Missed Cardiology Qs

1. Tearing chest pain with mid-scapular radiation in an elderly patient with known atherosclerosis and hypertension carries a high index of suspicion for Type III aortic dissection.

Summary of DeBakey Classification of Aortic Dissection:

Type I: Dissection of ascending and descending thoracic aorta

Type II: Dissection of ascending aorta

Type III: Dissection of descending aorta

2. Treatment for acute right ventricular infarction includes fluids to increase pre-load and thus increase cardiac output.
1. Cardiac catheterization may be needed if less invasive treatment does not work but it is not the initial step
2. The diagnosis is right ventricular infarction caused by occlusion of the right coronary artery (RCA). Hypotension and jugular venous distention that worsens with inhalation (Kussmaul sign) are signs of right ventricular infarction. ST elevations in leads II, III and aVF indicate acute ischemia in the inferior left ventricular wall which is also associated with occlusion of the RCA.
3. Thiazide diuretics precipitate gouty attacks and can cause hypercalcemia, hyponatremia and hypokalemia, as well as many additional unwanted side effects.
4. Mobitz Type II second-degree AV block occurs when there is a constant PR interval followed by a dropped QRS complex.
1. Use a transcutaneous pacemaker for all patients with second-degree type II AV block and third-degree block.
5. Electrical therapy is reserved for unstable patients. Epinephrine is used for cardiac arrest arrhythmias (asystole, PEA, VF, VT). Atropine is used for bradyarrhythmias (symptomatic bradycardia). Adenosine is specifically used for stable SVT.
1. Supraventricular tachycardia is initially treated with vagal maneuvers, such as asking the patient to bear down or carotid massage, if the patient is awake and stable. The next course in management is adenosine because it drastically slows conduction through the AV node.
6. The differential diagnosis for syncope is big but the two main systems to focus on are neurological and cardiovascular. This patient has a heart rate of 40 indicating that a bradyarrhythmia is the most likely cause. This can be confirmed with an electrocardiogram (ECG).
1. A thorough history is important, especially asking about medications, but an ECG will confirm an arrhythmia
7. Atrial fibrillation with rapid ventricular response can be initially managed with diltiazem.
1. The ECG shown is atrial fibrillation with rapid ventricular response and treatment is aimed at rate control. The medications of choice are calcium channel blockers or beta blockers.
2. Procainamide is used for atrial fibrillation with Wolff-Parkinson-White syndrome, where AV nodal blocking agents like calcium channel blockers should be avoided.
3. Cardioversion is used for unstable patients. Hemodynamic instability means systolic blood pressure < 90, chest pain, shortness of breath, or confusion.
4. Digoxin can be used adjunctively but is less effective for rate control than calcium channel blockers or beta blockers.
8. Alcoholic dilated cardiomyopathy can cause a pre-excitation syndrome that may be observed as delta waves on the ECG.
1. Alcoholic dilated cardiomyopathy can cause a pre-excitation syndrome that may be observed as delta waves on the ECG.
9. Intravenous heparin is indicated for a patient evolving from stable to unstable angina
1. Antithrombotic therapy with intravenous heparin is indicated, along with additional antiplatelet therapy such as clopidogrel. Subcutaneous administration of low-molecular-weight-heparin (such as enoxaparin) is another possible treatment.
10. Hypertensive emergencies are associated with elevated blood pressures, usually > 179/119 mm Hg. Other clinical manifestations include: retinal hemorrhages and exudates, papilledema, malignant nephrosclerosis (leading to ARF, hematuria, and proteinuria,) and neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar infarcts, or hypertensive encephalopathy.
1. The initial aim of treatment is to rapidly lower the diastolic pressure to 100-105 mm Hg within two-six hours. The blood pressure should not be dropped by more than 25% of the presenting value. Medications that can be used to achieve this include: nitroprusside, nicardipine, clevidipine, labetalol, fenoldopam.
2. If you do not have rapid access to parenteral medications, sublingual or liquid nifedipine and sublingual captopril can be used.
3. Clonidine and hydrochlorothiazide have no role in the management of acute hypertensive emergencies.
4. unlike hypertensive emergency, there is no proven benefit from rapid reduction of blood pressure in patients with hypertensive urgency. The goal of management of hypertensive urgency is to lower the blood pressure to <160/100 mm Hg over several hour to days.
11. Hyperkalemia is associated with peaked T-waves on ECG.
1. The only choice that is associated with hyperkalemia is ACE-inhibitors. These drugs block the formation of angiotensin thus decreasing the secretion of aldosterone. This can lead to elevated potassium.
2. Calcium reverses the effects of potassium on the membrane potential and is the most rapid way to correct arrhythmia associated with hyperkalemia.
12. it would be very unlikely for a patient with WPW to develop any type of AV block.
13. ECG findings with digoxin toxicity include prolonged PR intervals, depressed (scooped) ST segments, and alterations in T wave morphology.
14. The first line of treatment for pulmonary hypertension due to congestive heart failure is loop diuretics, nitrates and morphine.
1. Echocardiogram will be needed to evaluate the ejection fraction but it is not the first step when there is respiratory distress from pulmonary hypertension
15. A baseline ECG should always be ordered first in the work-up of a cardiac patient. Although other modalities may be warranted, it is usually the ECG that should be ordered first.
16. Mitral regurgitation increases on expiration, is holosystolic, and increases with handgrip maneuver.
17. Use of the Framingham criteria (eight major and seven minor) is one method by which to organize the signs and symptoms of congestive heart failure (CHF). (diagnosis of CHF by this method, at least one major and two minor criteria are required).
1. Major criteria include
1. paroxysmal nocturnal dyspnea,
2. neck vein distention,
3. rales,
4. cardiomegaly,
5. acute pulmonary edema,
6. auscultation of an S3 gallop,
7. increased venous pressure, and a
8. positive hepatojugular reflux.
2. Minor criteria include
1. extremity edema,
2. night cough,
3. dyspnea on exertion,
4. hepatosplenomegaly,
5. pleural effusion,
6. vital capacity reduced by one-third from normal, and
7. tachycardia of 120 or more beats per minute.
3. weight loss of 4.5 kg or more during the course of therapy may be considered as a major or minor criterion.
18. The most common symptoms of digoxin toxicity are GI distress, blurry vision and arrhythmia. Hypokalemia can enhance digoxin toxicity.
1. Heart block (as seen with the prolonged PR interval) is a common side-effect of digoxin which usually does not cause any trouble.
2. Hypokalemia and renal failure can enhance digoxin toxicity.
19. Mitral stenosis is the most common valvular disease caused by rheumatic heart disease and is characterized by a loud S1, along with a mid-diastolic rumble at the cardiac apex.
20. Hypovolemic Shock: ↓ CO, ↓ PCWP, ↑ PVR

Cardiogenic Shock: ↓ CO, ↑ PCWP, ↑ PVR

Septic Shock: ↑ CO, ↓ PCWP, ↓ PVR

Missed OB Qs

1. Patients with HELLP syndrome should be managed according to length of gestation and disease severity. Patients symptomatic with headaches or abdominal pain with elevated liver enzymes should undergo immediate induction of labor if they are greater than 33 weeks gestation.
2. The stepwise approach to uterine atony includes: Uterine massage with oxytocin, Methylergonovine, prostin (PGF2), dilation and curettage, exploratory laparotomy, and hysterectomy.
3. Dyspnea of pregnancy is a common occurrence most commonly due to decreased Paco2 levels, resulting from a 30 – 40% increase in tidal volume.
1. Decreases in total lung capacity or increases in tidal volume can also contribute to this problem,
4. Intrahepatic cholestasis of pregnancy presents with pruritus and jaundice in the third trimester. Elevated bile salts confirm the diagnosis.
1. The most common cause of pruritus in the third trimester of pregnancy is intrahepatic cholestasis of pregnancy. It presents with generalized pruritus and signs of biliary obstruction (jaundice or icteric sclera). Increased circulating bile salts confirm the diagnosis. Elevated liver enzymes are generally not a feature
5. Symptomatic abnormal uterine bleeding should be treated with IV estrogen followed by admission to the hospital with subsequent D&C.
6. Maternal exposure to DES should be suspected in patients with incompetent cervix who have a history of recurrent painless spontaneous abortions.
1. In utero exposure to DES carries a high association with the future development of clear cell adenocarcinoma of the vagina.
7. Abortions occur before 20-weeks gestation. Know how to differentiate between the types based on bleeding, cervical dilation and loss of products of conception.
8. The management for inevitable abortion is emergent dilation and curettage.
9. When the hCG is below threshold for identifying an intrauterine pregnancy in a stable patient repeating the measurement in 48-hours is most appropriate.
1. The threshold for a transvaginal ultrasound is about 1500mIU/mL.
2. A rise of hCG of at least 65% after 48-hours is a good indication that the pregnancy is normal.
3. A plateau in hCG over 48-hours indicates a non-viable pregnancy but it still doesn’t identify the location. Transvaginal ultrasound is more sensitive than transabdominal
10. The most likely explanation for not being able to see the string of an IUD is that it has fallen out or it has moved into the uterine cavity. Because the next step is exploring the endocervix which could compromise a growing fetus you should always perform a pregnancy test first.
11. The management for PPROM complicated by infection is vaginal delivery as soon as possible.
1. There is a high risk of infection 18-hours after rupture of membranes.
2. The fetus is at high risk for a serious infection thus labor should be induced as soon as possible regardless of fetal lung maturity

Missed Infectious Disease Qs

1. A PPD should be done to confirm exposure before starting isoniazid therapy. For health-care workers a positive PPD is defined by induration greater than 10mm. For close contacts a positive PPD is defined by induration greater than 5mm.
2. First line prophylaxis for Traveler’s diarrhea is Quinolones such as Ciprofloxacin or Norfloxacin.
3. Giardia causes decreased fat absorption, leading to greasy foul-smelling stools.
4. A biopsy is the best first step in the management of leukoplakia.
1. It is a diagnosis of exclusion and a biopsy is the best way to rule out other possibilities such as Candidia, malignancy, and lichen planus. Hairy leukoplakia is a similar oral lesion found in immunocompromised patients, such as AIDS victims, due to an opportunistic EBV infection. While this patient may be HIV-positive or immunocompromised, it is more important to diagnose the chief complaint first
5. Ceftazidime (or cefepime) is a monotherapy of choice because it covers Pseudomonas. Vancomycin should be added if there is evidence of cellulitis or a catheter infection (B and D). Catheters don’t need to be removed immediately unless there is evidence of infection
6. Treatment of septic arthritis should be started with positive Gram stain results; do not wait for the culture to return.
1. Any swollen painful joint should be aspirated.
2. Septic arthritis is most commonly caused by Staphylococcus aureus. Salmonella septic arthritis is specific to sickle cell anemia, although staph is still the most common in sickle cell patients. Other causes include Neisseria gonorrhea, Streptococcus, Lyme disease, and pseudomonas.
3. Aspiration with polarizing microscopic exam is useful for crystal-induced arthritis, but gonococcus is most likely here due to the sexual history and other symptoms.
7. Patients on aminoglycosides for greater than 2 weeks are at risk for developing ototoxicity, especially with co-administration of loop diuretics.
1. Acute tubular necrosis leading to renal failure is a potential life-threatening effect of aminoglycoside therapy.
2. BUN and creatinine levels should be monitored in patients receiving treatment with aminoglycoside antibiotics, given their nephrotoxic potential
8. Esophagitis secondary to infection with Herpes Simplex Virus (HSV). These lesions are typically well circumscribed and have a “volcano” (deep and small) appearance, as opposed to esophagitis caused by CMV, which tend to be much larger, shallow ulcers.
1. the correct therapy would be oral acyclovir because of the nature of the ulcers.
2. Suspect CMV esophagitis in patients presenting with the triad of substernal burning with odynophagia, oral ulcerations and the presence of intracellular inclusions.
3. Suspect candida esophagitis in HIV patients with CD4 counts below 50 who present with odynophagia. Remember that there is an important difference in terminology for swallowing disorders. Dysphagia refers to difficulty swallowing wheras odynophagia refers to painful swallowing.
4. Esophagogastroduodenoscopy (EGD) is the most effective study to diagnose esophagitis.
5. Patients diagnosed with HIV esophagitis should receive treatment with oral fluconazole initially.
6. if presented with a vignette with an HIV-infected person with a CD4 count less than 50, initially treat for candidal esophagitis with oral fluconazole. If the patient can’t tolerate oral fluconazole due to pain then IV fluconazole may be used instead. If the patient does not improve, suspect another etiology and proceed with esophagoscopy with cytology, get a biopsy and initiate appropriate therapy pending on the results of the study. If CMV esophagitis is discovered, initiate treatment with oral ganciclovir. If HSV is discovered, treat with oral acyclovir.

CD4 <50: Lymphoma, CMV retinitis and esophagitis, Mycobacterium avium complex (MAC)

CD4 <100: Candida esophagitis, Cryptococcal meningitis, Cerebral toxoplasmosis

CD4 <200: Pneumocystis carinii (PCP), AIDS dementia

CD4 <500: Bacterial pneumonia, Tuberculosis, Kaposi’s sarcoma, Herpes zoster

9. Amoxicillin/clavulanate and second-generation cephalosporins are recommended for the prophylactic treatment of penetrating cat bites.
10. lymphogranuloma venereum (LGV) is a sexually transmitted chlamydial infection characterized by painful inguinal lymphadenopathy, fistulas and granulomas.
1. Characteristic findings include swollen painful inguinal lymph nodes with fistulas, strictures and granulomatous inflammation. Purulent discharge from the lymph node suggests a fistula. The painful lymphadenopathy usually occurs after a painless genital ulcer disappears. The organism is Chlamydia trachomatis types L1-L4.
11. Doxycycline is a tetracycline used for the treatment of Pasteurella multocida and other bacteria spread by cat and dog bites. It is the alternative to PCN and sulfa when there is an allergy. Fluroquinolones are not recommended in younger children due to the risk of tendon rupture and other adverse side effects, unless the injury is severe and/or several other treatment options have failed.
12. Although Streptococcus pneumoniae is the leading cause of bacterial pneumonia in all nursing home patients, individuals suffering from neurological impairment are particularly susceptible to pneumonia caused by anaerobic pathogens.
13. Early bacterial sepsis can manifest as respiratory alkalosis.
1. Patients who present with respiratory alkalosis should receive a CBC to screen for a leukocytosis and/or left shift to help determine if early sepsis is present.
2. Respiratory alkalosis occurs secondary to hyperventilation, which leads to hypocapnia (decreased PaCO2 levels)
14. Corynebacterium diphtheriae is characterized as a non-encapsulated, non-motile, gram-positive bacillus.
15. Chancroid is a sexually transmitted infectious disease characterized by painful ulcers, bubo formation, and painful inguinal lymphadenopathy. It is caused by Haemophilus ducreyi. Remember the mnemonic “ You DO cry with ducreyi."
1. Calymmatobacterium granulomatis is the causative organism of the sexually transmitted disease called granuloma inguinale. Patients with this condition present with large ulcerated lesions on the genitalia which are described as “beefy red” with friable granulation tissue. Unlike chancroid lesions, lesions of granuloma inguinale are painless and tissue analysis reveals characteristic Donovan bodies.
16. PPD Interpretation:

Results of > 5 mm and < 10 mm are positive in the following groups:

1. HIV-positive persons

2. Recent contacts of active TB patients

3. Persons with radiographic findings suggestive of old TB

4. Patients with organ transplantation and other severely immunocompromised states

Results of > 10 mm and < 15 mm are positive in the following groups:

1. Recent immigrants from high-prevalence countries

2. Intravenous drug users

3. Residents of high-risk congregate settings (e.g., prisons, nursing homes, shelters, hospitals)...this includes us (medical student/resident population)!

4. Mycobacteriology personal working in laboratory settings

5. Patients with high-risk conditions such as diabetes, leukemia, renal failure, and malnutrition

6. Children less than 4 years of age

Results of > 15 mm are positive in the following group:

1. EVERYONE

17. Immune Hypersensitivities:
1. Anaphylactic/Atopic (type I), Cytotoxic/antibody mediated (type II), Immune complex (type III), Delayed/cell mediated (type IV). Disease associated are:
2. Type I: anaphylaxis, allergic rhinitis (hay fever).
3. Type II: hemolytic anemia, ITP, erythroblastosis fetalis, rheumatic fever, Goodpasture syndrome, bullous pemphigoid, Graves disease, myasthenia gravis.
4. Type III: SLE, rheumatoid arthritis, polyarteritis nodosum, poststreptococcal glomerulonephritis, serum sickness, arthus reaction, hypersensitivity pneumonitis.
5. Type IV: type 1 diabetes mellitus, multiple sclerosis, Guillain-Barré syndrome, Hashimoto thyroiditis, graft-versus-host disease, PPD, contact dermatitis.

Missed Medical Ethics/Law Qs

1. Studies
1. A cohort study involves a large group of people and often looks at risk factors for developing disease and effectiveness of prevention. The Framingham heart study is one of the largest cohort studies. These groups share many common risk factors so as not to confound the variables in the study.
1. Cohort studies can be prospective or retrospective.
2. Prospective follow individuals whereas
3. retrospective look back at the past through medical records.
2. A case control study is a retrospective study where a few people with out a disease or illness are compared to only a few with the illness.
1. These are good for rare conditions, and provide information about the disease.
3. Cross-sectional studies involve people throughout a population and are good for determining information about that population.
1. Relative and absolute risk may be obtained.
4. Drug and therapy research often involves performing experiments to determine the effectiveness of treatment.
1. Single and double-blinded experiments are the most common.
2. In a double-blinded experiment neither the participants or the designers know who is receiving which treatment.
3. A single blinded study only the patient is unaware of the therapy they are receiving.
4. An open-study both the patient and the designer know the treatment. Open studies are good when you cannot withhold information, or when treatments are very similar.
2. A physician cannot force a teenager to take a drug test against their will.
1. When a parent suspects that their teenager is using drugs, the physician should investigate the issue further with the teenager alone.
2. The physician should assure the teenage patient that whatever they say will remain confidential. It is likely that the teenager feels uncomfortable discussing drug use in front of her parents.
3. The physician should investigate the issue with the teenager first and get their approval before parental involvement
3. Medical-Legal definitions are as follows:
1. Abandonment - Medical abandonment results when the caregiver-patient relationship is terminated without making reasonable arrangements with an appropriate person so that care by others can be continued.
2. Battery - Medical battery can be defined as an intentional act on the part of the caregiver to fail to respect a patient's advance directive.
3. Breach of duty - a failure to maintain the duty that the physician owes to the patient, deviating from the “standard of care”.
4. Standard of care - the level at which a professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances.
5. Vicarious liability – Employers are liable for negligent acts or omissions by their employees in the course of employment.

Missed OMT Qs

1. The cecum through the proximal colon refers to the right IT band in a proximal-to-distal manner.
1. Following the prostate and sigmoid through the distal transverse colon refer proximal to distal down the left IT band.
2. There is only a Chapman’s point for the rectum on the lesser trochanter located on the medial thigh.
2. OMM for URIs should be directed at the sphenopalatine ganglion.
3. The pedal pump can be a valuable tool for augmenting thoracoabdominal pressure gradients but is contraindicated in patients with DVT, fractures to the lower extremities, or those who have recently undergone surgery to the abdomen.
4. Patients suffering from complex regional pain syndrome of the lower extremities should receive treatment directed toward the T11-L2 cord levels.
5. Inhaled steroids are the first choice agents for persistent asthma that is not well-controlled by a rescue inhaler alone.
6. These four rules are critical for memorization and must be followed when diagnosing sacral torsions:

1) Sidebending of L5 and the sacral oblique axis must be engaged on the same side.

2) The sacrum rotates in the opposite direction of L5.

3) The seated flexion test must be positive for the diagnosis of sacral torsion.

4) The seated flexion test will be positive on the side opposite of the oblique axis.

7. The CV4 technique can increase the CRI
8. Rule of 3's (Spinous processes and Transverse processes):
1. T1-3, the spinous process is at the level of the corresponding vertebral body.
2. T4-6, the spinous process is half a level below the vertebral body.
3. T7-9, the spinous process is one level below the vertebral body.
4. T10, same as T7-9.
5. T11, same as T4-7.
6. T12, same as T1-3.
9. Cranial Dysfxn:
1. A) Compression occurs when the sphenoid and occipital bones are forced towards one another at the sphenobasilar synchondrosis (SBS) articulation. This commonly occurs when there is an impact to the back of the head, such as during a high speed motor vehicle accident. The associated clinical finding is a severely decreased (sometimes absent) CRI.
2. B) A flexion/extension straining pattern occurs when the cranium is restricted in either flexion or extension (named for the direction of ease). This is diagnosed by observing asymmetry while palpating the CRI.
3. C) Lateral strain occurs when the sphenoid deviates laterally in relation to the occiput. The cranium will feel like a parallelogram during palpation.
4. D) Torsion occurs when the sphenoid rotates about an anterior-posterior axis relative to the occiput at the SBS. The torsion is named by the side of the more superior greater wing of the sphenoid. Torsion can be a physiological variant if it does not interfere with the CRI.
5. E) Vertical strain occurs when the sphenoid deviates superior or inferior relative to the occiput. There will not be asymmetry between the greater wings of the sphenoid.
10. Posterior fibular head dysfunctions occur when the fibular head is stuck posteriorly and resists anterior spring.
1. Posterior fibular head dysfunctions lead to internal rotation of the talus causing foot inversion and plantarflexion.
2. Tx: Patient prone, dorsiflex and evert the foot to barrier and instruct patient to plantarflex against isometric resistance
3. The common peroneal nerve runs posteriorly in close proximity to the proximal fibular head and is subject to injury with fracture of the fibula or with posterior dysfunction of the fibula.
11. Flexion at the SBS causes the dura to be pulled in the cephalad direction. Recall the coordination of cranial motion. Craniosacral Flexion: midline bones flex, sacrum counternutates, paired bones externally rotate and the AP diameter decreases. Extension: midline bones extend, sacrum nutates, paired bones internally rotate, and the AP diameter increases
12. L5 and the sacrum always rotate in opposite directions. Sidebending of L5 engages the ipsilateral sacral oblique axis.
13. The uterus and cervix are innervated autonomically at the level of T10-L2
14. L4 nerve root entrapment giving rise to impairment of the tibialis anterior.
15. A forward sacral torsion on a left oblique axis is the correct diagnosis for patients with
1. a right deep sacral sulcus and
2. a left posterior ILA in the presence of
3. a negative lumbosacral spring test.
1. The lumbosacral spring test is an important test used to distinguish forward and backward sacral torsions.
1. In forward torsions, L5 has good spring and the lumbosacral spring test is negative.
2. In backward torsions, L5 does not have good spring and the lumbosacral spring test is positive.
16. During pronation the radial head moves posteriorly.
1. if the patient can pronate well, the radial head's position of ease is in the posterior position
2. Restricted passive range of motion implies that there is something impeding supination of the forearm, not simply pain preventing supination.
17. The anterior Chapman’s point for the myocardium is located at the 2nd intercostal space, near the sternum.
1. Chapman’s points for the upper and lower lungs are located at the 3rd and 4th intercostal spaces, near the sternum
2. The Chapman’s points for the stomach, liver and gallbladder are located at the 5th/6th intercostal space in the midclavicular line.
18. For direct muscle energy to the ribs, the patient holds their breath against the restriction barrier and the physician will push to counteract this force.
19. Rib Attachments
1. Rib 1: Anterior and middle scalenes
2. Rib 2: Posterior scalene
3. Ribs 3-5: Pectoralis minor
4. Ribs 6-9: Serratus anterior
5. Ribs 10-11: Latissimus dorsi
6. Rib 12: Quatratus lumborum

Missed Pediatric Qs

1. Neonatal respiratory distress syndrome causes hyaline membranes to form around the alveolar sacs secondary to leakage of proteins and cellular debris.
1. The pathogenesis involves lack of surfactant secretion and subsequent alveolar collapse (atelectasis).
2. The histology shows hyaline membranes surrounding the alveolar sacs. These membranes are made of protein and cellular debris that leaked out of blood vessels.
3. Type II pneumocytes secrete surfactant and they are immature
2. Meningococcal meningitis typically presents with high fever and petechial rash in pediatric patients.
1. You should suspect Neisseria meningitidis to be the causative agent in children who present with high fever and petechial rash. This characteristic rash is present in over 70% of pediatric presentations and is commonly found on the trunk, legs, mucous membranes, and conjunctiva.
2. Listeria monocytogenes is a common cause of meningitis in the newborn because of its potential to be transmitted vaginally but does not present with petechial rash.
3. Meningitis secondary to infection with Haemophilus influenza meningitis has been nearly eradicated in the United States since the initiation of the Hib vaccine and is not a likely agent based on the above presentation.
4. Group B strep (Streptococcus agalactiae) is the most common cause of meningitis in newborns and is typically contracted in the birth canal. This is an unlikely organism in a 16-month-old child.
5. Cytomegalovirus typically presents with fevers, malaise, pharyngitis, and splenomegaly which are symptoms consistent with infectious mononucleosis.
3. Colon biopsy is the definitive diagnostic test in Hirschsprung disease and is taken just distal to the expanded segment (megacolon).
1. Hirschsprung disease is defined by congenital aganglionosis of the distal bowel. Both the myenteric (Auerbach) plexus and the submucosal (Meissner) plexus are absent, resulting in reduced bowel peristalsis and function.
2. The area missing ganglion cells is just distal to the megacolon section, which has expanded due to feces that cannot be pushed passed the affected segment.
4. The treatment of choice for RSV infection in otherwise healthy children is supportive care
1. Asthma is more common > 2 years old and is more commonly associated with allergies.
5. Tracheoesophageal fistula: Tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus, often leading to severe or even fatal pulmonary complications. Most of the time, diagnosis is made immediately following birth or during infancy. The typical presentation includes excessive oral secretions, inability to feed, respiratory distress and gagging with meals. Esophageal atresia with distal TEF accounts for the majority of cases (80%).

Meckel’s diverticulum: Meckel’s diverticulum is the most common malformation of the intestinal tract, occurring in up to 2% of the population. The single most common presenting symptom is painless rectal bleeding in the form of melena, followed by intestinal obstruction from volvulus or intussusception. Occasionally the patient may suffer from painful diverticulitis mimicking appendicitis. Meckel's diverticulum is located in the distal ileum, usually within about 60-100 cm of the ileocecal valve. Remember the rule of 2’s when making the diagnosis: 2% (of the population), 2 feet (from the ileocecal valve), 2 inches (in length), 2% are symptomatic, 2 types of common ectopic tissue (gastric and pancreatic), age 2 the most common age of presentation, and males are 2

times as likely to be affected than females.

Duodenal atresia: Duodenal atresia refers to the congenital absence or complete closure of a portion of the duodenal lumen. The most common presentation is bilious emesis, which begins several hours following the initial post-delivery feeding. Radiographic evidence is of this condition is characterized by the finding known as the “double bubble” sign on abdominal radiography. This occurs due to the presence of gaseous distention in the gastric and duodenal portions of the GI tract. Duodenal atresia results from failure of the duodenal lumen to recanalize during the 8th to 10th weeks of gestation. Polyhydramnios occurs in approximately half of all cases due to impaired a

bsorption of amniotic fluid by the fetal intestines. Malrotation of the intestines and congential heart disease are also frequently present.

Omphalocele: An omphalocele is a type of abdominal wall defect that occurs when the abdominal viscera herniates through the umbilicus into a sac covered by peritoneal tissue and amniotic membrane. Diagnosis is most commonly made by prenatal ultrasound although diagnosis can also be achieved through AFP screening. Polyhydramnios is often noted in utero. Also of importance is that one in ten patients diagnosed with omphalocele with also have Beckwith-Wiedemann syndrome, a condition characterized by exopthalmos, macroglossia, gigantism, hyperinsulinemia and hypoglycemia. Don’t confuse the diagnosis of omphalocele with gastroschisis, a similar

birth defect, but one that does not involve the umbilical cord, and is not enclosed in a membranous sac.

Gastroschisis: Gastroschisis is a congenital abnormality involving the GI tract characterized by the evisceration of intestine through the abdominal wall, just lateral to the umbilicus. Unlike an omphalocele, the mass is edematous, dark in color, and typically appears to be covered by a gelatinous matrix of greenish material. There is no involvement of the umbilical cord.

6. When the areola and papilla form a secondary mound on the breast a female adolescent is considered stage 4 according to breast development. Pubic hair that is adult in quality but is limited to the pubic area, sparing the thighs is also considered stage 4.
1. The mean average age for a female adolescent to be in Tanner stage 4 is 13 years
2. Tanner stage 5 is considered sexually mature with projection of the papilla above the areola and breast mound and adult quality pubic hair that can also be found on the inner thighs.
7. Continuous positive-pressure ventilation (CPAP) with end-expiratory positive pressure, in addition to surfactant replacement therapy, has been linked to a reduced mortality in premature neonates suffering from RDS.
1. IV replacement therapy is also helpful in treatment of this condition but has not been linked to a reduction in mortality.
2. Although intubation may be warranted in some patients, it is not always necessary and should be reserved for neonates unable to tolerate CPAP.
8. 
9. Immunodeficiencies:
1. Bruton’s agammaglobulinemia is an X-linked disease (thus affects mostly boys) characterized by a profound deficiency in B-cells. B-cell deficiency increases the risk for severe bacterial infections especially from encapsulated organisms such as Streptococcus pneumonia. It usually doesn’t manifest until after 6-months of age when infants lose the passive immunity from their mother.
2. DiGeorge syndrome is characterized by lack of a thymus thus a lack of mature T-cells. T-cell deficiency increases the risk for viral, fungal and intracellular bacterial infections. Tetany is a common presentation due to hypocalcemia from lack of parathyroid glands.
3. Chronic granulomatous disease is characterized by a deficiency in NADPH oxidase. Patients have an increased risk for infection with catalase positive organisms such as Staphylococcus and Aspergillus. The diagnosis is confirmed when there is a lack of respiratory burst phase measured by the nitroblue tetrazolium test.
4. C1 esterase deficiency is characterized by recurrent, life-threatening angioedema. It usually presents in late childhood or adolescence. Episodes are provoked by stress, infection and trauma.
5. Chediak-Higashi syndrome is characterized by a defect in neutrophil chemotaxis. It is associated with albinism and neutrophils with giant cytoplasmic granules.
10. Imperforate hymen presents in neonates as a bulging yellow-gray mass at the level of the vaginal introitus and can lead to urinary obstruction. Recall that imperforate hymen is also a cause of primary amenorrhea with cyclic pelvic pain.
1. Pelvic ultrasonography is the study of choice in patients suffering from imperforate hymen.
2. Sarcoma botryoides (B) is a type of interlabial mass and the most common malignant tumor of the lower genitourinary tract in infant females. Vaginal bleeding and the characteristic appearance of a firm grapelike vaginal mass protruding through the introitus are common findings.
3. Direct needle aspiration is useful in the presence of a periurethral cyst
4. Computed tomography is sometimes warranted in cases of sarcoma botryoides.
11. Friedreich’s ataxia is a progressive degenerative disease affecting the dorsal columns and spinocerebellar tracts. It is highly associated with cardiomyopathies.
1. Scoliosis and high plantar arches are common findings.
2. More than 90% of these patients have an associated heart condition, the most common of which is cardiomyopathy.
3. The inheritance is autosomal recessive and in most cases the mutated gene contains GAA repeats
12. Human breast milk should always be recommended to parents over cow's milk. Human milk contains significantly higher levels of vitamin C (approximately 4 times) and carries the appropriate amount of nutrients needed for normal infant development. The only vitamin that is recommended for supplementation in breastfed infants is vitamin D. In addition, infants gain a significant amount of passive immunity from the antibodies in breast milk.
13. Adequate intake levels (AIs) for calcium are:

Age 1-3, AIs 500mg/day

Age 4-8, AIs 800mg/day

Age 9-18, AIs 1300mg/day

Age 19-50, AIs 1000mg/day

Age 51+, AIs 1200mg/day

14. The murmur of a VSD is a harsh pansystolic murmur at the left lower sternal border. An ASD, VSD, or PDA can progress to Eisenmenger’s syndrome.
1. Eisenmenger’s syndrome occurs when a long standing left-to-right shunt reverses and becomes a right-to-left shunt, thus bypassing the lungs and providing the organs with un-oxygenated blood. A congenital cardiac right-to-left shunt would have caused the patient to become cyanotic at a much earlier age
15. Biliary atresia is the most common congenital biliary anomaly. Typical symptoms include variable degrees of jaundice, dark urine, and light stools. In the most cases of biliary atresia, infants are typically full-term, although a higher incidence of low birthweight may be observed. In the majority of cases, acholic stools are not noted at birth but develop over the first few weeks of life. Appetite, growth, and weight gain, however, may be normal.
16. A large renal mass in a 3-year-old patient is most likely Wilms tumor. It is caused by a deletion in chromosome 11. Beckwith-Weidemann syndrome is Wilms tumor in association with organomegaly, macroglossia and neonatal hypoglycemia (due to excess insulin production). The cells of origin for Wilms tumor are mesodermal.
1. Elevated catecholamines is associated with a neuroblastoma which also presents as an abdominal mass in a 2-4-year-old patient. These tumors are normally found in the adrenal medulla, not the kidney Neural crest cells are the origin for neuroblastoma
17. Jaundice:
1. Physiological jaundice starts on the second to third day after birth and usually self-resolves by the end of the week (it may last two weeks in pre-mature infants). It is caused by immaturity of the conjugating enzymes. If the bilirubin rises above 15mg/dL phototherapy may be indicated to prevent kernicterus.
2. Biliary atresia is the most common cause of elevated conjugated bilirubin (direct fraction) in the neonate. Obstructive signs like dark urine and clay-colored stool are suggestive.
3. Kernicterus is an irreversible, potentially fatal complication of elevated indirect (unconjugated) bilirubin. The unconjugated fraction passes the blood-brain barrier and deposits in the basal ganglia. Symptoms include hypertonia, seizures, poor feeding and high-pitched cry.
4. ABO incompatibility causes hemolysis which leads to elevated indirect bilirubin and jaundice. Jaundice usually appears early and is confirmed by a positive Coombs test.
5. Hypothyroidism can also present with jaundice. Other findings include hypotonia, protruding tongue, lethargy and delayed closure of the fontanelles.
18. This patient has delayed puberty, which is defined as no breast development in girls aged 14 and no testicular enlargement in boys aged 14. After a careful history and physical exam, Tanner staging, and growth chart evaluation, the next step is to X-ray the patient’s left wrist to compare her bone age with her chronological age. Tanner stage 1 (pre-pubertal) is not normal for a 15 year-old girl
1. Checking serum TSH, growth hormone and hormone levels, FSH, LH and estradiol, should be attempted next if X-rays of the wrist are not revealing.
19. Cyclophosphamide is an anticancer alkylating agent contraindicated in pregnancy and breast-feeding because it interferes with fetal and infant growth.
1. It is recommended to continue breast-feeding in women with mastitis because it prevents milk stasis. The bacteria cannot survive in the infants GI tract thus it poses no risk.
2. Active, untreated tuberculosis is a contraindication to breast-feeding, not a positive PPD.
3. Breast cancer itself is not a contraindication but the anti-cancer drugs used to treat it could be.
4. Babies born to mothers with active hepatitis B must receive the vaccine and immunoglobin therapy but breast-feeding is not contraindicated.