Peads/Medical

History taking Chief complain; provisional & differentials

Inhalers w aerochamber
& PFM
Inhalers: preventers & controllers
MDI
(sit straight, shake, prime 1
st
, hold L upright, 3 slow deep breaths, exhale
completely; inhale simultaneously w pressing of canister, hold breath 10s,
exhale slowly, interval 1 min for next puff)
Aerochambers (3 sizes)
(1
st
time: prime into chamber by attaching mouthpieceto distal end, facial
mask horizontal to face; 1 puff=6 slow breaths in & out; interval 1 min then next
puff)
(clean by soaking in soaped water, wind dry, NEVER WIPE)
Peak Flow Meter (>5 y/o)
(?- post bronchoD reversibility, monitor dz progress OLD)
(insert mouthpiece, hold meter horizontally, indicator @ the bottom, seal
mouthpiece tightly, exhale w MAX effort/speed; repeat 3x take highest score)
Nebulizer ?- acute setting when failed inhaler (poor inspiratory effort)
Connected to O2 supply+humidifier to evapourise meds (>6L/min)
Salbutamol (<2y/o= 0.5cc; >2y/o=1cc)
Combivent (<5y.o=0.5cc; >5y/o=2.5cc)
* duration (10-15min course---- reassess again--- next neb)
Asthma action plan -personal details (individualized therapy) + parents details/contact num
-assess asthma status (intermittent/persistent) & current control
-triggering factors (to avoid)
-stratify into zones & tx accordingly
-explain about reliever + controller
Nprong/face mask/
venturi/ reservoir (O2 tx)
FiO2 Flow (L/min)
Nprong 0.2-0.4 <3
FM 0.35-0.5 5-10
VM 0.24-0.3 low
0.3-0.5 high
8-12
Reservoir 0.7-0.8 8-15
Fluid resus/ maintenance
-shocks
Resus 20cc/kg bolus 15-30min--- reassess (max 3x)
-NS 0.9% (all ages)
-Hartmaan (isotonic & good for mild acidosis d/t dehydration;
contraindications- CLD/CKD/CCF/lactic acidosis)
Maintenance (depending on age Na+ requirement 2-4mmol/kg/d)
-infants (1/5NS D5)
-paeds (1/2NS D5)
-adults (NS alternate D5)

* shocks
Cardio: dobutamine, dopamine (5-10mcg/kg/min)
Septic: NE, dopamine (>10)
Hypovolemic: dopamine (>10)
Anaphylactic: adrenaline
Electrolytes (correction)
-K/ Ca/ Na
(correction= deficit+daily M)
K deficit= (3.5-?)*0.4*BW
Na deficit= (140-?)*0.6*BW
Corrected Ca= (40-alb)*0.02 + Serum Ca
Fill in prescription form
-explain to parents on
AED
-complete details (including weight of child)
-Indication of starting medication (eg: epilepsy- elakkan kerosakan otak akibat
sawan)
-choices of medication (depending on dz)
-S/E each & safety net
-compliance issue
-fitting unresolved >5min (bring child to casualty)
-regular TCA (TDM- capai dose betul & elakkan dose tosik)

Fitting @ home During fitting:
-parents keep calm/ comfort & be with child
-remove danger from child
-in lateral position (X aspiration), wipe vomitus
-remove tight clothings
-DONT insert anything into mouth/ restrain child/ feed orally
* bring child to casualty immediately!

Simple febrile fit Epilepsy
Natural hx Benign/ good prognosis
-common age gp 6m-6y/o
-may be recurrent
-mostly d/t high grade fever
Primary/ secondary
Prevention Anticipate fever
-tepid sponging
-syr PCM/ tab/PR
Compliance to
medications
Acute tx PR diazepam 0.5mg/kg PR diazepam
Lumbar puncture
counseling

* informed consent


http://www.med.uottawa.ca/procedures/lp/e_guide.htm
WHAT: utk analysis air tulang belakang
(appearance, opening pressure, cell counts, Gram staining, C+S, PCR, biochem,
cytology, oligoclonal bands, save)
WHY: Diagnostic-infection, cancer, GBS/MS/paraneoplastic syndrome,
TRO leukemia CNS infiltration
Therapeutic- intrathecal for tx leukemia
Procedure: duration: 30-1hr, analgesia & anxiolytic (conscious), C-position,
aseptic technique, needle (22-25G) entry below saraf tunjang,
~2cc(x5containers)
C/I: ICP/SOL, AMS, focal neuro deficits, bleeding diasthesis, local site infection
Cx: post-tap headache, infection/bleeding, cerebral herniation
BMAT

* informed consent
* inform hemato (slides)
BMA
-@post iliac crest
Trephine
-solid core bone (PIC)
1) All cell lineages
morphology
-Ratio diff cell lines
(myeloid/erthyroid)
2) Foreign cells (mets)
3) IMhistochemical stain
Cytogenetics
IMphenotyping
Molecular analysis
4) Iron stain
1) Panoramic view
-architecture
-cellularity
-fibrosis
-infiltration
2) Lymphoma
3) Dry tap
*stop anticoagulant 2d before
Procedure: (30min-1hr)
*LA 1% lignocaine, IV midazolam, cardiac monitoring, BP, HR, SpO2 monitoring
*lateral decubitus position; 10cc syringe for BMA, then trephine
*sterile dressing on BMAT site for 1 hr to stop bleeding + analgesics 2-3d
(X wash site <24 hrs)
-C/I: severe bleeding d/s, local site infection; (thrombocytopenia is NOT C/I)
*cx: mild soreness/pain, bleeding, infection
Ryles tube -measurement (tip nose>earlobe>xiphoid process) & choose size (infant,
10,12,14)
-indication (diagnostic: UGIB, gastric specimens, TEfistula newborns)
(therapeutic: decompression, gastric lavage, nutrition)
-C/I (facial trauma, Base skull #, AMS, esophageal perforation, aspiration)
-preparation (ryles tube, clean gloves, KY jelly, kidney dish, 10cc syringe, litmus
paper, plaster, drainage bag, +/- cup of water)
-procedure clean (sitting 45
0
, clean gloves, lubricate end w KY/lignocaine,
patent nostrils, head lean forward, pt swallow & advance till mark)
-in place (10cc air push auscultate, draw fluid out litmus paper, observe
secretions flowing out, CXR) - anchor well & connect to drainage bag

ORS -indication (dehydration/purging- correct electrolyte imbalance; those who can
tolerate orally)
-content (Na, K, Cl, HCO3, glucose, 258mmol/L)
-10cc/kg per per purge (V/D)
Preparation:
-dilute 1 sachet in 250ml boiled cooled water
(remaining ORS in fridge <24hrs use)
-give freq slow sips
-if vomit, wait 10min, then feed again
-feed until purging stops
* cont breastfeeding as usual
MSU UFEME
interpretation

Immunization -types of vaccines
Live BCG, MMR, rotavirus, varicella, typhoid, OPV
Killed IPV, Hep A, rabies, cholera
Conj Pneumococcal, Meningococcal, HiB
Polysacc P+M, typhoid
Recombinant HepB, HPV
Toxoids Diphth, Tetanus
Subunits Accellular Pertussis
-schedule
-absolute C/I any vaccine (anaphylaxis); acute febrile illness (postponed)
-absolute C/I live vaccine (IMC-
cancer, irradiation, primary IMD
, chemo<6m,
systemic steroid
delay3m;unless inhaled/topical or low dose systemic <2w or EOD>2w
,
IVIg<3m, pregnancy, last live vaccination<4w)

Weaning counselling -definition: introduce other food besides breastmilk (still continue)
WHO? >6months
WHY? for growth of child (added nutrients from variety food)
HOW? -slow & gradually increase; variety of healthy food, NO EXTRA
sugar/salt/MSG
WHAT?
- dipuri/dilecek/separa pejal (meat, fish, eggs, dairy products)
- main meals=2-3x/day
-sneks=1-2x/day
Iron chelating therapy -indications
-choices (s/c & oral: 3 types)
-advantages & disadv s/c & oral
-when to combine
-method using s/c & oral
-side effects & safety net
Anthropometry & plot
growth chart
HC, weight, length (newborns)
* growth chart plotting (corrected age)
* comment (this current readings= normal/@/below centiles); cannot
comment FTT until prev readings reviewed
Radiology
-diaphragmatic hernia,
RSD, TOF, CoA

-D hernia: (L)>,indistinct L hemiD w opacification of part of hemithorax,
gastric bubble/NGT @ heart level, scaphoid abd
-RSD : generalized ground glass/granular, bell shaped thorax-low vol, air
Bronchogram
-BPD: usually overaerated, diffuse small cystic hyperlucency, generalized
opacities obliterating heart borders, linear opacities (fibrosis)
-TOF : boot shaped heart, oligemic lung field, pul A bay
-CoA : inverted 3 in descending aorta, rib notching(roesler sign), LVH
-TGA : egg on string
-truncus arteriosus: cardiomegaly, pul congestion (collaterals), widened
mediastinum



Truncus arteriosus


Coactation aorta

Infant RDS

BPD

congenital D hernia

Short stature refer peads protocol
Medical genetics Break bad news
-infant w chromosomal abN
-G6PD
-ambigous genitalia

Genetic counseling:
-condition of child
-confirmatory Ix for diagnosis
-implications of condition
-management options (biopsychosocial)/ prognosis
-role of hereditary (risk of recurrence next pregnancy & possible prevention)







Notification (phone/
form)
Call Pej daerah (nearest)
-introduce (saya dr- HUSM, buat notifikasi.)
-speak to PPKP infectious unit
-summary of case (full name, age, ic, contact num, address,
suspected/diagnosed case by clinical/lab results, warded pt?, date onset & now
day 5 fever/rashes?
-thank you
ABG
Insulin injection

Surgical