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
Tx of klinefelters syndrome
> symptom improvement: testosterone injections, breast reduction surgery, IVF
klinefelters increases your risk of…
> breast cancer comp to men
osteoporosis
diabetes
what is kallmans
> delayed puberty - hypogonadotropic hypogonadism
X linked recessive inheritance
features of kallmans
> lack of smell (anosmia)
delayed puberty
blood tests in kallmans
> sex hormone levels are low
LH, FSH levels are inappropriately low/normal
management of kallmans
> testosterone supplementation
androgen insensitivity syndrome
> X linked recessive condition
mutation in androgen receptor gene
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
Phenotype in AIS
> Testes in abdomen or inguinal canal
absence of uterus, upper vagina, ovaries just notmal female external genitalia (AMH produced by testes)
what do ppl w AIS lack
> pubic hair
male type muscle development
facial hair
Presentation of AIS
> lack of hair - facial/ pubic
micropenis
clitomegaly
bfid scrotum
dimished male characteristics
how does AIS present?
> Androgen insensitivity syndrome often presents in infancy with inguinal hernias containing testes.
Alternatively, it presents at puberty with primary amenorrhoea.
hormone tests in AIS
> Raised LH
normal or raised FSH
normal/raised testosterone for a male
raised oestrogen levels for a male
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
Generalised tonic clonic seizures
> loss of conciousness
tonic (muscle tensing) and clonic (muscle jerking) movements
may be associated tongue biting, incont, groaning, irregular breathing
after a tonic clonic seizure there is a ? Period
prolonged post ictal period - person feels confused, drowsy and feels irritable/ low
Mx of tonic clonic seizures
> First line: sodium valproate
Second line: lamotrigine or carbamazepine
focal seizures
> start In temporal lobes
They affect hearing, speech, memory and emotions.
how do focal seizures present
> hallucinations
flashbacks and déjà vu
strange beh on autopilot
Tx of focal seizures
> reverse of that of tonic clonic
First line: carbamazepine or lamotrigine
Second line: sodium valproate or levetiracetam
absence seizures
> typically happen in children
stare into space
unaware of surroundings
10 - 20s
Mx of absence seizures
First line:sodium valproateorethosuximide
atonic seizures
> drop attacks
usually less than 3 minutes
can indicate lennox gastaut syndrome
Mx of atonic seizures
> First line: sodium valproate
Second line: lamotrigine
myoclonic seizures
> sudden brief muscle contractions
ppt remains awake during the episode
juvenile myoclonic epilepsy
Mx of myoclonic seizures
> First line: sodium valproate
Other options: lamotrigine, levetiracetam or topiramate
infantile spasms
> West syndrome
starts around 6 months
full body spasms occur
Tx of infantile spasms
> Prednisolone
Vigabatrin
febrile convulsions
> seizures that occur in children whilst they have a fever
not caused by epilepsy
Ix for epilepsy
> EEG - after second tonic clonic seizure (children are allowed one simple seizure before investigating for epilepsy)
MRI brain
Sodium valproate
> first line for most types of epilepsy except focal seizures
What are the side effects of sodium vaporate
> Teratogenic
Liver damage and hepatitis
Hair loss
Tremor
side effects of carbamazepine
> Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions
carbamazepine
1st line for focal seizures
phenytoin SE?
> Folate and vitamin D deficiency
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitamin D deficiency)
Ethosuximide se
> Night terrors
Rashes
lamotrigene se
> SJS/ Dress syndrime
leukopenia
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.
status epilepticus
> med emergency
seizure lasting more than 5 min or 2+ seizures w/o regaining consciousness
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)
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
community meds for status epileptica
buccal midazolam and rectal diazepam
CF genetics
> autosomal recessive
in CTFR gene on chromosome 7
delta F508 mutation
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
meconium ileus
> first sign of CF
not passing meconium within 24 hrs, abd distentuon and vomiting
Sx of CF
> Chronic cough, thick sputum
stearrhoea
abd bloating and pain
FTT
recurrent RTI
salty sweat
Signs of CF
> Nasal polyps
finger clubbing
crackles and wheeze
abd distention
diagnosis of CF
1) Newborn blood spot testing
2) sweat test - gold standard
3) amniocentesis for genetic testing for CTFR gene
why should children w CF avoud other children w CF
To prevent pseudomonas transmission
CF Mx
> Chest physiotherapy
high caloriw diet
CREON tables - panc insufficiency
prophylactic flucoloxacillin
bronchodilation - salbutamil
Vaccinations for CF
pneumococcal,influenzaandvaricella
Monitoring for CF
> Spurum for bacteria
hey also need monitoring and screening for diabetes, osteoporosis, vitamin D deficiency and liver failure.
salmon pink rash is seen in…
Systemic onset JIA (AKA Still’s disease) has a characteristic salmon-pink rash
A child with hip pain, limp and recent infective illness →
? transient synovitis
A young boy is noted to have learning difficulties, macrocephaly, large ears and macro-orchidism ->
fragile X
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.
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
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.
features of anorexia
> severe weight loss/ low BMI
ammenorrhoea
low BP
lanugo hair growth
tiredness
hair loss
electrolyte abn
behaviours in Eds
> over exercising
laxative use
bulimia nervosa features?
> self induced vomiting
binging
enlarged salivary glands
fluctuating weight
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
puberty in girls
• breast development (Tanner stage 2 )
• menarche follows within 2 y
• early growth spurt
puberty in boys
• testicular enlargement (Tanner stage 2 ) • later growth spurt
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
Ix of CFS
> FBC, U&Es, LFT, glucose, TFT, ESR, ferritin, coeliac screening, urinanalysis
CFS Mx?
> refer to CFS service if 3+ months
exercise overseen by ME team
CBT
triad of hyperglycaemia (T1D)
Polyuria, polydipsia, weight loss
Other Sx of T1D
> Secondary enuresis (previously dry child)
recurrent infections
recent coxsakie B virus
Ix for T1D?
> FBC, U&Es, Lab glucose
blood cultures if fever
TPO, anti TTG, ab testing
Ab in T1D?
Insulin antibodies,anti-GAD antibodiesandislet cell antibodies
basal bolus regime
> long acting insulin - background
bolus - e.g. actrapid usually 3x a day before meals
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.
Insulin pumps
> need to be over 12 and have difficulty controlling HBA1C
tethered pumps
patch pumps
Ad of insulin pumps
better blood sugar control, more flexibility with eating and less injections.
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
microvascular comps of diabetes
> Peripheral neuropathy
Retinopathy
Kidney disease, particularly glomerulosclerosis
features of hypoglycaemia
> sweating
shaking
hunger
nausea
severeL weakness, vision changes, confusion, dizziness
Whipples criteria
> hypoglycaemia
1) symptoms of hypogly
2) low BG
3) resolution of symptoms with correction of BG
insulinoma
> serum insulin elevated
low BG
serum C peptide elevated
Mx of hypoglycaemia: community
1) oral glucose
2) glucogel
3) hypokit - glucagon for IM/ SC injection
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
DKA triad?
> hyperglycaemia
Met acidosis
ketosis
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.
diagnosis of DKA?
> bg > 11
pH under 7.3
ketones > 3 or urine ketones ++ on dipstick
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
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
DKA - cerebral oedema
> espec in kids
headache, altered mental status, seizures, and focal neurological deficits
especially with fluid replacement
Patau syndrome (trisomy 13) symptoms
> Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
Edward’s syndrome (trisomy 18) Sx
> Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
Fragile X Sx
> Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
Noonan syndrome Sx
> Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
Pierre Robin syndrome
> Micrognathia
Posterior displacement of the tongue
Cleft palate
Prader-Willi syndrome
> Hypotonia
Hypogonadism
Obesity
Williams syndrome
> Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
Cri du chat syndrome (chromosome 5p deletion syndrome)
> characteristic cry
feeding problems, poor weight gain
LDs
Microcephaly and micrognathism
Hypertelorism
genetics of downs
> 3x chromosome 21 - trisomy 21
Features of downs
> hypotonia
brachycephaly (small head w flat back)
short
prominent folds on eyes
single palmar crease
complications of downs
> LDs
recurrent otitis media
deafness - eustachian tube abn
hypothyroidism
what is more common in childrens w downs
leukemia and dementia
antenatal screening for downs
> combined test: first line
triple test
quaruple test
Downs: combined test
> 11-14 weeks gestation
US: measures nuchal transluency (increased)
Beta HCG (higher risk when greater value)
PAPPA - lower result -> greater risk
triple test for downs
> 14 - 20 weeks gestation
beta HCG - higher value = more risk
AFP and serum oestriol = lower value -> greater risk
quadruple test for downs?
> beta HCG, AFP, serum oestriol
plus inhibin A - higher value -> greater risk
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
monitoring for downs
> Regular thyroid checks (2 yearly)
Echocardiogram to diagnose cardiac defects
Regular audiometry for hearing impairment
Regular eye checks
Genetics of fragile X
> mutation in FMR1 gene
X lined - males always affected but females vary in how much they’re affected
Mx of fragile X
> supportive
manage ADHD, autism or seizures if they occur
What is haemachromatosis
> autosomal recessive
iron overload (iron stiorage disorder)
genetics of haemachromatosis
> C282Y mutation in HEF gene on chromosome 6
Presentation of haemachromatosis?
> usually after 40 when iron overload becomes symptomatic
later in females due to menstruation
bronze skin
testicular atrophy
amenorrhoea
hepatomegaly
ED
diagnosis of haemachromatosis
> serum ferritin - first Ix
transferrin saturation
genetic testing
liver biopsy w Perls stain
Mx of haemachromatosis
> venesection
monitoring serum ferritin
sickle cell genetics
> autosomal recessive affecting gene for beta globin on chromosome 11
one copy of the mutation: sickle cell trait
screening for sickle cell
newborn blood spot
complications of sickle cell
> anaemia
acute chest
avascular necrosis
crises
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
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.
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.
Mx of splenic sequestration crisis
> emergency
Management is supportive, with blood transfusions and fluid resuscitation to treat anaemia and shock.
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
Aplastic crisis?
> temp absence of creation of new RBC
usually triggered by parovirus B19
Leads to aplastic anaemia
Acute chest syndrome presents w
Acute chest syndrome presents with fever, shortness of breath, chest pain, cough and hypoxia. Achest x-raywill showpulmonaryinfiltrates.
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
Hydroxycarbamide
works by stimulating the production of fetal haemoglobin (HbF) -> reduced freq of vaso-occlusive crises
Crizanlizumab
Mab against P selectin -> reduced freq of vaso-occlusive crises
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
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
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
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
Naseptin
> can be prescribed for 10 days after a nosebleed to reduce crusting, inflammation, infection
CI in peanut or soya allergy
final common pathway for mucous drainage
middle turbinate
which sinuses drain to the middle meatus
> frontal
maxillary
anterior ethmoidal
which sinuses drain to superior meatues
> sphenoid
posterior ethmoidal
choanal atresia
causes of nosebleeds
> Trauma
Insertion of foreign bodies
Bleeding disorders such as ITP
cocaine use
features of sinusitis
> facial pain- typically frontal pressure pain which is worse on bending forward
nasal discharge: usually thick and purulent
nasal obstruction
Mx of sinusitis
> analgesia
nasal decongestants
intranasal steroids if symptoms for 10+ days
oral ab if severe - phenoxymethylpenicillin first-line
chronic rhinosinusitis?
> inflammation of nasal sinuses for 12+ weeks
predisposing factors for chronic sinusitis?
> atopy
nasal obstruction e.g. septal deviation or nasal polyps
recent infection
swimming
smoking
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
Management of recurrent or chronic sinusitis
> avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
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
who are nasal polyps more common in?
> men
not commonly seem in children/ elderly
Associations w nasal polyps
> CF
asthma - paticularly late onset
aspirin sensitivity
Kartagener’s syndrome
samters triad
asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad.
features of nasal polyps
> nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
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
nasopharyngeal carcinomas
> sq cell carcinoma of the nasopharynx
common in southern china
associated w EBV infection
Features of nasopharyngeal carcinomas
> cervical lymphadenopathy
unilateral serous otitis media
Nasal obstruction, discharge and/ or epistaxis
Cranial nerve palsies e.g. III-VI
Tx of nasopharyngeal carcinomas
radiotherapy
Imaging in nasophyrangeal carcinomas
combined CT and MRI
intramural gas on AXR ->
NEC
DDH in an older child
An older child with missed DDH may present with a Trendlenberg gait and leg length discrepancy
There is often the loss of internal rotation of the leg in flexion in
slipped capital femoral epiphysis
gold standard for diagnosis of hirschsprungs disease
Rectal biopsy is the gold standard for diagnosis of Hirschsprung’s disease
Grips
Palmer, Point, Pincer - 6, 9, 12
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.
murmur seen in turner’s
Turner’s syndrome is associated with an ejection systolic murmur due to bicuspid aortic valve
meconium ileus ->
Muconeum ileus -> Hirschsprung or CF
blood in stool in pre-mie
Blood in stool in pre-term baby -> NEC
SCFE presentation
Obese boy with groin/thigh/knee pain → ?slipped capital femoral epiphysis
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
what is associated w malrotation?
Exomphalos and diaphragmatic herniae are commonly associated with malrotation.
what is not seen in downs syndrome
rocker bottom feet - seen in trisomy 18 or Edwards
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
billous vomitig on first day ->
Bilious vomiting on the first day is likely due to intestinal atresia
limp pathways
- Fever and limping - bloods to r/o septic arthritis
- Trauma and limping - XR to r/o #
- No fever, not unwell, no trauma and limping - reassure, analgesia advise and GP follow-up if not improving with good safetynet
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.
eczema herpeticum
> rapidly progressing painful rash
caused by herpes simplex 1 or 2
seen in kids w atopic eczema
Mx of eczema herpetcium
> IV aciclovir - life threatening
lesions in eczema herpeticum
monomorphic punched out
how is acute epiglottitis diagnosed
direct visualisation from senior anaesthatist
BLS algorithm for kids - order of intitial steps
1) 5 rescue breaths
2) check pulses
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
what feature of bronchiolotis would necessitate immediate ref to hosp
grunting
when can steroids not be used for kids with meningitis
under 3 months - DO NOT give steroids
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.
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.
Barlows vs ortlanis
> Barlow (B is before in the alphabet) Ortali (O is after).
You dislocate FIRST (Barlows)
most common fractures seen in NAI
Humeral, radial, femoral
Double bubble sign ->
DUOdeal atresia
leg appearance in a hip fracture
Leg is shortened and EXTERNALLY ROTATED with hip fracture
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.
pathogen causing NF in Chickenpox ppts
Invasive group A Streptococcus, a β-haemolytic Streptococcus,
causes of snoring in kids
> obesity
nasal problems
recurrent tonsillitis
downs syndrome
hypothyroidism
which heart lesion is associated w DMD
dilated cardiomyopathy
cardiac problem associated w downs
AVSD
FIRST LINE IN WHOOPING COUGH
azithromycin or clarithromycin if the onset of cough is within the previous 21 days
IVDU w IE can present w
discitis
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
what does downs inc risk of
Alzheimers disease
what can cause diabetes in kids
CF
What is used to promote patent ductus arteriosus
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
inheritance seen in PWS
IMPRINTING
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
pattern seen in roseola infantum
fever when rash Improves
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)
mesenteric adenitis
> sim pres to appendicitis but preceding history of viral infection
does not need Tx
acute vs chronic subdural haemtoma on CT
> Chronic: old blood which appears black
Fresh blood is white
intercranial bleed in an alcoholic ->
chronic subdural haem
initial Mx of hirschprungs Dx
rectal washouts, bowel irrigation
children under 3 months w a UTI ->
Children under 3 months with a suspected UTI should be referred to specialist paediatrics services
PS leads to…
elevated bicarb, hypocholaramic hypokalaemic alk
