Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

PPALs Paediatric Round up From: Sas Hewapathirana, Baraah Ali & Tobi GummContents: Respiratory: Cardiology + Gastroenterology: Neurology/Psych: Derm/Haem: Bronchiolitis Endocrinology: Pyloric stenosis Epilepsy ALL VIW Cyanotic vs Intussusception Febrile convulsions ITP Asthma acyanotic Biliary atresia Benign rolandic HSP Croup TOF Necrotising seizure Iron deficiency Epiglottitis TGA enterocolitis Cerebral palsy anemia Pertussis VSD Hirschsprung Autism Kawasaki disease Cystic fibrosis ASD CMPA ADHD Scarlet fever Tonsillitis Volvulus Development Meningitis Type 1 diabetes Quinsy DKA Malrotation Chickenpox Toddlers diarrhoea Impetigo GORD NAI Coeliac diseaseRespiratoryCase 1: What is the most likely 4 month old baby brought into GP with runny nose, cough and mild fever diagnosis? for 3 days, increasing breathlessness and wheezing. A. VIW Sibling is also ill with a runny nose and flu like symptoms but parents are B. Asthma worried about baby due to him being off his feeds, less than 50% of C. Foreign body normal feeds. D. Bronchiolitis However baby has had 1 wet nappy today, no dirty nappies. E. Croup No significant PMHx and no regular medications. Normal vaginal delivery at 39 weeks. Immunisations up to date. Do they need to be admitted to hospital or not? And why? O/E- Use of accessory muscles, intercostal recession and head bobbing. What is the management for this RR 72 (ausc- mild widespread crackles), HR 126 condition? (ausc- HS I+II+0), BP 90/60, O2: 95%Case 1: Bronchiolitis Most commonly RSV with 90% of patients being 1-9 months old and peak incidence in 3-6 months of age. Newborns are protected by maternal IgG. Risk factors: Prematurity, downs syndrome, cystic fibrosis, under 3 months old Referral to hospital: a. Immediate: apnoea, unwell child, respiratory distress, cyanosis, O2 <92% b. Consider: RR over 60 breaths/min, less than 50-75% of normal feeds, clinical dehydration Management= Supportive: Dehydration- orally when possible, if not NG or IV. Small frequent feeds as full stomach can restrict breathing Supplementary oxygen + Nasal drops/Suction Vent support if requiredCase 2: What is the most likely diagnosis? A. VIW 2 year old child brought into GP with runny nose, dry cough and mild fever for 3 days, increasing breathlessness and wheezing. No one at home B. Asthma is ill, however does attend nursery. C. Foreign body Lives at home with parents and cat D. Anaphylaxis Has been slightly off food E. Croup No significant PMHx and no regular medications. Normal vaginal delivery at 39 weeks What is the severity? Immunisations up to date. A. Mild B. Moderate C. Severity/ life threatening O/E: Is crying when examined. D. Impending resp failure RR 45 (ausc- widespread expiratory wheeze), HR 130 (ausc- HS I+II+0), O2- 96%. PEWS: 1 What is the management for this condition?Case 2: VIW 50% of children have at least 1 wheezing episode in early childhood- most are wheeze free by 6yrs old. Viral induced wheeze and Risk factors: environment (animals, mold and cigarette smoke), asthma are very similar- the maternal smoking during pregnancy, FHx of asthma, main difference is age. daycare/nursery/school attendance Before the age of 5 we can’t History: know for sure if a child has Ask about prior wheezing episodes- especially relating to hospital asthma as we are unable to test admittance/PICU, resp support in past, Atopic history and FHx of atopy. them accurately (peak flow or Investigations: spirometry) Consider chest X-Ray- especially for severe/life threatening cases If we have high suspicion of this developing into asthma such as: (exclude pneumonia/pneumothorax) Venous/ capillary blood gas in severe cases (PH, CO2, Lactate and K+) atopy, fhx, interval symptoms and limitation on activity, Severity classification table- next page treatment can be given. Management dependant on severity- next page Severity End of bed RR HR 02% Mild Expiratory wheeze and mild IWB Slightly raised Normal >94% Moderate Expiratory/inspiratory wheeze + Tachypnoea Slight raised 92-94% moderate IWB Severe/ Life Agitated, expiratory/inspiratory Marked rise Marked rise <90 threatening wheeze, severe IWB, silent chest Impending Cyanosis, reduced respiratory effort, Reduced Marked rise <90 lethargy, acidosis Severity Management Mild Salbutamol via spacer, burst therapy (3 doses, 20 minutes apart), frequent reassessment, oral steroids (1-2mg/kg for 1-3 days). Moderate Salbutamol burst therapy, stretch doses to 3-hourly, consider ipratropium, oxygen, oral prednisolone. Severe Early senior involvement, burst salbutamol/ipratropium, oxygen, intravenous steroids, possible magnesium sulphate/aminophylline/salbutamol, consider higher-level care.Case 2 continued: Describe the chest X-ray Same 2 year old child was sent given burst therapy and was sent home on 3-hourly salbutamol and safety netting. Eventhough, at first she was getting better, she 2 days later, she worsened What is the most likely in condition at home and was brought straight to PAU. diagnosis? She had increased dyspnoea, with productive cough, high temps of 39.0. A. Severe VIW B. Exacerbation of asthma C. Pneumonia O/E: Has intercostal recession and tracheal tug. D. Cystic Fibrosis RR 62 (ausc- reduced breath E. Croup sounds with crackles), HR 152 (ausc- HS I+II+0), O2- 92%. PEWS: 10 What are this child's risk factors Chest X-Ray was performed: to get pneumonia?Case 2: Pneumonia Pneumonia is dangerous in children and should be diagnosed ealy. Cough may not always be present. There may be chest pain or pleuritic chest pain. However, in younger children, they may complain of abdo pain instead. Risk factors: Under 5yrs old, recent viral RTI, chronic resp diseases (CF), immunosuppression and secondary smoke Investigation: Bloods (FBCs, CRP, U&Es), blood cultures and sputum cultures, VBG/CBG, Chest X-Ray Management: Always escalate to a senior. Oxygen, Amoxicillin PO (Azithromycin) or IV Co-amoxiclav +/- Clarithromycin (Clarithromycin and Ceftriaxone)Case 2 continued: Same child now attending GP as a 4 year old child with recurrent chest infections, she has had 3 chest infections in the span of 9 months now. She has also had a wet cough for over 8 weeks. Not following growth chart: As seen Goes to Pre-school Lives at home with parents and cat What investigations should be No significant PMHx and no regular medications performed? Normal vaginal delivery at 39 weeks Immunisations up to date. Further questioning found that the child was not born in the UK (parents are both of south asian descent) What is the most likely diagnosis? She is referred to the paediatric respiratory doctors in Manchester. A. Bronchopulmonary dysplasia Investigations: Chest X-ray (multifocal radiographic changes), sweat B. Bronchiectasis test: Positive , IGRA test for TB: Negative, genetic testing sent, C. Immunodeficiency immunological tests sent. D. Cystic Fibrosis E. Latent TB Case 2: Cystic Fibrosis In the UK, there is neonatal blood spot testing done, which has greatly reduced the cases of missed diagnosis. However outside of Europe, CF is rare and therefore testing is not done routinely. Even in the UK, 5% of children are diagnosed after the age of 18 due to false negatives. Tests: Heel prick test in neonates, sweat test: normal is <40, CF is >60, genetic testing Common presenting features: 40% due to recurrent chest infections, 30% due to malabsorption (steatorrhoea + failure to thrive), 20% neonatal (meconium ileus + prolonged jaundice), 10% other (liver disease). Management: chest physio, high calorie diet, pancreatic enzyme supplements, CF patients should avoid contact with other CF patients due to opportunistic infections and Burkholderia cepacia infection is a contraindication for Lung transplantationCase 3: 6 year old with 1 week history of wheeze and dry cough. He has had a dry What is the most likely diagnosis? cough for a while now, and seems to get worse in the winters. Mum has A. VIW noticed a nocturnal cough for about 6 months now. She has also noticed B. Asthma that her son can’t run around as much as the other kids as he seems to C. Anaphylaxis stop often to catch his breath D. Epiglottitis E. Croup Lives at home with parents Mum had gestational hypertension and diabetes controlled by diet PMHx- Spent 1 week in the NICU due to prematurity, eczema DHx- topical emollients and topical steroids How would we manage this patient? FHx- eczema and hayfever Emergency C-section at 34 weeks due to spontaneous rupture of the membrane Immunisations up to dateCase 3: Asthma A diagnosis in under 5’s can be given, with atopy and interval Can only be diagnosed from age 5 and up: Guidance as seen symptoms: Under the age of 5: can be treated with steroids with regular review If they have primary or secondary (admission to hospital or 2 or more admissions to ED with a wheeze for atopy: eczema, asthma, hay fever or food allergies more than 12 months) and after age of 5 if symptoms continue, test as Interval symptoms: nocturnal seen above. cough, exercise induced wheeze, pets and allergies Assessment: Severe Life-threatening ● O2 <92% ● SpO2 <92% ● PEF 33-50% best or predicted ● PEF <33% best or predicted ● Heart rate: >140 (1-5 years), >125 (>5 years) ● Silent chest + poor respiratory effort ● Respiratory rate: >40 (1-5 years), ● Bradycardia, dysrhythmias, hypotension >30 breaths/min (>5 years) ● Agitation ● Too breathless to talk or feed ● Altered consciousness ● Use of accessory neck muscles ● CyanosisCase 3: Asthma Acute Management: Bronchodilator therapy ● give a beta-2 agonist via a spacer (for a child < 3 years use a close-fitting mask) ● give 1 puff every 30-60 seconds up to a maximum of 10 puffs ● if symptoms are not controlled repeat beta-2 agonist and refer to hospital Steroid therapy ● should be given to all children with an asthma exacerbation ● treatment should be given for 3-5 days Severe + Life-threatening should always be admitted into hospital with specialist input- use of nebs and possible PICU admissionCase 3: Asthma Chronic Management: Under 5s: 8 to 12 week trial of twice-daily paediatric low-dose ICS as maintenance therapy + SABA as required- stop after 8-12 weeks if symptoms resolve. Review after 3 months 5-11yrs: Twice-daily paediatric low-dose inhaled corticosteroid (ICS) + short-acting beta2 agonist (SABA) as neededCase 4: What is the most likely diagnosis? A. VIW 1 year old child with a mild fever at home and a runny nose for 4 days, B. Epiglottitis has now developed a barking cough for 48 hours now, waking up in the C. Foreign body aspiration night from the cough. D. Whooping cough E. Croup No one else at home is ill Lives at home with parents What is the severity? Has been off food recently A. Mild No significant PMHx and no regular medications. Normal vaginal delivery at 38 weeks B. Moderate Immunisations up to date. C. Severe O/E- inspiratory and expiratory stridor, intercostal recessions and sternal wall retraction, significant What is the management for this distress and agitation. RR 55, O2% 94%, HR 142 child? PEWS 8. Case 4: Croup Assessment: Mild Moderate Severe ● Occasional barking ● Frequent barking cough ● Frequent barking cough cough ● Easily audible stridor at ● Prominent inspiratory ● No audible stridor at rest stridor at rest rest ● Suprasternal and ● Marked sternal wall ● No or mild suprasternal sternal wall retraction retractions and/or intercostal at rest ● Significant distress and recession ● No or little distress or agitation, or lethargy or ● The child is happy and agitation restlessness (a sign of is prepared to eat, ● The child interested in hypoxaemia) drink, and play its surroundings ● Tachycardia (a sign of hypoxaemia) Case 4: Croup Admitting into hospital: Moderate/severe croup, <3 months of age, known URT abnormalities (downs syndrome), uncertainty about diagnosis Investigations: Most are diagnosed clinically, however X-Rays can be done, posterior-anterior view has steeple sign (subglottic narrowing) and lateral view has thumb sign (acute epiglottic swelling) Management: Oral dexamethasone (0.15mg/kg), prednisolone if dex in unavailable Emergency- high flow oxygen and nebulised adrenalineCase 5: 2 year old child with 1 day history of high fevers and stridor. She is What is the most likely struggling to breath with her hands on her knees and leaning forwards. diagnosis? Mother has als noticed that she has been drooling and has a very muffled A. Whooping cough voice when talking. No cough has been present. B. Epiglottitis No one else at home is ill C. Foreign body aspiration Lives at home with parents and older sister. D. Anaphylaxis No significant PMHx and no regular medications. E. Croup Normal vaginal delivery at 40 weeks No immunisations (due to parents being scared as sister had a reaction to a vaccine when younger) What is the management? O/E- inspiratory and expiratory stridor, significant distress and agitation. RR 55, O2% 94%, HR 142, Temp 39, PEWS 5.Case 5: Epiglottitis Acute epiglottitis is a rare but serious infection, in the UK children are vaccinated against it via the HIB (haemophilus influenza B) vaccine. Prompt recognition and treatment is essential as the airway may obstruct due to its rapid nature. Do not attempt to visualise as this may cause the child to go into laryngospasm. Only trained staff should do so. X-ray ay also be done Management: Immediate senior involvement and those who can provide emergency airway support (Anesthetics/ ENT), ET tube may be needed. Oxygen IV antibioticsCase 6: What is the most likely 2 month old with cough and coryzal symptoms for over 2 weeks, more diagnosis? recently mum has noticed that each time she coughed, she vomited A. Whooping cough afterwards. Sometimes going blue and quiet after coughing. Dad is also ill B. Epiglottitis with a cough, has also had it for a prolonged time. C. Foreign body aspiration Lives at home with parents D. Anaphylaxis Mum had gestational hypertension and diabetes controlled by diet E. Croup Spent 1 week in the NICU due to prematurity but no regular medications. Emergency C-section at 34 weeks due to spontaneous rupture of the membrane Immunisations up to date What is the management?Case 6: Pertussis Also known as whooping cough is commonly known as the 100 day cough Features: Early (catarrhal): URTI which lasts for about 1-2 weeks The whooping cough vaccine Main (paroxysmal): Cough increases in severity, coughing bouts is routinely given as part of followed by vomiting + central cyanosis, inspiratory whoop, infants the: may have spells of apnea, lasts 2-8 weeks Easing (convalescent): Cough subsides over weeks to months ● 6 in 1 vaccine– for Investigations: per nasal swab culture for Bordetella pertussis Management: infants under 6 months should be admitted, oral babies at 8, 12 and 16 weeks macrolide (clarithromycin, azithromycin or erythromycin) if the onset of ● 4 in 1 pre-school the cough is within 21 days to eradicate the organism and reduce the booster– for children spread. Contacts should be offered prophylactic antibiotics. School exclusion: 48 hours after commencing antibiotics (or 21 days from aged 3 years 4 months onset of symptoms if no antibiotics ) Complications: subconjunctival haemorrhage, pneumonia, bronchiectasis and seizuresCase 7: 9 year old with sore throat seen in ENT clinic, he has difficulty swallowing What is the most likely and mild fever, this has happened many times now, over 5 times in the past 2 year. Mum has noticed severe snoring at night and sometimes diagnosis? “stops breathing” and is getting very worried now. A. Whooping cough B. Epiglottitis Lives at home with parents C. Tonsillitis Has been slightly off food due to sore throat D. Quinsy Multiple ED visits due to sore throat but no regular medications. E. Croup Normal vaginal delivery at 39 weeks Immunisations up to date. What is the acute and long term O/E- see image management for this condition? Case 7: T onsillitis Inflammation of palatine tonsils is most common, mostly viral infections but can be bacterial Investigations: throat swab to determine the type of infection Management: Treatment of acute tonsillitis if bacterial antibiotics need to be given Complications of tonsillitis include: (Phenoxymethylpenicillin) along with ensuring that they have plenty of ● otitis media fluids and rest ● quinsy - peritonsillar abscess Long Term treatment is surgery- ● rheumatic fever and ● At least seven episodes in the preceding year glomerulonephritis very rarely ● At least five episodes a year in the past two years ● At least three episodes a year in the past three years Or: ● Obstructive sleep apnea ● Breathing difficulty ● Swallowing difficulty, especially meats and other chunky foods ● An abscess that doesn't improve with antibiotic treatment Case 8 part 2: What is the most likely The same 9 year old is back before his scheduled surgery, he had diagnosis? complained of pain in his right ear and sore throat, including difficulty A. Whooping cough swallowing, his mum also mentioned that there seems to be a change in B. Epiglottitis his voice, almost like a he has a hot potato in his mouth at all times. C. Tonsillitis D. Quinsy E. Croup O/E- see image, He is also struggling to open his mouth fully What is the management?Case 8 part 2: Quinsy It is a peritonsillar abscess, a complication of tonsilitis. Diagnosis: Liverpool Peritonsillar Abscess (LPS) score criteria: Unilateral sore throat – 3 points Trismus – 2 points 3 or less is unlikely, Male gender – 1 point 4 or more is more likely, The most common organism is Hot potato voice – 1 point 6 or more is very likely streptococcus pyogenes (group A strep), but it is also commonly Management: Analgesia (NSAIDs), IV fluids: to re-hydrate with poor caused by staphylococcus aureus and haemophilus influenzae. oral intake, IV antibiotics (benzylpenicillin and metronidazole or clindamycin/clarithromycin monotherapy), Corticosteroids: dexamethasone may reduce inflammation and relieve trismus- however not always used. Or surgical management with incision and drainage- with tonsillectomy as an end goal to prevent reoccurance Cardiology + EndocrinologyCase 1: What is the most likely A girl is born and her APGAR score being 4. She is cyanotic at birth with diagnosis? A. TOF tachypnoea and tachycardia. She seems to be in respiratory distress with B. TGA irregular breaths. C. Tricuspid atresia D. PDA Mother has gestational diabetes, treated E. VSD with metformin O/E- cyanotic baby RR 55, 02 88% on 15l non-rebreather, HR 182 PEWS- 13 What is the clinical feature seen Chest X-Ray was performed- as seen in the chest X-ray?Case 1: TGA Transposition of the great arteries is a condition where the attachments of the aorta and the pulmonary trunk to the heart are swapped. The moment the baby has to use their It can also be associated with: lungs, there's cyanosis due to the ● Ventricular septal defect ● Coarctation of the aorta transposition. Antenatal scans will ● Pulmonary stenosis normally detect this Management: 1. If there is VSD, this allows some time to allow for mixing of blood and time to come up with definitive treatment. 2. A prostaglandin infusion used to maintain the ductus arteriosus. 3. Balloon septostomy: inserting a catheter into the foramen ovale via the umbilicus, and inflating a balloon to create a large atrial septal defect. This allows blood returning from the lungs to flow to the right side of the heart and out through the aorta to the body. 4. Open heart surgery is the definitive management. What is the most likely diagnosis? Case 2: A. TOF B. TGA C. Tricuspid atresia D. PDA 6 month old baby presenting with poor feeding and weight gain. Mum has E. VSD also noticed some cyanotic episodes where baby goes blue when he cries too much and passes out sometimes. What is the clinical feature seen in the chest X-ray? Lives at home with parents No significant PMHx and no regular medications. Mum had an “elderly” pregnancy at 42 yrs old, but no abnormal scan throughout. She also had gestational diabetes, treated with metformin Elective C-section at 36 weeks and baby took a bit longer than normal to start spont breathing. Immunisations up to date. O/E- Slightly cyanotic lips, RR 45, O2 90%, HR 151 (ejection systolic murmur heard) PEWS 5 Chest X-ray- as seen Case 2: TOF Tetralogy of fallot is the most common cyanotic heart disease, commonly starts presenting at 1-2 months old but may be later to get picked up. It is 4 conditions in one: ● ventricular septal defect (VSD) ● right ventricular hypertrophy ● pulmonary stenosis (ejection systolic murmur) causing right ventricular outflow tract obstruction ● overriding aorta The severity of the right outflow tract obstruction determines the degree of cyanosis and clinical severity. Risk factors: ● Rubella infection ● Increased age of the mother (over 40 years) ● Alcohol consumption in pregnancy ● Diabetic motherCase 2: TOF Other features: ● Cyanosis ○ Can have “tet” spells. Which include tachypnoea and severe cyanosis that occasionally results in loss of consciousness. This occurs when an infant is upset, is in pain or has a fever ● causes a right-to-left shunt ● a right-sided aortic arch is seen in 25% of patients ● chest x-ray shows a 'boot-shaped' heart, ECG shows right ventricular hypertrophy Management: neonates, a prostaglandin infusion can be used to maintain the ductus arteriosus. Total surgical repair by open heart surgery is the definitive treatment, however mortality from surgery is around 5%.Case 3: 6 month old child brought in with failure to thrive. She isn't feeding well What is the most likely diagnosis? A. ASD and has some breathlessness. B. PDA Mum has tried changing diet but it doesn’t seem to help C. VSD D. Coarctation of the aorta Lives at home with parents E. Aortic valve stenosis PMHx- Has downs syndrome but no regular medications. Elective C-section at 36 weeks Immunisations up to date. Why does this not cause cyanosis? O/E- happy playful baby, RR- 55, O2 95%, HR 145 (pansystolic murmur with systolic thrill on palpation). PEWS 1Case 3: VSD VSDs are the most common heart defect at 30% This causes a shunt from the left to right side. Which can then cause right-sided overload, right heart failure and pulmonary hypertension Management: An echocardiogram confirms the diagnosis. A paediatric cardiologist will manage patients with a VSD. ● Active monitoring (small defects may close on their own) ● Percutaneous transvenous catheter closure (via the femoral vein) ● Open-heart surgery VSDs increase the risk of infective endocarditis.Case 4: 12 year old boy presenting to GP with recurrent chest infections, poor What is the most likely diagnosis? weight gain and shortness of breath. A. ASD He has noticed he is unable to run as far as his friends and that he isn’t B. PDA able to gain weight too quickly either and is feel self conscious about this. C. VSD D. Coarctation of the aorta Lives at home with parents and 2 siblings (one younger and one older) E. Aortic valve stenosis PMHx- Has had many chest infections over the years with some requiring hospital admission but no regular medications. Elective C-section at 36 weeks Immunisations up to date. O/E, RR 16, O2 99%, HR 100 (mid-systolic, crescendo-decrescendo murmur loudest at the upper left sternal border. And a fixed split second heart sound)Case 4: ASD Pathophysiology: when the heart is forming there are 2 walls for the atria, septum primum and septum secundum. Defects in these walls cause ASD. This once again causes a left to right shunt, which is why the child doesn’t get cyanosed. The types: ● Patent foramen ovale, where the foramen ovale fails to close ● Ostium secundum, where the septum secundum fails to fully close ● Ostium primum, where the septum primum fails to fully close (tends to lead to an atrioventricular septal defect) Management: An echocardiogram confirms the diagnosis. Complications: ● Active monitoring (small defects may close on their own) ● Stroke in the context of VTE ● Percutaneous transvenous catheter closure (via the femoral vein) ● Atrial fibrillation or atrial ● Open-heart surgery flutter ● Pulmonary hypertension and right-sided heart failure ● Eisenmenger syndromeCase 5: 15 year old with weight-loss and lethargy in GP. She reports that she has What is the most likely diagnosis? to wake up in the middle of the night to urinate as well as excessive thirst A. Diabetes type 1 causing her to wake up in the night to drink water too. B. Diabetes type 2 C. Diabetes insipidus Lives at home with parents and 2 siblings (2 older siblings) D. DKA PMHx- Has been checked for iron deficiency anemia and hypothyroidism E. Insulinoma in the past: both negative. DHx- vit D tablets FHx- Hypothyroidism Normal vaginal delivery at 41 weeks Immunisations up to date. What is the management for this patient? O/E- Urine dipstick- ++ glucoseCase 5: Type 1 diabetes Management: It is thought to be highly genetically linked as well as linked with other autoimmune diseases (such as hypothyroidism). There is also some Patient and family education ● Subcutaneous insulin regimes viruses that can trigger it such as the Coxsackie B virus and enterovirus. ● Monitoring dietary For new diagnosis: carbohydrate intake ● Baseline bloods including FBC, renal profile (U&E) and a formal laboratory glucose ● Monitoring blood sugar levels on waking, at each meal and ● HbA1c before bed ● Thyroid function tests and thyroid peroxidase antibodies (TPO) to test for associated autoimmune thyroid disease ● Monitoring for and managing complications, both short and ● Tissue transglutaminase (anti-TTG) antibodies for associated long term coeliac disease ● Insulin antibodies, anti-GAD antibodies and islet cell antibodies to test for antibodies associated with destruction of the pancreas and the development of type 1 diabetesCase 5 continued: 15 year old with abdo pain and pear breath brought in by her friends after she vomited and was confused at the mall. She has been ill recently What is the most likely diagnosis? with a common cold. A. Diabetes type 1 Lives at home with parents and 2 siblings (2 older siblings) B. Diabetes type 2 PMHx- Has been checked for iron deficiency anemia and hypothyroidism C. Diabetes insipidus in the past: both negative. D. DKA DHx- vit D tablets E. Insulinoma FHx- Hypothyroidism Normal vaginal delivery at 41 weeks Immunisations up to date. What is the management? O/E- Urine dipstick- +++ glucose, ++ ketones, Ketones 4.5Case 5 continued: Parameter Value Reference Range pH 7.20 7.35–7.45 What does this VBG show? HCO₃⁻ (mmol/L) 18 22–28 BE (mmol/L) -8 -3 - +3 Glucose 26 3-7 Lactate 1.9 0.5-2Case 5 continued: DKA Most DKAs are triggered by infection, or other underlying conditions. For DKA there is 3 diagnostic criteria: hyperglycemia, ketosis + acidosis. The most dangerous aspects of DKA are dehydration, potassium imbalance and acidosis. Management: FIG-PICK mnemonic ● F – Fluids – IV fluid resuscitation with normal saline (1 litre in the first hour, followed by 1 litre every 2 hours) ● I – Insulin – fixed rate insulin infusion (Actrapid at 0.1 units/kg/hour) ● G – Glucose – closely monitor blood glucose and add a glucose infusion when it is less than 14 mmol/L ● P – Potassium – add potassium to IV fluids and monitor closely (every hour initially) ● I – Infection – treat underlying triggers such as infection ● C – Chart fluid balance ● K – Ketones – monitor blood ketones, pH and bicarbonateGastroenterologyCase 1: What is the most likely diagnosis? A 6 week old infant presents to PAU with his parents due to vomiting. Mum says baby is hungry all the time, looks pale. A) GORD He has reduced nappies. B) Pyloric Stenosis On further questioning, the child has been projectile vomiting immediately after feeds. C) Intussusception D) Cow’s milk protein allergy Normal vaginal delivery, no issues with pregnancy. E) Biliary atresia No PMH. Up to date with immunisations. O/E Baby has dry mucous membranes, looks pale with an increased CRT. On palpation of the abdomen, there is an olive shaped mass.Case 1: What does this ABG show and why? Parameter Value Reference Range pH 7.50 7.35–7.45 CO2 4.8 4.5–6.0 kPa HCO₃⁻ (mmol/L) 32 22–28 Sodium (Na⁺, mmol/L) 135 135–145 Potassium (K⁺, mmol/L) 3.0 3.5–5.0 Chloride (Cl⁻, mmol/L) 88 98–107Case 1: Pyloric Stenosis Pyloric stenosis occurs due to hypertrophy of the pylorus preventing food from travelling from the stomach to the duodenum. After feeds, there is increased peristalsis against this narrowed pylorus causing projectile vomiting. Investigations Abdominal ultrasound Management Laparoscopic pyloromyotomy (Ramstedt's Operation) - incision in pylorus to allow food to pass through.Case 1 What is your most likely Another 6 week old child presented with vomiting. differential? Spitting up milky fluid after every feed. Vomiting is non-projectile and worse when lying flat How do you manage this condition? The child constantly cries after feeds. Birth and Medical history unremarkable. Up to date with immunisations. O/E Infant looks alert and well. No abnormalities on abdominal examination.Case 1: GORD GORD occurs in babies because contents of the stomach reflux back up through the immature lower oesophageal sphincter. Babies present with irritability and crying after feeds, vomiting worse on lying flat, reluctance to feed and poor weight gain. Management is with: - Conservative - Regular burping - Small regular feeds - Keep baby upright after feeds - Medical - Gaviscon mixed with feeds - Thickened milk - PPIs - Surgical - Surgical fundoplication (RARE) - wrapping fundus of stomach around base of LES.Case 2: A 3 week old girl is brought to the GP by her parents due to persistent jaundice. It has been present since birth. On further questioning, the infant has pale stools and dark urine. Normal feeding and nappies. The child was born at 34 weeks via caesarean section. Up to date with immunisations. O/E Child looks alert and well. Visible jaundice on inspection. Mild hepatomegaly.Case 2: Reference What is the most likely diagnosis? Parameter Value Range A. Breast milk jaundice B. Biliary atresia C. Duodenal atresia Alanine Aminotransferase (ALT) 50 IU/L 10 - 50 D. Necrotising enterocolitis Alkaline Phosphatase (ALP) 873 IU/L 25 - 115 Bilirubin 135 µmol/L < 17 Conjugated Bilirubin 110 µmol/L 0 – 8Case 2: Biliary Atresia Congenital narrowing/absence of the bile duct causing cholestasis. Bile cannot go from the liver to the bowel. This causes a build up of conjugated bilirubin as it is usually excreted in bile. Babies with persistent jaundice after 14 days/21 days (premature babies) Investigations: - LFTs - Measure conjugated bilirubin - Abdominal USS - Liver histology by percutaneous biopsy Management Hepatoportoenterostomy (Kasai Procedure) - new pathway from liver to bowel Liver transplantCase 3: What is the most likely diagnosis? A 1 week old boy presents with a 2 day history of vomiting. Vomiting is described as green immediately after feeding. Prior to these A. Volvulus episodes he was feeding normally. Mum has noticed blood in the B. Intussusception nappies. C. Pyloric stenosis He has reduced feeding and reduced nappies. He has been crying and is D. Biliary atresia very irritable. E. Coeliac disease Normal birth history and PMH Up to date with immunisations How do we manage acutely? O/E The baby looks pale. There is distension of the abdomen High pitched bowel soundsCase 3: Volvulus Malrotation is when the midgut undergoes abnormal rotation and fixation during embryogenesis. This increases risk of volvulus where the bowel twists on the mesenteric axis. Presents with bilious vomiting, feeding intolerance, constipation. Investigations - VBG - U&Es - electrolyte imbalance due to dehydration - Barium enema - AXR - dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction, absence of air in rectum Management - Nil by mouth - NG tube - DRIP AND SUCK - IV fluidsCase 4: A 3 month boy presents with a 1 day history of extreme irritability. He What is the most likely diagnosis? has been crying inconsolably and has been having red goopy stools. He A) Gastroenteritis has had 2 episodes of milky vomiting today. Sometimes the child draws B) Intussusception C) Volvulus his legs up to his stomach. D) Pyloric stenosis Normal birth history and PMH Up to date with immunisations E) Appendicitis How do we diagnose this condition? O/E Child looks pale and distressed. On palpation of the abdomen, there is a sausage shaped mass in right upper quadrant.Case 4: Intussusception Intussusception is when the bowel invaginates(telescopes) on itself. Most common at ileocecal region. This increases the size of the bowel but narrows lumen at the point where it telescopes on itself. This why we can feel the palpable mass. Investigations Abdominal USS Management - Enema - contrast/water/air are pumped into the colon to force it back into its normal position - Surgical reduction - Resection - gangrenenous or perforationCase 5 What is the most likely differential? A 4 month baby boy is brought to the GP by his parents with a history of vomiting, diarrhoea and an red, itchy rash. He started having this A. Lactose intolerance symptoms at 6 weeks of age and this has gotten worse. Vomiting occurs B. Coeliac disease immediately after feeding and he has been producing loose greasy C. GORD stools. The infant cries when feeding bringing his legs up. D. Cow’s milk protein allergy The baby is exclusively formula fed. E. Cow’s milk protein intolerance Normal birth history and PMH Up to date with vaccinations. How do we manage this? FH of asthma and hay fever on maternal side. O/E - Baby looks irritable at rest - Erythematous eczema like rash on cheeks and trunkCow’s milk protein allergy Cow’s milk protein allergy affects children usually in first 3 months of life. Hypersensitivity reaction to cow’s milk protein. IgE mediated -> within 2 hours of ingestion Non IgE mediated -> slowly over several days Cow’s milk intolerance = NO ALLERGIC SYMPTOMS More common with history of atopy. Present with: abdominal pain, vomiting, diarrhoea, bloating, windy child + allergic symptoms -> angioedema, wheeze, rash, watery eyes. Investigations - Skin prick/patch testing - Total IgE and specific IgE (RAST) for cow’s milk protein Management - Breast feeding mothers - avoid dairy - Replace formula with hydrolysed formula - Every 6 months trial milk ladderCase 6: What is the most likely diagnosis? A 2 week old baby is admitted with a 5 day history of vomiting, abdominal distension and producing blood stained stools. Vomiting is A. Sepsis described as green in colour B. Necrotising enterocolitis C. Hirschsprung's disease D. Gastroenteritis Birth history E. Biliary atresia - born at 32 weeks due to premature rupture of membranes - Admitted to neonatal unit for observation No PMH Up to date with vaccinationsNecrotising enterocolitis Necrotising enterocolitis is when the bowel becomes necrotic in neonates. This can lead to perforation and shock. Risk factors: very low birth weight, formula feeds, sepsis, PDA/congenital heart disease, respiratory distress. Presents with: vomiting (bilious), intolerance to feeds, abdominal distension, blood stained stools, absent bowel sounds. Investigations: - Bloods - FBC, CRP, Capillary blood gas, blood culture - Imaging - abdominal xray - supine + lateral - Dilated loops of bowel, Bowel wall oedema (thickened bowel walls) - Pneumatosis intestinalis is gas in the bowel wall - Pneumoperitoneum = perforation - Gas in the portal veins Management - Nil by mouth, IV fluids , TPN and antibiotics, NG tube - Urgent surgical referral, may remove necrotic bowel - Temporary stoma - Can have short bowel syndrome after surgeryCase 7: What is the most likely diagnosis? A baby was born 48 hours ago. The baby has failed to deliver stool, has a swollen abdomen and has been producing green vomit. What is the definitive diagnostic Birth history - normal vaginal delivery for the most likely diagnosis No PMH A. Abdominal USS B. Abdominal X ray O/E C. Clinical exam - Infant is irritable at rest - Normal observations D. Rectal biopsy - Abdomen is distended on examination E. Jejunal biopsy - The boy has upslanting palpebral fissures, a small nose with a flat nasal bridge and single palmar creases.Hirschsprung's disease Congenital condition with absence of the myenteric/auerbach's plexus in the distal bowel/rectum. This forms the enteric nervous system (brain of gut) and is responsible for peristalsis of large colon. Parasympathetic ganglion cells usually migrate down bowel during fetal development. In Hirschsprung's a section of the bowel doesn't have these cells. Total colonic aganglionosis = entire colon affected The aganglionic section of colon does not relax, causing it to becomes constricted -> obstruction in the bowel. Proximal to the obstruction the bowel becomes distended and full. Associated with FH, downs syndrome Waardenburg syndrome, neurofibromatosis Presents with: delay in passing meconium, bilious vomiting, abdominal distension, chronic constipation, failure to thrive Investigations - AXR, rectal biopsy Management with surgical removement of anglangionic bowel Hirschsprung-associated enterocolitis (HAEC) is inflammation and obstruction of the intestine which can lead to toxic megacolon and perforation of the bowel. .Case 8: What is the most likely diagnosis? A 6 year old girl presents to the GP practice with her mother with a 1 year history of loose stools which are difficult to flush. She has been A. Inflammatory bowel disease having abdominal pains after meals. Mum has noticed she is more tired B. Coeliac disease than usual. She is the shortest in her class. C. Inflammatory bowel syndrome PMH D. Lactose intolerance Type 1 diabetes mellitus E. Cow’s milk protein allergy O/E - Patient looks pale and thin How do we investigate the most likely diagnosis? - Conjunctival pallor - No tenderness on abdominal palpationCoeliac disease What is the rash shown below? Autoimmune condition triggered by gluten. Gluten is found in wheat, barley and rye. Auto-antibodies are created which cause inflammation of the small intestine -> anti-TTG and anti-EMA Inflammation mainly affects jejunum causing villous atrophy and crypt hyperplasia Associated with HLA-DQ2 and HLA DQ8 genes Presents with: abdominal pain, bloating, diarrhoea/constipation, failure to thrive, fatigue, steatorrhoea, weight loss. Signs: mouth ulcers, angular stomatitis, muscle wasting Investigations - Bedside - abdo exam, plot height and weight, stool culture - Bloods - FBC (anaemia), haematinics, TFTs total IgA, anti TTG, anti EMA - Imaging etc - OGD and duodenal/jejunal biopsy Management - GLUTEN FREE DIET, extra vaccinations, supplementsCase 8: What are your most likely What if same child presented with difficulty passing stools for last 4 differentials? weeks. She passes rabbit dropping stools every 3-4 days. She has also been having some abdominal pain. Mum says she recently started at a A. Hirschsprung's disease new school and is avoiding using the toilet since. B. IBS C. Coeliac disease No PMH to note D. Constipation Up to date with vaccinations E. Hypothyroidism No concerns about development O/E - Patient looks alert and well - Distension of abdomenConstipation Constipation in children occurs where the child defecates fewer than three times per week or experiences significant difficulty in passing stool. Causes: lower fibre diet, avoidance of toilet, history of fissures, social changes Symptoms: hard pellet stools, overflow diarrhoea due to fluid moving past the hard stool in the rectum, pain and straining during defecation, retentive posturing Encopresis stretched and desensitized rectum retains large, hard stools, allowing only loose stools to leak out and cause soiling. Children who ignore the urge to defecate lose the sensation of needing to open their bowels, leading to fecal retention, impaction, and rectal stretching, which worsens rectal desensitisation Diagnosis based on clinical picture Management - High fibre diet + good hydration - Laxatives - movicol - Faecal impaction - disimpaction regimen - Scheduling visits, bowel diary, start chatsCase 9: What is your most likely A 3 year old child has had loose stools 3-4 times a day for the past 2 months. differential? The stools are mushy but not bloody or watery. Diet includes a high intake of fruit juices and processed snacks. No fever, vomiting, or weight loss. A. Cows milk protein allergy B. Lactose intolerance Normal birth history and PMH C. Toddler’s diarrhoea Normal growth and development. D. Gastroenteritis E. Coeliac disease O/E - Child looks alert and well - No abnormalities on examinationT oddler’s diarrhoea Functional diarrhea in toddlers is often due to an immature GI system and altered intestinal motility, which can result in frequent loose stools. Associated with high sugar intake (e.g., fruit juice), which increases the osmotic load in the intestines, leading to water retention and loose stools. Symptoms: Loose, watery stools 3–4 times a day, typically non-bloody and non-mucousy. Management - 4 F's - Reduce fruit juice - Fats - Increase fat intake - Fluids - adequate fluid intake - Fibre - ensure not too much fibre or too little in dietNeurology/PsychCase 1: ADHD What should be monitored ADHD incorporates features of Inattention and every 6 weeks whilst on hyperactivity/impulsivitiy. The features are persistent and methylphenidate: concerned with developmental delay. A) BP B) Heart rate Management: C) Height and weight 1. 10-week watch and wait D) Development 2. Referral to a paediatrician with a special interest in E) Serum creatine kinase behavioural disorders OR CAMHS 3. Drug therapy - last resort a. Methylphenidate - 6 week trial. b. Lisdexamfetamine c. DexamfetamineCase 2: Autism Autism is a neurodevelopmental disorder. It is characterised by: ● Impairment in social interaction and communication ● Repetitive stereotyped behaviour, interests, and activities Co-morbid with intellectual disabilities in 50% Management: ● Early education and behavioural interventions ● Pharmacologic Interventions ● Family support and counselling - parental educationCase 3: Cerebral Palsy Causes: ● Antenatal - cerebral malformation, and congenital infection (rubella, toxoplasmosis, CMV) ● Intrapartum - birth asphyxia/trauma ● Postnatal - intraventricular haemorrhage , meningitis, head-trauma Types: ● Spastic (increased tone frm damage to UMN) ● Dyskinetic (damage to basal ganglia and substantia nigra, athetoid movements and oro-motor problems) ● Ataxic (damage to cerebellum with typical cerebellar signs) ● Mixed Management: What is an early sign of cerebral palsy: ● Tx for spasticity a) Progressively worsening ● MDT ○ Intrathecal baclofen b) Normal tone ● Anticonvulsants ○ Botulinum toxin type A ● Analgesia as required. c) Paralysis ○ Orthopaedic surgery d) Marked preference for one hand or foot e) Sensory deficitsCase 4: Febrile seizures The same child with fever has had a generalized tonic-clonic seizure lasting about 2 minutes on your ward. The seizure stopped on its own, but she appeared drowsy afterward. She had a fever of 39°C (102.2°F) during the last set of obs. She has no prior seizure history. She has been irritable and withdrawn.Case 4: Febrile seizures A child has a febrile convulsion, 1. Paracetamol they had one three months previously too. Which of the 2. Monitoring at home if no recurrent seizures following should prompt referral and infection has resolved to paediatrics: 3. Reassurance and guidance on seizure first aid A) The mother describing a tonic-clonic seizure and when to return for further care B) The child still being drowsy 4. Admit to paediatrics - if a first seizure OR 2 hours after a seizure C) The temp being 38.1 after complex seizure the seizure 5. Rescue rectal diazepam or buccal midazolam D) A family history of epilepsy E) Examination findings consistent with otitis mediaOther causes of seizures ● Epilepsy ● Perinatal Hypoxic Ischaemic Encephalopathy ● Intracranial haemorrhage ● Neonatal hypoglycaemia ● Neonatal infections ● Lennox-Gastaut syndrome ● Benign rolandic epilepsy ● Reflex anoxic seizures ● Breath holding spellsDerm/HaemCase 1: An 8-year old boy presents with a two-day history of: ● Rash: Non-blanching purpura on lower legs and buttocks ● Abdominal pain: intermittent, colicky ● Joint pain: knees and ankles, no swelling No fever or systemic symptoms. Recent upper respiratory tract infection 1 week ago. On examination: Name some differentials you would considerCase 1: HSP ● Supportive ● IgA vasculitis. ● Monitor with ○ Urine dipstick - for renal involvement ● Features: ○ Blood pressure - for hypertension ○ Abdominal Pain ○ Renal disease ○ Palpable purpura ● Prognosis = good ○ Arthritis ○ Usually recover within 4-6 weeks ○ IgA deposits on renal biopsy ○ ⅓ recurrence in 6 months ○ Small proportion develop end stage renal failureCase 2 A 5-year-old girl presents with a 3-day history of: ● Bruising: Extensive bruises on arms and legs without trauma ● Petechiae: On the lower limbs and oral mucosa ● Epistaxis: Mild. self-resolving nosebleeds No fever, systemic symptoms. Or recent illness On examination:Case 2: ITP ● Immune mediated reduction in platelet count. ● Type II hypersensitivity reaction ● May follow infection or vaccination ● Investigation: ○ FBC -> Thrombocytopenia ○ Blood film ○ Bone marrow examinations - last resort ● Treatment: ○ No treatment usually required! ○ Resolves within 6 months in ~80% of children ○ Avoid activities that may result in trauma e.g. team sportsCase 3 A 4-year-old boy presents with a 2-week history of: ● Fatigue and pallor ● Bruising: Unexplained bruises on legs and arms ● Fever: low-grade and intermittent Parents also note reduced appetite and weight loss. On examination:Case 3: INVESTIGATIONs FBC: ● WBC count: Elevated at 18,000 cells/μL with a high proportion of lymphoblasts ● Hemoglobin: Low at 8.2 g/dL (indicating anemia) ● Platelet count: Low at 45,000/μL (indicating thrombocytopenia) Peripheral blood smear ● Numerous lymphoblastsCase 3: ALL Cancer of bone marrow, which makes too many lymphocytes (WBC) Most common malignancy affecting children Peak incidence 2-5 years More common in boys Features: ● Bleeding ● Infection ● Lymphadenopathy ● FeverCase 4 A 3-year-old girl is brought to A&E with a swollen, bruised left arm. Parents report she "fell off the sofa" two days ago. Further history reveals: ● Bruising: Multiple bruises of varying ages on the torso and thighs. ● Delay in presentation: Parents delayed seeking medical attention. ● Inconsistent story: Details of the incident change when asked again. An x-ray showed the following:Case 4: NAI Imaging ● Full skeletal survey ● Neurological imaging - CT/MRI Reporting -> ● Involve Safeguarding team/child services “Kids that don’t cruise, rarely ● Child may be admitted to paediatric ward bruise” whilst social worker puts safety plan in placeCase 5 A 2-year-old boy is brought to the paediatric clinic with a 5-day history of: ● Fever: Persistent, high-grade, unresponsive to paracetamol ● Rash: Polymorphous, covering trunk and extremities ● Red eyes: Bilateral conjunctival injection without disacahrge ● Swollen lips and tongue: Cracked lips, ‘strawberry tongue’ ● Swollen hands and feet: erythema and induration, peeling noted. Parents noted irritability but no respiratory or gastrointestinal symptoms. On examination:Case 5: Kawasaki’s Investigations: Management: 1. CBC (will show normocytic anaemia, neutrophilia), ● IV immunoglobulin 2. LFTs (ALT and AST may be and high-dose aspirin raised), ● Repeat 3. Urinalysis (sterile pyuria) echocardiography and 4. Echocardiography (to elicit long-term cardiology coronary artery involvement) reviewCase 6 A 6-year-old girl presents with a 3-day history of: ● Fever: High-grade, associated with sore throat ● Rash: Fine, sandpaper-like, starting on the trunk and spreading to the extremities ● Enlarged papillae with a white coating initially Parents note recent contact with a classmate who was unwell On examination:Case 6: Scarlet Fever Investigations: 1. Throat swab - for group A streptococcus 2. Antistreptolysin O titer 3. Raised inflammatory markers Management: 1. Penicillin V for 10 days (or alternative if allergic) 2. Symptom relief 3. Exclude from school for at least 24 hours after starting abxCase 7 What are your A 3-year-old child presents to the emergency differentials? department with a fever. The parent reports that the What are your fever began two days ago and has been persistent. investigations? The child is more irritable than usual and has been less interested in food and fluids.Case 7: Meningitis B rudzinkski’s sign: flexion of the hips and knees in response to neck flexion Kernig’s sign: resistance to extension of leg whilst the hip is flexed Buging fontanelle in infants Petechial or purpuric rash - meningococcal infectionCase 7: Meningitis Investigations: Management: ● Bloods: FBC, CRP, blood cultures, 1. IV abx - trust guidelines lactate. 2. IV fluids for shock ● Lumbar puncture: 3. Dexamethasone if bacterial ○ Elevated WBC, low glucose, meningitis is likely high protein in CSf 4. ICU if signs of septic shock or ○ Gram stain shows organisms raised ICP (e.g., meningococci or pneumococci) ● PCR for bacterial/viral pathogensPaediatric History T aking Presenting Complaint and Systems Review ● Feeding: ○ What do they usually eat or drink? ○ Any change in their normal eating and drinking habits? ○ For infants, are they breastfeeding or bottle feeding? How often do they feed? If bottle feeding, what formula? ● Toileting: ○ Change in the urine output? ○ How many wet nappies per day? ○ How often do they open their bowels? ○ What do their stools look like? ● Other: ○ Paeds specific: noisy breathing, laboured breathing, projectile vomiting, abnormal movements, irritability, limp, rashesHistory T aking continued… Birth History Paediatric History Social History ● Abnormal scans or ● Is the child meeting ● Who’s at home? Type of screening test? their developmental accommodation? ● Have social services ● Any medications milestones? been involved ever? during the pregnancy? ● Any developmental ● What do they like to do ● What type of birth? concerns? regarding play and Any interventions? ● How is their height leisure? ● Premature? Late? and weight growth? Birthweight? ● Are they immunised? ● Are they at school? How ● Admission following have they found it? birth? ● Smoking at home? Alcohol? Drugs? Thank Y ou! Any Questions?