1. Chronic NBNB vomiting (w/ weight loss) in an infant:
--Refuses food: likely GERD (esp younger than 3-4 months) since kids’ abdominal/diaphragm muscles are weak and can’t keep food down. At >3-4 months, think other causes. An inflammatory malabsorption (esp with diarrhea), intussuception (esp with blood in stool

--Doesn’t refuse food: think obstruction vs milk allergy.  In a neonate or young infant, think congenital obstruction, in an older kid, think constipation. R/o with abd x-ray to look for fecal impaction, u/s to look for pyloric stenosis. Think cow’s milk allergy if the kid has recently been weaned from breast milk (unless the mom drank a ton of cow’s milk, there will have been little cow milk protein in her milk). Change to very hydrolyzed formula (nutramigen) and see if it resolves. 

2. Bartter’s syndrome (NKCC2 R mutation): it’s like they’re on Lasix all the time. Shutting down the receptor means greater volume of more dilute urine- you can’t remove salt at TALH, so you can’t remove water in collecting ducts. You lose the cycling of K (K comes in through NKCC, goes out through K channel), so you lose the net positive charge in kidney tubule lumen, which is the driving force for the reabsorption of divalent cations. This leads to kidney wasting of Ca & Mg. You don’t waste Na, since your kidneys ramp up reabsorption of Na at the DCT and CD, at the price of losing K and H. Additionally, the loss of Cl at NKCC means that your body will also reclaim bicarbonate to make up the charge balance, worsening the alkalosis. Treatment is to figure out which electrolytes are low, and to replenish.

3. Gittleman’s syndrome: NaCl R mutation: its like you’re on a thiazide diuretic all the time. Gordon’s syndrome: mutation in the regulation of NaCl, leading to increased expression, the opposite of being on a thiazide: you retain water and salt, and become hypertensive. Tx with a thiazide diuretic (now isn’t that convenient?

4. Lasix tolerance: starting Lasix diureses great at first, but over time the kidneys compensate. I.e. upregulation of Na-Cl receptors in the DCT. This compensatory process is driven in part by hypochloremia. Replenishing chloride will often cause diuresis to resume, as will adding a thiazide diuretic (which will possibly worsen the hypochloremia

5. Complete asthma history:

--Age of dx, +eczema/allergies, previous classification: symptoms/week (wheezing, coughing, SOB), nighttime symptoms/month (waking up to cough

--History: number of ER/hospital visits in the last year/lifetime. Lifetime ICU/intubation/bipap. How often do you miss school/work or does asthma interfere with activities.

--Medication: rescue inhaler/nebs, controller medicine, allergy medicine. Ask: how often are each used/using a spacer?

--Triggers: smoke, weather, exercise, pets, scents, mold, colds.

--Family Hx of atopy

6. Rolandic epilepsy: a benign epilepsy of childhood, peak incidence at 7-9 years of age, usually resolves by 13 on its own. Associated with centro-temporal spikes on EEG. A partial simple epilepsy that involves the face muscles, occurs generally at night (can be missed). Can generalize to tonic-clonic seizures. Generally not managed with AED: meds decrease generalization, but don’t decrease incidence of partial seizures. 

7. DDx of hemoptysis in a child:

--Infectious: TB, lung abscess (strep/staph), bronchiectasis (CF)

--Mechanical: foreign object, tracheal erosion from suctioning someone on a ventilator, trauma

--Rheum: Wegener’s (GPA), goodpasture, sarcoidosis, churg-strauss

--Vascular/Blood: AVM, PE

--Other: diffuse alveolar damage (precursor to ARDS), malignancy

--Cardiac: diastolic failure => backup of blood in lungs => pulmonary hypertension & blood leaking into alveoli. Think mitral stenosis, diastolic heart failure (amyloid/sarcoid), pulmonary hypertension. 

--Differentiate from hematemesis: pH (hematemesis will be acidic, hemoptysis will be alkaline), appearance (hemoptysis will be frothy) 

8. Babies fed exclusively goat's milk or who are vegan/fed with breastmilk from a vegan woman can suffer from B12 or folate deficiency and end up with megaloblastic anemia, or worse, methylmalonic acidemia --- inability to convert MMA to succinyl-CoA, MMA accumulates in myelin and can lead to seizures, neurodevelopmental consequences. 

9. The only indications for soy formula are galactosemia, or strict vegetarian diet. Babies that are allergic to milk have a 10-15% cross-allergy with soy, so it's better to put them on hydrolyzed cow's milk formula. 

10. Review of hypersensitivities: 

--type 1: anaphylaxis, IgE mediated

--type 2: autoantibodies against fixed structure (i.e. basement membrane-- goodpastures)

--type 3: autoantibodies against non-fixed antigen (i..e. IgM against IgG)

--type 4: cell-mediated, delayed.

1. Most infants will drink 2-6 oz of formula/breast milk per meal, and will drink every 1-3 hours. The baby will decide how much is enough-- don't deny an infant food. If s/he eats more, she will likely spit up more, that's ok. Don't let a neonate go >4 hours without food.
2. "wry neck" aka congenital torticollis, can be due to in-utero malposition or birth trauma, due to shortening of one of the SCM muscles. SCM is shortened, resulting in head being turned towards unaffected side and tilted towards the affected side, and sometimes well feel tight/have a calcified portion. Since the baby tends to turn its head one way, it may result in asymmetric head shape from lying preferentially on one side/in one way. Tx is to stretch it for by purposefully turning towards unaffected side and massaging the muscle for 30-60 seconds, multiple times a day (i.e. every time you change the diaper).
3. At 9 months, a child should be able to clap its hands/wave bye bye, have a pincer grasp, sit up on its own, crawl, say mama/dada, and is beginning to become afraid of strangers. This can make the exam more difficult, because baby is afraid of you: sit them in parents' lap for exam. They should be sleeping through the night; if baby is waking up wanting to be fed in the night, tell parents not to feed til morning. Put baby back to sleep in crib when it's tired but not yet asleep, that way baby will learn to fall asleep on its own (i.e wont be dependent on being rocked to sleep by parent).
You draw blood for:
-CBC to check for anemia, since 6-9 months is when their iron stores from mom run out). If breast feeding, should start supplementing iron at 4-6 months 1mg/kg/day.
-Lead results. No level of lead is "ok" but we aim for a blood lead level <5. If it's over 10, then the state will send people to examine the house. BLL>45 can be associated wtih lethargy, anorexia, decreased activity, vomiting, abd pain, constipation, anemia. BLL>70: acute encephalopathy, comna, seizures, ataxia, behavioral changes. Over 30s-40s, treat with succimer (DMSA). Over 70, treat with EDTA/dimercaprol. If a kid comes in with a high lead level, x-ray them to look for lead in their GI tract. If there are paint chips in their belly, chelation is pointless and will only encourage greater absorption. Most common sources of lead: paint chips, window frames, soil (from leaded gasoline and demolition of old buildings), pipes. Lead poisoning more common in kids with iron deficiency.
4. At 2 months, baby should be able to hold its head up off the table, follow an object past midline (eyes don't focus til ~4 months), coo, recognize faces and have a social smile. Infants can see black, white and red but not other colors well. At 2 month visit, they should be vaccinated with: oral polio, DTaP, Prevnar (13-valent pneumococcus), hep B, HiB. No flu shots. No water since that can lead to hyponatremia.
5. When doing a well-baby checkup, ask about
(1) developmental milestones  (2) eating (breast vs formula, how much, how frequent) (3) wet diapers - should be >6/day (strength of urination), BM- should be >1-4/day (color, consistency-- tell them to call docs if poo is black, red, or clay-beige colored). (4) home safety (car seats, smoke detectors, pets, cigarette smoke in the home)
When doing an infant exam, check fontanelles, red reflex, ears, neck for LN, clavicle, abdomen for masses, femoral pulses, testicular descent (boys), diaper rash, spine, reflexes- moro, babinksy.
6. Car safety for kids:
Infant-2 years: rear facing carseat in back,\
Age 2-4 years/up to 40 lbs: forward-carseat, \
Age 4-8 years/til 4'9": booster seat, age 8+/4'9"+: seat belt.
Can't sit in the front until age 13.
7. Obesity leads to type 2 DM in children, sleep deprivation may compound the risk. In children younger than 10, most DM is type 1 with type 2 being rare, but the ratio of type 2 gradually increases as you go up in age from 10-19
8. Rashes in kids: often eczema or contact dermatitis. Treat with topical steroids: high- and low-potency depending on the severity of the breakout. No high-potency steroids on face or groin: skin is thinner and more sensitive. Higher systemic absorption, darkening. Psoriasis is rare in children, usually presents as guttate after strep. Seborrheic keratosis common in infancy (cradle cap) but rare afterwards.
0. Causes of childhood rash:
First disease: measles
Second disease: scarlet fever
Third disease: rubella
Fourth disease: n/a
Fifth Disease: parvo- erythema infectiosum
Sixth disease: roseola (HHV-6/7)-- assoc with high fever (38.5-40.5) for 3-5 days, followed by maculopapular blanching rash. Assoc with bulging fontanelles and febrile seizures (assoc with 20-30% of first febrile seizures in children)
Others: RMSF, VZV/chickenpox, mumps, rhinovirus, allergic rxn to pencillins
10. Small umbilical hernias are common in children of color (up to 80%).

1. Child presents with fatigue, easy bruising. CBC comes up with a WBC of 100K, 98% blasts, hb 5 and platelets 5k. You suspect ALL.
Workup:
-BMP: ALL kids often have high K/Phos (since cells are lysing) and low Ca (since phos is high).
---Tx hyperK: shift K intracellularly (albuterol neb, insulin+glucose, bicarb if they're acidotic) and excrete it (lasix, kayexylate). Give kayexylate PO, not rectally, b/c kids with ALL are often effectively neutropenic. Even if their counts are high, their neutrophils suck/are blasts.
---To prevent Ca-Phos crystals, do not supplement Ca unless they are symptomatic, aim for a Ca*Phos<60, and do not alkalinize beyond 8.
---Keep an eye on BUN/Cr since crystal precipitation (urate/ca-phos) and tumor invasion/compression of GU system can cause renal failure.
-Uric Acid & LDH: both will give you a sense of tumor burden and of tumor lysis syndrome. To prevent uric acid crystals from forming, alkalinize slightly with bicarbonate.
-CXR: look for mediastinal mass
-Immunophenotyping: figure out if its acute vs chronic, lymphocytes vs monocytes, T-cell vs B-cell.
-Coag studies: PT/PTT & d-dimer/fibrinogen to r/o DIC
 2. Preventing tumor lysis syndrome: give allopurinol with chemotherapy. If someone is symptomatic, you can give a uricase, which directly breaks down urate. However, it is very expensive and thus not indicated for broad use in everyone. Steroids can help lower tumor burden in a slightly slower, more controlled way.
3. DDx of anterior mediastinal mass: lymphoma (hogkins/non-hodgkins), T-cell ALL (esp in teenager), thymoma, germ cell, thyroid. Posterior mediastinal mass: neuroblastoma (check urine/serum VMA/HVA)
4. It's hard/potentially dangerous to sedate someone with a mediastinal mass: they often have diminished respiratory capacity; in sedation, you lose negative intrathoracic pressure and respiratory muscle tone, further reducing ease of breathing (and also of mechanical ventilation). This can cause the mass to fall onto the mediastinum and compress either the respiratory structures (even a trach wouldn't help you then) or the major vessels, leading to a precipitous fall in preload and then to cardiac arrest.If you're going to sedate someone with a mediastinal mass, load them up with IV fluids beforehand and have an ECMO on standby.
5. Hyperleukocytosis can lead to leukostasis (sludging of WBC) esp if white count is in the hundreds of thousands. Sludging of capillaries in lungs (leading to respiratory insufficiency) and brain (leading to neurological deficits ranging from fatigue or behavior changes to ataxia, seizures, stroke) are most concerning. Kidneys can also take a hit.
6. In terms of leukostasis, myeloblasts are the worst because they are big, least deformable, and trap plasma between them. Lymphoblasts are slightly better (i.e. you need a higher "leukocrit" to have the same clinical sequelae) and mature lymphocytes are the best. The body will often decrease the hematocrit in an attempt to reduce blood viscosity-- thus, in someone with leukostasis, do not transfuse unless absolutely necessary, even if their hb is very low.
7. Spinal cord compression can happen in neuroblastomas, adrenal tumors, spinal  osteosarcoma. First sx is pain, then paresthesias, final loss is bladder/bowel. Tx is with high-dose steroids and laminectomy.
8. Any temperature over 100.4 F/38 C in a newborn (measured rectally) requires emergent hospitalization for at least 48 hours, with blood and urine cultures and a LP (neonate BBB is less developed). Most common bugs causing infection in a neonate: listeria, e.coli/GNR, enterococcus, GBS. (Slightly older neonate: HiB, S.pneumo, Neisseria). Treat empirically with Amp+Gent, or Amp+Cefotaxime in places with widespread gent resistance. Amp covers listeria, e.coli and other easy GNR (hib, kleb, proteus etc), and easy gram pos like strep and non-b-lactamase-staph. Cefotaxime is a 3rd generation cephalosporin like ceftriaxone, and has excellent gram negative coverage-- hits everything except pseudomonas.
9. Constipation is a common occurrence in kids. Treat with stool softeners first (PEG, like miralax): titrate up the dose if its not working at first. Go to stimulant laxatives (like senna) only after the stool softeners have failed. If you do give a stimulant, you must also concomitantly give a stool softener.
10. Treat a penicillin-induced allergic rash with benadryl (children: 1-2 mg/kg q6 hours)

1. Type 1 RTA: distal tubule, error with H-K transporter in a-intercalated cells. Associated with severe acidosis due to inability to excrete H, and hypokalemia due to inability to re-absorb K. Easily treated with bicarbonate, children will often "outgrow" it. In adults, often due to autoimmune disease (sjogren's lupus) and can often be a presenting feature of the disease. In children, can be due to genetics (mutated transporter) or nephrotoxic drugs (ifosfamide).
2. Type 2 RTA: proximal tubule, error with Na-Bicarbonate transporter. Kidneys waste bicarbonate; Treatment is bicarbonate supplementation, but it's like filling a bucket with a leak in the bottom. Difficult to treat, often associated with significantly damaged tubules, often requires lifelong treatment. Sometimes associated with Fanconi's syndrome. In adults, often due to accumulation of immunoglobulin light chains (multiple myeloma), which are resistant to degradation by lysosomal enzymes of prox tubule cells and will thus accumulate there.
3. Type 4 RTA: distal tubule, error with aldosterone action; either aldosterone deficiency or resistance. Results in hyperkalemia (aldosterone causes loss of K). Treat with aldosterone-mimetic.
4. All cases of RTA will cause non-anion gap acidosis, since "the kidneys compensate for NaHCO3 loss by retaining NaCl in an attempt to preserve volume, with the net effect being a mEq-for-mEq exchange of chloride for bicarbonate and no change in the AG." -uptodate
5. Common presenting symptoms of RTA in children: failure to thrive, kidney stones, paralysis/weakness (from electrolyte abnormalities), tachypnea.
6. Giving maintenance fluids: if you give isotonic maintenance fluids, people will eventually become edematous. People with normal kidneys will naturally pull back the vast majority of the sodium in their urine, leading water to go with it. Water follows salt, so the more salt you give the more water you give. Additionally, the stress response (2/2 pain, stress from being in the hospital) leads to ADH secretion, which pulls back more water and leads patients to become volume overloaded. If you want to avoid this, you give hypotonic maintenance fluids, so that there is less salt in their system. However, when you do this, you risk diluting out their serum and giving them hyponatremia.
-In adults, who often are suffering from some degree of heart or renal failure, you don't want to volume overload them, so you tend to give more hypotonic solutions (0.5NS, for example)
-In children, who have healthier hearts, you're more worried about hyponatremia, so you give isotonic solutions (0.9 NS, or LR).
7. Insensible fluid losses: 400-600 ml/m2/day. Max Na replenishment rate: 10 mEq/day
8. if you're really worried about edema/third spacing, you can give someone albumin to pull all the fluid out of their third spaces, and then chase them with lasix.
9. Most common cause of congenital blindness in utero: CMV, then rubella. Most common cause of preventable blindness in infants: chlamydia. Erythromycin eye drops cover GC, but not chlamydia well. if you're worried about chlamydia, do systemic erythromycin.
10. Treatment for moms with GBS: first line penicillin (0% resistance). Next line clinda (15% resistance). If resistant to clinda, give vanc. Side effects of ceftriaxone (biliary sludging/cholecystitis), erythromycin (pyloric stenosis), doxycycline (stained teeth/bones since it's a Ca chelator)

1. Criteria for admission for anorexia/bullemia: bradycardia (criteria says <50, but in reality it's low 30s), electrolyte imbalances, rapid weight loss.
2. Family centered counseling/therapy leads to 90% remission at 5 years.
3. Things to worry about in anorexia:
-electrolye abnormalities (hypokalemia/hyperchloremia from vomiting, hyponatremia)
-volume depletion (leading to decreased GFR, mitral valve prolapse)
-osteopenia/osteoporosis (can happen in first 6 mos of illness, can have life long consequences bc pt fails to reach maximum bone density)
-concomitant mental illness or substance abuse (i.e. OTC or illegal weight loss supplements)
4. Most drugstore OTC weight loss drugs contain caffeine as a major ingredient, because it's an appetite suppressant.
5. Grading for asthma:
-Intermittent: <2 days/week of symptoms and of rescue albuterol use, 0 nights a month (<5 years) or <2 nights/month (5+) of waking up at night with coughing/wheezing.
-Mild Persistent: 3-4 days/week of symptoms and of rescue albuterol use, 1-2 nights a month (<5 years) or 3-4 nights/month (5+) of waking up at night with coughing/wheezing
-Moderate Persistent: daily symptoms and of rescue albuterol use, 3-4 nights./month (<5 years) or >1 night/week (5+) of waking up at night.
-Severe Persistent: multiple times a day symptoms and rescue albuterol use, >1 night/week (<5 years) or nightly (5+) waking up at night.
6. First line for asthma controller medicine is inhaled corticosteroids (flovent). Often given 2x a day, morning and night. Use a spacer: kid breathes out, then you puff the inhaler, they either breathe in and out 6x or breathe in and hold their breath for 10 seconds-- the older kids can handle the latter.
7. If flovent alone fails to control the asthma, you can increase the dose or add a long acting beta agonist. Advair/symbacort are LABA+steroid. Montelukast (singulair) is especially helpful in kids who have a mix of asthma and allergies, with the allergies triggering the asthma. If the kid has a lot of upper respiratory swelling and inflammation (like swollen turbinates) you can add flonase (fluticasone nasal spray) to remedy that.
8. Most common cause of pediatric dialysis use is obstructive uropathy, in boys often secondary to persistent posterior urethral valve. Sometimes you can get tethered cord leading to neurogenic bladder, which can lead to obstructive uropathy. Once they are sick enough to need dialysis, usually they are on dialysis until they get a transplant.
9. You can transplant an adult kidney into a child-- there is space in the abdomen to fit it. The transplants will generally last decades. Some people/kids need heavy-hitting sets of immunosuppressants (steroids, calcineurin inhibitors, cellcept aka mycophenolate mofetil) while other people are ok with just a calcineurin inhibitor. There are some research groups out of san francisco figuring out blood tests to predict which people are in which group.
10. Having cats in the home at a very young age is associated with decreased future incidence of autoimmune disease.

1. A small study (n=50) found that facial plastic surgery (facelift/brow lift/neck lift) recipients looked, when evaluated by anonymous viewers, only 3 years younger and no more attractive than they were before. c/o NPR shots blog. http://archfaci.jamanetwork.com/article.aspx?articleid=1722859
2. "Gentamicin is a vestibulotoxin, and can cause permanent loss of equilibrioception, caused by damage to the vestibular apparatus of the inner ear, usually if taken at high doses or for prolonged periods of time.....However, gentamicin is sometimes used intentionally for this purpose in severe Ménière's disease, to disable the vestibular apparatus. These side effects are most common when the drug is administered via drops directly to the eye." -Wikipedia 
3. Good website for antibiotics and their coverage: http://www.erwize.com/Quick_Reference/Professionatls/ID/Antibiotics/body_antibiotics.html
4. Wounds of all sorts that are frequently debrided heal faster than wounds that aren't. For diabetic foot ulcers: weekly debridement led to wound healing in 21 days, debridement done once every 2 weeks led to wound healing every 64-76 days. For traumatic wounds, frequent debriding: 14 days, once every 2 weeks: 42-49 days. (c/o PodMed podcast out of Johns Hopkins). The paper in JAMA dermatology (n>300,000)
http://archderm.jamanetwork.com/article.aspx?articleid=1720508
5. GDF-11 is a protein found in the blood that may be associated with reversal of age-related cardiac hypertophy http://www.cell.com/abstract/S0092-8674(13)00456-X?switch=standard. Researchers injected blood from younger mice into older mice and were able to significantly decrease cardiac size. (c/o Radiolab blood)
6. "A significant association between maternal smoking during pregnancy and offspring conduct problems was observed among children reared by genetically related mothers and genetically unrelated mothers." (c/o PodMed podcast) http://archpsyc.jamanetwork.com/article.aspx?articleid=1716166
7. Glioblastoma multiforme tumor burden is thought to double every 9 days.
8. The (common) differential for a pelvic mass
-Benign: corpus luteum cyst (clear cystic), hemorraghic cyst/endometrioma (homogenous cyst), fibroma/fibroid (solid), dermoid cyst (complex cyst), serous/mucinous cystadenoma
-Malignant: serous/mucinous cystadnenocarcinoma, malignant dermoid
Any solid mass >8cm should be removed, since they tend not to regress and are at risk of torsion or progression to malignancy.
9. Genetic screens for breast cancer: BRCA1/2, BART, BreastNext (which includes 15 genes, including rare ones like NBN- nibrin)
10. Lithium use in utero is associated with ebstein's anomaly.

1. In postpartum hemorrhage, if massive transfusion is needed, ACOG recommends starting at a ratio of 6:4:1 of pRBCs, FFP and platelets. Generally, 1 unit of pRBCs => 1 g/dL of hemoglobin, 1 unit of platelets=> 5,000-8,000. Cryoprecipitate is a concentrated version of FFP, and has more fibrinogen and vWF.
2.Causes of symmetric IUGR: fetal troubles, such as congenital/chromosome abnormalities, TORCH infections. Asymmetric IUGR: fetus shunts blood to brain, spares abdomen. Usually environmental troubles, such as things that cause placental insufficiency (hypertension, maternal drug/alcohol/cigarettes, clotting diseases, vasculitidies).
3. In pregnancy, penicillin G is the only antibiotic you use to treat syphilis. If mom is allergic, skin test to figure out how allergic. Even for anaphylaxis, you desensitize by giving small amounts. Erythromycin doesn't cross the placenta, and has an >10% fail rate. Tetracyclines are CI in pregnancy, no other abx work.
4. If you get LSIL on a pap, you go to colpo unless they're post menopausal/adolescent (can follow with paps) or pregnant (defer colpo). In premenopausal women, the risk of finding CIN 2/3 in someone with an LSIL pap is nearly 15%. http://www.asccp.org/LinkClick.aspx?fileticket=uUGOqspsCBU=
5. Re:mammogram, ACOG/American cancer society/American college of radiologists recommend annual mammograms starting at 40. The average sojourn time for women in their 40s is 2-2.4 years. The USPSTF recommends screening every 2 years starting at 50, and mammograms for women in their 40s only if there is a family history.
6. Risperidone is an atypical antipsychotic that causes worse hyperprolatincemia than other antipsychotics. It's a dopamine/5HT antagonist
7. Women who are post term need to be followed with twice weekly NST/BPP if the don't want to be induced.
8. For decreased fetal movement, do an NST, if non reactive, likely 2/2 sleeping baby. Wake with vibroacoustic stimulation, and try again. If still non reactive, go to BPP.
9. Minimal variability in a fetal heart tracing can be due to a sleeping baby or to narcotic pain management in mom.
10. Pregnant women don't react to shock in the same way as normal people, especially if they are in the hospital and are being supported on crystalloids. They tend to have stable appearing vitals until they lose about 30% of blood volume, and then they tend to precipitously crash.