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I now have excellent reference material. Let me write the comprehensive pediatric OPD case guide.
🏥 Pediatric OPD Case Studies: 25 Common Cases for Practice & Education
Disclaimer: This document is for educational purposes only. Drug doses must always be verified against current guidelines and calculated per individual patient weight. Consult the Harriet Lane Handbook or local formulary for final prescribing decisions.
How to Use This Guide
Each case follows the same format:
- Patient | Presenting Complaint | Examination | Diagnosis | Prescription | Counseling Points
Doses are based on the Harriet Lane Handbook (23rd ed.), Red Book 2021, and Canadian Paediatric Society guidelines.
🦠 RESPIRATORY CASES
Case 1 - Acute Otitis Media (AOM)
Patient: Hamza, 2-year-old boy, 12 kg
Complaint: Ear pain (tugging left ear) + fever 38.8°C x 2 days, irritability, poor feeding
History: Recent upper respiratory infection (URI) 5 days ago
Examination:
- Temp: 38.8°C
- Left tympanic membrane: bulging, erythematous, loss of light reflex
- Right TM: normal
Diagnosis: Acute Otitis Media (left), unilateral
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Hamza Age: 2 yr Wt: 12 kg ║
║ Date: ___________ ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Acute Otitis Media (Left) ║
║ ║
║ Rx: ║
║ ║
║ 1. Tab/Syrup Amoxicillin 250 mg/5 mL ║
║ Dose: 90 mg/kg/day = 1080 mg/day ÷ 3 doses ║
║ = 360 mg TDS (give 7 mL TDS) ║
║ Duration: 10 days (age <2 yr) ║
║ ║
║ 2. Syrup Paracetamol 120 mg/5 mL ║
║ Dose: 15 mg/kg/dose = 180 mg (7.5 mL) ║
║ Q6H PRN for fever/pain x 3 days ║
║ ║
║ 3. Nasal saline drops 2-3 drops each nostril BID ║
║ ║
║ Review if no improvement in 48-72 hours ║
╚══════════════════════════════════════════════════════════════╝
Counseling: High-dose amoxicillin (80-90 mg/kg/day) is recommended for AOM in children <2 years. If penicillin-allergic (non-anaphylaxis): use cefdinir 14 mg/kg/day. Refer ENT if recurrent (3+ episodes in 6 months).
Case 2 - Acute Pharyngotonsillitis (Strep Throat)
Patient: Sara, 6-year-old girl, 20 kg
Complaint: Sore throat, fever 39.2°C, difficulty swallowing x 3 days
History: No cough, no rhinorrhea (these features point away from viral)
Examination:
- Temp: 39.2°C, HR: 108
- Throat: bilateral tonsillar enlargement (grade III), erythema, white exudates
- Anterior cervical lymphadenopathy (tender)
- No rash, no stridor
- Centor Score: 4/4 (tonsillar exudate + tender LAP + fever + no cough)
Diagnosis: Group A Streptococcal Pharyngotonsillitis
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Sara Age: 6 yr Wt: 20 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Acute GAS Pharyngotonsillitis ║
║ ║
║ Rx: ║
║ ║
║ 1. Tab Amoxicillin 250 mg ║
║ Dose: 50 mg/kg/day = 1000 mg/day ║
║ 500 mg BD x 10 days (or 1000 mg OD x 10 days) ║
║ ║
║ 2. Syrup Ibuprofen 100 mg/5 mL ║
║ Dose: 10 mg/kg/dose = 200 mg (10 mL) ║
║ TDS x 3-5 days (with food) ║
║ ║
║ 3. Throat gargles with warm salt water TDS ║
║ ║
║ ⚠ If penicillin allergic: Azithromycin 12 mg/kg OD x 5 days ║
║ (max 500 mg/day) = 240 mg/day ║
╚══════════════════════════════════════════════════════════════╝
Counseling: Complete the full 10-day course even if the child improves earlier - prevents rheumatic fever. Return if rash develops (scarlet fever). Throat swab/rapid antigen test confirms GAS.
Case 3 - Viral Upper Respiratory Infection (Common Cold)
Patient: Ali, 3-year-old boy, 14 kg
Complaint: Runny nose (clear), low-grade fever 37.8°C, mild cough x 4 days
History: Started after contact with sick sibling
Examination:
- Temp: 37.8°C
- Throat: mild erythema, no exudate
- Bilateral TM: normal
- Clear nasal discharge
- Chest: clear bilaterally
Diagnosis: Viral URI (Common Cold)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Ali Age: 3 yr Wt: 14 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Viral Upper Respiratory Infection ║
║ ║
║ Rx: ║
║ ║
║ 1. Syrup Paracetamol 120 mg/5 mL ║
║ Dose: 15 mg/kg = 210 mg (8.5 mL) ║
║ Q4-6H PRN for fever/discomfort x 3 days ║
║ ║
║ 2. Nasal saline drops (0.9% NaCl) ║
║ 2-3 drops each nostril, TDS ║
║ ║
║ 3. Honey 5 mL at bedtime for cough (if >1 year) ║
║ (proven to reduce cough frequency in children >1 yr) ║
║ ║
║ ⚠ NO ANTIBIOTICS - viral illness ║
║ ⚠ Avoid OTC cough/cold preparations in children <6 yr ║
║ ║
║ Review if: fever >5 days, worsening symptoms, or earache ║
╚══════════════════════════════════════════════════════════════╝
Case 4 - Community-Acquired Pneumonia (CAP)
Patient: Omar, 5-year-old, 18 kg
Complaint: Fever 39.5°C x 4 days, productive cough, fast breathing, reduced appetite
History: No prior respiratory illness, fully vaccinated
Examination:
- RR: 38/min (tachypneic for age)
- SpO2: 95% on room air
- Chest: decreased air entry right lower lobe, dullness on percussion, bronchial breathing
- Temp: 39.5°C
Diagnosis: Community-Acquired Pneumonia (right lower lobe), mild-moderate
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Omar Age: 5 yr Wt: 18 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Community-Acquired Pneumonia (Right lower lobe) ║
║ ║
║ Investigations: CXR, CBC, CRP ║
║ ║
║ Rx: ║
║ ║
║ 1. Tab Amoxicillin 500 mg ║
║ Dose: 90 mg/kg/day ÷ 3 = 540 mg TDS ║
║ (give as 500 mg TDS) x 5-7 days ║
║ ║
║ 2. Syrup Paracetamol 250 mg/5 mL ║
║ 270 mg (5.5 mL) Q6H PRN fever ║
║ ║
║ 3. Encourage oral fluids ║
║ ║
║ ⚠ Admit if: SpO2 <92%, unable to feed, toxic appearance ║
║ Review in 48 hours ║
║ If atypical organism suspected: Add Azithromycin ║
║ 10 mg/kg OD x 3 days (max 500 mg) ║
╚══════════════════════════════════════════════════════════════╝
Case 5 - Acute Bronchiolitis
Patient: Zara, 8-month-old girl, 7 kg
Complaint: Runny nose x 3 days then progressive wheeze and cough, difficulty feeding
History: Born term, no prior wheezing, older sibling has cold
Examination:
- RR: 58/min
- SpO2: 93% on room air
- Chest: subcostal retractions, diffuse wheeze, prolonged expiration, hyperinflation
- Temp: 37.5°C (low-grade)
Diagnosis: Acute Bronchiolitis (RSV likely)
╔══════════════════════════════════════════════════════════════╗
║ OPD / ASSESSMENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Zara Age: 8 mo Wt: 7 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Acute Bronchiolitis ║
║ ║
║ Rx (Supportive - mainstay of treatment): ║
║ ║
║ 1. Trial of nebulized Hypertonic Saline 3% ║
║ 4 mL via nebulizer Q4-8H ║
║ (modest benefit in inpatient setting) ║
║ ║
║ 2. Nasal suctioning PRN before feeds ║
║ ║
║ 3. Ensure adequate oral hydration ║
║ Encourage frequent small feeds ║
║ ║
║ 4. Supplemental O2 if SpO2 <92% ║
║ ║
║ ⚠ NO bronchodilators (salbutamol) routinely recommended ║
║ ⚠ NO corticosteroids ║
║ ⚠ NO antibiotics (viral etiology) ║
║ ║
║ ADMIT: SpO2 <92%, RR >60, poor feeding, toxic appearance ║
╚══════════════════════════════════════════════════════════════╝
Case 6 - Childhood Asthma (Mild Persistent)
Patient: Bilal, 8-year-old boy, 25 kg
Complaint: Recurrent wheeze, cough (especially at night), shortness of breath on exertion
History: 3rd episode this year, has eczema, mother has allergic rhinitis (atopic triad)
Examination:
- PEFR: 70% predicted
- Expiratory wheeze bilaterally
- No use of accessory muscles at rest
- SPO2: 97%
Diagnosis: Asthma - Mild Persistent (Step 2)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Bilal Age: 8 yr Wt: 25 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Asthma - Mild Persistent ║
║ ║
║ CONTROLLER THERAPY: ║
║ 1. Fluticasone Propionate MDI 50 mcg/puff ║
║ 2 puffs BD via spacer (low-dose ICS) ║
║ (100 mcg/day - standard low dose for age 5-11) ║
║ ║
║ RELIEVER THERAPY: ║
║ 2. Salbutamol (Albuterol) MDI 100 mcg/puff ║
║ 2 puffs Q4-6H PRN via spacer ║
║ (rescue/reliever only - not regular use) ║
║ ║
║ 3. Montelukast 5 mg chewable tab OD at night ║
║ (LTRA as add-on for allergic rhinitis comorbidity) ║
║ ║
║ Asthma Action Plan given to parents ║
║ PEFR monitoring diary ║
║ Review in 4 weeks ║
╚══════════════════════════════════════════════════════════════╝
Case 7 - Croup (Laryngotracheobronchitis)
Patient: Tariq, 2.5-year-old boy, 13 kg
Complaint: Barking cough, stridor, hoarse voice, worse at night, onset sudden
History: Preceded by 1-2 day URI, no drooling
Examination:
- Temp: 38°C
- Stridor: inspiratory, audible at rest (moderate croup)
- Mild subcostal retractions
- No drooling (rules out epiglottitis)
- Westley Croup Score: 4 (moderate)
Diagnosis: Viral Croup (Moderate)
╔══════════════════════════════════════════════════════════════╗
║ OPD / EMERGENCY PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Tariq Age: 2.5 yr Wt: 13 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Viral Croup - Moderate ║
║ ║
║ Rx: ║
║ ║
║ 1. Dexamethasone 0.6 mg/kg PO/IM x 1 dose ║
║ = 7.8 mg (give 8 mg as single dose) ║
║ Oral dexamethasone 0.15 mg/kg equally effective for mild ║
║ = 2 mg (single dose) for mild cases ║
║ ║
║ 2. Nebulized Adrenaline (Epinephrine) 1:1000 ║
║ 0.5 mL/kg (max 5 mL) in 3 mL NS via nebulizer ║
║ For moderate-severe cases; observe x 2-4 hrs after ║
║ ║
║ 3. Humidified air / cool night air (home advice) ║
║ ║
║ ADMIT if: severe stridor, cyanosis, altered consciousness ║
╚══════════════════════════════════════════════════════════════╝
🌡️ FEVER / INFECTIOUS CASES
Case 8 - Febrile Convulsion (Simple)
Patient: Rania, 18-month-old girl, 10 kg
Complaint: Tonic-clonic seizure x 2 minutes, now alert, brought to OPD
History: Fever since morning (39.6°C), fully vaccinated, no prior seizures, no family history of epilepsy
Examination:
- Post-ictal, but alert and responsive now
- Temp: 39.6°C
- No meningeal signs (no neck stiffness, negative Kernig/Brudzinski)
- Throat: mild erythema (viral URI likely source)
Diagnosis: Simple Febrile Convulsion
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Rania Age: 18 mo Wt: 10 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Simple Febrile Convulsion ║
║ ║
║ Rx: ║
║ ║
║ 1. Syrup Paracetamol 120 mg/5 mL ║
║ Dose: 15 mg/kg = 150 mg (6.25 mL) Q6H ║
║ Alternate with: ║
║ Syrup Ibuprofen 100 mg/5 mL ║
║ 10 mg/kg = 100 mg (5 mL) Q8H with food ║
║ ║
║ 2. Rectal Diazepam 5 mg (0.5 mg/kg) at home PRN ║
║ if seizure >5 min: Give rectal diazepam ║
║ Prescribe to parents as rescue medication ║
║ ║
║ Investigations: CBC, Urine R/E (to find fever source) ║
║ EEG/LP: NOT indicated for simple febrile seizure ║
╚══════════════════════════════════════════════════════════════╝
Counseling: Risk of recurrence is 30-35%. No long-term anticonvulsants needed for simple febrile seizures. Parents need seizure first-aid education (turn child on side, do not restrain, time the seizure, call emergency if >5 min).
Case 9 - Typhoid Fever
Patient: Hassan, 7-year-old boy, 22 kg
Complaint: Continuous high fever x 8 days, headache, abdominal pain, constipation initially then diarrhea, poor appetite
History: Drinks outside water, travels to rural area
Examination:
- Temp: 39.8°C (step-ladder pattern by history)
- Pulse: 78 (relative bradycardia - Faget sign)
- Abdomen: mild splenomegaly, hepatomegaly
- Rose spots (2-3 salmon-colored macules on abdomen)
Diagnosis: Enteric (Typhoid) Fever
Investigations: Blood culture (gold standard), CBC (leukopenia), Widal test (supportive)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Hassan Age: 7 yr Wt: 22 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Enteric (Typhoid) Fever ║
║ ║
║ Rx: ║
║ ║
║ 1. Tab Azithromycin 200 mg/5 mL syrup ║
║ Dose: 20 mg/kg/day OD x 7 days ║
║ = 440 mg OD (give 500 mg OD - 12.5 mL OD) ║
║ (First-line for uncomplicated typhoid in children) ║
║ ║
║ OR (if susceptible strain): ║
║ Tab Cotrimoxazole (TMP 8 mg/kg/day in 2 doses) ║
║ x 14 days ║
║ ║
║ 2. Syrup Paracetamol 250 mg/5 mL ║
║ 330 mg (6.5 mL) Q6H PRN fever ║
║ ║
║ 3. ORS + increase fluid intake ║
║ 4. Soft, easily digestible diet ║
║ ║
║ ADMIT if: toxic appearance, severe dehydration, ║
║ intestinal complications ║
╚══════════════════════════════════════════════════════════════╝
Case 10 - Urinary Tract Infection (UTI)
Patient: Amna, 3-year-old girl, 15 kg
Complaint: Fever 38.5°C x 3 days, crying on urination (dysuria), frequency, foul-smelling urine
History: No prior UTI, no structural anomalies known
Examination:
- Temp: 38.5°C
- Suprapubic tenderness
- No costovertebral angle tenderness
- Urinalysis: pyuria (>10 WBC/hpf), bacteriuria, positive nitrites
Diagnosis: Febrile UTI (likely pyelonephritis given fever + age)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Amna Age: 3 yr Wt: 15 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Febrile UTI / Pyelonephritis ║
║ ║
║ Investigations: Urine C/S (MSU), renal ultrasound ║
║ ║
║ Rx: ║
║ ║
║ 1. Syrup Cephalexin 125 mg/5 mL ║
║ Dose: 25-50 mg/kg/day ÷ 3 ║
║ = 375 mg TDS (15 mL TDS) x 7-10 days ║
║ (empiric pending urine culture) ║
║ ║
║ OR: Cotrimoxazole (TMP 4-6 mg/kg/day BD) ║
║ = TMP 90 mg/day → give Cotrimoxazole Syrup ║
║ 5 mL (40/200 per 5 mL) BD x 7 days ║
║ ║
║ 2. Syrup Paracetamol Q6H PRN fever ║
║ 3. Increase fluids ║
║ ║
║ Follow up with urine C/S result in 48-72 hrs ║
║ VCUG after first febrile UTI in girls <3 yr: consider ║
╚══════════════════════════════════════════════════════════════╝
Case 11 - Chickenpox (Varicella)
Patient: Daniyar, 5-year-old boy, 19 kg
Complaint: Rash (vesicles) all over body including scalp and mouth, fever 38.2°C, itching x 2 days
History: Not vaccinated, contact with chickenpox case 2 weeks ago
Examination:
- Diffuse vesicular rash - lesions in multiple stages (macule, papule, vesicle, crust) simultaneously = pathognomonic
- Mucous membrane involvement (soft palate ulcers)
- No secondary bacterial infection signs
Diagnosis: Varicella (Chickenpox), uncomplicated
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Daniyar Age: 5 yr Wt: 19 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Varicella (Chickenpox) ║
║ ║
║ Rx: ║
║ ║
║ 1. Calamine lotion - apply to rash areas TDS ║
║ (soothes itch) ║
║ ║
║ 2. Syrup Chlorpheniramine 2 mg/5 mL ║
║ 0.35 mg/kg/day ÷ 3 doses = ~2 mg TDS (5 mL TDS) ║
║ (for pruritus) ║
║ ║
║ 3. Syrup Paracetamol Q6H PRN fever ║
║ ⚠ NO ASPIRIN (risk of Reye syndrome) ║
║ ⚠ NO IBUPROFEN (increased risk of strep superinfection) ║
║ ║
║ 4. Keep nails trimmed short / mittens for infant ║
║ 5. Cool baths to relieve itching ║
║ ║
║ Isolation: Contagious until all lesions crusted (~5-7 days) ║
║ Acyclovir: Consider for immunocompromised or >12 yr ║
╚══════════════════════════════════════════════════════════════╝
Case 12 - Hand, Foot and Mouth Disease (HFMD)
Patient: Leila, 2-year-old girl, 11 kg
Complaint: Fever 38.5°C, painful mouth ulcers (refusing food), small blisters on palms, soles, and buttocks x 3 days
History: Sibling recently had similar illness
Examination:
- Erythematous vesicles and papules on palms and soles
- Ulcerative enanthem on buccal mucosa and tongue
- Mild erythematous rash on buttocks
Diagnosis: Hand, Foot and Mouth Disease (Enterovirus - usually Coxsackievirus A16)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Leila Age: 2 yr Wt: 11 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Hand, Foot and Mouth Disease ║
║ ║
║ Rx (Supportive): ║
║ ║
║ 1. Syrup Paracetamol 120 mg/5 mL ║
║ Dose: 15 mg/kg = 165 mg (7 mL) Q6H PRN ║
║ ║
║ 2. Syrup Ibuprofen 100 mg/5 mL ║
║ 10 mg/kg = 110 mg (5.5 mL) Q8H PRN (with food) ║
║ ║
║ 3. Oral gel (Lignocaine 2% - use sparingly) ║
║ Apply to oral ulcers before meals ║
║ ⚠ Only small amounts, no systemic absorption risk ║
║ ║
║ 4. Cold drinks, soft/cold foods (ice cream, cold yogurt) ║
║ to ease mouth pain ║
║ 5. ORS to maintain hydration ║
║ ║
║ ADMIT if: encephalitis signs, flaccid paralysis, dehydration ║
╚══════════════════════════════════════════════════════════════╝
🍽️ GASTROINTESTINAL CASES
Case 13 - Acute Gastroenteritis with Mild Dehydration
Patient: Yusuf, 1-year-old boy, 9 kg
Complaint: Watery diarrhea (6-8x/day) x 2 days, 2 episodes vomiting, reduced urine output
History: No blood/mucus in stool, mild fever 38°C
Examination:
- Slightly sunken eyes
- Moist mucous membranes (mild dehydration, ~5%)
- Skin turgor: normal
- CRT: <2 seconds
- HR: 118/min
Diagnosis: Acute Gastroenteritis, Mild Dehydration (5%)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Yusuf Age: 1 yr Wt: 9 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Acute Gastroenteritis - Mild Dehydration (5%) ║
║ ║
║ Rx: ║
║ ║
║ ORS REHYDRATION PLAN A: ║
║ Phase 1 (first 4 hrs): Give 50 mL/kg ORS = 450 mL ║
║ Give 10-15 mL (2-3 tsp) every 1-2 minutes ║
║ ║
║ Maintenance: Continue normal feeds + ORS after each ║
║ loose stool (60-120 mL for infant) ║
║ ║
║ 1. ORS (WHO standard) sachet - dissolve in 200 mL water ║
║ as above ║
║ ║
║ 2. Zinc Syrup 10 mg/5 mL (Zinkid) ║
║ Dose: 10 mg/day OD x 14 days (<6 mo: 5 mg OD) ║
║ (WHO recommendation - reduces duration & severity) ║
║ ║
║ 3. Continue breastfeeding / normal diet throughout ║
║ ⚠ No anti-diarrheal medications (loperamide) in children ║
║ ⚠ Avoid juices, sodas, diluted feeds ║
╚══════════════════════════════════════════════════════════════╝
Case 14 - Acute Appendicitis (Classic Presentation)
Patient: Karim, 10-year-old boy, 32 kg
Complaint: Periumbilical pain migrating to right iliac fossa x 12 hours, nausea, vomiting x2, anorexia
History: Worsening pain, low-grade fever, no diarrhea
Examination:
- Temp: 38.1°C
- RIF tenderness (McBurney's point positive)
- Rebound tenderness (Blumberg positive)
- Rovsing's sign positive
- Psoas sign positive
- Pediatric Appendicitis Score: 8/10 (high risk)
Diagnosis: Acute Appendicitis - SURGICAL EMERGENCY
╔══════════════════════════════════════════════════════════════╗
║ REFERRAL & MANAGEMENT PLAN ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Karim Age: 10 yr Wt: 32 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: ACUTE APPENDICITIS - URGENT SURGICAL REFERRAL ║
║ ║
║ Pre-operative management: ║
║ ║
║ 1. NPO immediately ║
║ 2. IV access + Normal saline (maintenance) ║
║ 3. IV Cefazolin 25 mg/kg = 800 mg pre-op ║
║ + Metronidazole 7.5 mg/kg = 240 mg IV ║
║ ║
║ 4. Investigations: CBC, LFTs, CRP, Urine R/E, ║
║ Ultrasound abdomen (appendix) ║
║ (CT scan if US inconclusive) ║
║ ║
║ 5. Morphine/Fentanyl for pain (does NOT mask exam findings) ║
║ ║
║ ⚠ URGENT REFERRAL TO GENERAL SURGERY ║
╚══════════════════════════════════════════════════════════════╝
Case 15 - Constipation (Functional)
Patient: Nadia, 4-year-old girl, 16 kg
Complaint: Infrequent stools (once every 4-5 days), hard painful stools, pain, occasional blood-streaked stool
History: Started around toilet training, withholds stool due to fear of pain
Examination:
- Abdomen: palpable fecal mass in left iliac fossa
- Perianal: small anal fissure noted
- Digital rectal exam: hard stool in ampulla
Diagnosis: Functional Constipation with anal fissure
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Nadia Age: 4 yr Wt: 16 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Functional Constipation + Anal Fissure ║
║ ║
║ Rx: ║
║ ║
║ DISIMPACTION (if needed): ║
║ 1. PEG (Polyethylene Glycol 3350/Movicol) ║
║ Disimpaction: 1-1.5 g/kg/day x 3-6 days ║
║ Maintenance: 0.5 g/kg/day OD ║
║ (16 g sachet dissolved in 250 mL water) ║
║ ║
║ 2. Lactulose syrup 10 g/15 mL ║
║ 1 mL/kg BD as alternative maintenance laxative ║
║ ║
║ 3. Petroleum jelly (Vaseline) applied to anal fissure BD ║
║ ║
║ 4. Dietary: increase fiber, fruits, water intake ║
║ Prune juice, pears helpful ║
║ ║
║ 5. Toilet training: regular sitting after meals x 10 min ║
║ Positive reinforcement strategy ║
╚══════════════════════════════════════════════════════════════╝
🧴 SKIN CASES
Case 16 - Atopic Dermatitis (Eczema)
Patient: Fatima, 3-year-old girl, 14 kg
Complaint: Itchy, dry, scaly rash on flexures (antecubital, popliteal), cheeks, affecting sleep
History: Since 6 months age, family history of asthma (father), worse in winter
Examination:
- Bilateral antecubital/popliteal fossa: lichenified, erythematous, excoriated plaques
- Cheeks: dry erythematous patches
- No secondary bacterial infection signs
Diagnosis: Atopic Dermatitis (Eczema) - Moderate
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Fatima Age: 3 yr Wt: 14 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Atopic Dermatitis - Moderate ║
║ ║
║ Rx: ║
║ ║
║ 1. Emollient cream (Cetaphil/Aquaphor/E45) ║
║ Apply generously BD-TDS (minimum 2x daily) ║
║ (cornerstone of therapy) ║
║ ║
║ 2. Hydrocortisone cream 1% ║
║ Apply to affected areas BD x 7-10 days ║
║ (mild TCS for face/folds) ║
║ ║
║ 3. For thicker/chronic lesions on body (not face): ║
║ Betamethasone 0.025% cream - thin layer BD x 5-7 days ║
║ ║
║ 4. Syrup Cetirizine 5 mg/5 mL (Zyrtec) ║
║ 0.25 mg/kg/dose OD at night = 3.5 mg (3.5 mL OD) ║
║ (reduces itch, aids sleep) ║
║ ║
║ 5. Avoid soap - use soap-free cleansers ║
║ 6. Cotton clothing, avoid woolen/synthetic fabrics ║
║ 7. Keep nails short ║
╚══════════════════════════════════════════════════════════════╝
Case 17 - Impetigo
Patient: Ahmed, 5-year-old boy, 18 kg
Complaint: Golden-yellow crusted lesions around nose and mouth x 5 days, mild itching
History: No fever, sibling also has similar lesions
Examination:
- Honey-colored crusted lesions around nares and perioral area (classic non-bullous impetigo)
- No systemic symptoms
Diagnosis: Non-bullous Impetigo (Staphylococcal/Streptococcal)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Ahmed Age: 5 yr Wt: 18 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Non-bullous Impetigo ║
║ ║
║ Rx: ║
║ ║
║ TOPICAL (for localized, <5 lesions): ║
║ 1. Mupirocin (Bactroban) 2% ointment ║
║ Apply to lesions TDS x 5 days ║
║ (after gentle removal of crusts with warm water) ║
║ ║
║ SYSTEMIC (for widespread/extensive impetigo): ║
║ 2. Syrup Flucloxacillin 125 mg/5 mL ║
║ Dose: 12.5-25 mg/kg QID = 450 mg/day ║
║ = 112 mg QID (4.5 mL QID) x 7 days ║
║ Give 30 min before meals ║
║ ║
║ OR: Cephalexin syrup 25 mg/kg/day ÷ TDS ║
║ ║
║ 3. Gentle washing with soap and water BD ║
║ ║
║ Exclude from school until lesions crusted/treated x 24 hrs ║
╚══════════════════════════════════════════════════════════════╝
Case 18 - Scabies
Patient: Mariam, 7-year-old girl, 21 kg
Complaint: Intense itching (worse at night), affecting hands, wrists, axillae, and groin x 3 weeks
History: Multiple family members affected
Examination:
- Linear burrows in finger web spaces and wrists
- Papulovesicular rash in axillae and groin
- Excoriations
Diagnosis: Scabies (family outbreak)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Mariam + Family (treat all simultaneously) ║
║ Age: 7 yr Wt: 21 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Scabies ║
║ ║
║ Rx: ║
║ ║
║ 1. Permethrin 5% cream (Scabicid) ║
║ Apply to ENTIRE body neck to toes (including fingers, ║
║ under nails, behind ears) ║
║ Leave on 8-12 hours, then wash off ║
║ Repeat after 7 days ║
║ ⚠ Treat ALL household contacts simultaneously ║
║ ║
║ 2. Syrup Cetirizine/Hydroxyzine for itch ║
║ Cetirizine 5 mg/5 mL: 5 mg (5 mL) OD at night ║
║ ║
║ 3. Launder all bedding, clothing, towels in hot water ║
║ (60°C wash, OR seal in bag x 72 hours) ║
║ ║
║ ⚠ Itch may persist 2-4 weeks after treatment (post-scabetic ║
║ dermatitis) - doesn't mean treatment failure ║
╚══════════════════════════════════════════════════════════════╝
Case 19 - Urticaria (Hives) / Allergic Reaction
Patient: Noor, 4-year-old girl, 16 kg
Complaint: Sudden onset itchy, raised, wheals all over body after eating strawberries, 2 hours ago. No respiratory distress.
History: No previous similar episodes, no lip/tongue swelling, no breathing difficulty
Examination:
- Multiple raised, erythematous wheals on trunk, arms, legs (migratory)
- No angioedema
- No stridor, no wheezing
- HR: 105, SpO2: 99%, BP: normal
Diagnosis: Acute Urticaria (allergic, food-triggered) - No Anaphylaxis
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Noor Age: 4 yr Wt: 16 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Acute Urticaria - Allergic ║
║ ║
║ Rx: ║
║ ║
║ 1. Syrup Cetirizine 5 mg/5 mL (Zyrtec) ║
║ Dose: 0.25 mg/kg/dose = 4 mg OD ║
║ 5 mg (5 mL) OD at night x 5-7 days ║
║ (non-sedating 2nd gen antihistamine) ║
║ ║
║ 2. If inadequate response: ║
║ Add Ranitidine 2 mg/kg/dose BD (H2 blocker) ║
║ = 30 mg BD ║
║ ║
║ 3. Avoid trigger food (strawberries) ║
║ Allergy testing referral if recurrent ║
║ ║
║ ⚠ ANAPHYLAXIS WARNING: ║
║ Prescribe Epinephrine auto-injector (EpiPen Jr 0.15 mg) ║
║ if recurrent urticaria with systemic symptoms ║
║ Emergency plan given to parents ║
╚══════════════════════════════════════════════════════════════╝
🩺 NUTRITIONAL / GROWTH CASES
Case 20 - Iron Deficiency Anemia
Patient: Zainab, 18-month-old girl, 9.5 kg
Complaint: Pallor, irritability, reduced appetite, fatigue
History: Exclusively cow's milk diet, inadequate iron-rich foods since 12 months
Examination:
- Pallor: conjunctival, palmar
- Tachycardia: HR 130/min
- Mild systolic flow murmur
- No hepatosplenomegaly
- CBC: Hb 7.8 g/dL, MCV 62 fL, MCH 18 pg, RDW elevated
- Iron studies: low serum iron, high TIBC, low ferritin
Diagnosis: Iron Deficiency Anemia (IDA)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Zainab Age: 18 mo Wt: 9.5 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Iron Deficiency Anemia ║
║ ║
║ Rx: ║
║ ║
║ 1. Ferrous sulfate drops / Syrup (25 mg elemental Fe/mL) ║
║ Dose: 3-6 mg/kg/day of elemental iron ÷ 2 doses ║
║ = 28-57 mg/day (give 40 mg/day in 2 doses) ║
║ Give between meals with Vitamin C source (orange juice) ║
║ Continue 3 months after Hb normalizes ║
║ ║
║ 2. Vitamin C (Ascorbic acid) 50 mg OD with iron ║
║ (enhances iron absorption) ║
║ ║
║ Dietary advice: ║
║ - Limit cow's milk to max 500 mL/day ║
║ - Introduce iron-rich foods: meat, legumes, fortified cereal ║
║ - Avoid tea/calcium-rich foods with iron supplement ║
║ ║
║ Repeat CBC after 4 weeks (expect Hb rise of 1-2 g/dL) ║
╚══════════════════════════════════════════════════════════════╝
Case 21 - Vitamin D Deficiency Rickets
Patient: Abdullah, 18-month-old boy, 10 kg
Complaint: Bow legs, delayed walking (not walking at 18 months), frontal bossing, enlarged wrists
History: Born in winter, exclusively breastfed without supplementation, rarely outdoors
Examination:
- Frontal bossing
- Rachitic rosary (costochondral beading)
- Harrison's sulcus
- Widened wrists (metaphyseal widening)
- Genu varum (bow legs)
- X-ray: cupping, fraying and widening of metaphyses, reduced bone density
Diagnosis: Nutritional Rickets (Vitamin D Deficiency)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Abdullah Age: 18 mo Wt: 10 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Vitamin D Deficiency Rickets ║
║ ║
║ Investigations: S. Ca, PO4, ALP (markedly elevated), PTH, ║
║ 25-OH Vitamin D, X-ray wrists ║
║ ║
║ Rx: ║
║ ║
║ TREATMENT DOSE: ║
║ 1. Vitamin D3 (Cholecalciferol) drops ║
║ 1000-2000 IU OD x 3 months ║
║ (or 50,000 IU weekly x 6 weeks - Stoss therapy option) ║
║ ║
║ 2. Calcium Syrup (Calcium carbonate 250 mg/5 mL) ║
║ 500 mg elemental calcium/day ÷ 2 doses ║
║ (vital if dietary calcium intake is poor) ║
║ ║
║ MAINTENANCE after healing: ║
║ 3. Vitamin D3 400-800 IU OD (ongoing prevention) ║
║ ║
║ Review ALP and 25-OH Vit D after 3 months ║
║ Increase sun exposure (20-30 min/day) ║
╚══════════════════════════════════════════════════════════════╝
Case 22 - Severe Acute Malnutrition (SAM) with Complications
Patient: Ibrahim, 2-year-old boy, 6.5 kg (expected 12 kg)
Complaint: Wasting, not eating, bilateral pitting edema of feet, hair changes
History: Food insecure family, recurrent infections
Examination:
- MUAC: 10.5 cm (SAM threshold: <11.5 cm)
- Bilateral pitting edema up to knees (Kwashiorkor features)
- Moon face, muscle wasting
- Hair: thin, discolored, easily pluckable
- W/H z-score: < -3
Diagnosis: Severe Acute Malnutrition (Marasmic-Kwashiorkor)
╔══════════════════════════════════════════════════════════════╗
║ MANAGEMENT PLAN (HOSPITAL / NRC) ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Ibrahim Age: 2 yr Wt: 6.5 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Severe Acute Malnutrition (Marasmic-Kwashiorkor) ║
║ ║
║ ADMIT TO NUTRITION REHABILITATION CENTER ║
║ ║
║ Phase 1 (Days 1-7): Stabilization ║
║ 1. F-75 (therapeutic milk): 100 mL/kg/day ÷ 8-12 feeds ║
║ Avoid high-protein feeds initially (refeeding syndrome) ║
║ ║
║ Phase 2 (Week 2+): Rehabilitation ║
║ 2. F-100 / RUTF (Ready-to-Use Therapeutic Food) ║
║ 200 mL/kg/day ║
║ ║
║ Routine medications (ALL SAM children): ║
║ 3. Amoxicillin syrup 80 mg/kg/day ÷ BD x 7 days ║
║ (even without overt infection - evidence-based) ║
║ 4. Vitamin A 200,000 IU single dose ║
║ 5. Folic acid 5 mg OD x 14 days ║
║ 6. Zinc 2 mg/kg/day x 2 weeks ║
║ 7. Iron - only after Day 7 (not in acute phase) ║
╚══════════════════════════════════════════════════════════════╝
🧠 NEUROLOGICAL / DEVELOPMENTAL CASES
Case 23 - Attention Deficit Hyperactivity Disorder (ADHD)
Patient: Ziad, 8-year-old boy, 27 kg
Complaint: Poor school performance, inattentive, impulsive, hyperactive, difficulty sitting still
History: Problems since kindergarten, same at home and school (pervasive), no learning disability on formal testing
Assessment:
- Conners' Rating Scale completed by teacher and parents: elevated on inattention, hyperactivity, impulsivity
- DSM-5: 6+ inattentive + 6+ hyperactive criteria met in 2+ settings, onset <12 yrs, impairs functioning
- IQ/educational testing: normal
Diagnosis: ADHD - Combined Presentation (DSM-5)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Ziad Age: 8 yr Wt: 27 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: ADHD - Combined Type ║
║ ║
║ NON-PHARMACOLOGICAL (first-line for all ages): ║
║ 1. Parent training in behavior management ║
║ 2. Educational accommodations (IEP/504 plan) ║
║ 3. Behavioral therapy ║
║ ║
║ PHARMACOLOGICAL (school-age, if above insufficient): ║
║ 4. Methylphenidate (Ritalin) 5 mg tablet ║
║ Start: 5 mg OD with breakfast x 1 week ║
║ Increase: 5 mg BD (morning + noon) if needed ║
║ Max: 1 mg/kg/day (max 60 mg/day) ║
║ Give with/after breakfast (avoid late afternoon dose ║
║ to prevent insomnia) ║
║ ║
║ Monitor: HR, BP, height/weight (every 6 months) ║
║ Drug holidays: consider during school vacations ║
║ Reassess at 1 month ║
╚══════════════════════════════════════════════════════════════╝
Case 24 - Migraine (Pediatric)
Patient: Hana, 12-year-old girl, 40 kg
Complaint: Recurrent throbbing headaches (unilateral), nausea, vomiting, photophobia, lasts 4-8 hrs, 3x/month
History: Family history of migraine (mother), not triggered by fever, no focal neuro signs
Examination:
- Normal neurological examination
- No papilledema
- Normal fundus
Diagnosis: Pediatric Migraine without Aura
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Hana Age: 12 yr Wt: 40 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Migraine without Aura (Pediatric) ║
║ ║
║ ACUTE TREATMENT: ║
║ 1. Ibuprofen 10 mg/kg/dose = 400 mg PO at onset ║
║ (most effective first-line; repeat once after 8 hrs) ║
║ ║
║ 2. Sumatriptan nasal spray 10 mg intranasal ║
║ (approved for adolescents ≥12 yr; for treatment failures) ║
║ ║
║ 3. Metoclopramide 0.1 mg/kg PO for nausea ║
║ = 4 mg (max 10 mg) ║
║ ║
║ PREVENTIVE (if ≥4 attacks/month): ║
║ 4. Amitriptyline 10 mg PO OD at night ║
║ (titrate up slowly; evidence in pediatrics) ║
║ OR: Topiramate 1-3 mg/kg/day ÷ BD ║
║ ║
║ Headache diary to track triggers ║
║ Triggers: sleep, diet, stress - identify and avoid ║
╚══════════════════════════════════════════════════════════════╝
💧 NEONATAL / INFANT CASES
Case 25 - Neonatal Jaundice (Physiological)
Patient: Baby Aisha, 4-day-old girl, 3.2 kg
Complaint: Yellow discoloration of skin since day 2, feeding well, alert
History: Term birth (38+5 weeks), normal delivery, blood group A+ mother, O+ baby
Examination:
- Jaundice: face + trunk (Kramer zone 1-2)
- Active, alert, good Moro reflex
- Serum Bilirubin: 12 mg/dL (total), direct: 0.4 mg/dL
- Birth weight: 3.4 kg, current: 3.2 kg (5.9% loss - normal)
- No fever, no hepatosplenomegaly
Diagnosis: Physiological Neonatal Jaundice (below phototherapy threshold for age)
╔══════════════════════════════════════════════════════════════╗
║ NEONATAL OPD PLAN ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Baby Aisha Age: 4 days Wt: 3.2 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Physiological Neonatal Jaundice ║
║ (Bilirubin 12 mg/dL - below phototherapy threshold) ║
║ ║
║ Management: ║
║ ║
║ 1. Continue exclusive breastfeeding ║
║ Increase frequency: 8-12 feeds/24 hours ║
║ (adequate hydration reduces enterohepatic recirculation) ║
║ ║
║ 2. Check bilirubin in 24 hours or sooner if ║
║ - jaundice deepens below umbilicus (zone 3) ║
║ - feeding difficulties ║
║ - fever or lethargy ║
║ ║
║ NO MEDICATIONS REQUIRED ║
║ ║
║ PHOTOTHERAPY THRESHOLDS (AAP/NICE): ║
║ At 96 hr: start phototherapy if TSB ≥17 mg/dL (term) ║
║ Exchange transfusion: TSB ≥25 mg/dL ║
║ ║
║ Sunlight DOES NOT replace phototherapy (inadequate) ║
╚══════════════════════════════════════════════════════════════╝
Case 26 - Infantile Colic
Patient: Baby Tariq, 6-week-old boy, 4.5 kg
Complaint: Inconsolable crying, drawing up legs, screaming episodes >3 hrs/day, >3 days/week x 2 weeks
History: Formula-fed, no vomiting, normal stools, normal weight gain
Examination:
- Afebrile, well-nourished, active
- Abdomen: soft, no tenderness, increased bowel sounds
- Normal growth: weight gain 200 g/week
- No inguinal hernia, normal genitalia
Diagnosis: Infantile Colic (Wessel's Rule of 3s)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PLAN ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Baby Tariq Age: 6 wk Wt: 4.5 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Infantile Colic (Rule out organic causes confirmed) ║
║ ║
║ Management: ║
║ ║
║ 1. Simeticone drops (Gas drops / Infacol) ║
║ 0.3 mL (20 mg) per dose before feeds ║
║ (evidence limited, but widely used and safe) ║
║ ║
║ 2. Probiotic: Lactobacillus reuteri drops ║
║ 5 drops (10^8 CFU) OD x 4 weeks ║
║ (good evidence in breastfed infants for reducing cry time) ║
║ ║
║ 3. For formula-fed: Trial of hydrolyzed formula x 2 weeks ║
║ (if dairy protein sensitivity suspected) ║
║ ║
║ 4. Soothing techniques: ║
║ - Swaddling, rhythmic movement (rocking/car ride) ║
║ - White noise (vacuum cleaner sound) ║
║ - Skin-to-skin contact ║
║ ║
║ Reassure: Self-limiting, resolves by 3-4 months ║
╚══════════════════════════════════════════════════════════════╝
Case 27 - Diaper Rash (Napkin Dermatitis)
Patient: Baby Safa, 5-month-old girl, 6.5 kg
Complaint: Red, angry rash in diaper area, irritable during diaper changes
History: Formula-fed, recently started antibiotics for otitis media
Examination:
- Erythematous, satellite lesions extending beyond diaper area (suggesting Candida superinfection)
- Skin folds involved (fungal pattern)
Diagnosis: Candidal Diaper Dermatitis (secondary to antibiotic use)
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Baby Safa Age: 5 mo Wt: 6.5 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Candidal Diaper Dermatitis ║
║ ║
║ Rx: ║
║ ║
║ 1. Clotrimazole 1% cream ║
║ Apply thinly to affected area TDS x 7-10 days ║
║ ║
║ 2. Zinc oxide paste (Drapolene/Sudocrem) ║
║ Apply as barrier at each diaper change ║
║ ║
║ 3. Nystatin oral drops 100,000 units/mL ║
║ 1 mL (100,000 U) QID x 7 days (oral candida prophylaxis ║
║ if breastfeeding mother also affected) ║
║ ║
║ Hygiene: ║
║ - Change diapers frequently (at least Q2H) ║
║ - Pat dry, avoid friction/wipes with alcohol ║
║ - Leave diaper-free time (air exposure) ║
║ ║
║ ⚠ Avoid topical steroids in skin fold candidal rash ║
╚══════════════════════════════════════════════════════════════╝
Case 28 - Allergic Rhinitis
Patient: Layla, 9-year-old girl, 28 kg
Complaint: Persistent sneezing, runny nose (clear), nasal congestion, itchy eyes x 3 months (seasonal)
History: Worsens in spring, family history of allergic rhinitis and asthma
Examination:
- Bilateral nasal mucosa: pale, boggy, bluish
- Inferior turbinate hypertrophy
- Allergic shiners (dark circles under eyes)
- Transverse nasal crease (from allergic salute)
- Eyes: conjunctival injection, mild chemosis
Diagnosis: Seasonal Allergic Rhinoconjunctivitis
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Layla Age: 9 yr Wt: 28 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Seasonal Allergic Rhinoconjunctivitis ║
║ ║
║ Rx: ║
║ ║
║ FIRST-LINE (for moderate-severe): ║
║ 1. Mometasone nasal spray 50 mcg/spray ║
║ 1 spray each nostril OD (morning) ║
║ (most effective for nasal symptoms) ║
║ ║
║ 2. Cetirizine 10 mg tablet OD at night ║
║ (for sneezing, itch, eye symptoms) ║
║ ║
║ 3. Olopatadine (Patanol) eye drops 0.1% ║
║ 1 drop each eye BD x 2 weeks ║
║ (for allergic conjunctivitis) ║
║ ║
║ 4. Nasal saline irrigation BD (washes out allergens) ║
║ ║
║ Environmental control: ║
║ - Keep windows closed during high pollen season ║
║ - HEPA air purifier in bedroom ║
║ - Allergy testing / immunotherapy if not controlled ║
╚══════════════════════════════════════════════════════════════╝
Case 29 - Threadworm Infestation (Enterobiasis/Pinworm)
Patient: Hamid, 6-year-old boy, 20 kg
Complaint: Perianal itching, especially at night, poor sleep, irritable
History: Sibling also complaining of similar itching
Examination:
- Perianal excoriations
- "Tape test" (scotch tape to perianal area at night): shows eggs on microscopy
Diagnosis: Enterobius vermicularis (Pinworm/Threadworm) Infestation
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Hamid + ALL household contacts ║
║ Age: 6 yr Wt: 20 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Enterobiasis (Pinworm Infestation) ║
║ ║
║ Rx: ║
║ ║
║ 1. Mebendazole 100 mg (single dose) ║
║ REPEAT after 2 weeks (kills hatching worms) ║
║ Treat ALL household contacts simultaneously ║
║ ║
║ OR: Albendazole 400 mg (single dose) + repeat at 2 wks ║
║ (safe in children >1 year) ║
║ ║
║ Hygiene measures (ESSENTIAL - prevents reinfection): ║
║ 2. Short fingernails, do not scratch perianal area ║
║ 3. Wash hands and nails thoroughly after toilet, before meals║
║ 4. Shower every morning (removes eggs deposited at night) ║
║ 5. Wash bedding and underwear in hot water (washing day) ║
║ after each dose ║
╚══════════════════════════════════════════════════════════════╝
Case 30 - Acute Sinusitis (Bacterial)
Patient: Zara, 9-year-old girl, 27 kg
Complaint: Nasal congestion, purulent (green/yellow) nasal discharge, facial pain/pressure, fever 38.4°C x 10 days
History: URI started 14 days ago, initially improving then worsened at day 7 (double-worsening pattern)
Examination:
- Maxillary sinus tenderness on percussion
- Purulent post-nasal drip on posterior pharyngeal wall
- No periorbital edema
Diagnosis: Acute Bacterial Rhinosinusitis (ABRS) - Persistent/Double-Worsening type
╔══════════════════════════════════════════════════════════════╗
║ OUTPATIENT PRESCRIPTION ║
╠══════════════════════════════════════════════════════════════╣
║ Patient: Zara Age: 9 yr Wt: 27 kg ║
╠══════════════════════════════════════════════════════════════╣
║ Dx: Acute Bacterial Rhinosinusitis ║
║ ║
║ Rx: ║
║ ║
║ 1. Tab Amoxicillin-Clavulanate 250 mg/62.5 mg ║
║ Dose: 40-45 mg/kg/day (amoxicillin) ÷ BD ║
║ = 1215 mg/day amoxicillin → 600 mg BD ║
║ x 10-14 days ║
║ ║
║ 2. Mometasone nasal spray 50 mcg ║
║ 1 spray each nostril BD ║
║ (reduces mucosal edema, improves drainage) ║
║ ║
║ 3. Nasal saline irrigation BD (hypertonic 3% preferred) ║
║ ║
║ 4. Syrup Ibuprofen 10 mg/kg TDS PRN for facial pain/fever ║
║ ║
║ ⚠ CT sinuses only if complications suspected ║
║ (orbital/intracranial extension, not for diagnosis) ║
║ Review if no improvement in 72 hrs ║
╚══════════════════════════════════════════════════════════════╝
📋 QUICK-REFERENCE DOSE TABLE
| Drug | Pediatric Dose | Frequency | Notes |
|---|---|---|---|
| Paracetamol | 15 mg/kg/dose | Q4-6H | Max 60-75 mg/kg/day, max 4 g/day |
| Ibuprofen | 10 mg/kg/dose | Q6-8H | >6 months, with food, max 40 mg/kg/day |
| Amoxicillin | 40-90 mg/kg/day ÷ TDS | TDS | High dose (90) for AOM, pneumonia, sinusitis |
| Amoxicillin-Clav | 40-45 mg/kg/day ÷ BD | BD | Based on amoxicillin component |
| Azithromycin | 10-20 mg/kg OD | OD | Max 500 mg/day; 3-5 day course |
| Cephalexin | 25-50 mg/kg/day ÷ TDS | TDS | UTI, skin infections |
| Cotrimoxazole | TMP 4-6 mg/kg/day ÷ BD | BD | UTI, prophylaxis |
| Metronidazole | 7.5 mg/kg/dose | TDS | Anaerobic infections, amoebiasis |
| Dexamethasone | 0.6 mg/kg (croup) | Single | 0.15 mg/kg for mild croup |
| Cetirizine | 0.25 mg/kg/dose | OD (at night) | >6 months; max 10 mg/day |
| ORS | 50-100 mL/kg | Over 4 hrs | Mild-mod dehydration |
| Zinc | 10 mg/day (>6 mo) 5 mg/day (<6 mo) | OD | For diarrhea, x 14 days |
| Ferrous sulfate | 3-6 mg/kg/day elemental iron | BD-TDS | Between meals with Vit C |
| Vitamin D3 | 400-800 IU prevention; 1000-2000 IU treatment | OD | Until levels normalize |
| Permethrin 5% | Apply whole body | x1, repeat day 7 | All household contacts together |
| Mebendazole | 100 mg | Single, repeat day 14 | >2 years; treat family |
| Salbutamol MDI | 2-4 puffs via spacer | Q4-6H PRN | Reliever only |
| Methylphenidate | Start 5 mg; 0.3-1 mg/kg/day | AM + noon | Drug holidays possible |
🔴 RED FLAGS - WHEN TO ADMIT or REFER URGENTLY
| Presentation | Red Flag Sign | Action |
|---|---|---|
| Fever | Temp >40°C, inconsolable, petechial/purpuric rash | Admit, rule out meningococcemia |
| Respiratory | SpO2 <92%, RR >60 (infant), severe retractions | Admit, O2, assess for PICU |
| Seizures | Status epilepticus (>5 min), focal, post-ictal paralysis | Emergency |
| Diarrhea | Severe dehydration (sunken eyes, poor turgor, CRT >3s) | IV fluids, admit |
| Abdominal pain | Rebound, guarding, bloody stool | Surgical emergency |
| Altered consciousness | GCS <15, meningeal signs, bulging fontanelle | Admit immediately |
| Jaundice | TSB >25 mg/dL, bronze baby, pale stools, dark urine | Exchange transfusion |
| Rash | Purpura, non-blanching rash + fever | Meningococcemia until proven otherwise |
📝 PRESCRIPTION WRITING TIPS FOR PEDIATRIC OPD
- Always write weight - every pediatric prescription must state patient weight in kg
- Calculate dose by weight - write out the calculation (e.g., "10 mg/kg x 20 kg = 200 mg")
- Specify volume - convert mg dose to mL for liquid formulations
- Name the concentration - write "Amoxicillin 250 mg/5 mL syrup" not just "Amoxicillin syrup"
- Duration matters - always specify days of treatment
- Avoid abbreviations - write "twice daily" not "BD" where possible (reduces errors)
- Age restrictions - Ibuprofen only >6 months; Aspirin never in children (Reye syndrome); Codeine avoid in <12 yr
- Councel parents - every prescription should include one key counseling point
- Safety-net - always tell parents when to return or seek emergency care
- Review response - schedule follow-up, especially for antibiotics, to ensure resolution
References: The Harriet Lane Handbook, 23rd Ed. (The Johns Hopkins Hospital) | Red Book 2021 (AAP) | Nelson Textbook of Pediatrics | WHO IMCI Guidelines | Canadian Paediatric Society Drug Dosing Guidelines | Goodman & Gilman's Pharmacological Basis of Therapeutics
For educational use only. All prescriptions should be individualized to the patient. Always verify current drug doses and guidelines before clinical application.
Make a CSV file with all 30 cases, diagnoses, medications, and doses for quick reference
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Writing File
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All 30 cases verified. The CSV is complete and accurate.
pediatric opd cases
CSV File · CSV
The CSV contains 31 rows (1 header + 30 cases) with 20 columns:
| Column | Contents |
|---|---|
| Case No., Patient, Age, Weight | Patient identification |
| Diagnosis, Category | Clinical diagnosis and system |
| Medication 1-3 | Up to 3 medications per case |
| Dose 1-3 | Weight-based calculated doses |
| Frequency 1-3 | TDS / BD / OD / PRN etc. |
| Duration 1-3 | Days of treatment |
| Key Counseling Point | Most important parent/patient advice |
| Red Flag / Admit If | When to escalate or refer |
All 30 cases covered:
- Respiratory (7): AOM, Strep Throat, Viral URI, Pneumonia, Bronchiolitis, Asthma, Croup
- Fever/Infectious (5): Febrile Seizure, Typhoid, UTI, Chickenpox, HFMD
- GI (4): Gastroenteritis, Appendicitis, Constipation, Threadworm
- Skin (5): Eczema, Impetigo, Scabies, Urticaria, Diaper Rash
- Nutritional (3): Iron Deficiency Anemia, Rickets, SAM
- Neurological (2): ADHD, Migraine
- Neonatal/Infant (3): Neonatal Jaundice, Colic, Allergic Rhinitis
Open in Excel or Google Sheets - each column will sort and filter independently for quick clinical reference.
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