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
> Chronic cough
> Hoarse cry
> Distress, crying or unsettled after feeding
> Reluctance to feed
> Pneumonia
> Poor weight gain
105
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:
106
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
107
Vomiting - red flags - not keeping down food?
pyloric stenosis or intestinal obstruction
108
Vomiting - red flags - projectile/ or forceful vomiting?
pyloric stenosis or intestinal obstructio
109
vomiting - bile stained?
IO
110
vomiting - haematemsis/ melena?
peptic ulcer, oesophagitis or varices
111
vomiting - abd distension?
(intestinal obstruction
112
vomiting - Reduced consciousness, bulging fontanelle or neurological signs
meningitis or raised intracranial pressure)
113
vomiting - blood in stool?
astroenteritis or cows milk protein allerg
114
vomiting, rashing, angioedema?
cows milk protein allergy
115
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)
116
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
117
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
118
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
119
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.
120
PS ABG?
hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
121
diagnosis of PS?
abd US - shows thickened pylorus
122
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
123
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)
124
Most common cause of GE?
Rotavirus
125
E coli GE?
> Abd cramps, vomiting, bloody diarrgoea
126
HUS?
> E coli
> use of ab inc risk
127
how is e coli spread?
It is spread through contact with infected faeces, unwashed salads or contaminated water.
128
Camplyobacter jejuni?
> most common cause of bac GE worldwide
> spread by:
> Raw or improperly cooked poultry
> Untreated water
> Unpasteurised milk
129
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
130
How is shigella spreaD?
spread by faeces contaminating drinking water, swimming pools and food
131
inc period for shigella?
he incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatmen
132
shigella GE?
causes bloody diarrhoea, abdominal cramps and fever
133
Which toxins produce HUS?
Shigella and E coli
134
salmonella spread?
Salmonella is spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals.
135
salmonella inc period?
Incubation is 12 hours to 3 days and symptoms usually resolve within 1 week.
136
salmonella symptoms?
Symptoms are watery diarrhoea that can be associated with mucus or blood, abdominal pain and vomiting
137
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.
138
bac cereus time frame?
The typical course is vomiting within 5 hours, then diarrhoea after 8 hours, then resolution within 24 hours.
139
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
140
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.
141
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.
142
staph a foods?
Staphylococcus aureus can produce enterotoxins when growing on food such as eggs, dairy and meat.
143
staph a time course?
start within hours of ingestion and settle within 12 to 24 hours
144
Giardiasis?
> parasite
> faecal oral transmission
145
RF for giardiasis?
> foreign travel
> swimming/drinking water from a river or lake
> male-male sexual contact
146
most common cause of travellers diarrhoea?
E coli
147
E coli summary?
> Common amongst travellers
> Watery stools
> Abdominal cramps and nausea
148
Giardiasis?
Prolonged, non-bloody diarrhoea
149
Cholera?
> Profuse, watery diarrhoea
> Severe dehydration resulting in weight loss
> Not common amongst travellers
150
Shigella?
> Bloody diarrhoea
> Vomiting and abdominal pain
151
Staph A?
> Severe vomiting
> Short incubation period
152
campb?
> A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
> May mimic appendicitis
153
comp of campb?
GBS
154
bac cereus?
> Two types of illness are seen
vomiting within 6 hours, stereotypically due to rice
> diarrhoeal illness occurring after 6 hours
155
Amoebiasis?
Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks
156
1-6 hrs incubation ?
Staphylococcus aureus and Bacillus cereus
157
12-48 hrs?
Salmonella, Escherichia coli
158
48-72 hrs
Shigella, Campylobacter
159
> 7 days?
giardiasis, amoebiasis
160
Mx of giardiasis?
Metronidazole
161
Mx of cholera?
1. Doxycycline or 2. Ciprofloxacin
162
Mx of shigella?
1. Ciprofloxacin or 2. Azithromycin
163
Mx of campb?
Clarithromycin
164
Mx of Bac cerus?
Self Limiting OR Severe = Vancomycin
165
Mx of amoebiasis?
Metronidazole + + Diloxanide Furoate
166
Bloody diarrhoea?
> Bloody diarrhoea (Blood SAC)
- Shigella
- Amoebiasis (gradual onset)
- Campy (flu s+s)
167
ab in coeliac?
anti-TTG abd anti EMA
168
inflammation in coeliac?
Inflammation affects the small bowel, particularly the jejunum. It causes atrophy of the intestinal villi.
169
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
170
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)
171
Neuro symptoms of coeliac?
> Peripheral neuropathy
> Cerebellar ataxia
> Epilepsy
172
Test all T1D patients for…
coeliac
173
gene is coeliac?
HLA-DQ2
174
Testing for coeliac ab?
test for TTG and EMA, test total IgA levels as some ppts have igA deficiency
175
Endoscopy and intestinal biopsy show (coeliac)
“Crypt hypertrophy”
“Villous atrophy”
176
Comps of untreated coeliac?
> osteoporosis
> EATL
> non hodgkins lymphoma
177
Tx of coeliac?
lifelong gluten free diet
178
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
179
Presentation of intestinal obst?
> pers vomiting, might be billous (containing bright green bile)
> abd pain & distention
> high pitched, tinkling bowel sounds, absent later
180
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.
181
Mx of intest obst?
> paeds surgical unit as an emergency
> make them nbm abd insert nasogastric tube
> IV fluids to correct dehydration
182
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.
183
pathophys of hirscprungs disease?
> aganglionic sections become constricted as they cannot relax
> loss of movement of faeces -> bowel obst
184
Genetic associations of hirschsprungs disease?
> downs
> neurofiromatosis
> waardenburg syndrome
> MEN 2
185
Waardenburg syndrome
a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair
186
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
187
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.
188
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
189
Ix of hirschspring
> Abd XR - bowel obst
> rectal biopsy
>
190
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.
191
def Mx of hirschsprung?
Definitive management is by surgical removal of the aganglionic section of bow
192
Intussusception occurs in?
> infants 6 months - 2 yrs
> more common in boys
193
What is Intussusception assoc w ?
> concurrent vital illness
> HSP
> CF
194
key feature of intussuception?
Redcurrant jelly stool
195
Presentation of tussuscepeption?
> severe, colicky abd pain
> pale, lethargic, unwell
> RUQ mass on palpation - sausage shaped
> intest obstruction and vomiting
196
Ix of intussception?
US
197
Mx of intussception?
> therapeutic enemas
> surgical reduction if enemas don’t work
> surgical resection if bowel becomes gangerenous
198
comps of intussception?
> Obstruction
> Gangrenous bowel
> Perforation
> Death
199
appendicitis?
> abd pain - starts central then moves to RIF
200
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.
201
CFs of appendicitis?
> anorexia
> N and V
> Rosvings sign
> rebound tenderness and guarding (peritonitis)
> percussion tenderness
202
Rosvings sign?
> palpation of the left iliac fossa causes pain in the RIF
203
Diagnosis of appendicitis?
> CP and raised inflammatory markers
> CT can be done to confitm
> US in female patients to exclude gynae
204
signs of appendicitis but Ix negative means….
> diagnostic laparoscopy
205
DDs of appendicitis?
> ectopic pregnancy
> ovarian cysts
> meckles diverticulum
> appendix mass
206
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.
207
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.
208
Mx of appendicitis?
> appendicectomy
> laparoscopic fewer SE vs laparotomy
209
PS summary?
> Projectile non bile stained vomiting at 4-6 weeks of life
> Diagnosis is made by test feed or USS
210
Mesenteric Adenitis?
> Central abdominal pain and URTI
> Conservative management
211
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
212
Oesophageal atresia
> Associated with tracheo-oesophageal fistula and polyhydramnios
> May present with choking and cyanotic spells following aspiration
213
Necrotising enterocolitis main RF?
PREMATURITY. Also Increased risk when empirical antibiotics are given to infants beyond 5 days
214
features of nec enterocolitis?
> abd distension
> passage of bloody stools
215
XR of nec enterocolitis?
> X-Rays may show pneumatosis intestinalis and evidence of free air
216
Tx of nec enterocolitis?
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
217
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.
218
SBO features on abd XR?
> Dilated bowel
> central abd location
> lines completely crossing bowel
219
LBO features on XR?
> Dilated bowel
> peripheral location
> and haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’)
220
Mx of child constipation - faecal impaction?
> Movicol paed plain - first line
2) stimulant laxative if disimpaction not achieved within 2 weeks
221
Mx of child const?
1) movicol
2) add stimulant laxative
3) substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated.
222
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
223
Infants who have been weaned - constipation Mx?
> offer extra water, diluted fruit juice and fruits
> if not effective consider adding lactulose
224
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
225
features suggestive of hypernatreamic dehydration?
> jittery movements
> increased muscle tone
> hyperreflexia
> convulsions
> drowsiness or coma
226
For children with no evidence of dehydration
> continue breastfeeding and other milk feeds
> encourage fluid intake
> discourage fruit juices and carbonated drinks
227
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)
228
most common cause of chronic diarrhoea in children?
cows milk intolerance
229
CF of toddlers diarhoea?
> frequent, poorly formed brown and slightly offensive stools
> food material easily recognisable in the stools is a hallmark feature
230
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.
231
diet in toddlers diarrhoea?
high fruit intake of fruit juices
232
Mx of toddlers diarrhea?
reassurance & avoidance of fulll strength fruit juices
233
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.
234
Symptoms of UTI in babies?
non specific: Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
235
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
236
Diagnosis of Pyelo is made if there is either:
> A temperature greater than 38°C
> Loin pain or tenderness
237
Urine dipstick results in UTI?
> Nitrite + - best measure
> leucocyte esterase + - don't treat as UTI if only this is present
238
tests in UTI?
> Dipsrick > send to microbiology if positive
> MSU sent for culture and sensitivity testing
239
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.
240
Mx of UTI - children over 3 months?
> oral ab if othewise well
> if features of sepsis or pyelo, treat w IV ab
241
Typical antibiotic choices in urinary tract infections in children are:
> Trimethoprim
> Nitrofurantoin
> Cefalexin
> Amoxicillin
242
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
243
children w recurrent UTIs should have ? Within ? Weeks
abdominal ultrasound within 6 weeks
244
Children with atypical UTIs should have an abdominal ultrasound
during the illness
245
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
246
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
247
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.
248
Mx of UTIs?
> children less than 3 months - refer to paeds
> ab prophylaxis for recurrent UTIs
249
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
250
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
251
Ix for haematuria and proteinuria?
> urinalysis
> FBC, u&Es, clotting
> ACR
> GFR
252
Primary nocturnal enuresis
where the child has never managed to be consistently dry at night.
253
Causes of PNE?
> Most common: variation of normal development
> OAB
> Fluids before bed
> failure to wake
254
secondary causes of PNE?
chronic constipation, urinary tract infection, learning disability or cerebral palsy
255
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
256
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
257
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.
258
Causes of secondaru NE?
> UTI
> const
> T1D
> psych problems or maltreatment
259
what is diurnal enuresis?
daytime incontinence. Dry at night but episodes of incontinence during the day
260
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.
261
meds for eneuresis?
> desmopressin
> oxybutinin
> imipramine
262
primary assessment of child w decreased LOC?
> ABCDE
> D: use GCS or ACVPU
263
What would suggest ICP in a previously normal child?
decorticate or decerebrate positioning
264
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
265
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
266
cushings triad?
> slow HR
> abn breathing
> Widening pulse pressure (raised bp)
> late sign of raised ICP
267
Mx of ICP?
> reduce pCO2 by hyperventillating
> Head elevation to 30
> mannitol or hypertonic saline
> catheter and monitor u/o
268
Mx of oedema in a SOL?
Dexamethasone
269
cerebral perfusio pressure?
> cerebral perfusion pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain
> CPP = mean arterial pressure - ICP
270
causes of raised ICP?
> Idiopathic intercranial HTN
> traumatic head injuries
> hydrocephalus
> meningitis
> tumours
271
features of raised ICP?
> headache
> vomiting
> reduced levels of consciousness
> papilloedema
272
Ix for raised ICP?
> CT/MRI - looking for underlying cause
273
ICP - removing CSF?
> repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
> ventriculoperitoneal shunt (for hydrocephalus)
274
Immediate management of a child with raised ICP?
> abc assessment
> Oxygen
> GCS
> tilt head up
> O2
> Mannitol
> Dexamethasone
275
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%.
276
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
277
differentials for decreased LOC?
> Meningitis
> acute hydrocephalus
> hypoglycaemia
> intoxication
> HTN
278
Sepis?
> htn
> tachycardia
> tachypnoea
> WCC raised
> non blanching rash
