Paediatric as HO

Paediatric books to study in HO

In our hospital when I am in paediatric department posting, mainly using the paediatric protocol book. It is quite important as we use it when we have presentations in department. 

Other than paed protocol, I found that the following other books and website is also useful. 

Neonate Paediatric / Oncology paediatric:

Paediatric Protocol

MOH Paediatric Protocols for Malaysian Hospitals, 4th edition

General Paediatric:

 Ampang guideline

https://myhow.files.wordpress.com/2013/11/hoguidepeds1.pdf

Physical examination:

MRCPH website

https://mrcpch.paediatrics.co.uk/

Medications

Frank Shan book

**highly recommend to get the physical copy, as some alignment in the ebook is not as accurate. 

Things to prepare:

• Pens
• Measuring tape
• Mini calculator (either those pocket size or the ones that you can hang on your landyard)
• Scissors
• Durapore

Notes to bring along

• Fluid requirements 
• Growth development
• Growth chart
• Normal readings of blood test
• Normal values for vital signs (RR, BP percentile) 
•  it is quite challenging and difficult to memorise the whole chart, easier to bring it around and refer when needed. 
• mini toy/ cute things 
• (to help kids to calm down before any procedures, eg: taking blood/ punctures)
• I have a mini duck with me most of the time, and i find it very useful in making the kids happy and cooperate. However later on I realise they just like anything that is in bright colour, not necessarily toys.  Even a cute plaster could make them feel so happy. 

Good Attitude

• kids are often affected by our mood/ emotions, so do make sure you are treating them with joy, patience and love.

* Always stay vigilant, observant and a good attitude helps you get through paediatric posting. 

You might enjoy it in the end too!

Abdominal examination for paeds

Abdominal examination:

 

General Examination

• General surroundings
• equipments : NG tube/ PEG tube
• nutrition: milk, food
• Growth chart
• Hand
• finger clubbing
• crt, pulse volume, warm/cold peripheries
• rashes? 
• Face
• eyes: anemia? edema?
• mouth: gum bleed/ hydration
• cyanosis
• overall inspection
• Neck
• spider naevi
• inflammation/ edema on the neck
• lymph node
• Abdomen
• Inspection
• shape
• distension
• masses
• rashes/scar/striae/stoma 
• Palpation
• pt should be in supine position, gently ask if it is comfortable to lie down if having abdominal distension
• superficial, deep palpation
• liver/ spleen/ kidney palpation/ abdominal mass
• Percussion
• shifting dullness/ fluid thrill
• Auscultation
• resonance/ dull
• Lower back
• sacral edema?
• Lower limbs
• pedal edema

Sample video

Special cases

• Nephrotic syndrome : ascites/ periorbital edema/ pedal edema/ sacral adema/ pleural effusion

Causes of hepatomegaly

• 1.  Structural: Extrahepatic biliary atresia, choledochal cyst, intrahepatic biliary hypoplasia, congenital hepatic fibrosis, polycystic disease

  2 . Storage/ metabolic:

    – Carbohydrate- glycogen storage disease (Type 1,3,4,6), hereditary fructose intolerance, galactosaemia,, mucopolysaccaridoses-

  – Mineral: Wilson’s disease, juvenile haemachromatoses

  -Nutrition: Protein calorie malnutrition, TPN-Bile flow: progressive familial intrahepatic cholestaisis syndrome

  -Protease: Alpha-1-antitripsin

  -Electrolyte: CF

  – Amino acid: Tyrosinaemia type 1, urea cycle disorder

  -Lipid – Gaucher, Nieman-Pick diease, cholesteryl ester storage disease

  3. Haematological: Thalassaemia, sickle cell disease, ALL, AML CML

  4. Heart/ Vascular: Congestive heart failure, constrictive pericarditis, obstructive IVC, Budd-Chiari syndrome

  5. Infection: Viral – rubella, CMV, coxsackie virus, echovirus, hepatitis ABCDE, EBV  ; Bacteria – E.coli TI, TB, syphilis ; Parasite – Malaria, toxoplasmosis, Schistosomiasis

Reference: 

1. https://mrcpch.paediatrics.co.uk/abdominal/abdominal-examination-guide/

Cardiovascular examination for children

 Some physical examination compilation of videos to help with revision

Cardiovascular examination

Introduce yourself and ask the kid politely for some information that could aid in your diagnosis later

- age, growth chart, development milestones

- history - any dyspnea/palpitations, exercise intolerance, dizziness/ syncope, family hx (Marfan, chromosomal, CHD in 1st degree relative)

- any vital signs?

- current complain

Next, we go to physical examinations

- general examination (cyanosis, dysmorphic features)

- peripheral pulses (finger clubbing, pulse volume, capillary refill - radial/carotid/femoral)

- check for any signs of anaemia, dehydration

cardiovascular examination:

- palpation - apex/ heave/ thrill

- auscultation - lying down, sitting up forward, hold breath

• timing (systolic/ diastolic)
• quality (soft/ harsh)
• intensity- grade II (innocent), grade III or higher (possible thrill)
• louder with exercise / anaemia / fever / position?
• any other sounds?

- check for edema - sacral/ leg

- hepatomegaly (common in heart failure children)

other references: https://www.pedscases.com/approach-heart-murmurs

Common Questions about Intestinal obstruction (IO)

 1. What are the cardinal symptoms of IO?

-, colicky abdominal pain, abdominal distention and vomiting, no BO, no flatus (obstipation/ absolute constipation)

- other history you want to establish 

• chief complain
• to explore regarding the cardinal Sx
• duration of symptoms
• abdominal pain: to see the location so we can locate either small or large bowel. 
• if its small bowel pain : felt in the upper abdomen and central (periumbilicus) while if large bowel pain is felt in lower abdomen
• these are all visceral pains that is why you referred to area of referred pain

- onset of pain? which one comes earlier? small or large?

• small bowel first
• proximal, smaller in diameter- which would cause distension early, higher level of obstruction 
• small bowel is also active in peristalsis, so once they are obstructed they will cause intense colicky pain. 

- vomiting

• onset : 
• small bowel is active in absorption of nutrients in GI tract. It produces a lot of fluids. If it is obstructed there will be a lot of fluid accumulation so the vomiting will occur early. 
• while in large bowel there is not much of fluid and it is distal, the vomiting occurs late

• content : we will be able to observe the content either from vomiting, or from an NG tube insertion. then we can see the colour content in the bag
• if its feculant material : lower small bowel
• greenish or bile content : high small bowel

Q2. causes of IO and how do you classify

• dynamic
• adynamic
• first we need to rule out mechanical obstructions first
• intraluminal : tumor
• impacted stool: rare, usually in pt with hirchsprung disease
• colon tumor: left sided tumor (Large bowel obstruction)
• small pellet stool, constitutional symptoms, blood in stool
• bowel habit
• PR bleed
• mucous discharge
• tenesmus
• family hx of colon Ca
• intramural, 
• extramural : adhesion, hernia 
• hernia usually affects the small bowel. so if the patient with cardinal symptoms mention above leading towards SBO, remember to confirm regarding their abdominal surgery and hernia. 

Q3. Complications of IO

• perforation
• pain became severe and intolerable
• localised pain became generalised
• presence of high grade fever
• abdomen become more distended

Ortho HO must know

 Clerking key points:

- age/ race/gender

- chief complain

- presenting history (how it happens-where they fall, how, why; pain-what kind of pain-location, intensity, relieving factors) 

- other related signs and symptoms: LOC(loss of consciousness), headache, N&V(nausea and vomiting)

- treated by any other hospital?

- past medical history: underlying disease? DM/HPT? well controlled?

- Social hostory: ADL, who he is staying with?

- P/E- relevant and related: Observe, palpate, motor: Range of movement of limbs, sensitivity, neurological

- report any X-ray or CT scan done

Review pt in the morning. 

- the header is S/B Dr. XXX or <AM review> 

format:

- age/race/gender

- Post operation Day/ Day admission, what kind of surgery, 

- pt condition: oral and toiletry, SOB, fever, cough/flu, pain(pain score), 

- vital signs: BP, Pulse, T

- P/E: dressing, wound/condition

- Plan: continue previous meds, change dressing, physio referral, feeding, pain medication

Must know: (for ortho)

- how to read the spine X-ray/ any xray

    - check alignment

    - body: vertabral body, spinous process, antevertebral body, 4 lines of X-ray, 

    - any burst /compression fracture

    - to determine via TLCIS if the person with thoracolumbar injury needs surgery or not. 

- physical examination

    - motor, sensory and neurological: any abnormalities, know what is it testing for 

- differences between Upper Motor neuron and Lower Motor Neuron, 

    - Cauda Equina 

    - end of UMN is L2

COMMON TO DO LIST

• TO do ABG, use the blue needle and syringe to extrct the blood
• to do line, use pink needle, find the vein on pt hand, feel and put it in. 
• to do slap, need a friend to help with releasing the water from the back slap(10 layers)
• to do skin traction: prepare the cover and weight(10% of pt body weight)
• to be prepared always for mo who is coming for pt. 

fracture classifications

Common classifications used during orthopedic posting. 

In a glance:

Gustilo classification: open fracture

Gartland classification - supracondylar humerus fracture

Mason classification: radial head

Schatzker classification: radial head

Monteggia fracture dislocation: radial head dislocation

Galleazi fracture classification: distal radius

Salter-harris fracture: epiphyseal disk (growth plate) fracture

Garden classification: femural neck

Winquist fracture: femur shaft fracture

Evan's classification : intertrochanteric fracture

Danis Weber classification: ankle joint 

colles fracture

distal radial fracture

DFU classification (Wagner)

Management principles that we use commonly

• 4R: resus, reduce, retain, rehab

• Principle of open fracture:
• antibiotic - empirical - 6wks
• unasyn : for DM 
• cloxacillin :
• c. penicillin :
• tazocin :
• wound irrigation and debridement
• stabilization - or immobilization : external fixation/ skeletal traction
• wound closure - dressing, 2ndary wound closure 
• complication:
• mal union
• nonunion
• OM
• infected non union
• closed fracture
• internal fixation
• pop
• indication of External Fixation
• open fracture
• infected non union
• bone lengthening
• open book fracture
• comminuted, intraarticular fracture esp eadius
• joint fusion (knee)