Long cases for final year MBBS medical student in Sri Lanka
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Transcript of Long cases for final year MBBS medical student in Sri Lanka
1
Long Cases for Final Years
Dr Rasnayaka M MudiyanseDepartment of Paediatrics,
Faculty of Medicine,University of Peradeniya
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Possible Long Cases
• Acute Problems
– Diagnosis– List of problems – Acute Management – Prevention
• Chronic Problems
– List of problems– Diagnosis– Long term care – Acute Management – Prevention
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Possible Long Cases
• Acute Problems– Fever– Diarrhea– RTI – Febrile fits– Meningitis– Arthritis – Nephritis– UTI– Gen Body swelling
• Chronic Problems – Chronic disability– Br Asthma– Nephrotic syndrome– Transfusion
dependent anemia– CRF– FTT– Syndromic child
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General Advice
• Think and Plan • Completeness and Accuracy is important • Plan your discussion
– What is the diagnosis/DD– What are the problems– What is your management ( investigations and
Management)
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History
• Introduction– Name, age, sex ,address, informant, distance,
locality
• Presenting complaint /s and duration• History of presenting complaint
– Onset ( gives an idea about the etiology) – Progress ( helps in diagnosis and management) – Final stage ( helps in acute management)
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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
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History Ct.
• Dietary History • Bowel Habits and Micturition• Social history
– Education, Play activities– Family members ( Mother, Father, Siblings)
• Knowledge, Attitudes and Expectations• Mother perspective of the disease
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Examination
• General comment ( tem chart, mother, spacer device, drips, mood )
• Growth – Weight, Height and OFC• General examination – Dismorphic features • RS - ( RR, recessions)• CVS – (HR,BP and position of apex )• Abdomen (perineum, upper border of liver)• CNS ( development)• Loco motor and skin
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Discussion
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Discussion – most important 10 minutes
• What is your diagnosis?• What are the problems?• How are you going to manage?• Describe emergency care• Describe long term care
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What is your diagnosis?
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What is your diagnosisTry 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 viralgastroenteritis
Sever dehydration ( now corrected) and malnutrition PCM grade 2
VSD Large VSD PHT, cardiomegaly FTT and recurrent chest infections
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What is your diagnosisTry 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 neprhoticwith steroid side effects, UTI and short stature
AGN AGN (probably post streptococcal )
Complicated by LVF and sever hypertension
Haemophilia Severe hemophiliawith acute bleed in to the L knee
Early deformities in left leg and target joint
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Complete Diagnosis 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
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Complete Diagnosis
Incomplete diagnosis Complete diagnosis
Dengue DHF grade 3 now recovered
Had fluid over load and required ICU care
Epilepsy Poorly controlledepilepsy on 3 AED
Mental retardation and poor compliance
Arthritis JCA ( ICA)Pause articularChronic
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What are the problems ?
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What are the problems?
Acute problem
Chronic problemComplicationsAssociated/other diagnoses
Growth and nutrition
Immunization
Therapy related All Rights Reserved From Dr R.M
Mudiyanse
What are the problems?
Knowledge Attitudes & expectations Social problems Economic problems Problems- mother & father
Problems - Siblings
Society /school
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List of Problems Cerebral Palsy List of Problems Cerebral Palsy Acute problem Severe Bronchopneumonia (due to
aspiration) Long standing Medical problem
Quadriplegic cerebral palsy
Complications Multiple contractures, sever FTT, constipation, recurrent RTI
Associated /other diagnoses
VSD and uncontrolled seizure disorder
Routine care 1. Difficulties in feeding2. Bowel habits3. Micturition4. Oral hygiene 5. Immunization
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List of Problems - Cerebral Palsy Ct Therapy 1. Mobility ( GM, physio, wheel chair, toilets, steps)
2. Activities ( Fine motor occupational therapy)3. Hearing and speech ( ENT, hearing aids4. Vision5. Educational6. Nutrition
Mother/caregiver problems
1. Knowledge, attitudes, skills and expectations2. Lack of respite and social life 3. Depression and anxiety4. Relationships5. Family planning
Economic problems
1. Cost of care and lack of income
Siblings 1. NegligenceAll Rights Reserved From Dr R.M Mudiyanse
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List of Problems - Br Asthma List of Problems - Br Asthma
Acute problem Severe exacerbation of asthma secondary lower respiratory tract infection
Long standing Medical problem
Moderate persistent asthma
ComplicationsAssociated /other diagnoses
Eczema
Routine Care 1. Immunization2.Dental careAll Rights Reserved From Dr R.M
Mudiyanse
What are the problems- Br Asthma
Therapy 1.Inhaler technique2.Knowledge about acute relief
medication3.Precipitating factors
Mother/caregiver problems
1.Anxiety2.Over protection of the child
Economic problems
1. Financial difficulties ( money to buy inhalers)
Siblings 1. Attention All Rights Reserved From Dr R.M
Mudiyanse
What are the problems – Nephroticsyndrome
Acute problem Bronchopneumonia and 12th relapse of NS
Long standing Medical problem
Steroid resistant NS managed with cyclophosphamide
Complications Hypertension
Associated /other diagnosesRoutine care 1. Immunization
2. Nutrition and Diet3. Schooling and education
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What are the problems- NS
Therapy 1.Compliance to drugs 2.Long distance to travel
Mother/caregiver problems
1.Knowledge, attitudes and expectations
Economic problems
1. Expenses for travelling
Siblings 1.Negligence2. Immunization
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What are the problems – Haemophilia Acute problem Acute sever bleed in to R knee joint
Long standing Medical problem
Severe haemophilia with target joint
Complications Multiple contractures, severe FTT,
Associated /other diagnoses
Eczema
Routine care 1. Schooling and education2. Oral hygiene 3. Immunization
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What are the problems- Haemophilia Therapy 1. Mobility ( physio, wheel chair, toilets, steps)
2. Activities ( occupational therapy)3. Educational4. Non availability of drugs
Mother/caregiver problems
1. Knowledge, attitudes, and expectations2. Social life 3. Depression and anxiety4. Family planning
Economic problems
1. Cost of care and lack of income
Siblings 1. NeglectAll Rights Reserved From Dr R.M
Mudiyanse
What are the problems –ThalassaemiaAcute problem -
Long standing Medical problem
Beta thalassaemia majorInadequate transfusion and chelation
Complications 1. Massive Splenomegaly2. Diabetes mellitus3. Cardiac involvement
Associated /other diagnoses
-
Routine care 1. Schooling and education2. Oral hygiene 3. Immunization 4. Diet
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What are the problems- Thalassaemia Therapy 1. Drug compliance
2. Non availability of drugs3. Delay in routine investigations ( Ferritin
level , Echo, PPBS) Mother/caregiver problems
1. Knowledge, attitudes, and expectations2. Social life 3. Depression and anxiety4. Family planning5. Screening siblings
Economic problems
1. Cost of care and lack of income
Siblings 1. Negligence and not been screenedAll Rights Reserved From Dr R.M Mudiyanse
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Try to understand problems
• Severity - impact on patient, family and society
• Cause of the problem• What has been done• Patients perspective
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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?
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Students response depending on the priorities fixed by the caseBe practical and realistic
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Students responseDepending 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
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Students response Depending on the priorities fixed by the case
Be practical and realistic Immediate action is to … ABC care / control fever /give
oxygen I will start …………..Take blood samples / pulse oxymeter
Bronchial asthma
I will investigate Long duration fever , arthritis, FTT
I will evaluate available investigations
Thalassaemia, FTT, CP,
I will talk to mother Maternal anxiety lack of knowledge
I will refer /discuss with Needs multidisciplinary approachAll Rights Reserved From Dr R.M
Mudiyanse
If you were the HO on admission of this patient ?
Describe how to manage………..
This patient is getting readmitted ….,
If this patient develop ……., what are you going to do?
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Febrile Fits• ABC – Positioning, secretions give oxygen • Reassure mother• Give rectal diazepam ( 0.5 mg/kg)• Observe for ten minute • Establish an IV access
– Blood sugar – Take blood for …..– Control temperature– Evaluate for causes
• Repeat IV diazepam – observe for 5 minutes • Try paraldehyde• Phenobarbitone or Phenytoin• Evaluate for Causes and complications • ICU care and ventilation
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Other options to control fits
• As a first line drug – Midazolam 0.5 mg/kg
• IM, Buccal or Nasal • High efficacy • Same respiratory depression
– Lorazepam – IV - Long lasting , less respiratory depression
• Magnesium sulphate
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What is the cause for fits
• Febrile fit• Meningitis/encephalitis• Epilepsy• Electrolyte imbalance• Metabolic causes
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What are the complications of prolonged convulsions?
• Pulmonary oedema
• Hyperthermia
• Cardiac dysrhythmias
• Hypertension
• Cerebral oedema
• Myoglobinuria
• Disseminated intravascular coagulationAll Rights Reserved From Dr R.M Mudiyanse
Acute severe asthma
• Start Oxygen connect to a pulse oximeter• Nebulize with salbutamol
– ( 2.5 or 5 mg 0.5 ml or 1 ml + 2 cc saline)• Repeated or back to back nebulization • Add IBM • IV line – Hydrocortisone, Aminophylline,
Antibiotics • Exclude other possibilities • ICU care
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Diarrhea Dehydration
• Appropriate 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
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11
Dengue with circulatory failure
• ABC – detect circulatory failure • Fluid bolus – 10 ml/kg Crystalloid X 3; Colloids
x2• Oxygen• Monitor• FBC
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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
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Acute bleeding in a hemophiliac
• Patient had been in severe pain – PCM or Morphine– Resting
• Factor 8
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How are you going to manageGo through the problem list
• Out of many problems ………………..needs immediate attention
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What investigations
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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
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Fever short duration or long duration
• Second line– Bone marrow– Echo– US abdomen– CT– LP– ANF/DDNA
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Rickets
• X-ray • Alk posphatase• Ca• PO4• Response to treatment • Blood gases+ serum electrolyte (Cl-) + urine Ph• Urine – Sugar + Amino acids
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How are you going to evaluate this child?
How are you going to manage this child?
So what are going to do?
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Disabled child ..
• The immediate problems is….• Other problems are …..
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FTT
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Anaemia
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14
Jaundice
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Transfusion Dependent anemia
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Petechial Haemorrhages
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Bronchial Asthma
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15
Nephrotic Syndrome
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CRF
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Short stature
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Now patient is ready to go home. On discharge what are you going do
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16
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
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Diarrhoea on discharge
• Explain to mother and child• This child is already below the 3rd centile…
– Need for nutritional rehabilitation
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Thank You!Best of Luck!
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