Diagnosis: Bronchiolitis (most likely RSV-related)

Why Bronchiolitis?

• Swanson's Family Medicine Review

Pathophysiology

• Inflammation, edema, and necrosis of the epithelial lining of small airways
• Increased mucus production and bronchospasm
• Resulting in wheeze, cough, accessory muscle use, tachypnea, and rhinorrhea

Additional Signs to Look For

• Tachypnea (RR >60)
• Intercostal/subcostal retractions and nasal flaring
• Wheeze or fine crackles on auscultation
• Hypoxemia (O2 sat <90% in severe cases)
• Hyperinflated chest on X-ray (air trapping)

Chest X-Ray Findings

Differential Diagnoses to Consider

1. Bacterial pneumonia - more likely if focal consolidation on CXR, toxic appearance, WBC markedly elevated
2. Pertussis (whooping cough) - at 2 months, partially or unvaccinated; paroxysmal cough, post-tussive vomiting, whoop
3. Viral pneumonitis - often co-exists with bronchiolitis
4. Congenital heart disease - poor feeding + respiratory symptoms, but usually without fever
5. Chlamydia trachomatis pneumonia - afebrile pneumonia in this age group (but fever here makes it less likely)

Management (Evidence-Based)

• Hydration: IV fluids if not tolerating feeds (poor feeding + RR >60-70 = aspiration risk)
• Supplemental oxygen: if SpO2 persistently <90%
• Nasal suctioning: provides temporary relief
• NOT recommended: routine bronchodilators, corticosteroids, antibiotics, or chest physiotherapy
• Antibiotics only if: confirmed bacterial coinfection (positive culture, AOM with bulging TM, consolidation on CXR)

Prevention

• Palivizumab (15 mg/kg IM monthly x5): for high-risk infants (premature, congenital heart disease, chronic lung disease, immunodeficiency)
• Strict hand hygiene and contact precautions in hospital settings

• Swanson's Family Medicine Review, p. 583
• Red Book 2021 - Report of the Committee on Infectious Diseases (AAP), pp. 977-980
• Sherris & Ryan's Medical Microbiology, 8th ed., p. 352

Eye Drops After IOL (Cataract) Surgery - Duration Guide

1. Antibiotic Eye Drops

• Usually started 1-2 days before surgery
• Used several times daily in the first week
• Discontinued once infection risk has passed (usually by day 7-14)
• Note: Many modern surgeons now inject antibiotics directly into the eye at time of surgery, so post-op antibiotic drops may not always be required

2. Anti-inflammatory Eye Drops (Steroid + NSAID)

• These are the most important drops to complete fully
• Often started 2 days before surgery
• The dose is tapered: e.g., 4x/day for week 1-2, then 2x/day, then 1x/day before stopping
• Do NOT stop abruptly without your surgeon's instruction - stopping early risks rebound inflammation

3. Lubricating / Artificial Tear Drops

• These are not medicated and are safe to use freely
• Most patients need them for 1-3 months

General Timeline Summary

Important Tips

• Wait 5-10 minutes between different eye drops - do not put multiple drops in at once
• Always wash hands before applying
• Do not touch the dropper tip to your eye or eyelid
• If you run out early, contact your doctor - do not stop halfway through a course
• Report any sudden pain, vision loss, redness, or discharge immediately

The exact schedule always depends on your surgeon's instructions. Some surgeons have different protocols, especially if a combined antibiotic-steroid drop is used. Always follow what you have been specifically prescribed.

• AAO guidance on post-cataract eye drops

Your Role as an FMG Intern in the SNCU

1. Admission & Triage

From the delivery room / inborn:

• Birth weight <1800 g and/or <34 weeks (minimum 24 hours observation)
• APGAR score <6 at 1 minute / gasping / delayed cry
• Respiratory distress (tachypnea, grunt, retractions, central cyanosis)
• Asphyxia / suspected HIE (Hypoxic Ischemic Encephalopathy)
• Symptomatic hypoglycemia
• Suspected sepsis (unstable)
• Major congenital anomalies requiring monitoring

From community (babies <28 days):

• Delayed cry >5 minutes
• Respiratory distress, central cyanosis or spells
• Bile-stained vomiting
• Abdominal distension
• Suspected sepsis - unstable baby
• Unstable baby with congenital abnormality

2. Daily Ward Rounds (Morning and Evening)

3. Clinical Procedures (Learn and Practice)

4. Key Conditions to Manage (Know These Well)

Neonatal Sepsis

• Early onset (<72 hrs): GBS, E.coli, Listeria
• Late onset (>72 hrs): Staph aureus, Klebsiella, Pseudomonas (nosocomial)
• Work-up: CBC, CRP, blood culture x2, urine culture, LP if stable
• Treatment: Ampicillin + Gentamicin (early onset); Cloxacillin + Amikacin (late onset/nosocomial)

Neonatal Jaundice

• Physiological vs pathological (onset <24 hrs = always pathological)
• Know phototherapy thresholds by age in hours and gestation
• Know exchange transfusion indications
• Investigations: TSB, direct/indirect bilirubin, blood group, Coombs test, G6PD

Respiratory Distress Syndrome (RDS) / Hyaline Membrane Disease

• Preterm babies, <34 weeks
• Grunting, retractions, cyanosis from birth
• CXR: ground glass opacification, air bronchograms
• Management: surfactant, CPAP/O2, temperature, nutrition

Hypoglycemia

• Blood glucose <45 mg/dL
• Asymptomatic: oral/NG feeds; Symptomatic: IV dextrose bolus (2 mL/kg of D10)
• At-risk: LBW, preterm, IDM (Infant of Diabetic Mother), asphyxiated

Hypothermia

• Very common in preterm/LBW
• Use radiant warmer, incubator, skin-to-skin (KMC)
• Warm the room, warm fluids, delayed baths

Birth Asphyxia / HIE

• APGAR scoring at 1 and 5 minutes
• Therapeutic hypothermia if eligible (>36 weeks, <6 hours of age)
• Supportive: glucose, ventilation if needed, seizure management

5. Documentation (Critical Duty)

• Admission note: birth history, weight, gestation, APGAR, vitals, examination findings, provisional diagnosis, plan
• Daily progress notes: SOAP format (Subjective, Objective, Assessment, Plan)
• Drug charts: Verify doses using weight-based dosing (always per kg)
• Fluid charts: Input/output, daily fluid requirements
• SNCU online register: In India, every SNCU logs data on the NHM SNCU online portal
• Discharge summary: Final diagnosis, treatment given, follow-up plan, immunization status

6. Common Drugs in SNCU (Know Your Doses)

7. Infection Control in SNCU

• Hand hygiene is non-negotiable - wash before and after touching every baby
• The SNCU is a high-risk zone for nosocomial infections
• Wear gloves for all invasive procedures
• Clean incubators and warmers regularly
• Do NOT cross-contaminate between babies (use individual equipment)

8. Counselling Parents

• Explain diagnosis and treatment in simple language
• Demonstrate KMC to mothers
• Teach mothers to recognize danger signs before discharge
• Discuss breastfeeding support and expressed breast milk (EBM)
• Arrange follow-up after discharge (weight check, immunization, ROP screening if needed)

9. Discharge Criteria (Know When Babies are Ready)

• All acute problems resolved
• Baby accepting breast feeds or spoon feeds well
• Adequate weight gain for 3 consecutive days
• Baby weight >1.5 kg
• Mother confident to manage at home
• If jaundice with exchange transfusion: arrange BERA (hearing test)
• If weight <1800 g or <32 weeks: arrange ROP screening (Retinopathy of Prematurity)

Quick Summary: Intern's Daily SNCU Routine

1. Morning: Check vitals sheet overnight, update fluid and feed charts
2. Rounds: Assess each baby systematically, present to senior
3. Procedures: Heel pricks, IV cannula, blood draws, NG feeds
4. Documentation: Progress notes, drug chart updates
5. Phototherapy: Check bilirubin results, adjust therapy
6. New admissions: Admission note, initial stabilization
7. Evening: Handover note, pending investigations, critical baby watch

Remember: In the SNCU, every gram of weight and every degree of temperature matters. When in doubt, escalate to your senior immediately - sick neonates can deteriorate very rapidly.

Pediatric Ward New Admission: Complete Intern's Guide

STEP 1 - Take Vitals First (Before Anything Else)

How to Measure Each Vital Sign

• Use digital thermometer; axillary route in children <5 years
• Normal: 36.5 - 37.5°C

• 37.5°C = fever; >38°C rectal = significant fever

• <36°C = hypothermia (common in neonates, malnourished, shocked)

• In infants: feel brachial/femoral pulse; in older children: radial
• Count for full 60 seconds - do not estimate
• Note: rate, rhythm, volume (thready = shock)

Tachycardia is the earliest sign of cardiovascular compromise. A thready pulse with tachycardia = shock until proven otherwise. Bradycardia in a sick child = impending cardiorespiratory failure.

• Count chest movements for full 60 seconds (do not use stethoscope - observation only)
• Best done when child is calm or sleeping

WHO definition of tachypnea (danger sign): >50/min in 2-11 months; >40/min in 1-5 years

• Use correct cuff size: cuff bladder should cover 2/3 of upper arm
• Too small a cuff = falsely HIGH reading; too large = falsely LOW reading
• Formula to estimate normal systolic BP:
  • Children ≥1 year: (Age in years × 2) + 90 mmHg
• Minimum acceptable systolic BP (hypotension threshold):
  • 0-28 days: 60 mmHg
  • 1-12 months: 70 mmHg
  • 1-10 years: 70 + (2 × age in years) mmHg

  • 10 years: 90 mmHg

Remember: Children maintain BP until very late in shock (>30% blood loss). Hypotension is a late and ominous sign. Don't wait for it.

• Normal: >95% in room air
• 90-94% = moderate hypoxia - give oxygen
• <90% = severe hypoxia - urgent

• Weigh every new admission - all drug doses are weight-based in pediatrics
• Use beam balance or electronic scale; remove clothes and nappy
• If unable to weigh: estimate - Weight (kg) = (Age in years + 4) × 2 (for 1-10 years)

• Quick assessment: Alert / Voice response / Pain response / Unresponsive
• Full GCS for older children with neurological complaints

STEP 2 - Write the Complaint

Format:

"[Name], [age], [gender], brought by [mother/father/caregiver] with complaints of:

1. [Chief complaint] - since [duration]
2. [Associated complaint] - since [duration]
3. [Associated complaint] - since [duration]"*

Rules for Writing Complaints:

• List in order of importance or chronological order
• Include duration for each complaint
• Keep it brief - this is not the history, just the complaints
• Use lay terms that reflect what was reported, then translate

Common Examples:

1. Cough - 5 days
2. Fever - 3 days
3. Fast breathing - 1 day
4. Poor feeding - 2 days

1. Loose stools (6 episodes/day) - 3 days
2. Vomiting - 2 days
3. Decreased urine output - 1 day
4. Fever - 2 days

1. Abnormal body movements (generalized tonic-clonic) - 2 episodes today
2. Fever - 1 day
3. Post-ictal drowsiness - 30 minutes

STEP 3 - Write the History (for the Admission Note)

A. History of Present Illness (HPI)

• When did it start? What happened first?
• Progression: getting better / worse / same?
• Any treatment given before coming here?
• For each complaint, ask: onset, duration, severity, progression, aggravating/relieving factors, associated symptoms

B. Birth History (especially <2 years)

• Term or preterm? (gestational age)
• Mode of delivery (NVD / LSCS)
• Birth weight
• Any cry at birth? Any NICU/SNCU admission?
• Antenatal complications

C. Feeding History

• Exclusively breastfed? Formula? Complementary foods started?
• Current feeding pattern and appetite
• Any feeding difficulty?

D. Developmental History (especially <5 years)

• Milestones: social smile, neck holding, sitting, standing, walking, words, sentences
• Any regression?

E. Immunization History

• Up to date as per national schedule (BCG, OPV, IPV, Penta, PCV, MR, etc.)?
• Note the last vaccine given and date

F. Past Medical History

• Previous hospitalizations, operations, chronic illnesses
• Known allergies (especially drug allergies)

G. Family History

• Siblings' health; similar illness in family?
• Consanguinity (relevant for genetic/metabolic disorders)

H. Socio-economic / Environmental History

• Housing, water source, sanitation
• Exposure to TB contact, smoke, animals

STEP 4 - Physical Examination (Systematic)

General Examination (always first)

• Build & nutrition: well-nourished / moderately malnourished / severely malnourished (use MUAC, weight-for-height)
• Pallor: check conjunctiva, palms, nail beds
• Icterus: check sclera, skin
• Cyanosis: central (tongue, lips) vs peripheral (fingertips)
• Clubbing: grade I-IV
• Lymphadenopathy: location, size, tender/non-tender, matted
• Edema: pitting? location?
• Dehydration signs: sunken eyes, sunken fontanelle, dry mouth, skin turgor, capillary refill

Systemic Examination

• Respiratory: RR, chest shape, retractions (subcostal/intercostal/suprasternal), air entry, wheeze/crackles
• CVS: heart sounds, murmur, pulse character, CRT (normal <2 sec)
• Abdomen: distension, tenderness, organomegaly (liver 1-2 cm below RCM is normal in infants), bowel sounds
• CNS: GCS/AVPU, fontanelle (bulging = raised ICP; sunken = dehydration), tone, reflexes, meningeal signs
• ENT: throat (red/tonsils), ears (TM), nose

STEP 5 - Write the Provisional Diagnosis

Format:

Provisional Diagnosis: A [age] [gender] child with [key complaint] likely due to:

1. [Primary diagnosis] - based on [key findings that support it]
2. Rule out: [Differential 1]
3. Rule out: [Differential 2]

Example 1:

Provisional Diagnosis: A 3-year-old male child presenting with fever and fast breathing likely has:

1. Community-acquired pneumonia (right lower lobe) - based on fever, tachypnea (RR 58), subcostal retractions, decreased air entry and crepitations on right side
2. Rule out: Bronchiolitis (age slightly older, no wheeze)
3. Rule out: Pulmonary TB (no contact history, short duration)

Example 2:

Provisional Diagnosis: A 10-month-old female child with loose stools and vomiting likely has:

1. Acute gastroenteritis with moderate dehydration - based on 6 loose watery stools/day, sunken eyes, reduced skin turgor, irritable, RR normal, HR 140
2. Rule out: Intussusception (if blood in stool / colicky pain)

STEP 6 - Write the Initial Management Plan

• IV access: establish, send bloods (CBC, CRP, electrolytes, blood culture if sepsis suspected)
• Fluids: IV/oral rehydration plan (ORS for mild-moderate dehydration; Ringer's Lactate/Normal Saline IV for severe)
• Oxygen: if SpO2 <94%, start O2 via nasal prongs 1-2 L/min
• Temperature: paracetamol 15 mg/kg/dose if fever >38.5°C
• Empirical antibiotics: only if sepsis/pneumonia suspected - hold pending senior review
• Nothing by mouth (NPO): if surgical abdomen, altered consciousness, severe respiratory distress
• Monitoring: chart vitals every 4 hours (or more frequently if sick), record urine output

Quick Pre-Round Checklist

• Vitals recorded on chart (T, HR, RR, SpO2, BP, weight)
• Complaints written in order with duration
• History taken and documented
• General + systemic examination done
• Provisional diagnosis written
• IV access established (if needed)
• Baseline investigations sent (CBC, CRP, urine, blood culture, etc.)
• Drug chart started with accurate weight-based doses
• Fluid chart started (input/output)
• Previous records / referral letter reviewed