Pediatrics- Ward Notes (Part III)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:


Hemolytic Uremic Syndrome:
Decreased platelets, Anemia, Peripheral film shows egg shaped cells/burr cells

Congenital Adrenal Hyperplasia:
21 alpha hydroxylase deficiencies are the most common. It causes virulization in females of feminization in males. Cortisol is not formed. Males are usually dehydrated. Urinary 17 ketoesterides is diagnostic. 17 hydroxyprogesterone levels in blood can be checked as well.

Global Retardation- Considered when all developmental parameters are deficient. Chronic Severe Malnutrition- Considered when all 3 growth parameters are <>

Complications of multiple blood transfusions:
Hemosidereosis, Blood group incompatibility, Splenomegaly
Treatment- Deferoxamine

Pneumonia:
Investigations- CBC, CXR, ABG’s (hypoxia, metabolic acidosis, hypercapnea), UCE, Blood culture, Tracheal swab/Bronchial lavage Immediate management- Oxygen, Electrolytes, Antibiotics
Pneumonia should be treated with antibiotics for 5-7 days. Identification of lobe involved can be checked by percussing laterally.
Atypical viral respiratory infections and Sarcoidosis can mimick Miliary TB in a CXR.

Causes of Microcephaly:
Trisomies, TORCH infections, CHARGE syndrome, Cruzen syndrome (early fusion of skull bones)

D/D for 1 day high grade fever with Neutrophilia- Bacterial tonsillitis, Pharyngitis, Otitis media, Urinary Tract Infection

Guillan Barre Syndrome is a lower motor neuron lesion.

Causes for a false -ve Monteux test- Steroid drugs (>20 mg/day for 2 weeks), Grade III malnutrition, Active measles infection

Rickets (Vitamin D deficiency in children):
Repeated chest infections, Craniotabes (ping pong head), Caput quadratum (square shaped head), Wide fontanelle, Frontal bossing (also seen in thalassemia), Pot belly, Widening of wrist, Harrison's sulcus, Rachitic rosary

In the history, ask about adequate sun exposure (UV rays do not penetrate household glass windows), ask about drinking cow's milk (high phosphate content in cow's milk binds to calcium and causes excretion).

Measles:
Fever, Maculopapular rash (appears at the hairline and behind the ears, extends downwards across the whole body, and then disappears in the same fashion of appearance), Cough, Coryza, Conjunctivitis, Koplik spots (white/sandy color spots found in the buccal mucosa in front of the lower molars. These appear before other symptoms). When the rash for Measles subsides, it leaves a dark, desquamated appearance. Measles antibodies may be seen 4-28 days after the rash appears. Ask about vaccination and drug history/allergies.

D/D Measles- Rubella, Scarlet fever, Meningococcemia, Typhoid (rose spots), Insect bites, Drug rash Measles is associated with a high grade fever while Rubella's fever is low grade with enlargement of the posterior auricular and occipital lymph nodes.
Scarlet fever has a dry, sand paper rash present on the upper limbs and trunk and is seen usually at 5-15 years of age.
Meningococcemia presents with meningeal irritation, petechial hemorrhage, and urological symptoms.

Complications of measles: Pneumonia, Laryngitis, Meningitis, Encephalitis, Otitis media, Diarrhea, Myocarditis, Encephalitis, Reactivation of primary Tuberculosis

Measles encephalitis is of 3 types: Measles encephalitis (viremia), Post measles encephalitis (autoimmune), Sub Sclerosing PanEncephalitis (may occur years later)

Measles treatment: Keep the patient at home, Antipyretics, Cough suppression, Nutrition (fluids and diet in short intervals), Antibiotics for superimposed infections.
Vitamin A should be given orally in all children with measles. 100,000 IU in children <>1 year.

Measles surveillance in Pakistan- Serology (2 cc) of patients with clinically diagnosed cases of measles are sent to Islamabad.

Daily requirement of Vitamin A is 1,500 IU. Vitamin A is not available over the counter in Pakistan. Thus, the multivitamin Rovigon (30,000 IU) is given instead.

Vit A deficiency- Night blindness, Xerosis conjunctiva, Xerosis cornea, Thisis bulba

Short Stature:
If systemic causes, then patient is short and thin. If endocrinological causes, then patient is short and obese. Height velocity is important.

Factors effecting growth in utero- Uterine size, Nutrition, Insulin, Insulin like growth factors.
Growth hormone and Thyroid hormone play a vital role in the post natal growth process.
Children whose absolute height is below 2 SD from the mean have pathological growth abnormalities.
Observe the child’s height over a period of at least 6 months. Precocious puberty can cause early bone fusion and a deranged bone age.

Target Height- Determines genetic growth potential. Calculate Mid-Parental height as well. Arm span may also be used if unable to obtain a standing height.

Short stature should be determined as proportionate or disproportionate.
Upper segment : Lower segment ratio- 1.7 at birth, 1.3 at 3 months, 1 at 10 years.
Skeletal dysplasias (spondylodysplasia) and Klinefelter’s syndrome are associated with a decreased U:L ratio. Achondroplasia is associated with an increased U:L ratio.

Proportionate with Increased Ht/Wt- Growth hormone deficiency, Hypothyroidism
Proportionate with Decreased Ht/Wt- Malnutrition, Renal disease, Chronic diseases/infections.

Normal variants of short stature include- Familial short stature and Constitutional growth delay.


As this is a series, there will be more to come soon!