Pedia-CS

Pediatric Clinical Cases

Case / Diagnosis	Full Scenario Details	Relevant Questions (History)	Specific Physical Exam Signs	Investigations	Differential Diagnosis (DDx)	Management / Treatment Plan
Henoch-Schönlein Purpura (HSP) / IgA Vasculitis	Scenario A: A 7-year-old boy presents with a 1 day history of mild abdominal pain and vomiting. He is afebrile and has no diarrhea. He also complains of ankle pain bilaterally. Within 24 hours he develops a rash on his legs and buttocks. On examination, you notice a palpable purpuric rash over his gloves and buttocks with swelling of both ankles. Abdominal examination is unremarkable. Scenario B: A 2 year old boy develops a widespread purpuric rash, most prominent over the legs and buttocks. Although initially treated with 48 hours of intravenous antibiotics for meningococcal sepsis, no evidence for infection is subsequently found and this diagnosis is discounted. The child remains afebrile and well, but develops swelling of the knees and ankles and becomes reluctant to weight-bear. Urinalysis persistently shows mild proteinuria. Scenario C: An 11 year-old female presents with complaints of recent development of abdominal pain, joint pain, and a new skin rash. Her stool is positive for Occult Blood Test.	• “Has the child recently had a sore throat or upper respiratory tract infection (URI)?” (Common trigger for HSP). • “Has he complained of tummy pain, joint swelling, or have you noticed blood in his stool/urine?” (Screening for intussusception or renal involvement). • Bloody stools? (Most relevant Q in Scenario A). • Headache, anorexia before onset? • Abdominal pain and vomiting? • Scrotal edema or subcutaneous edema? • Hematemesis? • Arthritis/Arthralgia (usually oligoarticular)? • Hematuria? • History of intussusception/bowel perfusion signs?	• Skin: Palpable Purpura: Non-blanching rash, symmetrically distributed, typically on the back, buttocks, upper extremities, and lower limbs (extensor surfaces / extensors of legs / ankles). Erythematous macular, urticarial, blanching papules, hives, target lesions. • Scrotal edema (Most relevant sign in Scenario A). • Joints: Arthralgia and swelling (knees/ankles). • GU: Penile edema, priapism, orchitis. • CNS: Bilateral subperiosteal orbital hematomas.	• Urine: Urinalysis: Critical to check for hematuria, proteinuria, pyuria, casts (to monitor for HSP Nephritis). • Vitals: Blood Pressure: Check for hypertension (renal involvement) and ensure ongoing monitoring. • Blood: FBC/CBC (high WBC), Platelets (should be normal, distinguishing from ITP). Normal clotting parameters (Most likely finding in Scenario A). Coag profile (PT/PTT), U&E, Albumin, Factor VIII/XIII, IgA, ANA/RF, ESR, C1, C3, C4, CH50, BUN/Cr, Electrolytes, Amylase/Lipase, D-dimer, TAT complex. • Stool: Check for occult blood / Guaiac test. • Imaging: Abd US (intussusception), Contrast radiography, MRI, CT. • Path: Renal biopsy (if deterioration).	• Idiopathic Thrombocytopenic Purpura (ITP) • SLE • IgA Nephropathy • Leukemia • Inflammatory Bowel Disease (IBD) • Acute Glomerulonephritis • Acute Renal Failure • Mononucleosis • Orchitis • Pancreatitis • Chicken Pox • Gastroenteritis • GI Bleeding • Hand-Foot-Mouth Disease • Intussusception • Kawasaki Disease • Meningitis/Encephalitis • Septic Shock	• Supportive Care: Hydration, rest, pain medication (Acetaminophen). Analgesia (NSAIDs like Ibuprofen are often used short term for joint pain/arthritis, provided there is no significant renal impairment). • Monitoring: Long-term follow-up of BP and monthly Urinalysis (up to 6-12 months / at least 180 days) to rule out or detect late-onset nephritis/renal dysfunction. • Steroids (Corticosteroids/Prednisone): Reserved for severe abdominal pain (to reduce intussusception risk), GI pathology, or severe renal involvement. • Specific: Discontinue antigenic stimulants (drugs). • Other: Plasmapheresis.
Guillain-Barré Syndrome (GBS)	Scenario A: 7-year-old Saudi girl was brought to ER with complaints of ‘pins and needles’ sensations in her toes and proximal muscle weakness of the lower extremities. She had diarrhea 4 weeks prior to ER visit which was associated with abdominal pain and last for few days only. She was a healthy child before these events with normal development and she completed the national immunization schedule. O/E: HR 90/M, BP:110/76, Temp 37.6c. Chest: equal BS on both sides. CVS: Short systolic murmur grade 2/6 at LLSB with normal pulses in all limbs. Scenario B: A 3-year-old boy brought to ER by his mother, she noticed that the child is c/o abnormal sensation in the lower limbs (pins and needles sensation) and he had a Hx of common cold preceding these symptoms by week. And he’s polio-immunized. Scenario C (Fragment): “Case 3 7 years ER - weakness and dyspnea” (Raw text fragment: “dishon” suggests dyspnea (shortness of breath) or dysphagia (difficulty swallowing), both red flags in GBS).	• “Did the child have a tummy bug (diarrhea/Campylobacter) or cold/respiratory infection 1–3 weeks ago?” • “Did the weakness start in the feet/legs and move upwards / progressing weakness starting from legs?” (Ascending paralysis). • Prickling, “pins and needles” sensations in other parts (fingers, ankles, wrists)? • Does weakness spread to upper body (ascending)? • Difficulty with eye/facial movements (speaking, chewing, swallowing)? • Severe pain (worse at night)? • Bladder/bowel control difficulty? • Rapid heart rate / Difficulty breathing? • For Scenario B: Fever, joint pain, skin rash, vomiting, diarrhea, FHx of poliomyelitis?	• Neuro: Areflexia or hyporeflexia (Absent deep tendon reflexes, lower limbs first). Ascending Weakness: Symmetrical weakness/paralysis starting distally and moving upwards. Hypotonia, Sensory changes. • CN: Facial weakness (VII), Ophthalmoparesis, Dysphagia, Dysarthria, Ptosis. • Resp: Poor inspiratory effort, paradoxical breathing. • Autonomic: Tachycardia/bradycardia, BP lability. • Abd: Paralytic ileus (paucity of bowel sounds), Suprapubic fullness (urinary retention).	• Lumbar Puncture (CSF): Albuminocytologic dissociation / albamino-cytological dissociation (High Protein, Normal White Cells). • Resp: Spirometry (FVC) and pulmonary function parameters to monitor respiratory muscle reserve (vital capacity) / respiratory function. • Nerve: EMG, Nerve Conduction Studies (NCS) (Signs of demyelination). • Blood: CBC, Metabolic panels, ESR. • Imaging: MRI/CT Spine (enhancement).	• Acute myelopathy (transverse myelitis, compression) • Poliomyelitis (Asymmetric, fever) • Chronic inflammatory demyelinating polyneuropathy • Spinal cord compression/Tumor • Toxic neuropathies (lead, arsenic, thallium) • Tick paralysis • Botulism • Vitamin deficiency (B12) • Conversion disorder • Porphyria • Vasculitic neuropathies • Acute cerebellar ataxia • Neurotoxic fish • Paraneoplastic • Posterior fossa lesion • Vascular: infarction or thrombosis • Encephalitis	• Admission: Hospital/ICU admission for respiratory and cardiac monitoring/support. • Specific Tx / Immunotherapy: IVIG (Intravenous Immunoglobulin) or Plasmapheresis. • Monitoring: Monitor respiratory function (FVC). • Supportive: Physiotherapy, pain control, bowel/bladder care, DVT prophylaxis.
Chickenpox (Varicella)	Scenario (History): History of exposure to an infected person, followed by fever, malaise, and an itchy vesicular rash appearing on the face, with a red-brown appearance on the hands. Scenario (Clinic): A 6 y/o boy present to the clinic with his mother with fever and malaise lasting for 2 days followed by red skin rash almost all over the body.	• “Is the child fully up to date with immunizations (or missed the Varicella vaccine)?” • “Is the child on steroids or immunocompromised?” (Risk of severe disease). • Itching/Pain? • Sick contacts? • Start site of rash?	• Rash Characteristics: Polymorphic/Pleomorphic Rash: Macules, papules, vesicles, and crusts present simultaneously. Small red flat spots → Papules → Vesicles/Blisters → Dry brown scabs. • Appearance: “Dewdrop on a rose petal” appearance.	• Clinical: Usually a clinical diagnosis. • Labs (if uncertain): PCR from vesicle fluid, Serology (IgM/PCR), Tzanck smear (from vesicular scrapings), ELISA, Latex agglutination.	• Dermatitis • Impetigo • Allergic Reaction	• Isolation: School exclusion until all lesions crusted over (approx. 5 days). • Supportive & Symptomatic Treatment: Hygiene (warm water cleaning), Fluids, Paracetamol/Antipyretics, Calamine lotion, Antihistamines for itching. • Medication Warnings: Avoid Ibuprofen / NSAIDs due to the risk of Necrotizing Fasciitis. Avoid Aspirin. • Medical Tx: Antivirals (Acyclovir) given in high-risk groups or if complications arise. • Safety Net: Watch for bacterial superinfection (redness/pain) or ataxia (varicella encephalitis).
Developmental Delay / Microcephaly	Scenario: A 7-month-old boy brought by his parents as he was not gaining milestones. The child was often quiet. His parents were not concerned, but his grandmother noticed the child’s head looked smaller (microcephaly), and the child was somewhat stiff. (Context: Possible as a clinical case or OSCE).	• “Were there any infections (e.g., CMV, Zika) or complications during pregnancy/birth, and what is the birth history (any HIE/asphyxia, trauma, ICU admission)?” • Pregnancy hx (infection, drugs, radiation)? • “How is his feeding and does he startle easily?” (Screening for CP/neurological issues). • Family hx of similar cases? • History of Meningitis/Encephalitis?	• Measurement: Microcephaly: Head circumference <2nd centile or <3rd percentile (plotted on chart). • Neuro: Hypertonia / Spasticity: Increased tone (stiffness), scissoring of legs/posture, fisting of hands (suggesting Spastic Cerebral Palsy). • Dev: Persistent primitive reflexes, Delayed milestones, hyperreflexia.	• Imaging: Brain MRI / CT Brain to look for structural malformations or calcifications (TORCH). • Genetic/Metabolic: Genetic Testing (Microarray/Karyotype, Chromosomal analysis), metabolic screening. • Infectious: TORCH Screen (Blood/Urine) for congenital infections. • Neuro: EEG.	• Congenital CMV infection • Familial Microcephaly (Genetic) • Genetic syndromes • Metabolic disorders (Inborn Error of Metabolism) • White Matter Disease (Leukodystrophy) • Craniosynostosis	• Team Approach: Multidisciplinary Team (MDT). • Therapies: Physiotherapy / Occupational Therapy (OT) for stiffness, Speech and Language Therapy for feeding. • Medical: Botulinum toxin (for spasticity), Anticonvulsants. • Referrals: Paediatric Neurology referral.
Child Abuse (Safeguarding) & FTT	Scenario A: 4 month old girl, well child visited clinic. Mother complained about poor wt gain… Mom alleged that feeding was going well (breastfeeding). Wt = 5kg. Went to ER at age 5 months. Wt was “down”. Infant transferred to a childrens hospital for inpatient stay. Infant refusing to breast or bottle feed. Received NG tube feeds for approx 2 weeks. Wt gain rapidly picked up at 6 month. Scenario B: A 3 month old baby is referred by a GP who noticed bruises when the baby was seen for their routine immunization. The baby attends with both parents. There is a 1 cm circular bruise to the abdomen. The baby is quiet, and it is mentioned that his feed reduced that day, but he is otherwise well.	• Mechanism / Detailed Account: “How exactly did the bruise/injury happen?” (Inconsistencies are red flags. Does the detailed account match the child’s development?). • Development: “Does the baby roll or move independently?” (Crucial rule: “Those who don’t cruise, don’t bruise”). • Social/Family: Who is at home? Who was present? Any domestic violence, substance misuse, stressors, unemployment? • Feeding: Details (formula mixing, frequency)? • Medical Hx: History of trauma/bruises (unexplained)? Bleeding disorder history/Family background?	• Skin/Physical: Full Skin Survey: Check hidden areas (ears, neck, buttocks) for other bruises (at different stages of healing) or scars. Signs of trauma, Hygiene, Interaction with parents. • Ocular: Fundoscopy: Check for retinal hemorrhages (Shaken Baby Syndrome). • Oral: Oral Exam: Check for a torn frenulum. • Skeletal: Skeletal Exam: Palpate/survey for old fractures. • Growth: Check plotting on centile charts. Weight dropping > Height/Head. “Sawtooth” chart or crossing major percentiles twice.	• Imaging: Skeletal Survey (X-rays/CT Scan) to check for occult/old fractures (ribs, metaphyseal bucket-handle fractures). • Neuro-imaging: CT Head to rule out subdural accumulation/intracranial injury (especially if CNS signs are present). • Bloods/Labs: Coagulation Screen / Profile (to rule out bleeding disorders e.g., Hemophilia), CBC, Electrolytes. • Documentation: Medical photography / photos of bruises. • Social: Social work assessment.	• Organic FTT (Celiac, CF, Pyloric Stenosis) • Bleeding Disorders (Hemophilia, ITP) • SLE	• Immediate Action: Maintain High Authority: Escalate immediately to Consultant, Safeguarding Lead, and Social Services. • Documentation: Confirmatory Documentation: Accurate drawings (body map / diagrams), photos, and verbatim recording of history. • Safety/Admission: Take Child to Safe Place: Admit the child to the ward (hospitalization as a place of safety) pending investigation; do not let the child go home. Observe feeding, document wt gain. • Investigations/Social: MASH referral (Multi-Agency Safeguarding Hub), check sibling safety, and investigate other family members/siblings. CPS if needed, Multidisciplinary Team. • Nutrition: Catch-up growth calories.
Diabetic Ketoacidosis (DKA) / IDDM -	Scenario: A 9-year-old boy brought to your clinic by his mother. She noticed that he’s not feeling well for the past one week with a bed-wetting. On examination he is found to be dehydrated. Note: “acetone and glucose in urine Diagnostic Criteria: Symptoms + Casual glucose ≥11.1 mmol/L (200mg/dL) OR Fasting ≥7.0 mmol/L (126mg/dL) OR OGTT 2hr ≥11.1 mmol/L. HbA1c ≥6.5% (if available). DKA Severity: Mild (pH<7.3), Moderate (pH<7.2), Severe (pH<7.1). Type 1 vs Type 2: Type 1 (acute onset, DKA common, low C-peptide, positive antibodies, insulin dependent); Type 2 (obesity, acanthosis nigricans, insulin resistance, HHS risk).	• 4 classic symptoms: Polyuria, Polydipsia, Weight loss, Polyphagia? • DKA symptoms: Vomiting, Abdominal pain (can mimic surgical abdomen), Kussmaul breathing, Acetone breath, Drowsiness/Confusion? • Risk factors: Family Hx (Type 1: ≤10%), Recent infection, Omission of insulin/pump failure, Trauma? • Type 2 indicators: Obesity, Acanthosis nigricans, Slow onset, Pubertal age? • HHS indicators: More CNS symptoms, higher glucose (>33.3 mmol/L), minimal ketones?	• Vitals: Tachycardia, Kussmaul breathing (deep, rapid), Tachypnea, Hypotension, Fever. • General: Dehydration (dry membranes, ↓ skin turgor, sunken fontanelle), Altered LOC (drowsiness to coma). • Breath: Acetone smell (fruity). • Abdomen: Tenderness, distension (ileus). • CNS: Cerebral edema warning signs: Headache, high BP, bradycardia, vomiting, focal neuro deficits, altered consciousness (emergency!).	• Blood: Glucose (>200mg/dL), Blood Gas (pH<7.3, HCO3<15), β-hydroxybutyrate ≥3mmol/L, HbA1c, Electrolytes (Na, K - watch for ↓K despite normal levels due to shifts), Urea/Creatinine, Osmolarity. • Urine: Ketones (moderate/severe). • CBC: Infection screen. • Precipitating factors: Cultures, CXR if indicated.	• HHS (Hyperglycemic Hyperosmolar State): pH>7.25, bicarb>18, osmolarity>320, minimal ketones, higher mortality. • Diabetes Insipidus (DI): Dilute urine, no acidosis. • Gastroenteritis (vomiting/dehydration but no acidosis/hyperglycemia). • UTI (enuresis/polyuria but no systemic acidosis). • Acute Abdomen (appendicitis - but DKA can cause pseudo-surgical abdomen). • Psychogenic Polydipsia (dilutes urine, no ketones). • Chronic Renal Failure (uremia, different electrolyte pattern).	• Emergency ABC: 2 IV lines, gastric tube if obtunded, catheter if needed, ICU/HDU admission. • Fluid Resuscitation: - Shock: 20mL/kg NS/Ringer bolus (repeat up to 3x, don’t subtract from deficit). - Severe dehydration: 10-20mL/kg over 20-30 mins. - Maintenance + Deficit: Holliday-Segar formula (M + ½ deficit over 24h). Use 0.45% NS + 5% dextrose when BG 250-300mg/dL. • Insulin: Start 1hr AFTER fluids. IV 0.1U/kg/hr (or 0.05U/kg/hr if <5yrs or pH>7.15). Continue until DKA resolved. Target glucose drop: 2-5mmol/hr. • Potassium (CRITICAL): - Start KCl 40mmol/L when urine output confirmed AND K+ 3.5-5.5. - If K+<3.5: Give K+ first, DEFER insulin until K+>3.5. - If K+<2.5: 0.5mmol/kg/hr until >3.5. - If K+>5.5: Give insulin, defer K+ until urine passes. • Phosphate: Replace if <1mg/dL (0.32mmol/L) - risk of rhabdomyolysis, hemolysis, respiratory failure. • Bicarbonate: Only if pH<6.9 with circulatory compromise (causes paradoxical CNS acidosis). • Cerebral Edema Management (EMERGENCY): - Reduce fluids by 1/3, elevate head. - Mannitol 1g/kg over 20-30 min OR 3% NaCl 2.5-5mL/kg. - Move to ICU, consider ventilation (keep PaCO2 >3.5kPa). • Monitoring: Hourly vitals, glucose, neuro obs (GCS). 2-4hly U&E, gases. • HHS specifics: Slower fluid replacement, anticoagulation (LMWH if >12yrs), watch for rhabdomyolysis. • Transition: SC insulin once eating (overlap IV/SC 1-2hrs). Basal-bolus or pump. • Prevention: Sick day rules, never stop insulin, ketone testing when BG>240mg/dL or sick.
Stridor/Wheezing Differential: Approach to Infant Upper Airway Obstruction	Scenario: Infant/child presenting with stridor, wheezing, or respiratory distress. Differentiate based on onset, associated symptoms, and patient appearance.	• Onset: Sudden (foreign body) vs Gradual (infection/congenital)? • Character: Barking cough (croup) vs No cough (laryngomalacia)? • Trigger: Crying/excitement (laryngomalacia) vs Feeding (vascular ring)? • Appearance: Toxic (epiglottitis) vs Non-toxic? • Drooling? • Position: Tripod (epiglottitis) vs Supine preference?	• General: Toxic vs Non-toxic appearance (key differentiator). • Airway: Inspiratory vs Expiratory vs Biphasic stridor. • Work of breathing: Retractions, nasal flaring, cyanosis. • Voice/Cry: Hoarse (croup) vs Normal (laryngomalacia) vs Muffled (epiglottitis).	• Laryngoscopy: Direct visualization (epiglottitis = cherry-red, swollen epiglottis). • Imaging: X-ray Neck (Steeple sign - croup; Thumb sign - epiglottitis). • CXR: Hyperinflation (foreign body aspiration - check for asymmetry). • Barium swallow/CT/MRI: Vascular rings, tracheomalacia.	• Acute onset: Foreign Body Aspiration, Epiglottitis, Bacterial Tracheitis, Anaphylaxis • Chronic: Laryngomalacia, Vascular Ring/Sling, Subglottic Stenosis, Tracheomalacia • Infectious: Viral Croup, Spasmodic Croup, Diphtheria • Other: Retropharyngeal abscess, Angioneurotic edema, Vocal cord paralysis	• Emergency: Secure airway first in suspected epiglottitis (DO NOT examine throat/needle procedures). • Croup: Dexamethasone ± Racemic epinephrine. • Foreign body: Heimlich/back blows (if complete obstruction), Bronchoscopy for removal. • Laryngomalacia: Conservative (self-resolves by 12-24 months), surgery only for severe cases. • Vascular rings: Surgical division of ring.
Shock Case 1 (Trauma/Hypovolemic)	Scenario: 12 years old boy came to ER with abdominal injuries caused by flipping over bicycle which happened 4 hours ago. No loss of consciousness, wearing helmet. Increasing abdominal pain. HR 130, BP 110/50, RR 30, SpO2 92%.	• Events leading to presentation? • Allergies/Meds/PMH/Last meal (SAMPLE)?	• Primary Survey: Airway patent? Breathing? Circulation (Tachycardia, Normal/Low BP). • Abd: Bruising, tenderness.	• FAST scan. • Blood type and cross. • CBC, Electrolytes.	• Hypovolemic Shock (Hemorrhagic) • Splenic/Liver Laceration	• ABCDE Approach. • Airway: Secure in-line. • Circulation: IV Fluid 20mL/kg (max 3 doses - 3rd for blood transfusion mostly). • Refractory: Blood transfusion if no response to fluid.
Shock Case 2 (Septic)	Scenario: 10 years old girl with high grade fever (40C) and lethargy. Known case of leukemia. Becoming more confused over last hour. HR 130, BP 80/30 (Hypotensive), RR 35, SpO2 93%.	• Recent chemotherapy? • Central line present? • Sick contacts?	• General: Lethargy, Confusion (Altered mental status). • Vitals: Fever, Hypotension, Tachycardia. • Skin: Check for petechiae/purpura.	• Blood: Blood culture, CBC, Lactate, Electrolytes. • Urine: Culture.	• Septic Shock • Tumor Lysis Syndrome • Intracranial Hemorrhage	• ABCDE Approach. • Airway/Breathing: O2 mask / Oropharyngeal airway. • Circulation: NS 20mL/kg bolus over 5-10 min. • Meds: Broad-spectrum Antibiotics (within 1 hr), Epinephrine infusion (if fluid refractory).
Shock Case 3 (Obstructive/Desaturation)	Scenario: 6 years old boy who was intubated due to decreased mental status. You are called because of sudden desaturating (orig: “desating”) while he is on mechanical ventilation. HR 140, BP 80/54, SpO2 68% on 100% O2.	N/A - Acute Event	• DOPE Mnemonic: • Displacement of tube? • Obstruction of tube? • Pneumothorax (Hyperresonance, tracheal deviation)? • Equipment failure?	• CXR (stat). • Auscultation (diminished breath sounds).	• Tension Pneumothorax • Mucus Plug • Tube migration	• Immediate: Disconnect from vent and bag manually. • Pneumothorax: Needle decompression → Chest tube.
Shock Case 4 (Cardiogenic)	Scenario: 4 months old girl, increased work of breathing, substernal/intercostal retractions, weak cry, wheezing. 3 days ago treated with steroids/Ventolin (asthma misdiagnosis) with no improvement. HR 200, BP 60/30 (Hypotensive), RR 60, SpO2 89%, Temp 37.5C. Weight 7kg. Cold extremities.	• History of feeding difficulties/sweating? • Family Hx?	• Signs of HF: Hepatomegaly (- key sign of right-sided heart failure in infants), JVP (distended neck veins), Edema/Sacral edema.) • Lung: Crepitations/Wheezing (Pulmonary edema). • CVS: Murmurs, Gallop.	• CXR (Cardiomegaly, Pulmonary edema). • Echo. • ECG.	• Cardiogenic Shock • Congenital Heart Disease • Myocarditis • Sepsis (misdiagnosis)	• ABCDE Approach. • Fluid: Cautious! 5-10 mL/kg (not 20) to avoid worsening failure. • Meds: Inotropes (Dopamine/Dobutamine/Epinephrine).
Hypoxic-Ischemic Encephalopathy (HIE) —/	Scenario: 5 days old female baby Mariyam, weighing 2.9kg and K/C of birth asphyxia delivered via CS due to breech presentation at 38 weeks of gestation was admitted on 15-9-2013 with C/O, Fits for 1 day, reluctant to feed for 1 day. HISTORY OF PRESENTING COMPLAIN: According to attendant, baby was in usual state of health 1 day back when she started having fits in the morning. Fits were focal and involved either one limb at one time with flickering of eyes and lasting 5-10 secs occurring every 2 to 3 hrs. Hx: Tazocin/Vancomycin.	• Maternal history (Sentinel event)? • Meconium stained amniotic fluid? • Apgar scores/Resuscitation details? • Cord pH? • Feeding history (NPO)?	• Neuro: Altered LOC, Hypotonia, Seizures, Absent reflexes. • Systemic: Weak breathing, peripheral cyanosis.	• Imaging: MRI Brain (DWI sequences). • Labs: Blood gas (Metabolic acidosis), Lactate, LFT, Bilirubin. • Neuro: aEEG.	• Metabolic Disorder • Meningitis • Stroke • Intracranial Hemorrhage	• Neuroprotection: Therapeutic Hypothermia (Head Cooling) within 6h. • Support: Mechanical Ventilation, BP support. • Seizures: Control seizures (Phenobarbital).
Juvenile Idiopathic Arthritis (JIA)	Scenario A: A 5-year-old boy brought by his mother who noticed a skin rash on his chest and he also c/o left knee joint pain. He was normal before that. On examination his vital signs are stable except the temperature it was high (38.5). Scenario B: 9 years old girl presented with two months history of multiple joints pain associated with limitation of movements & morning stiffness. Clinically had multiple joints effusions & tenderness which prevent her from daily activities as well as walking. Scenario C (Case 280): 4 years old female who been limping with swelling on Right knee. For several month she can’t fully extend Right Knee.	• Fever (duration, onset, course)? • Morning stiffness duration (>30 mins)? • Rash (all over chest or one part)? • Weight loss/Fatigue/Anorexia? • Eye redness (uveitis)? • Raw milk ingestion (Brucellosis check)? • Family Hx?	• Joints: Swelling, effusion, warmth, tenderness, limitation of ROM (“slougy synditis” → boggy synovitis). • Systemic: Rash, Lymphadenopathy, Hepatosplenomegaly, Rheumatic nodules. • Eyes: Slit lamp exam (Uveitis). • General: Pale, in pain.	• Inflammatory: ESR, CRP (High). • Serology: ANA (uveitis risk), RF (Scenario B was +ve), Anti-titer. • Blood: CBC, Blood Culture. • Imaging: X-ray joints. • Other: Brucella titer (if raw milk hx), Urine analysis, LFT, U/E.	• Rheumatic Fever • Leukemia (ALL) • Septic Arthritis • SLE • Brucellosis ("") • Kawasaki Disease • HSP • Enthesitis-related arthritis • IBD • Psoriatic JIA • Reactive arthritis • Sarcoidosis	• Meds: NSAIDs (Naproxen 250mg BID), Methotrexate (15mg/week) + Folic Acid, Corticosteroids (Methylprednisolone IV 30mg/kg pulse then oral Prednisone taper), Zantac (150mg), Calcium (500mg), Vit D (10 drops). • Support: PT/OT, Ophthalmology consultation. • MDT: Rheumatologist, Nurse, Social Worker, Psychologist.
Hemolytic Uremic Syndrome (HUS)	Scenario: Case with bloody diarrhea and renal failure.	• Diarrhea (Bloody)? • Oliguria/Anuria? • Uncooked meat ingestion / Food poisoning? • Petechiae/Bruises?	• General: Pallor, Lethargy/Weakness. • Renal: Hypertension, Edema. • Abd: Liver/Spleen swelling. • Neuro: Changes.	• Blood: CBC (Anemia, Thrombocytopenia, High Retics), Smear (Schistocytes), LFT (High Bilirubin/AST/Amylase), RFT (High Cr). • Urine: Hematuria, Protein, Casts. • Stool: Culture (E. Coli / Shiga toxin).	• ITP • DIC • HSP	• Supportive: Hydration, Dialysis (if needed), RBC transfusion. • Control: Hypertension. • Contraindicated: Antibiotics, Platelet transfusion, Anti-diarrheals.
Acute Lymphoblastic Leukemia (ALL)	Scenario: A 4-year-old girl was generally unwell, lethargic, and occasionally febrile over a period of 9 weeks. Two courses of antibiotics for recurrent sore throat failed to result in any benefit. Her parents returned to their general practitioner when she developed a rash. Blood smear was done and showed smudge cells.	• Bone pain? • Bleeding/Bruising/Nasal bleeds? • Weight loss/Anorexia? • Radiation exposure? • Vomiting/Headache (CNS)?	• General: Pallor, Fever, Petechiae/Ecchymosis/Bruising. • Organomegaly: Hepatosplenomegaly, Lymphadenopathy. • MSK: Bone tenderness.	• Blood: CBC (Pancytopenia or blasts), Peripheral Smear (Blasts/Smudge cells). • Marrow: Bone Marrow Aspiration/Biopsy (Definitive). • Other: CXR (Mediastinal mass), LP (CNS).	• ITP • Aplastic Anemia • Infectious Mononucleosis • Lymphoma (Non-Hodgkin’s) • SLE • Megaloblastic anemia	• Chemotherapy: Prednisone, Vincristine, Asparaginase, Doxorubicin, Cytarabine, Cyclophosphamide, Methotrexate, Mercaptopurine. • Support: Transfusions. • Transplant: BMT.
Lymphadenopathy Approach	Scenario: Child with enlarged lymph nodes. Red flags: Supraclavicular node, >2cm, fixed/hard, systemic symptoms (fever, wt loss). (General scenario).	• Duration/Onset? • Painful? • Systemic symptoms (fever, night sweats, wt loss)? • Cat/Animal exposure? • TB exposure?	• Character: Size (>2cm worrisome), Consistency (hard/matted/rubbery), Fixation, Tenderness. • Location: Supraclavicular (High risk malignancy).	• Blood: CBC, ESR, CRP, Serology (EBV, CMV, Bartonella). • Imaging: CXR, US. • Biopsy: If red flags present or persistent.	• Infection (Viral, Bacterial, TB, Cat Scratch) • Malignancy (Lymphoma, Leukemia, Neuroblastoma) • Autoimmune (SLE, JIA)	• Infectious (Acute/Tender): Oral antibiotics (Flucloxacillin). • Red Flags: Urgent referral for biopsy/oncology.
Chronic Limp / Knee Swelling	Scenario: 4 years old female who been limping with swelling on Right knee. For several month she can’t fully extend Right Knee. (Verbatim from raw text: “Case 280”).	• Skin Rash - ocular Rash? • Heart disease? • Fever / Loss of appetite? • Other Joint Affected? • Family history? • Raw milk Ingestion?	• Examine Joint. • Examine Lymph node. • Rheumatic nodule.	• Antititer. • Rheumatoid Factor. • Chest x-ray. • ECG.	• Rheumatoid Juvenile Arthritis • Brucellosis (common in regions where unpasteurized/raw milk is consumed) • Septic arthritis, Transient synovitis (aspiration to confirm) • Leukemia • Kawasaki disease	• Meds: NSAIDs (“NISAR”) to prevent Joint damage/dec pain. • Steroid. • Physiotherapy (orig: “Phytotherapy”). • Modifying agent.
Septic Arthritis	Scenario: Swollen limb or joint with warmth & erythema. Inability to use the extremity (non-weight bearing). Joint effusion & severe pain on passive movement. (From Sepsis/Febrile file).	• Trauma? • Recent infection? • Fever?	• Joint: Swollen, warm, erythematous, effusion. • Function: Non-weight bearing, severe pain on passive ROM (pseudoparalysis).	• Joint Aspiration (Synovial Fluid): Culture, Cell count, Gram stain. • Blood: Culture, CBC, ESR/CRP. • Imaging: US/MRI.	• Transient Synovitis • Osteomyelitis • JIA • Trauma/Fracture • Cellulitis	• Urgent: Orthopedic consultation. • Procedure: Joint aspiration/Washout. • Meds: IV Antibiotics.
Viral Croup / laryngo-tracheo-broncho-pneumonitis	Scenario: Ali is 20 month old male who presents to the emergency department with a chief complaint of cough. Two days ago he developed rhinorrhea, fever, a hoarse cry and a progressively worsening, harsh, “barky,” cough. Today he developed a “whistling” sound when he breathes. Exam: VS T 38.5, P 140, R 36, BP 90/64. He is alert, with good eye contact. He has a dry barking cough and a hoarse cry.	• Stridor at rest? • Symptoms subside during day? • Rapid progression (<12 hrs)? • Drooling/Swallowing difficulty? • Vaccination status? • Previous episodes? • Known airway abnormality? • Ability to tolerate oral fluids?	• Resp: Inspiratory Stridor, Barking cough, Hoarseness, Retractions (suprasternal/subcostal), Cyanosis/Air entry, Wheeze. • General: Alert, good eye contact (differentiates from Epiglottitis).	• Imaging: X-ray Neck AP (Steeple Sign), Chest X-ray. • Oximetry. • Lab: CBC. • Caution: Do not agitate child with invasive exams if stable.	• Acute Epiglottitis • Bacterial Tracheitis • Foreign Body Aspiration • Retropharyngeal/Peritonsillar Abscess • Spasmodic Croup • Angioneurotic edema • Laryngeal diphtheria	• Mild: Mist therapy (warm/cool), Reassurance. • Mod/Severe: Dexamethasone/Corticosteroids. • Emergency: Nebulized Racemic Epinephrine. • Severe Airway: Assess patency by direct laryngoscopy, Intubation.
Brief Resolved Unexplained Event (BRUE)	Scenario: Infant < 1 year stops breathing, change in muscle tone (limp/rigid), turns pale/blue, unresponsive. Event lasts < 1 minute (usually 30-60s). Returned to baseline. (General scenario).	• History of reflux/choking? • Recent cold? • Medications/Toxins? • Trauma/Abuse?	• General: Appearance (well vs unwell). • Neuro: Responsiveness. • Resp: Signs of infection/distress. • Trauma check.	• Low Risk: Often no testing needed. • High Risk: CBC, Electrolytes, ECG, Pertussis PCR, RSVP, Monitoring.	• GERD (Reflux) • Seizure • Infection (Whooping cough/RSV) • Arrhythmia • Abuse • Metabolic disorder (Organic acidemia) • Foreign body aspiration	• Low Risk: Discharge with education/CPR training. • High Risk/Concern: Admission for monitoring (HR/Breathing).
Cardiac Syncope	Scenario: 11-year-old girl passed out during reading; awoke after 3 min. She was stiff with eyes rolled back ~ approx. 3 min. Now awake and alert; no retractions; skin color is normal. Normal appearance, normal breathing, normal circulation. Vital signs: HR 70; RR 20; BP 90/60; T 37.7° C Wt 39 kg; O₂ sat 99%. Three similar episodes; Preceded by palpitations, one of them associated with “exercise.” PMH and FH: Negative.	• Palpitations? • Exercise induced? • Family Hx (Sudden death)? • Post-ictal state (absent)?	• CVS: Murmurs, Rhythm. • Neuro: Normal usually.	• Cardiac: ECG (Long QT, WPW, Brugada), Holter, Echo, Cardiac MRI, Stress ECG. • Labs: Electrolytes (Ca, Mg, PO4), Cardiac enzymes, CBC.	• Seizures (Epilepsy) • Vasovagal Syncope • Arrhythmia (LQTS, CPVT) • Structural (HOCM, AS) • Myocarditis	• Dependent on cause: • LQTS: Beta-blockers. • Vasovagal: Hydration. • Structural: Surgery/Restriction.
Dermatology Cases -------=-=-=-=-=]-=-=	Scenario A (Contact Dermatitis): 14-year-old girl with severe itching, linear erythema, blisters on arms/legs after hiking in woods. History of allergic rhinitis. Scenario B (Seborrheic Dermatitis): 15-year-old with redness and scaling of eyebrows and alar crease, no itching, moisturizers failed. Scenario C (Alopecia Areata): 15-year-old boy with single asymptomatic patch of alopecia, progressed to multiple patches. Mother denies hair pulling. Scenario D (Tinea Capitis): Broken hair with scales, follicles present (fungal infection). Scenario E (Hemangioma): Superficial bright red plaque, raised above skin, blanching; or deep bluish subcutaneous mass. Presents at birth or shortly after. Scenario F (Port Wine Stain/Sturge-Weber): Pink-red patches along V1 (forehead, eyelid, nose) distribution. Risk of glaucoma, seizures, developmental delay. Scenario G (Mongolian Spots): Congenital dermal melanocytosis - blue-gray patches on buttocks/back, present at birth. Scenario H (Neurofibromatosis Type 1): Multiple café au lait spots (>6, >5mm), axillary freckling (Crowe’s sign), Lisch nodules, cutaneous neurofibromas. Scenario I (Impetigo): Golden honey-colored crusted lesions, contagious bacterial infection. Scenario J (Erythema Multiforme): Targetoid lesions (3 concentric zones), often herpes-triggered. Scenario K (SJS/TEN): Severe mucocutaneous reactions, widespread bullae, skin detachment, positive Nikolsky sign, drug-induced. Scenario L (Scabies): Intense nocturnal itching, burrows in web spaces, secondary excoriations. Scenario M (Fifth Disease/Parvovirus B-19): “Slapped cheek” rash followed by lacy reticular rash on extremities. Scenario N (Shingles/Herpes Zoster): Painful grouped vesicles in dermatomal distribution, VZV reactivation. Scenario O (Hand-Foot-Mouth Disease): Coxsackie virus - oral ulcers plus vesicles on palms/soles. Scenario P (Candidiasis/Diaper Dermatitis): Beefy red rash with satellite pustules/lesions.	• For Contact Dermatitis: Recent exposure to plants (ivy/poison oak), outdoor activity, new cosmetics/detergents? • For Hair Disorders: Hair pulling behavior (trichotillomania vs alopecia areata), family history of autoimmune disease? • For Vascular Lesions: Age of onset (congenital vs acquired), growth pattern, associated neurological symptoms (Sturge-Weber)? • For Pigmented Lesions: Number and size of café au lait spots, family history of NF1? • For Infectious Rashes: Sick contacts, fever, vaccination status (Fifth disease), pain/itching pattern (scabies = nocturnal), immunocompromise (shingles)? • For Severe Reactions: Recent medication exposure (SJS/TEN), mucosal involvement, systemic symptoms?	• Contact Dermatitis: Linear streaks of erythema, vesicles, blisters; sharp demarcation at exposure site; intense pruritus. • Seborrheic Dermatitis: Greasy scales on scalp/eyebrows/nasolabial folds; salmon-pink patches; minimal inflammation. • Alopecia Areata: Well-circumscribed smooth patches, “exclamation mark” hairs at margins, nail pitting. • Tinea Capitis: Scaling with broken hair, black dots (fractured hair shafts), lymphadenopathy, possible kerion (boggy mass). • Hemangioma: Superficial (strawberry mark) or deep (subcutaneous blue mass); involutes over years. • Port Wine Stain: Flat pink-red macule that darkens with age; follows V1 trigeminal distribution; no blanching. • Mongolian Spots: Blue-gray macules on sacrum/buttocks; fade by age 5. • NF1: Café au lait spots (>6, >5mm), Crowe’s sign (axillary freckling), neurofibromas, macrocephaly. • Erythema Multiforme: Target lesions with central dusky erythema, pale ring, outer erythematous halo; symmetric. • SJS/TEN: Mucosal ulceration, widespread painful erythema, flaccid bullae, positive Nikolsky sign, epidermal detachment. • Scabies: Linear burrows in finger webs/wrists/genitalia; excoriations; nocturnal worsening. • Fifth Disease: Bright red “slapped cheek” followed by lacy reticular rash on limbs (spares palms/soles). • Shingles: Grouped vesicles on erythematous base in dermatomal pattern; pain precedes rash; T3-L3 most common.	• Skin: KOH prep (fungal hyphae - tinea), Tzanck smear (multinucleated giant cells - herpes), Skin scraping for scabies (mites/eggs). • Biopsy: For SJS/TEN (full-thickness epidermal necrosis), for NF1 (neurofibromas). • Wood’s Lamp: Coral-red fluorescence (erythrasma), green fluorescence (Microsporum). • Imaging: MRI Brain (Sturge-Weber - leptomeningeal angioma), orbital US (glaucoma risk). • Labs: CBC, ESR/CRP, ANA (autoimmune alopecia), IgE levels, viral PCR (VZV, HSV, Parvovirus B-19). • Ophthalmology: Slit lamp for NF1 (Lisch nodules), Sturge-Weber (glaucoma).	• Contact Dermatitis: Allergic vs irritant; Poison ivy (urushiol). • Tinea Capitis: Trichophyton tonsurans (most common), Microsporum. • Alopecia: Tinea capitis (scaling present), trichotillomania (irregular patches, broken hairs), alopecia totalis/universalis. • Vascular Lesions: Hemangioma (grows then involutes) vs Port wine stain (grows with child); Vascular malformations. • Exanthems: Fifth disease (parvovirus), Roseola (HHV-6), Measles, Rubella, Scarlet fever. • Severe Reactions: EM major vs SJS vs TEN (spectrum); Stevens-Johnson/toxic epidermal necrolysis overlap. • Blistering: Bullous impetigo vs SSSS vs SJS. • Neurocutaneous: NF1, Sturge-Weber, Tuberous sclerosis (hypopigmented ash-leaf spots).	• Contact Dermatitis: Avoid trigger, wash with water; IU Steroids (topical then systemic if severe), Antihistamines for pruritus; calamine lotion. • Seborrheic Dermatitis: Corticosteroid + Antifungal combination; selenium sulfide shampoo; ketoconazole cream/shampoo. • Alopecia Areata: Mild potency steroids (intralesional triamcinolone); minoxidil; immunotherapy for extensive cases. • Tinea Capitis: Oral Griseofulvin (6-8 weeks) or Terbinafine (4 weeks); selenium sulfide shampoo adjunct; treat family contacts; kerion needs systemic steroids with antifungals. • Hemangioma: Observation (most involute); Propranolol (1st line for complicated lesions e.g. obstructing vision/airway, ulceration, FTT); Screen liver (US) if $\ge 5$ skin lesions. Timolol gel (superficial); laser; surgery for residual lesions. • Port Wine Stain: Pulsed dye laser (treatment of choice); treat before age 5 for best results; ophthalmology follow-up for V1 lesions; anti-seizure meds if CNS involvement. • SJS/TEN: Stop drug + Supportive Care (Burn Unit). Steroids are controversial/risky (sepsis). Discontinue offending drug immediately; ICU/burn unit care; IVIG, cyclosporine; fluid management; prevent sepsis; NO steroids (controversial in TEN). • Scabies: Permethrin 5% cream (from neck down, 8-12 hours, repeat in 7 days); treat all household contacts; oral ivermectin (crusted scabies/institutional outbreaks). • Fifth Disease: Supportive care; avoid contact with pregnant women (hydrops risk) and immunocompromised; transfusion if aplastic crisis in sickle cell. • Shingles: Acyclovir/Valacyclovir within 72 hours; pain management; post-herpetic neuralgia prevention in elderly; avoid contact with immunocompromised/pregnant. • NF1: Multidisciplinary follow-up; blood pressure monitoring (pheochromocytoma risk); surgical resection if neurofibromas symptomatic; no cure.
Down Syndrome with CHD	Scenario A: A 3-month-old girl who has Down syndrome exhibits poor weight gain, tachycardia, tachypnea, and a low-pitched grade 2 systolic murmur. Oxygen saturation 94% in room air. Chest radiography reveals cardiomegaly and increased pulmonary vascularity. Scenario B: 18 days girl known as Down Syndrome come to clinic complaining of refuse feeding. She is tachypneic, tachycardia. On Examination she has 2nd Grade murmur.	• Sweating with breast feeding? • Bluish discoloration (Cyanosis)? • Feeding difficulty / fatigue? • Weight gain history? • GI symptoms/Cough?	• General: Dysmorphic features of Down Syndrome. • CVS: Central cyanosis, Murmur, Hyperactive precordium. • Resp: Basal crepitation, Wheezing. • Other: Edema.	• Imaging: Echocardiogram (Gold standard), CXR. • Electrical: ECG.	• AVSD (Complete Atrioventricular Septal Defect) • Heart Failure (Dx) • VSD / ASD • Myocarditis • Bronchiectasis	• Medical: ABC, Resuscitation, Anti-failure meds (Diuretics/Lasix, ACEi/Captopril, Digoxin, Inotropes/Dopamine). • Nutrition: High calorie formula. • Surgical: Repair (Open heart surgery).
Acute Myocarditis	Scenario: 3 months old previously healthy infant developed fever and runny nose for 3 days followed by pallor, anorexia, excessive sweating. On examination Resp. rate: 40 breaths/min. HR of 160 beats/min, hepatomegaly, and a gallop rhythm. No heart murmurs are detected. Chest X-Ray showed massive cardiomegaly.	• Sweating during feeds? • Viral prodrome (flu-like)? • Family Hx of CHD or Cardiomyopathy? • Feeding pattern (interrupted, small amounts, tired)? • Cyanosis (crying vs feeding)? • Facial puffiness / Cough? • Consanguinity?	• CVS: Tachycardia (out of proportion to fever), Gallop rhythm, Displaced apex beat (lateral), Weak pulses. • Systemic: Hepatomegaly, Pallor, Resp distress, Edema (pretibial/sacral), Ascites. • General: Dysmorphic features.	• Cardiac: Echocardiogram (dilated/poor function), Cardiac Enzymes, ECG, Arterial Blood Gases. • Infection: Viral PCR/Serology, Blood Culture. • General: CBC, LFT, Renal Profile, U&E, Metabolic screen.	• Dilated Cardiomyopathy • Congenital Heart Disease (VSD, ASD) • Supraventricular Tachycardia (SVT) • Infective Endocarditis	• Admission: Hospital/ICU. • Support: Supplemental Oxygen, Bed rest. • Meds: Inotropes (Dopamine/Dobutamine), Diuretics (Lasix), ACE Inhibitors (Captopril), Digoxin, IVIG. • Treat underlying infection, Correct anemia.
Tetralogy of Fallot (TOF)	Scenario A: a 3 month old male infant who presents to the emergency department with a history of having episodes of excessive crying followed by limpness, cyanosis and fainting… his cyanosis increased with crying. Scenario B: 4 month old baby presented to the er .His mother noticed bluish discoloration of his lips specially when he gets angry then he puts his knee to his chin and gets relieved. Systolic ejection murmurs and parasternal heave.	• Cyanosis onset/triggers (crying/feeding)? • Squatting behavior? • Tet spells history? • Feeding difficulty?	• CVS: Single S2, Ejection Systolic Murmur (LUSB), Bounding pulse, Parasternal heave. • General: Cyanosis, Clubbing.	• Imaging: CXR (“Boot-shaped heart”), Echocardiogram. • ECG: RVH. • Cath: Cardiac catheterization.	• Other Cyanotic CHDs (TGA, Tricuspid Atresia) • Pulmonary Stenosis • Severe Bronchiolitis/Pneumonia	• Acute Spell: Knee-chest position, O2, Morphine (pain/sedation), IV Fluids, Phenylephrine. • Maintenance: Beta-blockers. • Surgical: Modified Blalock-Taussig (BT) Shunt (palliative, if the infant is very cyanosed in the neonatal period) → Complete Repair at ~6 months.
Heart Failure	Scenario: General case scenario with feeding difficulties and hepatomegaly.	• Feeding difficulty/Sweating? • Growth history? • Blue discoloration? • SOB with exercise? • Hx of cardiac disease/admissions?	• Signs: Hepatomegaly, Gallop, Tachycardia, Tachypnea, Edema. • CVS: Murmur location/intensity, Femoral pulse.	• Labs: CBC, LFT, KFT. • Imaging: CXR, Echo, ECG.	• Congenital Heart Disease • Cardiomegaly • Rheumatic Fever • Anemia	• Meds: Inotropes (Dopamine), Diuretics (Furosemide/Spironolactone), ACEi, Digoxin. • Surgical: Palliative (banding) or Definitive repair/Transplant.
Nutritional Rickets	Scenario: The mother of a 23 month old dark skin infant expresses concern that her son has bowing legs and he is not growing properly. He was exclusively breastfed until 11 month of age. He is a picky eater.	• Diet (Vit D/Calcium)? • Sun exposure? • Family Hx of similar illness? • Seizures/fractures/muscle weakness?	• Skeletal: Frontal bossing, Open fontanelle, Rachitic rosary, Widened wrists, Bowing legs (Genu varum), Craniotabes, Dental abnormalities. • General: FTT, Hypotonia.	• Blood: Ca (Low/N), PO4 (Low), ALP (High), PTH (High), Vit D (Low). • X-ray: Wrist (Cupping/fraying of metaphyses, widening of physis).	• Vitamin D Dependent Rickets (Genetic) • Familial Hypophosphatemic Rickets • Renal Osteodystrophy	• Supplements: Vitamin D (therapeutic dose), Calcium. • Diet: Fortified milk, egg yolk, fish. • Prevention: Sun exposure, Vit D supplements.
Rheumatic Fever	Scenario: An 11 year old male presents with fever up to 39 degrees (102 degrees F), joint pain and swelling, along with shortness of breath. The fever comes and goes at random times of the day. The symptoms have been present now for 4 days. Two days ago, his right knee was painful and swollen, but today it has improved. The joints involved today include the right ankle and left knee. They are quite tender, painful and also swollen. The shortness of breath occurs with walking, but he is now unable to walk because of the joint pain. He also has some shortness of breath with lying down flat when he is trying to sleep.	• Recent sore throat or scarlet fever? • Chest pain/Shortness of breath? • Rash (Erythema marginatum)?	• Jones Criteria: • Major: Carditis (Murmur/Failure), Polyarthritis, Chorea, Erythema Marginatum, Subcutaneous nodules. • Minor: Fever, Arthralgia.	• Infection: Throat culture (Group A Strep), ASO titer, Anti-DNAse B, Streptococcal antibody titer. • Inflammation: ESR, CRP. • Cardiac: ECG (Prolonged PR), Echo, CXR.	• Gonococcal Arthritis • JIA • Lyme Disease • Infective Endocarditis	• Antibiotics: Penicillin (Tx infection + Prophylaxis). • Anti-inflammatory: Aspirin (Arthritis), Steroids (Severe Carditis). • Support: Bed rest, HF management.
Sickle Cell Disease (Painful Crisis)	Scenario: A 3 year old boy is brought to your general pediatric clinic with left knee pain. Upon further history taking, you elicit that the pain has lasted for 5 days. Today, he is unable to bear weight and the left knee is swollen. His mother has given him acetaminophen periodically the past few days; however it has not provided him with relief. There is no history of injury or trauma… The family originally from Alhasa region. Mom says that the knee is warm to touch, but there is no redness.	• Family Hx of SCD? • Previous crises/Hand-foot swelling? • Triggers (Dehydration, Cold/Hot, Infection, Vacation)? • Vaccination/Penicillin prophylaxis?	• General: Pallor, Jaundice. • Abd: Splenomegaly (in young), Hepatomegaly. • MSK: Dactylitis (Hand-foot), Joint swelling/warmth. • Skin: Rash.	• Blood: CBC (Low Hb, High Retics), Hb Electrophoresis. • Infection: Blood Cx, Joint aspiration (r/o Septic arthritis/Osteo). • Imaging: Knee X-ray.	• Septic Arthritis • Osteomyelitis • JIA • Hemophilia with hemarthrosis • Trauma • Cellulitis	• Hydration: IVF (1.5x maintenance). • Analgesia: NSAIDs (Ibuprofen), Opioids (Morphine). • Antibiotics: If febrile (Ceftriaxone). • Transfusion: If severe anemia/ACS. • Prevention: Hydroxyurea, Folic acid, Omega 3, Penicillin, Vaccinations. • Genetic counseling • Avoid temp extremes
GERD	Scenario: A one month old male is brought to your office by his first time parents with a complaint of constant irritability and spitting up. The 2.8 kg product of an uneventful full term pregnancy and delivery. He always seems to be hungry, and since his mother is certain that she is not producing enough milk, she has been following the breast feedings with formula for the last 2 weeks… The vomiting generally occurs immediately after feedings. It is not forceful, nor is it blood or biletinged… Despite all this, he weighed 3.5 kg at the two week checkup and he now weighs 4.3 kg.	• Forceful vomiting (Pyloric)? • Blood/Bile in vomit? • Amount diapers per day? • Arching of back (Sandifer)? • Apnea/Cough/Recurrent chest infections?	• Growth: Check for FTT. • Abd: Check for olive mass (r/o Pyloric). • Resp: Signs of aspiration, Stridor.	• Standard: Clinical diagnosis. • Severe: 24-hour pH monitoring / Impedance testing. • Anatomy: Upper GI Series (Contrast studies), Endoscopy (Biopsy).	• Pyloric Stenosis • Cow’s Milk Protein Allergy • Irritable Bowel Syndrome • Tracheoesophageal Fistula • Peptic Ulcer Disease	• Conservative: Reassurance, Thicken feeds, Upright positioning (30 mins), Smaller frequent feeds. • Meds: H2 blockers (Ranitidine) / PPIs / Prokinetics (Domperidone). • Surgical: Fundoplication (Laparoscopic).
Gastroenteritis	Scenario: An 18 month old male is brought to the emergency department with a chief complaint of diarrhea and vomiting for 2 days. His mother describes stools as liquid and foul smelling, with no mucous, slime or blood. Vomiting after every feeding, even water. He has about 6 episodes of diarrhea and 4 episodes of vomiting per day. His mother reports that he is not feeding well and his activity level is decreased.	• Urine output (wet diapers)? • Fluid intake? • Blood/Mucus in stool? • Sick contacts? • Pyrexia?	• Dehydration Status: Cap refill, Skin turgor, Fontanelle (sunken), Mucous membranes, Mental status (lethargy), Cool peripheries. • Abd: Tenderness.	• Labs: Electrolytes (U&E), Blood gas (if severe), FBC, LFTs. • Micro: Stool MC&S (Microscopy, Culture, Sensitivity).	• Inflammatory Bowel Disease • Appendicitis • Food Allergy • Crohn Disease	• Rehydration: Oral Rehydration Solution (ORT) is first line (Dioralyte). • Severe: IV Fluids (Bolus then maintenance). • Adjunct: Zinc supplementation. Potassium once urine passes.
Acute Hepatitis	Scenario: A 13 y/o girl present to the clinic with history of fever, malaise, and loss of appetite in the last 2 weeks, now she developed yellow discoloration in her eyes.	• Blood transfusion/IV drug use? • Stool/Urine color change? • Family Hx of blood disease? • Abd pain/Nausea/Vomiting? • Itching? • Medications?	• General: Jaundice (Scleral icterus). • Abd: Hepatomegaly (tender). • Skin: Rash (esp HCV).	• Liver: LFTs. • Serology: Anti-HAV (IgM/IgG), HBsAg/Anti-HBc IgM, Anti-HCV. • Blood: CBC (hemolytic anemia). • Imaging: Abd US.	• Hemolytic Anemia • Drug Induced • Gilbert’s Syndrome • Cholestasis	• HAV: Supportive care. • HBV: Interferon, Nucleoside analogues (Lamivudine). • HCV: Interferon alpha, Ribavirin.
Iron Deficiency Anemia	Scenario: 17-month-old boyl, presenting with pallor. Mom states his appetite is also poor and he is more irritable than usual. There is no history of splenectomy, gall stones at an early age, or other anemia in the family.	• Diet (Excess cow’s milk >24oz)? • Pica? • Stool color (blood)? • Prematurity? • Family History?	• General: Pallor (palms/conjunctiva), Irritability. • Specific: Koilonychia (spoon nails), Glossitis (beefy tongue), Cheilosis. • CVS: Tachycardia, Systolic murmur.	• Iron Panel: Serum Iron (Low), Ferritin (Low), TIBC (High). • CBC: Microcytic Hypochromic Anemia, RDW (High), Differential. • Stool: Occult blood.	• Thalassemia (Trait/Major) • Lead Poisoning • Sideroblastic Anemia • Copper Deficiency	• Supplement: Oral Iron (Ferrous sulfate 4-6mg) with Vit C (juice). • Diet: Limit milk, increase animal protein/green veg.
Hemophilia A	Scenario: A 4-year-old boy presented to ER with swollen ankle and knee joint with multiple bruises. (Patient Name: Adel Algahtani).	• Bleeding post-circumcision/vaccine? • Family Hx (males) / Bleeding disorders? • Trauma history? • Bleeding from mouth/gums/nose? • Blood in urine/stool? • Spontaneous hemorrhage?	• MSK: Joint swelling, warmth, limited ROM (Hemarthrosis). • Skin: Ecchymosis, Hematomas. • General: Pallor (if significant bleed), Weakness.	• Coag: PTT (Prolonged), PT (Normal), INR (Normal). • Specific: Factor VIII, IX, XI Assay. • CBC: Platelets (Normal). • Other: Bleeding time, vWF antigen.	• Von Willebrand Disease • ITP • Child Abuse • Platelet Disorders • Hemophilia B/C	• Replacement: Factor VIII concentrate / FFP / Cryoprecipitate. • Adjuvant: Desmopressin (DDAVP). • Supportive: RICE, Social worker involvement.
Von Willebrand Disease	Scenario: A 2-year old boy was brought to the emergency department by his mother for oozing blood from his mouth following a fall nearly 6 hours ago. His mother related that he tended to bleed for prolonged periods from his immunization sites.	• Family Hx bleeding? • Epistaxis (nose bleeds)? • Gum bleeding? • Easy bruising? • Prolonged bleeding from cuts?	• Skin/Mucosa: Mucocutaneous bleeding, Bruising on body. • General: Continuous bleeds.	• Coag: Bleeding Time (Prolonged), PTT (Prolonged or Normal), PT. • Specific: vWF Antigen & Activity, Fibrinogen. • Factor: Factor VIII, IX, XI essays.	• Hemophilia A/B/C • Platelet disorders • Anti-platelet drug ingestion • Fibrinolytic defects	• Meds: Desmopressin (DDAVP). • Product: Plasma-derived vWF concentrate, Cryoprecipitate. • Adjunct: Tranexamic acid.
VUR / UTI	Scenario: A 2 years old boy presented to the ER with recurrent fever due to UTI.	• Fever/Vomiting/Malaise? • Dysuria/Frequency/Urgency? • Urine incontinence? • Irritability?	No specific VUR physical signs in text, but derived from UTI presentation.	• Urine: UA (Leukocytes/Nitrites/RBC/Sp. Gravity), Culture. • Imaging: Renal US (Anatomy), MCUG/VCUG (Reflux diagnosis).	• Pyelonephritis vs Cystitis • Posterior Urethral Valves (PUV) • Asymptomatic bacteriuria • Vaginitis • Trauma	• Acute: Antibiotics (Trimethoprim, Nitrofurantoin, Amoxicillin, Gentamicin, Cefotaxime). • Surgical: Prophylactic antibiotics, Laparoscopic deflux injection.
UTI / Pyelonephritis	Scenario A: A 5 year female presented to the clinic complaint of flank pain since 7 months. Scenario B: A 6-year-old girl presented to ER with history of red urine which is started a week ago. There was history of upper respiratory illness 3 weeks prior to this presentation. Systematic review is unremarkable except of mild lower abdominal pain with history of frequency and urgency. On examination, she is looking well, BP is normal with mild tenderness in supra-pubic area. Laboratory test showed normal renal function, C3 is normal, urine RBC 200 / hpf, +ve leukocyte esterase and specific gratify is 1.015.	• Fever/Malaise/Vomiting? • Dysuria/Urgency/Frequency?	• Abd: Flank or costovertebral angle tenderness, Suprapubic tenderness. • General: Fever.	• Urine: Urine culture (Most diagnostic), Urinalysis. • Imaging: Renal US, MCUG.	• Pyelonephritis vs Cystitis • Asymptomatic bacteriuria • Vaginitis • Trauma	• Acute: Antibiotics (Trimethoprim, Nitrofurantoin, Amoxicillin, Gentamicin, Cefotaxime).
Viral Croup (Laryngotracheobronchitis)	Scenario: 20-month-old with rhinorrhea, fever, hoarse cry, progressive “barky” cough, and inspiratory stridor. Alert with good eye contact.	• Stridor at rest? • Symptoms subside during day? • Rapid progression (<12 hrs)? • Drooling/Swallowing difficulty? • Vaccination status? • Previous episodes?	• Resp: Inspiratory stridor, Barking cough, Hoarseness, Retractions. • General: Alert, good eye contact (KEY: differentiates from epiglottitis).	• X-ray Neck AP: Steeple sign (subglottic narrowing). • Oximetry. • Caution: Do NOT agitate child with invasive exams if stable.	• Epiglottitis (toxic, drooling, tripod) • Bacterial Tracheitis (toxic, severe distress) • Foreign Body (sudden onset, witnessed choking) • Spasmodic Croup (abrupt nighttime onset, no fever) • Angioneurotic edema	• Mild: Cool mist, reassurance, single dose Dexamethasone (0.15-0.6 mg/kg). • Moderate: Nebulized racemic epinephrine (2.25%, 0.5mL in 3mL NS). • Severe: Hospitalization, intubation if impending airway compromise. • Hydration: Encourage fluids.
Acute Epiglottitis (Bacterial - H. influenzae type b)	Scenario: 2-year-old with acute severe respiratory distress, stridor, unable to swallow secretions, drooling, tripod position, toxic appearance, high fever (40°C).	• Sudden onset? • Immunization status (Hib vaccine)? • Severe throat pain? • Voice changes (muffled “hot potato”)?	• General: Toxic, anxious, febrile. • Position: Tripod (sitting upright, neck extended, chin forward). • Airway: Severe inspiratory stridor, drooling, unable to swallow. • Voice: Muffled voice (no hoarseness/barking cough). • Vitals: Tachycardia, hypotension.	• Lateral Neck X-ray: Thumb sign (swollen epiglottis). • Blood cultures (after airway secured). • CBC: Leukocytosis. • CRITICAL: Do NOT examine throat or do invasive procedures until airway secured.	• Viral Croup (barking cough, hoarse, non-toxic) • Bacterial Tracheitis (severe, purulent secretions) • Retropharyngeal abscess • Foreign body aspiration	• EMERGENCY - Airway First: Maintain calm; allow child to remain in position of comfort. • Definitive airway: Orotracheal intubation in OR with experienced team + surgical backup. • Antibiotics: IV 3rd generation cephalosporin (Ceftriaxone) + coverage for MRSA (if suspicion). • Supportive: Humidified O2, IV fluids.
Laryngomalacia (Congenital Laryngeal Stridor)	Scenario: 6-week-old with high-pitched inspiratory stridor that worsens with excitement/crying. No respiratory distress, no hoarseness. Feeding well.	• Onset (usually 2 weeks - 2 months)? • Worse supine vs prone? • Feeding difficulties? (Red flag if present) • Growth pattern? • Cyanotic spells?	• Airway: Inspiratory stridor (high-pitched, squeaky) - loudest over larynx. • Provoked by: Crying, feeding, excitement, supine position. • General: Well-appearing, good weight gain, normal cry (not hoarse). • Absence: No retractions at rest, no cyanosis.	• Flexible laryngoscopy: Collapse of supraglottic structures on inspiration (diagnostic gold standard). • CXR: Usually normal. • Barium swallow: To r/o vascular ring if atypical features.	• Vascular ring/sling (biphasic stridor, feeding difficulty) • Subglottic stenosis • Tracheomalacia • Vocal cord paralysis • Laryngeal web/cyst	• Conservative: Reassurance (resolves spontaneously by 12-24 months). • Positioning: Prone positioning during sleep. • Feeding: Small frequent feeds, thicken feeds if reflux. • Surgical: Supraglottoplasty only for severe cases (failure to thrive, cyanotic spells, apnea).
Vascular Ring / Sling (Congenital Vascular Anomaly)	Scenario: Infant with biphasic stridor (inspiratory + expiratory), persistent respiratory distress, poor feeding, recurrent respiratory infections.	• Persistent vs positional symptoms? • Choking with feeds? • Recurrent pneumonias? • Apneic spells? • Associated cardiac symptoms?	• Airway: Biphasic stridor (tracheal compression). • Feeding: Difficulty swallowing, coughing with feeds (esophageal compression). • Resp: Recurrent lower respiratory infections (aspiration). • General: Failure to thrive.	• Barium Swallow: Posterior indentation of esophagus (double aortic arch = “reverse 3 sign”). • CT Angiography/MRA: Gold standard - defines anatomy. • Bronchoscopy: External compression of trachea. • Echo: Associated cardiac defects.	• Laryngomalacia (inspiratory only, worse with crying) • Tracheomalacia • Tracheal stenosis • Subglottic stenosis • Esophageal foreign body	• Surgical: Division of vascular ring (via left thoracotomy or thoracoscopic) to release trachea/esophagus compression. • Pre-operative: Manage respiratory infections, optimize nutrition. • Post-op: Symptoms usually resolve; some residual tracheomalacia may persist.
Foreign Body Aspiration (Complete vs Partial Obstruction)	Scenario A (Complete): Teenager choking on peanuts, anxious, unable to produce sound, no longer coughing, appears cyanotic. Scenario B (Partial): Toddler with sudden onset choking episode, persistent cough, unilateral wheeze, decreased breath sounds on one side.	• Witnessed event? (Food, small toy, nuts) • Complete vs partial obstruction? • Coughing effectiveness? • Prior similar episodes? • Delayed presentation (recurrent pneumonias)?	• Complete obstruction: Universal choking sign (hands to throat), inability to speak/cough, cyanosis, loss of consciousness. • Partial obstruction: Unilateral wheeze, decreased air entry, paroxysmal coughing, respiratory distress. • Delayed: Recurrent/persistent pneumonia in same lobe.	• CXR: Hyperinflation (obstructive emphysema), atelectasis, or radiopaque object. • Expiratory/Decubitus films: Air trapping (obstructive emphysema on affected side). • CT: If high suspicion, X-ray negative. • Bronchoscopy: Diagnostic + therapeutic.	• Asthma (bilateral, responsive to bronchodilators) • Croup / Epiglottitis (fever, infectious symptoms) • Bronchiolitis (viral prodrome) • Pneumonia (fever, infiltrates) • Tracheomalacia	• Complete obstruction (Conscious child >1 year): Heimlich maneuver (abdominal thrusts). • Complete obstruction (Unconscious): CPR with each rescue breath checked for foreign body removal. • Partial/Stable: Bronchoscopy (rigid for removal) - do NOT delay if suspected. • Supportive: Oxygen, IV access.
Bronchial Asthma	Scenario: Recurrent wheezing, cough, dyspnea with triggers (viral, allergen, exercise, stress). May present with acute exacerbation (status asthmaticus) or diagnostic workup in child ≤5 years with persistent symptoms.	• Pattern: Nocturnal cough? Exercise-induced? Seasonal? • Triggers: Viral URTI, allergens, weather change, emotions, smoke exposure. • Family Hx: Atopy, asthma, eczema. • Severity: Sleep disturbance, school absence, ER visits, ICU admission. • Current medications: Controller vs reliever use.	• Inspection: Prolonged expiration, accessory muscle use, hunched posture, allergic facies (Dennie-Morgan, allergic shiners, nasal crease). • Auscultation: Bilateral wheezing, reduced air entry (severe), silent chest (life-threatening). • Hypertrophy: Periorbital darkening, nasal polyps. • Skin: Eczema/dermatitis.	• Spirometry: FEV1/FVC <80% (≥6 years), reversibility with bronchodilator. • FeNO: Elevated eosinophilic inflammation. • Allergy testing: Skin prick or specific IgE. • Imaging: CXR (r/o pneumothorax, FB, infection). • Sweat chloride: Rule out CF in atypical cases. • mAPI (modified Asthma Predictive Index): For <3 years with recurrent wheezing (≥4 episodes/yr + 1 major or 2 minor: Major = parental asthma, eczema, aeroallergen sens; Minor = food allergy, wheeze unrelated to colds, eosinophilia ≥4%).	• Infectious: Bronchiolitis, Pneumonia, Pertussis • Anatomic: Foreign body, Tracheobronchomalacia, Vascular ring, Subglottic stenosis • Other: CF, Primary ciliary dyskinesia, GERD, Vocal cord dysfunction, Heart failure • Infiltrative: ABPA, Sarcoidosis	• Stepwise approach based on GINA/NAEPP guidelines: • Step 1 (Mild intermittent): SABA PRN. • Step 2 (Persistent): Low-dose ICS (Beclomethasone/Budesonide). • Step 3: Low-dose ICS + LABA or Medium-dose ICS. • Step 4: Medium-dose ICS + LABA ± LTRA. • Step 5: Referral, high-dose ICS + LABA, biologics. • Exacerbation: SABA (nebulized or MDI with spacer) → Ipratropium → Systemic steroids early → MgSO4 → Terbutaline/Aminophylline → Mechanical ventilation if needed. • Education: Inhaler technique, written action plan, trigger avoidance.
Bronchiolitis	Scenario: Infant with wheezing and respiratory distress following URTI.	• Prematurity? • Feeding ability? • Recent URTI? • Smoking exposure (social)?	• Resp: Tachypnea, Retractions, Crackles/Wheezes. • Vitals: O2 sat, Fever.	• Pathogen: Nasopharyngeal aspirate/culture (RSV/Virus). • Imaging: CXR. • Gas: Blood gases.	• Asthma • Pneumonia • Bronchitis	• Supportive: Symptomatic relief, Hydration (NG/IV), Oxygenation. • Isolation: Admission.
Posterior Urethral Valves (PUV)	Scenario: 2-year-old boy with dilated urethra/bladder on MCUG (from list item 30).	• Poor urine stream? • Straining to void?	• Palpable bladder. • Poor growth.	• MCUG (Voiding Cystourethrogram). • Renal US.	• VUR • Neurogenic bladder	• Valve ablation (Surgical).
Kawasaki Disease	Scenario: Fever ≥ 5 days plus ≥ 4 of specific clinical features (Conjunctivitis, Lips/Tongue changes, Extremity changes, Rash, Lymphadenopathy). (From Sepsis/Febrile file).	• Duration of fever (>5 days)? • Redness of eyes/lips? • Peeling skin?	• Eyes: Bilateral conjunctival injection (non-purulent). • Mouth: Strawberry tongue, cracked lips. • Limbs: Edema/Erythema of hands/feet. • Skin: Polymorphous rash. • Neck: Cervical lymphadenopathy (>1.5cm).	• ECHO (Coronary artery aneurysms). • ESR/CRP (Elevated). • CBC (Platelets may be high later).	• Viral Exanthem (Measles, Adenovirus) • Scarlet Fever • Toxic Shock Syndrome • Stevens-Johnson Syndrome	• IVIG (Intravenous Immunoglobulin). • Aspirin (High dose then low dose). • Goal: Prevent coronary artery aneurysms.
Abdominal Pain Cases	Scenario A (Mesenteric Lymphadenitis): Child with periumbilical or left-sided pain, recurrent tonsillitis, fever; tender mobile nodes in RLQ; diagnosed by US. Scenario B (Infantile Colic): First few months of life, baby flexes hip joint with gas/flatus, inconsolable crying, started after formula change from breast milk. Scenario C (Intussusception): 6-month-old peak, colicky abdominal pain, vomiting (bilious if late), “red currant jelly” stool, lethargy between episodes, palpable sausage-shaped mass. Scenario D (Meckel’s Diverticulum): Painless rectal bleeding (maroon/dark red), rule of 2s (2% population, 2 feet from ileocecal valve, 2 inches long, symptoms by age 2); technetium scan positive. Scenario E (Hirschsprung Disease): Newborn failure to pass meconium within 48 hours, chronic constipation, abdominal distension, explosive stool upon rectal exam, toxic megacolon risk. Scenario F (Bowel Obstruction - SBO/Volvulus): Bilious vomiting, abdominal distension, obstipation, surgical scars (adhesions), hyperactive then absent bowel sounds. Scenario G (Acute Pancreatitis): Epigastric pain radiating to back, vomiting, elevated amylase/lipase (3x normal), gallstones/alcohol/trauma etiology in adolescents. Scenario H (Nephrolithiasis/Renal Colic): Severe flank pain radiating to groin, hematuria, dysuria, family history of stones, calcium oxalate most common in pediatrics. Scenario I (Testicular Torsion): Acute scrotal pain, high-riding testis, absent cremasteric reflex, horizontal lie, nausea/vomiting; urological emergency. Scenario J (Pneumonia/Referred Pain): T9 dermatome shared pathway - lower lobe pneumonia presents with abdominal pain; tachypnea, fever, absent bowel signs, respiratory distress. Scenario K (Familial Mediterranean Fever): Recurrent fever with serositis, consanguinity, normal exam between attacks, respond to colchicine. Scenario L (Functional Pain/IBS): Chronic intermittent pain >2 months, normal growth, no organic cause, relieved by defecation, stool pattern changes, school stress trigger.	• For Inflammatory/Obstructive: Fever progression? Bilious vomiting? Passage of flatus/stool (obstipation)? Peritoneal signs (rebound/guarding)? • For Intussusception: Current jelly stool? Lethargy between episodes? Duration of colicky episodes (classic 10-15 min cycles)? • For Hirschsprung: Meconium passage within 48h of birth? Chronic constipation since infancy? Explosive stool after rectal exam? Enterocolitis symptoms (toxic megacolon)? • For Pancreatitis: Alcohol use? Gallstones? Trauma history? Family history of hypertriglyceridemia? • For Renal Colic: Hematuria (gross vs microscopic)? Radiation to groin? History of prior stones? Diet (high oxalate, low fluid)? • For Testicular Torsion: Onset (sudden vs gradual)? High-riding testis? Absent cremasteric reflex? History of prior episodes (intermittent torsion)? • For Referred Pain: Respiratory symptoms? Tachypnea? Pleuritic chest pain? • For FMF: Consanguinity? Ethnicity (Middle Eastern, Mediterranean)? Response to colchicine? Family history of amyloidosis? • For Functional: Duration >2 months? School attendance issues? Anxiety/stress correlation? Growth parameters maintained? Alarm features (weight loss, bleeding, nocturnal pain)?	• Mesenteric Lymphadenitis: Tender mobile lymph nodes in RLQ, low-grade fever, URI symptoms, mild abdominal tenderness without rebound. • Intussusception: Intermittent severe crying with legs drawn up, pallor, vomiting, sausage-shaped abdominal mass in RUQ, empty RLQ (Dance sign), red currant jelly stool (late sign). • Hirschsprung: Abdominal distension, failure to thrive in chronic cases, explosive stool after rectal stimulation, absence of ganglion cells on biopsy. • SBO/Volvulus: Distended tympanic abdomen, high-pitched hyperactive bowel sounds early, absent bowel sounds late, surgical scars, visible peristalsis, signs of peritonitis if strangulated. • Pancreatitis: Epigastric tenderness, Cullen sign (periumbilical ecchymosis), Grey Turner sign (flank ecchymosis) in hemorrhagic cases, fever, tachycardia. • Renal Colic: Costovertebral angle tenderness, colicky pain pattern, microscopic/gross hematuria, urinary urgency if distal stone. • Testicular Torsion: Acute scrotal swelling, erythema, high-riding horizontal testis, absent cremasteric reflex, severe tenderness, no relief with elevation (Prehn’s sign negative). • Pneumonia with referred pain: Tachypnea, nasal flaring, chest retractions, decreased breath sounds at bases, absent abdominal findings.	• US (First-line): Mesenteric lymphadenitis (enlarged nodes), intussusception (target/donut sign, pseudokidney sign), appendicitis, pyloric stenosis, Hirschsprung transition zone, renal stones (hydronephrosis). • Abdominal X-ray: Obstruction (air-fluid levels, step ladder pattern), perforation (free air under diaphragm), constipation (fecal loading), Hirschsprung (transition zone with dilated proximal bowel). • CT Scan: Appendicitis (non-contrast or with contrast), pancreatitis (peripancreatic fluid, necrosis), complex obstruction, abscess. • Meckel Scan: Technetium-99m pertechnetate (ectopic gastric mucosa uptake in Meckel’s diverticulum). • Rectal Biopsy: Gold standard for Hirschsprung (absent ganglion cells, hypertrophied nerve trunks). • Labs: Amylase/Lipase (pancreatitis - >3x normal), CBC/CRP (inflammation), urinalysis (pyelonephritis, stones), serum calcium/urate/citrate (metabolic stone workup). • Doppler US: Testicular blood flow (absent in torsion, increased in epididymo-orchitis). • CXR: Pneumonia (referred pain), free air under diaphragm (perforation).	• Mesenteric Lymphadenitis: Viral enteritis, appendicitis (early), mesenteric adenitis, Crohn disease, Yersinia infection. • Intussusception: Gastroenteritis, appendicitis, Meckel’s diverticulum (if lead point), Henoch-Schönlein purpura (if intussusception secondary to submucosal hematoma). • Hirschsprung: Chronic functional constipation, hypothyroidism, intestinal neuronal dysplasia, anorectal malformations. • Bowel Obstruction: Constipation, paralytic ileus, pseudo-obstruction (Ogilvie’s), intussusception, volvulus. • Pancreatitis: Perforated peptic ulcer, cholecystitis, mesenteric ischemia, inferior MI. • Renal Colic: Pyelonephritis, appendicitis (retrocecal), ovarian torsion, ectopic pregnancy (in adolescent females). • Testicular Torsion: Epididymo-orchitis, torsion of appendix testis, incarcerated hernia, trauma. • Referred Pain: Basal pneumonia, pleurisy, diaphragmatic irritation (Kehr’s sign with splenic injury), pericarditis.	• Mesenteric Lymphadenitis: Supportive care, hydration, analgesia; antibiotics only if bacterial etiology suspected (Yersinia); usually self-limiting. • Intussusception: Air/Contrast/Water enema reduction (non-surgical first-line, contraindicated if perforation/peritonitis); surgical reduction if enema fails or peritonitis present; hydration, NG tube decompression pre-procedure. • Meckel’s Diverticulum: Resection of diverticulum plus adjacent ileum (if ulceration); laparoscopic or open; treat bleeding with resuscitation. • Hirschsprung: Definitive pull-through surgery (Swenson, Duhamel, or Soave procedures); colostomy if severe enterocolitis/malnutrition; treatment of enterocolitis with antibiotics/NG decompression. • SBO/Volvulus: NG tube decompression, IV fluids, electrolyte correction; emergency surgery if strangulation/peritonitis; volvulus requires detorsion ± bowel resection; adhesiolysis if adhesive obstruction. • Acute Pancreatitis: NPO initially, aggressive IV hydration, analgesia (IV opioids - morphine), antiemetics; ERCP if gallstone pancreatitis with obstruction; treat underlying cause. • Renal Colic: Hydration, analgesia (NSAIDs first-line - ketorolac, then opioids if needed), antiemetics; ureteroscopy/ESWL for persistent/large stones; metabolic workup for recurrence prevention (increase fluids, reduce sodium/oxalate). • Testicular Torsion: EMERGENCY: Manual detorsion (if within hours), but urgent surgical exploration (orchiopexy of both testes) within 6 hours to salvage testis; Do not let imaging delay surgery. If the clinical suspicion is high • Pneumonia: Antibiotics per guidelines (amoxicillin first-line), oxygen if hypoxic, bronchodilators if wheezing; treat abdominal pain secondarily as referred.