Tuesday, August 28, 2018
Sunday, August 26, 2018
Wednesday, August 22, 2018
Tuesday, August 21, 2018
Saturday, August 18, 2018
Friday, August 17, 2018
Nephrotic Scheme
do GPE of 6 year old hamna.
6 yr old Hamna is a conscious cooperative child having obvious facial puffiness , abdominal distension , and pedal edema.
She has PR,Bp,RR, temp .
OFC,Ht, Wt, which i wld like to plot on percentile chart.
She has marked periorbital puffiness , pedla pitting edema extending upto mid tibia, and sacral edema.
She is pale with no jaundice, clubbing, koilonychia, palmer erythema, bruises , or lymphadenopathy.
6 yr old Hamna is a conscious cooperative child having obvious facial puffiness , abdominal distension , and pedal edema.
She has PR,Bp,RR, temp .
OFC,Ht, Wt, which i wld like to plot on percentile chart.
She has marked periorbital puffiness , pedla pitting edema extending upto mid tibia, and sacral edema.
She is pale with no jaundice, clubbing, koilonychia, palmer erythema, bruises , or lymphadenopathy.
Leukemia Scheme
Do GPE of 2 yr old child.
2 year old sehar is a sick looking , conscious and irritable throughout my examination having multiple bruise marks of different sizes and ages on her whole body.
She has radial pulse rate of 95 per minute which is regular and good in volume, BP of 90/50 mmHg, RR of 28/min and temp of 99degF.
her OFC is 48.5 cm , height is 83 cm, weight is 13 Kg all of which appear to be approproate for her age but i would like to plot them on percentile charts.
She has multiple bruises over her body in different ages, the largest measuring 8 by 8 cm on her back, with no gum , nose , ear ,conjunctival or joint bleed.She is pale , with anterior cervial lymphnodes palpable B/L, multiple lymph nodes measuring 3 by 5 cm,which are nontender, nonmatted, mobile, nonadherent to overlying skin, and the overlying skin is healthy. There are multiple medial and apical axillary lymph nodes palpanble on both sides with similar features having maximum size of 5 by 5 cm. There is no supraclavicular or inguinal lymphadenoapthy, no clubbing ,koilonychia,palmererythema, jaundice, examination of nose ear and oral cavity is no0rmal, BCG is present, examination of neck for thryoid swelling is unremarkable, There is bine tenderness however i cld nt appreicate it fully since child is very irritable.
There is a circular scar mark over right iliac crest , hypopigmented and measuring 0.3 by 0.3 cm.
on further extending my examination , she has soft non tender abdomen , with hepatomegally 5 cm below rt s/c margin in midclaviluar line wih 9 cmc total span of liver, liver is nontender, having sharp border, firm in consistencey, smooth surface, left lobe is not pal[pable, spleen is enlarged 10 cm along its axix toward rt iliac fossa, splenic notch is palpable , it is not ballotable and hand could not be instituite between spleein and ribs. therer is no other visercomergaly and no eviden if free fluid in abdominal cavity. Her exmiantion of respiratory systemi is unremakbale.
Pt hasnt passed stools in pampers yet, which i would like to see for blood.
D/D
Acute Leukemia
Disseminated Tuberculosis
Gaucher disease
Ix for leukemia, and t/m
--------------------------------------------------
so in this case there are bruises with lymphnodes. when we have either of these we look for the other of these.
and next we look for bleeding at other sites. and lymph nodes at other side. (not forgetting to measure both).
then we also dont foget to miss FEVER - bone TENDERNESS - BCG scar.
then we further FIND bone marrow biopsy scar !!!!!
and chk for viscera , and chest auscultwation.
--------
2 year old sehar is a sick looking , conscious and irritable throughout my examination having multiple bruise marks of different sizes and ages on her whole body.
She has radial pulse rate of 95 per minute which is regular and good in volume, BP of 90/50 mmHg, RR of 28/min and temp of 99degF.
her OFC is 48.5 cm , height is 83 cm, weight is 13 Kg all of which appear to be approproate for her age but i would like to plot them on percentile charts.
She has multiple bruises over her body in different ages, the largest measuring 8 by 8 cm on her back, with no gum , nose , ear ,conjunctival or joint bleed.She is pale , with anterior cervial lymphnodes palpable B/L, multiple lymph nodes measuring 3 by 5 cm,which are nontender, nonmatted, mobile, nonadherent to overlying skin, and the overlying skin is healthy. There are multiple medial and apical axillary lymph nodes palpanble on both sides with similar features having maximum size of 5 by 5 cm. There is no supraclavicular or inguinal lymphadenoapthy, no clubbing ,koilonychia,palmererythema, jaundice, examination of nose ear and oral cavity is no0rmal, BCG is present, examination of neck for thryoid swelling is unremarkable, There is bine tenderness however i cld nt appreicate it fully since child is very irritable.
There is a circular scar mark over right iliac crest , hypopigmented and measuring 0.3 by 0.3 cm.
on further extending my examination , she has soft non tender abdomen , with hepatomegally 5 cm below rt s/c margin in midclaviluar line wih 9 cmc total span of liver, liver is nontender, having sharp border, firm in consistencey, smooth surface, left lobe is not pal[pable, spleen is enlarged 10 cm along its axix toward rt iliac fossa, splenic notch is palpable , it is not ballotable and hand could not be instituite between spleein and ribs. therer is no other visercomergaly and no eviden if free fluid in abdominal cavity. Her exmiantion of respiratory systemi is unremakbale.
Pt hasnt passed stools in pampers yet, which i would like to see for blood.
D/D
Acute Leukemia
Disseminated Tuberculosis
Gaucher disease
Ix for leukemia, and t/m
--------------------------------------------------
so in this case there are bruises with lymphnodes. when we have either of these we look for the other of these.
and next we look for bleeding at other sites. and lymph nodes at other side. (not forgetting to measure both).
then we also dont foget to miss FEVER - bone TENDERNESS - BCG scar.
then we further FIND bone marrow biopsy scar !!!!!
and chk for viscera , and chest auscultwation.
--------
ITP scheme
Do GPE of 4 year old ahsan.
4 year old Ahsan is a healthy looking child who remained conscious and cooperative during my examination having multiple bruises in different stages all over his body.
He has radial pulse rate of 90/min which is regular , good in volume , BP of 100 / 60 mmHg, RR of 24 / min and temp of 98 degF.
His OFC is 50 cm , height is 100 cm , weight is 14 KG, which appear normal for his age but i would like to plot them on percentile charts.
He has multiple bruises in various ages over his trunk and limb the maimum of which meaures 5 by 8 cm, there is no associated gum bleeding, nose ear or conjunctival haemorrhage and the examination of joints is normal.There is no pallor, jaundice , lymphadenoapthy or bone tenderness., clubbing,koilonychia, palmer eryhtema, the examination of oral cavity is normal.there is no neck swelling and bcg scar is present. except for bruises there is no sign of any micronutrient deficieny ?
Both radial bones are palpable and there is no eczema.
on extending my examination, the examiantion of abdomen is unremarkable for any visceromegally.
------------------------
D/D
ITP
drug induced thrombocytopenia
vWD
leukemia (on t/m)
---------------------------------------------------------
Ix ( cbc, USS abd, HIV screen as in chr , EBV serology ?, coombs for evan syndrome)
Counselling and reassurance of parents.
no IM injections, no NSAIDS,
remove offending drug or get its drug levels, (NSAID, valproic, vanco , steroids, Heparin IT)
monitor for progression of bruises, get cerial CBC,
tm if less than 10,000 plt count.
(steroids, IVIG, RhoGam ( ICH ? plt , PCV transfusion)
romiplastin stimulates platelet production.
---------------------
if this were a FEMALE child,
i would include SLE in D/D and look for clinical signs of SLE,
and in investigation include workup for SLE also.
since i found bruises, i have to look for other sites of bleeding, and specially for joint bleeds,
and for cause of bleeding >>> acute hepatitis , CLD, malnutrition with Vit K deficiency, hemphilia, vWD or Plt related disorders,
4 year old Ahsan is a healthy looking child who remained conscious and cooperative during my examination having multiple bruises in different stages all over his body.
He has radial pulse rate of 90/min which is regular , good in volume , BP of 100 / 60 mmHg, RR of 24 / min and temp of 98 degF.
His OFC is 50 cm , height is 100 cm , weight is 14 KG, which appear normal for his age but i would like to plot them on percentile charts.
He has multiple bruises in various ages over his trunk and limb the maimum of which meaures 5 by 8 cm, there is no associated gum bleeding, nose ear or conjunctival haemorrhage and the examination of joints is normal.There is no pallor, jaundice , lymphadenoapthy or bone tenderness., clubbing,koilonychia, palmer eryhtema, the examination of oral cavity is normal.there is no neck swelling and bcg scar is present. except for bruises there is no sign of any micronutrient deficieny ?
Both radial bones are palpable and there is no eczema.
on extending my examination, the examiantion of abdomen is unremarkable for any visceromegally.
------------------------
D/D
ITP
drug induced thrombocytopenia
vWD
leukemia (on t/m)
---------------------------------------------------------
Ix ( cbc, USS abd, HIV screen as in chr , EBV serology ?, coombs for evan syndrome)
Counselling and reassurance of parents.
no IM injections, no NSAIDS,
remove offending drug or get its drug levels, (NSAID, valproic, vanco , steroids, Heparin IT)
monitor for progression of bruises, get cerial CBC,
tm if less than 10,000 plt count.
(steroids, IVIG, RhoGam ( ICH ? plt , PCV transfusion)
romiplastin stimulates platelet production.
---------------------
if this were a FEMALE child,
i would include SLE in D/D and look for clinical signs of SLE,
and in investigation include workup for SLE also.
since i found bruises, i have to look for other sites of bleeding, and specially for joint bleeds,
and for cause of bleeding >>> acute hepatitis , CLD, malnutrition with Vit K deficiency, hemphilia, vWD or Plt related disorders,
Thursday, August 16, 2018
GPE scheme
DO GPE and relevant of 5 yr old child.
5 Yr old Ali is a conscious co-operative child with sallow complexion having double lumen catheter passed on left side of neck , with an obvious circular hypopigmented scar on right side of neck and IV line passed on dorsum of right hand.
He has radial pulse rate of 90/min which is regular and good in volume.,BP of 140/90mmHg, RR of 22/min and temp of 98 degF .
His OFC is 51cm, height is 90 cm and weight is 14 KG, both height and weight appear to low for his age which i would like to plot on centile charts.
He has pallor with no jaundice ,clubbing ,koilonychia , palmer erythema, or lymphadenopathy.
examination of eyes,nose,ears and oral cavity is unremarkable except for the presence of dental caries.BCG scar is present and there is no neck swelling.There is B/L pitting pedal edema extending upto mid of tibia, there is a horizontal straight scar mark 10 cm in length extending from umbilicus towards right side , with multiple suture scar marks around this scar. the scar is hypopigmented. There is another hypopigmented circular scar measuring 0.5 by 0.5 cm , 5 cm to the left of umibilicus,
Patient has genu valgum deformity , with intermalleolar distance of 15 cm., he is able to walk stooping forward .
Examination of back is normal , he has male type genitalia with prepubertal SMR.
On extending my examination -
(abdomen, )
gower?
every GPE should include BCG, thyroid exam, genitalia , back.
------------------------------------
bruise ?
macule - patch ?
scar ?? measure measure measure !!!!! --- by --- cm
lymph node palpable? do all maeuvers of swelling, and MEASURE
suspected renal case? lower limb issues? CNS case? EXAMINE back , palpable bladder, older child look for pampers !
look of passed IVVV Line , look for scar mark of RENAL BIOPSY on back in a case OF NEPHROTIICCC or CKD ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,of SLEEEEEEEEEEEEEEEEEE !!!
CUSHING SYNDROME !!! LOOK FOR biopsy scar mark on back !!!!!!!!!!!!!!!!
(nephrotic, SLE on t/m)................(asthma case ?)
SPEED up thinking about what i have to do next after i am done doing this step !!!!!!!!!!1 (GPE or any systme exam)(SPEED UP THIS WAY)
Must not forget patient weaing GLASSES ? HEARING AID ?? PAMPERS ??
Having wheel chair by him?
foley passed/ NG passed/ iv ? central line?
watch close for petechiae, and bruise, if present, look for gingival bleed, nose ear conjunctival bleed, joint bleed, and check pampers for blood !!!!!!!!!!!!!!!!!
wATCH out for sickness status, irritability, play fullness of child.
-----------------------------------
WHILE taking history do not say BAJI, APA, aunty... ask them what language he/she prefers. punjabi ?
DO NOT LEAD, find shortcut questions to cover up complication or systems, like chalnay phirnay ka koi masla hua tha - to cover up for any stroke like illness/ joint issues/ etc.
give 3 min initally to mother to speak !!!!!
---------------------------
WHILE doing GPE, say it in your mind all positive findings that you are seeing.
So GPE finding will lead , where and WHAT you have to see more in GPE and , what in systemic examination
-----------------------------
5 Yr old Ali is a conscious co-operative child with sallow complexion having double lumen catheter passed on left side of neck , with an obvious circular hypopigmented scar on right side of neck and IV line passed on dorsum of right hand.
He has radial pulse rate of 90/min which is regular and good in volume.,BP of 140/90mmHg, RR of 22/min and temp of 98 degF .
His OFC is 51cm, height is 90 cm and weight is 14 KG, both height and weight appear to low for his age which i would like to plot on centile charts.
He has pallor with no jaundice ,clubbing ,koilonychia , palmer erythema, or lymphadenopathy.
examination of eyes,nose,ears and oral cavity is unremarkable except for the presence of dental caries.BCG scar is present and there is no neck swelling.There is B/L pitting pedal edema extending upto mid of tibia, there is a horizontal straight scar mark 10 cm in length extending from umbilicus towards right side , with multiple suture scar marks around this scar. the scar is hypopigmented. There is another hypopigmented circular scar measuring 0.5 by 0.5 cm , 5 cm to the left of umibilicus,
Patient has genu valgum deformity , with intermalleolar distance of 15 cm., he is able to walk stooping forward .
Examination of back is normal , he has male type genitalia with prepubertal SMR.
On extending my examination -
(abdomen, )
gower?
every GPE should include BCG, thyroid exam, genitalia , back.
------------------------------------
bruise ?
macule - patch ?
scar ?? measure measure measure !!!!! --- by --- cm
lymph node palpable? do all maeuvers of swelling, and MEASURE
suspected renal case? lower limb issues? CNS case? EXAMINE back , palpable bladder, older child look for pampers !
look of passed IVVV Line , look for scar mark of RENAL BIOPSY on back in a case OF NEPHROTIICCC or CKD ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,of SLEEEEEEEEEEEEEEEEEE !!!
CUSHING SYNDROME !!! LOOK FOR biopsy scar mark on back !!!!!!!!!!!!!!!!
(nephrotic, SLE on t/m)................(asthma case ?)
SPEED up thinking about what i have to do next after i am done doing this step !!!!!!!!!!1 (GPE or any systme exam)(SPEED UP THIS WAY)
Must not forget patient weaing GLASSES ? HEARING AID ?? PAMPERS ??
Having wheel chair by him?
foley passed/ NG passed/ iv ? central line?
watch close for petechiae, and bruise, if present, look for gingival bleed, nose ear conjunctival bleed, joint bleed, and check pampers for blood !!!!!!!!!!!!!!!!!
wATCH out for sickness status, irritability, play fullness of child.
-----------------------------------
WHILE taking history do not say BAJI, APA, aunty... ask them what language he/she prefers. punjabi ?
DO NOT LEAD, find shortcut questions to cover up complication or systems, like chalnay phirnay ka koi masla hua tha - to cover up for any stroke like illness/ joint issues/ etc.
give 3 min initally to mother to speak !!!!!
---------------------------
WHILE doing GPE, say it in your mind all positive findings that you are seeing.
So GPE finding will lead , where and WHAT you have to see more in GPE and , what in systemic examination
-----------------------------
Tuesday, August 7, 2018
Sunday, August 5, 2018
Wednesday, August 1, 2018
calcium and phosphate labs
to differentiate further between fanconi syndrome and x linked hypophosphatemic rickets , get serum HCO3 levels.
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