Understand the various physiologic functions of the renal system.  L2 

• Glomerulus filters.
• Collecting duct reabsorbs, secretes, excretes.
• The kidney's basic role is to defend the circulating volume, no matter what.

Understand the relationship between serum creatinine levels and renal function. L1

• Serum creatinine levels and renal function are inversely related.  As serum Cr ↑, renal function ↓

Develop a differential diagnosis for “red urine” or a hemoglobin-positive rapid urine dipstick. L2

• Glomerulonephritis
• Interstitial nephritis (consider in setting of sterile pyuria)
• Cystic kidney disease
• UTI
• Nephrolithiasis
• Obstruction of urinary tract
• Viral cystitis
• Tumor (rarely causes hematuria)
• Trauma
• FB

Construct an evaluation for a pediatric patient presenting with “true” hematuria. L3

• Hx
  • Fever, recent URI sxs, pain
• Physical
  • Edema, heart & lung sounds (crackles or a gallop bc of fluid expansion?), rash, joint swelling or tenderness?
  • BP and VS
• Labs/Diagnostic Eval
  • BUN, Cr, electrolytes, albumin if edematous
  • Renal u/s
  • Urine C/S

Differentiate between upper and lower urinary tract bleeding. L2

• Upper tract
  • Brown/"smoky" urine
  • + RBC casts and dysmorphic red cells
  • Proteinuria 2+ or greater

• ---

  Lower Tract
  • Tends to be Bright Red Urine
  • Eumorphic red cells
  • Minimal associated proteinuria
  • Dysuria, flank, or loin pain

Presentation and findings in patients with post-streptococcal glomerulonephritis. L3

• Post-strep Glomerulonephritis
  • Presentation
    • 2-3 weeks after strep/URI
    • Grossly bloody urine x 5-7d
    • NO PAIN
  • Findings
    • + ASO or Streptozyme
    • C3 low for 4-6 wks
    • Possible significant Htn, edema

Presentation and findings in patients with IgA nephropathy. L3

• Presentation
  • Recurrent episodes of grossly bloody urine usually with supraimposed illnesses
  • + loin pain
  • Most common in adolescent males
• Findings
  • Nl C3
  • Potentially high serum IgA (high rules disease in, but low doesn't rule dz out)

• Presentation
  • Younger children
• Findings
  • Rash on LE
  • +/- bloody diarrhea
  • Joint swelling and tenderness
  • Scalp edema
  • at renal level, histologically identical to IgA nephropathy

• Presentation
  • Generally seen in teenage females
  • More common in AA and Hispanics
  • Fever
  • Malar Rash
  • Joint sxs
• Findings
  • Check C3, ANA, anti-dsDNA

• Presentation
  • Microhematuria
  • Proteinuria
  • May look like acute Post-strep glomerulonephritis
• Findings
  • Persistent low C3
    • if C3 doesn't return to nl, then consider this
  • Persistent proteinuria

Construct a differential diagnosis for lower urinary tract bleeding. L2

• UTI
• Nephrolithiasis
• Obstruction of the urinary tract
• Viral cystitis (most commonly adenovirus causing trigonitis)
• Tumor
• Trauma
• FB

Design an evaluation for a pediatric patient presenting with hematuria. L3

Define proteinuria and translate a rapid urine dipstick result into approximate values for urinary protein loss. L2

• Proteinuria is abnormal amounts of protein spilled in the urine.  Normal is spilling less than 200 mg/d (negative or trace dipstick); proteinuria is >200mg/d.
• Urine dipstick of 1+ or more is abnl.
• 1+ = 30mg/dl
• 2+ = 100mg/dl
• 3+ = 300mg/dl
• 4+ = 1000mg/dl

Understand the typical presentation and findings in orthostatic proteinuria. L2

• Defined as an exaggeration of the nl ↑ in proteinuria assoc with activity
  • Most common reason to see proteinuria in an otherwise healthy individual
• Presentation
  • Generally in asymptomatic adolescents with isolated proteinuria.
  • Nl BP, nl physical,  nl serum Cr, nl anatomy, must NOT have assoc hematuria.
  • Morning Pro:Cr<.2, Afternoon higher but NOT in nephrotic range.

Presentation, findings and tx of nephrotic syndromes. L3

•  Presentation
  • Typically present < 6 y/o, but can occur at any age
  • Periorbital swelling
  • Oliguria
  • Edema and fluid retention
    • may cause dyspnea
  • Possible hypotension d/t significant "third-spacing" of plasma volume
• Findings
  • Significant proteinuria
    • 2+ dipstick
    • Pro:Cr > 2.0
  • Low serum albumin
    • <2.5 gm/dl (bc so much is being lost through the urine and contributing to proteinuria)
  • Assoc hyperlipidemia
  • Complications may include:
    • ↑ risk of infxn by any encapsulated organism (classically pneumococcal peritonitis)
    • ↑ risk of clotting bc of loss of anti-thrombin 3
    • Assoc Htn
    • Compromising edema leading to dyspnea, tissue breakdown, difficulty voiding, and hernia formation
• Tx
  • Prednisone 2 mg/kg/d (max 80 mg)  daily x 6 wk then transition to alternate days, followed by slow taper.
  • If no remission by 6 wks of daily tx, then "pulse" tx.
  • Follow BP, edema, and UA

• Presentation
  • Most common cause of nephrotic syndrome
  • Typically presents in young children
  • Signficant periorbital and pretibial edema
  • +/- ascites
  • Rarely may be hypertensive
• Findings
  • Serum albumin <2.5 gm/dl
  • Cr may be low
  • Should not have significant hematuria
• Tx
  • Extended course of prednisone

• Presentation, Findings and Tx
  • Generally presents in older chldren (> 6y/o)
  • Cause of nephrotic syndrome
  • More commonly ↑ BP and Cr
  • More likely to have hematuria
  • Cause of corticosteroid resistant or frequent relapsing nephrotic syndrome
  • More prone to progressive kidney failure and developing ESRD, but this can recur after transplant occurs

• Another cause of nephrotic syndrome; severity ranges in between Nil disease and FSGS
• May present at any age
• Immunoflourescence of Bx: + IgM
• Tx: prednisone (more likely to respond than FSGS, but less so than Nil)

Design an evaluation for a pediatric patient presenting with proteinuria. L3

Distinguish between the pathophys, Hx, PE, and lab findings of pts with pre-renal, post-renal and intrinsic acute renal failure.  L2

• Pathophys
  • Pre
    • Results from ↓ renal perfusion
    • Either ↓ effective circulating volume or renal arterial occlusion
  • Intrinsic
    • Renal tissue is directly damaged/affected
  • Post
    • Nl urine flow is impeded either congenitally or acquired obstruction
• Hx
  • Pre 
    • oliguria
    • Decr effective circulating volume-Blood loss, dehydration, HF, sepsis, ACEI use
    • NSAID use leading to renal arterial occlusion
  • Intrinsic
    • poly or oliguria
    • URI sxs
    • PCN or cephalosporin exposure
  • Post: poly or oliguria
    • 
      
• PE
• • Pre: sepsis, hypovolemia, hypotensive
  • Intrinsic: 
  • Post: palpable bladder, abdominal masses
• Labs
• • Pre
    • Relatively greater BUN than Cr
    • Low urine Na+
    • High urine spec grav
  • Intrinsic
    • Relatively greater serum Cr
    • High urine Na+ (most meaningful in setting of low urine, since it indicates the oliguria is functinoal and defending volume)
    • Active urine sediment
  • Post
    • High urine Na+
    • Low urine spec grav

Define arthritis and understand the criteria for the diagnosis of juvenile rheumatoid arthritis, also known as juvenile idiopathic arthritis. L1

• Defn
  • Joint swelling or effusion OR
  • Presence of two or more of:
    • Limited ROM
    • Tenderness or pn with motion
    • Warmth
• Dxn Criteria of JRA/JIA
  • Age of onset < 16 y/o
  • Arthritis in 1+ joints
  • Duration of Disease >6wks
  • Exclusion of other forms of juvenile arthritis
  • Onset type (systemic, polyarticular, pauciarticular, oligo, enthesitis) defined by type of disease in the first 6 months

Differentiate the presenting symptoms, findings, and potential complications of pediatric patients with systemic JIA, oligo JIA, poly JIA, and spondyloarthropathies.  L3

• Systemic JIA
  • Presenting Symptoms
    • Arthritis (generally polyarticular, affecting both large and small joints)
    • Fever of >39C with rapid return to baseline or lower (qd or bid, often in late afternoon or evening)
    • Rash that rarely persists in one location >1hr, is commonly on the trunk, proximal extremities and over pressure areas.
      • Discrete salmon-pink macules of different sizes
      • AKA Still's Rash
  • Findings
    • Hepatosplenomegaly
    • Lymphadenopathy
    • Serositis
    • Hepatitis
    • Tenosynovitis
    • Joint fluid will have ↑ PMNs and low glucose
  • Potential Complication
• Oligo JIA
  • Presenting Symptoms
    • arthritis >4 joints, assymetrically large joints
    • Leg length discrepancy and muscle atrophy
  • Findings
    • Uveitis (inflammation of iris, ciliary body)
      • +ANA ↑ risk of uveitis
  • Potential Complication
• Poly JIA
  • Presenting Symptoms
    • Arthritis in >5 joints by 6 mo
      • Both lg and small joints in a symmetric pattern
    • Possible low-grade systemic sxs (fatigue, anemia of chronic disease, growth failure)
  • Findings
  • Potential Complication
• Spondyloarthropathies
  • Presenting Symptoms
    • Enthesitis (inflammation at the insertion of tendons) leading to heel pain, plantar fasciitis, tendonitis, SI joints
    • Acute iritis
  • Findings
    • Early peripheral arthritis with late axial involvement
    • Absent RF and ANA
    • HLA-B27 +
  • Potential Complication
    • Aortic valve insufficiency

Understand the appropriateness of laboratory testing (ESR, ANA, RF, and CCP) and x-rays in patients with suspected JIA.  L2

• ESR
  • markedly ↑ with acute systemic arthritis
  • Mildly ↑ with polyarticular involvement
• ANA
  • primarily useful in oligoarticular JIA for determining risk of uveitis
• RF
  • Only helpful in determining prognosis in polyarticular JIA (all other JIA forms will be RF- anyway)
• CCP
  • CCP have high specificity for JIA (100%, means helpful for ruling disease IN; positive test means really positive), but relatively low sensitivity (means that negative results don't rule the disease out)
• X-rays
  • Not diagnostic of early JIA
  • primary purpose in early disease is to exclude other conditions that may be assoc with bony changes

Design a differential diagnosis of a pediatric patient presenting with painful joints. L3

• Infectious
  • Bacterial: sepsis, septic arthritis, osteomyelitis
  • Viral: parvovirus, EBV, reactive arthritis
• Malignancy
  • Leukemia
  • Neuroblastoma
  • Other: lymphoma, rhabdo, osteosarcoma, Ewing's
• Rheumatic diseases
  • Rheumatic fever
  • SLE
  • Other: dermatomyositis, vasculitis, mixed connective tissue disease
• Other
  • Growing pains
  • Complex regional pain syndrome

Differentiate between the presentation, physical exam findings, and lab/x-ray evaluation of a patient with reactive arthritis and septic arthritis.  L3

• Reactive Arthritis
  • Presentation
    • Acute onset
    • Usually unilateral hip or groin pain, but may also be polyarticular pain that migrates
    • Otherwise well, excepting for mild systemic symptoms (fever, malaise)
    • May have recently had URI
  • PE Findings
  • Lab/XR Eval
• Septic Arthritis
  • Presentation
    • Rapid onset of joint pain progressing to systemic illness with clinical signs of sepsis and refusal to use extremity
  • PE Findings
    • Irritable, toxic-appearing
    • Holds joint rigidly
    • Significant pain with any movement
    • May have assoc swelling, redness and warmth (but may be absent for deep joints such as hips, shoulders)
  • Lab/XR Eval
    • Labs
      • Peripheral WBC and ESR usually ↑
      • Bacterial etiology found in 50-70% of appropriate cultures (blood, synovium)
    • XR
      • May not be helpful early, but may show subtle ↑ in joint space/soft tissue swelilng
    • US
      • May reveal joint effusion
    • Joint Aspiration
      • Mandatory for cell count, gram stain, and culture (if septic hip suspected)
      • Usually >100,000 WBC with >90% PMNs

Recognize the epidemiology, presentation, laboratory evaluation, and potential complications of patients with systemic lupus erythematosus. L2

• Epidemiology
  • 5-10k children in US with .6/100,000 children/year
  • Females>Males, AA>Asians>Latinos>Caucasians
  • Peaks in late adolescence - young adulthood
• Presentation
  • Malar Rash
  • Discoid rash
  • Photosensitivity
  • Oral/nasal ulcerations
  • Serositis
  • Arthritis
  • Nephritis
  • CNS disease
  • Heme abnormalities
  • ANA positivity
  • Positive SLE serologies
• Lab Evaluation
  • ESR (nonspecific elevation)
  • ANA (+ in 95% of SLE)
  • Extractable Nuclear Antibodies
    • Smith
    • Ribonucleoprotein (RNP) (High titer in Mixed CT disease)
    • Anti-DNA antibodies (specific to SLE; correlates to disease activity, esp renal)
  • CBC
  • UA with micro
  • Electrolytes, BUN, Cr to investigate for other causes
• Potential Complications
  • Premature MI
  • Osteoporosis (nosocomial)
  • Infertility (nosocomial)
  • Future malignancy
  • Psychosocial impairment
  • Infections
  • CNS involvement
  • Pulmonary hemorrhage
  • GI bleeding
  • Renal complications
  • MI
  • Malignancy

Given the blood pressure normative values for children, classify a pediatric patient’s blood pressure as: normal, high, significant or severe. L1

• Nl BP <90%ile
• High BP 90-95%ile
• Significant 95-99%ile
• Severe > 99%ile

Understand the relative risk of various etiologies of secondary hypertension in a pediatric patient with elevated blood pressure. L2

• When <12 y/o, secondary etiologies compose 70-85% of Htn.
• When 12-18, secondary etiologies compose 5-15%
• Pathology of Renal parenchyma: 60-70%
  • Glomerulonephritis
  • Interstitial nephritis
  • HUS
  • PUV
  • UPJ obstruction
  • Renal cystic disease
• Aortic coarctation: 10-20%
• Renovascular: 5-10%
• Endocrine: 3-5%
• Tumor: 1-5%
• Other: 1-5%

Design an evaluation of a pediatric patient with hypertension. L3

Hx portion

• Hx
  • PMH
    • Including birth history (prematurity, etc)
    • Prior hx of UTI
  • Meds Hx
    • OTC meds, decongestants, receational drugs
  • FHx
    • Htn, renal dz, DM, CVD, hyperlipidemia, inherited dz and other syndromes
  • HA, epistaxis, visual disturbances
    • Renal etiology htn sxs: gross hematuria, edema, enuresis, recurrent UTI
    • CV: CP, dyspnea, palpitations
    • Endocrine: sweating, wt gain/loss, constipation, diarrhea, flushing
    • Rheumatologic: rash, joint sxs, fever
    • CNS: neurologic complaints

• Growth with wt and ht %ile
  • Poor growth in chronic renal insufficiency
  • Changes in wt with: thyroid dz (hyper OR hypo), pheochromocytoma, cortisol excess
• VS
  • Get LE BP measurement (should be higher than in arms)
  • Fever (rhematologic dz)
  • Tachycardia (hyperthyroidism, pheochromocytoma)
  • Bradycardia (hypothyroidism)
• Thyroid Exam
• CV exam
  • murmur suggestive of coarc (Loud murmur best at 2nd ICS radiating to L axilla)
• Fundoscopic exam
  • Hypertensive retinopathy
  • Incr ICP
• CNS
  • Abnl suggestive of CNS tumor or incr ICP

Recognize the typical findings and treatment of the following disorders of the ear auricle: pre-auricular pit, auricular hematoma and perichondritis. L2

• Preauricular pit: a dimple at the anterior portion of the helix  that is a congenital malformation.  It can be left alone or be removed for cosmetic reasons (but when removed, all the skin and soft tissue along its tract must also be removed).  If it gets infected, tx with ABX and then refer to ENT for excision.
• Auricular hematoma: large protrusion in the scaphoid fossa that signifies a hematoma between the cartilage and the perichondrium.  Should remove to prevent cosmetically undesirable scarring.  To remove, make an incision, remove the blood clot, and then sew a dental roll on either side x 1 week to press the cartilage against the perichondreum.
• Perichondritis: infection of the cartilage.  Will see distinct erythema that only overlies the areas of cartilage (spares the lobe).  Usually the result of cartilage piercing.  Will need abx that can penetrate cartilage: Augmentin, Fluoroquinolones

Recognize the typical findings and treatment of the following disorders of the auditory canal: otitis externa, granulomas, exostosis, and osteomas. L2

• Otitis Externa
  • Findings: inflammation of the skin lining the ear canal and surrounding soft tissue; pn and itching in the ear (esp with chewing or pressure on the tragus; movement of pinna and tragus cause pain). Drainage may be minimal (until it's from draining PET or TM perf); ear canal is swollen shut, debris is noticeable in the canal.  Often impossible to visualize the TM.  Hear is nl unless complete occlusion has occured.
  • TX: Ototopical FQ drops x 5-7d; if canal is too edematous for drops to get through, place a Pope ear wick (expandable sponge) x first few d for ABX delivery.  Oral+topical abx if any signs of systemic illness (cellulitis of auricles, fever, tender postauricular lymph nodes).  F/u in 1 wk to document intact TM.  Avoid swimming (cotton ear plug is not helpful)
• Granulomas:
• Exostosis
  • Findings: bony growths in ear canal that result from swimming in cold water; usually more than one (can tell it's bone and not pus by touching it; if it's bone, it will induce pain/discomfort).
  • Tx: none unless skin is trapped and it gets infected.
• Osteomas
  • Findings: usually single, benign bony tumor in the canal that can occlude canal (impeding epithelial migration) or grow to touch the TM
  • Tx: excision

Differentiate the clinical findings, treatment and potential complications of the following tympanic membrane/middle ear disorders: tympanosclerosis, TM performations, TM retractions, and cholesteatoma.  L3

• Tympanosclerosis
  • Clinical Findings: bright white plaque on the TM, but is surrounded by nl appearing TM; this area will move with pneumatotoscopy
  • Tx: none
  • Potential Complications: none
• TM perfs
  • Clinical Findings: shiny middle ear mucosa is visible through the TM
  • Tx: refer to ENT if not healed after 2 weeks or immediately if dizzy.  Most will heal spontaneously, but if not healed soon, surgical intervention will be necessary.
  • Potential Complications: Hearing loss; inner ear fluid leakage possible if dizzy
• TM Retractions
  • Clinical Findings: abnl/no light reflex; pars flaccida is sucked in around the middle ear, may see all the bones of the middle ear clearly.
  • Tx: Ear tubes
  • Potential Complications: chronic infection, ossicular damage (the bones of the middle ear may get resorbed d/t chronic pressure of the TM), conductive hearing loss, and acquired cholesteatoma
• Cholesteatoma
  • Clinical Findings: greasy looking or pearly white mass seen in a retraction pocket or perforation and is not surrounded by nl TM; +/-dc
  • Tx: refer to ENT
  • Potential Complications

Understand the risk factors for the development of pediatric urinary tract infections. L2

• Males < 1 y/o
• Females < 4 y/o
• Lack of circumcision
• Obstructive urologic abnormalities (VUR, UPJ obstruction, posterior urethral valves
• Dysfunctional Voiding

Compare the diagnostic accuracy of various exam and laboratory tests in pediatric patients with suspected urinary tract infections. L2

• Urine dipstick is 88% sensitivity at best (for ruling out UTI)
  • if nitrite and leukocyte esterase (LE) +: good chance of UTI
  • Nitrite or LE positive: 50% chance of UTI
  • Nitrite and LE negative: still 7% chance of UTI
• Standard microscopy: 65-80% sensitivity
• Enhanced UA: >90% sensitivity
• Urine Culture: Gold Standard

Design an evaluation of a pediatric patient with suspected and confirmed urinary tract infection.  L3

• Clinical Features (based on age)
  • Full term <3 m/o: fever (so should follow fever protocol to find UTI), FTT, jaundice (conjugated) and/or vomiting
  • Preterm <3m/o: feeding intolerance, apnea/bradycardia, lethargy/tachypnea
  • Children <2y/o: suprapubic tenderness (elicited), FWS (>39 or 102.2) >48 h, Fever >40 (104), lack of circumcision, Hx or FHx of previous UTIs
  • Verbal children: ab pn, new-onset enuresis, back pn, dysuria and/or frequency
• Important H&P clues
• Dysfxnal elimination
• Previous UTI or frequent undxn febrile illnesses
• FHx: UTI, urologic abnormalities
• Elevated BP and poor growth
• Enlarged bladder or kidney(s)
• Bladder/CVA tenderness
• External genitalia exam
• Lower back exam
• Urine dipstick
• Urine Culture
• Renal U/S ASAP
  • All proven pediatric febrile UTI
  • All pediatric UTI with FH of renal disease, urologic abnormalities, poor growth
• Voiding Cystourethrogram (VCUG)
  • Done as soon as asymptomatic/convenient with the same indications as renal u/s

Differentiate the management of pediatric febrile urinary tract infection vs. uncomplicated cystitis. L2

• Pediatric Febrile UTI
  • Hospitalize <2m/o, ill-appearing, immunocompromised, vomiting/intolerance of oral meds, concern about adequate f/u, failing outpt oral tx
  • Blood c/s not needed for pts treated under outpt
  • Outpt therapy
    • 2nd and 3rd generation cephalosporins (Cefixime is strawberry flavored; can give Ceftriaxone injection) x 10d
      • follow closely for first 2-3 d
      • Change ABx as needed when C/S returns
      • If concerned about enterococcus (chronic cath pt): add amoxicillin
    • Repeat urine c/s not needed if clinically resolved
• Uncomplicated cystitis
  • 2-13 y/o: 2nd or 3rd gen cephalosporin x 5-7 d
  • 13+ y/o: TMP-SMX or cephalosporin x 5-7 d
  • Renal US/VCUG indicated for:
    • <3 y/o with 1st UTI
    • All boys with UTI
    • All with recurrent UTI, not previously imaged

Understand the expected clinical course of vesicoureteral reflux (VUR) and its management, including the risks associated with poor management. L2

• Grades I and II: likely to outgrow by age 5
• Grade III: <2 y/o and unilateral disease have greater chance for resolution; otherwise, will require surgery
• Grade IV: unilateral disease will have more resolution (otherwise, will require surgery)
• Grade V: rarely resolves spontaneously; almost always requires surgery
• Management Options
  • Prophylactic ABx/watchful waiting to see if they outgrow it
  • Surveillance with prompt tx of febrile UTI
  • Open surgical reimplantation (>95% success)
  • Endoscopic correction (75-85% success, but less invasive)
• Poor management incr risk of renal scars and decr renal fxn

Design an approach to the management of a pediatric patient presenting with nocturnal enuresis.  L3

• UA to r/o pathology
• Assess commitment and motivation of parents and, most important, child.
  • Tx will take several months
  • Suggest reward charts for dry nights
• Bladder Training
  • Check the volume weekly: target volume (oz)=age (yrs) + 2)
• Fluid Management
  • 40% before noon, 40% from 12-5 pm, 20% after 5 pm, no caffeine after 5 pm
• Bed-wetting alarms
  • Relatively inexpensive (50$)
  • Need 12-16 wks for success
  • Teach child what to do when the alarm goes off (strip the bed, change pajamas, put sheets and wet pjs in the washing machine and turn it on, etc).  Everytime they remember the procedure and do it, they get a star.
• Meds
  • ADH (.2 mg initially, titrate to .6 mg over 2 weeks; helpful for overnight camp, but not for long term use. Once the meds are stopped, the enuresis returns)

Understand the relative risk of cross-reactivity among various allergens. L2 

• If allergic to __________, then cross-reactivity risk with _______________ is ____________________
  • legume (peanut), other legumes (beans, lentils, peas) is about 5%
  • Tree nut, other tree nuts about 37%
  • fish, other fish 50%
  • Shellfish, other shell fish about 75%
  • grain, other grains about 20%
  • Cow's milk, beef about 10%
  • Cow's milk, goat's milk about 92%
  • Cow's milk, mare's milk (from horse) about 4%
  • Pollen, fruits/vegetables about 55%
  • Peach, other rosaceae (apple, plum, cherry, pear) about 55%
  • Melon, other fruits (watermelon, banana, avocado) about 92%
  • Latex, fruits (kiwi, banana, avocado) about 35%
  • Fruits (kiwi, avocado, banana), latex about 11%

Understand the evaluation of a child presenting with suspected dysfunctional voiding.  L2

• Sxs: urgency, holding maneuvers
  • Late sxs: hesitancy, dribbling, straining,
  • Assoc with constipation, UTIs and possibly ADHD
• Labs
  • UA (preferably first morning)
    • If proteinuria-serum creatinine
  • Urine Cx
  • If obstruction suspected, renal u/s

Design an approach to managing a child with dysfunctional voiding.  L3

• Behavior Modification
  • Timed voids q 2-3h
  • Treat constipation
  • Urinate prior to urgency
  • Don't strain to urinate
  • Wait until the show ends!
  • Avoid caffeine, bubble baths
  • Rewards for program adherence
  • May need urology consult

Understand the expected course, risks, and management associated with undescended and retractile testes. L2

• Expected course
  • Most undescended testicles descend spontaneously, most by 6 m/o
  • Retractile testicles may represent an undescended testes; with growth, the spermatic cord may be too short and ascend
• Risks
  • testicular Ca (even with descended)
  • Poor fertility (in both testicles)
  • Testicular torsion
• Management
  • Note retractile testicles and examine annually until puberty (be sure to examine while sitting cross-legged)
  • Surgery recommended b/t 6 and 12 m/o OR
  • Hormonal Tx with hCG or GnRH

Recognize the signs and symptoms of balanitis and balanoposthitis.  L1

• Balanitis/balanoposthitis: pain, swelling, erythema of the glans penis, penile dc and dysuria
  • balanoposthitis involves the foreskin (so it only occurs in uncircumcised)
  • Assoc with poor hygeine (xs smegma) or aggressive cleaning with soap (after xs smegma)
• Be sure to examine for tender, palpable bladder-urinary retention (for urgent referral)

Design a management plan for a patient presenting with balanitis or balanoposthitis. L2

• If Candida: topical bacitracin, bactroban, or nystatin
• If GAS suspected: Cx and oral abx
• Proper hygeine
  • Teach parents of uncirc boys how to slide a catheter under the foreskin and flush it out gently; xs rough cleansing is unnecessary.
• If urinary retention/recurrence: urology referral
  • if recurs: medically necessary circumcision

Identify the appropriate management for children with suspected hearing loss. L2

• Refer to audiologist and otolaryngolotist
• If conductive: will need to fix fluid or buildup
• Sensorineuronal Hearing Loss: not reversible, fixed with amplification (possible cochlear implant)

Understand the indications for ENT referral of ear disorders. L2

• Continuous infections of pits
• Osteoma/exostoses removal
• FB you can't remove
• Perfs with vertigo or not healed in 2 weeks
• Ear tubes
• Mastoiditis
• Complicated OM (not healing like it should)

Understand the typical presentation and causes of chronic renal failure. L2

• Presentation
  • Most commonly d/t congenital malformations (renal dysgenesis)
  • Anemia
  • Growth Failure
  • Protein-calorie malnutrition
  • Retention of phosphate and lowered Ca2+
  • Disturbed H20, Na, K, acid-base balance
  • Accumulation of uremic toxins
• Causes
  • Malformations: Reflux, Obstruction, Hypoplasia
  • Hereditary conditions: PKD, Alport's syndrome, Cystinosis
  • Vascular: HUS, Renal Vein Thrombosis, Ischemic injury
  • Glomerulonephritis

Recognize the typical presentation of a patient with hemolytic-uremic syndrome. L2

• Usually follows diarrheal illness (with E. coli)
• Most commonly in young children, < 5y/o
• Begins with prodrome of abdominal pain, diarrhea, and vomiting.
• Followed by oliguria, pallor, and bleeding manifestations (usually GI)
• Htn and szs develop in some, who also develop severe renal failure and fluid overload
• Profound anemia, thrombocytopenia
• Hematuria, proteinuria

Design an approach to an infant with a history of prenatal hydronephrosis. L2

• Obtain postnatal renal US
• If it shows nl, then it's unclear what occurred.  No need for further procedures
• If it shows hydronephrosis, then obtain VCUG.
  • If VCUG indicates nl, then mild hydronephrosis is likely.  Repeat RUS in 6 mos.
  • If VCUG reveals Vesicourethral Reflux (VUR), then moderate-severe hydronephrosis.  Obtain Lasix Enhanced Renal Nuclear Scan.

Understand the typical presentation of a patient with urinary tract obstruction. L1

Understand the typical presentation of a patient with urinary tract obstruction. L1

Design an evaluation for a patient suspected of having the most common types of urinary tract malformations: vesicoureteral reflux and ureteropelvic junction (UPJ) obstruction. L3

Understand the typical presentation and evaluation of a patient with renal tubular acidosis. L2

• Growth failure
• Occasional GI disturbances (N/V)
• May have high urine output
• Episodes of dehydration
• Electrolyte disturbances
• May have rickets d/t chronic acidosis
• May have renal stones or nephrocalcinosis

Design an evaluation of a pediatric patient with hypertension. L3