Wednesday, July 20, 2016

Common mistakes in Per Abdominal examination

1. Forgetting to Expose abdomen adequately:
Before examination, patient should ideally be exposed from nipples to mid thigh. Failure to do so may lead to missing findings during examination eg. Hernia



2. Abdominal symmetry and movement: Should be examined tangentially and from leg end. Comment should be made on movement of all quadrants with respiration.

3. Forgetting to relax abdomen before palpation:
Flex the legs at knees and arms should be by side of body. Head should be rested on a pillow. Only after abdomen is in relaxed position palpation should be proceeded.

4. Missing points on palpation:
a. Remember to ask for pain in any site before palpating. The part with pain should be skipped and palpated at the end.
b. Look for rigidity and guarding besides tenderness.
c. Tenderness should be assessed by looking at facial expression +/- guarding
d. Remember to palpate urinary bladder
e. Hernial orifices should be palpated and is commonly missed point.
f. Make the patient sit and check for renal angle fullness and tenderness.


Rarely grading can be asked.


5. Remember- Shifting dullness is done in percussion and fluid thrill is done in palpation, in a patient with abdominal distension.

6. Auscultation- Look for Renal bruit, Hepatic bruit etc in indicated cases. Bowel sound  should be listened to. When bowel sounds are not present, one should listen for a full 3 minutes before determining that bowel sounds are, in fact, absent.



Recommended reading
https://meded.ucsd.edu/clinicalmed/abdomen.htm
http://www.ncbi.nlm.nih.gov/books/NBK420/

Friday, July 15, 2016

Birth Asphyxia and its manifestations

Definition: Birth asphyxia Birth asphyxia is defined as a reduction of oxygen delivery and an accumulation of carbon dioxide owing to cessation of blood supply to the fetus around the time of birth.

Although , APGAR score is retrospective scoring , it has been used to assess the severity of Asphyxia.
Apgar score 8~10: no asphyxia
Apgar score 4~8: mild
Apgar score 0~3: severe



Clinic manifestations
Complications:
CNS: HIE, ICH
Respiratory system: MAS, RDS, pulmonary hemorrhage
CVS: heart failure, cardiogenic shock
Gastrointestinal system: NEC, stress gastric ulcer
Others: hypoglycemia, hypocalcemia, hyponatremia

Diagnosis
American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) suggest that all of the following must be present for the designation of perinatal asphyxia severe enough to result in HIE:
  1. Profound metabolic or mixed acidemia (pH < 7) in an umbilical artery blood sample, if obtained
  2. Persistence of an Apgar score of 0-3 for longer than 5 minutes
  3. Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)
  4. Multiple organ involvement (eg, kidney, lungs, liver, heart, intestines)
Suggested reading: Thompson Scoring for HIE

Here is the details for MBBS students on HIE- A CNS manifestation of Asphyxia




Any confusions can be cleared from author through comments. Feedback are welcomed.