Block test preparation Flashcards
Discuss the causes of pain in a patient with HIV/AIDS
- Oral cavity: aphthous ulcers, candida, herpes
- Abdominal pain: UTI, colitis, pancreatitis, hepatitis
- Headaches: sinusitis, meningitis, encephalitis
- Neuromuscular: encephalopathy
- Ears: otitis media and externa
- Skin: sores and rashes
- Chest: pneumonia/TB
- ART side effects: diarrhoea, headache, muscle pain
- Procedural pain
List the components of total pain
- Physical
- Emotional
- Social
- Spiritual
Discuss the pharmacological management of chronic pain in a 5-year old child,
according to the WHO. Also mention the special considerations.
Management:
• Level 1: non-opioid analgesics (NSAIDS and paracetamol)
• Level 2: weak opioids with/without non-opioids
• Level 3: strong opioids with/without non-opioids
Special considerations according to the WHO:
• “by the clock”
o for persistent pain use a regular schedule
o give breakthrough doses if needed
• “by the mouth”
o give orally where possible
§ simplest
§ most effective
§ least painful
o if oral route is not an option, DON’T use IMI route
• “by the individual”
o dose paracetamol and NSAIDS according to weight
o consider capacity to metabolise
§ malnourished children will have a low metabolism
o use the lowest effective dosage for effective pain relief with
acceptable side-effects
o always titrate opioids
o don’t be scared to use morphine, BUT don’t use codeine
Discuss the pathophysiology of pallor (not anaemia)
- Hypoperfusion
- Anaemia
- Metabolic
- Asphyxia
- Oedema
Discuss how you would approach a pale child
A. Determine whether pallor is acute or chronic B. History • Duration • Other associated symptoms C. Determine the vital signs D. Observe the colour of the child • Skin: not a good indicator for anaemia • Mucous membranes of the mouth • Conjunctiva • Creases of hyperextended hand E. Determine the primary affected system F. Plan investigations and/or management
Discuss the pathophysiology of anaemia (not pallor)
- Decreased haemoglobin
- Decreased production of RBC
- Haemolysis (metabolic)
- Increased destruction (at the spleen)
- Chronic blood loss (leukaemia)
Discuss the characteristics of a lymph node and when you should worry in children
• AGE: Usually benign in children
• CONSISTENCY: Hard and firm LNs indicate malignant
• FIXATION: fixed LNs
• TENDERNESS: tender lymph nodes are worrisome
• LOCATION: supraclavicular lymphadenopathy has the highest risk of
malignancy. Epitrochlear nodes are always abnormal. Isolated inguinal
adenopathy is less likely to be malignant
• SIZE: worrisome if size is 1.5-2cm
• DURATION: nodes lasting more than 2 weeks and showing progression is
worrisome
• ASSOCIATED SYMPTOMS: fever, night sweats, weight loss, bone pain,
petechiae
List the common infectious causes of generalized lymphadenopathy
a. HIV
b. CMV
c. TB
d. Toxoplasmosis
e. Lymphocytic interstitial pneumonitis
What is the significance of enlarged groin lymph nodes in a two-month-old child?
a. Sign of acute regional infection
b. Sign of haematological and other malignancies
c. Sign of TB infection
d. Investigations:
i. Fine needle aspiration to dx TB
ii. Resections of an entire node to diagnose lymphoma
Examining lumps and bumps
Site, Size, Shape, Surface, Skin, Scar Tenderness, Temperature, Transillumination Consistency Attachment Mobility Pulsation Fluctuation
List the signs of childhood cancer
Continued unexplained weight loss
Headaches, often with early morning vomiting
Increased swelling or persistent pain in bones, joints, back or legs
Lump or mass, especially in the abdomen, neck, chest, pelvis or armpits
Development of excessive bruising, bleeding or rash
Constant infections
A whitish colour behind the pupil
Nausea which persist or vomiting without nausea
Constant tiredness or noticeable paleness
Eye or vision changes occurring suddenly and persist
Recurrent or persistent fevers of unknown origin
List the warning signs of cancer in children
Seek : Medical help for persistent symptoms
Eye : White spot, bulging eye, blindness
Lump : Abdomen and pelvis, head and neck, testes, gland, limbs
Unexplained : Fever, loss of weight and appetite, pallor and fatigue,
Aching : Bones, back, joints and easy fractures
Neurological signs : Change in behaviour, balance, gait and milestones
Define a wheeze and state the most common origin.
Continuous, high-pitched whistling sound, accompanied by a prolonged expiration.
Usually from an intra-thoracic origin.
List and discuss three collateral signs of an infant with a wheeze
a. Hyperinflated chest • Increased AP diameter • Loss of cardiac and liver dullness on percussion • Liver inferiorly displaced b. Hoover sign • Paradoxical inward movement of subcostal area during inspiration c. Prolonged expiration • Due to intra-thoracic obstruction
Give a differential diagnosis for an infant with a
wheeze
- Foreign body aspiration
- Asthma
- GORD
- Cystic fibrosis
- Reactive airway disease
- Airway malformation
- Bronchiolitis
- Bronchiectasis
- Bronchomalacia/tracheomalacia
List the typical features of asthma
• More than 1 typical symptom o Wheeze o SOB o Cough o Tight chest • Worse at night or early morning • Symptoms vary over time and in intensity • Usually triggered
List the features of an allergic face in a child
- Periorbital shiners
- Denni-Morgan lines
- Conjunctivitis
- Nasal crease
- Upturned nose
- Long face due to excessive mouth breathing
Provide reasons for poor asthma control
- Inhaler skills
- No medication
- Ongoing triggers
- Wrong diagnosis (asthma responds to bronchodilators)
- Co-morbid conditions eg. allergic rhinitis
- Adherence
- Understanding
How would you assess the degree of control in an asthmatic child?
- Coughing
- Waking up at night due to asthma symptoms
- Using reliever medication more than twice a week
- Exercise induced asthma
List 5 cyanotic heart diseases
Truncus arteriosus Transposition of the great arteries Tricuspid atresia Tetralogy of Fallot Total anomalous pulmonary venous return
List 5 acyanotic congenital cardiac lesions.
- Ventricular Septal Defect
- Atrial Septal Defect
- Patent Ductus Arteriosus
- Atrio-Ventricular Septal Defect
- Endocardial Cushion Defect
Give a list of the modified Jones criteria and when the disease will be diagnostic
5 Major Criteria Carditis Polyarthritis Sydenham chorea Erythema marginatum Subcutaneous nodules
5 Minor Criteria Increased PR interval on ECG Arthralgia Increased CRP?ESR/WBC Fever History of previous RF
Diagnosis:
- Evidence of strep infecion
- Two major/one major + two minor criteria
List five signs of cardiac failure
- Tachypnoea
- Tachycardia
- Hepatomegaly
- Raised JVP
- Oedema
How would you treat cardiac failure?
- Preload decrease – diuretics
- Increase contractility – inotropes/digoxin
- Decrease afterload – vasodilators
- Control compensatory mechanisms – B-blockers
List the characteristics of nephrotic syndrome
- Proteinuria
- Hypalbuminaemia
- Oedema
- Hyperlipidaemia
List the clinical features you would find in a child with nephrotic syndrome
- Periorbital oedema
- Peripheral oedema
- Ascites
- Anasarca (generalized oedema)
List the main secondary causes of nephrotic syndrome
- Post-infectious glomerulonephritis
- Chronic infections eg. Hep B and HIV
- Drugs eg. ACE inhibitors
- Vasculitis eg. Henoch-Schönlein Purpura
- Auto-immune diseases eg. SLE
List the main complications of nephrotic syndrome
- Infections – capsulated organisms like S. pneumoniae
- Thrombosis
- Hernias
- Volume depletion and acute renal failure
- Decreased proteins = hypothyroidism, rickets, iron deficiency
- Protein-energy malnutrition
List the features of a child with DKA
- Acidotic breathing
- Nausea
- Vomiting
- Abdominal pain
- Decreased LOC
- Coma
What are the biochemical criteria for DKA?
- Hyperglycaemia (BG > 11 mmol/l)
- Venous pH <7.3
- Serum bicarbonate < 15 mmol/l
- Ketonuria
Discuss DKA management
K – Potassium
I – Insulin
N – nasogastric tube in comatose patient
G – glucose administration once serum levels drop
F – Fluid infusion (corrected sodium)
U – urea and creatinine monitoring every 4 hours
NB: do not give NaHCO3 (bicarbonate)
Dawn phenomenon vs Somogyi effect
Dawn:
Relatively normal glucose until 3am then starts to rise
Hyperglycemia on awakening due to release of counter-regulatory hormones in pre-dawn hours eg growth hormone
Reduced tissue sensitivity to insulin between 5-8am
Endogenous insulin secretion decreases
Somogyi:
Nocturnal hypoglycemia (from fasting) leads to surge of counter-regulatory hormones eg glucagon and epinephrine that produce early morning hyperglycemia
Rebound hyperglycemia
Due to excessive amounts of exogenous insulin
Long term diabetic complications
Macrovascular: Coronary artery disease Diabetic myonecrosis Peripheral vascular disease Stroke
Microvascular: Retinopathy Neuropathy Nephropathy Cardiomyopathy Encephalopathy
List the five major causes of under-5 mortality in South Africa which can be
prevented by important interventions such as PMTCT, EPI and IMCI.
- HIV/AIDS
- Acute respiratory infections
- Prematurity
- Birth asphyxia/trauma
- Diarrhoea
Discuss the levels of prevention
- Primordial
Health promotion
Prevent lifestyle factors with high disease risk
Target groups where risks are not yet high
2. Primary prevention Health promotion Health education Nutrition Personal development Education Housing Recreation Specific protection Immunisation Personal hygiene Environmental controls Protection from occupational hazards and accidents
3. Secondary prevention Early diagnosis Screening Case-finding Prompt treatment Arrest disease process
4. Tertiary prevention Treatment Prevention or limitation of disability Rehabilitation Retrain remaining capacities maximally Retrain maximal independence including employment
Which vaccines are contra-indicated in immunocompromised individuals and why?
Live attenuated vaccines can cause active disease in these individuals • MMR • Yellow fever • BCG • Influenza • Chicken Pox (VZV) • Endemic typhus • Polio oral and rota oral • Typhoid
List the signs of kwashiorkor
• Growth failure • Oedema • Dermatosis • Immune suppression • Others o Mental changes o Atrophic bowel - diarrhoea o Liver changes - fatty o Glucose intolerance - hypoglycaemia o Anaemia o Purpura due to thrombocytopenia
What are the five poor prognostic signs of severe kwashiorkor?
- Severe infection
- Hypothermia
- Liver- jaundice
- Hypoglycaemia
- Collapse due to dehydration
SAM vs MAM
W/H Z score
MUAC
Bilateral pitting oedema of nutritional origin
Discuss the ten steps of SAM management according to the WHO
- Treat/prevent hypoglycaemia
- Treat/prevent hypothermia
- Treat/prevent dehydration
- Correct electrolytes
- Treat/prevent infection
- Correct micronutrients
- Start cautions feeding
- Achieve catch-up growth
- Support emotionally and psychologically
- Prepare for discharge and follow-up
Cerebral palsy
Definition
Insult to the developing brain which leads to a permanent damage in posture and
movement.
Cerebral palsy
Causes
- Vascular
- Infection
- Genetic
- Toxins
- Metabolic
Cerebral palsy
Early signs
- Sparse movement
- Poor/high pitched cry
- Asymmetry of movement
- Spontaneous clonus
- Motor developmental delay
- Tonic bite
- Abnormal movements
- Poor head control
- Truncal hypotonia
Cerebral palsy
Clinical presentation
- Upper Motor Neuron Signs
- Pathological Reflexes
- Limbs may be hypertonic & with abnormal posture
- Increased Tone
- Delayed Gross motor milestones
- Contractions
- Primitive reflexes integrate later
Cerebral palsy
Co-morbidities
- Feeding problems
- Orthopaedic problems
- Constipation
- Visual and hearing impairment
- Perceptual problems
- Reflux
- Oral Hypersensitivity & drooling
- Behavioural problems
- Learning difficulties
- Epilepsy
- Mental retardation
- Speech problems
Classification of simple vs complex febrile seizure
Duration Phenotype Recurrence frequency Prior neurologic diagnosis Poct-ctal pathology
An 18-hour old well looking neonate presents with yellow discoloration of the
eyes. What would your most likely diagnosis be?
- Biliary atresia
- Congenital CMV infection
- ABO incompatibility
- Rh-incompatibility
- Hypothyroidism
- Gilbert syndrome
When will a child be diagnosed with non-physiological jaundice
• Onset before 24h • Rise > 8.5 mmol/l/h • Signs of underlying illness o Vomiting o Lethargy o Poor feeding o Excessive weight loss o Tachypnoea o Temperature instability • > 8d term, 14d preterm • Direct bilirubin > 34 mmol/l at any time
What are the causes for conjugated hyperbilirubinemia?
• Alagille syndrome • A-antitrypsin deficiency • Biliary atresia • Bacterial o UTI o Sepsis o Syphilis • Choledochal cyst • Cystic fibrosis • Caroli’s disease • Drugs and toxins
Teratogen definition
A drug, chemical, infections or physical agent, maternal disease or metabolic agent
that by acting on the developing foetus can cause a structural or functional
abnormality present at birth
Describe the features of a child with FAS
• Small stature • Microcephaly o Mental deficiency o Poor fine motor skills o Hyperactivity • Facial dysmorphisms o Short nose o Inner epicantic folds o Smooth philtrum o Thin upper lip o Small midface • Others defects: o Cardiac – septal defects o Skeletal
List the important clinical features of dehydration
- Dry mouth and mucosa
- Reduced urine, sweat and tears
- Sunken eyes and fontanelle
- Reduced skin turgor
- Acidotic breathing
- Restlessness and irritability
- Prolonged capillary filling time (>3s)
- Hypotension and shock with tachycardia
- Apathy to coma and convulsions
List and discuss the complications of diarrhea in a child
• Dehydration Can lead to shock which includes cerebral complications, NEC and lung shock • Metabolic acidosis o Loss of base in stools, poor tissue perfusion, starvation and decreased renal H+ clearance o Kussmaul breathing (compensatory breathing) o Peripheral vasoconstriction o Neonates can present without clinical signs • Electrolyte disturbances o Hypokalaemia § Weakness and hypotonia § Cardiac arrhythmias § Ileus o Hyponatraemia § Early: N+V, muscles twitching and lethargy § Late: seizures and coma o Hypernatremia § Water moves from intracellular to extracellular and masks clinical signs of dehydration § Intracellular brain loss: irritability and convulsions • Associated features o Fever o Convulsions o Ileus o Protein losing enteropathy o NEC • Dysfunctional gut o Decreased digestion and absorption
List the constituents of SOROL
Na K Cl Base Glucose
A 10 month old infant present to casualties with a two day history of severe vomiting and
diarrhoea. He is lethargic and has signs of dehydration and shock. His weight is 10kg
A) Describe the steps you would take to resuscitate this child. Mention the type of fluid,
amount and administration route.
- If shocked: IV fluids
- Gain IV access through IV line or interosseous line
- Give ringers or 0.9% saline 20ml/kg bolus (ISOTONIC FLUIDS!)
- Reassess child
- If more needed: another 10-20ml/kg bolus
- Give ORS 10-15 ml/kg/h
List the possible causes for acute diarrhoea in childhood.
• Viral o Rotavirus o Calicivirus o Norovirus o Enteric adenovirus o CMV • Bacterial o Salmonella o Shigella o S. aureus o Vibrio cholera o E. coli
How can acute diarrhoea in children be prevented?
- Hygiene and sanitation
- Exclusive BF for 6 months
- Prevent malnutrition and intervene early
- Immunize eg. measles and rotavirus
List 5 causes of chronic diarrhea
Crohn's disease Ulcerative colitis Cystic fibrosis Coeliac disease Cow's milk intolerance
Discuss the features of Measles in a child
- Cough
- Coryza
- Conjunctivitis
- Concurrent fever and rash
- Coplik spots (Koplik)
- Cephalocaudal spreading rash
Discuss the complications of Measles
- Immune suppression
- Acute encephalitis
- Diarrhoea
- Otitis media
- Corneal ulceration
- LTB
- Encephalopathy
- SSPE (subacute sclerosing panencephalitis)
Meningitis complications
- Subdural effusion
- Sepsis
- Shock
- Abscess of brain
- Oedema of brain
- Infarct of brain
- Deafness
- DIC
- Hydrocephalus
- Empyema
- Palsies of CNs
Name the diagnostic criteria of Kawasaki disease
Name the diagnostic criteria of Kawasaki disease
A. 5-day fever
AND
B. 4 of 5:
• Conjunctivitis – non-exudative and bilateral
• Rash – non-vesicular and polymorphous
• Adenopathy – cervical and usually unilateral
• Skin – oral mucosa/lips are red OR lips are peeling/crusting
• Hands – oedema or erythema of hands/feet
