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PAEDIATRIC: PBL PRESENTATION

ENURESIS:

Definition: involuntary voiding of urine beyond the age of anticipated control. Diurnal enuresis is daytime wetting, Nocturnal enuresis is nighttime wetting. PRIMARY/SECONDARY

CAUSES:
Alcohol consumption- increases urine production. Attention deficit hyperactivity disorder (ADHD) Caffeine:increases urine production Constipation:when the bowels are full, it can put pressure on the bladder Infection/disease: secondary nocturnal enuresis and with daytime wetting- urinary tract infection )

Insufficient anti-diuretic hormone (ADH) production normally increases ADH hormone levels at night, More severe neurological-developmental issues Patients with mental handicaps have a higher rate of bedwetting problems. Physical abnormalities: small bladder size Psychological Psychological issues e.g., death in the family, sexual abuse, extreme bullying- secondary nocturnal enuresis <neuropsychological disorder, the bedwetting is considered a symptom of the disorder>

Sleep apnea-associated with bedwetting. O/E: Snoring and enlarged tonsils/adenoids are a sign of potential sleep apnea problems

Sleepwalking
Stress- secondary nocturnal enuresis e.g. moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity contributing to returning bedwetting

Unconfirmed, controversial, or mixed causes Heavy sleeping -enuretic children were harder to wake up -possible connection between sleep disorders and ADH production. Insufficient ADH therefore difficult to transition from light sleep to being awake

Improper toilet training

Dandelion- reputed to be a potent diuretic *In French dandelions are called pissenlit, which means "urinate in bed"; likewise "piscialletto", an Italian folkname, and "meacamas" in Spanish

CAUSES:
Incomplete emptying of the bladder Irritable bladder Constipation Stress Urinary tract infection Urgency (not making it to the bathroom in time) Anatomic abnormality Poor toileting habits Small bladder capacity Medical conditions like overactive bladder disorder

diabetes mellitus diabetes insipidus bladder outlet obstruction, small bladder capacity detrusor instability urethral valves meatal stenosis cerebral palsy spina bifida pelvic mass impacted stool sedating medications nocturnal seizures

Secondary etiologies of urinary incontinence include urinary tract infections (UTIs), chronic kidney disease, hypercalcemia, hypokalemia, chemical urethritis, constipation, diabetes mellitus or insipidus, sickle cell anemia, seizures, pinworm infection, spinal dysraphism, neurogenic bladder, hyperthyroidism, sleep-disordered breathing, drugs (selective serotonin reuptake inhibitor, valproic acid, clozapine) and giggle or stress incontinence. abnormalities of the urinary tract, making ultrasonography or uroflowmetry indicated. Otherwise, anatomic abnormalities are rarely associated with either nocturnal or diurnal enuresis such that invasive studies are generally contraindicated. Urinalysis and urine culture will rule out infectious causes and the elevated urine osmolality associated with diabetes mellitus.

MEASURING BLOOD PRESSURE


Sphygmomanometer with a proper cuff size (to cover 2/3rd of the upper arm or should be 20% wider than the diameter of the upper limb) Improperly sized cuffs : -narrow cuff: spuriously high BP -bigger cuff: spuriously low BP Measured in terms of mmHg SYSTOLIC BP-appearance of successive sounds DIASTOLIC BP- appearance of diastolic knock or a sudden muffling of sounds

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