DR.

SC Foong- Homework 22/09/2022

Physical examination findings

General Inspection
● Patient was sleepy, on nasal prong.
● Looked jaundice from the head down to the lower abdomen
● Body habitus
○ Head circumference, weight and height need to be plotted on a growth chart
● Scleral icterus
● Scars / pigmentation over the arm

Abdomen Examination
Inspection
● Abdomen distended with visible dilated veins, suggestive of portal venous hypertension
● umbilicus everted and bulged out
● No scars
Palpation
- Non tender
- No organomegaly or mass present
- Fluid thrill positive
Percussion
- Dullness over the whole abdomen
Genitalia: Vulvar grossly edematous

No pedal oedema

Unable to look for sacral oedema as the baby was uncomfortable

What could it be?

Differential diagnosis
● Liver cirrhosis
- Biliary atresia, if not treated by 2 months of age will lead to progressive liver
cirrhosis or persistent cholestasis after kasai procedure, recurrent ascending
cholangitis
(https://www.msdmanuals.com/professional/pediatrics/congenital-gastrointestinal-
anomalies/biliary-atresia)
● SEPSIS
- Congenital TORCHES infection
(https://www.ncbi.nlm.nih.gov/books/NBK560528/)
- Especially CMV, toxoplasmosis, syphilis
● Liver abscess (https://m.pghn.org/pdf/10.5223/pghn.2019.22.4.400)
 - History of neonatal sepsis
- s E.coli, Klebsiella, Streptococcus, Staphylococcus, and anaerobes.
- Neonatal sepsis can be caused by bacteria such as Escherichia coli (E
coli), Listeria, and some strains of streptococcus. Group B
streptococcus (GBS) has been a major cause of neonatal sepsis.
● Hepatoblastoma(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110540/)
● Hepatocellular carcinoma
● Necrotising enterocolitis
● Biliary tract rhabdomyosarcoma
● Inborn error of metabolism
○ galactossemia
○ However, a thorough history from the mother is need (eg birth history)

?
Acute Liver Failure
Viral Hepatitis (B or C)
DR. WC Foong -HOMEWORK 19/09/2022

1) Features of Down’s syndrome

● A flattened, round face, especially the bridge of the nose
● Flat occiput in infants, third fontanelle
● Almond-shaped eyes that slant up (upslanted palpebral fissures)
● Epicanthic fold
● Brushfield spots iris (pigmented spots)
● A short neck
● Small ears, glue ears
● Small mouth
● Dental hypoplasia
● A tongue that tends to stick out of the mouth (protruded tongue)
● Tiny white spots on the iris (colored part) of the eye
● Small hands and feet, short and broad hand
● A single line across the palm of the hand (palmar crease/ simian
crease)
● Small pinky fingers that sometimes curve toward the thumb
(Clinodactyly)
● Hyperflexible joints
● ROUND back due to hypotonia
● Poor muscle tone or loose joints (Hypotonia)
● Shorter in height as children and adults
● Sandal gap
● Deep fissure between the big toe and second toe
● Brachycephaly
● Delayed anterior fontanelle closure due to enlarged anterior
fontanelle, closure taking place more than 18 months
2) How to identify Low sets ears?
● 2 ways
1) Draw a line from the outer canthus to external occipital protuberance
2) Or draw a line joining the inner and outer canthus
● If the ears lie below the line, it is low set
● Normal ears will have ⅓ of upper pinna lie above the line
●

3) Courses of meningitis (disease progression)

●
● Common causative agents
●
4) Acute & chronic complications of blood transfusion

Acute complications Chronic complications

5) Immunization in childhood
● Birth
- BCG
- Hepatitis B
● 2-3 m
 - DTap-IPV-Hepatitis B-Hib
● 4m
- Pneumococcal dose 1
● 5m
- DTap-IPV- Hepatitis B- Hib
● 6m
- MMR
- Measles (sabah)
- Pneumococcal dose 2
● 8-9m
- MMR
- Japanese Encephalitis (Sarawak)
● 12m
- MMR
● 15m
- Pneumococcal booster
● 18m
- DTap-IPV-Hepatitis B-Hib
● 21m
- Japanese encephalitis
● 7 years old
- MR (measles rubella)
- Diphtheria
- tetanus
● 13 years old
- HPV
● 15 years old
- ATT (tetanus)
6) Febrile fit
? within febrile episodes
● Fever occur often during RAPID TEMPERATURE RISE
? within 24 hours
● Febrile seizures that are focal, prolonged, or multiple within the first 24
hours are defined as complex
 7) Simple partial seizure vs complex seizure

Simple partial seizure Complex seizure

Usually affect age 6 months to 5 Usually affect those less than 6

years months or more than 5 years

Generalized tonic–clonic seizure The episode last longer than 15

mins
Regain consciousness after fitting
Recurrent episodes within same
Because the fit is transient, it does febrile illness
not really affect the development
Focal seizure

Regain conscious during postictal

state

Because the fit is transient, it does

not really affect the development

8) MODE OF TRANSMISSION OF HFMD

● Contact
● Oral secretion
● Fecal oral transmission
9) Absorption site of iron, B12, folate
● Iron
- upper part of the intestine, the duodenum and proximal jejunum
● B12
- distal ileum
● folate
- duodenum and jejunum
10) clinical presentation of paracetamol poisoning and iron poisoning
(acute & delayed features)
Paracetamol poisoning Iron poisoning/ iron overload
Acute features Acute features
● anorexia, ● GI Upset (nausea & vomiting)
● vomiting, ● Diarrhea
● abdominal pain, ● Haematemesis
● Melaena
● Acute gastric ulceration
Delayed features
● jaundice, acute liver failure (12 hours to 24 Delayed features
hours) ● 6-12 hours: drowsiness, coma,
● hematuria and shock, liver failure,
● metabolic acidosis hypoglycemia, convulsions
● Most notable organs with iron deposition
are the liver, heart, and endocrine glands
● encephalopathy lead to specific organ damage.
● Stevens-Johnson syndrome (SJS), ● Damage to the liver can result in chronic
● toxic epidermal necrolysis (TEN), and liver disease, cirrhosis and lead to
hepatocellular carcinoma.
● acute generalized exanthematous pustulosis ● Damage to the heart muscle can lead to
(AGEP) heart failure and irregular heart rhythms.
● Damage to the pancreas can lead to
elevated blood glucose levels and
"bronze" diabetes.
● Hypothyroidism and hypogonadism can
result in fatigue, hair loss, infertility, and
decreased libido.
● Deposits on thyroid gland lead to
hypocalcemia and hypopaarathyroidism
● Joint involvement leads to arthritis.

11) dengue rash

● The convalescent rash of dengue fever appears about 2-3 days after
defervescence.
● It is characterized by generalized confluent petechial rash which does
not blanch on pressure, with multiple small round islets of normal
skin. It is otherwise called “white islands in a sea of red”.

12) List of causes of congenital heart disease

- How are they distinct
- Additional sounds
- Peripheral signs

acyanotic cyanotic

13)
[ DISCUSSED]
LOOSE STOOL
Scenario 5 (Group R)
You received this referral letter to be told to act on it.

Dear Doctor,

S: 7-month old infant, PP who is still purging for the past 3 weeks.

B: He had episodes of vomiting and fever earlier which have now resolved.
His stools remain watery without blood. He will purge about 4-6 times a
day (half to fully soaked diapers each time) besides passing out flatus
intermittently

A: On examination, there are no signs of dehydration and his vital signs are
within normal limits. His abdomen is soft and not tender. There are
hyperactive bowel sounds.

R: I suspect PP is having secondary lactose intolerance and would like you

to take over his management.

Thank you

Nurse PQR

● Need to clarify/ confirm the history

● Fit to any other ddx
● how bad has this disease
● Past 3 weeks, non stop diarrhea- impact of disease on the child and
parents
● DDX
- Celiac disease
- Recurrent AGE/ unresolving AGE
 - UTI
- Septicemia
- IEM
- Secondary of lactose intolerance
● Diagnosis of exclusion
● Stop all milk- still have purging (purging last for days)

1. Do you agree with the diagnosis? Explain.

Yes

- Past infection , recent fever

- Persistent loose / watery stool
- Increased passing out flatus
- 7 months old, patient might have started with solids (change in diet)

Secondary lactose intolerance

- child who is breastfed develop AGE with diarrhea

- Intestinal wall epithelium very fragile —> lactase deficiency
- Cannot digest milk (breastmilk / formula)
- Lactose free formula milk for 3-4 weeks, then is able to go back to
normal
- However, if baby is exclusively breastfeeding, alternate between
breastfeed and lactose free
- If baby is on formula, completely stop formula, start with
lactose free formula

2. Are there any further history you may enquire about? If yes, what further
history?

● Does the diarrhea stop when the patient stops drinking milk?
● Any exacerbating/ relieving factors
 ● Dietary HX- has he started solid food? Formula milk? Breastfeeding?
● Any lactose intolerance in the family?
● Any similar episodes prior to this?
● Feeding history

3. How would you manage a case of secondary lactose intolerance?

- Start on lactose free formula (preferably cow’s milk based)

- Normal formula can usually be reintroduced after 3-4 weeks
- Treating underlying condition (if there is)
Scenario 6 (Group R)
QQ, a 12 months old infant presents with diarrhoea for 2 weeks. His
stools are very soft, paste-like and is greenish brown in colour. He
now opens his bowels 3-4 times a day compared to once daily
previously. He is otherwise active and playful. There is no other associated
findings of concern. QQ’s mother is concern about QQ’s bowel habits
changes and has done some search for causes which include toddler’s
diarrhoea and celiac disease.

Ask the mother what does she know

Engage the mother understands

Happen to milk intake

Color changes with foods

● Toddler’s diarrhea
- Formed stools
- +_ food particles
- Colour changes
- Explain to the mother
● Why no need to do anything

● Celiac disease
- Rye, wheat, barley
● Pasta
 ●

* counsel parents how to read food labels

* especially processed foods

* how is it transmitted

* genetic

- Family members with same problem

- Intake of gluten
● complications
- : Malnutrition
● FTT
- Duodenal biopsy (diagnostic test ) + serology
● Vili atrophy
● Stop gluten, get normal vili ( trial of gluten)
● Loss of villi again (confirm)
● No cure
●
1. How would you address the mother’s concerns?

● Enquire infant diet hx

- Is it worse when taking foods that contain any barley, rye or
wheat, including farina, semolina, durum, couscous and spelt.
● Hygiene milk / food preparation?
○ Did she boil the milk with the maximum temperature of water?
How’s her living condition e.g. did she live in an area with a
clean water supply? Did she wash her hand prior to milk / food
preparation?
- Enquire about travel Hx or any sick contact
- Immunization status esp Rotavirus vaccine
- There is a possibility that the child may suffer from food sensitivity
such as celiac disease, lactose intolerance but there are ways to
manage symptoms and prevent damage to the intestine

- Toddler diarrhea almost always improves with age - inform the

mother that she does not have to worry
- Work our best to investigate the cause of the diarrhea
- Ask history relating back to coeliac disease / toddler’s diarrhea - what
do you know about these diseases? Why do you think of these
conditions?
- Advice: Slowly give your child more fluid to drink, wash her hands
often esp before changing a diaper, before handling food and after
toilet
- Get support e.g. from local organizations
2. What are the key symptoms and signs which will indicate the need for
an escalation level of care?

● Symptoms
- Persistent diarrhea (lasted for 2 weeks)
- Reduce feeding

● signs
- Hydration status
- Loss of weight - how fast the pamper is full
- Sunken eyes
- Less or no tears
- Impalpable pulse