INV Flashcards
(52 cards)
A mother brings her 14-month-old boy because he is not well. She observed that her child has recently lost his appetite and became disinterested in playing. The mother says that she got another baby 3 weeks ago, and in the last 2 months, she stopped breastfeeding her older child and started to give him mashed potatoes cooked rice with some added sugar and boiled macaroni. On examination, the child looks distressed, coughing with cyanosis and grunting but he is not feverish. His weight is 8 Kg. His temp is 36.3 C and his respiratory rate is 60 breaths/m. He looks edematous with sparse light color. His lips are pale
Kwashiorkor complicated with pneumonia & respiratory failure
Investigations
* CBC: Anemia, leukocytosis (Infection)
* Serum albumin: ↓
* Serum globulins»_space;> ↓ alpha and Beta globulins
* Electrolytes:
* Hyponatremia. It is dilutional
* Total Na increased (aldosterone), but serum Na decreased (water retention)
* Hypokalemia + Hypoglycemia + Hypomagnesaemia
A mother brings her 12 months old boy because he is always crying. She observed that her child is wasted and looks markedly wasted. On examination, the child is crying most of the time he looks very thin and wasted. His weight is 6.5 kg. His lips look pale with macerated mouth angles. Subcutaneous fat is lost over the abdomen, buttocks, with senile face. Chest examination reveals scattered rales and crepitations all over the chest.
A case of Marasmus 3rd degree complicated with pneumonia
Investigations
o CBC: Anemia, leukocytosis (Infection)
o Markers of infections: CRP, ESR, stool analysis …
o Serum proteins: Not markedly ↓ (DD: kwashiorkor)
o Electrolytes, blood glucose
A 1.5-year-old boy presents with abnormal gait and poor weight gain. He was breast fed for the first year without any other supplementation. On examination, he is pale with prominent forehead and a marked abdominal distension. He has small chest swellings. His length is on the 25th centile and his weight on the 10th centile. The hand and foot show abnormal fixed position. And the child started to convulse.
A case of rickets complicated with hypocalcemic tetany & convulsion
Investigations
- Laboratory:
o Serum calcium: Usually normal but may be decreased in cases with:
o Serum phosphorus: low
o Serum alkaline phosphatase: ↑↑ (Earliest manifestation)
o Radiological improvement start to occur after 2 weeks of vitamin D therapy)
A 5 years old girl was noticed to be pale and lacking energy. She was complaining that her legs were aching. She had an ear infection with a high temperature that was slow to respond to antibiotics. On examination she is quite and pale. Her temp is 37.8C. She has a generalized lymphadenopathy. She is pale but not jaundiced. She has bruises on her shins, left and right upper arm. The liver is 4 cm below the right costal margin and her spleen is palpable 2 cm below the left costal margin.
A case of Leukemia
Investigations
o CBC: anemia -thrombocytopenia – WBC (increased, decreased or normal)
o Peripheral blood film may show blast cells
o Bone marrow examination: is essential to confirm the diagnosis (blast cells)
o Lumbar puncture to identify disease of CSF
o Chest X-ray to identify mediastinal mass characteristic of t-cell disease.
An 18-month-old boy presents with a chief complaint of pallor. He is a picky eater taking small amounts of meat and some vegetables; he survives mainly on bottles of milk. On examination. He looks pale but not icteric. He is an active toddler. His heart rate is 100/m and he has grade 2/6 ejection murmur at the left sternal edge.
A case of iron deficiency anemia
- Blood picture:
o Low Hb.
o Microcytic hypochromic anemia
o Reticulocytic count is normal. It shows mild increase with therapy. - Blood chemistry: Low serum iron, serum ferritin but increase iron binding capacity
Detect the cause:
o Proper history taking and Focused and systemic clinical examination to rule out other causes of anemia.
A 2-year-old previously well boy is brought to the office by his aunt. She reports that he developed pallor and red urine and jaundice over the past few days. He has not been exposed to a jaundiced person, but he is talking Sulphamethoxazole- trimethoprim for otitis media. His aunt seems to recall his 4-year-old brother having had similar problem after a viral illness, which also caused a short-lived period of anemia and jaundice
A case of acute hemolytic anemia (G6PD)
Investigations
- During the attack:
o CBC: Anemia (normocytic normochromic)
o Reticulocytosis in blood film (hemolysis)
o Chemistry: indirect hyperbilirubinemia -hemoglobinemia – hemoglobinuria
o Blood film»_space;> Heinz bodies - Estimation of enzyme activity after at least 3 weeks of hemolytic attack, because immediately after hemolysis, bone marrow release reticulocytes with normal enzyme level giving misleading normal result.
A 5-year-old girl is referred to the pediatric clinic because of pallor and progressive abdominal distention with a history of repeated blood transfusion since the age of 6 months. On examination she appears pale and she has yellow sclera. Her heart rate is 105/m. Her height and weight are below the 5th centile. She has a grade 2/6 ejection systolic murmur at the left sternal edge. She has HSM but NO purpura or generalized lymphadenopathy.
Diagnosis: A case of Chronic hemolytic anemia mostly B Thalassemia major
Investigations
* To prove anemia: CBC shows Low hemoglobin
* To prove hemolysis:
o Blood film: Reticulocytosis and Abnormal shape
▪ Elevated serum indirect bilirubin
▪ Increased urinary urobilinogen
▪ ↑ serum iron, ↑ serum ferritin,
▪ ↓ iron binding capacity
o X ray findings: (poor value) bone marrow expansion
- Hemoglobin electrophoresis
o In affected child: Hb F is markedly elevated (10-90%) with reduced Hb A.
o Parents: increased of Hb A2 > 3.5% (normal: 3%).
A 2-year-old girl was brought to the emergency department with sudden severe hematemesis. History revealed umbilical sepsis during neonatal period. The child appears pale and physical examination reveals a firm spleen palpable 7 cm below costal margin. She does not exhibit hepatomegaly, ascites or lymphadenopathy. Laboratory findings show a hemoglobin level of 6 gm/dl.
Diagnosis: Portal hypertension (Pre hepatic type due to portal vein thrombosis)
Investigations
▪ Upper GIT endoscopy: detect esophageal varices
▪ Abdominal ultrasonography and Doppler:
o Direction of flow within the portal system.
o Patency of the portal vein and.
▪ CT angiography and MR venography (demonstrate vessel patency).
▪ Liver function test in other types.
▪ Investigation for the cause:
* Hepatitis markers, autoimmune screening
A 4 weeks old full-term female presents to the office with increasing jaundice over the last week. Her parents’ report that 2 weeks previously, she began to have yellow eyes and skin her stools is clay in color for the past 10 days along with dark urine. There were no complications noted at birth. On examination her weight and height are at the 50th percentile. Her skin is jaundiced with scleral icterus. Her liver is felt 4 cm below the costal margin firm in consistency and no splenomegaly is noted.
A case of neonatal cholestasis
Investigations to diagnose cholestasis
* Increased total and direct bilirubin: Direct bilirubin > 20% of total bilirubin
* Increased AST and ALT (mild)
* Increased ALP and GGT (marked)
- Search for treatable cause
– Galactosemia: Galactose 1 phosphate in blood
– Septicemia and bacterial infections: CBC, CRP, ESR, cultures.
- Search for treatable cause
- Search for TORCH infections
– Total lgM antibody
– Specific lgM antibodies of TORCH agents e.g. CMV lgM
- Search for TORCH infections
- Search for metabolic conditions: Alpha 1 antitrypsin assay
- Exclude choledochal cyst: abdominal ultrasonography
A 12-year-old boy is brought to the clinic by his parents. He has been complaining of mild abdominal pain and his parents noticed that the sclera looked yellow. He has been scratching himself mildly. The parents report that he had flu like illness with fever nausea and poor appetite over the last 10 days. He has previously been healthy, but he went to a summer camp 5 weeks previously on examination he is jaundiced and appears uncomfortable but alert and fully oriented. His temp is 37.8 C and his liver is palpable 4 cm below the costal margin and mildly tender.
A case of acute Hepatitis A
o AST and ALT»_space;> elevated (10 folds)
o Bilirubin: direct hyperbilirubinemia
o Urine analysis: bilirubin is present.
- To diagnose acute hepatic failure
o INR > 2 uncorrectable with vitamin K
o High blood ammonia level
o Metabolic Acidosis.
o Hypoglycemia, Hypokalemia and Hyponatremia. - To diagnose the causative virus
▪ Anti HAV lgM»_space;> recent infection (acute disease)
▪ Anti HAV IgG»_space;> immunity
Hepatitis E»_space;> Anti HEV (lgM)
A Newborn infant delivered at 34 weeks gestation by vaginal delivery after 96 hours of ruptured membranes. His birth weight was 2 kg. A breast feed was attempted, but was unable to suckle and swallow properly. At the age of 6 hours, he developed frequent apneic episodes. On examination, the baby appears lethargic and hypotonic. His temperature is 35.8 C.
A case of neonatal septicemia.
Investigations
* CBC with differential :
o Most predictive»_space;> WBCs <5,000 cells/mm³ and ANC <1,000.
- CRP
- Cultures:
o Blood culture
o Thrombocytopenia, PT, PTT, INR in severely ill neonates»_space;> DIC
o Lumber puncture for suspected meningitis: CSF analysis
o Chest X ray and arterial blood gas for suspected pneumonia
A 4-day-old full-term infant is referred to the pediatric outpatient clinic by his GP because of jaundice. This is the first baby of a 22-year-old mother His mother states that the jaundice started within the first 24 hours of life, His birth weight was 3.7 kg on Examination the sclera is yellow and the jaundice is extending to the palm and soles. There are no other signs.=
Diagnosis: A case of neonatal jaundice.
Investigation
* Serum bilirubin (total and direct) to determine type of hyperbilirubinemia.
* Conjugated bilirubin (> 20% of the total)»_space;> cholestasis
- Unconjugated hyperbilirubinemia:
o Blood picture:
▪ Hb and reticulocytosis hemolysis.
▪ WBC count and I/T ratio→ septicemia.
o To exclude hemolytic disease:
▪ Blood grouping (ABO and Rh) for baby and mother.
▪ Coombs’test
o To exclude hemolytic anemia:
▪ Enzyme assay: G6PD deficiency.
▪ RBCs morphology and osmotic fragility test: spherocytosis.
o Thyroid profile: if not done
A term 4200 gm female infant was delivered by CS because cephalopelvic disproportion. The amniotic fluid was clear, and the infant cried almost immediately after birth. Within the first 15 minutes of life, however the infant’s respiratory rate increased to 70 breath/minute, and she began to have mild chest retractions and intermittent grunting respirations. The infant was transferred to neonatal unit. On admission, chest examination showed bilateral fair air entry.
Transient tachypnea of the newborn.
Investigation
* X ray:
o Prominent pulmonary perihilar markings (dilated lung lymphatics).
o Fluid in the interlobar fissures
Treatment: basic life support and monitoring. Supplemental O2 and IV fluids. Tube feeding until normal Respiratory rate
A term female infant was born to a 28-years-old mother by CS after an obstructed labor. Apgar scores were 3 and 4 at 1 and 5 minutes, respectively. She required vigorous resuscitation at birth and was admitted to the NICU under observation. She developed generalized tonic clonic seizures 10 hours after delivery. On examination her tern was 36.8 C heart rate was 140/m and respiratory rate 60/m she is no respiratory distress but she is sleepy. Head shoes mild molding. There is generalized hypotonia. Blood sugar and calcium were normal.
A case of hypoxic ischemic encephalopathy.
- Postnatal:
▪ Monitoring of ABG - saturation - blood glucose- serum electrolytes - temperature - serum calcium.
▪ Renal function -bleeding profile.
▪ Liver function tests.
o Imaging:
▪ Cranial ultrasound.
▪ EEG: abnormal background activity, early encephalopathy or seizures.
▪ MRI: at 7-10 ± 14 days: bilateral abnormalities in basal ganglia and thalamus.
▪ Echo (cardiac dysfunction and persistent pulmonary hypertension).
A 23-years-old lady in her first pregnancy is admitted to hospital at 29 weeks gestation because she has had spontaneous rupture of membranes. Forty-eight hours later she goes into spontaneous labor and a baby boy is delivered weighing 900 gm Two hours after delivery. He develops marked subcostal and sternal recession with audible shunting.
Diagnosis: Respiratory distress syndrome.
- Chest x-ray:
– Diffuse reticulogranular pattern
– Complete opacification of both lung fields (white lungs) in severe conditions. - Blood gases»_space;> hypoxia, hypercapnia and acidosis.
- Electrolytes, calcium and glucose.
- Others: CBC, CRP and ESR.
A 12-year-old boy is referred by his GP with a chronic nocturnal cough. He has been losing weight and has had a poor appetite 3 months ago. He lies with his mother and three younger siblings in a damp two bed room flat and his mother has also been coughing a lot over the last month with occasional blood-tinged sputum. They are uncertain which immunizations he has received. On examination, he is very thin and his weight is on the 3rd percentile. His heart rate is 80/m and his respiratory rate is 26 breaths /m. There is no wheeze but there are bronchial breath sounds in the right upper zone of his chest.
Diagnosis: a case of TB pneumonia
- CBC: Lymphocytosis.
- ESR: Very high ESR usually above 100.
- Tuberculin test
- Isolation and culture of organism:
o Direct smear with ZN stain - Biopsy of lymph nodes or pleura: For pathological study.
- Radiological studies: Chest x-ray and chest computed tomography (CT scan).
A 3 years old girl presented 4 days previously with a cough and fever and was diagnosed with viral upper respiratory tract infection. On examination, she is febrile 38.8 with capillary refill of 2 seconds. Her pulse is 140/m, oxygen saturation is 85% in air and BP is 85/60. Her respiratory rate is 48/m with nasal flaring. There is dullness to percussion in the right lower zone post. With decreased breath sounds and bronchial breathing. Oxygen saturation is given, however respiratory distress worsens (RR more than 60/m, severe Intercostal recession. She becomes cyanosed and lethargic.
Diagnosis: A case of Pneumonia with respiratory failure
- Chest X-ray: to Confirm the diagnosis.
- Complications: effusion- empyema- pneumothorax- lung abscess.
- Blood gas: in severe cases lowered O2 tension and raised CO2.
- CBC, ESR, CRP: DD/ bacterial and viral causes.
- Culture and sensitivity test: sputum culture.
A 9 year old boy is seen in the emergency department. This is his third attendance with an acute wheeze in the 3 months. He has developed a cold and became acutely breathless. On examination, he is quite but able to answer questions with short sentences. His chest is hyper inflated and he is using his accessory muscles of respiration. On auscultation there is equal but poor air entry with widespread expiratory wheeze. His pulse is 125 /m with good perfusion.
Acute asthma
CXR: normal in between attacks
CBC, CRP, ESR to exclude pneumonia
Peak expiratory flow rate: decrease expiratory flow rate
Spirometery: shows obstructive pattern
A 3-year-old boy was seen because of a cough and fever and was diagnosed as having a viral upper respiratory tract infection. On examination, he miserable, flushed, toxic and febrile 38.8 C. His pulse is 140 beats/m. His respiratory rate is 48 breath/m with nasal flaring. There is dullness to percussion in the right lower zone posteriorly. With decreased breath sounds and bronchial breathing.
Diagnosis: A case of Lobar Pneumonia (RT lower lobe pneumonia)
- Chest X-ray:
- Confirm the diagnosis. opacity in effected lobe
- Blood gas: in severe cases lowered O2 tension and raised CO2.
- CBC, ESR, CRP: DD/ bacterial and viral causes.
- Culture and sensitivity test: or sputum culture.
A 5 months old boy developed a runny nose and a cough 2 days previously, but has become progressively and has now gone off his feeds. He has two older siblings who also have colds. On examination, he is febrile. 37.8, has clear nasal secretion and dry wheezy cough. His respiratory rate is 65 /m with intercostal and subcostal retraction. On auscultation, there are widespread fine crackles and expiratory wheezes.
A case of acute bronchiolitis
- Chest x-ray: hyperinflation of the lungs with focal atelectasis.
- Blood gas analysis: hypoxia- CO2 retention.
- RSV antigen detection from nasopharyngeal secretions.
An 11-year-old girl is admitted with drowsiness and difficulty breathing. She was well until 3 weeks previously, when she began feeling tired, thirsty and losing weight. On examination she responds only to pain. Her breath has an abnormal smell, is deep and rapid 25/m, her heart rate is 100/m and her temp is 36.8 C. She has cool peripheries and capillary refill time of 5 seconds
A case of diabetic Ketosis
Investigations
* Blood glucose: hyperglycemia (above 200 mg/dl)
* Urine analysis: glucosuria and ketonuria
* Blood gas analysis: metabolic acidosis
* Urea, creatinine and electrolytes (especially potassium)
- Evidence of a precipitating cause e.g. infection (CBC + blood and urine cultures)
The mother of a 2-week-old infant reports that since birth her infant sleeps most of the day; she has to awaken her every 4 hours to feed, and she will take only an ounce of formula at a time. She also is concerned that the infant has persistently hard pellet like stools. On examination, you find an infant with normal weight and length, but with an enlarged head. The heart rate is 75 beats/m and the temp is 36 C the child is still jaundiced. You note large anterior and posterior fontanelle, a distended abdomen and an umbilical hernia
A case of congenital hypothyroidism.
Investigations
- Laboratory: Thyroid profile: T3, T4 and T.S.H.
- Imaging:
o Plain X ray: delayed bone age.
o Thyroid scanning (radioactive iodine: iodine 123) essential for diagnosis of cause
o Thyroid Ultrasonography
- Neonatal thyroid screening:
o Timing: between 3 and 7th day of life.
A 10-years-old patient calls his parents from summer camp to state that he has had fever, muscular pain (especially in the back), headache and malaise. He describes the area from the back of his mandible towards the mastoid space as being full and tender and that his ear lobe on the affected side appears to be sticking upward ad outwards. Drinking sour liquids causes much pain. When his father calls your office, you remind him that he had refused immunization for his child due to concerns regarding vaccine safety.
Diagnosis: A case of Mumps.
TTT:
Prophylaxis:
1. Passive: mumps gamma globulins early in the incubation period.
2. Active: MMR vaccine.
Treatment: Symptomatic: analgesics and antipyretics
A 4-years-old boy is brought by his parents to the pediatric clinic with mild fever and a few small blisters on the shoulder and chest. The parents state that fever was noted for 1 day, and then the skin lesions appeared. These lesions began as tiny papules which progressed rapidly to vesicles. On examination, he has a widespread skin rash at different stages, the rash is more concentrated on the trunk than the limbs. The parents report that that have been several other children with similar lesions at his school.
Diagnosis: A case of Chickenpox.
TTT:
1. Antipruritic agents (local and systemic)
2. Antipyretics.
* Aspirin should not be used as it increases the risk of Reye syndrome (acute encephalitis
- Antiviral drugs: Acyclovir I.V in (immunocompromised - encephalitis - pneumonia)
