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1
Q

What is the epidemiology of ADHD?

A

Boys>girls

5% population – v common

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2
Q

What are the RF for ADHD?

A

Risk factors: premature, fetal alcohol, neurofibroma –> acquired brain injury, Fhx

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3
Q

What is the diagnostic criteria for ADHD?

A

Must show evidence of behaviours at less than 17 years
Development inappropriate subsequently
Impacts on them socially, academically or occupationally

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4
Q

What are the three domains of ADHD?

A

Inattention, hyperactivity and impulsivity

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5
Q

What are the symptoms of Inattention?

A

Disruptive, not performing as well should academically, easily distracted, forgetful in daily activities, does not appear to be listening when spoken to directly, makes careless mistakes and loses things

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6
Q

What are the symptoms of hyperactivity?

A

Fidgeting, running and climbing excessively, can’t remain still, talking excessively (more common in girls), finger or toe tapping, noisy, on the go, loud

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7
Q

What are the symptoms of impulsivity?

A

Shout out, push in, accidents, unplanned pregnancy, drug use, interrupting others, difficulty waiting for their turn

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8
Q

What score do you need for ADHD diagnosis?

A

NEED score of 6/9 for inattentive and 6/9 hyperactive/impulsive

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9
Q

What situations make ADHD typically worse?

A

typically worsens in unstructured, boring, repetitive, distraction filled, low supervision situations

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10
Q

what Comorbidities does ADHD often overlap with?

A

Commonly overlaps with over diagnoses eg mental health, ASD, tics, oppositional defiance disorder

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11
Q

what investigation do you do for ADHD?

A

QB test

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12
Q

What is the Management of ADHD?

A

Driving counselling
CVS assessment
Education for parents and child
Methylphenidate/ lisdexamefetamine

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13
Q

What are social communication symptoms of ASD?

A

LEARN LANGUAGE UNUSUALLY; Lack desire to communicate; Stop saying words; Communicate needs only; Echolalia – repeat speech;No eye contact; Over gesture; Pedantic, literal understanding

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14
Q

What are Social interaction symptoms of ASD?

A

Friendly but odd;Don’t want reciprocal interaction; Don’t understand unspoken social rules; May touch inappropriately, find it hard to take turns and make eye contact; Struggle with new situations due to lack of problem solving; Imagination; Practical, non-sharing play; Use toys as objects; Learn by rote and not understanding; Low empathy; Follow rules exactly; Black and white thinking

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15
Q

Behaviour and rigidity ASD sx?

A

Obsessions to comfort them and have fun —> difference between this and OCD being that obsessions are non-comforting to them - egocyntonic vs egodystonic; Resist changes and new situations; Sensory issues

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16
Q

Management of ASD

A 
Look out for comorbidities 
Education 
Communication toys 
Written instructions/ visual cues
timetables 
PECS
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17
Q

What are reticulocytes?

A

Reticulocytes are precursor RBC

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18
Q

how are rbc made

A

RBC ar made from pluripotent cells, triggered by EPO from kidneys due to hypoxia

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19
Q

What are signs of anaemia?

A

Signs: pale, conjuctiva, tongue or palmar creases, pica (eating non food materials)

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20
Q

What are causes of anaemia by low production?

A

aplasia eg parvovirus, diamond blackfan, Fanconi. OR ineffective erythropoiesis eg iron deficient, folic acid low, ot malacsorb chronic inflamm or renal failure

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21
Q

What are causes of anaemia by high destruction?

A

membrane, enzyme disorders, haemoglobinopathies, haemolytic new-born disease

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22
Q

What are causes of anaemia by loss?

A

lose blood eg GI, vWB

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23
Q

what does cytic and chromic mean?

A

Micro, normo and macrocytic refer to size

Hypochromic means the RBC are pale –> this will be due to low haemoglobin

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24
Q

What does reticlocyte count indicate?

A

If reticulocytes are low there is low production, if high it indicates haemolysis/blood loss

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25
Q

What is physiological anaemia of the new born?

A

Haemoglobin naturally falls after birth, reaching lowest point of 2 months
This is due to increasing plasma volume, lower RBC production, neonate RBC having shorter life spans, switch from fetal haemoglobin to adult –> greater unloading of oxygen to tissues - lower oxygen affinity of HbA relative to HbF.

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26
Q

What is prematurity anaemia?

A

LBW means poor EPO response

Protein content of breast milk may not be sufficient for haematopoiesis in the premature infant.

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27
Q

What are sx of prematurity anaemia?

A

Signs and symptoms: apnoea, poor weight gain, pallor, decreased activity, tachycardia

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28
Q

Iron deficiency anaemia RF in children?

A 
Diet!!
More at risk if breast fed as lower iron 
Cow’s milk in excess can prevent uptake 
Hookworm infection 
Milk intolerance
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29
Q

sx of iron deficiency anemia?

A

Sx: pallor, irritable, anorexia, splenomegaly, tachycardia, cardiac dilatation, murmur

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30
Q

what would ix show for iron deficiency anaemia?

A

microcytic, hypochromic, low/normal reticulocytes
Pencil cells
High ZPP (Zinc protoporphyrin is a compound found in red blood cells when haem production is inhibited by lead and/or by lack of iron)
Low ferritin (protein that stores iron) and serum iron
Increased TIBC (total iron binding cap- blood ability to bind iron with transferrin, as if there is more transferrin available I.e. unbound to iron then the amount of TIBC will increase)

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31
Q

What is the management of iron deficiency anaemia?

A

PO iron for 3-6 months, measure reticulocytes for progress

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32
Q

What is the pathophysiology of haemolytic anaemia?

A

Increased RBC turnover and lower lifespan
There are increased reticulocytes due to increased production to try to compensate
Increased unconjugated bilirubin due to increased RBC break down
As abnormal cells must be broken down -> more breakdown products

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33
Q

What is the difference between intra and extra corpuscular destruction in haemolytic anaemia causes?

A

Intra corpuscular destruction: haemoglobin, enzyme and membrane problems
Extra corpuscular: Autoimmune – Fragmentation – Hyper splenism – Plasma factors - cancer - infection

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34
Q

What is mx of haemolytic anaemia and what are SE + their mx?

A

blood transfusion
Iron overload – deposits in organs (from long term transfusion of haemolysis) - monitor their ferritin. Manage with penicillamine (chelates the iron)

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35
Q

Sx of haemolytic anaemia?

A

Jaundice due bilirubin overload –> gallstones
Oedema due to protein increase - ascites
Leg ulcers
Aplastic crisis
VTE

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36
Q

What are the sx of rhesus disease?

A

Symptoms: enlarged spleen and liver due to compensatory hyperplasia for severe anaemia

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37
Q

What is the mx of rhesus disease?

A

Management: – prevention of sensitization with Rh immune globulin – intrauterine transfusion of affected fetuses

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38
Q

What is rhesus disease?

A

Mother rhesus negative and child positive
Mother makes antibodies against the baby’s blood group antigen which cross the placenta
• Haemolysis of Rh Pos fetal cells

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39
Q

How do you diagnose rhesus disease?

A

Positive coombs test to diagnose

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40
Q

What are examples of haemoglobinopathies?

A

SCD and thalassemia’s -They both have abnormal hb (different globin or imbalance of chains)

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41
Q

investigations for haemoglobinopathies?

A

Ix: Blood smears (may see mexican hat cells/ codocytes), high performance liquid chromatography (hb electrophoresis can still be used but less common) , FBC
SCD: raised hbF and have HbS no HbA; raised reticulocytes
thalassemia: HbA2 and ferritin raised

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42
Q

What is the inheritance for SCD?

A

AR

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43
Q

Pathophysiology SCD?

A

HbS polymerises inside the RBC –> spherical shape –> can become trapped in blood vessels leading to occlusion and ischaemia, this is exacerbated by cold and dehydration

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44
Q

SCD presentation?

A

• Anaemia – cardiomegaly (high output) – low Pulse Ox – high WBC
Splenomegaly
• Infarction – low O2 –> sickling due to Hb structure changes – pain crises – Strokes
• Infection/sepsis – more predisposed to infection due to asplenia from filtering abnormal RBCs – fever a serious sign
Priapism
• Splenic sequestration- blood can pool in spleen –> hypovolemia
• Acute chest – infection or infarction -sx include pain crisis, hypoxia, fever, neuro sx.

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45
Q

What causes an aplastic crisis in SCD?

A

• Aplastic crisis – parvovirus B19 infection (slapped cheek) - shutsdown rbc production, would normally be fine but bc these cells don’t live long anyway it bad

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46
Q

What are long term complication of SCD?

A

stroke, adenotonsillar hypertrophy (sleep apnoea syndrome), heart failure, renal dysfunction, gallstones

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47
Q

WHat is seen on FBC for SCD?

A

retic count raised, chronic low RBC, elevated WBC

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48
Q

What is the management of SCD?

A

Neonate screening - given penicillin if diagnosed as neonate
Give vaccines –pneumococcal, flu, meningococcal
Prophylactic penicillin (as high risk for sepsis)
Transfuse and chelate
stem cell transplant (if severe eg stroke or acute chest- need HLA match of sibling and 5% chance of fatal complications)
hydroxycarbamide (increase HgF- SE: teratogenic)
-infection: treated seriously, antipyretics, IV fluids, culture, CXR
-Pain: Treat mild with paracetamol and NSAIDs, fluids, O2, may need morphine –> presents as dactylitis in children due to unfused bones
-Acute chest syndrome: Admit, transfuse and give O2 and abx

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49
Q

What type of anaemia is thalassaemia?

A

Microcytic anaemia

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50
Q

What is thalassaemia?

A

Beta major means no functional beta chains are produced, minor only one allele has the mutation
Alpha involves gene mutations of HBA1 and 2 –> less alpha chains –> unstable beta only chains aka HbH

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51
Q

Presentation of major beta thalassaemia?

A

Minor –asx, mild anaemia
Major- severe anaemia, low MCV, HbF and A2 increased
Sx: jaundice, splenomegaly, fail to thrive, skeleton deformed, delayed puberty

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52
Q

Management of major beta thalassaemia?

A

Management: gene counselling, blood transfusions, manage iron overload - chelation eg deferasirox, bone marrow transplant if sefvere enough

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53
Q

How is G6PD inherited?

A

X linked inherited

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54
Q

What is the presentation of G6PD?

A

Presentation: neonate jaundice, haemolytic non-spheroctyic anaemia, intravascular haemolysis- causes fever, malaise, dark urine, abdo pain, haemoglobinuria, rigors, back pain
May have brown urine due to the myoglobin and free haemoglobin from rhabdomyolysis

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55
Q

What are triggers for G6PD sx?

A

Induced by drugs, FAVA BEANS, fever, acidosis

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56
Q

Mx of G6PD?

A

Stop precipitant, transfuse, support kidneys

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57
Q

Ix of G6PD?

A

Ix: Bite cells seen and hemighosts, G6PD levels measured when stable (appear misleadingly higher when unwell due to higher levels in reticulocytes)
normocytic anemia

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58
Q

What are other types of enzymopathies?

A

Pyruvate kinase deficiency

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59
Q

Hereditary Spherocytosis pattern of inheritance?

A

AD inheritance

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60
Q

What is Hereditary Spherocytosis ?

A

Affects protein membranes - part of it is lost after passing through the spleen resulting in an abnormal surface area to volume ratio

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61
Q

Presentation of Hereditary Spherocytosis?

A

Clinical presentation ranges from mild to transfusion dependent
Sx: jaundice, anaemia, splenomegaly, gallstones- same sx as all haemolytics

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62
Q

Ix of Hereditary Spherocytosis ?

A

blood film

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63
Q

What are causes of aplasia anaemia (failure to make blood cells from bone marrow)?

A

parvovirus B19, diamond black fan anaemia, Fanconi’s anaemia, lymphoma, leukaemia, neuroblastoma, osteopetrosis

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64
Q

FBC results for aplasia?

A

Reticulocytes very low with normal bilirubin

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65
Q

What are signs of diamond black fan anaemia

A

Commonly have physical abnormalities: craniofacial, thumb, deaf, MSK, renal, cardio

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66
Q

Mx of diamond black fan anaemia?

A

Treat with steroids

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67
Q

What three things are needed for clotting?

A

For clotting it needs platelets, coagulation factors, vascular integrity eg damaged in ehlos danlos or marfans

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68
Q

What Ix should be done for clotting disorders?

A

FBC, blood film, PT (for factors 2, 5, 7 and 10), thrombin time (for fibrinogen), quantitative fibrinogen assay, D dimers, biochemical screen

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69
Q

What is ITP (Idiopathic Thrombocytopenic Purpura)?

A

often follows virus
Bruises all over but well in self
if chronic may have associative bleeds eg GI, nose, gingivae

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70
Q

How is ITP diagnosed?

A

Is a diagnosis of exclusion!! so check bloods and look for leukaemia and SLE
blds will show: increased bleeding time and low plaelets

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71
Q

What is the mx of ITP?

A

watchful waiting. Check spleen and neutrophils. If don’t recover spontaneously may need steroids, Ig or splenectomy

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72
Q

What is the pathophysiology of DIC?

A

Inappropriate activation clotting cascade -> Fibrin deposition in the microvasculature and consumption of coagulation factors - blocking lots of small vessels -> use up clotting factors
Due to severe sepsis or shock or trauma

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73
Q

How does DIC present?

A

may have chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts of the body - depending on location of clot
bleeding eg in urine, stool, petechiae, purpura
ix: low platelets, d-dimer elevated (unique to DIC), prolonged PT (as clotting facttors used up) and bleeding time increased due to this, fibrinogen low (as has been used up)

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74
Q

Mx of DIC?

A

platelet transfusion and treat cause

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75
Q

What is a d dimer?

A

D-dimer is a fibrin degradation product- used to measure the aftermath of presence of large clotting in body. It is so named because it contains two D fragments of the fibrin protein joined by a cross-link.

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76
Q

What are coagulopathies? Give examples

A 
Errors in clotting cascade 
Bleeding disorders (haemophilia and von Willebrand's) and hypercoagulable states (protein C, antithrombin)
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77
Q

What does factor V and thrombin do?

A

Factor V converts prothrombin to thrombin which then converts fibrinogen to fibrin

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78
Q

What is Von Willebrand disease?

A

AD inheritance
low or non-working VWF
VWF is an adhesive link between platelets and damaged subendothelium
It also carries factor 8 around

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79
Q

What are the sx of Von Willebrand ?

A

Sx: mild bleed eg bruise, epistaxis, menorrhagia, prolonged bleeding after surgery

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80
Q

What is the ix of Von Willebrand disease?

A

Ix: clotting screen, APTT increase (measures the speed at which blood clots), vWF and factor 8 low

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81
Q

What is the mx of Von Willebrand disease?

A

Mx: tranexamic acid, DDAVP (desmopressin), Factor 8 or VWF plasma if severe

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82
Q

How is haemophilia inherited?

A

X linked – boys

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83
Q

What is the difference between haemophilia A and B?

A

Factor 8 low – haemophilia A and factor 9 low is haemophilia B

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84
Q

What are the sx of haemophilia?

A

Sx: muscle and joint bleeds –> arthritis and deformity, starts early childhood, bruising, in neonates may see bleeding from umbilical cord, ICH (cephalohaemotoma)

Increased APTT but with normal PT

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85
Q

What is the mx of haemophilia?

A

Mx: desmopressin can be used in mild casesof haemophilia A as promotes endogenous release of factors 8 and vWF

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86
Q

What is the most common type of leukaemia in children?

A

ALL is most common (85%) with AML being second most common

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87
Q

How does leukaemia present?

A

Presentation: anaemia, infection, bleeds, systemic sx, organ infiltation, weight loss, night sweats, loss appetite, sometimes mediastinal mass in T cell leukaemia

Ix: anaemic, WCC up or down, neutropenia, thrombocytopenia, blast cells, look at bone marrow and LP

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88
Q

How do fluids leave the body?

A

60% urine, 35% skin and lungs, 5% stool

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89
Q

What are causes of dehydration by reduced intake?

A

dysphagia, N+V (gastroenteritis, URTI, GORD, chemo), anorexia, neglect

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90
Q

What are causes of dehydration by increased loss?

A

gut (gastroenteritis, ibd), urine (DI, renal dysplasia), skin (fever, CF, burns), lungs (trache, cardio, CF)

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91
Q

What are signs of mild dehydration? (<5%)

A

Thirst • Dry lips • Restlessness, irritability

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92
Q

What are signs of Moderate (5-10%) dehydration?

A

Sunken eyes • Reduced skin turgor • Decreased urine output

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93
Q

What are signs of Severe (>10%) dehydration?

A

Reduced consciousness • Cold, mottled peripheries • Anuria

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94
Q

How would you manage dehydration?

A

NGT

IV fluids

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95
Q

What is the formula for calculating dehydration correct fluid bolus?
How about for maintenance fluids?
WHat is the fluid choice?
How do the boluses work?

A

Formula: Deficit(%) x 10 x Wt(kg) — over 24 or 48 hrs (do 48 so slower if sicker eg have diabetes or cardio problems)

maintenance: 
1st 10 kg is 100ml/kg/day
2nd 10kg is 50ml 
rest of bodyweight is 20ml
EG a 27kg child would be (10x10) + (10x50) + (7x20) / 24 hrs = 68ml/hr

FLUID CHOICE:
Older children - 0.9% NaCl and 5% dextrose

in DKA: Patients presenting with shock should receive a 20 ml/kg bolus of 0.9% saline over 15
minutes. Shock is defined as the APLS definition of tachycardia, prolonged central
capillary refill etc – it is not just poor peripheral perfusion. Following the initial 20 ml/kg
bolus patients should be reassessed and further boluses of 10 ml/kg may be given if
required to restore adequate circulation up to a total of 40 ml/kg at which stage inotropes
should be considered. Boluses given to treat shock should NOT be subtracted from the
calculated fluid deficit.

All patients with DKA (mild, moderate or severe) in whom intravenous fluids are felt to be
indicated AND WHO ARE NOT IN SHOCK should receive an initial 10 ml/kg bolus over
60 minutes. Shocked patients do NOT need this extra bolus. This bolus SHOULD be
subtracted from the calculated fluid deficit

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96
Q

What is the cause of a limp that particularly affects children aged <4 years?

A

Toddler fracture

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97
Q

What are the causes of a limp that particularly affects children aged 4-10 years?

A

Transient synovitis

Legg calve perthes disease

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98
Q

What is transient synovitis?

A

– post viral infection which leads to synovitis of the hip

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99
Q

What are the causes of a limp that particularly affects children aged >10 years?

A

osgood Schlatters disease

SCFE- slipped capital femoral epithesis

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100
Q

What is osgood Schlatters disease?

A

patella attached to tibia due to osteochondritis of patella tendon, usually very active teenage boys

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101
Q

What is the differential for a child with a limp at any age?

A

All ages: juvenile arthritis, osteomyelitis/septic arthritis/discitis, benign/malignant tumour, trauma

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102
Q

What is the difference between discitis, osteomyelitis and septic arthiritis?

A

Osteomyelitis = infection bone - metaphysis of long bones

Septic arthritis= infection joint

Discitis – get referred pain from inflammation of vertebral discs

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103
Q

how do growing pains present in a child?

A

If growing pains normally bilateral, no systemic sx, exam and ix normal, no limp, generalised

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104
Q

Which pathologies present with a toe walking gait?

A

Clubfoot, CP, limb length discrepancy

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105
Q

Which pathologies present with a trendelenburg gait?

A

Legg-Calve Perthes disease; DDH; SCFE; hemiplegic CP

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106
Q

What is the trendelnburg gait?

A

Trendelenburg gait is an abnormal gait resulting from a defective hip abductor mechanism. The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking.

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107
Q

Which pathologies present with a circumduction gait?

A

CP, limb length discrepency

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108
Q

what is a circumduction gait?

A

gait in which the leg is stiff, without flexion at knee and ankle, and with each step is rotated away from the body, then towards it, forming a semicircle (hemiplegic gait)

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109
Q

Which pathologies present with a steppage gait?

A

CP, myelodysplasia; freidrichs ataxia; charcot-marie-tooths disease

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110
Q

what is a steppage gait

A

form of gait abnormality characterised by foot drop or ankle equinus due to loss of dorsiflexion. The foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking.

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111
Q

What are the possible causes of trauma to a leg in a child?

A

Non accidental; accident; osteogenesis imperfecta; vit D deficiency

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112
Q

What are common features of Osteogenesis imperfecta?

A

blue sclera, fracture often, Fhx

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113
Q

What is a Toddlers fracture?

A

Toddler’s fracture – undisplaced spiral fracture of tibia. Periosteum (blood supply) in tact. (similar to a greenstick fracture ie bend bone but periosteum in tact)

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114
Q

What are red flags in a limping child?

A

Anxiety/ severe pain – compartment syndrome
Night pain, weight loss - tumour
red and swollen, rash or bruise- juvenile arthritis, henoch-schonlein purpura, abuse

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115
Q

What is compartment syndrome?

A

muscle damage in fascia –> increased pressure in compartment –> pressure higher than capillaries –> no blood supply and subsequent necrosis

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116
Q

How does discitis present?

A

radicular pain - radiates from your back and hip into your legs through the spine. The pain travels along the spinal nerve root.
numb, paraestheia, mule weakness

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117
Q

How does Osteomyelitis present?

A

acute
Pseudo paresis, fever, swelling and tender
Blood cultures usually positive

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118
Q

What is the mx of osteomyelitis?

A

Abx immediate given, surgical drainage done if unresponsive to abx

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119
Q

Septic arthritis RF?

A

RF: premature, c-section, invasive procedures/ trauma causing direct inoculation, haemotogenous seeding, adjacent bone- osteomyelitis

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120
Q

What micro-organisms cause septic arthiritis (in neonates vs children)?

A

Commonly strep B (neonate), S.areus (child)

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121
Q

How does septic arthiritis present?

A

Present: recent trauma or infection, acute pain, systemic sx eg fever, limp or wont weight bear, raised ESR, hold still -pseudoparesis

O/E- swollen, red, tender, warm, severe pain on passive ROM. Leg held flexed, abducted, ext rotated

122
Q

What Ix do you do for septic arthiritis?

A

Ix: WCC, ESR, needle in synovium to see if pus (pus can lead to dissolve of chondral surfaces- affects growth plate), blood cultures, U/S if deep joint eg hip,

123
Q

What is the mx of SA?

A

Mx: surgical wash out, abx, rest

124
Q

WHat is the Kocher criteria for SA?

A 
WCC >12,000 
Inability to bear weight 
Fever >38.5 
ESR >40 
If score 0 - <0.2% chance of septic arthritis
125
Q

What is the Mx for transient synovitis?

A

Mx: Treat with NSAIDs and let go home

126
Q

What are RF for transient synovitis

A

trauma, allergy, viral infection, previous transient synovitis

127
Q

How does transient synovitis present?

A

URTI, mild/no fever, acute groin/thigh pain, refuse to weight bear, improves during day, restriction of internal rotation, painless arc of motion, no pain at rest

128
Q

How does (DDH) developmental dysplasia of the hip present?

A

Shortening
Reduced Abduction
Skin crease asymmetry
Barlow / Ortolani positive

129
Q

What is the Barlow/ Ortolani test?

A

Barlow is newborn test for DDH which dislocates (hear/ feel clunk) the hip by adducting the hip at a flexion of 90 degreed and then giving pressure at the knee in a downwards direction
Ortolani reloctes hip joint - do opposite- push thigh anterior and then abduct
Remember B before O!

130
Q

What are RF for DDH?

A

Screening risk factors: Family Hx, Breech, >98th centile birth weight, Multiple pregnancies

131
Q

What is Perthe’s disease?

A 
avascular necrosis (loss blood supply-> death) of the proximal femoral epiphysis in children 
Possibly caused by abnormal clotting factors eg Protein S and C deficiencies, thrombophilia
132
Q

What are RF for Perthe’s disease?

A

RF: LBW, male, 4-8 yrs, unilateral more often

133
Q

What is the presentation of Perthes disease?

A

insidious onset, see XR including density of the femoral head, leg length discrepancy, waddle gait, Many develop OA secondary due to aspherical femoral head

134
Q

What is the Mx of Perthes disease?

A

Mx: Resolution of symptoms – NSAIDs, traction, crutches. Restoration of ROM – physio, muscle lengthening. Containment of hip – osteotomy

135
Q

What is slipped capital femoral epithesis (SCFE) ?

A

slippage of the metaphysis relative to the epiphysis

136
Q

What is the presentation of SCFE?

A

Usually adolescent obese males and hypothyroid, low GH, renal osteodystrophy association
Groin, knee and thigh pain, Limp – antalgic gait, externallyk rotated foot progression angle,
Duration – symptoms usually present for weeks to several months before diagnosis
Examination- Decreased hip ROM – obligatory Ext Rotation during passive flexion, Loss of hip IR, abduction, and flexion

137
Q

What would you see on an Xray of SCFE

A

Diagnose on XR, klein’s lines to look at femoral leg and length

138
Q

What is the mx of SCFE?

A

Mx: percutaneous pinning

139
Q

What is the terminology in derm?

A 
Macule = small flat area of altered colour eg café au lait spot, freckle, mumps, rubella 
Patch = large area of altered colour or texture eg vitiligo 
Papule = small and raised eg acne, allergy 
Maculopapular = both, eg measles, parvovirus, scarlet fever 
Plaque = latrge raised region eg psoriasis 
Nodule = large raised region with deeper part eg nodular lesion of the erthema nodusum 
Vesicle = small clear blister eg varicella 
Bulla = large clear blister eg trauma, impetigo 
Weal = transient raised lesion due to dermal oedema eg urticaria 
Pustule = pus containing blister eg paronychia 
Pupura = bleeding into the skin, smaller areas = petechiae, non blanching eg meningococcal septicaemia, Henoch Schönlein purpura, DIC, ITP 
Scales = flakes of dead skin eg cradle cap 
Crust = dry exudate containing serum, scales, pus, dried blood eg impetigo
140
Q

What is a strawberry mark?

A 
Strawberry marks (haemangioma) – raised, red. 
self limiting (increase first six motnhs and usually disappear by 7) but beware over eye and in airway. 
Can treat with propranolol or steroids if that doesn’t work.
141
Q

what is a port wine stain?

A

Port wine stain/ capillary malformation – permanent. Flat and red/purple
Usually unilateral and on face, chest or back. Deepen in colour with hormones changes.
If along trigeminal nerve may be sturge weber sndrome

142
Q

What is a mongolian blue spot?

A

Mongolian blue spot - usually non-Caucasian ancestry.

Blue-grey bruise like marks, non permanent.

143
Q

what may a cafe au lait spot inidicate

A

more than 5 = neurofibromatosis.

144
Q

What are milia?

A

(milk spots) – sebaceous plugs.

145
Q

How does eczema usually present?

A
  • itchy rash, erythema, weeping, crusting. Excess rubbing leads to lichenification.
  • complications: infection with S aureus or herpes (eczema herpeticum)
  • Infancy - dry, red, itchy and sore patches of skin over the flexor surfaces (the inside of elbows and knees) and on the face and neck.
  • Young children - occurs on the extensor surfaces
146
Q

How is eczema mx?

A

-mx: emoillients, topical corticosteroids, avoid irritants, occlusive banadages
corticosteroids:
mild: hydrocortisone
moderate + severe: betamethasone valerate 0.025% or clobetasone butyrate 0.05%
-Flucloxacillin is the first-line choice for infected eczema

147
Q

What is a primitive reflex?

A

Primitive reflexes = present at birth but want gone by 6 months

148
Q

What are the primitive reflexes?

A

startle reflex with abduction of arms and open palms with load noises, moro (4 letters, gone by 4 months), grasp/palmar (6 letters, gone by 6 months), rooting/placing, ATNR

149
Q

What are the milestones for gross motor?

A

Newborn
Flexed arms and legs
Equal movements

3 months
lifts head on tummy

6 months
Chest up with arm support
Rolls
Sit unsupported – six months is sitting

9 months
Pulls to stand
crawls

1 year
cruises

18 months
walking

2 years
Walks up steps with rail
runs

3 years
Jumps
stairs without rail

4 years
Hops

5years
Rides a bike

150
Q

What are the milestones for fine motor and vision?

A

3 months
fix and follow
reaches
holds rattle briefly

6 months
palmar grasp
passes palm to palm

8 months
Takes a cube in each hand
points

12 months
scribbles with a crayon
pincer
namgs toys

18 months
Builds a tower of 2 cubes

2 years
tower of 6 cubes
draws line

3 years
Tower of 8/9 cubes
draw circle

4 years
draws cross

5 years
square and traingle and diamond

In terms of drawing usually able to scribble then do face then do cross then do rectangle then square then triangle then diamond by 5 yrs

151
Q

What are the speech language and hearing milestones?

A

3 months Laughs and squeals, turns to voice

6 months: babbles eg adah

9 months ‘dada, mama’

12 months 1 word outside mama and dada, simple command following, knows name

2 years 2 words sentences Names body parts

3 years Speech mainly understandable, colours known, Talks in short sentences (e.g. 3-5 words)
Asks ‘what’ and ‘who’ questions
Identifies colours
Counts to 10 (little appreciation of numbers though)

4 years Asks ‘why’, ‘when’ and ‘how’ questions

5 years Knows meaning of words e.g what is a lake?

152
Q

What are the social and self care milestones?

A

6 week Smiles spontaneously

6 months Finger feeds

9 months Waves bye – bye, shy, puts things to mouth, peek a boo

12 months Uses spoon/fork, helps a bit with dress and undress

2 years Feed a doll, Puts on hat and shoes

3 years Play with others, name a friend and Put on a t-shirt, uses spoon and fork

4 years Dress no help and play a board game, uses knife and fork

153
Q

What are feature of the Healthy child Programme?

A

Eg the Neonate exam, the red book

Have the ASQ that health visitors do

154
Q

What are red flags in the milestone checks?

A

Not sitting by 1 year or walking by 18 months
Hand preference before 18 months
Not smiling by 3 months or clear words by 18 months
No response to carers interactions by 8 weeks, or playing with peers by 3 yrs
Regression in milestones
Poor health n growth
Safeguarding issues

155
Q

what are causes of developmental delays?

A 
chromosome abnormalities eg downs  
Single gene disorders eg Rett syndrome or Duchenne's 
Polygenic, autism, ADHD 
Congenital infections eg CMV 
Exposure to alcohol/drugs 
MCA infarct – cerebral palsy - motor impairment most common cause 
Prematurity 
Birth asphyxia 
Infection eg meningitis, encephalitis  
Chronic disease 
Metabolic conditions 
ABI 
Hearing or visual impairment 
Abuse and neglect 
Remember the categories: genetic, pregnancy, childhood, birth, environmental
156
Q

What are the ix for developemntal delays?

A

If boys not walking by 18 months do a CK check for Duchenne’s
If neuro signs do an MRI brain
If a Fhx consider karyotyping
If unwell or failing to thrive then do metabolic ix
If global delay consider CGH microarray

157
Q

What is the aetiology of paediatric malignancy?

A

oncogenes, inherited (eg retinoblastomas), some conditions put you at increased risk (eg downs, immune compromised and NF1)

158
Q

What is the most common form of leukaemia in children?

A

ALL

159
Q

How does leukaemia present in childrem?

A

Bone marrow infiltration – bony pain -> anaemia, neutropenia, thrombocytopenia
Anaemia – pale and tried
Neutropenia – recurrent infection
Thrombocytopenia – bruising, petechiae and nosebleeds

Other sx
extramedullary disease.
lymphadenopathy and hepatosplenomegaly.
weight loss, bone pain, and dyspnoea.

Signs or symptoms of CNS involvement: rarely seen at presentation.
eg headache, nausea and vomiting, lethargy, irritability, nuchal rigidity, papilloedema. Cranial nerve involvement (most frequently involves 3rd, 4th, 6th and 7th nerves)

Testicular involvement at diagnosis is rare. However, if present, it appears as painless testicular enlargement and is most often unilateral. - do U/S if this occurs

160
Q

Ix for leukaemia?

A

blood film, CXR (mediastinal mass), bone marrow aspirate and biopsy (confirms diagnosis, plus do immunophenotyping, cytogenetic and molecular analysis to classify type), LP (check if in CSF and if need intra thecal therapy)

161
Q

mx for leukaemia?

A

Before start treatment correct anaemia with blood transfusion and fluids plus allopurinol if WCC high and kidneys at risk of rapid cell lysis. chemo in five stages, with one year longer for boys due to possible testicle infiltration, stem cell transplant in high risk patients during first remission and relapsed patients.

162
Q

How does CNS cancer usually present?

A

caused by raised ICP: headache (worse lie down), early morning vomiting, papilloedema, squint (6th nerve palsy), nystagmus, ataxia (loss of skill in younger child), personality change, seizures

163
Q

ix for CNS tumour?

A

MRI, remember check ICP before LP

164
Q

What are the indications for a MRI in a child other than a tumour?

A

papilloedema, decreased acuity, visual loss
If also other neurological signs (or they develop)
If recurrent and/or early morning
If associated with vomiting
if persistent, more frequent, preceded by headache
If also have short stature / decelerated linear growth
If have symptoms of diabetes insipidus
If age < 3 years
If child has neurofibromatosis (NF1)

165
Q

WHat is the mx for a CNS tumour?

A

surgery better if low grade and easily and fully resectable, VP shunt, radio and chemo- needs to penetrate BBB (the more young the child is the more likely to lead to disability so radiotherapy is generally CI in very young)

166
Q

when should lymphadenopathy be biopsied?

A

Biopsy if supraclavicular, persistent or has associated sx of lymphoma

167
Q

what causes lympthadenopathy?

A

Lymphadenopathy is caused by an increase in lymphocytes and macrophages due to viruses or infection. Can build up with infection in nodes themselves like lymphadenitis, or with neoplastic lymphocytes in lymphoma or with metabolic laden macrophages in gaucher disease. Consider HIV.

168
Q

ix for lymphadenopathy?

A

lymph node biopsy, CT/MRI if non hodgkins

169
Q

what is the mx for hodgkins vs non hodkins lymphoma?

A

NHL- chemo, radio only in rare case of spread to testes/CNS
Hodkins- chemo and radio (due to residual bulk disease)
Do stem cell transplant if relapse

170
Q

What is associated with cancerous abdo mass?

A

pain, haematuria, constipation, htn or weight loss asociated

171
Q

What are the differentials for an abdo mass in a child?

A

heaptoblastoma, wilm’s, neuroblastoma, lymphoma/leukaemia, sarcoma, constipation, polycistic kidneys

172
Q

what is the difference between a neuroblastoma and a wilms tumour?

A

Neuroblastoma (bone marrow disease) tumours tends to wrap around middle and cross midline. Do surgery if low risk alone. Do chemo is higher risk or have had sx from tumour eg SCC, resp problems. Generally poor prognosis.

Wilms: doesn’t tend to cross midline on scan. Treat with chemo , nephrectomy if uni and partial if bi, radio if high stage

173
Q

ix for a suspected cancerous abdo mass?

A

Ix: U/S, CT, biopsy

174
Q

what is a neuroblastoma?

A

Arises from neural crest of adrenal medulla and SNS
Most common before age 5yrs
Raised catecholamine levels are suggestive ie VMA/ HVA

175
Q

how does a neuroblastoma present?

A

Present: pale weight loss, abdo mass, hepatomegaly, bone pain, limp

176
Q

mx for a neuroblastoma?

A

Treat with chemo, stem cell therapy and radio

177
Q

What is a wilms tumour?

A

aka nephroblastoma

Originates from embryonic renal tissue, most present before 5 yrs

178
Q

how does a wilms tumour present?

A

haematuria, abdo mass

179
Q

What is a retinoblastoma?

A

Retinoblastoma occurs due to an inherited mutation in a tumour suppressor gene known as RB1.

Most children with inherited retinoblastoma generally have tumours involving both eyes. The RB1 gene is an autosomal dominant gene. When a child inherits the gene, there is a 75 to 90 percent chance for the second mutation to occur, resulting in retinoblastoma.

180
Q

what are the sx of retinoblastoma?

A

leukocoria – loss of red reflex (also called cat’s eye), Strabismus, pain or redness around the eye, poor vision or change in child’s vision

181
Q

what is the mx of retinoblastoma?

A

chemotherapy, radio, laser therapy, phototherapy, thermal therapy, cryotherapy, enucleate the eye via surgery

182
Q

What are the cancer differentials for proptosis?

A

neuroblastoma, rhabdomyosarcoma

183
Q

What are the cancer differentials for Recurrent discharge from ear?

A

rhabdomyosarcoma, Langer cell histiosis

184
Q

How do CNS tumours tend to differentiate in children vs adults?

A

In comparison to adults they are nearly always primary tumours and majority arise below the tentorium

185
Q

how does discitis present?

A

locally tender, reluctant to walk, pain on flexion spine, see on XR + MRI, fever

186
Q

what is Spondylylolysis?

A

stress fracture in vertebrae, usually due to sports, if bilateral can be spondylolisthesis – lead to SCC

187
Q

what are red flags for back pain in children?

A

young, fever, night waking, focal neuro signs eg nerve root irritation, bowel or bladder sx, systemic sx

188
Q

How may a UTI present in a child?

A

miserable, fever, vomiting, may be able to communicate dysuria

189
Q

What ix may be done for a UTI?

A

Do urine dipstick and culture
Culture – most common growth is e.coli, if other organism is regarded as atypical
USS needed for structural abnormalities and renal scarring secondary to recurrent UTIs

190
Q

mx for UTI?

A

Start oral antibiotic treatment — first line options include trimethoprim (if there is low risk of resistance), or nitrofurantoin (if eGFR ≥ 45ml/minute). Second line options include nitrofurantoin (if eGFR ≥ 45ml/minute) if it has not been used as a first-line option, amoxicillin (only if culture results available and susceptible), or cefalexin.

191
Q

summary of osteomyelitis

A

Usually hx of trauma, pain, lethargy
Blood cultures and XR
S. aureus common cause – sensitive to flucloxacillin
IV cefuroxime for 6 weeks

192
Q

summary of meningitis

A

Fever, GCS dropping, purple rash
Think is it bacterial meningitis or meningococcal sepsis
IV cefotaxime , ceftriaxone or benylpenicillin
Ix blood culture, CSF

193
Q

summary of pneumonia

A 
Pyrexia, malaise, SOB 
Do CXR and blood cultures 
S.pneumoniae main causitive agent 
Give IV benzylpenicillin if severe or PO amoxicillin if mild 
If lack of response look for empyema
194
Q

Which babies are more at risk of hearing problems?

A

premature, chemo, CF, CMV at birth, head trauma, cleft palate and downs as more at risk of hearing loss

195
Q

What happens at baby hearing tests?

A

Measure: hearing threshold, frequency, each ear in turn, conductive vs sensorineural
Plot on an audiogram

196
Q

When do hearing tests take place and what tests are done?

A

Behavioural Observation Audiometry – . A computer generated click is played through a small earpiece. The presence of a soft echo indicates a healthy cochlea
0-6 Months

Distraction Test – bility of the baby to hear a sound then turn to locate it. The sounds are produced to the right or left behind the baby out of their field of view.
6-18 Months

Visual Reinforcement Audiometry – Ask child simple questions - e.g. ‘where is the teddy?’
6-30 Months

Performance Testing – This involves teaching your child to listen and wait for a sound, and then respond in some sort of play activity to the sound
24 Months+

197
Q

What is conductive hearing loss and what causes it?

A

normally a middle ear problem and temporary with Max 60 dB hearing loss

198
Q

How is conductive hearing loss managed?

A

Manage: usually self-limiting as eustachian tube increases in size, grommets to release fluid, BAHA (bone anchored hearing aid) if more permanent

199
Q

What causes conductive hearing loss?

A

Causes: most common- glue ear (otitis media + effusion), otitis media, eustachian tube problem (downs and cleft palate linked), perforated eardrum, build up of wax

200
Q

What is sensorineural hearing loss?

A

Inner ear problem, more permanent
Profound hearing loss
Doesn’t improve

201
Q

What causes sensorineural hearing los?

A

genetic, antenatal infection, preterm, post natal infection, head injury or drugs

202
Q

mx of sensironeural hearing loss?

A

Manage with amplifier hearing aid or cochlear implant

203
Q

In mixed hearing loss should conuctive or sensironeural be fixed first?

A

conductive

204
Q

What makes up the auris externa/ media/ interna?

A

Outer= pinna to tympanic membrane

Middle = ossicles, eustachian tube, chorda tympani, facial nerve

Inner = nasopharynx, cochlea, saccule, utricle, vestibulocochlear nerve

205
Q

What are the different parts of tympanic membrane/ eardrum and how are they different?

A

Pars flaccida = 2 layers

Pars tensa = main part of ear drum, taught, 3 layers as has fibrous layer

206
Q

How does the ear develop embryologically?

A

Pinna develops from mesoderm from branchial arch

207
Q

List some congenital problems of the ear

A

outer ear: failure of arches, microtia (pinna fails to form properly), atresia, pre-auricular sinus, accessory auricles ( buds on ears), prominent ears (cosmetic issue)

Middle ear • Abnormal ossicles • Craniofacial syndromes

Inner Ear • Scheibe (cochleosaccular) dysplasia • Mondini (cochlear) dysplasia • Bing-Siebenmann (vestibulocochlear) dysplasia – membranous labyrinth affected • Michel aplasia – complete labyrinthine aplasia

208
Q

How will otitis externa present and what is usual mx?

A

will be painful, itchy, reduced hearing, inflammed, often swimmer/ runner
treat with microsuction/ topical abx

209
Q

How will otitis media present?

A

fluid, pain if ear perforates, hearing loss, signs of infection

210
Q

How is otitis media managed?

A
  1. Conservative: Do nothing, Eustachian tube autoinflation (Otovent balloon) – 2. Ventilation tubes (Grommets) – 3. Hearing aids: alternative to surgical intervention where surgery is contraindicated or not acceptable
211
Q

What are complications of otitis media?

A

mastoiditis (inflamm behind ear), cholesteatoma.

212
Q

what is a cholesteoma?

A

skin cells grow in ear – which presents with repeated infection, offensive discharge, perforated eardrum and white material in ear

213
Q

what are the sinuses of the face?

A

frontal, ethmoid, sphenoid, maxillary

214
Q

What is Choanal atresia and what is its presentaion?

A

nose fails to canalise

Presentation: cry and go pink then go blue then cry and go pink again, no misting on cold spatula, cant pass NGT

215
Q

mx of choanal atresia?

A

secure airway then refer for dilatation and stent

216
Q

What are causes of craniofacial abnormalities ?

A

Syndromic – Down, Apert, Pfeiffer, (bulgy eyes an narrow face) Crouzon, Treacher Collins
May have problems with airway – OSA, midfacial hypoplasia

217
Q

What may be a posible sign of foreign body inhalation ?

A

Unilateral discharge

218
Q

What are the 3 different parts of the pharynx?

A

naso -> oro -> hypo

219
Q

Why is the nose prone to bleeding?

A

Rich blood supply – particularly littles area which is anteroinferior part of nasal septum where four arteries anastomose

220
Q

What are triggers or epistaxis?

A

Triggers: nose pick, inflammed, foreign body, trauma, clotting disorder

221
Q

What is the mx of epistaxis?

A

ABC, packing, naseptin, silver nitrate cauttery, electrocautery if bad. Blood transfusion.

222
Q

What should you be cautious of in a teenage boy with persistent nosebleeds?

A

juvenile nasopharyngeal angiofibroma

223
Q

What is sinusitis associated with?

A

(Rare in paeds)

Associated with nasal polyps

224
Q

What can be a complication of sinusitis and what does it involve?

A

Preorbital cellutlitis

Medical emergency
• URTI followed by painful swollen eye
• Proptosis
• Red colour vision: sign of optic nerve compromise

Mx• IV Abx • Incision and drainage of abscess

225
Q

Name a difference in the throat between adults and children?

A

Childs narrowest point is cricoid ring vs VC in adults

226
Q

Where are the adenoids vs the tonsils?

A

Both are collection of lymphoid tissue (Waldeyer’s ring)

tonsils: visible, pharyngeal, two
adenoids: not visisble, palatine

227
Q

What is larygngeal atresia?

A

larynx fails to open - need trache

228
Q

What is laryngomalacia and how it presented?

A

softening of larynx- floppy voice, stridor when feeding, worse when supine, FTT, increased work of breathing

229
Q

how is laryngomalacia ix?

A

Flexible nasendoscopy examination: omega shaped epiglottis, short aryepiglottic folds, bulky, prolapsing arytenoids

230
Q

mx of laryngomalacia?

A

Close monitoring • Weigh (?daily/weekly at first) • Antireflux • If not coping NG tube • ?surgery – microlaryngobronchoscopy + aryepiglottoplasty • Is self limiting stridor lessens and gone by 2 years old

231
Q

What does the type of stridor reveal about its location?

A

Inspiratory: laryngeal – Biphasic: subglottis/trachea – Expiratory: bronchi

232
Q

Summarise epiglottitis

A

Epiglottitis rare age 2-5: sudden onset v unwell, drooling, stridor – Haemophilus influenzae B (HiB) • Medical emergency • Do not agitate child • Theatre (intubate if poss)

233
Q

summarise croup

A

Laryngotracheobronchitis • Common • Low grade fever • Not v unwell • Parainfluenza virus types 1 and 2 • Stridor- biphasic and barking cough • O2 , steroids, adrenaline nebulisers

234
Q

What can enlarged tonsils and adenoids cause?

A

Obstruction sleep apnoea – Apnoeas: cessation of breathing + desaturations

235
Q

How may OSA present?

A

• Snoring/stertor (upper airways noises)
• Restless
• Sweaty
• Poor eaters – will choke (drink milk copiously)
• Failure to thrive
• Pauses in breathing at night, gasping – apnoeas
• Behavioural problems: hyperactivity, tiredness as wont sleep
O/E: mouth breathing, adenoid facies (long face syndrome) • Large tonsils • Pes excavatum

236
Q

Ix for OSA?

A

?Domiciliary sleep study/polysomnography (EEG, ECG, O2 sats, infra red cameras, movement detectors)

237
Q

Mx of OSA?

A

Adenotonsillectomy

Monitor O2 sats overnight post op and give nasal prong

238
Q

How may liver problems present?

A

encephalopathy, jaundice, epistaxis, cholestasis (pale stools and dark urine), ascites, rickets, varices, spider naevi, wasting, bruising, palmar erythema

239
Q

Which vitamin absorptions are affected by liver problems and why?

A

Fat malabsorption - as long chain fat is not absorbed well without bile leading to essential fatty acid deficiency (vitamins ADEK) and therefore fat-soluble vitamins deficiency.

240
Q

How may the low vitamin absorption secondary to liver pathophysiology present?

A

Vit A low – night blindness
Vit K low – bleeding
Vit E low – peripheral neuopathy, ataxia
Vit D low – rickets and fractures

241
Q

How does biliary atresia present?

A

Mild jaundice and pale stools
Raised bilirubin and abnormal LFTs
ERCP diagnostic

242
Q

How do the testes migrate down during development?

A

The testes migrates down the inguinal canal due to testosterone from SRY gene in embryo

243
Q

What is the difference between ectopic and intrabdominal undescended testes?

A

intraadbdominal= in inguinal canal but furhter up

Ectopic = below external inguinal ring but outside scotum

244
Q

What is the mx of undescended testes (cryptorchidism)?

A

commonly do nothing and will resolve itself
review at 3m and surgery at 6m
Bilateral and impalpable - urgent Orchidoplexy

245
Q

How does testicular torsion present?

A

Neonate and puberty most common
Sudden onset severe pain, vomiting, tender testicle, red and swollen LATE signs
Have 6 hrs to save testis via surgery

246
Q

How does torsion of appendix testis present?

A

mimics testicular torsion- is more common
often in prepubertal boys
pain not usually as severe or as acute onset as torsion
can be a “blue dot” (1/3 of cases) - only reliable way to differentiate from testicular torsion

247
Q

What is the appendix testis?

A

remnant of paramesonephric (Mullerian) duct

248
Q

What are medical indications for circumcision?

A

balanitis, reccurrent UTI, needs intermittent cathetrisation, HIV prophylaxis

249
Q

How does hypospadias present?

A

Three features – ventral urethral meatus, ventral curvature penis, hooded foreskin

250
Q

mx for hypospadias?

A

Refer to paediatric urology
Check the testicles are palpable
May have surgery
Make sure not to circumcise

251
Q

What should be done on examination of a scrotal lump?

A

Can you get above it?

Light torch?

252
Q

How does an inguinal hernia present?

A

Present as lump groin, more visible strain, may be able to plapate cord structure

older: may be increase with cough, appear w lifting, dragging sensation, pain

253
Q

What is the difference between a direct and indirect hernia?

A

Indirect: a protrusion through the internal inguinal ring passes along the inguinal canal through the abdominal wall, running laterally to the inferior epigastric vessels.

Direct: the hernia protrudes directly through a weakness in the posterior wall of the inguinal canal, running medially to the inferior epigastric vessels.

254
Q

which inguinal hernia is more common in children?

A

indirect (though direct can be more common in premmies who have weak muscle wall)

255
Q

What is warning sign for surgery with inguinal hernias in children?

A

If contents of hernia are irreducile/ incarcerated it becomes painful, may cause obstruction and torsion

256
Q

How does a hydrocele differ from an inguinal hernia?

A

Same anatomy as hernia but the processus vaginalis though patent is not wide enough to form a hernia

257
Q

How may a hydrocele present?

A

Normally asx, sometimes seem blue, usually can still feel testis, can GET ABOVE and it transilluminates

258
Q

mx of a hydrocele?

A

Leave alone - normally resolves spontaneously as processus vaginalis closes

259
Q

What is a varicocele and which side is it more common on?

A

Scrotal swelling of dilated veins

Commoner on the L side due to drainage of gonadal vein into L renal vein

260
Q

How may a varicocele present?

A

o/e may be blue, feel like bag of worms

261
Q

How is a varicocele managed?

A

Mx usually conservative, can occlude veins through surgery eg embolisation if sx

262
Q

What are some embryological causes of neck lumps?

A

Thyroglossal remanants - Painless, firm midline neck mass, usually near the hyoid bone, which elevates with swallowing and tongue protrusion

Branchial arch/cleft remnants - Usually diagnosed in late childhood/adulthood after previously undiagnosed cyst becomes infected
Often a history of preceding upper respiratory infection
Painless, firm mass lateral to midline, usually anterior to the sternocleidomastoid muscle, which does not move with swallowing

263
Q

What is omphalitis?

A

Omphalitis of newborn is the medical term for inflammation of the umbilical cord stump in the neonatal newborn period, most commonly attributed to a bacterial infection

264
Q

What is gastroschisis?

A

Gastroschisis is a birth defect in which the baby’s intestines extend outside of the abdomen through a hole next to the belly button.

265
Q

What is Omphalocele?

A

Omphalocele, is a rare abdominal wall defect in which the intestines, liver and occasionally other organs remain outside of the abdomen in a sac because of failure of the normal return of intestines and other contents back to the abdominal cavity

266
Q

What is oesophaegeal atresia?

A

Esophageal atresia is a congenital medical condition that causes the esophagus to end in a blind-ended pouch rather than connecting normally to the stomach.

Associated with tracheo-oesophageal fistula and polyhydramnios

May present with choking and cyanotic spells following aspiration
VACTERL associations

267
Q

What is duodenal atresia?

A

Duodenal atresia is the congenital absence or complete closure of a portion of the lumen of the duodenum. It causes increased levels of amniotic fluid during pregnancy and intestinal obstruction in newborn babies.

268
Q

How may duodenal atresia present?

A

Associated T21
Vacterl - vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities
Double bubble on XR
Bilous vomiting

269
Q

Summarise Hirschprung’s disease?

A

Distal aganglionosis that causes:
Failure to pass meconium
Progressive abdominal distension
mx : Usually washouts then pull through operation

270
Q

summarise meconium ileus

A

Affects CF patients a lot
Thick intestinal secretions from pellets
Blocks terminal ileum
X-Rays will not show a fluid level as the meconium is viscid, PR contrast studies may dislodge meconium plugs and be therapeutic
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs

271
Q

Summarise Necrotising enterocolitis

A

Necrotizing enterocolitis is a medical condition where a portion of the bowel dies. It typically occurs in newborns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.
Caused by poor blood flow and infection

Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

272
Q

What is the difference between single gene disorders, chromosomal and multifactorial inheritance?

A

Single gene disorders – mendelian inheritance eg CF, HD, haemophilia

Chromosomal – affects thousands of genes and multiple organs eg T21

Multifactorial – several genes act with environment eg neural tube defect, diabetes, cleft palate, schizo

273
Q

How may trisonomy 21 present in terms of dysmorphic features?

A

Epicanthic folds and other dysmorphic features: round face and flat nose, brushfield spots in iris, small ears, small mouth, flat occiput, thirs fontanelle, short neck, single palmar crease, sandal gap between first and second toe, hypotonia

274
Q

How may T21 present, in terms of medical issues?

A 
Intellectual disability 
duodenal atresia, hirshprungs  
Delayed development 
microcephaly 
Heart problems 
Visual and hearing problems 
Obstructive sleep apnoea 
Hypothyroisism 
Early onset Alzheimer's 
epilepsy
275
Q

What are the different types of trisomies?

A 
T21 = downs
T13= pataus 
T18 = edwards
276
Q

What is the pathophysiology of downs syndrome?

A

Linked to raised maternal age
Can be caused by Robertsonian translocation (second mos common cause) – part of chromosome breaks off and joins other so there’s double at chromosome 21
Non disjunction occurs at meisosis and is associated with maternal and paternal increased age

277
Q

How is T21 diagnosed?

A

Cytogenetics: non disjunction, translocation or mosaicism

Screen for downs with nuchal thickening on US and markers in blood

278
Q

Describe AD inheritance?

A 
50% chance inheritance 
No skipped generations 
Equal transmission with sexes 
Variable expression and penetrance 
Vertical transmission 
Only one copy of gene pair altered 
Gonadal mosaicism may occur
279
Q

What are examples of AD inheritance?

A

polycystic kidney disease, hypercholestraemia, marfans, HD, familial breas and ovarian cancer – BRAC1 and 2, FAP, hnpcc

280
Q

What is gonadal mosaicism?

A

where mutations occur in egg/sperm so found in adults blood but parents are not affected only their children – associated with ASD, schizophrenia

281
Q

What is variable expressivity?

A

refers to the range of signs and symptoms that can occur in different people with the same genetic condition eg treacher collins

282
Q

What is autosomal recessive inheritance?

A

Need two germline mutations – one from each parent – heterozygous carriers
Unless consanguinity usually only one generation affected
¼ risk siblings
2/3 (66%) risk carrier unaffected siblings - IF know that they dont already have the disease

283
Q

Give examples of AR inheritance?

A

CF PKU, haemochromatosis, SMA

284
Q

What is X linked inheritance?

A

Girls unaffected
Females carriers
50% sons affected and 50% daughters carriers
None of offspring of affected males have disorder
Gonadal mosaicism may occur

285
Q

What are examples of x linked inheritance?

A

Duchenne’s and beckers muscular dystrophy, fragile X syndrome, haemophilia, fabrines

286
Q

How does Duchenne’s present?

A 
motor milestones delayed
waddling gait
gowers sign
hypertrophy calf muscles
FTT
speech delay 
fatigue 
CK level high at first presentaion
287
Q

What is fragile X syndrome?

A

Most common form on inherited learning diability
Female carriers also have learning difficulties

Clinical features: learning difficulty, macrocephaly, long face, long and everted ears, broad forehead, mitral valve prolapse, scoliosis. Macro-orchidism

288
Q

What are the different kinds of non-mendelian inheritance?

A

multifactorial; mitochondrial; imprinting

289
Q

What is multifactorial inheritance and give an example?

A

Eg neural tube defect – failure of fusion of vertebrae

Combination genetic eg meckel gruber syndrome, with folic acid and maternal DM environmental factors

290
Q

What is a mitochondrial inheritance and give an example

A

Maternally inherited from cytoplasm of ovum and mitochondrial DNA

Eg MELAS (lactic acidosis, stroke like episodes), MERRF (myoclonic epilepsy, ragged red fibred on biopsy)

291
Q

What is imprinting and give some examples

A

For most genes both copies are expressed but with some genes only the maternal or paternal is expressed this is imprinting –> eg two copies of one parental chromsone and none of other OR a deletion mutation occurs

EXAMPLES: prader willi and angelmans

292
Q

Describe Prader Willi syndrome?

A 
Neonate hypotonia and poor feeding 
Learning diability 
Small geneitalia 
hypotonia
Later obese - as overeat (Hyperphagia)
293
Q

Describe Angelman’s syndrome?

A 
“happy puppet” - unprovoked laugh or cry 
Microcehally 
Seizures 
Learning disability 
Ataxia 
Broad based gait
294
Q

List all non-significant lesions of the newborn.

A

mongolian blue spot
milia
Neonatal urticaria (erythema toxicum) – a
common rash appearing at 2–3 days of age,
consisting of white pinpoint papules at the centre
of an erythematous base. The lesions are concentrated
on the trunk; they come and go at different sites
Capillary haemangioma or ‘stork bites’ – Flat red or pink patches on a baby’s eyelids, neck or forehead at birth and are vascular in cause
Strawberry naevus (cavernous haemangioma).

295
Q

List some derm abnormalities of the newborn that dont go away

A

Port-wine stain (naevus flammeus).

296
Q

How does psoriasis present?

A

Child presents with recurrent symptoms of dry, flaky, scaly, erythematous skin lesions, they are raised and rough patches over the extensor surfaces of the elbows and knees and on the scalp.
associated HLA-B13 and abnormal T cell activity stimulates keratinocyte proliferation.

297
Q

Describe pataus

A

Microcephalic, small eyes
Cleft lip/palate
Polydactyly (extra fingers)
Scalp lesions

298
Q

Describe edwards

A 
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingersThere are several ultrasound markers which are suggestive of Edwards syndrome and should prompt further investigation. These include:
Cardiac malformations
Choroid plexus cysts
Neural tube defects
Abnormal hand and feet position: clenched hands, rocker bottom feet and clubbed feet
Exomphalos
Growth restriction
Single umbilical artery
Polyhydramnios
Small placenta
299
Q

Describe noonans

A

Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis

300
Q

Describe malrotation

A

High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
Diagnosis is made by upper GI contrast study and USS
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a Ladd’s procedure is performed

paediatrics (8 decks)

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