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Common presentations

Common presentations. Farheen, farid & phil. Common presentations:. Pyrexia Dyspnoea Rash Abdominal pain Dehydration Head injury Key history, exam, differentials, red flags and management. pyrexia. Pyrexia: key history.

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Common presentations

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  1. Common presentations Farheen, farid & phil

  2. Common presentations: • Pyrexia • Dyspnoea • Rash • Abdominal pain • Dehydration • Head injury • Key history, exam, differentials, red flags and management

  3. pyrexia

  4. Pyrexia: key history • Age - generally worried >39.5 except in <3m anything over 38 significant • Temperature (measured), pattern • Duration >5/7 ?Kawasakis etc • Behaviour ? Drowsy, irritable, poor feeding • Seizure? Description, duration, fhx • Risk factor - CP, prem, immunosuppressed, leukaemia • Improves after antipyretics? • Immunisations UTD? • Foreign travel, ill contacts, dodgy food • May have specific symptoms, cough, wheeze, sob, limp, joint pain but often non-specific compared to adults e.g. Irritable, poor feeding

  5. Pyrexia: key exam • Airway • Breathing – tachypnoeic, rr, distress • Circulation – cap refill, cool peripheries, tachycardic, hypotension (late sign), murmur (may be flow) • Disability – AVPU, GCS, grizzly • Exposure and ENT – rashes, mottling, lymphadenopathy, tonsils, tongue, TMs, abdomen • Fluid and fontanelle – sunken eyes, skin turgor, mucous membranes, nappies, output • Glucose

  6. Pyrexia: red flags • Persistent (5/7>) • Fever + 4 of: bilateral non-purulent conjunctivitis, cervical lymphadenopathy, membrane changes, erythema/desquamation ?Kawasaki • Meningism (neck pain, photophobia etc) • Joint pain (swelling, erythema, limp) • No obvious focus

  7. Pyrexia : differentials • LRTI, pneumonia, croup, influenza • Tonsillitis, otitis media. • Kawasaki disease • Meningitis • UTI, pyelonephritis • Ostemyelitis, septic arthritis • Wound infections, abscesses • Gastroenteritis • NAI - cerebral bleeds can cause fever, irritablility

  8. Pyrexia : management • Identify and treat cause appropriately i.e admit to hospital if needs investigations, iv abx etc • Simple regular antipyretics • Encourage fluids • Not advised to use cold sponging, fans as increases core temp • (febrile convulsions – the rapid rate of rise not the actual number is the problem, 6/10 recur, slight increase risk epilepsy against background population)

  9. Pyrexia: references • Spotting the sick child - https//www.spottingthesickchild.com/fever/key-bacground-information/facts-and-figures/42 • NICE quick reference guide May 2007 - Feverish illness in children (children under 5) http://www.nice.org.uk/nicemedia/live/11010/30524/30524.pdf

  10. Dyspnoea

  11. Dyspnoea: key history • Age (e.g. <1yr bronchiolitis) • Ex-prem (nicu etc) • Parents definition of respiratory distress • Apnoea, cyanosis • Cough • Pyrexia • Noisy breathing (?new) • Feeding (wet nappies) • Fhx atopy (sleep, play disturbance) • Admissions, steroids, intubated? • If has inhalers, compliant? Also frequency when ill.

  12. Dyspnoea: key exam • ABCDEFG as always! • Alert and interested? Agitation or lethargy • Posture (sitting up) • Speech (if old enough), broken, triggers cough, hoarseness • Noisy breathing – coryza, wheeze, stridor, grunting, strained crying • RR – tachypnoeic (can be normal if periarrest), prolonged exp phase

  13. Dyspnoea: key exam • Respiratory distress – nasal flaring, tracheal tug, recession - supraclavicular, sternal, intercostal and subcostal. Accessory muscle use - head bobbing and abdominal breathing. • Sats & HR – 98-100%, needs O2 if less than 95%, tachycardic (can be normal if periarrest). • Auscultation (not as valuable as small chest so lots of transmitted sounds) wheeze, creps and air entry. • PEFR is appropriate age and mild/mod.

  14. Dyspnoea: red flags • Choking • Apnoea • Status asthmaticus

  15. Dyspnoea: differentials • Bronchiolitis • Asthma • Croup • Pneumonia • Cardiac abnormality • etc

  16. Dyspnoea: management • Depends on cause • if very unwell to hospital e.g needs O2, tiring or poor feeding • Can try 5-10 puffs salbutamol via spacer, if needs more than 4hrly needs admission • If facilities try nebuliser

  17. Video: respiratory distress • https://www.spottingthesickchild.com/symptoms/difficulty-in-breathing/key-background-information/facts-and-figures/25

  18. Dyspnoea: references • Spotting the sick child -https://www.spottingthesickchild.com/symptoms/difficulty-in-breathing/key-background-information/facts-and-figures/25 • British Thoracic Society June 2011 Asthma Management http://www.britthoracic.org.uk/Portals/0/Guideline /AsthmGuidelines/sign101%20June%202011.pdf

  19. RASH

  20. Parent perspective Worry! Likely concerns? “Her bottom’s ever so red!” “His cousin’s had chickenpox and now he’s poorly with these little spots” “Her eczema’s got much worse, all crusty and weepy” “He just had some peanut butter then five minutes later he came out in this rash” “I’ve done the tumbler test!”

  21. GP perspective Common presentation Often benign – viral/fungal/allergic/eczema Approach Is the child sick? Could there be serious underlying disease? Who will manage them, where, when? Likely concerns Meningococcal septicaemia Anaphylaxis Toxic shock syndrome

  22. RASH: key history • General features – fever, rigors, conscious level, irritability, vomiting, breathing difficulty • Feeding, nappies • Evolution and distribution of rash; itchy? • Associated symptoms: headache, photophobia, abdominal pain, joint pain, cough, conjunctivitis • Unwell contacts? Exposure to known allergen? • Recent illness or injury? • Relevant past history – atopy? Food allergy? Immunisations?

  23. RASH: key exam 1. ABCDEFG as always! 2. The rash itself • Distribution • Configuration • Morphology

  24. Meningococcal septicaemia A sick child: lethargic or irritable, feverish, rigors, not feeding, joint pain, tense fontanelles. May not have signs of meningism. Then the rash: • non-specific erythema • petechial • purpuric Then cardiovascular collapse [pictures removed]

  25. Meningococcal disease Neisseria meningitidis 2/100 000 Serogroup B 50% of cases: children <4y 85% of cases septicaemic:15-20% mortality Peak incidence: winter 1-2 cases per GP career

  26. Immediate managementNICE CG102 June 2010 Suspected meningococcal disease: Parenteral abx + urgent transfer - 999 Give IM/IV benzylpenicillin: 300mg (<1y) / 600mg (1-9y) / 1.2g Withhold only if hx of anaphylaxis DO NOT DELAY TRANSFER FOR ABX [Suspected bacterial meningitis without non-blanching rash: Urgent transfer - 999 Parenteral abx only if anticipate significant delay in transfer]

  27. Differentials for purpuric rash A relatively well child has abdominal pain, joint pain and this rash: [pictures removed] What diagnosis are you considering?

  28. Henoch-Schönlein Purpura Immune mediated necrotising vasculitis M>F Peak incidence 3-8y Which obs and bedside tests would you do? BP, urinalysis Admit? Pain management, renal assessment, intussusception

  29. Differentials for purpuric rash A completely well child with a petechial/purpuric rash [picture removed] Investigate? FBC: ?ITP (?leukaemia) Usually acute and transient in children Admit? Refer to paediatrician

  30. Anaphylaxis History of exposure followed by life threatening hypersensitivity response A – angiooedema B – bronchospasm C – circulatory collapse Widespread rash usually present: • urticarial • erythematous • combination

  31. Anaphylaxis:emergency management 999 IM adrenaline 1:1000 0-6y: 150 mcg = 0.15mL 6-12y: 300 mcg = 0.3mL >12y: 500 mcg = 0.5mL

  32. Toxic shock syndrome Unwell child with high fever, diarrhoea, recent hx of minor burn Burn may appear normal Widespread erythematous rash – sunburn like; later desquamates Admit? IV antibiotics

  33. More rashes… Miserable child Prodrome of fever, malaise, arthralgia Painful, itchy skin and mucosal lesions Not drinking Recent mycoplasma infection [pictures removed] Possible diagnosis? Stevens-Johnson Syndrome Admit? May need fluids, antibiotics

  34. More rashes… Irritable child with fever for 5d +… [pictures removed]

  35. Kawasaki Disease Febrile systemic vasculitis 30-70% untreated cases: coronary artery stenosis/aneurysm Risk of myocarditis and MI Admit? May need IV Ig in acute stage Aspirin

  36. RASH: red flags Symptoms/signs suggestive of: • Meningococcal septicaemia • Henoch-Schonlein Purpura • Idiopathic Thrombocytopaenic Purpura • Leukaemia • Anaphylaxis • Toxic shock syndrome • Stevens-Johnson syndrome • Kawasaki disease

  37. RASH: differentials • Viral • Fungal • Eczema • Allergic

  38. RASH: management • Approach • Depends on cause • Seek timely advice, referral or transfer +/- appropriate immediate management

  39. RASH: references • Spotting the Sick Child https://www.spottingthesickchild.com/symptoms/rash/ • NICE clinical guideline CG102 – bacterial meningitis and meningococcal septicaemia (under 16y) June 2010 http://guidance.nice.org.uk/CG102 • GP notebook- http://www.gpnotebook.co.uk/

  40. TIME FOR A QUICK BREW FOLKS!

  41. Abdominal pain

  42. Abdo pain: key history • Acute or chronic • SOCRATES • Vomiting ?bilious • Constipation, diarrhoea, bloody • Eating and drinking, appetite • Fever • Growth, failure to thrive • Disturbed sleep • Stress • Dysuria, frequency and back pain (not useful in young) • Ill contacts, dodgy food, foreign travel

  43. Abdo pain: key exam • ABCDEFG as always! • Pallor • Hydration • Mass (faecal, Wilm’s etc) • Tenderness • Guarding • Bowel sounds • Peritonism • Genitalia, hernia, scrotal oedema • Do NOT do a PR

  44. Abdo pain: red flags Signs of: • Peritonism • Intussuception (‘redcurrent jelly stool’) • Abdominal mass (?Wilm’s tumour) • Torsion of testes • Vomiting bile (?obstruction)

  45. Abdo pain: differentials • Mesenteric adenitis • Appendicitis • Intussuception • Gastoenteritis • Tumour e.g Wilm’s • UTI • Torsion • Hernia • Anxiety

  46. Abdo pain: management • Identify and treat cause appropriately • Simple analgesia • NBM if suspect surgical cause • Explore stress related issues if relevant

  47. Abdo pain: references • Spotting the sick child – https://www.spottingthesickchild.com/symptoms/abdominal-pain/key-background-information/facts-and-figures/87

  48. DEHYDRATION

  49. DEHYDRATION: key history • Vomiting when, bilious, blood, frequency, duration • Diarrhoea ?blood, frequency, duration • Abdominal pain • Polyuria, polydipsia • Systemically well ?drowsy • Intake, normal feeding, output, wet nappies • Weight loss • Ill contacts • Recent foreign travel, dodgy food • Consanguity

  50. DEHYDRATION: key exam • ABCDEFG as always! • Hydration - sunken eyes, sunken fontanelle, reduced skin turgor, reduced output, dry mucous membranes • Cold peripheries, tachycardia, reduced cap refill, hypotension

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