Nutrition

.......
......
Nutrition DR. Abo-Asrar

:

: : :
:

Nutrition
Infection neonatology

Nutrition

,,, Nutrition

,,,

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nutritional disorder
pure
Genetics

,,,
,,,

Nutritional disorder
marasmus Kwashiorkor
Rickets
,,,

,, full sheet
full history examination
discussion examiner
Direct face to face
,,, discussion

,,
no excuse
,,,

,,,
Nutritional disorder fatal
Nutritional disorder fatal
: ,,
,,,
,,,
,,,
,,

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Pure written
clinical
written

,,

Tetany
tetany
Nutritional assessment
title nutritional disorder
written
,,,
Hyper vitaminosis D
D
Hypo Hyper vitaminosis

,,, written
Hyper vitaminosis D
dose vitamin D

written
written
clinical
clinical written
,, written
written clinical
,,,
Rickets
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Marasmus Kwashiorkor
Rickets Marasmus Kwashiorkor
Rickets

% 80

,,,
Rickets
Rickets
rickets
rickets
23 22
basics bone
bone

) (

bone
Medulla
cortex
bone medulla cortex
medulla hematology

cortex
,,
cortex

cortex
,,, Protein part
cortex protein
protein soft tissue osteoid tissue
Protein part cortex soft tissue part
bone
osteoid tissue
,,, bone
matrix
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,,
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cement
Mineral part
Mineral part
Ca phosphate

,,

,,,

,,,

cement
Ca phosphate
,,
,,
,,
,,,

,,,
,,
collagen fibers
collagen fibers

cortex
fragile bone ,,,

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fragile
liable to fracture
,
,,,

protein part
part
osteoporosis
osteoporosis
defect protein part
bone
osteoporosis
defect protein part bone
osteoid tissue

Protein part bone

protein deficiency
Marasmus
Kwashiorkor


,, Muscle muscle
muscle ,,, bone
bone
Osteoporosis
bone osteoporosis
,,
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mineral part
mineral part

Rickets
rickets defect bone mineralization
rickets defect mineral part of the bone

adult Osteomalacia
Rickets
Osteomalacia
Osteomalacia defect in mineralization of the bone
Rickets defect in mineralization of the bone
,,,
collagen fibers

Liable to fracture
bone diseases
X -ray
Osteogenesis imperfecta ,,,

collagen fibers supporting bone
bone diseases
,,, osteogenesis imperfecta
X - rays

,, defect cortex
Protein part cortex osteoporosis
Mineral part bone rickets
collagen fibers supporting bone
osteogenesis imperfecta

rickets
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defect mineralization of the bone

Mineralization of the bone
,,, Mineralization of the bone

,,,

,,

,,
,,

,,, Mitosis apotosis
,,
mineralization of the bone
,,,
mineral part

active functioning

,,, New bone
bone

Mineral part

,,,

,,,

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,,,
,,,

osteoblast cell
osteoblast cells ) (
Osteoblast New bone

deposition of calcium and phosphate inside the bone
New bone formation
,,,

Osteoclast cells
,,,
Osteoclast bone
osteoblast bone
Osteoblast osteoclast
) (
Branched cells
branched cells ,,,

bone marrow
Osteoblast osteoclast bone marrow
bone marrow stem cells
stem cells bone marrow
osteoblast osteoclast
,,,
colony
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Dendritic cells
Dendritic cells
dendritic cells
dendritic cells generation stem cells of the bone marrow
bone marrow
osteoblast new bone formation
osteoclast old bone

,,
Mineralization of the bone
osteoblast
osteoblast osteoblast
New bone formation
Patho physiology Rickets
patho physiology Rickets
,,,
) (

10 2012

Ca metabolism
vitamin D metabolism biochemistry
Rickets
vitamin D deficiency

Patho physiology and clinical manifestations of
rickets
,,,
Osteoblast
bone
10
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osteoblast
dendritic cells
dendritic cells
nucleus

,,,

Osteoblast ) (
Osteoblast blood
bone Mineralization bone
vesicle

vesicle
vesicle blood
bone Phosphorus
vesicle

blood
,,,
In organic

phosphorus In organic
chemistry

In organic
phosphorus is in organic
calcium phosphorus osteoblast

11
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vesicle Osteoblast
Ossification calcification osteoblast
osteoblast
,,,,
osteoblast
vesicle

,,
,,
Phosphorus vesicle
phosphorus vesicle Organic phosphate
Organic phosphate
Phospho ethanol amine

Phospho ethanol amine
phospho ethanol amine
Organic organic phosphate
Phosphorus In organic
Organic form
Organic phosphate
Organic phosphate Phospho ethanol amine
vesicle
in organic
phospho ethanol amine organic

,,
New bone formation osteoblast
,,,

osteoblast

,,,
12
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osteoblast
vesicle cell membrane

vesicle cell membrane
bone matrix
Organic phosphate

bone matrix
Organic phosphate
bone matrix

,,,
New bone
,,, cytoplasm osteoblast

osteoblast
cytoplasmic enzyme cytoplasm
organic phosphate In organic form
phosphorus

Alkaline phosphatase
,,,
cytoplasm osteoblast
alkaline phosphatase
alkaline phosphatase organic phosphate
in organic phosphorus

In organic
bone matrix
In organic
Phosphorus In organic

bone

bone
13
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calcium phosphate
) ( ) (
bone crystals
calcium apatite crystals

,,,
,,

,,,
,,

crystal
calcium apatite crystal

,,,

)
(
crystals
,, technology
dynamics
,,

Underlying physiology
,,
Physiology
Manual worker

,,,
,,
Manual worker
14
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bone mineral density

Mineral part
,,,
,,
fracture
Non manual worker

,,

manual worker
Mental worker
,,
manual work vast activity

bone

,,

,,,

fracture
,,

,, fissure fracture

,,
comminuted fracture
,,

bone
15
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manual workers

muscular activity
Osteoblast
Osteoblast
,,

muscle origin Insertion
muscular activity
muscle contraction
origin Insertion
origin Insertion bone
bone
bone crystals

pressure

,, friction energy

Osteoblast
main stimulus inside the bone
friction bone crystals calcium apatite
crystals
calcium phosphorus crystals
muscle contraction
osteoblast
Osteoblast calcium phosphate
New crystals
,,
,,
bone fully saturated
16
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muscle contraction
crystals
crystals ,, ,,

Pressure

,,
,,

bulk

,,
,,
crystals

Osteoblast
,, saturation osteoblast

,,
,,,

,,,

17
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,,

,,

,,

,,

crystals bone

crystals bone

,,,
,,

,,
Rickets

phosphate
crystals
crystals
crystals bone rickets
,,
18
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,, Osteoblast activity
rickets
,,, Osteoblast alkaline phosphatase

organic phosphate ( In organic ( Phosphorus

crystals

serum
alkaline phosphatase serum

laboratory investigations
rickets
rickets alkaline phosphatase

Osteoblast hyperactivity
osteoblast hyperactivity
rickets
osteoblast
!!!! rickets
osteoblast

osteoblast hyperactivity

osteoblast alkaline phosphatase
alkaline phoshphatase
alkaline phosphatase rickets
osteoblast hyper activity
activity osteoblast
number of calcium apatite crystals
bone crystals bone

19
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friction energy
continuous stimulation Osteoblast

,,,
,,

:
:
:
,,
: rickets

:
osteoblast activity
Osteoblast activity
rickets!!!
:
calcium apatite crystals
,,

,,,

apatite crystals
friction energy
osteoblast
osteoblast alkaline phosphatse
20
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) (
rickets
Hypophosphatsia
Hypo phosphatsia
bone

organic phosphate
In organic form
bone
rickets rickets
,,, diagnostic investigation
Hypophosphatasia
alkaline phophatase
,, alkaline phosphatase
,, alkaline phosphatase
marasmus kwashiorkor alkaline
phosphatase
Hypophosphatasia

)
organic ( in organic

) phospho ethanol amine ( organic phosphate
bone

,,
Urine
urine
21
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diagnostic investigation
hypophosphatasia
urine
Organic phosphate
urine phosphorus
in organic

Organic phosphorus Urine
Hypophosphatasia
diagnostic investigation
urine
hypo phosphatsia

,,
Hypo phosphatsia
resistant rickets
,, ,,

,,,

calcium metabolism
Ca metabolism
Factors affecting calcium absorption
22 23
factors affecting calcium absorption
factors affecting calcium absorption

PH of the duodenum

22
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Calcium site of absorption first part of the duodenum
absorption
PH of the duodenum
calcium absorption
,,,
calcium absorption
Acidic PH
absorption acidic PH

,, acidic PH
alkaline PH
alkaline PH calcium absorption
,,,
,,
breast milk
nutrient
breast milk reaction
nutrient acidic alkaline
acidic alkaline
PH of the stomach
PH of the stomach
duodenum
acidity
calcium absorption
cow milk
reaction alkaline
alkaline calcium
cow buffalo milk
rickets

23
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calcium phosphorus ratio

absorption
calcium phosphorus ratio gut 1 : 2
1 : 1
,, 1 : 2
calcium phosphorus
absorption
calcium phosphorus ratio 1 : 2
,, exactly breast milk
breast milk
1 : 2
Level of absorption of calcium in breast milk
,, cow milk
phosphorus

excess phosphate
phosphorus calcium gut

absorption
cow milk
buffalo milk
rickets
PH alkaline
excess phosphate
excess phosphate
absorption calcium

gut absorption
content of the food
contents food
iron
protein vitamin C absorption
absorption
24
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,, absorption
vitamin C acidic
activity absorption
,,,
acidity
acidity
acidity
absorption
calcium
,,,
absorption
Phytate oxalate iron

absorption

,,,
Hormonal factors
Hormonal factors
metabolism
hormonal factors
hormone active form of vitamin D
dihydroxy cholcalciferol 25 ,1
vitamin D3
Active form of vitamin D
dihydroxy cholcalciferol 25 ,1
active form of vitamin D

,,
vitamin D
main goal bone calcium
Phosphorus
Osteoblast
calcium phosphorus
25
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bone
bone formation

serum calcium
serum calcium
bone
,, vitamin D

receptor GIT
receptors calcium and phosphorus absorption
,, receptors GIT
Phosphorus absorption
GIT

GIT
) (
GIT

kidney
Kidney re absorption of phosphate mainly
calcium
kidney phosphorus
,,
bone
bone
bone
osteoblast
activity
osteocalast
suppression osteoclast activity
26
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bone
stimulation osteoblast
suppression osteoclast
activation suppression cells
,, dominant

,,
peace maker heart
S. A. node
,,
decerbrated
brain death
Monitor beats
,,
neurologically died
heart
Normal peace maker of the heart
,,
peace maker
sympathetic
Para sympathetic
thyroxin
thyroxin ,,
,,
factors peace maker
,,
Osteoblast bone

,, Local dynamic

,, osteoblast
Osteoclast
new bone formation
27
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,, vitamin D
GIT
kidney

osteobalst calcium and phosphate
,,, bone
New bone
mineral part bone
rickets
osteomalacia

) (

)
(

,,,,

,,,

(
28
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vitamin D
Hyper vitaminosis D
D
vitamin D

,, calcium intake

vitamin D
,,,

vitamin D without with out calcium
viatmin D
vitamin D

Vitamin D GIT phosphorus
Phosphorus
tubules phosphorus
Osteoblast
,,, bone
osteoblast activity
Osteoblast serum

serum calcium
serum calcium osteoblast
,,,
osteoblast serum calcium phosphate
new bone
serum calcium
Hyper vitaminosis D without ca supplementation
hypo calcemia
hypo calcemia tetany
tetany
29
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vitamin D

GIT Phosphorus
,,,
Osteoblast
Osteoblast

fully saturated

,,
,, Osteoblast
vitamin D
Osteoblast :

,,,
fully saturated

,, ,,
serum calcium
calcium
,, Phosphate
pathological calcification
Pathological calcification
urine phosphate
calcium phosphate
Oxalate
calcium oxalate stones
renal parenchyma
30
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Nephro calcinosis
vessels calcification
valves of the heart calcification
calcification
hyper calcemia
And metastatic calcification

Hypo vitaminosis D rickets

hyper vitaminosis D hypo calcemia and tetany
calcium supplemention
Hyper calcemia metastatic calcification
adequate calcium supplemention

para thyroid hormone
,,,, GIT vitmain D
,,,,
serum calcium
serum calcium

para thyroid calcium sensor
calcium receptor
calcium senosr serum clacium
8.5 10.5

,,
,, para thormone horomone
,,,
Para thormone hormone
31
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serum calcium
,,
,,,

bone
,,,
bone
suppression osteoblast
Hyper activity osteoclast
osteoblast
activity Osteoclast
,, bone

receptors kidney
Urine
urine
,,,
serum calcium
bone calcium
,,,
serum calcium bone calcium
serum phosphate
serum phosphate
,,
,,
urine
32
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calcium Urine
Phophate urine
calcium urine phosphate urine

calcium phosphate
bone calcium Phosphate
,,,,
serum calcium
serum phosphate
urine phosphate
urine urine calcium
calcium Phosphorus bone
rachetic manifestations bone

,,
calcitonin ,,

Ultra violet rays
,,,
,,

dark races
,,

ultra violet rays
Nucleus

receptors Ultra violet rays
sensitivity ultra violet rays
33
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ultra violet rays

Ultra violet rays receptors ultra violet rays

sensitivity Ultra violet rays
,,,
extremities

,,

Ultra violet rays

,,,
Ultra violet rays
Ultra violet rays vitamin A and vitamin D

,,,

white races

,,
receptors
sensitivity receptors
vitamin D

Ultra violet rays
34
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,,, Ultra violet rays
Ultra violet rays
12 4
Ultra violet rays

,,,

Ultra violet rays

Ultra violet rays
skin burn
cnacer

,,,
Ultra violet rays

extremities of the day
,,
,,,

Ultra violet rays
Human being
,,,
,, Ultra violet rays
,,, Ultra violet rays
Ultra violet rays

ultra violet rays

Ultra violet rays
35
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Pollution

Ultra violet rays

,,
ultra violet rays

,,,

skin
receptors Ultra violet rays

) dehydro 7
( cholesterol
vitamin D3
ultra violet rays
Ultra violet rays
skin
cholesterol
dehydro cholesterol 7
ultra violet rays
vitamin D3
cholcalciferol
vitamin D vitamin D
vitamin D
ultra violet rays

Intake
Intake
plant sources
36
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animal sources
Plant
ergosterol
ergosterol Ultra violet rays
vitamin D2
ergo calciferol
calciterol
ergosterol

Ultra violet rays
ergo calciferol
ergo calciferol vitamin D2
vitamin D
vitamin D2
vitamin D3
vitamin D
Vitamin D3
vitamin D3

,,
Liver
Liver site of the stores
,,,

,,,

vitamin D3
,,,
,,, vitamin D

vitamin D3
37
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vitamin D3
!!!!
,,
,,,
( vitamin D3 ( cholecalciferol
vitamin D2
vitamin D2

vitamin D2 stomach
stomach vitamin D3
cholecalciferol

calciferol
vitamin D3 vitamin D2

vitamin D3 stomach
vitmain D3 fat soluble
fat soluble absorption
bile
absorption vitamin D
first part of the duodenum
second part
second part
Even jejunum
absorption
vitamin D3
vitamin D3
exposure to ultra violet rays
in take

Vitamin D3 site of the stores
38
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Liver
Liver stores
Vitamin D3
,,

vitamin D stores
Liver

Iron ,,
breast milk animal milk
deficient vitmain D
deficient vitamin D
,,,
Milk
animal milk
breast milk
Both are deficient of vitamin D
,,, stores
deficiency breast milk
artificial milk
rickets

rickets
,,
stores ,, iron deficiency
stores
stores
stores
Preterm
stores
39
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Intra uterine growth retardation
stores
stores
onset of rickets
Vitamin D deficiency rickets

:
stores
rickets
:
,,
rickets ,,
:
preterm

,,,
stores )

"

}"{96

) (
(
stores ,,,
,,,
,,
40
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weaned

,,
,,

vitamin D
,,
: ,,
,, :
,,
rachitic
stores
breast milk artificial milk

delayed weaning
Rickets
faulty weaning
Faulty weaning :

,,
,,

vitamin D
faulty weaning
,,,
delayed weaning
faulty weaning
vitamin D
,,
41
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activation
activation
vitamin D
activation
activation
OH
active form
dihydroxy ,1,25
2OH
carbon atom 25 Liver
hydroxy cholcalciferol 25
carbon atom 1 Kidney
dihydroxy cholcalciferol ,1,25
,,
metabolism of Vitamin D
Metabolism
) (
Vitamin D deficiency

Intake
vitamin D
faulty weaning
non nutrition
,, ,,
malnutrition faulty weaning
,,
absorption
vitmain D deficiency
malabsorption
malabsorption syndrome
42
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bile
bile absorption vitamin D
Obstructive jaundice
repeated attacks of gastroentritis
,,

: ,,
,,

) (

,,

:

,,
repeated infection
repeated attacks of gastroenteritis
,,,
rickets
:
rickets rpeated gastroentritis
gastroenteritits

complication rickets
,,,
absorption
,,,
Intake
absorption
Ultra violet rays
:
: ,,
43
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,,
,,,
,, : ,,

:
,,

Ultra violet rays
,,

:
,,
ultra violet rays
) (

:
rickets

,,

,, ultra violet rays

,, ,,

Ultra violet rays
,,,
,,
ultra violet

Ultra violet rays
44
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,,,
,, rickets
,

pollution

Ultra violet rays
,,,
,, Liver
Liver
liver cirrhosis
Liver ,,, stores
rickets
renal disease rickets
Hydroxylation
,,
durg induced
rickets
Drug induced rickets
Drug induced rickets
drugs rickets
anti epileptic

,,
:
rickets

:
anti epileptic drugs

45
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vitamin D Liver
catabolism Liver
vitamin D Liver
toxic rapid hydroxylation
,,
,,
osteoporosis Osteomalacia
osteoporosis
,, osteomalacia

cortisone block vitamin D receptors GIT
block vitamin D receptors GIT

:
osteoporosis Osteomalacia
,,
:
,,
osteoporosis osteomalacia
:
osteoporosis
:
catabolism of protein
bone
osteomalacia
:
block vitamin D receptor GIT
absorption

,,,
ant acids
rickets
anti acids rickets
46
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calcium absorption
antiacids rickets calcium absorption
.
,,
history
etiology
History

rachetic
rachetic
rickets
hisotry

rickets
,,,

:
,,

Full term preterm
:
,,
preterm
,,,
: full term Preterm
Pre term

stores
:

:

47
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:
,, 700
800

stores

:

,,
,,,
:
,,

:
,,
artificial milk
rickets
alkaline PH
phosphate calcium absroption
:
,, ,,

:
,,,
,,,
,,
:

48
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,,
:
,,
delayed weaning
stores

,,,
:

:
,,,
:

,,
delayed weaning
delayed weaning

:
,,
,,,

delayed delayed weaning

,,
:
,,

,, vitamin D
!!!!!
49
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:

,,

,,

,,

faulty weaning
,,,
vitamin D
,,,
absroption
:
,,
:
,,
mal malabsroption
Liver affection
jaundice
vitamin D
obstructive
:
,,
Liver
,,

,,

:
,,
50
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,,
:
,,,
anti epileptic drug
,,

Chronic ITP
rickets
What ever
,,,

,,

33 : 6

metabolism of calcium
Factors affecting calcium metabolism
vitamins D metabolism
rickets
rickets in general
patho physiology of rickets
51
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patho physiology
,,,
satisfied

,,,
Patho physiology of Rickets

bone

Mineral part of the bone
mineral part
rickets defect mineralization of the bone
,,,
mineral part bone

calcium
calcium mineral part
rickets
calcium cortex of the bone
suppression osteoid tissue deposition
,,
osteoid tissue depot
over depot
bone
Mineral part
part osteoid tissue

cement mineral part
,,,

52
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,,
,, ,,,

,,,
,,

calcium bone
over deposition of osteoid tissue
Limit

suppression

osteoid tissue

,,,
,,,

osteoid tissue
Over deposition

,,,
53
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,,,
bone bone

bone
Joint
,,

,,
,, Joint
two bones joint

,,
Joint ,,
,,,
,, joint

Joint
,,
very smooth ,,

,,,
,,

cartilage smooth
cartilage smooth

cartilage
cartilage smooth surface

,,,
54
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......
)
(
cartilage

Joint space
joint space synovial fluid

synovial fluid

,,,

,, cartilage

,, cartilage
,,,
cartilage

,,
,,,
cartilage
,,

cartilage
,,,

cartilage
cartilage

,,
,, cartilage
proliferation
55
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,,
,,,
calcium bone
osteoid tissue deposit

,,
proliferation of the cartilage

,,
patho physiology of rickets
05 : 9
rickets
rickets
vitamin D
,,

vitamin D ,,,
absorption Phosphorus
GIT
reabsorption kidney
deposits of calcium bone
bone
rickets
bone

,,,
,,,

suppression Osteoid tissue
suppression cartilage proliferation

,, excess osteoid tissue deposit
56
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proliferation of the Of the cartilage
,,,
Mineral part
,,

,,,
osteoid tissue ,,,
growth

growth of the bone rate
,,,
muscle
,,

,,,
skeletal system bone and muscles
bone and muscles weak
weak
,,,
Motor development
Normal
,,,
History delayed motor development

growth and development
Neck support

,,
,, crawling
supported with one hand

57
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.......
......
In child manner
In child manner
say

,,
,,,
:

,,,

:

:
,,
) ,, (
,,

:
,,

:
,,
,,
) (

:

) (

58
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,, : " "
"

.......
......
:
,,

,,, rickets
history
History of delayed motor development
,,
,,
teeth
teeth skeletal system bone
,, Mineral part
,,, teeth sockets

Jaw
cartilagenous
ossification
,,
calcification
eruption of the teeth
,, Mineral part
,,
,,
,,
Lateral incisor
,, last
molar

,,

59
| Page
" " :
,, : " "
"

.......
......

,,, ,,

,,

:

,, rickets
delayed dentation and delayed motor development

rachetic delayed motor
development
delayed dentitation
,,
,,,
) ( Phenomena
Phenomena
phenomena
two parameters

teething
Motor development
,,
,,,
,,
,,
) ( Motor development
crawling
60
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" " :
,, : " "
"

.......
......
Motor development
,,,

,,
,,,

,, dentitation
Motor Motor development

,,
,,
,,
Phonemoena
rachetic
rachetic
Hisotry
History of delayed motor development
delayed dentitation

Osteoid tissue

,,,
flat bone of the skull
New bone formation
growth
flat bone
center of the growth
,,
,,, development frontal bone

61
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,, : " "
"

.......
......
Parital bone
,,,
,,,
flat bone
new bone formation

,,
sutures
,,,
fontanell
New bone formation

mineral part

frontal bone
pareital bone
fontanells
anterior fontanel

anterior fontanell

,,, anterior fontanell
2.5
delayed closure
delayed closure
delayed closure fontanell
62
| Page
" " :
,, : " "
"

.......
......
failure of growth of the flat bone of the skull
failure of growth
New bone formation
,,,
excess osteoid tissue deposit
soft tissue bone
bone
New bone formation

layers Layers Osteiod tissue
Layers of osteoid tissue
)
(

frontal bone

,,,

box shaped skull

box shaped skull
pareital frontal bone
bossing

frontal and pareital bossing
Excess osteoid tissue deposit
excess osteoid tissue deposit

deficiency of calcium inside the bone
,,
)
(
63
| Page
" " :
,, : " "
"

.......
......
skull circumference
,,, skull circumference
skull circumference

Increase of skull circumference
signs skull
frontal bossing
pareital bossing box shaped skull
skull circumference

fontanell
,,,

,,,
sutural line

sutural line
,,,
sutural line

,,,

,,
) (
craniotabes
craniotabes
rickets
,,,

craniotabes rickets

hydrocephalus
64
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" " :
,, : " "
"

.......
......
,,
Hydrocephalus
:
rickets craniotabes

,,,
:

:
,,
,, ,,

,,
Pressure effect

) (

,,,
board ) (

board
,,

,,
65
| Page
" " :
,, : " "
"

.......
......
craniotabes ,,,
still rachetic

suture line
,,,
,,

,,, craniotabes
joint space so narrowing

skull manifestations of rickets
frontal bossing
pareital bossing
box shaped skull
skull circumference
delayed closure anterior fontanell
craniotabes

rickets
,,
section chest
thoracic verteberae ,,
transeverse spine
ribs ,,,, transverse spine
,,
rib

bony part
rib sternum
cartilagenous part
X - ray chest and heart
sternum
66
| Page
" " :
,, : " "
"

.......
......
rib
,,,
,,, cartilagenous part
cartilage
,,,
Intra thoracic pressure
Positive Negative
Negative
Intra thoracic pressure negative pressure
Negative pressure
,,, ,, Negative pressure

traction bone
suction bone
traction
negative negative pressure
rib flat bone
,,
,, traction
,, ,,
,,
,, ,,,
,,, rickets
,, Mineral part
Mineral part
traction
,,,
traction

rib
rib
,, rib

67
| Page
" " :
,, : " "
"

.......
......
rib verteberae

,, vertebrae
,,
rib

cartilage
cartilage
traction
,,, Rib
rib
rib
,,, sternum
,,,
cartilage

costo chondoral junction
rib

,,,

,,

costo chondral junction
costo chondoral junction
,,
groove sulcus
groove sulcus
10 : 29

68
| Page
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,, : " "
"

.......
......

groove sulcus
,,,

,, Longitudinal sulcus
Longitudinal sulcus
,,,
sternum

,,, Longitudinal sulcus
sternum
chest
deformity
sternum
groove
sternum
Protruded anteriorly
,,,

,, sternum sternum
sternum

,,,

sternum
) Pigon chest ,, (
chest ,,
69
| Page
" " :
,, : " "
"

.......
......
,,, pigon Pigon chest
,,,
sternum
sternum negative pressure
sternum
sternum
,,, antero posterior diameter of the chest

sternum
antero posterior diameter
flat chest
flat chest
shoe maker chest
Pectus exacavtum
What ever
flat chest

sternum Negative suction
,,
rib ,, Longitudinal sulcus
longitudinal sulcus pigon chest
flat chest

Lower ribs
ribs ,,,
diaphragm
,,,
diaphragm ribs ,,,
ribs diaphragm
diaphragm very powerful muscle
rib
rib
,,, insertion of the diaphragm
rib ,,,
70
| Page
" " :
,, : " "
"

.......
......
rib
Insertion of the diaphragm
,,, insertion of the diaphragm
) (
,,
)
(
,,
Insertion of the diaphragm
,,,
,,
,, groove sulcus
Horizontal Longitudinal
Horizontal sulcus
Miss Harrison
Harrison Harrison sulcus
,,,
Harrison sulcus
Horizontal sulcus
traction of the diaphragm weak ribs
groove Insertion of the of the diaphragm

chest
mechanism
,,

cartilage ,,
Proliferation of the of the cartilage
cartilage
Proliferation
cartilage
costo chondral junction
cartilage
71
| Page
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,, : " "
"

.......
......
Thicken
cartilage thick
,,, growing cartilage
proliferation
proliferation
chest rachetic rosere

,,,
,, ,,,
rib

rib

,, cartilage proliferation
,,,
clinical signs
chest
chest signs rickets
Longiutidnal sulcus
Harrison sulcus
pigon chest
flat chest
rachetic roseri
,,,
Manifestations chest

,,

72
| Page
" " :
,, : " "
"

.......
......
) (

Long bones
long bones ,,,
,,,
tibia Normal
,,
straight
,,,

,, Mineral part
collagen support

muscles
,,, Muscles support bone

,,,
,,,

,,,
,,,
,,,

,,,

) wires (

,,
73
| Page
" " :
,, : " "
"

.......
......
,,,

,,,

,,
,,
,,,

,,,

,,

,,,
support
support bone

Muscles
adductor abductor
flexors extensors
muscle
support equal

osteoid tissue

Muscle
74
| Page
" " :
,, : " "
"

.......
......
muscle
Muscle
support
wire

,,,
,,
Muscle supporting bone

Deformities
deformities

rickets

,,
,, crawling
crawling
,,,

Muscle
,,
,,,
,,

,,,
bowing
upper limb
bowing
bowing
Muscle weakness
bone weakness excess osteoid tissue
75
| Page
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,, : " "
"

.......
......

,,

!!!!

,,,

genu
valgus
genu valgus deformity

,,,
,,,

,,,

,,,

,,,
genu varus deformity
,,,
76
| Page
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,, : " "
"

.......
......
curvature tibia
curvature femur
What ever deformity
extremities
deformity upper limb bowing
Lower limb genu varus
genu valgus
deformity femur curvature tibia

deformity
Bone weakness
Muscle weakness
53 : 42

cartilage extremities
proliferation
cartilage
,,,
Proliferation
cartilage

,,, shoulder Hip
shoulder muscles
deltoid shoulder
cartilage deltoid
,,
Hip joint
77
| Page
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,, : " "
"

.......
......
Muscles
cartilage Hip joint
,,, knee
cartilage extremities
radius ulna
cartilage proliferation
proliferation of the cartilage
radius ulna

broadening
broadening

broadening

,,,
,,, rickets

,,,

,,

foot
,,,
,,,

,,,
78
| Page
" " :
,, : " "
"

.......
......
14 : 45

,,,

,,
osteoid tissue

cartilage

proliferation
broadening
,,
bone is very weak pressure
proliferation of the the cartilage
,,,,

,,,
tibia fibula
tibia ) ,, ( Maleollus
tibia
tibia Medial lateral
Medial
tibia
embryology
tibia
bone maleouli two separate bones
79
| Page
" " :
,, : " "
"

.......
......

maleollus
fibula maleollus
,,

,,, cartilage
cartilage
cartilage
cartilage
cartilage
cartilage
joint ,,,
Human being
fusion
anatomy ,,
joint non functioning

rickets

Proliferation of the cartilage
cartilage
,,,
,,,
cartilage maleollus shaft

ankle
,,,
broadening
broadening cartilage proliferation
,,,
groove
80
| Page
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"

.......
......
medial Lateral Maleollus

groove
,,,
two lines of growth
cartilage
two horizontal groove

Marfan sign
Marfan sign cartilage proliferation at two different points
Lower end tibia fibula
maleolli
,,,
Marfan sign Medial maleollus
medial Lateral

,,
,,,
extremities
deformities broadening upper limb
wrist
Marfan sign
,,
muscle
generalized muscle weakness
generalized muscle weakness
,,,

,,,

81
| Page
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"

.......
......
sensors para thyroid gland

serum calcium
serum calcium 8.5

para thormone
Para thormone
para thormone serum calcium
,,,

,,, bone
Kidney

urine
serum phosphate

,,,
Muscle ATP
adenosine tri phosphate
Phosphate
ATP
Msucle energy
Muscle weakness even degeneration of the muscle
generalized muscle weakness and hypotonia
Myopathy
generalized muscle weakness and hypotonia

,,,
,,
,, back muscle
82
| Page
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,, : " "
"

.......
......

weakness back muscles
Kyphosis

Scoliosis
Khypho scoliosis
muscle weakness of the back
,,,
deformity vertebrae
Muscle
muscle

,,,

kyphosis scoliosis kypho scoliosis
,,,

vertebrae deformity
muscle weakness
correctable kyphosis
,,,

) (

Pot belly abdomen
pot belly abdomen
,,

83
| Page
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"

.......
......
hernia
Umblical Inguinal hernia

Ligaments Liver spleen
Muscle
liver spleen
ptosed of the organ
Ptosis Liver spleen
,,
,, weakness
severe condition respiratory muscle
respiratory muscle

stagnant secretion chest
.T.B repeated repeated chest infection

complications of rickets

Pathophysiology of rickets
clinical manifestations of rickets

clinical pictures rickets
Clinical pictures of rickets

history of delayed motor mile stones

delayed dentation
84
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" " :
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"

.......
......
deformities
:
,,

complications
,,,
By examination

Examination

,,,
skull circumference
frontal bossing parietal bossing
abnormal shape of the skull
box shaped skull
fontanel delayed closure of the anterior
fontanel
craniotabes

,,
chest deformity
sternum pigon chest
flat chest
longitudinal Horizontal sulcus
rachetic rosari

,,

,,
,, ubmlical hernia Inguinal
hernia
liver spleen Upper border
ptosed Liver spleen
85
| Page
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"

.......
......
,,, extremities
extremities
broadening
Marfan sign
deformity bowing ( genu varus - genu valgus -
( deformity in femur - curvature of the femur - curvature of the tibia
,,,
,,
kyphosis
scoliosis
Kypho scoliosis

correctable kyphosis scoliosis kypho scoliosis
,,,

57
Complications of rickets
complications

Repeated chest infection
,,, rickets

:
chest Infection
brochiolitis pneumonia bronchopneumonia
86
| Page
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"

.......
......
What ever chest infection

infantile rickets complicated bronchitis
complicated
:
,,, repeated chest infection

clinical
,,

:
rickets repeated chest infection
,,,
,,,
defect in immune function
Immune deficient
rickets
defect in immune deficiency

chemotaxis
macrophage migration
phagocytosis
Intra cellular killing
,,
,,,
macrophage nearly paralyzed
,,
macrophage

defect in macrophage migration

,,,
immune function
87
| Page
" " :
,, : " "
"

.......
......
:
defect Macrophage Migration
immune deficiecny Down
defect T cell function
T cell
humoral and cell mediated
Immune deficiency

repeated chest infection
immune deficiency
chest deformity
flat chest
Pigon chest
Lung Inflation

Infaltion
stagnant stagnant secretion
chest infection

muscle weakness and hypo tonia
,,
muscle weakness hypo tonia
Muscle weakness hypo tonia
,,,
stagnant secretion
chest infection

,,,
GIT ,,,
complications
muscle weakness
88
| Page
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"

.......
......
Even gut muscle may be affected
,,

Muscle weakness
,,,
rickets ,,
constipation
diarrhea
Infection gastroenteritis
Liable to infection
gastroentritis

,, motility of the gut
motility of the gut
anterior abdominal muscles are weak
The muscle is weak

,,, Potential cyanosis
Potential cyanosis
defecation micturation
local reflex
contraction of the wall and relaxation of the sphincter
,,,

diaphragm
vertical diameter
contraction anterior abdominal wall muscle
89
| Page
" " :
,, : " "
"

.......
......
,,,
vertical diameter Intra abdominal pressure
evacuation of the viscous
muscle
,,
,,

Local reflex
,,
,,

,,,

,,

Muscle weakness
constipation
May be complicated by gastro entritis
complicated gastro entritis
Macro phages defected
diarrhea
complications
deformity
,,, complications
bone deformity
complications
90
| Page
" " :
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"

.......
......
tetany and convulsions

hypo calcemia and tetany
Hypo calcemia and tetany

Hypo calcemia and tetany
Laboratory investigations
tetany and convulsions

anemia
Complication ,,,
,,, anemia
rickets pallor
,,,
:
Pallor
:
:
rickets
,, commonly rickets
associated with iron deficiency anemia
complications
association

factors Ca absorption
Iron
Phytate oxalate
iron deficiency
rickets
,,,
iron deficiency anemia
91
| Page
" " :
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"

.......
......
Lymph adenopathy
organomegaly
,,,
,,, neglected cases
pallor
generalized lymph adenopathy
Lymph node
spleen
,,, Pallor
Lymph node
spleen
Leukemia
,,
Leukemia
bone marrow
bone marrow
pseudo leukemia infantum
pseudo leukemia infantum
pallor
Organo megaly
Lymph adenopathy
anemia
)
(
,,,
,,,
,, hemolytic anemia
Hemolytic anemia
: ) ( RBCs
,,, life span
120

Hemolytic anemia
92
| Page
" " :
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"

.......
......
,, ,,

,,,
repeated infection
repeated infection
,,,
reticuloendothelial system hyperplasia
reticulo endothelial system Hyper plasia
spleen reticulo endo thelial system
,,
spleen infection
Phagocytic function
trabeculi ,, RBCs
hemolytic anemia
hyper splenism
reticulo endothelial system hyper plasia
repeated infection

,,
pallor
Lymph adenopathy
splenomegaly
rickets
anemia
organo megaly lymph adenopathy
associated iron deficiency anemia
,,,
rickets
anemia
Lymph adenopathy splenomegaly
93
| Page
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"

.......
......
complication
,,

deformity Pelvis
female
,,
obstructive labor
,,,
complications
,,,
Repeated chest infection
GIT ) constipation ,, ( gastroentritis
deformities
tetany
anemia
adult obstructed labor
deformity in pelvis
,,,
investigations
Investigation
Investigations rickets
radiological
laboratory investigations rickets

rickets
vitamin D
Vitamin D deficiency
What ever the etiology
vitamin D ,,
calcium absorption GIT
absorption GIT
,,,
94
| Page
" " :
,, : " "
"

.......
......
serum calcium
serum calcium
vitamin D
serum calcium
,,

Para thyroid
Para thyroid
calcium sensors
serum calcium
Para thyroid hormone
,,,
serum calcium
serum calcium

bone
stimulation osteo clast
And suppression for osteoblast
bone calcium
phosphate
45 : 11 : 1
bone
bone

,,,

95
| Page
" " :
,, : " "
"

.......
......

kidney
kidney renal tubules
Kidney
renal tubules

kidney
:
Urine

urine
,,,
parathormone
bone
rachetic manifestations bone
,,,

:
bone ,,, Mineralization of the bone
rickets
,,
vitamin D
parathormone

,,
New bone formation
,,, Old bone
,,,
bone mineralization
mineralization of the bone
vitamin D
96
| Page
" " :
,, : " "
"

.......
......
Parathormone
,,,
,,,

serum clacium
serum calcium
normal
low
Parathormone
serum calcium Normal
serum calcium serum calcium Low
serum calcium Low
tetany
,,,
tetany rickets
,,

serum clacium

serum calcium parathormone
failure Parathyroid gland
hypo parathyroid gland
Para thyroid
serum clacium
failure of the para thyroid gland

parathyroid
!!!!
bone
bone
bone matrix
:
97
| Page
" " :
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"

.......
......
,,
bone ,,
neglected cases of rickets
stores of calcium
bone
Parathormone ,,,

,,
serum calcium
severe type of rickets of bone stores
,,,
tetany complications

,,,
,, D
rachetic

vitamin D
Shock therapy
600,000 vitamin D

vitamin D

serum bone
bone
serum calcium
tetany
iatrogenic

vitamin D without calcium supplementation
98
| Page
" " :
,, : " "
"

.......
......
tetany
tetany
failure of the parathyroid gland
of the bone stores severe type of
rickets
Iatrogenic High dose of vitamin D

without calcium supplementation
,,,
,,, ,,
radiological
26 : 17 : 1
radiological

rickets ,,,
serum calcium
Normal serum calcium
8.5 10.5
,,,

Normal serum calcium
9 11
serum calcium
Normal
Low
,,,
Parathormone
serum calcium normal Low
99
| Page
" " :
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"

.......
......

rickets serum phosphate
normal serum phosphorus
4.5 6.5
level

serum phosphorus
serum Phosphorus
urine
urine Parathromone
,,,
Hypo phosphatemia
Phosphate even 1.5
,,
rickets
,,,
,,, ,,
osteoblast
,,,
Number of crystals of the bone
bone crystals

stimulation osteoblast
Osteoblast hyper activity
osteoblast Hyper activity
100
| Page
" " :
,, : " "
"

.......
......
Hyper activity Osteoblast

of the bone crystals
,,
bone crystals

Normal level alkaline phosphatase
140 international unit 200

,,,

500

international unit per liter 500
,, Osteoblast osteoclast
bone S.A.node heart
Other factors peace maker of the heart
sympathetic Para sympathetic
thyroxin
heart rate
,,, brain death
heart

,,
Osteoblast
main control osteoblast
bone
,,

101
| Page
" " :
,, : " "
"

.......
......
serum calcium normal or low
serum phosphate low

,,,
urine analysis
urine analysis

urine ,,,
parathormone
urine analysis
Phosphate

,,
research
rickets
level
rickets
very poor
rickets
,,
research
vitamin D level
hydroxy cholicalciferol 25
hydorxy cholicalciferol 1,25

,,,
vitamin D deficiency rickets
Vitamin D
parathyroid hormone

102
| Page
" " :
,, : " "
"

.......
......
,,
for research
Parathormone 700 - 600
parathormone
,,,
parathormone

Level
vitamin D
urine generalized amino aciduria
vitamin D
role amino acid reabsorption
tubules
vitamin D
amino acid excretion urine
generalized amino aciduria
urine
radiological investigations

treatment
,,
Treatment
rickets

,,,
rickets
rickets
prevention
103
| Page
" " :
,, : " "
"

.......
......
rickets
,,,
treatment
preventive medicine
rickets

iron supplementation
vitamin D and calcium

stores

,, breast feeding
artificial milk
artificial milk rickets
vitamin D
early proper feeding
vitmain D
vitamin D supplementation

,,
vitamin D supplementation

400 800

dose
400 800
full term
104
| Page
" " :
,, : " "
"

.......
......
preterm
800 1200
inter national unit per day 1200 - 800
stores
requirements
400 800
pre term Intra uterine growth retardation
800 1200
,,
,,,
rickets
Vitamin D deficieny rickets

vitamin D

,,
800 1200
vitamin D Oral
,,
Oral international unit 6000 - 2000
5000 - 1500

minimum 1500 international unit
,,,
international unit per day 6000
Oral
,,,
,,
oral
vitamin D Injection
vitamin D Intra muscular
105
| Page
" " :
,, : " "
"

.......
......
: vitamin D intra muscular Intra venous

:
IM
IV
Oil
IV fat embolism
fat embolism
intra muscular
IV fat embolism
,,

) (

international unit 600,000

calcinosis
,,,
shock therapy
one injection
,,,
supplementation
calcium absorption
vitamin D
vitmain D
,,,
complications
deformity
106
| Page
" " :
,, : " "
"

.......
......

,,,

,,

Normal
lab or radiological
laboratory

normal
,,,
osteoblast activity
laboratory alkaline
phosphatase
Normal alkaline phosphatase
,,,
phosphate
,,,
:
alkaline phosphatase Normal

,,,,
107
| Page
" " :
,, : " "
"

.......
......
clinical manifestations of rickets

clinical pictures
:
rickets
hisotry of delayed motor development
Delayed dentation
bone deformity
complictions
On examination
skull circumference
Pareital bossing frontal
box shaped skull
craniotabes
fontanel delayed closure
Pigon chest
flat chest
longitudinal sulcus
Harrison suclus
rachetic rosari
chest

,,
pot belly abdomen
spleen liver Ptosis
,, extremities
Upper limb boradening
genu valgus gene varus Knee Lower limb
Knee deformity
deformity Marfan sign
,,
correctable Kyphoscoliosis Scoliosis kyphosis

,,,
Page |
108
: " "
" " : ,,
"

.......
......
complications
GIT complications constipation diarrhea
gastroentritis
tetany tetany
bone deformities
anemia
adult period Obstructed labor
Investigations
serum calcium normal Low
serum phosphate Low
Urine phosphate
amino acids urine
vitamin D
Parathormone

Prevention
vitamin D
complications

radiological finding
rickets
renal rickets
,,
radiological finding of rickets
Radiological finding of rickets

,,, hisotology of the bone
109
| Page
" " :
,, : " "
"

.......
......

,,

bone
bone ,,,
two lines of growth
two lines of growth

linear growth
linear growth
,,,
Linear growth
,,

Linear growth
Linear growth of the bone
epiphysis
growing centers
,,,
,,,

,,,

,,,

,,
110
| Page
" " :
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"

.......
......
increase waist growth horizontal growth
,,,
two lines of growth
Linear
waist growth
linear growth

)
!!!! (

,,,
Linear growth waist growth
Linear growth
,,,
femur
femur

femur bone cartilage
,,, femur
mature bone

Morphology of the bone line of epiphysis
,,,
cartilage

layer
layer columnar cells
Layer columnar cells
zone of resting cartilage
zone of resting cartilage
zone ,,
111
| Page
" " :
,, : " "
"

.......
......
single layer of collagenous fat

Level Layer rounded cells

zone of proliferating cartilage
layer
layer
Single colmnar cell
colmnar cells
Layer
rounded cells
cartilagenous cells
Proliferating cells replicating cells active cells
,,

layers

layers celluar acellular

Vascular avascular layer
Avascular
vessel
Layer ,,

acellular and avascular layer

osteoid tissue + mineral part
Protein mineral
bone
112
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,, : " "
"

.......
......
zone of provisional calcification

zone of provisional calcification board
layer avascular
acellular
Osteoid tissue Mineral part
,,
Layer of mature bone

,,,
blood vessel bone Phosphorus
,,

rickets
,,, dendritic cells
stem cells bone marrow
bone
zone of mature bone
Ossified bone
What ever layers
mature bone bone

linear growth of the bone

,,

new bone formation

,,,
113
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" " :
,, : " "
"

.......
......
all through
peri osteum
Periosteum
10 : 10
periosteum
,,, ,,,
periosteum new bone formation
New bone
osteoid tissue
calcium phosphate
Mature bone
periosteum
Periosteum mineral part

two active parts Bone
bone linear growth
Periosteum active part New bone formation

X- ray
X- ray

radiation

transparent
transparent
,, Particles
114
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" " :
,, : " "
"

.......
......
,,,

transparent

,,,

Lung X - ray

soft tissue Muscle

,,

soft tissue X - ray grey

partial absroption irradiation
bone ,,,
calcium phosphate
calcium Phosphorus
115
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" " :
,, : " "
"

.......
......
bone X - ray

,,,
bone X - ray
calcium phosphate
,,,
,,
Irradiation

X -ray
Mineral part

,,,
,,
rickets
vitamin D
,,
vitamin D
calcium calcium absorption
serum calcium
serum calcium ,,
Parathormone
Parathormone ,,
,, serum calcium

parathormone rickets
bone
mineral part bone
116
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"

.......
......
X -ray bone

,,,
X -ray
X -ray decrease bone density

rarefaction of the bone
decrease of bone density
rarefaction decrease in bone density
rarefaction decrease bone density
bone
Parathormone bone
serum calcium
rickets

,,,
Histology bone
Linear growth

) (
) !!!!!!!!!!! (

bone
Hisotolgy
X - ray

) Linear growth
,,, ( epiphysis
117
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,, : " "
"

.......
......
cartilage irradiation
Irradiation
irradiation
X -ray
X -ray
zone of provoisional
cartilagenous part

bone
bone

,,,
,,

,,

excess of osteoid tissue
Osteoid tissue
Osteoid tissue
,,,
,,,
,,
,,,

,,,

,,,

118
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" " :
,, : " "
"

.......
......
,,,
cartilage

,,,
cartilage
,,
cubbing X -ray
,,,
Osteoid tissue
Mineral part
broadening
broadening
,,,
cartilage

cubbing

cubbing
broadening
,,
,,,
Pathophysiology
,,
,,, proliferation of the cartilage
Proliferation of the cartilage ,,,
thickness cartilage

cartilage
Proliferation of the Of the cartilage
119
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"

.......
......
,,,

cartilage cartilage
proliferation
zone of provoisonal calcification

cartilagenous band zone of provisional calcification
cartilage radi lucent radio opaque
radio lucent
X - ray
,,,
,,,

chondroblast

fraying
,,, bone
rarefaction
rarefaction X -ray

rarefaction
hyper parathyroidism
Mineral part of the bone
cubbing broadening

,, Osteoid tissue
120
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"

.......
......
Mineral part
Pressure cubbing broadening
fraying
fraying
cartilagenous chondroblast
proliferation

,,
,,,
,,
periosteum Mature bone
bone
bone
X - ray
) (
Periosteum
Periosteum

Parathormone

Periostuem
Periosteum
osteoid tissue
osteoid tissue periosteum
X -ray
osteoid tissue
,,
parathromone Periosteum
121
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"

.......
......

two periosteum
Periosteum ,,

Periosteum
Seperated bone
seperated bone
periosteum 2

Double periosteum line
,,
Rarefaction
Broadening
) ( cubbing
Fraying
Double periosteal line

,,,

bone bone deformity

deformity X -ray
Genu vara - genu valgus
femur
curvature tibia
,,,

rickets

,, Limit

122
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.......
......
,,

,,,

,,,
green stick fracture

,,
Green stick fracture

,,,
Manifestations of active ricktes
Manifestations of active rickets
rarefaction
cubbing
Broadening
Fraying
Double perosteal line
123
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"

.......
......
Bone deformity, even green stick fracture

,,

fraying X -ray

active rickets
,,
Treatment
,,
vitamin D

serum calcium
Parathyroid hormone ,,
vitamin D Osteoblast
new bone formation
extremities
linear growth
New bone formation
Linear growth
deposit of calcium

deposit
deposit zone of provisional calcification

chondroblast
chondroblast
X - ray

new bone formation
mature bone
124
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"

.......
......
,,
line of ossification
,,,

rickets
new bone formation
,, cubbing broadening
even rarefaction of the bone
X -ray
X -ray


cubbing broadening
fraying
linear deposits of
Healing rickets
Healing rickets

,,,,
,,

Osteoblast

,,,

,,
125
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" " :
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"

.......
......
,,

,,
osteoclast
osteoclast

,,,

,,
bone density
Periosteal line

Healed rickets

Radiologically
activ rickets
Rarefaction of the bone
cubbing
broadening
fraying
double periosteal line
bone deformity
healing rickets active
fraying
line of ossification
126
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"

.......
......
healed rickets
,,,
thick ossification bone
pathophysiology radiological finding of rickets

:
zone of provisional calcification healed rickets
after healing
thick line
thick line
thick line

,,

,,,
thick line
,,,
line of calcification

Osteocalst

x -ray

X -ray rickets
,,,
127
| Page
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"

.......
......
osteoclast
bone
hydrocortisone oral
absorption of vitamin D
,,,
block vitamin D receptors
block vitamin D receptors

Osteomalacia and osteoporosis

,, Oral cortisone
oral crotisone
Intra muscular
,,,
Oral IM

systemic effect

cortisone oral
GIT receptors
Intra muscular GIT
receptors
!!!!!!
,,,
( adult child
)
,,,
,,, two months
,,
,,,

:

,,,
,,
128
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" " :
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"

.......
......

,,,
Renal Rickets
renal rickets

) (

,,,
renal rickets
,,,
,,,
nowadays
,,
MCQ
MCQ renal rickets
rickets
renal rickets
Oral and MCQ
essay

oral MCQ

,,,

129
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,, : " "
"

.......
......
,,

,,
renal rickets

glomerular
tubular

,,,

Tubular
Glomerular
tubular glomerular
,,,
tubular rickets glomerular rickets

) (

clinical
renal rickets
glomerular

:
,,
tubular glomerular
rickets
:
serum phosphate
serum phosphate tubular type very low
serum phosphate low
very low
130
| Page
" " :
,, : " "
"

.......
......
vitmain D deficiency rickets

serum phosphate
Normal
serum phosphate even zero
glomerular type
serum phosphate is high

:
Laboratory finding
:
serum calcium Normal Low
serum phosphate Low

Urine
amino acids urine
vitamin D parathormone

,,
:
,, rickets phosphate
,,,
rickets serum phosphate
glomerular type of renal rickets
serum phosphate

renal osteodystrophy
chronic renal failure

nephrology

,,,
131
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" " :
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"

.......
......
serum phosphate rickets Low

glomerular type of renal rickets

parathyroid hormone
Parathyroid hormone
,,,
Parathyroid hormone
tubular phosphate ,,
,,,

Parathormone

,,

,,,
urine

Parathormone
Normal
tubular type
Parathyroid Normal
,,,
glomerular type
glomerular type
Phosphate
,,,

Parathyroid
Parathyroid hormone very high
,,
: Parathyroid hormone rickets
132
| Page
" " :
,, : " "
"

.......
......
:
Usually high
,,,
:
rickets Parathyroid hormone Normal
:
tubular type
parathyroid hormone normal
.
,,,

Glomerular type

,,,
glomerular type
rickets
rickets
,,,
rickets chronic renal failure
renal osteodystorphy
rickets chronic renal failure
)
,,,
,,,

) ,,

133
| Page
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"

.......
......
(
,,,,
Chronic renal failure
rickets
,,, ,,
renal failure
kidney hydroxylation of vitamin D 1
hydroxylation of vitamin D 1
hydroxylation of vitamin D 1
25 ,1
rickets rickets
rickets renal osteodystrophy
failure of hydroxylation of vitamin D

acidosis
renal failure
Metabolic acidosis
acidosis
Failure of excretion acidotic material
.loss of bicarb Urine
metabolic acidosis
,, acidosis
,,, calcium carbonate bone
bicarb bone
bone calcium calcium carbonate
acidosis Melting of bone calcium

bone calcium carbonate
bone
134
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.......
......
manifestations of rickets
,,

chronic renal failure failure of excretion of phosphate
retention of phosphate
phosphate
phosphate

) = (
,,
parathyroid Parathyroid hormone
parathyroid hormone
Parathyroid hormone

Parathyroid hormone
,,,
serum calcium
serum phosphate
,,,

,,,,

,,
kidney
target kidney
rickets
parathormone Kidney
Parathormone reabsorption of calcium
loss of phosphate
Kidney
kidney
135
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" " :
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"

.......
......
parathormone hormone
Parathormone
,,,
calcium urine
Parathormone hormone
Parathormone

,,,

Parathormone
bone
,,,
,,,

renal failure osteitis fibrosa
cystica
bone cyst
,,,
rickets renal failure
failure of hydroxylation of vitamin D
acidosis Melting of bone calcium
retention of phosphate hyper parathyrioidism
rachetic manifestations

Clinically

renal failure

136
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" " :
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"

.......
......
Laboratory
renal failure

Manifestations of rickets
Laboratory
serum clacium
rickets phosphorus
serum calcium
Normal
Low
bone
Urine calcium Normal
,,, Low
,,,
renal osteodystrophy Low
tetany
,,,
acidosis
tetany
tetany ,,
acidosis tetany
acidosis tetany
,,, phosphate
,,, phosphate
alkaline phsphatase
rickets
,,,
Urine
Urine
137
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" " :
,, : " "
"

.......
......


urine
,,

,,,
,,, vitamin D
,,,
25 ,1
hydroxy 25 Normal
cholicalciferol vitamin D3 Normal
1,25
hydroxy 25 Normal
vitamin D Normal
vitamin D Normal
vitamin D3 cholcalciferol
Normal
hydroxy vitamin D3 25
normal
1,25
,,,
,,,
hydroxylation 1
,,,

,,,
radiologically
diagnostic radiologically
Manifestations of active rickets osteitis
fibrosa cystica
138
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" " :
,, : " "
"

.......
......
Manifestations of active rickets osteitis

fibrosa cystica

Treatment

renal failure
rickets
rickets

vitamin D
vitamin D

1,25 hydroxy 1
hydroxy 1
liver
25 active form
vitamin D
vitamin D without calcium

,,
,,,

acidosis
acidosis
calcium carbonate bone
sodium bicarb
acidosis
,,,
excess phosphate
phosphate

139
| Page
" " :
,, : " "
"

.......
......

,,,
,,,,

) giving ( phosphate binders
gut Phosphate absroption
,,,
resistant cases parathyroid
Parathyroid
Parathyroidectomy
resistant cases
parathyroidectomy
parathyroid

active form of Vitamin D

resistant cases parathyroid gland
glomerular type
acidosis

binders Phosphate absorption
resistant cases parathyroidectomy
renal failure
,,,
acidosis bicarb
with salt and water retention
renal failure salt and water retention
sodium bicarb
!!!!!
140
| Page
" " :
,, : " "
"

.......
......
salt and water retention

,, sodium bicarb

sodium bicarb

,,,,

,,,
hydrocephalus

,,

,,,

type one type two

,,,,

,,,
endocrine

,,,

116
,,,
exercise ,,,,
,,,,
141
| Page
" " :
,, : " "
"

.......
......
,,

123
8
,,,

,,

,,,

:

,,,
,,,
,,

,,

)

"
}( "{49

,,
,,,
,,,,,
,,,
,,,

142
| Page
" " :
,, : " "
"

.......
......

,,,

,,,

:
,,,
,,,
:

:

sodium bicarb
bicarb salt and water
retention

sodium bicarb salt and water retention
19 :11 :1

24
1
143
| Page
" " :
,, : " "
"

.......
......

,,

!!!!!

(
Tubular type
tubular type
Primary tubular type
primary hypophosphatemic rickets
primary hypo phosphatemic rickets
X-linked
dominant disease
genetics
X -linked dominant
X - linked dominant

gene
gene tubular defect
144
| Page
" " :
,, : " "
"

.......
......
tubular defect failure of reabsorption of phosphate

kidney phosphate
Phosphate
urine
excretion of phosphate in urine
urine
,,
,,, bone calcium calcium phosphate
calcium phosphate
new bone formation
mineral part bone
rickets
clacium bone
Phosphate bone
,,,
Phosphate
,,,
Normal
rickets
,,,
rickets

calcium bone
Parathyroid hormone Normal
bone
calcium bone Normal
Normal bone
osteoid tissue deposit

frontal parietal bossing
skull circumference
broadening
Marfan
rachetic rosari
145
| Page
" " :
,, : " "
"

.......
......
Osteoid tissue deposit

Delayed dentation teeth

delayed motor development bone
Hypo tonia
Muscle weakness
delayed closure of the fontnel

delayed closure of the fontanel
symptoms

,,,
,,,
Investigations
Phosphate is too low
normal
Parathyroid hormone normal
alkaline phosphatase High
alkaline phosphatase Normal
,,,
crystals bone
crystals bone
osteoblast
,,,
,, X -ray
radiological finding rickets
,,

,,,

146
| Page
" " :
,, : " "
"

.......
......
2

,,,
,,,

,,,

even
What ever

,,,

bone
New bone formation

,,, vitamin D
phosphate
consumption
,,, vitamin D

,,

,,,
,,,
,,,
:
bossing broadening Marfan sign
rachetic rosari
:
Primary hypo phosphatemic rickets
associated defect in hydroxylation of vitamin D inside the kidney
gene
,,, hydroxylation of vitamin D inside the
the kidney
147
| Page
" " :
,, : " "
"

.......
......
,,,
,,
vitamin D
severe rickets
,,


,,,
Fanconi syndrome Fanconi anemia
Fanconi Syndrome
Fanconi anemia
hematology
Fanconi syndrome
hereditary
Gene defect
gene autosomal recessive gene
Mode of inheritance
Autosomal recessive gene
secondary
Secondary to nephrotoxic drugs
What ever nephrotoxic drug
secondary to metabolic diseases

hepatomegaly
metabolic diseases
glycogen storage disease
galactosemia
lipid storage diseases
148
| Page
" " :
,, : " "
"

.......
......
tyrosinemia

Wilson disease
What ever
associated metabolic diseases
kidney

congenital acquired
congenital type autosomal recessive
Fanconi syndrome
tubular defect
tubular defect tubules

urine

amino acids
amino acids filtration
glomerulus of the kidney
complete reabsorption of the proximal convoluted tubules
amino acids
Urine
amino acids protein
,,,
,,, amino acids urine
,, failure to thrive
failure to grow
failure to thrive
weight loss
short stautre
,,,
,,
,,
149
| Page
" " :
,, : " "
"

.......
......
failure to thrive
weight and hight both are affected

Fanconi

say 12
,,
:
,,,
,,,
Fanconi

amino acids urine

urine
urine
Hypo hyper kalemia
hypo kalemia
electrolyte disorder
) (
bradycardia
Paralytic ileus

diarrhea
Manifestations of hypo kalemia
,,
Loss of glucose
150
| Page
" " :
,, : " "
"

.......
......
Loss of glucose in urine

urine
urine
oliguria polyuria
osmotic diuresis poly uria

,,,
,,,
and poly uria
polydepsia

diabetes
Normal low

,,,
poly phagia
polyphagia
,,,
,, feeding center

urine
,,
poly phagia
poly uria
poly depsia
weight loss
differential diagonsis of diabetes
,,

loss of bicarb urine
loss of bicarb urine
bicarb urine
urine alkaline acidic
urine acidic alkaline
151
| Page
" " :
,, : " "
"

.......
......
urine acidic
urine alkaline
,,,

Infection
urinary tract infection
UTI nephrology
Infection
Organism urine
Infection
Organism acidic media
urine acidic
Organism proteus
proteus
alkaline media
:
,,
urinary tract infection proteus
,,
urinary tract infection proteus!!!!

:
urinary tract infection proteus
Fanconi

:
Fanconi PH urine
Alkaline
media Proteus
152
| Page
" " :
,, : " "
"

.......
......
Loss of bicarb acidosis

acidosis melting of bone calcium
bone calcium
calcium bone
rickets
,,,
Fanconi
Loss of phosphate urine
,,,
rickets
:
Loss of bicarb in urine melting of bone calcium

bone calcium

Loss of phosphate in urine

bone
bone

,,

) energy (
Hydrocephalus
bossing
rachetic rosari
Marfan
boradening
bone
bone acidosis
bone
urine
153
| Page
" " :
,, : " "
"

.......
......
,,,
Fanconi Syndrome
,,

,,,
failure to thrive
manifestations of hypo kalemia
manifestations diabetes
manifestations of acidosis
rickets

,,, Osteoporosis
amino acids
,,,
,,,
Investigations
Investigations
,,,,
Investigations
Fanconi
,,,
) (
,,, Investiagtions
Fanconi

blood
urine
,,,
urine

154
| Page
" " :
,, : " "
"

.......
......
,,,
Treatment

,,,
rickets
high protein diet
amino acids loss urine

phosphate

sodium bicarb
acidosis
frequent meals
glucose

frequent meals
,,,

hypoglycemia

frequent meals
,, ,,,
KCL

,,,
renal transplantation

renal transplantation
155
| Page
" " :
,, : " "
"

.......
......

,,, active form of vitamin D and calcium

calcium bone

vitamin D calcium
tubular defect
associated hydroxylation of vitamin D
active form
Fanconi

Lignac Syndrome
) spelling
---
syndrome ( Lignac syndrome
)
,, (
)
(
mode of inheritance
Autosomal recessive
Autosomal recessive

,,, cystine amino acid
deposit in varient tissue
In born error of metabolism
cystine amino acid

kidney
156
| Page
" " :
,, : " "
"

.......
......
tubules of the kidney

Fanconi Syndrome
) (
secondary primary Fanconi
Secondary
Fanconi kidney
,,,
cystine amino acid
reticulo endothelial system deposit
reticulo endothelial system
lymph nodes
generalized lymph adenopathy
spleen
splenomegaly
,,,
hepatomeagly
hepatosplenomegaly
,,,
bone marrow
aplastic anemia marrow cavity
pan cytopenia pan
reticulo endothelia system
generalized lymph adenopathy lymph nodes
hepatosplenomegaly
aplastic anemia
bone marrow failure

,,,

cornea ,,,
cornea slit lamp
Wilson
Kayser flisher ring
cornea cystine crystals
Page |
157
: " "
" " : ,,
"

.......
......
,,,
autosomal recessive disease
cystine amino acid deposit renal tubules
Fanconi syndrome
deposit reticulo endothelial system
lymphadenopathy
splenomegaly ,, hepatosplenomegaly
bone marrow failure
,,,
cornea
cystine crystals in cornea

Treatment
Fanconi
cystine free diet
,,, chelation of cystine tissue
Wilson
)
( 53 : 34 :1
) (
Wilson
chelator of cupper tissues
chelation of cystine tissues

D penicillamine
chelation
,,, D pencilamine nephro toxic

specific chelator
cystiamine
cystiamine specific chelator of cystine amino acid
Rickets Fanconi
158
| Page
" " :
,, : " "
"

.......
......

,,,
lowe's syndrome
Lowe's Syndrome
lowe's syndrome
X - linked recessive
Mode of inheritence renal rickets
X - linked recessive
Lowe's syndrome
combination ,,,
triad
triad
triad
Occular manifestations cataract glaucoma

cerebral manifestations Mental retarded
generalized muscle weakness and hypo tonia
differential diagnosis floppy baby
generalized hypo tonia
renal manifestations
Fanconi syndrome
Lowe's syndrome Fanconi syndrome
rickets
Oculo-cerebro-renal synddrome
,,,,
,,,
)
(
,,,
manifestations of rickets in X - ray
active rickets
Rarefaction of the bone
cubbing
159
| Page
" " :
,, : " "
"

.......
......
broadening
fraying
double periosteal line
bone deformity

,,,,
healing phase
,, line of ossifications
healed rickets
,,, thick line of ossification
thick line
Renal rickets
glomerular type renal osteodystrophy

rickets
hydroxylation of vitamin D Kidney
metabolic acidosis Melting of bone
calcium
retention of phosphate hyper para thyroidism
,,,
,,,
Clinically renal failure rickets
laboratory

serum phosphate ,,
Parathormone
calcium Normal Low

160
| Page
" " :
,, : " "
"

.......
......
,, urine
urine
excess calcium
low in phosphate
renal failure ,,,
active form of vitamin D ,,,
calcium
acidosis
sodium bicarbonate
diet restriction of phosphate
phosphate binder
para thyroidectomy resistent cases
,,,
tubular type
X - linked dominant disease Primary hypo phosphatemic rickets
Loss of phosphate in urine defect
rickets
rickets rickets
Manifestations
delayed closure of the delayed motor development just delayed dentitation
fontanel
manifestations of osteoid tissue over deposit

proliferation manifestations of cartilage
,,

drug Phosphate
calcium vitamin D
Fanconi syndrome
Urine
amino acids
glucose

bicarb
phosphate
Page |
161
: " "
" " : ,,
"

.......
......
bicarb
rickets
Fanconi syndrome

High protein diet

acidosis

frequent meals glucose loss in urine
phosphate Vitamin D calcium

Cystinosis
cystine amino acid deposit
cornea corneal crystals
reticulo endothelial system Lymph adenopathy
hepatospleno megaly bone marrow failure
tubules of the kidney Fanconi Fanconi Anemia
Fanconi
cystiamine cystine amino acid chelator
Lowe's syndrome
Occular cataract glaucoma
Cerebral mental retardation Hypo tonia
Fanconi syndrome

) (
) (
)
(

,,,
Vitamin D dependent rickets
Vitamin D dependent rickets
,,
Vitmain D dependent rickets
deficient rickets
162
| Page
" " :
,, : " "
"

.......
......
deficient rickets
,, vitamin D dependent rickets
vitamin D dependent rickets
Hereditary defect vitamin D metabolism
vtimain D

,,,
hereditary defect kidney
,,,
,, Kidney hydroxylation of 1
vitamin D

kidney
vitamin D dependent rickets type one

vitamin D dependent rickets type one
,,,
di hydroxy cholicalciferol 1,25
rickets

,,
vitamin D dependent rickets type two
vitmain D metabolism
,,,
Liver hydroxylation 25
Kidney hydroxylation carbon atom 1
active form

defect receptors of vitamin D
receptor defect
163
| Page
" " :
,, : " "
"

.......
......
receptors
,,, :
GIT
Bone
Kidney
vitamin D
,, receptors

vitamin D
defect ,,, Number function
end organ resistence
vitamin D ,,
,,

receptors
active form ,,

receptors
,,,
,, defect function number
,, High doses of active form of vitamin D

,,
,, associated other defect
,, alopecia totalis
) alopecia areata area

164
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"

.......
......
alopecia areata

alopecia totalis
alopecia
alopcia totalis
alopecia universalis ,,
(
common association alopecia areata

,,

,,, ,,
,,, hepatic rickets
Hepatic Rickets
hepatic rickets
liver affection
liver affection rickets

,,

Bile
obstructive jaundice
bile liver GIT
absorption of fat
fat soluble vitamins vitmain D
mal absorption vitamin D
,,
,, cirrhosis
cirrhosis rickets
Liver cirrhosis rickets
:
,, ,, stores Liver ,,
vitmain D Liver

165
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"

.......
......
defect stores
,, hydroxylation of vitamin D 25
Liver
Liver cirrhosis rickets :

depletion of the stores
hydroxylation vitamin D
liver
,,
,,, anti epileptic drugs
: anti epileptic fat soluble
fat soluble excretion liver
secretion Liver
toxic hepatic hydroxylation
,,, OH
OH vitamin D
vitamin D
Inside the inside the liver
,,
Hepatic rickets
Rickets Liver affection

liver cirrhosis
,,
,, ,,

166
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"

.......
......
,, celiac rickets
Celiac rickets
celiac rickets
malabsorption in general ,,
mal absroption syndrome
malabsroption syndrome
,, Malabsorption syndrome Loops of the gut
Loops intestine
malabsorption
,, malabsroption
,,
gut
absroption

gut absorption
,,,
mal absorption synddrome In general
,,
fatty acids
fatty acids
,,,

chemical reaction fatty acids
,,
fatty acids
fatty acids calcium soap
,,,
fatty acids

167
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"

.......
......
absorption
Intestinal villi

,,, intestinal villi :
Intestinal villi mal absorption
,,
vitmain D oral
,,, vtimain D parentral
) !!!!! suppository (

gut
,,
vitamin D parentral

hypo phosphatasia
Hypo Phosphatsia
Hypo phosphatsia
autosomal recessive disease
alkaline phosphatase enzyme
,,
decrease alkaline phosphatase
Hypo phosphatasia
,, osteoblast alkaline phosphatase

alkaline phosphatase organic phosphate
rickets
alkaline phosphatase Organic phosphate

Phosphorus
bone matrix
) Organic ( In organic
phosphrus calcium
bone crystals
rickets
168
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.......
......
bone matrix
Organic phosphate phospho ethanol amine
phosphorus
phosphorus the bone crystals
,,,
alkaline phosphatase autosomal recessive disease

,,
osteoblast organic phosphate phosphrus
,,
new bone
ricketic manifestations
,,
calcium ,,, bone
bone ,,
calcium
Hyper hyper calcemia
Hyper calcemia even nephro calcinosis
Organic phophate
absroption ,,,
Metabolism
Urine
,,,, Urine urine analysis
,,, urine organic
organic phosphate
,,
diagnostic ,,,
urine
organic phosphate phospho ethanol amine In urine
phospho ethanol amine urine
diagnostic hypo Hypo phosphatasia
,,

169
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.......
......
,, alkaline phosphatse
,,,
,,,

,,,
marasmus Kwashiorkor phospho ethanol amine
urine
dianostic Hypo phosphatasia
organic phosphate urine
hypo phosphatasia
vitamin D

serum
,,
,, ,, plasma transfusion

serum
,,,
,,
: rickets
blood transfusion
vitamin D Phosphorus
,,

Hypo phosphatasia

170
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"

.......
......
alkaline phosphatase plasma

Plasma plasma transfusion

Hypo phosphatasia organic phosphate
Organic phosphate bone
In organic
bone Osteoblast
osteoblast Organic

,,
,,

hyper para thyroidism
Hyper Para Thyroidism

Hyper para thyroidism
primary hyper para
secondary
Hyper para thyroidism vitamin D deficiency rickets
glomerular rickets
,,
Hyper para
secondary hypo calcemia
primary
para thyroid gland tumor
benign
malignant
,, adenoma
adenoma parathormone hormone
171
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.......
......
Parathyroid hormone
:
bone
Kidney
,,, bone
,, Kidney phosphate

,, ,,,
bone
bone rachetic manifestations
osteotitis fibrosa cystica glomerular type
,,
serum calcium ,,,
,, serum phophate
,, para thyroid hormone
,, alkaline phosphatase ,, alkaline
phosphatase crystals bone

Surgical ,,
tumor adenoma para thyroid

para thormone
calcium

rickets ,,
calssifications of rickets

: ,, ,,
: ,,
172
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"

.......
......
,,
rickets
classifications of rickets
Classifications of Rickets
classifications
,,

classifications of rickets
,,
classifications ,,
vitamin D metabolism

,, ,, ,, ,,
,,

,, ,, classifications
basics
,, basics
,,,
classification
Rickets
rickets :

,, vitamin D deficiency rickets

vitamin D oral
,, ,, cholecalciferol
vitamin D3
oral

, Intake ,,, Mal nutrition
173
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"

.......
......
exposure ultra violet rays

atrophic rickets associated malnutrition In general
atrophic rickets

vitamin D3 :

,,
vitamin D3 oral

absorption
,,,
:
Intake

,, atrophic rickets Intake
,,
:
defect intake
defect exposure to ultra violet rays

atrophic rickets

,, ,,
,,,
atrophic rickets marasmus Kwashiorkor
,,
,, vitamin D oral
vitamin D oral ,,
174
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"

.......
......
,, absroption ,,
vitamin D oral ,,

,, Celiac rickets
Celiac rickets
Malabsroption synddrome
,, vitmain D oral absroption
vitamin D parentral

,, ,, Hepatic rickets
Obstructive jaundice ,,
bile absroption
,, ,,
Liver cirrhosis
vitamin D ,,
vitamin D3 hydroxylation
Liver
Liver cirrhosis
,, 25 di hydroxy cholicalciferol 1,25

D
,,
,, anti epileptic drugs
,,
active form
,,
hepatic rickets :
Liver cirrhosis
175
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"

.......
......

Celiac rikcets
,,
renal rickets
glomerular renal osteodystrophy
vitamin D ,, active form
,,,
tubular defect
vitamin D

,, vitamin D
glomerular tubular
vitamin D resistant rickets
,,
vitmain D dependent rickets type one

Kidney Hydroxylation vitamin D
vitamin D
hydroxylation
active form
type two
end organ
Oral vitamin D
,, high doses active form
Hypo phosphatasia
vitamin D
plasma alkaline phosphatase
176
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"

.......
......
tumor Para thyroid

vitamin D
vitmain D resistant rickets
rickets :
Vitamin D deficiency rickets .1
oral vitamin D3 cholicalciferol
Oral ,,

,,
Vitamin D resistant rickets .2
oral vitamin D
Modifications ,,

,, ,,

vitamin D deficiency rickets ,

,,

,, ,,
: ,,, ,,

)
(
!!!! ,,
,,
,,
,,
,,

,, ,,
,,

177
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,, : " "
"

.......
......
,,

,, (
: )

) (

,,
,,
) (
) (

) (

vitamin D
,, ,,
vitamin D
Manifestations of rickets
: normal variability
,,,

,, ,,
,,,
recent classification
Rickets
,, recent calssifications
:
recent classifications ,,
:

: end organ resistance

vitamin D dependent rickets type two

178
| Page
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,, : " "
"

.......
......
,,
: vitmain D

rickets phosphorus
vitmain D calcium intake
phosphorus
,,

phosphate
phosphate ,,
tubular defect ,, Primary hypo phosphatemic
Fanconi
cystinosis
renal tubular acidosis
Lowe's syndrome
,,,


Phosphate
bone

,,,

bone
bone

bone vitmain D
dihydroxy cholicalciferol 25 ,1
179
| Page
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"

.......
......
bone vitamin D
dihydroxy cholicalciferol 25 ,1
25 ,1

:
Defect ,, intake
,, vitmain D
lack of exposure to ultra violet rays

atrophic rickets
,, Hepatic rickets
hepatic :
Cirrhosis
Toxic hepatic hydroxylation
active form
glomerular type of rickets ,,

renal failure
glomeruli hydroxylation vitamin D
vitmain D dependent rickets type one
dihydroxy cholicalciferol 25 ,1 ,,
bone
rickets
,,
,, primary hypo calcemic rickets
dihydroxycholicalciferol 25 ,1
,,, primary hypo phosphatemic rickets
phosphorus
180
| Page
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"

.......
......
tubular defect
,,, end organ resistance
vitmain D resistant rickets type two

,, ,, rickets
vitmain D Phosphorus
,,
metabolism
rickets resembling conditions

rickets
rickets ,, vitmain D ,,
:
hypo phosphatasia
hyper para thyroidism
,,
,, Primary hypo calcemic dihydroxy cholicalcefrol 25 ,1
,, primary hypo phosphatemic tubular defect
,, end organ resistance type two vitamin D resistant rickets
,, rickes resembling conditions Hyper para thyroidism
hypo phosphatasia
calssifications

,,,
oral questions
tetany
,,
,, ,,

Oral questions
181
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,, : " "
"

.......
......
:
)
( ,,,
,, ,,,
,,

) ( ,, ,,,
,, ,,

,,,
,, !!!!!!

,,
,,
,,
,, :
,,,
,,
,,

,,,
rickets
,,, ,,
sheet
: sheet ,, sheet ,,
,,
eye examination rickets
rickets
,,
: rickets
examiner eye
rickets!!!!
182
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"

.......
......
,, ,, jaundice
rickets Jaundice
,,, Jaundice obstructive jaundice
,, hepatocellular cirrhosis
rickets
,, eye infection

Repeated infection
conjuctivitis
,,
,,, ,,
cataract
Intra occular pressure

cataract
,, cataract
rickets
: rickets cataract
Lowe's syndrome
Lowe's syndrome cataract glaucoma
Lowe's syndrome
,, In born error of metabolism
galactosemia
galactosemia ,, !!!!
:
rickets
,, galactosemia ,,
galactosemia Fanconi syndrome
rickets
galactosemia
Cataract
: galactosemia
cataract
tubular defect Fanconi syndrome Fanconi
rickets
183
| Page
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.......
......
,,,
,, cornea Kayser
flisher ring
Wilson disease
Wilson Kayser flisher ring
Wilson
Wilson Fanconi syndrome
Fanconi rickets
cornea cystine crystals
cystine cyrstals cystinosis Lignac Syndrome
cystine crystals cornea cystinosis
lignac syndrome
,,
cornea ,, Ulcers
,, herpes
Herpetiform corneal ulcer
tyrosinemia
: ,, tyrosinemia
,,
: Fanconi secondary to in bron error ,,
inborn error ,, tyrosinemia mechanism
of hepatomegaly
,,
tyrosinemia mechanism
of hepatomegaly
herptic form of corneal ulcer
tyrosinemia Fanconi
,,

,,,
Jaundice
Infection
Cataract
Kayser flisher ring
Cystinosis
184
| Page
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"

.......
......
Corneal ulcer

hyper para cataract
,, ,, : occular
manifestations
,, : ,, corneal manifestations
rickets
corneal ,,
,,

,,
,, : rickets abdomen
palpable liver and spleen
rickets abdomen liver spleen
Liver spleen ,,

Ptsois of the organs ,,
hypo tonia

,, repeated infection ,,
cooley's anemia
associated lymph adenopathy Hepato splenomegaly
hepato spleno megaly

,, cystinosis cystinosis liver spleen
,,
,, wilson
hepato megaly hepato spleno megaly
Wilson Fanconi
tyrosinemia hepato spleno megaly
,, ,,
,,
,,
Glycogen storage disease
185
| Page
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"

.......
......
,, liver spleen Fanconi

syndrome
Liver disease chronic abscess hepatitis

cirrhosis
,, splenomegaly shrunken liver
,, portal cirrhosis Portal hypertension

,,,

written
,,

:
: tyrosinemia galactosemia Wilson
,,, ,,
,,
,,, rickets
rickets
rickets
!!!!!!!!!!!!!!! !!!!!!
,, rickets

:
rickets
rickets
rickets
cataract rickets
kayser flisher ring rickets
,,,
,,
,, ,,,
nerve cell
Nerve cell excitability

physiology
186
| Page
" " :
,, : " "
"

.......
......
Nerve and muscle
,,,,,
,, : nerve cell excitation
,,, stimulus
stimulus ,,
threshold
,, threshold

threshold ,, stimulus

abdominal reflexes
,, reflex abdominal wall
Underlying muscles contraction
,, abdominal reflex is so exaggerated
,, ,,
,, ,,

,,

,,,,
pain threshold
,,,
,, ,,
vaso vagal attack
,, ,,
15
: ,,
local anesthesia
: ,,
,,
threshold ,,
,,
,, threshold firing of the cells
187
| Page
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,, : " "
"

.......
......
cells stimulated
Once firing of the cells depolarization
,,
,,
: stimulus firing of the cells
:
cell membrane Neuronal cell
,,
,,
firing of the cell
,,, stimulus
,,
depolarization of the cell
!!!
,, : ,,
| Nerve cell

gate of Na
Nerve cell
: Ionizable calcium
ionizable calcium gate of Na channel nerve cells
Influx of Na inside the cell
stimulus
stimulus Ionizable calicum
channel
non ionizable form
Ionizable calcium repelling
,,,
,, Non ionizable calcium
,,,
,,
,,
depolarization of the cell excitation of the cell

188
| Page
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,, : " "
"

.......
......

,, excitation of the cell
ionizable calcium channel of the
nerve cell

,,,

: ionizable calcium threshold
threshold ,, stimulus ,,
non ionizable calcium
,,, Ionizable calcium ,,, threshold ,,

stimulus

threshold excitation of the nerve cell
ionizable calcium cell membrane of the
nerve cell
Ionizable calcium ,, threshold

,,
,, ionizable calcium ,,

threshold
stimulus excitation of the cell
ionizable calcium

autonomous excitation of the cell

,,
,,
,,
tetany
Tetany
definition of tetany
Definition
189
| Page
" " :
,, : " "
"

.......
......
hyper excitability of the nerve cell

hyper excitability excited
,,,
threshold is so low
Even stimulus ,,,
Etiology
,,
,,,

,, ionizabel calcium
: in general
serum calcium in general
: serum calcium
ionizable
non ionizable
,,
Excitable

serum calcium normal
,,

tetany
,,
total serum calcium averge say 10

serum calcium
% 45 ionizable active form
% 55 non ionizable form
,, total serum calcium

% 45 ,, ionizable ,,
% 55 non ionizable
tetany
190
| Page
" " :
,, : " "
"

.......
......
ionizable form
mg per dl 3
% 30
,,
mg / dl 10
% 45 mg 4.5 ionizable
mg 5.5 non ionizable
tetany
,, mg 3 ionizable
,,
,, ,,
acidosis non ionizable calcium ionizable calcium
alkalosis ,, alkalosis
acidosis Non ionizable ionizable
alkalosis
renal failure rickets
tetany
Say ,,
renal failure
serum calcium 6
6 mg 4 ,, ionizable
mg 2 non ionizable
tetany
,,
total serum calcium
,, acidosis ionizable form
tetany
,, serum calcium
alkalosis

say ionizable calcium mg 2.5
non ionizable mg 7.5
191
| Page
" " :
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"

.......
......
Ionizable ,, mg 3 tetany tetany

total serum calcium Normal
,, ,, tetany
alkalosis
alkalosis tetany
ionizable form of serum calcium
,, tetany
,, Mg
Mg
Mg Para thormone
Para thormone hormone synthesis
,,
Mg hypo para thyroidism ,,,
Para thormone hormone ,,

Hypo calcemia
Hypo calcemia
Tetany
,, tetany :
total serum calcium
.1
alkalosis
.2
Hypo Mg
.3

tetany ,,,,
total serum calcium ,,
serum calcium ,,,
,,,
,, : serum calcium
serum calcium
,,
192
| Page
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"

.......
......

,,,

vitmain D
,, vitmain D

,,,
,,,
Para thyroid hormone bone
,,, para thyroid hormone clacium bone
,, ,,,
,,
) (
vitmain D
para thormone

,, ,, ,,
,,
,,,
,, vitmain D
vitmain D deficiency Hypo calcemia
tetany
,,,
,,,
,,, ,,
)
,, (
,,
,,,
,,
,,
193
| Page
" " :
,, : " "
"

.......
......
,,
,,,
,,

,,
para thyroid
Para thyroid

,,
Para thyroid ,,
,,, Hypo para thyroidism

,, Para thyroid gland is still
immature
,, ,,
,,,
para thyroid gland is still immature

pre term,,
intra uterine growth retardation
hypoxia Para thyroid
Infant of diabetic diabetes
,, Para thyroid gland
gland
gland ,,
hypo para thyroid gland
hypo calcemia
hypo calcemia
,,
intra uterine Hypo calcemia
calcium
,, hypo calcemia
hypo calcemia 72
tetany 72
194
| Page
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,, : " "
"

.......
......
early neonatal hypo calcemia

early neonatal hypo calcemia 72
para thyroid gland still immature
pre term
intra uterine growth retardation
Infant of diabetic mother
fetal hypoxia
,, ,, para thyroid gland ,,

,,
,,,,

para thormone
,,
,, compensation serum calcium
hypo calcemia

activity
,,, serum
clacium

,,
,,,
,, cow milk feeding
:
,,, ,,, ,,,
: ,,, pre mature formula artificial milk
Powdered milk
vitamin D
: ,,
,,
,, : ,,
,,
195
| Page
" " :
,, : " "
"

.......
......
,,

,, ,,

cow milk ,,
: ,, ,,,

,,,
,, cow milk

,,

cow milk ,,, alkaline
cow milk excessive phosphate
calcium
,,,
,, para thormone
,,,
para thyroid ,,
: late neonatal hypo clacemia
tetany
,,
,,

:
,,

,,
,, ,,
,,
196
| Page
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,, : " "
"

.......
......
tetany
,,,
late neonatal hypo calcemia
,, early neonatal hypocalcemia Para thyroid immature

,, late neonatal hypo calcemia cow milk
buffalo milk so early
,, Para thyroid Para thyroid
congenitally absent para thyroid gland

endocrine
Congenital absence of the parathyroid
Di Gorge syndrome
syndromes Di Gorge syndrome
Di Gorge syndrome :
,,, Para thyroid gland ,,
3rd pharyngeal pouch arch
,,, embryology parathyroid
,,, thymus
thymus
,, T cell maturation defect T. Cells function
Immune deficiency
abnormality aortic arch
heart anomaly
immune deficiency thymus
parathyroid hypo
calcemia and tetany
,, para thyroid surgically removed ,,

hyper para
hypo thyroidism tetany
197
| Page
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,, : " "
"

.......
......

surgical removal of the para thyroid
para thyroid

Hodgkin's lymphoma
cervical lymph nodes ,,
Local irridation neck
local irridiation neck
Irridiation Hypo para
irridiation para thyroid
,,
,, Wilson disease
cupper deposit ,, para thyroid
hemosiderosis
chronic hemolytic anemia
para thyroid
:
Irridiation
Wilson disease
Hemosiderosis
,,,
auto immune destruction
Auto immune hypo parathyroidism
anti body Para thyroid
Rare familial cause

para thyroid
)
(
198
| Page
" " :
,, : " "
"

.......
......
,,, calcium
Urine
urine
calcium urine
,,,

,,
,,, ,, ,,

,, serum calcium

clacium ,, EDTA citrate
EDTA Citrate chelation calcium
exchange transfusion
citrate EDTA
serum
urine

hypo calcemia
,, Alkalosis
)

,, (
alkalosis acid base disturbance
,, :

hyper ventilation
,, ,,, ,,

,,

,,
199
| Page
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"

.......
......
hyper ventilation
carbon dioxide wash
carbon dioxide wash
respiratory alkalosis
respiratory alkalosis
tetany

: ,,
,,
,, ,,
,, anti epileptic drugs
: ,,
: ,, ,,, :

,, ,,
,, hyper ventilation
alkalosis
epilpesy
,, : epilpesy
,,, epilpesy
,,, ,,
attack
,,
,,
,,
,,
epilpesy
,,
,, ,,, acidosis
bicarb
bicarb

alkalosis
200
| Page
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"

.......
......
,,
Over correction of acidosis
alkalosis
alkali therapy

alkali therapy ,,,
,,
,, Persistence vomiting
,,, alkalosis

HCL
HCL ,, ,,,
,,
HCL bicarb
,, alkalosis
alkalosis
,, acid base disturbance
,, Hypo magensemia
Mg ,,
Mg
mal nutirition in general
,, Mal absorption chronic diarrhea
EDTA citrate chelation ,,
chelation Mg

Clinical manifestation of tetany
clinical manifestations of tetany

,,, manifest tetany
,, manifest tetany ,,
,, attack of tetany

201
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"

.......
......
differential diagnosis
,, manifest tetany
,, manifest tetany carpo pedal spasm
carpo pedal spasm
,, ,,
) (
,,,
) carpal
( pedal
Planter flexion

,,
,,
,, spasm ,,
generalized convulsion

,,,
laryngeal spasm
,, laryngeal spasm ,,
laryngesmus stridolus
,, manifest tetany
carpo pedal spasm
convulsion
even laryngeal spasm
,, Manifest ,,
degree
: diabetic mother prenatal asphyxia
early neonatal hypo calcemia
: Para thyroid still immature
infant of diabetic mother
202
| Page
" " :
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"

.......
......
prematurity Neonatology
,,,
,, latent tetany
Latent tetany
Ionizable calcium
Normal % 45
,, Low % 30 mg 3

mg 4.5 mg 3
mg 3 Manifest tetany
Say ,,
ionizable calcium ,,, 3.5 mg
ionizable calcium
,,, manifest tetany
threshold ,,

,, Nerve cell
,,

: complications of rickets
tetany
!!!! ,, complications
tetany
rickets
,,,, against you
,,,

rickets marasmus Kowashirkor
,,

:
rickets ,,
203
| Page
" " :
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"

.......
......
,,
: complications of rickets
tetany
tetany ,,,
tetany rickets
,,
: tetany
,,,
tetany !!!!!
: Manifest tetany
,,
latent tetany
,,
,,,
,,
rickets
Phosphorus alkaline phosphatase

: Normal Low
: ,, serum calcium Normal
: Investigations
: clinically serum clacium Normal
Low
: serum calcium Low
Manifest tetany
latent tetany
,,
Manifest tetany
,,
Latent tetany
204
| Page
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"

.......
......

threshold
sign
,,
tempro mandibular joint
neck of mandibule
Neck Mandibule ,, tapping
hammer
,, neck mandibule
tapping hammer
facial nerve
facial nerve nerve Hyper excitable
facial muscle ,,
contraction
,,
contraction

Chevostek sign
,,
: ,, ,,
,,

: ,,
,,,

pressure systole mins 3
,,
Carpal spasm
mid thigh
pedal spasm

Trouseau sign
205
| Page
" " :
,, : " "
"

.......
......
,, ,, ,, systole
carpal pedal spasm

arm thigh
,,
,, fibula
Neck of the fibula anterior tibial nerve
anterior tibial nerve supply ,,
tibialis anterior
,, neck of the fibula

hammer ,,
,, threshold ,, Nerve excitation
tibialis anterior contraction
tibialis anterior contraction
dorsi flexion eversion of the foot
Dorsi flexion
Eversion of the foot

Peroneal sign
ECG ,, QT interval ,,
ECG

Treatment
tetany
calcium
,, slowly IV
brady arrhythemia
cardic arrest
heart
206
| Page
" " :
,, : " "
"

.......
......
slowly IV ml / Kg 4 - 2
calcium gluconate slowly IV
very slowly IV
,,
hypo Mg
alkalosis
tetany ,, vitmain D calcium

supplementation

tetany
36
37
clinical written
criteria of adequate diet
Criteria of adequate diet

adequate diet :
,,, adequate total Caloric supply ,,
,, Caloric supply
,,
caloric supply
,,
,, Premature Pre term
Calori / Kg 120 ,,
Pre term Calori / kg / day 120
neoborn full term
,,
,,, 100 Calori / Kg / day 120
:
pre term Calori / kg / day 120
207
| Page
" " :
,, : " "
"

.......
......
full term ,, 100

Calori / Kg / day 120
,,

,,,
Calori / kg / day 100

,,
Calori / day 100
,,
,, Calori / kg / day 50
,,
Calori / kg /day 50
,, ,,
,,
Calori / kg 20
,, ,,

,,,
8
8

x 100 = 800
,,

,,
,, x 100 = 800 8
800
12 ,,

1100
208
| Page
" " :
,, : " "
"

.......
......

12
,,
,,,

,,
100
x 10 = 1000 100
) 50 2
(
x 50 = 100 2
1100 = 100 + 1000
,,, 25 ,,,

1600

,, MCQ

25 daily requirement

25

,, 100
,, 50
,, 20

x 100 = 1000 10
x 50 = 500 10
x 20 = 100 5
209
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......
1600

,,

criteria of adequate diet
adequate total caloric supply
caloric requirements

10 ,,,

1000
,, 1000
composition of diet
criteria of adequate of diet
,, Porportional diet
Proportional diet

% 50 total Calories carbohydrates
% 15 total Calories protein
% 35 total Calories fat
,, Calories
% 50 Carbohydrates
% 15 protein
% 35 fat
:
total Calories
composition ,, fat ,, carbohydrates
protein
,,
,,
210
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"

.......
......
:
carbohydrates 500
proteins 150
fat 350
,, Calories ,,

,,
Carbohydrates 4.1 ,, 4
500 ,,
500 ,, = 4/ 500 ,, 125

fat 9.3 ,, 9
350 ,,
350 ,, 9 ,,
fat
38.8 = 9 / 350 ,, 39 fat
protein 4.1 ,, 4
150 ,,
150 ,, 4

37.5 = 4 / 150 ,,
,,
diet Calories supplied
fat protein carbohydrates

adequate diet
,,, adequate amount of vitamins and

minerals
,,
salts
211
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"

.......
......
,, ,, ,, minerals
Mg

vitamins
vitmains ,, vitmains
vitmains
,,
,,
vitamins
,, ,, caloric supply
carbohydartes fats Proteins
vitamins minerals
,,
,,
,, adequate amount of water
: criteria of adequate diet
Total Caloric supply

,, Proportional diet fat carbohydrates Proteins

Adequate amount of vitamins and minerals
Adeqeuate amount of water
,,
,, diet Rules
,, carbohydrates ,, fat ,, Proteins

,,
,,

212
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"

.......
......
,, ,,
,, Proportional diet
,, Proportional diet
Caloric supply
fat
carbohydrates
vitamins
Minerals
,,
,, ,,

,,
,,
:
,,
: ,, ,,,
,, ,,
,,
,,
,, ) palatable (
,,
,,

,, ,,
palatable
,,
: ,,
,, ,,
,, ,,
,, ,,, ,,
213
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"

.......
......
,,
,, palatable

,, nutritional disorder
,,,
,,
1000
,, ,, 1000
1000 ,,
Say 500 ,,

,,
total caloric supply
,,

,,
,, ,, fat
35 ,, 15 ,,
vitamins ,, Minerals

,, % 50
,,
,, : ,,

,,
,,
Under nutrition
,, Under nutrition reduction of foot staffs ,,
food contents ,,
% 50 ,, % 30 ,, % 20
,,
,,
Under nutrition
all food contents are reduced ,,
214
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"

.......
......
1000 ,, 500
% 50

Under nutrition
under nutrition ,, ,,

Marasmus
,, marasmus ,, under nutrition
,,
,,
,, ,, :
,, ,, caloric supply
adequate or even
,,,
,,
,,
,,
,,
1000
,, 1500 ,,
1500 ,,, ,,
fats

,,

,,

Kwashiorkor
Kwashiorkor
215
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"

.......
......
,,,
,,,
,, Iron ,,,

Iron deficiency anemia
,,
,, ,,
folic acid

Megalo blastic anemia
,, vitmain D

rickets

,, deficiency
,,,
,,,
,, ,,,
1000
1500

obesity
title malnutrition

,,, malnutrition :
,,

,,,
216
| Page
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,, : " "
"

.......
......
,, ,,
,, vitamin D deficiecny
rickets
vitamin D iron
vitmain D toxicity
,, iron deficiency anemia
,,
,,
hyper vitaminosis vitmain Minerals

,,
malnutrition
Malnutrition
reduction excess in one component of the food staffs
,,
,,
under nutrition
Malnutrition caloric supply
,,

,,,
,, :
1000
500

Under nutrition
,,
,,
,,
217
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"

.......
......
,,,

Marasmus Under nutrition

Kwashiorkor
marasmic Kwashiorkor ,,,,
Marasmus
,, edema manifestations Kwashiorkor

,, Marasmic kwashiorkor
Mixed under and malnutrition
,, Nutritional disorder
under nutrition
malnutrition
mixed under and malnutrition
,, nutritional clinically
Clinically
1977
,, Most applied clinically
classifications
,, ,,

,,
Wellcome classification
wellcome classification 1977

35

:
actual body weight
218
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"

.......
......

,,

standard weight
,,, standard weight
,,
,,
,,

,,, standard deviation
score
percentile curve
,,
standard weight
) ideal (
,,
expected weight
,, expected body weight

growth retarded
3 3.5
3 standard
2.5 3.5
standard 3

3
:

,,

,,
219
| Page
" " :
,, : " "
"

.......
......

,,

growth development
,,, 3/4

3/4 ,,,
,,

,, birth weight
6
,,,
,,
,,
,,

6
8
,,,
,,,

,, weight 9
,,,
,, 2

,,
,,
220
| Page
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"

.......
......
12 ,, ,,
growth
,,,
,,
8
expected weigth
: ,, ,,,,
actual body weight
,,,
,,
actual body weight

,,
expected weight standard weight
,,,

expected weight
expected

expected

,,,
% 60 expected
% 40
,,
,,

,,

) (

221
| Page
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"

.......
......
,,
,,, ,, edema
edema
edema
,,,
,, edema
edema
wellcome marasmus
edema
marasmic Kwashorikor
,,
,, edema marasmus
,,, edema marasmic kwashiorkor
,,

:
,, expected weight ,,

,,
:
marasmus
marasmic kwashiorkor
,,,
,, edema marasmic kwashiorkor
,, edema marasmus
,,
:
marasmus marasmus
: ,, ,,
:
222
| Page
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"

.......
......
wellcome classification 60
expected
:
marasmus
Marasmic kwashiorkor
,,, edema
edema
marasmus

,,,

,,,

,, ,,
,, spleen

: Marasmus
: ,,,
,,
: ,, Marasmus
: Marasmus ,, ,,

,, marasmus
,, Marasmus
marasmus
,,, ,, ,,

,,
rules
,,
,,,

223
| Page
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"

.......
......
: 6
,, % 75 expected weight

:
,, edema kwashiorkor
,, edema simple under weight
,,,
,, edema Kwashiorkor
,, edema simple under weight

wellcome calssification
marasmus
Marasmus

edema
,, wellcome classification : marasmus
marasmic kwashiorkor kwashiorkor simple under weight
,, wellcome
) classification
(
,, classification inborn error
toxicology toxicology
,,,
,,

,,,

,,, marasmus
marasmus ,,, chronic under nutrition
Marasmus ,,
224
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,, : " "
"

.......
......

,,

:

,,
,,
,, ,, ,,
,,

,, ,,
,,
,,
,,
,,
,,
,,

,,
,,
,,,
,,

,,,
,, ,,
,,
,,

,,
,, ,,
,,
,,
,,,, ,,
,,,
: ,,,
,,

: ,,
225
| Page
" " :
,, : " "
"

.......
......

,,
...............
,,,
,, ,, ,,

Marasmus

marasmus
Marasmus
total caloric supply
,,,
,,,
Etiology

,,, dietic error
,, Primary type
primary type

,,
dietic error
quantity
,, total caloric supply 1000
500 ,, quantity
,,,
fat ,,
500

scanty breast milk
Scanty breast milk
226
| Page
" " :
,, : " "
"

.......
......
,, ,, ,,
infant feeding
:
: ,,

Is not stasfied after feeding

,, ,, stool Urine

bowel habits stool
: ,,
Intake
,,

% 88 ,, ,,

,, ,,
failure to growth

Under feeding

,, ,,
,,

: ,,
quantitiy
,, ,, ,,

,, dietic history
infant feeding

227
| Page
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,, : " "
"

.......
......
,,
Infant feeding
age month x 10 + 100
,, ,,
8
x 10 + 100 = 180 8
,, 180

120 : 90
,,
120
,, 180 ,,
90
total amout per feed
artificial milk small amount
180 ,, 120 90
,,
,, ,,
,, ,, ,,
Infant feeding
,, ,, ,,
,, 6

6 ,,
6 ,, ,,

,, 9 ,,

,, 12 ,,
3
3 ,,
6 ,,
228
| Page
" " :
,, : " "
"

.......
......
9
9
,,

,, ,,
: ,,
,, ,,
,,

,, ,,

,,
,, ,,
,,,

,, ,,
,, ,, ,,

,,,
,,

,,
,,
6 9 ,,

:
,,
,,,
,,

6
10
2
6
229
| Page
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,, : " "
"

.......
......
9

,,

,,
,,,
11 ,, 12 ,,

8 ,,
,,
:
: 180

,,

,,
widely spaced feed

,,
scanty breast milk ,,
,, artificial small amount per ,,
,, feed widely
spaced feed
,, quantity artificial
breast milk
,,
Caloric supply
,, weaning
,,
,,
230
| Page
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"

.......
......
:
delayed weaning
weaning Infant feeding
delayed weaning
delayed weaning
,,
,, delayed
weaning
iron deficiney anemia delayed weaning
rickets delayed weaning
marasmus delayed weaning
,,
delayed weaning ,, iron deficiency anemia
,, rickets marasmus

,, quantity ,,
quality
,, quality of milk quality of milk
quality of breast milk

,,
,,
,,
breast milk
,, ,,

,,
,,
,,
,,
available
Bebe lac 1 Bebe lac
,,
cover
cover
,, ,,
231
| Page
" " :
,, : " "
"

.......
......

,, ,,

,,

,,
,, ,,

,, ,,

,, 30
30 30 Milk

,,
180

180

30

180 :
,,
:
:

:
:
: 180 ,,

: ,, ,,

,,
232
| Page
" " :
,, : " "
"

.......
......
,, 180 ,, diluted formula
:
: ,,
,,
:
,,
,,

diluted formula
,,,
quanitity
quality
,, quality ,, cow milk

,, cow milk cow milk allergy
cow milk allergy ,,
cow milk buffalo
,, ,,

,,
,,
:

mentally retarded
,, ,,
: ,,
,, Mentally ,,
retarded
,,,
:
: 12
: ,,
,,

233
| Page
" " :
,, : " "
"

.......
......
:
,,
: ,,
,,
Cow milk protein allergy

endocrine
,, cow milk
,, buffalo milk type one diabetes % 36

type one diabetes % 0.5

% 0.5 % 36 buffalo cow milk

,, ,,
,,
: ,,,

,,
: ,, ,,
,, human being not an animal
,,
cow milk protein allergy
,, cow milk protein allergy
chronic diarrhea vomiting
,,
,,
quality
,, Marasmus

Nursing errors
irregular feeding
,, ,, ,,,

,, ,,
234
| Page
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,, : " "
"

.......
......
,,
: ,,

: ,,
,,
irregular feeding
,, ,, ,,
,,
,, ,,,

,, ,,,

,, ,,
,,

,,
,,, ,,

irregular feeding
,,
Marasmus

,,

hydrocephalus
,, ,,
: ,, ,,
: ,, ,,
engorgement of the breast
,, breast
,,
,, very painful
,, engorgement of the breast
235
| Page
" " :
,, : " "
"

.......
......
,, Irregular feeding
,, failure of eructation

,,

,, ,,

,, ,, ,, ,,

,,
,,
,,
: ,,, air emboli
air emboli !!!!!
!!!!
,,
,, ,,
,,
,,,
,,
,, ,,

,,
,,
,,
,, ,, fat muscle

,,
,, ,,

236
| Page
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,, : " "
"

.......
......
,,

: ,,
,, ,,
,,

,, 100 ,, 100

,, ,,
gravity

) Push (
: ,, ,,
,,
,,

,,
,, ,,
,, : ,, ,,
,,
,, ,,
Intestine
abdominal distention
,,

,,
,, conditioned reflex
: ,,,
,,
,,

237
| Page
" " :
,, : " "
"

.......
......
,,,

,, colic
,, eructation of the baby is very important
,,
difficulty of breast feeding

cleft lip cleft palate
,, suckling
,,
,, flat nipple everted nipple
: ,,
,,,
!!!!
,, Nipple
difficulties of breast feeding

marasmus
,, weaning Marasmus

,, ,,
,, Proportionate

,,
,, ,, ,,
marasmus

dietic errors
238
| Page
" " :
,, : " "
"

.......
......
,, secondary marasmus
secondary marasmus
,, ,,
,, consumption of food

,, parasitic infection
marasmus

,,
marasmus
marked chachexia

:

: ,,
,,

: ,, ,, ,,
,, !!!!!
,, ,, ,,
,,
,, ,, ) ( ,,

,,
,,
:
.1 ,,,
Most common Parasitic infection
Parasitic infection

pitryasis alba ,,
239
| Page
" " :
,, : " "
"

.......
......
,,

.2
,, ,, thyrotoxicosis endocrinal causes

,, thyrotoxicosis
.3
,, ,, diabetes
,, :
Parasitic infection
Thyrotoxicosis
diabetes
parasitic infection
,, ,,
,,
,,
clenching of the jaw
parasitic infection
clenching Jaw
infection mechanism

:
,,
saliva
Excessive salivation
,,

: ) (

excessive saliva

,, thyrotoxicosis
,, tremors tachycardia
240
| Page
" " :
,, : " "
"

.......
......
endocrine thyroid swelling

,, diabetes
Investigations

,, hyper metabolic state
thyrotoxicosis diabetes
increase consumption parasitic
parasite consumption ascris
,, ,, anorexia
,, ,,
anorexia
,, anorexia

,,

anorexia
anorexia :
chronic infection
chronic disease
,,,
chronic infection ,, attacks of gastro entritis
malabsorption ,, anorexia
.T. B tuberculosis
,, anorexia
,, urinary tract infection ,, Otitis media

What ever chronic infection anorexia
,,
,, chronic disease
Liver disease anorexia
renal disease anorexia
What ever disease renal tubular acidosis
,, Renal failure

chronic disease
241
| Page
" " :
,, : " "
"

.......
......
Mechanism anorexia
heart disease
heart disease anorexia
,,,, unable to suckle

congenital heart disease
,, dyspnea

,, Heart failure dyspnea
,,
chronic infection chronic disease
Heart anorexia

,, GIT
,, GIT GIT
GIT
gastro esophageal reflux
cardic sphincter

marasmus
Pyloric stenosis
duodenum
absorption
marasmus
gut
duodenal atresia
,,, cleft lip cleft palate

,, gut anomaly
interference with feeding
242
| Page
" " :
,, : " "
"

.......
......
,, multi factorial
multi factorial multi factorial

pre term
pre term marasmus
Marasmus
,, Neonatology
,, preterm jaw muscles
,, weak suckling

Jaw muscles
weak suckling
,,
bulbar cranial nerves
Mature enough
,, ,, Poor swallowing

: ,, ,,
,,
,,
,, suckling swallowing
,,

gut still immature
digestion absorption

,, multifactorial
Inborn error of metabolism
Metabolic disease
,, galactosemia glycogen storage
243
| Page
" " :
,, : " "
"

.......
......
,, Inborn error
marasmus
Multifactorial
,, chromosomal Down syndrome
marasmus
central cause
gum
,,
marasmus

Clinical manifestations of marasmus
clinical manifestations of marasmus
patho physiology
,,
: cow milk
,, ,,
,,
: ,,
,, ,,
,,
,, ,,
,,,
,,
,,

,,

milk ,, fermentation oral mucsoa
,,

244
| Page
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,, : " "
"

.......
......
,,
,, reflux
apsiration ,, ,
empty stomach
growth hormone
other growth factors

full stomach
growth hormone other growth factors

,, ,, ,,
,,,

,,,
Marasmus
Patho physiology
marasmus patho physiology so easy
decrease total caloric supply
calories
Calories supply

,, ,, glycogen stores Liver
Liver glycogen
glycogen stores
glycogens calories
,,
glycogen stores Liver
fat
245
| Page
" " :
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"

.......
......
fat
lipolysis of fat
fat loss marasmus : degrees
First
Second
Third
fat ,, fat abdominal wall

fat abdominal wall
fat
,,
fat abdominal wall ,, Loss of fat of the
anterior abdominal wall
first degree marasmus
,, fat extremities
upper and lower limbs
,, ,,
second degree
skin
,,
,, skin multiple folds

,,
loss fat buccal pad of fat
Loss fat buccal pad of fat

,,
senile senile faceis
: loss of subcutaneous fat

abdominal wall
extremities
buccal pad of fat
,, buccal pad of fat loss of intra abdominal fat

third degree marasmus
246
| Page
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"

.......
......
anterior abdominal wall fat
Intra abdominal fat ,, ,,

scaphoid abdomen
fat
,,
,, fat ,,
,, ,,
,, ,, Muscles
protein Muscle
Muscle protein
Muscle
,, degeneration of the muscle Muscle wasting

,,
mid arm circumference
Mid arm circumference
Mid arm circumference Mid thigh
mid arm acromion process
,, acromion
olecranon
acromion olecranon

,,
acromion
Olecranon

Mid arm circumfernece
skin bone
bone muscle
muscles subcutaneous fat
247
| Page
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"

.......
......
Marasmus
fat
muscle
fat msucle ,, muscle

,, ,,
support
multiple skin folds
,,
,,
Of the bone
bone Osteoid tissue
,, caloric supply
Osteoprosis bone
pathogenesis of marasmus
Osteoporosis bone
,,
,,
,,

,, ,, ,,

" :

"

,,
,,
,,
,, Muscle skin
,,
: ,,
,,
:

248
| Page
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"

.......
......
,,

Osteoporosis
Clinically

marasmus
marasmus clinically
,, ,,
,,

complications
,,

8 :

4 :
,, 8 ,, % 50 expected
edema
growth failure
% 60 expected wellcome
classification without edema
,, Loss of subcutaneous fat
loss of subcutaneous fat
Marasmus grades degrees :
,, first degree loss of subcutaneous fat of abdominal wall
,,, second degree loss of subcutaneous fat of extremities
,, third degree loss of buccal pad of fat and intra abdominal
senile face
249
| Page
" " :
,, : " "
"

.......
......
,, Muscle wasting

,, ,, mid arm circumference

,,
13.5
Marasmus ,, 12.5
,, 12.5
,,
standard deviation score
centile

,, pallor
pallor anemia
Marasmus anemia
iron deficiency anemia
kwashiorkor
megaloblastic anemia
kwashiorkor
anemia pallor
,, skin manifestations of marasmus
skin manifestations of marasmus
,, ,, Multiple
folds
Multiple folds muscles

buttocks buttocks
folds of skin
quadricepis muscles
thigh multiple folds of skin

,, forearm legs
250
| Page
" " :
,, : " "
"

.......
......
buttocks arm
Multiple folds of skin
thigh
,,
,, ,,
fold of skin

,, ,,
,, ,, ,,
fat
skin elasticity :

,, ,, fat dehydrated
dehydration
,,

Loss of skin elasticity
,, Marasmus dehydration
signs of dehydation
Loss of skin elasticity
: skin elasticity
Marasmus
sternum
sternum fold of skin
dehydrated
dehydration
,,
skin manifestations
abdomen
,,
251
| Page
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,, : " "
"

.......
......
clinical
abdomen
,,, fat abdominal wall
muscle
Intra abdominal
,, scaphoid abdomen
anterior abdominal wall ,,,
scaphoid abdomen
,,
,,, Intestine
Intestinal motility visible
abdominal wall is very thin
Intestinal motility
,,
irritable
Irritable
,, ,,

Irritable
Hunger sensation
,,
,, oral ,, sublingual
,,
,,, Hypo thermia
hypo thermia
decreased caloric supply
caloric supply ,, ,,
,, :

,,

,,
,, ,, ,, ,,
252
| Page
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,, : " "
"

.......
......
,, caloric supply
,,
caloric supply
,, ,,, ,,

,,
Hyper thermia
,, ,, ,,,

decreased caloric supply ,,
decreased caloric supply !!!!!
,,,
,,,
,, ,, ,,

,, ,,

,, ,,
,,
,, ,,
,, ,,
,, ,,
,, ,,
Muscle rigors
muscle contraction ,,
,,
,,
,,
,, ,,

,, rigors generators
253
| Page
" " :
,, : " "
"

.......
......
,, muscles heat production
,,
,, ,, ,,
,,

Heat loss
,, Muscle generator ,,
,, muscle wasting production
,, fat
fat Heat loss

fat females Males
,,
,,

,,
,,
,,
,, ,,
,, ,,

,,
fat heat loss
marasmus fat Loss of fat

Hypothermia
dehydration

dehydration
dehydration hypo thermia
254
| Page
" " :
,, : " "
"

.......
......
spesis Hypo thermia
37
,, 38

complications
Muscle wasting
pallor anemia
skin manifestations
irritable
abdominal manifestations
hypo thermia
,,
,, hypo thermia :
Intake ,, caloric supply
,, ,, muscle Muscle ,, wasting
Heat production
,, subcutaneous fat ,, Loss Heat loss

,, hypo thermia ,,
,,
,, hypo thermia dehydration
dehydration GIT
dehydration total blood volume
peripheral vascular collapse

blood volume
water loss
collapse Peripheral vessels
,, ,, ,,

endogenous temperature
255
| Page
" " :
,, : " "
"

.......
......

,, vascular flow
vascular flow Peripheral vessels
,, Pale
,,, dehydration ,,
,, ,, Peripheral vascular collapse
,, Hypo thermia septic shock
septic shock infection
,, septic shock

infection
infection ,,, bacterial viral
cell destruction
cell destruction
pyrogens
Pyrogens false impression heat regulating centres
brain

,,
,, ,,
,, ,,

: ,,
40
40
,,

central
heat regulating center
,, Pyrogens cell destruction
256
| Page
" " :
,, : " "
"

.......
......

Heat regulating center

muscle ,, shivering
,, shivering Production of heat
,,,
,, ,, ,,
:

false impression heat regulating center
,, compensation ,,
,, ,, severe infection
severe infection
,,
toxins Heat regulating center
,,, toxins peripheral vaso dilatation
,, peripheral vaso dilatation flushing extremities
heat loss

septic shock ,,
shock

peripheral vaso dilatation toxins
Peripheral vaso dilatation Heat loss
,,
Infection
257
| Page
" " :
,, : " "
"

.......
......
,,, :
,, ,,
,,
fever
,,
infection fever good sign
stable ,,
,, ,,
infection
,,,
,, toxins Pus

Not reacting to infection
,, Infection
it is a good sign
,,, infection
,,
,, Infection
it is a very bad sign ,,

septic shock
,,, Hypo thermia
Hypo thermia :
toxins heat regulating center
toxins peripheral vaso dilatation heat loss
,,, ,, clinical manifestations marasmus

GIT manifestations
GIT manifestations of marasmus
apetite
marasmus ,,
,,, : Irritable
,,
258
| Page
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"

.......
......
,,,, ,, ,,, ,,

,,
anorexia
,,

,,
program
:

,,,
,, ,, ,, ,,
,,
,, failure
,,

,,

,,
: ,,

anorexia
anorexia Central cause
Central cause

endocrine
feeding center satiety center
amino acids neuro transmitter signals
,,
amino acids
Kwashiorkor
amino acids ,,,
anorexia

,,, ,,
259
| Page
" " :
,, : " "
"

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......
,,
constipation diarrhea
,, constipation
,,, constiaption ,, diarrhea
clinical
: diarrhea
:
diarrhea
diarrhea marasmus
gastro entritis
immunity ,,
immunity
,, ,, immune system
immune system
Immune system
immunity
Immunity ,, repeated infection
GIT
gastro entritis
,, :
normal intestinal villi ,, malnutrition
atrophy intestinal villi
Intestinal villi atrophy
villi
) normal intestinal
villi ( atrophied intestinal villi
surface absorption
surface absorption malabsorption
,,,
GIT Intestinal villi ,,
digestive juices
disaccridases lactase enzyme
Lactose
digestive enzyme
260
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......
digestive enzyme ,, ,,,
,, maldigestion
,, diarrhea gastro entritis

maldigestion ,,,
Malabsorption ,,

,, diarrhea
,,
starvation diarrhea
starvation ,, Marasmus Kwashiorkor

starvation diarrhea
starvation diarrhea
,,
,, Intestinal villi shedding ,,
intestinal cells
Lumen Intestine
cells
wall of the gut
cells
,,
,, cells ulcers
,,
) (
raw area ulcer
raw area Ulcer ,,
serum
GIT serum
mucous
raw area ulcer mucous secretion
: Mucous ulcer
261
raw area
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Mucous protective mechanism

raw area ,,
ulcer
Mucous raw area
raw area healing
raw area excess mucous healing

,,
Lumen bacterial flora
Lumen
,, sheded epithelial cells
,, Mucous
bacterial flora ,,
sheded epithelial cells

Mucous
bacterial flora
,, bacterial flora ,,
mucous ,,
fermentation Mucous
fermentation ,, Mucous fermentation
H2S

H2S

very offensive ,,,

,,
,, H2S iron

,,
262
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......
H2S Iron
: Iron
Iron absorption
,,
Iron absorption
,, absorption lumen
Iron Lumen H2S
,, H2S FeS
FeS ,,
: ,,,
,, :
: ,, ,,
,,
,,
huge amount of watery stool
,,
,, Small amount ,,
loose ,,
,,,
dark
:

H2S
,, GIT
,, stool

,,

: ,,
,, ,,

very offensive
263
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H2S
criteria of starvation diarrhea

:
,, criteria of starvation diarrhea starvation diarrhea
gastro entritis ,, malabsorption ,, maldigestion
starvation diarrhea
,, ,, small amount
,, diarrhea Loose

,, very offensive

,, ,, ,,
:

mucous
bacterial flora
Microscopic examination stool
,, stool
,,
: marasmus
diarrhea constipation
: constipation Intake
,,, ,,
diarrhea
: ,, gastro entritis
gastro entritis
: immune deficiency
Immune deficiency
: ,, Immune system
,, maldigestion
Maldigestion
264
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......
: ,, malnutrition ,,, atrophy intestinal

villi
digestive jucies
Full digestion of food
,, absorption
,, malabsorption

: ,, atrophy Intestinal villi
surface absroption

: starvation diarrhea
: starvation diarrhea
diarrhea
: starvation diarrhea criteria :
,, ,, ,,,
malabsorption Maldigestion gastroentritis
huge amount of stool
,, ,, loose ,, loose
,, ,, greenish in color diarrhea
,,
,, ,, dark greenish in color
,, very offensive stool ,,
: ,, stool greenish stool

offensive

) stool greenish FeS very offensive ( H2S
,, microscopic examination stool
:
Sheded epithelium cells

Mucous
265
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......
Bacterial flora

,, ,, ,, gastro entritis
marasmus
,, gastro entritis ,,
marasmus complications marasmus
: complications

,, ,, ,,

:
,,
complications
,,, ,, ,,
,,, gastro entritis
marasmus
GIT Cardiovascular system
cardio vascular system
,, pulse
,, radial pulse ,,

apical pulse
,, heart rate Low

cardic muscle
slow and weak pulse
weak pulse
,, dehydration
rapid and weak pulse
dehydration rapid and weak
pulse
shocked ,,

respiratory
266
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......
respiratory muscle ,, wasting

muscle
wasting respiratory muscle
respiration
respiratory
,, cc of air 500
500
say ,, 300
shallow respiration

,,
,, weak respiratory movement ,, weak
cough reflex

,,
repeated chest infection Immune deficient
shallow respiratory movement
weakness respiratory muscle shallow respiratory
movement
weak cough relfex

,, ,, complications
complications
intercurrent infection
vitmains Mineral deficiency
vitamin Deficiency toxicity

complications
Intercurrent infection
broncho pneumonia
sinusitis
bronchitis
Otitis media
pyelonephritis
267
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......
gastro entritis
Infection
Infection ,,, Immune system

immune system

,,
complications bleeding ,,
Severe hemorrhage
bleeding
fat cells Protection
blood vessel
subcutaneous fat
,, subcutaneous fat protection wall of
the vessel
,, ,,
,, ,,

,,

,,
,, blood vessels
,,
fat
,, fat ,, vascular
support
,, vascular support vessel Liable to bleed
,,
wall of the vessel
wall of the vessel
collagen fibers
collagen ,,
collagen fibers supporting wall of the vessel
,, wall fragile
wall of the vessel ,, fragile :
,, Loss of subcutaneous fat ,,
268
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......
,, collagen fibers supporting the vessel ,,

,, ,, bleeding Infection dehydration
,, dehydration
dehydration Infection ,,
dissminated intra vascular coagulopathy
DIC
Intra vascular thrombus
fibrinolytic system
,,
fibrinolytic system ,,

,,,

,, consumption platelets
coagulation factors
hematology
consumption Platelets coagulation factors
platelets
coagulation factors

: bleeding
vessel wall collagen
supporting vessel
subcutaneous fat
consumption platelets ,, coagulation factors
DIC
DIC severe infection
dehydration
dehydration DIC
Infection DIC

,, complications ,,
,,, ,,
269
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......
,,
mainly
,, ,,
,,
,,
Caloric supply
,, ,, marasmic kwashiorkor
edema
,, edema
marasmic kwashiorkor
faulty management
,, caloric supply
,,,

complication ,, hypo thermia
,,
hypo glycemia ,,
hypo glycemia hypoglycemia

hypoglycemia marasmus
hypoglycemia
,,
hypoglycemia!!!!!
hypoglycemia hypoglycemia hypoglycemia
,, ,,
,,,
,,
,, hypoglycemia Intake
,,
Intake
,, hypoglycemia
,,
270
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......
,,, ,,
,, absorption
malabsorption
malabsorption
,, ,, wall digestion
malabsorption
,, : ,, ,,
absorption
,, Lactase lactose
absorption
,, malabsorption,, absorption
,, ,,

stores Liver glycogen
,, stores glycogen liver
fasting
,, glycogen stores
fat
glycogen storage Liver
,,,
,, ) ,,
,, (
,, glycogen stores ,,

glycogen stores depleted

,, ,,
counter regulatory hormone
blood glucose
,, cortisone
epinephrine
271
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......
counter regulatory hormones
,,,

,,

hormone
counter regulatory hormone
,,

,,

:
!!!!!!!!!
,,
,,
,, epinephrine

,,
,,
,, fat acetyl Co A
Acetyl Co A metabolism
,,
,, counter regulatory hormones
glycogen Muscle glucose
,,
epinephrine Nor epinephrine counter regulatory hormones
amino acids
tyrosine phenylanine
,, counter regulatory
horomones
thyroxine
thyroxine tyrosine
272
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......
,, tyrosine
thyroxine
Kwashiorkor

Hypoglycemia ,,,
Hypoglycemia
hypoglycemia marasmus
Kwashiorkor
decrease intake
,, malabsorption
,, glycogen stores
,,
"
"
,,,

,,

" "
,,
:
,,
,, " "
!!!!
,,
,,
: ,,

" " : ,,

!!!!
:
: ,,

,,
,,
,,,
273
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......
,,,
,, : " " ,,

:

: ,,

!!!!! ,,
:

,,
,,,
,,
: !!!!! ,,

,,, ,,

,,
" " :
: ,,

:
: ,,

: ,,
,, ,,
:
,,,

" " : ,,
,,
:
,,
274
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......
,,

" " ,,

,,,

!!!!!!
(
,,
,, ,,
,,
:
,,

,,

,,
:
,,
,, ,,

,, :
,,
,,

full esophagus
275
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......

,,

,,
,, ,,
,,

,,

the same

,,
sepsis infection
sepsis ,, hypoglycemia
sepsis infection hypoglycemia
Organism
Organism
infection hypoglycemia
Hypoglycemia excess consumption of the glucose
excess consumption of glucose
hypoglycemia
Nutritional disorder Marasmus

,,
peptic ulcer
peptic ulcer
peptic ulcer
Intestinal villi shedding intestinal villi
276
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......
shedding wall of the stomach

shedding wall of the stomach
,, raw area
,, stomach PH acidic
HCL raw area

severe ulceration
hematemesis
Peptic ulcer ,, erosion of the wall of the
intestine
,,
,, marasmic kwashiorkor
total caloric supply ,, kwashiorkor
muscle ,,

,,
,, edema
edema so early protein
,,
edema so early
still % 60
edema
,, % 60 ,, edema kwashiorkor
marasmic kwashiorkor marasmic kwashiorkor
,, ,, kwashiorkor
,,
,,
,,

,,
,,,
investigations of marasmus
Investigations
277
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......
investigations of marasmus
marasmus Is a clinical diagnosis

marasmus clinically

:
8 :

:
:

:
actual body weight % 60 ) expected
expected
centile 50 centiles (
,, edema marasmus
marasmus it is a clinical diagnosis
Investigations
Investigations ,, marasmus
,, Marasmus
,, complications

marasmus
Investigations ,,
: urine stool ,,
stool ,, Undigested food :
,, Malabsorption
mucous ,, gastroentritis
gastroentritis complications
history
: stool fat
278
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......
absorption of fat
steatorrhea
: ,, fat absorption
: ,, fat 9
caloric intake
,,
,,, Urine analysis
urine say
pus cells RBCs
urinary tract infection
urinary tract infection ,, complication

: ,, chronic infection
marasmus
marasmus repeated infection

,, urine glucose
,, glucose with or without keton bodies
blood glucose
blood glucose 250 300

,, urine glucose polyuria

diabetic
diabetes
Loss of weight
endocrine
,,
: diabetes
,, urine glucose
blood glucose
diabetic
diabetes marasmus
,, Marasmus
diabetes
279
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......
Once ,, : ,,
,,
,, ,, Urine
urine amino acids
,, glucose ,, phosphorus
,, PH alkaline
Fanconi Fanconi like
Fanconi
Fanconi
Loss of amino acids urine
Loss of glucose
caloric supply ,, urine
,, Fanconi
Fanconi failure to thrive
failure to thrive

urine analysis
marasmus
,,
,, Marasmus urine
glucose
Marasmus urine ,, amino acids
,, Marasmus
marasmus

,,
chest X - ray
marasmus chest X - ray
chest X - ray
cardiomeglay chest X - ray
heart chest X - ray
280
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.......
......
heart VSD ,, ,,
,,
marasmus
marasmus
VSD
,,
Marasmus VSD
,, cardiology
nutrition
VSD marasmus sheet nutrition
cardiology
,,
marasmus congenital heart disease
congenital heart disease ,,
sheet cardiology
congenital heart disease most probably VSD
complicated by marasmus
marasmus complication VSD
,, ,,
: third degree marasmus
!!!! complicated by VSD

marasmus !!!!!
marasmus !!!!
VSD complicated by marasmus

chest X - ray ,, chest X - ray
heart
,, Murmur
lesion
281
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......
,, chest X - ray
chest infection
tuberculosis
.T.B Marasmus

,, chest X - ray finding suggesting tuberculosis

chest X - ray
exclusion .T.B
,,,
,, chest X - ray
complications
complicated pneumonia
complicated bronchitis
complicated
chest infection
,,

tuberculos ,, tuberculin
test
,,
tuberculin test Marasmus false negative

cell mediated immunity
Immune deficient
tuberculin ,, negative
,,
: tuberculos tuberculin test
: ,,
tuberculin test ,,

,, contacts marasmus

282
| Page
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.......
......
suggestive tuberculos
tuberculos until proved otherwise
,, tuberculin test
Immune deficient
false negative
tuberculin test contacts
,, Malabsorption Marasmus
,, intestinal villous biopsy
Intestinal villi malabsorption

,, Investigations
marasmus associated manifestations complications
,, pallor
CBC
pallor anemia
CBC anemia
anemia
kwashiorkor

anemia
MCV 60
MCH 25
Microcytic hypochromic anemia
microcytic hypochromic anemia
Nutrition
cupper deficiency
iron deficiency
iron cupper microcytic hypochromic anemia
kwashiorkor
kwashiorkor
microcytic hypochromic anemia
13
283
| Page
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.......
......
,, microcytic hypochromic cupper

Iron deficiency
,, Megaloblastic anemia
MCV
MCV 100 mean corpuscular volume
,, RBCs
macrocytic megaloblastic anemia
folic acid deficiency
folic acid stores hematology
folic acid
folic acid deficiency
kwashiorkor folic acid deficiency

,, anemia normocytic
normochromic anemia
normocytic normochromic ,,
,, ,, normocytic
normochromic anemia
Infection bone marrow depression
Normocytic normochromic anemia
,, ,,
anemia
,, CBC
CBC WBCs
Infection
,, ,, ESR ESR
,,
.T.B ,, ,,

ESR
,, : ,,
,, assessment chemistry
chemistry kwashiorkor
284
| Page
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.......
......
protein immune globulins

kwashiorkor
kwashiorkor
kwashiorkor unbalanced diet
,, caloric supply sufficient
,,
Etiology
,, etiology
kwashiorkor common first baby

kwashiorkor
,,
,,

,, ,,

,,
,,
:
:
,,

,,

,,
,,
,,
,, ,, ,,

285
| Page
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,, : " "
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.......
......
,, ,,
,,
,,
,,,

,,
,,
,, ,,
,,
,,
,,
,,
,,
,, ,,
pregnant
,,
,,

,,
,,
,, ,,

,,
,,

,,
,,
,,
: ,, ,,

286
| Page
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,, : " "
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.......
......
,, ,,
,,
,,
,,
:
,,

,,
,,
,,

,, ,,
,, ,, sore throat
,,
,,
) (
,, :
: ,,

,,
: ,,
:
: ,,
!!!
,,
,, ,,

,,,
,,

287
| Page
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.......
......
,,

,,,

,,,
,,
depression
,, anorexia
,,
,,
,,
,,
kwashiorkor
,, kwashiorkor common

,,
very rare Kwashiorkor
very rare kwashiorkor
,, Milk breast milk
artificial milk
Milk Proportionate diet
,,,, caloric supply

,, kwashiorkor
,, ,, marasmus
marasmus
,, kwashiorkor
,,
,, so rare

,, ,,
,,
288
| Page
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.......
......
,,
,,
kwashiorkor
kwashiorkor

,, ,,
,, kwashiorkor
kwashiorkor ,,

kwashiorkor
,, nurtrition Primary
,,

weaning
,, kwashiorkor
faulty weaning
faulty weaning
weaning ,, ,,
,,
,, ,, ,,

,, ,,
,,

: ,,
,,
:

: ,,
,, ,,
289
| Page
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,, : " "
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.......
......
,, ,, ,,

kwashiorkor
,,

,, ,, secondary secondary
,,,, kwashiorkor unbalanced diet secondary to other
disease
whooping cough
,,
,, text
secondary to disease
anorexia
,, anorexia ,,

,,, ,,
,, ,,
kwashiorkor

Pathophysiology of kwashiorkor

Pathophysiology of kwashiorkor
,, kwashiorkor :
,, excess caloric supply
caloric supply
,, fat excess caloric supply
fat
,,
,, excess carbohydrates intake
,, Protein
:

290
| Page
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,, : " "
"

.......
......

,, kwashiorkor

,,
,, ,,
,,
,,
,,
,, ,, ,,
,,

fat
,,
excess fat
: ,,

,, ,, ,,

,,
,, ,, ,,
,,
,,
excess calories
,,
fat ,,
fat
fat ,, fat
subcutaneous
,, subcutaneous fat ,,

fat
291
| Page
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.......
......
fat ,,
,, fat

,,, buccal pad of fat
,,,
:
,, ,, buccal pad of fat
carbohydrate facies
Kwashiorkor ,,
marasmus senile
Kwashiorkor
,,

,,
fat extremities
,,
: ,, ,,
,,
,,, ,,
,,,
,, ,,
,, ,,
,,

abdominal fat

subcutaneous fat marasmus
buccal
extremities
abdominal fat
Marasmus
subcutaneous space
fat
full ,,
292
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.......
......
fat Liver
Liver fat
liver fat
fat Liver Liver to react with protein
Liver
lipoprotein
react protein Liver
Liver fatty lipoproteins
low denisity lipoprotein
high denisity lipoprotein
biochemistry
Liver fat Lipoprotein
Liver lipoprotein fat
,,

Lipoprotein Liver blood
blood vessel
Lipoprotein blood vessel
lipotropic factors
fat liver cells

lipotropci factors
lipotropic factors lipoprotein Liver cells blood
vessel
lipotropic factors :
methionine amino acids
,, vitamin B complex one of the major lipotropic factors
vitmain B complex
,, ,, ,,
,,
293
| Page
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.......
......
fatty liver
,,
fatty liver
Lipid profile ,,
Lipoproteins
,, fatty liver
,, kwashiorkor
,,
liver Lipoprotein
fat liver
fat deposit Liver
fat Liver
,,
,, Lipotropic factors

lipoprotein Liver
Liver
Lipotropic factors
,, vitamin B complex
: Vitamin B complex
,,, vitamin B complex
absorption
Malabsorption maldigestion ,,
,, fat Liver
fatty liver
fat deposit liver
liver
,, fatty liver
,, deficiency of protein lipoprotein
deficiency of lipotropic factors amino acids
vitmain B complex
294
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,, : " "
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......

kwashiorkor Palpation Liver
: ,,
Liver ,,
fatty liver
fatty liver

,, ,, ,, subcutaneous fat
fat Liver
,, ,,

,,

,, Muscles
Muscles
Muscles
Muscle wasting
,, Marasmus
Muscle wasting
,, Loss
subcutaneous fat
,, Mid arm circumference Marasmus
,, Muscle wasting subcutaneous fat

: ,,
,, ratio Muscle fat
fat muscle
295
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......
Muscle to fat ratio

kwashiorkor
Muscle fat
Decrease muscle to fat ratio
Excess fat to muscle ratio
,,
Muscle fat
,, Muscle ,,
,, ,, bone
protein ,, bone osteoporosis
bone
bone
,, Neglected cases degeneration of the ,,
cardic muscle
cardic muscle ,, degeneration of the cardic muscle
,, ,, ,,

,, marasmus

,, muscle wasting Osteoporosis
degeneration cardic muscle
,, marasmus Heart failure
kwashiorkor Heart failure
degeneration cardic muscle
,, cardic muscle
: ,,
marasmus Liver ,,
stores ,, Liver
Liver fat deposits
Liver fat deposits compensation Liver
liver albumin
296
| Page
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.......
......
albumin
Liver
,,
Marasmus Liver
compensation
serum albumin
,,
,, liver support
support
,, kwashiorkor

,, Liver support Hypoproteinemia

,, degeneration
cardic muscle

,,
,,
,, ,, degeneration muscle
,,
,, ,,
,,,
,,
Plasma protein ,, osmotic
pressure
Nephrology
osmotic pressure ,, plasma protein
blood vessel
,, )
(
Plasma protein Osmotic pressure
intra vascular extra vascular
Intravascular volume ,,
Interstitium fluid
297
| Page
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,, : " "
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.......
......
,, vessel
vessel ,,
Nephrology
Heart ,,
volume receptors signals hypothalamus anti diuretics
hormone
anti diuretics hormone
,, ADH collecting tubules

osmotic pressure
Interstitium space
Interstitium space
,, Nephrology
blood volume ,, renal blood flow
renin
renin aldosterone
aldosterone salt and water retention
Interstitium space
osmotic pressure ,,
ADH
Aldosterone
ADH Aldosterone Liver
Liver ,,

,, edema
,, : edema
Marasmus
compensation Liver
edema
Decrease osmotic pressure

ADH
Aldosterone

,,
298
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......
,, intestinal villi
atrophy

,, ,,,
shedding
,, recovery GIT
GIT mechanical trauma
chemical trauma digestive jucies
,,
,, thermal trauma

contaminated
Mucosa GIT

rapid mitosis
,,
,, atrophy intestinal villi
Maldigestion malabsorption

,,, ,,
exocrine function of the pancreas
endocrine
degeneration exocrine function of the pancreas
endocrine function Infected
kwashiorkor ,,
,, ,, complications
Marasmus marasmus ,,
kwashiorkor acute malnutrition
,, complications
,, endocrinal dysfunction of
the pancreas
299
| Page
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,, : " "
"

.......
......

pancreas acini degeneration
pancreas enzymes
pancreatic enzymes ,, digestion
Maldigestion Malabsorption
,,, ,,, renal tubules
renal tubules hyaline degeneration
,, degeneration of the hyaline
tubular dysfunction
renal tubules
kidney
,,
brain
brain ,,
brain ,,,
brain ,, ,, ,, brain

thyroxine
,, ,,, thyrotoxicosis very irritable

,,,
cretinism
,, ,,
thyrotoxicosis
,, ,,
,,
brain cells
,, thyroxin
thyroxin tyrosine
,, ,, tyrosine thyroxine
Hypo thryoid function
300
| Page
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.......
......
thyroxine ,,
: ,,
,,
,,, ,, facial expression
hypo thyroidism
,,
neuronal cells
,, direct contact
neuro Neuron
synaps
synaps
neuron ,, Neuron
,, ,,,,,,,,
Neuron ,, ,, ,,

,,,
,,
,,
,, Optic nerve
Occiptial lobe
,,
Occipital lobe once ,, ,,
,, cortical blindness
cortical blindness
,, ,, Optic nerve ,,

,,,
,,
: ,,
Occipital lobe
,,
Occipital lobe ,,,
301
| Page
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,, : " "
"

.......
......

Occipital lobe ,, copy frontal lobe
Memory ,,
,,
frontal lobe ,, ,,

,,
,,
frontal lobe
,,
,,
temporal lobe
temporal lobe
,,,
,, temporal lobe frontal lobe
fronal lobe ,,
,, I dont know
,, ,, ,,

,, ,, ,,,
frontal lobe
actions neuro transmitter
,, transmitter
phenyl alanine tyrosine
,, neuro transmitter
tryptophan
phenylalanin tyrosine tryptophan
,,
302
| Page
" " :
,, : " "
"

.......
......
Neurotransmitter brain
,,,
,, brain
,, :
,, defect in neurotransmitter inside the brain deficiency of
phenylalanine, tyrosine and tryptophan
,, Hypothyroid function
mental changes

:
,, clinical manifestation of marasmus
: Hypothermia
: hypothermia
caloric supply
subcutaneous fat heat loss
Muscle bulk
dehydration
sepsis
,, GIT manifestations
:
Irritability Hunger sensation
anorexia
constipation
Marasmus diarrhea
gastro entritis
maldigestion
malabsorption
starvation diarrhea
starvation diarrhea
small amount
Loose stool
Dark greenish in color
Very offensive
stool examination :
dead epithelial cells
Mucous
303
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......
bacterial flora
,, cardio vascular
,,, bradycardia Low volume of the pulse
weak pulse
,, ,, dehydration rapid
weak pulse
,, respiratory
shallow respiration chest infection
,, respiratory vitamins deficiecny

,, complications Infection
edema faulty management
bleeding
hypothermia
hypoglycemia
gastric erosion Peptic ulcer
,, Investigations Marasmus
:
marasmus
associated manifestations
Stool and urine analysis

Chest X - ray
tuberculos tuberculin
biopsy wall of the intestine
malabsorption
CBC anemia
ESR
kwashiorkor ,,
caloric supply

304
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......
,, Milk
Milk
,, neglect
of protein
,, ,,
kwashiorkor faulty weaning
systemic disease anorexia
kwashiorkor
kwashiorkor ,, Pathophysiology
,, ,, subcutaneous fat
,, fat Liver
hepatomegaly
,, ,, Muscle wasting
degenration of the cardic muscle
edema
Maldigestion malabsorption intestine
kidney Mental changes

38
39
clinical manifestations of kwashiorkor
Investigations marasmic kwashiorkor
nutritional dwarfism

Clinical manifestations
clinical manifestations of kwashiorkor
Kwashiorkor wellcome
clasification 60 80
305
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.......
......
expected edema
: clinical manifestations of kwashiorkor

essential features
Non essential features

: kwashiorkor

age
:
expected weight

:

actual weight expected
,, edema
60 % 80 expected weight edema
wellcome classification
Kwashiorkor
,, : manifestations of kwashiorkor

,, kwashiorkor
wellcome
,, Manifestations of kwashiorkor
:
essential features
non essential features
essential features ,,

essential featrues of kwashiorkor
306
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"

.......
......
,, 80 - 60
% expected edema
essential features

essential features growth failure ,,
,,
:
,, marasmus
,,
% 60 expected
,, edema
,,
,, 60 % 80
expected
:
: ,,
,,
,, growth failure Loss of weight kwashiorkor
Masked
,,

fat ,,
,, ,, edema
,,
,, excess fat
,, growth failure is not observed by the mother
Masked by excess subcutaneous fat and edema
,, ,,
expected weight
expected
,, essential features
,, kwashiorkor ,, wellcome classification
edema
307
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"

.......
......
,, ,,
edema Kwashiorkor
edema ,, kwashiorkor
decrease osmotic pressure
Osmotic pressure
Osmotic pressure ,,
osmotic pressure
plasma protein ,, albumin

,,
Liver Is affected fat infiltration
liver compensation
plasma protein
osmotic pressure
,,
nephrology
osmotic pressure ,,
Intra vascular interstitial space
Intra vascular interstitial space

edema
,, ,,

,, vascular volume
Intra vascular volume ,,
blood vessel
vascular volume ,,, blood volume
blood volume ,, Nephrology
,,
volume receptors Hypothalamus
brain
anti diuretic hormone

ADH
ADH hypo volumia
308
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"

.......
......
volume receptors
hypo thalamus ADH
ADH

,,
,, ADH : kidney renal
tubules
water reabsorption renal tubules
water reabsorption renal tubules
,, osmotic pressure
blood vessel
edema
,,, Intra vascular volume
renal blood flow
renal blood flow ,, renin renin
aldosterone
aldosterone ,, supra renal
,, aldosterone ,,
aldosterone distal convoluted tubules of the kidney
sodium

,,
Kwashiorkor
sodium loss in urine
renal tubules
,,
Osmotic pressure
Interstitial
edema
,,

total body sodium
,,
309
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.......
......
serum sodium !!!!!

,,, ,,
,, ADH ,,

dilutional hypo natremia
Investigation
amount
,, concentration
retention of water retention of sodium
,,
,, Nephrotic syndrome
ADH aldosterone
liver destruction
ADH aldosterone Liver
destruction
Liver
,, ,, liver Infiltrated
fat
defect function of the liver cells
,,
destruction ADH Aldosterone

edema
,, ,, capillary permeability

capillary integrity
,, capillary fragile
,, Leak
permeability
capillary permeability
edema
310
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.......
......
decreased osmotic pressure

ADH Aldosterone
,, excess capillary permeability

,,
capillaries
capillary ,, pores ,,

capillary

,,
,,,
edema
edema

,, ,, pitting edema

dorsum of the hand
,, dorsum of the foot Legs
,, thigh
forearm
,, arm edematous

,, arm
,, lymphatic system
edema arm
,, ,,
severe condition edema
arm
,, edema ,,
very rare abdominal wall
very rare effusion Pleural effusion
ascites
311
pericardial effusion
| Page
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"

.......
......
,,
common
ascites pleural effusion
pericardial
effusion
,, serum albumin gram 1

,,

effusion
complications
kwashiorkor very early and very rapid
complications
,,
effusion
,,
abdominal wall edema
,, applied clinical
applied clinical
,, complications ,,
,,
,,
complications kwashiorkor
,,, ,,
,, essential features of kwashiorkor Mental
changes
,,
Mental apathy
,,
:
brain thyroxine
thyroixne tyrosine
tyrosine amino acids ,,
thyroxine
Hypothyroid function
Hypo mental function
312
| Page
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"

.......
......
,, Neuronal cells ,,
direct
,,
neurotransmitter
,,
neurotransmitters brain ,,
,, norepinephrine epinephrine
tyrosine phenyl alanine
,,
serotonine ) tryptophan
spelling (
neuro transmitters inside the brain protein sources
,, Neurotransmitters brain
connection cells
,, ,,, ,, ,,

,,
,,

facial expression
,, ,, ,,

,, :

,, ,,

,, ,,
facial expression
Mental apathy
,, ,, essential features of kwashiorkor
decrease muscle to fat ratio
313
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"

.......
......
,, : decrease muscle to fat ratio

Muscle fat ratio
,, muscle
fat
,, ,,

,, ) anthropometric
anthropology anthropometric
(
,,

X - ray diameter bone X - ray
,,
fat bone
Muscle
Muscle to fat
decreased muscle to fat ratio
,,
,,
:
kwashiorkor :
kwashiorkor :
wellcome classification

:
essential features ,,, growth failure ,, ,,
edema
mental change
: decrease of muscle to fat ratio

clinically decrease muscle to fat ratio

314
| Page
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"

.......
......
,, Non essential features of kwashiorkor

Non essential features of kwashiorkor
Non essential features

,,

palpation of the liver
hepatomegaly
Hepatomegaly fat deposit liver
fat deposit Liver

fat Liver
Liver ,, lipoprotein
,,
,,, lipoprotein
,, ,,
Lipoprotein Liver lipotropic factors
methainoine choline vitamin B complex
deficient kwashiorkor
,,
Hepato megaly
,, ,, non essential
hair changes
hair follicles
Hair follicle ) ( skin
,, skin
) ,, glue like material (
glue material ,, sulphar containing amino acids
,,, ,,, cystine cystiene
,, ,, ,,, sulphar
containing amino acids
,, ,,,
,,,
315
| Page
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"

.......
......
,, ,,
,,

,, ,,
Branched cell dendritic cell

Melanocytes
Melanocytes
melanin

melanocytes
,, thyroid follicle

uptake ,, tyrosine
thyroxine
,, uptake tyrosine amino acids

,, tyrosine
tyrosine amino acids Phenyl alanine
tyrosine amino acid
tyrosine

,, ,, tyrosinase
enzyme tyrosinase
tyrosinase enzyme tyrosine melanin
,,
,,
tyrosinase enzyme ,,
cofactor cupper
tyrsoinase cupper
melanocytes cupper
cupper
iron free
316
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"

.......
......
carrier protein
carrier protein cupper ceruloplasmin
ceruloplasmin alpha two globulin
carrier cupper
melanocytes
,, cupper Melanocytes
tyrosinase ,,
melanin
melanocytes
Melanocytes vesicles
,, vesicle
Melanocytes

,, ,,
,,
,,

hair follicle
body

Hair follicle ,,

hair follicle

,,

,,
,, kwashiorkor deficiency

:
317
| Page
" " :
,, : " "
"

.......
......
,,
,,

,,
,,
easily pickable hair

,,
: ,, easily pickable hair

,,
,,
,,
14
20

,,
: easily pickable hair
: deficiency of sulphar containing amino acids

sulphar containing amino acids
deficiency of sulphar containing amino acids

,,
Intake ,, phenyl alanine
tyrosine
Phenyl alanine tyrosine

tyrosine Phenyl alanine
enzymatic defects
318
| Page
" " :
,, : " "
"

.......
......
enzyme tyrosinase
enzyme amino acids sequance
,, ,,
Investigations
enzymes
tyrosinase

,, tyrosinase
,,
cofactor cupper

Malabsorption
,,
stores cupper Liver
Liver carrier protein
ceruloplasmin
ceruloplasmin
deficiency of cupper and ceruloplasmin
tyrosinase

,,
deficieny of phenyl alanine and tyrosine
deficiency of tyrosinase and permease
deficiency of cupper and ceruloplasmin
,,,
,,
,,

,,

,,
,,
319
| Page
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,, : " "
"

.......
......

,, ,,

,,

,,
,,
,, ,, ,,

clinical
,, fabricated
,,

,, ,,
,,
sign
cardiology Fallot tetralogy heart
X - ray

transposition egg on side :

,,
,, : flag sign
flag sign

,, flag ,,
,,
one color

,,
One color
320
| Page
" " :
,, : " "
"

.......
......

:

,,
,, ,,
: flag sign

,,
: flag sign
: ,,
Microscopic finding
,, finding
,, color
,,
,, ,,
) ,, :
!!! (

flag sign
: ,, flag sign
: Deficiency of melanin production
production
phenyl alanine tyrosine
tyrosniase
cupper ceruloplasmin

Hair changes kwashiorkor
,, skin changes
epidermis dermis
dermatology
,, ,,
epidermis
321
| Page
" " :
,, : " "
"

.......
......
epidermis thin layer of fat

subcutaneous fat
subcutaneous fat
,, fat
fat ,,
,, fat ,,
transparent
fat
essential fatty acids
essential fatty acids Non essential fatty essential
amino acids non essential amino acids
Non essential fatty acids ,, fatty acids

,, ,,
,,
acetyl Co A
Acetyl Co A fatty
acids
fatty acids non essential fatty acids ,,

,, essential fatty acids Intake
,,

,,
transparent
,,
:
,,
,,
322
| Page
" " :
,, : " "
"

.......
......
,, thickness female triple

thickness male
female male
,,,
,,
,, :
,, superficial layer of the skin
dehydration

fat ,, ,, ,,
,, ,, ,,,
,, evaporation of water ,,
superficial cells
,, dryness

,, fat fat
,,
,,
,,
,,

reflection of sun lights

,,,
Ultra violet rays
,,
,, effect sun burn

,,
,,
,,

,,
: ,,
protective mechanism
323
| Page
" " :
,, : " "
"

.......
......

,, :
,,
,,
,, opaque
,,
,, melanocytes

nucleus superficial cells ultra violet
rays
,,
,,

,,
,, cut
color
,,

,,
,, cut
,, ) (
,,

,,

,, superficial layer of fat
,,
,, !!!!!
,,

,,

324
| Page
" " :
,, : " "
"

.......
......

,,

,, fat

essential fatty acids ,,,
maldigestion
Malabsorption
protective layer

,,
,,
,, erythema

,, ,,
,,
,,
,, ,,
,,
,,
,, ,,, ,, erythema

erythema
,, Sun burn ,,
protective layer
erythema sun burn
,, erythematous area
325
| Page
" " :
,, : " "
"

.......
......
inflammation
,,
opaque layer
Opaque layer ,,
,,

dead cell
dead cell ,,
hyper pigmentation false expression
It is not acutally hyper pigmented area
dead layer of the skin
,,
,, ,, ,,

)

(
,,
,,
healing
Healing raw area ulcers
regeneration and recovery

raw area and ulcers
,, desquamation ,, raw area or
ulcer
,, Ulcer ,,

,,
ulcer ,, without melanin

hypo pigmentation
,, ,,
,,
326
| Page
" " :
,, : " "
"

.......
......
,, erythematous
,, hyper pigmented ,,
Ulcers
Hypo pigmented area

Flaking paint appearance
,,
,, mixed
stages

erythema
hyper pigmented
ulcers
hypo pigmented area
,, ,,

immunology
: defence mechanism Micro organism

adhesion of the cell
,, Micro organism
surface of the mucosa
surface of the skin
,, raw area Ulcer
raw area Ulcer ,, organism
severe infection
severe infection gangrene of the
skin
severe infection
,, Infection :
Infection
,, ,,, excess sweating
,,
,,
,, " "
327
| Page
" " :
,, : " "
"

.......
......
,,
,,

,,

,,
,,

,,
,, ,,
,,
,,
,, ,, Organism

}{30

"

"
flexture ares
axilla
,, Napkin dermatitis ( napkin
)
bacterial fungal
What ever
,,
Pressure areas
Pressure areas
Pressure areas
,, Pressure area ,,
,, vascularity

Organism
,,
,, :

!!!!!!
Organism ,, ,,

vascularity
vascular flow
328
| Page
" " :
,, : " "
"

.......
......
vascularity
,, Pressure area Pressure area buttocks
,, buttocks

,,
,, Infection
excess sweating
Pressure area
,,
skin changes
deficiency of essential fatty acids
,,
nictotine amide tryptophan
Integrity, recovery and healing
skin cells
recovery rpaid healing

,, vitamin A
vitmain A skin superficial layer of the
skin cornea
vitamin A recovery
,, vitamin A ,, rapid recovery
raw area Ulcer
deficiency
vitmain A deficiecny
,, clinical pictures
,, ,, zinc deficiency malabsorption
zinc ,,
zinc vitmamin A
vitamin A
,, skin changes
deficiency of essential fatty acids
deficiency of nictoin amide tryptophan
329
| Page
" " :
,, : " "
"

.......
......
deficiency of vitamin A
deficiency of zinc
skin manifestations
skin manifestations
GIT manifestations
,, kwashiorkor
anorexia
anorexia GIT trouble
anorexia ,, central
anorexia central
marasmus
feeding center
signals
signals Neurotransmitter ,,

,,
,,
,, signals
,,
,,

,, central anorexia Mental changes
Local GIT distrubance
,, ,, ,,
marasmus ,,, constipation not diarrhea
!!! diarrhea

Marasmus

diarrhea
Gastro entritis
maldigestion
Malabsorption
Starvation diarrhea
,, Iron atrophy of intestinal villi
,, ,,
330
| Page
" " :
,, : " "
"

.......
......
,,, ,, ,, Pallor
,, pallor anemic
:
Kwashiorkor
,,
,, anemia
Microcytic hypochromic anemia
deficiency of iron of cupper
,, megaloblastic anemia
,,
Megaloblastic Marasmus folic acid deficiency ,,
megaloblastic kwashiorkor B12 and folic acid deficiency ,,
B12 Liver
stores supply 12 15
Liver
Liver ,, fat deposition
depletion of stores B12
,,
,, marasmus megaloblastic anemia
kwashiorkor megalo blastic anemia
megaloblastic anemia ,, Marasmus
kwashiorkor
:
,, marasmus folic acid deficiency
,, kwashiorkor folic acid B12 deficiency

Kwashiorkor Liver affected
,, anemia deficiency of protein
,, ,,
RBCs
Normocytic normochromic anemia
,, ,, Infection
331
| Page
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"

.......
......
Infection anemia
:
bone marrow depression
hemolysis of the RBCs
RBCs depression of the bone marrow
,, ,, ,, abdominal
distention
,,,
,, marasmus scaphoid abdomen
kwashiorkor abdominal distention ,,
,,
,, ,,
weak abdominal muscles
abdominal muscles ,,
pot belly abdomen

,,

,, digestion absorption
,, lumen bacterial flora
fermentation
fermentation gases
,,, Lumenal parasites common

immune deficiency in general kwashiorkor
Giardia
Giardia duodenum Upper of the jujenum
Giardia parasites fermentation
,, ,,
,, : ,,, ,,
,,
,, distention generalized
percussion Hyper resonant abdominal allover
giardia
,,,
332
| Page
" " :
,, : " "
"

.......
......
giardia epigastrium
,,
Percussion hyper resonant
giardia
,, Giardia
,,
: stool analysis ,,
stool analysis ,, very rare giardia
giardia ,, nasogastric tube
aspirate duodenum
analysis
giardia
,,
giardia stool analysis

giardia fermentation
intestinal obstruction
Intestinal obstruction
Paralytic ileus
paralytic ileus :
,, hypokalemia ,,

,, diarrhea

diarrhea gut secretion
,, Hypokalemia
,, hypokalemia
,, Loss of gut secretion Hypokalemia
,, hypokalemia
aldostrone
aldosterone ,, aldosterone Loss
Urine

333
| Page
" " :
,, : " "
"

.......
......
hypokalemia Kwashiorkor :
loss diarrhea
Hyperaldosteronism aldosterone

,, ,,

Aldosterone
,, paralytic ileus toxins
toxins severe infection
: Liable to severe infection
toxic ileus

,, vitamin deficiency
,, vitamin deficiency ,, ,,
vitamin deficiency toxicity
vitamin deficiecny ,, vitamin A
vitamin A ) ,, ,,
,, Keratomalacia
,,
blindness
,,
,,

:

blindness vitamin A deficiency
,, vitamin A
malnutrition
,, vitamin A deficiency
,, decreased intake
,, Malabsorption absorption
: absorption ,,
stores
depletion of the liver stores
stores ,, Liver Liver
334
| Page
" " :
,, : " "
"

.......
......
stores liver
,, vitmain A ,, absorption
vitamin A
stores Liver
vitamin A
caroteen
vitamin A
,,
,,, vitamin A

liver
,, ,, Liver
,,
,, fat cells
deposition of fat

,, caroteen vitamin A
Liver
Liver
,,
Liver cells ,,
: ,, ,, vitamin
A
,, zinc
,, thyroxine
vitamin A zinc thyroxine
,,
,, thyroxine thyroxine tyrosine
tyrosine amino acids
hypo thyroidism
335
| Page
" " :
,, : " "
"

.......
......
,, ,, malabsorption zinc
,, ,, vitamin A
,, vitamin A deficiency

Intake
absorption
stores
vitamin A Liver
zinc T3 T4 thyroid

,, complications
complications Kwashiorkor
Complications
Marasmus
,, ,,

complications
complications
,, Marasmus
Intercurrent infeciton
Immune fucntion chemotaxis Macrophages
migration Phagocytosis
T cells ,, B cells Interferon ,,
: ,,, marasmus
: infection Marasmus
kwashiorkor
Infection kwashiorkor
kwashiorkor Immune deficient
good media Organism

336
| Page
" " :
,, : " "
"

.......
......
edema
,, Intercurrent infection

,,, ,, gastro entritis so common
,, ,,
,, DIC hemorrhage
Marasmus
,, hemorrhage in general ,, DIC
,, Marasmus bleeding
Loss of subcutaneous fat DIC
intervascular thrombosis
consumption Platelets coagulation factors
,,,
,, hypothermia
fat

,, : generators
,,
,,

,, heat production
,, Heat loss
,, generators ,, Muscle
,, muscle wasting decreased heat production
,,
,, sepsis
dehydration

complications hypoglycemia
337
| Page
" " :
,, : " "
"

.......
......
Hypoglycemia
,, Hypoglycemia ,,
hypoglycemia
Hypoglycemia

Hypoglycemia ,,
:
,, hypoglycemia hyperactivity hyper irritability
endocrine
: ,, ,,
Hyperglycemia
Hypoglycemia
Hypoglcyemia is a fatal
,,, Hypo glycemia
,, hyperglycemia is very weak
,,
,,
Say kwashiorkor
,, hypoglycemia
counter regulatory hormones epinephrine
Hyper irritable ,,
,,
tremors
,, Pupil dilated
,, cold skin
vaso constriction
,, Pale vaso constriction
epinephrine excessive sweating
: ,, ,, ,,
,, ,, ,,
338
| Page
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,, : " "
"

.......
......
,,
,, ,,
,,
,, Pulse rate heart rate
severe tachycardia
,,
,, ,, ,, Hypoglycemia false
impression
hypothermia

false imperssion Hypothermia
,, Hypoglcemia One of the complication ,,
hypoglycemia
Marasmus
,,
,, Intake
excess carbohydrate intake
,, Hypoglycemia decrease carbohydrate intake
,, excess carbohydrates
,,
Malabsorption
stores glucose ,,,
counter regulatory hormones ,,
,,, sepsis ,, consumption

,, ,,, Marasmus
heart failure
heart failure
heart failure kwashiorkor
Heart failure
Heart failure ,, :
,, degeneration of the cardic muscle
,,
,, Heart ,, degeneration of the cardic muscle
339
| Page
" " :
,, : " "
"

.......
......
cardiomyopathy
,,
Liver compensation
heart failure
: ,, Infection Marasmus
edema
Immune deficiency
severe infection toxic myocarditis
,, volume overload
: volume overload
management ,,
,, edema

Interstitium Intra vascular
Hyper voluemia ,, congestive heart failure

hyper voluemia during management
,, Investitagations of kwashiorkor
Investigations
Investigations kwashiorkor
Marasmus
,,,

assessment of the nutritional state
,,
,, fat
,,
electrolytes
Oral glucose tolerance curve

endocrine ,,
340
| Page
" " :
,, : " "
"

.......
......
,, curve hypoglycemic level

hypoglycemia

fat
free fatty acids
cholesterol
free fatty acids
free fatty acids

free fatty acids
fats
,,, Lipoprotein
Liver ,,
Minerals
,, phosphorus ,, ,, zinc ,,

,,,
,,
dilutional hyponatermia

,, dilutional hyponatermia

,,
total protein
non essential amino acids to essential amino acids ratio
albumin
globulins
carrier proteins
enzymes
,, total protein Nephrology
Normal total proteins 6 8
total proteins Low
,, normal non essential to essential amino acids ratio 2 1
341
| Page
" " :
,, : " "
"

.......
......
kwashiorkor
,,
Non essential ,,
essential
albumin ,, 2.5
albumin
,, globulins alpha ,,
alpha beta ,,, Intake
,, intake alpha beta
,,
,,, reticuloendothelial system
early gamma globulins ,, reticulo
endothelial system immune globulins
,,
,, advanced cases
suppression reticulo endothelial system
carrier protein
,, ,, transferrin Iron
ceruloplasmin cupper
,,, thyroid binding thyroxine
carrier protein
enzymes
,,
ALT AST
enzymes ,,
,,
ALT AST
ALT Liver affection
AST ,, Liver and muscle AST
muscle wasting
,,
342
| Page
" " :
,, : " "
"

.......
......
,,,
tetany
non ionizable form ionizable form
bound form of calcium
: kwashiorkor serum calcium
Low tetany
tetany
: acidosis
acidosis
,, Infection
,,
bound form of calcium
ionizable form

Investigations
Urine analysis
Urine Urea
,, kwashiorkor marasmus
urine
,, Marasmic kwashiorkor

Muscle
catabolism of protein
: ,, ,, Liver
urea cycle
urea
Urine
,,
Marasmus Hyper catabolism of protein of the muscles

Liver ,,
,, Urine
343
| Page
" " :
,, : " "
"

.......
......
,, Urine Marasmus

kwashorikor ,,
Liver
Liver ,,

: hepatic encephalopathy
: management

hepatic encephalopathy

,,

CBC
ESR
Tuberculin test
Stool analysis
intestinal vilous biopsy
Marasmus

,, ,, Marasmic kwashiorkor
,,

Marasmic kwashiorkor
marasmic kwashiorkor wellcome classification
marasmic kwashiorkor % 60
expected weight for age
344
| Page
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,, : " "
"

.......
......
edema
Marasmus
,, edema
essential features ,, Mental changes
mental changes

,, skin
Hair changes
,,
% 60 expected weight
edema
pre kwashiorkor
clinically laboratory
Pre kwashiorkor
clinical manifestations
,,
,, thalassemia

,,
,,
,,
genetic diagnosed ,,,
Especially hemoglobin electrophoresis
,,
,, follow up 13 14
thalasssemia intermedia
,,
iron chelators desferal
,, thalassemic
345
| Page
" " :
,, : " "
"

.......
......
,, ,,

kwashiorkor
follow up ,,

,,
pre kwashiorkor
pre kwashiorkor essential features
edema
edema
60 % 80 expected
,,
edema
Mental changes
kwashiorkor
edematous
60 % 80 expected
,, edema Kwashiorkor
prekwashiorkor
{ } edematous
,,
no edema
kwashiorkor
,,
,, non essential to essential
amino acids
2 1 3 1

,, Investigations kwashiorkor
3 1
2 1 3 1
,, serum albumin
2.5 2.85
346
| Page
" " :
,, : " "
"

.......
......
2.8 ,, 2.8 ,,
,,
,, ,, station
,,
,, ,,

12 : 8
!!!!!
12 : 8
10 : 8

,,
,, :

,,, ,,
,, ,,, ,,

station
,,,
,,
,,
albumin 2.85
Pre clinical kwashiorkor
,,
2.5
,,
Nutritional dwarfism
,,
,, Nutritional dwarfism for normal
growth
so deficient nutritional disorder
,,

compensation by slow rate of growth

347
| Page
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,, : " "
"

.......
......

,,
,, ,,
,,
10th percentile
endocrine
,, 10th percentile
,,
,,
,,

,,
,,
,,
,, ,, ,,
Nutritional dwarfism ,,
,, 39

,,

treatment of marasmus and kwashiorkor
Treatment of marasmus and Kwashiorkor
,,
,, prevention
prevention ,, ,,
,, ,,,
348
| Page
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,, : " "
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.......
......
,,
,,
,, ,,
,,,
breast feeding
,, assessment feeding ,,
,,
,, assessment
,, Under feeding ,, Over feeding
Infant feeding
,, weaning proper
weaning ,,
,, ,, balanced diet ,,
,, fat ,,
,, ,, ,,
,, Proper diet
,,
,,
,,, ,,
,, ,,
,, Malnutrition ,,
Immunity ,,
vaccination
.T.B
,,
Malnutrition
complication
whooping cough
Malnutrition
Measles Malnutrition
,, ,, ,,
,, ,, Nowadays
,, ,,, ,,,
,,
,, ,, ,,
,, ,,

349
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,, : " "
"

.......
......

,, ,,
,,
,, ,, ,,
,, ,, ,,
,, ,,
,, ,,

,, ,,

,, ,, ,, family planning
,, ,, ,,
,,
,, ,, ,,,
,, ,,
,, ,, ,,
,,
:
,,
,, family planning
,, ,,
balanced diet ,, ,,

,,,, ,,
,,,
,,
active treatment
treatment Marasmus Kwashiorkor
:
Dietic management .1
.2
Non dietic management
350
| Page
" " :
,, : " "
"

.......
......
: dietic management
,,

:
:
Investigations
treatment
Investigations ,,
,, dietic management
:
) (
is the child is full term but low birth weight, weaning at six :
months
,, full term weaning
,,
,,
Preterm
,, Neonatology catch up
phenomena
low birth weight weight loss

,,
,, ,,
even ,, full term
catch up phenomena
,, ,,, Low birth weight preterm
weaning
weaning

,, ,,
,, stores
,,
,, ,, gut mucosa
,, Mature enough ,,
,, ,,
351
| Page
" " :
,, : " "
"

.......
......
,, ,,
,,

,, ,, ,,

enzymatic function ,,
,,
,,, ,,
,, infant feeding
incidence of atopic diseases
incidence of auto immune disorder
,, ,,
,, ,, explanation
,,
:
dietic management
,, ,, dietic management
,, ,,
,,
,,
program
,,
,,
satisfied ,, ,,
,,
:
,, total calories
,, ,, marasmus
kwashiorkor
: dietic management
total calories
,, ,, total calories

total calories
marasmus
Marasmus 150
,, marasmus 150
kwashiorkor
: Kwashiorkor calories
352
| Page
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,, : " "
"

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......
,, Normal 120

Low birth weight
Preterm
,, Kwashiorkor
120
,,,
,,
,,
!!!!!

,, ,,
,,
,, expected weight ,,
,,,
,, expected weight actual body
weight ,,
,,
,,

,, Marasmus 4 ,,

,, Kwashiorkor 6 ,,,
marasmus
kwashiorkor
,,,
,,
expected weight
: first degree maramus
,,
,,
first degree marasmus expected
weight
,,
,,
353
| Page
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"

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......
,, Kwashiorkor ,, ,, second degree marasmus third

degree marasmus average weight
average weight
expected actual weight

,,

4 + 8 12
2 6

,,
,,
,,
,, actual body weight
expected weight
,, mean
Mean

,,
Mean

,, expected weight
first degree marasmus
,, total calories
,, total calories ,,
,, ,,
,, ,, ,,

: 1000 ,, !!!!!
,,
,, ,, :
,,
,,
354
| Page
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,, : " "
"

.......
......
,,
: Delayed weaning ,,
,,

,, ,,
,,
,,

,,,
,, 150 ,, 100
,, ,,
,,
15 ,, 10

,, ,,
calculator
,,
calculator
dose
,, 15 10
3 ,, 2
,,
,, Marasmus
averge weight 6
8 ,,, 4

12 6
average weight

,, average weight
355
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......
150 ,, ) Marasmus first
( degree
120 ,, ) ,, kwashiorkor (
,,
150 marasmus
120 kwashiorkor
,,
total calories ,,
,,
,, 3/2

,, 3/2
,, ,,
,,
,,
average weight
,,
,, average weight
150 Marasmus
120 kwashiorkor
total calories
,, Calories
3/2
,, volume of milk

,,
,,
,,
cc 1200

356
| Page
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"

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......
:

100
100
24 ,, 12
100
100 ,, 180
100 ,,
,,
small frequent meals

,,

,, maldigestion Malabsorption

,,,
24
,,

,,,
,, breast feed
)
(
breast feed is breast feeding
text book

breast feeding ,,
Marasmus kwashiorkor

357
| Page
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,, : " "
"

.......
......
,, ,, ,,

,, ,, ,, ,,

,,
artificial milk

GIT ,,
,,
,, maldigestion malabsorption
,,

,, Non complicated gut troubles
humanized milk
,,,
Humanized milk Infant feeding
,,

calories
humanized milk

humanized milk
,,,
Maldigestion malabsorption
maldigestion ,,
lactose intolerance
Lactase enzyme
,,
,,
,, Lactose
Lactose free milk
humanized milk
lactose
358
| Page
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,, : " "
"

.......
......
lactose intolerance
lactose free milk
,,
steatorrhea
,, steatorrhea ,,
skimmed milk

,,
,, malnutrition fat

fat ,, calories
skimmed milk fat
Fat absorption
Digested fat
Medium chain triglyceride
bile
,,
,, skimmed milk
Medium chain triglyceride caloric supply
:
total calories
total calories ,,

,,
,, Lactose intolerance Lactose free milk

,, steatorrhea skimmed milk medium chain
triglycerides
,, ,,

small frequent meals

,,
,,
359
| Page
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,, : " "
"

.......
......
,, ,, ,,
,, marasmus
Kwashiorkor hypo proteinemia
kwashiorkor
,,, marasmus
,, caloric supply
fat total calories
proteins

,,

protein milk
,,
protein milk
Protein milk
,, 100 5
,, 100 1.2
protein milk
,,, Protein milk Infant feeding
,, ,,
,, ,,
,,, ,,

,, 4
,,
,, gram 4
per kilo gram per day
gram 4

,,
muscles ,, enzymes ,,
360
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,, : " "
"

.......
......
,,,
,, ,, protein
milk
,,
:
,,, artificial milk artificial milk ,,
calories ,, diet
,,

: ,, ,,,
,,,
,, ,,
,,
mixed meat ,, ,,

,, ,, ,,
,, ,,
: ,,

Of high biological value
,, high biological value animal protein
: kwashiorkor ,,
,, ,,
,,
mental apathy
mental retardation
Planet protein
animal protein

,,
,, ,,
,,
) (
361
| Page
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,, : " "
"

.......
......
Mode of administration routes

,, ,,, ,,
,,
weaned ,, ,, ,,

,, ,, anorexia
,, 100 ,,,
50
,, ,, ,,
,,
,,
: ,,
,,, ,,

,,, ) - (

,,
anorexia
,, ,,

nasogastric tube
,,
: ,,,
,, Nasogastric
nasogastric
,, nasogastric tube
,, ,,
Persistent vomiting
nasogastric tube
toxic ilues severe infection
Chest infection oral

362
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,, : " "
"

.......
......
total parentral nutrition

total parentral nutrition central line ,,
,, central line
,, central line
central line

,, central line

amino acids

,,
total calories
total calories

,,
first sign of improvement
Is improvement of apetite
,, ,,
100
100 ,, 100
,,
first sign of improvement clinically
Improvement of apetite
dietic management
,,
: ,,

,,,
,, marasmus
,, ,,
!!!!
,,
363
| Page
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,, : " "
"

.......
......
,, ,,

Non dietic management
Non dietic management ,,

,, emergency management
emergency
,,

hypoglycemia
,, Intra venous glucose ,,
hypo glycemia
hypoglycemia !!!!
,, !!!! ,,
Hypoglycemia
,, Hypoglycemia intra venous glucose
,, dehydrated
re hydration ,,
,, hypo thermic
,,
,, ,,
,,
,, ,,,
,, shivering ,,
Loss
,,
,, ,, subcutaneous fat
,, Loss
,,
marasmus kwashiorkor generator
muscle
muscle wasting ,,,,, lost
364
| Page
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,, : " "
"

.......
......
,, generators
generators
,,
,,
,,
,,
,,
,, ,, ,,
,,

,,

,,

,, ,, ,,
)
: ,,

(
,,
,,,

,,
,, :
,,
,, ,,
Marasmus
marasmus ,, ,,
,,
,,
,,, shock
,, ,, shock shock

emergency management
,, ,,

365
| Page
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,, : " "
"

.......
......
marasmus Kwashiorkor blood

transfusion
,,
,, ,, fresh blood
fresh blood
,, fresh blood
,,
,,
fresh blood
.1 fresh blood ,, RBCs ,,
,, anemia
,, anemia fresh blood anemia
.2 fresh blood coagulation factors platelets
bleeding tendency
.3 fresh blood Immune globulins

immune state
immune globulins fresh blood
.4 fresh blood plasma protein
plasma protein ,, kwashiorkor
edema ,,
,,
,, enzymes
,,
,, general condition apetite

,,
,,
fresh blood
,,
: fresh blood
: fresh frozen plasma ,,
fresh frozen plasma coagulation factors
bleeding
366
| Page
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"

.......
......
fresh frozen plasma ,,

apetite enzymes edema

fresh frozen plasma
,, Immune globulins Immue state
,,
anemia
anemia
: fresh frozen plasma
: ,,, soft free albumin albumin
,,
albumin
: albumin
: amino acids amino acids
amino acids
,, amino acids

,, amino acids argenine ,,, amino acids

argenine stimulation islets cells of langerhans
insulin
,,
Hypoglycemia
amino acids
hypoglycemia argenine

,, ,, Immune deficiency
anti biotics
anti biotics
367
| Page
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,, : " "
"

.......
......
gram positive gram negative

penicillin ,, gentamycin
available antibiotics
broad spectrum antibiotics
,,
septic focus
marasmus ottitis media
Ottitis media
marasmus pharyngitis
Pharyngitis
Kwashiorkor Pyelonephritis
pyelonephritis
,,, septic focus

broad spectrum antibiotics protective mechanism

,,
common ,,
,, fungus infection
,, Immune deficiency fungus
mycostatin oral drops

oral moniliasis
,, Mycostatin

Oral monaliasis
,,

,,

,,
:
) ,,

)) ((
368
| Page
" " :
,, : " "
"

.......
......
)) ((
)) , ,
((
:

:
:
)) : ((
)) : ((
)) : ((

( 67
,,

,, ,,
,,
,,
,,

,,
,, ,,
,,

,,

,,
) (
,, ,,

,, ,, ,,

369
| Page
" " :
,, : " "
"

.......
......
,,

,, ,,
esophagus
,,
IQ
,,
,, ,,

,, ,,
,, Marker
,,
,,

,,
,,
,,

asthmatic ,,
aminophyline

,, ,,

,, ,,
:
:
,,

:
Oral
: ,,
:
370
| Page
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,, : " "
"

.......
......
: ,,
,,
moniliasis skin
,, Napkin dermatitis
skin moniliasis oral moniliasis
skin moniliasis ,,
Mycostatin
,,

cream mycostatin

,, Infection
,, Infection
vitamins and minerals
,, Marasmus Kwashiorkor
,, Kwashiorkor 50,000 vitamin
A

deposits of keratomalacia corneal ulcers

50,000 vitamin A
,, vitmain deficiency ,,
Mineral ,,
,, ,, ,, Multivitamins

,, correction of vitamin and mineral deficiency

,, Muscle wasting
anbolic hormones
anabolic hormones protein biosynesis
,, ,,
anabolic hormones
,, ,,
371
| Page
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,, : " "
"

.......
......
Carcinogenic effect
myosarcoma
,, ,,
marasmic
,,
,, ,, ,,
,, :

marasmus kwashiorkor
History

dietic
,,
failure

treatment Marasmus kwashiorkor

: blood transfusion
,, On admission
,,

,, ,,
!!!! thalassemia
What is the most common cause of death in marasmus and kwashiorkor
Most common cause of death Infection
Kwashiorkor Heart failure

,, ,,
Notes

,,
,, ,,
372
| Page
" " :
,, : " "
"

.......
......

21
38
21
18

,,

,,
: total calories average weight caloric requirements
,,, total calories

3/2
calories
,,
: ,,
,,
,, ,,
,,
,,

complications treatment
kwashiorkor Management

,,
Liver fat
Liver fat
,, dietic management High protein
373
| Page
" " :
,, : " "
"

.......
......
,,
,, ,,

kwashiorkor

Liver
Marasmus
,,

,,
,,
bacterial flora

,, absorption bacterial flora

gut
,,
,, Portal
Liver
Liver
,, Liver
,,
,, hepatic
encephalopathy
,, disturbed level of conscious
,,
Hepatomegaly ,,
,,
Hepatic encephalopathy
,, Nutritional recovery syndrome
High protein diet ,,, hepatic
encephalopathy
374
| Page
" " :
,, : " "
"

.......
......
,, ,, ,,
,,

calories Liver recovery
recovery fat
fresh frozen plasma
fat load Liver

,,
,, Kwashiorkor ,, edema
,,
Osmotic pressure
Osmotic pressure
Hyper volemia
Hyper volemia congestive heart failure

hypervolemia
Congestive heart failure
,,
,, Over hydration transient increase of the intra cranial
pressure
!!!! transient increase of intra cranial pressure

,, congestive heart
over hydration brain Heart
heart
,, : ,, Over hydration transient increase of the intra
cranial pressure
comatosed

,,
management kwashiorkor ,,

375
| Page
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,, : " "
"

.......
......
Hypokalemia

.1 diarrhea

.2 aldosterone ,,
aldosterone Urine
.3 ,, hypoglycemia

,, ,,,
gut diarrhea
Urine aldosterone
,, arrested

take care
check

,, Hypokalemia
Management of kwashiorkor

Over hydration
hypo kalemia
nutritrional recovery syndrome
prognosis
Prognosis
Prognosis of kwashiorkor
376
| Page
" " :
,, : " "
"

.......
......
kwashiorkor Marasmus
Kwashiorkor ,, ,, acute
,,, marasmus marasmus
,,
Kwashiorkor

complication
Prognosis of kwashiorkor
:
.1 kwashiorkor
,, prognosis ,, so bad
.2 ,, ,, kwashiorkor
Kwashiorkor
reversible ,,
irreversible
,, irreversible Protein losing enteropathy
anomaly gut protein
!!! gut transplantation
,, available
Prognosis is so bad

,,
,, reversible Prognosis
,, Irreversible Prognosis is so bad
.3 ,, ,, complications
complications
complications
complications
377
| Page
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,, : " "
"

.......
......

,,
complications ,,
Prognosis
hepatomegaly
,,
mental dysfunction mental changes
,, reversible

nutritional assessment

,, differential diagnosis

Nutritional Assessment
written
,,
tetany
Nutritional assessment ,,
:
.1 ,, history
dietic history
.2 clinical assessment
.3 anthropometric
,, development

title
.4 ,, laboratory assessment
kwashiorkor
378
| Page
" " :
,, : " "
"

.......
......

.5 Immunological assessment
,,
,, Dietic history
dietic history
clinical round ,, dietic
history
,,
dietic history

: ,,
,, fat ,, ,,
,,, vitamins minerals

,,

,, ,, ,,
,,
,, fat
,,
total caloric
count
fat count
protein count
vitamin count

,, ,,
,,, ,,

fat ,,
,,
379
| Page
" " :
,, : " "
"

.......
......
,, ,,
content ,,

salt
sugar
sugar
,,, calories
,,

,,
,,

,,
,,
,,
,,,

,, ,, ,,

,,
,, ,,
,,
,,
,, ,,
,, ,,

calories

I dont know

,,
iam so sorry ,,
,, ,,

380
| Page
" " :
,, : " "
"

.......
......
: ,,

,,

,,
,, ,,
,, ,, ,,

: ,,
: roughly

roughly

,, dietic history
,, amount

,, ,, clinical assessment
,, check
signs of malnutrition vitamin deficiency
deficiency
anthropometric
,, ,, anthropometric
anthropometry ,,
,,
sheet ,, ,,

standard deviation score percentile
381
| Page
" " :
,, : " "
"

.......
......
Length height

,,

,,
subcutaneous fat
skull circumference
chest circumference
chest to head circumference
anthropometric assessment

anthropometric detect anomalies ,,

,,
,, Laboratory assessment
laboratory assessment
glucose tolerance curve
,,
free fatty acids Lipid fat
Protein ,, essential and non essential amino acids ratio
,, albumin globulins
,, enzymes carrier protein

,, editor

lab
,, research work
,, researches
382
| Page
" " :
,, : " "
"

.......
......
,, research work
,,
researchs
,, available
.1 ,, ,,
,,
600- 500 ,,

,, ,, short

short Protein
early detection
,,
malnutrition
,,
600 - 500 ,,
600 - 500 ,,
,,
,,
,,

,,
,, : ,, ,,

,,

,,
,,
,, ,, ,,
,,

,,
,, ,, ,,
,, rabies
383
| Page
" " :
,, : " "
"

.......
......
: ,,
,,
,,
,, signs ,,
,, Isolation virus
,, ,,

: ,,

.2 ,, ,, free albumin
,, free albumin ,,
free albumin half life 48
,,, Loss so early ,,
.3 ,, somatomedin C
Half life short ,, 36
48 ,,
so early
C
somatomedins
editors
Immunological assessment
immune status
Immune status so early
Immune deficiency
nutritional assessment
vitmain Deficiency
vitamin toxicity Hypervitaminosis ,,
hyper vitaminosis D
Hyper vitaminosis D
384
| Page
" " :
,, : " "
"

.......
......
hyper vitaminosis D ,, High dose of vitmain D

international unit daily 20,000

,,

,, free albumin

,,
,,
,,
international unit per day 20,000
,,
,,
vitmain D
,, vitamin D
tetany
adequate calcium supplementation
hyper calcemia
hyper calcemia
vitamin D bone ,,
osteoblast :
serum calcium
,,
serum calcium
serum calcium ,, : manifestations of hypercalcemia
.1 gut
gut
constipation and vomiting
constipation vomiting
385
| Page
" " :
,, : " "
"

.......
......
intestinal motility
,, Intestinal motility
,, intestinal obstruction
,, anorexia
,, anorexia
: ,,
distention
wall of the gut

,, ,,
anorexia, vomiting and constipation
.2 ,,
,, minerals
kidney full reabsorption
,,
,,
renal threshold
urine
Urine ,, Mineral

,,
Poly uria
,,
,, ,,
dehydation
,,
kidney oxalates
renal stones
,,
nephro calcinosis
386
| Page
" " :
,, : " "
"

.......
......
renal impairment
.3 ,, generalized muscle weakness and
hypotonia
tetany

Ionizable calcium
ionizable calcium
nerve fibers
,,
tetany
) Ctrl + F
(
.4 ,, ,,
metastatic calcification
blood vessel
brain
,, metastatic calcification
,,
Investigations
serum calcium ,, Urine calcium

urine serum calcium

urine serum calcium
differential diagnosis
Hyper parathyroidism
hyper parathyroidism hyper calcemia
calcium urine
Parathormone ,,
urine
,, Urine
X - ray metastatic calcification
387
| Page
" " :
,, : " "
"

.......
......

.1 ,, vitamin D

,,
.2 ,, ,,

wash Kidney
renal stones
full hydration

.3 ,, ,,
vitamin D
calcium absorption
calcium absorption
alkaline
phytate
Oxalate
absorption
,, ,,
alkaline PH calcium absorption
,,
EDTA
EDTA chelation ,,
resistant cases
why

block vitamin D receptors gut
nutritional disorders
summary
388
| Page
" " :
,, : " "
"

.......
......
management of marasmus and kwashiorkor
:
breast feeding
proper weaning
Proper diet
proper vaccination ,,
family planning

dietic management
total calories
Marasmus 150
kwashiorkor 120
first degree marasmus expected weight
average weight

non weaned

total calories
3/2

Small frequent meals
,,
gut ,, humanized milk
,, lactose intolerlance lactose free milk
fat intolerance ,, steatorrhea skimmed milk
,,
kwashiorkor
liver infiltrated fat
,,, hepatic
encepahlopathy
,,
weaned
389
| Page
" " :
,, : " "
"

.......
......
,,
,,
,, available
,,

,, ,,
,, Naso gastric tube

,,
,, vomiting paralytic ileus
,, severe infection
total parentral nutrition
,,
first sign of improvement
apetite
non dietic management
:
: emergency management
,, Hypo thermic
,, hypoglycemic
,, dehydration
,, shock shock
,,
,, fresh blood transfusion blood
component
fresh frozen plasma
albumin
,, amino acids mixture
amino acids mixtures Hypo glycemia
argenine ,, amino acid stimulation islets cells of
langerhans
,,

,, Antibiotics Liable to infection
390
| Page
" " :
,, : " "
"

.......
......
,,
vitamins and minerals deficiency
,, anabolics
Nowadays ,,
underlying etiology
,,
take care
kwashiorkor Hyper volemia
,,
Hypo kalemia
Nutritional recovery syndrome
,,
Prognosis
Prognosis :
,,, bad prognosis

reversible irreversible
irreversible bad prognosis
complications complications bad
prognosis
bad prognosis
: main complications
hepato meglay
mental changes
,,
,,
Nutritional assessment :
,, Dietic history .1 ,,

,,
roughly ,,
,,
391
| Page
" " :
,, : " "
"

.......
......
,, Clinical assessment .2 check

signs of vitamins, minerals
Malnutritions
,, Anthropometric .3 mid arm circumference skull
circumference
,, Lab assessment .4 Investigations

Kwashiorkor
,,, ,, free albumin

somato medins C
.5 Immunological assessment
,, hyper vitaminosis D
hyper vitaminosis D
vitamin D international unit 20,000

tetany
calcium Hyper calcemia
Hyper calcemia
Anorexia, vomiting and constipation

Poly uria
Dehydration
Renal stones
Nephro calcinosis
Generalized muscle weakness
metastic calcification

nutrition
392
| Page
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,, : " "
"

.......
......

www.facebook.com/dr.tafreegh

393
| Page
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,, : " "
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Nutrition DR. Abo-Asrar

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Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

defect mineralization of the bone

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

,,, cytoplasm osteoblast

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

bone mineral density

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

,,, Osteoblast alkaline phosphatase

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

calcium phosphorus ratio

Nutrition DR. Abo-Asrar

active form of vitamin D

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

calcium urine phosphate urine

Nutrition DR. Abo-Asrar

Ultra violet rays

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

receptors Ultra violet rays

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Nutrition DR. Abo-Asrar

Patho physiology of Rickets

Nutrition DR. Abo-Asrar