NTI ped.Case studies

Case studies&OSCE:

Family medicine Training team Kasr Elaini Case studies&OSCE

Case 1:

Case 1 A family has moved into the area and bring their 1-yearold girl in for a well child check. They bring her medical records with them. Her parents have no concerns. Her growth chart concerns you, however.

What can you see ?:

What can you see ? length tracks along the 25th percentile. But her weight has gone gradually from the 25th to 50th percentile at 0–6 months, to the 10th percentile at 9 months, and is now at the 5th percentile at 1 year.

Which of the following most likely explains her pattern of growth:

Which of the following most likely explains her pattern of growth It is normal. Her parents are petite. She is finding her destined genetic pattern of growth. Familial short stature or constitutional delay. IUGR or prenatal insult such as exposure to drugs or infection. Hypothyroidism, growth hormone deficiency, or Cushing syndrome Feeding behaviors, lack of parental knowledge of infant feeding, or poverty.

Summary Failure to thrive:

Summary Failure to thrive is a description, not a diagnosis weights of infants are only helpful if accurate and plotted on a centile chart is present if an infant's weight falls across two centile lines(sever when crossing 3 lines) is mostly due to inadequate food intake is accompanied by abnormal symptoms or signs if there is organic disease most affected infants and toddlers do not require any investigations and are managed in primary care by increasing energy intake by dietary and behavioural modification and monitoring growth

Interpret these growth curves findings:

Interpret these growth curves findings Growth hormone deficiency Turner syndrome hydrocephalus

Slide 7:

In the first week the child returned to his predetermined weight (shift from intrauterine determined weight to genetic determined one)

Back to our case :

Back to our case Your patient presents to the ED at 15 months old. Her mother states that she has had several episodes of emesis over the last 48 hours and today began to have watery, foul-smelling diarrhea. Mother has lost track of number of episodes of emesis and diarrhea. She cannot tell if the child has had urine output because of the watery diarrhea .

Examination :

Examination On your exam the temperature is 39.2°, heart rate 180, respiratory rate 50, blood pressure 80/50. Her weight is 8 kg. She has dry, cracked lips and dry skin. She lies in her mother’s arms and is not very interested in your exam. Her capillary refill is about 4 seconds .

What is the most appropriate next step in the management of this patient’s condition?:

What is the most appropriate next step in the management of this patient’s condition? Evaluate for underlying bacterial source with blood, urine, and stool cultures. Admit to an inpatient unit and begin maintenance IV fluids Infuse 20 cc/kg normal saline IV over 20 minutes Begin oral rehydration Infuse 10 cc/kg D5 1/2 normal saline over 2 hours.

SIGNS AND SYMPTOMS OF DEHYDRATION:

SIGNS AND SYMPTOMS OF DEHYDRATION Mild (<5%): Normal skin turgor, moist lips, tears present, normal vital signs, consolable Moderate (10%): Dry skin and lips, slightly increased pulse, decreased urine output, normal capillary refill Severe (15%): Parched lips, sunken eyes, decreased or no urine output, elevated pulse, prolonged capillary refill, lethargic

Slide 12:

After completing the initial management, the patient is more interested in her surroundings. Her vital signs are now pulse 160, respiratory rate 36, and blood pressure 80/50 . Her lips are still dry and she is still irritable. The capillary refill is 2–3 seconds. She is more interactive with her mother.

What further treatment is indicated for her dehydration?:

What further treatment is indicated for her dehydration ? 80 cc/hour × 2 hours of D5 1/4 NS. 33 cc/hour × 24 hours of D5 1/2 NS with 20 mEq KCl . 50 cc/hour × 24 hours of D5 1/4 NS. 20 cc/kg NS over 20 minutes. 10 cc/kg D5 1/2 NS over 2 hours.

Slide 15:

Maintenance fluids can be calculated using the Holiday-Segar method : Daily water needs for the first 10 kg of body weight is 100 mL /kg/day water needs for 11–20 kg is 50 mL /kg/day each additional kg over 20 kg is 20 mL /kg/day . Remember to account for dehydration, which will require additional fluids (usual weight – current weight in kg = water replacement in L over 24 hours). Also, replaceongoing losses from diarrhea, emesis, etc .

Rapid osce:

Rapid osce

Case 2 :

Case 2 A 5 years old boy brought to you by his mother for a complaint of itching that involves the whole body specially at night ,, The mother itches too What is your diagnosis? What is the managenent ?

Scabies :

Scabies an infestation with the eight-legged mite Sarcoptes scabiei Diagnosis is made on clinical grounds with the history of itching and characteristic lesions. Permethrin cream (5%) should be applied below the neck to all areas and washed off after 8-12 hours. In babies, the face and scalp should be included, avoiding the eyes. Benzyl benzoate emulsion (25%) applied below the neck only (diluted according to age) and left on for 12 hours is also effective but smells and has an irritant action. Malathion lotion (0.5% aqueous) is another effective preparation applied below the neck and left on for 12 hours.

Case 3:

Case 3 A 12 years old female presented to you with hair loss after her father death. What is this lesion and how are you going to treat her ?

Alopecia areata :

Alopecia areata This is a common form of hair loss in children and, understandably, a cause of much family distress Hairless, single or multiple non-inflamed smooth areas of skin, usually over the scalp, are visible; remnants of broken-off hairs, visible as 'exclamation mark' hairs may be seen at the edge of active patches of hair fall. Reassure

Slide 21:

A mother of 3 month old baby presented to you complaining of this lesion. What is your diagnosis and how could you treat it?

Case 4:

Case 4 Josef is a 3-month old infant presented with vomiting since the first week of life. The vomiting occurs daily, is usually small in amount but occasionally is projectile. Physical examination reveals a happy infant who is thriving well. The breathing is noisy and an occasional cough is heard .

Slide 23:

?? What is your suggested approach based on suspected diagnosis?????

Slide 24:

The history is consistent with a diagnosis of gastro esophageal reflux or GER which is almost physiological in the first 3 months of life Posture and thickening the fluids is the treatment of choice A chest X-ray may indicate aspiration pneumonia On the other hand, infants with pyloric stenosis fail to thrive, lose weight and have projectile vomiting They almost never reach the age of 3 months without surgical correction

Case 3:

Case 3 A lady 40 years of age came to you asking your advice on what she has heard in the media that an elderly mother has a risk of delivering a Mongol baby? You took a deep breath and told her Yes the probability in general population is ------- and at your age is ----------------Then you advised doing a blood test, when the results came you told her she is in need of doing other confirmatory test to get 100% sure result?

Slide 26:

What is your comment on probabilities, blood test , the 100% confirmatory test, the name of the syndrome is it correct to call it Mongolism, Downs Syndrome, Down Syndrome, or Down's Syndrome.

Slide 27:

Down syndrome (this is the right nomenclature) have a general population incidence of 1/700 ( i -e among each 700 pregnancies there is a probability of one getting DS) this probability however differ with different ages to be 1/900 for young women <30years to 1/350 at the age of 35ys and 1/100 in our case of the lady aged 40y.

Slide 28:

The blood test is the Triple Test: in which you measure 3substances in maternal serum these are alpha feto protein, serum esteriol (both become low in preg with DS)and serum chorionic gonadotrophin or CGH (which becomes high in preg with DS) these data if coupled with the lady age, preg gestation, presence or absence of diab give a probability of DS of about 70% and if coupled with measuring inhibin A ( quadrible test) and fetal U/S for nuchael line, short femur will increase the probability .

Slide 29:

to have a probability of 100% you have to do karyotyping of fetal tissues ( ie chromosomal analysis) through amniotic fluid samples got with amniocentesis or fetal tissue through chorionic villus sampling CVS and find the trisomy21 ie 3copies of ch21

Case 5:

Case 5 A I4-month-old girl with a history of eczema develops generalised urticaria , wheeze and severe dyspnoea shortly after eating some peanut butter for the first time

. What is the MOST appropriate initial treatment?:

. What is the MOST appropriate initial treatment ? Adrenaline intramuscularly Adrenaline intravenously Hydrocortisone intravenously Chlorpheniramine intravenously Chlorpheniramine orally

Slide 32:

The history clearly describes an episode of anaphylaxis. Adrenaline is the most important single drug in anaphylaxis. It reverses upper and lower airway oedema , causes bronchodilation , increases blood pressure and causes peripheral vasoconstriction, reducing capillary leak. It should be given by the intramuscular route in most cases. The intravenous route should only be used by those experienced in this method and at a concentration of no greater than 1 in 10,000, with ECG monitoring.

Case 6 :

Case 6 A 5-year-old male presents to your clinic with his mother with a complaint of enuresis. Evidently, this child has never been completely continent at night, wetting his bed several times per week. This has become somewhat of a problem for him now that his friends are having sleep-over birthday parties. His mother confides that she is tired of paying for pull-ups and cleaning sheets. His incontinence is monosymptomatic

What percent of 5-year-old males continue to have enuresis?:

What percent of 5-year-old males continue to have enuresis ? 5% 10% 15% 20% 25%

Which of the following is likely to be part of this child’s history?:

Which of the following is likely to be part of this child’s history? A family history of enuresis. A stressful event in the family such as the birth of a new child or parental divorce. Increased fluid intake over the past 2 months. History of urinary tract infections. All of the above.

Further evaluation of this patient should include all of the following EXCEPT::

Further evaluation of this patient should include all of the following EXCEPT: Asking about a history of bowel problems. Assessment of growth and development. Investigation into family history of nocturnal enuresis. Spine MRI to rule out pathologic lesion. Urinalysis.

Slide 37:

You find no indication of an underlying cause, and you decide that this is primary enuresis. The parents are desperate for some sort of intervention to fix the problem since it is becoming a major source of anxiety in the home and of teasing at school

Which of the following has been shown to be effective in the treatment of primary enuresis?:

Which of the following has been shown to be effective in the treatment of primary enuresis? Motivational training ( eg , rewards for staying dry). Bladder retention training (holding in urine in an attempt to stretch the bladder and increase capacity). Enuresis alarms Pharmacologic therapy ( eg , desmopressin and tricyclic antidepressants). All of the above.

More cases:

More cases

Slide 40:

Patient with abdominal distension. a)What is the diagnosis? b)What are the 2 most frequent causes? c)Mention 3 preoperative measures.

Slide 41:

What is your diagnosis’

Slide 42:

A 16-year-old boy presents to his family physician complaining of “pimples.” He first noticed the bumps on his forehead around the hairline a few weeks ago, and since that time, new groups have come and gone on his nose and also on both cheeks. The bumps vary in appearance, some about the size of a pencil point and black, while others are white, a little larger, and have a ring of red around them.

Slide 43:

What is your diagnosis? What is the management based on the stage of disease

Acne vulgaris:

Acne vulgaris Grades Comedonal : No infl ammatory lesions present. Mild infl ammatory : comedones , infl ammatory papules. Moderate infl ammatory : comedones , infl ammatory papules, pustules. Nodulocystic : comedones , infl ammatory papules, pustules, nodules greater than 5 mm in diameter, scarring often present Treatement General advice topical preparations, such as benzoyl peroxide, azelaic acid, and retinoids Systemic with oral antibacterials referral to a consultant dermatologist who may prescribe oral isotretinoin

Slide 45:

A 12-month-old girl is brought to you for fever and fussiness. Her mother reports that her daughter has had a mild cough and nasal congestion for 1 week but has been acting normally. Two days ago, she developed a fever of 38.9° C (102.1° F) orally and became increasingly fussy. Her mother also notes that she has been tugging on her left ear. On physical examination, she is irritable and febrile to 38.8° C

Local examination of the left tympanic membrane:

Local examination of the left tympanic membrane What is your diagnosis Mention 3 organisms commonly cause this problem? What is your management

Acute Otitis media:

Acute Otitis media The most common causative organisms are Streptococcus pneumoniae (50%), H influenzae (30%), and M catarrhalis (25%). Of these, the most important pathogen is S pneumoniae , which if left untreated can progress to more invasive disease Amoxicillin– clavulanate , 90 mg/kg/d of amoxicillin component with 6.4 mg/kg/d of clavulanate Education : The parents of young patients with AOM should be educated concerning the importance of having the child finish the course of antibiotics as well as keeping follow-up appointments. They should also be made aware of signs of possible invasive disease (i.e., extreme irritability or somnolence, worsening pain, persistent fever).

Slide 48:

A mother brought her 4 years old child for evaluation of this rash. The child had fever 2dayss ago and wakened up yesterday with rash on the face What is the most likely diagnosis? How can this condition be differentiated from other viral exanthems?

Slide 49:

For how long should this child be dismissed from school?

school exclusion period of common childhood infections:

school exclusion period of common childhood infections Disease IP Infectivity period Exclusion from school Chickenpox ( varicella 10-23 (median 14) -2 to +5 days Until all lesions have crusted Viral gastroenteritis 1-10 NK 24 hours from last episode of diarrhoea Gastroenteritis (bacterial 1-10 depending on organism 1-3 weeks depending on organism 24 hours from last episode of diarrhoea except for E. Coli - 2 negative stools Herpes simplex stomatitis 3-5 NK Until lesions have crusted or been treated

Slide 51:

Impetigo 2-15 NK Until lesions are dry Mumps 15-24 (median 19) NK 7 days from onset of parotitis

Slide 52:

WHAT IS THE CUSATIVE ORGANISM? MENTION 2 COMPLICATIONS’

DON’T THINK ,TRY!:

DON’T THINK ,TRY!

Slide 54:

ANY QUESTIONS Saeedfm@hotmail.Com