#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

#Endocrinology 🍰🍭

T1DM:
• Autoimmune
• Screen for celiac disease at diagnosis, every 2 y
• Screen for microvascular cx: after 5 y
• Tx: Full bolus insulin regimen w once-daily insulin glargine
- Honeymoon period: hypoglycemia attacks when the pt first start insulin

DKA
• Diagnostic Criteria:
- Glucose >200 mg (11.1 mmol)
- pH 7.3
- Ketones in urine or serum
• Mx:
- Fluid & electrolyte tx💦
- Gradual decline in glucose (to minimize the risk of cerebral edema)💦🧠
- Potassium repletion:
Hyperkalemia -> K not given
Normokalemia -> Give K w insulin
Hypokalemia -> Give K before insulin⚠️
- Insulin: regular insulin, continuous infusion of 0.1 U/kg/hr

Normal Puberty
Female: Onset 8-13 yo
1. Thelarche
2. Pubarche
3. Growth spurt
4. Menarche (mean: 12.5 yo)

Male: Onset 9-14 yo
1. Testicular enlargement
2. Penile enlargement
3. Pubarche
4. Growth spurt

Approach to precocious puberty
Early secondary sexual development: (F <8 yo, M <9 yo)

Bone age: 🦴

1. Advanced Bone Age:
• Low basal LH -> GnRH stimulation test:
- Low LH: Peripheral precocious puberty
- High LH: Central precocious puberty (Brain MRI)🧠
• High basal LH: Central precocious puberty (Brain MRI)🧠

2. Normal bone age
• Isolated breast development: Premature thelarche (Pelvic US)
• Isolated pubic hair development: Premature adrenarche (test DHEA) 💉


Nutritional Rickets (Vit D def)
• RF: exclusive breastfeeding 🤱, inadequate sun exposure☀️
• Sx:
- Craniotabes (ping-pong skull)
- Widening of wrists
- Delayed fontanel closure
- Frontal bossing
- Costochondral joints hypertrophy (Rachitic rosary)
- Femoral & tibial bowing
• Dx: Labs and Xray
Labs:
⬇️Ca, P, Vit D
⬆️Alk Phos, PTH
• Mx: Vit D & Ca suppl

Familial Short Stature vs Constitutional Growth Delay
Family hx
Familial: Short stature
Constitutional: Delayed puberty
Bone age
Familial: Normal
Constitutional: Less than chronological age

#Dermatology 🧴

Atopic Dermtitis
• Sx:
- Infants (<2 y): Itchy, red, scaly, crusted lesions on extensor surfaces, trunk, cheeks, and scalp
- Child/adult: lichenified plaques in flexural creases
• Mx: topic emollients, steroids
• Cx:
- Bacterial like S. Aureus (grape-like pattern🍇)
- Viral like HSV/eczema herpticup

Impetigo
Nonbullous
• Pathogen:
1. S. Aureus
2. GAS (S. Pyogenes)
• Sx: Honey-crusted lesions🍯
• A pt w imptigo 1-2 w with low complement -> Post-strept GN
Bullous
• Pathogen: S. Aureus
• Sx: Rapidly enlarging flaccid bullae w yellow fluid🟡
Tx for Impetigo:
- Limited to skin: Topic Abx (Mupirocin)
- Extensive: PO Abx (cephalexin or clindamycin)

Cat Scratch Disease🐈😼
• Pathogen: Bartonella Henselae
• Sx: enlarged LNs
• Mx: Macrolides Abx (Azithromycin)

#Immunology

Wiskott-Aldrich Syndrome WAS
• Genetic condition characterized by impaired T cell function and thrombocytopenia
• Mutation in WAS gene 🧬 (X-linked recessive)
• Common in boys 👦
• Sx: Triad of:
1. Thrombocytopenia
2. Eczema
3. Recurrent bacterial infections
• Dx:
⬆️IgA & IgE

X-linked (Bruton) Agammaglobulinemia
• X-linked recessive disease causes a complete deficiency of mature B lymphocytes 🧬
• Common in boys👦
• Sx: starts at 3-6 mo after materal IgG starts to decline:
- Recurrent severe sinopulmobary and GI infections
- Small/absent lymphoid tissues (Tonils, adenoids, LNs)
• Dx: Low B Cells (CD19)
• Tx: IV immunoglobulins (IVIG)💉

#Rheumatology 🦴

Transient Synovitis vs Septic Arthritis
• Sx:
Transient: Well-appearing, Afebrile
Septic: ill-appearing, febrile🤒, non-wt bearing
• Dx:
Septic: synovial fluid WBCs >=50,000
• Tx
Transient: conservative
Septic: drainage & Abx

Juvenile Idiopathic Arthritis JIA
• Dx:
Persistent arthritis lasting for >6 w
• Females > Males
• All 4 types have negative RF, except in Seropositive Polyarticular JIA
• Uveitis screening:👁️
+ANA: every 3-6 mo (in <7 yo), every 6 mo (in >=7 yo)
-ANA: every 6 mo
Systemic JRA: every 12 mo

• Types:

Oligoarticular JIA (Most common)
• Arthritis: <=4 joints, asymmetrical, large joints
• Extra-articular sx: Anterior uveitis👁️
• Tx: NSAIDs💊

Seronegative polyarticular JIA
• Arthritis: >=5 joints
• Tx: MTX and NSAIDs💊

Seropostive polyarticular JIA
• Arthritis: >=5 joints, symmetrical
• Extra-articular sx: Rheumatoid nodules
• Dx: RF positive
• Tx: MTX and NSAIDs💊

Systemic JIA (Still’s disease)
• Arthritis: >=1 joint AND intermittent fever🤒 AND extra-articular sx
• Extra-articular sx:
- Transient migratory salmon-pink rash🍣
- Generalized lymphadenopathy
• Dx: Anemia, leukocytosis, thrombocytosis


Henoch-Schonlein Purpura HSP
• Most common vasculitis in children👧
• Often has Hx of URTI 1-3 w before sx onset
• Sx:
IgA deposits in small vessels of skin, joints, GI, and kidney
- Palpable purpura (buttocks, LL)
- Arthritis/arthralgia
- Abdominal pain, Intussusception
- Renal disease
• Dx:
Normal Plt
⬆️Cr, Hematuria🩸
• Tx
- Hydration & NSAIDs
- Severe: Systemic CS

Kawasaki Disease
• 90% age <5
• Diagnostic criteria:
Fever >=5 d + >=4 of the following:
- Conjunctivitis (bilateral👁️👁️, nonexudative)
- Mucositis: fissured lips/pharynx, strawberry tongue👅🍓
- Rash (erythematous generalized)
- Erythema and edema of hands/feet✋️🦶
• Tx: Aspirin & IVIG
• Cx: coronary artery aneurysms, MI🫀
• Poor prognostic factors (Kobayashi score):
- Na <=133
- CRP >=10 mg/dL (>=100 mg/L)
- Neutrophils >=80%

Juvenile Dermatomyositis
• Sx: muscle weakness, cutaneous features (Helitrope rash)
• Dx: High CK, ANA

#Toxicology 💊

Toxicity agents & their antidotes:
Paracetamol: N-acetylcystine
TCA: Sodium bicarbonate
Aspirin: Sodium bicarbonate
Narcotics: Naloxone
Iron: Deferoxanine
Lead: D-penicillamine
Copper: D-penicillamine
Organophosphates: Atropine

Acetaminophen Toxicity Phases
Phase 1
• 0.5-24 hours after ingestion
• Sx: asymptomatic or report anorexia, nausea or vomiting, and malaise
• PE: reveal pallor, diaphoresis, malaise, and fatigue

Phase 2
• 18-72 h after ingestion
• Sx: right upper quadrant abdominal pain, anorexia, nausea, and vomiting
• PE: Right upper quadrant tenderness, Tachycardia and hypotension

Phase 3: Hepatic phase
• 72-96 h after ingestion
• Sx: continued nausea and vomiting, abdominal pain, and a tender hepatic edge, jaundice, coagulopathy, hypoglycemia, and hepatic encephalopathy
• Acute kidney injury

Phase 4: Recovery phase
• 4 d to 3 wk after ingestion
• Patients who survive critical illness in phase 3 have complete resolution of symptoms

#Fluid_Management 💦

Indications for IV fluid:
1) Resuscitation
2) Replacement
3) Maintenance

1) Resuscitation (in shock)
10-20 cc/kg over 20-60 min

2) Replacement
- Dehydration % x wt (kg) x 10
- Bolus given to moderate-severe dehydration
^Degree of dehydration:

Mild: 5% (<2 yo), 3% (>2 yo)
Pulse: N
BP: N
Urine output: Decreased
Oral mucosa: Slightly dry
Ant fontanelle: N
Eyes: N
Skin turgor: N
CR: N (<2 s)

Moderate: 10% (<2 yo), 6% (>2 yo)
Pulse: Rapid
BP: N to decreased
Urine output: Markedly Decreased
Oral mucosa: Dry
Ant fontanelle: Sunken
Eyes: Sunken
Skin turgor: Decreased
CR: N to increased

Severe: 15% (<2 yo), 9% (>2 yo):
Pulse: Rapid, weak
BP: Decreased in shock
Urine output: Anuria
Oral mucosa: Parched
Ant fontanelle: Markedly Sunken
Eyes: Markedly Sunken
Skin turgor: tenting
CR: Increased

3) Maintenance
Holliday-Segar Method: 100:50:20 rule (24 hr)
First 10 kg: 100 cc/kg
Second 10 kg: 50 cc/kg
Remaining kilos: 20 cc/kg

Osgood schlatter disease 🦵
• Traction apophysitis
• Age 9-14 yo
• Sx: Tender lump over tibial tuberosity
• Self-limiting

Infantile Colic
• In 3-6 months old babies
• Dx: crying lasts for >=3 hr/d, >=3 d/week, for >=3 weeks
• Mx: behavioral change

Sudden Infant Death Syndrome SIDS
• RF: prematurity, prone sleeping, smoking, family hx of SIDS
• Prevention:
- Sleep in supine position
- Use pacifier during sleep
- Firm mattress, no pillows/blankets/stuffed animals🛏️
- In the first 6 mo: sleeping in the same room w/o bed-sharing
- Smoke-free🚭🙅‍♀️
- Avoid overheating
- Breastfeeding 🤱 until at least 4 mo
- Placing an infant prone while they’re awake

Primary protein-energy malnutrition
Main types:

Marasmus:
- Sx: Muscle wasting, loss of subcutaneous fat, no edema
- Deficiency: All major nutrients

Kwashiorkor:
- Sx: Bilateral pitting edema, distended abdomen, hepatomegaly
- Deficiency: Protein

Infantile Beriberi
• Caused by vitamin B1 deficiency
• Sx: anorexia, edema, aphonia

Scurvy (Vitamin C Deficiency)
• Sx: Follicular hyperkeratosis, gingivial hypertrophy, enlarged bluish purple friable gums

Common cause of vomiting in infants -> UTIs

Maternal phenobarbital consumption causes low vitamin K in fetus -> Prenatal 1 mg vitamin K1

Tanner Stages

☝🏻Beginning of SMLE Notes (Pedia)