Common Paediatric Problems General approach to Management.
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Transcript of Common Paediatric Problems General approach to Management.
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Common Paediatric ProblemsCommon Paediatric Problems
General approach to Management
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The common problemsThe common problems
(1). URTI symptoms: URTI, chest infection
asthmatic attack
(2). Abdominal pain: GE, gastritis
(3). Fever: UTI, febrile convulsion
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Febrile ConvulsionFebrile Convulsion
Def.: Seizure associated with fever in the absence of another cause, & not due to intracranial infection
3-4% of children (genetic predisposition) ; 6 months – 3 years
Rare after 6 years of age
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Febrile Convulsion--Febrile Convulsion--presentationpresentation
At peak of Fever/ sudden rise of temp.Occurs early in viral illnessGeneralized tonic-clonicUsu. Brief (1-2 mins, <10mins)No post-ictal drowsinessNo neurological signsOccur once within 24hr period
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PrognosisPrognosis
“Benign”
(1). Development of epilepsy
-- 2-4% develop epilepsy by 7 y.o
--7% develop epilepsy up to 25 y.o.
(2). Recurrence
--30% after 1st episode
--50-70% after 2nd
80% after 3rd
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Risk Factors of subsequent Risk Factors of subsequent epilepsyepilepsy
(1) Prolonged seizure in 1st episode (>30m)(2). Seizure is focal(3). Seizure recurs in same illness(4). Family Hx. of 1st degree relative with e
pilepsy/ >5 febrile convulsions(5). Prior abnormal developmental status 3x
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ManagementManagement
--To rule out other causes of seizure(infection screen) --To keep temperature low: remove warm clothing
+ tepid sponging --Antipyretics e.g paracetamol --Diazepam suppositories for any seizure > 5mins
--Reassurance to parents + education for 1st aid management
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Childhood FeverChildhood Fever
Def. :>37.4 C (oral or armpit); >37.8 (rectal)Rectal temp not always desirableHigh fever: caution in
– neonates: “Sepsis until proven otherwise”– <2yrs: beware of bacteremia/septicemia/mening
itis
*Margin of safety lower the younger the child
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Evaluate fever < 2y.oEvaluate fever < 2y.o
Immediate purpose: identify <sepsis??>DDx: URTI 60-70% of casesGE/ UTI next commonOther rare causes:Osteomyelitis/ arthritis/ meningitisConnective tissue disease/malignancy
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History & P/EHistory & P/E
Most accurate (?sepsis) : from observationPlayfulnessAlertness: drowsy/ irritableConsolability + nature of crying: high pitch?Motor activityFeeding: vomiting/nauseated
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P/EP/E
Hydration status
Periphery: cold/clammy?
Respiration: distress in pneumonia, metabolic acidosis, sepsis
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Ix Ix
In all patient with fever < 6 months:Extensive investigation needed for focusMinimally:WCC + diff.Blood C/STUrinalysis for C/ST, R/M (SPA /cath)Consider LP in most cases (if no CI)
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Urinary tract InfectionUrinary tract Infection
<11 y.o: 1% boys/ 3% girls (symptomatic)2 main principals of Mx:(1). Halt the complications(2). Thorough assessment & Ix after 1st epis
ode as:– >1/2 have structural abnormality– UTIscarHTCRF if scar bilateral
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Clinical featuresClinical features
Infancy –non-specific Fever; Lethargy/irritability Vomiting/diarrhea Poor feeding/failure to thrive Prolonged neonatal jaundice Septicemia Febrile convulsion (>6 months)
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Reminders…Reminders…
(1). As age increases, symptoms become more specific
(2). Dysuria without fever vulvitis in girls or balanitis in boys
(3). Social Hx. To be explored for ?sexual abuse
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Urine sample collectionUrine sample collection
Child in nappies:(1). Clean catch(2). Adhesive plastic bag applied to
perineum(3). SPA (preferred in severely ill infant
<1y.o. OR contaminated previous sample)(4). Bag urine in low index of suspicion
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?Reliance on microscopy or ?Reliance on microscopy or dipsticks?dipsticks?
If both +ve => treatBoth-ve but clinical s/s highly suggestive=>
treatIf microscopy shows equivocal result + dips
tick +ve for WCC/esterase/nitrite + clinical condition likely UTI => treat
If microscopy shows organism in addition to white cells => treat
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Simple measures to prevent Simple measures to prevent recurrencerecurrence
High fluid intake->high urine outputRegular voidingComplete bladder emptying (double micturi
tion) to empty residual urineMx of constipationGood perineal hygiene
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Follow-up in recurrent UTIs + rFollow-up in recurrent UTIs + renal scarringenal scarring
Routine Urine culture every 3-4 monthsBlood pressureLong term low dose antibiotic prophylaxis:
Trimethoprim (2mg/kg nocte) +/- nitrofurantoin +/- nalidixic acid
Regular assessment of renal function
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Typical Ix protocol for 1Typical Ix protocol for 1stst episode UTIepisode UTI
US +/- AXRGive prophylactic antibiotics until ALL Ix
completedAge: <1y.o: DMSA+MCUG 1-5 y.o: DMSA >5y.o: only if abnormal USGDMSA
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Subsequent need for cystograSubsequent need for cystogramm
Abnormal DMSAAbnormal USGAcute pyelonephritisFamily Hx of refluxUnexplained Recurrent UTI