END EXAM Flashcards

Question

investigations of acute congestive heart failure

Answer 1

1. chest x-ray 2. ECG: to diagnose arrhythmia. 3. Echocardiography: chamber size and cardiac anomalies. 4. Laboratory: arterial blood gas, CBC, ESR, CRP, ASOT and cardiac markers (Creatine kinase-MB and troponin)

Answer 2

1. Supportive measures Rest in semi sitting position Fluid restriction to 60-70% Salt restriction Oxygen therapy: to reduce distress and correct hypoxia Digoxin therapy to improve myocardial contractility Diuretic therapy: Furosemide (Lasix) to reduce preload After load reducing agents as captopril Grade 2: vasodilators nitroglycerine infusion, IV Dobiutamine, cpap grade 3: IV dopamine, capropril vasodilator

Answer 3

1. Upper GIT endoscopy: detect esophageal varices 2. Abdominal ultrasonography and Doppler: = Direction of flow within the portal system = Patency of the portal vein and = Presence of portosystemic collaterals. 3. CT angiography and MR venography (demonstrate vessel patency) 4. Liver function test 5. Investigation for the cause: Hepatitis markers, autoimmune screening, sweet chloride test, liver biopsy

Answer 4

Managment of portal hypertension 1. Emergency therapy for bleeding varices:- Hospitalization: Anti-shock measures: blood transfusion, intravenous fluids. Correction of coagulopathy: vitamin k, fresh plasma, platelets transfusion. Nasogastric tube placement. H2 receptor blocker (ranitidine) IV to decrease risk of bleeding from gastric erosion Third generation cephalosporins. Vasopressin infusion if bleeding persists. 2. Emergency endoscopy (if hemodynamically stable): and either injection sclerotherapy or band ligation. 3. Emergency shunt: Trans jugular intrahepatic Porto-systemic shunt (TIPSS) Surgical Porto-systemic shunts

Answer 5

1. complete liver function tests: attention to GGT 2. investigation of treatable causes galactose-1-phosphate-uridyl transferase for galactosemia TORCH IgM and DNA by PCR CBC, CRP, blood and urine cultures for neonatal sepsis and UTI succinyl acetone for tyrosinemia 3. bile salts 4. alpha 1 antitrypsin 5. andominal US to choledocal cyst and biliary atresia 6. liver biopsy to diagnose: biliary atresia Alagille syndrome: paucity of interlobular bile ducts

Answer 6

A L.E is chol kasai portoenterostomy replacement therapy symptomatic treatment liver translantation for end stage liver disease | 2.133

Answer 7

Laboratory 1. Karyotyping (for patient and his mother) to determine the genetic type of Down syndrome and risk of recurrence. 2. Complete blood count, if leukemia is suspected. 3. Thyroid profile and regular blood glucose checking. imaging 1. Plain X ray * Chest for pneumonia. - Abdomen to exclude GIT anomalies (in neonates’ e.g. duodenal atresia). 2. Echocardiography: to exclude cardiac anomalies. 3. Abdominal ultrasonography: to exclude renal and gastrointestinal anomalies Regular hearing and vision testing

Answer 8

rehabilitation and management of complications 1. Diagnosis and management of complications and associated anomalies: e.g. heart failure, chest infections and hearing aids if needed 1. General measures: special schools for rehabilitation and education. 2. Specific measures: speech therapy and physiotherapy.

Answer 9

Laboratory 1. Karyotyping: 45 XO 2. Hormonal study (gonadal failure); increased FSH and LH 3. Thyroid profile (hypothyroidism). Imaging 1. X ray to determine bone age 2. Echocardiography: may be aortic coarctation 3. Abdominopelvic ultrasound: may be renal anomalies (horse shoe, ectopic kidney) , uterine anomalies, ovaries (streaks of connective tissues)

Answer 10

A) Laboratory a. Urine e Urinalysis: Proteinuria (3+ or 4+) e Urine protein/Creatinine ratio > 2 e 24 hour urine proteins: > 40 mg/m’/ hr (needs timed urine collection which is difficult) e Proteinuria is selective (mainly albumin ,no high molecular weight proteins) b. Blood e Serum albumin < 2.5 g/dL e Serum cholesterol > 200 mg/dL e Kidney functions: Normal e Complement (C3 & C,): Normal (No consumption) == Invasive: Renal biopsy (not routine); indicated in: =Age at onset <1yror>10yrs = Gross hematuria = Persistent hypertension =Renal impairment = Hypocomplementemia (J C3 and/or C,) = Family history of NS = steroid resistant NS: failure to achieve remission after 4-6 weeks of steroid therapy

Answer 11

1. Place of Treatment a. Home management: Most cases with mild to moderate edema b. Hospital management: 1™ attack or relapses with marked edema or complications 2. Supportive Management e a. Diet: = Salt restriction * Protein intake: Normal intake or mildly increased " Lipid restriction ' Hypovolemia = Fluid restriction in cases of severe hyponatremia ——— b. Edema = Mild: Salt restriction = Moderate: Diuretics; Furosemide (1-2 mg/Kg/day) = Severe: Salt-free albumin + Furosemide (1-2 mg/Kg/day) c. Infection: Antibiotics (3 generation cephalosporin) 4. 3. Specific Management Induction: Prednisone (2 mg/Kg/day) Divided into 3 doses after meals for compiete 4 weeks > If the child is steroid-responsive (Maintenance): o Shift to alternate-day therapy (2 mg/Kg/day Single morning dose) o With gradual tapering over 3 months > If the child is steroid resistant :non minimal lesion o Do renal biopsy o Shift prednisone to alternate-day therapy with gradual tapering o Add angiotensin-converting enzyme inhibitors: adjuvant to reduce proteinuria o Add other immunosuppressive drugs: cyclosporine or tacrolimus b. Treatment of Relapses As the initial therapy, but with shorter induction and longer maintenance c. Treatment of frequently relapsing and steroid dependent NS - Medications used: Cyclophosphamide, Mycophenolate mofetil

Answer 12

1. Laboratory a. Urine (Urinalysis): Color: Brown, tea or cola-like or smoky Proteinuria (mild to moderate) b. Blood = KFT (1111Urea &1111 creatinine): may be impaired = Evidence of recent Streptococcal infection (111 ASOT, throat or skin contact) = v v C3 (returns to normal within 8 weeks) = Normal C4 2. Imaging: Renal U/S 3. Invasive: Renal biopsy is rarely indicated a. Severe renal impairment (Rapidly progressive GN = RPGN) b. Persistent hematuria or proteinuria > 6-12 months c. Normal C3 d. Persistent hypocomplementemia > 3 months

Answer 13

Treatment 1. Place of management b. Hospitalization: Complicated cases (renal failure, HF, encephalopathy) 2. General measures . Diet: = Salt restriction = Fluid balance b. Rest: During the oliguric phase 3. Supportive treatment a. Edema ® Salt restriction, fluid balance, diuretics (Furosemide 1-2 mg/Kg/day) = Ca channel blockers (Amlodipine 0.6 mg/Kg/day) 4. Treatment of complications a. Renal failure: Fluid balance, diuretics, dialysis (in severe cases) b. Heart failure: > Preload reduction: Diuretics > Afterload reduction: ACE inhibitors > Inotropes: Dopamine (digitalis should be avoided) c. Hypertensive encephalopathy: Antihypertensive (IV Hydralazine or diazoxide)

Answer 14

= Midstream urine collection = Bladder catheterization = Suprapubic aspiration (Method of choice in sick newborn and infants) urine analysis Pyuria (Pus cells > 5/HPF) is suggestive of UTI WBC casts is suggestive of pyelonephritis Urine culture = Colony count > 100,000 single pathogen is diagnostic = Any bacterial growth in a suprapubic aspirate or catheter sample is diagnostic = The presence of more than one organism suggests contamination Blood: = CBC: leukocytosis & neutrophilia = ESR, CRP & blood culture Imaging a. Ultrasonography = Indications: o First episode of febrile UTI (pyelonephritis) o Frequently occurring lower UTIs (cystitis) = Value: o Diagnosis of obstructive uropathy (hydroureter and hydronephrosis) o Detection of renal scarring b. Renal scan (DMSA) = Detection of renal scarring = Estimation of renal function (total & split function) c. Voiding cystourethrogram (VCUG) " Indications: o Febrile UTI with abnormal renal US o Febrile UTI with abnormal renal scan (DMSA) = Value: o Diagnosis of VUR o Diagnosis of PUV & neurogenic UB

Answer 15

Treatment should be started without delay then modified according to the culture result Cystitis: oral Trimethoprim-sulfamethoxazole for 5 days pyelonephriris: Ceftriaxone Or Cefotaxime Or Oral 3 gen. cephalosporin for 7-14 days نشرب مية كتير و نعمل حمام كتير لحد الاخر ناكل زبادي و نتجنب الامساك Third generation cephalosporin 1/3 dose

Answer 16

Blood picture: - Low Hb. - Microcytic hypochromic anemia - low MCV and MCHC - Reticulocytic count is normal. It shows mild increase with therapy. Blood chemistry: - Low serum iron < 50mcg % (normal: 90 -150 pg/dl) - Low serum ferritin |< 10 ng (normal: 30 -150 ng/ml) - Increased iron binding capacity (normal: 250 -350 ug/dl). Detect the cause - clinical history to discover dietary problems. - systemic clinical examination to rule out other causes of anemia - Stool analysis: to detect Ankylostoma - blood in stool — bilhariziasis - Endoscopy might be indicated: to exclude peptic ulcer or chronic H-Pylori infection

Answer 17

Treatment of the cause: (Schistosomiasis: Praziquantel) (Ankylostoma: Albendazole) lron therapy: Oral iron therapy: - Ferrous sulfate or gluconate 3-6 mg/kg elemental iron in 3 divided doses/day in between meals - Iron supplementation should be continued until the Hb is normal and then for a minimum of a further 3 months to replenish the iron stores. Parenteral iron dextran preparations: In poor compliance or malabsorption. iron dextran Diet: Rich in iron (Meat, liver, green vegetables) and vitamin C Successful ion therapy day1 Apetitie improved day2 Bone marrow erthyroid hyperplasia day3 reticulocytosis by 1st month elevated hemoglobin 1 gm 4-6 weeks increased stores

Answer 18

CBC: low Hb, microcytosis, anisocytosis, target cells, poikilocytosis. Hemoglobin electrophoresis or High Performance Liquid Chromatography (HPLC): o Inthe affected child: Hb F is markedly elevated (10-90%) with reduced Hb A. o Parents: increased of Hb A2 > 3.5% (normal: 3%)

Answer 19

Supportive treatment Restrict Iron in diet. Folic acid 1 mg/day. Hepatitis B vaccine. Calcium and vitamin D Lifelong Repeated packed RBCs transfusions: 10 -15 ml /kg every month to keep Hb level >10 gm/dl (hypertransfusion). = Iron chelating agents: (should be started after 10 times blood transfusion) Deferroxamine (Desferal): 20 — 40 mg/kg by S.C. Pump over 10 hours, Sdays/week. Deferiprone: Oral chelating agent (25mg /kg/dose, three doses per day) Deferasirox: oral chelating agent (20-40 mg/ kg/ day) = Splenectomy: Indications: Huge splenomegaly or hypersplenism after age of 4 Splenectomy care: o Before splenectomy: Vaccination (pneumococci- meningococci- H. influenza) o After splenectomy: lifelong daily oral penicillin prophylaxis is advised or Long acting penicillin prophylaxis =" Bone marrow transplantation: (best below 3 years) Induction of fetal hemoglobin synthesis hydroxyurea can stimulate Hb F production " Treatment of complications: - Gall bladder stone: cholecystectomy - Diabetes: insulin therapy - Short stature: growth hormone

Answer 20

To prove anemia: CBC shows Low hemoglobin To prove hemolysis: e Blood film: reticulocytosis (raised reticulocyte) & abnormal appearance of the red cells = sickled shaped) e Blood chemistry: elevated serum indirect bilirubin, serum iron, serum ferritin, decreased iron binding capacity, decreased the haptoglobin. e Increased urinary urobilinogen Hb electrophoresis: Hb S is present (> 50%) no HbA Parents: HbS 20-40% HbA60-—80%

Answer 21

A A water oxygen blood Treatment of acute crises — Painful crises should be treated with: 1. Oral or intravenous analgesia according to need (may require opiates); Good hydration (oral or intyavenous as required); Infection should be treated wii!) antibiotics; Oxygen therapy when oxygen saturation is reduced; Exchange transfusion is indicated for acute chest syndrome, stroke and priapism. Treatment of chronic problems — 1. Hydroxycarbamide, a drug which increases their HbF production 2. Bone marrow transplant,

Answer 22

G6PD Investigations: = During the attack: - CBC: Anemia ( normocytic normochromic) - Blood film shows Heinz bodies - Reticulocytosis in blood film (hemolysis) - Chemistry: indirect hyperbilirubinemia -hemoglobinemia — hemoglobinuria

Answer 23

= Urgent packed red cell transfusion (10 ml/kg) is lifesaving in very severe hemolysis = Prevention of subsequent attacks: A list containing oxidants materials (drugs, chemicals and food) should be given to parents.

Answer 24

Blood picture: Pancytopenia Bone marrow examination: hypocellular bone marrow

Answer 25

= CBC will show pancytopenia = Bone marrow aspirate and biopsy will show hypocellular bone marrow = Chromosomal breakage study : increased chromosomal breaks of peripheral blood lymphocytes to identify affected family members or for prenatal diagnosis. = Skeletal survey might show absent thumb or radius = abdominal U/S might show renal anomalies

Answer 26

* Supportive therapy :( Transfusion for controlling anemia — antibiotics for infection — coagulation factors for bleeding) * Bone marrow transplantation from normal, HLA- matched donor

Answer 27

- CBCwill show pancytopenia - Bone marrow aspirate and biopsy will show hypocellular bone marrow - Chromosomal breakage study (spontaneous and induced) will be normal

Answer 28

Treatment: Supportive therapy (controlling anemia — infection — bleeding) - Immunosuppressive therapy (Anti-thymocyte globulin (ATG) and/ or cyclosporine) e Moderate and Severe cases: - Bone marrow transplantation (BMT) is the treatment of choice from HLA matched sib.

Answer 29

1. CBC: anemia -thrombocytopenia - WBC (increased, decreased or normal) 2. Peripheral blood film may show blast cells 3. Bone marrow examination: is essential to confirm the diagnosis (blast cells) 4. Lumbar punctureto identify disease of CSF 5. Chest X-ray to identify mediastinal mass characteristic of t-cell disease

Answer 30

i. Supportive treatment: = Blood & platelet transfusion = Treating the infection = Hydration Chemotherapy: Combination of chemotherapy #Induction of remission: vincristine - asparagenase - —prednisone — cytarabine = Intrathecal: methotrexate, hydrocortisone- cytarabine #Systemic continuation therapy: 2- 3 years- {6 mercaptopurine — methotrexate} . Bone marrow transplantation in relapsing cases

Answer 31

CBC: - Thrombocytopenia, usually < 20,000 / mm? (Normal: 150,000 - 400.000mm?) - May be low Hb due to blood loss. - Normal WBCs count with relative lymphocytosis. ¢ Bone marrow examination: - Megakaryocytes are normal or increased in number with defective budding ¢ Anti-platelet antibodies: are found

Answer 32

in moderate cases Prednisone: Dose 2 mg/kg/d to inhibit antibody synthesis and phagocytic activity. For 2 weeks Intravenous immunoglobulin (IVIG): dose 1 gm/kg/day, Duration for 2 days. in severe cases: I.V. methyl prednisolone 20 mg /kg / day for 5 days IVIG platelet transfusion after starting steroid In chronic cases: (>12 months): - Careful evaluation for associated disorders (E.g. SLE: frequent screening of autoantibodies). : - Prednisone & IVIG. - OR Splenectomy (75% curative). - OR Immunosuppressive therapy (e.g. Cyclosporine).

Answer 33

1. Phase | coagulation defect (prolonged PTT) 2. Specific factor Vill assay (reduced below normal) Normal > 60% & Carrier 30 -60% (female). - mild hemophilia 5-30%: (bleeding with trauma or surgery) - moderate hemophilia 1-5%: (bleeding with minor trauma) - severe hemophilia < 1%: (spontaneous joint bleeding)

Answer 34

1. Cold compresses minimize bleeding in mild cases 2. Replacement (essential in moderate or severe cases) = I.V. infusion of cryoprecipitate (Plasma concentrate of factor VIII) (Dose: 25 — 50 Unit/ kg every 12 hours). This dose applies to hemarthrosis. = I.V infusion of Purified plasma derived factor VIII concentrate = I.V infusion of Recombinant factor 8. #Prophylactic F VIII in severe hemophilia (2 times per week) 3. Desmopressin:In mild hemophilia A it increases endogenous release of FVIII (ineffective in hemophilia B). 4. Physiotherapy specially after immobilization to prevent muscle wasting and joint contracture

Answer 35

Laboratory 1. Hypochloremic metabolic alkalosis 2. Hypokalemia imaging 1. Abdominal US: confirm the diagnosis. 2. Barium meal: shows Narrow pyloric canal "String sign"]

Answer 36

1- Correction of fluid & electrolyte disturbance 2- Pyloromyotomy (Ramstedt)

Answer 37

1. Serology: Tissue transglutaminase & anti-endomysial antibodies 2. Endoscopy: Jejunal biopsy shows flat mucosa with villous atrophy

Answer 38

1. Gluten-free diet for life is essential for reversal of growth failure, improvement of symptoms and reduction of the risk of intestinal malignancy 2. Oat is allowed

Answer 39

1. Laboratory: Hematocrit, blood glucose, calcium and magnesium. 2. Imaging: Chest X ray, Echocardiography, abdominal ultrasound.

Answer 40

1. Delivery should be in a hospital where the newborn can be carefully monitored 2. After birth: monitoring for metabolic disturbances especially hypoglycemia a. Blood glucose should be done within the first hour of delivery, then at least hourly for the first 6-8 hours postnatal b. Asymptomatic infants if clinically well should start early feeding. b. Breastfeeding should be started as soon as the infant is stable. d. If the infant is unable to tolerate oral feeding , glucose should be given by peripheral IV infusion at rate of 6-8 mg/kg/minute 3. Careful monitoring of complications > NICU admission for, unstable baby Echo, abdominal US, CT, MRI

Answer 41

nvestigations 1. Prenatal :Fetal biophysical profile - Doppler U/S( assess the cord blood flow) 2. Perinatal: blood gas analysis (acidosis) and saturation(hypoxia) 3. Postnatal: Laboratory a. Monitoring of ABG — saturation — blood glucose — serum electrolytes — temperature — serum calcium]. b. Renal function —bleeding profile. c. Liver function tests Imaging a. Cranial ultrasound b. Electroencephalogram (EEG, cerebral function monitor ) to detect :abnormal background activity , early encephalopathy or seizures c. MRI: at 7-10+ 14 days: bilateral abnormalities in basal ganglia and thalamus d. Echo (cardiac dysfunction and persistent pulmonary hypertension may occur)

Answer 42

Therapeutic hypothermia (cooling to a rectal temperature of 33-34 C°) for 72 hours should started within 6 hours of birth Treatment of seizures by anticonvulsants : discuss Treatment of hypotension by volume and inotropic support Treatment of hypoglycemia(glucose 10%) and hypocalcemia (Ca gluconate IV)

Answer 43

1. Intrauterine intra-umbilical blood transfusion 2. Induction of labor: between 33-34 weeks, with marked hemolysis. 3. Phototherapy, exchange transfusion if needed following delivery. 4. Elimination of foreign red cell antigens by giving Human anti-D globulin to the mother a. Timing: It is administered at 28-32 weeks gestation and b. Again within 72 hours of delivery or abortion. c. Dose: IM injection of 1 ml to neutralize fetal protein

Answer 44

CBC w 2 hemolytic w septicemia w thyroid 1. Blood picture HB % and reticulocytosis>hemolysis. WEC count and I/T ratio> septicemia. 2. To exclude hemolytic disease Blood grouping (ABO and Rh) for baby and mother. Coombs’test (to detect maternal antibodies that coat the baby's RBCs). 3. To exclude hemolytic anemia Enzyme assay: G6PD deficiency. RBCs morphology and osmotic fragility test: spherocytosis. 4. If septicemia is suspected: C reactive protein- Erythrocyte sedimentation ratecultures. 5. Thyroid profile if not done in neonatal screening program.

Answer 45

. Monitoring 1. Screen serum bilirubin level (TSB) or transcutaneous bilirubin (TCB) of any neonates before discharge 2. Plot total serum bilirubin on an hour-specific nomogram that identifies risk zones Phototherapy indicated in Bilirubin level higher than 15 mg/dl in full term newborn Exchange transfusion

Answer 46

1. Bilirubin level higher than 15 mg/dl in full term newborn or according to hour specific nomogram 2. Before, after or in between exchange transfusions (complementary treatment) 3. Prophylactic in very low birth weight infants, hemolytic disease of the newborn

Answer 47

1. Hemolytic disease of the newborn >early exchange transfusion a. Cord bilirubin 5 mg/dl or more, and or b. Cord Hb 10 gram % or less. c. Bilirubin level is rising over 1 mg/dl /hour in spite of phototherapy. d. The baby has a risk of kernicterus 2. Bilirubin level more than 25 mg/dl in spite of phototherapy.

Answer 48

1. Chest X ray * Diffuse reticulogranular pattern * Air bronchogram (air in the major bronchi appears in contrast with the white background of collapsed alveoli). * Complete opacification of both lung fields (white lungs) in severe conditions. 2. Blood gases hypoxia, hypercapnia and acidosis 3. Electrolytes , calcium and glucose 4. Other investigations : blood picture , C reactive protein and ESR

Answer 49

Treatment 1. Basic life support measures a. Thermoregulation b. Correction of acidosis, fluid and electrolyte balance. 2. Prophylactic antibiotics until cultures appear 3. Monitoring a. Heart rate, respiratory rate, arterial blood pressure and temperature. b. Oxygen saturation by transcutaneous O2 pulse oximeter. c. Arterial blood gases (Pa02, PaCO2, pH and base deficit). d. Hemoglobin, electrolytes, calcium, glucose and albumin. 4. Correction of hypoxemia a. In the delivery room : prophylactic Nasal continuous positive air way pressure (CPAP) b. NICU management : Nasal CPAP or Intermittent positive pressure ventilation (IPPV) or high frequency ventilation in cases of risk of air leak . Surfactant replacement therapy a. Natural or synthetic surfactant can be given via an endotracheal tube

Answer 50

X-ray a. Prominent pulmonary perihilar markings (dilated lung lymphatics). b. Fluid in the interlobar fissures and minimal pleural effusion

Answer 51

1. Basic life support measures a. Thermoregulation b. Correction of acidosis, fluid and electrolyte balance. 2. Prophylactic antibiotics until cultures appear 3. Monitoring a. Heart rate, respiratory rate, arterial blood pressure and temperature. b. Oxygen saturation by transcutaneous O2 pulse oximeter. c. Arterial blood gases (Pa02, PaCO2, pH and base deficit). d. Hemoglobin, electrolytes, calcium, glucose and albumin. 2. Supplemental oxygen to maintain adequate arterial oxygen saturation. 3. IV fluids, then tube feeding until respiratory rate has decreased enough to allow oral feeding

Answer 52

1. Suspected BIND : immediate exchange transfusion , preceded by phototherapy till blood 2. Established cases: Immediate exchange transfusion to minimize further brain damage 3. Prior to discharge :Auditory evoked potential> auditory brainstem response (ABR) audiometry

Answer 53

> Virus detection by cultures or PCR Urine, blood, throat, nose (rubella) Urine, saliva, blood (CMV) Skin scrapping, serum, CSF, urine, throat, oro and nasopharynx, conjunctiva (HSV) > Antibodies IgM for toxoplasmosis and rubella

Answer 54

1. Intensive supportive care when needed: Fluid balance, Oxygen, thermoregulation, nutrition 2. Specific antiviral and antimicrobial agents, e.g. ganciclovir for CMV, acyclovir for HSV. 3. Hepatitis B vaccine for all newborns

Answer 55

1. Complete blood count with differential = WBCs <5,000 cells/mm? and ANC (Absolute Neutrophilic Count )<1,000 are most predictive of infection = WBCs >20,000 and Immature/Total neutrophils (I/T ratio) >0.3 are suggestive of infection = Thrombocytopenia, PT, PTT, INR in severely ill neonates 2. CRP: serial measures 3. Cultures Blood culture and other cultures (urine culture obtained by catheterization or suprapubic aspiration, endotracheal tube and central line cultures) » Lumber puncture for suspected meningitis: CSF analysis (cells, protein, glucose) & CSF culture 4. Others = Hyperglycemia, metabolic acidosis may be present = Chest X ray and arterial blood gas for suspected pneumonia

Answer 56

1. Antibiotics Type: Empirically (first line): Ampicillin + Aminoglycoside (as gentamycin), then according to results of the culture. Duration: 14 days in proven sepsis, 3 weeks in meningitis and 6 weeks in septic arthritis 2. Supportive = Respiratory support including mechanical ventilation for pneumonia = Volume and pressor support for hypotension and poor perfusion = Anticonvulsants for seizures

Answer 57

A) Laboratory =Serum calcium: Usually normal but may be decreased in cases with: bone Ca depletion, parathyroid exhaustion or with the use of high dose of vitamin D =Serum phosphorus: ↓↓ (N = 4.5-6.5 mg/dl) "Serum alkaline phosphatase: 11 (Earliest manifestation) decreased vit D and increased Parathormone B) Imaging (Radiological improvement start to occur after 2 wks of vitamin D therapy) metaphysis broadning, cupping and farying during healing: dense concave white line of calcification Diaphysis ↓↓ bone denisty and fractures epiphysis: ↑↑ joint space then improved bone denisty

Answer 58

Prevention 1. Nutritional education: Value of breastfeeding, proper weaning... = Diet rich in vitamin D: Oily fish (salmon, sardines), egg yolk, liver, butter, fortified milk = Avoid rachitogenic diet 2. Vitamin D supplementation [40 IU = 1 yg] = Full-term: 400 IU/day (since birth) = Preterm: 800 IU/day (as early as the 1* month) 3. Sun exposure (UVR) Treatment A) Vitamin D therapy a. Oral therapy "Dose - Vitamin D3: 3000-4000-5000 IU/day for 2-4 weeks b. Parenteral therapy "Dose: Vitamin D3: 600.000 IU (Shock therapy) = Duration: Single IM dose = Advantages - More rapid - No need for parents compliance = Disadvantages (Side effects) - Tetany - Hypervitaminosis D B) Treatment of complications a. Tetany: IV Ca gluconate 10% "1 ml/Kg" (Slowly while monitoring heart rate, why?) Monitoring of HR is essential Stop if bradycardia occurs b. Deformities and Fractures: Orthopedic care (After complete bone healing) c. Infections: proper antibiotics d. lron deficiency anemia: Iron (6 mg/Kg/day)

Answer 59

Investigations for comlications CBC: Anemia, leukocytosis (Infection) Other markers of infections: CRP, ESR, stool analysis... Serum proteins: Not markedly J (DD: kwashiorkor) Electrolytes, blood glucose Investigations of non-nutritional marasmus Echocardiography liver function test renal function test X-ray

Answer 60

Laboratory = CBC: Anemia, leukocytosis (Infection) = Serum albumin: ↓↓ (N = 3.5-5.5 g/dl) = Serum globulins: ↓↓ a and B-globulins (↑↑ y-globulins due to infections) = Electrolytes: o Hyponatremia. It is dilutional (N: 135- 145 mEq/L) Total sodium increased (aldosterone), but serum sodium decreased (water retention) o Hypokalemia an hypoglycemia o Hypomagnesaemia

Answer 61

Prevention of protein energy malnutrition 1. General measures: Environmental sanitation, Socioeconomic development Adequate food supply, prevention of infection 2. Proper antenatal care 3. Promotion of breastfeeding: It is the simplest, cheapest and most effective method 4. Nutritional education: Value of breastfeeding, proper weaning... 5. Regular assessment of child health and growth pattern: Growth curves 6. Regular assessment of nutritional state: Early manifestations of nutritional disorders 7. Proper management of childhood infections: Especially GE... treatment: 1. hospitalization in =kwashiorker or =Marasmic kwashiorkor =3" degree marasmus =Complications 2. managment plan Infection (GE, pneumonia...): Proper antibiotics Shock: Shock therapy (Immediate IV fluid: Lactated ringer's 20 ml/Kg) - Dehydration: IV fluid therapy (Deficit therapy) - Electrolyte disturbances: should be corrected - Anemia: Packed RBCs - Hypoglycemia (IV glucose), - hypothermia: adequate clothing or radiant warmer Nutritional Managment ↑↑ calories 150 Kcal/Kg/day (start with 75 and increase amount and concentration according to the child tolerance rate of increase (5-10 kcal/kg/day) oraly or by nasogastric tube According to the age: = Milk-fed: Milk (Lactose-free may be used initially) then standard formula weaned infants: balanced diet (50 C, 35f, 15p) Vitamins Vitamins = Vitamin A - <6 months: 50.000 IU/day - 6-12 months: 100.000 IU/day - > 12 months: 200.000 IU/day _ = Vitamin B, C, D, E, Folic acid Minerals ® Iron (4-6 mg/kg/day) as zinc

Answer 62

Prevention of protein energy malnutrition 1. General measures: Environmental sanitation, Socioeconomic development Adequate food supply, prevention of infection 2. Proper antenatal care 3. Promotion of breastfeeding: It is the simplest, cheapest and most effective method 4. Nutritional education: Value of breastfeeding, proper weaning... 5. Regular assessment of child health and growth pattern: Growth curves 6. Regular assessment of nutritional state: Early manifestations of nutritional disorders 7. Proper management of childhood infections: Especially GE... treatment: 1. hospitalization in =kwashiorker or =Marasmic kwashiorkor =3" degree marasmus =Complications 2. managment plan Infection (GE, pneumonia...): Proper antibiotics Shock: Shock therapy (Immediate IV fluid: Lactated ringer's 20 ml/Kg) - Dehydration: IV fluid therapy (Deficit therapy) - Electrolyte disturbances: should be corrected - Anemia: Packed RBCs - Hypoglycemia (IV glucose), - hypothermia: adequate clothing or radiant warmer Nutritional Managment ↑↑ proteins 4-6 gm/Kg/day (start with 1 gm and increase amount and concentration according to the child tolerance rate of increase oraly or by nasogastric tube According to the age: = Milk-fed: Milk (Lactose-free may be used initially) then standard formula weaned infants: high protein diet (egg, meat, chicken, beans) Vegetables and fruits Vitamins = Vitamin A - <6 months: 50.000 IU/day - 6-12 months: 100.000 IU/day - > 12 months: 200.000 IU/day _ = Vitamin B, C, D, E, Folic acid Minerals ® Iron (4-6 mg/kg/day) as zinc

Answer 63

* Diagnosis is mainly clinical: Acute ascending symmitrical paralysis with hypotonia 1. CSF analysis (2 weeks after the onset of paralysis) Increased protein but with normal cell count and glucose (Cytoalbuminous dissociation) 2. EMG electromyography 3. Decreased nerve conduction velocity ( diagnostic)

Answer 64

1. ICU and mechanical ventilation for cases with respiratory muscles paralysis or bulbar paralysis (lifesaving). 2. IV gamma globulin in all patients for 5 successive days. The best choice 3. Plasmapharesis. 4. Physiotherapy should start from the second week of illness.

Answer 65

1. Serum CPK (creatine kinase) .Marked elevation even at birth (can be used as screening test). 2. Electromyography 3. DNA studies: deletion on Dystrophin gene 4. Muscle biopsy: diagnostic (absent Dystrophin).

Answer 66

1. Nutritional support and physiotherapy. 2 . Night splints to prevent contractures - Scoliosis is managed with a truncal brace 3. Treatment of chest infections and respiratory aids as CPAP. 4. Corticosteroids: to preserve mobility and prevent scoliosis (its action may be inhibition of muscle proteolysis, anti-inflammatory effect.). 5. Gene therapy is now available.

Answer 67

1. CT brain - MRI brain May determine the location and extent of structural lesion. May show associated malformations or brain atrophy. 2. EGG 3. TORCH screening to define the cause 4. Auditory assessment and VEP:(visual evoked potential)

Answer 68

Rehabilitation 2. Physiotherapy. 2. Positioning and splints to prevent contracture. 3. Associated complications and neurological problems as a. Epilepsy: antiepileptic drugs b. Orthopedic management: Tendon releases in contracture c. Treatment of chest infection d. Special feeding program

Answer 69

CSF examination 1. Differentiating bacterial meningitis from tuberculous and viral meningitis from table 2. Culture and sensitivity tests are essential: if bacterial infection is suspected 3. Detection of antigens (PCR) and antibodies (ELIZA) of viral infection 4. Ziehl-Nielsen staining of the CSF if TB meningitis is suspected other investigations 1. CBC: marked leukocytosis with bandemia 2. Blood culture 3. Kidney functions test and electrolytes 4. Coagulation screen if DIC is suspected 5. If TB is suspected: chest X ray, tuberculin rest. 6. CT with contrast to detect meningeal enhancement 7. MRI brain for better visualization of cerebral infarcts.

Answer 70

Treatment: A. supportive: ABC CCI =Care of coma =Anticonvulsants: diazepam and phenobarbitone. = IV fluid if meningitis is complicated by shock (otherwise fluid is restricted to minimize cerebral edema Assisted ventilation if respiratory failure occurs. B. Specific treatment a. Antibiotics: IV for at least 10- 14 days (in neonates 3 weeks). Neonates and infants below 2 months:- Third generation cephalosporins e.g. Cefotaxime 200 mg kg/day plus ampicillin 100mg/kg/day. Infants and children above 2_months:- Third generation cephalosporin e.g. Cefotaxime 200mg/kg/day or ceftriaxone plus vancomycin Dexamethasone in H influenza infection to decrease incidence of gliosis and hearing loss C. Follow up to detect late complications e.g. Epilepsy and mental retardation | B26

Answer 71

Oral penicillin V (50.000 unit/kg/day) or Amoxicillin 50 mg/kg/day In penicillin allergic patients oral erythromycin (50 mg/kg/day) for 7-10 days

Answer 72

Throat swab culture and rapid antigen-detection tests (RADs)

Answer 73

ear examination by otoscope reveals congested bulging eardrum

Answer 74

= An oral broad-spectrum antibiotic (Amoxicillin-clavulanate) 80-90 mg/kg/day in 2divided doses) to cover both gram-positive and gram-negative organisms is prescribed for 7-10 days. = If penicillin allergy, use third generation cephalosporin.

Answer 75

1. Chest x ray: a. Confirm the diagnosis b. Complications: effusion — empyema — pneumatoceles — lung abscess. 2. Blood gas: in severe cases lowered 02 tension and raised C02 3. Complete blood count, ESR, CRP: DD/ bacterial and viral causes 4. Culture and sensitivity test: morning nasopharyngeal aspirate or sputum culture.

Answer 76

1. Chest X-ray: hyperinflation of the lungs with focal atelectasis. 2. Blood gas analysis; hypoxia- CO2 retention. 3. RSV antigen detection from nasopharyngeal secretions.

Answer 77

1. Infants with minimal or mild respiratory distress (at home) a) Close observation: Increasing distress is an indication for hospitalization. c) Careful feeding to avoid aspiration. 2. Infants with moderate to severe respiratory distress (at hospital) a. Oxygen therapy to correct hypoxemia. b. I.V maintenance fluid therapy to prevent dehydration. c. Nebulized salbutamol d. No Corticosteroids or antiviral agents. (are not beneficial) e. Mechanical ventilation used in those with severe respiratory failure

Answer 78

A. Hospital management (7-10 days): 1. Indications = Severe pneumonia (severe RD) or complicated pneumonia = Small infants (Less than 6 months) 2. Supportive measures: - Humidified oxygen - IV fluid (NPO) — suction — mechanical ventilation 3. Specific treatment: Broad spectrum combined parenteral antibiotics to cover G+/- (Ampicillin 50- 100 mg/kg/day + gentamycin 4-6 mg/kg/day). 4. Treatment of complication: Drainage of empyema. Mechanical ventilation (in respiratory failure) B. Home management for most cases: 1. In Older children with mild pneumonia without distress. 2. Oral or better intramuscular antibiotics. 3. Amoxicillin 50 mg/kg/day or better broader-spectrum antibiotics such as amoxicillin-clavulanic acid for 7-10 days.

Answer 79

Sweat test, to confirm that the concentration of chloride in sweat is elevated. Sweat chloride test Sweating is stimulated by applying a low-voltage current to pilocarpine applied to the skin. = The sweat is collected into a special capillary tube or absorbed onto a weighed piece of filter paper. . < 30 mmol/L = negative result 30-59 mmol/L = borderline > 60 mmol/L = consistent with CF. Confirmation of diagnosis can be made by testing for gene abnormalities in the CFTR protein where AF508 is the commonest gene mutation.

Answer 80

The aim of therapy is to prevent progression of the lung disease and to maintain adequate nutrition and growth. A. Respiratory management B- Nutritional , GIT and hepatic management C-Psychological management A. Respiratory management 1. Anti-inflammatory drugs Anti-inflammatory drugs for CF corticosteroids and nonsteroidal anti-inflammatory drugs) 2. Antibiotics Prophylactic oral antibiotics (flucloxacillin) Additional oral antibiotics Vigorous parenteral antibiotics for 14 days Inhaled antipseudomonal antibiotics daily for Chronic Pseudomonas infection 3. Mucolytics Nebulized DNase, hypertonic saline, or N-acetylcysteine may be helpful to decrease the viscosity of sputum and to increase its clearance. 4. Physiotherapy: Children should have physiotherapy at least twice a day, aiming to clear the airways of secretions. 5. Bronchodilators As reversible airway obstruction occurs in many children with CF. 6. Lung transplant Bilateral sequential lung transplantation for end stage CF lung disease B. Nutritional, GIT and hepatic management = Nutritional status should be assessed regularly. = A high-calorie diet is essential. = Most patients require fat-soluble vitamin supplements. = Pancreatic insufficiency is treated with oral enteric-coated pancreatic enzymes replacement therapy = Oral bile acid therapy aimed at improving biliary secretion for cystic fibrosis associated liver disease. C. psychological and emotional support for CF patients and their families.

Answer 81

Management Prophylaxis 1. Active immunization : see immunization 2. Passive immunization with gamma globulin (0.25 ml/kg I.M) 2-5 days after exposure Treatment 1. Symptomatic: antipyretics - decongestants. In immunocompromised patients, the antiviral drug ribavirin maybe used. Antibiotics for complications as otitis media and pneumonia. Large doses of gamma globulin in encephalitis to reduce complications. Oral vitamin A (400,000 IU) modulates the immune response (reduces morbidity). | 1.133

Answer 82

1. Throat culture: group a beta hemolytic streptococcus. 2. Serologic tests: A significant rise of Antistreptolysin O titer (ASO titer). 3. CBC: Leukocytosis(PNL 10,000 — 20,000 /mm*) and anemia 4. Elevated ESR and CRP

Answer 83

1. Antibiotic therapy: = Oral penicillin V: 400. 000 IU/dose 4 times/day /10 days = Procaine penicillin: injection for 10 days = Erythromycin (50 mg/kg/day)in penicillin sensitive patient for 10 days 2. Antipyretics for the high fever.

Answer 84

Prophylaxis: 1. Alive attenuated varicella vaccine 2. Post exposure; VZIG: [varicella zoster immunoglobulin] early in the incubation Treatment: 1. Antipruritic agents (local and systemic) 2. Antipyretics. Aspirin should not be used as it increases the risk of Reye syndrome (acute encephalitis with fatty infiltration of the liver) 3. Antibiotics are indicated only if secondary bacterial infections occur. 4. Antiviral drugs: Acyclovir I.V in ( immunocompromised — encephalitis— pneumonia)

Answer 85

1. Drugs: Non-steroidal anti-inflammatory drug (NSAIDs) e.g. Ibuprofen — diclofenac (oligoarticular) b. Disease-modifying anti-rheumatic drugs (DMARDs): Methotrexate (1* line drug in polyarticular type) - Leflunomide. C. Biological agents: Anti-tumor necrosis factor-a (Etanercept) 2" line in polyarticular type, Anti-interleukin-1 (Anakinra) and anti-interleukin-6 (Tocilizumab) in systemic type following steroid therapy. D. Steroids: intra-articular steroids (oligoarticular type), systemic steroids (systemic type), topical steroids (uveitis). 2. Physiotherapy: to strengthen muscles and increase the range ofjoint motion. 3. Periodic slit-lamp ophthalmologic examinations: to monitor for asymptomatic uveitis 4. Family and psychological support.

Answer 86

Laboratory: 1. CBC, CRP, ESR, 2. kidney function tests 3. Liver function tests 4. Serum albumin 5. Urine analysis. 6. Anti-nuclear antibodies (ANA), anti dsDNA and anti-Smith antibodies. 7. Hypocomplementemia (Reduced C3, C4, CH50). 8. Anticardiolipin IgG or IgM. 9. Lupus anticoagulants. 10. Coombs test Radiological: 1. Echocardiogram, chest X ray, pelvi abdominal ultrasound. 2. Brain MRI in cases with neuropsychiatric manifestations. Renal biopsy: For staging of lupus nephritis

Answer 87

1. Sunscreen and avoidance of prolonged direct sun exposure may help control disease by sunblock creams, proper nutrition, vitamin D 2. Hydroxychloroquine: help to control skin and joint manifestation and improve outcome in all SLE patients. 3. Corticosteroids (oral and IV): the main stay of treatment in SLE. Oral 1-2mg/kg/day or pulse methylprednisone 4. Steroid-sparing immunosuppressive agents: Methotrexate and azathioprine (joint and blood affection), Mycofenolate mofetil and cyclophosphamine (renal and neurological affection). 5. Treatment of complications

Answer 88

Laboratory 1. Complete blood picture: normal platelet count 2. ESR, CRP : elevated (inflammation) 3. Urine analysis (screen for hematuria) 4. Stool analysis (screen for occult blood in stool) 5. Blood Urea, creatinine and C3: screen for nephritis 6. lg A level (maybe elevated) Imaging 1. Abdominal X ray and ultrasound if there is any doubt regarding gut perforation or intussusception 2. Magnetic resonance imaging and magnetic resonance angiography in cases with CNS manifestations for diagnosis of cerebral vasculitis

Answer 89

1. Supportive treatment with maintenance of good hydration and electrolyte balance. 2. Control of pain with simple analgesics 3. Control of hypertension if necessary 4. Prednisone has been advocated with severe gastrointestinal disease or hemorrhage. 5. Management of HSP nephritis with intravenous methyl prednisolone and cyclophosphamide

Answer 90

Laboratory Findings 1. Leukocytosis with neutrophilia, elevated ESR and CRP, hypoalbuminemia, thrombocytosis after week 1 2. Sterile pyuria 3. Elevated serum transaminases and plasma lipids. Echocardiography should be performed at diagnosis and again after 2-3 weeks of illness. If the results are normal, a repeat study should be performed 6-8 weeks after onset of illness.

Answer 91

Hospitalization, better in ICU 1. Initial measures A: Open the airway. B: Oxygen therapy. C: IV line. 2. Fluid therapy a) Resuscitation (Shock therapy) If the patient is shocked give bolus of 10 -20 ml /kg isotonic saline 0.9% rapidly over 30 min and reassess could be repeated 3 times b) Deficit therapy : according to the degree of dehydration Deficit (litres) = % dehydration x body weight (kg) mild=50ml/kg moderate=100ml/kg severe=150ml/kg c) Maintenance: According to body weight or surface area First 10 kg of body weight: 100 ml/kg/24 hours. For each kg from 11-20 kg: 50 ml/kg/24 hours For each kg above 20 kg: 20 ml/kg/24 hours 1. The total fluid (deficit plus maintenance) are given over (48 hours). Correction must be gradual, rapid rehydration > cerebral edema @ Use normal saline (0.45% saline is used in hyperosmolar cases). When blood glucose has fallen tos 300 mg/dl add glucose to the IV fluids to avoid hypoglycemia @ If the patient shows mild to moderate dehydration start the deficit + maintenance therapy without bolus fluids 3. Insulin therapy Started after resuscitation, after one hour from fluid therapy Continuous low dose IV infusion method. NO BOLUSES 1500.1unit/kg/hour, adjust the dose (rate of infusion) according to the blood glucose level. Infusion must be continued until correction of ketoacidosis Monitor the blood glucose regularly aiming for gradual reduction as rapid reduction cerebral edema. When glucose reaches 300mg/dl, glucose is added to fluids to maintain glucose >200 mg/dL When metabolic acidosis is corrected and the patient can tolerate feeding, sub cutaneous insulin is given then intravenous insulin is stopped 4. Acidosis The use of bicarbonate for correction of acidosis in DKA is generally not recommended except in case of severe metabolic acidosis not responding to therapy (pH 7 or less) This is because: a) Most cases will be self-corrected by fluids and insulin b) Bicarbonate can exacerbate hyperosmolarity and electrolyte disturbance c) Alkali therapy may result in alkalosis that has its own hazards. @ Resistant acidosis: suspect sepsis or renal failure 5. Potassium therapy - Potassium is added 30-40 mEq/L after the resuscitation, after the first hour and after the patient passes urine provided K is not elevated. Initial plasma potassium may be low or high but it will fall following treatment with insulin and rehydration If hypokalemia is present , it should be urgently treated 6. Clinical and laboratory monitoring - Hourly capillary blood glucose (strips) Plasma glucose, Na, K, blood gases and urinary ketones (plasma ketone by strips if available) and repeat every 2-4 hours Renal functions, CBC and sepsis screen if suspected 7. Management of complications * Shock: hypovolemic (polyuria, vomiting & dehydration) or septic Brain edema from rapid correction of hyperosmolarity and hypovolemia and from cerebral ischemic hypoxia (shock) Pulmonary edema from hyperosmolarity and HF(2ry to acidosis) Cardiac arrhythmias (secondary to acidosis and electrolyte disturbance especially K) | 2.150

Answer 92

1. Aspirin = It is used as anti-inflammatory and antithrombotic Anti-inflammatory 80-100 mg/kg/6hs or 30-50 mg/kg/6hours until patient is afebrile Antithrombotic: 3-S5mg/kg/day until normalization of ESR and platelets = Aspirin should be continued for 2 years if coronary abnormalities have resolved #Aspirin is continued for life if coronary abnormalities persisted * Children with large coronary artery aneurysm should receive anticoagulants as warfarin 2. IV immunoglobulin 228400 mg/kg/day on four consecutive days or single dose 2g/kg infused over 8-12 “ hours; it reduces the risk of coronary artery disease when administered within 10 days of the onset of fever. 3. Corticosteroids

Answer 93

hyperglycemia glucosoria ketonemia ketonuria ABG Metabolic acidosis CBC CRP ESR | 2.150

Answer 94

Laboratory: Thyroid profile: T3, T4 and T.S.H. 1. Low T4 (normal range 5-12 microgram/dl). 2. High TSH (normal: 0.5 — 4 micro unit/L). TSH is markedly elevated (above 50 micro unit/L). It is the most sensitive test for primary hypothyroidism. Imaging 1. Plain X ray: delayed bone age. it is characteristic for congenital hypothyroidism 2. Thyroid scanning (radioactive iodine : lodine 123) it is essential for diagnosis of the cause (it can differentiate between aplasia, ectopic dysplasia, and malfunction of the thyroid gland) 3. Thyroid Ultrasonography Neonatal thyroid screening It is implemented in Egypt for all newborns to prevent mental retardation. 1. Timing: between 3" and 7" day of life. 2. Technique: a blood drop is obtained by heel prick on filter paper and analyzed for TSH. 3. Interpretation: if TSH level > 20 mU/L, an immediate blood sample is withdrawn and analyzed. If data are confirmed treatment is immediately initiated. | 2.141

Answer 95

Lifelong therapy with L thyroxin to maintain normal growth, T3 and T4 1. Onset: should be started before 2 weeks of age to reduce the risk of impaired neurodevelopment. 2. Dose = Neonates: 10-15 microgram /kg/day. = Children: 100 microgram /m2 /day. 3. Monitoring = Clinical assessment Physical: Height every 3 months and Bone age every year. Mental development and I.Q. Sexual: Pubertal development should be within normal. « Laboratory assessment: good response is associated with:- T4 on high normal TSH on low normal.

Answer 96

1. Simple Measures: (Children > 4 years) . Explain to the parent and child that the problem is common and beyond conscious control so punishment should be avoided. b. VJ Fluid intake in the evening c. Urination before sleep d. Waking the child up few hours after sleep to void e. Rewarding for dry nights 2. Drug therapy (Children > 6 years) a. Anticholinergic (4< Bladder capacity): Oxybutynin : may be needed in nonmonosymptomatic nocturnal enuresis b. Desmopressin (synthetic vasopressin analogue): Single night dose c. Enuresis alarms (conditioning therapy): Auditory or vibratory alarm is attached to a wetness sensor in the underwear (wake the child up for urination) | 2.172

Answer 97

1. Acute phase reactants * CBC: Leukocytosis * Elevated ESR and CRP 2. Evidence of recent Streptococcal infection: * Recent scarlet fever. * Positive throat culture. * Rapid antigen test. * Antistreptococcal antibodies. * High titer of: Antistreptolysin O titer (ASOT). Antistreptokinase. Antihyaluronidase. Anti-DNase. 3. Cardiac assessment * CXR: Cardiomegaly * ECG. Tachycardia and prolonged PR interval * Echocardiography: assesses chamber enlargement, valve affection, and cardiac contractility and detects pericardial effusion.

Answer 98

For Gastroenteritis: A. To identify the causative organism: 1. Stool analysis: Parasites (E. histolytica & G. lamblia), WBCs (Bacterial etiology) 2. Stool culture & sensitivity: Bacteria & viruses 3. CBC, CRP, ESR, Blood culture: help in diagnosis of bacterial infections: B. To detect complications 1. KFTs (Urea & Creatinine): Renal failure. 2. Electrolytes: Na, Ca, K. 3. Blood gases: Metabolic acidosis. 4. Prothrombin time, platelet count, fibrin degradation products: DIC.

Answer 99

Home management: 1- Oral rehydration solution (glucose facilitated sodium absorption) Dose: Mild (50-80 ml/kg), moderate (80 ml/kg) Route: 1 spoon every 2 mins or nasogastric tube 2- Feeding 3- Symptomatic Treatment: Antipyretics and anti-emetics. 4- Specific Treatment: Metronidazole ( parasites), Tetracycline (cholera), Ampicillin (shigella or salmonella). However antibiotics may interfere with normal flora so increasing pathogens. 5- If persistent diarrhea: give lactose free formulas, soy protein based formula, and vitamin A B) Hospital management: IV fluid therapy for isonatemic dehydration Shock therapy: 10 ml normal saline over 20-30 mins. May be repeated by max. 30 ml. Deficit therapy: mild (50ml/kg) moderate (80ml/kg) severe (100ml/kg) of glucose: saline ratio 1:1 over 6-8h. Add K when patient passes urine and serum K is not elevated. Maintenance therapy: 1st 10 kg (100ml/kg) 2nd 10 kg (50ml/kg) the (20ml/kg) of glucose 5% to saline ratio 4;1 over 16-18 h * If dehydration is still present: give maintenance +deficit. * If dehydration has been corrected switch to oral intake. IV fluid therapy for hypernatremic dehydration Shock therapy: same. Deficit therapy: glucose: saline ratio 2:1 over 6-8h. Add K Maintenance therapy: same. * maintenance and deficit should be added and given over the period of correction (1.25 times maintenance rate) * correction should be slowly to avoid brain edema. Na must not decrease more than 12 mEq/L per 24h. * Resistant cases may need dialysis IV fluid therapy for Hyponatremic dehydration Shock therapy: same Deficit therapy: glaucose to saline ratio is 1:1

Answer 100

INV: 1. Abdominal US. 2. Plain X ray abdomen: distended loops, absence of gas in distant colon. 3. Barium enema: Claw sign of coiled spring sign. TTT: Depends of the time of presentation: 1. Air enema: pneumatic reduction. 2. Resection-anastomosis: in neglected cases

Answer 101

to diagnose acute hepatic injury CBA AA EE Bilirubin level (above 10 mg/d Low serum albumin High blood ammonia level Metabolic Acidosis. Hypoglycemia, Hypokalemia and Hyponatremia. To diagnose the causative virus (hepatitis markers) 1. Hepatitis A: * IgM antibodies to hepatitis A (anti HAV IgM): recent infection (acute disease). * IgG anti HAV antibodies persist after recovery (immunity). 2. Hepatitis B: * HBsAg (surface antigen) followed by anti HBc (core antibodies) IgM: indicate recent infection. * Anti-HBs (surface antibodies) appear after recovery and indicate immunity. * Persistence of HBsAg (surface antigen) and anti HBc IgG indicate chronicity. 3. Hepatitis C * Anti-HCV antibodies: these antibodies denote exposure to infection but do not mean recovery or development of immunity. * HCV-RNA antigen detected by PCR denotes viremia. * Viral load can be assessed by quantitative PCR for treatment purposes.

Answer 102

Treatment of any correctable condition: 1. Post viral: oral Antiviral drugs e.g., for hepatitis B. oral direct acting antivirals (DAA) for hepatitis C e.g., nucleotide/nucleoside analogue 2. Autoimmune hepatitis prednisolone and azathioprine. 3. Wilson disease: Penicillamine is a copper chelating agent Liver supportive measures: 1. Nutritional support * Vitamin, minerals and carbohydrate rich diet. * Fat in the form of medium chain triglycerides. 2. Ascites * Sodium and fluid restriction and diuretics. * Albumin infusions or Paracentesis for refractory ascites. 3. Encephalopathy * Treat precipitating factors e.g., GIT bleeding, sepsis * Oral neomycin * Protein restriction * Oral lactulose to ↓ ammonia reabsorption (it ↓ colonic pH and ↑ colonic transit) Liver transplantation in end stage liver disease: