7/11/21 Flashcards
Difference in presentation between cystitis and pyelonephritis in paediatrics.
- UTI/Cystitis → dysuria, frequency, urgency and lower abdominal discomfort
- Pyelonephritis → systemic features such as fever, malaise, vomiting and loin tenderness
Paediatrics: Duration of ABx for cystitis vs pyelonephritis. When are IV ABx required?
- if seriously unwell or <3 months → admitted for IV ABx
- if cystitis → 3-7 day course of ABx
- if pyelonephritis → 7-10 day course of ABx
ABx for non-severe pyelonephritis, be specific. (paedaitrics)
- trimethoprim + sulfamethoxaole 4+20mg/kg up to 160+800mg orally BD for 10/7. If clinical response is rapid, stop therapy after 7 days
OR
1. trimethoprim 4mg/kg up to 150mg orally, 12 hourly for 10/7. If clinical response is rapid, stop therapy after 7 days
- Cefalexin 12.5mg/kg up to 500mg PO Q6H for 10/7. If clinical response is rapid, stop therapy after 7 days
Clinical Feature of Paediatric Vulvovaginitis (4 points)
- Itching in the vaginal area
- Discharge from the vagina
- Redness of the skin of the labia majora
- Dysuria
Causes of Paediatric Vulvovaginitis (4 points)
- Lining of the vagina can be quite thin and therefore easily irritated.
- Moisture and dampness around the vulva → worsened by tight clothing or being overweight
- Irritants → soap residue, bubble baths, antiseptics
- Threadworms can sometimes cause or worsen vulvovaginitis → children with threadworms often scratch at night
Management points for Paediatric Vulvovaginitis (4 points)
- Wear loose cotton underwear and avoid tight jeans
- Maintain healthy weight - diet and exercise
- Don’t use a lot of soap in the bath or shower → remove soap residue
- Avoid bubble baths and antibacterial products
- Vinegar Baths → add half cup of white vinegar to shallow bath and soak for 10-15 mins. Daily for a few days
- Soothing Creams → soft paraffin or nappy-rash cream → settles the soreness as well as protect the skin from moisture.
History taking of a Straddle Injury (paeds) (7 points)
- Mechanism of Injury
- Timing and Setting of Injury
- First Aid
- Inability to pass urine or faeces
- Other Injuries
- Witnesses
- Consider whether injury is consistent with history → ?NAI
Management of a straddle injury. Minor vs Non-Minor.
- Contact local forensic paediatric service if concerned re: NAI
- Review Tetanus Status
- If MINOR Injury → bleeding is more and child can void spontaneously
- Salt water baths
- Simple analgesia
- Reduction of strenuous activity for 24/24 - reduce risk of re-injury
- Topical anaesthetic cream or barrier cream → reduce local pain on micturition
- If NON-MINOR injury → ongoing bleeding, laceration borders not visualised, labia minora tear, unable to void, clinician concern
- similar management as minor injury
- consider urethral catheter if unable to void (for example in the context of a vulval haematoma)
- refer to local paediatric team or local gynaecology/surgical service
Post-Natal Check (8 points)
- Enquire about vaginal discharge (lochia) and whether ceased
- Ask about healing of the perineum if vaginal delivery
- Review abdomen (uterus should be impalpable) and Caesarean Wound if present
- Check for any urinary or bowel problems (incontinence)
- Check if breast-feeding and whether there are concerns
- Check if intercourse has resumed and whether there are problems or concerns
- Discuss contraception options
- Advise on post-natal exercises
- Adequate diet, rest and personal care, sleep, exercise
- Psychological Health - Edinburgh Post-Natal Depression Scale , social supports
- Consider Pelvic Examination - checking perineum and pelvic floor strengths
- Cervical Screening Test (if due)
- Review antenatal screening tests for follow-up action - rubella booster
- Other → smoking and alcohol
Clinical Features of Post Natal Depression (4 points)
- difficulty coping with baby
- guilty thoughts of being a bad mother
- excessive anxiety of well-being of the baby
- irritability toward family
Management of Post Natal Depression. Mild to Moderate vs Severe.
Mild-Moderate Depression → psychological therapies
Severe Depression → antidepressants with SSRIs to be considered as first line therapy
Clinical Features of NORMAL CRYING
- at 6-8 weeks of age → a baby cries 2-3 hours per 24 hours
- increases in early weeks of life and peaks at around 6-8 weeks and usually improved by 3-4 months of age
- usually worse in late afternoon or evening but can occur at any time
- infant may draw legs up as if in pain → but NO EVIDENCE that this is due to intestinal pathology
2 main non-pathological causes of normal crying
-
Excessive Tiredness → if infants total sleep duration over 24 hours falls more than an hour short of the average of their age
- Birth - 16 hours
- at 2-3 months - 15 hours
- at 6 weeks - tired after being away for more than 1.5 hours
- at 3 months - tired after being awake for more than 2 hours
- Hunger - more likely if poor weight gain
Points of Management of a crying baby (5 points)
- Engage in partnership with parents → acknowledge concerns, taking time to observe the baby-parent interactions and offer follow-up
- Explain normal crying and sleep patterns
- Use normal crying curve to explain the natural history of a crying infant
- Use a sleep/cry diary to explain the infant’s cry/sleep/feeding patterns
- Encourage parents to recognise signs of tiredness → frowning, clenched hands, jerking arms and legs, crying and grizzling
- Assist parents to help baby deal with discomfort and distress
- Establish pattern to feeding/settling/sleep
- Aim to settle the baby for daytime naps and night-time sleep in a predictable way → quiet play, move to the bedroom, wrap the baby, give the baby a brief cuddle, then settle in the cot while still awake
- Avoid excessive stimulation - noise, light, handling. Excessive quiet should be avoided - gentle music
- Darken the bedroom for daytime sleeps
- Baby massage/rocking/patting
- Provide patient information
- NO ROLE FOR MEDICATION including anti-reflux medication, anticholinergic medications, colic mixtures, simethicone, limited evidence for probiotics use.
Causes of Delirium (9 points)
- Infections → urosepsis, pneumonia and CNS infections
- Metabolic Disturbance → hypo/hyperglycaemia, hyponatraemia
- Medication Toxicity and Drugs and Alcohol Toxicity
- Organ Failure → kidney or liver failure, respiratory failure with hypoxia/hypercapnia
- Intracerebral Events → Stroke, Subdural Haematoma, Haemorrhage
- Cardiac Events → MI, arrhythmias, CCF
- Seizures and Post-Ictal States
- Withdrawal States → from EtOH or benzodiazepines
- Pain and Discomfort → urinary retention or constipation
Delirium Screen (11 points)
- FBE
- UEC
- Calcium
- LFTs
- CRP
- Blood Glucose
- O2 Saturation → with or without blood gas measurement
- Urine Dipstick → urine MCS
- ECG
- CT Brain
- Chest X-Ray
Indications for use of Syringe Driver in Palliative care (6 points)
- Persistent Nausea and Vomiting
- Dysphagia
- Bowel Obstruction
- Coma
- Poor Absorption of Oral Drugs
- Patient Preference
The Final Five Drugs used in a syringe driver for palliative care (5 points + bonus for dosing)
- Morphine - 2.5-5mg via subcut infusion one hourly PRN for pain or dyspnoea
- Metoclopramide - 10mg subcutaneous injection Q4H PRN for nausea
- Haloperidol - 0.5mg subcutaneous injection Q4H PRN for agitation or delirium
- Clonazepam - 2-6 drops sublingually PRN for severe agitation or if sedation required in delirium
- Hyoscine Butylbromide - 20mg subcutaneous injection Q4H PRN for excessive secretions
Non-Pharmacological Management of T2DM (6 points)
Diet - Dietary review
BMI - 5-10% weight loss in those who are overweight/obese with T2DM
Physical Activity → 150mins of physical activity/week plus 2-3 sessions of resistance exercise
Cigarette Consumption → zero cigarettes/day
Alcohol Consumption → ≤2 standard drinks/day
Blood Glucose Monitoring → Advise 4-7mmol/L and 5-10mmol/L post-prandial
Review medication and also patient understanding of treatment and self-management
Diabetes Cycle of Care: 6 month, 12 month, 2 yearly (3,5,1)
6 Monthly
- Weight, Height + BMI
- Blood Pressure
- Assess feet for complication
12 Monthly
- Review and discuss diet, physical activity, smoking status, medications
- Assess diabetes management by measuring HbA1c
- Review and discuss complication prevention → eyes, feet, kidneys and CVD
- Measure Total Cholesterol, Triglycerides, HDL cholesterol
- Assess for microalbuminuria
2 Yearly
- Comprehensive eye examination - more frequent for those who are at higher risk
Diabetic medication changes in context of renal impairment.
Metformin, Sulfonylurea, GLP-1 receptor agonists. (tides), SGLT2 Inhibitors (flozins), DPP4 inhibitors (gliptins), insulin.
- *Metformin**
- eGFR 30-60 → reduce dose → 500mg PO Daily rather than BD → can increased to 1g daily depending on response
- eGFR <30 → contraindicated
- *Sulphonylurea (SU)**
- eGFR <30 → dose reduction (risk of hypoglycaemia increases as eGFR decreases)
- avoid glibenclamide if eGFR <60
- *GLP-1 Receptor Agonist**
- eGFR <30 → contraindicated
- *SGLT2 Inhibitors (dapagliflozin)**
- eGFR <45 → contraindicated (efficacy decreases)
- FLOzin FOrty-Five
- *Gliptins (DPP4 inhibitors)**
- safe with dose adjustment
- No dose adjustment for linagliptin
- *Insulin**
- normal doses titrated to blood sugar levels (risk of hypoglycaemia increases as eGFR decreases)
In the context of CKD - discuss the use of ACEi/ARB. When to cease? What is the other consideration prior to commencing an ACEi or ARB? How do you manage this.
- Essential in patients with CKD → unless drop in eGFR by >25% can continue ACEi/ARB
- Potassium → Caution should be exercised if baseline potassium is 5.5mmol/L → rises in potassium of 0.5mmol/L are expected
- Hyperkalaemia >6.5mmol → predisposes to cardiac arrhythmias
- Management → low K+ diet, potassium wasting diuretics, avoid salt substitutes, resonium → CEASE ACE inhibitor/ARB/Spironolactone if K+ persistently above >6.0 and non-responsive to above therapies
Differential Diagnoses for Behavioural and Development Problems in Children.
- Autism Spectrum Disorder
- Attention Deficit Hyperactivity Disorder (ADHD)
- Early-Life Trauma
- Post Traumatic Stress Disorder
- Oppositional Defiant Disorder/Conduct Disorder
- Anxiety Disorder
- Global Developmental Delay
- Intellectual Disability
- Language Disorder
- Vision/Hearing Impairment
- Child Abuse
- Fetal Alcohol Syndrome
History questions in context of behavioural and development problem in paediatrics. (8 points)
- FHx of ADHD, learning difficulties, developmental delay, intellectual disability
- Birth History → alcohol or drug use in pregnancy + APGAR scores
- Developmental Milestones - including attachment and behavioural history
- Concerns on previous vision or hearing testing
- Diet History in particular dietary iron intake
- Sleep History → quantity and quality
- History suggestive of absence seizures
- Previous Head Injuries or Concussions
- Symptoms of Hypothyroidism
- Educational Competency
Risk Factors for behavioural and developmental problems in paediatrics (6 points)
- Prenatal Exposure → infection, alcohol, smoking
- Birth Complications → prematurity or birth weight
- Perinatal Infections → herpes simplex virus, Zika Virus
- Medication Conditions → lead poisoning, congenital heart disease
- Genetic Conditions → Down Syndrome, Fragile X Syndrome
- Adverse Childhood or Family Experiences → Poverty including housing or food insecurity, exposure to racism, abuse or neglect
- Parental Unemployment or Mental Health problems
- Parents with limited educations/literacy
- Teenage Parents
Investigations in the context of behavioural and developmental problems in paediatrics. (4 points)
- FBE
- Audiology Testing
- Vision Testing
- Fe Studies
Investigations in the context of considering treatment in a patient with Chronic Hep C Infection (8 points)
Virology
- HCV PCR
- HCV Genotype
- Hepatitis B Serology → Hep B Surface Antigen (HBsAg), anti-HBc, anti-HBs
- HIV
- Hepatitis A Serology
Other
- FBE
- UEC including eGFR
- LFTs
- INR
- Pregnancy
- Liver Fibrosis Assessment → Fibroscan
- Liver U/S → should be performed in patients with cirrhosis to rule out hepatocellular carcinoma
What is involved in the pre-treatment assessment of patient with Chronic Hep C infection? (5 points)
All patients with HCV infection with life expectancy >12months should be considered for treatment
- Virological Evaluation
- confirm diagnosis of chronic HCV infection
- identify genotype of HCV infection
- document the HCV treatment history
- Evaluate for presence of cirrhosis
- Evaluate for presence of HIV or Hepatitis B
- Consider whether coexisting liver diseases are present
- Consider concomitant medications for risk of drug-drug interactions including ethinyloestrodiol-containing oral contraceptives, PPI, statins, OTC preparations and recreational substances
- Discuss the need for contraception
- Discuss the importance of treatment adherence
Causes of Early Pregnancy Bleeding (5 points)
- Ectopic Pregnancy
- Early Pregnancy Loss
- Implantation of Pregnancy
- Threatened Abortion
- Cervical, Vaginal or Uterine Pathology → polyps, inflammation/infection, gestational trophoblastic disease
Investigations in the context of Early Pregnancy Bleeding (3 points)
- Transvaginal Ultrasound → to determine the location and viability of early pregnancy
- Serial Beta-hCG - 48 hours apart
- Maternal Blood Group and Antibody Status
History Questions in Fever in Returned Traveller (8 points)
Signs and symptoms → time of onset
- Arthralgia + Myalgia
- Coryzal Symptoms
- Cough
- Headaches
- Jaundice
- Lymphadenopathy/Petechia/Bruising
- Abdominal Pain
- Vomiting/Diarrhoea/Constipation
- Sick Contacts
Travel Destinations + Timeline
- Urban vs Rural Travel, Altitude
- Possible infections given location
- Incubation Period of given illnesses based on timeline
Nature of Travel → Relevant activities + exposures
- Contact with Animals/Insects/Bites
- Sexual Contacts → use of condoms
- Food → unwashed vegetables, salads, street foods, unbottled water
- Swimming in freshwater
Drugs → prescription, complementary, illicit
General Medical Information → routine childhood and travel immunisations + prophylaxis (malaria)
Examination Findings in Fever in a Returned Traveller
- Evaluation of skin lesions + rashes → rose spots (typhoid), maculopapular (dengue and rickettsia), purpura/petichiae (meningococcal)
- Hepatosplenomegaly + Spelnomegaly
- Lymphadenopathy
- Jaundice
- Retinal or Conjunctival changes
- Genital Lesions
- Neurological Findings
DDx of Fever + Rash in a returned traveller (8 points)
- Dengue Fever
- Chikungunya
- Measles
- Enteric Fever
- Rickettsial Disease
- Acute HIV Infection
- Zika Virus
- Meningococcal
Syphilis Management (9 points)
- RPR testing on day of treatment as baseline
- Infectious Syphilis benzathine penicillin 1.8g IM stat, (weekly for 3 weeks if late latent syphilis)
- Educate regarding Jarisch-Herxheimer Reaction
- Notify State Health Department
- No sexual contact for 7 days following administering treatment
- No Sex with partners from the last 3 months (primary syphilis) and 6 months (secondary syphilis) until the partners have been tested and treated is necessary
- Contact Tracing
- Primary → 3 months plus duration of symptoms
- Secondary → 6 months plus duration of symptoms
- Late-Latent → long-term partners only
- Treat all sexual contacts of patients with primary or secondary syphilis regardless of serology with benzathine penicillin 1.8g IM, stat.
- Test of Cure (RPR testing) → at 3 months, at 6 months and at 12 months
- Consider Testing for HIV and other STIs at the 3 months review
Antiviral Therapy for Shingles. When is it recommended?
- Antiviral therapy is recommended for all patients who present within 72 hours of the formation of the rash or for immunocompromised patients at any time regardless of duration of the rash.
Antiviral Therapy
- valaciclovir 1g TDS for 7/7 (children >2yo -> 20mg/kg up to 1g)
Analgesia options for treatment of Shingles (3 options)
- *Neuropathic Pain**
- (to intact skin only) → lidocaine 5% patch, up to 3 patches applied at the same time to the painful area (after the shingles has healed), wear up to 12 hours then patch-free interval
- can use gabapentinoids in addition to, or as an alternative to, the lidocaine 5% patches
Noiciceptive Pain
Mild Pain
1. Ice Packs + Protective Dressings
2. Paracetamol 1g PO Q4-6H PRN up to max 4g daily
3. if pain severe → Prednisolone 50mg daily mane for 7/7, then taper over 14 days then cease → can reduce duration of pain in combination of anti-viral drug
Alternatives for severe pain:
- Amitryptilline 10-25mg PO nocte, increasing every 7 days to usual maximum dose of 75mg nocte
- OR opioid orally → usual principles of opioid prescribing apply → can start with endone 5mg Q4H (can also use tramadol and tapentadol)
Treatment of Post-Herpetic Neuralgia (6 points)
- Commence management with ice-massage and paracetamol
- Lidocaine 5% patch → up to 3 patches at the same time to painful area. Wear up to 12 hours followed by patch free interval.
- gabapentinoid (pregabalin 75mg PO daily)
- tricyclic antidepressant (amitriptyline 10mg PO)
- Can also consider Transcutaneous Electrical Nerve Stimulation (TENS) daily for 2 weeks
- Can consider opioid analgesic (tramadol 100mg PO daily)
Treatment for Actinic Keratoses (1 point)
- Fluorouracil 5% cream topically, once or twice daily for 2-4 weeks on the face or 3-6 weeks on the arms and legs
- Imiquimod 5% cream topically, at night 3 times weekly for 3-4 weeks. In the morning, wash the treated area with mild soap and water. Review patient at 4 weeks - if lesions persist, repeat treatment once.
- Ingenol Mebutate 0.015% gel topically on the face or scalp, once daily for 3 consecutive days OR 0.05% gel topically on the trunk or limbs, once daily for 2 consecutive days
