Abdominal and neuro lectures Flashcards
What’s:
- foetor oris + example of condition
Foetor oris -> bad breath (other conditions: DKA)
What can …. indicate in a child? :
- pulse character: weak or bounding
- BP
- Pulse character: weak pulse or bounding pulse -> sepsis
- BP (not indicated here) -> variable in fit/kids & are late signs of disease
Abdo exam in kids:
Inspection
What to look at/for?
Abdo exam in kids:
Inspection:
- inspect the gait as a child comes in (a lot of pain or not)
- bruising, rashes, lumps, scars, distention/shape of the abdomen
- pallor/ anaemia -> look at the face while inspecting
Abdo exam in kids
Palpation
What to look for/at?
Palpation
- Ask where the child is sore and start away from the pain
- All boys with abdo pain -> check testicles (in case of hernia/torsion)
- Guarding -> abdomen goes rigid if you touch it (difficult in a kid to say if that was voluntary or involuntary) -> distract them by talk (ask about interests, football etc)
Abdo exam in kids
Auscultation
What to look for/at?
Auscultation
- Tingling bowel sounds -> obstruction
- Normal bowel sounds
- No bowel sounds -> peritonitis, ileus, sepsis
- Hyperactive ( normal but a lot of them ) -> gastroenteritis due to a lot of going on within the bowel / increased activity
*possibly press with the stethoscope to assess for peritonitis / guarding
What the following results may indicate:
A_. Urinalysis_
- ketones on their own (with no increase in glucose)
- nitrates in the urine
B. Bloods
- neutrophils
A. Urinalysis
- Ketones on their own (with no glucose increased) -> have not been eaten
- Nitrates in the urine -> E.coli (in 50% of infections)
B. Bloods
- Neutrophils -> bacterial infection
Is a green/bile vomit normal?
Green/bile vomit – not normal (bile is yellow as it is produced, while vomiting goes through the stomach and interacts with HCL -> becomes green)
12y old girl with abdo pain. Do we do bHCG?
Do pregnancy test in girls from 12 y old presenting with abdo pain
Differential diagnosis for abdominal pain in children
Differential diagnosis:
- Appendicitis
- UTI
- gallstones + cholecystitis
- gastroenteritis
- DKA
- colitis (e.g. bowel, Crohn’s, infective -> depends on Hx)
- obstruction (volvulus, constipation, Coeliac)
- Hepatitis (jaundice + Hx)
- testicular torsion
- ovarian torsion (female)-> often associated with vomiting
- ectopic pregnancy (in adult/teen)
- pancreatitis
What not to miss in a child presenting with abdominal pain? (other than most common differentials)
Do not miss with abdo pain:
- toxins
- poisons
- pneumonia (R sided – similar presentation to appendicitis due to diaphragmatic irritation)
Is a breath-holding spell a seizure?
Breath holding spell -> it is not a seizure; triggered by emotional distress
Breath-holding spell - ‘seizurelike’ episodes in which children cry and hold their breath to the point of cyanosis and loss of consciousness. Their examination or investigation findings are normal and referral to a pediatric specialist results in no further investigation
- Thee are common (among children 6-48 months), frightening to watch episodes; however, they are paroxysmal and benign with no further negative outcome
- Once a clinical diagnosis is made, it is recommended to conduct an electrocardiogram and to rule out anemia, but no further investigation or referral is warranted
Febrile seizure
- common age range and why
- what do we need to exclude in a child presenting with a febrile seizure
- what is the prognosis for a child with febrile seizure
- Febrile seizure 6 months – 6 years old -> lower threshold for seizures
- important: fever may happen as part of meningitis -> need to exclude that a child does not have seizures due to meningitis -> look at signs and symptoms
- Febrile seizure: one off event, no risk of developmental delay
When a child can get a hypoglycaemic seizure?
Hypoglycaemic seizures -> in diabetic patients, when BM is low -> treat the underlying cause
Situations that may mimic seizure
Situations that may mimic seizure
- Difficult to distinguish seizures vs normal neonatal movements
- Nightmares/night terrors may mimic seizures
- Confusional migraines -> symptoms of a migraine and seizures
Simple seizure classification
A. Focal
B. General
What’s a focal seizure?
What are its subtypes?
Focal seizure – abnormal discharge in one area of the brain/one hemisphere (symptoms depend on location); may have aura – due to abnormal electrical activity
- Focal with LOC
- Focal without LOC
Subtypes of generalised seizure (just mention what they are, do not describe)
Generalised seizures:
- absence
- tonic-clonic
- myoclonic
- gelastic
Describe an ‘absence’ seizure
- Absence - unresponsive, vacant for few seconds (may happen several times a day); EEG – 3 Hz spike-wave (3 spikes and waves in 1 s) – may be induced by clinical manoeuvre -> hypoventilation (synchronises few abnormal electrical signals creating the seizures)
Characteristics of tonic-clonic seizure
- Tonic-clonic – loss of posture, falling, saliva – then stiff, jerky movements, incontinence
What’s status epileptics?
How long must it last for and why?
What’s the treatment?
- status epilepticus – 5 minutes (or more) lasting seizure
- as a seizure lasting >5 minutes can self-amplify, cause hypoxia and result in long term brain and soft tissues injury; also electrolyte imbalance -> kidney failure
- give rescue medication (outside of the hospital): Buccal midazolam (benzodiazepine)
What’re a myoclonic seizure’s characteristics?
- Myoclonic -> brief jerky movements, single sudden jerk-like moment (different as in clonic the jerky moments are recurrent)
Why do gelastic seizures happen?
What they are?
- Gelastic -> in pass mostly due to hypothalamic hamartoma; developmental abnormality in hypothalamus due to hemartoma (benign mas of disorganised neurones and glial cells - congenital malformation) = seizures
- includes spells of laughter (with no joy) or crying
Also associated with: temporal and frontal lobe lesions, tumours, atrophy, tuberous sclerosis, hemangiomas, and post-infectious foci, but mainly hypothalamic hamartomas
More info on gelastic seizures:
- usually, manifest itself between age 3-4
- areas: hypothalamus, temporal lobe
- usually, do not respond to medication
- the approach is to treat the cause, e.g. to remove the tumour
- if interfere with hypothalamic-gonadal axis - may cause precious puberty (hormonal Rx)
What is the difference between primary and secondary seizures?
Epilepsy:
- Primary -> no underlying cause
- Secondary -> due to a cause: HI, hypoxia, tumours
Diagnostic workout for the seizures (three primary questions we need to find the answer to)
Diagnostic workout:
- Is that a seizure
- What’s type
- What is the cause
What’s juvenile myoclonic epilepsy
Juvenile Myoclonic Epilepsy (JME) -> episodes of a single jerky movements – myoclonic seizure (e.g. while brushing teeth, opening door), very brief – lasting less than 1 s
* usually occur in an otherwise healthy child
* associated with sleep deprivation or alcohol consumption (sometimes photic stimulation)
* either sporadic or genetic (but multifactorial)
* usually respond quickly and completly to anti-seizure meds
* frequency will usually decrease with age, but most people require life- long anti-seizure meds
Management of seizures
- Examples for: local, Juvenile Myoclonic Epilepsy
- When to stop medications
Management
Choice: depends on type of seizure and patient’s profile
- Examples:
Benzodiazepines -> focal seizures
JME -> do not use sodium valporate (as it is teratogenic and causes weight gain)
*but UpToDate states that Valproate is the most effective so it’s 1st line. If not use Topiramate, Lamotrigine - or other drugs - depends on patient profile
- Stop medicine: 2 years of being seizure-free
Advice to the parents: what NOT TO DO in case of witnessing an epileptic attack
Advice to parent:
Don’t:
- Do not restrain
- Do not try to forcefully open mouth
- Do not try to give medicine forcefully
Advice to the parents: what TO DO in case of witnessing an epileptic attack
Do:
- Remove dangers from surroundings (e.g. objects, electricity sources)
- Try to prevent aspiration of saliva -> recovery position
- Buccal Midazolam – give after 5 minutes -> rescue medication plan
- If no rescue medication plan -> call the ambulance after 5 minutes
- Time the event
- Video record seizure on a mobile phone is that’s a new episode
Triggers for a person with epilepsy
Precautions
Triggers for a person with epilepsy: lack of sleep, screens (iphones etc in the bed + sleep hygiene maintained), missed dose of medicines
Precautions: swimming (unsupervised), driving
