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Full Chapter Basis of Pediatrics Tenth Edition Pervez Akbar Khan PDF
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SISYV
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NISHTAR
PUBLICATIONS
Model Town, Multan Tel: 0334-6344400 | 0321-2066562
© Nishter Publications (Pvt.) Ltd.
Basis of Pediatrics
by
Pervez Akbar Khan
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Copyright Holders.
This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, hired out or otherwise circulated
without the publisher's prior consent in any form of binding or cover other than that in which it is published and without a similar
condition including this condition being imposed on the subsequent purchaser.
Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment
and the use of drugs become necessary. The editors, contributors and the publishers have, as far as it is possible, taken care to
ensure that the information given in this text is accurate and up-to-date. However, readers are strongly advised to confirm that
the information, especially with regard to drug usage, complies with the latest legislation and standards of practice. Neither the
publisher nor the authors assume any responsibility for any loss or injury and/or damage to person or property arising out of or
related to any use of the material contained in this handbook.
Copyright © 2018
All Rights Reserved
(8
WR
NISHTAR
PUBLICATIONS
Model Town, Multan Tel: 0334-6344400 | 0321-2066562
ISBN: 978-969-791-631-3
Printed in Pakistan
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
dRf@zi (For free books visit - Library Genesis - libgen.is) FREE KNOWLEDGE FOR ALL!!!
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This book is written for undergraduates keeping in view their special requirements and their dire need of a small book
on Pediatrics. The main object of this book is to introduce the students with the elementary knowledge of Pediatrics and
to enable them to prepare for the examination. It may also be useful for internee doctors who opt to work in Pediatric
hospitals.
It is not meant to replace the standard textbooks of Pediatrics. Its topics have been carefully selected to include only
those aspects, which are either not touched upon or discussed in detail in Medicine. This has greatly helped me to limit
the volume of this book. Valuable suggestions and criticism will be greatly appreciated to this end.
Iam greatly indebted to my learned teachers, Prof. Shaukat Raza Khan, Prof. S. M. Haneef, Prof. Tariq Iqbal Bhutta,
Prof. Abdul Waheed Qureshi, and Prof. Fehmida Jaleel, who had great influence on me during my formative years. This
book reflects the salient features of the knowledge imparted to me during these years.
My gratitude is due to Dr. M. M. Zafarullah Kundi and Dr. Shukar Elahi for providing me the material and encouragement
in writing of this book. I am thankful to Dr. Muhammad Bakhsh Malik, for proof reading of this manual.
In the end, thanks are due to Mr. Karim Ullah Mazhar, for typing of this manuscript and Messer’s Caravan Book Center
for publishing it.
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
lam greatly indebted to students of Medical colleges and doctors working in children wards of different hospi-
tals who continue to look for a book which fulfill their partial needs and at time they have to refer to textbook
for further details. still feel the students complain of studying such a large book for preparation of their exam
|
and they require a brief version. The knowledge of pediatrics is ever expanding and have tried to limits its
|
volume to manageable size. For this have curtailed many detailed explanation of different aspects and
|
In have included the recent national statistics which were available from year 2017. In addition it
this edition |
was a great pleasure to get help from Dr Athar Abdul Razzaq to review neonatal section and include ail the
recent updates available and give it a complete newer look. Similarly Dr Muhammad Imran took immense
interest in updating Nephrology section and almost completely help us rewrite the section and including ail the
recent updates and brief essential new topics. It was a great effort on his part. |am also indebted to Dr Ghazi
Khosa who spared his precious time to revise the Gastroenterology and liver diseases section. {t will be
pleasure to get his help in future edition also. am extremely thankful to Dr Muhmmad Idrees who worked
|
meticulously to read the book and brought necessary changes from scrap and added almost more then fifty
paragraphs and cancel many diagrams which were unnecessary to limit the size of the book. He was also
responsible to bring all the necessary changes in this new edition. It was kind of him to spare his valuable time
from family life and medical profession. shall be failing in my duty if don’t mention the name of Dr Talat
| |
Pervaiz for valuable suggestion and Dr Asif Qamar Rana to taking the responsibility to draw the diagram of
growth and development and taking the responsibility to publish the book to international standards. hope |
i shall be looking forward to students and doctors for valuable suggestion and necessary ratifications of our
Prof Iqtadar Kh
Dean Mother and Child Health. Aga Khan Hospital,
Karachi
Peshawer
MMDC., Multan
Prof Salman /
oe
Quaid-i-Azam Medical College, Bahawalpur
Prof Fouzia Za
NMC, Multan
Dean Children Hospital Multan
Prof Samia Nat
Prof Mubarik Rawalpindi Medical College, Rawalpindi
Shaikh Zayed Rahim Yar Khan Medical College
Prof Tahir Maso
Prof Huma Arshad Children Hospital & institute of Child Health, Lahore.
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
3133
History Taking and Physical {es Behavioral and Psychiatric Disorders 70
Examination 1
Pica 70
Nocturnal enuresis 70
History 1
72
Encopresis
Physical examination 3
Attention Deficit Hyperactivity Disorder
Neonatal! reflexes 11
(ADHD) 73
(ey, Growth and Development 15 Autism spectrum disorder (pervasive develop-
Growth 15 mental disorder) 74
17 Tic disorder 75
Development
Red flags in development 24 Anorexia nervosa and bulimia nervosa........... 76
Puberty and the tanner stages 24
Growth charts 26 Pediatric Nutrition and Nutritional
Disorders 77
Immunization 35
Nutritional requirements 77
Definition 35
Infant feeding 78
Vaccine 35
Breastfeeding 79
Immunglobulins 35
Artificial feeding 82
Vaccination schedule 35
Weaning 83
Precautions and recommendations 36
Micro-nutrients and Macro-nutrients 84
Conditions which are not contraindicated to
Vitamin A 84
immunization 36
Vitamin D 86
BCG vaccine 36
Vitamin E 87
Poliomyelitis vaccine 37
87
Vitamin K
Diphtheria, Tetnus, and Pertussis (DTaP) 88
Vitamin Br
vaccine 37
Folic acid 88
Measles, Mumps, Rubella (MMR) vaccine 38
Vitamin C 88
Measles immunization 38
lron 89
Hepatitis B vaccine 38
90
Zinc
Meningococcal vaccine 39
lodine 90
Haemophilus influenza type B vaccine 39
90
Malnutrition
Pneumococcal vaccine 40
Classifications 92
Typhoid vaccine 40
Marasmus 94
Cholera vaccine 40
Kwashiorkor 95
Hepatitis A vaccine 41
Obesity and overweight 101
Rotavirus vaccine 41
Influenza vaccine 4) Fluid and Electrolyte Disorder 103
Varicella vaccine 41
Maintenance fluid therapy 103
Rabies immunization 42
Dehydration and replacement therapy 103
Social and Preventive Pediatrics 44 Sodium disorders 104
4)
Pakistan statistical data 44 Potassium disorders 106
Child rights 45 Acid-base disorders 107
Child abuse 45
Child neglect 47 Acutely ill Child 111
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
.
Drowning (submersion injury) Infectious Diseases 180
4
117
he
Head trauma (injury)
+
117
Acute diarrhea 180
Bal
Cholera 186
Neonatology 119
188
Shigellosis (bacillary dysentery)
Definitions nig Presistent diarrhea 189
History and examination of newborn infant... 119 Giardiasis 190
Neonatal resuscitation 121 Amebiasis 190
Care of the normal newborn infant 125 Typhoid (enteric) fever 191
Temperature regulation in newborn infant 125 Poliomyelitis 195
Hypothermia 126 Diphtheria 198
Hyperthermia 126 Pertussis (whooping cough) 202
Nutritional management of the newborn Tetanus 205
infant 127 Botulism 208
Total parenteral nutrition (TPN) 129 Measles 208
Birth asphyxia/Perinatal asphyxia 130 Mumps 212
Prematurity 133 Chickenpox (Varicella) 213
Causes of respiratory distress in the newborn infectious mononucleosis 216
infant 137 Malaria 217
Respiratory distress Syndrome (RDS) 138 Tuberculosis 221
Necrotizing Enterocolitis (NEC) 140 Rheumatic fever 229
Intraventricular Hemorrhage (IVH) 142 Dengue fever 234
Apnea 144 Leishmaniasis 236
Neonatal sepsis 145 Rabies 237
TORCH infections 148 Primary amebic meningoencephalitis
Toxoplasmosis 148 (Naegleria) 239
Rube a 149 Worm infestation (Helminthiasis) 240
Cytomegalovirus (CMV) 150 wi
Herpes Simplex Virus (HSV) 150 Respiratory Disorders 243
Tuberculosis 151 Choanal atresia 243
Hepatitis B virus 151 Acute Respiratory Infections (ARI) 243
Jaundice neonatorum 152 Acute pharyngitis 244
Unconjugated (indirect) Tonsils and adenoids 245
Hyperbilirubinemia 152 Acute epiglottitis 246
Conjugated (direct) Croup 247
Hyperbilirubinemia 159 Laryngomalacia 248
Post-term infant 160 Otitis media 248
Large for Gestational Age (LGA) infant 160 Bronchiolitis 250
Small for Gestational age infant (SGA) 161 Pneumonia 252
Meconium aspiration syndrome 162 Pleural effusion 256
Transient Tachypnea of the Newborn Bronchiecatasis 257
(TTN) 164 Pulmonary abscess 259
Hypoglycemia 165 Pneumothorax 259
Hypocalcemia 166 Asthma 260
Infant of Diabetic Mother (IDM) 167 Cystic fibrosis 266
Neonatal seizures 169
pea Gastrointestinal and Liver Disorders
Hemorrhagic disease of the newborn infant.. 171 te . 270
Anemia in newborn infant 172 Evaluation of a child with vomiting 270
Polycythemia in newborn infant 174 Gastroesophageal reflux disease 271
Neonatal thrombocytopenic purpura 175 Chronic diarrhea 272
Birth (trauma) injuries 177 Constipation 276
Neonatal conjunctivitis 178 Approach to abdominal pain 277
Peptic ulcer disease 278
Celiac disease 280
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
inflammatory Bowel Disease (IBD) 282 Generalized Seizures 347
Hepatomegaly 284 Partial Seizures 349
Acute hepatitis 285 Epileptic Syndromes 351
Acute viral hepatitis 285 Management of Epilepsy 351
Hepatitis A 285 Status epilepticus 354
Hepatitis B 286 Headaches 356
Hepatitis C 288 Migraine 356
Hepatitis D 290 Tension headache 356
Hepatitis 290 Headaches with increased intracranial
Hepatitis G 290 pressure 356
Fulminant hepatic failure 290 coma 356
Hepatic encephalopathy 291 Hydrocephalus 359
Autoimmune hepatitis 294 Dandy-Walker syndrome
Cirrhosis 295 (malformation) 362
Portal hypertension and varices 296 Intracranial Space Occupying Lesion
Liver abscess 297 (SOL) 362
Ascites 298 Intracranial tumors 362
Wilson’s disease 299 Brain abscess 363
Cholecystitis 301 Pediatric stroke 365
Acute pancreatitis 301 Cerebral Palsy (CP) 366
Acute peritonitis 302 Mental retardation 370
it Microcephaly 372
Cardiovascular Disorders 305 Ataxia 373
Fetal and neonatal circulation 305 Neurofibromatosis (NF) 374
Congenital heart disease 305 Tuberous Sclerosis 375
Cyanotic heart disease 307 Sturge-Weber Syndrome (SWS) 375
Tetralogy of Fallot (TOF) 307 Multiple sclerosis 377
Transposition of Great Arteries (TGA) 309
Ebstein anomaly 3i Neuro-Muscular Disorders 378
Total Anomalous Pulmonary Venous Duchenne muscular dystrophy 378
Drainage or Connections (TAPVC) 312 Myasthenia gravis 379
Truncus arteriosus 313 Fioppy infant 382
Tricuspid atresia 313 Spinal Muscular Atrophy (SMA) 383
Hypoplastic left heart syndrome 314 Degenerative disorders of CNS 383
Acyanotic heart disease 314 Sphingolipidoses 384
Ventricular Septal Defect (VSD) 314 Adreno-leukodystrophy 386
Patent Ductus Arteriosus (PDA) 316 Guillain-Barre Syndrome (GBS) 387
Atrial Septal Defect (ASD) 318 Bell's palsy 391
Aortic stenosis 319 Myotonic muscular dystrophy 392
Coarctation of aorta 319 Syringomyelia 393
Supraventricular tachycardia 320 Transverse myelitis 394
Congestive Cardiac Failure (CCF) 322
Infective endocarditis 325 Hematologic Disorders 396
Cardiomyopathy 327 Anemia 396
Myocarditis 328 Congenital Hypoplastic anemia 397
Diamond-Blackfan anemia 397
Neurologic Disorders 330 Transient erythroblastopenia of childhood 398
330 Microcytic anemia 398
Pyogenic meningitis
Tuberculous meningitis 336 (ron deficiency anemia 398
339 Beta-thalassemia 400
Encephaiitis
Cerebral malaria 342 Hereditary spherocytosis 403
Febrile convulsions 344 Sickle cell anemia 404
346 Macrocytic megaloblastic anemia 405
Epilepsy
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
Acquired aplastic anemia 406 Precocious puberty 451
Enzymatic defects 408 Delayed puberty 453
G6PD deficiency 408 Hypothyroidism 454
Fanconi anemia 409 Congenital hypothyroidism 454
Congulation defects 410 Juvenile (acquired) hypothyroidism 456
Normal Hemostasis 410 Thyroiditis 457
Hemophilia A 410 Hyperthyroidism 457
Hemophilia B 412 Graves disease 457
Von Willebrand’s Disease 412 Congenital hyperthyroidism 458
Consumptive Coagulopathy (DIC) 413 Hypoparathyroidism 458
Disorders of platelets 414 Pseudo-hypoparathyroidism 459
Albright hereditary osteodystrophy 459
Idiopathic Thrombocytopenic Purpura Hyperparathyroidism 459
(ITP) 414 Addison disease 460
Thrombocytopenia with Absent Radius (TAR) Congenital Adrenal Hyperplasia (CAH) 461
syndrome 417 Cushing’s syndrome 464
Blood transfusion 418 Diabetes mellitus 465
Acute Diabetic Ketoacidosis (DKA) 468
Neoplastic Diseases 421 Diabetes insipidus 470
Rickets 472
Leukemia 421
Acute leukemia 421
Metabolic Diseases 477
Lymphomas 426
Hodgkin Lymphoma (HL) 426 An approach to inborn errors of
Non-Hodgkin Lymphoma (NHL) 427 metabolism 477
Brain tumors in childhood 429 Glycogen storage disease 479
Neuroblastoma 430 Mucopolysaccharidoses 481
Wilms tumor 431 Hurler syndrome: (MPS |) 481
Retinoblastoma 432 Hunter’s syndrome: (MPS Il) 482
Bone tumors 433 Morquio syndrome: (MPS IV) 482
Osteosarcoma 433 Galactosemia 483
Ewing sarcoma 434 Phenylketonuria 484
Langerhans Cell Histiocytosis (LCH) 434
Splenomegaly 435 Reumatic Diseases 487
Lymphadenopathy 436 Juvenile Idiopathic Arthritis (JIA) 487
Systemic Lupus Erythematosus (SLE) 489
Immunologic Disorders 438 Neonatal Lupus 491
Evaluation of suspected Henoch-Schoniein Purpura (HSP) 492
immunodeficiency 438 Kawasaki disease 494
X-linked agammaglobulinemia 439
Common variable immunodeficiency 439 Pra Human Genetics 497
Digeorge syndrome (thymic hypoplasia) 440 Introduction 497
Servere Combined Immunodeficiency Chromosomal abnormalities 497
(SCID) 441 Down syndrome 498
Acquired Immune Deficiency Syndrome Edward syndrome 500
(AIDS) 442 Patau syndrome 501
Wiskott-Aldrich syndrome 444 Turner syndrome 501
Ataxia-telangiectasia 445 Klinefelter syndrome 502
Leukocyte adhesion deficiency 446 Single gene defects 502
Chronic granulomatous disease 446 Autosomal dominant inheritance 503
Autosomal recessive inheritance 504
Endocrine Disorders 448
X-linked recessive inheritance 504
Growth hormone deficiency 448 X-linked dominant inheritance 505
Short stature 448
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
Polygenic (multi-factorial) inheritance 506 Diaper dermatitis 549
Mitochondrial inheritance 506 Atopic dermatitis 549
Genetic counseling 506 Parasitic skin infections 550
Pre-natal diagnosis 507 Pediculosis 550
Fragile X syndrome 508 Scabies 551
Laurence-Moon-Biedle syndrome 509 Erythema multiforme 551
Prader-Willi Syndrome 509 Stevens-Johnson syndrome 552
Beckwith-Wiedemann syndrome 509
Noonan syndrome 510
Williams syndrome 510
Pediatrics Surgery 554
Vacterl association 511 Cleft lip/cleft palate 554
Charge syndrome 511 Esophageal atresia and trachea-esophageal
Pierre Robbin sequence (syndrome) 511 fistula 555
Duodenal atresia 557
Nephrology 512 Biliary atresia 558
Laboratory Evaluation of renal function 512 Meckel’s diverticulum 559
Imaging of urinary tract 513 Intussusception 560
Congenital anomalies of the kidney and Hirschsprung’s disease (congenital aganglionic
urinary tract (CAKUT) 513 megacolon) 561
Clinical evaluation of hematuria 514 Neural tube defects 562
Immunoglobulin A nephropathy Cryptorchism (undescended testes) 563
(Berger Disease) 516 Inguinal hernia 564
Acute post-streptococcal Acute appendicitis 564
glomerulonephritis 516 Posterior urethral valve 565
Hemolytic uremic syndrome 519
Poisoning and Toxicology 567
Henoch-schonlein purpura 520
Lupus Nephritis 521 General management 567
Nephrotic syndrome 522 Acetaminophen (paracetamol) poisoning 568
Idiopathic nephrotic syndrome 523 Ibuprofen poisoning 569
Secondary nephrotic syndrome 525 Aspirin poisoning 570
Congenital nephrotic syndrome 526 Calcium channel blockers toxicity 571
lii71V HOS FOGIIMONY (sruebqi - sisouey Avesgi] - WSIA Syood 404) IZOsYpP
dRf@zi (For free books visit - Library Genesis - libgen.is) FREE KNOWLEDGE FOR ALL!!!
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0€9 SUONRRIAZIQGY JO 3SI7
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68S Adevayy Snug 2143e1pad Be:
"ni Progression
History should be taken on the same pattern as in Relieving factors
0
adults but it differs in the: Exacerbating factors
6
1. Birth history Diurnal or seasonal variations
0
2. Feeding/nutrition history Associated symptoms
0
3. Vaccination history Contact with a case of communicable diseases e.g.
0
4. Developmental history tuberculosis and measles
e If symptoms point to a disturbance of a particular
Commonly, history is taken from the mother. Some
relevant points may be asked from an older child. organ system, then ask specific questions relating to
that system.
Always listen to the mother’s complaints and do not
interrupt her before asking the relevant questions. e Some general questions given below provide useful
First of all, introduce yourself to the patient/attendant. information:
Do not keep looking at your watch or notes in front of General i
you. Pay full attention to mother and child. e Weight loss
During history taking, keep watching everything the e §©Appetite
child is doing and also his/her reactions.
The name, age (or date of birth), sex of the patient and
address of the parents, etc., is recorded. e Shortness of breath on exertion
e Shortness of breath and sweaty on feeding
PRESENTING COMPLAIN
Record the immediate important complaints, which led
e Cyanotic spells (blue episodes)
the parents to seek medical advice. e Squatting
The chief complaints should be recorded in a e Chest pain or palpitations (rare)
chronological order i.e. complaints with longest e §=6Fainting or syncope
duration are mentioned first and complaints with e Cyanosis
shortest duration are mentioned last. For example: e Edema
Loose motions 15 days
© Vomiting 5 days thy
e «Sore throat
Oo Fever 2 days
e Earache
© Use the parents’ own words.
e Cough (nocturnal, in relation to exercise, productive,
HISTORY OF PRESENT ILLNESS |...) ins dry)
It isthe detailed description of the chief complaints e Wheezing (nocturnal, exercise induced)
with duration and their order of appearance. e Frequent chest infections
Enquire as to when the patient was last entirely well. e History of aspiration
There should be a daily documentation of events e Hemoptysis
leading up to the present time, including signs,
symptoms, and treatment, if any.
Deeper inquiry about important symptoms must be e Abdominal pain
made regarding: e Vomiting
Cc Time of onset e Jaundice
Site Diarrhea or constipation
9
e
Duration Blood in stool
90
e
Frequency
Severity
iiiT1V YOd FOGIIMONY (sruebqi] - sisoued Alesqs7 - ySiA Syoog 9e4 10-4) IZOsYP
CHAPTER 01
Whether she has taken iron, multivitamin tablets or
Fits any other drugs during pregnancy
Syncope, dizziness Enquire if mother has suffered from any illness during
Headaches pregnancy, e.g. hypertension, diabetes mellitus,
Visual problems preeclampsia, antepartum hemorrhage or infections
like rubella, urinary tract infections, syphilis,
Numbness, unpleasant sensations tuberculosis, etc.
Weakness, frequent falls Any history of exposure to irradiation (X-rays) during
Incontinence first trimester
in the past obstetric history, enquire about the
problems with previous pregnancies, stillbirths or
Stream
miscarriages, birth weight of previous children,
Dysuria prematurity and blood transfusions
Frequency Enquire about maternal vaccination against tetanus
Le
Nocturia, enuresis
Natal history (histobyidif del
Incontinence
Whether the delivery was conducted at home or in the
Hematuria
hospital
in Delivery conducted by a midwife, trained health visitor
Limp or a doctor
Joint swelling Technique of sterilization of instruments
Skin rash Length of gestation
Dry mouth or mouth ulcers Time of rupture of membranes
Dry or sore eyes Duration of labor whether prolonged or precipitated.
Hair toss Presentation and type of delivery, i.e. spontaneous
Cold extremities vaginal, forceps, vacuum extraction or cesarean
section
Any history of sedation or analgesia given to the
Enquire about the past illness, which can have mother during labor and any abnormal bleeding
relevance to the present one or present state of health
of the patient.
Also enquire about the medications taken previously Whether the child cried immediately after birth or was
and their side effects. cyanosed and apneic
Also enquire about the infectious diseases he/she has Need for resuscitation at birth and any problem with
suffered from and any complications thereof. respiration, sucking or swallowing
History of similar complaints in the past is also helpful. Any history of convulsions, fever, jaundice or rash after
birth or in the neonatal period
Ifhospitalized, check medical records.
Any procedures such as exchange transfusion,
BIRTHHISTORY fie umbilical artery catheterization undertaken or drugs
If the patient is neonatal, genetic, or developmental
a given during neonatal period
case, more detailed birth history is required regarding al!
miscarriages, terminations, stillbirths, or neonatal
deaths. Onset of feeding, i.e. how many hours after birth first
feed was given
Birth history should be taken under following three
Whether breast-fed or bottle-fed
headings:
1. Antenatal history Duration of breastfeeding
2. Natal history
At what age formula milk feeding was started.
Aisin
Any vitamin or iron supplements given
Antenatal history (history
Gf When solids were introduced in the diet, their nature
Health and nutritional status of the mother during and amount
pregnancy Current diet
4 CHAPTER 01:
Any dysmorphic features Lymph nodes (cervical, axillary, and inguinal) are
0 0
@
Pallor examined.
e §6Skin is examined for abnormal pigmentation, any
Cyanosis
evidence of bleeding (petechiae, bruises), perfusion,
Plethora
and dehydration.
Jaundice
0000
Edema
and size of lesions. Rash may be vesicles, papules,
Gait while the child is running around macules, petechiae, scratch marks, or ulcers.
Vital signs are monitored. These include: e Genitalia are also examined.
© Temperature
Fontanel een Wh
oO
Respiratory rate
Anterior closes by 18 months
© Pulse or heart rate
Posterior closes by 3-6 months
© Blood pressure or skin perfusion
Early closure: CP, hyperthyroidism Craniosynostosis
Oral temperature measurements are used in children
older than 5 years. In young children and infants, Delayed closure: Hypothyroidism, rickets, malnutrition
thermometer can be placed in the axilla or groin.
Temperature in the axilla or groin is about 0.5°C lower
Size, Shape
and the rectal temperature is about 0.5°C higher than
the oral temperature. Normal children have Large head:>3 SD above mean for age sex hydrocephalus
temperature between 36.5°C-37.5°C. Temperature is Small head:<3 SD below mean for age sex CP,
1°C higher in infants than in older children. Craniosynostosis, TORCH
Table Loi. Moreielpuler ae
se. Sutures all he,
Pulse (per Blood pressure Doses by 6 months of age
Age
minute) (mmHg) Delayed closure hydrocephalus
35-60 mean pressure
|
Newborn 120-160
|
by flush method.
|
'
— |
f
{
|
Up to 1 year 80-140 ~—''-
80/55
|
|
e
me
HHHEME
HAIR
e any cleft lip or cleft palate.
§©Note
Normal Consolidation
sea i Cavitation
iTaky a) |
e Examine the patient from the foot end of the bed and Local flattening Collapse
then from the right side of the chest and comment as e Fibrosis
follows:
a
Local bulging Pleural effusion
Pneumothorax Reduced on affected side Consolidation
Cavitation |
airway disease
_
Neonate 30-60 :@ Interstitial lung disease
Tenderness |
Stony dull e Pleural effusion
Crepitus
Palpable sounds
PVUrvallie-beteys)
hi
Auscultate early in the examination while the child is
Table 1.4: Tracheal ¢ spiacement.
cooperative.
None ~~
Consolidation Auscultate over supra-clavicular areas, upper, middle,
Cavitation and lower chest on both sides.
Bronchial asthma
:@ Following points are noted:
Chronic obstructive
© Breath sounds (intensity, character, i.e. vesicular
airway disease
|
Inspection mere
,
Bronchial ¢ Consolidation ¢ Look at the whole child.
Cavitation © Following points are noted:
|
:
bronchus
ie Fibrosis © Bulging of the precordium. Anterior bulging of left
|
@ just above a pleural |
|
a i
Palpation inal!
Vesicular e Interstitial flung disease
e Following points are noted:
|
® Cavitation |
Pectusexcavatum
i
:
I
bronchus |
Fibrosis .
Dextroposition (pulmonary
|
fibrosis, diaphragmatic
-
Reduced ° Collapse |
hernia)
|
Sustained
Pneumothorax |
vs
|
;
Percussion tik Bes
CARDIOVASCULAR SYSTE
e Percussion is sometimes required to assess cardiac
e Pulse is examined and rate, rhythm, volume, and
enlargement, pericardial effusion or cardiac
character are noted. Comparison with other pulses is
displacement.
important to note radio-femoral delay. Lift the arm to
feel the collapsing pulse.
Blood pressure is recorded.
Auscultation i ;
e e Auscultate all the four cardiac areas. Begin
@ Neck veins are examined. auscultation from the apex. Take care to palpate the
e Ensure adequate exposure of the precordium. right carotid pulse simultaneously for timing the
various cardiac sounds.
e §=6Alwayslisten at the back. Innocent murmurs do not
radiate to the back.
1. Symptom free
e Following points are noted:
1
§=
3. Short
sounds). Presence of third heart sound or gallop
rhythm indicates heart failure and friction rub 4. Soft.
indicates pericarditis.
5,
6
over a Small area
© Murmurs (timing, intensity, site of maximum Heard ronlya
intensity, radiation, character, pitch, effect of sound
respiration, effect ofposture). split ;
|
Pectusexcavatum)
Soft 1" and 2™ heart sounds | @ Pericardial effusion
9. No other Signs
abnormal
Loud 4° heart sound ASD
tests
(ec: xR):
or normal
t
|
@
Pulmonary stenosis
Loud A2 ;@ PDA
e Systemic hypertension Mid diastolic @ §6Mitral stenosis
|
Soft 2"¢ heart sound Pulmonary stenosis Early diastolic e Aortic regurgitation
Soft P2 Aortic stenosis Pulmonary regurgitation
Soft A2 Aortic regurgitation
|
Fixed split of 2" heart sound
*
e §6°ASD
Grade Murmur audible with great difficulty in a |
|"
|
|
:
|
:
quiet room
*
Single 2" heart sound TOF
Pulmonary stenosis ‘Gradetl —»Murmureasily ly audible but not loud.
murmur without
:
Grade IV Loud murmur with a
thrill
Aortic area Pulmonic area
ca
Grade V Very loud murmur, audible even outside
the:
precordium
Vi
audible
9
|
el,
|
Er
A7)
po
Nios
Inspection [
Following points are noted:
© Shape of abdomen (normal, scaphoid, distended).
In abdominal distension, skin is tense, shiny and
bleeding, etc.
Hernial orifices. Ask the patient to cough at this
Oo
Ask the patient whether there is pain abdomen at any Neurological assessment differs in infants and children
part of abdomen. according to the functional maturation of the nervous
Kneel on the floor or sit on a chair before you begin system. It depends on the child’s age and willingness
palpation. At all times look at the patient’s eyes to to cooperate.
check whether he or she feels pain. In infants various neurological reflexes and
Begin with the superficial palpation and begin in the developmental milestones represent the stage of
least tender area. development.
Palpate in all four quadrants. The higher mental functions, state of consciousness,
Following points are noted: speech and gait are assessed routinely in children.
i. Light palpation to note any rigidity, guarding or In infants, great information can be gained from
Cranial nerves
4, Check hernial orifices. = Motor system
Percussion f <=
Sensory system
Percuss far any palpable viscera or mass, fluid thrill Cerebellar signs
and shifting duliness. Signs of meningeal irritation
Auscultation ceo
Auscultate abdomen for 3-5 minutes for presence or Note appearance and behavior
absence of bowl sounds. Note their intensity. Assess orientation in time and place
Rectal examination Assess conscious level (Glasgow coma scale}
Tell the examiner that you "would like to perform a Evaluate memory and general intelligence
rectal examination and external genitalia.
Spontaneously 4
Eye Opening
omer
|
To verbal command To shout 3
To pain To pain 2
_ No response No response ,
a
Obeys |
Spontaneous 6
Localizes pain 5
Flexion-withdrawal 4
Motor Flexion-withdrawal ; ;
Response Flexion-abnormal (decorticate rigidity} Flexion-abnormal (decorticate rigidity) 3
|
No response No response “4
>5 Years |
2-5 Years 0-23 months
Disoriented/confused
|
Verbal Inappropriate words Persistent cries and screams | Persistent inappropriate crying 3
No response No response |
No response 1
|
Minimum score = 3
Maximum score = 15
Mild head injury = GCS 13-15
Moderate head injury = GCS 9—12 ;
;
Neuron paralysis —_—snneuronparalysis
e Bulk and nutrition of muscles is noted. Look for Bulk and nutrition | No wasting Wasting
wasting or hypertrophy.
* Muscle tone is assessed by resistance to passive Power _ Groups of muscles Individual muscles
,
Intention tremors
Superficial abdominal reflexes and cremasteric reflex
0
e
are also elicited as in adults. Rebound phenomenon
G6
coordination.
e Involuntary movements are noted. If present, note Signs of meningeal irrita mi
the type of involuntary movements and part of the e These include:
body involved. Oo Neck rigidity
© Kernig’s sign
0 No
© Brudzinski’s
sign
contraction
Fcker of contraction
¢ Presence of neurological reflexes is unique in the
2 Active movement, with gravity eliminated .
examination of nervous system in infants.
ge
3 Active movement against gravity e Primitive reflexes should disappear by 4—6 months of
age. Their persistence indicates significant neuro-
4 _
Movement against resistance developmental dysfunction.
Primitive reflexes |
(ii)
Grasp/plantar Birth 4-6 months
|
7
|
Stepping/placing Birth
|
4-6 months
|
lhe
Gallant Birth 6-9 months
|
yt
Tonic neck Birth 4-6 months
Grasp reflex
Landau 6-8 months 15 months-2 years
e palmar grasp elicited by placing the forefinger in
=6The is
i
the palm of the infant’s hand.
Parachute 6-8 Persists e The infant’s fingers will rapidly flex around the
months
examiner’s finger maintaining a grip.
Moro reflex vile:
e It iselicited by placing the infant supine upon the
examining table and allowing the head (supported by
the examiner’s hand) to drop 10-15 degrees.
e The reflex consists of abduction and extension of arms,
opening of the hands, and then adduction and flexion
ly
iii
of the arms as in an embrace.
i
e It is established after about 28 weeks of fetal life and
disappears at 4—6 months after birth.
e It is exaggerated or absent in a child with cerebral
irritability.
e It is decreased or absent in hypotonia.
e The response is asymmetrical if there is Erb’s palsy,
fracture of humerus or clavicle or spastic hemiplegia.
|
The pla tar grasp similariv ca_ be elicited by pressure
at the head of the metatarsals of the infant’s foot. The
>
toes will flex.
e This reflex is present at birth and disappears by 4-6
months of age.
é>
Placing reflex
ain e The baby is held vertically with the back against the
examiner; the dorsal part of one foot is moved forward
so that the dorsum of the foot touches the
undersurface of the edge of the table. The baby will
Doll’s eyereflex | Uli:
Mi! flex the knee and bring the foot up as though trying to
e Turn head slowly to right or left watching position of step on to the table.
the eyes. e is present at birth and disappears at about 4-6
§6|t
a | |
months of age.
walk.
e With baby in supine position, this reflex is elicited by
¢ Term infants will walk on the entire sole of the foot,
rotating the head to one side. There is extension of the
whereas preterm infants often on their toes
arm and leg on the side to which the head is rotated
and there is flexion of the arm and leg on the
contralateral side.
e Normally, it persists up to 3 months of age but if it
persists beyond 6 months then there is possibility of
spastic cerebral palsy.
iti
ney "iy
Infant is held prone by placing the hands underneath
the abdomen.
elicited by holding the
It is prone position and
the The normal response consists in slight extension of the
stroking with finger at the back parallel to the
first on one side and then on the other side. head, trunk and hips; and on flexion of the head there
spine,
is flexion of the trunk and hips.
e The trunk is curved towards the stimulated side.
It appears at 6-8 months of age and disappears at 15
® itis present at birth and disappears at 6-9 months.
months-—2 years of age.
~
<8
“4
Ne 1)
Parachute reflex iH
The infant is held prone as above, and allowed to fall
e The sole of the foot is pricked with a pin. few centimeters by displacing the hands downward.
e There is rapid flexion of the hip, knee and foot as to There is extension of arms, hands and fingers as he is
withdraw the foot from obnoxious stimulus. going to fly.
It appears at 6-8 months of age and never disappears.
age.
e §=It
| i
the change in size resulting from increase in the
is
The increase in weight is approximately 30 g/day or
200 g/week during first months and 150 g/week up
3
e 1 year 21 10
importance in relation to a sick child. 2 years 28 12
e Diseases tend to have more impairment when they 3.5 years 35 15
:
extrinsic factors are nutritional status, climate, season, 1-6 years x 5]+17 (year) x 2)+8
[age (year)
'
Birth 50
It means brain grows rapidly initially but after age one
1 year 75
2 years 85
year it slows down and increases minimally after age 5
3 years
years.
95
For measurement of head circumference, a tape
:
4 years .
100
measure is used which is not stretchy.
Most prominent part of the occiput to the most
Table 2.4: Porniwias*or eoproxiirvaie average height of
normal lafants gan chicren prominent part of the forehead is measured. Three
measurements are taken.
Age Centimeter Inches Record the largest of the three measurements as the
head circumference.
At birth 50 20
e Itincreases rapidly during infancy. Second molar 25-33 mos. 1G-12 yrs.
e lf head circumference is smail, then it should be Canine (cuspid) 47-23 mos. 9-12 yrs
Latera! incisor 10-16 mos. 7-8 yrs.
related to overall size and weight of the body. Smaller
Central incisor 6-10 mos. 6-7 yrs
babies tend to have smaller head. In preterm babies
head is proportionately larger than the overall size of
the body. Figure 2.1: Approximate 2¢2 for
delayed of veciduous teet
e Normally, head circumference is larger than the chest
circumference at birth. But chest circumference hypothyroidism, rickets, malnutrition
increases in size to become equal to head
circumference at one year of age and is larger
thereafter.
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"Onko Mrs Whitman hyvin sairas?"
Hän oli jo kuistin reunalla, kun hän huomasi, että jokin olento
liikuskeli vähän matkan päässä pimeydessä.
"Mrs Whitman. Eräs mies ratsasti tästä ohi pari minuuttia sitten.
Mrs
Whitman tarvitsee lääkärin apua."
Hän vihasi miestä senvuoksi, että tällä oli tuo voima hallita, vallita
joka tilanne ilman ponnistusta, luonnollisesti, ikäänkuin ei muuta
mahdollisuutta olisi olemassakaan. Hän vihasi häntä sen vuoksi, että
mies tiesi tarkalleen kuinka hän koetti taistella tuota vetovoimaa
vastaan ja hän vihasi häntä juuri sen vuoksi, niin katkerasti, että hän
sielussaan myönsi, että miehen oli onnistunut tehdä itsensä
mielenkiintoiseksi hänelle.
Nyt aikoi hän hallita, sillä hän oli päättänyt näyttää miehelle, ettei
hän hyväksynyt hänen julkeuttaan, jolla hän niin tyynesti vaati
itselleen voiman ja käskijävallan käyttöä.
Denver oli ontunut omia teitään kuistille. Hän seisoi nyt lähellä
Brannonia, samassa valopiirissä. Hän oli ääneti ja hänen kasvonsa
olivat ilmeettömät, mutta hänen mustat silmänsä olivat varuillaan ja
hänen katseensa liukui Josephinesta Brannoniin ja hänen ohitseen
seurusteluhuoneeseen. Hänen jalkansa oli yhä siteessä.
Josephinen ääni oli kylmä ja käskevä ja hän tiesi, että siinä soi
hitunen kostonhaluakin.
Ilme oli niin lyhytaikainen ja ovela, että ennen kuin Josephine sai
sen selväksi tajussaan vastaista harkintaa varten, oli se jo kadonnut
ja Brannon katseli häntä tyynenä, tarkkaavana.
"En", vastasi Denver hitaasti. "Luulen, että hän sai niellä asian."
Sanoilla "niellä asian" tarkoitti hän varmaankin, että Brannon ratsasti
nopeasti. Josephine tuumi kuinka pitkä aika hyvältä ratsastajalta —
esimerkiksi Brannonilta saattoi mennä Willetiin ja hän ajatteli miten
Ben Whitman pystyisi hoitamaan äitiään, kunnes lääkäri saapuisi.
Kolmekymmentä viisi mailia. Se merkitsi seitsemänkymmentä mailia
yhteensä. Se merkitsi myös sitä, että Mrs Whitman saisi kärsiä vielä
monta tuntia.
Yhdeksäs luku.
Josephinestä oli Denver kuin toinen ihminen. Hän oli tällä hetkellä
niitten näkymättömien vaarojen ruumiillistuma, jotka häntä olivat
uhanneet aina Lawsonin karjatalolla olonsa ensi hetkistä asti. Hän oli
vaara itse, jonka hänen harhaileva mielikuvituksensa oli kehittänyt.
Hän oli sen lupauksen täyttymys, jonka aava aroseutu oli antanut.
Hänen silmissään kuvastui seudun julmuus ja hänen käytöksessään
oli maan karu, raaka voima.
"Kas niin", sanoi hän. "Ajattelin tässä, että te tuskin käsititte, mitä
Brannon tarkoitti. Ette kai tullut ajatelleeksikaan sitä, vai? Te
kohtelitte häntä kuin koiraa. Se on naisten tapa. Heillä ei ole
paljoakaan järkeä, ja sen vuoksi miesten on niin helppo saada heidät
valtaansa. Jos te aiotte jatkaa minun kanssani samaan tapaan, niin
minä syön teidät elävältä! Ymmärrättekö?"
Hän ei voinut uskoa, että kukaan mies uskaltaisi yrittää sitä, mikä
selvästi paloi Denverin silmissä.
Denver naurahti.
"Te olette järkevä", sanoi hän. "Ei maksa vaivaa panna vastaan."
Kun Josephine kääntyi, ajatteli hän Chongia. Betty oli siis ollut
oikeassa, kehuessaan hänen luotettavuuttaan; hän oli tullut kreivin
aikaan.
"Te olette oppinut jotakin, Miss Hamilton", sanoi hän. "Te olette
oppinut, että mies ei aina tarkoita sitä mitä hän sanoo. Minä koetin
saada teitä ymmärtämään, ettei ollut turvallista jäädä karjatalolle
Denverin kanssa kahden. Mutta te olitte päättänyt noudattaa omaa
mieltänne."
"Callahan?"
Ehkä hän tunsi, että Brannonin voima oli kerran musertava hänen
vastustuksensa, että hänen tahtonsa, taistellen viimeiseen saakka,
kuten nytkin oli myöntyvä hänen tahtoonsa. Hän ei ainakaan aikonut
antautua. Brannonin hallitseva, alkuvoimainen lujuus, joka aina
ilmeni hänen joutuessaan vastakkain Josephinen kanssa, hänen
julma, häikäilemätön valtiutensa, joka piili hänen sileän,
metallimaisen ulkokuorensa alla, elämän kovuus tässä maailman
kolkassa, alaston julmuuden uhka, jota tuulen henkäykset kaikkialta
puhalsivat hänen kasvoilleen, kaikkea tätä hän kauhistui.
"Te olitte siis vakoilemassa", sanoi hän, "ja näitte tuon ratsastajan
—
Callahanin? Ja minä otaksun, että te kuulitte, mitä hän minulle
sanoi?"
"Niin on asianlaita."
"Miksi te teeskentelitte?"
"Lähetin Chongin."
"Chongin!"
"Miksi ette sitten — miksi sitten sallitte hänen —" hän keskeytti,
punastuen suuttumuksesta.