PEDIATRIC INTERSHIP BOOK

PEDIATRIC INTERSHIP BOOK

Contents of pediatric book

SOAP---------------------------------------------------------------------- 2----5
Drug calculation formula: ------------------------------ 5----8
History taking---------------------------------------------- 8----11

Part 21------------------------------------------------------ 11----29

1: Malaria
2: Pneumonia
3: Anemia
4: Tonsillitis
5: ICU.

Part 2.2 ------------------------------------------------------ 29---51

1: Tetanus
2: Burns
3: DKA
4: Nephrotic syndrome.
5: Nephritic syndrome.
6: Hemophilia

Part 2.3 ---------------------------------------------------- 51----87

1: Measles.
2: TB
3: Whooping cough.
4: Meningitis.
5: Chicken box.

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Part 2.4 -----------------------------------------------------87---103

1: Malnutrition {SAM & MAM}, { MARASMUS, Kuwashkor}

Part 2.5-------------------------------------------------------103---112
1: Dehydration
2: Acute water diarrhea: {AWD}

OPD: --------------------------------------------------------- 112---118

1: IMMUNIZATION

2: Growth parameters

3: Growth Charts
4: Stages of Development.
5: Screen.

IMCI --------------------------------------------------------- 118--- 123

CASE PRESENTATION.------------------------------------------- 123----- 145

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SOAP
S: Subject

O: Objective

A: Assessment

P: Plan

Subjective Note
 Family complain Diarrhea for 2 days more than 5 times per day , watery
 Night events with medical diarrhea large amount association abdominal cramping.
 Health comments
Vomiting 2 days non-projectile vomiting colour what
Objectives type of food eat, aggravated by due to feeding.

 Vital signs Fever for 2 days low grade fever intermittent relieve
 Physical Examination by paracetamol syrup.
 Investigations / daily weight monitor
O/E : Conscious , alert , sing of dehydration , sunken
eye , dry mouth , skin goes back rapidly.

Assessment Diagnosis: Some dehydration

o Introduction
o Status ( stable / unstable/ improve / non-improve, sub-improved)

Plan
Plan depend on status

1- New treatment

2- New diagnosis

3- Patient Education

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Admission criteria

1- Danger signs Total admission

2- Emergency signs

3- Priority signs

Totally admission 24 hour admission then discharge

Danger signs
1- unable to food /drink

2- Vomiting of everything

3- Convulsion

4- Lethargic / unconsciousness .

Emergency signs
3C

 Convulsion
 Coma
 Cynosis

3S
o Severe dehydration
o severe respiratory distress
o signs of shock e.g. Cold hand , weak pulse and refile ˂3s
O
Obstructive breathing or airway
Priority sign
3P
 Pallor
 Pain
 Poisoning

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3R
 Restless
 Respiratory distress
 Referral

MOB

o Malnutrition
o Oedema
o Burn

Daily monitor signs in inpatient

 Improvement
 Complications
 Failure of treatment

Hour or Minute
Solution: Drop/ minute = Amount × drop factor

Example: 500ml × 15 ml = 3 drop / minute

240 min

 Drop factor of colloid : 15 - 20 ml

 Drop factor of blood : 10- 15 ml
 Drop factor of Dexymitta : 60 ml

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Fluids

1- Nutrient solution - D5%

2- Electrolyte solution - Ringer solution /Normal saline solution

3- Volume Expanders - Colloids and Dextran, plasma and albumin.

Nutrients

 D5% , D10% and D50% - To prevent dehydration and ketone.

It is Monosaccharide it loss of body protein and nitrogen it uptake of K+ into cell s causes
Hypokalemia.

Electrolyte ( Crystalloid)

 Normal saline , Ringer and Mixed Colloid )

 Dextral : Volume Expanders it reduces blood viscosity and inhibition aggregating of
RBC.
Maintenance fluid are fluid composed water ,glucose ,sodium and K+ - mixed or ringer.
Goals of Maintenance fluid
 Prevent dehydration
 Prevent electrolytes disorder
 Prevent Ketoacidosis
 Protein degration

Drug calculations

Syrup + injection: Kg × required dose × ml

Dose of Hand

Tablet : Required dose × kg

Dose of Hand

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Choice of I.V fluid

 Resuscitation Normal saline / Ringer solution

 Maintenance Mixed solution ( NS/D5) or ringer with D5%.

Drug calculation formula:

( ) ( )
Results:=
( )

No Drug Name Hand Dose Required Dose Diluted Frequency

1 Ampicilin 250mg/500mg(5ml)/1000mg(10ml) 100-300mg/kg Three times
7 days
2 Gentamycin 80mg/2ml/40mg/20mg 5-8mg or 4-7mg/kg 6ml One times
saline 5 days
3 Ceftriaxone 250mg/500mg(5ml)/1000mg(10ml) 80-100mg/kg
4 Artisunate 1Box( 60mg pow, 5ml sal and 1ml <20Kg= 3mg > 20kg 2.4mg 0 hr -12hr-
24hr if not
respond
cont once 24
hr. start fr
zero hr
5 Co-artem( 20mg /120mg 1- 5-15 Kg-> 6 tab= 3days 1-0hr( 1)-
artemether 2- 15-25->12 tab = 3days >8hr(1)first
+lumefantine) 3- 25-35kg-> 18 tab= 3day day->12(1)-
>12(1) next
2days. other
same but no
drug
changed
6 Quinine 600mg/2ml Loading dose: 20mg/kg
Maintenance dose:
10ml/kg
7 Diazepam Rec: 2.5/10/20mg IV/IM: 5mg/ml IV: 0.3MG/kg Rec: 0.4-0.5 Div result 3
8 Phenobarbital 80mg iv or tab 30mg Iv or tab 1-2 mg/kg
9 Amox Syr 125mg/5ml 250mg/5ml 50ml/kg
10 Pracetamol 120mg/5ml 10mg/kg
11- Ibuprofen 125mg 10mg/kg
12- Penicillin G 5meg/3meg( 1mg:1000000mg/kg) 100000-300000mg/kg 4 times
13- Dexamethson 4mg/ml 0.6-0.8mg/kg

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14- Ferro-folic 60mg 4-6mg 3 times

15- Amox tab 125mg/5ml 50mg/kg
16- Lasix inj 20mg/2 0.5mg/kg
17- Metra syr 200mg/5ml Syr/tab 20-30mg/kg
18- Chloraph syr 1-2yr: 2-3ml 3-4yr: 4ml 7yr: 7-20ml
19- Cefazolin inj 500mg 50mg-100mg
20- Erythromycin 200mg/5ml 50mg/ml
21 Co-trimoxazole 250/5ml RD = 40mg /kg
syrup
22 Arthemeter 40- 80 mg loading dose = 3.2mg/kg
injection
Maintenance = 1.6mg/kg
23 Albendazole 200mg -400mg RD = 1-2 year = 200mg
single dose ˃ 2 year =
400mg
24 Zinc tablet ˂ 6 month = half tablet
(10mg ) × 14 day
˃ 6 month = 1 tablet
(20mg ) ×14 day
25 Vitamin A ˂ 6 month = 50,0000 ug
˃ 6 month = 100,000 ug
˃ 1 year = 200,000 ug

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History taking/pediatric
Should Ask
 Informed consent
 Growth and development
 Immunization history
 Birth History
1) Personal Data
Name , Age and address for last 6 months.

2) Chief complain - on mommy own words

3) History of present illness
4) Past medical History
o History of chronic disease
o Hospitalization
o Drug allergy
o Blood transfusion
5) Immunization History
 Complete
 Incomplete
 Up to date
6) Drug History - present taking drugs and past taking drugs
7) Birth History
Antenatal :
 Vaccination
 blood sugar
 Blood pressure of the mother
 Conditions of the mother
 HIV
Natal:
o Location of birth

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o way of deliver
o presentation of the child
o TIN
Postnatal
 Cry
 Colour
 Apgar Score
8) Feeding History
 Type of feeding
 Frequency
 Time of feeding - at least 10 month
9) Growth and development
 Growth History
 Measure weight /Height / Head circumference/ Chest circumference
 Developmental
o Speech
o Motor ( Gross , fine)
o Social
Family History
 Name of the mother
 Age
 Any sibling - yes - ask number
 Consequenty
Social
o Housing
o Numbering of housing
o water sources

Physical Examinations
1- General Appearance
 Conscious

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 Colour of the skin

 Oedema
 Lumphnates
2- HENT
o Hair
o Fontanels /sutures
o Eyes - sunken or puffy
o Nose- discharge
o Mouth- crown, ulcer
o Tonsil - oedema , pus
o Neck - lymphnode
3- CHEST
 Inspection - indrawing, deformity
 Palpitation - mass
 percussion- dullness/tumpan
 Ausculatation - wheeze, crepitation and Rhonhi

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Part 21
Topics
1: Malaria
2: Pneumonia
3: Anemia
4: ICU.

Malaria
Complain

I. Fever - high grade ˃ 37.5

II. Vomiting Uncomplicated malaria
III. diarrhea
IV. Chills
Complication malaria
Signs of Uncomplicated malaria plus
 Unable to feed
 Convulsion
 Vomiting due to weigh loss
 lethargic
 Hypoglycemia
 Respiratory distress
 Anemia
 Malnutrition

Malaria Treatment
( uncomplicated)
1st line
Co- artem ( 20mg arthemeter , 120 lumfatrine ) - 1st day 1 stat then 8 hour.
 ˂ 5 kg donot give 1×2 ×3
 5-14 kg : 6 tablet -- 1 stat then 8 hr then 1×2

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 15-24 kg : 12 tablet
 25-34 : 18 tablet -- First 3 tablet stat then 8 hr- give 3 tablet then 3×3
 ˃ 35 kg : 24 tablet --4 stat tablet stat then 8 hr - 4×4.
Complicated malaria
 1st line : Artesunate
 2nd line : Quinine 600mginjection
 3rd line : Arthemeter injection 40, 80mg
Arthemeter
Loading dose 3.2
5 day
Maintenance 1.6
Quinine 600mg /2ml
Loading dose 20mg × kg× 2ml
7 day
Maintenance 10mg × kg× 2ml
Plus Dextrose 10ml /kg
Example : 20 × 10 ×2ml = 0.66
60

Malaria
Malaria is protozoal disease caused by genus of plasmodium including:-
 Plasmodium falciparum
 Plasmodium malaria
 Plasmodium Vivax
 Plasmodium Ovale
 Plasmodium Knowles

Life cycle
o Asexual phase or Erytrocytic phase (Schizogony) in human
o Sexual phase (Sporogony ) in mosquito
Incubation period 6 30 days
Transmission by female anopheles mosquito
Plasmodium vivax and ovale are dominant liver hypnozoite which are not killed most drugs
and mostly relapse.

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Plasmodium malaria and falciparum mostly not damage hepatocyte or liver infect so they
have not (hepatocyte phase ) mostly they are in erytrocytic.
Long term relapse:- Mostly Plasmodium vivax and ovale whch are resistance in liver and
Plasmodium malaria persistance in RBC.
Plasmodium falciparum mostly identity from blood.
The most characteristic feature of malaria and differentiate other infections
Malaria febrile paroxyms
paroxyms occurs in rupture of RBC of every 48 hours in [Link] and ovale (tertian periodic) and
every 72 hours of [Link] (quartan periodian)
Clinical features of malaria
Classical symptoms
Fever, rigors, sweat, headache ) plus anemia and splenomegaly
Stages
A): Cold stage
decrease headache, nausea ,chilly followed by rigors ( 1 hour and 15 minute)
B): Hot stage
Patient feels burning hot skin , hot touch, headache in the pulse increase ( 2-6 hours)
C): Sweating stage
Fever comes down with profuse sweating , pulse slowers patient feels relieved (2-4 hours)

Investigations
 Thin and thick smear
 CBC

Differential diagnosis
Tuberculosis , Typhoid ,
Brucellosis , meningitis,
tetanus , relapsing kalazar,
liver abscess and toxoplasmosis.

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Pneumonia
Complain
 High grade fever
 Cough
 Fast breath
 Crepitation
 indrawing and flaring - severe
Respiratory rate
 ˂ 2 month : 60 breath/minute
 2-12 month : ˃ 50 b/minute
 1-5 year: ˃ 40 breath/minute
Treatment
1. Ampicilline
2. Gentamicine
3. SAlbutamol - if respiratory distress
 Ventoline 2.5mg
 Ventoline 1.5mg + 2.5 ml of N.S = 4ml
If not responding to Ampicilline and Gentamicine
4. Ceftraixone
Not responding its atypical pneumonia
5. Erytromycine/ Azithromycin

Pneumonia
Pneumonia is inflammation of parenchymal of the lungs.
Causes of Pneumonia
Bacteria
 Streptococcus pneumonia all age
 Chylamdia infants
 Mycoplasma ˃ 5 years
 haemophilus influenza and stphylococcus aures non vaccine

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Clinical feature
 Fever
 Tchypnea
 Respiratory distress ( intercostal and Subcostal retraction)
 Nasal flaring
 Indrawing
 Cyanosis
 Crackle
 Wheeze or crepitation
 Bronchial breathing
Types of pneumonia
A}: No pneumonia
Fever and Cough
B}: Pneumonia
Increase fever, Cough , Fast breathing , crackle /crepitation and ˃ 50 breath /min
C}: Severe pneumonia
Pnemonia + chest indrawing , nasal flaring , grunding O 2 saturation ˂90 mmhg
D}: Very pneumonia
Severe pneumonia + Cyanosis , inability to drink or breast feeding and O 2 saturation ˂80mmhg

Differentiate Viral and Bacterial pneumonia

Viral Bacteria
V.S  High grade fever
 Low grade fever
 WBC 15,000-40,000
 Pleural
WBCeffusion
˂ 20,000
 ↑ ESR / CRP
 Pneumothora
↓ ESR / CRP
X-ray X-ray
 Peri hilar changes  Bilateral lobar pneumonia
Complication of thicky
Peri bronchial pneumonia  Lung abscess
 Empyema

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
 Pleural effusion
 Pneumonia
 Sepsis
Investigation
 CBC
 Malaria
 blood culture
 CXR
Management
Very severe pneumonia and Severe pneumonia
 O2 neoplazer / salbutamol
 Hospitalization
 O2 neoplazer / salbutamol
 Ventoline 2.5mg
 Ventoline 1.5mg + 2.5 ml of N.S = 4ml
 Correct shock, hypoglycemia /dehydration
 Fluid maintenance
 Ampicilline 500mg - 100mg/kg
 Gentamicine 40mg = 5mg/kg or cefotaxime
No pneumonia
Home treatment
Amoxicillin 50mg/kg /12
Augmentine 125mg
90 mg ×kg × 7 days
 If pneumonia is staphylococcus use cloxacillin 100mg/kg
 If pneumonia is mycoplasma use erytromycin
 if pneumonia is viral use acyclovir.

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Differential Diagnostic of pneumonia

 Bronchitis
 Asthma
 Pulmonary edema caused by Heart failure

Anaemia
Anemia is reduction of hemoglobin blood or RBC count below average value for age and
sex.
Hp: is oxygen carrier capacity.
Causes of anemia :
1- Decreased production
A. Bone marrow failure
 Pure red cell anemia
 Aplastic anemia
 Marrow infiltrate = leukemia mydofi
B. Decreased production and normal RBC
 Anemia of chronic disease
 Chronic inflammation
 Chronic infection
 chronic renal failure

C. Specific factor deficiency
o Iron deficiency
o B12 ad folic acid
o protein deficiency

2- Increased destruction ( Hemolysis)

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A- Intracorpuscular

Membrane defect Hemeglobinopathy

Enzyme defect

 [Link]  α thalasemia  G6 PD deficiency

 [Link]  β thalasemia  Pyruvate kinese defect
 Paroxymal nocturia  Extra corpuscular
sickle cell disease
 Hemoglobinemia

Immologic Non-immologic

Combs - ve
Iso immologic Auto immonologic
Combs + ve

Microangiopanic H.A

DIC, HUS
Iso immune Auto immune
renal vein thrombosis

Passively acquired antobody Actively forming antibody

 Sepsis
 Malaria
 Wilson disease
 Drugs
3- Hemorrhagic anemia  Hypersplenism
 Acute Hemorrhagic
 Chronic Hemorrhagic
Classification of anemia

MCV ˂ 80 MCV 80-100 MCV ˃ 100

Microcytic hypochromatic anemia Normocytic anemia Macrocytic hypochromatic anemia

Microcytic hypochromatic anemia

 B12 deficiency
 Iron deficiency  Hemoly tic anemia  Folate
 Thalasemia  anemia of chronic due renal failure deficiency
 lead poison
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Clinical feature of anemia

Symptom
 Anorexia weigh loss
 Easy fatiguability
 Headache
 Tinnitus
 Sweating
 Fainting
Signs of anemia
 Pallor
 Tachycardia (Hemic murmur)
 Systolic follow murmur
 Heart failure
 Kolilonchia ( spooning)
 Angular stomatitis Iron deficiency anemia
 Glased Shing tender tongue
 Brittle nails

 jaundice
Hemolytic anemia
 Splenomegaly
 Leg ulcer Sickle cell anemia

 Neurological manifestation B12 deficiency

 Purpuric eruption and throat ulcer A plastic anemia

Types of anemia in Clinical

A. Mild anemia 10-12g/dl
B. Moderate anemia 9-10g/dl
C. Severe anemia ˂7g/dl

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Investigation
 CBC
Low MCV , Low MCH and Normal RDW
Management of anemia
Treat underlying cause
Ferrofollic 60mg
For 3 month
RD : 4-6 mg
If Ferro B- complex syrup
Child ˂ 1 year : 3-4 ml × 2
Child ˃ 1 year : 5-7 ml × 2
 ˂7 Hp with normal appetite and not malnutrition Ferrofollic phase 1
 ˂7 Hp with normal appetite and malnutrition Ferrofollic phase 2
 ˂7 Hp with stress and lethargic and not malnutrition Blood transfusion
15 ml - 20ml × kg for 4 hours then
furesemide 1-2 mg × kg
 If he has malnutrition or CHF
Blood transfusion
10ml ×kg / 4 hours + furesemide
 ˂ 4 HP in malnutrition = Blood transfusion
 ˃ 4 HP in malnutrition = Nutritional assessment
Furesemide 20mg 0.1× kg 30 minute before and after

Tonsillitis
Tonsillitis is inflammation of the tonsils, typically of rapid onset.

It is a type of pharyngitis.

Symptoms may include sore throat, fever, enlargement of the tonsils, trouble
swallowing, and large lymph nodes around the neck.

Complications include peritonsillar abscess.

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If viral: increased oral fluid intake for mycolysis

presecribe paracetamol or Ibuprofen if fever.
If bacterial especially streptococcus gropu A infection
Antibiotics
Penicillin V tablet 250 mg orally
< 1 year: 62.5 mg x4 {1/4 tab x 4 doses}
1--5 years 125 mg x4 {1/2 tab x 4 doses}
6---12 years: 250 mg x 4 {1 tab x 4 doses}
> 12 years: 500 mg x 4 {2 tab x 4 doses}
If vomiting:
Penicillin G Inj: 5 mega= 500, 00 IU/ml, 200.00 IU/kg in doses IV {0.1 ml/kg x 4
dose}
give orally {Penicillin V} as soon as possible for 10 days.

Laryngitis.
Laryngitis is an inflammation of your voice box (larynx) from overuse, irritation
or infection.
Inside the larynx are your vocal cords — two folds of mucous membrane covering
muscle and cartilage

mostly viral infection. also as complication.

increased oral fluid intake for mycolysis.
prescribe paracetamol or iburofen if fever..
Dexamethason Inj: {4 mg/1 ml 0.8 mg/kg in 3 doses IV {0.06 ml/kg x 3 doses}
Try adrenaline inhalation {1 ml adrenaline + 2 ml normale saline} via nebulizer
{stored on ICU}

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Gastritis
 If the child has only vomiting is Gastritis
 If the child has vomiting + diarrhea is Gastroenteritis
Investigation
CBC , Malaria, , Smear and Stool Examination
Treatment
I. ORS
II. Zinc
III. Albendazole
IV. Penicilline G + Gentamicine
V. Ranitadine 50mg/2ml
RD: 1.2mg/kg Add mixed solution 20-30mg/kg
Dextrose 10% , RD: 2.5mg/kg bolus

ICU
 Comma
 DKA
 Shock
 Asphyxia
 Premature
 Severe pneumonia
IMCI ˂ 2 months
1. Clump cord
2. Suction
3. Hambag ( ambu bag) 40/minute
4. Cardiac compression and adrenaline use ˂ 100 b/minute

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5. Tetracycline eye ointment

6. Vitamin K
If Pregnancy women taking T.B treatment in ˃ than 2 month of gestational age treat give
Neonatal INH in 6 month.
If pregnant taking T.B treatment in ˂ 2 months of gestational age neonatal full treatment of b in 6
months.
If pregnant women has HIV in delivery Neonate give Rifampicin the take PCR.
Management of Neonatal jaundice
Admission
Ǫ therapy
IV canula
If hypoglycemia give 10% dextrose
3ml × kg / 1hour
NGT tube for feeding
o Jaundice ˂ 24 hour age is pathological jaundice
o Jaundice ˃ 24 hour age is physiological jaundice encourage breast feeding.

Neonatal Asphyxia ( Perinatal asphyxia)

Neonatal Asphyxia is the medical condition resulting from deprivation of oxygen to a newborn
infant that causes physical harm , mainly to the brain or lack of breathing at one minute of life.
Pathophysiology
When fetal asphyxia happens , the body will show a self -defended mechanism which
redistribute blood flow to different organs called '' Inter-organs shunt '' in order to prevent some
important organs including brain , heart and adrenal from hypoxic damage.
Pathology
Lack of adequate breathing lack of oxygen supply to heart inability of heart to pump
adequate blood hypoxia + ischemic to organs ( particularly brain).

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ETIOLOGY
I- Intrapartum or antepartum ( 90%)
1. Maternal factors
1. Obstetric factor
 Diabetic mellitus
 Placenta previa
 Toxemia
 Cord prolapse
 Hypertension
 Pacental insufficiency
 Cardiac disease
 Polyhidramnion
 Infections
 Chorioamnitis.
 Iso immunication
 Drug addiction
II- Inpartum conditions
III- Fetal or neonatal conditions
 Abnormal presentation
 Prolonged delivery  Prematurity
 Respiratory distress syndrome
 Difficult delivery
 meconium aspiration syndrome
 Post term delivery  Sepsis, pneumonia
 Forceps or vacum delivery  cardiac or pulmonary anomalies.
Clinical feature
 Respiratory depression at birth
• Lack of crying
• bluish or gray skin color
 Poor heart rate
 Poor muscle tone
 Acidosis ( PH ˂ 7)
 seizure
Investigation
Apgar score 0 -10
 The doctor may suspect your baby has asphyxia neonatorum if they have an apgar score
of 3 or lower for more than minutes.

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Initial Management
 Admit in newborn unit ( Intensive care unit / ICU)
 Oxygen/ ventilation
 Maintenance of temperature
 Check vital signs
 Check hematocrit , sugar , ABG , electrolyte
 I.V line
Complication
 Hypoxia - encephalopathy
 Cerebral palsy: affects a child body movement , muscle control , muscle coordination,
muscle tone, reflex and posture and balance.
 Perventricucular leukomalacia : involves the death, or necrosis , to the white matter of
the brain.
 Developmental delay : cause delays in child's motor, physical , speech and mental
development.
 Mental retardation
 seizure disorders
 paralysis

Abscess Overview
A skin abscess is a tender mass generally surrounded by a colored area from pink to
deep red. Abscesses are often easy to feel by touching. The vast majority of them are
caused by infections. Inside, they are full of pus, bacteria and debris.

Painful and warm to touch, abscesses can show up any place on your body.

The most common sites on the skin in your armpits (axillae), areas around
your anusand vagina (Bartholin gland abscess), the base of your spine (pilonidal
abscess), around atooth (dental abscess), and in your groin. Inflammation around

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a hair follicle can also lead to the formation of an abscess, which is called
a boil (furuncle).

Abscess Causes

When our normal skin barrier is broken, even from minor trauma, or small tears,
or inflammation, bacteria can enter the skin.

An abscess can form as your body's defenses try to kill these germs with your
inflammatory response (white blood cells = pus).

Obstruction in a sweat or oil (sabaceous) gland, or a hair follicle or a pre-existing cyst

can also trigger an abscess.

The middle of the abscess liquefies and contains dead cells, bacteria, and other debris.
This area begins to grow, creating tension under the skin and further inflammation of
the surrounding tissues.

Pressure and inflammation cause the pain.

People with weakened immune systems get certain abscesses more often.

Those with any of the following are all at risk for having more severe abscesses.

This is because the body has a decreased ability to ward off infections.

 Chronic steroid therapy

 Chemotherapy
 Diabetes
 Cancer
 AIDS
 Sickle cell disease
 Peripheral vascular disorders
 Crohn's disease
 Ulcerative colitis

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 Severe burns
 Severe trauma
 Alcoholism or IV drug abuse

Other risk factors for abscess include exposure to dirty environments, exposure to
persons with certain types of skin infections, poor hygiene, and poor circulation.

Abscess Symptoms

Most often, an abscess becomes a painful, compressible mass that is red, warm to
touch, and tender.

 As some abscesses progress, they may "point" and come to a head so you can
see the material inside and then spontaneously open (rupture).
 Most will continue to get worse without care. The infection can spread to the
tissues under the skin and even into the bloodstream.
 If the infection spreads into deeper tissue, you may develop a fever and begin
to feel ill.

Abscess Treatment: Self-Care at Home

 If the abscess is small (less than 1 cm or less than a half-inch across), applying
warm compresses to the area for about 30 minutes 4 times daily may help.
 Do not attempt to drain the abscess by squeezing or pressing on it. This can
push the infected material into the deeper tissues.
 Do not stick a needle or other sharp instrument into the abscess center, because
you may injure an underlying blood vessel or cause the infection to spread.

Medical Treatment

The doctor may open and drain the abscess.

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 The area around the abscess will be numbed with medication. It is often
difficult to completely numb the area, but local anesthesia can make the
procedure almost painless.

 The area will be covered with an antiseptic solution and sterile towels placed
around it.
 The doctor will cut open the abscess and totally drain it of pus and debris.
 Once the sore has drained, the doctor may insert some packing into the
remaining cavity to allow the infection to continue to drain. It may be kept
open for a day or two.
o A bandage will then be placed over the packing, and you will be given

instructions about home care.

o Most people feel better immediately after the abscess is drained.

o If you are still experiencing pain, the doctor may prescribe pain pills for

home use over the next 1-2 days.

o You are usually sent home with oral antibiotics.

Prevention

Maintain good personal hygiene by washing your skin with soap and water regularly.

 Take care to avoid nicking yourself when shaving your underarms or pubic
area.
 Seek immediate medical attention for any puncture wounds, especially if:
o You think there may be some debris in the wound.

o The puncture wound was caused by a bite - human, insect or animal.

o You have one of the listed medical conditions.

o You are on steroids or chemotherapy.

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Part 2.2
Topics
1: Tetanus
2: Burns
3: DKA
4: Nephrotic syndrome.
5: Nephritic syndrome.
6: Hemophilia

Tetanus
Toxic infection of the nervous system caused by clostridium tetanus .
Pathophysiology
Wound Clostridium tetanus - spores germinate Proliferation locally
Produce 2 toxin ( tetanospasmin and tetanolys Travel along nerve trunk ( motor nerve
ending and motor nerve cell) then to blood stream.
The involvement of anterior horn cells results in rigidity and convulsion.
Incubation period : 6-10 days
Clinical feature of tetanus
1. Mild tetanus
Pain and stiffness of the site of injury for few week occur in patient who received anti toxin,
mortality ˂ 1%.
2. General tetanus
o Spasm occur in descending form with intact conscious.
o Spasm participated by visual or auditory stimuli.
Special signs
 Risus sardonicus
Grimacing face due to facial muscle spasm.
 Trismus
 Difficult of mouth opening due to masseter spasm.
 largeal spasm

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Stridor and may be suffocation.

 OPsthotonus
Arched back
 Tonic seizure
Fixed adducted arms and extended lower limb with colonic.

3. Cephalic tetanus
Followed by ead injury or otitis media, short incubation period with high mortality , involved
cranial nerve palsy may be generalized.
4. Tetanus neonatorum
Due to contaminated umblical stump.
Diagnoses
 History of wound and Atypical species
 Normal CSF
 Wound culture
Investigation
o No specific lab test for tetanus.
Differential diagnostic
 Meningitis
 Rabies : Dysphagia associated with spasm s of inspiratory and pharyngeal muscles, but
there is no trismus.
 Poisoning e.g. dystonic reaction drugs such as Phenothiazine and metocloropramide - other
cause muscle spasm.
 Hysterical : Trismus without generalized rigidity.
Management
 ICU
 Oxygen
 Diazepam
 Tetanus immunoglobim I.M 500 -2000 iu single
 Metonidazole 40mg

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 Dressing or wound care

 N.G tube

Prevention
Tetanus toxoid vaccine I.M 0.5ml

Complication of tetanus
Respiratory
 Largeal spasm suffocation
 Aspiration pneumonia ( Broncho- pneumonia )
 Pneumothorax
 Lung collapse
Mechanical
 In severe seizure
 Tongue laceration
 Vertebral fracture
 Muscle hematoma

Burn
Burn is damage to your body's tissue ad caused by thermal ,chemicals , electrical, sunlight,
radiation.
Clinical manifestation
 First degree:- Red , painful, dry non-blister , non-scar is epidermis and superficial.
 Second degree:- Painful, blister , non-scar is partial thickness.
 Third degree:- Painless , non-blister , scar is full thickness and require skin graft if ˃
1cm diameter.
 Fourth degree: In fascia , muscle and bone
Admission criteria
 ˃ 10% of BSA
 Special areas :- Face , hands , buttock ,groin, feet , neck and perineum.

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Investigation
o CBC
o Electrolytes
o Blood sugar

Management
If BSA ˃ 10% or special areas
 First aid
 ABC
 Fluid management
 Dressing and sulfadiazine
 Surgery
 Physiotherapy
 Rehabilitation
 Antibiotic

If BSA ˂10% or Non- special areas

 Rehydration
 Oral antibiotic
 Sulfadiazine or silver nitrate
 Tetanus toxoid
Fluid management
Using rule of nine
 Head /neck = 18%
 Front = 18%
 back = 18%
 hand = 9%
 hand = 9%
 leg = 14%
 leg = 14%

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Rule of palms
Every palms 1%
Fluid management
Bolus
20ml × kg of Ringer
Replacement of deficit
4 ml × kg × BSA/24 of Ringer
give first 8 hour
Second 16 hour
Maintenance ( Mixed)
 First 10 kg = 100 kg /day
 Second 10kg = 50 kg /day
 Apose = 20 × kg
or
Rule 4cc, 2cc and 1cc
o 4cc for first 10kg
o 2cc for second 10 kg
o 1cc for apose
Antibiotics
Penicillin G 100,000 ×kg
Gentamicin 40mg 5mg ×kg
Others
 Tetanus
 Blood transfusion
 Plasma albumin
Tetanus toxoid = vaccination as booster
Tetanus immune = Non-vaccine

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DKA
DKA is metabolic disorder due to acute insulin deficiency and common in type 1 DM.

Causes
 Infection
 Trauma
 Psychic
Mechanism of insulin action

↑ lipogenesis
↓ Blood glucose
Suppresses glucose release by the liver inform of glycogen and
glycogelys through and lipido fat by glucogenesis
regulates uptake of glucose by the
cell

Mechanisms of DKA

Lack of insulin
↑ lipolysis

↑ Blood glucose
decreased glucose in the cell ( starvation)

Increase glucose in blood

compensatory mechanism
Hyperglycemia

glycogenolysis
renal threshold ˃ 180

insufficient lipolysis
osmotic diuretic

Release FFA
polyuria

Converted into ketone bodies by the liverPage 35

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dehydration

compensatory mechanism

Thirst and polydipsia

Acetone
Aceto acitic
acid B-hydroxy butyric acid
Lungs

Kidney
Metabolic acidosis Acetone odor

 Pain
Ketonuria  vomiting
 Kussamal breathing

Compensatory mechanisms or puffering system

 Polyuria : from hyperglycemia - kidney compensate mechanism
 Vomiting : from metabolic acidosis - GI compensate mechanism
 Kussmaul's respiration: from metabolic acidosis to excreate more CO2 - Respiratory
compensate mechanism.
 Ketonuria : from ketonemia or acids in the blood - kidney compensate mechanism
 Thirst and polydipsia :from dehydration of polyuria
 Abdominal pain : due to hypokalemia and distension.
Clinical feature of DKA
Clinical History ( symptoms)
 Polyuria
 Polydipsia Classical signs
 Polyphagia
 weight loss
 Abdominal pain
 Vomiting

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Clinical signs
 Dehydration
 Deep sighing respiration (Kussmaul's respiration:)
 Lethargy / drowsiness + Vomiting
Biochemical signs
o Ketone in urine
o Blood glucose ˃ 300 or 11 mmol
o Acidemia PH ˂7.1
Investigation
 Blood glucose
 Electrolyte / Urea ( K+ and Na+ )
 Serum ketone
 Blood glucose
 CBC and blood culture
 ECG
 PH , HCO2 PACO2 ( blood gas)

Diagnoses

Keto Acidosis
Diabetic

 Blood glucose ˃300g/dl  Ketonemia  Metabolic acidosis

 Glucosuria  Serum ketone ˃ 3 mmol  PH ˂ 7.3
 Ketonuria  HCO3 ˂ 15
 ↓ Paco2

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Differential diagnoses of DKA

I. All causes of Acute abdominal pain
II. All causes of metabolic acidosis
 Renal failure
 Organic acidemia
 Lactic acidosis with sepsis
 Acute diarrhoea
 Real tubular acidosis
III. All causes of coma in DM patient
IV. Hyperosmolar ketone
 Blood glucose ˃ 800
 Serum osmolarity ˃350
 No or slight ketone
 Acidose mainly in lacic acid
V. Hypogycemia Coma
 Insulin overdose
 Exercise or delayed meals
 Seizure ( due to glycopenia in CNS)
Management of DKA
 Fluid therapy
 Insulin therapy
 Potassium therapy
 Antibiotic therapy

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Fluid therapy
Use
 5% in mild and moderate DKA or PH 7.1 or ˃ 7.1
 10% in severe DKA o PH ˂7.1
DEFICIT
Deficit = % of dehydration × kg
Deficit = % of dehydration × kg × 10
MAINTENANCE ml × kg/ 24 hour

ml × kg /hour o 3 - 9 = 80 ml/kg
 ˂ 10 kg = 2ml/kg/hour Or o 10 -19 = 70 ml/kg
 10 - 40kg = 1 ml /kg/hour o 20 - 29 = 60ml/kg
 ˃ 40kg = give 4 ml /hour o 30 - 50 = 50 ml/kg
o ˃ 50 = 35ml / kg

Use deficit 48 hour + maintenance / hour

Example : 20 kg with 5% or PH ˃7.1
Deficit Maintenance

20 kg × 5 = 1000  20 kg × 1ml = 20 ml
1000 ∕ 48 hour = 21 ml/hour

Deficit + maintenance / hour = 41 ml / hour

OR
20 kg × 5% × 10 = 2000
Maintenance
20 kg × 60ml = 1200/24hr or 2400/48 hr
Deficit + maintenance / hour = 41 ml / hour
2000 + 2400 = 4400/48 hr = 91 ml/hr

Use normal saline or Ringer due to lactic acidosis or Pt is shock

20 ml × kg of Normal saline 20 ml × 20 kg = 400 ml/kg over 1 hour

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Next hour
Deficit = 85 ml × kg
Maintenance
100ml ×kg = in first 10 kg
50 ml × kg = in second 10 kg
25 ml × kg = in remaining

Example: 20kg patient

Amount per hour: Deficit + Maintenance - Bolus
23 hour

Deficit : 20 kg × 85 ml = 1700 ml/kg

Maintenance : 1500 ml

Amount per hour: 1700 + 1500 - 400 = 121ml / hour

23 hour
Use Normal saline 045% or 0.9% not use ringer due to lactic acidosis and hypertonic.
 Ringer (R) : Hypertonic
 Normal saline (Na) : Isotonic
 Dextrose (D5%) : Hypotonic
Potassium therapy
Add every 500ml with 20 mEq of K+ phoasphate N.S 0.9%
and 20 mEq of K+ acetate so every 1 liter 40 mEq of K+
OR
Add every 500ml with 20 mmol K+ Chloride so every liter 400 mmol N.S 0.45%
Insulin Therapy
o Use Regular insulin in slow infusion 0.1/kg/hour without bolus dose.
o Use Second liter not 1st liter
o When blood glucose ˂ 250 use D5% to avoid hypoglycemia Add D5% in the Normal
saline.

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o Shift 0.2 - 0.4 u/kg every 6 -8 hour of insulin in S.C.

o When PH ˃7.3 , HCO3 ˃ 16 , Na 135 - 145 and No vomiting
o Give Na+ bicarbonate only in severe acidose unresponse to fluid therapy PH ˂ 7.1

RENAL D ISEASE
NEPHROTIC SYNDROME
Is clinical - laboratory condition characterized by
1. Heavy protenuria
o Protein ˃ 40 mg/ m2/hr
o Albuminemia ˃ 1g / m2 /24 hr
2. Hypoabunemia
˂ 2.5 g/dl
3. Hyper cholesterolemia
˃ 250 mg/dl
4. Generalized oedema
Anasarca - form face to feets
Histological classification
I. Minimal change nephropathy
II. Focal segmental glomerosclerosis
III. Mesencheal proliferation glumeronephritis
IV. Membrano proliferation
V. Membranous glomeronephritis
Causes of nephrotic syndrome
 Idiopathic in 90% ( primary)
Minimal change nephropathy 85% , Focal segmental glomerosclerosis
 Secondary nephrotic syndrome
SLE , Honoch- schonlein purpura , infection , Hepatitis B virus and Hepatitis C virus
 Congenital nephrotic syndrome

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Pathophysiology
Glomular membrane damage Glomular memebrane damage Hypoalbunemia

Heavy protenuria loosing 13.5 g/dl Lossing anti thrombin III liver compensate ↑
product of cholesterol
Hypoalbunemia Thrombosis
Hyper cholestemia
Decreased oncotic pressure Renal vein thrombosis
Hyperlipdemia
Increased Hydro static

Na+ and H2O

Edema

 Sometimes loose RBC and globuline = anemia

Clinical feature nephrotic syndrome

o Pitting oedema periorbital edema in early morning.
o Sudden on weight gain
o Ascites
o Abdominal pain
o Vomiting and Diarrhea- due to intestinal edema
o Respiratory distress due to pulmonary edema
Differential diagnosis
Congestive Heart failure
Liver cirrhosis
Protein loosing enteropathy

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Investigation
 Urine
 Serum albumin
 Low - density lipoprotein
 Raised ESR
 Blood sugar
 Hepatitis B serology
Treatment
Hospitalization and monitor
Urine output 24 hour
Blood pressure
Daily weight
Diet
 Salt restriction
 Fluid
 Increased protein intake
Avoid infection
Avoid thrombosis
 Low dose aspirin
 Avoid excess diuretic

Salt free abumin

Important drugs steroid without renal biopsy
Prednisolone in 12 week
2mg / kg mostly 50% children 1 - 7 respond steroid
If not responding in 12 weeks make renal biopsy.
Renal biopsy is contra indicated :
 Children under 10 years
 Known diabetic
 patient on drugs e.g. penicillamine ( only stop the drug)

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Complication
 Thrombo embolic
 Infection
 Pulmonary oedema
 Hypothydroidism
 Vitamin D deficiency
 Cushing syndrome

NEPHRITIC SYNDROME
Renal disease in which immunological mechanism triggers inflammation and proliferation
glomerular tissue that result damage of basement membrane messengium or cappilary
endothelium.
Causes of nephritic syndrome
Post infection ( strep, viral parasite , and fungi)
Systemic cause ( vascular collagen, and vascular disease)
Renal disease ( G.N and Berger disease)
Clinical feature
 Hematuria
 Protenuria
 Hypertension
 Uremia - due to retention waste product
 Azotemia - due to destruction protein to amino acid to nitrogen - renal insuficient.
 OLiguria
Investigation
 CBC
 Anti streptolysin O titre (ASO )
 Urinalysis --- red cell cast and Protenuria
 Urine culture
 Complement (C3 and C4)

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Diagnose of nephritic syndrome

Clinical sign
Anti streptolysin O titre (ASO) to see streptoccus

Differential diagnostic
I. Focal proliferation
Ig A nephropathy
Chronic liver failure
Celiec sprue
SLE
II. Diffuse proliferation
Membranous proliferation glomerulus
Cryoglobulunemia
SLE
Treatment
Treat underlying cause
Complication
 Micro hematuria persist for years -- Honoch- schonlein purpura.
 Chronic Rhematic fever .


Fractures

signs and symptoms.

severe pain, history of trauma, swelling, limited movement,

Treatment.

if fracture of extremity need to splint it.

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analgetics adapt to the pain level and kind of fracture and according to the
painkiller standard.

if need for surgery- preoperative care.

Hb control, blood group, PLT.

hepatitis serology, HIV

NPO

mixed solution.

blood sugar control.

surgical consultation.

if open fracture

antibiotic therapy.

clindamycin

> 4 weeks -- 14 yrs 15mg/kg/d in 3 doses for 14 days.

if vomiting Ampicillin 500mg IV

100mg/kg/d in 3 doses for 14 days.

Gentamicin diluted 80mg IV.

5mg/kg/d in 1 dosage for 14 days.

dressing.

Ask for tetanus vaccination.

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if dislocated fracture fix it, if needed extension.

Hemophilia

Hemophilia is an inherited bleeding disorder that affects approximately 17,000

people in the United States.

Children with hemophilia lack the ability to stop bleeding because of the low
levels, or complete absence, of specific proteins (called “factors”) in their blood
that are necessary for clotting.

Proper clotting of blood helps prevent excessive bleeding.

Types of hemophilia

Two of the many factors in the blood that affect clotting are factor VIII and
factor IX. Hemophilia may be classified as mild, moderate, or severe,
depending upon the level of the clotting factors in the blood. The two main
forms of hemophilia are:

Hemophilia A, which is caused by a lack of clotting factor VIII.

Approximately 85 percent of hemophiliacs have type A disease.

Hemophilia B, which is caused by a deficiency of factor IX.

What are the causes of hemophilia?

Hemophilia types A and B are inherited diseases passed on to children from
a gene located on the X chromosome. Females have two X chromosomes,
and males have one X and one Y chromosome. A female carrier of
hemophilia has the hemophilia gene on one of her X chromosomes.

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When a female hemophilia carrier is pregnant, there is a 50/50 chance that

the hemophilia gene will be passed on.

If the gene is passed on to a son, he will have the disease. If the gene is
passed on to a daughter, she will be a carrier. If the father has hemophilia but
the mother does not carry the hemophilia gene, then none of the sons will
have hemophilia disease, but all of the daughters will be carriers.

In approximately one-third of the children with hemophilia, there is no

family history of the disorder. It is believed that, in these cases, the disorder
could be related to a new gene mutation. Tests are available for possible
carriers to help determine whether or not they, in fact, carry the abnormal
gene.

Carriers of the hemophilia gene usually have normal levels of clotting

factors but may bruise easily, bleed more with surgeries and dental work,
and/or have frequent nosebleeds or excessive menstrual bleeding.

What are the symptoms of hemophilia?

Because hemophilia is a bleeding disorder, the most common symptom is
excessive, uncontrollable bleeding.

Hemophiliacs do not bleed faster than normal children, but they bleed for a
longer time.
The severity of hemophilia is determined by the amount of clotting factors in
the blood.

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Mild cases of hemophilia occur when people have 10 percent of normal

clotting factors levels. In these cases, people experience bleeding only with
major surgeries or tooth extractions. These children may not even be
diagnosed until bleeding complications from a surgery occur.

Severe hemophilia occurs when levels of factor VIII or IX are less than 1
percent of normal levels. Bleeding can occur with these children from
minimal activity associated with daily life and also can occur from no
known injury. Bleeding most often occurs in the joints and in the head.

Other symptoms of hemophilia include:

Bruising can occur from small accidents, which can result in a large
hematoma (a collection of blood under the skin that causes swelling). For
this reason, most diagnoses are made at 12 to 18 months of age, when the
child is becoming more active.

Bleeding easily from the nose, mouth and gums due to minor trauma, teeth
brushing, and/or dental work.
Bleeding into a joint, called hemarthrosis, can cause pain, immobility, and
eventually deformity if not medically managed properly. This is the most
common cause of complications due to hemophilia bleeding. Repeated joint
bleeds can lead to chronic and painful arthritis, deformity and crippling.

Bleeding into the muscles can cause swelling, pain, and redness. Swelling
from excessive blood in these areas can increase pressure on tissues and
nerves in the area, resulting in permanent damage and/or deformity.

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Bleeding from injury or bleeding in the brain is the most common cause
of death in children with hemophilia and the most serious bleeding
complication. A brain hemorrhage can occur from even a small bump on the
head or a fall. Small bleeds in the brain can result in blindness, mental
retardation, and a variety of neurological deficits, and they can lead to death
if not recognized and treated immediately.

Other sources of bleeding, such as blood found in the urine or stool also
may be a symptom of hemophilia.

The symptoms of hemophilia can resemble other blood disorders or medical

problems. Always consult your child‟s physician for a diagnosis.

How is hemophilia diagnosed?

In addition to a complete medical history and physical examination,
diagnosing hemophilia may include:

Clotting factor levels testing

Complete blood count (CBC)
Assessment of bleeding times
Genetic testing
The Coagulation and Thrombosis Lab provides state-of-the-art testing for
the center.
Treatment
A child's specific treatment plan, including the frequency of visits, the length
of treatment, side effects and long term effects are determined by the:

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Child's age, overall health, and medical history

Extent of the disease
Child's tolerance for specific medications, procedures, or therapies
Expectations for the course of the disease
The patient and family's opinion or preference

Treatment depends on the type and severity of the hemophilia. The goal of
hemophilia treatment is preventing bleeding complications (primarily head
and joint bleeds) parents can prevent bleeding complications by:
Purchasing soft toys with rounded corners for young children.
Dressing children in padded clothing and helmets when they are learning
to walk or becoming more active.
Evaluating contact sports in school for risks of injury to the child.
Having proper dental hygiene.
Not giving the child aspirin and aspirin-containing products if
recommended by the child‟s physician. These products have been linked to
bleeding problems.

A child's physician may take these preventative steps:

Give immunizations under the skin (subcutaneous) instead of in the
muscle (intramuscular) to prevent deep muscle bleeds.
recommend surgery for joint hemorrhages and/or immobilization.
Rehabilitation of the affected joint may include physical therapy and
exercise to strengthen the muscles around the area.

recommend infusions of replacement blood factors to increase the child‟s

clotting levels before surgery or dental work. The child also may receive
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infusions during and after the surgery to maintain the clotting factor levels
and to improve healing and prevention of bleeding after the procedure.

Part 23
Topics
1: Measles.
2: TB
3: Whooping cough.
4: Meningitis.
5: Chicken box.

Measles (Rubela and morbilli.)

Measles is highly contagious infection of the respiratory immune and skin system.
Etiology
Measles (rubeola) is caused by a single-stranded RNA paramyxovirus of the genus morbillivirus with
one antigenic type. Humans are the only natural host.
Measles virus infects the upper respiratory tract and regional lymph nodes and is spread systemically
during a brief, low-titer primary viremia.
A secondary viremia occurs within 5 to 7 days when virus-infected monocytes spread the virus to the
respiratory tract, skin, and other organs
Virus is present in respiratory secretions, blood, and urine of infected individuals.

Transmission: {Infection spreads through}:

 physical contact with an infected person

 being near infected person if they cough or sneeze

 touching a surface that has infected droplets of mucus and then putting fingers into the mouth,
or rubbing the nose or eyes

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Measles virus is transmitted by large droplets from the upper respiratory tract and requires close
contact ( person to person) and every patient can transmitted 12- 18 person.
Most young infants are protected from measles by transplacental antibody, but infants become
susceptible toward the end of the first year of life. Passive immunity may interfere with effective
vaccination until 12 to 15 months of age.

Symptoms

The symptoms of measles always include fever and at least one of the three Cs:

 cough

 coryza, or runny nose

 conjunctivitis

Symptoms will appear about 9 to 11 days after initial infection.

Symptoms may include:

 runny nose

 dry cough

 conjunctivitis, or swollen eyelids and inflamed eyes

 watery eyes

 photophobia, or sensitivity to light

 sneezing

 a reddish-brown rash

 Koplik's spots, or very small grayish-white spots with bluish-white centers in the mouth, insides
of cheeks, and throat.

 generalized body aches

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Complications

Complications from measles are fairly common. Some can be serious.

People most at risk are patients with a weak immune system, such as those with HIV, AIDS,
leukemia, or a vitamin deficiency, very young children, and adults over the age of 20 years.

Older people are more likely to have complications than healthy children over the age of 5
years.

Complications can include:

 diarrhea

 vomiting

 eye infection

 respiratory tract infections, such as laryngitis and bronchitis

 difficulty breathing

 ear infections, which can lead to permanent hearing loss

 febrile seizures Patients with a weakened immune system who have measles are more
susceptible to bacterial pneumonia.

The following less common complications are also possible:

 Hepatitis: Liver complications can occur in adults and in children who are taking some
medications.

 Encephalitis: This affects patients with measles. It is an inflammation of the brain that can
sometimes be fatal.

 Thrombocytopenia, or low platelet count, affects the blood's ability to clot.

 Squint: Eye nerves and eye muscles may be affected.

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Complications that are very rare but possible include:

 Neuritis, an infection of the optic nerve that can lead to vision loss

 Heart complications

 Subacute sclerosing panencephalitis (SSPE): A brain disease that can affect: . Convulsions,
motor abnormalities, cognitive issues, and death can occur.

Path-physiology of measles

Respiratory droplet of measles

Epithelial cells of the trachea / bronchi

Bind H. protein - then bind CD46 and CD150

Then spread to lung tissue

Then lymph node

Blood ( 1st viremia)

Multiplication

The second Viremia

Then General toxin

causing complication

Pneumonia Diarrhoea Encephalitis

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Clinical types of measles

 Typical
 Atypical
 Modified
Clinical stage or phase of typical measles
Measles infection is divided into four phases:
o incubation,
o prodromal (catarrhal),
o exanthematous (rash), and
o recovery.
Incubation period : 8 - 12 develop symptoms
o Prodromal / catarrhal) ( 3 - 5 days)
Characterized by low grade to moderate fever , hacking dry cough
3 C : Cough,Coryza, Conjucntivitis
Kopules spot (gray-white, sand grain-sized dots on the buccal mucosa opposite the lower molars))
1 -2 days before rash
Exanthematous / Eruptive (4 -5 days)
 Temperature rise 40 - 45 c
 Rash begin behind ear painless not touchable.
Rash is maculapapollar cephalo - caudal
1st 24 hour
Entire face - neck , upper arm and upper part of the chest.
Next 24 hours
Back , Abdomen , Entire arms and Thigh.
2 - 3 days finally reaches the face and begins to fade on face.
In severe cases It may be petechial or hemorrhagic (black measles). there is brownish
discoloration and desquamation called post measles staining and disappears 7 10 after.
Organ involvement
Cervical lymphadenitis, splenomegaly, and mesenteric lymphadenopathy with abdominal pain may be
noted. Otitis media, pneumonia, and diarrhea are more common in infants.

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
Clinical stage or phase of Atypical measles
Atypical measles: who received vaccination with original killed virus vaccine.
1- Mild measles
2- Severe measles ( Toxic and shock type)
3- hemorrhagic measles
4- Variant measles
Modified measles
Modified measles : Measles for vaccinated child , who received serum immnoglobin
o Milder symptoms
o Incubation periods 21 days
Risk factors for measles
 Age 6 months - 5 years
 developing country
 Un vaccinated
 History of contact
 HIV
 Malnutrition
 Poor socioeconomic
 More in winter
Diagnoses of measles
 Clinical symptoms
mouth : koplik spot on mucousa membrane in first 24 hours
Skin: muculopopular rash - definitive diagnose
Eye : Corneal loading and conjuntival line Stemson line)
 Laboratory
 CBC : ↓WBC , ↑ lymphocyte and ↓ plt
 Serological: ↓ testing for IgG and Igm - 7
 PCR - Visualizing measles RNA virus
 X-ray - Pneumonia
 Lumbar puncture

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 Skin biopsy
 Spicemen from ( nasopharynx urine)

Diffrential diagnostic
 Rubella
 Chicken pox - rash of painful and touchable
 Ruseola
 Scabies
 Toxoplasmosis
 Kawasaki disease
 Serum sick ness
 Mono nucleosis
 Drug rash
Treatment
There is no specific therapy for measles.
 Routine supportive care includes
 Oxygen
 NGT tube 150ml/kg
 maintaining adequate hydration and antipyretics.
 Oral scar - First normal saline wash , then Gemsa violation then oral nystatin drop.
 High-dose vitamin A supplementation .
Complication
o Otitis media
o Interstitial pneumonia
o Malnutrition
o Secondary TB
o Mesenteric lymphadenitis
o Anemia
o Encephalitis
o Corneal loading and conjuntival ulcer
Deaths most frequently result from bronchopneumonia or encephalitis.

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Prevention
1. Vaccination
2. Control source
3. Protection of susceptible person
Vaccination
Measles Mumps rubella vaccine (MMR)
Live attetunated vaccine
Dose1 : 9 month or ˃ 6 month in outbreak
Dose 2: MMR 4 -6 years or may be ˃ 4 week effect dose.
Contraindicated in pregnancy
 Re vaccination indicated
 Vaccination before 1st birth
 Vaccinated with kwed vaccination
 Vaccination with K1
 Become active in 2 weeks use upto 5 years

Whooping cough
the whooping cough syndrome, usually is caused by B. pertussis, a gram-negative pleomorphic bacillus
with fastidious growth requirements.
The mean incubation period is 6 days. Patients are most contagious during the earliest stage.
Classic pertussis is the syndrome seen in most infants beyond the neonatal period through school age.
The progression of the disease is divided into:-
 Catarrhal,
 Paroxysmal, and
 Convalescent stages.
The catarrhal stage
marked by nonspecific signs (injection, increased nasal secretions, and low-grade fever) that last 1 to 2
weeks.
The paroxysmal stage
 Coughing occurs in paroxysms during expiration, causing young children to lose their breath.

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coughing is due to the need to dislodge plugs of necrotic bronchial epithelial tissues and thick mucus. It
lasts approximately 2 to 4 weeks and worsening at night.
 The forceful inhalation against a narrowed glottis that follows this paroxysm of cough produces
the characteristic whoop.
 Post-tussive emesis is common ( Vomiting after cough) and
 Periodic apnea are common stage causing Hypoxic then hypoxic ischemic encephalopathy.
The convalescent stage
Coughing becomes less severe, and the paroxysms and whoops slowly disappear. Although the disease
typically lasts 6 to 8 weeks, residual cough may persist for months, especially with physical stress or
respiratory irritants.
Laboratory
 absolute number and relative percentage of lymphocytes in the peripheral blood
(lymphocytosis).
 The WBC count may increase from 20,000 cells/mm3 to more than 50,000 cells/mm3.

Differential diagnostic
 parainfluenza virus, and
 C. pneumoniae
Treatment
 Erythromycin, given early in the course of illness, eradicates nasopharyngeal carriage of
organisms within 3 to 4 days.
 Azithromycin and clarithromycin
Complication
 hypoxia,
 apnea,
 pneumonia,
 seizures,
 encephalopathy, and
 malnutrition.

Criteria of admission whooping cough

Symptoms of whooping

+
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danger sign

+
Complication
Meningitis
Meningitis is inflammation of the membranes (meninges) covering the brain and the spinal cord.
The most common causes are infection (bacterial, viral, fungal or parasitic),

What are the symptoms of meningitis?

The symptoms of viral and bacterial meningitis can be similar in the beginning.
However, bacterial meningitis symptoms are usually more severe.

The symptoms also vary depending on your age.

Viral meningitis symptoms

Viral meningitis in infants may cause:

 decreased appetite
 irritability
 sleepiness
 lethargy
 fever

 lethargy
 nausea and vomiting
 decreased appetite


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Bacterial meningitis symptoms

 altered mental status

 nausea
 vomiting
 sensitivity to light
 irritability
 headache
 fever
 chills
 stiff neck
 purple areas of skin that resemble bruises
 sleepiness
 lethargy

Fungal meningitis symptoms

 nausea
 vomiting
 sensitivity to light
 fever
 headache
 confusion or disorientation

Types of meningitis

1: Viral meningitis

Viral meningitis is the most common type of meningitis.

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 coxsackievirus A
 coxsackievirus B
 echoviruses

Other viruses can cause meningitis. These include:

 West Nile virus

 influenza
 mumps
 HIV
 measles
 herpes viruses
 Coltivirus, which causes Colorado tick fever

2: Bacterial meningitis

Bacterial meningitis is contagious and caused by infection from certain bacteria.

The most common types of bacteria that cause bacterial meningitis are:

 Streptococcus pneumoniae, which is typically found in the respiratory tract,

sinuses, and nasal cavity and can cause what‟s called “pneumococcal
meningitis”
 Neisseria meningitidis, which is spread through saliva and other respiratory
fluids and causes what‟s called “meningococcal meningitis”
 Haemophilus influenza, which can cause not only meningitis but infection of
the blood, inflammation of the windpipe, cellulitis, and infectious arthritis
 Listeria monocytogenes, which are food born bacteria
 Staphylococcus aureus, which is typically found on the skin and in the
respiratory tract, and causes “staphylococcal meningitis”

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3: Fungal meningitis

Fungal meningitis is a rare type of meningitis. It‟s caused by a fungus that infects
your body and then spreads from your bloodstream to your brain or spinal cord.

The most common funguses related to fungal meningitis include:

 Cryptococcus, which is inhaled from dirt or soil that is contaminated with bird
droppings
 Blastomyces, another type of fungus found in soil, particularly in the
Midwestern United States
 Histoplasma, which is found in environments that are heavily contaminated
with bat and bird droppings
 Coccidioides, which is found in soil

4: Parasitic meningitis

This type of meningitis is less common than viral or bacterial meningitis, and it‟s
caused by parasites that are found in dirt, feces, and on some animals and food,
like snails, raw fish, poultry, or produce.

One type of parasitic meningitis is rarer than others.

It‟s called eosinophilic meningitis (EM).

Three main parasites are responsible for EM. These include:

 Angiostrongylus cantonensis
 Baylisascaris procyonis
 Gnathostoma spinigerum

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5: Non-infectious meningitis

Non-infectious meningitis is not an infection. Instead, it is a type of meningitis

that‟s caused by other medical conditions or treatments. These include:

 lupus
 a head injury
 brain surgery
 cancer
 certain medications

Most common neonate bacterial meningitis

 Group B streptococci
 Escherichia coli
 Klebsiella
 Enterobacter
Most common ˃ 1 month bacterial meningitis
o Streptococcus pneumoniae
o Neisseria meningitidis
Viral meningitis is caused principally by entero-viruses, including coxsackieviruses, echoviruses.
Fungi caused by Cryptococcus neoformans and Candida.

Pathophysiology
Most often, the body’s immune system is able to contain and defeat an infection. But if the
infection passes into the blood stream and then into the cerebrospinal fluid that surrounds the
brain and spinal cord, it can affect the nerves and travel to the brain and/or surrounding
membranes, causing inflammation.
This swelling can harm or destroy nerve cells and cause bleeding in the brain.

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Clinical feature of meningitis

High grade fever continues
Convulsion continues ˃ 15minutes or ˃ one times / hour
Projectile vomiting indicate ↑ICP
Headache Increased intracranial pressure
diplopia( Squant or nystigma)
photophobia (intolerance of bright light)
Neck stiffness
Feeding history ( unable to feed)
Conscious level : unconscious, stupor, lethargic and delirium.
Bulging fontanella with excessive crying may be present in infant.
irritable
Ptosis, sixth nerve palsy, anisocoria( unaequal pupil size) , bradycardia with hypertension, and
apnea are signs of increased intracranial pressure with brain herniation.

Symptoms
Kernig's sign: Severe stiffness of the hamstrings causes an inability to straighten the leg when
the hip is flexed to 90 degrees.

Brudzinski's sign: Severe neck stiffness causes a patient's hips and knees to flex when
the neck is flexed.

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Differential diagnoses of meningitis

1. Complicated malaria

Some unconsciousness but has no pulging fontanella ( meningeal irritataion)

2. Encephalitis has coma

3. History of viral disease but no meningeal
4. Febrile convulsion ( 6 month - 6 years)
 Convulsion is one m/2h
 Convulsion ˂ 15 minutes
 Convulsion + fever
5. Tetanus - has lock jaw , wound and consciousness
6. Salmonella typhi - Fever + bradycardia + Convulsion and constipation
7. Toxoplasmosis - fever + organomegaly + lymphadenopathy + rash if HIV positive.

Investigation

In Somalia lumbar puncture not available so that we request only :

 CBC

 ESR

 Malaria

 Electrolyte

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 blood sugar

 X - ray

 CT scan

 MRI

Treatment of meningitis

If bacterial meningitis

• Dexamethasone injection give 30 minute before antibiotic for 2 - 4 days.

Uses:To Reduce Inflammation and to prevent Increase Intracranial Pressure(ICP).
• Ampicillin Injection for 7 to 14 days & Cefatriaxone Injection for 14 days
Uses: To Prevent Septicemia and Complication.
• Ibuprofen tab Or Syrup : For Inflammation
• Diazepam Injection 10mg 0.3mg/kg every convulsion to prevent Brain Damage.
• Phenobarbital tab 30mg ,at Night RD: 1-2mg/kg or 4-6 mg If convulsion > 2 times per day.
If viral meningitis
• Acyclovir 200mg 20-30mg/kg for 4-6times per day for 7 days ( 1 ×4)
• Supportive Treatments
Tubercular ( TB ) Meningitis:
• HRZE tab ¼ tab < 10kg ½ tab 10-14kg 1 tab 15-19kg for first 3 months
• HR tab ¼ tab < 10kg ½ tab 10-14kg 1 tab 15-19kg for second 8 months
• Prednisolone tab 5mg 2mg/kg, divide at morning & afternoon for first 1 month
Complications
 cerebral edema,
 venous sinus thrombosis,
 brain abscess ,
 septicemia,
 DIC and
 multi-organ failure (MOFS)
Pulmonary Tuberculosis

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T.B infection is in active infection only exposure to contain of diseased person and there is no
clinical feature and skin test+.
T.B disease is active form , there is contact and clinical feature are positive with X-ray, sputum
and skin test positive.
Tuberculosis : is infection disease caused by mycobacteium tuberculli which mostly occur in
lung.
Types of T.B
 Primary : initial infect mostly in children ( Pulmonary T.B)
 Secondary : Re-infection mostly in adult (( Pulmonary T.B))
 Millary : outside of the lung ( Extra pulmonaryT.B)

Pathophysiology of T.B
Pneumonia Granuloma with fibrosis Caseous necrosis Calcification( Ca + and salt
deposit Cavitations.
Predisposing factor T.B
 ˂ 5 years
 Malnutrition
 Lymphom Steroid use ( Nephrotic and Asthma )
 Post measles ˂ 6 weeks
 HIV
 Down syndrome
High risk group of T.B
 ˂ 3 years
 C.H.D : poor feeding due to when he feeds he feels dyspnea.
Poor feeding malnutrition anemia ↓ immune TB
Diagnose of T.B
1. Carefully history taken
 Clinical symptoms suggest T.B
 History Contact of T.B
- Timing - last 2 years

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- Closed contact Mother or sleeping in 1 room.

- Type of T.B contact
smear + T.B , X-ray + T.B and MDR T.B contact.
2. Clinical features
 Chronic Cough ˃14 days - not remitting not responding to antibiotics or
bronchodilator.
 Night sweat
 Fever , ↑ Respiratory rate
 Measure weight, height , MUAC and record on growth chart
 Weigh loss or flattened growth curve is signal chronic respiratory disease Like
T.B.
 Respiratory Wheeze - which is unilateral and is not responding to bronchodilator
or percussion - dullness is sign of pleural effusion.
 Fatigue reduced play fullness
3. HIV testing
HIV + and 2 or more
Symptom of T.B : Treat the pt 2 symptoms of T.B + T.B contact +No BCG vaccination
+ ˂ 5 year : treat the patient.

4. Bacteriological confirmation by using gene expert

 RR + and MTB+ = MDR
 RR- and MTB + = MDR risk ( treat pulmonary T.B or new case)
5. T.B investigation
o X-ray
o Sputum
o CT
o Skin tuberculi test

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Management of T.B
T.B Category
1. Category A
 Pulmonary T.B or new case
 Treat 6 month
 Phase 1: initial 1-2 month
 Phase 2: continuous 4 - 6 month
2. Category B
o Treatment failure:
Child taking Phase 1 ( 2 month) and taken sputum if it is positive
o Relapse MDR risk
o Defaulted : If child taking T.B treatment in 1 week and stops.
Differentiate MDR risk from MDR by using gene expert
 MTB ( Mycobacterium TB)
 RR ( Rifampicine resistance)
Treat in 9 month with steptomycine injection - 7 month -2 month streptomycine
If MTB and RR are positive

3. Category C
Outcome of T.B treatment
Cure
Complete
Failure
Death
Defaulter
Transfer
Drug calculation of T.B
1. 4 - 6 kg
Phase 1 : 1 HRZ + 1 E
Phase 2 : 1HR
2. 7 - 10 kg

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Phase 1 : 2 HRZ + 2 E
Phase 2 : 2 HR
3. 11 - 14 kg
Phase 1 : 3HRZ + 2 E
Phase 2 : 3HR
4. 15 - 19 kg
Phase 1 : 4 HRZ + 3 E
Phase 2 : 4 HR
5. 20 - 24 kg
Phase 1 : 5HRZ + 4E
Phase 2 : 5 HR

Subgroup of ˃ 25 kg
A. 25 - 39kg
Phase 1 : 2 HRZE
Phase 2 : 2HR
B. 40- 54kg
Phase 1 : 3 HRZE
Phase 2 : 3 HR
C. 55-70 kg
Phase 1 : 4 HRZE
Phase 2 : 4 HR
D. ˃ 70 kg
Phase 1 : 5 HRZE
Phase 2 : 5 HR

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Extra pulmonary T.B

occur 25% of T.B among children ˂ 5 year.
The most common forms :-
Peripheral Lymphnode T.B ( T.B adenopathy)
 Asymmetrical painless mostly 2 - 10 years
 Mass ˃ 3 cm and more the 1 month
 Discharge sinus mostly in the neck area
 use fine needle aspiration
Pleural T.B
Dullness on percussion
Chest pain
Reduced breath sound
CXR and Pleural aspiration
Meningitis T.B
 Sign of meningitis
 Lumbar puncture , CSF and CXR
 ˃ 5 years
Abdominal T.B
 Abdominal swelling ,Ascites , pain
 Ultrasound: Ascites fluid analyse
Spinal T.B
 Deformity of spine Lower limb weakness
 Paralysis , unable to work
 X -ray spine
Pericardial T.B
Cardial failure
distant heart murmur apex beat
CXR and Cardiac ultrasound

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Chickenpox

Chickenpox (chicken pox), also known as varicella, is a highly contagious infection caused by
the varicella zoster virus. Although uncomfortable, most people recover within 1-2 weeks.

There is a blister-like rash, which first appears on the face and trunk, and then spreads
throughout the body. Although not life-threatening, complications can arise.

Symptoms

 a general feeling of being unwell (malaise)

 fever, which is usually worse in adults than children

 aching muscles

 loss of appetite

 in some cases, a feeling of nausea

After the rash appears, there will be:

 Rash: Severity varies from a few spots to a rash that covers the whole body.

 Spots: The spots develop in clusters and generally appear on the face, limbs, chest, and
stomach. They tend to be small, red, and itchy.

 Blisters: Blisters can develop on the top of the spots. These can become very itchy.

 Clouding: Within about 48 hours, the blisters cloud over and start drying out. A crust
develops.

 Healing: Within about 10 days, the crusts fall off on their own.
During the whole cycle, new waves of spots can appear - in such cases, the patient might
have different clusters of spots at varying stages of itchiness, dryness, and crustiness.

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Treatment

Chickenpox generally resolves within a week or two without treatment. There is no cure,
but a vaccine can prevent it.

Pain or fever: Tylenol (acetaminophen), which is available to purchase online, may help
with symptoms of high temperature and pain. It is important to follow the instructions
provided by the manufacturer.

Aspirin containing products should NOT be used for chickenpox as this can lead to
complications.

Acetaminophen (Tylenol) can be used at any time during pregnancy.

Avoiding dehydration: It is important to drink plenty of fluids, preferably water, to

prevent dehydration. Some doctors recommend sugar-free popsicles or Pedialyte for
children who are not drinking enough.

Mouth soreness: Sugar-free popsicles help ease symptoms of soreness if there are spots
in the mouth. Salty or spicy foods should be avoided. If chewing is painful, soup might
be a good option, but it should not be too hot.

Itchiness: ltchiness can become severe, but it is important to minimize scratching to

reduce the risk of scarring.

The following may help prevent scratching:

 keeping fingernails clean and as short as possible

 placing mittens or even socks over a child's hands when they go to sleep, so that any
attempt at scratching during the night does not cut the skin

 applying calamine lotion or having an oatmeal bath to reduce itching

 wearing loose clothing

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Antiviral medication may be prescribed during pregnancy, for adults who get an early
diagnosis, in newborns, and for those with a weakened immune system. Acyclovir is one
example.

This works best if it is given within 24 hours of developing symptoms. Acyclovir reduces
the severity of symptoms but does not cure the disease.

Prevention

A vaccine is available for varicella. For children, 2 doses of the varicella vaccine are
given, one at 12 to 15 months and one at age 4 to 6 years. These are 90 percent effective
at preventing chickenpox.

In the United States, the chickenpox vaccine is routinely given to children.

Complications

Adults are more susceptible to complications than children, but even in adults, they are
rare.

Pregnant women, newborns, and infants up to 4 weeks old, as well as those with
weakened immune systems, are more likely to experience complications.

If the skin around the spots and blisters becomes red and tender or sore, they may be
infected. Some people with chickenpox can go on to develop pneumonia.

Encephalitis: An inflammation of the brain may occur.

Reye's syndrome: This rare but serious condition can occur when children and teenagers
are recovering from a viral infection, including chickenpox. It causes the liver and brain
to swell.

Most people who develop complications will make a full recovery.

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Chickenpox and pregnancy

During pregnancy, there is a slightly higher risk of developing pneumonia with

chickenpox.

There is also a danger of passing the infection on to the fetus.

If infection occurs during the first 20 weeks of pregnancy, there is a higher risk of fetal
varicella syndrome, which can lead to scarring, eye problems, brain drainage, and
shortened arms or legs.

If the infection happens later in pregnancy, the varicella may be transmitted directly to
the fetus and the baby can be born with varicella.

If you become exposed to varicella during pregnancy, whether chickenpox or shingles, it

is important to talk to a doctor right away.

Chickenpox and a weakened immune system

The risks of catching chickenpox and developing complications are higher in a person
with a weakened immune system.

 A weakened immune system can result if a person:

 is taking certain medications

 has cancer

 is undergoing treatment such as radio- or chemotherapy

 has a chronic condition, such as lupus or rheumatoid arthritis

Complications from chickenpox may include meningitis, sepsis or septicemia, or
pneumonia.

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Fluid
maintaince
deficit
burn:::: 4 ccxkg BSA R
dehydration::::: kgx/ of dehydrated x10.

ongoing loss.
vomiting: 10mlxkg.
dehydrated: 15mlxkg.
diape: 5mlxkg.

Bollus.
1: Mixed solution: 15mlxkg
2: Ringer solution: 15mlxkg

Growth parameters.
Weight.
Height.
Head circumference.
Chest Circumference.

Growth Measurement in length.

Recumbent length.
Statur.
Growth in length and statur.
Zygote= 0.14mm
Birth:: { boys: 50.5cm and Girls: 49.5cm},
1 years: boy: 76.1cm girls 75cm

At birth ........ 50cm.

6 months: 68cm.

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1 year: 75cm.
2 years: 87cm.
3 years: 94cm.
4 years: 100cm
Add 7cm/year.
5 years: 107cm.
6 years: 114cm
7 years: 121cm.
8 years: 128cm
9 years: 135cm
Add 5cm/year
10 years: 140cm.
11 years: 145cm.
12 years: 150cm: than 3 times at birth.

Growth in body weight.

conception.
Ovum ------- 0.005mg.
at birth
boy: 3.3kg.
girl: 3.1kg.
day 1----3 postnatal infants.
may loose up to 10% of body weight.
1 year:
boys: 10.2kg.
Girls: 9.5kg.

Average weight for Age.

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Weight for age in month.

At birth::::::: 3kg or 3.5kg.
1 month: 3.7 kg.
2 months: 4.5kg.
3 months: 5.25kg
4 months: 6kg. add 750g
5 months: 6.75kg
6 months: 7kg.
7 months: 7.5kg
2 times at birth. than Add 500g
8 months: 8kg.
9 months: 8.25kg.
10 months: 8.5kg.
11 months: 8.7kg Add 250g.
12 months: 9kg.
3 times at birth.

Weight for age for year.

2 years: 12kg
3 years: 14kg.
4 years: 16kg.
5 years: 18kg.
6 years: 20kg
Add 2kg.
7 years: 22.5kg.
8 years: 25kg.
Add 2.5kg
9 years: 27.5
10 years: 30kg.

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At birth
weight ---------- 3kg or 3.5kg. sometimes more than.
Height ---------- 50cm.
4 months.
weight ---------- 6kg. 2 times at birth
Height ---------- 100cm. 2 times at birth.
12 months ----- weight 9kg. 3 times birth weight.
12 years:
height ------- 150cm 3 times birth height.
10 years weight 30kg 10 times birth weight.

Formules for average weight.

Age Weight.
2---3 months agexmonth+9/2
1----6 years age yearx2+8
7---12 years age yearx7-5/2
Time of hight sketal
Estimated age for boys: 13.7 years.
Estimated age for girls. 11.8 years

Head Circumference
0----month ------- 35cm+8
6 months ------------ 43cm+4
1 year---------------- 47cm+2
2 years --------------- 49cm+2
6 years -------------- 51cm+2
12 years ----------- 53cm+2

Permanent teeth.
6 years ---------- first molar.
7---8 years -------- primary teeth

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12 years ----------- second molar.

> 18 years ---------- third molar.
Total= 32.

Notes
Fontonella close ------- > 18 months.
first molar ----------- 6 years.
second molar ------------ 12 years.
third molar ------------ 18 years.
Neonatal == HIV after 18 months
TB transmission== before 2 weeks or 2 months.
MDR treatment ---------- 2 years.
TB meningitis treatment ------- 12 months.
Osteoarticullar ---------- 12 months.
BCG --------- up to 1 year
Measles --------- up to 5 years.
OPV ------ up to 5 years.
Penta --------- up to 2 years.
MUAC --------- 6 months up to 5 years.
MDR risk catogor B -------- up to 9 months
TB treatment failure ------------- up to 2 months without response.
MUAC ----------- left upper arm.

Growth charge.
0---- 3 years.
weight
height
head circumference.
every 6 months.
4---- 8 years.
weight

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height
BMI.
every year
9----12 years.
weight
height
BMI and sexual maturity
Growth failure two types.
1: primary growth failure { low birth weight}
2: secondary growth failure {normal birth weight due to organic 20% or inorganic 80%.
Growth chart
Height for age -------- stanting.
Weight for age -------- under weight.
Weight for length ------ z-score
Weight for hight --------- wasting.
BMI.
Stages of developmental
infancy.
Neonate = 0----- 1 month.
infant = 1 month -------- 1year.
Early child hood.
toddler = 1----- 3 years.
pre-school = 3----- 6 years.
Mild childhood.
School age = 6----- 12 years.
late childhood.
Adolescent 13-------18 years.
when to screen
at least 3 times before age
9 months
18 months

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24---- 30 months.
Developmental milestone.
Fine motor.
Gross motor.
Language.
Social.
Calculating age.
date of test + date of birth.
age of the child or intellegence test.
IQ: mental age/chronological age.
130+ === gified.
145 + ==== genius.
70 - ==== mor.
55 - ==== imbecile.
25 - ==== idiot.

Gross motor development

new born= barely able life head.
6 months == easily life head.
chest, upper abdomen.
2 months ==== needs assistance.
6 months ==== can sit alone.
8 months ==== can sit with out support and engage inploy.
9 months ==== crawl.
1 year ===== stand independ from craw posh.
13 months ==== walk
15 months ===== can run.
8----10 years ===== team sport.
> 10 years ===== match sport to physical and emotional.

Mukhtar Abdi Yususf: dr qanciye

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Fine motor infant.

6 months ---- palmar grass.
uses entire hand to pick object
9 months
pincer grasp can grasp small object using thumb fore finger.

Speech milestone.
1---2 months ------- coos.
1--2 months -------- laughs, squals.
8---9 months -------- mamal, dad unspecifit.
10 ---12 months -------- mamal, dad specifit.
18--- 20 months ------ 20---30 wards 50% under.
22---24 months ------- 2 words sentence 75 under.
30--- 36 months ------ all most all speech.

Fine motor older toddler.

1 year == transfer object from hand to
2 years ==== can hold craya.
3 years ==== circle and cross biud small using.
4 years === use scissors, colors.
5 years ==== write some letters and drows person with.

Fine motor in pre-school.

butting clothing.
holding crayoh.
building with small blocks.
using scissors.
playing boards game
have child draw pictin him

Fine motor in school

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writing skulls improve

Fine motor in adolescent

begin challenge values relationship.
Adolescent behavioral problems.
anoroxia.
attention deficit.
anger issue.
suicide.
violecent.

Adolescent teaching.
relationship.
sexuality STD/AIDS.
substance use /abuse.
change activity.
drawing
access to weapons.
positioning in breast feeding.
1: cradle holding = using hand.
2: cross craddle or transtional holding= using 2 hands
3: football or clutch hold.
4: side lying position.

breast feeding.
exclussive only breast feeding.
complementary == 6 months complete.
early= < 6 months.
late > 6 months.
after 6 months give breast feeding + food.

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Baby's reflex.
1: rooting === good position and open mouth.
2: sucking === lip touch areola.
3: swallowing == swallows.
4: more.

breast feeding types.

1: Exclusive= only human milk or her mother breast.
2: All most exclusive 90 % human milk 10% animal milk.
3: partial or mixed 50% human milk 50% animal milk.
4: Token = all most not human milk.
5: any breast feeding = all of.
6: never breast feeding == never faced.

All vitamins get on breast milk except Vitamin D in sunlight.

Mechanical breast fed expression.

1: double pumping and nipple shell

Contraindicated of breast feeding.

1: maternal HIV.
2: Active TB petor
3: Syphilis.
4: Varicella.
5: Gallactossemia.

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Part 24
Topics
1: Malnutrition

Malnutrition is a state resulting from nutritional inadequacy or over nutrition related to excess
intake in which an individual‟s physiological and physical functions are impaired.

Malnutrition refers to deficiencies, excesses or imbalances in a person‟s intake of energy and/or

nutrients. The term malnutrition covers 2 broad groups of conditions.

One is „undernutrition‟—which includes

stunting (low height for age),

wasting (low weight for height),

underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of
important vitamins and minerals). The other is overweight, obesity and diet-related no
communicable diseases (such as heart disease, stroke, diabetes and cancer).

Symptoms

Signs and symptoms of undernutrition include:

 lack of appetite or interest in food or drink

 tiredness and irritability

 inability to concentrate

 always feeling cold

 loss of fat, muscle mass, and body tissue

 higher risk of getting sick and taking longer to heal

 longer healing time for wounds

 higher risk of complications after surgery

 depression

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 reduced sex drive and problems with fertility

In more severe cases:

 breathing becomes difficult

 skin may become thin, dry, inelastic, pale, and cold

 the cheeks appear hollow and the eyes sunken, as fat disappears from the face

 hair becomes dry and sparse, falling out easily

Eventually, there may be respiratory failure and heart failure, and the person may become
unresponsive. Total starvation can be fatal within 8 to 12 weeks

Children may show a lack of growth, and they may be tired and irritable. Behavioral and
intellectual development may be slow, possibly resulting in learning difficulties.

Even with treatment, there can be long-term effects on mental function, and digestive problems
may persist. In some cases, these may be lifelong.

Causes

Malnutrition can result from various environmental and medical conditions.

1) Low intake of food

for example, dysphagia, when it is difficult to swallow.

2) Mental health problems

Conditions such as depression, dementia, schizophrenia, anorexia nervosa, and bulimia can lead
to malnutrition.

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3) Social and mobility problems

Some people cannot leave the house to buy food or find it physically difficult to prepare meals.
Those who live alone and are isolated are more at risk. Some people do not have enough money
to spend on food, and others have limited cooking skills.

4) Digestive disorders and stomach conditions

If the body does not absorb nutrients efficiently, even a healthful diet may not prevent
malnutrition. People with Crohn's disease or ulcerative colitis may need to have part of the small
intestine removed to enable them to absorb nutrients.

Celiac disease is a genetic disorder that involves a gluten intolerance.

It may result in damage to the lining of the intestines and poor food absorption.

Persistent diarrhea, vomiting, or both can lead to a loss of vital nutrients.

5) Alcoholism

Addiction to alcohol can lead to gastritis or damage to the pancreas. These can make it hard to
digest food, absorb certain vitamins, and produce hormones that regulate metabolism.

6) Lack of breastfeeding

Not breastfeeding, especially in the developing world, can lead to malnutrition in infants and
children.

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Risk factors

most at risk of malnutrition are:

 older people, especially those who are hospitalized or in long-term institutional care

 individuals who are socially isolated

 people on low incomes

 those who have difficulty absorbing nutrients

 people with chronic eating disorders, such as bulimia or anorexia nervosa

 people who are recovering from a serious illness or condition

Triage for acute malnutrition

 Severe acute malnutrition (SAM)
 Moderate acute malnutrition (MAM)
 At risk of malnutrition
 Health
Severe acute malnutrition (SAM) or PEM
Complicate
 Medical complication Criteria for SAM
 No appetite o MUAC ˂ 11.5 cm
 Oedema ++ or +++ o Z-score ˂ -3 SD
Manage for SC o Bilateral pitting edema
Uncomplicated
 No edical complication
Criteria of admission Malnutrition
 Good appetite
 Oedema +  General danger sign
Management for OTP  Oedema

MAM  Poor feeding

 No weigh gain
Criteria for MAM
 Any child ˂ 3 kg
o MUAC 11.5- 12.5 cm  Anthrometric measurement

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o Z-score ˃ -3 SD or -2

The different types of malnutrition

Wasting Shunting Underweight
(W/H) ( H/A) W/A

Short stature Chronic malnutrition

Kwashkor Marasmus

N.B: W/H: {weight for height} H/A: {height for age and W/A: { weight for age}

Protein colorie malnutrition or Protein energy malnutrition

Classification

1. Wellcom Classification
using W/A and presence edema
 WFA ˃ 80% + oedema = Kwashikor
 WFA 60 - 80% and No edema = Simple under weigh
 WFA 60 - 80 % and No edema = Kwashikor
 WFA ˂ 60 and no edema = Marasmus
 WFA ˂ 60 and edema = Marasmus / Kwashikor
2. Water law Criteria
a) Changes in weight may indicator of acute malnutrition

Actually wt (Kg)
Expected wt for ht at 50th percent

 Grade 0 = ˃ 90% Normal

 Grade I = 80 -89% Mild
 Grade III = 70 - 79% Moderate
 Grade IV = ˂ 70 % Severe

b) Changes in height may be indicator of chronic malnutrition

c) Grade 0 = ˃ 95% Normal
d) Grade I = 90 -94% Mild
e) Grade III = 85 - 89% Moderate
f) Grade IV = ˂ 85 % Severe

3. WHO criteria

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 Wasting = ↓ WFA below median

 Stunting = ↓ HFA below median

4. Kanawahi criteria

Using MUAC
H.C

 Mild = ˂ 0.31
 Moderate = ˂ 0.28  Bilateral edema
 Severe = ˂ 0.25  Z-score ˂ -3
Kwashikor  MUAC ˂ 11.5
It is acute protein deficiency with normal or even high coloric intake.
This sickness the baby gets when new baby comes
Causes of kwashiokor
Primary
 Sudden weaning on starchy
 Maternal deprivation
 1st baby when 2 nd baby comes
 Depressed child
Secondary
 Pertusis - recurrent vomiting
 Chronic diarrhea - protein loss in stool
 Measles - complicating enterocolitis
 Parasitic infection - Giardiasis

Pathology of kwashikor
Acute protein loss lead
1. Decreased plasma protein
2. Brain slowly atrophy
3. Delayed bone growth - which causing reduction of total mass of bone
Osteoporosis
4. skeletal muscle - degenerative changes compensate ↓ plasma proteins
5. Liver - fatty infiltration ( steotosis) but usually no necrosis or cirrhosis
6. Gastro-intestinal tract - atrophy of villi decreased digestive and absorptive
enzymes
7. Pancreas - atrophy of acini ↓ digestive enzyme Steotorhea

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8. Heart degenerative changes in cardiac muscle weakness( Heart small in

early stage) .
Clinical feature of kwashikor
1. Constant feature
2. Variable feature

Constant feature
1. Oedema
 Starts in dorso of feet and hands then
 the upper and lower limbs
 Bilateral pitting and painless
 Shiny overlying skin
 facial oedema produce prominent pale cheeks ( Doll facies)
 Periorbital edema
 No ascites and pleural effusion

Kwo Hypoalbunemia Reduced plasma osmotic pressure Decreased anti-

oxidant (V.E , V.A, gluthaton) Free radical damage increased capillary permeability
+
Increased ADH Na and water retension.

Grade of oedema
Grade 1 : + both feet or ankle
Grade 2: ++ both feet , lower leg , hand and lower arm
Grade 3 : +++ generalized all limb and face

2. Mental change
Patient looks apathic , Miserable
3. Growth retardation
failure to thrive weigh follow by weigh loss
4. Muscle wasting
o Muscle are thin , atrophic and weak
o Decreased MUAC ˂ 12cm
o H.C / C.C ratio ˃1
Variable kwashikor
1. Hair changes - hair brittle - easy pickable
Black Brown yellow Gray
Brittle hair :Flag sign - Alternating bands of lights color and normal color occurs in long haired
with multiple relapsed due to tyrosine deficiency .

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Copper and tyrosonie Essential for melanin synthesis.

2. Dry scaling skin
 Erythems - hyper pigment
 Desquamation ( razy prving or flacky pint dermatosis)
Skin infectious come due to :
o Vitamin A deficiency
o Essential fatty acids deficiency
o Zinc deficiency
o oedema fluid
o Fissuring
kin infection sites :
Pressure area
 buttock
 Knees
 Ankle
Irritated area
 Groin
 Perineum
3. Hepatomegaly
o Reversible for treatment , No cirrhosis
o Fatty liver due to high fatty acid synthesis
4. Diarrhea
o Infectious - Gastroenteritis
o Non-infectious - due to malabsorption e.g. Lactulose intolerance
5. Abdominal distension
o Malabsorption
o Hypokalemia
o Toxic ileus with infection
o Gaseus
6. Anemia due to
o Iron deficiency - microcytic anemia
o Folic acid deficiency and B12 deficiency (megablatic anemia)
o Prothrombin deficiency (Heamorrhagic anemia)
o Protein deficiency ( Normochromatic mormocytic anemia)
7. Vitamin deficiency
Eye:
 Bitot spot s, Corneal ulcer
Mouth :
Stomatitis
Vitamin B12:

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 Angular Stomatitis
 Cheilosis
Vitamin D
 Rickets
Vitamin K
 Bleeding tendency
Vitamin C
 Spong gum bleeding

INVESTIGATION OF KWASHIKOR
Confirm diagnosis
 Plasma protein o Plasma protein
Albumin ˂ 2.5 o Non-essential aminoacids
 CBC o Low urinary urea/ Creatinine
 Electrolyte

MANAGEMET OF KWASHIKOR
˂ 6 month
Phase Objective Product Protocol Meal time
used
Phase 1 To restore metabolic F 75 75 kcal× kg every 3 hour
function, stabilizer , treat = 100ml for 24 hours
and prevent complication /kg/day
Transition  To change  F100 75 kcal× kg
Phase therapeutic milk  Plumpy- = 100 ml
 Observe the nut /kg/day
increase in food
intake
 To test the RUFT
Phase 2  Intent to promote RUTF 200 4 milk meals
Rehabilitation rapid weight gain kcal/kg/day + 2 RUFT =
and catch growth. 6 meal

˃ 6 month

Phase Objective Product Protocol Meal time

used
Phase 1 To restore metabolic F 75 75 kcal× kg every 3 hour
function, stabilizer , treat = 100ml for 24 hours
and prevent complication /kg/day
Transition  To change  F100 75 kcal× kg every 3 hour

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Phase therapeutic milk  Plumpy- = 100 ml for day

 Observe the nut /kg/day
increase in food
intake
 To test the RUFT
Phase 2  Intent to promote RUTF 200 4 milk
Rehabilitation rapid weight gain (B- 100) OR kcal×kg/500kcl meals + 2
and catch growth. PLUMPNET /day RUFT =
6 meal

Days of phases:
 Phase 1: Maximum 7 days
 Transition phase : 1 to 3 days
 Phase2 : 7 day
MARASMUS
Marasmus is a form of severe malnutrition characterized by energy deficiency . child with
marasmus looks emaciated.
Body weight is reduced to less than 60% of the normal ( Expected ) body weight for age.
Marasmus occurrence increases prior to age 1.
Clinical feature of marasmus
 Thin face or old face
 Muscle and subcutaneous fat wasting
 Dry skin and brittle hair
 Prominence of the scapula , spine and ribs
 irritable
The following can also occur :
 Mental change - intellectual disability (Growth retardation)
 Chronic diarrhea
 Respiratory infection
 Stunt growth.

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Treatment of marasmus

Phase Objective Product Protocol Meal time

used
Phase 1 To restore metabolic F 75 100 kcal× kg every 3 hour
function, stabilizer , treat = 130ml for 24 hours
and prevent complication /kg/day
Transition  To change  F100 130 kcal× kg
Phase therapeutic milk  Plumpy- = 130 ml
 Observe the nut /kg/day
increase in food
intake
 To test the RUFT
Phase 2  Intent to promote RUTF 200 4 milk meals
Rehabilitation rapid weight gain kcal/kg/day + 2 RUFT =
and catch growth. 6 meal

 In phase 2: assess progressive of the weight gain.

Every 3 days calculate
 5 kg Bad
 5-10 kg Moderate gain
 ˃ 10 kg Good weigh gain
If the child cannot take half amount of RUFT in 12 hrs - stop RUFT and give F75 1-2 days
then start RUFT.

Routine medical treatment at admission

Disease Treatment D1 D2 D3 D4 D5 D6 D7
Bacterial infection Amoxacillin X X X X X
Intestinal worms Albendazole X
Folic acid Folic acid X
deficiency
Malaria Systemic RDT X
Vaccines Measles X
PCV 10 X
Pent valent ( day of transfer
ATFC)
Vitamin A Retinol X
deficiency Minimum 4 month after last
dose
Contra indication of Iron in malnutrition
 It promotes bacterial overgrowth

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 Body tries to prevent itself by converting tree iron tofferitine and need ATP and amino acid.
 Free iron promotes promotion free radical leading to uncontrolled chemical react.

Malnutrition two types: >>>>>>

(1): under malnutrition.
(2): over malnutrition.

Under malnutrition
A: SAM
B: MAM

SAM
A} complicated and Uncomplicated

SAM complicated
less than 6 months and greater than 6 months

< 6 months marasmic and kuwashkor

marasmic
phase 1 F 100
130xKg /3 hours
No trans or phase 2 only breast feeding.

Kuwashkor
phase 1 F 75
100xKg /3hours
Trans phase same amount
phase 2 trans plumpet 200xKg/500 for 7 days.

> 6 months 1: marasmic and kuwashkur

F 75 than F 100 trans phase 2 plumte than discharge

Uncomplicated SAM
trans OTP than give 200xKg/500 7 days.

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MAM
Trans TSFP than give 200xKg/500kcl 7 days.
Malnutrition
SAM and MAM
< 6 MONTHS marasmic and kwashkor

Kuwashkor
F 75 than tran phase 2 five F 100 give same amnoun of F 75

Marasmic
phase 1 F 100 dilute 130xkg/ 3hours No transtional phase give breast feeding only.

> 6 months both marasmic and kuwashkor

Phase 1: F 75 ------ 100xkg / 3hours.
Transtional phase: F 100 100xkg/ 3 hours.
phase 2: Plumpnet ------ 200xkg/500 >>>>>> 7 days.

10 STEPS FOR CHILD WITH COMPLICATION SAM

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1. Hypoglycemia
Unconsciousness
Give:-
 D50% 1ml × kg
 D10% 5ml × kg
 D5% 10ml × kg

If you have not these : -

 Use on Rounded Teaspoon of sugar in 3 teaspoon of water ( 100ml) orally or 50ml

Dextrose 10% by NG tube Then start to re-feed F75 130× kg = /8 every 3 hour.

Example ( 1 ): child 10 kg

5×10 = 50 ml of D10% - 1: 4 Ratio

10% of 50 % + 40 of normal saline = 50 ml of 10%.
If you have not Dextrose 50% but you have D5% use 1:9 Ratio

Example ( 1 ): child 15 kg

 5×15 =75 ml of D5% - 1: 9 Ratio

 10% of 75 % = 7.5 of 50%. = 75 ml.

Rule 4: 1 Ratio : If does not have 10% you have 50% and 5%.
Rule 1: 9 Ratio : f does not have N.S of water and you need 10% , you have 5% and 50%.

2. Hypothermia
 Conguro method
 Warming
3. Dehydration:
look tearing without history diarrhea.
 Resomol 5 ml × kg every 30 minute for 2 hour
 Shock give Mixed solution 0.20 ml/kg or 15 ml
Example (1) : child 4 kg

 5 ml × 4 kg = 20 ml
 20 ml every 30 minute for 2 hour
 20 ml × 4 tmes ( 30 minute) = 80 ml for 2 hours.

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4. Electrolytes & Minerals

 ˂ month : Zn 10mg ˃ Zn 20mg
 Potassium
 Magnesium
5. Infection
Penicillin G + Gentamicine
6. Micronutrient
Ferrofolic acid 60 mg
Vitamin A
Only marasmus - Not kwashikor
Kwashikor only if eye sign
 ˂ 6 month 50,000 IU
 ˃ 6 month 200,000 IU
And ˂ month Post measles.
7- Initial feeding
Kwashikor F75 100ml/kg

˂ 6 month
Marasmus F100 130ml/kg

˃ 6 month Both start F75 phase 1.

Criteria of discharge inpatient :

 Completed antibiotics
 Good appetite and gaining weight
 Lost any oedema
 Appropriate support in the community or home
 Mother / carer:
- Available
- Understands child‟s needs
- Able to supply needs

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What are the effects of malnutrition on the human body?

Typical adverse effects of malnutrition include:
 reduced muscle and tissue mass,
 decreased mobility and stamina as a result of muscle wasting,
 breathing difficulties, and an increased risk of chest infection and respiratory failure,
 wounds take longer to heal and illnesses take longer to recover from
What are the different types of malnutrition?
There are two major types of malnutrition:

 Protein-energy malnutrition - resulting from deficiencies in any or all nutrients.

 Micronutrient deficiency diseases - resulting from a deficiency of specific micronutrients.

What are the different forms of malnutrition?

Protein-energy malnutrition has two severe forms: marasmus (a lack of protein and calories)
and kwashiorkor (a lack of just protein). Common micronutrient deficiencies include: a lack of
iron, iodine, and vitamin A. During pregnancy, due to the body's increased need, deficiencies
may become more common.

What are the diseases due to malnutrition?

It leads to clinical syndromes such as Kwashiorkor, Marasmus, and Anemia. Kwashiorkor is a
protein deficiency disease, caused due to poor intake of protein or quality protein over a
prolonged period of time. Kwashiorkor causes swelling in the body especially in the hands, feet
and the face
What are the risk factors for malnutrition?
According to the academy, here are common risk factors for malnutrition:

 Hospitalization.
 Advanced age, particularly if accompanied by dementia.
 Dental health problems.
 Loss of appetite.
 Serious head injury.
 Eating disorder.
 Serious infection.
 Organ failure.

What is wasting in malnutrition?

Moderate malnutrition (MM) is defined as a weight-for-age between -3 and -2 z-scores below
the median of the WHO child growth standards. It can be due to a low weight-for-height
(wasting) or a low height-for-age (stunting) or to a combination of both.

What causes chronic malnutrition?

Chronic malnutrition, or stunting, is another form of growth failure. Chronic
malnutrition occurs over time, unlike acute malnutrition. ... Stunting starts before birth and is
caused by poor maternal nutrition, poor feeding practices, poor food quality as well as frequent
infections which can slow down growth.

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What is severe acute malnutrition?

Inpatient treatment of severe acute malnutrition. Severe acute malnutrition is defined by a
very low weight for height (below -3z scores of the median WHO growth standards), by
visible severe wasting, or by the presence of nutritional oedema

Part 25
Topics
1: Dehydration

Dehydration is a condition that can occur when the loss of body fluids, mostly
water, exceeds the amount that is taken in.

With dehydration, more water is moving out of individual cells and then out of the
body than the amount of water that is taken in through drinking.

Medically, dehydration usually means a person has lost enough fluid so that the
body begins to lose its ability to function normally and then begins to produce
symptoms related to the fluid loss.

Although infants and children are at highest risk for dehydration, many adults and
especially the elderly have significant risk factors.

Symptoms and Signs of Dehydration in Children

Be concerned if your child has an excessive loss of fluid by vomiting or diarrhea, or if the child
refuses to eat or drink.
Signs of dehydration include:

 Sunken eyes
 Decreased frequency of urination or dry diapers
 Sunken soft spot on the front of the head in babies (called the fontanel)
 No tears when the child cries
 Dry or sticky mucous membranes (the lining of the mouth or tongue)
 Lethargy (less than normal activity)
 Irritability (more crying, fussiness with inconsolability)

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Symptoms and Signs of Dehydration in Adults

The signs and symptoms of dehydration in adults range from minor to severe.

Mild to moderate dehydration may include the following:

 Increased thirst
 Dry mouth
 Tired or sleepy
 Decreased urine output
 Urine is low volume and more yellowish than normal
 Headache
 Dry skin
 Dizziness

 Few or no tears

The above symptoms may quickly worsen and indicate severe dehydration with
signs and symptoms are developing; severe dehydration may include the
following:

 Severely decreased urine output or no urine output. The urine, if any,

produced is concentrated and a deep yellow or amber color.
 Dizziness or lightheadedness that does not allow the person to stand or walk
normally.
 Blood pressure drops when the person tries to stand after lying down (low
blood pressure or orthostatic hypotension)
 Rapid heart rate
 Fever
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 Poor skin elasticity (skin slowly sinks back to its normal position when
pinched)
 Lethargy, confusion, or coma
 Seizure

 Shock

N.B: Take the person to the hospital's emergency department if these situations
occur:

 Fever higher than 103 F (39.4)

 Confusion
 Lethargy
 Headache
 Seizures
 Difficulty breathing
 Chest or abdominal pain
 Fainting

 No urine in the last 12 hours

Ask five questions.

1: duration: {long time or short time}.

2: Frequency: {Hour, days, weeks, etc]

3: Amount: {Large or Small}

4: Character: {Color or consistency}

5: Order: {Bad or Not}

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LOOK ( GEMS)

I. G: General appearance - e.g. alert, irritable, and lethargic / conscious.

II. E: Eye - e.g. Normal , Sunken ,Deep sunken and puffy
III. M: Mouth - e.g. Drink normal ( moisture) , eagerly drink and unable drink
IV. S: Skin pinch - e.g. Rapid return , slowly , and very slowly.

Classification of dehydration
1) No dehydration: {Plan A}
 General appearance - alert
 Eye - e.g. Normal
 Mouth - e.g. Drink normal ( moisture)
 Skin pinch - e.g. Rapid return
2) Some dehydration: {Plan B}
o General appearance - e.g. irritable
o Eye - e.g. Sunken
o Mouth - e.g. eagerly drink
o Skin pinch - e.g. slowly Return.
3) Severe dehydration: {Plan C}
 General appearance - lethargic / Unconscious.
 Eye - e.g. Deep sunken eyes.
 Mouth - e.g. unable to drink
 Skin pinch - e.g. very slowly return.

Shock

capillary refill ˃ 3 second

Cold hands /feet
unconsciousness
Weak pulse and Hypotension

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Management of dehydration
1. No dehydration : {Plan A} Use ORS
50ml × kg for 4 hours
˂ 2 year Give 50- 100ml / stool
˃ 2 year give 200ml /each stool
For the worm use Albendazole 400mg
 ˂ 1 year Contraindication

 1-2 year give ½ = 200mg

 ˃ 2 give 1 tablet start single dose

Zinc
 ˂ 6 month give ½ = 10mg
 ˃ 6 month give 1 tablet = 20mg
2. Some dehydration: {Plan B} Use ORS- Ringer solution
- Use oral ORS or NGT
80ml /kg for 4 hours
- If vomiting increase
use Ringer 80ml /kg for 4 hours
- If the patient is malnutrition
Give Resamol 5 ml /kg every 30 minute for 2hours
Also give Albendazole 400mg
 ˂ 1 year Contraindication

 1-2 year give ½ = 200mg

 ˃ 2 give 1 tablet stat single dose

Zinc
 ˂ 6 month give ½ = 10mg
 ˃ 6 month give 1 tablet = 20mg
Erytromycin 250mg
 ˂ 6 month give ½ × 2 for 3 days
 ˃ 6 month give 1×2 for 3 days


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3. Severe Dehydration: {Plan C} use I.V fluids

 Ringer lactate solution
 If missed Normal saline
 Mixed solution for malnutrition
 SAM + Cholera + Severe dehydration Give Ringer solution.
Ringer solution 100ml ×kg
Phase 1
30ml×kg
 ˂ 1 year : for 1 hour
 ˃ 1 year : for 30 minutes
Ask urination if then Oliguria
Return 3o ml × kg
Phase 2
70 ml × kg
 ˂ 1 year : for 5 hour
 ˃ 1 year : for 2.5 hours
Give Albendazole , Zinc And erythromycin same as Plan B.
Also give ORS 5ml × kg
 Infant : 3- 4 hour
 Child : 1-2 hour
Ongoing loss
Vomiting :10 ml × kg
Diarrhea : 15ml × kg
Deficit
 ˂ 2 year : 50 - 100ml/Stool
 ˃ 2 year : 200ml/Stool
Maintenance
100l ×kg
Bolus
30 ml × kg
 Do not give dextrose because it causes Hyponatremia .

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Shock
1. Dehydration + Malnutrition
15 ml × kg = bolus for mixed solution for 1 hour

Not responding

Repeat 15 ml ×kg

Not responding

Cholera Suspect

Use Ringer 15 ml × kg ( unconsciousness) or consciousness use Resomal + F75

Not responding There is no hypovolemic

Suspect septic shock

Maintenance 4ml ×kg/hr
Blood transfusion
10 ml ×kg for 4 hours ( Whole blood + lasix 1ml ×kg)

2- Dehydration only
20ml × kg : Bolus

For Ringer lactate only

Not responding

Repeat 20 ml ×kg

Not responding there is no hypovolemic

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Suspect septic shock

Blood transfusion
15ml ×kg for 4 hours

Example: 10kg × 15 ml × 10 = 6 drop /minute

Differentiation
4 hour (between Malnutrition and dehydration
240 minute)
 Dehydration
 Dry mouth
 Oliguria
 Lack of tear
 Depressed fontanels in ˂ 18 months.

Acute water diarrhea: {AWD}

Cholera /Acute water diarrhea Case Management

Cholera has only patient aged 5 year or more presenting acute water diarrhea.
Confirmed cases: Those suspected for Vibro cholera or 0.39 has been confirm by culture or PCR.
Rice water + fever + No pain + Odorless = Cholera
Cholera kill the patient within 7 hours.
Assessment of diarrhea
I. Ask 5 questions
1. Duration
2. Frequency/ hour
3. Amount- large/small
4. Character - Colour/ consistent
5. Order
Ask urination To confirm degree of diarrhea
Anuria = ˂ 100 ml /24 hour
Oliguri = ˂ 300 ml/24 hour
Any case that hydrate water if not urinate 6 - 8 hour suspect Renal failure.

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II. Look For General Condition

Convulsion + Abdominal distension + muscle paralysis = Hypokalemia
Eye , Mouth and skin
Approach for Cholera
1. assessment of dehydration
2. Rehydration
3. Use of antibiotic
4. Management Complication
5. Treat Co-morbidities
6. Discharge
Case management
 Replacement
 Maintenance
 Antibiotics

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IMMUNIZATION
OPV0 Birth upto 15 day
BCG Birth upto 15 day - give BCG in left hand ( deltoid muscle) intradermal.
If missed BCG 45 days - 1 year
OPV1 Give 45 days
Penta1 Give 45 days - on the right thigh Site of injection

OPV2 30 days after dose  Penta 1 and 2 : Right thigh

Penta2  Penta 3 : Left thigh

OPV3 30 days after second dose

Penta3

Measles 9 month on the right hand + Vitamin A up to 5 years

In outbreak measles give ˃ 6 month.
BCG you can give until 11 month
OPV upto 5 years
Penta upto 2 years

Growth parameters

 Weight
 Height
 Head circumference
 Chest circumference

Growth measurement in length

o Recumbent length
o statuew
Growth in length and stature
 Zygote 0.14 mm in diameter

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 Birth: Boy: 50.5 cm

Girl: 49.9 cm
 Year : Boy: 76.6.5 cm
Girl: 75 cm
Growth in Length and Stature
 At birth: 50 cm
 6 months: 68 cm
 1 year : 75 cm
 2 years: 87 cm
 3 years: 94 cm
 4 years: 100 cm (2 times birth length).
 Between 4-8 years, the height increases about 7 cm/year.
 5 years: 107 cm
 6 years: 114 cm
 7 years: 121 cm
 8 years: 128 cm
 Between 8 -12 years, it is about 5 cm/year.
 9 years: 135 cm
 10 years: 140 cm
 11 years: 145 cm
 12 years: 150 cm (3 times birth length).
For a quick estimation of height/length,
length from 2-12 year = (age in years × 6) +77 cm.

Formula for average weight

Age Weight
 3 - 2 month : Age ( month ) + 9/2
 1 - 6 year : Age ( year) × 2 + 8
 7 - 12 year : Age ( year) × 7 -5 /2
Head Circumference
o 0 month 35 cm + 8

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o 6 month 43 cm + 4
o 1 years 47 cm + 2
o 2 years 49 cm + 2
o 6 years 51 cm + 2
o 12 years 53 cm + 2
Permanent Teeth
 6 years : First molar
 7 - 8 years : Primary teeth
 12 years : second molar
 ˃ 18 month : Third molar
Growth failure
 Primary : Low birth weigh
 Secondary : Normal Body weight due to organic 10% or inorganic 80%.
Growth Charts
Height for age : Stunting
Weigh for age: Under weight
Weigh for length: wasting
Weigh for height : wasting
BMI
Stage of development
o Neonate = 0 - 1 month
o Infancy = 1 month - 1 year
Early childhood
When to screen:
o Toddler = 1 - 3 year
At least 3 times before age 3
o Preschool = 3 - 6 year
Mild childhood  9 month
 18 month
o School age = 6 -12 years
 24 - - 30 month
Late childhood
o Adolescent = 13 - 18 years
Development of milestone
 Fine motor

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 Gross motor
 Language
 Social
IQ or Intelligent test = Mental change
Chronological age

130 + = Gifted
145 + = Genies
70- = More
55 - = imbecile
25 - = Idiot

Gross motor
New born = barely able to lift head
6 month = easily lift head ,chest , upper abdomen and can bear weigh on arm.
 2 month = needs assistance
 6 months : can sit alone
 8 month : can sit without support and engage in play.
 9 month: crawl
 1 year : Stand independent
 13 month : walk and toddler
 15 month: can run
 8 - 10 years : Team sports
 10 years : Match sports to physical and emotional .
Fine motor
6 month = Palmar grasp - Uses entire hand to pick an object.
9 month = Pincer grasp - can grasp small object using thumb and fore finger.
Speech milestone
 1 - 2 month : Coos
 2 - 6 month : laugh and sequels
 7 - 9 month: Mama and Baba unspecific

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 10 -12 month : Mama and Baba specific

 18 -20 month : 20 - 30 words 50% Under
 22 - 24 months : 2 words sentence 75 under
 30 - 36 months: all most all speech
Breast feeding : is the recommended method for feeding normal infants during approximately
the first 6 months of life.
The 24-hour intake of milk varies between mother-infant pairs from 440–1220 ml, averaging
about 800 ml per day throughout the first 6 months
 Exclusive only : breast feeding from 0 - 6 month.
 Complementary : 6 month - 2 years
Early = ˂ 6 month
Late = ˃ 6 month
Adequancy of milk intake :
1. Sixty to 8 times aday
2. Urine should be colourless
3. Loose yellow stool - 4 times /day.
4 positioning in Breast feeding
Cradle holding : Hand support of the infant
Cross- craddle or transitional holding : Support both hand , child 10 kg.
Foot ball or Clutch hold : sitting
Side lying position
Good feeding :
1. Position
2. Good attachment
 Mouth wide open
 More areola above
 Lower limp outward
 Chin touching breast
Baby's reflex
 Rooting reflex : good position and open mouth
 Sucking reflex : Lip touch areola

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 Swallowing reflex:

Tell the mother

 0 - 6 months = Breast feed only = complementary
 6 - 8 months = Begin Cereal 200kcl /day 3 times + Breast feed ( 3 spoon )
 9 - 11 months = begin Cereal 300kcal/day times + Breast feed
 1 year = Begin meet carrots, potatoes + breast feed 500 kcal/day plus 2 cup of milk , 3
paze food + salt no good to babies - give micro supplement + dewarming.

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IMCI
2 MONTH UP TO 5 YEARS

Ask about main symptoms

• Does the child have cough or difficult breathing.
• Look for chest {indrawing}
• Look and listen for {stridor}
• Look and listen for {wheezing}

Classify cough or difficult breathing

• Pink {severe pneumonia or very severe diseases}
• Yellow: {pneumonia}
• Green: {cough or cold}

Yellow {pneumonia}
• Amoxicillin 5 days.
• Wheezing {bronchodilator 5 days}
• Coughing for more than 14 days recurrent wheeze refer possible TB or asthma
assessment.
• Advise mother to return immediately follow up in 3 days.

Green {cough or child}

• If wheezing {bronchodilator for 5 days.
• If coughing for more than 14 days, or recurrent wheezing, refer for possible
TB or asthma assessment.
• Advise mother to return immediately.
• Then follow up in 5 days if not improving.

Does the child have diarrhea?

• If the yes the mother ask.
• 1: for how long?
• 2: is there blood in the stool?
• Then look and feel
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Look and feel

• General condition the child.
• 1: unconscious.
• 2: restless and irritable.
• 3: not able to drink or drinking poorly.
• 4: drinking eagerly thirsty.
• 5: pinch the skin of the abdomen does it go back {very slowly longer than 2
seconds slowly.

Dehydration
• Plan {A} Some dehydration
• Plan {B} moderate dehydration.
• Plan {C} severe dehydration.

Plan {C} color pink

• Two of the following signs.
• Unconscious
• Sunken eyes
• Not able to drink or drinking poorly
• Skin pinch goes back very slowly.

Pink severe dehydration [Plan} C

• Given ORS.
• Advise mother to continue breastfeeding.
• If the child in 2 yrs or older and there is cholera in area give antibiotic for
cholera.

Plan {B} some dehydration

• Two of the following signs
• 1: restless or irritable.
• 2: sunken eyes.
• Drink eagerly, thirsty.
• Skin pinch goes back slowly.

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Plan {B} some yellow color

• Fluid
• Zinc supplements
• Food for some dehydration.
• If the child severe urgently refer to hospital.

Not enough signs to classify

• As some or severe dehydration.
• Green no dehydration
• Fluid,
• Zinc supplements.
• Food to treat diarrhea at home {Plan A}
• Return 5 days not improving.

Dehydration or no dehydration
• Dehydration {pink severe diarrhea} refer to hospital.
• No dehydration {yellow diarrhea} multivitamins and minerals {including
zinc} for 14 days.
• Follow up in 5 days.

Blood in the stool

• Yellow dysentery:
• Give ciprofloxacin for 3 days.
• Follow up in 3 days.

Does the child have fever?

fever
• If yes
• For how long
• If more than 7 days has fever been present every day
• Has child had measles within the last 3 months

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Pink very severe disease

• Artesunate or quinine severe malaria
• Antibiotic
• Treat child present low blood sugar
• Paracetamol high fever 38.5 or above

Yellow malaria {+}

• Artesuante
• Paracetamol
• Antibiotic
• If fever is present every day for more than 7 days, refer for assessment

Green fever no malaria

• Paracetamol high fever 38.5
• Antibiotic
• If fever is present every day for more than 7 days rfer for assessment

Pink severe complicated measles

• Give vitamin A treatment.
• Give first does of an appropriate antibiotic.
• If clouding of the cornea or pus draining from the eye, appaly tetracycline eye
ointment.
• Refer to hopital

Yellow measles with eye or complicated

• Give vitamin A treatment.
• If pus draining from the eye, treat eye infection with tetracycline eye
ointment.
• If mouth ulcers, treat with gentain violent.
• Follow up in 3 days.

Green measles
• Give vitamin A treatment.
• Measles now or within the last 3 months.

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Does the child have an ear problem

• Pink {maatoiditis}
• Give first dose of an appropriate antibiotic
• Give first dose of paracetamol for pain.
• Refer urgentyl to hospital

Yellow acute ear infection

• Give an antibiotic for 5 days,
• Give paracetamol for pain.
• Dry the ear by wicking
• Follow up in 5 days.

Yellow chronic ear infection.

• Dry the ear by wicking
• Treat with topical quinolone eardrops for 14 days.
• Follow up in 5 days.

Green no ear infection

• No treatment.
• No ear pain and no pus seen draining from the ear.

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CASE PRESENTATION.
Pediatrics

History of personal Data

• Iqlas ali khalif aged at 14 months, female from dherkayley weights 8.8kg
and her length is 75cm, Z:<m admitted into pediatric department of Banadir
Hospital at 13/11/2017. Her mother brought to the Hospital due to fever for 3
days, cough for 3 days, vomiting for everything and rash for one day.

History of present illness

• Fever for 3 days before admission high intensity continues relieved by
paracetamol syrup and sponging not associated with chills and convulsion,
cough for 3 days dry worsening at night aggravated by giving milk.
• Vomiting for everything for one days.
• Rash for one day maculopapular rash started from the face, behind the ears
and hairline but still localized to the face
• not vaccinated at all, Measles contact
• O/E patients looks ill febrile maculopapular rash at the face, oral thrush,
conjunctivitis, nasal discharge, bilateral crepitation on auscultation,
• chest indrawing no signs of dehydration

T:38.9c , RR:48bpm, PR:140bpm

Questions
• What is the differential diagnosis?
• What is the diagnosis?
• What is the management?

Measles
• Measles is highly contagious viral disease which caused by single stranded
RNA paramoyxovirus.
• Human are the only natural host.
• Virus infects the respiratory tracts, skin, and regional lymph nodes.
• The infected persons are contagious(5 days before the onset of rash to 4 days
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after the .appearance of rash.

• Virus is present in respiratory secretions, blood, and urine of infected
individuals.
• virus is transmitted by large droplets from the URT and close contact.

Clinical manifestation
• Measles infection is divided into four phases:-
 incubation period
• 8 to 12 days from exposure to onset of symptoms or 14 days from exposure to
onset of rash.
 Prodromal phase(catarrhal).
• Fever usually above 38c or more
• Cough, coryza, conjunctivitis, stimson line and pathagnomic sign koplik
spots(last 12 to 24hrs).

Conti…
 Exanthematous phase(rash)
• The maculopapular rash begins on the head(often above the hair lines) and
behind the ears
• Spreads most the body within 24 hrs (cephalocadual).
• It fades in the same order of distribution.
• it may be petechial or hemorrhagic(black measles)
 recovery phases

How to diagnosis measles

• Diagnosis of measles is clinical diagnosis
• If child has fever with generalized maculopapular rash and either cough,
runny nose or red eyes, then the child has measles.
• koplik spots
• Measles contact.
• History of no vaccination
• Over crowding and poor housing

Laboratory and imaging

• Routine laboratory findings are non specific and do not aid the diagnosis.
• Leukopenia is characteritics
• Measles virus culture is not generally available.

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• Serologic testing for IgM antibodies which appear within 1 to 2 days of the
rash and persist for 1 to2 months that confirms the clinical diagnosis.
• Chest X-RAY may show interstitial or perihilar infiltrates that indicates
measles pneumonia or bacterial superinfection

Differential Diagnosis
• Rubella(German measles).
• Roseola infantum.
• Scarlet fever.
• Erythema infectiousum

Admission criteria
 Severe Complicated measles
• Inability to drink or breastfeeding
• Vomiting every thing
• Convulsion
• Lethargy or unconscious
• Corneal cloudy
• Deep or extensive mouth ulcers
• Severe Pneumonia
• Severe Dehydration from diarrhea
• Severe Acute malnutrition
• Stridor in calm patient

Risk factors for sever complicated measles

• Young age
• Malnutrition
• Overcrowding
• Immune deficiency
• Vitamin A deficiency

Management
 Vitamin A orally on day 1,2,8.
• Less than 6 month 50.000 I.U.
• Less than 1 year 100.000 I.U.
• Greater than 2 year 50.000 I.U.
 Prevent bacterial supper infection.

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• IV antibiotic if orally not suitable.

• Give orally as soon as possible

Conti…
 Tetracycline eye ointment(1x2 or 1x3 for 5 to 7days.
 Mouth care
• If lesions or ulcers: gentian violet 1x2 until lesions disappear.
• If oral thrush or candidiasis: nystatin 0.5mlx3 until oral thrush disappear.
 Antipyretics.

Monitor and treat complications

• High fever: give antipyretics such as paracetamol.
• If there is suspected coinfection such as malaria do malaria test or treat
clinically.
• Dehydration: assess degree of dehydration and classify no, some or severe
dehydration.
• Give orally by ORS in no and some dehydration or parental solution in severe
dehydration ( in malnutrition give resomol 5mlxkg for 30min for 2hrs.
• If not sufficient vomiting or severe dehydration: mixed solution 20mlxkg

Conti…
 Feeding
• If there is poor feeding decide NG tube for feeding.
 Check blood sugar
• If there is hypoglycemia dextrose 10% 5mlxkg iv or orally via NG tube.
• Photophobia: cover eyes with dressing.

Conti…
 Eye complication xerophthalmia
• Give vitamin A(day 1,2,8)
• Avoid touching of cornea be careful with cleaning of eyes.
• Prevent bacterial super infection by tetracycline eye ointment.
• Atropin eye drops for corneal cloudy.
•

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Complications and prognosis

• Measles is often complicated by otitis media.
• interstitial pneumonia(giant cell or, more commonly, pneumonia may result
from secondary bacterial infection.
• Measles may activate latent tuberculosis.
• Subacute sclerosing panencephalitis is a late neurologic complication of
slow measles infection that occurs in approximately 1 in every 1 million cases
of measles, developing an average of 8 to 10 years after measles.

prevention
• Live measles vaccine prevents infection and is recommended as MMR for
children.
 Contraindications to measles vaccine
• congenital immunodeficiency.
• severe HIV infection.
• leukemia, lymphoma, cancer therapy.
• immunosuppressive course of corticosteroids (≥2 mg/kg/day for ≥14 days).
• pregnancy;
Discharge criteria
• Able to drink or breastfeeding
• Non features of sever complicated measles such as:-
 severe pneumonia
 Severe Dehydration from diarrhea
 Corneal cloudy
 Deep or extensive mouth ulcer

Follow up
• Recovery of following acute measles is often delayed for many weeks and
even months especially malnourished children.
• Arrange for the child to receive the third dose of vitamin A before discharge.
Advise to return immediately if the child has any of these signs

Any sick child Not able to drink or breastfeed becomes

sicker develops a fever.
If the child has no pneumonia, cough or Fast breathing. difficulty of breathing.
cold, also return if.

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If the child has diarrhea, also return if. Blood in stool. drinking poorly.

Pediatrics

History of personal Data

• Suheyb c-risaq mohamed aged 36 months, male from hodon weights 9.2kg
and his length is 84cm, Z:<-2 admitted into pediatric department of Benadir
Hospital at 17/12/2017 informed by his mother

Chief complain

1-fever for 4 days

2-cough for 3 days

3-poor feeding for 2 days

4-Vomiting for everything for one day

History of present illness

• Pt complains Fever for 4 days before admission high grade continues no
aggravating factors but relieved by paracetamol syrup and sponging
associated rash for 3days. cough for 3 days dry aggravated by feeding
associated by vomiting ( non projectile and depend on feeding)
• Vomiting everything for one day.
• Rash for 3 days maculopapular rash localized started from the face, behind
the ears and hairline , chest and now is abdomen and back and disappear the
face.

Past medical history

• There is history of hospitalization(Atlantic Hospital) due to the diarrhea and
vomiting in the past year and stay for 8hrs and improved

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Drug history
• Antibiotics non specified
• Metro solution
• RL solution

All are past medications he used.

No known allergic drug

Birth history

• Antenatal : nutritional status of mother was poor.

• his mother visited in Benadir Hospital at one time during her course of
pregnancy and she was taking iron, folic acid and vitamins but she does not
used.
• She got TT vaccination (at BH) First dose at second trimester, her blood
sugar, BP and HB was not controled. Other doses missed.
• She had no medical illness and radiological, blood transfusion ,obstetric
complication, trauma, travel and surgical history during pregnancy.
• Impression: the mother does not had good antenatal care

Natal history
• he was born full term 38weeks at home delivered by TBA via SVD, cephalic
presentation, duration of labor was 8 hrs and the mother does not remember
the exact time of the membrane rupture
• Impression:

Post natal history

• The baby cried immediately after birth, his color appeared normal(pink) to
mother.
• he started movement as soon after the birth
• urine and muconiam passed 1,3 hr after birth respectively.
• There was not problems about sucking.
• Interpretation: good post natal care

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Feeding history
• Breast milk and water was his first meal within 1hr until [Link]
frequency of the feeding was 8-12 times per day . Minimum often 12
minutes was per feed.
• On his 9th month the baby was given formula milk (nunalac)5*per day with
soft food like (mashaariye), and banana for 2-3times per day.

After 2months she changed to ANCHOR milk 5spoons of milk powder mixed
with 150 ml of water for nearly four times per day..

• From 11 month up to the commence of his illness he used to take 3 cups of

milk plus 3times of family diet per day.
• Impression : not exclusive breast feeding ,lack of supplementary and poor
complementary feeding.

Immunization history

Mother said my baby was vaccinated only polio vaccine in my home.

Impression: incomplete vaccination

Developmental history
• No previous growth chart is available and the mother said I did not see any
difference from other normality of my old daughter.
• Gross motor: he can crawl and stand on wall when he was 9m
• Fine motor: he can transfer objects from hand to hand at that time. before
illness he was good. All other developmental milestones were good.
• Impression: His developmental milestones are normal according to his age.

Family history
• The mother is 19 yrs old and the father is 25 yr old they are not
consanguinity.
• The mother G:2 para:2+ 0
• He is the youngest out of 2 siblings.

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• His parents was well and there is no history of chronic illness.

• There is history of measles contact

Social and environmental history

• They live in hodon at a house consist 2 rooms, one toilet, rented , their water
source is tab water.
• The father works bakara market and the mother is house wife and their
income is insufficient as reported by the mother.
• No one in the family has bad habits.
 Impression: low socio economic income.

Systemic review
• CVS: has no edema, cyanosis, heart murmurs .
• Resp: there is cough and fine crackles but no hemoptysis and SOB.
• Genitourinary: urine output is well and no hematuria.
• CNS: normal
• HEENT: there is red eyes, pale conjunctive
• MSK: no abnormal movement, joint swelling and pain.
• Skin:maculopopular rash
• Endocrine: no tremor and heat intolerance.
• Hematological: no gum bleeding and epistaxis.
• GIT: was normal
• Impression: all systems are normal except respiratory and skin.

Physical examination
• General condition:
• The patient was alert conscious and no edema ,any swelling/ organomegaly ,
cyanosis, jaundice but there is pale and red conjunctivitis and skin rash

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Vital signs

On admission On examination

T: 38.6C T:36.8

P: 100bpm p:98

RR: 38bpm RR:29

 Impression: according to the age of the patient The vital sings are normal
except tem.

hyperthermia

Anthropometric

Weight: 9.2kg Height: 84cm

Z-score: <-2 MUAC: 14cm

W/A: under 5th percentile

H/A: under 5th percentile

W/H: under 5th percentile

 Impression: his anthropometric measurement is abnormal according to his

age.

Case summary
• Suheyb aged at 36months, male admitted into pediatric department of
Benadir Hospital at 17/12/2017 complaining Fever for 4 days before
admission high grade continues no aggrivating factors but relieved by
paracetamol syrup and sponging associated with rash, cough for 3 days dry
aggravated by feeding associated by vomiting non projectile.
• Vomiting for everything for one days.

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conti
• Rash for 3 days maculopapular rash localized started from the face, behind
the ears and hairline chest and now is abdomen and back and disappear the
face.
• O/E The patient was alert conscious and no edema ,any swelling/
organomegaly , cyanosis, jaundice there is pale and red conjunctivitis and
skin rash.

Suspect diagnosis
• Measles with chronic malnutrition

investigations
• CBC
• Malaria test
• X-ray

Progressive note
• On 18/12/2017 patient complain contiue fever relieved by spong and
paracetamol [Link] cough, skin rash of abdomen, back and face and
vomiting supsided feeding by NGT. And poor sleep
• O/E Tem 37.9c pulse 68 RR 35.
• Assmnt sub imroved
• Plan:Malaria test

Progressive Note

19/12/2017 Patient Complains dry cough Aggravated by Eating NO Relieving

Fever High Grade Continuous Not relieved by Paracetamol And spongy .

Skin Rush Continue At Abdomen Back .sleeping is unwell

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Progressive Note
• 20/12/2017 pt complains low grade fever intermittent without aggravating
factor but relieved paracetamol syrup, dry cough relieved by anti cough syrup
associated by poor feeding

O/E :pt look alert concious,oral ulcer ,conjunctivitis and pale.

V/S tem 37.8 RR 36 pulse 98

Progressive Note
• 21/12/2017 Pt complain dry cough without aggravating and relieving factor
no fever, urine and stool passed well sleeping is well feeding is good.
• O/E pt look alert, concious , conjunctivitis and pale.
• V/S:Tem 37.1 RR 30 pulse 100
• Plain: CM

Progressive Note
• 22/12/2017 Pt complain dry cough without aggravating and relieving factor
no fever, urine and stool passed well sleeping is well feeding is good.
• O/E pt look alert, concious , conjunctivitis and pale.
• V/S:Tem 37.1 RR 30 pulse 100
• Plain: CM

My Own Management
• Paracetamol Syrup >
• Tetracycline ointment
• Nystatin drop 0.5 drop
• Gentamycine 80mg 4.6ccx1
• Vit A 200000 IU 1.2.8
• P G 5mega 1ccx3
• Co artum 6 tab
• Ibuprofen syrup 4mlx2
• NGT for feeding

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• Chlorophenamide 2mlx3
• Dexamethazone

advice to the mother:

 to Give and complete vaccination here children
 To visit at MCH to take supplements and vaccination for here pregnancy
 TO GIVE her children Balanced diet specially protein rich in diet.
 To improve hygiene for her children and her home

Case Presentation
Severe Anemia

Banadir Hospital Pediatric Department

Personal Data

Name: Zakaria Nur Mohamed

Age: 15 Months Weight: 8.9 kg

Sex: Male Height: 80cm

Residence: Hamar JaJab Z-score: <-2

Information: Mother MUAC: 13

Date of admission: 08/03/2018

Date of history: 10/03/2018

History

Present Complain:

• Fever for a week

• Cough for three days
• Vomiting everything for three days
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• Diarrhea mocoid for a week

• Dysurea for a week
• Sometimes difficult urination

History of presenting illness:

• Fever

Onset: one week

Grading: High grade

Timing: Intermittent

Aggravating: Hot condition

Relieving: Sponging and Pracetamol syrup

Cough:

Onset: three days

character: productive

Aggravating: cold water

Relieving: vomiting

No Associating factor

Diarrhea:

Onset: One week

Type: Mocoid

Frequency: 3 times per day

Color: Greenish

Aggravating : Drinking milk

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Past medical history includes

Drug history include
• Past:
anti malaria, antibiotic, analgesic
• Presents:
Ampicillin 500mg injection, Gentamycine 80mg

Lab history history:

• Past : Hb-control was already done not remember result

Malaria smear (-)

• Present: WBC=8.9x10^9/L, HGB= 2.3gdl, PLT=297x10^9/L

MCV= 80.2 Fl, MCH= 25.5 pg

Birth history:

• A- Maternal history (antenatal history) before birth

– Health status of the mother:
• The mother is good health during pregnancy
– Nutritional status :
• The mother was good nutritional during pregnancy
• B- Anti natal care of the mother during the pregnancy before birth:

A -Supplemental iron and folic acid and vitamins

The mother was tacked vitamins during pregnancy

B - Blood transfusion of the mother

The mother was no any blood transfusion during pregnancy

C -Vaccination of the mother : yes

D-Radiological performed during pregnancy:

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The mother was not any radiological performing during the pregnancy

E- Medication of the mother during of the pregnancy:

The mother tacked vitamins during pregnant

F-Monitory of the blood sugar and blood pressure

The mother has monitoring of blood pressure, HB during the pregnant

G -Medical illness before during pregnancy

The mother was good during pregnant

H -Obstruct complication in past pregnancy

This child is her fourth baby

I-Trauma of the mother during pregnant , no

J-Travels of the mother during pregnancy

The mother was no any travels during pregnant

K-Surgery of the mother during pregnancy

The mother was no any surgery during pregnant

C-Natal or neonatal history: at birth

A- 38 wks of gestation age

B-Way of presentation; cephalic presentation Spontaneous delivery by home

delivery

C-Duration of labour is 8hrs

D-Membrane rupture is not clear

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D-Post natal history: After birth

A -Crying immediately at birth

B -Stool passes normally

C -Urine passes normally

8-Feeding history

• First feed was water

• After 2hrs give the breast milk and formula milk
• Continue up to 10 months
• She begin semi solid food at 6 months

9-Immunization or vaccination history

• partial immunization

Growth and developmental history

Developmental milestones
• Gross motor
– 2wks he moved head side to side
– 2moth lift shoulder while prome
• Fine motor
– 2month Eyes follow object to midline
• Personal behaviour
– At 2wks regard face
– At 2month smile responsively
– At 4month he look at hands
• Language
– At 2month he is cooing
– At 3month he laughs
• Reflex
– All reflexes are disappears

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11-Family history

A -Name of father Nur Mohamed Abukar age: 40 yrs

B -Name of the mother : Casho Nur Ja`far age: 28 yrs

C-the mother and father are no consanguineous

D-there have no any chronic disease

E-His mother and father are live together

12-Social economic history:

• His father has no Habits
• Living condition is normal
• Job. worker in business man
• Economic income : normal
• House hold: four rooms and one toilet
• Water source: tap water

Physical examination

Vital signs

– T. 36 . 4
– RR. Not known
– P. 120 per/min
Anthropometric measurements

– Weight 8.9 kg
– Height 80cm
– Z-score <-2
– MUAC 13

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• General appearance
• he is alert and looks ill
• he is consciousness and he reacts to the environment
• Head
• HC: not kown
• Size and shape of the head are normal
• Face
– No Rash
– No facial palsy
• Eye
– No ptosis.
– No eye discharge
– Pale conjunctivita
– No Sclera ulceration
• Mouth
– No oral lesion
– normal cleaf plate
– No Oral thrush
– No cyanosis
– No Dry mouth
• Nose
– No nasal discharge.
– No nasal congestion
– Normal Movements of alae nasi
• Ear
– No ear discharge
– Normal position of ear
– Normal set ears
• Neck
– No neck stiffness
– No abnormal swelling of the neck
– No palpable of cervical lymphanode
– Thyroid and neck veins and lymphanode are normal

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Chest and lugs

• Inspection
o Respiratory rate are normal
o The Shape of the chest is normal
o No Deformity
o Chest movement was normal
o No scar in the chest.
o No dyspne
• Palpation
• Chest expansion is also normal
• No palpeple mass
• Auscultation
– Creptation
– wheezing
• Heart
Inspection
• No Bulging of pericardium
• No Visible pulsations
Palpation
• NO Palpitation and tachycardia
• Palpation of pericardium is normal
AUSCULTAION
• No murmurs on auscultation
Abdomen
– Inspection
– normal
– Palpation
• No mass and hernia in the abdomen
Percusion: normal
– Auscultation: nothing heard
– Premium and genitalia
– No fissures

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– No bleeding in the vagina.

– No any Premium and genitalia dermatitis

Rectum

• No fissures
• No hemorrhoids no prolapsed
• Sphincter tone is intact.

Back of spine:

– normal
• Limbs
– Extension and Flexion of both limbs are normal
– Muscular system are normal
– Norm tonic
• Nervous system
– No abnormal sensory findings
– The baby was Conscious
– Sensation responses are normal
• Motor system
– Normal tonic
• Cranial system
– No abnormal l visual
– No abnormal hearing

Diagnosis
• Iron Deficiency anaemia

Deferential diagnosis
• Haemolytic Anaemia
• Pernicious Anaemia

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Investigations

Complete Blood Count ( CBC)

Management

Hospitalization

Blood transfusion: 135ml per 3 hours with blood grouping ( AB Rh + )

 Lasix 20mg injection = 0.9ml
Ampicillin 500mg injection 3ml x 3
Gentamycine 80mg injection dilute 4ml x 1

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