TBL 1 - BREATHLESSNESS

1. A 10 month old girl presented to the hospital with fever and cough for 3
days and breathlessness for a day. She has also been noted to be feeding
poorly for the past 2 days. There was a strong family history of bronchial
asthma in the father and an elder sibling.
On examination, the child was found to be lethargic with a temperature
of 39 C. Her pulse rate was 170 per minute and respiratory rate was 60
per minute. Her oxygen saturation via the pulse oximeter was 88%. There
was marked subcostal and intercostal recession and the chest was
hyperinflated. There was a soft ejection murmur heard over the left sternal
edge. Air entry was decreased bilaterally with occasional ronchi and
crepitations. Liver was palpable 3 cm below the right subcostal margin.
A blood count done showed the following: Hb 107 g/l, TW 25 X 10/L,
neutrophils 75%, Lymphocytes 20%, Platelets 486 X 10 /L.
BRONCHIOLITIS
- Evidence-based management of bronchiolitis
2. A six week old infant presented with a 2 day history of breathlessness and
poor feeding. The baby was born at term with a birth weight of 3.2 kg.
Since two weeks after birth, the mother had noticed that the baby always
required longer time to finish her milk feeds. For the past 2 days, the baby
had been extremely fretful and the mother had difficulty in feeding her
any milk at all.
On examination, the baby weighed 3.8 kg and appeared tachypneic,
with a respiratory rate of 60 per minute. However, the baby still appeared
alert and active. The pulse rate was 180 per minute, but not bounding.
The apex beat was situated over the 5th intercostal space, 1 cm lateral to
the midclavicular line. There was a gallop rhythm with a grade 3/6
pansystolic murmur heard throughout the precordium. There were fine
crepitations over the bases of both lung fields. Liver was palpable 3 cm
below the right subcostal margin.
A chest X-ray done showed a cardio-thoracic ratio of 0.65. An ECG was
done which showed left axis deviation.
HEART FAILURE
- What is the normal liver span according to age group ???
- Signs and symptoms of heart failure

3. A 10 year old boy presented with acute onset of breathlessness for one
day. He had been having fever for the past 5 days, associated with
vomiting and abdominal pain. At the same time, he also had frequent

micturition. On the day of admission, he had made a turn for the worse
and was not able to walk about.
Examination revealed a drowsy boy with a respiratory rate of 40 per
minute. His lips and tongue were dry and he was tachycardic with a heart
rate of 120 per minute. Lungs were clear and the heart size was normal.
Abdomen was soft with tenderness over the peri-umbilical region.
An arterial blood gas showed the following results: pH 7.05, pCo2
20mmhg, pO2 150 mmhg, Base excess -12.
After 2 days on the ward, he has made a good recovery and is able to go
home. On leaving hospital, the boy told the mother he would like to be a
medical researcher just like the woman who spoke to a couple of
children on his ward. His mother is concerned about the ethics of clinical
research involving participation of children - did their mothers know?
DIABETIC KETOACIDOSIS
Read the Paediatrics Protocol - the whole chapter on diabetic ketoacidosis
including criteria to diagnose , fluid therapy , management of cerebral
oedema

TBL 2 - HAEMATURIA
1. A one-month old infant was brought in by the mother complaining of
blood-streaked urine on the nappies. This has occurred on four occasions
but the baby did not cry during micturition and there was no associated
fever. Abdominal examination was unremarkable and there were no
ulcers over the genitalia. A blood test showed a serum creatinine of 25
mol/L. A urinalysis showed WBC of 5/HPF, RBC of 2/HPF and no organisms
except for some amorphous uric acid crystals.
Several weeks later, the baby presented with high grade fever for a week.
Abdominal examination was unremarkable but the urinalysis showed RBC
200/HPF and WBC 350/HPF. Urine culture taken from a suprapubic
aspiration grew E.coli > 105 /ml.
Subsequently, a micturating cystourethrogram showed a left sided
vesicoureteric reflux grade 3. A DMSA scan showed left renal scarring.

2. A 10-year-old boy presented with haematuria on the day of admission.

Associated with the haematuria, the child also had fever with flu
symptoms. He had five previous episodes of gross haematuria, all
associated with upper respiratory tract infections. The haematuria
subsided after several days. There was a positive family history of renal
disease in the family.
Examination revealed a comfortable boy without any bleeding diathesis.
The blood pressure was 90/60 mmHg and abdominal examination was
unremarkable. A urinalysis showed RBC packed field, WBC 30/HPF and no
organisms isolated. The serum creatinine was 55mol/L. Renal ultrasound

was normal.

3. An 11-year-old girl presented with generalized body swelling and

redcoloured
urine. The discolouration occurred throughout the whole urine
stream. There was no frothy urine but she has not passed urine for the past
24 hours.
Examination showed an alert patient with facial rash. There was pedal
oedema, ascites and facial puffiness. The blood pressure was 140/95.
Urinalysis showed RBC 544/HPF, WBC 25/HPF, protein ++ and glucose nil.
Serum C3 34 mg/dL, C4 10 mg/dL, ASOT 64 IU/L, serum creatinine 450
mol/L, Na 130 mmol/L, K 6.1 mmol/L, Cl 94 mmol/L. The blood gases
showed pH 7.20, pCO2 25 mmHg, pO2 150 mmHg, HCO3 12 mmol/L, base
excess 10.
Several hours later, the patient developed a generalized tonic-clonic
seizure.
Acute glomerulonephritis (nephritic syndrome)
Explain the pathogenesis of pedal oedema , ascites and facial puffiness
Facial rash , low complement levels (C3 & C4) , ASOT Diagnosis ???
Why did the patient develop seizure ?
Complications of nephritic syndrome
TBL 3 - SEIZURES
1. A 1 year old boy with previous episode of febrile seizure 2 months ago was
admitted to the ward for fever for 3 days and seizure occurring in the
outpatient
department, which was aborted with per rectal diazepam. He
was seen 2 days earlier by the general practitioner, was diagnosed to
have upper respiratory tract infection and was given antibiotics. In the
ward, the fever subsided and the patient remained seizure free. The
patient was discharged home after 2 days.
However, 2 days after discharge, the patient was again admitted for high
spiking temperature with irritability. A lumbar puncture was performed and
CSF results showed WBC 350 /l, 84% neutrophils, glucose 2.4 mmol/l,
protein 1.5 g /l, organism negative. He was commenced on appropriate
antibiotic therapy and the condition appeared to be improving with
resolution of fever and patient becoming less irritable.
Unfortunately, on day 8 of therapy, the patient again developed high
grade fever. Head circumference had also been increasing. A CT brain
was done which showed subdural effusion with hydrocephalus. Following
that, drainage of the effusion was done and a ventriculo-peritoneal shunt
was inserted. The child subsequently recovered and was discharged
home. The child had some residual neurological deficit with increased
tone confined to both lower limbs.
At the age of 4 years, the child was again admitted, this time for a

generalized tonic-clonic seizure. He was given per rectal diazepam in the

private clinic but the seizure continued for more than 40 minutes. On
arrival in the hospital, he was continuously fitting and unresponsive to call.
Complications of meningitis
Lumbar puncture - indications , contraindications , complications
Management of status epilepticus
CSF analysis

2. A 9 year old boy presented to the clinic with the chief complaint of
having 3 episodes of tingling sensation over the left side of the face over
the past one week. This usually occurred in the mornings when he was
about to get out of bed. During the episode, he would still remain
conscious. On one occasion, there was also twitching over his eyelids and
mouth. All the episodes lasted between 5-10 minutes. The episodes were
not precipitated by hyperventilation.
On examination, the patient was alert and oriented. There were no
cranial nerve abnormalities and neurological examination was essentially
normal. An EEG was done which showed spikes and sharp waves over the
right temporal area. A CT brain done was normal without any focal lesion.
The patient was started on sodium valproate following which the seizure
was well controlled. On follow up 6 months later, the doctor found an
enlarged liver of 4cm.
Epilepsy syndromes
Absence seizure
Anti-epileptic drugs
3. A 2 year old boy was brought to the emergency room with a status
epilepticus. He has been known for the past year and was on multiple
anticonvulsants including valproate, carbamazepine, and vigabatrin.
During the episode of seizure, the child would suddenly flex the neck, hip
and knee joints. During this episode of seizure, the child had a generalized
tonic-clonic seizure and was unresponsive to call. In the emergency room
the child was given 2 doses of per rectal diazepam before the seizure was
controlled. The mother reported that the child had been having some
diarrhea for the past 3 days.
Examination revealed a drowsy boy with bilateral brisk knee reflexes and
a positive Babinski response. He was afebrile without any neck stiffness
and Kernigs sign was negative. There were also several hypopigmented
macules on the face and some caf-au-lait spots on the trunk. Blood
sugar 12 mmol/l, Na 140 mmol/l, K 3.5 mmol/l, Cl 102 mmol/l. EEG
showed characteristic features.
Neurocutaneous syndromes - Tuberous sclerosis , neurofibromatosis

TBL 4 - RESPIRATORY DISTRESS IN THE NEWBORN

1. A 42-week gestation baby boy with a birth weight of 3.2 kg was born with
thick meconium stained liquor. The baby developed grunting five minutes
after delivery and had to be transferred to the special care nursery. Earlier in
the delivery room, the attending doctor carried out oral suction and found
meconium beyond the vocal cords. Clinically, the baby was tachypnoeic
with a respiratory rate of 70 per minute with subcostal recessions. The chest
was hyperinflated and there were fine crepitations over both lung fields. He
was initially put on head-box O2. The following blood gas were obtained:
pH 7.18
PCO2 60 mmHg
PO2 80 mmHg
BE - 2
A decision was made to ventilate the baby. A chest X-ray showed
characteristic changes. The endotracheal tube and the tip of the umbilical
artery catheter were placed appropriately. Half an hour later, the baby
suddenly turned cyanosed on the ventilator.

2. A 28 week baby boy was admitted to the neonatal unit. His mother was
treated for vaginal discharge during the third trimester of pregnancy. He was
born by SVD with birth weight of 1890 gram. Apgar score was 5 at 1 minute
and 9 at 5 minute. He required minimal resuscitation. He was put on to nasal
CPAP with 25% oxygen. Over the next few hours, his condition deteriorated
with increasing oxygen requirement. There was also subcostal recession and
he frequently developed apneic episodes. The baby was intubated and
UAC and UVC were inserted. The arterial blood gas showed:
pH 7.2
PCO2 55 mmHg
PO2 50 mmHg
HCO3 15 mmol/L.
The chest X-ray was done. The baby was treated with surfactant and
antibiotics. But the baby suddenly became bradycardic and oxygen
saturation dropped to below 50 %. Transillumination test showed bright
hemithorax. A chest drain resulted in re-inflation of the left lung. Later on, the
baby required long ventilation to maintain the oxygenation.
The baby remains on ventilation for total 24 days. Now he is weaned off the
ventilation and progresses onto low flow oxygen. He is gaining weight but he
still requires 0.5 L/min low flow oxygen.

3. A baby who was born at 39 weeks gestation by SVD after an uneventful

pregnancy was noted to be grunting at 6 hours of life. On examination, the
baby was noted to be mildly cyanosed and in respiratory distress with a
respiratory rate of 65/minute. The apex beat was displaced and the breath
sounds in the left lung were diminished. The abdomen was scaphoid in
shape. A chest radiograph was done. Following which, the baby was
intubated and ventilated. An urgent surgical referral was made.

TBL 5 - VOMITING
1. A 2-month-old baby girl presented to the clinic with complaint of vomiting
with small amount of blood in vomitus for the past two days. The baby
had been noted to have frequent regurgitation after feeding since birth.
This occurred about 4 5 times a day. There was no associated diarrhea.
The baby however, still fed vigorously and was gaining weight well.
Examination revealed an active, well-nourished baby. The abdomen was
soft and non-tendered without any masses.
The following blood results were obtained. Hb 120 g/L, TWC 8.8 x 10 9/L,
platelet 350 x 109/L. Partial Thromboplastin Time 34 seconds, Prothrombin
time 12 seconds, INR 1.1.
The baby was subsequently given some medications and discharged
home. However, a week later, the child presented to the hospital with
sudden onset of breathlessness following feeding. A chest X-ray showed
consolidation over the upper zone of the right lung.
GERD
Coagulopathy ? Haemorrhagic disease of newborn ???
Aspiration pneumonia
2. An 8-month-old baby boy presented to the hospital with history of
persistent vomiting for 2 days. For the past day, the vomitus also
contained greenish material. The vomiting was associated with
abdominal pain, which was intermittent and caused the child to cry and
flex his hips. In between the episodes of abdominal pain, the child was still
able to play normally. Bowel movement was normal.
On examination, the child appeared fretful but alert. His fontanelle was
sunken and skin turgor decreased. Abdomen was soft but the child was
restless and abdominal examination was difficult.
A few hours later, the child passed out some stool with large amount of
mucous and blood.
An abdominal X-ray was done which showed dilated loops of ileum and
jejunum. The urine specific gravity was 1.024 and the electrolytes were Na
130 mmol/L, K 2.8 mmol/L, Cl 90 mmol/L and blood urea 10 mmol/L. The
blood gases showed pH 7.50, pCO2 45 mmHg, pO2 115 mmHg, HCO3 35
mmol/L.
Intussusception
3. A 1-year-old baby boy presented to the casualty with 3 days history of
fever and vomiting. There was no associated diarrhoea. Baby had also
been noted to be more irritable.
On examination, baby was fretful. The perfusion was normal. There was
mild redness of right tympanic membrane and mild neck stiffness.
Abdomen was soft and non-tendered. Blood pressure was 100/60 mmHg.

A urinalysis showed no organisms but had a WBC of 500/HPF.

Meningitis vs. meningism .whats the difference ???
What is the source of infection ? URTI ? UTI ?
TBL 6 DEHYDRATION AND SHOCK
1. A 10 years old boy was admitted, with history of profuse diarrhea 10X/day
for the last 3 days. He was otherwise well before this. Hes been a regular
customer of an ice kacang stall situated near his school. Since the
morning of admission, hes not been able to hold down any food /water
given to him
Clinically, his eyes were sunken, and skin turgor ws laxed. PR 120/minute,
small volume. Though conscious, he was very drowsy. His blood pressure
was 90/60 mmHg. BU 14 mmol/L, K 2.5mmol/L, Na 135 mmol/L
a) Discuss the immediate management of the patients in detail.
b) What other investigation would you do?
c) Discuss the other measures required to be taken before hes allowed
to be discharged.
2. A 9 month-old-infant was brought in by his mother with history of passing
loose watery stool > 5X/day X 2/7. He is being taken care of by a
babysitter, and on formula milk. On further questioning the baby sitter said
that she mixed 8 full scoop of milk with 5 oz of water. He is also given
nestum. His weight is 11 kg. Temperature 38 C. PR 135 bpm, RR 45/ min,
ABG pH 7.2, HCO3 -15 mmol/L, paO2 10 kpa, pco2 3.8 kpa , BU 12
mmol/l, Na155, K 6 mmol/L.
In the ward, he was noted to be drowsy. And when the doctor started him
on intravenous therapy, he had a seizure.
a) What are his problems?
b) Discuss your management in detail.
3. AO a 10 year old boy, a known case of leukemia, is presently undergoing
induction chemotherapy. For the past 2 days, he had been febrile, with a
temperature of 39C 40 C.
Clinically, there was no identifiable focus of infection, although he had
been having running nose and coughing. He was prescribed
erythromycin 250 mg 8 hourly orally. His fever persisted and on the third
day of fever, mother pointed out a couple of painful skin nodules around
the anal region. He was tachycardic, PR 120 bpm, BP 100/70. Full blood
counts showed the following: Hb 10 grams, TW 1200, ANC 400, Platelets
8000/mm3. CXR showed patchy consolidation in the right lobe.
Blood culture was taken and parental antibiotics were given. His condition
however deteriorated. More nodules were observed, now involving the
buttocks. The 2 earlier nodules have now blackened. In addition,
petechiaes appeared all over the limbs. On the 6th day of illness, he had
hematemesis. Appropriate measures were taken by the doctor in charge.
Blood culture was reported to be negative, He was still febrile,
temperature remaining 40 C. He was anuric for the last 6 hours.
Soon after, his vital signs destabilized, BP reading between 89-70 systolic,
with diastolic becoming unrecordable. All efforts to resuscitate him failed.
a) List down his problems as the disease progressed. Explain the
pathophysiology.

b) How would you manage and investigate this patient?

TBL 7 - PYREXIA OF UNKNOWN ORIGIN
1. A 4-year-old boy was admitted for fever for 2 weeks duration. The fever
has been intermittent but without any chills or rigors. Other than some mild
rash over the trunk a week ago, there was no other symptom. He
remained relatively well with good appetite and activity. The family stays
in a palm oil estate where the father works as a labourer. Other than a
dog, they did not have any other pets.
Examination revealed an active boy with a temperature of 39C. There
was a liver measuring 3 cm and a spleen measuring 2 cm. There were
several palpable lymph nodes measuring about 1 - 2 cm over the cervical
region. He appeared pink without any bruises except for some palatal
petechiae.
Investigations: Hb 120 g/L, TWC 21 x 109/L, platelet 145 x 109/L. Blood film
for malaria parasite and the Widal - Weil Felix test were negative. Blood
and urine culture was negative. A peripheral blood film was normal
except for some atypical lymphocytes noted.
Differential diagnoses ??? Causes of fever + hepatosplenomegaly
Infectious mononucleosis
How to diagnose and what are the complications?
2. An 8-year-old girl presented with fever for 3 weeks. Fever has been
persistent and high grade. There was also some arthralgia particularly over
the large joints. There was no history of rash or recent travel.
Clinically, the patient was pink without jaundice. There was
hepatomegaly of 4 cm without splenomegaly. A right sided pleural
effusion was detected. There was mild joint tenderness without swelling.
Investigations: Hb 115 g/L, TWC 26 x 109/L, platelet 780 x 109/L, serum
albumin 30 g/L, serum globulin 80 g/L, AST 45 IU/L, ALT 70 IU/L, ALP 155 IU/L,
serum bilirubin 30 mol/L, ESR 94 mm/Hr. Anti-nuclear factor, antirheumatoid
factor and Widal-Weil Felix test were negative. A chest X-ray
showed a right-sided pleural effusion with cardiomegaly. Echocardiogram
was done and showed a moderate pleural effusion without any cardiac
lesions and with good heart contractility. ECG showed an S-T elevation.
Blood and pleural fluid culture was negative.
Revise the causes of joint pain with fever
SLE
Rheumatic fever
Jones Major and Minor Criteria
3. A 3-year-old boy was admitted for prolonged fever of 2 weeks. The child
has also been noted to be less active and frequently lay in bed. There was
also associated joint pain and abdominal pain.
Examination showed a miserable boy with pallor. There was a palpable
liver measuring 2 cm and a spleen was tipped. Prominent

lymphadenopathy over the inguinal and cervical area was found. The
right testis was also enlarged.
Investigations: Hb 82 g/L, TWC 105 x 109/L, platelet 45 x 109/L.
Two days after admission, the child was found to be drowsy and had an
episode of seizure. A repeat blood count showed Hb 62 g/L, TWC 450 x
109/L, platelet 50 x 109/L, Na 140 mmol/L, K 6.0 mmol/L, Cl 96 mmol/L,
creatinine 220 mol/L and calcium 1.6 mmol/L.
Acute lymphoblastic leukemia
- Why develop seizure?
- Why develop acute renal failure?
TBL 8 - DROWSINESS
1. A 4 month old girl was admitted to the ward for fever and flu symptoms for
4 days. On the day of admission, the child developed an episode of
generalized tonic seizure lasting 20 minutes. Prior to this, the parents had
brought the child to the general practitioner and fever medicine and
antibiotics were prescribed. For the past one day, the child had been less
active and was not feeding well.
On examination, the child was drowsy and was not able to recognize the
parents. There was generalized hypotonia and the plantar response was
equivocal. No neck stiffness was detected and the optic fundus was
clear. However, the fontanelle was bulging. Lungs were clear and the
abdomen was soft with a hepatomegaly of 2 cm.
Lumbar puncture results: RBC 10/l, WBC 50/l predominantly neutrophils,
protein 0.6 g/L, sugar 2.4 mmol/L, no organism were detected. Blood
sugar was 5 mmol/L/ CSF culture was negative.
Partially-treated meningitis
2. A one year old girl was admitted for progressive drowsiness over the past 3
days. She had been having fever and cough for the past 5 days and had
been prescribed various medications. The child had been restless and
crying inconsolably yesterday and today had become more combative
and was not able to recognize the parents.
Examination revealed a drowsy child with poor perfusion. A
hepatomegaly of 6 cm was detected without splenomegaly. There was
however no jaundice. Neurological examination demonstrated
generalized brisk reflexes but there was no neck stiffness. The blood
pressure was 140/90 and heart rate 88 per minute. Ptosis and a dilated
pupil were noted on the right side.
A lumbar puncture was not done. Other investigations are: Hb 120 g/dL,
TWC 15 X 10 / l, platelet 175 X10 PCV 0.36. Na 144 mmol/L, K 4.0
mmol/L, Cl 98 mmol/L, urea 1.2 mmol/L, Se protein 76 g/dl, albumin 35 g/l,
AST 1553 IU/l, ALT 1814 IU/l, ALP 450 IU/L, Se bilirubin 15 umol/l. Se ammonia
1208 mol/ l , INR 3.0, PTT 48 seconds.
Reyes syndrome

3. A 5 year-old-boy was admitted for fever for 4 days and rashes over the
trunk and limbs for the past 2 days. There were associated with
generalized body aches and malaise. Examination revealed an alert boy
who was poorly perfused. There were petechial rashes over the body and
hepatomegaly of 3 cm.
Investigations: Hb 115 g/L, PCV 0.45, TWC 3.8X 10/L, platelet 25X 10/L. Na
138 mmol/l, K 4.5 mmol/l, cl 94 mmol/l, urea 10 mmol/l. Se protein 80 g/l,
albumin 40 g/l, AST680 IU/l, ALT 728 IU/L, ALP 340 IU/l, bilirubin 10 umol/l, In
the ward, the child became progressively drowsy and was incoherent in
speech and he started having coffee grounds vomitus. Further
investigations: INR 2.6, PTT 150 seconds, Serum fibrinogen 0.8 g/l. Lumbar
puncture was normal.
Dengue shock syndrome