Clinical Pediatrics Ebook Notes

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Clinical Pediatrics
Clinical Pediatrics
How to examine
4th IC space just

I- Cardiology cases: outside MCL if
A. Combined inspection and palpation: < 4 years old
1. inspect around the 4th/5th intercostal spaces, look for pulsations of apex [normally
5th IC space
2. Inspect other 4 areas for pulsations.
if >4 years old
3. put your Rt hand at the site of apex (where u can see pulsations if possible),
confirm place detected by inspection, (don’t forget to count IC spaces with your Lt hand)
try to localize it with one finger (or if less than 2 cm, if more than 2 cm, it is diffuse)
comment on character and thrill felt: à normal character with no detected thrill
à Hyper dynamic character ‫ﺑﺘﺨﺒﻂ ﺟﺎﻣﺪ ﻓﻰ اﻳﺪك‬
à Slapping character: in Mitral stenosis (very rare in children)
4. put your Rt hand on the left Parasternal area to detect thrill (use roots of fingers)
and pulsations ( use your hand just below the wrist joint)
5. put your hand on pulmonary and aortic areas to detect thrill (roots of fingers)
and pulsations (with your finger tips)
6. Put your hand at epigastric area; try to detect origin of pulsations
à From RT side: enlarged Lt Ventricle.
à From left side: liver due to RT sided Heart Failure.
à Centered: aortic origin, normal.
B. Auscultation:
7. Auscultation: auscultate apex, left Parasternal, pulmonary and aortic areas.
N.B.; during examination, always use your left hand to

àCount ribs to know the numbers of spaces, or
àOn RT carotid for pulsations (systole/S1 is concomitant with pulse).
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¾ ¾ Rheumatic ¾ VSD ¾ Fallot

¾ Inspection &
palpation:
a. Precordial bulge: ¾ Present (only if u can see it) ¾ Present (only if ¾ Not present (mild Rt
u can see it) ventricular enlargement)
b. Apex: ¾ Site: shifted down & out ¾ S: shifted down ¾ S: in place
& out (4th IC just outside
MR: systolic thrill midclavicular line if < 4
MS: diastolic thrill & 5th IC if > 4 years old.)
MS: slapping
MR & AR: ¾ Area: localized ¾ A: localized ¾ A: localized
hyperdynamic ¾ Character: hyper dynamic ¾ C: ¾ C:
¾ Thrill: no ¾ T: No ¾ T: No
c. Parasternal area: ¾ Pulsations: present ¾ P: present ¾ P: +/- present
¾ Thrill: No ¾ T: yes ¾ T: No
d. Pulmonary area: ¾ Pulsations: yes ¾ P: yes ¾ P: no
¾ Thrill: no ¾ T: no ¾ T: yes in 50%
¾ Palpable S2: yes ¾ P: yes ¾ P: no
e. Epigastric area: ¾ Pulsations: yes ¾ P: no ¾ P: no
¾ Thrill: --- ¾ T: --- ¾ T: ---
¾ Dullness on pulmonary
¾ Percussion: area (pul. Artery dilatation) --- ---
¾ Dullness to the RT of the
sternum.
¾ Auscultation:
a. S2 (pulmonary area) ¾ Accentuated S2 ¾ Accentuated S2 ¾ No
b. Murmurs:
¾ Mitral regurge: ¾ VSD: ¾ Tetralogy of Fallot:
¾ Rule: use cone and Site: apex + muffled S1 S: 3rd, 4th Left S: 2nd left IC space
diaphragm in Area of propagation: axilla Parasternal spaces A:
examination of all areas. Character: soft A: all precordium C:
¾ Rule: if you hear Timing: pan systolic C: harsh T: ejection systolic
murmur at apex, move T: pan systolic
towards axilla, if its ¾ Mitral stenosis:
propagating towards S: apex + accentuated S1
axilla, it is mitral A: apex
regurge. C: rumbling
T: mid diastolic
¾ Aortic regurge:
S: 3rd left
A: apex
C: soft
T: early diastolic (decrescendo)
¾ Pulmonary hypertension:
S: 2nd left
A:
C: soft
T: ejection systole
So, you may hear murmurs at

apex/pulmonary/aortic area.
Parasternal and epigastric are
free
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¾ Mitral regurge= muffled S1 + rumbling mid diastolic murmur at apex.

¾ Mitral stenosis= accentuated S1 + soft pan systolic murmur at apex propagating to axilla.
¾ Aortic regurge= soft early diastolic murmur at 2nd aortic space (3rd Left intercostals) propagating to apex.
¾ Pulmonary artery dilatation= pulsations felt in 2nd left space, palpable S2, accentuated S2, soft ejection
systolic murmur.
VSD Fallot Rheumatic
¾ Muffled S1 + soft pansystolic murmur
propagating to axilla,or
Apex: free free ¾ Accentuated S1 + rumbling mid diastolic
murmur, or
¾ Free
+/- mild pulsations
Parasternal: Thrill + pulsations Free
(mild Rt vent hypertrophy)
50% with thrill
Pulmonary Pulsations Accentuated S2+Soft ejection systolic murmur
Ejection systolic murmur
¾ Free, OR,
Aortic Free Free ¾ Soft early diastolic murmur propagating to
apex.
epigastric free Free Free
II- Neurological cases:

1) Exposure, notice any Abnormal movement
2) State: normal/wasting/hypertrophy (compare Rt to Lt side)
3) Power: use a needle/pinch the child, if the child moves Öparesis
¾ P.S. power examination needs a cooperative patient: extension and flexion at every joint
passively and against resistance. So instead, apply a painful stimulus.
¾ If you are performing knee flexion against resistance, you are testing the power of the
extensor.
¾ Degree of power:
i. No movement at all.
ii. Horizontal movement ‫ﺣﺮك آﻒ اﻳﺪك ﻋﻠﻰ ﺗﺮاﺑﻴﺰة‬
iii. Movement against gravity.
iv. I, ii, and iii + can carry an object.
4) Tone: Shaking Hypertonia: hand and forearm Move as one unit

method in 4
limbs (wrists
Hypotonia: very loose movement
&ankles)
Passive flexion
&extension of
all joints
5) Reflexes: 9Rules: exposure - positioning
a) Superficial reflexes:
i. Plantar/Babinski reflex:
y Scratching the outer aspect of the sole of the foot.
y +ve response Ödorsiflexion + fanning (it normally disappears at 1 year).
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ii. Abdominal reflex:

y Move a blunt object(‫ )ﻏﻄﺎء ﻗﻠﻢ\ﻣﻔﺘﺎح‬on the patient's abdomen starting at flanks towards
the umbilicus.
y+ve response Öshift of umbilicus outwards, then it returns.
b) Deep reflexes: Hyperreflexia (compare Rt to Lt side) +/- clonus
Knee ankle biceps Triceps

Quadriceps Calf muscles Biceps Triceps
Response contraction contraction contraction contraction
(front of thigh) +dorsiflexion ankle (flexion elbow) (extension elbow)
Tendon Below
Tendon Achilles
knee joint Put your finger on Hit on triceps
Put your hand below
Where to (between tibial the biceps tendon aponeurosis above
the knee or at the thigh
hit tuberosity patella, and hit on your the back of the
raising the patient's leg
detect with your finger elbow joint.
above the table
finger)
Knee angle: 120
Position of Knee angle: 90 degrees Elbow angle: 120 Elbow angle: 90
the patient degrees Ankle angle: 90 degrees degrees
degrees
¾ Raise the hammer to the same height in both Rt and Lt sides to avoid a stronger hit on one side
than the other, as this may cause inaccurate results.
¾ Move your wrist when you are using the hammer (‫)ﻳﻨﺰل ﺑﺘﻘﻠﻪ‬
¾ How to detect clonus:

i. Hold the thigh, raising thigh and legs off the table
ii. Let the foot be in plantar flexion (its position in passive
state)
iii. Do sudden maintained dorsiflexion
iv. Response: Regular rhythmic movement of the foot.
c) Neonatal reflexes: abnormally persistent

E.g. Moros reflex:
¾ Loud noise at patient's ear
¾ Dropping the head, with the examiner's hand supporting the body
¾ Sudden withdrawal of blankets from underneath the patient.
y +ve response: extension and abduction followed by flexion and adduction of upper limbs. Fingers
are widely opened. This is followed by a cry.
y Significance: Persistence beyond 6 months indicates CP/mental retardation.
6) Sensation: if the patient can speak, ask him if he can feel.
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7) Cranial nerves:
a) Pseudo-bulbar palsy; (9, 10) is the commonest:

Weak muscles of palate & Chocking Öcan not be feeded
pharynx solid food
Exaggerated reflexes of Dysphagia
palate & pharynx
Nasal regurge (as palate shuts
nose during drinking)
Gag reflex: with a tongue depressor
b) Others:
1st: olfactory nerve: use coffee, every opening separately
2nd: optic nerve: see if the patient can follow the torch/ ask if the patient ‫ﺑﻴﺨﺒﻂ ﻓﻰ ﺣﺎﺟﺔ وهﻮ ﻣﺎﺷﻰ‬
3rd, 4th & 6th: occulomotor, trochlear and abducent nerves:
Move torch/pen at 6 cardinal directions and check the patient's eye direction. If affected Ö squint
5th: trigeminal nerve: JAW REFLEX
The mandible is tapped at a downward angle just below the lips at the chin while the mouth is held
slightly open. Normally this reflex is absent or very slight. However in individuals with upper motor
neuron lesions the jaw jerk reflex can be quite pronounced.
7th: facial nerve: ‫ ورﻳﻨﻰ ﺳﻨﺎﻧﻚ‬,‫ زر ﻋﻠﻰ ﻋﻨﻴﻚ‬,‫ ﺻﻔﺮ‬,‫اﻧﻔﺦ‬
If the patient is not cooperative, tell the examiner that facial expressions mean intact facial nerve
e.g.: crying.
8th: vestibulocochlear nerve
9th: glossopharyngeal nerve: gag reflex (palate and pharynx sensation)
10th: vagal nerve: ask patient to say 'aaah', check uvula mobility with a tongue depressor.
11th: accessory nerve: ask patient to turn face against resistance (sternomastoid)
Ask patient to elevate shoulders (trapezius)
12th: hypoglossal: ask patient to protrude his tongue Ö tongue will deviate towards paralyzed side.
III- Abdominal cases:

A. Inspection:
1) Shape: y bulging flanks: ascites/organomegaly

&contoury Generalized distension: ascites
2) Skin: y stretched +\- striae

y Umbilicus: à site: normal is midway between xiphsternum & symphysis pubis.
à Shape: everted in increased intra abdominal pressure
à Skin overlying: healthy/pigmented/dilated veins/ulcers
à Impulse on cough: present in cases of hernia.
y Scars: à site
à Length
à Healing: 1ry intention if thin scar, 2ry intention if thick/corrugated.
3) Subcutaneous tissue: dilated (visible) veins in case of portal hypertension.
4) Muscle: divarication of recti ‫ﻗﻮل ﻟﻠﻤﺮﻳﺾ ﻳﻬﻢ ﺑﻮﺳﻄﻪ‬
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5) Bone: sub costal angle: normally acute, gets wider in cases of prolonged distension.
6) Organs: localized bulge indicates organomegaly yE.g. fullness in left hypochondrium: splenomegaly.
B. Palpation:
1) Superficial palpation: à to detect tenderness, rigidity and superficial masses.
à Start at right iliac fossa.
à Move your hand in the 9 quadrants in an S – shaped manner.
à Use the gentle sliding technique.
Don’t forget to look at the face of the patient to detect tenderness.
2) Deep palpation: to detect organ enlargement.

à Knee of the patient should be hemi-flexed, to relax abdominal muscle wall.
à Start from the RT iliac fossa and proceed upwards to palpate RT lobe of the liver.
à Start from below the umbilicus upwards to palpate the Lt Lobe of the liver.
à Start in the RT iliac fossa & towards the left hypochondrium to palpate spleen. (Try to
insinuate your fingers between it and costal margin, to prove it is spleen)
à If the patient is relatively old, ask him to take a deep breath while palpating.
à DONT roll your hands.
à When you can feel the lower border of liver/spleen, measure the distance between it and the
costal margin.
à N.B. shrunken liver can't be palpated.
3) Bimanual examination:à the patient is on his back.

à Put your hand on the patient's back below the last rib, try to palpate the
kidney. Kidneys are normally felt in thin individuals and in neonates.
à If there's a swelling and I want to know if the origin was the kidney, perform
anterior pallotment.
à Anterior pallotment: Put your left hand under the back of the patient, and the
right hand on the swelling, and press with your right hand. If you can feel the
swelling with your left hand, then the origin of swelling is from the kidney.
C. Percussion: (wrist movement)

1) For upper border of liver: à start percussion at the 2nd right intercostal space.
à Normally dullness of the upper border of the liver is heard at the 5th IC
space, ask the patient to take a deep breath and hold it, percuss again,
resonance is heard (as the lung occupied this space and moved liver slightly
downwards. This is done to differentiate between dullness of upper border of
liver and lung fibrosis.)
à In case of cirrhosis (shrunken liver), dullness appears in the 6th IC space.
2) For ascites: à mild: knee chest position (NEVER done)

à Moderate amount: shifting dullness.
à Huge amount: transmitted thrill (most probably veno-occlusive disease.)
¾ Shifting dullness:
à Start from epigastric region till you reach dullness that represents the upper border of the bladder. (Mark
it to percuss above it)
à Start from epigastric region till umbilicus.
à Then to the RT of the umbilicus.
à Then to the LT of the umbilicus.
à When you find dullness, fix your hand there and ask the patient to turn his body to the other side, percuss
again, if you find resonance, this is called shifting dullness. (It happens because while the patient is on his
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back, moderate amount of fluid is present in flanks, so when you ask the patient to move to the other side,
the fluid is displaced and resonance is heard in a previously dull flank.)
¾ Transmitted thrill:
à Ask the patient to put his hand in the mid line. ‫ﻳﻀﻌﻬﺎ آﻮﻳﺲ وﻳﺪوس ﻟﺘﺤﺖ‬
(To make sure thrill is transmitted only through ascetic fluid, not through anterior abdominal wall muscles)
à ‫ ﺗﺤﺲ ﺑﺤﺎﺟﺔ ﺑﺘﺨﺒﻂ ﻓﻰ اﻳﺪك اﻟﺸﻤﺎل اﻟﻠﻰ ﻣﻮﺟﻮدة ﻋﻠﻰ اﻟﺠﻨﺐ اﻟﺸﻤﺎل ﻟﻠﻌﻴﺎن‬,‫اﺧﺒﻂ ﺑﺼﺒﺎﻋﻚ ﻓﻰ اﻟﺠﻨﺐ اﻟﻴﻤﻴﻦ‬
D. auscultation: à intestinal sounds

à Venous hum: Para umbilical vein is midway between sternum and umbilicus.
IV- General examination:

a. vital signs:
¾ Pulse rate is … beats per minute, beats are regular, with no special character, volume is average, and
equal in both sides ( examine both sides same time).
¾ Temperature is … (axillary's + 0.5)
¾ Blood pressure is …/…
¾ Respiratory rate is …
b. Measurements
¾ Head circumference is …
How to measure head circumference: make sure you place the meter correctly, on the supraorbital
ridge (2cm above eye brows) & on the occipital protuberance.
¾ Height is …
How to measure height: If < 4 years old: supine
If > 4 years old: standing: y make the patient take off the shoes.
y Patients heals are adjacent to the wall
y Feet close to each other
y Body adjacent to the wall
y Head neither flexed nor extended
y Put a book above patients head.
y Measure
¾ Weight is …
c. Head
¾ Skull: box shaped, wide anterior fontanelle/mongoloid features/cephalhematoma/ forceps
marks.
¾ Hair: Hair is light in color, sparse/silky.
¾ Eye: subconjunctival hge/ jaundice/ puffy eyelid/sunken/lateral upward slope.
¾ Cheek: loss of subcutaneous fat/moon face/butterfly rash of SLE.
¾ Mouth: pallor in lips/cyanosis in tongue/teeth extraction/ tonsillitis/angular
stomatitis/moniliasis/delayed dentition/small/protruded tongue.
¾ Ear lobules: underdeveloped, over folded helix, small external ear.
¾ Anxious look.
d. Neck:
¾ Carotid arteries show no exaggerated pulsations, they are equally felt on both sides with no special
characters or thrill/there is exaggerated carotid pulsations with/with out associated thrill.
¾ Neck veins are not congested shows systolic collapse/ neck veins are congested reaching … cm with
patient seated at 45 degrees position.
¾ Trachea is centralized, thyroid is normal, LNS are not felt.
¾ Short and broad/Buffalo hump
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e. Upper limbs:
¾ There is/ is no clubbing, pallor, splinter hge, oslar nodules.
¾ Broadening, convexity
¾ Short, Simian crease, clinodactyly.
f. Lower limbs:
¾ Dorsalis pedis arteries are equally felt in both sides. There is/is no lower limb edema, clubbing.
¾ Wrinkled/ulcerated/fissured skin, wasted muscles, prominent bones.
¾ Broadening, Knock knees, bow leg, Marfan sign.
¾ Short, broad, wide gap between 1st and 2nd toes.
g. Trunk: kyphosis/lordosis/skin is lemon yellow (unconjugated bilirubin)/umbilical sepsis/scrotal edema.
Cardiology sheet
Rheumatic heart disease:
Personal history: A … year old, male/female patient, named … … …, living at …

[Age should be 5 – 15 years old.]
Complaint: Dyspnea/cough/syncope/palpitation…etc [cardiac symptoms] / Arthritis
Present history:
¾ Onset, Course, Duration of complaint
¾ Then you've to comment on:
¾ The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset,
progressive/stationary/regressive course. It is/isn't related to exertion like suckling/crying. It is/isn't
associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal nocturnal dypnea.
¾ The patient has/doesn't have cough, which started … … ago with acute/gradual onset, progressive/
stationary/regressive course. It is/isn't related to exertion. It isn’t/is productive, sputum is of large/
average/little amount, whitish/yellowish/… color, offensive odor/odorless, and viscid/watery consistency.
¾ There is/is no history of hemoptysis, {syncope, fatigue, coldness of extremities}, {RT hypochondrial pain,
vomiting, recurrent chest infections}, {palpitation that is/isn’t related to exertion, chest pain, fever, chorea,
embolic manifestations as hemiplegia}, cyanosis.
¾ Patient does not have/has edema that started … … ago with acute/gradual onset, progressive/ stationary/
regressive course. It started first at the lower limbs/abdomen …etc, it is pitting.
¾ Patient gave history of arthritis that started … … ago with acute/gradual onset, progressive/ stationary/
regressive course. It affected large/small joints, without/with fleeting character as it started first in the
Rt/Lt/both, knee/hip/…etc joint(s). It was relieved after … days with salicylates/ … weeks spontaneously.
Rt/Lt, knee/hip/… joint was affected later. It is/isn't associated with tenderness, hotness, swelling, limitation
of movement. +/- It left the joint free.
¾ Review of other systems revealed no abnormality.
¾ Patient attended … hospital, where chest x-ray/echocardiography/… were done with no available results.
He/she received medications in the form of tablets/injections.
¾ Patient attended/was admitted to Abu el reesh hospital … ago where chest x-ray/echocardiography/… were
done with no available results. He/she is receiving medications in the form of tablets/injections.
Perinatal history:
1. antenatal history:
¾ During pregnancy, the mother had good health/suffered health problems in the form of …, she gave no/gave
history of skin rash in the form of maculopapules/vesicles, & fever. She did not take/took … drug and was
not/was subjected to irradiation. She did not suffer/suffered from diabetes, toxemia of pregnancy.
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2. natal history:
¾ The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/CS, with/without
sedation. At birth, the condition of the baby was normal/ the baby suffered health problems in the form of
…, he/she didn’t cry immediately/immediately cried after birth. Resuscitation was/was not required. The
birth weight was … kg.
3. neonatal history:
¾ During the neonatal period, there is/ is no history of cyanosis, jaundice, respiratory difficulties, fever,
convulsions, bleeding.
Developmental history:
1. Motor:
¾ The child was able to support his neck when he/she was … months, sit with support when he was … months,
sit without support when he was … months, stand when he was … months and walk when he was … months.
This reveals normal/delayed motor development.
2. mental:
¾ The child started smiling when he was … months, he started to recognize his mother after … months. He
showed stranger's anxiety when he was … months. He started babbling when he was … months, then was
able to talk when he was … months. This reveals normal/delayed mental development.
Nutritional history:
The child is breast fed/artificially fed with adequate/diluted/high concentration, … times per day. After each
feeding, the child sleeps denoting satisfaction. Weaning was started on the 4th/6th month with …,… then …&…,
the child does not receive/receives supplements in the form of vitamins, minerals.
Vaccination history:
The child received vaccinations at his/her birth, 2nd, 4th, 6th, 9th, 15th, 18th months. The mother knows about
the rest of the vaccination schedule.
Past history:
¾ There is past history of recurrent attacks of tonsillitis. There is/is no history of previous attacks of rheumatic
fever. The patient is on long acting penicillin/ the patient does not take any drugs and doesn't have/has drug
allergy (name of drug). There is/is no history of previous operations, trauma, accidents, exanthemas, asthma,
and allergies.
Family history:
¾ The mother of the child is … years old, with good health/health problems in the form of …, she's a
housewife/…etc. the father is … years old, with good health/health problems in the form of …, he's a
worker/…etc. there is/is no +ve consanguinity. He/she is the child number … in his/her family. He/she has …
brothers, …& …years old and …sisters, …&… years old. All with good health except for his … years old
brother who suffers from …
¾ There is no/is history of similar conditions in the family, There is no history of illnesses in the family/ there is
history of hypertension, DM. there is/is no history of abortion, still birth, previous deaths in the family.
Examination: (positive findings)
A. general:
a. vital signs:
¾ Pulse: Water hammer character and large volume in case of aortic regurge.
¾ Temperature: fever in infective endocarditis.
¾ Blood pressure: Big pulse pressure = Çsystole/Èdiastole in case of aortic regurge.
¾ Respiratory rate: tachypnea in chest infection
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b. Head
¾ Eye: subconjunctival hge/ jaundice/ puffy eyelid
¾ Cheek: butterfly rash of SLE
¾ Mouth: pallor in lips/cyanosis in tongue/teeth extraction/ tonsillitis.
c. Neck:
¾ Carotid arteries show no exaggerated pulsations, they are equally felt on both sides with no special
characters or thrill/there is exaggerated carotid pulsations with/with out associated thrill.
¾ Neck veins are not congested shows systolic collapse/ neck veins are congested reaching … cm with
patient seated at 45 degrees position.
¾ Trachea is centralized, thyroid is normal, LNS are not felt.
d. Upper limbs:
¾ There is/ is no clubbing, pallor, splinter hge, oslar nodules.
e. Lower limbs:
¾ Dorsalis pedis arteries are equally felt in both sides. There is/is no lower limb edema, clubbing.
B. Systems examination:
a. Heart:
i. Combined inspection and palpation:
¾ If apex is deviated outwards & downwards, localized, hyper dynamic = Lt ventricular
enlargement.
¾ If apex is deviated outwards, diffuse, with Lt parasternal & epigastric pulstations = Rt
ventricular enlargement.c
¾ If there is pulsations in 2nd Lt space = pulmonary artery
ii. Auscultation:
¾ Apex:
Muffled S1 + soft pan systolic murmur propagating to axilla = Mitral regurge
Accentuated S1 + rumbling localized mid diastolic murmur = Mitral stenosis
¾ Parasternal area: free
¾ Pulmonary area:
Free
Accentuated S2 + Soft ejection systolic murmur = pulmonary hypertension.
¾ Aortic area:
Free
Soft early diastolic murmur propagating to apex (decrescendo) = aortic regurge.
¾ Epigastric area: free
Diagnosis:
A case of chronic rheumatic heart disease with mitral regurge/aortic regurge/double mitral, +/-
pulmonary hypertension - biventricular enlargement - pulmonary artery dilatation. The heart is compensated
by ttt. The case is not complicated/is complicated with chest infection.
Some hints:
¾ Mitral regurge
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¾ Mitral stenosis:
¾ Aortic regurge:
c RT ventricular enlargement causes pulsations in Parasternal area. When it enlarges massively, it also causes
pulsations in epigastric area due to the pressure applied on the diaphragm from the massive dilatation.
¾ Dypnea:
¾ Orthopnea: when the child sleeps, Ç venous return Ö Ç congestion leading to cough.
¾ Paroxysmal nocturnal dypnea: by dawn (at the end of the night), Ç vagal tone Ö Ç venous return from
mesentery and lower limbs Ö Ç pulmonary congestion.
¾ Cough: is due to congestion that leads to irritation of the mucosa.
¾ Hemoptysis: is due to rupture of small alveoli. Rarely present.
¾ Plethora: active passage of blood to lungs, while
Congestion: passive passage of blood to lungs.
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¾ Cardiac Out Put = Heart Rate * Stroke Volume.

¾ In myocarditits:
SV (due to Inflammation) Ö È COP. So, in a trial for compensation, Ç HR Ö palpitation, tachycardia.
[I.e. COP = Ç HR * È SV.]
Myocarditis: leads to heart failure.
¾ Endocarditis +Ç pressure in left ventricle = valvular damage à 1st: mitral regurge
à Then: mitral stenosis (needs months)
à Aortic stenosis: needs 7 – 10 years, children
will have become adults and seek internists.
¾ Pericarditis: à auscultation: rub
à Precordial pain: patient may not be able to describe it .‫ﺣﻴﻘﻮﻟﻚ أﻧﺎ ﻣﺘﻀﺎﻳﻖ\ﺑﺎﻧﻬﺞ‬
¾ Peripheral signs of aortic regurge:

Head and neck: prominent carotid pulsations, suprasternal pulsations, head nodding [concomitant with
pulse.]
Upper limbs: capillary pulsations [press gently at tip of fingernail, pulsations appear], water hammer
pulse [pulse felt at middle of anterior aspect of forearm when its raised], increased pulse pressure.
Lower limbs: pistol shot, duroieziez sign [systolic and diastolic murmur over femoral artery], Hill sign
[blood pressure in lower limbs is 50 mmHg higher than UL, normally its 20 mmHg].
¾ Pistol shots: femoral artery midway between ASIS and pubic tubercle (roughly mid thigh),
.thrill ‫ أو ﻟﻮ ﻋﻠﻰ اﻟﺒﻨﻄﻠﻮن ﺗﺴﻤﻊ ﺣﺎﺟﺔ زى‬,‫ ﺗﺴﻤﻊ ﺻﻮت اﻟﺪم ﻳﻌﺪى واﻟﺴﻤﺎﻋﺔ ﺑﺘﺨﺒﻂ‬,‫ﺿﻊ اﻟﺴﻤﺎﻋﺔ‬
¾ In exam: Mitral regurge +/- aortic regurge [ from neck and water hammer pulse]
+/- Mitral stenosis [‫]ﺗﻚ ﺗﻚ ﺗﺎش‬
¾ In exam, you'll find history of dypnea, cough, and recurrent tonsillitis.
¾ But you will never find history of syncope, edema and no Rt hypochondrial pain.
¾ You will find arthritis (3/4 patients), carditis.
¾ But you will not see erythema (lasts only for a few days), subcutaneous nodules or chorea.
VSD
[Age: mostly an infant]
Complaint: difficulty feeding/failure to grow/difficulty breathing/recurrent chest infection. [due to congestion]
Present history:
¾ The patient does not suffer from/suffers from dyspnea that started … … ago, with acute/gradual onset,
¾ There is/is no history of hemoptysis, {syncope, fatigue, coldness of extremities}, {Rt hypochondrial pain,
vomiting, recurrent chest infections}, {palpitation that is/isn’t related to exertion, chest pain, fever },
cyanosis.
¾ Patient does not have/has oedema that started … … ago with acute/gradual onset, progressive/ stationary/
¾ There is/is no history of failure to grow.
More than you dream
Clinical Pediatrics
Perinatal history:
2. natal history:
3. Motor:
4. mental:
Past history:
¾ There is no/is past history of chest/cardiac/renal/hepatic/GIT/CNS infections. There is no/is history of
previous attacks of rheumatic fever/bilharzias/TB/…/exanthemes (name it). The patient does not take
any/takes … drugs and doesn't have/has drug allergy (name of drug). There is/is no history of previous
operations, trauma, accidents, asthma, and allergies.
Family history:
housewife/…etc. The father is … years old, with good health/health problems in the form of …, he's a
More than you dream
Clinical Pediatrics
Examination: (positive findings)

A. general:
a. vital signs:
b. Measurements
¾ Weight is … [usually underweight due to non-nutritional marasmus, so check thighs &buttocks]
a. Heart:
¾ If apex is deviated outwards and downwards, localized, hyper dynamic = Lt ventricular
enlargement.
¾ If apex is deviated outwards, diffuse, with left parasternal and epigastric pulstations = Rt
ventricular enlargement.
¾ Biventricular dilatation: normal is small VSD (apex is shifted downwards and outwards,
with pulsations in 3rd,4th Lt Parasternal spaces)
In VSD cases, apex is usually localized, in 5th space. Shifted downwards and outwards.
¾ Parasternal area: thrill during systole [detected by other hand on carotid]

¾ Pulmonary area:
Palpable S2 = pulmonary hypertension Always in this order
Pulsations = pulmonary dilatation
¾ Aortic area: Free
ii. Auscultation:
¾ Apex: free
¾ Parasternal area:
Site
3rd, 4th intercostals spaces at Parasternal line
Propagation
Murmur All over precordium
Character
Harsh
Timing
Pan systolic S1 S2
+/- Due to shift of apex outwards, if Ç shift Ö epigastric pulsations

Pulsations
¾ Pulmonary area: Accentuated S2 (pulmonary component) [valve ‫ ﺑﻴﺘﺮزع‬due to high pressure]
b. Chest: if there is bronchitis, medium sized crepitations and wheezes scattered on both lung fields by
auscultation.
More than you dream
Clinical Pediatrics
Diagnosis:
A case of congenital acyanotic heart disease in the form of VSD with biventricular
enlargement &pulmonary hypertension – compensated heart – not
complicated/complicated by chest infection.
Some hints:
Thrill at 3rd, 4th Parasternal spaces

¾ Passage of blood through the VSD causes
Thrill atat3rd
Murmur 3rd, 4, th4thParasternal
Parasternalspaces
spaces
È Cardiac Ç Respiratory rate (compensation)

output ‫ اﻟﻮﻟﺪ ﺑﻴﺸﺮق‬Õ ‫و اﻷم ﻟﺴﺔ ﺑﺘﺮﺿﻌﻪ‬
Load on Congestion Liver RT hypochondrial pain
RT heart
side Lung Infection
GIT Vomiting
¾ Pressure = flow* resistance

Pulmonary hypertension = ÇÇ flow * ÇÇ resistance [reflex vasospasm]
¾ Pulsations in epigastric area - which are due to massive enlargement of Rt ventricle (to the extent of
eisenmingers syndrome/shunt reversal i.e. cyanotic patient who was not previously cyanotic) causing shift of
apex that applies pressure in diaphragm during pulsations – do not occur in VSD cases due to medical care
and follow up.
Tetralogy of fallot
Complaint: cyanosis at rest/during exertion
Present history:
‫أزرق أﻣﺘﻰ؟‬
‫ﺑﻴﺰرق ﺟﺎﻣﺪ ﺳﺎﻋﺎت؟‬
‫ﺑﻴﻘﺮﻓﺺ؟‬
¾ Onset, Course, Duration of complaint [onset usually 3-4 months after birth, never at birth due to patent ductus
arteriosus]
¾ The patient does not suffer /suffers from dyspnea that started … … ago, with acute/gradual onset,
More than you dream
Clinical Pediatrics
¾ The patient sometimes suffers from hypercyanotic spells.

¾ The patient sometimes takes the squatting position.
¾ There is/is no history of hemoptysis, {syncope, fatigue, coldness of extremities}, {Rt hypochondrial pain,
vomiting, recurrent chest infections}, {palpitation that is/isn’t related to exertion, chest pain, fever },
cyanosis.
¾ Patient does not have/has oedema that started … … ago with acute/gradual onset, progressive/ stationary/
¾ There is/is no history of failure to grow.
Perinatal history:
2. natal history:
5. Motor:
6. mental:
Past history:
More than you dream
Clinical Pediatrics
Family history:
Examination:
A. general:
a. Measurements
¾ Weight: usually underweight due to non-nutritional marasmus, so check thighs &buttocks
b. Head
¾ Mouth: cyanosis in tongue/ pallor in lips.
c. Upper limbs:
¾ There is/ is no clubbing.
d. Lower limbs:
¾ There is/is no clubbing.
a. Heart:
¾ Apex: localized, 4th/5th space [always normal due to mild Rt ventricular enlargement].
¾ Parasternal area: +/ - mild pulsations
¾ Pulmonary area: 50% of cases with thrill [depends on degree of stenosis].
¾ Aortic area: free
iii. Auscultation:
¾ Apex: free
¾ Parasternal area:
¾ Pulmonary area:
Site 2nd left space
Murmur Character Soft
Timing Ejection systolic S1 S2
‫ﻗﺎدر أﻣﻴﺰ أول ﺻﻮت و ﺁﺧﺮ ﺻﻮت‬

Diagnosis:
A case of congenital cyanotic heart disease in the form of tetralogy of fallot. No
cardiomegaly or heart failure.
More than you dream
Clinical Pediatrics
Some hints:
¾ In F4, why there is no heart failure? Because there are no symptoms/signs of heart failure.
diagnosis Rheumatic fever VSD Fallot

Acyanotic congenital Cyanotic congenital
Causal Chronic rheumatic heart disease
heart disease heart disease
Anatomical:
¾ Ventricular ¾ Biventricular. ¾ Biventricular. ¾ No cardiomegaly
¾ Valvular ¾ Mitral regurge, aortic ¾ ---- ¾ ----
regurge, mitral stenosis.
¾ Pulmonary artery ¾ Pulmonary hypertension and ¾ Pulmonary ¾ ----
dilatation. hypertension.
No heart failure
functional compensated compensated
(rare)
Usually no/endocarditis/chest
infection/activity Arthritis
complications Carditis +/- chest infection ----
Chorea
More than you dream
Clinical Pediatrics
Neurology sheets
Cerebral palsy

Complaint: delayed developmental motor and mental milestones/convulsions/chest infection.
Present history:
¾ It is/isn't associated with convulsions, blindness, Para paresis, aspiration, dysphagia.
¾ Then try to determine the cause of brain insult:
Perinatal history:
2. natal history:
¾ The duration of pregnancy was … weeks, it was terminated by CS/normal vaginal delivery/
obstructed/prolonged delivery, with/without sedation. At birth, the condition of the baby was normal/ the
baby suffered health problems in the form of …, he/she didn’t cry immediately/immediately cried after
birth. Resuscitation was/was not required. The birth weight was … kg.
¾ During the neonatal period, there is/ is no history of fever, convulsions, admission to fever hospital
[meningitis], cyanosis, jaundice, respiratory difficulties, bleeding.
1. Motor:
2. mental:
Past history:
More than you dream
Clinical Pediatrics
Family history:
Examination:
A. general:
a. Measurements
¾ Head circumference is …[microcephalic with early closure of fontanelle]
¾ Weight is … [maybe undernourished]
Neurological:
State: disuse atrophy
Power: paralysis/paresis (hemiplegia, diplegia, quadriplegia)
Tone: spasticity +\- scissoring
Abnormal movements: chorea or asthetosis.
Reflexes; Hyperreflexia – ankle clonus.
+ve plantar reflex.
Lost abdominal reflexes.
Persistent neonatal reflexes.
Sensation: preserved.
Cranial nerves: UMNL in motor nerves.
Pseudo-bulbar is commonest. (check neuro examination)
Diagnosis:
A case of cerebral palsy post hypoxic, quadriplegic, spastic with chest infection.
Some hints:
¾ How to know CP at first sight: microcephaly, abnormal position (scissoring/spasticity).
¾ Commonest scenario of CP: delayed motor, mental development + convulsions – quadriparesis (movement
without useful function) – due to hypoxia (bleeding/ CS/ cyanosis/ delayed cry at birth)
¾ To perform a movement, group of muscles are required to act.

If all of them are not functioning Öparalysis
If only some are not functioning Ö paresis.
¾ Paresis: there is still some movement, but the affected part can not be used in a function i.e. used only when
needed, like with the application of a painful stimulus.
¾ Bulbar = medulla
¾ Pseudobulbar: as if nuclei in medulla are the ones affected, but actually motor area 4 or the pyramidal tract
are the ones affected (lesion is in a higher level).
¾ Sensation: is not affected as it is represented by a large area in the brain. Unlike motor area 4.
¾ Kerni = basal ganglia
¾ Antigravity muscles: adductors, pronators, biceps and calf muscles.
¾ Scissoring: because tone in adductors is × than tone in abductors.
More than you dream
Clinical Pediatrics
Hydrocephalus

Complaint: progressive head enlargement usually since birth
Present history:
¾ Onset, Course [progressive], Duration of complaint
¾ It is/isn't associated with convulsions, blindness, Para paresis, swelling in the back
¾ Then try to determine the cause of hydrocephalus:
Perinatal history:
history of skin rash in the form of maculopapules/vesicles, & fever. There was/was no contact with cats
[toxoplasmosis]. She did not take/took … drug and was not/was subjected to irradiation. She did not
suffer/suffered from diabetes, toxemia of pregnancy.
2. natal history:
¾ The duration of pregnancy was … weeks, it was terminated by CS/normal vaginal delivery/traumatic
(complicated/obstructed) delivery, with/without sedation. At birth, the condition of the baby was normal/ the
baby suffered health problems in the form of …, he/she didn’t cry immediately/immediately cried after
birth. Resuscitation was/was not required. The birth weight was … kg.
¾ During the neonatal period, there is/ is no history of fever, convulsions [meningitis], cyanosis, jaundice,
respiratory difficulties, bleeding.
3. Motor:
4. mental:
Past history:
More than you dream
Clinical Pediatrics
Family history:
Examination:
A. general:
a. Measurements
¾ Head circumference is …
b. Head
¾ The anterior fontanelle is … cm allowing … fingers. The sutures are/are not widely separated
with/with out Macewen (cracked pot) sign [resonant note on percussion]. The face is globular
with prominent forehead and sunset appearance in the eyes. The skin is/is not thin &shiny,
with/without prominent scalp veins.
c. Back:
¾ There is/is no meningocele/meningomyelocele.
d. Neck:
¾ Shunt is/not palpated.
Neurological:
Patient has/does not have spasticity of limbs, with/without paralysis.
Reflexes are exaggerated/patient has hypotonia, hyporeflexia and loss of sensation in lower
limbs (in cases of meningomyelocele).
Optic nerve atrophy in chronic cases/6th cranial nerve palsy in squinted patients.
Diagnosis:
A case of congenital hydrocephalus with/without meningocele/meningomyelocele.
Some hints:
¾ Toxoplasmosis: causes aqueduct stenosis.
¾ Traumatic delivery: causes intraventricular hge.
¾ Macewen's sign: cracked pot sound ‫ﺷﺒﻪ اﻹﻧﺎء اﻟﻤﻜﺴﻮر‬. This resonant note on percussion occurs as there
is change in the sound resulting from percussion after suture separation.
¾ Skull is made of face (cartilaginous bone from Infra-orbital ridge = upper end of face to the upper jaw =
lower end) and vault (membranous bone, from infraorbital ridge to highest point on anterior fontanelle).
Membranous part of skull increases with hydrocephalus. [in determining craniofacial disproportion which
occurs only before closure of sutures allowing head enlargement)
¾ After closure of sutures, if hydrocephalus occurs, brain is compressed against bones, so it appears as a
heterogonous white opacity with black dots. (‫ آﺄن واﺣﺪ ﺣﻂ اﻳﺪﻩ ﻋﻠﻰ اﻵﺷﻌﺔ ووﺳﺨﻬﺎ‬fingerprints)
¾ In cranial ultrasonography, a probe is put in the fontanelle.
¾ Ventricle presses on area 4 causing hypertonia and hyperreflexia.

¾ In meningomyelocele, damage of anterior horn cells causes hypotonia and hyporeflexia.
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Clinical Pediatrics
¾ Shunt prevents:
i. optic atrophy,
ii. brain atrophy,
iii. Further increase in the size of the head.
¾ Obstructed shunt is not removed because it may be partial obstruction, so it is better than nothing. Also due
to the adhesions/fibrosis surrounding it.
¾ In neonates, no brain damage occurred yet, so neurological examination will not be required.
¾ Back is very important in examination of hydrocephalus.
Marasmus
Personal history: A…year old, male/female patient, named … … …, living at … [Age:6 months – 2 years old]
Complaint: loss of weight/failure to gain weight/gastro-enteritis/chest infection.
Present history: OCD of complaint + determine type:

¾ The mother noticed that her child is losing/not gaining weight … months ago. The condition is gradual and
progressive.
¾ Nutritional history:
feeding, the child sleeps denoting satisfaction/does not sleep denoting inadequate nutrition. Weaning was
started on the 4th/6th month with …,… then …&…, the child does not receive/receives supplements in the
form of vitamins, minerals.
¾ The child is suffering from gastroenteritis that started … … ago, with an acute onset,
progressive/regressive/stationary course. There is vomiting … times per day/diarrhea … times per day. The
stool is scanty, dry and greenish.
¾ The child is suffering from chest infection. This condition started … … ago with acute onset,
progressive/stationary/regressive course. It is/isn’t improved with antibiotics. There is no/is cough that is
not/is productive with large/scanty amount of viscid/watery, yellow/white/…, offensive/odorless mucus. It
is/is not related to exertion. The patient does not suffer from/suffers from dyspnea that started … … ago,
with acute/gradual onset, progressive/stationary/regressive course. It is/isn't related to exertion like
suckling/crying. It is/isn't associated with failure to thrive. It is/isn't associated with orthopnea, paroxysmal
nocturnal dypnea.
¾ There is/is no history of cardiac problems as cyanosis/exertional dypnea, chronic renal symptoms like
polyurea, chronic hypertension, and hematuria.
¾ There is/is no history of prolonged/recurrent diarrhea, chronic vomiting.
1. Motor:
2. mental:
More than you dream
Clinical Pediatrics
Perinatal history:
2. natal history:
Past history:
Family history:
Examination:
A. general:
a. vital signs:
¾ Respiratory rate: tachypnea in chest infection.
b. Measurements
¾ Weight is … [ underweight]
c. Head:
¾ Eyes are/are not sunken, buccal fat loss indicates 3rd degree marasmus. The lips show pallor
with/without angular stomatitis, monilial infection, and delayed dentition. The patient has an anxious
look.
d. Lower limbs:
¾ Skin is wrinkled, as subcutaneous fat is lost in 2nd degree. Muscle is wasted and bones are
prominent. edema is not/is present indicating marasmic kwashiorkor.
a. Abdominal: loss of subcutaneous fat from the abdomen (by inspection).
b. Chest: in case of chest infection.
More than you dream
Clinical Pediatrics
Diagnosis:
A case of protein energy malnutrition (marasmus), nutritional/non-nutritional,
1st/2nd/3rd degree, not complicated/complicated by chest infection/gastroenteritis.
Some hints:
¾ Mental retardation can cause marasmus as:
i. No reaction, so does not ask for food.
ii. Uncaring mother
iii. Bulbar paralysis (palate/pharynx): dysphagia/aspiration.
¾ Investigations:
Hypoglycemia due to impaired glycogenolysis.
Normal plasma protein (6-8 mg/dl): in marasmus, Øprotein, Øalbumin (normally 5-6mg%), Ø alpha &
beta globulins, but ×gamma globulin (by associated infections).
× Na (aldosterone effect, associated with dilutional hyponatremia i.e. increased total Na but decreased
serum Na in relation to plasma), Ø K (aldosterone, diarrhea &decreased intake), ØMg.
Kwashiorker
Personal history: A … year old, male/female patient, named … … …, living at …[Age:6 months –2 years old]
Complaint: swelling of lower limb/gastro-enteritis/chest infection.
Present history: OCD of complaint + determine type:

¾ Patient does not have/has edema that started … … ago with acute/gradual onset, progressive/ stationary/
regressive course. It started first at the dorsum of the feet &hands/lower limbs/abdomen/…, and then
proceeded to the lower limbs/arms/cheeks, then it became generalized. It is pitting.
¾ Nutritional history:
feeding, the child sleeps denoting satisfaction /does not sleep well denoting poor nutrition. Weaning was
started on the 4th/6th month with rice, potatoes, starch, … then …&…. This shows wrong weaning with
carbohydrate diet mainly. The child does not receive/receives supplements in the form of vitamins, minerals.
not/is productive with large/scanty amount of viscid/watery, yellow/white/…, offensive/odorless mucus. it
nocturnal dypnea.
¾ There is/is no history of cardiac problems as cyanosis/exertional dypnea, or hepatic problems as history of
jaundice, or allergic history of drug intake and itching or chronic renal symptoms like polyurea, chronic
hypertension, and hematuria.
¾ There is/is no history of prolonged/recurrent diarrhea, chronic vomiting.
¾ The child is suffering from gastroenteritis that started … … ago, with an acute onset,
progressive/regressive/stationary course. There is vomiting … times per day/diarrhea … times per day. The
stool is scanty, dry and greenish.
¾ Patient attended abu el reesh hospital where blood analysis was done, with no available results. He received
medications in the form of… & ….
1. Motor:
More than you dream
Clinical Pediatrics
2. mental:
Perinatal history:
2. natal history:
¾ The child received vaccinations at his/her birth, 2nd, 4th, 6th, 9th, 15th, 18th months. The mother knows
about the rest of the vaccination schedule.
Past history:
Family history:
Examination:
A. general:
a. vital signs:
b. Measurements
¾ Weight is … [ usually not underweight due to compensation by edema]
c. Head:
¾ Hair is light in color, sparse. The lips show pallor with/without angular stomatitis, monilial infection,
and delayed dentition. The patient has an anxious look.
d. Lower limbs:
¾ Edema of the dorsum of the feet/of the whole limbs. Skin shows changes in the form of
cracking/fissuring/ulceration. Muscle is wasted and subcutaneous fat is lost indicating
marasmic kwashiorkor.
More than you dream
Clinical Pediatrics
a. Neurological: mental changes and apathy.
b. Chest: in case of chest infection.
c. Abdominal: No ascites. There maybe hepatomegaly in nutritional recovery syndrome.
Diagnosis:
A case of protein energy malnutrition (kwashiorker), not complicated/complicated
by chest infection/gastroenteritis.
¾ ¾ Nutritional marasmus ¾ Non nutritional ¾ Kwashiorkor

marasmus
¾ Blood ¾ Blood picture ¾ Blood picture ¾ Blood picture
¾ electrolytes ¾ Electrolytes ¾ Electrolytes
¾ Chemistry (glucose, ¾ Plasma proteins
amino acids, liver and
kidney functions)
¾ Urine ¾ ___ ¾ UTI, ¾ ___
¾ sugar
¾ Stool ¾ Analysis ¾ ___ ¾ ___
¾ culture
¾ imaging ¾ chest x-ray ¾ chest x-ray, ¾ chest x-ray
¾ abdominal sonar
¾ echocardiography
Rickets
Personal history: A … year old, male/female patient, named … … …, living at … [Age: 1 – 3 years old]
Complaint: Delayed developmental milestones/delayed dentition/chest infection (cough/shortness of
breath)/convulsions.
Present history: OCD of complaint:

¾ Developmental history: The mother noticed delayed motor development of the child as the patient is …
years old and still cant … .there is also delay in other motor milestones as …&… .This condition is also
accompanied with delayed mental milestones as the child is … years old and did not …/… yet.
¾ Nutritional history: The child is breast fed/fed with cow's milk/artificially fed with
adequate/diluted/high concentration, … times per day. After each feeding, the child sleeps denoting
satisfaction. Weaning is not started yet/was started on the 4th/6th month with rice, potatoes, cereals, … then
…&…. This shows inadequate intake of food rich in vitamin D as egg yolk/sea food/liver. The child does not
receive/receives supplements in the form of vitamins, minerals.
¾ The condition is associated with inadequate exposure to sunlight as the mother stated her fear from cold
weather and dust, so she excessively wraps her child and rarely exposes him/her to the sun rays directly.
¾ There is history of recurrent/persistent diarrhea.
¾ There is no history of polyurea.
¾ There is no history of chest infections/convulsions.
nocturnal dypnea.
More than you dream
Clinical Pediatrics
¾ The mother sought medical advice at … hospital where …&… were made with no available results. The
patient was given treatment in the form of injections/…, once/….after that the condition was
improved/didn’t improve.
¾ The patient was admitted to abu el reesh hospital … ago, where …&…were done with no available results.
He/she receives medications in the form of ….
Perinatal history:
5. natal history:
Past history:
Family history:
Examination:
A. general:
a. vital signs:
¾ Respiratory rate: tachypnea in chest infection e.g. bronchitis/pneumonia.
b. Measurements
¾ Head circumference is … [increased due to bossing]
c. Head:
¾ The skull is box-shaped, asymmetrically enlarged with wide anterior fontanelle allowing … fingers.
Mouth examination reveals pallor [and delayed dentations.]
d. Upper limbs:
¾ Distal ends of upper and lower limbs show broadening. Upper limbs show convexity towards extensor
surface. Lower limbs show bow legs/knock knees. There is a transverse groove at the medial malleoli
(Marfan's sign).
More than you dream
Clinical Pediatrics
e. Trunk:
¾ Kyphosis is not/is evident; it is correctable as it disappears by axillary suspension of the baby or
putting him/her in prone position. There is no/is lumbar lordosis on standing. There is no/is scoliosis.
[In Potts disease, kyphosis is not correctable]
a. Chest:
¾ Inspection: Rossary beads are/are not present at costochondral junction. Harrison's and longitudinal
sulci are/are not present. The chest is/is not pigeon shaped.
¾ Auscultation: in case of chest infection. (usually present)
b. Abdominal: there is no/is abdominal distension. The liver is palpable with the upper border of liver
detected by percussion at … intercostals space at/outside mid clavicular line. [below its normal level
which is 4th intercostals space at MCL, due to ptosis]
Diagnosis:
A case of vitamin D deficiency rickets (nutritional rickets), not
complicated/complicated by chest infection.
Some hints:
¾ If the complaint was convulsions, do not mix with CP.
¾ Motor and mental milestones in rickets are delayed, but not like in down's (to a less extent.).
¾ Rossary beads can be felt in a thin normal person, but they are exaggerated to some extent in case of rickets.
¾ To see rossary beads, ask the patient to raise his upper limbs.
¾ In exam, there are no Non-nutritional cases.

¾ In exam, bossing, broadening, marfan, rosary, distension are constant findings.
¾ Harrison, longitudinal sulci, pigeon chest& ptosed liver occur only in severe cases.
¾ In findings, say there is marfan sign and bossing/box shaped skull even if you can't find them.
¾ Do not mention dentition except if no teeth erupted at all
¾ Measure anterior fontanelle, length.
¾ Don’t forget ×respiratory rate and auscultation of the chest in case of chest infection.
¾ In investigations, by x-ray, pathological fractures are seen in the diaphysis of long bones (green stick
fractures). It looks like a fissure that does not lead to separation of the 2 ends of fractured bone
((‫ ﻟﻮ ﺗﻨﻴﺘﻪ ﻣﺶ هﻴﻨﻜﺴﺮ ﻟﻨﺼﻔﻴﻦ ﻣﻨﻔﺼﻠﻴﻦ‬,‫)زى أى ﻋﻮد أﺧﻀﺮ ﻣﻦ اﻟﺰرع‬
Chronic hemolytic anemia

Complaint: progressive pallor/yellowish discoloration of the skin and mucous membranes/progressive
abdominal distension/failure to grow
Present history:
¾ Pallor started gradually … ago when the patient was … months old [by the end of the 1st year], it had a
progressive course. It was improved when the patient was admitted to the hospital and received blood
transfusion.
¾ The condition is not/is associated with jaundice. Stool is normal brownish/very dark brown/clay colored,
urine is dark/red/normal colored.
¾ The condition is not/is associated with abdominal distension.
¾ the patient suffers from failure to thrive (if in early childhood)
More than you dream
Clinical Pediatrics
¾ There is no/is history of sudden pallor and red urine (indicating a hemolytic crisis). There is no/is history of
pain and swelling in the hands and feet (indicating vaso-oclusive crisis).
¾ There is no/is history of repeated blood transfusion every … weeks.
¾ There is no/is history of splenectomy, which was done because of …, after the operation the condition was
stable without/with complications in the form of fever/bleeding/….patient received pneumococcal
vaccine after operation.
¾ The patient was admitted to abu el reesh hospital where …&… were done with no available results. He/she
received blood transfusion and treatment in the form of ….
Perinatal history:
8. natal history:
feeding, the child sleeps denoting satisfaction. Weaning was started on the 4th/6th month with rice, potatoes,
starch, … then …&…. This shows wrong weaning with carbohydrate diet mainly. The child does not
1. Motor:
2. mental:
Past history:
Family history:
More than you dream
Clinical Pediatrics
Examination:
A. general:
a. vital signs:
¾ Pulse: tachycardia, water hammer pulse.
b. Measurements
¾ Head circumference is … [large head]
¾ Height is … [stunted]
c. Head:
¾ The lips show pallor. Eyes show mild jaundice. Mongoloid features are evident as the nasal ridge is
depressed, the maxilla is prominent and the upper central incisors are protruding.
d. Neck:
¾ lymphadenopathy
e. Upper limbs:
¾ There is/ is no pallor seen in nail beds.
a. abdominal:
¾ By inspection, there is generalized distension/bulging flanks, skin is stretched +/- striae, with visible
subcutaneous veins. The sub costal angle is wide and there is divarication of recti. The umbilicus is in its
normal place/shifted downwards/shifted upwards, and everted. The overlying skin is
normal/pigmented/fissured, +\- there is a scar, … cm, at the … quadrant/at left costal margin/transversely
besides umbilicus., healed by 1ry/2ry intention.
¾ By deep palpation, the lower border of the right lobe of the liver is felt in midclavicular line … cm below RT
costal margin, while the lower border of the left lobe is felt in midline … cm below costal margin. It is not
tender, firm in consistency with rounded border. The lower border of spleen is felt in midclavicular line…
cm below left costal margin. It is not tender, firm in consistency with rounded border. +\- notch can be felt.
¾ By percussion: upper border of liver is in the 5th intercostals space. There is NO ascites.
b. Heart
¾ Hemic murmur: short systolic murmur at aortic and pulmonary areas. (Heart base).
Diagnosis:
A case of chronic hemolytic anemia most probably thalassaemia major.
Some hints:
¾ In exam, don’t say your case is thalassaemia major, say chronic hemolytic anemia; most probably
thalassaemia because it is common is Egypt. (Because it might be sickle cell anemia or spherocytosis).
¾ How to identify case: y do not depend on pallor (recently received blood transfusion)
y Prominent maxilla, zygomatic process and upper central incisors.
y Pallor + jaundice + hemosiderosis (‫) ﻟﻮن اﻟﺘﺮاب‬
y Relatively old patient (10-12 years old).
y Blood transfusion is very important.
¾ If complaint was failure to grow: it is due to Øoxygen perfusion affecting tissue growth.
¾ In present history, usually there will be repeated blood transfusion every 4 weeks [blood addict].
The patient has to take blood transfusion when he feels hypotension, headache, palpitation and shortness of
breath.
More than you dream
Clinical Pediatrics
¾ Hemolysis of RBCs causes anemia Öhypoxia Ö Ï bone marrow Ö Ï immature cells + expansion in bone
marrow spaces. But still hemolysis is more than manufacture of RBCs Ö ‫ ﻳﺸﺘﻐﻞ ﺧﻂ اﻻﻧﺘﺎج اﻟﺘﺎﻧﻰ‬hyperplasia of
stem cells (hepatosplenomegaly - but also × hemolysis contributes to the splenomegaly). But still this is not
enough, Öso, the patient needs blood transfusion.
¾ Why blood transfusion every 4 weeks, although RBCs half life time is 120 days?
y The transfused cells were already living in the donor's
y The donor is most probably anemic (an Egyptian)
y Hb is not constant.
¾ Stem cells = totipotent cells/mesenchymal cells. Manufacture of RBCs is done by evacuating cell contents
until there is only membrane, Hb and enzyme.
¾ Spleen has 2 types of cells:

y Cells like bone marrow stem cells (3nd line of manufacture)
y Cells that phagocytose platelets and RBCs. Hyperfunctioning of these cells Ù hypersplenism.
¾ If patient used to receive blood every 4 weeks, then started to receive the transfusion every 2 weeks, this
indicates hypersplenism.
¾ Cause of hypersplenism: is unknown, but in some diseases where spleen functions excessively
E.g. toxins & blood diseases, with large amounts of abnormal RBCs
.‫ ﻓﺄﺻﺒﺢ ﻻ ﻳﻔﺮق ﺑﻴﻦ اﻟﺨﻼﻳﺎ اﻟﻄﺒﻴﻌﻴﺔ و اﻟﻠﻰ ﺷﺎﺧﺖ‬,‫اﻟﻄﺤﺎل ﺑﻴﺘﻀﻄﺮ ﻳﻜﺴﺮهﺎ‬
In pediatrics course, hypersplenism is only in bilharziasis and chronic hemolytic anemia.
¾ Usually, there is mild jaundice. If it is severe, it may be due to

y Transmission of hepatitis through blood transfusion.
y Iron (from hemolysis) caused liver cirrhosis.
¾ Depressed nasal bridge: because nose does not contain bone marrow spaces, while the surrounding bone
expands, making it appear as if depressed.
¾ Abdominal findings by inspection are due to × intra abdominal pressure (enlarged organs).
¾ Indications of splenectomy: y large Ö pressure symptoms Ö Orthopnea and dyspnea.
¾ If patient made splenectomy, and you don’t know, and the liver is enlarged where the left lobe is in the
direction of the spleen, how to differentiate between spleen and left lobe?
y Spleen usually enlarges longitudinally downwards. So, if you can feel a mass in the left side of the
abdomen, make sure you can feel most of it in the left side, and that it is descending longitudinally
downwards to some extent.
¾ In cases of splenectomy, adhesions make the liver borders not well identified, you'll be able to feel fullness
¾ Healing by 2ry intention: If scar of spleen is gapping/broad.
¾ Chronic hemolysis Ö pigmentary stones Ö laparoscopy scar, 2-3 cm, nearby umbilicus, to remove gall
bladder.
¾ Q: why this is spleen? y ans: c it's anatomical site (left hypochondrium)
d Presence of notch
e Can't insinuate my finger between it and costal margin.
¾ Sometimes, Iron overload Ö hepatitis Ö shrunken liver.
¾ Cause of death: hemic murmur.
More than you dream
Clinical Pediatrics
Purpura

[Any age, but aplastic patients are relatively old]
Complaint: reddish spots/mucous membrane bleeding (epistaxis, hematuria)
Present history:
¾ Condition started with an acute/insidious onset, … weeks/years ago, with a regressive(ITP)/stationary,
prolonged (aplastic anemia)/progressive course (malignancy).
¾ Spots are pinpoint/… mm, generalized all over the body, reddish, and they are not raised above the surface.
¾ There is no/is history of epistaxis, bleeding gums, hematemesis, hematuria. Bleeding was of
minimal/moderate/large amount, and there was no need for blood transfusion/the patient received blood
transfusion.
¾ The patient never received/received blood transfusion … times. (↑ 5 in aplastic anemia)
¾ There is no/is history of preceding fever, cytotoxic drugs, arthralgia/recent marked weight loss/continous
fever.
¾ The patient was admitted to abu el reesh hospital where …&… were done with no available results. He/she
received blood transfusion and treatment in the form of ….
Rest of history taking like chronic hemolytic anemia, (no findings of relevant importance
in purpura).
Examination:
A. general:
¾ vital signs: important
¾ Measurements: steroid (taken for ttt of aplastic anemia) affects growth.
¾ Head: eyes: subconjunctival hge, lips: pallor (severe in aplastic, mild or absent on ITP)
¾ Neck: lymphadenopathy (of leukemia), in exam say LNS are normal.
¾ Limbs & trunk: pinpoint petichial hge +/- echymosis. They are not raised and do not blanch on
pressure. They are reddish. Bone is not tender.
B. Abdominal: no hepatosplenomegaly (exclude leukemia)
Diagnosis:
A case of purpura, most probably ITP/aplastic anemia for further investigations.
Cases History examination

Short
Purpura
ITP Preceded by viral infection
Mild pallor
Blood transfusion only once
Prolonged
Bad general condition
History of drug intake
Aplastic Severe pallor
Repeated blood transfusion (not
Cushinoid (steroid ttt)
less than 5)
Bad general condition
Fever Pallor
leukemia Arthralgia Hepatosplenomegaly
Recent marked Loss of weight Lymphadenopathy
Tender bone
More than you dream
Clinical Pediatrics
Down syndrome

Complaint: delayed developmental milestones/chest infection/shortness of breath/hypotonia
Present history: OCD of complaint,
¾ The child is suffering from chest infection that started … … ago with acute onset,
nocturnal dypnea. [if the main complaint is chest infection]
¾ Down syndrome was discovered at birth/… … after birth
¾ When the child developed chest infection and received medical attention/As the mother noticed delayed
motor/mental milestones, where the child was … months and still could not …. Then condition is associated
with hypotonia.
¾ Developmental history:
1. Motor:
¾ The child is still unable to support his neck/was able to support his neck when he/she was … months, sit with
support when he was … months, sit without support when he was … months, stand when he was … months
and walk when he was … months. This reveals normal/delayed motor development.
2. mental:
¾ There is history of recurrent chest infection.
¾ The mother sought medical advice at … hospital where …&… were made with no available results. The
patient was given treatment in the form of injections/…, once/….after that the condition was
improved/didn’t improve.
¾ The patient was admitted to abu el reesh hospital … ago, where …&…were done with no available results.
He/she receives medications in the form of ….
Perinatal history:
11. natal history:
Family history:
More than you dream
Clinical Pediatrics
¾ The child is breast fed/artificially fed with adequate/diluted/high concentration, … times per day. After each
Past history:
Examination:
A. general:
a. vital signs:
b. Measurements
¾ Head circumference is … [small, brachycephalic]
¾ Height is … [short stature]
¾ Weight is … [usually underweight]
c. Head
¾ Head circumference is … cm. the occiput is flat, hair is silky,
¾ Eye: medial epicanthal fold and lateral upward slope of eyelid.
¾ Nasal bridge is short and depressed.
¾ Ear lobules are underdeveloped, with overfolded helix and small external ear.
¾ Mouth: small due to micrognathia, the tongue is protruded and fissured. (rugae/scrotal tongue).
d. Neck:
¾ Short and broad.
e. Upper limbs:
¾ Hands are Short and broad, with transverse palmar crease +\- clinodactyly.
f. Lower limbs:
¾ Feet are short and broad, +\- with a wide gap between the 1st and 2nd toes.
a. Heart: like VSD
b. Chest: if there is bronchitis, medium sized crepitations and wheezes scattered on both lung fields by
auscultation.
c. Abdominal:y distension.
y Hernia.
y Splenomegaly (leukemia as a complication in 1% of cases)
y If a relatively older boy, small genitalia (penis and scrotum).
d. Neurological: hypotonia.
More than you dream
Clinical Pediatrics
Diagnosis:
A case of Down syndrome, most probably non-disjunctional/translocation type, without/with
congenital heart disease in the form of VSD/chest infection.
Some hints:
¾ Down is the name of the scientist who diagnosed it.
¾ Non-disjunctional occurs when age of mother is × 30 years. It is common in female doctors children
due to late marriage.
¾ Patients with GIT anomalies never come in the exam because they are either treated or dead.
¾ Do not say brushfeild iris because it only appears with slit lamp examination.
¾ Causes of death in down: c accidents
d Heart Failure, infections, leukemia.
¾ The older the patient, the better the tone Ö relatively older patients can walk inspite of the severe hypotonia
in the beginning.
¾ The older the age, the less incidence of chest infections.
¾ Manifestations of hypotonia:c ‫رأﺳﻪ ﺑﺘﻄﻮح‬
d ‫رﺟﻠﻪ ﺗﻠﻤﺲ راﺳﻪ‬
efrog leg ‫رﺟﻠﻪ ﻣﻔﺘﻮﺣﺔ ﻟﻠﺨﺎرج‬
feverted umbilicus
g distension & hernia
h ‫ﺛﻨﻰ اﻷﺻﺎﺑﻊ ﻟﺪرﺟﺔ آﺒﻴﺮة ﻋﻜﺲ اﺗﺠﺎﻩ اﻟﻤﻔﺎﺻﻞ‬
¾ History of repeated abortions suggests translocation type.
¾ 50 % of cases have VSD, so you have to perform complete heart examination.
¾ Don’t say Mongolism ‫(ﻣﻨﻐﻮﻟﻰ‬country name).
¾ Silky hair: not necessarily silky, but softer than his siblings.
¾ Cause of chest infections in down:
y hypotonia Ö weak cough reflex Ö accumulation and stagnation of secretions Ö chest infection
y VSD Ö congestion Ö Ç possibility of infection.
Neonatal jaundice

Complaint: yellowish coloration of the skin and mucous membranes

¾ The condition started on the 1st/2nd/… day/week after labor, it has progressive/stationary/regressive course.
¾ The patient is the 1st/2nd child in the family.
¾ The stool is clay colored/has normal color, and urine's color is dark/normal.
Perinatal history:
history of skin rash in the form of maculopapules/vesicles, fever & lymphadenopathy. She did not take/took
… drug and was not/was subjected to irradiation. She received blood transfusion. She did not suffer/suffered
from diabetes, toxemia of pregnancy.
14. natal history:
¾ The duration of pregnancy was … weeks, it was terminated by normal vaginal delivery/traumatic delivery
resulting in cephalhematoma/CS, with/without sedation. There is no/is history of premature rupture of
membranes. At birth, the condition of the baby was normal/ the baby suffered health problems in the form
of …, he/she didn’t cry immediately/immediately cried after birth. Resuscitation was/was not required. The
More than you dream
Clinical Pediatrics
1. Motor:
2. mental:
feeding, the child sleeps denoting satisfaction. Weaning is not started yet.
¾ The child received vaccinations at his/her birth, The mother knows about the rest of the vaccination
schedule.
Past history:
Family history:
housewife/…etc, she gave history of previous abortion. the father is … years old, with good health/health
problems in the form of …, he's a worker/…etc. there is/is no +ve consanguinity. He/she is the child number
… in his/her family. He/she has … brothers, …& …years old and …sisters, …&… years old. All with good
health except for his … years old brother who suffers from …
history of chronic hemolytic anemia, hypertension, DM. there is/is no history of abortion, still birth, previous
deaths in the family.
Examination:
A. general:
a. Measurements
¾ Head circumference is … [micro cephalic in TORCH]
b. Head
¾ Head circumference is … cm.
¾ +\- cephalhematoma – forceps marks.
¾ Eye maybe jaundiced.
¾ Lips show pallor. [hemolytic anemia]
c. trunk:
¾ umbilicus: umbilical sepsis
¾ skin is lemon yellow (unconjugated)
a. Abdominal: hepatosplenomegaly (cholestasis).
b. Neurological: Moro and suckling reflexes, to exclude kernicterus.
Diagnosis:
A case of neonatal jaundice, most probably …
More than you dream
Clinical Pediatrics
Nephrotic syndrome
Personal history: A … year old, male/female pt, named … … …, living at… [Minimal lesion:2-6 years old]
Complaint: puffiness of the eyelids/swelling in lower limbs

¾ Edema started … … ago, with gradual onset, it started around the eyes, with intermittent course at the
beginning, more in the morning and disappears by the end of the day. Later it affected the dorsum of the
hand, scrotum, lower limbs, abdominal wall, and caused ascites. It is massive, pitting, +/- associated with
vomiting and abdominal wall.
¾ There are no cardiac symptoms like dypnea, orthopnea, no hepatic symptoms like jaundice. Also the
nutritional history reveals adequate nutrition, indicating absence of these factors as causes of edema.
¾ There is no/is hematuria, headache, hypertension.
¾ There are no symptoms suggestive of chest infection as cough/dyspnea.
¾ The patient soak medical advice at … clinic/hospital where urine, blood& … analysis were done with no
available results. he received medications (steroids/hypertensives)in the form of tablets, and the condition
was/was not improved.
¾ Patient was admitted to Abu el reesh hospital … ago where urine analysis/ chest x-ray /… were done with no
available results. He/she is receiving medications in the form of tablets/injections.
Perinatal history:
17. natal history:
3. Motor:
4. mental:
More than you dream
Clinical Pediatrics
Past history:
¾ There is no/is history of similar condition … … ago. There is no/is past history of
chest/cardiac/hepatic/GIT/CNS infections. There is no/is history of previous attacks of rheumatic
fever/bilharzias/TB/…/exanthemes (name it). The patient does not take any/takes … drugs and doesn't
have/has drug allergy (name of drug). There is/is no history of previous operations, trauma, accidents,
asthma, and allergies.
Family history:
Examination:
A. general:
a. vital signs:
¾ Blood pressure: hypertension in non-minimal lesion.
b. Head:
¾ Puffy eyelids
¾ Pallor in lips.
¾ Cushinoid features (moon face + buffalo hump)
c. Limbs:
¾ Bilateral, pitting, not tender edema in hands/feet, reaching below knew/above ankle.
d. Genitalia:
¾ Scrotal edema
a. Abdominal:
¾ Generalized distension/bulging flanks, with wide/normal subcostal angle, stretched skin (+\- striae),
visible veins, and divarication of recti. The umbilicus is in its normal position/shifted downwards and
everted.
¾ Superficial palpation shows tenderness [peritonitis]. Deep palpation shows no organomegaly, renal
angles are free in bimanual examination.
¾ Percussion shows moderate/huge ascites.
Diagnosis:
A case of generalized edema, nephritic syndrome, most probably minimal lesion type, 1st
attack/relapse, with/without chest infection as a complication.
Some hints:
¾ Moon face: due to fat in face, and buffalo hump is due to fat in back.
¾ Chest infection may occur due to decreased immunity (pneumococci) [Øerythropoeisis]
¾ Pallor is due to hypovolemia and affection of erythropoeisis.
More than you dream
Clinical Pediatrics Abdominal cases
¾ Abdominal Cases can be: hepatosplenomegaly, hepatomegaly, shrunken liver with huge splenomegaly.
a) Chronic hepatitis (cirrhosis/failure)
b) Metabolic liver disease
c) Bilharziasis
d) Malignancy
e) Chronic hemolytic anemia, a 2 years old patient, mongoloid features are not apparent yet,but with HSM
f) Veno-oclusive disease.
HepatoMegaly +\- liver failure +\- portal hypertension → bilharziasis.

HepatoMegaly + tense ascites → VenoOcclusive Disease.
HepatoMegaly → metabolic
Splenomegaly → leukemia
HepatoSplenoMegaly → leukemia
SplenoMegaly + shrunken liver + portal hypertension → post hepatic
cirrhosis.
¾ Jaundice+dark urine+clay stool = hepatitis, mostly HAV.‫اﻟﻌﻴﺎن ←ﻋﻨﺪﻩ اﻟﺼﻔﺮا وﺑﻮل ﻟﻮن اﻟﺸﺎى وﺗﻘﻞ ﻓﻰ ﺟﻨﺒﻪ اﻟﻴﻤﻴﻦ‬
This is usually associated with history of blood transfusion or unsanitary life style.
¾ In case of bilharziasis, there maybe repeated blood transfusion (3-4 times) due to ulcer resulting from
emergence of ova → injury of sub mucosa → bleeding.
¾ Chronic hemolytic anemia=repeated blood transfusion, (not only 5-6 times) regularly every month.
¾ History of repeated liver biopsy + onset of condition at 6th/7th month of life + similar family history +
associated symptoms = metabolic.
¾ Anemia + hypersplenism = ↓ platelets → echymosis + other abdominal symptom.
¾ Lipid storage disease: accumulation of lipid in liver, spleen and brain → hepatosplenomegaly + convulsions.
¾ Wilson: large liver + chorea.
¾ Glycogen storage disease: glycogen accumulation in liver and spleen → impaired glycogenolysis.
If patient did not eat well → hypoglycemia → convulsions.
¾ Abdominal distension: hepatomegaly or ascites. Ascites differs as it is collected in the most dependent parts,
except if very tense (fills all partitions).
¾ Distension: ‫ﺑﻄﻨﻰ ﺑﺘﻌﻠﻰ\ﺑﺘﻜﺒﺮ‬
¾ Pain: due to distension, usually in LT hypochondrium in splenomegaly.
¾ Biopsy = ‫ = ﺑﺬل‬taking a sample from ascetic fluid to be examined.
¾ esophageal varices = ‫اﻟﻌﻴﺎن ﺑﻴﻘﻮل ﻋﻤﻞ ﻣﻨﻈﺎر‬
¾ Jaundice: increased direct bilirubin as hepatic cells can conjugate but can't actively secrete.
¾ By examination, cirrhosis is detected by: on percussion: dullness below the 5th intercostal space.
Shrunken RT lobe (only LT is palpated).
More than you dream

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4th IC space just

N.B.; during examination, always use your left hand to

¾ ¾ Rheumatic ¾ VSD ¾ Fallot

So, you may hear murmurs at

¾ Mitral regurge= muffled S1 + rumbling mid diastolic murmur at apex.

II- Neurological cases:

4) Tone: Shaking Hypertonia: hand and forearm Move as one unit

5) Reflexes: 9Rules: exposure - positioning

ii. Abdominal reflex:

b) Deep reflexes: Hyperreflexia (compare Rt to Lt side) +/- clonus

Knee ankle biceps Triceps

¾ How to detect clonus:

c) Neonatal reflexes: abnormally persistent

6) Sensation: if the patient can speak, ask him if he can feel.

a) Pseudo-bulbar palsy; (9, 10) is the commonest:

Gag reflex: with a tongue depressor

III- Abdominal cases:

1) Shape: y bulging flanks: ascites/organomegaly

2) Skin: y stretched +\- striae

Don’t forget to look at the face of the patient to detect tenderness.

2) Deep palpation: to detect organ enlargement.

3) Bimanual examination:à the patient is on his back.

C. Percussion: (wrist movement)

2) For ascites: à mild: knee chest position (NEVER done)

D. auscultation: à intestinal sounds

IV- General examination:

g. Trunk: kyphosis/lordosis/skin is lemon yellow (unconjugated bilirubin)/umbilical sepsis/scrotal edema.

Personal history: A … year old, male/female patient, named … … …, living at …

Examination: (positive findings)

¾ Cardiac Out Put = Heart Rate * Stroke Volume.

¾ Peripheral signs of aortic regurge:

Complaint: difficulty feeding/failure to grow/difficulty breathing/recurrent chest infection. [due to congestion]

Examination: (positive findings)

¾ Parasternal area: thrill during systole [detected by other hand on carotid]

+/- Due to shift of apex outwards, if Ç shift Ö epigastric pulsations

Thrill at 3rd, 4th Parasternal spaces

È Cardiac Ç Respiratory rate (compensation)

¾ Pressure = flow* resistance

Complaint: cyanosis at rest/during exertion

¾ The patient sometimes suffers from hypercyanotic spells.

Murmur Character Soft

Timing Ejection systolic S1 S2

‫ﻗﺎدر أﻣﻴﺰ أول ﺻﻮت و ﺁﺧﺮ ﺻﻮت‬

¾ Aortic area: Free

diagnosis Rheumatic fever VSD Fallot

Personal history: A … year old, male/female patient, named … … …, living at …

¾ To perform a movement, group of muscles are required to act.

Personal history: A … year old, male/female patient, named … … …, living at …

¾ In cranial ultrasonography, a probe is put in the fontanelle.

¾ Ventricle presses on area 4 causing hypertonia and hyperreflexia.

¾ Back is very important in examination of hydrocephalus.

Present history: OCD of complaint + determine type:

Present history: OCD of complaint + determine type:

¾ ¾ Nutritional marasmus ¾ Non nutritional ¾ Kwashiorkor

Present history: OCD of complaint:

¾ In exam, there are no Non-nutritional cases.

Chronic hemolytic anemia

Personal history: A … year old, male/female patient, named … … …, living at …

¾ Spleen has 2 types of cells:

¾ Usually, there is mild jaundice. If it is severe, it may be due to

Don’t forget to look at the face of the patient to detect tenderness.

HepatoMegaly +\- liver failure +\- portal hypertension → bilharziasis.