Paediatric Short Case

Today I had my Paediatric Posting short case exam. I got a case of a child with severe cyanosis, and polycythamic. Clinical findings was fingers and toes clubbing, peripheral cyanosis, red conjunctiva suggestive of polycythaemia. On auscultation of the chest, I only found loud P2. There was no murmur, and no signs of heart failure. My initial diagnosis was pulmonary atresia, that was a bad step! I shouldnt have said that, the doctor asked me questions on pulmonary atresia and I couldnt answer. The she go on asking me questions on cyanotic heart diseases which I manage to answer some. But finally I came to a diagnosis of complex cyanotic heart disease.

Tomorrow I gonna have my MEQ exam at 4pm at Paediatric department. My supervisor wants to see me at 2pm tomorrow, I wonder is he gonna ‘hantam’ me as he usually does. This posting has really been stressful for me. With me being the group leader, so much responsibilities, sometimes when I make little mistakes, I got terrible ‘hantaming’ by the lecturers.

Just recently I almost quarrel with one of my groupmates over some clinical session. We wanted that particular lecturer cuz he haven taught us before during posting, but this guy insisted on having him instead. When I insisted on having that lecturer, he show me a sour face. Then after tat I decided to give in, I let him have that lecturer. That particular night, I was so frustrated and irritated. But now I decided to put this behind me, and look forward. Anyway I already to accept everyone in my group regardless of who they are. I have to keep on reminding myself, tat Im a christian, and should learn to be gracious to ppl.

Today i played badminton with a 1st yr medic gal. She is a thin and tall sweet gal from nurani. We knew each other for bout a month and I enjoy her company. Many time we met and talk, but rumours about us are spreading like hot goreng pisang! Many ppl are asking her wat is her relation with me. Fortunately she edi has a bf, otherwise ppl will be thinking that Im dating her. Gossips bout me in campus is not something uncommon. But im not worried, one day they get tired, they wil stop gossiping edi.

Tomorrow got CF, I wonder whether shud I go o not? Really feel malas wanna go…

Causes of respiratory distress in term infants

PULMONARY CAUSES

Common

Transient tachypnoea of the newborn – Caused by delay in the resorption of lung fluid and is more common after birth by C-section. CXR may show fluid in the horizontal fissure and additional ambient oxygen may be required. Condition usually settles within first day of life but can take several days to resolve completely.

Less common

Meconium aspiration – Meconium is passed before birth by 8-20% of babies. Rarely passed by preterm infants and occurs increasingly the greater the gestational age, affecting 20-25% of deliveries by 42 weeks. Asphyxiated infants may start gasping and aspirate meconium before delivery. Meconium is a lung irritant and results in both mechanical obstruction and a chemical pneumonitis. In meconium aspiration the lungs are overinflated, accompanied by patches of collapse and consolidation.

Pneumonia – Prolonged rupture of the membranes, chorioamnionitis and low birthweight predispose to pneumonia. In this kind of case, we usually start broad spectrum antibiotics early

Pneumothorax – May occur spontaneously in up to 2% of deliveries. May occur secondary to meconium aspiration, RDS or as a complication of ventilation

Milk aspiration – More frequently in preterm infants and those with respiratory distress or neurological damage. Babies with bronchopulmonary dysplasia often have gastro-oesophageal reflux, which predispose to aspiration

Persistent pulmonary hypertension of the newborn – This life-threatening condition is usually associated with birth asphyxia, meconium aspiration, septicaemia, or respiratory distress syndrome. As a result of high pulmonary vascular resistance, there is right-to-left shunting within the lungs and at atrial and ductal levels. Cyanosis occurs soon after birth. CXR may show pulmonary oligaemia. Most infants require mechanical ventilation and circulatory support in order to achieve adequate oxygenation. Inhaled nitric oxide, a potent vasodilator, is often beneficial. Extracorporeal membrane oxygenation (ECMO), where infant is placed on heart and lung bypass for several days, in indicated for severe cases.

Other rare causes

Diaphragmatic hernia, Tracheo-oesophageal fistula, Pulmonary hypoplasia, Airways obstruction, Pulmonary haemorrhage

NON-PULMONARY

Congenital heart disease, Intracranial birth trauma, Encephalopathy, Severe anaemia, Metabolic acidosis

News from Neonatal Intensive Care Unit (NICU)

I have been in NICU for bout 2 days. Its really terrible and saddening to see those newborns admitted to NICU. Some of them are jaundiced, some with breathing difficulties, some with Down syndrome and even some with congenital heart disease in failure. Some of them got ill due to maternal problem but some just got it without any reasons. Imagine you are a parent who just got a child and suddenly the doctor who delivered your child suspect your child to be Down syndrome. How do you feel? It really an agony to hear that, just like the world is crushing on you.

Today while oncall, I got to meet parents of a newborn in NICU. It was their first child, and the child was infected with multiple organism, both fungal and bacteria. The doctors suspected it to be immune deficiency and started the newborn on multiple antibiotics to cover fungal, gram positive and gram negative bacteria. The father seems to be in distress, asking me questions bout his child. But im doesnt really know the child and its problems, although the child seems stable currently. Then the father went on saying that some parents just throw their child away after giving birth but he and his wife has been trying hard to get a child. And when they finally got a child, it was not without problems…

I guess that’s how the world functions. Things that are easily obtained are owiz being unappreciated…

Recently Im beginning to accept those selfish kiasu coursemates of mine. My dad once said to me, these people are non-christians, many things they dun know and dun understand, we should pray for them. These kiasu ppl, I cant change their behavior, being upset over them is not going to do any better either… So now Im learning and trying to accept them as they are, hoping that one day they will realise wat they have been doing…

Neonatal Examination

These are the few tips I learned today on neonatal examination…

1. Firstly we look at the child’s general appearance. See whether the child is in respiratory distress, discomfort, pain. Also we should observe the patient’s posture and movements. (For us to do this, the baby needs to be fully undressed)

2. Find out the patient’s gestational age. If we suspect the patient’s is a pre-term baby, use the Ballard score to assess his/her gestational age. (I will share on Ballard score later…). Also we should not forget to measure his/her birthweight, length and head circumference and plot the growth chart. Take note if the patient’s birthweight/ length or head circumference is below 5th percentile or above 95th percentile.

3. Palpate both anterior and posterior fontanelle. Feel whether is it tense or not. A tense fontanelle when the baby is not crying may be due to raised intracranial pressure and cranial ultrasound should be performed to check for hydrocephalus. Also we should palpate the sutures. The sagittal suture is often separated and the coronal suture may be overriding.

4. Observe the face. Look for any syndromic facies such as flat occiput, flat nasal bridge, hypertelorism, low set ears, unslanting of palpebral brigde, cleft lips, increase intercanthal distance, small jaw. etc etc. This features could indicate Down, Edward, Patau or Turner syndrome.

5. Also look at the face for any plethoric, cyanosis, jaundice or paleness. If yes, check the haematocrit to identify polycythaemia or anaemia. Central cyanosis is best seen on tongue. Jaundice within 24 hours of birth requires further evaluation.

6. Examina the eyes, checked for red reflex with an ophthalmoscope (cataracts, retinoblastoma and corneal opacity). Inspect the palate, including posteriorly to exclude posterior cleft palate.

7. Observe patient’s breathing and chest wall movement. Look for any sign of respiratory distress such as subcostal recession and chest wall indrawing. Confirm it by counting the respiratory rate. ascultate the heart for any murmur and count the pulse rate. The normal rate in babies is 110-160 beats/min, but may drop to 85 beats/min during sleep

8. Palpate the abdomen. Feel for any intraabdominal masses which most commonly is renal in origin. The liver normally extends 1-2 cm below the costal margin, the spleen tip may be palpable, as may the left kidney.

9. Inspect the genitalia and anus. In boys, look for presence of testis in scrotum. In girls, look for labia majora and labia minora. You should be able to differentiate between the two. Also look for any fistula or discharges.

10. Palpate for femoral pulses. Femoral pulses is reduced in case of coarcation of the aorta. This can be confirmed by measuring the blood pressure in the arms and legs. Femoral pulses is increased in case of patent ductus arteriosus.

11. Assess the muscle tone by observing limb movements and on sitting the baby while supporting the head. Most babies will support the head briefly when the trunk is held vertically.

12. Whole of back and spine is observed looking for any midline defects of the skin

13. The hips are checked for development dysplasia of the hips (DDH). This is left last as the procedure is uncomfortable.

Cerebral Palsy (CP)

Def : Disorder of MOVEMENT and POSTURE due to a non-proggresive lesion of motor pathways in the developing brain.

It is the most common cause of motor impairment in children, affecting about 2 per 1000 live births. In addition to disorders of movement and posture, children with cerebral palsy often have other problems reflecting more widespread brain dysfunction. These include:

- Learning difficulties (about 60%)

- Epilepsy (40%)

- Squints (30%)

- Visual impairment from errors of refraction and cortical damage (20%)

- Hearing impairment (20%)

Causes

- 80% is antenatal in origin due to vascular occlusion, cortical migration disorders or even structural maldevelopment of the brain during gestation

- 10% due to hypoxic-ischaemic injury at birth

- 10% postnatal in origin. Preterm infants are especially vulnerable to brain damage from periventricular leucomalacia (PVL) secondary to ischaemia and/or severe intraventricular haemorrhage.

Clinical Presentation

Early features of CP include

- Abnormal limb tone and limb and/or trunk posture in infancy with delayed motor milestone; may be accompanied by slowing of head growth

- Feeding difficulties, with oromotor incoordination, slow feeding, gagging and vomiting

- Abnormal gait once walking is achieve

- Asymmetric hand function before 12 months of age.

There are 3 main clinical types of CP, namely spastic (70%), ataxic hypotonic (10%), dyskinetic (10%) and mixed pattern (10%)

A. Spastic (3 main types)

Hemiplegia : Unilateral involvement of the arm and leg, with the face spared. Affected children often presented at 4-12 months of age with fisting of the affected hand, a flexed arm, a pronated forearm, asymmetric reaching or hand function. Subsequently a tiptoe walk on the affected side may be evident

Quadriplegia : All 4 limbs are affected, often severly. The arms may be affected more than the legs. The trunk is involved with extensor posturing and poor head control. This form of CP is often associated with seizures, microcephaly and moderate/severe intellectual impairment

Diplegia : All 4 limbs, but the legs are affected to a much greater degree than the arms, so that hand function may appear relatively normal. Walking is abnormal

B. Ataxic hypotonic CP

Signs are relatively symmetrical. There is early trunk and limb hypotonia, poor balance and delayed motor development. Incoordinate movement, intention tremor and an ataxic gait may be evident later.

C. Dyskinetic CP

Dyskinesia (fluctuating tone) leading to frequent involuntary movements (generally of all 4 limbs) especially evident with movement/stress. These involuntary movement may be…

Chorea : irregular, sudden and brief non-repetitive movements

Dystonia and athetosis : Simultaneous and sustained contraction of agonist and antagonist muscles involving the trunk and proximal limbs (dystonis) or distal part of the limbs (athetosis)

Ref : Illustrated Textbook of Paediatrics

Acute Asthma

I just finished my clinical exam with Prof. today. Got an acute asthma case. Couldn’t decide whether my patient’s acute asthma is mild, moderate or severe.

This is how we classify acute asthma as mild, moderate or severe in Malaysia.

	Mild (admission unlikely)	Moderate (may need admission)	Severe (admission needed)
Altered consciousness	No	No	Yes
Physical exhaustion	No	No	Yes
Talks in	Sentences	Phrases	Words
Pulsus paradoxus	Not palpable	May be palpable	Palpable
Central cyanosis	Absent	Absent	Present
Rhonchi	Present	Present	Silent chest
Use of accessory muscle	Absent	Moderate	Marked
Sternal retraction	Absent	Moderate	Marked
Initial PEF	> 60%	40-60%	< 40%
SaO2	> 93%	91-93%	<90%

I think I really got a nice bashing this time around. Feel kinda depressed now…

Tomorrow will be MCQ. Hope things gets better…

Remedial Paediatric Posting

Im back in campus, have to do remedial for paediatric posting. Still feel the tiredness in me after the 8 hours journey from Shah Alam, so much to study, so much to cover… I didn’t expect to fail my paediatrics, seems medical life is unpredicatable. Paediatrics was my last posting, I expect to pass it and continue my elective in Hospital Klang, but wat happen…

Im reali disheartened over it, sad and heartbroken. I have gone thru so many setbacks in 4^th year, yet another problem prop up. I’m losing my self-esteem recently, every posting I struggle to pass. I did once failed my ORL posting, but thank God I managed to repeat the exam with the next group and then passed it.

So many thoughts are going thru my mind now, I dunno wat gonna happen soon. How is my future going to be? Wil I be able to make thru medical school?

My dad once said, as a Christian, we will have to undergo trials and tribulations. Only thru this trials and tribulations, our hearts and soul will be moulded to be better and better. When problem arise, we can choose to be bitter, or choose to rise up above the challenge. It never easy to do the latter, tat is to rise up above the problem, that’s y we need to come to God

I dunno how this two weeks of paediatrics gonna be, we are going to go thru clinical sessions, oncalls, and lectures. At the moment, besides studying, there’s nothing I can do, except to put all my hope, faith, trust in the Almighty God. Only with God, I shall see my paediatrics through. I guess I won’t be writing any blog until my exam over (which is next week). I will do my best for HIM!

Post-clinical Exam

I just finished my clinical exam at 4.00pm today. I got a febrile fits case, but the presentation doesn’t seems to be febrile fit. Beside fit, patient has blue spells, shortness of breath, pale. On examination, I found patient to have prolonged expiratory phase. My history and examination doesn’t tally at all. Bad la…

At least the patient was cooperative, although he was only 5 months. I did presented my case to doctor and was asked a number of questions which I couldn’t answer most of them. Dunno how?

Hopefully tomorrow MCQ will be much better. I just can’t wait to go back this thursday. Really cannot tahan staying in this campus…

Soar like an eagle.

It’s already 9.14pm and my body is reacting well to paracetamol I took bout half hour ago. Really a relieve for me. More than 1 hour ago, my body was aching terribly, with my temperature rising up, headache all over my frontal and occipital region. Really really bad. Maybe I guess its due to my excessive exercise! I have been playing squash for the past 5-6 days continously.

Now at least Im better, can continue my studies. I need to equip myself with sufficient knowledge before exam in 2 weeks time. I know I dun stand as tall as the ‘A’ student in my group. But I believe I can match them by the end of next year, which is my final year. When this happen, it will be a good chance for me to glorify God. A knowledgable doctor will bring benefits to his patient. I believe in Jesus, I believe in His power, I believe in His miracles. Im going to soar like an eagle in academics!!!

God has been so faithful to me. I finally passed my ORL posting (Have to take it twice!). I was relieve by that, my ORL posting has been worrying me the past 1 month. Really glad its over. Now only let Paediatrics to go on. Again Im relying on His grace to carry me through.

Sometimes I kinda feel afraid and reluctant writing blogs. Got some kind of fear that people might think negatively about me or even have some presumptous ideas about me. But this blog has been really useful for me to channel out my feelings and opinions without hurting anyone. Without this blog, I might be storing up my feelings, and one day it might explode.

One more thing I wanna thank God here is that, one of my non-christian fren has approached me, and asked me to give him some materials about Jesus to read. This has not happened to me for a long time and Im glad for this. I really hope and pray that God will open up his heart and bring his to salvation.

Tomorrow I will be going to Hospital Kota Bahru again. Hope to see more patient and learn more things there.

Finding new strength

It has been almost 1 week since I let go of my romantic feelings towards her. My heart is gradually healing and getting better. Though there is a sense of loneliness in my heart, but I just ignore it. I try to comfort myself by saying to myself, ‘There are many more people out there who were must more lonelier than me. At least I still have my family behind me at the time. Many sick people in ward were all alone battling against their illness’. It’s time to come back to reality and continue with life.

I also have been trying to keep myself busing with ward work in the hospital, getting my log book requirements done as fast as possible. Paediatrics in USM here really challenging, we are expected to be in ward from 8.00am till 5.00pm in the evening and oncalls at least once a week. Really no time to study at all. It’s already the 3^rd week of paedciatrics and I only got 4 case presentation! Getting worried and anxious… Will I make it in this posting?

Anyway, life in paediatrics ward has it’s pros too. Everytime I get stress or fed-up, but when I look at those cute little kids in the ward, some how my heart melted. I’m filled with compassion for their illness. Some of them are diagnosed with serious illness such as Down Syndrome, Immunodeficiency, pneumonia. These kids did nothing to deserve what they are suffering now! It’s just that they are unfortunate, sometime I do wonder why God allow such things happen to them? This is really an unfair world…

Yesterday I got to do an Exchange Transfusion (ET) for a little newborn. He was born with severe jaundice and needed that transfusions to bring his bilirubin’s level. I happen to be in the ward that time, and the nurse there asked me to come down to NICU to help the doctor there do ET. The ET was a long procedure, after a while I got tired, and sick of it. But when I looked into the baby’s eyes, and put myself in his shoes, imagining myself as the baby, I felt compassionate for the baby. So I soften my heart and continue the ET.

I believe patient in the wards not only needs the physical healing, they also need the spiritual healing from God. They need salvation. I’m the only Christian in my group, and most of the time, I noticed I’m the only Christian in the ward. I want to shine for Christ and bring the gospel of Jesus to the sick but all the times, my mouth just can’t open. I usually waits for the opportunity where the patient will say something that can make me bring out the picture of God but all the while, this has not happened yet…