Short cases for final year MBBS Medical Student in Sri Lanka

1
Short cases for Final MBBS
All Rights Reserved From Dr R.M
Mudiyanse
Dr Rasnayaka M Mudiyanse
Department of Paediatrics,
Faculty of Medicine,
University of Peradeniya
Possible short cases
• Examine a system
– CVS
– RS
– Abdomen
• Examine CNS
– Lower limbs
– Cranial nerves
• Examine a child
Mudiyanse
• Development assessment
• Evaluate growth
• Examine
– Face
– Leg
– Limbs
• Observe walking
Mudiyanse
CVS
Mudiyanse

2
Examine CVS
Common cases
• VSD
• Fallots tetrology
• PDA
• Complex heart diseases
• PS
• AS
Mudiyanse
Objectives of Examining CVS
1. Recognize the anomaly ( structural or functional)
2. Size/extent of the structural anomaly
3. Complications
1. Evidence of pulmonary hypertension
2. Cardiomegaly
3. Evidence of heart failure
4. Effecton growth and development
4. Associations
5. Cause of the CHD (etiology)
6. Evidence of interventions
Mudiyanse
Recognize the anomaly ( structural or
functional)
• Cyanotic heart disease
– T
– T
– T
– T
– T
– Critical pulmonary
stenosis
– Complex heart disease
– Shunt reversal
• Acyanotic Heart disease
– ASD
– VSD
– PDA
– PS
– AS
– Coarctation
– Peripheral pulmonary
artery stenosis
Mudiyanse
How to recognize the structural
anomaly
• VSD
– PSM +/- palpable thrill at lower left sternal edge
• Fallot’s tetralogy
– Cyanotic heart disease
– Ht Murmur over the pulmonary area
– No cardiomegaly
– P2 not loud
– Oligaemic lung field
• PS
– ESM murmur over the pulmonary area
– Soft P2
Mudiyanse

3
How to recognize the structural
anomaly
• ASD
– Split second sound ( fixed)
– SM over the PA
• PDA
– Machinery M or a long SM slightly lateral to PA
– Radiate to back
– Bounding pulse
Mudiyanse
Complications
• Pulmonary hypertension
• Cardiomegaly
• Ventricular hypertrophy (R & L)
• Heart failure
• Failure to Thrive
• Growth failure
• Shunt reversal
• Bacterial endocarditis
• Embolic phenomena
Mudiyanse
Evidence of Pulmonary Hypertension
• Loud P2
• Palpable P2
• Evidence of RVH
– Para sternal heave ( RVH)
– ECG
• Prominent R in R chest leads
• Deep S in L chest leads
• RAD
• Peaked P waves ( R Atrial hypertrophy)
• CXR – Peripherals pruning
Mudiyanse
Evidence of Heart Failure
• Tachycardia
• Gallop rhythm
• Tachypnea
• Cradiomegaly
• Hepatomegaly
• Rapid weight gain
• Lung crepitations
• FTT
• Edema
• Sweating while
feeding
• SOB on feeding
Mudiyanse

4
Effect on Growth
• FTT
– Current weight centile
– Growth pattern
• Flattening
• Crossing centile
• Growth failure – short stature - Chronic disease
• Why do they get FTT
– Increased BMR due to sympatheticover activity
– Difficulties in feeding and frequent vomiting
– Recurrent chest infections
– Associatedconditions
Mudiyanse
Cause of the CHD
• Syndrome
– Downs
– Turners/Noonas
– Digeorge syndrome/ Velocardio facial syndrome
– Others
• Associations
– VACTARAL
– CATCH
– ..
• Congenital infections
– Rubella
– Toxoplasma
Mudiyanse
Reason for Tachypnea
? HF or RTI
• HF
– Rapid shallow breathing
– Not much effort of breathing
– Fine crepitation ( not course)
– Other evidence of HF
• RTI
– Effort of breathing – recessions and noises
– Fever
– Corse creps
Mudiyanse
Reason for FTT
• Feeding
• Recurrent RTI
• HF ( sympathetic over activity  Increased BMR)
• Other
Mudiyanse

5
Size and extend of the lesion
• Any complications suggest large lesion
• Apical mid diastolic murmur in VSD or ASD
Intensity of the Heart murmur does not correlate
with size of the lesion. Loud murmur does not
mean that the lesion is small or large
Mudiyanse
Try to give a comprehensive diagnosis
• Large VSD or AV canal defect with pulmonary
hypertension and failure to thrive in a child
with trisomy 21, probably he has LRTI also.
• Complex cyanotic heart disease with growth
failure probably has had an embolism in the
brain.
• This syndromic child has tetrolgy of fallout
seems to be uncomplicated. Growth and
development seem satisfactory.
Mudiyanse
Mudiyanse
Mudiyanse

6
Mudiyanse
Mudiyanse
What investigations
• ECG
– Axis
– Ventricular hypertrophy
• CXR
• Echo
• Catheterization
• Angiography
Mudiyanse
How do you manage
• Treat the acute problem
• Plan for surgery
• Attend to nutrition
• Provide routine care
• Follow up and monitoring
• Social, economical and psychological support
• Attend to dental caries
Mudiyanse

7
Presentation of the case
1. This 3 year old boy with trisomy 21 has a large
VSD complicated by pulmonary hypertension
and heat failure. His growth seem inadequate
and currently he has a chest infection.
2. This 8 year old girl has a cyanotic heart disease
with evidence of cardiomegaly.Her P2 is loud,
growth is inadequate.She has some dimorphic
feature that does not fit in to a diagnosis.
Mudiyanse
RS
Mudiyanse
Examine the Respiratory System
Common cases
• Bronchial asthma
• LRTI
• Bronchiolitis
• Pneumonia
• Pleural effusion
• Upper airway obstructions ( Croup, Congenital
laryngomalacia)
Mudiyanse
Objectives
• What is the pathology/diagnosis
• What is the severity
• Acute or chronic
• Associated problems
– FTT
– CHD
– Other
Mudiyanse

8
What is the Pathology
• Upper air way – Stridor
• Lower airway – inspection, palpation, percussion, auscultation
– Diffuse – Bilateral signs
– Localized – Lobar pneumonia
• Pleural effusions
• Pus or other effusions
• Systemic pathology
Mudiyanse
What is the diagnosis
• Bronchiolitis
– Infantor young child
– Bilateral diffuse crepes +/- rhonchi
– Hyperinflation
– Look for associatedCHD,FTT
• LRTI
• Bronchial Asthma
• Pneumonia
• Pleural effusions
Mudiyanse
Lobar Pneumonia or Pleural effusion
• Pleural effusion
– Stony dull on percussion
– Reduced breath sounds
– Tracheal deviation to opposite side
– Evidence of aspirations
• Lobar pneumonia
– Dull on percussion
– BB
– No tracheal deviations
Mudiyanse
What is the severity
• Effort
– RR
– Recessions
– Accessorymuscles
– Noises – grunting, rhonchi, creps and striodr
• Efficacy
– Chest expansion
– Saturation
• Effects
– CNS – drowsiness
– CVS – Cyanosis/pallor
Mudiyanse

9
How to recognize sever asthma
Mudiyanse
How to recognize
life threatening asthma
Mudiyanse
Try to give a comprehensive diagnosis
• Moderately severe bronchiolitis in a child with
failure to thrive.
• Bronchial asthma – with mild distress in a
child with persistent asthma who has an
eczema as well
• Pleural effusion with some respiratory distress
probably a child recovering from DHF
Mudiyanse
Mudiyanse

10
Mudiyanse
Investigations
• CXR – only when indicated
• US scan – For effusions
• FBC
• CRP
• Sputum
Mudiyanse
How do you manage?
• Acute problem
– Depends on severity
• Long term care
Mudiyanse
Abdomen
Mudiyanse

11
Examine the abdomen
possible cases
• Massive hepatospleenomegaly ( ? Thal)
• Small hepatospleenomegaly
• Only liver or spleen
• Ascites
• Renal lumps
• Pelvic lumps
Mudiyanse
Massive hepato-spleenomegaly
• Transfusion dependent anemia
– Thalassemia – beta or E beta
– Aplastic anemia
– Heraditory spherocytosis
– Dyserythropoitic anemia
• Gouaches disease
• Osteopetrosis
• .
• .
Mudiyanse
Massive hepato-spleenomegaly
? Transfusion dependent anemia
• Objectives to achieve are to assess
– Adequacy of blood transfusions
– Type of chelation – Injection marks
– Adequacy of chelation
– ? Spleenectomy
– Complications
• Cardiac
• Endocrine
• Hepatic
• Other
Mudiyanse
Adequacy of Blood Transfusion
• Inadequate blood transfusion result in
– Growth failure
– Bony deformities
– Spleenomegaly or early spleenectomy
• Transfusion records will confirm it
– Pre transfusion will be below Hb 9-10 gr/dl
frequently
Mudiyanse

12
Chelation – Adequacy
• Inadequate chelation is suggested by
– Pigmentations
– Complications
• Cardiac
• Growth
• Pubertal delay
• Diabetes Mellitus
• Hypocalcaemia
• Hypothyroidism
• Treatmenthistory – dose and frequency and duration
of infusion
• Serum ferritin level
Mudiyanse
Complications of transfusion
dependent anemia
• HF
– Early heat failure may be asymptomatic
– MRI t2*/Muga scan
• Short stature
• FTT
• Sexual maturity - Tanner stage
• Diabetes mellitus
• Phypoparathyroidism
Mudiyanse
Reasons for Short Stature
• Chronic anaemia
• Nutritional
• Poor socioeconomic conditions
• Endocrine – Growth, thyroid, adrenal, gonadal
hormone function
• Recurrent infections
• Chelaters
• Zinc deficiency
Mudiyanse
Reasons for jaundice in thalassemia
patients
• Hemolysis
• Liver involvement – iron toxicity or infections
• Gallstones
• Coinheritance of Gilberts
Mudiyanse

13
What investigations
Mudiyanse
How are going to manage
• Evaluate the current management
• Find out the problems
– Blood transfusion
– Chelation
– Psychosocial problems
– Complications
Mudiyanse
Small liver +/- spleen
Be able to demonstrate
• DD
– Viral fever/IMN – Fever, skin rashes, palatal
hemorrhages
– Hepatitis
– Early hemolytic anaemia – Pallor, jaundice
– Typhoid
– Leukemia – pallor, pateche, LN, bone tenderness
Mudiyanse
Spleen or Kidney
• Spleen
– Has its shape and notch
– Can not feel the upper border
– Direction of enlargement is towrads RIF
– No band of resonance over the lump
– Lump is not balatoble
Mudiyanse

14
Mudiyanse
Ascites
• What clinical features
– Flank dullness
– Shifting dullness – be able to demonstrate
• Causes
– Nephrotic syndrome
– CRF
– Liver failure
– Malnutrition
Mudiyanse
Ascites – how to investigate
Mudiyanse
Examine Lower Limb
Mudiyanse

15
Examine lower limb
Possible short cases
• Duchene muscular dystrophy
• CP – Diplegia, hemiplegia, quadriplegia
• Gullian barre
• Rickets
• Other deformities
Adequate exposure and get the child to walk
Mudiyanse
Approach to
‘examination of lower limb’
• Functional of structural – inspection while
walking
• If functional
– UMN – hypertonia, clonus, hyper reflexia, up
going plantor
– LMN- hypotonia, hypo-reflexia, fasciculation
– Due to structural
• If structural – Bone, muscle or skin
Mudiyanse
Mudiyanse
Mudiyanse

16
Mudiyanse
DMD
• Calf muscle hyper trophy
• Demonstrate the weakness
• Look for cardiac involvement
Mudiyanse
Guillain-Barre
• Grade muscle power
• Hypotonic
• Areflaxia
• No sensory level
• Bladder not involved
• Check upper limb
• Check cranial nerves
Mudiyanse
CP
• Grade the severity
• Anatomical diagnosis
– Quadriplegic
– Hemiplegic
– Monoplagic
– Ataxic
– Chorio athetoid
• Complications
• Associated problems
• Cause
Mudiyanse

17
Development delay
• Describe the best ability and least disability
• Global or specific delay
• The cause
– CNS
– Peripheral nerves
– Muscles
– Other
• Complications – FTT, contractures, care …
Mudiyanse
Objectives
• What is the diagnosis/ likely diagnoses
• Impact on the child
• Complications
Mudiyanse
Examine a region
• Inspection
• Palpation
• Percussion
• Auscultation
• What is the
– anatomical diagnosis
– Pathological diagnosis
Mudiyanse
Child with Petechial Hemorrhages
• ITP
• Leukemia
• Aplastic anaemia
• Thrombocytopenia
– Dengue
Mudiyanse

18
Child with Echymosis
• Bleeding disorders
• ITP
• Leukemia
• Aplastic anaemia
• Thrombocytopenia
– Dengue
Mudiyanse
Could this be ALL
• Ill looking
• Bony tenderness
• Pallor
• Lymphadenopathy
• Splenomegaly
• FBC
– Abnormal cells
Mudiyanse
New Born Baby
• Good bed side manners
• Confirm normal – Wt, OFC, length
• Head to toe examination (total examination)
– Hips
– Spine
– Perineum
• Detect minor anomalies
Mudiyanse
Down syndrome
• Comment about mothers age
• Establish it is downs syndrome
• Assess
– Development & IQ (give a positive comment)
– Growth
– Cardiac involvement
– Hypothyroidism
– Evidence of gut surgery
Mudiyanse

19
Place for chromosomal analysis
• Non dysjunction
• Translocation
Mudiyanse
Examine the Face
• Facial palsy
• Cranial nerve palsy
• Dysmorphic features
– Downs syndrome
– Sturge weber
– Other syndrome
• Don’t miss obvious micro/macro-cephaly
Mudiyanse
Facial Palsy
• Observe all the clinical features
• Is it upper motor or lower motor
• Severity and complications
• What is the cause
Mudiyanse
Facial Palsy
• Observe all the clinical features
– Absent or asymatrical naso-labial folds
– Mouth Deviation
– Closing eyes
– Blowing the mouth
– Drooling saliva
– Bells sign
• Is it upper motor or lower motor
– Upper motor – only the lower half is affected
– Lower motor – both upper and lower half affected
Mudiyanse

20
Facial Palsy
• Severity and complications
– Exposurekeratitis
– Drooling of saliva
– Depression
– Bells palsy
– Ramsey-hunt – blisters in the external ear
– Brain stem tumors
• Cerebeller signs
• Other cranial nerves
• Long tract signs
Mudiyanse
Rickets
• Observe all the clinical features of rickets
– Head – fontal bossing, cross bun appearance
– Chest – rickety rosary, Harrison sulcus
– Limbs – widening of wrists and ankle, bowing
– General - hypotonia
• Anthropometric measurements
– Nutritional
– Renal
– Hypophospatemic
Mudiyanse
Comment about the X ray
• Widening
• Fraying
• Splaying
• Cupping
• Osteopenia
• Micro fractures
Mudiyanse
Investigations for rickets
• Alkaline phosphate – Increase in all forms of
rickets + some forms of metaphysial dysplasia)
• Serum calcium – low in hypocalceamic rickets (
but can be normal deu to PHT activity they will
have increased aa in urine)
• Serum phosphate – Low in hypophosphatemic
rickets ( increased 24 hr PO4 excretion)
• Renal functions – Renal rickets
• Urinary aa and sugar – Fanconi associated rickets
• Hypo K hyper Cl acidosis - RTA
Mudiyanse

Short cases for final year MBBS Medical Student in Sri Lanka

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Short cases for final year MBBS Medical Student in Sri Lanka

Similar to Short cases for final year MBBS Medical Student in Sri Lanka (20)

Recently uploaded

Recently uploaded (20)

Short cases for final year MBBS Medical Student in Sri Lanka