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Paediatrics > Case studies 2 > Flashcards

Case studies 2 Flashcards

1
Q

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

A
  • Urinary tract infection
  • ?LRTI/ Pneumonia
  • Consider other abdominal foci
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2
Q

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

A
  • Urine dipstix, microscopy and culture
  • Consider FBC/CRP, CXR, Throat swab if negative
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3
Q

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

A
  • Admit, IV 3rd gen. Cephalosporin or co-amoxiclav
  • Keep well hydrated
  • Follow-up Renal USS/ DMSA +/- MCUG
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4
Q

UTI follow up

A
  • 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
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5
Q

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?

A
  • Gastroenteritis (Ecoli 0157, Campylobacter, Salmonella, shigella, yersinia)
  • ?IBD if prolonged
  • Potential Haemolytic Uraemic Syndrome
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6
Q

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

A
  • Stool cultures (bacterial and viral)
  • Urine dipstix and blood pressure
  • Check blood count and film, U+Es, LDH
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7
Q

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

A
  • 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
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8
Q

How would you assess hydration?

A
  • 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?
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9
Q

What percentage of Ecoli-0157 cases develop haemolytic uraemic syndrome (HUS)?

A

~15%

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10
Q

Haemolytic uraemic syndrome is a triad of:

A
  • Microangiopathic haemolytic anaemia (fragments)
  • Thrombocytopenia (platelet consumption/ bruising
  • Acute renal failure (potential multi-organ involvement)
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11
Q

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?

A

Primary nocturnal enuresis (~15% 5y, 5% 10y, B>G)

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12
Q

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?

A
  • Day time dryness? Urgency? Frequency?
  • Fluid consumption: volume and timing
  • Constipation/ stool pattern
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13
Q

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

A
  • Urine dipstix +/- Culture
  • USS for pre/ post volumes
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14
Q

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

A
  • Increase daytime fluids (water not juice)
  • Decrease night fluids
  • Pads and alarms (bladder training)
  • Consider desmopressin +/- oxybutynin
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15
Q

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?

A

Probable cow’s milk protein allergy/intolerance with reflux

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16
Q

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?

A
  • Bile?
  • Blood in stool?
  • Breathless?
  • Cough?
  • Urine?
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17
Q

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

A

Probably none unless bilious vomits, FTT despite change of milk, markers of other pathology.

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18
Q

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

A
  • Trial of hydrolysed feed (not comfort, lactose free, soya)
  • Milk free advice for weaning via Health visitor
  • May need thickeners/ acid suppression
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19
Q

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?

A
  • CMPA (cow’s mil protein allergy)
  • Infection, constipation or a surgical cause.
20
Q

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?

A
  • Change in stool frequency/ infective contacts
  • Straining, pain, vomiting
  • Clarify weight gain
  • Family history of atopy*/ Milk (“Lactose”) intolerance
21
Q

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.

A
  • Stool culture
  • Maternal milk/dairy avoidance
  • Mother will need calcium/vit D supplementation and dietician input
22
Q

IgE mediated food allergy

Timing of reaction and resolution

A
  • Reactions within 2 hours of ingestion
  • Resolution of symptoms within 12 hours
23
Q

IgE mediated food allergy

Symptoms

A
  • GI - vomiting/ pain/ diarrhoea
  • Skin - urticaria/ angioedema/ pruritis
  • Resp - rhinoconjunctivitis/ wheeze/ cough/ stridor
  • Anaphylaxis and collapse
24
Q

IgE mediated food allergy

Typical food causes

A
  • egg
  • nuts
  • pulses
  • fish
  • grains
  • milk
25
Q

IgE mediated food allergy

Diagnosis

A
  • RAST and skin prick tests may be helpful
  • The best test is the history
26
Q

Non IgE mediated food allergy

Time of reaction and resolution

A
  • Symptoms develop over hours or days
  • Symptoms may last for many days
27
Q

Non IgE mediated food allergy

Symptoms

A
  • vomiting
  • diarrhoea
  • abdo pain
  • reflux
  • poor feeding
  • failure to thrive
  • eczema
28
Q

Non IgE mediated food allergy

Diagnosis

A
  • Tests are unhelpful,
  • Empirical trial of elimination diet
29
Q

How to faciliate milk free diet?

A
  • 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
30
Q

Milk Challenge at home

A
  • 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
31
Q

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?

A

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.

32
Q

When should children on a milk free diet be referred to a dietician?

A

When they are on the milk free diet for more than 8 weeks.

33
Q

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?

A

Probable febrile convulsion

Any evidence of epilepsy (Afebrile, asymetric, FMH)?

34
Q

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

A
  • 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
35
Q

Questions to ask about a convulsion?

A
  • 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
36
Q

Characteristics of febrile convulsion

A
  • 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
37
Q

These 3m old babies are brought in because mother is worried about their head shape.

What would you do?

A
  • Measure and plot head
  • Check and reassure over development
  • Check for fused sutures/ ridges
38
Q

These 3m old babies are brought in because mother is worried about their head shape.

What would you advise?

A
  • Tummy time/ change day time positions
  • Reposition toys in cot
  • Reassure; causes no harm, very common
39
Q

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

A

Diabetic ketoacidosis (with evidence of shock)

40
Q

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

A
  • 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
41
Q

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

A
  • 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
42
Q

Causes of short stature

A
  • 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)
43
Q

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?

A

X-ray

44
Q

Your role in potential non-accidental injury

A
  • 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
45
Q

Potential non-accidental injury

Likely next steps for the child (via specialist team)

A
  • 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
46
Q

Underlying medical causes which may present with fractures

A
  • rickets
  • very rarely osteogenesis imperfecta

Paediatrics (38 decks)

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