1. Skeleton slides

2. objectives Present case of measles Present mini-study of measles in TMC

3. Measles Outbreak Information regarding measles outbreak. Check Anne’s posts, baka relevant. Highlight why we want to make a grandrounds presentation on measles.

4. CASE PRESENTATION

5. History HPI 2 year old male CC: fever + rash 2 days PTC – fever + cough + colds, no consult blah.. 1 day PTC – still with fever, cough, colds, poor appetite, consult, prescribed blah.. Day of consult - … Fever Rash Coryza Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

6. History PMH Fever Rash Coryza Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

7. History ROS Fever Rash Coryza Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

8. History FH Fever Rash Coryza Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

9. History Vaccination Hx (+) measles vaccine Fever Rash Coryza (+) measles vaccine Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

10. History Birth History (if relevant) Fever Rash Coryza Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

11. History Developmental Hx Fever Rash Coryza (+) measles vaccine Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

12. PE General: weak-looking Vitals: HR, RR: 50s, BP, temp Anthropometrics (z score etc) Fever Rash Coryza (+) measles V Weak-looking Febrile Tachypneic Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

13. PE General: weak-looking Vitals: HR, RR: 50s, BP, temp Anthropometrics (z score etc) Fever Rash Coryza (+) measles V Weak-looking Febrile Tachypneic Crackles, bilateral (+) maculo-papular rash on face neck and upper chest Panel for noting salient features that will help in diagnosis of measles Panel for your usual history and Pe

14. Contextual analysis

15. Salient features Fever Rash Coryza (+) measles V Weak-looking Febrile Tachypneic Crackles, bilateral (+) maculo-papular rash on face neck and upper chest Salient features panel from hx and PE

16. Differentials Differential #1 : MEASLES Fever Coryza (+) measles V Weak- looking Tachypneic Crackles, bilateral (+) maculo- papular rash on face neck and upper chest Rule InRule Out Presents with: Fever rash coryza…..  Cannot be totally ruled out Laboratory findings: CBC: high WBC with lymphocytic predominance CXR: infiltrates (if with measles pneumonia) PRESENTER: This will serve as our “theoretical discussion”. NOTE: Since measles is a “simple” case and because this is not an sgd, we won’t have separate slides as to the etiology, pathogenesis, clinical manifestation of measles, diagnostics of measles. I.e. The presenter will hopefully discuss the clinical presentation (prodrome, even usu signs and symptoms), as he/she rules in measles through our history and symptoms. PRESENTER: This will serve as our “theoretical discussion”. NOTE: The presenter can discuss the expected diagnostic management for measles.

17. Differentials CBC results Laboratory findings: CBC: high WBC with lymphocytic predominance CXR: infiltrates (if with measles pneumonia) PRESENTER: while these results are being shown, presenter will add theoretics. Such as why was this done, what are we looking for? what is expected in measles, is this the gold standard?

18. Differentials CXR results Laboratory findings: CBC: high WBC with lymphocytic predominance CXR: infiltrates (if with measles pneumonia) Film and official rdg PRESENTER: while these results are being shown, presenter will add theoretics. Such as why was this done, what are we looking for? what is expected in measles, is this the gold standard?

19. Differentials UA Laboratory findings: CBC: high WBC with lymphocytic predominance CXR: infiltrates (if with measles pneumonia) Other labs done PRESENTER: while these results are being shown, presenter will add theoretics. Such as why was this done, what are we looking for? what is expected in measles, is this the gold standard?

20. Differentials Lab results Laboratory findings: CBC: high WBC with lymphocytic predominance CXR: infiltrates (if with measles pneumonia) What other labs could have been done? PRESENTER: Can talk about additional labs that could/should have been done (i.e. measles serology). What results are expected?

21. Differentials Differential #2 Fever Coryza (+) measles V Weak- looking Tachypneic Crackles, bilateral (+) maculo- papular rash on face neck and upper chest Rule InRule Out Presents with: Fever Tachypnea Crackles  Does not present with: rash blah… Laboratory findings: CBC: high WBC with neutrophilic predominance CXR: infiltrates Expected lab findings May help in ruling in or out PRESENTER: will comment that this does/does not coincide with previously presented lab findings.

22. Differentials Differential #3 Fever Coryza (+) measles V Weak- looking Tachypneic Crackles, bilateral (+) maculo- papular rash on face neck and upper chest Rule InRule Out Presents with: Fever Tachypnea Crackles  Does not present with: rash blah… Laboratory findings: CBC: high WBC with neutrophilic predominance CXR: infiltrates Expected lab findings May help in ruling in or out PRESENTER: will comment that this does/does not coincide with previously presented lab findings.

23. Primary Working Impression Measles (add other impresion: pneumonia? Dehydration? Blah) PRESENTER: will highlight why we are choosing measles as our PWI. This will serve as our “theoretical discussion”. A review of textbook -easles vs our patient’s measles. But if we find important diagrams to help with this, we can add a few slides. Like pictures of typical measles rash.

24. Management As intro to management we can present measles treatment protocol (of TMC or WHO or whatever) if ever

25. Management we can present ADMITTING ORDERS

26. Management Problem ListManagement 1. FeverParacetamol, tepid sponge bath 2. Rash 3. PneumoniaAntibiotics used 4. Decreased oral fluid intakeIVF Summary slide of problem list with management.

27. Management Problem ListManagement 1. FeverParacetamol, tepid sponge bath Important notes on progress of this problem during the course in the wards. How did it progress? How was it managed? Fever range: _____ Last day of fever

28. Management Problem ListManagement 3. PneumoniaAntibiotics used Day2 of hospitalization / day 4 of illness: Respiratory distress, intercostal retractions, oxygen saturation 80% Management: NSS nebulization  salbutamol nebulization Day3 of hospitalization / day 5 of illness: Still with intercostal restractions - CXR done Management: referal to pedia pulmo, antibiotics shifted from ceftriaxone to pip taz Important notes on progress of this problem during the course in the wards. How did it progress? Show films and official rdg for subsequent cxrs. How was it managed? PRESENTER: will comment on theoretics (such as why this drug is used, mechanism of action, standard dosing.. Etc)

29. Management Discharge orders

30. “STUDY” PRESENTATION Present statistics on TMC patients: How many measles cases were seen in the ER? How many were admitted? How does it differ from census of previous years (ask doc rica if we can have a copy of the census they reported nung last conference). Gender ratio? How many were vaccinated/not vaccinated? How does the presentation of measles in these cases differ from textbook-measles?

31. Contextual analysis large-scale contextual analysis. Stakeholders: patients, health practitioners, govt, etc.

32. Measles in TMC Info/statistics Present statistics on TMC patients: How many measles cases were seen in the ER? How many were admitted? How does it differ from census of previous years (ask doc rica if we can have a copy of the census they reported nung last conference). Gender ratio? How many were vaccinated/not vaccinated? How does the presentation of measles in these cases differ from textbook-measles?

33. Measles in TMC management How is measles being managed in tmc (different ba from the typical management?). Ask dr. Aguirre if you can have a copy of the forms that she presented last conference. The TMC team made ata a “pathway” or protocol of how to manage measles.

34. Prevention Present typical EPI protocol on measles. Any new vaccine protocols?

35. Public health Present public health news. Aside from vaccination, how can spread be prevented? Handwashing? Masks? How can caregivers (lay and medical health practiioners) be prevented from acquiring the infection if they are taking care of the sick?