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Clinical Cases in Pediatrics
R Rajamahendran, B Parthiban, K Ilayaraja
CASE 1:
Protein Energy Malnutrition
DEFINITION
CLASSIFICATION
Welcome's Classification (Clinical Classification)
Gomez Classification (International)
IAP Classification (Indian)
Jellife's Classification (Based on Weight)
Waterlow's Classification
Arnold's Classification
Gopalan's Classification
ANTENATAL HISTORY
NATAL HISTORY
POSTNATAL HISTORY (30 DAYS)
DEVELOPMENTAL HISTORY
DIET HISTORY
FAMILY HISTORY/SOCIAL HISTORY
Kuppuswamy Scoring
IMMUNIZATION HISTORY
CONTACT HISTORY
Classification of Consanguinity
GENERAL EXAMINATION
HEAD TO FOOT EXAMINATION
Mental State
Hair
Anterior Fontanelle
Head Circumference
Eyes
Ear
Nose
Mouth
Neck
Skin Changes
Abdominal Distension (Hypoproteinemia)
Foot
Anal Excoriation
Other Vitamin Deficiencies
Vitals
ANTHROPOMETRY
Weight of Baby
Newborn Weight Status
Height
IAP
Head Circumference (HC)
Chest Circumference (Measured at the Level of Nipples)
Mid-arm Circumference (MAC)
Systemic Examination
What type of Liver is there in Kwashiorkor?
INVESTIGATIONS
MANAGEMENT
WHO Classification for Undernutrition
OTHER ANTHROPOMETRIC INDICES
Upper Segment/ Lower Segment Ratio
Rao's Body Mass Index
Quetelet Index
Enderberg's Index
Dugdale's Index
Quack Stick Method
Kanawati's Index
Ponderal Index
Stem Stature Index (Crown Rump Length Index)
Skin Fold Thickness (Harpenden Skin Calipers)
Arm Span
MARASMUS (FIG. 1.2)
Etiology
Primary Causes
Secondary Causes
Classification
Viva: Why the buccal pad of fat remains until end?
Clinical Feature
Skin
Abdomen
Muscles
CNS
Others
Biochemical Changes
Pathological Changes
Diagnosis
Management
Prognosis
KWASHIORKOR (FIG. 1.3)
Classical Features
Incidence
Age
Etiology
Poverty
Faulty Feeding Habits
Prolonged Breastfeeding
Infections and Infestations
Sudden Loss of Protein
Sudden Demand
Seasonal Incidence
Size of Family
Clinical Profile
Apathy
Diarrhea
Malabsorption Syndrome
Edema
Muscle Wasting Nutritional Hypotonia
Skin Changes
Hair Changes
Hepatomegaly
Facies
Avitaminosis
Anemia: Moderate (7–11 g)
Growth Failure
Psychomotor Changes
Cardiovascular System
Biochemical Changes
Pathological Changes
Liver
Pancreas
Gastrointestinal Tract
Heart
Treatment
Course/Prognosis
Cause of Death
Prevention
Nutritional Recovery Syndrome (NRS)
Investigations
Viva Questions from PEM
Principles of Gopalan's Theory
SEVERE ACUTE MALNUTRITION (SAM) (FIG. 1.6)
History
Examination
Laboratory Tests
Treatment Guidelines
Use of Antibiotics in SAM
Feeding Volume in SAM
Starter Formula in SAM
Catch-up Formula in SAM
Criteria for Discharge in SAM
Criteria for Early Discharge in SAM
Forming the Diet Chart
Calorie Requirement
Protein Requirement
Cereals
Pulses
Leafy Vegetables
Milk/Milk Product
Fruits and Other Vegetables
Miscellaneous
For Easy Remembering
How to write the Diet chart in exams?
Before Admission
When and why to introduce supplements/additional feeds (weaning)
Weaning Foods
Contraindications for Breastfeeding
CASE 2:
Abdomen
HEPATOSPLENOMEGALY
Main Causes
Infective
Congestive
Hematological
Infiltrative
Storage Disorder
Inflammatory and Collagen Vascular Disorder
Miscellaneous
Practical Approach
Size
Consistency
Age of Child
Clues in the History
Clues in the Examination
History Taking and Examination of a Abdomen Case
History of Present Illness
History in Liver Disorders
Types of Fever
Other Histories
Past History
General Examination (Fig. 2.3)
Vital Signs
Anthropometry
Head to Foot Examination
Signs of Liver Cell Failure
Abdominal Examination
Inspection
Palpation
Grading of Splenomegaly (Fig. 2.4 and 2.5)
Percussion
Auscultation
Physical Examination of Liver
Other System Examination
Demonstration of Ascites
Liver Span
Discussion
Rare Causes
HEPATOMEGALY
Tender Hepatomegaly
How can you say it is a chronic liver disease?
DIFFERENTIAL DIAGNOSIS
Typhoid Fever
Investigations
Blood Widal (Tube Agglutination Test)
Complications of Typhoid Fever
Diagnosis of Typhoid Perforation
Management
MDR Typhoid
Treatment of Encephalitis
Indication of Steroids
Treatment of Carrier State
Other Drugs
Tuberculosis
Post-primary Complex
Treatment
Latest Diagnostic Tools
Sputum Microscopy
Chest X-ray
Mantoux Test
Interferon Gamma Release Assay
Quantiferon gold and T-spot test
Culture Methods
Polymerase Chain Reaction (PCR) Test
Serodiagnostic Tests
Histopathological Examination
Other Tests
Treatment
Intermittent SCC-LAG Period
Categorization of Patients
New Case Treatment
New Cases Treatment Continue
Previously Treated Case
Treatment Regimen Previously Treated Cases
Relapse > Failure and Default
Patientwise Drug Boxes
Pediatric PWB with Dosages
PWB for New Cases According to Weight Band
Drug Resistant TB
Latent Tuberculosis Infection: Chemoprophylaxis
Newborn to a Mother with TB
The Difference Category III is Phased out
Older Regime
Indications for Steroids
Genitourinary
Leptospirosis
Investigation
Treatment
Malaria
Investigation
Treatment
Chloraquine Resistant Falciparum
Chemoprophylaxis
Dengue Fever
Investigation
Consolidation of Investigations for an Abdomen Case
Preliminary
Specific Investigations
Accelerated BCG Test
Inference
Weeks
CASE 3:
Cerebral Palsy
CASE FORMAT
Complaints
Present Illness (Ask for Developmental Milestones)
History Suggestive of Cranial Nerves Dysfunctions
DEVELOPMENTAL HISTORY
Gross Motor
Fine Motor
Language
Personal/Social
Bladder/Bowel Control
DIETARY HISTORY
Immunization History
GENERAL EXAMINATION
EXAMINATION OF CENTRAL NERVOUS SYSTEM (FIG. 3.1)
Higher Functions
Examination of Cranial Nerves
Spino-Motor System
Autonomic System
Sensory/Cerebellar
Neonatal Reflexes (Refer Page No. 169)
Gait
Spine
Other Systems
Points Favoring
Diagnosis
Investigations
Management
CEREBRAL PALSY
Classification
Etiology
Natal
Postnatal
Ingram's Classification
Other Types
Associated Features
Investigations
Differential Diagnosis
Viva Questions
1. How will you suspect congenital intrauterine infections?
2. What is the use of Apgar score?
3. Posture:
4. Neurocutaneous markers:
CEREBRAL PALSY: LITTLE'S DISEASE
Definition
Epidemiology/Etiology
Classification
Spastic Hemiplegia
Spastic Diplegia
Spastic Quadriplegia
Athetoid
Viva
When will you suspect CP? Or what are the early markers of CP?
Why there are feeding difficulty in CP?
How will you assess muscle tone as a marker of cerebral palsy?
How will you assess the range of movement?
Adductor Angle
Popliteal Angle
Dorsiflexion
Heel-Ear Maneuver
Scarf Sign
History for Seizures
Management of Cerebral Palsy
CASE 4:
Renal System
DIFFERENTIATION BETWEEN NEPHRITIS AND NEPHROTIC SYNDROME
HISTORY TAKING
DD: EDEMA
PAST HISTORY
GENERAL EXAMINATION
Vital Signs
Anthropometry
SYSTEMIC EXAMINATION
DIAGNOSIS
Viva Questions
Urine in AGN is cola colored. Why? (Fig. 4.3)
ACUTE GLOMERULONEPHRITIS (AGN)
Investigations
Management of AGN
Prognosis: Excellent in AGN
Complications
Why renal edema is over face first?
What is cause of anemia?
Causes of palpable kidney?
What should be monitored before giving Frusemide?
NEPHROTIC SYNDROME
Investigations
Management (Figs 4.4 and 4.5)
Bed Rest
Complications of Nephrotic Syndrome
Prognosis
PROTEINURIA
Causes of Hematuria
Macroscopic Hematuria
Microscopic Hematuria
Tests to Detect Proteinuria
Heat Coagulation Test
Sulfosalicylic Acid Test
ACUTE STREPTOCOCCAL GLOMERULONEPHRITIS
Etiology and Epidemiology
Immunofluorescence
Electron Microscopy
Pathogenesis
Clinical Features
Diagnosis
Urinalysis
Blood
Serum C3
Chest X-ray
USG finding in AGN
Confirmation
Renal Biopsy
Considerations for Renal Biopsy
Other Organisms Causing AGN
Complications
Prevention
Prognosis
Differential Diagnosis for Hematuria (Acute Glomerulonephritis)
NEPHROTIC SYNDROME
Pathophysiology
IDIOPATHIC NEPHROTIC SYNDROME
Etiology
Pathology
Clinical Manifestation
Investigation
Complications
Treatment
General Measures to Treat Edema
Remission
To Prevent Relapse
End Stage Renal Failure
Renal Transplant
Glomerulonephritis (Fig. 4.7)
Tumors
Drugs
Congenital Nephrotic Syndrome
Congenital Nephrotic Syndrome (Finnish Type)
What is the Meaning of
Proteins Lost in Nephrotic Syndrome
CASE 5:
Cardiovascular System
HISTORY TAKING
Past History
Antenatal History
Natal History
Postnatal History
Development History
Diet History
Family History
GENERAL EXAMINATION
Vital Sign
SYSTEMIC EXAMINATION
Examination of Other Systems
Diagnosis
Investigations
MANAGEMENT
VENTRICULAR SEPTAL DEFECT (FIG. 5.3)
History Taking
CVS System Examination
Inspection
Palpation
Percussion
Auscultation
Diagnosis
Classification
Depending on the Location
Depending on the Size (Fig. 5.4)
VSD Murmur
Large VSD With Reversal
Clinical Features
Katz Wachtel Phenomenon
Maladie de Roger Syndrome
Name the conditions where you get precordial bulge?
Management
Investigations
Treatment
Medical Management
Surgical Treatment
Indications
Contraindications
Juxtaarterial VSD: (AR + VSD)
TETRALOGY OF FALLOT
History Related to TOF
Etiology
Components of TOF (Fig. 5.6)
Embryology
Associated Anomalies in TOF
Syndromes Associated with TOF
Hemodynamics (Flow Chart 5.1)
Compensatory Mechanisms in TOF
Pathophysiology of Cyanosis
Cyanotic Spells
Why in TOF Cyanosis Occurs > 6 Months of Life?
Cyanotic (Hypoxic) Spells
Treatment of Cyanotic Spells
Squatting Episode
Clinical Features
General Examination
Investigations
Complications (Fig. 5.2)
Medical Management
Surgical Management
Palliative
Definite
Brock's Procedure
Complications
Definite Procedure
History Related to TOF
History of Presenting Illness
Antenatal History
ATRIAL SEPTAL DEFECT (FIGS 5.9 AND 5.10)
Hemodynamics
Clinical Picture
Why there is a click in ASD?
Murmurs
Complications
Investigations
X-ray Chest
ECG (5.11)
Treatment
Medical
Surgical
Indications of Surgery
Contraindication
Complications
Types of ASD (Fig. 5.12)
Syndromes Associated with ASD
Differential Diagnosis
PATENT DUCTUS ARTERIOSUS (PDA) (FIGS 5.13 AND 5.14)
After Birth
HEMODYNAMICS IN PDA
Clinical Picture
On Examination
General Examination
Assessment of Severity
Complications
Differential Diagnosis (DD)
Natural History
Treatment
Medical
Surgical Induction
Procedure
When will you get mixed cyanosis?
Where will you get Harrison's sulcus?
Acute Rheumatic Fever
Definition
Jones Criteria
Describe the pathology of pancarditis?
Which is the commonest manifestation of rheumatic fever?
Describe polyarthritis
Describe Erythema Marginatum
What do you mean by primary prophylaxis/secondary prophylaxis of RF?
Benzathine Penicillin
Oral Penicillin
Sulfonamides
Erythromycin
Investigations in a Case of RF
Treatment
Treatment Schedule
CASE 6:
Respiratory System
HISTORY
Difference:
CLASSIFICATION
NEWBORN
Investigations
Treatment
FIRST 6 MONTHS
Bronchiolitis
Pathophysiology
Lipoidal Pneumonia (Interstitial Pneumonitis)
STAPHYLOCOCCAL PNEUMONIA
Complication
HYDROCARBON PNEUMONIA
PNEUMOCOCCAL PNEUMONIA (SCHOOL GOING CHILDREN)
Stages
Others
MANTOUX TEST
False Negative Cases
False Positive Cases
How to read Mantoux test?
HEAF TEST/MULTIPLE PUNCTURE TEST
CASE 7:
Newborn
CASES
Normal Newborn (Fig. 7.1)
Preterm (Fig. 7.2)
IUGR (Intrauterine Growth Restriction) (Fig. 7.3)
Neonatal Jaundice
NEWBORN: PRETERM
History/Examination
Antenatal History
Natal History
Postnatal History
Family History
Social History
Immunization History
General Examination
Anthropometry
Head to Foot Examination
Gestational Age Assessment
NORMAL NEWBORN
Anterior Fontanelle
Posterior Fontanelle
Diagnosed
X-ray Film
Classification
Growth Pattern
Term
IUGR (SMALL FOR GESTATIONAL AGE)
Features of Term Baby
CASE 1: PRETERM BABY
Causes
Socioeconomic
Maternal
Uterine Anomalies
Baby Causes
Maternal Risk Factors
Others
Classification
Prevention
Discussion in Preterm Case
Preterm Infant
Handicaps in Preterm
Management
CASE 2: NEONATAL JAUNDICE
Physiological Jaundice
Transcutaneous Bilirubinometer (TcB)
Criteria for Physiological Jaundice
Causes
Exaggeration of Physiological Jaundice
Causes
Criteria for Pathological Jaundice
Causes
What is the difference between?
Treatment
Treatment
Principle
Complications
Long-term Effects
Contraindication
Where will you give prophylactic phototherapy?
Types of Phototherapy
Exchange Transfusion
Complications
Monitor
Viva Discussion
Fed in the following ways:
Treatment of Newborn
Thermoneutral Environment
Treatment of Hypothermia
Fluid Management
Investigations
Treatment of Infections
CASE 3: IUGR (INTRAUTERINE GROWTH RESTRICTION) INFANT
Small for Gestational Age (SGA)
Causes
Classification
Complications of IUGR Baby
Meconium Aspiration Syndrome
Hypothermia
Infection/thrombocytopenia
Hypoglycemic
Bleeding manifests
Ossification Decreased
Congenital Malformations
Investigations
Treatment
Treat the Complications
Kangaroo Mother Care
Reflexes in Newborn
CASE 8:
Spotters
SPOTTER 1: HYDROCEPHALUS (FIG. 8.1)
Pathophysiology of CSF (FIG. 8.2)
Types of Hydrocephalus
ETIOLOGY
Clinical Features
On Examination
Features of Increased ICT
Differential Diagnosis
Investigations
Treatment
Complications
Osteogenesis Imperfecta
Other Features of Hydrocephalus
Hydrocephalus Ex vacuo
Differential Diagnosis
Diagnosis
SPOTTER 2: DOWN'S SYNDROME (LANGDON SYNDROME)
Complaints and Past History
Systemic Examination (Fig. 8.11)
Causes of Trisomy 21
Investigations
Treatment
Prognosis
Differential Diagnosis
Prenatal Diagnosis of Down Syndrome
SPOTTER 3: MICROCEPHALY (FIGS 8.12 AND 8.13)
Craniostenosis
Other Possible Spotters in Examination
Color Plate:
CASE 9:
Vaccination
IMMUNITY
Active
Passive
UNIVERSAL IMMUNIZATION PROGRAM (UIP)
IAP Immunization Table 2011
IAP Immunization Table 2012
DISCUSSION OF IMPORTANT VACCINES
BCG Vaccine
Protection:
Adverse Effects
Oral Polio Vaccine (OPV)
Administration
Surveillance for Acute Flaccid Paralysis (AFP)
Contraindications for OPV
DPT
Administration
Contraindications
Measles
Administration
Contraindications
MMR: Live
Administration
Importance
Contraindication
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