how to examine sick baby , approach to child medical examination , diagnosis of sick child , evaluation of sick baby , medical examination of children , child medical history and examination , care of children

1. EVALUATION OF THE SICK
CHILD IN THE CLINIC
Prof dr. Sayed
Ismail
Al-Azhar
university

2. Objectives
• 3 types of patients you can see in pediatrics clinic :
1. Patients who can be managed with close outpatient
follow-up
2. Patient who need admission to the hospital
3. Patient who need urgent care , stabilization and
transported to a higher level of care.

3. History
1. The presenting complaint
– Always ask the patient or the parents to describe their concerns, and
record their actual words.
2. Present history : ask about the onset , course , duration
3. Review of Systems
4. Past history : prenatal , natal , post natal
5. Family History : seizures, asthma , unexplained deaths …
6. Immunization history
7. Developmental history see next table..

4. Developmental
milestones
Review the patient
developmental skills

5. Symptom review from head to toe
1. HEENT
– Head : Is there a history of injury, headaches
– Eyes : How good is visual acuity
– Ear infection or discharge?
– Nasal discharge, snoring, or bleeding?
– Throat pain , dental problems, or mouth ulcers
2. Chest : Is there a history of cough, wheeze, chest pain, or exercise
limitation
3. Heart :Is there a history of heart murmur
4. Gastrointestinal : How good is the child’s appetite?
5. Genitourinary :Is there any dysuria, or haematuria, or discharge
6. Joints, limbs, and tissue: Is there any pain?
7. Nervous system : seizures, weakness, headaches
8. Skin ; Is there a rash?

6. Examining a child
 General examination :
1. Signs of severe illness (need urgent intervention):
– Severe respiratory distress
– Shock
– altered consciousness level
2. Vital signs : Pulse , RR, TEMP. , BP , SPO2
3. Height, weight, and head circumference
 Head to toe examination
– HEENT (head, eye, ear, nose and throat)
– chest , heart , abdomen , Genitourinary system
– skin , CNS, joints
Chest retraction in respiratory
distress

7. • It is reassuring to
see the child
moving about on
the parent’s lap
with ease and
without discomfort.

8. Vital signs
Pulse Rate
• In an infant, palpate for pulse over the brachial artery.
• In an older child the wrist is the optimal location
• Check SPO2 = oxygen saturation
Respiration Rate
• In infants and young children, breathing is mostly diaphragmatic;
the respiratory rate can be determined by counting movements of
the abdomen.
• In older children chest movement should be directly observed.
Blood Pressure
• To obtain an accurate blood pressure measurement, patient
relaxation is especially critical.
• Explain to a young child that the “balloon” will squeeze his arm and
encourage him to watch the display.
• Cuff width is also important. Choose a cuff width that covers 50% to
75% of the upper arm length. A too-narrow cuff may artificially
increase the blood pressure
reading.
• If you are concerned about the possibility of heart disease, check
blood pressure in all four extremities. Compare blood pressure
measurements with standard norms for age and sex.
Pulse oximeter determines the pulse and SPO2

10. Note: Persistence of abnormal vital signs may be due severe illness
• Tachycardia and poor perfusion may be secondary to myocarditis.
• Tachypnea may be the sole symptom in patients with pneumonia,
• Persistent irritability suggests
meningitis/encephalitis.

11. Febrile children can appear very ill,
initially appearing listless, tachycardic,
and tachypneic.
These patients should receive
antipyretic medications and be
reassessed once they have defervesced.
In the majority of children with
uncomplicated viral illnesses, the vital
signs normalize.

12. Height, weight, and head circumference assessment
• Accurate measurement is essential for growth assessment
• Weight : Babies up to the age of two years
should be weighed using specialized digital baby
scales.
For children over two years,
weight should be taken on
standing scales
Digital baby scales

14. Measurement of length

15. By plotting body weight , length and head circumference on the corresponding
growth charts , health care providers can achieve early identification of patients
at risk for being :
• Underweight < 5th centile
• Overweight > 95th centile
• Short stature < 5th centile
• Tall stature > 95th centile
• Small HEAD < 5th centile
• Large head > 95th centile
Use growth charts of WHO or CDC

16. PHYSICAL EXAM
• The anterior fontanelle is typically about 1
to 4 cm in diameter at birth and usually
closes between the ages of 6 and 26 months.
The posterior fontanelle is usually 0 to 2 cm
in diameter at birth and generally closes by 2
months of age.
• When describing fontanelles, mention
their status (open or closed), size, and
fullness.
• A tense or elevated fontanelle may
reflect increased intracranial pressure.
• A depressed fontanelle can be a sign of
dehydration
Bulging Depressed
Hydrocephalus

17. Assessment of the Eyes
• Check for full range of motion by attracting the
child’s attention with a toy or piece of equipment
• Strabismus
• Pupil size and reaction to light
• Condition of the eyelids — include edema (swelling),
erythema (redness), drooping, or the presence of
masses
• Hazy corneas— causes include glaucoma and inborn
errors of metabolism
• Injected or inflamed conjunctivae
• Icteric sclerae ( jaundice)
• Excess tearing —often caused by congenital
obstruction of the nasolacrimal duct
Jaundice
Strabismus

18. • The eyes
– Viral infections result in a
watery discharge or redness
of the bulbar conjunctivae.
– Bacterial infection, if
superficial, results in purulent
drainage;
– if the infection is more deep ,
tenderness, swelling, and
redness of the tissues
surrounding the eye are
present, as in periorbital
cellulitis

19. Nasal examination
• Check the nasal mucosae. Pale, boggy
mucosae with a watery discharge suggest
allergy
• Hyperemic mucosae with a mucopurulent
discharge suggest infection.
• Purulent nasal discharge in
sinusitis

20. • Examine eardrums using an
otoscope
• Grey and shiny: normal
• Red and bulging: suggests otitis
media
• Determining Hearing Acuity
– Watch the child’s face as you make noise with
a rattle or rustle paper behind each ear.
– Check to see whether the child is startled by
the sound (usually by 1 month of age) or looks
toward the source of the sound (by about 5
months of age).
Acute otitis media

21. Primary Teeth Eruption Chart
/wEPDwU

22. • Presence of enanthemas; seen in
many infectious processes, such as
hand-foot-and-mouth disease caused
by coxsackievirus.
• Documenting inflammation or
exudates on the tonsils, which
may be viral or bacterial.
HerpanginaThroat examination

23. The neck is examined
• for areas of swelling,
redness, or tenderness,
as may be seen in
cervical adenitis.
• Thyroid gland
Goiter

24. • NECK STEFFNESS
– should prompt
evaluation for signs of
meningeal irritation (i.e.,
Kernig and Brudzinski
signs) or a
retropharyngeal abscess.
Meningeal irritation
(Opisthotonos)
Neck stiffness and retraction

26. CHEST AND LUNGS
• Shape of the Chest : A barrel-shaped chest in a
child 6 years can be associated with asthma or a
chronic pulmonary disease such as cystic fibrosis.
• Check carefully for signs of respiratory
distress, including nasal flaring, retractions, or
grunting.
• Auscultation of the Lungs
– comparing air movement in the two lungs.
– Rales are fine crackles, reflect the presence of fluid in
the alveoli.
– Rhonchi are coarse inspiratory and expiratory sounds,
caused by secretions in the upper airway
– Wheezes are palpable and audible vibrations, often
musical in character, produced when airflow is
restricted. Expiratory wheezes are most common and
typically reflect lower airway obstruction
Respiratory distress
Asthmatic child

27. CIRCULATORY SYSTEM
• Palpate right-arm pulse strength and compare with femoral pulse strength,
which can be decreased in patients with coarctation of the aorta.
• Listen over the 4 cardiac areas
• Listen for a split second heart sound (S 2 ), heard best over the pulmonic area
during inspiration.
• Distant sounds can suggest pericardial fluid.
• Is there a third heart sound (S 3 )? (Usually heard at the apex, an S 3 may
indicate mitral valve prolapse or atrial septal defect.
• Is there a gallop rhythm which is consistent with congestive heart failure?
• Murmurs are described as follows:
• Loudness— reported as grades I to VI
• Timing as diastolic or systolic,
• Pitch— high or low
• Location— for example, apex, left lower sternal border
• Transmission across the chest— for example, radiating to the right lower sternal
Border
• Innocent Murmurs
Nonpathologic murmurs typically heard in childhood include Still murmur and venous hum.
– Still murmur is the most common murmur in children between the
ages of 2 years and adolescence. It is typically described as musical or vibratory,
short, high pitched, early systolic, and grades I to III. It is usually heard best in the
apical region.
– A venous hum is a continuous, low-pitched murmur heard under
the clavicle and in the neck. It is caused by blood draining down the jugular vein

28. ABDOMEN
• Abdominal Contour
– Is the abdomen flat, protuberant (common
in toddlers), or distended?
• Abdominal Wall Motion
– In young children, absence of abdominal
wall motion may be caused by peritonitis,
diaphragmatic paralysis, or large amounts
of fluid or air in the abdomen.
• Auscultation
– Normal sounds are short , occurring every
10 to 30 seconds.
– Excessively frequent and high-pitched
sounds can indicate gastroenteritis, or
intestinal obstruction.
– Absence of sounds for 3 minutes can occur
with paralytic ileus or peritonitis.
– Vascular obstruction may be indicated by a
murmur over the aorta or renal arteries. It
is especially important to check for
vascular obstructions in any child with
hypertension.
Abdominal distension

29. • Percussion : Percussion can be useful
to assess ascites, or air in the
gastrointestinal tract
• Palpation of the abdomen
– Rigidity and tenderness can indicate
a surgical condition
– Facial expression is the most reliable
sign of true tenderness.
– The spleen is often normally palpated
in the first few years of life. It can be
enlarged with infection (especially
infectious mononucleosis), sickle cell
or other hemolytic anemias, or
leukemia
– The liver generally can be palpated 1
to 2 cm below the right costal margin
Abdominal distension due to
hepatosplenomegaly

30. RECTUM AND ANUS
• Rule out fissures or anal
prolapse.
• Check for sphincter tone,
masses, and tenderness as
needed
Perianal streptococcal infection

31. GENITALIA
• Boys
– Examine the glans penis and
locate the meatus.
– Observe for inflammation of the
glans penis (balanitis) or of the
prepuce (posthitis).
– Palpate the testicles ,
epididymis and vas deferens
and note their location
balanitis

32. • The inguinal area and genitals are
then sequentially examined.
Left Inguinal hernia
• Undescended right testis

33. Girls
• Observe the labia majora, labia
minora, and clitoral hood/clitoris.
• Is there labial fusion? Are there signs
of injury? Is the clitoris enlarged?
• Observe the appearance of the
hymenal orifice
• Are there acute or healed signs of
injury or infection? Check for any
abnormal degree of redness, vaginal
discharge, or malodor. Also look for
other signs of sexually transmitted
diseases such as vesicles or
verrucous lesions and for additional
stigmata of trauma such as abrasions,
bruising, or scarring , possibility of
foreign bodies, which can present
with particularly foul-smelling vaginal
discharge.
Pediatric vulvovaginitis

34. Puberty
• The first signs of puberty are usually testicular enlargement in boys, and
breast budding in girls.
• Puberty is precocious if it starts before the age of 8 years in girls and 9 years
in boys.
• Puberty is delayed if onset is after 13 years in girls and 14 years in boys.
• A growth spurt occurs early in puberty for girls, but at the end of puberty
for boys.
• Menarche occurs at the end of puberty. Delay is defined as no periods by 16
years of age.
• Tanner stages
= 1 - 5 stages
• Stage 1 is prepubertal
• Stage 5 is adult.

35. Skin examination
Roseola infantum
(Tends to occur in younger children
with high fevers preceding a sudden
rash that begins on the trunk)
MEASLES :
ill-appearing child who presents with a morbilliform rash with
erythematous macules and papules. Lesions have coalesced on the
face and neck. Erythematous macules and papules begin on the
face and spread cephalocaudally and centrifugally . Measles is a
distinct clinical syndrome with the presence of high fever, Koplik
spots, characteristic conjunctivitis, upper respiratory symptoms,
and typical exanthem
MEASLES

36. Chicken pox
Kawasaki disease

37. Tuberous sclerosis
1.Adenoma sebaceum -red or pink papules over nose,cheeks and chin -1-4 years of age
2. ash leaf shaped(most characteristic)
3.Shagreen patch-leathery plaque with orange peel consistency -over lumbosacral or gluteal region -
develop between 2-5 years of age

38. • The extremities
– Observe the gait
– Limb swelling or tenderness
Limping child
MUSCULOSKELETAL SYSTEM
Toe walking

39. Rickets signs

40. • The spine and costovertebral
angle areas are percussed to
elicit any tenderness; such a
finding may be indicative of
vertebral osteomyelitis or
diskitis and pyelonephritis,
respectively.
• Check for scoliosis
Normal Scoliosis

41. Neurological assessment
• Conscious level
– AVPU scale = Alert/responds to voice/responds to pain/unresponsive
– Glasgow coma scale
• General observations
– Posture, and gait
– Dysmorphic features
• Cranial nerves
• Tone
– Hypotonia suggests LMN lesion
– Spasticity suggests UMN lesion and is seen in cerebral palsy
• Power
– Describe in upper and lower limbs
– Describe whether movement is possible against resistance oragainst gravity
• Coordination
– Finger–nose test and heel–shin test, and observe gait
– Very important if considering CNS tumours as cerebellar signs are common
• Reflexes
– Assess at knee, ankle, biceps, triceps and supinator tendons
– Clonus may be seen in UMN lesions
– Plantar reflex is upwards until 8 months of age, then downwards

42. • After the clinician evaluates the history, forming an idea of
possible diagnoses
• The clinical examination will rule out or confirm a diagnosis.
• if there is still uncertainty of diagnosis, the clinician should use
laboratory testing to increase or decrease the patient specific
probability of disease.
• Finally a decision is made whether or not to treat or to reassure
or to admit to the hospital and or a referral is needed.

43. CASE 1
History
Mohammed is a 3-month-old boy, brought to a paediatric clinic because of
persistent noisy breathing. He was born at term after an uneventful pregnancy
and is the fifth child of non-consanguineous parents. His birth weight was 3.7
kg (75th centile). Since he was a few weeks old, he has had noisy breathing,
which hasn’t affected his feeding, and his parents were repeatedly reassured
that it would get better. He has continued to have intermittent noisy
breathing, especially when agitated, and sometimes during sleep.
Over the last few days, his breathing has been noisier than usual. Otherwise
he has been well without any fevers. All of his siblings have recently had
coughs and colds.
Examination
He is active and smiles responsively. Oxygen saturations are 95 per cent in air
and his temperature is 36.9ºC. He is coryzal and has intermittent stridor. There
is a small ‘strawberry’ haemangioma on his forehead. Respiratory rate is
45/min, there is subcostal recession and mild tracheal tug. Air entry is
symmetrical in the chest, with no crackles or wheeze. Cardiovascular
examination is unremarkable. His weight is 6.7 kg (75th centile).
Questions
• What is the most likely cause of his stridor?
• What other important diagnoses need to be considered?
• How can the diagnosis be confirmed?

44. • Stridor is an inspiratory sound due to narrowing of the upper airway.
• Mohammed is most likely to have stridor due to laryngomalacia.
• This means that the laryngeal cartilage is soft and floppy. The larynx collapses
and narrows during inspiration .
• It is usually a benign condition with noisy breathing but no major problems with
feeding or significant respiratory distress.
• Most cases resolve spontaneously within a year as the larynx grows and the
cartilaginous rings stiffen.
• The reason Mohammed now has respiratory distress is that he has an
intercurrent viral upper respiratory tract infection.
• A very important diagnosis to consider in this boy is a haemangioma in the upper
airway.
• The majority of haemangiomas are single cutaneous lesions, but they can also
occur at other sites and the upper airway is one position where they can enlarge
with potentially life-threatening consequences. The presence of one
haemangioma increases the likelihood of a second one.
• This boy should be referred for assessment by an ENT surgeon.

45. There are many other possible congenital causes of stridor :
• Laryngomalacia
• Laryngeal cyst, haemangioma or web
• Laryngeal stenosis
• Vocal cord paralysis
• Vascular ring
• Gastro-oesophageal reflux
• Hypocalcaemia (laryngeal tetany)
• Subglottic stenosis
• Infectious causes of stridor, such as croup and epiglottitis, are very rare in this age group.
The diagnosis of laryngomalacia can be confirmed by visualization of the larynx using
flexible laryngoscopy. This can be done by an ENT surgeon as an outpatient procedure.
This demonstrates prolapse over the airway of an omega-shaped epiglottis or arytenoid
cartilages. Congenital structural abnormalities may also be seen. Lesions below the vocal
cords may require bronchoscopy, CT or an MRI scan for diagnosis.
KEY POINTS
• The commonest cause of congenital stridor is laryngomalacia.
• Laryngomalacia can be exacerbated by intercurrent respiratory infections.

46. Case 2
History
Ali a 3-year-old boy, is referred to the paediatric day unit by his GP with a history of
fever, cough, blocked runny nose and sticky eyes for 6 days. His GP prescribed
amoxicillin .2 days ago for otitis media, and that evening he started to develop a
rash around his ears and hairline. His parents stopped giving the antibiotics, but
the rash continued to spread over most of his body.
The parents report that he has been very miserable for the last 5 days.
They thought the rash may be an allergic reaction to amoxicillin. He attends
nursery but his parents are not aware of any other children there who have been
unwell. His parents are well, and he has an older brother who has autism.
Examination
Ali has a temperature of 38.5 C, his heart rate is 115 beats/min, respiratory rate
25/min,
and oxygen saturation is 97 per cent in air. He weighs 14.2 kg (50th centile). He has
a widespread maculopapular erythematous rash, which is coalescing over his face,
neck and torso. Heart sounds are normal, capillary refill time is 2 s. There is no
respiratory distress but he is coughing and there are lots of transmitted
upper airway noises heard throughout his chest. His abdomen is normal. His nose
is
streaming with catarrh and he has a purulent discharge from his right ear. His
pharynx is red and he has exudative conjunctivitis.

47. Questions
• What is the most likely diagnosis?
• What essential piece of history has been omitted?
• What complications may arise from this disease ?

48. This is a case of measles. The history is typical, commencing with
a catarrhal prodrome phase of fever, conjunctivitis, cough and
coryza, preceding development of the rash 3–5
days later. During the catarrhal phase, Koplik’s spots may be seen
as small white spots on the buccal mucosa. Although
pathognomonic of measles, they can be very hard to find and
have usually disappeared within 1 day of the rash starting. The
rash is maculopapular and starts around the hairline and behind
the ears, spreading downwards across the body. It often
becomes confluent on the upper body, resulting in a blotchy
appearance.
Usually children with measles are miserable.

49. Differential diagnosis of measles
Clinical distinguishing features
• Kawasaki disease : Not catarrhal
• Rubella: Much milder prodrome, occipital lymphadenopathy
• Epstein–Barr virus: Tonsillitis, lymphadenopathy, not catarrhal
• Roseola infantum: Fever ends as rash appears
• Scarlet fever : Pharyngitis or tonsillitis, not catarrhal

50. • An immunization history is an essential part of any paediatric
history and no details have been provided here. In fact,
Mohamed had not received the combined measles, mumps
and rubella (MMR) vaccine, which is usually given at 12
months of age.

51. Complications of measles
• Pneumonia
• Corneal ulceration
• Suppurative otitis media
• Gastroenteritis
• Febrile convulsions
• Encephalomyelitis (rare) and subacute sclerosing panencephalitis (very rare)
KEY POINTS
• Measles has a typical catarrhal phase before onset of the rash.
• The rash evolves in a characteristic fashion, starting around the hairline and behind
the ears and spreading downwards.
• Measles is a notifiable disease.

52. Case 3
History
• Tariq is a 2-year-old boy who presents to
paediatric outpatients with bow legs and poor
weight gain. He was breast-fed for the first
year. His mother states that he currently has
several bottles of cow’s milk a day and that he
has a poor appetite with a poor intake of
solids. He has no gastrointestinal symptoms.
His mother feels that he is not as active as
other boys his age. There is no history of
fractures. There is no family history of note.
Examination
• His is pale, with a prominent forehead and a
marked bow leg deformity. He has swollen
wrists (see X-ray ) and ankles. There are rosary
beads and Harrison sulcus . His height is on
the 25th centile, and his weight is on the 2nd
centile.

53. Tariq’s wrist X-ray.

54. Laboratories
• Haemoglobin 9.8 g/dL ( 11.5–15.5 g/dL)
• Mean cell volume 64 fL ( 70–86 fL)
• Mean corpuscular haemoglobin 22 pg ( 24–30 pg)
• White cell count 8.7 000/L ( 4.000–11.000 /L)
• Platelets 572 .000/L ( 150 .000–400 .000/L)
• Ferritin 4 ng/mL ( 15–200 ng/mL)
• Haemoglobinopathy screen Normal
• Sodium 137 mmol/L (135–145 mmol/L)
• Potassium 4.1 mmol/L (3.5–5.0 mmol/L)
• Urea 4.7 mmol/L (1.8–6.4 mmol/L)
• Creatinine 60 ìmol/L ( 27–62 ìmol/L)
• Calcium 2.21 mmol/L ( 2.20–2.70 mmol/L)
• Phosphorous 1.30 mmol/L ( 1.25–2.10 mmol/L)
• Alkaline phosphatase (ALP) 1372 U/L ( 145–420 U/L)
• Bilirubin 16 ìmol/L ( 2–26 ìmol/L)
• Alanine aminotransferase (ALT) 32 U/L ( 10–40 U/L)

55. • The history , the accompanying clinical signs, the high ALP, the borderline calcium and the
wrist X-ray all point to nutritional rickets.
• Furthermore, the poor nutritional intake, the pallor and the microcytic hypochromic
anaemia are typical of iron deficiency anaemia.
• Rickets is a disorder characterized by a failure in the mineralization of growing bones. The
nutritional Rickets is due to inadequate sunlight exposure coupled with nutritional
deficiency.
• Diseases that interfere with the metabolic conversion and activation of vitamin D, such as
severe renal and liver disease, can lead to rickets. Illnesses associated with malabsorption,
such as coeliac disease, can also lead to rickets. Other diseases that interfere with calcium
and phosphorus homeostasis can cause rickets, e.g. renal tubular defects, such as
hypophosphataemic rickets, in which there is failure of phosphate absorption, or Fanconi’s
syndrome in which there is a defect in the reabsorption of phosphate, glucose and amino
acids.
• Clinical features include swollen wrists and ankles, frontal bossing, prominent
costochondral junctions (a rickety rosary), bow legs or knock-knees, craniotabes, muscle
weakness, tetany and hypocalcaemic fits.
• The radiograph demonstrates the typical appearance in rickets with widening of the
growth plate and cupping, splaying and fraying of the metaphysis.

56. • Check vitamin D level to confirm the nutritional aetiology of the rickets .
• A ferritin level should be done to confirm the diagnosis of anemia and is likely
to be very low.
• Treatment consists of a 3-month course of high-dose oral vitamin D.
• This should be followed by maintenance doses of vitamin D for the long term.
• The prognosis for complete resolution of the deformities is good. In cases
where the serum calcium is low, calcium is also given initially until levels
normalize.
• There is often an accompanying iron deficiency anaemia, as in this case. Red
meat and green vegetables are good sources of iron and some foods, such as
cereals, are often fortified with iron.
• The anaemia should be treated with a 3-month course of oral iron.

57. • A dietetic referral and screening of the siblings for rickets
and iron deficiency would also be advisable.
KEY POINTS
• Rickets is usually secondary to inadequate exposure to
sunlight and poor nutrition.
• Swollen wrists, a rickety rosary and bow legs are typical
clinical features.
• Treatment is with vitamin D.
• Iron deficiency is very common in young children and can
be successfully treated with dietary advice and oral iron.

58. CLINICAL CASE 4
History
• Nabil is a 3-year-old boy from a
travelling family referred to the
paediatric day unit by the out-of-
hours GP service. He was seen 4
days ago with a cough and fever and
diagnosed with a viral upper
respiratory tract infection (URTI).
The following day he returned and
was commenced on oral antibiotics.
He is now complaining of tummy
ache and has vomited once. He has
not been immunized but there is no
other medical history of note.
Examination
• Nabil is miserable, flushed, toxic and
febrile (38.8C) with a capillary refill
time of 2 s. His pulse is 140
beats/min, his oxygen saturation is 91
per cent in air and his blood pressure
is 85/60 mmHg. He seems to be in
pain, especially when he coughs, and
his respiratory rate is 48 breaths/min
with nasal flaring. There is dullness to
percussion in the right lower zone
posteriorly with decreased breath
sounds and bronchial breathing. He
seems reluctant to have his abdomen
examined but bowel sounds are
normal.

59. INVESTIGATIONS
• Haemoglobin 11.8 g/dL 11.5–15.5 g/dL
• White cell count 25.4 109/L 6–17.5 109/L
• Neutrophils 20.8 109/L 3–5.8 109/L
• Platelets 467 109/L 150–400 109/L
• Sodium 126 mmol/L 138–146 mmol/L
• Potassium 3.5 mmol/L 3.5–5.0 mmol/L
• Urea 2.5 mmol/L 1.8–6.4 mmol/L
• Creatinine 48 ìmol/L 27–62 ìmol/L
• Glucose 4.5 mmol/L 3.3–5.5 mmol/L
• C-reactive protein 387 mg/L 6 mg/L
• Chest X-ray – see Figure

60. Questions
• What are the chest X-ray findings?
• What is the most likely causative organism?
• What complication may have arisen and how
would you confirm it?
• List the steps in management.

61. • The chest X-ray shows loss of the right hemidiaphragm, right lower zone consolidation
and a normal right heart border – the characteristic features of right lower lobe
pneumonia.
• Lower lobe pneumonia should always be on the list of differential diagnoses for
abdominal pain in children.
• The most likely causative organism is Streptococcus pneumoniae.
• Blood cultures may be positive. Children usually are immunized against Streptococcus
pneumoniae but not all strains are covered, there is emerging antibiotic resistance and
also ‘failed’ immunizations. Any immunized child with positive cultures should be
investigated for an underlying immune problem, including an absent spleen.
• Nabil has hyponatraemia. There are no pointers to excess sodium loss (e.g. diarrhoea or
significant vomiting) and hence the most likely cause is the syndrome of inappropriate
antidiur etic hormone secretion (SIADH), a known association with pneumonia.
• The hyponatraemia is dilutional. At the same time, urine should be sent for osmolality
and sodium.
• His serum osmolality is calculated as follows: 2 ([Na] [K]) [urea] [glucose] 266
mosmol/kg (normal 278–305)
• Normally a fall in serum osmolality would suppress antidiuretic hormone secretion to
allow excretion of excess water as dilute urine. In SIADH, urine osmolality is
inappropriately high (320 mosmol/kg) and urine sodium is usually 40 mmol/L (unlike
hypovolaemic states where it is 20 mmol/L).

62. Steps in management
• Oxygen to maintain saturation at 94 %
• Paracetamol for pain and fever
• Intravenous antibiotics according to local guidelines, e.g. co-amoxiclav
• Initial fluid restriction to two-thirds maintenance to help correct the hyponatraemia.
• Fluid balance, regular urea and electrolytes – adjust fluids accordingly.
• Weigh twice daily
• Physiotherapy, e.g. bubble blowing. Encourage mobility
• Monitor for development of a pleural effusion. an ultrasound will be diagnostic. If present, a
longer course of antibiotics is recommended to prevent empyema
• A chest drain may be necessary if there is worsening respiratory distress, mediastinal shift on the
chest X-ray, a large effusion or failure to respond to adequate antibiotics
• Ensure adequate nutrition – children have often been anorectic for several days.
• Low threshold for supplementary feeds probably via nasogastric tube
• Organise immunization programme before discharge
• Arrange a follow-up chest X-ray in 6–8 weeks for those with lobar collapse and/ or an effusion. If
still abnormal, consider an inhaled foreign body

63. KEY POINTS
• A lower lobe pneumonia should always be
considered in the differential diagnosis of an acute
abdomen in children.
• Vaccine failures’ should be investigated for an
underlying immune problem.