High Yield Paediatrics Flashcards
A woman brings her 18-month year old daughter to see the GP. She is concerned about a new cough, and coryzal symptoms for the last 3 days. She describes the cough as harsh and worse at night. The patient is up to date with her vaccinations and was born at term with no complications.
On examination: Mild stridor when mobilising. No intercostal recessions. Chest sounds clear.
Obs: Sats 96% (on air), Temp. 37.7 oC
Given the likely diagnosis, what is the most appropriate management?
Admit to hospital
Give humidified oxygen
Give a dose of dexamethasone
Give oxygen-driven salbutamol nebuliser
Prescribe a course of antibiotics
Give a dose of dexamethasone
- Croup
croup presentation
URTI
Stridor
“Barking” cough
Worse at night
croup is caused by
Parainfluenza virus- causes laryngeal oedema and secretionswhich creates that stereotypical cough
management of croup
One-offDexamethasonePO 0.15mg/kg
(Regardless of severity)
In emergency:
- High flow O2
- Nebulised adrenaline
acute epiglottitis summary
Swelling of the epiglottis caused by H.influenza B (HiB)
- affects those 1-6 yo (unvacinated)
presentation of epiglottitis
- Onset over hours
**- Stridor - Tripod position
- Drooling**
- V. high fever >38.5
- Significant respiratory distress
- No cough
management of epiglottitis
- Do not examine or upset the child
- Early senior help
- Secure airway - may involve intubation or tracheostomy
- IV antibiotics (e.g. ceftriaxone)
- Steroids (i.e. dexamethasone)
bronchiolitis background
Inflammation of bronchioles by RSV infection
Who? <1 year, RFx: Premies, lung disease
presentation of bronchiolitis
- wheeze
- cough
- low grade fever
- reduced oral intake
- gets worse before better
managemet of bronchiolitis
Mx: Supportive - humidified O2 and hydration/feed support
- CPAP or intubation if severe
which investigation will be key for croup, epiglottitis and bronchiolitis
Capillary blood gases are useful in severe respiratory distress and in monitoring children who are having ventilatory support.
vaccine for bronchiolitis
Palivizumab is a monoclonal antibody that targets the respiratory syncytial virus. A monthly injection is given as prevention against bronchiolitis caused by RSV. It is given to high risk babies, such as ex-premature and those with congenital heart disease.
PASSIVE PROTECTION
A 1 day old baby, who was delivered at 34 weeks, is found to have weak femoral pulses and significant increased work of breathing. There is concern for critical coarctation of the aorta and she will require surgery.
On examination the baby is grey and slightly floppy. There is a continuous ‘machinery-like’ murmur heard over the upper left sternal edge.
What is the most appropriate management while awaiting definitive surgical intervention?
Indomethacin infusion
Prostaglandin E1 infusion
Ibuprofen infusion
Monitor with echocardiograms
Percutaneous balloon aortic valvoplasty
Prostaglandin E1 infusion- to keep PDA open and allow some blood flow distal to coarctation
patent PDA background
- Failure to close of the ductus arteriosus which connects the pulmonary artery and aorta LEFT to RIGHT shunt
- Who? Premies or exposed to rubella
pathophysiology behind patent PDA
Physiology
- In foetus, ductus arteriosus shunts blood from pulmonary artery to aorta
- You don’t need blood going to the lungs because the baby is not breathing
After birth
- Closes within first few hours-days due to Oxygen decreasing prostaglandins
- Needs prostaglandins to stay open
But…
- In cases where it fails to close
- High pressure in aorta causes blood to be pushed into pulmonary artery (opposite of what it used to do!)
- Resulting in Left-to-right shunt
Increased pressure in pulmonary vessels –> pulmonary HTN –> RVH –> LVH
A man presents very distressed to ED with his 1 month old baby. He describes his son breathing rapidly and turning blue in the face and mouth while crying and then losing consciousness. He returned to normal breathing quickly after this and displayed no abnormal movements.
O/E: Alert and handles well. Mild cyanosis of the lips, and an ejection systolic murmur is noted.
An echocardiogram is performed.
What is the most likely pathology found on echo?
Atrial septal defect
Aortic stenosis
Aortic regurgitation
Transposition of the great arteries
Pulmonary stenosis
pulmonary stenosis - component of tetralogy of fallot
this episode describes a Tet spell
Tet spell
a Tet spell which is a hypercyanotic episode caused by the congenital heart condition tetralogy of fallot - really common exam topic.
The classic features here are the hyperventilating while distressed (crying) and losing consciousness and returned to normal (<10 seconds).
- No seizure-like activity
- ESM could be aortic or pulmonary stenosis but in the context of cyanosis, the right sided outlow obstruction that causes Tet spells and likely ToF, the correct answer here is PS
acyanotic congenital heart defects
VSD
ASD
PDA
Coarctation of aorta
cyanotic congenital heart defects
- Tetralogy of fallot
- Transposition of the great arteries
- Tricuspid atreis
VSD murmur
pan systolic
ASD murmum
mid systolic, split S2
PDA murmur
continous machine like
findings for coarctation of the aorta
weak femoral pulses
acyanotic presentations
Can be asymptomatic
Can present later in life
Don’t always need surgery
tetralogy of fallot murmur
ejection systolic over pulmonary
(pulmonary stenosis)
tricuspid atresia murmur
pan-systolic over tricuspid
cyanotic presentations
Presents at birth or within first months
Always need surgery
Innocent murmurs:
- Can occur up to 25% of children without CHD
- Often precipitated by febrile illness
- Soft, Systolic, Symptomless = Safe
tetralogy of fallot features
PROVE
* Pulmonary stenosis
* Right ventricular hypertrophy
* Overriding aorta
* VEntricular septal defect
Clinical presentation of terralogy of fallot
- Most cases found antenatally, if not – presents around 1-2 months
- Cyanosis (RIGHT to LEFT shunt)
- ‘Tet spells’
- SoB/Signs of HF
- Failure to thrive
- Murmur: Ejection systolic, ULSE (pulmonary)
Pulmonary Stenosis:
narrowing or obstruction of the pulmonary valve - restricts blood flow to the lungs
Right Ventricular Hypertrophy:
Increased pressure due to stenosis -> right ventricle having to pump harder -> becomes thickened and hypertrophied.
Overriding Aorta:
In tetralogy of Fallot, the aorta is positioned above both the left and right ventricles, allowing it to receive blood from both ventricles. This leads to mixing of oxygenated and deoxygenated blood.
Ventricular Septal Defect (VSD):
Lastly, there is a hole septum between ventricles, allowing blood to flow between them. Mixing of blood contributing to cyanosis.
A 4-year-old boy presents to GP with 4 days of fever, malaise and sore throat. He has also developed a widespread rash over his trunk. He has not received any MMR vaccinations due to parental concern.
O/E: Temperature 38.3oC; Rough, raised erythematous rash over his trunk; ENT examination finds a swollen red tongue and cervical lymphadenopathy. Eye exam is unremarkable
What is the most likely diagnosis?
Measles
Rubella
Scarlet fever
Kawasaki disease
Chicken pox
Scarlet fever
features of scarlet fever
unvaccinated child
- fever
- sore throat
- rash (sandpaper - rough and raised)
- strawberry tongue
features of measles
maculopapular rash that starts behind the ears
Koplik spots= white spots on bucca mucosa
Mneumonic: 3 Cs
- cough
- coryza
- conjuncitivitis
rubella presentation
maculopapular rash, affecting face then body
chicken pox presentation
viral prodrome
vesiscles and blistering
kawasaki presentation
crash and burn
scarlet fever background
Reaction to toxins produced by Group A Streptococcus (strep pyogenes)
- notifiable disease
Management
- 10 days Penicillin V (phenoxymethylpenicillin
- School exclusion until 24 hrs after first antibiotics
kawasaki background
medium vessel vasculitis
CRASH and BURN
- Conjuncitvitis
- Rash (+peeling)
- Adenopathy
- Strawberry tongue
- Hands and feet swollen
+
- Burn (fever >5 days or resistant to anti-pyrexials
kawasaki management
- IV immunoglobulin
- High dose aspirin to prevent fatal cardiac complications
- Screen with echo for coronary artery aneurysm
how long off school for: scarlet fever
24h after starting abx
how long off school for: measles
4 days from onset
how long off school for: mumps
5 days from onset
how long off school for: rubella
5 days
how long off school for: D and V
48 hours after symptoms stop
how long off school for: impetigo
untill lesions have crusted over or 2 days after abx
how long off school for: hand foot and mouth
no exclusion required
chicken pox
untill all lesions have crusted - 5 days ish
how long off school for: slapped cheek
no exclusion needed
- parvovirus B19
A 6 year old boy and his mother present to GP. He has complained of pain in his hip for 3 days and it is causing him to miss PE at school. PMH: Asthma and tonsilitis - for which he finished a course of antibiotics 7 days ago.
His mother is concerned as she remembers his sister requiring an uncomfortable harness for a long time as a baby.
O/E: He appears well but mobilises with a limp. Range of motion is grossly preserved, and a small effusion is present at the left hip. Temperature 37.5 oC. Weight 27kg (80th centile)
What is the most likely diagnosis?
Transient synovitis
Septic arthritis
Perthes’ disease
Slipped upper femoral epiphysis
Developmental dysplasia of the hip
transient synovitis
- pain and limp
- recent infective illness
paediatric hip pain causes
in age order
- Developmental dysplasia of the hip
- Perthes disease
- Transient synovitis
- Slipped upper femoral epiphysis
Developmental Dysplasia of the Hip (DDH)
Structural abnormality in utero
USS Screening (by 6 weeks) if:
FHx hip problem
Breech past 36 weeks
Multiple pregnancy
Investigations
- Barlow and Ortolani in NIPE
Management:
<6 months - Pavlik harness
>6months - Surgery + spica cast
Perthes’ Disease
Avascular necrosis
- 4-8 years (primary aged)
- Pain + limp + reduced range of motion
- X-ray changes seen
- 10% bilateral
**Management: **
- <6 years - rest + observation
- >6: Cast + braces +/- surgery
Transient Synovitis
‘Irritable hip’
- 3-10 years
- Pain, limp + recent infection
- Minority have mild fever or mild effusion
Management:
- Self limiting
- Fever >38 or limp <3 yrs needs urgent assessment
