Level 1 - Renal, Derm, MSK Flashcards
What is enuresis?
- Involuntary emptying of the bladder
Process of controlling passing urine?
- Day-time control is achieved first and eventually gaining autonomic bladder control at night
What age should children be continent in the day?
o 3-5 years old
Define nocturnal enuresis?
o Defined as continued wetting >5 years in girls and >6 years in boys
o Bedwetting >2 nights/week
o Genetically determined delay in acquiring sphincter competence
What is secondary enuresis? What conditions commonly?
o Loss of previously achieved urinary continence may be due to:
Emotional upset, UTI, Diabetes, chronic renal failure
Epidemiology of enuresis?
- Bedwetting in around 15% of 5-year olds and 5% of 10 year olds
- Boys 2:1 Girls
- Girls are earlier to achieve bladder control
What is daytime enuresis caused by?
Lack of attention to bladder sensation
Detrusor instability
Bladder neck weakness
Neuropathic bladder
UTI/Constipation
What is nocturnal enuresis caused by?
o FHx
o Stress
o Organic causes:
UTI, faecal retention, diabetes, chronic renal failure
Symptoms of enuresis?
- Incontinence during night/day
- Any changes in frequency/urgency
- Assess voiding habits
- Drinking excessive amounts (diabetes)
- History of recurrent UTI
Investigations in enuresis and bedwetting?
- Urine sample
o Glucose, protein, infection
- USS may be used to see structural abnormalities
- Urodynamic studies
General measures in preventing enuresis?
o Avoid caffeine-based drinks
o Toilet used regularly during day (4-7 times is typical)
Management of primary nocturnal enuresis? What behavioural techniques can be used? Medications?
o Explanation
Explain that common problem and beyond conscious control
Stop punishing children for it
o Star Chart
Child earns praise and a star each morning if bed is dry
o Enuresis Alarm (over 5)
Alarm placed in childs pants which sounds an alarm when it becomes wet
Child must wake, go to the toilet, returns and helps to make up bed
Takes several weeks to work but effective with perserverance
o Desmopressin (7 or over)
Short-term relief (e.g. sleepovers or holidays)
Synthetic ADH
o Self-help groups for advice from other parents
Management of daytime enuresis?
o Enuresis alarms (over 5)
o Desmopressin (7 or over)
Short-term relief (e.g. sleepovers or holidays)
Synthetic ADH
o Anticholinergic drugs (oxybutynin) dampen down bladder contractions
Define bacteriuria?
o presence of bacteria in the urine. This may be symptomatic or asymptomatic.
Asymptomatic bacteriuria should be confirmed by two consecutive urine samples
Define UTI?
o presence of characteristic symptoms and significant bacteriuria from kidneys to bladder o >105 (cfu/ml)
Define lower UTI?
- Lower UTI = infection of the bladder (cystitis)
Define upper UTI?
- Upper UTI = infection of kidney and ureters
Epidemiology of UTI?
- Females 3:1
Males having symptomatic UTI <6 years old
- 40% have genitourinary anomalies
Risk factors for UTI?
o Age <1
o Female
o Previous UTI
o Recent instrumentation of renal tract
o Abnormality of renal tract
o Antibiotic use
o Sexual Activity
o New sexual partner
o Pregnancy
o Immunocompromised
Causative organisms of UTI?
o E. coli in 90% of cases
o Proteus mirabilis (present under prepuce in boys)
o Staphylococcus saprophyticus (adolescent boys/girls)
o Pseudomonas, Serratia, Citrobacter (may indicate structural damage in urinary tract)
o Klebsiella
o Enterococcus
Symptoms and signs of UTI in infants?
o Fever, vomiting, lethargy, poor feeding, jaundice, septicaemia, offensive urine
Symptoms and signs of UTI in children?
Infants <3 months suspect in lethargy, irritability, poor feeding and FTT >3 months:
o Urine
Dysuria and frequency, haematuria, offensive cloudy urine
o Other symptoms
Abdominal pain/loin tenderness, fever and rigors, lethargy, anorexia, vomiting/diarrhoea
- Symptoms suggestive of a UTI may occur following sexual abuse
Common investigations in UTI?
- All infants with unexplained fever
- ABCDE and urine M, C&S
- Urine samples obtained either by ‘clean-catch’, adhesive plastic bag, urethral catheter
- In older children, use MSU
- Urine dipstick o Leukocytes and nitrites
- Urine microscopy and culture always in children <3 years old, if dipstick positive then send culture if >3 years
Other investigations to perform in chronic UTI?
- USS
o May rule out abnormal structures or obstruction
o Used if <6 months with UTI or >6m and recurrent UTIs
- DMSA scans for renal scarring
o All children with recurrent UTI
- Micturating cystourethrography
o Best way to exclude reflux
Antibiotics given in UTI?
<3 months
Refer immediately to paediatric specialist for urine analysis and parenteral antibiotics (IV cefotaxime)
>3 months with uncomplicated lower UTI
3-day course of trimethoprim PO, nitrofurantoin or amoxicillin/co-amoxiclav o >3 months with pyelonephritis or upper UTI
Consider referral to paediatric specialist
Oral ciprofloxacin/co-amoxiclav for 7-10 days
Alternatively, ceftriaxone IV for 2-4 days and then oral for total duration of 10 days Advise to come back if still unwell after 24-48 hours
Preventative advice given in UTI?
o Treat and prevent constipation
o Hygiene: clean perineum front to back
o Avoid nylon underwear and bubble baths
o Include fluid intake
Define recurrent UTI? If recurrent UTI, what management can be considered?
2 or more UTI with acute pyelonephritis/upper UTI 1 episode of UTI with acute pyelonephritis/upper UTI PLUS one or more UTI 3 or more UTIs
- Non-urgent referral
- Consider prophylactic Abx if recurrent UTIs or VUR:
o Trimethoprim at night= prophylactic
Define atopic eczema? Disease pattern?
- Atopic eczema (also known as atopic dermatitis) is a chronic, itchy, inflammatory skin condition that affects people of all ages
- Typically an episodic disease of flares and remissions; in severe cases, disease activity may be continuous
- A genetic deficiency of skin barrier function important in pathogenesis
- Usually resolves by the end of childhood
Epidemiology of eczema?
- UK prevalence is 20%
- Onset usually in first year of life
- Uncommon before 2 months
- 1/3 of kids have asthma
Risk factors for eczema?
- Genetic susceptibility – Family history
- Impaired epidermal barrier function
- Immune dysregulation
- Allergen (food and airborne) sensitization and infection
Causes of acute exacerbation of eczema?
- Bacterial infection e.g. staph aureus (MC), strep
- Viral infection e.g. HSV
- Ingestion of an allergen e.g. egg
- Contact with an irritant or allergen
- Environment: heat, humidity
- Psychological stress
Symptoms and signs of eczema? Where does infant and childhood eczema affect?
Acute eczema may be erythematous and weeping
- Chronic eczema may be lichenified and dry
- Eczema is itchy – itch, scratch cycle
- Often secondary changes of excoriation (skin loss due to scratching), post-inflammatory hypo/hyper-pigmentation and infection
- Infant eczema often affects cheeks, elbows, and knees with crawling
- Childhood eczema is often in flexures, but may also affect head and neck, nipples, palms and soles
DDx of eczema?
1) Psoriasis
2) Contact dermatitis
3) Seborrheic dermatitis
4) Fungal infections
5) Infestations
Investigations in eczema?
- Diagnosis is made clinically
- Elevated IgE levels
- Skin-prick tests to specific allergens
General management in eczema?
Assessment using severity tool
- Classified clear, mild, moderate, severe and infected General measures:
1) Soap avoidance
2) Limit showers/baths to 5-10mins in luke-warm water.
3) Moisturise immediately after bathing.
4) Wear loose fitting cotton undergarments.
5) Avoid over-heating.
6) Keep finger nails short
Management of mild eczema?
- Emollients applied liberally
- Mild topical corticosteroid (such as hydrocortisone 1%)
o Applied twice daily, applied thinly, avoid face use
o Excessive use can thin skin
Management of moderate eczema?
- Emollients applied liberally
- Moderately potent topical corticosteroid (for example betamethasone valerate 0.025% or clobetasone butyrate 0.05%)
- For delicate areas of skin (such as the face and flexures), consider starting with a mild potency topical corticosteroid (such as hydrocortisone 1%)
- Antihistamine for itch (cirtirizine)
Occlusive bandages useful Antibiotics useful for infected eczema
Management of severe eczema?
- Emollients applied liberally
- Potent topical corticosteroid (for example betamethasone valerate 0.1%)
- Antihistamine for itch
- If very severe and distressing, short course of an oral corticosteroid (refer children under 16 years of age)
Occlusive bandages useful Antibiotics useful for infected eczema
Preventative management in severe eczema?
- Maintenance regimen of topical corticosteroids
- Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are a second-line option.
However, they should only be prescribed by a specialist
Prognosis of eczema?
- Usually gets better with time.
However, not all children will grow out of it, and it may get worse in teenage or adult life.
Complications of eczema?
- Sleep disturbance
- Emotional upset
- Infection of atopic eczema MC due to Staph aureus
redness, fluid ooze, high temp (but no pain)
- Eczema herpeticum (caused by HSV (HSV also cold sores)
painful, fluid-filled blisters, high temp
- Growth delay
- Atopic cataracts
Definition of septic arthritis? Spread?
- Infection of a joint
- Spread haematogenous, puncture wound, infected skin lesion
- In young children, may spread from adjacent osteomyelitis where capsule inserts below epiphyseal growth plate
Epidemiology of septic arthritis?
- Most common in children <2 years
- Staphylococcus aureus is the most frequent pathogen responsible for septic arthritis
- 2/3 hip and knee joints
- Knees>hips>ankles
Risk factors of septic arthritis?
o Increasing age, diabetes, joint damage (RA, SLE, gout), Joint prosthesis, skin infection, HIV, haemophilia
Causative agents in septic arthritis?
o Staphylococcus aureus, Hib (unimmunised), group A strep (pyogenes), N gonorrhoea (sexually active)
Symptoms of septic arthritis?
o Erythematous, warm, swollen, acutely tender joint
o Infants often hold limb and cry when moved
o May present with limp/inability to weight bear
o Systemic illness, fever, rigors
Signs of septic arthritis?
o Reduced range of movement
o Pain on passive and active movement
DDx of septic arthritis?
- RA, OA, gout
- Reactive arthritis, osteomyelitis
- Transient synovitis
- Cellulitis
- Lyme Disease
Investigations needed in septic arthritis?
- Bloods
o FBC (increased WCC, CRP, ESR)
o Cultures
o Lyme titres if exposed
- Imaging
o USS, X-ray to exclude trauma (wider joint space), MRI
- Joint Aspiration
o Aspiration under USS for organism and cultures (diagnostic)
Medical management of septic arthritis?
o IV Abx (flucloxacillin/clindamycin), after aspirate taken, for 2-3 weeks and then oral Abx
Surgical management of septic arthritis?
o Orthopaedics – irrigation and debridement of affected joint (+drainage)
Physio in septic arthritis?
o Immobilise joint reduces pain and inflammation o Physiotherapy to avoid joint stiffness
Complications of septic arthritis?
- Chondrolysis, joint stiffness, avascular necrosis, bone destruction (osteomyelitis)
