Deja Review Pediatrics, 2nd Edition - 1st Edition

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I dedicate this book to doctors in training whose hard work, sacrifice, and excitement to learn keep the
medical profession moving forward.

Thank you to my family and friends for your unending support and encouragement
Contents

Contributors
Faculty Reviewers
Student Reviewers
Preface
Acknowledgments

Chapter 1 BIRTH AND PREMATURITY

Prenatal and Neonatal Health
Infections
Birth Trauma
Prematurity
Delivery Complications
Abdominal Wall Defects
Drug Exposure
Clinical Vignettes

Chapter 2 GROWTH, DEVELOPMENT, AND NUTRITION

Growth
Development
Nutrition
Clinical Vignettes

Chapter 3 SCREENING AND PREVENTION

General Screening
Newborn to 1 Year
Early Childhood
Adolescence
Immunizations
Injuries and Abuse

Chapter 4 ADOLESCENT MEDICINE

Puberty
Health Maintenance
Sexually Transmitted Infections
Male Genitourinary Conditions
Acne
Clinical Vignettes

Chapter 5 CARDIOLOGY
Arrhythmias
Cardiomyopathies and Heart Failure
Cardiac Examination
Structural Heart Disease
Acquired Heart Disease
Cardiac Surgery
Clinical Vignettes

Chapter 6 PULMONOLOGY
 Upper Airway Conditions
Lower Airway Conditions
Pneumonia
Neonatal Conditions
Congenital Lung Lesions
Genetic Conditions
Clinical Vignettes

Chapter 7 GASTROENTEROLOGY
Pediatric Gastroenterology
Genetic Diseases and Syndromes
Clinical Vignettes

Chapter 8 HEMATOLOGY AND ONCOLOGY

Hematology
Oncology
Clinical Vignettes

Chapter 9 INFECTIOUS DISEASE

Clinical Vignettes

Chapter 10 NEPHROLOGY AND UROLOGY

Physiologic Disorders and General Symptoms
Glomerulopathies
Newborn Urology
Urinary Infection and Reflux
Renal Failure
Acquired Adolescent Disorders
Clinical Vignettes

Chapter 11 NEUROLOGY
Neural Tube Defects
Cerebral Palsy
Seizure Disorders
Head Injuries
Headaches
Weakness and Neuromuscular Diseases
Ataxia
Neurocutaneous Diseases
Syncope
Sleep Disorders
Abnormalities in Head Size and Shape
Neuropathies
Complications of Antiepileptics
Neuro-Oncology
TIC Disorders
Clinical Vignettes

Chapter 12 MUSCULOSKELETAL DISEASE

Injuries
Growing Pains
Genetic Conditions
 Inflammation and Infection
Noninfectious Limp
Newborn Examination
Clinical Vignettes

Chapter 13 ENDOCRINOLOGY
Diabetes, Diabetes Insipidus, and Syndrome of Inappropriate Antidiuretic Hormone
Thyroid Disorders
Parathyroid Disorders
HPA Axis Disorders
Pubertal Disorders
Clinical Vignettes

Chapter 14 IMMUNOLOGY AND RHEUMATOLOGY

Immunology
Allergy
Rheumatology
Clinical Vignettes

Chapter 15 GENETIC DISEASE

Modes of Inheritance
Screening
Malformations
Trisomies
Syndromes and Inherited Disorders

Chapter 16 METABOLIC DISORDERS

Overview
Sugar Metabolism
Purine Metabolism
Amino Acid Metabolism
Cholesterol Metabolism
Glycogen Storage Disorders
Lipidoses
Lysosomal Storage Disorders
Urea Cycle Disorders
Clinical Vignettes

Chapter 17 DERMATOLOGY
Disorders of the Epidermis
Skin Infections, Infestations, and Exanthems
Genetic, Immunologic, and Rheumatologic Skin Disorders
Vascular Malformations and Melanocytic Lesions
Clinical Vignettes

Chapter 18 ENT AND OPHTHALMOLOGY

Neonatal Ophthalmology
Ophthalmologic Inflammation and Infection
Common Ophthalmologic Problems
Newborn ENT
Audiology
ENT Infectious Disease
 Anatomic Problems
Clinical Vignettes

Chapter 19 PSYCHIATRY
Developmental Psychology
Adolescent and Adult Psychology
Autistic Spectrum Disorders
Clinical Vignettes

Chapter 20 PEDIATRIC EMERGENCIES AND TRAUMA

Initial Evaluation and Triage
Airway Management
Hemodynamic Instability
Toxic Ingestions and Exposures
Trauma
Clinical Vignettes

Index
Contributors

John Babineau, MD
Fellow, Pediatric Emergency Medicine
Morgan Stanley Children’s Hospital of New York
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Genetic Disease

Marisol Betensky, MD, MPH

Resident, General Pediatrics
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Pulmonology

Brooke T. Davey, MD
Fellow, Pediatric Cardiology
University of Pennsylvania
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Cardiology
Neurology

Jessica Durst, DO
Resident, Department of Pediatrics
New York Presbyterian Chidren’s Hospital of New York
Columbia Unviversity Medical Center
New York, New York
Psychiatry
Immunology and Rheumatology
Screening and Prevention

Emily Kott Eida, MD

Resident, Department of Pediatrics
Morgan Stanley Children’s Hospital of New York
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Musculoskeletal Disease
Metabolic Disorders

Janienne Kondrich, MD
Fellow, Department of Pediatric Emergency Medicine
New York University Langone Medical Center
Bellevue Hospital
New York, New York
Dermatology
Pediatric Emergencies and Trauma
Jennifer Louis-Jacques, MD, MPH
Resident, Department of Pediatrics
Morgan Stanley Children’s Hospital of New York
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Adolescent Medicine
Endocrinology

Mahbod Mohazzebi, MD, FAAP

Pediatrician, Medical Director
Advocare Kressville Pediatrics
Cherry Hill, New Jersey
Nephrology and Urology
ENT and Ophthalmology

Sona Narula, MD
Fellow, Department of Neurology
University of Pennsylvania
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Neurology

Neha Dinesh Patel, MD

Resident, Department of Pediatrics
Morgan Stanley Children’s Hospital of New York,
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Gastroenterology

Nefthi Sandeep, MD
Resident, Department of Pediatrics
Morgan Stanley Children’s Hospital of New York,
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Birth and Prematurity
Hematology and Oncology

Aarti Sheth, MD
General Pediatrician
New York, New York
Infectious Disease
Growth, Development, and Nutrition
Faculty Reviewers

Fred Bomback, MD
Clinical Professor of Pediatrics
Columbia University
College of Physicians and Surgeons
New York, New York

Marina Catallozzi, MD
Assistant Professor of Pediatrics
Department of Population and Family Health
Columbia University College of Physicians and Surgeons
Mailman School of Public Health
New York, New York

Wendy Chung, PhD, MD

Director of Clinical Genetics
Department of Pediatrics - Molecular Genetics
Columbia University Medical Center
New York, New York

Mary Anne Jackson, MD

Chief, Section of Pediatric Infectious Diseases
Children’s Mercy Hospital and Clinics
Professor of Pediatrics
University of Missouri-Kansas City
School of Medicine
Kansas City, Missouri

Beth Kaufman, MD
Medical Director, Cardiomyopathy Program
Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Connie Kostacos, MD
Assistant Clinical Professor
Department of Pediatrics - General Pediatrics
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York

Michael E. McCormick, MD
Department of Otolaryngology—Head and Neck Surgery
Wayne State University School of Medicine
Detroit, Michigan

Nadia Ovchinsky, MD, MBA

Assistant Professor of Clinical Pediatrics
Department of Pediatric Gastroenterology
Morgan Stanley Children’s Hospital of New York
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York

Sameer J. Patel, MD
Assistant Professor of Pediatrics
Department of Pediatric Infectious Diseases
Columbia University
New York, New York

David Resnick, MD
New York Presbyterian Hospital
Allergy Division
New York, New York

Rakesh Sahni, MD
Columbia University
College of Physicians and Surgeons
New York, New York

Sujit Sheth, MD
Associate Professor of Pediatrics
Columbia University Medical Center
New York, New York

Nasreen Talib, MD, MPH

Medical Student Coordinator
Department of Pediatrics
University of Missouri-Kansas City
School of Medicine
Kansas City, Missouri

David Teng, MD
Morgan Stanley Children’s Hospital of New York
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York

Jeffrey J. Tomaszewski, MD
Department of Urologic Surgery
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Morgan Stanley Children’s Hospital of New York
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Student Reviewers

Ilana Harwayne-Gidansky
SUNY Downstate College of Medicine
Class of 2009
Fourth Year Medical Student

Rebecca Lambert
Weill Cornell Medical College
Class of 2010
Third Year Medical Student

Alison Santopolo
Weill Cornell Medical College
Class of 2010
Third Year Medical Student
Preface

Pediatrics is a broad and complex, yet exciting field, with a diverse and ever-evolving patient population. Deja
Review: Pediatrics, Second Edition is written by pediatric residents and fellows for medical students. The
most frequently tested pediatric subjects on those exams are covered in this book by new doctors in training
and graduating medical students who have recently taken the boards. It is an effective study guide that may be
used to study for Steps 1, 2, and 3 of the boards and the pediatric shelf exam. The topics addressed will
reinforce a broad base of pediatric knowledge with clinical pearls that apply to the subspecialties within the
field.

ORGANIZATION

The Deja Review series is a unique resource that has been designed to allow you to review the essential facts
and determine your level of knowledge on the subjects tested on your clerkship shelf exams, as well as the
United States Medical Licensing Examination (USMLE) Steps. All concepts are presented in a question and
answer format that covers key facts on commonly tested topics during the clerkship.

This question and answer format has several important advantages:

• It provides a rapid, straightforward way for you to assess your strengths and weaknesses.
• Prepares you for “pimping” on the wards.
• It allows you to efficiently review and commit to memory a large body of information.
• It serves as a quick, last-minute review of high-yield facts.
• Compact, condensed design of the book is conducive to studying on the go.

At the end of the book, you will find clinical vignettes. These vignettes are meant to be representative of the
types of questions tested on national licensing exams to help you further evaluate your understanding of the
material.

HOW TO USE THIS BOOK

This book is intended to serve as a tool during your pediatric clerkship, as well as pediatric subspecialty
rotations. Remember, this text is not intended to replace comprehensive textbooks, course packs, or lectures. It
is simply intended to serve as a supplement to your studies. This text was thoroughly reviewed by a number of
medical students and interns to represent the core topics tested on shelf examinations.

For this reason, we encourage you to begin using this book early in your clinical years to reinforce topics you
encounter while on the wards. You may use the book to quiz yourself or classmates on topics covered in
recent lectures and clinical case discussions. A bookmark is included so that you can easily cover up the
answers as you work through each chapter. The compact, condensed design of the book is conducive to
studying on the go. Carry it in your white coat pocket, so that you can access during any downtime throughout
your busy day.

We hope this review book brings medical facts to life and is not only informative, but also entertaining and
interesting. Good luck studying!

Brooke Davey, MD
Acknowledgments

Thank you all the medical students, residents, and attendings who worked so hard to complete this book. Your
contributions were made while pursuing and practicing the art of medicine. Thank you for donating your time
and keeping your commitment to the next generation of physicians.

The author would also like to recognize the faculty and staff at New York University School of Medicine,
Morgan Stanley Children’s Hospital of New York, and The Children’s Hospital of Philadelphia. Thank you to
Kirsten Funk, Cindy Yoo, Sapna Rastogi, and Midge Haramis at McGraw-Hill for their help in the process.

Finally, the author would like to acknowledge the following contributors and faculty reviewers for their work
on the first edition:

CONTRIBUTORS

Kristy Ahrlich, MD
John Babineau, MD
Emily P. Greenstein, MD
Catherine Lau, MD
Mahbod Mohazzebi, MD
Joni Rabiner, MD
Aarti Sheth, MD
Melanie Sisti, MD

FACULTY REVIEWERS

Fredric Bomback, MD
Wendy K. Chung, MD, PhD
Joseph Haddad, Jr., MD
Daphne T. Hsu, MD
Anupam Kharbanda, MD
Elvira Parravicini, MD
Prantik Saha, MD, MPH
Nan R. Salamon, MD
David Teng, MD
CHAPTER 1
Birth and Prematurity

PRENATAL AND NEONATAL HEALTH

Define the perinatal period, the neonatal period, and the postnatal period.
The perinatal period starts at 22 completed weeks’ gestational age (GA) and ends 7 days after birth. The
neonatal period lies between birth and 28 days of life and the postnatal period is from birth to 6 weeks of
life.
Why do babies born greater than 42 weeks GA typically have a normal height and head circumference
for their GA but decreased weight?
These “post-mature” infants have grown normally throughout pregnancy but then experienced placental
insufficiency late in the pregnancy and their nutritional needs were not met, slowing weight gain.
An infant is born weighing less than the 10th percentile for GA, and the weight, height, and head
circumference are proportional. How is this baby classified?
This baby is small for gestational age (SGA) and most likely had symmetric intrauterine growth
restriction (IUGR). Risk factors for symmetric IUGR are intrauterine infection, chromosomal
abnormalities, dysmorphic syndromes, and intrauterine toxins. In an infant with asymmetric IUGR the
head growth will be normal for gestational age and risk factors are maternal medical conditions such as
chronic hypertension, preeclampsia, and uterine anomalies.
If labor is going to be induced prematurely, what medicine should be given to the mother to promote
fetal lung maturity?
Steroids should be used prior to delivery to promote fetal lung maturity in premature infants. A lecithin to
sphingomyelin ratio greater than 2 in the amniotic fluid is an indication that fetal lung maturity has been
achieved.
How are infants who are large for gestational age (LGA) defined?
Infants with excessive fetal growth are defined as large for gestational age (LGA) or macrosomic. Their
weight is above the 90th percentile, which usually corresponds to a birth weight greater than 4000 g.
Neonatal complications include increased birth traumas, such as shoulder dystocia, brachial nerve palsy,
and perinatal asphyxia.
A diabetic mother gives birth to her LGA daughter. What blood test is important in the management of
this newborn and why?
Plasma glucose levels by means of dextrose stick should be obtained to check for hypoglycemia. This is
because the baby may have been exposed to high glucose levels in utero, which results in increased
insulin production by the pancreatic beta-cells. At birth, after the cord clamping, glucose levels drop but
the insulin levels remain high, causing hypoglycemia.
Impaired swallowing in the fetus causes what condition that can lead to premature labor?
Impaired swallowing of a fetus may lead to polyhydramnios, which is an excessive amount of amniotic
fluid over 2 L.
A fetus has bilateral renal agenesis. What additional deformities would you expect in this patient?
Bilateral renal agenesis causes oligohydramnios resulting in Potter sequence. Decreased amniotic fluid
causes compression of the fetus by the uterine wall resulting in features such as club feet, compressed
facial features, and pulmonary hypoplasia.
What are other common causes of oligohydramnios?
Other causes include post-maturity, intrauterine growth retardation, amniotic fluid leak, twin-to-twin
 transfusion syndrome, uteroplacental insufficiency, placental abruption, maternal preeclampsia, and
idiopathic causes.

INFECTIONS

What pathogens are the most common causes of congenital infections?

Toxoplasmosis, Treponema pallidum (syphilis)
Others, including hepatitis B, Epstein-Barr virus (EBV), and Parvovirus B19
Rubella
Cytomegalovirus (CMV)
Herpes, HIV
A baby is born with microcephaly and chorioretinitis. Soon after birth she has a seizure. CT scan shows
intracranial calcifications and hydrocephalus. What anticipatory guidance should have been given to
the mother during pregnancy to avoid this infection?
This baby likely has toxoplasmosis. Pregnant women should avoid changing kitty litter as cat feces may
be a source of exposure to the toxoplasma oocysts of this protozoal parasite. These mothers are often
asymptomatic during the initial infection.
What is the recommended treatment for a baby with stable or rising antibodies to toxoplasmosis?
Treatment consists of a synergistic combination of sulfadiazine and pyrimethamine. If a baby has falling
levels of IgG antibodies to toxoplasmosis during the first year of life, this likely represents the mother’s
transplacental antibodies rather than a congenital infection.
A newborn whose mother did not undergo prenatal testing develops a fever, maculopapular rash on the
chest, palms and soles, rhinitis, and hepatos-plenomegaly. The nasal secretions are placed under
darkfield microscopy and T pallidum is visualized. What is the next step in treatment?
This patient has syphilis and should be treated with IV penicillin G for 10 days. In addition, the mother
should be treated as the infection is most likely transmitted transplacentally.
What is the adequate treatment of syphilis in pregnancy?
Pregnant women with early acquired syphilis should receive two doses of penicillin G benzathine given 1
week apart.
In addition to a rapid plasma reagin (RPR) or Veneral Disease Research Laboratory (VDRL) and a
confirmatory fluorescent treponemal antibody absorption test (FTA-ABS), what additional tests are
typically performed on babies with suspected congenital syphilis?
Long bone radiographs should be obtained to rule out osteochondritis, in addition to a complete blood
cell and platelet count, chest radiograph, and liver function tests.
A baby is born with cataracts, sensorineural hearing loss, a patent ductus arteriosus (PDA),
meningoencephalitis, microcephaly, and mental retardation. The baby has a +IgM rubella antibody in
his blood. At what stage of pregnancy did this child acquire this congenital infection?
A first trimester infection of rubella often results in neurological impairments as well as visual, auditory,
and cardiac defects.
What are the clinical manifestations in an infant with a congenital rubella infection?
A baby with congenital rubella can present with classic “blueberry muffin spots,” liver dysfunction, bone
disease, and growth retardation. Congenital rubella has decreased dramatically in incidence due to
widespread use of the vaccine.
How does the syndrome of CMV infection compare to that of toxoplasmosis?
Both congenital infections cause similar lesions, including chorioretinitis, intrauterine growth retardation,
liver dysfunction, microcephaly, and intracerebral calcifications. On CT scans, the intracranial
calcifications of CMV are located periventricularly, while in toxoplasmosis, they are found in the basal
ganglia or in other locations in the brain. (Mnemonic: CMV calcifications circle the ventricles, Toxo
 calcifications traverse the cortex)
A neonate with suspected CMV is placed in isolation. If protective gowns and gloves are worn, is it
acceptable for a pregnant resident to care for the baby?
Babies with congenital CMV continue to shed the virus after birth, so despite the protective measures,
pregnant nurses, doctors, and other health care workers should not be exposed to this patient.
Is herpes simplex virus (HSV) typically transmitted congenitally or perinatally?
HSV is usually transmitted as the baby is exposed to active lesions during vaginal delivery. Therefore,
perinatal transmission is most common. It is important to remember that lesions may not be visible at
birth for the virus to be transmitted.
A mother who is 34 weeks pregnant states that she has had genital herpes in the past but on
examination you see no genital lesions. How should she be managed for the rest of her pregnancy?
Given her history of herpes, she should take oral acyclovir/valacyclovir during the last 4 weeks of
gestation to prevent the recurrence of genital lesions and hence the need for cesarean delivery. If there are
genital lesions at the time of delivery she should deliver via cesarean, otherwise she may deliver
vaginally.
An infant of a mother with active genital herpes is delivered via cesarean section. Is the infant’s risk of
perinatal HSV completely eliminated?
A mother with active genital herpes should always deliver via cesarean section. This infant’s risk of HSV
infection is reduced but not completely eliminated by cesarean delivery.
A 2-week-old newborn develops chorioretinitis, conjunctivitis, and vesicular lesions on the mouth and
skin. The mother had some new vaginal lesions prior to delivery. Should treatment be delayed until the
results of the laboratory tests come back?
No. This baby should be treated empirically with acyclovir as he or she likely has skin, eye, and mouth
(SEM) disease of HSV. Treatment should start immediately as this baby is at risk for HSV meningitis or
disseminated HSV.
How do patients with HSV meningitis typically present?
These patients often present with classic symptoms of meningitis including fever, irritability, lethargy,
and poor feeding. Additional symptoms seen in HSV meningitis include focal or generalized seizures;
subsequent disseminated disease causes liver dysfunction and disseminated intravascular coagulation
(DIC).
A mother develops chicken pox 3 days prior to the birth of her baby. What is the appropriate treatment
for a baby that does not show signs of infection?
This baby should receive varicella-zoster immune globulin (VZIg) at birth. Any infant whose mother
develops varicella 5 days prior to birth to 2 days after birth should receive VZIg within 4 days of life.
A baby is born with many cutaneous scars and central nervous system (CNS) abnormalities as well as
limb hypoplasia and growth retardation. Congenital varicella is the suspected culprit. Should this baby
be placed in isolation after birth?
No. This congenital infection likely occurred in the first trimester of pregnancy, so the baby is no longer
actively shedding varicella-zoster virus.
A 6-month-old infant born to a known drug user presents to clinic with persistent thrush. She has
frequent diarrhea, multiple infections, failure to thrive, and has not hit her developmental milestones.
She subsequently tests positive for HIV. How could this illness have been prevented?
Vertical transmission of HIV from mother to child is decreased by treating the mother with antiretroviral
medications in the third trimester, performing a C-section, avoiding breastfeeding, and treating the baby
with antiretroviral medications.
What treatment regimen is appropriate for a patient with congenital HIV?
These patients should receive multidrug antiretroviral therapy, trimethoprimsulfamethoxazole for
Pneumocystic carinii pneumonia (PCP) prophylaxis, as well as nutritional supplementation and treatment
for frequent bacterial and viral infections.
Why is erythromycin ophthalmic ointment given to neonates after birth?
This ointment is used primarily as prophylaxis to prevent ocular gonorrhea infection in neonates.