OBS HX TAKING (WHY I CLERK?) [note to myself]

Obstetric hx taking learning point:

Pt identification data: to assess risk, eg age>25 must do MOGTT, eg. If you get pregnant at age 25, your risk of having a baby with Down syndrome, for example, is about 1 in 1,250, according to the National Institutes of Health. At age 40, the risk is 1 in 100. If you'll be 35 or older on your due date, you'll be offered genetic counseling.

Occupation, socioeconomic class, does the mother able to take care of the baby after C-sec at home? Does the mother BF when she needs to go to work? the home using well water? can she take water after surgery while recovering?

gravida: G, P and +
multipara will has dx of false labour if dilatation is only 1cm
if +3 indicates recurrent miscarriage, need to find out cause

LMP: naegeles rule, SOD, regular menses, no BF, no hormonal therapy
EDD, REDD, POA
(must knw how to count)
used to detect postdate and also date for IOL for cases like GDM, PIH,...
date also help to identify IUGR, SGA...
read about U/S and discrepancy

C/O what bring pt to hospital? electively admitted? referred case?
(pt came in due to contraction pain? distinguish from braxton hicks, VE see any favourable cervix using Bishop score, ask for any show/leaking of liquor)


HOPI:
must knw disease:

1. GDM/pre-existing DM, clerk MOGTT, presence of risk factors, glycosuria, sx of DM (3Ps, numbness, blurring of vision), HbA1C, family hx of GDM, any congenital anomalies in fetus, any macrosomic baby, polyhydramnios, currently admitted blood sugar profile, insulin how many unit taken, any diet control? mx: IOL? cx that may arise, macrosomic, shoulder dystocia, perineal tearing? neonatal hypoglycemia?

2. Pre-eclampsia, Bp, proteinuria, mx

3. Placenta previa, PV bleed? pain? woody hard uterus?(abruptio) grade of placenta previa, causes such as multiparity,..., mx Mcafree Regime!

4. Postdate

5. Oligohydramnios, how to see AFI

6. Abnormal lie, whether to manually betulkan lie or let it be

anemia, iron metabolism
CVD, how to terminate pregnancy

IOL indications, C-sec indication, trial of scar


HOPP
missed period? UPT? (read UPT test principle, hCG, amino acids...)
failed contraception or planned pregnancy? assess pt's desire of having baby

if not because of missed period? sx of pregnancy? vomitting, abd distension, quickening?

confirm pregnancy where?

BOOKING! READ ABOUT EACH COMPONENT OF BOOKING AND KNOW WHY WE SHOULD KNOW.

(every month till 28, every  2w  until 36, every 1w until delivery)

SUBSEQUENT FOLLOW UP? ULTRASOUND OK?

quickening? primid 18-20w, multi 16-18w

sx of pregnancy, breast engorgement, frequency, constipation, ankle edema, backache? (look for any symptomatic tx?)

Immunization
ATT (principle)
hep B (3x) last time...
Rubella secondary sch

Past OBS

consanguinous marriage?

Mode of delivery, Complication? preterm, full term? C-sec? episiotomy? poor spacing? healing scar? exclusive breastfeeding?
Recurrent miscarriage?  D&C? (uterine scar...risk of placenta previa...)

any contraception?

Menstrual hx

menorrhagia? oligomenorrhea? amenorrhea?
PCOS? subfertility?

Gynae

PCOS? Uterine fibroid? any malignancy? ectopic pregnancy? recurrent miscarriage?

Pap smear done? when? where? result?  (check how many times pap smear must be done every duration?)

PAST MEDICAL, SURGICAL, DM? HPT? HEART DISEASE? ASTHMA? TB?
uterine surgery, risk of placenta previa...

Family hx?
GDM, DM, HPT, HEART DISEASE, twins pregnancy, recurrent miscarriage, stillbirth, congenital abnormalities, gynae malignancy...

Personal and Social hx
socioeconomic status
does husband take care of family
children under care of
smoking, alcohol (husband? pt?)

Drug hx
iron, folic acid, vit b, vit c
*vit b complex contained folic acid
*obimin contain all

insulin for GDM (read back why Oral hyperglycemic Agent cannot be given)
magnesium sulphate for PIH (not sure, read back)

Prostin induction of labour, syntometrine, pitocin...(how to use)

Miseprostol, mifepristone for expulsion of POC

check for drugs use for termination of pregnancy

progesterone for maintaining pregnancy in threatened miscarriage

infection in pregnancy how to treat? common: UTI

any traditional med? any OTC drugs? any allergy?

Dietary
DM diet

Summary
AGE, GRAVIDA, PARA, POA, C/O

Remedial O&G CT1,2 [note to myself]

CT 1: GDM case teaching by Dr. Akram
Booking at least at 6w
MOGTT when, result? Insulin unit? BSP controlled? HbA1C? U/S: congenital anomalies? polyhydramnios? macrosomia?
Use SFH to compare with POG
FHR must show u're counting for 1 min
if pre-eclampsia PE must check liver tenderness, epigastric pain

CT2: Placenta Previa case teaching by Prof Adibah
quickening at 28w? impossible, check LMP wrong date/abdomen too thick

how to present:

she noticed she is pregnant when UPT is done and confirmed her pregnancy after she experienced nausea, vomitting,...

Booking was performed at....
the parameters are as followed...
u/s done at....w, and showed fetus corresponding to dates, subsequent checking was done regularly, throughout her pregnancy, there was no hypertension,...

quckening at....w

1st dose of ATT was given at....w, subsequent dose at...w

at 29w, another u/s performed as routine procedure which show placental low-lyng,...otherwise no fetal abnormalities, however, never has APH,

ask any fibroid, previous uterine surgery (risk factor)

PE for placenta previa:
1. Pain? contraction pain can cause APH in placenta previa

2. Vital signs
Bp: rule out late onset of HPT, as pt has family hx
HR: Wolff-Parkinson white syndrome...due to hyperactive thyroid

3. pallor, signs of anemia, make sure pt not in dilutional anemia, Hb enough to compensate when APH happen

4. edema, she is at risk to develop HPT, so if very gross edema, assess renal problem...

Remedial O&G CT4 [note to myself]

Clinical teaching 4 with Prof Nik

Madame NH 24y/o, G1PO with a background history of subfertility for 3 years and undergone ovulation induction for 1 year (on Clomiphene ?dose) was electively admitted for management of postdate.

DOA: 6/8/2016; DOC: on the same day as admission

Last Menstrul Period: 2/12/2015; sure of date, irregular menstruation, ovulation induction

Ovulation induction(read on infertility IDA lecture) signifies there is ovulation during the LMP so LMP is trustable.

Expected date of delivery: 9/8/2016

Revised EDD(scan done around 9th week): 31/7/2016

Prof mentioned scan done around 9th week discrepancy can be up to 2-5d, find out u/s and discrepancy

the discrepancy was 1 week and so EDD counted from LMP is acceptable. (discrepancy not more than 2 weeks; find out)

currently POA: 39w 5d (if the case is presented as a Postdate case, then do not present 39w, not tally)

HOPI:

All parameters normal, excpet on ultrasound noted cord around neck and aminiotic fluid index: 1.3cm. (learn how to grade oligohydramnios, causes and management)

Beware on small AFI, usually on PE, u may find smaller fundal height

Patient is obese class I with BMI of 30.06kgm-2. (learning point: obesity cause PCOS hence irregular menstruation and subfertility?)

Subfertility, clomiphene: must ask for dosage(mg),  how many times taken a day, duration taken (clomiphene usually 1 tab 50mg OD, given at 5th to 9th or 2nd to 6th day of menstrual cycle)

noted that BMI >30, MOGTT as screening of diabetes must be done at 12-14w, 24-28w and 32-34w,
other risks factor:

1. Gestational diabetes previous pregnancy
2. Obesity (BMI >30)
3. Age > 25
4. Presence of glycosuria in >2 occasions
5. History of DM in first degree relatives
6. Previous big baby > 4.0 kg
7. Previous history of recurrent abortion or unexplained stillbirth
8. Previous congenital anomalies
9. Polyhydramnios

Physical examination:
rather than mention no resp distress, mention pt is breathing spontaneouly, well
only 5/5 palpable can be presented as balloptable fetal head (~floating)
Pt has high BP, must check CVS! check for radiofemoral delay, Coarctation of aorta! Treat pt as whole!
if not checking the breast, at least ask the pt whether there is presence of colostraum, which prepare pt for BF, student might miss pregnant mother who has breast cancer

Patient also has past medical hx of leukemia (unclear hx: so must ask what age diagnosed? completed chemotherapy? regularly follow up? whether cytotoxic drugs had caused the subfertility? and also a leukemic pt in the past need to have antenatal follow up in a tertiary centre! not district)

finally, presenter was asked to present CTG as there is cord around neck,

Prof's comment on how to present, this is a CTG of Madame NH, 24y/o Malay lady, G1PO, with a background hx of subfertility for 3 years and was on ovulation induction for 2 years, the CTG was taken on yesterday, 6/8/2016 2pm for a duration of _ hour, it shows that the baseline FHR was 140-150bpm, the beat to beat variability was 5-20bpm, there was presence of acceleration, no deceleration, the CTG taken is reactive. (any contraction? there was presence of regular uterine contraction with amplitude of?)

eventually, patient was given elective Caeserean section due to these following issue, subfertility, oligohydramnios and cord around neck. 

SO AGAIN, 
LEARNING POINT:
SUBFERTILITY CAUSES, CLOMIPHENE DOSAGE
PCOS
ULTRASOUND DISCREPANCY
OLIGOHYDRAMNIOS
CORD AROUND NECK
INDICATION FOR IOL/C-SEC (HOW TO CHOOSE)
HOW TO MANAGE POSTDATE IF NO CX ARISE?

EXTRA LEARNING POINT:
REVISE GDM
REVISE CVS, what may cause High Bp, RISK FOR pre-eclampsia

I asked a question why Prostin used in IOL is contraindicated in severe asthma/glaucoma?
Prof: only "severe" and its not absolute contraindication, if pt's asthma/glaucoma condition is well-controlled, Prostin can be used.

Lower Limb Peripheral Nerve Examination

Femoral nerve (L2,3,4)

motor: iliopsoas, test with hip flexion against resistance, 

           quadriceps, test with knee extension against resistance (also inspect for any wasting, check 

           knee jerk)

sensation: front of thigh, medial of leg and foot

usually caused by hematoma of illacus ( hemophilia or hip extension injuries)

Common peroneal nerve (lateral popliteal) L4,5,S1,2

motor: ant compartment (ant tibialis, extensor hallucis longus, extensor digitorum longus, peroneus tertius)

           peroneal compt (peroneus longus n brevis)

           foot ( extensor brevis)

test dorsiflexion (deep branch) and evertion (sup branch) of foot

sensation: first web of foot,dorsum of foot, front and side of leg

usually caused by if @ fibular neck, trauma (lateral ligament injury of knees or direct blow), pressure (cast/side iron of thomas splint; ganglion), ischemia ( tourniquet)

 if distal to fibular nerve, ant compartment syndrome

Tibial nerve (L4-S3)

motor: post comprt ( gastrocnemius, post tibialis, flexor hallucis longus, flexor digitorum longus)

           all the ms of sole via medial n lateral plantar n

inspect, ms wasting of sole, clawing of toe, trophic ulceration, test for power of toe flexion

sensation, sole of foot, dorsum of toe and nailbed

side of foot by sural nerve (tibial mix common peroneal)

proximal lesion of tibial nerve (wasting and loss of plantarflexion)

causes: proximal tibial fracture. post compartment syndrome, tight cast, diabetic neuropathy, tarsal tunnel syndrome

sciatic nerve (L4-S3)

motor loss: hamstring of thigh, tibial and peroneal nerve palsy

sensory loss: entire sole, foot, dorsum of foot, lateral aspect of leg, lateral half of calf, (if post cutaneous nerve of thigh is involved then back of thigh also lost sensation)

causes, usually post dislocation of hip, wound to post thigh (do not confused with sciatic palsy  2 to root involvement caused by PID)

absent ankle jerk

Lateral cutaneous n of thigh (L2,3)

maybe compressed by inguinal ligament (pain n parasthesia) or by spinal stenosis

sensory: lateral aspect of thigh

test, pressure over the nerve may give parasthesia to the thigh

neurological control of bladder, s2,3,4 supplies detrusor muscle of bladder and internal spincter

if cord transected above L2, thoracic spine fracture, voluntary control loss, still able to empty bladder 200-400ml every 2-4 hours, automatic bladder

if sacral centre damage or damage to cauda,  loss of reflex, atonic bladder

Bowel Preparation

 Taken from HUSM Endoscopy Unit
1 day prior to appointment
(Breakfast only)
Allow 2 piece of plain bread or plain mee and plain water. Do not take any meat, vegetables, fruits or any dairy product (produk tenusu). Please drink at least 2 litre of plain water until midnight. (If needed, take glucose drink dibenarkan sahaja jika perlu).

3pm and 7pm
Add 45ml of FLEET into a glass of plain water. Finish the dilution. This preparation(cirit-birit) works within 30 mins but may take as long as 3 hours.

12 midnight
Start fasting until colonoscopy done.

*********************************************************************************
Taken from H K.L Nurse's blog

Colclean or Fleet solution.(for patients with no renal impairment)

• ·         Avoid eating any dietary fibers at least 3 days before the scheduled procedure. E.g.: veggies, fruits, oats, etc. (for outpatients)
• ·         Can eat Breakfast and lunch.
• ·         Preparation must be done the day before the Colonoscopy procedure
• ·         45mls Colclean / Fleet + a minimum of 3 glasses of water to be given to the patient at 3.00pm. (No more meals are to be taken after the first dose.)
• ·         Your patient will start to have Diarrhea soon afterwards.
• ·         Another 45mls + a minimum of 3 glasses of water to be given at 6.00pm
• ·         Patient should be encouraged to drink lots of clear fluids afterwards to avoid dehydration and given IV Drips if necessary. Your patient is going to lose a lot of fluids.
• ·         Patient is allowed to drink clear fluids. No need NBM. (consult your Gastro M.O first)
• ·         On the day (8.00am) of the planned procedure, call Scope room to inform the case.
• ·         Call scope room if you are not sure about the bowel prep.

Fortrans - Poly Ethelyne Glycol (most Gastroenterologist likes to use this)

• ·         Avoid eating any dietary fibers at least 3 days before the scheduled procedure. E.g.: veggies, fruits, oats, etc. (for outpatients)
• ·         Can eat Breakfast and lunch.
• ·         One sachet of Fortrans is to be diluted with one liter of clear fluid.
• ·         3 sachet = 3liters
• ·         One liter of diluted Fortrans is to be taken at 6.00pm
• ·         Another liter of fortrans at 7.00pm
• ·         And another one at 8.00pm
• ·         All Diluted fortrans should be finished by the patient.
• ·         Patient should be encouraged to drink lots of clear fluids afterwards to avoid dehydration and given IV Drips if necessary. Your patient is going to lose a lot of fluids.
• ·         Patient is allowed to drink clear fluids. No need NBM. (consult your Gastro M.O first)
• ·         On the day (8.00am) of the planned procedure, call Scope room at to inform the case.
• ·         Call scope room if you are not sure about the bowel prep.
• this solution is safe for patients with fluid restrictions because it does not absorb the fluid in the system.

Now, please make sure that your patient has a FUNCTIONING I.V access (branula) before you send them to the scope room.

*FLEET can't be used for renal impairment or cardiac failure patient because the sodium will cause fluid overload.

Bronchiolitis in children

INTRODUCTION

Bronchiolitis is a lower respiratory tract infection that occurs in children younger than two years old. Differential for rapid breathing and wheezing in child less than 2 years old, usually asthma only be diagnose >2 years old and with strong history of atopy. It is usually caused by a virus. The virus causes inflammation of the small airways (bronchioles) (figure 1). The inflammation partially or completely blocks the airways, which causes wheezing (a whistling sound heard as the child breathes out). This means that less oxygen enters the lungs, potentially causing a decrease in the blood level of oxygen.

Bronchiolitis is a common cause of illness and is the leading cause of hospitalization in infants and young children. Treatment includes measures to ensure that the child consumes adequate fluids and is able to breathe without significant difficulty. Most children begin to improve two to five days after first developing breathing difficulties, but wheezing can last for a week or longer. Bronchiolitis can cause serious illness in some children. Infants who are very young, born early, have lung or heart disease, or have difficulty fighting infections or handling oral secretions are more likely to have severe disease with bronchiolitis. It is important to be aware of the signs and symptoms that require evaluation and treatment.

Bronchiolitis is typically caused by a virus. Respiratory syncytial virus (RSV) is the most common cause.

In tropical and semitropical climates, the seasonal outbreaks usually are associated with the rainy season. (Nov-Jan)

Virtually everyone will have been infected with RSV by the age of three years. It is common to be infected more than once. however, subsequent infections are usually milder.

Children who are older than two years typically do not develop bronchiolitis, but can be infected with RSV.  It usually causes symptoms similar to those of the common cold or mild wheezing.

Bronchiolitis usually develops following one to three days of common cold symptoms, including the following:

●Nasal congestion and discharge.

●A mild cough.

●Fever (temperature higher than 100.4ºF or 38ºC). How to take temperature in a child?

●Decreased appetite.

As the infection progresses and the lower airways are affected, other symptoms may develop, including the following:

●Breathing rapidly (60 to 80 times per minute) or with mild to severe difficulty

●Wheezing, which usually lasts about seven days

●Persistent coughing, which may last for 14 or more days (persistent cough also may be caused by other serious illnesses that require medical attention)

Differential for persistent cough:

• recurrent resp infection
• post-specific resp infection (pertussis, RSV, mycoplasma)
• asthma
• suppurative lung disease (cystic fibrosis, ciliary dyskinesia or immune disease)
• recurrent aspiration (GERD)
• persistent endobronchial infection
• inhaled foreign body
• cigarette smoking (active or passive)
• TB
• Habit cough
• airway anomalies (tracheo-bronchomalacia, tracheo-oesophageal fistula)

●Difficulty feeding related to nasal congestion and rapid breathing, which can result in dehydration

assess dehydration in the child

Apnea (a pause in breathing for more than 15 or 20 seconds) can be the first sign of bronchiolitis in an infant. This occurs more commonly in infants born prematurely and infants who are younger than 2 months.

Signs of severe bronchiolitis include retractions (sucking in of the skin around the ribs and the base of the throat) (figure 2), nasal flaring (when the nostrils enlarge during breathing), and grunting. The effort required to breathe faster and harder is tiring. In severe cases, a child may not be able to continue to breathe on his or her own.

Low oxygen levels (called hypoxia) and blue-tinged skin (called cyanosis) can develop as the illness progresses. Cyanosis may first be noticed in the finger and toenails; ear lobes; tip of the nose, lips, or tongue; and inside of the cheek. Any of these signs or symptoms requires immediate medical evaluation.

A child who is grunting, appears to be tiring, stops breathing, or has cyanosis needs urgent medical attention. 

Contagiousness — The most common cause of bronchiolitis, respiratory syncytial virus (RSV), is transmitted through droplets that contain viral particles; these are exhaled into the air by breathing, coughing, or sneezing. These droplets can be carried on the hands, where they survive and can spread infection for several hours. If someone with RSV on his or her hands touches a child's eye, nose, or mouth, the virus can infect the child. Adults infected with RSV can easily transmit the virus to the child or other adults.

A child with bronchiolitis should be kept away from other infants and individuals susceptible to severe respiratory infection (eg, those with chronic heart or lung diseases, those with a weakened immune system) until the wheezing and fever are gone.

The diagnosis of bronchiolitis is based upon a history and physical examination. Blood tests and x-rays are not usually necessary.

Emergent care — Parents should seek medical attention if the child seems to be worsening. A child who is grunting, appears to be tiring, stops breathing, or has blue-colored skin (cyanosis) needs urgent medical attention. Emergency medical services should be called, available in most areas of the United States by dialing 911. (See 'When to seek help' below.)

Severe bronchiolitis should be evaluated in an emergency department or clinic capable of handling urgent respiratory illnesses. This is a life-threatening illness and treatment should not be delayed for any reason.

Symptomatic care — There is no cure for bronchiolitis, so treatment is aimed at the symptoms (eg, difficulty breathing, fever). Treatment at home usually includes making sure the child drinks enough and saline nose drops (with bulb suctioning for infants).

Monitoring — Monitoring at home involves observing the child periodically for signs or symptoms of worsening. Specifically, this includes monitoring for an increased rate of breathing, worsening chest retractions, nasal flaring, cyanosis, a decreased ability to feed or decreased urine output. Parents should contact their child's healthcare provider to determine if and when an office visit is needed, or if there are any other questions or concerns. (See 'When to seek help' below.)

Fever control — Parents may give acetaminophen (sample brand names: Tempra, Tylenol) to treat fever if the child is uncomfortable. Ibuprofen (sample brand names: Advil, Motrin) can be given to children greater than six months of age. Aspirin should not be given to any child under age 18 years. cause Reye syndrome Parents should speak with their child's healthcare provider about when and how to treat fever.

Nose drops or spray — Saline nose drops or spray might help with congestion and runny nose. For infants, parents can try saline nose drops to thin the mucus, followed by bulb suction to temporarily remove nasal secretions (table 2). An older child may try using a saline nose spray before blowing the nose.

Instructions on using a bulb syringe

Nasal congestion from a cold can make it difficult for a young infant to breathe while eating. Mucus can be removed from the infant's nose with a bulb syringe.

Before using a bulb syringe, saline nose drops can be used to thin the mucus. Saline nose drops can be purchased in most pharmacies, or can be made at home by adding 1/4 teaspoon salt to 8 ounces (1 cup) of warm (not hot) water. Stir to dissolve the salt, and store the solution for up to 1 week in a clean container with a cover.

Place the infant on his or her back. Using a clean nose dropper, place 1 to 2 drops of saline solution in each nostril. Wait a short period.

Squeeze and hold the bulb syringe to remove the air. Gently insert the tip of the bulb syringe into one nostril, and release the bulb. The suction will draw mucus out of the nostril into the bulb.

Squeeze the mucus out of the bulb into a tissue.

Repeat suction process several times in each nostril until most mucus is removed.

Wash the dropper and bulb syringe in warm, soapy water. Rinse well, and squeeze to remove any water.

The bulb syringe can be used two to three times per day as needed to remove mucus. It is best to do this before feeding; the saline and suction process can cause vomiting after feeding.

Encourage fluids — Parents should encourage their child to drink an adequate amount of fluids; it is not necessary to drink extra fluids. Children often have a reduced appetite, and may eat less than usual. If an infant or child completely refuses to eat or drink for a prolonged period, urinates less often, or has vomiting episodes with cough, the parent should contact their child's healthcare provider.

Other therapies — Other therapies, such as antibiotics, cough medicines, decongestants, and sedatives, are not recommended. Cough medicines and decongestants have not been proven to be helpful, and sedatives can mask symptoms of low blood oxygen and difficulty breathing.

Coughing is one way for the body to clear the lungs, and normally does not need to be treated. As the lungs heal, the coughing caused by the virus resolves. Smoking in the home or around the child should be avoided because it can worsen a child's cough.

Antibiotics are not effective in treating bronchiolitis because it is usually caused by a virus. However, antibiotics may be necessary if the bronchiolitis is complicated by a bacterial infection, like an ear infection or bacterial pneumonia (very uncommon).

Sometimes, keeping the child's head elevated can reduce the work of breathing. A child may be propped up in bed with an extra pillow. Pillows should not be used with infants younger than 12 months of age.

Hospital care — Approximately 3 percent of children with bronchiolitis will require monitoring and treatment in a hospital. Most children receive monitoring of vital signs and supportive care, including supplemental oxygen and intravenous fluids, if necessary. Other treatments are individualized, based upon the child's needs and response to therapy.

Isolation precautions — Because the viruses that cause bronchiolitis are contagious, precautions must be taken to prevent spreading the virus to other patients and/orchildren. Parents may visit (and stay with the child) but siblings and friends should not. Toys, books, games, and other activities can be brought to the child's room. All visitors (nurses, doctors, parents) must wash their hands before and after leaving the room.

Feeding — Most infants and children can continue to eat, breastfeed, or drink normally while in the hospital. If the child is unable or unwilling to eat or drink adequately, the respiratory rate is too fast, or the child is having significant difficulty breathing or stops breathing, fluids and nutrition may be given into a vein (intravenously).

Treatments — Supplemental oxygen may be needed for children who are unable to get enough oxygen from room air; this is usually given by placing a tube (called a nasal cannula) under a child's nose or by placing a face mask over the nose and mouth. For infants, an oxygen head box (a clear plastic box) may be used. The child is tested periodically to determine the blood oxygen level when oxygen is turned off. The goal is to slowly reduce and then discontinue supplemental oxygen when the child is ready. If a child is severely ill and unable to breathe adequately on his or her own, or if the child stops breathing, a breathing tube (endotracheal tube) may be inserted into the mouth and throat. This is connected to a machine (called a ventilator) that breathes for the child at a regular rate. The use of an endotracheal tube and ventilator is a temporary measure that is discontinued when the child improves.

Discharge to home — Most children who require hospitalization are well enough to return home within three to four days. Children who require a machine to help them breathe usually need to stay in the hospital for four to eight days or longer before they are ready to go home.

Recovery — Most children with bronchiolitis who are otherwise healthy begin to improve within two to five days. However, wheezing persists in some infants for a week or longer, and it may take as long as four weeks for the child to return to his or her "normal" self. Recovery may take longer in younger infants and those with underlying medical problems (eg, prematurity, other lung diseases). The child should be kept out of daycare and/orschool until the fever and runny nose have resolved (ie, the time during which they are most contagious).

Fever: Taking temperature in a child

Frequently asked questions about fever in children

What is a fever?

The definition of fever depends upon the site where it is measured:

Rectal temperature above 100.4°F (38°C)

Oral temperature above 100°F (37.8°C)

Axillary (armpit) temperature above 99°F (37.2°C)

Ear temperature above 100.4°F (38°C) in rectal mode or 99.5°F (37.5°C) in oral mode

Forehead temperature above 100.4°F (38°C)

How do I measure my child's temperature?

The best method to measure temperature depends upon several factors. In all cases, rectal temperatures are the most accurate. However, measurements of temperature in the mouth (for children older than 4 or 5 years) is accurate when done properly. Temperatures measured in the armpit, in the ear, and on the forehead are least accurate, but may be useful as a first test.

Glass thermometers are not recommended due to the potential risks of exposure to mercury, which is toxic. If another (digital) thermometer is not available, be sure to carefully "shake down" the glass thermometer before use. Instructions for disposing of glass thermometers are available online (www.epa.gov/mercury/spills/index.htm).

Measuring a rectal temperature

The child or infant should lie down on his or her stomach across an adult's lap.

Apply a small amount of petroleum jelly (sample brand name: Vaseline®) to the end of the thermometer.

Gently insert the thermometer into the child's anus. The silver tip of the thermometer should be 1/4 to 1/2 inch inside the rectum.

Hold the thermometer in place. A glass thermometer requires 2 minutes, while most digital thermometers need less than 1 minute.

Measuring an oral temperature

Clean the thermometer with cool water and soap. Rinse with water.

Do not measure the temperature in a child's mouth if he or she has consumed a hot or cold food or drink in the last 30 minutes.

Place the tip of the thermometer under the child's tongue toward the back. Ask the child to hold the thermometer with his or her lips.

Keep the lips sealed around the thermometer. A glass thermometer requires about 3 minutes, while most digital thermometers need less than 1 minute.

Measuring an armpit temperature

Place the tip of the thermometer in the child's dry armpit.

Hold the thermometer in place by holding the child's elbow against the chest for 4 to 5 minutes.

Measuring an ear temperature

To measure temperature in the ear, the parent must pull the child's outer ear backward before inserting the thermometer.

The ear probe is held in the child's ear for about 2 seconds.

If the child has been outside on a cold day, wait 15 minutes before measuring the ear temperature.

Ear tubes and ear infections do NOT affect the accuracy of an ear temperature.