General paediatrics Flashcards
1
Q
Otitis media evaluation and management
A
Hx
- PC
- > preceding URTI
- > otalgia
- > fever
- > non verbal = irritability/crying/poor sleep/poor feeding
- Assess risk factors
- Identify red flags
- > hearing loss/developmental delay
- > cochlear implant
- > indigenous
- Explore alternative cause of fever
- > UTI
- > Resp
- > GI
- > Rheum
Exam
- Vitals
- Systems review
- Auroscope
- > haemorrhage/injected/cloudy TM (crying turns it red)
- > bulging TM
- > ottorhoea (consider otitis externa)
- > air fluid level/effusion (may take 3 months to resolve)
- > loss of ossicles
- > loss of light reflex
- Mastoiditis
- > post auricular erythema/oedema/tenderness/fluctuance
- > protruding auricle/external canal
Investigations
- none required
- > tympanocentesis by otolaryngologist
- > tympanometry not clinically useful
- consider CT/MRI if intracranial complications suspected
Management
- Analgesia
- > simple
- > 2% lidocaine drops if intact TM
- Antibiotics
- > if severely unwell/immunocompromised/red flags
- > otherwise, withhold for 48hrs then give if not improving
- > perforation does not alter management
- > amoxicillin 30-45mg/kg BD for 5 days
- > not improving at 48hrs = amoxicillin/clavulanate 22.5mg/kg BD
- Ineffective
- > decongestants
- > steroids
- > antihistamines
- Suspected mastoiditis
- > ENT review
- > third generation cephalosporin
- Otitis media with effusion (glue ear)
- > no treatment/referral usually required
- > no long term language/literacy/development issues
- > persistent 3 months = ENT + hearing assessment
2
Q
Kawasaki disease evaluation and management
A
Evaluation
- Criteria (CRASH & Burn)
- > fever for five days + 4/5 other criteria
- > conjunctivitis (non purulent)
- > rash polymorphous erythematous (no crust or vesicles)
- > adenopathy (cervical/often unilateral/tender)
- > strawberry tongue (red lips and pharynx + cracking)
- > hands/feet desquamation + painful oedema
- Common additional acute findings
- > irritability
- > aseptic meningitis
- > arthritis
- > sterile pyruria/dysuria
Investigations
- Echo
- > coronary artery ectasia (Z scores)
- > baseline + repeat at 6 weeks
- ECG
- Blood culture
- > sepsis/TSS
- ESR/CRP
- > very high
- 3/6 = diagnosis AT LAST
- > anaemia
- > thrombocytosis
- > leukocytosis
- > albumin low
- > sterile pyuria
- > transaminitis
Management
- Admit
- Consult
- > paediatrician
- > cardiologist
- > blood bank
- IVIg
- > 2mg/kg infusion on admission
- > second dose at 36hrs if still febrile
- Corticosteroids
- > consider if high risk/early (with paediatrician)
- > prednisone 2mg/kg oral until CRP normal
- Aspirin
- > 5mg/kg daily until normal echo follow up
- > risk of Reye syndrome
3
Q
HSP evaluation and management
A
Evaluation
- Core manifestations (P-JAR)
- Palpable purpura
- > can start as different rash and evolve
- > non blanching
- > symmetric and gravity dependent
- > lower limb/buttocks/periorbital/scrotal
- Joints
- > migratory/transient and oligoarticular
- > lower limb most common
- Abdo pain
- > colicky abdo pain
- > nausea and vomiting
- > occult GI bleeding is common
- Renal involvement
- > asymptomatic haematuria most common
- > can be severe nephritic or nephrotic syndrome
- > hypertension
- > can progress to renal failure
- Severe complications
- > bowel obstruction = intussusception
- > respiratory distress = alveolar haemorrhage
- > focal neuro = intracranial haemorrhage
Investigations
- Urinalysis
- > haematuria
- UACR
- Albumin
- EUCs
- > monitor kidney function
- Consider
- > FBC (leukemia/ITP)
- > serum IgA (non specific elevation)
- > C3/C4 (non specific consumption)
- > abdo ultrasound (intussusception)
- > ANA/dsDNA/ANCA (if severe renal disease)
Management
- Admit
- > severe renal
- > severe abdo
- > any neuro
- Consult
- > paediatrician (lung/neuro/severe renal involvement)
- > surgery (intussusception)
- Oedema
- > rest and elevation
- Analgesia
- > paracetamol 15mg/kg + NSAID 10mg/kg
- > prednisone 2mg/kg oral if severe/persistent pain
- Discharge
- > resolution within 4 weeks
- > abdo and joint pain within 3 days
- > 1/3 experience recurrence within months (milder)
- Follow up
- > regular GP follow up for renal surveillance for 1 year
- > almost always occurs within 6 months
4
Q
UTI evaluation and management
A
Hx
- Non-specific
- > fever
- > nausea/vomiting
- > poor feeding
- > lethargy/irritability
- Cystitis
- > frequency
- > urgency
- > dysuria
- > suprapubic pain
- Pyelonephritis
- > loin pain
- > fevers/rigors
- > nausea/vomiting
- Past
- > previous UTI
- > bladder/kidney disease
- > diabetes/immunosuppression
- Development and growth
- > any issues
Exam
- Vitals
- > HTN with kidney disease
- > fever
- Growth
- > plot
- Development
- > note
- Volume status
- Abdo
- > tenderness
- > constipation
- > palpable bladder
- > costovertebral angle tenderness
- Genitalia
- > discharge
Investigations
- Urine collection
- > midstream for older (contamination 25%)
- > clean catch for young (contamination 25%)
- > suprapubic/catheter for severely unwell
- Urinalysis
- > dipstick = leuks/nits (unreliable in neonates)
- > microscopy = pyuria
- > culture = single organism 10^8 CFU/L
- > contamination = squamous epithelial cells
- Systemically unwell
- > FBC
- > EUCs
- > blood culture
- > LP
- > renal ultrasound
Management
- Systemically unwell/Complicated
- > admit
- > empirical IV gentamycin + amoxicillin
- > ultrasound prior to discharge
- Oral antibiotics
- > cefalexin (3-7 days for cystitis/7-10 for pyelonephritis)
- Supportive
- > education + safety net + follow up
- > adequate analgesia
- > maintain hydration
- > outpatient US + specialist referral for recurrent
5
Q
Type 1 diabetes evaluation and management
A
Hx
- PC
- > polyuria/polydipsia
- > fatigue/weakness
- > weight loss
- Past
- > coeliac
- Family
- > autoimmune
- > diabetes
- Social
- > diet/exercise
- > care giver
Exam
- BMI
- BP
- Acanthosis nigricans
- Lower limb
- > ankle reflex
- > pulses
- > vibration/monofilament (loss of protective sense)
- Dilated fundoscopy
- > microaneurysms
- > cotton wool spots
- > dot/blot haemorrhages
- > new vessels over disc (proliferative)
Investigations
- Glucose
- > HbA1c = 6.5
- > fasting = 7
- > random = 11.1
- > GTT = 11
- C peptide
- > low
- Antibodies
- > GAD
- > Zinc transport 8
- > insulin
- > islet antigen 2 beta
- Urea/creatinine + UACR
- Lipids
- TSH
- Coeliac
Management
- Goals
- > glycemic control = improves microvascular outcomes
- > reduce CVD risk = improves microvascular outcomes
- Education
- > refer to diabetes educator = lower HbA1c vs usual care
- > disease process/risks
- > components/goals treatment
- Diet
- > refer to dietician
- > low GI/consistent carbs/avoid sweetened beverages
- > carb counting
- Exercise
- > prevent macrovascular complications
- > education on avoiding hypos
- Psychological
- > refer to support groups
- > psychotherapy available for diabetes distress
- Twice daily injection (<10 years old)
- > TDD = 0.1 units/kg
- > 2/3 mane + 1/3 nocte
- > each dose 2/3 intermediate acting + 1/3 short acting
- Multiple daily injections (>10 years old)
- > TDD = 0.1 units/kg
- > 0.4 long acting nocte + 0.2 x 3 rapid acting pre meal
- Continuos infusion
- > sub cut catheter + external pump with insulin reservoir
- > constant rapid acting + user bolus pre meal
- Monitoring
- > capillary prick 4x daily or continuous glucose monitor
- > record in book
- > glycaemic targets = HbA1c <7 + BGL 4-8)
- Diabetes clinic
- > at least every 3 months
- > plot growth + BMI = every session
- > glycaemic control = every session
- > lifestyle measures = every session
- > microvascular = after 5 years then every 1
- > lipids = every 5 years
- > autoimmune = every 2 years
6
Q
Sore throat evaluation and management
A
Hx
- Viral
- > cough
- > coryza
- > conjunctivitis
- > hoarseness
- > diarrhoea
- > rash
- Bacterial
- > no reliable signs
- Fluid intake
- Sick contacts
- > coxsackie
- > GAS
- Red flags
- > ATSI
- > immunosuppressed
- > previous ARF
- > family hx ARF
Exam
- Vitals
- > may be afebrile if viral
- Volume status
- Cervical lymphadenopathy
- Mouth
- > tonsillar exudate (GAS)
- > ulcers (HFMD)
- > viral endanthem
- Skin
- > scarlett fever (sandpaper/erythematous/perioral sparing)
- > HFM
- > viral exanthem
- Abdo
- > hepatosplenomegaly (EBV)
- Red flags
- > respiratory distress
- > drooling
- > hot potato voice
- > stridor
- > trismus/torticollis/neck swelling
Investigations
- Throat swab
- > only if high risk group
- > GAS is common coloniser and doesn’t indicate infection
Management
- Admit
- > upper airway obstruction
- > suppurative complications
- Suspected viral
- > supportive treatment only
- > fluids
- > paracetamol
- > NSAIDs
- > lozenges/honey/rest
- Suspected strep
- > preference for supportive only
- > prednisone 1mg/kg single dose if severe/resistant
- > safety net if symptoms >7 days or worsening
- > antibiotics only shorten symptoms by 1 day
- > antibiotics reduce risk of complications
- > antibiotics have side effects and risks
- High risk
- > oral phenoxymethylpenicillin BD for 10 days
7
Q
IM evaluation and management
A
Clinical manifestations
- PC
- > fever
- > fatigue (persistent and severe)
- > pharyngitis (may be exudative)
- > tender lymphadenopathy (posterior cervical)
- Additional
- > systemic (malaise/headache/myalgia)
- > maculopapular/petechial rash (amoxicillin/ampicillin)
- > neuro (GBS/palsies/meningitis/encephalitis)
Exam
- Mouth
- > palatal petechiae
- Abdo
- > splenomegaly
- > jaundice
Investigations
- FBC
- > leukocytosis most common
- > atypical lymphocytes (larger) on smear
- > haemolytic anaemia (rare)
- LFTs
- > transaminitis
- Heterophile antibody (rapid monospot)
- > confirms diagnosis with compatible syndrome
- > high false neg in early disease and children
- EBV specific antibodies
- > early antigens (onset for 4 months)
- > viral capsid antigen IgM (onset for 1 month)
- > viral capsid antigen IgG (onset)
- > EBV nuclear antigen (delayed)
- US spleen
- > splenomegaly
Management
- Supportive
- > paracetamol
- > NSAIDs
- Rest
- > no contact sport for 1 month
- > counsel on effect of fatigue for months
- IV corticosteroids
- > upper airway obstruction
- > haemolytic anaemia/immune thrombocytopenia
- IvIg
- > severe thrombocytopenia
- Prognosis
- > resolution within 2 weeks
- > fatigue may persist for months
8
Q
Acute rheumatic fever evaluation and management
A
Hx
- Carditis
- > dyspnoea/PND/orthopnoea (HF)
- > angina radiating to traps (pericarditis)
- > palpitations (heart block)
- Joints
- > migratory large polyarthritis
- > very sensitive to NSAIDs
- Chorea
- > uncommon
- > fidgety and uncoordinated
- > involuntary erratic movements
- > disappears with sleep/worse with volitional movements
- > emotional lability and personality change
Exam
- Subcutaneous nodules
- Erythema marginatum
- > pink
- > serpingous
- > begins as macule and expands with central clearing
- > comes and goes rapidly
- Chorea
- > bag of worms
- > milkmaids sign
- Carditis
- > HF
- > murmur (MR)
- > pericardial rub
Investigation
- ECG
- Blood cultures
- FBC
- > leukocytosis uncommon
- ESR/CRP
- Throat culture
- > rarely positive
- Serology
- > anti-streptolysin O
- > anti DNase-B
- Rapid antigen test
- > poor negative/positive predictive value
- Echo
- > valvulitis
- > carditis
- CXR
- > cardiomegaly
Management
- Acute infection
- > benzanthine benzylpenicillin IM single dose
- Prevention
- > repeat monthly injections
- > for 10 year or until 21 years old (which is longer)
- > longer if establish heart disease
- HF
- > diuresis
- > prednisone
- Arthritis
- > NSAIDs until 1-2 weeks post symptoms
- Chorea
- > carbamazepine
