Febrile Seizures/Convulsions are not uncommon - around 3% of children by the age of 6 years have had one.

As a parent they are one of the most terrifying events to witness - a lack of understanding, a lack of control of the situation and fear for the worst assures this.

Cause 

Febrile seizures normally happen when an infant with an minor infection has a temperature spike.

If the child appears severely unwell it is important to rule out more serious conditions such as pnuemonia, septicaemia, meningitis and malaria.

Most seizures (simple seizures) last less than 5 mins and have the following symptoms:

  • Stiffening of body, then twitching, or shaking
  • A dazed appearance
  • Eyes may roll backwards
  • Sleepiness afterwards - drowsiness lasting up to an hour

Seizures more rarely can also be ‘complex’ or occasionally can progress as far status epilepticus (as seen in epilepsy).

Action to take

Immediately

Note start time of seizure

Lie child on side with head on something soft

Try to lowertemperature - remove clothes

Give them a drink and some paracetamol (acetomorphin)

Stay with the child at night

After the seizure

Always try to see a doctor soon, they may need treatment for the infection.

Contact the ambulance/doctor immediately if:

  • The seizure lasts more than 5 mins
  • There is no improvement within an hour of the seizure ending
  • There is another seizure soon after the first
  • The child has difficultybreathing
  • There is suspicion of seriousillness

N.B.:

  • Febrile seizures are not normally dangerous, and usually result in no long term damage, or effects on intelligence etc.
  • There is little evidence to support the prevention of febrile seizures 
  • Febrile seizures are NOT a type of epilepsy
  • Febrile seizures are NOT  a reason to avoid vaccination
cluelessmedic

cluelessmedic:

Measles - Subacute Sclerosing Pancencephalitis

  • a rare and fatal late complication of measles infection
  • due to an immune reaction to the virus, causing inflammation, swelling of the brain, it is always fatal
  • it may appear years after apparent recovery 
  • rarely seen now in countries with vaccination programmes 

Taking Histories from specific patient groups - Gynae

As well as the basic medical history, there are some specific questions that you need to ask for a Gynaecological history:

Menses

  • 1st day of last menstrual period (LMP)
  • Length and regularity (days bleeding, days between starts of bleed)
  • Unscheduled bleeding - Post menopausal, inter-menstrual (IMB - in between periods), post coital (PCB)
  • Excessive bleeding - clots, numerous pads, flooding of pads
  • Pain - Dysmenorrhoea (painful periods), cyclical, intermittent

Sex and Contraception

  • Sexually active (always ask, older ladies might surprise you!)
  • Any pain with sex (dyspareunia)? - deep or superficial
  • Using contraception? - what type, how long for

Cervical Smears

  • When was last smear? Normal?
  • Ever had abnormal smear?

Urogenital/Prolapse/GI

  • Urinary - dysuria, frequency, nocturia, urgency, ‘any accidents, or leaks’
  • Any feeling of fullness in the vagina?
  • Any problems with bowel? - constipation, weight loss, appetite disturbance

Obstetric History

  • Gynae - previous preg.s ending < 24 weeks - miscarriage, ectopic, abortions, molar pregnancies
  • Obs - Previous preg.s delivered after 24 weeks, or live before 24 weeks

Dates and method of delivery

Any problems during pregnancy, delivery, or postnatally

Red Flags by System

When you are taking a history based around a presenting complaint, it is very useful to eliminate ‘red flags’ that might indicate serious underlying pathology. 

Here are some red flags for a variety of systems:

Cardiovascular

Pain, Palpitations, SOB (on exertion, at rest, orthopnoea, PND) Ankle Swelling, Dizziness, Smoking, Exercise, Diet

Respiratory

Wheeze, SOB, cough, sputum, haemoptysis, chest pain, calf pain/swelling, Smoking

GI

Loss of appetite, Weight loss, nausea/vomit, dysphagia, reflux, pain, change in bowel habit, blood/mucus PR, blood in stool/vomit, jaundice, itching, darkened urine, pale stool

Urogenital

Frequency, Urgency, Pain/tingling, Haematuria, lower back pain, Discharge, Menstrual problems, last Sexual Health check 

Neurological

Collateral hx of GCS/Cognitive change, Visual Disturbance, Hearing Loss,  Speech/Swallowing probs, Headache, Neck/Back Pain, Weakness, Parasthesia, Balance/Coordination, Bowel/Bladder Control

Rheumatological

Morning stiffness, joint pain/swelling/stiffness, deformity, malaise/fatigue, weight loss, arthralgia, myalgia, rash, raynauds, hair loss, red/sore/dry eyes, dry mouth, Oral/Genital Ulcers

Diabetic/Endocrine

Polyuria, polydipsia, fatigue, weight loss, neck swelling/tenderness, tremor, heat/cold intolerance, sweating, changes in appearance – hair, skin, voice, hands, feet, pigmentation.

ENT

Ear Pain/Discharge, Nasal Discharge/Crusting, Sore Throat

General

Fever, sweats, fatigue/malaise, loss of appetite, weight loss, lumps

paediatric Gait, Arms, Legs, Spine (or, pGALS)

pGALS is a screening tool designed to detect problems with the musculoskeletal system of school-aged children. 

NB - this tool is not appropriate for children younger than school age

There are two sections to the tool:

  1. A specific and focussed history
  2. A brief examination

As with any musculoskeletal examination, the key principles are detecting asymmetry and deformity, through a process of look, feel, move.

Key Questions:

  • Do you have any pain or difficulty in moving your arms, legs, neck or back?
  • When you get dressed, are you able to do this by yourself without any help?
  • Can you walk up and down stairs without any problems?

Examinaiton

Inspection - only takes a few seconds but is very important

Child should stand upright in only shorts, with a short sleeve top if a girl.

Look from:

  • The front, the side, behind of the whole body
  • The front and side of the face

Look for:

  • Asymmetry in muscle bulk, bone structure, joint swelling, shoulder/hip level
  • Deformity - Flexion, knock knee, scoliosis
  • Rashes

Gait

Ask child to walk to corner of room and back. Observe for:

  • Limping, gait rhythm, difficulty in turning around
  • Heel strike, stance phase, toeing off
  • Ask child about discomfort

Then ask child to walk on their heels and on their toes, ask about discomfort.

Arms

Sit child on couch - watch face for discomfort through exam

Inspect for: asymmetry, deformity, rashes

Manouvres

  • Supinate hands as much as possible
  • Make fists
  • Oppose thumb and each finger, repeat for other hand
  • Prayer sign, inverse prayer sign
  • Raise arms above head
  • Look up
  • Put hands behind head
  • Flex neck to each side
  • Ask child to put three of their own fingers into their mouth

Legs

Lie child flat on couch

Inspect for asymmetry of leg length and bulk, deformity rashes. Also check the bottom of feed for verucas or foreign bodies

Feel - see if knees are warm, and check for an effusion

Move

  • Check for full extension of the knee
  • Ask child to bring knee all the way to buttock 
  • Flex knee and hip to 90 degrees, then check internal and external rotation

Spine

Ask child to stand.

Ask child to bend forward and check that there is a consistent inline curvature of the spine from behind, and from the side.

Here is a link to the pGALS website. It has some great videos, so check it out!

Taking Histories from Specific Patient Groups - Paediatrics

With all histories, it is important to cover the basics (see previous post). In specific patient groups there are extra questions to ask which are unique to the group:

Paediatrics

Birth History

Antenatal

  • Uncomplicated?
  • infections, IUGR, other events, drugs (prescribed or other), alcohol

Delivery

  • Vaginal, C-section,
  • Any complications of delivery?
  • Full term or preterm
  • Birthweight (<2.5kg = low birthweight)

Postnatal

  • Resus required?
  • Any infections

Feeding

  • What they are being fed - breast, formula milk, solids
  • Any new foods recently?
  • Are they drinking well/ as normal

Vaccinations

  • What have they had - are they missing any?

Developmental History

  • Gross motor
  • Fine Motor
  • Speech, language, hearing, - reaction to sound?
  • Social interaction - does child seem unreasonably scared or uninterested in play

Social 

Home - smokers, safety, house condition - damp?

School - Attendance, enjoyment, performance

Growth - not really a history question, but it is very important to plot the weight and height of all children on a growth chart (link), and the head circumference of infants.

Red Flags - make sure to ask about these:

  • Little or no urination
  • Are they drinking well?
  • Are they playing well?
  • Parental concern - a lot, or none is worrying
  • Crossing centiles on growth charts

How to take a Medical History

Taking a good medical history is the most important skill to learn as a medical student, and is an art perfected over a whole career.

I am going to write about 3 things:

  1. How to take a basic medical history
  2. Things to include in histories from specific patient groups
  3. Red Flags to ask about when taking a history from a particular system

Contents of a Basic Medical History

(and suggestions on how to gather the info)

Patient Identifiers - Name of patient, DOB, Job/Retired (if adult)

Presenting complaint (PC) - the single reason the patient has come to see a doctor/the hosptial eg. Shortness of Breath, vomiting blood etc.

Past Medical History (PMH) - All previous hosptial admissions, operations and chronic health conditions

Systematic Review - (I just want to run through a few systems, to make sure we haven’t missed anything…)

Some people like to leave this until the end, but i think it helps to put this in with PMH as if you’ve missed anything (read - the patient forgets to mention it), you should be able to catch it here.

  • Cardiovascular - High BP, Heart Attack?
  • Respiratory - COPD, Asthma?
  • Gastrointestinal - Change in bowel habit?
  • Genitourinary - problems with waterworks?
  • Liver - ever become jaundiced or yellow at all?
  • Diabetes
  • Joints - Pain, stiffness or swelling?
  • Neuro - Altered sensation, vision, hearing, weakness?
  • Weight - unexpected gain or loss recently?
  • Psych - Had any mental health probs or experienced low mood?

Family History (FH) - any history of disease within the family?

Drug History (Drugs) - Take any regular medications for anything?

Again, this might reveal some more as yet unexplored PMH problems. Ask what each drug is for.

Ask: Name (generic if possible), Dose, Frequency, Route

Social History

  • Ever smoked? (how many per day, how many years)

It’s amazing how many people just quit recently, or are ‘cutting down’…

  • Alcohol - how much per week on average- work out units later
  • Living situation - alone, with family, mobility difficult? - stairs, any help around the house?

This is important information when it comes to discharge if the patient will need social support.

On Examination - Findings of relevant system examination.

Right, so that’s a good basic history, which you can adapt as you see fit in the context of each individual patient.

The most important thing when taking a history is to be nice. If the patient likes you, they will divulge key information much eagerly. On the other hand, if they feel like you are judging them, the 62 year old man with a persistent cough may tell you he doesn’t smoke much, and you may miss his cancer - disaster!

I’ll write about Red Flags and specific patient groups in another post, that’s all for now!

Starting Atypical Antipsychotics

Antipsychotics are often prescribed for people with Schizophrenia, Bipolar Disorder, Major Depressive Disorder and Mania, as they can be very effective at reducing the intrusive symptoms experienced.

  1. First line are ‘Atypical Antipsychotics’
  2. Second line are ‘Typical Antipsychotics’

Atypical Anitpsychotics

  • Olanzapine
  • Quetiapine
  • Rispiridone (can be given as 1-4 weekly depot injection)
  • Aripiprazole

Atypicals need monitoring for some well recognised side effects:

  • Metabolic Syndrome
  • Weight gain
  • Sexual characteristic dysfunction - Impotence, Gynacomastia, Menstrual Disturbances
  • Cardiovascular changes
  • Extrapyramidal SEs

Monitoring needs to be done before initiation of medication, then every 3 months for the first year, then as a yearly medication review. The monitoring is as follows:

Metabolic - glucose, HbA1c, Lipids

CVS - ECG, BP

Clincial - BMI, Waist circumference, dyskinesia assessment

Other general advice to be given before starting:

  • Take at same time each day - if one is missed take it when remembered, or skip if close to next dose
  • Don’t stop suddenly due to withdrawal effects
  • Enhances effects of alcohol
  • Driving is legal, but medication can cause drowsiness - take before bed if finding sedation a problem

NB - Side effects vary a lot between individual Atypicals, so trying more than one may be worth it.

Post Partum Haemorrhage (PPH)
PPH is the leading worldwide mortality of maternal death after giving birth, caused by:

80% of cases - Uterine Atony, Retained Placental matter
Other:
Perineal/vaginal trauma
Uterine rupture
Coagulopathy
Infection
Gestational trophoblastic disease

After birth the uterus should contract to prevent excessive blood loss, failure to do so is Uterine Atony.
There is huge capacity to lose blood, so it is essential to activate a Massive Transfusion Protocol and call specialist help (ITU/anaesthetics, obstetrician, haematologist) as soon as you become concerned.
Principles of Management
Resuscitate using usual ABCDE (link) approach
Stop bleeding
Encourage contraction of uterus
Repair or remove uterus
Definitive management
Specific Management

Empty Uterus
Remove placenta, or any retained tissue
Massage Uterus - can stimulate contraction
Increase uterine contraction medically
Oxytocin infusuion IV
Ergometrine IV or IM
Misoprostol (Prostaglandin) Rectally
Carboprost (Prostoglandin) IM, thigh or in uterus
Apply bimanual compression
Repair perineal/vaginal trauma, including tears
Uterine Tamponade
Balloon inserted into uterus and filled with warm saline
left in situ for 12-24 hours
Surgery - arterial ligation, sometimes proceeding to hysterectomy is needed.

Post Partum Haemorrhage (PPH)

PPH is the leading worldwide mortality of maternal death after giving birth, caused by:

80% of cases - Uterine Atony, Retained Placental matter

Other:

  • Perineal/vaginal trauma
  • Uterine rupture
  • Coagulopathy
  • Infection
  • Gestational trophoblastic disease

After birth the uterus should contract to prevent excessive blood loss, failure to do so is Uterine Atony.

There is huge capacity to lose blood, so it is essential to activate a Massive Transfusion Protocol and call specialist help (ITU/anaesthetics, obstetrician, haematologist) as soon as you become concerned.

Principles of Management

  1. Resuscitate using usual ABCDE (link) approach
  2. Stop bleeding
  • Encourage contraction of uterus
  • Repair or remove uterus
  1. Definitive management

Specific Management

Empty Uterus

  • Remove placenta, or any retained tissue

Massage Uterus - can stimulate contraction

Increase uterine contraction medically

  • Oxytocin infusuion IV
  • Ergometrine IV or IM
  • Misoprostol (Prostaglandin) Rectally
  • Carboprost (Prostoglandin) IM, thigh or in uterus

Apply bimanual compression

Repair perineal/vaginal trauma, including tears

Uterine Tamponade

  • Balloon inserted into uterus and filled with warm saline
  • left in situ for 12-24 hours

Surgery - arterial ligation, sometimes proceeding to hysterectomy is needed.