Principles of Preoperative & Operative Surgery (Part I)

Preoperative Evaluation-
Aim is not to screen broadly for undiagnosed disease but rather to identify and quantify any comorbidity that may have an impact on the operative outcome. Used to identify risk factors for postoperative morbidity and mortality. Communication between the surgeon and consultants is essential to define realistic goals and to expedite surgical management.


Cardiovascular:
ASA Classification for anesthetic risk has 5 strata:

I- Normal healthy patient
II- Patient with mild systemic disease
III- Patient with severe systemic disease that limits activity but is not incapacitating
IV- Patient who has incapacitating disease that is a constant threat to life
V- Moribund patient not expected to survive 24 hours with or without an operation

Cardiac Risk Indices-
Goldman Cardiac risk Index (1977), Detsky Modified Multifactorial Index (1986), Eagle’s Criteria for Cardiac Risk Assessment (1989), & Revised Cardiac Risk Index.

The current AHA/ACC recommendations are to start Beta-blockers therapy in the medium to high risk patients undergoing major to intermediate risk surgery as early as possible preoperatively and titrate to a heart rate of 60 beats/min.

An easy, inexpensive method to determine cardiopulmonary functional status for noncardiac surgery is the patient’s ability or inability to climb two flights of stairs. Two flights of stairs are needed because it requires greater than 4 metabolic equivalents (METs).


Pulmonary:

Preoperative evaluation of pulmonary function may be necessary for either thoracic or general surgical procedures.

Necessary tests include FEV1, FVC, and the diffusing capacity of carbon monoxide. Adults with an FEV1 of less than 0.8 L/sec, or 30% of predicted, have a high risk for complications and postoperative pulmonary insufficiency.

Preoperative interventions that decrease postoperative pulmonary complications include smoking cessation (>2 months before planned procedure), bronchodilator therapy, antibiotic therapy for preexisting infection, and pretreatment of asthmatic patients with steroids.
Perioperative strategies include the use of epidural anesthesia, vigorous pulmonary toilet and rehabilitation, and continued bronchodilator therapy.


Hepatobiliary:

Evidence of hepatic dysfunction may be seen on physical examination. Jaundice and sclera icterus may be evident with a serum bilirubin level greater than 3 mg/dL. Skin changes include spider angiomas, caput medusa, palmar erythema, and clubbing of the fingertips. Abdominal examination may reveal abdominal distention, evidence of fluid shift, and hepatomegaly. Encephalopathy or asterixis may be evident. Muscle wasting or cachexia can be prominent.

Here are ways to approach a patient with liver disease in selected cases:

Acute Hepatitis-
Postpone elective surgery at least until liver function tests have normalized.

Chronic Hepatitis-
Surgery is generally considered safe in these patients.

Obstructive Jaundice-
1) Perioperative fluid management to prevent renal dysfunction
2) No dopamine or mannitol
3) Lactulose may be helpful
4) Antibiotic prophylaxis
5) No routine preoperative biliary drainage
6) Check for abnormal coagulation parameters

Cirrhosis-
Child’s A and B- Treat ascites, coagulopathy and proceed to surgery
Child’s C- Postpone until the patient’s Child’s class could be improved or cancel surgery for conservative management

Coagulopathy- Target PT to be no more than 2 seconds above normal
1) Vitamin K- 10 mg subcutaneous
2) FFP if no improvement with Vit K
3) Give cryoprecipitate as needed

Ascites-
1) Fluid restriction
2) Diuretics- Furosemide and/or Spironolactone
3) Paracentesis- may be diagnostic or therapeutic with simultaneous administration of albumin

Encephalopathy-
1) Treat with lactulose
2) Prevent by treating precipitating conditions such as GI bleeding, alkalosis, uremia, avoidance of sedatives

Patients with cirrhosis may be assessed with the Child-Pugh classification, which stratifies operative risk according to a score based on several variables. Child’s class A, B, and C have mortality rates of 10%, 31%, and 76% respectfully during abdominal examinations.

Malnutrition is common in cirrhotic patients and is associated with reduction in hepatic glycogen stores and reduced hepatic protein synthesis.


References:
"Sabiston: Textbook of Surgery" Townsend, Elsevier. 2008

More to come soon...

Pediatrics- Ward Notes (Part IV)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:


Common causes of Hematuria:
Acute glomerulonephritis, IgA nephropathy, Stones, Urinary tract infection, Clotting disorders, Trauma, Drugs, PSGN

Severe complications of Acute GlomeruloNephritis:
Acute renal failure (anuria), Hypertensive encephalopathy, Left ventricular failure

During the 1st year of life, UTI is more common in males with an M to F ratio of 4:1.
Pyelonephritis characteristically presents with- Fever, Chills, Costovertebral tenderness

Strong indicators of UTI in a Urine D/R: (Multiple organisms usually indicate contamination)
Abnormal color or clarity, > 100,000 of the same organism/ ml, Nitrites +ve, Leukocyte esterase +ve
Damaged RBC casts in urine indicate Glomerular origin.
Creatinine is preferred over BUN because BUN is easily altered by dehydration and starvation while Creatinine is kidney function specific.

-Remember to ask about the number of stools/day because constipation is a risk factor for UTI. Examine the spinal cord.
-When did the child last urinate? If more than 6 hours, then suspect Acute Renal Failure.

Causes of Recurrent UTI:
Hypospadias, Meatal stenosis, Urethral/Ureteric stricture, Renal agenesis, Polycystic kidney disease, Horse-Shoe kidney, Obstruction at the PelvicUreteral Junction, Posterior Urethral Valve

When counseling for urine collection, ask mother if her child informs her when he wants to micturate.

Suprapubic Puncture: Procedure
Bladder should be full (>2 hours since last micturition). Palpate pubic symphysis and then puncture 2-3 cm above in the midline (avascular linea alba). The 10 gauge needle should be perpendicular. Next, aspirate urine out and then seal it. Remember, this is a blind procedure.
Complications- Infection, Trauma, Perforation

Posterior Urethral Valve:
Obstruction at the bladder neck because of posterior mucosal membranes. May present at any age despite being congenital.
Male child, Early presentation, Failure to grow, Oligohydramnios, Anemia, Acidosis, Increase in BP, Big bladder, Palpable kidneys

Investigations- CBC, Urine D/R, UCE, U/S KUB (echogenicity, corticomedullary differentiation, size, diameter, VUR), MCUG, DMSA scan (assess renal function)

Immediate treatment includes bladder decompression via catheterization. Surgical ablation via transurethral approach.

MCUG-
Investigation used for VesicoUreteral Reflux. One should look at the level of dilation of the ureter and the amount of dilation in the calyx and renal pelvis. Normally, contrast should not reflux into the ureters. Posterior urethral valves present as a black band (does not take up dye), between the bladder and urethra.
Urination begins in utero at the 12th week of gestation. Oligohydramnios may result in severe pulmonary hypoplasia. Therefore, a vesicoamniotic shunt should be created.

Ultrasound Kidney:
Echogenicity is compared to the echogenicity of the liver and spleen. The kidneys are normally less.
A dilated pelvis may indicate pelvoureteric stenosis.

DMSA Scan- Used to assess kidney function. A dye is taken up by the renal cortex.
DTPA- glomeruli
MAC 3- Tubules

Causes for Unilateral Kidney damage- Stones, Aberrant vasculature, Ureterocoele, abnormality of the PUJ (can be bilateral)

Grade I or II Hydronephrosis can be treated medically. The patient is advised to 'double micturate'.
Grade IV or V Hydronephrosis is treated surgically. Procedures include reimplantation of the ureters and Deflux surgery.

Management of VUR depends on the degree of damage. The bladder or urethra may need to be completely replaced.


Cesarean section and bottle fed babies are more prone to develop asthma when they grow up.
There is a high association between bronchiolitis and asthma.
A silent chest is a very severe condition.

Chest X-Ray in Asthma patients show streaky hilar shadows, hyperinflation, tubular heart
When Peak Expiratory Flow Rate is graphed, X-axis shows the value while the Height is plotted on the Y-axis.
Honey water or yakhni soup (Pakistani origin) can be given to clear secretions in mild asthma.
Asthma is diagnosed after the 3rd attack.
Status asthmaticus is diagnosed if the 3rd dose of short acting Beta agonists (bronchodilators) does not provide relief. Aminophyllin and steroids should be started.

Eosiniophilia in kids may be seen in:
Asthma, Ascaris infection, Loffler's syndrome, Hay fever, Hookworm infection

Differential Diagnosis for recurrent chest infections:
Cerebral palsy, GERD, Diaphragmatic hernia, DiGeorge’s syndrome, Fungal infection, Heart abnormalities, Pneumonia, Congenital bronchiectasis, Cystic fibrosis, Kartagener’s syndrome

Chest Physiotherapy- Since children under the age of 2 are unable to expectorate, physiotherapy is done to help remove secretions. Lay the child in the lateral tredelenburg position and percuss from below upwards on the chest. This is indicated in Bronchiectasis.

Neonatal Meningitis- E. coli, Group B streptococci, Klebsiella
Infantile Meningitis- H. influenza type B, S. pneumoniae, N. meningitidis
Tubercular Meningitis- glucose levels are low. Choroid Tubercles may be seen in the fundus of the eye
Viral- glucose levels are normal
Herpes- blood may be seen in the CSF
CSF- If there is an increase in lymphocytes, then the origin may be Tubercular, Viral, or partially treated bacterial. Glucose values are the last to change.

A single dose of antibiotics can render a Lumbar Puncture sterile. In such cases, Latex Particle AGglutination should be carried out.
Gram staining, and Herpes PCR can also be performed with CSF along with culture and sensitivity.

Band cells- Are immature neutrophils which signify overwhelming acute bacterial infection. Their nuclear material is arranged in a band within the cell.

Lymphocytic leukocytosis is seen in- Leukemia and Whooping cough

Chloride sweat test (uses pilocarpine) in a suspected Cystic Fibrosis case will be >80 mg/dL.

Barium meals show: Diaphragmatic hernia, Sliding hernia, Achalasia, Esophageal Stenosis/Atresia

Mumps- Advise not to eat sour foods. Complications include meningitis, otitis media, orchitis (males)

Flag sign- Seen in Kwashiorkor. Area of hyperpigmentation alongside an area of depigmentation

Cerebral Palsy- Non-progressive, permanent disorder of posture and movement that is usually a developmental problem. Mental retardation may be associated. Requires multi disciplinary management.

Ampicillin and Gentamycin are given prophylactically to cover gram +ve and gram -ve bacteria.

Dengue antibodies are seen 5 days after the fever begins.

Specific Typhoid investigations- Typhi dot and Bone marrow culture
Cross reactivity amongst Typhoid and Malaria is possible. Previous IgG typhoid is possible with vaccination.
Carriers for typhoid are identified as having three +ve consecutive stool cultures.

Causes of Pancytopenia:
Sepsis, HIV, Megaloblastic anemia, TB, Hypersplenism, Aplastic anemia

Thrombocytosis may be seen in Iron deficiency anemia and Kawasaki's disease.

Causes for Thrombocytopenia:
ITP, Sepsis, Malaria, Hemolytic ureamic syndrome, Hypersplenism, Dengue, TORCH infections, Iatrogenic, DIC, CLD, Hemangioma


Pakistan Statistics-
6 children are born every minute in Pakistan.

Neonatal Mortality rate is 40/1,000 live births, 20 of which are due to birth asphyxia.
Under 5 Mortality rate is 56/1,000 live births.
Perinatal Mortality rate (28 weeks gestation till 7 days after birth) is 60/1,000 live births.
Infant Mortality rate is 91/1,000 live births.
Maternal Mortality Ratio is 276/10,000.


Resuscitation Trolly:
Ambu bag (30-40 mm Hg pressure in infant type), Heater, ET tube (2.5 - 7.0), Laryngoscope, Mouthpiece, Epinephrine, Vitamin K, I/V chamber.

Incubators are used to regulate ventilation and temperature at 37 C degrees.
Blue light is usually used for phototherapy but cyanosis may not be seen. Hence, a yellow light may be used.

Babies at risk for Hypoglycemia- Birth asphyxia, Prematurity, Infants of Diabetic Mothers

If a neonate is limp, apply a painful stimuli. Start CPR when HR <>

Indomethacin is given for a duration of 3 days only after platelet and creatinine levels are termed normal.
Survanta- 4 mL/kG via endotracheal tube.

APGAR score of >7 is considered good.



As this is a series, there will be more to come soon!

Pediatrics- Ward Notes (Part III)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:


Hemolytic Uremic Syndrome:
Decreased platelets, Anemia, Peripheral film shows egg shaped cells/burr cells

Congenital Adrenal Hyperplasia:
21 alpha hydroxylase deficiencies are the most common. It causes virulization in females of feminization in males. Cortisol is not formed. Males are usually dehydrated. Urinary 17 ketoesterides is diagnostic. 17 hydroxyprogesterone levels in blood can be checked as well.

Global Retardation- Considered when all developmental parameters are deficient. Chronic Severe Malnutrition- Considered when all 3 growth parameters are <>

Complications of multiple blood transfusions:
Hemosidereosis, Blood group incompatibility, Splenomegaly
Treatment- Deferoxamine

Pneumonia:
Investigations- CBC, CXR, ABG’s (hypoxia, metabolic acidosis, hypercapnea), UCE, Blood culture, Tracheal swab/Bronchial lavage Immediate management- Oxygen, Electrolytes, Antibiotics
Pneumonia should be treated with antibiotics for 5-7 days. Identification of lobe involved can be checked by percussing laterally.
Atypical viral respiratory infections and Sarcoidosis can mimick Miliary TB in a CXR.

Causes of Microcephaly:
Trisomies, TORCH infections, CHARGE syndrome, Cruzen syndrome (early fusion of skull bones)

D/D for 1 day high grade fever with Neutrophilia- Bacterial tonsillitis, Pharyngitis, Otitis media, Urinary Tract Infection

Guillan Barre Syndrome is a lower motor neuron lesion.

Causes for a false -ve Monteux test- Steroid drugs (>20 mg/day for 2 weeks), Grade III malnutrition, Active measles infection

Rickets (Vitamin D deficiency in children):
Repeated chest infections, Craniotabes (ping pong head), Caput quadratum (square shaped head), Wide fontanelle, Frontal bossing (also seen in thalassemia), Pot belly, Widening of wrist, Harrison's sulcus, Rachitic rosary

In the history, ask about adequate sun exposure (UV rays do not penetrate household glass windows), ask about drinking cow's milk (high phosphate content in cow's milk binds to calcium and causes excretion).

Measles:
Fever, Maculopapular rash (appears at the hairline and behind the ears, extends downwards across the whole body, and then disappears in the same fashion of appearance), Cough, Coryza, Conjunctivitis, Koplik spots (white/sandy color spots found in the buccal mucosa in front of the lower molars. These appear before other symptoms). When the rash for Measles subsides, it leaves a dark, desquamated appearance. Measles antibodies may be seen 4-28 days after the rash appears. Ask about vaccination and drug history/allergies.

D/D Measles- Rubella, Scarlet fever, Meningococcemia, Typhoid (rose spots), Insect bites, Drug rash Measles is associated with a high grade fever while Rubella's fever is low grade with enlargement of the posterior auricular and occipital lymph nodes.
Scarlet fever has a dry, sand paper rash present on the upper limbs and trunk and is seen usually at 5-15 years of age.
Meningococcemia presents with meningeal irritation, petechial hemorrhage, and urological symptoms.

Complications of measles: Pneumonia, Laryngitis, Meningitis, Encephalitis, Otitis media, Diarrhea, Myocarditis, Encephalitis, Reactivation of primary Tuberculosis

Measles encephalitis is of 3 types: Measles encephalitis (viremia), Post measles encephalitis (autoimmune), Sub Sclerosing PanEncephalitis (may occur years later)

Measles treatment: Keep the patient at home, Antipyretics, Cough suppression, Nutrition (fluids and diet in short intervals), Antibiotics for superimposed infections.
Vitamin A should be given orally in all children with measles. 100,000 IU in children <>1 year.

Measles surveillance in Pakistan- Serology (2 cc) of patients with clinically diagnosed cases of measles are sent to Islamabad.

Daily requirement of Vitamin A is 1,500 IU. Vitamin A is not available over the counter in Pakistan. Thus, the multivitamin Rovigon (30,000 IU) is given instead.

Vit A deficiency- Night blindness, Xerosis conjunctiva, Xerosis cornea, Thisis bulba

Short Stature:
If systemic causes, then patient is short and thin. If endocrinological causes, then patient is short and obese. Height velocity is important.

Factors effecting growth in utero- Uterine size, Nutrition, Insulin, Insulin like growth factors.
Growth hormone and Thyroid hormone play a vital role in the post natal growth process.
Children whose absolute height is below 2 SD from the mean have pathological growth abnormalities.
Observe the child’s height over a period of at least 6 months. Precocious puberty can cause early bone fusion and a deranged bone age.

Target Height- Determines genetic growth potential. Calculate Mid-Parental height as well. Arm span may also be used if unable to obtain a standing height.

Short stature should be determined as proportionate or disproportionate.
Upper segment : Lower segment ratio- 1.7 at birth, 1.3 at 3 months, 1 at 10 years.
Skeletal dysplasias (spondylodysplasia) and Klinefelter’s syndrome are associated with a decreased U:L ratio. Achondroplasia is associated with an increased U:L ratio.

Proportionate with Increased Ht/Wt- Growth hormone deficiency, Hypothyroidism
Proportionate with Decreased Ht/Wt- Malnutrition, Renal disease, Chronic diseases/infections.

Normal variants of short stature include- Familial short stature and Constitutional growth delay.


As this is a series, there will be more to come soon!

Pediatrics- Ward Notes (Part II)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:

Metabolic Profile Investigations:
ABG's, Urinary amino acid chromatography, Sugar chromatography, Serum ammonium levels

Subtle Seizures- lip smacking, cycling movements, repetitive swallowing. 50% of neonatal seizures are subtle.
Jitteriness is differentiated from seizures by physically holding the child's hands. If the movements stop, then it is considered to be Jitteriness. If the movements cannot be forced to stop, then it is a Seizure.
Jitteriness may be caused by hypocalcaemia or hypoglycemia.

ER management of Neonatal Seizures:
Establish and maintain Airway Breathing Circulation, I/V Dextrose for hypoglycemia, I/V calcium for hypocalcaemia, Drugs
Uncontrolled seizures may be controlled with- Paraldehyde (suppository), Pyridoxine (vitamin B6), Generalized anesthesia

Drugs for seizures should not be discontinued unless there is a 2 year seizure free interval.
Teachers usually pick up Petit Mal seizures. Thus, counseling is necessary.

Risk factors for simple febrile fits developing into Epilepsy: (bad prognostic signs)
Young age of onset, Abnormal development, Delayed milestones, Prolonged duration of fits, Increased frequency of fits, Family history of seizures.
There is a 10% chance that complex seizures will develop into Epilepsy.

Before making the diagnosis of Febrile Fits, make sure you check for the signs of underlying Meningitis and Encephalitis:
Meningitis- Bulging anterior fontanelle (this may be the only sign present in a 6 month old child), Brudzinski's sign +ve (involuntary flexion of the legs when the neck is placed in flexion), Kernig's sign +ve (flexion of the leg 90 degrees at the hip joint with pain on extension of the leg thereafter)
Encephalitis- Drowsiness, Increased tone, Babinski's sign +ve (fanning out of the toes with extension of the halux when a painful stimulus is applied)

Infantile spasm- West syndrome. “Salaam” posture. Flexion.

Side Effects:
Phenobarbitone- Irritability, Behavioral changes, Ataxia, Exfoliative dermatitis
Phenytoin- Gingival hyperplasia, Hepatotoxicity, Folate deficiency, Ricket's, Hypersensitivity, Steven Johnson syndrome
Tetracycline- discoloration of teeth
Co-Trimoxazole- Steven Johnson syndrome, bone marrow suppression
Chloramphenicol- aplastic anemia, bone marrow suppression, grey baby syndrome
Cyclophosphamide- Infertility, Alopecia, Bone marrow suppression, Hemorrhagic cystitis

D/D's for fits with CNS infection:
Meningitis, Encephalitis, Cerebral malaria, Tuberculosis, Otitis media, Brain abscess (focal lesion)

D/D's for Focal seizures without Fever:
Stroke, Thrombus, Cardiac defects (endocarditis, PDA, arrhythmias), Hypocalcaemia, Autoimmune, Coagulopathies, Dehydration (causes hyperviscosity and stasis of blood), Polycythemia

SIADH may lead to seizures via hyponatremia.

Diarrhea:
Chronic Diarrhea- Diarrhea for 2 weeks with no organism detected. Diarrhea is defined to be 2-3 episodes of loose watery stools more than usual.
Safe water- Water suitable for drinking that is free of bacteria/contaminants and has normal biochemical values.

Indications for antibiotics in acute watery diarrhea:
Blood in stool, Suspected cholera outbreak, Amebiasis, Giardiasis, Focus of infection is outside of the GIT

Risk Groups for Dehydration:
Children <1>5 diarrheal stools within the previous 24 hours, Malnutrition, Children who cannot tolerate ORS before presentation, Infants who stop breastfeeding during illness.

Complications of Diarrhea:
Dehydration, Hypovoluemic shock, Metabolic acidosis (bicarbonate in stool), Renal failure, Hypokalemia, Hyponatremia (seizures), Hypoglycemia, DIC, Aspiration pneumonia
Signs of Hypokalemia- Paralytic Ileus (post diarrheal dehydration), Muscle weakness, Arrhythmia, Sluggishness

Treat dehydration with Ringer's lactate 100 mL/kg/day.
For ongoing losses use 1/5th Dextrose saline 250 mL/kg/day.
Potassium is supplemented over a time frame of at least 6 hours. Otherwise, cerebral edema may occur.
Normal saline can be used to compensate for losses of Vomiting.
Daily Na+ requirement is 2-3 meq/kg.
Ringer’s lactate does not cause sodium excess. It expands the circulating volume and helps correct metabolic acidosis. Ringolactate D has the addition of 5% dextrose.

Metabolic acidosis causes a shift in Potassium ions. 40 mEQ is the maximum amount of Potassium put in I liter.
The addition of exogenous potassium causes a “layering effect” because potassium floats to the top of the solution. Potassium chloride is notorious for this effect. This is avoided by using Plabolyte, a homogenized solution in which every drop has the same solution.

Diarrhea presents with deep, rapid breathing. To collect a stool sample, ask the mother to flip the diaper inside out.
Post diarrheal distention is mainly Iatrogenic. Causes include unnecessary antibiotics in viral causes, and use of anti-motility drugs.
New ORS has an osmolarity of 245. Glucose 75, Sodium 75.

Hypernatremic Dehydration: Suspected when mothers incorrectly prepare ORS or powdered milk formulas. Present with Jittery movements, Increased muscle tone, Hyperreflexia, Convulsions, Coma.

KYB diet- Kichiri, Yogurt, Banana.


Pulsus Alternans- Left ventricular failure

Pulsus Paradoxus:
Cardiac- Pericardial effusion, Cardiac tamponade, Cardiogenic shock
Pulmonary- Pulmonary embolism, Asthma, COPD
Others- Superior vena caval obstruction, Anaphylactic shock

Waterhammer (collapsing) Pulse:
Physiologic- Fever, Pregnancy
Cardiac- Hypertension, Bradycardia, Aortic regurgitation, PDA
Others- Anemia, A/V fistula, Beri-beri deficiency, Cirrhosis, Cor pulmonale, Thyrotoxicosis
(Mnemonic for Others- AABCCT)


As this is a series, there will be more to come soon!

Pediatrics- Ward Notes Series (Part I)

Here are some notes from around the wards during my rotation in pediatrics. Enjoy:

Schedule for vaccinations outside of EPI:
Previnar (Pneumococcal vaccine against S. pneumoniae)- 2nd, 4th, and 6th months
Rota Virus (Diarrhea)- 2nd and 4th month. Contraindicated after 6 months of age because of high risk of Intussusceptions
MMR (Measles, Mumps, Rubella)- 15 months, 5 years, and 10 years
Varicella (Chicken Pox)- 1st and 2nd years
Typhoid (Dysentery)- 2 years, then repeat every 3 years
Flu Shot- Normally given in the winter season, especially in children with Asthma, Cystic fibrosis, or Heart disease
Hepatitis A- Two doses, 6 months apart
Meningococcal (Meningitis)- Given to those children with a history of recent contact, family history, Hajj pilgrims, dormitory students, and army soldiers
HPV (Cervical cancer)- HPV strains 6, 11, 16, 18 are most common. Two doses are given beginning at the age of 9 years

Contraindications for Pertussis vaccine- Anaphylaxis or Encephalitis within 7 days of previous injection.
DTaP- for acellular pertussis. Contains different antigens from DTP.
Generally, Polysaccharide vaccines are not effective before the age of 2 years.

General Physical Examination:
Introduction, Ask permission, Record height and weight and note percentiles, Record vitals (BP important in GBS because of autonomic innervation), Comment on nutritional status, Look for scars, Signs of Jaundice, Conjunctival anemia, Periorbital edema, Nails, Ears, Buccal mucosa, Clubbing, Palms, Pedal edema (non pitting edema found in Myxedema-thyroid).
Extent of Edema is checked by ascending from the feet upwards. Abdominal wall edema is checked by pinching laterally (like skin pinch). Scrotal edema is checked by having the patient sit up for support (edema may be caused by infections).

Liver Palpation- Tenderness, Size, Span, Consistency, Margins, Surface, Bruit
Liver size is measured in centimeters palpable below the coastal margin, midclavicular line. When the liver is not palpable, there is no liver size.

Describing a Rash:
Site, Onset, Character, Itching, Color, Fever, Etiology

CardioVascular Examination:
Comment on the location and character of the Apex beat. Palpate for thrills in all areas.
Character- Tapping (RVH), Hyperdynamic (LVH), Forceful
Left parasternal heave is seen in Right ventricular hypertrophy.
Apex beat heave is seen in Left ventricular hypertrophy.

Murmurs:
Pulmonary Stenosis murmur- Harsh, systolic murmur. Radiates to the neck.
ASD murmur- Blood volume overload causes a Harsh, ejection systolic murmur.
VSD murmur- Harsh, pansystolic murmur. S1 is normal. If there is an associated loud P2, then there is also Pulmonary Hypertension.
Mitral Regurgitation murmur- Pansystolic murmur at the apex beat, radiating to the axilla. S1 is soft.

Clinical signs of Heart Failure:
Edema, Tachycardia, Basal crepts, Hepatomegaly, Galloping heart (S1+S2+S3)

How to differentiate the Spleen from the Kidney on examination:
Spleen moves on inspiration, the Upper border of the spleen cannot be palpated, Splenic notch will be felt on palpation of spleen while the normal round contours of the kidney will be felt otherwise, Spleen lays directed obliquely towards the right iliac fossa, Spleen cannot be palpated bimanually, Spleen has a dull percussion note while since the Kidney lays retroperitoneal there is no percussion note because of overlaying colon

Liver Function Tests:
If the major component of total bilirubin is Direct, then the cause is either Hepatic or Post Hepatic.
If the major component of total bilirubin is Indirect, then the cause is Hemolytic.
If Gamma GT is increased, then the cause is Obstructive.

Weight is an assessment of current nutrition while Height is an assessment of previous nutrition.

Two signs of BCG vaccination- Scar and Mantoux conversion

CT findings in Meningitis- Hydrocephalus, Meningeal enhancement, Periventricular darkening

Anterior fontanelle should close within the 8th to 18th months.
1 oz of milk (30 ml) has 23 calories.

Pinpoint pupil- Horner's syndrome, Morphine intoxication, Hypothalamic lesion
Mid-dilated pupil- Lesion in the Midbrain or Pontine

Papilledema is seen in raised intracranial pressure states.

Nasogastric Tube:
Indications- Diagnostic (stomach pH, stomach pressure), Therapeutic (gastric decompression, intestinal obstruction, esophageal varicies, paralysis of the muscles of mastication)
Contraindications- Esophageal tumors. Nasal polyps, Tonsillitis, Trauma to face
Complications- Trauma, Insertion into the trachea, Perforation, Kinking, Damage to nasal mucosa

Pulse in Anemia- Hemodilution causes rapid, strong, bounding pulse.
Pulse in severe Dehydration- Rapid, low volume, feeble pulse. There is associated decreased urinary output, cold extremities.

Waterhammer Pulse:
AV malformation, Thyrotoxicosis, PDA, Aortic regurgitation

Birth weight should be 2.5-3.5 kg. This is normally doubled at 5 months, tripled at 1 year, and quadrupled at 4 years.
Pulse of a full term newborn should be 120-160 beats/min.
Respiratory Rate of a full tern newborn should be 40-60 breaths/min.
Large babies (macrosomia) are at risk for- Hypoglycemia (glucose < 40), Hypocalcaemia, Cardiac lesions, Respiratory distress syndrome

Primitive reflexes include:
Sucking, Rooting, Grasping, Plantar, Moro's, and many others

X-Ray Skull:
Periventricular calcification- Cytomegalo Virus infection
Diffuse calcification- Toxoplasmosis infection
Premature babies are more prone to Intraventricular Hemorrhage

Thymic shadow normally persists up until the age of 6 months.

Points to note when taking a History of an Anemic patient:
Nutrition, PICA, Worms, Chronic infections, Lead poisoning, Rectal polyps, Prematurity, Twin-twin Transfusion syndrome, Feto-Maternal Transfusion syndrome, Hemorrhage, Hemolytic disease of newborn

Sites to check for Anemia:
Bulbar conjunctiva, Palms (darkened creases & redness), Nails, Buccal mucosa, Soles of feet

Risk factors for Anemia in Breastfed children:
Iron deficiency in Mother, Low birth weight, Late weaning

Diseases causing Anemia of Chronic origin (normocytic, normochromic)- Tuberculosis, Chronic liver disease, Chronic renal disease, Cystic fibrosis

Anemia workup- Reticulocyte count, Iron profile, Peripheral smear, Electrophoresis

Bone marrow profile with Iron staining is the gold standard to investigate for Iron deficiency anemia.
M:E ratio- Myelo Erythropoietin ratio??
6 mg/kg/day of iron in ferric form with meals should be given for 3 months to correct anemia.

Causes for Anemia with hepatosplenomegaly:
Thalassemia, Malaria, Sickle cell anemia, Leukemia, Hereditary spherocytosis, Autoimmune hemolytic (SLE, Drugs), Hypersplenism, G6PD deficiency, Portal hypertension/CLD, Glycogen storage disorders, TB, Ventricular heart failure
Investigations- CBC, Peripheral smear, Blast cells, Electrophoresis, Bone marrow scan, Solubility, G6PD levels.
Treatment- According to cause. Bone marrow transplant. Transfusion every 3-4 weeks lifelong with a chelating agent to avoid iron overload.
Complications- Infections (Hepatitis B & C), Malaria, Dengue, Heart failure, Congestive cardiac failure, Hemodermatosis, Growth retardation, Hypersplenism, Growth hormone deficiency, Hypothyroidism
Prevention- Avoid consanguineous marriages, Chorionic villous sampling before 12 weeks for abortion, Amniocentesis

Pallor becomes evident when hemoglobin levels are less than 7 g/dl.
HbF peaks at 26-28 weeks and persists until 6 months of age.
Serum ferritin may be increased simply due to fever.
The first indicator of appropriate iron therapy is Reticulocyte count. Clinically, cognitive functions will be the first to improve.


As this is a series, there will be more to come soon!