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Constipation in boys :

- Most children who are constipated are normal .


- Although it can signify a serious disorder eg Hirschprung dis, cystic fibrosis and hypothyroidism in some
- Children with a history of resisting toilet training are particular risk
- The first step should be DIETARY MODIFICATION
- If dietary modification fails >>> MILD LAXATIVE (MAGNESIUM HYDROXIDE )
- In a child with mild constipation with no encoperisis >> MGOH is an excellent choice
- Enemas and suppositories are reserved for severe constipation or fecal impaction.
Magnesium hydroxide: also known as milk of magnesia is a mild saline laxative that causes the osmotic retention if fluid in
the gut lumen It can be titrated to produce soft but non liquid stools
Bisacodyl suppositories are reserved for short term rescue therapy but it causes abdominal cramping diorhea and nausea.
Phosphate enemas can be used for bowel preparation prior to medical procedure but can cause electrolyte disturbances
Boy with UTI treated and then resolved next step : >>> VOIDING CYSTURETHROGRAM
VOIDING CYSTURETHROGRAM: Done in following :
1. Children under the age of five years with a febrile UTI
2. Males of any age with 1st UTI
3. Females under age of 3 with 1st UTI
4. Children with recurrent UTI
5. Children with UTI not responding to Antobiotics
Child with S/S of allergic rhinitis aggrevated by dog >>>> next best step
Avoid DOG
Infant 10-11 month with irritable and lethargy diagnosed as anemia ?
>>> ??? Iron deficiency anemia due to sole diet as breast milk.
Prevalent among children and women of child bearing age iron deficiency anemia is now the most common single nutrient
deficiency
Breast milk provides iron enough for the first 6 months of life , after that age iron supplementation become necessary
If iron intake remains inadequate iron deficiency anemia develops.
PUBERISM , AND DELAYED PUBERTY and CONSTITUTIONAL PUBERTY DELAY :
- The earliest sign of puberism is nocturnal increase in the LH surge this is followed by daytime increase in the levels
of gonadotropins and increase in testosterone levels
- Enlargement of testes is one of the earliest signs of onset of puberty
- DELAYED PUBERTY : is defined as the absence of any signs suggestive of puberty by 14 years of age .
- CONSTITUTIONAL PUBERTY DELAY is delayed puberty , retarded bone growth and a positive family history
without any evidence of systemic disorder
RX : These pt develop pubery without any intervention.
However if pt is worried of having problem at school , Treatment with with low testosterone ( testosterone
enanthate injection 50 mg for a period of 3-6 months will lead to development of secondary sexual characteristics
without compromising the final height.
Child with delayed puberty , retarded bone growth and a positive family history without any evidence of systemic disorder
>>>>> Constitutional puberty delay >> these pt develop puberty without any intervention.
HIV +ve child with no symptoms starting school >>> no need to separate him from other , treat normally
Child of acute otitis media treated with amoxicillin now he is symptomless , on Exam normal tympanic membrane with
decrease mobility ( suggesting an effusion ) next best step >>> Observe

An effusion commonly persists upto 3 months after acute otitis media is resolved
If no symptoms >>> Observe and Wait
If symptoms are present , the effusion is bilateral or has persisted more than three months >> further therapy.
TORCHE infections
Infant with non descended testes ?? when to operate and observe /
Cryptorchidism : Observe till 6 months >>> then Surgery
(because cryptorchid testicles usually donot descend spontaneously after this age and spermatogonia degeneration begins in
the undescended testicles at this age as well. )
Pneumonia in children :
Community acquired pneumonia (most likely cause S. Pnemonia) : amoxicillin T.O.C.
Mycoplasm/ Chlamydia : azithromycin or doxycycline
7-8 year old boy with sudden acceleration of growth and severe acne small testicles and enlarged penis coarse pubic and
axillary hairs >>>> Precocious puberty ??? OR Pseudoprecocious puberty ??
It is important to differntiate between them.
Precocious puberty :
- Premature activation of hypothalamus pituitary gonad axis
- Less dramatic than that of Pseudo
- Sequential development testicular enlargement , penis enlargement pubic hair growth and lastly growth spurt
Pseudoprecocious puberty:
- Is caused by gonadotropin independent process typically excess of steroids
- The pt presents with sign and symptoms of androgen excess eg severe acne , significant growth acceleration
- It can be caused by Late Onset congenital adrenal hyperplasia
Child with diorhea with NO Signs and symptoms of dehydration what to give
>>> Age appropriate food with less sugar and less fat ( excess sugar can increase the osmolarity and excess fat are known
to delay gastric emptying both can worsen diorhea
Level of Hb A in sickle cell disorders
Sickle cell BO thalesemic >>>> No Hb A
Sickle cell B+ thalesemic >>>> Type I --- 3-5 %
Type II --- 8-14 %
Type III --- 25 %
Sickle cell Trait
>>>> 60 %
Pt of TURNERS SYNDROME : must be screened
ECHO ( V.IMP) for detection of coarctation of the aorta , bicuspid aortic valve , MVP and hypoplastic heart.
VISUAL AND HEARING TEST :
RENAL U/S : >> horse shoe shaped kidney
TSH LEVELS : > autoimmune endocrinopathy ( primary hypothyroidism )
( Streak gonads should only be removed when turner is Mosaic >> increase chances of malignancy
Hormone replacement therapy should be started when 14 years of age is reached.

See NF 1 diagnostic criteria 230


Note : if the pt of NF 1 is a child there ais a 15 % probability of development of optic nerve gliomas ,

Current recommendations include having a detailed Opthalmic examination for early detection of this problem and lisch
nodule, IRIS haemartoma
Child with features suggestive of bacterial pharyngitis
>>>> rapid strep +ve >>> Oral penicillin or amoxicillin
>>>> rapid strep ve >>> do throat culture
Child which was previously treated for some disease with antibiotics now have a rash in diaper area also including genitalia
buttocks perineum and crural folds , tomatoe red plaques and satellite papules ???
CANDIDAL DIAPER INFECTION:
- tomatoe red plaques and satellite papules are characteristics of candidal intertrigo and perineal infection
- common in infants who received recent antibiotics so the normal flora is suppressed favoring yeast production
- RX : local antimycotics agents clotrimazole / nystatin
DIFF from diaper dermatitis ( which effect the same area but spare crural folds ) Rx: Zinc Oxide or petrolatum ointment
DIAPER DERMATITIS : (diaper rash)
Caused by combination of factors , overhydration friction maceration and prolonged contact with excretion
- Can appear after diorhea
- Management include frequent changing of diaper , avoid tight fitting diapers , exposing skin to air , using diapers
with supper absorbant surface and applying barrier creams such as zinc oxide or petrolatum
- An uncomplicated diaper wash resolves quickly if above measured are performed otherwise low potency steroids
should be used
2 month old baby with cough rhinorhea and poor feeding , O/E rales over lung field but no wheeze xray show hyperflation
peribronchial thickening and bilateral symmetrical interstitial infiltrates
Chlamydia pneumonia
Chlamydia pneumonia :
- Onset 2-19 weeks
- Characterized by absence of fever , staccato cough , history of concurrent conjunctivitis
- Auscultatory and radiologic findings out of proportion to a Healthy child
- Transmission take place at BIRTH but takes 2-19 weeks to appear
- RX: Erythromycin
Childhood absence epilepsy > starring episodes disappears with age
NEURO SEIZURES CHILD :
Lead poisoning;
Mild : < 45 : no therapy proven to affect long time some dr give DMSA or oral d-penicilamine
Moderate : ( between 45- 70 ) without symptoms of acute encephalopathy( headadche vomiting and seizures )
Give Chelation therapy: TWO regimens IV EDTA OR Oral DMSA ( derivative of dimercaprol )
Severe : levels > 70 or acute encephalopathy : Medical emergency >> Dimercaprol IM + EDTA IV
Bat exposure : immediately give rabies prophylaxis: SEE the REAL MCQ and Add
Administration of Immunoglobulin and five doses of anti rabies vaccine.
If exposure is greater than 72 hour and treatment is not given REPORT

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

2. Infants and childrens with TB meningitis , military TB and tuberculous Osteomyelitis should receive 12 months of
ATT ( bone brain and military )
3. In a pt with drug resistant therapy may be extended to 18-24 months
4. Tb pts are declared NON INFECTIOUS once if they are recieving ATT and had three consecutive ve results
on sputum acid fast smears performed on different occasions .
2 year Child with delayed speech everything normal >>>> Do hearing test .
Candidates for hearing evalution:
1. Children with a family history of hereditary childhood hearing loss
2. History of meningitis
3. History of recurrent of persistent otitis media with effusion for more than three months
4. Documented intrauterine infections
5. Craniofacial abnormalities
6. Ototoxic medication.
Indications for admitting Anorexic nervosa pt
1. Physiologic instability
2. Electrolyte abnormalities
3. Severe malnutrition ( under 75% of ideal wt )
4. Acute medical or psychiatric emergencies
5. Cardiac arrhythmias
6. Acute food refusal
7. Failure of opd treatment
Pt of anorexia nervosa started on feeding , after 2 -3 weeks comes back with symptoms of heart failure and edema next step ?
Start IV phosphate replacement
REFEEDING SYNDROME :
- Can develop during 2nd and 3rd week of nutritional therapy of pts with anorexia nervosa
- Due to severe hypophosphatemia
- Pt develops heart failure and edema which can progress to delirium and cardiac arrest.
- RX: IV Phosphate .
Bereavement in children can present in different ways according to he childs age .
Those who are younger than 7 years tend to react with disbelief
Those younger than 5 have magical thoughts anout death and can feel guilt or responsible
Those older than 7 years accept death as a final and can experience depression anxiety or have regressive behavior
Cat bite to child is deep >>> give amoxicillin and clavulanic acid prophylaxis >> if allergic give Doxycycline
Oral candidiasis : the best initial theray is Topical antifungal ( eg nystatin suspension or clotrimazole troches)
Calcium requirement for
- AGE 9-18 >.. 1300mg
- AGE 19-50 >> 1000 mg
- AGE 51 and older >>. 1200mg

Well appearing child with failure to thrive


Failure to thrive:
- Term to describe failure to gain weight in children younger than two years . children categorized as FTT weighs
less than 5th percentile more severe cases involve a slowing of linear growth and circumference as well

The three causes of FTT are inadequate calorie intake , inadequate calorie absorption and increased calorie
requirement
Infant need 110 kcal/jkg/day , child upto 12 months needs 100 kcal/kg/ day
Psychosocial factor are very important in FTT . clinician should explore
Organic causes of FTT while less common include feeding problems milk protein intolerance inborn errors of
metabolism , infection, cystic fibrosis GERD or renal tubular acidosis.
DIETARY MODIFICATION is the best initial approach for other wise healthy child.

Varicella vaccination of house hold contact of transplant recipient is relatively safe and is currently recommended
Transmission of vaccine associated virus is not typical except for some cases when post vaccination rash appears therefore
child should be monitored for the rash
Child with neonatal sepsis
Neonatal sepsis :
- Suspected when an infant has a poor appetite decreased reactivity to external stimuli , diminished oral intake and
lassitude or depressed sensorium
- The most commonly agents are GBS , E coli , Klebsiela and Enterobacter species
- Althoufh listeria is rare in united states ampicillin is recmended
- Cefotaxime , ceftriaxone or anti pseudomonal penicillin are used in combination
- A good combination of neonate is Ampicillin and Ceftriaxone / Cefotaxine
- Ceftriaxone should not be used if there is hyperbilirubinemia because it will increase both type of bilirubin
( note : Direct hyperbilirubinemia is probably induced by sepsis related cholestasis
Indirect hyperbilirubinemia suggest a physiologic jaundice )
Multi drug resistant TB is a rapidly emerging problem in developed countries .
Give chemoprophylaxis with rifampin in cases with resistance of INH only
And chemoprophylaxis with PZA + Ethambutol incases with MDR TB
Exposure to smoking is an important risk factors for the development of acute otitis media , parents should be urged to quit
smoking
Asthma and exercise :
- Exercise induced bronchoconstriction is usually seen after strenous exercise / activities .
- Bronchodilation initially occurs during exercise followed by bronchoconstriciton which begins after 3-5 minutes
and rapidly peaks within 10-15 minutes of cessation of exercise
- Extremely common in pt with asthma
- Prophylactic treatment with inhaled B-2 agonist ( albuterol) approximately 5-10 minutes before initiation of
exercise
- Close contact should know how to recognize and treat acute attack
- Donot stop pt exercising routine .
Lead intoxication : venous sampling always preferred than capillary sampling.
When a diagnosis is a bit unclear the physician should say that it is due to medical condtion (not giving false statement)
Adolescent with round back , On/Ex postural round back that is corrected by voluntary hyperextension
+ no lateral deformity and no angulation >>> Flexible kyphosis
Flexible kyphosis:
- Is a common finding in adolescent
- Typically noticed by others like parents or teachers who observe them in sitting or standing position

On lateral radiograph angle of thoracic kyphosis is normal or slightly increased ( normal 20-40 degree )
There is no evidence that flexible kyphosis leads to adverse physical effects.

Scheuermann disease :
- Unlike Flexible kyphosis, structural kyphosis is not corrected by voluntary efforts.
- Sharp angulation is commonly seen on farward bending
- The typical treatment for structural kyphosis that is not severe ( < 70-80 degrees ) is use of Milwaukee brace.
- In more severe cases significant angulation, intractable pain neurological abnormalities >> Surgery

Pt with inappropriate behavioral changes with strange movement of hand face and limbs and facial jerking , pronator sign +ve
patellar reflex delayed , changes in volume and pitch of voice with a murmer of mitral regurgtaiton
SEE AND REVISE RHEUMATIC FEVER CRITERIA
Sydenhams chorea :
- One of the manifestations of rheumatic fever
- It usually occurs in girls between 5-13 years of age and is chatacterized by jerking movement of the face hands and
feet.
- The pt has characteristic symptoms :hypotonic state positive pronator sign and sudden change in pitch and volume of
her voice.
- All pt must recieve penicillin prophylaxis as soon as possible. The therapy is to be given until adulthood.
- If the motor function is severely compromised valproic acid Phenobarbital or haloperidol can be started and the pt
must be referred to neurologist.
Pt with chroninc diorhea , iron deficiency anemia and eosinophilia coming from mexico >>>> Intestinal Parasitosis
Intestinal Parasitosis :
- Is a more frequent cause of chronic diorhea , iron deficiency anemia and eosinophilia
- Prognosis is excellent with adequate therapy
- Since the disease is easily transmitted prophylactic treatment should be given to the rest of household members
Capillary hemangioma: (strawberry )
- Evident at birth
- may undergo growth in for a period of several months (proliferation phase )
- spontaneous regression usually follows ( involution phase )
- 70 Percent resolve by 7years
- Observation is the best approach
- If on orbital area or on the face ( functional impairment ) >>> laser treatment
- If rapidly growing >> corticosteroids .
A history of anaphylaxis or encephalopathy in association with receipt of the DTaP vaccine is the only true contra
indication for receiving another dose of DTaP vaccine.
RASHES OF THE CHILD
Most common complication after acute otitis media is Another episode of acute otitis media
Acute otits media may lead to serious complication such as bacaterial meningitis , mastoiditis lateral sinus thrombosis
epidural or brain abcesses or even cavernous or carotid artery thrombosis however the advent of antibiotics therapy has made
these complications rare.
5-6 week old baby with c/o having constipation mother complains now adays once daily or tonce every two days what to do
next ?
The normal frequency of stools in infants is around 6-8 times daily one stool per episode of breastfeeding .
After the 4rth week there is decrease in the infants frequency of stool passage to once daily oe once per two days .

This has to be differentiated from true constipation in order to avoid exaggregated concern like hirshprung disease
Bacterial conjunctivitis is usually a self limiting diseasehowever it must be treated
>> because there is a small but real risk of keratitis which can leads to visual impairment
>> Erythromycin ointment or sulfa drops are the first line antibiotics agents for the treatment of pts with bacterial
conjuctivits
>> at least 24 hour after antibiotic pt can go t owork if necessary otherwise till discharge has cleared.

Most common complication of tick disease :


Although tick can transmit important infectious disease ( lyme , RMSF Ehrlichiosus ) the only complication in most of the
cases is local inflammation or local infection ( if wound is produced ).
The transmission of lyme disease occur at least 36-48 hours after the tick has started suctioning the pts blood
If the tick is found and it has not engorged in blood there is no risk of lymes disease as tick take least 24 hr to firly attach to
their victim
Child of ADHD on methyphenidate coming with c/o anorexia , nausea , vomiting tachycardia , increased bp , palpitation ,
dizziness headach nervousness euphoria agitation and aggressive or violent behavior
>>>methyl phenidate overdose
Methylphenidate therapy :
- Methyl phenidate therapy is associated with decreased weight and height.
- Sadness and irritability can be seen in 22 % of children at theurapeutic doses.
- Overdose present as anorexia , nausea , vomiting tachycardia , increased bp , palpitation , dizziness headach
nervousness euphoria agitation and aggressive or violent behavior
- Methyl phenicdate SHOULD NOT BE STOPPED ABRUBTLY because of high psychological dependence
- SHOULD BE TAPERED DOWN.
2 year child with bilateral breast enlargement and rest every thing normal physically and hormone levels normal
Benign premature thelarche
BENIGN PREMATURE THELARCHE:
- Bilateral breast enlargement not accompanied by other signs of isosexual precocious puberty
- RX : expectant because majority of pt remain stable or have reversal of breast enlargement in a few months.
Pt with BPT have a normal hormone profile
- Their final height is generally not compromised