NMT10 Medad Illustrations For Children Examination

Clinical Pediatrics 2nd Edition
Pediatrics X-rays
Prepared by
Maysa Marwan
Mohamed El Far
Typed by
Medical
Sources
Lectures of Prof Dr El Bledy

Notes of Prof Dr Mostafa Zakria
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Notes of Medad Team 10
X ray chest
Any pathology in lung either
1- radio opaque
2- Radio lucent opacity
1- Radio opaque

1- consolidation = pneumonia
2- collapse
3- effusion
How to differentiate?
1-
A- If the lesion is all heterogeneous
Consolidation
B- If the lesion is all homogenous

1-collapse
OR
2- effusion
a- If the trachea and the mediastinum are pulled to the same

side of opacity it is collapse + lobe collapse
b- If the trachea and the mediastinum are shifted to the other
side it is effusion + Effusion
2- Radio lucent opacity

1- pneumatocele
2- pneumothorax
3- emphysema
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1- pneumatocele :
cystic
Scattered in lung
Surrounded by radio opaque shadow of pneumonia
Usually caused by klebsiella & staph.
2- pneumothorax :
Homogeneous jet black opacity

Associated with lung collapse
So you will find the lung associated with tracheal air column &
mediastinum shifted to opposite side
3- emphysema :
broncho vascular markings are present

No jet black opacity
NB: never say jet black opacity in any chest x ray comment except in
( pneumothorax)
Cardiac shadow diminished
Ribs are separated with widen intercostal spaces
ribs
NB: Lung abscess versus pneumatocele

1- thick wall
2- horizontal fluid level
3- radio opaque base
Comment on any chest x ray

1- chest x ray : postero anterior view
2- centralization
2clavicles
If in same level: pt is well centralized
If not: pt is not well centralized
3- describe pathology in lung and start with the more affected lung if
both lungs are affected
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4- give full diagnosis

NB: Obliteration of the angle will be seen in all pleural effusion. But it
may occur due to collapse.
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Pediatrics CT Scans
Prepared by
Ibn El Waleed
Mohamed El Far
Typed by
Omaregy
Sources
Lectures of Prof Dr Mohamed Hesham

Book of Prof Dr Mahomoud El Naggar
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CT scans
Background:
outside view:
anterior: frontal lobe

lateral: temporal lobe (temporal lobe is a lateral lobe)
posterior: occipital lobe
Sagittal section:
anterior: frontal lobe

middle :parietal lobe (temporal lobe is a lateral lobe)
posterior: occipital lobe =at higher level
Cerebellum = =at lower level
ventricles: in midline (in sagittal section)
- 3rd ventricle : slit like
- 4th ventricle: in front of cerebellum
- 2 lateral ventricles: NOT appearing in midline, they are deep structures
having: # body #frontal horn
#occipital horn
# temporal horn
N.B.:- ventricle is a cavity filled with CSF
- CSF circulation: from 2 lateral ventricles=3rd ventricle=aqueduct of
sylvius=4th ventricle=subarachinoid space=systemic
circulation.
- Brain stem: in order: midbrain pons - medulla
Scale of density in CT scan:

100 unite:
highest degree of whiteness (completely while)

100 unite is BONE
0 (zero) unite:
completely black
0 unite is fluid or water- like (CSF)
in between 0 & 100 unites: according to whiteness:
80 unites:
white but less than bone (100 unite)

80 unite is calcification
60 unites:
white
60 unite is early/ acute intracranial hemorrhage
N.B.: 80 unit & 60 unit density can NOT be diffrerentiated by naked eye,
it can be differentiated by computer
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40 unit:
grey matter of brain tissue
in contrast- enhanced CT
20 unit:
white matter of brain tissue

in contrast enhanced CT
types of density in CT scan:

Isodense:
brain tissue (grey & white matter)

taking 40 unit for grey matter (because it is nerve cells so more vascular)
20 unit for white matter (because it is nerve fibers so less vascular)
hyper dense === brain ,
including the following:

skull bone: taking the anatomical normal position
hemorrhage( acute)
calcification
contrast enhancement CT scan
hypo dense == brain

all lesions other than that of hyper dense
e.g.: edema, abscess, cyst, tumors, infarction==break down in brain tissue
so decrease vascularity
they require contrast enhancement CT
To describe lesion in CT , use terms hyper dense or hypo dense
how to differentiate between:

1- abscess & cyst:
-
plain CT: both are hypo dense lesions

contrast enhanced CT:
abscess: hypo dense lesion with ring enhancement

abscess is surrounded by capsule which is more bascular , so give ring
enhancement
cyst: hypo dense lesion with no ring enhancement (same as plain CT)
cyst means degeneration so there is decreased vascularity (NO area of high
vascularity)
2- hemorrhage & calcification:

-
plain CT: both are hyper dense lesions

correlation to clinical findings:
if patient has hemiplegia & coma=hemorrhage

if patient has epilepsy= calcification
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Types of CT scan:
1- plain CT scan : for the following lesions:

hemorrhage (hyper dense)
calcification (hyper dense)
brain infarction (hypo dense lesion but using contrast is dangerous as the die
interfere with the poor supply to the infracted area)
ventricular dilatation: spaces black & dilated
2- contrast enhanced CT scan:

-
injection of radioopaque dye IV. So passes into vascular structure making it
more while
enhancement: making vascular structure more white (more dense , more

clear
- contrast is used in hypodense lesions (except infarction):
abscess: showing ring enhancement (more dense ring) of capsule
tomors: variable enhancement (No rule)
cyst: no enhancement
vascular : according to it's shape
levels of cut in CT scan:

1- supraventricular level:
characters:
no ventricles/ no black areas=most important

cut are small in diameter then increase in diameter
skull bones are thicker
in contrast enhanced CTs , there are 2 grades of density:

40 unit (more white): Grey matter (nerve cells: more vascular)
20 unit (more black): white matter (nerve fibers: less vascular)
2- Ventricular level:( level of bodies of lateral ventricle)

Character:
Appearance of lateral ventricle : black , NOT midline

Rule: Any ventricle in depth of brain, NOT in the midline is NOT the 3rd ventricle.
3- Ventricular level, level of horns of lateral ventricle, 3rd ventricle

Characters:
Appearance of 3rd ventricle :

midline
Appearance of central sulcus (sylvius fissure)
# shape :
Black because it contains CSF
#significance: appearance of lateral sulcus indicate that the lateral
structure is the temporal lobe (no more the parietal lobe)
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Appearance of quadrigeminal cistern:
How to know it? NOT lateral ventricle, NOT 3rd, NOT 4th ventricle
Definition: one of the CSF spaces

Shape: concave facing ANTERIORLY
Differentiate it from 4th ventricle: the 4th ventricle is concave facing

POSTERIORLY
4- Infra ventricular level, posterior fossa, 4th ventricle

Characters:
Appearance of petrous part of temporal bone

# Significance: - ensure that the lateral aspect of brain is the temporal lobe
-the posterior structure becomes cerebellum (no more occipital
lobe)
N.B.: air in the mastoid air cells is given a minus unite (more black than CSF)
N.B.: temporal lobe:
- lateral sulcus at ventricular level, 3rd ventricle
- Petrous part of temporal bone at infra ventricular level
Appearance of 4th ventricle:

Concavity facing anteriorly
Pontine cistern
Pons
Disappearance of frontal lobe & appearance of eye & appearance of medulla
at lower level.
Summary of levels of cut in CT scan

1- Level I : supraventricular:
No ventricles
2- Level II: ventricular level, level of bodies of lateral ventricle:

No lateral sulcus (sylvius fissure ) so parietal lobe
3- Level III: ventricular level, 3rd ventricle:

Lateral sulcus (sylvian fissure)is present, so temporal not parietal lobe
4- Level IV: infra ventricular level, posterior fossa:
Petrous part of temporal bone, so:

Temporal lobe , not parietal lobe
Cerebellum not occipital lobe
4th ventricle, with pons & medulla n front
Differential diagnosis of lesions:

Brain:
Hyper dense:
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Hemorrhage:
- Intraventricular : inside the ventricles
- Subdural: under the skull
- Extradural: concave with lateral position
- Subarachnoid: talking shape of sulci & gyri
- Intracerebral: taking any shape within cerebrum
Calcification
Contrast media
Hypo dense:
Focal: infarct abscess tumors

Diffuse: brain edema (ONLY)
Ventricles:
Dilatation:
1- Hydrocephalus
a- Obstructive hydrocephalus
- Not all ventricles are dilated
- It's due to obstruction in between ventricles
=between both lateral ventricles & 3rd ventricledilataion of 2 lateral
ventricles
=between 3rd & 4th ventriclesdilatation of 2 lateral ventricles % 3rd
ventricle
b- Communicating hydrocephalus:
- All ventricles are dilated
- It's due to obstruction after 4th ventricle i.e.: in subarachnoid space
2- Passive dilatation:
- It occurs in brain atrophy as there is shrinkage of brain substance leading to
passive dilatation
Compression:
5 items to comment on in CT scan

1- Type of CT:
Plain CT scan OR
Contrast enhanced CT scan
2- Level of cut:
Supraventricular level
ventricular level, level of bodies of lateral ventricle
ventricular level, level of horns of lateral ventricle & 3rd ventricle
infra ventricular level, 4th ventricle
3- showing: comment on :
brain: hyper dense or hypo dense lesion
ventricles: compression , dilatation or normal
4- anatomical site of lesion: e.g.: left frontal
5- diagnosis
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Hints on Examination
Prepared by
Heba Saif
Ahmed Mohsen
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Clinical Pediatrics
How to examine
4th IC space just
outside MCL if
< 4 years old
I- Cardiology cases:
A.
Combined inspection and palpation:
1. inspect around the 4th/5th intercostal spaces, look for pulsations of apex [normally
5th IC space
2. Inspect other 4 areas for pulsations.
if >4 years old
3. put your Rt hand at the site of apex (where u can see pulsations if possible),
confirm place detected by inspection, (dont forget to count IC spaces with your Lt hand)
try to localize it with one finger (or if less than 2 cm, if more than 2 cm, it is diffuse)
comment on character and thrill felt: normal character with no detected thrill
Hyper dynamic character
Slapping character: in Mitral stenosis (very rare in children)
4. put your Rt hand on the left Parasternal area to detect thrill (use roots of fingers)
and pulsations ( use your hand just below the wrist joint)
5. put your hand on pulmonary and aortic areas to detect thrill (roots of fingers)
and pulsations (with your finger tips)
6. Put your hand at epigastric area; try to detect origin of pulsations
From RT side: enlarged Lt Ventricle.
From left side: liver due to RT sided Heart Failure.
Centered: aortic origin, normal.
B.
Auscultation:
7. Auscultation: auscultate apex, left Parasternal, pulmonary and aortic areas.
N.B.; during examination, always use your left hand to

Count ribs to know the numbers of spaces, or
On RT carotid for pulsations (systole/S1 is concomitant with pulse).
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Inspection &
palpation:
a. Precordial bulge:
b. Apex:
MR: systolic thrill

MS: diastolic thrill
MS: slapping
MR & AR:
hyperdynamic
c.
Parasternal area:
d. Pulmonary area:
e.
Epigastric area:
Percussion:
Auscultation:
a. S2 (pulmonary area)
b. Murmurs:
Rule: use cone and
diaphragm in
examination of all areas.
Rule: if you hear
murmur at apex, move
towards axilla, if its
propagating towards
axilla, it is mitral
regurge.
Rheumatic
VSD
Fallot
Present (only if u can see it)
Present (only if
u can see it)
S: shifted down
& out
Not present (mild Rt

ventricular enlargement)
S: in place
(4th IC just outside
midclavicular line if < 4
& 5th IC if > 4 years old.)
Area: localized
Character: hyper dynamic
Thrill: no
Pulsations: present
Thrill: No
Pulsations: yes
Thrill: no
Palpable S2: yes
Pulsations: yes
Thrill: -- Dullness on pulmonary
area (pul. Artery dilatation)
Dullness to the RT of the
sternum.
Accentuated S2
Accentuated S2
No
Mitral regurge:
Site: apex + muffled S1
Area of propagation: axilla
Character: soft
Timing: pan systolic
VSD:
S: 3rd, 4th Left
Parasternal spaces
A: all precordium
C: harsh
T: pan systolic
Tetralogy of Fallot:
S: 2nd left IC space
A:
C:
T: ejection systolic
Site: shifted down & out
A: localized
C:
T: No
P: present
T: yes
P: yes
T: no
P: yes
P: no
T: ---
A: localized
C:
T: No
P: +/- present
T: No
P: no
T: yes in 50%
P: no
P: no
T: ---
---
---
Mitral stenosis:
S: apex + accentuated S1
A: apex
C: rumbling
T: mid diastolic
Aortic regurge:
S: 3rd left
A: apex
C: soft
T: early diastolic (decrescendo)
Pulmonary hypertension:
S: 2nd left
A:
C: soft
T: ejection systole
So, you may hear murmurs at
apex/pulmonary/aortic area.
Parasternal and epigastric are
free
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Mitral regurge= muffled S1 + rumbling mid diastolic murmur at apex.

Mitral stenosis= accentuated S1 + soft pan systolic murmur at apex propagating to axilla.
Aortic regurge= soft early diastolic murmur at 2nd aortic space (3rd Left intercostals) propagating to apex.
Pulmonary artery dilatation= pulsations felt in 2nd left space, palpable S2, accentuated S2, soft ejection
systolic murmur.
VSD
Fallot
Rheumatic
Apex:
free
Parasternal:
Thrill + pulsations
Pulmonary
Pulsations
Aortic
Free
Free
epigastric
free
Free
Muffled S1 + soft pansystolic murmur

propagating to axilla,or
Accentuated S1 + rumbling mid diastolic
murmur, or
Free
free
+/- mild pulsations

(mild Rt vent hypertrophy)
50% with thrill
Ejection systolic murmur
Free
Accentuated S2+Soft ejection systolic murmur
Free, OR,
Soft early diastolic murmur propagating to
apex.
Free
II- Neurological cases:

1)
2)
3)
Exposure, notice any Abnormal movement

State: normal/wasting/hypertrophy (compare Rt to Lt side)
Power: use a needle/pinch the child, if the child moves paresis
P.S. power examination needs a cooperative patient: extension and flexion at every joint
passively and against resistance. So instead, apply a painful stimulus.
If you are performing knee flexion against resistance, you are testing the power of the
extensor.
Degree of power:
i.
No movement at all.
ii.
Horizontal movement
iii.
Movement against gravity.
iv.
I, ii, and iii + can carry an object.
4)
Tone:
Shaking
method in 4
limbs (wrists
&ankles)
Hypertonia: hand and forearm Move as one unit

Hypotonia: very loose movement
Passive flexion
&extension of
all joints
5) Reflexes:
9Rules: exposure - positioning
a) Superficial reflexes:
i.
Plantar/Babinski reflex:
y Scratching the outer aspect of the sole of the foot.
y +ve response dorsiflexion + fanning (it normally disappears at 1 year).
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ii.
Abdominal reflex:
y Move a blunt object( ) \on the patient's abdomen starting at flanks towards the
umbilicus.
y+ve response shift of umbilicus outwards, then it returns.
b) Deep reflexes: Hyperreflexia (compare Rt to Lt side) +/- clonus
Response
Where to
hit
Position of
the patient
Knee
Quadriceps
contraction
(front of thigh)
Tendon Below
knee joint
(between tibial
tuberosity patella,
detect with your
finger)
Knee angle: 90
degrees
ankle
Calf muscles
contraction
+dorsiflexion ankle
biceps
Biceps contraction
(flexion elbow)
Triceps
Triceps
contraction
(extension elbow)
Tendon Achilles
Put your hand below
the knee or at the thigh
raising the patient's leg
above the table
Put your finger on

the biceps tendon
and hit on your
finger
Hit on triceps
aponeurosis above
the back of the
elbow joint.
Knee angle: 120

degrees
Ankle angle: 90 degrees
Elbow angle: 120

degrees
Elbow angle: 90
degrees
Raise the hammer to the same height in both Rt and Lt sides to avoid a stronger hit on one side
than the other, as this may cause inaccurate results.
Move your wrist when you are using the hammer ()
How to detect clonus:
i.
ii.
iii.
iv.
Hold the thigh, raising thigh and legs off the table
Let the foot be in plantar flexion (its position in passive
state)
Do sudden maintained dorsiflexion
Response: Regular rhythmic movement of the foot.
c) Neonatal reflexes: abnormally persistent

E.g. Moros reflex:
Loud noise at patient's ear
Dropping the head, with the examiner's hand supporting the body
Sudden withdrawal of blankets from underneath the patient.
y +ve response: extension and abduction followed by flexion and adduction of upper limbs. Fingers
are widely opened. This is followed by a cry.
y Significance: Persistence beyond 6 months indicates CP/mental retardation.
6) Sensation: if the patient can speak, ask him if he can feel.
7) Cranial nerves:
a) Pseudo-bulbar palsy; (9, 10) is the commonest:
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Weak muscles of palate &
pharynx
Chocking can not be feeded

solid food
Exaggerated reflexes of
palate & pharynx
Dysphagia
Nasal regurge (as palate shuts
nose during drinking)
Gag reflex: with a tongue depressor
b) Others:
1st: olfactory nerve: use coffee, every opening separately
2nd: optic nerve: see if the patient can follow the torch/ ask if the patient
3rd, 4th & 6th: occulomotor, trochlear and abducent nerves:
Move torch/pen at 6 cardinal directions and check the patient's eye direction. If affected squint
5th: trigeminal nerve: JAW REFLEX

The mandible is tapped at a downward angle just below the lips at the chin while the mouth is held
slightly open. Normally this reflex is absent or very slight. However in individuals with upper motor
neuron lesions the jaw jerk reflex can be quite pronounced.
7th: facial nerve: , , ,
If the patient is not cooperative, tell the examiner that facial expressions mean intact facial nerve e.g.:
crying.
8th: vestibulocochlear nerve

9th: glossopharyngeal nerve: gag reflex (palate and pharynx sensation)
10th: vagal nerve: ask patient to say 'aaah', check uvula mobility with a tongue depressor.
11th: accessory nerve: ask patient to turn face against resistance (sternomastoid)
Ask patient to elevate shoulders (trapezius)
12th: hypoglossal: ask patient to protrude his tongue tongue will deviate towards paralyzed side.
III- Abdominal cases:

A. Inspection:
1) Shape: y bulging flanks: ascites/organomegaly
&contoury Generalized distension: ascites
2) Skin:
3)
4)
5)
6)
y stretched +\- striae

y Umbilicus: site: normal is midway between xiphsternum & symphysis pubis.
Shape: everted in increased intra abdominal pressure

Skin overlying: healthy/pigmented/dilated veins/ulcers
Impulse on cough: present in cases of hernia.
y Scars: site
Length
Healing: 1ry intention if thin scar, 2ry intention if thick/corrugated.
Subcutaneous tissue: dilated (visible) veins in case of portal hypertension.
Muscle: divarication of recti
Bone: sub costal angle: normally acute, gets wider in cases of prolonged distension.
Organs: localized bulge indicates organomegaly yE.g. fullness in left hypochondrium: splenomegaly.
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B. Palpation:
1) Superficial palpation: to detect tenderness, rigidity and superficial masses.
Start at right iliac fossa.
Move your hand in the 9 quadrants in an S shaped manner.
Use the gentle sliding technique.
Dont forget to look at the face of the patient to detect tenderness.

2) Deep palpation: to detect organ enlargement.
Knee of the patient should be hemi-flexed, to relax abdominal muscle wall.
Start from the RT iliac fossa and proceed upwards to palpate RT lobe of the liver.
Start from below the umbilicus upwards to palpate the Lt Lobe of the liver.
Start in the RT iliac fossa & towards the left hypochondrium to palpate spleen. (Try to
insinuate your fingers between it and costal margin, to prove it is spleen)
If the patient is relatively old, ask him to take a deep breath while palpating.
DONT roll your hands.
When you can feel the lower border of liver/spleen, measure the distance between it and the
costal margin.
N.B. shrunken liver can't be palpated.
3) Bimanual examination: the patient is on his back.
Put your hand on the patient's back below the last rib, try to palpate the kidney.
Kidneys are normally felt in thin individuals and in neonates.
If there's a swelling and I want to know if the origin was the kidney, perform
anterior pallotment.
Anterior pallotment: Put your left hand under the back of the patient, and the
right hand on the swelling, and press with your right hand. If you can feel the
swelling with your left hand, then the origin of swelling is from the kidney.
C. Percussion: (wrist movement)
1) For upper border of liver: start percussion at the 2nd right intercostal space.
Normally dullness of the upper border of the liver is heard at the 5th IC
space, ask the patient to take a deep breath and hold it, percuss again,
resonance is heard (as the lung occupied this space and moved liver slightly
downwards. This is done to differentiate between dullness of upper border of
liver and lung fibrosis.)
In case of cirrhosis (shrunken liver), dullness appears in the 6th IC space.
2) For ascites: mild: knee chest position (NEVER done)
Moderate amount: shifting dullness.
Huge amount: transmitted thrill (most probably veno-occlusive disease.)
Shifting dullness:
Start from epigastric region till you reach dullness that represents the upper border of the bladder. (Mark it
to percuss above it)
Start from epigastric region till umbilicus.
Then to the RT of the umbilicus.
Then to the LT of the umbilicus.
When you find dullness, fix your hand there and ask the patient to turn his body to the other side, percuss
again, if you find resonance, this is called shifting dullness. (It happens because while the patient is on his
back, moderate amount of fluid is present in flanks, so when you ask the patient to move to the other side, the
fluid is displaced and resonance is heard in a previously dull flank.)
Transmitted thrill:
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Ask the patient to put his hand in the mid line.
(To make sure thrill is transmitted only through ascetic fluid, not through anterior abdominal wall muscles)
,
D.
auscultation: intestinal sounds

Venous hum: Para umbilical vein is midway between sternum and umbilicus.
IV- General examination:

a. vital signs:
Pulse rate is beats per minute, beats are regular, with no special character, volume is average, and
equal in both sides ( examine both sides same time).
Temperature is (axillary's + 0.5)
Blood pressure is /
Respiratory rate is
b. Measurements
Head circumference is
How to measure head circumference: make sure you place the meter correctly, on the supraorbital
ridge (2cm above eye brows) & on the occipital protuberance.
Height is
How to measure height:
If < 4 years old: supine
If > 4 years old: standing:
y make the patient take off the shoes.
y Patients heals are adjacent to the wall
y Feet close to each other
y Body adjacent to the wall
y Head neither flexed nor extended
y Put a book above patients head.
y Measure
Weight is
c. Head
Skull: box shaped, wide anterior fontanelle/mongoloid features/cephalhematoma/ forceps marks.
Hair: Hair is light in color, sparse/silky.
Eye: subconjunctival hge/ jaundice/ puffy eyelid/sunken/lateral upward slope.
Cheek: loss of subcutaneous fat/moon face/butterfly rash of SLE.
Mouth: pallor in lips/cyanosis in tongue/teeth extraction/ tonsillitis/angular
stomatitis/moniliasis/delayed dentition/small/protruded tongue.
Ear lobules: underdeveloped, over folded helix, small external ear.
Anxious look.
d. Neck:
Carotid arteries show no exaggerated pulsations, they are equally felt on both sides with no special
characters or thrill/there is exaggerated carotid pulsations with/with out associated thrill.
Neck veins are not congested shows systolic collapse/ neck veins are congested reaching cm with
patient seated at 45 degrees position.
Trachea is centralized, thyroid is normal, LNS are not felt.
Short and broad/Buffalo hump
e. Upper limbs:
There is/ is no clubbing, pallor, splinter hge, oslar nodules.
Broadening, convexity
Short, Simian crease, clinodactyly.
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f. Lower limbs:
Dorsalis pedis arteries are equally felt in both sides. There is/is no lower limb edema, clubbing.
Wrinkled/ulcerated/fissured skin, wasted muscles, prominent bones.
Broadening, Knock knees, bow leg, Marfan sign.
Short, broad, wide gap between 1st and 2nd toes.
g. Trunk: kyphosis/lordosis/skin is lemon yellow (unconjugated bilirubin)/umbilical sepsis/scrotal edema.
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IMCI
Prepared by
Mohamed El Far
Typed by
Medical
Sources
Lectures of IMCI, unit of Prof Dr

Mona Abu Zekry
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:
:
:
) (
:
: 100
: axillary
in mother's own words :
: , :
Initial visit
follow visit
initial visit
?Does the child have any general DANGER sign
CHECK FOR EVERY PATIENT
Assessment
if one of these DANGER sign is present , this indicates VERY SEVERE DISEASE
which requires rapid admission to hospital
1-not able to drink or breastfeed:

:
:
proceed to next question :Check by your self
: ) ( DANGER SIGN , too weak to suckle ..
proceed to next question , not hungry , refusing
2- Vomits everything:
:
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:
proceed to the next sign : .... ,,,,,,,, :
proceed to the next sign ,,,,,,, : ... " " ....
proceed to next question
DANGER SIGN
NB:
Vomits everything
Means that there is for example intestinal obstruction or meningitis. What goes down will come
up.
3- History of convulsions:
/ :
:
proceed to next step ,,,,,,, : DANGER SIGN
NB:
A- You should confirm that it is generalized Clonic , convulsions , not just
B- Do not ask leading question
4- Lethargic or unconscious:
- Lethargic:
infinity - Disinterested
- Conscious but lethargic
- - -
If still lethargic DANGER SIGN
5- Convulsions now
Classification:
If any of danger sign is present

1- Circle it
2- Put on yes
3- Put the word VERY SEVERE DISEASE in classify as box
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Does the child have cough or difficult breathing?

. :
put on NO and bypass this box assessment & classification box -
Assessment:
: -1
- if it is as for 30 days for example : it requires non urgent

referral (ex : TB )
2- Count breathes in ONE complete minute.

- Patient must be calm during counting
- focus by your eyes on apart of chest wall.
- use timer (press one time only)
- Normal respiratory rate & cutoffs
- if patient 2 months to less than 12 months ,so

cutoff is 50 / min
- if the patient is 12 months to 15 months , so
cutoff is 40 /min
-tachypnea (fast breathing more than cutoff) is an early sign of

pneumonia.
3. Chest indrawing

8
chest
upper chest lower chest abdomen

-
- This indicates extra work of diaphragm

- Precautions
Lower chest goes IN with INspiration

1- Patient must be flat and calm.
2- chest indrawing occurs with every cycle
3- in all parts
4- If you are in doubt , so there is no chest indrawing
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5.4. LOOK & LISTEN for stridor and wheezes

-listen to stridor
-look for chest for timing
If sounds are inspiratory, so it is STRIDOR

If sounds are expiratory so it is WHEEZES
Classification
- If checking & assessment of the box is NO , so write NOTHING in classify
- Red box indicates dangerous condition which necessitates urgent
referral to hospital.
- Yellow box indicates that specific ttt and follow up are needed.
- Green box is safe to pass
- Classify from above downwards, for example, if you found sign for both
red and yellow boxes, so classification will be the red box (take the
more dangerous classification)
, box -Write the classification EXACTLY as it is
Does the child have diarrhea?
Assessment:
:
Def .of diarrhea: is increased fluidity of the stool
regardless of number of stools
:
proceed to the next box :
. :
-1
: persistent diarrhea 14
Duration of gastroenteritis is 7-10 days
Persistent diarrhea may lead to dehydration
-2
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dysentery
Most common causes of dysentery is shigella
: : -
Classification:
A - Box for dehydration:

*4 signs
1- General condition:
Lethargic
Restless / irritant /
2- Sunken eyes:
Groove all around the eyes.
If you are in doubt, ask the mother

...
3- Not able to drink or drinking poorly

- In this sign, don't depend on asking the mother
- bring a cup of water and ask the mother to give it her baby and look

Normal danger sign too weak to drink danger sign thirsty /eagerly -
4- Pinch skin of abdomen

- pinch skin of the abdomen midway between umbilicus and flanks
pinch - pinch it for a while
If it returns instantly
normal
2 slow skin pinch
2 very slow skin pinch
Classification
- In diarrhea: at least 2 signs are required for diagnosis and
classification of red box. One sign is not enough.
- one sign , classify as yellow box
- One sign classify as: no dehydration, means NO clinically
detectable signs of dehydration, but if left he will develop some
dehydration.
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NB
No dehydration: means that the patient lost less than 5% of his weight
Some dehydration: means that the patient lost 10 % of his weight
Severe dehydration: means that the patient lost 10- 12 % of his weight.
Hypovolemic shock means the patient lost 15 % or more of his weight.
B Box for diarrhea 14 days or more :

- Rule for entry of this box:
* Patient should have continues diarrhea for 14 days or more
Classification:
* look at the previous box of dehydration:

If diarrhea is associated with dehydration, classify as: severe persistent
diarrhea
If no dehydration, classify as persistent diarrhea
Check for throat problem:
- Obligatory box, you must enter it (there is NO YES OR NO " )

In this box do not depend on mother, you should classify by yourself
due to increased incidence of rheumatic fever.
Assessment:
- If you find any sign, CIRCLE it

- ask:
1- Does the child have fever?
:
- you can identify fever either by :
a- direct question to mother
b- thermometer
c- By palpating the child by your hands.
2- Does the child have sore throat?

, :
- Look and feel:
3- Feel for enlarged and tender lymph nodes.

LN
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4-5- look for: by using tongue depressor
4- Congested throat
5- Whitish or yellow membrane
NB: normal color of throat is pink
General comments:
- if you find any sign ,CIRCLE it
24 sign -
Does the child have ear problems?
Assessment:
:
tick on NO & proceed to next box : proceed to further assessment : .1
Agonizing pain in last 24 hrs
:

NB
This agonizing pain is due to collection of pus under tension, if drum is perforated,
pain will decrease
- patient with agonizing pain is unable to sleep , he may sleep from exhaustion
.2

NB
If mother said there is pus, write it discharge not pus.

If less than 14 day acute
If more than 14 day chronic
3. Look at pus:
- if mother said there is discharge , look at that discharge & examine it ,if this
has criteria of pus , so it is PUS
* Criteria of PUS:
- Yellowish to greenish
- Offensive
- Sticky
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4. Look for tender enlarged swelling (bone) behind the ear:
- this swelling is mostly mastoiditis which is one of the severe serious
complication of acute otitis media
Classification:
- If no ear problem, tick on NO & proceed to next box.
* Red box:
- If bone behind the ear is tender, so classify mastoiditis
* Yellow box (1):
- If pus is seen coming from the ear & < 14 days so classify as " acute ear infection "
OR
- if there is agonizing pain ONLY , so classify as "acute ear infection"
* Yellow box (2):
- If you find pus for 14 days or more, so classify as chronic ear infection
* Green box:
- If mother said that there is ear problem ( if you entered box of ear problems ) , but
you found no signs , so classify as " NO ear infection "
- this may be foreign body in the ear but NOT infection
NB
If you ask the mother & she told you that there is NO ear problems , tick on " NO" &
DO NOT " write ANY classification , do NOT write EVEN " no ear infection ( LEAVE
the classification box EMPTY ) .
Does the child have fever?

* This box is the last box because it depends on your findings in previous
boxes.
* There is fever from:
- History
48
- by feeling under axilla
- by thermometer in axillary area , Temp. 37.5 or more
* circle the way or method by which you know that there is fever
NB
If mother said there was fever (fever by history) but by thermometer there is no fever,
this may be effect on antibiotics, so tick on YES
Assessment:
1- for how long ? :
2- if fever lasts for more than 5 days,
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You must ask the mother whether it is present every day or
not
-
if fever disappear and develop again so count from the day of

recurrence
if fever actively lasted for more than 5 days so it is prolonged fever
which may be due to TB or Typhoid
3- Has the child had measles within the last 3 months?

) ( : :
*Within the last 3 months, because complications of measles develop
during the following 3 months
4- Look for stiff neck: neck rigidity:

- Procedure:
chest chin chest chin
- Results:
Stiff neck .
* most probably due to meningitis
5- Look for signs of measles:

A- Generalized maculopapular rash erythematous rash (having the
criteria of measles)
AND
B- Cough or red eye or runny nose.
If A AND B are present, so it is measles
Classification:
- Always look at the previous boxes.
if you find stiff neck ( from this box)
OR danger sign (from box of danger signs)
So classify as VERY severe febrile disease
if you find apparent causes of fever as :
- pneumonia
- dysentery
- streptococcus pharyngitis
- acute ear infection
- abscess / carbuncle
So classify as fever - possible bacterial infection

if you do not find an apparent cause of fever ,
So classify asFever bacterial infection unlikely
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Assessment of measles:
- You should enter measles box when:
1- There is history of measles within the previous 3 months OR

2- Have measles by having the 2 criteria of measles.
a- rash
AND
b- cough or regular or runny nose .
1. Look at eyes:
a- Look for clouding of cornea.
NB: clouding may cause permanent loss of vision
b- Look for pus coming from the eyes.

Most probably due to mucopurulent conjunctivitis.
2. Mouth ulcers:
Look for deep ulcers
Classification of measles:
If find:
- general danger sign OR

- clouding of cornea
- deep & extensive mouth ulcers mouth OR
- measles now ( not history ) OR
- pneumonia
Classify as severe complicated measles
Check for malnutrition and anemia :

- obligatory box
Assessment of malnutrition
1- look for visible severe wasting
- Visible severe wasting 2nd or 3rd degree of marasmus

- How to identify visible severe wasting:
1- Loss of subcutaneous fat on deltoid (shoulder girdle)
2- Loss of subcutaneous over ribs (ribs )
3- Loss of subcutaneous over buttock leading to contour bagy pants
3
2- look for edema of both feet :

*Procedure:
-1
-2
3- Press on the dorsum of the foot.
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3- determine weight for age :

*Procedure:
-1
-2
growth curve -3
*Results:
If the point is below the lowest line, so classify as low weight

If the point is above the lowest line, so classify as NOT low weight
Classification of malnutrition:
- If you find:
* Visible severe wasting OR

* Edema of both feet
, so classify as severe malnutrition

- If you find:
Low weight for age, classify as low weight

Weight for age above lowest live, classify as NOT low weight
Assessment of anemia:
1- Test to detect degree of pallor (so detecting degree of

anemia).
- Check for pallor in:
* Mucous membrane
False impress
* Palmer pallor
- Procedure:
overstretch -1
comparison -2
- Interpretation:
If they are all red, so no palmer pallor
So classify as NO anemia
If they are mixed (white and red), so some pallor
So classify as anemia
If they are all white, so severe palmer pallor,
So classify as severe anemia.
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Photos
Prepared by
Mohamed El Far
Sources
Notes of Prof Dr Mohamed Hesham
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Normal newborn ( Vernix Caseosa )

The skin at birth is covered with vernix caseosa.
Normal
This whitish greasy coat is produced by epithelial cell breakdown and
Formation
Significance In utero, protects the skin from the amniotic fluid.
Mongolian spot
Bluish discoloration of an area of skin in lumbosacral region.
Definition
Significance It is of no significance, may be mistaken for bruising.
Fades gradually as the infant grows older.
Fate
Milia
Description & site
Fate
Treatment
It is characterized by white or pale yellow epidermal cysts found

on the nose, chin, and forehead.
Such benign lesions exfoliate and disappear spontaneously within
the first few weeks of life.
No treatment is necessary.
Neonatal gynecomastia
Incidence It occurs in both sexes during the first weeks of life.
Precaution It should not be squeezed.
Moro reflex
Incidence
Duration
How to elicit
Significance
The most common primitive reflex that is normally elicited in newborn

Disappears by 4-6 months.
It can be elicited by startling the baby.
Absent reflex may be due to - Intracranial injury.
- Cerebral depression.
- Prematurity.
Cephalhematoma
Definition It is a subperiosteal hemorrhage.
Treatment Is conservative, and aspiration is contraindicated.
Neonatal conjunctivitis
Causes
Include Chlamydia, gonorrhea and viruses.

Minor sticky eye is much more common, usually non-infective and responds
to frequent eye washes
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Facial palsy
Include compression of facial nerve by pressure from forceps blades
But may occur after normal delivery.
Presentation As unilateral weakness of facial muscles and drooping of mouth.
Most cases resolve within a few weeks after birth.
Fate
Causes
Erb's palsy
It results from injury of 5 and 6 cervical nerves.
Cause
Character Moro reflex is absent on the affected side, but grasp reflex is intact.
Treatment is by physiotherapy from second week.
Umbilical granuloma
Presentation Persistent serosangunious discharge and a fleshy protuberance from the
Treatment
base.
It can be treated by local application of silver nitrate or rarely by surgical
excision.
Tongue tie
It is a short lingual frenulum, which may be worrisome to parents.
Definition
Complications It only rarely interferes with eating or speech,
generally requiring no treatment
Treatment
Infant of diabetic mother

Large obese infants
Definition
due to poor control of maternal diabetes.
Cause
Complications include
1.
2.
3.
4.
Hypoglycemia
Respiratory distress syndrome
Polycythemia and
High incidence of congenital malformations.
Phototherapy
Procedure Exposure of infants to blue, white, or green lights of wave length 450-460
nm
Decreases unconjugated bilirubin levels.
Action
Indication It is mainly indicated for levels above 15 mg/dl in full term infants.
Include hyperthermia, dehydration, loose stools, and skin rash.
Side
effects
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Congenital hypothyroidism
Clinical features Includes coarse facies, large protruding tongue and umbilical hernia.
Of all newborns within a few days of birth ensures early diagnosis
Routine
and early treatment, to prevent mental retardation.
screening
Hydropes fetalis
Uncommon since the prevention of rhesus disease with anti-D
immunoglobulin.
Include pallor, gross generalized oedema, ascites, and heart
failure.
Includes exchange transfusion and ventilatory support.
Incidence
Features
Mainstay of
treatment
Necrotizing Enterocolitis
It is a serious illness mainly affecting preterm infants in the first weeks
of life.
It is caused by ischemia of the bowel wall and infecting organisms, and
Causes
may be accelerated by milk feeding.
Manifestations The abdomen becomes distended, milk is aspirated from stomach, and
the baby may rapidly deteriorate.
Is to stop oral feeding and give broad spectrum antibiotics.
Treatment
Definition
Inguinal hernia
It is the commonest condition requiring surgery during infancy.
Incidence
Presentation An intermittent swelling in the inguinal region or scrotum, noticed
Surgical
repair
during crying or straining.

Should be done as soon as possible, because the risk of strangulation is
high in young infants.
Hypospadias
Definition The uretheral orifice is situated on the ventral aspect of the penis at a site
proximal to the normal opening.
Treatment Circumcision should be delayed until corrective surgery is done, as the
prepuce may be needed for urethroplasty.
Cleft lip and palate

Complications Include feeding difficulties, speech problems and deafness.
Management Of feeding by a large teat, spoon or tube feeding.
Surgical repair usually gives excellent results.
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Imperforate anus
Diagnosis
This is usually diagnosed during routine examination immediately after

birth.
are found in 60% of cases.
Other
anomalies
Treatment Most cases need colostomy performed in the neonatal period.
Positional talipes
Definition The feet often remain in their in utero position.
Differential unlike true talipes equinovarus, the foot can be fully dorsiflexed to touch
the front of the lower leg.
diagnosis
Talipes equinovarus (Club foot)

Differential It can be differentiated from positional talipes because it can not be
passively corrected.
diagnosis
Treatment is by splinting, but surgical release may be needed.
Simian crease
Definition It is a transverse palmar crease seen in many chromosomal aberrations,
e,g, Trisomy 21
Meningomyelocele
Definition
Antenatal
diagnosis
Association
First aid
It is a neural tube defect.

is possible by ultrasound examination.
Hydrocephalus occurs in most of the case.
Includes covering by sterile dressing and neurosurgical referral.
Hydrocephalus
Definition It is dilatation of the ventricular system.
In infants,
Clinical
The head is enlarged with a large bulging anterior fontanelle,
picture
Scalp veins are prominent, and
The eyes are deviated downward (sun-set sign).
Treatment Is by shunt operation.
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Microcephaly
rd
Definition Head circumference is below the 3 centile for age and gestation.
Include congenital infections.
Known
causes
Impetigo
Caused by gram positive cocci e.g. staphylococcus aureus.
Organism
Presentation It is a superficial infection resulting in small pustules anywhere on the
Treatment
skin.
Extensive lesions should be treated with systemic flucloxacillin.
Oral moniliasis
Definition & It is a fungal infection caused by candida albicans.
etiology
Presentation It appears as white adherent plaques on the buccal mucosa and tongue.
Is by topical nystatin or miconazole.
Treatment
Perineal moniliasis
It gives a bright red confluent rash in the napkin area or around the
anus.
Presentation Typically, there are discrete satellite lesions lying peripheral to the rash.
By topical nystatin cream.
Treatment
Definition
Roseola infantum
Definition Acute viral illness caused by human herpes virus-6,
& etiology
Incidence Infants between 6 months-2 years.
Treatment Is mainly symptomatic i.e.antipyretics for the high fever.
Measles
It is characterized by typical maculopapular rash which starts behind
the ears and on the face. Then, it spread downwards to the trunk and
feet.
Kopliks spots Are pathognomonic. They appear as grayish white lesions on buccal
mucosa.
is symptomatic
Treatment
Complications Are mainly respiratory and neurological.
Rash
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Scarlet fever
Etiology
It is a bacterial disease caused by toxin-producing group A beta

hemolytic streptococci.
Include sore throat, fine popular rash, tongue changes and congested
eyes.
Diagnostic
features
Desquamation Occurs as the rash fades. It can involve hands and feet.
and peeling
Can follow other febrile illnesses eg Kawasaki disease.
Other causes
of Peeling
Chickenpox
-The rash appears in successive crops,
-is centripetal in distribution and
-pleomorphic.
-The rash is mainly papulovesicular.
Include
secondary infected lesions, pneumonia, and neurological
Complications
problems e.g.acute cerebellar ataxia
Characters of
rash
Pertussis( whooping cough )

During
coughing
paroxysms
The main
complication
Treatment
The intrathoracic pressure rises sharply leading to elevated capillary

pressure with subconjunctival hemorrhage and periorbital ecchymosis.
Is bronchopneumonia due to secondary bacterial infection, but there is a
significant mortality, particularly in infants as the infection can cause
apnea and sudden death. Small infants suffering severe spasms of cough
or cyanotic attacks should be admitted to hospital.
Is mainly symptomatic and oral erythromycin.
Henoch-Schonlein purpura
Is a purpuric rash involving the lower limbs and buttocks.
The
characteristic
skin lesion
It is a vasculitis with a normal platelet count.
Include arthritis, abdominal pain and nephritis.
Other
features
Fate
Most cases recover within few weeks.
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Systemic lupus erythematosus

Definition A multisystem autoimmune disease characterized by malar rash,
photosensitivity, mouth ulcers, arthritis, nephritis, pericarditis.

Malar rash, photosensitivity, mouth ulcers, arthritis, nephritis, pericarditis.
Features
Treatment Is by anti-inflammatory drugs and corticosteroids.
Purpura fulminans
This is large ecchymoses with irregular shapes evolving into
hemorrhagic bullae and then into black necrotic lesions.
Include sepsis (e.g. meningococcal), malignancy and massive trauma.
Causes
Management It carries a high mortality rate and intensive care management is
urgently needed.
Pathology
Hemophilia A
Definition It is an X-linked recessive disorder characterized by bleeding, easy bruising,
large hematomas, and hemarthrosis.
Bleeding, easy bruising, large hematomas, and hemarthrosis.

Features
Treatment Is by replacement therapy using fresh frozen plasma, cryoprecipitate, and or
factor VIII concentrate.
Urticaria
It is a common allergic manifestation.
There is itching, erythematous rash with wheals, and edema around the
eyes and mouth. -One serious complication: is laryngeal edema and airway
obstruction.
Treatment Is by s.c. adrenaline and systemic steroids.
Incidence
Clinical
features
Atopic eczema
-: Itching is the main symptom resulting in scratching and exacerbation of
Main
the rash.
symptom
Distribution Is age related:
Treatment
In infants the face is mainly affected.

In children, the skin flexures ( cubital and popliteal fossae ) is
mainly involved.
Is by avoiding irritants, emollients( moisturizing cream), and topical mildly
potent corticosteroids ointments.
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Scabies
It is caused by infestation with a mite
Etiology
By severe itching which is worse at night.
Clinical
feature
Distribution In infants and young children the distribution of the lesions often includes
Treatment
the palms, soles and trunk.

Is by permethrin cream 5%. If a child and other members of the family are
itching, suspect scabies.
Kwashiorkor
Etiology
Constant features
Other important
features
Complications
A common complication of faulty weaning by a low protein high

carbohydrate food.
Include edema, growth failure, mental changes and disturbed
muscle to fat ratio.
Include hair and skin changes.
include hypoglycemia, hypothermia, electrolyte disturbances and
serious infections
Rickets
Include large head, rosary beads (enlarged costochondral junction), Marfan
Clinical
sign, fractures, and limb deformities (bow leg and knock knee).
features
Treatment Is by vitamin D therapy for deficiency rickets.
Osteogenesis imperfecta
Incidence An uncommon genetic disorder,
Osteoporosis, bone deformities, fractures, blue sclera and defective
Clinical
dentition.
feature
Clinical severity depends on the subclass. Some variants are lethal. The diagnosis is
considered in suspected child abuse.
Dehydration
Dehydration and its complications are the usual cause of death from gastroenteritis.
Clinical features of Include depressed fontanelle, sunken eyes , dry tongue , loss of
skin turgor, and acute weight loss.
dehydration in
infants
-Infants are at
particular risk of
dehydration
Because of their greater surface area to weight ratio and higher

basal fluid requirement (100 ml/kg).
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Pediatrics Sheets
Prepared by
Mohamed El Far
Soma El 3ageeb
Ibn El Waleed
Typed by
Omaregy
Medical
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General Pediatric Sheet

Welcome the patient:
Introduce your self to the patient:
, .....
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

Present history
Analysis of complaint:
Onset: Course:
Duration:
Any investigation or ttt:
History of any other system affection:
Chest: Cardiac:
GIT: UTI: NEURO:
- FEVER:
Prenatal & perinatal history

antenatal history :
: Natal history:

..... Neonatal history:
:
....... . -
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Developmental history
Motor:
Mental:
Nutritional history:
Breast feeding:
Artificial
-
Weaning :
) ( minerals:
-
& Vitamins:
Vaccination history
40 -
Past history
See history of other system affection
-
Family history:
- .
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History taking of the normal newborn:

1- name , age , sex address , place of birth
2- Actual date of birth (hour). Expected date of birth if baby looks
premature.

-
12-complaint:
-

:

)
- .....
Antenatal history :
Natal history:
Neonatal history:
:
....... . -
Nutritional history
Breast feeding:
- artificial
Vaccination history

Family history
?Is he her first baby? If not how many siblings? Normal or not

-
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-- .
Neonatal hyperbilirubinemia
welcome the patient :
introduce your self to the patient :

.....
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

Present history
)? When did the mother notice the jaundice (onset

? What is the color of the urine or stool
? Does he vomit frequency

? Is he sleeping a lot & refusing feeds & does not seem very vigorous

Is there is any history of abnormal movements of history suggestive of

?convulsions

Analysis of complaint :
Onset:
Course:
Duration:
Any investigation or ttt :

history of any other system affection :
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Chest:
Cardiac:
GIT:
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UTI:
NEURO:
FEVER:

Antenatal history :
: Natal history:

:
....... . -
Motor:
Mental:
Nutritional history
Breast feeding:

) ( -
- artificial
weaning :
Vitamins: & minerals:
Vaccination history
40 -
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Past history

-
-
Family history
Is there any parent or sibling with jaundice or anemia or repeated

?blood transfusion

Is there history of neonatal jaundice in any of baby's brothers or

?sisters? Did they need admission to NICU
? Did they require exchange transfusion

? Is there history of liver diseases in the family
? Is the mother diabetic or did she suffer from diabetes with pregnancy

- .
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Marasmus


.....
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

Present history
* Ask for symptoms suggestive hunger: continuous cry and anxiety and
scanty stools
-
* History of diarrhea:
* History of any preceding illness

* Recurrent chest infection or persistent infection: e.g. TB

-
* History of urinary troubles

)* Symptoms of fat malabsorption (bulky, offensive, pale stool

* If wasting appear in very young infant, ask about history of persistent

)vomiting since early life (congenital pyloric stenos is

Onset: Course:
Duration:

Chest: Cardiac:
- GIT:
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UTI: NEURO: -
- FEVER:
Prenatal & prenatal history
Antenatal history: : Natal history:

..... Neonatal history: :
....... . -
Motor:
Mental:
Nutritional history
Breast feeding:
- artificial
Weaning :
) ( - minerals:
& Vitamins:
Vaccination history
40 -
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Past history

-
Family history
- .
Kwashiorkor


.....
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

Present history
History of diarrhea
History of any preceding illness , measles

History of skin or respiratory infection.
Onset: Course:
Duration:

- Chest:
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Cardiac:

GIT: UTI: NEURO: -
- FEVER:

....... . -
Motor:
Mental:
Nutritional history
Breast feeding:
- artificial
Weaning :
) ( - minerals:
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& Vitamins:
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Vaccination history
40 -
Past history

-
Family history
- .
Rickets


.....
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

present history
* Anorexia:
* Constipation:

* Housing condition:
-
* Exposure to the sunlight:

* Deformity:

* Excessive sweating
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* Recurrent chest infection:

.
Onset: Course:
Duration:

-
Chest: Cardiac:
GIT: UTI: NEURO: -
- FEVER:

....... . -
Motor:
Mental:
Nutritional history
Breast feeding:
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-
- artificial
Weaning :
) ( - minerals:
& Vitamins:
Vaccination history
40 -
Past history

-
Family history
- .
Down syndrome

.....
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

Present history
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Onset: Course:
Duration:
Stress on:
Difficult breathing or suckling

Cyanosis
Cough
Poor weight gain

History of any other system affection:
Chest: Cardiac:
GIT: UTI: NEURO:
- FEVER:

antenatal history :
: Natal history:

:
....... . -
Motor:
Mental:
Nutritional history:
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Breast feeding:
Artificial
-
Weaning :
) ( minerals:
-
& Vitamins:
Vaccination history
40 -
Past history
-
Family history:
- .
Nephrotic syndrome
Personal history
Sex and name:
Age:
Residence:
Consanguinity
Complaint

Present history

edema
sites: face & eyelids, lower limbs , abdominal enlargement, scrotal

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march of edema & relation to time of day

urinary symptoms:
change of color or amount

dysuria, frequency, loin pain

abdominal symptoms:
pain , vomiting, diarrhea

) jaundice (liver disease
) Dyspnea or cough. (Pleural effusion, chest infection, cardiac edema

Headache or history of diagnosis or treatment of hypertension
systemic symptoms : fever, rash, skin infections, joint pain
treatment (especially steroids or immunosuppressive) & response

) Previous similar attacks (relapsing N.S.
Nutritional history: if appropriate for age.
Rheumatic heart disease

Personal history
age
Sex
Inhabitance
School class

Complaint
, , -
history of present illness
analysis of complaint: onset , course , duration

other cardiac symptoms:
left ventricular failure:
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right ventricular failure
low cardiac output symptoms:

exercise intolerance
Palpitation

Chest pain

Fever & joint manifestation

neurological symptoms, syncope & stroke
investigations: ECG, chest x-ray, echocardiography
medications: digoxin, frusemide, captopril , long acting penicillin

Past history
Recurrent tonsillitis
Arthalgia, arthritis
Family history
Similar condition
History of a case of congenital heart disease

Personal history
Age:

Sex
Inhabitance:

Serial order:

Consanguinity

Complaint
": , , ,
History of present illness
analysis of complaint: onset, course , duration
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other cardiac symptoms:
cyanosis- cyanotic spells, squatting

dyspnea, sweating during feeding, exercise intolerance
) ( puffy eyelids, lower limb edema

palpitation:
neurological symptoms, syncope, convulsions, stroke
investigations:ECG, chest x-ray, echocardiography
medications:digoxin, frusemide, captopril , long acting penicillin

Past history
Antenatal history:

Maternal fever+ rash
Medications, diseases


Weight gain:
Nutritional historyFeeding pattern:

Breast feeding:

) ( - minerals:
- artificial
Weaning :
& Vitamins:
Mental & motor development

Motor:
Mental:
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-
Vaccination history
40 -
Family history:
Consanguinity:

hereditary diseases, congenital heart diseases

History taking in a case with abdominal

complaint
Personal history
Name:

Age

Sex
Residence & social class

Complaint

Present history
) analysis of complaint ( onset , course, duration

.
abdominal symptoms:
1- Hepatobiliary symptoms
Jaundice:
? Urine stool discoloration
Itching:
? Abdominal distension or enlargement
Lower limb edema:
Bleeding tendency:
Hematemesis:
If positive
* Frequency
* Amount & color:
* contain food particles
* Severity & received blood transfusion
* bleeding per rectum or melena
* Coma:
2- Spleen & RBCs :
history of pallor & recurrent blood transfusion

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symptoms suspecting leukemia or malignancy or autoimmune :

- Prolonged fever:
- Pallor, bleeding tendency
- Arthritis & infection
) LNs enlargement ( body swelling
3- general toxemic manifestations :
night fever , night sweat

anemia , loss of weight
4- Abdominal pain:
if present
Site, radiation
. Severity, character
timing and relation to meals
Precipitating & relieving pain
5- lower GIT symptoms :
Diarrhea
If positive
- Frequency:
) ( - Consistency, volume, color
- Presence of blood or tenesmus or pus
constipation :
If positive
- Onset, course:
- Degree:
- Dietary history
6- Upper GIT symptoms:
Vomiting, dysphagia, dyspepsia, flatulence

Review of other symptoms:
Chest: Cardiac:
GIT: UTI: NEURO:
- FEVER:
Past history
Bilharziasis
Hepatitis, jaundice

Fever, typhoid
)( TB
Blood transfusion
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Drugs, operations
Perinatal history
Prenatal history:
: -
Natal and postnatal history:

Natal history:
..... -
Neonatal history: :
....... . -
Mental & motor development

Motor:
Mental:
Dietary history
- Breast feeding:

-
- artificial
Weaning :
) ( Vitamins: & minerals: Weight gain:

Vaccination history
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-
Family history
Consanguinity:

hereditary diseases, congenital heart diseases

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Blood Report
Prepared by
Soma El 3ageeb
Typed by
Mohamed El Far
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6 Reports
2 RBCs
2 Platelets
2 WBCs
Hemolytic anemia
Fe deficiency anemia (Microcytic hypochromic anemia most probably Fe
deficiency anemia)
Pancytopenia
Not aplastic anemia
Thrombocytopenia
Not ITP
Bacterial
Viral
1. Hemolytic anemia:
Microcytic hypochromic anemia

Reticulocytosis
2. Fe deficiency anemia
Microcytic hypochromic anemia

No reticulocytosis
3. Pancytopenia
Anemia
Thrombocytopenia
Leucopenia
4. Thrombocytopenia
Thrombocytopenia
+/- Anemia
5. Bacterial infection
6. Viral infection
Leucocytes > 15,000

Leucocytes < 15,000
Polymorph
Lymphocytosis
Bandemia > 10%

--------------------------
How to give comment?
Comment
Diagnosis
Investigations to prove the diagnosis
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Interpretation:
Reticulocytosis
Hemolytic anemia
+ MCV & MCH
+ Platelet
Hypersplenism
Not ITP due to reticuloctosis
OR
+ Platelet (thrombocytosis)
Overall activity of bone marrow
After splenectomy
Comment:
Microcytic hypochromic anemia with marked reticulocytosis & thrombocytosis (OR

thrombocytopenia)
Diagnosis:
Hemolytic anemia with thrombocytosis due to overall activity of bone marrow or
due to splenectomy
Hemolytic anemia with thrombocytopenia due to hypersplenism
Investigations to prove diagnosis:

Hemolytic profile: Hb electrophoresis, G6PD assay & osmotic fragility test
Iron studies: serum iron, serum ferritin & iron bindig capacity
Interpretation:
All normal apart from MCV & MCH

Microcytic hypochromic anemia most
probably fe deficiency anemia
No reticulocytosis or may be mild due to therapy
Comment:
Microcytic hypochromic anemia with normal leucocytic count
Diagnosis:
Microcytic hypochromic anemia most probably Iron deficiency anemia

Iron studies: serum iron, serum ferritin & iron bindig capacity
Interpretation:
Thrombocytopenia
+ mild in Hb due to bleeding
Comment:
Severe thrombocytopenia with mild anemia
Diagnosis:
Thrombocytopenia with anemia possibly ITP

Bone marrow aspirate
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Interpretation:
All are
Anemia ( Hb + MCV OR MCV + MCH) + Thrombocytpenia ( Platelet) +
Leucopenia ( WBCs) + Reticulocytopenia ( reticulocytes)
Comment:
Microcytic (OR macrocytic) hypochromic anemia, thrombocytopenia, leucopenia

Pancytopenia
Diagnosis:
Pancytopenia

Bone marrow aspirate & biopsy
If macrocytic B12 & folic acid
Interpretation:
Leucocytosis (> 15,000) + Polymorph + Bandemia (> 10%) bacterial infection

Leucocytosis (> 15,000) + Polymorph + Bandemia (> 10%) + Hb (normocytic
normochromic)
Leucocytosis (> 15,000) + Polymorph + Bandemia (> 10%) + Hb & MCV & MCH
(microcytic hpyochromic)
Leucocytosis (> 15,000) + Polymorph + Bandemia (> 10%) + platelets (septicemia)
Comment:
Leucocytosis, Polymorph leucocytosis with increase in band cells (shift to left)

With anemia of infection
With microcytic hypochromic anemia (Iron deficiency anemia)
With mild thrombocytopenia septicemia
Diagnosis:
Bacterial infection with anemia

ESR, CRP & proper culture from possible infectious focus
Interpretation:
Leucocytosis + lymphocytosis viral infection
Comment:
Leucocytosis with predominant lymphocytosis (No shift to left), NO bandemia
Diagnosis:
Viral infection

ESR, CRP & ELISA/PCR if special viral infection is susceptible
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NMT10 Medad Illustrations For Children Examination

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Clinical Pediatrics 2nd Edition

Lectures of Prof Dr El Bledy

Clinical Pediatrics 2nd Edition

a- If the trachea and the mediastinum are pulled to the same

2- Radio lucent opacity

Clinical Pediatrics 2nd Edition

 Homogeneous jet black opacity

 broncho vascular markings are present

NB: Lung abscess versus pneumatocele

Comment on any chest x ray

Clinical Pediatrics 2nd Edition

4- give full diagnosis

Clinical Pediatrics 2nd Edition

Lectures of Prof Dr Mohamed Hesham

Clinical Pediatrics 2nd Edition

anterior: frontal lobe

anterior: frontal lobe

Scale of density in CT scan:

highest degree of whiteness (completely while)

in between 0 & 100 unites: according to whiteness:

white but less than bone (100 unite)

Clinical Pediatrics 2nd Edition

white matter of brain tissue

types of density in CT scan:

brain tissue (grey & white matter)

hyper dense === brain ,

including the following:

hypo dense == brain

To describe lesion in CT , use terms hyper dense or hypo dense

how to differentiate between:

plain CT: both are hypo dense lesions

abscess: hypo dense lesion with ring enhancement

2- hemorrhage & calcification:

plain CT: both are hyper dense lesions

if patient has hemiplegia & coma=hemorrhage

Clinical Pediatrics 2nd Edition

1- plain CT scan : for the following lesions:

2- contrast enhanced CT scan:

injection of radioopaque dye IV. So passes into vascular structure making it

enhancement: making vascular structure more white (more dense , more

levels of cut in CT scan:

no ventricles/ no black areas=most important

in contrast enhanced CTs , there are 2 grades of density:

2- Ventricular level:( level of bodies of lateral ventricle)

Appearance of lateral ventricle : black , NOT midline

3- Ventricular level, level of horns of lateral ventricle, 3rd ventricle

Appearance of 3rd ventricle :

Clinical Pediatrics 2nd Edition

Appearance of quadrigeminal cistern:

Definition: one of the CSF spaces

Differentiate it from 4th ventricle: the 4th ventricle is concave facing

4- Infra ventricular level, posterior fossa, 4th ventricle

Appearance of petrous part of temporal bone

Appearance of 4th ventricle:

Summary of levels of cut in CT scan

2- Level II: ventricular level, level of bodies of lateral ventricle:

3- Level III: ventricular level, 3rd ventricle:

4- Level IV: infra ventricular level, posterior fossa:

Petrous part of temporal bone, so:

Differential diagnosis of lesions:

Clinical Pediatrics 2nd Edition

Focal: infarct abscess tumors

Homogeneous jet black opacity

broncho vascular markings are present

If still lethargic DANGER SIGN

Lower chest goes IN with INspiration

If sounds are inspiratory, so it is STRIDOR