Comprehensive Student Notes: Febrile Seizures (Pediatrics)

History Taking

1. My name is ____, I’m a medical student and my doctor wants me to ask you a few questions about your child, is that all right? 
2. What’s his name? How old is he? Does he go to school?
3. What have you come here for today?
1. My child has convulsions/shaking strangely:
1. When did it start?
2. Is this the first time it happens?
3. How long did it last?
4. How was it like (how did it look like)?
5. Which part of the body was shaking?
6. Did his eyes roll up? Did he drool? Did he urinate or pass stool?
7. Was he sleepy and tired after the episode?
8. How many times did this happen since the first episode?
4. Associated symptoms:
1. Does he have a fever? How much is it? Did you measure it? Does it come and go?
2. Is he tired most of the time? Or crying a lot?
3. Does he have muscle aches?
4. Does he have a runny nose?
5. Does he scratch his ear or bend his head to one side?
6. Does he snore or breathe out loud? Does he have strange sounds on breathing?
7. Does he have a rash?
8. Does he have chest pain?
9. Does he have vomiting?
10. Does he have tummy pain?
11. Does he have diarrhea? When was the last time he passed motion? (Constipation)
12. Does he cry when he urinates? What color is the urine?
13. Does he have joint swelling or pain?
5. PMH: 
1. Has he been sick before?
2. Has he come to the hospital before?
3. Has he had any infections?
4. Does he take any medications?
5. What have you given him for this? Have you gone to a hospital/doctor for this time?
6. Does he have allergies? 
6. PSH: has he done any surgeries? 
7. FH: 
1. Does anyone have epilepsy or seizures?
2. Did anyone have similar problem when they were young?
3. Is anyone sick currently? 
8. Birth:
1. Born by natural delivery or cesarean?
2. How many weeks pregnancy?
3. Any complications during birth?
4. Was the baby crying when he first came out?
5. Did they take him to an incubator? Did he have yellow skin color (jaundice) few days later? Fever?
9. Feeding:
1. How many meals a day does he have? What do they consist of?
2. How long was he breast fed for? Was it exclusive?
3. When did you wean him? What did you start giving him first?
4. When did you stop breastfeeding completely?
10. Vaccination?
11. Growth:
1. How much did he weigh when he was born? Height?
2. How much does he weigh now? How tall is he?
12. Development:
1. Gross motor/fine motor/speech/social
13. Other:
1. a. Has he been with a friend/family member with similar complaint recently?
2. b. Has he fallen on his head?

Physical Examination

• Auscultation (do this at the very beginning before the baby/child starts crying):
• Lungs: breath sounds equal bilaterally? Crepitations? Wheezing? Stridor? Decreased air entry? Prolonged expiratory phase?
• Heart: S1 & S2 audible? Murmur? Grade of murmur? Systolic/diastolic? Ejection/holosystolic? Thrill?
• General: lying in bed comfortably? Conscious? Alert? Drowsy? Irritable? Connected to machines? Abnormal movements? Grunting? Nasal flaring?
• Vitals: RR, HR, temperature, blood pressure, pulse oximetry (oxygen saturation)
• Growth chart: height/length, weight, head circumference
• Hands: splinter hemorrhages, osler nodes, janeway lesions, no peripheral cyanosis, capillary refill
• Head: dysmorphic features? jaundice? Palor? mucus membranes dry? Throat congestion? Enlarged tonsils? Condition of teeth? Ear – tympanic membrane? Lymphadenopathy?
• Respiratory: 
• Inspection: chest shape is normal? Recessions? Skin discoloration - petechiae/purpura? 
• Percussion: dullness? hyperresonance?
• Abdominal: 
• Inspection: Skin turgor? Skin discoloration - petechiae/purpura? Distended abdomen? Inverted/everted umbilicus? Apparent masses?
• Palpation: Any tenderness? Rigidity? Guarding? Masses? 
• Liver: Hepatomegaly?
• Spleen: splenomegaly
• Kidney: Balotable? Pain at renal angle?
• Hernia orifices?
• Genitalia
• Musculoskeletal: swelling of joints? Tenderness of joints?
• Skin: skin mottling?
• CNS:
• Cranial nerves: (I will have a specific post on examining cranial nerves in a child/baby)
• Old enough child:
• Olfactory: what is this smell (lemon)?
• Optic: cover one eye and read a text, then the other eye with Snellen chart, with color blindness by asking to tell if an object is red or green, visual fields, ophthalmoscope
• Oculomotor: pupil reflex
• Oculomotor, abducens, trochlear: hold object in front of eye and move to see eye movements, convergence
• Trigeminal: touch face with cotton for sensation and see if baby reacts
• Facial: ask to smile, lift eyebrows, blow out cheeks and resist my fingers, close eyes and resist opening by my fingers
• Vestibulocochlear: 
• If old enough: distract beside one ear and whisper in other, then ask to repeat word whispered
• If younger: ask mother to distract with toy and you make a noise beside ear (out of sight) to see if they turn
• Call baby’s name and see if he responds if above is not working
• Vagus, glossopharyngeal: ask to open mouth and stick tongue out to check for uvula and ask to say “aah”
• Accessory: ask to shrug shoulders against resistance, ask to turn head to side
• Hypoglossal: stick tongue inside of cheek and push against my finger, open mouth and see tongue in rest for fasciculations.
• Very young child/infant/newborn:
• Oculomotor: pupil reflex
• Optic, oculomotor, abducens, trochlear: hold object in front of eye and move to see eye movements if possible
• Facial: see facial expressions, touch face and see if baby reacts, tactile stimulation of face or foot and see face
• Vestibulocochlear: startle reflex  loud clap beside ear out of sight (<7 months= startle reflex BUT >7 months= distraction test)
• Vagus, glossopharyngeal, hypoglossal: ask mother if he sucks well and see if he cries OR put your gloved hand in baby mouth and feel for sucking ability.
• Tone: move limbs passively. Hyper/hypotonia?
• Power: in older children who are cooperative you can ask them to resist. In younger uncooperative, see their movements. Give them something to hold.
• Reflexes: knee (L3-L4) and brachial reflex (C5-C6)

Differentials

• Febrile seizures secondary to an infection
• Shaking chills
• Metabolic: 
• Hyponatremia/hypernatremia
• Hypoglycemia 
• Drug toxicity: antipsychotics, antidepressants
• Trauma on the head
• Neurological: meningitis, encephalitis, abscess, tumor
• Epilepsy

Investigations

• Blood: CBC, CRP, blood sugar, urea and electrolytes, urinalysis, blood culture and urine culture
• CXR if signs of chest infection
• LP: ONLY AFTER STABILIZING PATIENT. CANNOT DO IF PATIENT IS HAS ALTERED MENTAL STATUS.
• If signs of meningitis or encephalitis 
• If child is <12 months old 
• If treated with antibiotics which mask meningeal signs
• EEG if status epilepticus or focal seizure

Management

• When the patient first presents to the ER, first I would do the ABCs, primary resuscitation and make sure he is stable.
• If patient presents with the seizure, give IV diazepam/lorazepam (better because they act faster than rectal and lorazepam has longer effect). If neonate, give phenobarbitone?
• Cold compresses AKA sponging
• Anti-pyretics (paracetamol)
• Antibiotics for the source of infection if found
• Hydration if needed

Febrile Seizures 

Definition

Seizures happening due to increased body temperature not caused by neurological causes with no history of previous afebrile seizures

Characteristics

• Simple: happen between ages 6 months to 6 years, generalized tonic-clonic convulsions, increased temperature, do not recur within 24 hours, family history, last <15 minutes
• Complex: focal convulsions, recur within 24 hours, last >15 minutes. Higher risk of developing future non-febrile seizures.

Risk factors

• High temperature
• Family history (genetic link)
• Viral infection has higher risk
• Immunization (fever on same day due to vaccine has higher risk)

Prognosis

Very favorable, risk of developing future non-febrile seizures is higher in complex febrile seizures (5-10%) and very low in simple (1-2%).

Status epilepticus

Definition

Unremitting seizure lasting longer than 30 minutes without returning to normal baseline 

Management

• Do the ABCs
• Assess airways and ventilate with oxygen
• Establish IV/IO access
• Assess vitals, oxygenation, blood glucose, signs of meningitis, head trauma.
• Treat hypoglycemia or fever if needed.
• Medications based on guidelines (in order starting with first line): 

1. Administer Lorazepam IV/IO
• If access not achieved in 3 minutes buccal/IM midazolam OR rectal diazepam
2. Administer Lorazepam IV/IO after 5-10minutes 
3. Administer Fosphenytoin IV/IO after 5-10minutes (in neonates, phenobarbital is)
4. Phenobarbital OR valproic acid after 5-15minutes

Reference

1. UpToDate. (2015). Management of convulsive status epilepticus in children.
2. UpToDate. (2015). Treatment and prognosis of febrile seizures
3. UpToDate. (2015). Clinical features and evaluation of febrile seizures
4. Pediatrics Recall 4th Ed. (2010). 

Year 3: Go-To Books

Pathology

1. Pathoma and Pathology Secrets: read them before TBLs. Even though short and may not be able to answer every question in TBL but you get the main idea of everything as well as understanding the logical reasoning behind pathological processes. The purpose of skimming the topic before the session is to have an idea and not attend class like a useless statue.
   
2. Robbins Basic Pathology: Most students tend to miss a lot of the required topic while reading Robbins before TBLs because it is too much to finish before a class. This is not productive in terms of keeping information in your mind. Why? As the pathology teacher explains the topic you have not covered before class, you won't keep up. Make sure to go over Robbins after TBL and read it to consolidate your information. 

Anatomy

1. No specific book. I studied from many different books and I found that helped me gain an advantage of understanding the subject better than others. That is why I decided to make blog posts about the cranial nerves. The many books I read each had a new piece of information about the subject and I wanted to integrate all that in one place. Refer to the posts for the books used for each cranial nerve.
   
2. Gray's Anatomy Review: before the exam, it is imperative to solve questions in this book. As all questions, they introduce you to information you may have overlooked that is significant and help you remember it. (I still remember some information about the blood and nerve supply of the pharynx and larynx thanks to the questions.)

Physiology: 

1. Guyton's Physiology: many students don't like it because it goes into details. If you are like me and would like to understand things to minute levels, then you will like this book for neuroscience.
   
2. Costanza: I personally haven't read it, but I have heard many compliment this book. Try it and tell me if it's worth buying or not.

Pharmacology: 

1. Lange's Pharmacology Flashcards: obviously it's not a book, but this was helpful for quick revisions: when you're on your way to school on the bus/metro, during a 10 minute break between classes, when you're having lunch.
   
2. Lippincott's Illustrated Review - Pharmacology: This book has great summary pictures for side effects. It is the teacher's main reference book.
   
3. Lange's Basic and Clinical Pharmacology: This book is has more information than a medical student needs to know (such as chemical structure of each drug) but it's explanations of side effects and mechanisms of action is ample for understanding. You can opt for it's summarized version: Katzung Pharmacology Examination and Board Review. But this version is not comprehensive in the explanation department (hence the "Review").

Studying Evidence-Based Medicine (EBM)

You'll be introduced to EBM in 3rd Year. It may seem daunting in the beginning and useless, but once you arrive to your clinical years, you'll start facing questions whose answers are not found in guidelines or books. Questions like: does adding a non-insulin drug to a type 2 diabetic on insulin, help in reducing blood sugar levels and morbidity as opposed to monotherapy on insulin only? Is it worth it to make this patient pay money to buy yet another drug aside from insulin? Or should I just keep him on insulin?

The university is not very proficient in teaching this subject. That is why, you must take it upon yourself to learn about it (we pay 95K for self-directed learning after all). 

EBM Help:
This website is the best I have found in teaching EBM to people who need it explained in a common sense way like I do. Most of the time EBM will be explained statistically and that is not the way to go about it. The reason it was invented was to translate statistics to clinical practice. And that is how you and I need to understand it.

If you have found other useful websites, please share them in the comments so others may benefit as well.

An essential book for me for understanding statistical concepts in a simplified way (also useful for the community-based research course) is Medical Statistics Made Easy by M. Harris & G. Taylor.

Year 4: Pediatrics Clerkship - Part 5

Books
By now, you would have realized that being a medical student means 10 resource books for 1 topic:

1. Basis of Pediatrics by Pervez Akbar Khan: This book is the mother of all underrated books. All books can be trashed in pediatrics except for this. That Nelson book everyone praises so much? Nothing compared to this book. Granted it isn't updated and you need to study management guidelines from your everyday practice & PBL cases, this sets up your pediatric basics as they should be, not an inverted triangle of basics that topples soon as you start going into details. This is THE go to pediatrics book in this rotation.
2. Nelson's Essentials of Pediatrics: Great for certain topics such as respiratory tract problems and development. Not as comprehensive as everyone makes it seem. 
3. USMLE Step 2 CK by Conrad Fischer: great for revision and summarizing important topics before the finals or during short breaks. By no means exhaustive or comprehensive.
4. First Aid for the USMLE Step 2 CK: more comprehensive than the one above it, but it is merely a book of notes, it does not explain things as you might need to understand them. So, only good for revision or getting an overview of a topic before reading it in depth.

How to study

1. Study every PBL topic before the PBL class and ATTEND every PBL class as they are very important. I can't stress this enough. Don't focus on the unimportant uncommon topics in books. Wanna know the common things? Go to hospitals. Attend PBLs. That is exactly what you will encounter on exams.
2. Practice history-taking and physical examination because they are different than any other. Dealing with children is nerve-wrecking especially during exams. You want to be prepared and well-trained in physically examining them (doctors can detect students who have never touched a child before the exam because nervousness will be evaporating out of every pore of your body). 

Hospitals
Qassimi:

• To put it simply, you won't be taught anything here. I'll give the same advice as OBG:
• This hospital is only for exposure to a variety of cases.
• You can make use of self-directed learning here as it is the only kind you can get. Find willing patients, take history from them and examine them.

Note: you are not allowed to practice hands-on skills on pediatric patients (IV line insertion, etc.)

• Clinics:
• The best clinic I attended was at the pediatric cardiology clinic. I learned many important things about management and clinical presentations of congenital cardiac problems as well as assessing the heart with echocardiography (not required of you, merely curiosity).
• The general pediatric clinic is also useful to attend as you can probably be able to do neonatal physical exams here.

Baraha:

• They'll give you a schedule to follow. During the free time you have, go to patients and take histories and do physical examinations. For some reason, this hospital has cooperative, willing parents more than others.
• Make use of the bedside teachings as they are the best of all hospitals in this aspect. 

Dhaid:

• The most beneficial time you will have is with either of the consultants at this hospital. Write down whatever they tell you on the rounds, bedside teaching. Those are the important things of pediatrics that you'll encounter.

OSCE

• You will not have physical examinations as there are no patients available.
• The exam will be comprised of history-taking, consultations, computer stations.
• Important presentations for history-taking:
• Fever in a newborn, infant or child
• Jaundice in a newborn
• Vomiting in an infant or child
• Seizure in a child or infant
• Cough, strange noise on breathing or shortness of breath in an infant or child
• Diarrhea in a child or infant
• Constipation in a child (mostly in a girl)
• Rash in an infant or child
• Consultations are most likely for a Down Syndrome or autistic child's parents'.
• Computer stations give you a small case scenario with pictures of x-rays or signs on the child to diagnose.

DOCEE
On the exam (and every other clinical exam ever), taking a comprehensive history and doing a physical examination will get you far in the grading department. The rest of the things (differentials, management, information) is all just a decoy.

You can study the common problems (the PBLs) you are likely to encounter but don't bet on it. I got a complicated case no one had imagined. But my history-taking was comprehensive (presentation of fever, abdominal pain, vomiting and seizure. I had to explode each symptom on its own); I did a physical examination for all the systems I thought were important, gave an exhaustive differentials list with the most likely at the top and I scored as well as those with gastroenteritis and bronchiolitis cases (dare I say better?).

Written
Do not rely on the previous years' blueprints. The pediatric doctors are smart enough to change most of the questions (they have a never-ending bank of questions).

Intro to Med School (Dear Foundation Year Self, This One's For You) - Part 2

Dear Foundation Year Self, 

I have nothing new to tell you that you don't already know. The things that people usually advise others with? Turns out they're cliche because they are true!
Maybe you're expecting me to give you life saving advice, but the truth is, you're still too young. You're too eager for life and you shouldn't be. Take life now slowly and enjoy it because at this point you still don't have much to worry about. You don't need to worry about where to go after graduating or which path to take. You don't have to worry about being professional and acting like an adult in the workplace. You don't have to worry about how to get along with reluctant lazy colleagues. You don't have to worry about getting a fair assessment from your hospital/clinic mentor who you've said 'hello' to once on arrival to the place and never seen again.

So for now, hurry yourself to worrying. You will get sick of it later.

General Advice:

1. Time management. I only learned to master this 5 years into college. Learn it now! It'll save you lots of hair-pulling, eye-gouging events later on.
   
   Understand procrastination now to help you stop the 'addiction'.
   
   Why do I procrastinate? Your brain is on hash. Except it's the weed of procrastination. It is in a situation similar to drug addiction. Basically, your brain's reward system wants shortcuts to feeling good FAST and NOW. It doesn't want to exhaust itself with solving stressful tasks (studying, assignments) only to wait a few weeks/months to get rewarded (grades, finishing a course). So it starts doing things that give it immediate reward (social media every few minutes, series). It goes into a vicious cycle of reward and stress.
   
   
   
   How do I break the cycle? Self rehab. It won't be easy the first few times. There's no magic or shortcuts. It's all in your mind powers:
1. Start by either deleting or signing off social media apps on your phone/tablet. Your phone/tablet is the easiest to access (well it is to me). Once I did that, I found I had a lot more free time when not wasted on scrolling facebook, twitter or instagram feeds. (I actually have time to continue painting and reading novels now!)
2. If you don't want to do that, close your gadgets/turn off their wifi/keep them somewhere you can't access while studying/give them to someone to keep while you study. Please resist opening that tab on your computer and watching an episode of Vampire Diaries and whatever useless teenager crap that is on at the time or socializing on facebook..etc.
3. Put small goals for yourself to achieve with prizes afterwards: If I finish this short chapter/6 pages, I will get to watch a funny youtube video.
4. Plan something crazy every weekend you can look forward to. Knowing my weekend was filled with fun helped me stay focus during the week on studying to my limits. It doesn't have to be hardcore so as to go clubs and party or whatever; to me it was just a night of movie marathon with my family, a full day of painting, reading the next novel in a trilogy. A day that pleases YOU!
5. Spice up studying by staying in college some days. Knowing others are struggling to study just beside you in the other room/other table helps in keeping you grounded. It is also a fun way to socialize. I'd plan to study a chapter and take a break by talking with friends. Also, I've made new friends during this time. Stressful times bring people together.
2. Social life. I am still confused in this aspect, so I cannot give you advice. I can only give you my point of view:
1. I was a lone wolf in foundation year. Is that a good thing? Not sure. I was freer. I didn't have any commitments to friends. I got to study whenever I could during free time instead of talking, spend time going to the gym and doing hobbies. It was a freeing year.
2. I'm running out of time for socializing with my peers and I regret having wasted a year not doing that during my free time instead of running away from class soon as it was dismissed. You don't need to be a public relations expert, just enough for you to stay socially healthy (bet you learned that the definition of health includes a social aspect by now!). 

"How to study" Advice:

1. What to study? Books. Not Lectures! B.o.o.k.s. Many people study lecture presentations instead of books (chemistry, physics, biology). I was doing well on exams and I kept hearing students complaining about how the material was not in the lecture. Forget about the lectures. They aren't references and may have many mistakes.
2. How to consolidate memory with galaxies of information? 
1. Understand concepts. I read the chapter once before class. Once after class. Once before the quiz. Once a few minutes before the quiz. Once before the midterm. Then for the final. Why read so much, you might ask? It is a scientific fact that you never understand something fully from the first reading. Exams rely on full-rounded understanding. Every reading adds a piece to the clarifying puzzle. Interspaced reading and understanding helps solidify knowledge in long term memory. (After foundation year, you will never have the time to do this.)
2. Explain things to others! Explain concepts to your parents, siblings, friends in scientific terms and simple terms. You may hesitate at points, not knowing how to put them to words. These are your weak points. Go read more about those. When you know something, you will never hesitate to put it into words.
3. Chemistry & Physics. Practice, practice, practice exercises. Do not read the exercise and mentally solve problems. Put pen to paper and use your hand to solve.
3. How do I organize my electives? Take Intro to Medicine in the first semester and get it over with. Leave the second semester for electives because they are easier. The second semester is when you'll be near burn out because the end of the year is approaching. 2 approaches to electives in this year:
1. Take the harder electives in the second semester and leave the easier electives for later years when you'll be loaded with more important studying.
2. Take the easier electives in the second semester to raise your GPA. Leave the harder electives for later years because after foundation year, it is only a matter of pass/fail for them. Their grades don't matter starting in year 1.