102. Cases 2 Flashcards
Child with strong smelling urine, vomiting, tachycardia. No chest abdomen or throat findings. Differentials?
UTI
URTI
Abdominal causation
Child with strong smelling urine, vomiting, tachycardia. No chest abdomen or throat findings. Investigations ?
Clean catch/mid stream recommended
Pads and bags- not great false negatives
Suprapubic catheters
Don’t wait for sample if someone is unwell!
FBC,CRP, CXR, throat swab
Child with strong smelling urine, vomiting, tachycardia. No chest abdomen or throat findings. Treatment ?
Yes
Child with strong smelling urine, vomiting, tachycardia. No chest abdomen or throat findings. Follow up investigations?
Look for VUR
Renal USS looks at anatomy
DMSA (looks for scars)
MCUG (looks for reflex is DMSA positive)
3 year old presents with 5 days of vomiting and bloody diarrhoea, Tolerating oral fluid and visited petting zoo. No skin changes, abdo discomfort. Differentials?
E.coli 0157 infection
Potential HUS
Can also be campylobacter, salmonella, shigella, yersinia
3 year old presents with 5 days of vomiting and bloody diarrhoea, Tolerating oral fluid and visited petting zoo. No skin changes, abdo discomfort. How do you assess hydration status?
Turgour Temperature Eyes sunken and tears Sunken fontanelle Drowsy Oliguria Tachycardia morning tachypnoeac
Look at pictures to confirm
3 year old presents with 5 days of vomiting and bloody diarrhoea, Tolerating oral fluid and visited petting zoo. No skin changes, abdo discomfort. Investigations?
3 stool samples and one stool virology
U&E’s, FBC, blood film
LDH- red cell fragmentation
3 year old presents with 5 days of vomiting and bloody diarrhoea, Tolerating oral fluid and visited petting zoo. No skin changes, abdo discomfort. Management ?
No antibiotics! Low threshold for IV fluids Maintain hydration status Monitor bloods for HUS Look into other family members infected
A child presents with bruising and pale. Differentials
HUS
Leukaemia
Sepsis
9 year old boy, parents concerned he wets the bed most nights (enuresis) primary- always been wet, secondary- been wet and comes back. No fever and abdominal/spinal/neuro exam is normal. differentials?
Diabetes
Childhood trauma
9 year old boy, parents concerned he wets the bed most nights (enuresis) primary- always been wet, secondary- been wet and comes back. No fever and abdominal/spinal/neuro exam is normal. History ?
Do they wet during the day Do they drink a lot during the day Urgency Frequency Constipation/stool pattern
9 year old boy, parents concerned he wets the bed most nights (enuresis) primary- always been wet, secondary- been wet and comes back. No fever and abdominal/spinal/neuro exam is normal. Investigations?
Urinalysis
Fluid chart
Blood glucose
9 year old boy, parents concerned he wets the bed most nights (enuresis) primary- always been wet, secondary- been wet and comes back. No fever and abdominal/spinal/neuro exam is normal. Management?
Desmospressen- ADH
Decrease night fluids
Pads and alarms
Consider desmopressin
3 month old bottle fed baby, loose stools, vomits each day. Health visitors want to change milk. Diagnosis
Cows milk protein allergy
3 month old bottle fed baby, loose stools, vomits each day. Health visitors want to change milk. History
Vomit history- colour, timing, how much feed they get Breathless Cough UTI NEURO
3 month old bottle fed baby, loose stools, vomits each day. Health visitors want to change milk. Investigations
None for cows milk allergy
If poor weight gain check FBC and thyroid for anemia and hyperthyroidism
Unless vomiting history suggests otherwise
3 month old bottle fed baby, loose stools, vomits each day. Health visitors want to change milk. Management
Top to examination
Nutramigen (hydrolysed milk)
Milk free weaning advice
May need thickeners/acid suppression to deal with reflux
4 week old otherwise healthy baby. Good weight gain, breast fed, present with streaks of fresh blood in stool for last 7 days, no fever of vomits.
Dad asthma mum has IBS
General/abdo exam normal. Differential?
Crohns- too young
HUS- too young breast fed, not diarrhoea
Tear- too young
Infection/ constipation
Most likely cows milk intolerance
4 week old otherwise healthy baby. Good weight gain, breast fed, present with streaks of fresh blood in stool for last 7 days, no fever of vomits.
Dad asthma mum has IBS
General/abdo exam normal. History questions ?
Family- food intolerance, atopy
Change in stool
Clarify weight gain
Straining/pain vomiting
4 week old otherwise healthy baby. Good weight gain, breast fed, present with streaks of fresh blood in stool for last 7 days, no fever of vomits.
Dad asthma mum has IBS
General/abdo exam normal. Management ?
Change mums diet as they’re breast fed Start with cakes a biscuits- protein more likely to be denatured, low protein (UK milk ladder) Make sure mum is taking enough calcium Most of them overcome it eventually Stool culture
What are the two types of food allergy?
IgE- rash, wheeze, anaphylacxis. Skin tests might help
Non IgE (more common e.g. milk allergy) takes days to come on, days to clear, no tests. Subtle. Only treatment is elimination
How do you treat eczema?
Topical steroids
If that doesn’t work try hydrolysed milk diet for 4 weeks
A 3 year old baby is brought to A&E with a 4 minute generalised tonic-clonic convulsions
She has a temperature of 39.5, a red throat and a runny nose
Differential
Rigor- awake, fine movement (leaning forward)
Febrile convulsion- not awake, rhythmic jerking (flat and extending). Tonic clonic
Epilepsy
4 week old otherwise healthy baby. Good weight gain, breast fed, present with streaks of fresh blood in stool for last 7 days, no fever of vomits.
Dad asthma mum has IBS
General/abdo exam normal. What would you ask in the history?
One half or both half’s- symmetrical- febrile convulsion Who witnessed Eyes rolling, fixed, vacant Colour blue pale red? Time to become back to normal Family history Post ictal phase? Not in febrile convulsion Developmental delays?
4 week old otherwise healthy baby. Good weight gain, breast fed, present with streaks of fresh blood in stool for last 7 days, no fever of vomits.
Dad asthma mum has IBS
General/abdo exam normal. Management ?
Bacterial and viral throat swabs
Benzodiazepines (seizures over 10 minutes) (medazalan)
Blood glucose of fitting for a prolonged time
Most just need observation
What is plagiocephaly?
Squint head- Latin
What is brachycephaly?
Flat head
What do you do with babies with funny heads?
Measure and plot the head
Check and reassure over development (smiling, visual tracking)
Make sure you don’t miss craniosynestosis. Heads are fixed so are more asymmetric over time
Encourage tummy time to fix back of head, reposition toys in cots so in different positions
10y old boy presents with 3w of excessive drinking, secondary nocturnal enuresis, lethargy and weight loss, and 2 days of abdominal pain and vomiting. Cold peripheries, tachyopeneac. Differentials?
Diabetic ketoacidosis
10y old boy presents with 3w of excessive drinking, secondary nocturnal enuresis, lethargy and weight loss, and 2 days of abdominal pain and vomiting. Investigations ?
IV access
D (glucose)
Ketones (bloods)
A capillary blood gas
10y old boy presents with 3w of excessive drinking, secondary nocturnal enuresis, lethargy and weight loss, and 2 days of abdominal pain and vomiting. Management?
IV insulin based on weight Additional fluids with potassium Subcut insulin thereafter Avoid bicarbonate Monitor electrolytes and acid base balance
A 4 month old girl is brought to A+E with a 3 day history of being unsettled and not feeding well. There is no fever or other systemic features No cough, D+V, rash, colour change
Examination shows she has reduced movements of her right leg but is otherwise normal differentials?
Yes
A 4 month old girl is brought to A+E with a 3 day history of being unsettled and not feeding well. There is no fever or other systemic features No cough, D+V, rash, colour change
Examination shows she has reduced movements of her right leg but is otherwise normal differentials? Investigations
USS
X-ray
What causes a spiral fracture of the femur
Rotational force of the femur
A 4 month old girl is brought to A+E with a 3 day history of being unsettled and not feeding well. There is no fever or other systemic features No cough, D+V, rash, colour change
Examination shows she has reduced movements of her right leg but is otherwise normal differentials. Child has a broken femur. What else do you want to ask?
How did it happen
When did it happen
Rickets
What is the most common injury that young siblings inflict on each other?
Bites
A 4 month old girl is brought to A+E with a 3 day history of being unsettled and not feeding well. There is no fever or other systemic features No cough, D+V, rash, colour change
Examination shows she has reduced movements of her right leg but is otherwise normal differentials? She has a broken femur. Management
Documentation of history Full examination Analgesia Peads and ortho Refer to social services
Skeletal survey
CR head, bone blood,retinal scam
Fix the cast
Where do children likely bruise?
Bony bits, knees and shins
