Case studies 3

Question 1

An 8 week old baby boy presents for routine examination to his GP. He is noted to have a murmur.

What history features should you ask about?

Answer 1

• Breathlessness (feeding or exertion)/ colour changes
• Poor feeding +/- weight gain
• Sweating

Question 2

An 8 week old baby boy presents for routine examination to his GP. He is noted to have a murmur.

What should you look for on examination?

Answer 2

• Tachycardia/ Tachypnoea
• Hepatomegaly
• Peripheral pulses (femorals/ brachials) , Gallop rhythm

Question 3

An 8 week old baby boy presents for routine examination to his GP. He is noted to have a murmur.

Investigations

Answer 3

• Refer to paediatrics if any uncertainty
• May need Sats, 4 limb BP, Echo, ECG +/- CXR
• Measurements and centiles

Question 4

Common features of innocent murmurs

Answer 4

• Soft- Grade I to II
• Systolic
• Localized (Left sternal edge common)
• Vary with activity, position and respiration
• Asymptomatic

Question 5

A 12h old baby girl is noted on routine post delivery examination to be blue (face, tongue and limbs). Peripheral pulses are present. A loud systolic murmur is present.

Differential diagnosis

Answer 5

Transposition of the great arteries (mixing via VSD/ PDA/ PFO)

Question 6

A 12h old baby girl is noted on routine post delivery examination to be blue (face, tongue and limbs). Peripheral pulses are present. A loud systolic murmur is present.

Transposition of the great arteries - managment

Answer 6

• Admit to neonatal unit and discuss with cardiac centre
• Sats, Gas, 4 limb BP, CXR and Echo
• May need volume expansion, correction of acidosis/ hypoglycaemia, inotropes
• IV Prostaglandins and potential ventilation (specialist use)

Question 7

What is the cardiac abnormality associated with each of the following?

• Down’s
• Turner’s
• Noonan’s
• William’s

Answer 7

• Down’s: AVSD
• Turner’s: Coarctation
• Noonan’s: Pulmonary Stenosis
• William’s: Supravalvular Aortic Stenosis

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 (low), MCV 57 (low), Plt 300, WBC 6.0

Diagnosis and differential?

Answer 8

• Iron deficiency anaemia
• Alpha/ Beta thalassemia’s
• Secondary anaemia

Question 9

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 (low), MCV 57 (low), Plt 300, WBC 6.0

Investigations

Answer 9

• blood film
• serum ferritin

Question 10

Iron deficiency management

Answer 10

• Increase dietary iron (red meat, green veg)
• Check (and reduce) milk consumption
• Dietician referral
• Oral iron supplementation

Question 11

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?

Answer 11

Acute leukaemia (Likely ALL)

Question 12

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.

Investigations

Answer 12

• FBC and Film to confirm
• Coag/ U+E/ LFT/ CRP
• Specialist investigations under oncologist guidance

Question 13

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.

Management

Answer 13

• Admit to hospital
• Urgent referral to paediatric oncologist

Question 14

Bruises, Purpura and Petechia

Non-thrombocytopenic causes

Answer 14

• Henoch-Schönlein purpura
• Sepsis (meningococcal/ ?viral)
• Trauma (accidental/ non-accidental)

Question 15

Bruises, Purpura and Petechia

Thrombocytopenic

Answer 15

• Idiopathic thrombocytopenic purpura (ITP)
• Leukaemia
• Disseminated intravascular coagulation (DIC)

Question 16

A 5y old girl presents with a 24h history of reluctance to walk and difficulty weight bearing. She had a “cold” 3 days ago.

Examination shows Temp 37.50, no swellings, normal perfusion, no skin changes, full range of movement in hips and knees.

Diagnosis and differential?

Answer 16

• Transient synovitis (Irritable hip)
• Reactive arthritis
• Trauma
• ?Septic arthritis

Question 17

A 5y old girl presents with a 24h history of reluctance to walk and difficulty weight bearing. She had a “cold” 3 days ago.

Examination shows Temp 37.50, no swellings, normal perfusion, no skin changes, full range of movement in hips and knees.

Management and investigation

Answer 17

• Self limiting illness (Rest and analgesia)
• if febrile or doesn’t settle after few days - FBC/ ESR/ CRP/ Blood culture/ Hip X-Ray

Question 18

Give some medical causes of a limping child

Answer 18

• Septic arthritis
• Osteomyelitis
• Reactive arthritis
• Juvenile Idiopathic Arthritis
• Rheumatic fever

Question 19

Give some orthopaedic causes of the limping child

Answer 19

• Perthe’s disease (AVN)
• Slipped upper femoral epiphysis (SUFE)
• Congenital hip dysplasia (CDH)
• Fracture
• Trauma

Question 20

A 3 week old baby boy (born at 29/40w) is on CPAP (21% O2). He develops a rapid rise in his oxygen requirements and respiratory rate.

Examination shows reduced air entry on the left

What is the likely diagnosis?

Answer 20

Tension pneumothorax

Question 21

A 3 week old baby boy (born at 29/40w) is on CPAP (21% O2). He develops a rapid rise in his oxygen requirements and respiratory rate.

Examination shows reduced air entry on the left.

Signs?

Answer 21

• Reduced air entry on left, Low sats
• Tachypnoea
• Heart sounds shifted to right
• Altered perfusion (Tachycardia/ ?Bradycardia)
• Chest Transillumination

Question 22

A 3 week old baby boy (born at 29/40w) is on CPAP (21% O2). He develops a rapid rise in his oxygen requirements and respiratory rate.

Examination shows reduced air entry on the left.

Tension pneumothorax - management

Answer 22

• ?Intubate, Oxygen, fluids (ABC)
• Needle thoracocentesis
• Chest drain

Question 23

A 26 day old baby girl is noted by the health visitor to be jaundiced. She is referred in to paediatrics for further assessment.

What history features should you ask about?

Answer 23

• Full birth history (gestation/ delivery/ resus/ wgt)
• Age of onset/ phototherapy at birth
• Mode of feeding/ Weight gain
• Colour of urine/ stools
• Siblings with jaundice

Question 24

A 26 day old baby girl is noted by the health visitor to be jaundiced. She is referred in to paediatrics for further assessment.

Examination

Answer 24

• Extent of jaundice
• Signs of anaemia or sepsis/ normal activity
• Evidence of increased hepato/splenomegaly
• Measurements and centile

Question 25

Differential diagnosis for neonate with jaundice

Answer 25

* Un-conjugated * Physiological jaundice * Breast milk jaundice * Infection (urinary) * Hypothyroidism * Haemolytic anaemia (ABO incompatibility/ G6PD) * Conjugated * Bile duct obstruction (biliary atresia) * Neonatal hepatitis (Congenital infection/ metabolic)

Question 26

A 26 day old baby girl is noted by the health visitor to be jaundiced. She is referred in to paediatrics for further assessment. Investigation

Answer 26

* All cases \> 3 weeks old need investigated * FBC/ Film/ Coombs/ Conjugated + Un-conjugated bilirubin/ LFTs/ TFTs * Urine dipstix +/- Culture

Question 27

A 26 day old baby girl is noted by the health visitor to be jaundiced. She is referred in to paediatrics for further assessment. Management

Answer 27

* Prolonged jaundice does not typically require phototherapy or exchange transfusion * Treat any underlying cause * If physiological/ breastfeeding * Continue regular breast feeding * Reassure regarding usual resolution by 6-8 weeks

Question 28

A 4y old boy is brought in to A+E from nursery following an abrupt onset of facial swelling, tight feeling in his throat and difficulty breathing. Examination shows he is lethargic, RR 50, HR 170, Sats 88, he has a wide spread urticarial rash and bilateral wheeze Diagnosis?

Answer 28

Anaphylaxis/ Type 1 hypersensitivity (likely to be due to nuts)

Question 29

Anaphylaxis management

Answer 29

* ABCDE approach. Get help. May need anaesthetic input/ senior help early * Oxygen 15 l/m and nebulised salbutamol * IM Adrenaline (10mcg/kg or EPIPen (Junior/ 150mcg\*) if out of hospital * IV Access + fluid resus if needed (20ml/kg 0.9% saline) * IV Hydrocortisone

Question 30

Anaphalphylaxis advice on discharge

Answer 30

* Careful dietary/ exposure history\* (check with nursery) * Probably avoid nuts if unclear trigger * Dietician review * Chlorphenarimine (piriton) at home/ nursery * Epi pen (junior) (parents, staff need training) * Emergency treatment plan

Question 31

Anaphylaxis follow up investigations

Answer 31

* Allergy clinic referral (if available) * RAST test (food/ nut screen) may be helpful * Consider hospital food challenge aged 7y

Question 32

A 6m old boy presents with 24h of fever, poor feeding and lethargy. He has no cough/ runny nose and has not passed urine or stools for 24h Examination- T 41.5o, HR 185, RR 60, CRT 6s, cool peripheries, drowsy, irritable on handling. Diagnosis

Answer 32

Meningitis with Septicaemia

Question 33

Sepsis 6 in children

Answer 33

1. Give high flow oxygen 2. Obtain intravenous or intraosseus access and take blood tests 3. Give IV or IO antibiotics 4. Consider fluid resuscitation 5. Involve senior clinicians / specialists early 6. Consider inotropic support early

Question 34

Estimating weight in children

Answer 34

* Under 1 Year * (Age (Months) x 0.5) +4 * 1y-5y * Age(y)x2 +8 * Over 5y * Age(y)x3 +7