Fifth (Silver Jubilee) Edition
Suraj Gupte MD, FIAP
Professor and Head, Postgraduate Department of Pediatrics Narayana Medical College/Narayana General and Superspeciality Hospitals,
Nellore 524002, AP, South India.
Honorary Director: Pediatric Education Network
Editor: The Short Textbook of Pediatrics, Recent Advances in Pediatrics (Series), Textbooks of Pediatric Emergencies, Neonatal Emergencies, Pediatric Nutrition, and Pediatric Gastroenterology, Hepatology and Nutrition, Towards MRCPCH Part II (Theory Examination), Pediatric Yearbook (Series), Newer Horizons in Tropical Pediatrics, etc.
Author: Differential Diagnosis in Pediatrics, Pediatric Drug Directory, Infant Feeding, Speaking of Child Care: Everything You Wanted to Know, The Baby Book: The Parents’ Guide from Birth to Infancy
Co-editor: Asian Journal of Maternity and Child Health (Manila, Philippines)
Section Editor: Pediatric Today (New Delhi)
Editorial Advisor: Asian Journal of Pediatrics Practice (New Delhi)
Editorial Advisory Board Member/Reviewer/Referee: Indian Journal of Pediatrics (New Delhi), Indian Pediatrics (New Delhi), Synopsis (Detroit, USA), Indian Journal of Pediatric Gastroenterology, Hepatology and Nutrition (Jaipur), Journal of Clinical Pediatrics (Patna), Maternal and Child Nutrition (Preston, UK), Journal of Pediatric Infectious Diseases (Turkey)
Examiner: National Board of Examinations (NBE) for DNB, New Delhi, All India Institute of Medical Sciences (AIIMS), New Delhi, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Indira Gandhi National Open University (IGNOU), New Delhi, Dr NTR University of Health Sciences (NTRUHS), and several other universities
Pediatric Faculty Selection Expert: All India Institute of Medical Sciences (AIIMS), Jammu and Kashmir Public Service Commission, Punjab Public Service Commission, Haryana Public Service Commission, Union Public Service Commission
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Instructive Case Studies in Pediatrics
© 2011, Novy Gupte, Executive Editor
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 1983
Second Edition: 1988
Third Edition: 1999
Fourth Edition: 2002
Fifth Edition: 2011
9788184489972
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset
To
My dear parents
whose inspiration, motivation, blessings
and moral support continue to contribute
a great deal to our academic endeavors
and
everybody striving to contribute to
child health and welfare for a
brighter future globally
At the very outset, I wish to express my gratitude to the celebrated author, Dr Suraj Gupte, for giving me an opportunity to go through the drafts of his latest work, i.e. the fifth edition of the noted book, Instructive Case Studies in Pediatrics (ICSP).
Dr Gupte, a well-known pediatric author, is reputed for his academic command and brilliance as also straight-forward, clear, lucid and easy-to-grasp style. This together with the wealth of additional valuable material contribute to the emergence of the excellent, expanded, revised and updated edition of the book. As many as 200 case studies provide a plethora of exercises that assist in refining skills in handling clinical problems and in applying remedial measures for overcoming the deficiencies methodically, efficiently and effectively.
The book has a special emphasis on problems which are particularly meaningful in the Indian subcontinent. I consider it an extra-strong feature of the book.
I am most pleased to recommend this remarkable book by Dr Suraj Gupte to the target audience (undergraduate and postgraduate students of pediatrics, pediatric residents, junior and practising pediatricians and pediatric teachers) across the board, more pointedly in the resource-limited countries.
Prof WE Peterson, md, frcp
Professor of Clinical Pediatrics
Institute of Child and Adolescent Health,
London, United Kingdom
Formerly, WHO Adviser
8Preface to the Fifth EditionIt is with a sense of pride that the fifth (Silver Jubilee) edition of the Instructive Case Studies in Pediatrics is being brought out. The book is further enlarged and updated, offering over 200 case studies, each virtually generating a scenario as though the reader indeed is face-to-face with the patient in the ward and in an intense interaction with a knowledgeable teacher.
The case studies assist the reader in refining his clinical skills and developing a logical approach to clinical problem-solving in the critical areas of pediatric diagnosis and therapeutics. The bottomline is to guide them through reasoning process around frequently-encountered presenting complaints. More than one cases are presented for major complaints to sharpen skills in differential diagnosis and management.
The whole gamut of clinical pediatrics is covered. Each and every case presentation is followed by a list of questions that probe facts warranting special attention. The answers that follow provide authoritative comments on issues under discussion, thereby boosting the teaching value of the treatise.
The treatise intends to be an ideal study tool for undergraduate and postgraduate students of pediatrics, interns, house-physicians, residents, junior pediatricians and practising physicians dealing with children and adolescents. Even established pediatricians and teachers of pediatrics shall find a great deal of valuable information.
Hopefully, the fifth edition of the ICSP with a continuing thrust on problem-solving approach shall turn out to be yet more useful for the target readership.
Suraj Gupte
9Preface to the First EditionSir William Osler, the Father of Modern Medicine, is on record as saying, “The best way to learn medicine or any of its disciplines involves taking histories, doing good clinical examination, planning investigations after reviewing the differential diagnosis, and discussion with seniors and colleagues”.
Even today, Osler's advice holds as good as it did several decades ago. Medical students, including postgraduates, and young doctors would undoubtedly learn eminently in this way. Yet, the fact remains that their job often becomes difficult because of one or another constraint. First, they may have constraints of time. Secondly, they may be hesitant in imposing themselves on the sick. Thirdly, they may lack sound and critical discussion from teachers. Fourthly, some of the important problems which they are supposed to be in a position to tackle may not have confronted them.
What has been said is most eminently true in the area of pediatrics.
These concerns have prompted me to prepare this book, offering 100 instructive case studies in pediatrics. The material covers the whole gamut of pediatrics from threadworm infestation in a toddler to leukemia in a grown-up child. Each case presentation is followed by a list of questions that probe facets deserving particular attention. The answers which follow the questions on the reverse page provide authoritative comments on the issues under discussion. In most of the cases, the emphasis has been on interpretation of history and physical examination rather than on special and sophisticated investigations. All this should enhance the teaching value of these case studies.
Let it be clarified that the case studies have been deliberately organized in a random order. The index is, however, in two sections: presenting problem and diagnosis. The reader is welcome to study the cases either at random, or by presenting problem or diagnosis.10
I extend my sincere gratitude to Dr K Indira Bai, President, Indian Academy of Pediatrics, for her courtesy in writing the Foreword to the volume at a time when she has been far too busy. Her warm recommendations have indeed boosted my morale.
I also wish to record my indebtedness to my family folks for providing generous help and encouragement at various stages of this project. My younger brothers, Rajendra, Subhash, Raju, and Dr Satish graciously helped me in many ways. My special hats off to my wife, Shamma, for not only showing lots of patience as the writing was in progress, but also correcting the proofs and making many a useful suggestion.
The help rendered by Mr Ayudhia Kaul, Mrs Veenu Kaul, Dr Harsh Mahajan, Dr (Mrs) Prem Mahajan, and many others is gratefully acknowledged.
I extend my thanks also to Mr R Kumar, the Managing Editor, and Shri Jitendar P Vij, Chairman and Managing Director of Jaypee Brothers Medical Publishers (P) Ltd for the excellent production qualities of the volume.
Suraj Gupte
“Gupte House”
60 Lower Gumat,
Jammu 180001
11AcknowledgmentsSpecial acknowledgments are due to:
- Prof WE Peterson, an eminent pediatric teacher and researcher of world repute, who found time to critically go through the manuscript of the ICSP-5. I am grateful to him for the feedback and for warmly recommending this treatise. He has done me an honor in writing the Foreword that lends this book a unique status.
- The Management and Administration of the Narayana Medical College and Hospitals, especially Dr P Narayana, Chairman, Dr CL Venkata Rao, Adviser, Dr S Vijay Kumar, Coordinator, Dr BA Ramakrishna, Principal, and P Veera Prasad, Medical Superintendent. P Veera Prasad, Medical Superintendent, kindly provided the moral support and motivation to complete this important academic assignment.
- My wife, Shamma and son, Manu, who contributed to the successful completion of the project in many a ways notwithstanding their other commitments.
- Dr Novy Gupte for doing a fine job as the Executive Editor.
- A large number of professional colleagues and readers, both within and outside India, for their suggestions, constructive criticism and patronization.
- Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, and their dedicated staff for the commendable production qualities of the book.
Auto-disable syringe
AED
Antiepileptic drug
AEFI
Adverse events following immunization
AFB
Acid-fast bacilli
AFP
Acute flaccid paralysis
AGE
Acute gastroenteritis
AIDS
Acquired immune-deficiency syndrome
ASD
Atrial septal defect
ASHA
Activated social health activist
ATT
Antituberculous therapy/treatment
BCG
Bacillus of Calmette and Guerin
BMI
Body mass index
CFT
Capillary filling time
CSF
Cerebrospinal fluid
CSSM
Child survival and safe motherhood
CT
scan Computed tomography scan
DLC
Differential leukocyte count
DOTS
Directly observed treatment schedule
DPT
Diphtheria, pertussis, tetanus
DT
Diphtheria, tetanus
DTP
Diphtheria, tetanus, pertussis
EBM
Expressed breast milk
EPI
Expanded program on immunization
GERD
Gastroesophageal reflux disease
GoI
Government of India
H/O
History of
Hb
Hemoglobin
HIV
Human immune deficiency virus
ICDS
Integrated child development services
IM
Intramuscular
IQ
Intelligence quotient
IT
Intrathecal
IU
International unit
IV
Intravenous
IVIG
Intravenous immunoglobulins
LP
LRTI
Lower respiratory tract infection
MAC
Mid-arm circumference
MAC
Mid-arm circumference
MRI
Magnetic resonance imaging
MUAC
Mid upper arm circumference
NGO
Non-governmental organization
NICU
Neonatal intensive care unit
NIDs
National immunization days
O
Oral
OFC
Occipitofrontal circumference
OPV
Oral polio vaccine
ORS
Oral rehydration salt
ORT
Oral rehydration therapy
PANDAS
Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection
PBF
Peripheral blood film
PEM
Protein-energy malnutrition
PEM
Protein-energy malnutrition
PICU
Pediatric intensive care unit
PR
Pulse rate
PS
Peripheral smear
R/R
Respiratory rate ratio
RNTCP
Revised national tuberculosis control program
SC
Subcutaneous
SSS
Scalded skin syndrome
SSSS
Staphylococcal scalded skin syndrome
TBA
Trained birth attendant
TLC
Total leukocyte count
TOF
Tetralogy of Fallot
TSS
Toxic shock syndrome
TT
Tetanus toxoid
U/L segment
Upper /lower segment ratio
UHC
Urban health center
UIP
Universal immunization program
URTI
Upper respiratory tract infection
US
Ultrasonography
UTI
Urinary tract infection
VAD
VAPP
Vaccine associated paralytic polio
VAPP
Vaccine-associated paralytic poliomyelitis
VPD
Vaccine preventable disease
VSD
Ventricular septal defect
VVM
Vaccine vial monitor