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* peds dr edward peuana
#161294
s786 - 02/13/07 11:58
USMLE Step 2 — Lesson 1
Pediatric Highlights for USMLE Step 2 Eduardo Pino, MD NEWBORN-APGAR Apgar Score 0 1 2
Appearance Blue, pale Body pink, ext blue All pink
Pulse (HR) 0 <100 >100
Grimace None Grimace Cough
Activity Limp Some flexion Active
Respiration Absent Slow irregular Good
NEWBORN-SKIN · Subcutaneous fat necrosis · Erythema toxicum · Acne neonatorum · Milia · Hemangiomas · Mongolian spots · Nevus sebaceous NEWBORN-HEAD · Caput-scalp swelling, crosses suture lines, resolves in days · Cephalhematoma - subperiosteal bleed, DOES NOT CROSS SUTURES, longer resolution · Fontanels-large, suspect hydrocephalus, hypothyroid o Closure-anterior, 9-18 months o Posterior, birth, 4-5 months NEWBORN-EYES,NOSE · Eyes o Red reflex=lens clear o White reflex=retinoblastoma o Lens opacity=cataract o Aniridia+hemihypertrophy=Wilms · Nose o Choanal atresia-blue baby pinks up on crying, catheter doesn’t pass nose NEWBORN-ABDOMEN, GU · Abdomen o Masses-polycystic kidney most common o Umbilical hernia-most close by 5 years o Omphalocele-sac o Gastroschisis-no sac · GU o Epispadias, hypospadias-don’t circumcise o Undescended testes-bring down after 1 year o Ambiguous genitalia-congenital adrenal hyperplasia (21 hydroxylase most common) NEWBORN-BIRTH INJURIES · Fractures-clavicle most common-crepitus · Forceps-facial nerve palsy, bruising · Brachial plexus o Erb-Duchenne:C5-C6, if C4, ipsilateral § diaphragmatic palsy § “waiter’s tip” o Klumpke:C8-T1, “claw hand” NEWBORN-SCREENING · PKU-autosomal recessive o mental retardation most common o eczema, musty odor, FAIR HAIR, FAIR SKIN, BLUE EYES · Galactosemia-autosomal recessive o jaundice, hypoglycemia, cataracts · Hypothyroid-T4 low, TSH high o large fontanel, jaundice, mottled, constipation, large tongue, umb. hernia NEWBORN-RESPIRATORY · Common signs/symptoms- Cyanosis, tachypnea, nasal flaring, retractions, grunting · Respiratory distress syndrome o Surfactant deficiency, seen in preterm o Ground glass appearance on X-ray o Treat with surfactant, ventilator support · Transient tachypnea of newborn o Rapid descent, C/S · Meconium aspiration syndrome NEWBORN-JAUNDICE · Physiologic o Appears >24 hours of age o peaks at 12.9 by 3 days o resolves by 1 week · Pathologic-first day, level >13, lasts > 1week o Etiology-hemolysis-Rh, ABO o biliary atresia-direct bilirubin, o acholic stools · Therapy-phototherapy only for indirect NUTRITION · Breast milk is best for infant · Iron supplement after 6 months · Contraindications- o active, untreated TB o syphilis o AIDS o herpes if breast lesions o galactosemia o varicella · Formula-20 cal/oz · Whole milk-only >1 yr. Bad for kidneys GROWTH-HEIGHT · Short stature hypopituitarism constitutional delay familial short stature deprivational dwarf Turner hypothyroidism chronic disease · Tall stature normal-familial obesity endocrine-GH excess o androgen excess o hyperthyroidism genetic o Marfans o Klinefelter GROWTH-WEIGHT Failure to Thrive Malnutrition Malabsorption Allergies Immune deficiency Chronic disease Obesity <5% secondary to syndromes Risk of obesity persisting to adults increases with advanced age of onset DEVELOPMENT · Newborn reflexes-most disappear by 4-6 mos, EXCEPT Babinski (18 mos), parachute (never) · Social smile 4-8 weeks · Rolls onto back 4 mos · Rolls onto stomach 5 mos · Sits with support 6 mos · Pincer grasp 9 mos · 3 cubes at 15 mos, 4 at 18, 7 at 24 BEHAVIOR · Attention deficit-inattentive, impulsive,distractible, hyperactive (4:1 males) · Enuresis-primary nocturnal most common · typically males, family history · disorder of sleep/arousal · treatment-time, alarms, imipramine DDAVP · Encopresis-boys more common, usually psychological cause
USMLE Step 2 — Lesson 2
IMMUNIZATIONS · NOT contraindications: · Fever<105 after DPT · Mild acute illness in otherwise well child · Concurrent antimicrobial therapy · Prematurity-immunize at chronological age · Family history of seizures · Family history of SIDS IMMUNIZATIONS · Don’t give live vaccines to immunocompromised · Killed polio now recommended for initial series · MMR-most effects 1-2 weeks later · Delayed schedule-give as many as possible · Missed immunizations-don’t start over IMMUNIZATIONS-HIV Vaccine No/ ModerateImmunosupporess(Category 1,2) SevereImmunosupress(Category 3)
DTP Yes Yes
OPV No No
IPV Yes Yes
MMR Yes No
Pneumococcal Yes Yes
Influenza Yes Yes
ID-SEPSIS/MENINGITIS · Etiology- Age dependent o Neonate-Group B Strep most common E. coli Listeria o >2 months-pneumococcus most common o College, military-meningococcus · Clinical-bulging fontanel in infants o Kernig, Brudzinski in older · Know CSF findings ID-SEPSIS/MENINGITIS · Steroids useful in preventing H. flu sequelae · Add vancomycin if Pneumococcus · Rifampin prophylaxis for H. flu, Meningococcus · Vaccines vs. H. flu, S. pneumoniae, N. meningitidis ID-ENCEPHALITIS · Etiology-viral o Arbo, enteroviruses in seasonal epidemics o HSV most common cause of sporadic · Clinical-more abnormalities of mental function-confusion, delirium, combative, ataxia ID-ENCEPHALITIS · Diagnosis - PCR from CSF · Temporal lobe involvement suspect HSV · Treatment - acyclovir if HSV ID-OSTEO/SEPTIC ARTHRITIS · Osteomyelitis o S. aureus most common o Sickle cell - Staph, Salmonella o Pasteurella after dog, cat bite o Pseudomonas after sneaker puncture o X-rays turn positive after 10-14 days · Septic arthritis - Staph, also Strep o Arthrocentesis test of choice o Differential - cellulitis, JRA, synovitis, ALL ID-PERTUSSIS · Clinical o conjunctivitis o coughing spasms o inspiratory whoop o ·facial petechiae · Lab-leukocytosis with lymphocytosis o ·positive culture o ·rapid fluorescent antibody stain ID-PERTUSSIS · History of incomplete immunizations · Immunize to prevent, erythromycin to close contacts · Erythromycin to patient shortens communicability ID-RASH DISEASES · Lyme disease-look for Long Island, Conn. o Rash-erythema chronicum migrans · Fifth’s disease-erythema infectiosum o Rash-“slapped cheek” o Parvovirus B19, can cause aplastic anemia ID-RASH DISEASES · Measles (rubeola) o Cough, coryza, conjunctivitis, Koplik o Rash accompanied by fever · Roseola-rash after fever · Rubella-3 day measles, lymphadenopathy ID-RASH DISEASES · Can immunize against measles, rubella, Lyme · Rocky Mountain Spotted Fever o Look for Carolinas o Rash includes palms/soles · Cat scratch-papule, granuloma, lymphadenitis o PCR most sensitive for diagnosis o Kittens transmit more than cats ID-MISCELLANEOUS · Mumps-orchitis rare before puberty · HIV-most pediatric infections acquired at birth-zidovudine to mother decreases transmission · Mononucleosis - atypical lymphocytes o Ampicillin rash
USMLE Step 2 — Lesson 3
POISONING · Acetaminophen-check liver functions o antidote: n-acetylcysteine · Aspirin-ferric chloride test-qualitative o metabolic acidosis with respiratory compensation in children · Carbon monoxide-cherry red blood o antidote-oxygen, hyperbaric POISONINGS · Tricyclic Antidepressants · Leading cause of death o seizures, arrhythmias · Hydrocarbons - kerosene o aspiration · Organophosphates - DUMBELS o antidote - atropine POISONINGS · Iron - signs of hemorrhagic gastroenteritis o antidote - deferoxamine · Lead - blood lead levels, lead lines o antidote - EDTA, BAL EYE · Conjunctivitis-chemical most common <24h old o Chlamydia most common infectious cause in newborn · Strabismus-transient is normal up to 4 months old EYE · Amblyopia-“lazy eye” o Hirschberg, Cover test o patch good eye · Cellulitis o orbital-eyeball doesn’t move, proptosis preorbital-eyelids and surrounding tissue TEETH-PRIMARY ERUPTION Lower(Mandibular) Upper(Maxillary)
Central Incisors 5-7 months 6-8 months
Lateral Incisors 7-10 months 8-11 months
Cuspids(canines) 16-20 months 16-20 months
First Molars 10-16 months 10-16 months
Second Molars 20-30 months 20-30 months
TEETH-SECONDARY Lower Upper
Central Incisors 6-7 years 7-8 years
Lateral Incisors 7-8 years 8-9 years
Cuspids 9-11 years 11-12 years
1st Premolars 10-12 years 10-11 years
2nd Premolars 11-13 years 10-21 years
1st Molars 6-7 years 6-7 years
2nd Molars 12-13 years 12-13 years
3rd Molars 17-22 years 17-22 years
EARS, NOSE, THROAT · Otitis media o Etiology - S. pneumo most common H. flu nontypable B. catarrhalis o Meningitis most common intracranial complication · Otitis externa-from repeated wetting Etiology - Pseudomonas, S. aureus Clinical-pain exacerbated by moving ear canal EARS, NOSE, THROAT · Sinusitis - S. pneumo, H.flu, Staph. Symptoms-purulent nasal discharge headache, sinus tenderness · Epistaxis - nose picking most common · Pharyngitis - viral/bacterial (Group A strep) o Throat culture is gold standard o Complications - rheumatic fever EARS, NOSE, THROAT · Peritonsillar abscess-tonsil bulges, uvula deviates to non-involved side “HOT POTATO VOICE” · Retropharyngeal abscess-Strep, look at lateral X-ray of neck · Cervical lymphadenitis-usually infectious o Viral/bacterial pharyngitis, TB, cat scratch, rarely tumors RESPIRATORY · Foreign bodies-peanut most commonly aspirated o Look for sudden onset respiratory distress, wheezing, may be witnessed event o Diagnosis-bronchoscopy, CXR hyper-inflated · Croup-parainfluenza virus o Clinical-barking cough, inspiratory stridor o P/A neck film-STEEPLE SIGN o Steroids beneficial RESPIRATORY · Epiglottitis H. flu type b o Age- 3-10 years o Clinical-dysphagia, drooling, muffled voice o CHERRY RED EPIGLOTTIS o THUMBPRINT SIGN on lateral neck o Tx-secure airway, antibiotics RESPIRATORY · Asthma-Reversible airways disease o wheezing is hallmark, no clubbing o Differential-congenital malformations § foreign bodies § cystic fibrosis § bronchiolitis o Tx-bronchodilators, steroids o Prevent-cromolyn, leukotriene antagonist RESPIRATORY · Bronchiolitis-RSV, children<2 years o Clinical-wheezing, rales, tachypnea o Prevention-monoclonal antibodies · Cystic fibrosis-autosomal recessive o chromosome 7, long arm o chronic obstruction-clubbing seen o SWEAT TEST RESPIRATORY · SIDS-most common cause of death 1-12 mo · Peak at 2-3 mo, winter, midnight-9 AM · Sleep position
USMLE Step 2 — Lesson 4
CARDIOVASCULAR · Innocent murmur-never diastolic o never >2/6 o 3-7 years of age o best at left lower, midsternal border o musical, vibratory o no significance CARDIOVASCULAR CLASSIFICATION STENOTIC R to L L to R MIXING
Aortic stenosis TOF PDA Truncus
Pulmonic stenosis Transposition VSD TAPVR
Coarctation Tricuspid atresia ASD Hypertrophic LH
CARDIOVASCULAR · ASD-systolic ejection murmur o WIDE FIXED SPLIT OF S2 · PDA-machinery murmur, to and fro o wide pulse pressure, bounding pulses o Tx-surgical closure indomethacin · VSD-most common heart defect o loud harsh pansystolic murmur o 30-50% of small defects close by 1 year CARDIOVASCULAR · Endocardial cushion defect-Common AV canal o Common in Down’s syndrome o CHF early-feeding difficulty, sweat while feeding, tachypnea · Coarctation of the aorta-common in Turner’s o Weak/delayed/absent lower extremity pulses, Rib notching on CXR CARDIOVASCULAR · Tetralogy of Fallot- Most common cyanotic o pulmonary stenosis o VSD o overriding aorta o RV hypertrophy o CXR-boot shaped heart, pulmonary markings o PE-cyanosis, single 2nd heart sound o Complications-cerebral thrombosis, ischemia, brain abscess CARDIOVASCULAR · Transposition-most common with cyanosis in 1st 24 hrs. o Keep ductus open with prostaglandin o CXR-egg on a string · Pulmonary atresia- cyanosis at 2-3 days · Tricuspid atresia- single S2 pansystolic murmur · Total anomalous pulmonary venous return o CXR-snowman or figure 8 CARDIOVASCULAR · Rheumatic fever- rheumatic fever-associated with Strep throat J=joints O=carditis (O looks like a heart) N=nodules (subcutaneous) E=erythema marginatum S=Sydenham’s chorea o minor criteria-fever, arthralgia, previous RF ESR, CRP, prolonged P-R interval + prior Strep infection o complications-valve disease-mitral, aortic CARDIOVASCULAR · Hypertension o Essential-no known underlying cause o More common in adolescents o Secondary-more common in infants and children o Look for renal disease-UTI, obstructive lesion of urinary tract, prior umbilical catheter as newborn GASTROINTESTINAL Diarrhea · Viral-rotavirus most common o adenovirus, Norwalk virus · Bacterial-E.coli think of HUS o Salmonella -tx prolongs carrier o Shigella-tx with trimethop/sulfa o Campylobacter-erythromycin o C. difficile-think of prior antibiotic o parasites-Giardia, cryptosporidium GASTROINTESTINAL VOMITING Constipation · Voluntary withholding most common (functional constipation) outside of infancy o also-imperforate anus § cystic fibrosis-meconium ileus § anteriorly displaced anus § Hirschsprung-aganglionosis § Dx by BIOPSY GASTROINTESTINAL VOMITING · Age related causes o neonate-obstruction o infants-gastroenteritis, reflux, allergy, over-feeding, inborn errors of metabolism o child/adolescent-gastroenteritis, toxic ingestion, appendicitis, pancreatitis · Duodenal atresia-bilious vomiting common in Down’s, DOUBLE BUBBLE GASTROINTESTINAL VOMITING · Reflux - chronic, cough, vomiting, apnea o pH probe is gold standard · Pyloric stenosis - NONBILIOUS, PROJECTILE VOMITING o more common in males, firstborn o lab-hypochloremic, hypokalemic metabolic alkalosis o Ultrasound test of choice GASTROINTESTINAL BLEEDING · Upper-esophagitis, ulcers, gastritis, epistaxis · Lower-neonate-swallowed blood-Apt test o necrotizing enterocolitis-premature, low Apgar, pneumatosis intestinalis o other-milk allergy, gastroenteritis, ANAL FISSURE (infants) GASTROINTESTINAL · Inflammatory bowel disease-ulcerative colitis and Crohn’s o Dx by biopsy o both cause bloody stools, fever, abdominal pain o Crohn’s-fissures, fistula, abscess GASTROINTESTINAL · Intussusception-typically 6-18 months o Clinical-crampy abdominal pain CURRANT JELLY STOOL o PE-sausage shaped abdominal mass o ·Dx-barium enema-coil spring sign GASTROINTESTINAL · Meckel’s diverticulum-disease of 2’s o 2% of population, 2:1 males, 2 years of age, 2 types of tissue, 2 feet from ileocecal valve o painless rectal bleed, can cause intussusception o Dx-technetium scan RENAL · Acute Glomerulonephritis o triad of hematuria,edema, hypertension o follows Group A Strep infection o C3 decreased o Complications-renal failure, hypertension · Alport’s · X-linked dominant · Clinical-microscopic hematuria, proteinuria, HEARING LOSS, CATARACTS RENAL · Nephrotic syndrome-proteinuria,edema, hypoproteinemia, hyperlipidemia o usually follows viral respiratory infection o C3 normal o Complications-INFECTION-peritonitis · Urinary tract infection o males more common <1 year, then females o E. coli most common o Urine culture is gold standard
USMLE Step 2 — Lesson 5
ORTHOPEDICS · Intoeing o Metatarsus adductus-can be brought to neutral o Talipes equinovarus-heel also deviated o Tibial torsion o Femoral anteversion ORTHOPEDICS · Limping o Congenital hip dysplasia-0-3 years, u/s o Legg-Perthes-4-8 years-avascular necrosis of femoral head o Slipped capital femoral epiphysis->11 years obese adolescent, think deficient gonads ORTHOPEDICS · Popliteal cyst (Baker)-painless, nonpulsatile · Osgood Schlatter-tenderness, swelling of tibial tubercle o common in physically active pubertal children · Radial head subluxation (nursemaid) o sudden traction to arm ORTHOPEDICS · tumors-occur in adolescence, rapid bone growth o Osteosarcoma-most common, risk if bilateral retinoblastoma o bone sclerosis on X-ray o Ewing’s-“onion skin” on X-ray ALLERGY/IMMUNOLOGY · Allergic rhinitis-IgE mediated o Clinical-sneezing, rhinorrhea, allergic salute, allergic shiners, nasal crease o Tx-antihistamines, leukotriene antagonists · Hereditary angioedema-C1 esterase inhibitor def. · Bruton’s-all major immunoglobulins involved o symptoms at 6-12 mos.-recurrent infections, esp. pneumococcus o Tx-replace IgG ALLERGY/IMMUNOLOGY · DiGeorge-T cell deficiency o TRUNCUS ARTERIOSUS, fishmouth, micrognathia o NEONATAL HYPOCALCEMIA is 1st manifestation · Wiskott-Aldrich: X-linked recessive o MR TEXT-low IgM, Recurrent infections, T(and B) cell deficiency, Eczema, Thrombocytopenia RHEUMATOLOGY · Juvenile Rheumatoid Arthritis Types- o polyarticular-many, small joints RF-, RF+ o pauciarticular-few, large joints o type I-ANA+, girls, iridocyclitis o type II-HLA B27+, boys, ankylosing spondylitis o systemic-fever, rash, then joints o Differential-rheumatic fever, SLE, Lyme, ankylosing spondylitis, osteomyelitis, ALL RHEUMATOLOGY · Systemic lupus erythematosus-autoimmune o BUTTERFLY (malar) rash o renal involvement in children o neonatal lupus-congenital heart block · Mucocutaneous lymph node syndrome (Kawasaki) o FEVER+ 4 of 5 of following: conjunctivitis, mucous membrane changes, peripheral extremity changes, rash, cervical lymph nodes o CARDIAC INVOLVEMENT RHEUMATOLOGY · Henoch-Schoenlein purpura o Rash usually below waist o Usually follows viral illness o Can have renal, GI involvement HEMATOLOGY ANEMIA · Iron Deficiency most common o cause-low birth weight, diet (9-24 mos) blood loss (ulcer, Meckel, whole cow’s milk in infants) o clinical-pallor, irritability, murmur o labs- ferritin, serum iron, binding capacity, FEP, Hgb o differential-lead, thalassemia, chronic disease o tx-iron-see reticulocytosis in 72h, Hgb 3-4 wks HEMATOLOGY ANEMIA · Hemolytic o Hereditary spherocytosis-autosomal dominant § presents as anemia, jaundice § labs-OSMOTIC FRAGILITY TEST § tx-splenectomy o Enzyme defects-pyruvate kinase, G6PD HEMATOLOGY ANEMIA · Sickle cell anemia - develops after 2 months o dactylitis 1st manifestation, splenic, bone infarcts, infections (Salmonella, Pneumococcus) · Dx-electrophoresis HEMATOLOGY · Idiopathic thrombocytopenia-autoimmune o Usually follows viral infection o Petechiae, but patient appears well o Bone marrow-normal o Tx-gamma globulin, steroids · Hemophilia o Factor VIII (classic, A)-X linked recessive § HEMARTHROSIS § Replace factor ONCOLOGY · Acute lymphocytic leukemia-most common childhood cancer o clinical-acute onset, anorexia, pallor, fever, bone pain in 1/4 o dx-bone marrow o tx-chemotherapy, radiation, transplant o RELAPSE TO TESTES, CNS · Wilms -nephroblastoma o abdominal mass o distorts renal outline ONCOLOGY · Neuroblastoma-many times abdominal, o presents anywhere there is neural crest o Increased catecholamines in urine · CNS-most common solid tumors o infratentorial (posterior fossa ) most common § cerebellar astrocytoma most common § clinical-morning headache, vomiting o supratentorial-craniopharyngioma cause of short stature
USMLE Step 2 — Lesson 6
NEUROLOGY · Seizures o Febrile-most common § rapid rise of temperature § generalized, tonic-clonic, 10-15 mins § normal EEG § tx-treat fever o Infantile spasms-West syndrome § EEG-hypsarrhythmia § tx-ACTH, prednisone o Petit mal-3/sec spike/wave, ethosuximide NEUROLOGY · Progressive mental retardation o Lesch-Nyhan-self-mutilation § gouty arthritis o Wilson’s-disorder of copper metabolism § initial signs are liver related § Kayser-Fleischer rings o Mucopolysaccharidoses-Hunter-X linked recessive, all others autosomal recessive o Tay-Sachs-lose developmental milestones, cherry red macula NEUROLOGY · Werdnig-Hoffman-spinal muscular atrophy o Severe hypotonia-floppy baby o Fasciculations, FROG LEG POSTURE o EMG-fibrillations o muscle bx-denervation o nerve bx-slowed conduction o Autosomal recessive · Guillain-Barré-follows viral illness o Ascending weakness, paralysis, lose deep tendon reflexes § tx-supportive, plasmapheresis, IVIG NEUROLOGY · Duchenne muscular dystrophy-X linked rec o most common inherited neuromuscular disease o Hip girdle weakness, Gower’s sign o dx-greatly elevated creatine kinase, muscle bx · Neurofibromatosis-von Recklinghausen o Café-au-lait spots, axillary/inguinal freckling o Lisch nodules, neurofibromas, acoustic neuroma o autosomal dominant, risk for malignancy NEUROLOGY · Tuberous sclerosis-autosomal dominant o Ash leaf spot, sebaceous adenomas, shagreen patch, periventricular calcified tubers on CT o seizures very common · Sturge-Weber-facial nevus-port wine stain o seizures difficult to control o intracranial calcifications o mental retardation ABUSE · Clinical-unexplained injury o physical and injury don’t correlate o lash marks, loop marks o bite >3 cm=adult o RETINAL HEMORRHAGE=shaken o old healing fractures, bruises o venereal disease in prepubertal child · Tx-treat any injury, infection o document, REPORT ADOLESCENT · Know Tanner stages · Breast buds 1st sign of puberty in females · Testicular enlargement 1st sign in males · Mortality-Accidents, especially motor vehicle o Suicide-males more successful o Homicide o Cancer-leukemia, Hodgkin’s, bone · Normal-breast asymmetry, gynecomastia, irregular menses · Acne-hormones, dirt, bacteria Pediatric Highlights for USMLE Step 2 Eduardo Pino, MD End
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