Conditions 1 Flashcards
Explain the difference between:
a) Indirect
b) Direct
hernias?
a) Indirect: sac passes through internal inguinal ring + along inguinal canal.
b) Direct: rare, usually prem baby/ CT disorder
How do you manage a hydrocele?
(can pinch above swelling, which can’t do w/hernia due to bowel)
Resolves with time (not emergency). Usually from newborn should resolve by 4yrs- if not then Patent Processus Vaginalus + needs op.
What is the key feature on USS of intussusception?
Target sign.
Classic presentation of pyloric stenosis?
1st born male children, ~6wks old.
Non-bilious (milky) projectile vomiting.
Poor/no wt gain, always hungry.
Hypochloraemic, hypokalaemia, hyponatraemic alkalosis!!!
What are the radiological features of Necrotizing Enterocolitis (NEC)?
Pneumatosis (gas in bowel wall). Bowel loops on Xray.
What does Malrotation with Volvulus show as on upper GI contrast?
DJ flexure to R of midline, corkscrew appearance of jejunum.
DJ should be to the left of vertical line + level w/ the gastric outlet
What is an Exomphalos?
Presence of abdominal contents in sac at umbilicus. Covered w/ membrannes.
A/w chromosomal anomalies.
What is Gastroschisis?
Abdominal contents through defect to right of umbilical cicatrix (not covered w/membrane).
No real associated anomalies (unlike exomphalos)
Causes of Bronchiolitis?
RSV (90%)
Rhinovirus
Adenovirus
Parainfluenza
Presentation of Bronchiolitis?
- Start w/coryza
- Wheeze, fine end-inspiratory crackles + dry cough
- Signs of respiratory distress
- Apnoea in <4months (serious)
Investigations for Bronchiolitis?
- Examination: overexpansion of chest, wheeze + creps, nasal flaring.
- Pulse oximetry
- Nasal swabs (PCR to identify RSV)
How is most bronchiolitis managed? (+ what prophylactics for high-risk groups?)
- At home, usually self-limiting (peak of illness: 3-5days)
- Prophylactic Palivizumab against RSV
When would you admit a child for Bronchiolitis?
- Apnoea
- Child appears seriously unwell
- Central cyanosis
- Severe resp distress
- Difficulty feeding (<50% feeds)
- Clinical dehydration
What is the supportive management for Bronchiolitis?
- Humidified O2 by nasal cannula
- NO bronchodilators (dont do anything)
- Consider maintenance fluids
- Consider CPAP if hypercapnia
What is Croup? (larngotracheobronchitis)
- Inflammation + ^secretions of the larynx, trachea + bronchi.
- Oedema in the subglottic area, v dangerous as can obstruct airway.
What are some causes of Croup?
(viral!)
- Parainfluenza (most common)
- Humanmetapneumovirus
- RSV
Presentation of Croup?
(often starts + worse at night)
- 6months-6yrs
- Coryzal prodrome
- Initial sx in larynx (stridor), then trachea/bronchi (barking cough + wheeze)
- Severe deterioration often accompanied by reduction in the stridulous noise.
Management of moderate-severe croup?
- Inhalation of warm air (no proven benefit but widely used)
- Inhaled salbutamol/budesonide
- Oral dexameth/ pred
- If severe obstruction = nebs adrenaline /oxygen given via facemask.
What is Bacterial tracheitis? (pseudomembranous croup)
Rare but dangerous.
Caused by: Staph. aureus.
Similar to severe viral croup except: ^fever, rapidly progressive airway obstruction w/ copious thick secretions.
What is Epiglottitis caused by?
Haemophilus influenzae Type B
How does Epiglottitis present?
- Affects 2-7yrs
- Child presents acutely w/signs of toxicity, fever, DROOLing, unable to swallow.
- Soft inspiratory stridor, not hoarse, rarely coughs.
- A/w sepsis
- Characteristic posture, sit upright w/chin thrust forward.
Management of Epiglottitis?
- Do NOT examine mouth/airway. Do NOT assess child lying down.
- Intubation (under GA)
- IV Cefuroxime/ Ceftriaxone or ampicillin
What prophylaxis should be offered to all household contacts of Epiglottitis?
Rifampicin
What is Transcient Early Wheezing?
Wheeze a/w immune response from viral infection (bronchiolitis), in most pre-schoolers.
Usually episodic. Often a/w coryzal sx/
Usually fully resolved by 5yrs, when ^airway size.
(vs persistent + recurrent wheezing)
Pathophysiology of asthma?
- Bronchial Inflam: oedema, ^mucus production, infiltration w/cells (eosinophils, mast cells, neutrophils, lymphocytes)
- Bronchial hyperresponsiveness
- Airway narrowing: reversible airflow obstruction (e.g. peak flow variability)
Organisms causing Pneumonia in:
a) Neonates
b) Infants
c) >5yrs
a) -Group B beta-haem strep (ONLY newborn)
- Gram -ve enterococci
b) (^likely virus)
- RSV
- Strep pneumoniae
- Haemophilus influenzae
- Bordatella pertussis
- Chlamydia trachomatis
c) (^likely bacterial)
- Mycoplasma pneumoniae (more insidious onset)
- Strep pneumoniae
- Chlamydia pneumoniae
What may a respiratory exam show in a child with pneumonia?
- End-inspiratory coarse creps.
- Classic signs of consolidation w/dullness to percussion often absent in young children
Management of pneumonia?
a) Acutely ill
b) Less ill/ older children
c) Newborn
d) If suspect mycoplasma
a) IV penicillin
b) Amoxycillin PO
c) Co-amox
d) Macrolide (erythromycin)
Causes of the common cold? (coryza)
- Rhinovirus, RSV.
- Mx: self limiting. Best treated w/Calpol or Ibuprofen.
Causes of Tonsillitis/ Pharyngitis?
-Group A Strep (biggest cause in children), adenovirus, enterovirus, EBV.
Treatment for Tonsillitis/ Pharyngitis?
Phenoxymethypenicillin (Pen-V), or erythromycin.
avoid amoxicillin > causes widespread macpap rash if infection caused by EBV
What is the mutant gene for CF , + what does this gene code for?
- Delta F508
- Codes for a protein which controls Na+ and Cl- transport across the membrane of secretory epithelial cells.
(leads to a higher salt content of sweat + thicker secretions)
What are 4 key complications of CF?
- Lungs: small airway obstruction, ^ infections.
- Pancreas: ducts obstructed > fibrosis.
- Biliary cirrhosis: poor lipid absorption.
- Vans deferens obstruction: infertility in males.
Presentation of CF?
- Recurrent chest infections
- Inefficiency of gaseous exchange (dyspnoea, chronic cough, hyperinflated chest)
- Meconium ileus
- Malabsorption + malnutrition (blockage of pancreatic duct)
- Steatorrhoea (pancreatic insufficiency- low elastase in faeces)
- Finger clubbing
- Reproductive tract failure
What may a chest Xray of CF show?
- Hyperinflation
- Bronchial thickening
- Upper lobe bronchiectasis
- Central lines
- ?Infection
What investigations are there for CF?
- Newborn heel-prick test (Guthrie test)- for immunoreactive trypsinogen (IRT)
- Sweat test (chloride conc: 60-125mmol/L)
Management of CF?
- Kaftrio: Symkevi (ivacaftor + tezacaftor) + elexacaftor.
- Recurrent chest infections: prophylactic Fluclox (usually via PICC line)
- Neb bronchodilators + steroids for nasal polyps.
- Nutritional mx (vit A, E, D, K).
What is used to measure disease progression in CF?
The FEV1 is an indicator of clinical severity + declines w/ disease progression.
What is the commonest late complication of CF?
DM
Why are middle ear infections more common in 6-12months?
Their eustachian tubes are shorter, horizontal + functionally poorer.
Common pathogens for acute OM?
RSV, rhinovirus, pneumococcus, HiB
Signs of acute OM?
Tympanic membrane is bright + red + bulging, loss of normal light reflection.
Potential perforation of ear drum, pus in ear canal.
Management of acute OM?
- Treat pain/fever w/ paracetamol + ibuprofen.
- Amoxicillin 5-7days can be given, but most cases resolve spontaneously.
- Abx shorten duration of pain, don’t reduce hearing loss.
Complications of Acute OM?
- Repeat OM can lead to OM w/effusion (GLUE EAR!)= most common cause of conductive hearing loss in children!
- Meningitis/Mastoiditis
Presentation of OME/GLue Ear/Serous OM?
- Common in 2-7yrs
- Asymptomatic apart from hearing loss (confirmed by tympanic hearing loss on a hearing test)
- Ear drum dull + retracted
Management of Glue ear?
- Usually resolve spontaneously
- Grommets (effusion drained)
Prevention of TB in high risk children?
BCG offered at birth to high risk.
DO NOT give BCG to HIV/immunosuppressed children due to risk of dissemination.
What are the systemic sx of TB? (when the bacilli is nolonger contained to the lungs + is circulating the body by lymphatics)
- Fever
- Wt loss
- Haemoptysis/cough
- Lymphadenopathy + lung lesions (constitutes the ‘Ghon complex’)
Investigations for TB?
- Mantoux test (falsely +ve due to past vaccinations- like BCG)
- CXR
- Sputum sample
- Ineterferon-gamma release assay (IGRA)
- ALWAYS test for HIV too (and vice versa for TB if have HIV)
Characteristic appearance of TB on a CXR?
- Calcified masses
- Enlargement of peri-bronchial lymph nodes
- Collapse + consolidation in affected lungs
- Pleural effusions
Treatment for TB? (+ what if they are during/after puberty?)
- Triple/Quadruple therapy: Rifampicin + Isoniazid + Pyrainamide + Ethambutol.
- After 2months: (reduce) Rifampicin + Isoniazid.
- Treatment duration is 6 months!
- If in/after puberty: add Pyridoxine!! (prevents peripheral neuropathy, complication of isoniazid)
Presentation of Whooping Cough?
- 1wk coryzal sx (catarrhal phase)
- 3-6wks of characteristic paroxysmal cough, followed by inspiratory whoop (paroxysmal phase)
- During a paroxysm- child goes red/blue in face + mucus flows.
- Sx gradually decrease (covalescent phase), but may last months
How may whooping cough present differently in infants?
-Cough may be absent + apnoea is a feature
Treatment for Whooping COugh?
- Erythromycin (only eradicates organism in catarrhal phase- but nearly always given anyway)
- Close contacts= erythromycin prophylaxis
What is neuropathic bladder? (a cause of enuresis in children)
- Bladder is enlarged + irregular thick walls. Fails to empty properly, distended on presentation.
- Associated w/ Spina Bifida
- Sometimes abnormal perineal sensation, anal tone, sensory loss in S2/3/4
What are some causes of secondary enuresis?
- Emotional onset (commenest)
- UTI
- Polyuria from osmotic diuresis in diabetes
Investigations for enuresis?
- Urine sample
- Consider a KUB USS (structural abnormalities?)
- Urodynamic studies
- Xray spine (vertebral abnormality)
- MRI: non-bony spinal defect e.g. tethering of the cord.
What is the definition of nocturnal enuresis?
Involuntary voiding of urine during sleep.
At least 2x/week.
Age >5yrs
Causes of Nocturnal Enuresis?
- Emotional (nearly always)
- UTI
- Severe faecal impaction
- DM
- Genetic link w/ delayed development of sphincter control
‘3 systems approach’ for nocturnal enuresis?
- (1st choice) Ability to wake to full bladder sensation (alarm!! Operant conditioning)
- Adequate functional bladder capacity (&daytime fluid, regulate toileting + ?oxybutynin which helps overactive bladder)
- Arginine vasopressin (desmopressin)
++++ Psychological wellbeing !!!
What is Desmopressin?
Drug for enuresis (for short term).
DONT use desmopressin spray in kids due to hyponatraemic s/e.
What are some other drugs for Enuresis?
- Imipramine (2nd line)- more s/e, concern of toxicity.
- Oxybutinin: for detrusor instability (daytime freq + wetting)
What organisms are responsible for UTI in children? (gram -ve)
- E coli (90% of ALL)
- Klebsiella
- Proteus (more common in boys, predisposes to formation of phosphate stones)
Organisms responsible for UTI in children? (gram +ve)
Staph saprophyticus
Enterococcus
Staph aureus
Pseudomonas- may indicate structural abnormality in UT affecting drainage.
Are UTIs more common in boys or girls?
- Neonatal period: boys>girls becuase posterior urethral valve more common in boy.
- > 1yrs: girls 3x more common
Red Flags of UTI in childhood?
- Fever <3months (temp would be sepsis until proven otherwise!!)
- Flank pain
- Irritable/floppy
- HTN (chronic kidney problem?)
Presentation of UTI in:
a) Neonate
b) Infants
c) Older
a) prolonged jaundice, apnoea, wt loss, collapse.
b) fever, irritable, D+V, failure to thrive, offensive urine, febrile convulsions (>6months)
c) More specific sx: dysuria, freq, loin/abdo pain, fever, lethargy + anorexia, offensive/cloudy urine, recurrence of enuresis.
Investigations for UTI?
- Urine sample (older: midstream. infants: ‘clean catch’)
- Look for other sources of infection
- Dipstick: Nitrates can have false -ves. Leucocyte +ve.
What is an Atypical UTI?
- Septic
- Poor urine flow
- Abdo mass
- ^creatinine
- Slow response to treatment
- Not E. coli
- Recurrent UTI
- MALE !!!!
How do you investigate an Atypical UTI?
- Renal USS (ALL <6months)
- DMSA radioisotope scan (for signs of renal scarring, do after active infection)
- MCUG (micturating cystourethrogram) indicated if <1yrs for bladder new outflow + VUR.
Interpretation of results in UTI:
a) Leucocyte esterase & nitrate +ve
b) Leucocyte esterase -ve & nitrate +ve
c) Leucocyte esterase +ve & nitrite -ve
a) Regard as UTI
b) Start abx treatment (diagnosis depends on urine culture)
c) Start abx treatment only if clinical evidence of UTI.
Nitrite: good indicator of UTI.
Leucocyte esterase: also positive in febrile illness, balanitis + vulvovaginitis.
Management of UTI? (no sepsis)
- Simple UTI: Trimethoprim 7days
- USS for UTI if <6months/ atypical/ recurrent.
Management of UTI in sepsis? (in very young, treat as if for sepsis)
- Broad spec 48hrs IV
- Oral switch to 7 day course
What 3 examinations are carried out in a child presenting with Haematuria?
- Blood Pressure. (HTN= renal malfunction –> admit)
- Oedema (peri-orbital + ankles = glomerulonephritis)
- Renal mass (hydronephrosis, polycystic kidneys or tumour)
What investigations would you carry out for potential Glomerular Haematuria?
- ESR, complement levels, anti-DNA abs.
- ASO titre + throat culture (recent strep infection precedes acute glomerulonephritis)
- Serum creatinine, U&Es
- Abdo/pelvic ISS
- Renal biopsy if indicated
What is the triad of Haemolytic Uremic Syndrome (HUS)?
- Acute renal failure
- Microangiopathic haemolytic anaemia
- Thrombocytopenia
What is the typical prodrome for HUS?
-Typical HUS is secondary to GI infection with verocytotoxin-producing E.coli 0157
(so prodrome of bloody diarrhoea, which results in microangiopathic haemolytic anaemia)
What are the causes of Glomerulonephritis in childgood?
Post-infectious (streptococcus) – commonest cause in childhood.
Vasculitis – Henloch-Schonlein purpura, SLE, polyarteritis nodosa.
IgA nephropathy + mesangiocapillary glomerulonephritis.
Anti-glomerular basement membrane disease (Goodpasture syndrome)
Presentation of Glomerulonephritis?
Haematuria + proteinuria classically appears 1-2wks after throat/skin infection.
Oedema
Mild oliguria only- in most children!!
Otherwise ASx (w/ slight malaise, headache + loin discomfort)
What is the difference between Transient + Persistent Proteinuria?
Transient- may occur during febrile illness/ after exercise. Doesn’t need Ix.
Persistent- significant, measure urine protein/creatinine ratio in early morning.
What can Nephrotic syndrome be secondary to?
- Henoch-Schonlein purpura (HSP)
- SLE
- Infections (malaria)
- Allergens (bee sting)
Investigations of Nephrotic syndrome?
- Urine protein + culture
- FBC + ESR + U&Es + Creatinine + Albumin
- Complement levels (C3&4)
- Antistreptolysin O / anti-DNAase titres + throat swab
- Hep B/C screen
- Malaria screen if travelled abroad.
Management of Nephrotic syndrome?
- Oral corticosteroids (pred), reducing dose after 4wks.
- If no response = renal biopsy (fusion of podocytes –> named minimal change disease)
What are the features suggestive of steroid-sensitive nephrotic syndrome?
- 1 to 10yrs
- No macroscopic haematuria
- Normal BP/ complement levels/ renal function
Complications of Nephrotic Syndrome?
- Hypovolaemia: peripheral vasoconstriction + urinary sodium retention. Requires urgent mx w/ IV albumin.
- Thromosis: due to urinary losses of antithrombin thrombocytosis (steroids), ^clotting factors due to ^haematocrit.
- Infection: ^risk (including spont peritonitis)
- Hypercholesterolaemia: correlates inversely with serum albumin.
What is Vesicoureteric Reflux?
Development anomaly of the vesicoureteric junction: retrograde flow of urine from bladder towards kidney.
A/w: pyelonephritis, scarring, bladder pathology (neuropathic bladder/ urethral obstruction)
How is Vesicoureteric Reflux investigated?
Imaging: cystogram- contrast outlines ureters + renal collecting ducts.
DMSA scan: scarring.
Management of Vesicoureteric Reflux?
- Longterm abx prophylaxis (trimeth/nitro), w/surveillance of renal growth.
- Surgery if severe reflux
- Tends to resolve with age!
Presentation of Posterior Urethral Valves? (only in boys!)
- Cystogram: dilated posterior urethra, normal anterior urethra. Keyhole appearance of bladder.
- UTI, abnormal voiding.
What should be excluded in bilateral hydronephrosis in a male infant?
Posterior urethral valves
What is the most common seizure-mimic?
Syncope leading to an anoxic (non-epileptic) tonic-clonic seizure.
What are some examples of seizure-mimics?
- Breath holding spells (sort of like tantrum, holds breath + goes blue, rapid recovery)
- Reflex anoxic seizure (minor pain/cold/fright, stops breathing + goes pale, rapid recovery. Due to cardiac asystole from vagal inhibition)
- Benign paroxysmal vertigo
- Tics
- Behaviour disorders
(movement disorders)
Presentation of Corticospinal (pyramidal) tract disorders?
- Weakness of distal joints.
- Brisk hyper-reflexia + extensor plantars.
- Fine finger movement lost.
(movement disorders)
Presentation of Basal Ganglia Disorders?
Either:
-Difficulty initiating movements with dystonia, dyskinesia, chorea.
Or;
-Writhing movements (athetosis)
(movement disorders)
Presentation of Cerebellar disorders?
- Difficulty holding posture (especially when eyes closed)
- Past pointing (dysmetria)
- Dysdiadochokinesis
- Scanning dysarthria
- Wide based gait
- Nystagmus
(peripheral motor disorders)
Disorders of the anterior horn cell?
- Spinal muscular atrophy
- Poliomyelitis
Signs of denervation (weakness, loss of reflexes, fasciculation + wasting)
(peripheral motor disorders)
Disorders of the peripheral nerve?
- Bell palsy
- Acute post-infection (Guillain-Barre)
Often distal nerves affected.
Motor or Sensory neuropathy, + loss of reflexes in either.
(peripheral motor disorders)
Disorders of neuromuscular transmission?
-Myasthenia gravis.
As end-plate acetylcholine stores become depleted, there is diurnal worsening through the day leading to fatiguability.
(peripheral motor disorders)
Muscle disorders? (myopathy)
- Muscle dystrophies (Duchenne/ Becker)
- Inflammatory myopathies (polymyositis/dermatomyositis)
- Metabolic myopathies
- Congenital myopathies
Weakness (often proximal), wasting + gait disturbance.
What is markedly elevated in Duchenne/Becker muscular dystrophy?
Serum creatinine phosphokinase.
