A 9 year old girl comes with her father with complaints of headache for 6 months. Tell the Differentials.
- Viral URTI
- Allergic rhinitis
- Migraine
- Tension headache
- Cluster headache
- Meningitis
- Sinusitis
- Encaphalitis
- Head trauma - SAH, SDH, EDH
- Brain tumour
- Raised ICP/ICSOL
- Eye problems - Refractive Error
- Ear problems - Acute Otitis Media
- Drug induced
- Psychogenic
- Cervical Spondylosis
2 year old Rao is brought to the GP by his father because of a history of runny nose and dry cough for 5 days.
Tell the possible causes.
Respiratory cause:
1. Post viral cough
2. Pertusis
3. Asthma
4. Sinusitis
5. Allergic rhinitis
6. Simple URTI
GI causes :
1. GERD
2. Cystic Fibrosis
Heart causes :
1. Congenital Heart Disease
Others :
1. Psychogenic cough
2. Irritants induced
3. Foreign bodies
4. Habit cough/Tic
Management of Pertusis
- Investigation :
- usually not required, clinical diagnosis
- Nasopharyngeal swab for PCR
- Pertusis serology Blood test (within 3 weeks)
- Treatment:
- Antibiotics: Azithromycin/Clarithromycin
- Notify DHS
- Exclusion from school or childcare for 5 days after starting the antibiotics or 21 days from the start of the cough
- Prophylaxis treatment is given to alll the people living in the house.
- Vaccination is present under the National Immunization Schedule usually given at 2,4,6,18months and 4 years of age
Adult booster - 12-13years of age - Give small frequent feeds
Keep house free from dust and irritants
No smoking infront of the child
Whom to give the prophylactic treatment of pertussis?
Everyone at home especially:
1. Any child less than 6 months old
2. Any pregnant lady in her third trimester
3. Child care worker
4. Healthcare worker in the maternity or newborn ward
5 year old boy is brought to the GP by his mother because he is not as active as before and is sleepy all the time.
What can be the causes?
T I R E D N E S S
T = Travel , Tumour
I = - Iron : Iron Deficiency Anaemia
Hemochromatosis
- Infective Endocarditis
- Infections : Pneumonia
UTI
Meningitis
Gastroenteritis
Hepatitis
STI
HIV
Ross River Fever
EBV
R = - Respiratory : Asthma
- Renal : AKI
E = Endocrine : Thyroid
DM
Addisons
Cushings
D = Depression
Anxiety
Drugs
Alcohol
N = Neoplasia/Malignancy
E = Eating Disorder
Excess work
S = - Sleep : OSA
Insomnia - night shift worker
- Stress
Son of a 40 year old man comes to the GP because his father is acting strange.
Tell the causes.
D E M E N T I A
D = Drugs
Alcohol
Depression
Anxiety
Dementia - Vascular, Frontotemporal, Lewy Body, Alzheimers, Senile, Alcohol induced
E = Electrolyte Imbalance
M = Metabolic : DM - Hypoglycaemia, Hyperglycaemia, DKA
Thyroid - Hypothyroidism, Hyperthyroidism
Liver failure - Hyperammonaemia
E = Eyes and Ear problems
N = Neurological : Stroke, TIA, Epilepsy
T = Trauma, Tumour
I = Infections
A = Acute coronary syndrome or Arrythmia
Causes of vomitting in children
- GER & GERD
- Oesophageal atresia
- Pyloric stenosis
- Duodenal atresia
- Intestinal obstruction
- Intusseption
- Hernia
- Hirschprung
- Infections : - Meningitis
- Otitis media
- Pneumonia
- Gastroenteritis
- UTI - Testicular torsion
- Trauma
- Tumour
- Foreign body
Management of UTI in children
Management of UTI :
• Condition - Uninary tract infection
• Cause - As it is veny close to the back passage, bugs can enten from the
back passage and infect the uninany tract
• Clinical featunes -
1. fever
2. vomitting
3. Painful & smelly urine
• Complications -
1.Dehydration
2. Infection may travel upwands and cause severe symptoms.
Treatment :-
1. As child is < 1year old, he is considened to be part of the vulnenable group of patients.
2 Transfer the child to the hospital via ambulance to be seen by the specialist for further evaluation and management.
- The urine dipstick done previously was just a screening test for the infection.
To confinm the Dx: - The pediatric registrar will do a
Suprapubic Aspiration of her urine
i.e:
- needle will be insented just below her umbilicus and into her unine bag.
- urine will be collected directly from there & sent for C/S to identify the specific bug
& destroy it
- to ensure no external contamination
- Completely painless procedure, done by the expent hands under local anaesthetia
Othen Investigation to rule out D/D
- FBE with ESR and CRP
- UEC
- Blood Cultures
- USG of hen uniray tract
for any structunal abnommalities causing this infection.
- Start Antibiotics
Panadol - for fever - Hygiene advice:
- Wipe from front to back
- Give ample amount of fluid - Most children recover fully, so don’t worry
- I can arrange a social worker for your other child.
Management of GOR in children
Condition - Gastroesophageal reflux
Cause - The lower end of the food pipe which is connected to the stomach is not well developed yet.
So the contents from the stomach flows back upwards and the baby vomits it out.
Commonality - Very common condition
Course - Usually settles by 4-6months after starting solids. And completely resolves by 1 year of age
Treatment:
- Try giving small, frequent feeds
- Decrease the duration of each feed (20mins on each breast)
- Thicken the feed by food thickeners called Gaviscon
- Don’t put the baby to sleep immediately after feeding.
Carry him around for a while and then put her to bed in the cod with the head of the cod higher - Give him ample fluids
- Don’t worry as long as the baby is feeding and gaining weight adequately there’s nothing to worry about.
- Red flags
And if no improvement- refer to child gut specialist
An 18 years old boy complaining of pain in the right groin and vomiting for 3 hours after riding a bicycle.
What are the D/Ds?
- Testicular torsion
- Trauma
- Epididymo-orchitis
- Strangulated hernia
- Incarcerated hernia
- UTI
- Renal stones
- Acute appendicitis
- Intestinal obstruction
Management of simple viral infection
Condition - Simple viral infectio/Recurrent viral infection
Cause - it is common for children to have 6 to 12 viral infections per year because their immune system is not well developed yet
But since his fever is never high, he is thriving well, and there are no obvious red flags
Management:
1. Exposure to passive smoking increases the risk of viral infections, so I can book another appointment to discuss more about the quitting of smoking.
- Antibiotics or antivirals are not effective in such cases.
Just Panadol for fever. - Whenever he feels sick:
- please give him adequate rest,
- ample amount of fluid and healthy diet - Keep his immunisations up-to-date
- Maintain a good hygiene and
- Avoid sick exposure or contacts.
- Red flags- If he develops a high fever, difficulty in breathing becomes irritable please report immediately
Causes of fever and rash in children
- EBV or infectious mononucleosis
- Scarlet fever
- Kawasaki disease
- Meningococcal meningitis
- ITP
- HSP.
- Leukaemia
- Lymphoma
If rash around the mouth:
1. Herpes stomatitis
2. Impetigo
3. Hand foot and mouth disease
4. Burn
Causes of non-blanchable rash
- ITP
- HSP
- Meningococcal meningitis
- Lymphoma
- Leukaemia
Causes of rash around the mouth
- Herpes stomatitis
- HFM disease
- Impetgo
- Burn
Things to mentionfor any Rash Description :
- Site and Distribution
- Morphology [papule, pustule, vesicle] and texture
- Palpable or not, Blanchable or not
- Scaling or sloughing
- Oozing - Blood or discharge
- Skin around it - itching or excoriation marks
- Redness or erythema or
- peeling off skin
11month old baby is crying, has become irritable and refusing to eat or drink since the last 2 days.
What is the condition and what is the management?
Condition - Herpes Stomatitis
Cause - A viral infection caused by Herpes Simplex virus,
transmitted from an infected person via direct contact or sharing the same clothes, towels, toys or utensils
Clinical features - 1. Painful ulcers/vesicles around the mouth, lips and gums
2. The child refuses to eat or drink because of the pain
Course - Highly contagious disease
Also a self-limiting one
Management :
1. Clinical diagnosis, no investigation is required
- No role of antivirals or antibiotics
- Panadol for the fever and pain
- Lignocaine gel/numbing gel over the ulcers/vesicles - to numb the area
- the try to feed the child
- can be applied every 3 hours - Don’t give him any hot food or drink
Give him cold to cool drinks (but no fizzy drinks)
Ample amounts of fluid and healthy diet - Exclusion from school and childcare- until the lesions have completely healed
- Own toys, utensils. No sharing
Red flags - 5Rs
A 2-year-old boy to GP clinic in a small
country town, 500 km from the city. The child has become lethargic and
febrile for the last 4 hours. He has had a mild URTI for the last 3 days.
What is the condition and the management?
Condition - Septicaemia due to meningococcal meningitis
Cause -
Septicaemia means : an overwhelming infection of the blood
Meningococcal meningitis : infection of the coverings of the brain and spinal cord caused by a bug called Meningococcus.
Transmitted via air droplets or direct contact with an infected person.
Clinical features -
1. Fever
2. Rash
3. Neck stiffness
4. Headache
5. Photophobia
6. Child rapidly deteriorates and becomes lethargic
Complications - Rapidly deteriorates to cause life threatening complications
Management:
1. Transfer the child immediately to the hospital .
Call an ambulance
Inform the doctors over there about his condition so that they are ready for him beforehand.
- Secure an IV access
Take blood samples for investigations
Start IV fluid - INVESTIGATIONS: Whole septic screening
• Blood - FBE with ESR and CRP
- UEC
- Blood Culture
• Urine (collected by Suprapubic aspiration of urine) - MCS
• Chest Xray - to rule out lung infection
• Lumbar puncture - most important one to rule out/confirm the infection of the brain and identify the specific bug
- a needle will be passed through his back into his spine
- the fluid surrounding the spine will be collected and sent for CS to indentify the specific bug. - Start him on broad spectrum antibiotics
And keep him under constant observation - If meningococcus is confirmed:
- notify the DHS
- notify the school/day care - Prophylactic treatment for the contacts:
• all close contacts in the household or day care within the last 7 days
• pregnant woman
• anyone who has given mouth-mouth resuscitation to the baby - 5R
You are an HMO in ED, the 4-month-old boy is brought to you by his
parents at 3 am. The baby has been unwell for the past 24 hours. No cause could be detected from history or examination.
What is the condition and what is the management?
Condition - Septisemia
Cause - Can be any infection:
1. Meningitis
2. Otitis media
3. Pneumonia
4. Gastroenteritis
5. UTI
Complications -
If we don’t identify and start treatment asap, it could rapidly deteriorate and cause life threatening complications
Management:
1. Admit to the hospital immediately
- Secure Iv access
And start IV fluids - INVESTIGATIONS: Whole septic screening
• Blood - FBE with ESR and CRP
- UEC
- Blood Culture
• Urine (collected by Suprapubic aspiration of urine) - MCS
• Chest Xray - to rule out lung infection
• Lumbar puncture - most important one to rule out/confirm the infection of the brain and identify the specific bug
- a needle will be passed through his back into his spine
- the fluid surrounding the spine will be collected and sent for CS to indentify the specific bug.
4.Start him on broad spectrum antibiotics
And keep under constant supervision
- Your next patient in a GP practice is a 6-year-old girl brought by her
mother due to fever and rash on the upper trunk and perioral pallor. - You are a GP and a 5-year-old child was brought in by mother
because of fever (38C), sore throat and rash.
What is the condition and the management?
Condition- Scarlet fever
Cause - Bacteria called Group A Streptococcus
Transmitted via direct contact or sharing clothes, towels, toys and utensils
Clinical features-
1. High fever and sore throat
2. Rash appears 12-48 hours later
- in the limbs and trunk
- sunburn appearance
- sandpaper texture
- lasts for 2-5 days and then skin peels off from the fingers and toes
3. Tongue - first white coating, then red inflamed/strawberry tony
4. Refusing to eat or drink
5. Generally unwell
Commonality- Common
Complications- Heart : Rheumatic fever
- Kidneys : PSGN
- Septicaemia
Management:
1. Investigations
Blood - FBE with ESR and CRP
- UEC
Urine - MCS
Throat swab - confirmatory
- Start antibiotics-
Phenoxymethyl penicillin (if not allergic)
If allergic- Cephalexin
For fever- Panadol - Ample amounts of fluid
Healthy nutritious diet - Exclusion from school and child care - 24 hours after starting the antibiotic and the child feeling well
- Keep separate clothes, toys, towels and utensils
4 years old Lily is brought by her mother because she has rash in her body but is otherwise well.
What is the condition and what is the management?
Condition : Acute Thrombocytopenia
* Our blood has three types of cells :
* RBCs carry oxygen, they are normal in number
* WBCs fight against infection, they are also normal in number,
* but the platelets that help in clotting or prevent bleeding are decreased, which is the reason why there are bruises in the skin due to bleeding.
Cause : reaction of the body to the viral infection.
Normally during infection, our body produces chemical substances called antibodies which fight against the infection.
But sometimes due to unknown reason, it acts on these platelets decreases its number and function in the body.
Course: self-limiting disease. Resolves by itself. Excellent prognosis
Management:
1. I will arrange hospital admission for observation as there is a risk of spontaneous bleeding during the early phase of the disease.
- if he develops active bleeding - Steroids or Immunoglobulins
- Advice: Do not play any contact sports, rest at home, no IV/IM injections including immunizations.
- If chronic thrombocytopenia (goes beyond 6 months), consider doing splenectomy.
