Category Archives: OPD

Seizures

Clinical, Emergency medicine, General paediatrics, Neurology, OPD

Seizures, fits, funny turns, convulsions, attacks…  None of these really has a medical meaning.  Convulsion suggests rhythmic motor activity, but that’s about it.  The implication of most of these is that there is excessive abnormal, involuntary muscle contraction, usually bilateral.  But more broadly, some involuntary, usually sudden and self terminating episode of abnormal (or at least non-purposeful) activity and/or impaired awareness. Can be sustained or interrupted.

Nottingham RCPCH approved guideline distinguishes:

  • Febrile?
  • Already on anti-epileptic medication?  Consider checking levels, or at least storing sample.
  • Predisposing conditions? eg neurodevelopmental problem, brain injury/surgery.
  • Neonate or young infant? Some additional possibilities eg hypoxic ischaemic encephalopathy (HIE), Fifth day fits, drug withdrawal (neonatal abstinence syndrome), pyridoxine dependent epilepsy.

Most commonly Febrile convulsions ie age related, benign.  Beware complex (multiple seizures in same illness, focal features, prolonged >15 mins) and any abnormal findings eg neck stiffness, bulging fontanelle, prolonged illness, abnormal cognition before/after.

Important differentials are:

  • meningitis
  • encephalitis
  • shaken baby (non-accidental injury)
  • brain tumour/haemorrhage, hydrocephalus
  • ingestion (deliberate or accidental)
  • metabolic (low glucose, calcium/magnesium, low/high sodium)

May represent first evidence of epilepsy.

Polycystic ovary syndrome (PCOS)

Endocrinology, General paediatrics, OPD

Now (2026) PMOS – polyendocrine metabolic ovarian syndrome. Takes focus off the ovarian cysts, which are not always seen, often seen incidentally, and probably the least relevant thing about it.

No single test. Also operator dependent esp teens.

  • Hirsutism (even male pattern baldness), But NOT virilisation (eg clitoromegaly, voice changes, musculature).
  • acne (moderate to severe),
  • irregular periods.  Can be amenorrhoeic, dysfunctional uterine bleeding, infertility but 20% have normal cycle.
  • Obesity (35-50%, not all),
  • Acanthosis nigricans.

Insulin resistance is associated, and obviously presents the most important long term risk. Acanthosis nigricans is highly associated with insulin resistance, family history of type 2 or gestational diabetes a clue.

Differential includes pregnancy, hypothyroidism, hyperprolactinaemia (mild hyperprolactinaemia commonly seen in PCOS, transient), late onset Congenital Adrenal Hyperplasia (CAH), ovarian/adrenal tumour, Cushing syndrome.

Investigations

  • LH/FSH – ratio often high (3:1 or more) but inconsistent so not considered diagnostic
  • Testosterone can be high (up to 4.8) – if higher, suggests alternative diagnosis
  • Free androgen index (=testosterone x100/SHBG) can be high but our lab only calculates for adults – reference range of up to 7
  • SHBG – low in PCOS (and in obesity, hypothyroidism, hyperprolactinaemia). Plus marker of insulin resistance),
  • Prolactin, 17OH Progesterone for differential
  • Fasting glucose/insulin ratio (under 4.5=insulin resistance, up to 7 in adolescents), glucose tolerance test, lipids.

No normal range for hormone tests in pubescent girls, so these only give a vague suggestion of an underlying issue.

Given there is no specific treatment, try not to focus on making the diagnosis (with attendant self image issues etc), but concentrate on managing symptoms (for young people, heavy irregular periods and hirsutism; for adults, infertility) and long term risk viz diabetes and cardiovascular disease.

Note that less than 4 menses per year has higher risk of endometrial cancer.

Consider:

  • oral contraceptive pill (OCP) – progesterone only, or combined, or else 12 week cycles of medroxyprogesterone acetate 5mg BD followed by 1 week break – NOT contraceptive!
  • Metformin
  • Spironolactone (has anti androgen effect)
  • Plucking/shaving/electrolysis/laser, eflornithine cream
  • Clomiphene for fertility.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1069067/]

Asthma

Common, General paediatrics, OPD, Respiratory

See BTS/SIGN/NICE 2025 guidance on asthma,  asthma prevention, asthma and obesity

FeNO is expensive and available in only a minority of GP practices and hospital services.  Requiring it means GPs can no longer make diagnosis themselves.

Spirometry results in most primary care patients with asthma are normal!

Spacer best for everyone! Orange aerochamber is small mask, up to 18 months, yellow is 1-5yrs. Green is 5+, blue is adult. You can get blue with mask, not green.

200 doses in an MDI.   2 puffs BD exhausts an MDI in 50 days. Multidosing 5 puffs 4hrly will exhaust it in 6 days.

Growth Restriction

Children who use inhaled steroids for asthma grow slower than their peers in the first year of taking the medication, by about half a centimetre per year. Metanalysis of 25 trials, various types of steroid.  Seems to be most obvious in initial year of treatment.  Only 1 study followed children into adulthood – budesonide, used for average of 4 years – reduction in final height of  1.2cm (Kelly, PMID 22938716).

Should therefore be prescribed at the lowest effective dose. Cochrane 2014 found significant difference between low dosing (50-100 Clenil equivalent) and medium dosing  of 0.2cm per year but noted that the  majority of trials did not report height data.

However, the small effect on growth needs to be weighed against the proven benefits of these drugs in controlling asthma, and ensuring children’s lungs grow to their full capacity.   Undertreated asthma is much more likely to have a harmful effect on a child’s development than a small reduction in growth.

Newer Therapies

Xolair=Omalizumab, monoclonal vs IgE. Subcut, 2-4 weekly, for age 6+ where conventional therapy not working.  Other criteria are total igE >30, positive tests for aeroallergens, FEV1<80%.

Airsonett is evidence based, temperature controlled laminar flow system for bedroom. Noisy!

Management

See National review of asthma deaths.  Recommendations include:

  • Refer specialist if >=2 courses oral steroids within 12 month period
  • Follow up after every ED/OOH attendance
  • Hospital follow up after every hospital attendance
  • Annual inhaler technique check
  • Personal asthma plan for everyone

See MyLungsMyLife.org website for self management.

Penis problems

Clinical, General paediatrics, OPD, Surgical

The foreskin cannot, and should not, be retracted in newborn babies.  It should gradually begin to separate in the first few years of life. Sometimes it takes until puberty.

Retraction should lead to a pouting appearance of the foreskin. Technically this is not phimosis, which implies an abnormality. Some ballooning with micturition is seen, and is not an indication for surgery.

Can try application of topical steroid cream to speed up separation eg 0.025% betamethasone (1 in 4, or RD) cream twice daily for 2 to 4 weeks.  Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin.  Steroid creams of higher potency may be tried if this fails.

Inflammation of the foreskin (posthitis), glans (balanitis) responds usually just to hygiene measures – bathing, cleaning, drying. Antibiotics might be needed if spreads on to shaft. Topical steroids can help.

Circumcision if significant phimosis and steroid creams fail.

Smegma pearls

Retained smegma can accumulate into substantial but painless lumps down the shaft of the penis.  Can be ignored.

Balanitis Xerotica Obliterans

A form of lichen sclerosus affecting the tip of the penis. No pouting of foreskin seen on retraction. Can be white, crinkly thickening. Can be bleeding, discomfort. No good evidence for topical steroids, usually surgical treatment.

Trichotillomania

Clinical, General paediatrics, OPD

Or repetitive hair pulling.  Previously classified as an impulse control disorder, ie a sense of tension that is only “satisfied” when hair is pulled out. However, many children do not get this tension and gratification so in DSM-V trichotillomania is included among obsessive-compulsive and related disorders.

Dutch cohort mostly girls, literature says no gender difference!   Nail biting can co-exist, as can stereotypies.  Many kids will also eat their hair once it is pulled out.  Most common age of onset is in early adolescence (9-13 years), but frequently occurs in early childhood, even as early as 12 months of age.  Triggering factors identified include concerns about physical appearance, family and school issues, and concurrent illness.  Parents sometimes also pull their hair, so maybe (partly) learned.

Two distinct types of trichotillomania described: automatic and focused

  • Automatic – outside of own awareness, may not recall actual pulling, but may admit to ‘playing with their hair’ or may have been noted to pull their hair in a distracted state.  Children tend to fall into this category.
  • Focused – aware, in response to negative emotion or urges

Parents often miss the hair pulling and only present when hair clumps noticed on surfaces (esp bed –  presumably due to pulling in sleep) or bald patches appear.

On Examination

Exclamation mark hairs (thin proximally, at scalp, normal distally), usually thought of being evidence of alopecia areata, may be seen, so not very predictive.  Pull test – gentle traction on about 20 hairs in 3 different locations.  Positive if more than 5 hairs extracted – suggests active alopecia areata.  You may miss dormant alopecia, but in that case hair regrowth should occur.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857813/]

Stereotypy

Clinical, General paediatrics, Neurology, OPD

Where children present with abnormal movements, consider:

Stereotypies are repetitive non-functional movements, typically hand flapping or twisting, body rocking, head banging/nodding, grimacing, arm flapping. As with tics, there is often a family history, and there is an association with obsessive compulsive tendencies.

They can be present in children with normal development, but are a feature of neurological disorders especially autism spectrum disorder and sensory impairment.  In these children, the movements are part of a period of introspective absorption, they make prefer such activity to conventional social interactions.

There are a number of differences from tics, although they can co-exist:

  • Sterotypy presents younger, eg under 2 yrs.  Tics present from 4 onwards.
  • Tics can vary over time, so grimacing moves on to  shoulder jerks, then moves on to clearing throat.  Stereotypy movements are unchanging.
  • Stereotypy movements are rhythmic, rather than just a single jerk
  • Tics are brief, stereotypy can be prolonged
  • Tics have a premonitory sensation (although only older children may be aware)
  • Tics can be suppressed with effort.  Children with stereotypy can be distracted but may resent it! (Similarly self gratification)

Excitement and stress are triggers for both.  Over time, the child usually becomes aware of social disapproval and may suppress the behaviour except in secret!

[Ulster Med J 2014;83(1):22-30]

 

 

 

Recurrent aphthous ulcers

Common, General paediatrics, OPD

Very wide range of risk factors and causes for aphthous ulcers including any sort of physical or chemical irritation, there are probably genetic factors.

Minor vs major vs herpetiform: how big and painful!  HSV is possible but tends to affect lips and produce crusts.

There is some suggestion that iron, Folic Acid and B12 deficiencies can trigger it.

Food triggers: acidic foods such as tomato, citrus. Nuts, chocolate, wheat and spices.

Cinnamon and benzoates – Glasgow study of adults with RAS or Orofacial granulomatosis and other oral mucosal diseases found significantly higher rates of positive patch testing in both groups (70%, cf 60% of controls!), esp food additives (benzoic acid, salicylic acid, tartrazine, glutamic acid, butylated hydroxytoluene, butylated hydroxyanisole, propylene glycol, sorbic acid and sodium metabisulphite), – 41% contact urticaria cf 22% controls – with high rate for benzoate,  Perfumes and flavourings 40.7% overall, vs 9% controls –  of which cinnamaldehyde most important (32.4%).  Chocolate was mentioned specifically but actually only 3.7% positive.  [QJM. 2000 Aug;93(8):507-11. PMID 10924532]

Aphthous ulcers can be a sign of an underlying problem including inflammatory bowel disease, coeliac disease, Behcet’s and PFAPA syndrome but you would expect other signs and symptoms.

The less obvious cause would be cyclic neutropaenia.

Aphthous ulcers can be a lifelong problem although they tend to be less of an issue after teenage years.

Treatment

Apart from Bonjela, Difflam spray, chlorhexidine mouth rinse.  Cholinesalicylate dental gel (not licensed under 16 years).

Steroids: Hydrocortisone dissolving tablets, else a steroid inhaler sprayed in to the mouth or Betametasone soluble tablets as  mouthwash (unlicensed).

BNFc mentions doxycycline rinsed in mouth!

Salt water rinses, applying teabags or Aloe juice directly to the ulcers!?

The GINI study

Allergy, General paediatrics, Immunology, Nutrition, OPD, Respiratory

German study from 1998.

Some potential benefit from using hydrolyzed formula in terms of preventing allergy.  The relative risk for the cumulative incidence of any allergic disease in the intention-to-treat analysis (n = 2252) was:

  • 0.87 (95% CI, 0.77-0.99) for partially hydrolysed whey-based formula (pHF-W),
  • 0.94 (95% CI, 0.83-1.07) for extensively hydrolysed whey-based formula (eHF-W) eg Pepti, and
  • 0.83 (95% CI, 0.72-0.95) for extensively hydrolysed casein-based formula (eHF-C) eg Nutramigen compared with standard cow’s milk formula.

The corresponding figures for atopic eczema/dermatits (AD) were 0.82 (95% CI, 0.68-1.00), 0.91 (95% CI, 0.76-1.10), and 0.72 (95% CI, 0.58-0.88), respectively.

In the per-protocol analysis (ie where patients stuck to protocol) effects were stronger (0.49 for eczema at 1yr). The period prevalence of AD at 7 to 10 years was significantly reduced with eHF-C in this analysis, but there was no preventive effect on asthma or allergic rhinitis.

[J Allergy Clin Immunol. 2013 Jun;131(6):1565-73. doi: 10.1016/j.jaci.2013.01.006. ]

Cochrane review 2009 biased towards GINI data.  Since then big Melbourne study (MACS) not in favour; per protocol analysis for eczema at age 1 yr did not show any benefit (0.55-1.93).

Even with GINI, NNT could be as high as 80!

[http://onlinelibrary.wiley.com/doi/10.1111/pai.12138/full]

15 yr follow up of GINI study – between 11 and 15 years,

  • prevalence of asthma was reduced in the eHF‐C group compared to CMF (OR 0.49, 95% CI 0.26–0.89)
  • cumulative incidence of atopic rhinitis was lower in eHF‐C (risk ratio (RR) 0.77, 95% CI 0.59–0.99]) and the AR prevalence lower in pHF‐W (OR 0.67, 95% CI 0.47–0.95) and eHF‐C (OR 0.59, 95% CI 0.41–0.84).
  • cumulative incidence of eczema was reduced in pHF‐W (RR 0.75, 95% CI 0.59–0.96) and eHF‐C (RR 0.60, 95% CI 0.46–0.77), as was the eczema prevalence between 11 and 15 years in eHF‐C (OR 0.42, 95% CI0.23–0.79).
  • No significant effects were found in the eHF‐W group on any manifestation,nor was there an effect on sensitization with any formula.

[Allergy 2016; 71: 210–219. http://onlinelibrary.wiley.com/doi/10.1111/all.12790/abstract]

Tension headache

Common, General paediatrics, Neurology, OPD

Tension headache

  • Mild to moderate rather than severe,
  • pressing or tightening rather than pulsatile,
  • Bilateral,
  • Not aggravated by routine physical activity.

Can be continuous. Phonophobia, photophobia, nausea are possible, but if more than one present, and particularly if vomiting or severe nausea, then migraine would be preferred diagnosis.

Often spreads into or arises from neck.

Chronic tension-type headache – as above but on >/15 days/month for at least 3 months. But gets messy – it is possible that a patient can have both this and Chronic migraine, viz only two of the four pain characteristics are present and associated with mild nausea. In all these cases consider Medication-overuse headache.

Headache

Common, General paediatrics, Neurology, OPD

Common problem in children, as well as adults!

Distinguish primary from secondary.

Most headaches get worse with exertion so that’s not a discriminating feature.  Headaches that get worse on standing suggest a CSF leak; worse on lying down suggests a tumour.  See NICE CKS.

Primary

Secondary