Abdominal and neuro lectures

Question 1

What’s:

• foetor oris + example of condition

Answer 1

Foetor oris -> bad breath (other conditions: DKA)

Question 2

What can …. indicate in a child? :

• pulse character: weak or bounding
• BP

Answer 2

• Pulse character: weak pulse or bounding pulse -> sepsis
• BP (not indicated here) -> variable in fit/kids & are late signs of disease

Question 3

Abdo exam in kids:

Inspection

What to look at/for?

Answer 3

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

Question 4

Abdo exam in kids

Palpation

What to look for/at?

Answer 4

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)

Question 5

Abdo exam in kids

Auscultation

What to look for/at?

Answer 5

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

Question 6

What the following results may indicate:

A_. Urinalysis_

• ketones on their own (with no increase in glucose)
• nitrates in the urine

B. Bloods

• neutrophils

Answer 6

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

Question 7

Is a green/bile vomit normal?

Answer 7

Green/bile vomit – not normal (bile is yellow as it is produced, while vomiting goes through the stomach and interacts with HCL -> becomes green)

Question 8

12y old girl with abdo pain. Do we do bHCG?

Answer 8

Do pregnancy test in girls from 12 y old presenting with abdo pain

Question 9

Differential diagnosis for abdominal pain in children

Answer 9

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

Question 10

What not to miss in a child presenting with abdominal pain? (other than most common differentials)

Answer 10

Do not miss with abdo pain:

• toxins
• poisons
• pneumonia (R sided – similar presentation to appendicitis due to diaphragmatic irritation)

Question 11

Is a breath-holding spell a seizure?

Answer 11

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

Question 12

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

Answer 12

• 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

Question 13

When a child can get a hypoglycaemic seizure?

Answer 13

Hypoglycaemic seizures -> in diabetic patients, when BM is low -> treat the underlying cause

Question 15

Situations that may mimic seizure

Answer 15

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

Question 16

Simple seizure classification

Answer 16

A. Focal

B. General

Question 17

What’s a focal seizure?

What are its subtypes?

Answer 17

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

Question 18

Subtypes of generalised seizure (just mention what they are, do not describe)

Answer 18

Generalised seizures:

• absence
• tonic-clonic
• myoclonic
• gelastic

Question 19

Describe an ‘absence’ seizure

Answer 19

• 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)

Question 20

Characteristics of tonic-clonic seizure

Answer 20

• Tonic-clonic – loss of posture, falling, saliva – then stiff, jerky movements, incontinence

Question 21

What’s status epileptics?

How long must it last for and why?

What’s the treatment?

Answer 21

• 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)

Question 22

What’re a myoclonic seizure’s characteristics?

Answer 22

• Myoclonic -> brief jerky movements, single sudden jerk-like moment (different as in clonic the jerky moments are recurrent)

Question 23

Why do gelastic seizures happen?

What they are?

Answer 23

• 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)

Question 24

What is the difference between primary and secondary seizures?

Answer 24

Epilepsy:

1. Primary -> no underlying cause
2. Secondary -> due to a cause: HI, hypoxia, tumours

Question 25

Diagnostic workout for the seizures (three primary questions we need to find the answer to)

Answer 25

Diagnostic workout:

1. Is that a seizure
2. What’s type
3. What is the cause

Question 26

What’s juvenile myoclonic epilepsy

Answer 26

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

Question 27

Management of seizures

• Examples for: local, Juvenile Myoclonic Epilepsy
• When to stop medications

Answer 27

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

Question 28

Advice to the parents: what NOT TO DO in case of witnessing an epileptic attack

Answer 28

Advice to parent:

Don’t:

• Do not restrain
• Do not try to forcefully open mouth
• Do not try to give medicine forcefully

Question 29

Advice to the parents: what TO DO in case of witnessing an epileptic attack

Answer 29

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

Question 30

Triggers for a person with epilepsy

Precautions

Answer 30

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