1. Cardiac catheterisation

SVC

RA 65% 4 LA 99% 6

RV 65 25/4 LV 98% 75/6

PA 65 25/15 AORTA 97% 75/50

Aorta > 94 % -acyanotic

o PA ( sao2) > SVC ----------- L -> R SHUNT

Pulm pressure high ---- large VSD / PDA

Normal ------ASD , Small VSD /PDA

o P A ( sao2) = SVC

LV pr > Ao ----- AS

RV pr > PA ------ PS

Asc Ao pr > desc ------ coarctation

< 94 % - CYANOTIC

o PA sao2 > Ao ----------- TGA

o PA pr

normal ------------

-fallot, Pr RV =LV

TGA , pr RV > LV

critical PS

High ------------ TGA +VSD, AVSD, EISSENMENGER

o LA sao2 decreased ---------- Tricuspid/ pulmonary atresia

2. ABGA

PH 7.35 -7.45 PCO2 4.5 -6 ( 35 -45 ) PO2 11-14 HCO3 -22-26 BE/BD - + /- 2

CBG All except po2 / VBG only Ph

Metab acidosis

Required

anion gap ,

lactic acid , osmolar gap,

urine anion gap, K , urine ph

Anion gap = Na +k ( hco3 + cl )= 12 +/- 2 ( 4 if k )

Osm gap = ( measured osm calc osm ) 2 Na + urea + glucose

Urine anion gap +ve ( Cl < Na + k )

High anion gap - Cl normal

Increased lactic acid

Poor perfusion hypoxia, shock, heart failure

Normal perfusion renal failure CRF , starvation

Normal lactic acid

High osm gap poison, toxin ( measured osm calc osm ) 2 Na + urea + glucose

Nl osm gap (< 10 ) DKA , IEM

Salicylate, PCM, ETHANOL,METHANOL, formaldehyde, metformin, NH4CL,ACETAZOLAMIDE

DKA Macidosis, high Na, low /N K , Low HCO3

NAGMA Increased Cl

Urine anion gap +ve ( Cl < Na + k )

Renal loss of HCO3 --- RTA

Low K , Urine Ph > 5.5 - Type 1

Low K , urine Ph < 5.5 - type 2

High k type 4

Urine anion gap ve ( CL> Na + k )

GI LOSS Of HCO3 --- persist diarrhoea

DURHAM ACETAZOLAMIDE , ADDISONS , GDM TYPE1

HCO3 Replacement = 0.3 *Wt *BD

Type 1 -distal Type 2 proximal

Urine ph > 5.8 never acid May be < 5.3

Severe hypokalemia K normal / low

Nephrocalcinosis

No increase in urine blood pco2 gradient

with nahco3 load

Increase

1-2 mmol/kg nahco3 Large dose

Obs uropathy

Nephrocalcinosis

Amphotericin, cyclosporin

Fanconi syndrome

Isolated / familial

Fanconi syndrome

Cystinosis ( not cystinuria

Tyrosinemia

Galactosemia

Lowe ( OCR )

WILSON

Lead, mercury, cadmium toxicity

Tetracycline, ifosfamide

Hyperchloremic NAGMA

Glycosuria normal glucose

Hypophosphatemia , low TRP, Rickets- no hypocalcemia

Hypokalemia

Growth faltering

Polyuria, polydipsia

Cystinosis transport of cysteine out of lysosome fanconi, recc conjunctivitis ( corneal crystals ,) photophobia, hypothyroid

Renal failure 8 yrs

White cell cysteinelevel

Supportive / cysteamine

METABOLIC ALKALOSIS

Look for - cl, BP, Urine cl, renin aldosterone

NORMOCHLOREMIC enteral /parenteral HCO3

Hypochloremic ( cl loss)

Normal BP

Urinary Cl >20 barter, gitelman

< 10 pseudo barter

High BP

Renin Aldosterone

Renal artery stenosis High High

Conns, adr tumor low High

Cushings, CAH, 11 b,

liddle

low low

Barter Na k 2 cl in thick asc limb

Polyuria, polydipsia

Mat polyhydramnios

Hypochloremic hypokalemic alkalosis ( cl unresponsive )

Renin, aldo increase ( vasc unresponsiveness )

Nl BP

Urine cl, na > 20 mmol

Urine calcium normal / high : nephrocalcinosis

Increased PGE2

Indomethacin / potassium supplements

Pseudo barter

Low urine Na , Cl < 10 (cl responsive )

o Cystic fibrosis

o Cong chloride diarhea

o Laxative abuse

o Cyclical vomiting

High urine electrolyte loop diuretics

Gitelman ( like thiazide )

Distal tubule Na cl cotransporter

Hypocalciuria

Hypomagnesemia

Resp acidosis INCREASE VENT PARAMETERS

Resp alkalosis ( low CO2 ) ------ DECREASE VR --- FiO2 ---- LAST pressure

Nonketotic hyperglycenimia R acidosis ( apnea )

UCD R alkalosis

Saliocylate R alkalosis --- m acidosis

Over-ventilation

High pH

with a Low PaCO2

Decrease the tidal volume

Do this first if the baby has good

chest movement and/or high

tidal volumes

Decrease the difference between the PIP

and PEEP (usually by decreasing the PIP)

Decrease the frequency Drop the rate.

If the gas is just a bit alkalotic, drop

by 5. If really alkalotic, you might

want to drop it by 10 or more.

it is futile to reduce the rate if the

baby is breathing above the back

up rate. So wean the pressure (or

VT) instead.

Under-ventilation

Low pH

with a High

PaCO2

Increase the tidal

volume

Do this first if the baby

has no chest movement

and/or low tidal

volumes

Increase the PIP till you get some chest

movement but look at the tidal volume

too.

In general, you should not increase the

PIP too high as you may find that the

tidal volume increases significantly. But

you need to give enough pressure to get

chest movement.

Increase the

frequency

Increase the rate. If a bit acidotic, increase by 5. If

really acidotic, you may need to increase it by 10 or

more.

For fast rates, it is really important that the

expiratory time is longer than the inspiratory time.

You may need to decrease the inspiratory time

accordingly.

If you find you need to give more than 70 breaths

per minute, think about HFOV as a ventilation

mode. Speak to the specialist on duty.

3. Water deprivation test (Miller-Moses) test

Central DI Idiopathic

Cranipharyngioma

Postop

Head trauma

Hereditary

Nephrogenic DI

Renal disease sickle cell,amyloidosis

Hypokalemia

Drugs lithium, ampho B, demeclocycline, orlistat

X linked nephrogenic DI

Treatment SIADH Meningitis, HIE

Pneumonia Carbamazepine Asthma, ventilation Lymphoma Bronchogenic carcinoma

Hyponatremia Inappropriate U osm > sr osm ( *** )

U Na > sodium intake ( > 20-30 ) Hypouricemia (

insipidus

Dilute urine ( < 200 mosm/kg ) U sp gvty < 1.005 Random Pl osm high > 287

Cerebral salt wasting (natriuretic peptide )

Hyponatremia Urine Na > 40 U na * U vol > Na intake ( equal in SIADH ) Hpouricema and High FE UA ( Persists even after correction of Na but not in SIADH) FE of phosphate high ( Not in SIADH )

Excessive water intake

Hyponatremia

pl osm less u osm less

Urine Na < 10 ?

Addisons Low Na , High K Hypoglycemia

Synacthen test

Cortisol < 450-500

Both DI & PSYCH POLYDYPSIA LOW urine osm

Water deprivation test ( nl U osm 800 )

Water deprivation for max 7 hours - wt, pulse BP, U osm hourly

Free access to fluid is permitted until the start of the test.

During the test, dry food is permitted but not fluid; at timed hourly intervals for up to 8 hours the following are measured:

weight

urine volume and osmolality

serum osmolality

2 mcg IM desmopressin is administered at the end of 8 hours. Urine is collected for a further 16

hours during which time fluid intake is allowed but restricted to a maximum of 1.5 times the urine

volume voided during the dehydration period. Blood is collected at the end of the 16 hours and plasma osmolality measured.

Results may be interpreted as:

urine osmolality after fluid

deprivation

urine osmolality after

desmopressin

diagonosis

less than 300 mosmol/ greater than 800 mosmol/kg cranial diabetes

insipidus

less than 300 mosmol/ less than 300 mosmol/kg nephrogenic

diabetes

insipidus

greater than 800 mosmol/kg greater than 800 mosmol/kg primary

polydipsia

U osm between 300 -800 Below 800 Partial DI or

Primary

poydypsia

Pl osm > 290 mosm /kg inapp low urinary osm ------- diabetis insipidus

Iniatial u osm low increases with test ------ psychogenic polypsia

If urinary osm < 200 mosm/kg ---- confirmed DI Urinary osm < 800 mosm/kg --- DI Eg urinary osm 800 , pl osm 250 mosm /kg --- psychogenic polydipsia

Stop the test if wt falls 5% ( 3% in children ) , sr osm > 295mosm/kg , urine< 300

mosm/kg

If sr osm > 290 mosm/kg & u osm < 290 mosm /kg test not required

Pseudohyponatremia -- (Isotonic)

1. Hyperlipidemia (Serum Triglycerides >1500 mg/dl) 2. Hyperproteinemia (Serum Protein > 10 g/dl)

4. Synacthen test

Cortisol > 450 -550 nmol /L at 30 min after synth ACTH

CORTISOL - increase in morning and decrease at midnight

5. Hypernatremic dehydration in new born

If significantly hypovolaemic (eg shocked), use isotonic fluid (0.9% saline) to restore circulating volume Otherwise, give hypotonic fluids (0.45% saline, 5% dextrose, oral water),

Water deficit (L) = TBW x ((serum [Na+] (mmol/L)/145) - 1) x weight Replacement volume (in L) = TBW deficit X [1 1 - (Na concentration in IVF mEq/L 154 mEq/L)]

Eg 3.4 kg 10 day with sodium 160 used 0.9% NS deficit =0.6 x (160 /145 1) = 0.06 l/kg = 0.211 L Replacement volume=0.211 X (1) = 0.211 L = 210 ml replaced over 24- 48 hours

Otherwise simple 0.6* bw * excess Na / Na content in fluid * 1000 ml

6. T3, T4, TSH , TPO AB pregnancy , non compliant , graves, hypothyroidism, HASHIMOTOS,

TSH secreting pit tumor

Pregnancy increase thyroid H. BP ------

increase in total T3 , T4

But normal free level

( also in clofibrate, chronic heroin, excess

estrogen )

GC, ANDROGEN, Phenytoin/CBZ Decrease THBP

NON compliant with treatment in

hypothyroidism

High TSH But T 4 normal

Graves RI Uptake increased, autoab to TPO/TG

TSH sec pit tumour TSH Normal / increased

DEQUERVAINS ESR high ,RI uptake low

HASHIMOTOS High titre of antithyroid ab ( antiTG )

PRETERM Very low T4 , TSH normal

6 weeks term level

Sick thyroid syndrome Normal free T4 And raised TSH

TSH response to TRH Rise at 20 min ----fall by 60 min

Contionued rise at 60 min hypothalamic

damage

Low baseline TSH Secondary

Raised TSH - PRIMARY

Free T3 5 -10

FREE T4 10 -22

TSH 0.4 -5

7. Ca PO4 , PTH, ALK PO4ase pseudo hypopth, hypopth 1 , 1* hyperpth, FHH, VIT D EXCESS,

SARCOIDOSIS

Primary hypoPTH Low calcium, high phos

Low PTH

Normal alk po4

Primary hyper PTH High Ca , low Phos

High PTH /n

High alk po4

U ca/cr high

Uric acid high

F. Hypocalciuric

hypercalcemia

High calcium

Phos/PTH/ alk po4 normal

NO Rx

PseudohypoPTH

( end organ resist)

Low calcium, high phos

PTH N/ INCREASED

ALK PO4 N/ incr

4TH

AND 5TH

metacarpal/

metatarsal

shortening,ectopic calcifn

Pseudo pseudo hypo pth Phenotype + BIochem N

VIT D EXCESS High ca & phos

Alk po4 Normal

PTH low

Exogenous PO4 EXCESS LOW ca . high phos

PTH normal

sarcoidosis high calcium, low po4

High alk po4

High vit D

IMMOBILISATION High ca/po4

Low PTH

NL 25 OH VIT D

PROX RTA HypoPO4 Rickets + acidosis

+ urine ph < 5.5

Distal RTA Vit D dep rickets

RENAL OD High po4

High alk po4

High PTH

Decrease 1,25 dioh vitd

Acidosis+

Nutritional rickets

(VIT D DEFF)

Low calcium/po4 , high PTH

25 OH VIT D low

1,25 DIOH VITD - NORMAL

LIVER DISEASE LOW LOW

Vit dep rickets type 1 (1

alpha oh ase deff)

Normal Low 1,25 dioh

VIT DEP TYPE 2 ( END ORGAN

RESIST )

HIGH

VIT D RESISTANT ( X LINKED

HYPOPO4 )

N

LOW PO4,

NORMAL CALCIUM, Normal

PTH

N

INCREASED u po4

8. Pheochromocytoma

( MEN 2 , NF 1 , VHL ) --- parox headache, recurrent sweat , nausea, palpitations, wt loss,

hypertension

24 HR urine VMA, HMMA

MIBG, CT abdomen

Carcinoid syndrome

5HIAA 24 hr urine

HT, Flushing, diarrhoea

Chronic PS/TR

Cushing syndrome

Hypokalemia , increase aldo

Metab alkalosis

Hypoglycaemia

Pigmentation ACTH PIT ADENOMA

24 Hr u CORTISOL

Dexamethasone sup test

9. Qp :Qs

Qp:Qs = ( Ao SVC) / (PV PA ) Saturations

Ao = 100, PV = 100 So (100-SVC/100-PA)

Eg. 100 (88) / 100 (95) = 2.5 LARGE VSD

Normally, this ratio is 1 because, normally, the volume of blood that is pumped to the lungs (Qp) is equal to the volume of blood that is pumped to the body (Qs).

In patients with left-to-right shunts, the QpQs ratio is greater than 1.

In general, a QpQs ratio of 1.5 or less is considered a small shunt; a QpQs ratio of 1.5 to 2.0 is considered a moderate shunt; and a QpQs ratio of more than 2 is considered a large shunt

10. QTc

Bazett's Formula

Corrected QT (QTC) = QT Interval / Sq rt (RR interval)

Normal QTc _ 440 msec.

Eg. QT 2 Sq RR 10 Sq 2* 0.2 / 10*0.2 = 0.4 / 2 =0.4/1.4 =0.35

Bazett's Formula- not accurate, and over-corrects at high heart rates and under-corrects at low heart rates.

11. LH/ FSH/PROLACTIN/ ESTROGEN PCOS, Pregnancy, pit tumor, 1*ov failure,

LH 2-10

FSH 2-10

PROLACTIN 50-450

ESTRADIOL 130 -600

PROLACTINOMA Prolactin > 2000

Pregnancy High PROLACTIN Elevated estradiol

PCOS 1

Non classical CAH

CUSHINGS

TESTOSTERONE MILD INCREASE

Non classical CAH 17 0H Prog > 33 nmol/l

12. PT/ APTT/BT

a.

Hemophylia APTT prolonged PT normal

Von willebrand disease Type 1

Ristocetin cofactor activity decreased Decreased factor 8 Decreased Vwf Bleeding time N / ^ APTT N / ^

2b thrombocytopenia ( hyperactive vwf ) increased LDRIPA 2M ( Plat binding Fn ) normal factor 8 2N Autosomal haemophilia

Vitamin k dependent bleeding

PT , APTT Both increased TT Normal Platelet, fibrinogen, FDP normal

Isolated PT Increased HDN, Liver failure, warfarin Isolated APTT increased VWD, Hemophilia,heparin,

lupus anticoag PT, APTT, TT all increased DIC,

heparin in tube Afibrinogenemia Factor 2 deff

13. Iron TIBC ,Transferrin sat, Lead poisoning

Fe TIBC Transferrin saturation

(nl 30 %)

Ferritin

IDA Low increased Decreased Decreased

Beta thal N /high N N Slight Incr

Sideroblastic

anemia

High/N LOW/N 100% HIGH

Chr disease Low low N N/INCREASED

IDA

Decreased ferritin earliest

Decreased transferrin saturation

Increase ratio of Zn protoporphyrin / heme

Increased soluble transferrin receptors

Decreased MCV

Decreased HB

G6pd deff

Decreased pl haptoglobin

Increased pl methemalbumin

Hemoglobinuria

Heinz bodies

14. CAH

Cong adrenal hyperplasia

21-Hydroxylase Deficiency

hyponatremia and hyperkalemia;

hypotension

Low glucose Metab acidosis

virilization of girls & ambiguous genitalia & dark scrotum in boys.

Increased 17 OH prog > 1000 ng /dl

Reduced 11 deoxy cortisol

11-b-Hydroxylase Deficiency

salt retention, hypertension & hypokalemic alkalosis.

(suppressed plasma renin activity

virilization of the female fetus.

elevation of serum 11-Deoxycortisol and 11-deoxycorticosterone.

17-a-Hydroxylase deficiency

salt retention, hypertension & hypokalemic alkalosis.

Undervirilization

genitalia is ambiguous in boys.

3BETA HSD DEFF:

SALT WASTING

CLITOROMEGALY IN FEMALE

INCREASED DHEA

MALE HYPOSPADIASIS

15. LUNG FUNCTION , FEVI,FVC,

OBSTRUCTIVE ( ASTHMA /

CF)

RESTRICTIVE

FVC

FEV1

FEV1/FVC N > 80%

PEFR

FEF25-75

Flow volume curve Concave Small volume

DMD FVC

GBS- VITAL CAPACITY

CF - FEV1

OBSTRUCTIVE FEV1 Decreased FVC - Normal

Restrictive -- both decreased

Mixed FEV1 DECREASED MORE ---- FVC DECREASED

CYSTIC FIBROSIS MIXED

ASTHMA FEF 25-75 BEST MEASURE FOR SMALL AIRWAY

But PEFR is easy ( measures only large airway )

16. AUDIOGRAM

< 40 DB LOSS CONDUCTIVE DEAFNESS

o---O----O Right air cond

xxx left air

[ -- [-- [-- [ right bone

]--]--] left bone

17. Weber / rinne

Rinne Right Rinne left weber

-ve +ve Right Rt Cond HL

-ve +ve left Lt SNHL

+ve +ve left Right SNHL

-ve -ve central B/L CHL /SNHL

-ve -ve Left Left CHL & Right

sNHL

18. Tympanogram

Right ear hypermobile ossicular discontinuity or normal

Flat tympanogram --- otitis media

19. EEG

SSPE - Large amplitude periodic slow wave cx

BRE U/L Centrotemporal spike

JME Generalised irregular spike cx

Lennox gestaut generalised multiple discharges of spike wave and polyspike cx

20. Mg/kg/min GDR = 10*Dextrose% *ml/hour / 6 * BW

0.9% ns = 150 mmol/l

0.18% = 30

Na req newborn = 4 mmol/kg

21. Glassgow coma scale

22. ,

OXYG INDEX = MAP*FIO2 / Pao2 kpa = *7.5

23. . glucagon stimulation test

An adequate cortisol response is defined as a rise of greater than 200 nmol/L to above 600

nmol/L. The value of 600 nmol/L is used to exclude adrenal insufficiency in view of variation

between analytical methods.

An adequate GH response is a rise to a value greater than 20 mU/L (

24. .

Gilbert

Crigler najar

Dubin Johnson

Rotor

25. Statistics

Confidence interval

95% Confidence interval - mean 1.96 SEM

SD = Sq rt variance SEM =SD/ sq rt N

SD, SEM used only in normal distribution

If Confidence interval contains 0 or 1 p > 0.05 ( not significant ) If CI not contains 0 or 1 ----- significant

( for odds ratio , Relative risk ----1 : weighted mean difference ---- 0 )

diseased Not diseased Exposd a B Non exposed c D

Absolute risk a/a+b & c/c+d Risk difference / absolute risk reduction

A B ( 0 No difference ) NNT ( No. of pts to be treated to get 1 benefit )

1/ARR

Relative risk / risk ratio Proportion of 1 group/ prop of other group (a/a+b) / c/c+d)

Relative risk reduction ( like RR but in control group )

( 1-RR ) *100 (Control event rate expt event rate )/control event rate

Odds ratio a/c / b/d = ad/bc

Cross over study Only for chronic disease/ fewer - not cured/ temporary relief No carryover effect

Increase the power of the study Paired t test ( continuous variable )

Case control- cross sectional- cohort

Null hypothesis

NH is true NH is false Accept null hypothesis ok !! alpha Reject 1 beta Ok

Type 1 error rejecting wrongly BETA Type !! error accepting wrongly ALPHA

Small sample size ---- lead to type !! error ---- less power Power of a study = probability (%) of correctly rejecting (1 beta )

Continuous variables 1. Normal distribution (mean of 2 group) >2 groups

Cross over trial Paired t test ANOVA ( Analysis of variance) 2 independent

groups Unpaired t test

2. Non normal distribution Small number ( median of 2 group )

Wilcoxon matched pair test Mann whittney U test

Kruskal wall ANOVA

Categorical variables ( binary ) 1 binary outcome ( compare proportions or

% ) Chisquare

2

small number Extreme %

Fisher exact test

3 Paired sample Mc Nemar test

Disease + No disease Test + Test -

26. . murmurs

Aortic stenois ESM Right USE Radiates to neck

Coarctation Syst murmur USE TO BACK Lt BP < Rt BP

Pulm stenosis

27. .ecg

QRS 100 msec narrow

WPW DELTA WAVE PROMINENT IN LEAD AVF AND V4

28. .

HOCM f/h sudden death

collapse during exercise

Prol QT Spont recovery in seconds

AS

VASOVAGAL SYNCOPE Prolonged standing Erect and supine BP, TILT

table test

29. .

3 mths Lifting head and chest

5 mths Roll over front to suoine

6Mths Sit with support

Lift chest on extended arms

1 year Walk with hand held

2 YEARS Walk up/down stairs 2 foot /steps.

Climb on furniture

Try kick ball

3 mths Hand regards

6 months Reach for / transfer objects Mouthing

15 mths Put things into container

To and fro scribbles

3 years Thread large beads

Circle 3 yrs, cross

Tower of 8 cubes

Draw head hands without trunk

Kick ball well

Scissors???

4 yrs Thread large beads

Square , plus

Tower 10 cubes , steps 6 bricks

Approx. thumb with each finger

Hop on preferred foot

Copy OX TH

5 yrs Count fingers with index finger of other hand

Hop forward

3 yrs 4 5 Head-legs

4 yrs 6(7) 7 Trunk

5 yrs 11 12 Head body legs, eyes

mouth nose

6 13 14

7 16 17

8 18 19(20)

4 weeks VEP

6 WEEKS Optokinetic nystagmus

6 mths Reach for toys

1 yr Preferential looking test

2 - 3 yrs Identification of toys

3 yrs Stycar letter matching 3 m

5 yrs Snellen

3 mths Turns to voice

9 mths Intonated babble

1 year Meaningful word

2 yr 2 word sentence, name objects

Telegraphic speech

3 yrs 3 word sentence, tell name , age, sex

Count to 10

4 yrs Tell stories, full name, address

5 yrs Fluent speech, tell address

3 Weeks startles

3 mths Calm with carers voice

6 mths Babbles

9 mths Peek a boo

1 yr Responds to come here

18 mths Solitary

2 yrs Spectator

3 yrs Pretend ( small container as car )

4 yrs Imaginative (use toys to create real life sitns cop and robbery )

5 yrs Role play ( car is driven)

6 yrs Fantasy play