Clinical Cases in Paediatrics A Trainee Handbook Clinical Cases in Paediatrics A Trainee Handbook Ashley Reece MBChB MSc FRCPCH Pg Cert (Med Ed) Consultant Paediatrician Department of Paediatrics, Watford General Hospital, Watford, UK Anthony Cohn MBBS MRCP FRCPCH Consultant Paediatrician Department of Paediatrics, Watford General Hospital, Watford, UK London • Philadelphia • Panama City • New Delhi © 2014 JP Medical Ltd. Published by JP Medical Ltd, 83 Victoria Street, London, SW1H 0HW, UK Tel: +44 (0)20 3170 8910 Fax: +44 (0)20 3008 6180 Email: [email protected] Web: www.jpmedpub.com The rights of Ashley Reece and Anthony Cohn to be identified as the editors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. 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However readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the editors assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. ISBN: 978-1-907816-47-5 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress JP Medical Ltd is a subsidiary of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India Commissioning Editor: Steffan Clements Editorial Assistant: Sophie Woolven Design: Designers Collective Ltd Copy edited, typeset, printed and bound in India. Preface Paediatric trainees in their first years of training rapidly develop the skills and knowledge required to manage acute paediatric problems. But with greater experience comes a new set of challenges which require more reflection than reaction; nowhere are these more evident than in the outpatient setting or paediatric clinic. Changes in paediatric practice over the last few decades mean that many conditions are now managed more or less exclusively in the outpatient setting, where previously they would be managed on the wards. For doctors who have spent their first few years learning on the wards and in emergency departments, this means tackling a new set of problems which require a different set of ‘tools’. Clinical Cases in Paediatrics: A Trainee Handbook has been written in response to these changes, to provide paediatric trainees with the practical guidance they need as they start to manage patients in the outpatient clinic. We also believe that this book will prove extremely useful for those preparing for work-place based assessments, supervised learning events and postgraduate examinations and assessments. One of the great advantages of editing this book has been that we have also been able to learn from our colleagues’ expertise. There have been numerous occasions when, in our own clinics, we have been able to refer to the chapters submitted when we felt we wanted more information. Whilst we have presented cases in a fairly formal way, we are aware that there are often many ways to manage a problem. Whilst we hope that this book will provide effective strategies for dealing with many of the children seen in paediatric clinics, we do not claim a monopoly on the truth, and encourage people to follow their own teaching and local advice. Ashley Reece Anthony Cohn December 2013 v Acknowledgements We are grateful on a daily basis to be part of the paediatric team at West Hertfordshire Hospitals. Our patients and colleagues make coming to work a true pleasure. One of the great strengths of our team – in no small measure down to our long serving Clinical Director, Emmanuel Quist-Therson – is that each of us is given the encouragement to develop individually and we feel completely supported in our work. This is a multi-author work and we would not have been able to complete it without all of our contributors. Their knowledge highlighted gaps in our own and we have learned so much from reading their work. We realise that some of them found the challenge daunting, but we hope they share our pleasure and satisfaction in the completed work. We are delighted to have contributions from other consultants in the Trust with whom we work closely and are especially gratified that some of our former trainees, who are still very much ‘part of the family’, have been able to contribute as well. Thanks to everyone at JP Medical, in particular Steffan Clements, who stood by us as deadlines came and went. Working together has strengthened our great friendship and we are both fortunate to be supported in our endeavours by our families. To Julie, Danielle, Gav, Eitan, Elny, Natasha and Strudel we owe you everything and you make everything worthwhile. AR, AC Dedication For Danielle, Natasha and my dear parents who have always supported me, my education and endeavours; and my dear late grandparents who would have been so proud. AR For Julie, Gav, Eitan, Elny, Opa and Oma o’h AC vii Contents Preface v Acknowledgements vii Section 1 Introductory chapters Chapter 1 How to run the clinic 3 Chapter 2 Clinic letters – writing, dictating and being assessed 11 Chapter 3 Managing nonattendance 14 Chapter 4 Learning and teaching in the outpatient clinic 17 Chapter 5 School issues 23 Chapter 6 Safeguarding issues 28 Chapter 7 Family issues 34 Section 2 Cases Case 1 Abdominal pain 43 Case 2 Absence seizures 49 Case 3 Acne 52 Case 4 Allergic reaction to food 56 Case 5 Allergic reaction: nuts 61 Case 6 Allergic reaction: urticaria 65 Case 7 Anaemia 69 Case 8 Asthma 73 Case 9 Autism 78 Case 10 Breath holding 83 Case 11 Change in behaviour 86 Case 12 Chest pain 91 Case 13 Chronic fatigue syndrome 96 Case 14 Clumsy child 101 ix x Clinical Cases in Paediatrics: A Trainee Handbook Case 15 Constipation/stool withholding 105 Case 16 Conversion disorder 109 Case 17 Cough 113 Case 18 Crying baby 119 Case 19 Daytime wetting 124 Case 20 Delayed walking 128 Case 21 Developmental delay 133 Case 22 Diarrhoea: teenager 138 Case 23 Diarrhoea: toddler 142 Case 24 Dizziness 147 Case 25 Down’s syndrome follow up 151 Case 26 Dribbling and drooling 155 Case 27 Dysmorphism 160 Case 28 Eczema 164 Case 29 Epistaxis 170 Case 30 Excessive blinking 173 Case 31 Failure to thrive 177 Case 32 Foreskin problems 181 Case 33 Gait abnormalities and limping 185 Case 34 Generalised seizures 191 Case 35 Growing pains 195 Case 36 Haematuria 200 Case 37 Headaches 205 Case 38 Hearing impairment 211 Case 39 Heart murmur 217 Case 40 Hoarse voice 222 Case 41 Infections: recurrent 225 Case 42 Infections: lower urinary tract infection 229 x Contents xi Case 43 Labial adhesions 233 Case 44 Lymphadenopathy 237 Case 45 Macroglossia 241 Case 46 MMR vaccination 245 Case 47 Multiple unexplained symptoms 248 Case 48 Neonatal follow up 252 Case 49 Nocturnal enuresis 257 Case 50 Noisy breathing 262 Case 51 Obesity 266 Case 52 Palpitations 270 Case 53 Partial epilepsies 274 Case 54 Plagiocephaly 278 Case 55 Polydipsia 282 Case 56 Poor feeding in a baby 286 Case 57 Poor feeding in a toddler 290 Case 58 Precocious puberty in girls 293 Case 59 Proteinuria 298 Case 60 Pyelonephritis 301 Case 61 Raynaud’s phenomenon 305 Case 62 Reaction to first vaccine 308 Case 63 Rectal bleeding 310 Case 64 Recurrent fever 314 Case 65 Recurrent tonsillitis 319 Case 66 Scoliosis 323 Case 67 Shared care of children with cancer 328 Case 68 Short stature 330 Case 69 Sickle cell disease 335 Case 70 Sleep problems 338 xi xii Clinical Cases in Paediatrics: A Trainee Handbook Case 71 Soiling 343 Case 72 Swollen joints 347 Case 73 Syncope 351 Case 74 Testicular problems 355 Case 75 Tics 358 Case 76 Tongue tie 362 Case 77 Tremor 365 Case 78 Visual problems 370 Case 79 Vulvovaginitis 373 xii Contributors Freddie Banks MD FRCS (Urol) Jane Hislop BA MB BChir MRCP FRCPCH Cases 32, 74 Cases 46, 62, 78 Consultant Urologist Consultant Community Paediatrician Watford General Hospital, Pat Lewis Children’s Centre, Watford, UK Hemel Hempstead, UK Kapila Batta MBChB MRCP MRCGP Ritika