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 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

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

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

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

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)

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

DYSPNOEA

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.

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

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.

DYSPNOEA: RED FLAGS

Choking

Apnoea

Status asthmaticus

DYSPNOEA: DIFFERENTIALS

Bronchiolitis Asthma Croup Pneumonia Cardiac abnormality etc

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

VIDEO: RESPIRATORY DISTRESS https://www.spottingthesickchild.com/

symptoms/difficulty-in-breathing/key-background-information/facts-and-figures/25

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

RASH

Parent perspectiveWorry!

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!”

GP perspectiveCommon presentation

Often benign – viral/fungal/allergic/eczema

ApproachIs the child sick?Could there be serious underlying disease?Who will manage them, where, when?

Likely concernsMeningococcal septicaemiaAnaphylaxisToxic shock syndrome

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?

RASH: KEY EXAM1. ABCDEFG as always!

2. The rash itself Distribution Configuration Morphology

Meningococcal septicaemiaA sick child: lethargic or irritable, feverish, rigors,

not feeding, joint pain, tense fontanelles. May not have signs of meningism.

Then the rash:1. non-specific erythema2. petechial3. purpuric

Then cardiovascular collapse[pictures removed]

Meningococcal diseaseNeisseria meningitidis2/100 000Serogroup B50% of cases: children

<4y85% of cases

septicaemic:15-20% mortality

Peak incidence: winter

1-2 cases per GP career

Presentation of meningococcal disease (%)15

2560

meningitis

septicaemia

both

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 - 999Parenteral abx only if anticipate significant delay in transfer]

Differentials for purpuric rashA relatively well child has abdominal pain,

joint pain and this rash:[pictures removed]

What diagnosis are you considering?

Henoch-Schönlein PurpuraImmune mediated necrotising vasculitisM>FPeak incidence 3-8y

Which obs and bedside tests would you do?

BP, urinalysis

Admit?Pain management, renal assessment,

intussusception

Differentials for purpuric rashA completely well child with a

petechial/purpuric rash[picture removed]Investigate?FBC: ?ITP (?leukaemia)

Usually acute and transient in children

Admit?Refer to paediatrician

AnaphylaxisHistory of exposure followed by life

threatening hypersensitivity response

A – angiooedemaB – bronchospasmC – circulatory collapse

Widespread rash usually present: urticarial erythematous combination

Anaphylaxis:emergency management999

IM adrenaline 1:10000-6y: 150 mcg = 0.15mL6-12y: 300 mcg = 0.3mL>12y: 500 mcg = 0.5mL

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

More rashes…Miserable childProdrome of fever, malaise, arthralgiaPainful, itchy skin and mucosal lesionsNot drinkingRecent mycoplasma infection

[pictures removed]Possible diagnosis?Stevens-Johnson SyndromeAdmit?May need fluids, antibiotics

More rashes…Irritable child with fever for 5d +…

[pictures removed]

Kawasaki DiseaseFebrile systemic vasculitis

30-70% untreated cases: coronary artery stenosis/aneurysm

Risk of myocarditis and MI

Admit?May need IV Ig in acute stageAspirin

RASH: RED FLAGSSymptoms/signs suggestive of:

Meningococcal septicaemia Henoch-Schonlein Purpura Idiopathic Thrombocytopaenic Purpura Leukaemia Anaphylaxis Toxic shock syndrome Stevens-Johnson syndrome Kawasaki disease

RASH: DIFFERENTIALS Viral

Fungal

Eczema

Allergic

RASH: MANAGEMENT Approach

Depends on cause

Seek timely advice, referral or transfer +/- appropriate immediate management

RASH: REFERENCES Spotting the Sick Child

https://www.spottingthesickchild.com/symptoms/rash/

NICE clinical guideline CG102 – bacterial meningitis and meningococcal septicaemia (under 16y) June 2010http://guidance.nice.org.uk/CG102

GP notebook -http://www.gpnotebook.co.uk/

TIME FOR A QUICK BREW FOLKS!

ABDOMINAL PAIN

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

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

ABDO PAIN: RED FLAGS

Signs of:

Peritonism Intussuception (‘redcurrent jelly stool’) Abdominal mass (?Wilm’s tumour) Torsion of testes Vomiting bile (?obstruction)

ABDO PAIN: DIFFERENTIALS Mesenteric adenitis Appendicitis Intussuception Gastoenteritis Tumour e.g Wilm’s UTI Torsion Hernia Anxiety

ABDO PAIN: MANAGEMENT

Identify and treat cause appropriately Simple analgesia NBM if suspect surgical cause Explore stress related issues if relevant

ABDO PAIN: REFERENCES Spotting the sick child –

https://www.spottingthesickchild.com/symptoms/abdominal-pain/key-background-information/facts-and-figures/87

DEHYDRATION

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

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

DEHYDRATION: RED FLAGSSymptoms/signs of:

Pyloric stenosis (projectile vomiting) DKA (urine dip, bm) Hypernatraemic dehydration (neuro signs) (Known) Inborn errors of metabolism (known) chronic disease e.g. CF or have

ileostomy

DEHYDRATION: DIFFERENTIALS Gastroenteritis/gastritis e.g. Rotavirus UTI URTI Abdominal obstruction DKA Poor feeding technique Pyloric stenosis Refusal e.g tonsillitis Inborn errors of metabolism

VIDEO: DEHYDRATION SIGNS https://www.spottingthesickchild.com/

symptoms/dehydration/key-background-information/facts-and-figures/81

DEHYDRATION: MANAGEMENT Identify and treat cause.

If refusal e.g. secondary to tonsillitis, simple analgesia or difflam may be sufficient to encourage.

Fluid challenge (diaraloyte, use syringe and record), if fails, admit for ng/iv fluids

If DKA or metabolic condition, send A+E urgently as will need senior input

DEHYDRATION: REFERENCES http://guidance.nice.org.uk/CG84

Spotting the sick child –https://www.spottingthesickchild.com/symptoms/dehydration/key-background-information/facts-and-figures/81

HEAD INJURY

Parent perspectiveWorry!Guilty…

Reasons for attending

“he’s got a cut (big bump) on his head”“she whacked it really hard”“he was knocked out”“she’s not been right since it happened”

GP perspectiveCommon presentation to CED300 000 CED attendances per yearMay or may not come via GPGP may have bigger role in after care

Likely concernsDiffuse axonal injuryIntracranial haemorrhageSkull fracturesVigilance for possible non-accidental

injury

HEAD INJURY: KEY HISTORY Witness account if possible

Mechanism of injury: forces, height, surface, helmet;beware falls, RTAs

LOC/amnesia

Seizure

Change in behaviour

Drowsiness/agitation

Headache

Vomiting

NAI risk factorsImplausible MOI/vague hx/eye & ear injuries

HEAD INJURY: KEY EXAM AVPU/GCS

General behaviour –quiet vs persistently drowsy; upset vs irritable

Focal neurology – pupil abnormalities, limb weakness.

Scalp:signs of skull fractureboggy haematoma, skull depression, Battle’s sign, panda eyes, bulging fontanelle, CSF otorhinorrhoea, haemotympanum

superficial wounds

Full exposure especially if concerned re NAI

HEAD INJURY: RED FLAGS Witnessed loss of consciousness > 5 mins

Amnesia (antegrade or retrograde) > 5 mins

Abnormal drowsiness

3 or more discrete episodes of vomiting

Clinical suspicion of NAI

Post-traumatic seizure but no history of epilepsy

Age > 1 year: GCS < 14 Age < 1 year: GCS (paediatric) < 15

Suspect open/depressed skull or tense fontanelle

Any sign of basal skull fracture

Focal neurological deficit

Age < 1 year: bruise, swelling or laceration > 5 cm

Dangerous mechanism (high-speed RTA, fall from > 3 m, high-speed injury from projectile or an object)

Any one of these in a child is an indication for a CT head

(NICE CG56, September 2007)

HEAD INJURY: MANAGEMENT Simple analgesia if indicated

If any red flags: CED; consider 999 + NBM

If well but concerned re NAI: refer to paediatrics

Close & dress wounds if competent and if confident the injury is non-significant

Safety netting, written advice if sending home

HEAD INJURY: REFERENCES NICE clinical guideline CG56 - Head Injury

September 2007http://guidance.nice.org.uk/CG56

Spotting the sick child -https://www.spottingthesickchild.com/symptoms/head - injury/