paediatric Flashcards by Fardowsa Mohamed

paediatric history

-patient profie (sex, name, age, DoB).
-antenatal hisotyr: mothers nutritional status, obstretic hisotry, maternal diseases/ infections/ mothers age/ gestational age. conception information/type of conception method.

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post natal hisotry

first cry? -cyanosed/ apnoeic.
infections, procedures done? and basic problems-suckling, respiratory issues/swallowing. birth weight/length.

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role of vitamin D in rickets?

calcium and phosphate metabolism. lack of mineralisaiton in bones due to imbalance b/w calcium and phosphate ionic ratio. bone deformity if prolonged and >18 months- 3yrs.

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prenatal and post natal growth & development

prenatal: fetal placental and maternal factors.
post natal: genetic and environment.

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developmental and growth

growth: increase in mass size due to multiplication and increase in intracellular substances.

development: maturation of functions due to maturation and myelination of nervous system-> achieve fine motor skills.

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growth factors affecting prenatal/ fetus

IGF 1 & 2 (from liver & kidney) - 70%.
epidermal GF, TNF-A, platelet derived, nerve and fibroblast GF.

activated platelets influence leukocytes to release EGF, TGF-beta and fibroblast to make type 1 & 3 collagen.

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growth spurts?

rapid- birth- 3 yrs,
slows till puberty: steady.
growth spurt at adolescent.
decrease in rate till maturation.

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growth inhibitors

inhibin.
Mullerian substance (AMH)
transforming growth factor B (TGF -B),

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fetal growth hormone prenatal?

predominatn in late gestation and postnatal.
insulin+ thyroxine for accretion and differentiation of tissue, glucorticoid suppports maturation of lung, liver and GIT.

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maternal factors ?

poor nutrient, high pariy, short time between pregnances, substance misue, anaemia, recent pregnancy, gestational HTN, chronic systemic disease, TORCH infections.

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placetAL FACTORS?

INCREASE VILLOUS AREA, DECREASED DIFFUSE DISTANCE, INCREASE CAPILLARY DILATUIN, DECREASE VASCULAR RESISTANCE.

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GENETIC FACTORS

chromosome defect; short stature: down and turner syndrome. tall stature: klinefelt .

gene mutations: short (prader willi syndrome and noonan syndrome
tall: marfan syndrome.

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nutreitn influence

macro vs micro nutreint.
micronutreint, calcum, vit A and D - fat soluble, zinc.
infections; diarrhea, recurrent RTI, TB, HIV, kala azar, chronic giardiasis, food toxins, food hygiene.malaria

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hormones

GH deficiency, hypothryoidisim, growth hormone resistance.
low socio economic, poor diet, humid climate, emotional factors- broken homes, culture and religion.

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barker hypothesis

IUGFR infants- DM, hypertension, hyperlipidemia later in life.

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hormones in each phase of life

infant- nutrition, GH, thyroxine.
childhood: GH and thyroxine
puberty: sex steroids & GH.

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laws f growth

different tisues and body growth at different rate.
brian and head rapid prenatal and post natal . 70 % in 1st tear and plateaus.
lymphoid tissuses, tonsil BM : peaks at late chilhood and declines.
reproductive (gonals) peaks at puberty.

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prenatal period

ovum- 0- 1 wks.
embroy= 2-8 wkss.
fetus= 9 wks - birth.
perinatal : 23 wks >

post natal: new born from birth till 28 days ( 1 month).
infant- 1 year.
toddler- 2-3 years.
preschool- 4-6
school-7-12
and adolescent till 10- 19.

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embronic period-

bi laminar, trilaminar ( 3 wks). 4 wks: human shaped, 4 cm and arm / leg buds.
5-8 wks: major organ system devleopment (maximum teratogenicity infleunce).
9 wks: fetal period begins/.
10 wks: external genitalia distinguished.
24 wks: 500 kgrams - viabilitiy. delivered be4 weeks-> immature lung maturity (low survive)
25 wks: 900 gm, 25cm.
38 wks: weight and length doubles from 25 wk.

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athropometry:

weight-kg, length-cm,height HC and chest circumferences. upper to lower segment ratio, arm span.
normal birth weight-2.5 -3.5 kg
lenght: 50 cm
u: L: 1.7
hC: 33- 35
CC: 35cm
HC> CC always as time progresses.

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postnatal growth

0-3 mnths: 25-30 grams/ day
4 m- 1 yr: 400 g/month
2yrs- puberty- 2/3 kg/ yr.

weight formula: wt in kg= age in years+ 4 )x2.
till 2 yrs: age in months + 9 / 2.

2x+ 8= wt for ( 2 yrs- 8 yrs).

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height

wechs formula ht in cm = age in yrs x 6)= 77.
accelerated growth from 0-3 month then steady and increase 3-10 yrs.
adolescent middle rapid 8-10 cm and 3.5 kg.

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drug precribing

consider in neonates: inefficient renal , deficiencies enzyme, inadequate detoxifying mechanism - high risk f toxicity.

parameters used to calculate dose - BW, SA and age.

mg/kg - consider metabolic rate and obese children.

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complex therapies

drugs- etiologic pathogenetic or symptomatic therapy.
other approaches: surgical, physiotherapy, daily regular regimen, diet, monitoring.

administration of drugs not synonymous w/ good care.

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general guidelines

smallest no. of drugs administered, inexpensive drugs used, dosage should be optimised, oral route preferred. adverse SE monitored. consider indication. safe dose/ overdose is even more important in infants.

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administration

frequent administration, daily dose given every 6,8 or 12 hrs. calculate daily dose / 24 hrs.
routes: IM, IV or oral. SC rectal (suppositories ) or inhalation.
theophylline, phenobarbital and digoxin loading/ maintenance considered.
medical forms: capsule pills, ampoules, syrups, drops.

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drug disposition

rapid/ slow.

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physical examination of respiratory system

inspect, RR, note:-chest retraction, cyanosis, discharge, voice, sputum, cough & chest - shape , symmetry,
-palpation: tactile fremitus- vibrate when crying.
percussion- resonance can be normal, increased, dull ( collapse, consolidation or fluid) or decreased.

auscultation- breath sounds (vesicular-normal) , bronchial (increased) decreased or absent.

chest sounds- crackles-fluid, rhonchi, wheeze-narrowing, plural rub (friction).

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CVD examination

inspection- heart hump, respiratory distress, scars.
palpation- trills, radial / femoral pulse apex beat.
BP, cyanosis, clubbing, tachy, sweats, tachypnoea, cardio/ hepatomegaly (HF features).
dextrocardia or plump children- difficult.

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GIT.

throat, oral cavity (use tongue depressor) abdomen- flat/ distended, rigid/ peristaltic 10-30 seconds (supine/ warm hands).
liver- below right costal margin (soft or sharp?)
spleen.
5 f’s - fat, fluid, faeces (constipation), foetus, flatus (malabsorption, obstruction). palpate from liver-> bladder (4 quadrant) w/ parent.
tip; use their hands first.

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GUS examination

inspect- labia, phimosis, kidney mass.
costovertebral angle tenderness (CVAT) - murphey punch sign - indicate pain in back percussion. observe signs for shortcoming - puberty development.

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neurology

CN, reflexes, abnormal signs- tremors, chorea and athetosis- damage to basal ganglia.
meningitis- high ICP, sensory examination IQ.

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opthalmic / ear examiantion

sclera-jaundice, pupils, discharge, tympanic membrane.
equipment- percussion hammer, stethoscope - small bell for infants.flashlight, therometer.

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MSK

defromed bones, joint swelling,arthalgia, muscle tone.

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rickets

low vitamin d3, ckd, liver failure, hypoparathyroidism, poor diet, dark skin, low sun light exposure.intestinal malabsorption (celiac and chrons).

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metabolism of vit d

failure of vit d to convert to calciterol is due to enzyme deficiency.
formed in liver: 25 (0H) d3 to 1.25 (OH) d3 in liver which is active form. renal tubule resorption of calcium and bone resorption.
PTH detects low calcium, causes bone resorption and excretes po3 in urine.

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lab result in rickets

high PTH, high ALP, hypocalcaemia- muscle spasm & twitching, low blood/serum phosphate. low vit D3
-xray: metaphyseal cupping, fraying and widening of plates. loose zones seen in pelvis.

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clinical (stages) of rickets

early stages: craniotabes, head sweating, irritability.
advanced: craniotabes, genu verum, loose/fragile bones, deformities, rachitic rosary, pigeon chest, harrisons grove, delayed frontal closure, frontal bossing, abdominal protruding.

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treatment

vit d3 supplement, treat underlying cause. mineral drops for neonates & infants. prophylaxis via giving maternal d3 supplies.
educate on good diet- increase fish, butter, eggs (good source), sunlight exposure.

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rational intake nutrient

high caloric use in infancy from 1-3 months (1:3: 6) for protein, fat and carbs ratio. this decreases as they reach 1 yr.
water : 120-140 ml/kg/ 24hrs
roughly about 1-1.5 litres.
note type of feed (milk), frequency, characteristic, duration of feed.
fat solube vit- a, d, e , k and water souble: c,b, b2,6 and 12.
protein- essential AA for synthesis and carbohydrates.

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breast milk for baby (+ benefit for mother).

contains all relevant nutrients for baby: lactose ( lactobacilli), secretory IgA, other immune components. vitamins and water (88%), reduces risk of HTN, DM, IHD, lyphoma, orthodontic issues, ear infection, URTI.
maternal benefit: uterine involution (prevent PPH), extra shed weight, reduces ovarian/ breast Ca, lactational amenorrhea (no subsequent pregnancy), reduce allergy.
-contains omega 2,3. vitamin (fat and water soluble), galactocerebrosides, lactoalbumin, reduce solute load on kidney, PUFA for myelination of PNS. AA like cysteine and taurine for nuerotransmission.

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food and what age to stary

1-4 months- strictly breast milk or formula. frequency: 6-7 times/ 24 hrs. and this reduces to 2 times till 9 mnths.
4+: veg madh.
5 months: yogurt, cereal, jelly, yolk. juice - small amount.
6 months: meat
7+: bread, cheese butter, sugar, oatmeal.
8: soup
9-12 : transition to food.

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when to not breast feed for the mother and baby.

mother: chronic disease, infectious disease (HIV, untreated TB), metnal disease, pharmacotherapy -> risk to spread to baby: tetracycline , metronidazole, bromcriptine, high dose diazepam. radioactive compound.
alcohol or drug >0.5 g/kg/day.
if she doesnt want to.

baby: lack of suckling reflexes- cleft lip/ palate deformity, aspiration pneumonia, cerebro-cranial trauma, RDS, metabolic disease (galactosemia- cant metbaolise most lactose -> damage organs, lactose intolerant )

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paediatric asthma

obstructive airway causing exhalation wheezing.
there’s persistent and recurrent wheezing or transient early wheezing (viral)- decreased LFT.
recurrent - igE modulated, skin prick / blood test can confirm.
atopic triad (stigmans present).

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causes:

genetic predisposition or environmental.
atopy-> inflammation, bronchial hypersensitivity, narrowing (peak flow-spirometry) + clinical picture (wheezing, cough, breathless, chest tightness.

ddx:
0-1 :broncholitis, foreign body( stridor, sudden wheezing), aspration, coup, URTU, abnormal anatomy.
1-4 yrs: early asthma, CF, pneumonia.
>5: vocal cord dysufnction, allergic bronchopneuonia aspergillus, hypersensitivity pneumonitis.

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investigations/ diagnosis

Albuterol efficacies + post bronchodilator response, spirometry (reduced FEF and FEV1), normal FVC peak flow meter.
consider allergy test if uncertain,
hospitalised (CXR).
clinical picture.
20% if respond to methoacholinic confirms dx.

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treatment+ management of asthma

albuterol! racemic albuterol if CVD. systemic steroid (IV, IM, oral) - 2 hrs, terbutraline (tachy), avoid intubation as pneumo risk. ketamine (broncho) and other inhalation agent.

cont- ICU management, continuous nebuliser.
Q2:2 hr on meds, asthma score.
Q4: dishcarge if no longer o2 supplement, no ards, no albuterol requirement< 4 hr.

LABA’s not for acute but exercise induced trx- salmeterol. corticosteroid with inhaled LABA. systemic SE: growth , adrenal suppresion, bone isues if high dose used. beclometasone.

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classification

classify asthma into intermittent (no more than 2 days a week and 2 nights per month), mild peristent (less than 1 daiy), moderate (daily) or severe episodes (LFT< 60 %) . consider no. of events and do patients experience episodes at night (cause awakening) & manage accordingly. counsel triggers (preventative measure). prevent arrest. use pulse oximeter< 92% severe- cyanosis, silent chest, peak flow< 50% poor respiratory effort.

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cystc fibrosis definiton

gene mutation on chromosome 7 with CFTR protein causing defect with trasnporting Cl- across mebrame-> viscous mucus & cl- sweat (dx-electrophoresis). sodium reabsoprtion along with water-> dehydration & water cannot attract mucus.
autosomal recessive.
genetic testing confirms disease + clinical picture.

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thick meconium-> SBO. distended abdomen, bilious vomiting-> perforation-> sepsis. (sx: Hypo, tachypnea/ cardia).

early childhood: pancreatic insufficiency: malabsorption, failure to thrive, stearrhoea, pancreatitis (backed up enzymes), avitaminosis A.
lung -> pneumonia- gram positive and adolescent- gram -ve & p.aureginosa , bronchiectasias (permeanent dilution),

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CF of cystic fibrosis

meconium ileum sbo, pancreatic insufficiency, biliary cirrhosis, stearrhoea, avitamosis, hemoptyosis broniechetasis, recurrent pneumonia,ABPA complications: hypovolemia, cardiovascular collapse,hypokalemia,contaction alkalosis.amenoorhe, subfertility in women

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theophylline

used in COPD, asthma and some HF treatment. trx use bronchodilators and mucolytics (nebuuzers, n-acetyl-cysteine)/ dornase-alpha), chest physiotherapy. antibotiocs and anti-inflammatory mediatricss. CTFR modulators (lumacaftor and ivacaftor- help w/ protein functions

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meconium x-ray + clinical test :soap bubble/ ground glass appearance, bowel loop, PFT (obstructive pattern)- FEV1 lower, bronchiectasis (cyst shadows, tram lines,

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forms of severe body weight anorexia

Forms-
◦ hypotrophy (light form), moderate
◦ marasmus (severe)
◦ kwashiorkor (severe)-sugar babies: oedema, flaky paint sin rash, hyperkeratosis, enlarged fatty liver, angular stomatis, depigmented hair, brady, hypotension, diarrhea, hypothermia, growth arrest , frequent infection

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treatment

IV fluids- careful too much can lead to HF, small feeds rich in protein, Ab, nutrients treatment, correct electrolytes. bakers hypothesis- under nutrient in utero can be fixed with first 2 years of altering poor growth prognosis.

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obesity

exceeds 95% percentile, RF for dyslipidemia, HTN, hyperinsulinism (DM type II) sugars lead to high insulin rise folowed by hypoglycemia
CNS and hypothalmaus- appetitie disorders, endocrine disorder, psychosocials
certain peptides like leptin decrease appetite and grelin increases hunger
tnf -A fat cells (increases insulin resistance affecting receptors)

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RF for obesity:

FmHx, high birth weight, bottle feeding. positve enrgy balance and primary disorders in fat metabolism.

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classifications of obesity

primary type (simple) or secondary (complicated) , diencephalon obesity- crangiopyharngeoma, hypothalamic syndromes, endocrine obesity (hypothyroidism, GH deficiency, Cushing), chromosomal obesity (downs, prader willi, turners) cerebral obesity (encephalitis, trauma).

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dx of obesity:

growth curve, skin fold caliper. degree of obesity (1-4 ). body composition (lean vs fat). fat mass _ upper -> central and android -> RF for long term complications), low type (peripheral and gynecoid type ) and general (till puberty).

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clinical

advanced puberty, bone age, adiomastia, flat foot (pes planus), tired & pain in limb, sweats, skin changes, acne, acanthosis nigricans, bulimia.

complications: orthopaedics, idiopathic ICP, hypoventilation syndrome- apnoea, HF, hypercapneia, Type II DM, HTN, lipid issues, increase malignant , PCO, irregular menses, early menarche,

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labs

hyperinsulinism, impaired glucose tolerance, serum cholesterol, cortisol-normal or high, sexual hormones, (testerone and androgen increased).
diffiuclt management- low diet energy intake 1-2k calories. increase fibers, low rapid absorbing carbs- sweets. and more low saturated lipids- skimmed milk. increas eprotein, workit, reduce leisure.

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acute abdomen

differnetial : acute appendicitis , cholecystitis, pyleonepthiris, gastroenteritis, ulcer, ectopic, ovarian / testicular torsion, ureteirc colic, peritonitis, IBD. SBo, LBO, aneurysm, MI, pancreatitis.mesenteric adenitis (common in children- confused w/ appendicitis)

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GIT in paediatric

regurgitation, nausea, rumination, hemetemesis, dysphagia, vomiting, visceral v parietal (peritoneum, localised and exacerbated by movement).
hirsprung disease, mecolonium ileum, hyper amysalemia, ascites, diarrhoea faire to thrive, constipation- 2-3 day stool.
hirschprung- absence to pass meconium stool, loose stool. Aganglionic left segment - bilious vomiting,toxic megacolon. pyloric stenosis (projectile- vomiting). intussception- currant jelly stool.
midgut volvulus- emergency. bilious vomiting- emergency.

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acute respiratory failure/ distress

pulmonary related or : sepsis, ingestion of toxics, metabolic acidosis, severe dehydration, HF. hypercapnia or inefficient gas exchange- tachypnea (in children-common, cant increase TVC).-> failure occurs due to overuse of inspiratory muscles.
nasal flaring- increase URT space. retraction: collapse of soft tissue- subcostal, suprasternal or intercostal retraction.

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continuation of distress sx

grunting: expiraotry noise, low pitch in deep throat to maintain alveolar volume.
see-saw breathing: excess use of abdominal mm (lower airway obstruction) to help exhalation.
upper airway: supra/ sternal retractions r common.
head bobbing: to expand lung volume-> later sign, assisted ventilation if failure leaves or if uncorrected CPR
trx: supplemental o2, positioning, oor bronchospasmolytics etc.
stress sx: airhunger look, diaphoresis.

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resporatory failure

definition: cannot use compensatory mechanism to exchange gas.

inadequate ventilation and oxygenation (pulse oximeter- o2 correction) (proved by ABG-cyanosis be4 arrest). o2 supplement can deceive as it saturates well.
tachycardia, hypertension, diaphoresis. hypercabia- suffocation feeling, exaggerated stress response, agitation, inability to settle.

more info

solemance (drowsiness), desaturation, co2 narcosis.

anatomical differences

smaller airway, reduced alveoli count, less elastic parenchyma, v/q mismatch 1:4.more resistance in URT. horizontal ribs -> limited chest expansion.
respiratory muscles: lack power/tone. < 4 yrs: obligate nose breathers.
primary pulmo disease: restrictive (impaired expansion, disease of parenchyma) vs reduced vital capacity vs narrow airways).

causes of respiratory disease:

infants: pnuemnia. foreign body, CF, bronchiolitis. congential disease.
older children: pnemonia, croup, peritonsilar abscess, CNS infections, NM disease (GBS, SC injury), metabolic acidosis (hypoglycemia, dM) Anemia (SOB). salicylism- overdose of salicylates.

CF + trx for ARF

tachypnea, dyspnea, stridor, cyanosis, wheezing, rhales, crackles, absent or decreased BSm altered LOC. cyanosis or tachycardia. # young pts irredponsive to bronchodilator
physiological parameter: 1-3 rd degree. if ph is below < 7.35 and pao2 is above 60 mmhg. idnciate hypercapnia and hypoxic.

labs: CXR, ABG, oxymetry CBC, ECG. intubation oxygen (face mask oxygen tent/ hood, catheter, mechanical ventilator).
dureitcs, bronchodilators, corticoseroids, AB, aspirate fluid and URT.- adrenergetic agent, cholinergic antagonist, methylxantins (10-20 PO or 5 mg/kg 20-30 min)

acute respiraotry infection

children are acuqiring immunity. feedin\Qng issues as theyre obligate nose breathers. cough, snuffles, wheeze, breathless and stridors are sx.
-sinusitis, acute otitits media, sore troat, and common cold.
fever-paracetamol.
sx: discharge, blockage, earache, acute exacerbation of asthma.

common cold

common infection- clea ror mucopurulemt discharge and blocked nse. viruses: rhinovirus, corona, RSVS. self limiting

pharyngitis (sore throat)

pharynx and soft palate inflamed, LN tender and large.
viruses: adeno, entero and rhinovirus. older: group A strep.
tonssilitis:purulent exudate, pathogen: EBV, strep A, s. pnemonie, s,aureusm H. influenza, m. catarrhalis.
sx: odynophagia, dysphagia, trismus, malaisa, otalgia, fever.

associated tonsilitis sx

-cervical, submandibular and jugulodigastric LN. exudate enlarged tonsils, strawberry tongue (scarlet fever and palatal petechiae (infectious mononucleosis).
trx: Ab -penicillin or erythromycin. 10 day trx, rest, warm saline gargle, analgesic /antypyretic. complication: rheumatic fever, GN, scarlet fever, arthritis.

otitis media (acute)

jan-april. 6-12 months. infants prone due to shorter, horizontal and poorly functioning eustachian tube. etiology: s.pneumonia. same agents as tonsillitis.
pre-disposing: obstruction (carcinoma, adenoid hypertrophy and barotrauma), URTI, allergic sinusitis+ chronic.

otoscopy examination in acute otitis media

recurrent infection-> effusion. fluid level visible. grommet helps to reduce fluid, to reduce conductive hearing loss. complication: TM perforation, ossicular necrosis, mastoiditis, labyrinthitis, CNS related (mengititis, abscess, CN 7 paralysis. 2-7 yr affected.
infection:10 day course of 80-90 g/kg amoxicillin and other penicillin.

sinuisitis

paranasal sinus infection -> upper RTI’s. pain, swelling/ tenderness over cheek from maxillary sinus infection. Ab+ topical decongestant. frontal sinus not formed properly yet.

influenza

flu, type A, B and C. coryza (catarrhal inflammation nasal membrane, myalgia (type B), fever, cough. autumn + winter.
complication: TRF- viral pneumonitis or bacteria super infection.
trx: self limiting, supportive. immunization if vulnerable

BOS (bronchial obstructive syndrome

not independent dx, but complex of etiology and symptoms. cause: function (reversible ) or organic (irreversible-congential stenosis). bronchial functional patency impaired.
etiology is key!
dx: fhx (allergy), recurrent RT, genetic predisposition of atopy.
main: acute bronchitis, asthma.

Sx of BOS & factors

prolonged exhaled, asthmatic fit, axillary muscle grp use, decrease in PaO2, productive cough, wheezing.
-poor immunity, early bottle feeding-rickets, malnourished, perinatal pathology, bronchia hyperactivity, prone to RT’s, passive smoking, coupled allergy hx.

causes/ pathogenesis. groups

groups: RT -croup, GI, hereditary & others: bronchopulmonary dysplasia ( immature alveoli), foreign body, TB. #
GI (SOB?): achalasia, oesophagitis, GERD TE fistula, diaphragmatic hernia.

hereditary: deficiency of alpha- 1 trypsin (disease includes COPD, liver, vasculitis, panniculitis), CF.
other: parasite/ immunodeficiency.

alpha 1 trypsinogen deficiency

liver-neonatal hepatitis, cirrhosis (child-Pugh classification), bronchiectasis, 2 bronchitits, copd. wt loss, tachycardia.
AAT produced in liver-> travel to lungs to protect against neutrophil elastase.

diagnosis of BOS

bloods : ABG, ascultation sounds (stridoe, wheezing, ARDS, aspiration), history. ENT
CXR: atelectasis, foreign body, exclude penumonia, bronchiectasis (honey comb)
screen for neonatal clamydia, mycoplasma, allergy test,

foreign body aspiration (upper RT obstuction)

partial or complete obstruction. if in glottis/sub can cause complete obstruction.
partial: gag, cough, biphasic inspiratory stridor, choke, dyspnoea, tachypnoea (high RR). unilateral wheezing (unlike asthma)
complete: unresponsive, cyanotic ,ARD’s (CPR).
dx: physical assessment, history, CXR- hyperinflation (de-inflation in ptx), infiltration and atelectasis, radiopaque object seen.
neck-AP/lateral. fluoroscopy, CT, laryngoscopy.
management: Heimlich’s manoeuvre (different for <1y (back/ chest thrusts) and >1 yr (5x abdomen).
ddx: viral -croup, laryngitis, epiglottis. trauma: collapse/haemorrhage, anaphylaxis

management

priortise oxygenation (o2 supplement-> facemask non breather - 15 litres), estabilish patent airway and secure.
parent education- cut up small piece, no distraction during food. smaller diameter and child explore with object so keep eye.
parent -> CPR class,
-some children 1/2 asymptomatic.
complication: atelectasis, edema, aspiration pneumonia

additional info

initial: violent paroxysmal.
asymptomatic: reflexes fatigue. subside sx.
laryngeal obstruction- croup, cough, drooling. lodge b/w VC in sagittal plane.
stridor-60% & wheezing 50%.tracheal:PA, lateral soft tissue X-ray shows abnormal in 92%. CXR: air trapping, emphysema, shifted of mediastinum to unaffected side.
obstructive emphysema, air trapping, atelectasis. lungs- R bronchi’s in 58%.
complication in 3rd stage- fever, haemoptysis, pneumonia, atelectasis.

aspirated

stridor if in trachea.
unilateral ‘asthma’ if bronchial.
if total- cough, lobar pneumonia, pneumothorax etc. use bloods to rule out infection - no WBC or febrile. p.s batteries dangerous since can erode aorta

bronchiolitis

inflammation due to RSV in bronchioles. in winter, common if <1yr esp in premature w/ chronic lung disease.
wheeze+ crackles, coryzal sx, ARDS, poor feeding, mild fever, aponoea’s.
sx of ARDS: SCM , abdominal, intercostal m used, nasal flaring, tracheal tugging, raised RR, grunting - against partially closed glottis to increase PEEK.

admissions

< 3 months, pre-existing conditions, clinical dehydration, < 50 % feeding, moderate- severe ARDS, parent cannot manage. RR> 70, PaO2 < 92%. signs of T2RF (acidotic, hypercapnia and hypoxic)- lows cannot ventilate-> collapse.
management: supportive, saline nasal drop/ suctioning, supplemental O2, increase oral, IV or NG feeding.
ventilatory support if severe: CPAP, high-flow humidified oxygen w/ tight cannula, intubation.
capillary & arterial BG.
prophylaxis: palivizumab- monoclonal AB injection (passive and last for 1 month)

acute and chronic bronchitis

non specifi brnchial inflammation- usually post viral URT’s, cough for 103 wks. oldfer children- angina.
key: exclude pnuemonia.
chronic:3 months or > for every year for 2 years. damaged epithelium-> recurrent infection -> investigate for systemic/ pulmo disorders.
dual infection of RSV & human metapnuemovirus is severe.

investigation of respiratory Respiratory viruses.

PCR analysis of nasopharyngeal secretion. pulse oximeter determines concentration of humidified oxygen needed.
rarely will airway be damaged leading to bronchiolitis obliterans (stenosis/ fibrosis/ occlusion)

acute pneumonia

infection of lung parenchyma- 20% overall deaths.colder monthss
LRTI’s-> deficiency in mechanism of mucocilary drainage, cell-humoral defence, cough reflex.
RF: poverty, prematurity, urban residence, smoking.
neonates: aspiration of infected amniotic fluid (GBS, ecolio).
1-3 months: RSV, infleunxa, human metapneumonvirus.
afebrile or atypical: chamydia and b. pertussis (check immunization hx).
3mont- 4 yrs: strep pneumonia, moraxella catarrhalis.
5 yrs: m. pneumonia & chalmydophilia species atypical.

CF of pneumonia

non specific CF: tachypnea (specific), hypoxemia, abdominal pain, increased breathing, ARDS (neonates after birth-tachy, poor feeding, temp instability).
bacterial: greater severity, sudden onset.
atypical: progressive, sudden fever and broad spec spectrum: sore throat, malaise, prolonged cough, headache, photophobia.
afebrile: conjunctivitis, diffused rales on examination, staccato cough, rhinorrhea.
viral: gradual, preceeded via fever and upper RT (congestion, cough)

ddx for pneumonia

transient tachypnea of newborn, RDS, bronchopulmo dysplasia, aspiration, copd, CF, aspiration pneumonia (GERD, cleft palate, NM disorders, TE fistula, orophyarngeal dysphagia), anatomical disorder0 bronchogenic cyst, congential lobar emphysema.

Hx: nature of cough, obset of symptoms, poor appetite, lethargy and poor appetite indicate severity.
vital signs + auscultation- bacterial lobar-dullness to percussion, rales, dminished breath sound (viral -low pitched wheezig throughout), oximetry.
dx: PCR for virus (secretion/sputum culutres), if severe- CXR, blood culture and CBC, Ab, hospitalization, if AB fails and severe ARD, toxic appearance, O2 <90%.

atreatment for pneumonia

< 3 months- 6 mnths-> hypoxmeia, bacteremia & deterioration-> hosptialized.
outpatient: depend on age & offending agent. if viral -> supportive.
bacterial: amoxicillin-> PO.
macrolides azithromycin: atypical pneumona.
aerythromycin-> afebrile due to chlamydia.
oseltamivir: influenza, higher risk of complication, high risk.
immunization status checked -> ampicillin IV for s. pneumonia.
inpatient: ceftriazone injection, atypical dual beta lactam+ macrolide/floroquionolones,
vancomycin (MRSA).
complication: PE, abscess, empyema. large loculated -> thoraco/ chest tube.
abscess (MRSA)- same trx.

chronic pneumonia

> 3 months or recurrent for > 3 x a year. CXR: atelectasis, pneumofibrosis, heavy bronchial marking+ permeanent lung lesions.
etiology: 2 pulmo disease. school age. defect in anatomy, immune system, cogneital L-R shunt, CF. SMA (severe hypotonia)
exogenous: MV, hyaline membrane disease, cronic tonisillitis/adenositis.
klebsiella, strep/staph, pseudomonas
CF: prolonged infection/ hypoxomia: anemia, clubbing, growth resitriction, ECG changes ( P-wave -> atria), VC changes.
exacerbation: bronchiectasis cavities blocked.
dx: bronchogra,/ bronchoscopy. clinical.
trx: diet, surgical, adenotonsillectomy, Ab, postural drain, VAT??

check for asthma and IgE mediated hypersensitivity…

growth- food allergy, malabsorption
kids treated with high dose inhaled/ nasal/ topical corticosteroid.
obstructive sleep aponea.
hyperinflated / Harrison’s sulci chest (under treated asthma).
role: identify triggers and manage multi-system diseases.
immunotherapy: solution of allergen is injected subcutaneous/ sublingual administration-> develop immune tolerance (3-5 yrs), UNDER SUPERVISION.
different allergic reaction co-exist, if 1 is present, look for others.

asymptomatic: local inflamaotyr reaction limits disease progression-> latent. (if mantoux +ve then isonazid & rifampicin for 3 mnths).
24mm induration using PPD (purified protein derivative). if >10 mm (no BCG) and >15 mm (BCG given).
CXR: marked L. hilar LN.
syptomatic: children dont infect others. Ghon complex-> calcifies, lung lesion, LN -> spreading to LN. inhaled tuberculi failed to be contained by hosts immune system.

systemic manifestation: anorexia, wt loss cough fever, CXR changes. peribronchial LN -> obstruction. 1 infection (lungs) but cold abscess and metastic lesions occur.
post primary-> disseminated/ miliary-> gut, bones,CNS common, pericardium.

TB manifestation in paeds population

TB menigitis ( emergency) if brain-> seizures.
dx: difficult to obtain sputum-> need NG gastric washes before food. urine, CSF, CXR, LN excision available.
PPD test: 0.1 ml intradermal injection-> 72 hrs in forearm (erythema/ papule).
IGRA used routinely-> specific.
trx: triple/quadriple therapy (ethambutol. pyrazinmide, rifampicin, isoniazid).
2months: rifampicin. isoniazid.
> puberty: pyrixodizine given weekly: reduce P Neuropathy assoc isoniazid.
TB menigitis: dexametheasone to reduce sequale.
uncomplicated: treat longer (6months) but disseminated then >.

vomiting

posseting- normal: small amount of milk accompanied w/ return of swallowed air.
vomiting- forceful coordination expulsion of gastric content.
ddx: infection (fever & associated sx: Gastroeneteritis, UTI)
regurgitation: GERD
dysphagia: achalasia,
nasuea and epigastric pain- gastritis
early morning- neurological (ICP, headache,papilloedema meningitis).

list DDX paediatric vomiting ?

neonates: / infants: pyloric stenosis, atresia, inutssception, malrotation, volvulus, hirsprung disease, hernia, otitis & other URTI’s, pertussis, inborn error of metabolism

metabolic disorder- unusual odor
Heme positive stool/melena- oesophagitis, ulcer (hemetemesis) .
virilisation in girl- congenital adrenal hyperplasia.
pregnancy, torsion of testis, coeliac disease.
flank pain- pyelonephritis, RF.
adolescent- bulimia/ eating disorder, appendicitis, coeliac, DKA, toxic ingestion, cyclic vomiting syndrome.

types of vomit (color, appearance and associated sx) & what is indicated?

bile stained vomiting- intestinal obstruction.
haematemesis- oesphagus disorders- esophagitis, varices, mallory weiss, boerhave syndrome, ulcer.

projectle vomiting after feeds start- pyloric stenosis (congential)

abdominal tenderness (N+V)- acute & surgical abdomen.
distension- obstruction, strangulated hernia.
hepatosplenomegaly- chronic liver disease

blood in stool- malignancy, intussception, strangulation, vasculitis, ischemia? gastroenteritis, parasitic (giardia, amoebic dysentery).
severe dehydration- severe GIT issues, UTI, sepsis, meningitis.
bulging frontanelle/seizures- ICP
failure to thrive- GED, coeliac, other GIT conditions.

necessary investigations to diagnose and ddx etiology of vomiting in paediatric population?

CBC- anemia in hemorrhage.
electrolyte- severe dehydration and vomiting causes metabolic acidosis or alkalosis (loss of stomach acid).
high BUN/ cr- dehydration or CKD?
liver enzymes -elevated.
hyperbilirubinemia- liver disease
urine culture-UTI
X-ray-air fluid level (meconium ileus and other bowel disorders).
contrast Xray- anatomic anomalie.
abdomen US- renal stone, gall stone, hydronephrosis, appendicitis. pancreatitis
endosocpy- varices, ulcer etc.
abdominal CT
head MRI- tumor, trauma, abscess etc.
pregnancy test.
physical exam & ausculation- absent peristalsis (if notheard 30 seconds indicate obstruction)
good history- bowel habits, frequency, time of vomit after feeds, assoc sx etc. signs of dehydration.

air flud level on Xray

bowels have normal fluid to air level. mutliple air fluid levels, distended bowels and clinical picture keeping with acute abdomen + vomiting indicate BO.
air rises to top and fluid at the bottom.however in lungs its always PATHOLOGICAL.

GERD

physiological GER up to 2 months.
LES under-developed, short intra-abdo length, horizontal lying, pre-dominantly fluid diet. crying: intragastric pressure increase.
resolve via 1 yr- LES matures/ higher tone, solid in diet, toddler sits up.
delayed gastric emptying time, impaired oesophagus motility, loss of anti-reflux barrier of diaphragm- depends on angle it enters stomach.

CF of GERD in paediatric?

small multiple episode volume’s of vomiting post feeds, effortless & painless. non bilious and no blood.

complication

failure to thrive if severe.
recurrent pneumonia aspiration of stomach content- apnoea, cough, whezing, pneumonia sx.
stricture, barretts, oesphagitis (acid irritate mucosa-> haemetesis, anemia.
ALTE.
sandifier (side and opitsononsis (back-arching).
older- hearburn, epigastric/chest pain.

investigations

history and physical exam.
regurgitation- spitters-> physiological. but > 2x/day & >2-3 wks.
infant reflux: normal till 2 yrs.
only if FTT, pulmo sx & esophagitis -> pathological.
investigation- necessary if sx persist> 18 mnths.
GERD clinical. if atypical: 24 hr ph test monitoring to quantify degree of reflux, barium swallow, radionucleotide scanning.
barium- anomalie.
trial of empiric therapy-> if fails then investigate.

management of GERDS in children?

frequent smaller feeds. minimize supine-> raise head 90 degree.
formula thickened with cereal, rice powder
if BF then mother diet avoid egg/ cow milk (consider mother milk protein intolerance).
1 hr before bedtime.
H2 blocker (ranitidine)- PPI (omeprazole)
surgery- nissen fundiplication.
formula- frisovom.
domperidone- improve motility & emptying time.

acute abdominal pain ddx

acute gastroenteritis:

< 2 years: UTI, intussception, IBO, incarcerated inguinal hernia, trauma, voluvus, malrotation -> ischemia.

> 2yr: SCA (vaso-occlusion of mesentery), lower lobe pneumonia(diffuse), UTI.

adolescent: IBS, pancreatitis, diverticulum, PID, ovarian. testicular torsion, ruptured ovarian cyst, ectopic, peritonitis/appendicitis, mittelschlerimers (small blood w/ folciule rupture irritates peritonium)

ddx by localisation

renal/ureteric pain- lat/posterior pain.
gastritis/GERD: epigastric/ chest.
peptic ulcer: night.
spinal/ back: lateral and over spine (movement).
liver/GBS: right hypochondrial pain.
constipation: BO relief.
gynecological: suprapubic/ iliac fossa ->
abdominal migraine-> acute attack/pallor & vomiting.
consider pyschosocial factors-abuse/bullying.
look for jaundice, color of vomits, IBS like sx,

acute appendicitis

commonin adolescent >3 yrs.
etiology: lymphoid hyperplasia infection) or fecoliths (acts like diverticulum-> obstructs).
1.localised abscess/ gangrenous.
sx: N+ V, anorexia, abdo pain (periumbilical and RLQ-mcburney point), fever, pain aggravated w/ movement., low grade fever.

ddx: IBS and yersinia infection, mesentery adenitis.

diagnosis + management

plain abdo xray: faecolith seen.
WBC elevated high, U/S, CT scan. thick and inflammatory changes.
pre-school: perforation due to poorly developed omentum, doesn’t surround appendix.
trx: hydrate & correct electrolyte abnormality Ab and appendectomy.
enterocutaneous fistula, perforation-> sepsis, pelvic abscess.

acute diarrhoea :definition & casuative agent.

increased stool output with loss of electrolyte and fluid. etiologic: infectious vs malabsorption.
osmotic (resolve w/ fast)or secretory (doesn’t increase w/ intake).
viral: rota (common in winter-> day care0.
norwick (cruise ship).
bacteria : e.coli, shigella (reptile), salmonlela, yersinia (pet/pseudoappendicitis)).clostridium
(Ab use)

parasite: emboetic histolytica, giardia.

features associated with each etiology.

rota virus: watery diarrhea 7-10 day +/- vomiting.
e.coli: daycare/nurseries.
salmonella: animal products, reptiels.
shigella: contamined food, seizures.
clostridium: Ab use significant
camylobacter: contamined food cans.
yersinia: pets, contamined food, arhtritis, rash assoc (mimick ibs/ appendicitis.
s.aureus: food posioning, 12 hr onset.

dx + management

stool sample, enzyme immunofluorescent.
management: viral (supportive)+ self limiting.
bacteria:
salmonella (if <1 yr, immunocompromised or toxic looking.
shigella .salmonella: trimethoprim+ sulfamethoxazole. + azithromycin.
camylobacter: macrolides (azithromycin, erythromcyin).
parasites: metronidazole.
c.difficle: oral vancomycin/metronidazole.
Yersinia: if < 3 month, septicaemia. then consider aminoglycosides or cephalosporin 3rd generation.

dx + management

stool sample, enzyme immunoflourescnet.
management: viral (supportive)+ self limiting.
bacteria:
salmonella (if <1 yr, immunocompromised or toxic looking.

units + classification of diarrhe based on mechanism?

5-10 k/kg infants
children: 200 g/day.
classificiation based on mechanism:
-osmotic: presence of non -absorble solute (lactose intolerance) e.g malabsorption. water follows-> diarrhoea. trx: 2-3 fasts.
-secretory: bacterial toxin (cl- & water increase secretion) doesnt resolve w/ fasting
-malabsorptive: osmotic /secretory-> less S.A .or impaired function of stomach (Short bowel syndrome/ pancreatic insufficiency)
-inflammatory: UC/chrons. loss of proteins, plasma, blood, mucosa in feces. loss of fluid.

classification b/w acute/chronic

acute:<2 wks chronic: > 2 wks. chronic causes: celiac, IBS, dietary factors. anatomic disorder/ absorption issues.
SE of antibiotics: diarrhea.
e.coli-> haemolytic uremic syndrome (HUS-> RF).
dehydration vital changes: tachy, hypotension, fever). lethargy+ distress.
emergency: dehydration sign, bilious vomiting, tender abdomen/distended/petechiae/pallor (allergy).
trx: fluid/ PO Ab-.
loperamide/IV hydration not for infants.
glucose, Na, complex carbs (75mEq/L)-> total 245 mOsm/L) start w/ small frequent uses.
100 mL/kg for moderate dehydration.

fluid + electrolyte haemostasis

80% water content.
EC water (fluid+ plasma) easy to lose, not stable, depends on colloid pressure /protein (hydrostatic P)>
IC- osmotic pressure/active membrane transport.
source: exogenous (fluid+ food)/endogenous (oxidation).
loss: urine-61, stool-6 & skin loss (sweat/breathing)-33%
sweating- CF greater loss .
tachypnea-water loss
reduced fluid intake (water)

vomiting, diarrhea, polyuria, sweats- water+ electrolytes.

dehydration degree and clinical signs?

degree: mild5% BW loss
moderate: 6-10% BW loss (letahry, U output reduced, lethargy.
severe- 11-15 % loss-> shock (hypovolemic, CNS sx)
CF: Wt loss, dry mucus, skin turgor, ant fontanel depressed, shock, eyeball sunken, pale/mottled skin, prolonged CR time, weak pulse, cold extremities, tearless, Decreases consciousness.

types - isotonic, hypertonic and hypotonic.

types of dehydration?

isotonic- loss of proprtional quanity of water+ eelctrolyte.normal osmolarity of ECF. V+ D.
hyertonic: Na+ > 150 meq/L. water loss from cells (IC-> EC shift) hyperventilation, watery diarrhea, high fevers seen.
DKA, DI or excess hypertonic infusion fluid,sodium bicarbonate. reduced fluid intae with tube feeding.

hypotonic: below <130 mEq/L loss of Na+. EC-> IC. low serum/blood Na+. uncommon. reduced vascular volume-> shock (heat exhaustion) and cell swelling (ICP, confusion-> cns manifestation-> heat stroke).

RF:

1.< 6 months or low birth weight neonates.
2.>6 stools/ 24 hrs
3. 3 or more episodes of vomiting in 24 hrs.
4.unable to tolerate extra fluids or malnutrition.

higher BM fluid requirement, greater S.A. greater insensible water loss (15-17 ml/kg per day).
immature tubular resorption (loss in urine). cannot communicate for fluid when thirsty.

dehydration physiology-> hormones!

hyerposmal- H20 loss. trigger ADH-> oliguria. intracell dehydration.
isosmolal-> proprotional loss -> burns, V+D.
hyosomalirity: lack of fluid intake, trigger 2 hyperaldosteronism (adrenal cortex release hormone-> h20 and water retention and H+ excretion) pick up blood volume-> cardiac output-> arterial pressure increase-> kidney release less renin.
IC overhydrated /swollen.

dehydration physiology-> hormones!

treatment & rehydration

admit pt.
OHS-> mild dehydration w/out vomiting.
90+ 20+ 30+80+ 111.
Na,K,NaHCO3, CL-, glu.
IV infusion/24hr.
hydrating solution-0.9% saline (154 mEq/L. 134-145 mmol/L normal range.
15 % KCL- 10 ml ampouls.
5% dextrose
8.4 % NahCo3-
5% albumin/plasma.

fluid: glucose (K+ infused inside) + (Na+ )in saline.
1.pathological loss
2.daily requirement-depend on wt.
3. current loss- involuntary activity.

calculations

loss of water: 10x weight (KG) x % of dehydration.
1-11 mn: age (mnth)+ 9/2
1-6 yrs: age (yrs)+ 8.
> 7: age in yrs + 10.
daily requirement: 1-10 kg-> 100 ml/kg.
11-20 + 50/kg.
>20 kg-> +20 ml/kg

Na+-> 100 ml/6-8 mmol
K+: 100 ml 2/3 mmol.
d.l- 3mol/kg . 6.8 mmol loss

3 phases of dehydration- 1/2 volume P.L
2nd 1.2 P.L + 1/3 D.L
2/3 D.L + C.L
NG tube if vomiting. fluid deficit relacement & maintenance fluid requirement.
ondansteron: anti-emetic.
oral is best. IV is only used if AMS, ileus, circulatory shock, abnormal Na.
4:2:1
holliday -segar method
emergency: 20ml/kg over 10-15 min. normal perered, lactate ringer (contain potassium).
repeat until V.S normalise. if blood loss- alumin, plasma 10ml/kg.
seizre via hyponatremia-10-12 kg 3% NS .
hypoglycemic-10% dextrose in 2.3 ml/kg.

malabsorption

FTT, specific deficiency, abnormal stool. can be either pan-malabsorption (pancrease/ intestinal) or highly specific.

1.coeliac disease: autoimmune disease->gluten-> inflammation in epithelial cell (anti-ttg/anti/ema)> rise & fa.
atrophy-> malabsorption. mouth ulcer.
dermatitis herpetiformis. type 1 DM linked.
dx: igA, endoscopy, biopsy, crypt hypetrophy, crypt atrophy.

cholestatic liver/biliary atresia- bile acid malabsopriton- fats/> stearrhoa.
short bowel-> resecteed (pan-malabsorption-> nutrient, water and electorlyte).
loss of TI (B12 , bile acid-> chrons).
exocrine-> starch, triglyceride,protein defect.
SI mucosal disease (celiac, specific enzyme),

syndromes

toddlers disease, food allergy, chrons, coeliac, UC.
toddlers: 3-5 x daily diarrhea. food in stool. high fibre trigger. self resolve.
food intolerance: allergies. invetiations: igE.
enzyme deficiency: lactase deficiency.
immune mediated; coeliac (genetic). chemical irritants (chillie).

chrons: whole bowel (transmural). perianal skin tag, ulcers. dx: biopsy & colonoscopy.
biologics+ immunosuppression needed.
UC: pan colitis. bloody diarrhea mucus. left sided.
complication: toxic megacolon, colorectal Ca, hemorrhage.
dx: goblet abscess+ goblet cell in MS.
extra-intestinal : erythema nodosa, arthiritis, liver + eye lesion.

hepatic disease

physical exam (firm costal edge) & auscultation for percussion (dull ) with margin of resonance above & below liver plane.
hepatomegaly: infection (radiation, toxin-drug, Kupffer cell hyperplasia), inflammation, infiltration (storage glycogen disease, DM, steatosis, Wilsons and Alpha-1 antitrypsin deficiency), excess storage, obstruction (biliary atresia, tumour, congestion (supra-hepatic, buddchari, restrictive pericardial disease, veno-occlusive in BM transplant patients).

infiltration disease

-parasitic cyst, extramedullary haematopoiesis, leukemia/ lymhpoma, hepatocellular carcinoma, heangioma and other benign tumours.

hyperbilirubinemia + associated with elevated conjugated bilirubin + elevated ALT/AST-> viral hepatitis (+ autoimmune, Wilsons, toxin, drug).
liver biopsy needed.
cholestatic pattern-> US / cholangiography.
unconjugated bilirubin level+ elevated reticulocyte count-> haemolytic disease.
google conjugated vs unCJ

age group: common disorders:

neonates: CHF, metabolic/ maternal disease,/ storage disease/ viral hepatits/TORCH, malnutrition, inappropriate drug metabolism.

children: anemia, biliary obstruction, CF., leukemia/ lymphoma, parasitic, obesity, systemic/sepsis.

splenomegaly

physical exam detected. < 1-2 cm below left costal margin, soft and non tender but palpable (1/3 neonates).
firm -pathological.
function of spleen:filtrate defective cells+ capsulated organism. abnroal RBC may get ingesteed via macrophage in splenic cord.
-reservoir for platelets & blood component.
dx:CBC, hx, LFT.
malaria, kala azar, chronic hemolytic anaemia, HTN protal.

patholgoical causes of splenomegaly

unrelated to diseases of the main organ but 2 manifestation: MPS, immunoregulation, Hemolysis disorder. neoplasia (ALL, non hodgkins), obstructive venous BF (intra/ extra hepatic aetiology), portal vein thrombosis, cirrhosis, CF, storage disease (gaucher, neimann-pick disease), abnormal lipid accumulation in splenic macrophage.
trauma-> palpable subcapsular hematoma. pseudocyst, congenital splenic cyst (6 months+ asymptomatic ).

pathology

hypersplenism-> excess function. 1) excess phagocytic activity, antibody destruction, sequestration-> reduce blood circulating elements.
sequestration is emergency-> hypovolemic shock due to rapid consumption of RBC in sickle cell (CF: sudden weakness, dyspnea, L sided abdo pain)
trx: underlying cause (systemic disease). splenectomy. prophylaxis with vaccination against encapsualted organism.

viral hepatitis (A,B,C,D,E)

virus target hepatocellular-> MHC 1. CD8+ recognise and cytotoxic. -> apoptosis (councilman body)-> liver damage.
sx: fever,malaise, N, hepatomegaly (pain), AST/ALThigher and last to return to normal blood).
atypcial lymphoctosis-> huge+ un/conjugted bilirubin (jaudnice0_. leak and cells cannot conjugate it.
darkurine, urobilinogen in SI (urine). chronic > 6 month (PT fibrosis)-> post necrotic cirrhosis.

differentiation

hep A: travels: feco-oral transmission. only acute. serology: HAV igM (active), HAV IgG (protective-vaccination/ recovery)>
HEV: acute, uncooked food, feco -oral, serious in pregnant (fulminant hep) . no vaccination.
hep C: IV, child birth, sex (blood/fluid).
test: enzyme immunossay- igG (not specific so use recombinant immnoblot)+ HCV RNA pcr test (early 1-2 wks-RNA detected). chronic+ acute. recovery: if falls-> recovery.
HBV:
acute & chronic
liver cancer
acute/chronic
serology: same tests as HCV. surface antigen detector / core antigen. depend on age (young children-> acute).
E antigen-> active infection & replication.
igM against core Ab (police)
igG (surface)-superhero.
less contagious look healthy.
immunization.

HDV: only infect if HBV (co-super infection). HDV igM and igD indicate active infection.

addition note for hepatitis

hep A: RNA vaccination for travels. cholestatic hepatitis & fulminant hepatitis. close contact pophylaxis with HNIG or vaccinated if 2 wk virus onset.

hep B: DNA , africa prevalent. chronic carriers-90%. no trx.
IGm for core antigen (anti-HBc)- acute
(HBsAg-ongoing) may have acute hepatitis.
fulminant- liver failure.
interferon trx for chronic HBV lamivudine (resistant). screen all mothers. babies relieve HB vaccination, check ab response.

HBC: HIV vertical transmission. chronic carriers-> carcinomas. RNA
trx: pegylated interferon and ribavirin (RSV)
hep D: RNA. cirrhosis likely.
HBE: considered the non- A to G hepatitis. if others aren’t confirmed in aetiology then its diagnosed. same as HBA. contaminated H20.
EBV: fulminant, asymptomatic. few jaundice.

ALF: hstory->fever, jaudncie, fatigue, D+V+ N, malignancy signs (subcut nodules), endemic traveller disease, nutrition issue, wt loss, bleeds, bruising, pruritis.
cause: infeciton/ deug/ metabolic/ autoimmune/ reye syndrome.

investifations for liver+ spleen issues

CBC (anemia), speripheral smears, ESR (leukemia, SCA, parasite), reticuclocyte count
LFT: albumin, ast,ALTALp, bilirubin, raised A-fetoprotein *hepatoblastoma).
ceruloplasmin (wilson)
CXR, sweat test (CF), HBsAg -hep B
USG abdomen-cyst, tumors, liver biopsy.

trx /approach to neonates/chidlren with hepatosplenomegaly

1.history, exam, screen lab test.
2.hyperbilirubinemia: fractionate (elevated direct/ indirect or mixed) .
2.1: indirect-> identify hemolysis sepsis (DIC, coagulopathy, CHF).
elevated direct bilirubin: elevated transminase-> viral serology, cerulosplasmin + liver bopsiy.

if ALp-> US/ cholangiography-> GBD obstruction.

if no hyperbilirubinemia -> check spleen.
1.1: splenomegaly: abdo US + doppler-> vascular obstruction, liver tumour, leukemia, parasite, storage disease, torch and sepsis.
no splenomegaly: DO BIOPSY/ viral hep/ obesity. primary tumours/ cyst/abscess.

Acid and base imbalance:

pH is the first blood component to analyse, disruption causes cell metabolism, metabolism of drugs, contractility, response to catecholamine.

difference in venous/ arterial is 0.05.
C02-> carbonic acid (acidotic blood).
low oxygen (acidotic.
manipulate acid base if ICP high-> as Vaso - constriction needed.
Cor pulmonale (ventilation to low carbon dioxide-> vasodilate/ normal-elevated pH.

normal range bicarbonate: 22- 26 mmeq/L.
tC02 represents it, kidneys regulate. as pH raises-> excrete more.
paO2- 80-100 mmhg. hypoxia hypovolemia (R->l shunt), diffusion limitation (COPD<, pneumonoa, atelectasis,a pneumothroax).

repsiratory acidosis

excess paC02-> T2RF. low ph and HC03- low-> normal or pa CO2 levels elevated.
conditons: CNS depressin (control ceners disurpted, narcotic, ansthestia, sedative (hypoventialtion).
SC< NM (diaphgramatic muscle use).
embolism-> obstrcted endotracheal tube, pain, angina, choking etc.
compensatory-> hyperventilation (compnesatory).
cellular bicarbonate buffering-> to nomrlaise pH not signifcant.
kidneys increase bicabonate reabsorption and carbonic expelled.

chronic and fully compensated

adult-choronic co2 retention (copd), and infant with BPD.
sx: heaahce, letharyg, restlenes, tremor, delirium, coma, tahchy, arrythmia, /pulmo HTN, dyspnea, ARDS, shallow breathing.

interventions fail and manifest to pathology.
mechanical ventilators-> RR, vnetilator pressure.
pharmacologic: furosemide, dilators, pains killers.
CT tubes.
activities to strenghten and clear secretion-> spirometry.
Displaced Obstruction Pneumothroax tension Equipment:

respiratory alkalosis

(RR)hyperventilation-anxiet, CNS , elevation, pain,, excess loss of paC02.
excess ventilation.
compensatory- mediated to lower RR+ depth. renal (slower).
decrease tidal, RR set and consider extubation.
acute anxiety- antioxyltic medications (use bag to re-breath C02).

metabolic acidosis-> high/ normal anion gap.
LA, DKA< CRF, methanol, low cardiac output, excess exercise trauma, infection, organic in toxification. diarrhoea, RTA.

metabolic alkalosis

HCL through NG tube, vomiting, diuretic aggressive. (sodium, K+ loss). drugs use ammonium chloride, antiemetics, diMOX.
DX: 1)Ph 2) PC02 EXCEED 35-45 (higher than 45 its acidotic.
TCO2 (METABOLIC). HIGHER THAN 22 (ACIDOTIC). dopamine is Ianotropic.
normal anion gap because electrolytes arent affected like Na+/K+ (no replacement needed).
-long standng diarhea, RFA< NaHcO3, diamox

mneomics

MUDPILERS & HARDUPS for non/anionic gap in metbaolic acidosis.
acidosis anion gap
: methanol, urenmai, DKA< paraldheyde, isoniaide ethanol renal, salicylates.

HARDUP’s: hyperalimentation, acetoazolamide, RTA, Diarrhea, uretero-elvic shunt, post-hypocapnia, spironolactone.

acute respi. acidosis-> anything causing hpoventilation.

CLEVERPD

contraction, licorice, endocrine, vomiting, excess alkali, refeeding (deranged electrolyte-> phosphate and other electrolyte loss), post hypercapnia, diuretics.
CHAMPS: CNS, hypocapnia, anxiety, mech. ventilation, salicylates, sepsis.

blood differnece in age:

Hb decrease from neonatal (cord blood) to adolescent via 17g/dl to 13 g/dl.
haematocrit-> decrease from mean 55 -> 38%.
leukocytes: 12-8k in adolescent, neutrophil increase, lymphocytes peak till 3 month and steadily decrease . monocyte peak at neonate, eosinophil normal.

cardiology history / exam in infants/ neonates

gestational + perinatal hx?
maternal hx: healthy during preg, prenatal care, US routine. (TORCH), medications (retinoic acid warfarin, lithium, pheytoin ) -> teratogenic cardiac malformation.
TORCH (toxoplasm, others rubella , CMV, herpes).
prenet/ post natal hx: developmental miestone, feeding issues, growth curve, cyanosis, decreased exercise tolerant, syncope?, angina, palpation (extra/skipped beat).
feeding-> exercise test for neonates.
1. Fmhx-> congential Hx, sudden unexplained death (drowing-> electrical issues/ pacemaker).

physical exam

general appearance/ inspection.
look mal/ well nourished,.
breathing effect.
palpation-> pericardium-> hyperdynamic, maximal point displaced, thrills?
femoral and brachial pulse (peripheral)-> compare/ bounding.
BP: upper/ lower extremity (get rid of gradient). coarctation in aorta if difference is >10mmhg (systolic).
auscultation-> S1 (mitral and trisciupid valve closure and S2 A2 AND p2 closure. splitting is variation in S2.

widely split-> volume overload, electric delay in right bundle branch block/
narrowly split-> cor pulmonale or aortic stenosis.
enitrely single _. severe stenosis, severe pulmo HTN.

murmurs

benign-> structurally normal blood moving
classification : systolic, diastolic, continuous , gallops, clicks.
grade murmurs: barely audible,
grade 2: soft but easily audible.
grade 3: mdoerate butno thrills (hand on pericardium)-> grade 6 (audible with stehtoscope off chest).
systilic murmur -> ejection /midsystolic or crescendo/ decrescendo (pulmo stenosis, aortic stenosis) , late (MT prolapse) and holosystic: triscipud , ventiricular defect.
early -> short regurgitant.

diastolic (early/ mid) -> always pathological. regurgitation of aorta/ pulmo depending on where it radiates.
higher pitched, aortic / pulmo regurgitation.
continous- venous hum (supine , neck extended louder), AV fisutla PDA (newborns), shunt post-surgery.
stills-. louder in supine.

gallops: diluted ventricules dysfunctional

S3: apex. normal in children/ young adults
S4. pathological.
clicks: ejection/ mid systolic/ diastolic opening snap (mitral stenosis)

rubs: pericardial friction rub-scratching. systolic/ diastolic component-> obscure normal S1 and S2. indicate pericarditis

physiological changes:

post natal alteration to extrauterine environment, rapid fall in vascular resistance, increase in f.ovale, ductus venosus (UV & V. inferior) and obliterate UA.
ductus arteriosus (functional -constriction and anatomical closure-8 wks).
heart size increase, ovale shaped, more horizontal lie, right ventricle pre-dominant as lungs. progressive function in l. ventriculi.
newborn : 140 bpm and infants 120 bpm.
BP: 76 + (mnths x2).
diastolic: 2/3 of BSP.
hx of frequent RTI’s could indicate cardiac issue.

palpation: PMI 4th IC in 6 yrs.
7 yrs- 5th IC.
thrills-> stenosis.
PDA: bounding /collapsing pulse.
aortic stenosis -low pulse. easier to find brachial P.
auscultation->
lab investigation: ECG. CXR, dopplier, Echo (note cardiothroacic ratio & pulmo vascualtures).

note: PMI, timing, radiation, duration and chnages in position.

causes of heart failure:

1.pump dysfunction/ systolic-> CO reduction-> congestion
2.voluem overload (preserved/ impaired function), increase preload.
3.pressure overload (increase pressure against heart-> afterload).
cardiomyopathies-diluted/enlarged (thin ventriculi wall, regurgitation), hypertrophic (preserved size, cavity smaller), restrictive 9relaxation impaired, pressure build up-> atrium or vascular oedema)
non compaction-> embryological defect-> spongy and dysfunction.

dysfunctional mycoardial tissue

myocarditis/ cardiomyopathies.
congential heatt malformation: detected within 1 yr.
l-R shunting (increased pre-laod) pDA, ASP, AVM.
volume overload-valvular dysfucntion (backload of blood-> next squeee is bigger), tachy to compensate stroke volume (increase CO).

pressure overload -> ventriculi contract against higher pressure-(r-sided) & (L-sided):aortic stenosis, co-arctation
(fixed), r-sided pulmo stenosis.

classification & staging: NYHA class 1(asx) -> 4 (most severe) present sx at rest (fatigue palpitation, dyspnoea, angina-> support/ transplant).

ross classification

for neonates and children adapted.
mild- short breath, feeding.
moderate: prolonged feeding time , fft, tachpnoea.
4: marked sx even at rest (end stage- advanced therapies).
stage A; RF. chemotheraphy -> cardio toxic. echo normal.surveilance.
B:structurual/ functional HD. EJV affected. ACEi (afterload, consume less O2-> maladaptive activation paused)
C :pass failure. beta blockers, aldosterone antagonist, lose dose digoxin, direutic (sx)
D: end stage (PEEK).

history

poor feeding, cachexia, ftt, diet diaphoresis, tachypnea..
chidlren: mistaken for GI pain, recurrent cough, vomiting. mistaken for asthma, viral syndrome,malaise
older children: palpitation, exercise intolerane, wheezing, edema.

physical: cold extremity, hypotension, tachypnoea, s3 (volume/ pressure overload-gallet sound).
rales/wheezing. systemic venous congestion-ascites/ abdo distension).
dx:CXR (diluted-> cardiomyopaty) increased vascular marking and bilatrial marking-> restrictive).
ECG:heart block, increased voltage (hypertrophy), decreased voltage (PE, myocarditis), ST changes.
echo-functional assessment.
blood test: CBC: hemocrit, esr, CBC, renal dysfunction, creatine, BUN, LFT, troponin, CRP, creatine kinase ,BNP (specific/ sensitive) +(inflammatory markers).
BNP-EJF (ddx respiratory).

other tests

MRI: anomalies anatomical. ddx between restrictive vs constrictive, edema, RV function, fibrosis seen.
cardiac catheterization-> etiology (biopsy )direct hemodynamic pressure in heart, measure CO.
severe cases: L. outflow obstruction-> cessation of Bf out of heart (ventricular arrhythmia/ syncope).
myocarditis: viral, bacteria and rheumatological.
arrhythmogenic: supra/ventricular -> dysfunction even after cessation.
surgical repair (induced dysfunction/ bypass).
congenital: PDA, VSD, ASD, aorto-pumo window, AVSD, single ventricle circulation / unobstructed BF.

aldosterone antagonist in heart failure

neuro-hormonal blockade necessary to treat systolic HF. CF: apnea periods, hepatomegaly , vein distension, catehcolamine-> sweating, grunting (dyspnea), irritability.

therapy:

digoxin (increase contractility,SV, BP, reduce HR. dose dependent on maintenance and total digitalising dose.
lowest if premature 0.05 ng/kg and infant its 0.015. loading dose: 4 doses every 12 hrs (36)
maintenance: 2 doses every 12 hrs (24 hr)
other inotropic dobutamine (2.5-15 mcg/kg/min IV) and dopamine (5mcg/kg/min IV).
diuretic: furosemide (hypokalemia, electrolyte disbalance) 1-3 mg/ kg IV.
spironolactone 2-3 mg/kg.
vasodilator systemic- captopril 1-4 mg/kg.
diet: sedation (diazepam 2-5 mg/day) low dose and oxygen. reduce sodium chloride, increase K+). aldosterone antagonist.

cyanotic HD (R-L shunt)

saturation 4-70 blue.
D-transpsition of the great arteries (normal heart-> swtich the pulmo trunk w/ the aorta) bypass lungs. ductal and atrial level mixing (shunt).
T anomalious venous congestion (TAPVC)utero_. connect with common pulmo v-> umbilico system. blood cannot leave lung (edema-> total cxr film) differentiate b/w ARDS.

ebstein anomaly: triscupid regurgitation severe, large atrial (big atrium- wall to wall CXR). r-l at atrial elvel
triscipud atresia (anomalie): never form, R. ventricule small/ non-existent).
foramen ovale-> body if DA open then to lungs. gradual hypoxemia.

pulmo stenosis/ atresia (TOF): r-> l through ovale, and some go through the DA (dificulty when that close).

hyercyanotic spell

tahcypnea, cyanosis, irritiability,
emergency: knee- chest position, oxyen, diazepam 0,5 mg/kg.
CHD surgical correction.
TOF: RVOTO, septal defect. RVH, aorta overriding VSD.
cyanotic at birth, increase till 6 yrs. grade 3-6 murmor, seizure, LOV.
exam: CXR (absence of pulmo markings, boot shaped heart (small PA and RVH), echo. ABG.
surgical palliation NAD CORRECTION AT 1-3 YRS. (BLALOCK -TAUSSIG SHUNT).

TGA

UNRESPONSIVE TO O2 THERAPY, severe hypoxia, acidosis and death. systolic murmurs.
dx: oval or egg shaped hsrt, icnreased lung marking. ecg (r/ axis deciation), pa o2 low).
trx: postraglandin E post birth to keep ductus open till surgery, balloon atrial septostomy to enlargge ASD and improve mixing.
total surgical correction.

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