Clinical Pediatrics MsMMaM
Content
Clinical Pediatrics
Clinical Pediatrics How to examine 4t IC space just outside MCL if
I- Cardiology cases:
A. Combined inspection and palpation: palpation:
< 4 years old
1. inspect around the 4 /5 intercostal spaces, look for pulsations of apex [normally 5th IC space 2. Inspect other 4 areas for pulsations. if >4 years old 3. put your Rt hand at the site of apex (where u can see pulsations if possible), confirm place detected by inspection, (don’t forget to count IC spaces with your Lt hand) try to localize it with one finger (or if less than 2 cm, if more than 2 cm, it is diffuse) comment on character and thrill felt: normal character with no detected thrill Hyper dynamic character اﻳﺪك ﻓﻰ ﺟﺎﻣﺪ ﺑﺘﺨﺒﻂ Slapping character: in Mitral stenosis (very rare in children) 4. put your Rt hand on the left Parasternal area to detect thrill (use roots of fingers) and pulsations ( use your hand just below the wrist joint) 5. put your hand on pulmonary and aortic areas to detect thrill (roots of fingers) th
th
and pulsations (with your finger tips) 6. Put your hand at epigastric area; try to detect origin of pulsations From RT side: enlarged Lt Ventricle. From left side: liver due to RT sided Heart Failure. Centered: aortic origin, normal.
B. Auscultation:
7. Auscultation: auscultate apex, left Parasternal, pulmonary and aortic areas.
N.B.; during examination, always use your left hand to Count ribs to know the numbers of spaces, or On RT carotid for pulsations (systole/S1 is concomitant with pulse).
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Clinical Pediatrics Inspection & palpation: a. Precordial bulge: b. Apex:
MR: systolic thrill MS: diastolic thrill
MS: slapping MR & AR: hyperdynam ic c. Parasternal area: d. Pulmonary area: e. Epigastric area:
Percussion:
Auscultation: a. S2 (pulmonary area) b. Murmurs:
R ule: use cone and diaphragm in examination of all areas. Rule: if you hear murmur at apex, move towards axilla, if its propagating towards axilla, it is mitral regurge.
Rheumatic
VSD
Fallot
Present (only if u can see it)
Not present (mild Rt ventricular enlargement)
Site: shifted down & out
S: shifted down & out
S: in place th (4 IC just outside midclavicular line if < 4 th & 5 IC if > 4 years old.)
Area: localized Character: h hy yper dynamic Thrill: no Pulsations: present Thrill: No Pulsations: yes Thrill: no Palpable S2: yes Pulsations: yes Thrill: -- Dullness on pulmonary area (pul. Artery dilatation) Dullness to the RT of the sternum.
Present (only if u can see it)
Accentuated S2
Mitral regurge: Site: apex + muffled S1 Area of propagation: axilla Character: soft Timing: pan systolic Mitral stenosis: S: apex + accentuated S1 A: apex C: rumbling T: mid diastolic Aortic regurge: S: 3rd left A: apex C: soft (decrescendo) T: early diastolic (decrescendo) Pulmonary hypertension: hypertension: S: 2nd left A: C: soft T: ejection systole So, you may hear murmurs at apex/pulmonary/aortic apex/pulmonar y/aortic area. Parasternal and epigastric are free
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A: localized C: T: No P: present T: yes P: yes T: no P: yes P: no T: ---
A: localized C: T: No P: +/- present T: No P: no T: yes in 50% P: no P: no T: ---
---
---
Accentuated S2
VSD: S: 3rd, 3rd, 4th Left eft Parasternal spaces A: all precordium C: harsh T: pan systolic
No
Tetralogy of Fallot: S: 2nd left left IC spa space ce A: C: T: e jection systolic
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Clinical Pediatrics
Mitral regurge= muffled S1 + rumbling mid diastolic murmur at apex. Mitral stenosis= accentuated S1 + soft pan systolic murmur at apex propagating to axilla. nd rd Aortic regurge= soft early diastolic murmur at 2 aortic space (3 Left intercostals) propagating to apex. nd Pulmonary artery dilatation= pulsations pulsations felt in 2 left space, palpable S2, accentuate accentuated d S2, soft ejection systolic murmur. VSD Fallot Rheumatic Muffled S1 + soft pansystolic murmur propagating to axilla,or Apex:
free
Parasternal:
Thrill + pulsations
Pulmonary
Pulsations
Accentuated S1 + rumbling mid diastolic murmur, or Free
free
+/- mild pulsations (mild Rt vent hypertrophy) 50% with thrill Ejection systolic murmur
Aortic
Free
Free
epigastric
free
Free
Free Accentuated S2+Soft ejection systolic murmur Free, OR, Soft early diastolic murmur propagating to apex. Free
II- Neurological cases: 1)
Exposure, notice any Abnormal movement normal/wasting/hypertrophy y (compare Rt to Lt side) 2) State: normal/wasting/hypertroph 3) Power: use a needle/pinch the child, if the child moves paresis
P.S. power examination needs a cooperative patient: extension and flexion at every joint passively and against resistance. So instead, apply a painful stimulus. If you are performing knee flexion against resistance, you are testing the power of the extensor. Degree of power: i. No movement at all. ii. Horizontal movement ﺗﺮاﺑﻴﺰة ﻋﻠﻰ اﻳﺪك ﺁﻒ ﺣﺮك iii. Movement against gravity. iv. I, ii, and iii + can carry an object.
4)
Tone:
Shaking method in 4
Hypertonia: hand and forearm Move as one unit
limbs (wrists &ankles
Hypotonia: very loose movement
Passive flexion &extension of all joints 5) Reflexes:
Rules: exposure - positioning
a) Superficial reflexes: i. Plantar/Babinski reflex:
Scratching the outer aspect of the sole of the foot. +ve response dorsiflexion + fanning (it normally disappears at 1 year).
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Clinical Pediatrics
ii.
Abdominal re reflex:
Move a blunt object( ﻗﻠﻢ\ﻣﻔ ﺎح )ﻏﻄﺎon the patient's abdomen starting at flanks towards the umbilicus. +ve response shift of umbilicus outwards, then it returns.
b) Deep reflexes: Hyperreflexia (compare Rt to Lt side) +/- clonus
Response
Where to
Knee Quadriceps contraction (front of thigh) Tendon Below knee joint (between tibial
hit
tuberosity patella, detect with your finger)
Position of the patient
Knee angle: 90 degrees
ankle Calf muscles contraction +dorsiflexion ank le Tendon Achilles Put your hand below the knee or at the thigh raising the patient's leg above the table Knee angle: 120 degrees Ankle angle: 90 degrees
biceps Biceps contraction (flexion elbow)
Triceps Triceps contraction (extension elbow)
Put your finger on the biceps tendon
Hit on triceps aponeurosis above
and hit on your finger
the back of the elbow joint.
Elbow angle: 120 degrees
Elbow angle: 90 degrees
Raise the hammer to the same height in both Rt and Lt sides to avoid a stronger hit on one side than the other, as this may cause inaccurate results. Move your wrist when you are using the hammer ()ﻳﻨﺰل ﺑﺘﻘﻠﻪ How to detect clonus: i. ii. iii. iv.
Hold the thigh, raising thigh and legs off the table Let the foot be in plantar flexion (its position in passive state) Do sudden maintained dorsiflexion Res onse: Re ular rh thmic mo movement of th the foot.
c) Neonatal reflexes: abnormally persistent E.g. Moros reflex:
Loud noise at patient's ear Dropping the head, with the examiner's hand supporting the body Sudden withdrawal of blankets from underneath the patient. +ve response: extension and abduction followed by flexion and adduction of upper limbs. Fingers are widely opened. This is followed by a cry. Significance: Persistence beyond 6 months indicates CP/mental retardation retardation.. 6)
Sensation: if the patient can speak, ask him if he can feel. 4
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Clinical Pediatrics
7) Cranial nerves: a) Pseudo-bulbar palsy; (9, 10) is the commonest:
Weak muscles of palate & pharynx
Chocking can not be feeded solid food
Exaggerated reflexes of palate & pharynx
Dysphagia Nasal regurge (as palate shuts nose during drinking) Gag reflex: with a tongue depressor
b) Others: 1 st: olfactory nerve: use coffee, every opening separately ﺎﻣ وﻩﻮ ﺣﺎﺟﺔ ﻓﻰ ﺑﻴﺨﺒﻂ 2 nd : optic nerve: see if the patient can follow the torch/ ask if the patient ﺷﻰ rd th th 3 , 4 & 6 : occulomotor, trochlear and abducent nerves: Move torch/pen at 6 cardinal directions and check the patient's eye direction. If affected squint 5 th: trigeminal nerve: JAW REFLEX The mandible is tapped at a downward angle just below the lips at the chin while the mouth is held slightly open. Normally this reflex is absent or very slight. However in individuals with upper motor neuron lesions the jaw jerk reflex can be quite pronounced.
7 th: facial nerve: ﺳﻨﺎﻧ ورﻳﻨﻰ, ﻋﻨﻴ زر ﻋﻠﻰ, ﺻﻔ,اﻧﻔﺦ If the patient is not cooperative, tell the examiner that facial expressions mean intact facial nerve e.g.: crying. 8 th: vestibulocochlear nerve glossopharyngea al nerve: gag reflex (palate and pharynx sensation) 9 th: glossopharynge 10th: vagal nerve: ask patient to say 'aaah', check uvula mobility with a tongue depressor. 11th: accessory nerve: ask patient to turn face against resistance (sternomastoid) Ask patient to elevate shoulders (trapezius) 1 2 : hypoglossal : ask patient to protrude his tongue tongue will deviate towards paralyzed side. th
III- Abdominal cases:
A. Inspection: ascites/organomegaly 1) Shape: bulging flanks: ascites/organomegaly &contour Generalized distension: ascites 2) Skin:
stretched +\- striae
Umbilicus : site: normal is midway between xiphsternum & symphysis pubis. Shape: everted in increased intra abdominal pressure Skin overlying: healthy/pigmented/dilated healthy/pigmented/dilated veins/ulcers Impulse on cough: present in cases of hernia. Scars: site Length Healing: 1ry intention if thin scar, 2ry intention if thick/corrugate thick/corrugated. d.
3) Subcutaneous tissue: dilated (visible) veins in case of portal hypertension. hypertension.
4) Muscle: divarication of recti ﺑﻮﺳﻄﻪ ﻳﻬﻢ ﻟﻠﻤﺮﻳﺾ ﻗﻮل
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Clinical Pediatrics 5) Bone: sub costal angle: normally acute, gets wider in cases of prolonged distension. 6) Organs: localized bulge indicates organomegaly E.g. fullness in left hypochondrium: splenomega splenomegaly. ly.
B. Palpation: 1) Superficial palpation: to detect tenderness, tenderness, rigidity and superficial masses.
Start at right iliac fossa. Move your hand in the 9 quadrants in an S – shaped manner. Use the gentle sliding technique.
Don’t forget to look at the the face of the patient to detect tender tenderness. ness. 2) Deep palpation: to detect organ enlargement. Knee of the patient should be hemi-flexed, to relax abdominal muscle wall. Start from the RT iliac fossa and proceed upwards to palpate RT lobe of the liver. Start from below the umbilicus upwards to palpate the Lt Lobe of the liver. Start in the RT iliac fossa & towards the left hypochondrium to palpate spleen. (Try to insinuate your fingers between it and costal margin, to prove it is spleen) If the patient is relatively old, ask him to take a deep breath while palpating. DONT DONT roll your your hands. When you can feel the lower border of liver/spleen, measure the distance between it and the costal margin. N.B. shrunken liver can't be palpated. 3) Bimanual examination: the patient is on his back. Put your hand on the patient's back below the last rib, try to palpate the kidney. Kidneys are normally felt in thin individuals and in neonates. If there's a swelling and I want to know if the origin was the kidney, perform anterior pallotment. Anterior pallotment: Put your left hand under the back of the patient, and the right hand on the swelling, and press with your right hand. If you can feel the swelling with your left hand, then the origin of swelling is from the kidney. C.
Percussion: (wrist movement) nd 1) For upper border of liver: start percussion at the 2 right intercostal space.
Normally dullness of the upper border of the liver is heard at the 5th IC
space, ask the patient to take a deep breath and hold it, percuss again, resonance is heard (as the lung occupied this space and moved liver slightly downwards. This This is done to differentiate between dullne dullness ss of upper border of liver and lung fibrosis.) In case of cirrhosis (shrunken liver), dullness appears in the 6 th IC space. 2) For ascites: mild: knee chest position (NEVER done) Moderate amount: shifting dullness. Huge amount: transmitted thrill (most probably veno-occlusive disease.)
Shifting dullness: Start from epigastric region till you reach dullness that represents the upper border of the bladder. (Mark it to percuss above it)
Start from epigastric region till umbilicus. Then to the RT of the umbilicus. Then to the LT of the umbilicus. When you find dullness, fix your hand there and ask the patient to turn his body to the other side, percuss again, if you find resonance, this is called shifting dullness. (It happens because while the patient is on his
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Clinical Pediatrics back, moderate amount of fluid is present in flanks, so when you ask the patient to move to the other side, the fluid is displaced and resonance is heard in a previously dull flank.)
Transmitted thrill: Ask the patient to put his hand in the mid line. ﻟﺘﺤﺖ وﻳﺪوس ﺁﻮﻳﺲ ﻳﻀﻌﻬﺎ (To make sure thrill is transmitted only through ascetic fluid, not through anterior abdominal wall muscles) ﻟﻠﻌﻴﺎ اﻟﺸﻤﺎل اﻟﺠﻨﺐ ﻋﻠﻰ ﻣﻮﺟﻮدة اﻟﻠﻰ اﻟﺸﻤﺎل اﻳﺪك ﻓﻰ ﺑﺘﺨﺒﻂ ﺑﺤﺎﺟﺔ ﺗﺤﺲ,اﻟﻴﻤﻴﻦ اﻟﺠﻨﺐ ﻓﻰ ﺑﺼﺒﺎﻋﻚ اﺧﺒﻂ D.
auscultation : intestinal sounds Venous hum: Para umbilical vein is midway between sternum and umbilicus.
IV- General examination: a. vital signs:
Pulse rate is … beats per minute, beats are regular, with no special character, volume is average, and equal in both sides ( examine both sides same time). Temperatur Temperaturee is … (axillary's + 0.5) Blood pressure is …/… Respiratory rate is …
b. Measurements Head circumference is … How to measure head circumference: make sure you place the meter correctly, on the supraorbital ridge (2cm above eye brows) & on the occipital protuberance. Height is … How to measure height: If < 4 years old: supine make the patient take off the shoes. If > 4 years old: standing: Patients heals are adjacent to the wall Feet close to each other Body adjacent to the wall Head neither flexed nor extended Put a book above patients head. Measure Weight is …
c. Head Skull: box shaped, wide anterior fontanelle/mongoloid fontanelle/mongoloid features/cephalhem cephalhematoma/ atoma/ forceps marks. Hair: Hair is light in color, sparse/silky. eyelid/sunken/lateral /lateral upward slope. Eye: subconjunctival hge/ jaundice/ puffy eyelid/sunken Cheek: loss of subcutaneous subcutaneous fat/moon face/butterfly rash of SLE. Mouth: pallor in lips/cyanosis in tongue/teeth extraction/ tonsillitis/angular stomatitis/moniliasis/delayed dentition/small/protruded stomatitis/moniliasis/delayed dentition/small/protruded tongue. Ear lobules: underdeveloped, over folded helix, small external ear. Anxious look.
d. Neck: Carotid arteries show no exaggerated pulsations, they are equally felt on both sides with no special characters or thrill/there is exaggerated carotid pulsations with/with out associated thrill. Neck veins are not congested shows systolic collapse/ neck veins are congested reaching … cm with patient seated at 45 degrees position. Trachea is centralized, thyroid is normal, LNS are not felt. Short and broad/Buffalo hump
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Clinical Pediatrics e. Upper limbs: There is/ is no clubbing, pallor, splinter hge, oslar nodules. Broadening, convexity Short, Simian crease, clinodactyly. f. Lower limbs: Dorsalis pedis arteries are equally felt in both sides. There is/is no lower limb edema, clubbing. Wrinkled/ulc Wrinkled/ulcerated/fissure erated/fissured d skin, wasted muscles, prominent bones. Broadening, Knock knees, knees, bow leg, Marfan sign. st
Short, broad, wide gap between 1 and 2nd toes.
g. Trunk: kyphosis/lordosis/skin is lemon yellow (unconjugated bilirubin)/umbilica bilirubin)/umbilicall sepsis/scrotal edema.
Cardiology sheet
Rheumatic heart disease:
Personal history: A … year old, male/female patient, named … … …, living at … [Age should be 5 – 15 years old.]
Complaint: Dyspnea/cough/sy Dyspnea/cough/syncope/palpitation ncope/palpitation…etc …etc [cardiac symptoms] / Arthritis Present Onset,history: Course, Duration of complaint
Then you've to comment on: The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/station ary/regressive course. It is/isn't related to exertion like suckling/crying. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal nocturnal dypnea. The patient has/doesn't have cough, which started … … ago with acute/gradual onset, progressive/ stationary/regressive stationary/regr essive course. It is/isn't related to exertion. It isn’t/is productive, sputum is of large/ average/little amount, whitish/yellowish/… color, offensive odor/odorless, and viscid/watery consistency. There is/is no history of hemoptysis, {syncope {syncope,, fatigue, coldness of extremities}, {RT hypochondrial pain, vomiting, recurrent chest infections}, {palpitation that is/isn’t related to exertion, chest pain, fever, chorea, embolic manifestations as hemiplegia}, cyanosis. Patient does not have/has edema that started … … ago with acute/gradual onset, progressive/ stationary/ regressive course. It started first at the lower limbs/abdomen …etc, …etc, it is pitting. Patient gave history of arthritis that started … … ago with acute/gradual onset, progressive/ stationary/
regressive course. It affected large/small joints, without/with fleeting fleeting character as it started first in the Rt/Lt/both, knee/hip/…etc knee/hip/…etc joint(s). It was relieved after … days with salicylates/ … weeks spontaneously. Rt/Lt, knee/hip/… joint was affected later. It is/isn't associated with tenderness, hotness, swelling, limitation of movement. +/- It left the joint free. Review of other systems revealed no abnormality. Patient attended … hospital, where chest x-ray/echocar x-ray/echocardiography/… diography/… were done with no available results. He/she received medications in the form of tablets/injections. Patient attended/was attended/was admitted to Abu el reesh hospital … ago where chest x-ray/echocardiography/… x-ray/echocardiography/… were done with no available results. He/she is receiving medicatio medications ns in the form of tablets/injections.
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
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Clinical Pediatrics 2. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Developmental history: Developmental 1. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development development..
2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed mental mental development.
Nutritional history: The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th th feeding, the child sleeps denoting satisfaction. Weaning was started on the 4 /6 month with …,… then …&…, the child does not receive/receives supplements in the form of vitamins, minerals.
Vaccination history: nd
th
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule.
Past history:
There is past history of recurrent recurrent attacks of tonsillitis. There is/is no history of previous attacks of rheumatic fever. The patient is on long acting penicillin/ the patient does not take any drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, exanthemas, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. the father is … years old, with good health/health problems problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: Examinatio n: (positive findings) A. general: a. vital signs: Pulse: Water hammer character and large volume in case of aortic regurge. Temperatu Temperature: re: fever in infective endocarditis. Blood pressure: Big pulse pressure = systole/diastole in case of aortic regurge. Respiratory rate: tachypnea in chest infection
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Clinical Pediatrics b. Head Eye: subconjunctival hge/ jaundice/ puffy eyelid Cheek: butterfly rash of SLE Mouth: pallor in lips/cyanosis in tongue/teeth extraction/ tonsillitis. c. Neck: Carotid arteries show no exaggerated pulsations, they are equally felt on both sides with no special characters or thrill/there is exaggerated carotid pulsations with/with out associated thrill. Neck veins are not congested shows systolic collapse/ neck veins are congested reaching … cm with patient seated at 45 degrees position.
d. Upper limbs: There is/ is no clubbing, pallor, splinter hge, oslar nodules. e. Lower limbs: Dorsalis pedis arteries are equally felt in both sides. There is/is no lower limb edema, clubbing. Trachea is centralized, thyroid is normal, LNS are not felt.
B. Systems examination: a. Heart: i. Combined inspection and palpation: If apex is deviated outwards & downwards, localized, hyper dynamic = Lt ventricular
ii.
enlargement. If apex is deviated outwards, diffuse, with Lt parasternal & epigastric pulstations = Rt ventricular enlargement. enlargement. nd If there is pulsations in 2 Lt space = pulmonary artery
Auscultation: Apex: Muffled S1 + soft pan systolic murmur propagating to axilla = Mitral regurge Accentuate Accentuated d S1 + rumbling localized mid diastolic murmur = Mitral stenosis Parasternal area: free Pulmonary area: Free Accentuate Accentuated d S2 + Soft ejection systolic murmur = pulmonary hypertension. Aortic area: Free Soft early diastolic murmur propagating to apex (decrescendo) = aortic regurge. Epigastric area: free
Diagnosis: A case of chronic rheumatic heart disease with mitral regurge/aortic regurge/aortic regurge/double mitral, +/pulmonary hypertension - biventricular enlargement - pulmonary artery dilatation. The heart is compensated compensated by ttt. The case is not complicated/is complicated with chest infection.
Some hints: Mitral regurge
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Clinical Pediatrics
Mitral stenosis:
Aortic regurge:
RT ventricular enlargement enlargement causes pulsations in Parasternal area. When it enlarges massively, iitt also causes pulsations in epigastric area due to the pressure applied on the diaphragm from the massive dilatation. Dypnea:
Orthopnea: when the child sleeps, venous return congestion leading to cough. Paroxysmal nocturnal dypnea: dypnea: by dawn (at the end of the night), vagal tone venous return from mesentery and lower limbs pulmonary congestion. Cough: is due to congestion that leads to irritation of the mucosa. Hemoptysis: is due to rupture of small alveoli. Rarely present. Plethora: active passage of blood to lungs, l ungs, while Congestion: passive passage of blood to lungs.
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Clinical Pediatrics Cardiac Out Put = Heart Rate * Stroke Volume. In myocarditits: SV (due to Inflammation) COP. So, in a trial for compensation, HR palpitation, tachycardia. [I.e. COP = HR * SV.] Myocarditis: leads to heart failure. st Endocarditis + pressure in left ventricle = valvular damage 1 : mitral regurge Then: mitral stenosis (needs months) Aortic stenosis: needs 7 – 10 years, children will have become adults and seek internists. Pericarditis: auscultation: rub Precordial pain: patient may not be able to describe it . ﻣﺘﻀﺎﻳﻖ\ﺑﺎﻧﻬ أﻧﺎ ﺣﻴﻘﻮﻟﻚ Peripheral signs of aortic regurge: Head and neck: prominent carotid pulsations, suprasternal pulsations, head nodding [concomitant with pulse.] Upper limbs: capillary pulsations [press gently at tip of fingernail, pulsations appear], water hammer pulse [pulse felt at middle of anterior aspect of forearm when its raised], increased pulse pressure. Lower limbs: pistol shot, duroieziez sign [systolic and diastolic murmur over femoral artery], Hill sign [blood pressure in lower limbs is 50 mmHg higher than UL, normally its 20 mmHg]. Pistol shots: femoral artery midway between ASIS and pubic tubercle (roughly mid thigh), .thrill زى ﺣﺎﺟﺔ ﺗﺴﻤﻊ اﻟﺒﻨﻄﻠﻮن ﻋﻠﻰ ﻟﻮ أو, ﺑﺘﺨﺒ واﻟﺴﻤﺎﻋﺔ ﻳﻌﺪى اﻟﺪم ﺻﻮت ﺗﺴﻤﻊ,اﻟﺴﻤﺎﻋﺔ ﺿﻊ In exam: Mitral regurge +/- aortic regurge [ from neck and water hammer pulse] +/- Mitral stenosis [ﺗﺎش ﺗﻚ ]ﺗﻚ
In exam, you'll find history of dypnea, cough, and recurrent tonsillitis. But you will never find history of syncope, edema and no Rt hypochondrial pain. You will find arthritis (3/4 patients), carditis. But you will not see erythema (lasts only for a few days), subcutaneous nodules or chorea.
VSD Personal history: A … year old, male/female patient, named … … …, living at … [Age: mostly an infant]
Complaint: difficulty feeding/failure to grow/difficulty breathing/recurr breathing/recurrent ent chest infection. [due to congestion] Present history:
Onset, Course, Duration of complaint Then you've to comment on: The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/station ary/regressive course. It is/isn't related to exertion like suckling/crying. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal nocturnal dypnea. The patient has/doesn't have cough, which started … … ago with acute/gradual onset, progressive/ stationary/regressive stationary/regr essive course. It is/isn't related to exertion. It isn’t/is productive, sputum is of large/ average/little amount, whitish/yellowish/… color, offensive odor/odorless, and viscid/watery consistency. There is/is no history of hemoptysis, {syncope {syncope,, fatigue, coldness of extremities}, {Rt hypochondrial pain, vomiting, recurrent chest infections}, {palpitation that is/isn’t related to exertion, chest pain, fever }, cyanosis. Patient does not have/has oedema that started … … ago with acute/gradual onset, progressive/ stationary/ regressive course. It started first at the lower limbs/abdomen …etc, …etc, it is pitting. There is/is no history of failure to grow. Review of other systems revealed no abnormality.
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Clinical Pediatrics Patient attended … hospital, where chest x-ray/echocar x-ray/echocardiography/… diography/… were done with no available results. He/she received medications in the form of tablets/injections. Patient attended/was attended/was admitted to Abu el reesh hospital … ago where chest x-ray/echocardiography/… x-ray/echocardiography/… were done with no available results. He/she is receiving medicatio medications ns in the form of tablets/injections.
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
2. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Developmental history: Developmental 3. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development.
4. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed normal/delayed mental development.
Nutritional history: The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th th feeding, the child sleeps denoting satisfaction. Weaning was started on the 4 /6 month with …,… then …&…, the child does not receive/receives supplements in the form of vitamins, minerals.
Vaccination history: nd
th
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule.
Past history: There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
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Clinical Pediatrics
Examination: (positive findings) Examination: A. general: a. vital signs:
Respiratory rate: tachypnea in chest infection
b. Measurements Weight is … [usually underweight due to non-nutritional marasmus, so check thighs &buttocks]
B. Systems examination: a. Heart: i. Combined inspection and palpation: If apex is deviated outwards and downwards, localized, hyper dynamic = Lt ventricular enlargement. If apex is deviated outwards, diffuse, with left parasternal and epigastric pulstations = Rt ventricular enlargement. Biventricular dilatation: dilatation: normal is small VSD (apex is shifted downwards and outwards, rd th with pulsations in 3 ,4 Lt Parasternal spaces) th
In VSD cases, apex is usually localized, in 5 space. Shifted downwards and outwards . Parasternal area: thrill during systole [detected by other hand on carotid] Pulmonary area: Always in this order Palpable S2 = pulmonary hypertension Pulsations = pulmonary dilatation Aortic area: Free Epigastric area: free
ii.
Auscultation: Apex: free Parasternal area:
Site Propagation
Murmur
rd
th
3 , 4 intercostals spaces at Parasternal line
All over precordium
Character
Harsh
Timing Pan systolic
+/Pulsations
S1
S2
Due to shift of apex outwards, if shift epigastric pulsations
Pulmonary area: Accentuated S2 (pulmonary component) [valve ﺑﻴﺘﺮزع due to high pressure] Aortic area: Free Epigastric area: free b. Chest: if there is bronchitis, medium sized crepitations crepitations and wheezes scattered on both lung fields by auscultation.
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Clinical Pediatrics
Diagnosis: A case of congenital acyanotic heart disease in the form of VSD with biventricular enlargement &pulmonary hypertension hypertension – compensated heart – not complicated/complicated complicated/com plicated by chest infection.
Some hints:
Thrill at 3rd, 4th Parasternal spaces Passage of blood through the VSD causes
thth Thrill atat3rd ,4 Murmur 3rd , 4 Parasternal Parasternalspaces spaces
Cardiac out ut
Load on
Congestion
RT heart side
Respiratory rate (compensation) ﻴﺸﺮ ﻟﻮﻟﺪ ﺘﺮﺿﻌﻪ ﻟﺴﺔ ﻷم و
Liver
RT hypochondrial pain
Lung
Infection
GIT
Vomiting
Pressure = flow* resistance Pulmonary hypertension = flow * resistance [reflex vasospasm] Pulsations in epigastric area - which are due to massive enlargement of Rt ventricle (to the extent of eisenmingerss syndrome/shunt reversal i.e. cyanotic patient who was not previously cyanotic) causing shift of eisenminger apex that applies pressure in diaphragm during pulsations – do not occur in VSD cases due to medical care and follow up.
Tetralogy of fallot Personal history: A … year old, male/female patient, named … … …, living at … Complaint: cyanosis at rest/during exertion Present history:
أﻣﺘﻰ أزرق ﺳﺎﻋﺎت ﺟﺎﻣﺪ ﺑﻴﺰرق ﺑﻴﻘﺮﻓﺺ
Onset, Course, Duration of complaint [onset usually 3-4 months months after birth, ne never ver at birth due to pa patent tent ductus arteriosus] Then you've to comment on: The patient does not suffer /suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/station ary/regressive course. It is/isn't related to exertion like suckling/crying. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal nocturnal dypnea.
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Clinical Pediatrics The patient sometimes suffers from hypercyanotic spells. The patient sometimes takes the squatting position. The patient has/doesn't have cough, which started … … ago with acute/gradual onset, progressive/ stationary/regressive stationary/regr essive course. It is/isn't related to exertion. It isn’t/is productive, sputum is of large/ average/little amount, whitish/yellowish/… color, offensive odor/odorless, and viscid/watery consistency. There is/is no history of hemoptysis, {syncope {syncope,, fatigue, coldness of extremities}, {Rt hypochondrial pain, vomiting, recurrent chest infections}, {palpitation that is/isn’t related to exertion, chest pain, fever }, cyanosis. Patient does not have/has oedema that started … … ago with acute/gradual onset, progressive/ stationary/ regressive course. It started first at the lower limbs/abdomen …etc, …etc, it is pitting. There is/is no history of failure to grow. Review of other systems revealed no abnormality. Patient attended … hospital, where chest x-ray/echocar x-ray/echocardiography/… diography/… were done with no available results. He/she received medications in the form of tablets/injections. Patient attended/was attended/was admitted to Abu el reesh hospital … ago where chest x-ray/echocardiography/… x-ray/echocardiography/… were done with no available results. He/she is receiving medicatio medications ns in the form of tablets/injections.
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
2. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Developmental history: Developmental 5. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development.
6. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed normal/delayed mental development. development.
Nutritional history: The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th th feeding, the child sleeps denoting satisfaction. Weaning was started on the 4 /6 month with …,… then …&…, the child does not receive/receives supplements in the form of vitamins, minerals.
Vaccination history:
nd
th
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about about the rest of the vaccination schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take
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Clinical Pediatrics any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: A. general: a. Measurements
Weight: usually underweight due to non-nutritional marasmus, so check thighs &buttocks
b. Head Mouth: cyanosis in tongue/ pallor in lips. c. Upper limbs: There is/ is no clubbing. d. Lower limbs: There is/is no clubbing.
B. Systems examination: a. Heart: i. Combined inspection and palpation: Apex: localized, 4th/5th space [always normal normal due to mild mild Rt ventricular ventricular enlargement]. enlargement]. Parasternal area: +/ - mild pulsations Pulmonary area: 50% of cases with thrill [depends on degree of stenosis]. Aortic area: free Epigastric area: free iii. Auscultation: Apex: free Parasternal area: Pulmonary area:
Murmur
nd
Site
2 left space
Character
Soft
Timing
Ejection systolic
S1
S2
ﺻﻮت ﺁﺧﺮ و ﺻﻮت أول أﻣﻴﺰ ﻗﺎدر
Aortic area: Free Epigastric area: free
Diagnosis: A case of congenital cyanotic heart disease in the form of tetralogy of fallot. No cardiomegaly or heart failure.
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Clinical Pediatrics
Some hints:
In F4, why there is no heart failure? Because there are no symptoms/signs of heart failure.
diagnosis
Rheumatic fever
Causal
Chronic rheumatic heart disease
Anatomical: Ventricular Valvular Pulmonary artery
functional
complications
Biventricular. Mitral regurge, aortic regurge, mitral stenosis. Pulmonary hypertension and dilatation.
compensated compensated Usually no/endocarditis/chest no/endocarditis/chest infection/activity Arthritis
Carditis Chorea
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VSD Acyanotic congenital heart disease
Fallot Cyanotic congenital heart disease
Biventricular. ----
No cardiomegaly ----
Pulmonary hypertension.
----
compensated compensated
No heart failure (rare)
+/- chest infection
----
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Clinical Pediatrics
Neurology sheets Cerebral palsy Personal history: A … year old, male/female patient, named … … …, living at … Complaint: delayed developmental motor and mental milestones/convulsions/chest milestones/convulsions/chest infection. Present Onset,history: Course, Duration of complaint
It is/isn't associated with convulsions, blindness, Para paresis, aspiration, dysphagia. Then try to determine the cause of brain insult:
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
2. natal history: The duration of pregnancy was … weeks, it was terminated by CS/normal vaginal delivery/
obstructed/prolonged delivery, with/without sedation. At birth, the condition of the baby was normal/ the obstructed/prolonged baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history:
During the neonatal period, there is/ is no history of fever, convulsions, admission to fever hospital [meningitis] , cyanosis, jaundice, respiratory difficulties, bleeding.
Developmental history: Developmental 1. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development development..
2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed mental mental development.
Nutritional history: The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th
th
feeding, child denoting satisfaction. wasof started on the 4 /6 month with …,… then …&…, the childthe does not sleeps receive/receives supplementsWeaning in the form vitamins, minerals.
Vaccination history: nd
th
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
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Clinical Pediatrics
Family history:
There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family. The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. the father is … years old, with good health/health problems problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from …
Examination: A. general: a. Measurements
Head circumference is … [microcepha [microcephalic lic with early closure of fontanelle] Weight is … [maybe undernourished] undernourished]
B. Systems examination: Neurological: State: disuse atrophy Power: paralysis/paresis (hemiplegia, diplegia, quadriplegia) Tone: spasticity +\- scissoring Abnormal movements: chorea or asthetosis. Reflexes; Hyperreflexia – ankle clonus. +ve plantar reflex. Lost abdominal reflexes. Persistent neonatal reflexes. Sensation: preserved. Cranial nerves: UMNL in motor nerves. Pseudo-bulbar is commonest. (check neuro examination)
Diagnosis: A case of cerebral palsy post hypoxic, quadriplegic, spastic with chest infection.
Some hints:
How to know CP at first sight: microcephaly, abnormal position (scissoring/spasticity). Commonest scenario of CP: delayed motor, mental development + convulsions – quadripar quadriparesis esis (movement without useful function) – due to hypoxia (bleeding/ CS/ cyanosis/ delayed cry at birth)
perform a movement, group of muscles are required to act. To If all of them are not functioning paralysis If only some are not functioning paresis. Paresis: there is still some movement, but the affected part can not be used in a function i.e. used only when needed, like with the application of a painful stimulus. Bulbar = medulla Pseudobulbar: as if nuclei in medulla are the ones affected, but actually motor area 4 or the pyramidal tract are the ones affected (lesion is in a higher level). Sensation: is not affected as it is represented by a large area in the brain. Unlike motor area 4. Kerni = basal ganglia Antigravity muscles: adductors, pronators, biceps and calf muscles. Scissoring: because tone in adductors is than tone in abductors.
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Clinical Pediatrics
Hydrocephalus Personal history: A … year old, male/female patient, named … … …, living at … Complaint: progressive head enlargement usually since birth Present history:
Onset, Course [progressive], Duration of complaint It is/isn't associated with convulsions, blindness, Para paresis, swelling in the back Then try to determine the cause of hydrocephalus:
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. There was/was no contact with cats [toxoplasmosis]. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered suffer/suffe red from diabetes, toxemia of pregnancy.
2. natal history: The duration of pregnancy was … weeks, it was terminated by CS/normal vaginal delivery/trau delivery/traumatic matic
(complicated/obstructed) delivery, with/without (complicated/obstructed) with/without sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imm immediately/immediately ediately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history: During the neonatal period, there is/ is no history of fever, convulsions [meningitis] , cyanosis, jaundice, respiratory difficulties, bleeding.
Developmental history: Developmental 3. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development development..
4. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed mental mental development.
Nutritional history: The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th th feeding, the child sleeps denoting satisfaction. Weaning was started on the 4 /6 month with …,… then …&…, the child does not receive/receives supplements in the form of vitamins, minerals.
Vaccination history: nd
th
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
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Clinical Pediatrics
Family history:
There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family. The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. the father is … years old, with good health/health problems problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from …
Examination: A. general: a. Measurements
Head circumference is …
b. Head The anterior fontanelle is … cm allowing … fingers. The sutures are/are not widely separated with/with out Macewen (cracked pot) sign [resonant note on on percussion]. The face is globular with prominent forehead and sunset appearance in the eyes. The skin is/is not thin &shiny, with/without with/with out prominent scalp veins. c. Back: There is/is no meningocele/meningomyelocele. meningocele/meningomyelocele. d. Neck: Shunt is/not palpated. palpated.
B. Systems examination: Neurological: Patient has/does not have spasticity of limbs, with/without paralysis. Reflexes are exaggerated/patient has hypotonia, hyporeflexia and loss of sensation in lower limbs (in cases of meningomyelocele). th Optic nerve atrophy in chronic cases/6 cranial nerve palsy in squinted patients.
Diagnosis: A case of congenital hydrocephalus with/without meningocele/meningomyelocele. meningocele/meningomyelocele.
Some hints: Toxoplasmosis: causes aqueduct stenosis. Traumatic delivery: causes intraventricular hge. Macewen's sign: cracked pot sound اﻟﻤﻜﺴﻮر اﻹﻧﺎ ﺷﺒﻪ. This resonant note on percussion occurs as there is change in the sound resulting from percussion after suture separation separation.. Skull is made of face (cartilaginous bone bone from Infra-orbital ridge = upper end of face to the upper jaw = lower end) and vault (membranous bone, from infraorbital ridge to highest point on anterior fontanelle). Membranouss part of skull increases with hydrocephalus. [in determining craniofacial disproportion which Membranou occurs only before closure of sutures allowing head enlargement) After closure of sutures, if hydrocephalus occurs, brain is compressed against bones, so it appears as a heterogonouss white opacity with black dots. (ووﺳﺨﻬﺎ اﻵﺷﻌﺔ ﻋﻠﻰ اﻳﺪﻩ ﺣﻂ واﺣﺪ ﺁﺄنfingerprints) heterogonou In cranial ultrasonography, a probe is put in the fontanelle. Ventricle presses on area 4 causing hypertonia and hyperreflexia. In meningomyelocele, damage of anterior horn cells causes hypotonia and hyporeflexia.
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Clinical Pediatrics Shunt prevents:
i. optic atrophy, ii. brain atrophy, iii. Further increase in the size of the head. Obstructe Obstructed d shunt is not removed because it may be partial obstruction, so it is better than nothing. Also due to the adhesions/fibrosis surrounding it. In neonates, no brain damage occurred yet, so neurological examination will not be required.
Back is very important in examination of hydrocephalus.
Marasmus Personal history: A…year old, male/female patient, named … … …, living at … [Age:6 months – 2 years old] Complaint: loss of weight/failure to gain weight/gastro-enteritis/chest weight/gastro-enteritis/chest infection. Present history: OCD of complaint + determine type: The mother noticed that her child is losing/not gaining weight … months ago. The condition is gradual and progressive.
Nutritional history:
The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each feeding, the child sleeps denoting satisfaction/does not sleep denoting inadequate nutrition. Weaning was th th started on the 4 /6 month with …,… then …&…, the child does not receive/receives supplements in the form of vitamins, minerals. The child is suffering from gastroenteritis that started … … ago, with an acute onset, progressive/regressive/stationary progressive/reg ressive/stationary course. There is vomiting … times per day/diarrhea … times per day. The stool is scanty, dry and greenish. The child is suffering from chest infection. infection. This condition started … … ago with acute onset, progressive/stationary/regressive progressive/stat ionary/regressive course. It is/isn’t improved with antibiotics. There is no/is cough that is not/is productive with large/scanty amount of viscid/watery, yellow/white/… yellow/white/…,, offensive/odorless mucus. mucus. It is/is not related to exertion. exertion. The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/stationary/regressive course. It is/isn't related to exertion like suckling/crying.. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal suckling/crying nocturnal dypnea. dypnea. There is/is no history of cardiac problems as cyanosis/exertional dypnea, chron chronic ic renal symptoms like polyurea, chronic hypertension, and hematuria. hematuria. There is/is no history of prolonged/recurrent prolonged/recurrent diarrhea, chronic vomiting. vomiting.
Developmental history: Developmental 1. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development.
2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed normal/delayed mental development.
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Clinical Pediatrics
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
2. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Vaccination history: nd
th
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: A. general: a. vital signs:
Respiratory rate: tachypnea in chest infection.
b. Measurements
Weight is … [ underweight] c. Head: rd Eyes are/are not sunken, buccal fat loss indicates 3 degree marasmus. The lips show pallor with/without angular stomatitis, monilial infection, and delayed dentition. The patient has an anxious look.
d. Lower limbs: Skin is wrinkled, as subcutaneous fat is lost in 2nd degree. Muscle is wasted and bones are prominent. edema is not/is present indicating marasmic kwashiorkor.
B. Systems examination: a. Abdominal: loss of subcutaneous fat from the abdomen (by inspection). b. Chest: in case of chest infection.
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Clinical Pediatrics
Diagnosis: A case of protein energy malnutrition (marasmus), nutritional/non-nutritional, nutritional/non-nutritional, st nd rd 1 /2 /3 degree, not complicated/complicated by chest infection/gastroenteritis. infection/gastroenteritis.
Some hints:
Mental retardation can cause marasmus as: i. No reaction, so does not ask for food. ii. Uncaring mother iii. Bulbar paralysis (palate/pharynx): (palate/pharynx): dysphagia/aspiration. Investigations: Hypoglycemia due to impaired glycogenolysis. Normal plasma protein (6-8 mg/dl): in marasmus, protein, albumin (normally 5-6mg%), alpha & beta globulins, but gamma globulin (by associated infections). Na (aldosterone effect, associated with dilutional hyponatremia i.e. increased total Na but decreased serum Na in relation to plasma), K (aldosterone, diarrhea &decreased intake), Mg.
Kwashiorker Personal history: A … year old, male/female patient, named … … …, living at … [Age:6 months –2 years old] Complaint: swelling of lower limb/gastro-enteritis/chest infection. Present history: OCD of complaint + determine type:
Patient does not have/has edema that started … … ago with acute/gradual onset, progressive/ stationary/ regressive course. It started first at the dorsum of the feet &hands/lower limbs/abdomen/…, limbs/abdomen/…, and then proceeded proceede d to the lower limbs/arms/cheeks, then it became generalized generalized.. It is pitting.
Nutritional history:
The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each feeding, the child sleeps denoting satisfaction /does not sleep well denoting poor nutrition. Weaning was th th started on the 4 /6 month with rice, potatoes, starch, … then …&…. This shows wrong weaning with carbohydrate carbohydra te diet mainly. The child does not receive/receives supplements supplements in the form of vitamins, minerals. The child is suffering from chest infection. infection. This condition started … … ago with acute onset, progressive/stationary/regressive progressive/station ary/regressive course. It is/isn’t improved with antibiotics. There is no/is cough that is not/is productive with large/scanty amount of viscid/watery, yellow/white/… yellow/white/…,, offensive/odorless mucus. mucus. it is/is not related to exertion. exertion. The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/stationary/regressive course. It is/isn't related to exertion like suckling/crying.. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal suckling/crying nocturnal dypnea. dypnea. There is/is no history of cardiac problems as cyanosis/exertional dypnea, or hepatic problems as history of jaundice, or allergic history of drug intake and and itching or chronic chronic renal symptoms symptoms like polyu polyurea, rea, chronic hypertension, and hematuria. hematuria. There is/is no history of prolonged/recurrent prolonged/recurrent diarrhea, chronic vomiting. vomiting. The child is suffering from gastroenteritis that started … … ago, with an acute onset, progressive/regressive/stationary progressive/regr essive/stationary course. There is vomiting … times per day/diarrhea … times per day. The stool is scanty, dry and greenish. Patient attended abu el reesh hospital where blood analysis was done, with no available results. He received medications in the form of… & ….
Developmental history: Developmental 1. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development.
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Clinical Pediatrics 2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed normal/delayed mental development.
Perinatal history: 1. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
2. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
3. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Vaccination history:
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows nd
th
about the rest of the vaccination schedule. schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: A. general: a. vital signs:
Respiratory rate: tachypnea in chest infection.
b. Measurements Weight is … [ usually not underweight due to compensation by edema] c. Head: Hair is light in color, sparse. The lips show pallor with/without angular stomatitis, monilial infection, and delayed dentition. The patient has an anxious look.
d. Lower limbs: Edema of the dorsum of the feet/of the whole limbs. Skin shows changes in the form of cracking/fissuring/ulcerati cracking/fissur ing/ulceration. on. Muscle is wasted and subcutaneous fat is lost indicating marasmic kwashiorkor.
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Clinical Pediatrics B. Systems examination: a. Neurological: mental changes and apathy. b. Chest: in case of chest infection. c. Abdominal: No ascites. There maybe hepatomegaly in nutritional recovery syndrome.
Diagnosis: A case of protein energy malnutrition (kwashiorker), (kwashiorker), not complicated/complicated complicated/complicated by chest infection/gastroenteritis. infection/gastroenteritis.
Nutritional marasmus
Blood
Blood picture electrolytes
Urine
___
Stool
Analysis culture chest x-ray
imaging
Non nutritional marasmus Blood picture Electrolytes Chemistry (glucose, amino acids, liver and kidney functions) UTI, sugar ___ chest x-ray, abdominal sonar echocardiography
Kwashiorkor Blood picture Electrolytes Plasma proteins ___ ___ chest x-ray
Rickets Personal history: A … year old, male/female patient, named … … …, living at … [Age: 1 – 3 years years old] Complaint: Delayed developmental developmental milestones/delayed dentition/chest infection (cough/shortness of breath)/convulsions.
Present history: OCD of complaint: Developmental history: The mother noticed delayed motor development of the child as the patient is … years old and still cant … .there is also delay in other motor milestones as …&… .This condition is also accompanied with delayed mental milestones milestones as the child is … years old and did not …/… yet.
Nutritional history: The child is breast fed/fed with cow's milk/artificially fed with
adequate/diluted/high adequate/dilu ted/high concentration, concentration, … times per day. After each feeding, the child sleeps denoting th
th
satisfaction. Weaning is not started yet/was started on the 4 /6 month with rice, potatoes, cereals, … then …&…. This shows inadequate intake of food rich in vitamin D as egg yolk/sea food/liver. The child does not receive/receives receive/rec eives supplements in the form of vitamins, minerals. The condition is associated with inadequate exposure to sunlight as the mother stated her fear from cold weather and dust, so she excessively wraps her child and rarely exposes him/her to the sun rays directly. There is history of recurren recurrent/persistent t/persistent diarrhea. There is no history of polyurea. There is no history of chest infections/con infections/convulsions. vulsions. The child is suffering from chest infection. infection. This condition started … … ago with acute onset, progressive/stationary/regressive progressive/stationar y/regressive course. It is/isn’t improved with antibiotics. There is no/is cough that is not/is productive with large/scanty amount of viscid/watery, yellow/white/… yellow/white/…,, offensive/odorless mucus. mucus. It is/is not related to exertion. exertion. The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/stationary/regressive course. It is/isn't related to exertion like suckling/crying.. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal suckling/crying nocturnal dypnea. dypnea.
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Clinical Pediatrics The mother sought medical advice at … hospital where …&… were made with no available results. The patient was given treatment in the form of injections/…, injections/…, once/….after that the condition was improved/didn’t improved/did n’t improve. The patient was admitted to abu el reesh hospital … ago, where …&…were done with no available results. He/she receives medications medications in the form of ….
Perinatal history: 4. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
5. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
6. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Vaccination history:
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule. schedule. nd
th
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: A. general: a. vital signs:
Respiratory rate: tachypnea in chest infection e.g. bronchitis/pneumonia. bronchitis/pneumonia.
b. Measurements Head circumference is … [increased due to bossing] bossing] c. Head: The skull is box-shaped, asymmetrically asymmetrically enlarged with wide anterior fontanelle allowing … fingers. Mouth examination reveals pallor [and delayed dentations.]
d. Upper limbs: Distal ends of upper and lower limbs show broadening. Upper limbs show convexity towards extensor surface. Lower limbs show bow legs/knock knees. There is a transverse groove at the medial malleoli (Marfan's sign).
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Clinical Pediatrics e. Trunk: Kyphosis is not/is evident; it is correctable as it disappears by axillary suspension of the baby or putting him/her in prone position. There is no/is lumbar l umbar lordosis on standing. There is no/is scoliosis. [In Potts disease, kyphosis kyphosis is not correctable]
B. Systems examination: a. Chest: Inspection: Rossary beads are/are not present at costochondral junction. Harrison's and longitudinal sulci are/are not present. The chest is/is not pigeon shaped. Auscultation: in case of chest infection. (usually present) b. Abdominal: there is no/is abdominal distension. The liver is palpable with the upper border of liver level detected by percussion at … intercostals space at/outside mid clavicular line. [below its normal level th which is 4 intercostals space at MCL, due to ptosis]
Diagnosis: A case of vitamin D deficiency rickets (nutritional (nutritional rickets), not complicated/complicated complicated/com plicated by chest infection.
Some hints:
If the complaint was convulsions, do not mix with CP. CP. Motor and mental milestones in rickets are delayed, but not like in down's (to a less extent.). extent.). beads beads, can be ask felt the in apatient thin normal person, but they are exaggerated to some extent in case of rickets. Rossary To see rossary to raise his upper limbs.
In exam, there are no Non-nutritional Non-nutritional cases. cases. In exam, bossing, broadening, marfan, rosary, distension are constant findings. findings. Harrison, longitudinal sulci, pigeon chest& ptosed liver occur only in severe cases. cases. In findings, say there is marfan sign and bossing/box shaped skull even if you can't find them. Do not mention dentition except if no teeth erupted at all all Measure anterior fontanelle, length. length. Don’t forget respiratory rate and auscultation of the chest in case of chest infection.
In investigations, by x-ray, pathological fractures are seen in the diaphysis of long bones (green stick fractures). It looks like a fissure that does not lead to separation of the 2 ends of fractured bone bone ﻜﻨﻩﻴ ﻣﺶ ﺗﻨﻴﺘﻪ ﻟﻮ, اﻟﺰر ﻣﻦ ﺮﻀﺧأ ﻋﻮد أى )زى (( ﻴﻠﺼﻔﻨﻣ ﻟﻨﺼﻔﻴﻦ ﺴﺮ
Chronic hemolytic anemia Personal history: A … year old, male/female patient, named … … …, living at … Complaint: progressive pallor/yellowish discoloration of the skin and mucous membranes/p membranes/progressive rogressive abdominal distension/failure to grow
Present history: Pallor started gradually … ago when the patient was … months old [by the end of the 1 st year], it had a progressive course. It was improved when the patient was admitted to the hospital and received blood transfusion.
The condition is not/is associated with jaundice. Stool is normal brownish/very dark brown/clay brown/clay colored, urine is dark/red/normal dark/red/normal colored. The condition is not/is associated with abdominal distension. the patient suffers from failure to thrive (if in early childhood) 29
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Clinical Pediatrics
There is no/is history of sudden pallor and red urine (indicating a hemolytic crisis). crisis). There is no/is history of pain and swelling in the hands and feet (indicating vaso-oclusive crisis). There is no/is history of repeated blood transfusion every … weeks. There is no/is history of splenectom splenectomy, y, which was done because of …, after the operation the condition was stable without/with complications in the form of fever/bleeding/….patient received pneumococcal vaccine after operation. The patient was admitted to abu el reesh hospital where …&… were done with no available results. He/she received blood transfusion and treatment in the form of … . Perinatal history: 7. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
8. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
9. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Nutritional history: th th The childthe is child breastsleeps fed/artificially fed with adequate/diluted/high concentration, concent timeswith per rice, day. After each feeding, denoting satisfaction. Weaning was started on theration, 4 /6 … month potatoes, starch, … then …&…. This shows wrong weaning with carbohydrate diet mainly. The child does not receive/receives receive/rece ives supplements in the form of vitamins, minerals.
Developmental history: Developmental 1. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development development..
2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed mental mental development.
Vaccination history:
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows nd
th
about the rest of the vaccination schedule. schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
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Clinical Pediatrics
Examination: A. general: a. vital signs: Pulse: tachycardia, water water hammer pulse. Respiratory rate: tachypnea in chest infection. b. Measurements Head circumference Height is … [stunted] is … [large head] c. Head: The lips show pallor. Eyes show mild jaundice. Mongoloid features are evident as the nasal ridge is depressed, the maxilla is prominent and the upper central incisors are protruding.
d. Neck: lymphadenopathy e. Upper limbs: There is/ is no pallor seen in nail beds.
B. Systems examination: a. abdominal: distension/bulging flanks, skin is stretched +/- striae, with visible By inspection, there is generalized distension/bulging subcutaneous subcutaneo us veins. The sub costal angle is wide and there is divarication of recti. The umbilicus is in its normal place/shifted downwards/shifted downwards/shifted upwards, and everted. The overlying skin is normal/pigmented/fissured, normal/pigmen ted/fissured, +\- there is a scar, … cm, at the … quadrant/at left costal margin/transversely besides umbilicus., healed by 1ry/2ry intention. intention. By deep palpation, the lower border border of the right lobe of the liver is felt in midclavicular line … cm below RT costal margin, while the lower border of the left lobe is felt in midline … cm below costal margin. It is not tender, firm in consistency with rounded border. The lower border of spleen is felt in in midclavicular line… cm below left costal margin. It is not tender, firm in consistency with rounded border. border. +\- notch can be felt. felt. th By percussion: upper border of liver is in the 5 intercostals space. There is NO ascites.
b. Heart
Hemic murmur: short systolic murmur at aortic and pulmonary areas. (Heart base).
Diagnosis: A case of chronic hemolytic anemia most probably thalassaemia major.
Some hints:
In exam, don’t say your case is thalassaemia major, say chronic hemolytic anemia; most probably thalassaemia because it is common is Egypt. (Because it might be sickle cell anemia or spherocytosis). do not depend on pallor (recently received blood transfusion) How to identify case: Prominent maxilla, zygomatic process and upper central incisors. Pallor + jaundice + hemosiderosis (اﻟﺘﺮاب ﻟﻮن ) Relatively old patient (10-12 years old). Blood transfusion is very important. If complaint was failure to grow: it is due to oxygen perfusion affecting tissue growth. In present history, usually there will be repeated blood transfusion every 4 weeks [blood addict]. The patient has to take blood transfusion when he feels hypotension, headache, palpitation and shortness shortness of breath.
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Clinical Pediatrics Hemolysis of RBCs causes anemia hypoxia bone marrow immature cells + expansion in bone more than manufacture manufacture of RBCs RBCs اﻟﺘﺎﻧﻰ اﻻﻧﺘﺎج ﺧﻂ ﻳﺸﺘﻐﻞ hyperplasia of marrow spaces. But still hemolysis is more stem cells (hepatosplenomegaly (hepatosplenomegaly - but also hemolysis contributes contributes to the splenomegaly). But still this is not enough, so, the patient needs blood transfusion. Why blood transfusion every 4 weeks, although RBCs half life li fe time is 120 days? The transfused cells were already living in i n the donor's The donor is most probably anemic (an Egyptian) Hb is not cconstant. onstant. Stem cells = totipotent cells/mesenchymal cells. Manufacture of RBCs is done by evacuating cell contents until there is only membrane, Hb and enzyme. Spleen has 2 types of cells: Cells like li ke bone marrow stem cells (3nd line of manufacture) Cells that phagocytose platelets platelets and RBCs. Hyperfunctioning Hyperfunctioning of these cells hypersplenism. hypersplenism. If patient used to receive blood every 4 weeks, then started to receive the transfusion every 2 weeks, this indicates hypersplen hypersplenism. ism. Cause of hypersplenism: is unknown, but in some diseases where spleen functions excessively E.g. toxins & blood diseases, with large amounts of abnormal RBCs ﺘﻴﺑ اﻟﻄﺤﺎل . ﺷﺎﺧ اﻟﻠﻰ و اﻟﻄﺒﻴﻌﻴﺔ اﻟﺨﻼﻳﺎ ﺑﻴﻦ ﻳﻔﺮق ﻻ ﻓﺄﺻﺒﺢ, ﻳﻜﺴﺮﻩﺎ ﺮﻀﻄ In pediatrics course, hypersplenism is only in bilharziasis and chronic hemolytic anemia. Usually, there is mild jaundice. If it is severe, it may be due to Transmission of hepatitis through blood transfusion. Iron (from hemolysis) caused liver cirrhosis. Depressed nasal bridge: because nose does not contain bone marrow spaces, while the surrounding bone expands, making it appear as if depressed. Abdominal findings by inspection are due to intra abdominal pressure (enlarged organs). Indications of splenectomy: large pressure symptoms Orthopnea and dyspnea. If patient made splenectomy, and you don’t know, and the liver is enlarged where the left lobe is in the direction of the spleen, how to differentiate between spleen and left lobe? Spleen usually enlarges longitudinally downwards. downwards. So, if you can feel a mass in the left side of the abdomen, make sure you can feel most of it in the left side, side, and that it is descending longitudinally downwards to some extent. In cases of splenectomy, adhesions make the liver borders not well identified, you'll be able to feel fullness Healing by 2ry intention: If scar of spleen is gapping/broad. Chronic hemolysis pigmentary stones laparoscopy scar, 2-3 cm, nearby umbilicus, to remove gall bladder. Q: why this is spleen? ans: it's anatomical site (left hypochondrium) hypochondrium) Presence of notch Can't insinuate my finger between it and costal margin. Sometimes, Iron overload hepatitis shrunken liver. Cause of death: hemic murmur.
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Clinical Pediatrics
Purpura Personal history: A … year old, male/female patient, named … … …, living at … [Any age, but aplastic patients are relatively old] Complaint: reddish spots/mucous membrane bleeding (epistaxis, hematuria)
Present history:
Condition started with an acute/insidious acute/insidious onset, … weeks/years ago, with a regressive(ITP)/stationary, regressive(ITP)/stationary, prolonged (aplastic anemia)/progressive course (malignancy). Spots are pinpoint/… mm, generalized all over the body, reddish, and they are not raised above the surface. There is no/is history of epistaxis, bleeding gums, hematemesis, hematu hematuria. ria. Bleeding was of minimal/moderate/large minimal/moder ate/large amount, and there was no need for blood transfusion/the patient received blood transfusion. The patient never received/received blood transfusion … times. ( ↑ 5 in aplastic anemia) There is no/is history of preceding fever, cytotoxic drugs, arthralgia/recent arthralgia/recent marked weight loss/continous fever. The patient was admitted to abu el reesh hospital where …&… were done with no available results. He/she received blood transfusion and treatment in the form of … .
Rest of history taking like chronic hemolytic anemia, (no findings of relevant importance in purpura). Examination: A. general: vital signs: important Measurements: steroid (taken for ttt of aplastic anemia) affects growth. Head: eyes: subconjunctival hge, lips: pallor (severe in aplastic, mild or absent on ITP) Neck: lymphadenopathy (of leukemia), in exam say LNS are normal. Limbs & trunk: pinpoint petichial hge +/- echymosis. They are not raised and do not blanch on pressure. They are reddish. Bone is not tender. B. Abdominal: no hepatosplenomegaly hepatosplenomegaly (exclude leukemia)
Diagnosis: A case of purpura, most probably ITP/aplastic anemia for further investigations. Cases ITP
Aplastic
leukemia
History Short Preceded by viral infection Blood transfusion only once Prolonged History of drug intake Repeated blood transfusion (not less than 5) Fever Arthralgia Recent marked Loss of weight
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examination Purpura Mild pallor Bad general condition Severe pallor Cushinoid (steroid ttt) Bad general condition Pallor Hepatosplenomegaly Lymphadenopathy Tender bone
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Clinical Pediatrics
Down syndrome Personal history: A … year old, male/female patient, named … … …, living at …
Complaint: delayed developmental milestones/chest infection/shortness infection/shortness of breath/hypotonia Present history: OCD of complaint, The child is suffering from chest infection that started … … ago with acute onset,
progressive/stationary/regressive progressive/stat ionary/regressive course. It is/isn’t improved with antibiotics. There is no/is cough that is not/is productive with large/scanty amount of viscid/watery, yellow/white/… yellow/white/…,, offensive/odorless mucus. mucus. It is/is not related to exertion. exertion. The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset, progressive/stationary/regressive progressive/stationary/regressive course. It is/isn't related to exertion like suckling/crying.. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal suckling/crying nocturnal dypnea. dypnea. [if the main complaint is chest infection] Down syndrome was discovered at birth/… … after birth When the child developed chest infection and received medical attention/As the mother noticed delayed motor/mentall milestones, where the child was … months and still could not …. Then condition is associated motor/menta with hypotonia.
Developmental history: 1. Motor:
The child is still unable to support his neck/was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development. development.
2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed normal/delayed mental development. There is history of recurrent chest infection. The mother sought medical advice at … hospital where …&… were made with no available results. The patient was given treatment in the form of injections/…, injections/…, once/….after that the condition was improved/didn’t improved/did n’t improve. The patient was admitted to abu el reesh hospital … ago, where …&…were done with no available results. He/she receives medications medications in the form of ….
Perinatal history: 10. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
11. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
12. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has …
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Clinical Pediatrics brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Nutritional history:
The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th th feeding, the child sleeps denoting satisfaction. Weaning was started on the 4 /6 month with rice, potatoes, starch, … then …&…. This shows wrong weaning with carbohydrate diet mainly. The child does not receive/receives receive/rec eives supplements in the form of vitamins, minerals.
Vaccination history:
The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule. schedule. nd
th
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Examination: A. general: a. vital signs: Respiratory rate: tachypnea in chest infection b. Measurements Head circumference is … [small, brachycephalic] brachycephalic] Height is … [short stature] Weight is … [usually underweight] c. Head Head circumference is … cm. the occiput is flat, hair is silky, Eye: medial epicanthal fold and lateral upward slope of eyelid. Nasal bridge is short and depressed. Ear lobules are underdeveloped, with overfolded helix and small external ear. Mouth: small due to micrognathia, the tongue is protruded protruded and fissured. (rugae/scrotal tongue). d. Neck: Short and broad. e. Upper limbs: Hands are Short and broad, with transverse palmar crease +\- clinodactyly.
f. Lower limbs: st nd Feet are short and broad, +\- with a wide gap between the 1 and 2 toes.
B. Systems examination: a. Heart: like VSD b. Chest: if there is bronchitis, medium sized crepitations crepitations and wheezes scattered on both lung fields by auscultation. c. Abdominal:
distension. Hernia. Splenomegaly (leukemia as a complication in 1% of cases) If a relatively older boy, small genitalia (penis and scrotum).
d. Neurological: hypotonia.
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Clinical Pediatrics
Diagnosis: A case of Down syndrome, most probably non-disjunctional/translocation non-disjunctional/translocation type, without/with congenital heart disease in the form of VSD/chest infection. Some hints: Down is the name of the scientist who diagnosed it. Non-disjunction Non-disjunctional al occurs when age of mother is 30 years. It is common in female doctors children due to late marriage. Patients with GIT anomalies never come in the exam because they are either treated or dead.
Do not say brushfeild iris because it only appears with slit lamp examination. Causes of death in down: accidents Heart Failure, infections, leukemia. The older the patient, the better the tone relatively older patients can walk inspite of the severe hypotonia in the beginning. The older the age, the less incidence of chest infections. Manifestations of hypotonia: ﺑﺘﻄﻮح رأﺳﻪ راﺳﻪ ﺗﻠﻤﺲ رﺟﻠﻪ frog leg ﻟﻠﺨﺎرج ﻣﻔﺘﻮﺣﺔ رﺟﻠﻪ everted umbilicus distension & hernia اﻟﻤﻔﺎﺻﻞ اﺗﺠﺎﻩ ﻋﻜﺲ ﺁﺒﻴﺮة ﻟﺪرﺟﺔ اﻷﺻﺎﺑﻊ ﺛﻨﻰ History of repeated abortions suggests translocation type. 50 % of cases have VSD, so you have to perform complete heart examination. name). Don’t say Mongolism (ﻣﻨﻐﻮﻟﻰcountry name).
not infections necessarilyinsilky, but softer than his siblings. siblings. Silky Causehair: of chest down: hypotonia weak cough reflex accumulation and stagnation of secretions chest infection VSD congestion possibility of infection.
Neonatal jaundice Personal history: A … year old, male/female patient, named … … …, living at … Complaint: yellowish coloration of the skin and mucous membranes Present history: OCD of complaint,
The condition started on the 1 /2 /… day/week after labor, it has progressive/stationary/regressive progressive/stationary/regressive course. st nd The patient is the 1 /2 child in the family. The stool is clay colored/has normal color, and urine's color is dark/normal. st
nd
Perinatal history: 13. antenatal history:
During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, fever & lymphadenopathy. lymphadenopathy. She did not take/took … drug and was not/was subjected to irradiation. She received blood transfusion. She did not suffer/suffered suffer/suffered from diabetes, toxemia of pregnancy.
14. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/traumatic delivery
resulting in cephalhematoma/CS, with/without with/without sedation. There is no/is history of premature ruptu rupture re of membranes.. At birth, the condition of the baby was normal/ the baby suffered health problems in the form membranes of …, he/she didn’t cry immediately/immediately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
15. neonatal history:
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Clinical Pediatrics During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Developmental history: Developmental 1. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development development..
2. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed mental mental development.
Nutritional history:
The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each feeding, the child sleeps denoting satisfaction. Weaning is not started yet.
Vaccination history:
The child received vaccinations at his/her birth, The mother knows about the rest of the vaccination schedule.
Past history:
There is no/is past history of chest/cardiac/renal/hepatic chest/cardiac/renal/hepatic/GIT/CNS /GIT/CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc, housewife/… etc, she gave history of previous abortion. the father is … years old, with good health/health problems in the form of …, he's a worker/…etc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of chronic hemolytic anemia, anemia, hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: A. general: a. Measurements
Head circumference is … [micro cephalic in TORCH]
b. Head Head circumference is … cm. +\- cephalhematoma – forceps marks. Eye maybe jaundiced. Lips show pallor. [hemolytic anemia] anemia] c. trunk: umbilicus: umbilical sepsis skin is lemon yellow (unconjugated) B. Systems examination: a. Abdominal: hepatosplenomegaly (cholestasis). b. Neurological: Moro and suckling reflexes, to exclude kernicterus.
Diagnosis: A case of neonatal jaundice, most probably …
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Clinical Pediatrics
Nephrotic syndrome Personal history: A … year old, male/female pt, named … … …, living at… [Minimal lesion:2-6 lesion:2-6 years old] Complaint: puffiness of the eyelids/swelling in lower limbs Present history: OCD of complaint,
Edema started … … ago, with gradual onset, it started around the eyes, with intermitten intermittentt course at the
beginning, more in the morning and disappears by the end of the day. Later it affected the dorsum of the hand, scrotum, lower limbs, abdominal wall, and caused ascites. It is massive, pitting, +/- associated with vomiting and abdominal wall. There are no cardiac symptoms like dypnea, orthopnea, no hepatic symptoms like jaundice. Also the nutritional history reveals adequate nutrition, nutrition, indicating absence of these factors as causes of edema. There is no/is hematuria, headache, hypertension. There are no symptoms suggestive of chest infection as cough/dyspnea. cough/dyspnea. The patient soak medical advice at … clinic/hospital where urine, blood& … analysis were done with no available results. he received medications (steroids/hypertensives)in the form of tablets, and the condition was/was not improved. Patient was admitted to Abu el reesh hospital … ago where urine analysis/ chest x-ray /… were done with no available results. He/she is receiving medications in the form of tablets/injections. tablets/injections.
Perinatal history: 16. antenatal history: During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
17. natal history: The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of …, he/she didn’t cry immediately/imme immediately/immediately diately cried after birth. Resuscitation was/was not required. The birth weight was … kg.
18. neonatal history: During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever, convulsions, bleeding.
Nutritional history:
The child is breast fed/artificially fed with adequate/diluted/high concentration, concentration, … times per day. After each th
th
feeding, the child sleepsThis denoting Weaning started ondiet the mainly. 4 /6 month withdoes rice,not potatoes, starch, … then …&…. showssatisfaction. wrong weaning with was carbohydrate The child receive/receives receive/rec eives supplements in the form of vitamins, minerals.
Developmental history: Developmental 3. Motor:
The child was able to support his neck when he/she was … months, sit with support when he was … months, sit without support when he was … months, stand when he was … months and walk when he was … months. This reveals normal/delayed motor development development..
4. mental: The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was able to talk when he was … months. This reveals normal/delayed mental mental development.
Vaccination history: 38
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Clinical Pediatrics The child received vaccinations at his/her birth, 2 , 4th, 6th, 9 , 15th, 18th months. The mother knows about the rest of the vaccination schedule. schedule. nd
th
Past history:
There is no/is history of similar condition … … ago. There is no/is past history of chest/cardiac/hepatic/GIT chest/cardiac /hepatic/GIT/CNS /CNS infections. There is no/is history of previous attacks of rheumatic fever/bilharzias/TB/…/exanthe fever/bilharz ias/TB/…/exanthemes mes (name it). The patient does not take any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents, asthma, and allergies.
Family history:
The mother of the child is … years old, with good health/health problems in the form of …, she's a housewife/…etc. housewife/… etc. The father is … years old, with good health/health problems in the form of …, he's a worker/…etc. worker/…e tc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old brother who suffers from … There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: A. general: a. vital signs:
Blood pressure: hypertension in non-minimal lesion. lesion. b. Head: Puffy eyelids Pallor in lips. Cushinoid features (moon face + buffalo hump) c. Limbs: Bilateral, pitting, not tender edema in hands/feet, reaching below knew/above ankle. d. Genitalia: Scrotal edema
B. Systems examination: a. Abdominal: Generalize Generalized d distension/bulging flanks, with wide/normal subcostal angle, stretched skin (+\- striae), visible veins, and divarication of recti. The umbilicus is in its normal position/shifted downwards downwards and everted. Superficial palpation shows tenderness [peritonitis]. Deep palpation shows no organomegaly, renal angles are free in bimanual examination. Percussion shows moderate/huge ascites.
Diagnosis: st
A case of generalized edema, edema, nephritic syndrome, most probably minimal lesion type, 1 attack/relapse, attack/relaps e, with/without chest infection as a complication.
Some hints:
Moon face: due to fat in face, and buffalo hump is due to fat in back. Chest infection may occur due to decreased immunity (pneumococci) [erythropoeisis] Pallor is due to hypovolemia and affection of erythropoeisis.
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Clinical Pediatrics
Abdominal cases
Abdominal Cases can be: hepatosplenomegaly, hepatosplenomegaly, hepatomegaly, shrunken liver with huge splenomegaly. a) Chronic hepatitis (cirrhosis/failure) (cirrhosis/failure) b) Metabolic liver disease c) Bilharziasis d) Malignancy e) Chronic hemolytic anemia, a 2 years old patient, mongoloid features are not apparent yet,but with HSM f) Veno-oclusive disease.
HepatoMegaly +\- liver failure +\- portal hypertension → bilharziasis. HepatoMegaly + tense ascites → VenoOcclusive Disease. HepatoMegaly → metabolic Splenomegaly → leukemia HepatoSplenoMegaly → leukemia SplenoMegaly + shrunken liver + portal hypertension → post hepatic cirrhosis.
Jaundice+d Jaundice+dark ark urine+clay stool = hepatitis, mostly HAV. اﻟﻴﻤﻴ ﺟﻨﺒﻪ ﻓﻰ وﺗﻘﻞ اﻟﺸﺎى ﻟﻮن وﺑﻮل اﻟﺼﻔﺮا اﻟﻌﻴﺎن ←ﻋﻨﺪﻩ This is usually associated with history of blood transfusion or unsanitary life style. In case of bilharziasis, there maybe repeated blood transfusion (3-4 times) due to ulcer resulting from emergence of ova → injury of sub mucosa bleeding. (not only 5-6 times) regularly every month. Chronic hemolytic anemia=rep anemia=repeated eated blood→ transfusion, History of repeated liver biopsy + onset of condition at 6th/7th month of life + similar family history +
associated symptoms = metabolic. Anemia + hypersplenism = ↓ platelets → echymosis + other abdominal symptom. Lipid storage disease: accumulation of lipid in liver, l iver, spleen and brain → hepatosplenomegaly + convulsions. Wilson: large liver + chorea. Glycogen storage disease: glycogen accumulation in liver and spleen → impaired glycogenolysis. If patient did not eat well → hypoglycemia → convulsions.
Abdominal distension: hepatomegaly hepatomegaly or ascites. Ascites differs as it is collected in the most dependent parts,
except if very tense (fills all partitions). Distension: ﺑﺘﻌﻠﻰ\ﺑﺘﻜﺒ ﺑﻄﻨﻰ Pain: due to distension, usually in LT hypochondrium hypochondrium in splenomegaly. Biopsy = ﺑﺬل = taking a sample from ascetic fluid to be examined. es esop opha hage geal al va vari rice cess = ﻣﻨﻈﺎر ﻋﻤﻞ ﺑﻴﻘﻮل اﻟﻌﻴﺎن Jaundice: increased direct bilirubin as hepatic cells can conjugate but can't actively secrete. th By examination, cirrhosis is detected by: on percussion: dullness below the 5 intercostal space. Shrunken RT lobe (only LT is palpated).
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