Case studies 2

Question 1

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?

Questions to ask?

Investigations?

Management?

Which milk would you advise?

Answer 1

Diagnosis - Cows Milk protein intolerance

Questions to ask:

• What does stool and vomit look like?

Investigations:

• 4 week trial of milk avoidance

Management:

• Hydrolysed protein feeds

Question 2

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

Diagnosis & differential?

Other questions to ask?

Management and advice?

Answer 2

Diagnosis - CMPA

Other questions - experiencing diarrhoea? vomitinh? family history of atopy

Management and advice:

• Mother to avoid dairy and milk
• Mother will need calcium and vit D supplements

Question 3

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

Examination; Pale, less sub cutaneous fat, muscle wasting, distended abdomen

Diagnosis?

Investigations?

Management?

Answer 3

Diagnosis - Coeliac disease

Investigations:

• Coeliac serology (Anti-tissue transglutaminase)
• Duodenal biopsy

Management:

• Gluten free diet for life

Question 4

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 differentials?

Other questions?

Management and investigations?

Answer 4

Diagnosis - GORD

Differential - Milk intolerance, pyloric stenosis

Other questions - Bilious vomit or not? Blood?

Management & investigations:

• Assess feeding routines and volumes
• Reassurance that it is common and resolves on its own

Question 5

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?
• Investigations?
• Management?

Answer 5

Differential diagnosis:

Intestinal atresia (in newborn babies only)

Malrotation +/- volvulus

Intussusception

Ileus

Crohn’s disease with strictures

Investigations:

• Abdo x-ray
• Contrast meal

Management:

• Urgent surgical opinion
• IV fluids
• NG tube

Question 6

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.

• Likely diagnosis?
• Other features from the history?
• Management and investigations?

Answer 6

Diagnosis - Febrile convulsion

Other features from the history:

• Who witnessed episode?
• Rolling eyes? Vacant?
• Limb movements
• Colour

Management and investigations:

• Determine cause of fever (URT/LRT/GI/Urinary)
• Observation

Question 7

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?

Management and investigation?

Answer 7

Diagnosis - DKA

Management and investigation:

Check blood ketone and glucose levels or urine dipstick analysis

IV fluids

IV Insulin

Question 8

A 2y old girl presents to her GP with 2 days of runny nose and cough. She has no fever and no change in appetite or activity.

•Examination shows no fever HR 100 RR 25, no chest findings but marked skin pallor.

An FBC shows Hb 5.3, MCV 57, Plt 300, WBC 6.0

Diagnosis and differentials?

Investigation and management?

Answer 8

Diagnosis - Dietary iron deficiency anaemia

Management:

Oral iron tablets or IV if oral not tolerated

Increase dietary iron

Question 9

What are the differences between IgE and non-IgE mediated food allergy reactions?

Answer 9

IgE mediated - quick reaction and resolution

Non IgE mediated - slowly developing reaction and may take a while to settle

Question 10

A 3y old boy presents with 4 weeks of lethargy, looking pale and recurring fevers.

Examination showed multiple bruises on the legs back and chest, enlarged cervical/ inguinal lymph nodes and hepato-splenomegaly

• Diagnosis and differential?
• Other causes of bruises/ petechiae/ purpura?
• Investigation and Management?

Answer 10

Diagnosis

–Acute leukaemia (Likely ALL)

–??Septicaemia (history too long)

Investigation

–FBC and Film to confirm

–Coag/ U+E/ LFT/ CRP

–Specialist Ix under oncologist guidance

Management

–Admit to hospital

–Urgent referral to paediatric oncologist