Common problems in paediatric out-patients

Question 1

Describe the referral pathway from primary to secondary care

Answer 1

Question 2

What info is needed in any referral letter regarding a child ?

Answer 2

• General health including growth- weight, height (and OFC) with centiles and development
• Age
• Vaccinations
• Relevant social information eg child on CP register (child protection issues?) or concerns re previous OP attendances
• Parental concern - what are they worried about?
• Impact on school

Question 3

What are the top 10 reasons for referral to general paediatric out-patient clinics ?

Answer 3

• Concern about growth
• UTI
• Constipation
• Abdominal pain
• Headaches
• Funny turns
• Heart murmur
• Food allergy/intolerances
• Minor abnormalities in infants –eg head shape
• Is it asthma?

Question 4

What do you need to consider as the cause of obesity in the very obese child who also has short stature ?

Answer 4

Endocrine cause

Question 5

UTI’s are very common in kids what are some of the specific signs/symptoms of UTI’s?

Answer 5

• Pain or a burning sensation when peeing
• Needing to pee frequently
• Deliberately holding in their pee
• Change in their normal toilet habits e.g. wetting themselves or wetting the bed
• Pain in their tummy (abdomen), side or lower back
• Unpleasant-smelling pee
• Blood in their pee
• Cloudy pee

Question 6

What are some of the causes which make some kids more vulnerable to UTI’s than others ?

Answer 6

Constipation – can sometimes cause part of the large intestine to swell, putting pressure on the bladder and prevent it emptying normally

Dysfunctional elimination syndrome – a relatively common childhood condition where a child “holds on” to their pee, even though they have the urge to pee

Vesicoureteral reflux – an uncommon condition where urine leaks back up from the bladder into the ureters and kidneys; this occurs as a result of a problem with the valves in the ureters where they enter the bladder

Question 7

When a child presents with a UTI what features potentially also seen would concern you (red flags)?

Answer 7

• Frequent infections
• Non-E.Coli pathogens
• Family history of renal disease
• Poor growth/general health
• Poor urinary flow in infant – e.g. posterior urethral valves (narrowing of the urethra)
• Voiding problems/constipation
• Spinal abnormality
• Raised blood pressure
• Renal tract abnormalities on antenatal scan
• Abdominal mass

Question 8

Define constipation

Answer 8

Pain, difficulty or delay in defaecation

Question 9

Define what is meant when someone soils themselves (soiling)

Answer 9

Escape of stool into the underclothing - often a sign of constipation

Question 10

What is encopresis ?

Answer 10

Usually caused by constipation caused by various physiological, psychological, or neurological disorders etc

Leads to faecal impaction – when a large, solid stool becomes stuck in their rectum (back passage) and begins to stretch and weaken the surrounding muscle walls. Watery stools then leak out from around this blockage.

At first, you may just notice streaks in your child’s underwear and assume they aren’t wiping properly, but it usually gets worse and can lead to entire bowel movements in their underwear.

Question 11

What is the management of constipation in kids ?

Answer 11

First line - Dietary modification (particularly increased intake of fluids and dietary fibre)

Plus - osmotic laxative (lactulose)

Question 12

Give some examples of underlying disease which can cause constipation in kids ?

Answer 12

• Hirschsprung’s
• Metabolic (thyroid)
• Coeliac
• Anorectal abnormalities
• Neuromuscular

Question 13

What is the characteristic sign of hirsprungs disease ?

Answer 13

Failure to pass meconium (dark, tar-like poo that healthy babies pass soon after being born) within 48hrs

Question 14

What are some of the concerning features in kids with abdo pain ?

Answer 14

• Involuntary weight loss.
• Deceleration of linear growth.
• Gastrointestinal blood loss.
• Significant vomiting.
• Chronic severe diarrhoea.
• Unexplained fever.
• Persistent right upper or right lower quadrant pain.
• Family history of inflammatory bowel disease.

Question 15

What are some of the signs/symptoms to be concerned about in kids with headaches ?(redflags)

Answer 15

• Headache on waking
• Worse with coughing or bending
• Associated vomiting- especially in the morning
• Visual disturbance
• Gait disturbance
• Cranial nerve palsy

Question 16

What is the investigation of choice for a kid referred with headaches ?

Answer 16

MRI - to exclude e.g. brain tumours and other conditions with cause raised intracranial pressure etc

Question 17

What is the most likely condition?:

Aged 3-8

History of sleepwalking

Episodes when sleeping of shouting and thrashing, has been known to even jump out of bed.

Answer 17

Night terrors

Question 18

What are the red flag signs for cardiac syncope in kids ?

Answer 18

• Syncope in a child with known congenital heart disease.
• Syncope during exercise or when supine.
• Family history of sudden death - prolonged QT syndrome or hypertrophic cardiomyopathy?
• Syncope preceded by palpitations.
• Heart murmur or other abnormalities on cardiovascular examination.

Question 19

What is the commonest kind of heart murmur in kids ?

Answer 19

Innocent heart murmur

Question 20

Resp infections are very common in kids - T/F ?

Answer 20

True

Question 21

What are some of the clinical features which point to the diagnosis of asthma in a kid ?

Answer 21

Personal history of atopic disease - hayfever, eczema

Family history of atopic disease and/or asthma

Widespread wheeze heard on auscultation

More than one of the following symptoms:

• Wheeze
• Cough
• Difficulty breathing
• Chest tightness

Particularly if these are worse at night/early morning and often in response to triggers e.g. pollen etc

Question 23

Which bacteria is the most common cause of uncomplicated UTI?

Answer 23

E.coli