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Content:
Anaphylaxis (NB. < 5 years old, ADHD focused group parents training
Short status program to parents or carers as first line treatment, do not
Status epileptic offer medication without a second specialist opinion)
Kawasaki Differential diagnosis:
DKA - Developmental variations
ADHD - Neurologic or developmental conditions
Down syndrome - Emotional and behavioral disorders
Sickle cells - Psychosocial or environmental factors
Abdominal pain - Certain medical problems
Constipation
Chronic diarrhea, chloride 2e case
Toxicology : iron, Paracetamol, organophosphate 2 days old, lethargic and hypotonic. How will you manage?
Brucellosis Any risk factor in mother, or fever in baby? Maternel fever in
Wilson pregnancy and rash, GBS positive at 36 weeks of pregnancy,
Bronchiolitis PROM
Pneumonia T° 35C, preterm, bulging FA,
Croup what’s your diagnosis? Maternofetal infection
Hypertension portal answer
Immunodeficiency - ABC resuscitation, and RBS, IV line
Limping - Admit in incubator to control the T°
Rectal bleeding - NPO, give IV fluid,
Child abuse - Investigation : blood culture, CBC, LP, blood
AHIA chemistry,
G6PD - brain US
Lymphadenopathy: Hodgkin - ATB before waiting for the results and because of
Enuresis the neurological symptoms give Cefotaxim
Autism 200mg/kg/24h BID in IVL 20 min (if baby stable and
dehydration well give amoxiciline) 10 days+ gentamycine 5
Neonate: maternofetal infection, hypoglycemia, jaundice, mg/kg/24h IVL over 30 min ( 48 hours)
NEC, PROM, SGB - Diagnosis maternofetal infection. SBG cocci gram
Positive
- Stop ATB if blood culture negative and baby well
1st case
10 years old with abnormal behavior. How will you manage? NB. Late management, should be early give mother antibiotic
Q: Please what form of abnormal behavior sir? when the symptoms appeared before labor, or if not, give the
A: mother said doing homework with him is a nightmare mother antibiotic 4 hours before labor, and management of
He never completes homework, the baby immediately at birth.
Teachers says his on the move and disrupts others swab from ear nasal anus procalcitonin not recommended by
Q: what’s your diagnosis? guidelines of the high authority of health 2017, urin analysis
not recommended at this age (do it for cases aged 21 days
Answer and more)
ADHD: CRP if ATB after 12 hours or do CRP after 48 of ATB
Diagnosis by: DSM 5, ICD 10 (hyperkinetic disorder) Ceftriaxone contraindicated in neonat
Management:
rd
- Offer group education, cognitive behavior therapy 3 case
(CBT) 6 years child with sudden pallor and Jaundice presents to
- Offer medications if symptoms are causing your clinic, how will you manage?
persistent and significant impairment, consult for Direct Coombs positive
pediatric cardiology and hypertension before Answer
prescription - Acute Hemolytic anemia
- First line therapy : methylphenidate, dose 5mg PO , - At pedia ER do ABC resuscitation, put 2 IV lines
BID can increase to 10, monitoring in the following - First Investigation: CBC + reticulocyte count, blood
up hight , weight, blood pressure, type, coombs test (DAT), peripheral blood smear
- Second line therapy : atomoxetine (SE: agitation, ,haptoglobin, bilirubin T,D, urine dipstick, renal
irritability, suicidal thinking, switch to mania)

function, infection screening, peripheral T-cell
subsets,
- admit to pedia ward or PICU to continue
investigation and management : CT chest abd and
pelvis, anti DNA, ANA, HIV,HBV, HCV
- Direct coombs test positive: autoimmune hemolytic
anemia I must found the cause but in the majority of
cases it’s idiopathic or primary, it can be secondary
of drugs like penicillin, or after a having a blood and
marrow stem cell transplant.
- If DAT IgG only positive : warm AIHA
- IF DAT IgG + C3 : mixed or cold AIHA
- management :
 treat any identified underlying cause , such
as infection
 If anemia is life threatening, transfusion of
ABO Rh and K matched red cells may be
preferable to waiting for full-compatibility
testing, 2 ml/kg/h
 Corticotherapy used for AIHA with warm
antibody : prednisone 1- 1,5 mg/kg/d for 3
weeks until Hb reaches 10g/dl , than
decrease slowly by 10-15 mg weekly
 Immunoglobuline efficiency 50%
 Rituximab (antibody monoclonal)
375mg/m2 weekly for median of 4 weeks
 splenectomy for warm AIHA unresponsive
or intolerant for medical TRT, must give
vaccination against penmococci,
meningococci , hemophilus, antibiotic
prophylaxis
 plasma exchange
 monitoring : pallor , vital signs, side effects
4e case
Q: doctor you are called to the new born that a child is not
looking normal, on entering you found out mother is 45yrs,
your diagnosis?
A: Probably Down syndrome
Q: What are the types and in order of frequency?
A: - nondisjunction 95%
- translocation 4%
- mosaic 1%
Q: hand features?
- broad short hands, single palmar (simean) crease,
clinidactyly,
- brachydactyly, hyper-extensibility, single crease in
little finger
Q: Common GIT signs?
A:
- commonly feeding difficulties and GERD,
- duodenal atresia,
- celiac disease,
- annular pancreas,
- umbilical hernia,
2
- Hirschsprung disease,
- Tracheo oesophage fistula.
th
5 case
A child was rushed to the ER, a known Hemophilia. History is
that of fall in school with? Trauma to head
How will you treat?
answer
Hemophilia A or B ? type A
Classification mild, moderate or severe with inhibitor or not
Management :
- ABC resuscitation + IV line
- Give in IVD Factor VIII 30-50 UI/kg , raise factor level
to 100%?
- Investigation : CT cerebral, CBC, factor IIIV
- Transfusion according to the result of CBC
- Monitoring factor levels to 100% every 8H for 3 days
- Continuous factor infusion at reduced dose for 3
weeks
100% for 3 days
80% for 4 days
50% for 2 weeks
Long-term prophylaxis often needed.
(N.B hemophilia B give 50-70 UI/kg raise factor level to 100%
every 12-24h for 3 days)
th
6 case
A mother comes with her 12 years old son for shortness
What will you do for them?
Answer
- Confirm if height < 3 PC
- See if there are previous height and the height at
birth, and draw a curve, calculate the speed of
growing , calculate the target size (height father +
height mother)/2 + 6,5
- Take the history if any chronic disease with
hospitalization or not, taking any medication for a
long time and which medication, how was his
development and school performance, ask about
nutrition , any complain
- Examine the patient if there is a particular facies or
dysmorphic or inequality of segments , examine
must be complete including skeletal and
neurological and manifestation of secondary sexual
characteristic
- According to the exam I will investigate, and I will do
the bone age
- Bone age delayed:
If it is less than the statutory age investigate first
hypothyroid, celiac disease
If it is equal, and according to the annual speed of
growing I will investigate GH …
- Management according to the results
Case 7

A child was brought in with paracetamol poisoning, how will
you treat?
- Take the history , at what time he ingested the drug
and how many tablet, see the box of tablet and the
dose if brought by parents, ask if he had vomited or
not, stool bleeding, nausea
- If the dose more than 150-200 Mg/kg or unknown
- ABC resuscitation, IV line
- If less than 1 hour , do a gastric lavage
- If we can have the level of paracetamol within 8
hour we can wait for the antidote but if the level of
paracetamol is not available or the dose is known
and toxic with clinical signs of toxicity ( nausea,
vomiting, right upper quadrant pain or tenderness)
we should start acetyl cystein
- Start standard acetyl cysteine treatment (ingestion
10-30g)
 Bag 1 : 200mg/kg max 22g in 7ml/kg of D5
or NS 0.9%, max 500 ml over 4 hours
 Following of : liver function , INR, level of
paracetamol , VBG, glycaemia, CBC
 Bag 2 : 100mg/kg max 11g in 14ml/kg max
1000ml over 20 hours
 ALT and paracetamol level 2 H before the
end of the second bag
 NAC should be continued if ALT is > 50U/l
 Ceasing NAC if ALT or AST decreasing, INR <
2 , patient clinically well
- Second option : Activate Charcoal 1g/kg Max 50 g if
ingestion less than 2 hours of ingestion> 10g , 4
hours if >30g
- Monitoring : vital signs, toxicity signs,
- Call poison center for advice if :
 very large overdoses — immediate release
or modified release paracetamol overdoses
of 50 g or over or 1 g/kg (whichever is less)
 high paracetamol concentrations of more
than triple the nomogram line
 intravenous paracetamol errors or
overdoses (as the treatment threshold is
lower)
 patients with hepatotoxicity (ALT > 1000
IU/L)
 neonatal paracetamol poisonings
- A liver transplant unit should be consulted if any of
the following criteria are met:
 INR greater than 3.0 at 48 hours or greater
than 4.5 at any time
 oliguria or creatinine greater than 200
µmol/L
 persistent acidosis (pH < 7.3) or arterial
lactate greater than 3 mmol/L
 systolic hypotension with blood pressure
below 80 mmHg, despite resuscitation
 hypoglycaemia, severe thrombocytopenia
or encephalopathy of any degree, or
3
 any alteration of consciousness (Glasgow
Coma Score < 15) not associated with
sedative co-ingestions.
NB.
 if ingestion over than 30g give DOUBLE dose
acetylcysteine treatment
 if child <6 years
- if 2-4 h paracetamol concentration is below 150mg/l
NAC not required
- if 2 h > 150 , should be repeated 4H after ingestion of
NAC
- for child who present later than 4 hours or age > 6 TRT
as described ↑
8 case
Mother brought her 4 years old with conjunctivitis what
Q: will you do?
A -Take the history: how long (8 days), any photophobia?
fever, itchy, eye discharge (no), any other complains in joints,
knee, abdominal pain, irritability? Or changing in mouth,
erythema of feet, hand? (Yes) rash? (No) , cervical
lymphadenopathy (yes)
Q: What’s diagnosis?
A –Kawasaki ??? without fever ?
Q: What will you do?
Answer
- ABC resuscitation, IV line
- evaluation of the vital signs
- Investigation : CBC , ESR, CRP, ASLO, ECG, Echo
cardiac, abdomino- pelvis US, liver function, renal,
function, urine dipstick, chest xray, LP, blood culture,
urine and stool culture
- and look for early complications :
 cardiac: myocarditis, pericarditis, arrhythmia
and other cardiac attainted,
 digestive: vomiting, diarrhea ,
hydrocholecystis, jaundice, ileus paralytic
 renal : pyuria , proteinuria , hematuria
 neurologic : irritability , meningitis aseptic
 other : pneumonia, myalgia , testis edema,
arthralgia, uveitis, epiglottis ,
lymphadenopathy obstructive
- management:
 Ig IV : high dose 2g/kg once
 Aspirin : 30 – 50 mg/kg/d on 4x/d for 2 weeks ,
than 3-5 mg/kg/d for 6 weeks if there no
complications
 If risk factor or not improving : corticotherapy
 Methylprednisolone 2 mg/kg/d IV for 5 – 7 days until
normalization of CRP than give it orally with decreasing
for 2- 3 weeks
 Or bolus methylprednisolone 10-30 mg/kg/d IV for 3 days
max 1g/d then orally 2 mg/kg/d for 4 days until
normalization of CRP then decreasing for 2-3 weeks
 If resistance of Ig give immunosuppressor

th th
- following up Between the 10 day and the 30
repeat echo cardiac once a week than every 4 weeks
to detect the cardiac complication and use Z score ( 2-
2,5 coronary dilatation , >2,5 <5 small aneurysm, >5
<10 moderate aneurysm, > 10 big aneurysm
- Repeat echo cardiac 2x/week if cardiac complication
- If a giant aneurysm give heparin therapy
- After Ig, the vaccination with live vaccine must be
reported after 11 months
N.B if child febrile give asprin 30-50mg/kg/d until he became
afebrile
9 case
A child eating with mother suddenly develops SOB
What will you do?
Is he hospitalized or coming to the ER?
Was he chocking while eating? No
Any urticarial, stridor, or wheeze? yes
Has he any edema?
His age? weight? any history of atopic background , asthma,
food allergy?
Q: What’s diagnosis?
A: anaphylaxis
Q: how will you treat?
Answer
- IM Epinephrine
 <10kg: 0.01 mg/kg/ dose
 10 – 25 Kg: 0.15 mg
 >25 – 50 Kg: 0.3 mg
 > 50 kg, maximum is 0.5 mg per dose
- ABC ressuscitation,
- lie patient flat, raise patient’s legs
- high flow O2 8-10l/min face mask
- IV fluid 20ml/kg IV NS 0.9%, evaluated and repeat
fluid bolus as needed
- Antihistamine: cetirizine given over 2 minutes IV
(6months – 5 yrs 2.5mg, 6-11 years 5-10 mg )
- Salbutamol: for bronchospasm resistant 0.15mg/kg
in 3ml NS inhaled via nebulizer, repeat as needed
- methylprednisolone 1mg/kg IV max 125
- norepinephrine or dopamine according to the blood
pressure
- Monitoring : pulse oximetry , ECG, blood pressure,
Urine output
10 case
Child comes in with VOC, How will you manage? Pain score to
guide analgesia like which score?
I need to know these information please:
- Is he known as sickle cell?
- Age?
- In which part is localized the vaso occlusive crisis
bones, abdominal or chest ?
- Characteristics of pain episodes:
 Frequency
4
 Duration
 usual home treatment
 usual emergency department treatment
 average number and duration of
 Is there any fever or other complain?
 hospitalizations
 Past medical treatment, splenectomy?
- Precipitating factors?
- Physical exam?
- Vaccination? Previous transfusion? allergy
Answer
- ABC resuscitation
- Vital signs + full physical exam, see other clinical care
paths for pain, acute chest syndrome, acute anemic crisis,
stroke, priapism, if present, hydration status, degree of
pallor, evidence infection, spleen size, neurologic
- Score of the pain (face score or numerous according to
the age of the child)
- Paracetamol 15mg/kg/dose po and/or ibuprofen 10mg/kg
Po ( avoid ibu if CI)
- If not improving moderate to severe pain : Morphine 0.1
-0.15mg/kg IV, reassess pain every 15-30 min repeat
0.02mg/kg IV every 15-30min to achieve pain relief,
alternative hydromorphone 0.015mg/kg
- If adequate pain relief with 1or2 doses of morphine,
consider giving tramadol 1mg/kg as outpatient therapy
- O2 by nasal cannula if needed to keep SO2 >92%
- FLUID IV1 +1/2 oral to maintain a good hydration, or
10cc/kg bolus over 1H, then maintenance rate
- Investigation :
 CBC with WBC count , platelet, reti count, blood
group if unknown, , renal function, electrolytes,
liver profile, urine analysis
 If transfused Before : viral serology, ferritin, red
blood cell phenotype
- If fever: blood and urine culture, LP(CSF) ,
- ATB IV ceftriaxone 100mg/kg single dose max 2g,
cefotaxim 50/mg/kg X3/d if severe infection (or
clindamycin 10-15mg/kg if allergy max 600mg)
- Add vancomycin for severe illness or CNS infect 10-
15mg/kg IV
- chest Xray if tachypnea, cough or chest pain, abdominal
US if abd pain, Xray hip if pain, MRI brain if neuro signs
- type and crossmatch if 1-2g/dl below baseline or evidence
of acute chest syndrome
- ortho consult if suspicion of osteomyelite or arthritis
- monitoring : every 2-4h according to the initial patient
status, vital signs, T°, oxymetry, hydration, score of pain,
input/output, repeat CBC 24H later
- before discharge put on:
 Penicillin prophylaxis 125mgx2/d <3y, 250x3/d
>3y, erythromycin if allergy
 Acid folic 1mg/d po

- Discharge if nontoxic and clinical stable, afebrile for
24H, negative cultures after 48h, tking oral fluid orally,
resolution of symptoms, no anemic crisis
- following up with specific plan with hematologist
and primary physician
N.B
 if acute chest syndrome
- add Azithromycin 10mg/kg po first dose than 5mg/kg/d,
erythromycin 40mg/kg/d or other macrolid,
- add vancomycin if severe status or pleural effusion
- Furosemide 0.5 – 1mg/kg IV if signs of fluid overload
- bronchodilatateur and steroid therapy if patient has reactive
arwaiy or wheezing on exam
- CPAP or mask BiPAP if poor respiratory effort or reduced
ventilation
- Transfusion if Hb >1g/dl below baseline
- exchange transfusion for Hb greater than 10g/dl and HbS or
HbS+C 30%
 if acute splenic sequestration
- admit in PICU, O2, paracetamol
- transfusion RBC 5-10cc/kg for Hb <5g/dl
 if aplastic crisis:
- consider coexistent splenic sequestration,
parvovirus, may associated with pain, bone marrow
necrosis, acute chest syndrome, stroke
- like acute splenic
- CBC and reti 10-14 d on siblings or close contact to
exclude simultaneous or sequential parvovirus
 Acute stroke or neurologic event
- Screening coagulation profile, electrolytes daily until
stable
- MRI if not immediately available do CT without
contrast
- Treat seizures if present
- O2,
- Hb electrophoresis after partial exchange transfusion
 Priapism: prophylaxis if >2/month or >4/y
peudoephedrine 30mg po <10y or 60mg >10y
- Episode >3-4 H emergency
- Urology to perform aspiration and irrigation with
sedation
- Do not use ice or ice pack cold water
- IV fluid 10cc/kg bolus 1H then maintenance rate
- Morphine
- Consider sleep study if obstructive sleep apnea
suspected
- Transfusion or partial exchange if no evidence within
12H
- Winter shunt if persists for 24h not responsive to
supportive care, aspiration , irrigation , transfusion
- Observe severe headache or neuro symptoms
(ischemic stroke my occur 1-10 d after onset of
priapism especially following transfusion referred to as
ASPEN syndrome)
5
 Anesthesia
 Transfusion for acute complication
 Chronic transfusion protocol
 Hydroxyurea protocol
 Stroke
11 case
A child with fever and submandibular lymphadenopathy,
what is your thoughts?
Answer:
- Unilateral or bilateral? Are there any other
symptoms or complains? Night sweat, thrills?
- History: since when is it acute or chronic? If no is the
size changed? BCG vaccine?
- Physical exam: I will ask to the following questions:
 are there any signs of inflammatory, is the
lymphadenopathy mobile or adherent to the
deep plan? What’is the size? Are there any other
lymphadenopathy cervical or in other area ? is
there any splenomegaly ?
 general signs pallor , bleeding
 exam of the buccal cavity: any tonsillitis,
pharyngitis, dental abscess
- manage the fever: paracetamol 15mg/kg/dose at
the ER
- initial lab : CBC and WBC count , ERS, CRP,
pharyngeal swab
- according to the results after 2 hours generally I will
manage the patient
- the diagnosis could be : ENT causes mouth, lips ,
nasal, throat
 infectious
 inflammatory
 lithiasic if colic salivary
 tumoral : Lymphoma or leukemia
- management: ATB amoxicilline or augmentin for 7
days and see the patient if unilateral
lymphadenopathy persistent and the size not
improving do a cyto- ponction? IF the result of
cytoponction is suspected do a biopsy
12 part INVESTIGATION:
What investigation to confirm immunodeficiency?
- CBC : leucopenia , lymphopenia, neutropenia
- Quantitative immunoglobulin measurement and
their titres
- Electrophoresis of Ig
- Chest xRAY : thymus
- Serology HIV
- Skin testing for hypersensitivity reaction!!!
13: 5 years old female with acute onset of anemia and
jaundice (acute hemolytic anemia) , differentials:
- AHIA
- Crisis of anemia hemolytic in sickle cells disease
- SHU
 6

- Deficit on pyruvate kinase - List reasons for metabolic acidose : forgot insulin or
- Spherocytosis anemia not taking it or wrong dose, infection, sepsis, GI,
- Toxic for heavy metal
- Malaria 18: Symptoms and signs of Child abuse in a 10 month old
14: 8 year old boy presents with acute onset of peri umbilical - Many hospital visits
abdominal pain - History not compatible with clinical state
- Q: list red flag medical and surgical : - Bleeding, burns, injuries, bruise, at different stages
 DKA, of healing
 Sickle cells abdominal vaso occlusive crisis - Fractures not habitual without trauma, like fracture
 constipation, of femur
 lower lobe pneumonia, - poorly nourished
 hepatitis - features of shaken baby syndrome : unconscious or
 lead poisoning, conscious, bulging fontanel, retinal hemorrhage,
 purpura cervical injuries, erythematous marks on the body
 Meckel diverticulum 19: Classify the causes of a floppy child
 peritonitis - central (T21, syndrome Willi Prader, cerebral palsy,
hypothyroid, hypocalcaemia, drugs) and periphery
 occlusion, intussusception
neural system (spinal amyotrophic , myopathy ,
 Post-surgery
myasthenia)
 Trauma : rupture of spleen
- list finding on examination : frog like posture,
 Non accidental injury
areflexia or hyper flexes, hypotonia ,
- Q: right lower abdominal :
20: types of crisis in sickle cell:
 appendicitis , - anemia: aplastic crisis , sequestration splenic ,
 pyelonephritis , hepatic sequestration, hyper hemolysis
 renal calulus - severe vaso- occlusive events : acute chest
 torsion testis, syndrome, stroke, severe infection, acute multi
 psoas abscess organ failure syndrome
- Q: metabolic acidosis: DKA, salicylate poisoning - manage VOC : hydration, analgesia , antibiotics,
depends on the site (acute chest syndrome,
15: priapism, stroke, bone pain)
- 2 weeks old with Conjugate hyper bilirubin 21: Early and late complications of prematurity -28 weeks:
Definition of conjugate hyper bilirubin: conjugaison - early cplt : asphyxia, respiratory distress syndrome
>20% of total bili (hyaline membrane disease), hypothermia,
- Possible causes : biliary atresia, kyste intrahepatic, , hypoglycemia, , infection, NEC (necrosis entero-
mucoviscidosis or cystic fibrosis, alpha 1 antitrypsine colitis) no feeding
deficit - late complication : bronco- pulmonary dysplasia,
- Investigation of biliary atresia: US, CT, +/- biopsy apnea, short bowel syndrome, periventricular
- Management of the biliary atresia : leukomalacia, difficulty of feeding, hemorrhage
 Choleretics: ursodeoxycholic intracranial, and intra ventricular
 Vit ADEK 22: A 10 year old male with painful limp + Fever
 Nutritional support Differentials: leucosis, septic arthritis of the hip,
 Surgical KASAI osteomyelitis, knee joint arthritis , brucellosis, arthritis
16: juvenile, rheumatic fever
Brought in dead: 23:
sleeping position, soft bed with excessive 5 years old brought to clinic hyperactive, aggressive poor
clothings and toys , smoking maternel, no fever, child abuse, school performance: ADHD, score DSM 5, education group
no evidence of trauma behavior, drugs TRT methyphenidrate, side effects (
hypertension, arrhythmia , insomnia, weight loss, stroke…)
17: DKA scenario
- Grade severity: PH <7.29 mild <7.19 moderate <7.1 24 case
severe, HCO <15, <10, <5 10 years old with abdominal pain and distress of 2 days.
- Physiopathology : hyperglycemia, hypoinsulinemia, What’s your approach?
hyperosmolality, ketone What questions will you ask?
- List goals of management: correct dehydration, Answer:
restore blood glucose to normal, monitor - Take quickly the history: Are there any symptoms of
complications polyuria, polydipsia, nausea, vomiting, weight loss,

tiredness? is he known as a diabetic? If yes, did he take
the right dose of insulin? Has he a fever? Check the
previous glycaemia and the dose of insulin
- Rapid physical exam: signs of dehydration, tachypnea,
kussmaul? Smell like acetone, confusion, lethargy,
drowsiness
- Investigation : Take quickly the bedside glucose and
VBG , urine dipsticks , chemistry, electrolytes , urea ,
creat, CBC , blood culture, urine culture
• Child has DKA, how will you manage?
- DKA glycemia >200mg/dl, PH <7.30, or Bicarbonate
<15mmol/l, ketonemia +/- ketonuria
- Admit in PICU, 2 IV lines
- According to the level of the severity of acidosis and
chock give
 If not chocked give IV NS 0.9% 5ML/KG/H for
moderate DKA, if severe give 7ml/kg/h
 If choked with hypotension give 10ml/kg over 5-10
min , chocked not hypotension give 10ml/kg/1H
 After 1H to 2H : IV maintenance +deficit:
According to the weight of the child : 100ml/kg <10kg
+50ml/kg for the next 10kg + 20ml/kg for the rest bellow
difict calculation 5% for mild and moderate DKA 10% for
severe, correct slowly over 48H, start 0.9% saline (with KCL)
40meq/l if Kcl <5.5
 Insulin
Mix 50 UI in 50 ml 0.9% NS start 1-2H from fluid initiation
Dose 0.05 – 0.1 UI/kg/h
 Correction of electrolytes disorders
 Trait infection : manage the fever with paracetamol
+ antibiotic after sending cultures
 Monitoring
- hourly: vital signs capillary blood glucose
(bed side) neurological status (pupil &
consciousness , intake & output
- 2-4H: blood gases
- 4h: blood gases, electrolytes, urea, creat,
phosphorus, calcium, magnesium
- Adjustment and troubleshooting:
 When G drops <250-300 add D5% to NS
 When G drops < 140- 150 add D10% to NS
 When rapid fall of G >100/H add D 10% and can
increase to max D12.5% if acidose is not
improving ( may decrease insulin to 0.005
UI/KG/H or even down to 0.03 UI if acidosis
improving
 Hypoglycemic attack give 2-5ml/kg D10% bolus,
Hold G 15-30 min then repeat G
 Psychosocial assessment
• Acidosis not correcting. What will you do? Repeat the
bolus 10ml/kg if chocked with hypotension can repeat 2x if in
initial step < 2H , if >2H don’t interrupt insulin, When rapid
fall of G >100/H add D 10% and can increase to max D12.5% if
acidose is not improving
7
• Child becoming drowsy, your diagnosis? Cerebral edema
- Mannitol 20% (0.5 -1g/kg over 10-15 min) or
hypertonic saline 3% (3-5ml/kg over 10-15min)
- drop fluid rate third of total
- elevate the head of the bed to 30°
- repeat Mannitol or hypersaline 30 min to 2H if no
intial reponse
• Risk factors for cerebral edema?
- <5 years
- Lower than expected Pco2 for degree of metabolic
acidosis
- High urea nitrogen upon presentation
- Inadequate hydration
- Fast correction of glucose
N.B signs of cerebral edema: severe headache, agitation, fall
in heart rate, increased level of consciousness, increased
blood pressure
Life threatening signs: deterioration in level of consciousness,
abnormalities of breathing pattern, oculo motor palsies,
abnormal posturing, pupillary inequality or dilatation
Electrolytes:
- K >5.5 hold K repeat level 2H
- K < 3.5 increase Kcl to 60 mmol/l
- <2.5 monitored administration of extra 1 mmol/kg
KCL over 2H
Indication to start of oral fluid and transition of
subcutaneous insulin:
- Fully conscious and willing to eat , no nausea no
vomiting
- Ketoacidosis resolved
- Venous ph >7.3
- Decrease progressly the IV fluid
- The first subcutaneous inj of insulin given 15-30 min
with rapid or insulin 1-2h with regular insulin, before
discontinuing the insulin infusion
- Insulin dose : if known DM1 resume patient previous
doses, if new DM1 start 0.75/kg/d 30% LONG ACTING 60%
RAPID ACTING lantus >3y levemir <3y
- Monitoring every 4h
- Diabetic education and diet
24 case
5 months old with cough, fever and stridor. How will you
manage?
- Croup
- Take history when started and when fever started and
if he had taken parcetamol before coming and at what
time, other complain?
- Rapid physical exam to look if there are any infection
evidence and if there are pulmonary signs, distress to
do chest x ray
- Manage:
 Dexamethasone 0.6 mg/kg IM or IV once, can repeat
if not improving max 16 mg

 Paracetamol 15mg/kg/dose/6H until no fever
 O2 if distress to maintain saturation > 92%
 Nebulization adrenaline 0.5ml in 3ml NS
 IV fluid to maintain hydration if distress and or
difficulty to oral feeding
 Investigation : CBC , CRP, blood culture, +/- Chest x
ray
 Antibiotic amoxicillin 100mg/kg/d every 6h or 8H
 Monitoring: vital signs, SO2
• What are your differentials?
- Retropharyngeal abscess
- Foreign body
- Respiratory allergy
- REGD
25 case
10 year old, bedwetting. How will you manage?
- Take a history: since when this symptom to know if
it is a primary enuresis or a secondary, if there are
any urine signs or anal signs? If there is association
with diurnal enuresis, any encopresis? Is there any
polyuria & or polydipsia?
- Physical exam : any abnormalities
- Investigation: urine dipsticks, urine culture, blood
glucose, and maybe US pelvis and renal and urine
tract
- If there is abnormalities in the results such as a
diabetes or UTI, I will manage these causes
- If the investigation is negative I will collect the urine
of 24 hours to prove that it’s a nocturne enuresis
and calculate intake also
- Diuresis nocturne must be less than 130% of theory
capacity of the bladder KOFF formula
130x((age+1)X30)/ 100 if he urines more than this
quantity so he is nocturne enuresis
• How will you classify enuresis: primary he doesn’t required
cleanliness or secondary he required cleanliness and had
enuresis after 4 years old.
• If he had achieved continence earlier and started
bedwetting, what duration before you classify him as
secondary? 4 years
• What are the causes of primary and secondary enuresis?
- Primary causes:
 a bladder that involuntarily contracts when full;
 REM (paradoxal) sleep, too deep, too long and
during which the child can dream of going to the
toilet;
 a hereditary predisposition. If one parent,
possibility is 25%. If both parents 65%
 a malformation of the urinary system;
 psychological disorders that delay the acquisition
of cleanliness and autonomy
- Secondary causes:
 Diabetes
 Urine infection
8
 Psychological
• This child has primary enuresis, how will you manage?
- behavioral treatment
 not put on diapers
 stop the sweets
 stop liquids 3 hours before going to bed
 go to the toilet before sleep and wake up
every 4 hours to pee
 or use the alarm
 give a calendar to the child, to put on it the
dries and wets nights/ week to evaluate at
the following up
- psychological opinion
- After 3 months of good application of these measures
if it does not work and if the child and parents wish a
medical treatment I will put him on Minirin
(desmopressine) if there is no CI (renal, cardiac,
hypoNa, diuretic, potomania) can be prescribed with
precautions stop liquids 2 hours before and 4 hours
after, dose 60mcg tablet can be increased by 60
every week if not improving max 180 , or spray
endonasal 10mcg/dose, 3 months TRT
• Urine mcs from MSU grew E coli 40,000 what is your
interpretation? It’s a urine infection, a pyuria
- Management I put him on ATB augmentin or
cefotaxim, and after 48 I will adapt the ATB
according to the test of sensitivity,
- US and DMSA , may need more investigation since
he is a boy, I will investigate a malformation of urine
tract
• Define sterile pyuria? Leucocytes <10 000/ml
26 case:
A 10 month old unvaccinated presented with a history of 3
day fever after which rash appeared from the foot and spread
to the face
- Is there any others signs? Nasal discharge, cough,
pharyngitis, conjunctivitis?
- The rush is it morbilliform (measles like)?
- Is there another member of the family has same clinical
signs?
- Diagnosis antibodies in the blood or in swab of the saliva
- If measles : treatment symptomatic of fever, may give vit
A , look for the complications, Ig and vaccination for
prevention
Same child came for vaccination and mother said he is allergic
to egg. Which vaccine will you not give? Yellow fever, flu
vaccine, tick borne encephalitis
27 case
A 6 month old was brought by the mother that he has
seizures and is sleeping excessively. Child is unconscious and
Brain CT showed subdural hematoma
Child abuse : shaken baby syndrome, consult neurosurgery
immediately and call the authority to investigate with the
parents to protect the child

28 case
You were called to the nursery that a 2 day old has bilious
vomiting. X-ray showed double bubble sign.
What is your diagnosis?
- Duodenal atresia
- ABC resuscitation, IV line
- NPO , NGT for gastric liquid discharge
- IV fluid for maintenance
- Transfer to pediatric surgery immediately
29 case
A 3 day old was brought because he was not feeding well and
jaundiced
- Take a history: when does the jaundice appears? What’s
the blood group of the mother and the child, are there
any infection risk factor? Any cases of neonate jaundice
in siblings, any hemolytic anemia in the family?
- Physical exam : any spleen or hepatomegaly, check the
reflexes , any signs of nuclear icteric
- Investigation : RBS, blood group, bilirubin T and D , blood
culture, CBC,
- IV fluid for maintenance
- Antibiotic : Ampicillin + gentamycin
- Monitoring : vital signs, T°, stool, urine, signs of nuclear
icteric
- Check the indication of phototherapy
30 case
A mother brought her 3 year old that she took some tablets
containing iron about 50min ago. How will you manage?
- Dose mild to moderate toxic is 20-60mg/kg, severe
>60mg/kg severe symptoms and mortality
- 50min to 2h it’s the GI phase : Take a history while
preparing the patient to a gastric lavage: is there any
vomiting , abdominal pain, hematemesis, diarrhea
bloody or dark, lethargy shock, acidosis, coagulopathy,
can causes necrosis and hemorrhagic
- Investigation if ingestion of 40mg/kg : electrolytes,
glucose, ALT,AST, Bilir, ABG, CBC, PT, PTT, urine analysis
- Specific measurement of serum iron concentration
- US abdomen pelvis
- Management :
 ABC assessment
 Whole bowl irrigation using NGT lavage solution
30ml/kg/h until rectal effluent is clear
 Antidote : desferrioxamine iron chelating
 if serum level >90mcmol/l, serum iron level 60-90
mcmol/l and tablet are visible in x ray,
 or patient presenting nausea , vomiting, diarrhea,
abdominal pain, hematemesis and fever,
9
 or with worsening symptoms of altered conscious
state , hypotension , tachycardia, tachypnea,
metabolic acidosis <7.1
 dose : 15mg/kg/h IV reduce rate after 4-6h IV
dose doesn’t exceed 80mg/kg/24H
 hemodialysis or peritoneal dialysis if oliguria
or anuria
NB.
- Salicylate dose toxic 3900mg/24H for >10 days,
mild and moderate toxicity 150-300mg/kg, severe 301-
500mg/kg,
hyperventilation, paradoxic aciduria with alkalosis
respiratory, dehydration hypokaliemia nausea vomiting,
vertigo, tachycardia
activate charcoal 1g/kg max 50g PO within 1-2 h
- Non-steroidal anti-inflammatory dose toxic >
100mg/kg :
Vomiting, nausea, drowsiness, blurred vision, hypothermia,
convulsion, metabolic acidosis , coma, hypotension, ataxia ,
nystagmus, headache, dysrhythmia, electrolytes
abnormalities, hyperkaliemia, antidote activate charcoal,
- Iron phase 6- 24h : metabolic acidosis, cyanosis,
hemo concentration, hypotension, hepatotoxicity
Case 31:
3 weeks baby came with convulsions. What’s your approach?
- ABC assessment, check bedside glucose
- It’s low 30 mg : hypoglycemia
- Will give Dextrose 10% bolus 2.5ml/kg IV ,RBS
repeated still Low ,give another bolus then corrected
- Negative history: everything is ok No poor feeding
,no vomiting and so on
- Unremarkable clinical exam, All labs were normal
,calcium magnesium Ammonia, urine ketone, screen
for sepsis
What you will do next?
- Imaging and EEG
- Screening of metabolic disease
- D10 IV fluid maintenance, if not improving give D
12.5% via central line
- If hyper insulinsm suspected maintain blood glucose
>3mmol/l,
- if persistent give glucagon +/- hydrocortisone
- Monitoring of neurological status, RBS, feeding
Case32:
12 years boy with 3 week’s history of abdominal pain &
diarrhea
What’s your approach?
- Take the history: has he any chronic disease
especially GI, Bloody mucoid stool, weight loss,
fever, skin rash, nausea, vomiting, and ingestion of
milk not pasteurized or meat not cooked well? Is
there any member of the family had a diarrhea also
and recovered?
- Only significant is weight loss
 10

Differential diagnosis:  Cefotaxim + gentamycin

- inflammatory bowel disease ,
- infectious GI parasitize or bacterial , brucellosis Case 37:
- celiac disease 12 years boy with deterioration of school performance and
- tumor endocrine making lots of quarrelling
- cow milk allergy With school mates
- pancreatic exocrine failure - What are the differentials??
ADHD
Case 33: Brain tumors
5 years boy vomited large amounts of blood Hypothyroidism
- ABC stabilization - Diagnostic criteria for ADHD (check DSM5)
- IV fluid , bolus NS if chocked - Diagnostic criteria
- CBC, blood group, coagulation - Treatment: behavioral training for parents
- transfuse him if needed Medications: stimulants and non-stimulants
- Differential diagnosis: Stimulants: methylphenidate
 Perforated peptic ulcer Non stimulants: tricyclic antidepressants
 Bleeding disorders Side effects of methylphenidate
 Portal hypertension with esophageal varices
- points in the exam to support Portal HTN, stigmata Case 37:
for chronic liver disease 6 years boy with cervical lymphadenopathy
 dilation of portal veins What’s your approach?
 hepatomegaly sometimes the lower edge is - History: since when is it acute or chronic? Has the
sharp in cirrhosis size changed? BCG vaccine?
 increase in abdomen volume with ascites - Physical exam: I will ask to the following questions:
- treating varices are there any signs of inflammatory; is the
 sclerotherapy lymphadenopathy mobile or adherent to the deep
 vasopressin IV plan? What is the size? Are there any other
lymphadenopathy cervical or in other area? Is there
any splenomegaly?
- general signs pallor , bleeding, exam of the buccal
cavity
- initial lab : CBC and WBC count , ERS, CRP, chest X
Case 34: ray , fine needle biopsy if not available or suspected
12 years boy who was top in his class, now his school result do the biopsy
performance deteriorated - the diagnosis could be :
What is your approach? - infectious
- Take the history: - inflammatory
 psychosocial - tumoral : Lymphoma or leukemia
 Drug abuse - the result of the anatomo- pathology :Reed-
Sternberg cells
 Wilson disease
- What is diagnosis? Hodgkin’s lymphoma
 Endocrine like hypothyroid
- Staging: 4 stages according to Anne Arbor :
 Brain tumor
 Stage I : 1 lymph node or 1 organ like thymus
 II: 2 nodes or more above the diaphragm
CASE 36:
5 days old baby with lethargy, poor feeding and plugging  III: lymph nodes on the both sides of diaphragm,
fontanel spleen
Your approach  IV: lymph nodes and at least one organ outside the
- History: preterm 32 weeks, weight 2. Membranes lymph system such as liver lungs , bone marrow
ruptured for 18 hours
- Labs : Septic work up , Cbc diff and chemistry, csf Case 38:
exam 12 years boy known to have history of sickle cell disease, had
- Most likely cause: GBS meningitis fainting attack in the school now he is fine brought by his
- What are the risk factors? mother
 Prematurity, low birth weight Your approach
This most likely stroke (transient ischemic)
 Prolonged ruptured of membranes
Will do CT Brain
- What the antibiotics of choice & the duration??

Ct scan confirmed stroke
What is your treatment? First exchange transfusion then
regular transfusion.
Definitive treatment: Bone marrow transplant
Case 39
5 years boy with fever and cough. Other family members also
with cough. Has low O2 saturation
- Physical exam: any shortness of breathing? Any
wheezing, crepitation or rhonchus?
- Chest X ray?
- After ABC stabilization, O2 to maintain saturation>
92%, IV fluid if shortness of breath
- Lab: CBC, CRP, blood culture, covid-19 Test, blood
chemistry, coagulopathy profile, liver and renal
functions
- What is your differential?
Viral infection: influenza, Para influenza, RSV, Turn to
be covid19
- What the syndrome happen in pediatric?
Multi system inflammatory syndrome
Multisystem Inflammatory Syndrome in Children (MIS-C)
 Criteria for Management:
- Patient with fever (>38.0°C for ≥24 hours, or report of
subjective fever lasting ≥24 hours), laboratory evidence of
inflammation an elevated CRP, ESR, fibrinogen, procalcitonin,
D-dimer, ferritin, LDH, or IL-6; elevated neutrophils; reduced
lymphocytes; and low albumin), and evidence of clinically
severe illness requiring hospitalization, with multisystem (≥2)
organ involvement (cardiac, renal, respiratory, hematologic,
gastrointestinal, dermatologic or neurological)
- No alternative plausible diagnoses
- Positive for current or recent SARS-CoV-2 infection by RT-
PCR, serology, or antigen test; or COVID-19 exposure within
the 4 weeks prior to the onset of symptoms
 Management:
- Admission to a pediatric intensive care unit is appropriate
for children with hemodynamic instability (shock,
arrhythmia), significant respiratory compromise, or other
potentially life-threatening complications
- Thromboprophylaxis Enoxaparin prophylaxis doses:
• Infants 1 - < 2 months: 0.75 mg/kg/dose subcutaneously
every 12 hours
• Infants ≥ 2 months, children, and adolescents: 0.5
mg/kg/dose subcutaneously every 12 hours
- Antiviral therapy
- Immuno modulator 1-2 g/kg/dose IV
- Glucocorticoids 1-2 mg/kg/day divided BID (prednisone,
prednisolone, methylprednisolone) 5 mg/m2 daily
(dexamethasone)
 and Monitoring - Assess cardiac function and fluid
status prior to giving to avoid fluid overload
- Baseline renal function tests, urine output, IgG level, CBC
- Monitor clinically for signs of hemolysis after first dose
- Potential adverse reactions: anaphylaxis,
11
- Infusion reaction, hemolysis, transaminitis, aseptic
meningitis
- Pulmonary adverse reactions; blood pressure (prior to,
during, and following infusion); clinical response.
- For patients at high risk of hemolysis (dose ≥2 g/kg, given as
a single dose or divided over several days, and non-O blood
type):
Hemoglobin or hematocrit prior to and 36 to 96 hours post-
infusion and again at 7 to 10 days post-infusion
- What is it and monoclonal antibodies used in its
treatment
Multi organs involvement with high inflammatory markers,
coagulopathy
Treatment: steroid (prednisolone/prednisone or methyl
prednisolone) and tocilizumab interleukin 6 antagonist
40
6weeks old baby mother noted sudden cyanosis, without any
preceding events, she gave mouth to mouth breathing and
brought baby to ER now baby is ok. One week back same
incident happened after feeding but it was brief than this
one, diagnosis and management
- Take the RBS, examine the baby
- wrong route, inhalation, wrong way of feeding, or
she didn’t regurgitate it
- Education of the mother how to feed her baby and
to regurgitate him
41
A 6 weeks old child, with lethargy. Poor feeding for 2 days.
What’s the diagnosis?
- Take the history: any fever, diarrhea, or vomiting,
abnormal movement?
- Physical exam and neurologic exam
- Diagnosis:
Dehydration
Sepsis
UTI
Hypothyroid
Child abuse (checking baby)
42
8 years old cerebral palsy with malnutrition, how to manage
and you need to admit or not
Yes admit the patient for investigation of anemia and other
deficit to correct them and consult the nutritionist to educate
the mother and give a supply if needed
43
10 years old girl, routine lab checkup reveals ALT 245UI, AST
200UI
rest of routine investigations normal, girl have no complaints
and look healthy...
chronic hepatitis DD,

discussed autoimmune hepatitis and then after that he told
girl has deterioration of school performance then discussed
about wilson
44
6 years old girl sudden pallor and jaundice....autoimmune
hemolytic anemia, diagnosis and treatment, asked about
blood transfusion as Hb is 4....what to transfused if
crossmatch blood not available ? IF NOT CHOCKED do not
transfuse give Ig IV, if chocked can give a bolus of NS or
plasmagel 10ml/kg over 10-15 min can repeat once
N.B Crossmatch beside the patient
One drop of the patient’s blood and one drop of the blood to
be transfused
Washed plasma can be used if available
45
9 months old boy has painful swelling of lateral side of thigh
X ray of the lower limb +/- US
.....abscess
46
3years old boy his mother buy powder from near
supermarket she found her baby eat it and full his mouth ,
eyes, clothes and the remaining of powder he put it on his
hair , his mother remove the clothes and wash the face he
Became drowsy and bring him to ER what is your Approach?
ABC stabilization
What’s the name of the powder? If she doesn’t know the
name I will ask her to bring the product or one of the
member of the family take the photo and send it
I will ask her also at what time he ingested it.
If ingestion less than 1hour I do a gastric lavage
IV fluid, lab toxicology, CBC, renal and liver function, X ray
Monitoring
47
3 years old boy have recurrent abdominal pain for one year
what is your approach?
- Take a history: localization of the pain, associated or
not with other complains like nausea, vomiting,
diarrhea, constipation? Are there any white WORMS
in the stool? Itchy of the anus? Does the pain
concomitant with a throat infection?
- Examine the abdomen: looking for distention,
localization of the pain, organomegaly
- Xray of abdomen
X ray shows severe constipation and dilated rectum how to
manage?
- Take a biopsy to eliminate hirschsprung disease
- Diet with fibers and enough of liquid to maintain the
bowl well hydrated
- Laxative drugs
48.
10 month old presented in ER convulsing with fever.
Approach to management?
12
- ABC stabilization, RBS
- Lateral surety position
- If the seizure doesn’t stop in 5 min (consider pre-
arrival seizure duration) give Lorazepam or
Midazolam 0.1mg/kg/dose IV if not available give
Diazepam 0.15mg/kg/dose IV, can be repeated once
IF NO IV or IO line available give IM midazolam one
dose 0.2mg/kg Or Diazepam 0.2mg/kg rectal
- Paracetamol 15 mg/kg/dose in IV
- After stopping the seizure examine the baby to look
of abnormalities to classify the febrile convulsion
simple or atypical
- Look for any evidence of infection
- Lab : if baby stable do LP, blood culture, urine
culture, electrolytes , liver and renal function
- Fontanel US +/- chest Xray if pulmonary signs
- If atypical convulsion do CT or MRI Brain , and EEG
- Correct any electrolyte abnormalities
- Monitoring
- If the seizure doesn’t stop at 20 min give phenytoin
20mg/kg/dose IV over 30 min, Or Valproat acid
40mg/kg max 3000mg or phenobarbital
20mg/kg/dose single dose
st
- After 40 min if you used phenytoin as 1 option give
phenobarbital and vice versa
- After 60 min refractory status epilepticus :
 Request for continuous EEG, consider central line, be
ready for intubation, monitor vital signs
 Bolus of midazolam infusion 0.2mg/kg then start
infusion at 1mcg/kg/min, increase by 2 every 10-15
min PRN, up to 24 mcg/kg/min
 Common side effects : hypotension and loss of
airway reflexes
 If seizure persistent : barbiturate coma
49
You were called to nursery to see a 10hr old neonate was
delivered to a 19 years old unbooked mother and was about
to be discharged and found to be lethargic. How are you
going to approach?
- ABC of resuscitation first. RBS bedside
- History: Has poor feeding. No fever or other
symptom, Pregnancy and delivery history normal,
history of risk factors of sepsis- none, examination
normal.
- Investigations- RBS- 35mg/dl.
- Treatment of hypoglycemia
- monitoring
- And RBS monitoring was discussed. RBS became
normal, still lethargic, what will you do?
- CBC, CRP at 12H, blood culture, LP
- Will you give antibiotics or wait for results? Yes I will
give ATB ampi genta and I will wait for result to
continue, adjust or stop ATB after 48H
50
An 18mth old with history of fever and SOB, what will you do.

- I started with ABC, Saturation?
- He said SPO2 88%. I commenced Oxygen
- History: since when, any fever, cough? is it the first
episode of SOB? Any other complains or symptoms?
No contact with Covid-19 patient? No choking or
allergy ? yes cough + fever
- Physical exam: tachypnea, distress, reduced air
entry, crepitation, fever, no wheeze
- Investigations: CBC, blood culture, CRP, ESR,
- CXR : Left lobar pneumonia
- Diagnosis: Lobar pneumonia
- History of 3rd pneumonia, last one was on the right
- Diagnosis now recurrent Pneumonia
- Causes:
 Immunodeficiency: hypogamma globulinemia
transient (late maturation) , complement,
common immunodeficiency
 Deficit of the function of the phagocytes
 Maybe 1 pneumonia due to obstruction of
st
foreign body, or node or tumor
 Stenosis or atresia bronchitis
 Cystic fibrosis,
 Bronchial malformation
 Bronchiectasis localised
51
12 years old boy with watery diarrhea for 3 days. How will
you approach?
- History: Is there any bloody, mucus? Other
symptoms, any chronic disease? Any travel in
endemic country? Fever? Other complains?
- Check the hydration
- Investigation: CBC, CRP, ESR, electrolytes, stool
analysis and culture, Xray abdomen and US
Non bloody, occasional bloating and undigested food
particles. Recurrent x 4 months, has weight loss in last 4
months
Chronic diarrhea watery (secretory) and occasional
maldigestion + weight loss
Causes:
- Crohn’s disease
- Colitis
- Post radiotherapy
- Cryptosporidiosis (travel in endemic country)
- Adenoma villous
- Microsporidiosis
- Colitis microscopic
- Giardia lamblia
- Immunodeficiency
- Ischemic colitis
Investigation: colic biopsy + Labs
52.
13
A mother came to your busy OPD with her 4 weeks old
jaundiced baby, Jaundice started 2 weeks ago. Normal
Pregnancy and delivery, previously well.
- Mention 1 investigation you want to do
- Serum bilirubin.
- Total was 200 and direct 180, what does that imply?
- Conjugated hyper bilirubin.
- What other investigation do you want to do?
- Abdominal US: findings of biliary atresia.
- Mother wants to go for a wedding and return for the
US after 2 weeks, what will you do?
- I will counsel her and educate her. I will explain the
need for the US if it confirms biliary atresia; baby will
need surgery before 6 weeks. If not done early, he
can develop biliary cirrhosis. He asked consequence
of biliary cirrhosis-
- surgery cannot be done, and baby will require liver
transplant.
53.
A 7 year old boy came to ER with hematemesis? Approach to
arrive at diagnosis?
- ABC stabilization. Heart rate, CRT and blood pressure
- He said PR 140, BP 90/45, CRT < 2 sec
- resuscitate with IVF Normal saline 10ml/kg bolus,
take urgent CBC and coagulation profile, blood group
if not known
st
- Take history if it’s the 1 time (yes), has he any
chronic liver disease, ulcer, bleeding from other
parts of body? no, taking drugs aspirin or anti-
inflammatory , corticoid? Hemoptysis, epistaxis ?
- Physical exam: Hepato splenomegaly (none), skin for
petechial, purpura (none), epigastric area tenderness
(none)
Differentials:
- Gastric varices
- Hypertension portal: esophageal varices
- Gastritis
- Mallory Weiss syndrome
- Gastro-duodenal ulcer
- Esophagitis
- Drugs: aspirin, doxycyclin
Endoscopy digestive needed
54.
A Mother brought her 18mth old child with loss of eye
contact x 2 weeks. Pregnancy and delivery were normal.
What is the approach?
- Is the child having stereotyped repetitive
movement or restricted range of movement? any
impairment in verbal or nonverbal communication?
yes.
- Child likely has autism.
what can be differentials of poor eye contact?

- Visual impairment, disorder of upward gaze from
brain tumor, ocular malignancy eg retinoblastoma,
refractive error,
Where do I want to examine?
- Eyes and CNS.
In CNS what do I want to examine?
- Gait,
- head circumference and anterior fontanel (should be
closed at this age)
- Reflexes.
- Motor movement
N.B
AUTISM
Persistent deficits in communication and social interaction
- Deficit in socioemotional reciprocity
- Deficit in non-verbal communication conducts and in
development
- Deficit in maintaining and understanding
relationships
Repetitive and restricted patterns of conducts, activities and
interests
- Motor movements, use of objects or stereotyped,
patterned or repetitive speech
- Resistance to change, inflexible adherence to
routines and routine behavior patterns
- Restricted interests, abnormal owing to their
intensity or focus
- Hyperreactivity or hyporeactivity to sensory stimuli
Cas 55
A 12 year old boy presents with headache x 4 months and
fever x 3 days.
What is your approach?
- History: is there any history of chronic disease? Has he
any myopia or other abnormal ophthalmic refraction?
Has he any chronic rhinitis or sinusitis? Has any
epistaxis? Vomiting, nausea? Does he use mobile or
any other stream all the time?
- Physical exam: pallor? T°, any infection evidence, blood
pressure, HE SAID tachycardia
- Investigation: CBC, CRP, blood culture, urine culture if
urine signs, chest Xray if pneumo signs
- CBC: Hb 7g/dl, PBF (microcytosis and hypochromic).
- Ferritin: iron deficiency anemia,
- What about other lab parameters of iron deficiency
anemia? TIBC, Transferrin, Serum iron
- All response in keeping with Fe deficiency.
- What other investigation?
- Stool microscopy for parasites, and micro bleeding,
urine dipstick for hematuria, ask if he has a chronic
diarrhea, any food allergy APLV or gluten
th
- iron supplement: 10mg/kg/d, reti at 10 day, repeat
CBC at D30 , and decrease the dose 5mg/kg/d for 3
months
14
- Diet rich of iron and vit C, he may have black stool and
abd pain
- Relationship between headache and iron deficiency?
- could it be dizziness not really headache
- Mention other symptoms of iron deficiency.
- Loss of hair, cheilitis, brittle nails, recurrent URTI
56.
A 13 year old girl brought by her mother complaining of short
stature. What will I do?
He asked what is the 1st thing will I do?
- Weight and height of child to plot on growth chart. And
previous weight and height to calculate the speed of
growing and to study the curve if any stagnation or
decline or broken of the curve
He said child’s height is < 3rd centile and weight on 50th
centile. Mother is 170cm and Father is 175cm.
rd
- the height target is 166, on the curve it’s not at the 3
centile
- Were any of the parents short in childhood? Father was
short when he was young.
- Is there a delay in menarche of mother? At 15 years
- Physical exam: tanner stage 1, the menarche usually
came 2 years after thelarche but she is 13, the tanner
still infantile, if we consider that she is as her mother
and will have menarche at 15 then she must have at
least stage 2? Any abnormality neck or facies?
- He asked investigation I want to do and finding? Bone
age? Delayed by 2-4 years,
- US pelvis to see the genital intern organs, uterus and
ovaries presents or not and their measures,
- thyroid function, karyotype, hormone investigation
LH, FSH, RH with and without stimulation, glycaemia
and GH with stimulation, GF1, hepatic and renal
functions, may be also sella turcica x ray, if all of these
results are normal than I will say that it’s constitutional
short height. Because this diagnostic is a diagnostic of
elimination
57
A 5 year old with redness of the eyes, what is the
approach? purulent or not? Non purulent.
Fever? Yes, x 1 week, high grade. Has red tongue, rash
on diaper area and some on trunk that disappeared and
unilateral cervical Lymph node,
but NO oedema/redness/desquamation of palms
and soles, but after some days there was desquamation.
No history of recent travel.
Diagnosis: Kawasaki disease
He asked investigations, each one I ask of he gives
results: CBC , WBC 15000, HB 7g/dL, Plt 550,000 CRP 80,
ESR 40, Urinalysis: pus cells, urine culture???
ECHO: he asked finding? Coronary artery aneurysm
(what classification according to z score?)
- management:
 15

 Ig IV : high dose 2g/kg once  Surgery intervention: to remove unviable necrotic

 Aspirin : 30 – 50 mg/kg/d on 4x/d for 2 weeks , intestine
than 3-5 mg/kg/d for 6 weeks if there no - Complications of surgery:
complications  Strictures, stenosis, adherences
 If risk factor or not improving : corticotherapy  Short bowl syndrome
 Methylprednisolone 2 mg/kg/d IV for 5 – 7 days until  Intestinal failure
normalization of CRP than give it orally with decreasing  Recurrent NEC
for 2- 3 weeks 60
 Or bolus methylprednisolone 10-30 mg/kg/d IV for 3 A 2 months old with Retinal hemorrhage and bruises –
days max 1g/d than orally 2 mg/kg/d for 4 days until Differentials:
normalization of CRP than decreasing for 2-3 weeks - Coagulation abnormalities
 If resistance of Ig give immunosuppressor - Leucosis (leukemia)
- Child abuse
- Antibiotic: augmentin or Cotrimoxazole, and wait for 61
the urine culture result, if positive check the sensibility 2 days old with Pallor and Jaundice differentials? Bilirubin
and adjust the antibiotic, she is a girl and if it’s the first indirect?
rd
UTI she doesn’t need investigation, but if it’s the 3 - Jaundice with coombs positive:
one , I will do US and DMSA, renal fonction •IFM rhesus, ABO, kell, kidd
th th
- following up Between the 10 day and the 30 - Jaundice with coombs negative
repeat echo cardiac once a week than every 4 weeks •Common: preterm, asphyxia, blood resumption, Crigler
to detect the cardiac complication and use Z score ( Najjar
2-2,5 coronary dilatation , >2,5 <5 small aneurysm, •Jaundice prolonged it’s not the case but there are 3 causes
>5 <10 moderate aneurysm, > 10 big aneurysm (breast feeding, hypothyroid, digestive obstruction
- Repeat echo cardiac 2x/week if cardiac complication •Hemolysis: IFM ABO, neonate infection, hemolysis
- If a giant aneurysm give heparin therapy constitutional ( spherocytosis, pyruvate kinase, G6PD)
- After Ig the vaccination with live vaccine must be - how to make a diagnosis of spherocytosis
reported after 11 months Test EMA
N.B if child febrile give asprin 30-50mg/kg/d until he became
afebrile
Case 62
58 12 year old boy with abdominal pain and recurrent vomiting
A Short obese 4 years old. What are your differentials? for 4 months. How to approach?
- Hypothyroid - Take the history: Any chronic disease? any fever? Other
- Deficit on GH complains? Any diarrhea or constipation? Urine signs?
- Hypercortisolemia Any medication? Investigation? Weight loss? Character
- Syndrome example Willi prader, of the vomiting and when?
- Trisomy - Physical exam: abdomen? Localization of the pain and its
characterizes? Any fecalome? Any abnormalities in other
59 organs?
A 28 week old baby fed by nurse on duty and noticed to be - Investigation: CBC, CRP, ESR, abdomen US, X ray
vomiting with abdominal distention abdomen
- Differentials? - Barium enema: dolichocolon?
 NEC diagnosis: US abdominal and pelvis? Xray - How to manage? (Chronic constipation).
abdominal  Diet fiber, liquids
 Infection, sepsis  Antiemetic
 Milk cow allergy  Laxative
 Sepsis with ileus  Physical activity
 Peritonitis
- Management: NEC Case 63
 NPO, NGT for gastric decompression, 13 years old with 6 week history of prolonged fever and
 IV fluid can use also TPN limping admitted to the ward.
 Respiratory support - How you will approach?
 ATB: ampicillin + gentamycin + metronidazole  Since when the fever? Is there any context of trauma?
 Or monotherapy by meropenem Pallor?
 ATB can be modified according to the results of blood
culture

- What you will look on exam? Signs of inflammatory,
swollen redness, pain in palpation? Splenomegaly,
hepatomegaly, any lymphadenopathy?
- What investigations you will request? X ray CT, CBC with
WBC diff, CRP
- If the patient has large cervical lymph node.
- What is the diagnosis? Leukemia, osteosarcoma,
idiopathic juvenile arthritis, synovitis, septic arthritis
Case 64
A 3 month old infant with diarrhea since 2 month of age.
Loose watery. Patient has uneventful delivery. on formula
feeding ..
how to approach?
Physical exam: Any signs of dehydration? Weight loose ?
fever ? Patient well thriving with average weight.
What is the work up you will request? CBC, stool analysis and
culture, blood chemistry and electrolytes, Test of hydrogen
for lactose allergy, IGE specific of cow milk protein allergy,
Case 65
12 year old boy presented with diarrhea and dehydration
resuscitated.
What could be the causes? Diarrhea is chronic.
- Infection
Bacteria: Shigella, Salmonella*, C. difficile (should be
considered whenever diarrhea develops within several
weeks of antibiotic treatment)
Virus: HIV
Parasites: Giardia*, Entamoeba histolytica,
Post infectious lactose intolerance*
Parenteral diarrhea due an an infection outside the GI tract,
frequently
associated with URTI, OM, and UTI. Unclear mechanism
- Food-sensitive diseases
Chronic non-specific diarrhoea (toddler’s diarrhoea)*
Coeliac disease
Cow and/or soy milk allergy or intolerance
Allergic and eosinophilic enteropathies
- Immune-mediated disorders
Inflammatory bowel disease* (IBD)
Primary immunodeficiency: common variable
immunodeficiency, severe combined immunodeficiency, IgA
deficiency
Autoimmune enteropathy
- Anatomical abnormalities
Short gut syndrome
Intestinal lymphangiectasia
- Pancreatic insufficiency
Cystic fibrosis
Shwachman-diamond syndrome (Pancreatic insufficiency,
chronic neutropenia and short stature)
- Others
Irritable bowel syndrome* (IBS)
Constipation with overflow incontinence*
Factitious diarrhea or Munchausen’s syndrome, Laxative
abuse
16
Congenital chloride diarrhea (diagnosed by history of
polyhydramnios, dialted intestine, low stool PH, metabolic
alkalosis, TRT replace chloride and hydration)
Prolonged use of AB (chlostredium deficile enduced colitis)
treated by stop the causing AB for 10-12 days, oral
vancomycin
NB.
- Plan C: 10% and more Dehydration/rehydration
according to WHO:
 <12 months 30ml/kg over 1 hour( can be repeated if
chock not improving) then 70ml/kg over 5 Hours
 >12 months give 30ml/kg over 30 min (can be repeated if
chock not improving) then 70ml/kg over 2 hours and half
 if not chocked no vomiting can give ORS orally +/- NGT
20ml/kg/h over 6H totally 120ml/kg

- Plan B: rehydration over 4 hours 75ml/kg
- Plan A: <2 years 50 to 100ml after each diarrhea, >2
years 100-200 ml
- Zinc can be given if no vomiting <6mois ½ tablet 10mg/d
>6 mois 1 atblet 20mg/d , for 10 to 14 days
Case 67
Child 3 years old with rectal bleeding Approach??
- ABC, Stable
- Paroxysmal pain?
- US urgent to eliminate an intussusception
- Ask 5 questions to reach diagnosis Color and amount??
- Food that color the stool? Or Medication: iron black
stool?
- Child abuse?
- Anal fissuring?
- Bright red moderate and Bleeding from any other sites??
No
- Risk for portal hypertension, upper GI bleeding No
- Any bile’s or painful perianal lasting No
- History of polyp’s AV malformation or Meckel
diverticulosis??
Differentials :
- Diverticulosis Meckel
- Intussusception
- Diarrhea invasive : salmonella, coli, shigellae
- SHU
- Anal fissure
- Hemorrhoids
- Angioma rectal, polype, purpura
-
Case 68
18 Months old with cough and SOB, Approach??
- Vitally stable? Yes. Saturation?
- History:
 Any fever? Low grade
 Coryza?
 Any history of chocking? Food allergy or anaphylaxes?
No
 17

 Atopic dermatitis? Sensitization to food?  Drugs: cipro, antimalarial (as primaquine), sulfa,
 Contact with covid-19? No vitamin K, diphenhydramine, loratadine and
 Family history of atopic? Mother allergic rhinitis halothane
 Is it the first episode of SOB?  Favism, 5-24 hrs after ingestion
- Physical exam: wheezing, crepitation? Crackles? Type of  Infection salmonella, Ecoli, B-hemolytic strep, viral
cough? Wheezes when is cold? hepatitis.
- Chest X ray? Is there a hyperinflation and increased  Hyperglycemia and DKA
bronchial mark? CBC WBC diff, eosinophilia? IGE? PCR of
RSV CASE 70
- Bronchiolitis 10 years old young female brought with 2months history of
- Treatment fever, bone pain fatigability limping??
 Oxygen to maintain SaO2 >92% Approach?
 Airway clearance and nasal suctioning - History
 IV fluid if distress, or small frequent feeding - Nocturnal symptoms of fever drainage sweating and
 Nebulization of NS 3 times the first hour every 20 min pain. No
, than every 4 hours, than every 6 hours from the - Weight loss? Mild due to poor appetite
next day, we can test salbutamol if it response we can - Type of limping gaits? Antalgic or tredenlburge gait
continue - No limping
 Corticosteroid can used for their anti-inflammatory - Exposure to radiation?? No
effect - Physically Pale?? Some pallor
- Monitoring - Jaundice?? Not clear
- Differentials: - Lympho reticular systems?? Hepato- splenomegaly
Foreign body lymphadenopathy?? Liver moderate enlargement
Aspiration - Spleen 7 cm
Heart failure - No LAP
Pneumonia - She received many antibiotics without response
Airway diseases - CBC: Microcytic hypochromic anemia
Pertussis - Leukocytes normal differential mild neutrophils
- Plat thrombocytosis
CASE 69 - So it is not leukemia lymphoma or any malignancy
6years old boy came with sudden pallor and jaundice?? Your - Could it be brucellosis? Yes it’s brucellosis
Approach? - Why you mentioned brucellosis? What’s with and what’s
- Vitally stable? Yes against?
- Color of urine? Dark red cola like  Prolonged fever
- Any preceded URTI or any infection? No  bone pain pallor
- Any preceded drugs or food ingestion?  hepato splenomegaly
- What kind of food you mean?  and endemicity
- Fava bean. Yes - Against brucellosis
- Any PMH of similar condition?? No  CBC finding
- What’s your diagnosis?? G6PD  Normal plates and leukocytes
- Other differential? AHIA - What is percentage of bi or pancytopenia in brucellosis?
- How you diagnose?? - I don’t know
1. CBC Normochromic Normocytic anemia - But common presentations
2. Peripheral smear marked anisocytosis and - How can you explain thrombocytosis??
poikilocytosis - IDA (Iron deficit anemia?)
3. Reticulocytosis may reach to ≥ 30% - Reactive due to infection
4. Heinz bodies - How you diagnose Brucellosis??
5. Low haptoglobin, Hemoglobinuria - Titer (widal for Brucella)
6. G6PD screening test: Fluorescent spot test is most - PCR
reliable and most sensitive - Brucella culture
7. G6PD quantitative assay by spectrophotometry, test - For how long culture take time??
should be repeated after few weeks of the hemolytic - 1-2 weeks, but can take 6 weeks
crisis due to possible false negative immediately after - How you treat?
hemolysis  <8years: Rifampicin+ bactrim
 >8 years doxycycline +rifampicin for 6 weeks
N.B factors  bactrim
 18

- How you assess for cure? Culture and CRP - Diuretic over use and laxative
What cause need referral to sub specialist?
N.B for serious neuro brucellosis and endocarditis : for 3 to - You mean nephrologist?
st st
12 months add gentamycin 1 2 weeks, ceftriaxone in 1 2-4 - It’s Barrters syndrome
weeks

Case 71
10years old child with 2months history of abdominal pain and CASE 73
increasing vomiting, Approach?? 12 years old with recent reduction in school performance
- Vitally stable? Yes Any evidence of chronic illnesses CKD: No
- Any history of constipation?? Differentials?
- What do you mean by constipation? - Hypothyroidism
- Infrequent Passage of hard stool, Or pain-full deification. - Hearing loss
Yes - Visual loss
- Any soiling?? No - Psychological
- What are differential? - Maternal deprivation, parents divorced
- Either non organic(functional) - Deaths of members of the family
- Dietary, low fibers with holding behavior - Epilepsy
- Decrease fluid intake - Wilson disease
- Organic How you diagnose Wilson?
- Spinal cord lesion lumbosacral - Itinerary ceruloplasmin
- Mega colon - Serum coppers and ceruloplasmin
- Sub acute or chronic IO - Ophtalmo examination : Kayser Fleischer ring
- He interrupted me and ask, MMT
- Dis impaction TRT: chelation by D- penicillamin or Zinc salt
- How?
- Fleet enema
- For how long? 4 to 7 days
- Then movicol treatement
- Adjusting dose according to response
- Dietary control
- Increase fluid intake
- Regular bowel opening with behavioral therapy
- For how long movicol? 3 to 6 months
-
CASE 72
3 months old infant with diarrhea for the last 2 months
He is on amino acid based formula without?
Diagnosis differential?
- Any peri anal excoriation? Why? To know if it’s acidic
diarrhea or alkaline
- Infectious
- Post infectious
- Congenital chloride loosing diarrhea
Then he asked, How can you diagnose CCLD?
- History examination and investigation
- Chronic diarrhea
- Exclude food milk soya, allergy, infection and post
infectious causes
- Then high chloride in stool
- Low or normal serum chloride
- With metabolic alkalosis
What are the causes of metabolic Alkalosis??
- Cystic fibrosis
- Pyloric stenosis
- Excessive vomiting