KAPLAN STEP 2 PEDIATRICS

USMLE Step 2 — Lesson 1

Pediatric Highlights for USMLE Step 2

Eduardo Pino, MD

NEWBORN-APGAR

Apgar Score 0 1 2
Appearance Blue, pale Body pink, ext blue All pink
Pulse (HR) 0 <100 >100
Grimace None Grimace Cough
Activity Limp Some flexion Active
Respiration Absent Slow irregular Good

NEWBORN-SKIN

 Subcutaneous fat necrosis

 Erythema toxicum
 Acne neonatorum
 Milia
 Hemangiomas
 Mongolian spots
 Nevus sebaceous

NEWBORN-HEAD

 Caput-scalp swelling, crosses suture lines, resolves in days

 Cephalhematoma - subperiosteal bleed, DOES NOT CROSS SUTURES, longer resolution
 Fontanels-large, suspect hydrocephalus, hypothyroid
o Closure-anterior, 9-18 months
o Posterior, birth, 4-5 months

NEWBORN-EYES,NOSE

 Eyes
o Red reflex=lens clear
o White reflex=retinoblastoma
o Lens opacity=cataract
o Aniridia+hemihypertrophy=Wilms
 Nose
o Choanal atresia-blue baby pinks up on crying, catheter doesn’t pass nose

NEWBORN-ABDOMEN, GU

 Abdomen
o Masses-polycystic kidney most common
o Umbilical hernia-most close by 5 years
o Omphalocele-sac
o Gastroschisis-no sac
  GU
o Epispadias, hypospadias-don’t circumcise
o Undescended testes-bring down after 1 year
o Ambiguous genitalia-congenital adrenal hyperplasia (21 hydroxylase most common)

NEWBORN-BIRTH INJURIES

 Fractures-clavicle most common-crepitus

 Forceps-facial nerve palsy, bruising
 Brachial plexus
o Erb-Duchenne:C5-C6, if C4, ipsilateral
 diaphragmatic palsy
 “waiter’s tip”
o Klumpke:C8-T1, “claw hand”

NEWBORN-SCREENING

 PKU-autosomal recessive
o mental retardation most common
o eczema, musty odor, FAIR HAIR, FAIR SKIN, BLUE EYES
 Galactosemia-autosomal recessive
o jaundice, hypoglycemia, cataracts
 Hypothyroid-T4 low, TSH high
o large fontanel, jaundice, mottled, constipation, large tongue, umb. hernia

NEWBORN-RESPIRATORY

 Common signs/symptoms- Cyanosis, tachypnea, nasal flaring, retractions, grunting

 Respiratory distress syndrome
o Surfactant deficiency, seen in preterm
o Ground glass appearance on X-ray
o Treat with surfactant, ventilator support
 Transient tachypnea of newborn
o Rapid descent, C/S
 Meconium aspiration syndrome

NEWBORN-JAUNDICE

 Physiologic
o Appears >24 hours of age
o peaks at 12.9 by 3 days
o resolves by 1 week
 Pathologic-first day, level >13, lasts > 1week
o Etiology-hemolysis-Rh, ABO
o biliary atresia-direct bilirubin,
o acholic stools
 Therapy-phototherapy only for indirect

NUTRITION

 Breast milk is best for infant

  Iron supplement after 6 months
 Contraindications-
o active, untreated TB
o syphilis
o AIDS
o herpes if breast lesions
o galactosemia
o varicella
 Formula-20 cal/oz
 Whole milk-only >1 yr. Bad for kidneys

GROWTH-HEIGHT

 Short stature

hypopituitarism

constitutional delay

familial short stature

deprivational dwarf

Turner

hypothyroidism

chronic disease

 Tall stature

normal-familial

obesity

endocrine-GH excess

o androgen excess
o hyperthyroidism

genetic

o Marfans
o Klinefelter

GROWTH-WEIGHT

Failure to Thrive
Malnutrition
Malabsorption
Allergies
Immune deficiency
Chronic disease
Obesity
<5% secondary to syndromes
Risk of obesity persisting to adults increases with advanced age of onset

DEVELOPMENT

 Newborn reflexes-most disappear by 4-6 mos, EXCEPT Babinski (18 mos), parachute (never)
 Social smile 4-8 weeks
 Rolls onto back 4 mos
 Rolls onto stomach 5 mos
 Sits with support 6 mos
 Pincer grasp 9 mos
 3 cubes at 15 mos, 4 at 18, 7 at 24

BEHAVIOR

 Attention deficit-inattentive, impulsive,distractible, hyperactive (4:1 males)

 Enuresis-primary nocturnal most common
 typically males, family history
 disorder of sleep/arousal
 treatment-time, alarms, imipramine DDAVP

 Encopresis-boys more common, usually psychological cause

USMLE Step 2 — Lesson 2

IMMUNIZATIONS

 NOT contraindications:
 Fever<105 after DPT
 Mild acute illness in otherwise well child
 Concurrent antimicrobial therapy
 Prematurity-immunize at chronological age
 Family history of seizures
 Family history of SIDS

IMMUNIZATIONS

 Don’t give live vaccines to immunocompromised

 Killed polio now recommended for initial series
 MMR-most effects 1-2 weeks later
 Delayed schedule-give as many as possible
 Missed immunizations-don’t start over

IMMUNIZATIONS-HIV

Vaccine No/ Moderate Severe

Immunosupporess Immunosupress
(Category 1,2) (Category 3)
DTP Yes Yes
OPV No No
IPV Yes Yes
MMR Yes No
Pneumococcal Yes Yes
Influenza Yes Yes
ID-SEPSIS/MENINGITIS

 Etiology- Age dependent

o Neonate-Group B Strep most common

E. coli

Listeria

o >2 months-pneumococcus most common

o College, military-meningococcus
 Clinical-bulging fontanel in infants
o Kernig, Brudzinski in older
 Know CSF findings

ID-SEPSIS/MENINGITIS

 Steroids useful in preventing H. flu sequelae

 Add vancomycin if Pneumococcus
 Rifampin prophylaxis for H. flu, Meningococcus
 Vaccines vs. H. flu, S. pneumoniae, N. meningitidis

ID-ENCEPHALITIS

 Etiology-viral
o Arbo, enteroviruses in seasonal epidemics
o HSV most common cause of sporadic
 Clinical-more abnormalities of mental function-confusion, delirium, combative, ataxia

ID-ENCEPHALITIS

 Diagnosis - PCR from CSF

 Temporal lobe involvement suspect HSV
 Treatment - acyclovir if HSV

ID-OSTEO/SEPTIC ARTHRITIS

 Osteomyelitis
o S. aureus most common
o Sickle cell - Staph, Salmonella
o Pasteurella after dog, cat bite
o Pseudomonas after sneaker puncture
o X-rays turn positive after 10-14 days
 Septic arthritis - Staph, also Strep
o Arthrocentesis test of choice
o Differential - cellulitis, JRA, synovitis, ALL

ID-PERTUSSIS
  Clinical
o conjunctivitis
o coughing spasms
o inspiratory whoop
o ·facial petechiae
 Lab-leukocytosis with lymphocytosis
o ·positive culture
o ·rapid fluorescent antibody stain

ID-PERTUSSIS

 History of incomplete immunizations

 Immunize to prevent, erythromycin to close contacts
 Erythromycin to patient shortens communicability

ID-RASH DISEASES

 Lyme disease-look for Long Island, Conn.

o Rash-erythema chronicum migrans
 Fifth’s disease-erythema infectiosum
o Rash-“slapped cheek”
o Parvovirus B19, can cause aplastic anemia

ID-RASH DISEASES

 Measles (rubeola)
o Cough, coryza, conjunctivitis, Koplik
o Rash accompanied by fever
 Roseola-rash after fever
 Rubella-3 day measles, lymphadenopathy

ID-RASH DISEASES

 Can immunize against measles, rubella, Lyme

 Rocky Mountain Spotted Fever
o Look for Carolinas
o Rash includes palms/soles
 Cat scratch-papule, granuloma, lymphadenitis
o PCR most sensitive for diagnosis
o Kittens transmit more than cats

ID-MISCELLANEOUS

 Mumps-orchitis rare before puberty

 HIV-most pediatric infections acquired at birth-zidovudine to mother decreases transmission
 Mononucleosis - atypical lymphocytes
o Ampicillin rash
 USMLE Step 2 — Lesson 3
POISONING

 Acetaminophen-check liver functions

o antidote: n-acetylcysteine
 Aspirin-ferric chloride test-qualitative
o metabolic acidosis with respiratory compensation in children
 Carbon monoxide-cherry red blood
o antidote-oxygen, hyperbaric

POISONINGS

 Tricyclic Antidepressants
 Leading cause of death
o seizures, arrhythmias
 Hydrocarbons - kerosene
o aspiration
 Organophosphates - DUMBELS
o antidote - atropine

POISONINGS

 Iron - signs of hemorrhagic gastroenteritis

o antidote - deferoxamine
 Lead - blood lead levels, lead lines
o antidote - EDTA, BAL

EYE

 Conjunctivitis-chemical most common <24h old

o Chlamydia most common infectious cause in newborn
 Strabismus-transient is normal up to 4 months old

EYE

 Amblyopia-“lazy eye”
o Hirschberg, Cover test
o patch good eye
 Cellulitis
o orbital-eyeball doesn’t move, proptosis preorbital-eyelids and surrounding tissue

TEETH-PRIMARY ERUPTION

  Lower(Mandibular) Upper(Maxillary)
Central Incisors  5-7 months  6-8 months 
Lateral Incisors 7-10 months 8-11 months
Cuspids(canines) 16-20 months 16-20 months
First Molars 10-16 months 10-16 months
 Second Molars 20-30 months 20-30 months

TEETH-SECONDARY

  Lower   Upper  

Central Incisors 6-7 years 7-8 years

Lateral Incisors 7-8 years 8-9 years

Cuspids 9-11 years 11-12 years

1st Premolars 10-12 years 10-11 years

2nd Premolars 11-13 years 10-21 years

1st Molars 6-7 years 6-7 years

2nd Molars 12-13 years 12-13 years

3rd Molars 17-22 years 17-22 years

EARS, NOSE, THROAT

 Otitis media
o Etiology - S. pneumo most common

H. flu nontypable

B. catarrhalis

o Meningitis most common intracranial complication

 Otitis externa-from repeated wetting

Etiology - Pseudomonas, S. aureus

Clinical-pain exacerbated by moving ear canal

EARS, NOSE, THROAT

 Sinusitis - S. pneumo, H.flu, Staph.

Symptoms-purulent nasal discharge headache, sinus tenderness

 Epistaxis - nose picking most common

 Pharyngitis - viral/bacterial (Group A strep)
o Throat culture is gold standard
o Complications - rheumatic fever

EARS, NOSE, THROAT

 Peritonsillar abscess-tonsil bulges, uvula deviates to non-involved side

“HOT POTATO VOICE”

  Retropharyngeal abscess-Strep, look at lateral X-ray of neck
 Cervical lymphadenitis-usually infectious
o Viral/bacterial pharyngitis, TB, cat scratch, rarely tumors

RESPIRATORY

 Foreign bodies-peanut most commonly aspirated

o Look for sudden onset respiratory distress, wheezing, may be witnessed event
o Diagnosis-bronchoscopy, CXR hyper-inflated
 Croup-parainfluenza virus
o Clinical-barking cough, inspiratory stridor
o P/A neck film-STEEPLE SIGN
o Steroids beneficial

RESPIRATORY

 Epiglottitis H. flu type b

o Age- 3-10 years
o Clinical-dysphagia, drooling, muffled voice
o CHERRY RED EPIGLOTTIS
o THUMBPRINT SIGN on lateral neck
o Tx-secure airway, antibiotics

RESPIRATORY

 Asthma-Reversible airways disease

o wheezing is hallmark, no clubbing
o Differential-congenital malformations
 foreign bodies
 cystic fibrosis
 bronchiolitis
o Tx-bronchodilators, steroids
o Prevent-cromolyn, leukotriene antagonist

RESPIRATORY

 Bronchiolitis-RSV, children<2 years

o Clinical-wheezing, rales, tachypnea
o Prevention-monoclonal antibodies
 Cystic fibrosis-autosomal recessive
o chromosome 7, long arm
o chronic obstruction-clubbing seen
o SWEAT TEST

RESPIRATORY

 SIDS-most common cause of death 1-12 mo

 Peak at 2-3 mo, winter, midnight-9 AM
 Sleep position
 USMLE Step 2 — Lesson 4
CARDIOVASCULAR

 Innocent murmur-never diastolic

o never >2/6
o 3-7 years of age
o best at left lower, midsternal border
o musical, vibratory
o no significance

CARDIOVASCULAR CLASSIFICATION

STENOTIC R to L L to R MIXING
Aortic stenosis TOF PDA Truncus
Pulmonic stenosis Transposition VSD TAPVR
Coarctation Tricuspid atresia ASD Hypertrophic LH

CARDIOVASCULAR

 ASD-systolic ejection murmur

o WIDE FIXED SPLIT OF S2
 PDA-machinery murmur, to and fro
o wide pulse pressure, bounding pulses
o Tx-surgical closure indomethacin
 VSD-most common heart defect
o loud harsh pansystolic murmur
o 30-50% of small defects close by 1 year

CARDIOVASCULAR

 Endocardial cushion defect-Common AV canal

o Common in Down’s syndrome
o CHF early-feeding difficulty, sweat while feeding, tachypnea
 Coarctation of the aorta-common in Turner’s
o Weak/delayed/absent lower extremity pulses, Rib notching on CXR

CARDIOVASCULAR

 Tetralogy of Fallot- Most common cyanotic

o pulmonary stenosis
o VSD
o overriding aorta
o RV hypertrophy
o CXR-boot shaped heart, pulmonary markings
o PE-cyanosis, single 2nd heart sound
o Complications-cerebral thrombosis, ischemia, brain abscess

CARDIOVASCULAR
  Transposition-most common with cyanosis in 1st 24 hrs.
o Keep ductus open with prostaglandin
o CXR-egg on a string
 Pulmonary atresia- cyanosis at 2-3 days
 Tricuspid atresia- single S2 pansystolic murmur
 Total anomalous pulmonary venous return
o CXR-snowman or figure 8

CARDIOVASCULAR

 Rheumatic fever- rheumatic fever-associated with Strep throat

J=joints

O=carditis (O looks like a heart)

N=nodules (subcutaneous)

E=erythema marginatum

S=Sydenham’s chorea

o minor criteria-fever, arthralgia, previous RF ESR, CRP, prolonged P-R interval + prior Strep
infection
o complications-valve disease-mitral, aortic

CARDIOVASCULAR

 Hypertension
o Essential-no known underlying cause
o More common in adolescents
o Secondary-more common in infants and children
o Look for renal disease-UTI, obstructive lesion of urinary tract, prior umbilical catheter as newborn

GASTROINTESTINAL

Diarrhea
 Viral-rotavirus most common
o adenovirus, Norwalk virus
 Bacterial-E.coli think of HUS
o Salmonella -tx prolongs carrier
o Shigella-tx with trimethop/sulfa
o Campylobacter-erythromycin
o C. difficile-think of prior antibiotic
o parasites-Giardia, cryptosporidium

GASTROINTESTINAL VOMITING

Constipation
 Voluntary withholding most common (functional constipation) outside of infancy
o also-imperforate anus
 cystic fibrosis-meconium ileus
  anteriorly displaced anus
 Hirschsprung-aganglionosis
 Dx by BIOPSY

GASTROINTESTINAL VOMITING

 Age related causes

o neonate-obstruction
o infants-gastroenteritis, reflux, allergy, over-feeding, inborn errors of metabolism
o child/adolescent-gastroenteritis, toxic ingestion, appendicitis, pancreatitis
 Duodenal atresia-bilious vomiting common in Down’s, DOUBLE BUBBLE

GASTROINTESTINAL VOMITING

 Reflux - chronic, cough, vomiting, apnea

o pH probe is gold standard
 Pyloric stenosis - NONBILIOUS, PROJECTILE VOMITING
o more common in males, firstborn
o lab-hypochloremic, hypokalemic metabolic alkalosis
o Ultrasound test of choice

GASTROINTESTINAL BLEEDING

 Upper-esophagitis, ulcers, gastritis, epistaxis

 Lower-neonate-swallowed blood-Apt test
o necrotizing enterocolitis-premature, low Apgar, pneumatosis intestinalis
o other-milk allergy, gastroenteritis, ANAL FISSURE (infants)

GASTROINTESTINAL

 Inflammatory bowel disease-ulcerative colitis and Crohn’s

o Dx by biopsy
o both cause bloody stools, fever, abdominal pain
o Crohn’s-fissures, fistula, abscess

GASTROINTESTINAL

 Intussusception-typically 6-18 months

o Clinical-crampy abdominal pain CURRANT JELLY STOOL
o PE-sausage shaped abdominal mass
o ·Dx-barium enema-coil spring sign

GASTROINTESTINAL

 Meckel’s diverticulum-disease of 2’s

o 2% of population, 2:1 males, 2 years of age, 2 types of tissue, 2 feet from ileocecal valve
o painless rectal bleed, can cause intussusception
o Dx-technetium scan
RENAL

 Acute Glomerulonephritis
o triad of hematuria,edema, hypertension
o follows Group A Strep infection
o C3 decreased
o Complications-renal failure, hypertension
 Alport’s
 X-linked dominant
 Clinical-microscopic hematuria, proteinuria,

HEARING LOSS, CATARACTS

RENAL

 Nephrotic syndrome-proteinuria,edema, hypoproteinemia, hyperlipidemia

o usually follows viral respiratory infection
o C3 normal
o Complications-INFECTION-peritonitis
 Urinary tract infection
o males more common <1 year, then females
o E. coli most common
o Urine culture is gold standard

USMLE Step 2 — Lesson 5

ORTHOPEDICS

 Intoeing
o Metatarsus adductus-can be brought to neutral
o Talipes equinovarus-heel also deviated
o Tibial torsion
o Femoral anteversion

ORTHOPEDICS

 Limping
o Congenital hip dysplasia-0-3 years, u/s
o Legg-Perthes-4-8 years-avascular necrosis of femoral head
o Slipped capital femoral epiphysis->11 years obese adolescent, think deficient gonads

ORTHOPEDICS

 Popliteal cyst (Baker)-painless, nonpulsatile

 Osgood Schlatter-tenderness, swelling of tibial tubercle
o common in physically active pubertal children
 Radial head subluxation (nursemaid)
o sudden traction to arm

ORTHOPEDICS

 tumors-occur in adolescence, rapid bone growth

 o Osteosarcoma-most common, risk if bilateral retinoblastoma
o bone sclerosis on X-ray
o Ewing’s-“onion skin” on X-ray

ALLERGY/IMMUNOLOGY

 Allergic rhinitis-IgE mediated

o Clinical-sneezing, rhinorrhea, allergic salute, allergic shiners, nasal crease
o Tx-antihistamines, leukotriene antagonists
 Hereditary angioedema-C1 esterase inhibitor def.
 Bruton’s-all major immunoglobulins involved
o symptoms at 6-12 mos.-recurrent infections, esp. pneumococcus
o Tx-replace IgG

ALLERGY/IMMUNOLOGY

 DiGeorge-T cell deficiency

o TRUNCUS ARTERIOSUS, fishmouth, micrognathia
o NEONATAL HYPOCALCEMIA is 1st manifestation
 Wiskott-Aldrich: X-linked recessive
o MR TEXT-low IgM, Recurrent infections, T(and B) cell deficiency, Eczema, Thrombocytopenia

RHEUMATOLOGY

 Juvenile Rheumatoid Arthritis

Types-

o polyarticular-many, small joints RF-, RF+

o pauciarticular-few, large joints
o type I-ANA+, girls, iridocyclitis
o type II-HLA B27+, boys, ankylosing spondylitis
o systemic-fever, rash, then joints
o Differential-rheumatic fever, SLE, Lyme, ankylosing spondylitis, osteomyelitis, ALL

RHEUMATOLOGY

 Systemic lupus erythematosus-autoimmune

o BUTTERFLY (malar) rash
o renal involvement in children
o neonatal lupus-congenital heart block
 Mucocutaneous lymph node syndrome (Kawasaki)
o FEVER+ 4 of 5 of following: conjunctivitis, mucous membrane changes, peripheral extremity
changes, rash, cervical lymph nodes
o CARDIAC INVOLVEMENT

RHEUMATOLOGY

 Henoch-Schoenlein purpura
o Rash usually below waist
o Usually follows viral illness
 o Can have renal, GI involvement

HEMATOLOGY

ANEMIA

 Iron Deficiency most common

o cause-low birth weight, diet (9-24 mos) blood loss (ulcer, Meckel, whole cow’s milk in infants)
o clinical-pallor, irritability, murmur
o labs- ferritin, serum iron, binding capacity, FEP, Hgb
o differential-lead, thalassemia, chronic disease

o tx-iron-see reticulocytosis in 72h, Hgb 3-4 wks

HEMATOLOGY

ANEMIA

 Hemolytic
o Hereditary spherocytosis-autosomal dominant
 presents as anemia, jaundice
 labs-OSMOTIC FRAGILITY TEST
 tx-splenectomy
o Enzyme defects-pyruvate kinase, G6PD

HEMATOLOGY

ANEMIA

 Sickle cell anemia - develops after 2 months

o dactylitis 1st manifestation, splenic, bone infarcts, infections (Salmonella, Pneumococcus)
 Dx-electrophoresis

HEMATOLOGY

 Idiopathic thrombocytopenia-autoimmune
o Usually follows viral infection
o Petechiae, but patient appears well
o Bone marrow-normal
o Tx-gamma globulin, steroids
 Hemophilia
o Factor VIII (classic, A)-X linked recessive
 HEMARTHROSIS
 Replace factor

ONCOLOGY

 Acute lymphocytic leukemia-most common childhood cancer

o clinical-acute onset, anorexia, pallor, fever, bone pain in 1/4
o dx-bone marrow
o tx-chemotherapy, radiation, transplant
o RELAPSE TO TESTES, CNS
  Wilms -nephroblastoma
o abdominal mass
o distorts renal outline

ONCOLOGY

 Neuroblastoma-many times abdominal,

o presents anywhere there is neural crest
o Increased catecholamines in urine
 CNS-most common solid tumors
o infratentorial (posterior fossa ) most common
 cerebellar astrocytoma most common
 clinical-morning headache, vomiting
o supratentorial-craniopharyngioma cause of short stature

USMLE Step 2 — Lesson 6

NEUROLOGY

 Seizures
o Febrile-most common
 rapid rise of temperature
 generalized, tonic-clonic, 10-15 mins
 normal EEG
 tx-treat fever
o Infantile spasms-West syndrome
 EEG-hypsarrhythmia
 tx-ACTH, prednisone
o Petit mal-3/sec spike/wave, ethosuximide

NEUROLOGY

 Progressive mental retardation

o Lesch-Nyhan-self-mutilation
 gouty arthritis
o Wilson’s-disorder of copper metabolism
 initial signs are liver related
 Kayser-Fleischer rings
o Mucopolysaccharidoses-Hunter-X linked recessive, all others autosomal recessive
o Tay-Sachs-lose developmental milestones, cherry red macula

NEUROLOGY

 Werdnig-Hoffman-spinal muscular atrophy

o Severe hypotonia-floppy baby
o Fasciculations, FROG LEG POSTURE
o EMG-fibrillations
o muscle bx-denervation
o nerve bx-slowed conduction
o Autosomal recessive
 Guillain-Barré-follows viral illness
o Ascending weakness, paralysis, lose deep tendon reflexes
  tx-supportive, plasmapheresis, IVIG

NEUROLOGY

 Duchenne muscular dystrophy-X linked rec

o most common inherited neuromuscular disease
o Hip girdle weakness, Gower’s sign
o dx-greatly elevated creatine kinase, muscle bx
 Neurofibromatosis-von Recklinghausen
o Café-au-lait spots, axillary/inguinal freckling
o Lisch nodules, neurofibromas, acoustic neuroma
o autosomal dominant, risk for malignancy

NEUROLOGY

 Tuberous sclerosis-autosomal dominant

o Ash leaf spot, sebaceous adenomas, shagreen patch, periventricular calcified tubers on CT
o seizures very common
 Sturge-Weber-facial nevus-port wine stain
o seizures difficult to control
o intracranial calcifications
o mental retardation

ABUSE

 Clinical-unexplained injury
o physical and injury don’t correlate
o lash marks, loop marks
o bite >3 cm=adult
o RETINAL HEMORRHAGE=shaken
o old healing fractures, bruises
o venereal disease in prepubertal child
 Tx-treat any injury, infection
o document, REPORT

ADOLESCENT

 Know Tanner stages

 Breast buds 1st sign of puberty in females
 Testicular enlargement 1st sign in males
 Mortality-Accidents, especially motor vehicle
o Suicide-males more successful
o Homicide
o Cancer-leukemia, Hodgkin’s, bone
 Normal-breast asymmetry, gynecomastia, irregular menses
 Acne-hormones, dirt, bacteria

Pediatric Highlights for USMLE Step 2

Eduardo Pino, MD
End