SEQs

2 year old boy with fever, headache, vomiting for 15 days. central cyanosis and grade 1 clubbing, normal vesicular
breathing, S1 S2 heard, 2/6 systolic murmur at 3rd and 4th left parasternal border. increased tone and reflexes in
upper and lower limbs with equivocal plantar reflexes.

diagnosis? TOF leading to infective endocarditis / Brain abscess

3 lab tests to help diagnosis? Blood culture , ESR/CRP , ASO/AntiDnaseB to rule out Rheumatic fever , CBC (anemia)

management?

● 4-6 weeks AB = penicillin/ceftriaxone+ gentamicin/ vancomycin

● HF: digoxin , diuretics , salt retsiction
● Surgical: repair the congenital defect ,remove vegetations or valvular replacement

2 organisms? Streptococcus viridans , Staphylococcus Aureus , staph epidermidis

A child who had recently undergone an elective hernia surgery cane with
Hb - 8 MCV 63 and MHCH was also decreased
Hb electrophoresis showed hba 98% and hba2 2%
A) what kind on an anemia is this?
what are the other causes for this kind of anemia
C) what is the cause of anemia in this child
D) other investigations which will help you with the diagnosis

celiac disease:
diagnosis,
what 3 conditions is it associated with, ( type 1 diabetes, vitiligo, downs, igA def)
investigations , anti transglutaminase igA antibody, antiiendomysial igA antibody, serum
IgA , intestinal biopsy
management: gluten free diet, corticosteroid in crisis

RDS:

diagnosis: Cyanosis. Tachypnea. Nasal flaring. Subcostal and intercostal retractions. Expiratory grunting. Apnea

d/d: foreign body, acute asthma, severe pneumonia, croup

 investigations: CBC, ABGs, UCE, chest x-ray Antenatal: lecithin/sphingomyelin ratio

management:

Oxygenation

INSURE

PPV with CPAP or BiPAP or consider intubation

put patient in prone position

IV epinephrine

IV fluids

IMNCI very severe disease:

classify: not able to drink/breastfeed. vomits everything. had fits or is convulsing right now. lethargic or unconscious.

management:

● diazepam if convulsing
● quick assessment
● prereferral medication
● treat low blood sugar
● keep child warm
● refer urgently

Criteria for Discharge:

Is able to feed, deficiencies have been corrected , underlying infection treated, immunization started.

Mother is mentally & financially able and willing to support and take care of the child.

hereditary spherocytosis:

diagnosis: fever, jaundice, low hb, splenomegaly, spherocytes on peripheral smear

definitive diagnosis tests:CBC, peripheral blood smear, LFTs, osmotic fragility test

3 complications: aplastic or hemolytic crisis, and cholecystitis and cholelithiasis

recurrent diarrhea and chest infections.

diagnosis: Cystic fibrosis

investigations: sweat test, serum immunoreactive trypsinogen , DNA test for CFTR gene mutation,

complications: sterility in men, hyponatremia, pneumothorax, meconium ileus

organisms causing chest infection?: staph aureus, pseudomonas aeruginosa

a baby with cynosis after 36 hours of birth brought to the nicu. a murmur was heard
diagnosis:tricuspid atresia

features: single S2, VSD murmur, cyanosis at birth

management:

PGE1 to keep Ductus arteriosus patent

diuretics for heart failure

surgery: bidirectional cavopulmonary Glenn shunt or hemi-Fontan procedure

antibiotic prophylaxis for endocarditis after surgery

complication: heart failure, Bacterial endocarditis and brain abscess

a boy with paralysis cant walk and has weakness on half of the body.

diagnosis: Poliomyelitis

investigation: viral culture of stool/throat swabs or CSF analysis

management: supportive management, analgesics, assess for respiratory support, physiotherapy, bed rest, proper nutrition and
hydration

holosystolic murmur with loud p2 and recurrent chest infections.

diagnosis: VSD

management:

small VSD = reassurance

large VSD =

● digoxin, diuretics for heart failure

● surgical repair or prosthetic valves

complications:

● congestive heart failure

● pulmonary hypertension
● recurrent respiratory infections
● infective endocarditis
● eisenmenger syndrome

baby born at 32 week GA presents with increased R/R, central cynosis 1 hour after birth. apgar score was 5 then 8 at 1
and 5 mins respectively.

diagnosis: Transient tachypnea of the newborn

3 D/D: RDS, congenital heart disease, meconium aspiration syndrome, neonatal sepsis, pneumonia

investigations: chest xray, CBC, blood culture

management:
 ● supportive therapy because its usually self limited
● admit in NICU if condition worsened
● continuous monitoring of vitals, RBS
● prevent hypothermia
● maintain IV access: send labs= ABGs, blood culture and give IV fluids
● oxygen supplementation
● keep patient NPO
● empirical antibiotics until sepsis ruled out

nephrotic syndrome presents with fever, cough, rigid abdomen

diagnosis: peritonitis

labs: peritoneal fluid analysis, gram staining, and culture, CBC

management: antibiotics

febrile fits

diagnosis: 6 weeks to 6 months, less than 5 mins, generalised tonic clonic, family history positive

imp points in history?: age, duration, viral illness at the moment, history of similar episodes, family history of febrile fits and
epilepsy,

poor prognostic factors:

● 1st febrile seizure before 18 months of age

● family history of epilepsy
● history of complex febrile seizure
● fever for <1 hour before 1st febrile fit
● neurodevelopmental abnormality
● fever of <104F when fit occured

neonatal jaundice:

features:

● caudocephalic yellow discolouration of skin (disappears in opposite direction)

● drowsiness, altered cry, seizures - if kernicterus
● Hepatosplenomegaly, petechiae, and microcephaly - if sepsis

diagnosis: serum bilirubin, cbc, reticulocyte count, blood groups of mother and child, direct coomb’s test

management:

● phototherapy - when bilirubin <5mg/dl

● exchange transfusion - when bilirubin >10mg/dl
● medications: phenobarbitone, Albumin, IV IG for Rh and ABO disease

nutritional rickets:

features:
 ● overall: disproportionate short height, hypotonia, seziures
● head: box head, frontal bossing, dental caries, late eruption of teeth,Craniotabes, late closing of fontanelle
● hands: widening of wrist
● back: kyphosis, scoliosis
● chest: rachitic rosary, pigeon shaped chest, harrison sulcus
● legs: knocked knees, bowed legs ( if >2 years old)

investigation:

● diagnosis of vit D: serum calcium, alkaline phosphatase, phosphorus levels, chest Xray
● finding cause: vit d levels, PTH

management:

● Stoss therapy: 300,000 - 600,000 IU vit D oral or IM in 2 to 4 doses in one day

● calcium supplements
● dietary counselling
● sunlight exposure
● supplementation for mother if on breastfeed
● followup after 6-8 weeks with Chest xray

epi schedule:

● birth: BCG, OPV°, hep B

● 6 weeks: OPV1, Pneumo1, Penta1, Rota1
● 10 weeks: OPV2, Pneumo2, Penta2, Rota 2
● 14 weeks: OPV3, IPV, Pneumo3, Penta3
● 9 months: measles 1
● 15 months: measles 2

which vaccines are live? measles, mumps, rubella, varicella, zoster,rotavirus, influenza, Oral polio vaccine, BCG, oral typhoid

12 y/o boy with cola coloured urine since 2 days, 10 days after sore throat . Bitemporal headache since 1 day. Rest
unremarkable.

8 year old boy presented with sudden pallor and dark coloured urine for 4 hours after taking some medication for
sore throat. his urine shows Hb +++ and RBC 720/HPF.

diagnosis: Post strep glomerulonephritis

investigation? which one confirms diagnosis?: urine DR, urea, creatinine, serum C3 levels, renal biopsy

What further question would you like to ask from parents?

● history of preceding sore throat?

● did they complete the antibiotic course?
● decreased urine output?

4 management steps:

● restrict salt and water to control edema and bed rest

● diuretics and ACE inhibitors for hypertension
● dialysis for hyperkalemia or uremia
 ● antibiotic penicillin

what instructions will you give to his parents?

salt restriction, do not give fruit juices, calories should be 400/m2/day

9 year old with respiratory distress and chest pain for 2 days. history of high grade fever, lethargy, vomiting for last 8
days for which he took some oral antibiotic. On examination he looks pale, grade 1 clubbing, H/R 140, R/R 40, temp
100F, murmur at left lower sternal border and splenomegaly.

Diagnosis?: infective endocarditis

how will you confirm diagnosis? ESR, echo, blood culture

2 organisms for this disease? streptococcus viridans, staph aureus, staphylococcus epidermidis

what prevention will you tell parents?

antibiotics: amoxicillin before and after surgeries

2 year old with cough, fever for 1 week. past history of recurrent chest infections and delayed passage of meconium
at birth. on examination weight and height are on 3rd centile, signs of respiratory distress present and bilateral
coarse crepitations.

5 imp points in history to reach diagnosis?

● consaginous marriage of parents?

● family history of cystic fibrosis?
● greasy stools?
● growth retardation?
● recurrent pulmonary infections and frequent diarrhea or dehydration?

how will you confirm diagnosis? sweat test, CFTR mutation DNA test

steps of management?

● chest problems: antibiotics, steroids, bronchodilators, inhaled saline

● nutritional problems: pancreatic enzyme replacement, supplementary fat soluble vitamins and zinc, high protein diet
● genetic counselling
● surgery for meconium ileus
● short stature: growth hormone

4 complications?

● dehydration
● rectal prolapse
● pneumothorax
● sterility in males
● type II diabetes

5 year old with fever vomiting and decreased oral intake for 3 days. jaundice and mild hepatomegaly. LFTs show:
total bilirubin 7.39, direct bilirubin 3.35, SGPT 1122, ALK PO4 172, gamma GT 60.

likely cause of this disease? hep virus A, B or C

how will you confirm diagnosis? viral serology or stool microscopy

how will you manage? supportive management, fluids, paracetamol, antiemetics,

prevention? good hygiene, vaccination in >2 year olds 2 doses, immunoglobulins IM with in 1-2 weeks of exposure

4 year old with fever, headache, vomiting for 2 day. 4 hours prior to admission he became unarousable. history of on
and off right ear discharge in the last 6 months. temp 38.5C, H/R 120, BP 100/50, capillary refill 5 sec. breathing is
shallow, unresponsive to commands, withdraws leg on painful stimuli. no rash.

3 likely diagnosis? meningitis, brain abscess, epidural abscess, sepsis

would you quickly do LP to justify your answer? No! check for unequal pupils → do CT scan → reduce ICP by mannitol → then LP can
be performed

2 imp therapeutic interventions?

● antibiotics, steroids for the infection

● mannitol for ICP

4 year old had high grade fever for last 10 days, with anorexia and weight loss. loose motions for 2 days and mild
colicky abdominal pain. he took some antibiotics for last 4 days. temp 104F, H/R 80, liver 2cm palpable, spleen tip
palpable. everything else normal. CBC shows: Hb 8.5, PCV 25, WBC 3000, neutrophils 80%, lymphocytes 12%,
monocytes 8%, platelets 356000, MCV 65, MCHC 28, MCH 22.

2 abnormalities in cbc? bicytopenia, microcytic anemia, bacterial infection

diagnosis? enteric fever

management? antibiotics and steroids

prevention? hygiene, typhoid vaccination, use boiled water

8 year old boy with recurrent high grade fever for 4 months. urine DR shows: colour pale yellow, specific gravity
1.015, pH 6.5, albumin 1+, WBC 25-30/HPF, RBC 10-15/HPF.

diagnosis? recurrent UTI

further investigations to find cause? urine C/S, U/S KUB, voiding urethrocystography, then DMSA scan

what are the possible underlying causes? vesicoureteral reflux, calculi, chronic constipation, improper hygiene or potty
training

management? antipyretics, analgesics, antiemetics, antibiotics broad spectrum and then according to sensitivity, proper
hydration

3 year old child, not gaining weight and failure to thrive. Had loose foul stools since weaning was started, stools are
hard to flush.

What is your diagnosis?: celiac disease

what questions to ask in history?

● foul smelling greasy diarrhea since weaning started?

● weight loss, lethargy, flatulence?
● anemia, easy bruising, bone pain?
● Do symptoms occur after taking milk?

tests for diagnosis?

● tTG-IgA antibodies, endomysial antibodies (EMA) - (best initial)

● duodenal biopsy (gold standard)
● bone mineral density, CBC, electrolytes - (for deficiencies)

4 differentials?

● Autoimmune enteropathy
● Cystic Fibrosis
● IBD
● IBS
● Protein Intolerance
Management.

What 2 conditions will you screen this disease in?

child developed systolic murmur, had a sore throat a few weeks ago which was not followed. Now joint pains, end
diastolic murmur?

diagnosis: rheumatic fever

differentials: juvenile idiopathic arthritis, kawasaki disease, reactive arthritis, SLE, PANDAS

investigations:

● throat culture
● ASO titers
● CBC, ESR, CRP
● Echo, ECG

management:

● antibiotics: penicillin for strep infection

● bed rest, diuretics, vasodilators for carditis
● NSAIDS for arthritis
● prophylaxis with penicillin for 5 years or until the patient is aged 18-21 years (whichever is longer).

child had viral illness, now alert and conscious but progressive weakness and paralysis of limbs/ whole body and
painful red spots on shins?

diagnosis: GBS

4 investigations:

● LP for CSF analysis

 ● EMG
● LFT and Pulmonary function test
● Viral serology

management:

● admit patient and monitor continuously

● IV immunoglobulins or plasmapheresis within 14 days of onset of symptoms
● steroids
● intubation and ICU care if respiratory problems
● analgesics
● physiotherapy

child comes with webbed neck, short stature.

diagnosis: turners

investigations:

● 30-cell karyotype analysis: show 45,XO

● LH, FSH, TSH, urine DR, UCE
● U/S KUB, Echo, bone density

what is the reason for hypertension: coarctation of aorta , aortic stenosis or renal abnormalities

management:

medical:

● growth hormone to prevent short stature

● levothyroxine if hypothyroidism
● estrogen replacement therapy after age 12
● vit D and calcium to prevent osteoporosis
● antihypertensives: beta blockers (propanolol) or ACE inhibitors (captopril)

counselling about disease; doest run in the family , primary amenorrhea and infertility, diet , exercise

surgery for cardiac problems

3 complications:

● aortic dissection
● infertility
● hypothyroidism
● hypertension
● otitis media
● IBD

Child with high grade fever and lethargy. In order to classify according to IMCI,

What will you ask mom?

● is the temp >37.5 ℃?
● present for how long?
● if present for more than 7 day, has it been present everyday?
● did the child have measles within the last 3 months?
What will you look for on exam?
● stiff neck
● runny nose
● any bacteria causes of fever: oral sores, can’t move limb, boils, lower abdominal pain, painful micturation
● signs of measles: generalised rash, cough, coryza, conjunctivitis
● any danger signs

Initial management before referring to hospital?

● antibiotic and/or artesunate first dose
● prevent low blood sugar
● paracetamol

A 12yr old boy presented with complaints of low grade fever and cough since 1 month. For last 2 days he had fresh
blood in sputum.
Diagnosis: Tuberculosis 
4 most relevant investigations?
● Chest xray
● Sputum culture and smear
● Sputum gene xpert
● Cbc OR Blood culture
First line therapy plus duration?
Ethambutol, pyrizinamide, isonizid and rifampin for first two months then INH+RIF for the rest of the 4 months.

A 6 months old child with a temperature of 40oC suffers a generalized tonic-clonic seizure.
What is the most important step in management?: ABC
After the child stops seizing, what medication would you give? anti-pyretics
How would you counsel the parents?: reassure, 0.02% risk of epilepsy, recurrence rate is 30-35%

An otherwise healthy child with jaundice on 3rd day of life.

Important points in history:
● anenatal history: maternal diabetes, infection, antimalarial use
● postnatal history: vomiting, poor feeding, delayed passage of meconium
● Family History: jaundice, anemia, hemolytic diseases, G6DP deficiency, blood group incompatibility
Three differentials: Breastfeeding jaundice, breast milk jaundice, physiological, hemolytic anemia.
Modalities to confirm diagnosis: Bilirubin levels ( total, direct, indirect), retic count, CBC, blood grp of mom and baby,
coombs test, G-6-P D
Management: Phototherapy, exchange transfusion, continue feeding, monitor bilirubin levels, IV hydration

A 6 years old boy presents to you with complaints of 3 episodes of wheezing and chest pain over the past 1 month.
He has been afebrile throughout. He is asymptomatic between attacks.
What is the diagnosis?: asthma
How would you manage this patient?
1.Short term b2 agonists PRN.
2. low dose ICS
3.classify: long term control medications.
A 9 years old girl presents to you with complaints of difficulty in expiration during the last 3 months. She says that
she has these episodes almost every week and usually after playing.
What is the diagnosis?: exercise induced asthma
How would you manage this patient?
short term mxn: nedocromil/cromolyn.

A 7 years old boy is brought to you with complaints of breathlessness, wheezing and chest tightness. His
respiratory rate is 22/min and his pulse is 98/min. He prefers to sit and seems to be using accessory muscles of
respiration. He becomes breathless on talking but is able to complete sentences.
What is the diagnosis? asthma exacerbation
How would you manage this patient in your clinic? O2, salbutamol nebs, ipratropium nebs, corticosteroids, Mg

A 12 years old boy comes with complaints of episodes of breathlessness, chest tightness and cough which have
been occurring on a daily basis for the past one month. Earlier they would occur less frequently. These days he is
taking inhaled corticosteroids and Ventolin inhaler on a daily basis.
What is the diagnosis? moderate persistent asthma
How would you manage it?
● low-dose inhaled corticosteroid (ICS) + long-acting beta-agonist (LABA) preferred choice
● OR inhaled medium-dose corticosteroid

A 7 years old boy has been taking inhaled steroids (100 mg/day) for the past 6 months. Since then he has not had a
single episode of chest tightness, breathlessness, cough or wheezing. He has come for a follow-up visit.
What is the diagnosis? mild asthma
How would you manage this patient? continue the same drugs

Child with fever since a couple of days, signs of meningeal irrigation positive, Cells 70% lymphocytes, Protein 200,
Glucose 20.

What do you think is the likely cause? Give justification: TB Meningitis; glucose is decreased, lymphocytes present and
protein increased

investigations with justification why you are ordering it:

● CT scan - shows infarcts, hydrocephalus, tuberculomas

● LP - for CSF analysis and AFB smear and culture
● Mycodot - antigen detected by PCR
● Chest Xray - for respiratory focus of TB OR Gene expert on sputum - confirmation of TB

short outline of management:

● ATT with steroids for 12 months:

- 4 drugs for 2 months: isoniazid, rifampicin, ethambutol, pyrizinamide
- 2 drugs for 10 months: isoniazid and rifampicin
● diuretics, mannitol, VP shunts for hydrocephalus
● paracetamol for fever
● phenobarbitone for seizures

complications:
 ● mental retardation
● hydrocephalus
● deafness
● blindness
● tuberculoma
● cranial nerve palsies

an unvaccinated kid with barking cough, fever and drooling of saliva, hyperextended neck, toxic looking child

most probable diagnosis: Acute epiglottitis

dds: croup, pneumonia, pertussis, anaphylaxsis

treatment outline:

● O2 supplementation
● ABC and evaluate for intubation
● antibiotics for 7 to 10 days
● paracetamol

prevention for the kids's younger sibling at home:

● Hib conjugate vaccine

● 4 day prophylaxis with rifampin to all close contacts

Neonate, umbilical hernia, coarse features, constipation since birth, passes stool after 3 to 4 days.

What is your diagnosis? congenital hypothyroidism

What other questions in history would you ask?

● born at term or post term?

● sleep too much?
● don’t cry much? hoarse cry?
● unexplained mental retardation in family history?
● maternal thyroid disease during or before pregnancy?
● antithyroid drugs for graves disease during pregnancy? or radioactive iodine after 8 weeks of GA?
● birth weight <2kg or >4.5kg?
● persistent jaundice and poor feeding

List 3 other features will you look for to confirm this diagnosis?

● jaundice
● hypotonia
● large fontanelles
● macroglossia

What investigations will you perform?

● 1st screening = TSH and T4 levels on 3rd day of birth

● Ultrasound OR thyroid scintigraphy OR radioactive iodine uptake

How will you manage this child?

 ● lifelong oral levothyroxine daily
● iodine fortified diet
● followup on
- weight, height, bone age and development
- TSH and T4 levels

How will you counsel this child?

● it is not an inherited disease

● if treatment started early there are no growth delays or mental retardation. the child will be normal.
● will need lifelong thyroid replacement therapy and regular follow ups

5 year old resident of Malir has high grade fever since one week. No signs of meningeal irritation.

1. What questions will you ask in history to reach diagnosis?

● Is malaria endemic in their region? or history to travel to an endemic area?

● pattern of fever?
- every 48 h tertian fever - for P falciparum, P vivax, and P ovale
- every 72 h quartan fever - for P malariae
● rigors and chills, headache, malaise, abdominal pain, lethargy, vomiting associated?
● did the child have seizures?

2. What else will you check to reach diagnosis?

● anemia, splenomegaly and fever - triad

● MP test - thick and thin smear

3. Differential diagnosis?

dengue fever, enteric fever, liver abscess, pyelonephritis

4. How will you manage this case?

● paracetamol for fever

● antiemetics
● correct dehydration and hypoglycemia
● antimalarials:
- artemether/ artesunate
- primaquine for hypnozoits

5. Classify this child according to imnc: Malaria

6 month old boy with fever and cough for 2 days and refusal to feed since morning. drowsy, H/R 120, R/R 65, temp
103F.

what other signs to look for to reach diagnosis? general danger signs or stridor

classification accordion to IMNCI? Severe pneumonia

management according to IMNCI? first dose of antibiotic and refer urgently

Mumps causing encephalitis (meningeal irritation signs present, negative csf culture, rt neck swelling)

diagnosis:

● viral culture from saliva, blood CSF

● enzyme immunoassay for mumps IgG and IgM

management: symptomatic support

antipyretics, bed rest, soft diet

Von willebrand disease (Girl with bleeding, hemorrhages, normal platelets)

investigations: CBC, PT, aPTT, von willebrand factor levels

treatment:

● desmopressin acetate
● cryoprecipitate
● antifibrinolytic drugs: aminocaproic acid