Case Study 1 Flashcards
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.
Diagnosis and differential?
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.
Other questions to ask?
- Vomits: Bilious or not/ Volume/ Amount/ Blood
- Feeding: Type/ Volume/ Frequency/ Position
- General: Weight gain+ centiles/Development/ Cough
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? N Exam?…..
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?
- Cows milk protein allergy
- infection, constipation or 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
Other questions to ask?
- Change in stool frequency/ infective contacts
- Straining, pain, vomiting
- Clarify weight gain
- Family history of atopy*/ Milk (“Lactose”) intolerance
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
Differential diagnosis?
- Should always ring alarm bells
- But remember to check if it is bile!
- Due to intestinal obstruction until proved otherwise
Causes: - Malrotation
- Intussusception (Usually older infants + toddlers)
- Ileus (?sepsis)
- Crohn’s disease (unusual in infants)
- Intestinal atresia (in newborn babies only!)
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.
Investigations?
Management?
Investigations:
- abdominal x-ray
- contrast meal likely to be needed
Management:
- urgent surgical opinion
- IV access
- IV fluids
- Nil by mouth
- NG tube
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
Diagnosis?
- additional questions to ask?
- features to check on examination?
Diagnosis:
- Constipation +/- impaction
History:
- Stool frequency/ consistency/ size/ pain/ blood
- Toilet training and use/ Soiling/ Withholding
- Diet/ appetite/ fluids/ activity/ school routine
Examination:
- inspect lower spine and anus
- check lower limb neurology
- measurements and centile
- no rectal exam
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
Management?
- Treat early and effectively!
- Stool softeners/ stimulants: Laxido/movicol, As long and as much as needed
- Increase fluid intake
- Fruit, veg and fibre
- Reduce milk/ sweets
- Toilet routine and comfort
- Praise and star charts
- Watch for “diarrhoea”
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 sub cutaneous fat, muscle wasting, distended abdomen
Diagnosis?
- Coeliac disease
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 sub cutaneous fat, muscle wasting, distended abdomen
Investigations?
- Stool screen (faecal elastase, electrolytes, reducing substances, culture)
- FBC, iron status, CRP, Renal, liver, bone profile, Vitamin D status
- Coeliac serology
- IgA (needs separate biochem sample)
- Small bowel biopsy (If screen positive)
what are some key milestones that become red flags if not met by a certain age? MUST BE AWARE OF THESE
- no social smile by 2 months
- not sitting unsupported by 9 months
- not walking unsupported by 18 months
- no words by 2 years
