Long cases for final year MBBS medical student in Sri Lanka

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Long Cases for Final Years

Dr Rasnayaka M MudiyanseDepartment of Paediatrics,

Faculty of Medicine,University of Peradeniya

All Rights Reserved From Dr R.M Mudiyanse

Possible Long Cases

• Acute Problems

– Diagnosis– List of problems – Acute Management – Prevention

• Chronic Problems

– List of problems– Diagnosis– Long term care – Acute Management – Prevention


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


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)


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


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


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


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


What is your diagnosis?


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


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


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


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


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


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


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


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


Steroid resistant NS managed with cyclophosphamide

Complications Hypertension

Associated /other diagnosesRoutine care 1. Immunization

2. Nutrition and Diet3. Schooling and education


What are the problems- NS

Therapy 1.Compliance to drugs 2.Long distance to travel


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


Severe haemophilia with target joint

Complications Multiple contractures, severe FTT,


Eczema

Routine care 1. Schooling and education2. Oral hygiene 3. Immunization


What are the problems- Haemophilia Therapy 1. Mobility ( physio, wheel chair, toilets, steps)

2. Activities ( occupational therapy)3. Educational4. Non availability of drugs


1. Knowledge, attitudes, and expectations2. Social life 3. Depression and anxiety4. Family planning

Economic problems


Siblings 1. NeglectAll Rights Reserved From Dr R.M

Mudiyanse

What are the problems –ThalassaemiaAcute problem -


Beta thalassaemia majorInadequate transfusion and chelation

Complications 1. Massive Splenomegaly2. Diabetes mellitus3. Cardiac involvement


-

Routine care 1. Schooling and education2. Oral hygiene 3. Immunization 4. Diet


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


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


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?


Students response depending on the priorities fixed by the caseBe practical and realistic


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?


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


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


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


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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Dengue with circulatory failure

• ABC – detect circulatory failure • Fluid bolus – 10 ml/kg Crystalloid X 3; Colloids

x2• Oxygen• Monitor• FBC


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


Acute bleeding in a hemophiliac

• Patient had been in severe pain – PCM or Morphine– Resting

• Factor 8


How are you going to manageGo through the problem list

• Out of many problems ………………..needs immediate attention


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What investigations


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


Fever short duration or long duration

• Second line– Bone marrow– Echo– US abdomen– CT– LP– ANF/DDNA


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?


Disabled child ..

• The immediate problems is….• Other problems are …..


FTT


Anaemia


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Jaundice


Transfusion Dependent anemia


Petechial Haemorrhages


Bronchial Asthma


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Nephrotic Syndrome


CRF


Short stature


Now patient is ready to go home. On discharge what are you going do


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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


Diarrhoea on discharge

• Explain to mother and child• This child is already below the 3rd centile…

– Need for nutritional rehabilitation


Thank You!Best of Luck!


Long cases for final year MBBS medical student in Sri Lanka

Health & Medicine

Transcript of Long cases for final year MBBS medical student in Sri Lanka