Lucas Adamson

Age: 1 year, 7-month-old male

Examiner

Marking Scheme

History

  • Ask when did mum or anyone notice weight loss and diarrhoea.
  • Ask about episodes of diarrhoea per day.
  • Ask if diarrhoea is bloody or with mucus.
  • Ask about vomiting.
  • Ask if he looks to be in pain- crying and drawing legs to his tummy.
  • Ask about abdominal distention.
  • Ask about skin rash –especially immediately or some hours after feeding.
  • Ask about SOB, wheeze, mouth swelling, tongue swelling—to rule out anaphylaxis.
  • Ask about appetite, what type of food he eats and how often he eats.
  • Ask about fluid intake
  • Ask if he is wetting nappies okay.
  • Ask if symptoms have changed since patient was last seen 5 weeks ago (If symptoms have not changed, no need for a F2F).
  • Ask if he has recurrent infections-sore throats, cough/chest infection, UTI’s etc.(recurrent chest infections can point to cystic fibrosis).
  • Ask about family history of bowel disease—particularly coeliac disease
  • Ask about PBIND history – Pregnancy, birth, immunization, nutrition and development. It is important to ask about new born screening to rule out cystic fibrosis.
  • Ask about medical conditions including asthma, eczema (to rule out food allergy).
  • Ask about other people at home- siblings, father etc.
  • ASK ICE- ask mum why she thinks its food allergy.
  • Make a diagnosis of faltering growth or failure to thrive.
  • Explain to mum “from everything you have said to me today, it does sound like your child has a condition we call faltering growth or failure to thrive”. This is a condition where a child’s current weight or rate of weight gain is significantly below that expected of similar children of the same sex, age and ethnicity. There are a number of things that could contribute. You are right that this maybe a food allergy but I do suspect another condition we call Coeliac disease.
  • Coeliac disease is a condition that is caused by an adverse reaction to gluten causing things like diarrhoea, weight loss etc.

Management

Management

  • Offer further blood test-coeliac screen, U and E’s, folate, b12, vitamin d, ferritin, FBC, thyroid function, liver function
  • Offer stool sample for routine culture to rule out infection and calprotectin.

Note: Calprotectin testing is generally not recommended for children under the age of 5. This is because inflammatory bowel disease (IBD) is less common in this age group, and baseline faecal calprotectin levels are naturally higher, making the results more challenging to interpret. However, very early-onset IBD (VEO-IBD) can occur in children less than 5, so it is sensible to offer this to this particular child

  • No need for F2F here as symptoms has not changed
  • Advise mum not to stop gluten containing meals until investigations are done
  • If initial test is positive, then you will refer to specialist. Also, if the test comes back negative, you will also refer to specialist as sometimes the test can come back falsely negative• Advise that if coeliac is confirmed, then the treatment is staying away from gluten. Inform her that she can access a range of gluten free products on prescription and also dietitians are available to guide her
  • Encourage mum to continue to feed but do not force feed
  • Liase with health visitors for constant monitoring of weight
  • Safety net re dehydration-not wetting nappies, lethargy, unwell, blood in stools etc. And follow up in 1 week time to discuss results and see how things are going.

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