Causes of gynaecomastia
G Genetic disorder (Klinefelter’s)
Y Young boy (pubertal)
N Neonate A Alcoholism
E OEstrogen
C Cirrhosis/cimetidine/calcium channel blockers
O Old age
M Marijuana
S Spironolactone
T Tumours (testicular and adrenal)
I Isoniazid/inhibition of testosterone
A Antifungal (ketoconazole)
Question::
Could human exposure to
magnetic field nonionizing radiation be
associated with increased risk of
attention-deficit/hyperactivity disorder(ADHD)
in children?
Answer::
Study found a statistically significant association
between a high level of maternal
exposure to magnetic field nonionizing
radiation, as captured with a monitoring
meter, during pregnancy and an
increased risk of ADHD in offspring. The
association was stronger for children
who received a diagnosis of ADHD in
adolescence (12 years of age) than for
those without such a diagnosis in
adolescence, and primarily for children
with ADHD with immune-related
comorbidities.
Meaning ::
The findings should spur more
research to examine the biological
association of in utero magnetic field
exposure with risk of ADHD disorder in offspring
Step-by-step approach available to support health professionals to guide individuals to make changes to their behavior and Obesity Management
Guiding and Enabling Behaviour Change
How to take a guiding and collaborative approach with patients to help support lifestyle behaviour change. It illustrates a five-step approach that will enable you to achieve this, and highlights where you may need to refer to other support services
The personal, social and economic cost of overweight and obesity is high. Obesity can affect an individual’s quality of life; their health and wellbeing; and their life chances. The stigma associated with obesity has a societal impact and individuals can become isolated and may experience discrimination.
An effective way to help people make changes to health-related behaviours is through the delivery of a brief intervention. Select interventions that motivate and support people to:
One approach that integrates these techniques is motivational interviewing. Adopting this approach during a consultation to discuss the issue of overweight and obesity may be extremely helpful in supporting behaviour change.
Step 1 Screen and Classify
The first step is to assess weight and height and calculate BMI. Waist circumference could also be measured. BMI is recommended as a practical estimate of overweight in children and young people and when assessing individual growth, height and weight If weight is a concern, you can assess BMI centile of an individual child BMI should not be used for children under two years. Waist circumference is not recommended as a routine measure but, may be used to give additional information on the risk of developing other long-term health problems.
Step 2 Providing Non-judgemental Feedback
If the cause of the individual’s obesity has been determined as lifestyle factors, then the second step involves raising the subject of weight, providing non-judgemental feedback and moving on to explore personal meaning.
Patients should be provided with their BMI and waist circumference results and an explanation of how these were calculated. Then ask the patient: “Would you mind if we spend a few minutes talking about your weight” ?
This creates the opportunity to share with the patient non-judgemental feedback regarding their current weight status.
Step 3 Helping Patients to Consider Their Options
It is important to help the patient to develop and verbalise arguments for change themselves, as this increases the likelihood of behaviour change. So having listened to the patient’s response to their assessment, ask the following two open questions.
What would be the benefits to you personally of losing weight?
If you did decide to lose weight, how would you go about it?
While the patient is responding to your question, try to make sure that you listen actively and with curiosity, resist the tendency to jump in with bits of advice and let the patient do most of the thinking and talking. Then summarise what you heard the patient say, and ask the following question.
What do you think you will do?
When asked what they want to do about their weight, some patients will decide there and then, others may need some further help deciding. Patients are more likely to stick with a decision if it is freely made, so we discourage telling the patient what they ‘should’ do. It is commonly helpful to share options with patients, to make the decision process easier for them. If this is the case, you might want to list their options. Would it be helpful to explore the options? You could:
a. Decide to stay as you are
b. Go away and think about it some more
c. Set a simple lifestyle- related goal
d. Access a local weight management service
Having listed the options it is important that you don’t jump in and make a decision for them. Try to help the patient make a decision by asking one of the following questions.
Can you think of any other options?
What do you think you will do?
So which one of these sounds right for you?
What do you think you want to do next?
As a health professional, it is important that you support and enable the patient to identify the right solution for them. You cannot, nor is it your job to, decide for them. The table below sets out a suggested health practitioner response to the different options that you may share with a patient, or that they themselves will have identified.
| Patient choice | Suggested health professional response |
| Option A: Stay the same, not yet ready to lose weight | Acknowledge the patient’s decisionTell them you would be willing to talk again if they became more ready |
| Option B: Go away and think about it some more | Affirm the decision: ‘It’s great you are thinking about losing weight, it’s one of the most important things you can do for your health’Offer some reading material to help them weigh up the pros and cons. You may wish to use the Change4Life leaflet ‘Swap It, Don’t Stop It’ Suggest a date for talking further |
| Option C: Setting lifestyle goals | Explore options with the patientAssess the person’s view of their weight and the diagnosis, and possible reasons for weight gainExplore eating patterns and physical activity levelsExplore any beliefs about eating, physical activity and weight gain that are unhelpful if the person wants to lose weightFind out whether the person has already tried to lose weight and how successful this has been, and what they learned from the experienceHelp them set simple lifestyle goalsArrange a follow-up appointment |
| Option D: Accessing local weight management services | Using the local obesity care pathway, determine the patient’s eligibility for available weight management services, and explore the options with the patientHelp them set a simple goal and take action to help them achieve it i.e. the patient may require a referral in order to access a local serviceArrange a follow-up appointment |
If a patient identifies that they would be interested in Option C (setting lifestyle goals), then helping them to develop a specific change plan will increase the likelihood of change. To do this you might want to ask the following question.
You’ve identified that you could make some changes to your lifestyle, what do you think you could do?
It may be that the patient has already given some thought to what they could do, alternatively you may need to help them identify appropriate options. Again, try to avoid telling the patient what they can do. If they are struggling to identify possible options, then it is helpful if you first elicit permission from them before sharing further information.
Would it be helpful for me to share some ideas about some of the things you might be able to do…? OR Would you be interested to know more about some of the changes you could make? OR Would it be okay if we talked a little about what changes you might be able to do
Having established that the patient is motivated to lose weight, co-creating their goals should be a priority, ideally with the aim of losing 1-2 lb per week.
In order to be successful, goals need to be patient centred.
It is helpful to think of SMART goals – any change should be:
Specific – Stick to clear aims, for example ‘I am going to walk for 30 minutes during my lunch hour every day.
Measurable – Patients can look back on a week and clearly assess which meals improved or on how many days they exercised.
Achievable – Suggest small, relatively easily achievable goals to increase positive beliefs and self esteem and the overall chances of success. Ambitious goals could be divided up into smaller steps e.g. a main aim of 12 kg loss divided into a set of smaller 2-3 kg per 12 weeks weight loss goals.
Relevant – choose goals that apply to your circumstances.
Time specific – For example instead of ‘I’ll start going to an exercise class’, think ‘this week I will start looking at all the exercise classes that I could go to and choose the one that I think I will enjoy the most. Next week I will start attending it regularly.
| Patient choice | Possible options from the Change4Life adult campaign | Possible options from the Change4Life children’s campaign |
| Option C: Setting lifestyle goals | Swaps to get you up and about: building activity into your day, your way | Up and about: Get moving |
| Portion swap: reducing portion sizes to decrease your calorie intake | 60 active minutes | |
| Snack swap: staying healthy without giving up all snacks | 5 a day | |
| Swap for 5 a day: getting your 5 a day, every day | Meal time | |
| Fibre swap: how to find fibre and why it’s important | Snack check | |
| Drink swap: how to cut down on calories in drinks | Me size meals | |
| Cut back on fat | ||
| Sugar swap |
Many areas now have obesity care pathways, from Tier 1 through to 4, which can include provision of available local weight management services. Eligibility criteria often determine patient suitability for each of the different tiers of service.
Typically overweight or obese individuals should be suitable, in the first instance, to access Tier 2 community lifestyle weight management programmes. It is important to note that such services will assess a patients readiness and motivation to change, this readiness to change is associated with success outcomes. If a patient identifies that they would be interested in accessing this type of service, then it can be helpful to offer them some more information on local provision and where appropriate facilitate a referral.
All lifestyle weight management services should address diet, physical activity and provide behaviour change support, however, the way in which the service is provided will vary from area to area. Some local commissioners have invested in well known services such as Weight Watchers or Slimming World, others have commissioned home grown interventions.
Having discussed with the patient the potential benefits to them of losing weight, and having explored the actions that they might take to improve their lifestyle, you are now bringing the consultation to a conclusion. It can be very helpful to summarise what has been discussed, and examples of how to do so can be seen on the right.
It can also aid behaviour change if you provide a copy of this summary to the patient, and provide any supporting information that may have been used during the discussion. In addition, it’s helpful if you can document the results of the discussion in the patient’s notes. This should include the following information:
So you’ve decided you are… [going to make some changes to your lifestyle]
This is because…[you want to be able to run around after your children]
Specifically, you are going to ….[walk to work three times a week and reduce your meal portion sizes]
It is important that you follow up on the patient’s progress at regular intervals, for example after 3, 6 and 12 months, using the initial steps as the basis for the discussion at each follow-up appointment.
Encouraging support from family members and/or seeking community/peer support relating to weight management is helpful.
Praise successes – however small – at every opportunity to encourage the person through the difficult process of changing established behaviour
INTRODUCTION
Chest pain in children represents approximately 5% of all referrals to pediatric cardiology services in a tertiary referral hospital. It is a common symptom in children and adolescents. Although the etiology is benign and non-cardiac in the majority of cases, chest pain as a complaint often leads to anxiety both in the child and parent, school absenteeism and restrictions on physical activity. Extensive public awareness on the association of chest pain with ischemic heart disease and myocardial infarction in the adult has led to an erroneous assumption that the same holds true for the pediatrics patient.
EPIDEMIOLOGY AND PRESENTATION
Pediatric chest pain as a primary complaint to the accident and emergency department has an occurrence rate of 0.249% and 0.288% per patient visit. There is no gender predilection in patients presenting and in the largest prospective study to date
the average age at presentation with this complaint is at a mean age of 11.9 years and a median age of 12.5 years. In the same study by Selbst et al, chest pain
was described as acute (less than 48 hours duration) in 43% of cases and chronic (greater than six months’duration) in 7%. In contrast to these figures, a study by Pantell et al in adolescents (mean age 16.2 years, 67% female) presenting to an out-patient’s department setting described an incidence of chronic chest pain
Non Cardiac Cause Of Chest Pain
.
Precordial catch syndrome
Precordial catch syndrome consists of a brief (several seconds), sharp pain inferior to the left nipple or at the lower sternal border. It is frequently pleuritic and can be accentuated by bending forward. This syndrome frequently forces the patient to breathe shallowly. Its cause is unknown.
Tietze’s syndrome
This syndrome is quite uncommon in children. It involves inflammation of one costochondral junction. The area involved is warm, swollen and tender.
Non-specific chest wall pain (idiopathic chest pain)
Non-specific chest wall pain may be the most common type of chest pain in children and adolescents. The pain is described as sharp. When asked to point to the pain, the patient will usually point to the centre of the chest or the infra nipple area. The pain lasts several seconds to several minutes and is ex- acerbated by deep breathing. Sometimes squeezing the thoracic cage or gently pressing the sternum can reproduce the pain. Frequently the pain cannot be reproduced by palpation or pushing on chest structures. The costochondral and costosternal joints are non-tender
Slipping rib syndrome
Slipping rib syndrome is quite rare, but it does produce rather intense pain, usually involving the eighth, ninth and tenth ribs. These ribs do not attach directly to the sternum but, rather, attach to each other. It has been postulated that trauma to the chest results in disruption of the connection of these ribs to each other and subsequent movement produces pain. A positive ‘hooking maneuver’ is said to be characteristic of this problem. The hooking maneuver is performed by the examiner putting his or her fingers under the inferior rib margin and pulling interiorly. This action will reproduce the pain and may produce a clicking sound.
TYPES OF CHEST CAGE AND CHEST WALL PAIN
Trauma and muscle strain
Obviously, injury to the chest wall produces chest wall pain. The history of prior trauma is suggestive and usually the pain can be reproduced by palpation of the chest wall. The same trauma, of course, could also produce myocardial contusion and, possibly, a haemopericardium, both of which can cause chest pain.
Costochondritis
Costochondritis involves two to four contiguous costochondral or costosternal junctions. Usually it is unilateral. More commonly it involves the more cephalad joints. The pain is described as sharp, lasting several seconds to several minutes, and it is exacerbated by deep breathing. The joints are not inflamed and there is no swelling of the joints.
Hypersensitive xiphoid syndrome
Hypersensitive xiphoid syndrome is uncommon in children. It can be diagnosed easily by digital pressure on the xiphoid reproducing the pain.
Sickle cell disease
Sickle cell crisis can produce chest wall bone pain. In addition, chest pain in children and adolescents with sickle cell disease can be of cardiac and pulmonary origin.
OTHER CAUSES OF CHEST PAIN
Asthma:-
Wiens et al described findings of reversible airways disease in 72.7% of children who had been referred to a cardiology out-patients’ clinic with no prior history of asthma or congenital heart disease. The mean age of children who underwent the treadmill test was 12.4 years old. Inhaled salbutamol resulted in a subjective improvement in chest pain in 97% and an objective improvement in pulmonary function tests in 70%. Reactive airways disease should be considered in patients with chest pain, particularly if there is a histor y of asthma, eczema, shortness of breath with exercise, exercise-associated chest pain, exertional cough, wheezing or a family history of atopy.
Infection:-
A number of infective processes can be associated with chest pain. Lower respiratory infections of all types can produce chest pain. Herpes zoster can produce chest pain frequently before the appearance of the typical vesicopustular rash.
Pericarditis:-
Classically, pericarditis is associated with chest pain, whether due to an infectious etiology or a non- infectious inflammatory cause. In general, the pain associated with pericarditis is described as fairly sudden in onset, located over the anterior chest wall and more severe than other forms of chest pain. It is frequently pleuritic in nature, being sharp and exacerbated with deep breathing. The pain may decrease in intensity when the patient sits up and leans forward and may radiate, especially to one or both trapezius ridges. Pericarditis is associated with typical electrocardiographic findings of generalized ST segment elevation.
Gastrointestinal:-
Gastro-oesophageal reflux disease (GORD) and oesophagitis can and frequently do cause chest pain. Additional gastrointestinal (GI) symptoms (e.g. reflux, heartburn) at the time of clinical presentation can greatly aid and are quite specific in the diagnosis of GORD as the etiology of the chest pain. In an adult study by Mousavi et al, GORD was found in 44.8% of patients presenting with non-ECG showing ST segment elevation in chest leads V2- V6 characteristic of acute pericarditis.
Cardiac Chest pain.
Berezin et al, investigating idiopathic chest pain in 8 children, described a GI cause in 78%. Oesophageal endoscopy and manometr y may detect abnormalities in children with chest pain, even without other GI symptoms. This was demonstrated in a study of 83 children with chest pain who underwent these procedures. A total of 57% had
normal oesophageal histology and normal motility. Among the others, 18% had oesophagitis on histology but normal motility, 15.6% had normal histology but gut dysmotility and 9.6% had both oesophagitis and dysmotility. It is likely that if GI causes of chest pain were sought more vigorously, this diagnosis would be made more frequently.
Pneumothorax:-
Among patients with chest pain, pneumothorax is uncommon; however, a pneumothorax is very frequently associated with chest pain, and the abrupt onset of severe chest pain with or without dyspnoea should alert the clinician to this differential, especially as the clinical signs of a small pneumothorax can be difficult to appreciate.
Pulmonary embolism:-
The most frequent discharge diagnosis in patients who initially presented with a clinically suspected (and subsequently out-ruled) pulmonary embolus is non-clues to the initial symptoms of a pulmonary embolus By the time of presentation to hospital, it can frequently be difficult to separate clinically pulmonary embolus from lower respiratory tract infection; however, careful history may give the specific chest pain being dyspnoea and/or pleuritic chest pain.
In a retrospective study by Bernstein et al over a 15- year period, the incidence of pulmonary embolism in adolescents was reported as 78 per 100,000 hospitalized adolescents. Females presented with twice the frequency of males. Common complaints were chest pain, dyspnoea, cough and haemoptysis. Major risk factors were oral contraceptive use and elective abortion in 75% of female patients and trauma
in 67% of male patients. In children, the presence of a central venous catheter is the most frequent underlying risk factor. Pulmonary angiography is still the gold standard in diagnosing pulmonary embolism with anti coagulation the mainstay of therapy.
CARDIAC CAUSES OF CHEST PAIN
Cardiac conditions are a rare but potentially serious cause of chest pain in children. Cardiac disease is more likely if chest pain occurs during exertion and is recurrent. Most conditions will be associated with an abnormal cardiac examination or co-existing symptoms. In patients with known heart disease, chest pain may indicate progression of the underlying condition.
• Severe left ventricular outflow tract obstruction caused by aortic stenosis (subvalvar, valvar or supravalvar), obstructive cardiomyopathy or coarctation of the aorta.
•Aortic root dissection associated with Marfan syndrome, Turner syndrome, Ehlers-Danlos syndrome, chronic systemic hypertension, homocysteinuria, rare familial aortopathies or cystic medial necrosis.
• Pericarditis and myocarditis, in which chest pain typically occurs with concomitant pericarditis.
• Coronary artery abnormalities, including congenital disorders or acquired conditions (e.g., coronary aneurysm or stenosis following Kawasaki disease; coronary stenosis after coronary re-implantation following arterial switch operation). Anomalous origin of the left coronary artery from the main pulmonary artery (ALCAPA) usually presents in infancy but can become symptomatic later in childhood.
• Ruptured sinus of valsalva aneurysm, a rare condition caused by congenital absence of media in the aortic wall behind the sinus of valsalva. The aneurysm typically ruptures into the right ventricle or right atrium, leading to intra-cardiac shunting and myocardial ischemia.
• Tachyarrhythmia’s (e.g. supraventricular tachycardia with or without underlying Wolff-Parkinson-White syndrome, ventricular tachycardia).
• Coronary thrombosis and acute myocardial infarct can children with isolated MVP for one month to eight years (mean 2.7 years). Chest pain developed in 12 children. Ohara et al studied the incidence of symptoms in 108 children with MVP. Chest pain was
the most common symptom, occurring in 11 children (10.2%). The chest pain was non-exertional, located in the left chest and intermittent. More recently, Van der Ham et al describes a cohort of 45 children with Exposure to vasoconstrictive agents, such as cocaine, can cause chest pain that is likely ischemic in origin. Hollander et al described a prospective cohort of 246 adult patients (median age 33 years) echocardiographically-proven mitral valve prolapse. There was no statistical difference in incidence among the sexes. The most commonly reported symptoms were shortness of breath and fatigue and not chest pain. Most of the children were asymptomatic.
TOXIC EXPOSURE:-:-
A total of 5.7% had suffered myocardial infarcts. Chest pain began a median of 60 minutes after cocaine use and persisted for a median of 120 minutes. Chest pain was most frequently described as substernal (71.3%) and pressure-like (46.7%) who had chest pain following cocaine use occur in premature arteriosclerosis, embolus or hypercoagulable state.
MITRAL VALVE PROLAPSE:-
paradoxical
The evaluation of chest pain requires a thorough history and careful physical examination.The details of the history should be obtained, paying specific attention to the onset, frequency, and precipitating and relieving factors, as well as the characteristic duration and location of the chest pain. Associated features that would heighten suspicion for a Whether mitral valve prolapse (MVP) is associated with chest pain is controversial. Greenwood et al studied true cardiac etiology would be exercise intolerance, palpitations or shortness of breath with activity, presyncope or syncope, or a family history of congenital heart disease or sudden cardiac death. In addition, it may be helpful to know whether other family members have chest pain, such as a parent or grandparent who experiences angina. This information might heighten the concerns of chest pain in the child.
A complete cardiovascular, respirator y and abdominal examination should be per formed. The physical examination of the patient presenting with chest pain should initially focus on the vital signs. After documenting a stable regular heart rate and rhythm, respirations and blood pressure, a thorough physical examination should focus on finding non- cardiac causes. The initial evaluation should include inspecting for trauma and bruises or abrasions on the chest wall. Palpation should focus on bony abnormalities and localized chest swellings and on the site of the pain indicated by the patient. There should be an attempt to reproduce the pain by palpation of the location indicated by the patient. Reproducible pain, particularly at the costochondral junction or over a rib, points to costochondritis as the etiology of the pain. A cardiac cause of chest pain may be suggested by auscultation of abnormal heart sounds or a cardiac murmur or abnormal pulse or blood pressure. Signs of left ventricular outflow obstruction include a systolic ejection murmur at the right upper sternal border and occasionally along the left sternal border. Coarctation of the aorta is associated with elevated blood pressure in the arms and a lower blood pressure in the legs. If the co- arctation is long standing (present for more than five to seven years), collateral vessels may form that connect the upper and lower portions of the aorta; these vessels create a continuous murmur over the lateral aspect of the ribs.
In patients with pericarditis, pain increases when manual pressure is applied to the sternal region. The pain typically improves with sitting up and leaning forward. Signs of pericarditis depend upon the size of the pericardial ef fusion. Patients with a small ef fusion typically have an audible pericardial friction rub, caused by rubbing together of the inflamed parietal and visceral pericardial surfaces. The rub is often continuous in systole and diastole. It is easier to hear with the diaphragm of the stethoscope when the patient is sitting and leaning forward. A rub will not be heard if the effusion is large because the two pericardial surfaces of the pericardium are not in contact with each other. A large ef fusion may result in cardiac tamponade, manifested by a narrow pulse pressure, elevated pulsus paradoxus (>10mmHg), elevated jugular venous pressure, distant heart sounds, hepatomegaly, ascites, and peripheral edema.
Signs of MVP are a constant, mid-systolic apical click and, occasionally, an apical systolic murmur of mitral regurgitation. Both auscultator y findings are more prominent when the patient is in the standing rather than supine position.
In most cases, the aetiology of the pain will be apparent after the history and physical examination.
DIAGNOSTIC TESTS
Most patients with chest pain have a normal physical examination or findings consistent with a musculo- skeletal aetiology. Further investigations are not needed in those cases.
Diagnostic studies may help establish a diagnosis in patients with abnormal physical findings or with associated symptoms that suggest organic disease. Although cardiac causes of chest pain are uncommon in children, patients with dyspnoea, palpitations, anginal pain and pain with exertion that cannot be attributed to respiratory disease or syncope should be referred to a pediatric cardiologist for further evaluation.
• A chest x-ray may show cardiomegaly, pulmonary vasculature, infective infiltrates, hyperinflation and pneumothoraces.
• An electrocardiogram can aid in the diagnosis of arrhythmias, left ventricular outflow tract obstruction, pericarditis, ALCAPA, pulmonary hypertension and pulmonary embolus. If an arrhythmia is intermittent, a 24-hour Holter monitor or King of Hearts event recorder may be needed.
• In diagnoses of suspected cardiac etiology, an echocardiogram can confirm cardiac structure, pericardial ef fusions and tamponade, cardiac function, anomalous coronar y anatomy, sinus of valsalva aneurismal rupture and aortic root pathology.
• GI evaluation in children with chest pain should be performed under the remit of a pediatric gastroenterologist. Investigation of the upper GI tract may reveal histological oesophagitis or gut dysmotility.
• Other tests should be based upon associated signs and symptoms and clinical suspicion. Further evaluation may include pulmonary function testing, a ventilation-per fusion scan, cardiac catheterization, exercise stress testing, a full blood count, serum reactive markers, appropriate cultures and toxicology screening.
OUTCOME OF CHILDREN WITH CHEST PAIN
Two studies of the outcome of chest pain in children have been reported. Selbst et al reported on the outcome of an initial 407 children with chest pain seen Thirty- four per cent of the original diagnoses were altered, usually in favor of a non-organic etiology. A new organic aetiology was uncovered in only 12 of 149 in the accident and emergency department. cases, with only one having a heart abnormality (MVP). Chest pain resolved in 57% of those followed. Driscoll et al had a similar rate of resolution of chest pain in his cohort of 43 patients, with 60% pain-free four to eight weeks later on telephone follow-up. Of note, in the group of Driscoll’s patients with a diagnosis of idiopathic chest pain, only 30% of them had resolution of chest pain follow-up.
IN SUMMARY
The primary role of the evaluating cardiologist is to rule out the unlikely prospect of serious cardiac pathology. An equally important role is to provide reassurance and support to the patient and family. Most patients will not have a serious underlying medical problem. A thorough and thoughtful history and physical examination help allay fears and are important in reassuring the patient
—
Recommend PreMedication for Contrast Media

LIVER FUNCTION TEST Interpretation

If AST > ALT —> wilson’s disease, fatty liver, Ch Hepatitis
Only AST >> ——> Hemolysis , Rhabdomyosin , myopathes,myocardial disease, recent rigours , Physical activityLiver Injury :- >AST, > ALT
Impaired Bileflow and Cholestasis
>ALP, Gamma Glutamyl Transpeptidase, GGTImpaired Liver Synthetic Function:- Serum Albumin, PT , PTT , INR , Factor 5 ,7
Hepatic Excretory Function :- bilirubin and bike acids
Hepatic Metabolic Function:- ammonia
Hepatic Cause :- a) Hepatocellar Injury ->
Disproportionate elevation of AST,ALT
compared to ALP
b) Biliary disease—>
Opp of above
Oral paediatrics dosage


zinc treatment for diarrhoea
upto 6 month 10mg/day for 14 days
more the 6 month 20mg/day for 14 days
Observe closely for sign of bowel obstruction and abnormalities in genitourinary tract
GI anomalities Gastroschisis,Duodenal atresia Oesophageal Atersia or TEF,Diaphragmatic Hernia,CNS anomalies with impaired swallowing Anenencephaly SMA,Chromosomal trisomies
Coughing or choking with feeds or excessive drooling
OLIGOHYROMINIOS
Renal and Urological anomalies Potter syn
Lung hypoplasia Limb deformities PROM Placental insufficiency
Hypertension
IUGR Intrauterine fetal demise
Preeclampsia, Eclampsia
IUGR, thrombocytopenia,neutropenia,fetal demise
Resus or other blood incompatible
Fetal anemia , hypo albuminia Hydrops jaundice
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