Acute otitis media:*Hx that support dx==>hotness, activity, sleep, oral intake, irritability, otorrhea, recent URI in him or contact, daycare, bottlefeeding, passive smoking, family hx, previous episodes of OM, vaccines ...*Exam==> Check for dehydration. Otoscope: erythematous membrane (normally pink/white), full or bulging membrane, lost light reflex, purulent discharge or a hole in membrane if perforation...*Investigations==> NONE. Do tympanocentesis and culture of exudate if immunocompromised, neonate, or not responding to therapy.*Mx:- Fever: acetaminophen, profen.- Dehydrated: oral rehydration or IV fluids, 7asab how severe- OM: Amoxicillin high dose (90 mg/kg/day) P.O for 10 days, with food, covers S. pneumonia and H. influenzae (weakly). If no response at 3 days of Abx, suspect resistance, give Amoxiclav high dose (90 mg/kg/day) or Cefuroxime P.O.- in case of vomiting and can't take oral meds, IM ceftriaxone.- give yogurt to prevent antibiotic diarrhea* Recurrent OM: >=6 episodes in the first 6 yrs of life. indicates craniofacial anomaly (cleft) or immunodeficiency. But most are otherwise healthy!

11 year old child had URTI for 3 days then suddenly develop petechial rash and decrase in level of conciousness ...First step befor addmission ??? IV AntibioticThe most imp investigation?? LPWhat must do befor it ?? Fundoscopy What is the organism??? Niesseria menigitiditisType of this organism??? Gram -ve diplococciOther test if patient took AB with -ve culture?? LatexCan we prevent this condition ?? Yes , meningiococal vaccineWhat about contact family??? If not vaccinated must took prophlaxis AB What is the AB ??? RifampicinWhat the emprical tt??? 3rd generation cephalosporin + vancomycinCan u give rifampicin for 1st trimester pregnant???

Management of Status Epilepticusin Children-- Approach• Initial assessment– A, B, Cs– Rapid neurologic examination– Brief history ( very imp to know ) Has the child ever had a seizure before History of trauma? Fever? Ingestion?Was the child his usual self prior to this event?What medications (including nonprescription) does the child take?Any medical problems?Any neurologic/developmental problems?If child has known epilepsy– Name and dosage of medications!!! Calculate if this is appropriate dosage.– Has the child missed dosage of medication• If so, consider loading with that medication– Be aware of paradoxical side effects of ACDS• Phenytoin and carbamazepine toxicity may precipitate SE

– Give high flow oxygen• Measure rapid blood glucose• Confirm epileptic seizure– Not all events are epileptic!!!! • Laboratory Studies– Glucose, electrolytes, calcium, magnesium ( very imp ) – CBC ( last imp ) – Serum anticonvulsant drug levels (if indicated) ( very imp ) – Toxicology screeningTreatment of Status Epilepticus

1.STOP the seizure with benzodiazepin. – IV Diazepam 0.5 mg/kg PR ( DOC in Jordan ) – IV Lorazepam ( Not in jordan ) 

– Midazolam: IV, buccal, nasal** If seizures continue another 10 minutes, repeat the dose.2. ADD fosphenytoin (either as second medication if seizure refractory, or to stop from recurring)– 20 PE/kg IV3. ADD third medication if necessary- Phenobarbital** dr prefere to start phenobarbital before phenytoin even they have same side effect but phenytoin highly alkline and may cause tissue and skin damage at the site of injection.• Refractory Status Epilepticus Definition: continued seizures after 2 or 3 antiepileptic drugs have failedWill usually need EEG monitoring at this point; typically titrate to burst suppression ( so indication for EEG is whenever you reach the anasthesia stage and if patient didn’t wake up after mediaction as mostly he entered what we called subclincle status ) 4. Call for back up from anesthetist or intensive care specialistThiopentalMidazolam anaphylaxis management : 1- IM adrenaline 2- place patient on supine position 3- IV fluid 20ml/kg 4- oxygen 5- inhaled B2 agonist 6- antihistamine + steroids

Hyponatremic Dehydration

 (copy/paste) From 2008 nicely written:Dx: Status epilepticus What will you do first? ABC What is ABC? Airway, breathing and circulation if ABC is OK, what will you do as management ? gluco-check if blood glucose is normal, what is your next step? if I have an IV access I will give lorazepam 0.1mg \kg

we don't have lorazaepam, what will you give him? Diazepam 0.5mg\kg per rectumif there was no response , what will you do? repeat the dose after 10 minno response till now, you next step? Paraldhydehyde 0.4mg PRno response ? Phenobarbital 18 mg \kg no response ? call anesthetist and consider intubation and referral to PICU repeat diazepam 2-3 times 10 mins apart then if no response give phenytoin 20mg/kg as a bolus then phenobarb then aesthesia. alternative to diazepam is na valproate

non blanchable rash*DDx: ITP, HSP, HUS, Acute leukemia, meningococcemia, viral infex

*Investigations depend on situation; -regardless u need--> CBC, blood film, PT, PTT-if toxic, febrile, hypotensive--> CRP, meningococcal PCR, blood culture-Hx of vomiting, diarrhea; bloody--> KFT, U analysis, stool culture-Fatigue, fever, wt loss, anorexia, abd pain/discomfort, bone pain, enlarged nodes--> LFT, serum electrolytes, BONE MARROW BIOPSY, +-LP, +-CXR, +-CT abdomen...

*Differentiation:- HSP=> ill child, classical distribution of purpura, bruising and urticaria on the buttocks and extensor surfaces of the limbs, sometimes associated with joint or abdominal pain, hematochezia and hematuria are possible.- ITP=> well child, with multiple bruises and petechiae noted over several days, epistaxis common

*Treatment of ITP:-generalization : ABC, +-IV fluid, steroids, IVIg, Anti-D (for Rh+ only), platelet transfusion, splenectomy (if life threatening).-known case of ITP || IF serious bleeding (e.g. SAH) &/or plt <10000 => admit, IV fluids, IV steroid, IVIg, send blood for type&screen, platelets transfusion!

-known case of ITP || IF just rash, otherwise well child, platelets>30000 => outpatient is appropriate, P.O steroid+- IVIg and close follow up...-u suspected ITP=> admit always, la2enno ITP is a dx of exclusion, so he needs further tests. 

*IVIg works by blocking receptors found on platelets surface, on which autoimmune IgG's work; decreasing destruction. Anti-D, works the same as IVIg plus it decreases phagocytosis of opsonized platelets. Steroids work by decreasing production of autoimmune IgG's.

*NO I won't give steroids. Leukemia needs to be excluded first. Leukemia+steroids= severely immunodeficient= die of an overwhelming infection.

*Leukemia never presents with isolated thrombocytopenia!*Platelets transfusion only in emergency, destruction of these is delayed by co-administration of IVIg...

HYPEROXIA TEST very important clinical test performed--usually on an infant-- to determine whether the patient's cyanosis is due to lung disease or a problem with blood circulation- We give the pt 100% O2 for 15 min. then take arterial sample for ABG then look at the partial pressure of O2 (PO2) . PO2 is > 250 so more likely to be a pulmonary disease; overcome by O2  PO2 is < 150 so more likely to be a shunt ; cardiac PO2 is 150-250 gray zone

swelling, wheezes & a history of bee sting : *Dx: anaphylaxis*Wheeze --> bronchial muscle spasms*Obstruction--> spasms+edema/swelling*type I; IgE-mediated*Airway, breathing, O2 mask, IM epinephrine +- IV steroid (to prevent

biphasic anaphylaxis, not gonna change this episode), +- Salbutamol nebulizer+-antihist.*iza 3endhom na7il ebe3ooh, la2enno this can recur m3 another sting, and the best thing to prevent it is to avoid the trigger. labsoo bracelet. mandatory to do desensitization. if same scenario occurs again, call 911, rush to ER..

strep score for pharyngitis ttexudate/swelling on tonsill +1tender ant.cervical LN +1fever +1no cough +1AGE:3-14 yr = +115-44= 0above 44= -1

Neonatal Encephalopathy: disturbed neurological function in the earliest days of life in the term manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, sub normal level of consciousness and often seizures infant. Aetiologies:( Ischemic, metabolic,  infection, drug, malformation and neonatal stroke) . stages : -stage 1 : Duration < 24 hours with hyperalertness Uninhibited Moro and stretch reflexes Sympathetic effects Normal electroencephalogram.-stage 2 :Obtundation Hypotonia Decreased spontaneous movements with or without seizures.-stage 3 :Stupor Flaccidity Seizures 

Suppressed brain stem and autonomic functions The EEG may be isopotential or have infrequent periodic discharges.Tt:1- Adequate resuscitation.  keep oxygen saturation > 95%

2- Cord gases should be collected

3- Apgar scores

http://www.adhb.govt.nz/newborn/guidelines/neurology/NE.htm

Meningitis :  - Hx : poor feeding , lethargy , irritability , sexiure jaundice, rash , fever diaroeha , vomiting photophobia , headache , projectile vomiting (in >2 yrs) family history travels symptoms of other causes of fever (UTI , Pneumonia , OM ...) and the rest of the usual hx - PE : Vital signs , Head circumferance , Fontanells , in case closed fontanells look for (sunset eyes , diplopia , papilledema ) , Meningeal signs (Neck stiffness , Kernig , Brudziniski ... those will be in child >2 yrs ) , Rash .- tt : according to kaplan Emperic ( vancomycin + 3rd gen. ceph. ) After Cx result : strep. pneumonia (pencillin 10-14 days) ... HiB (ampicillin 7-10 days) ... N.meningitids (pencillin 5-7 d) ... if pretreated (ceftriaxone 7-10 d) ... gram -ve (ceftriaxone 3 wks) cushing's triad of increased ICP ( hypertension , bradycardia , irregular breathing) treat by Mannitol and hyperventilation

Counseling about the benefits of breast feeding over bottle feeding: mother : a- enhances mother –child relationship .o b- decrease risk of post partium hemorrhage, longer period ofamenorrhea,reduce risk of ovarian & pre menopausal breast CA ,

& possibly reduce risk of osteoporosis.o c- contraceptive although not reliable.o d- reduce health care cost owing to lower incidence of illness in BFinfants.o e- reduce employee absenteeism for care attributable for infant illness. baby :o decrease the incidence or severity of diarrhea , resp.illnesses ,otitis media, bacteremia ,Bacterial meningitis , necrotizing enterocolitis.o Decrease the incidence of food allergy & eczema .o Contains protective bacterial & viral AB’s (secretory IgA) &non specific immune factors (macrophages & nucleotides),Which help limit infections.o Improve cognitive development.o Reduce the risk of insulin dependent diabetes , IBD, suddeninfant death syndrome (unproven)Later on in life.

A 3 Years old girl ,previously well, presented with sudden onset of fever for one day,after walking from sleep she could not walk ..1)what imp questions in the history ?2)what DDX?3)in physical examination you fin that BP 110/70 ,Temp 39c,what the examination you well do in the Right involved Leg?4)if you find flaccidity in the exam what is your dx?5)How to differntiated b/w Gillian Barre and Polio?Q1)Analysis of CC: onset ,Duration,Pain*,symmetry*,site*,progression and its nature y3ne Ascending or not *,previous similar attack . then Hotness,tenderness, warmth ,descrese mobilty ,limbing and skin rash* . b)Ask about trauma c) ask about GIT symptoms (diarrhea*) d) RENAL symptoms (hematuria,dysurea) e) Sore throat * f)family history of joint disorder Q2)DDX: SEPTIC ARTHRITIS ,Poliomyelitis, Guillian Barre, SLE, HSP,Brucellosis

 Q3)look for sign of inflamation first :swelling ,hotness,rednees ,tenderness,mobility, BOTH LEGS. Tone, Power, TENDON REFLEXES*........etc. Q4)Guillian Barre, Polio.Q5) to differntiated 1)symmetry of involvment 2) sensation loose on Gullian 3) LP Leukocytosis is in in Poilo 4)serological testing for viral serology demonstarting 4- fold rise in IgG . and IgM antibodies is diagnostic for POILO

CHD in 22 hour pt:-Hx: Antenatal scan ( cardiac malformation , fetal arrythmias , hydrops)Family hx of CHD Maternal illness ( diabetis , rubella , teratogenic drugs )Perinatal (premature , meconium aspiration , neonatal asphyxia ) - PE :tachycardia , tachypnea central cyanosis , differential cyanosis weak or unequal pulsesheart murmur hepatomegaly dysmorphic features - Invx :CXRhyperoxia test echocardiogram - tt:in general ... ABC Correct metabolic acidosis , electrolyte , hypoglycemia , prevent hypothermia IV protaglandin E if duct dependent Cardiologic consult !

 VP shunt, presented with nausea, vomiting, and fever:

 Most common organisms are S. epidermidis and S. aureus. Also gram negative organisms.  tt:Antibiotics including Vancomycin and Gentamycin External Ventricular Drainage Removal of the shunt.

 chronic shortness of breath( VSD) analysis of cc, ask about tachypnea, tachycardia,sweating during feeding, feeding difficulty , respiratory distree, FTT, recurrent LRTI,by exam: displaced apex beat, pansystolic murmur,hepatomegaly cardiomegaly, increase vascular marking.echo diagnostic.asymptomtic no need for tt spontaneous closure no restricion of activity no SBE prophylaxis if symptomatic surgical tt

11year old male patient refered from PRH after having seizure of 20 min duration which was aborted , in ER - KAUH the patient was drowsy and found to have BP of 200/110 *What ur diagnosis? Hypertensive encephalopathy*Managment? Na nitroprusside , hydralazine ..........*Investigation? CBC,KFT,LFT, electrolyte*KFT was abnornal and result show renal failure how to deffrentiated btween chronic and acute renal failure?Metabolic and electrolyte change and renal ultrasond *Other investigation ? Non contrast head CT scan *Treatment ??????? ACEI

9 year diagnose as have asthma came to ER ..*How to make sure enno un controlled asthma??1- daytime symptome more than twice/week2-limitation of activity3-nocturnal symptom 4-need for reliever more than twice /week 5- abnormal lung function * how to make it controlled ? Inhaled steroid , long acting B agonist , leukotriens inhibitor .....

* if she took drug but not improve what u think??1-not compliant 2-she dont use inhaler properly 3- wrong dose*how u manage in ER? O2, nebulizer salbutamol , ipratropium bromide , sys steroid , ketamine , ..... Intubation

status asthamticus 'O SIC SAMI'

O- O2S- salbutamolI-ipratropium bromideC-cortisone (iv hydrocortisone)

S-salbutamol continuousA- aminophyllineM- Magnesium sulphateI- intubation

common antidotes :Acetaminophine ... N-acetylcysteineOrganophosphate ... Atropine Benzodiazepine ... Flumazenil Heparin .... Protamine sulfate Iron ... Defuroxamine Isonizide ... Pyrodixine Methanol ... Ethanol Opioid .... Naloxone hydrochloride TCA/Salicylate ... Sodium bicarbonate

1.5 year old baby, his mother noticed that he is pale, he is exclusively breast feed: ask relevant questions what do u want to do investigation? what is ur diagnosis? what is the treatment? oral iron sulphate? dose? duration? what do u expect the first thing to improve? and why?

when does the retics increase? when does the hemoglobin increase back to normal?any further advice to the mother? about nutrition1- iron deficiency anemia2- ferrous salts (sulfate, fumarate, gluconate) orally.. for 8 weeks after Hb normalize dose (3-6mg/kg/day elemental iron ..... each 325 mg ferrous sulfate contains 65 mg elemental iron)3- appetite .. due to increase demand because the bone morrow is working4- within 72-96 hrs5- it increase by max of 1 g/dl/week (usually within 2 months)6- advice her to introduce food.. with the supplement avoid milk and give it with orange juice or so

CSF results going with bacterial infections what other specific test that confirms your diagnosis would you like to order other than PCR ?! gram stain and latex agglutination test Inherited disease causing meningococcemia ?!  terminal complement deficiencythe nurse in the ER is pregnant what antibiotic would you offer her? ceftriaxoneDKA:child with DM1 , non-compliant to insulin , 25% come as the initial presentatiob of diabetes **Hx of : infxn , stress , steroids ....**presentation : initially sx of hyperglycemia : polyuia , polydypsia , nocturia , enuresis , vomiting , abd pain kausmull breathing , ketone odor ** PEx : signs of dehydration , signs of RDS , altered mental status , signs of infxn if exists .** DDX : gastroenteristis , Pneumonia , acute abdomen , Salicylate toxicity, metabolic / respiratory acidosis ** what to order : CBC(WBC) , elect.(K, Na), KFT , blood glucose , ABGs(PH , HCO3) , urinalysis , blood ketone ** RX : 1.ABC , establish 2 IV lines .

2. give bolus NS : 20cc/kg , then assess degree of dehyd.3. start on IVF deficit & maintainance 4. within the 2nd hr start IV insulin 0.1 U/Kg/hr slowly ... to avoid cerebral edema .5. No NaHCO3 only if PH< 7.2 & severe enough to compromise cardiac contractility.6. if K<5 & the pt passed urine , replace KCl .7. SC insulin sliding scale.8. if concomittant Infxn > manage . if Pt developed cerebral edema > intubation , hyperventilation , mannitol . hourly monitor glucose , elect , vitals > major cause of death is cerebral edema> ketoacidosis is relieved once ketones are negative in urine , usually within 36 hrs . causes of mortality in DKA : cerebral edema hypoglycemiahypovolemia hypo/hyperkalemia failrue to make the diagnosis

child presented with pallor and jaundice .What ur initial diagnosis? Hemolytic anemiaWhat most imp q in history? Family hx of splenctomyWhat most imp in physical exam ? Weight,height,examine for splenWhat investigation u would like to do ? CBC-MCV-MCHC-HB eLectroporesis,blood filmU find spherocytosis in blood film wat diagnosis? Hereditary spherocytosisWhat specific test? Osmotic fragility testHis HB level is 4 , how u will treat him? Blood transfusion and consider splenectomyHow much blood u give? 15ml/kgHow u give the blood? In low rate to prevent heart failureWhat r complication of blood transfusion? Hemochromatosis ,

infection .........When do splenectomy? At age 5 yearHow to prepare him?? Give him vaccine 2 week before surgeryWhat u give him after surgery? Prohylactic ABThe parent ask u what is risk of recurrence for this disease ? 50%

you were called to ER for a child with UGIB, he is known to have liver disease , what comes to your mind? Coagulation disorder what is your first management? ABC if air way is patent, he is breathing what do you want to exam in circulation? PB, Pulse, Capillary refill if BP was low, Pulse is High, and Capillary refill was 4 sec, your next step will be? IV access, blood sample, and resuscitate him with 20ml\kg normal saline bolus dose? what other fluid you can use? I did answer this question well what investigation you will request? Hb, Platelets, and coagulation profile, and Blood x-match if Hb was 8, Platelets normal, PT and PTT are prolonged , your next step ? Fresh frozen plasma and may consider Blood transfusion?

2 day old boy with jaundice:

 ** Hx :- full term ?- breast fed ?- maternal blood grp (ABO & Rh .. if Rh -ve u should ask if this is the 1st baby or not , & paternal blood grp )- urine stool & color ( although this is most likely indirect type coz it's physiological )- exclude sepsis : hypo/hyper-thermia, poor feeding, hypoactivity ..etc- family hx of hemolytic disease, G6PD,jaundice, previous kid who had exchange transfusion

- maternal drug hx

** Invx:- CBC ( hb for hemolysis ,, wbc & plt for sepsis )- blood film .. spherocytosis- bilirubin ( total & direct)- if the mother has bld grp O or rh -ve >> bld grp & direct coomb's test- G6PD screen- if the baby has hyperbilirubinemia + hypoglycemia >> exclude galactosemia- if the baby has hyperbilirubinemia+ dysmorphic features >> exclude Alagilli's syndrome

** treatment:- phototherapy- double volume exchange transfusion ( if bilirubin cont. to rise despite intensive phototherapy &/or kernicterus is a concern )

** counselling : i think counselling depends on the cause of jaundice ..if Rh incompatibility then counsel her about anti D for future abortions or pregnancies, if breast feeding jaundice to increase the frequency of breast feeding.. if breast milk not to worry and to continue breast feeding, if galactosemia its contraindicated

Pneumonia:-Hx : cough, SOB, cyanosis , foreign object aspirationlethargy, poor feeding ,irritabilty ,fever vomiting, diarrhea, abdominal pain and signs of dehydrationdaycare attendance , travels , family hx-PE : 

vital signs (tachypnea, fever) , cynosissigns of RD ( retractions, grunting, use of accessory muscles , nasal flare, wheezing )signs of dehydration chest exam -admission : 1. Less than 3 months old 2. high fever , refuse to feed or vomiting3. Rapid breathing with or without cyanosis 4. systemic manifistation5. failrue of previous antibiotic therapy 6. recurrent pneumonia 7. severe underlying condition ( immunedeff. ) - ABs :amoxicillin is the best choice ...if no response add cephalosporin (cefotaxime , cefurexime .. ) if chalmydia or mycoplasma suspectedtreat with macrolide

breath since 3 days (I can't remember the duration) what comes to your minds? dr.wanted the answer Heart failure why do you think of HF? because DS is associated with cardiac anomalies that may complicated with HF what is the most common cardiac congenital defect in DS? A-V canal and VSD * what are the signs you look for in HF? Cardiomegaly, tachycardia, hepatomegally , basal lung crepitations how do you manage HF? please read it some where

2 year old boy...history of eating fish 30 minute ago, he is complaining of stridor and facial edema; what ur diagnosis what is ur next step? what is the treatment? mention it in order : IM epinephrine, steroid IV , antihistamine what is the mechanism of action for each? mast cell stabilizer, etc what do u want to advice the mother? pay attention for other food allergy : egg and drugs penicillin , and animals : bees what else : to teach them how to use epinephrine injection at home.

1. 8 year old girl with petechial rash, no fever?? - DDx: ITP, HSP, Leukemia -Hx: - Invx: CBC, everyhing normal just low platelets. What d u c in bld film? What if u find pancytopenia What is ur 1st treatment? steroids What u can give also? IVIG Platelets?? No, C/I why? Destruction