D.

D in pediatrics NMT11
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 Pneumonia: respiratory distress, ,nasopharyngitis ,otitis media& bronchial breathing & crepitations bronchilitis Peritonitis: abdominal distension & diffuse tenderness Gastrointestinal : G.E.(vomiting & Pyelonephritis: loin pain & diarrhea) Urinary : cystitis tenderness Meningitis :convulsions, neck (dysuria,frequency) retraction, increased intracranial Skin: abscess tension Arthritis or osteomyelitis: hotness ,redness ,tenderness & swelling 2. Fever without focus (simple fever): Viremia Bacteremia septicemia mild to moderate fever. More than 39.4 C High fever or hyperpyrexia (high fever ). Very bad general Fair general condtion. Bad general condition(look toxic &very condition(look ill). sick). Other findings: pallor, cold extremities, mottled skin, persistent vomiting & may be disturbed consciousness

Treatment : Broad spectrum Urgent hospitalization antipyretics antibiotics 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 .

D.D in pediatrics NMT11

Fever of long duration (more than 10-14 days) (prolonged fever) Infections(most common) Rheumatic Malignancy diseases Bacterial : Systemic lupus Leukemia o Systemic: TB, Brucellosis ,salmonellosis Juvenile Neuroblastoma o Localized: pyelonephritis ,endocarditis rheumatoid lymphoma ,abscess e.g liver, pelvic & perinephric arthritis Viral: Rheumatic hepatitis ,cytomegalovirus, infectious fever mononeucleosis . Parasitic: malaria, toxoplasmosis, visceral larva migrans. 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 Inflammation of the oral mucosa e.g. : monilial stomatitis. Gingivitis Gingivostomatitis Inflammation of the gums Inflammation of both gums with no or minimal affection & oral mucosa e.g. :herpetic of the oral mucosa . ginigvostomatitis. Arthritis infections Post-infections Collagen vascular diseases Bacteria (pyogenic or TB)- viral (mumps or rubella) Rheumatic fever Juvenile rheumatoid arthritis Systemic lupus erythematosus chronic disabling disorders Henoch-schonlein purpura Kwasaki disease acute disabling disorders Sickle cell anemia- hemophilia & leukemia ( hemoarthritis ) Inflammatory bowel disease

Heamatological GIT Traumatic

D.D in pediatrics NMT11

Neonatal convulsions Common causes Less common causes Hypoxic ischemic encephalopathy (most common) Kernicterus Intracranial hemorrhage (intraventricular, Congenital brain anomalies subdural, epidural) Metabolic hyponatremia, pyridoxine(B6) dependency Meningitis, septicemia & TORCH infections & hypomagnesemia Metabolic: hypoglycemia, hypocalcemia & hypomagnesemia N.B.: more than one cause may exist on the same case (e.g sepsis+hypoglycemia) Neonatal respiratory distress Pulmonary Respiratory distress syndrome Meconium aspiration syndrome Transient tachypnea of newborn Pneumonia(intrauterine aspiration of milk or secretion) Pulmonary air leak: pnumothorax pneumomediastinumpneumopericardium Pulmonary haemorrhge Congenital lobar emphysema Diaphragmatic Extrapulmonary 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

D.D in pediatrics NMT11

Neonatal vomiting Vomiting in healthy neonates Vomiting in sick neonates Milk Medical Overfeeding & irregular Increased intracranial tension e.g. intracranial feeding hemorrhage, CNS infections Gastroesophegeal Systemic infections: septicemia, gastroenteritis, reflux (vomiting after urinary tract infections the first week & Systemic & metabolic disorders : galactosemia persists) Surgical Mucoid Non bile stained: Amniotic gastritis Esophageal atresia with tracheosophageal (during the first few fistula: vomiting with the first feed days) Congenital hypertrophic pyloric stenosis : Blood stained vomiting after 2-3 weeks Hemorrhagic disease of Bile stained the newborn Intestinal obstruction (e.g. duodenal atresia, Swallowed maternal stenosis ,volvulus): plain X-ray abdomen blood shows multiple fluid levels Vomiting in infants & childhood Medical Overfeeding or irregular feeding Increased intracranial tension e.g. brain tumors, CNS infections Systemic infections e.g septicemia ,UTI Abdominal: gastroenteritis ,appendicitis ,hepatitis & pyelonephritis Respiratory: otitis media, acute bronchilitis ,pneumonia & whooping cough Systemic & metabolic disorders: Diabetic ketoacidosis Chronic renal failure Aminoacidopathy Hypervitaminosis D Surgical Intestinal obstruction (e.g. duodenal atresia , stenosis ,volvulus): plain Xray abdomen shows multiple fluid levels .

D.D in pediatrics NMT11

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. 2. 3. 4. 5. Chickenbox Herpes simplex Herpes zoster Papular urticaria Impetigo contagiosa Generalized oedema 1. 2. 3. 4. 5. Cardiac Hepatic Renal Nutritional Allergy

D.D in pediatrics NMT11

flobby baby central causes atonic cerebral palsy ataxic chromosomal defects : ..down syndrome ..cri-du-chat ..Trisomy 13 Peripheral cause 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

spastic infant 1-spastic cp 2-epilipsy Delayed dentition rickets osteogenesis imperfecta cretinism down syndrome

D.D in pediatrics NMT11

Macrocephally cranial causes Familial large head Chronic hemolytic anemia Cretinism Rickets Achondroplasia Osteoporosis Osteogenesis imperfecta Hyper phosphatemia intra cranial causes Hydrocephalus Hydraencephaly (replacement of brain by CSF) Megalencephaly (increase in number &size of brain cell) -MPS -MSUD -Galactosemia -Achondroplasia Porencephaly (hemispheric cyst) subdural hematoma subdural effusion brain tumors

a) b) c) d) e) f) g) h)

a) b) c)

d) e) f) g)

delayed closure of fontanelles 1-anterior fontanelle: rickets osteogenesis imperfecta cretinism mongolism hydrocephalus other causes of increased ICT 2-posterior fontanelle opened at birth in cretinism

D.D in pediatrics NMT11

Purpura A) Thrombocytopenic Production( 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) Destruction (normal or megakaryocytes) -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

D.D in pediatrics NMT11

Hepatosplenomegaly A) Neonatal&early B) Late infancy & infants(cases of cholestasis) early childhood
Intrahepatic a) Hepatocytes 1- Infections -neonatal sepsis -TORCH infection -UTI 2- metabolic -CHO: galactosemia -proteins:tyrosinemia&alpha1antitrypsin deficiency -lipids: Niemann-Pick 3- idiopathic neonatal hepatitis(most common) b) Intrahepatic bile ducts paucity 1- 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 Extrahepatic 1) Extrahepatic biliary atresia -85% have the atretic segment at or above the portal hepatis -15% have distal atretic segment 2) choledochal cyst: congenital saccular or fusiform dilatations of the CBD Chronic haemolytic anemia: thalassemia Metabolic: Gaucher, Nimann-Pick Malignancy

C) Late childhood

Chronic hepatitis Metabolic: Wilson disease Bilharziasis

Acute abdomen A) Medical causes Acute abdominal infection -most common cause of abdominal pain

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D.D in pediatrics NMT11

-differentiation depends on the site of pain & associated manifestations Site of pain gastroentritis hepatitis appendicitis cholecystitis pyelonephritis peritonitis pancreatitis UTI epigastric Rt hypochondrial Rt iliac fossa Rt hypochondrial Loin (Rt & Lt) diffuse epigastric Mesenteric adenitis Associated manifestations Diarrhea, vomiting Jaundice, dark urine Rebound tenderness, coughtenderness Haemolytic jaundice anemia,

Fever, rigors, dysuria Vomiting, distension Pain radiating to the back Follicular tonsillitis

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

Causes of intestinal obstruction

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D.D in pediatrics NMT11

Hematuria A-Glomerular Colour: 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 B-non-glomerular 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 Bronchial asthma(commonest cause of of wheezes in infancy) wheezes in children) Sever bronchopneumonia Recurrent aspiration(GERD, tracheoosophageal fistula) Foreign body inhalation(sudden onset Foreign body inhalation(unremoved) & chocking) Organo-phosphorous Chronic infection(immunodeficiency) poisoning(exposure, chest secretion, Bronchopulmonary dysplasia diarrhea, pinpoint pupils& coma) Interstitial pneumonia(expiratory wheezes)

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D.D in pediatrics NMT11

Cough
A- Acute cough (duration <2 wks) 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 B- Prolonged cough (2 wks-2 months) Complicated bronchitis (bacterial bronchitis, pneumonia,segmental collapse) Acute sinusitis Pertussus &pertussus like illness C- Chronic cough

Chronic infections: TB, bronchiectasis Lung abscess, empyema Persistent asthma Recurrent aspiration: GERD, tracheoosophageal fistula Cystic fibrosis immunodeficiency

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D.D in pediatrics NMT11

DR ABO EL-ASRARS MOST IMPORTANT D.D.

Blood
1. purpura: a) vascular system defect b) thrombocytopnea c) thromboathenia d) coagulation system defectcoagulation factors 2. rheumatic pain: a) rheumatoid (in winter cold weather, localized pain) b) hand foot syndrome (in winter ,diffuse ,burning pain) 3. G6PD History of exposure to oxidizing agent Bilateral Translucent heamoglobinurea 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 Rapid pulse with big volume No change in urine Low cardiac output Rapid week pulse Oligurea Acute pyelonephritis Lion pain ,red urine, fever ,rigor

Unilateral Opaque hematuria

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D.D in pediatrics NMT11

7. Hemophilia A & classic hemophilia: a) Congenital defect in factor 8 b) Acquired congenital defect as liver failure c) DIC

cardio
1. Murmur heard on the back of the patient : a) PDA b) VSD Maximum in isenmengers 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 Increased with breathing & cough decrease with holding breath 5. Fraction rub of precarditis Maximum intestiny allover the heart decrease with holding breath Murmur of PDA in Lt subclavian Not decrease with holding breath Machinery heard during systole & diastole precarditis Stitching pain Not related to breath or cough Not decrease with holding breath

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D.D in pediatrics NMT11

6. Caricomb murmur Rumbling all through without presystolic accentuation Normal s1 Permanent M.S. murmur Mid diastolic Rumbling with presystolic accentuation Accentuated s1

Genetics
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

GIT
1. Watery diarrhea: a) Diarrhea of enterotoxigenic pathway b) 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)

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