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 Antibiotic
The most imp investigation?? LP
What must do befor it ?? Fundoscopy
What is the organism??? Niesseria menigitiditis
Type of this organism??? Gram -ve diplococci
Other test if patient took AB with -ve culture?? Latex
Can we prevent this condition ?? Yes , meningiococal vaccine
What about contact family??? If not vaccinated must took prophlaxis AB
What is the AB ??? Rifampicin
What the emprical tt??? 3rd generation cephalosporin + vancomycin
Can u give rifampicin for 1st trimester pregnant???

Management of Status Epilepticus
in 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 screening
Treatment 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 IV
3. 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 failed
Will 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 didnt wake up after mediaction as mostly he entered what we
called subclincle status )
4. Call for back up from anesthetist or intensive care specialist
Thiopental
Midazolam
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
rectum
if there was no response , what will you do? repeat the dose after 10 min
no response till now, you next step? Paraldhydehyde 0.4mg PR
no 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 tt
exudate/swelling on tonsill +1
tender ant.cervical LN +1
fever +1
no cough +1
AGE:
3-14 yr = +1
15-44= 0
above 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 of
amenorrhea,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 BF
infants.
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 ABs (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, sudden
infant 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 pulses
heart murmur
hepatomegaly
dysmorphic features
- Invx :
CXR
hyperoxia 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/week
2-limitation of activity
3-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- O2
S- salbutamol
I-ipratropium bromide
C-cortisone (iv hydrocortisone)

S-salbutamol continuous
A- aminophylline
M- Magnesium sulphate
I- intubation
common antidotes :
Acetaminophine ... N-acetylcysteine
Organophosphate ... 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 anemia
2- 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 working
4- within 72-96 hrs
5- 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 deficiency
the nurse in the ER is pregnant what antibiotic would you offer her? ceftriaxone
DKA:
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
hypoglycemia
hypovolemia
hypo/hyperkalemia
failrue to make the diagnosis


child presented with pallor and jaundice .
What ur initial diagnosis? Hemolytic anemia
What most imp q in history? Family hx of splenctomy
What most imp in physical exam ? Weight,height,examine for splen
What investigation u would like to do ? CBC-MCV-MCHC-HB eLectroporesis,blood
film
U find spherocytosis in blood film wat diagnosis? Hereditary spherocytosis
What specific test? Osmotic fragility test
His HB level is 4 , how u will treat him? Blood transfusion and consider
splenectomy
How much blood u give? 15ml/kg
How u give the blood? In low rate to prevent heart failure
What r complication of blood transfusion? Hemochromatosis , infection .........
When do splenectomy? At age 5 year
How to prepare him?? Give him vaccine 2 week before surgery
What u give him after surgery? Prohylactic AB
The 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 aspiration
lethargy, poor feeding ,irritabilty ,fever
vomiting, diarrhea, abdominal pain
and signs of dehydration
daycare attendance , travels , family hx
-PE :
vital signs (tachypnea, fever) , cynosis
signs 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 vomiting
3. Rapid breathing with or without cyanosis
4. systemic manifistation
5. 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