Clinical Pediatric Notes

Clinical Pediatric Notes "All Team Production©"

General Pediatric History

2009 maternal age in down syndrom

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.

▪

All team "One Vision … One Mission" Mission" |

2


2009

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.

▪ ▪ ▪

▪

▪

All team "One Vision … One Mission" |

3


2009

Down Syndrome 1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ 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. 6. Perinatal History: ▪

Antenatal: Medical health during pregnancy. history: Previous abortion. Neonatal History.

▪ Natal ▪

7. Developmental History: "Very Important" 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" ▪ Weaning: Onset, Foods, Method & Amount . ▪ Supplements " Vitamins & Minerals ". 9. Vaccination History: Time of vaccines. 10. Past history: As general. 11. Family History: ▪ Maternal age. ▪ Consanguinity. ▪ Similar condition in the family.


4


Normal Newborn

2009

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

3. Personal History:  As usual, Age "actual date of birth, may be in hours – expected date of birth if baby looks premature"  Is baby one of twin?

3. Personal History:  The same.

4. Complaint: Coming for follow up.

Yellowish skin discoloration. ▪

5. Present History:

Onset: when the mother noticed the

jaundice. ▪

Color of urine and stools frequency of stooling. ▪ Refusing feed or vomit everything

No comment

"may be septicemia?" ▪

Abnormal movement "convulsions"

may be Kernicterus. 6. Perinatal History: ▪

Antenatal: Medical health during

pregnancy.  Infections (fever & rash).  Diabetes or toxemia of pregnancy.  Drugs or irradiation. ▪ Natal

history:  Duration of pregnancy.  Membranes rupture: how many

hours before delivery?  Delivery type ( VD – CS & Instruments).  Drugs (Sedation during labour).  Birth weight.  Birth Condition. Immediate cry – Resuscitation required – Need for incubation.

T H E S A M E

Neonatal history:  Cyanosis Convulsions.  Respiratory difficulties - Jaundice.

▪

–


5

Clinical Pediatric Notes "All Team Production©" T H E

8. Nutritional History: ▪ Type of feeding (breast or artificial)  Breast: frequency – Adequacy.  Formula: Amount per feed, Frequency & Concentration.

S A M E

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



2009

The Same 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.:  The onset of different types of jaundice:

 In physiological neonatal jaundice  2nd or 3rd Day of life.  In pathological neonatal jaundice "unconjugated hyperbilirubinemia"  in the 1st

Day of life.  In cholestasis "conjugated hyperbilirubinemia"  in the 10th Day of life.  In breast milk jaundice  in the 2nd day with discomfort after feeding.


6


2009

Rickets Yes

No

1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ Sex. ▪ Residence. 4. Complaint:  Delayed walking – Delayed dentition.  Chest infection "cough, wheezes or dyspnea". 5. Present History: ▪ Analysis of the complaint. ▪ Symptoms of the same system:

 Recurrent chest infections.  Recurrent diarrhea, Constipation or Anorexia.  Excessive sweating.  Exposure to sun light (housing condition).  Convulsions or carpo-pedal spasm.  Any observed bone deformities. ▪

Symptoms of the other systems:

 Hepatic or urinary problems. Medical attention:  Investigations, treatment "Vit. D injections"

▪

& hospitalization. 6. Perinatal History: ▪ Antenatal: ▪ Natal history:  Duration of pregnancy: history of prematurity or twins. ▪

Neonatal history.

7. Developmental History: ▪

Motor: Delayed walking

 Neck support – Sitting with support.  Sitting without support – Standing –Walking. ▪ Mental.


7


2009

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. ▪ Similar condition in the family.



For oral discussion "timing of the vaccines": Time

Vaccine BCG

In the first 3 months: 2 months: Polio Sabin (OPV) / DPT / HBV Polio Sabin (OPV) / DPT / HBV 4 months: 6 months: Polio Sabin (OPV) / DPT / HBV Measles 9-10 months: 15 months: MMR Polio Sabin (OPV) / DPT 18 months:


8


2009

Marasmus 1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ Sex. ▪ Residence. 4. Complaint:  Loss of weight or failure to gain weight.  Chest infection "cough, wheezes or dyspnea".  Gastroenteritis "diarrhea and vomiting". 5. Present history ▪ Analysis of the complaint. ▪ Symptoms of the same system:

 Recurrent chest infections.  Recurrent diarrhea or Persistent vomiting.  Symptoms of malabsorption: bulky offensive.  Symptoms of hunger: continuous cry, scanty stools & anxiety . ▪


 Hepatic or Urinary problems or Cardiac. ▪

Medical attention:

 Investigations, treatment & hospitalization.

6. Perinatal History: ▪ Antenatal. ▪ Natal history:  Duration of pregnancy: history of prematurity or twins. ▪ Neonatal history. 7. Developmental History: may be delayed ▪




9


2009

8. Nutritional History: "Very Important" Type of feeding "breast or artificial"  Scanty breast milk – Formula feeding "Diluted or

▪

decreased frequency ". ▪

Weaning: Improper weaning.

▪


No. 9. Vaccination History. 10. Past History. 11. Family History: ▪ Consanguinity. ▪ Similar condition in the family. ▪ Family history of TB.


10


2009

Kwashiorkor 1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ Sex. ▪ Residence. 4. Complaint:  Swelling of lower limbs "may be the dorsum of the foot only".  Chest infection "cough, wheezes or dyspnea".  Gastroenteritis "Diarrhea & Vomiting". 5. Present History: ▪

Analysis of the complaint: edema ….

▪

Symptoms of the same system:

 Recurrent chest infections.  Recurrent diarrhea or Persistent vomiting. ▪


 Hepatic or Renal or Cardiac ( to exclude

other causes of edema). ▪

Medical attention:  Investigations, treatment & hospitalization.

6. Perinatal History: ▪ Antenatal. ▪ Natal history:  Duration of pregnancy: history of prematurity or twins – New brother (maternal

deprivation ). ▪ Neonatal

history.

7. Developmental History: may be delayed ▪



8. Nutritional History: "Very Important" Type of feeding "breast or artificial"  Scanty breast milk – Formula feeding "Diluted or

▪

decreased frequency ".


11

Clinical Pediatric Notes "All Team Production©" ▪

2009

Weaning: Sudden weaning and with

carbohydrate foods only. ▪


No. 9. Vaccination History. 10. Past History. 11. Family History: ▪ Consanguinity. ▪ Similar condition in the family.


12


2009

Congenital Heart Disease VSD - FALLOT 1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ Sex. ▪ Residence. 4. Complaint:  Shortness of breath.  Bluish discoloration of skin and mucous membranes.  Chest infection "cough". 5. Present History: ▪ Analysis of the complaint. ▪ Symptoms of the same system:

 Lung congestion:  Difficult breathing or suckling.  Failure to weight gain.  Recurrent chest infections: cough & dyspnea.

 Rt. side failure: Puffy eyelids, lower limbs edema .  Low cardiac output: Peripheral coldness, sweating.  Others: Cyanosis, Cyanotic spells, Squatting, Fever & Palpitation. ▪


 Neurological symptoms; Syncope & Stroke. ▪

Medical attention:

 Investigations "ECHO, ECG & X– ray", treatment "digitalis,

diuretics" & hospitalization. 6. Perinatal History: ▪


▪

Natal history: Previous abortion. Neonatal history.

▪

7. Developmental History: ▪ Motor. ▪ Mental.


13


2009

8. Nutritional History: ▪ Type of feeding "breast or artificial" ▪ Weaning: Onset, Foods, Method & Amount . ▪ Supplements: " Vitamins & Minerals". 9. Vaccination History: Time of vaccines. 10. Past History. 11. Family History: ▪ Maternal age. ▪ Consanguinity. ▪ Similar condition in the family.


14


2009

Rheumatic Heart Sheet 1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History. 4. Complaint:  Shortness of breath ± Painful joint swelling. 5. Present History: ▪ Analysis of the complaint. ▪

Symptoms of the same system: cardiac

symptoms.

 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.  Right side heart failure "3": 

Edema: lower limb.



Pain: on the right hypochondrium .

 GIT congestion: e.g. vomiting.


15


2009

 Others "3":  Palpitation: related to exertion .  Chest pain ( pericarditis ).  Complications: Infective endocarditis

(fever, strokes) & Rheumatic activity (arthritis). ▪ ▪

Symptoms of the other systems. Medical attention:

 Investigations " ECHO, ECG & X– ray", treatment

"digitalis, diuretics, hospitalization.

long acting penicillin" &

6. Perinatal History. 7. Developmental History. 8. Nutritional History. 9. Vaccination History. 10. Past History:  Recurrent tonsillitis – Any previous activity. 11. Family History: ▪ Similar condition in the family.


16


Cerebral Palsy

2009

Hydrocephalus

1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ Sex. ▪ Residence. 4. Complaint:  Developmental delay – Convulsions. 5. Present History: ▪ Analysis of the complaint. ▪ Symptoms of the same system:

 Head enlargement.  Onset of head enlargement.

 Convulsions.  Dysphagia and nasal regurge ( pseudo bulbar palsy ).  History of fever, convulsions, or admission to fever hospital (CNS infections ). Symptoms of the other systems: ▪ Medical attention:  Investigations & treatment "physiotherapy". ▪

T H E S A M E



 Infections (fever & rash).  Diabetes or toxemia of pregnancy.  Drugs or irradiation. ▪ Natal history:  Duration of pregnancy.  Delivery type (VD – CS & Instruments).  Drugs (Sedation during labour).  Birth weight.  Birth Condition.

Immediate cry – Resuscitation required – Need for incubation.

T H E S A M E

Neonatal history:  Cyanosis Convulsions.  Respiratory difficulties - Jaundice.

▪

–


17

Clinical Pediatric Notes "All Team Production©" 7. Developmental History: ▪ Motor:  Neck support – Sitting with support.  Sitting without support – Standing –Walking. ▪ Mental:  Social smile – Maternal recognition – Speech.

2009 T H E S A M E

8. Nutritional History: in short. 9. Vaccination History: Time of vaccines. 10. Past History: ▪

Significant events: Trauma, Surgery &

The Same

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

The Same


18


2009

Nephrosis 1. Welcome the patient. 2. Introduce yourself to the patient. 3. Personal History: ▪ Name: full name. ▪ Age & Date of birth. ▪ 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…. ▪

Symptoms of the same system:

 Urinary symptoms "change in the amount or in the color ".  Headache "hypertension ".  Symptoms of complications:  Chest infection: fever, dyspnea.  Skin infection.  Abdominal: Pain, Vomiting &

Diarrhea. ▪


 Hepatic or Cardiac ( to exclude other

causes of edema).  Rash, Arthritis ( with lupus). ▪

Medical attention:

 Investigations,

treatment or ( steroids immunosuppressive: start of therapy and the response) & hospitalization.

6. Perinatal History: ▪ Antenatal. ▪ Natal history. ▪ Neonatal history. 7. Developmental History.


19


2009

8. Nutritional History:  To exclude nutritional edema.

9. Vaccination History. 10. Past History: ▪ Previous

attacks: relapses.

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

 N.B:

To exclude hypovolemic shock.

 Blood pressure & Temp. measurements are must in nephritic syndrome. To exclude infections.


20


2009

Abdominal 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:  Abdominal distention, Hematemesis.  Jaundice, Abdominal pain. 5. Present History: ▪ Analysis of the complaint. ▪ Symptoms of the same system:

 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.  Abdominal pain: Site of pain, Severity, Nature, Relation to meal – radiation, What increase & What decrease.  Blood disease:  Leukemia: Prolonged fever, Arthralgia or arthritis, Purpuric eruptions

& Any swellings (lymph nodes ).  Chronic hemolytic anemia: Pallor & History of repeated blood transfusion.  General toxemic symptoms: Night fever, Night sweat, Anorexia & Loss of weight.  Lower GIT: Diarrhea " frequency, consistency, volume & color " – Constipation.  Upper GIT: Vomiting, Dysphagia, Dyspepsia & Flatulence. Symptoms of the other systems. ▪ Medical attention:  Investigations, treatment & hospitalization. ▪


21


2009



▪ Natal ▪

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

7. Developmental History. 8. Nutritional History. 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. ▪ Family history of chronic hemolytic anemia. ▪ Family history of liver disease.


22


2009

Source:  Notes of Prof. Dr Mustafa Zakaria.


23


2009

 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.

 Neonatal gynecomastia:  What is the diagnosis of this condition?

 Neonatal gynecomastia: breast enlargement in both sexes during the first weeks of life due to transplacental passage of maternal hormones.  What is the treatment?  No thing except reassurance and - It should not be squeezed .

 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.


24


2009

 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.

 Moro reflex  It is the most common neonatal primitive reflex.  How can you elicit?  Dropping the head with the examiner’s hand supporting the body,  Making a loud noise near the infant’s 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 - Erb’s palsy .  Persistence of the reflex beyond 6 months  Cerebral palsy.

 Cephalhematoma:  What is the diagnosis of this condition? 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.  What is the treatment?  Conservative.  Aspiration is contraindicated.


25


2009

 Erb's palsy:  What is the diagnosis of this condition?  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.

 Facial palsy:  What is the diagnosis of this condition?

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.

 What is the etiology of this condition?  Compression of facial nerve by pressure from forceps blades but may occur after normal delivery.  What is the treatment?  Physiotherapy.  What is the prognosis?  Good, most cases resolve within a few weeks after birth.


26


2009

 Umbilical granuloma:

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

 Infant of diabetic mother:  What is the diagnosis of this condition?  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.

 Congenital hypothyroidism:  What is the diagnosis of this condition?  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.


27


2009

 Hydropes fetalis:  What is the diagnosis of this condition?  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 antiD immunoglobulin.  What is the treatment of this condition?  Exchange transfusion & Ventilatory support.

 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.

 Necrotizing enterocloitis:

 What is the etiology of this condition?  It is common in preterm infant.  It is due to ischemia of the bowel wall and infecting organism.  May be accelerated by early feeding. 

What is the treatment of this condition?  Stop oral feeding & give antibiotics.


28


2009

 Inguinal hernia & umbilical hernia:

 What is the diagnosis of this condition?  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.

 Imperforate anus  What is the diagnosis of this condition?  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.


29


2009

 Hypospadias:  What is the diagnosis of this condition?  Hypospadias: the urethral orifice is situated on the ventral aspect of the penis at a site proximal to the normal opening.  What is the treatment of this condition?  What to advise the parents?  Circumcision should be delayed until corrective surgery is done, as the prepuce may be needed for urethroplasty.

 Cleft lip & palate:

 What is the diagnosis of this condition?  Cleft lip & palate (1, 2) - Cleft lip (3).  What are the complications of this condition?  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.


30


2009

 Tongue tie:  What is the diagnosis of this condition?  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 .

 Talipes equinovarus (Club foot):

 What is the diagnosis of this condition?  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 ".  What is the treatment of this condition? 

Splinting , but surgical release may be needed.

 Microcephaly:  What is the diagnosis of this condition?  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.


31


2009

 Meningomyelocele:

 What is the diagnosis of this condition (1, 2)?  Meningomyelocele.  How to diagnose the condition antenatally?  Ultrasound examination

it is a neural tube defect .

 What are the complications of this condition?  Hydrocephalus occurs in most of the cases, Infections & Paraparesis.  What is the treatment of this condition?  First aid includes covering by sterile dressing and neurosurgical referral.

 Oral moniliasis:

 What is the diagnosis of this condition?  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.  What is the treatment of this condition?  Treatment is by topical nystatin or miconazole .


32


2009

 Perineal moniliasis:

 What is the diagnosis of this condition?  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.

 Neonatal conjunctivitis:

 What is the diagnosis of this condition?  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.


33


2009

 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.  What are the complications of this condition?  Respiratory: bronchitis, bronchiolitis and pneumonia.  Neurological: encephalitis, subscute sclerosing pan encephalitis.  What is the treatment of this condition?  Symptomatic i.e. antipyretics for the high fever.

 Roseola infantum:

 What is the type of rash shown?  Maculopapular rash.  Enumerate 3 possible causes?

 As above.

 What is the treatment of this condition?

 As above.


34


2009

 Scarlet fever:

 What is the diagnosis of this condition?  Scarlet fever: infection by group A β-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

 Impetigo contagiosa:  What is the diagnosis of this condition?  Impetigo contagiosa.  What is the etiology of this condition?  Infection by gram positive cocci e.g. staphylococcus aureus.  What is the treatment of this condition?  Local fucidenic acid cream.  Extensive lesions should be treated with systemic flucloxacillin.


35


2009

 Chickenpox:

 What is the type of rash shown?  Papulovesicular rash.  What is the most possible cause?  Varicella: successive crops, is centripetal in distribution and pleomorphic .  What are the possible complications?  Secondary bacterial infection of lesions and pneumonia.  Neurological problems e.g. acute cerebellar ataxia .

 Urticaria:  What is the diagnosis of this condition?  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.  What are the possible complications?  Laryngeal edema and airway obstruction.  What is the treatment of this condition?  Subcutaneous adrenaline and systemic steroids.

 Purpura:  What is the diagnosis of this condition?  Purpura for differential diagnosis.  What are the possible causes? "Causes of purpura"  ITP, Aplastic anemia & L eukemia.


36


2009

 Henoch-Schonlein purpura:

 What is the diagnosis of this condition?  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.  What is the prognosis?  Most cases recover within few weeks.

 Purpura fulminans:

 What is the diagnosis of this condition?  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.  What is the prognosis? 

High mortality rate and intensive care management is urgently needed.


37


2009

 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".  What is the treatment?  Avoiding irritants, topical mild steroids & creams.

 Scabies:  What is the etiology?  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.  What is the treatment?  Permethrin cream 5%.

 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.  What is the treatment of this condition?  Anti inflammatory drugs and steroids.


38


2009

 Hemophilia:  What is the etiology of this condition?  Genetic disease X-linked recessive.  What are the clinical features?  Bleeding, large hematoma "Muscle Hematoma", easy bruising & hemoarthrosis.  What is the treatment of this condition?  Fresh frozen plasma & factor VIII concentrate.

 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


39


2009

 Dehydration:  What is the diagnosis of this condition?  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).

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

 Rickets:

Rossary beads

Genu valgum

Genu varum


40


2009

 Kwashiorkor:  What is the diagnosis of this condition?  Kwashiorkor.  What is the etiology?  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.  What are the possible complications?  Serious infections.  Gastroenteritis and electrolyte disturbances.  Hypoglycemia & hypothermia.


41


2009

Source:  Notes of Prof. Dr Mohamed El-Nagger.


42


2009

comment 1) Type of CT " written on the slide":  Plain CT.  Contrast enhanced CT.

2) Level of the cut:  Supra ventricular  falx celebri  Ventricular.  Posterior fossa level " Infratentorial level".

3) Lesion:  Nature:

 Hyper or Hypo dense lesion.  Ventricular "dilatation or compression".  Site of the lesion "i.e.: left frontal lobe, right parietal lobe …"

4) Final diagnosis.

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:  Hyperdense lesion:  Cerebral calcification : no mass effect (compression) - mirror image .  Intracranial hemorrhage: mass effect - it may be intracerberal , intraventricular , subdural or extradural .  Hypodense lesion:

 Cerebral infarction.  Hemorrhagic infarction : mixed hypodense and hyperdense areas.  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 .


43


  

  

  

  

2009

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Dilated bodies of lateral ventricle.

Plain CT scan of head. Ventricular level " horns of lateral ventricle & 3rd ventricle". Dilated horns of lateral ventricle.

Plain CT scan of head. Ventricular level " horns of lateral ventricle & 3rd ventricle". Dilated 3rd ventricle.

Plain CT scan of head. 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"


44


  

  

  

  

2009

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Dilated bodies of lateral ventricle.

Plain CT scan of head. Ventricular level " horns of lateral ventricles & 3 rd ventricle". Dilated horns of lateral ventricle.

Plain CT scan of head. Ventricular level " horns of lateral ventricle & 3rd ventricle". Dilated 3rd ventricle.

Plain CT scan of head. 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.


45


  

2009

Plain CT scan of head. Supra ventricular level. Increased prominence of:  Cerebral sulci,  Inter hemispheric fissure &  Subarachinoid space "reduced cerebral mass

 prominent

CSF

spaces".

Brain atrophy

  

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Increased prominence of:  Cerebral sulci,  Inter hemispheric fissure &  Ventricular system "passive dilatation due to reduced cerebral mass".

Brain atrophy


46


  

2009

Plain CT scan of head. Supratentorial level. Diffuse cerebral hypo density with loss of grey-white interface – loss of all supra ventricular spaces " sulci & CSF spaces".

Brain edema "loss CSF spaces"

  

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"


47


  

2009

Plain CT scan of head. Supra ventricular level. Hyper dense lesion " diffuse, small dots", scattered all over the cortical tissue.

Punctuate calcification " congenital toxoplasmosis"

  

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

Periventricular calcifications "cytomegalic inclusion disease"

  

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

Supra sellar calcification " calcified cranio-pharyngioma"

  

Plain CT scan of head. Ventricular level " lateral ventricular horns & 3rd ventricle". Hyper dense lesion " bilatera l, symmetric", at the basal ganglia region.

Basal Ganglia calcification " hypoparathyroidism"


48


  

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Hyper dense lesion in the left frontopraietal lesion with mass effects compression of left lateral ventricle.

2009



Intracerebral hematoma   

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Hyper dense area affecting both lateral ventricles with ventricular dilatation.

Intraventricular hemorrhage   



Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Hyper dense concavo-convex lesion, affecting left fronto-parietal region with mass effect "compression of lateral ventricle".

Associated intracelebral hematoma "The arrow".

Subdural hematoma   



Plain CT scan of head. Ventricular level " bodies of latera l ventricle". 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".

Epidural hematoma


49


  

2009

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". 2 hypo dense localized areas in the right occipital region and left parietal region.

Localized infarction

  

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Hypo dense extensive lesion in left parieto-occipital region.

Extensive infarction

 

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".



 

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".



Hemorrhagic infarction


50


  

  

2009

Plain CT scan of head. Ventricular level " bodies of latera l ventricle". Big hypo dense area in right parietal region compressing the right lateral ventricle.

Contrast enhanced CT for the same patient. Ventricular level " bodies of latera l ventricle". Big hypo dense area with ring enhancement of abscess capsule in the right parietal region compressing the right lateral ventricle.

Big single brain abscess in the right parietal area

  

Contrast enhanced CT. Ventricular level " bodies of latera l ventricle". Small hypo dense area with ring enhancement of abscess capsule in the left frontoparietal region.

Small brain abscess

  

Contrast enhanced CT. Supra ventricular level. 2 small hypo dense areas with ring enhancement of abscess capsule in left parieto - occipital region.

Multiple brain abscesses


51


  

2009

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

Cerebellar astrocytoma

  

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

Medulloblastoma   

Contrast enhanced CT. Ventricular level " lateral ventricular horns & 3rd ventricle". Hyper dense " rounded, midline" lesion, in pineal body region.

Pinealoma

  

Contrast enhanced CT. Ventricular level " lateral ventricular horns & 3rd ventricle". Hyper dense large lesion, in the left occipital horn with dialed lateral ventricle.

Choroid plexus papilloma


52


  

2009

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

Acquired obstructive hydrocephalus due to intra ventricular hemorrhage

 

Ventricular level " bodies of latera l ventricle". Dilated lateral ventricle due to ventriculitis " enhancement of epindymal lining of ventricle ".

Acquired obstructive hydrocephalus due to ventriculitis

  



Contrast enhanced CT. Infra ventricular level " posterior fossa & 4th ventricle". Hyper dense "midline, rounded" lesion, in the posterior fossa compressing the 4th ventricle.

The same patient but at higher level " 3rd ventricle and horns of lateral ventricles" showing ventricular dilatation.

Acquired obstructive hydrocephalus due to Medulloblastoma Cranial and extra cranial lesions


53


2009

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 "


54


2009

Sources:  Notes of Prof. Dr Mustafa Zakaria & Lectures of Prof. Dr El-Belidy.


55


(A)

2009

(B)

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

 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.


56


(A)

2009

(B)

(C) Plain X-ray chest. Postero-anterior view. The Patient is not well centralized. Costophrenic angles are free on both sides. Cardio-thoracic ratio increased about 70% in (A), 60 % in (B, C) denoting cardiomegaly. Cardiophrenic angle on the left side is not visualized in (A) – obtuse in (B, C) denoting left ventricle dilatation.  Prominent pulmonary conus " pulmonary artery dilatation".      

 Bulging right cardiac border "right atrium dilatation".  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.


57


2009

Plain X-ray chest. Postero-anterior view. The Patient is not well centralized. Costophrenic angles are free on both sides. Cardio-thoracic ratio increased about 70%.  Cardiophrenic angle on the left side is acute " right ventricle dilatation".  Shelfing of the left cardiac border.  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.


58


2009

Pneumopericardium

     

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

Isolated Dextrocardia  Abnormal position of the heart  the heart lies mainly to the

Rt. Side.  The Lt. Cardiac border "made of LV "  is to Rt.; The Rt. cardiac border "made by RA"  is to left.  Mild cardiomegaly.  The liver shadow and gastric bubbles are in normal position.

Dextrocardia with Situs Inversus  Abnormal position of the heart the heart lies mainly to the

Rt. Side.  The Lt. Cardiac border "made of LV "  is to the Rt.; while the Rt. cardiac border "made by RA"  is to the left.  The liver shadow is in the left side while gastric bubbles are in the RT side.


59


(A)        

2009

(B)

Plain X-ray chest. Postero-anterior view. The Patient is well centralized. Costophrenic angles are free on both sides. Cardiophrenic angle is acute "may appear obtuse". Marked increase in the cardio-thoracic ratio about 85 % in (A) , 90% in (B) denoting huge cardiomegaly. Symmetrical bulge of the left and right cardiac borders. The borders are very well defined " stenciled".

 Broad cardiac base "accumulation of fluid".  Normal pulmonary vascular markings.

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


60


(A)

2009

(B)

(C) Plain X-ray chest. Postero-anterior view. The Patient is not centralized. Costophrenic angles are free on both sides. Cardio-thoracic ratio increased about 70%.  Cardiophrenic angle on the left side is acute " right ventricle dilatation". dilatation".     

" right atrium dilatation".  Marked bulge of the right border "right dilatation".  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. " lung plethora",  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 " pneumonia". ".

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


61


2009

Coeur en sabot: tetralogy of Fallot??

Plain X-ray chest. Postero-anterior view. The patient is not centralized. Costophrenic angles are free on both sides. Cardio-thoracic ratio is normal or mildly increased. " Rt. ventricle hypertrophy".  Cardiophrenic angle on the left side is acute with uplifted apex "Rt. hypertrophy ".     

" pulmonary hypoplasia ". hyp oplasia".  Exaggerated waist " pulmonary " lung oligemia".  Decreased pulmonary vascular markings "lung oligemia".

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

   

Cardio-thorathic ratio increased 70 %  cardiomegaly . The heart is globular in shape. The Lt. cardio-phrenic angel is acute  RV dilatation . Pulmonary vasculature slightly increased.


62


:

lain X-ray.

:

ostero-anterior view.

:

atient is centralized.

:

rachea.

: Costophrenic

2009

ngle on

the same side of the the lesion. :

esion.

 3 Groups of lesions:   

 

 

Pleural effusion "massive or moderate ". Lung collapse "total or lobar collapse ". Lobar pneumonia.

Hydro or pyopneumothorax. pyopneumothorax. Lung abscess "in association with pneumonia or effusion or both".

Pneumothorax. Emphysema "congenital lobar ".".


63


2009

Plain X-ray chest. Postero-anterior view. The patient is centralized. The right costophrenic angle is obliterated by homogenous opacity occupying also all the right hemithorax.  Shifting the mediastinum "the tracheal air column and heart" to the opposite side of the    

lesion "left side".

Right side massive pleural effusion


64


     

2009

Plain X ray chest and heart. Postero-anterior view. The Patient is centralized. Costophrenic A ngles are free on both sides. There is heterogeneous opacity "triangular in shape" on the apical part of the right lung. Central mediastinum " T racheal air column and heart".

Rt. upper lobe pneumonia

Plain X-ray chest and heart. Postero-anterior view. The Patient is centralized. Costophrenic A ngles are free on both sides. There is heterogeneous opacity on the upper part of the right lung corresponding to the infraclavicular area.  Central mediastinum "tracheal air column and heart".     

Rt. upper lobe pneumonia


65


(A)

2009

(B)

Plain X-ray chest. Postero-anterior view. The Patient is centralized. There is homogenous opacity occupying all the "left hemithorax in A "; "the right hemithorax in B".  The mediastinum "heart & tracheal air column" is shifted to the same side of the lesion.    

(A) Left side massive lung collapse

     

(B) Rt. side massive lung collapse

Plain X-ray chest. Postero-anterior view. The Patient is centralized. There is homogenous opacity occupying the upper third of the right lung. The heart and tracheal air column are shifted to the same side of the lesion " right side". Marked hilar congestion of the left lung.

Rt. upper lobe collapse


66


2009

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

Left side pyopneumothorax "or hydropneumothorax"

Plain X-ray chest. Postero-anterior view. The Patient is centralized. The right costophrenic A ngle is obliterated by homogenous opacity with upper border rising to the axilla " mild pleural effusion".  Heterogeneous opacity in the middle zone of right lung " pneumonia".  Mild shifting of the tracheal air column and heart to the opposite side of the lesion "left side".    

Rt. side pneumonia complicated by right side pleural effusion


67


(A)

2009

(B)

Plain X-ray chest. Postero-anterior view. The Patient is centralized. Costophrenic Angle on the right side it is obliterated by homogenous opacity raising to the axilla " pleural effusion".  The middle and lower zone of the right lung show a cavity with well-defined thick outline (abscess wall).  The lower part of the lesion is homogenous with transverse upper border " fluid" while    

the upper part of the lesion is jet black "air".  In (A) there is also heterogeneous opacity on the lower lung third " pneumonia".  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


68

Clinical Pediatric Notes "All Team Production©"    

2009

Plain X-ray chest. Postero-anterior view. The Patient is centralized. Costophrenic A ngle on the right side it is obliterated by homogenous opacity

raising to the axilla " pleural effusion".  The middle and lower zone of the right lung show a cavity with thick well-defined outline " abscess wall".  The lower part of the lesion is homogenous with transverse upper border " fluid" while the upper part of the lesion is jet black "air ".  There is also heterogeneous opacity on the lower lung third " pneumonia" with multiple

thin wall cyst " pneumatoceles "  The heart and tracheal air column are central.

Rt. side lung abscess, Rt. side pneumonia with pneumatoceles & Rt. side mild pleural effusion Most probably due to staph or Klebsiella pneumonia

Plain X-ray chest. Postero-anterior view. The Patient is centralized. Costophrenic A ngle on both sides is free.  The middle and lower lung zones of the left lung show heterogeneous opacity with multiple "airspace surrounded by    

thin wall" pneumatoceles .

Left side pneumonia with pneumatocele The cause is most probably staphylococcal or Klebsiella pneumonia


69


   

2009

Plain X-ray chest. Postero-anterior view. The Patient is centralized. Costophrenic angle on the right side is obliterated by homogenous opacity with upper

border rising to the axilla " pleural effusion".  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


70


(A)

2009

(B)

 Plain X-ray chest and abdomen; Postero-anterior

view.  The Patient is centralized.  The right hemithorax shows hypertranslucency with absent bronchovascular markings " jet-black": pneumothorax.  The right lung appears as homogenous opacity shifted against the vertebral column "compression collapse".  Intercostal tube is seen draining the pneumothorax " present in A & B"  The left lung shows homogenous opacity, which may be the original disease "RDS" or may be lung collapse.  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


71


2009

 Plain X-ray chest and abdomen; Postero-anterior

view.  The patient is centralized.  Costophrenic angles are free on both sides.  Lt. Lung: is hypertranslucent , voluminous with diminished bronchovascular markings and wide intercostals spaces. "lobar emphysema"  The upper part of the left lung herniates through the superior mediastinum.  Rt. lung: The upper part shows heterogeneous

opacity " pneumonia", while its lower part is hypertranslucent "compensatory emphysema".  The heart shadow appears small, and shifted with the tracheal air column to the right side.

Left congenital lobar emphysema & Rt. lung consolidation

 X-ray with contrast : barium meal, enema and follow through.  Postero-anterior view.  The patient is not centralized.  Herniated barium filled intestinal loops in the right hemithorax.  Shift of the heart and tracheal air column to the left side. (opposite side of the lesion )

Rt. side diaphragmatic hernia


72


(A)    

2009

(B)

Plain X-ray chest and abdomen Postero-anterior view (A, B). The patient is centralized. Costophrenic angles are free on both sides. The left hemithorax shows heterogeneous opacities present in the lower part simulating pneumonia, intermingled with multiple radiolucent cystic shadows simulating pneumatocele "herniated intestinal loops".

 The heart and tracheal air column are shifted to the opposite side of the lesion "right side".

Left side congenital diaphragmatic hernia  Lateral view (B) : intestinal loops appear in the retrosternal space pushing the heart

backward.


73


(A)     

(B)

2009

(C)

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

 Plain X-ray of the chest and abdomen

upright position.  Patient not centralized.  There are 2 large areas with air fluid levels "double bubble sign".

 X-ray of the abdomen with barium meal.  Markedly dilated stomach full of barium.  Fine elongated pyloric canal seen as a single line of barium

"String sign".  The pyloric tumor appears a rounded radiolucent shadow surrounding the narrow pyloric canal.


74


2009

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

 Plain X-ray chest and abdomen upright

position.  Free air "hypertranslucent area) in the peritoneal space under the diaphragm above the liver.  The abdomen is distended with gasses in (B).

( A)

(B)

 Plain X ray of the lower limbs "ankle and knee joints".  Wide joint space.  Cupping of the metaphyseal area with frayed

epiphyseal line.  Decreased bone density.  Bowing deformity of the tibia and fibula.


75


2009

Sources:  Dr Tamer Abdel Hamid.  Round Exams Questions.


76


2009

 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 e.

children in the outpatient clinic.

( )

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.

3.

He should be referred urgently to the hospital.

( )

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.

( )


77


2009

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 & manage ment: 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.

( )


78


2009

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.

( )


79


2009

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 s hould 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.

( )


80


2009

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 & doesn’t deserve treatment. ( )

20. A 12 months old child with cough, he is conside red 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 38.8 c & 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.


( ) ( ( ( (

81

) ) ) )


2009

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 38 C. 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.

( )


82


2009

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 39 C 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 38.5 C 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.

( )


83


2009

30. A 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 examinatio n he has sunken eyes e yes 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 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 33. A 12 month old baby with fever, fe ver, diarrhea and vomiting 2 days ago, he had a history hi story 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 34. An 11 month mont h old baby with history of running nose, cough and sore s ore 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. ( )


84


2009

35. A 35. A four f our years ye ars child with ear discharge & fever for last 3 days, there is no ea r pain. pai n. 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 36. An eight months old child c hild 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 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 38. A 8 months old ol d child with severe seve re diarrhea diarr hea & vomiting since yesterday, yeste rday, she can't keep kee p 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 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.

( )


85


2009

40. A 40. A 14 months child complaining of fever 38.5 C, runny nose & sore throat for 2 days, associated with earache & ear discharge for 5 days; On examination, no abnormality was detected. According to IMCI: 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 41. A male child aged 12 months his mother bring him to the hospital complaining of cough, difficult breathing & high fever 39 C, 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 42. A female aged 15 months, month s, her mother bring he r 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.

( )


86


a. b. c. d. e.

    

a. b. c. d. e.

    

2009

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. 

a. b. c. d.

   

a.  b.  c.  d. 

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. 

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. 

a.  b.  c.  d.  e. 

a.  b.  c.  d.  e. 


87


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.

a.  b.  c.  d.  e. 

a. b. c. d. e.

    

a.  b.  c.  d. 

a.  b.  c.  d. 

a.  b.  c.  d. 

a. b. c. d.

a.  b.  c.  d. 

a.  b.  c.  d. 

a.  b.  c.  d. 

a.  b.  c.  d. 

a.  b.  c.  d. 

a. b. c. d. e.

    

2009


88


2009

Source:  Clinical Course Lectures.


89


2009

Breast Feeding



 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.

(

)

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.

(

)

2- Attachment:


90


2009

Sources:  Notes of Prof. Dr Mustafa Zakaria.  Clinical Course Lectures.


91


2009

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.  How to Comment

The child is conscious, with good cry " he might be asleep " & activity. He looks ……

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 ".

N.B: if the child can't stand "CP" → he is measured as length not height.  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.

 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.


92


2009

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.  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. ♥

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.


93


2009

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.  1½ year  closed .

 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".

 




94

Clinical Pediatric Notes "All Team Production©" ♥

2009

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 ".


95


2009

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.


96


2009

Combined Inspection & Palpation:

  Precordial bulge "or no precordial bulge ", scars or dilated veins.

  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.

 Rheumatic heart: on the 6th 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.

 Aortic areas: 1st aortic area  2nd Rt. Space & the 2 nd aortic area  3 rd Lt. space.  Pulmonary area: "2nd left space"  Rheumatic heart: There is pulsation on the pulmonary area  pulmonary hypertension and dilatation.  VSD: There is pulsation on the pulmonary area.  Fallot: systolic thrill.

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

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


97


2009

Auscultation:

 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.

 



Murmurs " VSD": ♥

Site: 3rd and 4th 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.

♥

Ejection systolic murmurs heard at the pulmonary area.

♥

Normal other area.



Percussion:  Obsolete.


98


2009

Inspection:   Normally : flat abdomen with concavity at the flanks.  Abnormally:  Localized bulge localize its site.  Generalized abdominal distention with fullness in flanks  Scaphoid abdomen  in dehydration. →

 e.g.:

Ascites.

  Normally: freely mobile with respiration .  Abnormally: restriction of mobility  e.g. peritonitis, very tense ascites.

  By putting your thumbs on both costal margins "over the last ribs".  Normally: Acute angel "70-90 degrees".  Abnormally: Obtuse angel  organomegaly, ascites.

  If the child is cooperative, ask him to stop breathing.  Pulsations are seen & felt. "Look tangential"  Causes of the pulsations:  Rt. ventricular enlargement.  Liver pulsations.  Aortic pulsations.

  Cause: chronic increase in the intra-abdominal pressure

 organomegaly,

ascites.

 ♥

Site:  Normally: midway between xiphesternum & symphysis pubis .  Abnormally: shifted upwards or downwards .

♥

♥

Shape:  Normally: inverted.  Abnormally: everted  umbilical hernia . Impulse on cough:  Normally: no impulse on cough .  Abnormally: impulse on cough seen & felt  hernia.


99

Clinical Pediatric Notes

Recommend Documents