An interesting day in pediatrics

Tuesday (June 26) was the last day of the SDM medical students’ posting in pediatrics. Eva and I were scheduled to be there until Friday (June 29). I was a bit apprehensive that once again the faculty would not have any idea what to do with us. However, Wednesday was a pleasant surprise. Not only did I get asked to be an English teacher (presumably because of my complexion) J but we saw some very interesting cases in the Pediatric Out Patient Department (OPD). (One of the patient’s father asked, in broken English, if I would tutor his daughter, who is in 6th standard, in English. I tried to explain that I was in India as a student and not a tutor but I’m not so sure he understood. The conversation ended with me saying, “I no teach English.”)

We saw our first foreigner in the hospital, a Canadian. A white woman in her early 20s brought a young girl (with fever and diarrhea) to the clinic. She is in India working with a NGO at a school about an hour outside of Dharward. It was an interesting office visit… the physician was questioning the young girl in Kannada- the local dialect (which she didn’t seem to understand totally) and then speaking to the Canadian woman in English (which she didn’t seem to understand as her first language was obviously French). The physician prescribed some antibiotics and explained oral re hydration therapy. The physician said later that most NGOs in the area are fairly good at handling diarrhea, dehydration, and parasites.

Shortly after a family came in with their two and a half month old daughter. She was born with spina bifida, a developmental birth defect involving the neural tube (specifically the spinal cord and vertebrae), which was operated on at birth in a hospital in northern India. They brought their daughter to the OPD to ensure that she was recovering properly. The physician had a difficult time assessing this as there were no medical records from the patient’s previous care facility. He later explained to us that continuity of care is hard to come by in India.

After performing a general neurological exam, the physician said that the child most likely suffered from a meningocele. A meningocele is the least common form of spina bifida. In this condition some of the vertebrae are split (do not develop properly in utero) and the meninges are damaged and pushed out through the opening. This appears as a sac or cyst on the infants back. The sac contains both the meninges and cerebrospinal fluid (CSF). Luckily the spinal cord and nerves are not involved in a meningocele and neurologic function is generally normal. (In other forms of spina bifida, when the spinal cord is involved, neurologic function is impaired from the point of malformation in the spinal cord and below.)

Side note- the physician also observed that the patient exhibited the sunset sign (her eyes looked like a sun setting) which results from increased CSF pressure due to an obstruction in the flow- most likely at the location of the operation. (It is exciting when the stuff we have spent hours learning about at the library presents in a patient- makes all the time seem worth it.)

Next we were able to examine a six month old boy who suffered from severe hydrocephalus. Hydrocephalus is a condition where an abnormal accumulation of cerebrospinal fluid (usually due to a blockage in the CSF circulation) causes increased pressure inside the skull leading to progressive enlargement of the head. Infants with hydrocephalus have large heads because the increase CSF pressure has caused the individual skull bones (which have not fused with each other yet) to bulge outward. This child, who at 6 months is expected to have a head circumference of 40 cm, had a head circumference of 55 cm, the circumference expected for an adolescent. This child also exhibited the sunset sign. Compression of the brain by the accumulating fluid (increased pressure) eventually causes convulsions and mental retardation in these patients. The cause of this patient’s hydrocephalus is most likely genetic as he is the product of a consanguineous marriage (his parents are first cousins). The physician informed us that the patient would be admitted for a full evaluation and seen by the neurosurgeon on Monday (which is the day of the week the neurosurgeon is at SDM Hospital).

The treatment for hydrocephalus is surgery. A shunt is placed from the brain to the body cavity (most commonly), where the excess CSF can be resorbed. The shunting of the excess fluid relieves the increased intracranial pressure. It is difficult to say what the prognosis for this patient will be as it is probable that a great deal of neurologic damage has already occurred. There are also a number of shunt complications which can occur (malfunction, failure, and infection). If for some reason a shunt fails, CSF will begin to accumulate again, increasing the intracranial pressure and a number of symptoms can develop (seizures). Shunt failure rate is relatively high- patients often have multiple shunt revisions throughout life.

The remainder of this week in pediatrics was fairly uneventful (wellness checks and immunizations). Next week we begin our two week community medicine posting which should be very interesting. As far as this weekend goes… we are planning on relaxing and finalizing our travel plans for a world wind tour of India at the end of July. We will be leaving Dharward in just two short weeks, traveling around India (Bangalore, Mysore, Delhi and surrounding area, and Mumbai), and then returning home on August 1st.