case scenario eek ea ‘A mother brings her 12 months old boy because he is always crying. She observed that her child is wasted and looks markedly wasted. On examination, the child is crying most of the time he looks very thin and wasted .His weight is 6.5 kg his lips look pale with macerated mouth angles. Subcutaneous fat is lost over the abdomen, buttocks, with senile face .Chest examination reveals scattered 4 rales and crepitations all over the chest ‘Amother brings her 14 month old boy because he is not well. She observed that her child has recently lost his appetite and became disinterested in playing .The mother says that she got another baby 3 weeks ago, and in the last 2 months, she stopped breastfeeding her older child and started to give him mashed potatoes cooked rice with some added sugar and boiled macaroni. On examination, the child looks distressed, coughing with cyanosis and grunting but he is not feverish .His weight is 8 Kg. His temp is 36.3 C and his respiratory rate is 60 breaths/m. He looks edematous with sparse light color .His lips are pale nonia & respiratory fail A155 year old boy presents with abnormal gait and poor weight gain. He was breast fed for the first year without any other supplementation. On examination, he is pale with prominent forehead and a marked abdominal distension. He has small chest swellings. His length is on the 25th centile and his weight on the 10th centile. The hand and foot show abnormal fixed position. And the child started to convulse -121- Scanned with CamScannerMohamed M. Ismail case scenario 3 day old female infantis referred from a community hospital for bilious vomiting anda heart murmur. The baby was born at 37 weeks gestation to a 39 year old women. On examination, he appears jaundiced and has a flat facial profile, short upward slanting, flat nasal bridge with epicanthal folds; a small mouth with protruding tongue and single palmer crease. A loud holosystolic murmur is heard over the chest. Generalized hypotonia is present A 13 year old girl presents to your clinic for evaluation of short stature. The patient has not yet attained menarche and her mother reports no breast development. She has been well with no chronic medical problems. Her mother is 173 cm and had menarche at age of 12 Her father is 185 cm and started shaving at age of 15 years On examination her height is 120 cm less than Sth centile she is pre pubertal, has a webbed neck and widely spaced nipples the carrying angle is increased a case of turner syndror ‘A112 years old boy is brought to the emergency department after being stung by a bee .He initially complained of localized pain and swelling . Fifteen minutes later, he began to complain of shortness of breath and wheezed. He felt weak and dizzy On examination, he is drowsy and pale, and in mild respiratory distress, he has, generalized urticaria. His lung examination shows mild wheezing with minimal retractions bite hypersensitivit -122- Scanned with CamScannerMohamed M. Ismail case scenario A 10 year old boy presents with fever and joint pains, initially the pain affected his right wrist, but now affects his left wrist and right ankle He had tonsillitis 4 weeks previously treated with oral penicillin, On examination, his temp is 38.7 C respiratory rate 20/m, and heart rate 110/m. His left wrist and right ankle are tender ‘Mention possible investigations and treatment 'A3 months old boy presents with poor feeding, excessive sweating during feeding, and poor growth. On examination his respiratory rate is 80/minute, and blood pressure is 90/65 mmHg in the upper and lower extremities and the heart rate is 180 per minute. The cardiac exam reveals a systolic thrill and a grade 4 pansystolic murmur at the left sternal border An infant 11 months old preser 3 months ago. There is history of feeding difficulties, exertional dyspnea and recurrent attacks of cyanotic spells where the baby becomes more cyanosed with marked tachypnea. Examination revealed central cyanosis, and ejection systolic murmur over the 2nd left Space AS hours old male newborn on the postnatal ward is noticed to be blue around the lips and tongue, The baby was born by normal vaginal delivery and weighted 3.8 kg. The APGAR SCORES were 7 at 1 minute and 8 at 5 min. On examination the temp is 36.6 C’, hs lips tongue and extremities are cyanosed. He is crying normally. Heart rate is 160 /m femoral pulses are palpable and second heart sound is single, oxygen saturation is 70% in air and does not rise with oxygen mask -123- Scanned with CamScannerMohamed M. Ismail case scenario ‘A5 months old boy developed a runny nose and a cough 2 days previously, but has become progressively and has now gone off his feeds. He has two older siblings who also have colds ‘On examination, he is febrile. 37.8, has clear nasal secretion and dry wheezy cough. His respiratory rate is 65 /m with intercostal and subcostal retraction. On auscultation, there are widespread fine crackles and expiratory wheezes ‘A3 year old boy was seen because of a cough and fever and was diagnosed as having a viral upper respiratory tract infection On examination, he miserable, flushed, toxic and febrile 38.8 C. His pulse is 140 beats/m His respiratory rate is 48 breath/m with nasal flaring. There is dullness to percussion in the right lower zone post. With decreased breath sounds and bronchial breathing ‘A3 years old girl presented 4 days previously with a cough and fever and was diagnosed with viral upper respiratory tract infection. On examination, she is febrile 38.8 with capillary refill of 2 seconds. Her pulse is 140/m, oxygen saturation is 85% in air and BP is 85/60. Her respiratory rate is 48 /m with nasal flaring. There is dullness to percussion in the right lower zone post. With decreased breath sounds and bronchial breathing. Oxygen saturation is given, however respiratory distress worsen (RR more than 60/m, severe Intercostal recession. She becomes cyanosed and lethargic ‘A 12 year old boy is referred by his GP with a chronic nocturnal cough. He has been losing weight and has had a poor appetite 3 months ago. He lies with his mother and three younger siblings in a damp two bed room flat and his mother has also been coughing a lot over the last month with occasional blood tinged sputum. They are uncertain which immunizations he has received. On examination, he is very thin and his weight is on the 3rd percentile. His heart rate is 80/m and his respiratory rate is 26 breaths /m. There is no wheeze but there are bronchial breath sounds in the right upper zone of his chest -124- Scanned with CamScannerMohamed M. Ismail case scenario A9 year old boy is seen in the emergency department. This is his third attendance with an acute wheeze in the 3 months. He has developed a cold and became acutely breathless. On examination, he is quite but able to answer questions with short, sentences. His chest is hyper inflated and he is using his accessory muscles of respiration. On auscultation there is equal but poor air entry with widespread expiratory wheeze. His pulse is 125 /m with good perfusion A\12 year old boy is brought to the clinic by his parents He has been complaining of mild abdominal pain and his parents noticed that the sclera looked yellow .He has been scratching himself mildly . The parents report that he had flu like illness with fever nausea and poor appetite over the last 10 days. He has previously been healthy, but he went to a summer camp 5 weeks previously on examination he is jaundiced and appears uncomfortable but alert and fully oriented .His temp is 37.8 C and his liver is palpable 4 cm below the costal margin and mildly tender ‘A weeks old full term female presents to the office with increasing jaundice over the last week, Her parents' report that 2 weeks previously, she began to have yellow eyes and skin her stools is clay in color for the past 10 days along with dark urine. There were no complications noted at birth. On examination her weight and height are at ‘the 50th percentile. Her skin is jaundiced with scleral icterus. Her liver is felt 4 cm below the costal margin firm in consistency and no splenomegaly is noted Investigations and treatment: Neonatal cholestasis A 2 year old girl was brought to the emergency department with sudden severe hematemesis. History revealed umbilical sepsis during neonatal period. The child appears pale and physical examination reveals a firm spleen palpable 7 cm below costal margin. She does not exhibit hepatomegaly ascites or lymphadenopathy Laboratory findings show a hemoglobin level of 6 gm/dl -125- Scanned with CamScannerMohamed M, Ismail case scenario 1 year old girl has had diarrhea and non-bilious vomiting for 2 days. In the fast 8 hours. He vomited 5 times and passed 6 liquid stools. The infant passed a very little amount of urine during the last day. On examination, HR is 135/m, respiratory rate is 45/m, his temp is 37.7 and his capillary refill time is less than 2 seconds. His anterior fontanelle is depressed; eyes are sunken, skin pinch returns back slowly 9 months old male infant is brought to the emergency department by his mother with a4 day history of vomiting and diarrhea. On examination, respiratory rate is 45/m unlabored. Proximal pulses are poor, distal pulses are absent and extremities are cool. Capillary refill is 8 sec. HR is 185 /m and BP is 85/40. The infant is extremely lethargic and responds to pain only, with a minimal grimace A7 weeks old infant presents to the emergency department with 1 week history of non-bilious vomiting. His mother describes the vomit as very forceful. He has a good appetite but has lost 300 gm since he was last weighed a week earlier. He has mild constipation. On examination he is mildly dehydrated, his pulse is 170 beats /m, blood pressure 82/43 mm Hg and peripheral capillary refill 2 seconds. An olive like mass is felt in the right upper quadrant of the abdomen nigenital hypertrophic pyloric ste 'A7 months old infant was referred with a 2 day history of diarrhea with blood and mucous in the stools. His mother states that he has periods of inconsolable crying which are getting worse and more frequent. There is no history of contact with gastroenteritis, of travel, or of bleeding disorders. On examination he has a temp of 37.9 his pulse rate 186/m, blood pressure is 80/44 and capillary refills 3 seconds, He is difficult to examine due to frequent crying. But when examined during .2 period of quite, a sausage — like mass is felt on the right side of the abdomen Intussusce -126- Scanned with CamScannerMohamed M. Ismail case scenario al The mother of a 2 week old infant reports that since birth her infant sleeps most of the baby; she has to awaken her every 4 hours to feed, and she will take only an ounce of formula at a time .She also is concerned that the infant has persistently hard pellet like stools On examination, you find an infant with normal weight and length, but with an enlarged head. The heart rate is 75 beats/m and the temp is 36 C the child is still jaundiced. You note large anterior and posterior fontanelle, a distended abdomen and an umbilical hernia ‘An 11 year old girl is admitted with drowsiness and difficulty breathing. She was well until 3 weeks previously, when she began feeling tired, thirsty and losing weight. On examination she responds only to pain. Her breath has an abnormal smell, is deep and rapid 25/m, her hear6 rate is 100/m and her temp is 36.8 C, She has cool peripheries and capillary refill time of 5 seconds AS year old girl is referred to the pediatric clinic because of pallor and progressive abdominal distention with a history of repeated blood transfusion since the age of 6 months. On examination she appears pale and she has yellow sclera. Her heart rate is 105/m. Her height and weight are below the Sth centile, She has a grade 2/6 ejection systolic murmur at the left sternal edge she has HSM, BUT NO PURPURA OR GENERALIZED LYMPHADENOPATHY Chronic hemolytic anemia: Thalassemia major ‘A2 year old previously well boy is brought to the office by his aunt. She reports that he developed pallor and red urine and jaundice over the past few days He has not been exposed to a jaundiced person, but he is talking Sulphamethoxazole- trimethoprim for otitis media His aunt seems to recall his 4 year old brother having had similar problem after a viral illness, which also caused a short lived period of anemia and jaundice -127- Scanned with CamScannerMohamed M. Ismail case scenario ‘An 18 month old boy presents with a chief complaint of pallor. He is a picky eater taking small amounts of meat and some vegetables; he survives mainly on bottles of, milk. On examination. He looks pale but not icteric, He is an active toddler. His heart rate is 100/m and he has grade 2/6 ejection murmur at the left sternal edge, ‘A year old child develops bruising and generalized petechie two weeks after a viral syndrome. No HSM or lymph node enlargement is noted. The examination is otherwise unremarkable Laboratory testing shows the patent to have a normal Hb, hematocrit and white cell count and differential. The platelet count is 15,000. A 4 year old girl is referred to the pediatric unit with pallor and non-blanching skin rash. She had a cold and sore throat 2 weeks previously. She is otherwise very well. ‘On examination she has no dysmorphic features. Her height and weight are on the 25th centiles, There is no jaundice and she is afebrile. She is pale and clinically anemic. There are petechie mainly on her limbs. No hepatosplenomegaly no enlarged L.N, ‘A5 years old girl was noticed to be pale and lacking energy. She was complaining that her legs were aching. She had an ear infection with a high temperature that was slow to respond to antibiotics. On examination she is quite and pale Her temp is 37.8C. She has a generalized lymphadenopathy. She is pale but not jaundiced. She has bruises on her shins, left and right upper arm. The liver is 4 c below the right costal margin and her spleen is palpable 2 cm below the left costal margin. ‘AT year old girl presents with a 3 days history of rash and ankle swelling and painless frank hematuria, She had a cold 4 weeks previously, but has otherwise been healthy. She received no medications and is fully immunized. On examination, she has palpable non blanching purple spots 1-4 mm in diameter especially over the shins and buttocks. Her left ankle is swollen, worm and tender with restricted movement -128- Scanned with CamScannerMohamed M. Ismail case scenario ‘A year old boy fell while playing in the garden; he developed a very painful swelling of the right knee. He was born at 37 weeks gestation and experienced a prolonged bleeding after circumcision that necessitated an urgent blood transfusion. A family history of bleeding tendency is reported ‘4 year- old boy presents with a 2 weeks history of general malaise and puffiness of the face. There is nothing of note in the history. Examination reveals generalized puffiness with pitting edema of the lower limbs. Three is mid abdominal distention, but no tenderness or Organomegaly. His scrotum appears swollen. His blood pressure is 90/65 mm Hg A year old boy presents with a 3 day history of smoky colored urine, This is not associated with dysuria, although his urine output is diminished, He had tonsillitis 4 weeks previously. There is no family history of note. On examination, he is paraxial and well .Respiratory rate is 14 /m and pulse is 90/m with a blood pressure of 110/85 mm Hg Abdomen is non-tender with no masses AS year old girl has been passing urine frequently for the last 2 days and complaining of pain when doing so. She is febrile and had an episode of shivering. SHE HAS ALSO complained of pain in her lower back and has vomited three times today. On examination her temp is 39.1, her abdomen feels soft and is not distended, but there is significant discomfort when palpating right loin ‘An 8 year old boy wets the bed most nights, does not walk up when it happens and there is a large pool of urine. He has no previous medical problems and no recent illness. On examination, his height is 140 cm) 75th centile and his weight is 35 kg (75th centile). His blood pressure is 112/70 mmHg. Cardiovascular, respiratory and abdominal examinations are unremarkable -129- Scanned with CamScannerMohamed M. Ismail ‘case scenario 413 month old male was born at term by difficult vaginal delivery and birth weight was 4200 gm. At 6 months of age, his head control was poor. He is not able to sit or stand. His height and weight are both between the 25-50th percentiles. Some primitive reflexes such as the asymmetric tonic neck reflex persist and he has increased muscle tone especially in his legs A.15 months old boy presents with seizures associated with fever. He has been in good 404 health except for a high fever that developed today to about 38.8 C. He has slight ‘cough and mild nasal congestion Just prior to the seizures he was playing with some toys. Past medical history is unremarkable. 104 Examination shows congested throat, mucosa, congested ear drums and normal neurological examination Investigations and treatment: Page 233 A.13 month old girl presents to the emergency department with a 2 day history of low grade fever runny nose and increasing fussiness. SHE ALSO DEVELOPED A PETECHIAL RASH AND VOMITING On examination, her temp is 39.6C, heart rate is 170/m. Respiratory rate is 50/m and blood pressure is 80/50. Her extremities are mottled and her capillary refill is 4 seconds While 4-4 trying to obtain an IV access, the infant becomes more lethargic and her blood pressure drops further Meninge A9 year old boy presents in a confused state. He developed a fever 2 day previously. And E4 had been complaining of headache, fever and photophobia. He had vomited ‘once. Previous history was unremarkable on examination, his temp was 38 C and he has mild neck stiffness and photophobia. Heart rate is 82 beats/m and respiratory rate is 16 breaths/m. there are no other focal signs of infection A 4 year old boy's parents complain that their child has difficulty walking. The child rolled, sat and first stood at normal ages and first walked at 13 months of age. Over the past several months however, the family has noticed an increase inward curvature of the lower spine as he walks and that his gait has become more waddling. On examination, the child is oriented and interactive with the physician with an average body built. Enlargement of his calves has been noticed -130- Scanned with CamScannerMohamed M. Ismail case scenario For the past 7 weeks, a 3 year old girl was increasingly reluctant to get up in the morning and feel stiff all over. As the day goes by, her stiffness improves unless she has been sitting for a while. On examination both knees and her right ankle are mildly swollen and feel warm to touch, but there is no overlying skin changes. There is pain and decreased range of movement. There is similar findings in the proximal interphalangeal joint of the left index finger 2 year old boy is referred with a history of fever cough, runny nose and sticky eyes for 6 days. On examination, his temp is 38.5 C. he is miserable and lethargic. He has a wide spread maculopapular erythematosus rash, which is coalescing over the face, neck and trunk. There is no respiratory distress but he is coughing, His nose is streaming with catarrh and he has exudative conjunctivitis. He had not received all his childhood immunizations due to parental concerns regarding vaccine safety ‘A9 months old boy is brought by his parents because of fever for 5 days He has been slightly irritable and feeling less than usual. His temperature measures at home has been up to 40 C He looks quite well but his temp remains raised and no focus can be found .He is admitted to the ward overnight for observation and his temp subsides On the morning ward round he is found to have an erythematosus macular rash on his trunk A7 year old boy presents with fever, sore throat and a fine maculopapular rash for 2 days. On examination, he has enlarged erythematosus tonsils with exudates, enlarged tender cervical lymph nodes and a strawberry tongue. A diffuse blanching rash with a rough texture to touch is noted ‘A4 year old boy is brought by his parents to the pediatric clinic with mild fever and a few small blisters on the shoulder and chest. The parents state that fever was noted for 1 day, and then the skin lesions appeared. These lesions began as tiny papules which progressed rapidly to vesicles. On examination, he has a widespread skin rash -131- Scanned with CamScannerMohamed M. Ismail case scenario at different stages, the rash is more concentrated on the trunk than the limbs. The parents report that that have been several other children with similar lesions at his school A 10 year old patient calls his parents from summer camp to state that he has had fever, muscular pain (especially in the back), headache and malaise. He describes the area from the back of his mandible towards the mastoid space as being full and tender and that his ear lobe on the affected side appears to be sticking upward ad outwards. Drinking sour liquids causes much pain. When his father calls your office, you remind him that he had refused immunization for his child due to concerns regarding vaccine safety Aterm female infant was born to 2 28 year old mother by CS after an obstructed labor. Apgar scores were 3 and 4 at 1 and 5 minutes, respectively. She required vigorous resuscitation at birth and was admitted to the NICU under observation. She developed generalized tonic clonic seizures 10 hours after delivery. On examination her tern was 36.8 C heart rate was 140/m and respiratory rate 60/m she is no respiratory distress but she is sleepy. Head shoes mild molding There is generalized hypotonia .Blood suger and calcium were normal ghalopathy A 23 year old lady in her first pregnancy is admitted to hospital at 29 weeks gestation because she has had spontaneous rupture of membranes. Forty eight hours later she goes into spontaneous labor and a baby boy is delivered weighing 900 gm Two hours after delivery. He develops marked subcostal and sternal recession with audible grunting -132- Scanned with CamScannerMohamed M. Ismail ‘case scenario A term 4200 gm female infant was delivered by CS because cephalopelvic disproportion. The amniotic fluid was clear, and the infant cried almost immediately after birth. Within the first 15 minutes of life, however the infant's respiratory rate increased to 70 breath/minute, and she began to have mild chest retractions and intermittent grunting respirations .The infant was transferred to neonatal unit. On admission, chest examination showed bilateral fair air entry A.4 day old full term infant is referred to the pediatric outpatient clinic by his GP because of jaundice .This is the first baby of a 22 year old mother .His mother states that the jaundice started within the first 24 hours of life, His birth weight was 3.7 kg on Examination the sclera are yellow and the jaundice is extending to the palm and soles There are no other signs ‘A Newborn infant delivered at 34 weeks gestation by vaginal delivery after 96 hours of ruptured membranes. His birth weight was 2 kg. A breast feed was attempted, but, was unable to suckle and swallow properly. At the age of 6 hours he developed frequent apneic episodes. On examination, the baby appears lethargic and hypotonic His temperature is 35.8 C A 2 year old girl had a running nose for 2 days, @ cough for 1 day and developed noisy breathing 3 hours ago. Her father had a cold the previous week. On examination, her temp is 38; there is a loudly noisy breathing, mainly on inspiration and a barking cough. Her respiratory rate is 40/m with suprasternal and substernal recessions. On auscultation, there are no cracks or wheeze. -133- Scanned with CamScanner