Case studies 1 Flashcards
What is a pound?
~0.4536kg
An ounce is 1/16th of a pound
What is a fluid ounce?
28.4 ml
A 6y old boy presents with 12m of abdominal pain. He passes stools 1/week with occasional blood. He is on the 98th weight centile and 50th height centile.
Examination shows small soft masses in the LLQ.
What is the diagnosis?
Constipation +/- impaction
A 6y old boy presents with 12m of abdominal pain. He passes stools 1/week with occasional blood. He is on the 98th weight centile and 50th height centile.
Examination shows small soft masses in the LLQ.
What history would you want to obtain?
- Stool frequency/ consistency/ size/ pain/ blood
- Toilet training and use/ Soiling/ Withholding
- Diet/ appetite/ fluids/ activity/ school routine
A 6y old boy presents with 12m of abdominal pain. He passes stools 1/week with occasional blood. He is on the 98th weight centile and 50th height centile.
Examination shows small soft masses in the LLQ.
What examination would you want to carry out?
- Inspect lower spine and anus
- Check lower limb neurology
- Measurements and centile
- No rectal examination
A 10 week old boy presents with 4 weeks of frequent post feed effortless vomits and distress (back arching and pulling up knees).
Examination showed a soft abdomen with no palpable masses.
Differential diagnosis?
- Gastro-oesophageal reflux (GORD)
- +/- Milk intolerance
- Consider pyloric stenosis
- Consider surgical causes if bilious
A 10 week old boy presents with 4 weeks of frequent post feed effortless vomits and distress (back arching and pulling up knees).
Examination showed a soft abdomen with no palpable masses.
Questions to ask.
- Vomits: Bilious or not/ Volume/ Amount/ Blood
- Feeding: Type/ Volume/ Frequency/ Position
- General: Weight gain+ centiles/Development/ Cough
Management of GORD - feeding advice
- Feed routines (timing/ positioning/ adverse factors)
- Feed volumes (~150ml/kg/day)
- Reassurance (common, resolves, baby thriving)
Management of GORD - medical treatment
- Feed thickeners (carobel/ thick and easy/ gaviscon) sachets
- Milk free feeding (Baby +/- Mum + Dietician!)
- Acid reduction (Ranitidine/ Omeprazole)
- Pro-kinetics (Domperidone)
Management of GORD - surgery
- Uncommon
- Gastrostomy + Fundoplication
When should milk allergy be considered?
- No or poor response to anti-reflux medications
- Aversive feeding
- Personal or family history of atopy
How should children with suspected milk allergy be treated?
These babies merit trial of milk free diet/ hydrolysed feed
2y old boy referred for poor weight gain and loose, pale stools (1 year, 3-4 times/day)+ flatus, miserable. Picky eater, all normal diet, formula fed, tried milk free diet- no benefit.
No significant past illness or family history.
Examination; Pale, less subcutaneous fat, muscle wasting, distended abdomen.
Diagnosis?
Coeliac disease
Investigations for coeliac disease
- Coeliac serology
- IgA (needs separate biochem sample)
- Small bowel biopsy (If screen positive)
A 2 week old baby present with a 2 day history of vomiting all feeds. The parents bring in one of his baby grows. Weight is down 30g.
He is unsettled on examination.
What colour is bile?
Bile is green
Bilous vomiting is assumed to be what until proven otherwise?
Intestinal obstruction
Causes of bilous vomiting
- Malrotation
- Intussusception (Usually older infants + toddlers)
- Ileus (?sepsis)
- Crohn’s disease (unusual in infants)
- Intestinal atresia (in newborn babies only!)
Bilous vomiting immediate management
- Urgent surgical opinion
- IV Access
- IV Fluids
- Nil by mouth
- NG tube
Bilous vomiting investigations
- Abdominal x-ray
- Contrast meal likely to be needed
A 9 month old girl presents with 48h of increasing wheeze and respiratory effort and a 4d history of mild runny nose and cough.
Examination shows bilateral wheeze and crackles. She has sub-costal recession, a pink throat and red ears. Resp rate 60, Sats 93% and temp 37.9o.
Diagnosis?
Bronchiolitis
A 9 month old girl presents with 48h of increasing wheeze and respiratory effort and a 4d history of mild runny nose and cough.
Examination shows bilateral wheeze and crackles. She has sub-costal recession, a pink throat and red ears. Resp rate 60, Sats 93% and temp 37.9o.
Investigations?
Nasopharyngeal aspirate
A 9 month old girl presents with 48h of increasing wheeze and respiratory effort and a 4d history of mild runny nose and cough.
Examination shows bilateral wheeze and crackles. She has sub-costal recession, a pink throat and red ears. Resp rate 60, Sats 93% and temp 37.9o.
Management
- No proven role for any medications
- Oxygen not yet indicated (cut-off <90-92%)
- Symptoms will peak on day 4-5
- Feeding probably best marker of severity/recovery
- Cough will persist for 1-2 weeks
An 18m boy presents with a 4 hour history of barking cough and noisy breathing having been well the day before
Examination shows a runny nose, loud stridor, tracheal tug sub-costal recession, well perfused peripheries and temp of 37.8o
Differential diagnosis?
- Likely viral laryngotracheitis (croup)
- Consider foreign body
- Bacterial tracheitis, epiglottitis, diphtheria (all rare)
Management of croup
- Oral steroid (dexamethasone)
- Nebulised adrenaline if severe
A 3y old girl presents with a 4 day history of increasing lethargy, cough, fever and tummy pain. She has vomited x4 in the last 2 days.
Examination showed temp 39.8o, resp rate 40, nasal flaring, intercostal recession, no focal chest findings, RUQ discomfort, soft abdomen.
Differential diagnosis?
- LRTI/ Right lower lobe pneumonia
- ?UTI
- ?Appendicitis
A 3y old girl presents with a 4 day history of increasing lethargy, cough, fever and tummy pain. She has vomited x4 in the last 2 days.
Examination showed temp 39.8o, resp rate 40, nasal flaring, intercostal recession, no focal chest findings, RUQ discomfort, soft abdomen.
Investigations and management
- Check saturations (Consider admission ?Threshold)
- Consider CXR to confirm clinical signs/ bloods (but won’t confirm aetiology)
- Check urine dipstix/ culture
- Oral amoxicillin/ IV if vomiting
