Category Archives: Common

Bronchiolitis

Seasonal lower respiratory tract infection of young children, typically caused by RSV but can be others or mixed.

Classically wheezy cough, wheeze and/or crackles, reduced feeding and increased work of breathing.

Diagnosis

Clinical. You would probably have to do 133 Chest x-rays before you found something that would change diagnosis – overuse of CXR associated with increased (and inappropriate) use of antibiotics.

Swabbing for virus identification can help with cohorting and avoidance of nosocomial infection, which can be a major problem.

And UTI

Bacteriuria is not uncommonly seen with bronchiolitis, not always clear if this is true urine infection.

Prevention

RSV immunisation with Synagis. There’s an important story about the dangers of vaccine development.

Treatment – see here.

Nappy rash

Nappy rash is an irritant contact dermatitis affecting the skin where the moist nappy is in contact. It spares intertriginous areas.

Change nappies 6-8 times a day, dry thoroughly, use barrier eg zinc oxide cream.

Differential diagnosis:

  • candidiasis,
  • atopic dermatitis, seborrhoeic dermatitis
  • psoriasis,
  • Langerhans cell histiocytosis,
  • Acrodermatitis enteropathica (autosomal recessive zinc disorder), else nutritional zinc deficiency – +/- acral dermatitis, alopecia, malabsorptive diarrhoea)

Intertrigo (inflammation in the creases) can similarly be infective (bacterial or candidal), eczematous/seborrhoeic or psoriatic.

Croup

Upper respiratory infection (“acute laryngotracheobronchitis”) of young children, typically parainfluenza but can be RSV, enterovirus etc.

Classically barking cough, like a seal, with stridor. Often worse on waking, then settles once the panic has passed.

Mild fever typical. Rarely lasts longer than 24 hours.

Severe will cause increasing respiratory distress, with decreasing volume of stridor until respiratory arrest ensues.

An oxygen requirement implies lower rather than upper airway involvement (so the wrong, or mixed, diagnosis), or impending respiratory arrest.

Management

Supportive, and hands off – upsetting the child will provoke worsening of symptoms.

Paracetamol/difflam spray for the throat.

Recurrent croup

Some kids are prone to recurrent croup. Often strong family history of croup. Smoking doesn’t appear to be a factor!  Appears to be same viruses. Tend to be children with reflux and/or atopy.  [Pediatrics International, 51: 661–665.] [Annals of Otology, Rhinology & Laryngology 2008;117(6):464-69

26% have microlaryngobronchscopy findings suggestive of reflux – a clinical history is not predictive.  91% responded well to anti-reflux treatment.  High rate of recurrence in group with negative findings!  Kubba Journal of Laryngology and Otology 2013;127(5):494-500

Airway abnormalities eg tracheomalacia are common in children with recurrent croup and cannot be ruled out based on history (although biphasic stridor is highly suggestive). Having said that, most of the airway abnormalities will have a history of previous intubation, or are younger than 1 year, or are seen while inpatients, which all suggest pretty severe episodes. [Otolaryngology-Head and Neck Surgery 2011;144(4):596-601]

Foreign bodies, respiratory papillomatosis, double aortic arch reported. 

Pubertal staging

Tanner stages – verbal descriptions but images helpful esp for self assessment.

Pubic Hair Scale (both males and females)

  • Stage 1: No hair
  • Stage 2: Downy hair
  • Stage 3: Scant terminal hair
  • Stage 4: Terminal hair that fills the entire triangle overlying the pubic region
  • Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh

Female Breast Development Scale

  • Stage 1: No glandular breast tissue palpable 
  • Stage 2: Breast bud palpable under the areola (1st pubertal sign in females)
  • Stage 3: Breast tissue palpable outside areola; no areolar development
  • Stage 4: Areola elevated above the contour of the breast, forming a “double scoop” appearance
  • Stage 5: Areolar mound recedes into single breast contour with areolar hyperpigmentation, papillae development, and nipple protrusion

For males you then have testicular volume, measured by orchidometer (between £26 and £208):

  • 4 ml (1.8cm long by formula below) is first pubertal sign
  • Adult is >20 ml (or >3 cm long)

Cadbury’s Teasers and Truffles (from Celebrations box) are 8ml, equivalent to 50th centile at age 13.

If you only have a ruler, use maximum width in millimetres and the formula: (W-1.5)3 x 0.88, where ss is double scrotal skin thickness (for Tanner stages 1, 2, and 3).

Medically unexplained symptoms

“Persistent physical symptoms” preferred term? Chronic pain overlaps.

“Functional disorder” is used for various gastro and neurological problems, preferred by some adults, but needs explained!

Chronic fatigue syndrome and PANDAS are health disorders that appear to have a physical/scientific cause but disputed.

Health anxiety, malingering, or factitious illness, different from a psychological point of view.

Bleed the symptoms dry! [John Stone, Glasgow].

In a 1965 paper by Eliot Slater, more than half of patients diagnosed as having “hysteria” later turned out to have “organic” disease – but John Stone’s study of adult neurology referrals found very few who turned out to have an occult disease.

Louise Stone in Australia has done a lot of work in primary care. She identifies negative feelings and a lack of diagnostic language and frameworks as barriers to managing these patients effectively. The negative feelings (such as frustration, shame and helplessness), are shared between doctors and patients…

Managing your own feelings and frustrations, and finding ways of understanding and managing the therapeutic relationship important.

Let family feel validated for all concerns – at least in the first instance. Helps develop a therapeutic alliance.

Commit to the patient, which includes advocacy and support.

Family response to symptoms?

Explore beliefs, specific worries (eg cancer). May then allow broadening out to more general worries. 

Manage uncertainty – including managing the need for a disease name! Not having a predictable outcome is hard.

Harm minimisation. Shift from diagnosis to coping with ongoing symptoms.

Good to offer a tentative preamble to difficult conversations! “This is something we as doctors have to deal with every day – signs and symptoms that are very real, with a real impact on a child/family, but where physical examination and investigations do not offer any clues to what the underlying problem might be…”

Paed psychology if issues mostly seem related to child and this is a new problem; CAMHS if new problem adding to existing child/parent issues.  

Can be rewarding in the long term!

[Louise Stone, Aust Fam Physician 2013 Jul;42(7):501-2]

Keratosis pilaris

Common (familial) – rough, bumpy skin on upper arms, usually asymptomatic but cosmetically not great. Follicular plugging, basically.

Can get quite inflamed in some people.

Exfoliating, moisturizing may help.

Sometimes goes with inflamed cheeks – Keratosis pilaris rubra faciei, so typical KP of the arms (often perifollicular redness), but can lead to hair loss and atrophy of eyebrows and scalp. 

Urea containing (Balneum, Hydromol Intensive, Eucerin intensive) creams or salicylic acid (in zinc oxide) paste may help. Topical steroids can be tried if very red but risky for face, given tendency to atrophy anyway.

Threadworms

=enterobius. Common in young children, probably due to hygiene issues. Also called pinworms. Small (1-2cm), like white threads. Can be intensely itchy, usually in night when worms emerge to lay eggs.

Mebendazole effective at killing live worms in gut, not effective if eggs in vagina. Licensed from age 2 but can be used off license below that. Does not kill eggs however, and main issue is reinfection so consider treating whole family, with repeat doses after 2 weeks when any eggs will have hatched, and follow NHS Inform advice on hygiene.

Sometimes you just have to keep repeating treatment over months/years! Mebendazole is harmless, although symptoms may be caused by clearance of large worm burdens.