تشخيص ال
case seinario
Keys of Diagnosis :
دليل الأطباء والطبيبات نحو تشخيص الحالات ( 1 - 2 )Case scenarios :
Hematology :
1 - Diagnosis of acute leukemia :
at least 4 of : pallor - purpura - fever - infection - HSM - lymphadenopathy - tender bone
2 - Diagnosis of Aplastic anemia :
pallor - purpura - fever ( may be history of drug intake or viral infection )
3 - Diagnosis of I.T.P :
purpura ( only ) ( may be bleeding disorders due to decreased platelet count )
4 - Diagnosis of Hodgkin's lymphoma :
L.N affection ( mainly ) and its character +/- systemic manif. which is ( fever - loss of wt - anorexia - fatigue - night sweating )
5 - Diagnosis of Anaphylactoid purpura :
skin manif. ( rash and its sites and ch - purpura ) - GIT manif. ( melena - hematemesis ) - Joint pain ( arthralgia )
6 - Diagnosis of Thalassemia :
pallor - jaundice - HSM - Dark urine - Ch facies ( mongoloid features )
7 - Diagnosis of Sickle cell anemia :
jaundice - not palpable spleen - embolic manif ( hemiplegia - sudden paralysis and blindness - hematuria )
8 - Diagnosis of G-6-p def. anemia :
dark urine - progressive jaundice - pallor - acute abd. pain ( indicating acute hemolysis ) - history of drug or food intake
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Nephrology :
( H2 O2 = Hematuria, HTN, Oliguria, Oedema )
( hematuria , HTN ) more in AGN
( Oliguria , Oedema ) more in N.S
1 - Diagnosis of A.G.N :
Gross Hematuria ( red urine ) - HTN - puffiness of eye - ankle edema ( not generalized ) - ( may be RBCs cast - low serum C3 )
2 - Diagnosis of N.S :
Generalized edema ( puffiness of eye then L.L then abdominal ) - exam. of chest ( pleural effusion ) - ( may be heavy proteinuria - microscopic hematuria )
3 - Diagnosis of Nephritic Nephrotic syndrome ( 2ry nephrosis ) :
one or more of AGN + one or more of N.S
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Cardiology :
1 - Diagnosis of Rheumatic fever :
History of tonsillitis , sore throat , joint pain ( arthritis ) - age 5 - 15 years - apical PSM
( selective propagation to axilla , muffled S1 - pericordia exam. )
* ** If with basal early diastolic murmur - water hummor pulse - collapsing pulse >> Rh. MR & AR
2 - Diagnosis of TOF :
central cyanosis - ESM at base of heart or pul. area or Lt. sternal border - clubbing
3 - Diagnosis of VSD :
Pul. congestion ( dyspnea - heaemoptysis - chest infection ) - sys. murmur at Lt. sternal border - no cyanosis -
hyperdynamic Ashifted out and dowon ward apex
* TOF and VSD dating since birth
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Neonatology :
1 - Diagnosis of neonatal jaundice :
either Rh. incompatibility or breast milk jaundice
* Rh. incompatibility : mother and fetus Rh - jaundice and HSM at birth - pallor
* breast milk jaundice : 3-4 weeks - normal at birth - started with nursing - decreased with weaning
2 - Diagnosis of R.D.S :
start immediatly after bitrh - progressive worsening of resp. distress - fine crepitation -
risk factors ( prematur - maternal diabetes - perinatal asphyxia - male sex )
3 - Diagnosis of I.D.M :
increased size of baby ( macrosomia B.W > 4 )
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Genetics :
1 - Diagnosis of Down's syndrome :
Ch facies - M.R - hypotonia
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Endocrinology :
1 - Diagnosis of hypothroidism :
either congenital or juvenile ( acquired )
* congenital : open post. fontanel - umbilical hernia - post mature - edemetous face - overweight
* juvenile : M.R or subnormal I.Q - short stature - puffeniss eye - large protruded tongue
2 - Diagnosis of short stature :
mostly constitutional short stature , may be G.H deficincy
* constitutional : short stature - period of poor growth in 2nd year of life - delayed bone age - +ve family history of delayed puberty
* G.H deficiency ( pituitary dwarfism ) : normal mentality - underdeveloped genetalia - rounded face with prominent frontal process
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Neurology :
1 - Diagnosis of Hydrocephalus :
large head circumference , ch sound on percussion - sunset appearance of eye - wide ant. fontanel
2 - Diagnosis of C.P :
either spastic or atonic :
* spastic : paralysis L.L , weakness of U.L ( mostly diplegic ) - Hypertonia - Hyperreflexia - history of birth asphyxia
* Atonic : Hypotonia - brisk reflex - ms. weakness - history of birth asphyxia
3 - Diagnosis of Floppy infant :
In general : Generalized hypotonia - frog leg position - head lag - on ventral suspention > curved trunk
either atonic C.P , congenital cerebellar ataxia , degenerative brain disease , Werding-Hoffman disease and Guillian-Barre syndrome
* atonic C.P : as above
* congenital cerebellar ataxia : hypotonia - hyporeflexia - ( +/- nystagmus ) - intention tremors and ataxic gait
* Degenerative brain disease : after 6 - 7 montes - progressive loss of previously acquired neurological finding - rigidity followed by hypotonia
* Werding Hoffman disease : areflexia - bulbar palsy ( weak cough & cry ) - toungue faciculation - paradoxical resp.
* Guillian Barre syndrome : viral infection - ascending paralysis ( L.L > trunk > U.L > Bulbar ms > facial ms. > diaphragm
- areflexia - parasthesia - urine incontinence - abnormal pulse and Bl. Pr.
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Malnutrition :
1 - Diagnosis of Rickets :
delayed walking , sitting , standing - bone deformity - chest infection ( common ) - ( may be ch chest shape and multiple rosaries on chest palpation )
2 - Diagnosis of Kwo :
constant manif. ( generalized edema , dull attention ) - growth retardation - Wt before and now ( 60 - 80 % ) - Hepatomegally - Edema - mid arm circumference < 12.5 -
( may be skin and hair changes )
3 - Diagnosis of marasmus :
Wt + age ( percent of wt < 60 ) - wrinkled skin ( loss of S.C fat ) - thin extremities
4 - Diagnosis of Marasmic Kwo :
Marasmus + edema
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Hepatology :
1 - Diagnosis of neonatal cholestasis :
either I.N.H or B.A :
* I.N.H : neonate - deep jaundice within 1st week - marked increased transaminase - HSM
* B.A : neonate - deep jaundice at birth or 3rd to 5th week - marked increase alk. phosphatase & y-GT - HSM - pale stool > 10 days
2 - Diagnosis of autoimmune hepatitis :
adolescent female - jaundice - fatigue - anorexia - extrahepatic ( nephritis - gastritis - thyroiditis - cut. vasculitis )
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Pulmonology :
1 - Diagnosis of asthma :
recurrent - cough - wheezing - dyspnea - harsh vesicular breathing - precipitated by exposure to allergen - +ve family history of atopy
2 - Diagnosis of pneumonia :
fever - severe cough - poor feeding - grunting respiration - tachypnea , tachycardia - crepitation on auscultation .
either pneuomococcal - strept - chlamydia - staph. - Hib - mycoplasma ( specific features for each )
3 - Diagnosis of acute bronchiolitis :
2-6 months - viral infection - cough - wheezes - hyper-resonance on percussion - evidence of obstructive emphysema
دليل الأطباء والطبيبات نحو تشخيص الحالات ( 2 - 2)
Clinical cases :
Hematology :
We have 3 important signs :
either purpura , pallor or lymphadenopathy :
** purpura :
we have 4 DD ( ITP , anaphylactoid , acute leukemia or aplastic anemia )
# aplastic anemia : rare as it's isolated
# Acute leukemia : rare but if present => HSM + lymphadenopathy
# ITP : petechial and purpuric eruption over any site in body + echemosis over medial aspect of tibia
من الآخر اسأل الأم عنده كدمات في جسمه ولا ل
أ يالإضافة لأن الـ purpura
متنطورة في جسمه
# anaphylactoid : itchy and maculopapular rash occur in crops mainly in the back , L.L and buttoks - joint manif.
هتلاقي الـ rashes
متجمعة على بعضيها بالإضافة إلى إنك بتسأل أمه بيشتكي من مفاصله ولا لأ
** pallor :
mainly thalassemia
هتسأل الأم هتقولك عنده انيميا أو أنيميا البحر المتوسط
بالإضافة للكبد والطحال وأعراض الصفرا والـ
mongoloid features
وهتلاقي أسئلة عن الـ
hemolysis
** lymphadenopathy :
either Hodgkin or leukemia
هتسأل الأم ابنك بيسخن امتى
لو بيسخن على طول يبقى سرطان الدم
لو بيسخن ويبرد يبقى سرطان الغدة الليمفاوية
---بالإضافة لتضخم الكبد والطحال في سرطان الدم
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Nephrology :
either A.G.N or N.S :
** A.G.N :
completely normal
هتلاقيه داخل بكيس البول بتاعه
ولو سألت أمه هتقولك إن بوله بيحمر أو في دم في البول
** N.S :
generalized edema
الأم هتقولك مشكلته في الكلى وبياخد ستيرويد
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Cardiology :
either congenital ( VSD , TOF ) or Rheumatic ( with MR only , with MR and AR )
At first :
** IF < 5 years >>> CHD >> IF cyanosed ( TOF ) , IF NOT ( VSD )
* N.B : you must ask mother if he cyanosed or not . ( خاصة لما بيعيط بيبقا فالوت )
** IF > 5 years >>> History dating since birth >> CHD
>>> History of Rheumatic chriteria >> either M.R only or with A.R > If there's water hummur pulse > with A.R
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Genetic :
only down's syndrome ( very characterestic mongoloid facies )
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Endocrinology :
mostly hypothroidism
rarely short stature
** hypothroidism :
الأم هتقول عنده نقص ف الغدة باختصار
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Neurology :
either C.P , Hydrocephalus or floppy :
** C.P :
either spastic or atonic ( which mean floppy )
# spastic :
الأم هتقول عنده شلل دماغي أو مشكلة في الأعصاب
لو مسكت ايده وهزيتها ولقيتها متخشبة يبقى أكيد
spastic
# atonic ( floppy ) :
الأم هتقول عنده شلل دماغي أو ضعف في العضلات كلها
اعمل نفس الحركة اللي فوق
لو ايده بتتهز طبيعي يبقى
atonic
ممكن تتأكد
قومه على السرير وانتا ماسك دراعه وشوف راسه
لو وقعت لورا يبقى هوا ده التشخيص
** Hydrocephalus :
مش محتاجة كلام
دماغه كبيرة والأوردة بتيان كمان
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Malnutrition :
الأم هتقول عنده سوء تغذية
either marasmus , Kwo or rickets :
** Kwo : very rare ( if present > edema - hair and skin changes )
** marasmus : باختصــار هيكل عظمي
ومهم نفرق الدرجات بتاعته
غالبا بتيجي الدرجة التانية أو التالتة
بنفرقهم بشكل الوش
لو وشه متاكل يبقى التالتة
لو مش متاكل يبقى التانية
** rickets : تشوهات ومنظر الصدر المميز وممكن تلاقي عظمه متني
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Hepatology :
either neonatal cholestasis or HSM (+/- ascitis ) :
** neonatal cholestasis : أقل من شهر وعنده صفرا
** HSM :
أمه تقول عنده كبد وطحال وممكن تقول كان عنده فيرس
بعدين تسألها عن وجود مية على بطنه
وأغلب الحالات من غير مية
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pulmonology :
either wheezy chest ( mostly B.A ) or pneumonia :
** B.A : الأم تقول عنده أزمة ربو أو حساسية على الصدر أو تقول بياخد جلسات استنشاق
** pneumonia : crepitation on auscultation ( mainly )
mostly broncho , rarely lobar
نفرق بينهم عن طريق معرفة ما إذا كانت المشكلة في ناحية أو ناحيتين
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