Case studies

Question 1

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?

Answer 1

UTI (diagnosis)

DD: LRTI/ Pneumonia

Question 2

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 and management?

Answer 2

Urine dipstick, microscopy, culture

give IV antibiotics (3rd generation Cephalosporins or co-amixiclav)

Question 3

when managing a UTI?

Answer 3

Lower tract: oral trimethoprin/ co-amoxiclav

pyelonephritis: IV 3rd generation cephalosporin, co-amoxiclav

Question 4

what is a major worry when a child has a UTI?

therefore how would you investigate

Answer 4

VUR (reflux) and renal scarring

DMSA (isotope scan for scarring)

MCUG / MAG3 (scan for reflux if scarring)

Question 5

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?

Answer 5

Gastroenteritis

E.coli, campylobacter, salmonella

Question 6

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 abdominal discomfort

investigation:

Answer 6

stool cultures (bacterial and viral)

urine dipstick and blood pressure

check blood count

Question 7

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?

Answer 7

supportive care:

hydration

monitor urine output/fluid balance

monitor bloods

(antibiotics are NOT indicated)

Question 8

what is the triad of haemolytic uraemic syndrome?

Answer 8

Microangiopathic haemolytic anaemia (fragments)

Thrombocytopenia (platelet consumption/ bruising)

Acute renal failure (potential multi-organ involvement)

Question 9

what is the triad of haemolytic uraemic syndrome?

Answer 9

Microangiopathic haemolytic anaemia (fragments)

Thrombocytopenia (platelet consumption/ bruising)

Acute renal failure (potential multi-organ involvement)

Question 10

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.

diagnosis?

Answer 10

Primary nocturnal enuresis

Question 11

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?

Answer 11

cow’s milk allergy/ intolerance with reflux

Question 12

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

Answer 12

none unless they have bilious vomits

Question 13

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.

how do you manage?

Answer 13

trial of hydrolysed feed

milk free advice

Trial of Nutramigen or Aptamil pepti 1