In this edition of the Ulster Medical Journal, Curiositas takes a paediatric perspective on a range of interesting clinical scenarios.
. 2016 May;85(2):137–138.
Ulster Med J. 2016 May;85(2):137.
Can you identify five errors in this paediatric prescription?
Ulster Med J. 2016 May;85(2):137.
What is the title of this sculpture and where is it located?
Ulster Med J. 2016 May;85(2):137.
This nine month old presented with respiratory distress. A chest x-ray was performed.
What is the diagnosis?
How could you confirm the diagnosis and what would your management be?
Ulster Med J. 2016 May;85(2):137.
What is the likely diagnosis?
What are the key clinical features to elicit in a patient presenting with this condition?
What is the imaging modality of choice?
Ulster Med J. 2016 May;85(2):138.
All drugs must be prescribed generically.
Drug names must be written in capitals.
Prescriptions should be completed in black ink.
Acceptable abbreviations are ‘g’ for grams or ‘mg’ for milligrams. Micrograms, nanograms and units must not be abbreviated. Do not prescribe suspensions by volume (with the exception of combination preparations). If prescribing by volume always specify the concentration required E.g. CO-AMOXICLAV 5 mLs of 125/31 suspension.
Signatures must be accompanied by name in print.
Drug prescription and administration errors are the commonest error in medical practice, and are more common in paediatrics. Strict adherence to local prescribing policies, taking great care when making calculations, and double checking are the corner stones of safe prescribing.
Ulster Med J. 2016 May;85(2):138.
This is The Little Philosopher by Rosamund Praeger. A Praeger bronze replica sculpture was commissioned by the Royal Belfast Hospital for Sick Children Medical Staff from the Ulster Museum in October 1972 as part of the Hospital's centenary celebrations the following year. It currently resides in the small atrium at the original entrance to the Children's Hospital. The daughter of a Dutch emigrant who worked in the Belfast Linen Trade, Rosamund Praeger was a local sculptor born in 1867 in Holywood, County Down. The original Philosopher was exhibited at the Royal Academy in 1913, but now resides in the Colorado Springs Museum after it was purchased by an American Collector. Rosamund Praegar died in 1954 and permission was sought and granted from the late artists Estate to use the sculpture as a motif for the hospital by the Hospitals Centenary Committee in 1973.
Ulster Med J. 2016 May;85(2):138.
The diagnosis is a late presentation of a congenital diaphragmatic hernia (CDH). CDH occurs in around 1 in 3000 live births1. The majority of cases are diagnosed antenatally by ultrasound, or present shortly after birth with severe respiratory distress. Fewer than 3% of cases present outside the neonatal period with a milder variant as in this case2. These children may be completely asymptomatic or display non-specific respiratory or gastrointestinal symptoms. In general, right sided hernias cause respiratory difficulties predominantly, while left sided defects cause a mixture of gastrointestinal and respiratory symptoms2.
Diagnosis of late presenting CDH is difficult. Many are incorrectly labelled as pneumonia, pneumothoraces or congenital lung cysts3 resulting in morbidity through incorrect management2. There is no definitive diagnostic test. In this case, an upper GI contrast study confirms herniation of loops of small bowel into the left hemithorax with no mediastinal shift. In some cases, MR or CT imaging is useful to delineate the anatomy3, 4. Initial management requires insertion of a nasogastric tube to relieve obstruction. Definitive management involves surgical correction of the defect2.
References
- 1.Sridhar AV, Nichani S. Late presenting congenital diaphragmatic hernia. Emerg Med J. 2004;21:261–2. doi: 10.1136/emj.2003.007435. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Congenital Diaphragmatic Hernia Study Group. Late-presenting congenital diaphragmatic hernia. J Pediatr Surg. 2005;40:1839–43. doi: 10.1016/j.jpedsurg.2005.08.023. [DOI] [PubMed] [Google Scholar]
- 3.Hamid R, Baba AA, Shera AH, Wani SA, Altaf T, Kant MH. Late-presenting congenital diaphragmatic hernia. Afr J Paediatr Surg. 2014;11:119–23. doi: 10.4103/0189-6725.132799. [DOI] [PubMed] [Google Scholar]
- 4.Kesieme EB, Kesieme CN. Congenital Diaphragmatic Hernia: Review of Current Concept in Surgical Management. ISRN Surg. 2011;2011:974041. doi: 10.542/2011/947041. [DOI] [PMC free article] [PubMed] [Google Scholar]
Ulster Med J. 2016 May;85(2):138.
The likely diagnosis is periorbital cellulitis, an infection of the eyelid and periorbital soft tissues, commonly caused by Staphylococcus aureus, Staphylococcus epidermidis or Streptococcus species.
Careful ocular assessment is essential to elicit signs of orbital cellulitis which can be a sight threatening emergency. Worrying features include proptsis, loss of vision, pain on eye movement or an afferent pupillary defect (suggesting compression of the optic nerve)
CT is the imaging modality of choice. Investigations should also include culture of conjunctival discharge and blood culture. Prompt treatment with intravenous antibiotics is indicated.
