Category Archives: Clinical

Jaundice

Clinical, Gastro, General paediatrics

ie raised blood bilirubin.

First decide if conjugated or unconjugated.  Conjugated suggests a biliary problem, ie obstruction to bile flow, usually associated with raised gamma glucuronyl transferase (gamma GT).  Unconjugated (as measured in split bilirubin) implies haemolysis or else hepatocellular damage (transaminases also go up ie AST, ALT).  Unconjugated can also go up in conjugated disease, presumably competition for conjugation sites, or else because of secondary or mixed hepatocellular damage.

History – maternal if baby, immunisations, transfusions, outdoor activities, pets, holidays, drugs, tattoos. Family history (haemolytic conditions, in particular).

Look for signs of liver failure, lymphadenopathy, eyes (Wilsons – best with slit lamp), dysmorphic (Alagille’s).

Consider:

So do:

  • USS abdo – exclude obstruction.  Common bile duct stones can be obscured on USS by bowel gas.
  • FBC, U&Es, LFTs (including GGT, AST if not routinely done), CRP
  • Prothrombin time, glucose, ammonia, lactate – to monitor for failure
  • Amylase
  • Coombs test and reticulocytes – haemolytic anaemia seen in Wilsons
  • Paracetamol level
  • Cholesterol/TGs
  • Urate
  • ANA, anti SMA/LKM ab’s, Immunogloblulins
  • Ca/Phosph/Mg
  • Copper, caeruloplasmin (but not great for Wilsons if acute)
  • COVID, HHV6, HSV, HCV, CMV, EBV PCR
  • HBsAg
  • Hep A&E, Parvo B19, CMV, EBV Serology incl HIV, IM test
  • Viral throat swab (extended screen)
  • Alpha 1 AT if chronic
  • Slit lamps examination – (Wilson’s, also Alagille’s (posterior embryotoxin)
  • CXR to look for butterfly vertebrae (Alagille’s)
  • TTG ab
  • C3/4
  • Alfa fetoprotein
  • Urine amino/organic acids if under 5

If PT>15, give IV vitamin K (0.3mg/kg, max 10mg) and check daily. If resistant then refer.

Lymphadenopathy

Clinical, Common, General paediatrics, Haem/Oncology, Infectious disease

A good proportion of healthy children will have palpable lymph nodes in the neck.  Mostly these will be under 1cm in diameter.  Acute enlargement as part of an upper respiratory tract infection is usually accompanied by tenderness, and affected nodes will reduce in size over 4-6 weeks.

Guidance from NICE and the Scottish Government provide criteria when children with lymphadenopathy should be urgently referred for suspected cancer.

These criteria include the following:

  • lymph nodes are non-tender and firm/hard
  • lymph nodes are greater than 2 cm in size
  • lymph nodes are progressively enlarging
  • other features of general ill-health, fever or weight loss
  • the axillary nodes are involved (in the absence of local infection or dermatitis)
  • the supraclavicular nodes are involved.

But caveat is “Always refer any patient with Repeat presentations (3 or more times) of any physical symptoms which do not appear to be resolving or following a normal pattern, taking into account parental and patient concern”.

No need to do bloods in the absence of any of these criteria. Not that cancer is the only concern – differential includes developmental lesions (branchial cysts etc), TB, Cat-scratch disease, non-tuberculous mycobacterial infection (esp in neck).  These are always more than 2cm and there may also be systemic features and/or overlying skin discolouration too.

Malignancies often present in the head/neck region.  Hodgkins lymphoma usually affects teenagers, Non-hodgkins tends to affect school age children, neuroblastoma tends to affect pre-school children.  B-symptoms (recurrent fever, weight loss, night sweats, pruritus, lethargy) are only seen in a minority but does suggest more advanced disease, of course.  Airway or voice changes, swallowing difficulty, Horner’s syndrome, superior vena cava syndrome may all be seen due to mass effect. Most neuroblastomas have an abdominal mass.  Nasopharyngeal carcinomas are seen so look in the nose/throat.

Anisocoria

Clinical, General paediatrics

Which side is abnormal?!

Failure to dilate, failure to contract (usually exogenous anticholinergic, such as Hyoscine patch gone AWOL)?

Is eye lid sagging?  Is skin dry?  Reflexes?

Horners is small pupil with ptosis and dry skin – apical tumour (Pancoast) or lesion in brainstem/neck.

Dilated pupil can be part of third nerve palsy but you would usually also see ptosis and loss of adduction. Adie pupil is sudden onset mydriasis (dilated) with loss of reflexes (usually just ankle jerks) on the same side, can spread to other side.  Usually post viral. Can be excessive sweating. Loss of reflexes can be permanent.

Physiological anisocoria = size difference does not vary according to light/dark.

Sexual history

Clinical, General paediatrics,

Explain why (cf nosiness), offer confidentiality

Fear of disappointment/disapproval, parent/authority figure, stigma, genital examination.

Closed questions – curiosity not judgement:

  • Who was it with?  How old is she/he (clarify!).  Regular partner or casual (cf one off, one night stand, other judgemental terms).
  • Did you use a condom?  Did you use contraception (not the same thing)?
  • Did you want to?
  • Did you enjoy it? (!)
  • Do you tend to have sex when you’ve been drinking alcohol