Circulation system: Classification of congenital heart disease, main clinical feature, such as tetralogy of Fallot There are many

classifications in CHD. The most common classification is: 1. Cyanotic eg: A. pulmonary blood flow decreases TOF: Cyanosis first sign some baby become cyanotic after 6-12months with the progress of stenosis and PDA spontaneously closure. Clubbed fingers and toes due to long term hypoxia Squatting: lessens systemic venous return increase systemic circulatory resistance hypoxic spells caused by infundibular spasm and lower the blood perfusion. It happens when feeding , crying and other exertion. Pat. Present tachypnea, irritating and progressed cyanosis. The spasm last a few minutes or longer, result in syncope, metabolic acidosis, even death. Auscultation A systolic thrill is usually present anteriorly along the left sternal border. A harsh systolic ejection murmur is heard over the pulmonic area and left sternal border. When RVOTO is moderate, the murmur may be inaudible (more cyanotic patients have greater obstruction and a softer murmur). The S2 is usually single (cause the pulmonic valve closure is not heard). During cyanotic spells, murmurs may disappear, which is suggestive of lessened RV outflow to the pulmonary arteries

B. pulmonary blood flow increases -TAPVC (Total anomalous pulmonary venous connection), TGA(Transposition of Great artery) 1. non-cyanotic: VSD, ASD, PDA, PS Blood system: Definition, cause ,classification of anemia, such as iron deficiency anemia

Anemia is one of the most common symptoms. It can be caused by the hematopoietic system diseases and also can be the performance of other diseases. According to the etiology and pathogenesis anemia can be divided into three types: Anemia of inadequate production Hemolytic anemia Blood loss

Iron deficiency anemia Is caused by defective synthesis of hemoglobin, resulting in red cells that are smaller than normal and contain reduced amounts of hemoglobin. Causes: 1. Inadequate storage: Premature<3mon, Twins or Multiplets, Intrapartum hemorrhage, etc. 2. insufficiency of intake Iron is absorbed 2 to 3 times more efficiently from human milk than from cow's milk / Introduction of Solid Food 3.Growthblood volume increased > Iron intake 4.Disorder of Digestion and Absorption: chronic diarrhea, Repeated infection, Malnutrition 5. Losing too much: Protein allergy, Hookworm, Polyp, Diverticulum Urinary system: The diagnosis and clinical feature of nephrotic syndrome and acute nephritis
Acute nephritis: Clinical features: General features: Fatigue Abdominal pain: more than half Low-grade fever Loss of appetite Nausea Vomiting Headache Presentations: Edema: periorbital (first)/generalized.

 Diagnosis:

Hematuria: gross hematuria (50-70%; tea colored/cola colored/pink/red), microscopic hematuria (100%). Proteinuria: mild-moderate; sub nephrotic range Hypertension

1. Urinanalysis: Hematuria Gross Microscopic Proteinuria:1+-4+ Sediment: White blood cells Renal epithelial cells Casts: hyaline or cellular or Red blood cell 2. Blood analysis: Hemoglobin and RBC: drop (due to hypervolemia and hemodilution) 3. Blood chemistry: Elevated BUN and creatinine Hypoalbuminemia Electrolyte profile is usually normal Hyperkalemia, hyperphosphatemia and metabolic acidosis Significant renal functional impairment 4. Serological testing: ASO (antistreptolysin O) : Elevated ( pharyngeal infection) Anti-DNaseB 5. Complement level: C3: APSGN (Decreased: 90-95%; Return to normal: 6-8weeks) Lupus nephritis Infective endocarditis related nephritis Membranoproliferative GN C4: normal

6. Others: Renal US Chest X Ray: Pulmonary edema, cardiomegaly ECG ANCA, ANA, anti-dsDNA EBV, HBV Throat swab

Nephrotic syndrome: Clinical features: Edema: Insidious onset Generalized and distributed by gravity: face, particularly the periorbital regions tends to be swollen in the morning and the ankles later in the day. Along with coelom hydrops : plural effusions , ascites and pericardial effusion. Blood pressure Normal or low ; persistent hypertension is rare in minimal change diseases(MCD), focal segmental glomerulosclerosis(FSGS), but common in membrane proliferative glomerulonephritis(MPGN) volume contracted secretion of renin, aldosterone Hypovolaemia in NS Important signs: cold peripheries and diminished or delayed capillary return and a reduced jugular venous pressure.

Diagnostic criteria: 1. Nephrotic range proteinuria proteinuria(>50mg/kg/day) Urine protein 3+ or 4+ by dipstick testing (early morning protein :creatinine ratio) Spot urine (first void ), albumin to creatinine ratio greater than 3.5 (mg /mg) 2. Hypoalbuminaemia serum albumin less than 25g/l 3. Oedema The onset is insidious , with swelling around the eye and facial puffiness .Over the next few days ,it gradually increases to involve the extremities and abdomen 4. Hyperlipidemia Serum cholesterol more than 5.7mmol/l 5. Serology: C3,C4: Persistent(MPGN, lupus) Transient(APSGN) Antinuclear antibody (ANA)and anti-double stranded DNA antibodies Creatinine, urea, and electrolytes Hepatitis B serology

Nervous system: the clinical feature, diagnosis and csf characteristic of viral,purulent and tuberculous
meningitis.

CSF characteristics: Disease Purulent Tuberculous Pressure Appearance Cloudy Clear or slightly cloudy Clear WBC Protein >1000, neutrophils <500, lymphocytes(early neutrophils) <500, lymphocytes Glucose Chloride

Viral

Clinical features: Signs of systemic infection Fever Anorexia, Malaise Neurological manifestation Increased intracranial pressure: headache, vomiting(82%), herniation Meningeal irritation: nuchal rigidity(77%), kernig sign, brudzinski sign Seizure(20-30%): focal or generalized sensory and motor deficits Alteration of mental status and consciousness: hyperirritability, lethargy, coma

In Infants: Temperature: higher or lower Consciousness: drowsiness, irritation Vomiting, jaundice, cyanosis Irregular respiration Convulsion Anterior fontanel projection Diastases of skull Meningeal irritation signs rarely occur

In Neonates: Temperature: normal or fever or hypothermia Minimum or subtle seizure Less activity, less crying, poor feeding Jaundice, cyanosis Irregular respiration Anterior fontanel projection Decreased muscular tone

Respiratory system: the diagnosis, clinical feature ,classification and complication of pneumonia, the
characteristic of different pathogen pneumonia such as staphylococcus aureus pneumonia ,MPP, adenovirus, diagnosis of pneumonia complicated with heart failure; diagnosis of infant asthma and children asthma Classification of pneumonia: According to the route of transmission: Intrauterine (congenital) pneumonia: prenatal pneumonia Is acquired in utero with bacteria or virus (mostly TORCH family) Can cause immediate respiratory symptoms at birth. Diffuse inflammatory process with polymorphonuclear leucocytes present in the alveoli but bacteria often absent. Aspiration pneumonia: intrapartum pneumonia Acquired before or at the time of delivery. It is caused by aspiration of amniotic fluid which may contain meconium, blood or other materials in birth canal during prolonged labor or difficult deliveries. Densely cellular exudates with bacteria present, vascular congestion, hemorrhage, and necrosis. Postnatal acquired pneumonia Can be acquired during delivery or in the postpartum period; usually beyond the first week of life. Can be acquired in hospital or community. Cause by virus (RSV), bacteria, and chlamydia. Mostly frequently is bronchopneumonic or interstitial. Pathologic features commonly are Infiltration of bronchopulmonary, fibrinous alveolar exudates, and pleural reaction

According to the site of infection: CAP: community acquired pneumonia. A previously healthy person who acquired the infection outside the hospital or acquired it within 48 hours of hospitalization. A previously healthy person who hasnt been to hospital in the past 14 days. HAP: hospital acquired pneumonia

According to the pathology: Bronchopneumonia (lobular pneumonia) Fever, cough tachypnea, cyanosis, nasal flaring, head nodding, rib muscle retraction Interstitial pneumonia Lobar pneumonia

According to the course of the disease: Acute (<1month) Chronic (>3 months) Persisting (1-3 months)

According to the agent: Bacterial Viral Chlamydial Mycoplasma Aspiration Fungal

Clinical features: General: Infants with pneumonia can present with tachypnea, dyspnea, retractions, grunting, nasal flaring, cyanosis and the presence of rales or rhonchi on physical examination. They also may have associated systemic findings including lethargy, poor feeding, fever, apnea, temperature instability, tachycardia, poor perfusion, metabolic acidosis.

Prenatal pneumonia: Asphyxia; occur 24h after birth Increased respiratory rate Temperature instability Auscultation of lung: harsh breath sounds, lowered breath sound or lung rales.

Intrapartum pneumonia: Occur in days to weeks according to different pathogens: 3-5 days after birthbacterial infection 5-10 days after birthtype II herpesvirus 3-12 weeks after birth trachomatis

Postnatal acquired pneumonia: Fever or hypothermia, dyspnea, nares flaring, cyanosis,three depressions sign. There may be thin wet rales in both lungs in the course of disease wheezing rale in respiratory syncytial virus pneumonia

Diagnosis:

Maternal infectious history birth history infants clinical presentations and disease progression Chest X-ray: sexclude other respiratory disorders, show patchy or confluent infiltrates or increased interstitial shadowing. Meconium aspiration pneumonia: Chest X-ray shows widespread patchy infiltrates with area of collapse and peripheral emphysema from air trapping due to the meconium lung Blood and trachea secretions cultures Serological tests, rapid antigen tests, ESR, CRP

Characteristics of different pathogen pneumonia: staph aureus, MPP, adenovirus. MPP: Agent: Mycoplasma pneumonia Age group: School-aged children (5-19 years old), infants. Risk factors: Living or working in crowded areas. Peak season: early fall and winter. Route of transmission: Coughing, close contact Symptoms: headache, high fever, chills, excessive sweating, cough (dry at first), chest pain, sore throat. Signs: ronchi, rales and wheezing Metastatic infections: Pericarditis, CHF Meningitis, meningoencephalitis Hemolytic anemia, thrombocytopenia, DIC Stevens-Johnson syndrome Anorexia, nausea, vomiting, nephritis Pathological signs: Mononuclear alveolar exudates and infiltration with plasma cells. Bronchial walls thickened by edema and infiltration by macrophages, lymphocytes and plasma cells. May be accompanied by severe bronchiectasis with ulceration and fibrosis of the bronchial walls. Complications: atelectasis and bronchiectasis. Treatment: macrolides (azithromycin), erythromycin, glucocorticoids.

Staphylococcus aureus: Agent: S. aureus, S. epidermidis Age group: infants and neonates

Peak season: winter and spring Clinical features: Preceded by upper respiratory tract infection, conjunctivitis or an abscess in some other part of the body. Rapidly progressive disease in infancy. Continued fever, toxic appearance Progressive cough, respiratory distress, irritability Signs: Sternal retractions Tubular breath sounds with loud ronchi and moist rales. GI symptoms like vomiting, diarrhea and abdominal distension. Metastatic infections: Endocarditis, pericarditis Meningitis, osteomyelitis Scalded skin syndrome, Toxic shock syndrome Chest X-ray: necrotizing pneumonia Abscess formation Pyopneumothorax Pneumatoceles Symptoms appear before x-ray changes. Complications: persistent effusions, empyema, pneumatoceles, pulmonary abcsess

Adenovirus: Age group: >2 years of age; all age groups. Causes miliary pneumonia Rapid antigen test Rx: acyclovir, amantadine, interferon Complications: bronchiloitis obliterans, hyperlucent lungs syndrome

Chlamydia pneumonia: conjunctivitis; serological tests, macrolide Common pulmonary complications: Pleural effusion, Emphysema Atelectasis, pneumothorax, pneumatoceles

Diagnosis of asthma: Family history Clinical features: cough, wheezes, dyspnea, tachypnea, prolonged expiratory phase of respiration, use of accessory muscles for inspiration. Exposure to triggers like exercise, viral infections, weather changes, allergens, emotions.

Blood and sputum test: eosinophilia Allergen skin test X-ray: increased lung markings, hyperinflated lungs Rx: avoidance of triggers Mild and intermittent ( >twice each week): short acting inhaled B2 agonists. Mild persistent: low dose inhaled GCS+short acting B2 agonists. Moderate persistent: medium dose GCS + LABA + SABA (when symptomatic) Severe persistent: high dose inhales GCS + LABA + SABA

Neonate : various definition, such as perinatal period ,term infant, very low birth weight; diagnosis and clinical feature of neonate asphyxia, NRDS, jaundice Perinatal period: from 28 weeks of embryonic age to 7 days after birth, including late pregnant period, delivery process and early neonatal period. Full-term infant: an infant born 38 to 42 weeks (260293 days) after conception. Very low birth weight infants (VLBW) :neonates with a weight less than 1500 g NRDS: Clinical features: Respiratory distress within 2~6h after birth; dyspnea, cyanosis, flaring of alaenasi, inspiratory three-concave sign, expiratory groan; Progressively aggravated respiratory distress; Flat thorax, low breath sound, wet rales; Arterial duct opening at convalescence stage; Condition will improve after 3rd but the course will be longer if complications exist.

Diagnostic criteria: Perinatal risk factors: prematurity, maternal diabetes, perinatal asphyxia, C-section before uterine contraction. Patients present with tachypnea, grunting, nasal flaring, retractions, and cyanosis. Symmetrical ground-glass appearance; air bronchograms in non-surfactant-treated neonates, low-volume lungs, severe bilateral opacities (white out). Usually occurs in neonates 26-33 weeks GA. Respiratory and metabolic acidosis. LS ratios <2:1, phosphatidylglycerol (-) Shaking test

Jaundice: Clinical features:

Physiological jaundice: Onset of jaundice: full term 2-3 days of age , preterm :3-5days of age The time of peak level: full term 4-6 days of age , preterm5-7 days of age. The resolving time: Full term: 2 weeks of age .Preterm: 3-4 weeks of age . Level of total serum bilirubin: full term < 12.9 mg/dL , preterm <15mg/dl,rising at a rate <5mg/dl/24h Level of conjugated bilirubin: <2mg/dl Generally babies are in good conditions

Pathological jaundice: Onset of jaundice: too early, within 24 hours of age Level of total serum bilirubin: too high, full term > 12.9 mg/dL , preterm >15mg/dl, progress too rapid: rising at a rate >5mg/dl/24h The duration: too long, Full term> 2 weeks , Preterm>4 weeks Level of conjugated bilirubin: >2mg/dl Reappearance of jaundice

Diagnosis: Total and direct bilirubin Blood type for mother and baby Coombs test Red blood cells shape,hematocrit,reticulocyte Sepsis screen Liver and thyroid function Torch titers and liver scan

Neonatal asphyxia: Diagnostic criteria: Prolonged metabolic academia (pH<7) on an umbilical arterial blood sample Persistence of Apgar score of 0-3 for more than 5 min. Neurological manifestations: seizure, coma, hypotonia, HIE, multiorgan dysfunction

Clinical features: hypercarbia, lactic acidosis Fluid therapy: diagnosis ,classification and clinical feature of dehydrate, how to fluid infusion, know the calculation of osmotic pressure

Evaluation of Degree of Dehydration

Symptoms & Signs

Mild

Moderate

Severe

Weight loss General state

3-5%(30-50ml/kg) restless

5%-10%(50-100ml/kg) restless or lethargic

>10%(100-120ml/ irritableDrowsy; c

Tears/lips/ oral mucosa

Normal/Slightly dry

Decreased tears /Dry

Sunken,absence o

Fontanel

Normal

Slight depressed

Sunken

Skin turgor

Normal

Slight decreased

None, tenting

urine output

Normal to mildly reduced

Significantly decreased

anuria

pulse

Normal and strong

Rapid and slightly weak

Significantly tachy to not palpable

Extremity / RCT blood pressure

Normal/ <2sec Normal

Light cold / 2-4sec Orthostatic hypotension

Cold/ >4sec, mottl hypotension

Types of dehydration

Isotonic dehydration

Hypotonic dehy. (Hyponatremic)

Hypertonic dehy. (Hypernatremic) >150

Na+ ( mmol/L)

130-150

<130

ECF

reduced

Obviously reduced

reduced

ICF

normal

increased

Obviously reduced

Common diseases (Causes)

Diarrhea,vomit, Burn(large area), short-period hungry

Chronic diarrhea, malnutrition, lack salt,uresis

Insufficient water intake,high fever,s some virus enteritis, etc.

CM

General CM &signs of dehydration

CM of CNS-obvious (Lethargy,coma/convulsion); CM of dehydration-severe(SHOCK)

CM of CNS--severe

CM of dehydrationnot severe (mil other two) CM of ICF dehy.

Others: vitamin D deficiency