS
1. Forward slip of a vertebral body (usually L5)
a. Occurs in patients who have spondylolysis
i. Spondylolysis represents pars
interarticularis defects that are
often due to overuse injury and can
be unilateral or bilateral
2. Most common in adolescents (age 10-19) growth
spurts due to ↑ physiologic lumbar lordosis
(exposing L5) and decreased bone mineralization
3. Athletes with repetitive back extension and
rotation (eg, gymnasts and divers) are at greatest
risk
4. Clinical features
a. Back pain which ↑ with extension
b. Radiculopathy (eg, radiating pain)
5. Examination
a. Palpable step-off at the area of vertebral
displacement
6. Diagnosis
a. Lumbar radiograph
7. Treatment
a. Conservative
i. Limited activity
ii. Physical therapy
iii. Analgesics
b. Surgery in case of:
i. Persistent pain
ii. Progressive vertebral displacement
iii. Neurologic abnormalities (eg, weakness, incontinence)
8. Differentials
a. Disc herniation:
i. Pain becomes worse with FLEXION, not extension
ii. Pain can be elicited by straight leg raising
b. Vertebral compression fracture:
i. Occurs with osteoporosis
ii. Worsens with sitting and standing
iii. Point tenderness, rather than a palpable step-off is present on examination

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ANKYLOSING SPONDYLITIS
1. Inflammatory arthritis
2. Presents with:
a. Vertebral or sacroiliac joint pain and stiffness
i. Worsens at night
ii. Improves with activity
3. Examination
a. Sacroiliac joint tenderness
b. Limited lumbar flexion

METARSUS ADDUCTUS
1. Medial deviation of the forefoot with a normal neutral position of the hindfoot.
2. Usually bilateral and occurs in firstborn infants because of smaller primigravid uterus
3. Overcorrect by both passively and actively into lateral deviation
4. No treatment necessary

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CALCANEAL APOPHYSITIS

1. Differentials:
a. Plantar Fasciitis:
i. It is most commonly unilateral (while calcaneal apophysitis can be bilateral)
ii. Pain is worst on first stepping out of bed and improves throughout the day

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CONGENITAL MUSCULAR TORTICOLLIS:

1. Ipsilateral head tilt
2. Contralateral chin deviation
3. Risk Factors:
a. Breech position
b. Oligohydramnios
c. Multiple gestations
4. Leads to positional plagiocephaly
a. Anterior displacement of forehead and ear is seen
b. Missed or delayed diagnosis leads to craniofacial asymmetry
5. Diagnosis is made at age 1-6 months when the baby prefers head to one side

UNICAMERAL BONE CYST

1. Located at proximal femur or humerus
2. Pathologic fracture is most common presentation
3. X-ray: cystic lesion with well-defined margins

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Ophthalmology

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NEONATAL BACTERIAL CONJUNCTIVITIS

1. Due to
a. Neisseria gonorrhea
b. Chlamydia trachomatis
2. Neisseria conjunctivitis can be prevented by erythromycin ointment but chlamydia cannot be
prevented this way
3. The best way to prevent these is by screening for and treating these infections in pregnant
women:
a. Age <25 years
b. With risk factors

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GLAUCOMA IN CHILDREN

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RETINOBLASTOMA
1. Most commonly diagnosed in children age <2 years
2. Presenting features:
a. Leukocoria (most common presentation)
b. Strabismus (second most common presentation)
c. Nystagmus
d. Vision impairment
e. Ocular inflammation
3. Immediate ophthalmology referral is required to prevent metastasis to contralateral eye and
brain
4. Diagnosis
a. MRI of brain and orbit
b. Biopsy is contraindicated due to risk of tumor seeding
5. Differentials
a. Retinopathy of prematurity
i. Can present with leukocoria but occurs in infants born at <30 weeks gestation
b. Strabismus
i. Shows asymmetric red reflex
1. More intense reflex in deviated eye
ii. Corneal light reflex is also asymmetric

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PAPILLEDEMA

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TRACHOMA
1. Due to C trachomatis serotypes A, B and C
a. It spreads in crowded or unsanitary conditions
2. Symptoms
a. Mild eye redness
b. Scant watery discharge
c. Concomitant nasopharyngeal infections (eg, rhinorrhea, pharyngitis)
3. Signs
a. Follicular conjunctivitis
b. Pannus (vascularization) formation in the cornea
c. Tarsal conjunctiva inflammation
4. Chronic trachoma leads to
a. Scarring of the eyelids
b. Inversion of the eyelashes (trichiasis)
i. Lashes rub on the eye → ulceration → blindness (cicatricial trachoma)
5. Diagnosis
a. Clinical
b. Giemsa stain
6. Treatment
a. Oral azithromycin
b. Eyelid surgery for patients with trichiasis

CHLAMYDIAL CONJUNCTIVITIS
1. Presents in age 5-14 days
2. Symptoms
a. Eyelid swelling
b. Watery or mucopurulent discharge
c. Chemosis
3. Diagnosis
a. Cannot be seen on gram stain or grow on culture
b. Do PCR
4. Prevention
a. Screening and treatment of mothers
5. Treatment
a. Oral azithromycin
i. Monitor for pyloric stenosis

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STRABISMUS

1. Intermittent strabismus is normal in infants age <4 months due to immaturity of extraocular
muscles
2. Strabismus beyond early infancy ↑ risk of amblyopia
a. First 5 years are critical as it is the time of visual cortex maturation

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AMBLYOPIA

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ALLERGIC CONJUNCTIVITIS
1. Look for
a. Bilateral involvement of eyes
b. Clear watery discharge
c. Ocular pruritus
d. Edema of conjunctiva and eyelids
2. Prevention
a. Avoidance of allergen
3. Treatment
a. Topical agents
i. Antihistamines
ii. Mast cell stabilizers
iii. Artificial tears

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VISUAL ACUITY TESTING

1. Vision is evaluated at EVERY WELL-CHILD VISIT
2. Visual acuity testing is performed routinely at age 4 but can be performed as early as age 3 in
cooperative children
3. Following should prompt ophthalmologic referral:
i. Visual acuity worse than 20/40 at age 4
ii. Visual acuity worse than 20/30 at age ≥5
iii. Pupillary asymmetry of ≥1 mm
iv. Nystagmus
v. Ptosis
vi. Other conditions obstructing visual field

MYOPIA

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DACRYOSTENOSIS

ORBITAL CELLULITIS

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ORBITAL COMPARTMENT SYNDROME

OPTIC NERVE INJURY

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RETINITIS PIGMENTOSA

1. Pathophysiology:
a. Photoreceptor degeneration due to genetic mutation
i. This degeneration begins with rods, which are the responsible for vision in dim
light. They are located on the outer retina
ii. Based on the above information, it stands to reason that when degeneration of
rods occur, patient presents with night blindness and visual field defects in
midperiphery (because of high density of rods in periphery of retina)
iii. Eventually degeneration of cones occur which lead to ↓ visual acuity
2. Presentation:
a. Due to rods degeneration:
i. Night blindness
ii. Midperipheral visual field loss
b. Due to cones degeneration (late finding):
i. Flashing lights (photopsia) adjacent to blind spot (scotoma)
ii. ↓ visual acuity
3. Diagnosis:
a. Funduscopy:
i. Retinal vessel attenuation (ie, narrower vessels due to ↓ retinal metabolic
demand)
ii. Waxy, pale optic disc (due to nerve gliosis and atrophy)
iii. Pigment deposition in a bone-spicule pattern (due to degeneration of retinal
pigment)
1. This is a late finding and may not be present during the early course
4. Treatment generally involves measures to slow disease progression with omega-3 fatty acids
but most patients are legally blind by age 40

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Poisoning & Environmental Exposure

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METHEMOGLOBINEMIA Findings in Alcohol

1. When exposed to oxidizing agent, at least one of the four iron Overdose:
molecules in hemoglobin is oxidized to the ferric (Fe+3) state • ↑ plasma osmolal gap is
a. Ferric iron is unable to bind to oxygen seen after ethanol,
b. In addition, the ferric state changes the hemoglobin structure methanol or ethylene
and causes remaining ferrous sites to have an ↑ affinity for glycol ingestion
oxygen (ie, left shift) → prevents oxygen release in peripheral
Antidotes
tissue (ie, decreased oxygen delivery)
• Dimercaprol → lead
2. Some examples of oxidizing agents are:
poisoning (increases the
a. Dapsone
urinary and fecal
b. Nitrites
excretion of lead)
c. Local/topical anesthetics
• Fomepizole → ethylene
3. Symptoms
glycol or methanol
a. Cyanosis
ingestion (inhibits
i. It doesn’t get better with 100% oxygen
alcohol dehydrogenase
b. Tachypnea
and prevents the
4. Findings
metabolism of these
a. Pulse oximetry readings of approx. 85%
alcohols to their toxic
i. Because it measures bound oxygen
metabolites)
b. ABG shows normal PaO2
• Glucagon → beta
i. Because it measures unbound oxygen
blockers or calcium
c. Co-oximetry test analyzes hemoglobin absorption wavelengths
channel blockers
and can identify hemoglobin, methemoglobin and
• N-acetylcysteine
carboxyhemoglobin
→acetaminophen
i. ↑ methemoglobin will be seen
toxicity (restores
5. Treatment
glutathione)
a. Immediately discontinue the medication/agent causing
• Pralidoxime →
methemoglobinemia
cholinergic toxicity
b. Methylene blue
i. Methylene blue accepts electron from NADPH and Radiopaque Tablets:
becomes leucomethylene blue, which in turn reduces • Lead
methemoglobin to hemoglobin • Iron
c. Vitamin C
i. When methylene blue is unavailable
ii. When methyl blue is contraindicated (eg, glucose-6-
phosphate deficiency)

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LEAD POISONING
1. Treatment
a. Succimer
i. Used when lead levels 45-69 µg/dL
b. Dimercaprol (British anti-Lewisite) + calcium disodium edetate (EDTA)
i. Used when lead levels ≥70 µg/dL
ii. Used when there is acute encephalopathy
2. Patients with ↑ lead levels should be screened for iron deficiency
a. Comorbid iron deficiency can ↑ gastrointestinal absorption of lead
b. Prescribe oral ferrous sulphate

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CAUSTIC INGESTION
1. Management
a. Secure airway, breathing and circulation first
b. Then remove any contaminated clothing
c. Upper GI endoscopy should be done within 24 hours
i. Delayed endoscopy ↑ perforation risk
ii. During endoscopy, NG feeding tube can be placed under direct visualization to
prevent perforation
2. Patients with persistent dysphagia or significant esophageal burns on endoscopy should
undergo barium contrast studies 2-3 weeks after ingestion to assess for esophageal strictures or
pyloric stenosis
3. Any intervention that can provoke vomiting should be AVOIDED.
4. Don’t try to neutralize an acid with an alkali or an alkali with an acid as it leads to an exothermic
reaction and causes mucosal damage

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IRON POISONING

INFANT BOTULISM

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HEAT EXHAUSTION
1. It presents similar to exertional heat stroke but mentation remains normal and temperature is
≤40 C (104 F)
2. Risk factors:
a. Older age
b. Poor physical fitness
c. Infections
d. Certain medications (eg, anticholinergics)
e. Cystic fibrosis:
i. Due to ↑ infections
ii. Due to ↑ rates of sodium and chloride loss in sweat

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Psychiatry

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SEXUAL BEHAVIOR IN A CHILD

SELECTIVE MUTISM
1. Refusal to speak in a specific social situation
2. Diagnosis requires consistent (≥1 month) failure to talk in situations in which it is expected
despite the patient’s speaking in other situations
3. Treatment
a. Cognitive behavioral therapy (CBT)
b. Family therapy
c. SSRIs

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ADHD

1. Treatment
a. Stimulants
i. First-line
ii. Methylphenidate
b. Non-stimulants
i. Atomoxetine
c. α-2 adrenergic agonist
i. Clonidine
ii. Guanfacine

REACTIVE ATTACHMENT DISORDER

1. Risk factors
a. Abuse
b. Neglect
c. Prolonged institutionalization
d. Inconsistent care (eg, frequently moving between foster homes)
2. These risk factors disrupt normal healthy and secure attachment to caregivers
3. Findings
a. Do not respond to attempts to comfort them
b. Seldom seek comfort
c. Hoarding
d. Lack of social responsiveness
e. Lack of positive emotions
f. Episodes of unexpected irritability
g. Sadness in response to nonthreatening encounters

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DISINHIBITED SOCIAL ENGAGEMENT DISORDER

1. It is another possible outcome as a result of early neglect
2. Findings
a. Overfamiliarity
b. Unhesitant approach to unfamiliar adults

Some other disturbances seen in children with history of abuse or neglect include:

1. Poor emotion regulation

2. Toileting
3. Sleep difficulties
4. Anxiety
5. Aggression
6. Hyperactivity
7. Impulsivity

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TOURETTE SYNDROME

1. Characterized by multiple motor and one or more vocal tics that present before age 18 years
2. More common in males
3. Diagnosis is made if bouts of tics occur every day for at least 1 year
4. Comorbid conditions
a. Most common
i. ADHD
ii. OCD
1. Typically develop 3-6 years after tics first appear
b. Others
i. Anxiety disorders
ii. Autism
iii. Depression
iv. Learning disorders
v. Impulse-control disorders
vi. Disruptive disorders
vii. Conduct disorders

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TRICHOTILLOMANIA

STRANGER ANXIETY
1. Normal response in children which starts at age 6 months, peaks at 6-9 months and generally
resolves by age 2 years.
a. Resolves when child develops object permanence around age 18-24 months
b. It occurs even when parents are in the same room as the patient
2. Differentials
a. Separation anxiety disorder
i. Diagnosed in older children

SOCIAL (PRAGMATIC) COMMUNICATION DISORDER

1. Difficulties with social interaction involving:
a. Verbal communication
b. Nonverbal communication
2. Impairment is evident in multiple settings

LANGUAGE DISORDER
1. Persistent difficulties in comprehension and/or production of spoken and written language
2. It may involve:
a. Vocabulary → limited vocabulary
b. Rules → errors in grammar
c. Functional use of language
3. Language disorder can lead to specific learning disorder (eg, reading and writing disabilities)
4. Treatment
a. Structured language therapy
b. Stimulating language development at school and at home

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CHILDHOOD-ONSET FLUENCY DISORDER

1. It is also known as stuttering

RETT SYNDROME

1. Breathing abnormalities are characterized by alternating episodes of hyperventilation and

hypoventilation or apnea
a. They tend to occur during periods of heightened emotion
2. Retropulsion (rocking back and forth) is also seen

LANDAU KLEFFNER SYNDROME

1. Severe epileptic attacks → regression of language skills
2. Language skills typically deteriorate at age 3-6 years

IMAGINARY FRIENDS
1. Common in children age 3-6 years
2. It is normal and helps the child’s creativity and helps the child to navigate social relationships
3. There is NO EVIDENCE that imaginary friends negatively impact real friendships

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NEONATAL ABSTINENCE SYNDROME

1. Due to withdrawal from maternal use of opiates
2. Symptoms
a. High pitched cry
b. Sleeping and feeding difficulties
c. Tremors
d. Seizures
e. Autonomic dysfunctions
i. Sweating
ii. Sneezing
f. Tachypnea
g. Vomiting
h. Diarrhea
3. Withdrawal presentation time
a. Heroin → within 48 hours
b. Methadone → 48-72 hours

PRENATAL EXPOSURE TO COCAINE

1. Jitteriness
2. Excessive sucking
3. Hyperactive Moro reflex

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AUTISM
1. Severe autism can present by age 5 with language or intellectual disability
2. Mild autism can present later when social deficits start affecting peer relationships and become
more noticeable

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PYROMANIA

OCD

FIREARM INJURY

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DEVELOPMENTAL MILESTONES

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DEVELOPMENTAL MILESTONES DURING FIRST YEAR

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FEATURES OF CHILD ABUSE

MINOR CONSENT

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MEDICAL CAUSES OF PSYCHOSIS:

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Renal System

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HYPERNATREMIA
1. Signs & symptoms:
a. Neurologic
i. Lethargy
ii. Altered mental status
iii. Irritability
iv. Seizures
b. Muscular
i. Cramps
ii. Weakness
iii. Decreased deep tendon reflexes
2. Can be because of:
a. Hypovolemic hypernatremia
b. Hypervolemic hypernatremia
3. Hypovolemic hypernatremia can occur secondary to:
a. Renal losses (eg diuretic use, glycosuria)
b. Extrarenal causes (eg, GIT upset, excessive sweating)
4. Hypervolemic hypernatremia occurs due to:
a. Excessive sodium intake
b. Mineralocorticoid excess (eg, hyperaldosteronism)
5. Treatment
a. Decrease sodium, but slowly. Otherwise it will lead to cerebral edema
i. Give 0.9% saline
1. Normal saline
2. Ringer’s lactate

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MINIMAL CHANGE DISEASE

1. Signs & symptoms Renal scintigraphy:
It is used to evaluate renal
a. Edema
function and is useful in
i. Periorbital in the morning
setting of kidney
ii. Gets more pronounced in legs and genitals later in
dysfunction. Consider this
the day
option only if patient has
b. Fatigue
abnormal creatinine and
c. Proteinuria
urine output.
d. No hematuria
2. Confirmation of nephrotic-range proteinuria is done on the basis of
24-hour urine collection
3. Inherent problem is increased glomerular permeability to albumin.
Giving IV albumin to patient will not correct it.
• Hematuria with normal
4. Renal biopsy is not the first step. Its indications are as follows:
appearing RBC suggests
a. Child with age >10 years with nephrotic syndrome
extrarenal cause
b. Child with nephritic syndrome
c. If MCD does not respond to steroids Normal Creatinine:
It is seen in:

1. Henoch Schonlein
purpura
2. Autosomal
dominant polycystic
kidney disease

Normal caloric intake of

an infant:
32 ounces of formula a day

Membranoproliferative
Glomerulonephritis renal
biopsy:
Mesangial hypercellularity

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POSTSTREPTOCOCCAL GLOMERULONEPHRITIS

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HENOCH-SCHONLEIN PURPURA

1. Look for: *purPARA = Palpable purpura, Arthralgia, Renal disease, Abdominal pain*
a. URTI or GIT infection at least a week ago
b. Palpable purpura on lower extremities, back and buttocks (especially when there’s a
renal problem and a rash together, make sure if the rash is on lower extremities or not)
i. It is a nonblanching rash
c. Abdominal pain without rebound or guarding
i. It is due to local vasculitis
d. Arthralgia/arthritis which is self-limiting with NO long-term joint destruction
e. Hematuria +/- proteinuria
i. Red cell casts
ii. Normal or very slightly elevated creatinine (remember, it is increased in IgA
nephropathy)
2. Complications
a. GI hemorrhage
b. Bowel perforation
c. Intussusception
i. In contrast to idiopathic intussusception which is ileocolic, this intussusception
is ileoileal.
ii. Currant jelly bloody stools
iii. Target sign on ultrasound
3. Diagnosis
a. Clinical
b. Renal biopsy in patients with atypical presentation
i. Mesangial deposition of IgA

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TIME OF PRESENTATION OF IGA NEPHROPATHY VS PSGN

• IgA nephropathy: hematuria 1-2 days after URTI
• PSGN: 1-4 weeks after strep pyogenes infection

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ALPORT SYNDROME
1. Progressive disease with abnormal type IV collagen in:
a. GBM
b. Cochlea (sensorineural deafness)
c. Eye (anterior lenticonus)
2. Presentation
a. Boy
b. Age <10 years
c. Gross hematuria after recent URTI. Gross hematuria may be accompanied by:
i. Hypertension
ii. Proteinuria
iii. Chronic renal failure
d. Positive family history of chronic kidney disease or hereditary hearing loss
3. Diagnosis
a. Increased creatinine
b. Normal complement levels
c. Renal biopsy
i. Thinning and splitting of GBM (lamellated GBM)
d. Molecular genetic testing
4. Management
a. Supportive
b. Renal transplant in patients with ESRD

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RENAL COMPLICATIONS OF SICKLE CELL TRAIT

1. Renal papillary necrosis
a. Painless hematuria which is massive but the episodes are mild and resolve
spontaneously
b. Urinalysis: normal appearing RBC
2. Renal medullary carcinoma
3. UTI
4. Hyposthenuria
a. Inability to concentrate the urine
5. Distal renal tubular necrosis
a. Tubular damage with impaired H+ secretion

*Note: patients with sickle cell presenting with acute kidney injury should be evaluated for alternative
etiologies of acute kidney injury (eg, NSAIDs use, papillary necrosis)

HYPOSTHENURIA AS A COMPLICATION OF SICKLE CELL TRAIT

1. Inability of kidneys to concentrate urine
a. Due to vasa rectae damage with inability to maintain concentrated medullary gradient
2. Low urine specific gravity
3. Sickle cell disease and sickle cell trait can cause this
4. Symptoms:
a. Polyuria and nocturia despite fluid restriction
b. Normal serum sodium (due to intact antidiuretic hormone)
c. Urinary diluting capacity is also intact as it is a function of superficial loop of henle,
which is not supplied by the vasa recta
5. Differentials:
a. Diabetes insipidus: Serum sodium is increased
b. Primary polydipsia: Serum sodium is decreased
6. Treatment:
a. Sickle cell trait: No treatment
b. Sickle cell disease: RBC transfusion

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WATER DEPRIVATION TEST

1. Water deprivation test is NOT carried out in very young children due to risk of severe
hypernatremia
2. An alternate test is the administration of desmopressin to assess for renal concentrating ability

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ENURESIS • Oxybutynin, an
1. It is urinary incontinence in children age ≥5 years anticholinergic can be
a. Primary enuresis used in conjunction with
i. Children who have NEVER achieved dryness desmopressin in children
b. Secondary enuresis with BOTH nighttime
i. Incontinence after ≥6 months of dryness and daytime urinary
ii. Pathologic incontinence.
iii. Requires evaluation

PRIMARY ENURESIS
1. Boys with positive family history have higher chances of prolonged
bedwetting
2. Management
a. Initial steps
i. Behavioral modifications (eg, voiding before bedtime,
minimizing evening fluid intake)
ii. Enuresis alarms in those who do not respond to
lifestyle changes
1. Most effective long-term intervention
2. Takes 3-4 months to be effective
iii. Desmopressin for those who require immediate
improvement
1. Advise patients to minimize evening fluid intake
to prevent hyponatremia due to the therapy
2. Rate of relapse on discontinuation of therapy is
high
iv. Last resort is imipramine which is left out for the last
because of serious side effects (eg, increased
suicidality, cardiotoxicity)

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 PEDIATRICS

DIABETES MELLITUS TYPE 1

*Diabetes insipidus also presents like DM-1, but it is less common in children*

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 PEDIATRICS

EXERCISE-INDUCED HYPOGLYCEMIA
1. When muscles contract repeatedly, uptake of glucose is increased in skeletal muscles
a. In normal individuals, counterregulatory hormones maintain glucose levels in the blood
but patients with DM-1 (or those taking exogenous insulin) are vulnerable to exercise-
induced hypoglycemia
2. Management:
a. Because of increased insulin sensitivity associated with exercise, a reduction in insulin
dose is appropriate
i. Training sessions within 3 hours of a meal: Decrease the premeal bolus
insulin dose preceding exercise
ii. Prolonged exercise (eg, marathon): Decrease basal insulin +
premeal bolus insulin dose
b. Patients who initiate a strenuous exercise regimen should also be counseled to increase
carbohydrate intake, particularly if training sessions are >60 minutes in duration

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 PEDIATRICS

CYSTITIS VS PYELONEPHRITIS

UTIS IN INFANTS

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 PEDIATRICS

UTIS IN CHILDREN

1. Risk Factors
a. Girls at any age
b. Uncircumcised boys at age less than one year
c. Underlying renal anomaly
i. Vesicoureteral reflux
ii. Posterior urethral valves
d. Presence of fever greater than 102.2 F in any child age <3 prompts evaluation of occult
UTI
2. Diagnosis:
a. Urethral catheterization
b. Urinalysis
c. Urine culture
d. Midstream clean-catch urine specimen
i. Not appropriate for patients who wear a diaper
3. Empiric management is with third generation cephalosporins (eg, cefixime)

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 PEDIATRICS

INDICATIONS FOR RENAL & BLADDER ULTRASOUND

1. Infants and children age <24 months with a first febrile UTI
a. At increased risk of complications
b. Give a course of antibiotics for 1-2 weeks
c. Ideally, ultrasound is performed AFTER improvement of fever and symptoms to
minimize false positive results from acute inflammation
i. Do ultrasound however if patient has persistent or worsening symptoms to
assess for renal abscess.
2. Recurrent febrile UTIs in children of any age
3. UTI in child of any age with:
a. Positive family history of renal or urologic disease
b. Hypertension
c. Poor growth
4. Children who do not respond to appropriate antibiotic treatment

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 PEDIATRICS

VESICOURETERAL REFLUX

1. Retrograde flow of urine

2. Most common pediatric urologic problem
3. Risk factor for recurrent UTIs
a. Patient is at risk for renal scarring
4. Diagnosis
a. Children age 2-24 months presenting with first UTI = renal and bladder ultrasound
b. Recurrent UTIs or first UTI with organism other than E coli in newborns age <1 month
and children age <2 years = voiding cystourethrogram (VCUG)
i. Gold standard to diagnose vesicoureteral reflux
5. Indications of VCUG:
a. ≥2 febrile UTIs
b. Abnormal renal ultrasound
c. Fever ≥39 C (102.2 F) with bacteria other than E coli
d. Signs of chronic kidney disease (ie, poor growth, hypertension)
6. Management:
a. If high-grade VUR (eg, grade IV or V) is detected on VCUG, daily antibiotic prophylaxis is
considered to prevent further UTIs and renal damage

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 PEDIATRICS

PEDIATRIC CONSTIPATION LEADING TO CYSTITIS

1. Constipation compresses the bladder, hence preventing voiding

a. This urine is a breeding ground for bacteria and leads to cystitis
i. Dysuria
ii. Pyuria (≥5 wbc/hpf)
iii. Suprapubic pain
iv. Bacteriuria (50,000 colony-forming units/mL from a catheterized specimen)

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PEDIATRICS

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 PEDIATRICS

POSTERIOR URETHRAL VALVES

1. Most common cause of urinary tract obstruction in newborn boys

2. Clinical features
a. Limb deformities
b. Flat facies
c. Pulmonary hypoplasia
d. Poor urinary stream
e. Straining with voiding
f. Urosepsis
g. Failure to thrive
h. Renal failure
3. Findings
a. Bladder distension
b. Bilateral hydroureters
c. Bilateral hydronephrosis
d. Oligohydramnios
4. Diagnosis
a. VCUG
b. Cystoscopy
5. Treatment
a. Posterior urethral valves ablation
b. Urinary diversion
6. Despite prenatal diagnosis and early surgical intervention, patients are at high risk for
permanent kidney damage

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 PEDIATRICS

HEPATITIS B VIRUS-ASSOCIATED MEMBRANOUS NEPHROPATHY (HBVMN)

1. Presentation
a. Edema
b. Hypoalbuminemia
c. Markedly elevated urine protein
d. Hepatitis B +
2. Pathogenesis: deposition of HBeAg or its corresponding antibody in the glomeruli
3. Diagnosis
a. 24-hour urine sample
b. Serum C3
i. It is typically low in HBVMN
c. Anti-nuclear antibody
i. Elevated in lupus
d. Renal biopsy
i. Thickened basement membrane
ii. Subepithelial “spikes”

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 PEDIATRICS

RENAL TUBULAR ACIDOSIS

1. 3 types
a. Type 1 = alkalotic urine
i. Associated with nephrolithiasis
b. Type 2 = acidotic urine with Fanconi syndrome
c. Type 4= high serum potassium and chloride
i. Obstructive uropathy and aldosterone insufficiency are common causes in
children
2. Presentation
a. Normal anion gap acidosis
i. Due to low serum bicarbonate and hyperchloremia
ii. Normal anion gap should make you think of either a renal or a GIT cause
b. Failure to thrive
i. Growth failure (due to poor cellular growth and division in acidic conditions)
3. Treatment is oral sodium bicarbonate

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 PEDIATRICS

NEPHROTIC VS NEPHRITIC SYNDROME

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 PEDIATRICS

WILMS TUMOR
1. Asymptomatic abdominal mass which doesn’t cross the midline
2. A few patients might present with:
a. Abdominal pain
b. Hypertension
c. Hematuria
d. Fever
3. It is usually unilateral
a. Only 10% present with bilateral Wilms tumor (stage V disease)
4. Diagnosis
a. First, do ultrasound
b. Then do CT scan
i. Of abdomen to evaluate nature and extent of mass
ii. Of chest to identify any pulmonary metastases (lungs are most common site of
metastatic spread in Wilms tumor)
5. Differentials:
a. Nephroblastoma:
i. It presents in children age <2 years
ii. Mass arises from neural crest cells (eg, adrenal glands) instead of kidney
b. Pheochromocytoma:
i. It occurs with episodic symptoms of headache, tachycardia, sweating, and/or
hypertension

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 PEDIATRICS

WAGR SYNDROME

1. Screening:
a. Abdominal ultrasound:
i. It is performed every 3 months in infancy and early childhood

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 PEDIATRICS

NEUROBLASTOMA
1. Third most common pediatric cancer
2. Most common cancer in first year of life
3. Classic presentation
a. Abdominal mass that crosses the midline
b. Systemic symptoms (eg, fever, weight loss)
c. Can arise anywhere along sympathetic nervous system but typically involves adrenal
glands
4. May also present with periorbital ecchymoses (“raccoon eyes”)
5. Opsoclonus myoclonus syndrome can occur
6. Can lead to Horner syndrome by involving cervical paravertebral sympathetic chain
a. Ptosis
b. Miosis
c. Anhidrosis (absent facial flushing on affected side = harlequin sign)

387
 PEDIATRICS

VON HIPPEL-LINDAU SYNDROME

PROTEINURIA IN ADOLESCENTS
1. There are 3 types:
a. Transient proteinuria
i. Most common cause
ii. Can be caused by
1. Fever
2. Exercise
3. Seizures
4. Stress
5. Volume depletion
b. Orthostatic proteinuria
i. Increased protein when patient is in upright position that returns to normal
when the patient is recumbent
c. Persistent proteinuria
i. Requires further evaluation
2. Transient and orthostatic proteinuria are benign conditions
a. Do urine dipstick at two separate specimens to rule out these conditions
3. If proteinuria persists on repeat sample of urine dipstick or initial studies were abnormal,
patient should be evaluated for underlying renal disease. Further investigations will include:
a. 24-hour urinary collection for protein
b. Renal ultrasound
c. Renal biopsy

388
PEDIATRICS

389
 PEDIATRICS

Reproductive System

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 PEDIATRICS

PUBERTAL GYNECOMASTIA Turner’s Syndrome

1. Gradually enlarging breast tissue in adolescent boys Investigations:
2. Age of presentation: 12-14 years during midpuberty (Tanner stage 3- 1. Pelvic ultrasound first
4) 2. Then do karyotyping
3. Etiology: imbalance of estrogens & androgens during mid-puberty a. If karyotyping is
4. Clinical features normal but
a. Small (<4cm) subareolar mass suspicion for
b. Unilateral or bilateral turner syndrome
c. No pathologic features is high, do FISH
i. Nipple discharge to detect
ii. Axillary lymphadenopathy mosaicism.
iii. Systemic illness High-dose GnRH agonist
iv. Rapidly enlarging mass (leuprolide) therapy:
5. Management: Reassurance and observation Used to suppress symptoms
6. Laboratory and radiologic evaluation is done in patients with of endometriosis and
pathologic features only. uterine leiomyoma by
7. Resolves within a year creating hypoestrogenic
8. Differentials: state. However, they do no
a. Breast cancer: presents with pathologic features and work fast enough to control
overlying skin changes acute bleeding. Also, they’re
b. Klinefelter: Present with small and firm testes with bilateral not recommended in
gynecomastia. Pubertal gynecomastia has normal testicular adolescents due to
volume. decreased bone mineral
c. Cyst: Breast cysts are located peripherally, not subareolar. density with prolonged use.
d. Prolactinoma: Presents with galactorrhea
Risks of Vacuum
delivery:
1. Clavicular fracture
2. Cephalohematoma
a. Subperiosteal
bleed which
doesn’t cross
suture lines

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 PEDIATRICS

PRIMARY AMENORRHEA
1. Absence of menarche at:
a. Age ≥13 years WITHOUT secondary sexual characteristics
b. Age ≥15 years WITH secondary sexual characteristics
2. Rule out anatomical causes with Pelvic ultrasound first

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 PEDIATRICS

TURNER SYNDROME
1. Clinical Features:
a. Webbed neck
b. Carpal and pedal NONPITTING edema
c. Nail Dysplasia
d. Horseshoe kidney
e. Coarctation of aorta
f. Bicuspid aortic valve
g. Streak Ovaries
h. Cystic Hygroma
2. The edema swelling is due to congenital lymphedema due to lymphatic obstruction
a. Leads to accumulation of PROTEIN-RICH interstitial fluid in the hands, feet and neck
i. The edema is non-pitting due to high protein content
3. Pitting edema is seen with:
a. Liver failure (hypoalbuminemia)
b. Nephrotic Syndrome (proteinuria)
c. Congestive heart failure (ventricular hypocontractility)

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 PEDIATRICS

SMALL FOR GESTATIONAL AGE INFANTS:

1. Infants are small for gestational age when their birth weight is below the 10th percentile
2. Maternal causes
a. Preeclampsia
b. Malnutrition
c. Drug use
d. Multiparity
e. Placental insufficiency
3. Fetal causes:
a. Genetic factors
b. Chromosomal abnormalities
c. Congenital infections
d. Inborn errors of metabolism
4. Complications:
a. Hypoxia
b. Perinatal asphyxia
c. Meconium aspiration
d. Hypothermia (due to decreased subcutaneous fat)
e. Hypoglycemia (due to low glycogen stores)
f. Hypocalcemia (due to decreased transfer of calcium across placenta)
g. Polycythemia (due to increased erythropoietin production in response to fetal hypoxia)

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 PEDIATRICS

ADRENAL HYPERPLASIA

395
 PEDIATRICS

CLASSIC ADRENAL HYPERPLASIA

1. Most patients with CAH develop salt wasting, but electrolyte abnormalities (ie, hyponatremia,
hyperkalemia) do not occur until 1-2 weeks. This is because in the first few days, electrolytes are
normal due to the presence of maternal adrenal hormones

396
 PEDIATRICS

NONCLASSIC ADRENAL HYPERPLASIA

ABNORMAL UTERINE BLEEDING DUE TO ANOVULATORY CYCLE

1. Abnormal uterine bleeding in adolescence is defined as menstrual bleeding <21 days or >45 days
apart.
2. In adolescents, abnormal uterine bleeding is most commonly caused by immature
hypothalamic-pituitary-ovarian axis.
a. Results in anovulation
b. No ovulation leads to persistent endometrial proliferation because of unopposed
estrogen stimulation. Eventually, endometrium sheds and leads to breakthrough
bleeding
c. Leads to painless, irregular and heavy bleeding
3. Diagnosis
a. Initial evaluation
i. CBC
ii. Pregnancy test
iii. Coagulation studies
2. Treatment:
a. Hemodynamically unstable patients (eg, tachycardia, hypotension)
i. Dilatation and curettage
ii. Packed RBC
b. Hemodynamically stable patients
i. IV estrogen
ii. High-dose oral estrogen/progestin contraceptive pill
iii. High-dose progestin (in patients with contraindication to estrogen eg, history of
thromboembolism)

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 PEDIATRICS

CLAVICULAR FRACTURE

1. Clavicular fractures heal rapidly in neonates (7-10 days)

2. Clavicular fractures in older children are less likely to heal spontaneously and may require
treatment, such as:
a. Surgical reduction
i. For displaced fractures
b. Figure-of-8 splint
i. For nondisplaced fractures

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 PEDIATRICS

EMERGENCY CONTRACEPTION

1. Oral levonorgestrel is also known as Plan B

a. It delays ovulation
2. Ulipristal is more effective than levonorgestrel
a. Delays follicular rupture
b. Delays ovulation
c. Impairs implantation

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 PEDIATRICS

ROUTINE NEWBORN RESUSCITATION

1. Skin-to-skin contact:
a. Provides warmth
b. Helps initiate breastfeeding
2. Early feeding:
a. Prevents hypoglycemia
b. Prevents hyperbilirubinemia
3. Vitamin K, Hep B vaccine and erythromycin ointment can be delayed for up to an hour to allow
skin-to-skin time

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 PEDIATRICS

ECTOPIC PREGNANCY

401
 PEDIATRICS

DISSEMINATED GONOCOCCAL INFECTION

402
 PEDIATRICS

NEONATAL HSV INFECTION

1. Transmitted by vertical transmission Neonatal Virus Infection:
1. Severe microcephaly
a. Intrauterine (rare and fatal)
2. Hypertonia
b. Perinatal (most common)
3. Contractures
c. Postnatal
4. Ocular abnormalities
2. Presentation can be of 3 types:
5. Hearing loss
a. Skin-eye-mouth disease
i. Characteristic vesicles on an erythematous base Congenital Varicella
b. Disseminated disease syndrome:
i. Sepsis 1. Growth restriction
ii. Hepatitis 2. Skin lesions
iii. Pneumonia 3. Ocular defects
c. CNS disease 4. Limb abnormalities
i. Seizures 5. Seizures
ii. Fever a. Cortical atrophy
iii. Lethargy
iv. Temporal lobe hemorrhage/edema
1. Increased ICP (full fontanelle)
3. Diagnosis
a. Viral surface cultures
b. HSV PCR of samples collected from blood or CSF
c. Bloody tap on LP
4. Empiric acyclovir is started while awaiting confirmation of HSV PCR
testing of CSF

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 PEDIATRICS

ANDROGEN INSENSITIVITY SYNDROME

MULLERIAN AGENESIS

404
 PEDIATRICS

VWF DEFICIENCY

1. Patients have
a. Normal platelet count
b. Abnormal platelet adhesion
c. Normal aPTT in those with:
i. Mild disease
ii. Increased vWF synthesis (eg, pregnancy, OCP use, acute stress, thyroid hormone
supplementation)
d. Normal PT time
e. Prolonged BT
2. Patients present with heavy mucocutaneous bleeding eg, epistaxis or heavy menstrual bleeding
3. For menstrual bleeding, check to see following:
a. Heavy bleeding
b. Regular menses (if irregular, keep anovulatory cycles in your mind)
c. Anemia
d. Normal coagulation studies
e. No painful menses
4. Differentials:

Endometriosis • Painful menses

throughout
• Immobile uterus
Anovulatory bleeding • Irregular cycles
Endometrial polyps • Intermenstrual
bleeding
Leiomyoma • Large, irregularly
shaped uterus

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 PEDIATRICS

PRIMARY DYSMENORRHEA
1. At onset of menarche, adolescents have irregular hypothalamic-pituitary-ovarian axis
a. There is no ovulation in the beginning
2. As this axis matures, ovulation can cause excessive prostaglandin release during menses which
results in
a. Crampy, bilateral lower abdominal pain
b. Nausea, vomiting, diarrhea
c. Fatigue and dizziness
3. Primary dysmenorrhea is common in up to 90% adolescents
4. Features
a. Starts 1-2 days before onset of menses
b. Resolves a few days after ONSET of menses
c. Normal pelvic examination
d. No pain after menses ends
e. No heavy bleeding
f. Gets better as the patient ages
5. Risk factors
a. Age <30
b. BMI <20 kg/m2
c. Tobacco use
d. Menarche at age <12
e. Heavy/long menstrual periods
f. Sexual abuse
6. Treatment:
a. NSAIDs
b. Combination OCPs
7. Differentials:

Adenomyosis • Age >40

• Symmetrically enlarged
“globular” uterus
Endometriosis • Pain persists
THROUGHOUT menses
• Immobile uterus

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 PEDIATRICS

PREPUBERTAL VAGINAL BLEEDING

1. Most common cause is maternal withdrawal of estrogen
a. Bleeding occurs within 2 weeks of life
b. Effect of maternal hormones may also lead to temporary breast bud and external
genitalia engorgement during first month of life
c. Physiologic leucorrhea (whitish vaginal discharge) is seen
2. Vaginal trauma
a. Look for lacerations
3. Vaginal foreign body
a. Most commonly toilet paper
b. Bleeding
c. Foul-smelling discharge
d. Normal physical examination (no trauma) and no pain
e. Management:
i. If foreign body is easily visualized = Irrigation with warm fluid
ii. If foreign body is not easily visualized = vaginoscope
4. Uterine Prolapse
a. Beefy red protrusion at the urethra
b. Topical estrogen

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 PEDIATRICS

INFANT OF DIABETIC MOTHER- COMPLICATIONS

408
 PEDIATRICS

HYDROCELE

1. It is of two types:
a. Communicating hydrocele (patent processus vaginalis)
i. Fluctuates with straining or crying (increased intra-abdominal pressure)
b. Noncommunicating hydroceles (processus vaginalis obliterates but tunica vaginalis does
not reabsorb the fluid)
i. Irreducible and constant in size
2. Clinical features
i. Painless
ii. Scrotal swelling (unilateral or bilateral)
3. Diagnosis is by transillumination:
a. If it transilluminates, it is a hydrocele
b. If it does not transilluminate, workup for inguinal hernia
4. Treatment:
a. Before 1 year of age = observe
b. After 1 year of age = surgical correction

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 PEDIATRICS

VARICOCELE

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 PEDIATRICS

CRYPTORCHIDISM
1. Poorly rugated and hypoplastic scrotum
2. Wait for 6 months for testes to descend. If they don’t, do surgery.
3. Orchiopexy should be performed BEFORE 1 YEAR of age to avoid complications. Complications
are:
a. Testicular torsion
b. Infertility
c. Testicular malignancy
4. Prognosis after Orchiopexy
a. Risk for testicular torsion DECREASES
b. Risk for testicular cancer remains INCREASED
c. Cancer detection is INCREASED because it is easy to palpate a mass in scrotum than in
abdomen
d. Although fertility improves, but still sperm count and quality remains BELOW AVERAGE

411
 PEDIATRICS

HYPOSPADIAS

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 PEDIATRICS

FIBROADENOMA
1. A benign lesion
a. Rubbery, mobile and well-circumscribed
b. Located in outer quadrant of the breast
c. Classically presents as premenstrual tenderness
2. Management
a. If patient is an adolescent
i. Reexamine over one menstrual cycle. If size and/or tenderness decrease after
menstrual period, reassure the patient
b. If patient is not an adolescent or the mass is persistent
i. Do ultrasound

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 PEDIATRICS

Respiratory System

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 PEDIATRICS

ANAPHYLAXIS Severe coughing

1. Severe IgE-mediated type I hypersensitivity reaction affecting ≥2 paroxysms:
organ systems OR hypotension: • May result in
a. Cardiovascular: involves both cardio and vascular subcutaneous
i. Cardio: tachycardia emphysema
ii. Vascular: vasodilation • Do CXR to rule out
1. Hypotension pneumothorax
2. Tissue edema
Congenital
b. Respiratory: involves both upper and lower airway
Diaphragmatic Hernia:
i. Upper airway edema: stridor & hoarseness 1. Loops of bowel in
ii. Lower airway: Bronchospasm leads to wheezing hemithorax
which is diffuse instead of focal 2. Displaced cardiac
c. Cutaneous: urticarial rash, pruritis and flushing silhouette
d. GIT: vomiting, nausea and abdominal pain 3. Gasless abdomen
2. Triggers 4. Condition worsens with
a. Food (most common) noninvasive positive-
b. Medications (eg, beta lactams) pressure ventilation
c. Insect stings a. Do intubation
3. Treatment: instead
a. IM epinephrine
i. If one dose doesn’t work, administer an additional Tip for management of
dose upper airway
b. Airway management obstruction:
c. Volume resuscitation Don’t do any painful
d. Adjunctive therapy (eg, antihistamines, glucocorticoids) intervention as agitation can
e. Venom immunotherapy for those allergic to insect stings worsen upper airway
i. This can decrease risk for repeat insect sting obstruction.
anaphylaxis
Opacification of all
sinuses in CF:
Opacification of all sinuses
may occur in a patient with
CF as early as age 8 months.
Surgical debridement may
be needed.

415
PEDIATRICS

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 PEDIATRICS

FOREIGN BODY ASPIRATION

1. They can cause variable amount of obstruction:
a. Partial obstruction
i. Leads to air trapping during expiration
1. This causes hyperinflated lungs
b. Complete obstruction
i. Leads to
1. Atelectasis
2. Post-obstructive pneumonia
3. Localized bronchiectasis (late feature)
2. Management
a. Immediate rigid bronchoscopy

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 PEDIATRICS

DROWNING
1. Complications of drowning are a result of hypoxemia from fluid aspiration
a. Cerebral edema:
i. It occurs due to hypoxic brain injury
b. Arrhythmia:
i. It occurs as a response to hypothermia and hypoxemia and are present on initial
presentation
c. Respiratory distress syndrome:
i. The aspirated liquid washes out alveolar surfactant → pulmonary edema,
respiratory insufficiency, and ARDS
ii. ARDS occurs insidiously over 72 hours
2. Hypothermia due to drowning can trigger peripheral vasoconstriction → perceived volume
overload → Decreased ADH → resultant diuresis leads to hypotension and hypovolemic shock
findings which are NORMAL to have in such a case
3. Pneumonia can also occur if patient is submerged in contaminated water

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 PEDIATRICS

RESPIRATORY FAILURE IN ASTHMA

1. Most cases improve with medical management:
a. Nebulized albuterol
b. IV bronchodilators (eg, magnesium sulfate, terbutaline)
c. IV corticosteroids
2. In moderate to severe exacerbations which do not resolve with medical management, do
noninvasive positive pressure ventilation (eg, bilevel positive airway pressure [BiPAP])
3. Signs of impending respiratory failure:
a. Altered mental status (eg, agitation, confusion)
b. Persistent hypoxemia
c. Hypercarbia
4. Patient has minimal air entry and difficulty speaking (due to poor air entry)
5. Last resort is endotracheal tube insertion

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 PEDIATRICS

CYSTIC FIBROSIS

420
 PEDIATRICS

CYSTIC FIBROSIS EMPIRIC MANAGEMENT

1. Staphylococcus aureus is the most
common pathogenic organism in young
children with CF in the setting of
concurrent influenza
a. Give empiric vancomycin and
cefepime
i. Don’t give nafcillin as
cefepime provides
coverage for MSSA and
pseudomonas both. Vanco
should be given for MRSA
2. Long term azithromycin has been shown
to slow lung function decline in patients
with CF

421
 PEDIATRICS

PRIMARY CILIARY DYSKINESIA

422
 PEDIATRICS

RESPIRATORY DISTRESS SYNDROME

1. Common in premature babies (especially ≤28 weeks)

a. Very low birth weight (<1500g)
b. Problem is surfactant deficiency
2. Risk Factors:
a. Prematurity (most common)
b. Male sex
c. Perinatal asphyxia
d. Maternal diabetes
i. Maternal hyperglycemia → fetal hyperinsulinemia → insulin antagonizes cortisol
→ blockage of maturation of sphingomyelin → decrease in surfactant
production → RDS
e. Cesarean section without labor
3. Intrauterine stress decreases risk of RDS. Following are few examples of factors which decrease
risk of RDS:
a. Intrauterine growth restriction
b. Maternal hypertension
c. Prolonged rupture of membranes
d. Vaginal birth

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 PEDIATRICS

4. Symptoms
a. Tachypnea (rate >60/min)
b. Grunting (to increase end-expiratory pressure)
c. Nasal flaring (to decrease nasal airway resistance)
d. Retractions (intercostal muscles contract and pull in the compliant chest wall)
e. Hypoxia and cyanosis (reflect significant atelectasis)
5. Diagnosis
a. CXR
i. “Ground-glass” opacities
ii. Air bronchograms (bilateral perihilar linear opacities)
iii. Low lung volumes
6. Treatment
a. Maternal
i. Antenatal glucocorticoids
b. Neonatal
i. Early
1. Continuous positive air pressure ventilation
ii. Severe cases
1. Intubation
2. Mechanical ventilation
3. Exogenous surfactant therapy

424
PEDIATRICS

425
 PEDIATRICS

BRONCHOPULMONARY DYSPLASIA
1. Etiology:
a. Mechanical ventilation
b. Prolonged oxygen exposure
c. Inflammation
2. Risk factors:
a. Prematurity
b. Low birth weight (<2500 g)
c. Respiratory distress syndrome
d. Mechanical ventilation
3. Presentation:
a. Tachypnea
b. Rhonchi
c. Rales
4. Diagnosis:
a. X-ray:
i. Haziness and decreased lung volumes
5. Most patients improve over 2-4 months
6. Surfactant therapy does not prevent bronchopulmonary dysplasia development but may reduce
mortality from it
7. Complication:
a. Pulmonary arterial hypertension

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 PEDIATRICS

PARAPNEUMONIC PLEURAL EFFUSION

1. It can present as:
a. Small effusion with no respiratory distress or hypoxia
i. Give ORAL antibiotics
ii. Closely monitor
b. Moderate/large effusion OR respiratory distress OR hypoxia:
i. Do following if either of the above-mentioned presentations are seen:
1. Ultrasound
2. IV antibiotics
3. Drainage

2. Chest X-ray confirms presence of pleural fluid by following findings:

a. Obscuring of costophrenic angle
b. Layering fluid on lateral decubitus film
3. Diuretics are NOT indicated in case of parapneumonic effusions
a. Give diuretics in case of TRANSUDATIVE pleural effusions, eg:
i. Secondary to cardiac failure
ii. Cirrhosis

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 PEDIATRICS

TRANSIENT TACHYPNEA OF NEWBORN

428
 PEDIATRICS

BRONCHIOLITIS

1. Look for respiratory infection in children during winter season

2. Bronchiolitis Presentation
a. In children >2 years
i. Mild
ii. Upper respiratory tract infection
b. In children <2 years
i. Lower respiratory tract infection
ii. Wheezing and/or crackles and respiratory distress
1. Waxing/waning course that peaks on days 3-5 of illness
c. In children age <2 months
i. High risk of developing apnea and respiratory failure
ii. Recurrent wheezing throughout childhood
3. Diagnosis:
a. Mainly clinical
b. Chest X-ray:
i. It is done to rule out other causes (eg, pneumonia)
ii. It may be warranted for patients with severe symptoms (eg, cyanosis, apnea)
iii. It may be warranted for patients with atypical progression (eg, worsening
symptoms after day 5 of illness)
iv. Chest X-ray findings:
1. ↑ interstitial markings
2. Peribronchial cuffing (haziness around bronchial wall, reflecting airway
inflammation)
3. Hyperinflation and atelectasis may be present
4. Absence of a focal consolidation
4. Treatment:
a. Mainly supportive
b. Palivizumab in children age <2 years with high risk of complications

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EPIGLOTTITIS

1. Most common cause is H influenzae

a. It can cause epiglottitis in both, vaccinated and unvaccinated children
2. Management:
a. Endotracheal intubation immediately
b. Emergency tracheotomy if intubation fails

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CHYLOTHORAX
1. Exudative effusion
a. Exudate occurs when fluid moves into the interstitium due to increased permeability of
capillary membranes or disruption of thoracic lymphatic drainage
2. Chyle composition
a. T lymphocytes
b. Chylomicrons
c. Immunoglobulins
3. Diagnosis of chylothorax
a. Milky-white fluid in thorax (with lymphocytic predominance *remember the
composition*)
b. Increased triglycerides
4. Causes
a. Traumatic (eg, cardiothoracic surgery)
b. Congenital malformations
c. Down Syndrome
d. Noonan syndrome
e. Malignancy
5. Management
a. Drainage via:
i. Thoracentesis
ii. Chest tube placement
b. Limitation of dietary fats
c. Thoracic duct ligation
6. Differentials
a. Empyema
i. Low ph
ii. Low glucose
iii. Increased neutrophils
iv. Positive gram stain and bacterial culture
b. Hemothorax
i. Bloody pleural fluid
ii. >50% hematocrit of peripheral blood

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THYMUS
1. Visible on CXR of children age <3 years
2. Location
a. In anterior mediastinum
b. In front of heart, aortic arch and trachea
3. Rebound hyperplasia: it can shrink in times of stress or illness and rebound later to a larger size
after recovery.
4. CXR = sail sign

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CONGENITAL DIAPHRAGMATIC HERNIA

1. Mostly occurs in left side
2. Results in:
a. Pulmonary hypoplasia
b. Pulmonary hypertension
3. Findings
a. Polyhydramnios (because of esophageal compression)
b. Scaphoid (concave) abdomen
c. Barrel shaped chest
d. In case of left diaphragmatic hernia, following are lung findings
i. Left Lung
1. Displaced
2. Impaired growth
3. Absent left breath sounds
ii. Right lung
1. Fair lung aeration
2. Impaired right lung development
e. Right-sided heart sounds
4. Management
a. Emergency intubation
b. After airway is secured, place a nasal or orogastric tube
i. Connect it to continuous suction to prevent bowel distension against the lungs
c. Place an umbilical artery line for close monitory of blood gases and blood pressure
d. Place an umbilical venous catheter to administer fluids and medications
e. Surgical correction is the definitive treatment

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CROUP
1. Laryngeal and tracheal inflammation
a. Subglottic edema and narrowing
2. Features
a. Hoarseness
b. Inspiratory stridor that worsens with crying
c. Barky cough
3. Management:
a. No stridor at rest: corticosteroids
b. Stridor at rest: corticosteroids + nebulized epinephrine
c. Endotracheal intubation can be done if the medical management fails and the patient
starts showing signs of respiratory failure

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