HI-YIELD FACTS IN INTERNAL MEDICINE & PEDI ATRICS [from USMLE clerkshi-e!i"#rics $ IM & Pe" %r"i' Hi-(iel! Me!icie) CARDI*L*+Y Imor#"# #erms [from c"r!iolo,( l.e ook) Anterior wall MI Occurs in anterior leads [V1-V4] Aschoff nodules Granulomata in heart th that is pathognomonic of acute rheumatic rheumatic fever Aus ttiin-fl in int mu murmur Apical la late di diastoli c murmur he heard in in "or#ic is.fficiec(, is.fficiec(, a pseudoMitral stenosis murmur Bainbridge reflex Increase in heart rate due to rise in atrial pressure Barlows s!ndrome " mitral $lopp! posterior mitral #al#e cusp resultin% i n apical systolic murmur #al#e prolapse w"c radiates to the a&illa w/ ejection click w"c Bec's trtri ad ad hi %h %h (u (u%ular ##eenous pr pressure, lo low ar arterial B) B), *u *uiet he heart, of often se seen in c"r!i"c #"mo"!e Bern Bernhe heim ims s s!n s!ndr drom omee O+st O+stru ruct ctio ionn of #ent #entri ricu cula larr ouflo ouflow w w" #ent #entri ricu cula larr failu failure re,, ./ ./ w" w" #entricular septal aneur!sm Bernsteins te tes t .0 is is pl plac ed ed in into di di st stal es esopha%us to to di di fffferentiate chest pain from reflux esophagitis .!potension +rad!cardia followin% iferior /"ll MI Bezold-jarisch sch reflex Blal Blaloc oc''-.a .anl nlon on proc proced edur uree 2ur% 2ur%er er!! for for ./ ./ o crea create te an A2/ A2/ Blaloc' Blaloc'-3 -3aus aussi% si% proc procedu edure re $or ./ ./,, w" anast anastomo omosis sis of su+ su+cla# cla#ian ian A to pulmo pulmonar nar!! A Boer Boerha haa# a#e ess s!nd s!ndro rome me 2pon 2ponta tane neou ouss rupt ruptur uree of esop esopha ha%u %uss into into 0 pleu pleura rall spac spacee associated w/ retching Bornholm disease 5pidemic pleurodynia [m!al%ia] pleurodynia [m!al%ia] sec to o&sac'ie or 5cho#iruses ompression of feedin% arter! results in a+rupt slowin% of . in p&s %r"h"m0s si, w" large arteriovenous fistulas Bundle of 'ent accessor! +!pass tract seen in 1P1 s(!rome are are!!-o oom om+ +ss mur murmu murr Apic Apical al mid-d mid-dia iast stol olic ic murm murmur ur asso associa ciate tedd w" Ac.#e Rhe.m"#ic 2"l3.li#is Murmur is au%mented durin% inspiration in p&s w" tricuspid stenosis C"r3"llos si, or tricuspid regurgitation ha%as disease aused +! T4 cr.5i, ardiome%al!, me,"colo, cr.5i, manifested +! c ardiome%al!, me,"colo, esopha%eal d!sfunction laudication eproduci+le le% pain w" wal'in% 6 is relie#ed +! rest, seen in /V3 l a! a! -+ -+ ro roo' si si %n %n up up tu tu re re of of a+ a+d om om in ina l # is cu cus ma ma ! c au aus e au sc sc ul ul ta tat io n o f he ar ar t an d +reath sounds in a+domen on%enit on%enital al u+ella u+ella s!ndrom s!ndromee ./ w" w" /A and pulmon pulmonar! ar! arter! arter! stenos stenosis is onn onns s s!nd s!ndro rome me )rim )rimar ar!! 7h! 7h!pe pera rald ldos oste tero roni nism sm w" .)8, .)8, h!po h!po'a 'ale lemi micc al' al'al alos osis is,, 9 reni reninn Corrigan’s pulse :ater-hammer pulse seen in "or#ic is.fficiec( /a ost osta ass s!nd s!ndro rome me ard ardia iacc neu neura rast sthe heni niaa eff effor ortt s!nd s!ndro rome me 8on 8on-an -an%i %ina nall ches chestt pai pains ns associated w" an&iet! /res /ressl sler ers s!nd s!ndro rome me Auto Autoim immu mune ne,, fe#e fe#err, per peric icar ardi dititis, s, pleu pleura rall effu effusi sion on,, leu' leu'oc oc!t !tos osis is,, ; 52 52 2"2&< 6 Ps = Ps = ericarditis, neumonia, leuritis, !re&ia, ain [chest] /uchenne muscular 2e&-lin'ed, w" V strain 5>G pattern d!stroph! 3o and fro murmur when stet is pressed o#er femoral arter!, seen in D.ro5ie50s si, "or#ic re,.r,i#"#io 5+steins anomal! that is displaced inferiorl! i nto V ca#it! Abnormal TV that 5isenmen%ers s!ndrome Any L to shunt w"c de#elops pulmonar! .)8 w" su+se*uent shunt re#ersal and c!anosis /ullness on percussion, increased fremitus, and +ronchial +reachin% E/"r#0s si, +eneath the an%le of 0 scapula in pericardial effusion $ic's method /!e dilution method for measurement of O O+li*ue fissure of the ear lo+e associated w" A/, /M and .)8 Fr"k0s si, Gauc Gauche her rss dise diseas asee Beta Beta-% -%lu luco coce cere re+r +ros osid idas asee defi defici cien enc! c! res resul ulti tin% n% in in accu accumu mula lati tion on of of %lucocere+roside Grah Graham am-s -ste teel el murm murmur ur )ulm )ulmon onar ar!! dia diast stol olic ic mur murmu murr of pulmo pulmoni nicc insu insuff ffici icienc! e nc! see seenn in .lmo"r( HPN Gre%%s triad ataract, heart defect 6 deafness in co,ei#"l r.ell" s(!rome .am ma mans di disease 2pontaneous me mediastinal em em ph ph!sem a H"mm"0s si, Mediastinal crunch secondar! crunch secondar! to air in tissues .ills si%n 2een in se#ere "or#ic re,.r,i#"#io, re,.r,i#"#io , femoral arter! pressure ?@ mm.% +rachial pressure .olt.olt-Or Oram ams s s!n s!ndr drom omee A2/, A2/, upp upper er lim+ lim+ defe defect cts, s, a+s a+sen ence ce of of radi radial al +on +one, e, and and cla cla#i #icu cula larr h!poplasia .omans si%n alf tenderness w" palpation seen in /V3 .!pert .!perten ensi#e si#e emer%e emer%enc! nc! 2"2& 2"2& [some [some w" w" heada headache che,, chest chest pain, n , s!nc s!ncope ope]] endend-or% or%an an dama dama%e %e .!pertensi#e emer%enc! B) ?@@"1?@ that is A2& [some w" headache, chest pain, s!ncope] Inferior wall MI Occurs in leads ?, 6 AV$ .!potension and tach!cardia followin% "#erior /"ll MI Jame’s reflex Canewa! lesion 2' in er! tthhem a and purpl e dis co coloration due to "c#eri"l e!oc"r!i#is >arta% >arta%ene eners rs s!ndro s!ndrome me triad triad Bronch Bronchiec iectas tasis, is, sinusit sinusitis is and situs situs in#ersus in#ersus >awasa'i " Mucocutaneous $e#er, er!thema, eema, des*uamation of hands and feet, i nfected 08 s!ndrome con(uncti#a, associated w" coronar! A aneur!sms >erle! B lines 2een in .lmo"r( co,es#io, co,es#io, dilatation of pulmonar! l!mphatics results in horiDontal lines across +asal part of lun%s
7.ssm".l si, 0ei+man-2a 0ei+man-2achs chs endocard endocarditis itis Le3ie0s si, 0ute 0utem+ m+ac ache her rss s!nd s!ndro rome me M al al i% i%n an an t . )8 )8 Mallor! +odies Marf Marfan ans s s!n s!ndr drom omee !onneret’s pulse Mull Muller ers s s!n s!ndr drom omee 8oon 8oonan ans s s!nd s!ndro rome me Ortn Ortner ers s s!nd s!ndro rome me Osler s nodes )omp )ompe es dis disea ease se ) ot ot tt s pr oc oc ed ed ur ur e )ri nD nDmetal an%i na na )ulsus par#us et tardus P.ls.s "r"!o8.s <.ike0s si, oth spots 2h!2h!-/r /ra% a%er er s!nd s!ndro rome me 2 ilil en en t i sc sc he he mi mi a 2ti l s mu murmur 2to' 2to'es es-A -Ada dams ms s!nc s!ncop opee 2udd 2udden en card cardiac iac deat deathh 2wan 2wan-G -Gan anDD cath cathet eter er 2!ndrome & " micro#ascular an%ina 3ietDes s! s!ndrome )rima )rimar! r! car cardi diac ac arr arres estt 2econd 2econdar! ar! card cardiac iac arre arrest st :olff-)ar'inson-:hite s!ndrome B) F 14@" F @ B) F 1@, F H = ki!s of m.rm.r M.rm.r Crescendo"decrescendo Crescendo"decrescendo / ejection Plateau or holosystolic murmur /ecrecendo murmur Crescendo murmur
)arado&ical rise in CV) on inspiration in cos#ric#i3e eric"r!i#is or chroic os#r.c#i3e "ir/"( !ise"se 8on+acter 8on+acterial ial #erruco #errucous us endoca endocarditis rditis secondar! secondar! to 205 205 MI descri+ed +! clenched fist o#er the heart om+ om+in inat atio ionn of of A2/ A2/ w" M2 e na na l f ai ai lu lur e, e, e ss ss en en titi al al .) 8, 8, enc ep ep ha ha lo pa pa th th! w " /B ) 1? @ m m. m.% .!aline +odies seen in "lcoholic cirrhosis Auto Autoso soma mall domi domina nant nt 3 dise diseas asee w" w" ara arach chno noda dact ct!l !lia ia,, m!&o m!&oma mato tous us de%eneration of aorta and mitral #al#es Brad!cardia associated w" (aundice Auto Autoso soma mall domi domina nant nt inher n herit ited ed h!p h!per erch chol oleste e stero role lemi mia, a, &an &anth thel elas asma ma,, and cardiac disease ./ ./ w" pulm pulmon onar ar!! sten stenos osis is and and 3urne urner rss s!nd s!ndro rome me 0 #oca #ocall cor cordd par paral al!s !sis is seen seen in M2 due due to to enl enlar ar%i %in% n% 0 atri atrium um )ainful indurated fat pads of fin%ers in "c#eri"l e!oc"r!i#is Gl!c Gl!co% o%en en stor stora% a%ee diseas s easee due due o alph alphaa-%l %luc ucos osid idas asee defi defici cien enc! c! w" macro%lossia, cardiome%al! and wea'ness $ or or . . /, /, an ana st st om om os os is is of of de de sc sc en endi n% n% ao ao rtrta to to pu pul mo mo na na r! r! ar ar te ter ! oronar! #asos pa pasm causin% an%i na na :ea', dela!ed carotid upstro'e A decrease in S%P 9 :; mmH, durin% mmH, durin% inspiration in c"r!i"c #"mo"!e Visi+le pulsation on nail +ed secondar! to "or#ic is.fficiec( or h(er#h(roi!ism O#al retinal hemorrha%es w" pale central area occurrin% in "c#eri"l e!oc"r!i#is )rima )rimar! r! aut auton onom omic ic d!sf d!sfun unct ctio ionn resu resultltin in%% in orth orthos osta tatic tic h!p h!pot oten ensi sion on A +s +s en enc e of c he hes t p ai ai ns ns 5 #i #i de de nc nc e of i sc sc he hem ia +! r es es titi n% n% 5 G G , am+ulator! 5G monitorin%, e&ercise 5G test, or echocardio%raph! Vi +r +rator! *u *ual it! of of ea earl ! to mi mid-s!s ttool ic e( e( ec ec ttii on on mu murmur, innocent murmur in children 2!nc 2!ncop opee sec sec to to card cardia iacc arrh! arrh!th thmia mia,, usua usuall! ll! 2A 2A noda nodall disea disease se Ene& Ene&pe pect cted ed deat deathh occ occur urri rin% n% w"in w"in 1 hour hour from from ons onset et of s!mp s!mpto toms ms Ventricular fi+rillation IV cath cath that that meas measur ures es card cardia iacc and and pulmo pulmona nar! r! arte arter! r! pres pressu sure ress Esuall! in pre-menopausal women 4 3!pical or at!pical chest pains w" normal coronar! an%io%ram Ma! +e due to constriction of small coronar! arteries or enhanced pain sensiti#it! ostochondri titi s resulti n% n% in in ch chest pa pai n ard ardia iacc arrh arrh!t !thm hmia ia cau causin sin%% hemo hemod! d!na nami micc colla collaps pse e ar ardi diac ac arr arres estt is mainl! due to arrh!thmia ardia ardiacc hemod! hemod!na namic mic collap collapse se causi causin% n% cardi cardiac ac arrh! arrh!thm thmia ia ard ardiac iac arrest is mainl! due to circulator! or respirator! failure B!pass atrio#entricular conduction trait associated w" supra#entricular tach!cardia 5G shows delta wa#e and shortened ) inter#al B) %oal in uncomplicated .38 B) %oal in dia+etic patients
E8"mles Aortic # pulmonary pulmonary stenosis Mitral tricuspid regurgit ation! "#$ Aortic re%ur%itation 6 pulmonar! insufficienc! !itral # tricuspid stenosis
Si#es of ".sc.l#"#io Aortic #al#e upper sternal +order )ulmon )ulmonic ic #al#e #e 0 upper upper sterna sternall +ord +order er 3ricu 3ricusp spid id #al#e #al#e 0 lowe lowerr stern sternal al +ord +order er Mitral #al#e Ape& 7oro#koff so.!s & ,r"!i, of m.rm.rs Ch"r"c Ch"r"c#er #er of of 7oro#k 7oro#koff off so. so.!s !s +r"!i +r"!i, , of m.rm m.rm.rs .rs )hase 1 J tappin% Grade 1 J faintest murmur that can +e heard )hase ? J swishin% Grade ? J soft, readil! audi+le murmur )hase J louder, crisper Grade J prominent murmur w"o thrill )hase 4 J a+rupt, mufflin% Grade 4 - loud murmur w" palpa+le thrill )hase J sounds disappear Grade J murmur audi+le w diaphra%m Grade K J murmur audi+le w" stet S#"!"r! c"r!io#hor"cic r"#io [C>T r"#io) Adults @ [upri%ht]L @ [supine] Infants @K Ac.#e coro"r( s(!romes 1 Acute MI w" w" 235MI, transmu transmural, ral, wa#e MI MI
1
Mostl! due to atherosclerotic pla*ue fissures, ruptures 6 ulcerates M complaint< chest pain )5< su+sternal chest pain @ mins diaphoresis ? unsta+ unsta+le le an%ina an%ina non-235MI, non-transmural, non-transmural, non- non- wa#e wa#e MI, non-235MI •
Acute heart failure
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M pathoph!siolo%!< l"?.e r.#.re, r.#.re, erosion, w" superimposed non-occlusi#e
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throm+us $allmark% low"substernal low"substernal chest pain or epigastric pain
S#",es of MI S#",e Acute .ealin% .ealed
0 side sidedd .$
$orward .$
Cri#eri" for MI !i",osis Mo!ifie! 1H* cri#eri" for MI 1 prolon%ed prolon%ed chest chest pain " discomfort discomfort ? 5G e#idence dence of MI or ischemi schemia a 23 ele#at ele#ation ion w" w" wa#es wa#es + 23 ele#atio ele#ationn w"o wa#es wa#es c 23 ele#atio ele#ationn 6 or 3 wa#e wa#e chan%e chan%ess at least least ? fold fold rise in >-MB >-MB
EC+ cri#eri" for MI 1 23 ele#ation ele#ation ? mm conti%u conti%uous ous .523 .523 leads or 1 mm in ? or more conti%uous 0IMB leads ? wa#es wa#es @@4 secs secs [1 small small s*uare] s*uare]
Mo!ifi"le 3s4 No-mo!ifi"le risk f"c#ors for "#herosclerosis Modifia+le ris' factors .)8, /M ?, d!slipidemia, smo'in%, o+esit!, lac' of of e&ercise, e&ercise, hi%h cholesterol diet 8on-modifia+le A%e, male %ender, %enetics, famil! histor! Asol.#e 3s4 rel"#i3e co#r"i!ic"#ios #o #hromol(#ic #her"( Asol.#e co#r"i!ic"#ios Rel"#i3e co#r"i!ic"#ios 1 acti#e interna internall +leedin% +leedin% [e&cept menses] menses] 1 +leedin% +leedin% diathesis diathesis ? recent recent in#asi#e #e sur%er! sur%er! [w"in ? w's] ? pre#ious ous strepto'ina strepto'inase se treatment treatment suspected suspected aortic aortic dissect dissection ion ( )* + .0-/.-.0-/.-- on at at least , readin readings gs 4 acti# acti#ee )E/ )E/ 4. previous h& of hemorrhagic hemorrhagic 5. h& of thrombotic CVA CVA CVA recent recent head trauma trauma K prolon%ed prolon%ed ) 1@ mins H /M retin retinop opath ath!! '( persisten persistentt )* + ,--/., ,--/.,-N pre%na pre%nanc! nc! @ ,eer"l cl"sses of MI comlic"#ios 1 5lectrical [le#h"l "rrh(#hmi"s) J "rrh(#hmi"s) J !C cause of death in !1 ? Mechanical [.m Mechanical [.m f"il.re) J f"il.re) J primary primary cause of in"hospital death !ise"ses> LR sh.#s sh.#s A2 / V2 / )/A
RL sh.#s sh.#s 3O$ 3A 3GA
Molec.l"r m"rkers i !i",osis of "c.#e MI Tes#s es#s Time Time Pe"k Pe"k D.r" D.r"#i #io o Sche Sche!. !.le le 3rop rop 3 [2n= [2n=4 4,, 2p=K 2p=K@] @] -1? -1? . ?4 . 1@-1 1@-144 d Once Once at leas leastt 1? hrs hrs post post-p -pai ainn Tro I [SB6'SB;) -:@ H @= H 6-:; ! Once at least 1? hrs post-pain >-MB K-1? . 1d d 1? hrs & " at K hrs post-pain 2GO3 ?4 hrs ?d 4d Once at least 1-? d post- pain Once at least 1-? d post- pain %$& '( hrs 'd )* d N*TE> >-MB< total > ratio = ? 1 EC+ J EC+ J %old stan dard in d& of MI at 1 st K hrs [23 ele#ation, [] wa#es ? card cardia iacc #ro I J I J used w"in 1 st 4 hrs up to H-1@ d, mos# secific C7-M% J C7-M% J test of choice in 1 st ?4 hrs post-MI Lef#-si!e! 3s4 R-si!e! CHF L-si!e! CHF .!potension, tach!cardia, hi%h pulmonar! #enous pressure, d!spnea
.i%h-output .$
sided .$ 2!stolic .$ /iastolic .$ Bac'ward .$
D.r"#io $ew hrs to H d H-?N d ? d
Cl"ssific"#io of co,ei#"l he"r# T(e *s#r. *s#r.c#i c#i3e 3e V )2 0V A2 0V A
hronic heart failure 0ow0ow-ou outp tput ut .$
R-si!e! CHF 0ower e&tremit! edema, ascites, distended nec' #eins
S(s#olic 3s4 !i"s#olic !(sf.c#io Fe"#.res S(s#olic !(sf.c#io A%e K !o omor+id illness I./, .38, DCM, /M, V. V./ DCM, /M )ulmonar! em+olism /isplaced )MI, 2 gallop on%estion, cardiome%al! 5G"echocardio%raph! wa#es, 5$ F 4@P
Di"s#olic !(sf.c#io K !o I./, .3 .38, HCM' RCM, RCM, /M 2ustained )MI, 23 gallop on%estion, normal heart siDe 0V., normal 5$ @P
Are decompensated and in mar'ed respirator! distress )&s can ha#e a normal heart siDe Ma! +e sta+le or ma! +e decompensated More More comm common on t!pe t!pe of of s!st s!stol olii 0V 0V d!sf d!sfun unct ctio ionn w" w" low low O O 3hi 3hiss cau cause sess #asoconstriction, oli%uria, and low B) Associated w" h!per'inetic circulator! state w" hi%h O 3his causes #asodilatation, and widened pulse pressure 2!mp 2!mpto toms ms of e&e e&ert rtio iona nall d!s d!spn pnea ea,, ort ortho hopn pnea ea,, and and paro paro&! &!sm smal al noct noctur urna nall d!spnea w" disended nec' #eins and +ipedl edema )ro+lem of poor cardiac contractilit! )ro+lem in rela&ation of a stiff 0V Ventricle fails to dischar%e its contents or fails to fill-up normall! 2&< acute pulmonar! edema /ue to inade*uate dischar%e of +lood into the arterial s!stem 2&< a+normal fluid retention
NC Cl"ssific"#io for HPN Cl"ssific"#io S%P S% 8ormal F 1?@ 2ta%e 1 .)8 1?@-1 2ta%e ? .)8 1K@
D%P F N@ N@-N 1@@
H(er#esio m"",eme# i!ic"#ios M"ifes#"#ios Tre"#me# /M w" proteinuria A5Is .$ B-+loc'ers, A5Is, diuretics MI B-+loc'ers, A5Is Osteoporosis 3hiaDides B). Alpha-a%onists )eripheral #ascul ar ar disease Bs Secific cl.es #o !iffere# c".ses of HPN T(e Cliic"l cl.es 5ssential .)8 Onset< ?@-@ !rsL famil! h& of .)8 hronic renal disease A+normal E"L ma! ha#e hi%h creatinine 8eo#as 8eo#ascula cularr diseas diseasee A+domi A+dominal n al +rui +ruit, t, sudde suddenn onset onset at F ?@ ?@ !o !o or @ !o !o )heochromoc!toma )aro&!sms of palpitation, diaphoresis, an&iet!, episodic .)8 )rimar! )rimar! aldost aldostero eronis nism m /ecrea /ecreased sed serum serum > OA B) on arms le%sL mids!stolic murmurL < aortic indentation, ri+ notchin% ushin%s s!ndrome ushin%hoid appearance [e& central o+esit!, hirsutism] Secific cl.es #o !iffere# c".ses of ches# "i> ostochondritis"musc 2harp, localiDed pain ulos'eletal M!ocardial hest hea#iness, pressure, or pain, t!picall! radiatin%, to 0 arm, infarction"an%ina shoulder and (aw )ericarditis hest pain radiatin% to shoulder, nec' or +ac', worse w" deep +reathin% or cou%h [pleuritic], relie#ed +! sittin% up"leanin% forward Aortic dissection 2e#er chest pain radiatin% to +ac', can +e associated w" une*ual pulses or une*ual B) in and 0 arms A+scess"mass Often sharp, localiDed pain, pleuritic )ulmonar! em+olism Often pleuritic, associated w" tach!pnea, and tach!cardia )neumonia )leuriic, fre*uentl! associated w" h!po&ia G5/ Burnin% pain, d!spha%ia, ma! +e similar to pain of MI +eer"l ,.i!elies #o !iffere#i"#e ches# "i Fe"#.res MI 2e#e 2e#eri rit! t! Ver! er! se#e se#ere re /uration @ mins $re* $re*ue uenc nc!! )ers )ersis iste tent nt pain pain 3imin 3imin%% At rest rest 8itro%l!cerides 8o relief Other 2& An&iet!, d!spnea, diaphoresis, nausea
Us#"le ",i" Mode Modera rate tel! l! se#e se#ere re 1-@ mins ; fre* fre*ue uenc nc!! At rest rest or w" e&er e&ertition on Esuall! 8O 0ess than MI
S ##""le ",i" Mild Mild F 1 mins 2ta+ 2ta+le le,, less less fre* fre*uuent ent w" e&er e&ertition on Qes 0ess than MI
C"re#er0s f.c#io"l cl"ssific"#io of mi#r"l is.fficiec( Rone 1 Middle Aorta, celiac a&is, pro&imal 2MA 6 renal A, 2MV, IMV Rone ? Epper la lateral enal A A an and V V R on one ) el el #i #i c I li ac ac A a nd nd V Rone 4 )ortal )ortal V, hepatic A 6 IV %r"./"l!0s %r"./"l!0s cl"ssific"#io of s#"le ",i" lass 1 8ew onset, onset, se#ere se#ere or acceler accelerated ated an%ina, an%ina, p&s w" an%ina an%ina F ? mos duration, duration, precipitated +! less e&ertion, no rest pain in last ? mos
T(es of he"r# f"il.re
2
lass ? lass
An%ina at rest, su+acute, p&s w" 1 an%ina at rest durin% the precedin% month An%ina at rest, acute, p&s w" 1 an%ina at rest durin% the precedin% 4N hrs
.$"#olume o#erload states • •
D.ke0s cri#eri" of ifec#io.s e!oc"r!i#is Fe"#.res Ac.#e "c#eri"l e!oc"r!i#is )atho%en 2 aureus [#irulent] Manifestations .i%h fe#er, acute course ardiac patholo%! 8 cardiac #al# es, [-] murmurs )ro%nosis $atal in K w's if untreated
S."c.#e e!oc"r!i#is 2 #iridans, eneterococci 0ow fe#er, su+acute course /ama%ed #al#es, [] murmur Better pro%nosis
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C.#"eo.s & oc.l"r si,s of s."c.#e e!oc"r!i#is )etechiae 2een in con(uncti#a, oral ca#it! 6 s'in 2plinter hemorrha%es 0inear su+un%al hemorrha%e that do 8O3 reach distal nail +ed Oslers nodes 2mall "if.l re! o!.les in distal phalanges Canewa! lesions 2mall er!thematous, o#e!er m"c.les on palms soles oth spots 2mall white retinal infarcts surrounded +! hemorrha%e Pre,"c( & c"r!i"c !ise"se ? M 6 important cardiac c onditions in pre%nanc! o Val#ular heart disease [esp rheumatic heart disease] o )reeclampsia [pre%nanc!-induced .)8] /ru% treatment for .)8 in pre%nanc! o Meth!ldopa [aldomet] o .!dralaDine [apresoline] o Atenolol [+eta-+loc'ers] o 8ifedipine [adalat] •
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Periher"l si,s of chroic "or#ic re,.r,i#"#io orri%ans pulse )ulses w" a+rupt distention 6 *uic' collapse, water-hammer pulse /e-mussets si%n .ead +o++in% 3rau+es si%n )istol shot sound on femoral arter! /uroDieD si%n 2!stolic murmur heard o#er femoral A when compressed pro&imall! Mullers si%n 2!stolic pulsation of u#ula uin'es si%n apillar! pulsation pressin% a %lass slide on p&s lip .i l s si %n ) op li tea l c uff 2 B) +r ac hi al cu ff 2 B) + ! K@ mm .% Prim"r( re3e#io of Rhe.m"#ic fe3er BenDathine )8 1? M units"IM PCN 2 - D*C for RHD ?@ m% 3I/"orall! 5r!throm!cin or @ m%"'%"d, ma&imum of 1 #ancom!cin %m"d in -4 doses
Once 1@ da!s 1@ da!s
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C"r!i"c !r.,s for HF cl"ssifie! "ccor!i, #o hemo!("mic effec#s> Mainl! relo"! .lo"!ers Increase contractilit! Mainl! "f#erlo"! unloaders +arterial +,enous dilators dilators /iuretics, nitrates /i%o&in, do+utamine, A5 inhi+itors, an%iotensin ? dopamine anta%onists, ./R, nitroprusside No#e> %oal of preload unloaders is to 9 0V end diastolic pressure, while the %oal of afterload unloaders and dru%s for contractilit! is to ; cardiac output 2"l.e of h8 i !e#ec#i, c".se of "li#"#ios> P"#ie# his#or( Pro"le c".se Occasional 4flip"flops56 skip beats )remature +eats 7*VC or *AC8 2udden onset, rapid, regular 2upra#entricular tach!cardia or #entricular tach!cardia 2udden, onset, rapid, irregular )aro&!smal atrial fi+rillation Gradual onset, re%ular w" e&ercise 2inus tach!cardia Associated w" dru%s 3o+acco, coffee, tea, etc Associated w" at!pical chest pain An&iet!, mitral #al#e prolapse, and h!per#entilation s!ndrome I!e"l lii! rofile> 3otal choleste rol 3ri%l!cerides 0/0 ./0
F ?@@ m%"dl F ?@@ m%"dl [if 1,@@@ are ris' for de#elopin% pancreatitis] F 1@ m%"dl m%"dl [./0 K@ is cardioprotecti#e]
Choice of "#ih(er#esi3e !r.,s "se! o "#ie#0s ch"r"c#eris#ics> Cl"ss Recomme!e! i A3oi! i A5 inhi+itors .$, /M 52/ B et a- +l oc 'e rs A n&i ou s, young indi,iduals Athletes, +ronchopulmonar! disease alcium A/ diltiaDem], peripheral #ascular .$ [diltiaDem and #erapamil] anta%onists disease [nifedipine] /iuretics Gout, d!slipidemia .lderly patients, renal disease,
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.eparin does not dissol#e alread! present clotsL rather, it pre#ents future ones from formin% A N !"o man, who was dischar%ed from hospital after MI ? w's a%o, presents w" fe#er, chest pain, and %eneraliDed malaise 5G shows diffuse #- wa,e changes< !ressler0s s(!rome A K? !"o smo'er presents complainin% of episodes of se#ere hea#! chest pain this mornin% 5ach episode lasted - mins, +ut has no pain now .e has ne#er had this t!pe of pain +efore< .s#"le ",i" A K4 !"o man presents w" fre*uent episodes of dull, hest pain, on and off for N mos he sa!s the pain wa0es him from sleep< ri5me#"l0s ",i" auses of parado&ical splittin% of 2?< h!pertropic cardiom!opath!, aortic stenosis, and 0BBB A ? !"o man +ecomes se#erel! d!spneic and collapses while running laps .is father had died suddenl! at an earlier a%e< HCM A !oun% man presents w" at!pical chest pain and mid-systolic clic0 < mi#r"l 3"l3e rol"se onditions w" wide pulse pressure< Aortic re%ur%itation, .!perth!roidism, Anemia, :et +eri-+eri, .!pertrophic su+aortic stenosis, .)8 )&s w" aortic stenosis should +e considered for #al#e replacement for< )ersistent s!mptoms, Aortic orifice F @H cm? B2A, Gradient H@ mm.% A r.mli, !i"s#olic m.rm.r can +e due to MS or TS [increase w" inspiration] The m.rm.rs G i#s !escri#ios Mitral stenosis /iastolic rum+le w" opening snap Mitral"tricuspid re%ur%itation, V2/ .olos!stolic, +lowin% murmur radiatin% to axilla Mitral #al#e prolapse !id"systolic click .M 2!stolic, +ris' upstro'e, parasternal lift )/A ontinuous, machinery murmur A2/ 9i&ed6 split 2, V2/ 2!stolic, radiates to the ri%ht Aortic re%ur%itation :ater"hammer pulse, decrescendo, mid-diastolic Aortic stenosis .arsh, s!stolic murmur that radiates to carotids 4*arvus et tardus5 R si!e! "c#eri"l e!oc"r!i#is is most fre*uentl! associated w" non-sterile techni*ue in 1" drug abusers He"r# lock C".ses of Moi#5 : C".ses of Moi#5 @ Inferior wall MI, di%italis Inferior wall or septal MI, conduction to&icit!, increased #a%al tone s!stem disease auses of rd de%ree heart +loc' [ DIC]< Di%italis to&icit!, Inferior wall MI, Conduction disease .)8 due to pheochromoc!toma is characteriDed +! ectopic production of 5p and 85p, causin% wide swin%s in B) Aortic dissection due to s!philis occurs +ecause #reoem" infects the #asa #asorum of aorta 3here is stron% association btw streptococcus bo,is and colonic neoplasms An! murmur 9 ,r"!e is patholo%ic Onl! manifestation of $ causin% permanent cardiac dama%e< c"r!i#is [start prednisone and aspirin] A K !"o %irl w" )/A de#elops fe#er and anore&ia .%+ = , w" hematuria, ; 52, rheumatoid factor and immune comple&es are present< "c#eri"l e!oc"r!i#is A ? !"o +o! w" fe#er de#elops non-exudati,e conjuncti,al injection +ilaterall!, er!thematous lips, palms, and soles and an enlar%ed tender anterior cer,ical %2< 7"/"s"ki !ise"se w" boot"shaped heart , decreased pulmonar! #ascular ma'in%s, and a aortic arch conotruncal facies< T*F w" egg on a string appearance< #r"sosi#io of ,re"# 3essels A ? mos old male +orn at term appeared well until w's a%o when he +ecame d!spneic and had difficult! in feedin% A loud pansysolic murmur is heard at the % lower sternal border and 5G shows 0V. and V.< 2SD In a normal neonate, the ductus arteriosus closes primaril! in response to a !.c#"l P*@ 9 6; mmH,4 A 4 !"o +o! w" recurrent episodes of s!ncope while pla!in% has a harsh systolic murmur radiating to the carotids, diminished cardiac pulses and se#ere 0V.< co,ei#"l "or#ic s#eosis
R"i! re3ie/ 8ormal ran%e of cardiac output< M cause of sided .$ M #iral cause of m!ocarditis M con%enital #al#e a+normalit! M cause of death in p&s w" .$ M #al#e affected +! ./ [ MAT] M cause of death from ./ in 1 st month of life M con%enital heart lesion in A/E032 M ./ seen in /owns s!ndrome M con%enital heart disorder M complication of )/A in late childhood All isolated h!percholesterolemia is
??- 0"min per m? L si!e! HF co&sac'ie B Aortic stenosis Arrh!thmia Mitral Aortic Tricuspid .!poplastic 0 heart s!ndrome A2/ A2/ J primum t!pe V2/ Infecti#e endocarditis 3!pe IIa
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1st line therap! for acute pulmonar! edema< N*MAD lassic choice for p&s w" :): /ilatation of 0 atrium is a ma(or cause of A cause of short 3 inter#al 8ear all p&s w" Marfans s!ndrome ha#e
Nitro%l!cerine, *&!%en, Morphine, Aspirin, Diuretics )rocainamide Atrial fi+rillation .!percalcemia MV)
END*CRIN*L*+Y A woman presents w" recurrent #a%inal candidiasis that is refractor! to treatment< DM T(e : DM must use insulin 3he! cannot use O.As +ecause the! ha#e no functioning beta cells3 A p& presents w" persistent morning hyperglycemia, despite steadil! increasin% his ni%httime 8). insulin dose .e also complains of fre*uent ni%htmares .is wife +rin%s him now +ecause she witnessed him ha#in% seiDure in the mi ddle of the ni%ht< somo,(i effec# D7A is mostl! associated w" t!pe 1 /M, while N7HC is associated w" t!pe ? A ? !"o woman w" inability to lactate after childbirth /eli#er! was complicated +! +lood loss and hypotensi,e< sheeh"0s s(!rome A K !"o woman complains of amenorrhea for 1 !ear, increasin%l! +ad headaches, clumsiness, and sporadic nipple discharge L +eta-.G le#els are normal< rol"c#iom" Other causes of e&cess A/. secretion< adrenal failure, renal failure, edema, fluid loss auses of lar%e ton%ue [macro%losia]< acrome%al!, m!&edema, am!loidosis A !"o female w" a h& of h!perth!roidism and a recent flu presents w" nec0 pain and an ele,ated .#4< s."c.#e #h(roi!i#is M% deficienc! is seen in< alcoholism, 2IA/., and pancreatitis A @ !"o woman presents w" perioral paresthesias and a lon% 3 inter#al on 5G 2he recentl! had sur%er! for a th!roid %oiter< h(o"r"#h(roi!ism An 1N !"o man w" hemophilia A, who was recentl! mu%%ed [recei#in% multiple +lows to +ac' and a+domen] is now complainin% of diDDiness, a+dominal pain, dar' patches on his el+ows and 'nees, and uncontrolla+le cra#in%s for piDDa and $rench fries< rim"r( "!re"l is.fficiec(4 ushin%s disease can +e distin%uished from ushin%s s!ndrome +! the presence of h(eri,me#"#io A 4? !"o woman on lon%-term steroids for asthma, has e&cess adipose tissue in her nec' and upper nec' and upper trun', a wide S moon faceT and #er! fine hair< c.shi,0s s(!rome A 44 !"o woman has .)8, muscle cramps, and excessi,e thirst < h(er"l!os#eroism A N !"o woman on la+etalol presents w" poorl! controlled .)8, fre*uent headaches, and palpitations< heochromoc(#om" A 1@ !"o %irl has ? hr postprandial +lood %lucose of @@ m%"dl and a lar%e amount of glucose and trace 0etones in her urine 2he has lost 1 '% of wei%ht< #(e : DM A ? hr old new+orn has plasma %lucose of ?@ m %"dl )5 shows a lar%e plethoric new+orn w" macrocephaly B: is @ th percentile and . is at @ th percentile< h(eris.liism P of th!roto&icosis in children is caused +!< .3eile +r"3e0s !ise"se A 1@ !"o %irl has a !r h& of %rowth failure A moderate-siDed multinodular goiter is palpated 34 is 1 UE"d0, and 32. is ??< "c?.ire! h(o#h(roi!ism A 1@ !"o %irl has se#ere a+dominal pain and %ross hematuria 2he passes a calculus in her urine 2he had recei#ed no meds and has no famil! h& of renal stones< rim"r( h(er"r"#h(roi!ism An infant has h!po%l!cemia and a micropenis< h(oi#.i#"rism 0ar%e +a+ies due to o,erproduction of 1%56 < eck/i#h-/ei!em" s(!rome A H !"o %irl de#elops enlar%ed +reast K mos later she de#eloped pu+ic and a&illar! hair .er menses +e%an at a%e N< i!io"#hic recocio.s .er#( A !"o %irl has nontender, unilateral breast enlargement w" no masses or no dischar%e 1 st noted mos a%o< h(siolo,ic #hel"rche An &-lin'ed h!po%onadotrophic, h!po%onadism, affectin% males and females, associated w" anosmia, clef lip"palate, and other midline defects< 7"llm" s(!rome
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Fol"#e deficienc! can +e differentiated from 3i#"mi %:@ deficienc! +! the lack of neurologic abnormalities( *ernicious anemia is associated w" increased ris' for ,"s#ric CA A !"o male presents complainin% of wea'ness, +ac' pain and (aundice .e reports of +ein% started on ciproflo&acin ? da!s a%o for a pneumonia< +PD !eficiec( 2econdar! pol!c!themia is associated with< hypernephroma! cerebellar hemangioma! hepatoma and giant uterine myomas3 3!picall!, one transfuses platelets if he! drop +elow ?@,@@@ or if there are si%ns of +leedin% ) unit increases platelets by )*!*** A @ !"o female, who is in the IE for sepsis has purpura and %in%i#al +leedin% on da! ? of her hospital da! All her coa%ulation factors are el e#ated< DIC )3, )33 are normal in TTP, whereas the! are ele#ated in DIC Enli'e in 21D, +leedin% time in hemohili" A is unaffected +ecause no a+normalit! w" platelets is present A!3erse effec#s of chemo#her"( ",e#s> isplatin 8ephroto&icit! Bleom!cin )ulmonar! fi+rosis Vincristine 8euroto&ic, palsies /o&oru+icin ardioto&ic 3amo&ifen Va%inal +leedin%
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A K@ !ear old man w" punched out l!tic lesions in s'ull, and mild anemia .e complains of low +ac' pain, h!percalcemia, anemia, and aDotemia< m.l#ile m(elom" A ? !"o man presents w" %!necomastia, su+sternal pain, d!spnea, wea'ness, cou%h, fe#er, wei%ht loss ra! showed mediastinal mass< ,erm cell #.mor
Imor#"# #erms & coce#s 2erum $e Iron a#aila+le for heme production 3IB Amount of protein 8O3 +ound to iron 2erum ferritin $e protein that re%ulates iron states 6 trnsport Indirect coom+s test 3ests for anti+odies to Bs in p&s serum /irect coom+s test 3est for sensitiDed er!throc!tes istocetin cofactor Measures a+ilit! of V:$ to a%%lutinate platelets in #itro, in presence of assa! ristocetin Acute prom!eloc!tic 2u+t!pe of AM0 often associated w" /I e*uires proph!lactic heparin leu'emia [AM0-M] therap! 8eutropenic fe#er $e#er in p&s w" a neutrophil count of F @@ cells"microliter
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E8#r"3"sc.l"r 3s4 I#r"3"sc.l"r hemol(sis Fe"#.re E8#r"3"sc.l"r hemol(sis B morpholo%! A+normal .emo%lo+inemia"uria .emosiderinuria 2erum hapto%lo+in 8ormal 2plenome%al! 5&les
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R"i! re3ie/ M .0A %enot!pes in t!pe 1 /M M or%anism i n spontaneous +ac terial peri tonitis M cause of h!poth!roidism in patients older than N !ears of a%e M of am+i%uous %enitalia Most important test in pheochromoc!toma M pituitar! tumor :hipples triad of h!po%l!cemia
M cause of primar! amenorrhea M causes of secondar! amenorrhea M cause of pseudohermaphroditism M %!necolo%ic complaint HEMAT*L*+Y-*NC*L*+Y
.0A-/ and /4 5 col i .ashimotos th!roiditis [chronic l!mphoc!tic th!roiditis] on%enital adrenal h!perplasia B) [h!pertensi#e paro&!sms are an important dia%nostic clue] )rolactinoma )lasma %lucose F K@ m%"dl, 2& of h!po%l!cemia, Impro#ement of s!mptoms +! administerin% %lucose 3urners s!ndrome )re%nanc!, stress, and pol!c!stic o#ar! disease A. [?1-h!dro&!lase def] /!smenorrheal
Iro s#.!ies i "#ie#s / J Microc(#ic "emi" Dise"se Ser.m Fe TI%CJ#r"sferri I/A 9 ; A/ 9 9 2idero+lastic ; 8ormal"; 3hlassemia 8ormal"; 8ormal";
I#r"3"sc.l"r hemol(sis 8ormal /ecreased 3ransfusion reactions, microan%iopathic hemol!tic infections [++esiosis, malaria], GK)/ deficienc!, )8.
Ser.m ferri#i
*#hers
9 8ormal"; ; 8ormal";
0oo' for +lood loss Ma!+e normoc!tic Gi#e p!rido&ine [BK] hec' .+A?, .+$
L" fi!i,s of 3"rio.s lee!i, !isor!ers Dise"se PT PTT %T Pl"#ele#s V:/ 8 8"hi%h .i%h 8 .emophilia A or B 8 .i%h 8 8 /I .i%h .i%h .i%h 0ow 3hrom+oc!to)58IA 8 8 .i%h 0ow 3hrom+oc!to)A3.IA 8 8 .i%h 8 hronic li#er disease .i%h .i%h 8 8 N*TE> Petechiea [Platelet deficienc!], Ca#ities"(oints [Clottin% factor deficienc! Cliic"l s#",i, of Ho!,ki0s l(mhom" S#",e Cliic"l s#",i, 1 0imited to 1 anatomic re%ion ? ? or more re%ions of disease on same side of diaphra%m /isease on +oth sides of diaphra%m limited to 08, spleen, walde!ers rin% 4 Metastatic disease
Ris#oce#i 8"low 8 8
L""ro#om( s#",i, :ed%e li#er +iops! 2plenectom! )eriaortic chain, mesenter! 6 hepatoduodenal 08 samplin% Iliac crest, BM +iops!
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Re( cl"ssific"#io of Ho!,kis l(mhom" 2u+t!pe )roportion )atholo%! 0!mphoc!te -1@ )redominantl! normal appearin% predominant l!mphoc!tes 0!mphoc!te depleted 1@-1 $ew l!mphoc!tes, pleiomorphic cells, fi+rosis Mi &e d c el lu la ri t! ? -4@ ) lei om or ph ic c el ls 8odular sclerosis @-N@ 0!mphoid nodules, colla%en +ands
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)ro%nosis Ver! %ood )oor Go od Good
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A"#om( & h(siolo,( anatomic sta%es of fetal er!throtopoiesis< Meso+la stic Qol' sac 1@-14 da!s AOG [-N w's] .epatic 0i#er K-N w's AOG [K-N w's] M!eloid Bone marrow ? nd trimester of pre%nanc! [?N w's onwards] 2pleen -?N w's •
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2ites of BM aspiration< "#erior #ii" [F 1 !o]L A2I2 [F 1@ !o]L PSIS [ 1@ !o] 0ifespan of B< K@-@ d [neonates]L 1?@ d [adults]
P"#holo,( Anemia< .+ F 1? %"dl or K :-: ,J!l [eo"#es) lassification of anemia< [%"dl] +e!er Mil! Mo!er"#e Se3ere Male 1@-1? N-1@ FN $emale -11 H- FH • •
)oi'iloc!tosis J #ariation in shape of B Anisoc!tosis J #ariation in siDe of B C".ses of "emi"> Dise"ses E#iolo,(J"#holo,( Anemia of prematurit! Be%ins at 1s w' of life up to K-N w's 3erm< -11, )reterm< H-%"dl /iamond-Blac'fan s!nd" Inherited, /%A: ,ee m.#"#io con%enital h!poplastic o chr4 :?:, ; 5)O le#els 3ransient er!thro+lastopenia Ac*uired B aplasia in children of childhood [35] Immunolo%ic er!thropoiesis is 9 )ure red cell aplasia Autoimmune .i%h incidence of "ac*uired h!poplastic anemia th!momas Associated w" 205 )earson-Marrow pancreas ; .+$ +7 ringed sideroblasts s!nd"con%enital h!poplastic Associated w" pancreatic fi+rosis • •
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Imm.olo,ic m"rkers i le.kemi"> S# em c el l M (e lo i! %- cel l AL L / 11, 1 / 1@, 1 dt! &%8-$4 / = / 14, / ?@, ?? •
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Tre"#me# )rotein supplements, r.E 5)O, +lood transfusion 2teroids, immunosuppresants, B3,BM3, 2I 2upporti#e orticosteroids has 8O #alue orticoseroids, andro%ens, splenectom!, th!mectom! 2upporti#e, G-2$
A pre#iousl! health! 1 !"o male infant had a c old N w's a%o .e now is pale and irrita+le and refuses to eat B shows .%+ @, .ct 1@P, MV N@, retic count @P, :B , platelets 4@@>< #r"sie# er(#hrol"s#osis of chil!hoo! A mos old child who has +een fed whole mil' from earl! i nfanc! presents w" the followin% la+s< .%+ H %, MV K?, B ?< IDA A ? !"o +o! w" h!peracti#it! li#es in old apartment +uildin% w" peeling paint on the walls .is %ait has +ecome ata&ic and his speech has re%ressed .is .%+ = N %< le"! oisoi, Mutation causin% sic'le cell disease< +l.- G2"l A 1 !"o African-American %irl is limpin%< sickle cell !ise"se A !"o +o! has re*uired transfusion since earl! infanc!< e#"-#h"l"ssemi" m"or Th"l"ssemi" #(es .% + +a rt s < 4 %e ne de le ti on -th al as sem ia mi nor "t rai t< ? %ene de le ti on .%+ .< %ene deletion 2ilent carrier< 1 %ene deletion .eteroD!%ous< W-thalassemia minor .omoD!%ous< W-thalassemia ma(or [ Cole(0s "emi" ] A pre#iousl! well +lac' male child is treated w" sulfonamide ? da!s later, he de#elops fe#er, +ac' pain, dar' urine and anemia Blood smear shows fra%mented er!throc!tes< +PD !eficiec( A health!-appearin% %irl has a microcytic! hypochromic anemia .er de#elopment has +een normal< IDA A male child has sudden onset of dar' urine, pallor and (aundice, after an e&posure to an o&idant stress< +PD !eficiec( A 4 !"o +o! has pallor and famil! h& of %allstone sur%er! .is .%+ is N, retics 11, +iliru+in ?< here!i#"r( shero(#osis One of the causes of pro&imal 3A< f"coi s(!rome $anconis anemia is an inherited disorder of +one marrow failure, whereas $anconis s!ndrome is s!ndrome is disorder of renal tu+ules 1@ da!s after an episode of #iral diarrhea, a ? !"o +o! has pallor and icterus and petechiae of the s'in and mucous mem+ranes .is mother reports that he has not urinated & ?4 hrs haracteristics la+ findin%s include fra%mented er!throc!tes on smear, increased BE8, increased retic count, indirect h!per+iliru+inemia and normal platelet count< HUS
A 4 !"o pre#iousl! health! %irlw" purple s'in l esions had a #isit to 5 w" EI a month a%o B is normal e&cept for low platelets< ITP A child presents w" epista&is, prolon%ed +leedin% time and normal platelet count< 3o /iller"!0s !ise"se 1 unit of VII"'% = increase ?P 1 unit of I"'% = i ncrease 1P 1 unit of +lood is 4@ ml 6 should increase .%+ +! 1 %"dl and the .ct +! P An N !"o +o! presents w" fe#er & 1 w' after reurnin% from # acation On )5 has splenome%al!< m"l"ri" A !"o %irl has had fe#er, anore&ia and fati%ue for the past month 2he has l ost '%, w" pallor, cer#ical 0A/, splenome%al!, s'in ech!moses and petechiae< "c.#e le.kemi" Le.kemi"s> Arres# i Le.kemi" #(e M!elo+last AM0 )rom!elo+lasts AM0-M )roer!throo+last AM0-MK Me%a'ar!o+lasts AM0-MH
T- ce ll A LL / ?, / , H
Pl" #el e# s / 4?, 4? / :
Er(# hro i! 5lycophorin 8
Important t!pes of A00 6 AM0 A00-01 M t!pe, +est pro%nosis, w" rim"like cytoplasm A00-0 Bur'itts l!mphoma, worst pro%nosis, w" cytoplasmic vacuolation AM0-M Acute mono+lastic t!pe< 82 propensit!, gingi,al hypertrophy , poor pro%nosis AM0-Ma Mono+lastic< sunny"side up nucleoili A M0 -M + M on oc !t ic < clefting or binucleation AM0-MK 5r!throleu'emia< poor pro%nosis, w" bi;arre"looking normoblasts AM0-MH Me%a'ar!o+lastic< w/ pseudopods # cytoplasmic budding, in $own syndrome
%loo! comoe# #her"( %loo! comoe# Co#e#s $resh whole +lood )ac'ed B itrate-)O4 $$) All, e8ce# F6 & )latelet concentrate r!oprecipitate $N, V:$, fi+rino%en, fi+ronectin r!osupernate $?, H,
I!ic"#ios 5&chan%e transfusion, acute massi#e hemorrha%e Aemi" , 82 disease, 5)O alternati#es Li3er !ise"se' DIC, multiple $ deficienc! 3hrom+oc!topenia, throm+asthenia, .emophilia A, h!pofi+rino%enemia, V:/, $1 deficienc! .emophilia %, $? $H deficienc!
.3eile 3s4 Ac.#e chroic m(elo,eo.s le.kemi" Fe"#.res CML A%e of onset F 4 !o 0A/, s'in lesions, +leedin%, infections ommon 5le#ated :B, +lastic phase Enusual .+ F 1?, monoc!tosis, ele#ated .B$ ommon )latelets /ecreased Ph chromosome' %cr-"l ,ee f.sio Ase# 0A) decreased Varia+le Median sur#i#al 1-? !rs 3reatment BM transplant R"i! re3ie/ Most primiti#e sta%e of %ranuloc!tes M source of ener%! for B Best indicator of chronic deficienc! M cause of fatal sepsis in p&s with sic'le cell disease M cause of $anconi s!ndrome M throm+oc!topenia of childhood M hereditar! +leedin% disorder Most fre*uent cause of hemol!sis worldwide M mali%nanc! M meta+olic disorder or B M amon% p&s w" sic'le cell disease 3riad< endothelial dama%e, chan%e in +lood flow, h!percoa%ula+ilit! haracteristic of .od%'ins l!mphoma .emol!tic anemia, throm+oc!topenia, neurolo%! chan%es, decreased renal function, fe#er Bac' pain, anemia, and renal insufficienc!
ACML 4 !o Enusual ommon Varia+le Increased Prese# ommon 4- !rs .!dro&!urea, +usulfan
M!elo+lasts Em!e-Me(erhoff "#h/"( ))) .M) B folate 2trep pneumoniae !stinosis I3) Von wille+rand disease Malaria 0eu'emia GK)/ deficienc! 2almonella osteom!elitis Virchows eed-2tern+er% cells lassic pentad in 33) Multiple m!eloma triad
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INFECTI*US DISEASES Al'aline urine is su%%esti#e of i nfection with< ro#e.s mir"ilis or .re"l"sm" .re"l(#ic.m 3he dischar%e of ,oorrhe" is purulent , whereas w" Chl"m(!i" it is non-purulent V/0") false [] are seen in< 205, infectious mononucleosis, and hepatitis .)V t!pes 1K, 1N, 1, 4, 1, ? and are associated w" cer3ic"l c"cer / recommendations for .IV post-e&posure proph!la&is< Di do#udine, lami#udine, and indina#ir & 4 w's AI/2 pro%ression< o 2tatus of disease< /4 count o ate of pro%ression< #iral load [measure of .IV 8A] Loss of LAD is a mar'er of disease pro%ression in AI/2 An .IV [] p& presents w" dr! cou%h & 1 w' /enies fe#er, ni%ht sweats, and chills .is white count is normal< m(col"sm" e.moi"e An .IV p& w" a low /4 count presents w" fe#er, chest pain, and producti#e cou%h< s#re#ococc.s e.moi"e [comm.i#(-"c?.ire!) /ifferent presentations of AI/2< AI/2 p& w" +rain lesion in% enhancin% lesion w" mass effect< to&olasmosis )eri#entricular rin%< MV Other< 82 l!mphoma [associate w" 5BV] A I/2 p& w" di ar rh ea r !pt os por idi a< [ro und ] Isospora [oral] Microsporidia AI/2 p& w" menin%itis 2ensation of smell and +eha#ioral chan%es< .2V [temporal lo+e] India in' stain w" round or%anisms< cr!ptococccus
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.IV associated mali%nancies< o ..V-K,N< k"osis s"rcom" o .)V 1K, 1N< cer3ic"l CA
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.BV< hepatocellular A A ? !"o .IV p& presents w" /4 count of 1@@, une&plained fe#er, and ele#ated al'aline phosphatase< M(co"c#eri.m "3i.m comle8 An .IV p& presents w" painful, poorl! healin%, perirectal lesion< HS2 A %roup of pre#iousl! health! !oun% people de#elop an acute respirator! illness< demonstrate a widened mediastinum w" clear lun% fields< "#hr"8 A pre#iousl! health! ? !"o +an'er li#in% in a +i% cit! contracts a se#ere pneumonia characteriDed +! the rapid de#elopment of respirator! failure, shoc', +leedin%, and other si%ns of s!stemic inflammator! response s!ndrome 2putume re#eals %m [J] +acilli w" +ipolar stainin%< (ersii" es#is Ad#erse effects of tetrac!clines< photosensiti#it!, ; pre-e&istin% prerenal aDotemia, +rown"!ellow deposits in teeth and +rittle +ones in children A 4? !"o woman who recentl! camped in he woods presents to the 5 w" 1 sided facial droop< l(me0s !ise"se [presents w" Bells pals!] )resents w" fe#er that follows a c!cli cal pattern e#er! 4N or H? hrs should +e considered for< m"l"ri" A !"o +o! w" sudden onset of hi%h fe#er and reddish-purple spots .e is rapidl! pro%ressin% to shoc0 < mei,ococcemi" *( carinii is now known as *neumocystis jiroveci w"c is classified as f.,.s rather than protoDoan 4dew drops on a rose petal T and multiple crops of lesions in #arious sta%es are t!pical of< 3"ricell"
le+siella More common in newborns riteria for /& of Ac*uired )rothrom+in omple& /eficienc! s!ndrome [APCD) o ? w's to 1 !r [usuall! occurs at 1-? mos]
Most on +reastfeedin% onl! 2"2& of +leedin%< pallor 6 i ncreased I) o /ecreased clottin% factors ?,H,,1@ [#itamin ' dependent] o .epatome%al! /ia%nostic criteria of 7"/"s"ki0s !ise"se> o emittent fe#er, spi'in% up to 41X 6 persistin% for da!s o Bilateral con(uncti#a in(ection [w"o e&udates] o han%es in mouth 6 lipsL straw+err! ton%ue, diffuse reddenin% of oral ca#it!, er!thema 6 crac'in% of lips o 5r!thema 6 edema of hands 6 feet o )ol!morphous e&anthem o Enilateral cer#ical 0A/ [ 1 cm in diameter] o
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Cl"ssific"#io of !ih#heri"> T(e M"ifes#"#ios 8asal t!pe lear water! dischar%e, [] pseudomem+rane, no toxemia $aucial"phar!n%eal Mos# !re"!e! form[] massi#e pseudomem+rane, cer#ical adenitis causin% 9ball-nec0: asphyxia, to&emia 0ar!n%eal Inspirator! stridor, dry metallic cough, aphoria, mild to&emia Enusual t!pe 2een in #ul#o#a%inal, con(uncti#a, ears, cutaneous [wrist] See c".ses of !i"rrhe" i "#holo,( & microiolo,( o#es Mos# commo c".ses of FU* i chil!re> Infection Bacterial, #iral, chlam!dial, fun%al, parasitic Autoimmune disease CA, )A8, 205 8eoplasia .od%'ins disease, leu'emia, l!mphoma, neuro+lastoma Endia%nosed ?P Dise"se "ssoci"#ios of e#ero3ir.s> .and, foot 6 mouth disease Acute hemorrha%ic con(uncti#itis Aseptic menin%itis, polio-li'e paral!sis )etechial e&anthema w" menin%itis )ericarditis, m!ocarditis $ulm inant neonatal hepatic necrosis Acute l!mphonodular phar!n%itis .erpn%ina )leurod!nia " epidemic m!al%ia
o&sac'ie A, 1@, 1K o&sac'ie A?4 6 5ntero#irus H@ 5ntero#irus H1 5ntero#irus o&sac'ie B 5ntero#irus 11 o&sac'ie #irus A1@ o&sac'ie A?, 4, K, N, 1@ o&sac'ie B,
+r"!i, of !e,.e fe3er [Nimm"i#(" & H"ls#e"!) +r"!e M"ifes#"#ios 1 $e#er nonspecific constit utional 2&< anore&ia, #omitin%, a+dominal pain, hepatome%al!, flushed s'in ? Grade 1 spontaneous +leedin%< %um +le edin%, epista&is, petechiae on pala te 6 a&illae, rashes on e&tremities Grade ? circulator! failure< rapid 6 wea' pulse, narrowed pulse pressure [?@ mm.%], h!potension, cold clamm! s'in, restlessness 4 Grade profound shoc' Cliic"l s#",es of !e,.e fe3er> $e+rile [1-4 d] $e#er, .A, flushed a'in, anore&ia, #omitin%, a+dominal pain, hepatome%al! Afe+rile [-H d] Mos# cri#ic"l erio!, lethar%! se#ere a+dominal pain, restlessness, epista&is, melena, %um +leedin% on#alescent Impro#ed appetite, petechial rash [ Herm"0s r"shJ ,lo3e & s#ocki, r"sh] = good prognostic indicator /.$ $ e#e r, h em or rh a% ic M &, th rom +oc !t op eni a, he moc onc en tr at io n /22 /.$ h!potension 6 narrow pulse pressure
2ta%in% of tetanus< Fe"#.res S#",e : [mil!) Incu+ation period 14 d )eriod of onset Kd 3rismus Mild 2tiffness 0ocaliDed •
2pasms 82 o#eracti#it!
Mild, +rief A+sent
S#",e @ [mo!er"#e) 1@-14 d -K d isus sardonicus )ronounced, %eneraliDed ri%idit! w" opistotonus 0on%er, fre*uent A+sent
R"i! re3ie/ M cause of neonatal septicemia M presentation in AI/2 M a( or cau se of de at h i n i mm un oc om pr om is ed per so ns M transmitted #irus to a child +efore +irth
S#",e [se3ere) F 1@ d Fd se#ere 2e#ere opistotonus causin% #erte+ral fracture Violent, fre*uent, prolon% )resent
Group B strep 2u+acute or chronic menin%itis M V MV
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Most #irulent t!pe of den%ue #irus 3O for menin%ococcemia
3!pe IV penicillin
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NEPHR*L*+Y & ACID-%ASE DIS*RDERS' UR*L*+Y & +YNEC*L*+IC DISEASES A 4 !"o dia+etic man w" renal insufficienc! has a normal anion %ap > is hi%h, .O is low< #(e = RTA [h(oriiemic h(o"l!os#eroism) 7"(e8"l"#e is the onl! t& of h!per'alemia [other than dial!sis] that remo#es potassium from the +od! In p&s w" underl!in% cardiac failure, consider furosemide to maintain diuresis and pulmonar! arter! pressure monitorin% to a#oid #olume o#erload .un%r!-+one s!ndrome is the rapid transfer of a into +ones followin% remo#al of a h!peracti#e parath!roid nodule *eripheral neuropathies and renal osteodystrophy are features of uremic s!ndrome not seen in A38 82AI/2 usuall! do not cause interstitial nephritis, +ut +! inhi+itin% prosta%landin s!nthesis the! decrease the G$, w"c can precipitate renal failure in a p& w" underl!in% renal pro+lems Aller,ic i#ers#i#i"l ehri#is is characteriDed +! :Bs, eosinophils and white cell casts in the urine 3reat w" steroids and stop the offendin% a%ent 4maltese crosses5 seen in polariDed li%ht e&amination of urinar! sediment are indicati#e of choles#erol i #he .rie4 If a p& presents w" hematuria immediatel! after an infection, thin' I,A ehro"#h( But if a p& presents ? wee's after infection, thin' os#-ifec#io.s ,lomer.loehri#is )C casts are patho%nomonic of an! ,lomer.loehri#is4 G$ and creatinine clearance< for each dou+lin% of serum creatinine, the G$ has decreased +! @P 0ar%e 'idne!s are seen on sono%ram in< dia+etes, am!loidosis, and pol!c!stic 'idne! disease Isos#he.ri" < ina+ilit! of the 'idne! oconcentrate urine fi&es specific %ra#it! at 1@1@ A !"o man presents w" se#ere +ac' pain and hematuria .e is writin% around, una+le to find a comforta+le position, and is nauseous< re"l colic !.e #o .roli#hi"sis @P of F mm stones will pass spontaneousl! @P of stones -N mm will pass P of stones N mm will pass A K w' old child w" pro(ectile #omitin% that is not +ile-stained .e is deh!drated and sli%htl! (aundiced< h(ochloremic me#"olic "ci!osis 3he primar! defect in distal renal tu+ular acidosis is< defect in the secretion of hydrogen ions A 1 !"o child is +rou%ht to 5 w" #omitin%, constipation, and decreased urine production hild is found to +e acidotic A renal E3R re#eals medullar! nephrocalcinosis< !is#"l RTA A ? !"o +o! de#elops +lood! diarrhea a few da!s after eatin% in a fast food restaurant $ew da!s later, he de#elops facial edema, pallor, lethar%!, and decreased urine output Blood wor' shows a low .ct and platelet count E"A re#eals +lood and protein in the urine< HUS seco!"r( #o E4coli ;:6>h ifec#io *li,.ri" is< F 1-? ml"'%"hr urine production A 4 !"o +o! de#elops oli%uria 1?hrs after operation for a ruptured appendi& reatinine = @ m%"dl, BE8 = ? m%"dl, urine 8a = 1? m5*"0< rere"l "5o#emi" [oli%uria is most often due to /.8] In p&s w" prerenal A$< ser.m %UNJCr is 9 @; A !"o p& w" A$ has an 5G showin% pea'ed 3 wa#es and a widened 2 comple& inter#al< H(erk"lemi" On routine e&am, a 1@ !"o %irl has .38 confirmed +! repeated measurements .er B)= 1K@"@ in arm and same i n 0 arm and le%< re"l !ise"se [then order for E"A] An N !"o p& recei#in% peritoneal dial!sis for 52/ de#elops mental status chan%es and fe#er< eri#oi#is A pre#iousl! health! +o! has 0 sided flan' mass disco#ered +! mother )5 re#eals B) = 11@"H@ and a lar%e mass arisin% in his 0 flan' E"A shows -1@ er!throc!tes and ?- leu'oc!tes< /ilm0s #.mor An N !"o %irl has an easil! palpa+le 'idne! E2 shows c!stic 'idne!s, hepatic fi+rosis and portal .38< ARP7D A 1 w' old male new+orn has a wrin'led a+domen that lac's anterior a+dominal musculature .e also has clu+feet and is i n respirator! distress .is +ladder is distended and easil! palpa+le and neither testis is in scrotum 0a+ findin%s include BE8 = @, r = ?, and .O = 1< r.e ell( s(!rome 3he ma(or patholo%ic findin% in con%enital nephritic s!ndrome is< dilation of the proximal tubules A ? !"o +o! has a 1 w' h& of edema B) = 1@@"K@ w" %eneraliDed edema and ascites r =@4, al+umin 14 %"dl, and cholesterol = K m%"dl EA shows 4 protein and no +lood< miim"l ch",e !ise"se [ehri#ic s(!rome) A 4 !"o %irl presents w" malaise, perior+ital edema, and smo0y-colored urine 2he had a strep throat infection ? w's prior A serum complement le#el decreased, and an antistreptol!sin O [A2O] titer is increased< PS+N A p& presents w" hemopt!sis, sinusitis, and %lomerulonephritis< /e,eer0s ,r".lom"#osis A p& presents w" d!spnea, hemopt!sis and A$< ,oo!"s#.re0s s(!rome 5lectron microscop! of memr"o.s +N shows< 4spike and dome5 on epithelial side of =)! /e%rees of proteinuria< 1< @ m%"dl < @@ m%"dl •
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4< ?@@@ m%"dl
An N !"o +o! presents w" % flan0 pain radiating to his % testicle )ain does not chan%e w" mo#ement or positionin% and is colic'! in nature Erine dip is for +lood< .roli#hi"sis onsider nosocomial ;1s w/ Pseudomonas and M4#8 in institutionaliDed or recentl! hospitaliDed p&s A ? mos old male infant w" fe#er, #omitin% and decreased fluid inta'e EA re#eals 1@@ :Bs< E4 coli UTI A H !"o %irl presents w" urinar! ur%enc!, fre*uenc!, suprapu+ic pain, and no flan' pain or mass EA shows man! leu'oc!tes, ?- Bs and no protein or casts< ne&t step is .rie c.l#.re A hospitaliDed K mos old infant w" E3I remains fe+rile after ade*uate anti+iotic t&< ne&t procedure is re"l UTO A 1 !"o +o! w" se#er pain on his testicle w"c occurred suddenl! while pla!in% +as'et+all )5 re#eals tender, swollen, firm testicle w" a trans#erse lie 2o cremasteric reflex on the 4 < #es#ic.l"r #orsio A 1K !"o pre#iousl! health! +a+! +o! e&periences a sudden onset of a+dominal and scrotal pain )5 shows se#ere tenderness in the in%uinal canal on the and the side of sc rotum is empt! E"A is :80< #es#ic.l"r #orsio of " .!esce!e! #es#is [operation] +r"!i, of 2UR Grade 1 efl u& into undilated ureter Grade ? eflu& in to upper collectin% s!stem w"o dilatation Grade eflu& into dilated ureter and +luntin% of cal!ces G ra de 4 ef lu& int o c los el ! di lat ed ur ete r Grade Massi#e reflu& w" si%nificant ureteral dilatation and tortousit! and loss of papillar! impression
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E3R shows multic!stic o#aries resem+lin% 4pearl necklace5% PC* )ain$E0 ulcers< ch"croi!' heres )ain0522 ulcers< L+2' s(hilis Erethral dischar%e is predominant in< %onorrhea, hlam!dia, trichomonas A 1K !"o +o! w" lower left abdominal pain and % testicular pain & ? w'spalpation of testis is normal e&cept for isolated tenderness of the epidid!mis remasteric refle& is normal< ei!i!(mi#is A 1 !"o female presents to the 5/ w" fe#er for 1 da!, d!spareunia, and #a%inal dischar%e 2he had unprotected se& w" a new male partner ? w's a%o )5 re#eals adne&al tenderness, cer#ical motion tenderness, and fria+le cer#i&< PID A !"o %irl presents w" malodorous +lood! #a%inal dischar%e< forei, o!( Pro,ressi3e loss of ki!e( f.c#ios .s."ll( follo/s = s#",es> 2ta%e 1 /iminished renal reser#e G$ = @-N@P of normal 2ta%e ? hronic renal insufficienc! G$ = @-@P of normal 2ta%e hronic renal failure or $ G$ = 1@-@P of normal 2 ta% e 4 5 nd sta% e r ena l d is ea se or 52 / G $ F 1@ P o f n or ma
C".ses of ARF Prere"l .!po#olemia [/.8, hemorrha%e] ardio%enic shoc' 2epsis /ru%s [82AI/s] enal arter! stenosis
Re"l [i#risic) A38 Acute interstitial nephritis Glomerulonephritis 3hrom+oem+olism
R"i! re3ie/ M cause of h!percalcemia in the outpatient Mali%nanc! is the M cause in the in-patient M cause of A$ in toddlers M causes of .38 in children are secondar! causes
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M manifestation of 205 in childhood M renal tumor in children F 1 !o M cause of nephritic s!ndrome in adults M cause of %ross hematuria in children M cause of testicular pain in +o!s 1? !"o M cause of testicular tension M dia%nosed o#arian cause of hirsutism M %erm cell tumor 0eadin% cause of 52/ durin% 1 st decade of life
Pos#re"l )rostate disease 8ephrolithiasis )el#ic tumors ecent pel#ic sur%er!
)rimar! h!perparath!roidism .E2 enal [HP], infection, G8, .E2, o+structi#e uropath! 0upus nephritis :ilms tumor Mem+ranous G8 I%A nephropath! 3esticular torsion )oor fi&ation of testis inside scrotum [+ell clapper deformit!] )O s!ndrome 2eminomas enal h!poplasia
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PULM*N*L*+Y 3he most important determinant of the amount of O? deli#er! to tissues< hemo,loi Tr"s.!"#es 3s4 e8.!"#es Tr"s.!"#es E8.!"#es .$, cirrhosis, nephrosis 3umor, trauma, infection • •
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5mp!ema [pus in pleural space] positi#e culture, or loculated effusion alwa!s re*uire chest tu+e A ?H !"o p& has pneumonia, +ullous m!rin%itis, and a chest film that loo's worse than e&pected< m(col"sm" e.moi"e A p& w" .IV who has /4 count of ? does not ta'e anti-retro#iral medications or 3M)-2M, is h!po&ic on room air, and has diffuse +ilateral infiltrate on chest film< Pe.moc(s#is c"riii e.moi" [PCP) An elderl! man presents w" pneumonia, GI3 s!mptoms, +rad!cardia, and h!ponatremia< le,ioell" Likel( !i",osis for l., ifec#ios> H8' PE' l"s Likel( !8 If !ou see currant-jelly sputum >le+siella If !ou see rusty sputum )neumococcus If a p& de#elops post-infuenDa pneumonia )neumococcus If !ou see bulging fissure on film >le+siella If there are o "c#eri" o ,m-s#"i 0e%ionella and m!coplasma If serum 0/. is hi%h )) If !ou see small %m [J] rods w" halo on %m stain . flu 0oefflers pneumonia is a'a i!io"#hic eosiohilic e.moi" A p& is +rou%ht in +! am+ulance in status epilepticus 3he p&s famil! mem+er sa!s he has no medical histor! e&cept 3B< I8. to&icit!, treat w" p!rido&ine Emh(sem" 3s4 chroic rochi#is Pik .ffers [emh(sem") %l.e lo"#ers [rochi#is) Barrel-shaped chest heart failure 3hin and wasted )ol!c!themia 0ow )O?, normal to low )O? .i%h )O?, low O?
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S.leme#"l *@ is the onl! therap! for O)/ pro#en to e&tend life A 4 !"o male w" pancreatitis %oes into respirator! failure shows +ilateral infiltrates< ARDS [sepsis is the M cause of A/2] M causes of chronic cou%h< postnatal drip, asthma, G5/ 3he classic SwhoopT caused +! rapid air inspiration a%ainst a closed %lottis is rarel! seen in adults M or%anisms to coloniDe +ronchiectatic lun%< &3 inlfluenzae! #3 aureus! P3 aeruginosa A p& w" hemopt!is, sinusitis, and %lomerulonephritis< we%eners %ranulomatosis A p& w" d!spnea, hemopt!sis, and A$< ,oo!"s#.re0s s(!rome A ?@ !"o tall man arri#es c omplainin% of sudden onset of se#er shortness of +reath and pleuritic chest pain< rim"r( so#"eo.s e.mo#hor"8 H"mm"0s si,< a crunchin% sound occurrin% w" heart+eat seen in pneumomediastinum A H !"o %irl is well when she lea#es for school +ut arri#es home afterwards w" a sore throat and runn! nose< rhio3ir.s Most fre*uent illness of childhood and the M reason to miss school< common colds " EI " nasophar!n%itis A 1H !"o se&uall! acti#e adolescent has acute onset of fe#er, cou%h, con(uncti#itis and phar!n%itis< "!eo3ir.s 3he +est t& for common colds is to increase oral fluids, not pharmacolo%ic t& An 1N mos old +a+! +o! w" inspirator! stridor and a +ra'in% cou%h and a%itation when l!in% down is +rou%ht at ni%ht to the 5 +! parents .e has steeple si%n and +alloonin% on &ra!< cro. A 4 !"o +o! +rou%ht to 5 is lushed, ma'in hi%h-pitched noises on forced inspiration, leanin% forward in his mothers lap and droolin% ra! shows thum+ si%n< ei,lo##i#is A pre#iousl! health! 4 mos old who had rhinorrhea, cou%h and low-%rade fe#er de#elops tach!pnea, mild h!po&emia, and h!perinflation of lun%s< RS2 rochioli#is A H !"o +o! w" an EI occasionall! has +lac', tarr!, foul-smellin% stools +ut is otherwise health! ra! shows ? discrete densities located on upper lo+e of the lun%s %rochiec#"sis ?nd M d& in children a%ed 1-1 !"o in pediatric clinic< h"r(,i#is )neumonia w" hilar adenopathy on chest &ra!< "!eo3ir.s 4ound pulmonary infiltrate in <=4 < strep Pe.moi"e A ? month old w" fe#er, tach!pnea, and mottled s'in has a showin% infiltrate of the upper lun% lo+e, a pneumatocele +bleb and pleural effusion< S#"h4 A.re.s e.moi" A pre#iousl! health! !"o +o! has a H da! h& of increasin% cou%h, low %rade fe#er and fati%ue on e&ertion shows widespread diffuse perihilar infiltrates < m(col"sm" e.moi"e )ulmonar! a+scess occur M at< posterior segment of upper lobe and superior segment of lower lobe( 42ail sign5 on C> is characteristic of< .lmo"r( "scess ommon cause of death in pertussis< "c#eri"l e.moi" 4)utterfly pattern5 on C>% er#.ssis 3here is a hi%h ris' for h!pertrophic p!loric stenosis in infants F K wee's t& with< oral erythromycin I#erre#"#io of PPD [M"#o.8 #es#) I!.r"#io I#erre#"#io F mm hildren in close contact w" 'nown suspected cases of acti#e 3B, +ased
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on consistent or clinical findin%s, immunosuppressed children hi ld ren F 4 !" o, w" ch roni c i l ne ss hildren 4 !"o w"o an! ris' factors
3he %ene for c!stic fi+rosis is CFTR, the mutation is !el#" F6; M pulmonar! 2& in c!stic fi+rosis< co.,h A !"o has had K episodes of pneumonia w" )seudomonas +ein% isolated from sputum, loose stools, and is at the ?@ th percentile for %rowth< c(s#ic firosis $alse [] sweat test [not $Y is seen in< 8ephro%enic /I, M!&edema, Mucopol!saccharidosis, Adrenal insufficienc!, 5ctodermal d!splasia P of cases of meconium ileus is due to< CF $at solu+le #itamin deficiencies< A J ni%ht +lindness 5 J neurolo%ic d!sfunction / J decreased +one densit! > J +leedin% $ot potato voice is seen in< ei,lo##i#is "! eri#osill"r "scess lassic trilo%! of asthma< bronchospasm6 mucus production6 inflammation and edema of airway mucosa Most important stud! in asthmaL spirometry A !"o +o! w" a h& of sleepin% pro+lems presents w" a non-producti#e nocturnal cou%h and shortness of +reath and cou%h durin% e&ercise< "s#hm" A !oun% p& +ein% treated as an in-patient for asthma e&acer+ation is an&ious, has a flushed face, and is #omitin% repeatedl!< "mioh(llie #o8ici#( Forei, o!( "sir"#io> 3oddlers< 4 > % mainstemL Adults< 4 mainstem predominates )ercussion of lun% fields< .!perresonant [o#erinflation]L /ull [atelectasis] A ? !"o +o! is +rou%ht to 5 w" acute onset of audi+le wheeDin% = ?4 w"mild i ntercostals retractions .is +a+!sitter found him pla!in% in his room< forei, o!( "sir"#io A pre#iousl! health! +o! de#elops pneumonia w" consolidation of lower lo+e on different occasions in K mos< "sir"#io of forei, o!( ?nd M con%enital lun% lesion< c(s#ic "!eom"#oi! m"lform"#io [increases ris' for pulmonar! h!poplasia] Cliic"l si,s #h"# i!ic"#e e.moi"> K@"min @ to F ? mos old @ ? to 11 mos old 4@ 1?mos to !o
Norm"l resir"#or( r"#es i chil!re A,e %ir#h #o /ks /eeks #o @ (4o 4-K@"min 4@"min •
@- (4o @"min
*3er :; (4o ?@"min
Si,s of resir"#or( !is#ress> $larin% ala nasi 1nspiratory J +reath-in etractions 2u+costal [chest indrawin%], intercostals [anteroposterior] .ead +o++in% Sair hun%erT, si%n of ; respirator! effort, %aspin% for air [e& /2 1] Gruntin% 2ound comes out at initial phase of e&piration [acidosis] :heeDin% 2ound comes out at last phase of e&piration 2tridor .i%h-pitched sound elicited durin% inspiration [E3I]
Resir"#or( ifec#ios "! "#ho,es Resir"#or( !ise"se Mos# commo "#ho,e roup )arainfluenDa #irus 5pi%lottitis 2 pneumonia e, . influenDae t!pe B 3racheitis 2 aureus, . influenDae t!pe B Bronchiolitis 2V Bronchitis Viral )har!n%itis Viral, %roup A strep Bacterial pneumonia 2 peumoniae )ulmonar! a+scess 2 aureus •
-:; (4o ?"min
Cl"ssific"#io of e.moi"> Cl"ssific"#io ; #o K @ mos4 Ver! se#ere An! dan%er si%ns [stridor, disease con#ulsions, drowsiness, lethar%!, se#ere malnutrition] Ver! se#ere 8o dan%er si%n, no c!anosis, not pneumonia a+le to feed, se#ere chest indrawin%, fast +reathin%, cou%h 2e#ere 8o dan%er si%n, no c!anosis, a+le pneumonia to feed, chest indrawin%, fast +reathin% [K@ +pm] 8on-se#ere pneumonia 8o pneumonia 8o si%ns of 1, ?,
Si,s "! s(m#oms Bar'in% cou%h, s#eele si, 3ripod position, #h.m si, apidl! pro%ressi#e )aro&!smal wheezing )roducti#e cou%h 2ore throat, tonsillar in,ol,ement ou%h, lo+ar de%eneration a#it! w" air-fluid le#el
@ mos4 #o 6 (4o An! dan%er si%ns [fe#er, stridor, wheeDin%, drowsiness, lethar%!, con#ulsions 8o dan%er si%n, no c!anosis, chest indrawin%, difficult! +reathin%, not a+le to drin' 8o dan%er si%n, no c!anosis, chest indrawin%, cou%h, a+le to drin', difficult! +reathin% 8o dan%er si%ns, c!anosis, or chest indrawin%, fast +reathin% 8o si%ns of 1, ?, 6 4
Tre"#me# of e.moi"
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P"#ie# #(e O)/ - A) )& w" /M, O)/, .$, alcoholic, renal failure A) J inpatient 2e#ere A) J inpatient 8osocomial pneumonia
S.sec#e! "#ho,es 2 pneumoniae, M!coplasma, hlam!dia, .i+, #iral 2 pneumoniae, .i+, %m [-] rods, 2 aureus, 0e%ionella 2 pneumonia, .i+, anaero+es, le%ionella, hlam!dia 2ame as a+o#e )seudomonas, 2 aureus, le%ionella, mi&ed flora
C".ses of resir"#or( os#r.c#ios Fe"#.res As#hm" 2!mptoms Intermittent 2putum /urin% e&acer+ations )$3s 8ormal, ZY methac holi ne, o+struction ZY B/ " 3 .!perinflated 3reatment
Others
Inhaled corticosteroids, +a%onists, anti-leu'otrienes, theoph!lline G5/ )ost-nasal drip, cou%h AB)A
C".ses of h(o8i" V mismatch 2hunt .!po#entilation /ecreased +arometric pressure /ecreased $IO? /iffusion impairment
C*PD Alwa!s 2putum mos"!r O+struction w" 8O B/ .!perinfla ted Anticholiner%ics, +a%onists, theoph!lline, inhaled corticosteroids hec' o&!%en 2mo'in% cessation eha+, hec' 1-A3
Ii#i"l co3er",e 5r!throm!cin, 38, clarithrom!cin [smo'ers] ?nd %en cephalosporins [cefuro&ime] ?nd or rd %en cephalosporins [cefota&ime, ceftria&one] 5r!throm!cin macrolides rd %en cephalosporins amino%l!coside [%entamicin]
%rochiec#"sis Alwa!s /ail!"copious O+struction w" 8O B/ .!perinfla ted, w" dilated, thic'-walled +ronchi Anti+iotics, +ronchodilators, chest )3 hec' sweat test hec' A8A, $
Asthma, O)/, I)$, )ulmonar! em+olism Blood, pus, water, atelectasis, anatomic shunt 8ormal A-a %radient Altitude 8O3 altitude
Disor!ers "ssoci"#e! /J "irflo/ os#r.c#io Cliic"l #erm Si#e Cliic"l fe"#.res Chroic Bronchus Mucous %lnd rochi#is h!perplasia, h!persecretion Bronchus Airwa! dilation and %rochiec#"sis scarrin% Bronchus 2mooth muscle As#hm" h!perplasia, e&cess mucus, inflammation Acinus Airspace Emh(sem" enlar%ement, wall destruction Bronchiole 2carrin% and %rochioli#is o+literation S#",i, of rochoe.moi"> S#",e M"ifes#"#ios Mild Basal rales, lon% h& of cou%h 6 fe#er Moderate ales in +oth lun% fie lds, I 6 2 retractions 2e#ere Alar flarin% a+o#e 2"2&
E#iolo,( 2mo'e, air pollutants
)ersistent or se#ere infections Immunolo%ic or undefined causes
SJS8 ou%h, sputum production ou%h, purulent sputum fe#er 5pisodic wheeDin%, cou%h, d!spnea
Cliic"l scori, for Cro.> Fe"#.res ; Inspirator! +reaths 8ormal 2tridor 8one ou%h 8one etractions 8one !anosis 8one 2core of K or more = intu+ate
: .arsh w" rhonchi Inspirator! .oarse cr! $l ari n% 6 s upras ternal retractions In air
R"i! re3ie/ M cause of hemopt!sis M s!mptom of lun% A A ma(or cause of croup M cause of stridor in a fe+rile child and also the M infectious cause of acute upper airwa! o+struction M serious respirator! infection in infanc! M cause of +ronchiolitis M complication of +ronchiolitis M s!mptom in chronic +ronchitis 2taccato cou%h is characteristic of Most relia+le si%n of pneumonia is M lethal inherited disease of aucasians and is also the M cause of se#ere, chronic lun% disease in chil dren M chronic lun% disease in children and is also the M cause of cou%h in school a%e children Most fre*uent cause of stridor in infants M con%enital lun% lesion /O for %roup A +eta-hemol!tic strep<
)enici l in lindam!cin )enicillin Ampicillin )8 G )enicillin Methicillin8afcillin"O&acillin Amino%l!coside )8 5r!throm!cin )8
@ /ela!ed Inspirator! 6 e&pirator! Bar' [1] su+costal 6 intercostals retractions In 4@P O?
3B hronic cou%h )arainfluenDa roup Bronchiolitis 2V .!po&ia [then /.8] ou%h hlam!dia trachomatis 3ach!pnea !stic fi+rosis Asthma 0ar!n%omalacia on%enital lo+ar emph!sema )enicillin
RHEUMAT*L*+Y ommon causes of spinal cord compression< multiple myeloma! lymphoma! metastatic lung! prostate! and breast <8 ommon deformities in RA> •
3o+acco smo'e
/!spnea
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2mo'e, air pollutants
o Elnar de#iation of the di%its
ou%h, d!spnea
o )outonniere’s deformity < hyperextension of $1P and flexion of P1P o 2wan neck deformity% flexion of $1P! and extension of the P1P3
Tre"#me# ? mos-? !rs< ampicillin ? !rs< pen G, steam inhalation, ; fluids Ampicillin, )8, steam inhalation, increase fluid inta'e Ampic illin, )8, mucol!tics, steam inhalation, increase fluid inta'e, er!throm!cin
Scori, of If"# Resir"#or( Dis#ress S(!rome or H("lie Memr"e !ise"se Fe"#.res : @ F K@ K@-N@ N@ etraction 8one Mild 2e#ere !anosis 8one )resent )resent )erfusion Good $air )oor Air entr! Good $air )oor Gruntin% 8one )resent )resent 2core of 4- = intu+ate Resir"#or( !is#ress> Sil3erm" scori, +r"!e ; Epper chest 2!nchroniDed 0ower chest 8o retraction iphoid retraction 8one 8ares dilation 8one 5&pirator! %runtin% 8one
Dr.,s of choice for e.moi"s> Bac teri al pneumoni a 2 pneumoniae 0un% a+scesess Anaero+es .ospital ac*uired 2 pneumoniae pneumonias . influenDa Grp A strep )eptococcus 2taph pneumonia Gm [-] pneumonias )neumonias in 2 pneumonia, . immunocompromised influenDa, m!coplasma
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: 0a% on inspiration Cust #isi+le Cust #isi+le Minimal 2tet onl!
@ 2ee-saw Mar'ed Mar'ed Mar'ed 8a'ed ear
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If :B count is low in an A p&, thin' of Fel#(0s s(!rome [triad of 48! splenomegaly! and leucopenia] 8ote that in dru%-induced 205, there is no 'idne! or 82 in#ol#ement *steoarthritits affects the *uter (oints of the hand [ DIPs] while A affects the inner (oins [M)s and )I)s] A ?H !"o +lac' female presents w" %eneral malaise, arthral%ias, oral ulcers and a photosensiti#e rash< SLE A ?4 !"o woman presents w" a h& of m ultiple miscarria%es 2he has no 'nown medical h& :"c anti+odies would !ou test for lupus anticoa%ulant and anticardiolipin /&< "#ihosholii! s(!rome A 4@ !"o woman presents w" d!spnea, malaise, #isual distur+ances, and a rash s hows bilateral hilar %8$< s"rcoi!osis )ol!m!ositis and dermatom!ositis can +e distin%uished from m!asthenia %ra#is +! the lac' of ocular in#ol#ement [ ptosis] A H !"o woman complains of difficult! %ettin% out of a chair and difficult! com+in% the hair< ol(m(osi#is A !oun% man w" stiffness in lower +ac' that impro,es w/ exercise< "k(losi, so!(li#is %ehce#0s .lcers pain the male +ut spare the female [painless in women] *athergy test% inflammator! reaction of s'in to an! scratches If there is no response to anti+iotics for presumed gonococcal arthritis, consider Rei#er0s s(!rome )A8 J spares the lun%s, hur%-2trauss-0un% s!mptoms predominate +oo!"s#.re0s s(!rome is the other disease that in#ol#es +oth lun%s and 'idne! riad of glomerulonephritis! pulmonary hemorrhage! anti-5BM 8b
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#"k"("s.s is also called Spulseless diseaseT and Saortic arch s!ndromeT .!peruricemia is caused +!< increased urate production, decreased urate e&cretion AV8 of the hip in children is call ed< Le,,-C"l3e-Per#hes !ise"se C".ses of os#eom(eli#is ( ",e> Infants F 1 !ear or F mos Group B strep, 2 aureus, 5 coli 1-1 !o 2 aureus, %roup A strep, 2 pneumoniae A !"o +o! w" definite h& of penicillin aller%! de#elops osteom!elitis 2mear of the aspirate shows %m [] cocci n clusters< treat child w" #ancom!cin A 1K !"o +o! complaints of 'nee pain )5 re#ealed tenderness and swellin% o#er ti+ial tu+erosit! .e is otherwise health!< *s,oo!-schl"##er !ise"se [t& w" acti#it! restriction] A K !"o +o! presents w" hip and 'nee pain limpin% On )5, he is una+le to a+duct and internall! rotate his hip< le,-c"l3e-er#hes !ise"se An o+ese 14 !"o +o! has pain i n 0 anterior thi%h & ? mos on )5, there is limited passi#e fle&ion and internal rotation of his hip< SCFE Rei#er0s !ise"se< cant pee, cant see, cant clim+ a tree 2i%ns and s!mptoms of sr"is Grade 1 )ain"tenderness w"o loss of motion Grade ? )ain"tenderness, ecch!mosis w" some loss of ran%e motion Grade 0i%ament is completel! disrupted, pain"tenderness, swellin% and ecch!mosis, (oint insta+ilit!, and complete loss of ran%e of motion A ? !"o +o! complains of 0 arm in a fle&ed pronated position and refuses to supinate his forearm durin% e&amination .is mother remem+ers pullin% him +! the arm !esterda!< s.l.8"#io of #he r"!i"l he"! 7nursemaid’s elbow8 A p& has had dull, achin% pain for se#eral m onths that has suddenl! +ecome more se#ere< os#eos"rcom" A presentin% s!mptom of 5win%s sarcoma< bone pain A 1@ !"o +o! complaints of pain in his 0 le% On )5, there is localiDed swellin% and pain in the middle of his 0 femur .is temperature is 1@@N $ [N? ], and 52 is ele#ated $urther *uestionin% re#eals a ? mos h& of increasin% fati%ue and wei%ht loss< E/i,0s s"rcom" :hile doin% )5 on a mos old female infant, the doctor notices that her 0 'nee is lower when her hips are fle&ed )& was +orn #ia +reech deli#er!< DDH [!e3elome#"l !(sl"si" of #he hi) ?rtholani’s test < slowl! a+duct fle&ed hip 3he femoral head will shift into the aceta+ulum producin% a clun' Barlow’s test < dislocate the hip +! fle&in% and adductin% the hip w" a&ial pressure A ? !"o child is +rou%ht in w" a radial fracture after li %htl! +umpin% his arm ra! shows multiple healin% fractures On )5, p& has +lue sclera, thin s'in, and h!poplastic teeth< os#eo,eesis imerfec#" A !"o +o! must use his hands to push himself up when risin% from a supine position< +o/er0s m"e.3er T(e = Ehler0s-D"los s(!rome is associated w" a wea'ened uterus, +lood #essels or intestines 2creenin% for scoliosis should +e%in at< - (Jo O+li*ue &-ra! #iew of spine shows a characteristic 42cottie dog sign5< so!(lol(sis T(es of os#eo,eesis imerfec#"> 3!pe 1 MC #(e< fractures in childhood, hearin% loss 3!pe ? 0ethal in perinatal period, #er! rare 3!pe $ractures at +irth, pro%ressi#e deformit! 3!pe 4 2'eletal fra%ilit!, 8O hearin% loss, moderate %rowth failure
oi# fl.i! ""l(sis Disor!er 3rauma eacti#e arthritis Cu#enile A 2eptic arthritis
M +one lesion in 1 st decade M sites of metastasis in 5win%s sarcoma M sites of Osteoid osteomas M +one tumor in children M mass in popliteal fossa M osteoporosis s!ndrome in children M cause of nec' muscle strain M muscular d!stroph! M cause of low +ac' pain in adolescent athletes [%!mnasts, dancers, foot+all pla!ers] M site of dis'itis as seen in MI M cause of dis'itis
+l.cose 8ormal 8ormal 0ow to normal 0ow to normal
Chil!hoo! fr"c#.re [N*T RELATED T* A%USE) 3orus fracture " Impaction in(ur! in children in w"c the +one corte& is +uc'ed +ut not Buc'le fracture disrupted, a sta+le fracture Greenstic' fracture Incomplete fracture in w"c corte& is disrupted on onl! 1 side 3oddler fracture 8on-displaced spiral fracture of the ti+ia, s& include pain, refusal to wal', and minor swellin% R"i! re3ie/ M cause of osteom!elitis M site of osteom!elitis M cause of pol!articular septic arthritis M cause of limpin% 6 acute hip pain in children -1@ !"o lassic presentation of Spainless limpT M orthopedic hip disorder occurrin% in adolescence M cause of chest pain in children M primar! mali%nant neoplasm of +one
2taph aureus Metaph!sis of lon% +ones 8 %onorrhea 3o&ic s!no#itis 0e%%-cal#e-perthes disease 2$5 [slipped capital femoral epiph!sis] ostochondritis Osteosarcoma
0um+ar spines 2taph aureus
NEUR*L*+Y :atershed in(ur! descri+es ischemic in(ur! of +rain tissue located at distal end of cerebro,ascular tree, usuall! due to a low-flow state :hen menin%itis is suspected on clinical %rounds, do not wait for results of la+ tests or ima%in% studies< treat empiricall! %oss of bowel or bladder function and tongue biting are important clues in the dia%nosis of a seiDure In m("s#hei" ,r"3is, repetiti#e muscle use *uic'l! induces fati%ue, whereas in E"#oL"mer# s(!rome, repetiti#e muscle use impro#es muscle stren%th Amino%l!cosides can precipitate m("s#heic crisis A N !"o man presents w" droolin% and facial ner#e paral!sis On e&am, he has #esicular lesions or er!thematous +ases in ear canal< R"ms"(-H.# s(!rome auses of painful #ision loss< optic neuritis! giant cell arteritis! acute-angle closure glaucoma auses of painless #ision loss< central retinal arter! occlusion [ pallor and cherry red spot ], central retinal #ein occlusion [ thunderstorm], retinal detachment [ curtain] A K? !"o woman presents w" headache, pain when she chews, and scalp tenderness< #emor"l "r#eri#is o%niti#e decline is a late feature of Par0inson’s A N !"o man went to a mo#ie theater and e&perienced acute nausea, headache and +lurred #ision 5&am shows dilated pupils w" shallow anterior cham+er< "c.#e ",le-clos.re ,l".com" •
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Ph(siolo,( & emr(olo,( [For Pe!i"#rics) ?ormal $C @ ." cm, its rate of %rowth is @ cmJmo4 [1st mos], : cmJmo4 [?nd mos], @ cmJmo4 [1 !r of a%e] Norm"l CSF fi!i,s> Term Pre#erm *l!er chil! uantit! 4@ m 1@-@ ml Appearance lear to &anthochromic lear to &anthochromic B @-1@@ @-1@@ :B @-? @-1 Glucose H@-N@ H@-N@ )rotein K@-1@ K@-?@@ •
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Cells J L B:B, F ?,@@@ :B ?,@@@-1@,@@@ mononuclear :B ,@@@-K@,@@@ :B [neutrophils] K@, @@@ :B, @P neutrophils
5win%s sarcoma 0un%s, +one [spine], and +one marrow $emur and ti+ia Osteochondroma Ba'ers c!st Osteo%enesis imperfecta 3orticollis /uchennes muscular d!stroph! 2pond!lol!sis
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Norm"l ICP> o 8ew+orns< K mm.G o hildren< K-1 mm.% o Adolescents"adults< @-1 mm.% entral #enous pressure< 8ew+orn = 4-H cm .?OL hild = N-1 cm .?O 8ormal openin% pressure = ;-@;; mm H@* 8ormal closin% pressure = :;-@; mm H@* 3raumatic tap [2A.]< 1 m% protein = N@@-1@@@ B or 1 :B = K@@-1@@@ B [clear = traumatic tap, &anthochromic = 2A.] Other causes< h!per+iliru+inemia, carotenemia, increase protein $ontanelles< Fo#"elle Fe"#.res Clos.re Loc"#io A nt er io r / ia mo nd 1 ?- 1N w' s [ 1? -1N m os ] B tw c or ona l 6 s a%i tt al )osterior 3rian%ular 1K w's [-4 mos] Btw parietal 6 occipital Norm"l e.rolo,ic !e3elome# of " chil!> @A w0s $in%er to nose test Arms must +e a+ducted at shoulder to mo#e fin%er to a different place each time .eel to shin test $le& heel until it touches the shin
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0um+ar puncture< L=-L6 [new+orns], L-= [children] J needle insertion thru su+arachnoid space See orm"l CSF fi!i, 3s4"#holo,ic
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P"#holo,( Bacterial menin%itis is of %reatest ris' amon%< -:@ mos4 ol! )h!siolo%icall! the earliest conscious manifestation of a seiDure< presence of an aura ommon s& of comple& partial seiDure< automatisms :hile e&aminin% an N !"o %irl, the child suddenl! de#elops a blan0 stare and flic0ering eyelids ?@ seconds later she returns to normal and acts as if nothin% has happened< "sece sei5.re A fe+rile seiDure lastin% 1 minutes su%%est an or%anic cause such as< mei,i#is or #o8i e8os.re 4port"wine stain5 is characteristic of< s#.r,e-/eer s(!rome .erniation s!ndromes that ma! result in coma< o Ipsilateral oculomotor d!sfunction< .c"l heri"#io o he!ne-sto'es respirationsL transtentorial +central herniation Cernig’s sign< fle& p&s le% at +oth hip and 'nee )ain on e&tension is a [] si%n Brudzins0i sign< in#oluntar! fle&ion of the hips and 'nees w" passi#e fle&ion of the nec' while l!in% down )upil reacts poorl! to li%ht +ut accommodation is normal, seen in neuros!phillis< ar%!l-ro+ertson pupil A 1 w' old child +orn to an immunocompromised mother presents w" difficult! feedin%, trismus, and ri%id muscles< ,eer"li5e! #e#".s 2!ndrome characteriDed +! micro#esicuar steatosis and a+errant mitochondrial meta+olism< Re(e0s s(!rome .allmar' feature of hepatic encephalopath!< mental status chan%es [related mostl! to f.lmi"# 3ir"l he"#i#is] Infantile +otulism is associated w"< in%estion of hoe( Best test for posterior fossa tumor< MRI 3est of choice in AVMs< ",io,r"h( 4*opcorn appearance5 on !1 < c"3ero.s hem",iom" Gold standard for su+dural hematoma< CT sc" )& w" lucid inter,al < ei!.r"l hem"#om" S.!.r"l he"m"#om" appear crescent"shaped 7concave8 on 3 and will not cross the midline +ut will cross ipsilateral suture lines Ei!.r"l hem"#om"s are lens"shaped 7conve&8 on 3 and will not cross the midline or other cranial structures 3he onl! cause of h!drocephalus from increased 2$ production< choroi! le8.s "illom" E#iolo,ies of h(!roceh"l.s> T(e Ch"r"c#eris#ics O+structi#e [non-communicatin%] /ue to stenosis or narrowin% of a*ueduct of h!drocephalus 2!l#ius [4th #entricle] 8on-o+structi#e [communicatin%] $ollows su+arachnoid hemorrha%e, h!drocephalus menin%itis or intrauterine infection .!drocephalus e& #acuo esults from decreased +rain parench!ma • • • •
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ifampicin = ?@ m%"'%"da! )!raDinamide = @ m%"'d"da! riteria for %i#in% anti-con#ulsants in +eni%n fe+rile seiDures< [an! ? of these factors] o A%e F 1 !o o omple& form of seiDure J multiple, focal, w" neurolo%ic deficit o 8eurolo%ical status of child prior to seiDure o $amil! h& o 55G findin%s in selected ?" of the population riteria for d& of %FC< o A%e K mos J K !o o 8o 82 infection or meta+olic pro+lems present o 3emp N de%rees o
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osenthal fibers are seen in< "s#roc(#om" "! Ale8"!er0s !ise"se Ne.rofirom"#osis #(es 3!pe 1 hr 1H af\-au lait spots, childhood onset 3!pe ? hr ?? Bila teral acoustic neuromas, teen-a%ers, multiple 82 tumors A teena%e %irl has a headache and cape-li'e distri+ution of pain and temperature sensor! loss that de#eloped after a minor motor #ehicle accident< cer3ic"l s(ri,om(eli" /J .!i",ose! chi"ri I esults from a de#elopmental failure of the root of the Dth ,entricle to form, resultin% in a c!stic e&pansion into posterior fossa< !"!(-/"lker m"lform"#io ?nd M posterior fossa tumor and is the M +rain tumor in children F H !"o< me!.lol"s#om" J PNET Cliic"l s#",i, of #.erc.lo.s mei,i#is> 2ta%e 1 [earl!] 8on-specific 2"2&, no cloudin% of consciousness, no neurolo%ic deficits 2ta%e ? [intermediate] 0ethar%!, alteration in +eha#ior, menin%eal irritation, minor 8 palsies 2ta%e [ad#anced] A+normal mo#ement, con#ulsions, stupor, coma, paresis S#",es of T% mei,i#is 1 2ta%e of irrita+ilit! [1 w'] ? 2ta%e of pressure or con#ulsi#e [1 w'] )aral!tic or terminal sta%e [1 w'] •
)rodromal 2& of anore&ia, apath!, irrita+ilit!, #omitin%, si%ht to moderate %rade fe#er )eriods of drowsiness 6 irrita+ilit!, menin%eal irritation, increased I) Mentall! inaccessi+le, stuporous, comatose, w" neurolo%ic deficit, mortalit! rate = N@P
M%t of T% mei,i#is< o I8. = ?@ m%"'%"da!
ecommendations for T% chemo#her"(> 1st ? mos I8$, I$, )RA 2M or 5MB & ? mos 8e& t 1 @ m os I 8. I $ CSF fi!i, i !iffere# !ise"ses 9 %lucose, )M8 predominance 8ormal %lucose, l!mphoc!tic predominance 8umerous Bs in serial 2$ samples Increased %amma%lo+ulins
Bacterial menin%itis Aseptic #iral menin%itis 2A. Multiple sclerosis
Commo eiles( s(!romes 0ocaliDation related epileps! 2eiD ures secondar! to a focal 82 lesion Beni%n olandic epileps! Infre*uent partial seiDures arisin% ou of sleep, %ood response to anti-epileptic dru%s :est s!ndrome"infantile Tri"!> if"#ile s"sms' "rres# of !e3elome# "! neoplasm h(s"rrh(#hmi" , t& +! IM A3. Cu#enile m!oclonic epileps! epetiti#e m!oclonic (er's particularl! in the mornin%, A5/ response is %ood hildhood a+sence epileps! 2tron% %enetic predisposition, il"#er"l H5 sike "! /"3e Cu#enile a+sence epileps! 552 spi'e and wa#e often faster than .D 0enno&-Gaustaut s!ndrome 3onic, atonic and at!pical a+sence seiDure t!pes 0andau->leffner s!ndrome A'a ac*uired epileptic aphasia, pro%ressi#e loss of spontaneous speech Mesial temporal sclerosis Gliotic scarrin% and atrop! of hippocampal formation creatin% seiDure focus H.# "! Hess Sc"le for SAH GA/5 1 As!mptomatic GA/5 ? 2e#ere headache, nuchal ri%idit! GA/5 /rows!, minimal neurolo%ic deficit GA/5 4 2tuporous, moderate to se#ere hemiparesis GA/5 /eep coma, decere+rate ri%idit! Commo #(es of s#roke & #heir m"ifes#"#ios MA Aphasia [dominant], ne%lect [non-dominant], contralateral hemiparesis, %aDe preference, homon!mous hemianopsia A A 0 e% pa res is , am nes ia , pe rs on al it ! c ha n% es , fo ot d ro p, % ai t d! sfu nc ti on )A .omon!mous hemi anopsia, memor! defic its, ale&ia or d!sl e&i a Basilar A oma, 8 pals!, apnea, #isual 2&, drop attac's, d!spha%ia 0acunar stro'e /!sarthria-clums! hand s!ndrome, ata&ic hemiparesis MC "ssoci"#e! /J HPN & DM 3IA 3ransient neurolo%ic deficit lastin% F ?4 hrs )ure motor stro'e 1-sided loss of face, arm, le%-len%th [8O sensor! loss or cortical d!sfunction] R"i! re3ie/ M primar! intracranial neoplasms M cause of +lindness in E2 M cause of dementia M s!mptom in simple partial seiDures M seiDure d"o durin% childhood M etiolo%! of neonatal seiDure M s!mptom of o+structi#e sleep apnea M de%enerati#e ata&ia M t!pe of headache in pediatric population M t!pe of aneur!sms M presentation of aneur!sm M presentation of ca#ernous heman%ioma M presenti n% s!m ptom in arterial throm+osis M c aus e o f t hr om +oe m+ ol ic st ro' e i n ch il dr en Most fre*uent focal +rain in(ur! in sports and is the M form of sports related intracranial hemorrha%e M cause of infantile spasms
Astroc!tomas Macular de%eneration AlDheimers Motor acti#it! 2imple fe+rile seiDures .!po&ic ischemic encephalopath! 2norin% Ata&ia-telan%iectasia ommon mi%raine 2accular aneur!sm 2A. 2eiDure 2eiDure ar di ac a+n orm al iti es 2u+dural hematoma 3u+erous sclerosis
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M cause of epidural hematoma M cause of death associated w" #on .ippel-0in dau dse M t!pe of Arnold-hiari malformation w"c is associated w" menin%om!elocele M posterior fossa tumor in childhood lassic findin% in posterior fossa tumors .allmar' of ett s!ndrome .)8, +rad!cardia, +rad!pnea Interstitial 'eratitis, pe%-shaped incisor, deafness [t& +! IV penicillin] 3& of choice for herpetic menin%itis
3emporal +one f& [laceratin% the middle menin%eal arter!] enal A 3!pe ? ere+ellar astroc!toma 8!sta%mus epetiti#e hand wrin%in% and resultant loss of use of the hands ushin%s triad .utchin%sons triad in con%enital s!philis Ac!clo#ir
DERMAT*L*+Y Erticaria, an%ioedema, anaph!la&is, and atopic dermatitis are e&les of #(e : h(ersesi#i3i#( reactions occurrin% in the s'in .enoch-2chonlein purpura< o Associated w" strep infection penicillin o 2mall-#essel #asculitis o )urpura of lower e&tremities and +uttoc's o A+dominal pain o I%A deposits in %lomeruli o More common in children A !oun% person presents w" pruritic, spotted rash on trun' that +e%an as 1 solitar! lar%er patch< i#(ri"sis rose" A !"o has salmon"colored papules co#ered w" sil#er!-white scale on his scalp, el+ows, and 'nees< sori"sis A ? !"o woman has a cou%h and a showin% mediastinal %8$ 2he has painful s0in nodules on s'in of the ti+iaL er(#hem" o!os.m $erpes simple& virus accounts for most cases of rec.rre# er(#hem" m.l#iforme S#",es of !ec.i#.s .lcers> 2ta%e 1 8on-+lanchin% er!thema of intact s'in 2ta%e ? )artial-thic'ness s'in loss in#ol#in% epidermis and"or dermis [superficial ulcer] 2ta%e $ull-thic'ness s'in loss in#ol#in% epidermis and dermis 2ta%e 4 $ull-thic'ness s'in loss w" e&tensi#e dama%e to muscle, +one, or other supportin% structures
Inea facialis 3inea capitis 3inea +ar+ae On!chom!cosis 3i nea # er si col or
T(es of m"li,"# mel"om" Fe"#.res S.erfici"l sre"!i, Appearance /ar' +rown, irre%ular, as!metric /istri+ution Bac', le%s
Eniform, dar', l.eerr(-like o!.le Arise rapidl!
5pidemiolo%!
@s, M = $
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$ace 2calp Beard, mustache area 8ails 2 upe rfi ci al , A 2&
@-@s, M =$, H@P of cases
No!.l"r
Acr"lle#i,.o.s Brown-+lac' macule or papule )alms, soles, mucosa, nails K@s, M $, in Asians
R"i! re3ie/ Atopic dermatitis, aller%ic rhinitis, asthma 2 lou %hi n% off of the epi der mi s w " % en tl e m an ua l p res su re M cause of recurrent er!thema multiforme that are not idiopathic
Le#i,o m"li," S%eo%raphicT shape, Sstrain-li'eT appearance .ead, nec', hands, sun-e&posed K@s, M = $, fair s'inned
Aller%ic triad 8i 'ol s' ! s s i%n .2V
+ASTR*ENTER*L*+Y An N month old infant has +een hospitaliDed for 4 mos in chronic care unit 8urses ha#e noted that he is re%ur%itatin% se#eral times an hour .e ma'es chewing mo,ements precedin% these episodes of re%ur%itation< r.mi"#io A 4 w' old infant w" da! h& of #omitin% after feedin%s )5 shows a hun%r! infant w" prominent peristaltic wa#es in epi%astrium< h(er#rohic (loric s#eosis -ra! shows 4string sign6 shoulder sign and double tract sign5< (loric s#eosis -ra! shows a 4double bubble sign5< !.o!e"l "#resi" -ra! shows 4bird"beak appearance5< 3ol3.l.s -ra! shows 4dance’s sign6 target sign6 donut sign # pseudokidney sign5< i#.ss.sce#io A+sence of Meissners and Auer+achs ple&us in distal colon leadin% to lar%e +owel o+struction< Hirschr.,0s !ise"se A well-nourished infant is +rou%ht to 5 +ecause of constipation, +lood-strea'ed stools, and e&cessi#e cr!in% on defecation< ""l fiss.re A ? mos old infant w" fe#er and diarrhea 2tools are +lood-strea'ed w" mucus An hour later p& de#eloped a +rief generalized seizure< shi,ell" somei A 1@ !"o %irl w" spots on her lips has cramp! a+dominal pain associated w" +leedin%< e.#5 e,hers s(!rome A !"o %irl presents w" protu+erant a+domen and wasted e&tremities< ,l.#e-i!.ce! e#ero"#h( 2mallest 'nown 8A #irus< hepatitis B 7delta agent8 Ma(or protease inhi+itor< alpha . antitrysin Prim"r( ili"r( cirrhosis < women! autoimmune disease Prim"r( sclerosi, chol",i#isQ men! ulcerati,e colitis Most li'el! clinical manifestation of A1A3 deficienc! in new+orn< jaundice/neonatal cholestasis 4
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:" proper treatment, sta%e 1 and ? ulcers heal w/in )-@ w0s 2ta%e and 4 ulcers heal w" in ()@ w0s A ?4 !"o medical student wor'in% in the IE held a p&s endotracheal tu+e w" his un%lo#ed hand to 'eep it from fallin% out ? w's later he has a ,esicular lesion on an er!thematous +ase that is e&tremel! painful< here#ic /hi#flo/ A 4H !"o male presents w" pearl!, painless, ulcerated nodules w" o#erl!in% telan%iectasias< "s"l cell CA Actinic keratosis s a premali%nant precursor to SCCA Bysplastic nevus is a premali%nant precursor to m"li,"# mel"om" :hen there is herald patch followed +! a rash in S christmas tree pattern5< #(ri"sis rose" Itch that rashes< "#oic !erm"#i#is [due mostl! to staph aureus] 4Cradle cap5 [%reas! scales o#erl!in% the scalp]< seorrheic !erm"#i#is 4$oney"colored crust5 is classic for< ime#i,o 42trawberry tongue5 is seen in< sc"rle# fe3er .2V su+t!pes K, 11, 1K, 1N, 1, , , and 44 are precancerous )resence of umbilicated6 pearly papules and inclusion +odies is c haracteristic of< moll.sc.m co#",ios.m w" h!phae and !east forms in 4spaghetti and meatball appearance5< #ie" 3ersicolor /iaper rash is often superinfected w" andida w"c manifests as er!thematous satellite lesions Threadlike burrows are classic for< sc"ies lassic si%n of small #essel dama%e< "l"le .r.r"
Imor#"# #erms & coce#s Acanthosis ni%ricans /ar', thic'ened, dirt!-appearin% #el#e!-pla*ues on a&illae, nec', %roin, 6 ano%enital re%ion Acne #ul%aris Inflamed pilose+aceous units 6 a+normal 'eratiniDation associated w" pol!c!stic o#arian s!ndrome 6 propioni+acterium acnes, t&< clindam!cin Open comedones Blac'heads [#s closed comedones or whiteheads] 8i'ols'!s si%n )ressure on +ullae causes lateral e&tension of +listers Oncol!sis 0iftin% of nail plate 2eDar!s s!ndrome Ad#anced form of m!cosis fun%oides, %eneraliDed er!throderma, 0A/ C.#"eo.s f.,"l ifec#ios 3inea pedis Sathletes footT 3inea cruris S(oc' itchT, %roin 3inea corporis Srin%wormT, +od! 3inea manum .and
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A 4 !"o man w" a h& of ulcerati#e colitis presents w" (aundice and ele#ated GG3 and al'aline phosphatase< rim"r( sclerosi, chol",i#is T(es of +IT c"cers "se! o re,io> 5sopha%us 2*uamous and adenocarcinoma /uodenum and (e(unum Adenocarcinoma Ileum arcinoid, lipoma, l!mphoma A KN !"o man in the hospital & w's fo pneumonia returns w" new onset diarrhea< C4 !ifficile A H@ !"o woman presents w" miroc!tic anemia, wei%ht loss and a #a%ue a+dominal pain that is not related to food or time of da!< c olorectal A< endocarditis w" strep +o#is or clostridium septicum is associated w" colon A Blood! diarrhea< CASEES [Camp!lo+acter, Amoe+a, Shi%ella, E histol!tica, E coli, Salmonella] Bermatitis herpetiformis is a pruritic rash associated w"< celi"c sr.e A 4 !"o farmer who has +een sufferin% w" diarrhea, wei%ht loss and arthral%ias for the past few months s +rou%ht in +! his wife for memor! deficits that ha#e +een occurrin% for the past wee's< /hile0s !ise"se
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$amilial adenomatous pol!posis Gardner s!ndrome 3urcot s!ndrome )eutD-(e%hers s!ndrome
haracteriDed +! 1@@ pol!ps in colon and rectum )ol!posis, desmoid tumors, osteomas, se+aceous c!sts )ol!posis, meduloo+lastoma and %lioma Multiple hamartomatous pol!ps, melanotic pi%mentation of s'in and mucous mem+ranes
R"i! re3ie/ Barium swallow< o Birds +ea' or steeple si%n< o or'screw-shaped< Gold standard for cholec!stitis M cause of esopha%itis M cause of acute intestinal o+struction F ?!"o< M cause of +owel o+struction in children ? mos- !"o< Intermittent colic'! a+dominal pain, +illous #omitin%, currant (ell! stool M cause of emer%ent sur%er! in childhood M s& of infestation w" entero+ius M d& re*uirin% sur%er! M childhood +owel tumor Most widespread cestode Ma(or cause of nosocomial diarrhea
Mali%nant potential Qes Qes Qes 2mall
Achalasia /iffuse esopha%eal spasm .I/A scan andida intussusception [usuall! ileocolic] Intussusception 3riad of intussusception Appendicitis )erineal pruritus In%uinal hernia Cu#enile pol!posis coli 5chinococcus )seudomem+ranous colitis
+ENERALITIES IN PEDIATRICS 8ormal arterial +lood %ases 3emperature K-H p. H-H4 pO? -4 pO? N@-1@@ .O ??-?K O? sat 4-1@@P Base e&scess ? •
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Actual caloric #alues of mil' formulas 1 ounc e po wd er ed mi l' ? @ c al or KH cal "da ! 1 ounce e#aporated mil' 4@ cal 1 tsp su%ar ?@ cal 1 ounce su%ar 1?@ cal
A)GA scorin% Si, ; : @ Appearance Blue, pale e&tremities Bod! pin' ompletel! )ulse A+sent F 1@@ 1@@ Grimace 8o response Grimace r!, sneeDe, cou%h Acti#it! 0imp $le&ion of e&tremities Acti#e motion espiration A+sent 2low, irre%ular Good, stron% cr! 2O5< -:; at 1 minute is considered #i%orous, =- moderatel! depressed, ;- se#erel! depressed Most important parameter in A)GA< he"r# r"#e /entition for the 1 st !r of life< no of teeth = a%e [in mos] J K •
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.ei%ht calculations< .ei%ht [cm] .ei%ht [inches]
@@@ %ms :t [%ms] = a%e [mos] & K@@ B: :t [%ms] = a%e [mos] & @@ B: :t [%ms] = a%e [!rs] & ? N :t [%ms] = a%e [!rs] & H- " ?
A%e [!rs] & N@ A%e [!rs] & ? ?
+ESTATI*N AND %IRTH' NE*NAT*L*+Y Maternal triple screen< measures A$), uncon(u%ated estriol 6 .G [done a 1K-N w's] Amniotic fluid #olume< Oli%oh!dramnios OM, re"l "om"lies, se#ere heart disease, placental insufficienc! )ol!h!dramnios /M, anencephal!, 83/, duodenal atresia, +I "orm"li#( • •
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F"mili"l ol(osis s(!romes [FAP) 2!ndrome 2i%ns and s!mptoms
:ei%ht calculations< At +irth F K mos K-1? mos 1-K !rs K-1? !rs
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Gestational a%e< 2GA 2een in .)8, preeclampsia, smo'in% mothers, 3O., chromosomal anomalies 0GA 2een in I/M, Bec'with s!ndrome, lar%e parents, h!drops fetalis Mechanism of heat loss [h!pothermia] in infants< adiation .eat loss from infants to a colder nearby objects onduction /irect heat loss from infant to surface w" w"c he is in direct contact on#ection .eat loss from infant to surrounding en,ironment 5#aporation .eat loss +! water e#aporation from s'in of infant
Ne/or PE fi!i,s> 2ITAL SI+NS 3emperature B) ) C*L*R )lethoric [deep red] Caundice [!ellow] )allor [white] )eripheral c!anosis entral c!anosis Acroc!anosis &arleEuin coloration C.#is m"rmor"#" Mottli n% [l ac! red] RASHES Milia 5r!thema to&icum al+icans rash Acne neonatorum NE2I 2tor' +i tes )ort-wine stain Mon%olian spot a#ernous heman%io ma 2traw+err! heman%ioma HEAD 0ar%e anterior fonanelle 2mall anterior fontanelle Bul%in% fontanelle 2un'en fontanelle aput succedaneum ephalhematoma -monitor hyperbilirubinemia ranios!nostosis raniota+es NEC7 2hort nec' FACE $acial 8 in(ur! EARS 0ow-set ears .air! ears EYES [look for R*R)
N*RMAL 2ALUE N*TES K-H [rectal] /etermines core temperature, anal patenc! 4@-K@ cpm /epends on a%e an use thi%h 1?@-1N@ +pm an +e H@-N@ +pm if asleep INDICATI*NS )ol!c!themia, o#ero&!%enated, o#erheated .!per+iliru+inemia, carotenemia, increase protein Anemia, +irth asph!&ia, shoc', )/A Me#hemo,loiemi" on%enital heart or lun% diseases Bluish hands 6 feet Indicates shuntin% of +lood [persistent pulmonar! .)8 or OA] 2een in /own, 5dwrads 6 )atau s!ndromes In col d stress, .Q)O# ol emi a, sepsi s INDICATI*NS ash w" tin! se+aceous retention c!st [chin, nose, forehead, chee's Areas of red s'in w" !ellow-white papule at center 5r!thematous pla*ues, diaper rash, w" ele#ated +orders 2een on chee's, chin, forehead, ma! re*uire 'eratol!tic a%ents [22A] INDICATI*NS Or macular heman%ioma 8e#us normall! s een in occipital area, e!elids 6 %la+ella It disappears spontaneousl! w"in 1 st !r of life Or ne#us flammeus /oesnt +lanch w" pressure, 6 doesnt disappear /ar'-+lue or purple-+lue macular spots usuall! noted in sacrum ed, c!stic masses that re%ress w" a%e, ma! re*uir e corticosteroids Or macular heman%ioma Bri%ht-red, sharpl! demarcated lesion in face that re%resses spontaneousl! INDICATI*NS .Q)Oth!roidism, osteo%enesis imperfecta, autosomal a+8, h!po)O4 .Q)5th!roidism, micocephal!, cranios!nostosis [premature closure] 5le#ated I) as in h!drocephalus 6 menin%itis /eh!drated new+orn /iffuse edematous swellin% of scalp tissue e&tendin% to suture lines 2u+periosteal hemorrha%e that 85V5 e&tend across suture lines, usuall! secondar! to traumati deli#er!, resol#es in K w's )remature closure of 1 or more s'ull sutures, +on! rid%e of suture line 2oftenin% of s'ull that usuall! occur around suture lines, seen in a deficienc!, s!philis 6 osteo%enesis imperfecta INDICATI*NS 2een in 3urners, 8oonans 6 >lippel-$eil s!ndromes INDICATI*NS $acial as!mmetr! w" cr!in%, corner of mouth drops, [-] nasola+ial fold INDICATI*NS 2een in 3reacher-ollins, triploid!, trisom! 6 1N 2een in I/M INDICATI*NS
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on%enital cataract Bluish sclera SBrushfields spotsT M*UTH An'!lo%lossia or ton%ue tie anula 5psteins pearls Mucocoele Macro%lossia $roth! or copious sali#a NAIL 2poon nail Beaus line )aron!chia 2plinter hemorrha%e TH*RA Pectus Carinatum )ectus e&ca#atum A%D*MEN Omphalocoele Gastroschisis 2caphoid a+domen 2plenome%al! 5nlar%ed 'idne!s ETREMITIES 2!ndact!l! )ol!dact!l! 2imian crease 3alipes euino#arus Ortholaniss si%n Barlows si%n NER2*US SYSTEM Moro refle& 5r+-duchene pals! >lump'es paral!sis
2een in mothers w" u+ella [opacification of lens, a+sent O] 2een in osteo%enesis imperfecta S2alt 6 pepperT spec'lin% of iris seen in /owns s!ndrome INDICATI*NS Ma! need sur%er! !stic swellin% on floor of mouth >eratin c!sts on hard 6 soft palate Oral mucosal lesion that occur secondar! to trauma in sali#ar! ducts Ma! +e due to con%enital heman%iomas, in Bec'withs 6 )ompe dse 2een in esopha%eal atresia w" 35$ INDICATI*NS onca#e nails, seen in I/A 3rans#erse depression associated w" acute se#ere illness Inflammation of s'in around nail ed-+rown linear strea' on nail +ed as seen in su+acute +acterial endocarditis 6 trichinosis INDICATI*NS SPi%eon ChestT sternum is displaced anteriorl! as i n asthma 6 O)/ Sfunnel chestT sternal depression, compresses heart causin% murmur INDICATI*NS Intestines co#ered w" peritoneum, um+ilicus is centrall!-located Intestine is 8O3 co#ered +! peritoneum, usuall! at of um+ilicus 2een in diaphra%matic hernia 2een in MV, u+ella, infection, sepsis, leu'emia 2een in pol!c!stic 'idne! dse, renal V throm+osis, h!dronephrosis INDICATI*NS A+normal fusion of rd 6 4th fin%er or ? nd H rd toes 2upernumerar! di%its of hands 6 feet 2in%le trans#erse palmar crease seen in /owns s!ndrome Or clu+foot $oot is turned downward 6 inward, sole directed mediall! )lace infant in fro%-le% position then a+duct the hips usin% middle fin%er to appl! inward 6 upward pressure o#er %reater trochanter Adduct the hips +! usin% thum+ to appl! outward 6 +ac'ward pressure o#er the inner thi%h INDICATI*NS As!mmetr!, fractured cla#icle, hemiparesis, +rachial ple&us in(ur! -K in(ur! Adduction 6 internal rotation of arm, pronated forearm H"N-31 in(ur! .and is flaccid
Fe#ofe#"l #r"sf.sio s(!rome Arter! of 1 twin will drain into the circulation of the other twin 2uspected w" a difference in $b of gm/dl 6 ,- weight difference +tw the ? twins Ar#eri"l si!e [!oor si!e) 2eo.s si!e [reciie#) Oli%oh!dramnios Polyhydramnios 2maller %arger Malnourished Fell-nourished )ale, Anemic Phlethoric! Polycythemic .!po#olemic &yper,olemic Microcardia
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Hemol(#ic !ise"se of e/or ommon amon% home"delivered # breastfed babies .as decreased to a+sent #itamin > dependent factors [?, H, , 1@] /&< increased protime 7most significant8 , )3, 3 M%t< e&o%enous #itamin > Breast Feedin% (aundice occurs in First wee', while +reast Mil' (aundice occurs Man! wee's later • • • • •
%re"s#fee!i, 3s4 re"s# milk ".!ice %re"s#-fee!i, ".!ice Also 'nown as Snot enou%h mil' (aundiceT due to decreased or poor mil' inta'e Searlier (aundiceT /urin% 1 st wee' of life J pea's durin% ?- da!s educed enteral inta'e leadin% to infre*uent and scant! +owel mo#ements and increased enterohepatic circulation of +iliru+in
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Defec#s of co.,"#io of ilir.i> ri%ller-8a((ar t!pe 1 /eficient %lucuron!l transferase $efecti,e conjugation only E8responsi#e to use of )heno+ar+ital ri%ller-8a((ar t!pe ? /eficient %lucuron!l transferase $efecti,e upta0e conjugation of bilirubin esponsi#e to )heno+ar+ital Gil+erts s!ndrome $efecti,e upta0e conjugation of bilirubin omplications of phototherap!< o etinal de%eneration o 0BM, fluid loss, rashes [photosensiti#it!] o Congenital erythropoietic porphyria o )ron;e baby syndrome< con(u%ated h!per+iliru+inemia secondar! to photodestruction of copper 6 porph!rins causin% discoloration of s0in urine o No#e> me#"lloorh(ris act to inhi+it heme o&!%enase causin% 9 +iliru+in production M%t< phototherap! at =@;-=; m [ma&imum a+sorption of +iliru+in] o Blue hue interferes w" s'in color assessment o Blac' e!e patch< pre#ent from retinal hemorrha%e o 2hould +e 1-?@ cm from li%ht s ource
%ilir.i eceh"lo"#h( Ph"ses> )hase 1 )oor suc', h!potonia, depressed sensorium )hase ? $e#er 6 h!pertonia )hase .i%h-pithed cr!, hearin% 6 #is ual a+normalit!, poor feedin% •
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7eric#er.s< post-mortem d& of patholo%ic findin%s of +iliar! to&icit! of +rain, w" characteristic spared cerebral corte& necrosis of +asal %an%lia, hippocampal corte& 6 su+thalamic nuclei S#",i, of keric#er.s> A Infant is initiall! lethar%ic, h!potonic 6 una+le to suc' #i%orousl! B Infant shows spaDticit! w" opisthotonus 6 seiDures, fe#er /ecreased spasticit! / 0ate se*uelae< spasticit!, athetosis, deafness, M 5 Biliru+in encephalopath! •
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RH icom"#iili#( Isoimmune hemol!tic anemia w"c results when . incompati+ilit! de#elops +tw an Rh [-) mo#her [pre#iousl! s!nthesiDed w" h 7B Ag8 6 her Rh [$) fe#.s is' factors< 1 st +orn, fetomaternal hemorrha%e, ABO incompati+ilit!, o+stetric ["2] m ale infants
%re"s# milk ".!ice 0ate J start to rise at da! 4 En'nown )ro+a+l! due to B%lucoronidase in +reas mil' If +reastfeedin% stopped apid 9 +iru+in le#el in 4N hrs
Uco.,"#e! or I!irec# H(erilir.iemi" Ph(siolo,ic ".!ice> de,elops H @D hrs of life 6 resol#es spontaneousl! %"sis Term Pre#erm Onset K hrs K hrs )ea' -4 d -K d :ane Hd 14 d
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%re"s#-milk ".!ice )rolon%ed uncon(u%ated h!per+iliru+inemia thou%ht to +e due to inhi+itor to +iliru+in con(u%ation in +reast mil' of some mothers After 1 st wee' of life J pea's after ? nd-rd wee' 3ransient, unless se#ere uncon(u%ated h!per+iliru+nemia 8o treatment is necessar!
%re"s#fee!i, 3s4 %re"s# milk ".!ice P"r"me#ers %re"s#fee!i, ".!ice Onset rd J 4th da! of life )athoph!siolo%! 9mil' inta'e ; enterohepatic circulation Mana%ement $l uid 6 cal ori c supplementation
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2"2&< (aundice [uncon(u%ated h!per+iliru+inemia at 1 st ?4 hrs of life], anemia, hepatosplenome%al!, h!drops fetalis /&< 7D8 direct comb’s test is diagnostic M%t< ho%am"h immuno%lo+ulin J %i#en at ?N-? w's AOG, amniocentesis, E3R of fetal scalp, IVIG
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Co.,"#e! or Direc# h(erilir.iemi" 2i%n of hepato+iliar! d!sfunction that appears after ) st w0 of life •
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Defec#s i ile secre#io> Idiopathic neonatal hepatitis"%iant cell hepa 5&trahepatic +iliar! atresia
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)rolon%ed con(u%ated h!per+iliru+inemia w"o e#idence of %eneral #iral illness 0uminal o+literation or a+sence of all se%ments of e&trahepatic +iliar! s!stem
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Defec#s i i#r"he"#ic ili"r( os#r.c#io> Ala%ille s!ndrome Intrahepatic cholestasis w" paucit! of +ile ducts 3)8 cholestasis Intrahepatic cholestasis w" normal +ile ducts /u+in-(ohnson s!nd Genetic defect in cannalicular transport s!stem, [] dar' li#er otors s!ndrome /efect in hepatic upta'e 6 stora%e of or%anic anions, [-] dar' B!lers disease Or recurrent familial cholestasis
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Defec#s i e8#r"he"#ic ili"r( os#r.c#io> Biliar! atresia la!-colored stool h ol edoc hal c! st s /i la ta ti on of par t of .B 3 holedocholithiasis 2tone in .B3 !stic fi+rosis
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M%t of con(u%ated h!per+iliru+inemia< o cholest!ramine J promotes +ile flow 6 decreases serum +iliru+in 6 +ile salts le#el o )heno+ar+ital J increases concentration of li%andin in li#er cells
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7r"mer0s cl"ssific"#io of i#esi#( of ".!ice> Ooe ".!ice A3er",e ilir.i 1 0imited to head 6 nec' K ? O#er upper trun' O#er lower trun' 6 thi%h 1? 4 O#er arms, le%s 6 +elow 'nees 1 .ands, feet 1
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M"8im.m ilir.i N 1? 1K 1N -
Cri#eri" #o RJ* h(siolo,ic ".!ice> linical (aundice in 1 st ?4 hrs of life o Increase in total serum +iliru+in a m%"dl"da! o 3otal serum +iliru+in 1? m%"dl in full term 6 1 m%"dl in preterm o /irect +iliru+in 1-?@ m%"dl o Caundice lastin% for more than 1 w' for term 6 ? w's for preterm I!ic"#ios of ho#o#her"( for #8 of h(eriir.iemi" o 2erum +iliru+in 1@ m%P increasin% up to 1 m% P o )remature w" +iliru+in at 1-?@ m% P o After all e&chan%e transfusions o Ver! sic' p& Refer #o 4 : of PEA %RAIN for ilir.i me#"olism Neo"#"l choles#"sis> Fe"#.res Neo"#"l he"#i#is %ili"r( "#resi" A%e an +e at +irth 1 st J ?nd w' of life ourse :a&in% or wanin% )ersistent olor Golden !ellow Martian %reen 2tool "- acholic Acholic A ris' Increased 8one o
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Main source of ener%! for %rowin% fetus< carbohydrates losure of ductus arteriosus is aborted by *=E. and f"cili#"#e! ( i!ome#h"ci [#ia inhi+ition of prosta%landin s!nthesis] $ailure of 'idne!s to de#elop can lead to< oli,oh(!r"mios $ailure of 'idne!s to mi%rate can l ead to< ec#oic ki!e(s A horseshoe 'idne! %ets cau%ht on IMA durin% descent L>S r"#io in amniotic fluid 9 indicates fetal lung maturity M2A$) is hi%h in< M.l#ile ,es#"#ios [MC)' $etal neural tu+e defects 6 Gastroschisis M2A$) is low in< trisomies ,. and .0 M cause for a+normal A$)< incorrect dates )renatal infections that M cause +irth defects< T*RCH o To&oplasmosis o *thers [hepatitis )6 syphilis6 VFV ] o Ru+ella o CMV o H#" or &1" V) in new+orn is 4-H cm .?@ and N-1 cm .?@ in a child Macro%losia or lar%e ton%ue is seen in< h!poth!roidism, /owns and Bec'with-:iedemann s!ndrome )rushfield spots [salt and pepper spec'lin% of irisY is seen in< !o/0s s(!rome C".# s.cce!"e.m is e&ternal to periosteum and crosses the midline of s'ull and suture lines V2 ceh"lhem"#om" w"c is +elow periosteum and does not cross suture lines
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w's old infant presents w" paro&!smal cou%h and tach!pnea, +ut no fe#er, +ilateral diffuse crac'les, h!perinflation and patch! infiltrates on &-ra!, had con(uncti#itis at 1@ da!s of a%e< Chl"m(!i" #r"chom"#is )ostmature, 41 w' %estational a%e new+orn on 1 st da! of life has %runtin% respirations, si%ns of air trappin% and 1@@"min< mecoi.m "sir"#io .i%h indirect serum +iliru+in le#els in the 1 st ?4 hrs of life are ne#er ph!siolo%ic In neonates, there is a cephalopedal pro%ression of (aundice, appro&imate le#els for in#ol#ement< o .ead and nec'L 4-N m%"dl o Epper trun'< -1? m%"dl o 0ower trun' and thi%hs< N-1K m%"dl o )alms and soles< 1 m%"dl
Pre"#"l !is#.r"ces Dise"se E#iolo,( 3o&oplasmosis /ue to in%estion of ooc!sts from feces of infected cats, A2& u+ella esult from con%enital ru+ella s!ndrome MV 3ransmitted thru infected +lood, +reast mil'
To8is "! #er"#o,es Alcohol G MC ocaine .eroin or methadone 3o+acco )hen!toin 3etrac!cline Isotretinoin :arfarin
Fe"#.res Microcephal!, h!drocephalus, intracranial calcifications, chorioretinitis, seiDures Menin%oencephalitis, microcephal!, cataracts, sensorineural hearin% loss, ./ [)/A] IEG, 0B:, petechiae"purpura, (aundice, hepatosplenome%al!, microcephal!, chorioretinitis, intracranial calcifications
M, microcephal!, midfacial h!poplasia, micro%nathia, shortened nasal philtrums, renal and cardiac defects, h!pospadias .i%h ris' for spontaneous a+ortion, placental a+ruption, fetal distress, meconium stainin%, preerm +irth, IEG, 85, 2I/2 Associated w" IEG, 2I/2, and infant narcotic withdrawal s!ndrome Associated w" decreased +irth wei%ht Associated w" fetal h!dantoin s!ndrome [IEG, M, d!smorphic facies, h!poplasia of nails and phalan%es] auses tooth discoloration and inhi+its +one formation .!drocephalus, microtia, micro%nathia, and aortic arch a+normalities auses a+normal cartila%e de#elopment, M, deafness and +lindness
R"i! re3ie/ M intra-a+dominal or%an affected in difficult deli#er! M head in(ur! durin% traumatic deli#er! M s'ul l frac ture t! pe duri n% traumati c del i# er! M facial in(ur! durin% traumatic deli#er! M +one in(ur! durin% traumatic deli#er! ?nd M +one in(ur! durin% traumatic deli#er! M cause of e&trahepatic +iliar! o+struction M caus e of uncon(u%ated h!per+i li ru+i nemi a M con%enital heart defect M terato%en M cause of a+dominal mass in new+orns M a( or cau se of se #er e s! st em ic inf ec ti on in neo nat es )rincipal cause of %m [J] sepsis and menin%itis in new+orns M presentation of c!stic fi+rosis in neonatal period
0i#er 2u+dural hematoma 0inear s'ul l frac tures 8asal septal dislocation la#icle .umerus +iliar! atresia Al pha-1 antitr!psi n defici enc! V2/ Alcohol 5nlar%ed 'idne! G B2 5 coli Meconium ileus
PREMATURITY )remature infant< deli#ered prior to H w's from 1 st da! of 0M) 0B: infant< wei%ht F ?,@@ % V0B: infant< wei%ht F 1, @@ % )roduction of surfactant can +e accelerated +! maternal steroid [ e#h"me#h"soe] administration +est if %i#en ?4-4N hrs prior to deli#er! 2erious se*uelae of NEC< intestinal strictures! malabsorption! fistulae! short bowel syndrome A K da! old, ? l+ neonate de#elops episodes of apnea, a+dominal distention and +lood! diarrhea< NEC • • • •
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Necro#i5i, e#erocoli#is [NEC) Ac*uired neonatal d"o in w"c there is com+ination of #ascular, mucosal 6 to&ic insults Most fre*uent feature< premature baby w/ asphy&ia6 h& of feeding early diving"seal refle& G +lood flows to #ital or%ans of the +od! 2"2&< presents in 1 st w' of life or -H d after feedin%, abdominal distention +) st #x , ileus, +lood per rectum, si%ns of shoc', peritonitis 6 perforation linical /&< triad of feeding intolerance! abdominal distention hematochezia 0a+ /&< [] %uiac stools, &-ra!< air in +owel wall called as e.m"#osis i#es#i"lis ["#ho,omoic) M%t %oal< pre#ent pro%ression of disease, remo#e > from IV$, %i#e low-dose dopamine • • • •
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Neo"#"l sesis
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M cause< ,ro. % s#re#ococc.s Most important ris' factor< prematurity # L):6 rupture of membranes H )I hrs +@ nd 2"2&< h!pothermia, irrita+ilit!, c!anosis, mottlin%, h!poension [late si%n] /&< cultures 7gold standard8 , A% detection test, %m stain of fluids M%t< initial therap! of ampicillin, %entamicin or ami'acin
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Ae" & erio!ic re"#hi, Apnea< a+sence of respirator! %as flow for a period of ?@ sec [preterm] 6 1 sec term] 3!pes< Ce#r"l "e" A+sence of %as flow w" no respirator! effort, MC #(e O+structi#e ontinued respirator! effort not resultin% in %as flow Mi&ed apnea om+ination of central 6 o+structi#e apnea )eriodic +reathin% periods of apnea lastin% sec or more w"in ?@ sec period, not associated w" c!anosis or +rad!cardia
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Apnea w"in ?4 hrs after deli#er! is usuall! 8O3 apnea of prematurit! [+ut due to sepsis] M%t< supplemental O?, )A), #heoh(llie, caffeine, !o8"r"m, cutaneous stimulation
H("lie memr"e !ise"se [RDS #(e :) )reterm 8B w" tach!pnea, chest retractions 6 c !anosis that persists o#er 1 st 4N-K hrs of life is' factors< prematurity , "2, perinatal asph!&ia, chorioamnionitis )atholo%ic /&< [] eosinophilic h!aline mem+rane 0a+ /&< findin% of uniform reticulonodular pattern or ecil-le"! & ,ro.! ,l"ss "e"r"ce 6 air +oncho%ram M%t< intubation 7 mechanical ,entilation +mainstay , )A), anti+iotics, surfactant replacement [e&osurf or sur#anta] omplications< retinopathy of prematurity6 bronchopulmonary dysplasia6 *BA
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Tr"sie# #"ch(e" of e/or [RDS #(e @) 5arl! onset respirator! distress that im pro#es w"in ?4-4N hrs etention of fetal lun% fluid [thoracic s*ueeDe< ;-=; ml e&truded out] is' factors< prematurity , "2, +irth asph!&ia, maternal o#ersedation 0a+ /&< flattenin% of diaphra%m on +ecause of retained fluid M%t< O? •
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At @ (Jo, a child uses ?- word phrases and follows ? step commands, and others can understand half of the childs lan%ua%e At (Jo, a child uses word sentences, and others can understand _ of the childs lan%ua%e At = (Jo, a child should +e 4@ l+s and 4@ inches tall and +e a+le to draw a 4 sided fi%ure )arasomnias [sleep d"o] +e%in near a%e !ears 2omnam+ulism [sleepwal'in%] occurs in non-5M sleep and is M at a%es 4-N !"o h"ses of i#r".#erie !e3elome#> O#ular phase 1 st ? w's from time of fertiliDation until the D!%ote is well implanted in uterine endometrium 5m+r!onic sta%e $rom ?nd w' to end of ? nd month, a w"c time ma(or differentiation of or%ans 6 tissues occur $etal phase $rom +e%innin% of rd month to +irth, when fetus +ecomes an Sinfant 6 rapid %rowth 6 acceleration of function to maturation For"me o3"le & !.c#.s 3eos.s functionall! closes at +irth, while the for"me "r#erios.s functionall! close at N-1? w's Ne/or me"s.reme#s> :ei%ht K ^ l+s or @@@ % 0en%th @ cm .ead ci rcum ference ?-? cm hest circumference cm A+dominal %irth 1 cm 2inuses< m"8ill"r( & e#hmoi! are present at birth while frontal 6 sphenoidal are still underde#eloped Brain +e%ins to de#elop at =- /ks AOGL m!elination starts at -:@ /ks 6 is completed +! ? !rs Auditor! s!stem is full! functional from +irth, localiDation of sounds at mos4 At mos4 acute taste discrimination is achie#ed +! new+orn 5motional ties +tw mother 6 +a+! is called bondling
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Persis#e# .lmo"r( HPN Mar'ed pulmonar! .)8 6 altered pulmonar! #asoo#eracti#it! causin% to 0 e&trapulmonar! shuntin% of +lood 2"2&< c!anosis 6 tach!pnea linical /&< h!po&ia unresponsi#e to 1@@P O? 0AB /&< o&imeter readin%, h!per#entilation test, radio%raph! M%t< dopamine, tolaDoline •
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S.mm"r( of ,erm cell l"(ers !eri3"#i3es Ec#o!erm Ne.r"l cres# cells [ec#o!erm) 82, )82 2pinal ner#es, 8 2ensor! epithelia of ,H,,1@ e!e, ear and nose Autonomic %an%lia 5pidermis, hair, nails Adrenal medulla Mammar! %lands, Menin%es pituitar! %land, )i%ment and %lial su+cutaneous %lands cells of peripheral 3ooth enamel ner#es
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Mecoi.m "sir"#io is' factors< post"term pregnancy 7!C8 , preeclampsia-eclampsia, oli%oh!dramnios 0a+ /&< findin% of patch! infiltrates interspersed w" areas of emph!sema or so/s#orm "e"r"ce M%t< suctionin%, pulmonar! toilet, ABG, anti+iotics • •
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R"i! re3ie/ Spneumatosis intestinalisT is patho%nomonic M cause of neonatal sepsis M t!pe of apnea Ssnow-storm appearance on
85 Group B streptococcus entral apnea Meconium aspiration
+R*1TH AND DE2EL*PMENT A term infant re%ains to B: +! ? wee's A child should +e & B: +! his 1 st +irthda! 3antrums pea's at< ?-4 !o [toddler sta%e] $etal wei%ht %ain is %reatest durin% rd trimester B! a%e ? ^, c hildren should ha#e all of their primar! teeth includin% ? nd molars 2econdar! [permanent teeth] +e%in to erupt +! a%e K-H !rs 1ei,h# is affected 1 st in $33 followed +! hei%ht and head circumference A child smiles spontaneousl!, +a++les, sits w"o support, reaches, feeds herself a coo'ie +ut has no pincer %rasps< - mos4 [pincer %rasps is 1@ mos] Enilateral loss of Moro refle& is associated w" cla#icle or humerus fracture and +rachial ple&us pals! .andiness is seen at< !o M!elination of the ner#ous s!stem +e%ins mid%estation and continues until ? !rs of a%e )rimiti#e refle&es are present after +irth and diminish +! K mos An 1N mos old infant +rou%ht in for temper tantrums has normal %ross and fine motor s'il ls +ut lac's lan%ua%e de#elopment and is cooperati#e and alert on e&am< he"ri, loss At : (Jo, a child uses 1 word, and follows a 1 step command • • • • • • • •
Meso!erm
E!o!erm
3, cartila%e, +one 2triated and smooth muscles Blood and l!mphatic s!stems O#aries, testes, %enital ducts 2erous mem+ranes linin% +od! ca#ities 2pleen, adrenal corte&
5pithelial linin% of GI3, respirator! tract and middle ear includin% 5ustachian tu+e 3onsil parench!ma 3h!mus )arath!roid and th!roid %lands 0i#er and pancreas
+es#"#io"l "! emr(oic l"!m"rks 1eeks Fe"#.res 1 9ertili;ation in ampulla of fallopian tu+e, implantation +e%ins ? Hteroplacental circulation begins, complete implantation, endo 6 ectoderm form Mesoderm formed [trilaminar em+r!o], paired heart tu+es +e%in to wor' 4 )rimordial atrium is di#ided into 0 and +! septa primum and secundum 2u+di#isions of fore+rain, mid+rain and hind+rain are formed H $eart formed N )rimar! or%ano%enesis complete, placentation occurs .st muscular contraction )ermanent 'idne!s +e%in functionin%, somatic changes 1@ Mid%ut returns from um+ilical cord, where it was de#elopin% to a+dominal ca#it!, while under%oin% countercloc'wise rotation 9ace is recogni;ably human( 1-1 )reathing # swallowing movements 1K Iuickening 1H =rasping refle& ?4 )rimiti#e al#eoli are formed and surfactant production +e%ins ?K 3esticles descend 6 e!es start to open ?K-?N $etus is acti#el! suc'in% ?H $ull de#elopment of %raspin% refle& 4-H 3estis is at le#el of in%uinal rin% mos N mos 3estis is at le#el of scrotum
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+r"homo#or miles#oes ?4 mos or ? !o 2c ri+l li n% spontaneousl! @ mos Vertical stro'e mos .oriDontal stro'e K mos or !o Circle [:s# fi,.re) 4? mos ross 4N mos 2*uare K@ mos 3rian%le
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H? mos
l-
Di"mo! [l"s# fi,.re)
)hosphorous
R"i! re3ie/ 1st tooth to erupt [+tw -N mos] 0ast tooth to erupt [+tw ?@-@ mos] Or%ans palpa+le at +irth 2inuses present at +irth lear #ision is achie#ed at Visual acuit! of ?@"?@ is achie#ed at 1st #isi+le si%ns of pu+ert!<
entral incisors ? nd molars %i,er! spleen 0idneys Ma&illar! 6 ethmoid 1K w's of a%e H !rs 3esticular enlar%ement [M]L +reast +uddin% [$]
M!elination is completed at
H !rs old
NUTRITI*N & %REASTFEEDIN+ RA ;;> oomin%-In 6 Breastfeedin% Act of 1? T(es of fee!i, omplementar! feedin% Artificial feedin% immediatel! follows +reastfeedin% 2upplementar! feedin% Artificial mil' alternates or replaces +reastfeedin% • •
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Refle8es #h"# f"cili#"#e re"s#fee!i,> )rolactin refle& 0et-down or mil' -e(ection refle& ootin% refle& 2uc'in% refle& Ga%%in% refle& 2wallowin% refle& 2atiet! refle&
Iron
Iodine o+alt $luoride
opper
Rinc
)rolactin stimulation from anterior pituitar! O&!tocin stimulation from posterior pituitar! 1 st to come into pla! , al#eolar area to mouth 2*ueeDin% sinuses of areola
Man%anese
Mil' in infants mouth
Mol!+denum 2i#"mis Vitamin A
D.ri, re"s#fee!i,' oser3e for #he ff,> ?-4 w's an suc'le [+est simulate +reasfeedin%] 4 w's Ade*uate suc'lin% 6 swallowin% F ? w's 3u+e feedin%"OG3 A+solute "I to +reastfeedin%< AI/2, 3B, cardiac disease, th!rotoicosis, ad#anced nephritis, mental 6 seiDure disorders [ e8ce# he"#i#is %] 8ew+orns re*uire 11@-11 'cal"'%"da! and %row at a rate of a+out @ %"da! 8ew+orns usual l! +e%in feedin% win 1 st K hrs of life 8ew+orns should +e +reast or formula fed e#er! -4 hrs thereafter olostrum is secreted from +reast toward the end of pre%nanc! and for ?-4 da!s after deli#er! I,A accounts for N@P of protein in the colostrum Breastfed infants ha#e lactobacillus bifidus while artificiall! fed infants ha#e lactobacillus acidophilus 2olid food should +e introduced +etween 4-K mos 5stimated a#era%e re*uirement = BM & ph!sical acti#it! le#el Endernutrition has the %reatest effect on +rain de#elopment from 1- mos of a%e /o not %i#e an infant under K mos old water or (uice [water fills them upL (uice contains empt! calories and e&cess su%ar can cause diarrhea 3!pical formulas contain ?@ 'cal"ounce Holi!"(-Se,"r me#ho!Q o Gi#e 1@@ ml"'% of water for the 1s 1o '% o $or a child 1@-?@ '%, %i#e 1,@@@ ml @ ml"'% for each '% a+o#e 1@ '% o :here 1 '% = ?? l+s 3he rise in serum 8a in the correction of chronic h!ponatremia should not e&ceed ? m5*"0"hr or cere+ral pontine m!elinosis ma! occur s econdar! to fluid shifts from the intracellular fluid $or e#er! @1 unit reduction in serum p., there is an increase in serum > of a+out @?-@4 m5*"0 A w' old infant feedin% poorl! on standard formula switched to cows mi l' has an afe+rile %rand mal seiDure and tremulousness< h(oc"lcemi" seco!"r( #o is.fficie# 3i#"mi D A 14 mos old infant presents w" anore&ia, pruritus and failure to %ain wei%ht, has +ul%in% anterior fontanelle and tender swellin% o#er +oth ti+ias Mother +u!s all foods at a natural foods store< h(er3i#"miosis A Accounts for the %reatest P of caloric inta'e in an infants diet< carbohydrates
hromium 2elenium
Vitamin B1 [thiamin] Vitamin B? [ri+ofla#in] Vitamin B [niacin] Vitamin BK Vitamin B1? Biotin $olacin Vitamin >
Vitamin
Vitamin /
Vitamin 5
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2i#"mi "! mier"l s.leme#s 8a $luid #olume in #essels 6 tissues /eficienc!< 8AV, diarrhea, muscle cramps, /.8, h!potension 5&cess< edema > Muscle contraction, maintains cell inte%rit! /eficienc!< diarrhea, />A, muscle weakness6 abdominal distention a Bone 6 teeth structure, permea+ilit! of cell mem+rane /eficienc!< poor mineraliDation of +ones 6 teeth, osteomalacia, ric'ets, tetan! 5&cess< heart block6 renal stones M% MineraliDation of +ones 6 teeth /eficienc!< malabsorption6 tetany
Gastric (uice, maintains normal fluid electrol!te +alance /eficienc!< h!pochloremic al'alosis, prolon% #omitin% e&cess sweat Buffer su+stance for acid-+ase +alance /eficienc!< ric'ets, muscle wea'ness 5&cess< tetany from rickets 8ew+orn iron stores are sufficient for K mos in a term infant )reterm +reast-fed infants should start at ? mos of a%e /eficienc!< anemia [h!pochromic, microc!tic] and %rowth failure onstituent of th!roid hormones /eficienc!< goiter6 cretinism onstituent of co+alamine 5&cess< cardiomyopathy 2upplement after K mos of a%e /eficienc!< dental caries 5&cess< fluorosis J mo##li,, stainin%, or h!poplasia of enamel $unction on some eD!mes in B production 6 $e meta+olism /eficienc!< refractor! anemia, osteoporosis, neutropenia 5&cess< cirrhosis 7J8 onstituent of car+onic anh!drase [decreases AG5 6 E3I] /eficienc!< dwarfism, IDA, acrodermatitis, h!po%onadism, oor /o.! he"li, 5&cess< GI upsets $ormation of mucopol!saccharides 5&cess< to&icit! from chronic inhalation Insulin cofactor )rotects cells from o&idati#e dama%e /eficienc!< cardiomyopathy , arthritis [`] O&idation of aldeh!des 6 sulfides, facilitates man! cellular processes Fe"#.res /eficienc!< ni%ht +lindness, 8erosis co.c#i3"e [1st clinical 2&], 'eratomalacia [i#o#0s so#s J dr! sil #er-%ra! pla*ues in +ul+ar con(uncti#ae] 5&cess< .!per#itaminosis A [1@@,@@@ U%] J +ul%e fontanelle, diplopia, papilledema 6 8 palsies su%%esti#e of se.!o#.mor cereri Important in s!nthesis of Ach for ner#e conduction /eficienc! [+eri-+eri]< ho"rseess [MC S8)' neuritis, tin%in%, paesthesia, 9 /3 2ensiti#e to li%ht 6 al'ali, important in AA, $A 6 .O8 meta+olism, cellular respiration /eficienc!< cheilosis, %lossitis, 'eratitis, con(uncti#itis, seorrheic !erm"#i#is onstituent of co5 1 6 ?, 8A/"8A/) /eficienc! [pella%ra]< dermatitis 7casal necklace8 , diarrhea, dementia [#ri"!) $or acti#e transport of AA [linoleic acid] /eficienc!< microcytic anemia6 bladder stones 5ssential for maturation of B oenD!me for O? transport )articipates in s!nthesis of purines 6 p!rimidines .uman +reast mil' is deficient in #itamin > thus it is necessar! to administer a 1 m% #itamin > shot at +irth /eficienc!< hemorrhagic disease of the newborn $unctions to chelate metals, role in s!nthesis of arachidonic acid from linoleic acid /eficienc! [scur#!]< pseudoparal!sis, edema alon% shafts of le%s, bluish-purple spongy swelling of gums, scor.#ic e"!s [rosar! at costochondral (oints], ground"glass appearance of 'nee tra+eculae on &-ra! w" prominent white line of 9raenkel $acilitates intestinal a+sorption of a 6 )O4/eficienc! [ric'ets]< craniotabes 7early sign8 , r"chi#ic ros"r( [palpa+le enlar%ement of costochondral (oints], hhic'enin% of wrist 6 an'les 5&cess< h!potonia, h!pera, corneal clouding6 4metastastic calcification Acts as fat-solu+le antio&idant [alpha-tocopherol] /eficienc!< muscle wea'ness, focal necrosis of striated muscle
Aemi"s> Iron Vitamin BK [p!rido&ine] $olic acid Vitamin B1? [c!anoco+alamin]
I/A [microc!tic anemia] Microc!tic anemia Me%alo+lastic anemia )ernicious anemia
A#roome#ric me"s.reme#s> :ei%ht for a%e Inde& for acute nutritional depletion .ei%ht for a%e eflects %rowth failure 6 chronic undernutrition
Prici"l Fe"#.res of Pro#ei-C"lories Deficiec( Fe"#.res M"r"sm.s Other names Infantile atroph!, inanition, athrepsia a usual a%e @-? !ears + essential features 1 edema none ? wastin% %ross loss of su+cutaneous fat "ll ski "! oes
7/"shiorkor 8utritional edema s!ndrome, mali%anat malnutrition, )luridef s!ndrome 1- !ears Prominent edema +cardinal sign sometimes hiddenL sometimes fat, +lu++er!
17
muscle wastin% 4 %rowth retardation mental chan%es c #aria+le features 1 appetite ? diarrhea s'in chan%es 4 hair chan%es face features K hepatic enlar%ement H other features d +iochemistr! 1 serum al+umin ? urinar! urea " % creatinine urinar! h!dro&!)roline " % creatinine 4 serum essential AA li#er +iops!
o+#ious o+#ious usuall! apathetic, *uiet
sometimes hidden sometimes hidden usuall! irrita+le, moanin%, also apathetic
usuall! %ood often [past or present] seldom seldom ol! m" f"cies seldom Po# ell(' /i,e! sc".l"
usuall! poor often [past or present] 6la0y paint or enamel dermatosis Gra!ish or reddish 9flag sign: Moonfacies Alwa!s Anemia [me%alo+lasticL I/A]
normal or low normal or low
0ow 0ow
low
0ow
normal normal or atrophic
0ow fatty change
PEDIATRIC META%*LIC DISEASES & IMMUN*L*+IC DISEASES )hen!l'etones< phen!l-acetate, -lactate, and Jp!ru#ate, in urine /ecreased pi%mentation in )>E is secondar! to inhi+ition of t!rosinase +! phen!lalanine $a+r!s disease is &-lin'ed recessi#e .unters s!ndrome is &-lin'ed recessi#e A mos old, +reastfed infant has failure to thri#e, se#ere hepatome%al!, thin e&tremities, fastin% h!po%l!cemia, lipemia, and meta+olic acidosis< 2o-,ierkes Mc Ardles affects the muscles )ompes affects the pump A ? w' old neonate has (aundice, hepatome%al!, and urinar! reducin% su+stance Odor of urine is normal< ,"l"c#osemi" H(o,l(cemi"> plasma %lucose le#el of F 4@ m %"dl [term"preterm], characteristic hi,h-i#ch cr( H(oc"lcemi"> decreased a +! 1, M ris' is prematurit!, t& +! citrated +lood transfusion Maternal serum anti+odies [I%G] transferred across the placenta to protect infant from +irth until appro&imatel! K-1? mos of a%e A childs own anti+odies +e%in de#elopin% +etween K mos to 1 !ear of a%e Anaph!lactoid reaction o linicall! similar to anaph!la&is o 8ot I%5 mediated o /oes not re*uire pre#ious e&posure $or the past ? w's, a K !"o +o! has had a%%ressi#e edema of #arious s ites, puff! chee's and e!es on awa'enin% and swellin% of feet and a+domen as the da! pro%resses .is h& includes an upper respirator! illness and a stin% +! a !ellow (ac'et< ser.m sickess Peicilli "ller,(> o T(e :< anaph!la&is o T(e @< hemol!tic anemia o T(e < serum sic'ness H(ersesi#i3i#( #o !r.,s> 3!pe 1< I%5-mediated )8, in sulin, cephalosporin 3!pe ?< !toto&ic A+ )8, *uinidine 3!pe Immune-comple& )8, sulfonamides, cephalosporins 3!pe 4< cell-mediated 8eosporin, antihistamines • • • • •
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•
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•
Vitamin A deficienc! C(s#ie' "r,iie' #".rie [not threonine]
PRE2ENTI*N *F ILLNESS AND INURY IN CHILDREN AND AD*LESCENTS DT" is the preferred for children under years of age , T! is %i#en after y/o !!6 K*V6 small po&6 typhoid6 nasal influen;a and varicella #accine are li#e #irus #accines • •
EPANDED PR*+RAM *N IMMUNIOATI*N [see D*H o#es) 2"ccie Miim.m ",e Doses Miim.m i#er3"l "# :s# !ose e#/ee BG At +irth, or an! 1 time after +irth /)3 At K w's 4 w's At K w's At K w's At mos
1
Si,s "! s(m#oms of Fe"#.res P +od! wei%ht loss General .eart rate B) 3ears Erine 2'in tur%or A nt er io r f onta ne l e apillar! refill Mucous mem+ranes
!eh(!r"#io Mil! -P onsola+le e%ular 8ormal 8ormal 8ormal 8ormal $ la t F ? secs Moist
4 w's 4 w's
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•
•
Co#e#s 0i#e attenuated /3 = to&oid, ) = 'illed +acteris 0i#e attenuated ecom+inant 0i#e attenuated
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•
Mo!er"#e K-P Irrita+le Increased 8ormal"low educed educed 3entin% 2 of t ?- secs /r!
R"i! re3ie/ 3 he l ead in % c au se o f d ea th f or ado le sc en ts Virtuall! dia%nostic of ph!sic al a+use in an infant
Se3ere 1@P 0ethar%ic " o+tunded More increased 0ow 8one Oli%uric"anuric 8one 2 un 'e n secs )arched"crac'ed
A cc id en ts an d hom ic id e 5piph!seal-metaph!seal in(ur!
C*N+ENITAL MALF*RMATI*NS AND CHR*M*S*MAL AN*MALIES A female infant has slanted palpe+ral fissures, epicanthal folds, and dela!ed de#elopment< !o/ s(!rome A new+orn infant has l!mphedema of hands and feet, e&tra s'in folds at a short nec', widel! spaced nipples, and decreased femoral pulses< ,o"!"l !(s,eesis [=6') or #.rer0s s(!rome Male adolescent presents w" hematuria, proteinuria, and decreased hearin%< "lor#0s s(!rome In a normal pre%nanc!, there is appro&imatel! K@@ ml of amniotic fluid surroundin% the +a+! at 4@ w's AOG Ui?.e fe"#.res of some me#"olic !isor!ers> Iso#aleric academia, %lutamic academia 2weaty feet .aw'insinuria 2wimmin% pool Maple s!rup urine disease Maple s!rup"sweet odor .!permethionemia, t!rosinemia Boiled cabbage Multiple car+o&!lase deficienc! 3om cat write )>E !ousy/musty odor 3rimeth!laminuria ottin% fish •
•
•
•
•
$op’s like )lue diaper syndrome hinese restaurant s!ndrome
•
R"i! re3ie/ M cause of +lindness worldwid e in !oun% children essential AA for 0B: infants
O)V .5)A B M5A2052
Oasthouse urine disease Indicanuria Glutamic acid disorder
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•
A 1@ !"o %irl hs a persistent, unresponsi#e, infection of the oral ca#it! and nails< chroic m.coc.#"eo.s c"!i!i"sis A ? mos old infant w" ./ is hospitaliDed w" cou%h and tach!pnea show diffuse infiltrates and no th!mic shadow 2erum a is K m%"dl [low]< Di+eor,e s(!rome A 14 !"o +o! has had lifelon% s'in i nfections .is leu'oc!tes a re una+le to reduce nitro+lue tetraDolium< chroic ,r".lom"#o.s !ise"se
T(es of Imm.o!eficiecies om+ined immunodeficienc! 3 cell deficienc! .umoral deficienc! )ha%oc!tosis Others
2I/ /iGeor%e s!ndrome, chronic mucocutaneous candidiasis Brutons a%amma%lo+ulnemia, I%A deficienc!, VI/ hronic %ranulomatous disease, hedia'-.i%ashi s!ndrome, Co+ s!ndrome :is'ott-Aldrich s!ndrome, Ata&ia-telan%iectasia
R"i! re3ie/ A%e 1, )u+ert! A%e 1N can 5lect A%e ?1 can /rin' )& s w" downs s!ndrome de#elop AlDheim ers at M cause of primar! amennorhea Branched-chain AA 1st immuno%lo+ulin to appear in the +loodstream after the 1st e&posure to an anti%en [primar! anti+od! response] 2ecretor! anti+od! response Ma(or anti+od! to protein anti%ens M causes of urticaria in children M causes of dru% reactions M site for the manifestation of dru% reaction M immuno%lo+ulin deficienc! and is the M humoral anti+od! deficienc! M inherited d"o of pha%oc!tosis Ma(or immuno%lo+ulin in upper airwa! 5arliest site of ata&ia-telan%iectaia 3hrom+oc!topenia, ecDema, and recurrent +acterial infections in males
)ataus s!ndrome 5dwards s!ndrome /owns s!ndrome a%e 3urners s!ndrome 0eucine, isoleucine and #aline I%M I%A I%G #iral infections )8, sulfonamides 2'in 2electi#e I%A deficienc! hronic %ranulomatous disease I%A Bul+ar con(uncti#ae :is'ott-aldrich s!ndromre triad
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SPECIAL *R+ANS G EYE' EAR' AND N*SE A 4 mos old child presents w" an e&udati#e e!e dischar%e and a painful, red lacrimal sac< !"croc(s#i#is Infection of the %lands of Reis< e8#er"l hor!eol.m or s#(e Infection of the mei+onian %land< i#er"l hor!eol.m 3he most specific si%n of acute otitis media< decreased mobility of tympanic membrane Otitis media is also 'nown asL s/immer0s e"r Mali%nant otitis e&terna is caused +!< *( aeruginosa A 4 !"o +o! presents w" what loo's li 'e herpetic #esicles in the ear canal and t!mpanic mem+rane< r"ms"(-h.# s(!rome [includes ipsilateral facial ner#e paral!sis and loss of taste in the anterior ?" of the ton%ue] At +irth, onl! the m"8ill"r( "! e#hmoi! si.ses are present 3he M location of epista&is in children is from the anterior nasal septum +ecause >iessel+achs ple&us is located here
Vol um e e &pa nde rs 8alo&one .0
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/e&trose [%lucose]
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8a .O /opamine
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O&!%en
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R"i! re3ie/ Also called as laD! e!e M cause of am+l!opia M #iral cause of con(uncti#itis M disorder of the lacrimal s!stem M or%anisms causin% +oth preor+ital and or+ital cellulitis M cause of leu'ocoria M primar! mali% nant intraocular tumor in chil dren M or%anisms causin% otitis media M o#erall complication of otitis media M i ntracrani al compl icati on of oti tis medi a M atopic disease Verti%o, tinnitus, and hearin% loss
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Am+l!opia 2tra+ismus Adeno#irus /acr!ostenosis 2 aureus, . influenDae, 2 pneumoniae ataract etino+la stoma 2 pneumoniae, . influenDae, M catarrhalis .earin% loss Meni n%i tis Aller%ic rhinitis Menieres triad
PSYCHIATRY A !"o +o!s mother has +een called to school +ecause her son has not done his homewor' .e claims that he did not ' now a+out the assi%nments .e interrupts other 'ids and is alwa!s %ettin% up durin% class< ADHD ? areas are particularl! affected in autistic disorder< communication and social interactions A !"o +o! is +rou%ht in +! his parents +ecause the! thin' he is deaf .e shows no interest in them or an!one around him and spea's onl! when spo'en to directl! .e often lines his to!s up in a strai%ht line .earin% tests are normal< ".#ism A 1 !"o +o! has had uncontrolla+le +lin'in% since he was !"o recentl! he has noticed that he often in#oluntaril! ma'es a +ar'in% noise that is em+arrassin%< #o.re##e0s !isor!er A 1K !"o %irl has a K mos histor! of amenorrhea and a ? l+s wei%ht loss 2he is thin w" 3anner sta%e 4 de#elopments of +reasts and pu+ic hair 3h!roid cascade is normal "ore8i" er3os" A 1 !"o %irl has +ilateral parotid %land swellin% and erosion of the posterior aspect of dental enamel of her upper incisors< .limi" er3os" Ina+ilit! to e&press emotion< "le8i#h(mi" •
espirator! failure< 8B5 > P?@ K (* mm&g! P@ H AA mm&g! p& K 3D Most arrest in children is caused +! pro%ressi#e respirator! failure and circulator! collapse M%t of drownin%< AB, administer 8a.O, rewarmin% measures
Dr., #o8ici#ies Dr., Acetaminophen [1@@-1@ m'd in 'ids, N %m adults] Belladonna al'aloids BenDodiaDepines austics hloramphenicol 5th!l alcohol [ %m in 'ids or -N %m in adults] .ea#! metals 6 insecticides I8.
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Iron [?@@-@@m'd] Isoproph!l alcohol
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>erosene or petroleum Methanol, eth!lene %l!col [ 4ml] Opiates, cou%h 6 cold mi&tures Or%anophosphates
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R"i! re3ie/ M d ia %no si s i n ou tp at ien t ps !c hi at ri c c li ni cs Inattention, h!peracti#it!, impulsi#it! M si%nificant +eha#ioral s!ndrome in childhood M cause of death in anore&ia ner#osa is
co nd uc t d is or der cardinal si%ns of A/./ A/./ ardiac arrh!thmia secondar! to h!po'alemia
PEDIATRIC LIFE SUPP*RT M%t of airwa!< he"! #il#-chi lif# & "/ #hr.s# m"e.3ers M%t of +reathin%< loo'in% at chest 6 a+domen for mo#ement, listenin% for e&haled air flow 6 feelin% for e&haled air M%t of circulation< increase perfusion pressure, stimulate spontaneous or more forceful m!ocardial contraction, accelerate cardiac rate 8eonates ? thum+s are placed on middle rd of sternum +elow intermammar! line w" fin%ers Infants ? fin%er are placed o#er the sternum, a fin%ers +reah +elow intermammar! line hild .eel of compressin% hand is placed ? fin%er +reaths a+o#e &iphisternum [ compressions @ . breath6 .-- compressions per minute8 •
)rednisone uinolones ed-tide poisonin% 2alic!lates [if 1@ m%"'%"dose] 2ulfonamides 3A
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M%t of forei%n +od! inhalation< Heimlich0s m"e.3er [if w"o air e&chan%e = do +ac'flows 6 chest thrust] or +ronchoscopic remo#al [if w" air e&chan%e] Dr.,s .se! i res.sci#"#io> 5pinephrine D*C for c"r!i"c "rres# auses peripheral #asoconstriction [], 6 enhance cardiac contractilit! [W] = / = @1 m%"'% or @1 ml"'% IV of 1<1@,@@@ solution * - mins prnb Atropine )aras!mpathetic medication for +rad!cardia associated w" h!potension 6 poor perfusion [AV +loc's] 0idocaine ontrol of #entricular distri+ution 6 suppress dischar%e of ectopic
foci I n I /M 8arcotic anta%onists, %i#en to new+orn in resir"#or( !is#ress [/ = @1 m%"'%] except newborn of drug-addicted mothers 3& of h!po%l!cemia .G3 determination w"in @ mins after +irth< asph!&iated infants, I/M, re#erm [GI = 4-K m%"'%"min] 3 & of m et a+ ol ic ac id os is 8 ot fo r ac ut e pha se , h !d rat ed 3& of h!potension ff% resuscitation if p& is in shoc' a U%"'%"min J +eta, causes ; . 6 contraction + 1@-?@ U%"'%"min J alpha, causes #asoconstriction, ;B) c ?@ U%"'%"min - 9 mesenteric +lood flow If p& is in respirator! distress
3etrac!cline
Si,s "! s(m#oms GeneraliDed malaise, 8AV, (aundice, +leedin%, meta+olic acidosis, renal and m!ocardial dama%e, coma, /elirium, fe#er, flushin%, dr! mouth, !il"#e! .ils 2edation, slurred speech, motor incoordination, sesori.m Acid< li*uefacti#e necrosis of esopha%us Al'ali< coa%ulati#e necrosis of stomach Gra! +a+! s!ndrome J #omitin%, ashen color, cardio#ascular collapse Muscle incoordination, diDDiness, slured speech, h!pothermia 6 depressed sensorium [coma or stupor] /iarrhea, sweatin%, sali#ation, urination, miosis 8AV, slurred speech, h!per"arefle&ia, seiDures, meta+olic aacidosis, coma A+dominal pain, wea'ness, 9sensorium 8AV, a+dominal pain, hematemesis, ata&ia, diDDiness, stupor or coma ou%h, d!spnea, alar flarin%, retractions, rales, wheeDe, stupor or coma Into&ication, +lindness [formic acid], seiDure, confusion !ost dangerous Brad!pnea, apnea, coma, ioi# .ils Malathione [mild], parathione [#er! to&ic] 2ali#ation, +rad!cardia, miosis, .)8 Growth retardation and cataracts Ma! cause cartila%e defects in children 2a&io&in +! dinofla%ellates 3in%lin%, num+ness, wea'ness, ata&ia, paral!sis Re(e0s s(!rome J hepatic in(ur!, h!po%l!cemia, #omitin%, tach!pnea, fe#er, .A, co3.lsios' sweatin% >ernicterus in infants Anticholiner%ic, widened 2, flattened 3 wa#es
Tre"#me# "! "#i!o#e 8-acet!lc!steine [mucorm!st]
$lumenaDil 2teroids, .? +loc'ers, endoscop!
Gastric la#a%e, emesis
/imercaprol, 5/3A )!rido&ine, acti#ated charcoal, decontamination helation w" defero&amine 2upporti#e, correction of acid-+ase distur+ance Gastric la#a%e, acti#ated charcoal 5thanol, fomepiDol, acti#ated charcoal 8alo&one Atropine, pralido&ime
Gastric la#a%e, supporti#e Acti#ated charcoal
Intu+ation and acti#ated charcoal, sodium +icar+onate
Gra! enamel of permanent teeth, affects +one %rowth
Acetaminophen to&icit!< 2ta%e 1 F 1? hrs Anore&ia, 8AV, diaphoresis, malaise 2ta%e ? 1? hrs Ma! +e as!mptomatic, minimal serum enD!me ele#ation 2ta%e K hrs J ? d .epatic encephalopath! w" centrilo+ular necrosis, w" acti#e li#er failure, meta+olic m!ocardial 6 renal a+normalities 2ta%e 4 4N-H? hrs eturn to normal of li#er, renal 6 meta+olic functions, return of li#er patholo%! to normal +! mos •
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2creenin% test for to&idromes< ferric chlori!e #es#s [salic!lates, phenothiaDines], N"*H #es# [car+on dio&ide in +lood], &-ra!, la#a%e If NP 3B2A, %i#e c r!stalloids 6 proteins should +e 1-? %ms 3he leadin% cause of pediatric arrest in children o#er a%e 1 !ear< injury 3he num+er 1 cause of pediatric in(uries< M"8 Improper openin% of the airwa! is the M cause of ineffecti#e rescue +reaths
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Infant compressions< ? fin%ers o @T-1T depth o ate 1@@"min o <1 ratio hild compression< heel of palm o 1T-1T depth o ate = 1@@"min o <1 ratio Infant airwa! o+struction = +ac' +low chest thrusts hild [ 1 !"o] airwa! o+struction = Heimlich m"e.3er 2i%ns of respirator! distress< tach!pnea, nasal flarin%, %runtin%, retractions 0ar!n%oscope +lade< Infant - miller @ A%e 1- J miller ? A%e F 1 J miller 1 A%e J mac ?
533 siDe = [a%e"4] 4 Initial fluid +olus in shoc'< ?@ ml"'% <1 rule< ma! need o administer & esti mated fluid loss Cl"sses of shock i e!i"#rics lass 1 @-1P loss, normal #itals lass ? 1-@P loss, mildl! ; ., prolon%ed capillar! refill, mil d an&iet! lass @-4@P loss, ; ., 9 B) and EO, poor capill ar! refill, confused lass 4 4@P loss, #er! low B), ne%li%i+le urine output, lethar%ic, pale or c!anotic •
M underl!in% factor in infants +orn w" deformations M cause of .)8 J children M ac*uired GI3 emer%enc! in neonates [preterm, 0B:] M e&tracranial solid tumor of childhood M fatal mali%nanc! in children M peripheral ner#e in(ur! in childhood M epithelial mali%nanc! in children M endocrine meta+olic disease in childhood M sarcoma in children M factors associated w" 2GAinfants M cause of neonatal respirator! distress M lethal %enetic disease affectin% white populations M cause of mortalit! in postnatal infants in E2 3he sin%le M cause of death from li#er disease in earl! childhood 3he sin%le most haDardous period in life
Eterine constraint enal stenosis [c!stic disease :ilms] 85 8euro+lastoma 0eu'emia 8eonatal +rachial ple&us in(ur! 0i#er tumors [M = hepato+lastoma] /M t!pe 1 5m+r!onal rha+dom!osarcoma Maternal factors /2 or h!aline mem+rane disease !stic fi+rosis 2udden infant death s!ndrome Biliar! atresia 8eonatal period
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2hoc' mana%ement< .!po#olemic 2eptic shoc' ardio%enic
$luids Multiple +oluses, dopamine and epinephrine Initial +olus, do+utamine or epinephrine
8ew+orn ABs< position, suction, stimulate cr!, warm and dr! If meconium is present durin% deli#er!, a%%ressi#el! suction h!pophar!n& as soon as head is deli#ered
R"i! re3ie/ Ominous si%n of e&tensi#e neonatal death M cause of dru% o#erdose in children ?nd M caus e of dru% o#erdosa%e M t!pe of +urns in children 3he narrowest part of pediatric airwa! 3he num+er 1 worldwide cause of shoc'
ere+ral edema ou%h 6 cold mi&tures [antidote< nalo&one] Isoni aDid [antidote< p!ri do&i ne] 2caldin% in(ur! ricoid cartila%e .!po#olemia
MISCELLANE*US Mos# commo M mali%nant ocular neoplasm in children M cause of stridor in infants M cause of lower GI +leedin% in children M cause of throm+oc!topenia in children M cause of throm+oc!topenia in otherwise health! new+orn M tumors in infanc! M soft tissue sarcoma in children M A in infants 6 children M testicular tumor in children up to !o M A dia%nosed in infants F 1 !o M mali%nant e!e tumor in childhood M primar! heart tumor in infants 6 chil dren M primar! renal tumor in childhood M cause of AMI in children M cause of ac*uired cardiac disease in children M lesion that presents w" c!anosis 6 .$ in neonates M s!mptomatic arrh!thmia in pediatric a%e %roup M cause of clu++in% of fin%ers as a si%n of pulmonar! disease in children M complication [e&trahepatic] of ame+iasis M mali%nant tumor in infants 6 children M cause of profound wea'ness durin% childhood M o+structi#e urethral lesion in infants M pediatric cause of aneur!sm M cause of persistent (aundice in new+orn M terato%en M fetal #iral infection M +irth in(ur! Most important +irth in(ur!
etino+lastoma 0ar!n%omalacia Mec'els di#erticulum 3O. Isoimmune throm+oc!topenia .eman%iomas ha+dom!osarcoma Qol' sac tumor Qol' sac tumor 8euro+lastoma [site- adrenal medulla] etino+lastoma ha+dom! osarc oma :ilms tumor >awasa'i disease >awasa'i disease 3ransposition of %reat #essels 2V3 !stic fi+rosis .epatic a+scess A00 Infantile spinal muscular atroph! [:erdni%-.offman s!ndrome] )osterior urethral #al#es Infectious aneur!sm Biliar! atresia Alcohol MV la#icular fracture Intracranial hemorrha%e
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