PEDIATRICS FCPS MCQS AND TOACS: Pediatrics TOACS: Orthopedics

PEDIATRICS FCPS MCQS AND TOACS: Pediatrics TOACS: Orthopedics: A 2-week-old male infant is at a health supervision visit. He was delivered at term by vaginal delivery and was discharged from the hospit...

Pediatrics TOACS: Orthopedics

A 2-week-old male infant is at a health supervision visit. He was delivered at term by vaginal delivery and was discharged from the hospital after 2 days. His mother reports that prenatal testing was normal. On physical examination in the newborn nursery, it was noted that his left foot was turned inward. The remainder of his examination findings was normal. The boy is otherwise healthy. Physical examination reveals a left foot deformity. The foot can be passively stretched almost to the midline, but it is not possible to dorsiflex the ankle to a neutral position.

Of the following, the BEST next management step for this neonate is

A. bracing with reverse last shoes

B. home stretching exercises with reevaluation at age 6 months

C. immediate referral to orthopaedic surgery for casting

D. referral to orthopaedic surgery for surgical reconstruction at age 6 months

Answer on Thursday 10 am.

PEDIATRICS FCPS MCQS AND TOACS: NICE Guideline for imaging in Urinary Tract Infect...

PEDIATRICS FCPS MCQS AND TOACS: NICE Guideline for imaging in Urinary Tract Infect...: NICE Guideline for imaging in Urinary Tract Infection (UTI) Ultrasound Indicated during the acute infection for: §   Infants below ...

NICE Guideline for imaging in Urinary Tract Infection (UTI)

NICE Guideline for imaging in Urinary Tract Infection (UTI)

Ultrasound

Indicated during the acute infection for:

§  Infants below 6 months

§  Atypical UTI

§  Recurrent UTI

MCUG

Done at 2-4 weeks post UTI allowing bladder inflammation to resolve

Indications:

§  After a second UTI is diagnosed

§  After a first UTI with:

-        Abnormal ultrasound findings e.g. hydrnephrosis, scarring, obstructive      uropathy or VUR

-        Poor urine flow

-        Non E.coli UTI

-        Family history of vesico-ureteral reflux (VUR)

DMSA scan

Done at 4-6 months in order to avoid a false positive result due to renal parenchymal inflammation that may resolve

Indications:

§  Child > 3 years of age with clinical pyelonephritis

§  Atypical UTI o recurrent UTI

PEDIATRICS FCPS MCQS AND TOACS: WATER DEPRIVATION TEST

PEDIATRICS FCPS MCQS AND TOACS: WATER DEPRIVATION TEST: WATER DEPRIVATION TEST : The aims of this test are: • To establish the diagnosis of diabetes insipidus (DI). • To distinguish betw...

WATER DEPRIVATION TEST

WATER DEPRIVATION TEST:

The aims of this test are:

• To establish the diagnosis of diabetes insipidus (DI).

• To distinguish between nephrogenic and central DI.

Principle:

In a normal individual even after a period of water deprivation, homeostatic mechanisms to maintain serum osmolality and euvolemia within the normal range are activated. Urine output decreases and urine becomes progressively concentrated, but serum sodium (reflecting intravascular volume status) and serum osmolality remain normal.

Patients with DI in whom the renal concentrating ability is impaired can maintain euvolemia only by increasing their water intake. When deprived of water, urine output continues to be high and urine remains dilute. The serum sodium and serum osmolality rise.

Precautions and planning of the water deprivation test:

The test should be performed in a day care where a period of observation for 8–10 hours is possible, or in an in-patient setting

Patients with DI may get rapidly dehydrated on water deprivation; hence resource and expertise for fluid resuscitation should be readily available during the test.

Test procedure: Many protocols for water deprivation test are described. Most protocols entail hourly sampling and can be performed if a heparinized IV cannula is left in place and test results are obtained within 1 hour. Hence a modification of this test may be adopted in practice.

Step 1: Thyroid and adrenal function should be assessed before the water deprivation test.

Water deprivation should be started at midnight. No water or drinks or food should be allowed during the period of testing. Baseline weight is recorded; baseline samples are collected for S. sodium, S. osmolality, urine osmolality

Starting at 9 am, hourly estimations of the above parameters are done. The results are procured as soon as possible

Step 1 stopped at 12 noon (after 12 hours of water deprivation) and Step 2 is started

Step 1 may be terminated at any stage and Step 2 is started if:

Urine osmolality is more than 600 mOsm/L as DI is ruled out

If there is weight loss of more than 5% body weight or there is hemodynamic compromise

If S. osmolality exceeds 300 mOsm/kg at any stage, DI is diagnosed and no further testing is required

Serum arginine vasopressin levels may be collected, if available.

Step 2: Child is allowed some water orally. Desmopressin 5 mcg is administered intranasally or 0.3 mcg is given subcutaneously. Hourly samples are collected for the next 4 hours (Table).

Limitations of Water Deprivation Test:

It cannot be performed in neonates and infants due to higher risk of dehydration during the test. In such situations, estimation of serum and urine osmolality may be a useful guide to diagnosis, coupled with a therapeutic trial of desmopressin when clinical suspicion of DI is high.

Interpretation of the water deprivation test:

S. osmolality (mOsm/kg)	U. osmolality (mOsm/kg)	U. osmolality after dDAVP	Diagnosis
<295	>600	—	Normal response
>295	<300	>600	CDI
>295	300–600	>600	Partial CDI
>295	<300	Rise <100 above baseline	NDI

CDI: Central diabetes insipidus      NDI: Nephrogenic diabetes insipidus 

PEDIATRICS FCPS MCQS AND TOACS: GI FOREIGN BODIES (FB): When to remove?

PEDIATRICS FCPS MCQS AND TOACS: GI FOREIGN BODIES (FB): When to remove?: GI FOREIGN BODIES (FB): When to remove? §   FB in the esophagus such as button battery, sharp FB and symptomatic FB should be removed ...

PEDIATRICS FCPS MCQS AND TOACS: MESENTERIC LYMPHADENOPATHY: When to investigate?

PEDIATRICS FCPS MCQS AND TOACS: MESENTERIC LYMPHADENOPATHY: When to investigate?: MESENTERIC LYMPHADENOPATHY: When to investigate? 1.       Isolated detection of mesenteric lymph nodes in the absence of signs and sym...

PEDIATRICS FCPS MCQS AND TOACS: Pediatric TOACS:

PEDIATRICS FCPS MCQS AND TOACS: Pediatric TOACS:: A term baby is noted to have a degree of FRONTAL BOSSING, as does his mother. A chest X-ray is performed. Q # 01: Describe th...

GI FOREIGN BODIES (FB): When to remove?

GI FOREIGN BODIES (FB): When to remove?

§  FB in the esophagus such as button battery, sharp FB and symptomatic FB should be removed immediately.

§  Coins and smooth FBs in the esophagus can be removed within 24 hours and it is imperative that underlying esophageal stenosis should be excluded.

§  Most FBs in the stomach, which are small, smooth and round, are passed out naturally and therefore it is preferable to observe and wait for at least a week or even more. FBs retained in the stomach for more than 7 days need endoscopy removal.

§  However, larger objects greater than 2 cm, long greater than 5 cm, sharp objects, needles and button battery in the stomach should be removed endoscopically.

§  Button battery ingestion is a common problem in children and these batteries should be removed as early as possible as leaking button batteries can cause perforation and tissue necrosis.

MESENTERIC LYMPHADENOPATHY: When to investigate?

MESENTERIC LYMPHADENOPATHY: When to investigate?

1.      Isolated detection of mesenteric lymph nodes in the absence of signs and symptoms like anemia, anorexia, weight loss, bowel wall thickening or free fluid in the abdomen does not warrant any specific therapy.

2.      Mesenteric nodes are said to be significant if

§  These are more than 5 in number,

§  more than 14 mm along its long axis and

§  Are matted or present in clusters.
Large, matted nodes or nodes in clusters may warrant further investigation.

3.      If the nodes are small it is preferable to repeat USG after 3–6 months.

4.      Diagnostic laparoscopy is planned if there is an increase in size or               in number of the nodes.

Pediatric TOACS:

A term baby is noted to have a degree of FRONTAL BOSSING, as does his mother. A chest X-ray is performed.

Q # 01: Describe the abnormalities on the X-Rays chest.

Q # 02: What is the diagnosis?

PEDIATRIC NEPHROLOGY: Basic Approach to Hematuria

APPROACH TO HEMATURIA

We should exclude other causes of red urine without RBCs by urine analysis (Dipstick) which includes:-

A.     Heme positive:

a.      Hemoglobinuria in case of acute hemolytic anemia.

          CBC shows fragmented RBCs & reticulocytosis and Hemoglobin in urine

b.      Myoglobinuria in case of rhabdomyolysis (myositis, crush)

  High serum creatine kinase.

B. Heme negative: Foods e.g. Beet roots, black berries.

Drugs e.g. Rifamipicin, Desferal, Nitrofurantoin.

Urate crystals (red diaper).

History

A.     Glomerulonephritis: sore throat/rashes/body swelling

B.      UTI: fever/frequency/dysuria.

C.      Renal stones: colicky abdominal pain/family history.

D.     Coagulopathy: easy bruising.

E.      Trauma

F.      Family history: hematuria, deafness (Alport’s), sickle cell disease.

Examination

A.     Blood Pressure (use age,sex and height appropriate blood pressure centiles)

B.      Abdomen: palpable masses (polycystic kidneys, tumors, hydronephrosis).

C.      Skin: rashes.

D.     Joints: pain/swelling.

Investigations

A.      It is important to identify serious, treatable, and progressive conditions.

B.      During an acute illness, exclude UTI by urine culture.

C.     Asymptomatic or ‘benign haematuria’ in children without growth failure,        hypertension, oedema, proteinuria, urinary casts, or renal impairment is a      frequent finding.

Localize hematuria:

	Glomerular	Extra glomerular
Acute nephritic syndrome	Present	Absent
Color	Cola or tea colored	Bright red
Clots	Absent	May present
RBCS Shape	Dysmorphic (distorted)	Normal
RBCS casts	Present	Absent
Proteinuria	> 30 mg / dL.	< 30 mg / dL.

For Glomerular hemturia:

A.     Hematology

  CBC with differential

B.      Chemistry

  Electrolytes, Ca

  BUN/ Creatinine /Creatinine clearance

  Serum protein/Albumin /Cholesterol

  Urine protein

C.   Immunology

  C3/C4

  ASO/Anti-DNase B

  ANA

  Antineutrophil antibody

Reduced C3 in

-        Post infectious glomerulonephritis

-        Systemic lupus nephritis (and low C4)

-        Nephritis with chronic infection

-        Membrano proliferative glomerulonephritis

D.   Renal Biopsy

Unexplained persistent or recurrent gross hematuria

Lupus nephritis

Glomerulonephritis with:

Nephritic nephrosis

Absent low C3

Unexplained acute renal

For extra glomerular hematuria

Step 1: Urine culture

Step 2: Urine calcium/creatinine ratio, rule out sickle cell anemia, renal/bladder ultrasound

Step 3: Urinalysis: siblings, parents, serum electrolytes, Cr, Ca, if crystalluria, urolithiasis, or nephrocalcinosis: 24-hour urine for Ca, creatinine, uric acid, oxalate and if hydronephrosis/pyelocaliectasis: Cystogram, renal scan.

Treatment:

A.     If obvious cause (e.g. UTI), treat.

B.    If complex diagnosis (impaired renal function, proteinuria, or family history)   refer to paediatric nephrology unit.

C.   If no cause found and normal renal function, BP, and no proteinuria, monitor   until resolves.

D.  If no resolution after 6mths or change in any of above parameters refer to paediatric nephrology unit.