have been away from posting clinical pearls received for the month because i was on surgery and the hours did not allow for even 45 minute blocks of time to write and copy, i will have to transpose those notes at a later date. lost ten lbs during that rotation, was sleep deprived, unshaven and had a constant facial/stress rash the whole time, had a great time though haha!
so to get caught up, now on last rotation, pediatrics, having a great time as well- totally different culture than surgery, medicine, ob/gyn, neuro. the hospital is more tolerable as well, art and paintings on the wall, and more windows with larger rooms. after this the clinical year will be over. it was
definitely fatiguing, but well worth the effort.
three bugs of neonatal meningitis
-E. coli
-GBS
-L. moncytogenes (need ampicillin to cover this)
meningitic doses are 100mg/kg - start w/cefotaxime until culture rules out.
dont want to use ceftriaxone in newborn because this drug can spike bilirubin.
axillary temp should be 1 degree higher than rectal
Glycogen storage disorder type 1 (von gierke's) here is some next level pimping courtesy of the liver fellow - whats the difference between von gierke's type 1a 1b and 1c?
1a - lack of the G-6-phosphatase
1b - lack of transporter - get IBD like symptoms
1c - lack of cofactor in the transporter
clinical significance? in 1b you get neutropenia, won't get that in other types
clinical presentation of von gierke's - obese, overfed, ^triglycerides, 60-70% hepatic adenoma, small percentage of this population goes onto HCC
indications for intestinal transplant
-tpn dependent (lifestyle issue)
-good post op care
-no social contraindication (sex drugs and rock'n'roll stuff)
-loss of vascular access
-intestinal failure associated w/liver disease
-recurrent sepsis
contraindications
-cant be immunosuppressed (cancer)
KVO abbreviation for keep vein open - run fluid at low rate so you don't have to hep lock the IV
when dealing with an oppositional teenager be concrete - "if you don't take your insulin, you will lose you limbs, go blind, then die"
methylmalonic aciduria - give metronidazole to decrease proprionic acid (made by enteric flora), proprionic acid is substrate used to make more methylmalonic acid
Serious bacterial infxn
-uti, bacteremia, menin
gitis
Oragel - not good for teething babies, can cause methemoglobinemia
baby physcial exam pointers:
increased fontanelle size associated with hypothyroid
posterior closes in 1st six months, anterior closes 1.5 yrs
nasal septal polyps think associated w/cystic fibrosis
ear pits (dimples anterior to tragus) associated w/sensorineural hearing loss -not associated w/renal anomalies
Heart exam: most babies have a systolic ejection murmur best ascultated at the left sternal border, its called peripheral pulmonic stenosis, it goes away in 6 months
Vaginal bleedi
ng from a neonate- everythings ok! the babies baby endometrium has responded to maternal hormones.
hip dysplasia increased risk in females because they are more sensitive to hormone relaxin, get sonograms upto 4-5 months then switch to x-ray b/c neonatal skeleton will have calcified to the point where it can be visualized.
now for my favorite thing ever! the asymmetric tonic reflex, this primitive reflex is elicited by turning the babies head to one side, and the baby will pose his arms just as seen in the picture below- its also aptly referred to as the fencer's reflex-
i could not get enough of this, its so cute. ok babies are cute.
primitive reflexes should be gone by 4 months.
medical metaphor-
open a book and read a page, how often do you know what it is about? you need to read the pages leading upto the current page to get any idea of the story. so it is with patients, you must get the history!
pelvic inflammatory disease can lead to tuboovarian abscess which can lead to fitz hugh curtis abscess.
3 things you can never miss in ER
1. ectopic pregnancy
2. ovarian torsion
3. appendectomy
lower abdominal pain w/vaginal bleeding is rule out ectopic until proven otherwise.
ovarian torsion - radiates to groin, intermittent and sudden
sti's - fevers, discharge, dyspareunia
kids can get abd pain in UTI's
doing an abdominal/intracavitary ultrasound to rule out ectopic pregnancy? need to document two things
1. +/- intrauterine pregnancy
2. if +, document fetal heart rate if possible
tip- aminoglycosides increase botulinum levels and can precipitate botulinum toxicosis
maternal lupus can have maternal antibodies that cause complete heart block in neonate, may also present w/cutaneous lesions
bowel viral gastroenteritis can lead to secondary lactose intolerance (transient), as well as strip the gut of disaccharidases therefore don't give fruit juices because just make it worse because of osmotic diarrhea, also don't give cold fluids (i don't know why i just wrote that down)
allergic eosinophilic gastroenteritis is non IgE mediated - its secondary to multiple food allergies, can have patient on inhaled steroid but swallow it!! don't inhale.
milk protein allergy: presents young and this one is IgE mediated, bloody stools
oral allergy - from eating raw fruits can get swelling tingling in mouth, allergic to skins/pollens etc and this is IgE mediated
an adverse reaction to MMR vaccine is usually an allergy to the gelatin in which it is carried.
egg allergy? no flu or yellow fever vaccine
UTI's
risk: boys >> girls for first 18months because of increased bladder pressures, then girls >> boys in risk from thereafter
patient was a 20 year old female w/neuropsychiatric lupus complicated by episodes of immune mediated thrombocytopenia, before giving IVIG you have to check... IgA levels, bone marrow biopsy before giving steroids to make sure not a hematological malignancy
3 stages of whooping cough - only worth treating if you catch it in the catarrhal phase - use a macrolide (not erythromycin because can lead to pyloric stenosis vis a vis its gastric activity)
1. catarrhal phase (low grade)
2. paroxysmal (whooping stage)
3. convalescent stage
viral gastroenteritis? BBRAT diet
bread banana rice apples toast - only good for 24 hours
