Community Paediatrics Flashcards
1
Q
What is a skeletal survey?
A
Series of x-rays to include whole skeleton or at least axial skeleton
2
Q
What is a key sign of a shaken baby?
A
Retinal haemorrhages
Therefore need assessment from opthalmology
Bleed in brain due to tearing of bridging vessels, and back of the eyes
3
Q
Why must x-rays be repeated following suspected abuse?
A
Look for bone healing e.g. periosteal reaction
Do not assume initial imaging is normal, might not often be able to see initial fracture
4
Q
What are the clinical features of autism?
A
Social communication impairments and repetitive behaviours present during early children 2-3
Abnormality of social interaction, communication, stereotyped behaviours
Impaired social communication and interaction
Play alone, uninterested in other children
Poor eye contact
Failure to use facial expression or body language
Failure to pick up emption
Restrictive or repetitive behaviours, interests, activities Preoccupations with unusual subject Need for routine Licking objects Motor mannerisms - hand flapping
Sensory issues
Severely restricted diet
Teeth brushing or hair cut hard
Intolerance to loud noises
High pain threshold - self harm
5
Q
What general examination is recommended for autism?
A
Skin stigmata of neurofibromatosis or tuberous sclerosis
Signs of injury, self harm, maltreatment
Congenital anomalies, dysmorphic features
6
Q
What are the differentials for autism?
A
Learning difficulties Attachment disorders Rett's syndrome - regression of skills Schizophrenia Specific language disorders
7
Q
What is the management of autism?
A
Behavioural management strategies
Education, Health and Care Plan for higher needs funding
Treatment of co-morbidities
SSRIs, antipsychotics, methylphenidate for ADHD
Parental education
8
Q
What are the clinical features of ADHD?
A
Symptoms must be early onset - before 6 years old
Hyperactivity - fidgets, talks excessively, on the go
Inattention - early distracted, forgetful, not concentrated
Impulsivity - difficulty waiting turn, blurts out answers
Present before age of 12 for at least 6 months
9
Q
What are some differentials for ADHD?
A
Auditory processing disorder
Opposition defiant disorder or conduct disorder
10
Q
What are some investigations?
A
Conner’s questionnaire
Qb test
11
Q
What is the management of ADHD?
A
Preschool - no meds
Mild-mod - behavioural strategies and CBT first line
Severe - medication
- methylphenidate - stimulant
- lisdexamfetamine
- atomoxetine if associated tic or anxiety disorder
- Guanfacine - non stimulant, if not suited or tolerated
Side effects include raised BP, palpitations, disturbed sleep
Impaired growth and appetite, aggression
12
Q
What is cerebral palsy?
A
Disorder of movement and posture due to non-progressive lesion in motor pathways of the brain
13
Q
What are causes of cerebral palsy?
A
Antenatal - infections, trauma
Perinatal - birth asphyxia, pre-term birth
Postnatal - meningitis, severe neonatal jaundice, head injury
14
Q
What are the types of cerebral palsy?
A
Spastic - hypertonia, reduced function due to UMN damage
Dyskinetic - (jaundice)
Problems controlling muscle tone, hypertonia, hypotonia
Damage to basal ganglia
Ataxia - problems with coordinated movement
Damage to cerebellum
Mixed
15
Q
What are the types of spastic cerebral palsy?
A
Monoplegia - one limb
Hemiplegia - one side
Diplegia - four limbs, mostly legs
Quadriplegia - four limbs affected more severely, seizures, speech disturbance, other impairments
16
Q
What is the presentation of cerebral palsy?
A
Becomes more evident during development Failure to meet milestones Increased/decreased tone Hand preference below 18 months Problems with coordination Speech problems Walking problems Issues with feeding/swallowing Learning difficulties
17
Q
What does gait analysis indicate in cerebral palsy?
A
Hemiplegic - UMN Broad based/ataxic - cerebellar High stoppage - foot drop/LMN Waddling gait - pelvic muscle weakness due to myopathy Antalgic gait - localised pain
18
Q
What are UMN signs?
A
Muscle bulk preserved
Hypertonia
Power slightly reduced
Brisk reflexes
19
Q
What are the LMN signs?
A
Reduced muscle bulk Fasciculations Hypotonia Power dramatically reduced Reflexes reduced
20
Q
What are the lesion signs in cerebral palsy?
A
Increased muscle tone and spasticity leads to hemiplegic gait
Extended leg
Plantar flexion of foot
Means have to swing extended leg round
UMN signs
Athetoid movements - indicate extrapyramidal basal ganglia involvement - constant writhing movements, spastic hands etc
21
Q
What are the complications and associated conditions with cerebral palsy?
A
Learning disability Epilepsy Kyphoscoliosis Muscle contractures Hearing and visual impairment Gastro-oesophageal reflux
22
Q
What is the management of cerebral palsy?
A
Physiotherapy
Occupational therapy
Speech and language
NG/PEG fitted, dieticians
Orthopaedic surgeons - tendon release, lengthen
Paediatricians for -
muscle relaxants, anti-epileptics for seizures, glyopyrronium bromide for excessive drooling
Social workers, support
23
Q
What is global developmental delay?
A
Delay in all domains
Down's Fragile X Fetal alcohol syndrome Rett syndrome Metabolic disorders
24
Q
What is gross motor delay?
A
In the gross motor domain
Cerebral palsy Ataxia Myopathy Spina bifida Visual impairment
25
What is fine motor delay?
```
Specific to fine motor domain
Dyspraxia
Cerebral palsy
Muscular dystrophy
Visual impairment
Congenital ataxia (rare)
```
26
What can occur in language delay?
```
Specific social circumstances e.g. multiple languages, family members do all the talking
Hearing impairment
Learning disability
Neglect
Autism
Cerebral palsy
```
27
What may a personal and social delay indicate?
Emotion/social neglect
Parenting issues
Autism
28
What perinatal problems may indicate a neurodevelopment problem?
Birth asphyxia, encephalopathy
Leukomalacia, haemorrhage
Dysmorphic features
Abnormal behaviour e.g. tone, feeding, movement, seizures, inattention
29
What problems in infancy may indicate a neurodevelopment concern?
Global developmental delay
Delayed or asymmetric motor development
Vision, hearing concerns
Neurocutaneous/dysmorphic features
30
What. are causes of abnormal motor development?
Central motor deficit e.g. cerebral palsy
Congenital myopathy/primary muscle disease
Spinal cord lesions e.g. spina bifida
Global developmental delay
31
What are some investigations for developmental delay?
Chromosome karyotype, FISH analysis
TFTs, bloods, blood gases
Congenital infections screen
Cranial ultrasound in newborn, CT, MRI
Skeletal survey, bone age
EEGs for seizures
Nerve conduction studies
```
Hearing, vision
Cognitive assessment
Child psychiatry
Dietician
Nursery/school reports
```
32
What can occur in dyskinetic cerebral palsy?
Chorea - irregular sudden brief non repetitive movements
Athetosis - slow writhing movements, e.g. fanning fingers
Dystonia - simultaneous contraction of agonist and antagonist muscles of trunk and proximal muscles gives twisting appearance
33
What are types of learning difficulties?
General - typically measured by IQ, borderline is 70-80, moderate 50-70
Severe 35-50 tends to have organic cause
Specific -
Dyspraxia - disorder of motor planning or execution with no significant findings on neurological exam - poor handwriting, messy eating, dribbling
Dyslexia - reading skills disproportionate to IQ, 2 years behind
Dyscalculia, dysgraphia - calculation or writing skills
Disorder of executive functions - consequence of brain injury, poor concentration, forgetfulness, volatile mood, overeating, poor social skills
34
What are the causes of hearing impairment?
```
Sensorineural
Majority genetic
Congenital infection
Postnatal infection, injury
Neurodegenerative
Management with amplification or cochlear
```
Conductive
Otitis media with effusion
Eustachian tube dysfunction - Down's, cleft palate, Pierre Robin sequence
Wax
35
How many loss of vision in infancy present?
```
Loss of red reflex - cataract
White reflex - retinoblastoma, cataract, ROP
Not smiling by 6 weeks
Lack of eye contact
Visual inattention
Random eye movements
Nystagmus
Squint
Photophobia
```
36
What are the types of squints?
Misalignment of visual aex
Concomitant - due to refractive error, glasses - light reflex, reflection should be in same position in both eyes
Paralytic - SOL
37
What are causes of visual impairment?
Genetic
Cataract, albinism
Retinal dystrophy
Retinoblastoma
Antenatal and perinatal
Infection, ROP, HIE
Cerebral abnormality
Optic nerve hypoplasia
Postnatal
Trauma
Infection
Juvenile idiopathic arthritis
38
What is trisomy and examples?
Extra chromosome, three copies of particular one
Patau's - trisomy 13
Edwards - trisomy 18
Down's - trisomy 21
39
What are examples of translocation disorders?
Portion of one chromosome swapped with portion of another
Predisposes to conditions such as cancer and infertility e.g. Philadelphia in acute myeloid leukaemia
40
What is an example of a duplication chromosomal disorder?
Charcot Marie Tooth
Chromosome 17 duplication of short arm
Sensory and motor neuropathy, pes caves high arching foot
41
What are the dysmorphic features of Down's?
```
Hypotonia
Brachycephaly - small head, flat back
Short neck, short stature
Flattened face and nose
Prominent epicanthic folds
Upward sloping palpable fissures
Single palmar crease
Sandal gap
```
42
What are some of the complications for Down's syndrome?
```
Learning disability
Recurrent otitis media
Deafness
Visual problems
Hypothyroidism
Cardiac defects
Atlantoaxial instability
Leukaemia
Dementia
```
43
What screening is available for Down's?
Combined test:
USS - nuchal translucency, thickness is over 6mm
Blood tests - beta HCG higher, PAPPA lower
Triple test
Beta HCG
Alpha fetoprotein
Serum oestriol
Chorionic villous sampling
Amniocentesis
if high risk
44
Who is involved in the management of Down's?
```
MDT
OT, SALT, physio, dietician
Paediatrician, GP
Cardiologist
ENT
Audiologist
Optician
Social services, support
```
```
Routine check ups:
Thyroid 2 yearly
ECHO
Audiometry
Regular eye checks
```
45
What is Klinefelter's and its features?
Male has additional X - XXY
```
Taller height, wider hips
Gynaecomastia
Weaker muscles
Small testicles
Reduced libido
Shyness, infertility
Subtle learning difficulties
```
46
What is the management of Klinefelter's?
Testosterone injections
IVF, breast reduction
MDT, OT, physio, SALT
47
What are the features of Turner's?
45 XO - single x in females
```
Short stature
Webbed neck
High arching palate
Downward sloping eyes, ptosis
Broad chest, wide nipples
Cubitus valgus
Underdeveloped ovaries
Late/incomplete puberty
Most women infertile
```
48
What are the associated conditions with Turner's?
```
Recurrent otitis media
Recurrent urinary tract infections
Coarctation of the aorta
Hypothyroidism
Hypertension
Obesity
Diabetes
Osteoporosis
Various specific learning disabilities
```
49
What is the management of Turner's?
GH therapy
Oestrogen and progesterone
Fertility treatment
Management of e.g. HTN hypothyroidism
50
What is Noonan syndrome and its features?
```
Autosomal dominant condition
Short stature, broad forehead
Downward sloping eyes
Hypertelorism - wide space between eyes
Low set ears, webbed neck
Wide spaced nipples
```
```
Associated with heart disease, ASD
Cryptochordism - infertility
Learning disabilities
Bleeding disorders
Lymphoedema
```
51
What is Fragile X and its features?
FMR1 mutation, x linked
```
Intellectual disability
Long narrow face
Large ears
Large testicles
Hypermobile joints
ADHD, autism, seizures
```
52
What is Prader-Willi syndrome and its features?
Deletion, loss of genes on chromosome 15 from father
```
Constat insatiable hunger
Obesity
Hypotonia as an infant
Learning disability
Hypogonadism
Fair, soft skin - bruising
Mental health problems
Dysmorphic features, narrow forehead, downturned mouth
```
53
What is the management of Prader Willi?
GH aimed at improving muscle development and body composition
Weight control
MDT input
54
What are some features of Angelman syndrome?
```
Unusual fascination with water
Happy demeanour
Widely spaced teeth
Inappropriate laughter
ADHD, epilepsy
Speech delay
Fair skin, light hair, blue eyes
```
55
What are some of the features of William syndrome?
```
Broad forehead
Starburst eyes - star like pattern on iris
Flattened nasal bridge
Trusting personality
Wide mouth, big smile
```
Associated with supravalvular aortic stenosis
ADHD, hypercalcaemia
56
What are the features of anorexia nervosa?
```
Excessive weight loss
Amenorrhoea
Lanugo hair
Hypokalaemia
Hypotension
Hypothermia
```
Cardiac complications - arrhythmia, cardiac atrophy
57
What are the features of bulimia nervosa?
Body weight fluctuates, normal body weight
Binging, purging
```
Alkalosis due to vomiting
Hypokalaemia
Erosion of teeth
Swollen salivary glands
Mouth ulcers, GORD
Russell's sign - calluses on knuckles
```
58
What is referring syndrome?
Starved cells start to process glucose protein and fats
| Leads to hypomanesaemia, hypokalaemia and hypophosphataemia
59
What is the management of referring syndrome?
Slowly reintroducing
Magnesium, potassium, phosphate, glucose monitoring
Fluid balance monitoring
ECG monitoring
Supplementation with electrolytes and vitamins
60
What are the categories of abuse seen in children?
Physical - physical harm to child
Emotional - emotional ill-treatment resulting in harm to emotional development
Neglect - persistent failure to meet needs of child
Sexual - forcing or enticing child into sexual activity
Almost all cases have crossover
61
What things would make you worry a child may be being abused? (V long list)
```
Inconsistent stories
Genital injury
Pregnancy or STI <13yo
Sexualised behaviour
Unresponsive or negative towards child
Inappropriate threats
Reported change in behaviour
Extreme emotional response
Female genital mutilation
Fractures of different ages
Retinal haemorrhage
Suspicious burns, scalds, bites, bruising
Injuries to non-mobile baby
Poor hygiene/dirty clothes
Fail to get medical help
Fail to thrive
```
62
When might you suspect a non accidental injury with a fracture?
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register
63
How can physical abuse manifest?
Fractures - tend to occur less than 18 months
Head injury - shaking, leads to small vessel rupture and subdural haemorrhage
Burns and scalds - symmetrical, bilateral, glove and stocking areas or buttocks, shape of burn
Abdominal injury
Bruises in non mobile child usually uncommon, back, face and buttocks
64
What are findings in a shaken baby?
```
Subconjunctival haemorrhage
Apnoea
Poor feeding
Convulsions
Reduced consciousness
Signs of raised ICP
No signs of bruising
Retinal haemorrhages
```
65
What are important investigations for physical abuse?
Bruising - coag screen, FBC check for bleeding disorder, check birth markers, infection markers
Fractures - full skeletal survey, CT scan, bone biochemistry
Ophthalmological exam
66
What is the presentation of neglect?
Medical:
Unimmunied, DNA, poor compliance with treatment
Failure to seek advice
Nutritional
Faltering growth or obesity
Emotional abuse
Poor school attendance
Physical
Inadequate hygiene, severe or persistent infection, inappropriate clothing
Failure to supervise
Frequent A&E, preventable injuries, ingestion of harmful substances
67
What are the symptoms of emotional abuse?
Developmental delay
Poor sleep, persistent crying
Irritable, feeding difficulties
Difficult violent behaviour, academic failure
Delayed social/language skills
Depression, self-harm, substance abuse, criminal activity, eating disorders, relationship difficulties
68
What can be the presentation of sexual abuse?
```
Allegation - disclose abuse
Pregnancy, STIs
Ano-genital injury
Unexplained vaginal or rectal bleeding
Recurrent vaginal discharge
Soiling, bowel problems, enuresis
Behavioural difficulties
```
69
What is sexual abuse?
Physical contact, including penetrative or non-penetrative acts, exposure to sexually explicit material, child sexual exploitation
70
How do you respond to disclosure of abuse?
```
Try not to look shocked
Let the child know you believe them
Tell them they are not in trouble
Listen to what they have to say, don’t make an excuse to leave
Don’t ask leading questions – this may affect the case if it goes to court
Don’t make promises you cant keep
Be honest at all times
Inform your senior
```
71
What is achondroplasia?
Cause of disproportionate short stature, type of skeletal dysplasia
Autosomal dominant
72
What are the features of achondroplasia?
Avg height of 4 feet
Limbs most affected, proximal limbs more than forearm and lower leg
Normal trunk length
Short digits
Bow legs - genu varum
Disproportionate skull - different areas grow by different methods
Foramen magnum stenosis
Endochondrial ossification affected leads to flattened mid-face and nasal bridge
73
What are the associations with achondroplasia?
Recurrent otitis media due to cranial abnormalities
Kyphoscoliosis
Spinal stenosis
Obstructive sleep apnoea
Obesity
Foramen magnum stenosis - cervical compression, hydrocephalus
74
What are the 2 main types of deliberate self-harm?
Self-poisoning
| Self-injury
75
Name 3 risk factors for repeated self-harm
Previous self harm
Psychiatric Hx
```
Unemployment, low SE
Hx trauma or abuse
Forensic Hx or violence
Single, divorced, separated
Family Hx - 4x risk
```
76
List motives for acts of deliberate self-harm
Wish to die
Cry for help
Communication
Unbearable symptoms
77
What are the stages involved in management of self harm?
1 Acute management - suture wound, antidotes
2 Assess risk - consider MHA section 2
3 Treat psychiatric issue
4 Resolve social issues
5 Future planning
78
What are the gross motor milestones at 3 months?
Little or not head lag on being pulled to sit
| Good head control
79
When can a baby sit without support?
7-8 months
80
What are the red flags for gross motor development?
Cannot sit without support at 12 months
| Cannot walk unsupported at 18 months
81
When should a baby crawl by?
9 months
82
When should a baby being walking unsupported?
Cruises at 12 months
| 13-15 months
83
When can a child run?
2 years
84
What can a child do at 3 years?
Ride a tricycle
| Walk up stairs without holding on to a rail
85
What can a child do at 4 years?
Hop on one leg
86
At what age can a child do the pincer grip?
9 months
| Good grip at 12 months
87
When does a child point with finger?
9 months
88
When does a child use palmar grasp?
6 months
89
At what age can a child build towers of bricks?
2 - 15 months
3 - 18 months
6 - 2 years
90
At what age can a child do a circular scribble?
18 months
91
At what age can a child copy a circle?
3 years
92
At what age can a child draw a triangle?
Copies square and triangle age 5
93
What does a hand preference before 12 months indicate?
Abnormal
| Cerebral palsy
94
When will a child turn book pages one at a time?
2 years
95
When does a baby turn their head towards sound?
3 months
96
When does a baby start to babble?
Double syllables at 6 months
97
When does a baby start saying words?
Mama and dada at 9 months
98
When can a child know and respond to own name?
12 months
99
When can a child combine two words?
2 years
Can also point to parts of the body
100
When can a child talk in short sentences?
3 years
101
When does a child start to smile?
6 weeks
102
What is a red flag for social behaviour milestones?
Refer at 10 weeks if not smiling
103
When does a child start to put everything in their mouth?
Becomes shy
At 9 months
104
How does feeding develop up until 1 year?
6 months - may put hand on bottle when being fed
12-15 months - drinks from cup, uses spoon, develops over 3 month period
105
When can a child become competent with spoon, or not spill drinks?
2 years
106
When can a child use their knife and fork?
5 years
107
At what age can a child be helped getting dressed/undressed?
12-15 months
108
At what age can a child dress independently except for laces/buttons?
4 years
109
At what age can a child wave bye bye?
12 months
110
When will a child play with other children?
By 4 years of age
111
What is a child born with difficult temperament prone to?
Predominantly negative moods, whinging, crying
Intense emotional reactions
Irregular biological functions - lack of rhythm in sleeping, hunger, toileting
Negative initial response to new situations
Protracted adjustment to new situations
112
What are reasons a child may not settle at night?
```
Too much sleep in afternoon
Displaced sleep cycle
Separation anxiety
Overstimulated in evening
Kept awake by siblings etc
Erratic parental practices
Use of bedroom as punishment
Dislike of darkness and silence
Chronic physical conditions
```
113
What can be some causes of antisocial behaviour e.g. stealing, lying, disobedience, picking fights?
Failure to learn when to exercise social restraint
Lack of social skills
Responding to challengers of peers
Chronically angry, resentful
Find own notions of good behaviour overwhelmed by sadness or temptation
114
What are some causes of underachievement at school?
```
Visual or hearing problems
Dyslexia
Generalised learning probs
Hyperactivity
Anti-education family background, chaotic fam
```
```
Recent onset problems e.g.
pre-occupation with divorce, bullying etc
Fatigue
Depression
Rebellion
Sexual abuse, drugs
Prodromal period of illness
Degenerative brain condition
```
115
What is CSF?
Persisting high levels of subjective fatigue
High levels of exhaustion on minimal physical or mental exertion
Myalgia, migratory arthralgia, headache, difficulty getting off to sleep, poor concentration
Depressive symptoms
Exercise therapy
CBT
116
What can be asked to assess suicide risk after adolescent overdose?
```
P - problems longer than a month
A - alone at the time
T - plan overdose for more than three hours ago
HO - feeling hopeless
S - were you sad before
```
117
What may be some features indicating substance misuse?
Intoxication
Unexplained absences from home or school
Mixing with known users
High rates of spending or stealing money
Possession of equipment required for drug use
Medical complications associated with use
