Child Health 2 Flashcards
1
Q
RF for appendicitis?
A
> Male
10 - 20 yrs old
FHx
White
2
Q
Causes of appendicitIs?
A
> fecaliths - most common cause of luminal obstruction
lymphoid hyperplasia
foreign bodies
carcinoid tumours/ neoplastic growths
3
Q
most common cause of sepsis in the uk?
A
pneumonia
4
Q
appendicitis pathophys?
A
> ischemia and inflammation -> tissue necrosis -> appendiceal wall weakening -> perforation > peritonitis -> sepsis
5
Q
appendicitis CFs?
A
> pain - starts central and radiates to RIF
vomiting
mild pyrexia
possible diarrhoea
anorexia common
6
Q
pain seen in appendicitis?
A
> 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.
7
Q
examination in appendicitis?
A
> generalised peritonitis if perf
DRE - boggy sensatuon if pelvic abcess present
8
Q
2 classic signs of appendicitis?
A
Rosvings and Psoas sign
9
Q
Rosvings sign?
A
> palpation in the LIF causes pain in the RIF
10
Q
Psoas sign?
A
> pain on extending hip if retrocaecal appendix
11
Q
Ix of appendicitis?
A
> neutrophil dominant leucocytosis common
urine analysis to exclude renal colic and UTI
exclude pregnancy
US if pelvic organ pathology suspected
12
Q
Ectopic pregnancy?
A
> 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
13
Q
ovarian torsion?
A
> 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
14
Q
PID?
A
> in pelvic inflammatory disease pain is typically bilateral, there is vaginal/cervical discharge and cervical motion tenderness on examination
15
Q
Acute mesenteric adenitis?
A
both this and appendicitis can cause lower abd pain with guarding
16
Q
Differences between acute mesenteric adenitis and appendicitis?
A
mesenteric adenitis typically occurs inchildrenafter aviral upper respiratory tract infectionand it does not cause localised tenderness
17
Q
Meckles diverticulum?
A
> can cause RIF pain
clinically indistinguishable from acute appendicitis, often identified when normal appendix found during appendicectomy
18
Q
Crohns?
A
Crohn’s disease often presents with chronicdiarrhoeaand there may be a positive family history
19
Q
Acute cholesystits vs appendicitis?
A
> 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
20
Q
ureteric stones?
A
in nephrolithiasis, pain is typically in the flank, colicky in nature and radiates to the groin
21
Q
UTI?
A
urinary tract infections typically present with dysuria, urgency and frequency and affect older adults more commonly
22
Q
Mx of appencitis?
A
> laparascopic appendicectomy
prophylactic ab
23
Q
RF for pyelo?
A
> Female sex
Structural urological abnormalities
Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
Diabetes
24
Q
most common cause of LUTI?
A
E COLI - rod shaped, gram negative, anaerobic bacteria
25
Triad of pyelo?
> Fever
> Loin or back pain (bilateral or unilateral)
> Nausea / vomiting
26
other CFs of pyelo?
> dysuria, suprapubic discomfort and increased frequency
> loss of appetite
> renal angle tendernes
> haematuria
27
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
28
Abs used for pyelo?
> Cefalexin
If culture results available:
> co-amoxi
> trimethoprim
> ciproflocaxin
29
chronic pyelo?
> recurrent episodes of kidney infection
> can lead to CKD and end stage renal failure
> DMSA scans used to assess damage
30
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
31
When should pyelo be suspected over UTI?
> Fever
> Loin or back pain
> Nausea or vomiting
> Renal angle tenderness on examination
32
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.
33
When is a MSU required?
> not all ppts w uncomplicated UTIs require this
> pregnancy
> atypical sx
> no improv w AB
> recurrent UTIs
34
Tx of UTI?
> Nitro > avoid in GFR < 45
> trimethoprim - avoid in pregnancy
35
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
36
Mx of UTI in pregnancy?
> 7 days ab, MSU required
> cefalexin is typical choice
> amoxicillin after sensitivies known
> nitro
37
use of nitrofurantoin in pregnancy?
avoud in T3 - risk of neonatal haemolysis
38
Trimethoprim in pregnancy?
avoid in T1 - can cause congenital abn- avoided throughout pregnancy
39
Cysts in pre vs post menopausal women
> common in pre-menopausal women
> in post-menopausal, concerning for malignancy
40
diagnosis of PCOS?
> String of pearls appearance of ovaries alone not enough
> at least 2 of 3 required:
> anovulation
> hyperandrogenism
> polystic ovaries on US
41
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.
42
Follicular cysts?
> most common type
> cysts persist when the follicle fails to rupture and release the egg
43
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
44
Serous Cystadenoma
These are benign tumours of the epithelial cells.
45
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.
46
endometrioma?
These are lumps of endometrial tissue within the ovary, occurring in patients with endometriosis. They can cause pain and disrupt ovulation.
47
Dermoid Cysts / Germ Cell Tumours
> benign ovarian cysts
> teratomas
> associated w ovarian torsion
48
sex cord stromal tumours?
> rare, can be benign or malignant
> arise from stroma (CT) or sex cords
49
Assessment of ovarian cysts involves?
> assessing for features of malignancy
50
gen malignancy features
> Abdominal bloating
> Reduce appetite
> Early satiety
> Weight loss
> Urinary symptoms
> Pain
> Ascites
> Lymphadenopathy
51
ovarian malignancy features?
> Age
> Postmenopause
> Increased number of ovulations
> Obesity
> Hormone replacement therapy
> Smoking
> Breastfeeding (protective)
> Family history and BRCA1 and BRCA2 genes
52
link between number of ovulations and ovarian cancer
more ovulations -> inc risk of ovarian cancer
53
factors reducing number of ovulations and therefore risk of ovarian cancer
> late menarche
> early menopause
> any pregnancy
> use of COCP
54
Ix of ovarian cysts?
> US
> CA125 for ovarian cancer
55
Women under 40 years with a complex ovarian mass require
> tumour markers for a possible germ cell tumour
> LDH
> AFP
> HCG
56
Risk of malignancy index
> estimates the risk of an ovarian mass being malignant, taking account of three things:
Menopausal status
Ultrasound findings
CA125 level
57
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
58
Simple ovarian cysts in premenopausal women can 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
59
Meig's syndrome?
> triad of:
> ovarian fibroma - overian benign tumour
> pleural effusion
> ascites
60
pleural effusion + ovarian mass ->
Meigs syndrome
61
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
62
Abd pain in kids?
> constipation
> UTI
> coeliac
> IBD or IBS
> mesenteric adenitis
> HSP
> pyelo
63
Abd pain in girls?
> Dysmenorrhea (period pain)
> Mittelschmerz (ovulation pain)
> Ectopic pregnancy
> Pelvic inflammatory disease
> Ovarian torsion
> Pregnancy
64
Surgical causes of abd pain - appendicitis
central abd pain > RIF
65
Surgical causes of abd pain - INTUSSUSCEPTION
colicky non-specific abdominal pain with redcurrant jelly stools
66
Surgical causes of abd pain - bowel obst
pain, distention, absolute constipation and vomiting
67
surgical causes of abd pain - torsion
sudden onset, unilateral testicular pain, nausea and vomiting
68
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
69
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
70
treating acute attacks of abd migraine
> Low stimulus environment (quiet, dark room)
> Paracetamol
> Ibuprofen
> Sumatriptan
71
Preventative medications for abd migraine:
> Pizotifen, a serotonin antagonist
> Propranolol, a non-selective beta blocker
> Cyproheptadine, an antihistamine
> Flunarazine, a calcium channel blocker
72
Pizotifen
>prev med for abd migraine
> needs to be withdrawn slowly - withdrawal symptoms
73
mesenteric adenitis
> inflamed lymph nodes within mesentery
> similar symptoms to appendicitis but more coryzal symptoms due to viral infection beforehand
> higher fever than appendicitis
74
mesenteric adenitis vs appendicitis
> MA: higher fever
> MA: pain STARTS in RIF
75
Tx of mesenteric adenitis
self limiting, no Tx required
76
CD pain
> diarrhoea
> weight loss
> abd mass in RIF
77
uc features
> bloody diarrhoea
> abd pain in left lower quadrant
> tenesmus
78
Red flags in cases of acute abd pain?
> billous vomiting
> fullness/ masses/ hepatosplenomegaly
> perianal/ rectal disease
> tenderness over spine
79
appendicitis under 5
> long history
> D&V prominent in early stages
> may not have pain
> can present with abd pain
80
appendicitis under 2
most perforated at presentation, collapse and sepsis syndrome
81
management of appenicitis in kids?
> fluid resus
> surgery
> 48 hr ab
82
recurrent abdominal pain?
> pain can't be explained by physical condition
> pain at other sites like headache or limb pain common
83
RAP - IBS
Bloating, loose stools, pain lessens after defecation
84
RAP - FAP?
Func abd pain - continuous from time to time
85
RAP - FAPS
Loss of daily activities plus headaches, limb pain, difficulty sleeping
86
abd migraine?
> intense pain around umbilicus
> reduced appetite, and activities
> nausea vomiting, headache, photophobia
87
Ix for abd pain
> IgA
> IgE to allergens, total IgE
> Fecal calprotectin
> and US, endoscopy/ colonoscopy
88
functional dyspepsia Tx
rantidine/ omeprazole
89
IBD is most common in
12- 16 yrs olds
90
IBD - paediatric presentation
> fever
> anaemia
> weight loss
> FTT
> ammenorrhoea
> retarded bone development, mineral deficiencies
91
necrotising enterocoliotis history
abdominal distension, tenderness, abdominal wall erythema, haematochezia, bradycardia
92
examination in nectrotising enterocolitis
> abd distension
> bradycardia
> haematochezia
> tenderness
93
investigations for NEC?
> Bloods
> abd XR
> US
94
xr findings in NEC?
> dilated bowel loops, lack of normal intestinal gas pattern
95
testicular torsion history
> acute onset testicular pain
> N & V
> may be repeated episodes
96
examination in tT
> tender, oedema,
> affected testicle may appear higher
> absent cremasteric reflex
> no psin relief w elevation of scrotum
97
Ix of torsion
duplex US
98
puberty in girls
> breast buds > pubic hair > periods 2 yrs from the start of puberty
99
puberty in boys
testicle enlargemeny > penis > scrotum darkening > pubic hair development > deepening of voice
100
staging for puberty
Tanner
101
Hypogonadotrophic hypogonadism
deficiency of LH and FSH
102
hypergonadotrophic hypogonadism
lack of response to LH and FSH by the gonads (the testes and ovaries)
103
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
104
what can delay onset of menstruation in girls?
excessive exercise or dieting
105
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
106
Hypergonadotrophic hypogonadism is 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)
107
kallman syndrome
> genetic condition
> causes hypogonadotropic hypogonadism
> failure to start puberty
> associated w reduced/ absent sense of smell
108
when should we investigate for delayed puberty?
girl aged 13 or boy aged 14
109
Initial Ix for delayed puberty?
> FBC - anaemia
> U&Es - CKD
> anti TTG or anti EMA - coeliac disease
110
hormonal blood tests for delayed puberty
> early morning gonadotropins
> TFTs
> GH testing
> prolactin levels
111
early morning gonadotropin results
> low in hypogonadotropic hypogonadism
> high in hypergonadotropic hypogonadism
112
genetic testing for delayed puberty
> Kleinfelter’s syndrome (XXY)
> Turner’s syndrome (XO)
113
imaging in delayed puberty
> X ray of the wrist - const delay
> pelvic US in girls
> MRI pituitary - Kallman syndrome
114
Delayed puberty w normal stature
> polycystic ovarian syndrome
> androgen insensitivity
> Kallman's syndrome
> Klinefelter's syndrome
115
delayed puberty w short stature
> Turner's syndrome
> Prader-Willi syndrome
> Noonan's syndrome
116
Mx of delayed puberty
> replacement sex hormones
117
what happens in turners syndrome
female has a single X chromosome making them 45XO
118
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
119
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)
120
3 classical features of turners syndrome
> short stature, webbed beck and widely spaced nipples
121
conditions associated w turners
> recurrent otitis media
> recurrent UTIs
> hypothyroidism
> osteoporosis
> diaberes
122
Tx of turners?
> GH replacement - prevents short stature
> oestrogen and progesterone replacement - establishment of secondary sex characteristics
> fertility TX
123
most imp long term health problems for women w Turners
> biscuspid aortic valve
> coarctation of aorta
> inc risk of aortic dilatation
124
hormone levels in turners?
gonadotropins elevated
125
features of turners in neonates
lymphodema - espec feet
126
what is PWS
> Loss of genes on the proximal arm of chromosome 15 inherited from the father
127
features of PWS?
> Constant insatiable hunger
> hypotonia as an infat
> hypogonadism
128
PWS facial features
> Narrow forehead
> Almond shaped eyes
> Strabismus
> Thin upper lip
> Downturned mouth
129
Mx of PWS
> Controlling access to food
> GH to improve muscle development and body composition
130
Inheritance of noonan syndrome?
> autosomal dominant
131
features of noonan syndrome?
> short stature
> broad forehead
> downward sloping eyes w ptosis
> wide space between eyes
> webbed beck
> wide spaced nipples
132
conditions associoated w noonan syndrome
> Congenital HD - pulmonary valve stenosis, cardiomyopathy, ASD
> Cryprochidism -> infertility
> leukemia
> neuroblastoma
133
Mx of noonan syndrome
> supportive
> main comp is CHD - often requires corrective heart surgery
134
Genetics of klinefelter syndrome
> males 47 XXY - additional X chromosome
135
Features of klinefelter syndrome
> usually normal until puberty
> wider hips
> gynaecomastia
> small testicules
> reduced libido
> infertility
136
Tx of klinefelters syndrome
> symptom improvement: testosterone injections, breast reduction surgery, IVF
137
klinefelters increases your risk of…
> breast cancer comp to men
> osteoporosis
> diabetes
138
what is kallmans
> delayed puberty - hypogonadotropic hypogonadism
> X linked recessive inheritance
139
features of kallmans
> lack of smell (anosmia)
> delayed puberty
140
blood tests in kallmans
> sex hormone levels are low
> LH, FSH levels are inappropriately low/normal
141
management of kallmans
> testosterone supplementation
142
androgen insensitivity syndrome
> X linked recessive condition
> mutation in androgen receptor gene
143
pathophys of AIS
> Extra androgens -> oestrogen
> female secondary sexual characteristic
> patients are genetically male - XY chromosomes
but have a female phenotype - breast tissue and female genitals
144
Phenotype in AIS
> Testes in abdomen or inguinal canal
> absence of uterus, upper vagina, ovaries just notmal female external genitalia (AMH produced by testes)
145
what do ppl w AIS lack
> pubic hair
> male type muscle development
> facial hair
146
Presentation of AIS
> lack of hair - facial/ pubic
> micropenis
> clitomegaly
> bfid scrotum
> dimished male characteristics
147
how does AIS present?
> Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes.
> Alternatively, it presents at puberty with primary amenorrhoea.
148
hormone tests in AIS
> Raised LH
> normal or raised FSH
> normal/raised testosterone for a male
> raised oestrogen levels for a male
149
Mx of AIS?
> Bilateral orchidectomy (removal of the testes) to avoid testicular tumours
> Oestrogen therapy
> Vaginal dilators or vaginal surgery can be used to create an adequate vaginal length
150
Generalised tonic clonic seizures
> loss of conciousness
> tonic (muscle tensing) and clonic (muscle jerking) movements
> may be associated tongue biting, incont, groaning, irregular breathing
151
after a tonic clonic seizure there is a ? Period
prolonged post ictal period - person feels confused, drowsy and feels irritable/ low
152
Mx of tonic clonic seizures
> First line: sodium valproate
> Second line: lamotrigine or carbamazepine
153
focal seizures
> start In temporal lobes
> They affect hearing, speech, memory and emotions.
154
how do focal seizures present
> hallucinations
> flashbacks and déjà vu
> strange beh on autopilot
155
Tx of focal seizures
> reverse of that of tonic clonic
> First line: carbamazepine or lamotrigine
> Second line: sodium valproate or levetiracetam
156
absence seizures
> typically happen in children
> stare into space
> unaware of surroundings
> 10 - 20s
157
Mx of absence seizures
First line: sodium valproate or ethosuximide
158
atonic seizures
> drop attacks
> usually less than 3 minutes
> can indicate lennox gastaut syndrome
159
Mx of atonic seizures
> First line: sodium valproate
> Second line: lamotrigine
160
myoclonic seizures
> sudden brief muscle contractions
> ppt remains awake during the episode
> juvenile myoclonic epilepsy
161
Mx of myoclonic seizures
> First line: sodium valproate
> Other options: lamotrigine, levetiracetam or topiramate
162
infantile spasms
> West syndrome
> starts around 6 months
> full body spasms occur
163
Tx of infantile spasms
> Prednisolone
> Vigabatrin
164
febrile convulsions
> seizures that occur in children whilst they have a fever
> not caused by epilepsy
165
Ix for epilepsy
> EEG - after second tonic clonic seizure (children are allowed one simple seizure before investigating for epilepsy)
> MRI brain
166
Sodium valproate
> first line for most types of epilepsy except focal seizures
167
What are the side effects of sodium vaporate
> Teratogenic
> Liver damage and hepatitis
> Hair loss
> Tremor
168
side effects of carbamazepine
> Agranulocytosis
> Aplastic anaemia
> Induces the P450 system so there are many drug interactions
169
carbamazepine
1st line for focal seizures
170
phenytoin SE?
> Folate and vitamin D deficiency
> Megaloblastic anaemia (folate deficiency)
> Osteomalacia (vitamin D deficiency)
171
Ethosuximide se
> Night terrors
> Rashes
172
lamotrigene se
> SJS/ Dress syndrime
> leukopenia
173
Management of Seizures
> Put the patient in a safe position (e.g. on a carpeted floor)
> Place in the recovery position if possible
> Put something soft under their head to protect against head injury
> Remove obstacles that could lead to injury
> Make a note of the time at the start and end of the seizure
> Call an ambulance if lasting more than 5 minutes or this is their first seizure.
174
status epilepticus
> med emergency
> seizure lasting more than 5 min or 2+ seizures w/o regaining consciousness
175
Mx of status epileptica (ABCDE approach)
> Secure the airway
> Give high-concentration oxygen
> Assess cardiac and respiratory function
> Check blood glucose levels
> Gain intravenous access (insert a cannula)
176
Meds used for status epileptica
> IV lorazapam - repeat after 10 if seizures cont
> If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin
177
community meds for status epileptica
buccal midazolam and rectal diazepam
178
CF genetics
> autosomal recessive
> in CTFR gene on chromosome 7
> delta F508 mutation
179
pathophys of CF
> Thick pancreatic secretions -> blocked duct -> lack of digestive enzymes like lipase
> low volume airway clearance -> infections
> Congenital bilateral absence of the vas deferens in males -> infertility
180
meconium ileus
> first sign of CF
> not passing meconium within 24 hrs, abd distentuon and vomiting
181
Sx of CF
> Chronic cough, thick sputum
> stearrhoea
> abd bloating and pain
> FTT
> recurrent RTI
> salty sweat
182
Signs of CF
> Nasal polyps
> finger clubbing
> crackles and wheeze
> abd distention
183
diagnosis of CF
1) Newborn blood spot testing
2) sweat test - gold standard
3) amniocentesis for genetic testing for CTFR gene
184
why should children w CF avoud other children w CF
To prevent pseudomonas transmission
185
CF Mx
> Chest physiotherapy
> high caloriw diet
> CREON tables - panc insufficiency
> prophylactic flucoloxacillin
> bronchodilation - salbutamil
186
Vaccinations for CF
pneumococcal, influenza and varicella
187
Monitoring for CF
> Spurum for bacteria
> hey also need monitoring and screening for diabetes, osteoporosis, vitamin D deficiency and liver failure.
188
salmon pink rash is seen in…
Systemic onset JIA (AKA Still's disease) has a characteristic salmon-pink rash
189
A child with hip pain, limp and recent infective illness →
? transient synovitis
190
A young boy is noted to have learning difficulties, macrocephaly, large ears and macro-orchidism ->
fragile X
191
Consider referring children with bronchiolitis to hospital if they have any of the following:
> a respiratory rate of over 60 breaths/minute
> difficulty with breastfeeding or inadequate oral fluid intake (50-75% of usual volume, taking account of risk factors
> clinical dehydration.
192
Mitochondrial diseases are inherited following 3 principles:
> Affected males cannot pass it onto their . children
> Affected females will pass it onto all of their children
> All individuals who inherit the affected mitochondria, will have the disease
193
Denying Tx as a child
In England and Wales a child has the ability to consent to, but not refuse, treatment. Whether a child has demonstrated capacity (as per the Fraser guidelines) is not the relevant issue.
194
features of anorexia
> severe weight loss/ low BMI
> ammenorrhoea
> low BP
> lanugo hair growth
> tiredness
> hair loss
> electrolyte abn
195
behaviours in Eds
> over exercising
> laxative use
196
bulimia nervosa features?
> self induced vomiting
> binging
> enlarged salivary glands
> fluctuating weight
197
Avoidant / restrictive food intake disorder
(ARFID)
> Can be a mix of signs and symptoms associated with
anorexia and bulimia
> Most common type of eating disorder
198
puberty in girls
• breast development (Tanner stage 2 )
• menarche follows within 2 y
• early growth spurt
199
puberty in boys
• testicular enlargement (Tanner stage 2 ) • later growth spurt
200
CFS/ Myalgic encephalomyelitis symptoms
> fatigue - worseened by activity not releived by rest
> post exertional malaise
> sleep problems - insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep-wake cycle
> painful lymph nodes w/o enlargement
> sore throat
> cognitive dysfunction
> general malaise
> min of 6 weeks in adults and 4 weeks in children
201
Ix of CFS
> FBC, U&Es, LFT, glucose, TFT, ESR, ferritin, coeliac screening, urinanalysis
202
CFS Mx?
> refer to CFS service if 3+ months
> exercise overseen by ME team
> CBT
203
triad of hyperglycaemia (T1D)
Polyuria, polydipsia, weight loss
204
Other Sx of T1D
> Secondary enuresis (previously dry child)
> recurrent infections
> recent coxsakie B virus
205
Ix for T1D?
> FBC, U&Es, Lab glucose
> blood cultures if fever
> TPO, anti TTG, ab testing
206
Ab in T1D?
Insulin antibodies, anti-GAD antibodies and islet cell antibodies
207
basal bolus regime
> long acting insulin - background
> bolus - e.g. actrapid usually 3x a day before meals
208
lipodystrophy
> Injecting into the same spot repeatedly can cause a condition called lipodystrophy, where the subcutaneous fat hardens and prevents normal absorption of insulin when further doses are injected into this area. For this reason patients should cycle their injection sites. If a patient is not responding to insulin as expected, ask where they inject and check for lipodystrophy.
209
Insulin pumps
> need to be over 12 and have difficulty controlling HBA1C
> tethered pumps
> patch pumps
210
Ad of insulin pumps
better blood sugar control, more flexibility with eating and less injections.
211
Macrovascular comps of diabetes
> Coronary artery disease is a major cause of death in diabetics
> Peripheral ischaemia causes poor healing, ulcers and “diabetic foot”
> Stroke
> Hypertension
212
microvascular comps of diabetes
> Peripheral neuropathy
> Retinopathy
> Kidney disease, particularly glomerulosclerosis
213
features of hypoglycaemia
> sweating
> shaking
> hunger
> nausea
> severeL weakness, vision changes, confusion, dizziness
214
Whipples criteria
> hypoglycaemia
1) symptoms of hypogly
2) low BG
3) resolution of symptoms with correction of BG
215
insulinoma
> serum insulin elevated
> low BG
> serum C peptide elevated
216
Mx of hypoglycaemia: community
1) oral glucose
2) glucogel
3) hypokit - glucagon for IM/ SC injection
217
Mx of hypoglycaemia: hosp
> quick acting carb if alert
> If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.
> Alternatively, intravenous 20% glucose solution may be given through a large vein
218
DKA triad?
> hyperglycaemia
> Met acidosis
> ketosis
219
Features of DKA?
> V high BG - blurred vision, headache, lethargy
> Kussmal breathing
> acetone breath
> abd pain, nausea and vomiting (ketosis)
> often precipitated by infections, poor compliance with insulin therapy, or newly diagnosed diabetes mellitus.
220
diagnosis of DKA?
> bg > 11
> pH under 7.3
> ketones > 3 or urine ketones ++ on dipstick
221
management of DKA?
1) fluid replacement - isotonic saline
2) IV insulin infusion (dextrose added when BG is under 14)
3) monitor potassium (falls w insulin use)
4) long-acting insulin should be continued, short-acting insulin should be stopped
222
DKA - endocrinologist review
> both the ketonaemia and acidosis should have been resolved within 24 hours. If this hasn't happened the patient requires senior review from an endocrinologist
> the patient should be reviewed by the diabetes specialist nurse prior to discharge
223
DKA - cerebral oedema
> espec in kids
> headache, altered mental status, seizures, and focal neurological deficits
> especially with fluid replacement
224
Patau syndrome (trisomy 13) symptoms
> Microcephalic, small eyes
> Cleft lip/palate
> Polydactyly
> Scalp lesions
225
Edward's syndrome (trisomy 18) Sx
> Micrognathia
> Low-set ears
> Rocker bottom feet
> Overlapping of fingers
226
Fragile X Sx
> Learning difficulties
> Macrocephaly
> Long face
> Large ears
> Macro-orchidism
227
Noonan syndrome Sx
> Webbed neck
> Pectus excavatum
> Short stature
> Pulmonary stenosis
228
Pierre Robin syndrome
> Micrognathia
> Posterior displacement of the tongue
> Cleft palate
229
Prader-Willi syndrome
> Hypotonia
> Hypogonadism
> Obesity
230
Williams syndrome
> Short stature
> Learning difficulties
> Friendly, extrovert personality
> Transient neonatal hypercalcaemia
> Supravalvular aortic stenosis
231
Cri du chat syndrome (chromosome 5p deletion syndrome)
> characteristic cry
> feeding problems, poor weight gain
> LDs
> Microcephaly and micrognathism
> Hypertelorism
232
genetics of downs
> 3x chromosome 21 - trisomy 21
233
Features of downs
> hypotonia
> brachycephaly (small head w flat back)
> short
> prominent folds on eyes
> single palmar crease
234
complications of downs
> LDs
> recurrent otitis media
> deafness - eustachian tube abn
> hypothyroidism
235
what is more common in childrens w downs
leukemia and dementia
236
antenatal screening for downs
> combined test: first line
> triple test
> quaruple test
237
Downs: combined test
> 11-14 weeks gestation
> US: measures nuchal transluency (increased)
> Beta HCG (higher risk when greater value)
> PAPPA - lower result -> greater risk
238
triple test for downs
> 14 - 20 weeks gestation
> beta HCG - higher value = more risk
> AFP and serum oestriol = lower value -> greater risk
239
quadruple test for downs?
> beta HCG, AFP, serum oestriol
> plus inhibin A - higher value -> greater risk
240
Antenatal Testing for Downs Syndrome
> when risk score is greater than 1 in 150
> amniocentesis offered later in pregnancy
> chronic villus sampling earlier
> non invasive prenatal testing
241
monitoring for downs
> Regular thyroid checks (2 yearly)
> Echocardiogram to diagnose cardiac defects
> Regular audiometry for hearing impairment
> Regular eye checks
242
Genetics of fragile X
> mutation in FMR1 gene
> X lined - males always affected but females vary in how much they're affected
243
Mx of fragile X
> supportive
> manage ADHD, autism or seizures if they occur
244
What is haemachromatosis
> autosomal recessive
> iron overload (iron stiorage disorder)
245
genetics of haemachromatosis
> C282Y mutation in HEF gene on chromosome 6
246
Presentation of haemachromatosis?
> usually after 40 when iron overload becomes symptomatic
> later in females due to menstruation
> bronze skin
> testicular atrophy
> amenorrhoea
> hepatomegaly
> ED
247
diagnosis of haemachromatosis
> serum ferritin - first Ix
> transferrin saturation
> genetic testing
> liver biopsy w Perls stain
248
Mx of haemachromatosis
> venesection
> monitoring serum ferritin
249
sickle cell genetics
> autosomal recessive affecting gene for beta globin on chromosome 11
> one copy of the mutation: sickle cell trait
250
screening for sickle cell
newborn blood spot
251
complications of sickle cell
> anaemia
> acute chest
> avascular necrosis
> crises
252
Sickle cell crisis
> They can occur spontaneously or triggered by dehydration, infection, stress or cold weather.
> hydrate
> analgesia (avoid NSAIDs when renal impairment)
> keep warm
253
vaso-occlusive crisis?
> painful crisis
> distal ischemia
> t typically presents with pain and swelling in the hands or feet but can affect the chest
> It can cause priapism in men by trapping blood in the penis, causing a painful and persistent erection.
> Priapism is a urological emergency, treated by aspirating blood from the penis.
254
splenic sequestration crisis
> RBCs block blood flow in spleen
> enlarged and painful spleen
> Blood pooling in the spleen can lead to severe anaemia and hypovolaemic shock.
255
Mx of splenic sequestration crisis
> emergency
> Management is supportive, with blood transfusions and fluid resuscitation to treat anaemia and shock.
256
comps of splenoc sequestration
> Splenic sequestration crisis can lead to splenic infarction, leading to hyposplenism and
> susceptibility to infections, particularly by encapsulated bacteria (e.g., Streptococcus pneumoniae and Haemophilus influenzae).
> Splenectomy in recurrent cases
257
Aplastic crisis?
> temp absence of creation of new RBC
> usually triggered by parovirus B19
> Leads to aplastic anaemia
258
Acute chest syndrome presents w
Acute chest syndrome presents with fever, shortness of breath, chest pain, cough and hypoxia. A chest x-ray will show pulmonary infiltrates.
259
ACS Mx
> Analgesia
> Good hydration (IV fluids may be required)
> Antibiotics or antivirals for infection
> Blood transfusions for anaemia
> Incentive spirometry using a machine that encourages effective and deep breathing
> Respiratory support with oxygen, non-invasive ventilation or mechanical ventilation
260
Hydroxycarbamide
works by stimulating the production of fetal haemoglobin (HbF) -> reduced freq of vaso-occlusive crises
261
Crizanlizumab
Mab against P selectin -> reduced freq of vaso-occlusive crises
262
Pathophys of epistaxis
> originate from Kiesselbach’s plexus, which is also known as Little’s area
> when mucosa is disrupted in this area such as a child picking their nose -> bleeding
263
Presentation of epistaxis
> can be triggered by nose picking, colds, vigorous nose blowing, trauma and changes in the weather.
> if they swallow during the bleed, can present witj vomiting blood
> bilateral bleeding can indicate a bleed from posterior nose
264
You may have to advise patients and parents on how to manage a nosebleed:
> Sit up and tilt the head forwards. Tilting the head backwards is not advised as blood will flow towards the airway.
> Squeeze the soft part of the nostrils together for 10 – 15 minutes
> Spit any blood in the mouth out rather than swallowing
265
Nosebleeds: hospital admission
> When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, from both nostrils or they are unstable, patients may require admission to hospital. Treatment options are:
> Nasal packing using nasal tampons or inflatable packs
> Nasal cautery using a silver nitrate stick
266
Naseptin
> can be prescribed for 10 days after a nosebleed to reduce crusting, inflammation, infection
> CI in peanut or soya allergy
267
final common pathway for mucous drainage
middle turbinate
268
which sinuses drain to the middle meatus
> frontal
> maxillary
> anterior ethmoidal
269
which sinuses drain to superior meatues
> sphenoid
> posterior ethmoidal
270
choanal atresia
271
causes of nosebleeds
> Trauma
> Insertion of foreign bodies
> Bleeding disorders such as ITP
> cocaine use
272
features of sinusitis
> facial pain- typically frontal pressure pain which is worse on bending forward
> nasal discharge: usually thick and purulent
> nasal obstruction
273
Mx of sinusitis
> analgesia
> nasal decongestants
> intranasal steroids if symptoms for 10+ days
> oral ab if severe - phenoxymethylpenicillin first-line
274
chronic rhinosinusitis?
> inflammation of nasal sinuses for 12+ weeks
275
predisposing factors for chronic sinusitis?
> atopy
> nasal obstruction e.g. septal deviation or nasal polyps
> recent infection
> swimming
> smoking
276
features of chronic sinusitis?
> facial pain: typically frontal pressure pain which is worse on bending forward
> nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
> nasal obstruction: e.g. 'mouth breathing'
post-nasal drip: may produce chronic cough
277
Management of recurrent or chronic sinusitis
> avoid allergen
> intranasal corticosteroids
> nasal irrigation with saline solution
278
Red flags symptoms for sinusitis
> unilateral symptoms (such as obst, discharge, crusting, facial swelling)
> persistent symptoms despite compliance with 3 months of treatment
> epistaxis
> cancer referral pathway
279
who are nasal polyps more common in?
> men
> not commonly seem in children/ elderly
280
Associations w nasal polyps
> CF
> asthma - paticularly late onset
> aspirin sensitivity
> Kartagener's syndrome
281
samters triad
asthma, aspirin sensitivity and nasal polyposis is known as Samter's triad.
282
features of nasal polyps
> nasal obstruction
> rhinorrhoea, sneezing
> poor sense of taste and smell
283
Mx of polyps
> Unusual features which always require further investigation include unilateral symptoms or bleeding.
> all patients with suspected nasal polyps should be referred to ENT
> topical corticosteroids shrink polyp size in around 80% of patients
284
nasopharyngeal carcinomas
> sq cell carcinoma of the nasopharynx
> common in southern china
> associated w EBV infection
285
Features of nasopharyngeal carcinomas
> cervical lymphadenopathy
> unilateral serous otitis media
> Nasal obstruction, discharge and/ or epistaxis
> Cranial nerve palsies e.g. III-VI
286
Tx of nasopharyngeal carcinomas
radiotherapy
287
Imaging in nasophyrangeal carcinomas
combined CT and MRI
288
intramural gas on AXR ->
NEC
289
DDH in an older child
An older child with missed DDH may present with a Trendlenberg gait and leg length discrepancy
290
There is often the loss of internal rotation of the leg in flexion in
slipped capital femoral epiphysis
291
gold standard for diagnosis of hirschsprungs disease
Rectal biopsy is the gold standard for diagnosis of Hirschsprung's disease
292
Grips
Palmer, Point, Pincer - 6, 9, 12
293
duodenal atresia
duodenal atresia is commoner in Down's patients, it is also the most common cause of bilious vomiting in the first few days of life.
294
murmur seen in turner's
Turner's syndrome is associated with an ejection systolic murmur due to bicuspid aortic valve
295
meconium ileus ->
Muconeum ileus -> Hirschsprung or CF
296
blood in stool in pre-mie
Blood in stool in pre-term baby -> NEC
297
SCFE presentation
Obese boy with groin/thigh/knee pain → ?slipped capital femoral epiphysis
298
child w limp/ pain and a fever
If a child with a limp/hip pain has a fever they should be referred for same-day assessment, even if a diagnosis of transient synovitis is suspected
299
what is associated w malrotation?
Exomphalos and diaphragmatic herniae are commonly associated with malrotation.
300
what is not seen in downs syndrome
rocker bottom feet - seen in trisomy 18 or Edwards
301
loss of internal rotation of the leg
There is often the loss of internal rotation of the leg in flexion in slipped capital femoral epiphysis
302
billous vomitig on first day ->
Bilious vomiting on the first day is likely due to intestinal atresia
303
limp pathways
1. Fever and limping - bloods to r/o septic arthritis
2. Trauma and limping - XR to r/o #
3. No fever, not unwell, no trauma and limping - reassure, analgesia advise and GP follow-up if not improving with good safetynet
304
mneumonic for kawasakis
> C: conjunctivitis (bilateral).
> R: rash (non-vesicular).
> A: adenopathy (cervical).
> S: swollen, strawberry tongue.
> H: hand swelling (or feet).
> Burn: fever lasts >5 days and is very high.
305
eczema herpeticum
> rapidly progressing painful rash
> caused by herpes simplex 1 or 2
> seen in kids w atopic eczema
306
Mx of eczema herpetcium
> IV aciclovir - life threatening
307
lesions in eczema herpeticum
monomorphic punched out
308
how is acute epiglottitis diagnosed
direct visualisation from senior anaesthatist
309
BLS algorithm for kids - order of intitial steps
1) 5 rescue breaths
2) check pulses
310
what is the koebner phenomenon
> The Koebner phenomenon describes skin lesions that appear at the site of injury. It is seen in:
> psoriasis
> vitiligo
> warts
> lichen planus
> lichen sclerosus
> molluscum contagiosum
311
what feature of bronchiolotis would necessitate immediate ref to hosp
grunting
312
when can steroids not be used for kids with meningitis
under 3 months - DO NOT give steroids
313
massive rectal bleeding in a 1/2 yr old
Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
314
Features of atypical UTI:
> Seriously ill
> Poor urine flow
> Abdominal or bladder mass
> Raised creatinine
> Septicaemia
> Failure to respond to treatment with suitable antibiotics within 48 hours
> Infection with non-E. coli organisms.
315
Barlows vs ortlanis
> Barlow (B is before in the alphabet) Ortali (O is after).
> You dislocate FIRST (Barlows)
316
most common fractures seen in NAI
Humeral, radial, femoral
317
Double bubble sign ->
DUOdeal atresia
318
leg appearance in a hip fracture
Leg is shortened and EXTERNALLY ROTATED with hip fracture
319
how does ITP present
ITP is often preceded by a viral illness and the presence of an isolated thrombocytopaenia is typical of ITP. In TTP, schistocytes are often seen on blood smears.
320
pathogen causing NF in Chickenpox ppts
Invasive group A Streptococcus, a β-haemolytic Streptococcus,
321
causes of snoring in kids
> obesity
> nasal problems
> recurrent tonsillitis
> downs syndrome
> hypothyroidism
322
which heart lesion is associated w DMD
dilated cardiomyopathy
323
cardiac problem associated w downs
AVSD
324
FIRST LINE IN WHOOPING COUGH
azithromycin or clarithromycin if the onset of cough is within the previous 21 days
325
IVDU w IE can present w
discitis
326
summary of school exclusion req
> CP - all lesions crusted over
> impetigo - 48hrs after ab
> Scarlet fever - 24 hrs after ab
> MMR - mumps - 5 letters, M&R - 4 days after rash onset
> Whooping cough - 2 whoops - 2 whoops so can return to school 2 days after antibiotics (48hrs) or 21 days from onset of illness if no antibiotics.
> HFM - no exclusion required
327
what does downs inc risk of
Alzheimers disease
328
what can cause diabetes in kids
CF
329
What is used to promote patent ductus arteriosus
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
330
inheritance seen in PWS
IMPRINTING
331
for a man with his mitochondrial disease how many of his children will inherit the condition
0% - Mitochondrial diseases are inherited from mother to child only
332
pattern seen in roseola infantum
fever when rash Improves
333
mneumonic for paeds red flags
> Really Sick Babies Get Antibiotics
1. Recessions (moderate or severe chest wall recessions)
2. Skin turgor reduced
3. Blue or mottled appearance
4. Grunting
5. Asleep (does not wake if aroused)
334
mesenteric adenitis
> sim pres to appendicitis but preceding history of viral infection
> does not need Tx
335
acute vs chronic subdural haemtoma on CT
> Chronic: old blood which appears black
> Fresh blood is white
336
intercranial bleed in an alcoholic ->
chronic subdural haem
337
initial Mx of hirschprungs Dx
rectal washouts, bowel irrigation
338
children under 3 months w a UTI ->
Children under 3 months with a suspected UTI should be referred to specialist paediatrics services
339
PS leads to…
elevated bicarb, hypocholaramic hypokalaemic alk
