Professional Documents
Culture Documents
8 00 - 8.15 AM
Registration
8.15 - 8.30 AM
8.30 - 9.30 AM
9.30 - 10.30 AM
10.30 - 10.45 AM
Coffee break
10.45 12 noon
12.00 1.00 PM
1.00 - 2.00 PM
Lunch
2.00 - 3.00 PM
3.00 - 4.00 PM
4.00 - 5.00 PM
5.00 - 6.00 PM
6.00 - 7.00 PM
iii
8.00 - 9.00 AM
9.00 - 10.00 AM
10.00 -11.00 AM
11.00 - 11.15 AM
Coffee break
11.15 - 12 Noon
Inauguration function
Lunch
2.00 - 3.00 PM
3.00 - 4.00 PM
4.00 - 5.30 PM
5.30 - 6.00 PM
iv
Organizing Committee
Patrons
Organizing Committee:
Dr Jayanthi Ramesh
Dr.Kalpana Gowrishankar
Dr Lalitha Janakiraman
Dr.LakshmiSundararajan
Academic coordinators
Dr.Major K.Nagaraju
Dr.V.S.Sankaranarayanan
Dr.S.Muralinath
Dr.S.Balasubramanian
Dr.S.Namasivayam
Dr BalaRamachandran
Dr.PriyaRamachandran
Organizing secretaries:
Dr.RahulYadav
Dr.Janani Sankar
Dr K.G.Ravikumar
Dr.R.Radhika
Dr.T.Ravikumar
Dr T.Vasanthi
Dr.V.Viswanathan
Dr.Arathi Srinivasan
Mr.Sivakumar
Dr.AmrutaKanjani
Mr.Ananthanarayanan
Dr.Eswararaja
Dr.R.Ganesh
Dr.M.Lakshmi
Dr.Padma Balaji
Dr.SenthilGanesh
Dr S. Srinivas
Dr.N.Suresh
Disclaimer
This book contains the academic materials covering the common clinical exam topics
in Pediatric Medicine. This material is prepared based on the information from the standard
Textbooks. However there is absolutely no assurance that any statement contained in this
material is precise, or up-to-date. Neither the individual contributors, nor anyone else
involved in the preparation of this material take responsibility for any errors in the text on this
material. We strongly recommend the readers to refer standard Textbooks in Pediatrics
vi
vii
FOREWORD
Prof.Dr.K.Mathangi Ramakrishnan
Chairperson-CTMRF
viii
Venue
Prof V.I.Mathan,
Gastroenterologist & Senior Consultant,
UNAIDS / NACO, Bangladesh
Venue
Hotel Savera
Dr Kusum Verma,
Prof & Head, Dept of Pathology,
AIIMS, New Delhi
Venue
Hotel Savera
Venue
ix
Venue
Venue
Dr.K.M.Cherian,
Cardio Thoracic Surgeon,
Frontier Lifeline Ltd, Chennai
Venue
Prof.Boix Ochoa
Professor in Pediatric Surgery,
University Barcelona, Spain
Venue
Dr.A.V.Ramanan
Consultant Pediatric Rheumatologist and
Hony. Senior Lecturer, University of Bristol,
United Kingdom
Venue
Prof.Y.K.Amdekar, Mumbai
Venue
Prof.Anupam Sachdeva
Hemato Oncologist, Delhi
Venue
Venue
Prof. S.Mahadevan
JIPMER, Pondicherry
Venue
xi
Contents
Sl.No.
Topic
Page No.
01
Developmental Assessment
02
Cerebral Palsy
03
04
11
05
Floppy Infant
16
06
Hydrocephalus
19
07
Neurodegenerative Disease
22
08
Tuberculous Meningitis
25
09
28
10
31
11
33
12
Neonatal Cholestatsis
38
13
44
14
Thalassemia
49
15
51
16
58
17
Bronchiectasis
60
18
62
xii
Developmental Assessment
Dr. Ganesh, Dr.Suresh
Consulting Paediatrician KKCTH
Item/Age
Gross motor
Social
Hearing &
language
6 weeks
3 months
Grasp reflex
Head control
Social smile
Cooing
Recognises
Turns head to
mother
4 months
sound
Reaches for
objects
7 months
Rolls over
Palmar grasp
Crawling
Transfers objects
Smiles at mirror
Babbling
(ba,da,ka)
from hand-hand
for support
10 months
Pincer grasp
Waves bye-bye
Plays pat-a cake
Pivoting-turns round to
Uses amma,
appa
Turns to name
Tells 2 words
with meaning
by pointing
Drinks from cup
Bottom shuffling
1 years
Waves bye-bye
Makes tower of 3
cubes
Turns 2-3 pages in
a book at a time
Scribbles
Dry by day
Holds spoon-takes
Solitary play(
Points to parts
plays alone)
of the body
when asked
Echolalia
command:
food to mouth
Walks backwards
2 year
Obeys simple
Makes tower of 6
cubes
Copies vertical
line
Turns page in a
Gives name
Obeys two step
commands(pick
the toy and put
in the basket)
book singly
Turns door knob
Unscrews lids
Post Graduate Clinical Training in Pediatrics [2013]
Page 1
Item/Age
Gross motor
Hearing &
language
2 year
Copies horizontal
line
Makes tower of 7
cubes
Recognize
themselves in
Names one
color
photos
Pretends play
Makes train
3 year
Goes upstairs -1
foot/step & down
stairs-two foot/step.
Pedals tricycle
Stands on one foot for
one second
Knows own
name, age, and
Dry by night
gender
Dresses and
(boy/girl)
undresses if
helped with
buttons
Knows some
nursery rhymes
Names 3 colors
cubes
Can thread large
beads on to a
string
Cuts paper with
scissors
4 year
Dresses without
supervision
(boy/girl) and
three parts
Copies gate(6
stairs-one foot/step.
cube steps)
name, age,
gender
Knows own
address
Names 4 colors
Threads small
beads
Right-left
discrimination
5 year
Skips
Copies triangle
Makes 10 cube
steps
Knows own
name, age,
gender
(boy/girl)
address and
birthday
Page 2
CEREBRAL PALSY
Name :
Age :
Sex :
Complaints :
Convulsions.
Description of compliants.
Describe all 4 developmental domine important mile stones achieved by the child
o Gross motor
o Fine motor
o Language
o Social and adaptive mile stones.
Mannerisms, stereotypies.
Bladder, bowel involvement.
Page 3
For etiology :
Family history :
H/O Complication :
Convulsions
Recurrent LRTI
H/O Treatment :
Immunization:- ?? DPT
Diet History
Page 4
CNS :
Higher Functions
Cranial nerves
Exaggeration of reflexes:-
Neonatal reflexes
Hearing
Vision
Primitive reflexes
Diagnosis
Name-------------, aged---------- has static encephalopathy/ Spastic or
dyskinetic or atonic CP /hemiplegia or quadriplegia/microcephaly /seizures/Cranial
nerve dysfunction squint, cortical visual blindness, hearing deficit, pseudo-bulbar
palsy,/with
Gross
motor
functional
classification
of
---------/
with
learning
Page 5
Early markers of CP
2)
Functional grades of CP
3)
Neonatal reflexes
4)
Audiometry
5)
MRI correlates in CP
6)
7)
8)
Associated problems
9)
Page 6
Age :
Sex :
Complaint:
History of weakness in limbs :
Where does it start: From lower limbs and progresses upwards or vice versa
Bladder/bowel disturbance
Wasting of muscles
Page 7
Etiological history:
H/O fever with exanthem(herpes, mumps, rubella, entero/ EBV)H/O pain swelling
Examination:
Decubitus especially of lower limbsDemonstrate flaccidity
Vital parameters: Heart rate, Blood pressure for autonomic dysfunction
Throat---patch for diphtheria
Anthropometry with interpretation
Blue line on gums, NC markers
Spine
CNS
Fasciculations
Thickened nerves
Page 8
Bladder distension
Respiratory system
Involvement of respiratory muscles: increased respiratory rate , movements of alae
nasi and other accessory muscles of respiration, inability to cough or sniff with full
depth, Single breath count .Paradoxical abdominal movements due to diaphragmatic
immobility. Deltoid paralysis suggests impending respiratory paralysis
Observation of patients capacity for thoracic breathing while abdominal muscles are
splinted manually
Page 9
Guillain-Barr
syndrome
Traumatic neuritis
Transverse myelitis
Installation of
paralysis
24 to 48 hours onset
to full paralysis
From hours to 10
days
From hours to
4 days
Fever at onset
Not common
Commonly present
before, during and
after flaccid paralysis
Rarely present
Flaccid
paralysis
Acute, usually
asymmetrical,
principally proximal
Generally acute,
symmetrical and
distal
Asymmetrical, acute
and affecting only one
limb
Muscle tone
Reduced or absent in
affected limb
Global hypotonia
Reduced or absent in
affected limb
Sensation
Decreased to absent
Globally absent
Decreased to absent
Absent in lower
limbs early
hyperreflexia late
Deep-tendon
reflexes
Severe myalgia,
backache, no sensory
changes
Cramps, tingling,
hypoanaesthesia of
palms and soles
Pain in gluteus,
hypothermia
Anesthesia of lower
limbs with sensory
level
Cranial nerve
involvement
Often present,
affecting nerves
VII, IX, X, XI, XII
Absent
Absent
Respiratory
insufficiency
In severe cases,
enhanced by
bacterial
pneumonia
Absent
Sometimes
Autonomic
signs &
symptoms
Rare
Frequent blood
pressure
alterations,
sweating, blushing
and body
temperature
fluctuations
Hypothermia in
affected limb
Present
Cerebrospinal
fluid
Inflammatory
Albumin-cytologic
dissociation
Normal
Normal or mild in
cells
Bladder
dysfunction
Absent
Transient
Never
Present
Nerve
conduction
velocity: third
week
Abnormal: anterior
horn cell disease
(normal during the
first 2 weeks)
Abnormal: slowed
conduction,
decreased motor
amplitudes
Abnormal: axonal
damage
Normal or abnormal,
no diagnostic value
EMG at three
weeks
Abnormal
Normal
Normal
Normal
Sequelae at
three months
and up to a
year
Severe, asymmetrical
atrophy, skeletal
deformities
developing later
Symmetrical
atrophy of distal
muscles
Moderate atrophy,
only in affected lower
limb
Flaccid diplegia
atrophy after years
Page 10
Age :
Sex :
Address :
Consanguinity :
Handedness :
CHIEF COMPLAINTS
Paucity of movements of right/left side of the body.
Convulsions
Onset-Catastrophic/acute/sub acute/chronic/static/episodic
Progressive/ static/ improving
Involving the upper limb preferentially/equally
Detailed H/O CNS involvement
H/O Complications
Bed sores/shortening of limbs/contractures /trophic ulcers
ETIOLOGICAL HISTORY
H/o Trauma
Hematological causes
H/O pallor
Page 11
Cardiac causes
Infectious Causes
Dehydration
FAMILY HISTORY
BIRTH HISTORY
Preterm-Subependymal Hemorrhage-Intraventricular hemorrhage
Full-term- Breech/ Traumatic delivery/Birth Asphyxia
H/O Umbilical sepsis / Catheterization (Embolism)
H/o Rash/ fever/ petechae/jaundice (IU infection)
Page 12
EXAMINATION:
General Examination-Routine examination plus look for dysmorphic features
Anterior Fontanelle
Head Circumference
Pallor/Cyanosis/Clubbing
Xanthomas
Eyes-Ectopia lentis
Neurocutaneous Stigmata
CNS
Higher Functions- Speech (dysphasia seen in involvement of dominant hemisphere)
Visual fields for field defects& partial visual neglect (A field defect infers a lesion at
or above the internal capsule)
CVS Examination
1. Higher mental function
2. Cranial nerves
3. Motor system
a. Tone
b. Power
c. Bulk/Nutrition
Post Graduate Clinical Training in Pediatrics [2013]
Page 13
d. Involuntary movements
e. DTR
4. Sensory system
5. Meningeal signs
6. Spine and cranium
7. Primitive reflexes
Differential involvement (Upper limbs more than lower or lower limbs more
than upper)
Astereognosis
Page 14
C)
Dense Hemiplegia
Hemianaesthesia
Homonymous hemianopia
Dysarthria
Same as cortical lesion but features such as convulsions & loss of cortical
sensation are absent
Lesion in Midbrain
WEBER SYNDROME- 3rd nerve palsy plus crossed Hemiplegia
BENEDICTS SYNDROME-3rd nerve palsy + crossed hemiplegia +
Red nucleus affected (Tremor, rigidity, ataxia on the opposite side)
B)
Lesion in Pons
MILLARD GUBLER SYNDROME-7th nerve palsy +Crossed hemiplegia
FOVILLE SYNDROME-6th nerve palsy + 7th nerve palsy + contra lateral
Hemiplegia
C)
Lesion in Medulla
JACKSON SYNDROME-12th nerve palsy + crossed hemiplegia.
Page 15
FLOPPY INFANT
Complaints :
ELABORATION OF C/C.
ETIOLOGY
H/O constipation, prolonged neonatal jaundice (if MR, coarse facies for
hypothyroidism)
Page 16
ANTENATAL HISTORY
H/o decreased fetal movements, fever with rash, irradiation, drug exposure (lithium/
phenytoin/ carbamazepine). ,polyhydramnios / prolonged labour / LSCS.
PERINATAL HISTORY - breech presentation, h/o birth asphyxia, h/o limpness, feeding
difficulties, breathlessness, convulsions in neonatal period, neonatal hyperbilirubinemia.
FAMILY HISTORY - h/o deaths in infancy in sibling
MILESTONES - motor +mental
DIET & IMMUNIZATION- last vaccine given (for GBS/ polio)
EXAMINATION
Anterior fontanelle
Cataracts(Lowe syndrome)
Page 17
ENT
CNS EXAMINATION
Cranial nerves
Tongue fasciculations
Deep reflexes
Sensory system
P/A-----hepatomegaly----GSD
RS--------r/o LRTI
Orthopedic examination
Page 18
HYDROCEPHALUS
Name :
Age :
Sex :
DOB :
Complaints :
History s/o raised ICT (if the onset of hydrocephalus is more than 2 yrs (or)
Etiological History
ANTENATAL HISTORY
Page 19
FAMILY HISTORY-
Skulla) Head circumference & Shape of the skull noted- in terms of AP diameter, Biparietal
diameter, Frontal bossing& Occipital prominence.
b) Presence of dilated veins
c) Anterior & posterior fontanelle-(note their size, shape, borders, pulsation,tension in sitting
& supine position)
d) Sutural separation
e) Transillumination-more than 2 cm in frontal & more than 1 cm in Occipital (it is positive
only if the cerebral mantle is less than 1cm). It is positive in massive dilatation of the
ventricular system or in Dandy Walker syndrome.
f) Bruit over the head-It is positive in many cases of vein of Galen AV malformation.
g) Prominent occiput in Dandy Walker/post fossa tumor/arachnoid cyst
h) Flat occiput in achondroplasia/Arnold Chiary Malformation
i) Craniotabes
Sunsetting (paralysis of upward gaze)
Spine-Neural tube defects. Look for tuft of hair
Post Graduate Clinical Training in Pediatrics [2013]
Page 20
Page 21
NEURODEGENERATIVE DISEASE
Name :
Age :
Sex :
DOB :
Informant :
Chief complaints:-
convulsions
In certain epilepsy syndromes, convulsions are the hallmark which precede the
onset of regression.
o e.g. West Syndrome - Infantile spasms - Lennaux Gestaut syndrome - tonic
spasms .
o Certain aminoacidopathies & organic acidurias patients / urea cycle defects
convulsions may be due to metabolic disturbances like hypoglycemia,
hyperammonemia etc )
o SSPE - Myoclonic jerks
2.
Progressive dementia / personality changeso Scholastic backwardness - SSPE, HIV, encephalopathy Wilsons disease.
o Behavioural changes - hyperactivity - sanfillipo, X linked ALD,
o Autistic behavioural - Autism, Rett's Syndrome
o Sudden
- Post encephalitis
Page 22
Progressive hydrocephalus
Vision problems :
1] Progressive loss of vision hydrocephalus, Tay sachs disease
Neuronal ceroid lipofuschinosis,
Wilson's disease ( Cataract)
2] Visual inattention - autistic spectrum disorders, Rett's syndrome
6.
9.
Page 23
Pulse
respiration
BP
Anterior fontanelle
optic atrophy
Retinitis pigmentosa
PA - organomegaly
Fundus
Diagnosis:
Page 24
TUBERCULOUS MENINGITIS
Name
Age
Sex
Address
Handedness
Complains:
1. Fever
2. Convulsions :- focal / generalised seizures
3. Altered sensorium :- onset - sudden / insiduous.
4. Vomiting
5. Focal neurological deficit Hemiplegia / monoplegia / cranial neuropathies.
Origin/Duration/Progress
Complains in details.
H/o.
Convulsions
Page 25
H/o. seizures.
Birth History :
Developmental history.
Decubitus
2]
3]
4]
5]
6]
Anterior fontanelle
7]
8]
9]
Page 26
Diagnosis :---years old M/F child with chronic meningoencephalitis with / without
hemi / monoparesis with / without cranial nerve palsy with / without involuntary movement
with / without signs of increased intracranial pressure.
Probable etiology being TBM.
Page 27
H/o streptococcal pharyngitis Fever , sorethroat - in the recent past (2-3 weeks back)
H/o Joint pain, swelling, duration, joints involved,characteristics of pain and relief with
medications (arthritis),migratory or not
H/o dyspnoea,palpitations easy fatigability ,exercise intolerance, chest pain, syncope ( s/o
Carditis)
Examination :
General Vitals, Growth parameters, Scars, Chest asymmetry, icterus, teeth- caries , lymph
nodes. Skin - erythematous rash & subcutaneous nodes over extensor surface of head, back
& limbs. Nails - pallor, clubbing, cyanosis. Joints - pain, swelling, tenderness & restriction of
movements.
Page 28
Cardiovascular examination
Peripheral - Venous, major arterial pulses & Blood pressure (upper & lower limbs).
Precordium
o Inspection Scars, symmetry, apical pulsation
o Palpation Apex position, point of maximal impulse (PMI), heaves,
(parasternal, substernal, apical) Thrills (Suprasternal, supraclavicular and over
precordium) Palpable S2- (pulmonary hypertension)
o Auscultation- (use diaphragm initially, then the bell)
CNS
Diagnosis - Investigations:
Throat culture, ASLO (second antibody titre/ rising titres if initial is normal)
Page 29
Page 30
Checklist:
1. Complaints:
a. Cyanosis age of onset,Distribution,precipitating and reliving factors.
b. Cyanotic spellfrequency of episode, improving or worsening, drugs
c. Growth retardation/FTT
d. Dysmorphis facies conotruncal facies
e. History of vaccination due to association with Digeorge syndrome
(T cell def)
f. History of complicationfever with altered sensorium (abscess)
g. Prolonged fever with chills and rigorsIE
h. Older childsyncope/chest pain/arthritis(gout)
i. Any iron supplementation
2. Antenatal history:
a. Mothers ageDowns
b. Maternal drug intake
3. Development history
4. Dietary history
5. Immunization history: stress on T cell dependent vaccine
(ass. With Digeorge syndrome)
6. Family and socio economic history
7. Examination findings:
a. Cyanosis,clubbing,Polycythemia
b. Anthropometry
c. Inspection:
i. Precordial bulge
ii. Apical impulse will be normal in position
d. Palpation:
i. Parasternal heave
ii. Palpable murmurs
Page 31
e. Auscultation:
i. P2 is delayed & soft ,it is inaudible
ii. S2 is single which is aortic component
iii. ESM at left 3rd & 4th ICS
iv. Continuous murmur if collaterals / after shunt surgery
Diagnosis : case of cyanotic congenital heart disease/with decresed pulmonary blood
flow/single s2/no s/o CCF or IE/sinus rhythm/
Page 32
Age:
Sex:
Religion:
Care taker:
Address:
Presenting complaints
-
Associated complaints
-
Polyuria, Polydypsia
Recurrent infections
Birth History
- Age of expectant mother
-
Prematurity
IUGR
Perinatal complications
Dietary history
- Calorie intake / day
-
Calculate calories and protein and calculate the calorie gap and protein gap as
compared to ICMR recommendation
Page 33
SOCIO-ECONOMIC HISTORY
- Education of parents, occupation
-
Family size
Toilet habits
Working mother.
Psychosocial history
Cultural practices
Page 34
On Examination
Anthropometry
1. Weight - Beam balance, electronic scale - simplest, most widely used, most reliable.
2. Height Infantometer, stadiometer
3. US : LS ratio
4. MAC between 1 5 yrs of age, done on left arm midway between acromion &
olecranon. (<12.5 cms severe PEM, 12.5 13.5 moderate PEM, >13.5 normal )
Not a good parameter for growth monitoring during 1 5 yrs of age.
5. Head circumference maximum occipito frontal circumference
6. Chest circumference
7. Skin fold thickness
8. Somatic quotient average of Wt, Ht head circumference, MAC expressed as % age
of expected
Age independent anthropometric indicators
1. The Bangle test inner diameter of bangle of 4 cms crosses above elbow
2. The Shakirs tape green (13.5 cms), yellow ( 13.5 12.5 cms), red ( < 12.5 cms)
3. The Quac stick Quackers arm circumference stick
4. Modified Quac stick
5. The Nabarrows thinness chart
6. The head circumference to chest circumference ratio ( > 1
- normal)
0.32 to 0.33
- normal )
0.28 0.31
- mild PEM
0.25 0.279
- moderate PEM
< 0.249
- severe PEM
> 2.5
- normal
2.0 2.5
- borderline PEM
< 2.0
- sever PEM
> 0.79
- normal
< 0.79
- malnutrition
Page 35
> 0.15
- normal
71 80
II
61 70
III
51 60
IV
< 50 %
Oedema
Type of PEM
60 - 80
Kwashiorkor
60 - 80
Under weight
< 60
Marasmus
< 60
Marasmic Kwashiorkor
(IV)
Normal
> 90 %
75 90
60 75
< 60 %
- Waterloos classification
Wt for age
McLareins classification
Page 36
Ht for age
Waterloos
McLareins
Normal
> 95
> 93
90 - 95
80 - 93
85 - 90
< 85
< 80
Wt for age
Waterloos
McLareins
Normal
> 90
> 90
80 - 90
85 - 90
70 - 80
75 - 85
< 70
< 75
Wt for age
HA & WH
> - 2 SD
Normal
Normal
Normal
< - 2 SD
Stunted
Wasted
Spectrum of PEM
- Kwashiorkor / Marasmus / Marasmic Kwashiorkor / Pre-Kwashiorkor/
-
Clinical Signs
-
Growth retardation
Hair changes
Page 37
Glands.
Hepatomegaly
Purpura or Bleeding
Investigations
- Hb, CBC, Platlet count, Priferal serum, RBS, BUN, S electrolytes, S protein, Alb,
CXR, MT, Urine R & CS, LFT, RFT, CSF
Management 4 STEPS
- Resuscitation, Hospital care
-
Restoration,
Rehabilitation
Prevention care
Resuscitation..
Treat medical emergencies
o What emergencies? Hypothermia, hypoglycemia, electrolyte disturbance,
sepsis , shock, dehydration, cardiac failure, Anemia
Restoration.
Achieve weight for height - How?
150-200Cal/actual weight , 3-4gm protein/actual weight , 150-165 ml fluid/ actual
weight and Multivitamins and minerals
Given as 2hrly feeds with a feed late night and early morning -Oral or gavage feeds
What type of feed?
Breast feeds, High energy milk
Isodense formulas ,Hyderabad mix, amylase rich food, Cereal pulse mix
Rehabilitation
Allow RDA as per ICMR recommendations
Supplementary through various national nutrition programmesICDS
Growth monitoring
Developmental stimulation
Post Graduate Clinical Training in Pediatrics [2013]
Page 38
Prevention
Prevent LBW babies.Antenatal care & Care of adolescent girls
NIMFES .. Nutrition, Immunization, Medical care, Family planning, Education,
Stimulation
NUTRITIONAL RECOVERY SYNDROMES
Gynecomastia, Parotid swelling, Hypertrichosis, Hepatomegaly, Ascites, Spleenomegaly,
Eosinophilia, "Kwashi shake" All are self limited but keep the baby under observation.
Commonly asked questions
Complications of PEM / Poor prognostic signs
National programmes in nutrition
Classifications of PEM
Nutritional recovery syndromes
Difference between marasmus / Kwashiorkor
Diet chart for PEM
To prevent malnutrition the Three plank protein bridge
by Jelliffe to prevent PEM
-
Continue breastfeeding
Page 39
NEONATAL CHOLESTASIS
Name :
Age :
Sex :
DOB :
Consanguinity :
C/O
Jaundice
Onset of Jaundice
Associated with high colored urine +/- clay colored stools (Obstructive jaundice)
Abdominal distension
Urine output
Stool history
History of etiology
Dysmorphic features
History of complications
Altered sensorium
Ascites
Examination
General examination
Jaundice,
Page 40
Edema, anasarca
Anemia
Cataracts
Abdominal examination:
Deep Palpation
o Hepatomegaly
o Splenomegaly
Tender/Nontender
Surface: Smooth/Nodular
Consistency: Soft/firm/hard
Consistency: Soft/firm
Splenic notch
Kidneys
Divarication of recti
Hernial sites
Diagnosis
Neonatal jaundice
With/without hepatosplenomegaly,
With/without ascitis
With/without dysmorphic features
With/without anemia
With/without associated anomalies
Page 41
Investigation:
Jaundice in newborn
Conjugated jaundice
Unconjugated jaundice
Biochemical/
Morphological
Tests
Routine tests
Other tests
LFT including
Blood culture
USG abdomen
X-ray spine:
Bilirubin
Urine culture
Hepatobiliary
(Alagille)
SGOT/SGPT/GTP/
Alk.PO4
Stool culture
Scan
X-ray chest:
CRP
Cholangiogram
(Cardiomegaly)
PT/PTT
VDRL
(Peroperative/
Fundoscopy:
Total proteins
TORCH titres
Laproscopic)
(Chorioretinitis)
RFT
Hemogram
HbsAg, HIV
S.electrolytes
S.Ammonia
Antitrypsin levels
VBG
UAA/PAA
RBS
Histopathology
Staining with HE
and PAS.
Page 42
Treatment:
General measures:
Proper nutrition and multivitamin supplementation in cholestatic doses
Vitamin K supplementation
Phenobarbitone
Cholestyramine/Urodeoxycholic acid
Specific measures
Toxoplasmosis: Sulphamethaxazole, pyrimethamine
Galactosemia: Galactose free diet
Biliary Atresia: surgical intervention
Choledochal cyst: Surgical intervention
Page 43
Name:
Age : Sex :
Religion:
Address:
HISTORY:
Complaints
Abdominal distension
Abdominal lump
Associated with lump elsewhere
H/o anorexia, nausea, vomiting, dysphagia, diarrhea, constipation, clay colored stools,
worms, mucus in stools.
Etiological history:
No
h/o
altered
sensorium/
unconsciousness/
coma/
convulsions
(hepatic
encephalopathy)
Page 44
EXAMINATION:
Vital signs.
Genitals
Skull/ spine
SYSTEMIC EXAMINATION
Abdominal system:
INSPECTION:
Abdomen:
There are scars, abdominal tap marks, liver biopsy, sinuses or dilated veins.
Page 45
PALPATION:
Deep palpation :
Liver : Enlarged ------- cms in Right midclavicular line and --------- cms in midline below the
xiphisternum; upper border of liver dullness is in --------- Right Intercostal space; span ------cm. The edge is sharp/ round/ leafy. The surface is smooth/nodular/ tender/nontender.
Consistency----soft/firm/hard. Moves with respiration. Pulsations-Rub/bruit over the liver.
SPLEEN is--------cm from the left subcostal margin; is non tender; smooth in consistency;
soft/firm or hard; anterior notch is felt; there is/ is no bruit.
PERCUSSION : S/o free fluid in the form of puddle sign (120cc)/ Shifting dullness (>1
litre)/ Fluid thrill (>2 litres).
AUSCULTATION : Bowel sounds, Bruits
hematemesis/ malena/ IU infection/ umbilical vein catheterization with, failure to thrive, with
vitamin deficiency A/D/E/K. with s/s of liver cell failure, with s/s of Portal hypertension with
s/s of hypersplenism with dysmorphic features, or s/s of congenital infection/ cataracts or s/s
of storage disorder.
Differential diagnosis:
Hepatosplenomegaly:
Splenohepatomegaly:
Page 46
Hepatomegaly:
Splenomegaly:
Page 47
Disseminated Kochs
Cirrhosis of liver- post hepatitis, Indian childhood cirrhosis, Wilsons Disease, portal
hypertension
Malignancy-rarely ascites.
Page 48
THALASSEMIA
Name:
Age : Sex :
Religion:
Address:
Complaints:
Abdominal distension
Failure to thrive
Elaboration of complaints:
Page 49
Facial
features-Frontal
bossing/Parietal
bossing/Chipmunk
facies
Maxillary
Pulse
Slow
Alternans
(CCF),
Hyperdynamic(anaemia)
Abdomen
Lower limbs and gait- Leg ulcers , Ankle odema (CCF), Bony tenderness
Gait examination for long tract signs-----due to vertebral bony expansion and cord
compression
Hearing(sensorineural deafness)
Page 50
To ascertain that the child is indeed short, measure height/ length with infantometer
till 2 years of age and with stadiometer later on by appropriate technique. This
parameter is plotted on growth charts. Different growth charts are available like
NCHS, Tanners, ICMR , K.N.Agrawal .
A child is said to have short stature if his/her height is below the 3rd percentile or more
than 2SD below the mean for the reference population.
A child is said to have growth retardation if his growth ( height) velocity is below 25th
centile of reference population.
History :
School, home or physician records of previous heights and weights must be sought and
charted on growth charts.
Page 51
Antenatal history
Birth history
Type of delivery (breech), Mode of delivery,
Full term / preterm/ post term . Birth weight
Neonatal period.. Seizures , prolonged hyperbilirubinemia, feeding
difficulties, hypoglycemic episodes, delayed cry.
Family history ..
Pedigree, Consanguinity , height of parents, Age at onset of puberty
in parents, Presence of similar complaints in other family members.
Developmental milestones
Dietary history
Calories and proteins intake.
Psycosocial history.
A well taken history can give clues to aetiology of short stature like:
Page 52
On Examination :
Anthropometric measurements like weight, standing and sitting height, upper to lower
segment ratio, arm span, rhizo, meso and acromelic lengths , head circumference, must be
taken.
Plot the height against mid parental height range .Mid parental height (MPH) is
calculated by adding 6.5cm to the average of mothers and fathers height in boys and
by subtracting 6.5cm in case of girls. This should be plotted on growth chart with a
range of about 8.5 cm below or above MPH. If a child lies within this range he has a
genetic cause of short stature.
Dysproportionate
short
stature------skeletal
dysplasia,
rickets,
congenital
hypothyroidism
Dysmorphism------congenital syndromes
Midline defects-------hypopituitarism
Page 53
Visual field defect, optic atrophy, optic nerve hypoplasia, papilledema----pituitary/hypothalamic tumour ,septooptic dysplasia
Bone age is done to study the skeletal maturity IT IS DONE BY TAKING HAND AND WRIST
X-RAY OF LEFT HAND. Two systems for reading bone ages are available-Greulich and
Pyles Atlas method and Tanner and Whitehouse scoring method.
Normal ranges of bone age range:
Range + 2SD
Chronological age
Male
Female
+/- 3-6 mo
0-1yr
0-1yr
+/- 1-1.5 yr
3-4 yr
2-3yr
+/- 2yr
7-11yr
6-10yr
13-14yr
12-13yr
If height is normal for national standards and midparenteral height and growth velocity is
normal on follow up then reassurance is needed without any further investigations.Normal
bone age at outset usually rules out pathological cause of short stature.
Page 54
Investigations
Laboratory tests can be requested if clinical findings are suggestive of a disease. Chest
x-ray ,2-D Echo for cardiac defect, Thyroid functions for hypothyroidism, skeletal
survey for skeletal dysplasias etc. However where there is no clue on history and
examination and with delayed bone age and low growth velocity screening
investigations are needed.
Weight for height gives an important clue for investigations i.e. poor weight for height can
suggest malabsorption or other systemic illnesses while good weight for height may mean
growth hormone deficiency.
Screening investigations for finding cause of short stature are:
Sr.Creatinine------CRF
If screening tests are normal suspect Turner syndrome, GHD, malabsorption .Other
investigations like karyotyping, provocative assays for growth hormone and special tests for
malabsorption need to be done.
Page 55
Yes
1) Is the height within midparental height (MPH) range
Yes
BA= CA >HA
BA =HA <CA
CDGP
Hormone deficiency
Page 56
Note
Upper segment, lower segment ratio should be calculated in all short children to check
for disproportionate short stature.
2]
Stages of coma
3]
4]
5]
6]
Types of herniation
7]
8]
9]
Complication of TBM
Page 57
Page 58
Examination
Anthropometry - Short stature, Disproportionate short stature
Bony features of rickets
Craniotabes (young infants)
Wide open / persistent open anterior fontanelle
Fronto parietal bossing giving a hot cross bun appearance
Rachitic rosary
Harrison sulcus
Pectus excavatum
Widening of wrists
Double malleolus
Bowing of long bones
Genuvarus / genu valgus
Coxa vera/ coxa valga deformity.
Dental feature: Delayed eruption of teeth, dental abcess, pulp defects, dental problem usually affect the
secondary detention.
Muscle and ligament: Proximal muscle weakness causing waddling gait, difficulty in climbing stairs, difficulty in
getting up squatting position. Visceroptosis, laxity of ligaments.
Associated problems: Pallor, Icterus, other vitamin deficiencies, hypertension, alopecia, hepatosplenomegaly,
cataracts, glaucoma, sensorineural hearing loss.
Diagnosis:
Page 59
BRONCHIECTASIS
Name :
Age : Sex :
Address :
HISTORY:
PRESENTING COMPLAINT: Patients typically present with fever, chronic cough,
purulent sputum, weight loss and loss of appetite.
A) RESPIRATORY SYSTEM
SYMPTOMS
o Impaired exercise tolerance
o Cough-frequency/severity/nocturnal/exercise induced/change in
pattern.
o Sputum-volume/color/blood tinged/recent change
o Fatigue/Dyspnea/Chest pain
o Chronic sinusitis
o Wheezing might point towards allergic bronchopulmonar aspergillosis
o Bronchodilators required and response to their use
PAST COMPLICATIONS : pneumothorax/hemoptysis
INVESTIGATIONS DONE : Sputum culture, chest x-ray, pulmonary function tests,
pulse oximetry.
THERAPY RECEIVED - exercise, physiotherapy, nebulised saline, bronchodilators
or antibiotics.
B) GASTRO INTESTINAL SYSTEM : Generally GI symptoms are present in cystic
fibrosis or in IgA deficiency. Liver is affected in alpha 1 antitrypsin deficiency.
Page 60
B) Affected system
RESPIRATORY SYSTEM
Inspection
Palpation
Percussion
Auscultation -
Hyperinflation /consolidation
Coarse leathery crepts over the affected region (First heard in the upper
lobes in cystic fibrosis)
Wheeze may be present
Loud second heart sound in pulmonary hypertension
Gallop rhythm in cor pulmonale
Dextrocardia in Kartagener syndrome
DIAGNOSIS:
Page 61
Firstly, exams are just a phase in life. It too will pass. So, do not make it a do-or-die
experience.
Be systematic.
Plan ahead.
Set realistic goals.
Work towards your goals.
Keep motivating yourself.
Remember, it is just an examination.
The real test, is your daily routine--- saving lives of kids. So
dont lose focus on that.
If you are sincere and hard working at taking care of kids
under your care, you will know what to do in the exams.
Look at the exams as stepping stones. Do what you need to do to reach the top. Dont
think of the difficult nature of the stones.
People have cleared the exams. So it is not impossible.
Start with a positive attitude.
Preparing for theory examination:
Page 62
You may jumble up systems or sit with a single system till that is over, that is a
personal choice. But do not omit any system.
Prepare notes in your own style and revise them whenever possible.
You must know the salient points in each topic, not necessarily every point.
Work out previous question papers.
You will get an idea of the pattern of questions and will be a good guide to your
progress.
Do not forget community medicine, vaccination, recent advances.
If possible, formulate your own questions in each topic. Think about how you would
answer that.
Prepare algorithms and flowcharts for questions like approach to a disease or a
condition, line of treatment.
Make a list of questions you want to revise the day before.
On the night before the exam, stop reading by dinner time, have a good dinner, relax
and give your body time to ease out the tension. Try to get a good night sleep.
Do not worry about the questions, it is not in our hands. Do not think about all the
what if questions the fill our heads with fear.
It is just another day of your life. Face it with courage, determination and a will to
win.
Writing the theory paper:
Page 63
Use different colour / capitals/ underlining , to show the different parts of the same
question. Marks are being allotted in parts. Ensure they know what is where.
Space out neatly and write, let it not go on for pages.
Make the answers neat, precise and legible.
There is a high probability that you may not know the answer to a question or you are
not sure of it completely. Do not panic.
Face questions one at a time. Focus on the answer you are writing. Do not think and
worry about a question you do not know.
If you do not know the answer, leave out a few pages, write the remaining, come back
to that question at the end when you will be able to think and write.
For clinical questions, you can imagine what you would do, how you would approach
a child with the given condition in the ER / OP.
Do not think about the paper you have written and submitted. It is done. You cannot
change. Focus on the next paper. That is the best thing to do.
Practical examination:
Relax for a few days / weeks after theory exams and then start preparing for
practicals.
Prepare a list of systems and diseases that are commonly kept in the clinicals.
Write a fake case sheet for each disease ,so that you know what all needs to be
covered in history, clinical examination.
Present the entire history to your colleagues and teachers, dont worry about making
errors, it is better to make them now than in the exam. Learn from your mistakes and
others too.
Try to finish taking history and clinical exam within 45 minutes.
Page 64
Request your teachers and friends to correct you / show you how to elicit signs and do
the examination.
Do not make errors in the basics.
Be sure of the order of presentation.
Be thorough in anthropometry, nutrition and immunization. These are what separate
the kids from adults, pediatrics from general medicine. There is no excuse if you falter
in these areas.
Prepare for osce (objective structured clinical examination) parallelly.
There are certain topics that need to be covered compulsorily for osce preparation.
Dress neatly.
Wear a coat with long sleeves.
Take some toys / chocolates / biscuits to befriend the kid who is helping you in the
exam (by being your patient)
Do not panic if they ask you a question to which you do not know the answer. Try to
think and answer or else respectfully say you do not know. But dont make it a habit.
Be loud and clear while you talk.
Be confident.
They are only making you do what you have been doing daily in the hospitaltake
history, do clinical examination, derive at a differential diagnosis, plan the line of
management.
You need to talk, converse and not keep quiet because by not doing that you are
making it hard for them to help you.
Do not worry about the reputation of the teachers / examiners. At the end of the day,
you have to perform.
Be at your best.
Page 65
Page 66