Case Studies 2 Flashcards
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
a) diagnosis?
b) investigations?
c) management?
a) bronchiolitis
b) nasopharyngeal aspirate
c) 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
a) diagnosis and differential?
b) management?
a) likely viral laryngotracheitis (croup), consider foreign body, bacterial tracheitis, epiglottitis, diptheria
b) dont examine throat, keep calm to avoid distress and anxiety, oral steroid (dexamethasone or ?prednisolone), nebulised adrenaline if severe
A 14-month-old girl presents with 12h of increasing wheeze and respiratory effort and a 3d history of runny nose and cough.
Examination shows bilateral wheeze, no creps and sub-costal recession, a pink throat and red ears. Resp rate of 60 and temperature 37.5o
a) diagnosis and differential?
b) other history features to help you decide?
c) management
a) viral induced wheeze (secondary to URTI), ?bronchiolitis
b) rapidly worse (‘they were okay yesterday’), previous wheeze or atopy? FMH atopy?
c) salbutamol MDI via spacer (up to 10 puffs), consider oral prednisolone + nebuliser 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.
a) Diagnosis and differential?
b) Investigation and management?
Diagnosis and differential:
LRTI/right lower lobe pneumonia
?UTI
?Appendicitis
Investigations and management:
- check saturations (consider admission ?threshhold)
- consider CXR to confirm clinical signs/bloods
- check urine dipstix/culture
- oral amoxicilline/IV if vomiting, macrolide 2nd line
A 6-month-old girl presents with 3d of fever (>39o), vomiting, poor feeding, being unsettled and having strong smelling urine.
Examination showed RR 40, HR 150, no focal findings in the chest, abdomen, ears or throat
Diagnosis and differential?
Investigations and Management?
Diagnosis and differential:
- UTI
- ?LRTI/pneumonia
- consider abdominal foci
Investigations:
- urine dipstix, microscopy and culture
- consider FBC/CRP, CXR, throat swab if negative
Management:
- admit, IV 3rd gen cephalosporin (trimethoprim) or co-amoxiclav
- keep well hydrated
- follow up renal USS/DMSA +/- MCUG
UTI in children follow up investigations
- main worry is reflux (VUR) and renal scarring
- renal USS (hydronephrosis/kidney size)
- DMSA (isotope scan for scarring)
- MCUG (younger) MAG3 (older) for reflux if scarred
A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo
Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort
Diagnosis, causes and potential complications?
Investigation and management?
Diagnosis:
- Gastroenteritis (E.coli 0157, campylobacter, salmonella, shigella, yersinia),
- ?IBD if prolonged
- potential haemolytic uraemic syndrome
Investigations:
- stool cultures (bacterial and viral)
- urine dipstrix and blood pressure
- check blood count and film, U+Es, LDH
Management:
- good hydration
- monitor urine output/fluid balance
- monitor bloods (HUS can present 10-14 days later)
- may require dialysis +/- blood/platelet treatment
A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.
He has no fever and abdominal/ spinal/ neuro examination is normal.
What is the likely diagnosis?
What other information do you need to gather?
Investigations? Management options?
Diagnosis:
- Primary nocturnal enuresis
- Wet >2/w if >5y + no CNS issue (1 in 5 at 10y, 16%/y get better, Boys>Girls)
Additional questions:
- day time dryness? wetting? urgency? frequency?
- fluid consumption: volume and timing
- constipations/stool pattern
- sleep disturbance/snoring
- daytime cognitive functioning
- family history
Investigation:
- limited role
- urine dip/culture to rule out infection
- ?USS for pre/post volumes
Management:
- increase daytime fluids (water not juice)
- toilet/bladder emptying routines
- decrease night fluids/caffeine
- reduce protein/salt before bed
- pads and alarms (bladder training)
- treat constipation
- consider desmopressin +/- anticholinergics
An 8-week-old baby boy presents for routine examination to his GP. He is noted to have a murmur.
What history features should you ask about?
What should you look for on examination?
Management and investigation?
History: (Inc. Symptoms of cardiac failure)
- Breathlessness (feeding or exertion)/ colour changes
- Poor feeding +/- weight gain
- Sweating
Examination: (Inc. Signs of cardiac failure)
- Tachycardia/ Tachypnoea
- Hepatomegaly
- Peripheral pulses (femorals/ brachials) , Gallop rhythm
Management and investigation
- Usually none required
- Refer to paediatrics if any uncertainty
- May need Sats, 4 limb BP, Echo, ECG +/- CXR
- Measurements and centiles
A 12h old baby girl is noted on routine post delivery examination to be blue (face, tongue and limbs). Peripheral pulses are present. A loud systolic murmur is present
Differential diagnosis?
Management and investigation?
Differential diagnosis (Cyanotic heart disease):
- Transposition of the great arteries (mixing via VSD/ PDA/ PFO)
- Pulmonary Atresia/ Tricuspid Atresia
- Truncus Arteriosus
- Obstructed Total Anomalous Pulmonary Venous Drainage (TAPVD)
- Tetralogy of Fallot
Management:
- Admit to neonatal unit and discuss with cardiac centre
- Sats (post ductal), Gas, 4 limb BP, CXR and Echo
May need volume expansion, correction of acidosis/ hypoglycaemia, inotropes
- IV Prostaglandins and potential ventilation (specialist use)
Down’s syndrome can present with which cardiac abnormality?
ASVD
Turner’s syndrome can present with which cardiac abnormality?
coarctation of aorta
Noonan’s syndrome can present with which cardiac abnormality?
- pulmonary stenosis
William’s syndrome can present with which cardiac abnormality?
- supravalvular aortic stenosis
A 2y old girl presents to her GP with 2 days of runny nose and cough. She has no fever and no change in appetite or activity.
Examination shows no fever HR 100 RR 25, no chest findings but marked skin pallor.
An FBC shows Hb 5.3, MCV 57, Plt 300, WBC 6.0
Diagnosis and differential?
Investigation and Management?
Diagnosis and differential:
- Iron deficiency anaemia secondary to dietary intake
- ?Alpha/ Beta thalassemia’s
- Anaemia of chronic disease
Investigation and Management:
- Check blood film/ serum ferritin/ ?Hb electrophoresis*
- For iron deficiency:
Increase dietary iron (red meat, green veg)
Check (and reduce) milk consumption
Dietician referral
Oral iron supplementation (~3m)
