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2.23.

2015

PEDIATRIC NOTES
Outline + Q&A's
Key:
Appeared once, twice, three, four, five, six, seven, eight, and nine times in Question Banks as main
symptom or deciding factor for a question
S/Sx = Signs & Symptoms
Tx = Treatment
Dx = Diagnosis

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Contents: Ctrl + Click to Jump

Neonatology

Pulmonary

Cardiology

Nephrology & Urology

Gastroenterology

Infectious Disease

General/Random Info

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Neonatology

Neonatal Tooth
o If loose, can fall out and be aspirated
Extraction by pediatric dentist
o Midline or pointed tooth can be associated w/ genetic syndromes
Sturge-Weber Syndrome
o Vascular cutaneous malformation w/ trigeminal distribution
Port wine stain (Facial Angioma)
Also involves meninges
Seizures, MR, contralateral hemiparesis
o Choroidal angiomas
Twin to Twin Transfusions
o 15% of monochorionic twins
o S/Sx
Hct difference of 15% between twins
Recipient
Polyhydraminos, plethora, Hct, hyperviscosity syndrome,
hyperbilirubinemia
Polydactyl
o Postaxial (5th finger side)
Normal occurrence in AA
Surgical removal
Abnormal in whites
Careful cardiac exam
o Preaxial (thumb)
Abnormal in all races
Investigate further
o Associated w/ Trisomy 13
Cleft Lip and Cleft Palate
o Complications
Recurrent otitis media
Hearing loss
Speech defects
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Tx

Repair
Lip

o 2-3m
Palate
o 6m to 5y
Propranolol (during pregnancy)
o Causes growth retardation, hypoglycemia, apnea
o ability of asphyxiated newborn to HR/CO
Opioid (Narcotics) in Newborn
o Hx of maternal narcotic use
Demerol for labor pain control
Heroin
o S/Sx
Lethargic, limp, depressed respirations
o Tx
Manage ABCs
Naloxone
Subgaleal (or subaponeurotic hemorrhage)
o S/Sx
Similar feel to cephalohematoma (squishy), crosses midline (entire scalp),
fluid wave
Rapidly expands
Signs of hypovolemia from hemorrhage
Tachycardia
o Tx
Careful monitoring, transfer to NICU
Erb-Duchenne Palsy
o Cervical nerves 5 and 6
o S/Sx
Unable to abduct, externally rotate, or supinate
Arm will remain internally rotated at side w/ forearm protonated
Wont move w/ Moro reflex
o May coexist w/ phrenic nerve palsy (Cervical nerves 3,4,5)
Ipsilateral hemiparesis of the diaphragm
Asymmetry on inspiration when it doesnt flatten
See Saw
Typically resolves on own
Clavicle Fracture
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Initial presentation may be pseudoparalysis


Refusal to move arm
Mimics Erb-Duchenne
o Dx
Can be identified at birth by crepitus
Those not discovered in newborn present later with a callus formation
o Tx
Reassurance
Hypothermic Infant
o In reaction will metabolic rate and subsequently RR to maintain O
Metabolic acidosis
Become tachypenic
o Tx
Warmer
Bleeding in the Newborn
o W/ hematemesis or melena first establish source
Maternal vs. Fetal
Apt-Downey test
o Fetal Hb is alkali resistant
Breast Feeding Contraindications
o Active TB, HIV
o Medications
Antineoplastic, lithium, cyclosporine, illicit drugs, amphetamines, ergotamines,
and bromocriptine ( lactation)
Most ABx safe (except Tetracyclines)
o Galactosemia
Acrocyanosis
o W/ Cutis Marmorata (mottling of the skin w/ venous predominance)
Vasomotor instability
Milia
o Small cysts around the pilosebaceous follicles
White papules surrounding the nose
Disappear in 1st weeks
Pustular Melanosis
o Benign transient rash characterized by small dry superficial vesicles over a dark base
o Blacks
o Differentiate from HSV or Bacterial (ex. Impetigo)
o Lesions are filled w/ eosinophils
Erythema Toxicum Neonatorum
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

Benign rash in first 72h


Erythematous macules, papules, & pustules (flea bite like)
On trunks & extremities
Not palms/soles
o Lesions are filled w/ eosinophils
Nevus Simplex (Salmon Patch or Telangiectastic Nevus)
o Most common vascular lesion of infancy
o Pink macular lesion on nape of neck (stork bite), upper eyelids, galbella, or nasolabial
folds
Nevus Flammeus (Port Wine Stain)
o Capillary hemangioma over face or trunk
o Those over CN V-1 (Trigeminal) may be associated w/ intracranial or spinal vascular
malformations, seizures, & intracranial calcifications
Sturge-Weber Syndrome
Neonatal Acne
o 1-2w after birth (not present @ birth)
Caput Succedaneum
o Diffuse edema of soft tissue of the scalp that crosses sutures & midline
o Can sometimes be ecchymotoic
Cephalohematomas
o Subperiosteal hemorrhages secondary to birth trauma, confined by sutures (bc
subperiosteal)
o No ecchymosis discoloration
o Usually parietal or occipital bones
Craniosynostosis
o Premature skull fusion
Abnormal shape
Macroglossia
o Beckwith-Wiedeman Syndrome
Hemihypertrophy, visceromegaly, macroglossia
o HoThyroidism
Midline clefts or Masses
o Goiter
Secondary to maternal antithyroid meds or maternal thyroid stimulating Auto
Ab
Neonatal Torticollis
o Asymmetric shortening of SCM
o Causes
Fixed position in utero
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Postnatal hematoma
Poland Syndrome
o Chest asymmetry from agenesis of pectoralis
Periodic Breathing
o Normal in preterms
Irregular breathing w/ short apenic bursts 5 to 10s
Umbilicus
o 2 arteries, 1 vein
1 artery suggests renal malformation
Diastasis Recti
o Separation of the rectus abdominis @ midline
o Benign
Umbilical Hernia
o Soft swelling beneath umbilicus
o May protrude during crying
o Most close spontaneously
Persistent Urachus
o Urine draining from bladder to umbilicus
Hydrometrocolpos
o Cysts between the labia
Caused by an imperforate hymen and collection of secretions behind
Male Genitalia
o Hypospadias
Urethral Meatus Ventral
Not associated w/ incidence of urinary malformations
o Epispadia
Urethral Meatus Dorsal
Often associated w/ bladder extrophy
Protrusion of bladder from abdominal wall, w/ exposure of its mucosa
o Hydrocele
Scrotal swelling
Fluid in tunica vaginalis
Resolve spontaneously
o Cryptorchidism
Surgery should not take place < 1 y/o
Typically descend by 12m
o If fails risk of malignancy
Surgical correction after 1 y/o
Extremities
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Absence/Hypoplasia of Radia
TAR Syndrome (thrombocytopenia, absent radii), Fanconi Anemia, Holt-Oram
Syndrome
o Edema of feet w/ hypoplastic nails
Turner Syndrome & Noonan Syndrome
o Rocker Bottom Feet
Trisomy 18
Post term (>42w)
o Placental insufficiency
Intrauterine asphyxia, meconium aspiration, polycythemia
Small for Gestational Age (SGA)
o Complications
Hypoxemia, perinatal asphyxia, hypocalcemia
Hypomagnesaemia
Floppy
Polycythemia (>65% Hct)
From erythropoietin in response to hypoxia
blood viscosity
o hyperviscosity syndrome
Jittery, seizures
Changes in cerebral blood flow
Renal V. thrombosis
NEC
Tx
o Partial exchange fusion
Hypothermia
From ability to thermoregulate from subq fat
Hypoglycemia
From glycogen stores
Manage w/ early and frequent feeds
o Associated w/ higher incidence of major congenital abnormalities
Large for Gestational Age (LGA)
o Causes
Diabetes, Beckwith-Wiedmann Syndrome, Prader-Willi Syndrome,
Nesidioblastosis (diffuse proliferation of pancreatic islet cells)
Cyanosis
o Related to the amount of unoxygenated Hb
>3 arterial or >5 capillary
o Causes
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

5 Ts of Cyanotic CHD, Polycythemia, intraventricular hemorrhage,


hypoglycemia, hypocalcemia, hypothermia, HoThyroidism
o 100% O Test
w/ Cyanotic Heart Disease (slight )
Those w/ Pulmonary blood flow (ex. TOF) will only have slight in
PaO (10-15 mmHg)
w/ Normal or Pulmonary blood (ex. Truncus Arterious), PaO will
15-20 mmHg, but not close to 150mmHG total
w/ Lung Disease
PaO will a lot (150 mmHg)
o Except w/ Persistent Pulmonary HTN of New Born
May have a large RL shunt through PFO or PDA
PaO will not 10-15 mmHg
Respiratory Distress Syndrome, RDS (Hyaline Membrane Disease or Surfactant deficiency
Syndrome)
o Preterm
o Sufficient surfactant @ 30-32w
RDS more likely/severe <30w
o Asses Fetal Lung Maturity
Lower the L:S ratio, the risk of RDS
o CXR
Diffuse Reticular Granular Pattern
o Tx
Supplemental O
Mechanical Ventilation if hypercarbia & Resp Acidosis
Exogenous Surfactant
o Complications
Acute
Pneumothorax, intraventricular hemorrhage, RL shunt through PDA
Chronic
Broncho Pulmonary Dysplasia (Chronic Lung Disease)
o Criteria:
Mechanical ventilation w/in first 2w
Classic signs of resp compromise >28d
Need supplemental O for >28d
Characteristic CXR
Retinopathy of prematurity
Term infant w/ Respiratory Distress
o Persistent Pulmonary HTN (PPHN)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Especially w/ C section
o Meconium Aspiration Syndrome (MAS)
Especially post term
Persistent Pulmonary HTN (PPHN)
o Any condition other than CHD w/ low blood flow to the lungs after birth
o Causes
Perinatal asphyxia
Can result in pulmonary pressure while the systemic BP falls
o Causes a persistent R to L shunt across PDA or PFO
Results in PPHN
MAS (meconium aspiration syndrome)
Any cause of fetal stress
o PVR
RL Shunt through PFO or PDA
o Cyanosis from Respiratory Failure
o Pre and Post Ductal PO differences
o CXR
????????????????????
o Echo
Rule out CHD, assess shunt
o Tx
O
Important b/c hypoxemia is a potent vasoconstrictor (want to PVR)
NO
Meconium Aspiration Syndrome (MAS)
o Respiratory distress in term or post term newborn
o Pea Soup or Meconium stained amniotic fluid
o Meconium (first stools)
Can be passed as result of distress (e.g. hypoxemia)
o CXR
Lung Vol, diffuse patchy atelectasis, parenchymal infiltrates alternating w/
hyperinflation
Possible pneumothorax
Diminished breath sounds on side
Loss of lung markings on CXR
o Endotraceal Suction after whole body is delivered (not intrapartum or after head only
according to ACOG and AAP)
Apnea of Prematurity
o Respiratory pause > 20s
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o
o

Caused by immature respiratory center


Or pause of any length if accompanied by bradycardia/cyanosis or O desat
Types
Central
Absent chest wall movement & no airflow
Apnea secondary to Obstruction
Chest wall movement w/out airflow
Wont show as apnea on home monitors
o Tx
Maintain neutral temp environment & Stimulation
Respiratory stim med
Caffeine or Throphylline
Neonatal Jaundice
o Visible jaundice in neonate TB >5
o Peak
Term: Day 3-4
Preterm: Day 5-7
o Evaluate always if
Jaundice in <1 day old
Rate >.5/hour
Suggestive of hemolysis
o Direct Hyperbili Eval
Hepatic US (Choledochal Cyst), Serology (Hepatitis), Radio isotope scan for
hepatobilliary tree (biliary atresia), sepsis
o Tx
Phototherapy
Exchange transfusion for rapid rises in TB from hemolysis or extremely high TB
Complications: coagulopathy (bleeding)
o Complications
Indirect crosses BBB
Acute Bilirubin encephalopathy
o High pitched cry, lethargy, poor feeding, hypotonia
Localizes in Basal Ganglia & Hippocampus
Heroin Withdrawal
o Jitteriness, hyperreflexia, irritability, tremulousness/tremors, feeding intolerance
o High pitched cry
Esophageal Atresia w/ Transesophageal Fistula (TEF)
o Often associated w/ Polyhydramnios
o Copious oropharyngeal secretions
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

risk of aspiration, choking, or pneumonia feeding attempted


o Associated malformations
CHD, anorectal, renal, skeletal, or the VACTERL Association
CH5 III.A.8
o Evaluation
Insert oral gastric tube until resistance
CXR tube in upper part
o Type III can have air in stomach that crossed across the fistula
Omphalocele
o Centrally
Through umbilicus
o True hernia sac
Covered w/ peritoneal sac
But not w/ skin like in an umbilical hernia (which can resolve on own, usually
protrudes w/ crying)
o Frequent association w/ other congenital malformations (heart, kidney)
CHD
TOF & ASD
Beckwith-Wiedemann Syndrome
Exophthalmos, macroglossia, gigantism, hyperinsulinemia,
hypoglycemia, midline defects (eg. Omphalocele)
o Dx
Polyhydramnios on US
90% diagnosed Prenataly (so usually pt. w/ no prenatal care)
o Tx
Wrap in sterile wet gauze
Surgery
Gastroschisis
o Fissure of abdominal wall located right paraumbilical area (non midline)
Umbilicus looks normal
o Not true hernia sac
No peritoneal sac covering
o No association w/ other malformations
o Increased risk of damage to bowel from exposure to amniotic fluid
o Tx
Immediately wrap in sterile saline dressings and cover in plastic
Surgery
Intestinal Obstruction
o Meconium ileus
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

CF
Air remains trapped in meconium giving it a soap bubble appearance on XR
Hypoglycemia
o Glc <40
o Can be from excess insulin
Infants of diabetic mothers
Transient hypoglycemia
Nesidioblastosis
Islet Cell Hyperplasia
Persistent hypoglycemia
o S/Sx
Diaphoresis, jitteriness, feeding problems, tachycardia, hypothermia, hypotonia,
seizures
o Tx
Oral feedings
IV Glc if necessary
Infants of Diabetic Mothers
o Large bc of body fat and visceromegaly
Liver, adrenals, heart
o Typically LGA, but can be SGA if mother has serious DM w/ vascular complications
causing placental insufficiency
o Complications
Hypoglycemia (typically 1st 24h), polycythemia, hypocalcemia (typically 4896h), hypomagnesaemia Hypertrophic Cardiomyopathy, PPHN, RDS, renal vein
thrombosis
Hypocalcemia presents w/ twitching/tremors, seizures, arrhythmias
o Tx: IV Calcium Gluconate
Malformations
Structural heart, CNS, Musculoskeletal, Hypoplastic Left Colon, Caudal
Regression Syndrome (hypoplasia of the sacrum and LE)
Polycythemia
o Hct >65%
o Causes
Erythropoietin in response to placental insufficiency, fetal hypoxia,
placental transfusion from delayed cord clamping
o Tx
Partial Exchange Transfusion
Blood is removed and then replaced w/ same volume of plasma (normal
saline)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Choanal Atresia
o S/Sx
Trouble breathing when sleeping or eating
Improved breathing w/ crying
o Dx
Unable to pass NG tube
Lack of fogging on a cold metal instrument under the nares
o CHARGE association
Coloboma
Absence or defect of ocular tissue
o Usually the retina
o Impaired vision
Heart disease (TOF)
Atresia of the choanae
Retarded growth and development
Genital hypoplasia
Ear abnormalities (cup ears & hearing loss)

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Pulmonary

Sounds
o Stridor
Squeaky, whistlelike sound that results from turbulence between supraglottis
and trachea
Extrathoracic obstruction
Laryngomalacia
o Congenital Inspiratory Stridor
"Noisy Breathing"
Worse in supine
Relieved when standing up or prone
Exacerbated by crying/feeding
o Softening and weakness of laryngeal cartilage
Collapses the airway
o Dx
Laryngoscopy
Omgea shaped epiglottis
Collapse of the supraglottic structures w/
inspiration
Croup
Foreign body aspiration
Retropharyngeal Abscess
o Fever, drooling, dysphagia, neck pain, stridor
o Dx
CT
Vascular Rings
o Persistent Stridor
o Branch of aortic arch encircles the trachea & esophagus
o Biphasic stridor and feeding difficulties
From tracheal or esophageal enacement
o Improves w/ neck extension
o Wheezing, rhonchi, and rales due to narrowing/congestion of bronchioles
o Expiratory Wheezing
Intrathoracic obstruction
Asthma
Bronchiolitis
o Crackles or Rales
Parenchymal Disease
Pneumonia
Pulmonary edema
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S2
Pulmonary Pressure
Tracheitis
o Bacterial
S. aureus most common cause
Hx of recent URI
Previous viral laryngotracheobronchitis (croup, inspiratory stridor)
Follows w/ acute elevation in temperature, trouble breathing, change
to biphasic stridor (expiratory & inspiratory)
Brassy cough, high fever, respiratory distress
Tx for croup (mist & racemic epinephrine) dont help
Tx
Secure airway (intubation)
IV ABx
Epiglottis
o Acute inflammation and edema
o Most common 2-7 y/o
o Causes
HIB
Blood culture will be + 90%
Unvaccinated typically
GAS ( Hemolytic), Moraxella
o Sx
Rapid upper airway obstruction
Can cause Resp Arrest
High Fever (~104)
Muffled Speech
Inspiratroy stridor
Dysphagia w/ drooling
Sitting forward in tripod position w/ neck hyper extension
o Signs
Thumbprint on lateral xray
Cherry Red epiglottis
o Tx
2nd/3rd Generation Cephalosporin
Rifampin prophylaxis for non-immunized if HIB
1st step Have sterile environment and skilled personal for
nasotrachealintubation
Croup (Laryngotracheobronchitis)
o Inflammation/Edema of Subglottic Larynx, Trachea, & Bronchi
o Types
Viral
Most common, 3m to 3y, Late Fall/Winter
Spasmodic
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Preschool children, Secondary to Hypersensitivity

Viral Croup
Causes
Parainfluenza (most), RSV, Adenovirus, Influenza
Viral Prodrome for 2-3d (rhinorrhea, low grade fever)
Followed by inspiratory stridor (means upper airway/extrathoracic) &
cough, fever
o Barky Cough
Stridor worsens at night
AP XR Steeple Sign (Subglottic Narrowing)
Spasmodic Croup
Acute onset, mainly at night
Recurs & Resolves w/out Tx
Tx
NO ALBUTEROL (can worsen)
If stridor @ rest
Systemic Corticosteroids
o Dexamethasone ( edema)
O w/ humidified air (Cool Mist/Air)
Resp Distress
Racemic Epinephrine Aerosol
o Always try trial of epi before intubation
o :Vasoconstriction Edema
o : Smooth muscle relaxation of air way

Feature

Supraglottic
(Epiglottitis)

Subglottic
(Croup)

Stridor

Quiet

Loud

Cough

None

Barky

Voice

Muffles

Hoarse

Dysphagia/Drooling

Present

Absent

Fever

High

Low to Mod

Posture

Neck Extended, Tripod Position

XR

Thumbprint

Steeple Sign
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Asthma
o Decreased Expiratory Flow
o Sx
Nocturnal Cough (#1), wheezing (usually expiratory, really severe if
inspiratory), dyspnea
o Asthma Triad Family Hx
Eczema (atopic), Allergic Rhinitis, and Asthma
o Classification & Tx
Mild Intermittent
<2 Daytime per week
<2 Night time per month
Dont require daily, just Albuterol (short acting -agonist)
Mild Persistent
>2 Daytime per week
<4 Night time per month
Anti Inflammatory (low dose inhaled corticosteroid) + short acting agonist
Moderate Persistent
Daily symptoms?
>1 night time per week
Options
o Medium-dose corticosteroids + short acting -agonist
o Low-dose corticosteroids and a long-acting -agonist
Severe persistent
Continual Sx?
High-dose inhaled steroids + as long-acting -agonists + oral steroids
o Tx
If oral thrush from inhaled steroids, rinse mouth after
If signs of impeding respiratory failure
MS, silent chest (not moving air bilaterally), hypoxemia (low pO), CO
retention (acidosis)
Intubation w/ mechanical ventilation
Bronchiolitis
o Inflammation/obstruction of the bronchioles by viral infection
o Most Common Lower Respiratory Infection of First 2y
o Nov to April (winter)
o Significant in those w/ chronic lung disease, CHD, prematurity
o Causes
RSV (most), Parainfluenza, Adenovirus, Rhinovirus, Influenza
o Sx
Initial gradual URT Sx
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Rhinorrhea, nasal congestion, fever, cough


Progression
Tachypnea
Scattered fine rales /coarse breath sounds(crackles), wheezing
Palpable liver & spleen
o From Hyperinflation
Hypoxemia (respiratory failure) & Apnea (esp. <2m) can occur
Esp. w/ premature

CXR

Dx

Tx

Hyperinflation from air trapping


Flat diaphragm
Patchy infiltrates
Atelectasis

Viral antigen/Ab testing

Supportive w/ Nasal Bulb Suctioning


Monitor oxygenation & hydration
RSV Monoclonal Ab (Palivizumab)
Prophylactic in RSV season for premature& chronic disease pts
(bronchopulomnary dysplasia).
Pneumonia (Lower Respiratory Tract Infection)
o Infection & Inflammation of the Lung Parenchyma
o Cough, fever, tachypena, abnormal chest auscultation
Rales
Heard in Pneumonia & CHF
Wet or Crackly inspiratory breath sounds
o Due to alveolar fluid/debris
Wheezing
o Causes
0 to 3m
Congenital Infections
Intrapartum (First few days of life)
o GBS (Most), Gram Rods (E. coli), Listeria
o HSV
IV Acyclovir
Postpartum
o RSV
Afebrile Pneumonitis
o Chlamydia trachomatis, Ureaplasma urealyticum
Tx
o Ampicillin + Gentamicin (or Cefotaxime)
3m to 5y
Viruses
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

> 6y

o Adenovirus, influenza, parainfluenza, RSV (Not after 2y)


Bacteria
o Strep pneumoniae
Mycoplasma &Chlamydia (Walking Pneumonias)
Viruses (Not RSV)
Strep pneumoniae

Types
Viral Pneumonia
URI Sx
o Rhinorrhea, nasal congestion, fever, cough
Interstitial infiltrates
WBC < 20,000 (Lymphocytic)
Supportive Tx
Bacterial Pneumonia
More rapid/severe
o Cough & Dyspnea worse, often without preceding URT Sx
WBC > 20,000 (n)
Complications
o Lung abscess (empyema)
Purulent infection in the pleural space
Typically w/ S. aureus, S. pneumoniae, S. pyogenes
breath sounds on affected side
On CXR: Near complete whiteout
Tx
Vancomycin bc of varying resistances
o Tension Pneumothorax
Esp. S. aureus
Rupture of alveoli into pleural space from bacterial
toxins
Acute worsening
Tx
Insert needle into 2nd/3rd intercostals space at
midclavicular line
Tx
o ABx
Chlamydia trachomatis
Most common cause of Afebrile Pneumonia
1-3 m
Staccato Type Cough, dyspnea, NO Fever, Wheezing, rales/rhonchi
50% Hx of Conjunctivitis @ birth
Dx
o Erythromycin, CXR w/ Hyper inflation & Interstitial infiltrates
(ground glass appearance: fine reticular opacities)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

Direct Fluorescent Ab
Eosinophilia

Tx

o Erythromycin
Mycoplasma pneumoniae
Older children & adolescents
Widespread rales & rhonchi
o Physical exam is worse than would expect by history
CXR
o Interstitial infiltrates
Dx
o + Cold Agglutinins, IgM Mycoplasma Titer
Tx
o Erythromycin or Azithromycin
Same as Chlamydia trachomatis in Afebrile Pneumonia
ICU Patients who are Intubated or have Central Lines
Pseudomonas or Candida
VZV Pneumonia
Skin findings

Pertussis
o Whooping Cough
o Immunization @ 12m
o <6m @ risk for severe disease
o 3 Stages
Catarrhal Stage
1 to 2w
URT Sx
o Rhinitis, sneezing, cough
Paroxysmal Stage
2 to 4 w
Forceful Coughing (Paroxysms)
o Can cause vomiting
Whoop
o Inspiratory gasp @ end of cough
o Rare in young infants
Cyanosis, apnea, & choking can happen in young infants
Convalescent Phase
Weeks to Months
Recovery
o Severity/frequency of Paroxysms
o WBCs (Lymphocytosis)
o Dx
Culture on Regan Lowe or Bordet-Gengou
o Tx
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Erythromycin for all contacts


Allergic Rhinitis
o Can also cause Nasal Polyps from chronic inflammation
o Headache and Congestion, but not fever/purulent discharge (Acute Rhinitis)
o Seasonal Variability
Cystic Fibrosis
o Sx/Signs
Cough that starts off dry/hacking but progresses to productive
Meconium Ileus @ Birth
Bilious vomiting
Inspissated meconium consistency
If suspected, get XR first bc can identify air in peritoneum, a surgical
emergency
o Next contrast enema
Distal Colon will be small
Microcolon
Hyperosmolar enema may be therapeutic
If fails, surgery
FTT, progressive Resp Insufficiency, Pancreatic Insufficiency (fat malabsorption
steatorrhea /foul smelling)
Gray stools
Fat vitamin deficiency
Nasal Polyps w/ chronic sinusitis
Headache, fever, cough (from postnasal drip), purulent discharge
Tender sinuses, unable smell, snoring
Opacification on CT of all sinuses by 8 y/o
Expiratory Flow Rate (Consistent w/ obstructive 1st)
Lung Vol. (Consistent w/ Restriction 2nd)
Rectal Prolapse
Jaundice, Biliary Cirrhosis
Recurrent Pneumonia
1st get S. aureus
2nd get P. aeruginosa (Transition around 20 y/o)
Hypoxemia
Digital Clubbing
Hyponatremia
Increased salt loss in sweat
o Dx
Abnormal Sweat Chloride Test
o Pancreatic enzyme replacement and fat vitamin supplements
Chronic Lung Disease (Bronchopulmonary Dysplasia)
o O Dependent past 28d
o Most common in Prematures born w/ ARDS
o Follows Acute Lung Trauma
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Barotrauma from Mechanical Ventilation, Meconium Aspiration Syndrome,


Infections
Followed by secondary lung injury (oxidants & proteases)
Healing of lung tissue is abnormal
Both Restrictive (from tissue fibrosis) & Obstructive (from dysplastic
narrowed airways) Lung Disease

S/Sx
Diminished Oxygenation ( PaO)
Hypercarbia (PaCO)
Intermittent Tachypnea, wheezing, respiratory distress
Frequent Infection
Foreign Body Aspiration
o Laryngotracheal (Extrathoracic)
Inspiratory Stridor, Cough
o Bronchial (Intrathoracic)
Asymmetrical lung findings on PE
Decreased air movement on affected side
Initially cough, drooling, and choking
Later avoid feeding
Complete
Atelectasis
Partial Ball-Valve
Unilateral Emphysema
Hyperinflation
Localized Wheezing, Recurrent/Persistent Pneumonia
o Chest and Abdominal X-rays first
If negative and still symptomatic, Endoscopic Evaluation
Normal Inhalation and Abnormal Expiration
One side will remain hyperinflated on expiration
o Partial ball valve obstruction, lets air in but not out
o Tx
Bronchoscope to remove if tracheal/bronchial obstruction
Flexible Endoscopy for esophageal obstructions
Congenital Diaphragmatic Hernia
o Can DX w/ US (esp. when Hx of Polyhydramnios)
o Should be suspected in any full term infant w/ severe resp distress
Esp. w/ decreased breath sounds on one side
Severe respiratory acidosis
o Scaphoid (sunken) abdomen w/ Ipsilateral prominent chest
o Cardiac impulse is displaced and decreased breath sounds on opposite side
o Prognosis is based on Lung Hypoplasia not size of defect
o Never bag mask, because will further distend the bowels
o CXR
Bowel air fluid level in thorax
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Tx

1st nasogastric suction to decompress the bowels


2nd intubation
Surgical Correction
Transient Tachypnea of Newborn (TTN)
o Early onset Tachypnea w/in 3h
w/ nasal flaring, grunting, retractions, cyanosis
o Relieved w/ supplemental O
o Lungs are clear to auscultation
o Risk Factors
C-section
Absence of the thoracic squeeze and hormones from labor
o Research shows more likely related to hormones than the
mechanical forces, primarily cortisol
o CXR
Temporary pulmonary edema
Perihilar Streaking in the interlobar Fissure
From excess fluid in the alveoli spilling over into the extra-alveolar
interstitium
Hyperexpansion
o Flat diaphragm
Prominent pulmonary markings
o Resolves in 2 to 3d
o Corrects easily w/ O
Neonatal Pneumonia
o More common with premature, mothers w/ intrapartum fevers, PROM
o S/SX
Respiratory Distress soon after birth, circulatory collapse, jaundice, poor
feeding, abdominal distension, tachycardia, apnea, higher calorie requirement
o CXR
Nonspecific patchy infiltrates or bilateral alveolar densities w/ air
bronchograms
Persistent Pulmonary HTN of Newborn
o Tachypnea and Severe Cyanosis
o Murmur from Tricuspid insufficiency may be heard
o CXR
Pulmonary Vasculature Markings
Meconium Aspiration
o Respiratory Distress soon after birth
o Pneumothorax/mediastinum may result
o CXR
Patchy infiltrates, Coarse Streaking, & Hyperinflation (Flattened Diaphragm,
AP Diameter)
Neonatal Respiratory Distress Syndrome (Hyaline Membrane Disease)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

Most important risk factors: Preterms & Infants of Diabetic Mothers


S/Sx
Presents w/in minutes of birth w/ 25Tachypnea (RR > 60), duskiness, grunting,
nasal flaring, retractions, shallow rapid breathing, and cyanosis
Cyanosis is minimally responsive to supplemental O
Ex. 75% to 90%
o Decreased lung compliance, reduced lung volume, right-to-left shunt of blood
o Labs
Metabolic/Respiratory Acidosis
CXR
Lung parenchyma w/ Fine Reticular Ground Glass Appearance and Air
Bronchograms
Histological
Homogenous, acidophilic, granular membranes lining alveolar
ducts/alveoli
o Tx
Prophylactically giving Corticosteroids to help promote lung maturity
Surfactant
Retinopathy of Prematurity (ROP)
o Risk Factor: Supplemental O & Prematurity
Risks w/ supplemental O in Preterms
o ROP
o Persistent PDA
o Intraventricular Hemorrhage
o Necrotizing Enterocolitis
SIDS & Apnea
o Apnea of Infancy
Unexplained cessation of breathing 20s
Or shorter if bradycardia, cyanotic, or hypotonia
Not expected in Term infants (unlike preterm)
Investigate for congenital heart defects
o Apnea of Prematurity
20 s
50% of those born between 30 to 31 w and nearly all born less than 28w
Immature Central Resp Control
Often associated w/ bradycardia and cyanosis
Tx
Methylxanthines (Stimulate)
o Caffeine & Theophylline
o Periodic Breathing
3 respiratory pauses for 3s w/in 20s
o SIDS
< 1y
Unexplained by investigation, autopsy, & clinical Hx
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Risk Factors
Prone (on belly) sleeping, soft bedding, premature, twin of someone
dying of SIDS, not breastfed
Reduced dramatically by sleeping on back
Phrenic Nerve Injury
o Cyanotic w/ S/Sx of Respiratory Distress
Grunting, retractions, tachypena
o Risk factor Macrosomia/LGA (esp. infants of diabetic mothers)
o With accompanying Erb-Duchenne Palsy (e.g. tone in arm)
o CXR may appear normal
US will reveal asymmetric diaphragmatic motion
See Saw motion
Hydrocarbon Aspiration
o Gasoline, kerosene, furniture polish
o S/Sx
Dyspnea, cyanosis, respiratory failure
o Charcoal is ineffective and emesis is contraindicated (further aspiration)
o Tx
Monitor
Symptomatic
Idiopathic Pulmonary Hemosiderosis (IPH)
o Chronic history of recurrent pulmonary insults
Fever, respiratory difficulty, wheezing, cyanosis, hemopytis (pulmonary
hemorrhage)
Occult blood from swallowed pulmonary secretions
Rapid clearing on repeat CXR
Chronic hypoxia: digital clubbing
o Hypochromic/Microcytic anemia from Iron Deficiency
o Some have hypersensitivity to cow milk (Heiner Syndrome)
o Dx
Bronchoalveolar Lavage
Hemosiderin-laden macrophages
Retropharyngeal abscesses
o Suppurative infection of lymph nodes between P. Pharyngeal Wall and Paravaterbal
Fascia
o Most common organism: S. aureus, GABHS, oral anaerobes
o S/Sx
Hx of Pharyngitis
Abrupt onset of fever and severe sore throat (difficulty swallowing)
Refusal of food, drooling, muffled voice (looks like epiglottis)
Fluctuant mass
o Dx
Bulge in the P. Pharyngeal Wall
o Tx
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Incision & drainage


ABx
Congenital Cystic Adenomatoid Malformation
o Cystic mass causes improper development of bronchioles
Respiratory distress
Mass may compress lungs causing Pulmonary hypoplasia and shifting heart
across midlines
Not to be confused w/ diaphragmatic hernia
Cystic Mass is usually detected on US
Primary Ciliary Dyskinesia (PCD) (Immotile Ciliary Syndrome)
o Dysfunctional ciliary leading to mucous clearance
o Kartagener syndrome
Triad: Situs invertus, chronic sinusitis, airway disease (e.g. bronchiectasis)
Heart heard on right
Dx
Biopsy shows random orientation of cilia
Obstructive Sleep Apnea (OSA)
o Risk factors: obesity and craniofacial abnormalities
o S/Sx
Snoring, nighttime awakenings, behavioral, apnea, daytime sleepiness
o Tx
Polysomnography (sleep study)

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Cardiology

Loud Systolic Murmur @ Apex


o Mitral Regurgitation
Venous Hum
o Harmless
o R. mid clavicle
o Loudest sitting
Disappears supine
Stills Murmur
o Harmless
o Mid L. Upper Sternal Border
o Loudest Supine
Pulmonic Systolic Murmur
o Harmless
o L. Upper Sternal Border
o Loudest when Supine
Peripheral Pulmonary Artery Stenosis
o Heard in the pulmonic area (upper L. sternal border) and radiates to the axillae and
back
o Common in newborns, benign
Endocardial Cushion Defect
o Associated w/ Down Syndrome
o Complete Atrioventricular Canal (40%)
Combined ASD & VSD
Abnormal mitral & tricuspid valves
CHF by 6w
Dyspnea w/ feeds, poor appetite, lethargy, hyperactive precordium
Systolic ejection murmur
o From flow across pulmonary valve
Single S2 from pulmonary HTN
o VSD (30%)
o Large ASD (15%)
Early on CHF, hepatomegaly, FTT
Systolic ejection murmur w/ wide fixed split S2
o Markedly enlarged heart
All four chambers enlarged
Left axis deviation
Tall P Waves (R. atrial enlargement)
Infants of Diabetic Mothers
o Most common heart defect
Asymmetric Septal Hypertrophy
Only along the LVOT
o Systemic circulation
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Weak pulses
BP
Capillary refill time
o Higher incidence of Retained Lung Fluid (TTPN)
Tachypnea w/ perihilar edema and fluid in the fissures
Congestive Heart Failure
o Secondary to Congenital HDD
From bld pulmonary flow
Large VSD/PDA, Transposition of the GA, Total Anomalous Pulmonary
Venous Connection
o Secondary to Acquired
Viral Myocarditis
High Output CHF
Severe anemia
Rapid infusion of fluid
Esp. in prematures
o S/Sx
Tachypnea, cough, wheezes/rales (Pulmonary Edema), FTT, exercise intolerance
o Tx
Cardiac Glycosides (Digoxin)
Takes a while
Loop Diuretics (Furosemide, Ethacrynic Acid)
DOC b/c of rapid onset, Sx relief, and improve respiratory distress
Inotropic (Dobutamine or Dopamine)
Severe CHF
Murmur not needing workup
o Innocent flow murmurs
Typically grade I or II midsystolic ejection murmur
Changes w/ position (louder supine, disappear standing)
Acyanotic Congenital Heart Disease
o ASD
Prone to Tachyarrhythmias, Eisenmenger's Syndrome, pulmonary infections
Most small (< 8mm) close spontaneously w/in first 2 years
Ostium Primum
Lower Portion
Down Syndrome
S/Sx
RV Impulse
Systolic Ejection Murmur
o L. Upper Sternal Border
o From Pulmonary bld flow
Wide Fixed Splitting S2
o Loss of variation splitting w/ inspiration
o Ventricular Septal Defect (VSD)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Acyanotic
Pulmonary bld flow
Pulmonary HTN
Pulmonary Markings

Holosystoloic Murmur L. Lower Sternal Border


Size of VSD 1/ Murmur intensity (smaller VSD, louder Murmur)
o Large defects, soft murmur

Moderate to large defect


murmur (Grade I to II), CHF Sx (Weight Loss, Dyspnea), Mitral Filling
Rumble @ apex
Atrial/Ventricle enlargement
Pulmonary vascular resistance (PVR) murmur and CHF
(initially)Eventually Pulmonary HTN (irreversible) -> Eventual reversal,
Eisenmenger Syndrome
Tx
Echo
o Small close spontaneously 75%
Surgical closure
o Large
By 3-6 m
o Small to Med
By 2-6 y/o
Patent Ductus Arteriosus (PDA)
High incidence in preterms
Associated w/ Maternal Rubella infection
Aorta to Pulmonary Artery (L R shunt)
Large
S/SX
o Apical heave
o CHF Sx
From pulmonary bld flow
Pulmonary vasculature markings on CXR
Risk for Pulmonary HTN (irreversible)
o Continuous machine like murmur
L. Upper Sternal Border
o Widened Pulse Pressure
> 30 mmHg
Brisk Pulses (accentuated) (bounding)
Tx
Surgery or Indomethacin
Coarctation of the Aorta
Associated w/ Turner Syndrome
Also associated w/ Bicuspid Aorta
If preductal, PDA can help maintain bld flow to LE w/ collateral from the
intercostals
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

High BP Upper Extremity, Low BP LE


Diminished and delayed pulses in legs
LE BP is normally 10pts >UE
Neonates
Initially present w/ S/Sx of Cardiogenic Shock
o Pale, mottled
Some CHD may rely on PDA, initially minimal Sx, restlessness
o Eventual CHF Sx w/ PDA closure
Diminished pulses in all extremities, HoTN, Absent
Murmur
Older Children
HTN (esp. R. arm), HoTN LE
Headaches
Femoral Pulse after Radial Pulse (usually before)
o Radio Femoral Delay
Intercostal A. Collateral
o Anterior Rib notching
50% have bicuspid aorta/Aortic Stenosis
o Systolic Ejection Murmur
Bruit of turbulence @ coractation radiates to L. Upper
Back near Scapula
Dx
Echo
Tx
Symptomatic Neonate
o IV PGE1
Keep PDA
o Low Dose Inotropic agents ( Contractility) & Dopamine
(Maintain Renal Perfusion)
Aortic Stenosis
Most caused by bicuspid aorta
Neonates w/ Severe (Critical AS)
CHF @ 12-24h
Neonates w/ Non-severe
Asymptomatic till severe
o Later Exercise Intolerance & Syncope
Systolic Ejection Murmur R. upper sternal border
May have ejection click
May be accompanied by aortic insufficiency
Diastolic murmur
Tx (If gradient > 50-70 mmHg)
Balloon Valvuloplasty
o Unless insufficiency is also present
Surgery
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

5 -10 years after BV or if regurg present


Prosthetic Valve or own Pulmonic Valve (Rose Procedure)

Pulmonic Stenosis
RV Output
Severe @ Birth
R L Shunt through PFO
Mild to Moderate @ Birth
Asymptomatic
Tx
If gradient >35-40
o Balloon Valvuloplasty
Hypoplastic Left Heart
o Presents w/ central cyanosis & CHF w/in first weeks of life
o In newborn presents w/ signs of cardiogenic shock (so does Coarctation)
Pale and Mottled
o Flow murmur
Cyanotic Congenital Heart Disease
o TOF, Transposition of Great Arteries, Tricuspid Artesia, Truncus Arteriosus, Total
Anomalous Pulmonary Venous Connection
o PDA Dependent
Coarctation of the aorta, Transposition of Great Arteries, Hypoplastic L. Heart
Syndrome, Total Anomalous Pulmonary Venous Connection, Tricuspid Atresia
Give PGE1 to maintain patency (typically closed by day 3)
o O saturation of 75 to 90% w/ perioral cyanosis
o Peripheral Cyanosis
Can be a reflection of vasomotor instability or constriction from Cold
o Central Cyanosis (tongue and mucous membrane)
Both cardiac and non-cardiac causes
o 100% O Challenge Test
No/minimal rise in O Sat
Cyanotic CHD
o Tetralogy of Fallot (TOF)
Most common cause of cyanosis >1m
VSD (at least one), Overriding Aorta, Pulmonary Stenosis (RV Outflow
Obstruction), RVH
R L Shunt through VSD into Overriding Aorta
o Pulmonary Bld Flow & Mixing
Cyanosis
Systolic Ejection Murmur L. Lower Sternal Border
Crescendo-decrescendo systolic murmur
Pulmonary Stenosis
o Poor blood flow through results in a Single heart sound
ECG
Right axis deviation
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

RVH

CXR

Boot Shaped Heart


Worsening of R L Shunt (Cyanosis)
SVR
o Exercise, vasodilatation, vol. depletion
Resistance through ROVT
o Tachycardia, crying
Hypercyanotic "Tet" Spells
Crying or with feeding, sudden cyanosis & Murmur
RVOT Resistance
o Worsening of R L Shunt
Squat to compensate
Venous Return to the heart SVR R
L Shunt
Knee Chest Position to SVR and R L Shunt
Morphine Sulfate to sedate and relax pulm vessels
Facemask O
o Stimulates pulmonary vasodilatation
Tx
Maintain PDA
o PGE1
Surgical Correction
Transposition of the Great Arteries
Most common cyanotic heart defect in first month (typically presents first 24h)
Aorta arises from RV, Pulmonic A. from LV
Adequate oxygenation only by shunting
PFO, ASD, VSD, or PDA
Cyanosis @ Birth
Single LOUD S2 (FAs Qbank said normal s1 s2, can be both)
Pulmonic Valve is Posterior, cannot hear
No murmurs typically if mixing through PFO
Murmur if mixing w/ PDA or VSD
CXR
Smaller heart (egg on a string)
o Narrow mediastinum from abnormal positioning of the
pulmonary vessels
Either anteriorly or posteriorly
pulm markings
Tx
PGE to keep PDA open (first)
Emergent balloon Atrial Septostomy
o ASD or PFO
Tricuspid Atresia

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

ASD or PFO always present


If No VSD
Pulmonary atresia is always present
o Must have PDA for blood flow to lungs
Cyanosis once PDA closes
No Murmur
Single S2
o No Pulmonic
If VSD
VSD murmur, Holosystoloic
EKG
RA/LA enlargement
o P wave on EKG
L. Axis Deviation
o R waves in V1-3
LV Hypertrophy
Only cause of CHD cyanosis w/ LAD & LVH
Truncus Arteriosus
Strong association w/ DiGeorge Syndrome
Aorta & Pulmonary A. arise from Truncus
VSD typically present
Pulmonary bld flow Pulm HTN CHF
Mildly cyanotic from mixing in Truncus
PE
Both systolic and diastolic murmur
Systolic Ejection Murmur @ Base from flow in truncus
o If high pitched, Truncal valve insufficiency
Diastolic Murmur @ Mitral
o From pulmonary bld flow into the LA
Single S2
Widened pulse pressure
Total Anomalous Pulmonary Venous Connection
Pulmonary V. drains into systemic circulation (SVC, RA, or Coronary Sinus)
instead of LA
Mix of Sat & Desat blood in all 4 chambers
Enlarged RA & RV
Bld passes from RA through PFO or ASD into LA
Only blood flow in LA comes from RA through ASD
o Small LA and LV
Pulmonary congestion from backing up of blood in pulmonary vein
Pulmonary crackles
Widely Fixed Split S2
From increased return to Right Heart
Cyanosis & Pulmonary Flow Murmur (from flow)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Cardiogenic Shock (TGA and Truncus Arteriosus present w/ CHF instead of


cardiogenic shock)
Acidosis w/ weak pulses
Prolonged capillary refill
Snowman on CXR (Enlarged Supracardiac Veins & SVC)
Tx
Surgical anastomosis of Pulm V. to LA
Cyanotic Heart Disease

Dx

Exam

CXR

Transposition of the Great


Vessels

Single S2

"Egg-on-a-String" heart

+/- VSD Murmur

(Narrow Mediastinum)

TOF

Harsh Pulmonic Stenosis murmur "Boot-Shaped" Heart

Tricuspid Atresia

VSD Murmur (Not always


noticeable, bc large)

RVH

Single S2

Minimal pulmonary blood flow


( pulmonary vascular
markings)

VSD Murmur
Total Anomalous Pulmonary
Venous Return w/ Obstruction

Severe Cyanosis
Respiratory Distress

Pulmonary Edema, "Snowman"


sign (Enlarged Supracardiac
Veins & SVC)

Infective Endocarditis
o 80% underlying Structural Defect
o 50% after Cardiac Surgery
o Gram + Cocci
Strep ( hemolytic [S. viridians]) & Staph
o Dx
Duke Criteria
Major
o Two + Blood Cultures
o Echo showing vegetations, abscess
Minor
o Fever, predisposing cardiac condition, echo evidence, vascular
phenomena (Janeway lesions, pulmonary infarct), immunologic
phenomena (Osler nodes, Roth spots, glomerulonephritis)
o Roth's Spots
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Round White Spots in Retina


ESR and other Acute Phase Reactants
Dx
Transesophageal Echo
o Who receives Prophylactic Antibiotics? (Varies, need to look up recent source)
All structural heart defects except Secundum ASD
Cyanotic heart defects
All postop cardiac for 6m
All prosthetic valves
Pericarditis
o Causes:
Infection, Collagen Vascular Disease (SLE), Uremia, Inflammatory Response from
Cardiac Surgery (Postpericardiotomy Syndrome [autoimmune])
Viral
Coxsackie, Echovirus, Adenovirus, Influenza, EBV
Purulent
Primary or disseminated from pneumonia
o S. aureus & S. pneumoniae
High incidence of Constrictive Pericarditis
o Can lead to exudates & transudate
Cardiac Tamponade LV output
o Signs
Chest pain relieved by sitting forward
Pericardial Friction Rub, Distant Heart Sounds ("Muffled"), Pulsus Paradoxus (
> 10 mmHg reduction in Systolic BP w/ inspiration), Hepatomegaly (from
congestion and backing up)
Cardiomegaly on Xray
o Dx
Dyspnea and Fever
Pericardiocentesis
Both Therapeutic and Diagnostic
ESR
Low Voltage QRS w/ larger effusions
Echo
o Tx
Aspirin or Steroids for Viral or Postop
Myocarditis
o Cause of sudden death in young athletes
o Causes
Viruses
Enteroviruses (Coxsackie B), Adenoviruses
Bacteria
Corynebacterium diphtheriae, S. pneumoniae, S. aureus
Protozoa
o
o

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Sx

Follows Viral or Flu Like Illness


Dyspnea & malaise
Resting Tachycardia & Muffled heart sounds
Tachycardia doesn't correct with fluids
Signs of CHF
Hepatomegaly, plus Sx above
Impaired systolic and diastolic function
Cardiomegaly
o >50% cardiothoracic ratio

Dx

Chaga's (Trypanosoma cruzi)


SLE, Rheumatic Fever, Sarcoidosis, Kawasaki

ESR, CK MB fraction, & CRP (Inflammatory Markers)


Endometrial Biopsy
Echo
Global hypokinesis

Tx

Supportive
Diuretics and Iontropes
Cardiomyopathy
o Dilated
Mainly idiopathic, viral myocarditis, MT abnormalities, Carnitine deficiency,
Selenium & Thiamine deficiency, Doxorubicin
Sx of CHF
Dx
Echo, EKG (low voltage QRS)
o Hypertrophic Cardiomyopathy
LVH
Commonly Asymmetric Septal Hypertrophy
AD
Poor LV filling, Dynamic LVOT Obstruction, hypertrophy can lead to ischemia
(O demand), arrhythmias (from chaotic muscle organization/formation)
Sudden death young athletes
FHx of Sudden Death
S/Sx
Harsh Systolic Ejection Murmur @ Apex
o w/ maneuvers that LV Volume (ex. Valsalvas or Standing)
Worsens obstruction, by having less volume to push
septum out
Tx for Symptomatic
blockers & Ca2+ channel blockers
o Reduce LVOT obstruction
Antiarrhythmics
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Hypertrophic Cardiomyopathy and Maneuvers


Effect

Change in murmur

Preload

Sustained Handgrip

Afterload

Squatting

Afterload & Preload

Passive Leg Raise

Preload

Valsalva (Straining Phase)


Abrupt standing
Nitroglycerin

Restrictive
diastolic filling from rigid walls
Causes
Amyloidosis
Inherited infiltrative DO
o Fabry, Gaucher, Hemosiderosis, Hemochromatosis
Sx
Exercise intolerance, hepatomegaly & edema from Central Venous
Pressure (CVP)
Tx
Reduce CVP w/ diuretics
blockers and Ca2+ Channel Blockers
o Diastolic filling time
Ebsteins Anomaly
o Downward displacement of tricuspid valve into the RV (Atrialization)
o May result from maternal Li+ use during 1st trimester
Used as mood stabilizer in Bipolar Tx
o Tricuspid regurg, small RV, RVOT obstruction (from small RV)
Causes RA Vol.
Leads to cyanosis
P wave on EKG
R. Axis deviation
o Severe defect
Cyanosis, systolic murmurs, massive cardiomegaly in the newborn
o Associated w/ WPW and SVT
o S/Sx
SVT
Tx: Ablate the pathways responsible for long term Tx
Fatigue and palpitations may not present till later
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Quiet precordium (also seen with constrictive pericarditis)


Holosystoloic murmur from the Tricuspid Regurg
Gallop rhythm (3 or 4 Heart Sounds)

SVT
o

180 to 300 bpm


Regular narrow QRS Tachycardia (Ventricular Tachycardias have Wide)
o OTC Cold Medications containing Sympathomimetic amines may precipitate
o Ebstein Anomaly can be a cause (maternal Li+ use for Bipolar)
o If accessory track backwards
WPW
Palpitations, chest pain, syncope
Associated w/ Sudden Death
Delta Wave (upslurring), QRS, PR interval
o Ventricular Preexcitation
o Tx
Vagal Maneuvers
Ice pack on face (mammalian dive reflex), carotid massage
IV Adenosine if hemo stable
Synch Cardioversion if hemo unstable
Radiofrequency Ablation of accessory pathways
Heart Block/AV Block
o 1st Degree
PR
o 2nd Degree
Type I
Progressive PR until a beat is dropped
Type II
No progression, abrupt drop
o 3rd Degree
Complete block, no conduction A V
Causes
Can be congenital in infants w/ mothers w/ SLE
Post-Surgical AV Block
o After VSD closure close the conduction system
Bacterial Endocarditis
Lyme Disease
Sx
Fatigue, syncope
Prolonged QT Syndrome
o QT-interval >500 ms
o Risk of Torsades De Pointes (ventricular arrhythmia)
o Causes
Inherited
Family history for deafness or sudden death
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

Jervell-Lange-Nielson Syndrome
o AR
o Deafness
Romano-Ward Syndrome
o AD
o No Deafness

Drugs
Phenothiazines, TCAs, Erythromycin
Syncope, sudden cardiac death, arrhythmias (Ventricular Tachycardia), may be a
family history of sudden death/drowning
Hypocalcemia, hypokalemia, hypomagnesaemia

Tx

Implantable defibrillator
Propanolol (Class II, QT)
Murmur Maneuvers
o Handgrip
SVR, CO, LV Vol.
Differentiate AS from MR
AS
MR
HCM
o Valsalva
Venous Return (Preload)
RV/LV Vol
All flow murmurs , only HCM
o Inspiration
RV Vol
Both diastolic and Systolic R. sided murmurs
L. sided murmurs
o Supine to Squatting/Standing
Venous Return (Preload), SV, Arterial Pressure
Reflex HR
R. & L. Murmurs
HCM

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Nephrology & Urology

Hematuria
o Microscopic: 6 RBCs/hpf
o Urinary dipstick
Hemoglobin or Myoglobin
False w/ excess Vit. C
o RBC Casts
Diagnostic of Glomerular bleeding
Acute/active glomerulonephritis
o RBC Morphology
Dysmorphic (blebs in membrane)
Originating in the glomerulus
Biconcave
Originating in the lower urinary tract
o Acute Hemorrhagic Cystitis
Large number of RBCs esp. w/ dysuria
From bacterial, viral (adenovirus), or cyclophosphamide
Proteinuria
o >100 mg/m2/d is pathological
o Urinary dipstick
Detects albumin
False + w/ very concentrated (>1.025) & Alkaline urine (pH 7.0)
False w/ very dilute urine
o 24 urine collection
Normal < 100
Most accurate but most difficult, therefore use Random Spot Urine Total
Protein to Cr Ratio (TP/CR)
o TP/CR
Normal infants (6 to 24m): < .5
Normal TP/CR (>2y): <.2
o Classifications
Benign Transient Proteinuria
Protein urinary excretion associated w/ exercise, fever, dehydration
Orthostatic Proteinuria
while upright, but not while supine
Benign, no further workup
Compare an Afternoon TP/CR and a Morning TP/CR
Persistent Pathological proteinuria
Marker for progression of renal disease
Amount of proteinuria is correlated w/ seriousness of renal disease
o Highest amounts are seen in Nephrotic Syndrome
o May have Glomerular origin or Tubular origin
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Glomerular Proteinuria
Caused by Permeability of the glomerular capillaries to LMWT
proteins (microglobulin) by the tubular epithelial cells
Most common
Tubular Proteinuria
From Reabsorption of LMWT proteins
Urinary Microglobulin
o Marker for Tubular Proteinuria
Examples
o Interstitial Nephritis, Ischemic Renal Injury (Acute Tubular
Necrosis), Nephrotoxic drugs
Glucosuria & aminoaciduria may accompany diffuse injury to the
tubular epithelial cells
o Evaluation
Repeat Protein UA, if (transient proteinuria), if + ask if orthostatic
Early Morning TP/CR and Late Afternoon TP/CR
o If Early Morning <<<<< Late Afternoon, then Orthostatic, if not
then likely Persistent Pathological Proteinuria
Glomerular Proteinuria?
Dx w/ urinary Microalbumin
Ex: glomerulonephritis, Nephrotic Syndrome
Tubular Proteinuria?
Dx w/ urinary -microglobulin
Ex: Acute Tubular Necrosis, Interstitial Nephritis
Glomerulonephritis
o Typically immune-mediated (complex formation)
o Presents w/
Some w/ acute Nephritic Syndrome
Gross Hematuria, HTN, & occasionally signs of fluid overload from renal
insufficiency
Some w/ Nephrotic Syndrome
Heavy proteinuria, hypercholestermia, edema
o Labs
UA: RBC Casts
Urinary TP/CR for Persistent Pathological Proteinuria
Urinary Microalbumin
ASO titers
Rheumatic Fever
IgA levels
IgA Nephropathy
Types of Glomerulonephritis
o Poststreptococcal Glomerulonephritis (PSGN)
8 to 14d after skin infection or pharyngitis w/ a nephritogenic strain of Group A
Hemolytic Strep (S. pyogenes)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

Hematuria (gross), proteinuria (not to nephrotic lvl), HTN, edema


o Coca Cola urine
Low Serum Complement (C3)

Dx

The latency period after Impetigo may be 21 to 28d


Longer than IgA nephropathy

Prior Strep Infection


o ASO titer
+ 90% of Pharyngitis, 50% Impetigo
o ADB titer
+ after both Pharyngitis and Impetigo
Biopsy only if significant renal failure or no normalization after 8w
o Mesangial Proliferation & Mesangial Matrix
o Iummno Fluorescence
Lumpy Bumpy

Tx

Supportive
Prompt ABx Tx of Nephritogenic strains of GABHS doesnt incidence
of PSGN, but does incidence of RF
IgA Nephropathy (Bergers Disease)
Most common chronic glomerulonephritis
Asia, Australia, New Zealand
Rare in AA
Typically in young males
clearance of IgA complexes
Recurrent bout of gross hematuria w/ resp infections
Presents much earlier than PSGN
Persistent Microscopic hematuria between infections
Dx
Renal Biopsy
o Mesangial Cell Proliferation & Mesangial Matrix
Same as PSGN
Immunofluorescent shows mesangial IgA deposits
50% have IgA and Normal C3 levels
o Complement w/ PSGN
Tx
Supportive
ACEI, Steroids reserved for pathological proteinuria or renal
insufficiency
Henoch-Schonlein Purpura (HSP) Nephritis (also just general HSP info)
IgA mediated vasculitis (small vessels)
Mesangial IgA deposits (same w/ IgA Nephropathy)
Typically seen after URI
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

Nonthrombocytopenic (Platelet count is normal!) palpable purpura on


the buttocks and lower extremities
Typically: Abdominal pain (Colicky), arthritis (Knees & Ankles), and
gross/microscopic hematuria, mild proteinuria
If severe proteinuria, suggestive of Glomerular inflammation
o Glomerular Involvement
RBC Casts, Hematuria, Proteinuria
Monitor w/ weekly UA during active disease and then monthly for 6m after, bc
of risk of Acute Glomerulonephritis
Most cases self limited, resolve in months
o Membranoproliferative Glomerulonephritis (MPGN)
Three forms of Glomerulonephritis w/ similar features
Lobular Mesangial Hypercellularity and thickening of GBM
S/Sx
Nephrotic or Nephritic w/ gross or microscopic hematuria
HTN
Low Serum Complement
Variable course, but most develop end stage renal disease
Tx
No definitive Tx, some respond to corticosteroids and ACEI to slow
progression
Nephrotic Syndrome
o Heavy Proteinuria ( >50 mg/kg/d), hypoalbuminemia, hypercholesterolemia, edema
o 2/3 of cases present before 5 y/o
o Three Categories
Primary NS
90% of childhood cases
o Minimal Change Disease (most common)
Podocyte Feet Fusion on EM
NS that results from other primary Glomerular diseases
IgA Nephropathy, PSGN, MPGN
NS that results from other primary Glomerular diseases
SLE and HSP
o Caused by a loss of the normal charge/size selective glomerular barrier
protein loss
Hypoalbuinemia
Plasma protein production (including lipoproteins)
o Hypercholesterolemia
Frothy Urine
o S/Sx
Most present w/ edema
Ranges from periorbital to scrotal/labial to widespread edema
Edema often follows an URI
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o Pleural effusions may occur


Predisposed to thrombosis, 2 to hypercoagulability
May present w/ Stroke, Renal Vein Thrombosis, DVT, and Sagital Sinus
Thrombosis
Risk for infection w/ encapsulated bacteria bc of loss of complement & Ab
(proteinuria) and steroid treatment
Strep pneumoniae
o May present w/ spontaneous bacterial peritonitis (more of a
concern w/ Gram -), pneumonia, or overwhelming sepsis
(bacteremia)

Dx

UA

3+/4+ protein, TP/CR


If RBC Casts, then something other than MCD
Renal biopsy
Normal Light Microscopy
EM: Fusion of foot processes

Tx

If widespread edema, scrotal or labial edema, HoTN, or pleural effusion


IV infusions of 25% albumin
Respond to Corticosteroids
If steroid resistant: Cyclophosphamide or Cyclosporine
If febrile, due to S. pneumoniae risk, cultures and CXR, broad spectrum ABx
o Prognosis
Mortality 5% in steroid resistant
Can develop Focal Sclerosing Glomerulosclerosis (FSGS) w/ End Stage
Renal Disease
Hemolytic Uremic Syndrome (HUS)
o Acute Renal Failure in the presence of Microangiopathic Hemolytic Anemia (H/H)
and Thrombocytopenia (petechiae)
o Two Subtypes
Shiga Toxin-Associated HUS
Most common in childhood
Result of E. coli 0157:H7 infection
o Undercooked beef, unpasteurized milk
Vascular endothelial damage
o Esp. in renal vasculature, leading to platelet thrombi formation
and renal ischemia
Diarrheal Prodrome (bloody) followed by sudden onset of Hemolytic
Anemia, Thrombocytopenia, Fever, and Acute Renal Failure
Tx
o ABx are not indicated and ABx Tx of E. coli hemorrhagic colitis
may risk of HUS
Hereditary Renal Diseases
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Alports Syndrome
Progressive hereditary nephritis from defective Type IV Collagen in the GBM
X-linked Dominant
S/Sx
Renal
o HTN, Hematuria, ESRD
Hearing loss
Ocular (bowing of lens into A. chamber) abnormalities
Tx
ACEI to slow disease progression
Transplant
Multicystic Dysplastic Kidney
Most common asymptomatic renal mass of newborns in first few months
Typically unilateral Cysts w/out function
Bilateral presents like Renal Agenesis
o Incompatible w/ life
Differs from Polycystic Kidney Disease in that it retains no function
ARPKD (autosomal recessive polycystic kidney disease)
Cortical Cysts, arising in the distal tubules and collecting ducts
S/Sx
Olighydraminos from kidney function
o lung hypoplasia
Greatly enlarged cystic kidneys
o Abdominal fullness w/ bilateral irregularly shape contour
masses
Most common cause of abdominal mass of renal origin
in the newborn
o Radial spoke pattern on imaging
Severe HTN, Cr
Liver Cirrhosis
o Caput Medusa (from portal HTN)
o Esophageal varices
Tx
Renal transplant
ADPKD (autosomal dominant polycystic kidney disease)
Presents in adulthood (20 to 40 y/o)
S/Sx
Abdominal pain, flank masses, UTI
Gross or microscopic hematuria
HTN, renal insufficiency
Associated with Cerebral Aneurysms
Tx
Transplant
Medullary Sponge (Cystic) Kidney
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

AD
Presents later in life (Non pediatric)
May be asymptomatic, hemaruria, UTI, or Nephrolithiasis
Progresses to ESRD
Small Kidneys w/ Medullary cysts (not cortex like ARPKD)
o Nephronophthisis-Medullary Cystic Disease Complex (NPH-MCD)
Juvenile Form
AR
Leads to ESRD in childhood
Adult Form
AD
ESRD later in life
Renal Tubular Acidosis
o Kidney unable to maintain normal acid-base balance bc of defects in bicarbonate
retention or defects in the excretion of H+
o Causes
Acquired
Nephrotoxic Drugs (amphotericin)
o S/Sx
Infants/young children
FTT, vomiting, metabolic acidosis
Older Children/Adults
Recurrent calculi, muscle weakness, bone pains
Classic presentation: Hyperchloremic Metabolic Acidosis w/ a Normal serum
Anion Gap
o Types
Distal RTA (Type I)
Inability to Excrete H+
Associated w/ Nephrotic Syndrome, Amphotericin, Connective Tissue
Disorders (ex. Ehlers-Danlos )
S/Sx
o Positive Urine Anion Gap
o Vomiting, Growth Failure, Nephrocalcinosis and Nephrolithiasis
o Hypokalemia, Acidemia
Tx
o Low doses of Oral Alkali
o Potassium Citrate
Corrects K+ deficit
Safer than Bicarb Salts
Proximal RTA (Type II)
Bicarbonate Reabsorption by the proximal renal tubules
Associated w/ Intoxication of:
o heavy metals, gentamicin, acetazolamide ( bicarb secretion),
global defects in tubular reabsorption (Fanconi Syndrome)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Dx

S/Sx
o Vomiting, Growth failure, Acidosis, Muscle Weakness
Tx
o High doses of Oral Alkali
Type IV RTA
Transient Acidosis
Hyperkalemia is the hallmark
o Secondary to Aldosterone Deficiency
o Tx
Sodium Polystyrene Sulfonate (Kayexalate)
Associated w/ renal disorders and aldosterone deficiency states
Tx
o Furosemide to lower Serum K+
o Oral Alkali
Calculation of Urine Anion Gap
Urine Na + Urine K - Urine Cl
o Positive urine anion gap is seen in Distal Tubular RTA (Type I)

Renal Failure
o Acute Renal Failure
Abrupt in Nitrogenous excretion (sudden in GFR & tubular function)
o Types
Prerenal
In renal perfusion causes a GFR
Examples
o Dehydration, hemorrhage, CHF, septic shock
Labs
o BUN/Cr Ration > 20
o Urine SG 1.030
o Urine Osmolality > 500
o Urine Na+ < 20
o FENa < 1% in older children, <2.5% in neonates
Renal Parenchymal
Damage to:
Tubules (Acute Tubular Necrosis)
o Causes: Ischemic injuries from renal hypoperfusion
o Urinary -microglobulin
o FENa > 1% in children, > 2.5% in neonates
Damage to the Interstitium (Acute Interstitial Nephritis)
o Causes: Semisynthetic Penicillins (Ampicillin) and NSAIDS
o Urinary -microglobulin
o Eosinophilia, eosinophiluria
Post Renal
Obstructive urine flow
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

S/Sx

Tx

Causes
o Stones, Posterior Urethral Valves
Dilation of renal collecting system on US
Vascular
Perfusion of the kidneys
Causes
o Renal Artery Embolus
Umbilical A. catheter
o Renal V. Thrombosis
Sudden onset gross hematuria w/ flank mass
incidence in infants of diabetic mothers
renal blood flow on Nuclear Renal Scan
Oliguria ( Urine Output <1 ml/kg/hr) or Nonoliguria

If volume depleted
Restore intravascular first
Then restrict total fluid intake to insensible plus output (urine , stool)
replacement
Typically restrict protein, Na, K, Phosphorus
Dialysis when conservative Tx fails
Bladder Outlet Obstruction
o Posterior Urethral Valves (males)
One of most common cause for CKD leading to ESRD
Poor or absent urinary stream (Dribbling)
Bladder dilation
o Leads to a dysfunctional detrusor muscle
o VUR
Only boys
Tx
Surgical correction
o Prune Belly Syndrome
Prune Belly Syndrome
o Absence of rectus muscles
Lax, dilated, wrinkled abdominal wall
o Bladder outlet obstruction
Dilated urinary tract
Possibility of Olighydraminos
Lung Hypoplasia
o Cryptorchidism
o Other associations: Congenital Hip Dislocation, Club Feet, & Malrotation
Renal Agenesis
o Failure of development of mesonephric duct or blastema
o Unilateral is more common than bilateral (die in perinatal)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Bilateral results in Olighydraminos


Leads to Pulmonary Hypoplasia and Potter Sequence
o Limb contractures, compressed flat face

Renal Dysplasia
o Concentrating defects, RTA, renal insufficiency
o Mild
Improve in childhood only to deteriorate later in adulthood
o Severe
Nonfunctional Kidney
Most common abdominal mass discovered in newborns is the Multicystic
dysplastic kidney
Usually has atretic ureter
If bilateral, incompatible with life
o Potter Syndrome
Vesicureteral Reflux (VUR)
o Abnormal Ureterovesical Junction
Reflux from bladder into ureters and kidney
o In 30-50% of infants with UTIs
o AD inheritance
o Manifestations
Most w/ lower grades have spontaneous resolution
risk of pyelonephritis
Renal scarring
Reflux Nephropathy
From severe VUR
ESRD and HTN
Kidneys show segmental scars, contraction, interstitial nephritis
o Dx
Voiding Cystourethrogram (VCUG)
All those under 5 w/ UTI should undergo VCUG to evaluate for VUR
o Answer varies between sources, need a guideline
o Tx
Low-dose prophylactic ABx
UTIs until they outgrow VUR
Grade 4 or 5 consider surgical reimplantation
Strong considerations: If persists into adulthood, Cr (renal failure),
likely to become pregnancy (ureters relax and cause even more urine
stasis)
Urolithiasis
o Uncommon in peds, consider metabolic DO
o Associated conditions
Hypercalciuria
Can be caused by furosemide use (esp. infants)
Hyperoxaluria
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Secondary to enteric malabsorption (IBD)


Distal RTA
Hyperuricosuria
Tx of Leukemia or Lymphoma (Tumor Lysis Syndrome)
Lesch-Nyhan Syndrome
Gout
Cystinuria
AR
Radiopaque
Absorption of COLA Amino Acids
Proteus Mirabilis (UTI)
Gravel Like Stones
Struvite
Hyperparathyroidism

S/Sx
Flank/abdominal pain, hematuira, Sx of cystitis/pyelonephritis
Urinary Tract Infection (UTI)
o Enteric Bacteria
Esp. E. coli
Others: Klebsiella, Pseudomonas, S. saptrophyticus (esp. sexually active
adolescent females), Proteus (high urine pH)
o S/Sx
Infants
Nonspecific: fever, irritability, jaundice, abdominal pain
Older Infants
Fever, vomiting, irritability
o Suspect pyelonephritis if fever or systemic Sx
o Dx
Neonates/infants
Clean bag sample is only okay for screening, suprapubic aspiration or
urethral catherization must be used for culturing
Older Children
Clean catch
UA
Leukocytes
o Pyruia: 5 WBCs/hpf
+ nitrite or leukocyte esterase
Urine Culture
10,000 colonies from sterile urethral catherization
50,000 to 100,000 from clean catch
All pyelo, all recurrent, all males, and females < 4 y/o w/ cystitis(from question
book) 2 y/o and infection other than E. coli, all 1m, 2 y/o w/ recurrent
(from Uworld)
Imaging for VUR (VCUG) and Renal US
o

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

Answer varies between sources, need a guideline

Tx

Empiric ABx
TMP-SMX
Cephalexin
Neonates are admitted
IV Ampicillin or Gentamicin
Infants w/ pyelonephritis
Bc of risk of scarring, receive prophylactic ABx for 3m after
WAGR Syndrome
o Wilms Tumor, Aniridia, Genitourinary Anomalies, Retardation
o Microdeletion of 11p13
o Renal abnormalities
Ex. Duplicate left Collecting Duct
T1DM
o Polyuria, Polydipsia, weight loss, wetting bed at night
o Confirm w/ fasting blood Glc
Hypospadias
o Circumcision is contraindicated, bc the skin is used in the repair
CAH
o Low Na+
o High K+
o Tx
Corticosteroid Supplementation
Choriocarcinoma Testicular Tumor
o Pure Choriocarcinoma is rare
o Metastasis hematogenously early
o -hCG
Can cause gynecomastia
Labial Adhesions
o Typically benign condition, labia minora fused
o Most common in the low estrogen preadolescent state
o Can cause urine pooling and risk of UTIs
o Tx
Observation as most resolve in adolescent
Or Nightly Application of Estrogen Cream for a week
Physiological Discharge
o White vaginal discharge (sometimes mixed with blood)
o Related to Estrogen w/drawl
o Tx
Reassurance, will resolve in weeks
Goodpasture Syndrome
o Acute Glomerulonephritis
Hematuria/Proteinuria (Pink Frothy Urine), edema, HTN, renal insufficiency
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o Pulmonary hemorrhage, hematuria


o Ab to Type IV collagen in the GBM and Alveoli
Rhabdomyoloysis
o Brown urine (looks like hematuria)
+ dipstick for blood, but 0 WBC/RBCs under microscopy
+ From the Myoglobin
o Can result from strenuous exercise/trauma
o Complications
RTA from Myoglobin accumulation in tubules
Dysrhythmias
Wrong cuff size is a common cause of inappropriately attributed HTN
Neurogenic Bladder
o Can be seen in Spina Bifida
o Leads to urine stasis and recurrent UTIs
When evaluating UTIs, review intermittent catheterization regimen to make
sure they are doing it
If incorrect, urine stasis and UTIs
Preauricular Pits
o Benign congenital malformation of the external ear associated with renal structural
abnormalities
Obtain Renal US
Renal US
o For those with
Preauricular Pits, fail newborn hearing screen, FHx of Deafness
Diabetes Insipidus (DI)
o Excessive thirst w/ large amounts of extremely dilute urine
o Unable to reabsorb HO
o Serum Na+ and Osmolality
o Urine Output
Urine Na+ & Osmolality
o Causes
Differentiate w/ Vasopressin (ADH) test
Central
Positive Vasopressin test
Brain is producing insufficient ADH & kidneys respond to it
Nephrogenic
Can be hereditary
o Suspect in Male infant w/ Polyuria, hypernatremia, & diluted
urine (Hereditary Nephrogenic DI)
X Linked
Doesnt respond to ADH
Tx
o Thiazide diuretics to promote Na+ loss and reabsorption of HO
in proximal tubules
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Imipramine
o TCA used to bladder contractions in Nocturnal Enuresis
Desmopressin
o Vasopressin (ADH) synthetic analog
o Used to treat Primary Nocturnal Enuresis
Doxazosin
o -antagonist
o Tx
Daytime enuresis
Reduces bladder outlet resistance

Gastroenterology

Protein Intolerance (Milk Protein-Induced Enterocolitis)


o Majority of cases result of Milk Protein (can be from moms consumption of milk)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o
o

Presents age 2-8w


Eczema
Enteropathy
Diarrhea, Severe reflux/vomiting, colicky abdominal pain
Chronic blood loss in stools can lead to anemia
Protein loss in stools causes FTT & Edema
o Enterocolitis
Acute
Diarrhea, painless blood & mucus in stool
Protein loss in stools causes FTT & Edema
o Tx
Breastfeeding mother remove protein (Milk & Soy)
Can continue to breast feed
Resolves by 1-2 y/o
Elemental (hydrolyzed) formula
Evaluation of Bilious Vomiting in Newborn

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Bilious Emesis

Stop Feeds
NG tube decompression
IV Fluids

Abdominal Xray

Dilated Loops of Bowel

Free Air, hematemesis,


unstable vitals

Surgery

Contrast Enema

NG tube misplaced in
duodenum

Dubble Bubble Sign

Upper GI Series

Duodenal Atresia

Microcolon

Rectosigmoid
Transitional Zone

Ligament of Treitz on
the right side of
abdomen

Meconium Ileus

Hirschsprung Disease

Malrotation

Hirschsprung Disease
o Typically rectosigmoid colon
o Also associated w/ Down Syndrome
o Normal meconium consistency
o S/Sx
Rectal examination reveals tight anal canal may lead to explosive expulsion
Squirt Sign
Bilious or Feculent vomiting (newborns), abdominal distension, constipation
(older children)
Failure to pass meconium
Or delayed (>48 h)
o Barium Swallow
Dilated proximal bowel w/ narrow distal segment
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Dx

Screen
Anorectal manometry
Diagnostic
Lack of ganglionic cells on punch biopsy
Duodenal Atresia
o Down Syndrome
o S/Sx
Bilious Vomiting w/in first 2 days of life
Double Bubble Sign on XR
Air w/in distended stomach and proximal duodenum
o Hx of Polyhydramnios
o Dx
Prenatal Ultrasound
o Associated with Down Syndrome
o Tx
Nasogastric decompression first
IV Fluids & ABx
Surgery
Diarrhea/Vomiting and Dehydration
o Most commonly caused by Viral Gastroenteritis
o Hyponatremic, hypovolemic, hypoosmotic, low urine sodium, low serum osmolarity
Celiac
o Presents between 6m and 2y
o Gluten is in wheat, barley, rye, & oats
o S/Sx
Fatigue, weight loss
Diarrhea, vomiting, bloating
Abdominal pain & large foul smelling stools
Dermatitis Herpetiformis
Erythematous Vesicles on extensors
o Pruritic
o Associated w/ Vitiligo and T1DM
o Malabsorption
Osteoporosis/osteomalacia
Can lead to iron deficiency anemia
o Dx
Biopsy
Short villi, deep crypts, & vacuolated epithelium w/ lymphocytes
IgA endomysial Ab & Serum Tissue Transglutaminase Ab
IgG in IgA deficient pt.
o Tx
Corticosteroids for severe diarrhea
Short Bowel
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o
o

GER
o
o

Colic
o
o

Malnutrition with carb & fat malabsorption w/ steatorrhea


FTT
Distal resection
B12 & Bile Acid reabsorption
Causes
Congenital
Gastroschisis, volvulus, or atresia that require resection
Crohns, tumors, & radiation enteritis
Complications
TPN cholestasis w/ resulting Gallstones
Bacterial overgrowth
TPN induced Liver failure
Tx
Early enteral feedings for remaining bowel & liver function
Liver transplant
Normal physiologic state in which stomach contents move retrograde
Happy Spitters
w/out GERD Sx
Benign emesis/spitting up
Not related to over feeding
Resolves by 6-12m
Tx
Reassurance
Positioning therapy
Crying in an otherwise healthy infant for >3h daily (usually evening), >3x per week, for a
duration of >3w
Tx
Soothing techniques

GERD
o Infants present w/
Emesis/spitting up, Suboptimal calorie intake (feeding refusal), & if severe FTT
Irritability
Sandifer Syndrome
Torticollis w/ arching of the back from painful esophagitis
o Older Children presents w/ Typical GERD Sx
o Causes
Inappropriate Transient LES Relaxation (TLESR)
o Complications
Upper/lower Airway Disease
Induces bronchopulmonary constriction
o Risk of aspiration
Chronic Laryngitis
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o Hoarseness, wheezing, vocal cord nodules


Barretts esophagus
FTT
Esophageal strictures

pH probe is gold standard


Bronchoscope w/ alveolar lavage when aspiration is strongly suspected

Dx

Tx

Conservative
Positioning & meal timing first (before pharmacotherapy)
Thickened feeds
H Blockers & PPI
Motility agents
Metoclopromide
o High side effects (1/3)
Drowsy, restlessness
LES tone or Gastric Emptying
Surgery
Nisses Funoplication
o Usually followed with gastrostomy tube to maintain
feedings/nutrition while stomach adjusts to volume
Choledochal Cyst
o Congenital abnormality of biliary ducts
Dilation of intra or extra-hepatic biliary ducts or both
o S/Sx
Infants
Jaundice, acholic stool (like biliary atresia)
Children
Abdominal pain, jaundice, recurrent pancreatitis, dark urine
Bilirubin
o Dx
US or MRI
Cystic Extrahepatic mass
Hypertrophic Pyloric Stenosis
o Projectile Vomiting
Nonbilious
Early in life, three to five weeks
Hypokalemic, hypochloremic, metabolic alkalosis (loss of H+)
High PCO
Hypokalemia results from aldosterone in response to volume
depletion from vomiting
HCl, HO, and NaCl lost in vomit
Will still seem hungry
o Risk Factors: w/ Trisomy 18, first born male, erythromycin, formula feeding
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Physical
Olive Mass (epigastric/RUQ)
Peristaltic Wave in abdomen after feedings
o Dx
US
Thickened and elongated pylorus
Barium Swallow
May show string sign
o Small amount of barium getting past
o Tx
Correct electrolytes/dehydration (DONT OPPERATE IF ELECTROLYTE
ABNORMALITIES)
Must correct, IV hydration + Potassium
Partial pylorectomy
Malrotation of the Gut & Midgut Volvulus
o Bilious vomiting <1m
Typically asymptomatic till Volvulus
o Midgut twists around SMA (Volvulus)
Obstruction or infarction
o Common in those w/ Heterotaxy
Organs abnormally arranged across LR axis
o Lack of fixation to the abdominal wall
Can cause peritoneal bands (Ladds Bands)
Can obstruct
o S/Sx
Bilious Vomiting & Sudden onset of Abd Pain
Distension, blood in stools
Shock as bowel ischemia progresses
Peritonitis
o Imaging
Proximal distension, with little to no gas
First CXR to rule out pneumotperitoneum (free air)
UGI study of choice
Abnormal position of ligament of Tritz & Jejunum
o Right side of abdomen
o Indicates Malrotation
Corkscrew pattern indicates volvulus
Duodenum obstruction
o Tx
Surgical emergency (Ladd Procedure)
Intussusceptions
o Peak 5 to 9m
Before age 2 typically
o Ileocolic intussusceptions most common
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

Viral Gastroenteritis can also cause a lead point through inflammation of the
Peyers patches
Hematomas from HSP & Mekels can also serve as lead points

Sudden crampy/colicky abd pain


Periods of Colic and then normal behavior (playing laughing) or
lethargic
Vomiting
Currant Jelly Stools (Bloody Mucus) from edema and sloughing of mucosa
Sausage shaped mass in RUQ

US

Dx

Target Sign

Tx
Air/Contrast enema is gold standard
Avoid hydrostatic if prolonged, perforated, or peritonitis
o Air is preferred
Coil Spring Sign
May reduce the intussusceptions (therapeutic)

General
o Abdominal Rigidity
Peritoneal Process
o Restlessness
Colicky Pain
o Constant Abdominal Pain
Suggests strangulation or torsion
o Intestinal Obstruction PE
High pitched bowel sounds, abdominal distension, tenderness, & visible
peristalsis
o Peritonitis
/absent bowel sounds
Rigidity w/ guarding
Rebound Tenderness
o Appendicitis
Pain referred to T-10 (umbilicus)
PE
Tenderness @ McBurngs
Guarding
Rebound Tenderness
WBC and neutrophils
o Acute Pancreatitis
Uncommon in children
Causes
Trauma #1, idiopathic #2, infection
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

Pain @ periumbilicus & epigastric


o Radiates to back
Severe w/ blood along the fascial planes
o Gray Turner Sign
Bluish discoloration of the flanks
o Cullen Sign
Bluish discoloration of periumbilical

Labs
Amylase
Lipase
Abdominal US for Dx
CT for complications
Pseudocyst formation
Tx
ABx if Necrotizing
Small Pseudocyst can resolve on own, but large ones may require
Cyclic Vomiting Syndrome (CVS)
o Acute and frequent vomiting that resolves spontaneous w/ no Sx in between episodes
o FHx of migraines
o Thought to be linked to abdominal migraines
o Dx
Criteria
3 episodes in 6-month
Easily recognizable to family
Lasts 1-10d
Vomiting 4 times/hr @ peak
No Sx in between episodes
No underlying condition
o Tx
Antiemetic (ondansetron [Zofran])
If FHx of migraines: Sumatriptan
Cholecystitis
o Inflammation of the gallbladder
Most commonly w/ stones
Less commonly w/out (Acute Acalculous Cholecystitis)
o Uncommon in children unless:
CF, TPN, or Sickle Cell
o RUQ Pain w/ Guarding
o + Murphys Sign
Palpation of the RUQ upon inspiration, intense pain, inspiration ceases
o Imaging
US
Stone or thickened GB Wall
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Cholescintigraphy may be useful


Mild LFT & TB
Tx
ABx
Cholecystectomy if peritonitis
Constipation
o Risk factors: Dairy, toilet training, school entry
o S/Sx
Abdominal pain, passage of pellet like stools, <2 defecations/week
o Complications
Anal fissures, hemorrhoids, encopresis, UTI, vomiting
o Functional
Functional Fecal Retention (FFR)
Most common cause during childhood
Inappropriate constriction of external anal sphincter
o Result of traumatic events (painful diet, diaper rash, abuse)
Tx
o Evacuation using mineral oil before behavior modification
o Education most important
Organic
o Hirschsprung
o Delayed Meconium Passage (>48h)
o Tx
Increase fiber, limit cows milk, laxative (polyethylene glycol, mineral oil)
IBD
o Peaks 15 to 20 y/o & @ 50 y/o
o Includes
Crohns Disease
Ulcerative Colitis
o Tx
Immunosuppressive Agents
Induce long term remission
Corticosteroids
For acute exacerbation & induce remission
Ulcerative Colitis
o Limited to colon
o Continuous & Limited to the Mucosa
Mucosa is friable and bleeds
o Typically bloody diarrhea w/ mucosa
At least 3-4w
o Ranges in Severity
Rectal Bleeding, diarrhea, abdominal pain, Hypoalbuminemia
o P-ANCA
o Complication
o
o

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Toxic Megacolon
Risk for Colorectal Cancer

Tx

Sulfasalazine
Can be cured w/ total proctocolectomy, but reserved for intractable colitis
Immunosuppressive Agents & Corticosteroids
Crohn's Disease
o Any segment (mainly terminal Ileum)
Can have mouth ulcers
o Skip lesions & segmental inflammation
o Transmural inflammation
Fistulas, Crypt Abscesses, Strictures
o Malabsorption
Vit B12, Zinc, Folate, Fe2+
o Perianal disease (very common) often precedes intestinal disease
Skin Tags, abscesses, fistulas
o Extraintestinal Manifestations
Much more common than in UC
FUO, arthritis, mouth ulcers, skin manifestations (erythema nodosum), weight
loss, malaise, and growth retardation
o Anti- Saccharomyces cerevisiae Ab
o Granulomas (30%)
o Imaging
String Size
Thickened bowel folds w/ narrowing of the tract
o Tx
Metronidazole
When fistulas presents
Esp. w/ inflammation
Immunosuppresive Agents & Corticosteroids
Azathioprine, cyclosporine, tacrolimus, TNF-
GI Bleed
o Hematemesis
Coffee ground appearance
o Hematochezia
Bright red, lower GI or significant rapid upper GI
o Melena
Dark tarry, upper GI (proximal to Ligament of Treitz)
o Occult bleeding from GI
Guaiac +
False +
o Ingested iron
False o Large amounts of ingested Vit. C
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Upper GI Bleeding
o Swallowed maternal blood
o Endoscopy if active bleeding w/ hemodynamic changes
o Tx
Initial:
Fluid Bolus w/ IV access
Octreotide for varices
PPIs
Arteriographic embolization for serious bleeding
Vascular malformations
Lower GI Bleeding
o Necrotizing Enterocolitis (NEC)
Consider in any newborn w/ rectal bleeding, feeding intolerance, & abdominal
distension
More common in prematures & Low birth weight
Immaturity of the stomach plus exposure to bacteria from enteral feeds leads to
bowel inflammation and damage
Caused by local ischemia, dilation, and infarction of loops of bowel
S/Sx
Abdominal distension, Hematochezia (or occult blood), pneumatosis
intestinalis (air in the bowel wall, double line/train track appearance)
Blood in NG tube
Complications
Intramural air spreading to portal vein (venous portal gas)
Later on intestinal perforation
o Pneumoperitoneum
Breast feeding reduces the risk of NEC
Tx
Mild
o Decompression, electrolyte repletion, IV ABx, serial abdominal
exams checking for perforation
Severe (perforation)
o Severe if perforation (free air on lateral decubitus or under
diaphragm), fixed dilated bowel on serial X-rays, abdominal wall
cellulitis
o Surgical resection and reanastomosis (exploratory laparotomy)
Following surgery, parenteral feeds for 14d
Allows for bowel rest
o Juvenile Polyps
#1 cause beyond infancy (>5 y?)
Bleeding is painless, intermittent, & often streaky
Tx
Colonoscopy w/ polypectomy
o Allergic Colitis
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Sensitization to Milk Protein


Infectious Entercolitis
Salmonella, Shigella, Yersinia, & E. Coli
o Meckel's Diverticulum
Outpouching terminal ileum
Infants 2% (typically <2 y/o)
Contains ectopic gastric tissue that produces H+
Damages mucosal tissue
Painless acute rectal bleed in otherwise healthy
Hematochezia (maroon)
Test
Nuclear Medicine Scan (Technetium)
Tx
Surgical resection to prevent future bleeding or intussusception
o HUS
Intestinal ulceration & infarction of the bowel cause bleeding
Hepatocellular Enzymes
o AST
Sensitive, but not specific
o ALT
Specific for liver disease
o LDH
Nonspecific for liver disease, but may serve as a marker for liver necrosis
Biliary Enzymes
o Alkaline Phosphate
in Biliary Disease
Can also be in Rapid Growth, Renal/GI disease, & trauma
o Gamma Glutanyl Transpeptidase & 5NT
Biliary disease
5NT more specific than GGTP for biliary tract disease
Infant Jaundice
o TB
Clinically evident TB > 3
o Kernicterus
Risk w/ indirect hyperbilirubinemias 20
Risk factors
Sulfisoxazole and other drugs that bind albumin and dissociation of
bilirubin
Metabolic acidosis, bilirubin dissociation
Hypoalbuminemia
Sepsis
o Interrupts BBB
Phenobarbital induces glucuronyl transferase
o Normal Physiologic
o

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

First 2-4d of life (peak)


No higher than 12 mg/dL
Disappears by 1w
Rate of rise <5 mg/dL in 24h
Conjugated levels <1 mg/dL
High Hb (from RBCs) turnover
UDG activity
Asians have even lower
Sterile newborn gut
Unable to break down
Breastfeeding jaundice
Inadequate calories & dehydration
Breast feeding failure: inadequate feedings, poor latching
enterohepatic circulation
o Indirect Hyperbilirubinemia
Signs of dehydration
o Decreased wet diapers
o May not regain birth weight
o Brick red urate crystals in diapers
Typically second to fourth day (first week)
Tx
Rehydrate w/ fluids or formula
Lactation consult
o Should be breastfeeding ever 2-3h for 10-20mins each breast
Threshold for phototherapy
o 4d old
>20
Threshold for transfusion therapy
o 4d old
>25
Breast milk Jaundice
Enzyme in milk is inhibitor of glucuronyl transferase
indirect bilirubin
Gaining weight, no signs of FTT
Typically during second week (>7d)
Tx
If Pathological (~17-20) DC breast feeding for 1 to 2d, formula then
o Resume breastfeeding after precipitous drop in TB w/out fear of
rise to toxic levels
Reassurance if levels are not too high
Cholestatic Jaundice
Retention of bile in liver
Direct Bilirubin > 2
Cholestasis
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

> 50% caused by neonatal hepatitis or Biliary Atresia


If suspect cholestasis, HIDA Scan
o Inspissated Bile Syndrome
Associated w/ Hemolysis or very large hematoma
Starts w/ Indirect, but switches to direct as the liver ramps up
o UDP-Glucuronyl Transferase Deficiencies
Gilbert's Syndrome
50% Enzyme
Mild Jaundice w/ stress or poor nutrition
Crigler Najjar
Indirect Hyperbilirubinemia
Type I
o 100% Enzyme absent
o AR
o Kernicterus caused by TB
Type II
o 90% Enzyme Deficient
o AD
o Bilirubin lvls are variable w/ chance of Kernicterus
Cholestasis
o Retention of Bile in liver
o Direct bilirubin
o Causes
Infections (Sepsis, hepatitis)
Metabolic (CF, HoThyroid)
Extrahepatic obstruct (Biliary atresia, Bile duct stenosis)
Intrahepatic obstruct (Paucity of intrahepatic bile ducts, Alagille Syn)
Idiopathic (Neonatal Hepatitis)
1 Antitrypsin deficiency
TPN associated
o Signs/Sx
Jaundice
Acholic or light stools
Dark Urine
Hepatomegaly
Bleeding (from PT)
FTT
Neonatal Hepatitis
o #1 cause of neonatal jaundice
o S/Sx
Jaundice, hepatomegaly 1st week of life
o Self limited, 70% full resolution
o Tx
Supportive
Formulas w/ Med Chain TG & Vit. AEDK b/c of fat absorption
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Ursodeoxycholic Acid
Used to bile flow/ viscosity
Don't use before R/O Obstructive Jaundice

Biliary Atresia
o Progressive fibrosclerotic changes of extrahepatic bile ducts
o Presents w/in first 2m of life
o S/Sx
Jaundice, dark urine, acholic (pale) stools
Moderate TB
Direct Hyperbilirubinemia
Rapid progression w/ Bile duct obliteration & cirrhosis by 4m
Hepatomegaly, Ascites, Coagulopathy, Edema
o Some have associated Polysplenia Syndrome
Bilobed lings, abdominal Heterotaxy, & situs invertus
o Dx
First perform US
Lack of Gallbladder and Triangle Sign
Will also catch other Gall Bladder DO
Hepatobiliary Scintigraphy
Failure of tracer excretion from liver
Intraoperative cholangiogram w/ Laparotomy to examine biliary tree (gold
standard)
o Tx
Kasai Portoenterostomy
Establishes bile flow by attaching intestinal loop to porta hepatis
Success is highest if <50 days old
Cholangitis is common complication (50%)
Liver transplant for liver failure
Supportive nutrition: fat vitamins (ADEK)
Ursodeoxycholic Acid
Once flow is reestablished
Viral hepatitis
o Hepatobiliary obstruction can result from swelling
Hep A
o IgM Anti HAV, early, can persist for 6m
o IgG Anti HAV, early, lifelong immunity
Hep B
o risk of HCC from Chronic Hep B
o HbsAg
First evidence of Active disease
o HBsAb
Protection: vaccine or normal infection
o HBcAb
From infection, lifelong
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

HBeAg
Rises very early in active disease
Marker for viral replication and infectivity
Dx: Acute infection
o Graph 316
o Tx
All newborns of mothers w/ active Hep B (HbsAG, HBeAG + esp.) receive HBIG
(Hep B immune globulin) & Vaccine
Autoimmune Hepatitis
o Destructive & Progressive
o serum transaminases, hypergammaglobulinemia, auto-Ab
o Types
Type I
Antinuclear Ab (ANA) or Anti-Smooth muscle Ab
More common than Type II
Type II
Anti-Liver Kidney Microsomes?
o Females before puberty
o S/Sx
50% w/ Acute Hepatitis
Mimics viral hepatitis
50% Chronic liver disease
Mild to Moderate Jaundice
o Tx
Corticosteroids
Immunosuppressive Agents
Azathioprine
6-MP
Lead Poisoning
o Remove from environment
Esophageal atresia
o Vomiting , choking, coughs w/ first feeds
o Frothing at mouth
o May have respiratory distress, abdominal distension depending on fistula
presence/location
o Associated w/ VACTER Constellation
Vertebral anomalies, anal atresia, cardiovascular anomalies, transesophageal
fistula, renal/radial anomalies
Usually accompanied by tracheoesophageal fistula leading to
abundance of gas in GI tract
o Immediate coiling of nasogastric tube confirms
Mallory-Weiss Tear
o Lower esophageal tear from forceful retching w/ or w/out vomiting
Hematemesis
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Painless bleeding
Beckwith-Wiedmann Syndrome
o Overgrowth Syndrome w/ predisposition to neoplasms
Neoplasms
Wilms Tumor & Hepatoblastoma
o Screening w/ Abdominal US and AFP
Large-sized patients
Hemihyperplasia
Macrosomia
Macroglossia
Liver/Kidney enlargement
Hyperinsulinism
Hypoglycemia at birth
Midline abdominal defects
Omphalocele, umbilical hernia

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Infectious Disease
Age
0-1 month

Bacterial
GBS, E. coli, Listeria

1-3 months

GBS, Strep pneumoniae, Listeria

3 months 3 years

Strep pneumoniae, HIB,


Neisseria meningitidis
Strep pneumoniae, Neisseria
meningitidis

3 years adult

GBS
o
Listeria
o
o
o

Empiric ABx
Ampicillin + Gentamicin or
Cefotaxime
Ampicillin + Cefotaxime (or +
Vancomycin if suspect bacterial
meningitis
Cefotaxime (or + Vancomycin if
suspect bacterial meningitis)
Ceftoxamine (or + Vancomycin if
suspect bacterial meningitis)

S. agalactiae

Neonates are prone, especially those w/ T Cell defects


Gram + Rod
Can be maternally acquired from unpasteurized dairy, soft cheeses
Mom may just have flu-like illness
Has predilection for causing amnionitis
Brown, murky fluid
Can result abortion, stillbirth, neonatal sepsis
o Neonatal distress: Respiratory distress, temperature instability,
poor feeding, lethargy/irritability
o Severe form
Gramulomatosis Infantiseptica
Pathognomic for Listeriosis
Granuloma formation and tissue destruction
o Skin (popular or ulcerative necrosis), liver, adrenals, lymphatics,
lung, & brain
Meningitis
o Bacterial
Most common in first month of life
w/ HIB vaccine
Risk Factors

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

Labs

Young age, immunodeficiency (asplenia, humoral defect, terminal


complement deficiency (MAC)), Anatomic Defects (basilar skull Fx,
shunt)
Neisseria Meningitides
o Children 2 y/o at greatest risk
o Will have petechial rash prominent on ankles, wrist, axilla,
flanks
o Complication
Waterhouse-Friderichsen
Fulminant Meningococcemia
Vasomotor collapse
o Severe HoTN
Large purpura and petechiae on flanks from
Adrenal hemorrhage
Infants
o Nonspecific, fever may be present or absent
Poor feeding, irritability, lethargy, resp distress
o Bulging fontanelle
Older children
o Fever
o Alteration in lvl of consciousness
Irritability, somnolence (lethargic)
o Nuchal Rigidity
+ Kernigs & Brudzinskis signs
o Seizures
o Photophobia, emesis, headaches
HIB
o Growth on Chocolate Agar
E. Coli
o Pink colonies on MacConkey Agar
N. meningitidis
o Can grown on Chocolate Agar, but grows best on Thayer-Martin

Dx

Before an LP, if there is signs of ICP, must do CT


LP (as part of neonatal sepsis workup)
o Pleocytosis
N
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o
o

>5,000
Hypoglycocchacia (Low CSF Glc)
Ratio of CSF to serum Glc < .4
Protein
+ Gram Stain/Culture

Tx

ABx by age and the most likely pathogen


o Newborns (0-28d)
Ampicillin + Gentamicin
Or 3rd generation cephalosporin (Cefotaxime)
IV Acyclovir if suspected HSV
o Young Infants (1-3m)
Ampicillin + 3rd generation cephalosporin (Cefotaxime)
+ Vancomycin if Bacterial Meningitis is suspected (given
the resistance of pneumococccus)
o Older infants & Children (>3m)
3rd generation cephalosporin (Cefotaxime)
+ Vancomycin if Bacterial Meningitis is suspected (given
the resistance of pneumococccus)
Corticosteroids
o chance of hearing loss w/ HIB meningitis
Monitor Na+ levels to watch out for SIADH
Complications
Hearing loss (most common, 25%)
Global Brain Injury (5-10%)
SIADH, seizures, hydrocephalus, brain abscess, CN palsy
Can have developmental regression
o Ex. Forgetting how to copy shapes
Aseptic Meningitis
Definition
Inflammation of the meniges w/ CSF lymphocytic pleocytosis
And if caused by a virus
o Normal Glc, normal to minimally protein
Causes
Viral most common
o If involves the brain also, then meningoencephalitis
o Eneteroviruses
Most common in US
Summer & Fall
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

S/Sx

Mumps, Herpes Viruses


Viruses that cause encephalitis
Arboviruses (St. Louis, Western equine, Eastern equine,
West Nile), influenza, Herpes viruses
Bacterial (some can cause aseptic presentation)
o TB (Children <5 y/o)
o Borrelia burgorferi (Lyme)
o Treponema pallidum (Syphilis)
Fungal
o Coccidioides immitis, Cryptococcus neoformans, Histoplasmosis
capsulatum
Parasitic
o Taenia solum (cysticerosis)
o Toxoplasma gondii (immunocompromised pt.)
Similar to bacterial
Viral
o Mild Sx, w/ fever, headache, & emesis
o Severe w/ MS & seizures
TB
o Initially nonspecific
o 2nd week, Sx progress rapidly
CN palsy, MS, paraplegia, death

Dx

Viral
o
o

PCR
EBV, CMV, HSV, Enteroviruses
+ Surface cultures from throat/rectum for enterovirus, suggests
enterovirus meningitidis (most common viral cause)

TB
o

CSF: Lymphocytic pleocytosis, hypoglycorrhachia,


protein
o Imaging shows Basilar Enhancement
o + CSF acid fast
RPR for Syphilis
India ink for Cryptococcus
CSF Ab testing for coccidioidomycosis, Lyme, Cysticerosis

Most cases of viral, self-limited

Tx

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

TB

o Isoniazid, rifampin, pyrazinamide, streptomycin


o Corticosteroids
Low BP w/ normal HR may indicate trending towards sepsis
Pathogen
WBC Differential
Protein
Glc
Tests
Acute Bacterial
100-50,000 (PMN) High
Low
+ Culture/Gram
Stain (also OP)
Partially treated
1,000-10,000
Normal to high
Low normal
- Culture/- Gram
bacterial
Stain
Viral
10-1,000
Normal to high
Normal
Enteroviruses may
be in culture
TB
10-500
Very High
Low to very low
AFB smear and
(Lymphocytes)
culture rarely +
Fungal
25-500
Normal to high
Low
Culture may be +
(Lymphocytes)
India ink + for
Cryptococcus
Parameningeal
10-200 (polys or
High
Normal
- Culture
focus (brain
monos may
abscess)
predominate)
Upper Respiratory Infections (URI)
o Simple URI (Common Cold)
Rhinovirus, parainfluenza, coronavirus, RSV
S/Sx
Low grade fever, rhinorrhea, cough, sore throat
o Resolves in 7-10d
Color of nasal discharge alone doesnt predict the presence of
concurrent sinusitis
o Purulent nasal discharge may occur early in course of URI
Persistent Sx (>10d) or fever, suspect bacterial superinfection (sinusitis,
otitis media)
o Sinusitis
Clinical Diagnosis
Persistent Sx, 10d w/out improvement
Or Severe Sx (Fever 102F, purulent nasal discharge, face pain 3d)
Or Worsening Sx 5d after initial improvement of Viral URI
Pus drainage from the meatus
Formation
Ethmoid & Maxillary: present at birth
Sphenoid: Develop between 3 to 5 y/o
Frontal: 7 to 10 y/o
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Categories
Acute, subacute, chronic (based on duration of Sx)
Complications
Cerebral Abscess
o Visualized by CT or MRI
S/Sx
Persistent fever, neurologic deficits, headache,
seizures
ICP
o From accompanying edema from
abscess
Tx
Antibiotics
o Oral Amoxicillin-Clavulanic Acid (Augmentin)
Covers the most common (S. pneumoniae &
nontypeable Haemophilus influenzae)

Pharyngitis
Causes
Viral
o Coxsackievirus, EBV, CMV
Bacterial
o Strep pyogenes (GA hemolytic Strep [GABHS] aka Strep
Throat)
o Arcanobacterium hemolyticum, Corynebacterium diphtheria
(diphtheria)
S/Sx
Viral and GABHS overlap
Viral
o Simple URI Sx
o Can have tonsillar exudates
o EBV Pharyngitis
Enlarged posterior cervical lymph nodes, malaise, &
hepatosplenomegaly
o Coxsackievirus Pharyngitis
Painful vesicles/ulcers on P. Pharynx
Soft palate (herpangina)
Blisters on palms/soles (hand-foot-mouth disease)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Dx

GABHS pharyngitis
o Typically school age (5-15 y/o), winter & spring
o Lack of other URI Sx (rhinorrhea, cough)
o S/Sx
Sore throat
Exudates on the tonsils, Petechiae on soft palate,
Strawberry Tongue, enlarged tender A. Cervical LN
Fever
Scarlatiniform rash (also in Scarlet fever)
Sandpaper rash
o Dx
Rapid Strep
o Tx
Amoxicillin
Erythromycin for penicillin allergic
o Complications
PSGN (ABx don't prevent) and Rheumatic Fever (ABx
prevent)
Peritonsillar Abscess
Asymmetric tonsilar bulge
o Displaces uvula to side
CT
Tx
o Drainage
o ABx for GABHS & oral anaerobes
Diphtheria
o Low-grade fever & gray, adherent tonsillar membrane
o Toxin-mediated cardiac and neurological complications
GABHS
o Culture (gold standard) and Rapid Strep Test (antigen)

Tx

EBV: corticosteroids
Diphtheria
o Oral erythromycin or penicillin
o Antitoxin
o Isolation
Acute Otitis Media (AOM)
o AOM: Acute infection of the middle ear
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Otitis media w/ effusion (OME): fluid w/ middle ear without Sx of infection


Can have a retracted TM
If >3m then conduct audiometry testing to assess hearing loss
If normal hearing then give ABx or can observe
Causes
Bacterial
S. pneumoniae (most common), non-typeable H. influenzae, Moraxella
catarrhalis
Viruses
S/Sx of AOM
AOM usually develops after simple URI
Fever, ear pain, hearing, pulling at ear
If TM perforates, may have drainage from ear
Dx
Dx of AOM: fluid in middle ear (bulging TM, absent motility, otorrhea) & Sx of
Infection (erythema of TM)
Pneumatic Otoscopy identifies abnormal movement of TM
o From fluid
o Most reliable way of detecting middle ear fluid
o Bulging TM
Complications
Cerebral Abscess
Visualized by CT or MRI
S/Sx
o Persistent fever, neurologic deficits, headache, seizures
o ICP
From accompanying edema from abscess
Mastoiditis
Erythematous, swollen, tender, skin overlying mastoid
Conductive hearing loss
Can spread to the meninges
Tx
Dont have to treat if 2 y/o and nonsevere
Treat if worsen w/in 48-72h
ABx if used
Amoxicillin (80 mg/kg/day BID) initially
o Higher dose than for Strep throat
If attended daycare w/in previous 2 months, then increased likelihood
of penicillin resistant S. pneumoniae
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

High dose amoxicillin, amoxicillin-clavulanic acid, or a


cephalosporin
Macrolide (Erythromycin) if penicillin allergic
No ABx for OME
Tube placement only if >3 infections in 6m or >4 infections in one year
Otitis Externa (OE)
o Infection of the external auditory canal (EAC)
o Predisposition
Cerumen removal, trauma, maceration of skin from swimming, excess moisture
o Causes
Pseudomonas aeruginosa, S. aureus, or C. albicans
2 to perforated TM from AOE
o S/Sx
Pain, itching, and drainage
o Dx
Erythema/edema of EAC
Sometimes purulent white discharge
o Tx
Restore EAC to natural acidic state
Mild (minimal pain/discharge): acetic acid
Severe: Topical ABx/Corticosteroids
Perforated AOM w/ OE: Both oral & topical ABx
Cervical Lymphadenitis
o Enlarged, inflamed tender lymph nodes
o Causes
Localized Bacterial Infection
S. aureus, most common
o Fever & Tender
S. pyogenes, common
Mycobacterium: TB and MAC (atypical mycobacteriums)
Francisella tularensis
o Ulcerative lesion at inoculation site
o Regional extremely tender lymphadenopathy
B. henselae (cat scratch disease)
o May have Hx of cat exposure
o Papules develop at scratch site
o Nontender local lymphadenopathy: Cervical, inguinal, axial
o Nonspecific Sx: low-grade fever, malaise, fatigue
o Gram bacilli on Warthin-Starry Stain
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Tx

S/Sx

Viral

Reactive lymphadenitis: EBV (tender generalized lymphadenopathy),


CMV, HIV
Kawaskai
Unilateral cervical lymphadenitis
T. gondii
Mono like illness w/ cervical lymphaenopathy
o Bilateral, symmetric, tender or nontender cervical adenopathy
Infected node: mobile, tender, warm, and enlarged
Overlying skin is erythematous
Systemic signs may be present

Tx

Typically self limited, but can give Azithromycin

Empiric ABx against S. pyogenes & S. aureus


First generation cephalosporin (cephalexin) or anti-staphylococcal
penicillin (nafcillin)

Parotitis
o Inflammation of the parotid salivary glands
o Causes
Mumps and other Viruses (CMV, EBV, HIV)
Bilateral
Before vaccination, mumps was #1 cause
Bacterial parotitis (acute suppurative parotitis)
Unilateral
S. pyogenes & TB
o S/Sx
Fever
Neck Swelling centered above the angle of the jaw & fever
Pus in oropharynx
Can be expressed from Stensens Duct
o Complications
Mumps: meningoencephalitis (also complication of bacterial), orchitis (most
common complications, esp. for post puberty), & epididymitis, pancreatitis
Bacterial Skin/Soft Tissue Infections
o Impetigo
Superficial skin, dermis and above
Causes
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

S/Sx

S. aureus (#1), S. pyogenes (GABHS)

Honey-crusted or bullous lesions


o Face and around nares
Fever is absent
Easily transmittable
Cultures are not required for Dx
Tx
Topical muprinocin
Oral ABx: dicloxacillin, cephalexin (1st gen), or clindamycin
Complications
PSGN (Not Rheumatic HD), SSSS

Staphylococcal Scaled Skin Syndrome (SSSS)


S. aureus exfoliative toxin
Scarlatiniform erythema
More erythematous in skin flexures and periorally
Fever, tender skin, bullae
Intact bullae are sterile (unlike impetigo bullae)
Nikolsky Sign
Extension of bullae when pressure applied
Skin Sloughs off
Extensive fluid and electrolyte loss
Tx
Clean and moisten skin w/ isotonic or burrow solution
IV Oxacillin or Naficillin (penicillinase resistant)
Scarlet Fever
GABHS that produce erythogenic toxin
S/Sx
Exanthem may develop during any GABHS infection
o Begins on trunk
Moves peripherally
o Skin is erythematous w/ skin colored papules (scarlatiniform
appearance)
Sandpaper Rash texture
o Pastia's Lines
Petechiae w/in skin crease
o Desquamation of dry skin as infection resolves
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Fever
White exudates on inflamed tonsils, pharyngitis
Strawberry tongue w/ circumoral pallor

+ Culture/Throat Swab

Dx
Tx

Goal is to prevent Rheumatic Fever


Oral Penicillin VK, IM Benzathine Penicillin, or for penicillin allergic
erythromycin or Macrolide
Complications
PSGN (ABx doesn't prevent), rheumatic fever (ABx prevent), Post Strep
Arthritis (ABx doesn't prevent)
Pediatric autoimmune neuropsychiatric disorder associated w/
streptococcal infection (PANDAS)
o Acute OCD or Tic DO after Strep Infection
o ABx prevents
o Toxic Shock Syndrome
Toxin Mediated
Fever, shock, desquamating skin rash, multiorgan dysfunction
Causes
S. aureus #1, GABHS also
Tampons
Dx: 5 of 6 probable, 6 of 6 confirmed
Fever > 101
HoTN (SBP <90)
Diffuse macular erythroderma (looks like sunburn)
Desquamation (10-14d after illness)
Multisystem Involvement
o GI, Myalgias (CPK), Hyperemia of mucous membranes
(pharyngitis, vaginits), pyuria, thrombocytopenia, CNS (MS)
- cultures other than S. aureus (CSF, blood, pharynx)
Tx
Reverse shock, ABx, IVIG
Diarrhea
o Viral
Rota and Norwalk
Rotavirus
Most common infectious cause of gastroenteritis
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

o Winter Months
Incubation is 1-3d
Vomiting, watery osmotic diarrhea, dehydration
o Self limited for 4-7d
Supportive Tx
Norwalk Virus
Outbreak of gastroenteritis in all age groups
o Esp. closed populations (day care, cruise ships)
Same Sx as Rotavirus, just more prominent vomiting
o Shorter duration, 2-3d
Evaluation
Recent ABx
C. difficile
Unusual pets (e.g. turtles)
Salmonella
ELISA
Rotavirus, Giardia lamblia, C. difficile
If WBCs absent, culture is of limited use
Non-anion gap Hyperchloremic Metabolic Acidosis
Result of bicarb loss in stools
Tx
Fluids
ABx for: Table

Bacterium
ETEC
(Enterotoxigenic)

Clinical Features
Traveler's Diarrhea
Watery

Diagnosis
Stool WBCs absent

EPEC
(Enteropathogenic)
EHEC

Watery, seen in
preschoolers
O157:H7 causes HUS

Stool WBCs absent


Culture = Diagnostic
Stool WBCs present
Culture = Diagnostic

Shigella sonnei

Bloody diarrhea
Seizures (2 to
Neurotoxin)

Stool WBCs present


Culture = Diagnostic

Salmonella

Bloody or nonbloody
Poultry, milk, eggs,

Stool WBCs present or


absent

Management
ABx (Quinolones or
Sulfonamides in
Children)
Quinolones or
Sulfonamides
If HUS is present, ABx
are avoided (HUS can
worsen from
endotoxin release)
Third Generation
Cephalosporin
(Cefotaxime) or
Fluoroquinolones
No Tx, bc duration
Tx only if invasive
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Campylobacter jejuni

Yersinia enterocolitica

Clostridium difficile

turtles/lizards
Sickle Cell:
Osteomyeleitis or
Bacteremia
#1 cause of bloody in
US
Self limited, spread by
poultry
May cause Mesenteric
Adenitis w/
Gastroenteritis that
may mimic acute
appendicitis
After ABx use

Stool WBCs present if


blood present

Stool WBCs usually


present

Third Generation
Cephalosporin
(Cefotaxime

Metronidazole
Oral Vanc if resistant
Fluid replacement is
critical
ABx may shorten, but
not typically given
Preformed toxin: ABx
are ineffective

Vibrio Cholerae

Developing Countries
Massive Watery
Diarrhea

Dx by toxin in stool
Pseudomembrane
Dx: Watery diarrhea
after returning from
endemic area

S. aureus

Vomiting first, followed


by diarrhea

Preformed toxin, vomit


w/in hours

HIV & AIDS


o S/Sx

disease (Third
Generation
Cephalosporin
[Cefotaxime])
Oral Erythromycin (but
Sx usually resolve on
own)

Infants typically asymptomatic for the first few years


Early Sx of HIV infection
FTT, Thrombocytopenia, Recurrent Infections (otitis media, pneumonia,
sinusitis) Generalized Lymphadenopathy, Parotitis, Recurrent Thrush,
loss of developmental milestones, Severe VZV, diarrhea
Older children may present w/ weight loss (FTT), AIDS defining illnesses (e.g.
oral lesions), lymphadenopathy

Dx

Infants
All infants born to HIV infected mothers have maternal Ab that may last
18-24m
o HIV specific DNA PCR is the test <18m (bc maternal Ab will
interfere)
HIV specific DNA PCR is performed at birth & monthly until 4m to
detect those infected perinatally
Negative HIV specific DNA PCR @ 4m consistent w/ non infected
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o Followed till 18-24m when lose maternal Ab


Older Children
ELISA, confirm Western Blot

Tx

Infants born to HIV mothers


Zidovuidine for 6w postexposure prophylaxis after birth
o Also for mother starting @ second trimester
TMP/SMX for PCP prophylaxis at 6 weeks old until HIV DNA PCR - @4m
No breastfeeding
Urine CMV Culture to detect CMV/HIV coinfection (5%)
HIV infected children
Antiretroviral agents, prophylaxis
Immunizations
o Receive all vaccines except the live varicella
MMR, even though alive is still recommended
o Annual pneumococcal, influenza vaccine
o Annual TB skin testing
Complications
PCP
Most common
Infection risk correlates with CD4 number
Fever, hypoxia, interstitial pulmonary infiltrates
Tx
o TMP/SMX prophylaxis
o Infection: TMP/SMX, pentamidine, or atovaquone
MAC
Fever, weight loss, night sweats, abdominal pain
Bone marrow suppression, LFT
Risk is highest when CD4 <50
Fungal
Candidal infections
o Thrush, esophagitis
Cryptoococcal
o Meningitis, pneumonia
Viral
CMV
o Retinitis, esophagitis, colitis
HSV/VZV
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Toxoplasmosis
Lymphoma
Esp. B cell
o Caused by EBV
Infectious Mononucleosis
o EBV #1 cause
Toxoplasmosis, CMV, and HIV can cause a similar clinical syndrome
o S/Sx
Young children may be asymptomatic
Older children: typical S/Sx
Fever, up to 2w
Malaise & Fatigue
Pharyngitis (typically exudative, resembling GABHS)
Posterior cervical lymphadenopathy
Hepatosplenomegaly
Takes weeks to months to resolve
o Complications
Post infectious Bells Palsy
o Dx
CBC shows atypical lymphocytes
May also have neutropenia, thrombocytopenia, & LFT
Monospot (first line)
Measures heterophile Ab
Less sensitive for children <4 y/o
o Instead have EBV Ab Titers
Viral Capsid Antigen (VCA) & EB Nuclear Antigen (EBNA)
Acute infection: IgM-VCA and absent EBNA
Ab
CMV causes the majority of monospot negative mononucleosis
Tx: supportive, corticosteroids for severe pharyngitis
Complications
Neurological, CN palsy and encephalitis
Severe pharyngitis can cause obstruction
Amoxicillin-Associated Rash
o EBV infected pts. who are misdiagnosed w/ GABHS and
prescribed amoxicillin develop a diffuse pruritic maculopapular
rash 1 week after
Splenic rupture
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Malignancy: Burkitt's lymphoma and nasopharyngeal carcinoma


Measles (aka Rubeola, 10 day measles)
o Highly infectious
o S/Sx
Appear 8 to 10d after incubation
Classic prodrome followed by a transient enanthem (rash on mucous
membranes) and exanthem (skin rash)
Classic prodrome, The Three C's (Cough, Conjunctivitis, & Coryza)
Other early Sx: Photophobia & fever
Enanthem: Koplik spots (small gray papules on an erythematous base on the
buccocal mucosa)
Pathogonomic and present before the generalized exanthem
Exanthem: erythematous maculopapular eruption, begins around neck & ears,
spreads down the chest and upper extremities during 24h
Covers the LE by 2nd day and becomes confluent by the third day
Fever
o Complications
Bacterial Pneumonia
Otitis media, laryngotracheitis, encephalomyelitis (inflammation of brain and
spinal cord), subacute sclerosing panencephalitis
o Tx
Supportive, Vitamin A
IVIG for immunocompromised postexposure prophylaxis
Rubella (German Measles, 3 day measles)
o Unlike measles, typically mild or asymptomatic, incubation 14-21d
o S/Sx
Prodrome: Mild URI w/ low grade fever (<101F)
Painful lymphadenopathy
Suboccipital, posterior auricular, and cervical nodes
Exanthem follows the adenopathy
Nonpruritic, maculopapular, and eventually confluent
Begins on Face and spreads to trunk/extremities
o Complications
Meningoencephalitis
Polyarthritis
Teenage girls/young women
Congenital Rubella Syndrome
First trimester infection

William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Thrombocytopenia, Hepatosplenomegaly, jaundice, purpura (blueberry


muffin baby), MR
XR
o Longitudinal striations in metaphysis (osteochondritis or
periostitis = congenital syphilis)
Triad
o Cataracts, PDA, Sensorineural Hearing Loss
Pregnancy test priority if woman is infected of childbearing age

Aspergillosis
o Invasive or Allergic
o Invasive
Severely immunocompromised (bone marrow/organ transplant)
Tx:
Amphotericin B
Surgical removal of the aspergilloma
o Allergic
Wheezing, eosinophilia, pulmonary infiltrates
Occurs in those w/ chronic lung disease (e.g. CF)
Candidiasis
o Oral thrush, diaper dermatitis, vulvovaginal candidiasis
Coccidioidomycosis
o Southwestern US and Mexico
o Most are asymptomatic or mild pneumonia
o Immunocompromised
Disseminated: severe pneumonia, meningitis, osteomyelitis
Cryptococcus
o Cryptococcal meningitis: AIDS defining illness
Amebiasis
o Entamoeba histolytica
o Ingested cyst in contaminated food or water
Sx begin 1-4w later as trophozoite emerges from cyst and invades mucosa
o S/Sx
Ranges from asymptomatic to disseminated Extraintestinal amebiasis
Most asymptomatic
Symptomatic: mild Colitis to severe Dysentery
Cramping abdominal pain, diarrhea w/ blood or mucus, tenesmus
(feeling of constantly needing to pass stools, despite an empty colon)
o Can mimic IBD in chronic forms
Can last for weeks
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Abdominal complications
o Intestinal perforation, hemorrhage, strictures, local
inflammatory mass (ameboma)
Extraintestinal amebiasis
Abscess, most commonly in the liver, although can form in brain or
lungs

Dx

Trophozoites or cysts in stool


Serum Ab Assay
US/CT of for liver cyst

Metronidazole plus a luminal amebicide (iodquinol or paromomycin)

Tx

Giardiasis
o Giardia lamblia
o Travelers to Russia and drinking/swimming in contaminated mountain water in the
western US, daycare
o S/Sx
May persist for 2-6w (prolonged)
Diarrhea
Voluminous, watery, & foul smelling
Bloating, flatulence, weight loss
o Dx
Cysts & trophozoites in stool
Stool ELISA
o Tx
Metronidazole (same w/ Amebiasis)
Malaria
o Plasmodium: falciparum, vivax, malariae, ovale
o S/Sx
Initial: flulike Sx, headache, anorexia, fever
Cyclical fevers: correlate w/ RBC rupture
Hemolytic anemia, splenomegaly, jaundice
o Dx
Thin and thick Giemsa peripheral smear
o Tx
Chloroquine, quinine, mefloquine, doxycycline
o Prevention
Chemoprophylaxis: chloroquine, mefloquine, doxycycline, atovaquone
Toxoplasmosis
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

o
o

Chemical

Gonococcal

Chlamydial

T. gondii
Congenital
Triad
Diffuse Intracranial Calcifications, chorioretinitis, hydrocephalus
jaundice, hepatomegaly,
Transmission: cat feces, ingestion of cyst contaminated, transplacental
S/Sx
Mononucleosis-like illness
Malaise, fever, sore throat, myalgias, lymphadenopathy
Neonatal Conjunctivitis
Age of Onset
Findings
First day
After application of
Silver Nitrate
prophylaxis
Tearing w/ mild
conjunctival irritation
2-5d of life
Marked eyelid swelling
Profuse purulent
discharge
5-14d of life

Mild swelling of eyelid


Thickened, injected
conjunctivae (chemosis)
Watery or
mucopurulent eye
discharge
Blood stained eye
discharge
Conjunctival
pseudomembrane

Tx
Supportive, resolves
w/in 24h

IV or IM Ceftriaxone or
Cefotaxime
(topical erythromycin is
prophylaxis)
Oral Erythromycin to
avoid chlamydial
pneumonia
(Only prophylaxis is
maternal screening, bc
Oral Erythromycin
carries risk of pyloric
stenosis )

Pinworm
o Nocturnal anal pruritus or vulvovaginitis in prepubertal females
o Dx
Scotch Tape Test
o Tx
Mebendazole
Toxocara
o Dirt eating children can ingest the larva from dog feces contaminated soil
o Larva penetrate intestines and migrate to lung (wheezing), liver (hepatomegaly), brain
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

Dont return to intestines


Stool is for ova/parasites

Toxocara ELISA

Dx
Tx

Abendazole
Congenital CMV
o S/Sx
IUGR (w/ microcephaly)
Cataracts, chorioretinitis seizures, hepatosplenomegaly, jaundice, purpura
Periventricular calcifications
Sensorineural hearing loss
o If mother was previously infected, IgG will protect fetus in event of reactivation
o Can be shed in urine for years
Bells Palsy
o Post infectious
HSV #1
EBV, VZV, Lyme have also been implicated
o Tx
Eye drops to keep eye lubricated
Can do Glucocorticoids
Animal Bite
o Cat-Dog Bite
Pasteurella multocida (#1) & S. aureus
P. multocida causes swelling within 24-48h w/ tenderness, erythema, and
sanguinopurulent discharge
Complications: tenosynovitis, osteomyelitis, septic arthritis
Tx
Covers both: Amoxicillin-Clavulanate (Augmentin) (Ampicillin alone
doesnt cover S. aureus)
Dont close, leave open to heal if possible
Scabies
o Multiple excoriated & crusted (w/ blood) erythematous plaques
Typically on extensor elbow, webs of fingers, axillary folds, near nipples
o Burrows
Thin grey, brown, or red lines
o Commonly family involved
o Tx
Permethrin Cream
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Dry clean all linens/clothes


Acute Osteomyelitis
o Occurs from hematogenous spread, indirect spread of infected soft tissue, direct
inoculation from trauma
o S/Sx
Fever, erythema
Tenderness (to palpation) & Motility (unable to stand on leg)
o Causes
Children: S. aureus (most common), Group A Strep
After dog bite: Pasturella multocida
Puncture wound through shoe (rubber): Pseudomonas
Sickle Cell Anemia: Salmonella
o Xray
Deep tissue edema
TB
o Fever, weight loss, and LRT S/Sx
o PPD
5mm
+ if exposure history, abnormal CXR, or immunodeficiency
o Prolonged contact w/ someone diagnosed w/ TB
Number one risk factor for children
No sign of disease
o High risk, should start Isoniazid prophylaxis even if initial
negative TB skin test
If repeat TB skin test is negative in 8 to 12w can
discontinue
3 to 8w after exposure is needed before
developing hypersensitivity to TB
CXR shows Pulmonary disease
o 6 months: Isoniazid + Rifampin
o Plus Pyrazinamide and Ethambutol for the first 2 months.
Tinea Capitis (ringworm of scalp)
o Dermatophyte
Trichophyton tonsurans (most common) or Microsporum canis
Trichophyton tonsurans: creates black dot pattern, spores w/in hair shaft
Microsporum canis: spores surround hair shaft
o S/Sx
Multiple scaly circular patches of the scalp
Where hair has broken off
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Dx

o Patchy hair loss


o Breaks off at level of scalp
Enlarged lymph nodes

Woods Lamp
Blue-green fluoresce: Microsporum canis
No fluoresce: Trichophyton tonsurans
Potassium hydroxide prep of culture
Grows on Sabourad Medium

Tx

Oral Griseofluvin
Postviral Synovitis (Transient Synovitis)
o 1 to 2 weeks after an URI or Rubella Vaccine
o S/Sx
Tenderness of joint
May refuse to weight bear/walk
Fever is absent or low grade
o Typically resolves spontaneously w/in one week
Citrobacter koseri
o Neonatal meningitis
80% develop an abscess
o Tx
3rd/4th generation cephalosporin and draining of abscess
Septic Arthritis
o Infection of the joint space
red, swollen, tender joint, w/ limited mobility
o ESR
o Dx
Arthrocentesis for joint fluid
WBC > 50,000 w/ >90% N indicates bacterial
Glc
o Tx
1st IV Empirical ABx
2nd Surgical drainage/debridement
Diaper Dermatitis
o From irritant contact dermatitis
Urine, feces, moisture, heat
o Erythematous scaly patches that spare skin creases
o Tx
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Severe
Low dose corticosteroids and/or Zinc oxide

Candidiasis
o Well demarcated papules and plaques
Affects the skin folds (unlike Diaper Dermatitis)
o Can develop super imposed on diaper dermatitis
o Tx
Topical antifungal
Molluscum Contagiosum Virus
o Spread by skin to skin
o More common in people w/ HIV, atopic dermatitis, immunocompromised
o Red to pink glossy papules w/ umbilicated centers
Pruritic
Causes further self annoculation (Koebnerization)
o Results in linear aggregations of papules
Often surrounded by molluscum dermatitis
Mild eczematous eruption
o Tx
None, will reduce on own
HSV
o Herpetic Whitlow
Infection of distal finger
Painful coalescing vesicles w/ erythematous base
Tx
Analgesics and observation
o Acyclovir may shorten duration
Orbital Cellulitis
o S/Sx
Proptosis, periobrital swelling, painful eye movements, & opthalmoplegia
Fever
o Associated w/ preexisting sinusitis
o Tx
Head CT to asses degree of orbital involvement
Broad Spectrum ABx
Both anaerobic and aerobic
Bacterial Conjunctivitis
o Acutely painful and red eye w/ copious purulent discharge
No fever or impairment of extraoccular movements
Torch Infections
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o Isolate neonate from pregnant women


Meningitis due to TORCH Infections
o Toxoplasmosis, Other, Rubella, CMV, HSV
o Jaundice, hepatosplenomegaly, rashes
Can present w/ seizures
o Head CT
Intracranial calcifications
Lyme Disease
o Erythema Migrans
o Tx
Doxycycline 8 y/o
Because of tooth discoloration
Amoxicillin <8 y/o
DIC
o Can result from overwhelming sepsis
o Mechanism: widespread thrombi in small vessels w/ resultant platelet & factor
consumption resulting in mix bleeding/clotting picture
VZV
o Vesicles, pustules, & crusts in various stages of evolution/healing.
o Complications
Pneumonia
Uncommon, but most common cause of hospitalization following VZV
infection
o More common in immunocompromised (ex. ALL)
Progressive dyspnea, fever, and dry coughs
Tx: IV Acyclovir
Superinfection w/ GAS
Most common complication
Tx: Acyclovir not indicated, Tx bacterial infection
CNS
Rare
Cerebellar ataxia
No Tx required
o Tx
If mom develops infection
w/in 5 days prior to delivery or two days after delivery
o VZIG for infant
Full term infants > 10 days old do not need prophylaxis after sick contact, but do
need to be isolated from that person for the course of their infection (e.g. mom)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Dont give the vaccine before 1 y/o


Children >13 y/o
Oral Acyclovir
Younger w/out complication, no acyclovir
IVIG (VZIG) for pregnant women exposed
X-linked Agammaglobulinemia (Burton's Agammaglobulinemia)
o B-lymphocyte Tyrosine Kinase Defect
o May have absent tonsils
o Dx
Male w/ FHx of recurrent resp bacterial infections, normal T-lymphocytes
(CD3+), Absent B-lymphocyte (CD19+)
o Live vaccines are contraindicated
o Tx
Regular infusions of IVIG
Congenital Syphilis
o Treponema pallidum
o Severe
Still birth, neonatal death, over infection (e.g. hydrops fetalis)
o Early manifestations w/in 5w (other source said <2y??????)
Cutaneous lesions on palms/soles (Rash all over body)
Hepatosplenomegaly, jaundice, anemia, snuffles (profuse rhinorrhea)
Metaphyseal dystrophy and periostitis on radiographs
o Late manifestations w/in first 3m (other source said >2y??????)
Can be prevented w/ early Tx
Frontal bossing, short maxilla, high palatal arch, hutchinsons triad (blunted
upper incisors, interstitial keratitis, CN 8 Deafness), saddle nose, perioral
fissures
o Scrapies from skin contain treponemes
Congenital HSV
o Vesicular rash
o Three patterns w/in 4w
Localized to skin, eyes, mouth
Localized to CNS
Focal Seizures
Fulminant, multiple organs
o Highest risk of transmission 3rd trimester
Half mothers unaware theyre infected
GBS Infection
o First 7 days of life (usually first 24h)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

o
o

Risk factors: Delivered at home


Sepsis, pneumonia, and/or meningitis
Most common cause of neonatal meningitis
o Fever, lethargy, irritability, respiratory distress
o Blood culture: gram + cocci in chains
Rocky Mountain Spotted Fever
o American dog Tick, Midalantic region
o Rash begins on ankles and wrist and spreads centrally
o Headache, fever, malaise
DIC can follow or MS in severe cases
o Tx
Doxycycline (even in young pt.)
Roseola (Sixth Disease)
o HHV 6
o Children 6m to 3 y/o
o High Fever (103 to 106)
o Rosy rash (maculopapular) after 3d of high fevers (Fever resolves)
Starts on trunk and spreads to his arms/face
Non-pruritic
o Self-limited, no Tx
Hand-foot-mouth disease
o Prodrome
Fever & anorexia
o Ulcers on tongue and oral mucosa
o Vesicular rash on hands & feet
Blueberry Muffin Rash
o TORCH infections, specifically CMV and Rubella
o Result of extramedullary hematopoesis
Hepatitis C
o No contraindication to breast feeding
Hepatitis A
o 90% asymptomatic
o Daycare outbreaks
o Shed in stools for 2-3w before Jaundice and up to 1w after
o Dx
IgM HepA
Peaks 4 to 6w, but doesnt last past 6m
o IgG HepA
Persists a lifetime and doesnt mean active infection
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Tx

IG prophylaxis for household and close contacts w/in 2w of exposure

Asplenia
o Vulnerable to
Encapsulated: Strep pneumoniae, HIB, Neisseria meningitidis
Malaria, babesiosis
Group A Strep
o Strep progenies
o Pharyngitis
Rapid Step Test
+
o Treat immediately w/ penicillin
o Confirm w/ culture
Kawasaki Syndrome (KS)
o Medium Sized Artery Vasculitis
o Most common in Asians < 5 y/o
o Hydrops of Gallbladder
Gallbladder becomes distended w/out stone or inflammation
Abdominal pain
Seen in:
KS, GAS, Leptospirosis, Henoch-Schonlein Purpura
o S/Sx
Strawberry Tongue
Erythema w/ prominence of papillae
Seen in
o Scarlet Fever, KS, Toxic Shock Syndrome
High Grade Fever >4d, Unilateral enlarged cervical lymph nodes (>1.5cm)
Exanthem (widespread polymorphic rash)
Eventual desquamation
Thrombocytosis (>500,00 often much higher)
o Complication
Coronary Artery Aneurysm
Can lead to an MI
o Dx
Fever > 4d, Bilateral Bulbar Conjunctivitis (non-purulent), Lesions of the
lips/oral cavity (strawberry tongue, cracked lips, pharyngeal erythema),
peripheral extremity edema/erythema (swollen red hands/feet), rash, and
cervical lymphadenopathy (unilateral cervical, > 1.5cm)
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

Tx

IVIG and High Dose ASA


Yeast in urine is seen w/ those on ABx or Immunocompromised
Rheumatic Fever
o GAS
Follows infection by 2 to 4w
o Major Criteria
Migratory Polyarthritis, erythema marginatum, sub cutaneous nodules, chorea
(hand movements, lip smacking, facial twitches), carditis
(endo/myo/pericarditis)
Erythema Marginatum: Erythematous, serpiginous (wavy margins),
macular (flat, < 1cm,) lesions w/ pale centers that aren't pruritic (itchy)
o Minor Criteria
ESR/CRP, First Degree AV Block
o ASO titers
Anti-DNase B, antistreptolysin O, antihyaluronidase
o Murmurs
Mitral Regurgitation
Pansystolic
Mitral Stenosis
Loud S1 w/ mid-diastolic rumble at the apex
Can cause atrial fibrillation from LA enlargement
o EKG
PR interval
o Tx
Infection
Penicillin
Symptoms
NSAID for the arthritis
Steroids for the carditis
Diuretics & Inotropic agents if CHF
Prophylaxis against recurrence
Daily oral Penicillin or monthly IM
o Rheumatic Fever w/out Carditis
For 5y or until 21 (whichever is longer)
o Rheumatic Fever w/ Carditis, but w/ no residual heart or
valvular disease
For 10y or until 21 (whichever is longer)
o Rheumatic Fever w/ Carditis and valvular or heart disease
William Martin
MD MBA 2016 TTUHSC SOM
OC USN

2.23.2015

For 10y or until 40 (whichever is longer)

Parvovirus B19
o Fifth disease (aka Erythema infectiosum)
o Slapped Cheek Rash
Starts on face before spending to trunk and extremities
Lace like
Intense Red on face
o In absence of rash presents as arthraligas (esp. in older females)
o Mild systemic Sx
Low grade fever (~99)
o Aplastic Anemia
If underlying sickle cell anemia, hereditary spherocytosis
o Infection during pregnancy can cause nonimmune hydrops fetalis

William Martin
MD MBA 2016 TTUHSC SOM
OC USN