Home » Theme : CASE HISTORY OF ILL CHILD

Theme : CASE HISTORY OF ILL CHILD

June 16, 2024

Theme : CASE HISTORY OF ILL CHILD

PATIENT’S CURATION AND WRITING OF THE CASE HISTORY

History taking

Communication skills

1. Communication with the patient and/or family:

• Establish rapport with the patient and family.

• Identify the primary concerns of the patient and/or family.

• Recognize the triangular relationship between the physician, patient and parent and be able to communicate information to both the patient and parent, making sure both understand the diagnosis and treatment plan and have the opportunity to ask questions; be aware that the relationship changes with increasing age of the child.

• Provide anticipatory guidance during health maintenance visits, including the newborursery visit.

• Recognize the important role of the patient’s education in management of acute and chronic illnesses.

2. Written communication skills:

• Write a complete summary of the history and physical examination in a timely manner which is suitable to place in the patient’s chart.

• Outline the different formats for documenting the history and physical examination which may be used in different clinical settings.

• Write admission orders for a hospitalized patient.

• Write a prescription.

3. Oral communication skills:

• Present a complete, well organized summary of the findings of the patient’s history and physical examination, modifying the presentation to fit the situation.

• Communicate effectively with other health care workers, including consultants, nurses and social workers.

• Explain the thought process that led to the diagnostic and therapeutic plan.

• Use precise descriptions of physical findings and avoid vague terms and jargon, such as “clear” and “ARD”.

Interviewing

1. Patient interviews occur in a variety of clinical settings, including initial history for a hospital admission or first ambulatory visit, health maintenance visit, acute care visit, interim visit for a child with an acute or chronic health condition. The doctor should develop an awareness that in conducting a medical interview in a variety of settings, it is sometimes appropriate to obtain a complete medical history, while at other times a more limited, focused or interval history is appropriate. Initially, the emphasis should be on obtaining complete medical histories. Opportunities to do more focused work-ups should be available as the doctor builds competence.

2. Obtain a medical history from thesecond party (usually the parent), as well as from the patient, noting the increased reliability of obtaining information directly from the patient as the patient matures. The doctor must be aware of issues of appropriate privacy at all ages and confidentiality in older children and adolescents.

3. Obtain a relevant history that is unique to paediatrics in addition to the standard medical history.

Chief complaint

The chief complaint represents the specific reason for the child’s visit to the clinic, office, or hospital. The chief complaint may be viewed as the theme, with the present illness as the setting of this problem. Six guidelines determine appropriate recording of the chief complaint: (1) it consists of a brief statement, (2) it is restricted to one or two symptoms, (3) it refers to a concrete complaint, (4) it is recorded in the child’s or parent’s own words, (5) it avoids the use of diagnostic terms or translations, and (6) it states the duration of the symptoms.

The doctor elicits the chief complaint by asking open-ended neutral questions such as, “Tell me what seems to be the matter?”, “How may I help you?” or “What brings you here?”. Labeling-type questions such as, “How are you sick?” should be avoided, since it is possible that the reason for the visit is not because of illness. For example, the visit may be for a routine health assessment, or the chief complaint may be of a nonphysical nature.

Examples of properly recorded chief complaints for a variety of situations may be: (1) ambulatory clinic – “My child has had a runny nose and sore throat for 4 days, but today it is worse”, (2) hospital admission – “I need to have my tonsils fixed”, sore throat and repeated earaches for 5 years, and (3) health center – “We are here for a routine checkup”, last visit 1 year ago.

If the visit is for a well-child examination, one can ask, “Before we begin, is there anything of particular concern that you would like to discuss?”. This type of statement encourages the parent (or child) to bring up an issue that may not surface during routine interviewing.

Occasionally it is difficult to isolate one symptom or problem as the chief complaint because the parent may identify many. In this situation it is important to be as specific as possible when asking questions. For example, asking informants to state which one problem or symptom caused them to seek help now may help them to focus on the most immediate concern.

Present illness

The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Its four major components are (1) details of onset, (2) complete interval history, (3) present status, and (4) reason for seeking help now. The focus of the present illness is on all those factors that are relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present.

Analyzing a symptom. Since pain is often the most characteristic symptom denoting onset of a physical problem, it is used as a prototype for analysis of a symptom. The nurse should assess pain for (1) type, (2) location, (3) severity, (4) duration, and (5) influencing factors. The type or character of pain should be as specific as possible. However, with young children, it is almost always impossible for them to describe the pain. Asking the parents how they know the child is in pain may help to describe its type, location, and severity. For example, a mother stated, “My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help”.

The doctor can help older children to describe the pain by asking them if it is sharp, throbbing, dull, aching, stabbing, and so on. Whatever words they use should be recorded in quotes.

The location of the pain also must be specific. “Stomach pains” is too general description. Older children can better localize the pain if the doctor asks them to “point with one finger to where it hurts”. The doctor can also determine if the pain radiates by asking, “Does the pain stay there or move? Show me where it goes with your finger“.

The severity of pain is best determined by finding out how it affects the child’s usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. It is preferable to record pain in terms of interference with activity, rather than to quote the parent’s or child’s adjectives.

Duration of pain should include the duration, onset, and frequency of attacks. It may be necessary to describe this in terms of activity and behavior, such as “pain lasted all night because child refused to sleep and cried intermittently”.

Influencing factors are anything that causes a change in the type, location, severity, or duration of the pain. These include (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down, and so on), and (5) associated events (meals, stress, coughing, and so on).

A standard method of analyzing a symptom is listed in the following outline. These three categories – onset, characteristics, and course since onset – comprise the essential data for the present illness. Although the analysis of a symptom has concentrated on discussion of physical complaints, the same process of description and investigation can be used for emotional or psychosocial problems.

Analysis of a symptom

I. Onset

a) Date of onset,

b) Manner of onset (gradual or sudden),

c) Precipitating and predisposing factors related to onset (emotional disturbance, physical exertion, fatigue, bodily function, pregnancy, environment, injury, infection, toxins and allergens, therapeutic agents, and so on).

II. Characteristics

a) Character (quality, quantity, consistency, or others),

b) Location and radiation (of pain),

c) Intensity or severity,

d) Timing (continuous or intermittent, duration of each, temporal relationship to other events),

e) Aggravating and relieving factors,

f) Associated symptoms.

III. Course since onset

a) Incidence

• Single acute attack.

• Recurrent acute attacks.

• Daily occurrences.

• Periodic occurrences.

• Continuous chronic episode.

b) Progress (better, worse, unchanged),

c) Effect of therapy.

I. Past History:

• Neonatal history, including birth weight; approximate gestational age; maternal complications, such as extent of prenatal care, infections, exposure to drugs, alcohol or medications; and problems in the newborn period, such as prematurity, respiratory distress, jaundice and infections.

• Immunizations

• Development, noting the importance of assessing developmental milestones in evaluating the health of the child.

• Diet, noting the importance of assessing the amount, type, and method of infant feeding.

II. Family History: number and ages of siblings; consanguinity, known genetic disorders, early childhood deaths, cardiovascular disease, depression and alcohol abuse.

III. Social History: assessment of the home environment, school and peer relationships.

IV. Review of Systems: the relevant items are limited, but expand as the patient’s age increases.

Modify the medical history depending on the age of the child, with particular attention given to the following age groups: neonate, infant, toddler/preschool aged child, school aged child, adolescence.

The Physical Examination

I. Establish rapport with children of various ages in order to perform the physical examination.

II. Recognize that the age of the child influences the areas included in the exam, as well as the order of the examination, and the approach to the patient.

III. Recognize the important role of observation as a method of obtaining data in the assessment of the child.

IV. Perform complete physical examinations on an infant, child and adolescent, including the observation and documentation of normal physical findings.

V. Demonstrate the appropriate use of the limited or focused examination, particularly in the ambulatory setting.

VI. Use developmental assessment as part of the physical examination for all ages.

• Observe how normal behaviours, such as stranger anxiety, affect the ability of the examiner to perform the examination, and develop strategies for improving rapport.

• Perform the Denver Developmental Screening Test, and know how it is used to assess motor, language and social development.

• Identify the physical changes of puberty and be able to conduct Tanner staging.

VII. Observe and demonstrate physical exam findings unique to the pediatric age group, and understand how findings have different clinical significance depending on the age of the child. Some examples are:

• Appearance

1. Recognize signs of acute illness in an infant, toddler and child by evaluating skin colour, respiration, hydration, mental status, cry and social interaction.

2. Recognize the importance of observing the psychosocial condition of the child, including behaviour, development, body habits (height, weight, body fat), relationship to parent and examiner, and general condition.

• Vital signs

1. Measure heart rate, respiratory rate, blood pressure and temperature in an infant and child, demonstrating knowledge of the appropriate sized blood pressure cuff, interval to count respirations, and normal variation in temperature depending on the route of measurement (oral, rectal, axillary or tympanic).

2. Understand that normal values of the heart rate, the respiratory rate and the blood pressure change with age.

3. Recognize the importance of assessing vital signs in the evaluation of acute illness.

• Measurements

1. Accurately measure height, weight and head circumference.

2. Plot the data on an appropriate growth chart.

3. Understand the normal relationships between height, weight and head circumference.

4. Recognize the usefulness of longitudinal data.

• Head

1. Identify the anterior and posterior fontanels and assess them.

2. Recognize the need for careful observation of the head size and shape, symmetry, facial features, ear size and hair whorls as a part of the examination for dysmorphic features.

3. Recognize the red reflex and strabismus.

4. Assess hydration of the mucous membranes.

5. Examine the tympanic membranes using pneumatic otoscopy.

• Neck

1. Palpate the lymph nodes, know what anatomic areas they drain;

2. Know that the lymph nodes are more prominent during childhood

3. Recognize and demonstrate maneuvers that test for nuchal rigidity.

• Chest

1. Remember how the rate and pattern of respirations change with age, and that abdominal respirations are normal in infants.

2. Observe the rate and effort of breathing as a measure of respiratory distress.

3. Recognize stridor, wheezing and rales and be able to distinguish between the inspiratory and expiratory obstruction.

4. Interpret less serious respiratory sounds such as transmitted upper airway sounds.

• Cardiovascular

1. Palpate pulses in the upper and lower extremities and auscultate the heart for rhythm, rate, quality of the heart sounds and murmurs.

• Abdomen

1. Understand that the liver edge, spleen tip and kidneys may be palpable in the normal newborn.

2. Examine the umbilical cord for signs of infection.

3. Examine the abdomen for distention, tenderness, rebound and mass lesions in an infant or young child with lethargy, irritability or signs of acute illness, noting the inability of the patient to communicate symptoms of abdominal complaints.

4. Be able to do a rectal examination and recognize when it is indicated.

• Genitalia

1. Recognize the appearance of normal male and female genitalia in the newborn.

2. Recognize abnormalities, including cryptorchidism, hypospadias, testicular mass in the male.

3. Be able to examine the external genitalia of a female patient.

4. Recognize the need for privacy at all ages.

• Extremities

1. Examine the hips of a newborn for dysplasia.

2. Recognize arthritis.

3. Evaluate gait and limp.

• Back

1. Know how to test for scoliosis.

• Neurologic examination

1. Elicit primitive reflexes.

2. Assess tone, gait, strength and reflexes, recognizing the importance of symmetry.

3. Assess developmental milestones; recognize that much of the neurologic examination of infants and children is accomplished through observation alone.

• Skin

1. Recognize jaundice, petechiae, purpura, common birth marks (such as nevus flammeus and Mongolian spots), vesicles, urticaria and common rashes, such as erythema toxicum, impetigo, eczema, diaper dermatitis and viral exanthems.

2. Recognize common skin findings associated with child abuse.

3. Assess skin turgor.

Inspection

The method of observation is used during physical examinations. Inspection, or “looking at the patient,” is the first step in examining a patient or a body part.

Palpation

The method of “feeling” with the hands is used during physical examinations. The examiner touches and feels the patient’s body part with his hands to examine the size, consistency, texture, location, and tenderness of an organ or body part.

Auscultation

This method used to “listen” to the sounds of the body during a physical examination can be performed by listening with the ear but is usually done by listening through a stethoscope. Health care providers routinely auscultate a patient’s lungs, heart, and intestines to evaluate the frequency, intensity, duration, number, and quality of sounds. Health care providers also use auscultation to listen to the heart sounds of unborn infants.

Percussion

A method of “tapping” of the body parts during Ошибка! Недопустимый объект гиперссылки.with fingers, hands, or small instruments to evaluate the size, consistency, borders and presence or absence of fluid in body organs. Percussion of a body part produces a sound (like playing a drum) that indicates the type of tissue within the organ. Lungs “sound” hollow on percussion because they are filled with air. Bones and joints “sound” solid. The abdomen “sounds” like a hollow organ filled with air, fluid, or solids.

I. Y. GORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITY

DEPARTMENT of PEDIATRICS №2

The head of the department

Doctor of Medicine,

Professor G.A.Pavlyshyn

Manager of the group

____________________

MEDICAL CARD

__________________________________________________________________

name, surname of the patient

_______________ age of the patient

Clinical diagnosis: basic diagnosis ______________________________________

__________________________________________

Complication __________________________________________

__________________________________________

Concomitant disease __________________________________________

__________________________________________

Mark for the writing

of the case history ______________ Curator ____________________________

The group __________, the course ______

Mark for the defense

of the case history ______________

TERNOPIL

2012

GENERAL INFORMATION ABOUT PATIENT

Name ________________________________

Surname _______________________________________________________________

Date of birth ____________________________, age ___________________________

Home address __________________________________________________________

Preschool or school institution _____________________________________________

Date of admission to the hospital ___________________________________________

Institution which has directed patient to the hospital ____________________________

Pre-admission diagnosis ___________________________________________________________________

___________________________________________________________________

Patient’s department _____________________________________________________

I. COMPLAINTS

Main: ________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

Additional: ____________________________________________________________

_________________________________________________________________________________

_____________________________________________________________________

II. ANAMNESIS OF THE DISEASE

The onset of disease acute, subacute, gradually (the necessary underline). The duration of the diseases is ______________. What preceded the disease (cooling, defects of nutrition, viruses infection, the contact with ill person, etc) _____________________

_________________________________________________________________________________

_____________________________________________________________________

The development of disease _______________________________________________

____________________________________________________________________

_____________________________________________________________________

The result of previous additional methods of investigation (if they were presence) ____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

The previous treatment (if it was presence): ____________________________________________________________________

_________________________________________________________________________________________________________________________________________

The effect of previous treatment _____________________________________________________________________

_____________________________________________________________________

The reason of hospitalization _____________________________________________________________________

_____________________________________________________________________

III. ANAMNESIS VITAE

For children till 3 years

The child from ____ (behind the account) pregnancy, _____ delivery. Age of the mother during the given pregnancy. The pregnancy proceeded (with, without) gestosis in ___ trimester, on a background (without) of the extragenital pathology _____________________________________________________________________

________________________, or inflectional diseases _________________________

___________________________________ or somatic illness ___________________

________________________________________________ in _______ trimester.

The mother used such medicines (to specify the trimester) ________________________________________________________________________________

_____________________________________________________________________

Harmful habits at the mother: ____________________________________________,

at the father __________________________________________________________.

Conditions of work of the mother during pregnancy ____________________________

Conditions of life of the mother during pregnancy ______________________________

Delivery at timed or premature (the necessary underline), in ___ weeks of gestation. Labor via vaginal way or by cesarean section, with (without) medicamental stimulation _______________________ (the necessary underline). The child was mature or immature, according Apgar’s score _____ points at first min. and ____ points at 5th min. Birth weight was ______ g, length of the body was ___ сm, head circumference was ___ сm, chest circumference was ___ cm. The umbilical stump (residual cord) has fallen off in ___ days. After the stump has fallen off, the state of cord base was dry, or was weeping during __________ weeks.

The child discharged from maternity department on ____ day (when it was more than 5-6 days, specify the cause of delay) __________________________________________.

During the firs year the child was at ___________________ feeding. The reason of artificial feeding was ____________________________________________________. Mother used to such ______________________________________________________

formulas. The term of introduction of fruit juice __________, fruit puree ______, egg yolk __________, cottage cheese ___________, meat ____________. The first addition food was __________________ at _______ mo. The second addition food was _______ ____________ at _____ mo. The third addition food was _____________ at _____ mo.

The dynamics of body weight ______________________________________________ _____________________________________________________________________. Dynamics of body length _________________________________________________

_____________________________________________________________________. Dynamics of head circumference __________________________________________. Dynamics of chest circumference ___________________________________________. The psychomotor development of the child ___________________________________

__________________________________________________________________________________________________________________________________________

For all children irrespective of age

The child had such diseases (before admission) ________________________________

_____________________________________________________________________

Housing conditions of the child is satisfactory or not satisfactory (the necessary underline and explain why) __________________________________________________________.

Character of nutrition before present disease (character of meal, schedule of feeding) __________________________________________________________________________________________________________________________________________.

Allergological history

Presence of allergy symptoms _____________________________________________. The intolerance of products _____________________________________________, that accompanied with ___________________________________________________, The intolerance of medicament (drug) _______________________________________

that accompanied with ___________________________________________________.

Prophylactic vaccinations _________________________________________________.

_____________________________________________________________________

The nearest relatives have such chronic somatic illnesses ________________________

__________________________________________________________________________________________________________________________________________, genetical illnesses ______________________________________________________,

allergic reactions _______________________________________________________.

Epidemiological history

The child didn’t contact with patients who suffered with inflectional diseases last 3 weeks. The symptoms of diarrhea were _______________ during last three days.

Objective examination of the child

The patient’s general condition is extremely grave, grave, moderately grave, satisfactory, good (the necessary underline).

The state of consciousness is clear, sopor, stupor, coma (the necessary underline).

The mental state is (not) adequate or not adequate (the necessary underline).

Position of the child in bed is active, passive, forced (attitude) (the necessary underline).

The patient is asthenic, hyposthenic, hypersthenic constitution (the necessary underline). The child is of regular, irregular body build (the necessary underline) _________________

_____________________________________________________________________

Anthropometrical measurements

Criterion In patient Norm

according empiri-cal formulas Deviation, cm Deviation, %

Weight, kg

Height (stature), cm

Head

circumference, cm

Chest circumference, cm

The index of fatness by Chulitska

–

The index by Erismann –

Evaluating of physical development according percentile tabl s

Criterion percentile Conclusion

Weight, kg

Height (stature), cm

Head circumference, cm

Chest circumference, cm

Summary: _____________________________________________________________

The Skin and mucous membranes

Colour of a skin ________________________________________________________

_____________________________________________________________________,

lip-nose triangle ___________________________________, cyanoses _____________

_____________________________________________________________________.

Rashes (colour, characteristic lesions, localization, size, presence of warmth, itching, type of distribution) _____________________________________________________________

_____________________________________________________________________

Surface of a skin is (smooth, velvety, rough, dry, moist)__________________________________. The elasticity of the skin is ________________________________________________.

Temperature of a skin ___________________________________________________.

The dermographism is ___________________________________________________

Sensitivity of the skin: temperature ___________, pain ______________, tactile _____. Nails: (shape, colour, thickness, quality) _____________________________________, _____________________________________________________________________.

Hair: (color texture, quality, distribution, and elasticity) _________________________

_____________________________________________________________________

Mucous membranes of a mouth (colour, moisture, presents of lesions) ______________

_____________________________________________________________________

Gums: (colour, presents of lesions, ability to bleeding) __________________________

___________________________. Conjunctiva and sclera of eyes _________________

_____________________________________________________________________. The subcutaneous fat is distributed _________________________________________. The skinfold thickness is _____ cm on abdomen, _____ cm under the scapula, _____ cm on the shoulder, _____ cm on thigh. The oedema ___________________________

_____________________________________________________________________. The skin turgor is kept, decreased, flabby (the necessary underline).

Lymphatic system

Such groups of lymph nodes are palpable (describe each group according their localization, quantity, size, shape, mobility, consistency (elastic or dense), temperature, tenderness and visible change of enlarged nodes) __________________________________________________

The tonsils. The stage of enlargement of the tonsils ____________________________ they are reddened, loose, and tender on palpation (the necessary underline). Presence of haemorrhages _______ , pus in the crypts _________, erosions ___________________ ulcers __________________, the tonsils are covered with a ___________ (colour) film in size ____ cm.

Muscular system

The development of muscles is satisfactory, well-developed; symmetric, asymmetric (the necessary underline), presence of atrophy on _______________________________. Muscular tone is _______________, hypotonia of _____________________________, atony of ______________________________________________________________, hypertonia _____________________________________________________________, presence of muscular dystonia _____________________________________________. The range of motions is ___________________________________________________

_____________________________________________________________________ The strength of muscles ____________________________________________. Presence of pain during palpation of the muscles ______________________________. Presence of infiltrations or consolidation of ___________________________________ groups muscles. Trousseau’s sign is _____________, Chvostek’s symptom _________, Lust’s symptom _____________.

Bone system

Head circumference is _______ сm, (normal, microcephalia, macrocepalia (the necessary underline)). The head is dolichocephalic, brachycephalic, mesocephalic (the necessary underline). form (shape). There is hyperplasia of ________________________________ skull’s bones, occipital bones is _____ flat. Anterior fontanel (presence, size, shape, mould of the skull bones and attitude against the skull bony edges (does it taut or depressed) and pulsation) _________________________________________________

_____________________________________________________________________

Posterior fontanel (fused, size, shape) _______________________________________.

Lateral fontanels ______________________. Sutures __________________________.

The tooth formula:

p- permanent * – caries

d – deciduous O – growth disorder

Chest is conical, cylindrical, asthenic, normosthenic, hypersthnic, symmetrical, asymmetrical, barrel, funnel, keeled, phthinoid, rachitic breast (the necessary underline). Beading of the ribs _________. An epigastric angle ______ degrees. Chest circumference is _______ cm (normal, abnormal).

Spine (physiological curvatures, scoliosis and kyphosis) _________________________

_____________________________________________________________________

The extremities are ___ symmetrical, ____ deformed with deformation _____________

_____________________________________________________________________,

anomalies of development ________________________________________________,

_____________________________________________________________________

The feet are ____ normal with deformations __________________________________

_____________________________________________________________________

Others bone are ________________________________________________________

_____________________________________________________________________

The joints (shape, size, temperature, the range of motion, tenderness, swelling, the change of the skin over them) ______________________________________________

_____________________________________________________________________

Gluteal folds are ___symmetrical, _____________________________________ Angle of hip abduction is _____ degrees.

Cardiovascular system

Inspection: During inspection of the chest bulging ________ noted on left side, visible pulsation ______ seen, in _______ intercostals space ____________ line, epigastric pulsation _____ visible. Distended and pulsated neck veins ______ visible during inspection of the neck. Cyanosis ____________________________________________

_____________________________________________________________________, edema _______________________________________________________________, _____________________________________________________________________

Palpation: The apical or cardiac trust (beat) (the necessary underline). is located in ______ intercostals space ______________ line, area _____ сm2, is positive or negative (the necessary underline). Systolic or diastolic vibratory thrills (the necessary underline) _________ palpable at __________________. Pericardial friction rubs _________________________.

Pulse (rate) is _________ beats per minute; is rhythmic, arrhythmic; is synchronic asynchronic; is full, swift, galloping, large, small, soft, tense, thready; pulse deficit (the necessary underline).

Blood pressure of upper extremities _____ mm Hg, of lower extremities _____ mm Hg.

Border’s of hearts relative dullness

Border In patient Norma

Right

Upper

Left

transversal size

Border’s of hearts absolute dullness

Border In patient Norma

Right

Upper

Left

transversal size

Auscultation: the heart sounds strong, weakened, muffled, rhythmical, arrhythmic (the necessary underline), ________ beats per min. S1 is heard loudest at the _______ of the heart, S2 is heard loudest at the _______ of the heart. Presence of accent ____________

_____________________________. Presence of organic, functional, systolic, diastolic, holosystolic, (the necessary underline) murmurs, place of the best auscultation __________

_____________________________________________________________________

duration ________________________________, intensity ________________, timbre __________________, conductance _________________________________________ evaluation of its intensity in relationship to the child’s position ___________________ _____________________________________________________________________.

Extracardiac murmurs ___________________ (pericardial friction rubs, pleurocardiac), localization ____________________________. During auscultations of carotic, subclavicular, femoral arteries, abdominal aorta, jugular veins are heard ______sounds, ___________________ murmurs.

Respiratory system

Cyanosis of nasolabial triangle, perioral region, nails plates, acrocyanosis __________ in rest or during physical exercises (the necessary underline). Nasal breathing is fee, difficult, absent (the necessary underline). Voice is normal, hoarse, soundless, snuffling, silent, aphonic (the necessary underline). Cough __________ present, dry, moist, troublesome, brassy paroxismal cough, pertussis-like, barking cough, constant, cough of mucus, cough of pus, blood spitting (the necessary underline), frequent in _________ time of day. Dyspnea, asphyxia ____________________ occurs in rest, during physical exercises (the necessary underline). Chest has cylindrical, conical, asthenic, normosthenic, hypersthnic, symmetrical, asymmetrical ______________________________, barrel, funnel, keeled, phthinoid, rachitic breast. The intercostal spaces are _______________,

Harrison’s groove ______________. Movements of etch parts of the chest are symmetrical, asymmetrical (the necessary underline) _____________________________________________________________________

Marked retraction of intercostal, suprasternal supraclavicular (the necessary underline) muscles ___________ noted. Type of breathing is thoracic, abdominal, combined (the necessary underline). Dyspnea is absent, inspiratory, expiratory, mixed (the necessary underline). The respiration rate is _____ per minute (normal, tachypnea, bradypnea). The breathing is regular, irregular, deep, hard (difficult), paradoxical, periodic, shallow, interrupted, whistling, stridulous, stenotic, Kussmaul’s breathing, Cheyne-Stokes respirations, Biot’s breathing (the necessary underline).

Palpation: Pain is __________ in maxillary and frontal sinuses. Pain in chest ________ during palpations. Vocal fremitus is normal, decreased, increased, absent ___________

_____________________________________________________________________

Pleural friction rubs, crepitation ____________________________________________.

In comparative percussing of the chest is heard ________________________________

_____________________________________________________________________

The lower costal margin of the lungs according to topographic percussing

Line right left

midclavicular

midaxillary

vertebral

The excursion of the low margin of the lung (at midaxillary line) is ___ cm on left, ___ cm on right. The location of the apex of the lung _______________________________

_____________________________________________________________________

The width of Crenig’s areas _______________________________________________

Auscultation of the lungs: the breathing is ___________________________________

_____________________________________________________________________

presence of rales, rhonchi and crepitations ____________________________________

_____________________________________________________________________

Bronchophony is ______________________________________________________.

Digestive system

Inspection: The colour of mucous membranes of oral cavity is ____________, dry or moist (the necessary underline), incrustation (coating) _____________, fissure and aphtha _____________________________, colour of the tongue is _______________, coated with _______________ fur, state of papillas of tongue _______________________, dry, moist, atrophic, smooth, enlarged, normal size (the necessary underline). Colour of tonsils is ____________, coating ______________________, moisture _________ fissure and aphtha ______________. The odour from oral cavity __________________

In vertical position the abdomen has normal shape, distended, scaphoid, pendulous symmetrical or asymmetrical (the necessary underline) enlarged because of _________________________, abdominal circumference _____ cm, moves or doesn’t move with breathing, visible peristalsis ___________________, the umbilicus is centrally located, is flatten, inverted, everted, displased upwards (the necessary underline). In horizontal position the abdomen has ___________ shape, moves or doesn’t move with breathing, abdominal circumference _____ cm, the umbilicus is centrally located, is flatten, inverted, everted, displased upwards (the necessary underline). Distended veins of the anterior abdominal wall ______________, “caput Medusae” _________________.

In superficial palpation there is soft, mild, moderate, demonstrable, board-like muscular tension of anterior abdominal wall (the necessary underline). Hyperesthesias ___________, the divergence of straight muscles _____ present, the tumour _______ present in region _____________________________. Blumberg’ sign is positive or negative; painless, extreme tendernees in McBurney’s point (the necessary underline).

Deep palpation according to Obraztsov-Strazhesko

Sigmoid colon is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Caecum is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Colon transversum is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Colon ascendens: is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Colon descendens is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Mendel’s symptom is positive or negative (the necessary underline).

The liver ______ palpable, ______ tender, is extended ____ cm below the costal margin, shape of edge is sharp, rounded, smooth, elastic, firm (the necessary underline). Ortner’s symptom is _________, Ker’s symptom is _________, Murphy’s symptom is _________, Mussi-Georgievsky’s symptom is _________. The spleen ______ palpable, ______ tender, is extended ____ cm below the costal margin, shape of edge is sharp, rounded, smooth, elastic, firm (the necessary underline).

Meyo-Robson’s symptom is _________. The pancreas _____ palpable, ____________

consistency, ______ tender, smooth, elastic, firm (the necessary underline).

In auscultation intestinal peristalsis is absent, sluggish, increased, not impaired, (the necessary underline).

Stool is _____ time per day, formed, liquid, semi-liquid, regular, irregular (the necessary underline), _________ colour, with or without an admixing _______________________.

Urinary system

Inspection: _________ oedema on legs ___________, face, sacral part, on the lower part of abdomen. The colour of lumbar region is ________. The odour of urine is _____

Examination of sacral area, lower abdominal part (changing of the color of the skin ___________________, protrude ______________________, edema______________, asymmetry_______________________).

Examination of the external sex organs: stage of development ____________________. Presence of excretion from urinal channel _____________________.

In boys: asymmetric, symmetric development of the scrotum (the necessary underline). Tests _________ present in the scrotum; presence of inflammation of penis, _________ anomalies of penis development, phimosis, paraphimosis (the necessary underline).

In girls: colour of mucous membranes of external sex organs is __________________, presence an excretions from vagina _________________________________________.

Kidneys ______ palpable in vertical or horizontal position, _______________shape, _________________ consistency, _______ movable, ______ tender, smooth, firm (the necessary underline). Pasternatsky’s symptom is _____ on right , ________ on left side.

Urinary frequency _____ per day, Daily urine flow _________ ml, proportion between day and night diuresis ____________. Presence of uncontrolled urinations _________.

Endocrine system

Examination: face expression __________________, presence of the eyes symptoms ____________________________________________________________________, changes of anterior cervical surface __________________. The level of development subcutaneous fat is ____________________________________________________. Thyroid gland _____ palpable, of _______ stage, ___________surface, ___________ consistence, ____________ pain.

Sex development (according formulas F, L, Ax, P, V for boys and for girls – Ma, Ax, P, Me) __________________________________________________________________

Summary ______________________________________________________________

_____________________________________________________________________

Nervous system

The consciousness is kept, stupor, sopor, is absent (the necessary underline). The mental development ______ corresponds to the age of child. Reaction on environmental is does not adequate (the necessary underline). Dream is isn’t quiet (the necessary underline).

Expression of the face is ___________________. There are some minor abnormalities

_____________________________________________________________________

_____________________________________________________________________. Nystagmus is ___________ horizontal, vertical. Pupils are (un)equal in size; presence of mydriasis, miosis (the necessary underline). The light reflex is retained (absent). The coordination of movement _______ kept.

The pain sensitivity is kept, (is absent, hyperesthesia, hypoesthesia) (the necessary underline). Tactile sensitivity is kept (is absent, pathologic) (the necessary underline). Thermoesthesia is kept (is absent, pathologic) (the necessary underline). Vibration sensation is kept (is absent, pathologic) (the necessary underline).

Newborn reflexes (the necessary underline): Sucking – is normal, hypoactive, hyperactive; Rooting – is normal, hypoactive, hyperactive; Defence – is normal, hypoactive, hyperactive; Lip or trunk reflex – is normal, hypoactive, hyperactive; Grasp – is normal, hypoactive, hyperactive; Babinski’s – is normal, hypoactive, hyperactive; Moro – is normal, hypoactive, hyperactive; Supporting – is normal, hypoactive, hyperactive; Dance or step – is normal, hypoactive, hyperactive; Perez – is normal, hypoactive, hyperactive; Crawling – is normal, hypoactive, hyperactive; Bauer’s – is normal, hypoactive, hyperactive; Galant – is normal, hypoactive, hyperactive. Upper Brudzinski’s reflex – is normal, hypoactive, hyperactive; middle Brudzinski’s reflex – is normal, hypoactive, hyperactive; low Brudzinski’s reflex – is normal, hypoactive, hyperactive. Tendon reflexes brisk, (equally marked on both sides, more hyperactive on the ______ than on ______ side, equally diminished, increased) (the necessary underline). Karniga’s sing positive, negative (the necessary underline). The paralyses (palsy) _____________________________________________________________________

The hyperkinesias _____________________________________________________

The dermographism is red, white, stria with ____ см in wide, appears in ____ second, disappears in ____ second, arises over surface of a skin (the necessary underline).

The pilomotor reflex – pulse is increasing (is decreaseing) for ____ minutes (the necessary underline). Reflex by Danini-Ashner – pulse is increasing (is decreaseing) for ____ minutes (the necessary underline). The orthostatic reflex – – pulse is increasing (is decreaseing) for ____ minutes (the necessary underline), blood pressure decreased for systolic _____ mm Hg, diastolic _______ mm Hg.

Psycho-motor development of the child

Gross motor development _________________________________________________

__________________________________________________________________________________________________________________________________________

Fine motor development __________________________________________________

_____________________________________________________________________

Sensory development _____________________________________________________

_____________________________________________________________________

Vocalization development _________________________________________________

_____________________________________________________________________

Socialization development _________________________________________________

_____________________________________________________________________

Summery: ______________________________________________________________

Substantiation of the provisional diagnosis

On the establishment of the patient’s complaints _______________________________

Anamnesis vitae _______________________________________________

_____________________________________________________________________

Data of objective examinations ___________________________________________

It possible to make provisional diagnosis : ____________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ The plan of examination of the patient

1) ___________________________________________________________________

2) ___________________________________________________________________

3) ___________________________________________________________________

4) ___________________________________________________________________

5) ___________________________________________________________________

6) ___________________________________________________________________

7) ___________________________________________________________________

8) ___________________________________________________________________

9) ___________________________________________________________________

10) __________________________________________________________________

11) __________________________________________________________________

12) __________________________________________________________________

Results of additional methods of examination

Rooting blood analysis

date Нb Eryth.

х1012 CI Leuc

х109 eos bas juv. band seg. lym mon ESR Blood clotting time

Bleeding time

The general examination of urine

date Amount Spesific gravity pH Proteinuria Glucosuria ketonuria Epithelium

Leucocytes Erythrocytes

Casts

Cristals:

Mucous

Urinal examination according to Nechepurenco _______________________________

Biochemical analysis of blood

date protein glucose bilirubin creatinine urea ALT AST Amylase

total total conjugated

Urinal examination according to Zymnitzky

Portion 1 2 3 4 5 6 7 8

Quantities

of urine

specific gravity

Stool test ______________________________________________________________

_____________________________________________________________________

Analysis of feces on worm ova _____________________________________________

_____________________________________________________________________

Test on enterobiosis ______________________________________________________

_____________________________________________________________________

Others methods of examination __________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ECG: _________________________________________________________________ __________________________________________________________________________________________________________________________________________

USD __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Endoscopies examination of ______________________________________________

X-ray examination ______________________________________________________

Differential the diagnosis

Clinical diagnosis

On the establishment of the patient’s complaints _____________________________

Anamnesis vitae __________________________________________________

_____________________________________________________________________

Data of objective examinations ____________________________________________

Data of additional methods of examination ___________________________________

It possible to make clinical diagnosis:

basic diagnosis __________________________________________

__________________________________________

Complication __________________________________________

__________________________________________

Concomitant disease __________________________________________

__________________________________________

The temperature list

data

Stool

Weight

diuresis

Treatment of the patient

Regimen ____________________________________________________________ ______________________________________________________________________

Diet № ___ _______________________________________________________ ____________________________________________________________________________________________________________________________________________

The menu for infant:

Medicamental treatment:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physiotherapeutic measures:

Epicrisis

The patient ____________________________________________________________

_______ age, __________ date of birth, home address __________________________

_____________________________________________________________________ _____________________________________________________________________ received treatment in __________________________________________________ _______________________ from ________ 200_ on _______ 200_ with the diagnosis of: ___________________________________________________________

The general state and data of objective examination of the patient on admission (shortly) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Rooting blood analysis

date

Нb

Eryth.

х1012

Leuc

х109

eos

bas

juv.

band

seg.

lym

mon

ESR

Blood clotting time

Bleeding time

The general examination of urine

date

Amount

Spesific gravity

Proteinuria

Glucosuria

ketonuria

Epithelium

Leucocytes

Erythrocytes

Casts

Cristals:

Mucous

Urinal examination according to Nechepurenco _______________________________

Biochemical analysis of blood

date

protein

glucose

bilirubin

creatinine

urea

ALT

AST

Amylase

total

conjugated

Urinal examination according to Zymnitzky

Portion

Quantities

of urine

specific gravity

Stool test ______________________________________________________________

_____________________________________________________________________

Analysis of feces on worm ova ________________________________________

_____________________________________________________________________

Test on enterobiosis ________________________________________________

_____________________________________________________________________

Endoscopies examination of ______________________________________________

X-ray examination ______________________________________________________

Prescribed treatment

Dynamic of the main syndromes during treatment; the objective state of the patient at the moment of his discharge from the hospital

Recommendations:

1. Diet № ___________________________________________________________

2. Regimen ___________________________________________________________

3. Medical measures _________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Sanatorium treatment __________________________________________________

__________________________________________________________________________________________________________________________________________

Literature

The curator (signature) __________________

laboratory methods of functional state of organs and system. Rulers and technique of taking materials for examination. Methods of examination of Immunodeficiency states in children

Laboratory methods of investigation of functional state of organizm and systems of child organizm.

Rules and technics of stuff collection for the research.

Grafical structure of theam.

Chemical- Methods of hematologikal investigation:

Concentration HB in 1 mcl of blood.

Number of eritrocytes in 2 mcl of blood.

Colour indicator

Number of leucocytes in 1 mcl of blood.

Formula of leucocytes.

Speed of sedamentation of eritrocytes.(mm/hour)

reticulocytes, resistans of eritrocytes E cells, basis phosphatosa, glicogen, fats, trombocytes.

Methods of investigation of homeostasis system:

methods of investigation: trombocyto-vessels homeostasis: time of bleeding , resistanse of capilars, number of trombocytes, retention of trombocytes, aggregation of trombocytes, retraction of blood clot.

intestigated methods of blood: rolling time of blood rolling ;

General rules of taking blood samples for tests are the following:

– It is advisable to do it in the morning, on empty stomach

– Before taking medical products

– Physiotherapeutic procedures are forbidden before the tesr

– It is advisable to avoid physical and psychological stress before taking blood samples for test

– Blood is usually taken from the tip of the third phalanx of finger, in children of early age, it is possible to take blood from the soft part of heels, in some cases it I possible to take blood from vein

Erythrocytes and hemoglobin

The normal quantity of erythrocytes in children differs according to age

Quantity of hemoglobin (Hb)

Neonatal period

5,4 ×10¹² / L (at the beginning of the period)

4,7× 10 ¹² /L (by the end of the period)

Breast feeding period-14 years

4,2 ×10¹²/L-4,8 ×10/L

Older than 14 years

In boys 5,2× 10¹² /L

In girls 4,8 ×10 ¹²/L

Newborn period

220-180 g/L-150 g/L

1 month-5 months

120-150g/L

5 months-5 years

120-140 g/L(not less than 110g/L)

Older 5 years

130-150g/L (not less 120 g/L)

Urine physical properties:

microscopial clearness, pH, spesific gravity

methods chemical properties:

protein, glucosa, suggar,

ketone bodies, biliary pigments

microscopi of sediment:

leukocytes, eritrocytes, cylindres, endotelial cells.

Stool phisical properties:

stell, shope, pH, visible admixture, colour.

chemical properties:

blood, stercobilin, bilirubin, aminoacid, amonium.

microscopia :

dedritis, muscular fibres, connective tissue, cellulose and amylum, fat acid, soap, mucousis, cells of intestinal epitelium, leukocytes, erytrocytes, hamblia, helminths

Sputum phisical properties:

quaulity, colour, solidity, smell, divigion on the levels, character,

chemical properties: proteins, bilirubin.

microscopia: Krusherman’s spirals, eozinophiles, Sharko-Leyden’s cristals,elastic fibres, alveolar macrophages, Litrish’s corcs, echinococus elements.

bacterioscopia: microorganism of tuberculosis microflora.

Native preparates:

Ecsudat and transudat:

phisical and chemical properties specific gravity, presents and quolity of proteins.

microscopia: eritrocytes, leicocytes, tumor’s cells, dedrites, fat cells, cristale of cholesterin, mucosis, actinomicetes.

paint preparates: neurophites leucocytes limlhocytes, losipophiles, plasmatic cells, histeocites, macrophages, cells of mesotelium, tumor’s cells.

bacterioscopia: microbacterium of tuberculosis.

Liquor phisical properties: colour specific gravitis

microscopia: limphocytos, plasmatic cells, monocytes, macrophages, neutrophiles, eosinophiles, epiteliae cells, cristals, tumor’s sells, echinococus elements.

clinikal investigation: protein, suggar, chlorides, globulines.

time of retraction stabilisated blood, protrombine time, tromboelastographia, electrocoalographia, researching of blood rolling factors, concentration of antiroling factors, fibrinogens, and its following substanses, activiti of VIII factor.

Methods of investigation of fibrinolitical system of blood

general methods: measuring of time of lisis blood clots or euglobuline fraction of blood.

Methods of clinical biochemistri

Investigation of conteins general proteins, protein fractions, sedimentation test,(timoles, sulemo’s, deltman’s test),enzimes,(AlAT, AcAT,LDG,amylasa, lipasa etc) low-molecular nitrates substanses (blood urea, creatinina,urea ecid, aminoacides and peptides, indicane, pigments (bilirubin, porphirines); hydrocarbonatis ( glucose, lactat, acid, suggar,); fats (cholesterin,and its etheres threeglycerides, phosphlipides).

Urine: for investigation tace all portion of morning urine after diligent toilet of sexual organs; in the clean and dry plates; keep only 1,5 hour not more in could place.

150-200 ml – for investigated of phisical properties.

Demands to the researches material

Stool: investigated not more 8-12 hours after its secretion; keeping in temperature 3-5 C ; collected in dry and clean plates (wishes glasses)

Gastrik physical properties:

secretion quantity, colour, smell, admixture.

chemical properties:

total acidy, free acidy, debit HCL, presents of milk acid (lactat)

Gastric juse: receiving of emply stomach, after stimulation, aspiration basiae and stimulated juse.

Sputum: fresh secretion spidun in cough collected in the dry, clean plates (wishes glasses), before secretion child rinse oral cavity by boling water; in babies we can call cough by means to tough with stranges on the radix of toung, collection by means special instrument in the Petri’s cap. For desinfection –5% solution chloramine.

Transudat and ecsudat: receiving in punction of cavities, collected in clean dry plates, add citrat of sodium (1g on 1l) , or heparin, and all this mixture send immideatly on the investigation.

Lijuor: receive it by neans lumbal , suboccipital and ventricularpunction, which leaded in operating or procedure room; collected in dry and clean bottle, for bacteriological investigation – on the sterilisate bottle.

3.Technics of collection material for investigation

Taking the throat and nasal kavity svab

Make use of sterial cotton wool tampons on the small stisk it the steril test-tube; whith left hand press on root of tongue, and with right hand take off tampon from test-tube. Touch to surfacies of tonsile glands , and take off from mouth and put into tese-tube; with left hand a little raise the end of nose and with right hand tampon put into the first in the right then in the left nasal ways with turn moves. Then fasten to the test-bube card with surname of patient, aim of investigation, date of takinganalyses. Thenimediatly to send it in the laboratory.

Collection sputum for bacteriological investigation

In the steril cup of Petry

Common rules collection of urine:

The first portion of urine have to be taking after slipping in the morning;

Before taking the analysis the patient must be washed and he have to collect the urine in the clear bottle,then send it to laboratory.

General analyses of the urine:

Collect the morning urine, middle; inverstigate physical properties, and lead microscopy.

Bacteriological investigation:

10 ml of urine in the steril test-tube.

Quantities method:

Method of Kakovsky-Addis:

In the clear bottle collect urine, which was excreted of urine while 10 night’s hours(from 22 to 8) Count formed elements of daily urine

Ambyrze’s method

Use for investigate “minute leukocyturia” formed elements which excreted of urine while one minute

Nechepurenko’s method

Taking middle portion of urine,near 2-3 ml.

Count number formed elements in the 1 ml. Urinary sediment.

Zymnyckiy’s test

Collect 8-portion urine while 24 hours; from 6(this portion do not take).While every 3 hours to the 6 of other day.

Collect of faces

Koprologik investigation includes four groups of methods: bacteriologic,chemical,micro and macroscopic methods.

Faces should be taken from the middle. Every portion investigate separately. Morning faces are sent to the laboratory in the dry, clear bottle.

Semiotics disorders

Changes from the side of general blood analysis:

Anemia, erythremia, increasing or decreasing of hemoglobin, color index,

Thrombocytopenia, raised leucocytes, bond neutrophils, eosinophils,lymphocytes, elevation of the erythrocytes sedimentation rate.

Changes from the side of general analysis of urine:

Low or high specific gravity of urine, proteinuria, ketonuria, glucosyria, leucocyturia, casts in urine, bacteria’s in urine.

Changes from the side of koprograms:

Indigested muscular fibers,steatorrhea, lientery, bacteria’s in the feces.

Changes from the biochemical analysis of the blood side:

Decrease blood protein, lipids, Ca, P, sugar.

Increase blood urea, creatinine, bilirubin.

Changes from liquor’s side:

Increase protein, sugar, leucocytes, presents meningococs, microbacterics tuberculosis.

Changes from sputum analysis side:

Increase proteins, presents: columnar ciliated epithelium, alveolar macrophages, siderophages, elastic fibrils, Charcot-Leiden crystals, Kurschman’s spirals, Ditrich’s plugs, microbacteries tuberculosys.

INSTRUMENTAL EXAMINATION OF CHILDREN WITH GASTROINTESTINAL PROBLEM

Rapid strides have been made in gastro-intestinal endoscopy (gastroscopy, colonoscopy, ERCP, and related techniques) in the last thirty years. Gastro-intestinal endoscopy, once largely diagnostic, has evolved such that therapeutic procedures are often performed at the same time. This may prevent the need for major surgery. Safe and effective sedation has been a major factor in the development of therapeutic endoscopy. However, not all patients require sedation for endoscopic procedures. Some patients are quite comfortable with no sedation, or only minimal sedation, depending on the type and duration of the procedure.

Patients usually have three major concerns prior to endoscopy – the outcome of the procedure (could it be cancer?), complications of the procedure, and most importantly the question “Doctor, how much will I feel the procedure?” or “Will it hurt?” With modern sedation and careful monitoring the great majority of patients will feel comfortable during the procedure.

Before the Endoscopy

It is most likely that you will have your endoscopy in a day surgery unit in a public or private hospital. During the procedure an anaesthetist or sedationist (doctor or nurse trained in sedation and resuscitation) will be present throughout the procedure to provide monitoring of your level of consciousness, your cardiorespiratory state and provide the right amount of anaesthetic sedation to keep you comfortable throughout.

Prior to the procedure, you will meet the doctor giving the sedation. You will be asked (by the doctor or nursing staff) to provide your medical history, including the reason you are having the test, whether you have heart or lung disease (including asthma, angina or heart failure), liver or kidney disease, gastro-intestinal bleeding or other bleeding problems, or anaemia. The anaesthetist will wish to ensure you have fasted (i.e. not had food or drink) for the required number of hours before the procedure. A brief physical examination may be performed. If you are dehydrated, intravenous fluids may be administered. The doctor will wish to know your allergies and a list of your medications.

This is the time to ask any questions you may have regarding the sedation. An intravenous cannula or needle will be placed in the back of the hand or forearm. This is for the administration of intravenous sedative drugs.

During the Endoscopy

When you are wheeled into the procedure room, you will be connected to monitoring equipment which is essential when sedative agents are to be used. Monitoring detects early signs of impaired lung or heart function resulting from the sedatives, permitting early correction, thus maximising patient safety. Years ago, the anaesthetist would monitor the patient by checking skin colour, pulse rate, and rate of breathing. Modern equipment, in combination with careful clinical observation, can do much better than this.

You will also be given a mask or some type of oxygen delivery system to increase the level of oxygen in the air that you are breathing – this is now standard for endoscopic procedures. Oxygen will continue throughout the procedure. When you are asleep you may be aware of suction in the mouth or throat, which is used to remove any unwanted secretions.

After the endoscopy

Usually you will be regaining conscious awareness just as you are being wheeled to the recovery area. You may be attached to the same monitors as were used in the procedure area. You will be closely monitored at this time by experienced nursing staff, who will check your blood pressure and vital signs frequently. This is a time to relax and gradually awaken. A long awaited cup of tea and a light meal may be provided about an hour after your procedure. Often it is wise to eat only lightly for the rest of the day following an endoscopic procedure.

You will be fit for discharge when you are wide awake, have had some food, and are able to get up, get dressed, and walk around without any unsteadiness. Another person should accompany you home. You must not drive or use machinery for the remainder of the day.

Remember:

For the remainder of that day (and sometimes the next, if you still feel tired and unsteady),

do not –

• drive a motor vehicle

• use machinery that requires judgement or skill

• drink alcohol

• cook (because of the risk of burns)

• take sedative medication unless prescribed by your doctor

• sign legal documents

• make major financial decisions

• be the only person in charge of children or other dependent individuals.

Pulse Oximetry

Pulse oximeters are the most important monitors to have been developed in the last fifteen years. They should be used in every endoscopy procedure room, and be available in recovery areas.

The pulse oximeter measures the differential absorption of red and infra-red light by oxygenated and deoxygenated haemoglobin. A light emitting diode, located in a fingertip probe, sends a light wave through the tissues and monitors the reflected wavelengths coming back as the blood passes through the capillaries. The pulse rate and oxygen level (saturation) of haemoglobin in the blood can be measured. All healthy patients will have an oxygen saturation greater than 96% when breathing room air. If the oxygen saturation in the blood drops, the machine will alarm, and the anaesthetist will undertake measures to correct the situation to avoid an emergency.

Blood Pressure and ECG Monitoring

These measures are also frequently used when sedative agents are given, particularly in elderly patients or patients who have a cardiac history. The ECG is useful for detecting cardiac rhythm abnormalities (arrhythmias) and insufficiency of blood supply to the heart muscle (cardiac ischaemia).

A typical print-out from a patient monitor is shown below. The top tracing is an ECG, the bottom tracing the pulse rate. The monitor also shows continuously the pulse rate, the last blood pressure recording, and the oxygen saturation.

Colonoscopy

What is the Purpose of Colonoscopy?

To examine the lower gastrointestinal tract (colon or large bowel), to remove polyps (small benign growths), inject bleeding blood vessels, and to take samples of tissue (biopsies) for examination by a pathologist. Colonoscopy is the most reliable method of bowel examination but small abnormalities including cancers can very occasionally be missed.

How are you Prepared?

Prior to the procedure you will be given a bowel preparation kit with instructions. The bowel preparation cleans the colon. Without this it is not possible to perform a full examination of the colon. Although the bowel preparation is unpleasant, it is very rare for it to be harmful. If you have had difficulties with the preparation in the past, or if you have severe heart, lung, or kidney disease you should discuss this with the doctor.

How is Colonoscopy Done?

A long, thin flexible tube is passed around the bowel from the anus. This takes about 15 minutes and is done under intravenous sedation (Midazolam, Fentanyl, and sometimes Propofol). Reactions to these medications are rare. After the procedure you must not drive or use machinery until the next day, or longer if you feel unsteady or tired the next day. If you object to the use of sedation please discuss.

Colonoscopies are done in a hospital, usually on a day case basis. You would be required to attend the hospital for about 3 hours if you have sedation for your colonoscopy. You will need to arrange transport to and from the hospital.

Are there Alternatives to Colonoscopy?

A barium enema x-ray of the bowel will give similar information but it is not as accurate for certain problems, it does not allow biopsies or removal of polyps. It does not require sedation or hospital admission.

Complications

Colonoscopy and polypectomy are very safe. Serious complications are rare. These include:

• Reaction or sensitivity to medication used for sedation (this may affect your breathing briefly)

• Perforation (puncture) of the lining of the bowel (about 1 patient in 2000-5000)

• Bleeding – if blood vessels are injected or a polyp is removed (about 1 patient in 300-500)

• Infection of the bowel, blood, and other organs

• Heart attacks, cardiac arrest, blood clots, and breathing problems (very rare)

• There are other very rare complications – please advise if you wish to be given more details

Everything will be done to minimise the risk of these complications. There are ways of detecting these complications early and specific treatments are available if they do arise. Very rarely there may be a need for hospitalisation, major surgery, intravenous feeding, or blood transfusion. Although death can result from complications of colonoscopy this is very rare.

Special Precautions will need to be taken:

• if you suspect or know you are pregnant or if you are breastfeeding

• have severe heart, lung, or kidney disease

• have lymphoma, leukaemia, or you are receiving chemotherapy

• if you have had heart valve disease, a pacemaker, aortic graft or other blood vessel graft

• if you bleed very easily or if you take blood thinning tablets (warfarin), aspirin, or arthritis tablets

• if you are allergic or sensitive to any medication

Liver Biopsy

A liver biopsy involves your doctor taking a small piece of tissue from your liver so that they can examine it to see if there is any damage or disease to the liver.

The reasons why your doctor may want to do a liver biopsy could be that your liver function tests (LFTs) may be abnormal, possibly suggesting that your liver is not working properly or you may have an enlarged liver. For the doctor to accurately determine what is wrong with your liver, a liver biopsy may be the best approach.

Before you have your liver biopsy, the doctor will do some tests to ensure that the risks of the biopsy are kept to a minimum. First, your doctor will take some blood to see if it clots properly (since the liver produces some of the factors that help blood to clot). Your doctor will also ask you what medications you take . make sure you mention .blood thinning. medications, including aspirin. One week before surgery, it is recommended that you stop taking aspirin, ibuprofen and anticoagulants (such as warfarin).

You have to go to the hospital for a liver biopsy. For the biopsy, you will be lying on a hospital bed and the nurse will put in an intravenous (IV) line so that you can be given medication for the procedure.

When you have the biopsy, you will be lying on your back or turned slightly on your left side, with your right arm above your head. You will be given some local anaesthetic with a needle to numb the area and then the doctor will make a small incision (.cut.) in your right side, near your ribcage. The doctor will then put a biopsy needle in and take out a small piece of your liver within the needle. Sometime the doctor may use an ultrasound image of your liver to help guide the needle to the right spot.

The doctor will ask you to hold your breath for 5-10 seconds while they put the needle into your liver. You might feel a dull pain when this happens. The actual procedure should take only a few minutes. After the biopsy, you will get a bandage put over the incision and you will have to lie on your right side, pressed up against a towel, for at least 2 hours. Sometime patients may need to stay in hospital for up to 24 hours after the biopsy to recover from the sedative and to allow the medical staff to check for complications before you can go home.

Since you may be having a sedative, you will need to arrange for someone to drive you home, as you can.t driver after having a sedative. You have to go directly home and remain in bed for 8-12 hours, depending on what your doctor tells you. And to make sure that the incision and you liver can heal, you shouldn.t exert yourself too much for the next week. You might get a little bit of soreness at the incision site and you might get some pain in your right shoulder.

There are some risks involved in having a liver biopsy, such as puncture of the lung or gallbladder, infection, bleeding and pain, but these complications are rare. You should ask the doctor about these complications, how to recognise them, and what action to take.

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

The nature of the test, including possible side-effects and complications, will be discussed with you before the test. If you wish to have more information please advise your doctor before the test.

What is the Purpose of ERCP?

To examine the bile ducts and pancreatic ducts, to remove gallstones from the bile ducts, to dilate strictures in the bile ducts, to dilate or cut strictures due to a tumour of the duodenum, pancreas or bile ducts, and to keep open a stricture by the use of a plastic or metal tube called a stent. The procedure also allows samples of tissue (biopsies) to be taken for examination by a pathologist.

Sphincterotomy

Sphincterntomy involves making a small cut in the lower part of the bile duct where the duct opens into the duodenum. This is done using an instrument passed through the endoscope. You do not feel the cut. This procedure allows better access into the bile duct, removal of gallstones, and other procedures to be performed.

How are you Prepared?

Prior to the procedure you will asked not to eat or drink, usually for 8 hours. This is to allow a satisfactory examination and to minimise the risk of vomiting during the test. You will be asked to come to the hospital before the test to complete admission procedures, be admitted and checked for any medical problems, have an intravenous line inserted, and have any premedication and antibiotics if required.

How is ERCP Done?

The test is done in the X-Ray Department (you will be taken there from the Ward). After the sedation is given, a long, thin flexible tube is passed into the stomach via the mouth and a thin plastic tube inserted into the bile and pancreatic ducts. In about 5% of patients this is not successful. The procedure takes up to 45 minutes and your are under intravenous sedation throughout (Midazolam, Fentanyl, and sometimes Propofol). Reactions to these medications are rare. After the procedure you must not drive or use machinery until the next day, or longer if you feel unsteady or tired the next day. If you object to the use of sedation please discuss with your doctor.

Are there Alternatives to ERCP?

Similar information can be obtained by Percutaneous Cholangiography which is done by a Radiologist. This is generally a more difficult procedure with a slightly higher risk of complications. Removal of gallstones and treatment of strictures and tumours also can be done by open surgery, which involves an operation under general anaesthetic, a much longer stay in hospital, and higher risk of complications. If gallstones are left in the bile ducts, or if blockage of the bile ducts is not relieved, life-threatening problems may occur.

Sometimes ultrasound, CT cholangiography, and MRI cholangiography can give very similar information to that provided by ERCP, however these investigations do not allow therapeutic procedures to be performed. Your doctor will discuss these investigations with you if you wish.

Complications

ERCP, sphincterotomy, and stent insertion are normally safe procedures and are only done when other methods of diagnosis or treatment have failed. Complications (mostly minor) occur in about 5% of patients, including:

• Reaction or sensitivity to medication used for sedation (this may affect your breathing briefly)

• Pancreatitis (inflammation of the pancreas) (mild pancreatitis occurs in about 1 patient in 20)

• Bleeding following sphincterotomy (about 1 patient in 100)

• Perforation (puncture) of the lining of the duodenum or bile duct (about 1 patient in 1000)

• Infection of the bile ducts, blood, and other organs

• Incomplete removal of gallstones due to impaction, or to an instrument impacting in the bile duct

• Stent displacement with damage to bowel wall including perforation & bowel obstruction

• Heart attacks, cardiac arrest, and breathing problems (very rare)

• There are other very rare complications – please advise if you wish to be given more details

ERCP is a technically difficult procedure and in about 5% of patients there is a need to repeat the procedure at a later date for a variety of reasons e.g. to check that gallstone extraction has been successful, or to remove residual gallstones.

Special Precautions will need to be taken:

• if you suspect or know you are pregnant (x-rays are used in this test) or if you are breastfeeding

• have severe heart, lung, or kidney disease

• have lymphoma, leukaemia, or you are receiving chemotherapy

• if you have had heart valve disease, a pacemaker, aortic graft or other blood vessel graft

• if you bleed very easily or if you take blood thinning tablets (warfarin), aspirin, or arthritis tablets

• if you are allergic or sensitive to any medication, including iodine

Some useful links providing further information:

ASGE policy and procedure manual on GI endoscopy

http://www.asge.org/gui/patient/index.asp

General information about colonoscopy

http://www.gastro.com/html/colonoscopy.shtml .

Immunologic deficiency disorders

To understand immunologic deficiency disorders and their serious, often life-threatening consequences, it is helpful to review the normal functioning of the immune system. In simple terms the function of the immune system is to recognize “self” from “non-self” and to initiate responses to eliminate the non-self or the foreign substance known as antigen. However, the specific processes involved in this function are complex and interrelated. The following is a review of the major responses.

The immune system includes the primary lymphoid organs (thymus, bone marrow, and probably liver) and the secondary lymphoid organs (lymph nodes, spleen, and gut-associated lymphoid tissue ). The functions of the immune system are basically two types: nonspecific and specific. Nonspecific immune defenses are activated on exposure to any foreign substance but react similarly regardless of the type of antigen; they are unable to identify the antigen. The principal component of this system is phagocytosis, the process of ingesting and digesting foreign substances. Phagocytic cells are composed of neutrophils and monocytes.

Specific defenses are those that have the ability to recognize the antigen and respond selectively. The com¬ponents of adaptive immunity are humoral immunity and cell-mediated immunity. The cells responsible for these two forms of immunity are the lymphocytes, specifically B-lym-phocytes and T-lymphocytes.

Humoral immunity

Humoral immunity is involved with antibody production and complement. The principal cell involved in antibody production is the B-lymphocyte. In humans the exact site of production of the B-lymphocyte is speculative, although it is probably the bone marrow. In chickens the site is clearly identified as a hind-gut organ known as the bursa of Fabricius, hence the term “B-lymphocyte,” or “B-cell.” When challenged with an antigen, B-cells divide and differentiate into plasma cells. The plasma cells produce and secrete large quantities of antibodies specific to the antigen. Five classes of antibodies or immunoglobulins (lg) have been identified: G, M, A, D, and E, each serving a specific function .

On initial exposure to an antigen, the B-lymphocyte system begins to produce antibody, predominantly lgM, which appears in 2 to 3 days. This process is referred to as the primary antibody response.

With subsequent exposure to the antigen, a secondary antibody response occurs. Antibody, chiefly lgG, is produced in much greater quantities within I to 2 days. An example of the secondary response is consecutive administration of immunizations, often called boosters. Memory B-cells allow the immune system to recognize the same antigen for months or years.

When antibody reacts with antigen, they bind to form an antigen-antibody complex. This binding serves several functions. Antibody aids in the phagocytosis of antigen by sensitizing it in such a manner that it is more readily destroyed by phagocytes, a process known as opsonization.

Antibody also activates or fixes complement, the second component of humoral immunity. The complement system is a series of nine major factors (Ci and 09) present in serum that results in a cascade of enzymatic actions and death of a viable antigen. It also serves to bridge cellular and humoral immunity. After being activated by antibody, complement produces a chemotactic factor that summons T-lymphocytes and macrophages to the antigen site.

Cell-mediated immunity

Cell-mediated immunity is involved in a variety of specific functions mediated by the T-lymphocyte. The T-lymphocyte is so named because it passes through the thymus during the differentiation process, which leads to the mature T-cell. T-lymphocytes do not carry typical immunoglobulins on their surfaces as do the B-cells. However, they are functionally heterogenous in that several subsets have been identified, including cytotoxic T-cells, memory T-cells, helper T-lymphocytes, and regulator T-lymphocytes.

Specific functions of T-lymphocytes include: protection against most viral, fungal, and protozoan infections and slow-growing bacterial infections, such as tuberculosis, rejection of histoincompatible grafts, mediation of cutaneous delayed hypersensitivity reactions, such as in tuberculin testing, and probably immutie surveillance for malignant cells. In addition, they also have regulatory functions within the immune system. For example, helper T-lymphocytes assist B-lymphocytes and other types of T-cells to mount an optimum immune response.

The cellular immune response is initiated when a T-lymphocyte is sensitized by antigen. In response to this contact the T-cell releases numerous humoral factors called lymphokines, which eventually bring about death of the antigen. For example, chemotactic factor promotes the migration of phagocytes and other T-lymphocytes to the antigenic area, migratory inhibitor factor prevents their leaving the site, transfer factor transforms nonsensitized T-cells into sensitized T-lymphocytes, blastogenic factor initiates the rapid mitosis of sensitized T-cells, and macrophage activation factor transforms local macrophages to highly phagocytic cells. Another lymphokine is interferon, which nonspecifically inhibits viral replication, promotes phagocytosis, and stimulates the killer activity of sensitized lymphocytes.

The immunologic properties of the mucosal lining of the gastrointestinal tract are immature, which predisposes this system, like the respiratory system, to increased risk of in¬fection and inflammation.

The immunologic system undergoes numerous changes during the first year. The newborn receives significant amounts of maternal lgG, which confers immunity for about 3 months against antigens to which the mother was exposed. During this time the infant begins to synthesize his own lgG, and about 40% of adult levels are reached by I year of age. Significant amounts of lgM are produced at birth, and adult levels are reached by 9 months of age. The production of IgA, lgD, and lgE is much more gradual, and maximum levels are not attained until early childhood.

The defense mechanisms of the tissues and blood, particularly phagocytosis, are much more efficient in the toddler than in the infant. The production of antibodies is well-established. Immunoglobulin G (lgG), which neutralizes microbial toxins, reaches adult levels by the end of the second year of life. Passive immunity from maternal transfer disappears by the beginning of toddlerhood, necessitating the use of artificial immunizations. Immunoglobulin M (lgM), which responds to artificial immunizing techniques and combats serious infection, attains adult levels during late infancy. Immunoglobulins A, D, and E increase gradually, not reaching eventual adult levels until later childhood. Many young children demonstrate a sudden increase in colds and minor infections when entering nursery school or kindergarten because of the exposure to new antigens.

Severe combined immunodeficiency disease

Severe combined immunodeficiency disease is characterized by absence of both humoral and cell-media immunity. The terms “Swiss type lymphopenic agamr globulinemia,” an autosomal-recessive form of disease, s “x-linked lymphopenic agammaglobulinemia” have be used to describe this disorder, which, as the names imp can follow either mode of inheritance.

Pathophysiology

The exact cause of SCID is unknown. The theories i elude (1) a defective stem cell that is incapable of differe: tiating into B- or T-cells, (2) defective organs responsib for the differentiating process, primarily the thymus ar lymphoid complex, or (3) an enzymatic defect that supresses lymphocytic cell function.

The consequence of the immunodeficiency is an ovei whelming susceptibility to infection and to the graft-vs-hoi reaction. The latter occurs when any histoincompatible tis sue from an immunocompetent donor is infused into the im munodeficient recipient. Because of its immunodeficiency the body is unable to reject the foreign incompatible tissue There fore, the antigenic donor cells attack the host’s tissues. The graft-vs-host reaction is a serious complication in the only known treatment for SCID, bone marrow transplant.

Clinical manifestations

Obviously the most common manifestation is susceptibil¬ity to infection early in life, most often by 3 months of age when maternal immunity is low. Specifically the disorder in children is characterized by chronic infection, failure to completely recover from an infection, frequent reinfection, and infection with unusual agents. In addition, the history reveals no logical source of infection. Failure to thrive is a consequence of the persistent illnesses.

If the child should receive a foreign tissue, such as blood supplements, signs of graft-vs-host reaction, such as fever, skin rash, alopecia, hepatosplenomegaly, and diarrhea, are expected. Since the reaction requires 7 to 20 days for tissue damage to become evident, the symptoms may be mistaken for an infection. However, the presence of a graft-vs-host reaction increases the child’s susceptibility to overwhelming infection and, therefore, is a grave complication.

Diagnostic evaluation

Diagnosis is usually based on a history of recurrent, se¬vere infections from early infancy, a familial history of the disorder, and specific laboratory findings, which include lymphopenia, lack of lymphocyte response to antigens, and absence of plasma cells in the bone marrow. Documentation of immunoglobulin deficiency is difficult during infancy be¬cause of the normally delayed response of the infant to pro¬duce his own immunoglobulins and maternal transfer of im-munoglobulin G.

HIV infection

Acquired immunodefidency syndrome (AIDS) is a rowing problem in the pediatric population Many IIV-infected children are asymptomatic, have only lild symptoms, or have AIDS-related complex ARC).

About 80% of infected children acquire the virus crinatally from an infected mother. Blood transfusions (between 1978 and 1985) and factor concen-•ates are responsible for most of the remaining casesa small percentage of pediatric cases, the mode f transmission is sexual, drug related, or unknown ecause an adequate history is not available. In in-tances of perinatal transmission, the most common isk factors or behaviors in themother are intravenous lrug use or heterosexual contact with a bisexual or ^ug-using partner, drug use in either parent accounts xmore than 70% of perinatal transmission. Perinatal JDS occurs more commonly in blacks (about 60% if cases) and Hispanics (25%).

Clinical Findings •

Children with HIV infection present to the ED with a wide spectrum of initial presentations and asso¬ciated complications. Many who live in chaotic social environments use the ED as their primary source of medical care. Table 125-1 indicates the most common presentations of HIV infection in children.

The typical case of pediatric HIV infection is a child born to a mother at risk who develops recurrent bac¬terial infections, thrush, failure to thrive, lymphade-nopathy, and hepatosplenomegaly in the first few years of life. However, both those who acquire HIV perinatally and those who acquire infection by trans-fusion may not present with symptoms until several years of age.

BACTERIAL INFECTIONS

The types of infections are similar to those in patients with hypogammaglobulinemia. Infections with the encapsulated organisms, Haemophilus influenzae type B, Streptococcuspneumoniae, and enteric gram-negative rods are common and can cause chronic or recurrent otitis media, pneumonia, lymphadenitis, bacteremia, mastoiditis, and meningitis. Malignant external otitis, a disease usually seen in older patients, also occurs. Other common conditions include der¬matitis, particularly eczema; in those patients Staph-ylococcusaureusts also an important pathogen. Sal-monella infections can be quite severe and may cause prolonged gastroenteritis or bacteremia; frequent re¬lapses may occur.

RESPIRATORY INFECTIONS

Pulmonary infection is a common and serious man¬ifestation of HIV infection. The most commonly di¬agnosed infection is Pneumocystis carinii pneu¬monia (PCP), which can present acutely with respiratory distress or with a history of progressive cough and respiratory symptoms over days to weeks. Clinically, it may be difficult to distinguish PCP from more typical causes of childhood pneumonia. The chest x-ray typically shows a diffuse interstitial pneu-monitis, although almost every pattern of infiltrate has been seen with PCP.

A second common pneumonitis is lymphoid in¬terstitial pneumonitis (LIP); the cause is unknown. Children with LIP often have a longstanding history of pulmonary symptoms, particularly cough. They are usually not febrile or acutely dyspneic, and rarely have significant auscultatory findings. A concomitant infection can cause a child with pre-existing LIP to present acutely. LIP is most often seen in children with other lymphoproliferative manifestations of HIV such as lymphadenopathy and parotitis; these patients may have signs of chronic pulmonary disease such as clubbing. The chest x-ray shows a diffuse interstitial infiltrate similar to that seen with PCP, but in some longstanding cases there may be a diffuse nodular pattern with widening of the superior mediastinum and hilum. LIP is currently a diagnosis of exclusion.

In addition to PCP and LIP, other routine and op¬portunistic infections must be considered in an HIV-infected child with respiratory distress. Bacterial

pathogens are frequent. Another common pathogen is respiratory syncytial virus (RSV), an extremely common viral infection in young infants and children, which can cause giant cell pneumonia in the com¬promised host. Cytomegalovirus can be cultured from the lung in these patients, although it is not always clear that it is the primary pathogen. Other oppor¬tunistic pulmonary infections are also in the differ¬ential diagnosis, including atypical mycobacteria and fungi.

CENTRAL NERVOUS SYSTEM DISORDERS

CNS disorders are a prominent part of the clinical spectrum of HIV infection in children. Encephalop¬athy, either static or progressive, is ofteoted. Man-ifestations often include acquired microcephaly, progressive motor dysfunction, loss of developmental milestones, ataxia, and extrapyramidal rigidity. Iso¬lated seizures are unusual but may occur with a con¬comitant febrile illness. Focal neurologic signs are uncommon in pediatric AIDS and should suggest possible CNS lymphoma. Opportunistic infections, particularly cryptococcal meningitis, may be present in the child with CNS symptoms. However, in most series of children dying with HIV encephalopathy, opportunistic infection of the CNS is rare, and most signs and symptoms are secondary to HIV infection of the nervous system.

GASTROINTESTINAL ILLNESS

Gl illnesses, especially diarrhea, are a major problem for HIV-infected patients. Salmonella can be a per¬sistent problem, particularly in patients with blood or mucus in the stool. Severe or prolonged diarrhea in pediatric AIDS patients also occurs with parasitic enteric pathogens, most notably Glardia lamblia, and cryptosporidium. In some instances, even after ex¬tensive evaluation, no specific etiology can be found to account for the diarrhea.

OTHER ENTITIES

Many of the usual childhood infections are seen in HIV-infected patients, but they may present in a more severe form. Oral candidiasis (thrush) is extremely common, particularly in infancy. HIV-infected pa¬tients often have extensive thrush, in the absence of previous antibiotic therapy. Infection may extend to the esophagus or the larynx and is resistant to the ” usual forms of therapy. Viral diseases such as herpes simplex, varicella, and measles can be quite aggres¬sive in HIV-infected children. Herpes simplex may cause prolonged or recurrent ulcerations and varicella may disseminate to cause pneumonia, encephalitis, r hepatitis. Measles can also cause a severe pneu-monia; the first measles deaths in the United States jto several years have recently occurred in HIV-in-lected children.

‘ A unique feature in pediatric HIV infection is the •elopment of parotitis. This can be chronic, with v, progressive, painless growth, or it can be acute, xiated with rapid enlargement, fever, and pain. he etiology is unknown.

f, A number of other entities described in pediatric ihiv infection are also important to recognize. These ^Include a nonspecific hepatitis, cardiomyopathy, and I the nephrotic syndrome. f Hematologic syndromes are also well described; jtilrombocytopenia is the most common, but anemia, I secondary to hemolysis, and neutropenia can be seen.

Clinical Evaluation and I Ancillary Data

I Use an aggressive diagnostic approach, because many of the acute illnesses are treatable. For example, a I child with HIV infection who presents with fever is I quite likely to have a bacterial infection; obtain a I complete blood count (CBC), blood culture, urinal-j ysis, and chest x-ray if there is no obvious source of I fever on examination. Other imaging studies such as I sinus films may be indicated. If the child has a history I of neutropenia or is receiving azidothyrnidine (AZT), j the absolute neutrophil count may be depressed, I which would influence therapeutic decisions. I The new onset of pulmonary symptoms requires a I thorough evaluation. Although many of these patients I may not have an easily treated form of pulmonary I disease, early therapy is important. Because it is dif-1 ficult to clinically differentiate the common forms of I pneumonia in pediatric AIDS patients, hospitalization f is often required. In such patients, the initial diag-1 nostic tests include chest x-ray, CB^, blood culture, I and, in the appropriate epidemiologic setting, na-Isopharyngeal swabs for immunofluorescence or cul-j ture.

I Weight loss and diarrhea may be acute or chronic I and are often quite severe. In addition to routine I bacterial culture, obtain stool for ova and parasites. I Assess the patient’s state of hydration clinically and I measure serum electrolytes, blood urea nitrogen, and jcreatinine, since enormous fluid losses and profound I electrolyte imbalances are sometimes present. I CNS symptoms and physical signs will determine I whether lumbar puncture or scanning is appropriate. I If a spinal tap is performed, obtain more fluid than I necessary to diagnose bacterial meningitis, because {additional tests are often indicated, such as a culture for acid-fast organisms, viral culture, and cryptococcal antigen. If focal neurologic signs are present, arrange for a CT scan to evaluate for lymphoma or toxoplas-mosis.

Treatment and Disposition •

The treatment plan and the decision to hospitalize the patient must be made in conjunction with the family; many families want aggressive diagnostic and therapeutic plans, while others may prefer to keep medical intervention limited, with the goal of making the patient comfortable.

Consider hospitalizing HIV-infected patients with fever without a focus of infection, recent onset of pulmonary or CNS manifestations, or severe failure to thrive or diarrheal disease.

Patients who are not acutely ill and do not require hospitalization may require antibiotic therapy. If a focal infection is identified, such a sinusitis or otitis media, and there is no evidence of bacterernia, the patient can ordinarily be managed as an outpatient. However, a longer duration of therapy is required; for example, treat sinusitis for a minimum of 3 we6ks.

In cases of possible bacterernia, the antimicrobials must be effective against the encapsulated organisms and the enteric gram-negative rods.

For any HIV-infected patient who does not require hospitalization, arrange for the necessary follow-up of the acute problem with the primary physician and make appropriate referrals for long-term manage¬ment. Because of the chronic and complex nature of pediatric HIV infection, non-urgent problems are best handled in the calmer, more familiar outpatient office or clinic, not the ED.

Isolation techniques are based upon the mode of transmission of the disease .