Practical Child Health Care

BY: MDM 40 STUDENTS CONTACT: @MDM_40 1
‫عدد الدرجات‬
18.75

Nutritional & Developmental History
Before taking any history, you should take care of initial impression
[Consciousness, Vital colour, Respiratory destress].
❖ Pediatric History contains:

• Personal history
• Complain
• Present history
• Past history
• Medical history
• Perinatal history[ Prenatal, natal, postnatal]
• Vaccination
• Nutritional
• Developmental
• Family history
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❖ Nutritional History
Q/ What is the component of nutritional history?
o Type of infant feeding [breast feeding, artificial feeding,
complementary food].
o Period of breast feeding.
o When mother starts weaning and type of this food.
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❖ Breast Feeding:-
Q/ Define exclusive breast feeding.
o Infant receives only breast milk, not given any other liquids or solids
(even water).

Q/ How can you know if the breast feeding is sufficient for baby or
not?
1. Frequency of breast feeding (dependant on baby demand)
[normal 8-10 times]
2. Period of breast feeding (at least 15 min)
3. Enough sleep after breast feeding
4. Normal rate of weight gain
5. Normal urine and stool
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❖ Artificial Feeding:-
We should ask the mother about:
o Type of artificial feeding
o Method of preparation
o Amount of each feed and frequency of feeding
Q/ When should mother start giving baby the complementary food?
o 4-6 MONTHS
Q/ Why shouldn’t mother give food before 4 months?
1. RISK OF ALLERGY
2. NO FULL MATURATION OF GIT
3. NO FULL MATURATION OF LIVER
Q/ Why should mother start giving food at 6 months?
1. TO AVOID CALORIC GAP
2.TO AVOID DEFICIENCY OF IMPORTANT VITAMINS AND MINERALS
Q/ About which should we ask the mother according to food?
o WHEN SHE START COMPLEMENTARY FOOD .
o TYPE OF FOOD.
o AMOUNT OF FOOD

Q/ What are the suggested foods according to age ?
➢ 4months → yogurt and honey
➢ 5 months → Mehalabia
➢ 6 months → fruits ( arange -apple )
➢ 7 months → lentils & potatoes
➢ 8 months → chicken,meat & rice
➢ 9 months → beans ,Tehena & fish
➢ 10 months → Macaroni
➢ 11 months → 1/8 bread
➢ 12 months → As previous
Q/ What is the food should be avoided in weaning diet?
o Food that cause chocking as nuts, fruits with seeds, potato chips…
o Artificial colors and flavors foods.
o Salted food and junk food.
o Highly spiced and fatty food.
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Q/ What are the precautions of complementary feeding?
o INTRODUCE SINGLE INGREDIENT FOODS INITIALLY .
o ALLOW AT LEAST 7 DAYS BETWEEN EACH NEW FOOD .
o MOTHERS SHOULD WASH THEIR HANDS BEFORE PREPARATION AND FEEDING .
o WEANING FOOD SHOULD BE SOFT AND EASILY DIGESTED .
o COVER COOKED FOOD TO KEEP IT CLEAN .
o YOUNG INFANT SHOULD BE FED 4-5 TIMES DAILY .
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Q/ What is the component of developmental history?
1. GROSS MOTOR
2. FINE MOTOR
3. MENTAL AND SOCIAL
4. LANGUAGE

Q/ Mention causes of delayed speech and language.
o Deafness
o Emotional and social deprivation
o Mental retardation
o Paralysis in muscles of tongue and articulation

Q/ Mention causes of delayed walking.
o CEREBRAL PALSY
o MENTAL RETARDATION
o PERIPHERAL NERVES DISORDERS
o MUSCLES DISORDERS
o CHRONIC SYSTEMIC DISORDERS
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Anthropometric measures
1. Head circumference .
2. Arm circumference .
3. Length & hight .
4. Weight .
Firstly : weight
Q/ what are the precautions of weight assessment?
o minimize clothes & no shoes .
o The child stand on digital floor scale & measures to nearest 0.1 Kg .
o Put results correctly on the centile .
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Q/ what is the device and its use ?

 A: balanced infant scale .
 Measure weight for child < 2 Y .
➢ N.B : baby should completely undressed .

Q/ what is this device and its use ?
 A: standing scale
 Measure weight for child > 2Y .
➢ N.B : undressing of shoes .
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Secondly: length & height.

Q/ what is the difference between length and height ?
 A: length for child < 2y
 B: Height for child >2y
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Q/ def the measurement in this pictures ?
 Recumbent length for child < 2y .
Q/ what are the precautions of recumbent length ?

1. Straight knee .
2. On straight surface .
3. Measure from vertex .
4. Remove shoes .

Q/ def the measurement in this pic ?
 Height ( stature ) for child > 2y .
Q/ precautions?
1) Remove shoes
2) His heal together against wall with angle 60 in between .
3) Child head into line of sight
4) 5 sites close to the wall : occiput , shoulder , buttocks , cuff muscle , heal .
5) hands at sides .
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Q/ what is the measurement in this pic ?
 Measurement of head circumference .
Q/ precautions ?
 Above ear .
 Just above eye led .
 Above occiput .
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Q/ what is the measurement in this picture ?
 Mid upper arm circumference

1- Malnutrition
2- Normal child

Q/ Enumerate types of percentile.
1. WEIGHT FOR AGE.
2. WEIGHT FOR LENGTH .
3. HEIGHT FOR AGE & LENGTH FOR AGE.
4. HEAD CIRCUMFERENCE FOR AGE
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Q/ Enumerate uses of growth charts.
 Diagnose growth disturbances in children.
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Q/ Enumerate plotting of growth chart.
1. Select the appropriate chart.
2. Take care of SEX (male- female).
3. Take care of AGE ( birth to 36 months2years to 21 years)
4. Start with horizontal axis, determine the value and draw vertical line
5. Shift to the vertical axis, determine the value and draw horizontal line
6. Locate the position of intersection point.
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N.B : assessment of any anthropometric measures :
1. Introduce your self .
2. Take the consent .
3. Do the procedure .
4. Thank the patient .
َ ،‫اسمها َب َّر َة‬ َ ‫ى‬ ُ ‫صَّل‬ ‫ى‬

-‫اسمها‬َ ‫فح َّو َل‬ ُ ‫وكان‬- ‫ويرية‬ ‫هللا عليه وسلم من عند ُج‬ ‫هللا‬
ِ
ُ ‫خرج َر‬
‫سول‬
َّ َّ َ َّ َ ُ
!‫ال يف ُم َصَّل ِك هذا؟‬ ‫ي‬ ‫ز‬ ‫ت‬ ‫لم‬ :‫فقال‬ ،‫ها‬ ‫َّل‬ ‫مص‬ ‫ف‬ ‫ي‬ ‫وه‬
‫ي‬ ‫ورجع‬ ،‫ها‬ ‫َّل‬ ‫وه يف مص‬ ‫ي‬ ‫فخرج‬
َ ْ ُ
َّ ‫مرات لو ُوزنت بما قلت لوزن ْت‬َ َّ َ َ َ ‫لت َب ْع َدك‬
َ ‫أرب‬ ُ ُ ْ ‫ َن َع‬:‫قالت‬
:‫هن‬ َِ ِ َ ٍَ ‫ثالث‬ ‫مات‬ ‫ل‬ ‫ك‬
ٍ ِ ْ ِ ‫ع‬ ‫ق‬ ‫قد‬ :‫قال‬ . ‫م‬
َ ْ َ
ْ ‫ وزنة ع‬،‫ ورضا نف ِسه‬،‫وبح ْم ِده َع َد َد َخل ِقه‬ َ ‫بحان هللا‬ َ ُ
‫ماته‬
ِ ‫ومداد ك ِل‬ ِ ،‫ه‬ ‫ش‬ِ ‫ر‬ ِ ِ ِ ‫س‬

Nutritional classifications
‫تيج ازاي؟‬
‫ي‬ ‫ االسئلة فالراوند ده ممكن‬
‫ ويقولك‬case ‫ يجيب‬-1
classify according to welcome or water low classification
‫ وسؤال‬diagnosis ‫ ويسألك في ال‬rickets ‫ او‬marasmus ‫ او‬KWO ‫ يجيب صورة‬-2
nutrition ‫من النظري شابتر ال‬
Define welcome classification?

Nutritional disorders are classified according to body weight and
the prescience of edema.
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How to determine nutritional disorder according to welcome
classification?
1. determine ideal weight (50th centile)
2. divide actual by ideal

𝒂𝒄𝒕𝒖𝒂𝒍 𝒘𝒆𝒊𝒈𝒉𝒕 (‫) معطي في السؤال‬
percentage = ╳100
𝒊𝒅𝒆𝒂𝒍 𝒘𝒆𝒊𝒈𝒉𝒕 ( 𝒄𝒆𝒏𝒕𝒊𝒍𝒆 ‫) بتجيبه من علي ال‬
3.determine the presence of edema or not

4.choose the category
edema kwashiorkor
welcome 60_80 %
under
classification no edema
weight
(weight for edema
marasmic
age ) kwashiorkor
<60 %
no edema marasmus

CASE 1
Classify according to welcome: male 2 years, body weight 6 kg with edema.
 Items:
Male / 2Y / 6Kg / with edema
 Calculate ideal weight:
(We use weight for age percentile: Egyptian boys, birth to 36 months. 2years
→ 24 months)
ideal weight= 13.25kg
 Divide actual weight by ideal weight:
(6÷13.25) x100 = 45.3%
 Classify according to welcome:
boy < 60% and has edema.
 diagnosis
it is marasmic kwashiorkor.
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CASE 2
Classify according to welcome: female 11 months, body weight 3.5 kg, with
edema.
 Items:
female / 11month / 3.5Kg / with edema
 Calculate ideal weight:
(We use weight for age percentile: Egyptian girls, birth to 36 months.)
ideal weight=8.75kg
 Divide actual weight by ideal weight
(3.5 8.75) x 100 = 40%

 Classify according to welcome
girl < 60% and has edema
 diagnosis
it is marasmic kwashiorkor
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Q/Define water low classification.
Nutritional disorders are classified according to weight for length

and length for age.
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Q/How to determine nutritional disorder according to water low
classification?
weight for length
1. Determine ideal weight for height (50th centile).
2. Divide actual by ideal
3. Choose the category (Normal/Wasted)
length for age
1. Determine ideal length for age (50th centile).
2. Divide actual by ideal
3. Choose the category (Normal/ Stunted)
Combine the two results
water low
classification
weight for
length for age
length
≥ 80% < 80% ≥ 90% < 90%
wasted stunted
normal normal
(acute PEM) (chronic PEM )

CASE 3
Classify according to water low: Male 1 year, height 60 cm, weight 4 kg.
 Items:
male/1y/4Kg/60cm
 Calculate ideal weight for length:
(We use weight for recumbent length percentile:
Egyptian boys, birth to 36 months.)
ideal weight for length= 5.75kg

 Divide actual weight length by ideal
weight for length
(4÷5.75) x100 = 69.6%
 Classify according to water low
• boy <80%
• it is wasted.
 Calculate ideal length for age:

(We use recumbent length percentile Egyptian boys, birth to 36 months.)
ideal length = 76cm

 Divide actual length by ideal length for age
(60 ÷76) x100 = 78.9%
 Classify according to water low
• boy <90%
• it is stunted.
 Combine both results
the boy is stunted and wasted

Cases of PEM
Case 1
Nouran is a 9-month-old girl presented by reduced appetite during the last 10 days
Taking dietetic history revealed that: nouran was breast feed till the age of six
month, when her mother stopped breast feeding as she believed that she had no
milk in her breast and she started to feed her rice-based cereals, boiled rice with
no vegetables nor meat
On Examination: she was very irritable, has bilateral pitting edema on the dorsum
feet she also has angular stomatitis and glossitis She had dry skin with flaky rash
on low limb, which consist of hyperpigmented patches that flake off to reveal
hypopigmented patches with small ulceration
 Anthropometric measurement:
➢ Her weight was 6kg
➢ Her length was 64cm
 According to welcome classification

➢ (6/8) x100=75%
➢ Edema (kwashiorkor)
 Water low classification
➢ Weight for length
➢ 88%=> normal, not wasted
➢ Height for age
➢ 91.4%=> normal, not stunted

Q/ what investigation do you think will be helpful
1. CBC: this patient can have any type of anaemia
2. Serum albumin and total PTN: hypoalbuminemia
3. Urine analysis: albumin Nil
4. Liver and kidney function: may be impaired
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Q/ Management of the patient?
 Give her protein and the needed calories Gradually and not push her in
feeding with High protein at this time for fear of feeding Syndrome
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Q/ Do you want to push this patient in feeding with high Ptn at
time being?
 No, for fear of refeeding syndrome
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Q/ Hospitalize this patient or no need for hospitalization?
 This patient is decompensated and it is very Important to keep her
under strict follow up of the following
o Conscious level
o Vital data
o Random blood sugar
o Tolerance of feeding
o Serum electrolytes (Na, k, Ca, PO4 & Mg)
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Q/ What the indications for hospitalization in cases of malnutrition?
o Hypothermia
o Infection
o Fluid and electrolyte imbalance
o Convulsions
o Unconsciousness

o Jaundice, purpura
o Raised liver enzymes
o Severe anemia and congestive cardiac failure
o Xerophthalmia
o Severe dermatosis Extreme weight deficit
o Bleeding
o Marked hepatomegaly
o Persistent vomiting Severe anorexia
o Distended tender abdomen
o Age less than 1 year
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Q/ How can we start feeding?
We will start protein on 0.7 gm/kg/day
o 0.7 x 6 = 4.2 gm protein /day

o Calories on 80 kcal/kg/day "take care of refeeding syndrome"
o 80 x 6 = 480 kcal/day
‫ بس نقلل البداية ونزود تدريجيا وبردو هندیله‬2gm/Kg/daily‫طبيع هندیله بروتي‬
‫ي‬ ‫لو العيان دا‬
For fear of refeeding syndrome ‫ کالوریز كبداية وتزود تدريجيا‬%60
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DON'T FORGET:
o Zinc 10-20 mg/kg
o vitamin A 200,000 IU
o Vitamin D 5000 IU
o B complex Folic acid 5 mg on 1st day then 1 mg/day
o vitamin E vitamin K vitamin C
 N.B: Iron supplementation should be postponed till the patient has

good appetite and gaining Weight after complete resolution of any
Associated infection.

Case 2
Omar is a 7-month-old boy presented with Acute Gastroenteritis (AGE) (Fever,
Vomiting, Diarrhea) with mild dehydration and noted To be small for his age.
 Anthropometric data
o weight 6.075 kg
o Length 67.5 cm
o Weight history: crossing percentiles (from 50th to 3rd) from The age of
3 months To now Referred to dietitian For nutritional Assessment.
o Bet 25 th ,10 th
 Welcome classification
(6.075/7.25) ×100=83%=>normal
‫وبينزل‬50 th‫ ألنه كان األول عند ال‬Malnutrition ‫ لسه نورمال لكنه عنده أعراض‬finding ‫هو الـ‬
stunted‫ وممكن يوصل‬wasted ‫ هيكمل يبقى‬management ‫لو كمل بدون‬3rd‫دلوقتي في اتجاه الل‬
Q/ Which component of food/nutrition-related History need to be
assessed?
1. Breastfeeding history
2. Intake of infant formula
3. Complementary feeding
➢ Breastfeeding history
• Still on breastfeeding
• very frequent feeding when mom at home Likes to latch on
➢ Use of infant formulas: not used
➢ Complementary feeding:
• Age of Introduction: - started at age of six Months
• Type and food texture: - rice with added soap
• Feeding technique: - element of force feeding, Child will cry during
mealtimes
• Quantity: - 2 tbsp - twice daily
• Other habits: - thumb suckling

Q/ Nutritional Diagnosis and Management.?
1. Inadequate oral intake: Poor weight gain.
2. Poor feeding practices: Choice of Infant formula
3. Iron-fortified cow's milk based infant formula is the most appropriate
milk feeding from birth to 12 months for infants who are not breastfed or
who are partially breastfed.
4. feeding is not established yet
5. Other dietary emphasis: Iron-rich foods Nutritional Diagnosis and
Management.
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Case 3
Ahmed is 11-month-old boy born FT with BW 3.03kg Admitted with dehydration
Secondary to Viral AGE Referred to dietitian for nutritional assessment.
 Anthropometric data: Weight on admission - 3.325 kg

Weight crossing percentiles from 50th to 3Rd Percentiles, length - 57 cm
(is <60% sever PEM)
 Nutrition-focused Physical findings:

• Wasted
• Poor muscle bulk and fat stores
 Nutritional History:
• Breastfeeding -until age of one month
• Supplemented with Infant formula claimed Not enough supply on
standard infant formula (Bebelac 1 dilution 2 scoops: 90 ml water),
which was later changed so Nactalia 1 at Similar dilution Also given
glucose drinks.
• Below 3rd persentile (underweight)

According Welcome classification
• (3.325/9) x100=36.9%
• No edema (marasmus)
According water classification
weight for length
• (3.325/5.25) x100=63.3%
• (wasted)
Water low Classification
Length for age
• (57/74.5) x100=76.5%
• Stunted
Q/Nutritional intervention?
• Nutrition education
• Correct feeding dilution
• Standard dilution
• Stop glucose drinks
• Ensure all feeds are from infant formula
• Good hygiene practices
• Hand washing
• Sterilization techniques feeding bottles & Teat
• Continuation of breastfeeding
‫قال رسول هللا صَّل هللا عليه وسلم‬
“‫ سبحان هللا وبحمده يف يوم مائة مرة حطت خطاياه وإن كان مثل زبد البحر‬:‫”من قال‬

Case 4
An exclusively breastfed boy infant developed Atopic Dermatitis at the age of 4 months. In The
beginning, the eczema was treated with Antibiotics, topical steroids and brief courses of oral
steroids. The mother was dissatisfied by the outcome of the paediatrician’s advice So she
consulted a naturopathic doctor who Prescribed a restricted diet. At 6 months the child's daily
diet consisted rot Rice, fruits, rice poultry and vegetable broth. After about 2 months of this
diet, the child Began to reject the food, in particular solid Foods and to suffer from dysphonia
and Dysphagia due to the occurrence of laryngeal Edema. Because of this the child was given
Only rice milk. After a few days the edema appeared on his Feet, legs and upper extremities
followed by a Reduced urine output. He had no symptoms of Gastroesophageal reflux, but he
had forceful Vomiting. When hospitalized, he was in a poor clinical Condition With generalized
edema and low Urine output. He weighed 7.600 kg from the age of six Months up to 1 year.
Blood and urine findings were normal except for the following results:
• Total protein 3g/dl

• Albumin 1.365 g/dl (45.5%)
• Total serum IgE 30 KUA/L (normal)
• Specific serum IgE milk 0.64 KUA/L, albumen 1.74 KUA/L. (normal)
• Protein was not found in the urine.
He required central access due to difficulty Obtaining peripheral access due to severe Edema.
He was also found to be anaemic with a Haemoglobin 5.7 g/dl and he received 4g of Albumin
three times in 48 h, a red blood cells Transfusion, oral iron and folic acid. The child was
immediately fed with cow's Milk, which was well tolerated, and the edema Gradually resolved.
After few days diuresis increased and weight Initially decreased. Eczema improved with topical
treatment. After 10 days, there was a normalization of Total protein, albumin and clotting
tests. On follow up, the skin prick test was negative to milk and egg allergy. Because of a long-
lasting low blood calcium Level (7.3 mg/L), he developed Demineralization of his teeth,
persisting at the Follow up visits up at 2 years of age.
What is your diagnosis?

 Bulging anterior fontanelles

 Kwashiorkor
)‫ يف الصورة ال فالنص‬hair changes ‫(عشان ال‬
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what is your diagnosis?
 hair changes in kwashiorkor
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 edema in kwashiorkor
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 flad sign of kwashiorkor
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 marasmus

what is your diagnosis
 Kwashiorkor
what are the Features?

Edema (puffy face), apathic look, skin changes and abdominal distension
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 Kwashiorkor
Edema (puffy eye) and hair changes
(Dry, sparse and easily pickable)
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Other features of Kwashirkor :
constant features:
1. growth failure: Weight for age 60-80% with edema (welcome classification)
2. Pitting Edema
3. Apathy
4. muscle wasting with preservation of subcutaneous fat
Non constant features:

1- Skin changes:
 Erythema then hyperpigmentation and desquamation then ulceration
and fissuring
 infection of skin and even gangrene

2 -Hair changes:
 Hair become dry, lusty, sparse and easily pickable
 Progressive lightening of hair
 Flag sign (Alternating bands of normal and hypopigmented hair)
3- Anemia:
 All types of anemia (Normocytic, macrocytic,microcytic....)
4- Vitamin deficiency (Vit A,B12, C, D)
5- GIT:
 -Hepatomegaly
 -Diarrhea
 -Abdominal distension
causes of death:
 Recurrent infections
 Electrolyte imbalance
 Hypoglycaemia
 Hypothermia
 Heart failure
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 Marasmus

 Growth failure, muscle wasting, loss of subcutaneous fat (senile facies)

 Marasmus
 Growth failure, muscle wasting,
loss of subcutaneous fat (senile facies)
Classification of marasmus according to welcome classification:
 Weight for age less than 60 % without edema
Causes of death: As kwashiorkor
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 rickets (frontal bossing of head)
---------------------------------------------------------------------------------
 rickets rickets (rachitic rosary beads)
---------------------------------------------------------------------------------
 rickets (knock knee /genu valgum)

 rickets (broadening of wrist joint)
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Manifestations of rickets:
 Skeletal
• Head: Bossing, wide anterior fontanelles
• Thorax: Pigeon shaped, Rosary beads, Harrison sulcus
• Spinal Kyphosis, scoliosis, Lordosis
• Limbs: Marfan sign, Genu valgum, Genu varum
 Muscular hypotonia
 Abdomen
• pot belly abdomen
• Organomegaly
 increased infection susceptibility
---------------------------------------------------------------------------------
 Active rickets
What are the Features?
• Metaphysis: Clubbing, fraying and widening of ends of bones

• Diaphysis: low bone density
• Wide joint space

 Healing Rickets
What are the Features?
 Thick concave white line of provisional Calcification
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A) normal
B) healed rickets
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 Healed Rickets
What are the Features of Healed rickets:

1- Thick dense epiphyseal line
2- Normal cortical density is regained
3- Radiological joint space become normal
4- Healing of fractures

Genetics
turner Down Klinfilter
45X 47XXY
(45X+46XX) Trisomy 21 mosaic
mosaic
• Intrauterine • Mental retardation • Tall
(polyhydramins/ • Growth retardation • Slow to learn but not mentally
lung hypoplasia) • Features: retarded
• Neonatal • Feet (shrot&broad&sandle • Micropenis/cryptorchidism/hypospa
(cyctic hygroma gap)
/lowe posterior hair • Hand(short dias/lack secondary sexual
line /lymphedema of &broad&simiancrease&clinod characters
hand &feet actyly) • Gynecomastia/sterility
• Childhood • Trunk(thin skin&hernia)
(intelligence • Neck(short &broad&laxity)
normal/short • Head: (depressed nasal
stature/webbed bridge/protruded
neck/low posterior tongue/small oral cavity)
hair line/road • Ear( low set/over folded
chest/coarctation of helix/OM/sinusitis)
aorta/bicuspid • Eye(medial epicanthial
aortic valve) fold/brushfieldspot/upward
• Adolescene slanting)
(absence secondary • Skull9silky
sexual hair/microcephaly/delayed
characters/primary closure anterior fontanel)
amenorrhea/infertilit
y/risk of
hypertention)
• Screening for cardiac • No TTT only supportive • Testosterone at adolescence
diseases
• GH for short stature
• Esteogen therapy at
puperty

What are systemic features of down?
• Cns: (mental retardation/ alzahimer/ hypotonia)
• Chest: ( recurrent infection)
• Cvs: (congenital heart defects /septal defects)
• Git (duodenal atresia/hirschspring/chronic constipation /vomit/ aspiration)
• Endocrinal (hypothtrodism /obesity/insulin resistance)
• Blood and skin disorder&leukemia
---------------------------------------------------------------------------------
What are cytogenetics of down?
Non dysjunction mosaicism Translocation
Failure Non dysjunction Translocation to 21
separation 21 post fertilization →1/3 DOWN
homologous Translocation to
D(13-14-15) G(22)
→100%DOWN
Mother-46 Parent-46 Parent(genotype
Baby-47 Baby(46-47) 45-phenotype
‫يزيد بتقدم عمر االم‬ normal)
Baby(genotype46-
phenotype47)
‫يورث‬

What is the karyotyping ?
Normal femal male down Female turner
Normal male Male klinfilter Turner

(shield chest/webbing
neck/cubitus
vulgus/short stature/
widespread nipples)
---------------------------------------------------------------------------------
What is the Diagnosis and featurs of these picture?
 Down syndrome
2 1 3
4
What is the Diagnosis of these picture?
 Down syndrome
6 7 8 9
---------------------------------------------------------------------------------
What are special down features of the picture?
1. Upward slant & depressed nasal bridge
2. Microcephaly &upward slant & saddle nose
3. Silky hair& protruded tongue &low set ear &depressed nasal bridge
4. Low set ear
5. Brush field spot &epicanthal fold &upward slant & silky hair& depressed
nasal ridge
6. Brachydactyly & clinodactyly & semian crease
7. Brachydactyly & clinodactyly & semian crease
8. sandal gap
9. syndactyly BTW 4&5 finger
‫ الصور اللي فوق دي مترقمة كل صوره هيسألك عن التشخيص والمميز فيها‬

‫شوف رقم الصورة وبعدها المميز اللي برقمها‬
---------------------------------------------------------------------------------
َّ َ ُ َ َ َ َّ َ ُ َ َ ْ ِّ َ َ ِّ َ َّ ُ ‫ى‬
‫آل محمد‬ ِ ‫اللهم صل وسلم عَّل محم ٍد وعَّل‬

What are special down features of the picture?
A.brush field
B. thinking skin & low set ear
C. Sandel gap
D. flabby baby
---------------------------------------------------------------------------------
 Cleft lip (May be with cleft palate)
 Work up: karyotyping, echo
---------------------------------------------------------------------------------
A.normal set ear
B. low set ear
---------------------------------------------------------------------------------
 Case of mosaicism down
---------------------------------------------------------------------------------

Symbols of family pedigree
---------------------------------------------------------------------------------

Vaccination
1/ What is (Define) the immunity?
 It's the ability to recognize, destroy and eliminate the antigenic materials which
is foreign to the body.
---------------------------------------------------------------------------------------------
2/ What is (Define) the Herd immunity?
 It's the level of immunity of population, which determine the behavior of the
disease in that particular herd.
➢ (As in covid19: is the time at which level of disease decrease after outbreak
that indicate the people have immunity against the disease)
NB: outbreak of diseases be more in developed than developing as Herd immunity
decrease outbreak of diseases.
---------------------------------------------------------------------------------------------
3/ What Herd immunity results from?
• Subclinical infection
• Deliberate artificial active immunization
• Passive immunization of polio
---------------------------------------------------------------------------------------------
4/ Enumerate the types of immunity ?
• Natural acquired immunity (Active or Passive)

• Artificial induced immunity (Active or passive)
NB: active mean that the immune system participates.
---------------------------------------------------------------------------------------------

5/ What is the types of natural acquired immunity (active) ?
It may be:
• Subclinical infection (have the disease but no clinical symptoms (manifestation)
• Manifest infection (have the disease with clinical symptoms (manifestation).
---------------------------------------------------------------------------------------------
6/ Enumerate the types of immunity developed after recovery
from manifest infection?
• Absolute immunity: - there's no second attack as yellow fever

• Solid: - there's high degree of long- lasting immunity as measles, mumps,
diphtheria, small pox and chickenpox (may be second attack)
• Moderate: - repeated attacks as common cold and enteric fever
---------------------------------------------------------------------------------------------
7/ What's the types of natural acquired immunity (passive)?
• Trans placental: - IgG, last for 6 months after birth

• Breast feeding: - , colostrum milk
---------------------------------------------------------------------------------------------
8/ What's the meaning of seroprophylaxis?
• Immunization (passive) in which the subject is given already formed

Antibodies for protection for few weeks only then be destructed
---------------------------------------------------------------------------------------------
9/ What's the types of passive artificial induced Immunity
(seroprophylaxis ) ?
1) Human IG: -
l. Human normal IG: - prepared form plasma of multiple donors exposed to
an infectious disease as rubella or infectious hepatitis.
ll. Human specific IG: - prepared from donors have immunization (antibody)
against specific disease as rabis or tetanus 2).

2) Animal anti-sera: -
(Prepared from which infected by the diseases and antibody against it)
• Antitoxin sere: - diphtheria, tetanus

• Antiviral sera: - anti-rabies serum
---------------------------------------------------------------------------------------------
10/ Define the vaccine? (Active artificial induced immunity)
• Microbial agent or antigen product that stimulate the immune system to get
response against it
---------------------------------------------------------------------------------------------
11/ What's vaccine composition?
Component Purpose Example
Microbial agent
Adjuvants Promote an earlier, more Aluminum salts

potent response
Preservatives Prevent bacterial or fungal thiomersal

contamination of
The vaccine
Additives Stabilize the vaccine Gelatin

from physical conditions
as heat
----------------------------------------------------------------------------------------
12/Who prepare the first vaccine against which diseases ?
 Edward Jenner for (small box)

----------------------------------------------------------------------------------------

13/ What's the stages of vaccine trial?
• Phase I: include small group of healthy adult volunteers (10-15).

• Purpose: detect vaccine's safety
• Phase Il: - include target age group
• purpose: assess dose response, safety and toxic dose
• Phase Ill: - comparative efficacy trails
• purpose: assess efficacy
---------------------------------------------------------------------------------------
14/ How we measure vaccine efficacy?
• VE = ARU-ARV /ARU X100
• VE: vaccine efficacy
• ARU: Attack rate in unvaccinated population
• ARV: Attack rate in vaccinated population
---------------------------------------------------------------------------------------------
15/ What is the types of vaccines?
• Traditional vaccines
• New vaccine technology
----------------------------------------------------------------------------------------
16/ Enumerate types of traditional vaccines?
• Inactivated vaccines: - produced by killed microorganism in booster doses
as Typhoid fever, pertussis, Rabies, cholera, Salk vaccine, plague killed by heat
or chemical (formalin)
• Live attenuated vaccine: - living organism lose its virulence but not lose its
immunogenicity not recommended in immunocompromised patients, HIV,
pregnancy) as BCG, Sabin, MMR, yellow fever
• Toxoid - subunit vaccine: - produced by organism's toxins detoxified by
formalin to destroy the toxin effect and maintain the antigenicity as
diphtheria, tetanus
ُ ُ ُ ْ ِّ ُ
‫ وأفضل الدعاء الحمد لل‬،‫ ال إله إال هللا‬:‫أفضل الذكر‬

17/ Enumerate new technology vaccines?
•Conjugate vaccine as HIP: organisms cause pneumonia as streptococcus
pneumoniae, Neisseria meningitidis and H.influenzae type B. this organism have
polysaccharide antigen which linked to a protein carrier which immune system
have antibody against it as diphtheria
•Subunit vaccine: as A cellular pertussis vaccine. which prepared by parts of cell
of:
• Recombinant DNA vaccine: - HBV
• Dendritic cell vaccine
----------------------------------------------------------------------------------------
18/ Enumerate current new vaccines?
• Pneumococcal vaccine: types (very important as pneumococci one of child

killed disease)
1. pneumococcal conjugated vaccine (BCV7) in 2,4,6months, 1 year not
taken in child more than 5 years
2. pneumococcal polysaccharide vaccine (BPV23). Not for children less
than 2yrs, provided to groups as old age, splenectomy, sickle cell anemia,
thalassemia.
• Japanese encephalitis vaccine
• HPV: 3doses (IM) types: -
1. Quadrivalent HPV: - against anogenital wart, cervical cancer
(Applied for males, females)
2. bivalent vaccine: - against cervical cancer only (applied for females)
• Rota virus vaccine: - live attenuated vaccine taken oral. Efficacy 100% types:
1. Rotateq (5 strain): 3 doses

2. Rotarix (1 strain): 2 doses the second dose is preferred to be from the
same vaccine of the first dose to achieve highest effect
---------------------------------------------------------------------------------------------

Cold chain vaccine
1/ Define Cold chain.
➢ It means all the people and equipment necessary to keep vaccines safe
throughout their long journey from the manufacturer to the recipient
--------------------------------------------------------------------------------------------
2/ Mention the map of vaccine cold chain.
➢ Manufacture Airport →Central vaccine store →regional vaccine store
→ District store →Health center Consumer.
--------------------------------------------------------------------------------------------
3/ Identify the equipment and its use
 Vaccine Carrier.
(One of the equipment in the cold chain vaccine).
 Used to carry the vaccine during its distribution

---------------------------------------------------------------------------------------------
4/ Identify the equipment.
 Ice box.
---------------------------------------------------------------------------------------------
5/ Enumerate Cold Chain equipment.
1. Refrigerator.
2. Vaccine carriers
3. Cold Box.
4. Ice packs
---------------------------------------------------------------------------------------------

6/ Identify the equipment and name its parts.
 Refrigerator
 Parts
1- Freezer
2- Top shelf
3- Middle shelf
4- Bottom shelf
----------------------------------------------------------------------------------------
7/ Mention the arrangement of vaccines in the refrigerator
 Freezer Ice → packs and ice cups

 Top shelf →oral polio + measles
 Middle shelf →BCG + DTP+ TT+ Hepatitis B+ thermometer
 Bottom shelf →colored water bottle.
----------------------------------------------------------------------------------------
8/ Mention things put in the freezer.
 Ice packs and ice cups

----------------------------------------------------------------------------------------
9/ Why are vaccines not put in the freezer?
 As they're sensitive to freezing and get destroyed by it. Especially toxoids e.g
(TT)
----------------------------------------------------------------------------------------
10/ Mention vaccines put in the upper shelf
 OPV + measles
----------------------------------------------------------------------------------------

11/ Mention vaccines put in the middle shelf
 Pentavalent vaccines: DPT + Hib + HBV

----------------------------------------------------------------------------------------
12/ What is the importance of colored water bottles?
Why are they colored?
 For keeping temperature in case of electric power failure. They're colored to

prevent healthcare workers or anyone from drinking them.
N.B: MCQs:
1- most sensitive vaccine to freezing: Tetanus toxoid (TT)
2- most sensitive vaccine to sunlight: BCG, Measles
--------------------------------------------------------------------------------------------
13/ Enumerate rules for keeping vaccines in the refrigerator.
1- Arrange vaccines with air spaces in between. New vaccines coming to the
health center should be put at the back.
2- Check the temp everyday by the thermometer. (The optimum temp is
between OPC and 8QC)
3- Don't put vaccines in the door
4- No vaccines are put in the freeze. Note that toxoids are damaged by
freezing. (Never put in the freezer)
5- Don't put any food or drink in the refrigerator
6- Keep the refrigerator door shut and use a lock.
---------------------------------------------------------------------------------------------
14/ How can the cold chain be broken?
1- Vaccines are left in the airport for longtime without refrigeration.

2- Power failures can damage vaccines in electric refrigerators.
3- People may leave vaccines standing in direct sunlight during an
immunization session.

15/ How to keep vaccines cold during an immunization
session?
1- An insulated pot & ice are needed to keep both the vaccine & diluents cold.
2- Sit in a cool place away from the sun.
3- BCG & measles vaccine are very easily damaged by sunlight. They are
usually put in colored vials (brown).
---------------------------------------------------------------------------------------------
16/ How to identify failure of the vaccines?
1- Expiry date
2- Color change for polio vaccine
3- Shaking test
4- Vaccine vial monitor (VVM)
---------------------------------------------------------------------------------------------
17/ Mention example of using shaking test to detect failure of
vaccine.
➢ DPT vaccine spoiled by freezing on shaking* turbidity* if left for 30 min

sediment will be formed in the bottom of the bottle.
---------------------------------------------------------------------------------------------
18/ Define Vaccine vial monitor (VVM).
➢ a label that changes in color when the vaccine vial exposed to heat over a period
of time.
---------------------------------------------------------------------------------------------
19/ What does this slide refer to?
It refers to Vaccine vial monitor.

20/ Are these vials good to be utilized? And why?
Yes, they are. As the center square is lighter than the
surrounding circle.

21/ What does this slide refer to?
It refers to Vaccine vial monitor.

22/ Are these vials good to be utilized? And why?
No, they are not. As the center square is equal to or darker

than the surrounding circle.
---------------------------------------------------------------------------------------------
23/ Mention site and route of administration of the

following vaccines.
• BCG: in upper left arm, strict intradermal

• DPT: in left outer mid-thigh, intramuscular
• OPV: in mouth, oral
• HPV: in right outer mid-thigh, intramuscular
• Measles: in upper right arm, subcutaneous
• Tetanus Toxoid: in outer upper arm, intramuscular
----------------------------------------------------------------------------------------
24/ Mention the compulsory vaccines must be completed for
a child at 2 months.
 DPT + Hib + HBV (Pentavalent)

 TOPV
----------------------------------------------------------------------------------------
25/ Mention the compulsory vaccines must be completed for
the child at 9 months.
 Vit. A
 TOPV

Adolescent health and care
Define Adolescence.
 Adolescence is a transitional stage between childhood and adulthood It is characterized
by rapid physical and emotional and psychological change.
WHO defines 'Adolescents' as…?
 individuals in the 10-19 years age group
 adolescence is the phase from:
• the appearance of secondary sex characteristics (puberty) to sexual and
reproductive maturity
• the development of mental processes and adult identity
• the transition from total socio-economic and emotional dependence to relative
independence.
What are the three psychosocial developmental phases of adolescence?
1. Early adolescence: Approximately age 10–14 years (middle school)
2. Middle adolescence: Approximately age 15–17 years (high school)
3. Late adolescence: Approximately age 18–19 years (college or work)
Characters of EARLY ADOLESCENCE
• Body changes and self-conscious about appearance
• Peer group becoming more influential; less affection shown for parents
• High levels of physical activity
• Many mood swings and impulsive
• Cognitive development: Concrete thinking: Unable to fully analyze different situations
Characters of MID-ADOLESCENCE
•Greater desire for independence
•Peer group dominates social life; efforts to make new friends and select role models
•Risk behaviors more prevalent
•Sexuality is of great interest
•Improved work habits and sense of right and wrong (conscience)
•More concern about future plans and intellectual interests
•Unrealistically high expectations of self-alternate with poor self-concept
•Cognitive development: mix of concrete and abstract way of thinking

Characters of LATE ADOLESCENCE
• Able to compromise and develop useful insight
• Adult appearance, clear sexual identity
• Uncertainties about sexuality, future relationships and work possibilities
• Accepts social institutions and cultural traditions.
• Cognitive development: Abstract thinking (Adult way of thinking): analyze different
situations with correlation of long term sequences for better decision making.
Several tasks characterize the development of the adolescent. These tasks include:
1. Achieving independence from parents
2. Adopting peer codes and lifestyles
3. Increased importance to body image and acceptance of one's body
4. Establishing sexual, ego, vocational, and moral identities.
What are the common problems in adolescent age? Adolescent health problems
1- Reproductive system e.g., Hydrocele, varicocele, endocrinal disorders in females
and breast disorders.
2- Dermatological health problems e.g., Acne
3- eating disorders e.g. anorexia nervosa, overweight and obesity.
4- Psychological problems e.g. Depression.
5- Special orthopedic problems e.g. Scoliosis.
6- Sexually transmitted diseases e.g. HIV/AIDs, chlamydia, gonorrhea, herpes
simplex. and sexual abuse.
7- Behavioral problems e.g. Adjustment reaction.
8- Accidents.
9-Substance abuse and smoking; stages from experimental use, regular use,
problematic use, substance abuse, addiction
10-Infectious diseases: Parasitic infestation, Streptococcal infection and its sequelae
11-violence from peer o family members and abuse (Sexual, physical, and
emotional.)
12- school problems: school refusal, poor school work as a result from emotional
problems lead to decrease the concentration
What are the most frequent causes of death in adolescents?
 accidents, mostly motor vehicle crashes
 related to drug or alcohol use-followed by homicide and suicide.

What is Role of the Family Physician in Adolescent Health Care?
 Family physicians are optimally trained in providing and addressing the health care
needs of the adolescent.
 All adolescents should have at least an annual physician visit that includes a
screening interview and full physical exam.
 Anticipatory guidance should be offered to parents regarding normal
development, risk behaviors, and role modeling.
Psychosocial Screening:
(HEADSSS).
) home-eating-education-drugs-suicide-sex-safety)
Home
➢ Where do you live?
➢ How long have you lived there?
➢ Who lives at home with you?
➢ Do you have any pets?
➢ Do you feel safe at home?
➢ How are your relationships with family members?
➢ Is there any physical violence at home?
Eating
➢ Do you feel comfortable with your body or weight?
➢ Do you eat in front of the TV/computer?
➢ Do you feel comfortable with your eating habits?
➢ Do you ever think about ways to lose weight?
➢ Do you ever eat in secret?
➢ Do you use diet pills or laxatives?
Education
➢ Have you changed schools recently? What do you like or not like about school? Do
you feel safe at school? What are your grades like? What were your grades like last
year? What do you want to do after finishing school? Activities What do you do for
fun? What do you and your friends do together? Do you have a best friend? Do

you drive (motorbike, car)? Do you exercise? How do you spend his/her time? Do
you participate in any sports or other activities? How about video games? Are you
supervised during your free time? With whom do you spend most of your time?
Drugs
➢ Do any of your friends smoke or drink? Do you know anyone who smokes or
drinks? Do you drink caffeinated beverages (including energy drinks)? Do you
smoke? Have you tried to drink alcohol? Have you used illegal drugs? If there is
any substance use, to what degree and for how long?
Suicide/depression
➢ What is your mood from day to day? Have you ever run away from home? Have
you ever cut yourself intentionally? Have you ever been so sad you thought about
hurting yourself? Have you ever tried? Do you feel sad now?
Sex
➢ Have you ever had sex? How old were you when you first had sex? Has anyone
ever touched you in a way you did not want to be touched or forced you to do
something you did not want to do sexually? Do you feel safe discussing sexuality
issues with parents or other caregivers?
Safety
Do you regularly wear a bicycle helmet? Seatbelt? Have you ever been seriously
injured? Do you always wear a seatbelt in the car? Have you ever ridden with a
driver who was drunk or high? When? How often? Does the violence ever get
physical? Is there violence at your school? In your neighborhood? Among your
friends?
General teen assessment

General assessments include the following:
• medical and psychosocial history
• measurements (such as height, weight, blood pressure)
• sensory screening (vision and hearing)
• developmental/ behavioral assessment
• physical examination
• immunizations
• anticipatory guidance (in such areas as injury prevention and nutrition counseling),
• dental referral
• laboratory tests (such as blood work or a urinalysis).

What are the five premises that are useful when caring for adolescents?
1. Explain Facts: adolescents should have a clear understanding of their illness.
2. Explore Fears adolescents may have concerned their illness or its effects on their life.
They may also be worried about their body image, their identity, their peers, or other
interpersonal relationships.
3. Address any Fables: adolescents may be misinformed about their illness or about
adolescence; e.g., the effects of masturbation.
4. Explore the adolescent's relationship with their Family. What are communication and
trust like within the family unit? How does the teen settle conflicts that arise at
home?
5. Ask how the adolescent views the Future. We make it clear that we are accessible,
and the teen is given a contact phone number
During physical examination you should…?
1. Respect privacy and avoid unnecessary exposure. Keep the doors closed and do
not open until the adolescent is fully dressed. Parents should be permitted to
remain if the adolescent makes this request.
2. Physical examination is a good teaching tool and opportunity to provide useful
reassurance. Talking and explanation increase knowledge about their bodies and
relaxation.
3. Some indications for a pelvic, rectal, and genital examination include a direct
request from the patient, the patient is sexually active, or the patient has
abdominal or pelvic pain. It does not need to be done routinely on every
adolescent.
4. Special attention to assess pubertal development.
Q/ Mention items of practical approach to adolescent?

• Parents
• Setting
• Confidentiality [conversation should be confidential]
• Listening
• Identity preservation
‫احافظ علي وقاري كدكتور مش اعامله كصديق وقولي ياسطا و غيره عشان ميحسش اني‬
‫بستقصد اقرب منه عشان يكلمني فييجي بنتيجة عكسية‬
• Judgmentalism [avoid conflict with adolescent to impose your view and opinion]
• Establishing rapport

Q/ How should the physician deal with adolescent’s parents?
1- Establish The parent’s concerns
2- Ask about family history and medical problems
3- Ask the parents to wait in the waiting room for speaking privately with the adolescent
4- Interview the adolescent alone and perform physical examination
5- Parents back to the room and discuss your findings
Q/ What are the criteria of the office setting?
• Space: sit beside the adolescent, private space, No barriers
• Appointments: Take enough time for conversation
• Availability of educational materials: Place books, pamphlets, reliable web site in
the waiting room on topics as puberty, sexually transmitted diseases...
‫تحسسه بالراحة وتخليه يسألك بنفسه عنها‬
• Attitude [ Non-judgmental]: Avoid conflicts with the adolescent, do your best to
understand him.
• Note taking: Avoid taking many notes ‫مش كل اللي بيقولهولك تكتبه قدامه الن دة هيحسسه انك‬
‫بتكتب كل اسراره وان أي حد ممكن يقرا الكالم‬
Q/ Enumerate the communication skills during conversation with

adolescent.
1- Introduce yourself and ask for permission
2- Insure confidentiality
3- Listen effectively
4- Maintain eye contact
5- Being not judgmental
6- Ethical consideration during examination
Q/ Mention methods or approaches to adolescents.
• Announcement: Most of young adults (try to smoke, or have a girl or boyfriend, do you?
• Three wishes approach: If you could change yourself as body image, your family as their
stander of living, your life, what would you change?
• Indirection: Could you like to talk about something you don’t like in your friends
behaviors? Some tells you don’t share in as their talk about sex?
• Comparative approach: How would you rate your family, your home, your peer relation,
body image?

IMCI
❖ What do the IMCI guidelines explain?
The IMCI case management process involves these steps.
1. Assess all sick infants and children for:
 Signs of serious illness that requires urgent referral, then
 Signs of common health conditions, and then
 Nutrition status, immunization status, and other problems.
2. Classify each health condition using color-coded IMCI charts:
 RED: very serious condition requires urgent pre-referral treatment and
referral
 YELLOW: serious condition needs treatment and advice in the clinic
 GREEN: less serious condition needs home treatment and advice
3. Treat
 After classifying all conditions, you will review all treatments identified
in each classification.
 If a child requires urgent referral, give essential treatment before the
patient is transferred.
 If a child needs treatment at the clinic, you will often give the first dose
in the clinic. ✓ Give immunizations if needed.
 You will advise caregivers on home treatment.
4. Counsel
 A critical component of IMCI is counselling caregivers on home treatment
(giving oral drugs), feeding and fluids, breastfeeding, and other well
childcare.
 Advise the caregiver to return for follow-up on a specific date. Teach
caregivers when to return immediately if child shows signs of severe
illness.

5. Provide follow-up care
 When a child returns to the clinic as requested, give follow-up care as
required.
 Re-examine conditions to see if the issues are improving, the same, or
worsening
Q/ What is the definition of IMCI?
➢ IT IS an integrated approach to child health that focus on the well –
being of the whole child.
➢ NB: - IMCI aims to reduce death, illness and disability and to
promote the growth and development.
➢ NB: - the age from 28 days to 5 years is Special for IMCI.IT IS
SUBDIVIDED to two groups: -
 First group from 28 days to 2 months
 Second group from 2 month to 5 years
➢ NB: - IMCI include preventive and curative elements
➢ NB: - IMCI IS prepared by the MOHP and supported by WHO /CHD
Q/ enumerate the steps for IMCI guidelines?
1. Assess
2. classify
3. identify treatment and treat the child
4. give follow-up care
5. Counsel the mother
Q/ Enumerate topics covered by IMCI for the < 2m infant?
1. Check for possible bacterial infection
2. Check for significant jaundice
3. Diarrhea
4. Feeding problems or low weight
5. Treat young infants: appropriate oral antibiotics, first dose of
intramuscular antibiotic, convulsing young infant

6. Teach the mother to treat local infections at home: skin pustules or
umbilical infection, mouth thrush, eye infection
7. Teach correct positioning and attachment for breastfeeding
8. Teach the mother to express breast milk if indicated Give
9. follow-up care for the sick young infant
Q/ ENUMERATE The topics covered for the 2m - 5 years child by
IMCI?
1. Danger signs, cough, diarrhea
2. Sore throat, ear problems, fever, measles
3. Malnutrition and anemia
4. Immunization status and Vit. A supplement
5. Appropriate oral antibiotic
6. Teach mother to give oral drugs at home
7. Teach mother to treat local infections at home (eye infection, mouth
ulcers, relieve cough safely)
Q/ what is the process for integrated case management?
A) Check for danger signs: -
1- convulsion 2- Lethargy/ unconsciousness
3- Inability to drink/breastfeed 4-Vomiting
B) Second Assess main symptoms: -
1- Cough/difficulty in breathing. 2- Diarrhea
3-ear problems 4- fever
C) assess nutrition, Immunization status and Immunization status
problem
D)Check for other problems
E) Classify the condition of the child and assign to one of the
three color codes: -

➢ RED COLOR:- very serious condition requires urgent preferral
treatment and referral
➢ Yellow color:- serious condition needs treatment and advice in
the clinic
➢ Green color:- less serious condition needs home treatment and
advice .
F) Identify the treatment actions as per the actions listed in that
color band
Q/ how to manage (CLASSIFY AND TREAT) general danger signs by
IMCI?

Q/ how to manage diarrhea by IMCI?

Q\How to treat diarrhea according to IMCI?

Q/ According to shown IMCI complete the following data? OR MICI
CLASSIFICATION FOR THIS CASE?
‫ممكن ييجي اكتر من‬classification ‫ف ال‬case ‫الواحدة عادي جدا‬
:‫ملخص لطريقة الحل‬
1 - identification data : name, age, sex, initial visit or not...... Etc. .
2 - assessment
‫ نشوف عنده ايه ونقارن بالجدول ونكتب اللي موجود ونفس اللي مش موجود طالما اتقال في ال‬case ‫يعني‬
‫ لو قال مفيش‬discharge ‫نكتب‬
NO discharge ،‫ وهكذا‬.،‫لكن لو مجبش سيرته منكتبهوش‬،
3- classification: according to assessment .
4 - Management : according to assessment & classification.
‫الخالصة االمتحان هييجى فى صورة حالة وانت هتشخصها وتكتبلها العالج على حسب الجداول اللى فوق‬
CASE 1:
Amira Ahmed is 2 years old. She weighs 12 kg. She has diarrhea for 3 days. No
blood in stool. Her eyes looked sunken. She drinks eagerly. Skin pinch goes
back slowly.
HOW TO MANAGE ACCORDING TO IMCI?
CLASSIFY: - some dehydration of diarrhea
‫ بردو فى الجدول‬-: Treatment
CASE 2:
Ahmed 2 years presents to you with his mother complaining of watery
diarrhea for 2 days ago, no blood in stool, no dysentery. Also, the mother
claims that Ahmed's eyes are sunken, he is irritable and drinks eagerly, skin
fold goes back slowly.
HOW TO MANAGE ACCORDING TO IMCI?
CLASSIFY: - severe dehydration of diarrhea

Practical Child Health Care

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Practical Child Health Care

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BY: MDM 40 STUDENTS CONTACT: @MDM_40 1

BY: MDM 40 STUDENTS CONTACT: @MDM_40 2

❖ Pediatric History contains:

BY: MDM 40 STUDENTS CONTACT: @MDM_40 3

BY: MDM 40 STUDENTS CONTACT: @MDM_40 4

BY: MDM 40 STUDENTS CONTACT: @MDM_40 5

BY: MDM 40 STUDENTS CONTACT: @MDM_40 7

Q/ what is the device and its use ?

 Measure weight for child < 2 Y .

➢ N.B : baby should completely undressed .

BY: MDM 40 STUDENTS CONTACT: @MDM_40 8

➢ N.B : undressing of shoes .

Secondly: length & height.

Q/ what are the precautions of recumbent length ?

BY: MDM 40 STUDENTS CONTACT: @MDM_40 9

 Mid upper arm circumference

BY: MDM 40 STUDENTS CONTACT: @MDM_40 10

َ ،‫اسمها َب َّر َة‬ َ ‫ى‬ ُ ‫صَّل‬ ‫ى‬

BY: MDM 40 STUDENTS CONTACT: @MDM_40 11

Define welcome classification?

1. determine ideal weight (50th centile)

2. divide actual by ideal

3.determine the presence of edema or not

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Nutritional disorders are classified according to weight for length

≥ 80% < 80% ≥ 90% < 90%

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Egyptian boys, birth to 36 months.)

ideal weight for length= 5.75kg

 Calculate ideal length for age:

ideal length = 76cm

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 According to welcome classification

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o 0.7 x 6 = 4.2 gm protein /day

 N.B: Iron supplementation should be postponed till the patient has

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 Anthropometric data: Weight on admission - 3.325 kg

(is <60% sever PEM)

 Nutrition-focused Physical findings:

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‫قال رسول هللا صَّل هللا عليه وسلم‬

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• Total protein 3g/dl

What is your diagnosis?

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 hair changes in kwashiorkor

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what are the Features?

Non constant features:

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what are the Features?

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 rickets rickets (rachitic rosary beads)

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What are the Features?

• Metaphysis: Clubbing, fraying and widening of ends of bones

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What are the Features of Healed rickets:

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