Long cases for for final MBBS in paediatrics
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Long cases for for final MBBS in paediatrics

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Long cases for for final MBBS in paediatrics

Long cases for for final MBBS in paediatrics

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Long cases for for final MBBS in paediatrics Presentation Transcript

  • 1. Long Cases for Final Years Paediatrics Dr Rasnayaka M Mudiyanse MBBS.DCH.MD.MRCP Consultant pediatrician Teaching Hospital Peradeniya
  • 2. Possible Long Cases • Short duration fever – Respiratory tract infections – GIT infections ( diarrhoea) – UTI – Hepatitis – IMN – Typhus • Long duration fever
  • 3. Possible cases • Arthritis – Acute – Chronic • FTT • Syndrome child /Birth defect • Jaundiced baby
  • 4. Possible cases • • • • • Cerebral palsy Developmental delay Febrile fits Epilepsy Guillain-Barre syndrome
  • 5. Possible cases • • • • • • • • Bronchial asthma Bronchiolitis Pneumonia Nephrotic syndrome AGN UTI Thalassaemia ITP
  • 6. General Advice • Completeness – History – Examination • Accuracy • Plan your discussion – What is the diagnosis/DD – What are the problems – How are you going to investigate – What is your management
  • 7. History • Introduction – Name, age, sex ,address, informant, distance, locality • Presenting complaint /s and duration • History of presenting complaint – Onset ( gives an idea about the aetiology) – Progress ( helps in diagnosis and management) – Final stage ( helps in acute management)
  • 8. History Ct. • System analysis (exclude , search for cause and complications) • PMH – look for other problems (may help in diagnosis) • Treatment History • ANH/BH/Neonatal period • Growth and development • Immunization
  • 9. History Ct. • Dietary History • Bowel Habits and Micturition • Social history – Education – Play activities – Family members • Mother • Father • Siblings
  • 10. Examination • General comment ( tem chart, mother, spacer device, drips) • Growth – Weight, Height and OFC • General examination • RS - ( RR, recessions) • CVS – (HR,BP and position of apex ) • Abdomen (perineum, upper border of liver) • CNS ( development) • Locomotor and skin
  • 11. What is your diagnosis?
  • 12. What is your diagnosis Try to give complete diagnosis Incomplete diagnosis Complete diagnosis Asthma Acute Severe exacerbation moderate persistent asthma with chr eczema and rhinitis Cerebral palsy Respiratory tract infection Bed ridden Quadriplegic cerebral palsy with severe contractures , FTT and constipation Diarrhea Acute viral gastroenteritis Sever dehydration ( now corrected) and malnutrition PCM grade 2 VSD Large VSD PHT, cardiomegaly FTT and recurrent chest infections
  • 13. What is your diagnosis Try to give complete diagnosis Incomplete diagnosis Complete diagnosis Thalassaemia Beta thalasaemia major Inadequately transfused and complicated by iron over load with HF, pubertal delay and diabetes Nephrotic syndrome 10th relapse of nephrotic syndrome Steroid resistant neprhotic with steroid side effects, UTI and short stature AGN AGN (probably post streptococcal ) Complicated by LVF and sever hypertension Haemophilia Severe hemophilia with acute bleed in to the L knee Early deformities in left leg and target joint
  • 14. What is your diagnosis Try to give complete diagnosis Incomplete diagnosis Complete diagnosis Down’s syndrome Down’s syndrome with large VSD and behavioral problems and social problems Febrile fits Simple febrile fits Viral gastroenteritis with mild dehydration Bronchiolitis Severe bronchiolitis Premature delivered baby who had been ventilated for 3 days and severe Failure to thrive UTI Culture positive recurrent febrile UTI Grade 3 VU reflux with scaring
  • 15. What is your diagnosis Try to give complete diagnosis Incomplete diagnosis Complete diagnosis Dengue DHF grade 3 now recovered Required ICU care Epilepsy Poorly controlled epilepsy on 3 AED Mental retardation and poor compliance Arthritis JCA ( ICA) Pause articular Chronic
  • 16. What are the problems ?
  • 17. What are the problems Try to give a complete list of problems Acute problem Long standing Medical problem Complications Associated /other diagnoses Routine care
  • 18. What are the problems Try to give a complete list of problems Acute problem Therapy Mother/care giver problems Economic problems Siblings
  • 19. What are the problems - Cerebral Palsy Acute problem Long standing Medical problem Complications Associated /other diagnoses Routine care Severe Bronchopneumonia (due to aspiration) Quadriplegic cerebral palsy Multiple contractures, sever FTT, constipation, recurrent RTI VSD and uncontrolled seizure disorder 1. 2. 3. 4. 5. Difficulties in feeding Bowel habits Micturition Oral hygiene Immunization
  • 20. What are the problems- Cerebral Palsy Therapy 1. 2. 3. 4. 5. 6. Mother/care 1. giver problems 2. 3. 4. 5. Economic problems Siblings Mobility ( GM, physio, wheel chair, toilets, steps) Activities ( Fine motor occupational therapy) Hearing and speech ( ENT, hearing aids Vision Educational Nutrition Knowledge, attitudes, skills and expectations Lack of respite and social life Depression and anxiety Relationships Family planning 1. Cost of care and lack of income 1. Negligence
  • 21. What are the problems – Br Asthma Acute problem Long standing Medical problem Complications Associated /other diagnoses Routine Care Severe exacerbation of asthma secondary lower respiratory tract infection Moderate persistent asthma Eczema 1.Immunization 2.Dental care
  • 22. What are the problems- Br Asthma Therapy 1.Inhaler technique 2.Knowledge about acute relief medication 3.Precipitating factors Mother/care 1.Anxiety giver problems 2.Over protection of the child Economic 1. Financial difficulties ( money problems to buy inhalers) Siblings 1. Attention
  • 23. What are the problems – Nephrotic syndrome Acute problem Bronchopneumonia and 12th relapse of NS Long standing Medical problem Complications Steroid resistant NS managed with cyclophosphamide Hypertension Associated /other diagnoses Routine care 1. Immunization 2. Nutrition and Diet 3. Schooling and education
  • 24. What are the problems- NS Therapy 1.Compliance to drugs 2.Long distance to travel Mother/care 1.Knowledge, attitudes and giver problems expectations Economic 1. Expenses for travelling problems Siblings 1.Negligence 2.Immunization
  • 25. What are the problems – Haemophilia Acute problem Acute sever bleed in to R knee joint Long standing Medical problem Complications Severe haemophilia with target joint Associated /other diagnoses Eczema Routine care 1. Schooling and education 2. Oral hygiene 3. Immunization Multiple contractures, severe FTT,
  • 26. What are the problems- Haemophilia Therapy 1. Mobility ( physio, wheel chair, toilets, steps) 2. Activities ( occupational therapy) 3. Educational 4. Non availability of drugs Mother/care 1. Knowledge, attitudes, and expectations giver 2. Social life problems 3. Depression and anxiety 4. Family planning Economic 1. Cost of care and lack of income problems Siblings 1. Neglect
  • 27. What are the problems – Thalassaemia Acute problem - Long standing Medical problem Complications Beta thalassaemia major Inadequate transfusion and chelation 1. Massive Splenomegaly 2. Diabetes mellitus 3. Cardiac involvement - Associated /other diagnoses Routine care 1. 2. 3. 4. Schooling and education Oral hygiene Immunization Diet
  • 28. What are the problems- Thalassaemia Therapy 1. Drug compliance 2. Non availability of drugs 3. Delay in routine investigations ( Ferritin level , Echo, PPBS) Mother/care 1. Knowledge, attitudes, and expectations giver 2. Social life problems 3. Depression and anxiety 4. Family planning 5. Screening siblings Economic 1. Cost of care and lack of income problems Siblings 1. Negligence and not been screened
  • 29. Teachers question/reaction • • • • • • • So ? Ok? Go ahead. What next How are you going to manage? What is your plan of management? What are you going to do?
  • 30. Students response Depending on the case • • • • • • Immediate action is to … I will start …………..Take blood samples I will investigate I will evaluate available investigations I will talk to mother I will refer /discuss with
  • 31. Students response Depending on the case Be practical and realistic Immediate action is to … I will start ………….. Take blood samples / pulse oxymeter I will investigate ABC care / control fever /give oxygen Bronchial asthma Long duration fever , arthritis, FTT I will evaluate available investigations Thalassaemia, FTT, CP, I will talk to mother Maternal anxiety lack of knowledge Needs multidisciplinary approach I will refer /discuss with
  • 32. If you were the HO on admission of this patient ? On admission of this patient, you were the H/O Describe how to manage………..
  • 33. Febrile fits • ABC • Reassure mother • Control temperature – Physical methods ( taped rub) – Paracetamol if rectal available • Give rectal diazepam ( 0.5 mg/kg) • Observe for ten minute
  • 34. Acute severe asthma • ABC - Oxygen connect to a pulse oximeter • Nebulize with salbutamol – ( 2.5 or 5 mg 0.5 ml or 1 ml + 2 cc saline) • Rpt x 2 • Neb with IBM • IV line – Aminophylline, Hydrocortisone Antibiotics • ICU care
  • 35. Diarrhea Dehydration • ABC care • Evaluate & Treat shock with 20 ml/kg Hartmann • Correct dehydration – 30 ml/kg over 30 minutes ( slower in infants and FTT) – 70 ml/kg over 3.5 hrs • Electrolytes
  • 36. Dengue with circulatory failure • ABC – detect circulatory failure • Fluid bolus – 10 ml/kg Crystalloid X 3; Colloids x2 • Oxygen • Monitor • FBC
  • 37. Bronchiolitis • ABC – neck position, oxygen • Evaluate severity – Severity– Tachypnea, grunting, head nodding, feeding affected, apnoea, exhausted, pulse oxymeter in air < 90% , CHD, Ventilated Prem babies • • • • • IV fluid + oxygen IV antibiotics CXR – when the child is fit to go for it or in ward Explain to mother ICU care
  • 38. Acute bleeding in a hemophiliac • Patient had been in severe pain – PCM or Morphine – Resting • Factor 8
  • 39. How are you going to manage Go through the problem list • Out of many problems ………………..needs immediate attention
  • 40. What investigations
  • 41. Fever short duration or long duration • First line – – – – – – – – – FBC UFR and U culture Blood culture Blood picture LP ? CRP CXR ECG SAT, ASOT, Dengue serology, IMN
  • 42. Fever short duration or long duration • Second line – Bone marrow – Echo – US abdomen – CT – LP – ANF/DDNA
  • 43. Rickets • • • • • • • X-ray Alk posphatase Ca PO4 Response to treatment Blood gases+ serum electrolyte (Cl-) + urine Ph Urine – Sugar + Amino acids
  • 44. How are you going to evaluate this problem
  • 45. FTT
  • 46. Short stature
  • 47. Anaemia
  • 48. Jaundice
  • 49. Petechial Haemorrhages
  • 50. Bronchial Asthma
  • 51. Nephrotic Syndrome
  • 52. AGN
  • 53. Now patient is ready to go home. On discharge what are you going do
  • 54. Br Asthma • • • • • Main problem is ………………. I will talk to mother + father together I will talk to the child Check inhaler technique once again Advice of precipitating factors
  • 55. Diarrhoea on discharge • Explain to mother and child • This child is already below the 3rd centile… – Need for nutritional rehabilitation
  • 56. Thank You! Best of Luck!