USMLE Step 2 Lesson 1

Pediatric Highlights for USMLE Step 2

Eduardo Pino, MD
NEWBORN-APGAR
Apgar Score 0

Appearance Blue, pale Body pink, ext blue All pink

Pulse (HR)

<100

>100

Grimace

None

Grimace

Cough

Activity

Limp

Some flexion

Active

Slow irregular

Good

Respiration Absent

NEWBORN-SKIN

Subcutaneous fat necrosis

Erythema toxicum

Acne neonatorum

Milia

Hemangiomas

Mongolian spots

Nevus sebaceous

NEWBORN-HEAD

Caput-scalp swelling, crosses suture lines, resolves in days

Cephalhematoma - subperiosteal bleed, DOES NOT CROSS SUTURES, longer

resolution

Fontanels-large, suspect hydrocephalus, hypothyroid

o

Closure-anterior, 9-18 months

Posterior, birth, 4-5 months

NEWBORN-EYES,NOSE

Eyes
o

Red reflex=lens clear

White reflex=retinoblastoma

Lens opacity=cataract

Aniridia+hemihypertrophy=Wilms

Nose
o

Choanal atresia-blue baby pinks up on crying, catheter doesnt pass nose

NEWBORN-ABDOMEN, GU

Abdomen
o

Masses-polycystic kidney most common

Umbilical hernia-most close by 5 years

Omphalocele-sac

Gastroschisis-no sac

Epispadias, hypospadias-dont circumcise

Undescended testes-bring down after 1 year

Ambiguous genitalia-congenital adrenal hyperplasia (21 hydroxylase most

GU

common)

NEWBORN-BIRTH INJURIES

Fractures-clavicle most common-crepitus

Forceps-facial nerve palsy, bruising

Brachial plexus
o

Erb-Duchenne:C5-C6, if C4, ipsilateral

diaphragmatic palsy

waiters tip

Klumpke:C8-T1, claw hand

NEWBORN-SCREENING

PKU-autosomal recessive
o

mental retardation most common

eczema, musty odor, FAIR HAIR, FAIR SKIN, BLUE EYES

Galactosemia-autosomal recessive
o

jaundice, hypoglycemia, cataracts

Hypothyroid-T4 low, TSH high

o

large fontanel, jaundice, mottled, constipation, large tongue, umb. hernia

NEWBORN-RESPIRATORY

Common signs/symptoms- Cyanosis, tachypnea, nasal flaring, retractions, grunting

Respiratory distress syndrome

Surfactant deficiency, seen in preterm

Ground glass appearance on X-ray

Treat with surfactant, ventilator support

Transient tachypnea of newborn

o

Rapid descent, C/S

Meconium aspiration syndrome

NEWBORN-JAUNDICE

Physiologic
o

Appears >24 hours of age

peaks at 12.9 by 3 days

resolves by 1 week

Pathologic-first day, level >13, lasts > 1week

o

Etiology-hemolysis-Rh, ABO

biliary atresia-direct bilirubin,

acholic stools

Therapy-phototherapy only for indirect

NUTRITION

Breast milk is best for infant

Iron supplement after 6 months

Contraindicationso

active, untreated TB

syphilis

AIDS

herpes if breast lesions

galactosemia

varicella

Formula-20 cal/oz

Whole milk-only >1 yr. Bad for kidneys

GROWTH-HEIGHT

Short stature
hypopituitarism
constitutional delay
familial short stature
deprivational dwarf
Turner
hypothyroidism
chronic disease

Tall stature
normal-familial
obesity

endocrine-GH excess
o

androgen excess

hyperthyroidism

genetic
o

Marfans

Klinefelter

GROWTH-WEIGHT
Failure to Thrive
Malnutrition
Malabsorption
Allergies
Immune deficiency
Chronic disease

Obesity
<5% secondary to syndromes
Risk of obesity persisting to adults increases with advanced age of onset

DEVELOPMENT

Newborn reflexes-most disappear by 4-6 mos, EXCEPT Babinski (18 mos),

parachute (never)

Social smile 4-8 weeks

Rolls onto back 4 mos

Rolls onto stomach 5 mos

Sits with support 6 mos

Pincer grasp 9 mos

3 cubes at 15 mos, 4 at 18, 7 at 24

BEHAVIOR

Attention deficit-inattentive, impulsive,distractible, hyperactive (4:1 males)

Enuresis-primary nocturnal most common

typically males, family history

disorder of sleep/arousal

treatment-time, alarms, imipramine DDAVP

Encopresis-boys more common, usually psychological cause

USMLE Step 2 Lesson 2

IMMUNIZATIONS

NOT contraindications:

Fever<105 after DPT

Mild acute illness in otherwise well child

Concurrent antimicrobial therapy

Prematurity-immunize at chronological age

Family history of seizures

Family history of SIDS

IMMUNIZATIONS

Dont give live vaccines to immunocompromised

Killed polio now recommended for initial series

MMR-most effects 1-2 weeks later

Delayed schedule-give as many as possible

Missed immunizations-dont start over

IMMUNIZATIONS-HIV
Vaccine

No/ Moderate

Severe

Immunosupporess Immunosupress

(Category 1,2)

(Category 3)

DTP

Yes

Yes

OPV

No

No

IPV

Yes

Yes

MMR

Yes

No

Pneumococcal Yes

Yes

Yes

Yes

Influenza

ID-SEPSIS/MENINGITIS

Etiology- Age dependent

o

Neonate-Group B Strep most common

E. coli
Listeria

>2 months-pneumococcus most common

College, military-meningococcus

Clinical-bulging fontanel in infants

o

Kernig, Brudzinski in older

Know CSF findings

ID-SEPSIS/MENINGITIS

Steroids useful in preventing H. flu sequelae

Add vancomycin if Pneumococcus

Rifampin prophylaxis for H. flu, Meningococcus

Vaccines vs. H. flu, S. pneumoniae, N. meningitidis

ID-ENCEPHALITIS

Etiology-viral

Arbo, enteroviruses in seasonal epidemics

HSV most common cause of sporadic

Clinical-more abnormalities of mental function-confusion, delirium, combative, ataxia

ID-ENCEPHALITIS

Diagnosis - PCR from CSF

Temporal lobe involvement suspect HSV

Treatment - acyclovir if HSV

ID-OSTEO/SEPTIC ARTHRITIS

Osteomyelitis
o

S. aureus most common

Sickle cell - Staph, Salmonella

Pasteurella after dog, cat bite

Pseudomonas after sneaker puncture

X-rays turn positive after 10-14 days

Septic arthritis - Staph, also Strep

o

Arthrocentesis test of choice

Differential - cellulitis, JRA, synovitis, ALL

ID-PERTUSSIS

Clinical
o

conjunctivitis

coughing spasms

inspiratory whoop

facial petechiae

Lab-leukocytosis with lymphocytosis

o

positive culture

rapid fluorescent antibody stain

ID-PERTUSSIS

History of incomplete immunizations

Immunize to prevent, erythromycin to close contacts

Erythromycin to patient shortens communicability

ID-RASH DISEASES

Lyme disease-look for Long Island, Conn.

o

Rash-erythema chronicum migrans

Fifths disease-erythema infectiosum

o

Rash-slapped cheek

Parvovirus B19, can cause aplastic anemia

ID-RASH DISEASES

Measles (rubeola)
o

Cough, coryza, conjunctivitis, Koplik

Rash accompanied by fever

Roseola-rash after fever

Rubella-3 day measles, lymphadenopathy

ID-RASH DISEASES

Can immunize against measles, rubella, Lyme

Rocky Mountain Spotted Fever

Look for Carolinas

Rash includes palms/soles

Cat scratch-papule, granuloma, lymphadenitis

o

PCR most sensitive for diagnosis

Kittens transmit more than cats

ID-MISCELLANEOUS

Mumps-orchitis rare before puberty

HIV-most pediatric infections acquired at birth-zidovudine to mother decreases

transmission

Mononucleosis - atypical lymphocytes

o

Ampicillin rash

USMLE Step 2 Lesson 3

POISONING

Acetaminophen-check liver functions

o

Aspirin-ferric chloride test-qualitative

o

antidote: n-acetylcysteine

metabolic acidosis with respiratory compensation in children

Carbon monoxide-cherry red blood

o

antidote-oxygen, hyperbaric

POISONINGS

Tricyclic Antidepressants

Leading cause of death

o

Hydrocarbons - kerosene
o

seizures, arrhythmias

aspiration

Organophosphates - DUMBELS
o

antidote - atropine

POISONINGS

Iron - signs of hemorrhagic gastroenteritis

o

antidote - deferoxamine

Lead - blood lead levels, lead lines

o

antidote - EDTA, BAL

EYE

Conjunctivitis-chemical most common <24h old

o

Chlamydia most common infectious cause in newborn

Strabismus-transient is normal up to 4 months old

EYE

Amblyopia-lazy eye
o

Hirschberg, Cover test

patch good eye

Cellulitis
o

orbital-eyeball doesnt move, proptosis preorbital-eyelids and surrounding

tissue

TEETH-PRIMARY ERUPTION
Lower(Mandibular) Upper(Maxillary)
Central Incisors

5-7 months

6-8 months

Lateral Incisors

7-10 months

8-11 months

Cuspids(canines) 16-20 months

16-20 months

First Molars

10-16 months

10-16 months

Second Molars

20-30 months

20-30 months

TEETH-SECONDARY
Lower

Upper

Central Incisors 6-7 years

7-8 years

Lateral Incisors 7-8 years

8-9 years

Cuspids

9-11 years

11-12 years

1st Premolars

10-12 years 10-11 years

2nd Premolars

11-13 years 10-21 years

1st Molars

6-7 years

2nd Molars

12-13 years 12-13 years

3rd Molars

17-22 years 17-22 years

6-7 years

EARS, NOSE, THROAT

Otitis media
o

Etiology - S. pneumo most common

H. flu nontypable
B. catarrhalis

Meningitis most common intracranial complication

Otitis externa-from repeated wetting

Etiology - Pseudomonas, S. aureus
Clinical-pain exacerbated by moving ear canal

EARS, NOSE, THROAT

Sinusitis - S. pneumo, H.flu, Staph.

Symptoms-purulent nasal discharge headache, sinus tenderness

Epistaxis - nose picking most common

Pharyngitis - viral/bacterial (Group A strep)

o

Throat culture is gold standard

Complications - rheumatic fever

EARS, NOSE, THROAT

Peritonsillar abscess-tonsil bulges, uvula deviates to non-involved side

HOT POTATO VOICE

Retropharyngeal abscess-Strep, look at lateral X-ray of neck

Cervical lymphadenitis-usually infectious

o

Viral/bacterial pharyngitis, TB, cat scratch, rarely tumors

RESPIRATORY

Foreign bodies-peanut most commonly aspirated

o

Look for sudden onset respiratory distress, wheezing, may be witnessed

event

Diagnosis-bronchoscopy, CXR hyper-inflated

Croup-parainfluenza virus
o

Clinical-barking cough, inspiratory stridor

P/A neck film-STEEPLE SIGN

Steroids beneficial

RESPIRATORY

Epiglottitis H. flu type b

o

Age- 3-10 years

Clinical-dysphagia, drooling, muffled voice

CHERRY RED EPIGLOTTIS

THUMBPRINT SIGN on lateral neck

Tx-secure airway, antibiotics

RESPIRATORY

Asthma-Reversible airways disease

o

wheezing is hallmark, no clubbing

Differential-congenital malformations

foreign bodies

cystic fibrosis

bronchiolitis

Tx-bronchodilators, steroids

Prevent-cromolyn, leukotriene antagonist

RESPIRATORY

Bronchiolitis-RSV, children<2 years

o

Clinical-wheezing, rales, tachypnea

Prevention-monoclonal antibodies

Cystic fibrosis-autosomal recessive

o

chromosome 7, long arm

chronic obstruction-clubbing seen

SWEAT TEST

RESPIRATORY

SIDS-most common cause of death 1-12 mo

Peak at 2-3 mo, winter, midnight-9 AM

Sleep position

USMLE Step 2 Lesson 4

CARDIOVASCULAR

Innocent murmur-never diastolic

o

never >2/6

3-7 years of age

best at left lower, midsternal border

musical, vibratory

no significance

CARDIOVASCULAR CLASSIFICATION
STENOTIC

R to L

L to R MIXING

Aortic stenosis

TOF

PDA

Truncus

VSD

TAPVR

Pulmonic stenosis Transposition

Coarctation

Tricuspid atresia ASD

Hypertrophic LH

CARDIOVASCULAR

ASD-systolic ejection murmur

o

WIDE FIXED SPLIT OF S2

PDA-machinery murmur, to and fro

o

wide pulse pressure, bounding pulses

Tx-surgical closure indomethacin

VSD-most common heart defect

o

loud harsh pansystolic murmur

30-50% of small defects close by 1 year

CARDIOVASCULAR

Endocardial cushion defect-Common AV canal

o

Common in Downs syndrome

CHF early-feeding difficulty, sweat while feeding, tachypnea

Coarctation of the aorta-common in Turners

o

Weak/delayed/absent lower extremity pulses, Rib notching on CXR

CARDIOVASCULAR

Tetralogy of Fallot- Most common cyanotic

o

pulmonary stenosis

VSD

overriding aorta

RV hypertrophy

CXR-boot shaped heart,

PE-cyanosis, single 2nd heart sound

Complications-cerebral thrombosis, ischemia, brain abscess

pulmonary markings

CARDIOVASCULAR

Transposition-most common with cyanosis in 1st 24 hrs.

o

Keep ductus open with prostaglandin

CXR-egg on a string

Pulmonary atresia- cyanosis at 2-3 days

Tricuspid atresia- single S2 pansystolic murmur

Total anomalous pulmonary venous return

o

CXR-snowman or figure 8

CARDIOVASCULAR

Rheumatic fever- rheumatic fever-associated with Strep throat

J=joints
O=carditis (O looks like a heart)
N=nodules (subcutaneous)
E=erythema marginatum
S=Sydenhams chorea

minor criteria-fever, arthralgia, previous RF

interval + prior Strep infection

complications-valve disease-mitral, aortic

CARDIOVASCULAR

ESR, CRP, prolonged P-R

Hypertension
o

Essential-no known underlying cause

More common in adolescents

Secondary-more common in infants and children

Look for renal disease-UTI, obstructive lesion of urinary tract, prior umbilical
catheter as newborn

GASTROINTESTINAL
Diarrhea

Viral-rotavirus most common

o

adenovirus, Norwalk virus

Bacterial-E.coli

think of HUS

Salmonella -tx prolongs carrier

Shigella-tx with trimethop/sulfa

Campylobacter-erythromycin

C. difficile-think of prior antibiotic

parasites-Giardia, cryptosporidium

GASTROINTESTINAL VOMITING
Constipation

Voluntary withholding most common (functional constipation) outside of infancy

o

also-imperforate anus

cystic fibrosis-meconium ileus

anteriorly displaced anus

Hirschsprung-aganglionosis

Dx by BIOPSY

GASTROINTESTINAL VOMITING

Age related causes

o

neonate-obstruction

infants-gastroenteritis,

reflux,

allergy,

over-feeding,

inborn

errors

metabolism
o

child/adolescent-gastroenteritis, toxic ingestion, appendicitis, pancreatitis

Duodenal atresia-bilious vomiting common in Downs, DOUBLE BUBBLE

GASTROINTESTINAL VOMITING

Reflux - chronic, cough, vomiting, apnea

o

pH probe is gold standard

Pyloric stenosis - NONBILIOUS, PROJECTILE VOMITING

o

more common in males, firstborn

lab-hypochloremic, hypokalemic metabolic alkalosis

Ultrasound test of choice

GASTROINTESTINAL BLEEDING

Upper-esophagitis, ulcers, gastritis, epistaxis

Lower-neonate-swallowed blood-Apt test

o

necrotizing enterocolitis-premature, low Apgar, pneumatosis intestinalis

other-milk allergy, gastroenteritis, ANAL FISSURE (infants)

GASTROINTESTINAL

Inflammatory bowel disease-ulcerative colitis and Crohns

o

Dx by biopsy

both cause bloody stools, fever, abdominal pain

Crohns-fissures, fistula, abscess

GASTROINTESTINAL

Intussusception-typically 6-18 months

o

Clinical-crampy abdominal pain CURRANT JELLY STOOL

PE-sausage shaped abdominal mass

of

Dx-barium enema-coil spring sign

GASTROINTESTINAL

Meckels diverticulum-disease of 2s
o

2% of population, 2:1 males, 2 years of age, 2 types of tissue, 2 feet from

ileocecal valve

painless rectal bleed, can cause intussusception

Dx-technetium scan

RENAL

Acute Glomerulonephritis
o

triad of hematuria,edema, hypertension

follows Group A Strep infection

C3 decreased

Complications-renal failure, hypertension

Alports

X-linked dominant

Clinical-microscopic hematuria, proteinuria,

HEARING LOSS, CATARACTS

RENAL

Nephrotic syndrome-proteinuria,edema, hypoproteinemia, hyperlipidemia

o

usually follows viral respiratory infection

C3 normal

Complications-INFECTION-peritonitis

Urinary tract infection

o

males more common <1 year, then females

E. coli most common

Urine culture is gold standard

USMLE Step 2 Lesson 5

ORTHOPEDICS

Intoeing
o

Metatarsus adductus-can be brought to neutral

Talipes equinovarus-heel also deviated

Tibial torsion

Femoral anteversion

ORTHOPEDICS

Limping
o

Congenital hip dysplasia-0-3 years, u/s

Legg-Perthes-4-8 years-avascular necrosis of femoral head

Slipped capital femoral epiphysis->11 years obese adolescent, think deficient

gonads

ORTHOPEDICS

Popliteal cyst (Baker)-painless, nonpulsatile

Osgood Schlatter-tenderness, swelling of tibial tubercle

o

common in physically active pubertal children

Radial head subluxation (nursemaid)

o

sudden traction to arm

ORTHOPEDICS

tumors-occur in adolescence, rapid bone growth

o

Osteosarcoma-most common,

bone sclerosis on X-ray

Ewings-onion skin on X-ray

risk if bilateral retinoblastoma

ALLERGY/IMMUNOLOGY

Allergic rhinitis-IgE mediated

o

Clinical-sneezing, rhinorrhea, allergic salute, allergic shiners, nasal crease

Tx-antihistamines, leukotriene antagonists

Hereditary angioedema-C1 esterase inhibitor def.

Brutons-all major immunoglobulins involved

o

symptoms at 6-12 mos.-recurrent infections, esp. pneumococcus

Tx-replace IgG

ALLERGY/IMMUNOLOGY

DiGeorge-T cell deficiency

o

TRUNCUS ARTERIOSUS, fishmouth, micrognathia

NEONATAL HYPOCALCEMIA is 1st manifestation

Wiskott-Aldrich: X-linked recessive

o

MR TEXT-low IgM, Recurrent infections, T(and B) cell deficiency, Eczema,

Thrombocytopenia

RHEUMATOLOGY

Juvenile Rheumatoid Arthritis

Typeso

polyarticular-many, small joints RF-, RF+

pauciarticular-few, large joints

type I-ANA+, girls, iridocyclitis

type II-HLA B27+, boys, ankylosing spondylitis

systemic-fever, rash, then joints

Differential-rheumatic
osteomyelitis, ALL

RHEUMATOLOGY

fever,

SLE,

Lyme,

ankylosing

spondylitis,

Systemic lupus erythematosus-autoimmune

o

BUTTERFLY (malar) rash

renal involvement in children

neonatal lupus-congenital heart block

Mucocutaneous lymph node syndrome (Kawasaki)

o

FEVER+ 4 of 5 of following: conjunctivitis, mucous membrane changes,

peripheral extremity changes, rash, cervical lymph nodes

CARDIAC INVOLVEMENT

RHEUMATOLOGY

Henoch-Schoenlein purpura
o

Rash usually below waist

Usually follows viral illness

Can have renal, GI involvement

HEMATOLOGY
ANEMIA

Iron Deficiency most common

o

cause-low birth weight, diet (9-24 mos) blood loss (ulcer, Meckel, whole
cows milk in infants)

clinical-pallor, irritability, murmur

labs-

differential-lead, thalassemia, chronic disease

tx-iron-see reticulocytosis in 72h,

ferritin,

serum iron,

binding capacity,

Hgb 3-4 wks

HEMATOLOGY
ANEMIA

Hemolytic
o

Hereditary spherocytosis-autosomal dominant

presents as anemia, jaundice

FEP,

Hgb

labs-OSMOTIC FRAGILITY TEST

tx-splenectomy

Enzyme defects-pyruvate kinase, G6PD

HEMATOLOGY
ANEMIA

Sickle cell anemia - develops after 2 months

o

dactylitis 1st manifestation, splenic, bone infarcts, infections (Salmonella,

Pneumococcus)

Dx-electrophoresis

HEMATOLOGY

Idiopathic thrombocytopenia-autoimmune
o

Usually follows viral infection

Petechiae, but patient appears well

Bone marrow-normal

Tx-gamma globulin, steroids

Hemophilia
o

Factor VIII (classic, A)-X linked recessive

HEMARTHROSIS

Replace factor

ONCOLOGY

Acute lymphocytic leukemia-most common childhood cancer

o

clinical-acute onset, anorexia, pallor, fever, bone pain in 1/4

dx-bone marrow

tx-chemotherapy, radiation, transplant

RELAPSE TO TESTES, CNS

Wilms -nephroblastoma
o

abdominal mass

distorts renal outline

ONCOLOGY

Neuroblastoma-many times abdominal,

o

presents anywhere there is neural crest

Increased catecholamines in urine

CNS-most common solid tumors

o

infratentorial (posterior fossa ) most common

cerebellar astrocytoma most common

clinical-morning headache, vomiting

supratentorial-craniopharyngioma cause of short stature

USMLE Step 2 Lesson 6

NEUROLOGY

Seizures
o

Febrile-most common

rapid rise of temperature

generalized, tonic-clonic, 10-15 mins

normal EEG

tx-treat fever

Infantile spasms-West syndrome

EEG-hypsarrhythmia

tx-ACTH, prednisone

Petit mal-3/sec spike/wave, ethosuximide

NEUROLOGY

Progressive mental retardation

o

Lesch-Nyhan-self-mutilation

gouty arthritis

Wilsons-disorder of copper metabolism

initial signs are liver related

Kayser-Fleischer rings

Mucopolysaccharidoses-Hunter-X linked recessive, all others autosomal

recessive

Tay-Sachs-lose developmental milestones, cherry red macula

NEUROLOGY

Werdnig-Hoffman-spinal muscular atrophy

o

Severe hypotonia-floppy baby

Fasciculations, FROG LEG POSTURE

EMG-fibrillations

muscle bx-denervation

nerve bx-slowed conduction

Autosomal recessive

Guillain-Barr-follows viral illness

o

Ascending weakness, paralysis, lose deep tendon reflexes

tx-supportive, plasmapheresis, IVIG

NEUROLOGY

Duchenne muscular dystrophy-X linked rec

o

most common inherited neuromuscular disease

Hip girdle weakness, Gowers sign

dx-greatly elevated creatine kinase, muscle bx

Neurofibromatosis-von Recklinghausen
o

Caf-au-lait spots, axillary/inguinal freckling

Lisch nodules, neurofibromas, acoustic neuroma

autosomal dominant, risk for malignancy

NEUROLOGY

Tuberous sclerosis-autosomal dominant

o

Ash leaf spot, sebaceous adenomas, shagreen patch, periventricular

calcified tubers on CT
o

seizures very common

Sturge-Weber-facial nevus-port wine stain

o

seizures difficult to control

intracranial calcifications

mental retardation

ABUSE

Clinical-unexplained injury
o

physical and injury dont correlate

lash marks, loop marks

bite >3 cm=adult

RETINAL HEMORRHAGE=shaken

old healing fractures, bruises

venereal disease in prepubertal child

Tx-treat any injury, infection

o

document, REPORT

ADOLESCENT

Know Tanner stages

Breast buds 1st sign of puberty in females

Testicular enlargement 1st sign in males

Mortality-Accidents, especially motor vehicle

o

Suicide-males more successful

Homicide

Cancer-leukemia, Hodgkins, bone

Normal-breast asymmetry, gynecomastia, irregular menses

Acne-hormones, dirt, bacteria

Pediatric Highlights for USMLE Step 2

Eduardo Pino, MD

End