A
If you wish to make an apple pie from scratch, you must first invent the universe
A
Here is a structured paediatric assessment and management plan for a 1-month-old infant presenting with:
-
Feeding issues
-
Heart murmur
-
Poor weight gain
🧠 Initial Differential Diagnosis
These signs raise concern for congenital heart disease (CHD), particularly a lesion causing heart failure or poor perfusion. Consider:
-
Congenital Heart Defects (e.g., VSD, AVSD, coarctation of aorta, PDA, critical aortic stenosis)
-
Failure to thrive due to cardiac or metabolic causes
-
Sepsis or other systemic illness
-
Feeding intolerance / reflux as a secondary issue
🩺 Immediate Assessment
A. History:
-
Feeding: volume, duration, effort, fatigue, sweating, cyanosis
-
Weight trends (growth chart)
-
Respiratory symptoms (tachypnoea, grunting, nasal flaring)
-
Diaphoresis with feeds
-
Urine output
-
Family history of CHD or sudden infant death
B. Physical Exam:
-
General: Alertness, perfusion (cap refill, extremity temp)
-
Weight and weight gain trajectory
-
Cardiac: Murmur characteristics, heart sounds, gallop rhythm, pulses (brachio-femoral delay)
-
Respiratory: Tachypnoea, retractions, crackles
-
Hepatomegaly (sign of heart failure)
📋 Initial Investigations
-
Vitals: HR, RR, BP in all 4 limbs, SpO₂ (pre- and post-ductal)
-
ECG
-
CXR – assess heart size and pulmonary vasculature
-
Echocardiogram – URGENT if heart failure or significant murmur suspected
-
Bloods:
-
FBC, U&E, LFTs
-
Blood glucose
-
Lactate (signs of perfusion failure)
-
Infection screen if febrile/unwell
-
🩹 Management Plan
-
Admit urgently to a paediatric unit / NICU for monitoring.
-
Feeding Support:
-
Consider NG tube feeding if oral intake is poor or tiring.
-
High-calorie formula or fortified EBM may be needed.
-
Monitor weight and hydration closely.
-
-
Cardiology Review:
-
Arrange urgent echo if CHD suspected.
-
Discuss with regional paediatric cardiology if echo not readily available.
-
-
Supportive Care:
-
Supplemental oxygen if SpO₂ low.
-
Diuretics (e.g., furosemide) if signs of heart failure (after cardiac review).
-
Fluid restriction if pulmonary oedema present.
-
-
Parental Support and Education:
-
Keep caregivers informed.
-
Offer lactation support if breastfed.
-
🚨 Red Flags
-
Poor perfusion, prolonged capillary refill
-
SpO₂ < 95% or differential cyanosis
-
Significant hepatomegaly
-
Signs of respiratory distress
-
Lethargy or altered consciousness
A
The heat is not bad at all. It is very humid, but one soon gets used to being wet all through, and I don't even carry an umbrella; the monsoon is not too heavy here, and when it rains and you're outside you just get rained on. Everyone else is wet through too, so you don't even bother to mop your brow.
A
So with bureaucracy: every single person in the establishment must read the entire document in question, commenting upon it minutely: 'Ah, Sanskrit! You are a pandit! I know a little Sanskrit: "Dharmakshetre kurukshetre" [The beginning of the Bhagavad Gita] ... Ah, Shantiniketan! A beautiful place. I have never been there. So, New York! I have a brother in Yugoslavia. You are only twenty-two? So young to be travelling alone! You must visit the Punjab. That is my home. I hope you will enjoy your stay in India...[etc.] Namaskar.' This conversation must take place with each of the twenty-five clerks who have to sign the document, and I am convinced that the only reason that all twenty-five have to sign it is that they all want to read it and talk to you.
A
At night the insects swarm in thick masses around the lights, almost blotting out the light, and in the morning they are all dead on the ground, forming a bed that goes crunch when you walk over it before the sweepers come and clean it out.
A
The rhythm is a combination of the Indian tunes, with their five- or seven-beat syncopation, and the steady beat of a kind of jungle rhythm, and a real jazzy off-beat, and a calypso lilt, and the tune is equally lively and mixed up. All the children carry candles and dance around, really dance, and shout and it's altogether the most fun imaginable. Then, at midnight, we went down to the Ganges and sat by one of the ghats; the river was lit by candles and lights all up and down the bank, and there were thousands of little pole-driven boats floating up and down, lit with candles and overflowing with people. One after another they heaved the great images into the river and dived in after them, shouting and pushing them under the water, then splashing the holy water on everyone, and making way for the next image, and all the time the drums and flutes were playing, and people singing
A
No comments:
Post a Comment