nutrition

Nutr i t ion DR. Abo-Asrar

P a g e | 1

Nutrition

Infection neonatology

Nutrition

Nutrition

nutritional disorder


pure

Genetics


P a g e | 2

Nutritional disorder

marasmus Kwashiorkor Rickets

full sheet

full history examination

discussion examiner

Direct face to facediscussion


no excuse

Nutritional disorder fatal

Nutritional disorder fatal


Pure written

clinical

written

Tetany

tetany


P a g e | 3

Nutritional assessment

title nutritional disorder

written

Hyper vitaminosis D

D

Hypo Hyper vitaminosis

written

Hyper vitaminosis D

dose vitamin D

written


written

clinical

clinical written

written

written clinical

Rickets

Marasmus Kwashiorkor

Rickets Marasmus Kwashiorkor

Rickets

80 %

Rickets

Rickets rickets

rickets

basics bone


P a g e | 4

bone

bone

Medulla

cortex

bone medulla cortex

medulla hematology

cortex

cortex

cortex

Protein part

cortex protein

protein soft tissue osteoid tissue

Protein part cortex soft tissue part bone

osteoid tissue

bone matrix

cement

Mineral part

Mineral part

Ca phosphate


P a g e | 5

cement

Ca phosphate

collagen fibers

collagen fibers

cortex

fragile bone

fragile liable to fracture

protein part

part

osteoporosis

osteoporosis

defect protein part

bone

osteoporosis

defect protein part bone

osteoid tissue

Protein part bone

protein deficiency

Marasmus


P a g e | 6

Kwashiorkor


Muscle muscle

muscle bone


bone

Osteoporosisbone osteoporosis

mineral part

mineral part

Rickets

rickets defect bone mineralization

rickets defect mineral part of the bone

adult Osteomalacia

Rickets

Osteomalacia

Osteomalacia defect in mineralization of the bone

Rickets defect in mineralization of the bone

collagen fibers

Liable to fracturebone diseases

X -ray

Osteogenesis imperfecta

collagen fibers supporting bone


P a g e | 7

bone diseases

osteogenesis imperfecta

X - rays

defect cortex

Protein part cortex osteoporosis Mineral part bone rickets

collagen fibers supporting bone osteogenesis imperfecta

rickets

defect mineralization of the bone

Mineralization of the bone


Mitosis apotosis

mineralization of the bone

mineral part

active functioning

New bone

bone

Mineral part


P a g e | 8

osteoblast cell

osteoblast cells

Osteoblast New bone

deposition of calcium and phosphate inside the bone

New bone formation

Osteoclast cells

Osteoclast bone

osteoblast bone

Osteoblast osteoclast

Branched cellsbranched cells

bone marrow

Osteoblast osteoclast bone marrow

bone marrow stem cells


P a g e | 9

stem cells bone marrow osteoblast osteoclast

colony

Dendritic cells

Dendritic cells

dendritic cells

dendritic cells generation stem cells of the bone marrow

bone marrow

osteoblast osteoclast

osteoblast new bone formation

osteoclast old bone



osteoblast

osteoblast osteoblast

New bone formation

Patho physiologyRickets

patho physiology Rickets

Ca metabolism

vitamin D metabolism biochemistry

Rickets

vitamin D deficiency

Patho physiology and clinical manifestations of rickets

Osteoblast

bone

osteoblast


P a g e | 10

dendritic cells

dendritic cells

nucleus

Osteoblast

Osteoblast blood

bone Mineralization bone

vesicle

vesicle

vesicle blood

bone Phosphorus

vesicle

blood

In organic

phosphorus In organic

chemistry

In organic

phosphorus is in organic

calcium phosphorus osteoblast

vesicle Osteoblast

Ossification calcification osteoblast

osteoblast


P a g e | 11

osteoblast

vesicle

Phosphorus vesicle

phosphorus vesicle Organic phosphate

Organic phosphate

Phospho ethanol amine

Phospho ethanol amine

phospho ethanol amine

Organic organic phosphate

Phosphorus In organic

Organic form

Organic phosphateOrganic phosphate Phospho ethanol amine

vesicle

in organic

phospho ethanol amine organic

New bone formationosteoblast

osteoblast

osteoblast

vesicle cell membrane

vesicle cell membrane

bone matrix


P a g e | 12

Organic phosphate

bone matrix

Organic phosphate

bone matrix

New bonecytoplasm osteoblast

osteoblast

cytoplasmic enzyme cytoplasm

organic phosphate In organic form

phosphorus

Alkaline phosphatase

cytoplasm osteoblast

alkaline phosphatase

alkaline phosphatase organic phosphate

in organic phosphorus

In organic

bone matrix

In organic

Phosphorus In organic

bone

bone

calcium phosphate

bone crystals

calcium apatite crystals


P a g e | 13

crystal

calcium apatite crystal

crystals

technology

dynamics

Underlying physiology

Physiology

Manual worker

Manual worker

bone mineral density

Mineral part

fracture

Non manual worker

manual worker


P a g e | 14

Mental worker

manual work vast activity


bone

fracture

fissure fracture

comminuted fracture

bone

manual workers

muscular activity

Osteoblast

Osteoblast

muscle origin Insertion

muscular activity

muscle contraction

origin Insertion

origin Insertion bone


P a g e | 15

bone

bone crystals

pressure

friction energy

Osteoblast

main stimulus inside the bone

friction bone crystals calcium apatite crystals

calcium phosphorus crystals

muscle contraction

osteoblast

Osteoblast calcium phosphate

New crystals

bone fully saturated

muscle contraction

crystals

crystals

Pressure

bulk


P a g e | 16

crystals

Osteoblast

saturation osteoblast

crystals bone

crystals bone


P a g e | 17

Rickets

phosphate

crystals

crystals

crystals bone rickets

Osteoblast activity rickets

Osteoblast alkaline phosphatase


organic phosphate In organic Phosphorus

crystals


serum

alkaline phosphatase serum

laboratory investigations rickets

rickets alkaline phosphatase

Osteoblast hyperactivity

osteoblast hyperactivity

rickets

osteoblast

rickets

osteoblast

osteoblast hyperactivity


P a g e | 18

osteoblast alkaline phosphatase


alkaline phoshphatase

alkaline phosphatase rickets

osteoblast hyper activity

activity osteoblast

number of calcium apatite crystals bone crystals bone

friction energy

continuous stimulation Osteoblast




rickets

osteoblast activity

Osteoblast activity

rickets

calcium apatite crystals


P a g e | 19

apatite crystals

friction energy

osteoblast

osteoblast alkaline phosphatse

rickets


Hypophosphatsia

Hypophosphatsia



bone

organic phosphate

In organic form

bone

rickets rickets

diagnostic investigation

Hypophosphatasia

alkaline phophatase



marasmus kwashiorkor alkaline phosphatase

Hypophosphatasia


organic in organic

phospho ethanol amine organic phosphate


P a g e | 20

bone

Urine

urine

diagnostic investigation hypophosphatasia

urine

Organic phosphate

urine phosphorus

in organic

Organic phosphorus Urine

Hypophosphatasia

diagnostic investigation


urine

hypo phosphatsia

Hypo phosphatsia resistant rickets

calcium metabolism

Ca metabolism

Factors affecting calcium absorption

factors affecting calcium absorption

factors affecting calcium absorption


P a g e | 21

PH of the duodenum

Calcium site of absorption first part of the duodenum

absorption

PH of the duodenum

calcium absorption

calcium absorption

Acidic PH

absorption acidic PH

acidic PH

alkaline PH

alkaline PH calcium absorption

breast milk

breast milk reaction nutrient

nutrient acidic alkaline

acidic alkaline

PH of the stomach

PH of the stomach duodenum

acidity

calcium absorption

cow milk

reaction alkaline

alkaline calcium

cow buffalo milk

rickets


P a g e | 22

calcium phosphorus ratio

absorption

calcium phosphorus ratio gut 2 : 1

1 : 1

2 : 1

calcium phosphorus

absorption

calcium phosphorus ratio

exactly breast milk

breast milk

Level of absorption of calcium in breast milk

cow milk

phosphorus

excess phosphate

phosphorus calcium gut

absorption

cow milk

buffalo milk

rickets

PH alkaline excess phosphate

excess phosphate

absorption calcium

gut absorption content of the food

contentsfood

iron

protein vitamin C absorption

absorption


P a g e | 23

absorption vitamin C acidic

activity absorption

acidity

acidity

acidity

absorption

calcium

absorption

Phytate oxalate iron

absorption

Hormonal factors Hormonal factors

metabolism

hormonal factors

hormone active form of vitamin D

1, 25 dihydroxy cholcalciferol

vitamin D3 Active form of vitamin D

1, 25 dihydroxy cholcalciferol

active form of vitamin D

vitamin D

main goal bone calcium

Phosphorus

Osteoblast

calcium phosphorus

bone


P a g e | 24

bone formation

serum calcium

serum calcium

bone

vitamin D

receptor GIT

receptors calcium and phosphorus absorption

receptors GIT

Phosphorus absorption

GIT

GIT

GIT

kidney

Kidney re absorption of phosphate mainly

calcium

kidney phosphorus

bone

bone

bone

osteoblast

activity

osteocalast

suppression osteoclast activity

bone

stimulation osteoblast

suppression osteoclast


P a g e | 25

activation suppression cells

dominant

peace maker heart

S. A. node

decerbrated

brain death

Monitor beats

neurologically died

heart

Normal peace maker of the heart

peace maker

sympathetic

Para sympathetic

thyroxin

thyroxin

factors peace maker

Osteoblast bone

Local dynamic

osteoblast

Osteoclast

new bone formation

vitamin D

GIT

kidney


P a g e | 26

osteobalst calcium and phosphate

bone

New bone

mineral part bone

rickets

osteomalacia

vitamin D

Hyper vitaminosis D

D

vitamin D

calcium intake


P a g e | 27

vitamin D

vitamin D without with out calcium

viatmin D

vitamin D

Vitamin D GIT phosphorus

Phosphorus

tubules phosphorus

Osteoblast

bone

osteoblast activity

Osteoblast serum

serum calcium

serum calcium osteoblast

osteoblastserum calcium phosphate

new bone

serum calcium

Hyper vitaminosis D without ca supplementation

hypo calcemia

hypo calcemia tetany

tetany

vitamin D

GIT Phosphorus

Osteoblast

Osteoblast

fully saturated


P a g e | 28

Osteoblast

vitamin D

Osteoblast

fully saturated

serum calcium

calcium

Phosphate

pathological calcification

Pathological calcification

urine phosphate

calcium phosphate

Oxalate

calcium oxalate stones

renal parenchyma

Nephro calcinosis

vessels calcification valves of the heart calcification

calcification

hyper calcemia

And metastatic calcification

Hypo vitaminosis D rickets

hyper vitaminosis D hypo calcemia and tetany


P a g e | 29

calcium supplemention

Hyper calcemia metastatic calcification

adequate calcium supplemention

para thyroid hormone

GIT vitmain D


serum calcium

serum calcium

para thyroid calcium sensor

calcium receptor

calcium senosr serum clacium

8.510.5

para thormone horomone

Para thormone hormone

serum calcium

bone

bone

suppression osteoblast

Hyper activity osteoclast

osteoblast

activity Osteoclast

bone


P a g e | 30

receptors kidney

Urine

urine

serum calcium

bone calcium

serum calcium bone calcium

serum phosphate

serum phosphate

urine

calcium Urine

Phophate urine

calcium urine phosphate urine

calcium phosphate

bone calcium Phosphate


serum calcium

serum phosphate

urine phosphate

urine urine calcium

calcium Phosphorus bone

rachetic manifestations bone


P a g e | 31

calcitonin

هندخل بقا على جزئية تانية Ultra violet rays

dark races

ultra violet rays

Nucleus

receptors Ultra violet rays

sensitivity ultra violet rays

ultra violet rays

Ultra violet rays receptors ultra violet rays

sensitivity Ultra violet rays

extremities

Ultra violet rays


P a g e | 32

Ultra violet rays

Ultra violet rays vitamin A and vitamin D

white races

receptors

sensitivity receptors

vitamin D

Ultra violet rays

Ultra violet rays

Ultra violet rays

124

Ultra violet rays

Ultra violet rays

Ultra violet rays

skin burn

cnacer

Ultra violet rays


P a g e | 33

extremities of the day

Ultra violet rays

Human being

Ultra violet rays

Ultra violet rays

Ultra violet rays

ultra violet rays

Ultra violet rays

Pollution

Ultra violet rays

ultra violet rays

skin

receptors Ultra violet rays

7 dehydro cholesterol

vitamin D3

ultra violet rays

Ultra violet rays

skin

cholesterol


P a g e | 34

7 dehydro cholesterol ultra violet rays

vitamin D3

cholcalciferol

vitamin D vitamin D

vitamin D

ultra violet rays

Intake

Intake

plant sources

animal sources Plant

ergosterol

ergosterol Ultra violet rays

vitamin D2

ergo calciferol

calciterol

ergosterol

Ultra violet rays

ergo calciferol

ergo calciferol vitamin D2

vitamin D

vitamin D2

vitamin D3

vitamin D

Vitamin D3

vitamin D3

Liver


P a g e | 35

Liver site of the stores

vitamin D3

vitamin D

vitamin D3

vitamin D3

vitamin D3 cholecalciferol

vitamin D2

vitamin D2

vitamin D2stomach

stomach vitamin D3

cholecalciferol

calciferol

vitamin D3 vitamin D2

vitamin D3stomach

vitmain D3fat soluble

fat soluble absorption

bile

absorption vitamin D

first part of the duodenum

second part

second part


P a g e | 36

Evenjejunum

absorption

vitamin D3

vitamin D3

exposure to ultra violet rays

in take

Vitamin D3 site of the stores

Liver

Liver stores

Vitamin D3

vitamin D stores Liver

Iron

breast milk animal milk

deficient vitmain D

deficient vitamin D

Milk

animal milk

breast milk

Both are deficient of vitamin D

stores

deficiency breast milk

artificial milk

rickets

rickets

stores iron deficiency


P a g e | 37

stores

stores

stores

Preterm

stores

Intra uterine growth retardation

stores


stores

onset of rickets Vitamin D deficiency rickets

stores

rickets

rickets

preterm



stores

stores


P a g e | 38

weaned

vitamin D

rachitic

stores

breast milk artificial milk

delayed weaning

Rickets

faulty weaning

Faulty weaning

vitamin D

faulty weaning

delayed weaning

faulty weaning

vitamin D


P a g e | 39

activation

activation

vitamin D

activation

activation

OH

active form

1,25, dihydroxy

2OH

carbon atom 25Liver

25 hydroxy cholcalciferol

carbon atom 1Kidney

1,25, dihydroxy cholcalciferol

metabolism of Vitamin D

Metabolism


Vitamin D deficiency vitamin D deficiency

Intake

vitamin D

faulty weaning

non nutrition

malnutrition faulty weaning

absorption

vitmain D deficiency

malabsorption malabsorption syndrome

bile

bile absorption vitamin D


P a g e | 40

Obstructive jaundice

repeated attacks of gastroentritis

repeated infection

repeated attacks of gastroenteritis


rickets

rickets rpeated gastroentritis

gastroenteritits

complication rickets

absorption

Intake

absorption Ultra violet rays


P a g e | 41

Ultra violet rays

ultra violet rays

rickets

ultra violet rays

Ultra violet rays

ultra violet

Ultra violet rays

rickets

pollution

Ultra violet rays


P a g e | 42

Liver

Liver

liver cirrhosis

Liver stores

rickets

renal disease rickets

Hydroxylation

durg induced

rickets

Drug inducedrickets

Drug induced rickets

drugs rickets

anti epileptic

rickets

anti epileptic drugs


vitamin D Liver

catabolism Liver

vitamin D Liver

toxic rapid hydroxylation

osteoporosis Osteomalacia

osteoporosis


P a g e | 43

osteomalacia

cortisone block vitamin D receptors GIT

block vitamin D receptors GIT

osteoporosis Osteomalacia

osteoporosis osteomalacia

osteoporosis

catabolism of protein

bone

osteomalacia

block vitamin D receptor GIT

absorption

ant acids rickets

anti acids rickets

calcium absorption

antiacids rickets calcium absorption

history

etiology

History


P a g e | 44

rachetic

rachetic

rickets

hisotry

rickets

Full termpreterm

preterm

full term Preterm

Pre term

stores

700

800


stores


P a g e | 45

artificial milk

rickets

alkaline PH

phosphate calcium absroption

delayed weaning

stores


P a g e | 46

delayed weaning

delayed weaning

delayed delayed weaning

vitamin D

faulty weaning

vitamin D

absroption


P a g e | 47


mal malabsroption

Liver affection obstructive jaundice

vitamin D

Liver

anti epileptic drug

Chronic ITPrickets

What ever

6 : 33


P a g e | 48

metabolism of calcium

Factors affecting calcium metabolism

vitamins D metabolism

vitamin D deficiency rickets

rickets in general

patho physiology of rickets

patho physiology

satisfied

Patho physiology of Rickets bone

Mineral part of the bone

mineral part

rickets defect mineralization of the bone

mineral part bone

calcium

calcium mineral part

rickets

calcium cortex of the bone

suppression osteoid tissue deposition


P a g e | 49

osteoid tissue depot

over depotbone

Mineral part

part osteoid tissue

cement mineral part

calcium bone

over deposition of osteoid tissue

Limit

suppression

osteoid tissue


P a g e | 50

osteoid tissue

Over deposition

bone bone

bone

Joint

Joint

two bones joint

Joint

joint

Joint

very smooth

cartilagesmooth

cartilage smooth


P a g e | 51

cartilage

cartilage smooth surface

cartilage

Joint space

joint space synovial fluid

synovial fluid

cartilage

cartilage

cartilage

cartilage

cartilage

cartilage

cartilage


P a g e | 52

cartilage proliferation

calcium bone

osteoid tissue deposit

proliferation of the cartilage

patho physiology of rickets

9 : 05

rickets

rickets

vitamin D

vitamin D

absorption Phosphorus

GIT

reabsorption kidney

deposits of calcium bone

bone

rickets

bone

suppression Osteoid tissue

suppression cartilage proliferation

excess osteoid tissue deposit


P a g e | 53

proliferation of the Of the cartilage

Mineral part

osteoid tissue

growth

growth of the bone rate

muscle

skeletal system bone and muscles

bone and muscles weak

weak

Motor development

Normal

History delayed motor development

growth and development

Neck support

crawling

supported with one hand

In child manner

In child manner


P a g e | 54

say


P a g e | 55

rickets

history

History of delayed motor development

teeth

teeth skeletal system bone

Mineral part

teeth sockets Jaw

cartilagenous

ossification

calcification

eruption of the teeth

Mineral part

Lateral incisor

last molar



P a g e | 56

rickets

delayed dentation and delayed motor development

rachetic delayed motor development

delayed dentitation


Phenomena

Phenomena

phenomena

two parameters

teething

Motor development

Motor development crawling

Motor development

dentitation

Motor Motor development


P a g e | 57

Phonemoena

rachetic

rachetic

Hisotry

History of delayed motor development

delayed dentitation

Osteoid tissue

flat bone of the skull

New bone formation

growth

flat bone

center of the growth

development frontal bone

Parital bone

flat bone

new bone formation

sutures

fontanell


P a g e | 58

New bone formation

mineral part

frontal bone

pareital bone

fontanells


anterior fontanel

anterior fontanell

anterior fontanell

2.5

delayed closure

delayed closure

delayed closure fontanell

failure of growth of the flat bone of the skull

failure of growth

New bone formation


soft tissue bone

bone

New bone formation

layers Layers Osteiod tissue

Layers of osteoid tissue

frontal bone


P a g e | 59

box shaped skull

box shaped skull

pareital frontal bone

bossing

frontal and pareital bossing

Excess osteoid tissue deposit


deficiency of calcium inside the bone

skull circumference

skull circumference

skull circumference

Increase of skull circumference

signs skull

frontal bossing

pareital bossing box shaped skull

skull circumference

fontanell

sutural line

sutural line


P a g e | 60

sutural line

craniotabes

craniotabes

rickets

craniotabes rickets

hydrocephalus

Hydrocephalus

rickets craniotabes

Pressure effect


P a g e | 61

board

board

craniotabes

still rachetic

suture line

craniotabes

joint space so narrowing

skull manifestations of rickets

frontal bossing pareital bossing

box shaped skull skull circumference

delayed closure anterior fontanell

craniotabes

rickets

section chest

thoracic verteberae

transeverse spine


P a g e | 62

ribs transverse spine

rib

bony part

rib sternum

cartilagenous part

X - ray chest and heart

sternum

rib

cartilagenous part

cartilage

Intra thoracic pressure

Positive Negative

NegativeIntra thoracic pressure negative pressure

Negative pressure

Negative pressure

traction bone

suctionbone

traction

negative negative pressure

rib flat bone

traction

rickets

Mineral part

Mineral part

traction


P a g e | 63

traction

rib

rib

rib

rib verteberae

vertebrae

rib

cartilage

cartilage

traction

Rib

rib

rib

sternum

cartilage

costo chondoral junction

rib

costo chondral junction

costo chondoral junction


P a g e | 64

groove sulcus

groove sulcus

29 : 10

groove sulcus

Longitudinal sulcus

Longitudinal sulcus

sternum

Longitudinal sulcus

sternum

chest

deformity

sternum

groove

sternum

Protruded anteriorly

sternum sternum

sternum

sternum

Pigon chest


P a g e | 65

chest

pigon Pigon chest

sternum

sternum negative pressure

sternum

sternum

antero posterior diameter of the chest

sternum

antero posterior diameter

flat chest

flat chest

shoe maker chest

Pectus exacavtum

What everflat chest

sternum Negative suction

rib Longitudinal sulcus

longitudinal sulcus pigon chest

flat chest

Lower ribs

ribs

diaphragm

diaphragm ribs

ribs diaphragm

diaphragm very powerful muscle

rib

rib

insertion of the diaphragm

rib


P a g e | 66

rib

Insertion of the diaphragm

insertion of the diaphragm

Insertion of the diaphragm

groove sulcus

Horizontal Longitudinal

Horizontal sulcusMiss Harrison

Harrison Harrison sulcus

Harrison sulcus

Horizontal sulcus

traction of the diaphragm weak ribs

groove Insertion of the of the diaphragm

chest

mechanism

cartilage

Proliferation of the of the cartilage

cartilage

Proliferation

cartilage

costo chondral junction

cartilage

Thicken


P a g e | 67

cartilage thick

growing cartilage

proliferation

proliferation

chest rachetic rosere

rib

rib


clinical signs

chest

chest signs rickets

Longiutidnal sulcus Harrison sulcus pigon chest

flat chest rachetic roseri

Manifestations chest

Long bones

long bones


P a g e | 68

tibia Normal

straight

Mineral part

collagen support

muscles

Muscles support bone

wires


P a g e | 69

support

support bone

Muscles

adductor abductor

flexors extensors

muscle

support equal

osteoid tissue

Muscle

muscle

Muscle

support

wire


P a g e | 70

Muscle supporting bone

Deformities

deformities

rickets

crawling

crawling

Muscle

bowing

upper limb

bowing

bowing

Muscle weakness

bone weakness excess osteoid tissue


P a g e | 71

genu

valgus

genu valgus deformity

genu varus deformity

curvature tibia

curvature femur

What ever deformity

extremities

deformity upper limb bowing

Lower limb genu varus

genu valgus

deformity femur curvature tibia

deformity

Bone weakness Muscle weakness


P a g e | 72

42 : 53

cartilage extremities

proliferation

cartilage

Proliferation

cartilage

shoulder Hip

shoulder muscles

deltoid shoulder

cartilage deltoid

Hip joint

Muscles

cartilage Hip joint

knee

cartilageextremities

radius ulna



radius ulna

broadening

broadening


broadening


P a g e | 73

rickets

foot

45 : 14

osteoid tissue

cartilage

proliferation

broadening

bone is very weak pressure


P a g e | 74

proliferation of the the cartilage

tibia fibula

tibia Maleollus

tibia

tibia Medial lateral

Medial

tibia

embryology

tibia

bone maleouli two separate bones

maleollus

fibula maleollus

cartilage

cartilage

cartilage

cartilage

cartilage

cartilage

joint

Human being

fusion

anatomy

joint non functioning

rickets


P a g e | 75

Proliferation of the cartilage

cartilage

cartilage maleollus shaft

ankle

broadening

broadening cartilage proliferation

groove

medial Lateral Maleollus

groove

two lines of growth

cartilage

two horizontal groove

Marfan sign

Marfan sign cartilage proliferation at two different points

Lower end tibia fibula

maleolli

Marfan sign Medial maleollus

medial Lateral


P a g e | 76

extremities

deformities broadening upper limb wrist

Marfan sign

muscle

generalized muscle weakness

generalized muscle weakness


sensors para thyroid gland

serum calcium

serum calcium 8.5

para thormone

Para thormone

para thormone serum calcium

bone

Kidney

urine

serum phosphate

Muscle ATP

adenosine tri phosphate

Phosphate

ATP


P a g e | 77

Msucle energy

Muscle weakness even degeneration of the muscle

generalized muscle weakness and hypotonia

Myopathy


back muscle

weakness back muscles

Kyphosis

Scoliosis

Khypho scoliosis

muscle weakness of the back

deformity vertebrae Muscle

muscle

kyphosis scoliosis kypho scoliosis

vertebrae deformity

muscle weakness

correctable kyphosis


P a g e | 78

Pot belly abdomen

pot belly abdomen

hernia

UmblicalInguinal hernia

Ligaments Liver spleen

Muscle

liver spleen

ptosed of the organ

Ptosis Liver spleen

weakness

severe condition respiratory muscle

respiratory muscle

stagnant secretion chest

T.B. repeated repeated chest infection

complications of rickets

Pathophysiology of rickets

clinical manifestations of rickets

clinical pictures rickets


P a g e | 79

Clinical pictures of rickets

history of delayed motor mile stones

delayed dentation

deformities

complications

By examination

Examination

skull circumference

frontal bossing parietal bossing

abnormal shape of the skull

box shaped skull

fontanel delayed closure of the anterior fontanel

craniotabes

chest deformity

sternum pigon chest

flat chest

longitudinal Horizontal sulcus

rachetic rosari


P a g e | 80

ubmlical hernia Inguinal hernia

liver spleen Upper border ptosed Liver spleen

extremities

extremities

broadening

Marfan sign

deformity bowing genu varus genu valgus deformity in femur curvature

of the femur curvature of the tibia

kyphosis

scoliosis

Kypho scoliosis

correctable kyphosis scoliosis kypho scoliosis


57

Complications of rickets

complications


Repeated chest infection

rickets


P a g e | 81

chest Infection

brochiolitis pneumonia bronchopneumonia

What everchest infection

infantile rickets complicated bronchitis

complicated

repeated chest infection

clinical

rickets repeated chest infection

defect in immune function

Immune deficient

rickets

defect in immune deficiency

chemotaxis

macrophage migration

phagocytosis

Intra cellular killing

macrophage nearly paralyzed

macrophage

defect in macrophage migration


P a g e | 82

immune function

defect Macrophage Migration

immune deficiecny Down

defect T cell function

T cell

humoral and cell mediated

Immune deficiency


immune deficiency

chest deformity

flat chest

Pigon chest

Lung Inflation

Infaltion

stagnant stagnant secretion

chest infection

muscle weakness and hypo tonia

muscle weakness hypo tonia

Muscle weakness hypo tonia

stagnant secretion

chest infection


GIT

complications

muscle weakness


P a g e | 83

Even gut muscle may be affected

Muscle weakness

rickets

constipation

diarrhea

Infection gastroenteritis

Liable to infection

gastroentritis

motility of the gut

motility of the gut

anterior abdominal muscles are weak The muscle is weak

Potential cyanosis

Potential cyanosis

defecation micturation

local reflex

contraction of the wall and relaxation of the sphincter

diaphragm

vertical diameter

contraction anterior abdominal wall muscle



P a g e | 84


vertical diameter Intra abdominal pressure

evacuation of the viscous

muscle

Local reflex

Muscle weakness

constipation

May be complicated by gastro entritis

complicated gastro entritis

Macro phages defected

diarrhea

complications

deformity

complications

bone deformity

complications tetany and convulsions

hypo calcemia and tetany

Hypo calcemia and tetany


P a g e | 85

Hypo calcemia and tetany

Laboratory investigations

tetany and convulsions

anemia Complication

anemia

rickets pallor

Pallor

rickets

commonly rickets associated with iron deficiency anemia

complications

association

factors Ca absorption

Iron

Phytate oxalate

iron deficiency

rickets

iron deficiency anemia

Lymph adenopathy

organomegaly

neglected cases

pallor

generalized lymph adenopathy

Lymph node


P a g e | 86

spleen

Pallor

Lymph node

spleen

Leukemia

Leukemia

bone marrow

bone marrow

pseudo leukemia infantum

pseudo leukemia infantum

pallor Organo megaly

Lymph adenopathy

anemia

hemolytic anemia

Hemolytic anemia

RBCs

life span

120

Hemolytic anemia

repeated infection

repeated infection

reticuloendothelial system hyperplasia

reticulo endothelial system Hyper plasia


P a g e | 87

spleen reticulo endo thelial system

spleen infection

Phagocytic function

trabeculi RBCs

hemolytic anemia

hyper splenism

reticulo endothelial system hyper plasia

repeated infection

pallor

Lymph adenopathy splenomegaly

rickets

anemia

organo megaly lymph adenopathy

associated iron deficiency anemia

rickets

anemia

Lymph adenopathy splenomegaly

complication

deformity Pelvis

female

obstructive labor


P a g e | 88

complications

Repeated chest infection GITconstipation gastroentritis

deformities

tetany

anemia

adult obstructed labor deformity in pelvis

investigations

Investigation

Investigations rickets

radiological


rickets

vitamin D

Vitamin D deficiencyWhat ever the etiology

vitamin D

calcium absorption GIT

absorption GIT

serum calcium

serum calcium

vitamin D

serum calcium

Para thyroid

Para thyroid

calcium sensors


P a g e | 89

serum calcium


Para thyroid hormone



serum calcium

serum calcium

bone

stimulation osteo clast And suppression for osteoblast

bone calcium

phosphate

1 : 11 : 45

bone

bone

kidney

kidney renal tubules

Kidney

renal tubules

kidney

Urine


P a g e | 90

urine

parathormone

bone

rachetic manifestations bone

bone Mineralization of the bone rickets

vitamin D

parathormone

New bone formation

Old bone

bone mineralization

mineralization of the bone vitamin D

Parathormone

serum clacium

serum calcium

normal

low

Parathormone

serum calcium Normal

serum calcium serum calcium Low


P a g e | 91

serum calcium Low

tetany

tetany rickets

serum clacium

serum calcium parathormone

failure Parathyroid gland

hypo parathyroid gland

Para thyroid

serum clacium

failure of the para thyroid gland

parathyroid

bone

bone

bone matrix

bone

neglected cases of rickets

stores of calcium

bone

Parathormone

serum calcium

severe type of rickets of bone stores


P a g e | 92

tetany complications

D

rachetic

vitamin D

Shock therapy

600,000vitamin D

vitamin D

serum bone

bone

serum calcium

tetany

iatrogenic

vitamin D without calcium supplementation


tetany

tetany

failure of the parathyroid gland

of the bone stores severe type of rickets

Iatrogenic High dose of vitamin D without calcium

supplementation


radiological


1 : 17 : 26


P a g e | 93


radiological

rickets

serum calcium

Normal serum calcium

8.5 10.5

Normal serum calcium

911

serum calcium

Normal

Low

Parathormone

serum calcium normal Low

rickets serum phosphate normal serum phosphorus

4.5 6.5

level

serum phosphorus

serum Phosphorus

urine

urine Parathromone

Hypo phosphatemia

Phosphate even 1.5



P a g e | 94


osteoblast

Number of crystals of the bone

bone crystals

stimulation osteoblast




Osteoblast hyper activity

osteoblast Hyper activity

Hyper activity Osteoblast

of the bone crystals

bone crystals

Normal level alkaline phosphatase

140 200international unit

500


500 international unit per liter



P a g e | 95

bone S.A.node heart

Other factors peace maker of the heart

sympathetic Para sympathetic

thyroxin

heart rate

brain death

heart

Osteoblast

main control osteoblast

bone


serum calcium normal or low serum phosphate low

urine analysis

urine analysis

urine

parathormone

urine analysis

Phosphate

research

rickets

level


P a g e | 96

rickets

very poor

rickets

research

vitamin D level

25 hydroxy cholicalciferol 1,25 hydorxy cholicalciferol


Vitamin D

parathyroid hormone

for research

Parathormone 600700

parathormone

parathormone

Level

vitamin D

urine generalized amino aciduria

vitamin D

role amino acid reabsorption

tubules

vitamin D

amino acid excretion urine

generalized amino aciduria

urine

laboratory investigations

radiological investigations


P a g e | 97

treatment

Treatment

rickets

rickets

rickets

prevention

rickets

treatment

preventive medicine

rickets

iron supplementation

vitamin D and calcium

stores

breast feeding

artificial milk

artificial milk rickets


vitamin D

early proper feeding

vitmain D


P a g e | 98

vitamin D supplementation

vitamin D supplementation

400 800

dose

400800

full term

preterm


8001200

800 - 1200 inter national unit per day

stores

requirements 400800

pre term Intra uterine growth retardation 8001200

rickets

Vitamin D deficieny rickets

vitamin D

8001200

vitamin D Oral

Oral 2000 - 6000 international unit

1500 - 5000

minimum 1500 international unit


P a g e | 99

6000 international unit per day

Oral

oral

vitamin D Injection

vitamin D Intra muscular

vitamin D intra muscular Intra venous

IM

IV

Oil

IV fat embolism

fat embolism

intra muscular

IV fat embolism

600,000 international unit

calcinosis

shock therapy

one injection


P a g e | 100

supplementation

calcium absorption

vitamin D

vitmain D

complications

deformity


Normal

lab or radiological laboratory


normal

osteoblast activity

laboratory alkaline phosphatase

Normal alkaline phosphatase

phosphate



P a g e | 101

alkaline phosphatase Normal

إحنا قولنا إيه النهاردا ؟؟؟

clinical manifestations of rickets

clinical pictures

rickets

hisotry of delayed motor development

Delayed dentation bone deformity

complictions

On examination

skull circumference

frontal Pareital bossing box shaped skull craniotabes

delayed closure fontanel

chest

Pigon chest flat chest longitudinal sulcus Harrison suclus rachetic rosari

pot belly abdomen Ptosis liver spleen

extremities

boradening Upper limb

Lower limb Knee gene varus genu valgus deformity Knee

Marfan sign deformity


P a g e | 102

kyphosis Scoliosis Kyphoscoliosis correctable

complications


GIT complications constipation diarrhea gastroentritis tetany tetany

bone deformities

anemia

adult period Obstructed labor

Investigations

serum calcium normal Low

serum phosphate Low alkaline phosphatase

Urine phosphate

amino acids urine

vitamin D

Parathormone

Prevention

vitamin D

complications

radiological finding rickets

renal rickets

radiological finding of rickets


P a g e | 103

Radiological finding of rickets

hisotology of the bone

bone

bone

two lines of growth

two lines of growth

linear growth

linear growth

Linear growth

Linear growth

Linear growth of the bone

epiphysis

growing centers


P a g e | 104

increase waist growth horizontal growth

two lines of growth

Linear

waist growth

linear growth

Linear growth waist growth

Linear growth

femur

femur

femur bone cartilage

femur

mature bone

Morphology of the bone line of epiphysis

cartilage

layer

layer columnar cells

Layer columnar cells

zone of resting cartilage

zone of resting cartilage

zone

single layer of collagenous fat


P a g e | 105

Level Layer rounded cells

zone of proliferating cartilage

layer


layer

Single colmnar cellcolmnar cells

Layer

rounded cells


cartilagenous cells

Proliferating cellsreplicating cells active cells

layers

layers celluar acellular

Vascularavascular layer

Avascularvessel

Layer

acellular and avascular layer

osteoid tissue + mineral part

Protein mineral

bone

zone of provisional calcification

zone of provisional calcification board


P a g e | 106

layer avascular

acellular

Osteoid tissue Mineral part

Layer of mature bone

blood vessel bone Phosphorus


rickets

osteoblast osteoclast

dendritic cells

stem cells bone marrow

bone

zone of mature bone

Ossified bone

What everlayers

mature bone bone

linear growth of the bone

new bone formation

all through

peri osteum

Periosteum

10 : 10

periosteum


P a g e | 107

periosteum new bone formation

New bone

osteoid tissue

calcium phosphate

Mature bone

periosteum

Periosteum mineral part

two active parts Bone

bone linear growth

Periosteum active part New bone formation

X- ray

X- ray

radiation

transparent

transparent

Particles

transparent


P a g e | 108

Lung X - ray

soft tissue Muscle

soft tissue X - ray grey

partial absroption irradiation

bone

calcium phosphate

calcium Phosphorus

bone X - ray

bone X - ray

calcium phosphate

Irradiation


P a g e | 109

X -ray


Mineral part

rickets

vitamin D

vitamin D

calcium calcium absorption

serum calcium

serum calcium

Parathormone

Parathormone

serum calcium

parathormone rickets

bone

mineral part bone

X -ray bone

X -ray

X -ray decrease bone density

rarefaction of the bone


decrease of bone density

rarefaction decrease in bone density

rarefaction decrease bone density

bone


P a g e | 110

Parathormone bone serum calcium

rickets



Histology bone

Linear growth

bone

Hisotolgy

X - ray

Linear growth epiphysis

cartilage irradiation

Irradiation

irradiation

X -ray

X -ray

zone of provoisional

cartilagenous part

bone

bone


P a g e | 111

excess of osteoid tissue

Osteoid tissue

Osteoid tissue

cartilage

cartilage

cubbing X -ray

Osteoid tissue

Mineral part

broadening

broadening

cartilage

cubbing


P a g e | 112

cubbing

broadening


Pathophysiology


Proliferation of the cartilage

thickness cartilage

cartilage

Proliferation of the Of the cartilage

cartilage cartilage proliferation

zone of provoisonal calcification

cartilagenous band zone of provisional calcification

cartilage radi lucentradio opaque

radio lucent

X - ray

chondroblast

fraying

bone

rarefaction

rarefaction X -ray


P a g e | 113

rarefaction

hyper parathyroidismMineral part of the bone

cubbing broadening

Osteoid tissue

Mineral part

Pressure cubbing broadening

fraying

fraying

cartilagenous chondroblast

proliferation


periosteum Mature bone

bone

bone

X - ray

Periosteum

Periosteum

Parathormone

Periostuem

Periosteum


P a g e | 114

osteoid tissue

osteoid tissue periosteum

X -ray

osteoid tissue

parathromone Periosteum

two periosteum

Periosteum

Periosteum

Seperatedbone

seperated bone

2 periosteum

Double periosteum line

Rarefaction Broadening ( cubbing ) Fraying Double periosteal line

bone bone deformity

deformity X -ray

Genu vara - genu valgus femur

curvature tibia


P a g e | 115

rickets

Limit

green stick fracture

Green stick fracture

Manifestations of active ricktes

Manifestations of active rickets


P a g e | 116

rarefaction

cubbing

Broadening Fraying Double perosteal line Bone deformity, even green stick fracture

fraying X -ray

active rickets

Treatment

vitamin D

serum calcium

Parathyroid hormone

vitamin D Osteoblast new bone formation

extremities

linear growth

New bone formation

Linear growth

deposit of calcium


deposit

deposit zone of provisional calcification

chondroblast

chondroblast

X - ray


P a g e | 117

new bone formation

mature bone

line of ossification

rickets

new bone formation

cubbing broadening

even rarefaction of the bone



X -ray

X -ray


cubbing broadening

fraying

linear deposits of

Healing rickets

Healing rickets

Osteoblast


P a g e | 118

osteoclast

osteoclast

bone density

Periosteal line


Healed rickets

Radiologically

activ rickets

Rarefaction of the bone

cubbing broadening

fraying double periosteal line

bone deformity green stick fracture

healing rickets active

fraying

line of ossification



P a g e | 119

healed rickets

thick ossification bone

pathophysiology radiological finding of rickets

zone of provisional calcification healed rickets

after healing

thick line

thick line

thick line

thick line

line of calcification

Osteocalst

x -ray

X -ray rickets

osteoclast

bone


P a g e | 120

hydrocortisone oral

absorption of vitamin D

block vitamin D receptors

block vitamin D receptors

Osteomalacia and osteoporosis

Oral cortisone

oral crotisone

Intra muscular

Oral IM

systemic effect

cortisone oral

GIT receptors

Intra muscular GIT

receptors

adult child

two months


P a g e | 121

Renal Rickets renal rickets

renal rickets

nowadays

MCQ

MCQ renal rickets

rickets

renal rickets

Oral and MCQ

essay

oral MCQ

renal rickets

glomerular

tubular


P a g e | 122

Tubular Glomerular

tubular glomerular

tubular rickets glomerular rickets

clinical

renal rickets

glomerular

tubular glomerular rickets

serum phosphate

serum phosphate tubular type very low


serum phosphate low

very low

vitmain D deficiency rickets

serum phosphate

Normal

serum phosphate even zero

glomerular type

serum phosphate is high


Laboratory finding


P a g e | 123

serum calcium Normal Low

serum phosphate Low


Urine

amino acids urine

vitamin D parathormone

rickets phosphate

rickets serum phosphate glomerular type of renal rickets

serum phosphate

renal osteodystrophychronic renal failure

nephrology

serum phosphate rickets Low

glomerular type of renal rickets

parathyroid hormone


Parathyroid hormone

Parathyroid hormone

tubular phosphate

Parathormone


P a g e | 124

urine

Parathormone

Normal

tubular type

Parathyroid Normal

glomerular type

glomerular type

Phosphate

Parathyroid

Parathyroid hormone very high

Parathyroid hormone rickets

Usually high

rickets Parathyroid hormone Normal

tubular type

parathyroid hormone normal

Glomerular type

glomerular type

chronic renal failure


P a g e | 125



rickets


rickets

rickets chronic renal failure

renal osteodystorphy

renal osteodystrophy


rickets chronic renal failure

Chronic renal failurerickets

renal failure

kidney 1 hydroxylation of vitamin D

1 hydroxylation of vitamin D



1, 25 rickets rickets

rickets renal osteodystrophy

failure of hydroxylation of vitamin D

acidosis

renal failure

Metabolic acidosis


acidosis


P a g e | 126

Failure of excretion acidotic material

loss of bicarb. Urine metabolic acidosis

acidosis

calcium carbonate bone

bicarb bone

bone calcium calcium carbonate

acidosis Melting of bone calcium

bone calcium carbonate


bone

manifestations of rickets

chronic renal failure failure of excretion of phosphate

retention of phosphate

phosphate


phosphate

parathyroid Parathyroid hormone

parathyroid hormone

Parathyroid hormone

Parathyroid hormone

serum calcium

serum phosphate


P a g e | 127

kidney

target kidney

rickets

parathormone Kidney

Parathormone reabsorption of calcium

loss of phosphate

Kidney

kidney

parathormone hormone

Parathormone

calcium urine

Parathormone hormone

Parathormone


Parathormone

bone

renal failure osteitis fibrosa cystica

bone cyst

rickets renal failure

failure of hydroxylation of vitamin D

acidosis Melting of bone calcium


P a g e | 128

retention of phosphate hyper parathyrioidism rachetic

manifestations

Clinically

renal failure


Laboratory

renal failure

Manifestations of rickets

Laboratory

serum clacium

rickets phosphorus alkaline phosphatase

serum calcium

Normal

Low

bone

Urine calcium Normal

Low

renal osteodystrophy Low

tetany

acidosis

tetany

tetany

acidosis tetany

acidosis tetany


P a g e | 129

phosphate

phosphate

alkaline phsphatase

rickets


Urine

Urine


urine

vitamin D

1, 25

25 hydroxyNormal

cholicalciferol vitamin D3Normal

1,25

25 hydroxy Normal

vitamin DNormal

vitamin D Normal

vitamin D3 cholcalciferol

Normal

25 hydroxy vitamin D3

normal

1,25

vitmain D deficiency rickets

1 hydroxylation


P a g e | 130

radiologically

diagnostic radiologically

Manifestations of active rickets osteitis fibrosa cystica

Manifestations of active rickets osteitis fibrosa cystica

Treatment

renal failure

rickets

rickets

vitamin D

vitamin D


1,25 1 hydroxy

1 hydroxy

liver

25 active form


vitamin D

vitamin D without calcium

acidosis

acidosis

calcium carbonate bone

sodium bicarb


P a g e | 131

acidosis

excess phosphate

phosphate

giving phosphate binders

gut Phosphate absroption

resistant cases parathyroid

Parathyroid

Parathyroidectomy

resistant cases

parathyroidectomy

parathyroid

active form of Vitamin D

resistant cases parathyroid gland


glomerular type


acidosis

binders Phosphate absorption

resistant cases parathyroidectomy

renal failure

acidosis bicarb


P a g e | 132

with salt and water retention

renal failure salt and water retention

sodium bicarb

salt and water retention

sodium bicarb

sodium bicarb

hydrocephalus

type one type two

endocrine

116


P a g e | 133

exercise

123

8


P a g e | 134

sodium bicarb

bicarb salt and water retention

sodium bicarb salt and water retention

1: 11: 19


P a g e | 135

Tubular type tubular type

Primarytubular type

primary hypophosphatemic ricketsprimary hypo phosphatemic rickets

X-linked dominant disease

genetics

X -linked dominant

X - linked dominant

primary hypo phosphatemic rickets

gene

gene tubular defect

tubular defect failure of reabsorption of phosphate

kidney phosphate

Phosphate

urine

excretion of phosphate in urine

urine

bone calcium calcium phosphate

calcium phosphate


P a g e | 136

new bone formation

mineral part bone

rickets

clacium bone

Phosphate bone

Phosphate

Normal

rickets

rickets

calcium bone

Parathyroid hormone Normal

bone

calcium bone Normal

Normal bone

osteoid tissue deposit


frontal parietal bossing

skull circumference

broadening

Marfan

rachetic rosari

Osteoid tissue deposit



Delayed dentationteeth

delayed motor development bone Hypo tonia

Muscle weakness

delayed closure of the fontnel

delayed closure of the fontanel


P a g e | 137

symptoms

Investigations

Phosphate is too low

normal

Parathyroid hormone normal

alkaline phosphatase High

alkaline phosphatase Normal

crystals bone

crystals bone

osteoblast



X -ray

radiological finding rickets

2

even

What ever


P a g e | 138

bone

New bone formation

vitamin D

phosphate

consumption

vitamin D



bossing broadening Marfan sign

rachetic rosari

Primary hypo phosphatemic rickets

associated defect in hydroxylation of vitamin D inside the kidney

gene

hydroxylation of vitamin D inside the the kidney

vitamin D


severe rickets


Fanconi syndrome Fanconi anemia


P a g e | 139

Fanconi Syndrome Fanconi anemia

hematology

Fanconi syndrome

hereditary

Gene defectgene autosomal recessive gene

Mode of inheritance

Autosomal recessive gene

secondary

Secondary to nephrotoxic drugsWhat ever nephrotoxic drug

secondary to metabolic diseases

hepatomegaly

metabolic diseases

glycogen storage disease

galactosemia

lipid storage diseases

tyrosinemia

Wilson disease

What ever

associated metabolic diseases

kidney

congenital acquired

congenital type autosomal recessive

Fanconi syndrome

tubular defect

tubular defect tubules

urine


P a g e | 140

amino acids

amino acids filtration glomerulus of the kidney

complete reabsorption of the proximal convoluted tubules

amino acids

Urine

amino acids protein

amino acids urine

failure to thrive

failure to grow

failure to thrive

weight loss

short stautre

failure to thrive

weight and hight both are affected

Fanconi

say12

Fanconi

amino acids urine


P a g e | 141

urine

urine

Hypo hyper kalemia

hypo kalemia

electrolyte disorder

bradycardia

Paralytic ileus

diarrhea

Manifestations of hypo kalemia

Loss of glucose

Loss of glucose in urine

urine

urine

oliguria polyuria

osmotic diuresis poly uria

and poly uria

polydepsia

diabetes

Normal low

poly phagia

polyphagia

feeding center


P a g e | 142

urine

poly phagia

poly uria

poly depsia

weight loss

differential diagonsis of diabetes

loss of bicarb urine

loss of bicarb urine

bicarb urine

urine alkaline acidic

urine acidic alkaline

urine acidic

urine alkaline

Infection

urinary tract infection

UTI nephrology

Infection

Organism urine

Infection

Organism acidic media

urine acidic

Organism proteus

proteus

alkaline media

urinary tract infection proteus


P a g e | 143



Fanconi

Fanconi PH urine

Alkalinemedia Proteus

Loss of bicarb acidosis

acidosis melting of bone calcium

bone calcium


calcium bone

rickets

Fanconi

Loss of phosphate urine

rickets

Loss of bicarb in urinemelting of bone calcium

bone calcium

Loss of phosphate in urinebone

bone

energy

Hydrocephalus


P a g e | 144

bossing

rachetic rosari

Marfan

boradening

bone

bone acidosis

bone urine

Fanconi Syndrome

failure to thrive

manifestations of hypo kalemia

manifestations diabetes

manifestations of acidosis

rickets

Osteoporosis

amino acids

Investigations

Investigations

Investigations

Fanconi

Investiagtions

Fanconi


P a g e | 145

blood

urine

urine

Treatment

rickets

high protein diet

amino acids loss urine

phosphate

sodium bicarb

acidosis

frequent meals

glucose

frequent meals

hypoglycemia

frequent meals


P a g e | 146

KCL

renal transplantation

renal transplantation

active form of vitamin D and calcium

calcium bone

vitamin D calcium

tubular defect

associated hydroxylation of vitamin D

active form

Fanconi

Lignac Syndrome spelling

syndrome Lignac syndrome

mode of inheritance

Autosomal recessiveAutosomalrecessive

cystine amino acid

deposit in varient tissue

In born error of metabolism


P a g e | 147

cystine amino acid

kidney

tubules of the kidney

Fanconi Syndrome

Fanconi primary secondary

Secondarykidney Fanconi

cystine amino acid

deposit reticulo endothelial system

reticulo endothelial system

lymph nodes

generalized lymph adenopathy

spleen

splenomegaly

hepatomeagly

hepatosplenomegaly

bone marrow

marrow cavity aplastic anemia

pan pan cytopenia

reticulo endothelia system

lymph nodes generalized lymph adenopathy

hepatosplenomegaly

aplastic anemia

bone marrow failure

cornea

slit lamp cornea


P a g e | 148

Wilson

Kayser flisher ring

cystine crystals cornea

autosomal recessive disease

cystine amino acid deposit renal tubules

Fanconi syndrome

deposit reticulo endothelial system

lymphadenopathy

splenomegaly hepatosplenomegaly

bone marrow failure

cornea

cystine crystals in cornea

Treatment

Fanconi

cystine free diet

chelation of cystine tissue

Wilson

1: 34 : 53

Wilson

chelator of cupper tissues

chelation of cystine tissues

D penicillamine

chelation

D pencilamine nephro toxic

specific chelator

cystiamine


P a g e | 149

cystiamine specific chelator of cystine amino acid

Rickets Fanconi

lowe's syndrome

Lowe's Syndrome lowe's syndrome

X - linked recessive

Mode of inheritence renal rickets

X - linked recessive

Lowe's syndrome

combination

triad

triad

triad

Occular manifestations cataract glaucoma

cerebral manifestationsMental retarded generalized muscle

weakness and hypo toniadifferential diagnosis floppy baby

generalized hypo tonia

renal manifestations

Fanconi syndrome Lowe's syndrome Fanconi syndrome

rickets

Oculo-cerebro-renal synddrome

manifestations of rickets in X - ray

active rickets

Rarefaction of the bone

cubbing

broadening

fraying

double periosteal line


P a g e | 150

bone deformity


healing phase

line of ossifications

healed rickets

thick line of ossification

thick line

Renal rickets

glomerular type renal osteodystrophy chronic renal failure

rickets

hydroxylation of vitamin D Kidney metabolic acidosis Melting of bone calcium retention of phosphate hyper para thyroidism

Clinicallyrenal failure rickets

laboratory

serum phosphate

Parathormone


calcium Normal Low


urine

urine

excess calcium

low in phosphate

renal failure


P a g e | 151


calcium

sodium bicarbonate acidosis

restriction of phosphate diet

phosphate binder

resistent cases para thyroidectomy

tubular type

Primary hypo phosphatemic ricketsX - linked dominant disease

defect Loss of phosphate in urine rickets

rickets rickets

Manifestations just delayed dentitationdelayed motor developmentdelayed closure of the fontanel

manifestations of osteoid tissue over deposit

manifestations of cartilage proliferation

Phosphate drug

vitamin D calcium

Fanconi syndrome

Urine amino acids

glucose

bicarb phosphate

bicarb

rickets

Fanconi syndrome

High protein diet

acidosis


P a g e | 152

frequent meals glucose loss in urine

phosphate Vitamin D calcium

Cystinosis

cystine amino acid deposit cornea corneal crystals

reticulo endothelial system Lymph adenopathy hepatospleno megaly

bone marrow failure

tubules of the kidney Fanconi Fanconi Anemia

Fanconi

cystiamine cystine amino acid chelator

Lowe's syndrome

Occularcataract glaucoma

Cerebralmental retardation Hypo tonia

Fanconi syndrome

Vitamin D dependent rickets

Vitamin D dependent rickets

Vitmain D dependent ricketsdeficient rickets

deficient rickets

vitamin D dependent rickets

vitamin D dependent rickets

Hereditary defect vitamin D metabolism

vtimain D

hereditary defect kidney



P a g e | 153

Kidney 1 hydroxylation of vitamin D

kidney

vitamin D dependent rickets type one

vitamin D dependent rickets type one


1,25 di hydroxy cholicalciferol


rickets

vitamin D dependent rickets type two

vitmain D metabolism

Liver hydroxylation 25

Kidney hydroxylation carbon atom 1

active form

defect receptors of vitamin D

receptor defect

receptors

GIT

Bone Kidney

vitamin D

receptors

vitamin D

defect Number function

end organ resistence

vitamin D


P a g e | 154

receptors


active form

receptors

defect function number

High doses of active form of vitamin D


associated other defect

alopecia totalis

alopecia areata area

alopecia areata

alopecia totalis

alopecia

alopcia totalis

alopecia universalis

common association alopecia areata

hepatic rickets

Hepatic Rickets hepatic rickets

liver affection

liver affection rickets


P a g e | 155


Bile

obstructive jaundice

bile liver GIT

absorption of fat

fat soluble vitamins vitmain D

mal absorption vitamin D


cirrhosis

cirrhosis rickets

Liver cirrhosis rickets

stores Liver vitmain D Liver

defect stores


Liver

Liver cirrhosis rickets

depletion of the stores hydroxylation vitamin D liver



anti epileptic fat soluble

fat soluble excretion liver

secretion Liver

toxic hepatic hydroxylation

OH

OH vitamin D

vitamin D

Inside theinside the liver


P a g e | 156



Hepatic rickets

RicketsLiver affection


liver cirrhosis anti epileptic drugs

celiac rickets

Celiac rickets celiac rickets

malabsorption in general

mal absroption syndrome

malabsroption syndrome

Malabsorption syndrome Loops of the gut

Loops intestine

malabsorption

malabsroption

gut

absroption

gut absorption

mal absorption synddrome In general

fatty acids

fatty acids


P a g e | 157

chemical reaction fatty acids

fatty acids

fatty acids calcium soap

fatty acids

absorption

Intestinal villi

intestinal villi

Intestinal villi mal absorption

vitmain D oral

vtimain D parentral

suppository

gut

vitamin D parentral

hypo phosphatasia

Hypo Phosphatsia Hypo phosphatsia

autosomal recessive disease alkaline phosphatase enzyme

decrease alkaline phosphatase

Hypo phosphatasia



alkaline phosphatase organic phosphate


P a g e | 158


rickets

alkaline phosphatase Organic phosphate Phosphorus

bone matrix

Organic In organic phosphrus calcium

bone crystals


rickets

bone matrix

Organic phosphate phospho ethanol amine

phosphorus

phosphorus the bone crystals

alkaline phosphatase autosomal recessive disease

osteoblast organic phosphate phosphrus

new bone

ricketic manifestations

calcium bone

bone

calcium

Hyper hyper calcemia

Hyper calcemia even nephro calcinosis

Organic phophate

absroption

Metabolism

Urine

Urine urine analysis

urine organic organic phosphate

diagnostic


P a g e | 159

urine

organic phosphatephospho ethanol amine In urine

phospho ethanol amine urine

diagnostic hypo Hypo phosphatasia


alkaline phosphatse

marasmus Kwashiorkor


marasmus Kwashiorkor phospho ethanol amine urine

dianostic Hypo phosphatasia


organic phosphate urine

hypo phosphatasia

vitamin D




serum

plasma transfusion

serum

rickets blood transfusion

vitamin D Phosphorus


P a g e | 160

Hypo phosphatasia


alkaline phosphatase plasma

Plasma plasma transfusion

Hypo phosphatasia organic phosphate

Organic phosphate bone

In organic

bone Osteoblast

osteoblast Organic


hyper para thyroidism

Hyper Para Thyroidism Hyper para thyroidism

primary hyper para

secondary

Hyper para thyroidism vitamin D deficiency rickets

glomerular rickets

Hyper para

secondary hypo calcemia

primary

para thyroid gland tumor

benign


P a g e | 161

malignant adenoma

adenoma parathormone hormone

Parathyroid hormone

bone

Kidney bone

Kidney phosphate

bone

bone rachetic manifestations

osteotitis fibrosa cystica glomerular type

serum calcium

serum phophate


alkaline phosphatase alkaline phosphatase crystals

bone

Surgical

tumor adenoma para thyroid Para thyroid hormone

para thormone active form of vitamin D calcium

rickets

calssifications of rickets

rickets

classifications of rickets


P a g e | 162

Classifications of Rickets classifications

classifications of rickets

classifications vitamin D metabolism

classifications

basics

basics

classification

Ricketsالتقسيمة القديمة للrickets


vitamin D oral

cholecalciferol

vitamin D3

oral

Intake Mal nutrition

exposure ultra violet rays

atrophic rickets associated malnutrition In general

atrophic rickets

vitamin D3


P a g e | 163


vitamin D3 oral

absorption

Intake


atrophic rickets Intake


defect intake

defect exposure to ultra violet rays

atrophic rickets

atrophic rickets marasmus Kwashiorkor

vitamin D oral

vitamin D oral

absroption vitamin D oral

Celiac rickets

Celiac rickets

Malabsroption synddrome

vitmain D oral absroption

vitamin D parentral


P a g e | 164

Hepatic rickets


bile absroption

Liver cirrhosis

vitamin D

vitamin D3 hydroxylation Liver

Liver cirrhosis

25 1,25 di hydroxy cholicalciferol




D


active form

hepatic rickets

Liver cirrhosis



Celiac rikcets

renal rickets

glomerular renal osteodystrophy vitamin D

active form

tubular defect

vitamin D


P a g e | 165

vitamin D

glomerular tubular

vitamin D resistant rickets

vitmain D dependent rickets type one

Kidney Hydroxylation vitamin D

vitamin D

hydroxylation

active form

type two

end organ

Oral vitamin D

high doses active form

Hypo phosphatasia

vitamin D

plasma alkaline phosphatase

tumor Para thyroid

vitamin D

vitmain D resistant rickets

rickets

Vitamin D deficiency rickets vitmain D deficiency rickets

oral vitamin D3 cholicalciferol

Oral

Vitamin D resistant rickets oral vitamin D

Modifications


P a g e | 166


vitamin D

vitamin D

Manifestations of rickets

normal variability

recent classification


P a g e | 167

Ricketsالتقسيمة الحديثة للrecent calssifications

recent classifications

end organ resistance

vitamin D dependent rickets type two

vitmain D

rickets phosphorus

vitmain D calcium intake

phosphorus

phosphate

phosphate

tubular defect Primary hypo phosphatemic

Fanconi

cystinosis

renal tubular acidosis

Lowe's syndrome


Phosphate

bone


P a g e | 168

bone

bone

bone vitmain D

1, 25 dihydroxy cholicalciferol

bone vitamin D


1, 25

Defectintake

vitmain D

lack of exposure to ultra violet rays

atrophic rickets

Hepatic rickets

hepatic

Obstructive jaundice Cirrhosis Toxic hepatic hydroxylation

active form

glomerular type of rickets

renal failure

glomeruli hydroxylation vitamin D

vitmain D dependent rickets type one


bone

rickets


P a g e | 169

primary hypo calcemic rickets

1, 25 dihydroxycholicalciferol


phosphorus

tubular defect

end organ resistance

vitmain D resistant rickets type two

rickets vitmain D Phosphorus

metabolism

rickets resembling conditions

rickets

rickets vitmain D

hypo phosphatasia

hyper para thyroidism

Primary hypo calcemic 1, 25 dihydroxy cholicalcefrol

primary hypo phosphatemic tubular defect end organ resistance type two vitamin D resistant rickets

rickes resembling conditions Hyper para thyroidism hypo phosphatasia

calssifications

oral questions tetany


P a g e | 170

Oral questions

rickets

sheet

sheet sheet

eye examination rickets

rickets

rickets

examiner eye rickets

jaundice

rickets Jaundice

Jaundice obstructive jaundice

hepatocellular cirrhosis

rickets


P a g e | 171

eye infection


Repeated infectionconjuctivitis

cataract Intra occular pressure

cataract

cataract

rickets

rickets cataract

Lowe's syndrome

Lowe's syndrome cataract glaucoma Lowe's syndrome

In born error of metabolism

galactosemia

galactosemia

rickets

galactosemia

galactosemia Fanconi syndrome

rickets

galactosemia Cataract

galactosemia

cataract

tubular defect Fanconi syndrome Fanconi rickets

cornea Kayser flisher ring

Wilson disease

Wilson Kayser flisher ring

Wilson

Wilson Fanconi syndrome

Fanconi rickets


P a g e | 172

cornea cystine crystals

cystine cyrstals cystinosis Lignac Syndrome

cystine crystals cornea cystinosis lignac syndrome

cornea Ulcers

herpes

Herpetiform corneal ulcertyrosinemia

tyrosinemia

Fanconi secondary to in bron error

inborn error tyrosinemia mechanism of hepatomegaly

tyrosinemia mechanism of hepatomegaly

herptic form of corneal ulcer

tyrosinemia Fanconi

Jaundice Infection Cataract Kayser flisher ring Cystinosis Corneal ulcer

hyper para cataract

occular manifestations

corneal manifestations rickets

corneal

rickets abdomen palpable liver and spleen

rickets abdomen liver spleen

Liver spleen


P a g e | 173

Ptsois of the organs

hypo tonia

repeated infection

cooley's anemia

associated lymph adenopathy Hepato splenomegaly

hepato spleno megaly

cystinosis cystinosis liver spleen

wilson

hepato megaly hepato spleno megaly

Wilson Fanconi

tyrosinemia hepato spleno megaly

Glycogen storage diseaseliver spleen Fanconi syndrome

Liver disease chronic abscess hepatitis cirrhosis

splenomegaly shrunken liver

portal cirrhosis Portal hypertension

written

tyrosinemia galactosemia Wilson

rickets rickets

rickets

rickets


P a g e | 174

rickets

rickets

rickets

cataract rickets

kayser flisher ring rickets

nerve cell

Nerve cell excitability physiology

Nerve and muscle

nerve cell excitation stimulus

stimulus

threshold

threshold

threshold stimulus

abdominal reflexes

reflex abdominal wall

Underlying muscles contraction

abdominal reflex is so exaggerated

pain threshold


P a g e | 175

vaso vagal attack

15

local anesthesia

threshold

threshold firing of the cells

cells stimulated

Oncefiring of the cells depolarization

stimulus firing of the cells

cell membrane Neuronal cell

firing of the cell

stimulus

depolarization of the cell

Nerve cell

gate of Na

Nerve cell

Ionizable calcium

ionizable calcium gate of Na channel nerve cells

Influx of Na inside the cell

stimulus

stimulus Ionizable calicum channel

non ionizable form

Ionizable calcium repelling


P a g e | 176

Non ionizable calcium

depolarization of the cell excitation of the cell

excitation of the cell

ionizable calcium channel of the nerve cell

ionizable calcium threshold

threshold stimulus non ionizable calcium

Ionizable calcium threshold

stimulus

threshold excitation of the nerve cell

ionizable calcium cell membrane of the nerve cell

Ionizable calcium threshold

ionizable calcium

threshold

stimulus excitation of the cell

ionizable calcium

autonomous excitation of the cell

tetany

Tetany definition of tetany


P a g e | 177

Definition

hyper excitability of the nerve cell

hyper excitability excited

threshold is so low

Evenstimulus

Etiology

ionizabel calcium

in general

serum calcium in general

serum calcium

ionizable

non ionizable

Excitable


serum calcium normal

tetany

total serum calcium averge say 10

serum calcium

45 %ionizable active form

55 %non ionizable form

total serum calcium

45 % ionizable

55 % non ionizable


P a g e | 178

tetany ionizable form 3 mg per dl

30 %

10 mg / dl

45 % 4.5 mg ionizable

5.5 mg non ionizable

tetany

3 mg ionizable

acidosis non ionizable calcium ionizable calcium alkalosis alkalosis

acidosis Non ionizable ionizable

alkalosis

renal failure rickets

tetany

Say

renal failure

serum calcium 6

6 4 mg ionizable

2 mg non ionizable

tetany

total serum calcium

acidosis ionizable form

tetany

serum calcium

alkalosis

say ionizable calcium 2.5 mg

non ionizable 7.5 mg

Ionizable 3 mg tetany tetany total serum calcium

Normal


P a g e | 179

tetany alkalosis

alkalosis tetany

ionizable form of serum calcium

tetany

Mg

Mg

Mg Para thormone

Para thormone hormone synthesis

Mg hypo para thyroidism


Hypo calcemia

Hypo calcemia

Tetany

tetany

total serum calcium

alkalosis

Hypo Mg

أسباب ال,,,, نمسك بقا tetany

total serum calcium

serum calcium

serum calcium

serum calcium

vitmain D


P a g e | 180

vitmain D


Para thyroid hormone bone

para thyroid hormone clacium bone

vitmain D

para thormone

vitmain D

vitmain D deficiency Hypo calcemia

tetany

para thyroid


P a g e | 181

Para thyroid

Para thyroid

Hypo para thyroidism

Para thyroid gland is still immature

para thyroid gland is still immature

pre term

intra uterine growth retardation

hypoxia Para thyroid

Infant of diabetic diabetes

Para thyroid gland

gland

gland

hypo para thyroid gland

hypo calcemia

hypo calcemia

intra uterine Hypo calcemia

calcium

hypo calcemia

hypo calcemia 72

tetany 72

early neonatal hypo calcemia

early neonatal hypo calcemia 72

para thyroid gland still immature

pre term

intra uterine growth retardation

Infant of diabetic mother

fetal hypoxia


P a g e | 182

para thyroid gland

para thormone

compensation serum calcium

hypo calcemia

activity

serum clacium

cow milk feeding

pre mature formulaartificial milk

Powdered milk

vitamin D

cow milk

cow milk

cow milk alkaline


P a g e | 183

cow milk excessive phosphate

calcium

para thormone

para thyroid

late neonatal hypo clacemia tetany

tetany

late neonatal hypo calcemia

early neonatal hypocalcemia Para thyroid immature

late neonatal hypo calcemia cow milk buffalo milk so early

Para thyroid Para thyroid

congenitally absent para thyroid gland

endocrine

Congenital absence of the parathyroid

Di Gorge syndrome

syndromes Di Gorge syndrome

Di Gorge syndrome

Para thyroid gland 3rd pharyngeal

pouch arch embryology parathyroid



P a g e | 184

thymus

thymus

T cell maturation defect T. Cells function

Immune deficiency

abnormality aortic arch

heart anomaly

immune deficiency thymus

parathyroid hypo calcemia and tetany

para thyroid surgically removed

hyper para

hypo thyroidism tetany


surgical removal of the para thyroid

para thyroid

Hodgkin's lymphoma

cervical lymph nodes

Local irridation neck

local irridiation neck

Irridiation Hypo para

irridiation para thyroid

Wilson disease

cupper deposit para thyroid

hemosiderosis

chronic hemolytic anemia

para thyroid

Irridiation


P a g e | 185

Wilson disease Hemosiderosis

auto immune destruction

Auto immune hypo parathyroidismanti bodyPara thyroid

Rarefamilial cause

para thyroid

calcium Urine

urine

calcium urine

serum calcium

clacium EDTA citrate

EDTA Citrate chelation calcium

exchange transfusion

citrate EDTA

serum

urine

hypo calcemia

Alkalosis

alkalosis acid base disturbance


P a g e | 186

hyper ventilation

hyper ventilation

carbon dioxide wash

carbon dioxide wash

respiratory alkalosis

respiratory alkalosis

tetany


hyper ventilation

alkalosis

epilpesy

epilpesy

epilpesy

attack

epilpesy


P a g e | 187

acidosis bicarb bicarb

alkalosis

Over correction of acidosis

alkalosis

alkali therapy

alkali therapy

Persistence vomiting alkalosis

HCL

HCL

HCL bicarb

alkalosis

alkalosis

acid base disturbance

Hypo magensemia

Mg

Mg

mal nutirition in general

Mal absorption chronic diarrhea

EDTA citrate chelation chelation Mg

Clinical manifestation of tetany

clinical manifestations of tetany

manifest tetany


P a g e | 188

manifest tetany

attack of tetany

differential diagnosis

manifest tetany

manifest tetany carpo pedal spasm

carpo pedal spasm

carpal

pedal

Planter flexion

spasm generalized convulsion

laryngeal spasm

laryngeal spasm

laryngesmus stridolus

manifest tetany

carpo pedal spasm

convulsion

even laryngeal spasm

Manifest

degree

diabetic mother prenatal asphyxia early neonatal hypo calcemia

Para thyroid still immature

infant of diabetic mother

prematurity Neonatology


P a g e | 189

latent tetany

Latent tetany

Ionizable calcium

Normal 45 %

Low 30 % 3 mg

4.5 mg 3 mg

3 mg Manifest tetany

Say

ionizable calcium 3.5 mg

ionizable calcium

manifest tetany

threshold

Nerve cell


tetany

complications tetany

rickets


against you

rickets marasmus Kowashirkor

rickets


tetany


P a g e | 190

tetany

tetany rickets

tetany

tetany

Manifest tetany

latent tetany


Phosphorus alkaline phosphatase

Normal Low

serum calcium Normal

Investigations

clinically serum clacium Normal Low

serum calcium Low

Manifest tetany

latent tetany

Manifest tetany

Latent tetany

threshold

sign

tempro mandibular joint

neck of mandibule

Neck Mandibule tapping hammer


P a g e | 191

neck mandibule

tapping hammer

facial nerve

facial nerve nerve Hyper excitable

facial muscle contraction

contraction

Chevostek sign

pressure systole 3 mins

Carpal spasm

mid thigh

pedal spasm

Trouseau sign systole

carpal pedal spasm

arm thigh

fibula

Neck of the fibula anterior tibial nerve

anterior tibial nerve supply

tibialis anterior

neck of the fibula


P a g e | 192

hammer

threshold Nerve excitation

tibialis anterior contraction

tibialis anterior contraction

dorsi flexion eversion of the foot

Dorsi flexion Eversion of the foot

Peroneal sign

ECG QT interval

ECG

Treatment

tetany

calcium

slowly IV

brady arrhythemia

cardic arrest

heart

slowly IV 2 - 4 ml / Kg

calcium gluconate slowly IV

very slowly IV

hypo Mg

alkalosis

tetany vitmain D calcium supplementation

tetany


P a g e | 193

clinical written

criteria of adequate diet

Criteria of adequate diet adequate diet

adequate total Caloric supply

Caloric supply

caloric supply

Premature Pre term

120 Calori / Kg

Pre term 120 Calori / kg / day

neoborn full term

100 120 Calori / Kg / day

pre term 120 Calori / kg / day

full term 100 120 Calori / Kg / day

100 Calori / kg / day

100 Calori / day

50 Calori / kg / day

50 Calori / kg /day


P a g e | 194

20 Calori / kg

,,, ما معنى هذا الكالم

8

8

x 100 800

x =

800

12

1100

12

100

100 x 101000

50 2

2 x 50100

1000 100 1100

25

1600

MCQ


P a g e | 195

25 daily requirement

25

100

50

20

10x 100 1000

10x 50 500

5x 20 100

1600


adequate total caloric supply

caloric requirements

10

1000

1000

composition of diet

criteria of adequate of diet

Porportional diet

Proportional diet

50 % total Calories carbohydrates


P a g e | 196

15 %total Calories protein

35 %total Calories fat

Calories

50 % Carbohydrates

15 %protein

35 %fat

total Calories

composition fat carbohydrates protein

carbohydrates 500

proteins 150

fat 350

Calories

Carbohydrates 4.1 4

500

500 500 /4 125

fat 9.3 9

350

350 9 fat

350 / 9 38.8 39 fat

protein 4.1 4

150

150 4

150 / 437.5

diet Calories supplied

fat protein carbohydrates


P a g e | 197

adequate diet

adequate amount of vitamins and minerals

salts

minerals

Mg

vitamins

vitmains vitmains

vitmains

vitamins

caloric supply

carbohydartes fats Proteins

vitamins minerals

adequate amount of water


Total Caloric supply Proportional dietfat carbohydrates Proteins

Adequate amount of vitamins and minerals

Adeqeuate amount of water

diet Rules carbohydrates fat Proteins


P a g e | 198

Proportional diet

Proportional diet

Caloric supply

fat

carbohydrates

vitamins

Minerals

palatable

palatable

palatable


P a g e | 199



1000

1000

1000

Say500

total caloric supply

fat

15 35

vitamins Minerals

50 %

Under nutrition Under nutrition reduction of foot staffs

food contents

20 % 30 % 50 %

Under nutrition

all food contents are reduced

1000 500

50 %

Under nutrition

under nutrition

Marasmus

marasmus under nutrition


P a g e | 200

caloric supply adequate or even

1000

1500

1500 fats

KwashiorkorKwashiorkor

Iron

Iron deficiency anemia

folic acid

Megalo blastic anemia


P a g e | 201

vitmain D

rickets

deficiency

1000

1500

obesity

title malnutrition

malnutrition

vitamin D deficiecny

rickets

vitamin D iron

vitmain D toxicity


hyper vitaminosis vitmain Minerals

malnutrition

Malnutrition

reduction excess in one component of the food staffs


P a g e | 202

under nutrition

Malnutrition caloric supply

1000

500

Under nutrition

MarasmusUnder nutrition

Kwashiorkor

marasmic Kwashiorkor Marasmus

edema manifestations Kwashiorkor

Marasmic kwashiorkor

Mixed under and malnutrition


under nutrition

malnutrition

mixed under and malnutrition

nutritional clinically


P a g e | 203

Clinically

1977

Most applied clinically

classifications

Wellcome classification

wellcome classification 1977

35

actual body weight

standard weight

standard weight

standard deviation score

percentile curve

standard weight

ideal

expected weight

expected body weight

growth retarded

3 3.5

3 standard


P a g e | 204

2.5 3.5

standard 3

3

growth development

3/4

3/4

birth weight

6

6 8

weight 9


P a g e | 205

2

12 growth

8

expected weigth

actual body weight

actual body weight

expected weight standard weight

expected weight

expected

expected

60 % expected

40 %


P a g e | 206

edema

edema

edema

edema

edema

wellcome marasmus

edema

marasmic Kwashorikor

edema marasmus

edema marasmic kwashiorkor

expected weight

marasmus

marasmic kwashiorkor

edema marasmic kwashiorkor

edema marasmus

marasmus marasmus

wellcome classification 60 expected

marasmus


edema


P a g e | 207

edema marasmus

spleen

Marasmus

Marasmus

Marasmus

marasmus

Marasmus

marasmus

rules

6

75 % expected weight

edema kwashiorkor

edema simple under weight

edema Kwashiorkor


P a g e | 208

edema simple under weight

wellcome calssification

marasmus

Marasmus

edema

wellcome classification marasmus marasmic kwashiorkor kwashiorkor

simple under weight

wellcome

classification

classification inborn error

toxicology toxicology

marasmus

marasmus chronic under nutrition

Marasmus


P a g e | 209

Marasmus

marasmus

Marasmus

total caloric supply

Etiology

dietic error

Primary type

primary type


P a g e | 210

dietic error

quantity

total caloric supply 1000

500 quantity

fat 500

scanty breast milk Scanty breast milk

infant feeding

Is not stasfied after feeding

stool Urine

bowel habits stool

Intake

88 %

failure to growth

Under feeding

quantitiy

dietic history infant feeding


P a g e | 211

Infant feeding

age month x 10 100

8

8 x 10 100 180

180

120 90

180 120 90

total amout per feed

artificial milk small amount

180 120 90

Infant feeding

6

6

6

9

12

3

3

6

9

9


P a g e | 212

6 9

6

10

2

6

9

11 12

8


P a g e | 213

180

widely spaced feed

scanty breast milk artificial small amount per feed

widely spaced feed

quantity artificial breast milk

Caloric supply

weaning

delayed weaning

weaning Infant feeding delayed weaning

delayed weaning

delayed weaning

iron deficiney anemia delayed weaning

rickets delayed weaning

marasmus delayed weaning

delayed weaning iron deficiency anemia rickets marasmus

quantity

quality

quality of milk quality of milk

quality of breast milk


P a g e | 214

breast milk

available

Bebe lac 1 Bebe lac

cover cover

30

30 30 Milk

180

180

30

180


P a g e | 215

180

180 diluted formula

diluted formula

quanitity quality

quality cow milk

cow milk cow milk allergy

cow milk allergy

cow milk buffalo

mentally retarded

Mentally retarded

12


P a g e | 216

Cow milk protein allergy

endocrine

cow milk

buffalo milk type one diabetes 36 %

type one diabetes 0.5 %

0.5 % 36 % buffalo cow milk

human being not an animal

cow milk protein allergy

cow milk protein allergy

chronic diarrhea vomiting

quality

Marasmus

Nursing errors irregular feeding

irregular feeding


P a g e | 217

irregular feeding

Marasmus

hydrocephalus

engorgement of the breast

breast

very painful

engorgement of the breast

Irregular feeding

failure of eructation

air emboli

air emboli


P a g e | 218

fat muscle

100 100

gravity

Push

Intestine

abdominal distention


P a g e | 219

conditioned reflex

colic

eructation of the baby is very important

difficulty of breast feeding

cleft lip cleft palate

suckling

flat nipple everted nipple

Nipple

difficulties of breast feeding

marasmus

weaning Marasmus

Proportionate

marasmus


P a g e | 220

dietic errors

secondary marasmus

secondary marasmus

consumption of food

parasitic infection

marasmus

marked chachexiamarasmus

Most common Parasitic infection

Parasitic infection

pitryasis alba


P a g e | 221

thyrotoxicosis endocrinal causes

thyrotoxicosis

diabetes

Parasitic infection Thyrotoxicosis diabetes

parasitic infection

clenching of the jaw

parasitic infection

clenching Jaw

infection mechanism

saliva

Excessive salivation

excessive saliva

thyrotoxicosis

tremors tachycardia

endocrine thyroid swelling

diabetes

Investigations


P a g e | 222

hyper metabolic state

thyrotoxicosis diabetes

increase consumption parasitic

parasite consumption ascris

anorexia

anorexia

anorexia

anorexia

anorexia

chronic infection

chronic disease

chronic infection attacks of gastro entritis

malabsorption anorexia

T. B. tuberculosis

anorexia

urinary tract infection Otitis media

What everchronic infection anorexia

chronic disease

Liver disease anorexia

renal disease anorexia

What everdisease renal tubular acidosis

Renal failure

chronic disease

Mechanism anorexia

heart disease

heart disease anorexia

unable to suckle

congenital heart disease


P a g e | 223

dyspnea

Heart failure dyspnea

chronic infection chronic disease

Heart anorexia

GIT

GIT GIT

GIT

gastro esophageal reflux

cardic sphincter

marasmus

Pyloric stenosis

duodenum gut absorption

marasmus

duodenal atresia

cleft lip cleft palate

gut anomaly

interference with feeding

multi factorial

multi factorial multi factorial

pre term

pre term marasmus

Marasmus


P a g e | 224

Neonatology

preterm jaw muscles

weak suckling

Jaw muscles

weak suckling

bulbar cranial nerves

Mature enough

Poor swallowing

suckling swallowing

gut still immature

digestion absorption

multifactorial

Inborn error of metabolism

Metabolic disease

galactosemia glycogen storage

Inborn error

marasmus

Multifactorial

chromosomal Down syndrome

marasmus

central cause

gum

marasmus


P a g e | 225

Clinical manifestations of marasmus

clinical manifestations of marasmus

patho physiology

cow milk

milk fermentation oral mucsoa

reflux

apsiration

empty stomach growth hormone

other growth factors

full stomach

growth hormone other growth factors

Marasmus


P a g e | 226

Patho physiology

marasmus patho physiology so easy

decrease total caloric supply

calories

Calories supply

glycogen stores Liver

Liver glycogen

glycogen stores

glycogens calories

glycogen stores Liver

fat

fat

lipolysis of fat

fat loss marasmus degrees

First Second Third

fatfat abdominal wall

fat abdominal wall

fat

fat abdominal wall Loss of fat of the anterior abdominal wall

first degree marasmus

fat extremities

upper and lower limbs

second degree

skin

skin multiple folds


P a g e | 227

loss fat buccal pad of fat

Loss fat buccal pad of fat

senile senile faceis

loss of subcutaneous fat

abdominal wall extremities buccal pad of fat

buccal pad of fat loss of intra abdominal fat

third degree marasmus

anterior abdominal wall fat

Intra abdominal fat

scaphoid abdomen

fat

fat

Muscles

protein Muscle

Muscle protein

Muscle

degeneration of the muscle Muscle wasting

mid arm circumference

Mid arm circumference

Mid arm circumference Mid thigh

mid arm acromion process

acromion

olecranon

acromion olecranon


P a g e | 228

acromion Olecranon


Mid arm circumfernece

skin bone

bone muscle

muscles subcutaneous fat

Marasmus

fat

muscle

fat msucle muscle

support

multiple skin folds


Of the bone

bone Osteoid tissue

caloric supply

Osteoprosis bone

pathogenesis of marasmus

Osteoporosis bone

Muscle skin


P a g e | 229

Osteoporosis

Clinically

marasmus

marasmus clinically

complications

8

4

8 50 % expected edema

growth failure

60 % expected wellcome classification without edema

Loss of subcutaneous fat

loss of subcutaneous fat

Marasmus grades degrees

first degree loss of subcutaneous fat of abdominal wall second degree loss of subcutaneous fat of extremities

third degree loss of buccal pad of fat and intra abdominal senile face

Muscle wasting

mid arm circumference


P a g e | 230


13.5

Marasmus 12.5

12.5

standard deviation score

centile

pallor

pallor anemia

Marasmus anemia


kwashiorkor

megaloblastic anemia

kwashiorkor

anemia pallor

skin manifestations of marasmus

skin manifestations of marasmus

Multiple folds

Multiple folds muscles

buttocks buttocks

folds of skin

quadricepis muscles

thigh multiple folds of skin

forearm legs

buttocks arm thigh

Multiple folds of skin

fold of skin


P a g e | 231

fat

skin elasticity

fat dehydrated

dehydration

Loss of skin elasticity

Marasmus dehydration

signs of dehydation

Loss of skin elasticity

skin elasticity Marasmus

sternum

sternum fold of skin

dehydrated

dehydration

skin manifestations

abdomen

clinical

abdomen

fat abdominal wall

muscle

Intra abdominal

scaphoid abdomen

anterior abdominal wall

scaphoid abdomen

Intestine


P a g e | 232

Intestinal motility visible

abdominal wall is very thin

Intestinal motility

irritable

Irritable

Irritable

Hunger sensation

oral sublingual

Hypo thermia

hypo thermia

decreased caloric supply

caloric supply

caloric supply

caloric supply

Hyper thermia




P a g e | 233

Muscle rigors

muscle contraction

rigors generators

muscles heat production

Heat loss

Muscle generator

muscle wasting production

fat

fat Heat loss

fat females Males


P a g e | 234

fat heat loss

marasmus fat Loss of fat

Hypothermia

dehydration

dehydration

dehydration hypo thermia

spesis Hypo thermia

37

38

complications Muscle wasting

pallor anemia

skin manifestations

irritable

abdominal manifestations

hypo thermia

hypo thermia

Intake caloric supply

muscle Muscle wasting Heat production

subcutaneous fat Loss Heat loss

hypo thermia

hypo thermia dehydration

dehydration GIT dehydration total blood volume

peripheral vascular collapse


P a g e | 235

blood volume

water loss

collapse Peripheral vessels

endogenous temperature

vascular flow

vascular flow Peripheral vessels

Pale

dehydration Peripheral vascular collapse

Hypo thermia septic shock

septic shock infection

septic shock

infection

infection bacterial viral

cell destruction

cell destruction

pyrogens

Pyrogens false impression heat regulating centres brain

40 40

central

heat regulating center


P a g e | 236

Pyrogens cell destruction


Heat regulating center

muscle shivering

shivering Production of heat

false impression heat regulating center

compensation

severe infection

severe infection

toxins Heat regulating center


toxins peripheral vaso dilatation

peripheral vaso dilatation flushing extremities heat loss

septic shock

shock

peripheral vaso dilatation toxins

Peripheral vaso dilatation Heat loss

Infection

fever


P a g e | 237

infection fever good sign

stable

infection

toxins Pus

Not reacting to infectionInfection

infection it is a good sign

Infectionit is a very bad sign

septic shock

Hypo thermia

Hypo thermia

toxins heat regulating center

toxins peripheral vaso dilatation heat loss

clinical manifestations marasmus

GIT manifestations

GIT manifestations of marasmus

apetite

marasmus

Irritable

anorexia

program


P a g e | 238

failure

anorexia

anorexia Central cause

Central cause

endocrine

feeding center satiety center

amino acids neuro transmitter signals

amino acids

Kwashiorkor

amino acids

anorexia

constipation diarrhea

constipation

constiaption diarrhea

clinical

diarrhea

diarrhea

diarrhea marasmus

gastro entritis

immunity

immunity

immune system

immune system

Immune system


P a g e | 239

immunity

Immunity repeated infection

GIT

gastro entritis

normal intestinal villi malnutrition atrophy intestinal villi

Intestinal villi atrophy

villi

normal intestinal villi atrophied intestinal villi

surface absorption

surface absorption malabsorption

GITIntestinal villi

digestive juices

disaccridases lactase enzyme

Lactose

digestive enzyme

digestive enzyme

maldigestion

diarrhea gastro entritis

maldigestion

Malabsorption

diarrhea

starvation diarrhea

starvation Marasmus Kwashiorkor

starvation diarrhea

starvation diarrhea

Intestinal villi shedding intestinal cells

atrophy intestinal villi

Lumen Intestine

cells


P a g e | 240

cells wall of the gut

cells ulcers

raw area ulcer

raw area Ulcer

serum

GIT serum

mucous

raw area ulcer mucous secretion

Mucous ulcer raw area

Mucous protective mechanism

raw area

ulcer

Mucous raw area

raw area healing

raw area excess mucous healing

Lumen bacterial flora

Lumen

sheded epithelial cells

Mucous

bacterial flora

sheded epithelial cells

Mucous

bacterial flora

bacterial flora

mucous


P a g e | 241

fermentation Mucous

fermentation Mucous fermentation

H2S

H2S

very offensive

H2S iron

H2S Iron

Iron

Iron absorption

Iron absorption

absorption lumen

Iron Lumen H2S

H2S FeS

FeS

huge amount of watery stool

Small amount

loose

dark

H2S


P a g e | 242

GIT

stool

very offensive

H2S

criteria of starvation diarrhea

criteria of starvation diarrhea starvation diarrhea gastro entritis

malabsorption maldigestion

starvation diarrhea

small amount

diarrhea Loose

very offensive

mucous

bacterial flora

Microscopic examination stool stool

marasmus diarrhea constipation

constipation Intake

diarrhea

gastro entritis

gastro entritis

immune deficiency

Immune deficiency

Immune system


P a g e | 243

maldigestion

Maldigestion

malnutrition atrophy intestinal villi

digestive jucies

Full digestion of food

absorption

malabsorption

atrophy Intestinal villi

surface absroption

starvation diarrhea

starvation diarrhea diarrhea

starvation diarrhea criteria

malabsorption Maldigestion

gastroentritis huge amount of stool

loose loose

greenish in color diarrhea

dark greenish in color

very offensive stool

stool greenish stool offensive

stool greenish FeS very offensive H2S

microscopic examination stool

Sheded epithelium cells Mucous Bacterial flora

gastro entritis marasmus


P a g e | 244

gastro entritis marasmus complications

marasmus

complications

complications

gastro entritis

marasmus

GIT Cardiovascular system

cardio vascular system

pulse

radial pulse

apical pulse

heart rate Low weak pulse

cardic muscle

slow and weak pulse

dehydration

rapid and weak pulse

dehydration rapid and weak pulse

shocked

respiratory respiratory muscle wasting respiratory muscle

wasting respiratory muscle

respiration

500 cc of air

500

say 300 shallow respiration

weak respiratory movement weak cough reflex


P a g e | 245


repeated chest infection Immune deficient

shallow respiratory movement

weakness respiratory muscle shallow respiratory movement

weak cough relfex

complications

complications

intercurrent infection

vitmains Mineral deficiency



vitamin Deficiency toxicity

complications

Intercurrent infection

broncho pneumonia

sinusitis

bronchitis

Otitis media

pyelonephritis gastro entritis

Infection

Infection Immune system

immune system

complications bleeding

Severe hemorrhagebleeding

fat cells Protection blood vessel

subcutaneous fat


P a g e | 246

subcutaneous fat protection wall of the vessel

blood vessels

fat

fat vascular support

vascular support vessel Liable to bleed

wall of the vessel wall of the vessel collagen fibers

collagen

collagen fibers supporting wall of the vessel

wall fragile

wall of the vessel fragile

Loss of subcutaneous fat

collagen fibers supporting the vessel

bleeding Infection dehydration

dehydration

dehydration Infection dissminated intra vascular coagulopathy

DIC

Intra vascular thrombus

fibrinolytic system

fibrinolytic system

consumption platelets coagulation factors

hematology

consumption Platelets coagulation factors

platelets

coagulation factors


P a g e | 247

bleeding

vessel wall collagen

supporting vessel subcutaneous fat

consumption platelets coagulation factors DIC

DIC severe infection dehydration

dehydration DIC

Infection DIC

complications

mainly

Caloric supply

marasmic kwashiorkor edema

edema

marasmic kwashiorkor

faulty management

caloric supply

complication hypo thermia

hypo glycemia

hypo glycemia hypoglycemia

hypoglycemia marasmus

hypoglycemia

hypoglycemia

hypoglycemia hypoglycemia hypoglycemia


P a g e | 248

hypoglycemia Intake

Intake

hypoglycemia

absorption

malabsorption

malabsorption

wall digestion

malabsorption

absorption

Lactase lactose

absorption

malabsorption absorption

stores Liver glycogen

stores glycogen liver

fasting

glycogen stores fat

glycogen storage Liver

glycogen stores

glycogen stores depleted

counter regulatory hormone

blood glucose

cortisone

epinephrine

counter regulatory hormones


P a g e | 249

hormone

counter regulatory hormone

epinephrine



fat acetyl Co A

Acetyl Co A metabolism


glycogen Muscle glucose


epinephrine Nor epinephrine counter regulatory hormones

amino acids

tyrosinephenylanine

counter regulatory horomones

thyroxine


thyroxine tyrosine

tyrosine

thyroxine

Kwashiorkor




P a g e | 250

Hypoglycemia

Hypoglycemia

hypoglycemia marasmus Kwashiorkor

decrease intake malabsorption

glycogen stores



P a g e | 251


P a g e | 252

full esophagus

the same

sepsis infection

sepsis hypoglycemia

sepsis infection hypoglycemia


P a g e | 253

Organism

Organism

infection hypoglycemia

Hypoglycemia excess consumption of the glucose

excess consumption of glucose

hypoglycemia Nutritional disorder Marasmus

peptic ulcer

peptic ulcer

peptic ulcer

Intestinal villi shedding intestinal villi

shedding wall of the stomach

shedding wall of the stomach

raw area

stomach PH acidic

HCL raw area

severe ulceration

hematemesis

Peptic ulcer erosion of the wall of the intestine

marasmic kwashiorkor total caloric supply

kwashiorkor

muscle

edema

edema so early protein

edema so early

still 60 %

edema

60 % edema kwashiorkor

marasmic kwashiorkor marasmic kwashiorkor

kwashiorkor


P a g e | 254

investigations of marasmus

Investigations

investigations of marasmus

marasmus Is a clinical diagnosis

marasmus clinically

8

actual body weight 60 % expected

expected 50 centile centiles

edema marasmus

marasmus it is a clinical diagnosis

Investigations

Investigations marasmus

Marasmus

complications

marasmus

Investigations

urine stool

stool Undigested food


P a g e | 255

Malabsorption

mucous gastroentritis

gastroentritis complications

history

stool fat

absorption of fat

steatorrhea

fat absorption

fat 9

caloric intake

Urine analysis

urine say

pus cells RBCs

urinary tract infection

urinary tract infection complication

chronic infection marasmus

marasmus repeated infection

urine glucose

glucose with or without keton bodies

blood glucose

blood glucose 250 300

urine glucose polyuria

diabetic

diabetes

Loss of weight

endocrine

diabetes

urine glucose

blood glucose

diabetic


P a g e | 256

diabetes marasmus

Marasmus

diabetes

Once

Urine

urine amino acids

glucose phosphorus

PH alkaline

Fanconi Fanconi like

Fanconi

Fanconi

Loss of amino acidsurine

Loss of glucose

caloric supply urine

Fanconi

Fanconi failure to thrive

failure to thrive

urine analysis marasmus

Marasmus urine glucose

Marasmus urine amino acids

Marasmus

marasmus

chest X - ray

marasmus chest X - ray

chest X - ray

cardiomeglay chest X - ray

heart chest X - ray congenital heart disease


P a g e | 257

heart VSD

marasmus

marasmus VSD

Marasmus VSD

cardiology nutrition

VSD marasmus sheet nutrition cardiology

marasmus congenital heart disease


sheet cardiology

congenital heart disease most probably VSD complicated by marasmus

marasmus complication VSD

third degree marasmus complicated by VSD

marasmus

marasmus

VSD complicated by marasmus

chest X - ray chest X - ray

heart


Murmur lesion

chest X - ray

chest infection

tuberculosis

T.B. Marasmus

chest X - ray finding suggesting tuberculosis


P a g e | 258

chest X - ray exclusion T.B.

chest X - ray complications

complicated pneumonia

complicated bronchitis

complicated

chest infection

tuberculos tuberculin test

tuberculin test Marasmus false negative

cell mediated immunity

Immune deficient

tuberculin negative

tuberculos tuberculin test

tuberculin test

contacts marasmus

suggestive tuberculos

tuberculos until proved otherwise

tuberculin test

Immune deficient

false negative

tuberculin test contacts

Malabsorption Marasmus

intestinal villous biopsy Intestinal villi

malabsorption


P a g e | 259

Investigations

marasmus associated manifestations complications

pallor

CBC

pallor anemia

CBC anemia

anemia kwashiorkor

anemia

MCV 60

MCH 25

Microcytic hypochromic anemia

microcytic hypochromic anemia Nutrition

cupper deficiency

iron deficiency

iron cupper microcytic hypochromic anemia

kwashiorkor

kwashiorkor

microcytic hypochromic anemia

13

microcytic hypochromic cupper Iron deficiency

Megaloblastic anemia

MCV

MCV 100 mean corpuscular volumeRBCs

macrocytic megaloblastic anemia

folic acid deficiency

folic acid stores hematology

folic acid

folic acid deficiency

kwashiorkor folic acid deficiency

anemia normocytic normochromic anemia

normocytic normochromic

normocytic normochromic anemia


P a g e | 260

Infection bone marrow depression

Normocytic normochromic anemia

anemia

CBC

CBC WBCs

Infection

ESR ESR

T.B.

ESR

assessment chemistry

chemistry kwashiorkor

protein immune globulins

kwashiorkor

kwashiorkor kwashiorkor unbalanced diet

caloric supply sufficient

Etiology

etiology

kwashiorkor common first baby

kwashiorkor


P a g e | 261

pregnant


P a g e | 262

sore throat


P a g e | 263

depression

anorexia

kwashiorkor

kwashiorkor common

very rare Kwashiorkor

very rare kwashiorkor

Milk breast milk

artificial milk

Milk Proportionate diet

caloric supply

kwashiorkor

marasmus

marasmus

kwashiorkor

so rare

kwashiorkor

kwashiorkor

kwashiorkor

kwashiorkor

؟؟؟ kwashiorkorما أسباب ال


P a g e | 264

nurtrition Primary

weaning

kwashiorkor

faulty weaning

faulty weaning

weaning

kwashiorkor

secondary secondary kwashiorkor unbalanced diet

secondary to other diseasewhooping cough

text

secondary to disease

anorexia

anorexia

kwashiorkor


P a g e | 265

Pathophysiology of kwashiorkor

Pathophysiology of kwashiorkor

kwashiorkor

excess caloric supply caloric supply

fat excess caloric supply fat

excess carbohydrates intake

Protein

kwashiorkor

fat

excess fat

excess calories

fat


P a g e | 266

fat

fat fat subcutaneous

subcutaneous fat

fat

fat

fat

buccal pad of fat

buccal pad of fat

carbohydrate facies

Kwashiorkor

marasmus senile

Kwashiorkor

fat extremities

abdominal fat

subcutaneous fat marasmus

buccal

extremities


P a g e | 267

abdominal fat

Marasmus

subcutaneous space full

fat

fat Liver

Liver fat

liver fat

fat Liver Liver to react with protein Liver

lipoprotein

react protein Liver

Liver fatty lipoproteins

low denisity lipoprotein

high denisity lipoprotein

biochemistry

Liver fat Lipoprotein

Liver lipoprotein fat

Lipoprotein Liver blood

blood vessel

Lipoprotein blood vessel

lipotropic factors

fat liver cells

lipotropci factors

lipotropic factors lipoprotein Liver cells blood vessel

lipotropic factors

methionine amino acids

vitamin B complex one of the major lipotropic factors

vitmain B complex


P a g e | 268

fatty liver

fatty liver

Lipid profile

Lipoproteins

fatty liver

kwashiorkor

liver Lipoprotein

fat liver

fat deposit Liver

fat Liver

Lipotropic factors

lipoprotein Liver

Liver

Lipotropic factors

vitamin B complex

Vitamin B complex

vitamin B complex absorption

Malabsorption maldigestion

fat Liver

fatty liver

fat deposit liver

liver

fatty liver

deficiency of protein lipoprotein

deficiency of lipotropic factors amino acids vitmain B complex

kwashiorkor Palpation Liver


P a g e | 269

Liver

fatty liver

fatty liver

subcutaneous fat fat Liver

Muscles

Muscles

Muscles

Muscle wasting

Marasmus

Muscle wastingsubcutaneous fat Loss

Mid arm circumference Marasmus

Muscle wasting subcutaneous fat



ratio Muscle fat

fat muscle

Muscle to fat ratio

kwashiorkor

Muscle fat

Decrease muscle to fat ratio


P a g e | 270

Excess fat to muscle ratio

Muscle fat


Muscle

bone

protein bone osteoporosis bone

bone

Neglected cases degeneration of the cardic muscle

cardic muscle degeneration of the cardic muscle

marasmus

muscle wasting Osteoporosis

degeneration cardic muscle

marasmus Heart failure

kwashiorkor Heart failure


cardic muscle

marasmus Liver stores Liver

Liver fat deposits

Liver fat deposits compensation Liver

liver albumin

albumin Liver

Marasmus Liver

compensation

serum albumin

liver support

kwashiorkor support

Liver support Hypoproteinemia


P a g e | 271


degeneration muscle

Plasma protein osmotic pressure

Nephrology

osmotic pressure plasma protein blood vessel

Plasma protein Osmotic pressure

intra vascular extra vascular

Intravascular volume

Interstitium fluid

vessel

vessel Nephrology

Heart

volume receptors signals hypothalamus anti diuretics hormone

anti diuretics hormone

ADH collecting tubules

osmotic pressure

Interstitium space

Interstitium space

Nephrology

blood volume renal blood flow

renin

renin aldosterone

aldosterone salt and water retention

Interstitium space


P a g e | 272

osmotic pressure

ADH

Aldosterone

ADH Aldosterone Liver

Liver

edema

edema Marasmus

compensation Liver

edema

Decrease osmotic pressure ADH Aldosterone

intestinal villi atrophy


shedding

recovery GIT

GIT mechanical trauma

chemical trauma digestive jucies

thermal trauma

contaminated

Mucosa GIT

rapid mitosis



Maldigestion malabsorption


P a g e | 273

exocrine function of the pancreas

endocrine


degeneration exocrine function of the pancreas

endocrine function Infected

kwashiorkor

complications

Marasmus marasmus

kwashiorkor acute malnutrition

complications

endocrinal dysfunction of the pancreas


pancreas acini degeneration

pancreas enzymes

pancreatic enzymes digestion

Maldigestion Malabsorption

renal tubules

renal tubules hyaline degeneration

degeneration of the hyaline

renal tubules tubular dysfunction kidney

brain

brain

brain

brain brain

thyroxine

thyrotoxicosis very irritable

cretinism

thyrotoxicosis


P a g e | 274

brain cells

thyroxin

thyroxin tyrosine

tyrosine thyroxine

Hypo thryoid function

thyroxine

facial expression

hypo thyroidism

neuronal cells

direct contact neuro Neuron

synaps

synaps

neuron Neuron

Neuron

Optic nerve Occiptial lobe

Occipital lobe once

cortical blindness

cortical blindness

Optic nerve

Occipital lobe

Occipital lobe


P a g e | 275

Occipital lobe copy frontal lobe

Memory

frontal lobe

frontal lobe

temporal lobe

temporal lobe

temporal lobe frontal lobe

fronal lobe

I don’t know

frontal lobe

actions neuro transmitter

transmitter

phenyl alanine tyrosine

neuro transmitter

tryptophan

phenylalanin tyrosine tryptophan

Neurotransmitter brain

brain


P a g e | 276

defect in neurotransmitter inside the brain deficiency of phenylalanine, tyrosine and

tryptophan

Hypothyroid function

mental changes

clinical manifestation of marasmus

Hypothermia

hypothermia

caloric supply

subcutaneous fat heat loss

Muscle bulk

dehydration

sepsis

GIT manifestations

Irritability Hunger sensation

anorexia

constipation

Marasmus diarrhea

gastro entritis

maldigestion malabsorption

starvation diarrhea

starvation diarrhea

small amount

Loose stool Dark greenish in color Very offensive

stool examination

dead epithelial cells

Mucous

bacterial flora

cardio vascular


P a g e | 277

bradycardia Low volume of the pulse weak pulse

dehydration rapid weak pulse

respiratory

shallow respiration chest infection

respiratory vitamins deficiecny

complications Infection

edema faulty management

bleeding

hypothermia

hypoglycemia

gastric erosion Peptic ulcer

Investigations Marasmus

marasmus associated manifestations

Stool and urine analysis Chest X - ray

tuberculos tuberculin

biopsy wall of the intestine malabsorption

CBC anemia

ESR

kwashiorkor

caloric supply

Milk

Milk

neglect of protein


P a g e | 278

kwashiorkor faulty weaning

systemic disease anorexia

kwashiorkor

kwashiorkor Pathophysiology

subcutaneous fat fat Liver

hepatomegaly

Muscle wasting

degenration of the cardic muscle

edema

Maldigestion malabsorption intestine

kidney Mental changes

38

39

clinical manifestations of kwashiorkor

Investigations marasmic kwashiorkor

nutritional dwarfism

Clinical manifestations


Kwashiorkor wellcome clasification 60 80

expected edema


essential features Non essential features

kwashiorkor

age expected weight


P a g e | 279

actual weight expected

edema

60 80 % expected weight edema wellcome classification

Kwashiorkor

manifestations of kwashiorkor

kwashiorkor

wellcome

Manifestations of kwashiorkor

essential features

non essential features

essential features

essential featrues of kwashiorkor

60 - 80 % expected edema

essential features

essential features growth failure

marasmus

60 % expected

edema

60 80 % expected

growth failure Loss of weight kwashiorkor Masked


P a g e | 280

fat

edema

excess fat

growth failure is not observed by the mother

Masked by excess subcutaneous fat and edema

expected weight

expected

essential features kwashiorkor wellcome

classificationedema

edema Kwashiorkor

edema kwashiorkor decrease osmotic pressure

Osmotic pressure

Osmotic pressure

osmotic pressure

plasma protein albumin

Liver Is affected fat infiltration

liver compensation

plasma protein

osmotic pressure

nephrology

osmotic pressure

Intra vascular interstitial space

Intra vascular interstitial space

edema


P a g e | 281

vascular volume

Intra vascular volume

blood vessel

vascular volume blood volume

blood volume Nephrology

volume receptors Hypothalamus brain

anti diuretic hormone

ADH

ADH hypo volumia

volume receptors

hypo thalamus ADH

ADH

ADH kidney renal tubules

water reabsorption renal tubules

water reabsorption renal tubules

osmotic pressure

blood vessel

edema

Intra vascular volume

renal blood flow

renal blood flow renin renin aldosterone

aldosterone supra renal

aldosterone

aldosterone distal convoluted tubules of the kidney

sodium

Kwashiorkor

sodium loss in urine

renal tubules

Osmotic pressure


P a g e | 282

Interstitial

edema

total body sodium

serum sodium

ADH

dilutional hypo natremia

Investigation

amount

concentration

retention of water retention of sodium

Nephrotic syndrome

ADH aldosterone liver destruction

ADH aldosterone Liver destruction Liver

liver Infiltrated fat

defect function of the liver cells

destruction ADH Aldosterone

edema

capillary permeability

capillary integrity

capillary fragile

Leak

permeability

capillary permeability


P a g e | 283

edema

decreased osmotic pressure

ADH Aldosterone

excess capillary permeability

capillaries

capillary pores

capillary

edema

edema

pitting edema

dorsum of the hand

dorsum of the foot Legs

thigh

forearm

arm edematous

arm lymphatic system

edema arm

severe condition edema arm

edema very rare abdominal wall

very rareeffusion Pleural effusion pericardial effusion ascites

common

ascites pleural effusion pericardial effusion

serum albumin 1 gram


P a g e | 284

effusion complications

kwashiorkor very early and very rapid complications

effusion

abdominal wall edema

applied clinical

applied clinical

complications

complications kwashiorkor

essential features of kwashiorkor Mental changes

Mental apathy

brain thyroxine

thyroixne tyrosine

tyrosine amino acids

thyroxine

Hypothyroid function

Hypo mental function

Neuronal cells direct

neurotransmitter

neurotransmitters brain norepinephrine epinephrine

tyrosine phenyl alanine

serotonine tryptophan spelling

neuro transmitters inside the brain protein sources

Neurotransmitters brain


P a g e | 285

connection cells

facial expression

facial expression

Mental apathy

essential features of kwashiorkor decrease muscle to fat ratio

decrease muscle to fat ratio

Muscle fat ratio

muscle

fat

anthropometric anthropology

anthropometric

X - ray diameter bone X - ray

fat bone

Muscle

Muscle to fat

decreased muscle to fat ratio

kwashiorkor

kwashiorkor

wellcome classification


P a g e | 286

essential features growth failure edema

mental change

decrease of muscle to fat ratio

clinically decrease muscle to fat ratio

Non essential features of kwashiorkor

Non essential features of kwashiorkor

Non essential features

palpation of the liver hepatomegaly

Hepatomegaly fat deposit liver

fat deposit Liver

fat Liver

Liver lipoprotein

lipoprotein

Lipoprotein Liver lipotropic factors

methainoine choline vitamin B complex

deficient kwashiorkor

Hepato megaly

non essential hair changes

hair follicles

Hair follicle skin

skin

glue like material


P a g e | 287

glue material sulphar containing amino acids

cystine cystiene

sulphar containing amino acids

Branched celldendritic cell

Melanocytes

Melanocytes

melanin

melanocytes

thyroid follicle thyroxine

uptake tyrosine

uptake tyrosine amino acids

tyrosine

tyrosine amino acids Phenyl alanine

tyrosine amino acid

tyrosine

tyrosinase

enzyme tyrosinase

tyrosinase enzyme tyrosine melanin

tyrosinase enzyme

cofactor cupper


P a g e | 288

tyrsoinase cupper

melanocytes cupper

cupper

iron free

carrier protein

carrier protein cupper ceruloplasmin

ceruloplasmin alpha two globulin

carrier cupper

melanocytes

cupper Melanocytes

tyrosinase

melanin

melanocytes

Melanocytes vesicles

vesicle

Melanocytes

hair follicle

body

Hair follicle

hair follicle

kwashiorkor deficiency


P a g e | 289

easily pickable hair


14

20


deficiency of sulphar containing amino acids

sulphar containing amino acids

deficiency of sulphar containing amino acids

Intake phenyl alanine tyrosine

Phenyl alanine tyrosine

tyrosine Phenyl alanine

enzymatic defects

enzyme tyrosinase

enzyme amino acids sequance

Investigations

enzymes


P a g e | 290

tyrosinase

tyrosinase

cofactor cupper

Malabsorption

stores cupper Liver

Liver carrier protein

ceruloplasmin

ceruloplasmin

deficiency of cupper and ceruloplasmin

tyrosinase

deficieny of phenyl alanine and tyrosine

deficiency of tyrosinase and permease

deficiency of cupper and ceruloplasmin


P a g e | 291

clinical

fabricated

sign

cardiology Fallot tetralogy heart X - ray

transposition egg on side

flag sign

flag sign

flag one color

One color

flag sign

flag sign

Microscopic finding

finding

color


P a g e | 292

flag sign

flag sign

Deficiency of melanin production

production

phenyl alanine tyrosine tyrosniase cupper ceruloplasmin

Hair changes kwashiorkor

skin changes

epidermis dermis

dermatology

epidermis

epidermis thin layer of fat

subcutaneous fat

subcutaneous fat

fat

fat

fat transparent

fat

essential fatty acids

essential fatty acids Non essential fatty essential amino acids non essential amino

acids

Non essential fatty acids fatty acids

acetyl Co A

Acetyl Co A fatty acids


P a g e | 293

fatty acids non essential fatty acids

essential fatty acids Intake


transparent

thickness female triple thickness male

female male

superficial layer of the skin

dehydration

fat

evaporation of water superficial cells

dryness

fat fat

reflection of sun lights

Ultra

violet rayseffect sun burn


P a g e | 294

protective mechanism

opaque

melanocytes

nucleus superficial cells ultra violet rays

cut color

cut

superficial layer of fat


P a g e | 295

fat



maldigestion

Malabsorption

protective layer

erythema

erythema

erythema

Sun burn

protective layer

erythema sun burn

erythematous area

inflammation

opaque layer

Opaque layer

dead cell

dead cell

hyper pigmentation false expression


P a g e | 296

It is not acutally hyper pigmented areadead layer of the skin

healing

Healing raw area ulcers

regeneration and recovery

raw area and ulcers

desquamation raw area or ulcer

Ulcer

ulcer without melanin

hypo pigmentation

erythematous

hyper pigmented

Ulcers

Hypo pigmented area

Flaking paint appearance

mixed

stages

erythema hyper pigmented ulcers hypo pigmented area


P a g e | 297

immunology

defence mechanism Micro organism

adhesion of the cell

Micro organism surface of the mucosa surface of the skin

raw area Ulcer

raw area Ulcer organism severe infection

severe infection gangrene of the skin

severe infection

Infection

Infection

excess sweating

Organism

flexture ares

axilla

Napkin dermatitis napkin ( bacterial fungal

What ever

Pressure areas

Pressure areas

Pressure areas

Pressure area

vascularity

Organism


P a g e | 298

Organism

vascularity

vascular flow

vascularity

Pressure area Pressure area buttocks

buttocks

Infection

excess sweating

Pressure area

skin changes

deficiency of essential fatty acids

nictotine amide tryptophan

Integrity, recovery and healing skin cells

recovery rpaid healing

vitamin A

vitmain A skin superficial layer of the skin cornea

vitamin A recovery

vitamin A rapid recovery raw area Ulcer

deficiency

vitmain A deficiecny

clinical pictures

zinc deficiency malabsorption

zinc

zinc vitmamin A

vitamin A

skin changes

deficiency of essential fatty acids


P a g e | 299

deficiency of nictoin amide tryptophan

deficiency of vitamin A

deficiency of zinc skin manifestations

skin manifestations

GIT manifestations

kwashiorkor

anorexia

anorexia GIT trouble

anorexia central

anorexia central

marasmus

feeding center

signals

signals Neurotransmitter

signals

central anorexia Mental changes

Local GIT distrubance

marasmus constipation not diarrhea

diarrhea

Marasmus

diarrhea

Gastro entritis maldigestion Malabsorption Starvation diarrhea

Iron atrophy of intestinal villi

Pallor

pallor anemic


P a g e | 300

Kwashiorkor

anemia

Microcytic hypochromic anemia

deficiency of iron of cupper

megaloblastic anemia

Megaloblastic Marasmus folic acid deficiency

megaloblastic kwashiorkor B12 and folic acid deficiency

B12 Liver

stores supply 12 15

Liver

Liver fat deposition

depletion of stores B12

marasmus megaloblastic anemia

kwashiorkor megalo blastic anemia

megaloblastic anemia Marasmus kwashiorkor

marasmus folic acid deficiency

kwashiorkor folic acid B12 deficiency

Kwashiorkor Liver affected

anemia deficiency of protein

RBCs

Normocytic normochromic anemia

Infection

Infection anemia

bone marrow depression hemolysis of the RBCs

RBCs depression of the bone marrow


P a g e | 301


marasmus scaphoid abdomen

kwashiorkor abdominal distention


weak abdominal muscles

abdominal muscles pot belly abdomen

digestion absorption

lumen bacterial flora fermentation

fermentation gases

Lumenal parasites common immune deficiency in

generalkwashiorkor

Giardia

Giardia duodenum Upper of the jujenum

Giardia parasites fermentation

distention generalized

percussion Hyper resonant abdominal allover

giardia

giardia epigastrium

Percussion hyper resonant

giardia

Giardia

stool analysis

stool analysis very rare giardia

giardia nasogastric tube

aspirate duodenum

analysis


P a g e | 302

giardia

giardia stool analysis

giardia fermentation

intestinal obstruction

Intestinal obstruction

Paralytic ileus

paralytic ileus

hypokalemia

diarrhea

diarrhea gut secretion

Hypokalemia

hypokalemia

Loss of gut secretion Hypokalemia

hypokalemia

aldostrone

aldosterone aldosterone Loss Urine

hypokalemia Kwashiorkor

loss diarrhea

Hyperaldosteronism aldosterone

Aldosterone

paralytic ileus toxins

toxins severe infection

Liable to severe infection

toxic ileus


P a g e | 303


vitamin deficiency

vitamin deficiency vitamin deficiency toxicity

vitamin deficiecny vitamin A

vitamin A Keratomalacia

blindness

blindness vitamin A deficiency

vitamin A malnutrition

vitamin A deficiency

decreased intake

Malabsorption absorption

absorption stores

depletion of the liver stores

stores Liver Liver

stores liver

vitmain A absorption vitamin A

stores Liver

vitamin A

caroteen

vitamin A

vitamin A

liver

Liver

fat cells


P a g e | 304

deposition of fat

caroteen vitamin A

Liver

Liver

Liver cells

vitamin A

zinc

thyroxine

vitamin A zinc thyroxine

thyroxine thyroxine tyrosine

tyrosine amino acids

hypo thyroidism

malabsorption zinc

vitamin A

vitamin A deficiency

Intake

absorption

stores

vitamin A Liver zinc T3 T4

thyroid

complications

complicationsKwashiorkor

Complications

Marasmus


P a g e | 305

complications

complications

Marasmus

Intercurrent infeciton

Immune fucntion chemotaxis Macrophages migration Phagocytosis

T cells B cells Interferon

marasmus

infection Marasmus kwashiorkor

Infection kwashiorkor

kwashiorkor Immune deficient

good media Organism

edema

Intercurrent infection

gastro entritis so common

DIC hemorrhage Marasmus

hemorrhage in general DIC

Marasmus bleeding

Loss of subcutaneous fat DIC

intervascular thrombosis

consumption Platelets coagulation factors

hypothermia

fat

generators

heat production


P a g e | 306

Heat loss

generators Muscle

muscle wasting decreased heat production

sepsis

dehydration

complications hypoglycemia

Hypoglycemia

Hypoglycemia

hypoglycemia

Hypoglycemia

Hypoglycemia



hypoglycemia hyperactivity hyper irritability

endocrine

Hyperglycemia

Hypoglycemia

Hypoglcyemia is a fatal

Hypo glycemia

hyperglycemia is very weak

Saykwashiorkor

hypoglycemia

counter regulatory hormones epinephrine

Hyper irritable

tremors

Pupil dilated

cold skin

vaso constriction


P a g e | 307

Pale vaso constriction

epinephrine excessive sweating

Pulse rate heart rate

severe tachycardia

Hypoglycemia false impression

hypothermia

false imperssion Hypothermia

Hypoglcemia One of the complication

hypoglycemia

Marasmus

Intake

excess carbohydrate intake

Hypoglycemia decrease carbohydrate intake

excess carbohydrates

Malabsorption

stores glucose


sepsis consumption

Marasmus

heart failure

heart failure

heart failure kwashiorkor

Heart failure

Heart failure


P a g e | 308

degeneration of the cardic muscle

Heart degeneration of the cardic muscle cardiomyopathy

Liver compensation

heart failure

InfectionMarasmus

edema

Immune deficiency

severe infection toxic myocarditis

volume overload

volume overload

management

edema

Interstitium Intra vascular

Hyper voluemia congestive heart failure

hyper voluemia during management

Investitagations of kwashiorkor

Investigations

Investigations kwashiorkor

Marasmus


assessment of the nutritional state

fat

electrolytes

Oral glucose tolerance curve endocrine


P a g e | 309

curve hypoglycemic level

hypoglycemia

fat

free fatty acids

cholesterol

free fatty acids

free fatty acids

free fatty acids

fats

Lipoprotein

Liver

Minerals

phosphorus zinc

dilutional hyponatermia

dilutional hyponatermia

total protein

non essential amino acids to essential amino acids ratio albumin

globulins carrier proteins

enzymes

total protein Nephrology

Normal total proteins 6 8

total proteins Low

normal non essential to essential amino acids ratio 2 1

kwashiorkor


P a g e | 310

Non essential

essential

albumin 2.5

albumin

globulins alpha

alpha beta Intake

intake alpha beta

reticuloendothelial system

early gamma globulins reticulo endothelial system immune

globulins

advanced cases

suppression reticulo endothelial system

carrier protein

transferrin Iron

ceruloplasmin cupper thyroid bindingthyroxine

carrier protein

enzymes

ALT AST

enzymes

ALT AST

ALT Liver affection

AST Liver and muscle AST muscle wasting

tetany

non ionizable form ionizable form

bound form of calcium


P a g e | 311

kwashiorkor serum calcium Low tetany

tetany

acidosis

acidosis

Infection

bound form of calcium

ionizable form

Investigations

Urine analysis

Urine Urea

kwashiorkor marasmus urine


Muscle

catabolism of protein

Liver urea cycle

urea

Urine

Marasmus Hyper catabolism of protein of the muscles

Liver

Urine

Urine Marasmus

kwashorikor

Liver

Liver

hepatic encephalopathy

management


P a g e | 312


CBC

ESR

Tuberculin test

Stool analysis

intestinal vilous biopsy

Marasmus


Marasmic kwashiorkorال

marasmic kwashiorkor wellcome classification

marasmic kwashiorkor 60 % expected weight for age

edema

Marasmus

edema

essential features Mental changes

mental changes

skin

Hair changes

60 % expected weight edema


P a g e | 313

pre kwashiorkorمكتوب عندكم ال

clinically laboratory

Pre kwashiorkor clinical manifestations

thalassemia

genetic diagnosed

Especially hemoglobin electrophoresis

follow up 13 14 thalasssemia intermedia

iron chelators desferal

thalassemic

kwashiorkor

follow up

pre kwashiorkor

pre kwashiorkor essential features

edema

edema

60 80 % expected

edema

Mental changes

kwashiorkor

edematous

60 80 % expected

edema Kwashiorkor


P a g e | 314

prekwashiorkor

} edematous {

no edema kwashiorkor

non essential to essential amino acids

2 1 3 1

Investigations kwashiorkor 3 1

2 1 3 1

serum albumin

2.5 2.85

2.8 2.8

station

8 : 12

8 : 12

8 : 10

station

albumin 2.85 2.5

Pre clinical kwashiorkor


P a g e | 315

Nutritional dwarfismاللي هي عندكم ال

Nutritional dwarfism for normal growth

so deficient nutritional disorder

compensation by slow rate of growth

10th percentile

endocrine

10th percentile

Nutritional dwarfism

39

treatment of marasmus and kwashiorkor



P a g e | 316

Treatment of marasmus and Kwashiorkor

prevention

prevention


breast feeding

assessment feeding

assessment Under

feeding Over feedingInfant feeding

weaning proper weaning

balanced diet fat

Proper diet

Malnutrition Immunity

vaccination

T.B. Malnutrition

complication

whooping cough Malnutrition

Measles Malnutrition

Nowadays


P a g e | 317

family planning

family planning

balanced diet

active treatment treatment Marasmus Kwashiorkor

Dietic management

Non dietic management

dietic management

Investigations treatment

Investigations

dietic management

is the child is full term but low birth weight, weaning at six months

full term weaning


P a g e | 318

Preterm

Neonatology catch up phenomena

low birth weight weight loss

evenfull term

catch up phenomena

Low birth weight preterm weaning

weaning

stores

gut mucosa Mature enough

enzymatic function

infant feeding

incidence of atopic diseases

incidence of auto immune disorder

explanation

dietic management : dietic management

program

satisfied

total calories

marasmus kwashiorkor

dietic management

total calories total calories

total calories


P a g e | 319

marasmus

Marasmus 150

marasmus 150

kwashiorkor

Kwashiorkor calories

Normal 120

Low birth weight

Preterm

Kwashiorkor

120

expected weight

expected weight actual body weight

Marasmus 4

Kwashiorkor 6

marasmus kwashiorkor

first degree maramus expected weight

first degree marasmus expected weight

Kwashiorkor second degree marasmus third degree marasmus

average weight


P a g e | 320

average weight

expected actual weight

8 4 12

2 6

actual body weight

expected weight

mean

Mean

Mean

expected weight

first degree marasmus

total calories

total calories

1000

Delayed weaning


P a g e | 321

150 100

15 10

calculator

calculator

dose

15 10

3 2

Marasmus

averge weight 6

8 4

12 6

average weight

average weight



150 Marasmus first degree

120 kwashiorkor

150 marasmus

120 kwashiorkor

total calories


P a g e | 322

3/2

3/2

average weight

average weight

150 Marasmus

120 kwashiorkor

total calories

Calories

3/2

volume of milk

1200 cc

100

100

24 12

100

100 180

100

small frequent meals


P a g e | 323

maldigestion Malabsorption

24

breast feed

breast feed is breast feeding

text book

breast feeding Marasmus kwashiorkor

artificial milk

GIT

maldigestion malabsorption

Non complicated gut troubles

humanized milk

Humanized milk Infant feeding

calories

humanized milk


P a g e | 324

humanized milk

Maldigestion malabsorption

maldigestion lactose intolerance

Lactase enzyme

Lactose

Lactose free milk humanized milk

lactose

lactose intolerance

lactose free milk

steatorrhea

steatorrhea

skimmed milk

malnutrition fat

fat calories

skimmed milk fat

Fatabsorption

Digested fatMedium chain triglyceride

bile

skimmed milk

Medium chain triglyceridecaloric supply

total calories

total calories

Lactose intolerance Lactose free milk


P a g e | 325

steatorrhea skimmed milk medium chain triglycerides

small frequent meals

marasmus

Kwashiorkor hypo proteinemia

kwashiorkor

marasmus

caloric supply fat total calories

proteins

protein milk

protein milk

Protein milk

100 5

100 1.2

protein milk

Protein milk Infant feeding

4

4 gram per kilo gram per day

4 gram


P a g e | 326

muscles enzymes

protein milk

artificial milk artificial milk calories

diet

mixed meat

Of high biological value

high biological value animal protein

kwashiorkor

mental apathy

mental retardation

Planet protein

animal protein

routes أو ال Mode of administrationال


P a g e | 327

weaned

anorexia

100

50

anorexia

nasogastric tube

Nasogastric

nasogastric

nasogastric tube

Persistent vomiting

nasogastric tube

toxic ilues severe infection

Chest infectionoral

total parentral nutrition

total parentral nutrition central line

central line


P a g e | 328

central line central line

central line

amino acids

total calories

total calories

first sign of improvement

Is improvement of apetite100

100 100

first sign of improvement clinically

Improvement of apetite

dietic management

marasmus



emergency management

emergency

hypoglycemia


P a g e | 329

hypo glycemia Intra venous glucose

hypoglycemia

Hypoglycemia

Hypoglycemia intra venous glucose

dehydrated

re hydration

hypo thermic

shivering Loss

subcutaneous fat

Loss

marasmus kwashiorkor generator

muscle

muscle wasting ,,,,, lost

generators

generators


P a g e | 330

Marasmus

marasmus

shock

shock shock


marasmus Kwashiorkor blood transfusion

fresh blood

fresh blood

fresh blood

fresh blood

fresh blood RBCs anemia anemia fresh blood anemia

fresh blood coagulation factors platelets

bleeding tendency

fresh blood Immune globulins

immune state


P a g e | 331

immune globulins fresh blood

fresh blood plasma protein

plasma protein kwashiorkor

edema

enzymes general condition

apetite

fresh blood

fresh blood

fresh frozen plasma

fresh frozen plasma coagulation factors bleeding

fresh frozen plasma

apetite enzymes edema

fresh frozen plasma

Immune globulins Immue state

anemia

anemia

fresh frozen plasma

soft free albumin albumin

albumin

albumin

amino acids amino acids

amino acids

amino acids

amino acids argenine amino acids


P a g e | 332

argenine stimulation islets cells of langerhans

insulin

Hypoglycemia

amino acids hypoglycemiaargenine

Immune deficiency anti biotics

anti biotics

gram positive gram negative

penicillin gentamycin

available antibiotics

broad spectrum antibiotics

septic focus

marasmus ottitis media

Ottitis media

marasmus pharyngitis

Pharyngitis

Kwashiorkor Pyelonephritis

pyelonephritis

septic focus

broad spectrum antibiotics protective mechanism

common

fungus infection

Immune deficiency fungus

mycostatin oral drops

oral moniliasis

Mycostatin


P a g e | 333

Oral monaliasis


P a g e | 334

esophagus

IQ

Marker

asthmatic

aminophyline

Oral

moniliasis skin

Napkin dermatitis

skin moniliasis oral moniliasis


P a g e | 335

skin moniliasis

Mycostatin

cream mycostatin

Infection

Infection

vitamins and minerals


Kwashiorkor 50,000 vitamin A

deposits of keratomalacia corneal ulcers

50,000 vitamin A

vitmain deficiency

Mineral

Multivitamins

correction of vitamin and mineral deficiency

Muscle wasting

anbolic hormones

anabolic hormones protein biosynesis anabolic hormones

Carcinogenic effect myosarcoma

marasmic

marasmus kwashiorkor History

dietic

failure

treatment Marasmus kwashiorkor


P a g e | 336

blood transfusion

On admission

thalassemia

What is the most common cause of death in marasmus and kwashiorkor

Most common cause of death Infection

Kwashiorkor Heart failure

Notes

21

38

21

18

total calories average weight caloric requirements

total calories

3/2

calories


P a g e | 337

marasmus بتاع ال treatment بتحصل أثناء ال complicationsبعد كده ندخل على ال

Kwashiorkorوال

kwashiorkor Management

Liver fat

Liver fat

dietic management High protein

kwashiorkor

Liver

Marasmus

bacterial flora

absorption bacterial flora

gut

Portal Liver

Liver

Liver


P a g e | 338


disturbed level of conscious

Hepatomegaly

Hepatic encephalopathy

Nutritional recovery syndrome

High protein diet hepatic encephalopathy

calories Liver recovery

recovery fat

fresh frozen plasma

fat load Liver

Kwashiorkor edema

Osmotic pressure

Osmotic pressure

Hyper volemia

Hyper volemia congestive heart failure

hypervolemia

Congestive heart failure

Over hydration transient increase of the intra cranial pressure

transient increase of intra cranial pressure

congestive heart

over hydration brain Heart


P a g e | 339

heart

Over hydration transient increase of the intra cranial pressure

comatosed

management kwashiorkor

Hypokalemia

diarrhea

aldosterone

aldosterone Urine

hypoglycemia

gut diarrhea

Urine aldosterone

arrested

take care

check

Hypokalemia Management of kwashiorkor

Over hydration

hypo kalemia

nutritrional recovery syndrome

prognosis


P a g e | 340

Prognosis

Prognosis of kwashiorkor

kwashiorkor Marasmus

Kwashiorkor acute nutritional disorder

marasmus marasmus

Kwashiorkor

complication

Prognosis of kwashiorkor

kwashiorkor

prognosis so bad

kwashiorkor Kwashiorkor

reversible

irreversible

irreversible Protein losing enteropathy

anomaly gut protein

gut transplantation

available

Prognosis is so bad

reversible Prognosis

Irreversible Prognosis is so bad

complications complications

complications

complications


P a g e | 341

complications Prognosis

hepatomegaly

mental dysfunction mental changes

reversible

nutritional assessment



Nutritional Assessment written

tetany


history

dietic history

clinical assessment

anthropometric development

title

laboratory assessment

kwashiorkor

Immunological assessment


P a g e | 342

Dietic history

dietic history

clinical round dietic history

dietic history

fat

vitamins minerals

fat

total caloric

count fat count protein count vitamin count

fat

content

salt sugar

sugar

calories


P a g e | 343

calories

I don’t know

iam so sorry

roughly

roughly

dietic history


P a g e | 344

amount

clinical assessment

check

signs of malnutrition vitamin deficiency

deficiency

anthropometric

anthropometric

anthropometry

sheet

standard deviation score percentile

Length height


subcutaneous fat

skull circumference

chest circumference

chest to head circumference


anthropometric assessment

anthropometric detect anomalies

Laboratory assessment

laboratory assessment

glucose tolerance curve

free fatty acids Lipid fat


P a g e | 345

Proteinessential and non essential amino acids ratio

albumin globulins

enzymes carrier protein

editor

lab

research work

researches

research work

researchs

available

500600

short

short Protein

early detection

malnutrition

500 600 500 - 600


P a g e | 346

rabies

signs Isolation virus

free albumin

free albumin

free albumin half life 48

Lossso early

somatomedin C

Half life short 36

48

so early

somatomedins C

editors


immune status

Immune status so early


Immune deficiency

nutritional assessment

vitmain Deficiency

vitamin toxicity Hypervitaminosis

hyper vitaminosis D

Hyper vitaminosis D hyper vitaminosis D High dose of vitmain D


P a g e | 347

20,000 international unit daily

free albumin

20,000 international unit per day

vitmain D

vitamin D

tetany

adequate calcium supplementation

hyper calcemia

hyper calcemia

vitamin D bone bone fully saturated

bone fully saturated

osteoblast

serum calcium

serum calcium

serum calcium manifestations of hypercalcemia

gut

gut

constipation and vomiting

constipation vomiting

intestinal motility

Intestinal motility

intestinal obstruction

anorexia

anorexia distention


P a g e | 348

wall of the gut

anorexia, vomiting and constipation

minerals

kidney full reabsorption

renal threshold

urine

Urine Mineral

Poly uria

dehydation

kidney oxalates renal stones

nephro calcinosis

renal impairment


tetany

Ionizable calcium

ionizable calcium

nerve fibers

tetany


P a g e | 349

Ctrl + F

metastatic calcification

blood vessel

brain

metastatic calcification

Investigations

serum calcium Urine calcium

urine serum calcium

urine serum calcium


Hyper parathyroidism

hyper parathyroidism hyper calcemia

calcium urine

Parathormone urine

Urine

X - ray metastatic calcification

vitamin D

wash Kidney

renal stones

full hydration


P a g e | 350

vitamin D

calcium absorption

calcium absorption

alkaline

phytate

Oxalate

absorption

alkaline PH calcium absorption

EDTA

EDTA chelation

resistant cases

why

block vitamin D receptors gut

nutritional disorders

summary

management of marasmus and kwashiorkor

breast feeding proper weaning Proper diet proper vaccination family planning

dietic management

total calories Marasmus 150 kwashiorkor 120 first degree marasmus expected weight


P a g e | 351

average weight

non weaned

total calories

3/2

Small frequent meals

gut humanized milk lactose intolerlance lactose free milk

fat intolerance steatorrhea skimmed milk

kwashiorkor

liver infiltrated fat

hepatic encepahlopathy

weaned

available

Naso gastric tube

vomiting paralytic ileus

severe infection

total parentral nutrition

first sign of improvement

apetite


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non dietic management


Hypo thermic

hypoglycemic

dehydration

shock shock

fresh blood transfusion blood component

fresh frozen plasma

albumin

amino acids mixture

amino acids mixtures Hypo glycemia

argenine amino acid stimulation islets cells of langerhans

AntibioticsLiable to infection

vitamins and minerals deficiency

anabolics

Nowadays

underlying etiology

take care

kwashiorkor Hyper volemia

Hypo kalemia

Nutritional recovery syndrome

Prognosis

Prognosis

bad prognosis reversible irreversible irreversible bad prognosis complications complications bad prognosis


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bad prognosis

main complications

hepato meglay mental changes



Dietic history

roughly

Clinical assessment check signs of vitamins, minerals

Malnutritions

Anthropometric mid arm circumference skull circumference


Lab assessment Investigations Kwashiorkor

free albumin somato medins C


hyper vitaminosis D

hyper vitaminosis D

vitamin D 20,000 international unit

tetany

calcium Hyper calcemia

Hyper calcemia

Anorexia, vomiting and constipation Poly uria Dehydration Renal stones Nephro calcinosis Generalized muscle weakness


P a g e | 354

metastic calcification

nutrition

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nutrition

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