case study: neonatal

Question 1

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

1. diagnosis?
2. What other signs might you find?
3. What action would you take?

Answer 1

1. Left sided pneumothorax ?Tension
2. Reduced air entry on left (??Percussion), Low sats
   Tachypnoea
   Heart sounds shifted to right
   Altered perfusion (Tachycardia/ ?Bradycardia)
   Chest Transillumination
3. Urgent help!
   ?Intubate, Oxygen, fluids (ABC)
   Needle thoracocentesis
   Chest drain

Question 2

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

1. What history features should you ask about?
2. What should you look for on examination?
3. Differential diagnosis?
4. Management and investigation?

Answer 2

1. History
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 

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

3. 
Un-conjugated
Physiological jaundice
Breast milk jaundice
Infection (urinary)
Hypothyroidism
Haemolytic anaemia (ABO incompatibility/ G6PD)

Conjugated
Bile duct obstruction (biliary atresia/ choledochal cyst)
Neonatal hepatitis (Congenital infection/ metabolic)
Intrahepatic biliary hypoplasia (Alagille’s- rare!)

4. All cases > 3 weeks old need investigated!!!!
   FBC/ Film/ Coombs/ Conj + Un-conj Bili/ LFTs/ TFTs
   Urine dipstix +/- Culture

5.
Prolonged jaundice does not typically require phototherapy or exchange transfusion (but might!)
Treat any underlying cause
If physiological/ breastfeeding
Continue regular breast feeding
Reassure regarding usual resolution by 6-8 weeks

conjugated- dark urine and pale stools!

Question 3

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. Not weight bearing

1. Diagnosis and differential?
2. Other causes of limp in children?
3. Management and investigation?

Answer 3

1. 
Transient synovitis (Irritable hip)
Reactive arthritis
Trauma
?Septic arthritis

2. Self limiting illness (Rest and analgesia)
   Detailed assessment to exclude pathology
   FBC/ ESR/ CRP/ Blood culture/ Hip X-Ray (if febrile or doesn’t settle after few days)

Question 4

the limping child msk causes

Answer 4

Perthe's disease (AVN)
Slipped upper femoral epiphysis (SUFE)
Congenital hip dysplasia (CDH)
Fracture 
Trauma
Mechanical joint pain
Referred pain
Primary bone tumor

Question 5

the limping child medical causes

Answer 5

Septic arthritis
Osteomyelitis
Reactive arthritis
Juvenile Idiopathic Arthritis
Rheumatic fever
Lyme disease
Enteropathic (IBD)
Connective tissue disorder
SLE, JDM, HSP
Leukaemia
Neuroblastoma
Cerebral palsy
Muscular dystrophies

Question 6

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

1. Diagnosis and differential?
2. Other causes of bruises/ petechiae/ purpura?
3. Investigation and Management?

Answer 6

1. Acute leukaemia (Likely ALL)
   ??Septicaemia (history too long)
2. FBC and Film to confirm
   Coag/ U+E/ LFT/ CRP
   Specialist Ix under oncologist guidance

3.
Admit to hospital
Urgent referral to paediatric oncologist

Question 7

non- thrombocytopenic causes of bruising and purpura?

Answer 7

HSP
Sepsis (meningococcal/ ?viral)
Trauma (accidental/ non-accidental)

Question 8

thrombocytopenia causes of bruising and purpura?

Answer 8

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

Question 9

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.

1. Likely diagnosis?
2. Other features from the history?
3. Management and investigations?

Answer 9

1. Probable febrile convulsion
   Was it a rigor? Or something else?
   Any evidence of epilepsy (Afebrile, asymetric, FMH)
2. History (see next slide)
   Get a clear description of exactly what happened and when
   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
   Development milestones
   Family history of epilepsy/ seizures

3.
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

Question 10

characteristics of febrile convulsion

Answer 10

Benign common condition of childhood (~3%).
It is not epilepsy but due to rapid rise in fever
Characteristics
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
If typical then risk of epilepsy not increased

Question 11

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.

1. Diagnosis?
2. Management and investigation?

Answer 11

1. Diabetic ketoacidosis (with evidence of shock)

2.
Take it seriously- Admit to A+E/ HDU
THINK, TEST, TELEPHONE (Same day)
Confirm diagnosis
Bedside Glucose + Ketones/ Capillary gas (?+/- Urine dip)
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

long term:
Involve diabetic team, specialist nurses, dietician
Re-establish oral diet when normalised
Start subcutaneous insulin
Education of parent and child

Question 12

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

1. Diagnosis?
2. Management?
3. Advice on discharge
4. Follow-up investigations

Answer 12

1. Anaphylaxis/ Type 1 hypersensitivity (likely to be due to nuts)
2. 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 and (IV Chlorphenarimine)
3. 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

4.
Allergy clinic referral (if available)
RAST test (food/ nut screen) may be helpful
Consider hospital food challenge aged 7y

Question 13

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.

1. Diagnosis?
2. Differential causes of fever in a 9m infant?
3. Investigations and Management?

Answer 13

1. Meningitis with Septicaemia

2.
Upper Respiratory Tract infections
Otitis media
Tonsillitis/pharyngitis
Viral Croup/ epiglottitis/ bacterial tracheitis
Lower Respiratory Tract Infections
Gastroenteritis
Urinary tract infection
Meningitis/ encephalitis
Septicaemia
Soft tissue infections/ Cellulitis
Bacterial Endocarditis
Appendicitis 
Septic arthritis/osteomyelitis
Kawasaki and non-infectious diseases
Autoimmunie (Systemic onset JIA/ SLE)
Tumours (Lymphoma/ ALL/ Neuroblastoma)
Drug reactions

3.
Management and Investigation (“Sepsis 6”)
Rapid Hospital admission
Urgent senior review
High flow oxygen
IV Access
FBC/ Coag/ Gas/ Lactate/ U+E/ LFT/ Glucose/ CRP/ Culture
Fluid Resuscitation (20ml/kg 0.9% Saline)
IV Cefotaxime/ Ceftriaxone
Lumbar puncture/ CXR when stable (may be hours later)
Review clinical parameters frequently
May need anaesthetic/ intensive care input early on