Child health Flashcards
1
Q
What is perthes disease?
A
childhood orthopaedic condition characterized by idiopathic avascular necrosis of the femoral head
2
Q
who does perthes disease occur in?
A
boys, aged 4-8
3
Q
Aetiology of perthes disease?
A
HLA, genetic predis, vascular abn, trauma
4
Q
staging of perthes disease?
A
Catteral staging
5
Q
features of perthes disease
A
> Pain - most common.
limping - antalgic or trendeleburg
limited motion
leg length discrepency
6
Q
what is trendeleburh due to?
A
abductor weakness
7
Q
pain in perthes disease?
A
> pain localized to the hip, groin, or medial thigh.
The pain may be aggravated by activity and alleviated by rest.
In some cases, pain may be referred to the knee
8
Q
radiological findings of perthes disease?
A
Findings include femoral head fragmentation, sclerosis, and flattening.
9
Q
scans used for perthes?
A
> MRI - can detect early stages
bone scintigraphy
10
Q
Cons management of perthes?
A
> pain management: analgesic, anti-inflammtories
physical therapy
orthotic devices
11
Q
surgical management of perthes?
A
> Indications for surgery include persistent pain, progressive deformity, or failed conservative management
12
Q
complications of perthes?
A
> residual deformaty
osteoarth
leg length discrepancy
femoracetabular impingement
avascular necrosis recurrence
13
Q
DDH?
A
> Often picked up on newborn examination
Barlow’s test, Ortolani’s test are positive
Unequal skin folds/leg length
14
Q
Transient synovitis (irritable hip)
A
> Typical age group = 2-10 years
Acute hip pain associated with viral infection
Commonest cause of hip pain in children
15
Q
FEATURES OF PERTHES DISEASE xr
A
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
16
Q
slipped femoral epiphysis epi?
A
> Typical age group = 10-15 years
More common in obese children and boys
17
Q
how does slipped uppe femoral epiphysis present?
A
May present acutely following trauma or more commonly with chronic, persistent symptoms
18
Q
features of slipped upper femoral epiphysis?
A
knee or distal thigh pain is common
loss of internal rotation of the leg in flexion
19
Q
features of juvenile idiopathic arthirits?
A
joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
20
Q
JIA is?
A
limp
21
Q
what can be positive in JIA?
A
ANA - assoc w anterior uveitis
22
Q
septic arthi?
A
Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint
23
Q
SUFE epi?
A
> head of femur slips along growth plate
more common in boys and obese children
24
Q
presentation of SUFE?
A
The typical exam presentation is an adolescent, obese male undergoing agrowth spurt. There may be a history ofminor traumathat triggers the onset of symptoms. Suspect SUFE if the pain is disproportionate to the severity of the trauma.
25
Sx of SUFE?
> Hip, groin, thigh or knee pain
> Restricted range of movement in the hip
> Painful limp
26
SUFE examination?
When examining the patient, they will prefer to keep the hip in external rotation. They will have limited movement of the hip, particularly restricted internal rotation.
27
SUFE dx?
> XR
> BTs normal
> bone scan, CT, MRI
28
Mx of SUFE?
Surgery - returns femoral head to correct position
29
septic arthiritis is most common in?
kids under 4
30
septic arthiritis is a common comp of?
joint replacement
31
presentation of SA?
Septic arthritis usually only affects a single joint. This is often a knee or hip. It presents with a rapid onset of:
> Hot, red, swollen and painful joint
> Refusing to weight bear
> Stiffness and reduced range of motion
> Systemic symptoms such as fever, lethargy and sepsis
32
Most common cause of SA?
> STAPH A
> Neisseria gonorrhoea (gonococcus) in sexually active teenagers
33
Ix in SA?
> joint aspiration b4 ab if poss - send for gram staining, culture, ab sensitivities
34
Mx of SA?
> IV ab
> surg drainage and washout of joint
35
what is osteomyelitis?
> inflammation of bone, usually due to bacteria - mostly staph aureus
36
key RF for osteomyelitis?
> open fractures
> Orthopaedic operations, particularly with prosthetic joints
> Diabetes, particularly with diabetic foot ulcers
> Peripheral arterial disease
> IV drug use
> Immunosuppression
37
The typical presentation of osteomyelitis is with:
> Fever
> Pain and tenderness
> Erythema
> Swelling
38
osteomyelitis XR findings?
> often normal in early disease
> Periosteal reaction (changes to the surface of the bone)
> Localised osteopenia (thinning of the bone)
> Destruction of areas of the bone
39
Imaging for osteomyelitis?
> MRI
> Blood tests will show raised inflammatory markers (e.g., WBC, CRP and ESR).
> Blood cultures and bone cultures
40
Mx of osteomyelitis?
> Surgical debridement of the infected bone and tissues
> Antibiotic therapy
41
Ab req for acute osteomyelitis?
> 6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks
42
Alt to flucloxacillin for osteomyelitis?
> Clindamycin in penicillin allergy
> Vancomycin or teicoplanin when treating MRSA
43
chronic osteomyelitis?
usually requires 3 months or more of antibiotics.
44
diagnosis of SA?
> The Kocher criteria for the diagnosis of septic arthritis:
> fever >38.5 degrees C
> non-weight bearing
> raised ESR
> raised WCC
45
Red flags that may indicate an underlying serious disease or condition in a child presenting with an acute limp include
Pain waking the child at night — may indicate malignancy.
Redness, swelling, or stiffness of the joint or limb — may indicate infection or inflammatory joint disease.
Weight loss, anorexia, fever, night sweats, or fatigue — may indicate malignancy, infection, or inflammation.
Unexplained rash or bruising — may indicate haematological or inflammatory joint disease, or child maltreatment.
Limp and stiffness worse in the morning — may indicate inflammatory joint disease.
Unable to bear weight or painful limitation of range of motion — may indicate trauma or infection.
Severe pain, anxiety, and agitation after a traumatic injury — may indicate neurovascular compromise or impending compartment syndrome.
A palpable mass — may indicate malignancy or infection
46
What is muscular dystrophy?
umbrella term for genetic conditions that cause gradual weakening and wasting of muscles.
47
Gowers sign?
Children with proximal muscle weakness use a specific technique to stand up from a lying position. This is called Gower’s sign.
48
there is a 5 year old boy presenting with vague symptoms of muscle weakness and the description is that you notice them using their hands on their legs to help them stand up, the answer is probably
Duchennes muscular dystrophy. They may ask “what is the underlying genetic inheritance of the most likely cause?” The answer is X-linked recessive.
49
Mx of DMD?
> Imp QOL - occupational therapy, physiotherapy and medical appliances (such as wheelchairs and braces)
> surgical and medical management of complications such as spinal scoliosis and heart failure.
50
What is DMD?
> Most common dystrophy
> caused by defective gene for dystrophin on CX
> X LINKED RECESSIVE
51
DMD presentation?
> Boys with Duchennes present around 3 – 5 years with weakness in the muscles around their pelvis.
> The weakness tends to be progressive and eventually all muscles will be affected.
> They are usually wheelchair bound by the time they become a teenager.
52
Beckers muscular dystrophy?
> dystrophin gene less affecred
> symptoms appear 8-12 yrs
53
myotonic dystrophy presents in?
adulthood
54
TP of myotonic dystrophy?
> Progressive muscle weakness
> Prolonged muscle contractions
> Cataracts
> Cardiac arrhythmias
55
key feature of myotonic dystrophy?
> prolonged muscle contraction - unable to let go of something, unable to release grip on something
56
Facioscapulohumeral Muscular Dystrophy
> usually presents in childhood
> weakness around face> shoulders > arms
57
classical initial symptom of facioscuapulohumeral dystrophy?
> A classic initial symptom is sleeping with their eyes slightly open and weakness in pursing their lips.
> They are unable to blow their cheeks out without air leaking from their mouth.
58
Oculopharyngeal Muscular Dystrophy pres?
usually presents in late adulthood with weakness of the ocular muscles (around the eyes) and pharyn
59
Oculopharyngeal Muscular Dystrophy features?
bilateral ptosis, restricted eye movement and swallowing problems. Muscles around the limb girdles are also affected to varying degrees.
60
Limb girdle dystrophy?
Limb-girdle muscular dystrophy usually presents in teenage years with progressive weakness around the limb girdles (hips and shoulders).
61
Emery-Dreifuss Muscular Dystrophy
> Emery-Dreifuss muscular dystrophy usually presents in childhood with contractures, most commonly in the elbows and ankles.
> Patients also suffer with progressive weakness and wasting of muscles, starting with the upper arms and lower legs.
62
gait in DMD?
waddling gait
63
DMD Ix?
CK - nearly always raised. Genetic testing uded to confirm diagnosus
64
DMD - what to check?
it is important to check the creatine kinase level in children who cannot walk by 18 months of age to screen for MD
65
Predicted heigh calc?
> Boys: (mother height + fathers height + 14cm) / 2
> Girls: (mothers height + father height – 14cm) / 2
66
complications of GORD in kids?
> reflux oesophagitis
> recurrent aspiration pneumonia
> recurrent otitis media
> dental erosion
67
Tx of GORD in kids?
1) Gaviscon infant - dual satchets
2) Ranitidine/ Omeprazole – oral suspension (2mg/ml)
68
Sig of bile stained vomiting?
In neonates or infants it is an indication of bowel obstruction until proven otherwise
69
intussuption?
> v young - can have non billous vomiting/no pain/ well
> Dance's sign - empty RIF
> USS usually +
70
double bubble sign?
duodenal atresia
71
bowel obst?
dilated bowel loops
72
air enema can be seen in?
inters
73
overflow soiling?
> v loose, smelly, passed without sensation or awareness
74
Hirscsprungs disease?
absence of air in bowel, constipation
75
Mx of const?
> bristol stool chart
> bowel habit diary
76
ribbon stool pattern?
anal stenosis
77
GE is a ? Diseease
notifiable - let HPA know
78
assessing dehydration/ shock?
> unwell
> lethargic
> pale/ mottled skin
> cold extremities
> sunken eyes
> dry membranes/ skin turgor
> tachycardia/ tachypnoea
79
No dehydration?
continue BF, ORS as supplement, no fruit juices
80
Dehydrated but at home (under 5)
> less than 5 yrs = 50ml/kg for deficit over 4 hrs + maintenance ORS
81
Dehydrated but at home (over 5)
> 200ml ORS after each loose stool plus normal fluid intake
> 5 ml/kg ORS after each watery stool to prevent recurrence
82
avoid ? Until dehydration corrected?
solids
83
most common cause of coeliac disease?
coeliac
84
sign of coeliac?
dermatitis herpetiformis
85
eneuresis?
> considered normal under 5 yrs
> over 5 at leasr 2x week
86
RF for enuresis?
> FH
> males
> const, faecal impaction
> sleep apnoea
> developmental delay
87
Mx of daytime wetting?
> double voiding bladder retraining
> oxybutynin or imipramine (AM)
88
Mx noctural enuresis?
> first line: alarm system
> desmopressin
89
How can constipation present?
> Less than 3 stools a week
> Hard stools that are difficult to pass
> Rabbit dropping stools
> Straining and painful passages of stools
> Abdominal pain
> Holding an abnormal posture, referred to as retentive posturing
> Rectal bleeding associated with hard stools
> Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
> Hard stools may be palpable in abdomen
> Loss of the sensation of the need to open the bowels
90
what is encopresis?
> faecal inc
> not pathological until 4
> usually sign of chronic const
> Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
91
what else can cause encopresis?
> spinal bfidia
> hirschrpungs disease
> CF
92
LF in const?
Habitually not opening the bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
93
secondary causes of const?
> hirschprungs disease
> CF - meconium ileus
> hypothyroid
> abuse
> cows milk intolerance
> anal stenosis
94
Constipation red flags - not passing…
Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
95
Constipation red flags - neurological…
Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
96
constipation red flags - vomiting?
Vomiting (intestinal obstruction or Hirschsprung’s disease)
97
constipation red flags - anb anus?>
anal stenosis, inflammatory bowel disease or sexual abuse)
98
constipation red flags - FTT?
oeliac disease, hypothyroidism or safeguarding)
99
Const red flags - acute severe abd pain and bloating?
obstruction or intussusception)
100
comps of constipation?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
101
first line laxative?
Movicol
102
Faecal impaction may require a
disimpaction regimen with high doses of laxatives at first
103
constipation lifestyle?
Correct any reversible contributing factors, recommend a high fibre diet and good hydration
Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
104
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
> Chronic cough
> Hoarse cry
> Distress, crying or unsettled after feeding
> Reluctance to feed
> Pneumonia
> Poor weight gain
105
causes of vomiting?
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
106
Vomiting - red flags - not keeping down food?
pyloric stenosis or intestinal obstruction
107
Vomiting - red flags - projectile/ or forceful vomiting?
pyloric stenosis or intestinal obstructio
108
vomiting - bile stained?
IO
109
vomiting - haematemsis/ melena?
peptic ulcer, oesophagitis or varices
110
vomiting - abd distension?
(intestinal obstruction
111
vomiting - Reduced consciousness, bulging fontanelle or neurological signs
meningitis or raised intracranial pressure)
112
vomiting - blood in stool?
astroenteritis or cows milk protein allerg
113
vomiting, rashing, angioedema?
cows milk protein allergy
114
Advice on managing vomiting?
> Small, frequent meals
> Burping regularly to help milk settle
> Not over-feeding
> Keep the baby upright after feeding (i.e. not lying flat)
115
Tx of severe vomiting?
> Gaviscon mixed with feeds
> Thickened milk or formula (specific anti-reflux formulas are available)
> Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate
116
Sandifer’s Syndrome
> causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants.
> torticollis - forceful contraction of the neck -> twisting
> dystonia - abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
117
Pyloric stenosis presentation?
> typically presents in the first few weeks of life, with a hungry baby that is thin, pale and generally failing to thrive.
> projectile vomiting
118
examination findings in pyloric stenosis?>
f examined after feeding, often the peristalsis can be seen by observing the abdomen. A firm, round mass can be felt in the upper abdomen that “feels like a large olive”. This is caused by the hypertrophic muscle of the pylorus.
119
PS ABG?
hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
120
diagnosis of PS?
abd US - shows thickened pylorus
121
Tx of PS?
Treatment involves a laparoscopic pyloromyotomy (known as “Ramstedt’s operation“). An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal. P
122
Key conditions to think about in patients with loose stools are:
> Infection (gastroenteritis)
> Inflammatory bowel disease
> Lactose intolerance
> Coeliac disease
> Cystic fibrosis
> Toddler’s diarrhoea
> Irritable bowel syndrome
> Medications (e.g. antibiotics)
123
Most common cause of GE?
Rotavirus
124
E coli GE?
> Abd cramps, vomiting, bloody diarrgoea
125
HUS?
> E coli
> use of ab inc risk
126
how is e coli spread?
It is spread through contact with infected faeces, unwashed salads or contaminated water.
127
Camplyobacter jejuni?
> most common cause of bac GE worldwide
> spread by:
> Raw or improperly cooked poultry
> Untreated water
> Unpasteurised milk
128
Symptoms of Camp GE?
> Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days. Symptoms are:
> Abdominal cramps
> Diarrhoea often with blood
> Vomiting
> Fever
129
How is shigella spreaD?
spread by faeces contaminating drinking water, swimming pools and food
130
inc period for shigella?
he incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatmen
131
shigella GE?
causes bloody diarrhoea, abdominal cramps and fever
132
Which toxins produce HUS?
Shigella and E coli
133
salmonella spread?
Salmonella is spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals.
134
salmonella inc period?
Incubation is 12 hours to 3 days and symptoms usually resolve within 1 week.
135
salmonella symptoms?
Symptoms are watery diarrhoea that can be associated with mucus or blood, abdominal pain and vomiting
136
bac cereus spread?
Bacillus cereus is a gram positive rod spread through inadequately cooked food. It grows well on food not immediately refrigerated after cooking. The typical food is fried rice left out at room temperature.
137
bac cereus time frame?
The typical course is vomiting within 5 hours, then diarrhoea after 8 hours, then resolution within 24 hours.
138
yersinia?
> raw/ undercooked porj
> also spread through contamination with the urine or faeces of other mammal such as rats and rabbits.
> most commonly affects kids
139
inc of yersinia?
Incubation is 4 to 7 days and the illness can last longer than other causes of enteritis with symptoms lasting 3 weeks or more.
140
how can yersinia present in older kids?
Older children or adults can present with right sided abdominal pain due mesenteric lymphadenitis (inflammation in the intestinal lymph nodes) and fever. This can give the impression of appendicitis.
141
staph a foods?
Staphylococcus aureus can produce enterotoxins when growing on food such as eggs, dairy and meat.
142
staph a time course?
start within hours of ingestion and settle within 12 to 24 hours
143
Giardiasis?
> parasite
> faecal oral transmission
144
RF for giardiasis?
> foreign travel
> swimming/drinking water from a river or lake
> male-male sexual contact
145
most common cause of travellers diarrhoea?
E coli
146
E coli summary?
> Common amongst travellers
> Watery stools
> Abdominal cramps and nausea
147
Giardiasis?
Prolonged, non-bloody diarrhoea
148
Cholera?
> Profuse, watery diarrhoea
> Severe dehydration resulting in weight loss
> Not common amongst travellers
149
Shigella?
> Bloody diarrhoea
> Vomiting and abdominal pain
150
Staph A?
> Severe vomiting
> Short incubation period
151
campb?
> A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
> May mimic appendicitis
152
comp of campb?
GBS
153
bac cereus?
> Two types of illness are seen
vomiting within 6 hours, stereotypically due to rice
> diarrhoeal illness occurring after 6 hours
154
Amoebiasis?
Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks
155
1-6 hrs incubation ?
Staphylococcus aureus and Bacillus cereus
156
12-48 hrs?
Salmonella, Escherichia coli
157
48-72 hrs
Shigella, Campylobacter
158
> 7 days?
giardiasis, amoebiasis
159
Mx of giardiasis?
Metronidazole
160
Mx of cholera?
1. Doxycycline or 2. Ciprofloxacin
161
Mx of shigella?
1. Ciprofloxacin or 2. Azithromycin
162
Mx of campb?
Clarithromycin
163
Mx of Bac cerus?
Self Limiting OR Severe = Vancomycin
164
Mx of amoebiasis?
Metronidazole + + Diloxanide Furoate
165
Bloody diarrhoea?
> Bloody diarrhoea (Blood SAC)
- Shigella
- Amoebiasis (gradual onset)
- Campy (flu s+s)
166
ab in coeliac?
anti-TTG abd anti EMA
167
inflammation in coeliac?
Inflammation affects the small bowel, particularly the jejunum. It causes atrophy of the intestinal villi.
168
Sx of coeliac?
> Failure to thrive in young children
> Diarrhoea
> Fatigue
> Weight loss
> Mouth ulcers
> Anaemia secondary to iron, B12 or folate deficiency
> Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
169
watery diarrhoea?
Watery diarrhoea (Water CCCEG)
- Cholera (rice water diarrhoea)
- Cryptosporidiosis (most common protozoal cause in UK)
- Can be Campy
- E.coli (traveller)
- Giardiasis (fatty stool)
170
Neuro symptoms of coeliac?
> Peripheral neuropathy
> Cerebellar ataxia
> Epilepsy
171
Test all T1D patients for…
coeliac
172
gene is coeliac?
HLA-DQ2
173
Testing for coeliac ab?
test for TTG and EMA, test total IgA levels as some ppts have igA deficiency
174
Endoscopy and intestinal biopsy show (coeliac)
“Crypt hypertrophy”
“Villous atrophy”
175
Comps of untreated coeliac?
> osteoporosis
> EATL
> non hodgkins lymphoma
176
Tx of coeliac?
lifelong gluten free diet
177
causes of intestinal obst?
> Meconium ileus
> Hirschsprung’s disease
> Oesophageal atresia
> Duodenal atresia
> Intussusception
> Imperforate anus
> Malrotation of the intestines with a volvulus
> Strangulated hernia
178
Presentation of intestinal obst?
> pers vomiting, might be billous (containing bright green bile)
> abd pain & distention
> high pitched, tinkling bowel sounds, absent later
179
Ix of intestinal obst?
> abd XR
> This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction.
> There will also be absence of air in the rectum.
180
Mx of intest obst?
> paeds surgical unit as an emergency
> make them nbm abd insert nasogastric tube
> IV fluids to correct dehydration
181
Hirscsprungs disease is caused by?
> absence of parasympathetic ganglion cells
> occurs when the parasympathetic ganglion cells do not travel all the way down the colon, and a section of colon at the end is left without these parasympathetic ganglion cells.
182
pathophys of hirscprungs disease?
> aganglionic sections become constricted as they cannot relax
> loss of movement of faeces -> bowel obst
183
Genetic associations of hirschsprungs disease?
> downs
> neurofiromatosis
> waardenburg syndrome
> MEN 2
184
Waardenburg syndrome
a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair
185
Symptoms of hirscprungs?
> Delay in passing meconium (more than 24 hours)
> Chronic constipation since birth
> Abdominal pain and distention
> Vomiting
> Poor weight gain and failure to thrive
186
Hirschsprung-Associated Enterocolitis
> inflammation abd obst of intestine
> ypically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.
187
what can HAEC lead to?
> It is life threatening and can lead to toxic megacolon and perforation of the bowel.
> It requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowe
188
Ix of hirschspring
> Abd XR - bowel obst
> rectal biopsy
>
189
Mx of hirschsprung?
> Unwell children and those with enterocolitis will require initial fluid resuscitation and management of the intestinal obstruction.
> IV antibiotics are required in HAEC.
190
def Mx of hirschsprung?
Definitive management is by surgical removal of the aganglionic section of bow
191
Intussusception occurs in?
> infants 6 months - 2 yrs
> more common in boys
192
What is Intussusception assoc w ?
> concurrent vital illness
> HSP
> CF
193
key feature of intussuception?
Redcurrant jelly stool
194
Presentation of tussuscepeption?
> severe, colicky abd pain
> pale, lethargic, unwell
> RUQ mass on palpation - sausage shaped
> intest obstruction and vomiting
195
Ix of intussception?
US
196
Mx of intussception?
> therapeutic enemas
> surgical reduction if enemas don’t work
> surgical resection if bowel becomes gangerenous
197
comps of intussception?
> Obstruction
> Gangrenous bowel
> Perforation
> Death
198
appendicitis?
> abd pain - starts central then moves to RIF
199
appendicitis - palpation?
> On palpation of the abdomen there is tenderness in McBurney’s point.
> This is a localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
200
CFs of appendicitis?
> anorexia
> N and V
> Rosvings sign
> rebound tenderness and guarding (peritonitis)
> percussion tenderness
201
Rosvings sign?
> palpation of the left iliac fossa causes pain in the RIF
202
Diagnosis of appendicitis?
> CP and raised inflammatory markers
> CT can be done to confitm
> US in female patients to exclude gynae
203
signs of appendicitis but Ix negative means….
> diagnostic laparoscopy
204
DDs of appendicitis?
> ectopic pregnancy
> ovarian cysts
> meckles diverticulum
> appendix mass
205
Meckel’s Diverticulum
Meckel’s diverticulum is a malformation of the distal ileum. It is usually asymptomatic, however it can bleed, become inflamed, rupture or cause a volvulus or intussusception.
206
Mesenteric Adenitis
> Mesenteric adenitis describes inflamed abdominal lymph nodes.
> This presents with abdominal pain, usually in younger children.
> This is often associated with tonsillitis or an upper respiratory tract infection.
207
Mx of appendicitis?
> appendicectomy
> laparoscopic fewer SE vs laparotomy
208
PS summary?
> Projectile non bile stained vomiting at 4-6 weeks of life
> Diagnosis is made by test feed or USS
209
Mesenteric Adenitis?
> Central abdominal pain and URTI
> Conservative management
210
intestinal malrotation?
> High caecum at the midline
> Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
> May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
211
Oesophageal atresia
> Associated with tracheo-oesophageal fistula and polyhydramnios
> May present with choking and cyanotic spells following aspiration
212
Necrotising enterocolitis main RF?
PREMATURITY. Also Increased risk when empirical antibiotics are given to infants beyond 5 days
213
features of nec enterocolitis?
> abd distension
> passage of bloody stools
214
XR of nec enterocolitis?
> X-Rays may show pneumatosis intestinalis and evidence of free air
215
Tx of nec enterocolitis?
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
216
Arrange same-day hospital admission if there is associated:
Bile-stained (green or yellow-green) vomiting, abdominal tenderness, mass, and/or distension — suggesting intestinal obstruction or another acute surgical condition needing paediatric surgery assessment.
217
SBO features on abd XR?
> Dilated bowel
> central abd location
> lines completely crossing bowel
218
LBO features on XR?
> Dilated bowel
> peripheral location
> and haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’)
219
Mx of child constipation - faecal impaction?
> Movicol paed plain - first line
2) stimulant laxative if disimpaction not achieved within 2 weeks
220
Mx of child const?
1) movicol
2) add stimulant laxative
3) substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated.
221
Mx of constipation in babies < 6 months?
> bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs
> breast-fed infants: constipation is unusual and organic causes should be considered
222
Infants who have been weaned - constipation Mx?
> offer extra water, diluted fruit juice and fruits
> if not effective consider adding lactulose
223
Children at inc risk of dehydration?
> children under 1
> low birth weight
> vomited more than 3x in 24 hrs
> 6x+ diarrhoea in 24 hrs
> stoooed breastfeeding in illness
224
features suggestive of hypernatreamic dehydration?
> jittery movements
> increased muscle tone
> hyperreflexia
> convulsions
> drowsiness or coma
225
For children with no evidence of dehydration
> continue breastfeeding and other milk feeds
> encourage fluid intake
> discourage fruit juices and carbonated drinks
226
If dehydration is suspected:
> give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts
> continue breastfeeding
> consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)
227
most common cause of chronic diarrhoea in children?
cows milk intolerance
228
CF of toddlers diarhoea?
> frequent, poorly formed brown and slightly offensive stools
> food material easily recognisable in the stools is a hallmark feature
229
what is the child normally like in toddlers diarrhoea?
Despite persisting diarrhoea the child is constitutionally well, normally active and has unimpaired growth. The child has a normal appetite and a normal or increased fluid intake.
230
diet in toddlers diarrhoea?
high fruit intake of fruit juices
231
Mx of toddlers diarrhea?
reassurance & avoidance of fulll strength fruit juices
232
always consider UTI in children w?
Fever may be the only symptom of a urinary tract infection, especially in young children. Always consider (and exclude) a urinary tract infection in a child with a temperature, unless there is a clear alternative source of infection.
233
Symptoms of UTI in babies?
non specific: Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
234
Signs and symptoms in of UTIs older infants and children are more specific:
> Fever
> Abdominal pain, particularly suprapubic pain
> Vomiting
> Dysuria (painful urination)
> Urinary frequency
> Incontinence
235
Diagnosis of Pyelo is made if there is either:
> A temperature greater than 38°C
> Loin pain or tenderness
236
Urine dipstick results in UTI?
> Nitrite + - best measure
> leucocyte esterase + - don't treat as UTI if only this is present
237
tests in UTI?
> Dipsrick > send to microbiology if positive
> MSU sent for culture and sensitivity testing
238
Mx of a UTI - all children under 3 should have…
> All children under 3 months with a fever should start immediate IV antibiotics (e.g. ceftriaxone) and have a full septic screen, including blood cultures, bloods and lactate.
> A lumbar puncture should also be considered.
239
Mx of UTI - children over 3 months?
> oral ab if othewise well
> if features of sepsis or pyelo, treat w IV ab
240
Typical antibiotic choices in urinary tract infections in children are:
> Trimethoprim
> Nitrofurantoin
> Cefalexin
> Amoxicillin
241
All children under 6 months with their first UTI should have an abdominal ultrasound within ? weeks
All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria
242
children w recurrent UTIs should have ? Within ? Weeks
abdominal ultrasound within 6 weeks
243
Children with atypical UTIs should have an abdominal ultrasound
during the illness
244
DMSA scan?
> DMSA scans should be used 4 – 6 months after the illness to assess for damage from recurrent or atypical UTIs.
> patches of reduced uptake -> scarring
245
VUR?
> Vesico-ureteric reflux (VUR) is where urine has a tendency to flow from the bladder back into the ureters.
> This predisposes patients to developing upper urinary tract infections
> MCUG used to diagnose
246
when should an MCUG be used?
(MCUG) should be used to investigate atypical or recurrent UTIs in children under 6 months. It is also used where there is a family history of vesico-ureteric reflux, dilatation of the ureter on ultrasound or poor urinary flow.
247
Mx of UTIs?
> children less than 3 months - refer to paeds
> ab prophylaxis for recurrent UTIs
248
children aged more than 3 months old with a lower UTI should be treated
with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin
249
children aged more than 3 months old with an upper UTI should be
considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
250
Ix for haematuria and proteinuria?
> urinalysis
> FBC, u&Es, clotting
> ACR
> GFR
251
Primary nocturnal enuresis
where the child has never managed to be consistently dry at night.
252
Causes of PNE?
> Most common: variation of normal development
> OAB
> Fluids before bed
> failure to wake
253
secondary causes of PNE?
chronic constipation, urinary tract infection, learning disability or cerebral palsy
254
first line PNE?
The initial step in management of primary nocturnal enuresis is to establish the underlying cause. It can be helpful to keep a 2 week diary of toileting, fluid intake and bedwetting episodes
255
management of PNE?
> Reassurance of under 5s that it is likely to resolve w/o Tx
> lifestyle changes
> treat underlying causes like constipation
> eneuresis alarms
256
what is secondary NE?
> where a child begins wetting the bed when they have previously been dry for at least 6 months. This is more indicative of an underlying illness than primary enuresis.
257
Causes of secondaru NE?
> UTI
> const
> T1D
> psych problems or maltreatment
258
what is diurnal enuresis?
daytime incontinence. Dry at night but episodes of incontinence during the day
259
2 types of diurnal eneuresis?
> Urge incontinence is an overactive bladder that gives little warning before emptying
> Stress incontinence describes leakage of urine during physical exertion, coughing or laughing.
260
meds for eneuresis?
> desmopressin
> oxybutinin
> imipramine
261
primary assessment of child w decreased LOC?
> ABCDE
> D: use GCS or ACVPU
262
What would suggest ICP in a previously normal child?
decorticate or decerebrate positioning
263
CI of LP?
> Signs of raised ICP
> neurological signs
> prolonged/ focal seizures
> GCS under 13
> dilated pupils
> Dolls eye reflex
> abn posture - decorticate or decerebrate
> coag disorder
264
dolls eye reflex?
> CI of LP
> eyes should move opp to head movement
> if dolls eye reflex is absent and eyes move W the head -> BS dysfunction
265
cushings triad?
> slow HR
> abn breathing
> Widening pulse pressure (raised bp)
> late sign of raised ICP
266
Mx of ICP?
> reduce pCO2 by hyperventillating
> Head elevation to 30
> mannitol or hypertonic saline
> catheter and monitor u/o
267
Mx of oedema in a SOL?
Dexamethasone
268
cerebral perfusio pressure?
> cerebral perfusion pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain
> CPP = mean arterial pressure - ICP
269
causes of raised ICP?
> Idiopathic intercranial HTN
> traumatic head injuries
> hydrocephalus
> meningitis
> tumours
270
features of raised ICP?
> headache
> vomiting
> reduced levels of consciousness
> papilloedema
271
Ix for raised ICP?
> CT/MRI - looking for underlying cause
272
ICP - removing CSF?
> repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
> ventriculoperitoneal shunt (for hydrocephalus)
273
Immediate management of a child with raised ICP?
> abc assessment
> Oxygen
> GCS
> tilt head up
> O2
> Mannitol
> Dexamethasone
274
A?
> Consider intubation if GCS is <8 (or patient is unresponsive to pain on the AVPU), unless the child is showing signs of improvement.
> Give 100% oxygen if oxygen saturations are ≤95%.
275
Circ?
Circulatory compromise should be considered if one or more of the following are present:
> mottled, cool extremities
> diminished peripheral pulses.
Consider circulatory shock if one or more of the following are present:
> systolic blood pressure is less than fifth percentile for age
> decreased urine output <1 mL/kg/hour
276
differentials for decreased LOC?
> Meningitis
> acute hydrocephalus
> hypoglycaemia
> intoxication
> HTN
277
Sepis?
> htn
> tachycardia
> tachypnoea
> WCC raised
> non blanching rash
