Child Health 2 Flashcards
RF for appendicitis?
> Male
10 - 20 yrs old
FHx
White
Causes of appendicitIs?
> fecaliths - most common cause of luminal obstruction
lymphoid hyperplasia
foreign bodies
carcinoid tumours/ neoplastic growths
most common cause of sepsis in the uk?
pneumonia
appendicitis pathophys?
> ischemia and inflammation -> tissue necrosis -> appendiceal wall weakening -> perforation > peritonitis -> sepsis
appendicitis CFs?
> pain - starts central and radiates to RIF
vomiting
mild pyrexia
possible diarrhoea
anorexia common
pain seen in appendicitis?
> patients often report the pain being worse on coughing or going over speed bumps. Children typically can’t hop on the right leg due to the pain.
examination in appendicitis?
> generalised peritonitis if perf
DRE - boggy sensatuon if pelvic abcess present
2 classic signs of appendicitis?
Rosvings and Psoas sign
Rosvings sign?
> palpation in the LIF causes pain in the RIF
Psoas sign?
> pain on extending hip if retrocaecal appendix
Ix of appendicitis?
> neutrophil dominant leucocytosis common
urine analysis to exclude renal colic and UTI
exclude pregnancy
US if pelvic organ pathology suspected
Ectopic pregnancy?
> Can cause RIF pain, N&V and fever like appendicitis
but ectopic pregnancies typically present with a 6-8 week history of amenorrhoea with or without vaginal bleeding and a positive pregnancy test
ovarian torsion?
> both appendicitis and torsion can cause RIF pain and N&V
a palpable adnexal mass is felt in 50-70% of cases of ovarian torsion
PID?
> in pelvic inflammatory disease pain is typically bilateral, there is vaginal/cervical discharge and cervical motion tenderness on examination
Acute mesenteric adenitis?
both this and appendicitis can cause lower abd pain with guarding
Differences between acute mesenteric adenitis and appendicitis?
mesenteric adenitis typically occurs inchildrenafter aviral upper respiratory tract infectionand it does not cause localised tenderness
Meckles diverticulum?
> can cause RIF pain
clinically indistinguishable from acute appendicitis, often identified when normal appendix found during appendicectomy
Crohns?
Crohn’s disease often presents with chronicdiarrhoeaand there may be a positive family history
Acute cholesystits vs appendicitis?
> Similarities: both present with right-sided abdominal pain with or without guarding and raised inflammatory markers
Differences: In cholecystitis pain is typically in the right upper quadrant region and there may be a palpable gallbladder
ureteric stones?
in nephrolithiasis, pain is typically in the flank, colicky in nature and radiates to the groin
UTI?
urinary tract infections typically present with dysuria, urgency and frequency and affect older adults more commonly
Mx of appencitis?
> laparascopic appendicectomy
prophylactic ab
RF for pyelo?
> Female sex
Structural urological abnormalities
Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
Diabetes
most common cause of LUTI?
E COLI - rod shaped, gram negative, anaerobic bacteria
Triad of pyelo?
> Fever
Loin or back pain (bilateral or unilateral)
Nausea / vomiting
other CFs of pyelo?
> dysuria, suprapubic discomfort and increased frequency
loss of appetite
renal angle tendernes
haematuria
Ix of pyelo?
> dipstick - nitrites, leukocytes, blood
MSU - culture and sensitivity testing
BT - raised WCC and CRP
Imaging - US ot CT to exclude other pathology
Abs used for pyelo?
> Cefalexin
If culture results available:
co-amoxi
trimethoprim
ciproflocaxin
chronic pyelo?
> recurrent episodes of kidney infection
can lead to CKD and end stage renal failure
DMSA scans used to assess damage
UTI sx?
> Dysuria (pain, stinging or burning when passing urine)
Suprapubic pain or discomfort
Frequency
Urgency
Incontinence
Haematuria
Cloudy or foul-smelling urine
Confusion is commonly the only symptom in older and frail patients
When should pyelo be suspected over UTI?
> Fever
Loin or back pain
Nausea or vomiting
Renal angle tenderness on examination
UTI - dipstick results?
> Where only nitrites are present, it is worth treating as a UTI.
Where only leukocytes are present, a sample should be sent to the lab for further testing.
Antibiotics may be considered where there is clinical evidence of a UTI.
When is a MSU required?
> not all ppts w uncomplicated UTIs require this
pregnancy
atypical sx
no improv w AB
recurrent UTIs
Tx of UTI?
> Nitro > avoid in GFR < 45
trimethoprim - avoid in pregnancy
Ab course for Utis?
> 3 days for women
5-10 days for IS women, abn anatomy or impaired kidney function
7 days for men, pregnant women or catheter related UTIs
change catheter when diagnosed w catheter related UTI
Mx of UTI in pregnancy?
> 7 days ab, MSU required
cefalexin is typical choice
amoxicillin after sensitivies known
nitro
use of nitrofurantoin in pregnancy?
avoud in T3 - risk of neonatal haemolysis
Trimethoprim in pregnancy?
avoid in T1 - can cause congenital abn- avoided throughout pregnancy
Cysts in pre vs post menopausal women
> common in pre-menopausal women
in post-menopausal, concerning for malignancy
diagnosis of PCOS?
> String of pearls appearance of ovaries alone not enough
at least 2 of 3 required:
anovulation
hyperandrogenism
polystic ovaries on US
ovarian cyst symptoms?
> most asymptomatic
pelvic pain
bloating
palpable mass - espec large cysts
fullness in abdomen
Ovarian cysts may present with acute pelvic pain if there is ovarian torsion, haemorrhage or rupture of the cyst.
Follicular cysts?
> most common type
cysts persist when the follicle fails to rupture and release the egg
Corpus luteum cysts?
> when corpus lutem fails to break down and instead fills w fluid
can cause discomfort, pain or delayed menstruation
often seen in early pregnancy
Serous Cystadenoma
These are benign tumours of the epithelial cells.
Mucinous Cystadenoma
These are also benign tumour of the epithelial cells. They can become huge, taking up lots of space in the pelvis and abdomen.
endometrioma?
These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
Dermoid Cysts / Germ Cell Tumours
> benign ovarian cysts
teratomas
associated w ovarian torsion
sex cord stromal tumours?
> rare, can be benign or malignant
arise from stroma (CT) or sex cords
Assessment of ovarian cysts involves?
> assessing for features of malignancy
gen malignancy features
> Abdominal bloating
Reduce appetite
Early satiety
Weight loss
Urinary symptoms
Pain
Ascites
Lymphadenopathy
ovarian malignancy features?
> Age
Postmenopause
Increased number of ovulations
Obesity
Hormone replacement therapy
Smoking
Breastfeeding (protective)
Family history and BRCA1 and BRCA2 genes
link between number of ovulations and ovarian cancer
more ovulations -> inc risk of ovarian cancer
factors reducing number of ovulations and therefore risk of ovarian cancer
> late menarche
early menopause
any pregnancy
use of COCP
Ix of ovarian cysts?
> US
CA125 for ovarian cancer
Women under 40 years with acomplex ovarian massrequire
> tumour markers for a possible germ cell tumour
LDH
AFP
HCG
Risk of malignancy index
> estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
When do cysts need to be referred?
> Complex cysrs or raised CA125 - 2WWW
dermoid cysts - gynae
cysts In postmenopausal women - gynae or 2WW if raised CA125
Simple ovarian cystsinpremenopausal womencan be managed based on their size:
> Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
More than 7cm: Consider an MRI scan or surgical evaluation
Meig’s syndrome?
> triad of:
ovarian fibroma - overian benign tumour
pleural effusion
ascites
pleural effusion + ovarian mass ->
Meigs syndrome
most common benign ovarian tumour in women under age of 30?
dermoid cyst. Also torsion is more likely w this than w other ovarian tumours
Abd pain in kids?
> constipation
UTI
coeliac
IBD or IBS
mesenteric adenitis
HSP
pyelo
Abd pain in girls?
> Dysmenorrhea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
Surgical causes of abd pain - appendicitis
central abd pain > RIF
Surgical causes of abd pain - INTUSSUSCEPTION
colicky non-specific abdominal pain withredcurrantjelly stools
Surgical causes of abd pain - bowel obst
pain, distention, absolute constipation and vomiting
surgical causes of abd pain - torsion
sudden onset, unilateral testicular pain, nausea and vomiting
red flags for serious abd pain
> Persistent or bilious vomiting
persistent RUQ/ RLQ pain
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia (difficulty swallowing)
Nighttime pain
Abdominal tenderness
abd migraibe
> Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
may be assoc aura, anorexia, N&V, pallor, photophobia, headache
treating acute attacks of abd migraine
> Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan
Preventative medications for abd migraine:
> Pizotifen, a serotonin antagonist
Propranolol, a non-selective beta blocker
Cyproheptadine, an antihistamine
Flunarazine, a calcium channel blocker
Pizotifen
> prev med for abd migraine
needs to be withdrawn slowly - withdrawal symptoms
mesenteric adenitis
> inflamed lymph nodes within mesentery
similar symptoms to appendicitis but more coryzal symptoms due to viral infection beforehand
higher fever than appendicitis
mesenteric adenitis vs appendicitis
> MA: higher fever
MA: pain STARTS in RIF
Tx of mesenteric adenitis
self limiting, no Tx required
CD pain
> diarrhoea
weight loss
abd mass in RIF
uc features
> bloody diarrhoea
abd pain in left lower quadrant
tenesmus
Red flags in cases of acute abd pain?
> billous vomiting
fullness/ masses/ hepatosplenomegaly
perianal/ rectal disease
tenderness over spine
appendicitis under 5
> long history
D&V prominent in early stages
may not have pain
can present with abd pain
appendicitis under 2
most perforated at presentation, collapse and sepsis syndrome
management of appenicitis in kids?
> fluid resus
surgery
48 hr ab
recurrent abdominal pain?
> pain can’t be explained by physical condition
pain at other sites like headache or limb pain common
RAP - IBS
Bloating, loose stools, pain lessens after defecation
RAP - FAP?
Func abd pain - continuous from time to time
RAP - FAPS
Loss of daily activities plus headaches, limb pain, difficulty sleeping
abd migraine?
> intense pain around umbilicus
reduced appetite, and activities
nausea vomiting, headache, photophobia
Ix for abd pain
> IgA
IgE to allergens, total IgE
Fecal calprotectin
and US, endoscopy/ colonoscopy
functional dyspepsia Tx
rantidine/ omeprazole
IBD is most common in
12- 16 yrs olds
IBD - paediatric presentation
> fever
anaemia
weight loss
FTT
ammenorrhoea
retarded bone development, mineral deficiencies
necrotising enterocoliotis history
abdominal distension, tenderness, abdominal wall erythema, haematochezia, bradycardia
examination in nectrotising enterocolitis
> abd distension
bradycardia
haematochezia
tenderness
investigations for NEC?
> Bloods
abd XR
US
xr findings in NEC?
> dilated bowel loops, lack of normal intestinal gas pattern
testicular torsion history
> acute onset testicular pain
N & V
may be repeated episodes
examination in tT
> tender, oedema,
affected testicle may appear higher
absent cremasteric reflex
no psin relief w elevation of scrotum
Ix of torsion
duplex US
puberty in girls
> breast buds > pubic hair > periods 2 yrs from the start of puberty
puberty in boys
testicle enlargemeny > penis > scrotum darkening > pubic hair development > deepening of voice
staging for puberty
Tanner
Hypogonadotrophic hypogonadism
deficiencyof LH and FSH
hypergonadotrophic hypogonadism
lack ofresponseto LH and FSH by the gonads (the testes and ovaries)
Causes of hypogonadotropic hypogonadism
> LH/ FSH deficiency > lack of test and oestrgen
result of abn functioning of hypo/ pituitary gland
prev damage e.g, radiotherapy, surgery
hypothyroidism
hyperprolactinaemia
chronic conditions
kallman syndrome
what can delay onset of menstruation in girls?
excessive exercise or dieting
what happens in hypergonadotropic hypogonadism
> gonds dont respond to stim from LH/ FSH
no negatieve feedback from sex hormones
AP produces more LH and FSH - meaning high gonadotropins and low sex hormones
Hypergonadotrophic hypogonadismis the result of abnormal functioning of the gonads. This could be due to:
> Previous damage to the gonads (e.g. testicular torsion, cancer or infections, such as mumps)
Congenital absence of the testes or ovaries
Kleinfelter’s Syndrome (XXY)
Turner’s Syndrome (XO)
kallman syndrome
> genetic condition
causes hypogonadotropic hypogonadism
failure to start puberty
associated w reduced/ absent sense of smell
when should we investigate for delayed puberty?
girl aged 13 or boy aged 14
Initial Ix for delayed puberty?
> FBC - anaemia
U&Es - CKD
anti TTG or anti EMA - coeliac disease
hormonal blood tests for delayed puberty
> early morning gonadotropins
TFTs
GH testing
prolactin levels
early morning gonadotropin results
> low in hypogonadotropic hypogonadism
high in hypergonadotropic hypogonadism
genetic testing for delayed puberty
> Kleinfelter’s syndrome (XXY)
Turner’s syndrome (XO)
imaging in delayed puberty
> X ray of the wrist - const delay
pelvic US in girls
MRI pituitary - Kallman syndrome
Delayed puberty w normal stature
> polycystic ovarian syndrome
androgen insensitivity
Kallman’s syndrome
Klinefelter’s syndrome
delayed puberty w short stature
> Turner’s syndrome
Prader-Willi syndrome
Noonan’s syndrome
Mx of delayed puberty
> replacement sex hormones
what happens in turners syndrome
female has a single X chromosome making them 45XO
Features of turners syndrome
> Short stature
Webbed neck
High arching palate
Downward sloping eyes with ptosis
Broad chest with widely spaced nipples
Cubitus valgus
Underdeveloped ovaries with reduced function
Late or incomplete puberty
Most women are infertile
cubitus valgus
When the arm is extended downwards with the palms facing forward,the angle of the forearm at the elbow is exaggerated, angled away from the body (turners syndrome)
3 classical features of turners syndrome
> short stature, webbed beck and widely spaced nipples
conditions associated w turners
> recurrent otitis media
recurrent UTIs
hypothyroidism
osteoporosis
diaberes
Tx of turners?
> GH replacement - prevents short stature
oestrogen and progesterone replacement - establishment of secondary sex characteristics
fertility TX
most imp long term health problems for women w Turners
> biscuspid aortic valve
coarctation of aorta
inc risk of aortic dilatation
hormone levels in turners?
gonadotropins elevated
features of turners in neonates
lymphodema - espec feet
what is PWS
> Loss of genes on the proximal arm of chromosome 15 inherited from the father
features of PWS?
> Constant insatiable hunger
hypotonia as an infat
hypogonadism
PWS facial features
> Narrow forehead
Almond shaped eyes
Strabismus
Thin upper lip
Downturned mouth
Mx of PWS
> Controlling access to food
GH to improve muscle development and body composition
Inheritance of noonan syndrome?
> autosomal dominant
features of noonan syndrome?
> short stature
broad forehead
downward sloping eyes w ptosis
wide space between eyes
webbed beck
wide spaced nipples
conditions associoated w noonan syndrome
> Congenital HD - pulmonary valve stenosis, cardiomyopathy, ASD
Cryprochidism -> infertility
leukemia
neuroblastoma
Mx of noonan syndrome
> supportive
main comp is CHD - often requires corrective heart surgery
Genetics of klinefelter syndrome
> males 47 XXY - additional X chromosome
Features of klinefelter syndrome
> usually normal until puberty
wider hips
gynaecomastia
small testicules
reduced libido
infertility