paediatrics osce instrument nutrition drugs mbbs students

Tony Krishnakumar 2010 MBBS Page 1

INSTRUMENTS

1.LUMBAR PUNCTURE /(L-P) Needle /(Spinal Needle)

Indications of LP

• Therapeutic :

• Analgesia • anesthesia • Antibiotics • Antineoplastics

• Diagnostic : • Infectious

• Meningitis • Encephalitis

• Inflammatory • Multiple Sclerosis • Gullain-Barre syndrome

• Oncologic • Metabolic • Spontaneous subarachnoid hemorrhage

• CONTRAINDICATIONS : • Increased intracranial pressure

• Cerebral herniation • Impending herniation • Possible increased ICP and focal neuro signs

• Coagulopathy • Prior lumbar surgery • Severe vertebral osteoarthritis or degenerative disc disease • Significant cardiorespiratory compromise • Infection near the puncture site • Space occupying lesions

The L-P needle (Spinal needle) consists of a pointed canula with a hub at one end & a stillete which fits into the canula.

• COMPLICATIONS • Herniation • Cardiorespiratory

compromise • Pain • Headache (36.5%) • Bleeding • Infection • Subarachnoid • epidermal cyst • CSF leakage

BONE MARROW ASPIRATION

2.Bone-Marrow Aspiration Needle : •

Diagnostic Indications : • Idiopathic Thrombocytopenic Purpura • Aplastic anemia • Leukemia • Megaloblastic anemia • Infections — e.g. Kala-azar • Storage disorders — e.g. Gaucher’s disease • PUO • Myelofibrosis

Therapeutic Indications :

• Bone - marrow Transplantation.

Site o >1 year

Iliac crest o <1 yr old

Proximal tibia medial to tibial tuberosity To prevent injury to pelvic structures in infants

3.Jamshidis bone marrow biopsy needle

It consists of :

• A Stillete

• A Thick body with nail The bone-marrow aspiration Needle consists of a Guard 2 cms from the tip.

No guard

With out guard

4.THREE-WAY CONNECTOR

The connector is devised in such a way that by turning the handle (which operates the screw) either of the 2 inlets can be connected with the outlet whereas the remaining inlet is disconnected from the outlet. This facilitates administration of IV medications through one inlet while IV fluids pass through the other inlet The inlet which is connected to the outlet can be determined by the direction of the arrows on the handle Uses :

o Administration of IV fluids & IV medications simultaneously by connecting the 3-way connector to the IV set.

o Exchange transfusion in case of Neonatal hyperbilirubinemia. o Hemodialysis in case of renal failure or poisonings. o Pleural or ascitic tap.

Semiautomated gun for liver biopsy

Indications of Liver Biopsy : • Cirrhosis of Liver :

o Cryptogenic Cirrhosis Indian Childhood Cirrhosis,Biliary Cirrhosis (Primary &Secondary)

• Storage disorders : o Hemochromatosis,Glycogen Storage

disorders,Wilson’s disease o Malignancy :

o Leukemia,Lymphoma,Wilm’s Tumour,Hepatoblastoma,Neuroblastoma

o Infiltration : o Tuberculosis,Sarcoidosis ,Infections ,CMV, Herpes.

• Complications

CONTRAINDICATIONS :

• Hemorrhagic disorders

• Skin infection or recent radiation therapy at the sampling site.

• Bone disorders such as osteomyelitis or osteogenesis imperfecta.

The Three-way connector is a T-shaped device containing 2 inlets & 1 outlet

• Local pain and infection • Bleeding in the liver • Bile leaks – intrathoracic and intraperitoneal • Pleural pain and pneumothorax • Penetration of other abdominal organs

• Contraindication • Bleeding disorders

• Purpura or prolonged prothrombin time or a platelet count <40,000/mm3

• Extreme dyspnoea, hydatid disease • Pyogenic abscess in right lobe of liver • Biliary tract infection, infection of

peritoneum, right pleura or lung • Suspected extrahepatic bile duct

obstruction with possibly dilated biliary tree, ascitis.

• INFANT FEEDING TUBE/nasogastric tube

• It is a plastic tube with a • blunt tip } prevent damage to

structures while introducing the tube

• opening on the lateral side close to the tip

• It also has a radiopaque marker so that it can be easily visualised on x-ray

Indications

Diagnostic Uses : o Diagnosis of internal bleeding in stomach & upper GIT o Diagnosis of Tuberculosis (Gastric lavage examined for AFB) o Diagnosis of Tracheo oesophageal fistula o Diagnosis of Poisoning (Gastric aspirate used for chemical analysis). o Localization of Oesophageal strictures. o Gastric analysis.

• Therapeutic Uses : o Nasogastric Feeds. o To remove gastric contents as in poisoning,persistent GI bleeding, abdominal

distention with bilious emesis,Hepatic encephalopathy o Conservative Treatment of Intestinal obstruction. o Management of Poisoning. o Administration of drugs.

o Pre-operatively to decompress the stomach if an emergency surgery is to be carried out & sufficient time for fasting is not available.

o Other Uses : o As an Oxygen catheter. o For nasal, endotracheal & Tracheostomy o suction. o As a tourniquet.

• Contraindications o head trauma patients, suspected coagulopathy etc

• Complications • Trauma to nose and pharynx. • Placement of tube in trachea • Vomiting with aspirations during the procedure. • Ulceration or infection of nasal mucosa

Suction tube

Scalp Vein Needle :

IV CANULA :

The advantages of IV canula over the scalp vein needle are : Being plastic in nature, the IV canula does notdamage the endothelium of the vein longer-

lasting than the scalp vein.

the plastic sheath being flexible can be inserted into thin & tortous veins easily (whereas the scalp vein being metallic & rigid would pierce these veins).

Tuberculin Syringe : It is a 1 cc syringe with a white piston Uses of the Tuberculin Syringe :

o To administer PPD for Mantoux Test. o To administer BCG vaccine. o To administer Test doses of drugs such as Penicillin. o Provocative Testing — To test for allergens in Bronchial asthma, Atopy. o Insulin injections in Diabetes Mellitus. o Giving small doses of drugs e.g. Gentamicin, Phenobarbitone, Digoxin.

It consists of a metallic needle attached to a

plastic tubing.

a butterfly-shaped plastic holder } At the junction

of the needle & the tubing there is which facilities

easy insertion of the scalp veinneedle into the vein.

o Flexible & colour-coded,

. Uses : Venipuncture for :

Collection of blood Infusion of IV fluids, drugs, blood, etc.

BONE MARROW ASPIRATION

A six year old boy was brought to opd with perpuric spots over the buttocks and lower limbs of two days

duration associated with joint pain.no historypain.No history of mucosal bleeds or other manifestations

.gives h/o fever one week back

O/E active child ,not sick looking ,PR-88/min , RR 20/min ,BP 100/74mm hg .

Plapable perpura over limbs,jonts normal, nomucosal bleeds , abdomen – liver span 2cm, spleen not

palpable , no other mass palpable ,other system NAD

Invwstigations

Hb-10.2 gm% TC-11000/mm3 , DC- P65 , L 30 E5

Platelet count -3.5/mm3

Ptt 18 sec , INR 1.1

S.creatinine 0.8mg%

SGPT 42 IU/dl

1. What is your diagnosis?

Henoch schonlein perpura

2. Give two complication?

Renal failure (<1%)

Intussusception

Bowel bleeding

Perforation

3. What is the skin biopsy finding?

Leukocytoclastic vasculitis with fragmentation of leukocytic nuclei in and around

arteriole,venule,capillaries surrounded by infiltrating neutrophil , monocyte in the presence

nuclear dust in the wall of arteriole

4. What is the treatment?

Supportive therapy- hydration , pain relif

Massive GI bleed or CNS involvement treated with prednisolone 1-1.5mg/kg/day for 2-3 wks

Infection lik streptococcus is treated with erythromycin and other suitable antibiotic

A 10 year old boy presented to causality with h/o abdominal pain. Pain present on the left upper part of

abdomen.it was severe colicky type with no bowl or bladder disturbance and was not related to food

intake.

O/E he had mild pallor, icterus + , and Per abdomen splenomegaly about 4cm below costal

margin, soft and tender on palpation. CVS ESM at base other system NAD

Investigations

Hb 8gm%

TLC 15000/mm3

DLC P56 L40 E4

Bilirubin direct- 6.1gm%

Bilirubin direct- 0.8gm%

MCV 60fl

MCHC >36%

Reticulocyte count 4%

DCT negative

Urine normal

What is your diagnosis?

Hereditary spherocytosis

Give peripheral smear picture?

Small RBC lacking central zone of pallor

Give 2 investigations to confirm diagnosis?

RDW increases due to spherocytosis and reticulocytes

Osmotic fragility increases and RBC lyse in solution of low salt concentration

What is the treatment?

Folic acid supplementation life long as high turnover of RBC deplete the body store of folate

Splenectomy

1. Do not cure the disease

2. Reduce the degree of hemolysis

3. Treatment of choice in severe hemolysis and high transfusion required cases

4. Prevent splenic rupture

5. Performed beyond 6 years

6. Vaccinate the child H. influenza B, Pneumococci, N. meningitis

7. Post splenectomy prophylaxis penincillin to prevent sepsis up to adulthood

Complications

1. gall stone and gall bladder disease

2. Hemolytic crisis , Aplastic crisis , Megaloblastic crisis

What is your diagnosis?

Acute epiglottitis

What are the DD?

Laryngo tracheobronchitis

Laryngitis

FB aspiration

Diphtheria

What are the etiological agents ?

H. inflenza (Commonest)

Pneumococcus

Beta Hemolytic streptococci

Staphylococci

How will you manage?

1. Hospitalization

2. Humidified oxygen

3. Don’t give sedatives

4. Adequate hydration by IV route

5. Antibiotics- cefotaxime or ceftriaxone

6. If not responding to antibiotics endotracheal intubation or tracheostomy

Study the pedigree and answer the questions

What is the pattern of inheritance?

Autosomal dominant

Name the condition having similar pattern?

1. Huntington chorea

2. Neurofibromatosis

3. Achondroplasia

4. Marfan syndrome

5. Crouzon disease

Draw pedigree showing parents with identical twins

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