EXAM PAEDS

Ini pengalaman saya exam masa nak lepasi posting paeds hari tu. Please double check semula jawapan.

🌹Acute Bronchiolitis

Patient 1 year old, presented with rapid breathing 1 day, preceded by fever 2/7 and cough+ runny nose 3/7. Documented temperature at home 37.9 

O/E : Tacypnic, crepitation and ronchi

1. Why you diagnose this patient as bronchiolitis? Why not pneumonia? 

📌Because low grade fever (usually suggestive viral infection,

usually bronchiolitis preceded by h/o 2-3 days coryzal symptom. 

And “Happy Wheezer”. Pneumonia patient will came with more lethargy, reduce oral intake, look less active.

2. What lung auscultation will be in bronchiolitis and bronchopneumonia? 

📌Bronchiolitis : ronchi

Penumonia : Crepitation

4. Pathology bronchiolitis vs bronchopneumonia?

📌Bronchiolitis : Inflammation in bronchiole - hypersecretion - mucus blockage

Pneumonia : infection of lung parencyma - consolidation

5. What common organism cause bronchiolitis? 

📌Viral - RSV 

6. Management bronchiolitis?

📌- Supportive : Oxygen + Neb hypertonic 3% saline 

-  Antibiotic : in superimpose infection

7. Why you give oxygen? 

How it will help patient?

📌It will help increase gas exchange : more effective ventilation/ perfusion - so patient will be less tacypnic 

8. How nebulization 3% saline will help patient? 

📌Increase mucus clearance

(However no evidence based)

🌹Dengue

1. 7 yo Malay girl, presented with history of fever 5 day, had vomiting x 1 in day 2 of illness. Rashes noted on the day of admisson (D5), D4 off illness went to GP, told suspected dengue with low platelet 140, then TCA next day to repeat FBC, wad told PLT worsening 62, thus refered to Hospital. At ED, platelet 70. Hb 13, HCT 35, TWC 2.

1. Differential diagnosis? 

- Dengue

- AGE

- URTI

- Acute pharyngitis

- Other viral fever

- Malaria

2. Type of dengue?

-  Dengue without warning sign

- Dengue with warning sign

- Severe Dengue (plasma leakage, haemorrhage, organ impairment)

3. What complication that we afraid?

- haemorrhage

4. What to look during review patient?

- CCTVR

Color (pink/pale)

CRT

Temperature

Volume - weak

Rate - tacycardia

5. How we can know whether can increase or decrease fluid for this patient? Without see the FBC(result might came late)

History - Overload symptom?

Clinically - Reduce breath sound? Fluid overload? Pufiness? Pedal edema? CCTVR, vital sign? 

Blood Ix - HCT, PLT, HB (drop - haemoragic, DIVC)

HCT improving or not by fluid that we give?

Need to check urine output, wheter negative or positive balance, urine SG during review to know we give correct amount of fluid or not. 

Cannot depent on FBC result only because result may came late.

6. What type of fluid we give? 

Normal saline 

7. Warning sign? 

(Mneumonic DENGUE F)

Decrease plt

Englarge, tender liver

Nausea Vomiting

GIT distubance

Unrest, lethargy

Eccymosis - bleeding

Fluid Overload

🌹Thallasemia

Patient 12 yo girl, presented at daycare for regular blood tranfusion

O/E : hyperpigmented skin, splenogemally 5 FB, hepatomegally 5 FB, 

1. Examine this patient 

(general and abdomen)

2. What differential diagnosis liver and spleen palpable?

🌸Leukaemia

Thallasemia

Liver Abcess

Typhoid, can cause splenic abcess

Etc

(Cari sendiri ya yang lain)

3. If thalasemia, if she diagnose at 7 year old, what type of thallasemia she might have?

🌸Thallasemia Intermedia

4. Other type of thallasemia?

- Alpha Thallasemia

- Beta Thallasemia : Major, Minor, Intermedia

- HBE Trait

5. If you suspect patient thallasemia, what investigation you might take?

🌸FBC — usually Hb low, can be 7, or 5. However need to repeat in 2 weeks time. Without presence of infection, because infection also can mask thallasemia, hb also will drop. 

Hb Analysis

Hb Electrophorosis

6. What complication usually patient on regular blood tranfusion will have?

🌸Iron overload - usually after 10-20 times blood tranfusion

7. How you treat iron overload?

🌸Iron Chelation agent.

Eg : Desferal/ DFP/ Etc

Need to give Vit C to increase iron absorbtion. 

8. Why patient thallasemia will have hyperpigmented skin?

🌸Because hemosiderin deposition in subcutaneous tissue.

9. How you monitor iron overload? Any blood parameter we can see?

🌸Serum Feritin level.

10. At what level of serum ferritin that we need to give iron chelation agent?

🌸If more than 1000 mcg/L

11. How we give desferal, by what route? For how long? 

🌸SC/ IV

Eg : DFO : sc infusion 8-12 hours  for 5 nights per week.

(Boleh double check Thallasemia Protocol Malaysia)

❤️Hydrocephalus

A, day 6 of life, delivered via ELLSC. With birth weight of 3.3Kg.

Head circumference 45 cm

No syndromic facies

No other abnormality

1. Examine this patient head, from where to where you measure?

✅Frontal - to - occipital

2. What other system that you would like to examine?

✅Spine examination

3. Why we also check spine in patient with hydrocephalus? What to look? Why?

✅Spina Bifida.

There is association between hydrocephalus patient with spina bifida, usually.

4. After delivery, after stabilize patient what you want to monitor in wad? At the same time you look for the cause (like usg cranium )

✅BP/PR/SPO2 monitoring

5. What you look in baby with increase inctracranial pressure?

✅BP will increase. Tacycardia. Apnea. Desaturation.

6. We rarely do fundoscopy in baby to look for increase ICP.

7. Why patient with hydrocephalus can have apnea?

✅Because increase ICP can compress repiratory centre in the brain lead to apnea. Disturb regular respiratory mechanism.

8. So, if patient had sign increase ICP, what you want to do?

✅Refer neurosurgery URGENT for OPERATION!

9. What operation we can do for patient with hydrocephalus?

VP Shunt.