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Symptom complexes in paediatrics (Children with swollen joints: History …
Symptom complexes in paediatrics
Child with a rash
Dermatologic lesions in children
Congenital
Neonatal
Medical history
duration, progression, variation
exposition
fever
pruritus
Concomitant disease
rheumatological
neurological
Rash cousing childhood disease:
Measles
Scarlet fever
Rubella
Duke's disase
Fifth disease (erythema infectiosum, parvovirus)
Roseola (examthema subitum)
Itchy skin conditions:
Atopic eczema
Chickenpox
Urticaria/allergic reactions
Contact dermatitis
Insect bites/papular urticaria
Scabies
Fungal infections
Pityriasis rosea
Atopic dermatitis:
Petechial, purpuric:
Bacterial
Meningococcal
Other bacterial sepsis
Infective endocarditis
Viral
Enterovirus
Other
Henoch schönlein purpura, HSP
Thrombocytopenia
Vasculitis
Malaria
Vesicular, bullous, pustular:
Viral:
VZV - chichenpox, shingles
HSV
Coxsackie - hand, foot and mounth
Bacterial:
Impetigo - Characteristic crusting
Boils - infection of hair follicle/sweat glands
Stafylococcal bullone impetigo
Staphylococcal scalded skin<
Toxic epidermal necrolysis
Other:
Erythema multiforme
Stevens-Johnsons syndrome
Maculopapular rash
Viral:
Roseola infants
Enteroviral rash
Parvovirus (slapped cheeks)
Measles
Rubella
Bacterial:
Scarlet fever (A- strep),
Erythema marginatum (rheumatic fever)
Salmonella typhi (rose spots)
Lyme disease - eryhtema migrant
Other: Kawasaki disase, JIA
Children with swollen joints:
History
How:
Came by itself
Woke up one morning
Related to infection
History of trauma
Diurnal variation?
Morning stiffness
Day-to-day variation
Pain
Any changes observed
Swelling
warm
Redness
(reactive arthritis, seotic arthritis, familial meditarranian fewer (FMF), systemic JIA
Functional changes? (high degree of adoptability)
Disability
Contractures
Blood tests:
SR, CRP, Hb, Leukocytes, throbocytes, ANA, IgM-RF, HLA-B27, Renal function parameters, Liver function parameters, IgG, IgA, IgM, Yersinia, Borrelia, Streptocuccus, parvovirus.
Radiograph if tumor or trauma suspicion
Diff. diagnosis:
Growing pain (nocturnal recurrent idiopathic pain syndrome)
very common!
occurs evenings/nights
Short lasting
Knees, calfes, pretibial
No clinical findings, normal x-ray/ultrasound
Paracetamol effectve
Coxitis/hipsynovitis
Osteomyelitis
Tests:
Blood tests:
Haematology, CRP, ESR, Blood culture
Biopsy: Bacterail culture, histology
MRI-scan: High sensitivity 90-100%
Bone scan (Tc-scan): (Problem: growth zones)
X-ray: elevation of periost after 10-20 days.
Symptoms:
Age dependent
Slow onset < 2 weeks
fever, poor general condition, sepsis
Local changes: swelling, heat, tenderness, erythema
reduced movement of affected limb
osteomyelitis of the spine often with vague symptoms.
JIA
Other
Sarcoidosis, cystic fibrosis, FMF
Haematological disease
Haemophila, thalassemia, sikcle cell disease
Malignant diagnosis
Leukaemia, bone tumors, neuroblastoma
Vasculitis
Henoch schönlein purpura, Kawasaki dis., Granulomatosis, with polyangisitis (wegener), Polyartheritis nodosa.
Autoimmune disease
SLE, Juvenile dermatomyositis, MCTD
Orthopaedic disease
Calvé-Perthe´s dis., epiphysiolysis, osteochondritis
PostInfectious arthritis
Strep. pyog., enteropathogenic
Infectiois arthritis
S. aureus, Heam infl., Borrelia, Parvovirus, Rubella
Children with anemia:
MCV and HgB are important.
Large MCV might indicate -> b12 deficiency
Small MCV might indicate -> Hgb deficiency (iron, protein)
Reticulocytes should be heigh in anemic pt.
Symptoms:
Surprisingly unaffected
Paleness may be neglected, also by parents
Tired, Dyspnea, Tachycardia, loose of appetite, irritability, systolic murmur.
Approach:
History and physical examination
A minimal set of blood values:
HgB, MCV, reticulocytes, platelets, WBC (leucocytes) with differential count
Additional tests:
Ferritin - iron stores
iron deficiency: first low feritin, then low MCV and MCHC and only with depleted stores low Hb and increased transferrin
s- iron unreliable
Hemolysis-tests
reticulocytes
Billirubin, LDH, haptoglobin, Coombs test
-Hb type (Hb fractioning)
Bone marrow examination
unexplained bi- or pancytopenia
Blood transfusion:
Why is the child anemic?
Only exceptionally in case of anemia of unkniwn cause:
Indication: marked symptoms (Hb<3 mmol/L)
Ensure all samples for diagnostics
E-transfusion: 15 ml /kg
Cause:
Iron deficiency (10-20% of 6 mo - 2 yr old children in DK)
Newborn does not have iron deficiency.
Anemia is a late sign of deficiency
Always low MCV, often low MCHC, relatively few reticulocytes, normal WBC, normal or increased platelets.
Ferritin always low (obs. increases during infections)
Infection associated anemia (moderate decrease in Hb 1-2 weeks after the illness)
Chronic diseases (autoimmune, infections)
Hemolytic anemia
Many different
Spherocytosis:
Dominant autosomal inherited
Spectrin defect
neonatal hemolysis
Plenomegaly
Diag: Fam. history, MCHC, reticulocytes, EMA binding test.
Treatment: observation, folic acid, transfusion, splenectomy.
Parvovirus may disclose chronic hemolysis.
20 % of pregnant women with parvovirus infection will transmit the virus to the fetus
Most fetusses survive wthout seq.
A few develop hydrops fetals
Commen in other countries:
erythrocyte enzyme defects and hemoglobinopathies
Thalassemia, sickle cell
Glucose-6-phosphatase dehydrogenase deficiency
Megalo blastic anemia.
Deficiency of vitamin B12 or folic acid extremely rare in children.
Vomiting and diarrhea in Children
Dehydration:
Physical examination:
comparison of patients weight before and after onset of illness (most important)
GCS
Hydration status:
Sunken frontanelle
Eyes sunken and tearless (important!)
Dry mucous membrane
Prolonged capillary refill time
-Reduced skin turgor
tachycardia, tachypnea
Dehydration in children Management
assess the severity of dehydration
rehydrate accordingly
correct electrolyte imbalance
Encourage oral intake
Treat according to the underlying cause
FLuid therepy:
Defecit
Loss
Maintenance
Initial management
oral if possible
IV saline (NaCl), isotonic, until blood chemistry
Secere dehydration 20 ml NaCl/kg the first Hour.
Diarrhea:
Description:
Bristol stool chart
Frequency x per day
Volume (normal 5-10g/kg/day)
Watery
Color
Blood/mucus
Normal: major variability
Chronic diarrhea > 14 days.
Etiology:
Gastroenteritis:
Virus (70-80 %)
Rota, noro, adeno, astrovirus
Bacteria: (< 20 %)
Most severe
Protozoan (rare)
Symptomatic (UTI, Resp, CNS infection, sepsis)
Surgical conditions (appendicitis, intussusception)
Food intolerance/allergy
Antibiotics
(constipation)
History:
same as for vomiting
Chronic Diarrhea:
Etiology:
Inflammatory bowel disease
Pancreas dysfunction (cystic fibrosis)
Psot infection
Food intolerance/allergy
Toddlers diarrhea
Medication (antibiotics)
Constipation
Celia disease:
Gluten intolerance
reversible mucsa damage
malabsorption
Distended abdomen, thin extremities
The major risk factor for celiac disease later in life is the HLA type (HLA-DQ2)
Diagnosis:
Transglutaminase antibody (IgA)
Biopsy from the small intestine
Diet
Acute diarrhea:
Intussusception:
Can be treated with surgery!
Rotavirus:
Leading cause of hospitalization for diarrhea in children
Most prevalent during winter season
Fecal-oral transmission, viral shedding can persist for 21 days
Acute onset of fewer followed by watery diarrhea, can persist up to a week
Vacc. in many countries but not DK
Vomiting
:
History:
age
Duration/frequency/volume
Onset
Association with food intake
Nature (projectile/explosive)
Color and content (food items, blood, bile, fecal material
Associated symptoms: Fever, pain, diarrhea, constipation, dysphagia
Birth history
Respiratory: cough, chest discomfort
Urinary: dysuria, hematuria
CNS: Irritability. drowsy, nech stiffness, headache
Medical history: neurologic, metabolic disease
Drug and allergy history
Nutritional history: change in food items e.g. milk
Other relevant history: travelling, family or freinds history
Infantile hypertrophic Pyloric stenosis (IHPS):
3 in 1000 live births
male: female, 4:1
Presentation/Symptoms:
presentation in the 3-6 week-old baby develops postprandial, non-bilious, often projectile vomiting. Demands to be re-fed = hungry vomiter
Palpable "olive like" mass at the lateral edge of the rectus abdominus muscle in the upper quadrant of the abdomen
The pt. eventually get emaciated and dehydrated
Labratory: hypochloremic, metabolic alkalosis resulting from the loss of gastric hydrocloric acid
Retention of food in the stomach
The diagnosis is supported by Ultra sound
Febrile illness in Children
Abdominal pain
:
Ask: Pain characteristics:
Onset, Progression, Migration, Character, Intensity and Localization.
Referred pain:
Phrenic nerve: Diaphragm distension -> pain in supraclavicular fossa.
Obturator: Hernia -> medial aspect of the thigh to the knee.
Genitofemoral: retroperitoneal irritation -> pain in testicle/labia/penis.
Accompanuing symptoms:
Nausea, vomiting, abdominal distension, Diarrhea, Constipation, Change i stools, Chills, Fever, urinary frequency, Hematuria, Jaundice
Physical excamination:
Observation
Full physical examination
Palpation/auscultation of abdomen
Direct/indirect, Tenderness, McBurney, Diffuse, Defence, Peritoneal. Bowel sounds (metallic, absent, frequent)
Digital rectal examination
Pain, bleeding
Inspection of genital region:
Hernia, Testicle torsion.
Paraclinic/investigation: ?
Functional abdominal pain:
Constipation:
Lactose intolerance:
Appendicitis:
Abdominal migraine:
Gastroenteritis:
Intussusception:
Celiac disase
:
