1st station: Dr wa2el hayajneh...

(the same scenario was repeated for 2

students) a 6 years old boy came to ER with fever 39 of one day duration..

consider me the patient take a hx, do physical exam and order
investigations.... in hx.. (all normal except vomiting and bloody diarrhea ( 6
times per day)... DDx... Gastroenteritis.

what are the 5 types of E coli?

There are four major categories of diarrheagenic Escherichia coli:
enterotoxigenic (a major cause of travelers' diarrhea and infant
diarrhea in less-developed countries), enteroinvasive (a cause of
dysentery),
enteropathogenic (an important cause of infant diarrhea), and
enterohemorrhagic (a cause of hemorrhagic colitis and hemolytic
uremic syndrome)
A less-well-defined fifth category of diarrheagenic E. coli is that of
enteroadherent E. coli

EHEC (enterohemorrhagic E. coli): Shiga toxins; bloody diarrhea,
10% with complications
ETEC (enterotoxigenic E. coli): secretory toxins; watery diarrhea
EPEC (enteropathogenic E. coli): toxin similar to Shigella toxin;
watery or bloody diarrhea
EIEC (enteroinvasive E. coli): invade epithelial cells; mucoid,
bloody diarrhea and fever
EAEC (enteroadherent E. coli): adhere to intestinal cells; watery
diarrhea
EAggEC (enteroaggregative E. coli): clump intestinal cells; chronic
mucoid watery diarrhea



types of shigella?
There are four species of Shigella: S. boydii, S.
dysenteriae, S. flexneri, and S. sonnei.



Second station; Dr Rula... (the same scenario was repeated for 2 students)

what is the most common cause of genetic disease in jordan?
(consanguinity marriage)
- what are the types of inheritance..? (mandalian / non mandalian)
- how many types do we have in mandalian inheritance?
( autosomal recessive, dominant, x-linked)
- which type of them is what we see in consanguinity marriages? (recessive)
- Examples? GALASCTOSEMIA , CYSTIC FIBROSIS , Sickle cell anemia ,
thalasemia

-thalasemia - types? alfa and beta
- the most common type in jordan? beta
- types of beta? major and minor
- presentations, symptoms of each?.....

Presentation of Anemia : Pallor, fatigue.etc

Alpha Thalessemia
1- Deletion of all 4 alpha genes : Hydrops fetalis/ In utero Death
2- Deletion of 3 alpha genes HbH disease: Severe Anemia with signs
of hemolysis
3- Deletions of 2 alpha genes alpha thalessemia trait : mild Anemia
4- Deletion of 2 alpha gene Slient Carrier: Asymptomatic
Beta Thalaessemia
1- Major : Severe Anemia, Bone Changes, chipmunk face, frontal
bossing, copper colored skin , hemolysis ( Jaundice, ictrus, HSM).
2- Minor: Generally Asymptomatic

Note : Hb electrophoresis is diagnostic :
- Normal : 97% Hba A , 3% HbF or Hb A2
- Thalassemia Alpha: decreased HbA with increase in HbH
depending on the severity
- Thalassemia Beta : Absent or demolished HbA, which is replaced
by HbF or HbA2.
- treatment of beta type? life long transfusion and in some cases
splenectomy Transfusions needed to keep Hb above 10.
Note: Splenectomy is needed, especially in sever hemolytic patients who
need recurrent transfusions.
- definitive treatment? BM transplant
- complication? hemochromatosis (asses iron overload with liver biopsy)
- treatment, dose? deferoxamine..
For Chronic Iron overload
Subcutaneous Administration
A daily dose of 1000-2000 mg (20-40 mg/kg/day) should be administered over 8-24 hour
- how long do they live?
Beta Thalassemia usually results in sever anemia with a fatal course by age
30 unless stem cell transplantation is performed.


what is the main cause of death? cardiac failure
- the complications of blood transfusion?

Complications of blood transfusion
Early
Haemolytic reactions
Immediate
Delayed
Non-haemolytic febrile reactions
Allergic reactions to proteins, IgA
Transfusion-related acute lung injury
Reactions secondary to bacterial
contamination
Circulatory overload
Air embolism
Thrombophlebitis
Hyperkalaemia
Citrate toxicity
Hypothermia
Clotting abnormalities (after massive
transfusion)
Late
Transmission of infection
Viral (hepatitis A, B, C, HIV, CMV)
Bacterial (Treponeum pallidum, Salmonella)
Parasites (malaria, toxoplasma)
Graft-vs-host disease
Iron overload (after chronic transfusions)
Immune sensitization (Rhesus D antigen)


Discussion about cystic fibrosis (from A---Z)



--------------------------------------------------------------------------------------------------------------------------------
------- 1st station: Dr mn aljeesh: x-rays
1.pneumothorax
2.double bubble sign .. what causes it and presentation and what trisomy associated
Down Syndrome, Trisomy 21
3.diaphragmatic hernia .. most common site and treatment
There are 2 types:
1- Morgagni : relatively uncommon ( Aterior parasternal )
2- Bochdalek: more common ( posterolateral, L>R)

4.air under diaphragm .. perforated viscus if 3 weeks necrotizing enterocolitis

5.foreign body .. radioopaque bal3 msare

-some questions about direct and indirect hyperbilirubinemia

Direct hyperbilirubinemia Indirect Hyperbilirubinemia
Biliary Atresia
Idiopthic neonatal hepatits
Choledochal cyst
TORCH infections
Alpha 1 antitrypsin def,
Galactosemia

Physiological Juandice
Abo incom./ Rh. Incom (+ coomb)
G6PD def.
Breast milk Jaundice
Hereditary spherocyotsis
Bilbert Disease
Crigler Najjar Syn.



2nd station: Dr mahmood alshyab :
1.what do we send when we do LP and normal lab results
Protein (15-45 mg/dl)
Glucose (50-75 mg/dl)
Cell count (0-5 mononuclear cells) and differential
Initial pressure (70-180 mm
Bacterial Culture / & Gram stain and PCR for viruses




2.lab called and told you its gram negative cocci what is this .. Neisseria meningitidis

3.Give me the shapes of the following bacteria and if it is gram positive or negative for each (staph,
Hib, listeria)

Gram Positve Gram Negative
GBS ( diplococcal)
Listeria monocytogenes ( rod-shaped)
Staphylococus ( grape-like)
Streptococus pneumonia ( diplococcic )

Niesseria meningitides
Hib ( bacillus or coccobacillus )
E. Coli (Rod- shaped )



4. How to treat meningoccemia .. 3rd generation and vanco
5.why vanco .. resistance
6.mechanism of action of vanco .. Vancomycin acts by inhibiting proper cell wallsynthesis in Gram-
positive bacteria. Due to the different mechanism by which Gram-negative bacteria produce their
cell walls and the various factors related to entering the outer membrane ofGram-negative
organisms, vancomycin is not active against Gram-negative bacteria (except some non-gonococcal
species of Neisseria).
7. Most common complication of miningococcemia Complications following meningococcal
disease can be divided into early and late groups. Early complications include: raised
intracranial pressure, disseminated intravascular coagulation, seizures, circulatory
collapse and organ failure. Later complications are: deafness, blindness, lasting
neurological deficits, reduced IQ, and gangrene leading to amputations

8.normal CSF results for new born

White cell count Biochemistry
Neutrophils
(x 10
6
/L)
Lymphocytes
(x 10
6
/L)
Protein
(g/L)
Glucose
(CSF:blood ratio)
Normal
(>1 month of
age)
0 5 < 0.4 0.6 (or 2.5
mmol/L)
Normal neonate
(<1 month of
age)
0 < 20 <1.0 0.6 (or 2.5
mmol/L)



1st station ; mn el jesh ;
- what are the causes of red urine? He wanted me to mention about 10...
1- Dyes like Knafeh and Shamandar!
2- Drugs Rifampicin , cyclophoshamide, antigoagulants!
3- Toxins like mucery or lead
4- excessive exercise aka Myoglobinurea
5-Blood In Urine! Aka Hemoglobinurea due to:
- Kidney Trauma
- UTI
- Kidney disease like IgA Glomerulonephritis
- HUS
- G6PD
- Sickle cell anemia
- Vasculitis HSP
- Bleeding disorders

- how can we differentiate between them?
History, physical exam and Labs!
Urine analysis! RBC, Casts, etc.

-what are the Causes of hypo- and hyper- calcemia,
and what are the clinical manifestations of each?

Hyperalcemia Hypocalcemia
GI: Constipation, Polydipsia nausea, vomit
Psychological: apathy, depression , irritibality..etc
Urinary: Polyuria, Stones
Skeletal: Bone pain

Stones, Bones, Abdominal groans and psychiatric
overtones!
Chvostek Sign
Trousseau sign
Neuro: perioral paraesthesia( early) , increased
deep tendon reflexes (late), confusion, seizures,
tetany
Psychiatric: paranoia, hallucination..etc
GI: Abdominal Cramps
RS: Stridor, laryngospasm
Hyperparathyroidism, Cancer, Zollinger- Ellison
Syndrome, Excessive Vit. D, Excessive vit.A,
Addisons disease, Acromegaly, Iatrogenic( Thiazide
Diuretics) , sarcoid, Immobility.etc
Short Bowel Syndrome, Vit. D deficiency, sepsis,
Acute pancreatitis, rhabdomyolysis , renal failure,
Hypomagnesemia, osteoblastic mets.
aminogycosides.



2nd : fesal Q ; - Take brief hx about stridor of 1 day duration ?
- What's the dx . Croup
-What's the cause of it Para influnza virus -Which type ? 1,2,3
-what's the indication of admission?

1- Wasta ..just kidding!

Up to date says :
Indications Children with moderate/severe croup whose condition worsens or fails to improve as
expected after treatment with nebulized epinephrine and corticosteroids should be admitted to the hospital
for repeated doses of nebulized epinephrine, observation, and supportive care. Poor response to nebulized
epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial
tracheitis .
Additional factors that influence the decision regarding admission include [8,31]:
Need for supplemental oxygen
Moderate retractions and tachypnea, indicating increased work of breathing, which may lead to
respiratory fatigue and failure
Degree of response to initial therapies
"Toxicity" or clinical picture suggesting serious secondary bacterial infection
Poor oral intake and degree of dehydration
Young age, particularly younger than six months
Ability of the family to comprehend the instructions regarding recognition of features that indicate the
need to return for care
Ability of the family to return for care (eg, distance from home to care site, weather/travel conditions)
Recurrent visits to the ED within 24 hours


Wts the rx ?
-Nebulized Epinephrine
-Corticosteroids


-Then another case of 6 weeks vomiting ? Take hx ? Dx?... pyloric stenosis . other ddx ?
...investigations ? lab results? Treatment ?

-Non- bilious projectile vomit
-US for Dx
ABG and electrolytes ( hypochloremic, Hypokalemic metaolic alkalosis )
-treat: rehydrate, correct electrolytes and Pylorotomy.
Other Ddx: GERD, Duodenal atresia, TEF