Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Important Topics Pediatric Problem Cards
Pediatrics Problem Cards
R.G.Kar Medical College
Document Created and Edited By: Prithwiraj Maiti
R.G.Kar Medical College (Batch 2015)
Email: Prithwiraj2009@Yahoo.In
Photo Courtesy: Suman Mandal
Answered By: Dr. Pradip Paria (RMO, Dept. Of Pediatrics,
RGKMC)
Additional references: Nelson's Pediatrics
23.9.2014
Urinary investigations
Problem no. 1
What is your diagnosis?
My diagnosis is nephrotic syndrome.
What are the positive points behind your diagnosis?
1. Typical onset of nephrotic syndrome: 2-6 years of life
2. Nephrotic range of proteinuria (4+)
3. Presence of lipid cast suggests hyperlipidemia
4. Absence of hematuria (exclude nephritic syndrome).
What do you mean by nephrotic range of proteinuria?
Any 1 of the following:
1. 24 hour urinary protein excretion: >2 gm/ 24 hours
2. Spot urine protein: creatinine ratio: >2.0
3. Total urine protein (according to body surface area) : >40 mg/sq.mt/hr.
What are the further investigations you will prefer to order?
1. 24 hour urinary protein excretion
2. Spot urine protein: creatinine ratio
3. Blood examination:
a. Hypercholesterolemia: >200 mg/dL
b. Hypoalbuminemia: <2.5 mg/dL.
4. Renal function test: Usually renal function remains normal in minimal change NS,
significant rise in serum urea-creatinine suggests a decrease in renal perfusion
and hypovolemia.
5. Chest X Ray and Mantoux test (to exclude renal tuberculosis)
6. HIV/ HBV testing.
Outline the management of the case (1st episode of NS).
General management:
High protein diet
Dietary salt and fluid restriction
Diuretics (Furosemide) should be used only in case of significant edema.
Specific management:
Agent of choice: Corticosteroid (Prednisolone/ Prednisone)
2 mg/kg/day (maximum 60 mg/day) in 2-3 divided doses for a duration of
6 weeks.
Followed by,
1.5 mg/kg/day (maximum 40 mg/day) single dose on alternate days for a
duration of 6 weeks.
Then discontinued.
What are the complications of nephritic syndrome?
1. Spontaneous bacterial peritonitis (SBP)
2. Renal failure.
What about the prognosis of nephrotic syndrome?
Type of nephrotic syndrome
Remission
Minimal change nephrotic syndrome
80-85%
Focal segmental glomerulosclerosis (FSGS)
60%
Membranous nephropathy
40-50%
Problem no. 2
What is your diagnosis?
My diagnosis is nephritic syndrome.
What are the positive points behind your diagnosis?
1. Nephritic range of proteinuria (2+)
2. Presence of hematuria
3. Presence of RBC cast.
How can you roughly tell the origin of hematuria?
If RBC in urine is <50/HPF, the hematuria is probably of glomerular origin, the
common causes of which are post-streptococcal glomerulonephritis (PSGN) and
IgA nephropathy.
If RBC in urine is >50/HPF, the hematuria is probably of non-glomerular origin.
What is the age group predominantly affected in PSGN?
5-12 years.
What are the further investigations you will prefer to order?
1. Blood investigation
2. ASO titer
3. Anti-DNase B
4. USG abdomen (to detect any ascites/ pulmonary edema, which are features of
acute left heart failure, a complication of PSGN).
Outline the management of the case?
Supportive management:
Absolute bed rest
Restriction of fluid and electrolytes
If urea creatinine is high, then also restrict dietary protein.
Specific treatment:
Treat oliguria: Diuretics (Furosemide)
Treat associated hypertension: Nifedipine/ Amlodipine.
What about the prognosis?
PSGN usually does not recur.
When will you perform a renal biopsy in a suspected case of PSGN?
Age of the patient <1 year or >9 years
Massive proteinuria
Persistent hematuria/ hypertension
Persistent low level of complement beyond 6 weeks
Before using immunosuppressive drugs.
Problem no. 3
What is your diagnosis?
Hematuria of non-glomerular origin.
What are the positive points behind your diagnosis?
RBC in urine >50/ HPF.
What are the common causes of non-glomerular hematuria?
1. Idiopathic hypercalciuria
2. Bladder stone/ trauma.
What are the further tests you would like to perform?
1. 24 hour urinary calcium excretion
2. Spot urine calcium: creatinine ratio
3. USG (to detect any stone).
Problem no. 4
What is your diagnosis?
Simple urinary tract infection (UTI)
What are the positive points behind your diagnosis?
1. Pus cells: 40/HPF
2. Bacteria: +ve
What investigations you would like to perform?
1. Urine sample collection and bacteriological analysis:
Mid-stream thin catch early morning sample has to be collected and examined
under microscope.
Significant bacteriuria: >105/ml (single bacteria species)
2. USG
3. Voiding cysto-urethrogram (VCUG): To rule out vesico-ureteral reflex
4. USG + DMSA/MCU scan*
[*DMSA: Di-mercapto-succinic acid, MCU: Micturating cysto-urethrogram]
When would you cal an episode of UTI as a `complicated' one/ pyelonephritis?
When infection is associated with any 1/ more of the following factors, which increase
the chance of acquiring bacteria/ decrease efficacy of therapy:
1. Abnormal genitourinary tract (Ex: stone etc.)
2. Immunocompromised host
3. Multidrug resistant bacteria.
Usually complicated UTI presents with features like fever, loin pain etc.
How will you treat the patient?
Antibiotic therapy:
1. In case of simple UTI: Duration 7-10 days
2. In case of complicated UTI: 10-14 days.
Name some of the antibiotics commonly used in UTI.
Simple UTI:
Cotrimoxazole
Nitrofurantoin
Amoxicillin
Complicated UTI: (all drugs in IV route)
Ceftriaxone
Cefotaxime
Ampicillin + Gentamicin.
Blood investigations
Problem no. 5
What is your diagnosis?
My diagnosis is ITP.
What are the positive points behind your diagnosis?
The platelet count is below normal (1.5-4.5 lakhs/L) with an otherwise normal blood
picture.
What are the additional history you will ask for?
1. H/O a preceding viral fever
2. H/O episodes of epistaxis, petechiae, gum bleeding, bleeding from other mucosal
surfaces etc.
What are the types of ITP?
ITP is of 2 types:
1. Acute ITP: Spontaneous resolution takes place within 6 months
2. Chronic ITP: Disease duration goes beyond 6 months and gets chronic.
Which diseases you should exclude in a case of chronic ITP?
HIV and SLE.
What further investigation you may order?
Bone marrow aspiration: Will show megakaryocytes.
Outline the treatment of the case.
ITP
Acute ITP
Chronic ITP
Corticosteroid ?
>20000/L
<20000/L
Splenectomy
Observe
IV Ig (2 gm/kg)
Problem no. 6
What is your diagnosis?
My diagnosis is Megaloblastic anemia.
What are the positive points behind your diagnosis?
1. Normochromic macrocytic anemia
2. Hypersegmented neutrophils
3. MCV: (Normal: 80-94)
What are the causes of Megaloblastic anemia?
1. Vitamin B12 deficiency
2. Folate deficiency.
What are the additional investigation(s) you will order?
1. Serum B12 level estimation
2. RBC Folate level estimation.
Outline the treatment of the case.
Vitamin B12 (1 gm/month IV) / Folate (500 g/day) supplementation: Until a definite
hematological response is obtained.
What are the first responses from supplementation therapy?
First subjective improvement
Improvement of lethargy
First objective improvement
Reticulocyte count
Problem no. 7
What is your diagnosis?
My diagnosis is pancytopenia.
What are the positive points behind your diagnosis?
1. RBC count: 1.3 mil ion/ L (Normal: 1.5-4 million/ L)
2. TC: 1200/ L (Normal: 7000-11000/ L)
3. Platelet count: 28000/ L (Normal: 1.5-4 million/ L).
What is the most common cause of pancytopenia?
Aplastic anemia.
What are the other causes of pancytopenia?
Pure red cell aplasia
Falconi's anemia
Paroxysmal nocturnal hemoglobinuria (PNH).
Name some common etiological factors behind aplastic anemia?
3I
1. Idiopathic: Autoantibody mediated
2. Iatrogenic: Many drugs may potentially cause aplastic anemia:
Anticancer drugs
Antibiotics: Chloramphenicol/ Sulfonamide
NSAIDs: Phenylbutazone
Anti-rheumatic drugs: Gold, Sulfasalazine.
3. Infections:
HIV
HBV.
What further investigation will you order?
Bone marrow aspiration: Marrow cells are replaced by fat cells.
What are the treatment options available?
Treating the cause
Bone marrow transplantation
Anti-thymocyte globulin (ATG) + Cyclophosphamide.
Problem no. 8
What is your diagnosis?
My diagnosis is acute lymphoblastic leukemia (ALL).
What are the positive points behind your diagnosis?
1. Presence of lymphoblast in blood smear
2. Typical age of presentation of the patient:
ALL: 2-5 years
AML: Adolescence.
What other investigations you will prefer to order?
1. Bone marrow aspiration: Presence of >25% of blast cells is diagnostic
2. To detect metastasis:
Lumbar puncture
Testicular USG.
Outline the treatment of the case shortly (mention the options only).
1. Chemotherapy:
It has 3 parts: induction of remission, intensification of remission and
maintenance of remission.
2. Bone marrow transplantation
3. Post-remission prophylactic cranial radiotherapy (to treat any meningeal
infiltration).
Problem no. 9
What is your diagnosis?
Iron deficiency anemia.
What are the positive points behind your diagnosis?
1. Microcytic hypochromic anemia
2. RDW:
What is the significance of RDW?
RDW is the objective measurement of subjective anisocytosis.
What are the further investigation you should order?
Serum iron studies:
I.
Serum iron:
II.
Serum ferritin:
III.
Serum transferrin saturation:
IV.
Total iron binding capacity (TIBC):
Outline the treatment of the case.
Oral FeSO4 (3-6 mg/kg) for 4-6 months.
Problem no. 10
What is your diagnosis?
Chronic hemolytic anemia.
What are the positive points behind your diagnosis?
1. Hypochromic microcytic anemia
2. Reticulocyte count: (Normal: 2-6% in infant and 1-2% beyond this age group)
It is an evidence of hemolysis.
3. Anisopoikilocytosis and presence of target cells (evidence of hemolysis).
What is the most common cause of chronic hemolytic anemia in pediatric age group?
Thalassemia.
How will you confirm the diagnosis?
HPLC (High performance liquid chromatography).
What are the treatment options available?
Blood transfusion + Iron chelating agent.
What are the different regimens of blood transfusion in thalassemia patients?
Regimen name
Set to control blood Hb to which level?
Palliative transfusion
8.5 gm %
Normo-transfusion*
9.0 ? 11.5 gm %
Hyper-transfusion
12 gm %
Super-transfusion
14 gm %
*Preferred in India.
Name some common iron chelating agents.
1. Desferoxamine: Parenteral route, removes iron from the blood
2. Deferiprone: Oral route, removes iron from the tissue
3. Deferasirox: Oral route, removes iron from both blood and tissue.
What is the indication of splenectomy in thalassemia?
When blood required for transfusion is >240 ml/kg/year.
Problem no. 11
What is your diagnosis?
Neonatal jaundice due to Rh incompatibility.
What are the positive points behind your diagnosis?
1. Mother's blood group O- and baby's blood group O+
2. Direct Coomb's test: +Ve (which detects antibody coated RBCs).
When will you start phototherapy in this case?
Weight of the baby (kg.)
Total serum bilirubin (TSB) level to start phototherapy (mg/dL)
1-1.5
12-14
1.5-2
16-18
2-2.5
20-22
What is the indication of starting exchange transfusion in a case of Rh incompatibility?
1. Cord bilirubin 5 mg/dL
2. Cord hemoglobin 10 gm/dL.
What are the differences between physiological and pathological jaundice?
Physiological jaundice
Pathological jaundice
Appears after 24 hours of age
Appears within 24 hours of age
Serum bilirubin level <15 mg/dL
Serum bilirubin level >15 mg/dL
Increase of bilirubin <5 mg/dL/day
Increase of bilirubin >5 mg/dL/day
Clinically not detectable after 14 days
Jaundice persisting after 14 days
Disappears without any treatment
Needs treatment according to the cause
What is the most common ABO incompatibility?
Mother
O
Baby
A/B/AB
Problem no. 12
What is your diagnosis?
Neonatal sepsis.
What are the positive points behind your diagnosis?
There are 5 criteria of diagnosing neonatal sepsis (2 should be +Ve):
1. Leukopenia (TLC < 5000/cu.mm)
2. Neutropenia (ANC < 1800/cu.mm)
3. Immature neutrophil to total neutrophil (I/T) ratio (> 0.2)
4. Micro-ESR (> 15mm 1st hour)
5. CRP +ve.
In the problem above, 2 criteria are +Ve:
1. I:T ratio= 0.21 (>0.2) [As band form is 21% of total neutrophils]
2. CRP: +Ve.
What are the choice of antibiotics in this case?
Ampicillin + Gentamicin.
CSF investigations
Problem no. 13
What is your inference?
Differential diagnosis:
1. Viral meningitis
2. Normal CSF.
What are the positive points behind your diagnosis?
Parameters
Normal
Viral meningitis
Value in problem
Cell count
0-6
100-500
30
(lymphocyte)
(predominantly lymphocytic)
(lymphocytes)
Glucose (mg/dl)
40-80
Unaltered
65
Protein (mg/dl)
20-40
50-100
78
What are the changes in appearances of CSF you know about?
Turbid: Suggests bacterial meningitis
Cobweb: Suggests tubercular meningitis
Red: Suggests trauma/ subarachnoid hemorrhage.
What is the virus most commonly causing viral meningitis?
Echovirus.
What further investigation you may order?
CT scan of brain.
What is the mainstay of treatment?
Supportive.
Problem no. 14
What is your inference?
It is a case of albumin-cytological dissociation; the common causes of which are:
Guillain-Barre syndrome
Subarachnoid hemorrhage
Froin syndrome (blockage in CSF flow).
What additional investigation(s) you will want to perform?
1. Electromyography (EMG)
2. Nerve conduction velocity (NCV) study.
What are the treatment options of GB syndrome?
Acute GB syndrome: IV IgG (2 gm/kg) + Supportive treatment
Chronic GB syndrome: Corticosteroid + Plasmapheresis.
Examination of pleural fluid
Problem no. 15
What is your inference?
Malignant pleural effusion.
What are the positive points behind your diagnosis?
There are mainly 3 causes of hemorrhagic pleural effusion:
1. Trauma
2. TB
3. Malignancy
As in the question there are plenty of lymphoblasts; it is better to say that it is a
case of malignant pleural effusion.
Can you say if the effusion is exudative or transudative?
= 10.5=2 (>0.5)
- This suggests an exudative effusion.
Outline the management of this case.
Supportive: water-seal drainage.
Problem no. 16
What is your diagnosis?
Empyema thoracis.
What are the positive points behind your diagnosis?
1. Exudative pleural effusion (Pleural fluid albumin: serum albumin= 2 [>0.5])
2. Gross appearance of pleural fluid is thick pus
3. Predominantly neutrophilic effusion
4. Culture sensitivity of the pleural fluid reveals growth of Staph.aureus.
What is the management?
Intercostal chest drain
If fails
Decortication
(ICD) + Antibiotic
Problem no. 17
What is your diagnosis?
Tubercular peritonitis.
What are the positive points behind your diagnosis?
1. Cell count in ascitic fluid shows predominant lymphocytosis
2. AFB: +Ve
3. SAAG <1.1 suggests a cause other than portal hypertension (SAAG>1.1 suggests
that the cause of ascites is portal hypertension)
4. Peritoneal biopsy: M.tuberculosis +Ve.
What do you know about the appearance of ascitic fluid and its relevant cause?
Clear/ straw colored appearance: Transudative cause (Heart failure/ cirrhosis/
nephrotic syndrome)
Turbid appearance: Suggestive of spontaneous bacterial peritonitis (SBP)
Hemorrhagic appearance: TB/ Malignancy/ Intra-abdominal bleeding
Greenish appearance: Ruptured gall bladder/ acute pancreatitis/ peroration.
What additional investigations you would like to perform?
1. Chest X Ray
2. Mantoux test.
Problem no. 18
What is your diagnosis?
Cirrhosis with ascites.
What are the positive points behind your diagnosis?
SAAG >1.1 is suggestive of ascites caused by portal hypertension (cirrhosis).
What is the most common cause of cirrhosis in pediatric age group in India?
Hepatitis B.
Problem no. 19
What is your diagnosis?
Acute hepatitis.
What are the positive points behind your diagnosis?
1. Total serum bilirubin (TSB): (Normal: <1 mg/dL: 80%: direct and 20%: indirect)
2. Direct bilirubin:
3. Indirect bilirubin:
4. AST: (Normal: 5-35 U/L): Suggestive of acute inflammation of hepatocytes
5. ALT: (Normal: 5-35 U/L): Suggestive of acute inflammation of hepatocytes
6. Rise of ALT > Rise of AST
7. ALP: (Normal: 21-100 U/L): Suggestive of intrahepatic cholestasis.
[Source of the normal values: IAP textbook of Pediatrics, 4th edition, Page no. 649]
What is the most common causative agent of acute hepatitis?
Hepatitis A virus (HAV).
What additional investigation you would like to perform?
IgM-HAV.
Outline the management of the case?
Symptomatic management:
A. Absolute bed rest
B. Bowel clearance: Lactulose
C. Circulatory support: Usually by dextrose containing fluid
D. Drugs: Avoid drugs that have a hepatic metabolism.
Problem no. 20
What is your diagnosis?
Chronic hepatitis with hepatocellular failure.
What are the positive points behind your diagnosis?
1. AST: (Mild)
2. ALT: (Mild)
3. ALP: (suggestive of cholestasis)
4. Rise of ALT> Rise of AST
5. PT: ; It is suggestive of hepatocellular failure and deficiency of extrinsic
pathway coagulation factors.
Which is the commonest cause of chronic hepatitis in pediatric age group in India?
Hepatitis B
Outline the treatment of the case.
Management consists of supportive treatment of complications:
A. Ascites
B. Bleeding varices
C. Coagulopathy.
This post was last modified on 01 September 2021