Wk 8 tutorial Chronic Disorders

WEEK 8 CHRONIC ILLNESS, CHILD ABUSE STUDENT NOTES

Patient 1. David, a 15years old male, has cystic fibrosis, asthma, and epilepsy.

Presenting symptoms
Hes had a loose cough for the past week, he took a fit four weeks ago, and were sick of it all.
We cant go on like this.

History of present illness

Loose cough for the past week, worsening. He usually has no cough
No sputum produced. No dyspnoea or wheeze, or other respiratory symptoms
No fever
Systems review
Appetite is fair, weight loss of 600g on last weight taken 3 weeks ago.
Bowels no stools for 2 days; last stool was soft, well-formed, but malodorous.
Has had some intermittent pains in the low left iliac fossa this morning.
No other abdominal symptoms.

He had a fit four weeks ago, a brief tonic-clonic convulsion, with no warning, and post-ictal
drowsiness. At the time, he was sitting quietly, reading a Pokemon magazine.

Past History
Cystic fibrosis diagnosed in the neonatal period, when he presented with meconium ileus.
NEONATAL PERIOD
Unrelated parents
Mothers first pregnancy; married, 22years old, wasnt expecting to be pregnant so soon.
SOL at term, SVD, good Apgar score, Birth parameters all around 25th centile.
Developed abdominal distention on day one
Diagnosed as having meconium ileus, bowel perforation with meconium peritonitis,
Laparotomy, right hemicolectomy
Post-operatively, needed respiratory support for several days, and had nutritional problems,
needing total parenteral nutrition (TPN) and tube feeding.
Genetic testing confirmed the presence of homozygous delta F508 mutation.
He went home at around four months of age.

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David, continued.

SUBSEQUENT COURSE
Most of Davids main problems in early childhood were gastro-intestinal.
However, in the last six years, there has been a deterioration in his lung function.
GIT:
Problems with weight gain: he has taken pancreatic enzyme supplements since birth; caloric
supplements since 3 years; brief period of overnight nasogastric tube feeding.
Poor weight gain around age 4; endoscopy showed duodenitis and oesophagitis; treated, follow-
up endoscopies are normal
Feeding difficulties around age 5, improved with behavioural management.
Small bowel obstruction around 7 years of age, due to adhesions.
Post-operatively, required prolonged TPN and had sepsis (infected central line), and was in
hospital for about 4 months.
Hepatomegaly been present, and stable, for the past 8 years. His serum transaminase levels were
elevated, probably due to TPN. He saw a gastroenterologist, and had liver biopsy (normal).
For the past 6 years, weight and height gain has been steady, along 25th centile; OFC 50th.

RESPIRATORY:
David has had about 12 hospital admissions with lower respiratory tract infections, the last being
about 5 months ago. David does not usually have a cough, or produce sputum, but when he is
unwell, the hospital physiotherapist is usually able to obtain a specimen for microscopy, culture
and sensitivity. Chest infections have been treated with intravenous antibiotics, to cover the likely
offending organisms, which your tutor will mention.
Four years ago, Pseudomonas aeruginosa was isolated from his sputum.
Davids lung function was 100% predicted 6 years ago, but has deteriorated gradually since then.
When last checked 3 months ago, it was stable, with FEV1 78% predicted, and FVC 84%
predicted. Routine chest Xray 6 months ago showed some mild hyperinflation and peribronchial
thickening, with no bronchiectasis.
David has a PEP mask, which he is supposed to use for hour a day.
He is also prescribed Seretide for asthma prevention, and salbutamol inhaler prior to exercise and
physiotherapy.
He used to enjoy jumping on the trampoline, but that is now boring. He likes riding his bike
around the neighbourhood, and used to play badminton, but stopped because it was inconvenient.

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He has dyspnoea on vigorous cycling.

OTHER
David has idiopathic epilepsy the past 3 years. He has had two generalized tonic-clonic
convulsions, with no obvious triggers, although the first occurred when he was playing Nintendo.
EEG showed spike/wave consistent with generalized epilepsy, with no changes on photic
stimulation. The fits have been well-controlled with carbamazepine.
Developmental milestones have been normal.
He is in grade 10 at the local high school, and is achieving in the low-average range.
Allergies: rash with Penicillin
Immunisations, including Pneumococcal, up to date

Medications:
Respiratory:
PEP mask, hour daily
Seretide, twice daily
Salbutamol prior to exercise
Gastro-intestinal-related medications:
Creon pancreatic enzyme supplement, several capsules with all meals;
Caloric Supplement Ensure Plus, 500mls/day
Ranitidine twice a day
Lactulose once a day
Vitamin supplements: Multivite once daily; Vitamin E daily; Vitamin K twice a week
Salt tablets (sodium chloride) 12 per day
Carbamazepine twice a day
*What do you think of Davids daily regimen? Your tutor will discuss this shortly

Physical examination
Alert, looks quite well, weight loss 600g, 10th-25th centiles, height still 25th.
Afebrile, HR, RR, BP, temperature normal.
No cyanosis, no pallor, no jaundice or oedema, no finger clubbing
Pre-pubertal, normal male genitalia
Loose cough couldnt produce sputum
Chest: no signs of respiratory distress, mild hyperinflation (upper border of liver 7th right
intercostal space),breath sounds normal, chest clear
Nose: no polyps
Stable hepatomegaly, non-tender, no masses
Skin: multiple scars from abdominal surgery and central and peripheral intravenous lines.
CNS: NAD

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Respiratory function tests show mild deterioration in lung function

*Adolescence to be discussed
*Chronic illness or disability often places a seemingly intolerable burden on the patient and
his/her family. What other history do you need to obtain?
*Puberty to be discussed
*Cystic Fibrosis to be discussed

CHILD ABUSE
Practical Paediatrics- P.94 Child abuse may be defined as involving physical injury, sexual
abuse, or deprivation of nutrition, care and affection in circumstances which indicate that injury
or deprivation may not be accidental or may have occurred through neglect. a spectrum of
presentations

From the moment child abuse is suspected, the safety and protection of the child must be
ensured. The child must be in a place of safety.
This may mean hospital admission, to assess the medical, family and social situation.

If you have grounds for suspecting abuse, then discuss the situation immediately with a
paediatrician, who can then assess, and contact the authorities (given below), as need-be.

Notification
The Law in most Australian States requires that medical practitioners report suspected child
abuse to protective authorities.
If the alleged perpetrator is a member of the childs family, contact the Department of Families.
If the alleged perpetrator is not a member of the family, then contact the Police, the Juvenile Aid
Bureau.

Assessment of child and family -multidisciplinary

Interview of the child

In cases of suspected abuse, it is reasonable to ask medical questions of the child, and note details

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of any disclosures of abuse.

In general, the fewer people who successively interview the child, the better. This is because
repeated questioning may confuse the child, small inconsistencies in the history may arise, and
any evidence may be weakened.
The interview is best conducted by the protective authorities, who make a video recording of the
procedure. If this is not possible, then it should be done by the paediatrician or other medical
practitioner specialised in this field, as they may be obliged to supply evidence to the courts.

Patient 2. Rosie. 6 years old, female

Presenting symptoms
Mother has brought her to your general practice, saying she has been complaining of a sore wee-
wee, and that mother has examined her and found she has a red vagina.
Shes worried that her ex-husband, Rosies biological father, has interfered with her, as shes
just spent the weekend with him, and had no symptoms before she visited.

*Discuss the relevant history

This is a very common scenario. The parents have separated, there may be an ongoing custody
dispute, and one of the parents has concerns that the other parent is mistreating the child.
*Your tutor will discuss appropriate examination and action.

Patient 3. Trevor, 7 years old.

Presenting symptoms
Mother very upset about his behaviour. She thought he was playing Lego in his room, with his 6
year old cousin, Peter. They were rather quiet, so she decided to see what they were up to. The
bedroom door was closed. She found them in the bedroom cupboard.
Peter was standing up, leaning forward, with his underpants and shorts pulled down. Trevor was

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kneeling behind him, and had his face close to Peters buttocks, and seemed to be trying to lick
him. Mother spoke angrily to him to stop, and called him out of the room. She asked him where
he had learned to do that, and he said Peter had told him thats what Uncle Harry does when he
visits. Peter denied this.
*Is this normal exploratory behaviour?

Patient 4. Latisha, 2 months old, female

Presenting symptoms
Crying, unsettled, not feeding well for the past 3 weeks, poor weight gain.
History
Parents in de facto relationship, both 23 years old. First baby, uncomplicated pregnancy and
delivery, discharged from hospital on Day 2. Attended Child Health nurse, baby wasnt back to
birth weight by 2 weeks of age, and was very unsettled. Mother was advised to formula-feed the
infant. Baby seems hungry, is feeding every 1 1/2 hours, but only takes about 30 mls at a time,
and wont settle, day or night. Mother exhausted
Family father Von Willebrands disease.
Posted here with the army, neither parent has family here
Examination
Unsettled, weight 10th centile, length 25-50th, looks thin, but healthy
Bluish bruise adjacent to mouth and on inner left thigh
*What do you think of these bruises?
What other history do you take?
In general terms, what history may alert you to NAI?
What else do you examine regarding NAI?
What is your differential diagnosis? What action should be taken?

Patient 5. Joseph, 3 years old male

Presenting symptoms
Referred to the Child Health paediatrician by a concerned policewoman, who noticed that he
didnt seem to be speaking properly.
History of presenting problem
Josephs father had called the police station several times to report attempted burglary at his
home. On attending the dwelling, a small, rented suburban house, the police noted multiple locks
on the doors and windows, and a security video camera at the entrance. Joseph only used the
occasional word. He and his father were the only occupants.
Examination
Normal growth parameters, normal physical appearance.
No clinical signs of nutritional deficiency.
Almost no eye contact, lively, used only single words, flitted from toy to toy, without

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constructive play.
Additional history
Review of medical records showed that mother had no antenatal care.
Joseph was unimmunised.
He had been fed on weet-bix and milk, with biscuits.
His father had attended Opportunity School (children with learning difficulties).
His mother had a psychiatric condition, and her whereabouts was unknown.
*What needs to be done?

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