Constipation in boys : Most children who are constipated are normal .

Although it can signify a serious disorder eg Hirschprung dis, cystic fibrosis and hypothyroidism in some

Children with a history of resisting toilet training are particular risk The first step should be DIETARY MODIFICATION

If dietary modification fails >>> MILD LAXATIVE (MAGNESIUM HYDROXIDE )

In a child with mild constipation with no encoperisis >> MGOH is an excellent choice

Enemas and suppositories are reserved for severe constipation or fecal impaction.

Magnesium hydroxide: also known as milk of magnesia is a mild saline laxative that causes the osmotic retention if fluid in the gut lumen It can be titrated to produce soft but non liquid stools

Bisacodyl suppositories are reserved for short term rescue therapy but it causes abdominal cramping diorhea and nausea.Phosphate enemas can be used for bowel preparation prior to medical procedure but can cause electrolyte disturbances

Boy with UTI treated and then resolved next step : >>> VOIDING CYSTURETHROGRAMVOIDING CYSTURETHROGRAM: Done in following :

1. Children under the age of five years with a febrile UTI

2. Males of any age with 1st UTI

3. Females under age of 3 with 1st UTI

4. Children with recurrent UTI

5. Children with UTI not responding to Antobiotics

Child with S/S of allergic rhinitis aggrevated by dog >>>> next best step

Avoid DOG

Infant 10-11 month with irritable and lethargy diagnosed as anemia ?

>>> ??? Iron deficiency anemia due to sole diet as breast milk.Prevalent among children and women of child bearing age iron deficiency anemia is now the most common single nutrient deficiency

Breast milk provides iron enough for the first 6 months of life , after that age iron supplementation become necessary If iron intake remains inadequate iron deficiency anemia develops.

PUBERISM , AND DELAYED PUBERTY and CONSTITUTIONAL PUBERTY DELAY :

The earliest sign of puberism is nocturnal increase in the LH surge this is followed by daytime increase in the levels of gonadotropins and increase in testosterone levels

Enlargement of testes is one of the earliest signs of onset of puberty

DELAYED PUBERTY : is defined as the absence of any signs suggestive of puberty by 14 years of age .

CONSTITUTIONAL PUBERTY DELAY is delayed puberty , retarded bone growth and a positive family history without any evidence of systemic disorder

RX : These pt develop pubery without any intervention.

However if pt is worried of having problem at school , Treatment with with low testosterone ( testosterone enanthate injection 50 mg for a period of 3-6 months will lead to development of secondary sexual characteristics without compromising the final height.Child with delayed puberty , retarded bone growth and a positive family history without any evidence of systemic disorder >>>>> Constitutional puberty delay >> these pt develop puberty without any intervention.HIV +ve child with no symptoms starting school >>> no need to separate him from other , treat normally Child of acute otitis media treated with amoxicillin now he is symptomless , on Exam normal tympanic membrane with decrease mobility ( suggesting an effusion ) next best step >>> Observe

An effusion commonly persists upto 3 months after acute otitis media is resolved

If no symptoms >>> Observe and Wait

If symptoms are present , the effusion is bilateral or has persisted more than three months >> further therapy.TORCHE infections

Infant with non descended testes ?? when to operate and observe /Cryptorchidism : Observe till 6 months >>> then Surgery

(because cryptorchid testicles usually donot descend spontaneously after this age and spermatogonia degeneration begins in the undescended testicles at this age as well. )

Pneumonia in children :

Community acquired pneumonia (most likely cause S. Pnemonia) : amoxicillin T.O.C.

Mycoplasm/ Chlamydia : azithromycin or doxycycline

7-8 year old boy with sudden acceleration of growth and severe acne small testicles and enlarged penis coarse pubic and axillary hairs >>>> Precocious puberty ??? OR Pseudoprecocious puberty ??It is important to differntiate between them.

Precocious puberty :

Premature activation of hypothalamus pituitary gonad axis

Less dramatic than that of Pseudo

Sequential development testicular enlargement , penis enlargement pubic hair growth and lastly growth spurt

Pseudoprecocious puberty:

Is caused by gonadotropin independent process typically excess of steroids

The pt presents with sign and symptoms of androgen excess eg severe acne , significant growth acceleration

It can be caused by Late Onset congenital adrenal hyperplasia

Child with diorhea with NO Signs and symptoms of dehydration what to give

>>> Age appropriate food with less sugar and less fat ( excess sugar can increase the osmolarity and excess fat are known to delay gastric emptying both can worsen diorhea Level of Hb A in sickle cell disorders

Sickle cell BO thalesemic >>>> No Hb A

Sickle cell B+ thalesemic >>>> Type I --- 3-5 % Type II --- 8-14 %

Type III --- 25 %

Sickle cell Trait >>>> 60 %

Pt of TURNERS SYNDROME : must be screened

ECHO ( V.IMP) for detection of coarctation of the aorta , bicuspid aortic valve , MVP and hypoplastic heart.

VISUAL AND HEARING TEST :

RENAL U/S : >> horse shoe shaped kidney

TSH LEVELS : > autoimmune endocrinopathy ( primary hypothyroidism )

( Streak gonads should only be removed when turner is Mosaic >> increase chances of malignancy

Hormone replacement therapy should be started when 14 years of age is reached.See NF 1 diagnostic criteria 230

Note : if the pt of NF 1 is a child there ais a 15 % probability of development of optic nerve gliomas , Current recommendations include having a detailed Opthalmic examination for early detection of this problem and lisch nodule, IRIS haemartoma Child with features suggestive of bacterial pharyngitis

>>>> rapid strep +ve >>> Oral penicillin or amoxicillin

>>>> rapid strep ve >>> do throat culture

Child which was previously treated for some disease with antibiotics now have a rash in diaper area also including genitalia buttocks perineum and crural folds , tomatoe red plaques and satellite papules ???

CANDIDAL DIAPER INFECTION: tomatoe red plaques and satellite papules are characteristics of candidal intertrigo and perineal infection common in infants who received recent antibiotics so the normal flora is suppressed favoring yeast production RX : local antimycotics agents clotrimazole / nystatinDIFF from diaper dermatitis ( which effect the same area but spare crural folds ) Rx: Zinc Oxide or petrolatum ointment DIAPER DERMATITIS : (diaper rash)

Caused by combination of factors , overhydration friction maceration and prolonged contact with excretion

Can appear after diorhea

Management include frequent changing of diaper , avoid tight fitting diapers , exposing skin to air , using diapers with supper absorbant surface and applying barrier creams such as zinc oxide or petrolatum An uncomplicated diaper wash resolves quickly if above measured are performed otherwise low potency steroids should be used2 month old baby with cough rhinorhea and poor feeding , O/E rales over lung field but no wheeze xray show hyperflation peribronchial thickening and bilateral symmetrical interstitial infiltrates

Chlamydia pneumonia Chlamydia pneumonia :

Onset 2-19 weeks

Characterized by absence of fever , staccato cough , history of concurrent conjunctivitis Auscultatory and radiologic findings out of proportion to a Healthy child Transmission take place at BIRTH but takes 2-19 weeks to appear RX: Erythromycin

Childhood absence epilepsy > starring episodes disappears with age

NEURO SEIZURES CHILD :Lead poisoning; Mild : < 45 : no therapy proven to affect long time some dr give DMSA or oral d-penicilamine Moderate : ( between 45- 70 ) without symptoms of acute encephalopathy( headadche vomiting and seizures ) Give Chelation therapy: TWO regimens IV EDTA OR Oral DMSA ( derivative of dimercaprol )Severe : levels > 70 or acute encephalopathy : Medical emergency >> Dimercaprol IM + EDTA IVBat exposure : immediately give rabies prophylaxis: SEE the REAL MCQ and Add

Administration of Immunoglobulin and five doses of anti rabies vaccine.

If exposure is greater than 72 hour and treatment is not given REPORT

TB therapy

1. Specific antituberculous therapy should be initiated early in all pts with clinically suspected tuberculosis meningitis

2. Infants and childrens with TB meningitis , military TB and tuberculous Osteomyelitis should receive 12 months of ATT ( bone brain and military )3. In a pt with drug resistant therapy may be extended to 18-24 months 4. Tb pts are declared NON INFECTIOUS once if they are recieving ATT and had three consecutive ve results on sputum acid fast smears performed on different occasions .

2 year Child with delayed speech everything normal >>>> Do hearing test .Candidates for hearing evalution:

1. Children with a family history of hereditary childhood hearing loss

2. History of meningitis

3. History of recurrent of persistent otitis media with effusion for more than three months

4. Documented intrauterine infections

5. Craniofacial abnormalities

6. Ototoxic medication.

Indications for admitting Anorexic nervosa pt

1. Physiologic instability

2. Electrolyte abnormalities

3. Severe malnutrition ( under 75% of ideal wt )

4. Acute medical or psychiatric emergencies

5. Cardiac arrhythmias

6. Acute food refusal

7. Failure of opd treatment

Pt of anorexia nervosa started on feeding , after 2 -3 weeks comes back with symptoms of heart failure and edema next step ?

Start IV phosphate replacement

REFEEDING SYNDROME : Can develop during 2nd and 3rd week of nutritional therapy of pts with anorexia nervosa Due to severe hypophosphatemia Pt develops heart failure and edema which can progress to delirium and cardiac arrest. RX: IV Phosphate . Bereavement in children can present in different ways according to he childs age .

Those who are younger than 7 years tend to react with disbelief

Those younger than 5 have magical thoughts anout death and can feel guilt or responsibleThose older than 7 years accept death as a final and can experience depression anxiety or have regressive behavior

Cat bite to child is deep >>> give amoxicillin and clavulanic acid prophylaxis >> if allergic give Doxycycline

Oral candidiasis : the best initial theray is Topical antifungal ( eg nystatin suspension or clotrimazole troches)

Calcium requirement for

AGE 9-18 >.. 1300mg

AGE 19-50 >> 1000 mg

AGE 51 and older >>. 1200mg

Well appearing child with failure to thrive

Failure to thrive:

Term to describe failure to gain weight in children younger than two years . children categorized as FTT weighs less than 5th percentile more severe cases involve a slowing of linear growth and circumference as well The three causes of FTT are inadequate calorie intake , inadequate calorie absorption and increased calorie requirement

Infant need 110 kcal/jkg/day , child upto 12 months needs 100 kcal/kg/ day

Psychosocial factor are very important in FTT . clinician should explore

Organic causes of FTT while less common include feeding problems milk protein intolerance inborn errors of metabolism , infection, cystic fibrosis GERD or renal tubular acidosis.

DIETARY MODIFICATION is the best initial approach for other wise healthy child.

Varicella vaccination of house hold contact of transplant recipient is relatively safe and is currently recommended

Transmission of vaccine associated virus is not typical except for some cases when post vaccination rash appears therefore child should be monitored for the rash

Child with neonatal sepsis

Neonatal sepsis :

Suspected when an infant has a poor appetite decreased reactivity to external stimuli , diminished oral intake and lassitude or depressed sensorium

The most commonly agents are GBS , E coli , Klebsiela and Enterobacter species Althoufh listeria is rare in united states ampicillin is recmended

Cefotaxime , ceftriaxone or anti pseudomonal penicillin are used in combination

A good combination of neonate is Ampicillin and Ceftriaxone / Cefotaxine

Ceftriaxone should not be used if there is hyperbilirubinemia because it will increase both type of bilirubin

( note : Direct hyperbilirubinemia is probably induced by sepsis related cholestasis

Indirect hyperbilirubinemia suggest a physiologic jaundice ) Multi drug resistant TB is a rapidly emerging problem in developed countries .

Give chemoprophylaxis with rifampin in cases with resistance of INH onlyAnd chemoprophylaxis with PZA + Ethambutol incases with MDR TB

Exposure to smoking is an important risk factors for the development of acute otitis media , parents should be urged to quit smoking

Asthma and exercise :

Exercise induced bronchoconstriction is usually seen after strenous exercise / activities .

Bronchodilation initially occurs during exercise followed by bronchoconstriciton which begins after 3-5 minutes and rapidly peaks within 10-15 minutes of cessation of exercise

Extremely common in pt with asthma

Prophylactic treatment with inhaled B-2 agonist ( albuterol) approximately 5-10 minutes before initiation of exercise

Close contact should know how to recognize and treat acute attack

Donot stop pt exercising routine .

Lead intoxication : venous sampling always preferred than capillary sampling. When a diagnosis is a bit unclear the physician should say that it is due to medical condtion (not giving false statement)Adolescent with round back , On/Ex postural round back that is corrected by voluntary hyperextension + no lateral deformity and no angulation >>> Flexible kyphosis Flexible kyphosis:

Is a common finding in adolescent Typically noticed by others like parents or teachers who observe them in sitting or standing position On lateral radiograph angle of thoracic kyphosis is normal or slightly increased ( normal 20-40 degree )

There is no evidence that flexible kyphosis leads to adverse physical effects.

Scheuermann disease :

Unlike Flexible kyphosis, structural kyphosis is not corrected by voluntary efforts.

Sharp angulation is commonly seen on farward bending

The typical treatment for structural kyphosis that is not severe ( < 70-80 degrees ) is use of Milwaukee brace.

In more severe cases significant angulation, intractable pain neurological abnormalities >> SurgeryPt with inappropriate behavioral changes with strange movement of hand face and limbs and facial jerking , pronator sign +ve patellar reflex delayed , changes in volume and pitch of voice with a murmer of mitral regurgtaiton

SEE AND REVISE RHEUMATIC FEVER CRITERIA Sydenhams chorea : One of the manifestations of rheumatic fever It usually occurs in girls between 5-13 years of age and is chatacterized by jerking movement of the face hands and feet.

The pt has characteristic symptoms :hypotonic state positive pronator sign and sudden change in pitch and volume of her voice.

All pt must recieve penicillin prophylaxis as soon as possible. The therapy is to be given until adulthood.

If the motor function is severely compromised valproic acid Phenobarbital or haloperidol can be started and the pt must be referred to neurologist.

Pt with chroninc diorhea , iron deficiency anemia and eosinophilia coming from mexico >>>> Intestinal Parasitosis Intestinal Parasitosis :

Is a more frequent cause of chronic diorhea , iron deficiency anemia and eosinophilia

Prognosis is excellent with adequate therapy

Since the disease is easily transmitted prophylactic treatment should be given to the rest of household members

Capillary hemangioma: (strawberry )

Evident at birth

may undergo growth in for a period of several months (proliferation phase )

spontaneous regression usually follows ( involution phase )

70 Percent resolve by 7years

Observation is the best approach

If on orbital area or on the face ( functional impairment ) >>> laser treatment

If rapidly growing >> corticosteroids . A history of anaphylaxis or encephalopathy in association with receipt of the DTaP vaccine is the only true contra indication for receiving another dose of DTaP vaccine.

RASHES OF THE CHILD

Most common complication after acute otitis media is Another episode of acute otitis media

Acute otits media may lead to serious complication such as bacaterial meningitis , mastoiditis lateral sinus thrombosis epidural or brain abcesses or even cavernous or carotid artery thrombosis however the advent of antibiotics therapy has made these complications rare.

5-6 week old baby with c/o having constipation mother complains now adays once daily or tonce every two days what to do next ?

The normal frequency of stools in infants is around 6-8 times daily one stool per episode of breastfeeding . After the 4rth week there is decrease in the infants frequency of stool passage to once daily oe once per two days . This has to be differentiated from true constipation in order to avoid exaggregated concern like hirshprung disease Bacterial conjunctivitis is usually a self limiting diseasehowever it must be treated

>> because there is a small but real risk of keratitis which can leads to visual impairment >> Erythromycin ointment or sulfa drops are the first line antibiotics agents for the treatment of pts with bacterial conjuctivits

>> at least 24 hour after antibiotic pt can go t owork if necessary otherwise till discharge has cleared.

Most common complication of tick disease :

Although tick can transmit important infectious disease ( lyme , RMSF Ehrlichiosus ) the only complication in most of the cases is local inflammation or local infection ( if wound is produced ).

The transmission of lyme disease occur at least 36-48 hours after the tick has started suctioning the pts blood

If the tick is found and it has not engorged in blood there is no risk of lymes disease as tick take least 24 hr to firly attach to their victim

Child of ADHD on methyphenidate coming with c/o anorexia , nausea , vomiting tachycardia , increased bp , palpitation , dizziness headach nervousness euphoria agitation and aggressive or violent behavior

>>>methyl phenidate overdose Methylphenidate therapy :

Methyl phenidate therapy is associated with decreased weight and height.

Sadness and irritability can be seen in 22 % of children at theurapeutic doses.

Overdose present as anorexia , nausea , vomiting tachycardia , increased bp , palpitation , dizziness headach nervousness euphoria agitation and aggressive or violent behavior

Methyl phenicdate SHOULD NOT BE STOPPED ABRUBTLY because of high psychological dependence

SHOULD BE TAPERED DOWN.2 year child with bilateral breast enlargement and rest every thing normal physically and hormone levels normal

Benign premature thelarcheBENIGN PREMATURE THELARCHE:

Bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty RX : expectant because majority of pt remain stable or have reversal of breast enlargement in a few months. Pt with BPT have a normal hormone profile Their final height is generally not compromised