Block 10 (GNK 481) Website : Mbchb IV (2006)

Block 10 (GNK 481) wEBSITE : MBChB IV (2006)

LEARNING THEMES AND OUTCOMES

Week 1

Week 2

Week 1: Evaluation of the sick child

1.1Outcome Indicators

1.2 Learning Themes

1.2.1 The patient/family interview and clinical examination

• Making an early diagnosis of treatable conditions
• Assessing physical, intellectual and emotional normality
• Identifying children who are especially at risk
• Appropriate counselling of parents

1.2.2 What is normal and healthy in childhood?

• Age-related normal values of vital signs
• Normality of growth and development

1.2.3Integrated Management of Childhood Illness

• Evaluating the degree of illness for appropriate management
• Triage for treatment or referral

1.2.4Sudden infant death syndrome, Cardiac arrest

• Categories

Life-threatening condition present, death unexpected at this time

Medical condition present, death unexpected

Medical condition unrecognised, found at autopsy

No disorder/disease known or found

• Risk factors for SIDS
• Supporting the family and facing the problem
• Medico-legal implications

1.4.5The ill child

• Subjective evaluation

Appearance and facial expression

Reactions and behaviour

Skin colour and feel

Mother’s opinion

• Objective measurements

Vital signs

Temperature

Fluid balance

• Signs of organ system dysfunction

Chronic

Acute

• Scoring systems

Paediatric Coma scale

1.4.6Manifestations of disease in infancy and childhood

The unconscious child

• The convulsing child

The cyanosed child

• The oedematous child

The short child/ Child with poor growth

• The child who is not thriving

The pale child

1.2.7The chronically ill child

Diagnostic evaluation

Impact of chronic disease on child and family

1.2.8 The role of the laboratory in evaluation

Diagnosis or support

Function, pathology, aetiology

Results for action

True, valid, significant?

Screening

1.3Case Studies

Case Study 1

You are the medical officer on duty at the local hospital, when a 4-year-old child is brought in unconscious at about noon.

The mother is in a highly agitated state, unable to give a coherent account.

It appears the child seemed to be well and was sent to the pre-school centre in the morning. When he came home, he seemed to be unduly quiet, and soon after was found unconscious in an adjoining room.

This is the first time something like this has happened. Mother does not know whether the child could have experienced trauma, a convulsion; whether he is ill or whether he could have been poisoned.

QUESTIONS

(a)What questions should be asked to the caregiver in a case of unexplained coma?

(b)What are the possible causes of sudden onset coma?

(c)List the important positive and negative features to identify on clinical examination in a case of coma.

(d)List the important sideroom and laboratory blood tests to do in a case of sudden coma?

(e)List the important monitoring procedures to perform in a case of coma?

RESOURCES

Coovadia & Wittenberg 4th ed: 473 - 477

Coovadia & Wittenberg: 5th ed: 485 - 489

Case Study 2

HM is an 11 year old boy who has been referred with the problem of chronic cough and blocked nose.

Since the age of 5 years old he has had this problem of coughing mainly at night and in the early hours of the morning. He also wakes up feeling short of breath and wheezes. His cough is brought on by exercise like running and by cold weather.

He also has a blocked nose, which he rubs often. He has a clear nasal discharge. His mother complains that he snores at night. He does not have hayfever.

On examination he is an unhappy looking boy with a long face and dark rings under his eyes. His nose is blocked completely and he has a transverse crease over the bridge of the nose.

His respiratory rate is a little fast at 18 per minute with somewhat prolonged expiration. He appears to have an increased antero-posterior diameter of his chest. The upper border of the liver is percussed below the 6th rib. The sternum is also resonant to percussion. Auscultation reveals no abnormal findings.

His mother is very worried about the possibility of serious disease, and also his lack of sleep. He is always tired and as a result is not doing well at school.

QUESTIONS

(a)What are the causes of cough?

(b)List the features of asthma

(c)What are the management steps in asthma?

(d)List the issues of concern to the family in cases of chronic disease in childhood

(e)List the issues of concern to the child who is suffering from a chronic disease

RESOURCES

Coovadia & Wittenberg 4th ed: 369 - 377

Coovadia & Wittenberg 5th ed: 377 - 384

Case Study 3

A seven-year-old boy is admitted three times within six months because of a problem of generalised body swelling.

No detailed history is available because he was transferred from another hospital. However, he does have a vague story of abdominal symptoms at some stage, including loose bloodstained stools. More recently he has had both abdominal discomfort and respiratory complaints including breathlessness and cough.

On examination he weighs 19.5kg and is 107cm tall. There is generalised pitting oedema. He is pale and breathing too fast. He has gross abdominal distension. His blood pressure is 120/60 and his pulse rate is 90/ min.

Urine dipstix shows no blood or protein, pH 6.

The serum biochemistry shows the following :

Na 140 mmol/l

K 2.8 mmol/l

Cl 106 mmol/l

CO2 28.4 mmol/l

Urea 0.7 mmol/l

Creatinine 35 µmol/l

Total protein 31.5 g/l

Albumin 16 g/l

Total cholesterol 1.9 mmol/l

QUESTIONS

(a)What are the causes of oedema?

(b)Are there clinical pointers to the mechanisms of oedema, which can be identified on examination?

(c)List the pointers to aetiology on history and clinical examination of a case of oedema?

(d)What sideroom tests are required in the diagnosis of a case of oedema?

(e)What blood tests are helpful in cases of oedema?

RESOURCES

Coovadia & Wittenberg 4th ed: 201; 275; 437

Coovadia & Wittenberg 5th ed: 196; 444; 528

Case Study 4

This 15-month-old little boy is brought to the doctor because his mother worries that he is not growing well or gaining weight satisfactorily .

His birth weight was only 2.3kg, but there was nothing wrong with him and he has not been ill. However at every visit to the clinic the sister has remarked on him being so small.

Mother thinks he must be getting enough because he rarely finishes his food. She has been advised to let him get hungry before feeds, this means that he is fed only 2 – 3 times per day. He enjoys drinking water.

QUESTIONS:

(a)What information is required regarding this child’s low birth weight and why?

(b)What information is required regarding this child’s poor appetite and why?

(c)What further information is required regarding this child’s food intake and why?

(d)What information is required regarding this child’s development and why?

(e)What information is required regarding the clinical features on examination and why?

(f)List the causes of a poor appetite in a baby?

(g)What features would reassure one that a poor appetite is not a serious problem?

RESOURCES

Coovadia & Wittenberg 4th ed: 105 – 106; 165 – 188

Coovadia & Wittenberg 5th ed: 119 – 126; 175 - 193

WEEK 2: FEEDING AND NUTRITION IN HEALTH AND DISEASE

2.1Outcome Indicators

Specific outcomes

Knowledge

L

Skill

L

Assessment

Normal nutritional requirements for growth and health at different ages

4

Obtain nutritional history

Physical examination

4

4

OSCE

2.2 Learning Themes

2.2.1 Normal feeds and feeding at different ages

Normal nutritional requirements (age-dependent)

Daily requirements RDA

Biological role of nutrients

Composition, quantity and frequency of feeds

Normal and healthy feeding at different ages

2.2.2 Risks of nutritional excess

Obesity

Vitamin toxicity

2.2.3 Clinical assessment of nutritional state

Dietary recall

Clinical evaluation

Laboratory evaluation

2.2.4 Iron deficiency

Pathophysiology and clinical features

Prevention

Management

2.2.5 Nutritional deficiency

Community perspectives on nutrition

Failure to thrive

Dietary advice and rehabilitation

Clinical syndromes of PEM

Clinical features of deficiency diseases

Prevention, diagnosis and management of nutritional deficiency

2.2.6 Maintenance of nutrition in disease

Needs and challenges

Special circumstances

Kidney diseaseLiver disease

Gut disease Heart disease

Cystic fibrosisCancer

2.3 Case Studies

Case Study 5

Miss A and her 8 month old baby Anna have recently moved to a flat in the city. She has now come to seek advice on feeding her baby.

Anna was born in a small rural town and immediately started on a whey-predominant starter formula, which Miss A’s mother bought for her. At approximately 4 months of age a baby cereal was added to the diet.

While Anna has been growing well so far. Miss A wants information on the following questions:

-Is the starter milk formula still the right milk to give to Anna, and how much must she give her in view of the price of the formula?

-Can she let Anna drink rooibos tea?

-Can she also give her other food, like “Purity”, and when could she give ordinary table food?

-How would Miss A know that she is giving the right kind and quantity of food?

-What about tonics?

QUESTIONS

(a)What is the difference between the different baby milk formulae on the market?

(b)How much milk should a baby drink at different ages?

(c)What is a balanced weaning diet?

(d)What are the nutritional requirements at different ages?

(e)What are the advantages and disadvantages of feeding an 8 month old baby the formula or juice by bottle rather than by any other way?

(f)What is the role of multivitamins and other tonics in infant and young child feeding in health and disease?

RESOURCES

Coovadia & Wittenberg 4th ed: 165 – 187; 191 – 192

Coovadia & Wittenberg 5th ed: 175 – 193; 198 - 199

Wittenberg DF. Bottle-feeding: practical issues

Case Study 6

JM, a 10 month old boy, is taken to hospital by his grandmother because he has started to swell up over the past week or so. He has also developed a rash which involves his nappy area, behind his knees and along the outer side of his lower limbs. The rash in the nappy area is peeling off, leaving pink exposed skin underneath. The affected skin on his legs is dark, dry and cracking. On his lower abdomen there are darkly pigmented spots. His mouth is sore with the lips and mouth angles being raw and ulcerated.

Grandmother has been looking after him since his mother disappeared about 2 months ago. She has only an old age pension to pay for the upkeep of herself and 5 other people in her house. The diet consists of mealie meal porridge with a little sugar. At first, JM was just miserable, but 2 weeks ago he started to cough. He also has loose stools.

QUESTIONS

(a) What are the clinical features of the different forms of protein-energy malnutrition?

(b)What are the physiological effects of protein-energy malnutrition ?

(c)What is the reason for different clinical forms of nutritional deficiency disease?

(d)How does the body adapt to nutritional deficiency?

(e)How is protein-energy malnutrition diagnosed?

(f)What is the pathogenesis of kwashiorkor?

(g)What other deficiencies does the diet described in case study 6 lead to?

(h)Why is kwashiorkor also called “infantile pellagra”?

(i)How should clinical protein-energy malnutrition be managed?

(j)Why do patients with kwashiorkor usually not show clinical signs of rickets?

RESOURCES

Coovadia & Wittenberg 4th ed: 188 – 214; 215 - 228

Coovadia & Wittenberg 5th ed: 194 – 218; 219 - 231

Case Study 7

Tiny is 7 years old and has been referred by the school nurse because of excessive obesity.

Her present weight is 67 kg, approximately 40 kg more than average.

She has always been overweight. This started when she was a baby and mother fed her by bottle. Because of a number of reasons, mother gave her a bottle whenever she was crying. She got into the habit of wanting to eat whenever she experienced any kind of stress. This has recently got worse at school where she is teased because of her size. Her response is to withdraw into a corner and eat.

She has not been ill. On examination, no abnormal findings are noted apart from obesity.

QUESTIONS

(a)What are the risks of obesity?

(b)Will an obese child grow up to be an obese adult?

(c)List the causes of obesity?

(d)How is pathological obesity (ie not due to environmental/social/emotional factors) recognized?

(e)How should obesity in childhood be managed?

RESOURCES

Coovadia & Wittenberg 4th ed: 211 – 214; 215 - 228

Coovadia & Wittenberg 5th ed: 216 – 218; 219 - 231

Case Study 8

Peter S, a 15 month old boy, is referred by the creche care-giver because he is very pale. He has also become listless and tired. He has been seen to eat sand in the playground.

When he was much smaller, his mother was told that milk is the best food for babies. As he grew, she continued to give him milk in large quantities. At present, he drinks at least 1 litre of dairy milk per day. For the rest, his diet consists mainly of cereals, biscuits and some bread.

QUESTIONS

(a)What are the different types of anaemia caused by dietary deficiency?

(b)Apart from deficient intake, what other conditions cause nutrient deficiency anaemia?

(c)How is the diagnosis made of the various deficiency anaemias?

(d)What advice should be given regarding the prevention and treatment of deficiency anaemia?

(e)What are the non-haematological effects of iron deficiency?

RESOURCES

Coovadia & Wittenberg 4th ed: 206; 411 - 414

Coovadia & Wittenberg 5th ed: 210; 419 – 422

WEEK 3:PSYCHOSOCIAL PAEDIATRICS

3.3Outcome Indicators

Assessment

3.2 Learning Themes