Neonatal
Condition Description
Transmission during
pegnancy/exposure to maternal
fluids during birth. Higher
CMV
transmission rate if mother
acquires disease during
pregnancy
Perinatal transmission; higher
rates if mother has primary
HSV infection during pregnancy. Most
are born to women who have
never experienced symptoms
Parvovirus
HIV
Congenital: anytime during
pregnancy.
VZV Acquired: mothers who develop
lesions 5d before- 2d after
delivery
Transmission at any time during
Rubella
pregnancy
Transplacental transmission; any
Syphilis time during pregnancy esp
1st/2nd trimesters
Toxoplasmosis
Signs/symptoms Ddx Treatment Complications
Preterm birth, IUGR, microcephaly,
poor feeding, lethargy,
petechiae/purpura, blueberry muffin
spots, jaundice, HSM MCC of infectious sensorineural
hearing loss
CMV in urine within first 2 wks of life Supportive; ganciclovir
Elevated liver enzymes, anemia, Developmental delay, MR, CP, dental
thrombocytopenia defects
intracranial (esp periventricular)
calcifications, seizures, chorioretinitis
Local disease: recurrent
First 4 wks:
mucocutaneous lesions
1) isolated mucocutaneous lesions,
Viral cx, DFA testing of scrapings. Encephalitis: cataracts/bindness,
keratoconjunctivitis
CSF: PCR IV acyclovir. microcephaly, DD/learning
2) encephalitis
EEG disabilities
3) disseminated disease involving
Disseminated: severe neuro
mult organs
impairment, death
Intrauterine blood transfusions,
Hydrops fetalis Maternal IgM, IgG levels None
supportive
Mostly asymptomatic
LAD/HSM, FTT, DD, encephalopathy, Prevention: zidovudine to mother
bacterial infections, opportunistic HIV culture, PCR during pregnancy, zidovudine to
infection, lyphoid interstitial infant for first 6 wks of life.
pneumonitis
Congenital: IUGR, "zigzag" scarring,
limb atrophy, ocular abnormalities
Acquired: widespread cutaneous
lesions, PNA, hepatitis, death
Maternal antibody titers during
Congenital rubella syndrome:
pregnancy
cataracts, sensorineural hearing loss,
After birth: elevated rubella IgM or
congenital cardiac defects, DD
IgG
Premature delivery, asymptomatic at
birth
Skin lesions, anemia,
thrombocytopenia, jaundice, Penicillin G Neurosyphilis, deafness
"snuffles", HSM, elevated liver
enzymes, skeletal abn
(osteochondritis, periostitis),
Dermatology
Condition Description Signs/symptoms Ddx Treatment Complications
Viral infections
Prodrome: fever, anorexia, oral pain
Crops of ulcers on tongue/oral mucosa,
Hand-foot-mouth Coxsackie A Vesicular rash on hands/feet/buttocks/ Supportive
thighs
- football shaped vesicles
Asymptomatic erythematous papular
Giannoti-Crosti Occurs 1-6 yrs, after URI eruption
Order hep B Supportive
Syndrome (papular - symmetrically distributed on face,
serologies - takes up to 8 wks
acrodermatitis) hepatitis B, EBV, varicella extensor surfaces of arms, legs, buttocks
- spares trunk

Primary infection with VZV
Varicella
fatal disseminated disease
in immunocompromised
Supportive
incubation 10-21d
- Antipyretics, daily bathing Progressive varicella:
prodrome: fever, malaise, anorexia,
meningoencephalitis,
morbilliform rash Clinical diagnosis
Administer VZV vaccine within 72h of hepatitis, pneumonitis in
next day: pruritic rash on trunk, spreading - Tzanck smear
exposure immunocompromised
peripherally. - DFA, viral culture,
- red papules --> clear vesicles (dewdrop PCR
Acyclovir/valacyclovir/famciclovir not Reye syndrome if
on rose petal) --> crusts
indicated for children with taking aspirin
- occurs in crops
uncomplicated primary varicella

Pain/pruritus
Reactivation of VZV from Vesicular eruption in crops, confined to Antivirals for immunocompromised,
dorsal root ganglia dermatome pts >12 yrs, children with chronic
Herpes zoster
- clears up in 7-14d disease, and those who have
Uncommon in children <10 Pain persists for wks-months received systemic steroids
(postherpetic neuralgia)
Poxvirus Small, flesh colored, pearly, umbilicated,
Molluscum dome-shaped papules in moist areas Curretage, cryotherapy, cantharidin,
contagiosum Common in childhood, - axilla, buttocks, groin PO cimetidine, imiquimod cream
wrestlers, sauna bathers - resolve in 1-2 yrs
Topical salicylic acid, liquid nitrogen,
HPV Verruca vulgaris: common wart
imiquimod cream, PO cimetidine, PO
Verruca plantaris: plantar wart
Verrucae zinc sulfate, injected
Spread by skin-skin contact Verruca plana: flat wart
immunotherapies (candida antigen),
or fomites Condylomata accuminata: genital wart
squaric acid dibutylester
Presumed viral exanthems
Viral URI prodrome sometimes
Rash begins as herald patch, 2-10cm oval Self limited
salmon plaque on trunk, neck, UE, or Antihistamines, topical steroids for
Pityriasis Rosea
thigh --> smaller lesions in christmas tree pruritis
pattern over trunk and UE. sunlight
- fades over 4-12 wks

2
Dermatology
Condition Description Signs/symptoms Ddx Treatment Complications
Unilateral thoracic
Exanthem on one side of trunk that spread
exanthem
centripetally Self limited - 6-8 wks
(asymmetric Children 1-5 yrs Often confused with
- variable: erythematous macules/papules Antihistamines, topical steroids for
periflexural Winter and spring contact dermatitis
with surrounding halo, morbilliform, pruritis
exanthem of
eczematous, scarlatiniform, reticulate
childhood)
Skin manifestations of bacterial infections
red macules --> bullous (fluid filled)
eruptions on erythematous base
Can be mistaken for
Bullous impetigo S. aureus toxin
cigarette burns
S. aureus can be cultured from vesicle
fluid
Limited: Muciprocin ointment
Numerous: cephalexin (1st gen)
papules --> vesicles --> 5mm pustules -->
- covers staph and strep
rupture --> honey colored crust over
group A beta hemolytic Suspect MRSA: clindamycin or TMP-
Nonbullous impetigo ulcerated base
strep, s. aureus SMX
Organism can be isolated from lesions
Remove honey colored crusts with
warm compress

abrupt onset erythema, skin tenderness,

irritability, fever --> flaccid bullae -->
rupture --> beefy red, weeping surface
- periorificial areas of face, flexural areas
S. aureus Mild-moderate: PO
Staph scalded skin around neck, axillae, inguinal creases
Common in infancy, rare antistaphylococcal medication
syndrome
beyond 5 yrs Severe: treat like 2nd degree burn
positive Nikolsky sign: separation of
epidermis after light rubbing

Unruptured bullae contain sterile fluid

Buttocks/lower legs of girls who shave

S. aureus
Infection of hair follicle shaft
Folliculitis
Hot tubs: pseudomonas
Deep forms:
antiseptic cleansers, topical
- furuncle (boil): areas of friction - scalp,
muciprocin
buttocks, axillae
- carbuncles: collections of furuncles

Silvery scales, tends to be on extensor

surfaces, symmetric, Auspitz sign
Eczema: pruritic,
Koebner phenomenon: psoriasis
flexural creases
appears at sites of physical/thermal/ Keep skin well hydrated
Family history, HLA mechanical trauma Topical steroids
Psoriasis Scalp lesions may Psoriatic arthritis
inheritance Vit D, UVB light
look like seborrheic
Nail pitting, onycholysis (detachment of Severe: MTX, immunosuppressants
dermatitis or tinea
nail plate), accumulation of subungual
capitis
debris.

Group A strep: common exacerbation

3
Dermatology
Condition Description
Acute, self limited
hypersenitivity reaction
Erythema multiforme - herpesvirus, adenovirus,
EBV
- recurrent EM: HSV 1
10% mortality if untreated
Stevens Johnson NSAIDs, penicillins,
syndrome sulfonamides, antiepileptic
meds, mycoplasma,
immunizations
Severe form of SJS
involving 30% of body
Toxic epidermal
30% mortality if untreated
necrolysis
Upregulated expression of
Fas-ligand in epidermis
Signs/symptoms Ddx Treatment Complications
Eruptions secondary to allergic reactions
Polycyclic urticaria:
can appear
Erythematous macules, papules, plaques, targetoid, but
vesicles, target lesions lesions are not fixed
- evolve over days and do not have
PO antihistamines, moist
- fixed, develop necrotic centers necrotic centers.
compresses, oatmeal baths
- dorsum of hands and feet, palms and Edematous,
soles, extensor surfaces, may spread to erythematous
trunk borders with central
clearing, resolving in
12-24 hrs
Hospitalization, fluid and electrolyte
Prodrome 1-14d: fever, malaise, myalgias,
support, moist compresses, oatmeal
arthralgias, HA, emesis, diarrhea
baths
Sudden onset fever, erythematous
purpuritic macules with duscky centers,
Oral mucosal: mouthwashes with
inflammatory bullae of mucous
lidocain, diphenhydramine, Maalox
membranes
- GI, resp, GU tract involvement if severe
Ophthalmology consult
Positive Nikolsky sign Fluid therapy, treat like a burn
Elevated liver enzymes, renail failure, fluid IVIG: may affect binding/effect of Fas
and electrolyte imbalance ligand
4
Pulmonology
Condition Definition Epidemiology Etiology Signs/symptoms Ddx Treatment Complications High Yield facts
Obstructive lung diseases

Choanal atresia: narrowing

of nasal passages
Laryngomalacia: large,
Noisy inspiration, increased work
Upper airway: nostril floppy arytenoid cartilage,
of breathing (nasal flaring,
to thoracic inlet MCC congenital stridor
accessory muscles), retractions BL choanal atresia:
- obstruction leads to Suspect subglottic
(suprasternal) presents with life
inspiratory hemangioma in child with Flexible bronchoscopy often required
Upper airway threatening respiratory
obstruction persistent stridor and to evaluate anatomy and dynamics of Tracheostomy
obstructive disease Obstruction of subglottic space: distress in delivery room.
- obstruction below cutaneous hemangioma upper airway
high pitched, monophonic stridor Oxygenation improves
thoracic inlet leads to
when infant is crying.
expieratory Older child: large adenoids
Obstruction above glottis: more
obstruction and tonsils
variable, fluttering stridor
laryngotracheitis,
peritonsillar or
retropharyngeal abscess

Pickwickian Restless sleep with position Polysomnography: measure severe OSA --> CHF, death
Changes in upper airway
Obstructive sleep syndrome: OSA changes, irregular snoring, respiratory muscle activity, air flow, Pickwickian syndrome: chronic
tone during sleep, anatomic Remove tonsils/adenoids, CPAP
apnea associated with daytime somnolence, poor oxygenation, sleep stage, and heart hypoventilation results in pulmonary
obstruction
obesity growth, enuresis rate hypertension and CHF

Remove inciting agents from

Prolonged respiratory infections, Methacholine challenge test
patient's environment, maintence
decr exerise tolerance, persistent CXR: hyperinflation, increased
anti-inflammatory medication
day/nighttime coughing bronchial markings
15-20% children in Acute exacerbation: inhaled
Acute exacerbation: wheezing, Ddx:
US bronchodilator
subcostal retractions, nasal - intraluminal inflammation or failure
25% in blacks and Persistent asthma: Inhaled
flaring, tracheal tugging, to clear secretions: bronchiolitis, Control vs severity:
hispanics corticosteroids
prolonged expiratory phase GER with aspiration, cystic fibrosis, severity = degree of
- symptom control, avoidance of
1) Reversible airway resulting from obstruction TE fistula, primary ciliary dyskinesia impairment prior to
most common cause exacerbations
obstruction - absence of wheezing/decr - intraluminal mass effets: foreign treatment, control =
of hospitalization
2) inflammation breath sounds indicate severe body aspiration, tracheal or brochial monitoring impairment
Asthma >50% present before Also b2 agonists, leukotriene
3) bronchial airway obstruction tumors or granulation tissue and risk of future
age 6 receptor antagonists
hyperresponsivenes - CXR: hyperinflation, focal - dynamic arway collapse: exacerbations
s atelectasis tracheobronchomalacia - assessing/maintaining
Risk factors: genetic, Theophylline: add on therapy in pts
- intrinsic narrowing of airway: control is more important
atopy, cigarette who do not respond to conventional
Severity/Control: determined by congenital/acquired stenosis than assessing severity
exposure, urban therapy, severe exacerbation.
impairment and risk - extrinsic compression: masses, LN
impoverished areas,
- Impairment: nighttime - cough variant asthma: chronic
rhinovirus/RSV URIs Omalizumab: monoclonal ab vs IgE,
awakenings, interference with cough triggered by exercise or noted
use in pts >12 yrs with severe
normal activity, lung function primarily at night during sleep. +/-
allergic asthma
- Risk: exacerbations requiring wheezing. Improves with
oral systemic corticosteroids corticosteroids
Corticosteroids PO or IV

Nasal polyps in any pediatric pt

should prompt further testing for
CF.
hemoptysis occurs in pts with severe
Frequent pneumonias: S aureus, bronchiectasis. Frequent coughin and
CFTR channel: cAMP H influenza, Pseudomonas Maintain effective airway clearance, inlfammation --> erosion of walls of
Elevated sweat chloride (>60mEq/L),
activated chloride channel aeruginosa (>90%), Burkholderia bronchodilators, abx, regular inhaled bronchial arteries --> sputum streaked
pancreatic insufficiency, chronic
AR, chromosome 7 on apical surface of (associated with accelerated tobramycin for pts with with blood. Blood loss >500mL in 24h
pulmonary disease.
delta F508 deletion epithelial cells in respiratory pulmonary deterioration and Pseudomonas, azithromycin, inhaled requires arterial embolization
- lower airways: bronchiectasis,
(single nucleotide tract, pancreas, sweat and early death) hypertonic saline
Cystic Fibrosis parenchymal loss, bleb on CXR
deletion) salivary glands, intestines, spontaneous pneumothorax: place
and repro system. GI: pancreatic insufficiency, Pancreatic enzyme replacement, chest tube. 50% recurrence unless
Newborn screen
Lifespan mid-late 30s Abnormally viscid bowel obstruction, rectal high calorie high protein diets. pleurodesis is performed
secretions and impairment prolapse, diabetes, diabetes, Maintain height/weight >25th
of mucociliary clearnace hepatic cirrhosis. percentile. chronic pulmonary HTN: results from
progressive airway obstruction/hypoxia
failure to thrive is most common in advanced disease.
manifestation of untreated CF.
Meconium ileus is
pathognomonic
Pulmonology
Condition Definition Epidemiology Etiology Signs/symptoms Ddx Treatment Complications High Yield facts

bronchial obstruction, sinusitis,

Light microscopy: abnormal ciliary
chronic otitis media, recurrent Same as pulmonary CF treatment, Pts do not have
Primary ciliary Impaired mucociliary DNA11 and DNAH5 beat
respiratory infections except do not need pseudomonas Bronchiectasis in 2nd or 3rd decade propensity to
dyskinesia clearance mutations Ultrastructural changes in ciliary
treatment. Pseudomonas infection
cells from nasal/bronchial scrapings
sxs same as asthma, CF

Tracheal cartilage
rings that completely "washing machine" inspiratory
Congenital encircle trachea and and expiratory noise, hypoxemia,
tracheal stenosis grow more slowly failure to thrive
than the rest of
trachea

wheezing made worse by

Widening of posterior
treatment with bronchodilator
membranous portion
Esophageal atresia with TE - bronchodilator makes the
Tracheomalacia fo trachea with
fistula is a common cause posterior tracheal membrane
dynamic collapse
more flaccid and more likely to
during exhalation
collapse

Dynamic bronchial collapse on

Poor cartilage or poor exhalation --> wheezing upon
Bronchomalacia elastic recoil in forced exhalation, failure to
surrounding tissues respond to bronchodilators or
steroids
Cardiology
Condition Description
Cyanotic Congenital Heart Disease: Ductal-independent lesions
Single arterial vessel arising from
base of heart
- VSD is always present
Truncus - Nonspecific murmur at birth
arteriosus - CHF develops in weeks
- 22q11 microdeletion (DiGeorge):
tetralogy of Fallot, interrupted aortic
arch, VSD
Parallel systemic and pulm circuits
- Most common form of cyanotic CHD
in first 24 h of life
D-transposition of - patent foramen ovale required to
great arteries mix circuits
- intact ventricular septum (60%),
VSD (30%), VSD + pulm stenosis
(10%)
Pulmonary veins not connected to L.
atrium.
- supracardiac (50%): drain into SVC
or brachiocephalic vein
- cardiac (20%): drain into coronary
Total anomalous
sinus or R. atrium
pulmonary
- infradiagphragmatic (20%): drain
venous
into portal or hepatic veins
connection
- mixed (10%) Obstruction: cyanosis, resp distress
- Loud, single/narrowly split S2
Obstruction: vein enters at acute - Tachypnea
angle. pulm venous HTN and severe - CXR: normal heart size, diffuse pulmonary edema
cyanosis - ECG: R ventricular hypertrophy
Cyanotic Congenital Heart Disease: Ductal-dependent pulmonary blood flow
Complete atresia of tricuspid valve.
hypoplasia of R. ventricle. VSD. PFO
- Normally related great arteries
(NRGA) - ductal independent
- Transposition of great arteries
(TGA) (30%) - ductal dependent
Tricuspid atresia systemic blood flow
- VSD in 90% - allows blood to pass
from L. ventricle to R. outflow
chamber and pulmonary arteries
- pulmonary blood flow depends on
size of VSD and degree of pulm
stenosis
1) VSD 2) Pulm valve stenosis 3) R.
ventricular hypertrophy 4) overriding
aorta
- R-->L shunt through VSD results in
cyanosis. Timing/severity depends on
Tetralogy of fallot
degree of R. ventricular outflow
obstruction
22q11 microdeletion, most common
CHD presenting in childhood
Cardiac exam Treatment
Systolic ejection murmur at left sternal border
- loud ejection click
Surgery:
- single S2
- close VSD
- widened pulse pressure; bounding pulses
- separate pulmonary arteries from
truncal vessel
CXR: cardiomegaly, incr pulm vascularity, R aortic arch
- place conduit between R. ventricle
(30%)
and pulmonary arteries
ECG: biventricular hypertrophy (70%)
Loud, single S2
VSD +/- pulm stenosis: systolic murmur
PGE1
CXR: mild cardiomegaly, incr pulm vascularity. "egg- Balloon atrial septostomy (Rashkind
shaped silhouette" procedure)
- ant aorta superimposed on posterior pulm artery results - enlarge PFO, incr atrial level mixing
in narrower mediastium Arterial switch procedure
ECG: R. ventricular hypertrophy
No obstruction: progressive CHF
- R. ventricular heave
- wide and fixed split S2 with loud pulmonary
component
- systolic ejection murmur at L. upper sternal border
- CXR: cardiomegaly, snowman contour
- ECG: R. axis deviation, R. ventricular hypertrophy Surgery
NRGA, pulm stenosis:
Significant pulm stenosis: progressive cyanosis - PGE1
No pulm stenosis: no symptoms - Blalock-Taussig shunt (neonate):
TGA: cyanosis, poor feeds connect subclavian and pulmonary
artery
Holosystolic VSD murmur at L. lower sternal border - Cavopulmonary anastomosis
Continuous PDA murmur (infancy): connect SVC to pulmonary
artery
CXR: normal heart size. - Fontan (2-5 yrs): connect IVC and
- TGA: cardiomegaly hepatic vein to pulmonary circulation
ECG: Left-axis deviation, R. atrial enlargement, L. TGA:
ventricular hypertrophy - PGE1
- severe arch obstruction: reconstruct
aortic arch
Tet spells: episodes of cyanosis, rapid/deep breathing,
agitation Tet spells: squatting, vagal
- incr in R. ventricular outflow tract resistance --> incr maneuvers (knee-chest position),
shunt across VSD O2, morphine sulfate
- squatting increases venous return and systemic - volume expansion, vasoconstrictors
perfusion to increase systemic vascular
resistance
R. ventricular heave - beta blockers to decr infundibular
Loud systolic ejection murmur at L. upper sternal spasm
border - sodium bicarb to reduce acidosis
and decr pulmonary vascular
CXR: boot shaped heart resistance
ECG: R. axis deviation, R. ventricular hypertrophy
Cardiology
Condition Description Cardiac exam Treatment
Severe: Cyanosis and CHF
Mild: fatigue, exercise intolerance, palpitations, mild
Inferior displacement of tricuspid into
cyanosis w/ clubbing
R. ventricle, small R. ventricle,
enlarged R. atrium, patent foramen
Widely fixed split S2, gallop
ovale (80%)
Blowing holosystolic murmur (tricuspid regurg)
- atrialization of R. ventricle PGE1
Ebstein anomaly - severe tricuspid regurg --> majority Avoid surgery
CXR: cardiomegaly with R. atrial enlargement and decr
of pulm blood flow comes from PDA Heart transplant if severe
pulm vascularity
- dilated R atrium results in
tachycardia
ECG: R bundle branch block with R. atrial
- Wolff-Parkinson White syndrome
enlargement
- Maternal Lithium use
- Wolff-Parkinson White: delta wave and short PR
interval
Cyanotic Congenital Heart Disease: Ductal-dependent systemic blood flow

PGE1
No corrective surgery available - only
Neonates: severely decr systemic blood flow when PDA
palliative
closes. Shock, tachycardia, tachypnea
Atresia/hypoplasia of mitral valve
Aortic atresia or stenosis First week:
Right ventricular heave
PDA - connect pulm artery and aorta
Single S2
Hypoplastic left PFO with L-->R shunt - atrial septectomy
Continuous PDA murmur
heart syndrome - connect R. ventricle to pulm artery
Decr blood flow through left heart. (modified blalock-taussig)
CXR: pulmonary edema and cardiac enlargement
Systemic blood flow is completely 3-6 months:
PDA dependent - cavopulmonary anastamosis (hemi
ECG: R. ventricular hypertrophy, poor R wave
Fontan)
progression
2-5 years:
- modified Fontan

Extreme coarctation of aorta

Type A: interruption beyond L.
subclavian
Interrupted aortic PGE1
Type B: Betw L. subclavian and L. Same as hypoplastic left heart syndrome
arch Connect interrupted aortic segments
common carotid (most common)
Type C: Betw L. common carotid and
brachiocephalic
Acyanotic Congenital Heart Disease
Paradoxical embolism
SVT from atrial enlargement
Ostium secundum: midportion
Ostium primum: lower septum
Systolic ejection murmur in pulmonic area (pulmonary
Sinus venosus defect: Junction of R.
Atrial septal valve), middiastolic rumble in lower right sternal
atrium and SVC/IVC
defect border (tricuspid valve)
Loud S1, fixed widely split S2
L-->R shunt: R. atrial and R.
ventricular enlargement
CXR: enlarged heart and main pulmonary artery
ECG: R ventricular enlargement

Most common congential heart defect

Muscular: muscular portion of

septum
Inlet: endocardial cushion defect, Eisenmenger
inlet portion of septum below tricuspid
Surgery
Ventricular septal Conoseptal hypoplasia: RV outflow Harsh systolic murmur at left sternal border
- may not be necessary
defect tract below pulmonary valve
- patch closure
Conoventricular: membranous CXR: mild cardiomegaly, incr pulm vascularity,
portion ECG: L atrial, L ventricular, or biventricular hypertrophy
Malalignment: infundibular septum
- anterior malalignment results in TOF
- posterior malalignment results in
aortic stenosis
Cardiology
Condition Description
Down syndrome
Endocardial cushion defect --> ostium
primum ASD, inlet VSD with lack of
septation of mitral and tricuspid
valves
Common Incomplete: CAVV leaflets attach
atrioventricular directly to muscular portion of
canal defect ventricular septum.
- ASD only. Some mitral regurg
Complete: CAVV is not attached to
muscular ventricular septum
- ASD and large inlet VSD. L-->R
shunting at ASD and VSD.
Premies
Patent ductus
Symptoms related to size of defect
arteriosus
and direction of flow
Coarctation of the Turner syndrome
aorta
Thickened, rigid, valvular tissue
Increased pressure in L ventricle --> L Thrill
Aortic stenosis
ventricular hypertrophy, decr
compliance
Dysplastic valve. Incr R. ventricular
afterload --> R ventricular
hypertrophy
Pulmonic stenosis
Critical stenosis: decr R ventricle
compliance --> incr R atrial pressure
--> opening of foramen ovale --> R
to L shunt
Cardiac exam Treatment
Incomplete: Same as ASD.
- Blowing systolic murmur at L. lower sternal border
and apex (mitral regurg)
CHF: ace inhibis and diuretics
Complete: CHF Repair large VSDs within 6 months
- blowing holosystolic murmur at L lower sternal to decrease risk of pulmonary artery
boder HTN and pulmonary vascular
- Widely split, fixed S2 obstructive disease
- CXR: cardiac enlargement, incr pulm vascularity
- ECG: superior axis (canal defect), enlargement of R and
L atria
Large, L-->R flow: CHF, FTT
- bounding pulses
Indomethacin
- continuous murmur after S1, peaks at S2, trails off
- risk of renal insufficiency
during diastole
- CXR: cardiomegaly, incr pulm vascularity
Usually closes by itself in first month
- ECG: L or biventircular hypertrophy
of life in FT infant
Reversal of flow (R-->L): cyanosis
Delayed/weak femoral pulses, upper extremity HTN
PGE1
nonspecific ejection murmur at apex
Surgery: anastomosis or patch
bicuspid valve: apical ejection click
aortoplastic
Interventional: balloon angioplastic
CXR: enlarged aortic knob, cardiomegaly
Restenosis common
ECG: R ventricular hypertrophy In neonate, L ventricular
hypertrophy in older pt
Harsh systolic ejection murmur at right upper sternal
murmur
Ejection click
PGE1
balloon valvuloplasty
CXR: cardiomegaly, pulmonary edema
ECG: L ventricular hypertrophy. ST depression, inverted T
waves (ischemia)
Most are asymptomatic
Severe: dyspnea on exertion, angina
Ejection click varies with inspiration
Harsh systolic ejection murmur on left upper sternal
border
Severe: thrill, R ventricular heave
CXR: enlarged pulmonary artery segment
Infectious disease

Bacteremia and sepsis:

Fever of unknown origin: Fever >14d, T>38.3C on mult occasions, uncertain etiology Occult bacteremia - appears in well-appearing child with no obvious source of infection
Ddx includes: infection, CT disease, malignancy, other (IBD, kawasaki, drug) - highest in children 2-24 mo, T >39.0C, leukocytosis
s/s: conjunctivitis, LAD, joint tenderness, thrush, heart murmurs, organomegaly, etc - MCC S. pneumo, resolves spontaneously
Diagnostic eval: Sepsis: bacteremia + systemic response, altered organ perfusion
- CBC + diff, electrolytes, BUN and creatinine, LFTs, alk phos, UA - Neonates: GBS, enteric gram neg, listeria
- Blood, urine, stool, CSF cultures - Children <5: S. pneumo, N. meningitidis
- ESR, CRP - Children > 5: S. aureus
- CXR, skin test for TB - Other: Salmonella, pseudomonas, viridans strep
- Evaluation: Blood, urine, CSF cultures, CXR if respiratory signs present

Condition Description Etiology Signs/symptoms Ddx Treatment Complications High Yield facts

1. High dose amoxicillin, topical

Narrowing of abx if perforated Hearing loss, otitis media
eustachian tube by Otitis media with effusion: fluid 2. augmentin, PO second or 3rd externa
edema in URI --> behind TM but no inflammation (no gen cephalosporin, or IM
Inflammation of middle ear vaccuum draws fever/ear pain) ceftriaxone Meningitis (MC intracranial)
Ear pain, fever, fussiness, URI
secretions from - no abx
sxs
Acute otitis Eustachian tube in children: nasopharynx to Myringitis: inflammation of eardrum S. pneumo: 50% penicillin Atopic constitution increases
media - angle of entry (horizontal) middle ear - no abx resistant. risk for recurrent OM Decr mobility of TM is
TMs bulging, opaque, aberrant
- short length Otitis externa (swimmer's ear): ear H. influenza and M. catarrhalis: most specific sign
light reflex, decr mobility
- decr tone MCC: pain, but TMs looks normal, beta- lactamase activity Mastoiditis: severe, but
- S. pneumo erythematous canal uncommon
- H. influenza - topical abx drops Consider tympanostomy tube if - high fever, tenderness of
- Moraxella moderate hearing loss, recurrent mastoid bone
AOM

HA, facial pain, sinus tenderness

Similar abx as AOM but longer
treatment course (14-21d) Complications uncommon
Same pathogens as Acute bacterial: 1) persistent Viral URI, allergic rhinitis, nasal
Sinusitis - bony erosion, orbital cellulitis,
AOM respiratory sxs (10-14d) 2) foreign body
Recurrent disease: sinus intracranial extension
severe sxs (high fever, purulent
aspiration
nasal discharge)

High fever, very sore throat

Vesicular lesions progressing to Primary herpetic
ulcers
Diagnosed during summer Enteroviruses:
Herpangina - soft palate, tonsils, pharynx widespread over gums, lips,
and fall in young children coxsackievirus, etc
Hand foot mouth dz: also lesions - HSV
on palms and soles
sore throat, f/HA/n/abd pain
PE: enlarged erythematous,
exudative tonsils, petechiae on
soft palate
School aged children and No rhinorrhea, hoarseness or
Streptococcal
adolescents, spread via oral Group A strep coughing
pharyngitis
secretions Scarlet fever: sandpaper rash
with fever and pharyngitis
- begins at neck/axillae/groin,
spreads to extremities, may
desquamate
gingivostomatitis:lesions are more
Self limited (5-7d)
mucosa
Suppurative: peritonsillar
abscess, retropharyngeal
abscess
Nonsuppurative: rheumatic
Viral pharyngitis, infectious
fever, poststreptococcal
mononucleosis
glomerulonephritis Do not treat
pharyngitis with abx
Definitive diagnosis requires throat
Rheumatic fever: 3wk following empirically bc most
culture or antigen detection test for
pharyngitis. Penicillin causes are viral -
GAS
PO penicillin (10d) prophylaxis to prevent make therapeutic
recurrent ARF decisions based on
Rapid antigen detection: high
Poststrep glomerulonephritis: throat culture or rapid
specificity, variable sensitivity
occurs following either antigen detection
(depends on quality of swab).
pharyngitis or skin infection results
confirm negative test with throat
- penicillin therapy and
culture
diuretics.
- majority of children recover
without renal sequelae (unlike
adults)
Condition Description
Primary EBV infection in
older children and
adolescents
Infectious monMajority of people are
infected with EBV and
seroconvert in early
childhood (usu
asymptomatic)
Virus induced inflammation
of laryngotracheal tissues,
resulting in upper airway
Croup Paramyxovirus
obstruction
Acute (parainfluenza?),
laryngotracheo can also result from
Most pronounced in young
bronchitis influenza or RSV
children due to narrow
caliber of subglottic region.
Peaks in late fall/winter
Acute viral lower respiratory
tract infection resulting in
inflammatory obstruction of
the peripheral airways
At least 50% of children are
infected before 1 yr of age,
Bronchiolitis recurrent infections are
common. 3% of infants in
first 12 mo of life are
hospitalized for bronchiolitis
Chornic lung disease,
congenital heart disease,
immunodeficiencies are risk
factors
URI and persistent cough in
Pertussis adults, life threatening Bordetella pertussis Paroxysmal phase: spasms of
disease in neonates/infants
Young children:
viruses MCC
acute inflammatory process
Pneumonia C. trachomatis at 2-3
occuring in lungs
mo
S. pneumo, etc
Etiology Signs/symptoms
Severe exudative pharyngitis,
EBV
fever, profound fatigue
Hoarse voice, barky/seal like
cough, inspiratory stridor which
may progress to respiratory
distress
Prodrome: low grade fever and
rhinorrhea 12-24h prior to onset
of stridor
Infected neonates may develop
RSV, also
life threatening apnea
parainfluenza,
Initial fever, cough, rhinorrhea
influenza, human
followed by respiratory distress
metapneumovirus,
PE: wheezing, rhonchi, crackles,
adenovirus
accessory muscle use
Almost all are afebrile
Catarrhal phase: 7-10d
incubation, 1-2 wks low-grade
fever, cough, coryza
coughing followed by sudden
inhalation ("whoop")
Convalescent phase: most sxs
resolve by cough persists 2-8wks
C. trachomatis: afebrile,
conjunctivitis, staccato cough
M pneumo and C. pneumo:
f/HA/myalgia
M pneumo:
macular/erythematous rash,
erythema multiforme
Viral: diffuse wheezing and
crackles
Bacterial: focal crackles/decr
percussion/egophony/bronchoph
ony
Young child: tachypnea out of
proportion to fever
Ddx Treatment Complications High Yield facts
CMV, toxoplasma gondii, HHV6,
adenovirus, HIV
Pancytopenia indicates malignancy Rare but serious: upper airway Pts infected with EBV
obstruction (rx: who receive
Leukocytosis or leukopenia, 50% Self limited, supportive care corticosteroids), splenic amoxicillin (for
lymphocyte, at least 10% atypical Activity restrictions due to risk of rupture, meningoencephalitis misdiagnosed
lymphocytes splenic rupture Immunocompromised at risk bacterial infection)
Heterophile antibody: limited for disseminated disease and may have
sensitivity in pts <4 lymphoproliferative disorders maculopapular rash
Thrombocytopenia, elevated hepatic
transaminase levels
AP neck and chest radiographs
show steeple sign (<50%)
Ddx: epiglottitis, bacterial tracheitis,
Cool night air/humidity for cough
foreign body aspiration,
and stridor
anaphylaxis, angioneurotic edema
Resolves in 4-7d
- Epiglottitis: life-threatening
emergency, thumbprint sign. Child
ER: give cool mist, racemic
drools and leans forward with chin
epinephrine, PO/IV/IM
extended. Emergent intubation or
corticosteroids
cricothyroidotomy. IV ampicillin-
sulbactam. Biggest risk factor is
failure to maintain Hib vaccination
status
Supportive, self limited
Rapid assays from nasal secretions
for RSV, influenza A and B, etc
Pavalizumab (IM RSV
CXR for ill or hypoxic pts or More airway
monoclonal ab): passive
recurrent wheezing hyperresponsiveness later in
prophylaxis. Give in winter to at
- lung hyperinflation, life
risk pts <2 yrs (heart dz, chronic
peribronchial thickening (cuffing),
lung disease of prematurity,
incr interstitial markings
premies <35 wks)
Hospitalized to manage apnea,
Leukocytosis with lymphocyte
cyanosis, hypoxia, and feeding
predominance
difficulties
PCR or culture of organisms in
nasopharyngeal secretions
Erythromycin or azithromycin
only in catarrhal phase,
CXR usually normal, infiltrates may
decreases infectivity, prophylaxis
be seen
in close contacts
If pleural effusion: drain, cell count,
High dose amoxicillin or Pleural effusion -->
gram stain, culture
amox/clav for most bacterial compromise respiratory effort.
pna. Erythromycin/azithromycin/ Chest tube Cold agglutinin titers
If high fever in child: blood culture
clarithromycin for M pneumo or - most large pleural effusions are elevated in M.
C pneumo. are caused by s. aureus pneumo, many viral
rapid influenza test,
Azithromycin/Erythromycin for C. pneumonia and some bacterial
DFA/PCR/tissue culture for C.
trachomatis pneumonias
trachomatis
Neonates: ampicillin and Lung abscesses due to
cefotaxime (or gentamicin) anaerobic infections
M pneumo: PCR or cold agglutinins
Condition Description Etiology Signs/symptoms
n/v, photophobia, irritability,
lethargy, HA, stiff neck
Viral prodrome: f/malaise, sore
throat, myalgias. Usually
Infection of leptomeninges
resolves in 2-4d
and CSF MCC enterovirus
Bacterial: no prodrome. High
Bacterial: S. pneumo
fever
Neonates: low birth weight, and N. meningitidis
Meningitis - HTN, bradycardia, apneic, incr
prolonged rupture of (neonates and
ICP
membranes, children <3 are
Lyme: low grade fever, HA, stiff
chorioamnionitis predispose highest risk)
neck, photophobia over 1-2 wks
to septicemia and meningitis
Kernig: knee extension -->
flexion of hip with pain
Brudzinski: passive neck flexion
--> involuntary leg flexion
Excessive stooling -->
dehydration, inadequate nutrition,
Salmonella, Shigella,
electrolyte abnormalities
E. Coli, Yersinia
enterocolitica,
Bacterial diarrhea: fever,
Campylobacter
abdominal cramping, malaise,
jejuni, Vibrio cholera
tenesmus, vomiting is less
common. Stools w/ mucus, guiaic
Rotavirus: major
positive
Gastroenteritis cause of
nonbacterial
Shigella: neurologic sxs
gastroenteritis in
Salmonella: extraintestinal
infants and toddlers
disease (meningitis and
osteomyelitis)
Giardiasis: MC
Shigella and E. Coli: hemolytic
intestinal disease in
uremic syndrome
US
Yersinia: erythema nodosum,
pseudoappendicitis
Enterobius
Pinworm Perianal, vulvar itching
vermicularis
Perinatally infected:
asymptomatic
HAV and HEV: diarrhea
Carrier state associated with
Hepatitis
hepatocellular carcinoma Scleral icterus or jaundice,
hepatomegaly, RUQ tenderness,
benign-appearing rash in early
HBV
Congenital: hepatomegaly,
splenomegaly, mucocutaneous
lesions, jaundice, LAD, snuffles
(bloody, mucopurulent nasal
discharge)
Congenital or sexually
Syphilis acquired. Commonly Treponema pallidum
Sexually acquired: primary
coinfection with other STD.
chancre that heals in 3-6 wks,
secondary dermatologic
involvement (palm and sole
rash), tertiary gummas in skin,
bone heart, CNS
Ddx Treatment Complications High Yield facts
Encephalitis, drug intoxiation or s/e,
anoxia/hypoxia, primary or
Neonates: ampicillin for GBS
metastatic CNS malignancy, Dp not attempt LP in
and Listeria + cefotaxime
bacterial endocarditis with septic a child with focal
Child: vancomycin + 3rd gen 10-20% develop persistent
embolism, intracrainial neurologic deficits
cephalosporin neurologic deficit: hearing loss,
hemorrhage/hematoma, malignant and/or increased ICP
developmental delay, motor
HTN, demyelination disorders until an expanding
Abx usually 10-14d incoordination, seizures,
mass lesion is
hydrocephalus
CSF analysis diagnostic: cell counts excluded by CT or
rifampin prophylaxis in close
+ diff, gram stain, glucose and MRI
contacts
protein levels, culture
PCR for HSV and enteroviruses
Abx prolongs Salmonella
shedding, increases risk of
Electrolyte and renal function
hemolytic uremic syndrome.
studies
Blood culture at time of initial
TMP SMX or azithromycin for
evaluation
shigella, erythromycin or
azithromycin for C. jejuni
Adhesive tape reinfections are common
mebendazole, pyrantel pamoate,
stool O&P not recommended - few handwashing is best
or albendazole
ova in stool prevention
Ddx: EBV, CMV, enterovirus, other HAV: fulminant hepatitis rare
viral infections. Autoimmune but mortality up to 50%
heptatitis, metabolic liver disease, HBV: chronic infection
biliary tract disorders, drug HDV: HDV and HBV
ingestions simultaneously infection puts
pt at greater risk for more
HAV: immune globulin,
HAV: anti-HAB IgM antibody = severe chronic hepatitis B and
administer within 14d of
infection higher mortality rate. HDV
exposure
HCV antibody: present in acute and superinfection on top of
chronic, 12 wk window period exisiting HBV results in acute
HCV RNA: positive wtihin 1 wk exacerbation and acclerated
- HCV RNA with negative antibody = course result.
acute infection (window period) HCV: 50% develo[ chronic
- negative HCV RNA = recovery hepatitis
VDRL and RPR: tests for antibodies
to lipoidal molecule rather than
organism itself.
- False positives in infectious mono,
connective tissue disease, Untreated infants may develop
endocarditis, and TB anemia, thrombocytopenia,
IM or IV penicillin G
FTA-ABS and particle agglutination: and radiography abnormalities
fewer false positives of long bones
Newborns: lumbar puncture to
identify neurosyphilis - pleocytosis
and elevated protein
Condition Description Etiology Signs/symptoms Ddx Treatment Complications High Yield facts
Genital HSV
HSV 2 or 1
infection
NAAT tests for gonorrhea and
chlamydia
Rx for N. gonorrhea, C. Decreased fertility, ectopic
Either cervical motion tenderness - must also offer testing for syphilis,
trachomatis, anaerobes pregnancy, dyspareunia,
C. trachomatis, N. or uterine/adnexal tenderness HIV, and other STI
chronic pelvic pain, adhesions
Pelvic gonorrheae - pregnancy test
C trachomatis and N. gonorrhea: N. gonorrhea: arthritis
inflammatory Usually polymicrobial - also anaerobes Additional criteria: oral T>101,
Single dose IV ceftiaxone + PO C. trachomatis: Reiter
Disease and enteric gram elevated ESR or CRP, WBCs in Gyn ddx: mucupurulent cervicitis,
doxycycline syndrome
negs vaginal secretions, mucopurulent ectopic pregnancy, ruptured ovarian
Both: Fitz-Hugh-Curtis
discharge, lab evidence cyst, septic abortion, endometriosis
Anaerobes: metronidazole syndrome (perihepatitis)
Nongyn ddx: appendicitis,
pyelonephritis, IBD

Candida occurs in women
with abx use, pregnancy,
Vulvovaginosis diabetes,
immunosuppression, OCP
use
Trichomonas: most
asymptomatic, malodorous,
frothy gray discharge and vaginal Trichomonas: PMNs and
discomfort. Penile discharge trichomonads on wet prep
Trichomonas: PO metronidazole
Candida,
Bacterial: thin, white, foul- Bacterial: vaginal pH > 4.5, clue Bacterial: PO metronidazole
Trichomonas,
smelling discharge with fishy cells Candida: antifungal creams or
bacterial
odor when mixed with KOH single dose of PO fluconazole
Candida: yeast and pseudohyphae
Candida: thick white vaginal on wet prep with KOH
discharge with vaginal itching
and burning

N gonorrhea and C Diagnosis: mucoid or purulent Gonococcal: 230mg IM

trachomatis urethral discharge, pos leuk ceftriaxone AND either 1 dose
- also mycoplasma Urethral discharge, itching, esterase, WBCs on first-void urine, PO azithromycin OR 7d of PO
Urethritis
genitalium and dysuria, frequency. gram neg intracellular diplococci on doxycycline
trichomonas gram stain - azithromycin preferred because
vaginalis - test pts for other STDs it covers mycoplasma genitalium

AIDS: AIDS-defining illness Pregnant women: zidovudine

occurs or when CD4+
lymphocyte count is less
than a defined number for
HIV and AIDS age
>90% in utero or perinatal
Risk of transmission is 25%
if untreated
Tick bite (wood tick, dog
Rocky Mountain
tick, lone star tick)
Spotted Fever
April-Sept
Tick bite (deer ticks, black
legged ticks)
Lyme disease
- infected tick must feed for
>48h
Generalized LAD, hepatomegaly,
splenomegaly, failure to thrive,
diarrhea, cadidiasis, parotitis,
ELISA and Western blot not useful
and developmental delay
in children <18 months
Resp: lymphoid interstitial PNA,
PCP PNA
Fever, HA, rash 7d after tick bite
- f/c/HA/n/v/myalgias
- rash on 2nd-5th day, blanching
erythematouc macular lesions
Rickettsia rickettsii
that prgress to petechiae or
purpura
- starts on wrists/ankles and
spreads inward
Erythema migrans (early
localized disease, 3-30d after
bite), f, HA, myalgias
Borrelia burgdorferi Early (days--> wks): multiple
erythema migrans lesions,
cranial nerve palsy meningitis
Late (>6wks): arthritis, usually
involving knee
(AZT), followed by treatment of
infant for first 6 wks of life
reduces vertical transmission to
2%
NRTI, NNRTIs, PIs
TMP-SMX prophylaxis against
PCP
No reliable diagnostic test. Abs
confirm diagnosis 10d after sxs Empiric rx - need to cover
erlichiosis and N. meningitidis
Thrombocytopenia and
hyponatremia doxycycline
add cefotaxime or ceftriaxone if
Ddx: erlichiosis, meningococcemia, suspecting meningococcemia
atypical measles
Atypical rash may be confused with
erythema multiforme or erythema
marginatum
Treatment prevents early
disseminated and late disease
Ddx arthritis: juvenie idiopathic
arthritis, reactive arthritis, Reiter
Young children: amoxicillin or
syndrome.
cefuroxime
Ddx meningitis: aseptic meningitis
Children >8yrs: PO doxycycline
Clinical diagnosis, elevated IgM titer
wks after tick bite
Heme
Condition Description Signs/symptoms Ddx Treatment Complications
Microcytic anemias

Occurs as early as 3 mo in premie.

Risk factors: extended exclusive
breastfeeding (>6 mo), low-iron formula, exercise tolerance. Skin/mucous membrane pallor,
low-iron solids, excessive cow milk.
Iron deficiency
anemia Occult blood loss: GI anomalies (meckel,
juvenile polyps)
Overt loss: bloody stools or traumatic
hemorrhage
Mild (6-8 g/dL): decr appetite, irritability, fatigue, decr
Iron supplement: reticulocyte count incr
tachycardia, systolic ejection murmur along left sternal
within 3d, Hb concentration normalizes
border Response to appropriate iron
within a month. Continue therapy for 2-3
supplementation is best diagnostic test
mo to replenish stores and prevent future
Severe (<3 g/dL): CHF, tachycardia, S3 gallop,
occurrence.
cardiomegaly, hepatomegaly, distended neck veins, rales
Glossitis, angular stomatitis, koilonychia in children with
isolated iron def anemia in developed nations

Hb Barts: Gamma-globin tetramers. High affinity for

Alpha thal: deletions
Beta thal: point mutations
Alpha and Beta
Imbalance between alpha and beta
thalassemia
chains --> excess of one type -->
unstable monomers that precipitate and
damages membrane
oxygen --> hypoxia, heart failure, HSM, edema, hydrops
fetalis
HbH: beta globin tetramer. HbH disease: deletion of 3 Alpha thal trait: normal electrophoresis,
out of 4 alpha genes.
- at birth: HbBarts predominates
- first few months: HbH predominates
- anemia, HSM, require intermittent transfusions
Alpha thal trait: deletion of 2 genes. Blacks and
Mediterranean. Often confused wtih Fe-def anemia
Beta thal: normal blood counts at birth (mostly fetal
Hb), severe anemia, organomegaly, growth failure during HbF
first year. Extramedullary hematopoiesis --> frontal
bossing, maxillary hypertrophy, overbite
Alpha thal major: HbBarts
HbH disease: 10-40% HbH, 60-90% HbA
similar to Fe deficiency
Beta thal major: normal blood counts at
birth.
- hypochromia, microcytosis, anisocytosis,
poikilocytosis
- elevated HbF
Beta thal minor: elevations of HbA2 and/or transfusion therapy
Thalassemia major: RBC transfusion to
eliminate anemia, suppress
extramedullary erythropoiesis, decr iron
Beta thal major: Iron overload due to
overload
hyperabsorption of dietary iron or
- goal is to maintain Hb >10g/dl
transfusional iron loading
- Splenectomy with incr transfusion
- cardiomyopathy, CHF
requirement
- cardiac disease is main cause of
death
Thalassemia intermedia (alpha or beta):
folic acid supplements for pts not on

Inflammation --> incr hepatic production TIBC low, ferritin normal or incr
of hepcidin -->
Anemia of internalization/degradation of ferroportin Mild anemia (8-10 g/dL) BM exam: Incr in storage iron, decr in iron-
Treat underlying inflammation
inflammation --> impaired release of iron from containing erythroblasts
macrophages and absorption of iron
from gut Usually normocytic initially
Nonmegaloblastic macrocytic anemias
Presents in first year of life.
Congenital pure red cell aplasia Macrocytosis, reticulocytopenia PO corticosteroids
Diamond-Blackfan
mutation in ribosomal protein S19 elevated HbF BM transplant
Anemia 25% have associated anomalies: short stature, web neck,
(RPS19) Elevated RBC adenosine deaminase
cleft lip, shield chest, triphalangeal thumb
Macrocytosis
RBC transfusions
Elevated HbF
Hematologic improvement with androgen
Hyperpigmentation, caf au lait spots, microcephaly, 10% develop leukemia
AR or X linked, pancytopenia therapy
Fanconi anemia microphthalmia, short stature, horseshoe/absent kidney,
Defect in DNA repair SC transplant
absent thumbs Confirm diagnosis by demonstrating
- decrease doses of radiation/chemo bc
increased chromosomal breakage with
they damage DNA
exposure to diepoxybutane (DEB)
Failure of hematoietic stem cells -->
pancytopenia CBC: cytopenia, microcytosis
BM transplant
Severe Aplastic - due to chemicals (benzene), drugs
Anemia, thrombocytopenia, neutropenia Immunosuppression if no donor can be
Anemia (chloramphenicol, sulfonamides), Diagnosis: peripheral pancytopenia +
found
infectious agents (hepatitis), ionizing hypocellular bone marrow
radiation. Usually idiopathic.
Disorders of hemostasis
CBC: normal, except thrombocytopenia
- large, young platelets Usually self limited
Antiplatelet autoantibodies -->
Immune Abrupt onset petechiae/bruising 1-4wks after Corticosteroids, IVIG, anti-D
destruction by RES
thrombocytopenia febrile/viral illness Diagnosis based on history, physical, immunoglobulin can temporarily increase
- primary, or secondary to SLE or HIV
blood count. Does not require BM exam, platelet count
lab testing, or antibody detection

Factor therapy to prevent joint damage

Hemophilia A: factor VIII
Hemophilia A and B
Hemophilia B: factor IX
from recurrent hemarthrosis (hemophilic
Older pts: received blood products with
arthropathy)
Unexplained post-op bleeding HIV --> AIDS is MCC death
Newborns: intracranial bleeding from delivery, bleeding
DDAVP: releases factor VIII from
after circumcision (avoid circumcision) Formation of inhibitors: neutralizing IgG
endothelial cells
abs vs factor VIII or IX
Aminocaproic acid: inhibits fibrinolysis
Onc
Condition Description
Most common pediatric cancer
(75%)
Most common is precursor B cell
(80%) good prognosis; T cell ALL
(19%), Mature B cell (Burkitt) (1%)
ALL
Poor prognosis: age >10 yrs or
<1 yr, WBC >50,000 at
diagnosis, failure to respond to
induction therapy, Philadelphia
chromosome
20% childhood leukemias
Best prognosis: M3 AML (APML)
and trisomy 21 pts with M7 AML
AML Worse prognosis: WBC
>100,000/mm3
Low risk: inv 16, t16;16, t8;21
High risk: monosome 5 or 7, or no
remission
Lympoblastic (50%): pre-T or pre-
B
Burkitt (35%) or large B cell
Anaplastic large cell (15%)
3rd most common malignancy in involvement, isolated lymph nodes,
Non-Hodgkin childhood, 10% of childhood
lymphoma cancers. Boys 3x as many as girls Burkitt: abdominal tumor w/ n/v,
Risk factors: congenital
immunodeficiency (Wiskott
Aldrich, SCID), acquired
immunodeficiency, Bloom
syndrome, ataxia telangiectasia
Signs/symptoms
Normochromic normocytic anemia, low
retic count, low WBC count variable
HSM and cervical LAD at diagnosis.
Extramedullary involvement in CNS,
skin, testicles (5%).
- HA emesis, papilledema, CN6 palsy
Fever, mediastinal mass (mostly T
cell),
Chloroma: soft tissue tumor in spinal
cord, brain, skin
Leukemia cutis: Neonates, Blueberry
muffin spots
Gingival hypertrophy
T cell lymphoblastic lymphoma:
mediastinal mass
B cell lymphoblastic lymphoma: bone
skin
intussusception, tonsils, bone marrow,
CNS
Anaplastic large: slowly progressive
disease with fever
Ddx
Leukemia
CBC: leukocytosis,
thrombocytopenia, anemia
CMP for tumor lysis
CXR for mediastinal mass
BM aspiration and biopsy
with flow cytometry
LP for CNS involvement
CT scan to assess extent ot
disease
Treatment Complications
Neutropenia (ANC < 500/mm3)
predisposes to serious bacterial and fungal
infections.
Induction therapy: 28d of vincristine,
High risk of tumor lysis syndrome:
steroids, intrathecal MTX,
hyperuricemia, hyperphosphatemia,
asparaginase. Add daunomycin for
hyperkalemia
high risk pts.
- especially in T cell ALL or Burkitt
lymphoma
Consolidation: intensification of
- greatest risk in first 3d of chemo
therapy to kill additional leukemic
- maintain Hb <10mg/dL
cells if induction fails
Hyperleukocytosis (WBC>200,000): can
Interim maintenance: vincristine, 6-
cause vascular stasis --> mental status
MP, MTX
changes, HA blurry vision, dizziness, sz,
dyspnea
Radiation therapy for CNS and
testicular disease, CNS prophylaxis.
Mediastinal mass --> SVC syndrome:
distended neck veins, swelling of
face/neck/upper limbs, cyanosis,
conjunctival injection
Chemotherapy more intense than
ALL Hyperleukocytosis (5-22%): dyspnea,
hypoxemia, etc
Induction: anthracycline + - treat earlier than ALL bc AML cells are
arabinoside larger and stickier than lymphocytes in ALL.
- maintain Hb < 10 mg/dL
Low risk: chemo only
High risk: BM transplant
Combination chemo
Burkitt: surgical resection
- tumor lysis: careful management
Mediastinal mass: SVC syndrome
with incr fludi intake, alkalinzation of
Burkitt: tumor lysis syndrome - even
urine, electrolyte observation,
before chemo is started.
allopurinol
- high risk of developing kidney
failure requiring dialysis from tumor
lysis
Onc
Condition Description
Increase incidence of immune
dysregulation
Association with EBV
Incr risk in ataxia teleangiectasia,
Wiskott-Aldrich, Bloom
Bimodal distribution
Hodgkin lymphoma
Subtypes:
- Nodular sclerosing (40-55%)
- Lymphocyte predominant (10-
15%)
- Mixed (30%)
- Lymphocyte depleted (5%)
Childhood embryonal malignancy heterochromia of iris on affected side
of postganglionic sympathetic
nervous system. 8% of all
childhood cancers <15yrs, most
common solid tumor outside
Neuroblastoma CNS.
- abdominal tumors (70%) from
sympathetic ganglia/adrenal
medulla, thoracic masses (20%) causing hepatomegaly
from paraspinal ganglia, neck
(5%) involves cervical ganglion
Most common renal tumor in
children, chromosomal loci 11p13
and 11p15
Wilms tumor
- most are unilateral
- most common renal tumor
- usually diagnosed in first 5 yrs
Signs/symptoms
Painless, rubbery, cervical LAD
(80%)
B symptoms: fever, night sweats,
weight loss
Enlargement of liver/spleen in
advanced disease
Abdominal tumors: hard smooth,
nontender abdominal masses palpated
in flank, displace kidney.
Neck: Horner syndrome,
Epidural invasion --> back pain and
cord compression sxs
Metastatic sequelae:
- Hutchinson syndrome: cortical bone
pain causing limp
- Pepper syndrome: liver infiltrate
Raccoon eyes: periorbital infiltratex
Paraneoplastic effects: watery diarrhea
in tumors secreting VIP, opsoclonus
myoclonus (chaotic eye movements,
myoclonic jerking, truncal ataxia)
Associated anomalies: sporadic
aniridia, hemihypertrophy,
cryptoorchidism, hypospadias, other
GU anomalies
Beckwith-Wiedemann:
hemihypertrophy, macroglossia,
omphalocele, GU abn
WAGR: Wilms, aniridia, GU abn,
mental retardation
Perlman syndrome: unusual facies,
islet cell hypertrophy, macroscomia,
hamartomas
Other findings: hematuria, HTN,
varicocele
Von willebrand's disease in 8%
Ddx Treatment Complications
Ddx reactive/inflammatory
nodes: bacterial
lymphadenitis, infectious
mono, TB, atypical
mycobacterial infection, cat
scratch, HIV, histo, toxo
1. CXR for mediastinal
Multiagent chemo Secondary malignant neoplasms (breast,
involvement, airway
thyroid, sarcomas), cardiac toxicity
compromise
Lymphocyte-predominance has best (anthracyclines), pulm (bleomycin),
2. Pulmonary function test,
prognosis hypothyroidism (XRT)
ECHO before anesthesia in
pts with mediastinal mass
3. Excisional lymph node
biopsy required for
diagnosis: Reed sternberg
cells
Eosinophilia (15-30%)
CNS tumors
Ddx: adrenal hemorrhage,
hydronephrosis, polycystic
kidney disease,
splenomegaly, renal cell ca,
Prognosis: INSS staging, DNA index
wilms tumor,
of tumor, MYCN gene amplification
hepatoblastoma, leukemia,
- Stage I, II, IVS have good
lymphoma, retroperitoneal
prognosis. Stage III, IV have poor
rhabdomyosarcoma
prognosis
Confirm mass by CT of
Surgery, chemo, radiation, etc.
chest/abd/pelvis
Chemo: vincristine,
tumor cells on BM aspirate
cyclophosphamide, doxorubicin,
+ elevated urinary
cisplatin
catecholamines
Tissue biopsy for histology,
DNA ploidy, and MYC-
related oncogene
Ddx: hydronephrosis, PKD, Surgical removal of kidney
splenomegaly Radiation therapy can be used for
Invasion of renal capsule, extension
metastatic sites
through adjacent vessels (IVC), regional
Abd US, CT, or MRI
nodes, lung, liver
Good prognosis: small size, younger
Lung most common site of metastasis
Staging done after age, no LN/metastases, no
exploratory laparotomy capsular/vascular invasion
Bone tumors
Onc
Condition Description
Undifferentiated sarcoma that
arises primarily in bone
- t(11;22) in 85% of pts
adolescents
Ewing sarcoma
- flat and long bones: femur
(20%), pelvis (20%), fibula (12%),
humurs and tibia (12%)
- begins midshaft in long bones
Tumor of bone-producing
mesenchymal stem cells
- arises in medullary cavity or
periosteum
Osteosarcoma
- usually at metaphysis of bones
with maximum growth velocity:
distal femur, proximal tibia,
proximal humerus
Leukocoria (absent red reflex)
Tumor of embryonic neural retina
Retinoblastoma Chromosome 13q14, BR1 locus
Trilateral rb: involvement of pineal or
- 60% unilateral
parasellar sites
Most common STS in children
<10
- Associated familial syndromes:
Rhabdomyosarcoma neurofibromatosis, Li Fraumeni
- 2 subtypes: embryonal (53%),
alveolar (21%)
- t(2;13) and t(1;13)
Heterogenous
Malignant peripheral nerve sheath
Non
tumors: associated with NF type I
rhabdomyosarcoma
- Malignant fibrous histiocytoma or
leiomyosarcoma
Signs/symptoms
Pain and localized swelling
rhabdomyosarcoma
Systemic: fever, weight loss, fatigue
Pain and localized swelling
Systemic manifestations rare (vs
Ewing)
20% have mets: lung most common
Gait disturbance, pathologic fractures
Soft tissue sarcomas
Head and neck (35%), GU (22%),
extremeties (20%)
25% have distant mets, lung most
common site
Ddx Treatment Complications
Ddx: osteomyelitis,
eosinophilic granuloma
(langerhans cell
histiocytosis),
osteosarcoma,
neuroblastoma or
Chemo + radiation
- chemo: reduce size and treat mets
metastasis to bone
(almost all pts have mets)
Radiographs: lytic bone
lesion with calcified
periosteal elevation
(onion skin) and/or soft
tissue mass
Ddx: ewing sarcoma,
benign bone tumors,
chronic osteomyelitis
lytic bone lesion with Surgical removal of primary tumor
periosteal reaction Resistant to radiation therapy (vs
(sunburst appearance) ewing)
Chemo: cisplatin, doxorubicin, MTX
MRI to assess extent, CT to
detect pulm mets (calcified
nodules), bone scan for
mets
Enucleation, chemotherapy, local
DDx: congenital cataract, therapies, radioplaques, external
medulloepithelioma, beam radiation
Toxocara canis - treatment depends on Reese-
endophthalmitis, persistent Ellsworth classification
hyperplastic primary
vitreous, Coats disease Child born to parent with BL
retinoblastoma or unilateral rb with
Ophthalmologic exam, known genetic mutation should be
MRI screened for rb at birth and at regular
intervals until 4 or 5 yrs
CT or MRI of site, chest CT
Surgery, radiation, chemo
and bone scan for mets
- chemo helps reduce tumor size and
bone marrow biopsy
mets
required
CT or MRI of site, chest CT
Surgery, radiation, chemo
and bone scan for mets
Immunology, Allergy, Rheum
Condition Description
X linked SCID: presents in first 6 mo with
1. X-linked: IL2RG gene - gamma
T cell immunity: viral/bacterial infections, diarrhea, failure to thrive.
chain of IL-2 receptors
SCID Lymphopenia, absent CD4 cells
2. DiGeorge
X linked agammaglobulinemia
(Bruton): no mature B cells. Life
threatening enterovirus infections
CVID: hypogammaglobulinemia,
Humoral immunity:
esp IgG and IgA. Decr antibody
Antibody deficiency
formation to vaccines. Incr
syndromes
lymphoma and autoimmune dz
Selective IgA deficiency: IgA <5
mg/dl, bacterial infections of
respiratory, GI, and urinary tracts
Wiskott-Aldrich: X linked, B and
T cell disorder. Host's abs do not
Combined respond to carbohydrate antigens
immunodeficiency
Hyper IgM: CD40L mutation.
Failure of class switching.
Insufficient number of PMNs
(neutropenia), cell dysfunction, or
migration defect
Chronic granulomatous
Phagocytic
disease: most common. Failure
immunity
to generate superoxide
Leukocyte adhesion deficiency:
defect in adhesion to endothelial
cells, most commonly CD18
Complement
Impaired opsonization
immunity
Chronic relapsing/remitting
reaction to allergens (food/env)
10% of pediatric population
Atopic dermatitis
genetic predilection
50% develop allergic rhinitis
and/or asthma
Signs/symptoms Ddx Treatment Complications
Immunology
Decreased absolute lymphocyte
Viruses, mycobacteria infections, fungi, PCP counts and T cells.
Absent T cell function: in vitro
mitogen stimulation, intradermal Immunoglobulin replacement,
delayed hypersensitivity testing aggressive identification and Vaccine associated diarrhea with
Absent antibody function (measure treatment of infections live/attenuated rotavirus vaccine
after 6 mo) BM transplant
Digeorge: congenital heart disease, hypocalcemic
tetany, malformed ears/face DiGeorge: absent thymic shadow on
CXR, FISH
Diagnostic evaluation:
- IgG, IgA, IgM levels
- serum protein screen - albumin or
transferrin to r/o other etiologies
- antibody titers after immunization
(tetanus and diptheria = protein
antigens; pneumococci and H
Recurrent infections with encapsulated organisms influenza = carb antigens)
IVIG
after 6 mos- otitis media, sinusitis, pneumonia
Transient
hypogammaglobulinemia of
infancy: delayed acquisition of
normal infant immunoglobulin levels
- most develop normal levels by 2-5
yrs, have intact responses to
vaccination
Incr susceptibility to virulent and opportunistic
infections, autoimmunity
Wiskott Aldrich: atopic dermatitis,
thrombocytopenia.
Hyper IgM: recurrent sinopulm infections, PCP
Neutropenia ddx: infection (esp
Gingivitis, skin infections, rectal inflammation, otitis
viruses), medication administration
media, pneumonia, sepsis. S. aureus and gram neg
(penicillin, sulfonamides,
infections. Acute neutropenia: no treatment
anticonvulsants), malignancy in BM,
- absense of inflammatory response --> no
aplastic anemia
erythema, warmth, or swelling Chronic neutropenia/infections:
- severe: ANC <0.5x10^3
recombinant human gametocyte
- chronic: >2-3 months
CGD: chronic/recurrent pyogenic infections by colony stim factor (rhG-CSF)
catalase pos organisms, abscesses. Failure to
CGD: WBC betw 10,000-20,000,
thrive, diarrhea, persistent candidiasis of motuh CGD: prophylactic TMP-SMX. BM
leukoerythroblastic response
transplant
- nitroblue tetrazolium test,
LAD: WBC counts 5-10x normal, unable to form
dihydrorhodamine reduction (DHR)
granulomas. Severe gingivitis, intestinal fistuals, LAD: BM transplant.
poor wound healing, delayed separation fo umbilica
LAD: flow cytometry analysis of
cord
CD18
Bacterial infections, rheumatologic disease
C5-C9 def: Neisseria meningitidis infections
C1-C4 def: SLE
Allergy
Pruritic, erythematous, weeping papulovesicular
Termination of itch-scratch-itch cycle:
reaction --> scaling, hypertrophy, lichenification
lotions, topical corticosteroids,
DDx: contact dermatitis, psoriasis Bacterial superinfection
pimecrolimus cream (inhibits T cell
<2 yrs: extensor surfaces
activation), topical tacrolimus
>2 yrs: flexor surfaces, neck, wrists, ankles
Immunology, Allergy, Rheum
Condition Description
T1 hypersensitivty, IgE
seasonal (hay fever): limited to
pollination months, uncommon
betfore 4-5 yrs
Allergic rhinitis
Risk factors: atopy, genetic,
smoking
- heavy exposure to animal
dander early in life reduces risk
Urticaria and Hereditary angioedema: C1
angioedema esterase deficiency
80% present in 1st year
Isolated cutaneous rxns, GI sxs, respiratory sxs,
Food allergies - peanuts, eggs, milk, soy, wheat,
life-threatening anaphylaxis.
tree nuts, fish
Signs/symptoms Ddx Treatment Complications
Ddx:
- Infectious rhinitis: more common in
infants/toddlers, mucopurulent
- Sinusitis: chronic rhinorrhea,
postnasal drip w/ facial tenderness,
Nasal congestion, rhinorrhea, postnasal drainage,
cough, and/or HA Allergen avoidance
sneezing, itching
- Nasal foreign body: unilateral, thick,
foul discharge H1 blocker: PO or intranasal
Nasal mucosa appears boggy and bluish
- Vasomotor rhinitis (idiopathic Intranasal cromolyn: preventive Recurrent sinusitis, otitis media with
nonallergic): exaggerated vascular Nasal topical steriods effusion
1. allergic shiners: dark circles under eyes
respons to irritant PO leukotriene receptor antagonists
secondary to venous congestions
- Rhinitis medicamentosa: overuse of Topical/inhaled sympathomimetics -
2. allergic salute: horizontal crease across middle
topical decongestants pseudoephrine
of nose due to upward wiping motion with hand
Elevated nasopharyngeal
eosinophils, serum
radioallergosrobant (RAST) test,
direct skin testing
Urticaria: raised edematous hives on skin/mucous Subcutaneous epinephrine:
membranes resulting from vascular dilation and emergency
increased permeability Also IV diphenhydramine and
- itch, blanch, resolve steroids
PO antihistamines,
Angioedema: lower dermis and subcutaneous sympathomimetics, PO steriods
areas, well demarcated area, no C1 esterase replacement for
pruritis/erythema/warmth hereditary angioedema
Ddx:
- Food intolerance: nonimmunologic Avoid offending food
(caffeine-induced tachycardia, - Cow milk, egg, soy, and wheat
lactose intolerance) allergies can be outgrown
- peanut, nut, and fish allergies
Double-blind placebo challenge - usually persist
food challenge: gold standard.
Rheumatology

Oligoarticular JIA: most common.

Chronic arthritis > 6 weeks in
individuals <16 yrs
Juvenile Idiopathic
synovitis: inflammation and
Arthritis
hypertrophy of synovium
- TNF alpha mediated
- girls 2-4yrs
- large joints (knee, ankle)
- joint contractures, muscle atrophy, increased
extremity growth in affected limb
- 75% have positive ANA test -- associated with
chronic nongranulomatous anterior uveitis -
asymptomatic, detect on slit lamp
Polyarticular JIA -
- RF positive: resembles adult rheumatoid arhtritis infections (septic arthritis, viral
- RF neg: adolescents, large and small joints, better arthritis, Lyme disease), malignancy
prognosis
Systemic JIA: autoinflammatory disorder
- extraarticular, intermittent high fever, salmon
colored rash, HSM, LAD, pericarditis.
- large and small joints
- acute phase rxn: leukocytosis, thrombocytosis,
anemia, incr ESR and CRP, incr ferritin.
Enthesitis-related arthritis: sacroiliac joints,
occurs at tendon insertions (achilles, plantar fascia,
ASIS)
Ddx: posinfectious arthritis (acute
rheumatic fever), systemic
inflammatory conditions (IBD,
connective tissue diseases, HSP),
Single large joint: intra-articular
corticosteroid injection
(leukemia, neuroblastoma, bone
Bony erosions, deformities, growth
tumors)
Multiple joints: methotrexate disturbances
- TNF-alpha, IL-L, IL-6, T-cell
Diagnosis:
costimulation
- acute phase rxn
- ANA associated with anterior uveitis
- RF only in 5%
- Synovial fluid: WBC > 2000/mm3
with mononuclear cells

Psoriatic arthritis: nail pitting, onycholysis,

dactylitis due to flexor tendon tenosynovitis
Immunology, Allergy, Rheum
Condition Description Signs/symptoms Ddx Treatment Complications
Anemia, leukopenia,
thrombocytopenia, elevated ESR,
CRP normal
Painless oral ulcers, malar rash, discoird lupus, Aovid sun
Abnormal cell death --> incr Positive coombs --> hemolytic
Systemic lupus photosensitivity. hydroxychloroquine for preventing
exposure to self nuclear anemia
erythematosus disease flares
components Decr complemet levels
Renal failure in Type IV LN (diffuse proliferative) NSAIDs, corticosteroids
ANA, antiphospholipid abs, anti
smith, anti-dsDNA, anti-RNP, anti-Ro,
anti-La
Ddx: polymyositis (no skin findings,
CD8 lymphocytes infiltrate muscle
fascicles and attack muscle fibers
directly), less common in children
Corticosteroid therapy, IVIG,
Violaceous dermatitis of eyelids (heliotrope),
elevated serum creatine cyclosporine
autoimmune disease involving hands, elbows, knees, ankles. Spontaneous perforation of bowel is
Dermatomyositis phosphokinase (released during
skin/skeletal muscles Gottron papules: scaly erythematous papules on leading cause of death
muscle breakdown), other muscle hydroxychloroquine: treats
extensor surfaces of fingers, elbows, knees
enzymes. Elevated VWF. cutaneous manifestations

Definitive diagnosis: muscle biopsy -

perivascular inflammatory infiltrate,
perifascicular atrophy

Skin, joint, GI, kidney disease. Supportive, Spontaneous resolution

Henoch Schonlein IgA immune complexes in vessel
Nonthrombocytopenic purpura on lower extremities, within 4 wks, sxs may persist for 12
purpura walls
buttocks. Scroal edema, extremity swelling wks
Fever with abrupt onset and termination

Familial Mediterranean Fever: MEFV gene, most

common. Peritonitis, erysipelas-like rash,
oligoarthritis

TNF receptor-associated Period Fever

Periodic Fever Syndrome (TRAPS): AD, fevers 7-21d, 2-3x/yr. Abd WBC, CRP, ESR elevated during
Syndromes pain, severe muscle aches with overlyting fever attacks
erythema, conjunctivitis, periorbital edema, large
joint arthritis

Periodic Fever, Apthous stomatitis, pharyngitis,

adenitis syndrome (PFAPA): 3 or more episodes
of fever, tender cervical LAD, pharyngitis/apthous
ulcers, normal WBC, CRP, ESR
Endocrine
Condition Description Signs/symptoms Ddx Treatment Complications
Nephrology and Urology
Condition Description Signs/symptoms Ddx Treatment Complications High Yield facts
Renal dysplastic and cystic diseases
Renal Dysplasia: Renal parenchymal tissue does not form correctly throughout, usually bilateral. incr risk of abnormal development elsewhere
- inability of kidney to concentrate urine
- impaired ability to resorb fluids --> frequency, incontinence, susceptibility to dehydration
- often does not present with HTN
- Renal US: kidneys appear hyperechoic

Failure of one or both kidneys to

form
Renal agenesis - Bilateral --> oligohydramnios -->
Potter sequence (clubbed feet,
cranial abnormalities)
Kidney consists of numerous
noncommunicating fluid filled
Most cases undergo spontaneous
cysts.
Postnatal US: noncommunicating involution
Multicystic - Almost always unilateral
cysts
dysplastic kidney
Renogram: lack of function Nephrectomy if kidney changes in
Most common renal cystic dz of
size or appearance, persistent HTN
childhood, most common
abdominal mass in newborn
ARPKD: dilated renal collecting
Palpable renal mass in infant
tubules --> small cysts
Polycystic kidney ARPKD: HTN, decline in renal
- dilated hepatic bile ducts Increased echogenicity on US ARPKD: dialysis
disease function
ADPKD: usually not detected until
ADPKD: HTN, hematuria
adulthood

MCC of hydronephrosis in
childhood
- Primary: intrinsic narrowing at
junction of renal pelvis and ureter
Ureteropelvic
or angulation of ureter from a
junction obstruction
crossing renal vessl
- Secondary: scarring, angulation
secondary to ureteral dilation
(stones)
Newborns: palpable abdominal
mass
Surgical correction: minimally
Older children: abd or flank pain, Renal US
invasive surgery or open pyeloplasty
cyclic vomiting, hematuria +
mass

Antibiotic prophylaxis for UTIs

Length of tunnel of ureter
through bladder submucosa is
Vesicoureteral reflux insufficient to prevent retrograde
flow of urine
- unilateral or bilateral
Obstructing leaflets within
posterior urethra --> partial-to-
complete bladder outlet
obstruction
- urethral dilation, bladder neck
Posterior urethral
hypertrophy, bladder trabeculation Older infants: weak/dribbling
valves
- males only
One of the most common causes
of end-stage renal disease in
male child
Incomplete development of distal
urethra --> malposition of urethral
meatus along ventral side of penis
Hypospadias
toward perineum
- chordee: associated curvature
of penis
VCUG: voiding cystourethrogram
- < 3yrs: amoxicillin
detects abnormalities at erteral
Frequent UTIs - older: bactrim or nitrofurantoin
insertion sites and allows
Retrograde flow of infected urine
classification of grade of reflux
--> pyelonephritis Surgery: lengthen intravesicular
- high grade: large tortuous ureters,
segment of tunnel (ureteral
distortion of renal pelvis and calyces
reimplantation)
Prenatal US: hydronephrosis and
bladder distention
Ablation of obstructing valve leaflets
Renal US: distended bladder with
Distended bladder or renal mass Abx prophylaxis if VUR is present
thickened walls and trabeculation. Chronic kidney
Bilateral hydronephrosis. disease -
Early surgical correction of reflux is
VCUG: visualization of posterior requires long
urinary stream or unexplained discouraged: bladder pathophys
urethral valvesx term follow up
daytime wetting changes over time, early surgery has
- dilated bladder, hypertrophied
high failure rate
neck, dilated posterior urethra with
shield-shape (spinnaker-sail)
Hypospadias + cryptorchidism Circumcision is contraindicated-
prompts ambiguous genitalia surgical repair may require preputial
workup (genetic karyotyping) tissue
Nephrology and Urology
Condition Description
Lack of posterior attachment to
Testicular torsion tunica vaginalis --> mobile testis
--> bell-clapper deformity
Hydroceles: fluid-filled sacs in
scrotal cavity consisting of
remnants of processus
vaginalis
- communicate with peritoneal
Hydroceles and cavity through patent processus,
varicoceles risk for incarceration
Varicocele: dilation of testicular
veins + enlargement of
pampiniform plexus
First year of life: girls = boys
UTI After first year: girls have 10x
incidence
Proteinuria, hypoalbuminemia,
hyperlipidemia, edema
- Primary: MCD (most common),
FSGS, MPGN, MN
Nephrotic syndrome
- Secondary: Infections, systemic
dz (SLE, HSP, IgA), drugs
(NSAIDs, heroin), malignancies,
genetic
Signs/symptoms
Acute onset unilateral scrotal
pain, n/v
Swollen, erythematous scrotum
Absent cremasteric reflex
Varicoceles: detectable in boys
during adlescence, more
common on left, nontender
- evident when pt is standing:
veins distend, "bag of worms"
Infants: fever may be only sign
- hematogenous seeding of
kidney
Older children: same as in adults
- upper tract involvement: incr
WBC, ESR, CRP
Nonspecific illness a few weeks
prior
Periorbital edema: first
abnormality noted
Dependent edema, weight gain
FSGS, secondary etiologies,
glomerulonephritis: gross
hematuria, HTN
Ddx Treatment Complications High Yield facts
Surgical emergency
Ddx:
- surgery within 6 hrs
- epididymitis (infectious or
- remove necrotic testes, fix CL testis
secondary to epididymal appendix)
to scrotal envelope
- appendix testes: "blue dot" sign +
normal cremasteric reflex
Testicular or epididymal appendix:
torsion resolves spontaneously
clinical diagnosis
Epididymitis: abx
Hydroceles: repair communicating
hydroceles and hernias to prevent
incarcerated hernia
Varicoceles: surgical repair
- unrepaired varicoceles incr risk for
infertility
UTI
DDx:
- Adenovirus: self-limited
hemorrhagic cystitis that does not
respond to abx
- Posterior urethralgia: benign, self- Pts with positive leukocyte esterase
limiting inflammation of posterior should be treated for presumed UTI
urethra in boys until culture results are available
Pyelonephritis:
- Lower lobe PNA in febrile child:
perinephric Bagged specimens are
f/chills/flank pain
abscess, renal inadequate for UTI
- Urolithiasis: dysuria, hematuria, Cystitis: amoxicillin, ampicillin,
scarring, renal evaluation
flank pain nitrofurantoin, or TMP-SMX
failure
All children <24 months must Pyelonephritis: PO cephalosporin or
undergo renal US to r/o IV ampicillin + gentamicin
hydronephrosis or structural lesions.
VCUG if hydronephrosis or
nonresponders to abx. DMSA if
suspected pyelonephrosis
Marked proteinuria: > 1000
mg/m2/day, spot urinary
protein:creatinine ratio > 2.0 Spontaneous
- results in hypoalbuminemia (<2.5 bacterial
g/dL) peritonitis - incr
risk of
Dietary salt restriction, oral steroid
Hyperlipidemia (lipases are lost in encapsulated
therapy
urine) organisms due
- stronger immunosuppressants in
Microscopic hematuria, mild to loss of
nonresponders (cyclophosphamide,
hyponatremia (fluid overload), proteins involved
calcineurin inhibitors)
hypocalcemia (albumin loss), incr in phagocytosis
creatinine (renal hypoperfusion) of capsule
IV albumin: induces temporary
diuresis
MCD: effacement of foot processes Thromboembolic
FSGS: mesangial hypertrophy, events,
tubular atrophy persistent
Diffuse MPGN: incr mesagnial hyperlipidemia,
cellularity, glomerular BM thickening steroid toxicities
MN: diffuse thickening of capillary
walls
Ophthalmology
Condition Description
4% of children
Esotropia: inward
Exotropia: outward
Strabismus
Associated with cerebral palsy,
down syndrome, hydrocephalus,
brain tumors
Reduced vision in otherwise
normal eye
- strabismic amblyopia:
suppression of retinal images in
Amblyopia
misaligned eye
- anisometropic amblyopia:
unequal refractive errors in two
eyes
Leukocoria
Failure of distal membranous end
Congenital
of nasolacrimal duct to open
nasolacrimal duct
- Common cause of overflow
obstruction
tearing
(dacryostenosis)
- 25% of neonates
Infectious Inflammation in conjunctiva
conjunctivitis Viral: adenovirus
Hordeolum: acute infection of
glands around eyelas follicle
- S. aureus
Styes
Chalazion: sterile
lipogranulomatous reaction within
glands in tarsal plate
Bacterial infection of eyelids/skin
anterior to orbital septum
- breaks in skin: s. aureus, group
A strep
Periorbital cellulitis
- hematogenous: s. pneumo, h.
influenza
- sinuses/resp: s. pneumo, h.
influenza, moraxella
Signs/symptoms
Amblyopia found in most pts with
esotropia
Subnormal vision
White pupil/absence of red reflex
Chronic tearing in absence of
conjunctival injection
H. influenza: same-sided otitis media
Hordeolum: localized tender swelling,
then rupture
Chalazion: firm, nontender area
Skin around eye is indurated, warm,
tender
Ddx Treatment Complications
Amblyopia,
Corrective lenses, occlusion,
Corneal light reflex, cover test reduced
atropine penalization, surgery
stereopsis
Correct refractive errors
Occlusion of better eye Permanent vision
loss, diminished
Treatment is unsuccessful beyond stereopsis
8 yrs
Enucleation, chemo, radiation, cryo
Retinoblastoma, cataracts (most Amblyopia
Cataract surgery
common), retinopathy of ROP: Retinal
ROP: laser ablation of retina or cryo
prematurity, congenital glaucoma, detachment,
reduces progression to retinal
ocular toxocariasis scarring
detachment/scarring
96% resolve spontaneously in 1 yr
Probing of nasolacrimal duct system
at 12-15 mo.
Antibiotic drops: polymyxin-
bacitracin, erythromycin
- abx limit infectivity and decrease
Corneal abrasion: Painful, tearing,
duration by 2 days
photosensitivity. Examination under
- Neisseria: IV ceftriaxone
blue light with fluorescein reveals
- H. influenza: amoxicillin-clavulanic
abrasion. Treat with eye patching.
acid
Heals in 24h
- HSV1: do not give steroid-
containing abx. Risk of more severe
disease and visual impairment
Hordeolum: warm compresses, abx
Chalazion: excision may be required
Orbital cellulitis: severe pain with IV abx
eye movement, proptosis, vision Breaks in skin: penicillin or 1st gen
changes, decr ocular mobility. cephalosporin
Confirm with CT. Cefuroxime
3rd gen ceph: prevent extension to
Trauma, edema, allergies, tumor meninges