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Pediatrics Dr Masood records Notes

‫هذه مالحظاتي من تسجيالت دكتور مسعود على مذكرة دكتورة االء في االطفال‬
‫ اذا حد عنده النسخة كاملة اتمنى يرسلي او ترسلي اياها‬، ‫لالمانة حسيت التسجيالت اللي عندي ناقصة‬
‫ انا صراحة ما ادري عن اي وحدة يقصد و‬، ‫ الدكتور دائما في التسجيالت يقول انه مثال ه ذا حلينا في المذكرة السابقة‬: ‫كمان مالحظة‬
‫ اذا حد عنده اياها ياريت يرسلها‬، ‫كان دائما يشدد انه نسمعها النه شرح فيها كثير شغالت بالتفصيل‬
Docterule.notes@gmail.com

‫الله يوفق الجميع و يرزقنا القبول دنيا وآخرة‬

Hepatology
Types of jaundice :
1- Prehepatic  unconjugated will be high (indirect) e.g. hemolysis due to : Rh isoimmunization
, ABO , G6PDD  treatment by phototherapy
2- Hepatic  both direct and indirect high
3- Post hepatic  conjugated high (direct) e.g. biliary atresia = treat the cause
phototherapy or transfusion ‫بمثال‬jaundice ‫ عالج ال‬indirect high ‫مالحظة اذا ال‬
biliary atresia ‫ نروح نعالج السبب مثال‬direct high ‫اما اذا ال‬
If the patient did not improve with phototherapy + he has high ALP = biliary atresia
ALP will be high in :
1- biliary system diseases e.g. biliary atresia
2- bone disease
Congenital hypothyroidism do screening at 3-5 days of life , very important to prevent mental
retardation , the treatment will be thyroxin therapy for life
Clinical presentation + jaundice + large fontanelle + hypotonia + large tongue +UMBILICAL HERNIA
The most important screening test in newborn  TSH screening
Jaundice + low heme (HB = 9) = hemolysis = high retics , many causes e.g.
- spherocytosis  do fragility test but he have to mention for you in the question about the
blood smear ( blood smear = spherocyte + Ansiocytosis )
- G6PDD  do G6PD essay
- Autoimmune hemolytic anemia  do coombs test positive
Jaundice indirect high only Gibret
Early life Jaundice e.g. 5 days  ask about blood group or RH
Charcot triad = fever + RUQ pain + Jaundice = Ascending cholangitis
This is emergency case = needs admission +IV antbiotics + ERCP
‫دائما في خالف مين يدخله قسم الجراحة او الباطنة‬
choledocal cyst
Child 5 days + direct high + brother has the same thing
Primary sclerosing cholangitis:
To investigate MRCP , best ERCP but it is invasive ( it will show dilatation)
PSC is associated with ulcerative colitis ,In case of UC = higher risk for colon cancer = do colposcopy

Hematology
RH pathophysiology
It happen when mother is RH negative
1st baby is RH positive
Now the baby RH + cells will enter mother blood  the mother will form antibodies against it
Then in the 2nd baby ( RH+) , now the preformed autoantibodies by the mother will attack the baby
Sickle cell patient complications :
1- The most common crisis in SCD patient is vasocclusive crisis  presented with generalized pain in
hand and feet  treatment by hydration and GOOD ANALGESIA / prevented by hydroxyrea
2- acute chest syndrome = has Chest pain + cough+ dyspnea + back pain +lobar consolidation 
treated initially by IVF + analgesia / prevented by hydroxyurea for life
3- sequestration crisis = RUQ pain + hemolytic anemia features (low Hb +high retics) + target cells +
inculsions bodies (may have history of URTI) on examination = large liver and spleen / if 1st attak =
give blood transfusion , if multiple sequestration attacks then do splenectomy
4- aplastic crisis  parvo virus B19 + aplastic anemia ( low hb) + low WBCs + low Platetes + NORMAL
RETICS
autosplencetomy happen in SCD patient

‫ باالختبار راح يجيب في الخيارات نقل دم‬، ‫حقه ابدي بسوائل و مسكنات‬hb ‫ واجا عندك بالطوارئ مهما يكون ال‬ACS ‫اذا المريض‬
‫بس ال تختاروا النه الخطوة االولى سوائل و مسكنات‬
SCA type of inheritance = AR , so if lady has child with SCD , then she remarried we have to check the
father , to rule out that he is a carrier for sickle cell gene
Beta thalassemia electrophoresis
- major = HbF high
- minor = HbA2 high

Thalasemia in 1 years = large forehead +FTT failure to thrive


thalassemia trait = microcytic anemia + retics high
maybe alpha or beta
IDA= microcytic anemia + low ferritin + high RDW
If in the question they didn’t give you ferritin , you will look to MCV
If MCV > 70 = IDA
If MCV < 70 = thalassemia trait , usually they patient is adolescent and he/she might be asymptomatic
If the patient : microcytic anemia + MCV (68) + low ferritin + low platetets = thalasmia
N.B: thalassemia patient might have low iron
In IDA = the patient will have Pica = eat papers , sand
Iron supplement complications : black stool + constipation
Antidote for iron intoxication = IV defroxamine
Anemia of chronic diseases high RBCSs + low hb + normal reticocyte + low MCV
If in the question he said high RDW = IDA
IDA in child below one year:
1st give oral iron , if not responding = do serum ferritin and iron to double check that it is IDA if
electrophoresis is present choose it
Splenectomy done in = ITP
Neonatal hemorrhagic disease (Hemorrhagic disease of newborn) = due to vitamin K deficiency
The hint in the question home birth + neonate with multiple bruises
High PT , APTT
Vitamin k needed for 1972 = factor 10,7,9,2
Affects common and extrinsic pathway
Hemophilia = most common presentation = hemoarthrosis
Hemophilia A = factor 8
Hemophilia B = factor 9
Factor 10 deficiency
The child will have high PT, APTT
1st Hb screening test : at one year
VWF disease :
Child bleeds after tooth extraction , then he started developing bruises , factor 8 positive
Tooth extraction bleed DDx :
1- hemophilia A : factor 8 will be low or negative ‫يعني مو موجود‬
2- VWF disease : factor 8 positive ‫موجود‬
The most common hereditary bleeding disorder is VWF because it is AD autosomal dominant
Bleeding after circumcision :
Hemophilia A , factor 8 deficiency
High APTT , normal PT , bleeding time
Bleeding after clamp of umbilicus = factor 13
Bleeding from umbilical artery after home delivery = vitamin K dependent factors
Gingival bleeding : vitamin C
HUS HEMOLYTIC UREMIC SYNDROME :
History of gastroenteritis then after 1 week hematuria
cause : ecoli o157h7 verotoxin
treatment : supportive
don’t give antibiotic because it will exacerbate the problem
ITP :
After viral infection URTI
Viral
Idiopathic plateles +purpuria
Supportive :
Give IVIG if
- If < 30,000 platelets count
- Bleeding else where ICH , internal bleed , hematoartsis, epistasis
Don’t give steroids because it will mask if there is any leukemia only in case of mild bleeding

Oncology
Weight loss in pediatrics may be due to cancer , you have to look for age
Leukemia = 2-8 years
Retinoblastoma = neonate
Neuroblastoma = 2 years
In general if he asks weight loss and failure to thrive most commonly will be psychosocial
ALL patient + Febrile neutropenia = do all septic work up + IV antibiotics
Septic work up includes = cultures e.g. blood culture + lactic acid + others
This is risky patient he might enter in sepsis anytime
Osteosarcoma = swelling + redness above knee
Usually does not affect the joint so no limitation of movement
Supraclavicular lymph node is usually a red flag indicating cancer
Left supraclavicular = gastric cancer named Virchow lymph node , if you find it do endoscopy
Spinal cord cancer (metastatic):
Usually will be as patient with lung cancer then he had back pain + neurologic symptoms = give
steroids then do MRI / steroids is given to relieve pain in pressure that happen in spinal canal
Wilms tumor nephroblastoma
Most common abdominal mass is children 2-4 years
Most common site of metastasis is lung
Other features : hematuria + anirideia ( absent iris) + abdominal mass that does not cross the midline
of the abdomen
1st investigation = CT
Neuroblastoma
Cross the midline of abdomen
Causes hypertension because it is in the adrenal =causes the release of metanephrins that causes HTN
Horner syndrome maybe present
Patient may presented to ER after fall by : fever + pale + hypertensive, o/e abdominal mass central
crossing the midline
Retinoblastoma :
Absent red reflex = immediate referral to ophthalmology
The diagnosis will be by : CT
Unilateral loss of red reflex = next to do = fundoscopy
Best time to check red reflex is at birth and at 6 w

Neurology
Cerebellar ataxia :
Inability to stand or sit unsupported + clumsy gait + resistance neck flexion (neck rigidity)
Causes : post infection or autoimmune or drug induced or paraneoplastic
History of chicken pox infection leads to complication called cerebellar ataxia
Cerebellum affection post trauma by 10 days ( head injury)
Child will lose the ability to feed himself with spoon = problem in balance and coordination
Febrile seizure :
History of tonic clonic seizure from 1 hour + now has only fever = give diazepam
Usually start with lorazepam then diazepam
If seizure < 5 minutes = don’t do anything
If > 5 minutes = start Anti seizure drugs to abort seizure
e.g. pneumonia developed fever then seizure : approach for seizure (febrile / status)
1. IV lorazepam / diazepam / midazolam
2. Rectal diazepam
After 5 minutes
3. Repeat does
After 5 minutes :
4. Phenytoin
5. Barbiturate
6. Mechanical ventilation
Don’t choose paracetamol
Absence seizure :
EEG : 3 wave spike + ‫ ثانية‬03, ‫الطفل يفهي لمدة‬
Tx : ethusuzamide
Cerebral palsy in kernicterus :
Type of cerebral palsy in patients with kernicterus = athetoid or dyskinetics
Kernicterus causes :
Hyperbilirubimeia e.g. ABO or rh
Can be complicated by : hearing loss
Kernicterus = hyperbilirubimeia deposit in basal ganaglia
Complications : cerebral palsy , hearing loss
Cerebral palsy :
Patient will have = fist hand and crossed legs
Types :
Diplegia = lower limb > upper limb
Quadriplegia = all affected in same manner
Hemiplegia = one side e.g. right or left
Athetoid : disorganized synergistic and antagonistic

Cardiology
VSD :
Small(2 mm) + asymptomatic = watchful waiting / follow up if present
< 2 = nothing
2-8 = regular gollow up
>8 = surgical correction
Murmur : holosystolic murmur
If symptomatic = surgical correction
Co arcuation of aorta :
Radiofemoral delay + upper extremities hypertension
Xray = rib notching
Investigations : start with echo , but if he asked about the confirmatory test = cardiac catherization
In turner syndrome cardiac features = bicuspid > coarcutation
Vascular malformation at legs (superficial)
We will remove it or intervene if it causes pain
Rheumatic fever :
URTI  arthritis + rash ( erythema marginatium) + subcutaneous nodule
Criteria : history URTI (ASO , rapid streptococcus or culture
Major : 2
Jointes
Carditis
Nodules
Syndenham chorea
Subcutaneous nodule
Minor :

Erythema marginatium is associated with 10 of heart damage


Investigation : next step : ecg , best echo
Or evidence of URTI infection
HOCM : AD
Sudden death in young age
Atheles + sudden collapse + jerky carotid pulse
Murmur : midsystolic in the left side
Treatment : beta blocker (metoprolol) because he has hypertrophied muscles , that will decrease
filling phase (diastolic filling phase ) so with bblocker we will decrease heart rate so that I can fill the
chamber with blood
Heart failure :
Nutritional requirement :Requires more calories
CHF due to diastolic dysfunction = B blocker + diuretics
CHF due to systolic = ACE I
Drugs decrease mortality in heart failure :
1. ACE inhibitor
2. Betablocker
3. Aldosterone inhibitor
TOF :
PS + overriding + RVH + VSD
Cyanosis +parasternal heave
Neonate with cyanosis in 2-3 week (cyanosis increase with feeding)
Murmurs types :
- ejection systolic at the left sternal border (pulmonary atresia or stenosis)
- Holosystolic murmur = because of VSD
Child crying then become cyanotic = give sedation (morphine)+ analgesia
If he cannot complete one sentence= intubation
If the child developed apnea = admit him as acute life threatening condition
Child with apnea after each feed , cause of admission = syncope < apnea
ECG finding : Right axis , RBBB
Treatment :Prostaglandin
Post Surgical treatment complications : after 6 months
New left parasternal diastolic decrescendo + single heart sound S1 + left parasternal impulse (
increase with inspiration) = pulmonary regurge ‫النه الدم يدخل القلب اسرع بالشهيق‬
Transposition of arteries is the most common in neonate
Most common heart disease in general ASD
In cyntoic in general TOF
PDA :
Machinery murmur
Typically acynotic , may be complicated and get Cyanosis in neonate 2 -3 week of life
Treatment : NSAID Indomethacin
NSAID helps in closure of DA in 1st 3 weeks
After 3weeks : it will not help, use other thing
TGA :
Cyanotic neonate
Xray = egg shape ,Decrease vascularity of the lung oligemia
Higher in = IODM (GDM)
Murmur
Systolic regure (PR):crescendo decrescendo murmur + late systolic + midsterum
PS : click + ejection systolic in the 2nd intercostal left side
AR: pistol shot murmur
Innocent murmur(stills)/ physiological : ejection systolic murmur + in normal child + change in
position = reassure and discharge
Hyperdynamic murmur :
Child with fever + infection found to have murmur = reexamine him after infection subsides
It maybe due to hyper dynamic state
Prolonged QT syndrome :
Jervill and large nelson syndrome associated with SNHL

Respiratory
Cystic fibrosis :
Child failure to thrive + cough+ wheezing + recurrent respiratory infections + murmur + poor feeding
CF may come with heart disease
Bronchiolitis :
Commonest cause of RDS 6-18 or 24 m
Commonest cause is RSV
Presentation : tachypnea + runny nose + wheeze +cough + conjunctivitis+ fever (38)
Diagnostic test is : nasopharyngeal swab then send it for PCR to check RSV
Treatment mainly supportive : oxygen ….etc / may use ribavirin (decrease rate of hospitilzation)
1st step in severe bronchiolitis (chest rescission ) = admit + fluids for dehydration + oxygen
If child has episodes of apnea : needs invasive management (ventilation) + admission
‫ كان موجود في الكبد وسوال عليه خالف‬RSV ‫ال‬
Larygeomalcia :
Congenial softening in the larynx : noisy breathing , chronic, no fever
Most common cause of respiratory stridor in infancy ( increases with feeding, change in position
(supine), decrease with prone
Age of presentation : 2-6 weeks( within 2 months)
Best investigation : flexible laryngoscopy Omega sign
Prognosis : >92% = resolve within 1 year
Tracheomalacia = diagnostic = broncoscopy
Croup : larygeotrachiobronchitis
Cause para influenza virus
Barking cough = inspiratory stridor due to subglottic narrowing
Maybe he will say croyza for 2 days with sore throat and difficulty swallowing of solid food only +
cervical lymphadenopathy , next = xray lateral neck
Xray : steeple sign
Best for diagnosis = clinical
Swab :Nasopharyngeal if needed
Treatment :
Racemic Epinephrine = moderate to severe ( repeat if needed)
Steroid = mild
Warning sign in croup : blue lips
Epiglottis :
Abrupt + toxic + high grade fever +Respiratory distress + drooling + tripod
Bacterial cause Group A beta hemolytics , staph aurse
Xray : thumb sign
Swab : nasopharnyx
Antibiotic : ceftriaxone 7-10days
Medical emergency = save airway = ABC = call ENT to come and intubate the patient
Don’t tiuch the patient
INFECTION
MALRIA
Blood film PICTURE = ring shape , headphone shaped trophozoite = falciprium
If you are suspecting malaria but blood smear negative = repeat blood smear each 8 hours for 2 days
Mumps :
Most common site = parotid gland
Infantile botulism :
First baby to the mother (give her baby honey below one years)
The baby will develop fever + neurologic symptoms ( mainly at eyes = ptosis + pupillary paralysis ( this
lead to weak reaction to light) + the baby will be lethargic + has constipation
Adenovirus :
Fever + bilateral conjunctivitis + abdominal pain(gastroenteritis) 2 weeks ago
Now has bilateral lung infiltration = viral cause (adeno )
If he said lobar infiltration = bacterial cause
Varicella :
Child had varicella + his brother is immune compromised = the management for his brother is to give
IVIG since he can not take the vaccine
Herps :
Vesicle at lips and gum ( gingivostomatitis) caused Herps simplex type 1
Scarlet fever :
Fully vaccinated + fever and sore throat at SAME day
Pharyngitis by Beta hemolyticus
Usually the patient may have strawberry tongue within 1 to 2 days of pharyngitis
Rash (sand like) in groin , axillar and antecubital fossa ,pastia lines , accentuated in flexure areas
Peritonsillar abscess (qunizy)
Fever + two large sized tonsils ( symptoms of pharyngitis + hint that we have two tonsillar masses )
Patient may have adenophagia (difficulty swallowing)
Or he will say that the child was having pharyngitis not responding to antibiotics after 1 week he came
with enlarged tonsils
Acute pharyngitis caused by Beta hemolyticus group A :
Immune mediated complications :
1. Scarlet fever = 1-2 days
2. PSGN = 1-2 weeks
3. Reactive arthritis
4. Acute rheumatic fever

Acute tonsillitis = fever + sore throat + difficulty swallowing + lymphadenopathy


on examination : white membrane covering tonsils
cause : streptococcus group A beta hemolyticus
complications : pharyngitis
treatment : augmentin
no need for prophylaxis of contact
Group A beta hemolytic : can cause vesicopustular rash
Measles : 3 Cs + rash
Cough , coryza , conjunctivitis + rash + whitish membrane (koplik spot)
Rash maculopapular from neck till back
Roseola infantium :
URTI + fever = subsides then rash appears
Caused by herpes virus 6
Rubella :
Infection in utero can lead to congenital cataract (leuckocoria)
Heart disease ( new murmur)
Rocky mountain fever other name spotted fever
Typically fever + headache  then petechial rash to all body
Complication: hearing loss
Fever + vomiting + rash on 2nd day
Meningococcemia :
Signs of meningitis + rash all of the body
Meningitis :
Fever + irritability + neck stiffness , high WBCs
Kering sign : hip flexed then bring the knee and raise it = resistance will develop
Bruzenki sign : flex neck on sternum = his knee will be elevated
CSF = table important
Normal glucose and protein + high lymphocyte = viral meningitis
Low glucose + high protein + neutrophils = Bacteria
High pressure + low glucose + protein high + lymphocyte = fungal
TB
Aseptic meningitis means non bacterial ( may be viral…etc )
Complications of meningitis :
Late complication : hearing loss,Seizure
Organisms causing meningitis :
>3 months : pneumococcal
Treatment : ceftriaxone + vancomycin we may give steroids as protection
Prophylaxis : rifampicin
Encephalitis :
Meningitis + confusion
EBV :
Sore throat + lymphadenopathy + HSM+ rash = may lead to meningitis
May have history of travel to Africa
Complication : burrkit lymphoma
Typhoid fever :
Fever (6days ) + tender splenomegaly + Diarrhea + abdominal pain = repeat blood culture ( multiple
blood culture)
Simple Cystitis :
Common in females , suprapubic pain = discharge on oral antibiotics (amoxillin or TMP/SMZ)
Otitis media :
Most common cause = bacterial infection amoxicillin 90mg/day * 10 days
Most common virus causing OM = rhinovirus ‫كافيروس بس االكثر تسببا هو البكتريا‬
Acute suppurative otitis media :
Acute otitis media symptoms( ear pain) + perforated TM + pus discharges in the ear canal
Otitis media with effusion :
It occurs as a late complications
Recurrent otitis media can lead to conductive hearing loss
Polio :
Child came from Africa + complete paralysis (weakness)
Not vaccinate
Septic arthritis :
Fever (high grade) toxic patient + Limping , non weight bearing , not allowing anybody to touch his
joint (swollen tender joint + limited passive movement)
Most common sites hip or knees
Most common organism : staph aurse
Single best investigation : joint aspiration
Treatment : IV antibiotics + joint aspiration and drainage
In case of sickle cell anemia patient the causative organism = salmonella
Impitigo :
Honey crust infection , caused by staph aurse
Complication of impetigo = PSGN (hematuria) ( ask about history of honey crust lesion before)
Pneumonia :
Productive cough + SOB+ yellow sputum
Atypical = Fever + bilateral lung infiltrates (lower lobes) + mildly ill
5-15 year = mycoplasma pneumonia
<5 = pneumococcus ( in the question she was 13 m)
Other presentation : child with tachypnea + cough + hemoptysis + bilateral infiltrates
Treatment for pneumonia = IV Antibiotics
Pleural effusion :
Pneumonia complication + stony dullness this case will be named paraneumonic effusion
TB :
Cough + low grade fever + dullness + hemoptysis + long history > 2 weeks
Candida infection
Oral thrush = treatment by mouth wash nystatin
Diper rash : you will have satellite lesions = give topical antifungal , it will not improve with steroids
Clostridium difficile :
Causes diarrhea(pseudomembranous colitis) after prolong use of broad spectrum antibiotics
Example of broad spectrum antibiotics :
1.clindamycin – most common antibiotic that predispose to clostridium difficile infectiom
2. penicillin
Best investigation : PCR
Septic shock
New guidelines in sepsis 2016 = we have sepsis andseptic shock
Old ones we were having 4 stages = sepsis severe sepsis SIRSseptic shock
Septic shock definition : sustained hypotension not responding to resuscitation and need vasopressin
to maintain the MAP > 65 ( new guidelines they added that : lactic acid must be > 2)
e.g. : child with petechial rash + fever + hypotension 70/55+ cold extremities + poo feeding = sepsis ,
but if he said not responding to IV fluids then it is septic shock
Best treatment = ABC + Hydration + IV broad spectrum antibiotics + blood cultures  vasopressors /
inotropes
Commonest cause of shock in children = sepsis
Sepsis :
SOFA criteria 2/3 to suspected (adult)
Mental status
SBP<100
RR> 22
+ evidence of infection
Amebiasis :
Abdominal pain + tenesmus + bloody diarrhea
Bloody diarrhea  can lead to oliguria (due to vomiting , diarrhea )
DDx of bloody diarrhea :
Amebiasis
Shigellosis
Hemorrhagic ecoli o157
Treatment = antibiotics
If the patient has hematuria = HUS
Pertussis prophylaxis : (post exposure prophylaxis)
If contact within 21 days : macrolides (e.g. erythromycin , azithromycin
Pertusiss vaccine : 10 years garuttee
Unvaccinated presented with hacking or whooping cough / typical presentation post tussive vomiting
Caused by bortedella
Complication of pertusiss : Pneumonia
Diagnosis by : nasopharyngeal swab ( like croup)
Erythema toxicium :
Rash with low grade fever (or no fever) = reassure the mother
Giardiasis :
Long history of watery diarrhea + abdominal pain + bloating + tensmus
Dengue fever :
Treatment = supportive + NEVER give NSAIDs
‫الحشرات اللي تنقل المرض تكون نشيطة في الصباح‬

Genetics :
Mode of inheritance : AR
17 alpha hydroxylase deficiency
21 hydroxylase : baby will have ambigious gentalia ( most common cause)
Cystic fibrosis
Mode of inheritance : AD
Neurofibromatosis type 1 ( multiple café au lait spots + axillary frecking ) chromosome affected= 17q
11 : if you have multiple members in the family with NF1 , you will educate the family about it, no
need to send for genetic testing because NF1 is a clinical diagnosis has special criteria ( >6 café au lait
…etc)
Mode of inheritance : X linked (boys diseases)
Wiskott Aldrich syndrome = triad of recurrent infections + ecema + thrombocytopenia in BOYs
Agammaglobinemia = same as Wiskott aldriech e.g. 4 boys died because of recurrent infection but
girls are fine ( usually lung infections) humeral immunity defect (antibodies defects)( on lab studies he
will have low B cells + normal t cells) , most common organisms = pneumococcal
Risk of inheritance :
In AR diseases = 25 % ( 2 carriers (father Aa + Mother Aa) = 25 % aa (diseased)/ 50% = carriers Aa /
25% AA = completely normal
Tuberous sclerosis :
The mother will have TCH1 gene mutation , to investigate the child do multiple gene testing ( more
accurate than single)

Syndromes
Edwards = trisomy 18
Rocker bottom feet + cardiac features + prominent occiput
Prader willi syndrome = chromosome 15 unsure
Hyperphagia + hypotonia + undescended testes + facial malformation + cleft palate
Turner 45 XO deletion confirmed by karyotyping
Amenorrhea + short stature + webbed neck + coarcutation of aorta + bicuspid aorta + hypothyroidism
+ wide spaced breast + hypertensive
Do FSH as investigation for amenorrhea hypergondotrophic hypogondaism
Down syndrome :
Most common cardiac abnormality = endocardial cushion defect AVSD (fixed S2 + ejection systolic
murmur)
Hypothyroidism
Genetics of down syndrome :
- Trisomy 21 most common
- Translocation
- The least incidence (rare) = mosasim – hereditatry
Quadriple test in pregnancy :HI/AE
High : hCG , Inhibin
Low : AFP, Estradiol
Risk factor for down syndrome = age >35
Short stature
If short + large tongue + short webbed neck = syndromal cause of short stature
Tall stature
Tall + flexible joints + pectus excavatum = marfan ( risk of aortic dissection )
Wilson disease :
KF ring in eyes

Development
Gross motor :
Waving : 9 m
Holding objects: 6 m
Trucal support at sitting : 4 m ‫يجلس و مايطيح‬
Delay speech :
Case 1 : At 2 years = can form 2 sentence
If below 2 years = 1st do hearing test , if normal then reassurance + revaluate at 24 months
Case 2 : At 3 years : understand two order commands + strangers can understand 75 % of his talk =
reassurance (this case dx is delay speech but we will reassure the mother

General
Sudden Infant Death Syndrome SIDS = infant died suddenly at their cribs , commonly at sleep
Risk factors parents are smoker+ Prone position of sleeping + baby preterm (defect in baby brain that
control arousal from sleep and breathing)
Ask parents for social history especially smoking
Breast enlargement in infancy
Asymmetric = do nothing = reassurance will disappear
Shaken baby syndrome :
Subdural hematoma + retinal hemorraghe + history of neglect + history of trauma somewhere
‫اذا قال في السوال البيت مو ضابط اعرف انه يريد يساعد بهنت معينة‬
Child abuse :
Head trauma + multiple bruises = ABC then call child protective services
Fully toilet trained girl, now has some bruises + fecal incontinence = think about sexual abuse
Sexual abuse = hymen will be affected at 6 o’clock
How to deal with child ( communication with children) in two ways :
Positive reinforcement : give gift ‫ تشجيه بعبارات عن ابطاله المفضلين‬، ‫تحفزه هدايا‬
Negative reinforcement : ‫نخوفه وكذا‬
‫دائما نبدي بالتحفيز افضل‬
Non invasive mechanical ventilation : do it in the emergency room
e.g. oxygen mask , nasal canula
Indications for admission :
Can’t tolerate oral intake especially in pediatrics because you are afraid from dehydration
Shock:
ABG in septic shock
PH :7.3 = starting to be acidotic
Pco2, HCO3 = normal = early shock
So early compensated shock
Physical activity :
The least time for physical activity = 60 min/day
Teeth pigmentation :
Most common cause = bottle feeding while sleeping ( bottle feeding dental caries)
Enuresis :
The muscle that is responsible for voiding is detrusor muscle (over activity)
Night bed witting considered normal till age of 5
Best treatment : alarum method
1st step in investigation : urinalysis ( to rule out infection)
Endocrine
Cushing syndrome :
Central obesity + stria + hypertension , suspecting cushing syndrome
Ix :
Serum cortisol level initial  then over night dexa suppression  if high the cushing  then look for
ACTH :
If ACTH high  MRI pituitary ( to rule out pituitary adenoma that secretes ACTH
If ACTH low  CT abdomen ( the cause mostly adrenal hyperplasia or adenoma or carcinoma) that
secretes cortisol
The most common cause exogenous  steroid intake
Endogenous :
ACTH dependent
ACTH indepengent

Adrenal physiology
- Zona gomeruloza  connected with RAAS system (aldosterone)
- Zone fasiculata  connected with hypothalamus and piturtary (ACTH CORTISOL )
- Zona reticulasa  sex hormone LH /FSH
Hyperparatyrodism
ER presentation with bone erosion+ high calcium and phosphorus = do hydration + bisphosphonates
+ diuretics
In hyperPTH , if it affects bones = give bisphosphonates
Primary hyperparathyroidism = sudden thigh pain + spiral fracture + high ca + high PTH
Types of hypertparathyrodism :
1. Primary : high calcium  high/normal PTH
2. Secondary : low/normal calcium + high PTH
3. Tertiary : high calcium + high PTH + high phosphate
Diabetes opthalmopathy screening
Type 1 = after 3 -5 years of diagnosis ( 5 more accurate) then it will be annually
Type 2 = immediately after diagnosis
DKA management :
Initial step : IV fluids  after 1 hour approximately we start insulin
DKA management complications
1. The most important critical complication to monitor during treatment of DKA is cerebral edema
o Don’t decrease glucose rapidly (use special protocol)
o Don’t give rapid infusion of normal saline
Cerebral edema features :
Clinically ; deep coma
Vitally : hypotensive + tachycardia (maybe the child will be intubated)
Lab wise : high sodium e.g. 165 , K normal e.g. 3.2, Cl high e.g. 115
2. Hypokalemia : maybe due to vomiting ‫بس مو هذا السبب االكيد االفضل الجواب حقت االنسلين‬
o Due to insulin administration ( potassium will be shifted from extracellular to
intracellular)

DKA counselling before discharge


If 1st presentation = listen to the patient and discuss with him + plan (listen to child)
If already diagnosed = give clear written plan
‫باالمتحان تاكد من السوال النه تقريبا اغلب االجوبة تنفع‬
Diabetes diagnosis :
If presented to ER with DKA ( glucose > 250 polyruea + vomiting + abdominal pain) = 1st investigation
urine dipstick
If he came in the clinic for screening = HbA1c
Diabetes mellitus type 1 treatment :
Usually the case will be about DKA  you will answer by regular insulin to treat the disease long term
( at home) , but if he asked you about which insulin in DKA management you choose Rapid insulin
‫في كثير اسامي لالنسلين احفظيها‬
Diabetic hypoglycemia :
If the child was on Glargine + aspart then he had fasting and postprandial hypoglycemia = decrease
both
If fasting only = decrease long acting night dose of glargine
If post prandial hypoglycemia only = decrease short acting pre meal i.e. aspart
Diabetic hyperglycemia :
Child didn’t eat from 3h , FBS=6.3 , why he has high glucose = decrease insulin intake
‫ فمعنى انه ماقاعد ياخذ انسلين او انه جرعته قليلة‬، ‫يعني هو من دون اكل سكره عالي‬
(: ‫الدكتور قال ركزوا على السؤال يمكن مو بهذه البساطة‬

Short stature :
1st step in approach = take parent height to assess mid parent height
Father + mother / 2 )+ 13 for boys
Father +mother/2 ) – 13 for girls
If low IGF = growth hormone deficiency , treatment recombinant GH
constitutional delay short stature = delay of growth within 2 years in bone age ‫تاخر طبيعي عادي‬
We will wait for puberty e.g. boy 9 years ,short , his bone age 7 = dx constitutional delay
Puberty :
Premature pubety = all puberty signs (breast + hair) in girls < 8 y , boys < 9y
Premature adrenalche only hair( axillary, pubic not essential to be both) , no clitoomegaly in girls 
do DHEAS(adrenal hyperplasia)
Premature therache : breast enlargement girls < 8
1st sign of puberty in girls  breast budding / boys  testicular enlargement
The most common cause of premature puberty  idiopathic or central
Delayed puberty :
Female we will wait till 15 years
Most common cause constitutional , wait for puberty
Tannger stages for puberty : male and female , 5 levels
Male :
1 = < 2 cm , < 0.5 testes size /
2 scrotom + testes enlarge + red skin + testes size4 /
3 : penis enlargement length > width
4 : dark skin + penis(width) ‫ينسال عنها‬
5: adult genitalia
--female
1 : prepubertal
2: slight pigmented hair + at medial border of labia ‫ينسال عنها‬
3: darker hair + curly
4: coarse abundant
5 : adult

*If stage 5 tanner + 7 years = premature puberty


Congenital hypothyroidism :
Recent delivered neonate has flat face + no smile + umbilcal hernia + wide fontanelle
Congential adrenal hyperplasia :
Presentation : in female : large clitoris + several episodes of vomiting
CAH crisis (salt losing adrenal crisis): Neonate with CAH came to ER with : dehydration + low glucose +
low sodium
Treated with IV fluid 1stly then glucose and steroids (corticosteroids + mineralocorticoids)
Investigation : high 17 OH progesterone
Treatment : in general daily hydrocortisone orally
GIT :
Levels of dehydration :
1. Mild ( thrist only ) = 5 % dehydration
2. Moderate ( signs.e.g. decreased skin turgor , depressed fontanelle …etc) = 10 % dehydration
3. Severe (hypotension + congusion + neurologic symptoms) = 15 % dehydration
Diarrhea acid base imbalance :
Hypokalemia , hyponatremia + metabolic acidosis
Vomiting Acid base imbalance :
Hypokalemic , hypochlorimic + metabolic alkalosis
Diarrhea without vomiting :
Mild to moderate dehydration = oral rehydration solution
Severe = IV fluids
If patient is vomiting = give IVF even if mild dehydration
ORS : oral rehydration solution :
If the patient is taking ORS but he still have mild dehydration = the cause is = glucose intolerance
Because the ORS has glucose inside it
Food poisoning :
Staphylococcus enteritis : 1-6 hours = abdominal pan + vomiting without diarrhea , resolve within 24
hours ,
The patient usually will give history of meat ingestion
Management :supportive (rehydration and pain management if needed)
Recurrent gastritis after food introduction in 12 months old :
If no vomiting = continue on ORS for 24 hr then gradually introduce food
Gastroenteritis
Most common gastroenteritis in preschool age (4 years )= viral rota
Day care watery diaarhea = rota virus
Treatment = supportive (rehydration)
Intussusception :
5-9 months usually + intermittent severe abdominal pain( the baby will raise his legs toward abdomen
with episodes of intermittent cries) + late sign Jelly like stool + RQ (Sausage shape mass)
In USS : target sign (doughnut shape)/ teleschoping ( USS very sensitive ( near sensitivity of barium
enema
1st Ix = USS not invasive if stable and you are not in hurry / confirmatory test : barium enema
Diagnostic + therapeutic : barium enema (radiologic reduction) other name hydrostatic reduction
Treatment : If signs of dehydration = IV fluid + stabilization then go for radiologic reduction
Tell the mother that the recurrence rate is high > 68 % , the possibility of the need for surgery is 70%
in the next episode
% 03 ‫ يومها راح نحتاج عملية بنسبة عالية‬، ‫الزبدة انه ممكن يحصل مرة ثانية مع ابنك و اذا حصل السمح الله‬
Meckels diveticulium :
Painless PR bleed(hematochezia) ( bloody diapers)+ asymptomatic
Meckels symptomatic in 2 % only as hematochezia
Volvulus :
Baby 6 days + passed stool after delivary + now has constipation
Midgut volvus :child aged 2 weeks normal passage of meconium now has abdominal distension +
pellet stool + bilious vomiting
Sigmoid volvus = coffee bean sign radiologically picture
Milk allergy :
Baby will have diarrhea
Intestinal obstruction :
Abdominal distention + vomiting + constipation
Start with xray to rule out perforation
If xray not present in choices = choose CT helps in identifying level , etiology , complication
USS not beneficial only in hernia
Appendicitis :
We use usually Alvadaro score to diagnose it
Pain at mac burney point + rebound tenderness
Complicated by appendix rupture  septic peritonitis  sepsis
In sepsis we have peripheral vasodilation
Confirmatory test for appendicitis = CT abdomen + contrast
Functional abdominal pain syndrome :
Related to psychological issues = early morning ( before going to school)
Continuous pain , not related to feeding
Affects daily activity
Not related to malingering
No any organic cause
Infantile colic :
Incidence : 20 – 40 % of infants
Presentation : excessive crying without a reason + no change in formula + large passages of flatus
Rule of 3 : Abdominal pain *3 hours/day , 3 times per week, for 3 months , without explanation
Peak at 6 week , at 3-6 weeks will disappear
Management : reassurance or behavioral adaptation
If he mentioned in the question that they change the formula or shift from breast feeding to formula
= we may have cow milk allergy
Gastroesophegeal reflex (physiological reflex): ‫من دون كلمة‬disease
Because LES is not that powerful
50% will disappear at 1 year
Presentation : the baby will spit after feeding + his weight for age in normal
Management : Reassurance
Put baby at semi sitting postion , raise head
Don’t feed him while sleeping
Formula allergy :
Baby with abdominal distension + diarrhea that change with time ( stool will get brighter with time)+
history of meconium passage at birth
Cow milk intolerance :
Change from breast feeding then change to formula , now has constipation +distention
Pyloric stenosis case :
Case of abdominal distension , 1st investigation = USS
Reproductive
Gonadal agenesis in female (mullarian agenesis)
Mullarian (embryonic structure shares in development of uterus and vaginal)
If primary amenorrhea e.g. 17 years + 2ry sexual character present 9 breast) = do pelvic US to see if
there is a uterus or not
Nephrology
Polycystic kidney disease :
Asymmetric kidney in US bilaterally
AR = pediatrics ( may accompanied by SAH aneurysm)
AD = adult ( HTN )
Diagnosis : initial = US then confirm by CT
UTI in Uncircumcised boy :
UTI signs : fever + pain + urinalysis : pyurea > 5 , nitrite +ve (e.coli) , leucocyte esterase +ve
In urine nitrate is normal finding , nitrite is pathological and it is very sensitive for UTI
Most common cause for UTI is ecoli :
Treatment :
Febrile UTI = IV ceftriaxone + admission
Afebrile = no need for admission + oral antibiotic
UTI in circumcised boy :
The child already treated with oral SMZ/TMP = depending of age to know if he will go USG, or MCUG
‫الدكتور ما استقر على شي باالخير بس قال انه السوال يجي اوضح باالمتحان‬
Urology
Mid shaft urethra during circumcision (Hypospadias) inform the surgeon because it is
contraindication for circumcision ( as we will use the circumcised skin in repair of hypospadias and
we will try to make the urethral opening in the glans penis
Hypospadias : abnormal urethral opening in the ventral part of the penis
Epispadias: abnormal urethral opening in the dorsal part of the penis
VUR :
VCUG/MCUG picture : has two phases ( filling and emptying phase)( you will fill the bladder with
contrast, then ask baby to void and look to the VU junction if there is any reflex (it has 5 grades)
You will do it after 4 weeks of infection ( not to spread infection proximally)
Indications for Voiding cystourethrogram , MCUG :
 UTI + < 5 years
 FEMALE > 2 UTI
 Any male with UTI
Renal US before MCUG to see if there is hydronephrosis ‫توسع‬
Even if the child improved after treatment and was afebrile
Musculoskeletal
DMD :
Gower sign positive (picture) ( climbing on him self to stand) proximal muscle weakness
Reactive arthritis :
Typical sites : knee , ankle
Common after viral infection ( eye or diarrhea or respiratory infections) followed by arthritis
The diarrhea maybe due to clostridium = you will find clostridium toxin in the stool
Rieters syndrome same as rective other name :
Triad of urethritis + conjunctivitis + (oligo articular , may be migratory) arthritis only in 1/3 of patient
it will come as this triad
manangement : supportive

JIA :
Chronic pain + fever ( FUO)
Osgood Schatter :
Adolescent + has relation with walking ( ascending or descending)
Pain at anterior tibial tubercle below knee , this case age was 2 years
DDx : growing pain : at night leg pain and everything is normal
Ankle sprint :
Growth spurt + leg pain
Slipped capital femoral epiphysis : picture was given
Rheumatology
SLE :
If ANA negative = do uveitis screening after 6 months
If ANA positive = screen after 3 months
Kawasaki : clinical diagnosis , means that labs mainly are normal
Criteria : fever > 5 days + 4/5
1. Nin exudative conjunctivitis bilateral
2. Pleomorphic rash
3. Edema , change in skin erythema , desequmation
4. Adenopathy mainly cervical
5. Mucosal involvement : lesions, fissures , crusting
Management
IVIG high dose 2 gram (main stay treatment) and preventive for complication
Aspirin given for fever only symptomatic ( continued for 2 months)
Complications :
Coronary artery aneurysm assessed initially by echo , definitive ix : angio more sensitive
Prognosis :
Poor prognosis = high CRP
Immunology
DiGeorge : 22 q 11 deletion
Neonatal tetanus (hypocalcemia)+ recurrent infections
Immune compromised patient ( no thymus )+ facial malformation + recurrent tetany (low calcium)
Don’t Give LIVE Attenuated vaccines
Heart abnormality =, interrupted aortic arch  PDA  TOF ( in order)
ESR vs CRP :
ESR = autoimmune conditions , viral infections
CRP: inflammations , bacterial infections
Food allergy :
Swollen airways after food consumption -> allergy and anaphlytaxic shock
Dermatology
Lesions :
If 1*2 cm at forearm since birth = do nothing only follow up
lesion ‫مو مذكور اسم ال‬
Pediatrics Psychiatry
Tourrete syndrome :
Child cant understand at school + aggressive + abnormal movements
Tics : has 2 types :
Repetitive eye movement
Motor movement
Eating disorder :
Bulimia nervosa = dieting with BMI (18) or normal = ‫عارضات االزياء‬
Anorexia nervosa = BMI low < 18
Dissociation disorder :
Child after his mother death , cannot concentrate in lecture ‫الله يحفظ امي من كل سوء‬
Vaccination
DTap :
Contraindications : absolute = encephalopathy within one week of vaccination
School age vaccinations aim to prevent :
HiB encephalitis
Nutrition
Malnutrition :
Marasmus = every thing is low ( atrophy everywhere)
Kawsrkoff = low protein  hypoalbuminemia  edema + ascites + muscle wasting
Rickets :
Abnormal shaped legs + delayed walking :
Vitamin D resistant rickets : high ALP + high Calcium + normal phosphate
Familial hypophosphatemia : AR mode of inheritance high calcium + High phosphate + low ALP
Management of rickets = vit D3 *
Breast feeding :
Clostrum : High in protein
Cow milk feeding :
baby in the first 12 month( first 9 months was breast fed then the following 3 months formula) may
have iron deficiency = Give baby oral ferrous sulfate ( iron supplement can lead to black stool), if he
cant take orally IM iron
Presentation : hypochromic anemia + target cells + reticulocytes + splenomegaly?
‫الدكتور ذكر انه الطحال ممكن ينحس باالطفال بس مو تضخم بهذا العمر‬
Cow milk feeding leads to iron deficiency (other symptoms = pale +weight loss)
It is contraindicated to give cow milk below 1 year’
Mechanism of IDA in cow milk feeders :Mucosal injury  leads to microscopic GI blood loss
Electrolytes
Dehydration
Lung cancer + low serum osmolality + high urine osomality = give normal saline to relieve dehydration
But DDx”:SIADH = the patient will have low Na = the treatment will be different = fluid restriction
Neonatology
IODM COMPLICATIONS :
Single umbilical artery at birth : due to GDM gestational DM
Heart disease (TGA)
Breast feeding jaundice :
Neonate ( 9 days old ) + jaundice only at face otherwise completely normal = most common cause
breast feeding jaundice ( physiological jaundice ?)
Breast milk jaundice = there is an enzyme in the breast milk that prevents conjugation in the liver, so
the indirect bilirubin will increase( in this case they will mention n the question that there is high
bilirubin
IODM :
To know if the baby will be normal do HbA1c Preconception ( before pregnancy)
If HbA1c > 10 = it is contraindicated to be pregnant since it carry higher risks for congenital
abnormalities
IODM hypoglycemia :
Treatment is glucose but according to the percentage you will choose the delivary mode
If glucose < 10%  peripheral line
If glucose > 10%  central line
‫ يعني‬، ‫ تبدي معاه سكر جلوكوز بشويش‬، ‫الزبدة لمن تجي تعالج طفل امه عندها سكري و انولد وصار عنده مضاعفات هبوط بالسكر‬
central ‫ اذا ردت تزيد عنها الزم تركب للطفل‬، 03‫ جلوكوز بعدين ترفعه شوي شوي الى ان توصل حد ال‬% 5.2 ‫مثال نعطي‬
‫ ما ينفع تعطي تركيز عالي من الجلوكوز بالوريد كذا‬line
Constipation in neonate :
Duodenal atresia = within 1 day + recurrent bilious vomiting + double bubble signs
Midgut volvus : 4-5 days + no abnormaity at birth + passed meconium <48hr + abdominal distension +
vomiting + coffee bean sign
Pylroic stenosis : within 2 -3 weeks + non bilious vomiting + recurrent vomiting leads hypokalemic
hypochoromic metabolic alkalosis , diagnostic and next step : USS thickening in the wall and
enlongation
Hirshpurg : delayed passge of meconium >48hr + constipation on rectal exam = flush of stool , 1 st test
xray , best test rectal biopsy
Head swelling after birth :
Cephalhematoma : deepest in location + history of vacuum + doesnot cross sutures appears within 1
days and disappear after 2-3 weeks
Caput succedaneum : highest (most superficial (skin and peiostium) + crosses sutures + max at birth
and with 1-2 days resolve
Subgleial hemorrhage : between apneurosis and periosteal disaapear within weeks
Most severe idk ‫الصوت قطع‬
Premature complications :
Hypothermia = can lead to increase in premature mortality rate
Apnea of prematurity (immature respiratory center in the brain in <36 weeks of GA): SOB +respiratory
distress
Neonatal sepsis :any infection below 1 month is called sepsis
Most common presentation in neonatal sepsis = Poor feeding
1. meningitis
Most common cause (GEL) = GBS + Ecoli+ Listeria
After 3 months : streptococcus (gram positive coccus), nisseia (gram negative) , hemophilius
Gram positive bacilli = listeria monocytogene ( other micro features= catalase + beta hemolyticus)
Empiric ampicillin for listeria monocytogenes + 3rd generation : Ceftaxime or gentamycin
After 1 month : ceftriaxone and vancomycin
2.pneumonia = SOB + fever + tachypnea + prolonged expiratory phase + CXR: bilateral infilitration
symptoms

Weight loss :
In the 1st week of life ( baby weight loss from e.g. ( 3.5  3.1) despite good nutrition
Up to 10 % babies n 1st 10 days they will lose weight ( due to loss of extracellular fluid)
After 10 days he will start gaining weight again
Vaginal discharge in newborn = reassure the mother (due to change in estrogen level)
Newborn examination :
hearing and vision
Screening : hypothyroidism
Meconium aspiration pneumonia MAP :
Post term baby + RDS at birth+ green discoloration of face (meconoium stain)
Treatment = ABC  surfactant ( to treat chemical pneumonia)
Transient tachypnea of newborn :
Most common RDS in newborn
Delay resorption of fluids
Acute RDS in newborn :
Common cause = prematurity
CXR : ground glass appearance + air Broncho gram
Decrease surfactant
Trauma
Fall on head :
Bleeding from ear + TM bulging and bleeds + CT showed Basal skull fracture through foramen ovale
Sturtures will be affected are the ones who pass through foramen ovale
OVALE Mnemonic
O = otic ganglion
V = nerve V3 which is mandibular branch from trigeminal nerve = function to supply muscles of
mastication
A = accessory meningeal artery
L = lesser petrosal nerve
E = emissary veins

Head trauma during delivery in stylomastoid foramen = affects the facial nerve = can’t open or close
the eyes
Fall on head :
Indications for CT after head trauma :symptoms e.g. ‫تاكدوا منها‬
Vomiting
Loss of consciousness
Irritability / headache
GCS < 15 (14 if child is crying non stop
Basal skull fracture signs : rhinorrhea, battle signs , raccon eyes
--
If no symptoms = watchful waiting (close observation )
Supracondylar fracture :
If without pulse = exploration directly (ORIF)
Green stick fracture at distal forearm:
Very common in children because the bones are soft
Treatment = splint > cast ( I mean close reduction)
‫ نختاره عادي‬cast ‫ بالسوال نختاره اما اذا مافي بس جبيرة‬splint ‫اذا كان موجود‬
The splint will be for 4 weeks and no need to repeat xray after that
Spiral fracture of tibia :
‫ بس بما انه الفف فالكسر اجا على‬، ‫ بس القوة المطبقة على الرجل قوية فانكسرت الرجل‬، ‫ رجوله لفت‬، ‫طفل ماشي و عثر في شي‬
spiral ‫شكل‬
Child has his legs twisted then he fall down
Usually the child will resist walking and preferred to be carried always
Fracture distal forearm (distal radius + ulna)
If good blood supply distally = do cast ( below elbow) + closed reduction
If open wound ( penetrate skin) = internal fixation + below elbow cast
Fracture thigh :
If angulation < 40- 50 % = hip spica + traction
Hip spica can be used in less than 9 years
RTA + thoracic injuries :
Aortic thoracic injury + splenic abrasion + hypotension = this patient has hemorrhagic shock the cause
mainly from aortic thoracic injury > splenic abrasion
Since in splenic abrasion the patient will not bleed too much
So the best is to call thoracic surgeon
RTA : open fracture
Open wound treat with ABC  Debridement + irrigation  ORIF ( by nailing for example)
Deep wound in the thigh :
Stab wound in thigh + deep wound 10 cm = start with ABC + apply direct pressure
We don’t do tourniquet as we are afraid from ischemia
Splenic injury
Approach of management in splenic injury depends mainly on the hemodynamic status of the patient
Stable = non operative conservative
Unstable = depends = either angio / or to operative theater
The same applied to kidney injury
Radial nerve injury :
Unable to move the extensors of the arm and forearm
Erbs palsy :
IODM , high weight (macrosomia) = absent moro reflex unilateral
Knee trauma :
If the patient has knee swelling after trauma = 1st ly Xray
Pharmacology
Extrapyramidal symptoms:
Metoclopramide (antiemetic)  jerky movement
Patient take metoclopramide developed neck stiffness or abnormal movement of shoulder focal
dystonia
Akathesia (restlessness)
Usually with chronic intake , but even if the patient took it and he developed symptoms within 24 hr
Treatment of extraoyramidal (jerky movement )
Benztropne or Diphenhydramine (antihistamine )  if present in the question choose it ‫اكثر دقة‬
Domperidone (antiemetic ) ‫اقل دقة‬
AEDs of choice :
Generalized tonic clonic = CZP
Partial = phenytoin
Absent = euthusuxamide
Status epileptics = loarazepam 1st line
Absolute contraindication in penicillin allergy :
Tazocin (Pipercillin/Tazobactam)
Radiology
Thumb print sign = epiglottis or bowel ischemia
Medicine | Reproductive
Painful tender breast + milk secretion + prolactin high + decrease libido = MRI brain
Lung nodule :
Solitary lung nodule 2*3 cm = ask for old film
Pericarditis :
Pain increase on lying down
Auscultation : friction rub
Diffuse ST elevation
Treatment : NSAID , indomethacin / aspirin
Hypercalcemia crisis :
Old male + confusion + postural hypotension
Acute increase in calcium = neurological features
Treatment : IVF and diuretics
When to use hydrocortisone ?
Coma :
Whatever the cause start with ABC
So it the patient is in deep coma  mechanical ventilation  then give antidote regardless its type
Most important medication to be given after MI = beta blocker
Inferior MI
Hypotension + raised JVP = RV infarction
JVP increase if problem in right side problem
Heart failure due to hypertrophy :
Diastolic dysfunction ( cant fill)
S1 : closure of mitral and triscupid ( btw atria and ventricles)
S2 : closure of pulmonary and aortic

70 passive and 30 active ‫يبدي الدم يفضي و يعبي الفنتركيلز‬mitral and tricuspid ‫اول ما يفتح صمام ال‬
then the mitral and tricuspid will be closed
Aortic and pulmonary will be opened
، ‫لمن الدم ينضخ الدم من الفنريكلز بنفس وقت الضخ فيه االتريم قاعد يتعبى الدم‬
systole ‫بعد نهاية ال‬s2 ‫ ويطلعلنا صوت القلب الثاني‬aortic and pulmonary ‫ يتسكر ال‬systole ‫اللحين بس يخص الضخ‬
LVH = short diastolic phase = ‫الحجرة ضيقة ما تمديه انه يعبي‬
Supraventricular tachycardia :
regular Narrow complex + HR 250-300 +