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!