2548

Topic for OPD round and teaching round

Cyanosis .
Topic OPD teaching
Dyspnea .
Syncope .

Topic for teaching round Topic for OPD teaching

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stridor .
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Topics for teaching round OPD teaching

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Topics for OPD and ward teaching round

approach .

Topics for OPD teaching

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Topic for teaching round Topic for OPD teaching

Abnormal growth & development .

12

30

35

55
59

77

Topic for OPD round and teaching round

: ..401
..502
..601
(central cyanosis)

4 round word 7 8
5 round word 7 8
4 OPD teaching 7 8
5 OPD teaching 7 8

-
-
- investigation
-
-

1. ,

2.

3.

4.

1.
2.

Cyanosis
..
Cyanosis : deoxygenated hemoglobin 3 g/dL blood
gas arterial oxygen desaturation (hypoxemia)
History taking:
1. Central or peripheral cyanosis:
Central cyanosis:
Peripheral cyanosis : acrocyanosis
- peripheral vasoconstriction 24-48
2. central cyanosis:
2.1 Cardiovascular system :cyanotic heart disease
2.2 Pulmonary system (ARDS, Respiratory distress)

2.3 Neurology system hypoventilation CNS dysfunction

Respiratory neuromuscular dysfunction
2.4 Hematology system hypoxemia ( O2 saturation > 95%
blood gas ) Methemoglobinemia, , Abnormal hemoglobin : Hb Tak
3. : TOF
(squatting) D-TGA, TAPVR
dyspnea, failure to thrive congestive heart failure
Physical examination :
1. Pattern of respiration:
intercostal subcostal retraction (nasal flare) grunting

2. Heart examination: murmur systolic ejection murmur 2
single S2
3. Clubbing of fingers
3. signs of CHF
Investigations:
1. Hematocrit transcutaneous oxygen
polycythemia oxygen saturation 95%

2. (CXR)
CXR
egg shape Transposition of great vessel boot shape
Tetralogy of Fallot
3. (Electrocardiogram-ECG)
QRS axis
Differential diagnosis:
(decreased pulmonary
blood flow-PBF) pulmonic (increased PBF)
CHF (dyspnea)
Cyanotic Heart
Disease
Decreased PBF
TOF
TA
PA

Increased PBF
TGA
TAPVR
Truncus

CXR ,ECG

TOF

SEM grade3-4/6 at LMSB,

single S2
Tricuspid atresia Similar to TOF
Pulmonary atresia No murmur or continuous
& intact ventricular murmur LUSB or PSM at LLSB
septum
(TR murmur ) , Single S2
D-TGA
No murmur or soft SEM,
Single S2
TAPVR
TRUNCUS

Decrease PBF,RVE,
(boot shape)
Decrease PBF,LVE
Decrease PBF,heart size
normal or cardiomegaly
(from RAE)
Increase PBF,
cardomegaly (egg
shape)
SEM LUSB, Split S2
Incresase PBF,
cardiomegaly (snowman)
Systolic or diastolic or continous Increase
PBF,cardiomegaly
murmur , Single S2

Right axis deviation, RVH

Superior QRS axis, LVH
Normal QRS axis,
RAE,LVH
Right axis deviation, RVH

Right axis deviation, RVH

Normal axis, Biventricular
Hypertrophy

Treatment:
1.
emergency modified BT shunt
2. TOF Hypoxic spell
Propanolol 1-4 mg/kg/day Ferrous sulfate syrup
Total correction TOF 10 kgs ( .. )
6
single ventricle repair Glen shunt
Total cavopulmonary shunt
3. D-TGA, TAPVR,TRUNCUS
CHF 6 CHF
lanoxin, lasix, ACE-inhibitor
3.
Brain abcess (amoxil) Bacterial
endocarditis
References
1. Park MK. Physical examination. In Pediatric cardiology for practitioners. 3rd ed. St. Louis, Mosby,
1996:10-33.
2. Fyler DC, Nadas AS. History, Physical examination and laboratory tests. In Fyler DC, editors.
Nadas s Pediatric Cardiology, St. Louis; Mosby:1992:101-116.

Topics for OPD teaching

..
: .. 502
.. 601
dyspnea, tachypnea
5 OPD teaching 4
6 OPD teaching 4

1.
2.
3. investigation
4.

5.

1. CHF respiratory distress

2. dyspnea cadiac cause (CHF), respiratory
cause (asthma) metabolic disease
3. ECG, CXR, Oxygen saturation echocardiography
4.

1.
2.

Dyspnea
..
(shortness of breath)
OPD (acute) (chronic)
unstable vital signs,
(hypoxia)
Differential diagnosis:
1 2
1. Respiratory asthma,pneumonia, bronchiolitis,
2. Cardiac congestive heart failure (CHF)
3. upper airway obstruction: Foreign body obstruction, croup, epiglottitis
4. metabolic acidosis sepsis, severe dehydration, DKA congenital metabolic
disorder
5. psychogenic disorder hyperventilation syndrome, pain, anxiety
6. neuromuscular disorder
7. hemotologic disorder :severe anemia
History taking:
respiratory cardiac

pneumonia, croup , bronchiolitis ,epiglottitis acute
pneumothorax , pulmonary embolism foreign body obstruction
(
) CHF
Congenital heart disease Left to right shunt (large VSD, large PDA, AV canal etc.)
cyanotic heart disease increased pulmonary blood flow
4-6 ()

CHF Acquired heart disease
acute rheumatic carditis, myocarditis pericarditis
(dyspnea on exertion) (orthorpnea)
11

Symptom or features in the history

Cough
Severe sore throat
Pleuritic chest pain
Orthopnea, nocturnal paroxysmal
Dyspnea, edema
Barking cough

Possible diagnosis
Asthma,pneumonia
Epiglottitis
Pericarditis, pulmonary embolism
Pneumothorax,pneumonia
Congestive heart failure
Croup

Physical examination:
respiratory failure sudden cardiac arrest
1
- hypotension, altered mental status unstable arrhythmia
- high respiratory rate, retraction, cyanosis oxygen saturation
- Stridor breathing effort air movement( upper airway obstruction )
- Unilateral tracheal deviation, hypotension unilateral breath sounds( tension
pneumothorax)
Vital sign, , mental status
clubbing finger
Pulmonary : tracheal deviation, chest wall subcutaneous emphysema chest wall
( dullness-consolidation, hyperresonance pneumothorax)
Cardiac: arrhythmia, distant heart sound, gallop,(S3, S4),murmur, P2
Sign of CHF: jugular venous distension, hepatomegaly, edema
21
Findings
Possible diagnosis
Wheezing ,accessory muscle use
Acute asthma
Fever, crackles, increased fremitus
Pneumonia
Edema, neck vein distension, gallop, murmur
Congestive heart failure
Hepatomegaly
Absent breath sounds, hyperresonance
Pneumothorax
Inspiratory stridor, rhonchi, retractions
Croup
Sridor, drooling, fever
Epiglottitis
Stridor, wheezing, persistent pneumonia
Foreign body aspiration

Investigations:

Pulse oximetry:
CXR:
Film lateral neck : upper airway obstruction croup, foreign body aspiration , epiglottitis
ECG: arrhythmia, ventricular hypertrophy
Echocardiogram:
CBC with platelet :
Management:

airway (breathing) circulation oxygen
endotracheal tube intravenous fluid

Reference
1. Zoorob RJ, Campbell JS. Acute dyspnea in the office. Am Fam Physician 2003; 68:1803-10.

Syncope
..

Syncope postural tone

syncope cerebral perfusion

cardiac output presyncope
pathophysiology syncope approach
15 8 18 syncope syncope
neurocardiogenic syncope benign syncope 6 syncope
breath holding cardiac arrhythmias syncope
1
cardiac syncope noncardiac syncope
syncope
benign neurocardiogenic
syncope (vasodepressor) syncope

Neurocardiogenic syncope
syncope benign recurrent transient recurrent
1-2 12 17

viral syndrome mild dehydration

3 prodrome

vertigo 2% loss of consciousness 5-20
rarely seizure-like activity incontinence recovery phase 5-30


Neurocardiogenic
Other vagal
Vasovagal
Micturation
Cough
Carotid sinus
Hypoglycemia

Neuropsychiatric

Hyperventilation
Syncopal migraine
Seizure disorder
Hysterical
Breath-holding

Cardiac syncope
LVOT obstruction
Pulmonary hypertension
Myocarditis
Tumor or mass
Coronary artery
Arrhythmia

, upright posture

, , visual changes

insulin

,
,

vague, visual changes

Aura, migraine,
Aura
Psychological distress

Agitation

Excercise
Anytime exercise
, exercise
, paroxysmal
Exercise

, SOB

SOB
SOB, ,
SOB,
SOB,
,

1 syncope
LVOT= left ventricular outflow tract; SOB= shortness of breath

Cardiac syncope
exercise, ,
, recurrent syncope sudden death. Exercise-induced syncope
hypertrophic cardiomyopathy, congenital coronary malformations pulmonary hypertension ( 1)
tachyarrhythmia ventricular tachycardia, cathecholaminesensitive tachycardia, supraventricular tachycardia long QT syndrome.
sudden death hypertrophic cardiomyopathy, long QT syndrome, Wolf-ParkinsonWhite syndrome arrhythmogenic right ventricular dysplasia.
cardiac impulse, peripheral pulse
systolic blood pressure 20 .
volume autonomic dysfunction.
fundoscopic examination, Rombergs sign, gait evaluation, deep tendon reflex, cerebella function proprioception

 syncope
neurocardiogenic syncope
-Tilt-table test 0- 90
supine 5
60 hypotension bradycardia
neurocardiogenic syncope80-90% recurrent
unexplained syncope, unexplained syncope with body injury, evaluation of therapy, recurrent prolonged dizziness
-Glucose, electrolyte, CBC, urinalysis positive 10%
-EKG sinus bradycardia complete
heart block WPW syndrome, LQTS
-Echocardiography structural heart defect
-EEG prolonged period unconciousness recovery period seizure activity
syncope neurocardiogenic

(presyncopal symptom)
fludrocortisone beta blockers(atenolol, metoprolol, pindolol)
prognosis

1. Johnsrude JL. Current approach to pediatric syncope. Pediatr Cardiol 2000;21:522-31.

2 .Lewis DA, Dhala A. Syncope in the pediatric patient. The cardiologists perspective. Pediatr Clin
North Am 1999; 46: 205-19.
3.Gutgesell HP, Barst RJ, Humes RA, Franklin WH, Shaddy RE. Common cardiovascular problems in
the young: Part I. Murmurs, chest pain, syncope and irregular rhythms. Am Family Physician
1997;56: 1825-30.

Chest

Topic for teaching round

..
: ..401
..502

1.
2.
3. stridor
4.

4 7 8
5 7 8

1. OPD teaching
2. OPD teaching
3. stridor OPD teaching
4.
4.1

4.2
4.3
4.4
4.5

1. OPD teaching
2. OPD teaching
3. stridor OPD teaching
4.
4.1 acute bronchitis, acute bronchiolitis pneumonia


4.2

4.3 pleural effusion, empyema thoracis, pneumothorax,

pneumatocele lung abscess
4.4

3.
4.

Topic for OPD teaching

: ..502
..601

1.
2.
3. stridor
4.

5 OPD teaching 3 4
6 OPD teaching 3 4

1.
1.1 protective reflex
mechanical, chemical thermal injury
1.2

1.3
1.4
2.
2.1

2.2
2.3 respiratory disease nonrespiratory disease
2.4
2.5 -
3. stridor
3.1 stridor

3.2 stridor
3.3
3.4
3.5
endotracheal tule maintain airway

4.

4.1

4.2
4.3
4.4

1.
1.1 cough reflex
1.2

1.3 chest X-ray, lateral neck X-ray, lateral
decubitus view, CT chest tuberculin skin test
1.4
2.
2.1
2.2
2.3 chest x-ray, lateral neck x-ray, fiberoptic
bronchoscopy, artecial blood gas, pulmonary function test
2.4
3. stridor
3.1 stridor
3.2
stridor
3.3
4.
4.1

4.2

4.3 ,
4.4

1.
2.


..



mechanical, chemical thermal injury
3

- ? ? ?
? ? ?
? ?

- failure to thrive ? immunodeficiency, cystic fibrosis

- pulmonary hemosiderosis
- respiratory distress / cyanosis reactve airway disease, asthma, infection
- rhinorrhea, congestion and swallen turbinates, periorbital edema, halitosis sinusitis
- signs of atopic disease allergic disease
- nasal polyps cystic fibrosis
- tracheal deviation mediastinal mass, foreign body aspiration
- barrel chest / digital clubbing chronic lung disease (brochiectasis)
- small foreign body ? chronic cough
- monophonic wheeze foreign body, mass, congenital lesion, tracheomalacia,
bronchomalacia polyphonic wheeze reactve airway disease, asthma, acute

bronchiolitis,cystic fibrosis
-

fine crackles pneumonia, interstitial lung disease, pulmonary edema

coarse crackles
heart murmur congestive heart failure

Complete blood count

Sputum examination
Chest X-ray


spirometry, mantoux test, pH probe, HRCT chest scan, barium
swallow, bronchoscopy, echocardiogram, immune workup, nasocilliary brushing, sweat choride test

-
- CPR airway, breathing,
circuration
- dry cough
/
(reassurance) 4

- (cough medication)

5 anticholinergic
effect (tachycardia, hypertension, blurred vision, drying of mucous membranes, phycosis, convulsion)
-


..
(dyspnea) (shortness of breath)
(feeling of difficulty breathing)

Congenital/Anatomic
- Subglottic stenosis, vocal cord paralysis, macroglossia, Pierre Robin syndrome, laryngeal atresia,
pulmonary sequestration, pulmonary hypoplasia
Infectious
- Lower airway: brochiolitis, pertussis, pneumonia, tuberculosis
- Upper airway: croup, epiglottitis, tracheitis, peritonsillar abscess
Toxic, Environmental, Drugs
- Aspiration (fluid or foreign body), carbon monoxide poisoning, methemoglobinemia, smoke inhalation
Tumor/Cysts
- Head/neck: dermoid cysts, branchial cleft cysts, lingual thyroid, hemangioma, teratoma, papilloma,
brainstem tumor
- Thoracic: teratoma, cystic hygroma, bronchogenic cyst, pericardial cyst, neurogenic tumor, lymphoma,
leukemia
- Abdominal mass: hepatic mass, hepatoblastoma, neuroblastoma
Allergy: anaphylaxis
Pulmonary: asthma, atelectasis, pneumothorax, pleural effusion, hemorrhage, embolism
Cardiac: pulmonary edema
Renal: renal failure, metabolic acidosis
Hematology: anemia, acute chest syndrome
Muscle weakness: duchenne muscular dystrophy, spinal muscle atrophy
Miscellaneous: high altitude, exercise, anxiety, psychogenic hyperventilation, panic disorder

- ? ?
? ?
?

/?
?

()
-

crackles rhonchi pneumonia, bronchiolitis, fluid overload

wheeze reactive airway disease, asthma,
anaphylaxis, brochiolitis

distant absent breath sounds foreign body aspiration,

pneumothorax, massive pleural effusion

barking cough croup

loud murmur gallop congestive heart failure

cyanosis poor oxygen perfusion

low blood pressure poor skin perfusion shock
digital clubbing chronic disease (cystic fibrosis, bronchiectasis cardiac
disease)

ascites edema fluid overload

Complete blood count

Mantoux test
Chest X-ray

Pulse oximetry arterial blood gas

laryngoscopy, bronchoscopy, pulmonary
function test, CT head and neck, HRCT chest scan, CT abdomen, sonography, barium swallow, pH probe,
sputum examination, immune workup, serum for infectious or toxic substance, electrocardiogram,
echocardiogram, sweat choride test, muscle enzyme, electromyogram, nerve conduction velocity

-
- ? CPR airway,
breathing, circulation

 stridor
..
stridor
(partial upper airway obstruction)
(extrathoracic airway)

stridor stridor
viral croup
laryngomalacia stridor snoring
(flutter) oropharynx
stridor

Nose and pharynx: choanal atrsia, lingual thyroid, thyroglossal cyst, macroglossia, micrognathia,
hypertrophic tonsils/adenoids, retropharyngeal or peritonsillar abscess
Larynx: laryngomalacia, laryngeal web, laryngeal cyst, laryngocele, laryngotracheobronchitis (viral croup),
acute spasmodic laryngitis ( spasmodic croup), epiglottitis, vocal cord paralysis, laryngotracheal stenosis,
intubation, foreign body, cystic hygroma, subglottic hemangioma, laryngeal papilloma, angioneurotic
edema, laryngospasm (hypocalcemic tetany), psychogenic stridor
Trachea: tracheomalacia, bacterial tracheitis, external compression

- stridor ? stridor ?

?
/ (choking) ? barking cough, brassy cough,
drooling, weak cry, muffled cry, hoarseness, snoring, dysphagia ?
? ?
?

inspiratory stridor glottis

expiratory stridor lower trachea
biphasic stridor glottis subglottis
larynx
hyperextension extrinsic obstruction at or above larynx
tripod drooling epiglottitis stridor
laryngomalacia
toxic appearance infection (epiglottitis, bacteria tracheitis,
retropharyngeal or peritonsillar abscess)

cutaneous hemangioma subglottic hemangioma

peripheral neuropathy vocal cord paralysis
urticaria/angioneurotic edema angioneurotic edema

AP and lateral views of neck tonsils adenoid

epiglottis retropharyngeal, subglottic tracheal

steeple sign subglottic area viral croup
AP and lateral views of chest radio-opaque foreign body pulmonary disease
FB aspiration
inspiratory and expiratory films
Barium swallow vascular compression, tracheoesophageal fistula
gastroesophageal reflux

Videofluoroscopy tracheomalacia, FB aspiration, vocal cord dysfunction

CT chest and MRA (magnatic resonance angiogram) vascular compression

Flexible and rigid bronchoscopy

- complete blood count, erytrocyte sedimentation rate, arterial blood gas,

electrocardiogram, echocardiogram

-
undrelying
disease precipitating cause upper airway obstruction score (Downes)
SCORE
Cough
Stridor
Retraction and Nasal flaring

0
None
None
None

Cyanosis
Inspiratory breath sounds

None
Normal

1
Hoarse cry
Inspiratory
Flaring and Suprasternal
retraction
In room air
Harsh with rhonchi

2
Bark
Inspiratory and Exspiratory
As under 1 + Subcostal and
Intercostal retraction
In 40% oxygen
Delayed

Score 0-3 mild airway obstruction, 4-7 moderate obstruction, >7 severe obstruction
score 7 artificial tracheal airway
-
-
(endotracheal intubation) tracheostomy
humidified oxygen

viral croup racemic epinephrine 0.05-0.1 ./. l-isomer of

epinephrine 5 . 1:1,000 solution normal saline (aerosol
therapy) 30 2
(rebound phenomenon) 4
stridor
steroids steroids 3

1. Dexamethasone 0.6 ./. Intramuscular single dose 6 .

2. Dexamethasone 0.15 0.3 0.6 ./. oral single dose
3. Nebulized budesonide 2 . 12 1


..
(lower respiratory tract infection)

acute bronchitis, acute bronchiolitis pneumonia
Acute bronchitis respiratory epithelium


(malaise) / rhinitis 3-4
dry, hacking cough productive cough
purulent leukocyte migration
2 3


coarse fine crackles scattered high-pitched wheezing
increased bronchial marking
antibiotics,
antihistamines, cough suppressants, expectorants

Acute bronchiolitis
respiratory syncytial virus (RSV)
50 RSV
2 2 6



RSV 2
surfactant protein A B immunologic
complex immune response, cytokines chemokines eosinophilic

cationic protein, IgE, IL-8, MIP, RANTES, IFG, leukotrienes

(38.5-39oC)
2-3
6
tachypnea ( hypoxemia

ventilation/perfusion mismatch (V/Q mismatch) / hypercarbia) work of breathing

(WOB) nasal flaring, chest retraction subcostal retraction fine
crackles wheezing prolongation of expiratory phase
hyperinflation hyperinflated lungs with patchy atelectasis

asthma, FB in trachea,
tracheomalacia, bronchomalacia, vascular rings, congestive heart failure pertussis
2-3 12 underlying congenital heart
disease, bronchopulmonary dysplasia, immunodeficiency disease
6
(supportive care)
hypoxemia cool humidified oxygen
WOB
nasogastric tube NPO parenteral
fluids bronchodilator (nebulized epinephrine, beta-agonist), corticosteroids
(parenteral,oral, inhaled)
Pneumonia
(respiratory bronchiole) (alveoli)

(empyema thoracic), (atelectasis), (lung abscess)

invasive communityacquired pneumonia 44-85 25-40
mixed infection Streptococcus pneumoniae RSV S. pneumoniae
Mycoplasma pneumoniae pneumonia 1. Lung disease:
asthma, cystic fibrosis 2. Anatomic problems: tracheoesophageal fistula 3. Gastroesophageal reflux with
aspiration 4. Neurological disorders that interfere with protection of the airway or compromise clearing of the airway
5. Disease of immne system: immunodeficiency, hemoglobinopathies
epidemiologic factors 4 immunization status health status

bronchiolitis viral pneumonia

brochiolitis 1 viral pneumonia 2-3
RSV, parainfluenza viruses, influenza viruses adenoviruses S.
pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae Streptococcus pyogenes,
Staphylococcus aureus, Haemophilus influenzae type b (),
nontypable Haemophilus influenzae, Chlamydia trachomatis ( 6
afebrile pneumonia) hospital-acquired pneumonia Staphylococcus

aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Acenitobacter spp., Enterobacter spp., E. coli,
Candida, Aspergillus viruses

viral bacterial pneumonia rhinitis

viral pneumonia bacterial pneumonia
tachypnea, increased WOB ( nasal flaring, subcostal,intercostal,suprasternal retractions, use of accessory
muscles) cyanosis respiratory failure
crackles / wheezing
hyperinflation chests viral, bacterial
Mycoplasma pathogens bacterial pneumonia
(restlessness)
consolidation dullness to percussion, decreased breath
sounds, bronchial breath sounds scattered crackles rhonchi stage of
pneumonia gastrointestinal vomiting, anorexia,
diarrhea abdominal distention ileus

1. Chest X-ray pneumonia

pleural effusion, empyema, atelectasis pneumothorax
pneumonia viral pneumonia hyperinflation
with bilateral interstitial infiltration and peribronchial cuffing bacterial pneumonia lobar
cosolidation, patchy infiltration, pneumatoceles, abscess
2. WBC count nonspecific lab viral pneumonia WBC

20,000/mm3 lymphocyte bacterial pneumonia

WBC 15,000-40,000/mm3 granulocyte (PMN)
3. 5-10 serologic testing acute
convalescent serum viral antigens

4. (definite diagnosis) blood, pleural

effusion lung positive
hemoculture 10-30 Mycoplasma pneumoniae cold agglutinins
titer > 1:64 50 influenza infection cold agglutinin negative

- supportive treatment specific treatment

maintenance fluid and electrolyte
(mechanical ventilation)
- Specific treatment antimicrobial drugs

 20 outpatient
1. afebrile pneumonia oral erythromycin (30-40 mg/kg/day divided 3-4 doses) oral
azithromycin (first dose 10 mg/kg, then 5 mg/kg/day for 4 days)
2. 4 -4 oral amoxicillin (80-100 mg/kg/day divides 3-4 doses)*
3. 5-15 oral erythromycin, azithromycin clarithromycin (15 mg/kg/day divides 2 doses)

8 oral doxycycline (4 mg/kg/day divides 2 doses)*

* amoxicillin/clavulanate, oral cephalosporins
4
(inpatient) newborn
1. IV ampicillin (100-200 mg/kg/day divided 4 doses)
5 IV pennicillin G (200,000-250,000 U/kg/day devided 4-6 doses)
2. IV cefotaxime (100-200 mg/kg/day devided 3-4 doses) IV cefuroxime
(100-150 mg/kg/day devided 3-4 doses) Staphylococcus aureus IV cloxacillin (100200 mg/kg/day divided 4doses)
3. highly penicillin-resistant S. pneumoniae methicillinresistant S.aureus IV vancomycin (60 mg/kg/day divided 4 doses) Gramnegative combination therapy IV
aminoglycoside (gentamicin, amikacin) IV ceftazidime (100-150 mg/kg/day divided 34 doses) IV imepenem, meropenem (60 mg/kg/day divided 3 doses)


..
(upper respiratory tract infection,URI)


common cold, sinusitis, otitis media, acute pharyngitis acute tonsillitis
Common cold rhinorrhea nasal obstruction
myalgia rhinovirus
6-7 10-15 12
2-3 1-3 sore throat, nasal
obstruction, rhinorrhea, sneezing, cough, fever 1 10
2 nasal secretion
secretion sinusitis bacterial superinfection
allergic rhinitis, foreign body in nose, sinusitis, pertussis,
streptococcal nasopharyngitis congenital syphilis otitis media
5-30 sinusitis 0.5-2 exacerbation of asthma
(symptomatic treatment)
- Antiviral: oseltamivir zanamivir influenza 48 pleconaril
rhinovirus
- Antipyretic drugs: acetaminophen ibuprofen
- Decongestant: 2 oxymetazoline,
xylometazoline phenylephrine
bradycardia, hypotention coma 3-5 rhinitis
medicamentosa pseudoephedrine (4 mg/kg/day)
CNS stimulation, hypertention palpitation
- Antihistamine (1st generation) 25-30 anticholinergic effect
ipratropium bromide
- bronchodilator, guaifenasin, vitamine C, zine Echinacea

- normal saline

bulb syringe
Sinusitis mucous menbranes paranasal sinuses
rhinosinusitis (RS) acute RS

 nasal discharge 10-14 (39oC)

purulent nasal discharge 3-4 bad breath (halitosis)
periorbital edema
3 chronic RS sinus plain films CT
scan opacification, mucosal thickening air-fluid level bacterial
RS
causative factors
URI, bacterial pathogens, allergy, adenoidal hypertrophy, airway pollutants,
structural anomalies of the sinus and nasal cavity, gastroesophageal reflux disease, immunologic defects,
primary ciliary dyskinesia cystic fibrosis antimicrobial treatment

suppurative complications
Streptococcus pneumoniae (~30%), nontypable Haemophilus influenzae (~20%)
Moraxella catarrhalis (~20%) amoxicillin (45 mg/kg/day) penicillin
cefuroxime axetil, cepodoxime, cefdinir, clarithromycin azithromycin
1-3 daycare 2
72 high dose
amoxicillin (80-90 mg/kg/day) amoxicillin/calvulanic acid (80-90 mg/kg/day of amoxicillin, 6.4 mg/kg/day of
clavulanate) 10-14 7 chronic RS
4 decongestant, antihistamine, mucolytic intranasal corticosteroid
bacterial RS
otolaryngologist

Otitis media 6-20

acute otitis
media (AOM) (irritable)
middle ear effusion rupture tympanic membrance with purulent otorrhea
recurrent AOM (AOM-R) AOM 4 6
otitis media with effusion (OME) middle ear effusion 8
AOM 2
daycare
(pacifier) (exposure to tobacco smoke)
pneumatic otoscopy tympanic membrane

AOM 48-72
2 Streptococcus pneumoniae
(~40%), nontypable Haemophilus influenzae (~25-30%) Moraxella catarrhalis (~10-15%)
amoxicillin (40 mg/kg/day) 2 high dose amoxicillin

(80-100 mg/kg/day) S. pneumoniae penicillin-intermediate some

penicillin-resistant strains 10

amoxicillin/clavulanic acid, cefuroxime axetil intramuscular ceftriaxone

cephalosporins cefpodoxime, cefdinir, cefprozil, cefixime cefaclor
otolaryngologist
Acute pharyngitis and tonsillitis mucous membrane pharynx tonsils
URI 33 sore throat
group A -hemolytic streptococcus (GABHS)
group C streptococcus, Arcanobacterium hemolyticum, Francisella tularensis,
Mycoplasma pneumoniae, Neisseria gonorrhoeae Corynebacterium diphtheriae
Adenovirus, Epstein-Barr virus (EBV), Coxsackievirus, Herpes simplex virus (HSV) streptococcal
pharyngitis sore throat
pharynx tonsils yellow, blood- tinged (petechiae) soft palate
posterior phartnx uvula anterior cervical lymph nodes
scarlet fever
viral pharyngitis rhinorrhea, cough, diarrhea
adenovirus pharyngitis (pharyngoconjunctival fever)
coxsackievirus pharyngitis small (1-2 mm), grayish vesicles punched-out ulcers posterior
pharynx (herpangina) small (3-6 mm), yellowish white nodules (acute lymphonodular pharyngitis)
EBV pharyngitis tonsils
(infectious mononucleosis) herpes simplex virus gingivostomatitis
GABHS throat culture falsenegative false-positive results GABHS
peritonsillar abscess, cervical lymphadenitis, mastoiditis rheumatic fever
streptococcal pharyngitis
penicillin V (250 mg/dose for children and 250-500 mg/dose for adolescent 3-4 )
amoxicillin 10 intramuscular dose of benzathine penicillin (600,000 U for children <
27 kg, 1.2 million U for larger children and adult) penicillin erythromycin
(erythromycin ethyl succinate 40 mg/kg/day erythromycin estolate 20-40 mg/kg/day 3-4
10 ) oral antipyretic/analgesic drugs (acetaminophen or ibuprofen)
(lozenges) benzocaine, phenol menthol
acute tonsillitis acute pharyngitis tonsils
/ adeniods
obstructive sleep apnea syndrome (OSAS) 4-10
chronic mouth breathing, nasal obstruction, hyponasal speech, hyposmia,

decrease appetite, poor school performance right-sided heart failure

loud snoring, choking, gasping, frank apneas, restless sleep, abnormal sleep positions,
somnambulism, night terrors, enuresis, diaphoresis, sleep talking
tonsils adenoids lateral
view OSAS pulmonologist
otolaryngologist

Topics for teaching round OPD teaching

..
: .. 401
.. 502
1.
2.
3.
4.
:
: 4
5

1

1.
2.
3.
4.
5.

Onset and duration

Intensity and location
Dyspeptic symptoms eg. Ulcer-like, reflux-like, or dysmotility-like dyspepsia
History related to lactose ingestion
Associated symptoms, including fever, vomiting, diarrhea, constipation, jaundice, abdominal
distension
6. Previous medical or surgical treatments e.g. drug-induced liver disease or pancreatitis
7. Past medical history related to abdominal pain, e.g. chronic hepatitis B and Family history

surgical condition medical condition

1. Signs of peritonitis, including tenderness, rebound tenderness, guarding and rigidity, absence bowel
sound, and Murphys sign
2. Signs of bowel obstruction, including abdominal distension, increased bowel sound
3.
4.
5.
6.

Organomegaly (e.g. hepatosplenomegaly), abdominal mass fecal mass

Anemia and jaundice
Look for any skin lesions e.g. palpable purpura in HSP
Per-rectal examination is very crucial.

2
surgical medical condition
1. signs of peritonitis bowel obstruction
2. acute appendicitis, acute pancreatitis, liver
abscess, acute cholecystitis, acute cholangitis, intestinal obstruction cause?

surgical condition
1. CBC, UA
2. LFT, amylase

3. Plain abdomen supine upright film intestinal obstruction

4. Ultrasound abdomen heptobiliary disease pancreatic disease
5. CT abdomen pancreatitis

medical condition
1. CBC, UA
2. Stool examination for parasite and occult blood
3. Plain abdomen fecal retention
4. gastroscopy clinical
5. Hydrogen breath test lactose intolerance

3

1. Onset and duration
2. feeding technique
3. type of formula e.g. cow milk vs. breast milk
4. characteristic of vomitus ,
5.
6. Associated symptoms cough, wheezing, abnormal posture, fever, diarrhea, constipation,
abdominal pain

1. growth and development
2. dehydration
3. epigastrium hypertrophic pyloric stenosis
4. Signs of intestinal obstruction increased bowel sound
5. Atopic rash skin
6. Per-rectal examination Hirschsprungs disease

4

1. Feeding technique force feeding
2. Gastroesophageal reflux disease
3. Cow milk allergy
4. Hypertrophic pyloric stenosis
5.
6.
7.
8.

Intestinal obstruction duodenal stenosis, intestinal malrotation, Hirschsprungs disease

Acute gastroenteritis
Gastritis and peptic ulcer disease
Metabolic diseases

 5
surgical medical condition
symptoms and signs
intestinal obstruction Hirschsprungs disease
meconium passage

6
acute diarrhea

(dehydration) 2 1)

10 .
9.5 . 500 5 %
5% deficit
(deficit) 500 . ( 500 =%deficit x BW x 10 ml) 2)
vital signs,
depressed anterior fontanelle, sunken eyeballs, poor skin turgor, urine output
3-5%, 6-9%, 10% deficit

(3-5%)
(6-9%)
Blood pressure

Quality of pulse

Heart rate

Skin turgor

Fontanelle

Mucous membrane

Eyes

Extremities

Capillary refill
Mental status

Urine output

<1 ././.
Thirst

(10%)

coma
<<1 ././.

 7

Virus: Rotavirus, Enterovirus 40, 41, Norwalk virus
Infection
Bacteria: Salmonella, Shigella, E. coli, Vibrio cholerae, Campylobacter
spp., Yersiner enterocolitica
Parasite: E. histolytica, Giardia, Isospora, Cryptosporidia
Inflammatory bowel diseases, Intussusception, Necrotizing enterocolitis,
Cow milk or soy protein allergy

Inflammation
Food poisoning
Antibiotic-associated diarrhea

8

oral rehydration therapy
morbidity mortality
AAP
ORT

Feeding

Mild dehydration

Moderate dehydration

50 ./. + concurrent loss

100 ./. + concurrent loss

Severe dehydration

NSS LRS 20 ././

4 . 4 . 1 . .
2 .

ORS vital

signs

Virus
Salmonella
Shigella

Campylobacter jejuni
Vibrio cholera
E. coli group
Amoeba

None
Co-trimoxazole, norfloxacin
Norfloxacin, co-trimoxazole, ceftriaxone, cefotaxime
Erythromycin
Tetracycline, erythromycin
Co-trimoxazole
metronidazole

 (Bleeding Disorders)
..

(hemostatic defect)

Hemostasis -

1. (vascular phase)
2. (platelet phase)
3. (plasma phase)

1. expose collagen subendothelium
von Willebrand factor (platelet adhesion and aggregation) platelet plug
2. factor XII prekallikrein coagulation intrinsic pathway
3. expose tissue thromboplastin tissue factor factor VII
coagulation extrinsic pathway
4. endothelial cells vessel tone

5. (Platelet phase) thrombin (factor II) platelet adhesion

aggregation
6. Plasma phase intrinsic extrinsic pathway
2 pathway prothrombin thrombin fibrinogen
fibrin fibrin polymer firm clot
7. (fibrinolysis)
endothelial cells plasminogen activators plasminogen plasmin
(fibrinolysis) fibrinogen fibrin clot fibrinogen degradation product (FDP)

 3 dynamic
thrombin platelet vascular phase FDP
fibrin platelet aggregation

(Hemostatic defect) 3

1. (Vascular defect)
collagen
2. (Platelet defect) 2
(thrombocytopenia) (platelet dysfunction)
(petechiae) (superficial ecchymosis)
3. (Coagulation defect)

2
-
()

- superficial ecchymosis
- petechiae -
- mucosal bleeding
- internal organ hemorrhage
2. -

- large deep ecchymosis

- hematoma
- hemarthrosis
- internal organ hemorrhage

1. coagulation defect
- Hemophilia A, B x-linked recessive factor VIII

IX

- Congenital factor VII deficiency autosomal recessive

- Hemorrhagic disease of the newborn (HDN) 7

, ,
- Idiopathic vitamin K deficiency in infancy (IVKDI) Acquired prothrombin complex deficiency (APCD)
2 2
- Secondary prothrombin complex deficiency biliary atresia, cirrhosis
2.
- Scurvy ()
-

Secondary vasculitis autoimmune vasculitis, Henoch-Schoenlein purpura

- Connective tissue disease Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta

3.

(thrombocytopenia)
-
Immune thrombocytopenia purpura (ITP)
Hypersplenism
Hemolytic uremic syndrome (HUS)
Giant hemangioma (Kasabach-Merritt syndrome)
Cyanotic congenital heart disease
Systemic lupus erythematosus (SLE)
-
Aplastic anemia
Acute leukemia

neuroblastoma, lymphoma
toxins
(platelet dysfunction)
Acquired platelet dysfunction with eosinophilia (APDE)
Drug induced , NSAIDs
Uremia
Congenital disorders Glanzmann disease, Bernard-Soulier syndrome

approach (Bleeding tendency)

1.
- - (multiple sites)

local
causes


- - mucous membrane bleeding
petechiae, superficial
ecchymosis
(intramuscular hematoma) (hemarthrosis) deep tissue or large ecchymosis
- (onset) -
(congenital or acquired)
- (spontaneous) (trauma)
- (severity and duration of bleeding)
-

- -
5-10
-
circumcision
congenital bleeding disorders
acquired disorders
-

2.
- x-linked recessive diseases hemophilia A, B
new mutation
30 hemophilia
- autosomal dominant recessive von Willebrand disease

3. ,
, ,
, Kasabach-Merritt syndrome
autoimmune SLE

4. , NSAIDs

platelet function heparin, H2 blocker

5.

6.

stable ,
, superficial bleeding (petechiae,
ecchymosis) deep bleeding (hematoma, hemarthrosis), mucous membrane bleeding

underlying diseases chronic renal
disease platelet dysfunction aplastic
anemia / acute leukemia

1. CBC with platelet count -

> 50,000/mm3
2. Peripheral blood smear leukemic cells
APDE (Acquired platelet dysfunction with eosinophilia)
ITP (Idiopathic thrombocytopenic purpura)
Wiskott-Aldrich syndrome
3. Bleeding time platelet-vascular interaction
platelet plug Ivys 2-7
thrombocytopenia platelet dysfunction
prolonged bleeding time APDE
von Willebrand disease
4. Venous clotting time (VCT)
two-syringe technique 5-15 coagulation factors

 prolonged VCT factors 1-2

factor bed side lab
clot retraction clot lysis
5. Clot retraction VCT 1-2

6. Clot lysis time - VCT
24-48 hyperfibrinolysis
7. Prothrombin time (PT) PT PT
1.5 1.5 coagulation factor I, II, V, VII, X
oral anticoagulant
8. Activated partial thromboplastin time (APTT) - coagulation factor I XII
factor VII control 10
lupus anticoagulant unfractionated heparin
9. Thrombin time fibrinogen factor I
fibrinogen < 100 ./.


- bone marrow aspiration acute leukemia aplastic anemia
- factor VIII, IX assays hemophilia A, B
- fibrinogen level, fibrinogen degradation product, D dimer DIC
- von Willebrand factor antigen ristocetin cofactor activity von Willebrand
Disease (vWD)

: rule out bleeding disorders

vWD bleeding time APTT

 1 coagulation tests
( Grabowski EF, Corrigan JJ, Jr3)

PT

Prolonged
TT
Normal
Vit K deficiency
Liver disease
Coumadin effect

Prolonged

Normal

PTT

PTT
Normal

Prolonged

F VII deficiency

F XI, IX, VIII deficiency

Heparin effect

Normal
F XIII deficiency

Prolonged
DIC
Fibrinogen defect
Heparin effect

PT prothrombin time
PTT activated partial thromboplastin time
TT thrombin time
Fibrinogen defect afibrinogenemia, dysfibrinogenemia

1. . . : ,

, , . . 3.
: ; 2538. 177-205.
2. , , . Approach to Bleeding Disorders. :
, . . : ; 2543. 23-31.
3. Grabowski EF, Corrigan JJ, Jr. Hemostasis: general considerations. In: Miller DR, Baehner RL, editors. Blood
Diseases of Infancy and Childhood, 7th ed. St Louis: Mosby-Year Book, Inc.; 1995. p. 849-65.

4. Hampton KK, Preston FE. Bleeding disorders, thrombosis, and anticoagulation. In: Provan D, Henson A, editors.
ABC of Clinical Hematology. London: BMJ Publishing Group; 1998. p. 43-5.
5. Manco-Johnson MJ. Hemostasis and Bleeding disorders. In: Rudolph AM, Hoffman JIE, Rudolph CD, editors.
Rudolphs Pediatrics. 20th ed. Stamford: Appleton & Lange; 1996. p. 1236-40.
6. McKenzie SE. Common problems in Hematology. In: Schwartz MW, Curry TA, Sargent AJ, Blum NJ, Fein JA,
editors. Pediatric Primary Care A Problem-Oriented Approach. 3rd ed. St Louis: Mosby-Year Book, Inc.; 1997. p.
579-84.
7. Montgomery RR, Scott JP. Hemostasis. In: Behrman RE, Kliegman RM, Jenson HB, editors. Nelson Textbook of
Pediatrics.16th ed. Philadelphia: W.B. Saunders; 2000. p.1504-8.

 (Anemia in Children)
..
.. 502 topics for OPD/ward teaching

(Anemia)
2 standard deviations
Oxygen metabolic demand

Oxygen saturation
Oxygen

Mean corpuscular volume (MCV)

1
1 (Mean corpuscular
volume, MCV)
Age (y)

Mean
Birth (cord blood)
1 week
2 months
3-6 months
0.5-2 years
2-6 years
6-12 years
12-18 years (F)
12-18 years (M)
18-49 years (F)
18-49 years (M)

Hematocrit (%)
Mean
-2SD

Hemoglobin (g/dL)

16.5
17.5
11.5
11.5
12.0
12.5
13.5
14.0
14.5
14.0
15.5

Mean

MCV (fL)
-2SD

-2SD
13.5
13.5
9.0
9.5
10.5
11.5
11.5
12.0
13.0
12.0
13.5

51
54
35
35
36
37
40
41
43
41
47

42
42
28
29
33
34
35
36
37
36
41

108
107
96
91
78
81
86
90
88
90
90

Nathan DG, Orkin SH. Nathan and Oskis Hematology of Infancy and Childhood. 5thed. Philadelphia:WB
Saunders,1998: p viii appendices

2-3
physiologic anemia

98
88
77
74
70
75
77
78
78
80
80

 MCV 6 2

Classification of anemia
3



(MCV) 2

2 (MCV)
Microcytic anemia
Iron deficiency
Thalassemia
Chronic disease
Sideroblastic anemia
Lead poisoning

Normocytic anemia
Acute blood loss
Hemolytic anemia

Splenic sequestration
Chronic renal disease

Macrocytic anemia
Folate deficiency
Vitamin B12 deficiency
Aplastic anemia
Hypothyroidism
Liver disease

1. onset

3
2.

, alloimmune hemolysis
congenital infection; 6
2
; 3-6 beta-Thalassemia
Hemoglobinopathy

x-linked recessive G6PD

hyperbilirubinemia underlying hemolytic anemia

G6PD, Hereditary Spherocytosis

( ) B12 ()
( ); (pica)

sulfa acute hemolysis G6PD;

phenytoin megaloblastic anemia
Parvovirus B19 Pure red cell aplasia

chronic hemolysis

Nathan DG, Orkin SH. Nathan and Oskis Hematology of Infancy and Childhood. 5thed. Philadelphia:WB
Saunders,1998:p 377

4
Skin

Face
Eyes
Mouth
Hands

Hyperpigmentation
Petechiae, purpura
Jaundice
Cavernous hemangioma
Frontal bossing, prominence of the malar and
maxillary bones
Edema of the eyelids
Icteric sclera
Blindness
Glossitis
Spoon nails

Hypoplasia of the thenar eminence

Fanconis aplastic anemia

Bone marrow aplasia, bone marrow infiltration, DIC
Hemolytic anemia
Microangiopathic hemolytic anemia
Thalassemia
Infectious mononucleosis, renal failure
Hemolytic anemia
Osteopetrosis
Iron deficiency, vitamin B12 deficiency
Iron deficiency
Fanconis aplastic anemia

Spleen
Enlargement
Hemolytic anemia, leukemia, lymphoma
Nathan DG, Orkin SH. Nathan and Oskis Hematology of Infancy and Childhood. 5thed. Philadelphia:WB
Saunders ,1998: p.378

3.

3.1 Complete blood count

3.2 RBC indices

- MCV : Mean corpuscular volume (Hct/RCC)
80-96 fL
- MCHC : mean corpuscular hemoglobin concentration (Hb/Hct) 32-36
g/dL Hereditary
spherocytosis
- MCH : mean corpuscular hemoglobin (Hb/RCC) 26-34 pg
- RDW : red cell distribution width (SD/MCV) coefficient of variation of the
red cell volume distribution 12-15%
(anisocytosis)
3.3 Peripheral blood smear inclusion
red cell
morphology
- Spherocyte: Hereditary spherocytosis, immune hemolytic anemia, severe burns
- Stomatocytes : Hereditary stomatocytosis, liver disease
- Target cells : Hemoglobin E, Thalassemia, liver disease
- Basophilic stippling : Thalassemia , lead poisoning, pyrimidine 5 nucleotidase
deficiency
- Schistocytes : microangiopathic hemolytic anemia DIC, HUS
3.4 Reticulocyte count
1-2%
hemolysis hypoxia
bone morrow
infiltrative condition
3.5 Additional hematologic investigations
- Serum iron/total iron binding capacity, serum ferritin
- RBC folate, serum vitamin B12 level
- Hemolysis investigations: indirect bilirubin, LDH, haptoglobin, supravital stain for inclusion bodies,
Heinz bodies, Coombs test, hemoglobin analysis, osmotic fragility test, RBC enzyme level
- Bone marrow aspirate and biopsy

* MCV reticulocyte count

1. Lanzkowsky P. Classification and Diagnosis of Anemia during Childhood. In: Lanzkowsky P, ed.
Manual of Pediatric Hematology and Oncology. 3rded. San Diego: Academic Press, 2000:1-12.
2. Oski FA, Brugnara C, Nathan DG. A Diagnostic Approach to the Anemic Patient. In: Nathan DG,
Orkin SH, eds. Nathan and Oskis Hematology of Infancy and Childhood. 5thed. Philadelphia: WB
Saunders,1998:375-83.
3. Schwartz E. The Anemias. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of
Pediatrics. 16thed. Philadelphia: WB Saunders,2000:1461-2.

 Approach to the diagnosis of anemia by MCV and reticulocyte count

( Lanzkowsky P. Manual of Pediatric Hematology and

Oncology. 3rd ed. San Diego:Academic Press,2000: p. 9)

 (Iron Deficiency Anemia)

..
topics for OPD/ward teaching
(red blood cell mass)
(hemoglobin concentration) 2 standard deviations

(developmental delay and cognitive impairment)

(Pathogenesis)
1.
2 3
cytochrome, myoglobin
(transferrin)
ferritin hemosiderin
2.

4-6

2-3
0.8 (0.6 ..
0.2 .. ) 2

duodenum jejunum 2
heme iron non-heme iron heme iron heme
heme iron non-heme
iron non-heme iron
(enhancer) ascorbic
acid (inhibitor) tannins calcium
(pica)

 0.5 ../
10-13 ../ 50
10 5
calcium ascorbic acid
transferrin
beta globulin transferrin total iron binding capacity (TIBC)
transferrin serum iron (SI) transferrin saturation SI/TIBC
35 serum iron TIBC
transferrin saturation
iron turnover
RE system 2 ferritin
hemosiderin reticuloendothelial cells liver parenchyma
cells
3.

bioavailability

4.
1. Iron depletion (storage iron)
storage iron serum ferritin bone marrow hemosiderin
2. Iron deficiency without anemia iron supply
biochemical markers serum iron transferrin
saturation total iron binding capacity hemoglobin
3. Iron deficiency anemia
hypochromia, microcytosis

exercise intolerance, tachycardia, cardiac

dilatation systolic murmurs
(koilonychia) (glossitis) (angular stomatitis)

1.

2. underlying disease

3.

1. Hematological tests
-Hemoglobin, hematocrit value 2 standard deviation

-Red blood cell indices: MCV, MCH, MCHC RDW

-Peripheral blood smear hypochromia microcytosis
-Reticulocyte count: ineffective erythropoiesis
-Bone marrow findings: (hypercellular erythroid hyperplasia) erythroblasts
cytoplasm poor hemoglobinization bone
marrow iron stain ( prussian blue) hemosiderin pigment
gold standard

2. Biochemical tests
-Ferritin storage iron ferritin

ferritin
acute phase reactant 20 mcg/L

-Serum iron (SI) transport iron (diurnal variation)

-Total iron binding capacity (TIBC) (available

iron binding sites) TIBC
malnutrition SI
Transferrin saturation (SI/TIBC) 35 Transferrin saturation
sideroblastic anemia
3.
- Reticulocyte hemoglobin concentration (CHr) iron containing protein reticulocyte
early indicator
anemia
- Serum transferrin receptor (TfR) receptor reticulocyte
anemia anemia of
chronic disease

- Zinc protoporphyrin (ZPP) Free erythrocyte protoporphyrin (FEP)

anemia
anemia of chronic disease
1 2
1 Hematologic markers for identifying iron deficiency*
Hematologic marker

Normal

Iron depletion

Iron deficiency
without anemia

Iron deficiency
anemia

Hemoglobin (g/dL)
6mo-2y of age

Mean corpuscular
volume (fL)

N
11
N
70-100

N
11
N
70-100

N
11
N
70-100

D
< 11
D
< 70

Red cell distribution

width (%)
Reticulocyte Hb content
(pg)

N
< 15
N
29

N
< 15
N
29

N
< 15

I
15
D
< 29

Reticulocytes

N
1-5

N
1-5

D
< 29
N
1-5

D
<1

2 Biochemical markers for identifying iron deficiency*

Hematologic marker

Normal

Iron depletion

Iron deficiency
without anemia

Iron deficiency
anemia

Serum ferritin
(mcg/dL)

N
10060
N
11550

D
< 20
N
< 115

D
< 10
D
< 60

D
< 10
D
< 40

N
33030
N
3515

N
360-390
N
< 30

N/I
390-410

I
410

N
< 35
N
< 40

I
35
N
< 40

< 20
I
35
I
40

< 10
I
35
I
40

Serum iron
(mcg/dL)
Total iron binding capacity
Transferrin saturation
(%)
Serum transferrin receptor
(nmol/L)
ZPP/heme (mcmol/mol)

N = normal, I = increased, D = decreased

* Wu AC, Lesperance L, Bernstein H. Screening for iron deficiency. Pediatrics in Review. 2002;23:5:171-8.


1.


iron fortified formula 4
iron fortified cereals whole cow
milk 1 cow milk protein intolerance chronic blood loss
(toddler) 1624 GI blood loss

2. ferrous salt 4-6 mg of elemental iron/kg/day

hemoglobin 1 hemoglobin 2-3

subjective improvement irritability 12-24 reticulocyte count
48-72 hemoglobin 4-30

1. Schwartz E. Iron deficiency anemia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of
Pediatrics. 16th ed. Philadelphia: WB Saunders; 2000, p.1469-71.
2. Wharton BA. Iron deficiency. In: Lilleyman J, Hann I, Blanchette V, eds. Pediatric Hematology. 2nd ed.
London: Churchill Livingstone; 1999, p.127-44.
3. Wu AC, Lesperance L, Bernstein H. Screening for iron deficiency. Pediatrics in Review. 2002;23:5:171-8.

Topics for OPD and ward teaching round

..
: .. 401
.. 502
..601
Fever in Children
4 5 ward 8
5 6 OPD 3-4

1.
2.
3.
4. approach investigate
5.

1.
2.
3.
4.

approach

1.
2.
3.

2.1 . . : , ,
. Update on pediatric infectious diseases. : ; 2540.
236-42.

2.2 . Rickettsiae. : , , .
Update on pediatric infectious diseases IV. : ; 2544. 184-90.
2.3 . Fever without localizing sign in young children. :
, , , ,
. Ambulatory Pediatrics 2. : ; 2542.
302-5.

2.4 Baker MD. Evaluation and management of infants with fever. Pediatr Clin North Am.
1999;46:1061-72.
2.5 Kramer MS, Shapiro ED. Management of the young febrile child: a commentary on recent
practice guidelines. Pediatrics 1997;100:128-34.
2.6 Luszczak M. Evaluation and management of infants and young children with fever. Am Fam
Physician 2001;64:1219-26.

 approach
..

(Body temperature 39C)

3
1. localizing signs
2.
3.
localizing sing

localizing signs

< 3

1.
2.

3 3

> 3

1. Nonspecific self-limiting illness

2. Otitis media/pneumomia/
phangngitis/meningitis
*3. Occult-bacteremia
- S. pneumoniae
- H. influenzaetypeb
- N. meningitidis
- Salmonella spp.

: , ().
Update on Pediatric Infectious Diseases. : ,2540: 236-42.
* Risk factors : toxic appearance, 39.4 oC, WBC < 5,000 > 15,000, increase neutrophil
count, band count, ESR, CRP

 > 3

1 - 3
- Observe
-
-
Virus

4 2

> 2

Fever of Unknown origin

1. Typhus group
(Epidemic typhus, Murine typhus)
2. Scrub typhus
3. Spotted fever group
4. Ehrlichiosis
5. Q Fever

- Work up
-

1.
2.
3.
4.

Infection Cause
Auto immune diseases
Malignancy
Resolved without
diagnosis
5. etc.

Topics for OPD teaching

..
..
: .. 502
.. 601
1.
2.
5 OPD teaching 3-4
6 OPD teaching 3-4
4 A,B,C 5-6
5 A,B,C 2-3

1.
1.1
1.2
1.3 investigation
1.4
2.
2.1
2.2 glomerular hematuria non-glomerular hematuria
2.3
2.4
2.5 nephrotic syndrome, AGN
2.6

1.
1.1
1.2
heart failure, PCM, cirrhosis, nephrotic syndrome, AGN
2.
2.1
2.2
2.3 proteinuria, hematuria
2.4 glomerular hematuria non-glomeular hematuria
2.5 Guideline investigation protienuria hematuria

1.
2.


..
1.
phosphate urate

pH 4.5-7.5
Spgr 1.001-1.030 osmolality
40-1200 mOsm/kg
2.

pH cell cast
15 . 2000 5
3-5 HPF 1-2 HPF
hyaline fine granular cast cellular cast, granular cast , fatty cast pigmented
cast
mid stream clean-voided, urethral
catheterization, suprapubic aspiration bag collection
4-8 C 24

Hematuria
Hematuria
1. Gross hematuria macroscopic hematuria

gross hematuria hemoglobinuria, myoglobinuria,

2. Microscopic hematuria 5 /HPF

5 ..
glomerular hematuria nonglomerular hematuria
1. glomerular hematuria

nonglomerular hematuria


2.
Localization of Hematuria
Glomerular hematuria
Brown or cola-colored urine
>2+ proteinuria by dipstick in the absence of gross bleeding
Erythrocyte casts, leukocyte casts
Deformed erythrocytes
Renal tubular epithelial cells in the urine sediment
Nonglomerular hematuria
Terminal hematuria
Passage of blood clots
Normal morphology of erythrocytes
< 2+ proteinuria in the absence of gross bleeding
Norman ME.2


Common Causes of Gross Hematuria

Non glomerular
Urinary tract infection
Meatal stenosis
Perineal irritation
Truama
Urolithiasis/hypercalciuria
Coagulopathy
Tumor
Glomerular
IgA nephropathy
Alport syndrome (hereditary nephritis)
Thin glomerular basement membrane disease
Postinfectious glomerulonephritis
Henoch-Schnlein purpura nephritis
Systemic lupus erythematosus nephritis
Davis ID, Avner ED.3

Guideline in the investigation of gross hematuria

Cola/brown urine?
Proteinuria (>30mg/dL)?
Acute nephritic syndrome?
YES
Glomerular hematuria
CBC with differential
Electrolytes, Ca
BUN/Cr
Cholesterol
C3/C4
ASO/Anti-Dnase B
ANA
Antineutrophil antibody
Throat/skin culture
(if indicated)
24-hour urine total protein
creatinine clearance

NO
Extraglumerular hematuria
Step 1
Urine culture
Step 2
Urine calcium/creatinine
Sickle prep (African American)
Renal/bladder ultrasound
Step 3
Urinalysis: siblings, parents
Serum electrolytes, Cr, Ca
If crystalluria, urolithiasis, or nephrocalcinosis :
24-hour urine for Ca, creatinine, uric aci,
oxalate
If hydronephrosis/pyelocaliectasis :
Cystogram, renal scan

Davis ID, Avner ED.3

References Hematuria
1. . Hematuria. : , , ,

. . :, 2540. 199214.
2. Norman ME. An office approach to hematuria and proteinuria. Pediatr Clin North Am 1987; 34: 545-60.
3. Davis ID, Avner ED. Conditions particularly associated with hematuria. In: Behrman RE, Kliegman RM, Jenson HB,
editors. Nelson textbook of pediatrics. Philadelphia: WB Saunders; 2003. p. 1735-7.

Acute poststreptococcal glomerulonephritis

Clinical manifestation
Gross hematuria
25-33%
Volume overload
Edema
85%
Hypertension
60-80%
Circulatory congestion
20%
CNS symptoms
10%
acute poststreptococcal glomerulonephritis (APSGN)

(latent period) 10 latent period
14-21 3 latent period 1
IgA nephropathy AGN
3
1. Gross hematuria 30%
gross hematuria 2-3 4
gross hematuria streptococcal
microscopic hematuria
2. Edema periorbital area
nephrotic syndrome
proteinuria
3. Hypertension AGN
hypertensive encephalopathy
volume expansion
4. Circulatory congestion dyspnea
orthopnea congestive heart failure pulmonary edema
5. Pallor hemodilution

6. rapidly progressive glomerulonephritis renal failure 1 %

Laboratory Findings
1. Urinalysis specific gravity
1.020 osmolality 700 mOsm/kg specific gravity underlying chronic
disease

Proteinuria nephrotic range labstix

trace 2+ 3+ quantitative 2 gm/m2/day

RBC, RBC cast WBC WBC cast RBC cast 60-85%

2. Hemogram mild anemia hemodilution diuresis
3. Renal function tests glomerular filtration rate (GFR) renal blood flow 50%
severe azotemia
4. Serologic examinations streptococcal pharyngitis ASO titer 80%
streptozyme test antideoxyribonuclease-B (anti-DNAase B), anti-NADase, AHT
ASO 100%
skin infection ASO titer streptolysino
anti-DNAase B titer
streptococcal infection ASO-titer
5. Bacteriologic culture
latent period carrier stage
6. Complement C3 hemolytic complement activity (CH50)
8 C3 8 membranoproliferative
glomerulonephritis, occult sepsis, SLE
7. Radiographic studies chest film pleural
congestion hilar cardiomegaly pleural effusion diuresis chest film

Treatment
supportive treatment
1. Activity acute phase hypertension bed rest
1
2. Fluid and salt restriction fluid overload
0.5 ml/kg/hr insensible loss protein
renal function BUN creatinine protein,
potassium phosphorus
3. Hypertension
hypertensive encephalopathy furosemide
sodium vasodilators hydralazine, adrenergic blocker calcium channel blockers nifedipine
sublingual route 1

1. Treatment of Hypertension Associated with Acute glomerulonephritis

Diuretics

Mild to Moderate
Furosemide IV or PO

Severe
Furosemide IV

Vasodilators

Hydralazine

Calcium channel
blocker

Nifedipine PO

Diazoxide IV
Sodium
nitroprusside IV
Nifedipine
sublingual

Converting-enzyme
Captopril PO
inhibitor
: Cole BR, Salinas-Madrigal L.4

Comment
Not sufficient alone in
severe disease
Watch for hyperglycemia
Monitor thiocyanate levels
May need to be coupled
with
-blocker and/or diuretic
Easy to administer
Watch K+

4. Volume overload congestive heart failure fluid salt restriction

diuretics digitalis renal failure
dialysis
5. Hyperkalemia 2

 2. Hyperkalemia in Acute Glomerulonephritis

Pathogenesis of hyperkalemia
1. Decreased GFR
2. Acidemia
3. Uncommonly, mild hemolysis
Therapeutic strategies
1. Increase excretion
2. Limit intake
Specific measures
1. Diet: decrease intake to as little as possible, about 0.5 mEq/kg/day
2. For [K+] 5-6 mEq/L: limit dietary intake and give furosemide
For [K+] 6-6.5: administer NaHCO3, sodium sulfonic polystyrene
For [K+] 6.5+: NaHCO3 glucose and insulin; consider dialysis
: Cole BR, Salinas-Madrigal L.4
6. Antibiotics penicillin 10
glomerulonephritis
7. Renal biopsy biopsy
acute renal failure rapidly progressive
glomerulonephritis
renal biopsy 3

 3. Indications for considering renal biopsy in acute glomerulonephritis*

Atypical presentation

Delay in rate of resolution

Etiology
Early
Absence of infection prior to onset
Oliguria and/or azotemia persisting past 2 weeks
Onset of renal symptoms coincident with infection
Hypertension persisting past 3 weeks
Absence of serologic evidence of streptococcal etiology
Gross hematuria persisting past 3 weeks
(using appropriate serologic tests)
C3 level continuing low beyond 6 weeks
Absence of depression of serum complement or C3 level Late
Early clinical course
Persistent hematuria and proteinuria past 6 months
Anuria
Persistent proteinuria past 6 months
Preseace of nephrotic syndrome
Persistent hematuria past 12 months
Azotemia out of proportion to other clinical findings
Miscellaneous factors
Age less than 2 years or more than 12 years
Prior history of renal disease
Abnormal growth rate
Family history of nephritis
Significant systemic symptomatology
* One or more of these indications may cause the physician to consider whether biopsy is, or is not, indicated.

: Brouhard BH, Travis LB.3

Course and Prognosis

95% complete recovery

hypertension
proteinuria

 4.

1. Typical presentation with no findings suggestive of systemic disease

2. Evidence of prior streptococcal infection
a. Throat or skin lesion culture positive for streptococcal
b. Elevated antibody titers using panel (acute and convalescent titers
must be done)
3. Complement abnormalities typical
a. Decreased CH50 and C3 during acute phase
b. C4 usually normal
c. Levels rise toward normal by 6-8 weeks
4. Beginning recovery in 1 week
a. Diuresis
b. Blood pressure normalizes
c. BUN, creatinine begin to fall
5. Normalization of urine sediment
a. Resolution of gross hematuria by 2-3 weeks
b. Resolution of proteinuria by 3-6 months
c. Resolution of microscopic hematuria by 1 year
:Cole BR, Salinas-madrigal L.4

References Acute poststreptococcal glomerulonephritis

1. . Acute glomerulonephritis. : , ,
, . . :,
2540. 229-42.
2. Davis ID, Avner ED. Acute poststreptococcal glomerulonephritis. In: Nelson textbook of
pediatrics. Philadelphia: WB Saunders; 2003. p. 1735-7.
3. Brouhard BH, Travis LB. Acute postinfectious glomerulonephritis. In: Edelman CM, Bernsteins J,
Meadow SR, Spitzer A, Travis LB, editors. Pediatric kidney disease. 2 nd ed., Boston: Little Brown
and company; 1992. p. 1199-1221.
4. Cole BR, Salinas-Madrigal L. Acute proliferative glomerulonephritis and crescentic glomerulonephritis.
In: Barratt TM, Avner ED, Harmon WE, editors. Pediatric nephrology. Baltimore: Williams &
Wilkins; 1999. p.669-89.

Proteinuria

1. dipstick protein 1+(30mg/dL) spgr

1.015 protein 2+ spgr>1.015
2. 24 protein 4-40 mg/m2/hr proteinuria 40
mg/m2/hr nephrotic range proteinuria
3. protein / creatinine

< 2
> 0.5

> 2
> 0.2

> 3 nephrotic range proteinuria

Guideline investigation
1. hematuria
investigate 24 hr protein, serum
complement, ANA, serum albumin, serum cholesterol, ultrasound renal biopsy
2. proteinuria

An algorithm describing suggested management of a patient with symptomless proteinuria

Cameron JS 3
References Proteinuria
1. . Proteinuria. : , , ,
. . :, 2540. 191-8.
2. Norman ME. An office approach to hematuria and proteinuria. Pediatr Clin North Am 1987; 34: 545-60.
3. Cameron JS. The patient with proteinuria and/or hematuria. In: Davison AM, Cameron JS, Grnfeld
JP, KerrDNS, editors. Oxford textbook of clinical nephrology vol I. Oxford: Oxford university
press; 1998. p. 441-54.

Nephrotic syndrome
Clinical manifestation
edema
heavy proteinuria > 40 mg/m2/hr
hypoalbuminemia < 2.5 d/dL
hyperlipidemia
85% nephrotic syndrome minimal change NS 90%
prednisolone
Treatment
1. activity restrict
2. - sodium restriction remission
- protein
3. Diuretics thiazide furosemide
4. 20% albumin (1g/kg) 4 furosemide 1-2 mg/kg
hypovolemia fluid overload
5. Specific treatment prednisolone

Algorithm for treatment of minimal lesion disease

Minimal Lesion Disease
(in children may treat without biopsy if presentation compatible)

Prednisolone 60 mg/m2/day (Up to

80 mg/day) x 4-6 weeks

Non response (Child:

biopsy)

Response

(Other
pathology)

(Minimal lesion)

Prednisolone 40 mg/m2/day
every alternate day
x 4-6 weeks

Steroid resistant:
Cyclophosphamide
or
Cyclosporine and
Prednisolone daily or
alternate day
******************

No Relapse

Relapse

Cured
******

Prednisolone 60 mg/m2/day
(up to 80 mg/day) until urine
protein-free; then 40 mg/m2
every other day x 4 weeks

Frequent relapses:

Cyclophosphamide
2 mg/kg/day
or
Chlorambucil 0.15 mg/kg/day
with tapering alternate day
Prednisolone x 8 weeks;
Levamisole; Long-term

Consult
nephrologist

Steroid dependent:

Cyclophosphamide
2 mg/kg/day x 8 weeks
or
Cyclosporine
6 mg/kg BW/day
(children)
5 mg/kg BW/day

Indications for renal biopsy

Pretreatment
Recommended :
1. Onset age < 6 mo
2. Macroscopic hematuria
3. Microscopic hematuria and persistent hypertension
4. Low plasma C3
5. Renal failure not attributable to hypovolaemia
Discretionary :
1. Onset between 6 and 12 mo of age
2. Persistent hypertension or microscopic hematuria
3. Onset age >12 yr
Posttreatment
Steroid resistance:
Indicated whether the child is an early or late nonresponder
Frequent relapses :
Not necessary in SSNS when drugs such as cyclophosphamide are being considered but
may be indicated before third-line drugs such as cyclosporine
Follow up and prognosis
90% minimal change NS prednisolone relapse
relapse prognosis renal failure follow up 5
remission
References Nephrotic syndrome
1. . Steroid responsive nephrotic syndrome. : , ,
, . . :,
2540. 281-96.
2. Vogt BA, Avner ED. Nephrotic syndrome. In: Behrman RE, Kliegman RM, Jenson HB, editors.
Nelson textbook of pediatrics. Philadelphia: WB Saunders; 2003. p. 1753-7.
3. Barratt TM, Clark AG. Steroid responsive nephrotic syndrome. In: Barratt TM, Avner ED, Harmon
WE, editors. Pediatric nephrology. 4th ed. Baltimore: Williams&Wilkins; 1999. p.731-47.
4. Bargman JM. Management of minimal lesion glomerulonephritis: Evidence-based
recommendations. Kidney Int 1999; 55: 53-56.

Edema
extra cellular space
pathophysiology
1. Increased hydrostatic pressure
Generalized edema

constrictive pericarditis
portal hypertension hypoproteinemia renal retention
of sodium
congestive heart failure
Budd-Chiari Syndrome

Localized edema

2.

3.

4.

5.

Thrombophlebitis
pressure effect tumor mass
Decreased oncotic pressure generalized edema
Inadequate intake
Impaired production of protein liver disease
Loss of protein nephrotic syndrome
Increased capillary permeability
Allergic reaction localized edema
Inflammatory reaction chemical, thermal bacterial rickettsial
infection generalized vasculitis
Sodium and water retension
Congestive heart failure
Hepatic cirrhosis
Chronic anemia
Acute glomerulonephritis
Nephrotic syndrome
Excessive saline administration
corticosteroid
Impaired lymphaticreturn localized edema


1. localized generalized edema
2.

3.
4.
5.

1. Wt/age, Wt/Ht, Ht/age

vitamin deficiency dermatosis
2. localized generalized
dependent area
renal diseases dependent area scrotum, labia ascites
liver disease ascites dilatation of abdominal vein
heart failure lungs crepitation
3. pleural effusion nephrotic syndrome congestive heart
failure, cirrhosis
4. shifting dullness ascites
5. edema pitting non-pitting
pitting edema protein loss obstruction of venous lymphatic flow
non-pitting edema salt retention
6. soft ear cartilage nephrotic syndrome
7. jaundice liver diseases
Investigation
1. Urinalysis : heavy proteinuria nephrotic syndrome
hematuria, cellular cast - nephritis
2. Serum albumin
hypoalbuminemia + proteinuria = nephrotic syndrome
hypoalbuminemia without proteinuria = cardiac, gastrointestinal hepatobiliary disease
3. Stool albumin protein losing enteropathy
4. Investigation liver function test, chest film, EKG,
echocardiography
References Edema
1. Green m. editor. Pediatric diagnosis. Philadelphia: WB Saunders company; 1998. p.414-8.
2. Norman ME. Edema. In: Schwartz MW, editor. The 5 minute pediatric consult. Philadelphia:
Lippincott William & Wilkins; 2000.p.34-5.

Topic for teaching round

..
.. 401
.. 502
: Growth & development
: 4 A, B C 5-6
5 A, B C 6-7
:
:
1. /
2.
3.
4.
5.
:
1. growth development failure to thrive, short stature,
developmental delay
2. growth development
3. growth curve developmental assessment

4.
5.
:
1.
2.
3.
:
1.
2.
:

Topic for OPD teaching

..
.. 502
.. 601
: Growth & development
: 5 OPD teaching 4
6 OPD teaching 4
:
:
1. /
2.
3.
4.
5.
:
1. growth development failure to thrive, short stature,
developmental delay
2. growth development
3. growth curve developmental assessment

4.
5.
:
1.
2.
3.
:
1.
2.
:

Abnormal growth & development

..
:
1. growth development failure to thrive, short
stature, developmental delay speech delay
2. growth development
3. growth curve developmental assessment

4.
5.
1. Failure to thrive (FTT) 5

Approach to the patient

growth failure plot

standard growth curve

malnutrition acute chronic, symmetry acute

parameter symmetric FTT malnutrition , chromosome
abnormalities, congenital infection teratogenic exposure

prenatal, development, nutrition

PE

Investigation

organic disease psychosocial intervention improve nutrition

FTT

FTT

Complete physical examination

Plot growth curve, weight, height, head circumference

Signs of malnutrition, edema, vitamin deficiency

Systemic diseases or syndromes
Neurological abnormalities
Signs suggest possible child abuse

CBC

Urinalysis

Tuberculin test

Anti-HIV

BUN, Cr, electrolyte, calcium, phosphorus, magnesium

Serum albumin

Bone age

1. Congenital/ anatomical: congenital syndromes, chromosome abnormalities, congenital heart

disease
2. Infectious: HIV, tuberculosis, parasitic infestation
3. Toxic, environment, drugs: emotional deprivation, poor feeding techniques, poor child-parent
interaction, parental drug abuse, lead poisoning
4. Endocrine/ metabolic: diabetes mellitus, thyroid disease, pituitary disease, galactosemia, rickets
5. GI: gastroesophageal reflux, chronic constipation
6. Neurologic: cerebral palsy, oro-motor dysfunction, diencephalic syndrome
7. Renal: chronic renal failure, renal tubular acidosis
8. Hematologic: thalassemia, iron deficiency anemia
9. Miscellaneous: upper airway obstruction, acquired heart disease
improve nutritional status close follow-up

1. , , . Failure to thrive and short stature. :

, , , ,
. Ambulatory Pediatrics 2. : , 2542: 278-84.
2. Christian CW. Failure to thrive. In: Schwartz MW, editor. The 5-minute Pediatric consult. 2nd ed.
Philadelphia: Lippincott Williams & Wilkins; 2000. p.36-7.

3. Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure to thrive.

Pediatr Clin North Am 1995;42:791-810.
4. Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev 2000;21:25764.
5. Zenel JA Jr. Failure to thrive: a general pediatricians perspective. Pediatr Rev 1997;18:371-8.
2. Short stature percentile 3 growth failure
percentile short stature growth failure
short stature
Approach to the patient

short stature growth failure growth

parameter

normal (familial or constitutional short stature) pathologic short stature

observe endocrinologist

mid-parental height

(height velocity)

Complete physical examination

Plot growth curve, upper / lower segment ratio

Weight / height ratio

Frontal bossing, flat nasal bridge, truncal fat deposition: GH deficiency

Webbed neck, increased carrying angle: Turner syndrome, Noonan syndrome

Leg bowing, rachitic rosary, widening of wrists: rickets, vitamin D deficiency

CBC

ESR

Urinalysis

Serum electrolyte, calcium, phosphorus, magnesium, BUN, Cr

Thyroid function test

Bone age

Chromosome study


1. Familial short stature: short parents, height velocity , onset of puberty ,
bone age ( chronological age), final adult height mid-parental height
2. Constitutional short stature: height velocity , delayed bone age ( height
age), delayed onset of puberty, positive family history, final adult height
3. Short stature with wt < Ht
Skeletal dysplasia, achondroplasia
Chromosome or congenital abnormalities
Chronic illness: CHD, GI, pulmonary, renal, hemato
Chronic malnutrition
4. Short stature with wt > Ht
Growth hormone deficiency
Hypopituitarism
Hypothyroidiasm
Pseudohypoparathyroidism
Cushing syndrome
Turner syndrome
Prader-Willi syndrome
5. Drugs: corticosteroids, sex steroids

consult endocrinologist delayed bone age,
abnormal thyroid function,

1. , , . Failure to thrive and short stature. :

, , , , .
Ambulatory Pediatrics 2. : , 2542: 278-84.
2. Beckeljauw PF. Short stature. In: Schwartz MW, editor. The 5-minute Pediatric consult. 2nd ed.
Philadelphia: Lippincott Williams & Wilkins; 2000. p.70-1.
3. MacGillivray MH. The basics for the diagnosis and management of short stature: a pediatric
endocrinologists approach. Pediatr Ann 2000;29:570-5.
4. Vogiatzi MG, Copeland KC. The short child. Pediatr Rev 1998;19:92-9.

3. Developmental delay
Approach to the patient

progressive nonprogressive

developmental regression

Complete physical examination

Weight, height, head circumference

Dysmorphic features

Neurocutaneous lesiond

Neurological signs

Developmental assessment

Hearing / vision screening

Chromosome study dysmorphic features

TORCH titer

EEG / CT, MRI , abnormal neuro sign developmental regression

Thyroid function test or metabolic screens growth faliure

1. Cerebral palsy:
2. Global developmental delay- mental retardation:
3. Speech delay ( speech delay)
underlying congenital anomalies,
congenital infection

1. First LR, Palfrey JS. The infant or young child with developmental delay. N Engl J Med
1994;330:478-83.
2. Grover G. Normal development and developmental assessment. In: Berkowitz CD, editor.
Pediatrics: a primary care approach. 2nd ed. Philadelphia: W.B.Saunders Company; 2000. p.48-54.
3. Levy SE, Hyman SL. Pediatric assessment of the child with developmental delay. Pediatr Clin
North Am 1993;40:465-77.
4. Newton RW, Wraith JE. Investigation of developmental delay. Arch Dis Child 1995;72:460-5.
4. Speech delay

2

4

6
,
9
bye-bye, ,
1
1
1.5

2
2 30-50
3

4
1-4
1-10
5
Approach to the patient

hearing deficit

Length, weight, head circumference

Macrocephaly, microcephaly, hypertelorism

Unusual facies or other dysmorphic features

Neurocutaneous lesions

Abnormal neurological signs

Hearing evaluation: audiogram, BAER (brainstem auditory evoked response)

Developmental assessment

developmental delay

1. Hearing loss:
, ,
2. Developmental language disorder:

3. Global developmental delay mental retardation:

4. Autistic spectrum disorder Pervasive developmental disorders:

5. Environmental deprivation:


underlying congenital anomalies,
congenital infection

consult ENT hearing deficit
developmental language disorder global developmental delay
OT pervasive developmental disorder


1. , . Language disorder. : ,
,
, , . Ambulatory Pediatrics 2. :
, 2542: 146-51.
2. Coplan J. Normal speech and language development: an overview. Pediatr Rev 1995;16:91-100.
3. Grover G. Language development: speech and hearing assessment. In: Berkowitz CD, editor.
Pediatrics: a primary care approach. 2nd ed. Philadelphia: W.B.Saunders Company; 2000. p.54-8.
4. Leung AK, Kao CP. Evaluation and management of the child with speech delay. Am Fam Physician
1999;59:3121-8.
5. Starr HL. Speech delay. In: Schwartz MW, editor. The 5-minute Pediatric consult. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins; 2000. p.74-5.