PEDIATRICS

TASK-1

1. Preliminary diagnosis: Acute bronchitis(caused by foreign body

aspiration), moderate-severe.
2. Investigations:
 CBC
 Biochemical blood analysis
 ECG, bronchoscopy
 Sputum culture, Nasopharyngeal swab
 Chest X-ray
 Consultation with pediatric pulmonologist.
3. Differential diagnosis:
 Asthma: Present with cough, dyspnea, wheezing and is typically
a chronic condition which has started from childhood.
 Chronic bronchitis: Present with chronic cough, dyspnea and
sputum production for more than 3 months for 2 years.
 Pneumonia: Presence of acute fever, cough, dyspnea,
pulmonary infiltrate on chest X-ray.
 Bronchiolitis: It is not common in children older than 2 years old.
 Tuberculosis: It can be ruled out because of the current x-ray as
peripheral lymphadenopathy is absent.
 Gastroesophageal reflux disease.
4. Treatment:
 Since complications are absent, hospitalization is not needed.
 Bed rest at home.
 Vitamin enriched diet.
 Expectorant and mucolytic drugs such as:

Prospan: 5ml 3 times daily

Fluditec: 5 ml for not more than 4 times a day

Bromohexine: 4mg 3 times a day

Ambroxol: 1 teaspoon 2-3 times a day(or) 30 mg (one tablet of Ambroxol)
to 120 mg (4 tablets of Ambroxol) taken in 2 to 3 divided doses .

 Analgesics and antipyretics:

Acetaminophen: 325-650 mg PO q4-6hr; not to exceed 1.625 g/day

for not more than 5 days unless directed by healthcare provider.
Ibuprofen: 5-10 mg/kg/dose PO q6-8hr; not to exceed 400 mg/dose
or 40 mg/kg/day.

 Systemic Corticosteroids:

Prednisolone: 1-2 mg/kg/day in single daily dose or divided q12hr

for 3-5 days.
Prednisone: 1-2 mg/kg/day PO in single daily dose or divided q12hr
for 3-10 days; not to exceed 80 mg/day.

 Inhaled corticosteroids

Beclomethasone: 40 mcg inhaled PO BID for patients with/without

prior history of inhaled corticosteroid use; may increase dose for
adequate response after ≥2 weeks therapy; not to exceed 80 mcg
inhaled BID
Fluticasone: Inhaled aerosol: Initial (not on inhaled corticosteroid):
50 mcg inhaled PO q12hr. Other patients and those with
inadequate response after 2 weeks: May increase to 100 mcg
q12hr.

Budesonide: prior therapy with bronchodilators alone: 0.5 mg once

daily or divided q12hr; not to exceed 0.5 mg/day
Prior therapy with inhaled corticosteroids: 0.5 mg once daily or
divided q12hr; not to exceed 1 mg/day
Prior therapy with PO corticosteroids: 1 mg once daily or divided
q12hr; not to exceed 1 mg/day.
 Bronchodilators: Albuterol sulphate, Terbutaline
 Antibiotics: Amoxicillin-clavulanic acid(Augmentin),
azithromycin
 Antivirals: Oseltamivir, zanamivir
 5. Prevention:
 Cleaning hands
 Getting recommended vaccines such as flu vaccine.
 Covering mouth and nose while coughing or sneezing
 The prognosis is very good. Most of the patients with
acute bronchitis recover without any complications.
TASK-2
1. Preliminary diagnosis: Scarlet fever, period of recovery,
complicated by post streptococcal glomerulonephritis,
nephritic and nephrotic syndromes, moderate severity.
2. Investigations:
 Nonspecific: CBC(usually shows leucocytosis), urinalysis,
Biochemical tests like liver function test, creatinine,
electrolytes, imaging tests like ECG, visualization of urinary
tract and kidney.
 Specific: Rapid streptococcal test for that clinical
scenario(to initiate the treatment) and throat culture swab
for beta haemolytic group streptococcus.
3. Differential diagnosis: It is not just simple acute
glomerulonephritis. The evidence of glomerulonephritis after
the previous disease brings to think of post-streptococcal
glomerulonephritis. The disease also was differentiated with
Kawasaki disease, because of the strawberry tongue. The
patient already had been diagnosed with scarlet fever and the
current clinical picture is in the period of recovery from scarlet
fever.
4. Treatment:
 Hospitalization in paediatrics department.
 Bed regime and limited activity.
 A low sodium, low protein diet should be maintained until
the kidney function recovers.
 No specific treatment for this condition.
5. Prevention and prognosis:
 Hand hygiene and prospered maintain of environmental
hygiene should be highly reinforced. Isolation patient for 10
days.
 Prognosis: Untreated scarlet fever has a worse prognosis
and before the use of antibiotics, scarlet fever had a
 mortality rate of about 15-20%. If antibiotics are used on
time then the mortality rate is less then 1%.
TASK-3:
1. Preliminary diagnosis: Acute bilateral pyelonephritis without
renal dysfunction, non-obstruction.
2. Investigations: Lab: CBC, creatinine, urea, liver function test,
urinalysis.
Instrumental: abdominal and renal ultrasound, consultation with a
nephrologist.
Microbiological investigation is a must.
3. Differential diagnosis:
 Acute glomerular nephritis was ruled out by the appearance
of leukocytes covering all field in microscopic view inn
urine.
 Cystitis is ruled out by ultrasound that shows slightly
enlarged kidneys bilaterally.
 Basal pneumonia: It is a febrile illness that cause pain in
the subcoastal area. The pleuritic nature of the pain and the
chest x-ray usually show differentiation.
4. Treatment:
 Complete bed rest for 3-4 dyas.
 Diet: Quantities of liquids should be 1.5 times more than
the age necessities. Fresh fruits and vegetables with
diuretic properties are desirable, especially melons).
At exacerbation period, it is necessary to give milk-vegetable
food with limitation of protein(1.5-2g/kg) and salt(2-3g)
 Because E coli causes 95% of all cases of acute
pyelonephritis in children, initial treatment should be
based on regional susceptibility to this pathogen. Initial
treatment should include cephalosporin amoxicillin-
clavulanic acid(augmentin)-20 to 45mg/kg/day in divided
doses every 12 hours), trimethoprim-
sulfamethoxasole(TMP-SMZ)-5mg/kg IV or
aminoglycoside(streptomycin 10-15mg/kg).
 Benzylpenicillin Na- 20,000-50,000 U/Kg for 7-10 days.
5. Prevention and prognosis: Prevention:
 Thorough treatment of chronic or recurrent urinary tract
infections as they may prevent many cases of
pyelonephritis.
  Keep the genital area clean. Wiping from front to back
help to reduce the chance of introducing bacteria from
the rectal area to the urethra.
 Drink more fluids.
 Urinate completely.
Prognosis: Early detection and treatment is good in case of
pyelonephritis as responds readily to antibiotic treatment without
further complications. Permanent renal scars develop in 18-24% of
children after acute pyelonephritis. Treatment within 5-7 days from
the significantly reduces the formation of renal scars.

TASK-4
1) Preliminary diagnosis: Mitral valve stenosis
2) Investigations:
a) Lab tests:
 Brain Natriuretic Peptide (BNP) or N terminal brain
natriuretic peptide (NT-pro BNP): Levels increase in
proportion to decrease of severity.
 CBC: leucocytosis may indicate an underlying infectious
(ex., infective endocarditis) or inflammatory process.
 Basic Metabolic Panel (BMP): may demonstrate evidence
of renal impairment.
 Liver function tests: may show elevations secondary to
congestive hepatopathy.
 CRP: suggests on going inflammation in rheumatic heart
disease.
b) Initial evaluation:
 Transthoracic echocardiography
 ECG
 Chest x-ray
c) Additional evaluation:
 Trans oesophageal echocardiography
 Stress testing
 Cardiac catheterization
3) Differential diagnosis:
 Aortic regurgitation
 Restrictive/hypertrophic cardiomyopathy
 Severe hypertension
 Pulmonary regurgitation
  Acute coronary syndrome
 Cor Triatriatum
 Endocarditis
4) Treatment:
 Bed rest
 Low diet
 Immediate medical stabilization and identification and
treatment of the underlying cause should be done in case of
acute heart failure. Diuretics are used as a standard therapy in
this case. Nitrates may reduce pulmonary congestion but
should be used with caution.
Furosemide 1-2mg/kg q6-8 hrs.
 Conservative management includes serial TTE examinations
optimizing medical therapy.
 Optimization of medical therapy includes screening and
treatment of all cardiac risk factors(ex., diabetes,
hyperlipidemia, and hypertension).
 Beta blockers (0.5mg/kg/day) are used to control the heart
rate.
 Anticoagulants : Heparin 75U/kg
 Captopril 0.15-0.3mg/kg/dose
 Interventional management includes procedures like
Percutaneous Mitral valve Balloon Commissurotomy(PMBC),
open commisurotomy and mitral valve replacement.
5) Prevention:
 Cutting alcohol
 Avoiding tobacco
 Prevention of infective endocarditis
 Maintaining healthy weight
 Keep blood pressure under control

TASK-5
1. Preliminary diagnosis: Bronchial asthma
2. Investigations;
 Spirometry
 Peak Expiratory Flow meter
 Chest x-ray
3) Diagnosis: Exacerbation of bronchial asthma, intermittent, mild
course.
4)Treatment:
Treatment goals:
 Correction of hypoxemia by short term oxygen therapy and
basic oxygen delivery systems.
 Reversal of lower airway obstruction with bronchodilators.
 Reduction of relapse risk.
Short acting beta-2 agonist: albuterol 10 puffs every 20 min during
the first hour. Levalbuterol 2 inhalations (90 mcg of levalbuterol free
base) repeated every 4 to 6 hours; in some patients, 1 inhalation
(45 mcg of levalbuterol free base) every 4 hours may be sufficient.

Systemic corticosteroids: Prednisone (oral therapy), parenteral

therapy like prednisolone and methylprednisolone.
Prednisolone: 2 mg/kg/day orally divided q 12 (maximum
30mg/dose) alternating with placebo (or) 4 mg/kg/day orally divided
every 6 hours (maximum 30 mg per dose).
Methylprednisolone: 1 to 2 mg/kg/day (maximum 60 mg)
Dexamethasone: 0.15–0.3 mg/kg/day (maximum 10 mg)

Short acting muscarinic agonists: Ipratropium bromide: Puffs (100

μg) every 20 min x 3 doses <20 kg = 3 puffs, >20 kg = 6 puffs.

IV Magnesium sulphate:
6. Prevention:
 Vaccination for influenza and pneumonia
 Identify and avoid asthma triggers
 Monitor breathing
 Identify and treat attacks early
 Increase quick-relief inhaler use.

TASK-6
1. Preliminary diagnosis: Chronic form of peptic ulcer disease
 2. Investigations:
Lab investigations:

 CBC: Detection of antibodies of helicobacter pylori in the

child’s immune system.
 Stool test: Detection of traces of H.pylori In the child’s
feces.
 Breath test: A rapid diagnostic test for H. pylori infection
that is based on the ability of H. pylori to produce urease,
an enzyme that converts urea to carbon dioxide and
ammonia. It is the most accurate method to detect H.
pylori infection.
Instrumental:
 X-ray
 Esophagogastroduodenoscopy to take biopsy sample.
3. Differential diagnosis:
 Gastroesophageal reflux diasease: History of heart burn or
pain rising from the lower chest to the throat is typical. May
have associated laryngitis, cough and atypical chest pain.
 Irritable bowel syndrome: Pain may be indistinguishable from
that of peptic ulcer disease, but alteration of bowel habit,
separates this syndrome. Bloating is a common complaint.
 Celiac disease: Diarrhea and evidence of malabsorption are
typical.
 Biliary colic: Pain occurs typically in the right upper quadrant,
about 30 minutes after meal, waxing and waning over minutes
or hours.
4. Treatment:
 Histamine H2-receptor agonists: Ranitidine (Zantac) –
9mg/kg/day.
 Antacids: Aluminium and Magnesium hydroxide (Mylanta)
 Antibiotics: Amoxicillin or Clarithromycin
Regimens for eradication of H. pylori:
Triple therapy:
 Bismuth subsalicyclate – 2 tablets qid
Metronidazole – 250mg qid
Tetracycline – 500mg qid
  Ranitidine Bismuth Citrate – 400mg bid
Tetracycline – 500mg bid
Clarithromycin/Metronidazole – 500mg bid
 Omeprazole – 20mg bid
Clarithromycin – 250/500mg bid
Metronidazole – 500mg bid
Amoxicillin – 1g bid
5. Prevention:
 Washing hands with soap regularly before meals.
 Cooking food thoroughly and eat balanced diet rich in
fruits, vegetables, and whole grains.
 Avoiding alcohol intake
 Avoid NSAIDs
TASK-7
1. Preliminary diagnosis: Community acquired pneumonia, left
side upper lobe.
2. Investigations:
Lab tests:
 CBC, inflammatory markers: increase in CRP, ESR,
leukocytosis.
 Serum procalcitonin: Procalcitonin is an acute phase
reactant that can help to diagnose bacterial lower respiratory
tract infections. PCT can be used to
guide antibiotic treatment but should not be used to decide
if antibiotic therapy is necessary on its own. PCT levels ≥ 0.25
mcg/L correlate with an increased probability of a bacterial
infection. Low PCT level after 2–3 days of antibiotic
therapy can help facilitate the decision to
discontinue antibiotics.
 Arterial blood gas analysis: to identify respiratory failure.

Microbiological studies: Sputum analysis- to identify bacteria.

Imaging studies:
 Chest x-ray: Opacity of one or more lobes, presence of air
bronchograms: appearance of translucent bronchi inside opaque
areas of alveolar consolidation.
 Bronchoscopy: to visually inspect the bronchi – the main
pathways of the lungs – to evaluate the extent of infection.
 Chest CT: to find localized areas of consolidation, air
bronchograms, Ground glass opacities, signs of pleural
effusion or empyema, nodules.
 Diagnostic thoracentesis.
3. Differential diagnosis:
 Bronchiolitis: Intoxication presents as subfebrile, expiratory
dyspnea, bandbox resonance.
 Acute obstructive bronchitis: Cough mostly occurs acutely
and maybe at night. It is not accompanied by intoxication.
It is characterized by expiratory dyspnea.
 Bronchiectasis: There is increased cough, worsening of
dyspnea. No consolidation on chest x-ray. Clubbing nail is
present.
4. Treatment:
 Bed regimen and monitoring
 Increased fluid intake and healthy diet for the patient.
 Drink warm beverages, take steam bath and use a
humidifier to help open the airways and ease your
breathing.
 Oxygen therapy

Criteria for hospitalization: CURB 65 score is needed.

Emperic antibiotic therapy:

 Monotherapy with amoxicillin, doxycycline, macrolide like

azithromycin and clarithromycin.
Azithromycin 10mg/kg on day one and 5mg/kg for the next 4
days.
 Doxycycline: 2.2 mg/kg/dose (Max: 100 mg/dose) PO every 12
hours on day 1, then 2.2 mg/kg/day PO once daily (Max: 100
mg/day). Continue 2.2 mg/kg/dose (Max: 100 mg/dose) PO
every 12 hours for severe infections.
Amoxicillin: 45 mg/kg/day (Max: 1,750 mg/day) PO in divided
doses every 12 hours or 40 mg/kg/day (Max: 1,500 mg/day) PO
in divided doses every 8 hours.
Clarithromycin: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every
12 hours for 5 to 10 days.

 Combination therapy with an anti-pneumococcal beta lactam

like amoxicillin-clavulanate, Cefuroxime, Cefpodoxime with
one of the macrolide (azithromycin, clarithromycin) or
doxycycline.
Control fever with NSAIDs such as ibuprofen 200mg.
Expectorants and mucolytics
Antitussives (codeine)
5. Prevention and prognosis:
 Pneumococcal vaccination
 Influenza vaccination
 Cessation of smoking
 Prognosis: Patients older than 60 years and younger than 4
years have relatively poor prognosis than young adults
TASK-8
1. Preliminary diagnosis: Gastroenterocolitis(E. coli infection),
typical form, severe degree, complicated by infectious-septic
shock.
2. Investigations:
 Stool examination: inflammatory changes, intestinal
enzymopathy.
 Culture of the stools
  Serologic reaction(IHAR in dynamics with fourfold title
increasing in 10-14 days) in children elder than 1 year if
fecal culture is negative.
3. Differential diagnosis:
 Acute non-infectious diarrheas
 Salmonellosis
 Shigellosis
 Staphylococcal infection
 Viral gastroenteritis
 Cholera
4. Treatment:
 Immediate hospitalization
 Rehydration and shock therapy

Using Plan C, we will administer:

Ringer Lactate Solution IV + electrolytes (based on serum
electrolyte levels)
Adrenaline 0.1% 1ml + Hydrocortisone. After 4-6 hours,
reassess the child.

 Nefuroxaxide or Cephotaxime 200mg/kg/day IV/IM qds.

TASK-9
1. Preliminary diagnosis: Viral hepatitis B, typical form, icteric
phase, severe course.
2. Investigations: CBC, Liver function test, liver biopsy,
serological tests like PCR and ELISA, urinalysis, consultation
with paediatric infectious disease specialist and paediatrician.
3. Differential diagnosis:
 Acute cholecystitis: Signs of intoxication
 Acute cholangitis: Charcot’s triad (fever, jaundice, pain in
the right hypochondrium.
 Other types of viral hepatitis
 Alcoholic hepatitis
  Autoimmune hepatitis
4. Treatment:
 Routine monitoring
 Giving energy diet
 Enterosorption
 IV detoxification (total 50-100 ml/kg/day) ringer lactate
solution
 Lactulose for 2.5 to 10 mL/day (1.67 to 6.67 g) PO given in
3 to 4 divided doses for 10-14 days. Adjust dosage every 1
to 2 days to produce 2 to 3 soft stools daily.
 Ursodeoxycolic acid: 10mg/kg
 Prednisolone: 1-3mg/kg 4 times a day divided in equal dose
in a course of 7-10 days.