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Source:
Notes of
Prof. Dr Mustafa Zakaria.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint.
5. Present History:
Analysis of the complaint:
Onset: Sudden, Acute or Gradual.
Course: Progressive, Stationary or
Regressive.
Duration.
Symptoms of the same system.
Symptoms of the other systems:
Chest:
Cough, Hemoptysis, Cyanosis, Chest
infections, and Fever.
Cardiac:
Difficulty in breathing, Dyspnea,
Difficulty in feeding, Cyanosis,
Palpitation.
GIT:
Vomiting, Diarrhea, Constipation,
Amount of stool, Jaundice.
UTI:
Difficulty in urination, blood in urine,
amount of urine, edema.
Neuro:
Loss of conscious, convulsions.
Hepato-biliary:
Jaundice, pain in right
hypochondrium, bleeding per gums,
wound healing.
Medical attention:
Investigations, ttt & Hospitalization.
6. Perinatal History:
Antenatal: Medical health during pregnancy.
Infections (fever & rash).
Diabetes or Toxemia of pregnancy.
Drugs or irradiation.
Natal history:
Duration of pregnancy.
Delivery type (VD CS).
Drugs (Sedation during labour).
Birth weight.
Birth Condition:
Immediate cry Resuscitation required.
Neonatal history:
Cyanosis - Convulsions.
Respiratory difficulties - Jaundice.
7. Developmental History:
Motor:
Neck support Sitting with support.
Sitting without support Standing Walking.
Mental:
Social smile Maternal recognition Speech.
8. Nutritional History:
Type of feeding "breast or artificial":
Breast: frequency Adequacy.
Formula: Amount per feed, Frequency &
Concentration.
Weaning: Onset, Foods, Method & Amount.
Supplements: "Vitamins & Minerals".
Down Syndrome
1. Welcome the patient.
2. Introduce yourself to the patient.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint:
Delayed motor and mental milestones.
Chest infection "cough, wheezes or dyspnea".
5. Present History:
Analysis of the complaint.
Symptoms of the same system:
Difficult breathing, or suckling & cyanosis.
Failure to weight gain.
Recurrent chest infections.
Symptoms of the other systems.
Medical attention:
Investigations, treatment & hospitalization.
6. Perinatal History:
Antenatal: Medical health during pregnancy.
Natal history: Previous abortion.
Neonatal History.
7. Developmental History: "Very Important"
Motor:
Neck support Sitting with support.
Sitting without support Standing Walking.
Mental
Social smile Maternal recognition Speech.
8. Nutritional History:
Type of feeding "breast or artificial"
Weaning: Onset, Foods, Method & Amount.
Supplements "Vitamins & Minerals".
9. Vaccination History: Time of vaccines.
10. Past history: As general.
11. Family History:
Maternal age.
Consanguinity.
T
8. Nutritional History: H
Type of feeding (breast or artificial) E
Breast: frequency Adequacy.
S
Formula: Amount per feed, Frequency &
A
Concentration.
M
E
9. Vaccination History:
The Same
Did he receive any vaccines?
11. Family History: The Same
Consanguinity. +
Age of the mother. Family history of neonatal jaundice
Any siblings (normal or not). in any baby.
Abortion or stillbirth.
Did they need admission to ICU?
N.B.:
The onset of different types of jaundice:
In physiological neonatal jaundice 2nd or 3rd Day of life.
In pathological neonatal jaundice "unconjugated hyperbilirubinemia" in the 1st
Day of life.
In cholestasis "conjugated hyperbilirubinemia" in the 10th Day of life.
In breast milk jaundice in the 2nd day with discomfort after feeding.
Rickets
Yes No
1. Welcome the patient.
2. Introduce yourself to the patient.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint:
Delayed walking Delayed dentition.
Chest infection "cough, wheezes or dyspnea".
5. Present History:
Analysis of the complaint.
Symptoms of the same system:
Recurrent chest infections.
Recurrent diarrhea, Constipation or
Anorexia.
Excessive sweating.
Exposure to sun light (housing condition).
Convulsions or carpo-pedal spasm.
Any observed bone deformities.
Symptoms of the other systems:
Hepatic or urinary problems.
Medical attention:
Investigations, treatment "Vit. D injections"
& hospitalization.
6. Perinatal History:
Antenatal:
Natal history:
Duration of pregnancy: history of
prematurity or twins.
Neonatal history.
7. Developmental History:
Motor: Delayed walking
Neck support Sitting with support.
Sitting without support Standing Walking.
Mental.
Time Vaccine
In the first 3 months: BCG
2 months: Polio Sabin (OPV) / DPT / HBV
4 months: Polio Sabin (OPV) / DPT / HBV
6 months: Polio Sabin (OPV) / DPT / HBV
9-10 months: Measles
15 months: MMR
18 months: Polio Sabin (OPV) / DPT
Marasmus
1. Welcome the patient.
2. Introduce yourself to the patient.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint:
Loss of weight or failure to gain weight.
Chest infection "cough, wheezes or dyspnea".
Gastroenteritis "diarrhea and vomiting".
5. Present history
Analysis of the complaint.
Symptoms of the same system:
Recurrent chest infections.
Recurrent diarrhea or Persistent vomiting.
Symptoms of malabsorption: bulky
offensive.
Symptoms of hunger: continuous cry,
scanty stools & anxiety.
Kwashiorkor
1. Welcome the patient.
2. Introduce yourself to the patient.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint:
Swelling of lower limbs "may be the dorsum of
the foot only".
Chest infection "cough, wheezes or dyspnea".
Gastroenteritis "Diarrhea & Vomiting".
5. Present History:
Analysis of the complaint: edema .
Symptoms of the same system:
Recurrent chest infections.
Recurrent diarrhea or Persistent vomiting.
Symptoms of the other systems:
Hepatic or Renal or Cardiac (to exclude
other causes of edema).
Medical attention:
Investigations, treatment & hospitalization.
6. Perinatal History:
Antenatal.
Natal history:
Duration of pregnancy: history of
prematurity or twins New brother (maternal
deprivation).
Neonatal history.
7. Developmental History: may be delayed
Motor: Delayed walking
Neck support Sitting with support.
Sitting without support Standing Walking.
Mental.
8. Nutritional History: "Very Important"
Type of feeding "breast or artificial"
Scanty breast milk Formula feeding "Diluted or
decreased frequency".
8. Nutritional History:
Type of feeding "breast or artificial"
Weaning: Onset, Foods, Method & Amount.
Supplements: "Vitamins & Minerals".
9. Vaccination History: Time of vaccines.
10. Past History.
11. Family History:
Maternal age.
Consanguinity.
Others "3":
Palpitation: related to exertion.
Chest pain (pericarditis).
Complications: Infective endocarditis
(fever, strokes) & Rheumatic activity
(arthritis).
Symptoms of the other systems.
Medical attention:
Investigations "ECHO, ECG & X ray", treatment
"digitalis, diuretics, long acting penicillin" &
hospitalization.
6. Perinatal History.
7. Developmental History.
8. Nutritional History.
9. Vaccination History.
10. Past History:
Recurrent tonsillitis Any previous activity.
11. Family History:
Similar condition in the family.
T
7. Developmental History: H
Motor: E
Neck support Sitting with support.
Sitting without support Standing Walking. S
Mental: A
Social smile Maternal recognition Speech. M
E
8. Nutritional History: in short.
9. Vaccination History: Time of vaccines.
10. Past History:
Significant events: Trauma, Surgery & The Same
Accidents.
11. Family History:
Consanguinity. The Same
Similar condition in the family.
Nephrosis
1. Welcome the patient.
2. Introduce yourself to the patient.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint:
Puffiness of the eyelid.
Abdominal distention.
Lower limb edema.
5. Present History:
Analysis of the complaint: edema march,
relation to the time of day.
Symptoms of the same system:
Urinary symptoms "change in the
amount or in the color ".
Headache " hypertension".
Symptoms of complications:
Chest infection: fever, dyspnea.
Skin infection.
Abdominal: Pain, Vomiting &
Diarrhea.
Symptoms of the other systems:
Hepatic or Cardiac (to exclude other
causes of edema).
Rash, Arthritis (with lupus).
Medical attention:
Investigations, treatment (steroids or
immunosuppressive: start of therapy and the response)
& hospitalization.
6. Perinatal History:
Antenatal.
Natal history.
Neonatal history.
7. Developmental History.
8. Nutritional History:
To exclude nutritional edema.
9. Vaccination History.
10. Past History:
Previous attacks: relapses.
11. Family History:
Consanguinity.
Similar condition in the family.
N.B:
To exclude infections.
Abdominal History
1. Welcome the patient.
2. Introduce yourself to the patient.
3. Personal History:
Name: full name. Age & Date of birth.
Sex. Residence.
4. Complaint:
Abdominal distention, Hematemesis.
Jaundice, Abdominal pain.
5. Present History:
Analysis of the complaint.
Symptoms of the same system:
Hepatobiliary:
Jaundice (denotes hepatitis or liver cell failure): Color of urine and stool,
Itching, History of previous blood transfusion, Bleeding tendency,
Lower limb edema & Encephalopathy.
Abdominal distention (denotes organomegly or ascites): Onset, Course &
duration.
Hematemesis (denotes portal hypertension): Number of attacks, Amount
of bleeding "Color contain food particles or not", Bleeding from
rectum, Melena & Needs for blood transfusion.
Abdominal pain: Site of pain, Severity, Nature, Relation to meal
radiation, What increase & What decrease.
Blood disease:
Leukemia: Prolonged fever, Arthralgia or arthritis, Purpuric eruptions
& Any swellings (lymph nodes).
Chronic hemolytic anemia: Pallor & History of repeated blood
transfusion.
General toxemic symptoms: Night fever, Night sweat, Anorexia &
Loss of weight.
Lower GIT: Diarrhea "frequency, consistency, volume & color"
Constipation.
Upper GIT: Vomiting, Dysphagia, Dyspepsia & Flatulence.
Symptoms of the other systems.
Medical attention:
Investigations, treatment & hospitalization.
6. Perinatal History:
Antenatal: Medical health during pregnancy.
Natal history.
Neonatal History: History of umbilical vein catheterization or umbilical sepsis.
7. Developmental History.
8. Nutritional History.
9. Vaccination History: Time of vaccines.
10. Past History:
Significant illness: Chest, Cardiac, Renal, Hepatic, GIT, CNS & Rheumatic fever.
Specific infections: TB or Bilharziasis.
Significant events: Trauma, Surgery & Accidents.
11. Family History:
Consanguinity.
Similar condition in the family.
Family history of chronic hemolytic anemia.
Family history of liver disease.
Source:
Notes of
Prof. Dr Mustafa Zakaria.
Photos Discussion
Mongolian spots:
What is the diagnosis of this condition?
Mongolian spot in lumbosacral area.
Bluish discoloration of an area of skin, it is of no significance.
What is the differential diagnosis of this condition?
1. Bruises "due to trauma or child abuse".
2. Ecchymoses "due to bleeding tendency".
What is the treatment?
No thing as it fades gradually as the infant grows older, so what is needed
is Reassurance.
Neonatal gynecomastia:
What is the diagnosis of this condition?
Neonatal gynecomastia: breast enlargement in both sexes during the first weeks of life due
to transplacental passage of maternal hormones.
What is the treatment?
No thing except reassurance and - It should not be squeezed.
Milia:
What is the diagnosis of this condition? Milia.
What is the nature of this condition?
It is epidermal cysts (white or yellow in color) found on the nose, chin
& forehead.
What is the prognosis?
It is benign lesion, it exfoliate and disappear spontaneously within
the first weeks, no treatment is necessary.
Moro reflex
It is the most common neonatal primitive reflex.
How can you elicit?
Dropping the head with the examiners hand supporting the body,
Making a loud noise near the infants ear, or
Sudden withdrawal of the blankets from underneath
the infant.
What is the significance of this reflex?
Normal response Normal CNS.
Absent Serious CNS affection:
Intracranial birth injury.
Cerebral depression by drugs.
Asphyxia or prematurity.
Asymmetrical response Fracture clavicle - Erbs palsy.
Persistence of the reflex beyond 6 months Cerebral palsy.
Cephalhematoma:
What is the diagnosis of this condition?
1. Cephalhematoma
2. Rt. parietal cephalhematoma and vacuum extraction site.
It is a subperiosteal hemorrhage, limited by suture lines, due to traumatic delivery or
ventous.
What are the expected clinical manifestations?
Anemia & jaundice.
What is the treatment?
Conservative.
Aspiration is contraindicated.
Erb's palsy:
What is the diagnosis of this condition?
Flaccid paralysis of the left upper limb.
It is held in adduction, internal rotation and pronation
(policeman tip).
Moro reflex is absent on the affected side, but grasp
reflex is intact.
What is the etiology of this condition?
It results from injury of 5th and 6th cervical nerve usually
due to traumatic delivery.
What is the treatment of this condition?
Physiotherapy from second week.
Facial palsy:
What is the diagnosis of this condition?
(1) (2)
1. Left facial palsy.
2. Right facial palsy.
Weakness of facial muscles, drooping of mouth and inability to close the eye on the
affected side.
Umbilical granuloma:
Congenital hypothyroidism:
What is the diagnosis of this condition?
Congenital hypothyroidism.
What are the clinical features of this condition?
Coarse facies, large protruding tongue & umbilical
hernia.
How to prevent this condition?
Routine screening of all newborns within a few
days of birth.
Hydropes fetalis:
What is the diagnosis of this condition?
Hydropes fetalis.
What are the clinical features of this condition?
Gross generalized edema, Ascites & Heart failure.
How to prevent - why this condition becoming
uncommon?
Uncommon since the prevention of disease with anti-
D immunoglobulin.
What is the treatment of this condition?
Exchange transfusion & Ventilatory support.
Phototherapy
What are the types of phototherapy?
White, Blue or Green "wave length: 450 - 460 nm".
What is the indication?
Bilirubin level above 15 mg% "full term - unconjugated
Jaundice".
What are the side effects?
Hyperthermia, Dehydration, Loose stool & Skin rash.
Necrotizing enterocloitis:
Imperforate anus
What is the diagnosis of this condition?
Imperforate anus.
How to diagnose this condition?
It is usually diagnosed during routine examination immediately after
birth.
What to do after its diagnosis?
Detailed examination as other anomalies are
found in 60% of cases.
Most cases need colostomy performed in the
neonatal period.
Surgical repair is performed later on.
Hypospadias:
What is the diagnosis of this condition?
Hypospadias: the urethral orifice is situated on
the ventral aspect of the penis at a site proximal
to the normal opening.
Tongue tie:
What is the diagnosis of this condition?
Tongue tie.
What is etiology of this condition?
It is due to short lingual frenulum.
What are the problems of this condition?
No problems, it rarely interferes with eating
or speech generally need no treatment.
(1) (2)
What is the diagnosis of this condition?
Talipes equinovarus (1).
What is the differential diagnosis of this condition?
Positional talipes (2) foot can be fully dorsiflexed to touch the front of the lower leg. "Can be
passively corrected".
What is the treatment of this condition?
Splinting, but surgical release may be needed.
Microcephaly:
What is the diagnosis of this condition?
Microcephaly "head circumference below the 3rd centile for age".
What are the causes of this condition?
Congenital infections: TORCH.
Causes of cerebral palsy: enumerate some causes.
Meningomyelocele:
Oral moniliasis:
Perineal moniliasis:
Neonatal conjunctivitis:
Measles:
Roseola infantum:
Scarlet fever:
Skin peeling
Impetigo contagiosa:
What is the diagnosis of this condition?
Impetigo contagiosa.
What is the etiology of this condition?
Infection by gram positive cocci e.g.
staphylococcus aureus.
What is the treatment of this condition?
Local fucidenic acid cream.
Extensive lesions should be treated with systemic flucloxacillin.
Chickenpox:
Urticaria:
What is the diagnosis of this condition?
Urticaria. It is a common allergic
manifestation.
What are the possible causes?
Exposure to allergens: insect bite, drugs or
certain foods.
What are the other features of the disease?
Itching, wheals & edema around the eyes and mouth.
What are the possible complications?
Laryngeal edema and airway obstruction.
What is the treatment of this condition?
Subcutaneous adrenaline and systemic steroids.
Purpura:
What is the diagnosis of this condition?
Purpura for differential diagnosis.
What are the possible causes? "Causes of purpura"
ITP, Aplastic anemia & Leukemia.
Henoch-Schonlein purpura:
Purpura fulminans:
Atopic eczema:
Scabies:
What is the etiology?
Infestation with a mite.
What is the main symptom of this condition?
Itching; usually other members in the family
have the disease & have itching.
What re the common sites for this condition?
Palm, Soles & Trunk.
What is the treatment?
Permethrin cream 5% .
Hemophilia:
Dehydration:
What is the diagnosis of this condition?
Sunken eyes: moderate or severe dehydration.
Loss of skin turgor: moderate or severe dehydration; It is a
complication of severe gastroenteritis.
What are the possible other features?
Depressed fontanelle, loss of skin turgor & acute weight loss.
Sunken eyes & dry tongue.
What is the main line of treatment? Rehydration.
Why infants are more prone to such problem?
Greater surface area to weight ratio.
Higher basal fluid requirement (100 ml/kg).
Osteogenesis imperfecta:
Uncommon genetic disease, characterized by bone fractures, blue
sclera and defective dentition.
Rickets:
Kwashiorkor:
Source:
Notes of
Prof. Dr Mohamed El-Nagger.
CT scan comment
1) Type of CT "written on the slide":
Plain CT.
Contrast enhanced CT.
2) Level of the cut:
Supra ventricular falx celebri
Ventricular.
Posterior fossa level "Infratentorial level".
3) Lesion:
Nature:
Hyper or Hypo dense lesion.
Ventricular "dilatation or compression".
Site of the lesion "i.e.: left frontal lobe, right parietal lobe "
4) Final diagnosis.
CT scan scheme
1) Look at the ventricles: Dilated Hydrocephalus.
Congenital communicating: all ventricles are dilated.
Congenital obstructive: all dilated except the 4th ventricle.
Acquired: due to brain tumor, intraventricular hemorrhage or ventriculitis.
2) Look at the brain sulci and gyri:
Brain atrophy: Prominence of cerebral sulci.
Brain edema: loss of sulci.
3) Look at the brain tissue:
Hyperdense lesion:
Cerebral calcification: no mass effect (compression) - mirror image.
Intracranial hemorrhage: mass effect - it may be intracerberal,
intraventricular, subdural or extradural.
Hypodense lesion:
Cerebral infarction.
Hemorrhagic infarction: mixed hypodense and hyperdense areas.
Localized lesion: with contrast - mass effect is present.
Brain tumor: solid (total enhancement) or cystic (ring enhancement but
with thick irregular wall)
Brain abscess: thin wall regular- ring enhancement.
A
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Dilated bodies of lateral ventricle.
B
Plain CT scan of head.
Ventricular level "horns of lateral ventricle & 3rd ventricle".
Dilated horns of lateral ventricle.
C
Plain CT scan of head.
Ventricular level "horns of lateral ventricle & 3rd ventricle".
Dilated 3rd ventricle.
D
Plain CT scan of head.
Posterior fossa level "4th ventricle".
Dilated 4th ventricle.
A
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Dilated bodies of lateral ventricle.
B
Plain CT scan of head.
Ventricular level "horns of lateral ventricles & 3 rd ventricle".
Dilated horns of lateral ventricle.
C
Plain CT scan of head.
Ventricular level "horns of lateral ventricle & 3rd ventricle".
Dilated 3rd ventricle.
D
Plain CT scan of head.
Posterior fossa & 4th ventricle.
Normal " not dilated"4th ventricle.
A
Plain CT scan of head.
Supra ventricular level.
Increased prominence of:
Cerebral sulci,
Inter hemispheric fissure &
Subarachinoid space "reduced cerebral mass prominent CSF
spaces".
Brain atrophy
B
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Increased prominence of:
Cerebral sulci,
Inter hemispheric fissure &
Ventricular system "passive dilatation due to reduced cerebral mass".
Brain atrophy
A
Plain CT scan of head.
Supratentorial level.
Diffuse cerebral hypo density with loss of grey-white interface loss of all supra ventricular
spaces "sulci & CSF spaces".
B
Plain CT scan of head
Infra tentorial level "posterior fossa".
Diffuse cerebra hypo density with loss of grey- white interphase loss of all infratentorial
spaces.
A
Plain CT scan of head.
Supra ventricular level.
Hyper dense lesion "diffuse, small dots", scattered all over the cortical tissue.
B
Plain CT scan of head.
Ventricular level "lateral ventricular horns & 3 rd ventricle".
Hyper dense "bilateral, nodular", protruding to the horns of lateral ventricle.
C
Pain CT scan of head.
Coronal section.
Hyper dense area, in supra-sellar region "".
D
Plain CT scan of head.
Ventricular level "lateral ventricular horns & 3rd ventricle".
Hyper dense lesion "bilateral, symmetric", at the basal ganglia region.
A
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Hyper dense lesion in the left frontopraietal lesion with mass effects
compression of left lateral ventricle.
Intracerebral hematoma
B
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Hyper dense area affecting both lateral ventricles with ventricular dilatation.
Intraventricular hemorrhage
C
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Hyper dense concavo-convex lesion, affecting left fronto-parietal region with mass
effect "compression of lateral ventricle".
Associated intracelebral hematoma "The arrow".
Subdural hematoma
D
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Hyper dense biconvex lesion affecting the right fronto-parietal region "the arrow" with
mass effect compression of right ventricle.
With left parietal fracture "The arrow".
Epidural hematoma
A
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
2 hypo dense localized areas in the right occipital region and left parietal region.
Localized infarction
B
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Hypo dense extensive lesion in left parieto-occipital region.
Extensive infarction
C
Plain CT scan of the head.
Ventricular level ( bodies of lateral ventricle)
Mixed lesion Hyper dense area "hemorrhage" in left tempo-parietal region.
Hypo dense area "infarction".
D
The same patient but at a lower level.
Ventricular level "lateral ventricular horns & 3 rd ventricle".
Mixed: Hyper dense area "hemorrhage" in left tempo-parietal region.
Hypo dense area "infarction".
Hemorrhagic infarction
A
Plain CT scan of head.
Ventricular level "bodies of lateral ventricle".
Big hypo dense area in right parietal region compressing the right lateral ventricle.
B
Contrast enhanced CT for the same patient.
Ventricular level "bodies of lateral ventricle".
Big hypo dense area with ring enhancement of abscess capsule in the right parietal
region compressing the right lateral ventricle.
C
Contrast enhanced CT.
Ventricular level "bodies of lateral ventricle".
Small hypo dense area with ring enhancement of abscess capsule in the left fronto-
parietal region.
D
Contrast enhanced CT.
Supra ventricular level.
2 small hypo dense areas with ring enhancement of abscess capsule in left parieto- occipital
region.
Multiple brain abscesses
A
Contrast enhanced CT.
Infraventricular level "posterior fossa & 4th ventricle".
Hypo dense "large & cystic" lesion, in the left cerebellar lobe with ring enhancement of tumor.
Cerebellar astrocytoma
B
Contrast enhanced CT.
Infra ventricular level "posterior fossa & 4th ventricle".
Hyper dense "midline, rounded" lesion, in the posterior fossa with ventricular dilatation
"obstructive hydrocephalus".
Medulloblastoma
C
Contrast enhanced CT.
Ventricular level "lateral ventricular horns & 3rd ventricle".
Hyper dense "rounded, midline" lesion, in pineal body region.
Pinealoma
D
Contrast enhanced CT.
Ventricular level "lateral ventricular horns & 3rd ventricle".
Hyper dense large lesion, in the left occipital horn with dialed lateral ventricle.
A
Contrast enhanced CT scan head different patient.
Ventricular level "bodies of lateral ventricles".
Hyper dense area affecting both lateral ventricles with ventricular dilatation.
B
Ventricular level "bodies of lateral ventricle".
Dilated lateral ventricle due to ventriculitis "enhancement of epindymal lining of ventricle".
C
Contrast enhanced CT.
Infra ventricular level "posterior fossa & 4th ventricle".
Hyper dense "midline, rounded" lesion, in the posterior fossa compressing the 4th ventricle.
D
The same patient but at higher level "3rd ventricle and horns of lateral ventricles" showing
ventricular dilatation.
Linear skull fracture in the right frontal bone "The arrow" with left subdural effusion.
Depressed skull fracture in the right parietal bone with bone fragmentation.
Sources:
Notes of
Prof. Dr Mustafa Zakaria &
Lectures of Prof. Dr El-Belidy.
(A) (B)
Plain X-ray chest.
Postero-anterior view.
The Patient is not well centralized.
Costophrenic angles are free on both sides.
Cardio-thoracic ratio increased about 70% (A), about 65% in (B) denoting
cardiomegaly
Cardiophrenic angle on the left side is obtuse(left ventricle dilatation)
Straight left cardiac border "waist obliteration": mitralized heart: dilated left
atrium and pulmonary artery.
Bulging right cardiac border "right atrium dilatation" (A).
Increase pulmonary vascular markings "hilar congestion extending upward".
(A) (B)
(C)
Plain X-ray chest.
Postero-anterior view.
The Patient is not well centralized.
Costophrenic angles are free on both sides.
Cardio-thoracic ratio increased about 70% in (A), 60 % in (B, C) denoting cardiomegaly.
Cardiophrenic angle on the left side is not visualized in (A) obtuse in (B, C)
denoting left ventricle dilatation.
Prominent pulmonary conus "pulmonary artery dilatation".
Bulging right cardiac border "right atrium dilatation".
Increase pulmonary vascular markings "hilar congestion extending upward in both lungs".
Pneumopericardium
Isolated Dextrocardia
(A) (B)
(A) (B)
(C)
Plain X-ray chest.
Postero-anterior view.
The Patient is not centralized.
Costophrenic angles are free on both sides.
Cardio-thoracic ratio increased about 70%.
Cardiophrenic angle on the left side is acute "right ventricle dilatation".
Marked bulge of the right border "right atrium dilatation".
In (A) the base of the heart is not narrow as expected in TGA due to overlapping thymus
shadow; in (B & C) the base is narrow.
Increased pulmonary vascular markings "lung plethora", in (B) there is in addition
heterogeneous opacity in the upper and middle zone of the right lung "pneumonia".
Chest X-ray
P: Plain X-ray.
P: Postero-anterior view.
P: Patient is centralized.
T: Trachea.
A: Costophrenic Angle on
the same side of the lesion.
L: Lesion.
3 Groups of lesions:
1. Unilateral opacity:
Pleural effusion "massive or moderate".
Lung collapse "total or lobar collapse".
Lobar pneumonia.
3. Unilateral translucency:
Pneumothorax.
Emphysema "congenital lobar".
2. Lobar pneumonia
3. Lung collapse
(A) (B)
Plain X-ray chest.
Postero-anterior view.
The Patient is centralized.
There is homogenous opacity occupying all the "left hemithorax in A"; "the right
hemithorax in B".
The mediastinum "heart & tracheal air column" is shifted to the same side of the lesion.
(A) Left side massive lung collapse (B) Rt. side massive lung collapse
(A) (B)
Plain X-ray chest.
Postero-anterior view.
The Patient is centralized.
Costophrenic Angle on the right side it is obliterated by homogenous opacity raising to
the axilla "pleural effusion".
The middle and lower zone of the right lung show a cavity with well-defined thick outline
(abscess wall).
The lower part of the lesion is homogenous with transverse upper border "fluid" while
the upper part of the lesion is jet black "air".
In (A) there is also heterogeneous opacity on the lower lung third "pneumonia".
The heart and tracheal air column are central.
Rt. side lung abscess, Rt. side pneumonia with pneumatoceles &
Rt. side mild pleural effusion
Most probably due to staph or Klebsiella pneumonia
Pneumothorax
(A) (B)
Plain X-ray chest and abdomen; Postero-anterior
view.
The Patient is centralized.
The right hemithorax shows hypertranslucency
with absent bronchovascular markings "jet-black":
pneumothorax.
The right lung appears as homogenous opacity
shifted against the vertebral column "compression
collapse".
Intercostal tube is seen draining the
pneumothorax "present in A & B"
The left lung shows homogenous opacity, which
may be the original disease "RDS" or may be lung
collapse.
Marked shift of the heart and tracheal air column to the left side.
(A) (B)
Plain X-ray chest and abdomen Postero-anterior view (A, B).
The patient is centralized.
Costophrenic angles are free on both sides.
The left hemithorax shows heterogeneous opacities present in the lower part
simulating pneumonia, intermingled with multiple radiolucent cystic shadows
simulating pneumatocele "herniated intestinal loops".
The heart and tracheal air column are shifted to the opposite side of the lesion "right side".
Lateral view (B): intestinal loops appear in the retrosternal space pushing the heart
backward.
1. Intestinal obstruction:
2. Duodenal atresia:
Plain X-ray of the chest and abdomen
upright position.
Patient not centralized.
There are 2 large areas with air fluid levels
"double bubble sign".
4. Intussusception:
5. Pneumoperitoneum:
Plain X-ray chest and abdomen upright
position.
Free air "hypertranslucent area) in the
peritoneal space under the diaphragm above
the liver.
The abdomen is distended with gasses in (B).
(
A) (B)
6. Active rickets:
Sources:
Dr Tamer Abdel Hamid.
Round Exams Questions.
2. A 10 months old child, his weight is exactly on the curve of 5th percentile for his age &
he is not pale. According to IMCI:
a. He is classified as low weight. ( )
b. He is classified as not low weight. ( )
c. He is classified as anemia. ( )
d. You should give the mother advice about how to feed the child to follow at home. ( )
e. He should be referred urgently to the hospital. ( )
3. 3) An infant aged 10 months with diarrhea for 12 days; he is irritable, thirsty, with
sunken eyes and slow skin pinch. According to IMCI:
a. He is classified as having severe persistent diarrhea. ( )
b. He is classified as having persistent diarrhea. ( )
c. He should be treated with extra fluid intake only "plan A". ( )
d. He should be treated with oral dehydration with ORS "plan B". ( )
e. He should be treated with IV Rehydration "plan C". ( )
4. An infant aged 11 months has fever 39 C with history of convulsions yesterday and he
convulsing now, should he managed with which of the following:
a. Wait until convulsions stops spontaneously, then re-examine. ( )
b. Refer urgently without giving any treatment. ( )
c. Refer urgently after giving anti-convulsant treatment. ( )
d. Give oral antibiotics and send the patient home. ( )
e. Give anti-pyretic before referral. ( )
5. A 14 months old child feverish without neck rigidity having diarrhea for 5 days with
blood in stools. He is irritable, thirsty, his eyes are sunken & his skin pinch goes back
slowly. According to IMCI :
a. His dehydration degree is classified as severe dehydration. ( )
b. His fever is classified as fever possible bacterial infection. ( )
c. He should be treated with IV fluids "plan A". ( )
d. He should be treated with ORS in the clinic "plan B". ( )
e. Oral antibiotics should be used to manage his condition. ( )
6. A 4 months old child has high fever since 3 days, his temp is 39 C there is no neck
rigidity but there is history of convulsions yesterday & he is not convulsing now.
According to IMCI:
a. Start oral anticonvulsant immediately as convulsions may recur. ( )
b. Refer urgently to the hospital. ( )
c. CNS infection can be ruled out due to absence of neck rigidity. ( )
d. His fever is classified as fever possible bacterial infection. ( )
e. Give antipyretic immediately. ( )
7. A 30 months old child having fever 38.2 C , mild earache & discharge from the ear for 3
weeks , but no pus seen coming out of the ear & no any other finding.
According to IMCI classification & management:
a. His ear problem is classified as having acute ear infection. ( )
b. His ear problem is classified as having chronic ear infection. ( )
c. Don't give any form of treatment for his ear condition; just referral for ENT specialist
for consultation. ( )
d. His fever is classified as fever bacterial infection unlikely. ( )
e. His fever is classified as fever possible bacterial infection. ( )
8. A child with bloody diarrhea for 10 days, he is irritable, thirsty, with sunken eyes &
his skin pinch goes back very slowly. According to IMCI classification & management:
a. His classification includes sever persistent diarrhea. ( )
b. His classification includes persistent diarrhea. ( )
c. His classification includes some dehydration. ( )
d. No need to give antibiotics to treat such diarrhea. ( )
e. IV fluid therapy "plan C" is needed for such patient. ( )
9. A child aged 12 months suffering from attack of acute diarrhea in the last 2 days, on
examination; he is playing, he doesn't want to drink, he has sunken eyes & his skin
pinch goes back immediately. There is no blood in the stools.
a. According to IMCI his condition is classified as some dehydration. ( )
b. The patient can be sent home instructing the mother to increase fluid intake to
compensate for fluid lost in diarrhea. ( )
c. The patient should be receive oral anti-diarrheal at home to be cured from the attack of
diarrhea. ( )
d. Encourage early feeding to prevent malnutrition. ( )
10. A child aged 2 years suffered from high fever yesterday, today he develop an attack of
convulsions followed by deterioration of level of consciousness. On examination we
found that the child is unconscious with neck stiffness & high fever 39 C.
a. According to IMCI his fever is classified as very sever febrile disease. ( )
b. According to IMCI, C.T. scan should be done immediately to confirm cerebral
infarction. ( )
c. CSF analysis is important to confirm your diagnosis. ( )
d. Presence of bulging fontanel can you confirm CNS infection. ( )
11. A child aged 36 months with sore throat, his Temp. is 39 C without stiff neck, he is not
able to drink; his throat is congested with exudates on the tonsils. According to IMCI:
a. His throat condition is classified as streptococcal sore throat. ( )
b. His fever is classified as fever possible bacterial infection. ( )
c. His fever is classified as very sever febrile disease. ( )
d. He should be referred urgently to the hospital. ( )
e. Send him home with oral antibiotics. ( )
12. A feverish child with ear problem in the form of discharge coming out of the ear for 5
days, but no pus is seen coming out of the ear during examination & on other
finding. According to IMCI :
a. He is classified as acute ear infection. ( )
b. He is classified as no ear infection. ( )
c. It is a mild condition needs no treatment a part from ENT consultation for reassurance.( )
d. Give him oral antibiotic for ten days. ( )
e. His fever is classified as fever possible bacterial infection. ( )
13. A child aged 2 years suffered from high fever since 2 days, associated with agonizing
ear pain in the left ear, one day later the pain disappear & yellow discharge came out
of the ear. On examination we found pus coming out of the ear & there is no tender
swelling behind the ear.
a. According to IMCI his ear problem is classified as acute ear infection. ( )
b. According to IMCI his fever is classified as fever bacterial infection unlikely. ( )
c. There is no need to give any form of antibiotics as pus has been coming out. ( )
d. Drying the ear & removing the pus is a good adjuvant to therapy. ( )
14. A child aged 12 months suffering from attack of acute diarrhea in the last 2 days; on
examination, he is irritable, thirsty, with sunken eyes & slow skin pinch, there is no
blood in stools.
a. According to IMCI the condition is classified as some dehydration. ( )
b. The patient should receive ORS solution to correct his dehydration state before he
leaves the hospital. ( )
c. The patient should receive oral antibiotics at home to be cured from the attack of
diarrhea. ( )
d. Breast feeding should be stopped until diarrhea is resolved. ( )
17. A child with diarrhea, he is irritable, thirsty, having sunken eyes & very slow skin
pinch. According to IMCI:
a. He is classified as having some dehydration. ( )
b. He is classified as having severe dehydration. ( )
c. He should receive antibiotics to treat the cause of diarrhea. ( )
d. He should be treated with plan B. ( )
e. He should be treated with plan C. ( )
18. An 11 months old child with cough, his respiratory rate 60/ min & he has chest
indrawing. According to IMCI:
a. Give oxygen immediately & wait for some times, then re-evaluate. ( )
b. Do X-ray & tell his mother to bring him back tomorrow. ( )
c. Refer urgently without giving any treatment. ( )
d. Refer urgently after giving pre-referral treatment. ( )
e. Give him bronchodilators to improve oxygenation. ( )
19. A 8 months old child with cough, his respiratory rate 30/min & no chest indrawing
but he is wheezy:
a. Give him oxygen IV fluids immediately because he may deteriorate at any moment. ( )
b. Give oral antibiotics for five days. ( )
c. Do not give antibiotics. ( )
d. Give bronchodilators to treat wheezes. ( )
e. Do not give bronchodilators because it is mild condition & doesnt deserve treatment.( )
20. A 12 months old child with cough, he is considered having fast breathing according to
IMCI protocol:
a. If his respiratory rate is 50 breath/min or more. ( )
b. If his respiratory rate is more than 50 breath/min. ( )
c. If his respiratory rate is 40 breath/min or more. ( )
d. If his respiratory rate is more than 40 breath/min. ( )
e. If his respiratory rate is more than 60 breath/min. ( )
21. A 15 month old child with fever 38.8c & stiff neck:
a. Refer urgently to hospital. ( )
b. CNS infection can be rolled out because there is neither bulging fontanel nor
convulsions. ( )
c. CSF analysis is important to roll out CNS infection. ( )
d. X-ray cervical spine immediately to roll out cervical trauma. ( )
e. Oral antibiotics will resolve the problem within a day or two. ( )
22. An 11 months old child with fever 38.5 C. & bloody diarrhea, he is irritable, thirsty,
with sunken eyes & skin pinch goes back slowly.
a. He is classified as severe dehydration. ( )
b. He is classified as some dehydration. ( )
c. He is classified as very severe febrile disease. ( )
d. He is classified as fever possible bacterial infection. ( )
e. He is classified as bacterial infection unlikely. ( )
23. A 12 months old child with diarrhea for 20 days, he is alert, thirsty, his eyes are not
sunken & his skin pinch goes back immediately:
a. He is classified as having no dehydration. ( )
b. He is classified as having some dehydration. ( )
c. He is classified as persistent diarrhea. ( )
d. He is classified as severe persistent diarrhea. ( )
e. Anti-diarrheal drugs are mandatory, otherwise diarrhea will not stop. ( )
25. A child aged 11 months his mother bring him to the hospital clinic complaining of
disturbed level of consciousness, cough, difficult breathing &high fever 39 C; on
examination he is lethargic, his respiratory rate was 45 per min& his throat
congested, no any other abnormality detected. According to IMCI.
a. He has the classification no pneumonia, cough, or cold. ( )
b. He has the classification very sever disease. ( )
c. He needs a follow up after 2 days for his cough classification. ( )
d. His fever is classifies\d as fever bacterial infection unlikely. ( )
e. He is classified as non streptococcal sore throat. ( )
26. A child aged 25 months his mother bring him to the hospital complaining of cough,
hoarseness of voice, sore throat, fever 38 C, his respiratory rate was 35 per min with
stridor while calm & no any other abnormality detected during examination.
According to IMCI.
a. He needs an urgent referral to the hospital. ( )
b. He is classified as having non streptococcal sore throat. ( )
c. He is classified as no pneumonia, cough, or cold. ( )
d. He is classified as very severe febrile disease. ( )
e. His cough classification needs a follow up after 5 days, if not improving. ( )
27. A feverish girl 18 months, her weight 11 kg, her mother bring her to the hospital
complaining of cough associated with severe sore throat so that she cannot eat or
drink any fluids; On examination her Temp. is 39C with respiratory rate 38 per min,
her throat is severely congested with follicular exudates, so that the child cannot eat
or drink any fluid, without any other abnormality. According to IMCI:
a. She has the classification low weight. ( )
b. Her cough is classified as no pneumonia, cough, or cold. ( )
c. Her fever is classified as very severe febrile disease. ( )
d. Give her IM injection of long acting penicillin, antipyretic & send home. ( )
e. Very severe disease is one of his classifications. ( )
28. A male child aged 11 month his mother bring him to the outpatient clinic
complaining of diarrhea with steaks of blood & fever 38.5C since 2 days; On
examination his eyes are sunken, he is thirsty, skin pinch goes back slowly & he is
irritable & no other abnormality detected during examination. According to IMCI:
a. He has the classification of severe dehydration. ( )
b. He has a mandatory follow up after 5 days. ( )
c. He has the classification of dysentery. ( )
d. He has the classification of fever, bacterial infection unlikely. ( )
e. He should be referred to the hospital immediately. ( )
29. A 10 month old child with history of 3 days cough; On examination he is feverish and
has chest indrawing. According to IMCI.
a. He is classified as pneumonia. ( )
b. He is classified as severe pneumonia. ( )
c. He should be managed at home. ( )
d. He must be referred urgently to hospital. ( )
e. Give antibiotics for 5 days and then follow up. ( )
30. A 12 month old infant with diarrhea since 15 days; On examination he had sunken
eyes with skin pinch goes back slowly. According to IMCI:
a. He is classified as acute diarrhea with some dehydration. ( )
b. He is classified as acute diarrhea with severe dehydration. ( )
c. He is classified as persistent diarrhea with dehydration. ( )
d. He is best managed at home. ( )
e. He must be referred to hospital. ( )
31. An 18 month old infant with diarrhea 4 days ago; On examination he has sunken eyes
and skin pinch goes back very slowly. According to IMCI:
a. He is classified as acute diarrhea with severe dehydration. ( )
b. He is classified as acute diarrhea with some dehydration. ( )
c. He is best managed at home. ( )
d. Plan B should start immediately. ( )
e. Plan C should start immediately. ( )
32. A 9 month old baby with pus and discharge from left ear since 15 days. According to
IMCI:
a. Give antibiotics for 5 days and paracetamol. ( )
b. Give antibiotics and refer to hospital. ( )
c. Refer to ENT specialist. ( )
d. He is classified as acute ear infection. ( )
e. Give paracetamol only. ( )
33. A 12 month old baby with fever, diarrhea and vomiting 2 days ago, he had a history of
convulsions 3 months ago following a booster dose of DPT. On examination he is
irritable with sunken eyes. according to IMCI:
a. He is classified as having very severe disease. ( )
b. He must be urgently referred to hospital. ( )
c. He is classified as acute diarrhea with some dehydration. ( )
d. Plan B must start immediately. ( )
e. Is best treated according to plan C. ( )
34. An 11 month old baby with history of running nose, cough and sore throat. According
to IMCI:
a. He is classified as streptococcal sore throat. ( )
b. Best treated with paracetamol and penicillin. ( )
c. He is classified as non streptococcal sore throat. ( )
d. He is classified as having no throat problem. ( )
35. A four years child with ear discharge & fever for last 3 days, there is no ear pain. On
examination there is neither tender swelling behind the ear nor pus coming out of
the ear, the neck is not stiff & there is no any other abnormality. According to IMCI:
a. Oral antibiotic is essential part of therapy. ( )
b. The patient may need ENT consultation. ( )
c. Follow up after2 days if he is still the same. ( )
d. His fever is classified as fever possible bacterial infection. ( )
36. An eight months old child with bloody diarrhea since yesterday, his eyes are sunken,
he is very tired & drinks poorly & his skin pinch goes back slowly. According to IMCI:
a. Start IV line immediately. ( )
b. Both anti-diarrheal & antibiotics are contraindicated. ( )
c. He is classified as very severe disease. ( )
d. He is classified as having diarrhea with some dehydration. ( )
37. A 4 years child with daily 28.5 C for last 7 days. On examination there is no neck
stiffness or any other abnormalities apart from some pallor. According to IMCI:
a. Start oral antibiotic therapy immediately. ( )
b. Refer the child to the hospital. ( )
c. Anemia is a part of the child's classification. ( )
d. His fever is classified as fever possible bacterial infection. ( )
38. A 8 months old child with severe diarrhea & vomiting since yesterday, she can't keep
anything in her stomach except 2-3 spoons of water you give her, her eyes are sunken,
she is thirsty & irritable and her skin pinch goes back slowly. According to IMCI:
a. Start IV line immediately. ( )
b. Don't give anything by mouth to avoid vomiting. ( )
c. She is classified as very severe disease. ( )
d. Refer her urgently to the hospital. ( )
39. A mother brings her 18 months boy, to the outpatient clinic, complaining of bloody
diarrhea & fever since yesterday you measure his temp. it was 37 C; on examination
you find that he is alert, thirsty, with sunken eyes & his skin pinch goes back
immediately. His weight is 9 kg. According to IMCI
a. Some dehydration is a part of his classification. ( )
b. He is classified as low weight. ( )
c. Fever possible bacterial is a part of his classification. ( )
d. The child should return back to the clinic in 2 days if diarrhea isn't stopped. ( )
40. A 14 months child complaining of fever 38.5C, runny nose & sore throat for 2 days,
associated with earache & ear discharge for 5 days; On examination, no abnormality
was detected. According to IMCI:
a. Treatment with antipyretics & safe remedy alone is good therapy. ( )
b. Drying ear by wicking is essential part of therapy. ( )
c. He is classified as having no sore throat problem. ( )
d. He is classified as having fever possible bacterial infection. ( )
41. A male child aged 12 months his mother bring him to the hospital complaining of
cough, difficult breathing & high fever 39C, his respiratory rate was 41 per minute.
He has chest indrawing & no any other abnormality detected during examination .
According to IMCI:
a. He is having a date for follow up after 2 days. ( )
b. This child is having fast breathing. ( )
c. He needs urgent referral to the hospital. ( )
d. His fever is classified a very sever febrile disease. ( )
42. A female aged 15 months, her mother bring her because she has bloody diarrhea for 3
days with fever. On examination she is alert, with normal eyes, very slow skin pinch
& she is thirsty. According to IMCI:
a. She is classified as having severe dehydration. ( )
b. Antibiotic therapy is contraindicated for her. ( )
c. She is classified as having fever bacterial infection unlikely. ( )
d. She needs plan B as a part of her management. ( )
The Key
1. 2. 3. 4. 5. 6.
a. a. a. a. a. a.
b. b. b. b. b. b.
c. c. c. c. c. c.
d. d. d. d. d. d.
e. e. e. e. e. e.
7. 8. 9. 10. 11. 12.
a. a. a. a. a. a.
b. b. b. b. b. b.
c. c. c. c. c. c.
d. d. d. d. d. d.
e. e. e. e.
13. 14. 15. 16. 17. 18.
a. a. a. a. a. a.
b. b. b. b. b. b.
c. c. c. c. c. c.
d. d. d. d. d. d.
e. e. e. e.
19. 20. 21. 22. 23. 24.
a. a. a. a. a. a.
b. b. b. b. b. b.
c. c. c. c. c. c.
d. d. d. d. d. d.
e. e. e. e. e. e.
Neonatology
Source:
Clinical Course Lectures.
Breast feeding
Breast Feeding
True or False:
1- Positioning:
a. The neck of the baby is straight. ( )
b. The body turned towards the mother. ( )
c. The body of the infant is close to mother's body. ( )
d. The infant whole body is supported. ( )
e. There is a Good Positioning. ( )
2- Attachment:
a. The chin touching the breast. ( )
b. The mouth wide opened. ( )
c. The lower lip is turned outward. ( )
d. More areola visible above than below the mouth. ( )
e. There is a Good Attachment. ( )
Sources:
Notes of Prof. Dr Mustafa Zakaria.
Clinical Course Lectures.
Examination
General Examination
1. General look: "2C 2A 1F"
Conscious level: mental changes in kwashiorkor "try to attract the attention of the child &
observe his response".
Cry quality.
Activity.
Appearance: Pallor chronic hemolytic anemia, cyanotic in fallot ., Wasting in CP.
Facies earthy look, cushinoid facies or no specific facies.
How to Comment
The child is conscious, with good cry "he might be asleep" &
activity. He looks
3. Vital signs:
Pulse "peripheral or apical":
Rate.
Rhythm: usually regular.
Character: e.g. water hammer pulse in aortic regurgitation .
Volume: average or large volume in aortic regurgitation "and in chronic Anemia".
Equality on both sides.
Peripheral pulsations Dorsalis pedis & femoral .
Normal values:
Neonate 120-160 beats/minuet.
Infant 110 b/m.
Early childhood 100 b/m.
Late childhood 90 b/m.
How to Comment
Pulse rate is ... Beats / minute, beats are regular with no special
character, volume is average, equal in both sides & peripheral pulsations are felt.
Temperature:
Oral in children above 5 years.
Rectal or axillary in infants "put thermometer in the axilla, so that its bulb is totally
surrounded by skin, then ask the mother to hold the arm to prevent the thermometer
from falling".
Normal Temp. 36.5-37.5 C.
Blood pressure: "cuff 2/3 of the length of the forearm "
Palpatory & auscultatory methods.
If you examine a case of coarctation of the aorta you should measure the pressure in
the lower limb also. "in the femoral artery"
Normal values:
Infant 80/50.
Early childhood 85/55.
Late childhood 90/60.
Regional Examination
4. Head examination:
Head: running the hand over the entire head then comment on.
Shape; in Down syndrome, in rickets "bossing"
Fontanelle: "the baby is sitting"
If Opened hydrocephalus rickets.
Bulging ICT.
Depressed Fontanelle dehydration.
Normal values: one finger closed/6 months
At birth 3 fingers. 1 year 1 finger.
6 months 2 fingers. 1 year closed.
How to measure the anterior Fontanelle:
The baby is sitting.
Measure transverse diameter of the Fontanelle by your right index & ring
fingers 2 fingers.
Try to insinuate your middle finger in between, if you can 3 fingers.
Cranitabes:
Press on the skull bone along the lumbdoid suture, it yield like a Ping Pong ball.
Positive in rickets and hydrocephalus.
Hair:
Silky in Down.
Hair changes in KWA "sparse-light in color; easily detached; gently pull a small group of hair and see
if it is easily removed or not".
Eye:
Shape: lateral upward slunt.
Conjunctiva: Subconjunctival hemorrhage / pallor.
Sclera: jaundice in day light, in the inferior fornix.
Cornea: Keratomalcia in PEM "separate the upper and lower eye lids to observe the cornea".
Pupil: for signs of lateralization "emboli".
Eye ball: Nystagmus.
Eye lid:
Puffy "nephrotic syndrome or heart failure".
Sunken eyes in dehydration "may be in Marasmus".
Ear:
Shape: highly folded.
Position: low set ear in Down syndrome "Draw a line from the inner & outer canthi across the
face The helix is below the line".
Nose:
Shape: depressed nasal bridge.
Ala nasi: working.
Mouth: Infant supine and parents restrain the arm; older child can be sitting.
Lips: Pallor - Angular stomatitis "in PEM".
Palate " hard and soft palate".
Tongue: cyanosis
Teeth eruption " delayed in rickets".
Tonsils (tongue depressor). " Better postpone to the end examination".
Cushinoid facies: in nephrotic syndrome under prolonged steroid therapy.
Mongolid facies: in chronic hemolytic anemia "depressed nasal bridge- Protruding upper
central incisors, maxillar expansion".
5. Neck:
Vessels:
Lymph nodes: face the child then palpate the occipital LN along the hair line, then
feel the pre & post auricular LN then feel upper & lower deep cervical lymph nodes.
Thyroid gland.
Trachea: central or shifted.
6. Upper limbs:
Pallor on the nail bed.
Clubbing.
Simian crease.
Splinter hemorrhage.
Broadening and may be deformity with rickets: convexity of radius and ulna, to
look for it undress the forearm.
Muscle atrophy: in marasmus or in marasmic kwashiorkor "the arm is uncovered,
grasp the biceps or triceps muscle and assess its bulk".
7. Lower limbs:
Pulsations: "femoral and Dorsalis pedis artery" are equally felt on both sides.
Edema: in nephrotic syndrome and in kwashiorkor "press on the dorsum of the foot for few
seconds and look for pitting edema, then chin of the tibia and ascend upward at different levels to
determine the level of edema, unilateral or bilateral".
Clubbing.
Broadening, marfan sign "at the medial maleolous" and may be bowing "the patient is
standing with his lower limbs are undressed rickets".
Loss of fat: in marasmus or marasmic kwashiorkor "grasp a pinch of skin and subcutaneous
fat beneath it, over the thigh and buttock".
Skin of the buttocks and groin: for crackles, fissuring and ulceration in kwashiorkor.
8. Trunk:
9. Thorathic cage:
In rickets: Rossary beads, Harrison sulcus, longitudinal sulcus and pigeon chest.
Heart Examination
Combined Inspection & Palpation:
Shape:
Precordial bulge "or no precordial bulge", scars or dilated veins.
Pulsations
Apex:
Site: < 4y 4th IC space MCL; while > 4y 5th IC space MCL.
Character: systolic bulge or systolic retraction.
Force: forcible or weak.
Localization: diffuse or localized.
Palpable sound & thrill.
Rheumatic heart: on the 6th space outside midclavicular line, localized "or may
be diffuse" hyperdynamic with no thrill.
VSD: apex is in the 5th space usually "or may be in the 4th space", localized.
Fallot: apex is normal. In the 4th space usually "or in the 5th space", localized.
Aortic areas: 1st aortic area 2nd Rt. Space & the 2nd aortic area 3rd Lt. space.
Pulmonary area: "2nd left space"
Left parasternal:
Rheumatic heart: There is pulsation "Rt. ventricular dilatation".
VSD: pulsation and systolic thrill.
Fallot: mild pulsation.
Epigastric area:
Auscultation:
Rheumatic heart:
1. Mitral area "apex":
The first heart sound is muffled -usually- "predominant regurge".
Soft pansystolic murmur, heard maximally over the apex, propagated to the axilla
"mitral regurgitation".
Mid-diastolic rumbling murmur with presystolic accentuation heard over the apex
with no selective propagation "mitral stenosis".
2. Pulmonary area:
Accentuation of the 2 nd heart sound.
Soft ejection systolic murmur.
3. Aortic area: early diastolic soft murmur at the second aortic area.
4. Tricuspid areas: are free.
VSD
Murmurs "VSD":
Site: 3rd and 4th intercostals space at parasternal line.
Area of maximum propagation: all over the precordium.
Character: harsh. Timing: pansystolic.
Sounds "Pulmonary hypertension":
Accentuation of the pulmonary component of the second heart sound.
Fallot
Ejection systolic murmurs heard at the pulmonary area.
Normal other area.
Percussion:
Obsolete.
Abdominal Examination
Inspection:
Others:
Caput medusa: dilated veins around umbilicus portal hypertension.
Pigmentations.
Discharge.
Nodules.
Back & Genetalia.
Any other abnormality:
Scars.
Pigmentations.
Dilated veins.
Palpation:
Superficial palpation:
To gain confidence of the baby.
To detect rigidity.
To detect superficial mass.
Deep palpation: "the knees are flexed to relax the muscle"
Palpate the intra-abdominal organs.
1. Liver
Ways of examination:
One hand method:
Press by finger tips or side of index from right iliac fossa upwards to feel the right
lobe.
From the umbilicus to xiphesternum to feel the left lobe.
Bimanual examination:
Put left hand behind the back of lower ribs.
By the Rt. hand palpate on the abdomen till the costal margin.
Hooking method:
In shrunken liver "oral only".
Dipping:
In tense Ascites.
Push the liver by tips of your fingers.
The liver is felt cm below the Rt. costal margin MCL & cm below
subcostal angel in the middle line. The consistency is ; its border is
; its surface is ; it is "tender or not" & it is "pulstile or not".
2. Spleen
The spleen is felt fingers below the Lt. costal margin MCL. The
consistency is ; its border is ; its surface is ......; it is "tender or not"
& the notch of the spleen can be "felt or not".
3. Kidney
Percussion:
Shifting dullness:
Transmitted thrill:
Ask Pt. to put his hand in the mid line "to abolish transport through Abd. Wall".
Elicit a thrill by your finger from one side.
Feel its transmission from the other side.
Auscultation:
Intestinal sounds.
Hum Portal hypertension.
Rub Pericapsulitis.
Neurological Examination
1. C O M CI:
Conscious level of conscious.
Oriented To time, place and person.
Mentality:
i. Infant from speech & Sphincteric control.
ii. Late childhood from school achievement.
Co-operative.
Intelligence.
2. Motor system "the most important issue":
State of muscles:
Wasting "Bilateral or Unilateral / Proximal or Distal".
Hypertrophy "compare Left to Right".
Pseudo-hypertrophy Duchenne.
Normal.
Abnormal movements:
Fasciculation.
Involuntary movements as chorea.
Tone:
The Results:
Hypotonia LMNL.
Hypertonia UMNL.
Power:
Reflexes:
Superficial reflexes:
1. Planter reflex (S1):
Scratching the outer aspect of the sole of the foot using a key.
Normally: planter flexion.
Abnormally: +ve Babinski Dorsiflexion + Fanning "normal up to 1 year".
1. Biceps (C5,6):
Elbow at angel 120.
Put your finger on the biceps tendon and hit on it.
UL Don't forget to expose the whole muscle while you are doing the test, to see the
response.
Response: flexion of elbow or just fine contraction of the biceps is seen.
2. Triceps (C6,7):
Elbow at angel 90.
Hit the tendon directly.
Response: extension of the elbow, or just contraction of the muscle.
3. Knee (L2,3,4)
Angel of the knee 90.
LL Hit the quadriceps tendon "between patella & tibial tuberosity" Quadriceps
contraction.
4. Ankle (S1)
Angel of ankle: 90 & Angel of knee: 120.
Hit on tendon Achilles contraction of calf muscles.
Clonus
Function:
UL
LL
Cortical:
Tactile localization.
2 point discrimination.
Sterognosis.
Graphesthia.
Sensory
Try to touch either side of the face with cotton while the child closes his eyes.
part
vii. Facial:
Inspecting the facial expression of the baby especially during cry.
.
viii. Vestibulocochlear:
Apply loud sound near his ear turns face towards the sound.
xii. Hypoglossal:
Ask the patient to stick out his tongue tongue is deviated to the weak side.
Emergency MCQs
& Equipments
Sources:
Clinical Course Lectures
Introduced By:
Prof. Dr Mohammed Hisham &
Prof. Dr Ahmed El-Belidy.
Emergency
True or False:
1. Pulse oximeter measure FIO2. [ False ]
O2 saturation.
2. Basic defect in type 2 respiratory failure in CO2 elimination. [ True ]
3. Stridor is a harsh expiratory sound caused by total obstruction. [ False ]
Inspiratory partial.
4. Pt. with O2 saturation <85% is mild hypoxia. [ False ]
Severely hypoxia.
5. Basic defect in type 1 respiration failure in oxygenation. [ True ]
6. Grade 1 stridor means stridor at rest. [ False ]
On exertion.
7. About 20% of cardiac arrest in ICU are respiratory in origin. [ False ]
> 50%.
8. Acute respiratory acidosis is the typical finding in type 1 resp. failure. [ False ]
Hypoxemia acute metabolic acidosis.
9. Antibiotics are routinely given in stridor. [ False ]
Bacterial only.
10. Type II respiratory failure is named pump failure. [ True ]
11. Mechanical ventilation is indicated in all hypoxic children with pneumonia. [ False ]
Hypoxic not responsive to simple measures.
12. There is no difference between simple O2 mask, venturi O2 mask. [ False ]
the venturi deliver precise O2 concentration.
13. Self inflating resuscitation bag can deliver only 100% O2. [ False ]
40 % ---- 100% only if with O2 reservoir.
14. Picture of cardiopulmonary arrest the same as cardiovascular death except the reactive
pupils. [ True ]
15. of the indications of admission in pediatrics is respiratory in origin. [ True ]
16. A case of acute epiglottitis "bacterial" can be treated at home. [ False ]
High fever & sever stridor one of the indication of hospitalization.
17. An 1 year infant with inspiratory sound, retractions and cyanosis is classified as
Grade 3 stridor. [ False ]
Grade 4.
N.B:
Cycling:
Def.: is the way by which the ventilator terminates inspiration.
Types:
Time cycling termination of inspiration after pre-set time.
Pressure cycling termination of inspiration after pre-set pressure.
Volume cycling termination of inspiration after pre-set volume.
SaO2:
> 95 % Normal.
90-95 % Mild hypoxia.
85-90 % Moderate hypoxia.
< 85 % Severe hypoxia.
Devices:
1. Bed side monitor for HR, RR, BP, temp. & O2.
2. DINAMAP for measure Bl. Pressure 83/58.
3. Infant receiving O2 by head pox "SaO2= 90%, HR= 124/min shown by pulse oximeter".
4. Nasal prongs.
5. Venturi O2 mask.
6. Self inflating bag "ambubag" with O2 saturation. Need O2 reservoir to deliver 100%.
7. Flow inflating bag "anesthesia bag" deliver 100% O2 at any time.
8. Pulse oximeter for measurement of O2 saturation.
9. O2 analyzer showing O2 concentration 97% "FIO2".
10. Mechanical ventilator:
Used in cases of resp. failure not responding to other methods of oxygenation.
Blood Reports
Source:
Notes of
Prof. Dr Mustafa Zakaria.
Blood Reports
Comment on the following blood reports and identify
the Confirmatory tests for these conditions:
Example 1:
WBCs: 5-6
4 - 11 Normal
Differential: Normal
MCV: 60 75 - 86 Microcytic
MCHC: 24 27 - 33 Hypochromic
Comment:
The blood picture show: Microcytic Hypochromic anemia with normal
reticulocyte count, indicating possibility of iron deficiency anemia.
Confirmatory tests:
Serum iron, iron binding capacity and serum ferritin.
Example 2:
WBCs: 6 4 - 11 Normal
Differential: normal
MCHC: 20 27 - 33 Hypochromic
Comment:
The blood picture shows: Microcytic Hypochromic anemia with
reticulocytosis indicating possibility of chronic hemolytic anemia.
Confirmatory tests:
Hemolytic profile, iron studies.
Example 3:
WBCs: 2 4 - 11 Leucopenia
Differential: normal
MCV: 78 75 - 86 normocytic
MCHC: 29 27 - 33 normochromic
Comment:
A blood picture of pancytopenia, possibility of aplastic anemia is present.
Confirmatory tests:
Bone marrow aspirate and biopsy are recommended.
Example 4:
WBCs: 5 4 - 11 Normal
Differential: normal
MCV: 81 75 - 86 normocytic
MCHC: 30 27 - 33 normochromic
Comment:
Severe thrombocytopenia with mild anemia, possibility ITP.
Confirmatory test:
Bone marrow aspirate is recommended.
Example 5:
MCV: 82 75 - 86 normocytic
MCHC: 30 27 - 33 normochromic
Comment:
There is leucocytosis "increased polymorph and band cells" indicating
possibility of bacterial infection.
Confirmatory test:
ESR, CRP & proper cultures.
Example 6:
WBCs: 14 4 - 11 Leucocytosis
Polymorph: 35% .
Band: 3% 5%
Lymphocytosis: 65%
MCV: 82 75 - 86 normocytic
MCHC: 30 27 - 33 normochromic
Comment:
There is leucocytosis with predominant lymphocytosis, normal band cells,
possibility of viral infection.
Confirmatory test:
ESR - CRP are recommended to differentiate between bacterial and viral
infections.
Test yourself
Report 1:
MCV: 70 75 - 86
MCHC: 30 27 - 33
??????????
Report 2:
WBCs: 7 4 - 11
Differential: normal
MCV: 54 75 - 86
MCHC: 20 27 - 33
??????????
All team "One Vision One Mission" | 118
Clinical Pediatric Notes "All Team Production" 2009
Report 3:
WBCs: 2 4 - 11
Differential: normal
MCV: 78 75 - 86
MCHC: 29 27 - 33
??????????
Report 4:
WBCs: 5 4 - 11
Differential: normal
MCV: 81 75 - 86
MCHC: 30 27 - 33
??????????
Report 5:
WBCs differential: 5 4 - 11
MCV: 55 75 - 86
MCHC: 25 27 - 33
??????????
Report 6:
WBCs: 13 4 - 11
Polymorph: 35%
Band: 3% 5%
Lymphocytosis: 65%
Hg reticulocytes: 11 11 - 13.5
MCV: 82 75 - 86
MCHC: 30 27 - 33
??????????
Answers
1. Bacterial infection.
2. Hemolytic anemia.
3. Pancytopenia.
4. Thrombocytopenia ITP.
5. Microcytic hypochromic anemia "most probably iron
deficiency anemia".
6. Viral infections.
Source:
Notes of
Prof. Dr Mohamed El-Nagger.
Blood Gases
"In the Emergency Book"
TEST YOURSELF
Example 1:
PaO2: 60 mmHg. PH: 7.1
PaCO2: 25 mmHg. Bicarbonate: 18 mEq/liter.
Comment:
Oxygenation:
Ventilation:
Acid base status:
Comment:
Oxygenation:
Ventilation:
Acid base status:
Comment
Oxygenation: Acid base status:
Ventilation:
Comment:
Oxygenation: Acid base status:
Ventilation:
Comment:
Oxygenation : Acid base status :
Ventilation :
Source:
Notes of
Prof. Dr Mustafa Zakaria.
Urine analysis
Items to be checked:
Physical:
Color: Yellow: normal.
Smoky: in nephritis.
Deep yellow: in hepatitis or cholestasis.
Aspect: Clear: normal.
Turbid: in urinary tract infection "infection" & nephritis "Inflammation".
Reaction: Acidic pH 5-7.
Specific gravity: 1015-1025.
Chemical:
Protein: Nil: normal.
Mild (+) in UTI.
Moderate (++) in glomerulonephritis.
Severe (+++) in nephrotic syndrome.
Glucose: Nil: normal "++ in diabetes mellitus".
Ketones: Nil: normal "++ in diabetic ketosis".
Bilirubin: Nil: normal "+ in hepatitis or cholestasis".
Hemoglobin: Nil: normal "+ in Acute hemolytic crisis".
Microscopic:
RBCs: Normal "1-5 cells /HPF".
Mild microscopic hematuria "10-20/HPF" in urinary tract infection.
Frank hematuria "more than 100/HPF" in glomerulonephritis.
WBCs: Normal "1-5 cells/ HPF".
Pus cells "50-100 cells /HPF" in urinary tract infection and nephritis.
Casts: Hyaline casts: normal.
Red cell cast in glomerulonephritis.
White cell cast in pyelonephritis.
Epithelial cells and crystals may be seen normally.
Exam form:
What does the test show?
What is the most likely diagnosis?
Mention one confirmatory test?
Example 1:
Physical:
Color: Yellow.
Aspect: Clear.
Reaction: Acidic.
Specific gravity: 1030
Chemical:
Protein: Nil.
Glucose: ++
Ketones: ++
Bilirubin: Nil.
Microscopic:
RBCs: 1-2cells/HPF. Casts: Nil.
WBCs: 1-3 cells/HPF.
Example 2:
Physical:
Color: Yellow.
Aspect: Clear.
Reaction: Acidic.
Specific gravity: 1025
Chemical:
Protein: Nil.
Glucose: Nil.
Ketones: Nil.
Bilirubin: ++
Microscopic:
RBCs: 1-2 cells /HPF. Casts: Nil.
WBCs: 1-3 cells /HPF.
Example 3:
Physical:
Color: Smoky.
Aspect: Turbid.
Reaction: Acidic.
Specific gravity: 1018
Chemical:
Protein: ++
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
RBCs: More than 100/HPF. Casts: Red cell cast.
WBCs: Pus cells 50-60 cells /HPF. Epithelial cells: Nil.
Example 4:
Physical:
Color: Smoky.
Aspect: Turbid.
Reaction: Acidic.
Specific gravity: 1025
Chemical:
Protein: ++
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
RBCs: 10-12 cells / HPF. Casts: White cell cast ++.
WBCs: pus cells more than 100/ HPF. Epithelial cells: Nil.
Example 5:
Physical:
Color: Yellow.
Aspect: Turbid.
Reaction: Acidic.
Specific gravity: 1025
Chemical:
Protein: +
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
RBCs: 3-5 cells / HPF. Casts: Nil.
WBCs: Pus cells more than 70-80 Epithelial cells: ++.
cells/HPF.
Example 6:
Physical:
Color: Yellow.
Aspect: Clear.
Reaction: Acidic.
Specific gravity: 1018
Chemical:
Protein: ++++
Glucose: Nil.
Ketones: Nil.
Bilirubin: Nil.
Microscopic:
RBCs: 3-5 cells / HPF. Casts: Hyaline casts.
WBCs: 2-3 cells / HPF. Epithelial cells: ++.
Stool analysis
Items to be checked
Macroscopic:
Color: Yellowish brown.
Consistency: Formed "loose in diarrhea and dysentery Watery in watery diarrhea?"
Reaction: Alkaline.
Mucous: Nil "excess mucous may be seen in dysentery or bacterial
gastroenteritis".
Blood: Nil "may be seen in dysentery or bacterial gastroenteritis".
Microscopic:
RBCs: Normally 0-2 cells / HPF.
More than 100 cells / HPF is seen in dysentery or bacterial gastroenteritis.
WBCs: Normally 0-5 cells / HPF.
Markedly increased in dysentery or bacterial gastroenteritis.
Protozoa: Nil.
E.hisolytica "vegetative form" in amebic dysentery.
Giardia "cyst" in giardisis.
Ova: Nil.
Ankylostoma ova: in Ankylostomiasis.
Schistosoma mansoni ova: in intestinal Schistomiasis
Oxyuris ova: in Oxyuriasis.
Exam form:
Example 1:
Macroscopic:
Consistency: Loose. Mucous: +++
Reaction: Alkaline. Blood: +++
Microscopic:
RBCs: More than 100 cells / HPF. Protozoa: Nil.
WBCs: More than 100 cells / HPF. Ova: Nil.
Example 2:
Macroscopic:
Consistency: Loose. Mucous: +++
Reaction: Alkaline. Blood: ++
Microscopic:
RBCs: More than 100 cells / HPF. Protozoa: E.hisolytica "vegetative form".
WBCs: 20-25 cells / HPF. Ova: Nil.
Example 3:
Macroscopic:
Consistency: Formed. Mucous: Nil.
Reaction: Alkaline. Blood: Nil.
Microscopic:
RBCs: 1-2 / HPF. Protozoa: Nil.
WBCs: 1-2 / HPF.
Ova: Oxyuris or may be Ankylostoma ova in Ankylostomiasis.
Schistosoma mansoni ova in intestinal Schistomiasis.