D.D. in Pediatrics

7/30/2019 D.D. in Pediatrics

http://slidepdf.com/reader/full/dd-in-pediatrics 1/16



D.D in pediatrics NMT11

2

Fever

• Fever of short duration (less than one week): 1. Fever with focus(localizing signs):

Diagnosis is established by clinical findings

Re-examination after 24 to 48 hours is essential as the focus may

be not evident.

Mild focal infections Serious focal infections

Respiratory: tonsillitis ,sinusitis

,nasopharyngitis ,otitis media&

bronchilitis Gastrointestinal : G.E.(vomiting &

diarrhea)

Urinary : cystitis

(dysuria,frequency)

Skin: abscess

Pneumonia: respiratory distress,

bronchial breathing & crepitations

Peritonitis: abdominal distension &diffuse tenderness

Pyelonephritis: loin pain &

tenderness

Meningitis :convulsions, neck

retraction, increased intracranial

tension

Arthritis or osteomyelitis: hotness

,redness ,tenderness & swelling

2. Fever without focus (simple fever):

Viremia Bacteremia septicemia

mild to moderate fever.

Fair general condtion.

More than 39.4° C

(high fever ).

Bad general

condition(look

sick).

High fever or hyperpyrexia

Very bad general

condition(look toxic &very

ill).

Other findings: pallor, cold

extremities, mottled skin,

persistent vomiting & maybe disturbed

consciousness

Treatment :

antipyretics

Broad spectrum

antibiotics

Urgent hospitalization

N.B.: -otitis media is very common in infants & children so,should examine the ear.

- vomiting is not a localized sign as it accompanies infections of many systems .




3

• Fever of long duration (more than 10-14 days) (prolonged fever)

Infections(most common) Rheumaticdiseases Malignancy

Bacterial :

o Systemic: TB, Brucellosis ,salmonellosis

o Localized:pyelonephritis ,endocarditis

,abscess e.g liver, pelvic & perinephric

Viral:

hepatitis ,cytomegalovirus, infectious

mononeucleosis .

Parasitic:malaria, toxoplasmosis, visceral larva

migrans.

Systemic lupus

Juvenile

rheumatoid

arthritis

Rheumatic

fever

Leukemia

Neuroblastoma

lymphoma

N.B.:- fever of unknown origin:

1) History of prolonged fever

2) Fever is documented in the hospital

3) History ,examination & routine investigations failed to reveal a cause

Painful oral lesions

Stomatitis Gingivitis Gingivostomatitis

Inflammation of the oral

mucosa e.g. : monilial

stomatitis.

Inflammation of the gums

with no or minimal affection

of the oral mucosa .

Inflammation of both gums

& oral mucosa e.g. :herpetic

ginigvostomatitis.

Arthritis

infections Bacteria (pyogenic or TB)- viral (mumps or rubella)Post-infections Rheumatic feve

Collagen vascular

diseases

Juvenile rheumatoid arthritis

Systemic lupus erythematosus chronic disabling disorders

Henoch-schonlein purpura

Kwasaki disease acute disabling disorders

Heamatological Sickle cell anemia- hemophilia & leukemia ( hemoarthritis )

GIT Inflammatory bowel disease

Traumatic




4

Neonatal convulsions

Common causes Less common causes• Hypoxic ischemic encephalopathy (most common)

• Intracranial hemorrhage (intraventricular,

subdural, epidural)

• Meningitis, septicemia & TORCH infections

• Metabolic: hypoglycemia, hypocalcemia &

hypomagnesemia

• Kernicterus

• Congenital brain anomalies

• Metabolic hyponatremia,

pyridoxine(B6) dependency

& hypomagnesemia

N.B.: more than one cause may exist on the same case (e.g sepsis+hypoglycemia)

Neonatal respiratory distress

Pulmonary Extrapulmonary

• Respiratory distress syndrome

• Meconium aspiration syndrome

• Transient tachypnea of newborn

• Pneumonia(intrauterine

aspiration of milk or secretion)

• Pulmonary air leak:

pnumothorax -

pneumomediastinum-

pneumopericardium

• Pulmonary haemorrhge

• Congenital lobar emphysema

• Diaphragmatic

Respiratory

• Airway :

Choanal atresia (bilateral)

Laryngomalacia

Trachea-esophageal fistula

Pierre-robin syndrome(micrognathia- glossoptosis)

• Chest wall:

Neonatal myasthenia

Thoracic dystrophy

Cardiac

• Congenital heart disease with heart failure

• Persistent fetal circulation

Central (cerebral irritation)

• Cerebral hypoxia

• Intracranial hemorrhage

• Meningitis

• Narcosis: maternal drugs

Metabolic

• Acidosis

• Hypothermia

• Hyperthermia

• hypoglycemia






6

Delayed walking

Cerebral Palsy , Mental Retardation ,rickets & malnutrition

Maculopapular rash

• Measles

• German measles

• Roseola infantum

• Scarlet fever

• Typhoid fever• Infectious mononucleosis

• Enteroviral infections

• Rheumatoid arthritis

• Systemic lupus erythematosus

• Dermatomyositis

• Sweat rash

• Urticarial rash

• Drug rash

Vesicular rash

1. Chickenbox

2. Herpes simplex

3. Herpes zoster

4. Papular urticaria

5. Impetigo contagiosa

Generalized oedema

1. Cardiac

2. Hepatic

3. Renal

4. Nutritional

5. Allergy




7

flobby baby

spastic infant

1-spastic cp

2-epilipsy

Delayed dentition

rickets osteogenesis imperfecta

cretinism

down syndrome

central causes Peripheral cause

atonic cerebral palsy

ataxic

chromosomal defects :

..down syndrome

..cri-du-chat

..Trisomy 13

spinal cord:

-werding Hoffman disease

-extensive polio

-meningeomyelocele

peripheral n:

-Guillane Barre syndrome

-post dephtritic

-Lead poisoning-drug induced

-axonal neuropathy

NMJ:

-OP Toxicity

-botulism

-ticks paralysis

Muscels:

-congenital myopathy

-congenital muscular dystrophy




8

Macrocephally

delayed closure of fontanelles

1-anterior fontanelle:

rickets

osteogenesis imperfecta

cretinism

mongolism

hydrocephalus

other causes of increased ICT2-posterior fontanelle

opened at birth in cretinism

cranial causes intra cranial causes

a) Familial large head

b) Chronic hemolytic anemia

c) Cretinism

d) Rickets

e) Achondroplasia

f) Osteoporosis

g) Osteogenesis imperfecta

h)

Hyper phosphatemia

a) Hydrocephalus

b) Hydraencephaly (replacement

of brain by CSF)

c) Megalencephaly (increase in

number &size of brain cell)

-MPS

-MSUD

-Galactosemia-Achondroplasia

d) Porencephaly (hemispheric

cyst)

e) subdural hematoma

f) subdural effusion

g) brain tumors




9

Purpura

A) Thrombocytopenic

Production( megakaryocytes) Destruction (normal or megakaryocytes)

- factors

a)folic acid

b)B12

c) thrombopoietin

-BM

a)aplastic anemia

i)congenital (fanconi anemia

&thrombocytopenia with absent

radius (TAR syndrome))

ii)acquired

b)BM infiltration

i)malignant (leukemia)

ii)metabolic (Gaucher)

iii)bone (osteopetrosis)

-immune

i)ITP(immune thrombocytopenic

purpura)

ii)SLE(systemic lupus erythematosus)

iii)neonatal isoimmune

thrombocytopenia

iv)maternal ITP

-non-immune

i)HUS(haemolytic-uremic syndrome)

ii)hypersplenism

iii)DIC

iv)infection

B) Non-thrombocytopenic

• Platelet dysfunction

-congenital(vWD(von Willebrand disease))

-acquired(aspirin, NSAID, uremia)

• Vascular

-immune(Henoch-Schonlein purpura)

-infection(meningococcemia)

-steroids(cushing)

-scurvy




10

Hepatosplenomegaly

A) Neonatal&early

infants(cases of cholestasis)

B) Late infancy &

early childhood

C) Late childhood

• Intrahepatica) Hepatocytes1- Infections

-neonatal sepsis-TORCH infection-UTI

2- metabolic-CHO: galactosemia-proteins:tyrosinemia&alpha1-antitrypsin deficiency-lipids: Niemann-Pick

3- idiopathic neonatal hepatitis(mostcommon)b) Intrahepatic bile ducts paucity1- Syndromic

-Alagille syndrome: cholestasis,CHD,vertebral anomalies

&abnormal facies)2- non syndromic-progressive familial intrahepatic

cholestasis(PFIC): TYPE 1,2&3-alpha 1-antitrypsin deficiency

• Extrahepatic1) Extrahepatic biliary atresia

-85% have the atretic segment ator above the portal hepatis-15% have distal atretic segment

2) choledochal cyst: congenital

saccular or fusiform dilatations of theCBD

• Chronic haemolyticanemia: thalassemia

• Metabolic: Gaucher,Nimann-Pick

• Malignancy

• Chronic hepatitis

• Metabolic: Wilsondisease

• Bilharziasis

Acute abdomen

A) Medical causes

• Acute abdominal infection

-most common cause of abdominal pain




11

-differentiation depends on the site of pain & associated manifestations

• Acute medical condition

-Henoch-Schonlein purpura-lower lobe pneumonia

-DKA

Drug intoxication: NSAID

-sickle cell anemia (vaso-occlusive crisis)

-acute rheumatic fever

B) surgical causes

• acute appendicitis• strangulated inguinal hernia

• intussusceptions

• volvulus

• impacted fecal masses

• worm masses

Site of pain Associatedmanifestations

gastroentritis epigastric Diarrhea, vomiting

hepatitis Rt hypochondrial Jaundice, dark urine

appendicitis Rt iliac fossa Rebound tenderness,

coughtenderness

cholecystitis Rt hypochondrial Haemolytic anemia,

jaundice

pyelonephritis Loin (Rt & Lt) Fever, rigors, dysuria

peritonitis diffuse Vomiting, distension

pancreatitis epigastric Pain radiating to the

back

UTI Mesenteric adenitis Follicular tonsillitis

Causes of intestinal

obstruction




12

Hematuria

A-Glomerular B-non-glomerularColour: brown, tea or cola like, smoky

,Proteinuria: often present ,Dysmorphic

RBCs: present ,RBC casts: present)

• Glomerulonephritis(all types but most

common with PSGN)

• Non-minimal change nephritic

syndrome

• Sickle cell nephropathy

• Haemolytic-uremic syndrome

• Renal vein thrombosis

Colour: bright red ,No proteinuria ,No

dysmorphic RBCs ,No RBC casts)

• Urinary tract infection(pyelonephritis

& cystitis)

• Trauma

• Tumors(Wilms tumor)

• Hypercalcuria

• Renal stones

• Hematologic:

a-purpura(ITP & Henoch-schonlein

purpura)

b-coagulopathy(haemophilia)

c-malignancy(leukemia)

• Anatomical abnormalities(cystic

kidney disease)

• Exercise

• Drugs(aspirin & warfarin)

Wheezes

A- Single(non-recurrent) B-chronic(recurrent)

• Acute bronchiolitis(commonest cause

of wheezes in infancy)

• Sever bronchopneumonia

• Foreign body inhalation(sudden onset

& chocking)

• Organo-phosphorous

poisoning(exposure, chest secretion,

diarrhea, pinpoint pupils& coma)

• Bronchial asthma(commonest cause of

wheezes in children)

• Recurrent aspiration(GERD, tracheo-

osophageal fistula)

• Foreign body inhalation(unremoved)

• Chronic infection(immunodeficiency)

• Bronchopulmonary dysplasia

• Interstitial pneumonia(expiratory

wheezes)




13

Cough

A- Acute cough(duration <2 wks)

B- Prolonged cough (2wks-2 months)

C- Chronic cough

• With RD :acute

bronchiolitis, acute

asthmatic attack,

pneumonia

• Without RD: acute

bronchitis, acute

laryngitis, acute

sinusitis,pharyngitis(more with

viral), post-nasal

discharge, passive

smoking

• Complicated bronchitis

(bacterial bronchitis,

pneumonia,segmental

collapse)

• Acute sinusitis

• Pertussus &pertussus

like illness

• Chronic infections: TB, bronchiectasis

• Lung abscess, empyema

• Persistent asthma

• Recurrent aspiration: GERD, tracheo-

osophageal fistula

• Cystic fibrosis

• immunodeficiency




14

DR ABO EL-ASRAR’S MOST IMPORTANT D.D.

Blood

1. purpura:

a) vascular system defect

b) thrombocytopnea

c) thromboathenia

d) coagulation system defect”coagulation factors”

2. rheumatic pain:

a) rheumatoid (in winter “cold weather”, localized pain)b) hand foot syndrome (in winter ,diffuse ,burning pain)

3. G6PD Acute pyelonephritis

Lion pain ,red urine, fever ,rigor

History of exposure to oxidizing

agent

Bilateral

Translucent “heamoglobinurea”

Unilateral

Opaque “hematuria”

4. Hypochromic microcytic anemia:

a) Thalassemia minor

b) Anemia of chronic haemorrhage

c) Sidereoblastic anemia

d) Lead poisoning

e) Chronic infections

5.

Purpura with thrombocytopnea:a) Aplastic anemia

b) Acute leukemia

6. Anemia Low cardiac output

Rapid pulse with big volume

No change in urine

Rapid week pulse

Oligurea




15

cardio

7. Hemophilia A & classic hemophilia:

a) Congenital defect in factor 8

b) Acquired congenital defect as liver failure

c) DIC

1. Murmur heard on the back of the patient :

a) PDAb) VSD ”Maximum in isenmenger’s syndrome”

c) Coarcitation of the aorta

d) Arteriovenous fistula in lung

2. Convulsions in fallot tetralogy:

a) Cyanotic spills

b) Brain abscess

c) Brain ischemia

3. Pink fallot =non cardiac fallot:a) Before closure of ductus arteriosus or hypertrophy of the infundibulum

b) After pariative surgery

c) Fallot traiology ”no overriding of the aorta”

4. Dry pleurisy precarditis

Stitching pain

Increased with breathing & cough decrease with holding breath

Not related to breath or cough Not decrease with holding breath

5. Fraction rub of precarditis Murmur of PDA

Machinery ”heard during systole & diastole”

Maximum intestiny allover the heart

decrease with holding breath

in Lt subclavian

Not decrease with holding breath




16

Genetics

GIT

6. Caricomb murmur Permanent M.S. murmur

Mid diastolic

Rumbling all through without

presystolic accentuation

Normal s1

Rumbling with presystolic

accentuation

Accentuated s1

1. Palpable liver & spleen in down syndrome:

a) Ptosed liver

b) Repeated infections

c) Congenital heart disease “ as a complication”

d) leukemia

2. Repeated chest infections in down :

a) Severe hypotonea “stagnation of secretions”b) Congenital heart diseases “lung congestion”

c) Defect in B & D cell function

d) High incidence of leukemia “20 times than normal”

1. Watery diarrhea:

a) Diarrhea of enterotoxigenic pathwayb) Osmotic diarrhea

c) Motility diarrhea

d) Secretory diarrhea

2. Gastroenteritis with hemolytic anemia:

a) Viral infections(diarrhea & post viral autoimmune hemolysis)

b) E.coli infection (diarrhea with hemolytic uremic syndrome)

Documents

D.D. in Pediatrics