Paediatrics Case Study Flashcards
Baby 1 (3m, Vomiting and unsettled): “He weighs 11lbs, he usually takes a 7oz feed 6 times per day, he always seems hungry and unsettled after his feed. What should we do?”
What does he weigh?
What are his feed volumes? (per feed)
What are his feed volumes? (per kilo per day)
What advice should you give the parents?
He weighs ~5kg
He usually takes ~210ml feed 6 times per day
1260ml/day =~250ml/kg/day
Advise reducing to 120-140ml (4-5oz) per feed (~155ml/kg/day)
Baby 2 (6m Bronchiolitis and feeding concerns):
“She weighs 151/2lbs, she usually takes a 10oz feed 5 times per day, she has just been taking 4oz every 3 hours. What should we do?”
What does she weigh?
What are her usual feed volumes? (per feed)
What are her usual feed volumes? (kg/day)
What are her current feed volumes? (per feed)
What are her current feed volumes? (kg/day)
What advice should you give the parents?
Baby 2 (6m Bronchiolitis and feeding concerns):
She weighs ~7kg
She usually takes 300ml 5 times per day
=~1500ml/ day = ~215 ml/kg
Currently taking 120ml every 3 hours
=~960ml/day ~130ml/kg/day
Reassure this is okay over the next few days
Seek review if feed volume dropping further
Could consider reducing usual feed to 600-700ml/day once recovered (~5-6oz x4- she is likely to be weaning)
What is a pound?
~0.4536kg/ 453.6g
What is an ounce?
1/16th of a pound (i.e. 28.35g)
What is an ounce in ml
28.4 ml
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 features of the history/ 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 examination
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 Senna, lactulose, 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”
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?
Other questions to ask?
Diagnosis and differential: Gastro-oesophageal reflux (GORD) \+/- Milk intolerance Consider pyloric stenosis Consider surgical causes if bilious
Other questions:
Vomits: Bilious or not/ Volume/ Amount/ Blood
Feeding: Type/ Volume/ Frequency/ Position
General: Weight gain+ centiles/Development/ Cough
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.
Management and investigations?
Feeding advice:
Feed routines (timing/ positioning/ adverse factors)
Feed volumes (~150ml/kg/day)
Reassurance (common, resolves, baby thriving)
Medical treatment:
Feed thickeners* (carobel/ thick and easy/ gaviscon) sachets
Milk free feeding (Baby +/- Mum + Dietician!)
Acid reduction (Ranitidine/ Omeprazole)
Pro-kinetics (Domperidone)
Surgery (FTT/ Aspirations/CP):
Uncommon
Gastrostomy + Fundoplication
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?
Investigations?
Management?
Diagnosis:
Coeliac disease
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)
Treatment:
Gluten free diet with dietitian input.
A 2 week old baby present with a 2 day history of vomiting all feeds. The parents bring in one of his baby grows (covered in green sick). Weight is down 30g.
He is unsettled on examination
Differential diagnosis?
Investigations?
Management?
DD:
Malrotation
Intussusception (Usually older infants + toddlers)
Ileus (?sepsis)
Crohn’s disease (unusual in infants)
Intestinal atresia (in newborn babies only!)
Management: Urgent surgical opinion IV Access IV Fluids Nil by mouth NG tube
Investigations:
Abdominal x-ray
Contrast meal likely to be needed
A 9 month old girl presents with 48h of increasing wheeze and respiratory effort and a 4d history of mild runny nose and cough.
Examination shows bilateral wheeze and crackles. She has sub-costal recession, a pink throat and red ears. Resp rate 60, Sats 93% and temp 37.9o
Diagnosis and differential?
Investigations?
Management? And role for medication?
Diagnosis:
Bronchiolitis
Investigations:
Nasopharyngeal aspirate
Management:
No proven role for any medications
Oxygen not yet indicated (cut-off <90-92%)
Symptoms will peak on day 4-5
Feeding probably best marker of severity/recovery
Cough will persist for 1-2 weeks
An 18m boy presents with a 4 hour history of barking cough and noisy breathing having been well the day before
Examination shows a runny nose, loud stridor, tracheal tug sub-costal recession, well perfused peripheries and temp of 37.8o
Diagnosis and differential?
Management and investigation?
Diagnosis and Differential:
Likely viral laryngotracheitis (croup)
Consider foreign body
Bacterial tracheitis, epiglottitis, diphtheria (all rare)
Management:
Don’t examine the throat!!
Keep calm avoid distress and anxiety (no needles)
Oral steroid (dexamethasone or ?prednisalone)
Nebulised adrenaline if severe
A 3y old girl presents with a 4 day history of increasing lethargy, cough, fever and tummy pain. She has vomited x4 in the last 2 days.
Examination showed temp 39.8o, resp rate 40, nasal flaring, intercostal recession, no focal chest findings, RUQ discomfort, soft abdomen.
Diagnosis and differential?
Investigation and management?
Diagnosis and differential:
LRTI/ Right lower lobe pneumonia
?UTI
?Appendicitis
Investigations and management:
Check saturations (Consider admission ?Threshold)
Consider CXR to confirm clinical signs/ bloods (but won’t confirm aetiology)
Check urine dipstix/ culture
Oral amoxicillin/ IV if vomiting
