Revision prof Mar

1) pts come w tall stature

a) further questions you want to ask?

-family hx, parental height

-birth hx : during delivery, antenatal period, dysparity of growth

-past medical hx

b) causes of tall statures

-marfan syndrome

-klinefelter syndrome

-familial tall stature, hyperthyroidism, homocystinuria,GH excess

c) Ix for tall stature

-karyotyping (confirmatory)

- TFT:T4,TSH

-urine:homocystine

2) short stature

a) causes of short stature

-turner syndrome, down syndrome

-hypothyroidism

-panhypopituitarism

-cushing syndrome

b) Ix

-karyotyping

-TFT

-pituitary fx test

-ovarian hormone?
c) Tx

- hypothyroid( thyroxine)

-panhypopituitarysm (growth hormone)

-estrogen replacement therapy

-cushing:cortisol

d) physical features

-hypothyroid:sluggish behaviour,umbiliocal hernia,constipation,open mouth,protruding

tongue,hoarse cry,cool dry skin

-cushing: rounded face,excess hair growth,darkened skin around neck,armpit,high bp

-turner: Lymphoedema of hands and feets in neonates, which may persist, Neck webbing or thick
neck, hypoplastic nails, broad chest, widely spaced nipple ,amenorrhea,ptosis,cataract, otitis media,
pigmented nevi, increased carrying angle

e) complications of turner:

-coarctation of aorta

- organ malformation: horseshoe kidney,

-recurrent otitis media

-hypothyroidism, hashimoto thyroiditis

f) pathophysiology turner

- XO,abscence of one set of genes from short arm of one of X chromosome

g) Tx

-growth hormone therapy

-ovarian estrogen: develop 2nd sexual characteristic

PBQ

2) pts come with diarrhea 3 days, lethargy, sunken fontanelle,, sunken eyes, no tears,CRT > 2
seconds,

a) Dx: AGE with severe dehydration

b) causative agent:

-viral : rotavirus, adenovirus,calici virus,astrovirus

-bacteria: e.coli, salmonella,shigella,campylobacter

c) classification of diarrhea( duration)

-acute: < 2 weeks (infection,non infection)

-persistent: 2 weeks, < 1 month (malabsorption,drugs)

-chronic: > 1 months (IBD)

d) pathophysiology:

-osmotic: Ingestion of non-absorbable substances/malabsorption or incomplete breakdown of

nutrients in the small intestine Retention of solute molecules within bowel lumes Increased
in osmotic forces within bowel lumens Causing leakage or drawing water into the lumen and thus
increased water retention in the stool Osmotic diarrhoea

-secretory: The responsible organism attached to the wall of small intestine Produces
enterotoxin that bind to specific receptors Activate production of second messenger
(cAMP,cGMP) Activate intermediate s(protein kinase) which act on apical membrane by
phosphorylating CFTR channel Cl secretion, and inhibit Na,Cl absorption across mucosa
epithelium (net secretion>net absorption) Secretory diarrhoea/watery diarrhoea

-invasive: Colonization of pathogen at the wall of intestine Pathogen invade and generate
cytotoxinin mucosal layer Inflammation of the bowel Mucosal ulceration and cell death
(erosion of the GIT wall) sloughing of dead cells Passing of liquid or semi-formed stool with
mucus and blood Invasive diarrhoea/dysentery

E)IX

-stool: routine examination:microscopy & macroscopy ova,cyst, C&S

-rotavirus screening: stool for rotavirus

-renal function test, FBC

-ABG: severe dehydration, to dx metabolic acidosis

f) outline management-severe dehydartion

- fluid resuscitation ( 20ml/kg NS 0.9 % as bolus , freely as fast as possible, calculate deficit fluid), % of
dehydration x weight x 1000ml & correct dehydration: 12-24 hours (iso and hyponatremic), 48-72
hours (hypernatremic)

-infusion maintenance fluid: according to calculation (1st 10kg:100ml/kg, 2nd 10kg: 5oml/kg), HSD5%

-replace continuing loss : IV NS

g) complications
- dehydration & shock

-acute renal failure

-electrolyte imbalance, hypoglycemia

-HUS (hemolytic uremic syndrome)

-malnutrition, met acidosis, 2nd lactose intolerance

-secondary lactose intolerance

h) prevention:

Prevent the spread of infection by maintenance of personal hygiene - good hand washing
practices

Maintenance of food hygiene

Safe water supply

Proper disposal of excreta-proper sewage system

Promote exclusively breastfeeding for the first 6 months of life to promote passive immunity
and guard against exposure to contaminated food and water.

Promote immunisation: rotavirus vaccine for all children.

Giving health education for prevention of diarrhea, home management of diarrheal diseases
and importance of ORS.

3) rash isle of white in the sea of red

a) dx: dengue fever

b) 1 clinical test that support diagnosis: torniquet test

c) IX

-FBC: decrese in platelet and wcc, increase hematocrit level

-LFT: elevated AST

-serology: IgM/IgG

-Ns-1 antigen detection

d) complications

-dengue hemorrhagic fever

-dengue shock
MCQ ( ithink laa)

1. hypothyroidism clinical features: coarse facies, open mouth, protruding & thick tongue,coarse
extremities, thick skin, umbilical hernia, sleep more, sluggish, chronic constipation

2. vasculitis

SLE

Symtopms / clinical features :DOPAMIN RASH (discoid rash, oral ulcer, photosensitivity, ANA, malar
rash, immunological phenomenon (ds DNA,) Neurological (seizures, psychosis), renal
(nephro,nephritic), arthritis, serositis, hematological (leukopenia, thrombocytopenia, anemia)

1. Malar rash
2. Bilateral joint swelling
3. Generalized lymphadenopathy , discoid rash.pleural effusion

Investigation ?- C3,C4
- anti ds DNA (T)
-ANA (T)
- blood culture (F)
- lymph node biopsy (F)

HSP

Symptoms : purpura rash, athralgia/athritis,abd pain,hematuria

a) joint pain (T)
b) purpuric rashes (T)
c) haematuria (T)
d) vomiting and cramping abdominal pain (T)
e) respiratory distress (F)

Complications HSP: progressive renal dz,intusseption, GI bleeding

Tx: steroid (gi bleed)

Pathophysiology HSP: vasculitis-shedding of blood vessel?

HSP APTT is prolonged

JIA (juvenile idiopathic athritis)

-IX: FBC,ANA,Rh factor, x-ray (decrease jt space, joint erosion, deformity,soft tissue swelling

-types: systemic JIA, polyarticular JIA, seronegative JIA, pauciarticular JIA

-tx: corticosteroids

DEVELOPMENTAL MILESTONE

12 month ( 1 year ) Gross : broad base gait ( like a bear )

 Fine : neat pincher grab , bang two cube
Speech: understand faces , 2-3 words with meaning ,
Social : casting , less mouthing , shy
15 months Gross : creep upstairs , can stand without support
Fine : Build tower of two cube , can scribble spontaneously ,
Speech : can point to object he wants , jabber & juggle
Social : can feed self with cup and spoon ( but spills :P )
can take off show
18 months Gross : gets up and down stairs holding on rail , sit on a chair ,
Fine : Tower of 3 cubes , visual test : pcture charts
Speech : points to 2/3 bodyparts
Social : toilet train , use spoon well , imitate housework , stop casting
2 years Gross : goes up and down stairs alone ( 2 steps at a time ) , can run ,
Thrown and kick ball
Fine : tower of 6 cubes , cube of train
Visual test : snellen chart ( yeah ..seriously )
Speech : 2 -3 words sentences
Social : pull on shoes , socks and pants
3 years Gross : goes up stairs ( one step at a time ) , goes down staird ( 2 feet at a
time ) , ride tricycle ,
Fine : can draw circle , build bridge ,
Speech : can count to 10
Social : Dress and undress with help
4 years Gross : goes up and down stairs one foot (dah terer )
Fine : can draw +
Speech : name 3 colours
Social : button clothes fully , attend to own toilet needs
5 years Gross : skip on both feet and run on toes
Fine : copy X ,triangle
Speech : knows age , name 4 colors
Social : tie shoe lace , dress and undress alone

X linked recessive X - linked dominant

Haemophilia, duchene muscular dystrophy, -fragile x syndrome, incontinentia pigmentia,
red/green color blindness congenital generalized hypertrichosis

Autosomal recessive Autosomal dominant

Thalassemia, sickle cell dz, albinism, cystic Huntington dz, pck, vw disease, congenital
fibrosis,g6pd, pku,congenital adrenal hyperplasia spherocytosis

Renal system

Pt presented with face puffiness : diff. diagnosis is

- nephrotic symdrome (tx: steroid)
-insect bites (tx: antihistamine)
- CHF
- acute Renal failure
-AGN (tx: penicillin)
-lupus nephritis

Ix: urine c&s,microscopy, complement level,

AGN:

-mx: mild HPT ( tx: furosemide), water retention, penicillin

UTI

-s/s: frequency, urgency, dysuria, fever, hesintacy, suprapubic pain

Diagnosis of UTI
- culture and urinalysis
- most sensitive (comfirmatory ) : urine culture and sensitivity
- ultrasound , DMSA scan and MSUG

Treatment UTI
- Trimetrhoprim
-Cefotaxime

Infectious Dz

-mumps

-s/s: swelling parotid glands,ear pain, dysphagia

-Ix: Clinical: examine parotid duct may show redness & swelling

Serology :mumps IgM in the 1st week of illness

Serum amylase high-pancreatic involvement

Complications: orchitis,viral meningitis,encephalitis,pancreatitis,myocarditis

-measles

Hallmark of measles : koplik spot

complication measles :
- respi : pneumonia , 2 bacteria infection , otitis media , trachitis
-neuro : febrile convulsion , EEG abnormality , meningoencephalitis , subacute subsclerosing pan
encephelatis (SSPE )
-others : diarrhea , hepatitis , appendicitis , corneal ulceration , myocarditis

Clinical features fever , cough , runny nose , conjunctivitis, marked malaise ,koplic spot , macular
papular rash

I.P: 12 days
Stages/phases: Four phases:

I. Incubation:8-12 days from exposure to the onset of symptoms and 14 days from exposure to
the onset of rash

II. Prodromal ( catarrhal)

High fever 40C to 45C; classic triad: cough, coryza, conjunctivitis( Stimson Line)

Pathognomonic Koplik spots

III. Exanthematous (rash)

Macular rash begins on the head(above hairline) and spread over most of body in 24 hr.-
cephalad to caudal pattern. Discrete maculopapular rash may be blotchy & confluent. It will
desquamate in the second week

Cervical lymphadenitis, splenomegaly & mesenteric lymphadenopathy with abdominal pain

maybe noted with rash

IV. Recovery

-Ix: Isolation of measles virus from a clinical specimen (urine, nasopharynx)

Serology : Positive serologic test for measles IgM antibody

Blood film :leukopenia & lymphopenia

Tx: vit A (decrease complications?),IV fluid,antipyretics

-diphtheria (corynebacterium diphtehria)

s/s: sore throat, fever, swollen glands and weakness. The hallmark sign is a sheet of thick, gray-
colored membrane composed of dead cells, bacteria and other substances. This membrane can
obstruct breathing causing difficulty and rapid breathing.

Complications: laryngitis,heart damage,nerve damage

-pertussis (bordetella pertusis): A highly contagious respiratory tract infection which cause classic
spasm (paroxysm) of uncontrollable coughing that is violent and persistent followed by a sharp, high
pitch intake of air which create characteristic WHOOP sound. Patient try to take deep breath
between cough

-s/s: Runny nose, nasal congestion, red watery eyes, fever.

Uncontrollable coughing that may end with a high-pitched "whoop" sound during the next breath of
air, cyanosis, facial congestion

Cx: inguinal hernia, Infants: Bronchopneumonia, seizures, brain damage

Adults: side effects of the strenuous coughing, ie; bruised or cracked ribs, abdominal hernias, broken
blood vessels in the skin or the whites of your eyes
CVS

Cyanosis : bluish discoloration of the skin and mucosal membrane due to more deoxygenated blood
Hb < 5g/dL

Causes of cyanosis :, ,
Respi : severe pneumonia , severe bronchiolitis ,
CVS : Eisenmenger syndrome , congenital heart failure

If patient present with cyanosis since birth other history yg kena tanya ( congernital heart dz n TOF )
- any feeding problem
-cyanosis of other part
- SOB ?
-Fever ?
-History of breath holding attack ?

Cyanotic heart dz Acynotic dz

TOF ASD
TGA VSD
Tricuspid atresia PDA
Trucus arterious

Tettralogy of fallot
-overriding of aorta
- pulmonary artery stenosis
- Right ventricular hypertrophy
-large VSD

Haemodynamic of TOF * :
-when there is pulmonary stenosis , only little blood go to pulmonary circulation
- a lot will be left in the Right ventricle Right ventricular hypertrophy
-together with VSD and overriding of aorta , blood in the right ventricle will be shunt to the left
ventricle
- mixing of blood aorta body cyanosis

Presentation
-poor feeding
-cyanosis during feeding
- fussyness
- Tachypnea
- agitation
Complication
-hypercyanotic spell ( rapid increase in cyanosis , irritability , inconsolable crying due to severe
hypoxia and SOB and pallor )
-MI
- CVA

-IE

Clinical features :
-clubbing
-systolic murmur upper left sterna edge
-single heart sound

Investigation :
-ECG- tall R wave ( Right ventrical hyperthrophy )
- Chest X ray : boot shape heart , pulmonary artery bay , reduce pulmonary vascular marking

Tx: treatment

-definitive surgery at 6 months of age, closing the VSD

- shunt (Blalock-taussig shunt) between subclavian artery and pulm artery in very cyanosed

- in hypercyanotic spells: sedation and pain relief( morphine), bicarbonate to correct acidosis, IV fluid
to reduce hyperviscosity, o2 adminikstration

VSD

Small VSD Large VSD

-asymtomatic - Clinical features of HF
- loud pan systolic murmur at lower left sternal - Failure to thrive
edge - Recurrent chest infection
-quiet P2 Sign
-chest x ray n ecg r normal -tachypnea , tachycardia
-large liver due to HF
-soft pan systolic murmur / no murmur
-apical mid diastolic murmur
- loud P2
-C xray : cardiomegaly , enlarged pulmonary
artery , enlarge pulmonary artery , increase
pulmonary vascular marking
-pulmonary congestion
-ECG : biventricular hyperthrophy

Haemodynamic changes :

VSD pressure in LV higher than RV Blood from the left ventricle right ventricle more
blood in pulmonary artery congestion HF ( no cyanosis )
Complication of vsd HF , RTI , IE , FTT, chest infection, coarctation of aorta

Immunization

Kill & live vaccine can be given together (eg:BCG &IPV)

BCG: at birth (tuberculous meningitis)if missed, give immediately

2,3,5,18 months:

1) polio- oral (live vaccines),IPV (kill vaccines)

-in breastfeed, oral polio can be given

2) h.influenza B-otitis media, sinusitis, pneumonia,meningitis,epiglotitis

3) DTaP

Pertussis: bordatella pertussis-family hx of febrile fits is not contraindication, can give vaccine

Complications in vaccination

-fever, pain, local abscess,infection, fits, anaphylactic reaction

Live vaccine Killed vaccine

-made from weakened organism - made of killed microorganism
-good mimickery of natural infection ( good - heat stable
humural and cell mediated immunity ) - no reversion to virulence
-longer duration of immunity (less dose required Disadvantages
) - poor mimicry
- IgA produced ( good mucosal immunity ) -shorter duration of immunity (more doses )
- Disadvantage : -IgA not produced ( poor mucosal immunity )
a) low temp stability
b) possible reversion to virulence

contraindication : Contraindication
- immune compromised patient -severe local or generalized reaction towards the
- severe anaphylaxis reaction towards the previous dose
vaccine
-leukemia pt Example
-HIV -Pertussis in DTaP , IM polio , influenza
-chemotherapy pt
-on high dose of steroid
-within 2 weeks of elective

Example :
BCG (Intradermal ) ,MMR ( IM ) , Per oral Polio ,
Varicella ( subcutaneous ) , Rotavirus ( oral )

Toxoid vaccine Diptheria and tetanus vaccine in (DTaP )

Subunite vaccine Hep B , human papilloma virus

Conjugate vaccine : HiB (IM )

Hepatitis vaccine
-all infant including yg born to HBsAG positive mothers ( 0 1 6 )
-health care personnel
-given IM ( give with immune globulin for infants of HBsAG positive mothers )

-side effects : fever and flu like symptoms,

Measles Vaccine
- side effects : transient rash , fever day 5 12 post vaccination , URTI symtopms , febrile convulsion
, encephalopathy

Pertusis :

-side effect : anaphylaxis , encephalopathy , high fever , fits within 72 hour , persistent inconsolable
crying

Optional Mandatory
-pneumococcal ( 2 months ) -BCG ( 0 )
-Influenza ( 6 bulan ) -Hep B ( 016 )
-rotavirus ( 6 weeks 6 months ) - DTap , IPV , HiB ( 2 3 5,18 )
Rotarex , Rotarix , RotaTeq - MMR ( 9,12) n boster 7 tahun )
-hep A ( 10 month ) -HPV ( 13 tahun - 3 doses )
- chicken pox ( 12 months )
Immunization : is a process whereby a person is made to be resistant to a infectious disease

H&L

Hypochromic microcytic anemia

1.IDA

-s/s: pica

-Ix: FBC,PBF,iron study, stool (microhemolysis?)

-Tx: iron supplement

2. thalassemia

-Ix: FBC,iron study, Hb electrophoresis, PBF( poikilocytosis,anisocytosis,target cell,tear drop

-Tx: blood transfusion,iron chelator(ferritin >1000mg?), vit c, folic acid, BM transplantation

Neuromuscular : Duchen muscular dystrophy

s/s: hyporeflexia,calf muscle enlargement,pseudohypertrophy ,gower sign, +ve family hx

-IX: CK level, muscle biopsy(Diagnostic),

Breastfeeding:

Mothersmilk: high calorie,low vit k,

Formula milk: high in electrolytes

Contra in breastfeed: HIV,HepB,psychotic mother,Tb,varicella,herpes

-in cleft palate, brestfeed is not contraindication,

Skin

Impetigo: strep pyogenes,staph

Scabies: itchy, burrow,erythematous papule,vesicular lesion like HFMD, family hx

Cases?

Pts fit 10-15mins, confuse,rash all body: meningitis?

1 y/o,tetanic spasm,minimum breastfeed expose, mother leg cramps: tetanic,hypocalcemia,vit D

Pts contact with mumps, what to do?: take vaccine at usual time
Pts 8-9 y/0,abd pain, kussmaul breathing,polyuria,thirsty: DKA

Short stature,wide carrying angle: karyotyping

Weight loss:-malignancy, tb, hyperthroid

Polyuria: UTI,DM,DI,CRF, compulsive polydypsia

Malar rash,lymphadenopathy, fever: SLE

Pleural effusion

exudate transudate
Infection,inflammation,malignancy:pneumonia,tb,RA.SLE, Inc venous pressure: cardiac
lymphoma failure,pericarditis
Hypoproteinemia:
cirrhosis,NS,malabsorption

Poliomyelitis GBS (guillain barre syndrome)

-motor loss,asymmetrical -asymmetrical
-LP: normal protein,wcc increase -LP:high protein
-fecal oral route

HFMD: coxsackie virus,purpuric lesion

IV IG: GBS,ITP,kawasaki dz

Malnutrition:

kwashiorkor marasmus
Edma, skin changes
Cx: infection

Tx: GOBF

ITP

Leukemia

Causes of stridor(noisy breathing during inspiration):

-bacteria: HiB,C.diphtheria

-viral: parainfluenza

Meningitis

pneumonia