سشنات د.رؤى

Pediatrics 6th stage

Session notes د.رؤى
Important steps not to be forgetten in the exam
1.greeting the parent
2. introduce yourself
3.take permission
4.thank them finally

GIT examination :

Examination steps :
General Exam
Abdominal exam :
1.Inspection :
Scar of previous surgery , hernia , dilated veins , abdominal distension , umbilicus
2. Paipation : first of all ask about any pain and try to avoid paiful area
A.Superficial : for tenderness , rigidity , mass
B.Deep :
a. liver : palpable in infant > 3 cm signicant , always palpable in neonate
> 3 cm below costal margin ( enlarged or palpable )
Interpretation :
Surface : smooth
Consistency : firm
Border : Blunt
Tender or not ( in acute HF sharp soft margin
10 +\- 2 = liver span
Infant spleen palpation begins from left iliac fossa
Spleen if palpable it is enlarged


Spleen left kidney
1.moves with respiration 1. Not movable
Towards right iliac fossa
2. notch is present 2.not is not present
3. cant get above it 3. Can get above it
4.on percussion : dullness 4.on percussion ( tympanic)
Of the mass
5.well defind medial border 5.rounded upper end
6. the mass is palpable 6.is ballotable

Febrile convulsion

Age 6 monthes – 6 years ( 6 m – 60 m )
Types :
a.simple ( generlized , < 15 min , occurs 1 time in 24 hours )
b. complex ( focal ( always seek for underlying causes )
> 15 min , > 1 time in 24 hours
c. status eplipticus
1.Age < 1 year
2.duration betwwen fever and seizure < 24 hours
3.Temperature 39 C
4.family Hx of epilepsy
5.male gender
6.hypernatremia ( young age )
* eyes if staring upward : generlized
If staring laterally : focal


Convulsion : emergency mangement
1.ABC ( airway , breathing , circulation )
2. Recovery position ( lateral )
3.Dont put any thing in the mouth
4.Suctioning
5. Diazepam IV
0.25 mg\kg + O2 slowely becaause diazepam lead to respiratory distress
if no response repeat dose
After 3 times if no response give phenytoin ( 60 mg\kg bolus + Normal saline ) , if no response
Phenobarbital " luminal " ( 20 mg\kg , 10 mg\kg slowely & direct infusion
If no response Genral anesthesia ( propofol )
*diazepam rectally if there is no IV acess
Define status epilepticus :
Recurrent attacks of convulsion without retaining consciousness between the attacks ( an attacks continues > 20 min )
Causes :
1.miss dose of anti-epileptic drug
2.febrile convulsion " most common "
3. meningitis
4.hyponatremia \ hypocalcemia \ hypomagnesmia \ hyponatremia
5.Intracranial hemorrhage
6. Subarachnoid hemorrhage
7.hypoglycemia
8. Drugs " nadixic acid = nigram "


In convulsion , the investigation we send :
1.blood sugar
2.Serum electrolyte
3.CBC
4.Blood culture
5.CRP
6.lumbar puncture more important in infants till age of 18 m0nth before it do fundoscopy , if child > 18 mo. As the fontanelle closed

If we give antibiotics before doing lumbar puncture what changes seen in CSF ?

CSF analysis not changed but culture always change

Procedure of LP :

1.patient siting position or leaning forward or laterally directed
2. sterilization of the area in circular pattern
3. ( 15 drops ) are collected

- Turbid CSF in 350 cell range

- in acute bacterial infection , at early phase ( 1st to 12 hours ) lymphocyte predominant , while later on , neutrophils predominant
- decrease in CSF is called hypoglycoratia
- Drugs Induced Fever :
1.pencillin
2. cephalosporin
3.quinnie
4.methyldopa
5.nitrofurntin
Drugs i=with convulsion : naldicicix acis \ aminophylline
In any convulsion not forget to ask about fever , trauma , meningitis

Meningitis
Symptoms : pyrexia , headache , meningism ( brudizinski sign , stiff necks , headache , photophobia , kernigs sign )
Normal CSF
-CSF : 0-5 cell\micorlter
- protein < 40 mg\dl
-clucise > 50% of blood glucose
Bacterial meningitis :
-CSF cells : PMNS increase
-protein : elevated
-glucose : < 50% of blood glucose
Viral meningists
-CSF : lymphocytes
-protein incres
Glucose normal
Tuberculous meningitis
Cell : lymphocyte
Protein increase
Glucose < 50% of blood glucose


Decrease in G-1-PH UT enzeme which essential in glucose metabloism
Presentation :
1.jaundice
2.hepatomegaly
3.feeding poorly
4.hepatic faiulre
5.vomiting
Pateint with galactosemia cant lie for long time ?
Because they are susceptible for sepsis E.coli
Indirect hyperbilirubenimia
1.Gilbert syndrome 2.Crigglar syndrome
Gilbert syndeome :
Benign condition time of stress such as fasting \ infection
Direct hyperbilirubinemia : biliary atresia ( diagnosed by US )
Operation ( post-enterostomy ) should not done at first 45 days
Neonatal sepsis
Hepatitis
Cystic fibrosis ( 100 mg , in fitter paper (40-60) sweat test , test not repeated if < 40 mg
galactosemia
investigation :
1.TSB ( total serum bilirubin ) + differenation ( direct or indirect )
2.blood culture
3.WBCs
4.reticulocyte
5.US of abdomen
6.PT + PTT
6. TFT
Neonatal jaundice :
DDx
1.biliary atresia
2.Cystic fibrosis
3.metabolic disease ( +ve family history , +ve consangity )
4. TORCH infection ( most impt CMV )
Markers for chronic liver disease ?
1.jauidice
2.spider naevi
3.ascites
4.palmar erythemia
5.internal bleeding ( noe echymosis , becuase this due to thrombocytopenia )
Causes of acute liver injury ?
1.viral hepatitis ( virus A > virus B & others )
2.aetominophen poisoning > 200 mg\kg ( dose in pediatric)
While in adult is ( 7 gm )
3.wlison disease
4. alpha anti-trypsin decrease
Glycogen storge disease : type 1 & 2 causes hetaptomegaly only
Caucher disease
Rx of chronic liver disease
Albumin 5 cc\kg , vit.K , blood transfusion , if there is infection , treated by antibiotics


In pt with convulsion , dont forget to ask about fever , trauma
If you ordesrd to take Hx from pt with abnormal body movement ( convulsion ) ask this quostion
1.when the convulsion begins ?
2.how many time \day ?
3.all the body involved or part of it ?
4.associated withe cyanosis ?
5.associated with vomiting ?
6.if older , incontinenc ( feces + urine )
7.it is temperture ?
8.how convulsion stop >
9.how many times it happened in day ?
10.did he receive any vaccination ( like DTP ) ?
11.describe the nature of convulsion ( flaccid \ tonic clonic , staring of eyes
12.conciouness laered or not
In review of system : begins with CNS review
Ask about : irritability , abnormal behaviours , conciousness , school performance ( vision & hearing if older enough )
Then GIT review ? because shigallosis mau cause convulsion
Respiratory review as ( pnemonia ) will predispose to convulsion
Skin rash ( dematologica; system : as measles & roesla infantum can cause convulsion )
GUT : UTI he cries while he pass urine ?
If younger age dont ask about dysuria
2.change in urine color ?
Post-medical Hx : ssk about chronic disease
Similar conditions in the family ?
Previous attacks
Drug Hx :
Chronic use of drug \ ask in detila about the drug included response to drug ?
Family Hx : Consanguity ? for autosomal recesive disaese ( metabolic disease as they are easily inherted
Convulsion in the family
Feeding Hx : ask about ( how to prepare milk ) ?
Because hypo\hypernatremia causes convulsion
In pt with malnutrition : important to focus on :
Feeding Hx & ( pre-natal , natal , post-natal Hx
Family Hx ( the others siblings )
What investigation you send for ?
1.GUE
2.Serum albumin level ( 35 – 50 ) normally
3.GSE
4.CXR
5.US
Iron not given to bigenner only after 3rd week
-try to be gradual in refeeding to avoid refeeding syndrome ?
It is electrolyte disturbance in special one : hypophosphotemia
-what are the difference between kwashirkor and marsmas
From the lecture of previous year
Note : cystic fibrosis it is impt to remember it in every case of dirrhea and cough
In pt with SOB : intermittent or continous ?
-in what position aggravated and reliefed ?
- at night ( astma ) ? and ( morning ) ?
-what they give him to releif SOB ?
-overcrowding is important ?
- vaccination Hx very imp ?
-similiar state in the family ?
In care of chronic or recurrent diarrhea ?
1.cystic fibrosis
2.celiac disease
3.weaning ( because of breast )
4.drugs ( azytromycin )
Investigation :
Stool exam for diarrhea
*shiglla : is suspected in bloody diarrhea
Pt with dehydration : what you consider ?
1.level of dehydration ? in older pt ( 3,6,9)%
Acorrding to severity \ in younger pts ( 5 , 10 , > 10 ) %


2.you find the deficit D= level of dehydration * wt ( gm)
3.then maintenance in 24 h
10 % wt * 100
10 % wt * 50
10 % wt * 20
Cow milk protein allergy
Diarrhea
SOB
-skin rash
-BPR
Surfactant formation start at 28 wks and complete
At 37 wks
For maturation of lung : before delivery give betamethasone
1 injection \ 24 hours
How we know this condition is RDS from the respiratory or CVS source ?
RT ; respond to O2
CVS : no R to O2
RDS ( pnemonia , bronchilitis , astma , PE , ARF , DKA , anemia , opoids
DDx of hyperinflated chest
1.astma
2. beonciolitis
3.emphysema


Supraclvicular LN : important in stomach cancer
PR always count foe 30 sec then multiply by 2
While RR count for 15 sec then mulyiply by 4
Recurrence rate in febrile convulsion 28% in those > 1 yr
Is there any indication for Anti-epileptics drugs in simple type ? no
In any convulsion , ask always " how did you stop pt seizure
In any convuldion , ask about " epliepsy family Hx \ convulsion family Hx )
Normal intellectual function in febrile convulsion
In taking drugs Hx , try to write in drtial the name of drugs the dose rhe response
In respiratory illness\ social " smokin and crowding very imt
Triggers for astma
1.viral infection
2.pollunant L anima; dander
3.GERD
4.LAIGHING
5.powder
6.smoking
7.emotional stress
Prematurity : have a respiratory distress , give ventolater
Lead to brochopulmonary dysplasia


S1 heard in mitral area
S2 heard in pulmonary area
Murmur
Phase
Grade
Radiation
In pan no s1 or s2
Change in position innocent murmur
Interscapular is PDA
Base of lung for HF
LOUD S1 ASD
Loud S2 pulm. HT , ASD , VSD
S3 ( normal , anemia ) , S4 ( abnormal )
S3 after S2 , S4 before S1

Infective endocarditis

Fever ( prolonged malaise ) weigt loss
Jane way leasion , splinter hemoorhage , changed murmur
Splenomegaly
Inx
Blood culture , ECHO vegetation
Pathogen
S.viridian , fungal infection , catheter ( s.epidermis )
Indication for prophylaxsis
RF , dental , prosthetic heart valve , previous attack , operation ( cardiac transplant , GIT , renal )
Only ( cardiac , resp , dental )


The important points in developmental history
Sitting with support at 5-6mo
Sitting without supportat 8-9mo
Walking with supportat12mo
Run stifflyat18mo
Run well2yrs
Stairs (crawl &ascend) at 15mo
On his feet goes up the stairs 2yrs
Ascend up the stairs like adult2yrs +6mo
Stand on one legat 3yrs.
Skip 5yrs
Ride tricycleat 3yrs
Ride bicycleat 6yrs.
Babbling soundsat6mo
Cooing soundsat 2mo
Say mamma / baba (but don't mean them exactly)10mo
Say mamma / baba(but he mean them exactly)at 1yr.
Rolls over from abdomen to his backat 4mo
Rolls over from the back to his abdomen at 6mo
Scribblesat18mo