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1 Failure to thrive (FTT)

12 month-old girl has poor weight gain with no etiology
Nonorganic FTT food/env/caregiver
Organic caused by something in the child itself
FTT below 3rd/5th percentile
Child less than 6 months who doesnt gain weight for
2/3 months
Loss of more than 2 percentiles in a short frame
Take good dietary history type of milk, frequency/quality
of feeding, vomiting, stool
Dilution of formula with water, type of juices and
solid foods
2 week food diary can help
Symptoms of sweating choking, cyanosis, difficulty
sucking
Occipital bald spot lying in bed not going thru mile stones
= FTT
Avoid eye contact, smiling, vocalizing, no comforting
Clinical should observe a feeding can help differentiate
organic/nonorganic
Do CBC, lead level, TFTs, LFTs, UA, culture, electrolytes, TB
test, HIV test
Infants 120 Kcal/Kg/day 1st year
100Kcal/kg/day for thereafter
FTT give 50-100% MORE
RTA Type 1/2/4= FFT
Urinalysis with high pH
Give Bicarb, correct chloride
2 Adolescent substance abuse disorder
Consider psychiatric, BUT ALSO DRUG ABUSE
16 year old declining school performance, erratic
behavioral change
New onset truant behavior, depression, euphoria, declining
grades substance abuse
Airway problems ABC airway, breathing, circulation
Drug testing in below 18 still ask for permission because
it can destroy doctor-patient relationship
PCP hyperactivity, hallucniations, abusive language,
nystagmus
3 Down Syndrome
1/368 at 35 increases in 1/106 at 40, and 1 in 11 by age
49
Brushfield spots grey spots in periphery of iris

o Approximately 50% of DS infants have cardiac

endocardial cushion defects VSD, Tetrology of Fallot
Echocardiogram is indicated
o Duodenal atresia double bybble
o Non disjunction 95% of cases
o 3% mosaic
o small chance of translocation with almost 100%
recurrence
o Strabismus, hearing loss, nystagmus, cataracts,
congenintal hypothyroid
Hearing at 3, ophthalmology at 6, thyroid function
routine new born
Leukemia, obesity, hypothyroid, premature aging,
alzhemier
o Trisomy 18 clenched hands, overlapping digits, small
palpebral fissure, short sternum, prominent occiput,
cardiac defects (ASD/VSD/ PDA/Coarc), low set ears,
microcephaly, rocker-bottom feet INGUINAL
HERNIAS, CLEFT PALATE, MICROOGNATHIA
Single umbilical artery, micrognathia, high
arched palate, small pelvis, short sternum
o Trisomy 13 cutis aplasia, polydactyly, cleft palate,
polydatly, coloboma, cardiac defects, cutis aplasia,
microcephaly, microopthalmia, omphalocele
Also single umbilical artery and
hypersensitivity to agents containing atropine
and pilocarpine
o Trisomy 21 Hypotonia, poor moro, flat faces, slanted
palpebral fissures, laxity of joints, excessive skin on the
back and neck
Case 4 Immunodeficiency
o Lymphadenopathy, organomegaly, weight loss, recurring
infection, oral lesions (candidiasis)
o Gather birth history (HIV), diet history test for HIV, CBC,
CMP, organ function, nutritional status
Maternal history IV drug use (HIV)
o Primary vs Secondary
Secondary malignancy, malnutrition, hepatic
disease, HIV
o Under 18 months DO HIV DNA PCR 95% S/S
Definitive exclusion 2 negative assays after 1
month of age
Over 18 months do ELISA and Westernblot
o HIV Elisa HIV IgG 2-6 months after exposrure

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S/S 99%
Western Blot direct visualization of virion proteins Confirmatory
FTT or atypical or difficult to iradicate infections =
Immunosupression
HIV typically acquired through vertical transmission or
breastmilk or secretions at delivery
Neonates test at birth and for 6 months
Give 6 weeks of zidovudine starting in first few hours of life
HIV POSITIVE give TMP for PCP prophylaxis at 6
weeks of age
Diabetes hyperglycemia promotes neutrophil
dysfunction, circulatory insufficiency ineffective
chemotaxis
LAD NEUTROPHILIA IS COMMON more than 50,000 cells
SCID Xlinked or AR
Di George No T cells, characteristic facies,
velocardiaiofacial defects, VSD, TOF, THYMIC/PARATHYROID
dysgenesis
Hypocalcemia, seizures
5 Kleinfeltter syndrome
Immature, insecure, gynecomastia, longer extrimities,
mental delay
@ 13 Tanner Stage 1
Nondisjunction XXY 1/600-800
Mental retardation diagnosed before 18 years of age
Ultimate diagnosis require IQ testing below 80
Kleinfeltters struggle with reading, spelling, math
although iQ may be normal
Most kleinfelter males go undiagnosed until
PUBERTY think about this diagnosis when presenting
with mental retardation/psychosocial or adjustment
problems at puberty
Elevated incidence of breast cancer, heme cancers in
kleinfelter
XYY explosive tembers, long and asymmetrical ears,
increased length vs breadth for hands, feet, cranium,
pectus excavatum
Tend to be taller and display aggressive or defiant
behavior
Large teeth, accelerated growth
Turner widely space nipples, broad chest, cubitis valgus
(increased carrying angle of arms), edema of hands and

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feet, congenital heart disease, horseshoe kidney, short

fingers, congenital hypothyroid, decreased hearing
Prematurity especially before 28 weeks
associated with complications
INTRAVENTRICULAR HEMORRHAGE = Mental
Retardation
Fragile X syndrome most common form of inheritied
mental retardation, primarily in boys who have
macrocephay, long face, high arched palate, large ears,
macroorchidism after puberty
6 Megaloblastic anemia in infant
GOAT MILK
Low in folate/b12 may have brucellosis
Got milk has lower sodium, higher potassium, chloride,
linoleic acid, arachidonic acid
Devoid of folate and B12
BM has IgA
Breast milk has everything except Vit D and Fluoride
Iron levels are also low in BM but because of
bioavailablity no need for supplementation until 4-6
months of age
Disadvantages of BM HIV transmission, jaundice
exacerbation, low vitamin K
Only formula feeding
PKU, or other amino acid disorders
Vegan mom infant has FTT, seizure, encephalopathy,
stroke Methylmalonic acidemia
GIVE B12 to MOM to prevent
Patient with Bleeding (PT, PTT), hemolytic anemia,
fontanelle fullness (Vitamin A) FAT MALABSORPTION
Cystic Fibrosis
Patient develops symptoms on FORMULA
GALACTOSEMIA
Patient breast fed switched to food at 6 months LOW
HB/HCT LOW MCV IRON DEF ANEMIA GIVE IRON
REVIEW DISORDERS OF METABOLISM
7 Rickets
Biliary atresia, poor bone mineralization, fractures
Diagnostic tests: Serum 25(OH)D, calcium, phosphorus,
ALP, Radiographs
Genu valgum Knick knees
Genu Varum bowed legs
Kasai bowel loop forms duct to allow ble to drain from
liver

o Liver failure poor bile salt secretion poor fat soluble

vitamin absorption low vitamin D low 2,5(OH)D,
reduced calcium, elevated ALP
o Nutritional rickets is rare usually in dark skinned people
who dont received vitamin D supplementation
o More common causes liver/renal failure
o MOST COMMON FORM is familial primary
hypophosphatemia (X-linked)***
Phosphate reabsorption is defecting, conversion to
1,25 OHD is abnormal in proximal tubule of kidney
Low 1,25OHD, low-normal calcium, low phosphate,
high ALP
Phyperphosphaturia WITHOUT hyperparathyroid
Calcium deficient rickets symptosm NOT SEEN
(myopathy, rachitic rosary, tetanty, pectus
deformatiy)
Radiologic findings: coarse appearing trabecular
bone and widening, fraying, cupping of metaphisis or
proximal and distal tibia, destial femur radius and
ulna
o Vitamin D def, hepatic disease, malabsorption,
anticonvulsive drugs
N or low Calcium
LOW PHOS
HIGH ALP
HIGH Urine Amino Acids
o Renal osteodystrophy hyperphosphaturia, results in
hypocalcemia then stimulates PTH enhanced bone
turnover
N or low calcium
Low phos
HIGH ALP
Variable UA amino aids
o Vit D dependent rickets LOW CALCIUM Reduced
activity of hydroxylase or mutation in
o RTA bicarbonaturia, hyperkaluria, hypercalcuria,
hypophosphatemia
o ALL RICKETS have elevated ALP If rickets without ALP
Chmid metaphyseal dysplasia AD dominant
condition
Case 8 Diabetic Ketoacidosis
o 5 year old with weight loss, polydipsia, polyuria presents
with
o Dehydration and kussmaul breathing

o Therapy for DKA

Aggressive volume repletion
Glucose control with insulin
Correction of metabolic abnormalities
o Most commonly present with symptoms of dehydration and
acidosis
Hypothermia, hypotension, jussmaul respirations,
acetone on the breath
o Electrolyte levels show hyponatermia and normal or
slightly elevated potassium
o Treatment vascular volume expansion (NORMAL SALINE)
Correction of hyperglycemia and hyperketonemia
Potassium is added to IV fluids after urine output is
established
Treatment of hyperglucemia and acodisis drives
potassium intracellulary SO AVOID
HYPOKALEMIA BY GIVING K+
o Avoid bicarb precipitate hypokalemia, worsen oxygen
delivery, overcorrect acidosis, recuts in worse cerebral
acidosis
o Cerebral edema may occur LIFE THREATNING
COMPLICATION OF DKA headache, personality
changes, vomiting, decreased reflexes
o DKA can be precipitated by bacterial infection so
evulation for infection sources SHOULD BE DONE
o Honey moon period of insulin after diagnosis patients
require less insulin BUT WILL NEED TO RETURN TO
INSULIN REQUIREMENTS AND THIS IS NOT A CURE
o PID can cause glucosuria- IT IS A STRESS RESPONSE
Case 9- Sickle cell disease
o HEMIPALAGIA or PAREYSIS THINK STROKE!!!
o Admit and arrage for ransfusion to reduce amount of
circulating sickle cells
o Second chance of stroke in 2 years is 70-80% - chronic
transfusion therapy is indicated
o SCD daily peniclling therapy at 2 months and folate by 6
months
o 23 valent pneumococcal and meningoccal vaccine
o SCD high risk for sepsis any SCD with fever above
e8.5 require evaluation
o Pain crisis can give morphine or hydromorphone if more
than oen or two doses of these is required at home ADMIT
TO HOSPITAL

o Acute chest syndrome if they have lower resp symptoms

and have hypoxemia with infiltrate on radiograph admit
and give oxygen, hydration, blood transfusion, pain control,
and Abx
o Splenic sequestration requires hospitalization
o About 10% of children with SCD have acute stroke
paresis, aphasia, seizures, CN palsty, headache, coma
NEUROIMAGING is warranted
Chronic transfusions to reduce recurrence
Routien visit Transcranial Doppler US identify
those with increased flow velocity in large
cerebral vessels chronic transfusion can help
reduce risk of first stroke
o Pallor, fatigue, lethargy = Aplastic crisis
o Pripaism 3,4 hours
o RUQ pain in SCD gallstones do US
o SCD requires periodic blood counts starting at 2
MONTHS OF AGE 23 valent is at 2 years of age while
conjugate accine is at younger ages as outlined
o CXR is obtained at 2 years of age and periodically
thereafter for screening
Case 10 Pneumonia = lower resp infection
o Chest Xray is indicated to ascertain changes
o Do a Pulse Ox, CBC, blood culture, nasal wash can help
differentiate etiology
o Septic shock can happen with pneumonia circulatory
failure
o Staccato cough pertussis and chlamydia
o Bacterial pneumonia is rapid, viral is more gradual
o Can present with increased work of breathing
Nasal flaring, accessory muscle use, tachypnea
(sensitive)
o LRTI occurs in the fall and winter 60% are bacterial
o Diagnosis and treatment is directed by patients symptoms
cultures are usualy not done
First few days Enterobacteriacea and GBS,
then staph, strep, listeria
Use Ampicillin and gentamicin or
ceforximine
HSV can happen first few days of life
First few months CHLAMYDIA trachnoatis
Staccato, conjunct, cough, maternal chlamydia
Have eosinophilia, bilateral infiltrates

After 5 years viral is common, adeno, rhino, RSV,

flu, paraflu
Can do PCR to confirm viral etiology
OLDER than 5 = MYCOPLASMA, then strep, staph
Give AZT and cephalosporines
Pneumonia in PICU with central line =
PSEUDOMONAS or CANDIDA, also aspergillus in CF
Rash + pneumonia = VZV
Retinitis + pneumonia = CMV
Legionella (water),
Aspergillus fugnal ball
TRAVEL TO MIDWEST THING FUNGAL cocioides
Sheep or cattle coxiella burnetti
Rocky mountains Histoplasma
5mm PPD is positive with symptoms and exposure
rifampin, isoniazid, pyrazinamide
ethambutol with drug resitance
Firs thing to do with pneumonia and tachypnea = PULSE
OX see if she needs oxygen
TB can cause weight loss, meningitis, military disease,
fever
M. pneumonia cold agluttnin disease** can help in
diagnosis lab
Could have NORMAL x-ray
11 organophosphate poisoning
Salivation, lacrimation, respiratory disress and GI
symptoms
Cofirm diagnosis decreased serum
pseudocholinesterase and erythrocyte
cholinesterase
Organophosphate leading cause of nonpharmaceutifcal
ingestion fatality in children
Decontiminate her clothing
Niconitic symptoms: Cardiac (HTN, tachycardia,
arrhythmia), muscles (fasiculations, weakness, tremors)
resp failure due to diaghragm paralysis
Muscurinic symptoms GI (emesis, inconteneinance),
bronchospasms bronhorrhea, cardiac (hypotension,
bradycardia), lacrimation, drooling, miosis
Most exposure children less than 5
Organophos posining can occur across skin or mucuous
membranes, inhalation, ingestion
Parathion, malathion, diazinon bind cholinesterase
and pseudocholinestrase in liver

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o Obtundation, seizure, apnea are also seen

o Serum pseydocholyn or erythrocyte cholinesterase levels
but poor correlation
Must have high index of suspicious
o Rapid decomontaimation of clothes and ALL SKIN
SURFACES
Gastric lavage or activated charcoal for
ingestion
ABCs
o Atropine/pralidoxime atropine inhibits muscurininc
o AFTER 1951 not lead ASBESTOS sprayed in school
ceilings as a fire retardant
o Small amount of mercury (thermomemter) nothing will
happen
If larger 0 GI complains if it was in vapor form
GI + fever, chills, headaches, visual changes,
cough, chest pain, pneumonitis, pulm edema
Dry batteries (merc) GI hematemesis, burns, vomit,
pain
CONTAMINATED FISH METHYL MERCURY
gingiviomastitis, tremor, neuropsychiatric disrubance
o Arsenic poisoning hemorrhagic gastroenteritis
nausea, vomiting, pain, diarrhea HYPOVOLEMIC SHOCK
due to hermorrhage in gut
Cardiac symptoms (QT prolong) and CHF
Seizures,, cerebral edema, encepholaphthy, coma
EARLY ON LOSS OF DEEP TENDON REFLEXES
o Transplacental toxins must be fat soluble
Case 12 Rectal bleeding/pain on defecation anal fissure
o Confirm red substance by doing fecal occult blood
test
Gelatin, breakfast cereals, beets can mimic blood
o Review vital signs make sure no rapid blood loss
Tachycardia is FIRST SIGN then hypovolemia
o GIVE STOOL SOFTNER oral polyethylene glycolate
o Parents DO NOT GIVE FOOD CAUSING constipation DAIRY
PRODUCTS
Increase water, avoid bulking agents
o Hematochezia Colon
o Melena Small intestine
o Stabilize isotonic saline, then packed red blood cells
o History of fever or diarrhea think colitis or enteritis
o Neonates? look at xrays NEC
o Ultrasound or air-contrast enema intussuception

o 3 month old or less - Allergic proctocolitis ALLERGY

TO COWs MILK standard infant formula stooling more
with streaks of blood no fever and happy
SOY MILK ALSO CAUSES CROSS-ALLERGY
Use ELEMENTAL FORMULAS made of amino acids
and NOT WHOLE PROTEIN
o 2 year old Meckels no fever and MELENA
o NEC occurs in preterm NOT TERM
Blood swallow syndrome 2nd/3rd day of life blood
from mothers nipple
DO APT TEST
o Intussception Most cmmon cause of intestinal obstruction
in children under 2 peristalsis is active and attempts
to correct thats why pain is colicky and intermittent
THIS IS A HALL MARK ischemic bowel blood may
appear
o Anal fissures most common cause of hematochezia
in infants, children, adolescents
o Newborns most often life thretaning NEC
o Tachycardia is first indication of volume loss
Case 13 Ear pain
o Acute otitis media
o URI + fever + ear ache = otitis media
o Confirmed with otoscope red, bulging, poorly moving
tympanic membrane
o Myringotomy and tubes surgical procedure involving TM
incision and placement of tube
o Otitis media with effusion fluid collects behind TM without
signs of Otitis media sometimes called serous otitis
media
o Pneumatic otoscopy obtaining a tight ear canal seal with
speculum apply slight positive negative pressure with
rubber bulb see if TM moves
o Etiology Strep, NONTYPEABLE HiB, Moraxella catarrhalis,
staph, e.coli, klebsiella, pseudomonas (neonates and
immunodeficiency)
o Viral can cause it when etiology is unknown
o Acute aom with fever more than 104, malaise, anorexia,
nausea, vomiting, diarrhea, headache
o Red bulging TM does not move will with pneumatic
otoscopy
o Amoxicillin for 7-10 days is initial treatment
If fail after 3 days amox-clav, cefuroximine, azt,
cefixime, ceftriasone or tympanocentesis

o Middle ear effusion is often a sequalae of AOM if

hearing is normal just watch
If it doesnt resolve myringotomy with PE is
implemented
o Complications mastoiditis, temporal bone
osteomyeilitis, facial nerve palsy, abscess, lateral
sinus thrombosis, otitic hydrocephalus
o Mastoiditis redness behind eat do a myringotomy
with antibiotics can do CT to confirm if it doesnt
improve in 48 hours surgical drainage is warranted
o Swimmers ear topical agents insertion of which
most liley pseudomonas, staph, or
candida/aspergillus
o Admit very young patients with AOM and systemic
symptoms could be bacteremia
Case 14 neonatal resuscitation
o Low HR (less than 100) initiate positive pressure
ventilation by bag and mask
o Mom received meperidine could ne opiate give
naloxone
o Narcosis deep stupor from drugs or anestethisia
o Therapy for narcotic related depression IV, IM, SQ, or
endotracheal admin of naloxone
o Do NOT DO BAG/MASK WITH CDH use intubation
o If HR is less than 60 even with 100% oxygen
MUST DO CHEST COMPRESSIONS if still 60 give
epinephrine
o Infant better resp when crying or cyanotic when eating
choanal atresia
If it is diagnosed intubate until surgery
Case 15 Cerebral palsy
o 12 month old boy cant crawl will legs, cant stand up,
scissoring posture when suspended
o CP is the most cmmon childhood movement disorder 1/3
have seizures, and 60% are mentally retarded
o Most have no identifiable risk factors CP is most likely
result of antenatal insults
o If CP is suspected imaging can be use in neonates
because clinical diagnosis at this time is near
impossible
Periventricular leukomalacia, atrophy, focal infarcts
o Divided into pyramidal (spastic) and extrapyrimadal
(nonspastic) categories

Extra can be dividided as choreoathetoid, ataxic,

dystonic, rigid
Diplegia 4 limbs involved, legs more than arms
Motor quotient dividing childs motor age with
chronicological age
75-100 is minimal, 55-70 mild, 40-55 moderate, less
than 40 severe
Divide should be months (14 months walking), with when
he did it (30 months) and use above numbers
16 Cystic Fibrosis
Small child ** with asthma symptoms, hemoptysis,
rhinorrhea, sinusitis**, rectal prolapse, digital
clubbing**
Gatehr family history, CXR, sweat test
Bronchiectasis by 18 months sometimes misdiagnosed as
asthma
Persistent bronchial obstruction from impaired
mucus secretion and damage to cilia can have
secondary bacterial infections in cycles leading to chronic
infection
Pneumona Staph then PSEUDOMONAS
Heavy, slime producing mucoid variants
PSEUDOMONAS
Bacteria are virtually impossible to eradicate
Pneumothorax, hemoptysis, cor pulmonale
Clubbing, hypertrophic oesteoarthropathy
underlying organ dusfunction
Nasal polyps with resultant obstruction, headaches, and
mouth breathing
Malnutrition leads to abdominal distension, rectal
prolapse, minimal fat and muscle, passage of oily,
malodorous, floating stools.
If glands become distended lumen filled with
material meconium ileus or intestinal obstruction
can occur
Fatty liver infiltration or focal biliary cirrhosis
hepatomegaly, esophageal varices, large spleen portal
hypertension
Choleliathsis
Azoospermia in men, enlarged salivary gland,
endocervicitis
FALSE POSITIVE SWEATTEST
Anorexia, hypothyroid
Nephrogenic diabetes insipisdus

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o Long arm chromosome 7 DF508

o CF screening performed on ALL NEWBORNS IN THE US
blood spot screening
Detects pancreative enzyme immunoreeactive
trypsinogen elevated in infants with CG
o DNA testing for 508 mutations
o Meconium illius obstruction in distal ileum, almost
always associated with CF
SURGICAL EMERGENCY volvulus and
perforation with peritonitis are common
complications
o SIDS diagnosed EARLY IN LIFE
o CF will lose excess sodium chloride will cause
hyponatremia, hypochloremic METABOLIC
ALKALOSIS
BAD VITAMINS increased PT/PTT, elevated RETICS
and hemolysis (Vit E)
THINK OF VITAMINS
o Negative sweat chloride DOES NOT PRECLUDE CF must
still consider it
o MECONIUM ILEUS IN NEWBORN IS PATHONOMIC FOR
CF
Case 17 ALL
o 6 year old boy with 1 week history of leg pain/limping
low grade fever HEPATOSPLENOMEGALY
(Extramedullary hematopoiesis), PETACHIAE
o Leukemia most common childhood cancer 40% of all
pediatric malignancies
o Peak incidence 2-4 years of age more frequently in boys
o Non-specific symptoms anorexia, irritability, lethargy,
pallor, bleeding, petechiae, leg and joint pain, fever
differentials
ITP, aplastic anemia, mono, JRA, leukomoid reaction
o ITP most common cause of bruising and petchaiae
with low platelet levels
Anemia, Hepatosplenomegaly absent
o Aplastic anemia
Lymphadenopathy, arthralgias, bone pain,
hepatosplenomegaly unusual
o Mono malaise, adenopathy, splenomegaly,
lymphocytosis,
o Leukomoid reaction
o ALL DIAGNOSED BY BONE MARROW EXAMINATION
More than 25% blasts

o Prognosis
Girls have better prognosis
AAs and Hispanics have worse prognosis
Under 1, older than 10 have worse prognosis
Higher leukocyte count above 50,000 worse
prognosis
T-cell ALL Worse than B-cell ALL
9:22 ALL and 4:11 AML
Blasts in CSF is worse prognosis
CXR mediastinal mass
Prednisoine, vincristine, apsparignase Induction
6MP, vincristine, 2-3 years to prevent replse
Therapy is discontinued for children after 2-3
years in remission
5 year survival better than 80%
Leukemia more common in
Kleinfelter, bloom, fanconi, ataxia
telangiectasia, NF, down syndrome
Live vaccines contraindicated in child with ALL
until at least 6 months after completion of
treatment
ITP - AFTER VIRAL INFECTION
Case 18 Diabetic mother
o Large newborn with resp depression DO ABCs
Check for hypoglycemia over next 24 hours
o Fetal hyperinsulin from hyperglycemia (maternal)
increased o2 requirements = neonatal distress
o Blood glucose 25-40 FEED THE BABy
Less than 25 IV GLUCOSE
o Resp distress, polycythemia and hyperviscosity,
hypocalcemia, hypomagenisum, hyperbilirubin
o Women screened for diabetes between 24-28 weeks
o VENOUS THROMBOSIS kidney and sinus, stroke, NEC,
persistent hypertension
o HYPOCALCEMIA IS COMMON causes irritability, sweating,
seizures
o Heart disease, small left colon, NTDs, caudal regression
o Infants born to diabetics neonatal RDS!
o Jaundice liver immature + polycythemia
Do Total bili and HCT
o RENAL VEIN THROMBOSIS can present as
abdominall mass kidney becomes congested
Gross hematuria, thrombocytopenia, oliguria

o Small left colon (congenital anomaly) FAILURE TO

PASS MECONIUM in first 2 days of life abdominal
distrension, vomiting
Case 19 Gilbert
o Jaundice on 12 day of life!!!
o Check serum bili could be GILBERT SYNDROME
o FAMILY HISTORY infants father has midly elvated
bilirubin he likely has Gilberts
o Kernicterus basal ganglia bilirubin encephalopathy
lethargy, poor feeding, loss of moro reflex = high
suspicoiusn
o Polycytthemia HCT over 65%
o Full term peak bili 5 -6 mg/dL between second-4th day of
life
o Nonphysiologic between 24-36 hours, bilirbuing
higher rate HIGHER THAN 5 per 24 hours, total bili
higher than 12, haundice after 10-14 days of life
o Causes septicemia, biliary atresia, hepatitis,
alactosemia, hypothyroid, CF, hemolytic anemia or
drug induced hemolytic anemia
o Jaundice within first 24 hours = IMMEDIATE
ATTNEION
Erythroblastosis fetalis, hemorrhage, sesis,
SMV, rubella, toxo
o Gilberts prolonged physiologic jaundice mild elevation
in bilirubin jaundice after fasting
Case 20 Asthma Exacerbation
o 10 year old boy with multiple episodes of respiratory
diffuclties
tachypnea, perioral cyanosis, pulsus paradoxus,
use of accessory, wheezing, delayed capillary refill
and drowsiness
o Tx ABCs, oxygen, inhaled b-agonist, systemic dose of
predinosone
Stat blood gas and SpO2
o Diagnosis can be made from history
o Diagnosis when
Episodic symptoms of airflow obstruction
Airflow obstruction is at least partially reversible
Alternative diagnoses are excluded
o Pulsus paracosus BP that varies more widely with
inspiration than normal (>10mmHg)
o Median age of onset is 4 years
o Atopy and family history of asthma

o 40-50% of children with RSV bronchiolitis later

develop asthma
o More than half of asthma symptoms resolve in
adulthood but many have abnormal PFTs only to
become later symptomatic in adulthood
o Heavy exposure to allergens makes resolution less likely
o Chronic night time cough think asthma
o Airway inflammation due to mast cell activation
immediate IGE response to env. Triggers occurs 15-30 mins
o B-antagonists and some NSAIDs can trigger asthma
o Late phase reaction (LPR) in asthma characterized by
infiltration of inflammatory cells into the airway
parenchyma
o Know TXs
o Increaesd wheezing is auscultated after alburterol
treatment because of lung areas previously
obstructed are now opening
o Wheezing baby = bronchiolitis give oxygen, nebylized
albuterol, epi
He can require mechanical ventilation and PICU
DO NOT REPSOND TO B-agonists
o Late phase reaction asthma symptoms after initial
wheezing episode by 2-4 hours
Case 21 Growth hormone deficiency
o 8 year old boy no significant medical history, normal exam
with growth failure No pubertal delay
o Test IGF-1, IGF-3, Bone age radiography, chromosomal
karyotype
o Replace via GH injection
o 1st year of life children grow 23-28 cm/year
then drops to 7.5-13cm per year for children aged 13 years
after puberty 4.5 -7cm per year
at puberty growth increases to 8-11 cm/year
o 24 months children settle into a percentile
o Children with constituinal growth delay HAVE NORMAL
GROWTH RATE
However family history is often positive for pubertal
delay one one parent (late bloomers)
Bone age would be early (delayed) not more than
chronological age
Can give monthly testosterone to jumpt start
pubertal process
o Bone age = chronological age = reassuring

o Boys height can be predicted (fathers height in cm +

mothers height in cm + 13) /2
o Girls height (Mothers height in cm + fathers height in
cm)/2
o Gh deficiency occurs in 1/4000 school-age children
Delayed bone ages
IGF1, somatomedic C, IGF BP3
o GH injections several times per week until child reaches full
adult height
o Other syx poor appetitis, weight loss, abdominal pain
diarrhea, unexplained fevers, headaches vomiting, weight
gain out of proportion to height, dysmoprthic features
CBC anemia
ESR high
Acidosis and renal abnormalities
Genera chemistry panel (hepatitis/liver dysfx)
Urinalysis (infection, renal disease)
Thryoid function
Chrmosomal analysis
o Tall for age kleinfellters
Case 22 GBS infection in neonate
o Rapid onset of symptoms, low WBC with left shift
o Chest xray consistent with pneumonia
o Early onset firs 6 days 85% occur in first 24 hours,
55 in 48 hours and reminder in next 4 days
o Late onset after 7 days before 90 days of life
o Signs can be subtle and nonspecific RDS, metabolic
disorders, IC hemorrhages, traumatic delivery
Temp instability, tachypnea, hypotension,
bradycardia
SHOCK = PALOR + POOR CAPILLARY REFILL
o Impaired consciousness, coma, seizures, bulging antetior
fontalnelle, focal cranial nerve signs, nuchal ridigity is
UNUSUAL
o Frequeent findings Pneumonia, tachypnea, gruntin, nasal
flaring, retractions, decreased breath sounds cyanosis
o Evolution hypoglycemia, metabolic acidosis,
jaundice
LOW WBC COUNT
INREASED NEUTOROPHILS
Thrombocytopenia platelets then 100,000
o C-reactive protein can be elevated
o BLOOD CULTURE IS CRUCUAL if positive culture
DO LP

o GBS most common fom up to 3 months of age 80%

is eraly onset
o Uo to 50% develop seizures within 24 hours of infection
o Risk factors
Prolonged rupture of membranes (more than 18
horus)
Chorioamnionitis
Intrapartum temperature greater than 100.4 (38)
Previous infant with GBS infection
Low birth weight or prematurity
o Screen mom 35-37 weeks gestation and offer abx
prophylaxis
o TX Iv aminoglycosides (gentamicin or tobramycin) or
penicillin (ampicillin)
o Late onset beta lactamase resistant antibiotics
(vancomycin) or 3rd gen cephalosporin
o For infants with convincing signs of symptoms of sepsis,
Abx may be continued even with negative cultures
positive cultures treat 10-21 days
Observe for abx toxicity
o Oral erythromycin increases risk for hypertrophic
pyloric stenois
o TTN do not have vigorous suck retained fluids
o MONOCYTOSIS RESPONSE = Listeria
Case 23 Sudden infant death syndrome
o After death coroner will perform autopsy, and police will
examine parents home for clues
o Apnea cessation of breathing for at least 20 seconds
may be accompanied by bradycardia or cyanosis
o SIDS most common cause of death between 1 week and
1 year
Majority between 1-5 months
More common in AAs and Native-american infants
o Risk factors prone or side sleep, sleeping on soft surface,
bed sharing, tobacco smoke, maternal use of opiates, overheating, late or no prenatal care, young maternal age,
preimaturty and low bith wright, male gender
o SIDS causes congenintal and acquired
Congenital: cardiac anomalies (arryhtmia), metabolic
disorders, CNS etiology
Acquired accidental or intentional death
o Kids who have expeirnce apparent life threathing event
may be at risk for sudden death

o Report of feeding difficulty, emesis leads to swalling

studies
o Unusual posturing or movements EEG
o CBC and bicarb at time of event can help with infectious
etology
o EKC to look for cardiac anaomly like long QT
o Infant with SIDS higher risk for SIDS
o Home cardioresp monitoring has been shown to decrease
incidence of SIDS monitor symptomatic infants
o Apnea of prematuriety is NOT A RISK FACTOR FOR
SIDS
Case 24 VSD
o Can present with progressive respiratory distress pulm
HTN
o Acyanotic heart lesion VSD most common ASD in down
o Sufficient size can result in CHF
o Acyonotic lesion volume overloand PULM HTN
Eisenmengers RL Cyanotic shunt
o MAJOR VSDs may have a less harsh murmur due to the
decrease in pressure gradients
Accompanied by dyspnea, feeding difficulties, growth
failure, profuse perspiration, can lead to cardiac
failure
o Most small VSDs close within 6-12 months of life
especially in the muscular septum
o Larger VSDs furosemide, chlorothiazide
o PDA most commonly seen in preterm infants closure
usually 10-15 hours or at most by 2 days
o Small PDA give indomethacin
Machine like, WIDENED PULSE PRESSURE
o Patients with COARC PDA IS VITAL TO MAINTAING BLOOD
FLOW
Ductus dependent lesion
o ASDs are often asymptomatic large defects may cause
growth failure or exercise intolerance
WIDELY SPLIT SECOND HEART SOUNDS THAT
DOESNT VARY WITH INSPIRATION
o Murmur NOT CAUSED BY ASD caused by high volume flow
from right ventricle into normal pulm artery left upper
and midsternal borders
o Xray enlarged right atrium
o Well tolerated by can lead to Pulmonary HTN

o Atrioventricular defects (AV canal, endocardial cusion)

contiious atrial and VSD as well as abnormal valves
correct with surgery
Cardiac failure, growth failure, recurrent pulmonary
infections
HTN Eisenmengers
o Abx prophylaxis ONLY FOR CYANOTIC LESIONS?
Case 25 TRANSPOSITION (MOST common cyanotic)
o Healthy appearing at birth develops cyanosis, hypoxia,
poor peripheral perfusion (appears dusky), tachypnea
o ADMINITSTER PGEs to keep ductus open
o 2 parallel circuits incompatible with life open
ductus and foramen ovale provide this connection
o Cyanotic disease often begin after PDA closes
o Blood is shunted PAST LUNGS and into circulation
Pulm valve stenosis, TGA
o Pulse oxiemter
Check sats proximal to ductus RIGHT HAND or
ear lobe
Then sats DISTAL TO DUCTUS lower extremity
Difference more than 3-4% then MAY BE A RIGHT TO
LEFT SHUNT ACROSS THE DUCTUSS
o Transposition egg on a string apperacnce of chest
radiography
o Initial management CREATION OF ATRIAL SEPTUM
BY CATHETER provides immediate symptom
palliation
o Definitive repair occurs in first 2 weeks of life
o Pulm valve stenosis Cyanotic accounts for 7% of CHD
Uppler left sternal murmur SYSTOLIC MURMUR
that radiates to left infraclavicular area and
SYSTOLIC CLICK
Can occur on NOONAN syndrome or Glycogen
storage diseases
o snowman on xray = TAPVR supracardiac shadow
caused by anamlous pulm veins and increased pulm
vasculatiry
o Hypoplastic left heart syndrome cardiomegaly and
increased pulmonary vascularity
o PULM STENOSIS + VSD = TOF
RT ventricular outflow obstruction Rt ventricular
hypertrophy
Swuatting position

o Cyanosis = TRICUSPID VALVE ATRESIA or EPSTEINs

ANAOMLY
Tricuspid atresia no outlets exist between right
atrium and right ventricle
Forcing venous return to enter left atrium THRU
FORAMEN OVALE or through an ASD
Ebstein anomly two leaflets displaced
inferiorly into the right ventricle and
unable to approximate each other also a
smaller ventricle chamgber which
obstructs ventricular outflow
BOTH ARE DUCTAL DEPENDSNET
o Benign flow murmur DOES NOT RADIATE
Problem if clicks or radiates, or shows with wisngs
(clubbing, cyanosis, exercise intolerance)
Peripheral pulmonic stenosis not radiating
Pulm stenosis and tricuspid atresia
Case 26 Juvenile Idiopathic Arthritis
o Fever or unknown origin THINK ABOUT THIS
Other DDX infectious hematologic, rhumatologic
causes
Rash + fever + joint symptoms = JRA
o 20 days high intermittent fever (chronic), body
aches that waxes and wanes with fever, 1 day
history REFUSAL TO BEAR WEIGHT,
Lymphadenopathy, organomegaly, joint swelling
CBC Leukocytosis, thrombocytosis, anmia
o Systemic onset JRA
o No lab tests
o Tx NSAIDs, methotrexate, glucocorticoids
o Daily high-spiking fevers very JRA
o Oligoarticular 1-4 joints
o Polyarticular 5 or more joints
o JRA is most common rheumatologic disorder in
children prior to age 16
Other causes gonococcal arthritis if sexually active
o Younger patients are usually RF negative, older patients
can be RF positive
o Most common joints cervical spine, temporomandibular
joints, hsoulders, hips
o Oligoarticular is MOST common manigestation persistent
and extended categories
Extended = progressive to affect more than 4 joints
in first 6 months

 ANA is often positive

Knee is most commonly affected then ankle do
ophthalmologic screening
will have iridocyclitis anterior uveitis
Evaluation of joint fluid to rule out septic joint
ROUTINE SLIT LAMP OPTHALMIC EXAMS for uveitis more
than 50% will persist into adulthood
Patients with parvovirus TRANSIENT RF positive
Mild anemia (retic of 0) NO CELL
PRECURSOR
ARTHRITIS
JIA = UVEITIS
Examine one joint above and one joint below the
affected joint WBC and eSR
JIA = Friction rub Give salicylates or steroids and
pediatric cardiology consult
27 B12 deficiency
NEC Surgery removal of ileum megaloblastic
anemia
Give monthly IM B12
Hypothyroid, trisomy 21, b12 def, folate def = Macrocytic
anemia with low retic count
Hemolysis = elevated retic count
Breast fed infants of mothers who adhere to a strict vegan
diet risk for B12 def
Irritability, loss of appetits, decreased activity signs of
anemia
Diphyllobothrium latym
IBD
Children with macrocytosis with NORMAL B12 and FOLATE

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Case
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Check bone marrow leukemia or myelodysplasia

hematologic consult
Smooth red tongue may be observed in juvenile
pernicious anemia = AR condition
Petechiae may occur with vitamin C/K deficiency
Muscle fasic Vitamin D or calcium
Hair loss with ZINC
North US, Alaska, Canada diphiloboth in seafood
Goat milk - -give B12, folate, iron
28 Lead toxicity
Abdominal pain, achy bones, vomiting constipation
MOVING TO OLD HOUSE
Do Blood Lead Level (BLL)

o
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Case
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o Initiate chelation therapy

o Other sources of lead welding, radiator repair, furniture
refinishing
o Plumbism alternate name for lead poison
o Paint is major source
Glzed pottery, jewelery, fishing equipment,
epxposure of burning lead containing batteries
o Signs anorexia, hyperirritability, altered sleep pattern,
decreased play
Developmental regression, especially with speech
Abdominal complaints
Vomiting, ataxia, alterec consciousness, coma,
seizures LEAD ENCEPHALOPATHY
o Chelation IM CaEDTA, DMSA, succimer
Hospitalized kidsthat are bad 2,3
dimercaptopropanolol and CaEDTA
When using CaEDTA it is renally exctered
BECAREFUL ENCEPH MAHY BE EXACERBATED
WITH OVERHYDRATION
o Recommendations by BLL
10-14 education, dietary, and follow up
15-19 dietary, environmental follow up blood lead
monitoring, follow up BLL in this range at least 3
onths
20-44 LABWORK, H&H, Iron staus, abdominal x-ray
45-69
CHELATION THERAPY, FPP, Zing
Protoporphryin (ZPP)
>70 HOSPITOILIZE CHELATE
DO NOT SEARCH FOR LEAD LINES
Test for neurophysiological exam,
Test hair teeth fingernails for lead
Xray long bones
Env investigation is recommended in patients with a
blood lead level of 20 micrograms/dL or above
LEAD DEPOSITS IN BONE chelation does not remove
all lead from the body it redistributes out and may
rise if it rebounds past 45 THEN RE-CHELATE
Methyl mercury congenital low birth weight,
microcephaly, seizures
Adults: ataxia, tremor, dysarthria, memory loss
(ALRERTED VISION, HEARING, SMELL, TASTE)
Aresenic GI distress, peripheral neuropathy and
encepholpathy

Ethanol can cause hypoglycemia in children and

seizures

Case 29 Postinfectoius GN
o Lab studies LOW C3 NORMAL C4, ASO+, Anti-DNase
B
o 98% o children recover
o ACUTE PROCESS
o Brown urine DDX
PIGN
Strenouous activity Rhabdomyolosis muscle
aches, fatigue, nausea, vomiting
IgA nephropathy painless hematuria, preceded by
URI
HSP
Lupus C3 DOES NOT NORMALIZE IN 6-12 WEEKS
o GN = glomerular inflammation hematuria, proteinuria,
hypertension
RBC casts marker for glomerular injury
o Rheumatic fever and PIGN RARELY occur together
o Abx use during initial GABHS infection reduces risk of
rheumatic fever
BUT HAS NOT AFFECT ON ACUTE PSGN
o Interval between GABHS pharyngitis and PSGN is 12 weeks
o Most have microscopic hematuria
85% have edema
60-80% HTN
o MOST IMP LAB TEST LOW C3 NORMAL C4
o Renal biopsy is NO LONGER routine
o HTN easily controld with CCBs
o Resolution is rapid and complete 12 days
o C3 levels normalize in 2-3 months
o Microcopic hematuria may persist for 1-2 years
o Everybody I nthe family has blood in urine BENIGN
FAMILIAR HEMATURIA
AD condition THIN MEMBRANE DISEASE
Case 30 Precocious puberty
o Most common cause idiopathic
o Do serum FSH/LH and bone radiographs
o Delayed pybtery no signs by 13 in girls or 14 in boys
o Precicoius pubtery, before 6-8 girls before 9 in boys
o True precocious puberty secretion of GnRH
o Questions to ask:

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Case
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Has the child been outgrowing shoes and clothes

Appetitis
Body odor
Are they on sterois?
What age pubtery?
Family history of CAH?
LH level is sensitity when using random blood sample
GnRH stimulation test
Bone age radiographs are advanced beyong
chronological age in precocious pubtery
GnRH agonists I stherapy
Premature thelarchy ovarian cysts, transient GnRH
release
Boys with CAH small testes high steroids
Measure 17-aAny girl with short stature do chromosomal analysis
Kleinfelters treatment is long acting testosterone
Precocious pubtery is idiopathic in 90% of girls
CNS abnormality is noted between 25%-75% of boys
31 Ambigious genitalia
Do karyotype, serum electrolutes, and 17a
Most likely DDx CAH
21 hydroxylase def inadequate production of cortisol,
excessive prodx of androgens
Hermaphroditism discrepancy with INTERNAL/EXTERNAL
gonads/genitalia
Microphallus penis size below 5th percentile for age less
than 2cm
Goal of therapy find etiology, assign gender, interve with
surgery or other tx
Hermaph
Female pseudohermaph 46xx MOST COMMON
CAH IS MOST COMMON ETIOLOGY phenotypic males
with normal o varies/uterus
Rare etiology congenital vaginal absence
Male pseudo 46XY testosterone dysthensies, 5a
reducatse D, AIS
Phenotypic females with normal testicular
tissue
Short pouch like vaginas
Diagnosed at puberty when amenorrhea is
noted
Maintain as females and offer vaginoplasty

True hermaph 70% 46XX and remainder ar 46XY or

mosaic
Bilateral ovotestes or ovary and testis on
opposite sides
75% assigned male
Mixed gonadal dysgensis 46XY, 45XO
Testis with sertoli and leydig NO GERMINAL
ELEMANTS
o On one side
Streak gonad on other side
Hyposadias, undecescended testes
Usually assiend female and undergo
gonadectomy
Critical finding presence or absence of testes in
labioscrotal compartment
Hyperpigmentation of scrotum (CAH)
Palpation of uterus
Phallic size is the most important factor in
determining na infants sex assignment
Do karyotype first
Urinary steroids and plasma andorgens before and
after ACTH and bHCG admin 5a reducatse
def
Reconstructive surgery with gonadecromy at 6
months
Male hypospadias often requires multiple
procedures to create phallic urethra
CAH administer hydrocortisone to inhibit
excessive production of androgens
Male infants with 21-a def can appear normal but
develop clinical symptoms (sale wastng) hypotonia,
floppy, diffuclty feeding
No feer, no appetitis, lethargy, dry oral mucosa
TEstic feminization AIS NO INTERNAL (XY)
Short atretic vagina mos common phorm of
male pseudohermaphro
Severe hypotonia, FTT, hypogonadism
Hyperphagia, obesity, mental retardation,
appearance of bizarre behaviors by 6
32 Syphilis
NONTENDER ULCER on shaft
Slight enduration around ulcer
Test for concominnant

Case
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o Accurate diagnosis without testing is difficult send blood,

urine, urethral secretions, lesion aspirit or scrapings
o Can have inguinal lymphadenopathy
o Dark field microscopy of scraping
o Urine chlamydia probe (for dysuria)
o ALWAYS DO HEPB and HIV with other STDs
o Chancre PAINLESS
o Chancroid PAINFULL
o Note for: dysuria,discharge, frequency, lesions, postural
rash, joint infection
o Chancroid tender lymphadenopathy
o Syphilis test with VDRL/RPR then MHA-TP or TP-PA
Any neurological symptom warrants LP for counts
and FTA-ABS or VDRL
o IM PENICILLIN G one to three times weekly
o Tertiary syph Minminm 10 days of IV Penicllin G
o Can give doxycycline
o Abdominal pain girl UTI, torsion, cyst, ectopic
Do urinlaysis and pregnancy testing
o Syphilis can do GC always order HIV with STD
o Fitz hugh Curtis can be G or C (C is more common!)
o Frequent douching no discharge dysuria
chemical urethritis
Case 33 Pityriases Rosea
o Tx supportive care with emollients and antihistamines
(for pruritis)
o Initial largish lesion on back 5-10 days later widespread
lesions
Oval round, scaly, pinkish, trunk, face, limbs
o DDX
In sexually active CONSIDER SECONDARY
SYPHILIS?
Pit can be found on palms and soles
Guttate psoriasis variant of psoariasis after
strep infection
Sudden eruption of oval psoriatic lesions
on trunk, face, limbs
Resolve with Abx (not pit)
Nummular dermatitis pruritic boggy or
vesicular round lesions extremities, buttocks,
shoulders
Pityriasis Lichnoides chronica

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Case
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Small reddish brown papules, covered

with grayish scale o ntunk and
extremities
CHRONIC and NO HERALD PATCH
Pyt rosea commonly preceded by a prodrome of fever
and malaise, rarely require medical attention
Negative KOH = Pit and not fungus
Lesions last 2-12 weeks and are asymptomatic
Tinea corporis = ring worm clear middle
Circular, scaly, erythematous, topical azoles
Pit alba hypopogmented macules around face, neck,
upper trunk, and proximal upper extemeities
Manifestation of dry skin
34 Bacterial meningitis
Fever, headache, stiff neck, altered mental status
Ddx meningoencephaliitis, trauma, toxic ingestion,
hypoglycemia
Brudzinski KNEE
Kernig pain on leg extension to 90 degrees with flexed hip
BASED ON AGE
Neonates GBS/Ecoli, listeria
Hematogenous spread NONSPECIFIC
SYMPTOMS
Poor feeding, emesis,
hypothermia/hyperthermia, seizures, irritability,
apnea, BULGING FONTANELLE
Older children Strep Pneumo or Neisseria
Vacciens ilimiate HiB(TYPE B)
SICKLE CELL higher risk with PNEUMOCOCCAL
(ENCAPSULTED)
Risk factors: sinusitis, otitis media, pneumonia,
head trauama and leaky CSF
Contraindications for LP = skin infection over planned
puncture site, increased ICP, critically ill patients
Neonates = ampicillin and third gen cephalosporin or
aminoglycoside (covers GBS, listeria, ecoli)
If penicillin resistant give VANCO and third
gen cephalosporin
Complications seizures, CN palsy, cerebral infact,
cerebral and cerebellar herniation, venous sinus
thrombosis, subdural effusions, SiADH, central
diabetes insipiduse
MOST COMMON SEQUALE IS HEARING LOSS (up to
30% with pneumococcus)

o Patient with meningococcemia SHOCK do the ABCs

o Sinusitis --< worsening emesis and nuchal rigidity
INTRACRANIAL ABSCESS
Do a CT scan first
o Retropharyngeal abscess can cause neck stiffness
Unable to eat posterior pharyngeal midline
fullness, he drools to avoid pain of swalling
Dysphagia, fullness in oropharynx
Lateral neck films
Case 35 Bacterial Enteritis
o Watery diarrhea progressing to bloody diarrhea with
mucus, new onset seizures
o Salmonella (not treated), Shigella,
o In this case without fever think Meckel, intussusception,
HSP, HUS, C. dif, polyps
o Salmonella warmer months
Facultative anaeronbes, do not ferment lactose
Pultry, raw eggs, iguanas, turtles
Sudden onset nausea, emesis, cramping abd pain,
watery or bloody diarrhea low grade fever
NEUROLOGIC SYMPTOMS confusion, headache,
drowsiness, seizures
5% can have transient bacteremia and arthritis,
oesteo, pneuomonia, meningitis,
Tx CORRECT FLUIDS AND ELECTROLYTES (no Abx)
o Shigella small g- bacilli
Non-lactose fermenting
Person to person infection
NEUROLOGIC FINDING
Can progress to sepsis like presentation (ekiri
syndrome) that quickly results in death
Abx can be used
o Yersenia can cause acute abdomen
o DO A STOOL CULTURE fecal leukocutes are
POSITIVE
On blood test WBCs is normal with
REMARKABLE LEFT SHIFT
o HUS most common cause of acute renal failure in children
most common with Eo517:H7
o Bloody stool, bilious emesis, colicky abdominal pain, RUQ
mass INTUSSCEPTION
o HUS blood diarrhea ANEMIA,
THROMBOCYTOPENIA, NEPHRPAHTYH

Dont confuse with HSP and IgA nephropathy not in

infectious setting
EDEMA, HTN
SUPPORTIVE CARE with fluids and electrolytes
o C. diff colonized half of normal healthy infants in the fisrt
12 months dont give Abx
Case 36 Appendecitis
o 15 year old periumbilical pain 8 hour duration with
anorexia, emesis, loose bowel movement
o no bowel sounds, rigid, abdomen, pain with DRE
o get PREGNANCY TEST even if she says shes not sexually
active
o Abdoinal pain followed by anorexia and vomiting suggests
appendeicitist
o Perfs in 65% of time if delayed by more than 36-48 hours
o Non specific but can have LEFT SHIFT on CBC (HIGH
BANDS)
o US is more sensitive for appendicitis then CT and is more
useful in females because of ovarian cysts and pregnancy
o Perforation can becomplicated by sepsis, abscess
formation, or prolonged paralytic ileus
o Pneumonia can cause abdominal pain (inflame of
diapghram) look out for fever, cough, abdominal
pain CXR
o Intraabdominal abscess after perfd appendix 5 days after
surg do CT and back to surgery
o PYURIA FROM APPENDECITIS cause by bladder wall
irritation or uretral irritation by inflamed appendix
o Strep throat can cause abdominal pain and emesis
o Emesis follows onset of pain in Appendecitis
Case 37 Mono EBV
o 10 day history malaise, headache, nausea, fever, sore
throat, morbilliform rash after taking ampicillin
o Fever rash tonsillay hypertrophy, posterior cervical
lymphadenopathy, splenomegaly
o DO A MONOSPOT (heterophil antibodies)
o Tx symptomatic care, avoid contact sports when spleen is
enlarged
o DDx
GAS pharyngitis no splenomegaly
CMV no throatache
o Rash with ampicillin/penicillin
o Virus is excreted in saliva replicates in oropharyngeal
epithelium and later in B lymphocytes

1-2 weeks prodrome fever, nausea, malaise,

headache, sore throat, abdominal pain
Physical findings during acute infection generalized
lymphadenopathy, splenomegaly, tonsillar
enlargement with exudate
Monospot MUST BE OLDER THAN 5
EBV viral capsid antigen, eaerly antigen, EB nuclear
antigen
IgG and IgM appear first, then Anti EBNA appear 1-2
months and persist for years
Thrombocytopenia is common
Mild elevated LFTs common
Sequalae bell palsy, seizures, aseptic menigits,
encephalitis, GB syndrome, optic neuritis, tranveser
myelitis
Splenomegaly in 50% of mono
EBV can stimulate human hemophagocytic syndrome hair
leukoplakia, smooth muscle tumors, lymphoid interstitianal
pneumonitis, or burkitt
Remember monospot not useful in younger kids do EBV
antigens
Persistent fever consider Kawasaki
If airway is obistructed in EBV think about steroids
38 Pinworms
Perianal and perineal pruritis worse at night
Enterobeus vermicularis
CELLOPHANET APE TEST
Management alben/mebendazole pyrantel pamoate
Most common nematode infection in NA humans are the
only natural host
Ascaris lumbricoides EGG INGECTIONS FROM SOIL OR
FECES hemoptysis, pulm infiltrate**, distension
Ova/egg in stool
Hookworm Ancylostoma/Necator larvae in soil
penetrate
Pruritis and rash at site of entry, diarrhea,
GI/resp sympptoms
Ovoid eggs in stool
Strongyloids Larvae penetrate skin and move to lings and
intestines epigastria cpain, emesis diarrhea,
malabsorption
IVERMECTIN

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Case
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o Toxocara, Baylisacaris procyonis VISCERAL OCULAR

LARVA MIGRANS egg ingestion or contaiminated
soil with dogs/cats
Fever ough, occasional abdominal pain,
hepatomegaly
SIGNIFICANT EOSINOPHILIA
Diethylcarbmamazine, albendazole,
mebenedzole
o Whipworms Tichuris trichurua- egg ingestion no
symptoms
RECTAL PROLAPSE, blood diarrhea
Lemon shaped eggs in stools
Mebendazole/albendazole
o WATCH OUT FOR PERIANAL CELLULITIS pinworm
doesnt cause erythema of anus
o Rectal prolapse = whipworm do stool test for ova
o Immunicompromised and strongyloides MASSIVE
INFECTION OF RGANS AND TISSUE DESTRUCTION
Case 39 Subdural hematoma
o Common in younger than 1 yr old
o Epidural hematomas are common in older children
o Seizures are COMMON in 75% of affected patients with
subdural
o 1/3 of subdurals have skull fracture are BILATERAL
o increased ICP is typical
o GCS Eye opening, Verbal, Motor response
o Subdurals
Acute within 48 hours
Subacute 3-21 days
CHRONIC SUBDURALS AR MORE COMMON IN OLDER
CHILDREN
Retinal hemorrhages are common (not in epidurals)
o Epidurals are unilateral
o Acute epidurals have higher mortality rate BUT LOWER
MORBIDITY THAN SUBDURAL
o MR can tell you hematoma age
Case 40 dysfunctional uterine bleeding
o Girl with heavy bleeding, anemia, orthostatic hypertension
o Management: IRON SUPPLEMENET, low dose OCPs for 3-6
months then FOLLOW UP Hb and H in 6 weeks
o 9% of women will have organic cause ectopic, threatened
abortion, cervicitis, HPB, trichomonas, Trauam, hormonal
contraceptives, hypothyroid, foreign body
DUB is a DIAGNOSIS OF EXCLUSION

o Hb characterizes severity of bleeding

More than 12 mild bleeding
9-12 moderately sever bleeding
less than 9 SEVER BLEEDING HOSPITLIZE
if poor response to pharma D AND C
Can give PREMARIN and high dose OCPs until
bleeding stops no thrombotic events if short use
o Continue OCPs for 3-6months
o Iron supplementation for 2 months after anemia has
resolved
o Ectopic leading killer in 1st trimester
o Gardisil 6, 1,, 16, 18 three doses Sx headache and
pain at injection site
Anaphylaxis to yeast is contraindication
Observe 15 minutes AFTER ALL VACCINES due to
syncome
o Sever anemia PREMARIN and HIGH DOSE OCPs
If successful continue high dose for a month then
move to low dose
If bleeding continues D AND C
Case 41 Simple febrile seizure
o At 2 years old can have positive brudzinski and kernig
Under 1 year are unreliable
DO AN LP if seizure, fever in under 1
o Diagnosis if febrile seizure can only be made AFTER ruling
out CNS infection
o IF a neurologic exam is ABNORMAL, seizure occurred
several days into illness, or child is unable to provide
adequate feedback during neck examination
DO AN LP
o DO A CT BEFORE YOU DO AN LP
o Seizures occur 6month-6 years show family history
o Simple febrile seizure lasts less than 15 minutes without
focal or lateralizing signs or sequalaue
If more than 1 total episode is less than 30 mins
o Complex lasts more than 15 minutes and may have
lateralizing signs
More than 30 mins
o If they last moer than 5 mins can give benzos CHECK
AIRWAY MANGEMENT THO Benzos can cause resp
depression
If unresponsive to benzos GIVE FOSPHENYTOIN
o Can do imaging for complex febrile seizure or in patients
with evidence of increased ICP

o Age 6mo-6years
Duration <15, no lateralizing signs, no focal seizures,
not recurrent Siple febrile OBSERVE
Copmlex NEED WORK UP
<1 yr old LP
>1 consider CT, EEG+/- LP
o younger than 1 50-65% recurrence, older have 20-30%
o Increased risk for epiplepsy with febrile seizures
o Seizure after trauma
Case 42 Musuclar dystrophy
o 4 year old boy has delayed walking, waddling gait,
clumsiness, proximal muscle weakness
o Test DNA Peripherap blood analysis
immunohistochemical detection of abnormal dystrophin on
a muscle biopsy
o Duchene X linked recessive
o Initial tests CK and DNA of peripheral blod
o ONGOING CARDIAC EVALUATION FOR CARDIOMYOPATHY
o DMD most common heridetary NEUROMUSCULAR
DEGENERATIVE DISEASES
1/330 30% are new mutations
o Sx frequent falling, difficulty climbing stairs, hip waddle,
proximal muscle weakness (gower sign)
Muscle enlargement, caused by hypertrophy of
muscle fibers and infiltration of fat and collagen
proliferation
Pseudohypertrophy and a woody feel in affected
area
Cardiomyopathy TALL R WAVES, and RIGHT and
DEEP Q WAVES on the left
Intellectual impairment
Brain atrophy can be seen on CT
o Patinet in wheel chair by 10-13 years of age have rapid
progression of scoliosis after loss of ambulation
o Distal muscles remain functional permitting manual
dexterity
o Diminsed pulm function due to muscle involvement
recurrent infections, can lead to aspiration
o DNA Blod nalysis is diagnostic in 2/3 cases = if its not do
muscle biopsy
Endomysial connetive tissue proliferation,
inflammatory cell infiltrates, areas of regeneration
interspersed with areas of degeneration, and areas of
necrosis

N 80% of cases female carirers have elevated

CK levels
Orthopaedic bracing and tendon lengthen can
prolong duration of ambulation and slow
progression of scoliosis
However, patients are prone to hyperthermia
with anesterhsia
Physiotherapy may delay contractures, significant
exercise can hasten muscle degeneration
Can offer PREDNISODNE
RESPIRATORY FAILURE OFTEN CUASE OF DEATH
GIVE ROUTINE VACCINES AND INFLUENZA
MYTONIC MUSCULAR DYSTROPHY is #2 in the uS
Autosomal dominant inverted V-shaped upper
lip, thin cheeks, wasting of temporalis
Head is narrow and palate is high and arched
Speech difficulties, GI problems,
endocrinpathies, immunodeficiency, cardiac
involvement
DMD = calf hypertrophy COMPENSATOIN FOR
PROXIMAL MUSCLE WEAKNESS
CK best SCREENING TEST
PRESENTATION OF weakness at 12 = BECKERs
Myotonic dystrophy can be congenital
43 Neonatal herpes
Nenoate = less than 60 days
10 day old fever, irritability, decrease oral intake,
VESICLES ON SCALP, SEIZURE LIKE ACTIVITY
LYMPHOCYTOSIS MENINGITS,
THROMBOCYTOPENIA
Left untreated majority will have disseminated or CNS
infection and DIE
Findings of VESICLES ON SCALP make HSV the most likely
pathogen
Absence of maternal symptoms (uncomplicated birth is a
usualy history) only 25% of mothers have symptoms at
delivery
Blood, urine, CSF test for HSV PCR
MAJORITY CAUSED BY HSV-2!!!! 75%
HSV-1 is not as bad
C-section if GENITAL HERPES or SYMPTOMS OF HSV
INFECTION
50% if delivery vaginal, 5% of C-section

o
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Case
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o Neonatal HSV localized skin, eye, mouth involvement

(SEM), encephalitis,
SEM 1-2 weks of life
CNS 2-3 weeks of life
FEVER is UNCOMMON
Dissimenated disease: fever, lethargy, irtiable,
anorexia, vomiting, Resp D, apnea, jaundice,
BULGING FONTANELLES< seizures, decerebrate
psture, COMA
o SKIN VESICLES on 2/3 cases
o Hepatitis, pneumonitis, shock and DIC in severe
cases
30% of these WILL NOT SURVIVE
o Tzank pre RAPID DIAGNOSIS but low sensitivity
o EEG/CT TEMPORAL LOBE ANOMALIES
o PARENTERA ACYCOLOVIR is treatment
Case 44 Atopic dermatitis
o 11 month dry, red, scaly exensotrs, cheecks, chin,
aroun the mouth, SPARING OF DIAPER AREA, INTENSE
PRURITIS, wakes up at night
o Atopic dermatitis
o Tx topical steroids, frequent use of emollients and control
pruritis
o NO FEVER
o Seborrheic dermatitis self limited, scaly, crust ONLY
ON SABECIOUS GLANDS (cradle cap)
Greasy brown scales
o 70% history of atopy and asthma
o Cause: Multifactorial, genetic abnormalities of epidermal
barrier, immune function, envoironmental expsiures,
infections
o FILAGGRIN gene loss of function ichthyosis
vulgaris AD
o AD occurs in three phases
Birth-2 - babt during winter months develops dry
red, scaling cheeccks without perioral and paranasal
chil is involved, diaper is spared
Cant sleep intense pruritis
Resolves 50% by 18months
2-12 FLEXURAL AREAS
adult >12 flexural phase hand dermitits,
inflammation around eyes, lichenification or
anogentials
DERMOGRAPHISM

o
o
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o
o
o
o
o
o
o
o

KERATOSIS PILARIS accentuated palmar

creases
Small fissures at base of earlobe
Dennie morgan creases under lower eye
lid
Eczema is an emotional disorder most cases preceipitate
by environmental stress on skin NOT AN ALLERGIC
REACTION
Labs not helpful IgE may be elevated
LIMIT BATHS to brie and moderature temoperautre with
mild or NO SOAP use
Use cetaphil
Apply lubricants after bath and air dry
Topical steroids (no side affets) Fluticasone cream
AVOID IN FACE, GENITALIA, and the
INTERTRIGINEOUS AREA BECAUSE THEY MAY
DEPIGMENT AND THIN THE SKIN
Use lowest effective potency
Tacromulus, pimecromilus immunomodulators
recommended for short term or long term INTERMITTENT
therapy twice daily
For refractive treatment
BLACKBOX for association with malignancy
Oral antihistamines to reduce itching often worse at
night, use sedating antihistamine
Loratidine, cetirizine,
AVOID TOPICAL ANTIHISTAMINE (skin irritation and
toxicity)
Cut finger nails short
Topical antibiotics Mupirocin (bactroban)
If strong history with exacertbation with food do food
challenege
Primary irritant dermaitits diaper, lip licker, shin guard
Allertic dermaitits 7-14 days after expsosure*****
Rhus poison oak, ivy, sumac
Nickel allergy snaps of jeans, ear lobes
Scalp, face, eye brows, auditory meautus, cheecks,
nasolabial folds YELLOW WAXY, Coems off with
frequent shampooing can be loosed with oil give
low-medium corticosteroids
AFTER DERMATITIS RAPID ONSET FEVER
Vesicular, red, punched out lesions with
umbilications

THIS IS ECZEMA HERPETICUM MEDICAL

EMERGENCY
IV Acyclovir and ADMIT
Eczeema recurrent infections EASY BLEEDING Do
CBC thrombocytopenia WA
High incidence of lymphoma and other malignancies
45 NEUROBLASTOMA (ADRENAL NEUROBLASTOMA)
Toddler with fatigue, decreased appetitis, periporbital
discoloration,
ENLARGING ABDOMINAL MASS CROSSING THE
MIDLINE
Next step imaging
Opsoclonoys-myoclonoys syndrome dancing eyes,
dancing feet
NB most prevalent extracranial tumor in children
more than HALF of all cancers in infancy
Most arise in abdomen from adrenals but can
be paraspinal neuronal ganglia
Cervical ganglia horners
Intrathoracic wheezing respiratory distress
Paraspinal compressive neuraligias, back
pain, urinary/stool retention
Abdominal masses non tender, irregular,
cross the midline
METS to skin, lungs, liver, bone
BLUE SKIN represents subcutaneous infiltration
Bone marrow infiltration causes bone pain and
pancytopenia, petachiae, brewing, pallow, fatigue
ORBITAL BONE INVOLVEMENT blue discoloration with
proptosis RACOON EYES
Generalized lymphadenopathy is common
PARANEOPLASTIC from neuroedncoetine,
opsoclonus=mycolnus can have cerebellar ataxia
DDX
Wilms tumor Hematuria, hypertension,
localized abdominal mass RARELY CROSSES
MIDLINE
CT msost useful
Labs elevated VMA and HVA observed in 90% of patients
Elevated enolase, ferritis, lactate dehydrogenase
Treatment involves scission AFTER chemo cure rates
of 90% with infants having a better prognosis then
older children

Case
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SKELETAL METS or N-myc GENE AMP = POOR

PROGNOSIS
MASS DOESNT CROSS MIDLINE No symptoms =
WILMs tumor
UA check for hematuria, CMP for renal hepatic
dysfunction
CBC for anemia
In the newborn MOST CAUSE OF PALPABLE MASS
Multicystic kidney do an ultrasound
- right
midquadrant abdominal mass
1 wk old DECREAED URINARY OUTPUT
nothing else is different
46 retropharyngeal abscess
Ill appearing toddler, SPRETHROAT, odynophagia, fever,
ABNORMAL POSTERIOR OROPHARYNX
Labs can do GAS immunoassay, LATERAL CERVICAL
XRAY and CT
Retropharyngeal space deep cervical fascia covered,
powsterior to esophagus, contains LYMPHATICS that drain
middle ear, sinuses, and nasopharynx
CONTIGIOUS WITH POSTERIOR MEDIASTIUNUM
Paraphyngeal (lateral) space anterior and posterior
compartments contain lymph nodes, CN, carotid sheat
Infection from oropharynx, middle ear, teeth
Peritonsillar abscess bordered by tonsillsa nd pharyx
muscles extension of acute tonsillitis
Epiglotittis infection of cartilaginous structures protecting
the airway during swalling; bacterial (Hib)
Odynophage pain on swalling
Dysphagia difficulty swalling
Trisumus unable to open mouth secondary to pain or
mass effect involving facial musculature
Toddler younger than 4 years coninciding with URI most
common patient for retropharyngeal abscess
Peritonsillar greater in adolescence and young
adults
Of all abscesses this is the most common one
All these infections present the same fever, irritability,
toxic appearing, sore throat, dysphagia, odynophagia,
trisumuss (more with peritonissillar or parapharyngeal
infection)
Neck lymphadenopathy is noted often in patients with
peritonesillar and parapharygnia
Soft palate swelling (peritonsillar)

Case
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o DROOLING AND INREASED WORK OF BREATHING OR

FRANK STRIDOR
o LATERAL CERVICAL XRAY best test
Widening retropharyngeal space
o Thumb sign epiglottitis
o CT differentiats between cellulitis and edema and rim
enhancing abscess
Can also dileniate extension into other structures
o All these infections can impact NEUROCASCULAR
ELEMENTS IN THE LATERAL SPACE due to erosion
or mass effect
Can spread to mediastinum cause problems with
cardiorespiratory or mediastinitus
o Neck abscess results from pharyngitis, odontogenic
infection, otitis, mastoiditis, sinusisitsi
o Exudatove pharyngitis, neck findings, RHINORREA and
COUGH = VIRUS!
o Can give penicillins and clinda/metro for anaerobes
o Surgeons watchful waiting approach or surgical
drainaiage
If infiltrative then DRAIN
o Others thyroglossal duct cyst or second branchial cleft
cust
Can become secondarly infected
Thyrodotis, sialadeitis also localized neck pain
o Thyroglossal duct cysts MIDLINE move with TONGUE
protrustion can have cough from superinfection
o Viral URI causes reactive lymphadenopathy supportive
care
o Strep presents with throat ache, headache, nausea,
and/or fever
o Strep vs tonsils
Tonsillar asymmetry, soft palate changes, nuchal
ridigity = abscess
Case 47 Esophageal atresia
o Newborn with choking, cyanosis, inability to pass
orogastric/nasogastric tube
o CXR is best test with orogastric tube in place
o Infatns with TEF present in newborn with excessive oral
secretions, coughing, cjoking, cyanosis,
H-type can PRESENT LATER IN LIFE
o VACTERL
Vertebral, anal imperf, CARDIAC, TEF, Radial,
Renal

DI GEORGE SYNDROME= ESOPHAGEAL ATRESIA

TEF
Case 48 TTN
o Give oxygen if necessary
o After C-secion mild resp distress
o Meconium aspiration Radiograph = Hyperinglation,
patchy infiltrate
As meconium plugs small airways
Areas of air trapping often present and may
lead to pneumothorax
RSD ground glass
o ECMO Extracorporeal membrane oxygenation a system
using modified heart-lung machine in severe pulmonary
failure cannulation of the carotid artery and jugular vein
is re uire to link the neonate to the system
o Term infant after Csection or vaginal birth
Slow absorption of lung fluid
CXR = perihilar streaking and fluid in fissures
Aerated lungs
o RSD = PREMATURE surfactant deficiency
o Supportive care o2 to get sats up to 90-95% - IV fluids or
nasogastric feeding to maintain hydration as the defree of
tachypnea usualy includes oral feeding
o NEONATE WITH RIGHT SIDEDH EART SOUNDS
UNILATERAL BREATH SOUNDS
Pneumothorax or CDH
Do an ABDOMINAL EXAMINATION
o Intubate a depressed infant with meconium at
delivery
o Pneumothorax excessive light transmission by
transillimunation and right-sided hyperesonance
ANY INFANT WITH MECONIUM OR RSD
HIGHER RISK FOR PNEUMOTHORAX
EVEN WORSE WITH Postiive EEP
Case 49 Malrotation
o Bilous vomiting, lethargy, abdominal distensionm
blood in dpaer
o ABD DISTRENTION BLOOD IN DIAPER!!!!
o Malrotation with volvulus
o Malrotation ligament of treitz located on theRIGHT SIDE
AND INTENSTINE MAY USE THE SMALL PORTION OF
ATTAHCHED MESENTRY TO TURN AND VOLVULUS
o With prolonged gut ischemia develop melena,
hematemesis, peritonitis, acidosis and sepsis

o AB XR corkscrew pattern of the duodenum, bird

beak second/third portion of duodenum
o LADD PROCEDURE
o Complications = short gut syndrome, adhesions =
obstruction
o Even asymptomatic malrotation requires surgery
SIGNIFICANT COMPLICATIONS
o Intussception paroxysmal abdominal pain, colicky
intermittent, currant jelly
SAUSAGE LIKE MASS
o Premature NEC
o 7 yr old Gastroenteritis
o ANYTIME VOMIT or Diarrhea pH AND ELECTROLYTES
o Pyrloric stenosis condition 4 times more common
in males
3rd-8 week of life with projectile emesis and
olive shaped mass
visible peristalsis
HYPOCHLOREMIC METABOLIC ALKALOSIS

US to confirm

Case 50 Acne vulgaris

o Adolescent girl presents with acne on face and shoulders
o Antebacterial sopas, keratlytic agent (benzoyl peroxide)
Comedilytic agent (tretinoin), erythromucin (topical),
tetracycline, isotretenoin (oral) reserved for
refractory cases such as nudolycistic acne
o Open comedone white head close comedone black head
o Papule Nodule
o Pustule elevated focus of inflammation and purulent
exudate around a comedone
o Pubertal hormonal surges lead to an increase in
sebum production by sebaceous glands

Proliferation or propinobacterium acnes

distenstion of follicular walls OBSTRUCTION OF
SEBUM
Neutrophils and liposomal enzymes are released
Scarring and pitting often may result
Noninflammatory acne = open/close comdeones
Inflmamatory papules, pustules, nodules, cyst
Treatment elimination lesions and dimishing scarring
Change can take up to a month after therapy with
flairups during treatment
Patients should be discouraged from manipulation
skin lesions doing so will increase inflammation and
promote scrarring
First line TOPICAL BENZOYL PEROXIDE or
Comedolytic agent (Retinoid)
One in morning retinoid at night
Benzoyl must be washed off face prior to application
of tretinoin or it will be rendered ineffectinve
Benzyol bactericidal and keratolytic (causing
follicular desquamation)
Topical tretinoin inhibits formation of microcomedones and
increases cell turnover
Patients should use dove or cetpahil to allow skin to dry 2030 mins before using nightly tretinoin
Differin is a retinoid that causes less irtiation and
photosensitivity, has more activity and can be used with
benzoyl
Tazorac retinoid against psoriasis
TERATOGENIG AND CAUSES IRRITAITON SO USE
WITH CAUTION
Topical rather then systemic Abx are preferd due to
less sideffects tetracycline most used
Isoretinoin treatment of choice in nodulocystic acne
5 months course
highly teratogenic and has many side effects
chelitis, conjunctivitis, hyperlipidemia, blood
dyscrasias, elevated liver enzymes,
photosensitivity
Monitor Lipid/liver/and CBC when using
NEGATIVE PREGNANCY TEST and TAKE
OCPs
Depression is a rare sideeffect of isoretinoin
refer to psychiatrist
Dont go out in sun and use sunscreen

o
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o BOY WORKS ON FARM ZITS ON FACE AND BEARD

AND MUSTACHE Tina Barbae
Dermatophytes resemble tinea capitis
exopsurese on farms
GIVE ORAL ANTIFUNGALS topical dont work
o Oral antibiotics may decreaed effectiveines of OCPs
So patient on Abx and retinoin oral TAKE
SECOND SET OF OCPs
o Dont take tetracycle with milk - TAKE ON EMPTY
STOMACH

Case 51 Posterior urethral valves

o Term new born SEVERE URINARY OBSTRUCTION
Hydronephrosis and hydrourterus
ABDOMINAL MASS
Dribbling urine
o Abdominal US is a useful and non invasise tool to diagnose
o With VCUG and veiscouretral reflux URETERS ARE
OUTLINED only urethra should be visualized
o Fetal US should show key hole appearance
hydronephrosis
o Oligohydramnios can happen with cases leading
to pulm hypoplasia
o Posterior valves most common cause of severe
urinary tract obstruction in boys occurring in 1 every
5000-8000 newborn males
o Neonates disteneded bladders, poor dribbling urinary
streams, palpable kidneys, reduced renal function UTI
o Older infants FTT, renal dysfunction, UTI
o Olderb oys diurnal enuresis frequency, voiding difficulty
o CONFIRM Posterior with urethral valve VCUG or
postnanal USG
o If UTO VCUG and USG
o Immediate relief
Cath bladder

Abx for UTO

Get electrolytes, BUN, creatnine
Monitor hemodynamic status sepsis can lead to
collapse
Endoscopic transurethral valve ablation if kidney is fine
and urethral siz permits
If too small urethrea, or creatning elevated, or
inresponsive UTO Vesicostomy
Follow up after surgery for UTI UA, USG,
serum elctrolytes, BP, linear growth
May have prolonged diurnal enuresis and
require urodynamic studies
Renal insufficiency is common and they can
require renal transplants
Any male infant with UTI do anatomy with VCUG
Infants with VUR- prophylactic antimicrobials
BW syndrome Wilms tumor, hepatoblastoma
gonadoblastoma,
Right sided hemihypertrophy
Nocturnal bed wedding with no other symtopms use
alarm clock
Post urethral valves are at high risk of renal failure EVEN
WITH treatment surgery
52 - ADHD
8 year old easily distractable, cannot do well in school or at
home
ADHD evaluation requires information regarding
behavior from home and teacher
3-10% of school-aged children with a signifncant
male predominance
25% have an affected primary relative
decreased activity of certain areas of frontal lobe (maybe)
Criteria
Inattention criteria careless mistakes, not
paying attention, not completing assignments,
avoiding sustained mental effort, frequently
losing things, easy distractability, forgetful
Hyperactivity criteria fidgeting, being out of
seat, running or climbing excessively, having
difficulty playing quite, talking execessively
Impulsivity blurting out answers, having a
tough time waiting for turn, interrupting or
intruding frequently
3 tyeps

o
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o
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Case
o
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o
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o
o

ADHD/I 6/9 inattention beahviors

ADHD/H 6/9 hyperactive or impulsive behavior
ADHD/C 6/9 in attention and hyperactive/impulsive
behavior
Symptoms at least 6 months of age in two or more
settings before the age of 7 sympotms result in
impaired function
SNAP, ADDH Check leist
Commmon coexisting disorders
Oppositional defiant most common
Conduct
Anxiety disorder
Depressive disorder
Learning disorders
Behavioral modification and pharmacological
Positive reinforcement, negative consEQUENCES
Small class slize, appropriate seating
arrangement
Stimulants first line methylphenidate and
dextroamphetamine
Straterra nonstiimulant SNRI
TCAs
Long term complications poor peer relationships, poor
fine motor control, increased risk of accidents, substance
abuse
50% lose by adultshood other 50 have it
Prior to developing treatment plan = assess the child for
coexisting learning or psychiatric conditions
53 Osgood-schlatter disease
Right tibial tubercle athelete
RICE
Knee pain inflammation of tibial tubercle, an extension of
the tibial epiphysis or growth plate PRIOR TO CLOSURE
OF GROWTH PLATE OSD
Edema and pain tibial tuberosity
Clinical diagnosis
Patellofemoral syndrome also common
Jumpers knee (patellar tendonitis) microscopic patellar
injury
Anterior chronic knee pain
Iliotibialr band friction syndrome lateral knee pain
in runners
SLIPPED CAPITAL FEMORAL EPIPHYSIS (SCFE) occurs in
obese adolescents during growth spurt

o
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Case
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Leads to a limp and growin or thigh pain HIP

PAIN MAY BE REFERRED TO KNEE
LIMITED HIP FLEXION and KNEE PAIN
@ risk for avascular necrosis
trauma, tumor, leukemia, and septic joint
Get orthopaedi consult dont order MRI yourself?
Case 54 Torticollis
o Breech, hip dysplasias, metatarsus adductus at higher risk
for torticollis
o Klippel-feil syndrome congenintal FUSION of
porstion sof cervical vertbrea
Restricted neck, short, neck, low hairline
Torticollis
o Sandier syndrome GER, Hiatial herniea, Posturing
of head
o Sprengel deformity congenital elevation of scapula
o Injury to SCM
o Next step XRAY to rule out vertebral deformity
Normal spine gentle massage
o If persists beyond 1st month consult orthoapedics
Can cause facial asymmetry
o Congenital cervical
o Down syndrome, visual disturbance
o Dystonic reactions (phenothiazine, haloperotidol,
metoclopramide)
Although you should evaluate for seizures
electrolytes, glucose, calcium
Diphenhydramine reverses this drug induced
dystonia
o Spinal cord/posterior fossa tumors
o Syringeyelia
o Wilsons, dystonia
o Retropharyngial abscess or cellulitis fever,
dysphagia, drooling, stiff neck, dyspnea, or airway stridor
Midline or unilateral swelling may become a fluctuant
mass
Case 55- Congenintal cataracts
o Get history, assess for chromosomal, metabolic, infectious
entities
o Aphakia absence of lens
o Amblyopia loss of vision caused by underuse of one eye
o CC insolated in 50-60% of cases
Syndromic in 20-25%
o AUTOSOMAL DOMINANT if its isolated

o Toxo, CMV, syphilis, rubella, HSV,

o Galactosemia, homocystenimia, galactokinase
deficiency, abetalipoproteinimia
o Fabry, hurlers, neiman pick, refsum, wilsons
o Retinitis pigmentosa, uveitis, retinal detachment
may lead to the development cataracts
o Chromosomal 13, 18, 21; turner syndrome, depletion and
duplication syndromes
o Next best step
TORCH
Galactosemia
o If no surgical correction of cataracts- make sure you dont
develop amblyopia (opacity of visual axis) so make sure
you make them use the bad eye (patch good eye)
o Remove opacity strengthen the weak eye by covering the
good eye or using eye drops in the good eye (penalizing
therapy)
o Maternal infection rubella FIRST TRIMESTER
cataracts, organomegaly, purpura, jaundice,
retinopathy, thrombocytopenia, hemolytic anemia
Sensineural hearing loss, endocrine diseases,
neurodevelopmental abnormalities,
hypogammaglobulinumia
o Increased tear production in left eye now yellow
discharge
BLOCKED NASOLACRIMAL DUCT
Abx and Massage
o Excessive tearing, photophobia, corneal enlargement
assymetrical eyes
CONGEINTAL GLAUCOMA
Classic triad, tearing, photophobia,
blepharoapsms
IMMEDIATE SURGERY WITH OPTHALMOLOGIST
NF1, mucopolysacchariades I, low oculocerbrorenal
syndrome
Sturge weber, mafan, chromorsomal abnormalities
Case 56 Severe hearing loss
o Healthy boy with severe language delay
o No Baba dad mama BY 9 MONTHS OF AGE
o Conductive Hearing los
o Retrochoclear (central) hearing loss Auditory nerve
or CNS
o Sensineural HL cochlea disorders
o >70dB profound hearing loss

o Sensineural can be congenital or acquired

50% genetic 70% syndromic
Waardenburg syndrome types I/II**
Partial albinism, deafness, lateral
displacement of canthi, heterochromic
irises, eyebrow confluence, broad nasal
bridge
Branchio-oto-renal syndrome**
PREAURICULAR PITS, branchial fistulas,
hearing imparitment, external ear
abnormal
Alport syndrome nephritis, renal failure,
SNHL, ocular abnormalities
Down, NF, Jervell and Lange-Nielsen (prolonged
QT)
Hunter-Hurler syndrome
o Prenatal CMV MOST COMMON INFECTIOUS CAUSE OF
CONGENITAL SNHL
It can cause hearing los infancy or childhood
Toxo, rubella, syphilis CONGENITAL SNHL
o Conditions in prenatal priod associated
Low birth weight, prematurity, low Apgars,
mechanical ventilation greater than 5 days, hyperbili,
bacterial meningitis, ototoxic drug exposure,
craniofacial anomalies
o Aminoglycosides, loops, cisplatin, isoretinoin, lead, arsenic,
qunine cause SNHL in utero
o Early diagnosis of hearing impairment can impact
developmental skils early intervention is best
o Auditory brainstem evoken response testing
diagnositc test of choice for mandatory newborn
screening
Measures EEF response and does not require
cooperation
o SNHL children increased risk for otogenic meningitis
and need vacciens against STEP PNUEMO
o Patients with mild hearing loss can get hearing aids as
young as 2 months
o Infants born with apgra 4 or less require audiologic
evaluation
Case 57 ITP
o Looks like HSP with low platelets = ITP

o Healthy 3 year old develop thrombocytopenia, petachiae,

purpuric lesions He is well appearing but recently had a
febrile illness WBC and Hb are normal
NEXT STEP = GET BLOOD SMEAR
o Purpuric lesions resulting from thrombocytopenia
No other signs like HUS or DIC
Normal Hb and WBC
o ITP platelets destruction antiglycoprotein IIb/IIIa
o Acute ITP most common cause of thrombocytopenia in well
child aged 2-10 years
o Equal gender distribution
o Bleeding from gingive and other mucous membranes
o Thrombocytopenia with NORMAL PLATELET SIZE or
INCREASED
o PT and aPTT are NORMALL
o Smear shows eosipnophila or atypical lymphocytes
Immature WBCs and abnormal RBCs are absent
(present in leukemia)
If they are present check on bone marrow
o Bone marrow = increased number of megakaryocytes
in ITP
o 50% resolve within a month, 30% within 6 months if
more than 6 months than chronic ITP
o complications
Intracranial hemorrhage less than 1%
Bleeding
o Tx Intavenous Ig 1-2 days, Intravenous anti-D therapy, 23 week of steroids
o Splenectomy may be considered if refractive
o Transfusions as necessary
o Chronic ITP may happen with HIV virus, or EBV virus
chronic infection
o Many drugs immune mediated thrombocytopenia
Penicillin, TMP/SMX, digoxin, quinine, quinidine,
cimetidine, benzodiazepine, heparin***
MMR VACCINE TOO
o HSP hemorrhage, obstruction, intussception,
abdomimal pai needs further review
o HUS pallor, lethargy, decreased urine output (hemolysis)
Hepatspleonomegaly, petachiae, edema
Hemolytic AND thrombocytopenic peripheral blod
Helmet and burr cells, framgemtend RBCs
ACUTE RENAL FAILURE HEMATURIA,
PROTEINURA, ELEATIVE CREATNINE

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58 child abuse
Next step obtain skeletal survery
Lack of trauma history in infant who is not mobile
Mother seeks treatment for 2 days concerning
Neglect is most common form of child maltreatment
Muchausen by proxy repeated hospitlizations with
vague and unfiagnose conditions
Caretaken who takes great interest in the
medical staff and intervension, and often times
has some type of medical background
Caretakes forms relationship with healthcare and
often noted to be an exemplary parent
Skeletal srvery
Accidental bruises found over bony surfaces
However, abdomen, butt, thigs, inner arms are
abuse
Intentional hot water stocking glove
Cigarette burns may look lke impetigo or insect bites
Ddx
Hemophilia, ITP, HSP, DIC
OI, scurvy, cortical hyperostosis, Menkes kinky hair
disease
Cupping/coining folk mediine
59 foreign body aspiration
2 year old previously healthy acute onset RD
next step: evaluate childs airway with
bronchoscopy
IV access for fluids and sedation
TAKE NOTHING BY MOUTH until distress rsolves
SpO2 monitored closely
Stridor monophonic (one pitch)
Wheezing polyphonic (multiple pitches)
Foreign body aspiration most common cause of RD in
hildren major cause of morbidity and mortality
BRONCH the patient even if Xray is normal and you
suspect
Ddx
Croup
Epiglottitis
DROOLING, Preference to sit in tripond or
upright (sniffing position), hoarseness, absnce
of cough
Bacterial trachieitis staph 5-7 days after croup*
Retropharyngeal abscess

Angioedema
Tracheomalacia
Aortic/vascular ring compression of airway, tumor
compressing airway
Intraluminal obstruction (papilloma, hemangioma)
Coins in trachea xray show up as LINES due to the
cartilagienous rings forcing it into that position
Coins in esophagus show up as circles
Objects small than carina right mainstem
May not be visualized but air trapping, mediastinal
shift towards normal lung
Hyperextended neck, tachypnea, incosonolable, cold
TAKE TO OR and KEEP INFANT CALM intubate and
tracheostomy
Spasmodic croup appear well during day, but
develop symptoms at night rough night cause is
unknown
Croup aerosolized epinephrine and steroids
60 Kawasaki syndrome
LOOKS LIKE INFECTION MEASLES
High skpiking fever, irritable, CONNJUNCTIVITIS,
LYMPHADENOPATHY, EDEMA HANDS AND FEET,
RASH, OROPHARGEAL ERYTHEMA< RED CRACKED
LIPS
No Labs do echo to monior heart
ESR and CRP will be elevated
Normocytic anemia
Theombocytosis supportdiagnosis
GIVE IVIG and ASPIRIN
INTERMITTENT FEVER FOR 4 days
Hydrops of gallbladder wall of gallbladder ecoems
acutely distended WITHOUT STONES OR
INFLAMMATION
Kwasaki, leptospirosis, HSP
STRAWBERRY TONGUE
Children younger than 4
Coronary artery disease***
COnjuncitivits in 90% of cases
Sterule pyuria, CSF pleocytsis, elevated hepatic
transimases
Abdominal pain, RUQ pain, vomiting (Hydrops of
gallbladder)
Arthlagias, arthritis, anterior uveisis
Can have effusion, myocarditis, coronary arery disease

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o Even with treatment 5% of children develop CA aDILATIOn

and 1% HAVE GIANT ANEURYSMS
Risk factors for aneurysm male, prolonged
fever, lower Hb, younger than 12 months,
higher Neuts and bands, lower hemoglobin,
platelet count less than 350,000
o DONT GIVE MMR OR LIVE WHILE ON IVIG interferes
with immune response
o CHILDREN ON PROLONGED ASPIRIN THERAPY GET
INFLUENZA VACCINE due to risk fo REYE SYNDROME
Electrolyes
o Bicarb is single most reliable lab LOWER in sever
dehydration
o Tachycardia is first sign HYPOTENSION IS LATE SIGN
o Degree of dehydration
Infant (6-9), Child (3-6)
Sunken fontanelles, decreaed tears, cap refill 23 seconds
Infant (>10), child (>6)
Deeply sunked fontan
ABSENT TEARS
>3 capillary refill
Minimal urine output
ORT for mild or moderate contraindications include
shock or acute abdomen
IV IO Subcut
o Therapy for SiADH restrict water, give loops
3% NaCL
o SiADH EUVOLEMIC Hyponateremia
o Hypervolemic hyponatremia CHF, Cirrhosis, Renal failure
Solute problem cant excrete sodium draws in
water
o Hypovolemic swalt wasting, adrenal insufc, third space
(burns, ascices, pleural effusion)
o Rate of correction do NOT exceed 0.5 mmol/L/hr or
12mmol/L/24 hours sodium
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