 dysmature baby:small at birth in ralation to duration of pregnancyis likly to be

smaller in later years.

 critical period in physical growth after which even normal diet will not restore the
child to average size.
 breast feed baby are more likly to suffer from underfeeding
 most common cause of underfeeding is fear of overfeeding
 overfeeding of young full term baby is virtualy impossible
 overfeeding a prematurebaby causes vomiting and loss of weight
 always be skeptic about the mother,account of dietry history
 excessve crying causes defective weight gainbecause of use of energyand loss of
fluids through lungs
 poor appetite in a well child is always due to food forcing
 in most cases of cystic fibrosis and celiac disease mother has not noticed anything
unusual
 donot suspect cystic fibrosis when a child develops a cough when he has cold
 suspect CF when there is bronchectasis,persistant radiological abnormality
unexplained generalized edema or prolapse of rectum
 you can not diagnose CF by inspecting stool
 giardiasis and salmonella cause fat malabsoption e.g neomycin
 tuberculous abdomen may cause steatorrhea
 congenital lactose intolerance starts as soon as breast feeding is initiated
 in fructosemia symptoms start after breast feeding is over
 fits with eating sugar=fructosemia
 in glactosemia benedict is positive but clinitest is not
 acidic stool=diasaccharidase deficiency
 one of presentation of hirshsprung disease is severe diarrhea and vomiting
 polyuria+constipation=RTA or idiopathic hypercalcemia or diabetes nsipidus
 acidic blood+alkaline=RTA
 hypospadias may be one of the presentation of CAH in boys
 children with asthma are small in height and below average weight
 acute infection even if recurrent don not cause defective weight gain
 in hypopitutrism thethe preprations are normal while in hypothyroidism they can not
 cushing disease is rare in paediatrics
 in babies weight should be recorded in relation to feeds
 well child +emaciated looks+appearence of weightloss=lipodystrophy
 any disease that causes persistant vomiting or persistatant diarrhea causes loss of
weight
 in weight loss never forget two tests:urine D/R with culture and mountoux
 normal temprature variations are frequently treated as infection
 a high ESR inthe face of fever mean that disease is present.A normal ESR makes its
unlikly
 dehydration fever of newborn is sudden rise of temprature a day after two after
birth,TX is increased fluid intake
 nephrogenic diabetes insipidus ,ectodermal dysplasia and idiopathic hypercalcemia
have high fever
 the most important common cause of fever in a child without abnormal physical sign
 is UTI
 roseola infantum:rash appears when fever subsides
 joint effusion+petechae=
 closed off abcesses e.g sub phrenic,perinephric abcess,pulmonary,brain
cause,prolonged fever
 prolonged fever+sign of infection=ascites
 corticosteroidscan lead to apical tooth infection
 amoebic liver abcess should be considered in PUO
 contineous or intermittent fever may last for monthsbefore a diagnosis of rheumatoid
arthritis is made
 many children with celiac disease donot respind to gluten free diet untill lactose and
sucrose are also excluded
 the initial symptoms of celiac disease is vomiting
 appetite in celiac is poor but cystic fibrosis has good appetite
 it takes 8weeks of gluten free diet before improvement is noted
 low grade anemia is an important organic cause of lack of energy and easy
fatigibility
 chronic UTI is common cause of fatigue and vague unwellness
 persistant hemolytic streptococcal infection may result in tiredness and lack of
energy.
 always look for an in completly resolved pneumonia in a child with tiredness
 a useful nonspecific test for fatigue in ESR
 overclothing is the most common cause of excessive sweating
 excessive sweating around the head=rickets
 unexplained attacks of excessive sweating not associated with
faining=hypoglycemia,pheochromocytoma and neuroblastoma
 pulmonary TB is unlikly cause of night sweats.
 the most important causes of splenic enlargement are infection and anemia
 infant and young children,splenic enlargement of slight degree is caused by very
many infection
 as the child grows older nfections are less likly to cause enlargement of
spleen,though they are a common cause
 in infective hepatitis enlargement of spleen is invariable
 spleen is almost always palpable in typhoid fever
 in infant slight enlargement of spleen and liver is common in upper respiratory tract
infection
 severe nutritional anemia can result in spleen enlargement
 in purpura if you can feel the spleen its not ITP or HSP
 in heartfailure,sometimes the spleen can be felt
 the most commom cause of lymhnode enlargement is infection
 bcg vaccination may give rise to axillary lymphnode enlagement
 almost all persons have palpable inguinal lymphnodes if they are realy enlarged
examine perianal area
 in new born baby,the usual cause of anemia is Rh-incompatibility
 dysnea on exertion is not a commom symptom except in asthmatic children and those
with congenital heart disease
 severe progressive dysnea occurs in cystic fibrosis
 pulmonary stenosis(with or withoutTOF) is the common cause of chronic
breathlessnessin the first 3-4 yrs of life
 proxyxmal tachypnea usualy masquerdes as bronchopneumonia on account of rapid
breathng and cough due to heart failure.missed in infants especialy in neonates
 diplopia should lead to CNS examination for SOL and fundal examination for
papilledema
 iridocyclitis causes diplopia
 mentaly retarded child is mistaken for blind for not taking interest in objects
 optic disc of normal babies is pale and mistaken as optic atrophy
 if squint is not corrected by the age of 9-12 months ,the child will suppress the
squinting eye and become blind in it
 by for the commenest cause of nystagmus in an nfant is defect of vision such as optic
atrophy
 phenytoin,phenobarbitone and primidron can cause nystagmus
 when you diagnose sub dural hematoma,look for large retinal haemorrhages
 some degree of strasbismus is normal before the age og 6months
 epicanthic fold causes pseudostrasbismus
 concomitant squintdoes not have diplopia(non paralytic)
 the rapid development of squint should alert for cerebral tumor
 the most common cause of proptosis in children is craniosynostosis
 neuroblastoma is the most common tumor causingroptosis 2nd is ostema
 orbital cellulitis is confused with cavernous sinus thrombosis clues for the later are
toxic child,rigors and fever
 myopia in childhood is associated with prematurity and eclampsia
 most common causes of ear pain are otitis media or a boil in meatus.2nd is reffered
pain.
 patient with athetoid cp are more likly to be deaf then spastic CP
 deafness syndromes
alport
wardenberg
pendred
treacher collin
klippel feil syndrome
retinitis pigmentosa
 meningitis and recurrent otitis media cause deafness
 cleft children patients may develop deafness in later years
 tinnitis in children is usualy psychological
 vertigo occurs in all anemic children
 in every case of ataxia fundus should be examined to rule out cerebral tumor or
abcess
 clumsiness +poor writting+emotional disturbance = early chorea
 moro and startle reflex are excessive in babies suffering from cerebral in stability
 first few weeks+sudden jerky movements resembling startle+sleep=normal
 if awake is convulsion
 in newborn jittery movements of limbs=tetany,hypoglycemia,IDDM
 jaw trembling is normal in young infants
 there is no carpopedal spasm in tetany among infants
 in hemiplegic child there is twitching of affected limb
 tics when complex can be confused with chorea,in tics same movements is repeated
again and again while in chorea any movement can occur
 tremors of hands is common in children especialy mentaly retarded one
 athetoid movements become obvious around 4years of age however tongue
protrusion appears in early months
 spasmus nutons seen 3-24month rhythmic jerking of neck,stoping when child
concentrates n an object,disappear by age 4
 parkinsonian movements results from encephalitis
 fits occur in 50% of children with spastic hemiplegia,40%in spastic quadriplegia,but
only 15% in spastic diplegia and 10% in athetoid CP
 convulsions are not due to teething
 cynotic attack is usually a convulsion in newborn
 cerebral haemmorhage in full term occurs on 3rd day of life
 sudden warming of cold child can result in convulsions due to hypoglycemia
 physiological hypocalcemia can occur on 3-5days of life
 loss of appetite in newborn is sepsis donot miss the sticky umblicus
 simple febrile convulsions can occur with in 12hours of onset of fever
 in breathholding attacks the child become blue,then has a fit.in epilepsy the child has
fit then become blue
 all small children bump their head that result in small subdural effusion this is not
child abuse
 tetany due torickets occurs especialy between the ages of 4months and 3 years
 tetany in resistant rickets is rare
 sickle cell anemia may cause convulsion during crises
 the most cause of fits after 2nd year of life is epilepsy
 there is no sleepiness after abscence seizures
 there is no color change in infantile spasm
 a sudden headache or abdominal pain lasting for few minutes and followed by sleep
could be epilepsy
 fit resemble a faint in GTC not absence
 a fit may take months or years to develop after head trauma,cerebral abcess and
subdural effusion
 remember AGN when evaluating for fits
 the lower eyelid should be examined for petechae in meningococcemia
 facial palsy in newborn disapears after a few days
 polio should always be considered in facial nerve palsy
 facial weakness may occur after a fit(todd)
 facial palsy may occur in 20% of hypertensive patients(haemorrhage into facial
canal)
 congenital muscular dystrophy resembles in SMA type 1(except tongue
fasciculation)
 the child with SMA type 1 cry feebly when foot is pricked but a child with injury of
cranial cord does not
 in atoni CP reflexes are exacerbated ,ankle clonus and plantars are present
 the commonest cause of increase muscle tone(persistant) is spastic CP
 donot confuse erb's palsy with spastic hemiplegia
 the most important cause of weakness of limbs in infancy is meningiomylocele
 todd's paralysis may last from few hours to few days
 transient synovitis of hip 18mo-7years,follow URTI lasts for 13 days
 both severe spasticity and severe hypotonia can predispose to DDH
 scurvey causes acute limb pain in infancy
 strains are the most important cause of joint pain
 hip joint is never involved in rheumatic fever
 a well child with arthritis does not have rheumatic fever
 a normal ESR rules out rheumatic fever
 a raised sleeping pulse eate is arthritis
 1 in 2 of all children have innocent murmur
 febrile aches and pains are often labled RF
 morning stiffness is JIA not RF
 neck and small joints are involved in JIA not in RF
 longer duration of joint involvement is JIA not RF
 iridocyclitis is JIA not RF
 under 5 and especialy under 3 ,RF is rare
 limb wasting is less in soastic hemiplegiz than polio
 true microcephaly is sloping forehead
 the obvious cause of crying in an infant is hunger and most likly cause of hunger is
fear of over feeding
 sudden loud noise,wet diaper,extreme heat and cold can make the infant cry
 crying when passing urine is normal till 6 months
 crying after weaning is food????
 unwell crying baby is due to infection or intestinal obstruction.examine the hernial
orifices and remember intussusption
 celiac and PKU patients cry excessivly
 crying of newonsetshould alert one to chorea
 high pitched shrill cry
meningitis
kernicterus
hydrocephalus
 hoarse cry-hypothyroidism
 hoarsness+stridor =vocal cord paralysis,web,papilloma
 SMA-weak cry
 grunting cry-pneumonia
 half of population has IQ <100
 an infant may be retarded in all aspects of development,yet prove to be normal later--
except when there is microcphaly
 prfering toys to persons is autism
 blind child smiles late
 beningn congenital myotonia walk at 5-6 years of age
 DDH does not cause delayed walking
 constant dribbling incontinence,look for PUV,bladder obstruction in boys and ectopic
ureter in girls
 deafness causing delayed speech is high tone deafness
 severe hypoglycemia can cause irriversible mental deficiency
 young babies and mentaly subnormal children may not show thirst and become
dehydrated
 discomfort on micturation is not always UTI,meatal ulcer,balanitis in boys and
soreness of vulval region in girls
 discomfort on micturation is an exception rather than a rule in UTI
 UTI can cause febrile convulsion
 chronic UTI has only poor appetite and lack of energy
 frequency is not a symptom of UTI
 frequency may occur in any polyuria
 AGN is the commonest cause of hematuria
 raised ESR indicates nephritis when BP and urea normal
 fross hematuria is un usual in pylonephritis
 renal vein thrombosis occur in first few months of life
 blood at the end of micturTion;meatal ulcer in boys and urethral carbuncles in girls
 any acute infection can cause albuminuria
 albuminuria is not constant in pyelonephritis
 well child+ facial edema only= angioedema
 ill child with facial edema=sinusitis,boils,dental abcess,orbital cellulitis
 newborn with edema leg=turner syndrome
 sternal edema at the onset of mumps
 infant with edema + no albumin=cystic fibrosis
 protein losing enteropathy does not have diarrhea
 facial edema in nephrotic syndrome may be asymetrical due ro posture
 undiluted cow's milk causes edema due to excessive minerals
 constitutional precocious puberty in girls is tall and march of event is same
 islolated thelarche,menarche,pubarche-----average for age
 the commonest adrenocortical tumor is cercinoma
 ovarian tumor causes more vaginal bleeding wth minimal breast changes and pubic
hair
 precocios puberty in girls is constitutional,in boys organic
 if penis fully developed and testespost pubertal,thecause is intracranial
 if penis fully developed but testes prepubertal,the cause is adrenal
 commonest cause of delayed puberty in girls is familial
 no secondary sexual characteristic+dysmorphism+dwarf girl=turner syndrome
 no secondary sexual characteristics+long arms and legs+normal body
proportions=pituatry dwarfism
 normal secondary sexual characteristics+no menstruation=absence of
vagina,uterus,hematocolpos
 the commonest cause of delayed puberty in boys isnconstitutional
 thin boys-late puberty
 obese boys-early pubery
 small testes+normal penis+no family hx=klinfelter syndrome
 vaginal bleeding is common between the age of 5-10days of life
 vaginal discharge in 1st few days of life is normal
 after infancy clear mucoid discharge is normal should be ignored until purulent
 oral thrush+vaginal discharge=vaginal candidiasis
 the most important feature precipitating thrush is previous antibiotic
 regular menstral cycle is established after 40 periods before that 6 month interval
may occur
 tongue tie doesnot cause delayed speech
 cow milk contains 4 times more calcium than breast milk
 there is no harm in keeping baby off the breast for 12-24 hrs if mother is tired
 if baby stops cryning when picked up he is not hungry
 ill and premature babies should be fed on rigid schedule since they donot demand
 most babies obtain nearly all the milk in first 8minutes of breast feeding
 weaning is normaly completed by 9 months
 most effective feed is in the morning
 rumination occurs after 3 months
 true constipation in breast fed babies is due to underfeeding
 rickets and cretinism can cause constipation
 gastroentritis is practicaly confined to artificialy fed babies
 fresh cow milk should be boiled till 6 month of age
 evaporated milk should be stored in refrigerator
 true constipation in bottle fed babies is due to underfeeding/overclothing
 underfeeding arises from feeding the baby by actual weight rather than expected
weight
 no baby should have bottle after 12 months of age
 larger child matures early and small child late,eventualy both are equal.
 head of premature baby and malnourished child appear larger for the body
 normaly headcircumfernce is greater than chest circumference till 6 months of age
 unusualy small or large head is usualy nothing but a familial feature
 larger babies have larger head and small babies have smaller head
 effect of moulding disappear after 2-3days,there after HC is reliable
 the microcephalic head tapes towards the vertex and has sloping forehead
 plagiocephaly corrects itself shortly after 1st birthday
 anterior fontanelle is small at birth and enlarges considerably during the 1st 2 months
after that it decreases
 early closure of anterior fontanelle (4-5month) may be on entirely normal variation
 posterior fontanelle is closed by 2 months to population
 sunset sign is seen in normal infants,sonnot enough to diagnose hydrocephalus
 caput succedenus disapear by 2-3 days(exudation of serous fluids)
 cephalhematima:should not be diagnosed as depressed fracture.does not occur in
premature,subsides 3-4 wks.very large may take 3 months
 occipital cephalhematoma has to be differentiated from occipital encephalocele
 craniotabes may be normal in first born in vertex presentation
 as a milestone of development,teething is useless
 teething produces nothing but teeth
 the premature loss of decidous teeth due to caries is major cause of malodor
 alveolar frenulum is treated at 11 years or later
 tongue tie should be treated at 2-3 years of age uf child is unable to lick his upperlip
and there is midline depression
 uniformed white tongue is normal in newborn unlike the discrete areas of candida
 black tongue is normal and due to overgrowth of tongue papillae
 geographic tongue :small round grey areas.....related to seborrhic dermatitis
 tonsils are quite large by 3-4 years of age become smaller by 7 years.no operation
 adenoids should beremoved as soon as they cause symptoms
 halitosis:well child -> FB,ill child-->tonsillitis,diphtheria
 chronic halitosis:bronchectasis,pulmonary abcess,atrophic rhinitis
 mentaly normal child control their saliva by 15 months
 sucking pads are normal in first few weeks of life
 epithelial pearls and epstein pearls are normal
 ammonical dermatitis spares the creases.rx......zinc oxide
 spider nevai are common in older children and disappear
 mongolian spots disappear in 2-3years
 the falling of hair in newborn after 2-3 wks is normal
 umblical cord usualy separates by 5-9days
 93% umblical hernia correct themselves by 1st year,the rest by 5years of age,its a
non-surgical condition
 diversecation of recti cures itself when child grows older
 congenital dermal sinus: operate if above the natal cleft.those in the natal cleft are
operated if deep
 breast of babies of both genders enlarges after 2-3 days after birth(not in premature)
 99% of full term babies and 50% of premature secretes milkon 2nd,3rd and 4th day
of life,continues till 3rd month of life
 enlargement of external genitalia is equaly common in both genders in the neonatal
period ,subsides in 1 month.
 erection of penis is seen in babies with cold hands
 the commonest cause of undescended testis is cold hands
 complete undescended may be klinfelter,testicular dysgenesis,pituitry dwarphism and
pseudohermaphrodism
















facts about puberty
 gynaecomastia occurs in 50% of boys between 10-
16 years,resolves in 3 years
 girls have adult looking breasts in SMR 3&5
 SMR 2-5 lasts about 3-5 yeas in both sexes
 menarche in SMR 3 or 4 pr within 2years of onset
of puberty
 investigate amenorrhea only after 2 years og
completion of puberty
 when menses start girls are at 2.5-5cm of adult
height
 early puberty =short adult height
 girls are TAMER than boys
T=thelarche
A=adrenarche
MER=menarchi
 boys "TAP HER"
T=testicular enlargement
A=adrenarche
P=penile enlargement
HER=height
 estrogen causes breast enlargement
 adrogen causes pubic hair growth
 girls with breast development and no pubic
hair=testicular feminization
 girls with pubic hairand breast
 development=increase androgen and decrease
estrogen
 girls with no breast development and no pubic hair
and no menarche=turner syndrome
 breast masses in girls are mostly benign
 ultrasound is the only test used for evaluation.no
mamography,no excision and biopsy required.
 fibrocystic disease:most
common,bilateral,tender...OCP
 fibroadenoma:unilateral,refer if persists beyond 3
cycles
 in precocious puberty,rule out testicular and
ovarian tumors by palpation,ultrasound and serum
LH and FSH level
 premature adrenarche is common in girls and
brought earlier to notice.
 CAH more likely than adrenal tumors
 premature thelarche:<8years unilateral or
bilateral.growth normal,reassure its benign
 delayed puberty is more common in girls
 prolactinomas should be in differential of every
patient with delayed puberty
 CDGP:bone age <chronological age,bone age =
HT age.
 hypogonadotrophic ovarian failure ,consider poor
nutrition or eating disorder
 kalman syndrome:all midline
structures,nose,pitting,penis,optic
 chiasma,hypogonadotrophic
hypogonadism+anosmia
 hypergonadotrophic ovarian failure =turner
syndrome
 2 year delay between bone age and chronological
age is normal
 familial short stature:birth lenghth normal,bone
age=chronological age ,proportionate HT and wt
 if child parents were malnourished,then mid
parental Ht is of no use in familial short stature
 short stature+micropenis+hypoglycemic fits=GH
defiency
 congenital GH deficiency=wt>Ht+delayed bone
age+short stature(decelarated growth rate)
 acquired GH deficiency=normal bone age
 if there is one pituitry hormone deficiency search
for others(FLAT PIG)
 short+overweight+delayed bone
age+constipation+dry skin=hypothyroidism
 CAH:precocious puberty+accelerated
growth+addison like picture
 nutritional short stature:bone age=chronological
age,HT<wt,
 gynaecomastia+small testis+lomgarms and
legs=klinfelter syndrome
 if with supirior sublaxation of lens its marfan
syndrome
 arm span > height=marfan syndrome
 overweight+tall+advanced bone age=simple
obesity
 overweight+short+delayed bone age=endocrine
cause
 obesity is risk for SCFE.
 if patient is tall ,its not cushing
 microcephaly+dysmorphism=chromosomal
abnormality
 HC+HT spared+wt falls off=caloric insufficiency
 quick drop in weight +no drop in height consider
workup for celiac and other malabsorption
syndrome,renal or metabolic disorder
 ht+ wt falling+ hc spared=endocrine cause
 primary craniosynostosis=normal benign imaging
 secondary craniosyostosis=abnormal brain
imaging
 ammanorrhea:rule out pregnancy,anatomic
obstruction and malformation
 LH-progesterone,FSH,estrogen,breast
 hypothyroidism causes increases prolactin level
 14-15+no breast+no menses=work up
 16-17 yrs+breast development+no menses=workup
 workup means:first Hcg then LH,FSH,TSH,PRL
 if signs of androgenization add
testosterone+DHEA
 delayed puberty+dec LH+dec FSH+inc
exercise=exercise induced amenorrhea
 breast development+no hair growth+no
 menses=testicular faminization syndrome
 low HR+hypothyroidism+orthostatic
hypotension+no menses=anorexia nervosa
 acne+no menses+hirsutism+insulin
resistance+LH:FSH ratio>2= polycystic ovarian
syndrome
 mood disorder+somatic component 5days before
menstruation=premenstrual syndrome
 dysmenorrhea does not have mood disorder
 the younger the patient severe the depression
 marijuanna can cause galactorrhea
 dont do pap smearin STD and menses because it
will give false +ve result
 most common STD is HPV
 when using anabolic steroids girls look and sound
like boys and vice versa
 prolong QT and ST depression in anorexia
 refeeding syndrome: enamel erosion+irregular
menses+hypokalemic hypochromic metabolic
alkalosis+inc amylase with fits,delirium+dec
Mg+dec Po4+rhabdomyolysis
 any painless testicular mass is cancer untill proved
otherwise
 hydroceles are painless,consider surgery after 1
year
 spermatocele are painless and don't change with
position
 varicocele are painless
 inguinal hernia are painful and changes with
position
 cremasteric reflex absent+pain on elevation of
testis is testicular torsion
 blue dot sign+painful=torsion of appendicular
testis
 dysuria+frequency+fever+no discharge+unilateral
pain=epididymitis
 unilateral pain+faver+no discharge+no
discharge+no dysuria=orchitis
 orchitis+testicular atrophy=cancer risk
 orchitis+bilateral pain=infertility
 age<3years+phimosis=balanitis
 in TSH normal,no problem with thyroid,best
screen
 babies normal at birth because thyroxin crosses the
placenta
 inc TSH+ dec T4+painless firm
goiter+antithyroglobulins=hashimotothyroiditis
 if thyroxin not started till 4 wks then congenital
delay
 thyroid nodules in kids are usualy malignant
 radioactive iodine uptake is high in Graves and
low in hashimoto
 PTU should not be the first line agent because of
toxicity
 hyperactivity+disorganized thinking+trouble
sleeping=hyperthyroidism
 neonatal thyrotoxicosis occurs in <10% of babies
of Graves disease mother
 inborn error of metabolism symptoms doesnot
occur in immediateneonatal period but symptoms
of graves do
 polyuria+short QT=hypercalcemia
 BONES+STONES+ABDOMINAL
GROONS+PSYCHIATRIC
MOONS=HYPERPARATHYROIDISM
 hypocalcemic seizures donot respond to
benzodiazapines
 the most common human renal stones are calcium
oxalate stones
 acidosis+ca oxalate crystals in urine=ethylene
glycol poisoning
 vit D deficiency risk groups
breast fed with no supplementation of vitD
breast fed with ni exposure to light
malabsorption
antiepileptic drugs
 there is no single lab patteren for rickets
 normal calcium+low Po4+normal25-OH
vitD3+normal PTH=familial hypophisphatemic
rickets
 low calcium+low Po4+inc PTH=severe vit D
deficiency
 low ca+normal Po4=healing stage of deficiency
rickets
 low ca+inc Po4+low PTH=hypoparathyroidism/
phosphorus overload/ pseudohypoparathyroidism
 normal ca +inc Po4=renal disease/GH excess
 treat with all 3(vit D,Po4,ca) when dealing with
rickets of prematurity
 cushing disease=central cause
 cushing syndrome=peripheral cause
 cushing is never tall
 tall+obese+stretch marks=high caloric intake
 patient with addison may have elevated ADHthey
should not be diagnosed as SIADH
 vomiting+dec Na+inc K=addison disease
 secondary adrenal insufficiencyhas normal K and
Na,has midline defects
 maintaince therapy for adrenal insufficiency
doesnot include fludrocortisone
 if 17-OH progesterne level raisedbut physical
examination normal,then repeat 17-OH
progesterone
 if family hx +ve for CAH,get gene testing done on
fetal cells
 boys with CAH often do not present at birth,so
screening is important
 late CAH can present with precocious puberty
 if parents carrier,oral dexamethasone should be
given until sex of baby is determined,if male stop
tx and if female continue
 ambigious genitalia+hypertension+normal
 sodium=11 hydroxylase deficiency(non-salt
wasting type)
 ambigius
genitalia+hypertension+hypokalemia+metabolic
alkalosis=17-OH deficiency
 micropenis: <2cm testes present
hypopitutrism
GH deficiency
kallman syndrome
prader willinsyndrome
 maternal aunt sterile then its testicular feminization
 no female internal structures present in testicular
feminization
 no hair,no menses,normal breasts=testicular
feminization
 normal penis/testis+rudimentry uterusand fallopian
tubes=MIH deficiency
 ovarian failure is indicated by high FSH,top 2
reasons are turner and autoimmune
 klinfelter have low upper to lower segment ratio
and low IQ
 HBA1C of 8 in kids is acceptable in paediatrics
>in bad
 DKA has pseudohyponatremia
 acanthosis nigricans is nit part of definition of
metabolic syndrome
 low HDL,high triglycerides+normal
glucose=acanthosis nigricans
 central obesity+inc BD+low HDL+high
triglyceride+FBS>100=metabolic syndrome
 gestational diabetes is not associated with
congenital abnormality
 a baby born to GBS +ve mother should be watched
in hospital for 48 hrs
 AFP is raised in conditions causing broken skin
 CVS should not be done for neural tube defects
 amniocentesis can identify neural tube defects via
raised AFP
 Quadraple screen:dec AFP,dec estriol,inc HCG,inc
inhibin
 for women trying to concieve 4mg of folic acid,if
not 0.4mg/day
 adolescent patient+arthritis+smelly greenish
discharge=gonorrhea
 pegged teeth are found in congenital syphilis and
incontinentia pigmenti
 consider lyme disease if FTA positive but VDRL
negative
 tzank smear is not specific for HSV ,do PCR
 treat vaginal adhesions only if causing dysuria
with estrogen ointment
 food allergies occur within 2 hes after exposure
 abdominal pain may be only sign of anaphylaxis in
food allergies
 allergies to eggs ,milk,soya will be outgrown by 5
years of age.
 breast milk or hypoallergenic formula may delay
the onsetof eczema
 treat milk allergy with casein hydrolysate formula
not soya
 protein induced enterocolitis resolves once GI tract
matures
 best test for protein enterocolitis is flexible
sigmoidoscopy
 protein enterocolitis is bloody and treated with
hydrolysate formula or aminoacid formula
 lactose intolerance is a disease of <5 years
 hydrogen breath test is for lactose deficiency and
bacterial overgrowth
 soya milk is the treatment for lactose intolerance ,it
contains sucrose instead lactose
 causes of seizures in TBM
raised ICP
electrolyte imbalance
infarction
febrile convulsion
tuberculoma
vasculitis
SIADH
INH therapy
 causes of hemiplegia in TBM
vasculitis
basal exudatesin sylvian fissure entraping MCA
lacunar infarcts in internal capsule
 calcification
tuberculoma
edema
 MDR TB suspect
a) any patient who fails a category 1 or III treatment
regimen
b) any category II patient who is sputum smear
positive at the end of 4 months of treatment or later
c)confirmed MDR TB cases
any MDR TB suspect who is sputum culture +ve
and whose mycobacterium that is resistant in vitro to
atleast INH and rifampicin with or without anti-TB
drugs
 XDR-TB
tb resistant to any fluroquinolones and atleast one
of injectable second line
drugs(kanamycin,amikacin,capreomycin)in addition
to MDR-TB
CATEGROY IV REGIMEN
 ethambutol,cycloserine,afloxacin,ethionamide,PZ
A
 continuation phase:18months
ethambutol,cyclocyrine,afloxacin,ethionamide,
4 sputum are collected and examined by smear and
culture(30 days apart) from 3rd to 7th month of
therapy and 3 monthly after 9monthsonward till
complition of treatment
 if culture in last 3 quarter become positive,it is
 followed by monthly cultures in the following 3
months
 culture converted:2 consective negative cultures 1
month apart
 smear converted:2consective negative smears
atleast 1month apart
 Diagnostic critaria for congenital TB:infant must
have tuberculous lesion and atleast 1 of following
 lesion in the 1st week of life
 a primary hepatic comlx or hepatic caseating
granuloma
 tuberculous infection of placenta or maternal
genital tract
 exclusion of possibility of post natal transmission
 BABY BORN TO MOTHER WITH TB
breast feeding to be cntinued
BCG at birth
if chest X ray normal,then give 6HR
if chestX ray abnormalthen 2HRZ+4HR
congenital TB 2HR+7HR
 causes of negative mountoux in TB:
malnutrition,TBM,milliry TB
viral:measels,mumps,chicken pox
immunecompromised:HIV, malignancy,drugs
CRF,young infants,stress due to surgery,burns
 Causes of vomiting in TBM
drug induced hepatitis(hepatomegaly and elevated
liver transaminase)
inc ICP secondry to ICP associated with
spasticity,garbled speech,brisk deep tendon
reflexes,and papilledema on fundoscopy
 gastritis due to steroids associated with epigastric
pain
 metabolic decompensation due to carbonic
anhydrase inhibitor(due to metabolic acidosis)
 poor prognostic factor in TBM
age < 2years
malnutrition
HIV
altered sensorium/seizure
residual neurological deficit
inadequate treatment
domplication like hydrocephalus
 poor prognostic factors in APM
age <6month
10*6 CFU in CSF
coma
seizure upto 7days
 Tuberculous lymphadenitis
posterior triangle
supraclavicular
multiple and bilateral
constitutional symptoms
sinuses and fistula
contact history
chest X ray
mountoux positive
 atypical
submandibular
preauricular
solitary,unilateral
 PAPILLEDEMA
bilateral
vision normal
pain absent
venous pulsation absent
 optic neuritis
unilateral
decreased
pain present
absent???