PEDIATRIC Notes

Pediatric- Ghazal’s and Mona’s notes.
Pediatrics
1-The newborn
Ø Assess every 1 and 5 min >> if HR less than 60 >
give epinephrine > SE of epinephrine:
tachypnea, HTN.
Ø When BABY born, we give > vitamin K,
Prophylaxis erythromycin.
Ø If mother HbsAG positive > start HB vaccine
and give IG immediately.
Ø Less than 37 >> preterm.
Ø From 37-42 term.
Ø IUGR > less than 5-10 percentile for gestational age, or less than 2500 gram.
symmetrical fetal cause, aneuploidy- genetic, infection, tubal defect all in US smaller than expected.
asymmetrical placental cause, TTTs, abruption.> also maternal cause, HTN, small in US head sparing but, abdomen
vessels disease, DM1, alcohol, tobacco smaller.
Ø If diabetic mother > measure baby GLUCOSE it would be low also Mg low > give dextrose infusion but the
SE will be hypo-G so be careful and keep on monitoring, baby will present large in size, plethoric, macrosomia,
tachypnea………
• Dextrose given peripherally in D5 and D10 but centrally in D12.5 and D15 and D20.
• We start ttt of neonatal hypoglycemia by inserting 2ml/kg of D10 *peripherally*
Treatment of hypoglycemia >> • If no response, persisted hypoglycemia so consider 12.5D through *central line*
• So initially it is peripheral line, not direct central line
• Frequent blood sampling is indication for central venous line, but in diabetic mother we need a fast
method, so answer is peripheral.
Ø RDS- 24/72 h post-delivery >> RR more than 60 HR more than 160, comes usually with prematurity > Low
surfactant- dipalmitoyl phosphatidyl choline > low FRC and atelectasis > hypoxemia then hypercapnia
and R acidosis.
o Initial > radio first (ground glass appearance).
o Accurate > L/S ratio.
o To treat first give O > definitive treatment intubation and give surfactant.
o Complication of ventilation > Broncho pulmonary hyperplasia.
TTN Meconium aspiration Diaphragmatic hernia

Wet lung syndrome, decrease compliance, Result of hypoxia, and fetal distress, lead to airway Pulmonary hyperplasia, distress, cyanotic, high
tachycardia. obstruction and pneumonitis, then fetal and RR.
pulmonary HTN.
x-ray air trapping, fluid in fissure, peripheral Patch infiltration increase AP diameters, flat Bowel in chest, scaphoid abdomen, increase
stroking diaphragm. AP diameter, gastric tube in chest.
improve after couple of hours, O2. Positive pressure ventilation, NICU. Intubation, soft mechanical ventilation, when
stable do surgery.
In the initial management for diaphragmatic hernia

o Immediate endotracheal intubation > Blow-by oxygen and/or bag-masking should be avoided > Placement of a nasogastric
tube connected to continuous suction for decompression of the stomach and intestine > Administration of (fluids and inotropic
agents) to maintain mean arterial blood pressure (BP) ≥50 mmHg > Administration of (surfactant therapy) to only preterm
infants (gestational age [GA] ≤34 weeks) who also have findings suggestive of respiratory distress syndrome > We recommend
that the timing of surgical repair be based on the patient's pulmonary status, which is dependent on the severity of pulmonary
hypoplasia and pulmonary hypertension, and his/her response to preoperative medical care> Long-term complications in
survivors of CDH include chronic respiratory disease, gastroesophageal reflux, failure to thrive, recurrence, neurodevelopmental
delay, and musculoskeletal deformities.
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Ø Sepsis
§ if less tan 72 h >> GBS, E. coli, listeria.
§ If less than 1 month same but add >> staph, klebsiella.
Ø Do septic workup.
Ø If meningitis suspected > ampicillin and cephalosporin, if not ampicillin and aminoglycoside.
Ø Congenital infections >> TROCH > UpToDate and u-world.
1. toxoplasmosis
**Mother get affected from cat feces/ uncooked meat.

Infant usually asymptomatic
or have fever, maculopapular rash, hydrocephalus/ microcephaly, cholestasis, chorioretinitis, intracranial classification, symmetrical IUG.
Infants with subclinical congenital toxoplasmosis who do not receive treatment have an increased risk of long-term sequelae.
The most common late finding is chorioretinitis, which can result in vision loss. Intellectual disability (mental retardation), deafness, seizures,
and spasticity also can be seen in a minority of untreated children.
Treatment > regimen includes pyrimethamine plus sulfadiazine and folinic acid (leucovorin) Glucocorticoids (prednisone 0.5 mg twice per
day) are added if cerebrospinal fluid (CSF) protein is >1 g/dL or when active chorioretinitis threatens vision.
2. CMV
**MC congenital infection worldwide,

o At birth asymptomatic, then they may developed >> Petechiae because low PLT like pint point (54 to 76 percent), Jaundice at
birth (38 to 67 percent), Hepatosplenomegaly (39 to 60 percent), Small size for gestational age (39 to 50 percent), Microcephaly
(36 to 53 percent), MC Sensorineural hearing loss, only in immunocompromised (SNHL, present at birth in 34 percent; delayed
SNHL can also occur), Lethargy and/or hypotonia (27 percent), Poor suck (19 percent), Chorioretinitis (11 to 14 percent), Seizures
(4 to 11 percent), Hemolytic anemia (11 percent), Pneumonia (8 percent).
Result in non-hereditary SN hearing loss (MC), mental retardation, cerebral palsy, visual impairment and seizure.
Intravenous (IV) ganciclovir and its orally available prodrug, valganciclovir, are the first-line antiviral agents of choice for treatment of
congenital CMV disease.
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3. Syphilis:
o Congenital syphilis is acquired through transplacental transmission of spirochetes.
o Women with untreated primary or secondary syphilis are more likely to transmit syphilis to their fetuses than women with latent
disease.
• Mc accurate test, treponema in scarping from any lesion, infant + VDRL and clinical sign, Prenatal penicillin.
Give Baby penicillin.
o Treponema pallidumis not transferred in breast milk
§ Hepatomegaly
§ Jaundice
§ Nasal discharge ("snuffles")
§ Rash
§ Generalized lymphadenopathy
§ Skeletal abnormalities, osteochondritis
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4. Rubella congenital:
• SN hearing loss, cataract, glaucoma, PDA- Pulmonary artery hypoplasia, bone disease, deafness, murmur- Harsh machine like
continues, low PLT, HSM, blueberry muffin spot, microcephaly.
• the mother > spontaneous abortion, fetal demise.
5. HSV:
• Start mild symptoms, first temperature instability, respiratory distress, poor feeding, lethargy, then rapid developed to
hypotension, J, DIC, apnea, and shock.
• Herpetic keratoconjunctivitis, vesicular or ulcerative, coronial disease, microcephaly, deafness, blindness, seizure, death, SMA. .
‫ﻋﻴﻮن‬
• Acyclovir
6. Varicella
• treat with VZIG if developed 5 days before or 2 days after.
• limb malformation- hypoplastic limb, scar on skin like Zig zag in a dermatomal distribution, microcephaly, chorioretinitis, cortical
atrophy and seizure, cataract.
7. Hep B:
• If mother HBeAH+ > Transmit vertically to baby, baby should take HBIG after birth, followed by recombinant HBV vaccine, within
12 hrs of birth.
• If mother HbsAG positive > start HB vaccine and give IG immediately.
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Umbilical Resolve spontaneously 90% close 5 years of age, surgery if not return in 5 years old or if strangulated.
hernia DON’T PUSH IT.
omphalocele Fail of intestine to return in abdomen. Com, R
Usually they have other anomalies, could be chromosomal related, or large failure,
baby, but it covers with sac. ischemia,
Small: close by itself, medium: close the skin hernia later, large need stage malrotation
For both of them if
reduction, silo. of gut.
large need
Gastroschisis not covered by sac, Edematous herniated bowel. Com, short stabelize (we do
related to RF ex smoking, alcohol use, young age mother, frequency of UTI. gut, stages and mesh
It is more urgent: inflamed bowel, not covered and intestine abnormality. ischemia, repair)
Stage repair with silo. stenosis,
If not large and no ischemia do stage reduction. atresia.
Imperforated Fail to pass stool, no anal opening. do surgery.

anus
hydrocele Fluid around testes- cystic scrotal mass, transillumination, palpate the cord above it, sometimes you can’t
feel the testes itself, soft, asymptomatic.
Communicating = connection to peritoneum, increase the size during the day or with Valsalva maneuver,
reducible.
Non- communicating = no communicating with peritoneum, non-reducible and no change in size, can extend
to abdomen and form= abdominal scrotal hydrocele.
DO doppler to exclude other causes.

Majority of newborn resolve spontaneously, by first to second year.
In older children and adolescent could be due to other cause like infection or trauma.
Differential diagnosis of painless scrotal mass.
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Ø Neonatal tetanus:
• Poor cord hygiene, Unimmunized mother, un-hygenated delivery,

• C.tetani, first few weeks of life > sign of umbilical infection, opisthotonus diffuse
hypertonicity, lockjaw difficultly feeding.
• Supportive, penicillin, tetanus immune globulin.
Ø Umbilical granuloma:
most common cause of an umbilical mass.

• It is a soft, moist, pink, usually pedunculated, friable lesion of granulation tissue that varies in size from 3
to 10 mm in length.
• first few weeks of life from excess tissue that persists at the base of the umbilicus after cord separation.
• Granuloma formation is more likely to occur when there is inflammation of the umbilical cord, usually
due to infection, which also delays cord separation.
• Umbilical granuloma is most often detected after the cord has separated because of persistent drainage of serous or
serosanguineous fluid, or moisture around the umbilicus.
• The most common treatment for umbilical granuloma is topical 75% silver nitrate. Caution should be
exercised in applying silver nitrate because it can cause chemical burns or staining of the surrounding skin.
• If fail, ligation of the granulation tissue can be performed in the office without discomfort.
Ø Hemangioma = strawberry nevus.
• Most common tumor in infancy.

• Highest risk factor, low birth Wight.
• Benign vascular tumor, rapid proliferation, followed by phase of spontaneous involution.
o 1- superficial>> bright red papule, nodule, plaque.
o 2- deep>> firm, rubbery nodule/ tumor, blue purple discoloration in the most severe cases, large
hemangiomas >> can be life-threatening.
• A large nevus can cause problems and deformities of the skin. It can affect breathing, vision, and hearing
as well.
• 2 days to 2 months of life usually regress by 6 months.
• Clinically, if atypical presentation >> do imaging to exclude other neoplasm or unusual vascular
malformation.
• Ulceration most common complication.
• Management: Propranolol, steroid, topical timolol > 6-9 months.
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Ø Inguinal hernia
• intermittent mass, a mass that is reducible, or incarceration.
• Most children with an inguinal hernia have a history of an intermittent bulge in the groin that may have
been noted at times of increased intraabdominal pressure, such as straining or crying.
• They are usually asymptomatic when this occurs.
• The "silk sign" is a palpable silky thickening of the cord.

• Reducible mass inguinal mass has developed, not spontaneously reduced. Nonspecific symptoms such as
irritability and decreased appetite may be reported. The inguinal mass can extend into the scrotum. It
should not be tender on examination.
• Incarcerated mass — Infants with an incarcerated inguinal hernia usually are irritable and crying.
Vomiting and abdominal distention may develop, depending on the duration of incarceration and whether
or not intestinal obstruction has occurred.
o Physical examination of children with incarcerated inguinal hernias usually is diagnostic. A firm,
discrete inguinal mass, which may extend to the scrotum or labia majora, can be palpated in the
groin. The mass usually is tender and often is surrounded by edema with erythema of the
overlying skin.
• The testicle may appear dark blue because of venous congestion caused by pressure on the spermatic
cord.
• In younger than 1 year old = repair should be done by 2-3 weeks, in older than 1 year= less urgency
because of low risk of incarceration, reducible hernia= do surgery after diagnosis immediately, open if
unilateral, if bilateral and large we do laparoscopic repair with mesh.
*** roll under finger, scrotal mass, groin plug, thick cord, silk sign, > possible sign during examination.
Indirect more, right side more, lateral to hess triangle. If through so called direct.
Ø The prune-belly (Eagle-Barrett) syndrome (PBS)
• congenital disorder defined by a characteristic clinical trial that includes abdominal muscle deficiency,
severe urinary tract abnormalities, and bilateral cryptorchidism in males.
• The term "prune-belly" reflects the characteristic wrinkled appearance of the abdominal wall in the
newborn due to the complete or partially complete absence of abdominal wall muscles
• A recessive X-linked defect is suggested by the predominance of affected males.
• However, this mode of inheritance is precluded by two observations:
§ Although rare, the disorder can occur in females.
§ Affected men suffer from azoospermia.
• The major renal change in PBS is dysplasia that affects a variable portion of renal tissue.
• Ureters are grossly elongated, dilated, and tortuous. Ureteral stenoses may occur due to kinking.
Peristalsis is ineffective or lacking.
• Bladder –enlarged , thickened walls, Prostate – A hallmark of PBS in males is a markedly hypoplastic or
dysplastic prostate, which leads to dilatation of the prostatic urethra, Testicles – Bilateral undescended
testes, Gastrointestinal malformations can occur and include (Malrotation of the midgut and persistence
of the embryonic wide mesentery, resulting in coecum mobile, elongation of the colon, and volvulus)
Hindgut abnormalities, leading to anorectal malformations (eg, persistence of the embryonic cloaca,
agenesis of rectum and anus, and congenital pouch colon), Skeleton — Skeletal, Lung — Lung hypoplasia
leading to respiratory insufficiency is frequently responsible for early mortality among patients with PBS.,
Heart — Rarely, complex cardiac anomalies can occur in association with PBS.
• Striking features on ultrasound may include:
●Bulging abdomen ●Polycystic or dysplastic kidneys
●Lack of abdominal muscle wall ●Oligohydramnios
●Dilatation of urinary bladder and ureters ●Fetal ascites
●Hydronephrosis with or without echo ●Hypoplastic lung
dense renal parenchyma
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✓ the respiratory system start to developed at 4th week, 28th weeks the alveoli will be formed.
Extra ✓ If baby born and have difficulty breathing almost always think RDS, do X- ray u will be found GG appearance,
atelectasis, air bronchogram. Give O2 then intubation and surfactant.
2-Genetics and dysmorphology

Ø Syndromes:
Down > tri 21 upward slanting palpebral fissure, iris (Burchfield spot), inner epicanthic folds, small stature, tongue
protrude, microcephalic, short neck, flat occipital, short metacarpal, short phalanges, single palmer crease,
hypotonia, hearing loss, gonadal deficit, ECD (Cushin syndrome ) > VSD> PDA > ASD> MVP, mental retard,
hypothyroidism, duodenal atresia, Hirschsprung, Atlanta axial instability.
Turner > 45, X > only Abnormal GH-IGF, gonadal dysgenesis, streak ovaries, primary amenorrhea, average IQ90, puffiness over
female Dorsey of fingers and toes, wide space nipple, broad chest, low P hairline, Webbed neck, cubits valgus,
horseshoes kidney, COA, bicuspid aortic valve, hypothyroidism, HTN.
Prader Willi genetic disease, obesity, mental retard, eating too much, small hand and feet, puffy gentile, hypothalamic
syndrome (pituitary> growth, thyroids, adrenal) hypogonadotropic hypogonadism, short status, poor growth
Edward > tri 18 second most common, VSD, low set ear, microcephaly, micrognathia small jaw, prominent occiput, clenched
hand, short sternum, rocker bottom feat, omphalocele. Cause of death cardiac arrest.
Klinefelter XXY Decrease IQ, behavioral and psychiatric problem, long limb, slim, hypogonadism hypo gonadotrophic,
gynecomastia, no body and pubic hair,
Marfan AD, tall with slim limb, arachnodactyly, joint laxity and kyphosis, lens subluxation, vision problem.
Patau tri 13 Single umbilical artery, postaxial polydactyly, scalp defect in partial occipital area, cutis aplasia, cleft lip and
palate, microcephaly, microphthalmia, mental retardation.
3-Growth and nutrition:

• For bone assessment > left hand and wrist.
• Growth chart is the most accurate method for assenting development.
Ø Short stature
Constitutional growth delay Familial Pathological

Equal Crossing in and out
Bone age less than chronological Parallel to growth curves, Craniopharyngioma + (vision problem),
fh.x of short stature. hypothyroidism, hypopituitarism,
nutritional problem.
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Ø FTT= < 3rd percentile, cross 2 curves, < 80% of expected.

• Low subcutaneous fat, muscle atrophy, alopecia, lethargy, R infection, dermatitis.
Organic Malnutrition, malabsorption, dx. documented calories

allergies, low immunity, intake and blood test also
chronic disease. sweet chloride.
Non organic / most Not feed adequate calories. dx. feeding under supervision
common.
• For obesity > exercise and balance diet NO medication.
o Overweight > BMI between the 85th and 95th percentile.

o Obese > BMI ≥95th percentile.
o Hypothalamic lesions > rapidly progressive severe obesity, which is particularly difficult to treat. MC after surgical
removal of craniopharyngioma.
• Breast milk have less iron than formula.

• Don’t add water for the baby.
• Mother with HBV can breast feed, after the neonate receive the vaccine.
• Add vit D with mother milk.
• Don’t breast feed if > HIV, CMV, HSV, TB, sepsis, cancer also medication such as
• Mastitis can Breast feed.
• Cow milk more protein, less iron.
• If cow milk in less than 1 year they might develop IDA.
• Cereal 4-6 months.
• No honey in first year.
• Egg better in 2 years, also fish.
• In case of nutritional deficiency Wight decrease before length.
✓ Baby could lose some Wight after 1st week.

✓ Post feeding spitting is normal.
✓ If flat buttock, non-bloody diarrhea, think celiac.
✓ Teeth discoloration could be related to the bottle use.
Extra ✓ If pale child due to vegetarian family > Give course of
ferrous sulfate.
✓ 60 min is the daily recommendation of child to exercise.
✓ In addition to measure the obesity u can also take girth
measurement.
✓ If child obese do full skin folded thickness.
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4-Development
Ø New born reflex:
• If persistence Moro after 6 months > CP.

• Moro disappear after 6 months.
• All reflex disappears after 4-6 months
except stepping at 2 months.
• For milestones > follow your imagination.
• If language delay > do hearing test.
• Conductive hearing loss could be because
of recurrent OM.
✓ Rooting = protruding the tongue out.

✓ Asymmetric Moro indicate = Earb’s palsy, happened to macrosomia baby Wight more than 4500.
Extra ✓ Erythema toxicum neonatorum, appear second day of life and contain eosinophil, macular rash over erythematous
base but No fever > normal reassure the mother.
✓ In dehydrated peds, bolus NaCl, for the maintenance if the calculation gives you number more than 500 give per 1
hr if less you can give per 1/2 hour.
5-Behavioral/ psychological disorder

Ø Pica:
• If after 2 years need investigation.
Ø Enuresis:
• Diagnosed after age of 5, could be due to detrusor muscle weakness.
Primary Hyposecretion of ADH or receptor Tx. Chart dryness, reward system, void before
dysfunction. sleep, put alarm, no punishment. If failed give
No period of dryness. DDAVP.
Secondary After more than 6 months dryness. Do UA, treat underlaying cause.
Psychological, UTI, constipation, DM.
If due day Abnormality in urinary tract. US, or flow study.
and night
Ø Encopresis:
• Feces in inappropriate places at age 4.
• Primary or secondary.
• Psychological, developmental delay, hard stool.
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Ø Sleep disorder:
• Stage 1 > easily awake.

• Stage 2 > deeper stable diff to awake.
• Stage 3 > deeper, GH.
• Stage 4 > dream.
✓ If the baby has pain at night while he is sleeping this will indicate >> there is a problem or disease.
✓ If the baby has bad behavior, try to encourage his good acts.
Extra
✓ If he doesn’t lessen to the orders you can reward him to motivate him.
✓ If the baby suffers from bed witting, use the alarm bed reinforcement.
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6-Immunization
• PCV if age 1-2 years give only 2 doses and 2 months apart, if 2-5 years, only one dose.
Ø Don’t give vaccine if
• baby having fever and he is ill, or there is hypersensitivity reaction.
• Immunodeficiency patients, leukemia, lymphoma, solid tumors.
• HIV, except MMR, and measles for symptomatic and asymptomatic.
• If on immunosuppressive medication. Ex steroid/ chemo.
• More than 14 days steroid, usually we give after discontinuation of steroid with 3 months.
• Within 3 weeks of another live vaccine > should be 4 weeks apart.
• Recent administration of immunoglobulin 3-11 months.
• TB should not receive measles until complete treatment
o If baby less than 2 kg and mother HBsAG negative delay the hepatitis vaccine only, if positive don’t
count birth dose.
o If baby immunodeficiency don’t give live attenuated, only asymptomatic HIV can receive MMR,
BCG, and IPV not oral.
o No OPV during hospitalization.
If splenectomy > pneumococcal, HIB, meningococcal > given 2 weeks before the surgery of splenectomy.
• SCA patients take all vaccination after blood transfusion except MMR no if the transfusion within
the 11 months.
• If any family member immunocompromised don’t give oral polio.
• Anti-toxoid vaccine > DTP.
• Pt in inactive IF gamma can NOT take BCG.
• Small box vaccine is contraindicated in patient with psoriasis and contact dermatitis.
• Rota vaccine is preventable cause of gastroenteritis.
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VACINE # of doses Indication Contra indication Side effects

BCG (LA) (ID) For all newborn, if PPD negative, for HIV if Self-healing ulcer, regional
asymptomatic. LAP, abscess.
DTaP (T) (IM) Primary 2-4-6 m >Booster 18m-4-6 y. No if immediate Local redness, swell, pain
anaphylaxis. General fever, drowsiness, anorexia,
Encephalopathy vomiting, persist crying, convulsion,
within 7 days, collapse with shock > give
K/C of epilepsy. acetaminophen before the vaccine
HIB (C) (IM) 2-4-6-18 m, not covers non-typeable Anaphylaxis reaction. Minimal swelling and pain.
Hemophilus.
HAV (K) (IM) 2 doses 6 months apart 12 months and above, Hypersensitivity to Fever, local reaction.
children in endemic area, chronic liver disease, vaccine
hemophilia, post exposure prophylaxis
HBV (K) (IM) At birth- 2-4-6 months. Previous Pain,
If in hemodialysis double the dose if less than 15 years half the doses, anaphylaxis induration,
For all newborn, for health care provider, high risk group (IV drug abuse, reaction. fever, muscle
illicit sexual contact, household contact) needle stick injury. pain.
If mother HBsAG+ baby should receive monoprophylaxis HBIG and
vaccine too at birth.
If preterm less than 2 kg the first does not count and the baby still have
3 doses when more than 2 moths or more than 2 kg.
Can be given for immunodeficient pt.
IV (IM) Age more than 6 months,1 dose during K= anaphylaxis Soreness at injection site,
(K-LA) influenzas season. reaction, fever, myalgia, allergic
For patient with cardio and pulmonary disease, hypersensitivity to response, GBS.
SCD, DM, CRD, metabolic disease, egg.
immunocompromise patient, health care LA= GBS, asthma,
providers. immunocompromised.
MMR (LA) (SC) At 1 years, 4-6 year. ITP within 6 weeks, Fever, mild rash- LAP, joint
Reaction to egg and manifestation, febrile
both conditions are convulsion.
controversial
MC (C) (SC-IM) 8 weeks apart, Travel to endemic area, SCA, Hx of GBS, Pain, local redness, fever,
asplenia, complement deficiency, collage hypersensitivity.
freshman, at age 11-12 years then 16 years.
V (LA) (SC) 12 months and above, 2 does, 4w apart T cell Pain, swell, red, V Like
immunodeficient, rash.
anaphylaxis
ROTA (LA) 2 does 4 weeks apart, 2-4-6 months. H of intussusception, or intestinal malformation, if
No after 8 months. acute gastroenteritis, febrile illness.
Depends on countries.
Polio (Oral-LA, 2-4-6-18 / 5 doses the last dose preschool Oral not to the If vomiting waits 15 min
IPV/OPV IM K) IPV given for immunodeficient immunocompromised give again,
patients, OPV > paralysis, IPV > local
If severe diarrhea and reaction.
vomiting postpone the
vaccine
PCV (C) (IM) 2-4-6-12 / 4 doses, other = SCD, nephrotic Anaphylaxis Slight fever, local
syndrome, C pulmonary disease, CSF leak, erythema, sourness.
cochlear implant
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7-Child abuse and neglect
• Types > psychological, pathological, neglect, bulling, sexual abuse, physical abuse.
• Consequence could happen to the child > FTT, developmental delay, disability.
• When to suspect? If unexplained injury, incompatible hx with the event.
• Physical abuse like (bruises which is the most common, fracture, burn like cigarette, intentional head
trauma, which is the MCC of death usually retinal hemorrhage, intrabdominal injury)
• Sexual abuse (look for gram negative intracellular diplococci- NG)
• MC because father and brother.
8- Respiratory
ّ
Ø Croup ‫اﻟﺨﻨﺎق‬:
• Viral > parainfluenza, sub-glottis, barking harsh seal cough, hoarseness- change in voice, inspiratory
stridor, rhinorrhea, fever, worsen at night, could be complicated to hypoxia.
• Initial= clinically.
• Accurate= PCR.
• steeple sign on X-ray, and sub glottis narrowing.
• Treatment usually supportive, if severe give epi-N nebulizer, can be repeated then steroids-
dexamethasone 1 dose.
Ø Epiglottis/ medical emergency:

• Epiglottis or subglottic.
• More common in toddler.
• Difficulty swallowing, sniffing position, drooling, Respiratory distress.
• High fever, dyspnea, toxic appearance.
• STRIDO LATE FINGING.
• HiB, streptococcus, s aureus.
• Accurate= C, S tracheal aspiration.
• Initial= Laryngoscope, cherry red swollen epiglottis.
• X-ray thumb sign.
• Intubate!! / Abx (3rd cephalosporine/ and ampicillin and clindamycin 7-10 days).
Ø Laryngomalacia:
• MCC of stridor, collapse of supraglottic.
• Inspiration stridor, they feel better in prone, acid reflux occurs.
• Clinically, confirmed by laryngoscope.
• Supportive/ observation resolve spontaneously > We can give PPI.
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Ø Foreign body:
• Chocking, wheeze asymmetric, decrease breath sound asymmetric.
• If not fully obstruction, start with x-ray to locate the object, definitive bronchoscopy, treat by rigid.
• To be noted it might complicate with infection.
• Infant > larynx, Toddler > R main bronchus.
• CXR reveal air trapping (ball valve mechanism).
Ø Bronchiolitis:
• RSV MC, then parainfluenza, adeno and mycoplasma.
• Usually less than 2 years in infancy like 3-6 months.
• On x-ray air trapping and hyperventilation with patchy atelectasis.
• We also can-do PCR nasopharyngeal swap.
• RF= prematurity, more than 12 weeks, neurological problem, immunodeficient,
• URI- decrease appetite, fever, irritable, paroxysmal wheeze, cough tachycardia, tachypnea, sometimes
they use accessory muscles, prolonged expiratory, crackles, apnea.
• Supportive- hypertonic saline nebulizer/ NO STEROID > ribavirin which is antiviral > use to treat RSV.
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Ø Pneumonia:
General information:
• It is LRTI.
• Pneumonia can cause meningitis as secondary infection by pneumococcal infection.
• In infant and newborn, it will be as consolidation in the right upper lobe because they are supine position >
aspiration.
• Radiating to abdomen if it was in the lower lobe. Radiating to neck if it was in the upper lobe.
• SCD they are at highly risk to get pneumonia by pneumococcal infection.
• If not productive > mycoplasm atypical.
CAP = MCC, viral infiction.

• Affected children less than 5 years.
• S pneumoniae most common in viral and bacterial.
• But for aquired we see viral more in less than 5 years age.
• MRSA > staph more.
• Younger than 1 year may developed “afebrile pneumonia of infancy.” seen between two weeks and three to
four months after birth. caused by Chlamydia trachomatis, but other agents, such as cytomegalovirus
(CMV), Mycoplasma hominis, and Ureaplasma urealyticum.
• RSV most common viral affected children less than 5 years, followed by paraI, I, adenovirus.
• M,C pneumoniae affected age school more than 5 years.
• Older than 5 years > S. pneumoniae, M,C,S aureus.
• Aspiration > anaerobic strept/ fusobacterium/ bacteroids/ prevotella.
HAP:
• > 48 H after admission.
• Usually by gram negative bacilli, or staph aureus.
• Usually in ICU or in catheter patient.
• In winter they at risk of RSV, PARA, INFLUENZA.
Immunocompromised:
• Gram negative bacilli, S aureus, aspergillus.
• If after transplant > viral > RSV, adeno.
Cystic fibrosis:
• Staph aureus, pseudomonas aeruginosa, H influanza
SCD:
• Atypical bacteria, M, C > acute chest syndrome
• Other, S pneumoniae, S aureus, HI.
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Lobar pneumonia single lobe or segment of a lobe > S. pneumoniae pneumonia. >> MC
Bronchopneumonia airways and surrounding interstitial > Streptococcus pyogenes and Staphylococcus
aureus pneumonia.
Necrotizing pneumonia associated with aspiration pneumonia and pneumonia resulting from S. pneumoniae, S.
pyogenes, and S. aureus.
Caseating granuloma as in tuberculous pneumonia.
Interstitial and with secondary parenchymal infiltration > severe viral pneumonia is complicated by bacterial
peribronchiolar pneumonia.
< 2 years Streptococcal pneumonia. Amoxicillin, Augmentin,

azithromycin.
School age Mycoplasma. Wheeze plus unproductive cough
> azithromycin/ macrolide.
ICU Staph aureus. Cefuroxime, vancomycin,
clindamycin.
Day care viral Post viral, stph.
neonate Listeria, E. coli -bacilli, GBS. Fever, lethargy, apnea.
Atypical C,M pneumonia Persistent cough, rales, bilateral.
18
19
Ø Cystic fibrosis:
Autosomal recessive, long Arm Chromosome 7, leads to thick, viscous secretions in the lungs, pancreas,
liver, intestine, and reproductive tract. Unable to secrete CL.
Intestinal tract Respiratory tract GU tract Sweat G

**First presentation **recurrent chest infections Delay sexually Skin salty taste.
10% infant meconium ileus non-typable HI, S aureus, P development, excessive loss of
aeruginosa. azoospermia, increase R salt especially with
X-ray: dilated loop, air fluid level, of hernia, hydrocele, gastroenteritis and
ground glass, Bubbly appearance. cough purulent mucus. undescended testes. F hot weather.
In exam= increase AP diameter, secondary amenorrhea
bulky greasy stool, fat soluble hyper-resonance, expiratory decrease fertility.
deficiency, hepatomegaly, wheeze, clubbing and cyanotic,
cholelithiasis, rectal prolapse Acute opacifies sinus.
Pancreatitis.
• Failure to clear mucosa secretion, increase salt content, Nasal Polyps, bronchiectasis, malabsorption
(FTT), fertility issues, sinuses congestion always.
• X-ray= hyper filtrate of chest, patchy atelectasis, hailer node, flat diaphragm.
• Clear airways with albuterol/ saline, mucolytic- daily, chest physio postural drainage.
• Acute chest infection > Tobramycin (aminoglycoside)
• To cover pseudomonas = piperacillin plus tobramycin or ceftazidime.
• Replace pancreatic enzymes.
Ø SIDS: nothing important.
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Ø Bacterial Tracheitis
• Toxic appearance
• Staph, HiB
• Similar to croup, but with rapid deterioration and Not responding to croup Tx.
• Require Intubation and IV Abx.
Ø Adenoid Hypertrophy
• snoring, mouth breather,
• Adenoid face
• OSA
• Lead to OM, rhinosinusitis, cough
• Do Adenoidectomy if : Affected sleep, Recurrent infections ( resistant!), suspicious of malignancy
Ø Tracheomalacia
• defect in the cartilaginous portion
• Croup-like cough.
• Improve spontaneously by 6 to 12 months.
Ø Pleural Effusion
• DDx —> congenital obstruction of lymph, CHD, pulmonary malformation, infection
• Do CXR
Ø Para-pneumoniatic Effusion/ empyema

• Streptococcus and Staph MC causative organisms.
• Px of pneumonia with failure to improve 48h after Tx of pneumonia.
• Start with CXR — > best next step to confirm is US.
• Acquire blood/ sputum cultures.
• Consider thoracentesis.
Ø Bronchiectasis > antibiotic.
21
9- asthma and allergy

Ø Allergic rhinitis:
• characterized by paroxysms of sneezing,
rhinorrhea, nasal obstruction, postnasal
drainage, and itching of the eyes, nose, and
palate, fatigue, irritability, reduced
performance at school and work, and
depression.
• "rhinosinusitis" This is because the nose and
sinus mucosa are contiguous, rhinitis and
sinusitis frequently occur together, rhinitis
commonly leads to sinusitis, and nasal
symptoms are common with sinusitis
• The diagnosis of allergic rhinitis is made

clinically, based upon a suggestive, physical
examination, and (if indicated) the
confirmed presence of allergen-specific
immunoglobulin E (IgE).
Physical findings
• Infraorbital edema and darkening due to subcutaneous vasodilation, findings that are sometimes referred
to as "allergic shiners", Accentuated lines or folds below the lower lids (Dennie-Morgan lines), which
suggests concomitant allergic conjunctivitis, A transverse nasal crease caused by repeated rubbing and
pushing the tip of the nose up with the hand (the "allergic salute"), "Allergic facies," > highly arched
palate, open mouth due to mouth breathing, and dental malocclusion, The nasal mucosa of patients with
active allergic rhinitis frequently has a pale bluish hue or pallor along with turbinate edema, Clear
rhinorrhea, Hyperplastic lymphoid tissue lining the posterior pharynx, (a finding called "cobblestoning"),
Tympanic membranes may retract, or serous fluid may accumulate behind tympanic membranes.
Associated condition:
• Allergic conjunctivitis, Sinusitis, Asthma, Atopic dermatitis (eczema), Oral allergy syndrome
• Other conditions> eustachian tube dysfunction, causing concomitant serous and acute otitis media, Nasal obstruction
due to severe allergic rhinitis can also cause sleep-disordered breathing and anosmia, there may be an increased
prevalence of migraine headache in patients with allergic rhinitis.
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Ø Acute bacterial rhinosinusitis:
• Non typable HI, strept p., Moraxella.

• Nasal discharge, cough more than 10 days,
• In immunocompromised >> pseudomonas Aeruginosa.
• RF+ viral URTI, allergic rhinitis.
Ø Chronic rhino-sinusitis:
• If patient with chronic RS, with nasal polyp, diarrhea, Wight loss > think cystic fibrosis.
Ø Food reaction:
• Elimination, epi/pin.
Ø Urticaria and angioedema:

• Duration less than 6 weeks have 2 types IgE mediated and non-mediated.
• Diagnosis mainly clinically, skin test, IgE specific test.
• Treat by avoidance to trigger, if sever epi and steroid.
• Hereditary angioedema is autosomal dominant.
• For chronic angioedema, IVIg or plasmapheresis.
• Can give also H1 and H2.
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10-Immune mediated disease

Ø agammaglobulinemia:
• X linked – bruton.
• Defect in B cell development.
• Mutation in long arm of X chromosome.
• Boy with pyogenic sinopulmonary infection.
• small to absent tonsil, and non-palpable lymph node.
• No B cell in flow cytometry, but T cell normal.
• Give monthly IVIG and Ab.
Ø Selective IgA deficiency:

• Most common immunodeficiency, absence of IgA, with normal B cell.
• Autosomal dominant.
• Also seen with CVID.
• Infection in respiratory, GI, and urogenital.
• Giardiasis very common.
• Treat the infection.
• IVIG not recommended.
Defect in cellular immunity T cell defect:
Ø DiGeorge syndrome thymic hypoplasia:
• T cell deficiency, Thymic and parathyroid hypoplasia, to aplasia.

• Great vessels abnormality, esophageal atresia, bifid uvula, congenital heart disease, facial dysmorphism,
thein upper lip, mandible hypoplasia, low set notched ear. Cleft palate, septal defect.
• 22q 11.2, dysmorphic features On X ray, absent thymine shadow.
• T cell count should be measured in patient with primary hypoparathyroidism, CHARGE, truncus
arteriosus, and interrupted aortic arch.
• They usually present with recurrent fungal infection, and PCP.
• Low lymphocytes low CD3, delay hypersensitivity reaction to skin test, and low Ca lead to neonatal
seizure.
• Highly associated with truncus arteriosus.
• Treat by transplantation from HLA, identical sibling.
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Combined antibody and cellular immunodeficiencies:
Ø Severe combined immunodeficiency:

• Absence of all adaptive immune function B-T, and NKC.
• X linked most common form, also have autosomal dominant.
• Small thymuses, spleen depletion of lymphocytes.

• Recurrent infection, chronic OM, sepsis, diarrhea (listeria), pulmo (PCP), oral thrush, FTT, small to absent
lymphoid tissue.
• lymphopenia from birth, low to absent T cell, absence to lymphocytes, low to absent IGs, and no AB
after immunization, mitogen stimulation test > absent T-B.
• Treat by transplantation, isolation, no living vaccine, AB prophylaxis, IVIG.
Ø Wiskott- Aldrich syndrome both T and B:

• Impaired humeral immunity, high variable concentration of IGs, reduce T cells, and variable mitogen
response.
• X-linked recessive, xp11.22.
o 1- thrombocytopenia, bleed after circumcision, bloody diarrhea, purpura and petechiae.
o 2- atopic dermatitis + eczema in scalp and flexor area.
o 3-Recurrent infection usually pneumonia.
• Clinically diagnosed also, most common low IgM, high IgA, IgE, normal to low IgG, variable reduce of T
cell.
• They diagnosed at 8 months and usually die at age 8 years.
Disorders of phagocytic function:
Ø Leukocytes adhesion deficiency:

• Disorder of leukocytes function.
• Autosomal recessive, it is affected Neutrophil adhesion, 21q22.3.
• Cause bacterial and fungal infection, decrease inflammatory response.

• Sever gingivitis, chronic mouth ulcer, skin infection, RT infection, and infection in genital, delay separation
of umbilical cord, no sign of inflammation, no pus,
• Organism is S aureus, candida, aspergillus.
• High circulating neutrophil count > The other function is abnormal.
• Low CD50-18 > Stem cell transplantation.
CGD:
• Neutrophil and monocytes cannot kill catalase positive organism, defect in PRODUCTION OF OXIDATIVE
METABOLITES.
• X linked, recurrent abscess, pneumonia, osteomyelitis, GI infection.
• S aureus, candida, aspergillus.
• By DHR doing the diagnosis it is flow cytometry.
• Stem cell transplant, interferon, supportive.
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11-12-Eye, ear, nose, and throat

1-Eye.
• Leukocoria: white reflex. Could be because of (retinoblastoma, cataract….).
• Cataract: most important congenital etiologies. (prematurity inherited- AD, TORCH, galactosemia, steroid
use.
• Strabismus: misalignment, diagnosed by Hirschberg corneal light reflex.
• Conjunctivitis: in neonate think bacterial in older more common viral.
Neonatal conjunctivitis/ ophthalmia neonatorum:
• Purulent eye drainage and eyelid swelling in the first week of life, Neisseria gonorrhoeae, start 2-5 days, eye
discharge, swelling, chemosis, if not treated lead to corneal ulceration, scaring, blindness. Gold standard:
Thayer Martin agar, 1 dose IM ceftriacsone.
• Chlamydia trachomatis:
• Oral azithromycin once daily, or doxy twice a day.
• 2nd week of life.
• Watery, mild purulent discharge, conjunctivitis.
• Tarsal conjunctivae.
• Bacterial conjunctivitis:
o Hyperemia, edema, mucopurulent exudate, crusting, eye discomfort.
o Uni or bilateral.\S pneumonia, HI nontypable, S aureus, strept.
o Warm compression and AB.
• Viral conjunctivitis:
o Watery discharge, bilateral, usually URI. Think chemical 1st day, NG
o Adeno (keratoconjunctivitis) / entro. first week, C second week
• Keratitis: which is the most
o Corneal involvement, H. simplex. Adeno, S aureus, S pneumonie. common.
• Pain and photophobia = corneal abrasion.
• GBS:
• Intrapartum ampicillin,
• Present as sepsis, pneumonia, 24-48 h.
Orbital/preorbital cellulitis:
OC POC
Clinical sign. Infection in orbital tissue, No eye movement, Chemosis, In lid and periorbital tissue
Inflammation, Proptosis, Fever. Inflammation with intact eye movement.
Double vision, ophthalmoplegia with diplopia. Normal vision, No proptosis.
Organism. Non-typable HI, Influenza, Staph-A, SP. HI/S-Pneu.

Dx. CT initial. Clinically.
Tx. Vancomycin + ceftriaxone/ cefotaxime TMT/SFX or clindamycin.
With combination with amoxicillin
Retinoblastoma:??
26
2-Ear.
Otitis externa/ swimmer’s ear:
• Most common because pseudomonas aeruginosa, S aureus.
• Pain, conductive hearing loss.
• Edema, erythema, thick otorrhea, peracular nodes.
• Topical otic preparation+ ssteroid.
Otitis media:
• Acute supportive OM accompanied with hearing loss.
• bacterial most common S pneumonie- nontypable HI, Moraxella.
• in less than 2 years baby.
• Cough, sneeze, ear pain, fever, irritable.
• otoscopy ( fulness bulging tympanic membrane and effusion and retraction, erythema )
• pneumatic otoscopy > mobility which is the most important factor.
• pain relief and amoxicillin high dose or /azithromycin for 10 days.
• If no improvement amoxicillin clavulanic acid / IM ceftriaxone single dose and can be repeated.
• if no improve do tempanocentesis or myringotomy.
• If OM with effusion: because repeated infection, if more than 3m assess hearing, tympanostomy
tube for bilateral OME and impaired hearing for more than 3 months.
• Complication, acute mastoiditis.
3-Nose.
Choanal atresia:
• Uni or bi.
• If uni could be asymptomatic.
• If bi > cyanosis> cannot breathe from nose, become pink.
• Inability to pass a 3-4 cm catheter through nose.
• Do CT, fix by stent.
Foreign body:
• unilateral purulent discharge could be bloody and bad smell.
• Needle forceps.
Epistaxis:
• Most common area anterior septum.
• Mcc trauma.
• Compress, if not stop local oxymetazoline or phenylephrine.
• If not work anterior nasal packing > cautery
Polyp:
• Most common cause is cystic fibrosis.
• Present with obstruction, mouth breath,
• Give intranasal steroid, systemic steroid, surgically.
Sinusitis:
• Majority with URI.
• Start as viral then complicated with bacterial.
• Strept pneumonia, non typable HI, M. catarrhalis, staph aureus.
• RF > URI, allergy, CF, immune deficiency, GERD, cleft palate, nose foreign body.
• nose congestion cough fever discharge, bad breath, decrease sense of smell.
• Dx > persistent URI sx without improvement.
• Tx > amoxicillin.
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4- throat.
Acute pharyngitis:
• bacterial > GASHS- less common in less than 2-3 years.
• Strept = rapid, fever, sever sore throat, headache, GI
symptoms, red pharynx, enlargement of tonsils, yellow
exudates, petechiae on palate, in posterior pharynx,
strawberry tongue, red uvula, tender A cervical nodes.
• Scarlet fever= pharyngitis + circumoral pallor, red finely
popular erythematous rssh like sandpaper, pastia’s line.
• Viral = more gradual with URI, no pus only erythema.
Herpangina Acute lymph nodular pharyngitis HFM syndrome

Small vesicle and ulcer on P Yellow white nodules on P pharynx with Inflamed oropharynx with vesicles on tongue, buccal mucosa,
pharynx. LAP. gingiva, lips, P pharynx, also in HFM buttocks and painful.
Complication, retropharyngeal and lateral abscess.

Clinical Fever, irritable, decrease oral intake, nick stiff, muffled voice.
examination Bulging of P or L pharyngeal wall.
diagnosis Incision and drainage.
Treatment Cephalo+ ampicillin/ clinda.
Postriot tonsillar abscess.
Clinical Adolescent with recurrent hx of acute pharyngotonsillitis, sore throat, fever, trismus.
examination Asymmetrical tonsillar bulge with displacement of uvula away from affected side.
Treatment Needle aspiration, incision and drainage, tonsillectomy.
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13- Cardiology
Congenital Heart Disease

**A-cyanotic (Left > Right Shunt)
• All might px. as poor feeding, FTT, murmur, HF sx., tachypnea.
• Medical Tx for Heart Failure in Peds include {Nutritional support, Diuretics, Prophylaxis to🔻
influenzas and RSV attacks.
• Best Initial is CXR.
• Do ECG.
• Definitive is Echo Always.
Defect Overview Presentation Diagnosis Treatment

VSD Presentation and diagnosis > Harsh Holo Systolic Murmur LLSB >> CXR (Large heart, P edema)
MC CHD, if not treated—> shunt becomes HF medical Tx/ Small defect close by 1-2 y mostly
bidirectional (Eisenmenger) > Cyanotic. Indications for surgery in 1st year: Moderate to large
Small < 4 mm defect associated with >>> Resistant FTT, P HTN, shunt
Moderate 4 to 6 mm fraction >2:1 ( L V dilation).
large > 6 mm
ASD Low-pitched diastolic murmur over lower sternum. Wide fixed splitting of S2
ECG > R axis deviation, RVH/ CXR (R heart enlargement)
Almost asymptotic in early life. But in childhood Mostly close spontaneously. Surgery or transcatheter
{varying degrees of exercise intolerance. If large defect device closure for all symptomatic pt, and after age 2
(>3mm). years in asymptomatic if not closed.
Endocardial 🔺🔺in heart size>> Precordial bulge and lift. Wide fixed splitting of S2
Cushion Defect CXR >> significant cardiomegaly, ECG > biventricular hypertrophy
AVSD, Cyanotic Spells “Mild”, Early HF, Surgery. Must be done in infancy! Post-surgery
infections. MC in Trisomy21 CHD complications >> heart block, arrhythmias
PDA So if large: Machinery Murmur, CXR >> P congestion/ ECG >> LVH
Blood flow Aorta >> Pulmonary artery. Related to May close spontaneously. Preterm infant >>
maternal Rubella, and premature. Small mostly Indomethacin [ NSAID] >> close it. Surgery if persists
asymptotic, large dose!
✓ If the baby cry and cyanotic, try to calm the baby and give analgesia-morphine (will decrease systemic
Extra > Venus return) and sedation put him in knee chest position, avoid O.
✓ With cyanotic disease give PGE1 keep ductal open.
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• ASD wide fixed split second sound.

Ø Trivial – <3 mm in diameter.
Ø Small – 3 to <6 mm in diameter.
Ø Moderate – 6 to 8 mm in diameter.
Ø Large – >8 mm in diameter.
• If less than 3 MM and asymptomatic no need to do surgery, it will close spontaneously by age of 2-5 years.
• The only 3 indication for surgery: 1- shunt ratio > 1.5:1/ 1- premium ASD/ 3- evidence of right heart over load.
• Secundum defects of moderate and large size, and types of ASDs other than secundum, are unlikely to close spontaneously.
• However, because there is a possibility, albeit small, of spontaneous closure during the first two years of life, intervention to close
even moderate and large isolated secundum ASDs is generally deferred until after the age of two years in asymptomatic patients
• We recommended ASD closure for children who have right heart enlargement, pulmonary over-circulation, and evidence of
substantial left-to-right shunting through an ASD (ie, ratio of pulmonary to systemic flow [Qp/Qs]>2:1 or other evidence of large
amount of left-to-right shunting as described above).
• These findings are typically associated with moderate to large ASDs. Such defects are unlikely to close spontaneously, and
observational data suggest that left-to-right shunting may increase with age, resulting in heart failure, exercise intolerance, and
increased risk of arrhythmia and pulmonary hypertension.
• As previously discussed, ASD closure is generally deferred until after the age of two years in asymptomatic patients because there is a
possibility, albeit small, of spontaneous closure during the first two years of life.
** Cyanotic (Right > Left Shunt)
• Baby is blue, marked clubbing, dyspnea (gasping)

• Do pulse oximetry or ABG!
• Echo Gold Standard
Defect Overview Presentation Diagnosis Treatment

TOF MC Cyanotic heart lesion/ include crescendo- CXR >> boot-shaped Ductal dependent (Cyanotic at birth) >>
(Pulmonary stenosis + VSD + decrescendo Harsh heart, dark lung fields PGE1 infusion. Surgery at 3-6 months. Treat
Overriding Aorta + RVH ). systolic ejection >> 🔻Pulmonary Blood acute spells with knee-chest positioning,
Pre correction >> prone to cerebral Murmur, no S2 split Flow (PBF) supplemental O2, IV morphine, and IV fluid
thrombosis, IE, HF. Hyper cyanotic (single S2). bolus.
("tet") spells >> inconsolability>>
hyperpnea > 🔺 cyanosis, gasping,
syncope ( child adapt squat to 🔺SVR
>> 🔻 R to L shunt)
Tricuspid Atresia No tricuspid valve. PBV depend Severe cyanosis at CXR >> 🔻PBF. ECG >> PGE1 >> then later we do 3 stages surgery.
entirely on presence of VSD. birth. Holosystolic LVH + L axis deviation Endocarditis + influenza prophylaxis.
Murmur along left **** unique
sternal border
TGA More common in infant of DM First type —> S2 single CXR >> Egg on a string. PGE1 !! Then do surgery in first 2 weeks!
mother, has 2 types: if no other and loud, no Murmur, 🔺PBF
anomaly—> once the PDA close —> Second type —>
sever cyanosis and shock (ductal depend on the other
dependent), if the there’s another anomaly.
anomaly like VSD baby px with mild
cyanosis and mainly Murmur.
Truncus Single arterial trunk and valve for both Systolic ejection CXR >> heart Treat HF. Surgery in first few weeks of life.
Arteriosus ventricles. VSD always there>> Murmur with loud enlargement with
minimal cyanosis. Associated with thrill, single S2. 🔺PBF
DiGeorge Syndrome
TAPVR Mixing lesion. Depending on the CXR >> snowman PGE1. Surgical correction ( if ASD absent
presence or absence of appearance. they need emergent surgery to survive)
ASD they px>> if no
ASD >> severe cyanosis
and shock ( not
responding to
ventilation or PGE1) If
px>> mild cyanosis
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Heart failure (HF)

• Symptoms >> FTT, easy fatigue, SOB, systemic fluid overload.
• The initial >> CXR, ECG, Echo, labs >> [BNP] or N-terminal pro-BNP [NT-proBNP], troponin, CBC, Chemistry
Acute Rheumatic Fever (ARF)
Post pharyngeal infection with Group A Strept, MC cause of acquired heart disease worldwide
Px:
• Carditis >> px as new heart murmur.
• Polyarthritis >> px as swollen painful joints.
• Hx. of throat infection up to 1 month.
• Fever.
Dx. Based on Jones Criteria
Oral penicillin/ erythromycin for 10 days

NSAID for joints inflammation
Add steroid if sever carditis + CHF
If chores is the only px >> give only phenobarbital
Prophylaxis drug of choice >> IM penicillin G every
month
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Rheumatoid Heart Disease (RHD)
• It’s pan carditis result always from ARF.

• Mitral regurgitation is the most common valve lesion.
• Diagnosis of rheumatic carditis is confirmed by echo (morphologic + Doppler evidence of valvular
involvement)
• Peds >> present predominantly with isolated MR
• Management is early dx. and Tx of ARF to prevent RHD + Tx of HF if present.
• Secondary prophylaxis to prevent another ARF attack:
Infective Endocarditis
RF:
• Cyanotic heart disease (uncorrected)
• Central venous catheter
• Prosthetic Heart Valve
• Rheumatic heart disease
• Congenital heart disease. (VSD> TOF> AVSD)
Pathology:
• Child with heart disease >> MC is Virdians streptococci
• Child without heart disease >> MC is S. aureus
Px:
• Subacute >> prolonged course of low-grade fevers, fatigue, arthralgias, myalgias, weight loss, exercise
intolerance, and diaphoresis.
• Acute >> high spiking fevers, shock or HF, S. aureus MC in acute IE
Diagnosis >> Duke Criteria
Treatment:
Native valve IE duo to strept:
1. Penicillin or ceftriaxone IV / 4 weeks
2. If beta lactamas allergic >> Vancomycin IV / 4 weeks
Native valve IE duo to Staph:

1. Methicillin susceptible >> oxacillin or cefazolin IV /4-6 weeks
2. Methicillin resistant >> Vancomycin IV / 6 weeks
Native or prosthetic valve due to enterococcal strains:

1. Penicillin + Gentamicin IV / 6 weeks
Prophylaxis >> amoxicillin

• Artificial/ prosthetic valve
• Previous attack
• Unfixed heart lesion/ Congnital heart disease.
• Dental procedure with gingival manipulation
32
33
14- Gastrointestinal disease

1- Acute Diarrhea > fecal/oral, abdominal pain, vomiting, nausea, fever+- UTI. For infant viral more than
bacterial, for poisoning always think staph, acute in general less than 2 weeks but this is not the way to
describe it, treat as supportive.
Campylobacter BD
Salmonella BD Egg, milk.
Shigella BD Food
Yersinia
C diff After AB. Colitis.
E. coli BD HUS + UTI.
Noro For adult more.
Rota Watery, high fever, URTI, vomit, abdominal pain.
giardiasis Traveler, steatorrhea, foul smelling.
E.H BD
2- Chronic diarrhea:
Shigella gastroenteritis
• High fever, rapid, abdo pain, watery diarrhea with mucus, + seizure , supportive if immunocomp. Give AB.
• If less than 8 years give amoxicillin.
• More than 8 give deoxy.
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Bilious vomiting Malrotation, duodenal atresia, HD.

Non bilious vomiting TEF, pyloric stenosis, GERD
1- Pyloric stenosis:
• First 2 month of life 2-8 weeks

• non bilious/ projectile vomiting, postprandial.
• still hungry after feeding, > 3 weeks, dehydration.
• hypo-cl/K and metabolic alkalosis
• olive shape palpable mass its hard RUQ.
• NGT, do US (>3>14) + streak-string- target sign, Double trac sign> barium > give electro+ D5 > do
Ramstedt Pylomyotomy in < 8w.
2- V malrotation:
• 75% 1st m, 33% 1st w, 90% 1 year.

• Bilious vomiting (but it is clear) in first week.
• RUQ pain, skin mottled, distention, lethargy, dehydration, +- bloody stool
• Acute surgical abdomen.
• If twisted more than 6 h will lead to ischemia.
• X ray (DB sign, air in stomach and dedendum, no gas in GI tract/ gasless abdomen.
• US bowel loop overriding liver, inversion of SMA.
• Upper GI: malbostion of ligmntum of teriz.
• Immediate surgery. LADD.
3- Intussusception:
• Most common bowl obstruction 2m to 2y.

• Followed Virali fiction (adeno, rota, URTI or OM), associated with HSP.
• sudden onset of severe pain, colicky in nature, leg flexed, lethargy, shock with fever, progressive
weakness, fever and shock, vomiting- bile stained, decrease tooling, +- bloody stool (first 12 h),
black jelly stool.
• sausage shape mass on right side.
• US (doughnuts shape- decrease visualization of liver) > air enema (coiled appearance).
• if perforated and sever surgery laparotomy.
• Reduction.
4- Meckel Diverticulum:
• In less than 2 years
• Intermittent Painless rectal bleed.
• +- obstruction, tenderness near umbilical, diverticulitis
• Role of 2.
• Self-limited > May developed anemia.
• Tc99m > Surgical excision/ laparoscopic.
35
5- Hirschsprung Disease:
• BO in neonate.80% rectosigmoid.
• Delay passage meconium >24h, bilious vomiting, early: abdominal distention, vomting.late:
chronic constipation and empty rectum
• They die from enterocolitis.
• Do rectal manometry.
• X-ray dilatated loop in colon.
• Barium retained contrast. Good prior to surgery.
• Rectal suction Biopsy definitive.
• Surgery (colostomy- laparotomy) laparoscopic single stage endorectal pull through.
6- Duodenal Atresia:
• + DOWN SYNDROME, esophageal atresia, imperforated anus, polyhydramnios.
• Distal to ampulla of voter.
• No abdominal distention, polyhydramnios prenatally/ prematurity, +- J.
• X RAY: DB no distal bowel gas. dilatated bowel proximal to obstruction.
• Decompression, AB, Duodenodoudenostomy, duodenojejunostomy> when stable.
7- Esophageal atresia EA-tracheoesophageal fistula TEF:

A- EA no TE.
B- TEF-H type.
C- EA + distal TEF. (MC).
*** INCREASE SALIVATION, RESPIRATOREY DISTRESS, VOMTING.
• Frothing, bubbling, cough, cyanosis, respiratory distress, regurgitation and aspiration with feeding.
• Associated with VACTERL (vertebral, anorectal, cardia, TEF, renal, limb.)
• Inability to insert NGT > coiled in blind pouch no distal gas.
• Suction blind pouch, AB,
• Surgical resection end to end anastomosis.
• If no air in stomach this is not TEF.
• Complication, GERD, recurrent, stricture, leak.
8- NEC- CHEST:
• RF= prematurity, early feeding, hypothermia, hypotension, CHD.
• bloody stool, apnea, lethargy, abdominal distention, vomiting, fever.
• Early sign: increase gastric residual with feeding, temp instability, poor feeding, distention, bilious
vomit, mucoid bloody stool, bradycardia, apnea.
• Late = anemia, thrombocytopenia, DIC, azotemia, metabolic acidosis.
• x-ray, air in bowel wall, pneumatosis intestinalis/ air in pretonial cavity.
• Do gut decompression, AB, surgery.
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15- Nephrology
UTI:
• Boys, MC organism, E. coli, klebsiella, proteus.
• RF: wiping, sex, pregnancy, uncircumcision, VUR, constipation, anatomical abnormality.
• If less than 2 months = admission.
• Neonate= IV ampicillin and gentamycin.
Cystitis. Pyelonephritis. Asymptomatic bacteriuria.

Dysuria, urgency, frequency, suprapubic Abdominal flank pain, fever, Positive urine culture, without sign and
pain, incontinence, NO fever. malaise, nausea, vomiting, symptoms, symptomatic if untreated.
Amoxicillin, tmp-sm. diarrhea.
• A positive result on the nitrate test is highly specific for UTI, typically because of urease-splitting organisms, such as Proteus
species and, occasionally, E coli; however, it is very insensitive as a screening tool, as only 25% of patients with UTI have a positive
nitrate test result. Child age of group: empiric oral treatment are a second- or third-generation cephalosporin,
amoxicillin/clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP). >> If with fever - for 7 days >> If without - for 3 days
• If baby hypotension starts with fluids.
• Epispadias, contraindicated in circumcision.
Vesicouretral Reflux:
• Abnormal back-flow of urine from bladder > ureter
• Risk to Recurrent UTI; pyelonephritis > scarring > HTN > ESRD
Dx —> Contrast voiding cystourethrogram VCUG for dx anacidd grading

• dimercaptosuccinic (DMSA) renal scan for scarring.
Tx:
• Watchful waiting ( must have urine cultures whenever there are symptoms suggestive of UTI or
unexplained fever)
• Prophylaxis single daily dose of Abx therapy ( (TMP-SMZ), TMP alone, or nitrofurantoin)
Surgery :
• Grade 3-4 (if on Abx and still have UTI OR serious Abx side effects)
• Grade 4-5 (if persistent to >2 years of age)
37
Diseases Present primarily with Hematuria:
Disease Presentation Labs Treatment

PSGN Coca Cola urine / HTN / Edema / 1-2 UA: RBC cast/ blood: Low C3 penicillin or erythromycin/
weeks post throat or skin infection Accurate: + throat Culture or furosemide> if sever
🔺 ASO, anti-DNAs AB dialysis /high HTN
Definitive: Biopsy (sub-epithelial nifedipine.
hump)
IgA Berger MC of GN, Asymptomatic recurrent US: RBCs / Blood: Normal C3, ACEI goal of bp less than
disease hematuria / URTI Worsen it (2 days Initial IgA level. 130/80.
post infection) > microscopic Accurate: biopsy mesangial
becomes Gross! proliferation/ IgA
Alport Deafness, 🚹, Asymptomatic Normal C3 / Biopsy: foam cells ACEI to slow the
syndrome X- recurrent hematuria microscopic/ Do genetic analysis progression
linked URTI Worsen it to Gross
Dominant
Chapter 19 Nephrology 453

Patient with hematuria
History and physical

examination
No hemoglobin ! Hemoglobin
Urinalysis Family Hx: dialysis, transplant, SLE, familial hematuria
19
No cellular elements " Cellular elements
PE: hypertension, edema, rashes, arthralgia
Lab: UA RBC casts, first AM urine protein/Cr ratio
serum BUN, Cr, lytes, urine Ca/Cr ratio (C3, ANA)
Search for other Search for causes of
causes of red urine hemoglobinuria or
myoglobinuria
Microhematuria Gross hematuria

(tea-colored/smoky,
RBC casts)
Glomerular hematuria
Nonglomerular hematuria
(RBC casts, dysmorphic RBCs)
(No RBC casts, eumorphic RBCs)
Proteinuria >1+
Acute nephrotic syndrome Acute
glomerulonephritis
Renal Urinary tract

Multisystem Isolated
renal Abnormal Normal No Hx of Hx of
disease workup workup prior infection prior infection
Acute interstitial nephritis
C3 (penicillin, NSAIDs, sulfa drugs, (eg, streptococcal)
furosemide, cephalosporins)
Sickle cell trait
Polycystic kidney Ultrasound ASO titer, streptozyme, complement
Low Normal Wilm’s tumor 24-hour urine protein if UA > 3+
Renal vein/artery thrombosis
Papillary necrosis
Kidney allograft rejection
SLE
Tubular necrosis Abnormal Nonsurgical Normal “Medical
(aminoglycosides cyclosporine, oncologic ANA, CBC, Atypical Typical
drugs, heavy metals, cyclophosphamide)
anatomy renal IgA course course/
Henoch-Schönlein purpura
Hemolytic-uremic syndrome Radiation nephritis disease” resolution
Granulomatosis with Arteriovenous malformation
polyangiitis Rare causes: Angioma, neurofibroma, polyps,
Goodpasture’s syndrome endometriosis, hemangioma, Treat BP; hospitalize if BP severe
Polyarteritis nodosa rhabdomyosarcoma, lymphoma, leukemia Surgical Follow or significant renal function
C3 Urology BP, hematuria,

referral/ creatinine, Nephrology consult
Cystitis
Urethritis intervention proteinuria
Low Normal Urolithiasis
Hypercalcemia
Meatitis Follow
Urethral prolapse
PSGN lgA nephropathy Bleeding diathesis,
MPGN Idiopathic, rapidly especially von
Shunt nephritis progressive GN Willebrand’s disease FIGURE 19-3
Chronic bacteremia Alport syndrome Epididymitis
(e.g., SBE) Thin glomerular Management algorithm for hematuria. (Data from Hay WM, Levin MJ, Deterding RR,
Hepatitis B basement membrane Azbug MJ, Sondheimer JM. CURRENT Diagnosis & Treatment Pediatrics. 21st edition.
HIV
Available at www.accessmedicine.com, Figure 24-1.
FIGURE 19-2
Diagnostic strategy for hematuria. GN, Glomerulonephritis; HIV, human immunodefi-
ciency virus; MPGN, membranoproliferative glomerulonephritis; NSAIDS, nonsteroidal b. Extraglomerular hematuria
antiinflammatory drugs; PSGN, poststreptococcal glomerulonephritis; RBC, red blood
cell; SBE, subacute bacterial endocarditis; SLE, systemic lupus erythematosus.
(1) Rule out infection: Urine culture, gonorrhea, chlamydia
(2) Rule out trauma: History, consider imaging of abdomen/pelvis
(3) Investigate other potential causes: urine Ca/Cr ratio or 24-hour
urine for kidney stone risk analysis, sickle cell screen, kidney/
bladder ultrasound. Consider serum electrolytes with Ca, consider
prothrombin time/partial thromboplastin time (PT/PTT).
D. Management (Fig. 19-3 )
38
HSP.
• MC vasculitis among Peds, Recent URTI (IgA deposition in small vessels)
• Palpable Purpura (legs and buttocks), Abdominal pain ( bowl angina )—> bloody diarrhea, Renal
Microscopic Hematuria ( nephritis), Arthralgia
• Tx = supportive
• Give steroids only with:
o Intussusception, perforation
o Testicular torsion
o Pancreatitis
o CNS involvements
o Nephritis
• kidney> immunotherapy
HUS.
Normocytic anemia, thrombocytopenia, edema,

following D symptoms > HUS
Shigatoxin Ecoli > food restaurant.
Schistocytes, Low PLT, bruises.
AKI, edema, elevated BUN, Cr.
Supportive and electro management.
Loperamide for diarrhea.
Characterized by microangiopathic hemolytic
anemia, thrombocytopenia, acute kidney injury.
More renal involvement
Congenital anomalies of Kidney and GUT:
Polycystic Kidney disease

Autosomal Recessive type (infantile) Autosomal Dominant type (Adult)
PKHD1 gene MC hereditary kidney disease, both kidneys
Both renal enlarged in size with many cyst enlarged.
PKD1 or PKD2 genes
Bilateral flank mass, +- potter sequence, HTN, Can px in infants /neonates US. Bilateral Macrocysts,
oliguria, acute renal failure. systemic cysts IN LIVER/spleen/pan.
Intracranial Berry aneurysm 🚨
Bilateral flank masses > pulmonary hypoplasia, Px > HTN, gross or microscopic hematuria,
Oliguria, HTN. proteinuria, infection of the cyst
Prenatal > US findings like oligohydramnios Dx > + 1st degree relative / + US findings
Supportive> dialysis and transplant ACEI, pain management and treatment of urinary
tract infection
39
Disease present with proteinuria:

** Nephrotic Syndrome (proteinuria (> 3g/day) / Hypoalbuminemia (< 2.5g/dL) / Hyperlipidemia /
Edema) >> Minimal Change disease MC nephrotic syndrome seen in Peds
Biopsy —> diffuse foot process effacement on electron microscopy and minimal changes.
Presentation Labs Treatment complication

Age 2-6 years, may follow UA: +3-4 protein. Blood: C3-C4 normal Empiric therapy with oral Infection/
infection, / Edema —> / 🔺lipids / 🔻Albumin <2.5 prednisone 4-6 weeks, thus peritonitis,
start around the 👀—> 🦵. Accurate: 24 h urine protein, cr avoiding renal biopsy. In high risk of
Diarrhea, abdominal pain, normal, cr/protein ration >2. case of edema give albumin thromboembolis
anorexia, could come with **consider biopsy if there’s: and diuretics. If steroid m.
HRN, Gross hematuria. Hematuria/ HTN/ heart failure / resistance give
Steroids resistance! cyclophosphamide.
** if patient, nephrotic, no need to change the diet. No increase it will worsen the case, if sever proteinuria
Extra give IV albumin to correct the edema, which is resistance to diuretics.
Chronic Kidney Disease:

Complications of CKD in Peds:
• Fluid and electrolytes abnormalities
• No activation of Vit D —> 🔻Ca+ —> 🔺PTH —> osteopenia
• Anemia, HTN
• Growth impairment, hyperuricemia, and uremia ( 🔺infections and impair PLT) was
** Uremia presentation:
• Metabolic Acidosis
• Fluid overload
• Encephalopathy
• 🔺🔺K
• Pericarditis
** Treatment:
• Vit D + Ca
• Erythropoietin + iron
• If bleeding > give Desmopressin —> improve PLT function
• Dialysis and transplants
• Control BP/ and CVS ris
40
Neurogenic Bladder:
Could be over or under active
Types:
• flaccid (hypotonic) > overflow incontinence
• spastic bladder > frequency, nocturia
• Mixed
Causes:
• Supraspinal cause = stroke, brain tumor, Parkinson disease
• Spinal = spinal trauma, MMC, MS
• Peripheral = DM, Alcoholic, B12 deficiency, Herpes Zoster, herniated pelvic disc, radical pelvic
surgery
Work Up:
• UA and C—UTI could be a cause or complication.
• U cytology —R/O bladder Ca.
• BUN/Cr / renal US—assess if kidneys affected / Pyelonephritis/ Anatomical anomaly.
• Voiding diary.
• Voiding studies.
Undescended testes Descended at age of 4th month or Treated bilaterally or Orchiopexy at 9-15
will remain undescended need uni but uni better in months
intervention to descended. fertility. If untreated
Empty scrotum lead to malignancy
(seminoma), hernia…
Testicular torsion Bell shape deformity, Most Transverse lie/ Emergent surgery,
common cause of testicular pain > horizontal, retracted, bilateral scrotal
12, acute pain, swelling, no C reflex. orchiopexy.
tenderness. Doppler color flows US.
Torsion of appendix Most common cause of testicular Blue dot, not do scrotal
testes pain 2-11, gradual onset, tender, hyperemic exploration??
inflamed mass on the upper pole
of testes
epididymitis Ascending retrograde urethral Young sexually active AB
infection, acute scrotal pain, and male. N gonorrhea and
swelling chlamydia.
Testicular tumor Palpable, not trans illuminate, Serum AFP, beta HCG Radical
painless orchiectomy
Epididymis orchitis Erythematous bilateral scrotum,
non-tender, not Tran illuminate.
41
16- Endocrinology
Diabetes Insipidus
Central DI - 🔻 ADH amount —> duo to any brain insult

Nephrogenic DI - renal disease —> not responsive to the effect of ADH
• 🔺Ca, 🔻k both inhibit the effect of ADH
• High volume urine, blood volume depletion and 🔺🔺Na.
• Neuro sx only if diuresis not equal to drinking
• To dx - give vasopressin - if case improved this is Central.
• Tx central with vasopressin (desmopressin replaces) / if nephrogenic correct the underlying renal
disease
Ambiguous Genitalia
• Congenital adrenal hyperplasia (CAH) is the MC cause
• Any suspect of CAH —> Check electrolytes every 24 to 48 hours to R/ O imbalance duo to adrenal
crisis
Adrenal crisis
• Hypotension or shock, electrolyte abnormalities (🔻Na, 🔺K, metabolic acidosis, and 🔻glucose)
• Treat immediately with IV fluid, and steroids stress dose!
• To prevent it —> stress doses of glucocorticoids when the child is sick or having surgery, or
trauma
21- Hydroxylase Deficiency is the MC type of CAH

• 🔻cortisol, 🔻Aldosterone (🔻Na, 🔺K), 🔺Androgen!!
• They are dehydrated not thriving well and doesn’t survive stresses duo to lack of steroid.
• They have 🔺17 - OH progesterone >3500 ng/dL (105 nmol/L).
• Definitive dx test —> is 17 - OH progesterone pre and post administration of ACTH.
• Tx with Hydrocortisone, and fludrocortisone if having salt imbalance.
• *** 17 hydroxy, is the useful tool for early detection, prior to the development of adrenal crisis.
Cushing Disease\ Syndrome
• MC is Cushing disease > 🔺🔺ACTH duo to pituitary adenoma.

• MC cause of Cushing syndrome is iatrogenic (excess administration of Steroids).
• They px. with FTT, delayed puberty and amenorrhea, pathological fractures.
• Best test > Dexa suppression test.
• Tx. the cause.
42
Thyroid disorders
Hypothyroidism Acquired:
Px with deceleration of growth, delayed puberty, headache, the rest same as adult
Congenital:
Hypotonia (open mouth), umbilical hernia, large tongue, puffy, wide fontanels, prolonged jaundice
Risk of cretinism and mental retardation if not treated
Screen all newborns >> 🔻T4, 🔺TSH >> Tx sodium thyroxine for life. ** give after lab no need for
further investigation.
Hyperthyroidism Majority Graves!
Peak at teenage
They are Hyperactive, lymphadenopathy and splenomegaly, emotional lability, 🔻school performance,
the rest same as adult
Thyroid storm Emergency!

🚨 Acute onset hyperthermia, severe tachycardia, restlessness
Tx with propylthiouracil or methimazole, beta blocker
Hypopituitarism
Deficiency of one or all hormones, GH common!

MC of acquired is Craniopharyngioma
• Growth impairment (GH) pubertal delay (FSH, LH)
• Acute Px. > hypoglycemic seizures, hypoadrenalism, hypothyroidism
• Screen for IGF-1 and IGF-binding protein3
• Definitive test GH stimulation test
• Assess all pituitary hormones’ functions
• MRI indicated in all of them
• Other DDx of growth impairment:
• Systemic condition—> Weight is often much less than height
• Constitutional delay —> delayed bone age, delayed adolescent growth spurt and pubertal development
• Familial short stature —> BA = CA, shorts parents
• Primary hypothyroidism
• Emotional deprivation (You need love to grow darling💕 )
Precocious Puberty
Secondary sexual characters
• Girls < 8 years
• Boys < 9 years
43
Pubertal progressive’s growth work up:

• First measure FSH, LH, and testosterone/Estradiol
⁃ In central causes—>basal LH 🔺 into the pubertal range 0.2-0.3
⁃ In peripheral and benign variant —> basal LH in pre pubertal range <0.2
⁃ All boys with CPP —> brain imaging—> high prevalence of CNS lesion
⁃ All girls with CPP and age <6 —> should have contrast MRI!
⁃ Boys and girls with peripheral—> do pelvic US/ Testes US to R/O germs tumors
** After DKA treatment > be careful from cerebral edema, and potassium disturbance.
** First sign in female in puberty > thelarche (breast)
** Thyroglossal cyst > neck swelling, moving with deglutition located in hyoid area.
** Conns syndrome: Polys, OGTT normal, CI high, Na high, another lab normal
** SIADH: Low Na
44
17- Orthopedic
1- DDH:
o RF= breech, female, fhx, first born, multiple Gestation, oligohydramnios.
§ Most common affected= female.
§ Most common sight left hip.
o Instability, subluxations, dislocation.
o For high risk group > screening at 6 weeks.
o PD= asymmetrical thigh, shortening, reduced abduction.
o Barlow suggestive= subluxable.
o Positive= Barlow positive.
o Ortolani positive= dislocated.
o Barlow- dislocate s dislocatable hip = adduction and depression = of flexed femur.
o Ortolani- reduce a dislocated hip= elevation and abduction= flexed femur.
o Galeazzi Limb length discrepancy= unilateral dislocation of hip= hip flexed knee in the table.
o Treatment: 0-6 months > Pavlik harness. 6-12 months > closed reduction and hip spika. 12-30
>open reduction and pelvic osteotomy. More than 30 moths > open reduction, pelvic osteotomy,
femoral shortening.
o If alpha angel more than 60 > no treatment required.
o If acetabulum dysplasia = static abduction brace.
45
2- LCPD:
• Idiopathic avascular necrosis.
• More in male and bilateral.
• Associations with = obesity, skeletal immaturity, and lower socioeconomic status have been
reported.
• RF= prematurity, positive family history, second hand smoker, abnormal presentation at
birth.
• Avascular necrosis also may occur secondary to an underlying condition (eg, renal failure,
glucocorticoid use, systemic lupus erythematosus, HIV, Gaucher disease).
• Gradual revascularization occurs subsequently.

• Observation for less than 8 years.
• Painless Progressive limping, hip stiffness, Trendelenburg gait.

• X-ray = crescent sign, medial space joint widening, irregular of femoral head ossification.
• Relived by rest.
3- SCFE:
• Obese, male, left hip, bilateral.
• + underlaying endocrine disorder (hypothyroidism, renal osteodystrophy, GH deficiency,
panhypopituitarism) + down syndrome.
• Mild limp and external rotation cannot stand or walk, knee pain, decrease hip rotation,
abduction.
• Osteonecrosis as complication.
• Percutaneous pin fixation.
46
4- Bone tumor:
5- OM and SA:
OM SA
Organism If healthy > S aureus. Less than 3 months >> S aureus, b strep, -ve bacilli,
with sickle > salmonella, staph aureus. more than 3 months>> staph, A strep.
Infant > GBS.
Lab. ESR to follow up., high WBC. high WBC, ESR, CRP.
Spread hematogenous (metaphysis), fever, irritable, Acute pain, swell, tenderness, limited range of
localized bone inflammation, point tenderness, motion, refuse to bear Wight, high fever.
swelling,
Initial X-ray X-ray
Accurate MRI US, effusion.
Definitive Bone biopsy Arthrocentesis US guided. More than 50000 WBC
Tx <3m vanco + cephalo/cefotaxime IV-AB, joint drain and detriment.
vanco/clinda + cephalon if at ICU. Vancomycin + Ceftazidime or ceftriaxone.
Ceftriaxone, Ciprofloxacin or spectinomycin.
>3m clinda or vanco, _ nafcillin or oxacillin Alternative gentamycin.
if SCD ** add 3rd cephalo.
47
6- Osgood Schlatter disease:
• Active adolescent.
• Swelling, tenderness, increase prominence of tubercle.
• Rest, immobilize. Knee.
7- Transient synovitis:
• After nonspecific URTI.
• Acute mild pain, limping, restrict movement.
• Pain also in groin, thigh, knee.
• Effusion, high ESR, xray normal,
• Bed rest
48
8- Tibia fracture:
• closed reduction / cast immobilization indications:

§ < 5 degrees varus-valgus angulation
§ < 10 degrees anterior/posterior angulation
§ > 50% cortical apposition
§ < 1 cm shortening
§ < 10 degrees rotational malalignment
§ if displaced perform closed reduction under general anesthesia
Operative
• external fixation
§ indications
o can be useful for proximal or distal metaphyseal fxs
§ complications
o pin tract infections common
§ outcomes
o higher incidence of malalignment compared to IM nailing
• IM Nailing
• indications
o unacceptable alignment with closed reduction and casting
o soft tissue injury that will not tolerate casting
o segmental fx
o comminuted fx
o ipsilateral limb injury (i.e., floating knee)
o polytrauma
o bilateral tibia fx
o morbid obesity
• contraindications
§ pre-existing tibial shaft deformity that may preclude passage of IM nail
§ previous TKA or tibial plateau ORIF (not strict contraindication)
Angulation is common Radius Fractures - Pediatric

Acceptance
1- < 9 yrs = 15-20°
2- > 9 yrs = 10 °
extra
3- Angulation less than 15° is acceptable in child < 10y
4- Less than 10° in child > 10 years
If more than that it’s unacceptable angulation and IMN or screws are indicated
Distal radius/ulna
30 for less than 9 years
20 for more than 9 years
49
18-Rheumatology
1- Juvenile Idiopathic Arthritis (RA of children)

• Clues—{ Fever (quotidian)/ Arthritis/ Rash ( worsens with fever, Salmon pink), Quotidian means one high
spike of fever a day to ≥38.5°C with normal or subnormal temperatures during the rest of the day ,
Arthritis (Morning stiffness, arthralgia, joint effusion, 🔻ROM)
• Other systemic sx.
o Generalized LN, splenomegaly, hepatomegaly
o Serositis ( pleuritis, pericarditis, peritonitis )
o Ophthalmologic sx.
Poor prognostic factors:
o RF+ / ACCP
o Hip involved
o Rheumatoid nodules
o Large number of affected joints
o Young age
o Systemic onset
Labs 🔺inflammation markers, Anemia for chronic disease, ANA, RF
Tx:
o Mild disease —> NSAIDS
o Methotrexate 2nd line
o Steroids —{ if severe disease, systemic
o Optha F/U
DDx of arthritis
o vasculitis
o Lyme
o psoriatic Arthritis
o IBD
o Malignancy refusal to bear weight 🚩
o Septic arthritis/ osteomyelitis - high-grade fever, localized severe pain swelling and redness,
limping, 🔺🔺WBC, 🔺🔺inflammatory markers
o Postinfectious arthritis / reactive arthritis > milder, resolve without aggressive tx, other
infection focus in PE & Hx
o Malaria
50
2- SLE
• Clues = Arthralgia and effusion, Malar/ discoid rash, 🔺BUN/Cr, 90% 🚺, More severe than adult
• Other > oral ulcers, anemia/ thrombocytopenia/ leukopenia (AB against them), photosensitivity
• Labs:
Ø WBC, RBC, PLT —>> might be 🔺🔺 acutely in response to inflammation
Ø 🔻C3, C4 ( in flaring )
Ø 🔺ESR, CRP
Ø ANA —1st screening test
Ø Anti DS-DNA —correlate with Nephritis
Ø Anti-smith AB —100% specific
Ø Anti Ro, Anti La AB —cross placenta and cause neonatal SLE —all sx transient
except Congenital Heart Block permanent —need pacemaker
Ø Ant histone AB —drug induced lupus —tetracycline, penicillin, methyldopa,
lithium
• Tx
• Hydroxychloroquine All pt
• NSAID for joints pain
• Steroids severe disease, Renal
• LMWH for thrombosis
3- Kawasaki
• Systemic inflammation (fever + mucocutaneous involvement , bilateral nonexudative
conjunctivitis, erythema of the lips and oral mucosa , 🍓tongue, cracked 👄, rash, and cervical
lymphadenopathy >> These findings are often not present at the same time!
• Cardiac findings = coronary aneurysm > screen them with echo!

• Tx: Acute > IVIG ( give ASAP before aneurysm develop), high dose aspirin ( give until laboratory
markers of acute inflammation subsided
• Subacute > low dose aspirin continue lifelong if echo abnormal!
• Postponing administration of live-virus vaccines for at least a year in children who have been treated
with IVIG because IVIG can interfere with vaccine immunogenicity
51
4- HSP.
• MC vasculitis among Peds, Recent URTI (IgA deposition in small vessels)
• Palpable Purpura (legs and buttocks), Abdominal pain ( bowl angina )—> bloody diarrhea, Renal
Microscopic Hematuria ( nephritis), Arthralgia
• Tx = supportive
• Give steroids only with:
o Intussusception, perforation
o Testicular torsion
o Pancreatitis
o CNS involvements
o Nephritis
• kidney> immunotherapy
52
19-Hematology
1- IDA:
◦ MCC of children anemia IDA and T.

◦ Universal screening recommended in 1 year.
§ Low= hg, R, MCV, first
hemosiderin, ferriten.
§ High= TIBC.
§ Micro/hypo.
◦ Pale, irritable, lethargy, high HR, systolic
murmur.
◦ Oral iron therapy/ Ferritin.
2- Lead poisoning:
• Preschool age, Behavioral changes, hyperactive and aggressive, cognitive developmental
dysfunction, GI = anoxia, pain, constipation, gingival lead line, basophils stippling in microscopic.
• Screen by 12-24 lead testing.
• Confirmatory by venues sample.
• X-ray of long bone, dense lead line, radiopaque in intestinal tract.
• Micro/hypo.
• Give chelation.
3- congenital pure red blood cell anemia
Blackfan- diamond
• Short program cell death, present at 2-6 months.
• Short stature, craniofacial deformity, triphalangeal thumb.
• macrocytosis, high HbF, high RBC, high ADA, high I, low R.
• cortico, transfusion and deferoxamine, splenectomy, transplant.
4- congenital pancytopenia:
Franconia anemia
• hyperpigmentation, cafe late spot, short, organ defect, absent / hypoplastic thumb, short
stature.
• WBC= N, RBC= L, PLT= L , HG= L, bone marrow hypoplasia, H= HbFautosomal recessive.
• >> neurofibromatosis.
• Hemolytic anemia, Normochrmoic/ normochromic.
• Increase risk of AML.
• Give steroid and androgen, BM transplant.
53
5- AOCD:
• Normocytic and chromic.
• Could be micro, R low, low erythropoietin, low hg, iron low, F slight increase.
• Control underplaying problem.
6- Megaloblastic anemia:
Folate deficiency:
• Macrocyclic, poor diet intake, or hemolysis.
• In vegetables, fruits, animal.
• LOW FOLATE.
B12 deficiency:
• only animal source.
• Lack intrinsic factor > pernicious anemia, - gastric surgery- impairs absorption, terminal
ilium removers.
• weakness, fatigue, FTT, irritability, pallor, glossitis, diarrhea, vomiting, jaundice,
neurological symptoms.
54
7- Hereditary spherocytes > Autosomal dominant.
• Jaundice for more than 1 week, defect of RBC

membrane.
• newborn, hypersplenism, biliary gallstone.
• smear spherocytes > do osmotic fragility.
• Crisis by parvovirus.
• Anemia and high indirect B, Increase MCHC,
Normal or slightly low MCV, low hg, High R, B.
• Conf, osmotic fragility test.
• Give folate, transfusion > splenectomy after 5-6
years.
8- pyruvet kinase> glycolytic enzyme.

• Coomb -ve, non-spherocytic hemolytic anemia, low hg, n to increase MCV, normal WBC, high R,
burr cell/ echinocytes, high LDH, high IB, decrease haptoglobin.
• 1st 24 of life > J > think PK, AR, Baby always tired and fatigue, anemic, pallor, J, SM,
polychromatophilia, macro.
• Do PL assay will show decrease activity.
• Exchange/ Transfusion/ folic acid/ chelation > splenectomy.
9- G6PD:
• Hines body/ bit cell.
• XLR > boys.
• Symptoms appear after 24-48 hours.
• Measure after 1-2 months, after acute episodes.
o Rapid drop of Hg, high J, LDH, B, R.
o Low hepatoglubinuria.
o -ve coomb.
10- SCA:
• Glutamic acid to valine, at beta gene.
• Presented at 2-4 months of age.
• By age of 5 all of them they have asplenia.
• First presentation > HF syndrome > dactylitis.
o High= R, mild to moderate anemia, normal=MCV.
o Target cell, Howell jolly bodies.
• BM hyperplastic.
Acute painful crises In extremities then abdomen, back, head, chest. They are more prone to
Participated by stress, fever, low O2, acidosis. encapsulated vaccine
Vaso-occlusive crisis. It is ischemic damage, retina, skin, hip, shoulder. (pneumococcal).
Acute splenic Confirmatory by Hb electrophoresis.
sequestration. On penicillin prophylaxis for 2
Aplastic crisis With paro. months tell age 5 years.
Acute chest syndrome The cause of mortality, along with sepsis. Give folate.
Stroke At 6-9 year. Transcranial doppler.
kidney First sign proteinuria, UTI, papillary necrosis. Hydroxyurea.
cholithiasis Symptomatic gallstone.
55
11- Thalassemia:
Alpha thalassemia:
◦ 3 genes > micro/hypo, target cell, mild ~SM, J, Chloethiasis. > not required transfusion or
splenectomy.
◦ MCV low
◦ 4 genes BART, high gamma tetramers >> lead to death >> immediate transfusion, > the only
cure > BM transplant, abnormal 4 alpha normal 4 beta.
Beta thalassemia major:
◦ Excessive alpha globin chain, no problem with gamma chain production, Homozygous beta.
◦ Absent beta globulin/ mutation in both genes, High A2 and F, present in 2nd month of life.
◦ severe anemia hg <4, HSM- hypersplenism, cardiac problem > expand medullary space/ hair on
end, extramedullary hematopoiesis.
◦ Low R, high B, high RBC nucleated > iron accumulation >BM hyperplasia.
◦ Transfusion dependent, Chelation therapy improves survival. / deferoxamine, BMT,
splenectomy.
T minor both alpha and beta:

• Normal distribution and microcytic.
• Asymptomatic, Found incidentally
• Small RBC, low MCV, normal RDW, High R means there are compensatory from the bone
marrow.
56
12- Hemophilia: prolonged PTT the rest NORMAL.
• Hemophilia A > X linked R only boys affected,

VIII def.
• Deep bleed not like VWD minor bleed.
• treat by replacing the factor, they stay in prophylaxis
dose. If the patient in severs case, and have recurrent
bleed, they might develop, inhibitor development, as
a complication of the treatment. U suspect this if the
pt. On replacement and still have bleeding. If those
patients need treatment, we can give factor VII. It’s
simply >> Like auto-AB against the factor introduced
to the body.
• will be corrected with mixing study, while
VWD will not corrected.
• Severity depends on factor deficiency. • So, if you have high PTT >> do mixing study.
• Initial > coagulation study and CBC > • But to differentiate between 2 types of
prolonged PTT the rest NORMAL. hemophilia > u need specific test.
• Recurrent hemarthroses > complication • avoid > antiplatelet and aspirin medication.
hemophilia arthropathy. • Mild cases we can give desmopressin.
13- VWD > AD. (increase PPT, BT )(normal PT, PLT).
• Bruising and mucosal bleed, postoperative bleeding, epistaxis, .

• DONT give (NSAIDs, aspirin, FFP).
• Give factors VW, VIII, and desmopressin.
• have minor bleed and patchie and ecchymosis.
14- Vit K defi: Prolonged PT time, PTT time, normal PLT and increase BT.
• New born need IM injection or they will be developed bleeding.

• Low ( II, VII, IX, X) and protein S,C.
• If baby presented after delivery with bleeding think vit K.
• Bruises, bloody stool, intracranial hemorrhage.
• Give k > the symptoms will resolve; it takes hours to work.
• If low mean poor placental transfer, Absent gut flora, immature liver function, inadequate level
of breast milk > so the second cause is nutritional.
*** factor VIII not by liver the rest YES. >> give FFB or cryo (will work in fibrinogen).
57
15- Platelets disorder:
ITP > L- PLT/ H-PTT/N-PT.
post 1-4 weeks of viral infection.

Low platelet, easy brushing and bleeding,
Petechiae and purpura, sever mucosal bleeding
isolated thrombocytopenia/ megakaryocytic.
Usually resolve within 6 months, If all trial of
treatment fail do splenectomy. If HSM and LAP
>>> nooooo ITP. No transfusion at all unless life
threatening, 80% will response to steroid.
58
20-ONCOLOGY
1- ALL:
• MC leukemia in children, because of bone pain
they might limb and refuse to walk, pallor,
bruising, thrombocytopenia, leukopenia, fever,
epistaxis, purpura, mucus membrane bleeding,
LAP, HSM, joint swelling.
• BM failure > low PLT, anemia, atypical
lymphocytes, neutropenia, pancytopenia, blast
cell, > decrease Ca, K.
• Aspiration > lymphoblast.
o 1- remission induction > combination drugs.
o 2-CNS treatment, intrathecal.
o 3-maintenance.
Complication > relapse, pneumocystis pneumonia,
TLS (hyperuricemia, hyperkalemia,
hypophosphatemia, hypocalcemia) treat this with
hydration and alkalization, MDL, sideroblastic.
2- Hodgkin lymphoma: painless/ non tender.
• MCC of cancer in late adolescent.
• Prolonged fever and LAP, especially if supraclavicular, Present first with B symptoms, and painless
LAP, large supraventricular node/ cervical> if cervical it is usually to infectious process, > mediastinal
mass, B symptoms.
• Reed stern berg, multipulated nuclei. Prominent multi giant cell

• X ray to see the mediastinal mass, which can lead to compressive symptoms, dysphagia, dyspnea.
• LN ex. biopsy is diagnostic.
3- Non-HL:
• EBV, Burkitt lymphoma, URTI, non-productive cough, usually no LAP.
• If HIV pt found to have abdominal mass >> this is NHL.
4- Brain tumor: second most malignancy > less than 7y.

Infratentorial> Astrocytoma and Medulloblastoma:
• initial, CT. Best MRI= intracranial mass.
Infratentorial MC, low grade fever, rarely invasive. MC, juvenile pilocystic astrocytoma
In cerebellum. Do resection, surgery, radiation, chemo.
supratentorial Craniopharyngioma MC, visual symptoms, headache, x ray to classification.

endocrine abnormality- Surgery and radiation no
panhypopituitarism, growth failure. chemo.
Optic glioma Benign slow progressive, uni visual Increase incidence of
loss, proptosis, eye deviation, optic neurofibromatosis.
atrophy, strabismus, nystagmus. Observation, surgery.
59
5- Wilms tumor/ nephroblastoma > Not crossing the midline/ non tender/
asymptomatic.
• Second MC malignancy/ but first in renal, More in male 2-5 years > high HTN
• uni more than bi > asymptomatic abdominal mass/ pain, high BP, gross hematuria, vomiting,
associated with WAGR
• Initial: US/ Confirmatory: CT. Low calcification in imaging.
• treatment surgery. chemo, radio.
6- Neuroblastoma > tender/cross midline > MC extracranial solid tumor of childhood, in

less than 2 > Nmyce.
• First year of life, can presented as Horner

(ptosis, mitosis, anhidrosis). less common than
Nephro, 90% calcifications + hemorrhage + HTN.
• Bluish skin nodules/ blueberry, Painful.
• Mc place adrenal > Mets to bone, skull.
• Start with MRI/CT/X-RAY. MRI-Best =
paravertebral mass, HVA/VMA, low ferritin.
• Surgery, chemo, radio. Transplant definitive.
7-Aplastic anemia:
BM, hypocellular with fatty infiltration.
60
21-Neurology
1- NTD:
Spina bifida occulta. No protrusion, MC asymptomatic, hair- dermal sinus.
Meningocele. Covered with skin, need to determine the extent by MRI, CT for head to check hydrocephalus,
surgery.
Myelomeningocele. Bowel and bladder incontinence, or perineal anesthesia without motor impairment.
Sac-like cystic, covered by thin, partially epithelized tissue.
Hydrocephalus. Increase head circumstances, bulging
Impaired circulation and absorption of CSF. anterior fontanel, distend scalp vein,
broad forehead, setting sun sign,
increase DTR, spasticity, clonus,
irritable, lethargy, poor appetite,
vomiting, headache, papilledema, six
nerve palsy.
Do shunting.
Dandy walker Cystic expansion of 4th ventricle.

malformation. Increased head size, prominent occiput, cerebellar ataxia, delay motor development, positive
transillumination.
2- Seizures.
Neonates seizures DDx.
• Due to immaturity of CNS, thy have subtle seizure.
• MC cause, hypoxic ischemic encephalopathy/ CNS infection / CNS hemorrhage (intra
asphyxia ventricular)/ withdrawal/ inborn error of metabolism.
• Do full septic work up.
• Give lorazepam/ phenobarbital.
Febrile seizure > MCC of seizure.

• 6m-6y, + F Hx.
o Typical simple > Generalized, tonic clonic < 10- 15 minutes / 10-20 seconds, brief
post ictal, DTP, MMR is risk factor.
o Atypical complex > Focality > 15 minutes, recurrence >1 /day.
o Treat by control the fever, then lorazepam if still seizing.
Epilepsy ( > 1 unprovoked seizures)
Partial seizures
Simple. no loss of con, no post ictal period on, < 2 min- 10-20 seconds. Phenytoin
ECG: spike, sharp multifocal.
Complex. mainly temporal lobe abnormality, loss of awareness, lip smacking, carbamazepine
hallucination, increase salivation, chewing. (Tegretol)
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Generalized
Absence 3 HZ spike. Ethosuximide

Blink roll eyes, induced by hyperventilation/ light, many times during
the day.
Tonic colonic stiff flexion and extension, eye roll, jaw clenched, < 30 seconds, Valporic Acid/
tongue bite, lose sensation, bladder incontinence. phenytoin
Myoclonic only Jerky movement, falling forward. Valporic acid
Infantile Spasms:
• Symmetric contractions of neck, trunk, extremities.

• Increase CRH > neuronal hyper excitability.
• ECG= hypsarrhythmia (asynchronous, chaotic bilateral spike end wave pattern).
1- cryptogenic = normal prior to seizure, good prognosis.
2-symptomatic = disease prior to seizure ex TB.
• Tx. With ACTH to suppress CRH, prednisone, anticonvulsant if no response.
Status epilepticus :
Ø 40 min, tonic clonic, > ABC > Lorazepam rectal or IM > 0.5 dextrose> repeat 3 doses
total> phyntoine bolus 20/kg over 20-25 min> phenobarbital> intubation.
Benign myoclonus of infancy:

• ECG normal, goes away after 2 years.
3- Neurofibromatosis
1-MC AD, Complication: hamartoma, optic glioma, malignant neoplasm, ischemic attack, hemorrhage, hemiparesis, seizure,
cognitive defect, attention defect…
Need genetic counsel, annual

ophthalmologic examination, and
examine family member.
For the tumor, surgical and pain relief

but it depend on the type, cutaneous
and subcutaneous not removed unless
for a specific need to remove, like pain,
bleeding, interfere with function.
if they developed pruritus, give
gabapentin.
optic glioma need close follow up, and
eye exam.
2 bilateral acoustic neuromas, hearing loss, facial weakness, headache, unsteady gait, skin findings, CNS tumors
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4- Cerebral Palsy:
• Diagnosed at 18 m of life, Most common idiopathic.
• Head and trunk hypotonia, limb hypertonia increase Reflex.
• (rigidity and spasticity) + seizure, abnormal speech, vision and intellect.
• Prematurity (78%) Low birth weight <1 kg —> most important RF
• Intrapartum Asphyxia only 10% > intraventricular hemorrhage and periventricular leukomalacia.
• MC px. is spasticity and rigidity
• MRI, >> For spasticity= dantrolene, baclofen, botulism.
• https://www.uptodate.com/contents/image?imageKey=PEDS%2F74533&topicKey=PEDS%2F616
7&search=cerebral%20palsy%20children&source=outline_link&selectedTitle=1~150
1/ hemiplegia. 2/ diplegia. 3/ quadriplegia.

Unilateral leg or arm, Bilateral LL, more than All limb, trunk involved,
arm more affected, fixed upper, motor difficulty, extensor posturing with arched
Spastic (MC) UMN damaged
arm, pronated forearm. no intellectual back, poor hand control,
Tip toe walk, scissor gait + disability. decrease central tone + seizure,
hemianopia. intellectual impairment.
Dyskinetic In BG, extrapyramidal, Chorea Floppiness poor trunk control, delay motor development,
involuntary movement, and Athetosis abnormal movement which disappear during sleep.
uncontrolled. Dystonia
Ataxia < 5%, intention tremor, weakness, unsteady wide gait, difficulty rapid or fine movement.
Mixed 10-15%
5- Wilson disease:
• Copper metabolism problem.

• Kayser Fleischer ring.
• MRI= dilated ventricle, atrophy of cerebrum.
• we suspect it in any child with chronic liver disease,
unexplained neurological behavioral, psychiatric changes.
• Screen= ceruloplasmin, Biopsy to confirm.
• Give= chelation, penicillamone, transplant.
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6- Myasthenia Gravis
• Neonate born to mother with MG, may have generalized hypotonia, weakness, feeding difficulty, respiratory
insufficiency >> Decrease acetyl choline receptors.
• Ptosis/ EOM weakness —> earliest sign, Feeding difficulty/ poor head control, limb gridle weakness and in
distal m of hand, also rapid muscle fatigue, Weakness peak at the end of the day.
• About 10 to 15 percent of those with myasthenia gravis have an underlying thymoma
There are two clinical forms of myasthenia gravis: ocular and generalized.
• In ocular myasthenia, the weakness is limited to the eyelids and extraocular muscles.
• In generalized disease, the weakness may also commonly affect ocular muscles, but it also involves a
variable combination of bulbar, limb, and respiratory muscles.
• EMG diagnostic
• Initial symptomatic therapy acetylcholinesterase inhibitor, Oral pyridostigmine is the most widely used
choice, SE: abdominal cramping and diarrhea. Muscarinic side effects can be controlled in many patients
with the use of anticholinergic drugs that have little or no effect at the nicotinic receptors, such
as glycopyrrolate.
• most patients with generalized MG require Glucocorticoids and/or other immunosuppressive therapies are
indicated for patients who remain significantly symptomatic on pyridostigmine.
• thymectomy has a therapeutic role in patients with thymoma.
• Therapeutic plasma exchange (plasmapheresis) and IVIG work quickly but have a short duration of action. In
addition to treatment of myasthenic crisis, these rapid therapies are useful in presurgical treatment of
moderate to severe MG. They are also used as a "bridge" when initiating slower-acting immunotherapies,
and as periodic adjuvants to other immunotherapeutic medications in refractory MG.
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7- Marie- Charcot- tooth disease:

• AD, peroneal muscle atrophy.
• Clumpsy fall easily, anterior compartment wasted, stork like appearance.
• Pes caves, foot drop, claw hand.
• CPK normal, decrease NCS, sural nerve biopsy.
8- Guillain barre syndrome:

• 10 days post viral infection, campylobacter, mycoplasma.
• Symmetrical ascending m weakness.
• 50% bulbar involvement (CN) —> anticipate Respiratory Failure.
• Autonomic involvement.
• Spontaneous recovery.
• Significant 🔺in CSF protein, normal glucose, decrease motor and sensory nerve
conduction.
• Admit all pt for observation.
• Tx supportive IVIG, some pt need plasmapheresis, steroid, interferon.
• Glove and stock syndrome.
9- Duchenne muscular dystrophy:

• Death muscle fibers, X linked 50% disease, death at 18 years.
• Gower sign, cardiomyopathy, scoliosis, IQ less than 70, pharyngeal weakness, aspiration,
repeated infection, calf pseudohypertrophy, hip gridle weakness.
• Lab= CPK, high initial = molecular genetics, biopsy= definitive.
• Tx. Tray to prevent calcium as possible, treat pulmo infection, give digoxin for heart failure,
10- Myotonic dystrophy:

• AD affected the muscle.
o Facial wasting, V shape lip, thin cheeks, scalloped concave temporalis muscle,
narrow head, high arched palate.
o Hypotonia, progressive distal muscle wasting.
o Progressive weakness in climbing steps, Gower sign.
o Slow GI emptying, constipation, arrhythmia, heart block, cataract, difficult
swallowing, poor speech.
• Diagnosed by CPK, best DNA.
• Supportive.
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11- Headache
Abdominal migraine
• mainly in children, ages five to nine years old, but can occur in adults as well.
• Abdominal migraine consists primarily of abdominal pain, nausea and vomiting.
• It is recognized as an episodic syndrome that may be associated with migraine, as links have been
made to other family members having migraines and children who have this disorder often grow into
adults with migraine.
• Most children who experience abdominal migraine grow out of it by their teens and eventually
develop migraine headaches.
• The pain associated with abdominal migraine is generally located in the middle of the abdomen
around the belly button. It is often described as dull or “just sore” and may be moderate to severe.
• In addition to the pain, there can be loss of appetite, nausea, vomiting and pallor. The attacks last
between 2-72 hours and in between attacks there should be complete symptom freedom.
• hydration therapy (particularly if there has been significant vomiting), NSAIDs, anti nausea
medication and the triptans.
• The choice of medications is somewhat affected by the age of the patient. When abdominal
migraines are frequent, preventive therapies used for other forms of migraines can be explored.
These include pizotifen, flunarazine, propranolol, cyproheptadine and topiramate.
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12- Ataxia
• Acute DDx. —> Acute cerebellar ataxia, GBS, anticonvulsant toxicity, brain tumor, trauma, neuroblastoma,
acute abyrinthintitis
13- Hypotonia
• 🔻Floppy baby/ Frog-like🔻position when supine.

• spontaneous activity muscle resistance to stretch
• DDx > chromosomal ( down), metabolic ( hypoglycemia, Kernicterus), perinatal ( CP, ICH),
endocrine ( 🔻thyroid, 🔻pituitary ) peripheral neuropathy or neuromuscular, Todd paralysis, MS,
MG
• In acute weakness R/O > SAH, Stroke, trauma, tumor, abscess, electrolytes imbalance, Metabolic
disorder.
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22-Infectious disease
1-Meningitis:
Bacterial.
• < 2 months, ((G-B-sterept, listeria, E.coli))
• 2 months / 12-year, S pneumonia, NM.
• Peds: Bulging fontanel in exam.
• No IP if (increase ICP- seizure/ focal/
confusion, sever cardio problem, skin inflicted
at the site)
• MC complication of pneumococcus, SN Harding loss.

• Immediate complication, seizure.
• Add dexamethasone if u suspected Hemophilus influenza type B,
Meningococcemia
• Rash, need high dose IV penicillin.
• If patient close contact to NM give rifampin as prophylaxis.
• If rapid progress > DIC, septic shock, septic shock, adrenal hemorrhage, renal and hear failure.
• In infant > look for Waterhouse-friderichsen syndrome > adrenal hemorrhage > sudden vasomotor
collapse, skin rash large in flanks > sudden hypotension > 100% mortality.
Viral meningitis.
• Self-limited, majority ((enterovirus)), such as group B coxsackievirus,
• Best diagnosis: PCR of CSF.
• Viral Culture.
• If HSV: give acyclovir, other supportive.
**** TB meningitis have severely low glucose.
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2-pertussis:
• pertussis gram negative cocci bacilli > (droplet) > highly contagious.
• Prevention > immunization.
• Usually affected > age more than 8 years.
• paroxysmal cough, inspiratory whooping cough.
• Phases:
Catarrhal phase 2 w, flue like symptoms.

Paroxysmal phase 2-5 w, sever cough, facial Petechiae, sub conjunctival
hemorrhage, post tissue Emesis.
Convalescent phase >2 w gradual resolution.
• PCR, nasopharyngeal swap, supportive care.

• erythromycin 14 days also all contact, if they are not immunized.
• For less than 1 month, azithro for 5 days why ?? because erythro cause pyloric stenosis.
• More than 1 month, azithro 5d- clarithro 7d- erythro 14d.
• MC complication > pneumonia/ sub-conjunctival hemorrhage/ bronchiectasis/ seizure.
3- TB:
• M tuberculin, first/acute affect lung with hailer adenopathy, then latent (+ test) but no clinical
features.
• Best to do > sputum culture (3 samples in morning).
• initial PPD and x-ray > apical posterior segment.
• add streptomycin in drug
resistance TB.
• If extra pulmonary > add 6
months.
• If cavity > add 3 months RI.
• If HIV> 24 months. Till -ve.
• If millary > repeat 12 months
and steroid.
Prenatal TB:
• If mother PPD + do chest x-ray if - and stable INH 9 months, if she delivered and we suspect TB don’t
give her baby tell x ray done, if the mother have disease give the baby INH 9 months, and give him to
his mother again, and the mother treat as TB tell culture negative.
69
4- cat scratch disease Bartonella:
• MCC of lymphadenitis, lasting more than 3 weeks.

• One or more red to white papules along the line scratch.
• Chronic regional lymphadenitis, fever, malaise, headache, anorexia.
• On stain gram negative bacilli.
• Self-limited, aspirate.
5- candida:
• white plaque if removed bleeding.
• C albicans. Diagnosis punctuate bleeding with abscess.
Oral Diaper dermatitis Catheter related Chronic mucocutaneus

thrush, white plaque, buccal Satellite lesion, see yeast with Affect any organ Defect of T
mucosa. KOH lymphocytes, With DM,
oral Nystatin. Topical nystaine (antifungal) Remove all catheter, auto-Immune.
one dose fluconazole. 1% hydrocortisone. amphotericin B
6-viral infection MTV> airborne.
Measles. Rubeola- Ill, Coryza, cough, conjunctivitis, fever, Maculo-papular rash cx.OM
Airborne (buccal/ Köp. like spot)-blenching. dx. clinically, tx. Vit-A, supportive.
from head/ hair line to down- Spare palms and soles. Go to school after 5-7 days.
Rubella Low GF, pint point rash, rose spot in soft palate, Congenital rubella syndrome.
Rubivirus, German retroarticular/P/ occipital LAP, forscheimer spot, Clinically, supportive.
measles. Droplet polyarthritis hand. Contagious 2 day before 5 day after.
Rosella- HHV6 High fever 40, URI, blenching maculo-papular rash rose color. Febrile seizure, aseptic
Start at neck and trunk then spread face and extremity, erythematous meningitis, low PLT, clinically,
papules in soft palate and uvula. Xanthema subitum Supportive.
Mumps Face swelling, fever, tender, bilateral, headache, Meningeoencephalomylitis/ meningitis.
Paramyxovirus malaise, salivary G swell, sub-mandible also clinically. Supportive.
parotid. ‫ ﺗﺮﺗﻔﻊ اﻻذن‬start uni then bilaterally.
Varicella/ chicken In S ganglia, reactive if low immunity. Scaring, Cerebellum ataxia or
box Herbs zoster > shingle. Airborne also direct contact. Macula > pneumonia, GAS, clinically, if low
papule > pruritic vesicles > open/ pustular > crusty. pruritic rash immunity acyclovir rest supportive.
purple from trunk to face to ex, fever, URT sym. fever and Self-limited.
malaise
SHINGLE Cause by deactivation of VZV. Typical dermatome, Compress with normal saline, analgesia and vir.
Hutchinson sign Give gabapentin for post neuralgia.
Fifth disease. URI, Read checks/ slap face, lacy rash/ reticular Aplastic crisis, clinically, supportive.
erythema rash on ex and trunk.
infectiosum. no palm and sole last 40 days,
Parvovirus B19 erythematous maculopapular rash, arthritis.
70
mouth or throat pain or refusal to eat, fever generally is low grade . The oral lesions, which may
occur in isolation, usually occur on the tongue and buccal mucosa. They begin as macules and
progress to vesicles, which rupture to form superficial ulcers. Oral lesions are painful and may
interfere with oral intake. The skin lesions, which may occur in isolation, are nonpruritic and
nontender. They may be macular, maculopapular, or vesicular and typically involve the hands,
feet, buttocks (particularly in infants and young children), and extremities.
HFM Coxsackie virus, group Vesicle and papule in erythematous Dehydration, supportive. > MC virus
disease. A base, vesicles in posterior oral cavity, responsible for pericarditis and
HFM, buttock. myocarditis. Also cause herpangina
NO Chorea.
HSV. 1-2. Vesicles/ papule in erythematous base, Supportive may add topical antiviral.
https://www.uptodate.com/contents/image?imageKey=PEDS%2F106132&to
picKey=PEDS%2F6037&search=HSV%20children&source=outline_link&selecte
dTitle=1~150 also in the anterior cavity,
multinucleated giant cell.
EBV. Adolescent age, Fever, fatigue, sore throat/ pharyngitis, Splenic hemorrhage or rupture, treat
infectious monoclonus, Generalized adenopathy A and P symptoms, steroid. Dx, atypical
associated with cervical, HSM, maybe exudate, rash if lymphocytes, heteropholAB- by
malignancy Burkett’s treated with penicillin or amoxicillin mono-spot.
lymphoma,
Scarlet GAS. Fever, Sore throat/tonsillitis, exudative Acute rheumatic fever, GN,
fever. pharyngitis, strawberry tongue tongue, penicillin/Amoxe/erythro.
maculopapular rash like Sand paper,
pastie line. More in folds skin
Influenza H1N1 Fever, headache, sore throat, unable to eat, myalgia, OM, Supportive.
virus. conjunctivitis, pharyngitis, dry cough, Malaise.
Adenovirus. Fever, pharyngitis, conjunctivitis, Supportive.
diarrhea, pharyngoconjunctival fever,
myocarditis, intussusception, no rash.
Polio. GIT Can cause URT sym, asymmetrical
flaccid paralysis
7- helminthic disease:
Ascariasis Hookworm Enterobiasis/ vermicularis

Ascaris lumbricoid, round worm. Ancylostoma duodenale and Pinworm, nocturnal perinatal pruritus.
nectar. Penetrate through skin.
Worm in diaper, blood stained Lack appetites, abdominal pain, Scratching anus, can’t sleep from it, no
sputum, cough, (lung) loeffler diarrhea, blood loss, skin green/ eosinophil, may come with nausea,
syndrome, colicky abdominal yellow. vomiting, abdo pain and vulvovaginitis. Dx
pain. by eggs/scotch on tape test.
Albenadazole, accurate> fecal Zole and Ferris sulfate, fecal albendazole repeat in 2 weeks. Or Pyrantel
smear. CBC> eosinophilia. smear> egg, CBC> eosinophils pamoate.
Also all house hold.
71
8- gangue fever:
• Mosquito/ flavivirus, 2 form

• Form 1= fever, headache, neck pain, flushing face, macula-popular rash, HM, retrobulbar pain.
• Form 2= hemorrhagic: bleeding, patchiest, bruises, hematuria, epitaxis, low BP. Lead to shock and
thrombocytopenia.
• If fever more than 10 days exclude.
• Lab high transminase low PLT.
• High IgG titer, RNA PCR.
• Fluid, supportive, give blood trans.
9- malaria:
• Ill patient, travel hx, thick and thin blood sever.
• Cyclic fever,
• PF= most common, high spike fever, flue like sym, abdo pain, diharhhea, myalgia, headache, cough,
HSM, low PLT, no leukocytosis. Comp cerebral malaria
10- -Enteric fever: typhoid

• Contaminated for or water
• Salmonella
• Travel endemic region
• abdominal pain, fever, and chills approximately 5 to 21 days after ingestion of the causative
microorganism, bradycardia, pulse-temperature dissociation, and "rose spots" (faint salmon-colored
macules on the trunk and abdomen). Hepatosplenomegaly, intestinal bleeding, and perforation may
occur, leading to secondary bacteremia and peritonitis. Laboratory findings may include anemia,
leukopenia, leukocytosis, and abnormal liver function tests.
• Tx if complicated: ceftriaxone. Uncomplicated: Cipro./ azithro/ ceftriacone.sytematic illness, dexa.
11- Leishmania??
12- HIV:
• Non specific symptoms, fever night sweet, wight loss,
• Hairy leukoplakia in tounge, kaposi sarcoma, G LAP, bacillary angiomatosis.
• CD4 lymph count.
• Treatment see reem file
• Chronic D, LAP, failure to thrive, sever infection, with opportunistic organism.
• Confirmed by PCR.
72
13- cellulitis:
• +abcess or both.
• Skin barries disruption, edema, Venus insuffency, low immunity,
• Beta hymolitic strept, Mc G-A. Also staph but less common,
• MC organism cause abcess, staph.
14- acute rheumatic fever:

• Untreated strept pharyngitis, GAS> to avoid
ARF give 10 days penicillin V.
• usually it is >> self-resolving.
• Prophylaxis for long time, IM venxathine
penicillin G/ month > To prevent the
recurrence.
• Carditis ((friction rub, prolonged PR interval-
diffuse ST elevation)).
• Chorea/jerk.
• Sulfadiazine if allergic to penicillin.
• Abx prophylaxis in Rheumatic fever:
• No cardiac involvement *5 years or till age of 21*
• If with cardiac involvement but no residual damage *10 years*
• If with residual damage at least *10 years and until age of 40*.
73
74
15- impetigo:
• Complication, PSGN.
16- Lyme disease:

◦ Rash not painful, could be itchy or like burn come with constitutional symptoms like headache,
fatigue, fever, malaise.
17- Acute lymphadenitis:

• staph > if less than 5y, tender, warm, erythematous.
• If not treated progress to >> suppression and abscess.
• Clinical, give > clindamycin.
• Unilateral cervical LAP, in children usually

because of staph aureus.
• Stph aureus> Mc organism affected cystic
fibrosis patient, / while pseudomonas
aeruginosa > pneumonia.
• Palpable LN in peds especially cervical >
observation. If soft mobile less than 2 cm no
systemic symptoms. If not like this so do
biopsy.
75
Inflammatory Bowel Disease

1. Classification/types:
1. Crohn’s disease: Transmural inflammatory process affecting any seg-
ment of the GI tract. Abdominal pain in majority of cases. Other common symptoms include weight loss,
diarrhea, lethargy, anorexia, fever, nausea, vomiting, growth retardation, malnutrition, delayed puberty,
psychiatric symptoms, arthropathy, and erythema nodosum.10
2. Ulcerative colitis (UC): Chronic relapsing inflammatory disease of the colon and rectum. Symptoms
(present for at least 2 weeks) include gross or occult rectal bleeding, diarrhea, abdominal pain with or
around time of defecation. Exclusion of enteric pathogens (e.g., Salmonella, Shigella, Yersinia,
Campylobacter, Escherichia coli 0157:H7, C. difficile) is necessary. Weight loss, anorexia, lethargy are less
common than in Crohn’s disease.
2. Evaluation:
1. Complete history and physical exam, including family history, exposure
to infectious agents or antibiotic treatment, assessment of hydration and nutritional status, signs of
peritoneal inflammation, signs of systemic chronic disease. Stomatitis, perianal skin tags, fissures, fistulas
are suggestive of Crohn’s disease. Presence of fever, orthostasis, tachycardia, abdominal tenderness,
distention, or masses suggests moderate to severe disease and need for hospitalization.
2. Laboratory assessment: CBC, ESR, CRP, serum urea and creatinine, serum albumin, liver function tests. IBD
is associated with decreased hemoglobin and albumin, rise in platelet count, ESR, CRP (although children
with UC may have normal hemoglobin, platelets, and ESR). Anti-neutrophil cytoplasmic antibodies (ANCA)
may be elevated in UC. Diagnostic endoscopy is typically used to make diagnosis.
3. Management:
1. First-line therapy: Corticosteroids, 5-aminosalicylates, antibiotics
2. Second-line: Immunosuppression includes thiopurines, methotrexate,
cyclosporine, tacrolimus, and anti-tumor necrosis factor (TNF) monoclonal
antibodies.
3. Surgical intervention is indicated only after medical management has
failed in both Crohn’s and UC. In Crohn’s, surgery is indicated for localized disease (strictures), abscess, or
disease refractory to medical management.
TTP:
• More CNS involvement > ttp.
• FAT > fever, altered mental status, renal, hemolytic anemia, thrombocytopenia
• Plasmapharesis.
• High (BT) N (PT,PTT) low (PLT, RBC).
76
Iron over load:

he manifestations of iron toxicity are typically described in five (often overlapping) phases:
Acute iron intoxication: Rapid overview - UpToDate 28/11/1440 AH, 3,49 PM
• Gastrointestinal (GI) phase: 30 minutes to 6 hours after ingestion
• Latent, or relative stability, phase: 6 to 24 hours after ingestion
• Shock and metabolic acidosis: 6 to 72 hours after ingestion
© 2019 UpToDate, Inc. and/or its aﬃliates. All Rights Reserved.
• Hepatotoxicity/hepatic necrosis: 12 to 96 hours after ingestion
Acute iron intoxication: Rapid overview
• Bowel obstruction: 2 to 8 weeks after ingestion
To obtain emergency consultation with a medical toxicologist, call the United States Poison Control Network at 1-800-222-1222 , or
access the World Health Organization's list of international poison centers.
History
What form of iron was ingested?
Ferrous gluconate (12 percent elemental iron)
Ferrous sulfate (20 percent elemental iron)
Ferrous fumarate (33 percent elemental iron)
How many mg/kg of elemental iron was ingested?
When did the ingestion occur?
Clinical features: Overlapping phases of clinical manifestations

Gastrointestinal phase (30 minutes to 6 hours): Abdominal pain, vomiting, diarrhea, hematemesis, melena, lethargy, shock (from
capillary leak and third spacing), metabolic acidosis.
Latent (6 to 24 hours): Improvement in gastrointestinal symptoms; may have poor perfusion, tachypnea, tachycardia.
Shock and metabolic acidosis (6 to 72 hours): Hypovolemic, distributive, or cardiogenic shock with profound metabolic acidosis,
coagulopathy, renal insufficiency/failure, pulmonary dysfunction/failure, central nervous system dysfunction.
Hepatotoxicity (12 to 96 hours): Coma, coagulopathy, jaundice. Severity is dose dependent.
Bowel obstruction (2 to 8 weeks): Vomiting, dehydration, abdominal pain, usually gastric outlet obstruction.
Diagnostic evaluation: For all patients with systemic symptoms, those who have ingested >40 mg/kg of
elemental iron, and those for whom the amount of elemental iron ingested is unknown
Serum iron concentration: Measure peak serum iron concentration (4 to 6 hours after ingestion of regular iron preparations; 8
hours after ingestion of extended release iron preparations)
Arterial or venous pH*
Abdominal radiograph looking for radiopaque pills*
Other initial labs: Electrolytes, BUN, creatinine, glucose, liver enzyme tests, total bilirubin, prothrombin and partial thromboplastin
time, CBC with differential, type, and screen*
Management
Secure airway and breathing.
Treat volume depletion appropriately with isotonic fluid administration.
Whole bowel irrigation: For all patients with a significant number of pills in stomach and small intestine on radiograph.
Orogastric lavage with a large-bore tube: Reserved for intentional overdoses with large numbers of visible gastric pills on abdominal
radiograph.
Deferoxamine: Continuous IV infusion (can cause hypotension). Begin at 15 mg/kg per hour. May increase to 35/mg/kg per hour
during first 24 hours for severe ingestions. A toxicologist and/or regional poison control center should be consulted to determine the
optimum dose of deferoxamine and duration of therapy. Treat in the following circumstances:
Severe symptoms: Altered mental status, hemodynamic instability, persistent vomiting, diarrhea
Anion gap metabolic acidosis
Serum iron concentration >500 mcg/dL
Significant number of pills on radiograph
BUN: blood urea nitrogen; CBC: complete blood count; IV: intravenous.
* Asymptomatic toddlers who have ingested a small but unknown dose of iron (<40 mg/kg of elemental iron) may be managed without
undergoing these studies.
Graphic 61711 Version 11.0
https://www.uptodate.com/contents/image?imageKey=EM%2F61711&top…&search=iron%20overdose&source=outline_link&selectedTitle=1~53 Page 1 of 2
77
Atopic dermatitis:
• onset before 5 years + asthma, allergic rhinitis, food allergies.
• 0-2 > Dry, vesicle, crusting, erythema, scaly lesion, in check, scalp, and extensor surface, spare diaper
area.
• 2-16 > lichenified plaques in flexor area, antecubital and popliteal fossa, volar aspect of wrists, ankle,
neck (atopic dirty neck), scaling.
• Adult: may involve face, neck, more in hands and feet.
• Treatment: skin care and lubricants with low water products.> antihistamine> topical steroid> topical
calcineurin inhibitors (tacrolimus ointment, pimecrolimus)
Chapter 8 Dermatology 181
Localized Yes Painful Yes Yes Tinea corporis

Annular?
rash? or itchy? Atopic dermatitis
No
Yes
Linear? Contact
dermatitis
No No
Psoriasis
Yes Moccasin- Yes
Hands/ Tinea
glove
feet? Pityriasis
pattern?
rubra pilaris
Juvenile No
Palmar Yes palmar/
surface? plantar Web Yes
dermatosis Tinea
spaces
No
No Yes Lichen No
Linear? Yes
striatus
Paronychia? Candida
No
Yes Psoriasis No
Annular?
Porokeratosis Yes
Dyshidrosis
Vesicular?
No Tinea
8
Seborrheic
Yes
dermatitis
Facial?
Perioral
dermatitis
No
Hands/ Yes Keratoderma

feet? Porokeratosis
Syphilis
Lichen planus
Yes Yes Yes Graft-versus-
Generalized Painful
Lichenoid? host disease
rash? or itchy?
Lichenoid drug
No eruption
Yes Psoriasis
Extensor
Pityriasis
surfaces?
rubra pilaris
No
Yes
Flexures? Atopic dermatitis
No
No
Yes
Seborrheic areas? Keratosis follicularis
No
Yes
Sun-exposed areas? Photodermatitis
Yes Pityriasis rosea

Truncal? Syphilis
Pityriasis lichenoides
No
Face, scalp, Yes

Seborrheic dermatitis
flexures?
No
Yes
Koebner
Lichen nitidus
phenomenon
FIGURE 8-14
Papulosquamous disorders algorithm. (Modified from Cohen BA. Atlas of Pediatric Der-
matology. 3rd ed. St Louis: Mosby, 2005:97.)
78
Condyloma acuminatum
appear as flesh-colored, pink, or brown soft moist papules that are a few millimeters in diameter. Over the course of weeks to
months, the papules may coalesce into larger plaques that often demonstrate a "cauliflower appearance" . In boys,
condylomata acuminata are most commonly detected in the perianal area and are less frequently found on the penile shaft.
Girls may present with lesions on the perianal area, vulva, hymen, vaginal vestibule, and/or periurethral areas. Anogenital warts
may also occur on the internal mucosal surfaces of vagina or rectum.
Although occasional lesions are pruritic or painful, condyloma acuminatum is usually asymptomatic. Rarely, bleeding occurs.
The possibility of sexual abuse should be considered in all children who present with condyloma acuminatum. Children over the
age of four years are more likely to have a history of sexual abuse than younger children. The evaluation for sexual abuse
typically begins with interviews with the caregivers and child, a complete physical examination, and screening for other sexually
transmitted diseases
Since most condylomata acuminata in children resolve within a few years, treatment is not required for most children with
asymptomatic lesions. For children with symptomatic lesions, lesions that fail to spontaneously resolve, immunosuppression, or
lesions that lead to emotional distress or social problems, we suggest treatment with imiquimod 5% or 3.75% cream or
podophyllotoxin 0.5% gel or solution. Children with lesions recalcitrant to topical therapy may benefit from laser therapy or
surgical procedure
-Important notes:
• Children no aspirin, reye syndrome, acute liver failure and encephalitis.
• Vercilla vaccine can cause rash and its contagious due to replication of the virus.
• Cat scratch > cause : -ve rod bartonella henslae >> fever, regional LAP, headache,
malaise.
• Entamoeba histolytica, cause bloody diarrhea, metro
79

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Pediatric- Ghazal’s and Mona’s notes.

TTN Meconium aspiration Diaphragmatic hernia

In the initial management for diaphragmatic hernia

Ø Congenital infections >> TROCH > UpToDate and u-world.

**Mother get affected from cat feces/ uncooked meat.

**MC congenital infection worldwide,

Imperforated Fail to pass stool, no anal opening. do surgery.

DO doppler to exclude other causes.

Differential diagnosis of painless scrotal mass.

• Poor cord hygiene, Unimmunized mother, un-hygenated delivery,

most common cause of an umbilical mass.

Ø Hemangioma = strawberry nevus.

• Most common tumor in infancy.

• The "silk sign" is a palpable silky thickening of the cord.

Ø The prune-belly (Eagle-Barrett) syndrome (PBS)

2-Genetics and dysmorphology

3-Growth and nutrition:

Constitutional growth delay Familial Pathological

Ø FTT= < 3rd percentile, cross 2 curves, < 80% of expected.

Organic Malnutrition, malabsorption, dx. documented calories

• For obesity > exercise and balance diet NO medication.

o Overweight > BMI between the 85th and 95th percentile.

• Breast milk have less iron than formula.

✓ Baby could lose some Wight after 1st week.

• If persistence Moro after 6 months > CP.

✓ Rooting = protruding the tongue out.

5-Behavioral/ psychological disorder

• Stage 1 > easily awake.

VACINE # of doses Indication Contra indication Side effects

7-Child abuse and neglect

Ø Epiglottis/ medical emergency:

CAP = MCC, viral infiction.

Caseating granuloma as in tuberculous pneumonia.

< 2 years Streptococcal pneumonia. Amoxicillin, Augmentin,

Intestinal tract Respiratory tract GU tract Sweat G

Ø SIDS: nothing important.

Ø Para-pneumoniatic Effusion/ empyema

Ø Bronchiectasis > antibiotic.

9- asthma and allergy

• The diagnosis of allergic rhinitis is made

Ø Acute bacterial rhinosinusitis:

• Non typable HI, strept p., Moraxella.

Ø Urticaria and angioedema:

10-Immune mediated disease

Ø Selective IgA deficiency:

Defect in cellular immunity T cell defect:

Ø DiGeorge syndrome thymic hypoplasia:

• T cell deficiency, Thymic and parathyroid hypoplasia, to aplasia.

Combined antibody and cellular immunodeficiencies:

Ø Severe combined immunodeficiency:

• Small thymuses, spleen depletion of lymphocytes.

Ø Wiskott- Aldrich syndrome both T and B:

Disorders of phagocytic function:

Ø Leukocytes adhesion deficiency:

• Cause bacterial and fungal infection, decrease inflammatory response.

11-12-Eye, ear, nose, and throat

Neonatal conjunctivitis/ ophthalmia neonatorum:

Organism. Non-typable HI, Influenza, Staph-A, SP. HI/S-Pneu.

• Viral = more gradual with URI, no pus only erythema.