Main worry is reflux (VUR) and renal scarring Renal USS (hydronephrosis/ kidney size) (All \<3y) DMSA (isotope scan for scarring) MCUG (younger) MAG3 (older) for reflux if scarred

Case studies 2 Flashcards by G H

A 6 month old girl presents with 3d of fever (>39o), vomiting, poor feeding, being unsettled and having strong smelling urine.

Examination showed RR 40, HR 150, no focal findings in the chest, abdomen, ears or throat.

Diagnosis and differential

Urinary tract infection
?LRTI/ Pneumonia
Consider other abdominal foci

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A 6 month old girl presents with 3d of fever (>39o), vomiting, poor feeding, being unsettled and having strong smelling urine.

Examination showed RR 40, HR 150, no focal findings in the chest, abdomen, ears or throat.

Investigations

Urine dipstix, microscopy and culture
Consider FBC/CRP, CXR, Throat swab if negative

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A 6 month old girl presents with 3d of fever (>39o), vomiting, poor feeding, being unsettled and having strong smelling urine.

Examination showed RR 40, HR 150, no focal findings in the chest, abdomen, ears or throat.

Management

Admit, IV 3rd gen. Cephalosporin or co-amoxiclav
Keep well hydrated
Follow-up Renal USS/ DMSA +/- MCUG

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UTI follow up

Main worry is reflux (VUR) and renal scarring
Renal USS (hydronephrosis/ kidney size) (All <3y)
DMSA (isotope scan for scarring)
MCUG (younger) MAG3 (older) for reflux if scarred

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A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo

Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort

Diagnosis, causes and potential complications?

Gastroenteritis (Ecoli 0157, Campylobacter, Salmonella, shigella, yersinia)
?IBD if prolonged
Potential Haemolytic Uraemic Syndrome

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A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo

Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort

Investigations

Stool cultures (bacterial and viral)
Urine dipstix and blood pressure
Check blood count and film, U+Es, LDH

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A 3y old boy presents with 5 days of vomiting and bloody diarrhoea. He is tolerating oral fluids and recently visited a petting zoo

Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort

Management

Supportive care
- Good hydration (low threshold for IV if HUS risk)
- Monitor urine output/ fluid balance
- Monitor bloods (HUS can present 10-14d later)
- May require dialysis +/- blood/ platelet Tx
Antibiotics not indicated
Notify public health

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How would you assess hydration?

Alertness/ conscious level?
Fontanel (if present) - sunken or level?
Sunken eyes?
Dry or moist tongue/ lips?
Heart rate? Resp rate?
Peripheral warmth or coolness? (hands / feet)
Skin turgor?
Urine output?

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What percentage of Ecoli-0157 cases develop haemolytic uraemic syndrome (HUS)?

~15%

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Haemolytic uraemic syndrome is a triad of:

Microangiopathic haemolytic anaemia (fragments)
Thrombocytopenia (platelet consumption/ bruising
Acute renal failure (potential multi-organ involvement)

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A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.

He has no fever and abdominal/ spinal/ neuro examination is normal.

What is the likely diagnosis?

Primary nocturnal enuresis (~15% 5y, 5% 10y, B>G)

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A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.

He has no fever and abdominal/ spinal/ neuro examination is normal.

What other information do you need to gather?

Day time dryness? Urgency? Frequency?
Fluid consumption: volume and timing
Constipation/ stool pattern

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A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.

He has no fever and abdominal/ spinal/ neuro examination is normal.

Investigations

Urine dipstix +/- Culture
USS for pre/ post volumes

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A 9y old boy is brought is because parents are concerned that he still wets the bed most nights.

He has no fever and abdominal/ spinal/ neuro examination is normal.

Managent

Increase daytime fluids (water not juice)
Decrease night fluids
Pads and alarms (bladder training)
Consider desmopressin +/- oxybutynin

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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

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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?

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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.

Investigations

Probably none unless bilious vomits, FTT despite change of milk, markers of other pathology.

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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.

Management

Trial of hydrolysed feed (not comfort, lactose free, soya)
Milk free advice for weaning via Health visitor
May need thickeners/ acid suppression

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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?

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CMPA (cow’s mil protein allergy)
Infection, constipation or a 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.

Important questions to ask?

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Change in stool frequency/ infective contacts
Straining, pain, vomiting
Clarify weight gain
Family history of atopy*/ Milk (“Lactose”) intolerance

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.

CMPA management and advice.

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Stool culture
Maternal milk/dairy avoidance
Mother will need calcium/vit D supplementation and dietician input

IgE mediated food allergy

Timing of reaction and resolution

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Reactions within 2 hours of ingestion
Resolution of symptoms within 12 hours

IgE mediated food allergy

Symptoms

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GI - vomiting/ pain/ diarrhoea
Skin - urticaria/ angioedema/ pruritis
Resp - rhinoconjunctivitis/ wheeze/ cough/ stridor
Anaphylaxis and collapse

IgE mediated food allergy

Typical food causes

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egg
nuts
pulses
fish
grains
milk

IgE mediated food allergy Diagnosis

* RAST and skin prick tests may be helpful * The best test is the history

Non IgE mediated food allergy Time of reaction and resolution

* Symptoms develop over hours or days * Symptoms may last for many days

Non IgE mediated food allergy Symptoms

* vomiting * diarrhoea * abdo pain * reflux * poor feeding * failure to thrive * eczema

Non IgE mediated food allergy Diagnosis

* Tests are unhelpful, * Empirical trial of elimination diet

How to faciliate milk free diet?

* Avoid all milk and foods made from milk * Teach label reading (whey and casein mean milk). * Milk free diet sheets from dietetics * Dietetic referral if diet on going - By 12 months

Milk Challenge at home

* Where initial symptoms were of eczema, poor weight gain, diarrhoea * Consider around 1 year/ or 6 months off milk * 50% achieve tolerance by 1 year, 75% by 3 years * Start with baked milk in biscuit/pancake * Then cooked milk in custard, build up over a week * Then yogurt * Then relax all solids * Finally stop milk substitute * Give guidance on adequate calcium intake

When should a 6-8 week trial of an extensively hydrolysed or amino acid formula be offered to a bottle fed infant less than 6 months?

When the infant has moderate to severe eczema that has not been controlled by optimal topical treatment, particularly if associated with GI symptoms and FTT.

When should children on a milk free diet be referred to a dietician?

When they are on the milk free diet for more than 8 weeks.

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. Diagnosis?

Probable febrile convulsion Any evidence of epilepsy (Afebrile, asymetric, FMH)?

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. Management and investigations

* Determine focus (history + examination) * URT / LRT / GI / Urinary / Exclude CNS * Most only need observation * Consider urine dipstix and throat swabs * Blood glucose if still fitting/ not awake

Questions to ask about a convulsion?

* Who witnessed the episode? * First change from normal/ alerting circumstance * Eyes: Rolling? Fixed? Vacant? * Limbs: Jerks? Tonic? Focal? Shivers? Floppy? * Colour: Pale? Blue? Red? * Responsiveness during episode/ preservation of posture * Time take to become responsive/ total duration * When (if) back to normal

Characteristics of febrile convulsion

* Age: 6m - 6y * Core temperature \> 38.5 * URTIs/ other viral illnesses are common triggers * No evidence of CNS infection * Single event in one illness * GTCS lasting \< 5 mins * No post ictal phase

These 3m old babies are brought in because mother is worried about their head shape. What would you do?

* Measure and plot head * Check and reassure over development * Check for fused sutures/ ridges

These 3m old babies are brought in because mother is worried about their head shape. What would you advise?

* Tummy time/ change day time positions * Reposition toys in cot * Reassure; causes no harm, very common

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

Diabetic ketoacidosis (with evidence of shock)

* Confirm diagnosis - Bedside Glucose + Ketones * IV Access +/- fluid resus (0.9% saline bolus no K+) * IV Insulin (0.1 u/kg/h no bolus) 1h after fluids * IV fluids (maintenance + correction with K+) * Avoid bicarbonate (expert guidance only) * Monitor electrolytes and acid-base balance

* Involve diabetic team, specialist nurses, dietician * Re-establish oral diet when normalised * Start subcutaneous insulin * Education of parent and child * Injection techniques * Blood glucose monitoring * Sick day rules * Hypo/ Hyper glycaemia * Diet and snacks

Causes of short stature

* Familial - Most common * Constitutional delay * Small for gestational age/ IUGR * Under-nutrition * Chronic illness (JCA, IBD, Coeliac) * Iatrogenic (steroids) * Psychological and social factors * Hormonal (GH deficiency, hypothyroidism) * Syndromes (Turner, P-W, Noonans) * Disproportionate (Achondroplasia)

A 4 month old girl is brought to A+E with a 3 day history of being unsettled and not feeding well. There is no fever or other systemic features (No cough, D+V, rash, colour change). Examination shows she has reduced movements of her right leg but is otherwise normal. What is the next appropriate investigation to do?

X-ray

Your role in potential non-accidental injury

* Document clearly (History, who, timings, examination) * Full examination (esp. skin, dev, neuro, other injuries) * Analgesia * Discuss with your seniors (Paeds and Ortho) * Refer to the child protection team

Potential non-accidental injury Likely next steps for the child (via specialist team)

* Skeletal survey * CT Head (Bleeds esp. subdural) * “Bone” bloods (FBC, Ca, PO4, LFT, Vit D, PTH)\* * Ophthalmology assessment (Retinal haemorrhages) * Joint police and social work investigation * Case conference and placement decision

Underlying medical causes which may present with fractures

* rickets * very rarely osteogenesis imperfecta

Case studies 2 Flashcards

(46 cards)