by Dr. M. Tauseef Omer
SEQs in Neonatology Written exam are well-structured problem/scenario based questions, followed by a set of questions asking for a diagnosis, or a differential diagnosis, investigation and/or management, and crucial associations or outcomes of the condition if any.
The SEQ hides a diagnosis, as well as it tells about multiple issues the baby is having at the moment.
The diagnosis could be a set of multiple conditions.
For example, the stem may guide you towards the diagnosis of Meconium aspiration syndrome. Many candidates will write the same answering the question that what is your diagnosis? Meconium aspiration syndrome.
However, an observant candidate will also dig out perinatal asphyxia, and more so Persistent Pulmonary Hypertension if there are clues.
So his/her diagnosis will be Perinatal Asphyxia with Meconium Aspiration Syndrome with persistent pulmonary hypertension of the newborn.
PEARL : WRITE/FORMULATE a complete diagnosis.
Moving further, the stem hides multiple issues. You have to try to make a diagnosis out of those issues, as well as address them all in your investigation plan and in the management.
For example, for the scenario may have a mention of abdominal distension with blood stained aspirates, or thrombocytopenia, or seizures, or hypoglycemia, so you have to address all of these issues alongside.
I remember a scenario in which a preterm baby was born at 30 weeks of gestation, and was now 30 days old and having poor weight gain, etc etc. So i addressed all the issues but i didnt forget that its the time for his Retinopathy of prematurity screening also.
PEARL: Treat patient as a whole, like we do in our real practice. Address issues apart from diagnosis in your investigations list, and in your management plan.
You may write issues separately while reading the stem, it will help you while writing management.
If differential diagnosis (D/D) is asked, and in the next question you are asked about investigations and management plan, then write investigations and management for all D/Ds.
And to add more, you have to manage a baby in such a way that the baby got better, got multidisciplinary consultation and management (as required) and was discharge home (on the drugs and multivitamins and/or minerals _____ , _________-, ________), and that this is your follow up plan in neonatology, for growth and development, and for any other discipline.
PEARL: Bachay ko gher pohancha ker followup kerwana hai, and growth and development and post discharge screenings and multidisciplinary followups nhi bhulna (like we do in real practice).
You have to discharge the baby home, have followup for growth & development, and mention post-discharge screening if any, and the followup in other specialties.
& in every management plan see that if the following content may be added, the mandatory care we give to every newborn:
General Management that you have to write almost in every answer:
Admit the baby in Neonatal Intensive Care Unit (NICU) and place under radiant warmer or incubator (as per scenario)
Thermoregulation: Maintain body temperature
Maintain neutral thermal environment with environmental temperature between 25 to 28°C and humidity around 60-70%
Maintain Normoglycemia: Keep glucose infusion rate (GIR) at 4 to 6 mg/kg/min; increase if required, BSR monitoring (as per scnario)
Maintain Airway, Breathing, Circulation
Monitor vital signs:
Attach oxygen saturation probe (SpO2)
Attach chest electrodes
Attach temperature sensor probe
Maintain vital signs monitoring sheet: pulse rate, respiratory rate, blood pressure, SpO2, temperature, capillary refill time (CRT)
Oxygen therapy with nCPAP/ high flow or low flow as required per stem, and pass orogastric tube for stomach decompression to prevent nCPAP belly, or if there is abdominal distension with aspirates etc, Replace OG loses with N/2 with 5% DW.
Add maintenance fluids:
Add Calcium on Day 0
Add Sodium and Potassium on Day 3
Differential Diagnosis, Nutrition & Supportive Care
If D/D asked, then write Ix for all D/D
Management for all D/D
Nutrition:
Orogastric tube feeding with expressed breast milk
If nothing per oral (NPO), give total parenteral nutrition (TPN) or peripheral parenteral nutrition (without lipids, <12.5% DW, <3% Protein); provide micronutrient and mineral supplements once approaching 100ml/Kg/day (except iron, that will not be added if there is sepsis)
Early initiation of OG feeds
Buccal colostrum 0.5 mL on both inner sides of cheeks every 6 hours to prevent necrotizing enterocolitis (NEC) and invasive bacterial infection
Neurodevelopmental Care:
Nesting of baby
Dimmed lights in the night
Pain management related to procedures
Minimal handling and clustering of care
Partial Kangaroo Mother Care (KMC) in NICU
Calculate Oxygenation Index (OI) in a ventilated baby
Counselling of parents relating to the condition, ongoing management, complications of the condition and management, and prognosis
POCUS (Point-of-Care Ultrasound)- such as screening cranial scan, or position check of lines, ETT, or for pneumothorax.
Multidisciplinary care as required
Follow-up after discharge, and growth & development monitoring, and Followup Cranial US Scnas, or renal US Scans, or ROP screening, as indicated.
Good luck doctor !
