Case studies 2 Flashcards
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
- Urinary tract infection
- ?LRTI/ Pneumonia
- Consider other abdominal foci
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.
Investigations
- Urine dipstix, microscopy and culture
- Consider FBC/CRP, CXR, Throat swab if negative
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.
Management
- Admit, IV 3rd gen. Cephalosporin or co-amoxiclav
- Keep well hydrated
- Follow-up Renal USS/ DMSA +/- MCUG
UTI follow up
- Main worry is reflux (VUR) and renal scarring
- Renal USS (hydronephrosis/ kidney size) (All <3y)
- 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?
- Gastroenteritis (Ecoli 0157, Campylobacter, Salmonella, shigella, yersinia)
- ?IBD if prolonged
- Potential Haemolytic Uraemic Syndrome
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
Investigations
- Stool cultures (bacterial and viral)
- Urine dipstix and blood pressure
- Check blood count and film, U+Es, LDH
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
Management
- Supportive care
- Good hydration (low threshold for IV if HUS risk)
- Monitor urine output/ fluid balance
- Monitor bloods (HUS can present 10-14d later)
- May require dialysis +/- blood/ platelet Tx
- Antibiotics not indicated
- Notify public health
How would you assess hydration?
- Alertness/ conscious level?
- Fontanel (if present) - sunken or level?
- Sunken eyes?
- Dry or moist tongue/ lips?
- Heart rate? Resp rate?
- Peripheral warmth or coolness? (hands / feet)
- Skin turgor?
- Urine output?
What percentage of Ecoli-0157 cases develop haemolytic uraemic syndrome (HUS)?
~15%
Haemolytic uraemic syndrome is a triad of:
- Microangiopathic haemolytic anaemia (fragments)
- Thrombocytopenia (platelet consumption/ bruising
- Acute renal failure (potential multi-organ involvement)
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?
Primary nocturnal enuresis (~15% 5y, 5% 10y, B>G)
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 other information do you need to gather?
- Day time dryness? Urgency? Frequency?
- Fluid consumption: volume and timing
- Constipation/ stool pattern
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.
Investigations
- Urine dipstix +/- Culture
- USS for pre/ post volumes
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.
Managent
- Increase daytime fluids (water not juice)
- Decrease night fluids
- Pads and alarms (bladder training)
- Consider desmopressin +/- oxybutynin
3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk.
Diagnosis?
Probable cow’s milk protein allergy/intolerance with reflux
3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk.
Other important questions to ask?
- Bile?
- Blood in stool?
- Breathless?
- Cough?
- Urine?
3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk.
Investigations
Probably none unless bilious vomits, FTT despite change of milk, markers of other pathology.
3m old boy, bottle fed, weight gain ~100-120g/w. Has loose stools (4-5/day) and several vomits a day. Older brother had asthma and mum had eczema. HV asking about changing the milk.
Management
- Trial of hydrolysed feed (not comfort, lactose free, soya)
- Milk free advice for weaning via Health visitor
- May need thickeners/ acid suppression
4 weeks old otherwise healthy baby. Good weight gain (150g/w), breast fed, presents with streaks of fresh blood in stool for last 7 days. No fever or vomits.
Dad has asthma. Mum has “irritable bowel.”
General/abdominal examination normal.
Diagnosis and differential?
- CMPA (cow’s mil protein allergy)
- Infection, constipation or a surgical cause.
4 weeks old otherwise healthy baby. Good weight gain (150g/w), breast fed, presents with streaks of fresh blood in stool for last 7 days. No fever or vomits.
Dad has asthma. Mum has “irritable bowel.”
General/abdominal examination normal.
Important questions to ask?
- Change in stool frequency/ infective contacts
- Straining, pain, vomiting
- Clarify weight gain
- Family history of atopy*/ Milk (“Lactose”) intolerance
4 weeks old otherwise healthy baby. Good weight gain (150g/w), breast fed, presents with streaks of fresh blood in stool for last 7 days. No fever or vomits.
Dad has asthma. Mum has “irritable bowel.”
General/abdominal examination normal.
CMPA management and advice.
- Stool culture
- Maternal milk/dairy avoidance
- Mother will need calcium/vit D supplementation and dietician input
IgE mediated food allergy
Timing of reaction and resolution
- Reactions within 2 hours of ingestion
- Resolution of symptoms within 12 hours
IgE mediated food allergy
Symptoms
- GI - vomiting/ pain/ diarrhoea
- Skin - urticaria/ angioedema/ pruritis
- Resp - rhinoconjunctivitis/ wheeze/ cough/ stridor
- Anaphylaxis and collapse
IgE mediated food allergy
Typical food causes
- egg
- nuts
- pulses
- fish
- grains
- milk
