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
IgE mediated food allergy
Diagnosis
- RAST and skin prick tests may be helpful
- The best test is the history
Non IgE mediated food allergy
Time of reaction and resolution
- Symptoms develop over hours or days
- Symptoms may last for many days
Non IgE mediated food allergy
Symptoms
- vomiting
- diarrhoea
- abdo pain
- reflux
- poor feeding
- failure to thrive
- eczema
Non IgE mediated food allergy
Diagnosis
- Tests are unhelpful,
- Empirical trial of elimination diet
How to faciliate milk free diet?
- Avoid all milk and foods made from milk
- Teach label reading (whey and casein mean milk).
- Milk free diet sheets from dietetics
- Dietetic referral if diet on going - By 12 months
Milk Challenge at home
- Where initial symptoms were of eczema, poor weight gain, diarrhoea
- Consider around 1 year/ or 6 months off milk
- 50% achieve tolerance by 1 year, 75% by 3 years
- Start with baked milk in biscuit/pancake
- Then cooked milk in custard, build up over a week
- Then yogurt
- Then relax all solids
- Finally stop milk substitute
- Give guidance on adequate calcium intake
When should a 6-8 week trial of an extensively hydrolysed or amino acid formula be offered to a bottle fed infant less than 6 months?
When the infant has moderate to severe eczema that has not been controlled by optimal topical treatment, particularly if associated with GI symptoms and FTT.
When should children on a milk free diet be referred to a dietician?
When they are on the milk free diet for more than 8 weeks.
A 3y old girl is brought in to A+E following a 4 minute generalised tonic-clonic convulsion.
She has a temperature of 39.5o, a red throat and a runny nose.
Diagnosis?
Probable febrile convulsion
Any evidence of epilepsy (Afebrile, asymetric, FMH)?
A 3y old girl is brought in to A+E following a 4 minute generalised tonic-clonic convulsion.
She has a temperature of 39.5o, a red throat and a runny nose.
Management and investigations
- Determine focus (history + examination)
- URT / LRT / GI / Urinary / Exclude CNS
- Most only need observation
- Consider urine dipstix and throat swabs
- Blood glucose if still fitting/ not awake
Questions to ask about a convulsion?
- Who witnessed the episode?
- First change from normal/ alerting circumstance
- Eyes: Rolling? Fixed? Vacant?
- Limbs: Jerks? Tonic? Focal? Shivers? Floppy?
- Colour: Pale? Blue? Red?
- Responsiveness during episode/ preservation of posture
- Time take to become responsive/ total duration
- When (if) back to normal
Characteristics of febrile convulsion
- Age: 6m - 6y
- Core temperature > 38.5
- URTIs/ other viral illnesses are common triggers
- No evidence of CNS infection
- Single event in one illness
- GTCS lasting < 5 mins
- No post ictal phase
These 3m old babies are brought in because mother is worried about their head shape.
What would you do?
- Measure and plot head
- Check and reassure over development
- Check for fused sutures/ ridges
These 3m old babies are brought in because mother is worried about their head shape.
What would you advise?
- Tummy time/ change day time positions
- Reposition toys in cot
- Reassure; causes no harm, very common
A 10y old boy presents with 3w of excessive drinking, secondary nocturnal enuresis, lethargy and weight loss, and 2 days of abdominal pain and vomiting.
He has cold peripheries, Temp 36.5o, RR 35, HR 140, no focal chest or abdominal findings.
Diagnosis
Diabetic ketoacidosis (with evidence of shock)
A 10y old boy presents with 3w of excessive drinking, secondary nocturnal enuresis, lethargy and weight loss, and 2 days of abdominal pain and vomiting.
He has cold peripheries, Temp 36.5o, RR 35, HR 140, no focal chest or abdominal findings.
Management and investigation
- Confirm diagnosis - Bedside Glucose + Ketones
- IV Access +/- fluid resus (0.9% saline bolus no K+)
- IV Insulin (0.1 u/kg/h no bolus) 1h after fluids
- IV fluids (maintenance + correction with K+)
- Avoid bicarbonate (expert guidance only)
- Monitor electrolytes and acid-base balance
A 10y old boy presents with 3w of excessive drinking, secondary nocturnal enuresis, lethargy and weight loss, and 2 days of abdominal pain and vomiting.
He has cold peripheries, Temp 36.5o, RR 35, HR 140, no focal chest or abdominal findings.
On going care
- Involve diabetic team, specialist nurses, dietician
- Re-establish oral diet when normalised
- Start subcutaneous insulin
- Education of parent and child
- Injection techniques
- Blood glucose monitoring
- Sick day rules
- Hypo/ Hyper glycaemia
- Diet and snacks
Causes of short stature
- Familial - Most common
- Constitutional delay
- Small for gestational age/ IUGR
- Under-nutrition
- Chronic illness (JCA, IBD, Coeliac)
- Iatrogenic (steroids)
- Psychological and social factors
- Hormonal (GH deficiency, hypothyroidism)
- Syndromes (Turner, P-W, Noonans)
- Disproportionate (Achondroplasia)
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.
What is the next appropriate investigation to do?
X-ray
Your role in potential non-accidental injury
- Document clearly (History, who, timings, examination)
- Full examination (esp. skin, dev, neuro, other injuries)
- Analgesia
- Discuss with your seniors (Paeds and Ortho)
- Refer to the child protection team
Potential non-accidental injury
Likely next steps for the child (via specialist team)
- Skeletal survey
- CT Head (Bleeds esp. subdural)
- “Bone” bloods (FBC, Ca, PO4, LFT, Vit D, PTH)*
- Ophthalmology assessment (Retinal haemorrhages)
- Joint police and social work investigation
- Case conference and placement decision
Underlying medical causes which may present with fractures
- rickets
- very rarely osteogenesis imperfecta
