term ‘borderline of viability’ to describe
extremely premature babies who are born at or
before 25 weeks and six days (pregnancy usually
lasts for 40 weeks). In England, 1,600 out of
584,000 (0.28 percent) deliveries were at the
borderline of viability in the year 2004-2005.1 This
percentage has been increasing since the
beginning of the 1980s, which may be due to
several factors, including the rise in fertility
treatment. Most extremely premature babies die,
but the age at which they can survive has dropped
by about one week for every decade in the past 40
years. A 1995 UK-wide study called EPICure showed
that the percentage of babies born alive in 1995
between 22 to 23 weeks who survived to leave
hospital was 1%; at 23 to 24 weeks it was 11%; at
24 to 25 weeks, 26%; and 25 to 26 weeks, 44% (see
Table 1 ). Survival before 22 weeks is very rare.2
More recent data from other countries and specific
areas in the UK indicate that survival rates have
become higher since EPICure, and these may be
more useful for providing advice to parents.
Most cases will be stable hence it'll be easy to distiguished between cyanotic or acyanotis plus minus heart failure
1) General inspection - mention cyanosis/acyanotic and failure/not and dysmorphism
2) Clubbing - will give clue straight away
3)Scar - Midline sternotomy definite complex heart. L/R thoracotomy the there're differential between cardiac and non cardiac surgery. If both present, it must be palliative ie BT shunt plus corrective repair ie if Fallot's removed RVO obstruction.
4) Most fear will be what murmur
Decide heart sound 1st . Can u hear 1st n 2nd. 2nd HS is it fixed, split or other sound(3rd/4th). Loud P2 assoc with pulmunory HTN, dont dig a hole if u r not sure.
Then what murmur
a.Ejection systolic
Acyanotic - ESM with suprasternal/carotid thrills - AS
Sometimes corrective surgery have diastolic component ie in Pulm stenosis with open heart, may have pulm regurg murmur or residual murmur
ESM with wide splitting - ASD
ESM with weak pulse - think coartation even repaired one can fail or type of repair with reduce pulse(subclavian flap)
OK. Now I have given some for acyanotic. Can anybody guide me of cyanotic heart???
Cyanosis
1) single heart sound - TOF
2) can somebody tell me how to find branch stenosis of pulm artery(how to differentiate)
Know some procedure
a) Blalok Tussaig - subclavian to pul artery
b)Glen - SVC to pulm artery
c)Fontan - SVC+IVC connected to pulm artery plus closed ASD
d)Norwood- Rebuilding aorta using R ventricle
I am neither nervous nor scared. It's similar drill that u have to do in any courses. It's hard to swallow if I didnt make it. I think I have improved a bit in certain area though there are a lot more to do. The good bits is that I have 'sparing' partners to discuss. It makes a lot more sense if u discuss, observe others doing exam and helping out each other. I think I am doing it alone here. May be ya all have yet to go through what I have been. It's not exausting journey, I enjoy reading, making revision and discussion. I havent given myself a break from exam. I believe in myself to be a competent paediatrician. I hope so do you all.
I am flying to Glasgow tomorrow. If u sit exam with me, we can discuss. Do not fear, the examiner is not going to eat you. Do with your own pace methodically. Proud to be yourself becoz you have done till this stage. I pray this will be my final one. It's not a matter of knowledge, becouse it's obtainable from reading and experience. It is about your confidence, being safe doctor, able to be competently becoming middle grade doctor, which I am right now.
I shall update you all about cases which we have seen(me and my friends). Please be free to add cases u have seen here. It's for benefit of all. Cases, I believe will come out again and again.
Yes, there are cases which can be predicted to come out. It's all in books. I have read about syndromes as expected, if I dont know then describe the abnormalities on clinical finding. Dont dig hole!!!Cases like Crohn, Cystic fibrosis, diabetes, asthma should be at the tips of ur finger. 9 mins is not long. Perhaps you will spend 5 mins examining only, the rest 4 mins for discussion. It may not be long if u r fluent enough.
I think I have run outta tips. Majority of them extracted from books, my own experience and my friends knowledge. I feel humbly need teaching if my info was incorrect, impractical and obsolete. This is easy exam as I said. It just need precision of ur clinical skills. Some of exam tailored for local graduate if the issues concerning community Paediatrics
. For example, they may discuss child protection issues, non accidental injury, extreme prematurity, non resuscitable children or fabricated induced illness. However, in the era of internet, all these info are obtainable, discussable and freely available.
I am sorry coz I am unable to provide comprehensive CVS XM details, I am yet to become cardiology doctor. Hopefully in my next job, I shall be well versed with paeds cardiology. I pray that God will give me the chance to do so.
In the midst of stress of exam, I am here just to let you know couple of cases seen by my friend
1) Resp case - Kartagener with bronchiectasis. Check situs inversus
2)CVS - Aortic stenosis. Advice prophylaxis abx and avoid strenous exercise in severe stenosis. Check other syndromic assoc like Williams
3) Neuro - Examine upper limb. 10 y old with hx fall 2/52 ago. Not sure what case is. Unable to move arm
4)Other - Nystagmus in a child
5)GI - 6/12 old with jaundice and have NG in situ. Think about extra or intrahepatic liver failure
6)Long case - Complex patient with hx of epilepsy. Presented with 6/12 hx of not sleeping. Stress multidisciplinary, problem with behaviour and look at social aspects
I have just completed my xm. SIGH....I am not confident at all this time. I hope time permits me to rewind back the history. I was hesitant in 2 stations. Anyhow, I reserved my deep hope inside me.
I startled at my first station but gaining momentum afterwards
1)Neuro - 11 y old who is clumsy. Examine. I was puzzled as was the instruction. Becoz of neuro station, I started examining the neuro of upper n lower limbs. I could find any thing initially. The examiner pushed me to do more quickly, I found he was unable to walk in straight line. It's ataxic, he has past pointing, no truncal ataxia, normal speech. Then i blank. He said anymore xm especially eye? Gosh i forgot nystagmus. So I was just not up to my pace at that stage...
2) GI - Child who is known to have hematuria. He has Tenchkoff catheter. Scar on umbilical, below the umbilical and 2 drainage site on R to umbilicus. I couldnt find any other abnormality. He asked me, what other scar for if it's not drainage site, easy enuff, previously inserted peritoneal dialysis cath
3) Other - I cocked up again. Child with multiple joint pain. Definite JIA, no major abnormality apart decreased ROM. I didnt expect musculoskeletal xm. I felt bad afterwards. No swelling, I did look-->feel-->move manouvre. Stop at that, the examiner asked about ROM. I was blank for a while coz I didnt expect that. I mention restricted on abduction, adduction..I didnt do flexion and extension of hip joint. I was awful though I demonstrated multiple joint pain....
4) CVS- Child with midline sternotomy with L thoracotomy. Got good murmur with thrills on praecordium and suprasternal notch. He's acyanotic. He's got both systolic and diastolic murmur. He came with lethargy. We didnt discuss what it is but the cause namely heart failure(which he's not), infective endocarditis(which I could find any stigmata). Now i remember post op I should mention arrythmia though in that case i did mention ECG as plus echo non urgent as part of my definitive test.
5)Resp Child who was diagnosed with asthma who have equivocal clubbing. I just said i would investigate for suppurative lung disease as my differential including CXR, sweat test and search delta F508
6)Development - Child with global developmental delay in all area. he has funny looking face, he's 2 y by the way, with scaphocephaly and low set ears. He can sit and commando crawl. He can hold crayon and making lines but more of scribble, he's building block up to 3 only, more babbles, smiles momentarily only. He has global developmental delay in all area
7)Long case - 13 y old recently diagnosed with diabetes. Focus hx about initial diagnosis, management and control. That was a good discusssion for me. He's on bolus insulin plus levemir(long acting one)
I will talk about communication next time. Let me go n relax. I am travelling home now. I think I didnt do that well. Hope is what i can say or else restart doing my paper again.
I reached home safely. Thank god. It's 12 am now. I wish as i said I can re do my xm and perfect my skills. It's not about xm, it's about pressure and stress. I am below par under this circumstances. I shall continue on my cases.
Communication 1
28/40 had NEC, was on antibiotic for 10/7, TPN. Now we are finding difficult to get TPN line. Discuss with mum about recommencing enteral feeding
My points
ask about mum if she understands NEC
Explain baby is improving, ventilated now extubated
plan for feeding - normality, gut motility
titrate feeding accordingly
answer mum concern of NEC, say he's getting older
stress important that nutrition is priority
Comm 2
Grace 7 y old known DM
. Admitted 3X with DKA in past 6/12. We HbA1C 10.5.. Discuss about mx with mum
My points
I explore mum confidence
supervision needed as she's only 7 y
keep diary
injection site to see any complication ie lipohyperthrophy decreased absorption insulin
look at my lifestyle- have 2 other children
compliance poor after starting on bolus insulin
offer education with dad - phone, attends clinic with Grace
Open access - Grace and family can contact ward or diabetic nurse specialist
My videos
1) Baby with laryngiomalacia
2)Child with Nephrotic syndrome -start steroid orally
3)Facial nerve palsy - nothing needed done(opt
4) Throat with pustular exudate and petechiae palate. Check EBV
5)Toddler in A&E with penut allergy. Body urticarial, scratching. Give anti histamine
6)Asian toddler with bowing genu varus, swelling wrist. Do wrist X ray for diagnosis.
7)Infantile spasm. Do EEG and MRI(check to exclude neuro cutaneous problem/ TS)
8)Heart of 16 y old. Doesnt look centrally cyanosed. Presented with SOB.No clubbing. Murmur seems to be sys and diastolic, with loud S2. The only reasonable answer - eisenmenger complex
BTW, I herewith my friens communication stations as well
1) Talk to SHO. He looks dishevelled. Underlying depression-problem getting trainig post in UK
2)6/52 weeks old presented with wheeze have healed fracture clavicle , talk to mum.
3) In her video, it's different than me thouh we're in same center. She mention acute SOB(asthma), rash staph, cover test, Down syndrome(do chromosomes)
In my long case we discuss about honeymoon, presentation diabetes, psychosocial aspect, monitor complication etc
Oh well, I will be dormant here for a while but I would like to dedicate Youtube song to my fellow muslim after ramadan. Eid, peace be to all. I am resigning now from writing. Thank you all for the support, hope everybody will be succeed in ur future, I sincerely hope. I have done my bits but I think there are still area needs improvement. I am also learning, also a trainee. Trainee to trainee. I may write from times to times.
Just to add few more memorize vidoe station with my friend's case
1) Cases of cornelia De lange. Complex medical problem. Known severe epilepsy. Talk to mum, hx about behavioural problem. I guess stress about psychosocial aspect. Highly relevant about control of seizure. May need adjuvant therapy but discuss with neurologist. May need to investigate if any other co incidental finding together with Cornelia De Lange, ie hypos episode or others. Offer monitoring in ward
2) Video
i) Child cam with status. Has linear rash on trunk. Ddx incontinentia pigmenti
ii) 10 y old smiling, poor gait ataxic, whriting hands, but talking influently. Learning difficulties Ddx Angelman Vs Retts. I think the former probable the best answer
iii)Child with pallor, feeding with bottle.Hb 4. What's next step. Give fe supplement, child is systemically well
iv)Toddler known 1/52 hx of limp. Afebrile, but restricted hip movement. Do FBC & ESR to exclude leukaemia or septic arthritis
v)Cover/uncover test - test for manifest Vs latent squint
Dear all,
I'm a bit bored now. Not much patient coming in thro my call today. I felt a bit tired after spending time studying. My option either;
1) Keep on studying...which I feel I may take a break now
2) Reading other valuable knowledge - Tony Buzzan always offer good selection of books about 'muscle' up your brain.
3)Writing articles - I have selection of ideas like, I have seen cases of recurrent chicken pox in immunocompetent individual or cases of neonatal stroke(which data collated primely from Canadian Stroke Registry).
4)Building up my website for paeds e learning which has been postponed for years.
I got 2 weeks free time. Fuh, life is after all full with activities, whether we are going to fulfil it correctly or just time wasted like that. Geez, I am also heading home to see my children. Perhaps, the less laborious job would be building up website and interlinked with various useful website for paeds.
BTW, my other friend has yet to supply me with updated cases that he has seen in Dundee. I believe he's done better this time. Fair play to him. GTG, may be i will have another chat next time....
p/s I am not keen for research, though somebody is pushing me to develop diabetic database(which also has been postponed) incorporated with blood sugar monitoring data to predict outcome and complications.
As I said so many things to do, so little time that we have!!!
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