Review OSCE Cases PDF

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Summary

Revision of basic paediatrics ailments are what the mains points and referral points...

Description

RTS Paediatrics Common childhood ailments: 1. Fever 2. Chicken pox 3. Headlice 4. Oral thrush 5. Nappy rash 6. Colic 7. Threadworm

Management for ailments 1. Fever   

Fluid: Prevent dehydration. Happens more rapidly in children Appropriately dressed for surroundings Antipyretics

Paracetamol & Ibuprofen 

Not used together. If still distressed before next dose is due try the other.



Paracetamol >2 months (page 4)



Ibuprofen >3 months (page 9)

*Fever may be a symptom of meningitis, to eliminate meningitis, ask about the following symptoms; tense or bulging soft spot on the head, high temperature, breathing fast/ difficulty breathing, cold hands and feet, blotchy skin (getting paler or turning blue), pin prick rash, extreme shivering.

2. Chicken Pox

 Highly contagious, common illness that mainly affects children. o Caused by varicella zoster virus. o Itchy, spotty rash. o Symptoms appear 1 to 3 weeks after becoming infected. o Main symptoms; EARLY SYMPTOMS: fatigue, high temp, nausea, headache, aching muscles, loss of appetite. (not universal – older children and adults) SPOTS – red raised spots develop on the face or chest before spreading to other parts of the body. BLISTERS – over the next few hours, very itchy fluid filled blisters develop on top of the spots. SCABS & CRUSTS – after a further few days the blisters dry out and scab over to form a crust. The crusts then gradually fall off by themselves over the next week or two.

Treatment o

Management options include painkillers, antipyretics and antipruritics.

o

Painkillers and Antipyretics

Paracetamol NOT IBUPROFEN: Due to increased risk of secondary bacterial skin complications. Lotions and creams  

Calamine (Antipruritic) Cooling gels

Antihistamines 

Chlorphenamine (Piriton)

3.Headlice DRY COMBING 1. Straighten and untangle dry hair using normal comb. 2. Switch to a detection comb. 3. Starting form back of head, comb the scalp from the scalp down to the end of the hair. 4. After each stroke examine the comb for live lice. 5. Continue to comb all hair in sections until the whole head has been combed. 6. The process can take 5 mins or more in people with shoulder length hair.

WET COMBING 1. Wash hair with normal shampoo. 2. Apply hair conditioner. 3. Repeat steps 1-5 as for dry combing. 4. Rinse out the conditioner.

*Wet combing is more time consuming and should be performed for all family members. *

Treatment Options Over 6 months: Permethrin, Dimeticone, Malathion Over 2 years: Isopropyl myristate

4. Oral Thrush Potential causes; recent antibiotics use/ recent course of antibiotics used by mothers, immature immune system, steroid inhaler use, inhaled corticosteroids 

Typically, patients present with patches that are irregular and vary in size that are difficult to remove



Usually causes some pain



Often effects tongue and cheeks



It is unusual in otherwise healthy adults – a healthy adult with no risk factors requires referral



Treatment (over 4 months) is with Daktarin.



4-24 months 1.25ml QDS (four times a day) after meals.



Adult risk factors: Diabetes Dry mouth Immunocompromised Ill-fitting dentures Recent antibiotics Inhaled corticosteroids

2 yrs+ 2.5ml QDS

5.Nappy Rash Preventative measures: 

Change wet/dirty nappies ASAP.

 Clean whole nappy area gently, wiping from front to back, using water or fragrance free and alcohol-free baby wipes.  Bath baby daily – not more than twice a day as may cause skin to dry out.  Dry baby gently after washing.  Leave nappy off for as long an as often as possible to let fresh air get to the skin.  Do not use soap, bubble bath or lotions.  Do not use talcum powder as it can irritate babies skin. Preventative measures:

o o o

Leave nappy off as long as possible each day Avoid using soaps for cleaning Change nappies as soon as they have been soiled

 

Treatment: Apply barrier cream – after each nappy change Eliminate infection – clotrimazole

6.Colic

Conditions to eliminate Acute infection – fever, no history of excessive crying Intolerance to cow’s milk protein – not as common as people think Gastro-oesophageal reflux disease – regurgitation >5x per day, failure to gain weight, refusal to feed

Treatment/Management of colic   

Holding baby during crying episodes. Sitting or holding upright during feeding. Use fast-flow teat if breastfeeding – holes in bottles that are too small may cause baby to swallow air as they feed.



Burping baby after feeds.

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Don’t drink too much tea, coffee and other caffeine drinks if breastfeeding.

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Avoid overstimulation of baby by continually picking them up and putting them down.

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Babies like movement e.g gentle rocking over the shoulder.



Background noise e.g. white noise may be soothing.

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Gentle stomach or back rubs or a warm bath may help.

Treatment:

None have a credible evidence base however parents generally want to give something a try. Lactase enzymes - Colief Simeticone - Infacol

7.Threadworm o

More common in school and pre-school children but still can infect adults

o

Transmitted most commonly by the faecal-oral route; eggs get lodged under finger nails

o

Eggs are very hardy and can easily be transferred to clothing, bed linen etc resulting in dust-borne infection

o

Clinical features:  Night-time perianal itching caused by mucus produced by females when laying eggs  Can range from local ‘tickling’ sensation to acute pain

o

Conditions to eliminate:  Other worm infections: round- and tape- worm infections usually contracted by adults visiting poor and developing countries  Contact irritant dermatitis: no recent history of infection, no visible signs of worms in faeces

Treatment Hygiene measures: (lifespan of threadworm approx 6 weeks) Strict attention to hygiene needed Nails kept short and clean Careful hand washing and nail scrubbing prior to meals and after each visit to the toilet Wash bed linen regularly – ideally every day Don’t share towels Underwear underneath night clothes Shower daily immediately on rising Damp dusting and daily vacuuming

Mebendazole for > 2years – whole family should be treated! Repeated dose after 14 days if re-infection suspected

Antihistamines OTC Medicines used to treat; o

allergies

o

reactions to insect bites or stings

o

motion sickness

o

nausea related to migraine

o

short term treatment for sleeping difficulties.

Usually divided into two main groups; 



1st Generation (Drowsy) Cross blood-brain barrier (BBB) – Chlorphenamine (Piriton), Diphenhydramine (Nytol), Promethazine (Phenergan), Buclizine (found in combination in Migraleve) 2nd Generation (Non-drowsy) Do not cross BBB– Loratadine (Clarityn), Cetirizine, Acrivastine (Benadryl Allergy Relief)



Rhinorrhea Runny nose with a discharge that is thin, clear and watery  Nasal congestion Inflammatory response to allergen that causes vasodilation and congestion  Nasal itching  Eye symptoms Eyes may be itchy and watery. Result of tear duct congestion and pollen grain caught in the eye  Sneezing Classic response is sneezing then rhinorrhoea then congestion

Management/ Treatment of Hay fever symptoms          

Wearing wraparound sunglasses to stop pollen getting in your eyes when outdoors. Taking a shower and changing clothes after being outdoors. Staying in doors when pollen count is high (>50 grains per cubic metre of air) Keeping windows closed when pollen count is high – particularly morning and evening. Apply a small amount of pertroleum gel to nasal openings to trap pollen grains. Don’t keep fresh flowers in the house. Vacuum regularly – high-efficiency particle arresting (HEPA) filter. Damp dust. Avoid cutting grass, playing or walking in grassy areas. Keep car windows closed - pollen filter can be bought for air vents in cars.

Medications  Antihistamines

 Steroid nasal sprays  Sodium cromoglicate  Decongestants Referral Criteria; wheezing, purulent conjunctivitis, earache and facial pain.

Motion Sickness

Non- drugs: Ginger, wrist straps Drugs: Antihistamines

Symptoms:     

nausea +/- vomiting dizziness pallor cold sweats hypersalivation

 

a/e and c/i as per hyoscine Cinnarizine - min. age 5 years - intermediate-acting (up to 8 hours)



Promethazine - min. age 2 years - long-acting (longer than 8 hours)

Insomnia Treatment/Medication  Sleep Hygiene  Drug(Antihistamine) diphenhydramine

Pharmacological Interventions Sedating Antihistamines: Promethazine Diphenhydramine Sleep Hygiene Avoid sleeping in warm rooms and drinking alcoholic/caffeine drinks. Associate bed with sleep only No naps, maintain a routine and if you cannot sleep get up to do something then go back to sleep.

Eyes

Referral; Under 12 Duration >3 weeks No known cause Previous undiagnosed medical conditions Symptoms suggestive of anxiety or stress

1. Conjunctivitis Viral – sticky pus, feel gritty i. Self-limiting therefore no treatment. ii. Hygiene measures to prevent spread to others as highly contagious i.e not sharing towels, washing hands etc. Allergic – red and watery iii. Mast cell stabilisers, antihistamines and sympathomimetics. (SEE RTS ANTIHISTAMINES MATERIAL) Bacterial iv. Brolene and Golden eye 1. >12 years 2. 1-2 drops up to four times daily 3. If no improvement within 2 days see GP v. Chloramphenicol eye drops/ointment 1. >2 years 2. Drops – 1 drop every 2 hrs for 48hrs followed by 4 times daily for 5 days. 3. Ointment – alone apply 4 times daily, or once daily at night if used with drops.

2. Blepharitis Common condition characterised by red, swollen eyelids. Additional symptoms; a. Itchy sore eyelids b. Crusty / greasy eyelashes c. Gritty burning sensation d. Abnormal eyelash growth or loss of lashes

Management Daily cleaning routine which includes; •

Using warm compress

•

Massaging eyelid gently

•

Cleaning eye lids (cooled boiled water and cotton buds)

3. Dry Eye Carbomer

Hypromellose & Carmellose

Polyvinyl

Treatment Options Wool Fats

Sodium Hyaluronate Refer if doesn’t clear up in 2 weeks. (GP)

Ears

Excessive Ear Wax What is ear wax? A normal secretion from the ear canal from ceruminous glands Purpose of ear wax: -Protects tympanic membrane -Trap foreign particles and dust, protects lining of canal -Repel water -Bactericidal and fungicidal activity

Two main types 1.Wet, honey to dark brown 2.Dry, grey and flaky If there is too much ear wax, the patient can experience temporary deafness or hard of hearing in the ear(s) affected. Wax normally migrates to outer ear – ‘self cleaning’ when it accumulates in the external auditory canal it can form a “ plug” Ear wax can build up in all but especially: people with lots of hair in the ear, those with narrow ear canals, people who use ear plugs/hearing aids and the elderly (wax becomes drier). Treatment for excess ear wax; Cerumenolytics Fixed and volatile oils (Olive oil, Almond oil, Arachis (peanut) oil, Earex®, Cerumol®) Docusate sodium (Waxsol®)

Na+ bicarbonate Urea, hydrogen peroxide (Exterol®, Otex®) Wax softening agents can be used by all, no interactions Don’t use cotton buds

How to use More comfortable if the drops are warmed (room temp) first Hold in hands or place in warm (not hot) water Lie down with the affected ear uppermost Gently pull pinna back and up (pull down and back in children) to open the ear canal Place correct number of drops into ear canal Stay in position for about 5 min

Referral Criteria Trauma / history of surgery Foreign body in ear canal Where OTC treatments have failed – will need syringing Ringing or dizzy sensation Severe pain / earache Fever and malaise in children Presence of discharge

Otitis externa Inflammatory condition of the pinna or outer ear canal – skin swells / tender to touch. Becomes chronic if it lasts for more than 3 months.

Symptoms      

Pain Discharge Itch / irritation External ear + / or canal appears red, swollen, or eczematous Deafness No systemic symptoms

Predisposing factors Ear trauma Use of cotton buds / ear trauma Syringing Dermatitis Chemicals (e.g. shampoo, hair dyes)

Excess moisture (e.g. frequent swimming) Humid environments

Treatment 

Diffuse OE

Choline salicylate (Earex Plus®) Acetic acid e.g. Earcalm® 

Furunculosis

Hot flannel Oral analgesics

Referral criteria Ear pain in children Inflammation of pinna Unsuccessful treatment Impaired hearing Mucopurulent discharge

Oral antibiotics if severe

Otitis Media Can affect one or both ears, 75% cases in children under 10 yrs where 1 in 4 children has OM before 10 yrs. Peak incidence – between 3 – 6 years.

OM Symptoms       

Earache (Otalgia) Discharge (Otorrhoea) if tympanic membrane perforates (sometime relieves pain, heals naturally) Children feel unwell Hot, irritable, sleeplessness, ear pulling / rubbing, crying child – could be ear infection Temporary deafness – conductive Fever Red / yellow / cloudy / bulging TM on examination

OM Treatment Most (80%) cases in children resolve within 3 days with no treatment Aim is to reduce severity and duration of pain and other symptoms and prevent complications Analgesia – e.g. paracetamol, ibuprofen

If severe or does not ease after 2-3 days may need Antibiotics (refer)

Referral Criteria  

Recurrent infections No improvement in 3 days

Women’s Health 1.Cystitis o

Infections of the urinary tract are especially common in women

o

Peak incidence early 20’s

SYMPTOMS o

‘Itching’ of urethra indicates an attack

o

Urgency & Frequency

o

Dysuria (discomfort/burning sensation when passing urine) – classical symptom

Treatment Analgesics e.g. paracetamol and ibuprofen

Refer: Longer than 7 days Women over 70 Children under 16 Diabetics Hematuria Men Immunocompromis ed Pregnancy Vaginal discharge Associated fever

Potassium and sodium citrate (symptomatic) to reduce acidity of urine– Low Evidence Antimicrobial therapy, where indicated, is highly effective, for first line therapy. Cranberry Juice – Low Evidence Empty bladder completely Use a hot water bottle – holding a hot water bottle on your tummy or between your thighs may reduce any discomfort Don't have sex until you're feeling better, because it may make the condition worse

Prevention Void the bladder completely when urinating Avoid delay in emptying the bladder After bowel motions, wipe from front to back If sexual intercourse seems to be a trigger, wash the peri-anal skin beforehand empty the bladder before and after

Use a lubricant to prevent trauma and soreness Avoid tight underwear made from synthetic materials and tight trousers Thoroughly rinse out detergent after washing clothes Avoid perfumed bath additives and vaginal deodorant Reduce intake of coffee and alcohol.

2.Vaginal Thrush o

Pruritus (Itch) often intense and burning in nature

o

Vaginal discharge is usually, but not always, present (a good diagnostic aid)

o

Discharge varies from watery to a creamycoloured, thick discharge

o

Discharge is odourless

o

Dysuria (pain on urination)

o

Dyspareunia (painful intercourse)

o

Treated without examination by GP but persistence indicates that a swab should be taken therefore REFER back

Refer: Discharge that has a strong smell Diabetes Treatment failure Under 16s and over 60s Pregnancy Recurrent attacks Immunosuppressed

Treatment Fluconazole 150mg

o o

Internal o

Pessary – 500mg pessary with applicator o

Intravaginal cream; 5g of 10% clotrimazole

Avoid wearing nylon underwear and tights Do not use vaginal deodorants, foam baths or perfumed soaps Recurrent symptoms require medical referral Topical imidazoles can damage latex condoms and diaphragms

and/or External cream; 2% Clotrimazole cream

3.Dysmenorrhoea o

Most common in adolescents and women in their 20s

o

Pain is usually described as cramping

o

Pain is rarely severe

o

Onset occurs shortly before the onset of menses and rarely lasts for more than 3 days

Refer: Heavy or unexplained bleeding Pain experienced before menses or if it increases after menses Signs of systemic infection Bleeding in postmenopausal women Women over 30 with new/worsening symptoms

Treatment NSAIDS - Ibuprofen - Naproxen HYOSCINE; motion sickness and postoperative nausea and vomiting

4.Menorrhagia o

Heavier than normal bleeding (more than 60 mls)

o

It can interfere with normal activities

o

Can occur with other symptoms

o

Need to be able to exclude sinister pathology

o

Medication related?

Medication Anticoagulants MAOIs Cimetidine Steroids Thyroid hormones

Referral Intermenstrual bleeding Pelvic pain Post coital bleeding/pain Treatment failure

GI Tract

Ulcers  Minor ulcers Last 5 – 14 days crops of one to five White or yellowish centre with an inflamed red outer edge Refer: Duration of longer than 3 weeks Associated weight loss Rash Suspected ADR Diarrhoea Treatment  Chlorhexidine mouthwash  Local Analgesics  Local Anesthetics

 Major aphthous ulcers (REFER) 30mm in diameter Crops of up to 10

Cold Sores Key points : Infection caused by herpes simplex virus (HSV1) Symptoms: o o o o o

Prodromal symptoms of itching, burning, tingling pain Occur a few hours to a couple of days before lesion Lesion appears as blister and associated redness These crust over within 24 hours resolve in 7-10 days

Treatment:  Antivirals – acyclovir, penciclovir  Ammonia and Phenol (Blistex®)  Urea – (Cymex®)

Heartburn Symptoms Burning discomfort experienced in the upper part of the stomach Aggravating factors: 1. Bending or lying down 2. Obesity 3. After a large meal

Treatment        

Referral ALARM symptoms Anaemia Loss of weight Anorexia Recent onset of progressive symptoms Melaenia, dysphagia & haematemesis Severe pain Persistent vomiting Pain radiating to arm, neck & jaw Failure to respond to antacids – 1 week

Antacids – neutralise acid Alginates – raft forming H2 antagonists Proton Pump Inhibitors – most effective Practical points: Food – small meal...