Case studies 1

Question 1

What is a pound?

Answer 1

~0.4536kg

An ounce is 1/16th of a pound

Question 2

What is a fluid ounce?

Answer 2

28.4 ml

Question 3

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.

What is the diagnosis?

Answer 3

Constipation +/- impaction

Question 4

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.

What history would you want to obtain?

Answer 4

• Stool frequency/ consistency/ size/ pain/ blood
• Toilet training and use/ Soiling/ Withholding
• Diet/ appetite/ fluids/ activity/ school routine

Question 5

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.

What examination would you want to carry out?

Answer 5

• Inspect lower spine and anus
• Check lower limb neurology
• Measurements and centile
• No rectal examination

Question 6

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.

Differential diagnosis?

Answer 6

• Gastro-oesophageal reflux (GORD)
• +/- Milk intolerance
• Consider pyloric stenosis
• Consider surgical causes if bilious

Question 7

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.

Questions to ask.

Answer 7

• Vomits: Bilious or not/ Volume/ Amount/ Blood
• Feeding: Type/ Volume/ Frequency/ Position
• General: Weight gain+ centiles/Development/ Cough

Question 8

Management of GORD - feeding advice

Answer 8

• Feed routines (timing/ positioning/ adverse factors)
• Feed volumes (~150ml/kg/day)
• Reassurance (common, resolves, baby thriving)

Question 9

Management of GORD - medical treatment

Answer 9

• Feed thickeners (carobel/ thick and easy/ gaviscon) sachets
• Milk free feeding (Baby +/- Mum + Dietician!)
• Acid reduction (Ranitidine/ Omeprazole)
• Pro-kinetics (Domperidone)

Question 10

Management of GORD - surgery

Answer 10

• Uncommon
• Gastrostomy + Fundoplication

Question 11

When should milk allergy be considered?

Answer 11

• No or poor response to anti-reflux medications
• Aversive feeding
• Personal or family history of atopy

Question 12

How should children with suspected milk allergy be treated?

Answer 12

These babies merit trial of milk free diet/ hydrolysed feed

Question 13

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 subcutaneous fat, muscle wasting, distended abdomen.

Diagnosis?

Answer 13

Coeliac disease

Question 14

Investigations for coeliac disease

Answer 14

• Coeliac serology
• IgA (needs separate biochem sample)
• Small bowel biopsy (If screen positive)

Question 15

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.

What colour is bile?

Answer 15

Bile is green

Question 16

Bilous vomiting is assumed to be what until proven otherwise?

Answer 16

Intestinal obstruction

Question 17

Causes of bilous vomiting

Answer 17

• Malrotation
• Intussusception (Usually older infants + toddlers)
• Ileus (?sepsis)
• Crohn’s disease (unusual in infants)
• Intestinal atresia (in newborn babies only!)

Question 18

Bilous vomiting immediate management

Answer 18

• Urgent surgical opinion
• IV Access
• IV Fluids
• Nil by mouth
• NG tube

Question 19

Bilous vomiting investigations

Answer 19

• Abdominal x-ray
• Contrast meal likely to be needed

Question 20

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?

Answer 20

Bronchiolitis

Question 21

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.

Investigations?

Answer 21

Nasopharyngeal aspirate

Question 22

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.

Management

Answer 22

• 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

Question 23

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

Differential diagnosis?

Answer 23

• Likely viral laryngotracheitis (croup)
• Consider foreign body
• Bacterial tracheitis, epiglottitis, diphtheria (all rare)

Question 24

Management of croup

Answer 24

• Oral steroid (dexamethasone)
• Nebulised adrenaline if severe

Question 25

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. Differential diagnosis?

Answer 25

* LRTI/ Right lower lobe pneumonia * ?UTI * ?Appendicitis

Question 26

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. Investigations and management

Answer 26

* 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