Clinical Pediatric Notes

Clinical Pediatric Notes "All Team Production" 2009
All team "One Vision One Mission" | 1

Check lists for History
Taking

Source:

g Notes of
Prof. Dr Mustafa Zakaria.



General Pediatric History

1. Welcome the patient.

2. Introduce yourself to the patient.

3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.

4. Complaint.

5. Present History:
Analysis of the complaint:
Onset: Sudden, Acute or Gradual.
Course: Progressive, Stationary or
Regressive.
Duration.
Symptoms of the same system.
Symptoms of the other systems:
Chest:
Cough, Hemoptysis, Cyanosis, Chest
infections, and Fever.
Cardiac:
Difficulty in breathing, Dyspnea,
Difficulty in feeding, Cyanosis,
Palpitation.
GIT:
Vomiting, Diarrhea, Constipation,
Amount of stool, Jaundice.
UTI:
Difficulty in urination, blood in urine,
amount of urine, edema.
Neuro:
Loss of conscious, convulsions.
Hepato-biliary:
Jaundice, pain in right
hypochondrium, bleeding per gums,
wound healing.
Medical attention:
Investigations, ttt & Hospitalization.

maternal age in down
syndrom


6. Perinatal History:
Antenatal: Medical health during pregnancy.
Infections (fever & rash).
Diabetes or Toxemia of pregnancy.
Drugs or irradiation.
Natal history:
Duration of pregnancy.
Delivery type (VD CS).
Drugs (Sedation during labour).
Birth weight.
Birth Condition:
Immediate cry Resuscitation required.
Neonatal history:
Cyanosis - Convulsions.
Respiratory difficulties - Jaundice.

7. Developmental History:
Motor:
Neck support Sitting with support.
Sitting without support Standing Walking.
Mental:
Social smile Maternal recognition Speech.

8. Nutritional History:
Type of feeding "breast or artificial":
Breast: frequency Adequacy.
Formula: Amount per feed, Frequency &
Concentration.
Weaning: Onset, Foods, Method & Amount.
Supplements: "Vitamins & Minerals".

9. Vaccination History: Time of vaccines.

10. Past History:
Significant illness: Chest, Cardiac, Renal,
Hepatic, GIT, CNS & Rheumatic fever.
Specific infections: TB or Bilharziasis.
Significant events: Trauma, Surgery &
Accidents.

11. Family History:
Consanguinity.
Similar condition in the family.



Down Syndrome
Sex. Residence.

4. Complaint:
Delayed motor and mental milestones.
Chest infection "cough, wheezes or dyspnea".

5. Present History:
Analysis of the complaint.
Symptoms of the same system:
Difficult breathing, or suckling & cyanosis.
Failure to weight gain.
Recurrent chest infections.
Symptoms of the other systems.
Medical attention:
Investigations, treatment & hospitalization.

Natal history: Previous abortion.
Neonatal History.

7. Developmental History: "Very Important"
Motor:
Mental

Type of feeding "breast or artificial"
Supplements "Vitamins & Minerals".


10. Past history: As general.

11. Family History:
Maternal age.
Consanguinity.



Normal Newborn Neonatal Jaundice
REVISE GENERAL SHEET
1. Welcome the patient. 1. Welcome the patient.
2. Introduce yourself to the
patient.
2. Introduce yourself to the
patient

As usual, Age "actual date of birth, may
be in hours expected date of birth if
baby looks premature"
Is baby one of twin?
The same.

4. Complaint: Coming for follow up. Yellowish skin discoloration.
5. Present History:

No comment

Onset: when the mother noticed the
jaundice.
Color of urine and stools -
frequency of stooling.
Refusing feed or vomit everything
"may be septicemia?"
Abnormal movement "convulsions"
may be Kernicterus.

Antenatal: Medical health during
pregnancy.
Diabetes or toxemia of pregnancy.
Natal history:
Membranes rupture: how many
hours before delivery?
Delivery type (VD CS &
Instruments).
Birth weight.
Birth Condition.
Immediate cry Resuscitation required
Need for incubation.
Neonatal history:
Cyanosis Convulsions.
T
H
E

S
A
M
E



Type of feeding (breast or artificial)
Breast: frequency Adequacy.
Formula: Amount per feed, Frequency &
Concentration.
T
H
E

S
A
M
E

9. Vaccination History:
Did he receive any vaccines?
The Same
11. Family History:
Consanguinity.
Age of the mother.
Any siblings (normal or not).
Abortion or stillbirth.

The Same
+
Family history of neonatal jaundice
in any baby.
Did they need admission to ICU?
Did they require ttt "Phototherapy
or exchange transfusion"?
Family history of jaundice, Anemia
or Repeated blood transfusion.
Family history of liver disease.

N.B.:
g The onset of different types of jaundice:
e In physiological neonatal jaundice = 2
nd
or 3
rd
Day of life.
e In pathological neonatal jaundice "unconjugated hyperbilirubinemia" = in the 1st
Day of life.
e In cholestasis "conjugated hyperbilirubinemia" = in the 10
th
Day of life.
e In breast milk jaundice = in the 2
nd
day with discomfort after feeding.



Rickets
Yes No
Sex. Residence.

4. Complaint:
Delayed walking Delayed dentition.

5. Present History:
E Recurrent chest infections.
E Recurrent diarrhea, Constipation or
Anorexia.
E Excessive sweating.
E Exposure to sun light (housing condition).
E Convulsions or carpo-pedal spasm.
E Any observed bone deformities.
E Hepatic or urinary problems.
Medical attention:
Investigations, treatment "Vit. D injections"
& hospitalization.

Antenatal:
Natal history:
Duration of pregnancy: history of
prematurity or twins.
Neonatal history.

Motor: Delayed walking
Mental.



8. Nutritional history: "Very Important"
Type of feeding "breast or artificial":
Prolonged breast feeding without weaning.
Weaning: with food do not contain Vit. D.
Supplements: "Vitamins & Minerals", usually
No.

9. Vaccination History.
10. Past history.
11. Family History:
Consanguinity.

For oral discussion "timing of the vaccines":

Time Vaccine
In the first 3 months: BCG
2 months: Polio Sabin (OPV) / DPT / HBV
9-10 months: Measles
15 months: MMR
18 months: Polio Sabin (OPV) / DPT


Marasmus

Sex. Residence.

4. Complaint:
Loss of weight or failure to gain weight.
Gastroenteritis "diarrhea and vomiting".

5. Present history
E Recurrent diarrhea or Persistent vomiting.
E Symptoms of malabsorption: bulky
offensive.
E Symptoms of hunger: continuous cry,
scanty stools & anxiety.
E Hepatic or Urinary problems or Cardiac.
Medical attention:

Antenatal.
Natal history:
Duration of pregnancy: history of prematurity
or twins.
Neonatal history.

7. Developmental History: may be delayed
Mental.



8. Nutritional History: "Very Important"
Scanty breast milk Formula feeding "Diluted or
decreased frequency".
Weaning: Improper weaning.
No.


10. Past History.

11. Family History:
Consanguinity.
Family history of TB.



Kwashiorkor

Sex. Residence.

4. Complaint:
Swelling of lower limbs "may be the dorsum of
the foot only".
Gastroenteritis "Diarrhea & Vomiting".

5. Present History:
Analysis of the complaint: edema .
E Recurrent diarrhea or Persistent vomiting.
E Hepatic or Renal or Cardiac (to exclude
other causes of edema).
Medical attention:

Antenatal.
Natal history:
Duration of pregnancy: history of
prematurity or twins New brother (maternal
deprivation).
Neonatal history.

7. Developmental History: may be delayed
Mental.

8. Nutritional History: "Very Important"
Scanty breast milk Formula feeding "Diluted or
decreased frequency".



Weaning: Sudden weaning and with
carbohydrate foods only.
No.

10. Past History.

11. Family History:
Consanguinity.



Congenital Heart Disease
VSD - FALLOT

Sex. Residence.

4. Complaint:
Shortness of breath.
Bluish discoloration of skin and mucous membranes.
Chest infection "cough".

5. Present History:
E Lung congestion:
Difficult breathing or suckling.
Failure to weight gain.
Recurrent chest infections: cough & dyspnea.
E Rt. side failure: Puffy eyelids, lower limbs edema.
E Low cardiac output: Peripheral coldness, sweating.
E Others: Cyanosis, Cyanotic spells, Squatting, Fever &
Palpitation.
E Neurological symptoms; Syncope & Stroke.
Medical attention:
Investigations "ECHO, ECG & X ray", treatment "digitalis,
diuretics" & hospitalization.

Natal history: Previous abortion.
Neonatal history.

Motor.
Mental.



Supplements: "Vitamins & Minerals".


10. Past History.

11. Family History:
Maternal age.
Consanguinity.



Rheumatic Heart Sheet

3. Personal History.
4. Complaint:
Shortness of breath Painful joint swelling.

5. Present History:
Symptoms of the same system: cardiac
symptoms.
E Left side heart failure:
Pulmonary congestive symptoms (3):
i. Dyspnea
At rest or exertion.
Association: Orthopnea
Paroxysmal nocturnal dyspnea
ii. Cough
Relation to exertion.
Character: dry (due to congestion)
or productive (infection).
Cough of cardiac diseases is usually dry
exertional and follow dyspnea.
iii. Hemoptysis. not common
Low cardiac output symptoms (3):
i. Syncope (the most important).
Other symptoms:
ii. Easy fatigue or fainting.
iii. Coldness of extremities or
claudications.
E Right side heart failure "3":
Edema: lower limb.
Pain: on the right hypochondrium.
GIT congestion: e.g. vomiting.



E Others "3":
Palpitation: related to exertion.
Chest pain (pericarditis).
Complications: Infective endocarditis
(fever, strokes) & Rheumatic activity
(arthritis).
Medical attention:
Investigations "ECHO, ECG & X ray", treatment
"digitalis, diuretics, long acting penicillin" &
hospitalization.
6. Perinatal History.

7. Developmental History.

8. Nutritional History.


10. Past History:
Recurrent tonsillitis Any previous activity.

11. Family History:



Cerebral Palsy Hydrocephalus

Sex. Residence.

4. Complaint:
Developmental delay Convulsions.

Head enlargement.

5. Present History:
E Convulsions.
E Dysphagia and nasal regurge (pseudo
bulbar palsy).
E History of fever, convulsions, or
admission to fever hospital (CNS
infections).
Medical attention:
Investigations & treatment "physiotherapy".

Onset of head enlargement.

T
H
E

S
A
M
E

Diabetes or toxemia of pregnancy.
Natal history:
Delivery type (VD CS & Instruments).
Birth weight.
Birth Condition.
Immediate cry Resuscitation required
Need for incubation.
Neonatal history:
Cyanosis Convulsions.

T
H
E

S
A
M
E



Motor:
Mental:
T
H
E

S
A
M
E

8. Nutritional History: in short.


10. Past History:
Significant events: Trauma, Surgery &
Accidents.
The Same

11. Family History:
Consanguinity.

The Same



Nephrosis

Sex. Residence.

4. Complaint:
Puffiness of the eyelid.
Abdominal distention.
Lower limb edema.

5. Present History:
Analysis of the complaint: edema march,
relation to the time of day.
E Urinary symptoms "change in the
amount or in the color".
E Headache "hypertension".
E Symptoms of complications:
Chest infection: fever, dyspnea.
Skin infection.
Abdominal: Pain, Vomiting &
Diarrhea.
E Hepatic or Cardiac (to exclude other
causes of edema).
E Rash, Arthritis (with lupus).
Medical attention:
Investigations, treatment (steroids or
immunosuppressive: start of therapy and the response)
& hospitalization.

Antenatal.
Natal history.
Neonatal history.




To exclude nutritional edema.


10. Past History:
Previous attacks: relapses.

11. Family History:
Consanguinity.

N.B:
To exclude hypovolemic shock.

Blood pressure & Temp. measurements are must in nephritic syndrome.

To exclude infections.



Abdominal History

Sex. Residence.

4. Complaint:
Abdominal distention, Hematemesis.
Jaundice, Abdominal pain.

5. Present History:
E Hepatobiliary:
Jaundice (denotes hepatitis or liver cell failure): Color of urine and stool,
Itching, History of previous blood transfusion, Bleeding tendency,
Lower limb edema & Encephalopathy.
Abdominal distention (denotes organomegly or ascites): Onset, Course &
duration.
Hematemesis (denotes portal hypertension): Number of attacks, Amount
of bleeding "Color contain food particles or not", Bleeding from
rectum, Melena & Needs for blood transfusion.
E Abdominal pain: Site of pain, Severity, Nature, Relation to meal
radiation, What increase & What decrease.
E Blood disease:
Leukemia: Prolonged fever, Arthralgia or arthritis, Purpuric eruptions
& Any swellings (lymph nodes).
Chronic hemolytic anemia: Pallor & History of repeated blood
transfusion.
E General toxemic symptoms: Night fever, Night sweat, Anorexia &
Loss of weight.
E Lower GIT: Diarrhea "frequency, consistency, volume & color"
Constipation.
E Upper GIT: Vomiting, Dysphagia, Dyspepsia & Flatulence.
Medical attention:



Natal history.
Neonatal History: History of umbilical vein catheterization or umbilical sepsis.


8. Nutritional History.


10. Past History:
Significant illness: Chest, Cardiac, Renal, Hepatic, GIT, CNS & Rheumatic fever.
Specific infections: TB or Bilharziasis.
Significant events: Trauma, Surgery & Accidents.

11. Family History:
Consanguinity.
Family history of chronic hemolytic anemia.
Family history of liver disease.



Photos with Q & A

Source:

g Notes of



Photos Discussion
g Mongolian spots:
What is the diagnosis of this condition?
Mongolian spot in lumbosacral area.
Bluish discoloration of an area of skin, it is of no significance.
What is the differential diagnosis of this condition?
1. Bruises "due to trauma or child abuse".
2. Ecchymoses "due to bleeding tendency".
What is the treatment?
No thing as it fades gradually as the infant grows older, so what is needed
is Reassurance.
g Neonatal gynecomastia:

Neonatal gynecomastia: breast enlargement in both sexes during the first weeks of life due
to transplacental passage of maternal hormones.
No thing except reassurance and - It should not be squeezed.
g Normal newborn: Vernix caseosa
What is the diagnosis of this condition? Vernix caseosa.
What is the nature of this layer?
Whitish greasy coat.
What is the etiology?
It is produced in utero by epithelial cell breakdown.
What is the function of this layer?
It protects the skin from the amniotic fluids.


g Milia:
What is the diagnosis of this condition? Milia.
What is the nature of this condition?
It is epidermal cysts (white or yellow in color) found on the nose, chin
& forehead.
What is the prognosis?
It is benign lesion, it exfoliate and disappear spontaneously within
the first weeks, no treatment is necessary.
g Moro reflex
It is the most common neonatal primitive reflex.
How can you elicit?
Dropping the head with the examiners hand supporting the body,
Making a loud noise near the infants ear, or
Sudden withdrawal of the blankets from underneath
the infant.
What is the significance of this reflex?
Normal response Normal CNS.
Absent Serious CNS affection:
Intracranial birth injury.
Cerebral depression by drugs.
Asphyxia or prematurity.
Asymmetrical response Fracture clavicle - Erbs palsy.
Persistence of the reflex beyond 6 months Cerebral palsy.
g Cephalhematoma:
1. Cephalhematoma
2. Rt. parietal cephalhematoma and vacuum extraction site.
It is a subperiosteal hemorrhage, limited by suture lines, due to traumatic delivery or
ventous.
What are the expected clinical manifestations?
Anemia & jaundice.
Conservative.
Aspiration is contraindicated.



g Erb's palsy:
Flaccid paralysis of the left upper limb.
It is held in adduction, internal rotation and pronation
(policeman tip).
Moro reflex is absent on the affected side, but grasp
reflex is intact.
What is the etiology of this condition?
It results from injury of 5th and 6th cervical nerve usually
due to traumatic delivery.
What is the treatment of this condition?
Physiotherapy from second week.

g Facial palsy:

(1) (2)
1. Left facial palsy.
2. Right facial palsy.
Weakness of facial muscles, drooping of mouth and inability to close the eye on the
affected side.
Compression of facial nerve by pressure from forceps blades but may occur after normal
delivery.
Physiotherapy.
Good, most cases resolve within a few weeks after birth.



g Umbilical granuloma:

What is wrong with this umbilicus?
Umbilical granuloma presents as a persistent serosangunious discharge and a fleshy
protuberance from the base.
Local application of silver nitrate, rarely by surgical excision or ligation.

g Infant of diabetic mother:
Infant of diabetic mother: large obese infants due
to poor control of maternal diabetes.
What are the complications of this condition?
Metabolic complications: hypoglycemia &
hypoglycemia.
Respiratory distress syndrome.
Polycythemia.
High incidence of congenital malformations.
What are the laboratory investigations that should be done in his case?
1. Magnesium & hematcrite. 2. Blood glucose & calcium.

g Congenital hypothyroidism:
Congenital hypothyroidism.
What are the clinical features of this condition?
Coarse facies, large protruding tongue & umbilical
hernia.
How to prevent this condition?
Routine screening of all newborns within a few
days of birth.


g Hydropes fetalis:
Hydropes fetalis.
What are the clinical features of this condition?
Gross generalized edema, Ascites & Heart failure.
How to prevent - why this condition becoming
uncommon?
Uncommon since the prevention of disease with anti-
D immunoglobulin.
Exchange transfusion & Ventilatory support.

g Phototherapy
What are the types of phototherapy?
White, Blue or Green "wave length: 450 - 460 nm".
What is the indication?
Bilirubin level above 15 mg% "full term - unconjugated
Jaundice".
What are the side effects?
Hyperthermia, Dehydration, Loose stool & Skin rash.
g Necrotizing enterocloitis:

It is common in preterm infant.
It is due to ischemia of the bowel wall and infecting organism.
May be accelerated by early feeding.
Stop oral feeding & give antibiotics.


g Inguinal hernia & umbilical hernia:

Inguinal hernia, it is the commonest condition requiring surgery during infancy.
Umbilical hernia subsides spontaneously.
What are the clinical features of this condition "inguinal hernia"?
It presents as an intermittent swelling in the inguinal region or scrotum, noticed during
crying or straining.
What is the treatment of this condition "inguinal hernia"?
Surgical repair should be done as soon as possible, because the risk of strangulation is high in
young infants.

g Imperforate anus
Imperforate anus.
How to diagnose this condition?
It is usually diagnosed during routine examination immediately after
birth.
What to do after its diagnosis?
Detailed examination as other anomalies are
found in 60% of cases.
Most cases need colostomy performed in the
neonatal period.
Surgical repair is performed later on.



g Hypospadias:
Hypospadias: the urethral orifice is situated on
the ventral aspect of the penis at a site proximal
to the normal opening.

What to advise the parents?
Circumcision should be delayed until corrective surgery is done, as the prepuce may
be needed for urethroplasty.

g Cleft lip & palate:

(1) (2) (3)

Cleft lip & palate (1, 2) - Cleft lip (3).
Feeding difficulties.
Aspiration pneumonia.
Speech problems and deafness.
What is the management of this condition?
Surgical repair usually gives excellent results.
Feeding by a large teat, spoon or tube feeding.



g Tongue tie:
Tongue tie.
What is etiology of this condition?
It is due to short lingual frenulum.
What are the problems of this condition?
No problems, it rarely interferes with eating
or speech generally need no treatment.

g Talipes equinovarus (Club foot):

(1) (2)
Talipes equinovarus (1).
What is the differential diagnosis of this condition?
Positional talipes (2) foot can be fully dorsiflexed to touch the front of the lower leg. "Can be
passively corrected".
Splinting, but surgical release may be needed.

g Microcephaly:
Microcephaly "head circumference below the 3rd centile for age".
What are the causes of this condition?
Congenital infections: TORCH.
Causes of cerebral palsy: enumerate some causes.



g Meningomyelocele:

(1) (2) (3)
What is the diagnosis of this condition (1, 2)?
Meningomyelocele.
How to diagnose the condition antenatally?
Ultrasound examination it is a neural tube defect.
Hydrocephalus occurs in most of the cases, Infections & Paraparesis.
First aid includes covering by sterile dressing and neurosurgical referral.
g Oral moniliasis:

Oral moniliasis: white adherent plaques on the buccal mucosa and tongue.
What is the cause of this condition?
It is a fungal infection caused by Candida Albicans.
What is the main presentation of this condition?
Refusal of suckling and crying.
Treatment is by topical nystatin or miconazole.


g Perineal moniliasis:

Perineal moniliasis.
What is the lesion shown?
Bright red confluent rash in the napkin area and around the anus.
Typically, there are discrete satellite lesions lying peripheral to the rash.
What is the cause? What is the treatment?
As oral moniliasis.

g Neonatal conjunctivitis:

Neonatal conjunctivitis.
What are the causes of this condition?
Chlamydia, gonorrhea & viruses.
Minor sticky eye is much more common, usually non-infective and responds to frequent eye
washes.



g Measles:

What is the type of rash shown?
Maculopapular rash Koplick's spots.
Enumerate 3 possible causes.
1. Measles: rash starts behind the ears and on the face, then spread downward.
2. German measles.
3. Roseola infantum: human herpes virus-6, infants 6 months to 2 years.
Respiratory: bronchitis, bronchiolitis and pneumonia.
Neurological: encephalitis, subscute sclerosing pan encephalitis.
Symptomatic i.e. antipyretics for the high fever.
g Roseola infantum:

Maculopapular rash.
Enumerate 3 possible causes? As above.
What is the treatment of this condition? As above.


g Scarlet fever:

Scarlet fever: infection by group A -hemolytic streptococci.
What are the diagnostic features of this condition?
Sore throat.
Fine popular rash.
Tongue changes (white, then red strawberry).
What are the possible complications?
Early: Sinusitis - Mastoiditis - Otitis media.
Late: Glomerulonephritis - Rheumatic fever.

Skin peeling

g Impetigo contagiosa:
Impetigo contagiosa.
Infection by gram positive cocci e.g.
staphylococcus aureus.
Local fucidenic acid cream.
Extensive lesions should be treated with systemic flucloxacillin.



g Chickenpox:

Papulovesicular rash.
What is the most possible cause?
Varicella: successive crops, is centripetal in distribution and pleomorphic.
Secondary bacterial infection of lesions and pneumonia.
Neurological problems e.g. acute cerebellar ataxia.
g Urticaria:
Urticaria. It is a common allergic
manifestation.
What are the possible causes?
Exposure to allergens: insect bite, drugs or
certain foods.
What are the other features of the disease?
Itching, wheals & edema around the eyes and mouth.
Laryngeal edema and airway obstruction.
Subcutaneous adrenaline and systemic steroids.
g Purpura:
Purpura for differential diagnosis.
What are the possible causes? "Causes of purpura"
ITP, Aplastic anemia & Leukemia.


g Henoch-Schonlein purpura:

Henoch Schonlein purpura; It is a vasculitis with a normal platelet count.
What is the characteristic lesion shown?
Purpuric rash involving the lower limbs and buttocks.
What are the other features of this condition?
Other features include arthritis, abdominal pain and nephritis.
Most cases recover within few weeks.
g Purpura fulminans:

Purpura fulminans.
What is the characteristic lesion?
This is large ecchymoses with irregular shapes evolving into
hemorrhagic bullae and then into black necrotic lesions.
What are the possible causes?
Sepsis: Meningococcal septicemia.
Malignancy.
Massive trauma.
High mortality rate and intensive care management is urgently needed.


g Atopic eczema:

What is the main symptom of this condition? Itching.
What are the common sites for this condition?
Face in infants, in children: Skin flexures "cubital & popliteal fossa".
Avoiding irritants, topical mild steroids & creams.
g Scabies:
Infestation with a mite.
What is the main symptom of this condition?
Itching; usually other members in the family
have the disease & have itching.
What re the common sites for this condition?
Palm, Soles & Trunk.
Permethrin cream 5%.
g Systemic Lupus Erythematosus:

What is the etiology of this condition? Autoimmune disease.
What are the clinical features?
Multisystem affection: Malar rash, Mouth ulcers, Arthritis, Pericarditis & Nephritis.
Anti inflammatory drugs and steroids.


g Hemophilia:
Genetic disease X-linked recessive.
What are the clinical features?
Bleeding, large hematoma "Muscle Hematoma",
easy bruising & hemoarthrosis.
Fresh frozen plasma & factor VIII concentrate.

g Pertussis "whooping cough":

What is the abnormality shown?
Subconjunctival hemorrhage & Periorbital ecchymoses.
What are the most likely causes?
Pertussis; during coughing paroxysms, the intra thoracic
pressure rises sharply leading to elevated capillary pressure and
rupture.
Chronic cough or vomiting & chronic straining.
What are the main complications of Pertussis?
Bronchopneumonia due to secondary bacterial infection.
What is the treatment of Pertussis?
Symptomatic and oral erythromycin



g Dehydration:
Sunken eyes: moderate or severe dehydration.
Loss of skin turgor: moderate or severe dehydration; It is a
complication of severe gastroenteritis.
What are the possible other features?
Depressed fontanelle, loss of skin turgor & acute weight loss.
Sunken eyes & dry tongue.
What is the main line of treatment? Rehydration.
Why infants are more prone to such problem?
Greater surface area to weight ratio.
Higher basal fluid requirement (100 ml/kg).

g Osteogenesis imperfecta:
Uncommon genetic disease, characterized by bone fractures, blue
sclera and defective dentition.

g Rickets:

Rossary beads Genu valgum Genu varum



g Kwashiorkor:
Kwashiorkor.
Faulty weaning by a low protein high carbohydrate diet.
What are the other manifestations?
Constant features include edema, growth failure, mental changes and disturbed muscle to fat ratio.
Other important features include hair and skin changes.
Serious infections.
Gastroenteritis and electrolyte disturbances.
Hypoglycemia & hypothermia.



CT scan with full comments

Source:

g Notes of
Prof. Dr Mohamed El-Nagger.



CT scan comment
1) Type of CT "written on the slide":
e Plain CT.
e Contrast enhanced CT.
2) Level of the cut:
e Supra ventricular = falx celebri
e Ventricular.
e Posterior fossa level "Infratentorial level".
3) Lesion:
e Nature:
Hyper or Hypo dense lesion.
Ventricular "dilatation or compression".
e Site of the lesion "i.e.: left frontal lobe, right parietal lobe "
4) Final diagnosis.
CT scan scheme
1) Look at the ventricles: Dilated =Hydrocephalus.
Congenital communicating: all ventricles are dilated.
Congenital obstructive: all dilated except the 4th ventricle.
Acquired: due to brain tumor, intraventricular hemorrhage or ventriculitis.
2) Look at the brain sulci and gyri:
Brain atrophy: Prominence of cerebral sulci.
Brain edema: loss of sulci.
3) Look at the brain tissue:
e Hyperdense lesion:
Cerebral calcification: no mass effect (compression) - mirror image.
Intracranial hemorrhage: mass effect - it may be intracerberal,
intraventricular, subdural or extradural.
e Hypodense lesion:
Cerebral infarction.
Hemorrhagic infarction: mixed hypodense and hyperdense areas.
e Localized lesion: with contrast - mass effect is present.
Brain tumor: solid (total enhancement) or cystic (ring enhancement but
with thick irregular wall)
Brain abscess: thin wall regular- ring enhancement.


A
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Dilated bodies of lateral ventricle.
B
Ventricular level "horns of lateral ventricle & 3
rd
ventricle".
Dilated horns of lateral ventricle.
C
Ventricular level "horns of lateral ventricle & 3rd ventricle".
Dilated 3rd ventricle.
D
Posterior fossa level "4th ventricle".
Dilated 4th ventricle.
Congenital communicating hydrocephalus "dilatation of all ventricular systems".
Lesion below the level of 4th ventricle "in subarachnoid space"


A
Dilated bodies of lateral ventricle.
B
Ventricular level "horns of lateral ventricles & 3
rd
ventricle".
Dilated horns of lateral ventricle.
C
Ventricular level "horns of lateral ventricle & 3rd ventricle".
Dilated 3rd ventricle.
D
Posterior fossa & 4th ventricle.
Normal "not dilated"4th ventricle.

Congenital obstructive hydrocephalus "above the level of 4th ventricle"
mostly due to congenital stenosis of aqueduct of sylvius.


A
Supra ventricular level.
Increased prominence of:
Cerebral sulci,
Inter hemispheric fissure &
Subarachinoid space "reduced cerebral mass prominent CSF
spaces".

B
Increased prominence of:
Cerebral sulci,
Inter hemispheric fissure &
Ventricular system "passive dilatation due to reduced cerebral mass".

Brain atrophy

Brain atrophy



A
Supratentorial level.
Diffuse cerebral hypo density with loss of grey-white interface loss of all supra ventricular
spaces "sulci & CSF spaces".

B
Plain CT scan of head
Infra tentorial level "posterior fossa".
Diffuse cerebra hypo density with loss of grey- white interphase loss of all infratentorial
spaces.

Brain edema "loss CSF spaces"

Brain edema "loss CSF spaces"



Punctuate calcification "congenital toxoplasmosis"

Periventricular calcifications "cytomegalic inclusion disease"

Supra sellar calcification "calcified cranio-pharyngioma"
Basal Ganglia calcification "hypoparathyroidism"

A
Hyper dense lesion "diffuse, small dots", scattered all over the cortical tissue.

B
Ventricular level "lateral ventricular horns & 3 rd ventricle".
Hyper dense "bilateral, nodular", protruding to the horns of lateral ventricle.

C
Pain CT scan of head.
Coronal section.
Hyper dense area, in supra-sellar region "".

D
Ventricular level "lateral ventricular horns & 3rd ventricle".
Hyper dense lesion "bilateral, symmetric", at the basal ganglia region.



Intracerebral hematoma

Intraventricular hemorrhage

Subdural hematoma

Epidural hematoma

A
Hyper dense lesion in the left frontopraietal lesion with mass effects
compression of left lateral ventricle.

B
Hyper dense area affecting both lateral ventricles with ventricular dilatation.

C
Hyper dense concavo-convex lesion, affecting left fronto-parietal region with mass
effect "compression of lateral ventricle".
Associated intracelebral hematoma "The arrow".

D
Hyper dense biconvex lesion affecting the right fronto-parietal region "the arrow" with
mass effect compression of right ventricle.
With left parietal fracture "The arrow".



A
2 hypo dense localized areas in the right occipital region and left parietal region.

B
Hypo dense extensive lesion in left parieto-occipital region.

C
Plain CT scan of the head.
Ventricular level ( bodies of lateral ventricle)
Mixed lesion Hyper dense area "hemorrhage" in left tempo-parietal region.
Hypo dense area "infarction".
D
The same patient but at a lower level.
Ventricular level "lateral ventricular horns & 3 rd ventricle".
Mixed: Hyper dense area "hemorrhage" in left tempo-parietal region.
Hypo dense area "infarction".

Localized infarction

Extensive infarction

Hemorrhagic infarction



A
Big hypo dense area in right parietal region compressing the right lateral ventricle.
B
Contrast enhanced CT for the same patient.
Big hypo dense area with ring enhancement of abscess capsule in the right parietal
region compressing the right lateral ventricle.

C
Contrast enhanced CT.
Small hypo dense area with ring enhancement of abscess capsule in the left fronto-
parietal region.

D
2 small hypo dense areas with ring enhancement of abscess capsule in left parieto- occipital
region.

Big single brain abscess in the right parietal area
Small brain abscess

Multiple brain abscesses



A
Infraventricular level "posterior fossa & 4th ventricle".
Hypo dense "large & cystic" lesion, in the left cerebellar lobe with ring enhancement of tumor.

B
Infra ventricular level "posterior fossa & 4th ventricle".
Hyper dense "midline, rounded" lesion, in the posterior fossa with ventricular dilatation
"obstructive hydrocephalus".

C
Hyper dense "rounded, midline" lesion, in pineal body region.

D
Hyper dense large lesion, in the left occipital horn with dialed lateral ventricle.
Cerebellar astrocytoma

Medulloblastoma

Pinealoma
Choroid plexus papilloma



A
Contrast enhanced CT scan head different patient.
Ventricular level "bodies of lateral ventricles".
Hyper dense area affecting both lateral ventricles with ventricular dilatation.

B
Dilated lateral ventricle due to ventriculitis "enhancement of epindymal lining of ventricle".

C
Infra ventricular level "posterior fossa & 4th ventricle".
Hyper dense "midline, rounded" lesion, in the posterior fossa compressing the 4th ventricle.
D
The same patient but at higher level "3rd ventricle and horns of lateral ventricles" showing
ventricular dilatation.

Acquired obstructive hydrocephalus due to intra ventricular hemorrhage

Acquired obstructive hydrocephalus due to ventriculitis

Acquired obstructive hydrocephalus due to Medulloblastoma
Cranial and extra cranial lesions



A

B

C

D

Linear skull fracture in the right frontal bone "The arrow" with left subdural effusion.

Depressed skull fracture in the right parietal bone with bone fragmentation.

Extensive bilateral cephalhematoma "extra cranial areas of heterogeneous opacity".

Traumatic head injury with multiple lesions
Cephalhematoma.
Skull fracture "The arrow".
Cerebral hematoma in the left fronto-parietal region and brain edema.
"Generalized hypodensity with loss of gray white interface"



X-Rays Shown by:
Prof. Dr Ahmed El-Belidy
with full comments

Sources:

g Notes of
Prof. Dr Mustafa Zakaria &
Lectures of Prof. Dr El-Belidy.



1. Cardiomegaly without special shape

(A) (B)

e Plain X-ray chest.
e Postero-anterior view.
e The Patient is not well centralized.
e Costophrenic angles are free on both sides.
e Cardio-thoracic ratio increased about 70% (A), about 65% in (B) denoting
cardiomegaly
e Cardiophrenic angle on the left side is obtuse(left ventricle dilatation)
e Straight left cardiac border "waist obliteration": mitralized heart: dilated left
atrium and pulmonary artery.
e Bulging right cardiac border "right atrium dilatation" (A).
e Increase pulmonary vascular markings "hilar congestion extending upward".

Cardiomegaly due to enlargement of left ventricle, left atrium, pulmonary
artery and right atrium - for differential diagnosis.
Most probably due to: Rheumatic heart disease.



(A) (B)

(C)
e Cardio-thoracic ratio increased about 70% in (A), 60 % in (B, C) denoting cardiomegaly.
e Cardiophrenic angle on the left side is not visualized in (A) obtuse in (B, C)
denoting left ventricle dilatation.
e Prominent pulmonary conus "pulmonary artery dilatation".
e Bulging right cardiac border "right atrium dilatation".
e Increase pulmonary vascular markings "hilar congestion extending upward in both lungs".

Cardiomegaly due to enlargement of left ventricle, left atrium, pulmonary
artery and right atrium for differential diagnosis.
Most probably due to: Rheumatic heart disease.


e Cardio-thoracic ratio increased about 70%.
e Cardiophrenic angle on the left side is acute "right ventricle dilatation".
e Shelfing of the left cardiac border.
e There is heterogeneous opacity in the middle and lower third of the right
lung "pneumonia" overlapping most of the right cardiac border.

Cardiomegaly due to enlargement of Rt. ventricle for differential diagnosis.
Most probably: Right side pneumonia.


e Plain X-ray chest and abdomen.
e The patient is not centralized.
e Hypertranslucency surrounding the cardiac shadow.
e Bilateral white lung denotes sever hyaline membrane disease.
e Endo-tracheal tube is inserted for mechanical ventilation.

e Abnormal position of the heart the heart lies mainly to the
Rt. Side.
e The Lt. Cardiac border "made of LV" is to Rt.; The Rt. cardiac
border "made by RA" is to left.
e Mild cardiomegaly.
e The liver shadow and gastric bubbles are in normal position.

e Abnormal position of the heart the heart lies mainly to the
Rt. Side.
e The Lt. Cardiac border "made of LV" is to the Rt.; while the
Rt. cardiac border "made by RA" is to the left.
e The liver shadow is in the left side while gastric bubbles are in
the RT side.
Pneumopericardium
Isolated Dextrocardia

Dextrocardia with Situs Inversus



2. Cardiomegaly with special shape

(A) (B)

e The Patient is well centralized.
e Cardiophrenic angle is acute "may appear obtuse".
e Marked increase in the cardio-thoracic ratio about 85 % in (A), 90% in (B) denoting huge
cardiomegaly.
e Symmetrical bulge of the left and right cardiac borders.
e The borders are very well defined "stenciled".
e Broad cardiac base "accumulation of fluid".
e Normal pulmonary vascular markings.

Cardiomegaly in the form of "flask shaped" most probably
due to pericardial effusion



(A) (B)

(C)
e The Patient is not centralized.
e Cardio-thoracic ratio increased about 70%.
e Cardiophrenic angle on the left side is acute "right ventricle dilatation".
e Marked bulge of the right border "right atrium dilatation".
e In (A) the base of the heart is not narrow as expected in TGA due to overlapping thymus
shadow; in (B & C) the base is narrow.
e Increased pulmonary vascular markings "lung plethora", in (B) there is in addition
heterogeneous opacity in the upper and middle zone of the right lung "pneumonia".

Cardiomegaly in the form of "Egg on side" most probably
due to transposition of great arteries



e Cardio-thoracic ratio is normal or mildly increased.
e Cardiophrenic angle on the left side is acute with uplifted apex "Rt. ventricle hypertrophy".
e Exaggerated waist "pulmonary hypoplasia".
e Decreased pulmonary vascular markings "lung oligemia".

e Cardio-thorathic ratio increased 70 % cardiomegaly.
e The heart is globular in shape.
e The Lt. cardio-phrenic angel is acute RV dilatation.
e Pulmonary vasculature slightly increased.
Coeur en sabot: tetralogy of Fallot??

Cardiomegaly in the form "Globular heart"
most probably pericardial effusion



Chest X-ray

3 Groups of lesions:
1. Unilateral opacity:
Pleural effusion "massive or moderate".
Lung collapse "total or lobar collapse".
Lobar pneumonia.

2. Air fluid level:
Hydro or pyopneumothorax.
Lung abscess "in association with pneumonia or effusion or both".

3. Unilateral translucency:
Pneumothorax.
Emphysema "congenital lobar".

P: Plain X-ray.
P: Postero-anterior view.
P: Patient is centralized.
T: Trachea.
A: Costophrenic Angle on
the same side of the lesion.
L: Lesion.



1. Massive Rt. pleural effusion

e The patient is centralized.
e The right costophrenic angle is obliterated by homogenous opacity occupying also all
the right hemithorax.
e Shifting the mediastinum "the tracheal air column and heart" to the opposite side of the
lesion "left side".

Right side massive pleural effusion


2. Lobar pneumonia

e Plain X ray chest and heart.
e The Patient is centralized.
e Costophrenic Angles are free on both sides.
e There is heterogeneous opacity "triangular in shape" on the apical part of the right lung.
e Central mediastinum "Tracheal air column and heart".

e Plain X-ray chest and heart.
e Costophrenic Angles are free on both sides.
e There is heterogeneous opacity on the upper part of the right lung corresponding to
the infraclavicular area.
e Central mediastinum "tracheal air column and heart".

Rt. upper lobe pneumonia

Rt. upper lobe pneumonia



3. Lung collapse

(A) (B)
e There is homogenous opacity occupying all the "left hemithorax in A"; "the right
hemithorax in B".
e The mediastinum "heart & tracheal air column" is shifted to the same side of the lesion.

e There is homogenous opacity occupying the upper third of the right lung.
e The heart and tracheal air column are shifted to the same side of the lesion "right side".
e Marked hilar congestion of the left lung.

(A) Left side massive lung collapse (B) Rt. side massive lung collapse

Rt. upper lobe collapse



Air fluid level

e Plain X-ray chest and heart.
e The Patient is not centralized.
e Costophrenic Angle on the left side is obliterated by homogenous opacity with
transverse horizontal upper border "fluid level".
e The remaining part of the left hemithorax is jet black "air".
e The heart and tracheal air column are shifted to the opposite side the lesion "Rt. Side".

e The right costophrenic Angle is obliterated
by homogenous opacity with upper
border rising to the axilla "mild pleural
effusion".
e Heterogeneous opacity in the middle
zone of right lung "pneumonia".
e Mild shifting of the tracheal air column and
heart to the opposite side of the lesion "left
side".

Left side pyopneumothorax "or hydropneumothorax"

Rt. side pneumonia complicated by right side pleural effusion



(A) (B)
e Costophrenic Angle on the right side it is obliterated by homogenous opacity raising to
the axilla "pleural effusion".
e The middle and lower zone of the right lung show a cavity with well-defined thick outline
(abscess wall).
e The lower part of the lesion is homogenous with transverse upper border "fluid" while
the upper part of the lesion is jet black "air".
e In (A) there is also heterogeneous opacity on the lower lung third "pneumonia".
e The heart and tracheal air column are central.

Rt. side lung abscess, Rt. side pneumonia (A) &
Rt. side mild pleural effusion
Most probably due to staph or Klebsiella pneumonia



e Costophrenic Angle on the right side it is
obliterated by homogenous opacity
raising to the axilla "pleural effusion".
e The middle and lower zone of the right
lung show a cavity with thick well-defined
outline "abscess wall".
e The lower part of the lesion is
homogenous with transverse upper border
"fluid" while the upper part of the lesion is jet black "air".
e There is also heterogeneous opacity on the lower lung third "pneumonia" with multiple
thin wall cyst "pneumatoceles"
e The heart and tracheal air column are central.

e Costophrenic Angle on both sides
is free.
e The middle and lower lung zones
of the left lung show
heterogeneous opacity with
multiple "airspace surrounded by
thin wall" pneumatoceles.

Rt. side lung abscess, Rt. side pneumonia with pneumatoceles &
Rt. side mild pleural effusion
Most probably due to staph or Klebsiella pneumonia
Left side pneumonia with pneumatocele
The cause is most probably staphylococcal or Klebsiella pneumonia


e Costophrenic angle on the right side is obliterated by homogenous opacity with upper
border rising to the axilla "pleural effusion".
e The middle and lower lung zones of the Rt. lung show heterogeneous opacity with
multiple "airspace surrounded by thin wall" pneumatoceles.

Rt. side pneumonia with pneumatocele-right side pleural effusion
The cause is most probably staphylococcal or Klebsiella pneumonia


Pneumothorax

(A) (B)
e Plain X-ray chest and abdomen; Postero-anterior
view.
e The right hemithorax shows hypertranslucency
with absent bronchovascular markings "jet-black":
pneumothorax.
e The right lung appears as homogenous opacity
shifted against the vertebral column "compression
collapse".
e Intercostal tube is seen draining the
pneumothorax "present in A & B"
e The left lung shows homogenous opacity, which
may be the original disease "RDS" or may be lung
collapse.
e Marked shift of the heart and tracheal air column to the left side.

Right side pneumothorax with Rt. lung compression collapse
Left side lung collapse OR the primary pathology



e Plain X-ray chest and abdomen; Postero-anterior
view.
e Lt. Lung: is hypertranslucent, voluminous with
diminished bronchovascular markings and wide
intercostals spaces. "lobar emphysema"
e The upper part of the left lung herniates through
the superior mediastinum.
e Rt. lung: The upper part shows heterogeneous
opacity "pneumonia", while its lower part is
hypertranslucent "compensatory emphysema".
e The heart shadow appears small, and shifted with
the tracheal air column to the right side.

e X-ray with contrast: barium meal, enema and follow through.
e Herniated barium filled intestinal loops in the right hemithorax.
e Shift of the heart and tracheal air column to the left side. (opposite side of the lesion )

Left congenital lobar emphysema & Rt. lung consolidation
Rt. side diaphragmatic hernia


(A) (B)
e Plain X-ray chest and abdomen Postero-anterior view (A, B).
e The left hemithorax shows heterogeneous opacities present in the lower part
simulating pneumonia, intermingled with multiple radiolucent cystic shadows
simulating pneumatocele "herniated intestinal loops".
e The heart and tracheal air column are shifted to the opposite side of the lesion "right side".

e Lateral view (B): intestinal loops appear in the retrosternal space pushing the heart
backward.

Left side congenital diaphragmatic hernia


1. Intestinal obstruction:

(A) (B) (C)
e Plain X-ray of the chest and abdomen upright position.
e Patient is not centralized.
e Upper loops are dilated with multiple horizontal air fluid levels
e Lower loops are not gaseous.
e Nasogastric tube is present in (A).
2. Duodenal atresia:

e Plain X-ray of the chest and abdomen
upright position.
e Patient not centralized.
e There are 2 large areas with air fluid levels
"double bubble sign".

3. Congenital pyloric stenosis:
e X-ray of the abdomen with barium meal.
e Markedly dilated stomach full of barium.
e Fine elongated pyloric canal seen as a single line of barium
"String sign".
e The pyloric tumor appears a rounded radiolucent shadow
surrounding the narrow pyloric canal.



4. Intussusception:

e X-ray of the abdomen upright position with barium enema.
e Patient is not centralized.
e Coil spring appearance.

5. Pneumoperitoneum:
e Plain X-ray chest and abdomen upright
position.
e Free air "hypertranslucent area) in the
peritoneal space under the diaphragm above
the liver.
e The abdomen is distended with gasses in (B).
(
A) (B)
6. Active rickets:

e Plain X ray of the lower limbs "ankle and knee joints".
e Wide joint space.
e Cupping of the metaphyseal area with frayed
epiphyseal line.
e Decreased bone density.
e Bowing deformity of the tibia and fibula.



IMCI Cases with Key
Answers

Sources:

g Dr Tamer Abdel Hamid.
g Round Exams Questions.



g Copy the following statements to your answer sheet;& write in
front of each one " - " if it is correct & " " if it is wrong:

1. Integrated Management of Childhood Illness "IMCI".
a. It is based on the most common causes of morbidity & mortality in early childhood. ( )
b. It is a management oriented classification. ( )
c. We check all children for throat problems to avoid development of throat abscess which
may be fatal. ( )
d. The five main symptoms of IMCI represent the majority of the complains of the sick
children in the outpatient clinic. ( )
e. It can be applied for children up to 70 months of age. ( )
2. A 10 months old child, his weight is exactly on the curve of 5th percentile for his age &
he is not pale. According to IMCI:
a. He is classified as low weight. ( )
b. He is classified as not low weight. ( )
c. He is classified as anemia. ( )
d. You should give the mother advice about how to feed the child to follow at home. ( )
e. He should be referred urgently to the hospital. ( )
3. 3) An infant aged 10 months with diarrhea for 12 days; he is irritable, thirsty, with
sunken eyes and slow skin pinch. According to IMCI:
a. He is classified as having severe persistent diarrhea. ( )
b. He is classified as having persistent diarrhea. ( )
c. He should be treated with extra fluid intake only "plan A". ( )
d. He should be treated with oral dehydration with ORS "plan B". ( )
e. He should be treated with IV Rehydration "plan C". ( )
4. An infant aged 11 months has fever 39 C with history of convulsions yesterday and he
convulsing now, should he managed with which of the following:
a. Wait until convulsions stops spontaneously, then re-examine. ( )
b. Refer urgently without giving any treatment. ( )
c. Refer urgently after giving anti-convulsant treatment. ( )
d. Give oral antibiotics and send the patient home. ( )
e. Give anti-pyretic before referral. ( )


5. A 14 months old child feverish without neck rigidity having diarrhea for 5 days with
blood in stools. He is irritable, thirsty, his eyes are sunken & his skin pinch goes back
slowly. According to IMCI :
a. His dehydration degree is classified as severe dehydration. ( )
b. His fever is classified as fever possible bacterial infection. ( )
c. He should be treated with IV fluids "plan A". ( )
d. He should be treated with ORS in the clinic "plan B". ( )
e. Oral antibiotics should be used to manage his condition. ( )
6. A 4 months old child has high fever since 3 days, his temp is 39 C there is no neck
rigidity but there is history of convulsions yesterday & he is not convulsing now.
According to IMCI:
a. Start oral anticonvulsant immediately as convulsions may recur. ( )
b. Refer urgently to the hospital. ( )
c. CNS infection can be ruled out due to absence of neck rigidity. ( )
d. His fever is classified as fever possible bacterial infection. ( )
e. Give antipyretic immediately. ( )
7. A 30 months old child having fever 38.2 C , mild earache & discharge from the ear for 3
weeks , but no pus seen coming out of the ear & no any other finding.
According to IMCI classification & management:
a. His ear problem is classified as having acute ear infection. ( )
b. His ear problem is classified as having chronic ear infection. ( )
c. Don't give any form of treatment for his ear condition; just referral for ENT specialist
for consultation. ( )
d. His fever is classified as fever bacterial infection unlikely. ( )
e. His fever is classified as fever possible bacterial infection. ( )
8. A child with bloody diarrhea for 10 days, he is irritable, thirsty, with sunken eyes &
his skin pinch goes back very slowly. According to IMCI classification & management:
a. His classification includes sever persistent diarrhea. ( )
b. His classification includes persistent diarrhea. ( )
c. His classification includes some dehydration. ( )
d. No need to give antibiotics to treat such diarrhea. ( )
e. IV fluid therapy "plan C" is needed for such patient. ( )


9. A child aged 12 months suffering from attack of acute diarrhea in the last 2 days, on
examination; he is playing, he doesn't want to drink, he has sunken eyes & his skin
pinch goes back immediately. There is no blood in the stools.
a. According to IMCI his condition is classified as some dehydration. ( )
b. The patient can be sent home instructing the mother to increase fluid intake to
compensate for fluid lost in diarrhea. ( )
c. The patient should be receive oral anti-diarrheal at home to be cured from the attack of
diarrhea. ( )
d. Encourage early feeding to prevent malnutrition. ( )
10. A child aged 2 years suffered from high fever yesterday, today he develop an attack of
convulsions followed by deterioration of level of consciousness. On examination we
found that the child is unconscious with neck stiffness & high fever 39 C.
a. According to IMCI his fever is classified as very sever febrile disease. ( )
b. According to IMCI, C.T. scan should be done immediately to confirm cerebral
infarction. ( )
c. CSF analysis is important to confirm your diagnosis. ( )
d. Presence of bulging fontanel can you confirm CNS infection. ( )
11. A child aged 36 months with sore throat, his Temp. is 39 C without stiff neck, he is not
able to drink; his throat is congested with exudates on the tonsils. According to IMCI:
a. His throat condition is classified as streptococcal sore throat. ( )
b. His fever is classified as fever possible bacterial infection. ( )
c. His fever is classified as very sever febrile disease. ( )
d. He should be referred urgently to the hospital. ( )
e. Send him home with oral antibiotics. ( )
12. A feverish child with ear problem in the form of discharge coming out of the ear for 5
days, but no pus is seen coming out of the ear during examination & on other
finding. According to IMCI :
a. He is classified as acute ear infection. ( )
b. He is classified as no ear infection. ( )
c. It is a mild condition needs no treatment a part from ENT consultation for reassurance.( )
d. Give him oral antibiotic for ten days. ( )
e. His fever is classified as fever possible bacterial infection. ( )


13. A child aged 2 years suffered from high fever since 2 days, associated with agonizing
ear pain in the left ear, one day later the pain disappear & yellow discharge came out
of the ear. On examination we found pus coming out of the ear & there is no tender
swelling behind the ear.
a. According to IMCI his ear problem is classified as acute ear infection. ( )
b. According to IMCI his fever is classified as fever bacterial infection unlikely. ( )
c. There is no need to give any form of antibiotics as pus has been coming out. ( )
d. Drying the ear & removing the pus is a good adjuvant to therapy. ( )
14. A child aged 12 months suffering from attack of acute diarrhea in the last 2 days; on
examination, he is irritable, thirsty, with sunken eyes & slow skin pinch, there is no
blood in stools.
a. According to IMCI the condition is classified as some dehydration. ( )
b. The patient should receive ORS solution to correct his dehydration state before he
leaves the hospital. ( )
c. The patient should receive oral antibiotics at home to be cured from the attack of
diarrhea. ( )
d. Breast feeding should be stopped until diarrhea is resolved. ( )
15. Integrated Management of Childhood Illness (IMCI):
a. Give us an accurate definite diagnosis of the case. ( )
b. It helps us to decide when to refer the patient. ( )
c. It is a management oriented calcification. ( )
d. It can replace the traditional pediatric teaching. ( )
e. It can be applied for children up to 5 years of age. ( )
16. According to IMCI classifications, the following classifications should be referred
urgently to the hospital:
a. A child classified as severe pneumonia or very severe disease. ( )
b. A child classified as some dehydration. ( )
c. A child classified as acute ear infection. ( )
d. A child classified as streptococcal sore throat. ( )
e. A child classified as very severe febrile disease. ( )



17. A child with diarrhea, he is irritable, thirsty, having sunken eyes & very slow skin
pinch. According to IMCI:
a. He is classified as having some dehydration. ( )
b. He is classified as having severe dehydration. ( )
c. He should receive antibiotics to treat the cause of diarrhea. ( )
d. He should be treated with plan B. ( )
e. He should be treated with plan C. ( )
18. An 11 months old child with cough, his respiratory rate 60/ min & he has chest
indrawing. According to IMCI:
a. Give oxygen immediately & wait for some times, then re-evaluate. ( )
b. Do X-ray & tell his mother to bring him back tomorrow. ( )
c. Refer urgently without giving any treatment. ( )
d. Refer urgently after giving pre-referral treatment. ( )
e. Give him bronchodilators to improve oxygenation. ( )
19. A 8 months old child with cough, his respiratory rate 30/min & no chest indrawing
but he is wheezy:
a. Give him oxygen IV fluids immediately because he may deteriorate at any moment. ( )
b. Give oral antibiotics for five days. ( )
c. Do not give antibiotics. ( )
d. Give bronchodilators to treat wheezes. ( )
e. Do not give bronchodilators because it is mild condition & doesnt deserve treatment.( )
20. A 12 months old child with cough, he is considered having fast breathing according to
IMCI protocol:
a. If his respiratory rate is 50 breath/min or more. ( )
b. If his respiratory rate is more than 50 breath/min. ( )
c. If his respiratory rate is 40 breath/min or more. ( )
d. If his respiratory rate is more than 40 breath/min. ( )
e. If his respiratory rate is more than 60 breath/min. ( )
21. A 15 month old child with fever 38.8c & stiff neck:
a. Refer urgently to hospital. ( )
b. CNS infection can be rolled out because there is neither bulging fontanel nor
convulsions. ( )
c. CSF analysis is important to roll out CNS infection. ( )
d. X-ray cervical spine immediately to roll out cervical trauma. ( )
e. Oral antibiotics will resolve the problem within a day or two. ( )


22. An 11 months old child with fever 38.5 C. & bloody diarrhea, he is irritable, thirsty,
with sunken eyes & skin pinch goes back slowly.
a. He is classified as severe dehydration. ( )
b. He is classified as some dehydration. ( )
c. He is classified as very severe febrile disease. ( )
d. He is classified as fever possible bacterial infection. ( )
e. He is classified as bacterial infection unlikely. ( )
23. A 12 months old child with diarrhea for 20 days, he is alert, thirsty, his eyes are not
sunken & his skin pinch goes back immediately:
a. He is classified as having no dehydration. ( )
b. He is classified as having some dehydration. ( )
c. He is classified as persistent diarrhea. ( )
d. He is classified as severe persistent diarrhea. ( )
e. Anti-diarrheal drugs are mandatory, otherwise diarrhea will not stop. ( )
24. A child complaining of agonizing ear pain & fever 38C.
a. Send the patient home with oral antibiotics & antipyretics. ( )
b. Oral antibiotics & antipyretics is not enough line of therapy, he should receive IV
antibiotics. ( )
c. Stop all kind of therapy once the ear pain disappears. ( )
d. If pus is coming out of the ear, refer urgently to the hospital. ( )
e. Tender swelling behind the ear is usually associated with that kind of ear pain due to
local spread of infection to the surrounding skin. ( )
25. A child aged 11 months his mother bring him to the hospital clinic complaining of
disturbed level of consciousness, cough, difficult breathing &high fever 39 C; on
examination he is lethargic, his respiratory rate was 45 per min& his throat
congested, no any other abnormality detected. According to IMCI.
a. He has the classification no pneumonia, cough, or cold. ( )
b. He has the classification very sever disease. ( )
c. He needs a follow up after 2 days for his cough classification. ( )
d. His fever is classifies\d as fever bacterial infection unlikely. ( )
e. He is classified as non streptococcal sore throat. ( )



26. A child aged 25 months his mother bring him to the hospital complaining of cough,
hoarseness of voice, sore throat, fever 38 C, his respiratory rate was 35 per min with
stridor while calm & no any other abnormality detected during examination.
According to IMCI.
a. He needs an urgent referral to the hospital. ( )
b. He is classified as having non streptococcal sore throat. ( )
c. He is classified as no pneumonia, cough, or cold. ( )
d. He is classified as very severe febrile disease. ( )
e. His cough classification needs a follow up after 5 days, if not improving. ( )
27. A feverish girl 18 months, her weight 11 kg, her mother bring her to the hospital
complaining of cough associated with severe sore throat so that she cannot eat or
drink any fluids; On examination her Temp. is 39C with respiratory rate 38 per min,
her throat is severely congested with follicular exudates, so that the child cannot eat
or drink any fluid, without any other abnormality. According to IMCI:
a. She has the classification low weight. ( )
b. Her cough is classified as no pneumonia, cough, or cold. ( )
c. Her fever is classified as very severe febrile disease. ( )
d. Give her IM injection of long acting penicillin, antipyretic & send home. ( )
e. Very severe disease is one of his classifications. ( )
28. A male child aged 11 month his mother bring him to the outpatient clinic
complaining of diarrhea with steaks of blood & fever 38.5C since 2 days; On
examination his eyes are sunken, he is thirsty, skin pinch goes back slowly & he is
irritable & no other abnormality detected during examination. According to IMCI:
a. He has the classification of severe dehydration. ( )
b. He has a mandatory follow up after 5 days. ( )
c. He has the classification of dysentery. ( )
d. He has the classification of fever, bacterial infection unlikely. ( )
e. He should be referred to the hospital immediately. ( )
29. A 10 month old child with history of 3 days cough; On examination he is feverish and
has chest indrawing. According to IMCI.
a. He is classified as pneumonia. ( )
b. He is classified as severe pneumonia. ( )
c. He should be managed at home. ( )
d. He must be referred urgently to hospital. ( )
e. Give antibiotics for 5 days and then follow up. ( )


30. A 12 month old infant with diarrhea since 15 days; On examination he had sunken
eyes with skin pinch goes back slowly. According to IMCI:
a. He is classified as acute diarrhea with some dehydration. ( )
b. He is classified as acute diarrhea with severe dehydration. ( )
c. He is classified as persistent diarrhea with dehydration. ( )
d. He is best managed at home. ( )
e. He must be referred to hospital. ( )
31. An 18 month old infant with diarrhea 4 days ago; On examination he has sunken eyes
and skin pinch goes back very slowly. According to IMCI:
a. He is classified as acute diarrhea with severe dehydration. ( )
b. He is classified as acute diarrhea with some dehydration. ( )
c. He is best managed at home. ( )
d. Plan B should start immediately. ( )
e. Plan C should start immediately. ( )
32. A 9 month old baby with pus and discharge from left ear since 15 days. According to
IMCI:
a. Give antibiotics for 5 days and paracetamol. ( )
b. Give antibiotics and refer to hospital. ( )
c. Refer to ENT specialist. ( )
d. He is classified as acute ear infection. ( )
e. Give paracetamol only. ( )
33. A 12 month old baby with fever, diarrhea and vomiting 2 days ago, he had a history of
convulsions 3 months ago following a booster dose of DPT. On examination he is
irritable with sunken eyes. according to IMCI:
a. He is classified as having very severe disease. ( )
b. He must be urgently referred to hospital. ( )
c. He is classified as acute diarrhea with some dehydration. ( )
d. Plan B must start immediately. ( )
e. Is best treated according to plan C. ( )
34. An 11 month old baby with history of running nose, cough and sore throat. According
to IMCI:
a. He is classified as streptococcal sore throat. ( )
b. Best treated with paracetamol and penicillin. ( )
c. He is classified as non streptococcal sore throat. ( )
d. He is classified as having no throat problem. ( )


35. A four years child with ear discharge & fever for last 3 days, there is no ear pain. On
examination there is neither tender swelling behind the ear nor pus coming out of
the ear, the neck is not stiff & there is no any other abnormality. According to IMCI:
a. Oral antibiotic is essential part of therapy. ( )
b. The patient may need ENT consultation. ( )
c. Follow up after2 days if he is still the same. ( )
36. An eight months old child with bloody diarrhea since yesterday, his eyes are sunken,
he is very tired & drinks poorly & his skin pinch goes back slowly. According to IMCI:
a. Start IV line immediately. ( )
b. Both anti-diarrheal & antibiotics are contraindicated. ( )
c. He is classified as very severe disease. ( )
d. He is classified as having diarrhea with some dehydration. ( )
37. A 4 years child with daily 28.5 C for last 7 days. On examination there is no neck
stiffness or any other abnormalities apart from some pallor. According to IMCI:
a. Start oral antibiotic therapy immediately. ( )
b. Refer the child to the hospital. ( )
c. Anemia is a part of the child's classification. ( )
38. A 8 months old child with severe diarrhea & vomiting since yesterday, she can't keep
anything in her stomach except 2-3 spoons of water you give her, her eyes are sunken,
she is thirsty & irritable and her skin pinch goes back slowly. According to IMCI:
a. Start IV line immediately. ( )
b. Don't give anything by mouth to avoid vomiting. ( )
c. She is classified as very severe disease. ( )
d. Refer her urgently to the hospital. ( )
39. A mother brings her 18 months boy, to the outpatient clinic, complaining of bloody
diarrhea & fever since yesterday you measure his temp. it was 37 C; on examination
you find that he is alert, thirsty, with sunken eyes & his skin pinch goes back
immediately. His weight is 9 kg. According to IMCI
a. Some dehydration is a part of his classification. ( )
b. He is classified as low weight. ( )
c. Fever possible bacterial is a part of his classification. ( )
d. The child should return back to the clinic in 2 days if diarrhea isn't stopped. ( )


40. A 14 months child complaining of fever 38.5C, runny nose & sore throat for 2 days,
associated with earache & ear discharge for 5 days; On examination, no abnormality
was detected. According to IMCI:
a. Treatment with antipyretics & safe remedy alone is good therapy. ( )
b. Drying ear by wicking is essential part of therapy. ( )
c. He is classified as having no sore throat problem. ( )
d. He is classified as having fever possible bacterial infection. ( )
41. A male child aged 12 months his mother bring him to the hospital complaining of
cough, difficult breathing & high fever 39C, his respiratory rate was 41 per minute.
He has chest indrawing & no any other abnormality detected during examination.
According to IMCI:
a. He is having a date for follow up after 2 days. ( )
b. This child is having fast breathing. ( )
c. He needs urgent referral to the hospital. ( )
d. His fever is classified a very sever febrile disease. ( )
42. A female aged 15 months, her mother bring her because she has bloody diarrhea for 3
days with fever. On examination she is alert, with normal eyes, very slow skin pinch
& she is thirsty. According to IMCI:
a. She is classified as having severe dehydration. ( )
b. Antibiotic therapy is contraindicated for her. ( )
c. She is classified as having fever bacterial infection unlikely. ( )
d. She needs plan B as a part of her management. ( )



The Key

1. 2. 3. 4. 5. 6.
a. -
b. -
c.
d. -
e.
a.
b. -
c.
d. -
e.
a.
b.
c.
d. -
e.
a.
b.
c. -
d.
e. -
a.
b. -
c.
d. -
e.
a.
b. -
c.
d.
e. -
7. 8. 9. 10. 11. 12.
a.
b.
c. -
d. -
e.
a.
b.
c.
d. -
e. -
a.
b. -
c.
d. -
a. -
b.
c. -
d.
a. -
b.
c. -
d. -
e.
a.
b. -
c. -
d.
e.
13. 14. 15. 16. 17. 18.
a. -
b.
c.
d. -
a. -
b.
c.
d.
a.
b. -
c. -
d.
e. -
a. -
b.
c.
d.
e. -
a.
b. -
c.
d.
e. -
a.
b.
c.
d. -
e.
19. 20. 21. 22. 23. 24.
a.
b.
c. -
d. -
e.
a.
b.
c. -
d.
e.
a. -
b.
c. -
d.
e.
a.
b. -
c.
d. -
e.
a. -
b.
c. -
d.
e.
a. -
b.
c.
d.
e.


25. 26. 27. 28. 29. 30.
a.
b. -
c.
d. -
e. -
a. -
b. -
c.
d.
e.
a.
b. -
c. -
d.
e. -
a.
b.
c. -
d.
e.
a.
b. -
c.
d. -
e.
a.
b.
c. -
d.
e. -
31. 32. 33. 34. 35. 36.
a. -
b.
c.
d.
e. -
a.
b.
c. -
d.
e.
a. -
b. -
c.
d. -
e. -
a.
b.
c. -
d.
a.
b. -
c. -
d.
a. -
b.
c.
d.
37. 38. 39. 40. 41. 42.
a.
b. -
c. -
d.
a.
b.
c.
d.
a. -
b.
c. -
d. -
a.
b. -
c.
d. -
a.
b. -
c. -
d. -
a.
b.
c.
d. -


Neonatology

Source:

g Clinical Course Lectures.



Breast feeding
Breast Feeding

g True or False:
1- Positioning:
a. The neck of the baby is straight. ( )
b. The body turned towards the mother. ( )
c. The body of the infant is close to mother's body. ( )
d. The infant whole body is supported. ( )
e. There is a Good Positioning. ( )

2- Attachment:
a. The chin touching the breast. ( )
b. The mouth wide opened. ( )
c. The lower lip is turned outward. ( )
d. More areola visible above than below the mouth. ( )
e. There is a Good Attachment. ( )



Full Detailed Pediatrics
Examination

Sources:

g Notes of Prof. Dr Mustafa Zakaria.
g Clinical Course Lectures.



Examination
General Examination
1. General look: "2C 2A 1F"

Conscious level: mental changes in kwashiorkor "try to attract the attention of the child &
observe his response".
Cry quality.
Activity.
Appearance: Pallor chronic hemolytic anemia, cyanotic in fallot ., Wasting in CP.
Facies earthy look, cushinoid facies or no specific facies.

2. Measurement: "compared to growth curves"
Height in children more than 2 years "using stadiometer".
Upper segment / lower segment ratio.
Length in infants less than 2 years "using infantometer".
e N.B: if the child can't stand "CP" he is measured as length not height.
g Steps of measuring the height:
Take off shoes.
Heals adjacent to the wall.
Feet close to each other.
Body adjacent to the wall.
Head neither flexed nor extended.
Put a book above his head.
g Steps of measuring the length:
The baby lies comfortably on the bed.
His knees are well extended.
Put a book beside his feet.
Put another book beside his head.
Measure the distance between both books.
Weight: the baby is completely undressed.
Head circumference.
How to Comment
The child is conscious, with good cry "he might be asleep" &
activity. He looks


3. Vital signs:
Pulse "peripheral or apical":
Rate.
Rhythm: usually regular.
Character: e.g. water hammer pulse in aortic regurgitation.
Volume: average or large volume in aortic regurgitation "and in chronic Anemia".
Equality on both sides.
Peripheral pulsations Dorsalis pedis & femoral.
- Normal values:
Neonate 120-160 beats/minuet.
Infant 110 b/m.
Early childhood 100 b/m.
Late childhood 90 b/m.

Temperature:
Oral in children above 5 years.
Rectal or axillary in infants "put thermometer in the axilla, so that its bulb is totally
surrounded by skin, then ask the mother to hold the arm to prevent the thermometer
from falling".
Normal Temp. 36.5-37.5 C.
Blood pressure: "cuff 2/3 of the length of the forearm"
Palpatory & auscultatory methods.
If you examine a case of coarctation of the aorta you should measure the pressure in
the lower limb also. "in the femoral artery"
- Normal values:
Infant 80/50.
Early childhood 85/55.
Late childhood 90/60.
Respiratory rate: "observing the movement of the chest or chest auscultation"
- Normal values:
Newborn 40-60 /min.
Infant 30/min.
Early childhood 25/min.
Late childhood 20/min.
How to Comment
Pulse rate is ... Beats / minute, beats are regular with no special
character, volume is average, equal in both sides & peripheral pulsations are felt.



Regional Examination
4. Head examination:
Head: running the hand over the entire head then comment on.
Shape; in Down syndrome, in rickets "bossing"
Fontanelle: "the baby is sitting"
If Opened hydrocephalus rickets.
Bulging ICT.
Depressed Fontanelle dehydration.
- Normal values: one finger closed/6 months
At birth 3 fingers.
6 months 2 fingers.
1 year 1 finger.
1 year closed.
g How to measure the anterior Fontanelle:
The baby is sitting.
Measure transverse diameter of the Fontanelle by your right index & ring
fingers 2 fingers.
Try to insinuate your middle finger in between, if you can 3 fingers.
Cranitabes:
Press on the skull bone along the lumbdoid suture, it yield like a Ping Pong ball.
Positive in rickets and hydrocephalus.
Hair:
Silky in Down.
Hair changes in KWA "sparse-light in color; easily detached; gently pull a small group of hair and see
if it is easily removed or not".
Eye:
Shape: lateral upward slunt.
Conjunctiva: Subconjunctival hemorrhage / pallor.
Sclera: jaundice in day light, in the inferior fornix.
Cornea: Keratomalcia in PEM "separate the upper and lower eye lids to observe the cornea".
Pupil: for signs of lateralization "emboli".
Eye ball: Nystagmus.
Eye lid:
Puffy "nephrotic syndrome or heart failure".
Sunken eyes in dehydration "may be in Marasmus".
Ear:
Shape: highly folded.
Position: low set ear in Down syndrome "Draw a line from the inner & outer canthi across the
face The helix is below the line".



Nose:
Shape: depressed nasal bridge.
Ala nasi: working.
Mouth: Infant supine and parents restrain the arm; older child can be sitting.
Lips: Pallor - Angular stomatitis "in PEM".
Palate "hard and soft palate".
Tongue: cyanosis
Teeth eruption "delayed in rickets".
Tonsils (tongue depressor). "Better postpone to the end examination".
Cushinoid facies: in nephrotic syndrome under prolonged steroid therapy.
Mongolid facies: in chronic hemolytic anemia "depressed nasal bridge- Protruding upper
central incisors, maxillar expansion".
5. Neck:
Vessels:
Carotid arteries: Pulsations are exaggerated in aortic regurgitation and in severe
anemia - Thrill over the arteries "in severe aortic regurgitation".
Jugular veins: neck veins are not congested
Position 45: make sure that the head is supported.
Look tangentially for the upper limit of congestion above
the clavicle.
If congested measure the amount of congestion in cm "while the
patient in semi sitting" by distance between level of congestion & sternal angle.
If more than 2 cm it is significant.
Glands:
Lymph nodes: face the child then palpate the occipital LN along the hair line, then
feel the pre & post auricular LN then feel upper & lower deep cervical lymph nodes.
Thyroid gland.
Trachea: central or shifted.
6. Upper limbs:
Pallor on the nail bed.
Clubbing.
Simian crease.
Splinter hemorrhage.
Broadening and may be deformity with rickets: convexity of radius and ulna, to
look for it undress the forearm.
Muscle atrophy: in marasmus or in marasmic kwashiorkor "the arm is uncovered,
grasp the biceps or triceps muscle and assess its bulk".



7. Lower limbs:
Pulsations: "femoral and Dorsalis pedis artery" are equally felt on both sides.
Edema: in nephrotic syndrome and in kwashiorkor "press on the dorsum of the foot for few
seconds and look for pitting edema, then chin of the tibia and ascend upward at different levels to
determine the level of edema, unilateral or bilateral".
Clubbing.
Broadening, marfan sign "at the medial maleolous" and may be bowing "the patient is
standing with his lower limbs are undressed rickets".
Loss of fat: in marasmus or marasmic kwashiorkor "grasp a pinch of skin and subcutaneous
fat beneath it, over the thigh and buttock".
Skin of the buttocks and groin: for crackles, fissuring and ulceration in kwashiorkor.

8. Trunk:
Scrotum (Genitalia): scrotal edema in nephrotic syndrome.
Skin: turgor, pigmentations, loss of subcutaneous fat in marasmus & bleeding tendency.
Breast: neonatal gynecomastia.
Back:
Spina bifida: by tuft of hair.
Spinal deformities with rickets: Kyphosis or kyphoscoliosis;
While the patient is sitting, if present check that it is correctable "patient lie
prone and ask him to raise his lower limb making his pelvis away from the bed".
Not correctable in Pott`s disease.
Meningiocele or Meningomyelocele: in hydrocephalus.
Mongolian spots.

9. Thorathic cage:
In rickets: Rossary beads, Harrison sulcus, longitudinal sulcus and pigeon chest.



Heart Examination

g Shape:
Precordial bulge "or no precordial bulge", scars or dilated veins.
g Pulsations
Apex:
Site: < 4y 4th IC space MCL; while > 4y 5th IC space MCL.
Character: systolic bulge or systolic retraction.
Force: forcible or weak.
Localization: diffuse or localized.
Palpable sound & thrill.

Aortic areas: 1
st
aortic area 2
nd
Rt. Space & the 2
nd
aortic area 3
rd
Lt. space.
Pulmonary area: "2
nd
left space"

Left parasternal:

Epigastric area:

Combined Inspection & Palpation:

Rheumatic heart: on the 6
th
space outside midclavicular line, localized "or may
be diffuse" hyperdynamic with no thrill.
VSD: apex is in the 5th space usually "or may be in the 4th space", localized.
Fallot: apex is normal. In the 4th space usually "or in the 5th space", localized.

Rheumatic heart: There is pulsation on the pulmonary
area pulmonary hypertension and dilatation.
VSD: There is pulsation on the pulmonary area.
Fallot: systolic thrill.

Rheumatic heart: There is pulsation "Rt. ventricular dilatation".
VSD: pulsation and systolic thrill.
Fallot: mild pulsation.

Rheumatic heart: There is pulsation in the Epigastric area "may be absent".
VSD: usually absent pulsation.
Fallot: absent pulsation.



g Rheumatic heart:
1. Mitral area "apex":
The first heart sound is muffled -usually- "predominant regurge".
Soft pansystolic murmur, heard maximally over the apex, propagated to the axilla
"mitral regurgitation".
Mid-diastolic rumbling murmur with presystolic accentuation heard over the apex
with no selective propagation "mitral stenosis".
2. Pulmonary area:
Accentuation of the 2
nd
heart sound.
Soft ejection systolic murmur.
3. Aortic area: early diastolic soft murmur at the second aortic area.
4. Tricuspid areas: are free.
g VSD
Murmurs "VSD":
Site: 3
rd
and 4
th
intercostals space at parasternal line.
Area of maximum propagation: all over the precordium.
Character: harsh. Timing: pansystolic.
Sounds "Pulmonary hypertension":
Accentuation of the pulmonary component of the second heart sound.
g Fallot
Ejection systolic murmurs heard at the pulmonary area.
Normal other area.

e Obsolete.

Auscultation:

Percussion:



Abdominal Examination

g Shape & contour:
E Normally: flat abdomen with concavity at the flanks.
E Abnormally:
Localized bulge localize its site.
Generalized abdominal distention with fullness in flanks e.g.: Ascites.
Scaphoid abdomen in dehydration.
g Movement with respiration:
E Normally: freely mobile with respiration.
E Abnormally: restriction of mobility e.g. peritonitis, very tense ascites.
g Subcostal angel:
By putting your thumbs on both costal margins "over the last ribs".
E Normally: Acute angel "70-90 degrees".
E Abnormally: Obtuse angel organomegaly, ascites.
g Epigastric pulsations:
If the child is cooperative, ask him to stop breathing.
Pulsations are seen & felt. "Look tangential"
E Causes of the pulsations:
Rt. ventricular enlargement.
Liver pulsations.
Aortic pulsations.
g Divarications of the recti:
E Cause: chronic increase in the intra-abdominal pressure organomegaly, ascites.
g Umbilicus:
Site:
E Normally: midway between xiphesternum & symphysis pubis.
E Abnormally: shifted upwards or downwards.
Shape:
E Normally: inverted.
E Abnormally: everted umbilical hernia.
Impulse on cough:
E Normally: no impulse on cough.
E Abnormally: impulse on cough seen & felt hernia.

Inspection:


Others:
Caput medusa: dilated veins around umbilicus portal hypertension.
Pigmentations.
Discharge.
Nodules.
g Back & Genetalia.
g Any other abnormality:
Scars.
Pigmentations.
Dilated veins.

g Superficial palpation:
To gain confidence of the baby.
To detect rigidity.
To detect superficial mass.
g Deep palpation: "the knees are flexed to relax the muscle"
Palpate the intra-abdominal organs.

Ways of examination:
One hand method:
Press by finger tips or side of index from right iliac fossa upwards to feel the right
lobe.
From the umbilicus to xiphesternum to feel the left lobe.
Bimanual examination:
Put left hand behind the back of lower ribs.
By the Rt. hand palpate on the abdomen till the costal margin.
Hooking method:
In shrunken liver "oral only".
Dipping:
In tense Ascites.
Push the liver by tips of your fingers.

1. Liver
The liver is felt cm below the Rt. costal margin MCL & cm below
subcostal angel in the middle line. The consistency is ; its border is
; its surface is ; it is "tender or not" & it is "pulstile or not".

Palpation:



One hand method:
Start from right iliac fossa, upwards & to the left.
Bimanual examination:
Lt hand at back & Rt. hand on the anterior abdominal wall.
If you not feel it, turn Pt to left lateral position.
Hooking.
Dipping.

One hand method:
By palpation each loin by your Rt. hand.
Bimanual method:

Items Kidney enlargement Spleen enlargement
Insinuation:
Can insinuate your hand
below LT costal margin
You cannot insinuate
Respiration: No movement Pushed downwards
Loin: Fullness in loin No
Light
percussion:
Dull with middle colonic
resonance
Continuous dullness
Notch: Absent Present
Ballottement: Posterior Anterior
Enlargement: Cannot cross mid line Can cross mid line
2. Spleen
The spleen is felt fingers below the Lt. costal margin MCL. The
consistency is ; its border is ; its surface is ......; it is "tender or not"
& the notch of the spleen can be "felt or not".

3. Kidney


1. Percussion of upper border of the liver "Tidal percussion":
Identify 2
nd
rib by sternal angel.
Percuss all spaces downwards starting from 2nd space MCL.
When you reach dull space, ask pt to take breath & keep it inside "if cooperative".
The dullness will become resonant denoting upper border of liver. "5
th
right space MCL"
2. Percussion for Ascites:
e Shifting dullness:
Upper border of Ascites: start percussion from Epigastric areas downwards.
Side border of Ascites: turn your hand 90 degrees to reach it.
If you notice dullness in side continue till the flanks.
Turn Pt. to his opposite side & wait minute then percuss.
You will observe resonance after being dull indicate shifting of the fluid.
e Transmitted thrill:
Ask Pt. to put his hand in the mid line "to abolish transport through Abd. Wall".
Elicit a thrill by your finger from one side.
Feel its transmission from the other side.

g Intestinal sounds.
g Hum Portal hypertension.
g Rub Pericapsulitis.

Auscultation:

Percussion:



Neurological Examination
1. C O M CI:
Conscious level of conscious.
Oriented To time, place and person.
Mentality:
i. Infant from speech & Sphincteric control.
ii. Late childhood from school achievement.
Co-operative.
Intelligence.
2. Motor system "the most important issue":

Wasting "Bilateral or Unilateral / Proximal or Distal".
Hypertrophy "compare Left to Right".
Pseudo-hypertrophy Duchenne.
Normal.

Fasciculation.
Involuntary movements as chorea.

e The Tone Elicited by:
Flexion & extension of the elbow & knee.
Passive by:
Shaking method of wrist & ankle.
Active: against resistance.
Gower test: for the shoulder.
e The Results:
Hypotonia LMNL.
Hypertonia UMNL.

State of muscles:

Abnormal movements:

Tone:



e If the patient is co-operative as it need resistance from the Pt.:
Shoulder abduction & adduction against resistance.
Flexion & extension of elbow & wrist against resistance.
Finger abduction & adduction against resistance:
Fist making:
Flexion & extension of knee & hip against resistance.
Abduction & adduction of the knee & hip against resistance.
Dorsiflexion & planter flexion against resistance.
e Degree of power:
i. No movement at all.
ii. Horizontal movement.
iii. Movement against gravity.
iv. As above + can carry an object.

g Superficial reflexes:
1. Planter reflex (S1):
Scratching the outer aspect of the sole of the foot using a key.
E Normally: planter flexion.
E Abnormally: +ve Babinski Dorsiflexion + Fanning "normal up to 1 year".
2. Abdominal reflex (T6-T12):
Scratch the abdomen by blunt object from the flanks towards umbilicus.
E Normal response: shift of the umbilicus towards the site of scratching.
3. Cremastric reflex (L1):
Stroke the medial aspect of the thigh elevation of the testicles.
4. Gluteal reflex (L4, 5).
5. Anal reflex (S3, 4, 5).

Reflexes:
Power:

UL
LL


g Deep reflexes "hyper-reflexia, hypo-reflexia": Hummer
1. Biceps (C5,6):
Elbow at angel 120.
Put your finger on the biceps tendon and hit on it.
Don't forget to expose the whole muscle while you are doing the test, to see the
response.
Response: flexion of elbow or just fine contraction of the biceps is seen.
2. Triceps (C6,7):
Elbow at angel 90.
Hit the tendon directly.
Response: extension of the elbow, or just contraction of the muscle.
3. Knee (L2,3,4)
Angel of the knee 90.
Hit the quadriceps tendon "between patella & tibial tuberosity" Quadriceps
contraction.
4. Ankle (S1)
Angel of ankle: 90 & Angel of knee: 120.
Hit on tendon Achilles contraction of calf muscles.

Hold the foot of the baby.
Do sudden maintained Dorsiflexion.
Response: Regular Rhythmic movements of the foot "Clonus".
g Neonatal reflexes:
Moro reflex.
Its presence beyond 6 months CP MR.

Function:

Clonus
UL
LL
UL
LL


3. Sensory system "reading":
g Superficial:
Pain by needle.
Touch by cotton.
Temp. by cold or hot water.
g Deep:
Vibration sense by tuning fork.
Muscle & joint sense
g Cortical:
Tactile localization.
2 point discrimination.
Sterognosis.
Graphesthia.
4. Coordination (ataxia): cerebellum "reading"
Nystagmus.
Staccato speech.
Head nodding.
Finger to nose / finger to finger test.
5. Cranial nerves: "the 2nd important issue"
i. Olphactory:
Close his eyes & close one nostril.
Introduce a familiar material to smell (perfume, coffee).
Response: working ala nasi & identification of the smell.
ii. Optic:
Visual acuity:
2-3 months fix & follow object.
7-8 m reach object.
9-10 m Pincer graft "thump & index "
2 years
Older Counting fingers-hand motion.
Visual field:
Sit opposite to the child, your eyes at the same level, bring object from
beyond field of vision, ask child to say yes when he sees object.
Pupil for light reflex.


iii. Occulomotor.
iv. Trochlear.
v. Abducent. "6
th
"
vi. Trigeminal: "5
th
"
Temporalis & Maseter muscles.
Med. & Lat. Pterygoids.
Chewing.
Try to touch either side of the face with cotton while the child closes his eyes.

vii. Facial:
Inspecting the facial expression of the baby especially during cry.
.
viii. Vestibulocochlear:
Apply loud sound near his ear turns face towards the sound.
ix. Glossopharyngeal.
x. Vagus.
xi. Spinal accessory:
Trapezius elevation of shoulder against resistance.
Sternomastoid turn his head against resistance.
xii. Hypoglossal:
Ask the patient to stick out his tongue tongue is deviated to the weak side.

Extra ocular muscle test
Fix patient's head; Ask him to follow the torch in
the 6 Cardinal directions, if fails Squint.
Motor
part

Sensory
part

Gag & palatal reflex by tongue depressor.
Uvula ask Pt. to say Aah uvula deviates to the healthy side.



Emergency MCQs
& Equipments

Sources:

g Clinical Course Lectures
Introduced By:
Prof. Dr Mohammed Hisham &
Prof. Dr Ahmed El-Belidy.



Emergency
e True or False:
1. Pulse oximeter measure FIO2. [ False ]
- O
2
saturation.
2. Basic defect in type 2 respiratory failure in CO2 elimination. [ True ]
3. Stridor is a harsh expiratory sound caused by total obstruction. [ False ]
- Inspiratory partial.
4. Pt. with O2 saturation <85% is mild hypoxia. [ False ]
- Severely hypoxia.
5. Basic defect in type 1 respiration failure in oxygenation. [ True ]
6. Grade 1 stridor means stridor at rest. [ False ]
- On exertion.
7. About 20% of cardiac arrest in ICU are respiratory in origin. [ False ]
- > 50%.
8. Acute respiratory acidosis is the typical finding in type 1 resp. failure. [ False ]
- Hypoxemia acute metabolic acidosis.
9. Antibiotics are routinely given in stridor. [ False ]
- Bacterial only.
10. Type II respiratory failure is named pump failure. [ True ]
11. Mechanical ventilation is indicated in all hypoxic children with pneumonia. [ False ]
- Hypoxic not responsive to simple measures.
12. There is no difference between simple O2 mask, venturi O2 mask. [ False ]
- the venturi deliver precise O
2
concentration.
13. Self inflating resuscitation bag can deliver only 100% O2. [ False ]
- 40 % ---- 100% only if with O
2
reservoir.
14. Picture of cardiopulmonary arrest the same as cardiovascular death except the reactive
pupils. [ True ]
15. of the indications of admission in pediatrics is respiratory in origin. [ True ]
16. A case of acute epiglottitis "bacterial" can be treated at home. [ False ]
- High fever & sever stridor one of the indication of hospitalization.
17. An 1 year infant with inspiratory sound, retractions and cyanosis is classified as
Grade 3 stridor. [ False ]
- Grade 4.



e N.B:
Cycling:
Def.: is the way by which the ventilator terminates inspiration.
Types:
Time cycling termination of inspiration after pre-set time.
Pressure cycling termination of inspiration after pre-set pressure.
Volume cycling termination of inspiration after pre-set volume.
SaO
2
:
> 95 % Normal.
90-95 % Mild hypoxia.
85-90 % Moderate hypoxia.
< 85 % Severe hypoxia.

e Devices:
1. Bed side monitor for HR, RR, BP, temp. & O2.
2. DINAMAP for measure Bl. Pressure 83/58.
3. Infant receiving O2 by head pox "SaO2= 90%, HR= 124/min shown by pulse oximeter".
4. Nasal prongs.
5. Venturi O2 mask.
6. Self inflating bag "ambubag" with O2 saturation. Need O2 reservoir to deliver 100%.
7. Flow inflating bag "anesthesia bag" deliver 100% O2 at any time.
8. Pulse oximeter for measurement of O2 saturation.
9. O2 analyzer showing O2 concentration 97% "FIO2".
10. Mechanical ventilator:
Used in cases of resp. failure not responding to other methods of oxygenation.



Blood Reports

Source:

g Notes of



Blood Reports
e Comment on the following blood reports and identify
the Confirmatory tests for these conditions:
Example 1:
Parameter Patient value Normal value Comment
WBCs:
Differential:
5 - 6
Normal
4 - 11 Normal
Hg:
Reticulocytes:
8
1
11.2 - 13.5
0.5% - 2%
Anemia
Normal
MCV: 60 75 - 86 Microcytic
MCHC: 24 27 - 33 Hypochromic
Platelets: 300 150 - 450 Normal

E Comment:
The blood picture show: Microcytic Hypochromic anemia with normal
reticulocyte count, indicating possibility of iron deficiency anemia.
E Confirmatory tests:
Serum iron, iron binding capacity and serum ferritin.



Example 2:

E Comment:
The blood picture shows: Microcytic Hypochromic anemia with
reticulocytosis indicating possibility of chronic hemolytic anemia.
Hemolytic profile, iron studies.

WBCs:
Differential:
6
normal
4 - 11

Normal

Hg:
Reticulocytes:
4
8%
11.2 - 13.5
0.5% - 2%
Anemia
Reticulocytosis
MCV:
54 75- 86 Microcytic
MCHC:
20 27 - 33 Hypochromic
Platelets:
400 150 - 450 Normal


Example 3:
Parameter
Patient value Normal value Comment
WBCs:
Differential:
2
normal
4 - 11

Leucopenia

Hg:
Reticulocytes:
5
0.3
11.2 - 13.5
0.5% - 2%
Anemia
reticulocytopenia
MCV: 78 75 - 86 normocytic
MCHC: 29 27 - 33 normochromic
Platelets:
25 150 - 450 thrombocytopenia

E Comment:
A blood picture of pancytopenia, possibility of aplastic anemia is present.
Bone marrow aspirate and biopsy are recommended.



Example 4:
Parameter
WBCs:
Differential:
5
normal
4 - 11

Normal

Hg:
Reticulocytes:
10.5
1
11.2 - 13.5
0.5 - 2%
Mild anemia
normal
MCHC: 30 27 - 33 normochromic
Platelets: 15 150 - 450 Thrombocytopenia

E Comment:
Severe thrombocytopenia with mild anemia, possibility ITP.
E Confirmatory test:
Bone marrow aspirate is recommended.



Example 5:
Parameter
WBCs:
Polymorph:
Band:
Lymphocytosis:
20
70%
12%
25
4 - 11
.
5%

Leucocytosis "marked"

Bandemia "shift to the left"

Hg:
10.5 11.2 - 13.5 Mild anemia
MCV:
82 75 - 86 normocytic
MCHC:
30 27 - 33 normochromic
Platelets:
300 150 - 450 normal

E Comment:
There is leucocytosis "increased polymorph and band cells" indicating
possibility of bacterial infection.
ESR, CRP & proper cultures.



Example 6:
WBCs:
Polymorph:
Band:
Lymphocytosis:
14
35%
3%
65%
4 - 11
.
5%

Leucocytosis

Hg: 11 11 - 13.5 normal
MCHC:
30 27 - 33 normochromic
Platelets:
300 150 - 450 normal

E Comment:
There is leucocytosis with predominant lymphocytosis, normal band cells,
possibility of viral infection.
ESR - CRP are recommended to differentiate between bacterial and viral
infections.



Test yourself
Report 1:
Parameter
WBCs differential:
Polymorph:
Band cells:
20000
70%
12%
4 - 11

Hg:
Reticulocytes:
10
1
11.2 - 13.5
0.5 - 2%

MCV: 70 75 - 86

MCHC: 30 27 - 33

Platelets: 300 150 - 450

??????????
Report 2:
Parameter
WBCs:
Differential:
7
normal
4 - 11

Hg:
Reticulocytes:
5
10%
11.2 - 13.5
0.5 - 2%

MCV:
54 75 - 86

MCHC:
20 27 - 33

Platelets:
400 150 - 450

??????????


Report 3:
Parameter
WBCs:
Differential:
2
normal
4 - 11

Hg:
Reticulocytes:
7
0.3
11.2 - 13.5
0.5 - 2%

MCV:
78 75 - 86

MCHC:
29 27 - 33

Platelets:
25 150 - 450

??????????

Report 4:
Parameter
WBCs:
Differential:
5
normal
4 - 11

Hg:
Reticulocytes:
11
1
11.2 - 13.5
0.5 - 2%

MCV: 81 75 - 86

MCHC: 30 27 - 33

Platelets: 18 150 - 450

??????????



Report 5:
WBCs differential:
5 4 - 11

Hg:
Reticulocytes:
8
2%
11.2 - 13.5
0.5 - 2%

MCV: 55 75 - 86

MCHC:
25 27 - 33

Platelets:
300 150 - 450

??????????

Report 6:
WBCs:
Polymorph:
Band:
Lymphocytosis:
13
35%
3%
65%
4 - 11

5%

Hg reticulocytes:
11 11 - 13.5

MCV: 82 75 - 86

MCHC: 30 27 - 33

Platelets: 300 150 - 450

??????????



Answers

1. Bacterial infection.
2. Hemolytic anemia.
3. Pancytopenia.
4. Thrombocytopenia ITP.
5. Microcytic hypochromic anemia "most probably iron
deficiency anemia".
6. Viral infections.



Blood Gases "ABG"

Source:

g Notes of
Prof. Dr Mohamed El-Nagger.



Blood Gases
"In the Emergency Book"

TEST YOURSELF

e Comment on the following ABG.
Example 1:
PaO2: 60 mmHg.
PaCO2: 25 mmHg.
PH: 7.1
Bicarbonate: 18 mEq/liter.
Comment:
Oxygenation:
Ventilation:
Acid base status:
Example 2:
PaO2: 110 mmHg.
PaCO2: 20 mmHg.
PH: 7.55
Comment:
Oxygenation:
Ventilation:
Acid base status:



Example 3:
PaO2: 55 mmHg.
PaCO2: 35 mmHg.
PH: 7.1
Comment
Oxygenation:
Ventilation:
Acid base status:

Example 4
PaO2: 50 mmHg.
PaCO2: 68 mmHg.
PH: 7.2
Comment:
Oxygenation:
Ventilation:
Acid base status:

e Comment on the following VBG.
Example 5:
PaO2: 45 mmHg.
PaCO2: 60 mmHg.
PH: 7.1
Comment:
Oxygenation :
Ventilation :
Acid base status :

Example 4
PaO2: 45 mmHg.
PaCO2: 25 mmHg.
PH: 7.2
Comment:
Oxygenation :
Ventilation :
Acid base status :



Urine & Stool Reports

Source:

g Notes of



Urine analysis
e Items to be checked:
Physical:
Color: Yellow: normal.
Smoky: in nephritis.
Deep yellow: in hepatitis or cholestasis.
Aspect: Clear: normal.
Turbid: in urinary tract infection "infection" & nephritis "Inflammation".
Reaction: Acidic pH 5-7.
Specific gravity: 1015-1025.
Chemical:
Protein: Nil: normal.
Mild (+) in UTI.
Moderate (++) in glomerulonephritis.
Severe (+++) in nephrotic syndrome.
Glucose: Nil: normal "++ in diabetes mellitus".
Ketones: Nil: normal "++ in diabetic ketosis".
Bilirubin: Nil: normal "+ in hepatitis or cholestasis".
Hemoglobin: Nil: normal "+ in Acute hemolytic crisis".
Microscopic:
RBCs: Normal "1-5 cells /HPF".
Mild microscopic hematuria "10-20/HPF" in urinary tract infection.
Frank hematuria "more than 100/HPF" in glomerulonephritis.
WBCs: Normal "1-5 cells/ HPF".
Pus cells "50-100 cells /HPF" in urinary tract infection and nephritis.
Casts: Hyaline casts: normal.
Red cell cast in glomerulonephritis.
White cell cast in pyelonephritis.
Epithelial cells and crystals may be seen normally.
e Exam form:

What does the test show?
What is the most likely diagnosis?
Mention one confirmatory test?


g Example 1:
Physical:
Color: Yellow.
Aspect: Clear.
Reaction: Acidic.
Specific gravity: 1030
Chemical:
Protein: Nil.
Glucose: ++
Ketones: ++
Bilirubin: Nil.
Microscopic:
RBCs: 1-2cells/HPF.
WBCs: 1-3 cells/HPF.
Casts: Nil.

g Example 2:
Physical:
Color: Yellow.
Aspect: Clear.
Reaction: Acidic.
Chemical:
Protein: Nil.
Glucose: Nil.
Ketones: Nil.
Bilirubin: ++
Microscopic:
RBCs: 1-2 cells /HPF.
WBCs: 1-3 cells /HPF.
Casts: Nil.

What does the test show? - Enumerate the positive findings.
What is the most likely diagnosis? - Diabetic ketosis.
Mention one confirmatory test? - Blood gas, blood glucose.
What is the most likely diagnosis? - Hepatitis.
Mention one confirmatory test? - Serum Bilirubin, liver enzymes "AST, ALT".


g Example 3:
Physical:
Color: Smoky.
Aspect: Turbid.
Reaction: Acidic.
Chemical:
Protein: ++
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
RBCs: More than 100/HPF.
WBCs: Pus cells 50-60 cells /HPF.
Casts: Red cell cast.
Epithelial cells: Nil.

g Example 4:
Physical:
Color: Smoky.
Aspect: Turbid.
Reaction: Acidic.
Chemical:
Protein: ++
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
RBCs: 10-12 cells / HPF.
WBCs: pus cells more than 100/ HPF.
Casts: White cell cast ++.
Epithelial cells: Nil.

What is the most likely diagnosis? - Glomerulonephritis.
Mention one confirmatory test? - Renal function "urea and creatinine", C3.
What is the most likely diagnosis? - Pyelonephritis "upper urinary tract infection".
Mention one confirmatory test? - Urine culture and sensitivity test.


g Example 5:
Physical:
Color: Yellow.
Aspect: Turbid.
Reaction: Acidic.
Chemical:
Protein: +
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
WBCs: Pus cells more than 70-80
cells/HPF.
Casts: Nil.
Epithelial cells: ++.

g Example 6:
Physical:
Color: Yellow.
Aspect: Clear.
Reaction: Acidic.
Chemical:
Protein: ++++
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
WBCs: 2-3 cells / HPF.
Casts: Hyaline casts.
Epithelial cells: ++.

What is the most likely diagnosis? - Urinary tract infection "lower tract infection".
Mention one confirmatory test? - Urine culture and sensitivity test.
What is the most likely diagnosis? - Proteinuria "nephrosis".
Mention one confirmatory test? - Serum albumin, serum lipids etc ...


Stool analysis
e Items to be checked
Macroscopic:
Color: Yellowish brown.
Consistency: Formed "loose in diarrhea and dysentery Watery in watery diarrhea?"
Reaction: Alkaline.
Mucous: Nil "excess mucous may be seen in dysentery or bacterial
gastroenteritis".
Blood: Nil "may be seen in dysentery or bacterial gastroenteritis".
Microscopic:
RBCs: Normally 0-2 cells / HPF.
More than 100 cells / HPF is seen in dysentery or bacterial gastroenteritis.
WBCs: Normally 0-5 cells / HPF.
Markedly increased in dysentery or bacterial gastroenteritis.
Protozoa: Nil.
E.hisolytica "vegetative form" in amebic dysentery.
Giardia "cyst" in giardisis.
Ova: Nil.
Ankylostoma ova: in Ankylostomiasis.
Schistosoma mansoni ova: in intestinal Schistomiasis
Oxyuris ova: in Oxyuriasis.

e Exam form:

What is the most likely diagnosis? "Or mention 2 possible causative agents".
Mention one confirmatory test.


g Example 1:
Macroscopic:
Consistency: Loose.
Reaction: Alkaline.
Mucous: +++
Blood: +++
Microscopic:
RBCs: More than 100 cells / HPF.
WBCs: More than 100 cells / HPF.
Protozoa: Nil.
Ova: Nil.

g Example 2:
Macroscopic:
Consistency: Loose.
Reaction: Alkaline.
Mucous: +++
Blood: ++
Microscopic:
RBCs: More than 100 cells / HPF.
WBCs: 20-25 cells / HPF.
Protozoa: E.hisolytica "vegetative form".
Ova: Nil.

g Example 3:
Macroscopic:
Consistency: Formed.
Reaction: Alkaline.
Mucous: Nil.
Blood: Nil.
Microscopic:
RBCs: 1-2 / HPF.
WBCs: 1-2 / HPF.
Protozoa: Nil.
Ova: Oxyuris or may be Ankylostoma ova in Ankylostomiasis.
Schistosoma mansoni ova in intestinal Schistomiasis.

Mention 2 possible causative agents. - Shigella, Enteroinvasive E.coli.
Mention one confirmatory test. - Stool culture.
What is the treatment of this condition? - Ampicillin 50 mg/kg for 5 days.
What is the most likely diagnosis? - Amoebic dysentery.
What is the treatment of this condition? - Metronidazol 25 mg/kg/day for 10 days.
What is the most likely diagnosis? What is the treatment of this condition?
- Oxyuris or Ankylostoma: - Mebendazol.
- Schistosoma: - Praziquentel.

Clinical Pediatric Notes

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Clinical Pediatric Notes "All Team Production" 2009

All team "One Vision One Mission" | 1

1. General look: "2C 2A 1F"

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