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Newborn Physical Findings:

Slate blue, well demarcated areas of pigmentation over the buttocks and back Mongolian
Spots
Small, white occasionally vesiculopustular papules on an erythematous base develop after 1-3
days. Contains eosinophils Erythema Toxicum
Vesiculopustular eruption over a dark macular base around the chin, neck, back, and soles.
Contains neutrophils Pustular Melanosis
Cysts appearing on the hard palate which is composed of accumulations of epithelial cells
Epstein Pearls
Pearly white papules seen mostly on the chins and around the cheeks Milia
Open and closed comedones or inflammatory pustules and papules on the cheeks of the baby
usually after a week from delivery Neonatal Acne
Pink macular lesions on the glabella, upper eyelids, or nasolabial region Nevus Simplex
Hair that covers the skin of preterm infants. Seen on term infants around the shoulders
Lanugo
Thick, white creamy material usually absent in post-term infants Vernix Caseosa
Mottling of the skin with venous prominence, cobblestone, lacy appearance Cutis Marmorata

Respiratory Conditions
Finely granular lungs; ground glass appearance Hyaline Membrane Disease
Prominent pulmonary vascular markings; fluid lines in fissure Transient Tachypnea of the
Newborn
Bubbly lungs and cystic lucencies Bronchopulmonary Dysplasia
Coarse streaking granular patterns of both lung fields Meconium Aspiration Syndrome
Perihilar streaking Neonatal Pneumonia

Jaundice WITHIN 24 Hours


First-born child ABO Incompatibility
Second-born child Rh Incompatibility
History of prolonged second stage of labor Sepsis
History of maternal infection during pregnancy TORCH

Jaundice AFTER 24 Hours


2-3 days. Baby otherwise normal Physiologic
3-4 days. Mother supplements breastfeeding with sugar water Breastfeeding Jaundice
>1 week. Baby is purely breastfed Breastmilk Jaundice

Congenital Infections
An IUGR baby born to a mother with hx of infection during pregnancy:
Vesicular lesions on the face and mouth HSV-2
Purpuric hemorrhagic lesions all over the body (blueberry muffin) Rubella
Maculopapular rash, periostitis of the bone, snuffles Syphilis
Chorioretinitis, periventricular calcifications CMV
Chorioretinitis, microcephaly, hepatosplenomegaly, intracerebral calcifications Toxoplasmosis
Cutaneous scars, cortical atrophy Varicella

Micronutrient Deficiencies:
Vesiculobullous, eczematous, dry, scaly or psoriasiform lesions; symmetric perioral, acral and
perianal areas, chronic diarrhea, low ALP, stomatitis, glossitis, irritability, superinfection Zinc
(acrodermatitis enteropathica)
Generalized scaly dermatitis, alopecia, thrombocytopenia, failure to thrive Essential Fatty Acid
Edema, erythema and burning of sun-exposed skin on the face, neck, hand on butterfly
distribution dermatitis around the neck, diarrhea, dementia Niacin (Vit B3)
Alopecia with neurological symptoms Biotin
Follicular hyperkeratosis, xerosis and night blindness Vitamin A
Follicular hyperkeratosis, perifollicular erythema and hemorrhage; bleeding, swollen gums
Vitamin C
Bowlegs or knock knees, caput quadratum, periosteal osteoid, craniotabes, pingpong ball
sensation, rachitic rosary, pigeon chest, Harrison groove Vitamin D
White line on end of shafts, scorbutic rosary/beads Vitamin C
Pellagra, Casal necklace, pellagrous glove and boots, glove and boots lesion Vit B3
Perleche Vit B2/Zinc/Vit C
Bitot spots, xerosis conjunctivae, xerosis cornea Vitamin A
Hyperostosis, absence of metaphyseal changes, pseudotumor cerebri Vit A intoxication

Non-inflammatory Diarrhea
Presentation: Watery diarrhea, vomiting
Day care center, infants and toddlers Rotavirus, E. coli
Profuse diarrhea and vomiting, flecks of mucous and voluminous diarrhea Cholera
Profuse diarrhea after eating raw oysters or undercooked shellfish V. parahaemolyticus
Person-to-person spread, vomiting, winter bug Norwalk virus
Greasy stool after camping, gas G. lamblia
Watery diarrhea with vomiting after history of travel E. coli

Inflammatory Diarrhea/Dysentery
Presentation: Bloody diarrhea, pus and WBC in stools
Trophozoites with ingested RBCs Amoebiasis
Abdominal cramps, systemic toxicity after antibiotic use C. difficile
Abdominal cramps, tenesmus, abundant pus and WBC in stool Shigella
High fever, headache, drowsiness, confusion, meningismus, seizures and abdominal distention;
hx of eating eggs, poultry unpasteurized milk Salmonella typhi
Diarrhea with blood after eating hamburger, renal failure EHEC

Presentation: Abdominal cramps, diarrhea, sweating, no fever


Ham, potato salad, cream, pastry S. aureus
Reheated fried rice B. cereus
Home-canned food, muscle weakness, diplopia, blurring of vision C. botulinum
Patients Presenting with Obstruction
Presentation: Abdominal pain, vomiting, +/- distention
Cannot pass NG tube, severe pain and emesis, omega sign or coffee bean sign on AXR, inverted
U sign Volvulus
Bloody currant jelly stools, sausage-shaped RUQ mass, absence of bowel sounds on RLQ, coiled
spring sign Intussusception
Post-prandial vomiting, nonbilious, ab distention, Down syndrome, olive-shaped mass, barium
studies show shoulder sign, double tract sign Pyloric Stenosis
Normal hx or recurrent obstructive sx, painless rectal bleeding, intermittent pain; scintrigraphy
scan to detect gastric tissue Meckel diverticulum

Renal Conditions
Presentation: Hematuria, hypertension and signs of renal insufficiency
Hx of hemoptysis and severe respiratory distress Goodpasture
3 weeks ago with SVI, purpuric rash most prominent at the buttocks, pain in the joints HSP
Hx of vomiting, bloody diarrhea and fever, hx of eating hamburger, dehydrated,
hepatosplenomegaly HUS

Sudden onset of gross hematuria, febrile with URTI or GIT infection, normal C3 IgA
nephropathy
Sudden onset of gross hematuria, hx of strep throat or pyoderma, severely depressed C3
APSGN
Child discovered to have asymptomatic microscopic hematuria during yearly checkup at school;
wears very thick glasses and hearing aid. Child has uncles with the same condition Alport
syndrome

Steroid-Resistant, Frequent Relapser, or Steroid-Dependent?


Relapse within 28 days of stopping prednisone therapy Dependent
Patient who responds well to prednisone therapy but relapse 4 or more times in a 12-month
period Relapser
Children who fail to respond to prednisone therapy within 8 weeks Resistant
Relapse on alternate-day steroid therapy Dependent
Children who continue to have proteinuria (+2 or greater) after 8 weeks of steroid therapy
Resistant

Pathology Cross-over

Membranous Glomerulonephritis
LM: Diffuse thickening of glomerular capillary walls
IF: Granular IgG and C3
EM: Subepithelial deposits of electron-dense material
Spike and Dome appearance
Minimal Change Disease
LM: Normal
EM: Diffuse effacement of epithelial foot processes; no deposits

MPGN
LM: Large, hypercellular glomeruli
Increased mesangial matrix
Double contour or tramtrack appearance

FSGS
LM: Focal segmental sclerosis and hyalinosis
EM: Loss of foot processes, epithelial denudation

What is the most common hereditary bleeding disorder? vWF disease


What is the most common and most serious congenital coagulation factor deficiency?
Hemophilia A
What is the most common hereditary hypercoagulable d/o? Factor V Leiden
What is the hallmark of hemophilia? Prolonged bleeding
What is the earliest joint hemorrhage in children? Ankle

Oncology
Most common malignancy? ALL
Most common solid tumor? Brain tumors
Most common solid tumor outside CNS? Neuroblastoma
Most common soft tissue tumor? Rhabdomyosarcoma
Malignancy with highest mortality? Brain (PNET)

CNS Infections:
Prefrontal headache, high fever, disturbance in smell, swimming in warm water N. fowleri
Bell palsy, systemic disease, cutaneous lesions, carditis Borrelia
Ascending paralysis, hx of GIT infection, hx of respiratory infection C. jejuni
Lethargy and irritability, hx of viral infection, chicken pox, aspirin use Reye Syndrome
Ocular nerve palsies, previous hx of TB, active TB TB meningitis
Sepsis, seizure, irritability, lethargy, bulging of fontanelles, rigidity. Patient is <2 months old
GBS

Presentation: headache, fever, confusion, lethargy, nuchal rigidity, vomiting


No mention of proper vaccination, <5 y/o HiB
Properly vaccinated child, abrupt in onset, toxic-looking with rashes all over Meningococcus
Young adults Pneumococcus
Renal transplant Listeria
Gradual onset of s/sx, not toxic-looking -- Enterovirus
RBCs in the CSF examination HSV
Presentation: sore, scratchy throat, nasal obstruction and rhinorrhea
Prominent itching & sneezing, nasal eosinophilia Allergic Rhinitis
Unilateral foul-smelling d/c, bloody nasal secretion Foreign Body
Headache, facial pain, periorbital edema, rhinorrhea for >2 weeks Sinusitis
Persistent rhinorrhea w/ onset in the first 3 months of life (snuffles) Congenital Syphilis
Hx of prolonged use of topical or oral decongestant Rhinitis Medicamentosa
Paroxysms of cough, leaving the baby breathless, subconjunctival hemorrhages Whooping
Cough

Upper Airway Obstruction


Patchy infiltrates & ragged tracheal column Bacterial tracheitis Antibiotics
Thumb sign Epiglottitis Antibiotics
Subglottic narrowing, steeple sign Croup Racemic Epinephrine/Dexamethasone
Air trapping on the right lung with mediastinal shift towards the right lung Foreign body
Rigid Bronchoscopy

Presentation: Wheezing
Hx of viral infection among the family members. Patient is 2 y/o Bronchiolitis
Hx of atopy in the family. Recurrent wheezing especially after mild viral infection or after
exercise Bronchial Asthma
Wheezes are e heard loudest over the trachea. Persistent wheezing never seems to go away
Chondromalacia
Absent breath sounds on the right lung. Patient is 3 y/o Foreign Body

Pneumonia: Fever, Cough and Tachypnea


Poorly nourished, unvaccinated, w/ onset of rashes all over the body Measles
Px has CF. Px has CGD. Px is neutropenic. Px is a burn px Pseudomonas
Px is a teen/young adult, lives in a dorm; initial cough is non-productive; CXR: diffuse infiltrates
Mycoplasma
Px has his own aviarium in his home Psittacosis
Hx of eye discharge during the 1st 5-14 days of neonatal period Chlamydia

Attaches to respiratory epithelium, inhibits cellular destruction, sloughed cellular debris and
inflammatory cells and mucus cause airway obstruction Mycoplasma
Extensive areas of hemorrhagic necrosis, irregular areas of cavitation, pneumatocoeles,
empyema and bronchopulmonary fistulas Staphylococcus
Diffuse infection with interstitial pneumonia, necrosis of tracheobronchial mucosa, formation of
large amounts of exudate, edema and local hemorrhage, involvement of lymphatic vessels and
pleura GABHS
Local edema that aids in the proliferation of organisms and spread into adjacent areas resulting
in focal lobar involvement Pneumococcus

Presentation: Child with cough, colds, fever, wheezing, stridor


Lobar consolidation Pneumococcus
Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing RSV
Prominent areas of cavitations and multiple pneumatocoeles Staphylococcus
Right-sided hilar adenopathy PTB

Types of Cough
Staccato Chlamydia
Brassy S. aureus
Barking seal Parainfluenza
Whooping; post-tussive vomiting Bordetella
Most severe in the morning Cystic Fibrosis
With vigorous exercise Asthma
Disappears with sleep Habitual cough
Tight-sounding w/ wheezing Asthma

Cyanosis
Manifesting within few hours at birth or within a few days of life TOGV
Manifesting after the first year of life, usually in an infant or toddler TOF

CXR Findings
Couer en sabot/boot-shaped TOF
Egg on a string TOGA
Figure of 8, snowman TAPVR
Rib-notching, inverted E, 3 sign CoA

Presentation: Complaints of exercise intolerance, easy fatigability


Late systolic murmur with opening click MVP
Disparity in pulsation and BP in the arms and legs; weak popliteal, posterior tibial and dorsalis
pedis pulses CoA
S2 widely split and fixed in all phases of respiration ASD
Loud, harsh, blowing holosystolic murmur VSD
Wide pulse pressure, bounding peripheral arterial pulses, continuous murmur PDA

Blalock-Taussig shunt with GoreTex conduit, aortopulmonary window shunt, Waterson Cooley,
Pott shunt TOF
Rashkind atrial septostomy, Jantene arterial switching, Senning and Mustard TOGA
Fontan procedure Tricuspid atresia
Norwood procedure, Glenn anastomosis Hypoplastic Left Heart Syndrome

Rubella PDA, pulmonic stenosis


DM TOGA
Lupus Complete heart block
Aspirin PPHN
Alcohol VSD, PS
Lithium Ebstein anomaly

Child Presenting with CHF


Presentation: Neonate w/ systemic hypoperfusion and shock w/ low CO and weak peripheral
pulses. Severe respiratory distress and grunting
Neonate is 4 days old and is not cyanotic Hypoplastic Left Heart
Neonate is 4 days old and is cyanotic TAPVR

6-week-old baby presenting w/ increasing respiratory distress, diaphoresis, lethargy CoA

Infective Endocarditis
Normal person, no underlying disease S. aureus
Underlying heart disease, dental procedure viridans Strep
GUT or lower bowel manipulation Group D Strep
After open heart procedure Fungal
IV drug abuser Staph, Pseudomonas
(+) CVP, (+) prosthetic valves CONS

Chills, fever, arthralgia, myalgia, acute-looking, developing a new heart murmur S. aureus
A child with known CHD w/ fever, fatigue, weight loss, panful skin lesions on fingers. Px has
poor oral hygiene or has just undergone root canal viridans Strep
A child with known CHD w/ fever, fatigue, weight loss, panful skin lesions on fingers. Recent
repair of VSD Fungal
A child with known CHD w/ fever, fatigue, weight loss, panful skin lesions on fingers. Child is an
IV drug user Pseudomonas

Red Eye in Neonates:


Red eye with purulent discharge, tense edema of eyelids with marked chemosis; inc period 2-5
days; onset at birth or until day 5 of life N. gonorrhea Ceftriaxone 50 mkD
Mild to severe swelling of eyelids with copious purulent discharge; inc period 5-15 days; tarsal
conjunctiva C. Trachomatic (inclusion blenorrhea) Erythromycin 50 mkD q6 x 2 weeks
Days 5-18; edema and erythema of eyelids, purulent discharge, pannus formation,
endophthalmitis, sepsis Pseudomonas Systemic antibiotics, gentamycin eye ointment
First 6-12 hours of life; clears in 24-48 hours Chemical Conjunctivitis Self-limiting

Conjunctivitis:
Red itchy eyes, thin exudate, pain & photophobia, +/- cough and colds Adenovirus
Red eyes, presence of pus S. aureus
Red eyes, pus, inclusion bodies in scrapings Chlamydia
Inturned eyelashes, corneal scarring, blindness Chlamydia

Eyelid Infections:
Bilateral eyelid swelling, eosinophils, muscle pain, hx of GIT infection Trichinella
Stye S. aureus
Unilateral inflammation at bite site around eye or mouth. Hx of travel to Mexico or South
America T. cruzi

Retinopathy w/ keratitis in a newborn or a young child. Mother has a hx of drug abuse CMV

Furuncle/carbuncle in the neck, axillae, face, buttocks S. aureus


Furuncle/carbuncle from neck down; has bath tub at home; loves to play in the bath tub
Pseudomonas
Inflammation of sebaceous glands & follicles in a teenager Propionibacterium

Cutaneous Lesions:
Multiple infected wounds on lower extremities. Lesions started as mosquito bites and child
kept on scratching them. Multiply dry, heaped up, tightly adherent crusts Echthyma
(ulcerative impetigo)
Lesions started as mosquito bite and child kept on scratching them. Initially vesicular. Honey-
crusted lesion, catalase negative, no pain, no systemic sx S. pyogenes
Lesions started as mosquito bite and child kept on scratching them. Initially vesicular. Longer-
lasting and bigger bullae formation. Catalase-positive S. aureus
Malignant pustule; pustule w/ dark red fluid, necrosis to black eschar Anthrax
Target lesion/bulls eye, fever, headache, rashy border, bite site Borrelia

Vesicular Lesions:
Preceded with neurological pain HZV
Very large bullous lesions, progressing rapidly, preceded by fever, fatigue, malaise; toxic-looking
patient; denuded areas S. aureus
Multiple vesicular lesions, some papules, some crusted, all at different age Varicella

Cellulitis or Subcutaneous Lesions


Presentation: Inflamed erythematous skin, tender and warm
Red, raised, butterfly rash in appearance with dermal pain and rapid spread Erysipelas
Following contact with saltwater or oysters Vibrio
Burn px, blue-green pus, grape-like odor Pseudomonas

Lymphatic Obstruction or Lymphocutaneous Lesions:


Solitary or lymphocutaneous lesions, rose gardeners, likes lying in the garden Sporotrichosis
W/ hx of painless genital ulcer LGV (Chlamydia)
Fever, headache, elephantiasis of limbs or genitalia Filariasis

Granulomatous Lesions and Draining Sinus Tract:


Jaw area swelling, sinus tract formation, yellow exudate, carious teeth, dental procedure,
yellow granules in exudates Actinomyces
Tropical fish enthusiasts Mycobacterium marinum
Subcutaneous swelling of shoulder; sinus tract formations; granules Nocardia
Usually in the cervical area; child has chronic cough TB
Infected Wound:
Hx of animal bite, cellulitis with lymphadenitis Pasteurella
Hx of cat bite or scratch, or no hx of bite but with pet kitty; lymphadenopathy with stellate
granulomas Bartonella henselae
Hx of shallow puncture wound through tsinelas or through rubber shoes Pseudomonas
Surgical wound (clean or dirty) S. aureus
Trauma C. tetani

ENT Infection:
AOM; red, bulging tympanic membrane, fever Pneumococcus
Sinusitis; sinus pain, low-grade fever Pneumococcus
Common cold, sneezing, scratching throat, runny nose Rhinovirus

Sore Throat:
Inflamed tonsils or pharyx, purulent, fever GABHS
White papules with red base on posterior palate and pharynx, first 3 years of life Herpangina
Purulent tonsils, fatigue, lymphadenopathy, hepatosplenomegaly EBV
Low-grade fever w/ gradual onset of membranous nasopharyngitis; bull neck from
lymphadenopathy Diphtheria
Finely popular, erythematous eruption producing a bright red discoloration of the skin, which
blanches on pressure, more intense along the creases of the elbows, axillae and groin. The skin
has goose-pimple appearance and feels rough. After 4 days, the rash begins to fade and is
followed by desquamation, sandpaper-like rash Scarlet fever (GABHS)

Infectious Arthritis: pain, redness, low-grade faver, tender joints, reduced mobility
All ages except between 15-40 S. aureus
15-40 y/o, sexually active N. gonorrhea
Prosthetic joint S. epidermidis
Following GIT infection few weeks ago Reiters disease

Osteomyelitis: fever, bone pain w/ swelling, redness, associated cellulitis


Adults, children, infants, w/o major trauma or special conditions S. aureus
Neonates, <1 month old S. aureus
Sickle cell anemia Salmonella
History of trauma Pseudomonas

Toxic-Looking Rashes:
Petechiae to purpuric lesions, generalized, abrupt onset w/ fever, chills, prostration and shock
N. meningitides
Petechiae to purpuric lesions, fever, headache, rash that includes palms and soles R. ricketsii
Petechiae to purpuric lesions, fever, headache, rash that spares palm and soles R. prowazekii
Erythematous, maculopapular rash, sandpaper-like, trunk and neck and then extremities,
associated with sore throat and fever Scarlet fever
Diffuse erythematous macular sunburn-like rash, trunk and neck and then extremities with
desquamation on palm and soles; acute onset of fever, pharyngitis, diarrhea, hypotension TSS

Rashes:
Cough, coryza, conjunctivitis, fever Rubeola
Posterior cervical or auricular LN Rubella
Slapped cheek then spreading to trunk with central clearing Erythema Infectiosum
Abrupt onset of fever with URTI for 3-4 days. Fever disappears and rashes appears on trunk and
spread Roseola
Preceded by rapid onset of fever, myalgia, ocular pain, hyperesthesia; rashes blanch on
pressure Dengue

Reference:
Topnotch Pedia Handout

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JB Goza-Borja