Clinical Exam, May 20th , 2006-05-21 Sydney RHW 1.Febrile Convulsion â€“ talk to father of 17 months old Johnatan A 17-month-old boy yesterday had generalised convulsion for 2 minutes. Parents took him to emergency department. He came with a temperature 38 C + mouth congestion + enlarged tonsils. Today he is fine.Ask: What Ix. Has been done? (FBC, Culture, LP, throat swab, Urine, PCR) Mx: Febrile convulsion/FC: fever and convulsion / seizures occur in 3- 4% of children aged 6 months to 5 years and are recurrent in 25-30%. If there is family history or FC onset early in infancy then risk is increase to 50%. Seizures are usually brief (last < 5 min.) and generalised. Investigations : Physical signs may suggest the need for tests for the cause of the fever. Lumbar Puncture: A seizure with fever may be an early sign of meningitis. Consider doing a lumbar puncture, even if signs of meningitis are absent: in infants <12 months of age ; if the seizure lasted more than 10 minutes; if the postictal period was longer than 30 minutes; if the infant was pale and unwell before the seizure ; if already being treated with antibiotics ;if you are unsure Electroencephalogram (EEG): an EEG is not a helpful prognostic indicator in febrile convulsions. even the finding of paroxysmal epileptogenic activity does not predict the subsequent development of epilepsy and should not be used as an indication for the prescription of anti-epileptic drugs. In general EEGâ€™s should not be done in children with febrile convulsions (simple or complex). Neuroimaging: neither CT nor MRI scanning is necessary in a neurologically normal child with febrile convulsions, however, if recurrent focal seizures from the same site occur or if a neurological abnormality develops, neuroimaging should be undertaken. Features that increase the risk of subsequent epilepsy: Epilepsy is more likely to develop in children with febrile convulsions if they have any of the following: a prolonged seizure (more than 15 minutes), or a focal seizure an underlying neurological or developmental abnormality more than one seizure on the same day a residual neurological abnormality as a result of the seizure a family history of epilepsy in a parent or sibling very frequent febrile convulsions If none of these is present, the risk of epilepsy is no greater than in other children. What is Mx ? Most children are admitted with a 1st attack ( OXGP 726).If FC has not ceased after 3-5 minutes it is matter of urgency to terminate the seizure usually with i.v. or rectal diazepam 0.2-0.4 mg/kg ( max 10mg); If IV injection is not immediately possible, give the intravenous solution rectally in a dose of 0.5mg/kg. As a general rule, children three years and under can be given 5mg rectally, and children over three years can be given 7.5 to 10mg rectally. Intramuscular diazepam is poorly absorbed and is not recommended. General temperature lowering measure/remove the clothing, tepid sponging/cool washes and Paracetamol 15 mg/kg. 4 hourly (max. 6 doses a day .Do not exceed 90 mg/kg per day. A dose of 90mg/kd/day should NOT be continued beyond 48hrs). Although paracetamol is widely used in children with fever, it is often ineffective in reducing fever and does not reduce the incidence of febrile convulsions. 2.Mid-cycle bleeding on OCP â€“ talk to pt. A 22-year-old woman is planning marriage ands she started OCP a 6 weeks ago. She is not sexually active. She came to your clinic for PV spotting of 4 weeks. Otherwise well, non-N/V, no fever. No relevant PHx noted. Task; Advice and Mx. Reassurance and observation. Take history; is it post-coital spotting/ bleeding? When was last PAP? Is PAP smear due? What formulation do you use? First, reassure her that irregular bleeding during the first couple of pill cycles is not unusual. She should be advised to continue for at least two months to see if this settles. Also, encourage her to take her pill at about same time each day. If breakthrough bleeding does not settle within 3 months than it would be time to change hormone preparation. Increase oestrogen eg. if she is on Microgynon 30 mcg , switch to Microgynon 50 mcg. This usually controls breakthrough bleeding. 3.Carpal tunnel syndrome â€“ examination 4.PHOTO lump on the neck â€“ find primary site,/examination/DDx 5.Benzodiazepines dependency â€“ talk to pt / SE 6.Delirium â€“ Examine pt / MS/ Mx. 7.Gastrointestinal system examination â€“ alcoholic pt . 8.Headache/Meningitis â€“ Take History/Examine the pt/ DDx 9.Enuresis â€“ talk to parents Nocturnal enuresis (secondary enuresis /wetness after > 6 monthsâ€™ dryness.)â€“ Task: Mx. Mother came with her 4 y.o. son â€“ bed-wetting at night. He was dry for 1 year .His father also had bed-wetting but became dry by the age of 6 yr. Secondary enuresis is wetting after normal continence of at least 3 months. History (-)ve, Examination (-ve) Ix. MSU, US,(-ve).Explain and advice,Pad&bell explain.Question asked: is there are any other drugs for my son ?( desmporessin)Will this problem will be solved with the time Ix: check boyâ€™s urine by Multistix test (glucose, infection and specific gravity) a urine for M, C, S. Renal US may be suggested but it is probably unnecessary (unless there is a great deal of parental anxiety).Disorders of upper urinary tract do not cause enuresis. IV pyelogram is not indicated. Having excluded any organic pathology and having ensured that there are no serious emotional problems MX: Empathy (to the parents and child - regarding excessive washing of bedclothes and pyjamas); Reassurance/ no organic pathology present; Restriction of fluid shown not to be effective but they should feel free to try that as occasionally help to some children. Explain aetiology; Treat constipation if any; Spontaneous remission rate is ~ 15%/per year, so all children 6 years and over should be offered treatment; Children < 6 y.o. no need for treatment â€“most will resolve spontaneously. Star chart/ Reward for dry nights. 1st line treatment: the procedure called a â€œ bell and padâ€ / bed alarm-detector placed in the mattress under the sheet, some used pads in the pyjamas (body-worn alarm such as Male night trainer) or recently develop alarms used small bakelite chip attached to child underwear by safety pin, lead connected to the buzzer outside the bed - the alarm rings as the child begins the wet during the sleep use condition rules to train children to achieve better bladder control. It will cure ~ 60% of children. It is important that child is motivated. Treatment last usually between 6-12 weeks. (Up to 3 mo). So I would like to see you within 2-3 weeks to see how thing are going and to review the process. It may be some weeks B4 success is achieved. Where I can buy those alarms? You do not need to buy them, you can hire through Royal Children Hospital or privately from pharmacies or community. They will explain to you how to use it. Right. What if no response? Well, we can try 3-6 mo. Break and start second alarm treatment and if no response I will refer you to paediatrician, he can start treatment with some medicine nasal spray Desmopressin (Minirin) initially 20mcg/at bedtime for 1 week. Maintenance 10-40 mcg/bedtime; 10.Pregancy & Pneumonia pt on Doxycycline â€“ History/Examination/Mx Change Doxycycline to Erythromycin (Safe or relatively safe during the pregnancy: Amoxycillin/Ampicillin/Cephalosporine/Erythomycin/Rifampicin/ Trimethoprim/Methyldopa/ 25 y.o. with a wheeze, cough,yellow sputum.Had similar attack a 12 months ago. She received therapy and was OK afterwards. She is now 22 weeks pregnant. TASK: Take history, examine the pt and manage: Issues: 20/40 pregnant, with wheeze and sputum. Ix: Mother & baby DD: Asthma, Respiratory infection Mx: immediate and long term (Sydney, Niget q. 2003)How are you feeling today? Not good doc, I have SOB, chest tightness and chest pain. Previously Rx Tetracycline Pregnancy â€“ OK, no pain, D/C, no contractions Medical history: Heart, Thyroid, BP, OK, and no medication. Allergy = penicillin! No smoking, no pets, no allergy to pollen/dust etc. No FH of Asthma.O./E: looks irritable, flushed. BP: 120/80 mmHg T=38.5 Pulse=120/min. Chest examination: rhonchi and wheeze. F/Height + F/H = OK. Dx: Acute exacerbation of asthma + chest infection (yellow sputum + increased T) Mx: Admit to hospital Ix: FBC, blood culture, sputum, ESR, MSU, culture, Rx: antibiotics I.v. + bronchodilatator (allergic to penicillin & cephalosporins) Erythromycin safe in pregnancy What to do - bronchodilatator (Salbutamol) Nebuliser Q: Steroids - Yes if not relief 11.Pain relief in labour â€“ talk to pt.who is 20/40 pregnant; P0G1.She is very concerned about pain in labour. ( Beischer, p. 411) Ask why she is worried about pain? Any particular reason? What is her understanding about pain relief during the labour ? CS / normal labour. Discuss pharmacological, sedative ( Diazepam max 20 mg ) and hypnotics, tranquillisers ( major: phenothiazines - chlorpromazine, promethazine, or minor: diazepam ), ( analgesics (non-narcotic: aspirin, paracetamol, codeine; narcotic: pethidine 50-100 mg IM; Morphine 10-15mg IM; SE: respiratory depression, nausea & vomiting, tachycardia, postural hypotension and delayed gastric emptying). Pethidine is preferred and usually given IM 100 mg; it is given by I>V route in some centres either intermittently in small doses 25mg over 1-2 minutes every 1-3 hours or self administered by the women ( PCA â€“ patient controlled analgesia)The usual duration of narcotics drugs is 2-4 hours. Preferably such drugs should not be administered within 1 hour of delivery â€“ and if it is the baby should be given Naloxone ( 0.02mg) IM immediately after birth. During this period inhalation or regional block are preferable; Narcotics are CI in women receiving MAO inhibitors. The use of sedatives, hypnotics and minor tranquillisers varies considerably in obstetric practice in different communities. Many practitioners rely on single injection of Pethidine 100 mg IM with either prochlorperazine (Stemetil) 12,5 mg or metoclopramide HCL (Maxolon) 10 mg Â± epidural analgesia for pain relief in labour. Inhalational analgesics: Nitrous Oxide (NO) in concentration of 50% is equivalent to 15 mg of Morphine. Nitrous oxide/oxygen given by mask â€œon demandâ€; It is useful for analgesia during the late first stage and second stage (i.e. during delivery) in a 50-70% concentration with the oxygen. In their late fist stage of labour the women sleeps between contractions but rouses and breathes on the mask when the contraction begins. Advantages: safety, reasonable analgesia, on-toxic and non-irritating to respiratory passages, quickly absorbed and eliminated, uterine contractions unaffected (no prolongation of labour or postpartum atonicity), vomiting rare; Disadvantages: requirement of machine to deliver the gas and disorientation of some women ;Occasionally, women will not use the mask because of felling of suffocation or because of disorientation. Mention : Local analgesia/Epidural/Paracervical block. Discuss if you have time. Epidural nerve block: the local analgesic is injected extrathecally into epidural space; the extent of analgesia is determined largely by the volume and concentration of drug injected; to control pain of late labour, a block of segments T10 â€“ L1 is adequate; for Caesarean section a higher block â€“ T8 or even T6 is needed; low dose epidural analgesia (0.125 Bupivacaine) increases mobility in labour and abolish the urge to push (pushing reflex) but not ability to push so that normal spontaneous delivery is still possible. Although epidural analgesia is associated with a higher incidence of forceps delivery it must be recognised that women who require epidural analgesia for pain relief are more likely to require forces delivery, usually because of dystocia resulting from occipitoposterior position. Indication for epidural: pain relief; symptomatic heart disease â€“ the pain and distress of labour is relieved, however extreme care is necessary if women has a fixed cardiac output (e.g. mitral or aortic stenosis, pulmonary hypertension); hypertensive disorders (preeclampsia/eclampsia, chronic hypertension), cerebrovascular disease (intracranial aneurism and angioma are usual indication); incoordinate uterine action (elimination of pain and fear often help normalize the activity); breech and twin delivery( opinion is divide on the value of epidural analgesia in these conditions: the relaxation of pelvic floor is advantageous but the lack of stimulus for the woman to push can lead to a higher interference rate; Contraindications for epidural analgesia: opposition by the woman; Recent antepartum haemorrhage( because compensatory vascular reflexes are partly abolished, sudden haemorrhage may produce marked hypotension; suspected cephalopelvic disproportion; sepsis ( in proposed area of operation);sensitivity to local analgesic agents; DIC ( sever preeclampsia - predispose to haemorrhage in the epidural space ). Complication of epidural analgesia: toxicity (from overdosage and/or intravascular injection; hypotension; uterine hypotonia- occurs in 5-10% of women in early labour but usually activity return in 15-30 minutes; collapse (with hypotension and apnoea may be due to toxic effect of the drug); headache (may result from accidental puncture of the dura and leakage of CSF; this can be treated by insertion of epidural at higher level; after the delivery Hartmann solution is infused into epidural catheter; woman should be nursed flat, adequately hydrated Â± aspirin, codeine, paracetamol ; loss of sensation may occur in bladder ( causing over distension);loss of bearing -down reflex, resulting in higher incidence of assisted delivery; backache Majority of the above complications are rare, however they need experienced personnel in this type of analgesia; Advantages of epidural analgesia: woman alert, cooperative reduced risk of inhalation of vomitus; Disadvantage of epidural analgesia: need for skilled personnel, the occasional serious complication, tendency to slow the labour (particularly second stage) increased incidence of operative delivery; intraoperative nausea, vomiting or restlessness in some women. In Caesarean section, regional analgesia has a number of advantages over general anaesthesia â€“ participation of the parents in the birth, better postoperative pain relief, early mobility, less fever, blood loss is 50 % less than with general anaesthesia. Disadvantages are that the method may fail, the woman feels pain and may require a general anaesthetic; it is technically more difficult to extract the infantâ€™s head from the uterus, especially if a Pfannestiniel incision is used, because abdominal muscles are not completely relaxed; Paracervical block: LA (6-10 mg of 0.25 Bupivacaine) injected beneath the mucosa of vagina in each lateral fornix. Acupuncture; Incidence of serious neurological complications due to epidural analgesia: Paraplegia, a severe complication to epidural analgesia â€“ rare. Because of the rarity of permanent neurological damage resulting from epidural analgesia, it is difficult to estimate its incidence. In a combined series of more than 50 000 epidural anaesthetics, only three patients suffered permanent leg weakness (0.006% - American Journal of Anaesthesia , Kane 1981) 12.Obese patent / BMI 45 â€“ counselling 13.Dizzines/Vertigo 60 yo â€“ history/DDX 14. CHEST PAIN: â€“ History/ (Pericarditis) DDx: MI/Angina/PE/Aorta dissection 50-year-old train driver, c/o chest pain. From the history: pain for the last 6 hours, constant, pain 8/10, radiates to the back (alleviating/aggravating factors?). Non-smoker, had history of chest infection a 3/52 ago. Vital signs â€“ pulse 96 regular, BP 140/97, Temp. 37.4 Âº C. Physical exam â€“ constant noise during auscultation? Not murmur; probably pleural rub ACUTE PERICARDITIS: chest pain, which may be intense, mimicking acute MI, but characteristically sharp, pleuritic and positional (relived by leaning forward) worse on inspiration; fever and palpitations are common Common causes: idiopathic; infections (particularly viral â€“ influenza, Coxsackie A/B) acute MI, metastatic neoplasm, radiation therapy for the tumour (up to 20 years earlier), connective tissue disease (SLE, RA) drug reactions (procainamide, hydralazine), â€œautoimmune â€œfollowing heart surgery of MI â€“ several weeks/months later (Dresslerâ€™s sy). Physical Examination: rapid or irregular pulse, coarse pericardial friction rub which may vary in intensity and is loudest with pt. sitting forward. Laboratory/ECG: Diffuse ST elevation (concave upwards) usually present in all leads except aVR and V1.CXR: increased size of cardiac silhouette if large (> 250 ml) pericardial effusion is present, with â€œwater bottleâ€ configuration ECHO: most sensitive test for detection of pericardial effusion which commonly accompanies acute pericarditis; Treatment: Aspirin 650 â€“975 mg qid or NSAID (e.g. indomethacin 25 â€“75 mg qid); for severe refractory pain, Prednisone 40-60mg daily and tapered over several weeks or months. Anticoagulants are relatively contraindicated in acute pericarditis because of risk of pericardial haemorrhage. ( Harrison, p583) 15.Intusussepction A 5 months old baby, vomiting. Chills was screaming and drawing his legs up when he had a pain attack.. Talk to mother Intussusception: Clinical features - the peak incidence is between 2 months and 2 years, but can occur at any age; the pain is colicky, with quiescent periods, often with marked pallor; vomiting â€” clear early, bile stained after 12â€“24 hours; there may be a palpable sausage-shaped mass, or fullness with some tenderness; there may be red currant stools ( red jelly stools): it is always important to do a rectal examination, as this sign may otherwise be missed. Intussusception can be a great mimicker, so always consider it as a differential diagnosis in children with vomiting with a provisional diagnosis of "head injury" or "meningitis"; and in any obtunded child, especially with "gastroenteritis". Take a careful history of the pain (and vomiting) and perform a full examination including a rectal examination. If this does not suggest an intussusception and the child is relatively well, with no pallor and no tachycardia, then observe and re-examine. If the child is unwell, discuss with a surgeon. Treatment: is urgent enema reduction (with air or barium). If this is not effective, then open surgical manual reduction or resection is required. Urgent fluid resuscitation is occasionally needed if the child is in hypovolaemic shock. Placing a venous cannula should be achieved quickly, so that there is no delay in getting on with the enema reduction. Recurrence occurs in ~ 9 % of children after enema reduction, usually within the days. DDX: gastroenteritis; volvulus, strangulated inguinal hernia, 16.Intermitent claudications A 55 y.o. man presents with cramping pain on walking .He taking ACE inhibitor TASK Examine his legs & Discuss Mx. With a Pt. From history: FH of cholesterol (there are another case with a HTN for long- time). After how long walking, you got the pain. 50 m, 100m? Where is the pain? O/E: capillary return, venous filling, renal art. â€“ Auscultate palpation cold, pulse â€“ all absent except femoral. Burger test â€“ no much change. Q. What is your diagnosis? PERIPHERAL VASCULAR DISEASE â€“ INTERMITENT CLAUDICATION Where is the block? Superficial femoral artery the commonest site :Obstruction in the thigh > a. femoris superficialis causes pain in the calf eg. 200-500 metres, depending on collateral circulation, a. profunda femoris claudication about 100 m and multiple segment involvement claudication 40-50 metres. What Ix ? , FBC â€“ to see if anaemia (going to vascular surgery). Duplex U/S, Arteriography, Blood sugar, cholesterol, ABI index. Q. What is ankle brachial index? Measure ankle and brachial systolic pressure and then determine the ankle-brachial index (ABI), which is ankle pressure divided by the brachial pressure. Typical levels are: Normal >0.9 (venous ulcer), Ischaemic < 0.5 (arterial ulcer), Claudicant 0.5-0.9, Impending gangrene <0.3 or ankle systolic pressure <50mmHg.Lung function if smoker, Mx. risk factors, surgery. Showed angiogram report. Q. What you need for successful graft? What vessel you will use for graft? Saphenous graft.