☝🏻هذا قديم. ما انصح به

ذاكرو نسخة ٢٠٢٣ او ٢٠٢٤
مع ملف مهدي بالنوتات

✅اذا هدفك نجاح فقط ، ملف مهدي يكفي والكارديو والبلمو والفاكسينيشن ذاكرها من صفدر ٢٠٢٣ او ٢٠٢٤.

صفدر برسوم

#Milestones 👶🚶‍♂️🏃‍♂️

Developmental domains:
1. Motor (M): Gross & Fine
2. Language (L): Receptive & Expressive
3. Cognitive (C)
4. Social & Emotional (S, E)

2 months
M: Raises head
L: Cooing (Co is 2 letters, 2 mo)
C: Fix and follow face/toy👀
S: Smile☺️

4 months
M:
- Roll from prone to supine
- Reaches for objects⭕️
- Sit w support
L: Laughs (HAHA is 4 letters, 4 mo)🤣
S: Stranger anxiety😥

6 months
M:
- Roll from supine to prone
- Crawls
- Sits briefly/Tripod position
- Transfer objects from hand to hand 🫱🫲

9 months
M:
- Sits w/o support
- Pull to stand, walk around furniture 🪑
- Palmar grasp🤜
L: Babbling, says Mama dada (8 letters, close to 9 -> 9 mo)

12 months
M: Pincer grasp🫰
L: says few words / more than 1 word (>1 word -> 1 year)

15 months
M:
- Walks alone🚶‍♂️
- Crawls upstairs🪜
- Stack 3 cubes🧊🧊🧊
L: Jargon
C: Follows simple commands

18 months
M:
- Runs to the doctor🏃‍♂️⭕️
- Walks upstairs🪜
- Draw straight line ✍️ ⭕️
- Throw and catch the ball ⚽️⭕️
S: Imitates mother⭕️

2 years
M:
- Runs🏃‍♂️
- Jumps
L: 3 words sentence
C:
- Builds a tower of 6 blocks
- Compares two items
- Knows body parts👁️👃👄
- Role-play🤱

3 years
M:
- Climbs a stair
- Rides a tricycle (3 y, TRIcycle)
- Shakes hand🤝
- Feeds himself 🍴
L: Says his name, gender, age
S: Separates easily from parents👋

4 years
M:
- Hops on one foot🦶
- Undo buttons/undress⭕️
L:
- Tells short stories
- Speaks clearly in sentences⭕️
- Names 4 colors, counts to 4
C: Draws a square◼️


Primitive Reflexes Disappearing Time
2 mo: Stepping reflex
3 mo: Sucking reflex🍼
4 mo: Rooting reflex👈, Palmar grasp reflex✋️
6 mo: Moro reflex👻 (Persistent -> Cerebral palsy🧠)
12 mo: Plantar grasp reflex🦶

Exercise & Activity🛝
<4 yo: 180 min/d
5-11 yo: 60 min/d
12-17 yo: 60 min/d, 3 d/w
>18 yo: 150 min/w

Midparental height (cm)
Girl’s target height:👧
(Mother’s + Farher’s - 13)/2
Boy’s target height:👦
(Mother’s + Farher’s + 13)/2

#Vaccines 💉

At Birth:🐣
- BCG
- Heptitis B

2 mo: to (2) Be DR. HIP🧑‍⚕️
- Heptitis B
- DTaP
- Rota
- Hib
- IPV
- PCV

4 mo: for (4) Being DR. HIP🧑‍⚕️
- Heptitis B
- DTaP
- Rota
- Hib
- IPV
- PCV

6 mo: DOn’t Be HIP🫤
- DTaP
- OPV
- Heptitis B
- Hib
- IPV
- PCV

9 mo: M&M 🍫
- Measles
- MCV4

12 mo: POMM i’m 1 yo👻
- PCV
- OPV
- MMR
- MCV4

18 mo: HOV i’m MAD😠
- Hib
- OPV
- Varicella
- MMR
- Heptitis A
- DTaP

2 y: got an A in second year🅰️
- Heptitis A

4-6 y: Very lazy MOoD VMOD from 4-6 pm🥱
- Varicella
- MMR
- OPV
- DTaP

Live vs Inactive Vaccines
Inactive:
Horrible Doctor killed A Baby Patient 👼
- Hib
- DTaP
- Heptitis A
- Heptitis B
- PCV

Live:
Veronica lives close By ROMe🇮🇹
- Varicella
- BCG
- Rota
- OPV
- MMR

Considerations:
- It’s safe to give killed or live vaccines to mild humoral immunity diseases (e.g. IgA def or complement def✅
- Mother took immunosuppressants (e.g. azathioprine) in 2nd trimester🤰-> Give the child vaccines after 6 mo
- Mother took immunosuppressants (e.g. azathioprine) in 3rd trimester🤰-> Give the child vaccines after 12 mo
- Pt is on biologics (IVIG) -> Delay MMR & Varicella for 8 mo
- Live vaccines are administered after 1 mo of High-dose CS discontinuation
- In preterm -> Vaccinates like term except: Delay Hep B till 2 kg or 1 mo old

Contraindications🙅‍♀️:
• Psoriasis, eczema, and contact dermatitis -> Smallpox (variola) vaccine🚫
• HIV -> OPV & BCG🚫
• Immunodeficiency -> Killed vaccines only
• Suspected immunodeficiency -> Defer all vaccines🗓️
• Egg allergy🍳 -> Yellow fever vaccine🚫
• Gelatin allergy -> MMR🚫
• Intussusception hx -> Rota🚫
• Active profuse diarrhea -> Postpone Rota🗓️
• Active vomiting -> Postpone OPV🗓️
• Immunosupressed contact -> OPV

#Genetics 🧬

Down Syndrome (Trisomy 21🧬)
• Features:
Face:
- Epicanthal folds
- Upslanting pelpebral fissures
- Brushfield spots👁️
- Small, low-set ears 👂
- Flat facial profile
- Large & Furrowed Tongue
Neck:
- Short neck with excess skin
Hand 🖐️:
- Hypoplastic incurved 5th fingure
- Single transverse palmar crease
Foot🦶:
- Sandal toe deformity

• Complications
- Endocardial cushion defect ECD (AVSD) -> The most common cardiac anomaly 🫀
- Duodenal atresia (Double bubble sign)
- Hypothyroidism
- Hypotonia (most common/most striking feature)
- Atlantoaxial instability-> Lateral cervical spine xray befote surgery🦴
- ALL
- Early onset Alzheimer
• For growth-> Down syndrome chart
• Lower incidence to result in Down -> Mosaicism
Edward Syndrome (Trisomy 18🧬)
PRINCE edward
Prominent occiput
Rocker-bottom feet
Intellectual disability
Non-disjunction
Clenched fist
Ears are low-set

• Other features
- Micrognathia
- Microcephaly
- Short sternum
- Overlapping fingers✊
- Limited hip abduction
• Complications
- Omphalocele
- Majority do not survive first year⚠️
- Commonly associated with heart defects specifically VSD🫀

Patau Syndrome (Trisomy 13🧬)
• Features:
- Microcephaly/Holoprosencephaly🧠
- Cutis aplasia (abcence of skin)
- Microphthalmia (small orbits)👁️
- Cleft lip/palate👄
- Polydactyly🖐️+👆
- Rocker-bottom feet 🦶
• Complications:
- Single umbilical artery
- Umbilical hernia, omphalocele
- Heart defects🫀
- Polycystic kidney

Pradar-Willi Syndrome
• Dx: Deletions on paternal 15q11-q13🧬
• Features:
Face:
- Narrow forehead
- Almond-shaped eyes
- Downturned mouth
Others:
- Hypotonia (weak sucking/feeding problems in infancy)
- Hyperphagia and obesity
- Short stature
- Intellectual disability
- Hypogonadism
• Complications:
- Sleep apnea (most common)
- T2DM
- Choking

Turner Syndrome
• Karyotype: 45,XO🧬 (girls)
• Features:
- Webbed neck
- Broad chest w widely spaced nipples
- Short stature
• Complications
- Coarctation of the aorta 🫀
- Bicuspid aortic valve🫀
- Horseshoe kidney (fusion of both kidneys)🐎
- Streak ovaries (amenorrhea, infertility)🤰❌
• Can have normal childhood and present as adolescent with Primary ovarian insufficiency:
High FSH, LH
Low Estrogen, Inhibin, Progestrone
• Increased risk of osteoporosis🦴

CHARGE syndrome
Coloboma👁️
Heart defects (TOF, VSD)🫀
Atresia choanae👃
Retardation of growth
Genital abnormalities
Ear abnormalities (abnormal shape, hearing loss)👂
• Patho: CDH7 gene mutation🧬

VACTERL association/syndrome
Verterbral🦴
Anal atresia
Cardiac anomalies🫀
TracheoEshopgageal fistula
Renal anomalies
Limb abnormalities🦵
• Patho: defect of mesoderm development

WAGR syndrome
Wilms tumor
Aniridia
Gentourinary anomalies
Mental Retardation
• Patho: Deletion on chromosome 11 (11p13)🧬

#Genetics 🧬

Wilms Tumor (Nephroblastoma) vs Neuroblastoma
• Most common intra-abdominal malignancy of infancy👩‍🍼:
1. Neuroblastoma
2. Wilms (Nephroblastoma)
• Origin:
Neuroblastoma: neural crest cells
Wilms: Kidney
• Crossing midline or Unilateral?
Neuroblastoma: Crosses midline
Wilms: Unilateral
• Clinical features
Neuroblastoma: less common
Wilms: More common
• If imaging show mass arising from:
Adrenal -> Neuroblastoma
Kidney -> Wilms
• Wilms can be associated with syndromes (like WAGR)
- Best initial dx for Wilm’s -> Abdominal US

Prune Belly Syndrome
Triad of:
1. Absent abdominal mm
2. Severe urinary tract malformations
3. Bilateral cryptochidism (Undescended testis)

Neurofibromatosis type I (von Recklinghausen’s Disease)
• AD, affected chromosome: 17🧬
• Dx: >=2 of the following:
1. More than 5 cafe-au-lait patches >1.5 cm in adults or >0.5 cm in <5 yo☕️
2. Axillary/inguinal freckling
3. Neurofibromas (benign peripheral nerve tumors)
4. Iris hamartoma (Lisch nodules)👁️
5. Optic gliomaa👁️
6. Distinctive bony lesion🦴
7. First degree relative w neurofibromatosis type I

Neurofibromatosis type II
• AD, Affected chromosome: 22🧬

Rett Syndrome
• X-linked gene mutation in methyl-CpG binding protein 2 gene (MECP2)🧬
• Affects girls (if a boy is affected, he dies shortly after birth)
• Features:
- Acquired Microcephaly
- Loss of language skills
- Stereotypical “Hand-washing” movements

Noonan Syndrome
• AD, normal karyotype🧬
• Resembles turner syndrome: Webbed neck, Shield-like chest🛡️
• Other features:
- Learning difficulty 🧠
- Prctus excavatum🫁
- Cardiac (Pulmonary valve stenosis, ASD)🫀
- Ocular hypertelorism (distant eyes) 👁️ 👁️

Maple Syrup Urine Disease
• AR🧬
• Defect in alpha ketoacid dehydrogenase complex-> accumulation of Leucine, isoleucin, and valine amino acids in plasma
• Features:
CNS: seizures🧠
Renal: Burnt sugar/maple syrup urine odor
Metabolic: Hypoglycemia 📉

Galactosemia
• AR defect in Galactose 1-phosphate uridyltransferase🧬
• Features:
- Hypoglycemia, glycosuria
- Jaundice🟡
- Acidosis🍋
- Cataract👁️
• Cx: increased risk of E. Coli sepsis⚠️

Fragile X Syndrome
• X-linked
• Features:
- Macrocephaly
- Macroorchidism (enlarged testes)
- Long face
- Large everted ears
- Hypermobile joints
- Intellectual disability
X -> XL (x large)

Tuberous Sclerosis
• Dx -> Single-gene testing
• Mother tested positive -> Targeted testing for familial variant

#Neonatology 👩‍🍼

Apgar Score
Points: 0, 1, 2
1. HR🫀: None, <100, >100
2. Respiration🫁: None, Shallow/Irregular/Gasps, Crying😭
3. Color: Blue🔵, Pale/Blue extremities, Pink
4. Tone: None, Weak/Passive, Active
5. Reflex irritability: None, Grimace, Active withdrawal

5-min apgar score:
Reassuring: 7-10
Moderately normal: 4-6
Low: 0-3

Neonatal Soft Tissue Injuries
Mostly caused by vaccum/forceps delivery
• Head molding: elongated head shape
• Caput succedaneum: benign edema extends accrods cranial suture lines
• Cephalohematoma: subperiosteal hematoma that is limited to cranial suture lines
• Subgaleal hemorrhage: rupture of emissary veins

Respiratory Distress in Newborns 🫁

Preterm
<6 hr: Respiratory distress syndrome RDS (Hyaline membrane disease HDM) -> Prevented by prenatal CS💊
>6 hr: Pneumonia

Term
<6 hr:
- Transient Tachypnea of Newborn TTN -> RF: C-section, Xray shows horizontal streaking “Wet silhouette”🩻💦
- Mecpnium Aspiration Syndrome MAS -> Nitric/nitrous oxide in severe cases
- Persistent pulmonary HTN of the newborn PPHN -> Nitric/nitrous Oxide (Hint: They will give pre- and post-ductal oxygen in the question)
>6 hr: Pneumonia

Neonatal Polycythemia 🩸🩸🩸
• Excessively high hematocrit (Hct >=65%) or Hb >=22📈
• Sx: Ruddy appearance🔴, respiratory distress🫁, acrocyanosis🔵, seizures🧠
• Mx
- Symptomatic -> Partial Exchange Transfusion PET
- Asymptomatic:
Hct 60-70%: observation, aggressive hydration
Hct >70%: PET
• Cx: Hypoglycemia

Congenital Diaphragmatic Hernia
• Sx: cyanosis at birth🔵, bowel sounds in the chest & unilateral absence of breath sounds🩺🫁, Scaphoid Abdomen
• Dx:
- Prenatal: US
- Postnatal: CXR🩻
• Mx:
Intubate -> NGT -> Stabilize -> Surgical correction

Neonatal Hypoglycemia
• Glucose <2.6 mmol or <45 mg
• Sx: Asymptomatic or lathergy, hypotonia, hypothermia, bradycardia
• Mx:
Asymptomatic -> Breastfeeding🤱
Symptomatic-> High conc. glucose up to 20% through central line (cuz peripheral line max is 12.5%)

Neonatal Jaundice🟡

• Types of bilirubin:
Unconjugated (Indirect):
- Lipid soluble
- cross BBB (can cause Kernicterus)
- no urine excretion
- Can cause physiologic vs pathologic
Conjugated (Direct):
- Water soluble 💧
- can’t cross BBB (doesn’t cause Kernicterus)
- Urinary excretion
- Causes only pathologic jaundice

• Kernicterus:
- unconjugated bilirubin crosses BBB causing accumulation in basal ganglia and brain stem
- Sx: hypotonia, siezure, sensorineural hearing loss👂

• Physiologic vs Pathologic Jaundice
Physiologic:
- Onset 1-7 d
- Peak bilirubin <13 mg
- Bilirubin rise <5 mg/day
Pathologic:
- Onset <24 h (except in biliary atresia)
- Bilirubin rise >5 mg/day

• Breast-Feeding vs Breast-Milk Jaundice
- Breast-feeding🤱: baby isn’t nursing well and not getting enough calories
- Breast-milk🥛: due to a glucoronidase present in some breast milk

Jaundice due to Biliary Atresia
• Patho: extrahepatic bile duct fibrosis
• Infants age 2-8 w
• Dx:
- Labs: ⬆️Conjugated bilirubin, Gamma glutamyl transpeptidase
- Initial test -> RUQ US
- Gold standard -> Intraoperative cholangiography
• Mx:
- Palliative -> Kasai procedure
- Definitive -> Liver transplant

Hirschprung Disease vs Meconium ileus

Hirschprung Disease
• Associated disorder: Down syndrome
• Sx: chronic constipation, Positive Squirt sign (Expulsion of stool after DRE💩), Empty rectum on DRE
• Level of obstruction: Rectosigmoid
• Dx:
- Initial -> Xray
- Confirm -> Rectal biopsy (no ganglion cells)
• Mx:
- Staged surgery:
First: diverting colostomy
Second: resection & anastomoses

Meconium ileus
• Intestinal obstruction due to failure of passing Meconium
• Associated disorder: Cystic fibrosis
• Level of obstruction: Ileum
• Mx: Enema w contrast 💩(surgery in perforation or volvulus)

#Neonatology 👩‍🍼

Bilious Emesis in Neonate🤮
1) Stop feeds, NGT decompression, IV fluids
2) Abdominal Xray:

Double bubble sign: Duodenal atresia

Dilated loops of bowel -> Contrast enema:
- Microcolon: Meconium ileus
- Rectosigmoid transition zone: Hirschsprung disease

NGT is misplaced in duodenum -> Upper GI series:
- Ligament of Treitz on the Rt side of abdomen: Malrotation


Intussusception
• A proximal part of the bowel invaginated into a distal part leading to obstruction and ischemia
• Peak incidence: 3-12 mo
• RF: Recent viral illness/Rotavirus vaccine
• Sx:
1. Intermittent abdominal pain
2. Red Jelly stool
3. Palapable RUQ Saudage-shaped abdominal mass🌭
• Dx:
- Initially -> US: Target sign🎯(Doughnut), Lead point
- Gold standard -> Contrast barium enema (therapeutic too)
• Most common location: Ileocecal
• Most common location in HSP: Ileoileal
• Mx:
- IV fluids & NGT decompression
- Pneumatic/hydrostatic (Air or saline) enema
- Sugery: Pathological Lead point, gangrene, perforation, or shock

Pyloric Stenosis
• RF: First-born, Eythromycin, Bottle-feeding🍼
• Sx: Projectile nonbilious emesis immediately after feeding, Olive-shaped abdominal mass🫒, non-tender
• Dx:
- US
- Labs: Hypochloremic metabolic alkalosis
• Mx:
1) IV bolus NS then 1/2 NS + Dextrose + KCl
2) Ramstedt Pyloromyotomy

Appendicitis
• Most common surgical emergency in childhood🚨

Necrotizing Enterocolitis NEC
• Most common cause of acute abdomen in premature infants 👶
• RF: prematurity, enteral feeding, birth wt <1.5 kg
• Sx: abdominal distention & erythema, bloody stool🩸💩
• Dx: Xray:
- Pneumatosis intestinalis (intramural gas w distended bowel)💨
- Portal venous gas💨
- Pneumoperitoneum💨
• Mx:
- Bowel rest, Abx, +/- surgery

Congenital Adrenal Hyperplasia
• Types:
21β-hydroxylase deficiency (Most common)
11β-hydroxylase deficiency
17α-hydroxylase deficiency

21β-hydroxylase deficiency
• Sx at age 1-2 w
• Sx:
- Ambiguous genitalia in girls (enlarged clitoris)
- Salt-wasting syndrome: Hypotension, dehydration, vomiting
• Dx: ⬆️K, ⬇️Glucose & Na
• Tx:
- Glucocorticoids & Mineralcorticoids
- Adrenal crisis🚨-> Cortisone + IV fluid + Dextrose

Neonatal Clavicular Fracture 🦴
• RF: macrosomia, instrumental delivery, shoulder dystocia
• Sx: Asymmetric moro reflex
• Dx: Xray
• Mx:
- Reassurance, gentle handling, analgesics
- Long-sleeved garment & pin sleeve to chest w elbow flexed at 90 degrees

Infantile Botulism
• Etiology: Clostridium botulinum (soil or contaminated honey🍯 )
• Sx: constipation, hypotonia, ptosis (inability to smile)
• Tx: IV human botulism immune globulin

#ENT👂 #Pulmonology 🫁

Laryngomalacia
• Collapse of supraglottic tissues on inspirations
• Sx: Inspiratory stridor worse when supine
• Peak at 4-8 mo
• Dx: Laryngoscopy -> Omega-shaped epiglottis
• Mx:
- Reassurance (will improve in 1 yo and resolves in 2 yo)
- Severe -> Supraglottoplasty

Tracheomalacia
• Weakening of the tracheal rings that lead to collapse w forced expiration or cough
• Sx: Expiratory stridor, Barking cough🐶, Noisy breathing
• Excacebated by viral infections
• Dx: Flexible bronchoscopy
• Mx
- Mild -> No intervention (will improve)
- Severe -> Tracheostomy for CPAP
• Resolves by 2 yo

Croup (Larngotracheobronchitis)🦠
• Organism: Parainfluenza
• Age: 6 mo-3 y
• Sx: Inspiratory stridor, Barking cough🐶, Hoarseness
• Dx: Xray -> Steeple sign
• Mx
- All patients: Dexamethasone
- Moderate/severe (stridor, dyspnea)-> Add Nebulized epinephrine, Intubate if necessary
• Discharge criteria:
- No stridor at rest
- Tolerate orally🥛
- Normal oximetry
- Good air exchange💨
- Normal color, consciousness👶

Epiglottitis⚠️
• Organism: Haemophilus influenza type b (Hib)
• Sx:
- Distress: Tripod position, Sniffing position, Stridor
- Dysphagia, dysphonia
- Drooling 🤤
- High fever🤒
• Dx: Xray -> Thumb sign👍
• Mx:
- Endotracheal intubation
- IV Abx

Bacterial Tracheitis
• Organism: Staph. Aureus
• Sx: ill-looking, high fever, productive cough, hoarseness, sore throat
• Dx: Bronchoscopy
• Mx: IV abx, respiratory support

Bronchiolitis🦠
• Organism: RSV
• Age: <2 y
• Sx: nasal congestion/discharge🤧, cough, Wheezing/crackles🫁, low-grade fever
• Mx: Supportive care and hydration
• Admission indications:
- Inadequate oral intake
- Toxic appearing child
- Hx of apneic episodes
• Cx: Apnea, Respiratory Failure (⚠️esp in <2 mo)
• Prevention in selected infants by Palivilizumab

Hearing Loss👂
• Major cause of conductive hearing loss CHL in children -> Otitis media OM w effusion (Glue ear)
• Most common cause for congenital non-genetic cause for sensorineural hearing loss SNHL in the developed world -> CMV

• Rinne & Weber Tests
Rinne
Normal and SNHL: +test (AC > BC both ears)
CHL: -test (BC > AC in affected ear)
Weber
Normal: Midline
CHL: Lateralize to affected ear
SNHL: Lateralize to unaffected ear

Acute Otitis Media AOM 👂🤒
• Caused by bacterial superinfection following a viral URTI
• Organisms: Strept. Pneumoniae, H. Influenza, or Moraxella catarrhalis
• Age: common in <2 y
• Sx: otalgia, fever, anorexia, bulging TM
• RF: Bottle feeding🍼, Inadequate breastfeeding, Pacifier use, Passive smoking🚬 , Day care centers, Poor socioeconomic
• Cx:
- Mastoiditis -> CT temporal bone
- TM perforation
- CHL
- Meningitis
• Mx:
Antibiotics indications:
- <6 mo
- Moderate-severe ill
- Fevere >= 39
- Sx >= 48 h
Antibiotics choice:
- 1st line: Amoxicillin (10 d in 6 mo-2 y, 5 d >=2 y)
- Recurrent in less than 30 d or refractory sx: Augmentin
- >3 episodes in 6 mo or persistent sx for >3 mo: Tympanocentesis w culture

Otitis Externa👂
• Organism: Pseudomonas aeruginosa
• RF: Water exposure, trauma
• Sx: Pain with auricle manipulation, erythrma, edema, debris
• Mx:
- Topical Neomycin + Polymyxin + Hydrocortisone (C/I in TM perforation)
- In TM perforation -> Ciprofloxacin + Dexamethasone + Ofloxacin

Foreign body aspiration 🥜
• Nuts🥜, seeds, small toys
• Age: 1-3 y
• Most common location: Rt bronchus
• Sx: wheezing, stridor, focal area of diminished brath sounds, sudden-onset cough, dyspnea, cyanosis
• Dx: Xray🩻
• Mx:
- Rigid bronchoscopy
- Small blunt object ingested in the stomach -> Observe

Cystic Fibrosis CF
• AR Mutation in CFTR gene🧬 that results in defective Chloride channels
• Sx: recurrent sinopulmonary infections, intestinal obstruction (Meconium ileus), Pancreatic insufficiency, DM, Male infertility
• Dx:
Criteria:
- Sweat chloride >=60 mmol on two occasions
- OR CFTR gene mutation
- OR abnormal nasal potential difference test
• DD:
Kartagener Syndrome:
- AR
- Sx: Triad of Situs inversus (visceral organs in opposite direction), Chronic sinusitis👃, Bronchiectasis🫁. Infertility in males due to immotile sperms.

#ID 🦠🤒

Meningitis🤒
• Sx: fever, neck stiffness, photophobia, altered mental status/sensorium (HSV), +Kerning, +Brudiznski sign

• Percaution: Droplet💧(TB is airborne😷)

• Organisms:
- Bacterial:
Adults/children:
- Streptococcus pneumoniae (most common)
- N. meningitidis (Meningococcal Meningitis; presents w petechiae/purpura)
^Tx: Ceftriaxone + Vacomycin
Neonates (0-28 d)👶:
- GBS
- Listeria Monocytogenus (Gram +ve rods/coccubacilus, extreme age, pregnant, immunocompromised, DM)
^Tx: Ampicillin + Cefotaxime

- HSV (altered sensorium, affected temporal area on imaging, aphasia)
- Naegleria fowleri (in Rivers)
- Cryptococcus (immunocompromised like HIV)
- Psudomonas aeruginosa (Hospital-acquired, post-op)

• Dx: LP (after ruling out increased ICP: if open bulging any fontanelle -> do LP, if closed fontanelle -> CT first)

CSF analysis:
Bacterial
- Glucose: Low
- Predominating cell: Neutrophils
- Protein: N/High
Viral
- Glucose: N
- Predominating cell: Lymphocytes
- Protein: N
TB, Cryptococcus:
- Glucose: Low
- Predominating cell: Lymphocytes
- Protein: N/High

Mx:
• Bacterial: IV Ceftriaxone + IV Vancomycin + IV Dexamethasone
- Listeria: IV Ampicillin
- Pseudomonas: IV vancomycin + IV Ceftazidime/Cefepime/Meropenem

• Viral: supportive
- Viral encephalitis (altered mental status, altered sensorium): IV Acyclovir

• Prophylaxis for contacts:
Rifampin: 4 doses in 2 days or
Ciprofloxacin PO: Single dose or
Ceftriaxone IM: Single dose

Cx of meningitis:
- Hearing loss👂❌
- Vision loss👁️❌

• DDx of meningitis: Poliomyelitis:
- Manifests w flu-like sx 🤧 and neurological sx🧠
- “Came back from Africa” -> Poilovirus

Fever of Unknown Origin FUO
• Children: Fever for >=14 d w/o identified etiology despite intense evaluation
• Adults: T >=38 on multiple occasions for >=3 w

Oral Herpes
• Pathogen: HSV
• Prodrome: fever, malaise
• Sx: lesions on: perioral skin and oral mucosa, especially on the inner cheek, soft palate, and tongue, tonsils and posterior pharynx

Infectious Mononucleosis
• Pathogen: EBV
• Sx: Fever, tonsillitis/pharyngitis, lymphadenopathy
• Dx: Transient heptitis
• Mx: Avoid sports for >=3 w (contact sports >=4 w) due to the risk of splenic rupture
⚠️Pt who develops rash following Amoxicillin for pharyngitis -> Infectious Mononucleosis

Pertussis
• Pathogen: Bordetella Pertussis
• Transmission: Droplet 💧
• Sx: Cough, Inspiratory whoop, posttusive vomiting
• Dx: Culture or PCR
• Mx: Macrolides (Azithromycin)
• Primary prevention: Acellular pertussis vaccine 💉 (needs booster vaccine after 10 y)
• Post exposure prophylaxis: Macrolides (Azithromycin, Clindamycin)
^Avoid Macrolides in congenital QT syndrome⚠️


Pediatric Infectious Rash

Fifth disease (Erythema infectiosum)
• Pathogen: Parovirus B19
• Rash: Slapped cheek appearance 👋

Measles
• Pathogen: Paramyxovirus
• Prodromal phase: 4C
- Cough 😷
- Coryza (rhinitis👃)
- Conjunctivitis 👁️
- Coplik (Koplic) Spots (white-gray spots on buccal mucosa👄)
• Rash: Starts in the head, spreads to the toes

Rubella
• Pathogen: Togavirus
• Prodrome:
- Lymphadenopathy
- Forchheimer sign (Enathem (spots) of the soft palate)
- Arthralgia🦴
• Rash: Starts in the head spreads to the toes. Faster and fainter
• Congenital Rubella: Triad 3C:
Cardiac defect
Cataracts
Choclear defect

Roseola Infantum
• Pathogen: Human herpes virus 6 HHV6
• Sx: High fever, Nagayama Spots (on uvula)
• Rash: Starts centrally

Varicella (Chickenpox)
• Pathogen: Varicella-zoster virus/Human herpes virus 3 HHV3
• Rash: Vesicles in different stages

Mumps
• Parotid swelling, ⬆️Amylase
• Most common organ affected by Mumps: Parotid

Hand Foot and Mouth disease ✋️🦶👄
• Pathogen: Coxsackie A Virus
• Vesicles on ✋️🦶👄
• Coxackie A virus can also cause Herpangina (painful vesicles over soft palate and posterior pharynx, fever)

Scarlet Fever
• Pathogen: Group A Streptococcus/Streptococcus pyrogenes
• Sx: Tonsillopharyngitis, Strawberry tongue 👅 🍓, Fever, Tender anterior cervical LNs
• Rash: Sandpaper-like
• Mx: Amoxicillinh

#ID 🦠🤒

Infectious Gastroenteritis GE
• Causes: Viruses (common), Bacteria, Parasites
• Transmission: fecal-oral, foodborne, waterborne
• Sx: abdominal pain, diarrhea, vomiting
• Norovirus and rotavirus are common in out-breaks
• Time btw food ingestion and GE sx:⏳
1-6 h > Staph. aureus
12-48 h > Salmonella, E. coli
48-72 > Shigella, Campylobacter
>7 d > Giardiasis, amoebiasis

• Types of Bacterial GE:

Watery diarrhea💦
- Bacillus cereus (rice)
- Enterotoxigenic E. Coli ETEC (recent travel)
- Clostridium perfrings
- Staphylococcus aureus
- Vibrio cholerae (profuse diarrhea)
- Clostridium difficile (used Abx)

Bloody diarrhea🩸
- Enterohemorrhagic E. Coli EHEC (trigger HUS)
- Clostridium difficile (recent Abx use)
- Shigella (trigger HUS)
- Amoebiasis (w mucous)

• Dx:
- Clinical
- Stool culture for Shigella, Salmonella, Campylobacter, Yersinia, Shiga toxin E. Coli
- Stool microscopy for ova/parasites

• Mx:
- Supportive tx: diet & fluid, antiemtics (ondastron), antimotility for acute diarrhea (loperamide)
- Abx (Azithromycin or Ciprofloxacin), indications:
- Shigella
- Severe GE, sepsis
^Abx is C/I in EHEC
- C. diff > PO Fidaxomicin or PO/IV Vancomycin (if not available -> Metronidazole)
^Fifaxomicin can ONLY be given orally (no IV)

• Cx:
- Cambylobacter > GBS, reactive arthritis
- Shigella, EHEC > HUS
- Cholera > severe dehydration

• Most common cause of dehydration in children -> GE

Amebiasis
• Organism: Entamoeba histolytica
• Sx: Bloody diarrhea, tenesmus, fever
• Tx: Metronidazole
• Types:
- Intestinal amebiasis
- Extra-intestinal amebiasis (Liver)

Streptococcus Infection (Group A streptococcus GAS)
S. PyAGINES
Pharyngitis
Acute rheumatic fever
Glomerulonephritis (poststrept)
Impetigo
Necrotizing fasciitis
Erysipelas
Scarlet fever

Pharyngitis
• Centor citeria for pharyngitis (3 required):
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy
- Fever 🤒
- Absence of cough
• Dx:
- Rapid antigen detection test
- Confirm > Throat culture
• Tx: Pencillin V

Acute Rheumtic Fever
• Jones Criteria:
2 major OR 1 major + 2 minor
Major:
- Polyarthritis🦴🦴
- Carditis🫀🔥(most common affected valve is mitral regurgitation)
- Syndenham chorea (involuntary limbs movements)
- Subcutaneous nodules
- Erythema marginatum (rash)
Minor:
- Polyarthalagia
- Fever
- ⬆️ESR or CRP
- Prolonged PR
• Confirm:
- ⬆️Antistreptolysin O Titer ASO
- ⬆️ADB
• Mx: First line: Pencillin V
- Main: High dose oral acetyl salicylic acid
• Secondary prevention w Abx (choose the longer duration)
- Uncomplicated -> 5 y or until 21 yo
- Carditis, no valvular dis. -> 10 y or until 21 yo
- Carditis + Valvular dis -> 10 y or until 40 yo

Scarlet Fever
• Sx: sandpaper-like rash, pharyngeal erythema, strawberry tongue🍓
• Mx: Penicillin V

• C. diff is associated w Omprazole use

Tuberculosis TB😷
• Transmission: Airborne⚠️ if active

• Dx: PPD >=10 mm for children <4 yo
- Screening: PPD or IGRA (if + do CXR, if CXR Normal it’s latent, if there’s cavitation it’s active)
- Sputum AFB (Acid Fast Bacilli)
- CXR in active TB🩻: upper lobe cavity
• PPD results for TB:
>=5 mm
- HIV, recent contact w active TB😷, CXR changes🩻, transplant
>=10 mm
- Recent travel from endemic area🇮🇳, IVDU💉, Healthcare👩‍⚕️, Comorbid🤕, Children 👧 <4 y
>=15 mm
- Normal population

Diphtheria
• Organism: Crynebacterium diphtheriae
• Transmission: Droplet💧
• Pathophysiology: exotoxin-induxed intracellular protein ribosylationy
• Sx: Malaise, fever, sore throat, grayish-white psuedomembrane over tonsils/posterior pharyngeal wall, cervical lymphadenopathy (Bull neck)
• Cx: Myocarditis, acute tubular necrosis, polyneuropathy
• Dx: Culture, Elek test
• Mx: Isolation, Abx (Pencillin G), Diphtheria antitoxin

Reye Syndrome
• Caused by using aspirin in children w influenza or varicella
• Can lead to Acute liver failure & Encephalopathy 🧠

#Cardiology 🫀

Congenital Heart Diseases

💙Cyanotic Heart Diseases💙
(R -> L), 5 Ts
- Truncus Arteriosus
- Transposition of great vessels
- Tricuspid atresia
- Total anomalous pulmonary vascular return
- Teratology of Fallot TOF:


Tetralogy of Fallot TOF:
1. Rt ventricular ouflow obstruction 🚫
2. Rt ventricular hypertrophy
3. Ventricular septal defect VSD
4. Overriding aorta
• Dx: Xray🩻: Boot 🥾
• Mx of Tet Spells (hypercyanotic, hypoxic episodes):
- O2, Squatting, Sedation
- No improvement -> Fluid, Beta blockers

❤️Acyanotic Heart Diseases❤️
(L -> R)
- ASD
- VSD
- Patent ductus arteriosus PDA
- Coarctation of Aorta CoA

CoA
• Common in turner syndrome
• Dx: Different pulse btw upper and lower limbs
• DDx: Aortic dissection: different pulse btw both arms
• Mx:
<4 mo: Surgical repair
>=4 mo: Balloon angioplasty🎈

AVSD
• Mx:
Initial -> Medical
Definitive -> Surgery at 3-6 mo

• Infants w congenital heart diseases require more nutrition
• Xray:🩻
- Egg on string🥚-> Transposition of great vv
- Boot shape 🥾-> TOF
- Rib notching -> CoA
• Mx of cyanosed neonate👶:
1. ABC
2. Prostaglandin to keep the duct open

Murmurs🩺👶
• VSD: Harsh holosystolic murmur over left sternal border
• ASD: Wide fixed splitting of S2
• Endocardial cushion defect ECD/AVSD: Wider fixed split S2 + apical harsh holosystolic murmur radiating to left axilla
• PDA: Continuous machine-like murmur🚜
• TOF: VSD murmur, Harsh pulmonic stenosis murmur
• Still’s Murmur:
- Most common innocent murmur in children 😇
- Commonly at 3-5 yo
- Change w different positions
- Pt is asymptomatic

Hypertrophic Obstructive Cardiomyopathy HOCM
• Congenital heart disease
• Sx: recurrent exertional chest pain and syncope in youg pt, Ejection systolic murmur
• Mx:
First line > BB
Second > CCB
• Hx of sudden cardiac arrest in young family member while walking🚶‍♂️☠️-> HOCM

HTN
• Diagnosing a child w HTN requires BP readings above 95th percentile

#GI 🍜

Celiac Disease
• Autoimmune disease causing malabsorption
• Sx: Diarrhea, Steatorrhea, Abdominal bloating, N&V, Loss of subcutaneous fat, Dermatological (Dermtitis herpetiformis)
• Dx:
- Serology: IgA Tissue Transglutaminase Antibody (tTG IgA), or Anti-endomysial antibody (2nd line)
- Confirmatory > EGD w Small Intestine Biopsy

Eosinophilic Esophagitis
• Chronic immune-mediated esophageal inflammation
• Associated w Atopy (Asthma, rhinitis, atopic dermtitis)
• Sx: Dysphagia (compensated by excessive chewing), reflux, chest pain
• Dx: Endoscopy & biopsy
• Mx:
- First line: PPIs
- Second: Topical steroids
- Dietary modifications

Sandifer Syndrome
• Movement disorder characterized by torticollis & arching of the spine
• Associated w GERD & Hiatal hernia

Lactose intolerance
• Dx -> Hydrogen breath test

#Neurology 🧠

Febrile Siezure🤒
• Siezure + Fever (>=38) in 6 mo-5 yo
• Simple vs Complex
- Simple (one of the following):
<15 min
Generalized tonic-clonic
No recurrence in 24 hr
- Complex (one of the following):
>15 min
Focal onset
Recur in 24 hr
• Mx:
- If >=5 min: Abortive tx (IV lorazepam)
- Antipyretics
- Reassurance

Rolandic Epilepsy (Benign Epilepsy w Centrotemporal Spikes)
• Most common form of benign epilepsy in children
• Sx: usually during sleep 😴, facial twitching and numbness
• Dx: EEG: Centrotemporal Spikes
• Mx:
- Anticonvulsants are only recommended in high frequency/severity

Infantile Spasms (West Syndrome)
• Sx: Multiple neck flexion followed by neck extension
• EEG: Very heterogeneous, hypsarrhythmia
Tx: ACTH, Steroid

Status Epilepticus
• Mx:
1. IV lorazepam (given again if no response) or IV/Rectal diazepam or Buccal midazolam
2. IV phenytoin (recurrent in ER > Fosphenytoin)
3. General anesthesia
• Absence seizure > Ethosuximide
• Generalized epilepsy > Sodium valporate

Guillian Barre Syndrome GBS
• Sx:
- Acute ascending areflexic paralysis and parasthesia
- Hx of URTI/GI inf (Cambylobacter jeujeni)
• Dx: clinically
• Mx: 1. IVIG or 2. Plasma exchange
• Excellent prognosis w full recovery ❤️‍🩹
• To monitor ventilatory impairment🫁 -> Bedside measurement of vital capacity

Cerebral Palsy
• Heterogeneous group of disorders affecting muscle tone and the development of movement and posture, non-progressive
• RF:
- Birth wt <1.5 kg
- Prematurity⚠️
- TORCH infection
• Red flags
🚩 Definite hand preference before 1 yo
🚩Persistent moro reflex (>6 mo)
• Types:
- Spastic (75%): Can result in hemiplagia (one side of the body), diplegia (both legs 🦵), quadriplegia (all limbs)
- Dyskinetic/Athentoid (Basal ganglia affected, maybe associated w kernicterus)
- Ataxic

Duchenne Muscular Dystrophy
• Type of Progressive Muscular Dystrophies
• X-linked recessive disorder
• Screening: Creatinine kinase
• Sx: Calf pseudohypertrophy, Grower maneuver (pt supports himself on his thighs and uses his hands to walk up his body until he’s standing)

#Hematology 🩸

IDA
• Screening for anemia:
- W/o risk factors -> At 12 mo
- W risk factors (Prematurity, LBW) -> At birth and 4 mo
• Primary causes of IDA in pediatrics -> Dietary issues
• Exclusively breastfeeding 🤱-> Iron supplements should be given from 4 mo
• No cow milk 🐮 in the first year of life
• Physiologic anemia:
- Term: 2-3 mo
- Preterm: 1-2 mo

Sickle Cell Anemia
• AR, Hallmarks in SCD is Vaso-occlusive phenomena, Hemolytic anemia
• Dx:
- Markers of hemolysis: high indirect hyperbilirubinemia, LDH, AST, reticulocyte
- Peripheral boold film: Sickle cell, Howell-Jolly body, Target cell
- Confirm: Hb electrophoresis

• Mx:
- Hydroxyurea: prevent cx (vaso-occlusive crises) by inc HbF
- Vaccines: pneumococcal, meningococcal, Hemophilus influenza type b
- Daily pencillin prophylaxis (until 5 y)

• Cx:

Acute:

Painful episode
- Triggered by: inf, dehydration, cold weather, high altitude
- Site: legs, arms, back
- Mx: Regydration & Pain management, If fever: Abx

Acute Chest Syndrome ACS
- Sx: fever, chest pain, hypoxemia, wheezing, cough, new pulmonary infiltrate
- Mx: broad spectrum Abx, Transfusion

Aplastic crisis
- Arrest of erythropoiesis
- Dx: dec reticulocytes, Acute drop of Hb
- Organism: Parovirus B-19

Splenic Squestration Crisis
- Life-threatening
- Dx: Acute drop of Hb typically two below baseline, reticulocytosis

Chronic:
- Stroke
- Renal impairment & HTN
- Pigmented gallstones

Hereditary Spherocytosis
- AD
- Family hx of gallbladder stone/Splenectomy
- Can presents as neonatal jaundice
Dx:
- Blood film: Spherocytes
- Gold standard: Erosin 5 Malemide (EMA) binding test
- Osmotic fragility test
- To differentiate from AHA: Coombs test (negative)
Tx:
- EPO, iron and folate
- Splenectomy (curative)

Hemophilia (A&B)
• A: Vlll, B: lX, X-linked
• Sx:
- Hemarthrosis (knee)
- Intracranial bleeding
- IM/Retroperitoneal hematoma
- Hematuria, hemospermia
• Dx:
- Prolonged aPTT
- Normal PT, thrombin time, bleeding time

Infantile Vitamin K-Deficient Bleeding
• Sx: presents at 2-7 d of life, easy bruising, umbilical/mucosal/GI bleeding, Intracranial hemorrhage
• Dx: prolonged PT
• Tx:
- IV vit K
- Unstavle -> FFP
• Prevention: IM vit K at birth
• Vit K dependent factors: II, VII, IX, X (2,7,9,10)

Immune Thrombocytopenia Purpra ITP
- Superficial bleeding, can be preceded by viral inf
- Dx: isolated thrombocytopenia (<100,000)
- Tx:
Cutaneous sx only -> Observe
Bleeding -> CS, IVIG, or Anti-D
- Tx in adults:
No bleeding, Plt 50,000-30,000 -> No tx
Minor bleeding, Plt 50,000-30,000 -> CS (prendnisone)
Severe bleeding or Plt less than 10,000 -> IVIG or Anti-Rho (anti-D)
Recurrent/Failed -> Splenectomy

Thrombotic Thrombocytopenic Purpura TTP
• Severe deficiency in ADAMTS13
• Sx: fever, neurological sx
• Dx:
CBC:
- Thrombocytopenia
- Low Hb
- Film: schistocytes (Microangiopathic hemolytic anemia)
Hemolysis:
- High reticulocytes
- High LDH
- Low Haptoglobin
Coagulation profile
- Normal/mildly prolonged PT, aPTT
- Normal/mildly elevated D-dimer
Liver chemistry
- High indirect bilirubin
BMP
- High BUN, Cr
Urinalysis
- Hematuria, proteinuria
• Tx: Plasma Exchange


Hemolytic Uremic Syndrome HUS
• Causes: E. Coli (O157:H7, O104:H4)
• Sx: Renal impairment
• Dx:
- Thrombocytopenia
- Film: schistocytes (Microangiopathic hemolytic anemia)
- AKI: ⬆️BUN and Cr
• Tx:
- Typical HUS > Supportive
- Atypical HUS > Eculizumab (causes fulminant meningococcal inf, screen for vaccin.)
⚠️Abx are C/I -> Injury to bacterial wall releasing large anounts of toxins!

#Nephrology

UTI
• RF:
- Females
- Uncircumcised boys
- Fever >=39
- Nitrate
- Age <12 mo
- Duration >=48 hr
- Vesicouretral reflux
- Constipation
• Sx: Fever, poor feeding, dec urine output
• Tx:
Mild sx (cystitis):
- Oral amoxicillin
- TMP/SMX
- Nitrofurantoin
Unstable UTI or Pyelonephritis:
- Inability to tolerate oral -> IV Ceftriaxone, Cefepime, or Ceftaxime

• Indications for Imaging:

Renal US
- First febrile UTI in <2 yo
- Recurrent febrile UTI
- UTI + Family hx of renal disease, poor growth, or HTN
- Not responsive to Abx

Voiding Cystourethrogram (look for vesicuretral reflux)
- Child <6 mo w recurrent UTI, atypical UTI, or UTI + US showing hydronephrosis
- Child 6 mo - 3 yo w atypical UTI or US showing hydronephrosis

Renal Scintiography (DMSA scan)
- To detect acute pyelonephritis and renal scarring

Glomerular Diseases

Nephrotic vs Nephritic syndrome
Sx:
• Nephrotic: generalized edema and peri-orbital edema
• Nephritic: HTN
Dx:
• Protein in 24 h urine:
- Nephrotic >3.5 gm
- Nephritic <3.5 gm
• Urine cast:
- Nephrotic: Fatty cast🟡
- Nephrtitic: RBCs cast🔴
• Hyperlipidemia and hypoalbuminemia
- Nephrotic: Yes
- Nephritic: No

Diseases in Pediatrics
Nephrotic Syndrome:
Minimal change disease
- Common in children👧
- Tx: steroid
- Confirm remission -> Urine dipstick negative or trace for 3 consecutive days

Nephritic Sybdrome:
Post-streptococcal glomerulonephritis PSGN
- 10 d after the infection
- Has Low C3

IgA nephropathy/Burger’s disease
- Presents within 3 d of URTI🤧

Alport syndrome
- Hearing loss👂❌, ocular :
findings👁️, +family hx of ESRD
- Cause: defect in collagen type 4

Primary Nocturnal Enuresis
• Urinary incontinence in >5 yo
• Caused by destrusor overactivity/instability
• Dx: >2 times per week for 3 mo in >5 yo patient
- Urinalysis to R/O other causes
• Mx:
- Lifestyle changes (minimize fluid intake before bed, void before bed, reward system like gold star chart)
- Enuresis alarm ⏰
- Desmopressin tx
• Bed-wetting is Normal behavior until 6 yo

Prevent progression of Nephrotic Syndrome -> Enalapril

Steroid resistant nephrotic syndrome is the Inability to induce a remission within 4 weeks of daily steroid therapy