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MSRA Content > Level 1 - Renal, Derm, MSK > Flashcards

Level 1 - Renal, Derm, MSK Flashcards

1
Q

What is enuresis?

A
  • Involuntary emptying of the bladder
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2
Q

Process of controlling passing urine?

A
  • Day-time control is achieved first and eventually gaining autonomic bladder control at night
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3
Q

What age should children be continent in the day?

A

o 3-5 years old

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4
Q

Define nocturnal enuresis?

A

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

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5
Q

What is secondary enuresis? What conditions commonly?

A

o Loss of previously achieved urinary continence may be due to:

 Emotional upset, UTI, Diabetes, chronic renal failure

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6
Q

Epidemiology of enuresis?

A
  • 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
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7
Q

What is daytime enuresis caused by?

A

 Lack of attention to bladder sensation

 Detrusor instability

 Bladder neck weakness

 Neuropathic bladder

 UTI/Constipation

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8
Q

What is nocturnal enuresis caused by?

A

o FHx

o Stress

o Organic causes:

 UTI, faecal retention, diabetes, chronic renal failure

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9
Q

Symptoms of enuresis?

A
  • Incontinence during night/day
  • Any changes in frequency/urgency
  • Assess voiding habits
  • Drinking excessive amounts (diabetes)
  • History of recurrent UTI
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10
Q

Investigations in enuresis and bedwetting?

A
  • Urine sample

o Glucose, protein, infection

  • USS may be used to see structural abnormalities
  • Urodynamic studies
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11
Q

General measures in preventing enuresis?

A

o Avoid caffeine-based drinks

o Toilet used regularly during day (4-7 times is typical)

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12
Q

Management of primary nocturnal enuresis? What behavioural techniques can be used? Medications?

A

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

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13
Q

Management of daytime enuresis?

A

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

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14
Q

Define bacteriuria?

A

o presence of bacteria in the urine. This may be symptomatic or asymptomatic.

Asymptomatic bacteriuria should be confirmed by two consecutive urine samples

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15
Q

Define UTI?

A

o presence of characteristic symptoms and significant bacteriuria from kidneys to bladder o >105 (cfu/ml)

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16
Q

Define lower UTI?

A
  • Lower UTI = infection of the bladder (cystitis)
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17
Q

Define upper UTI?

A
  • Upper UTI = infection of kidney and ureters
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18
Q

Epidemiology of UTI?

A
  • Females 3:1

Males having symptomatic UTI <6 years old

  • 40% have genitourinary anomalies
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19
Q

Risk factors for UTI?

A

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

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20
Q

Causative organisms of UTI?

A

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

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21
Q

Symptoms and signs of UTI in infants?

A

o Fever, vomiting, lethargy, poor feeding, jaundice, septicaemia, offensive urine

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22
Q

Symptoms and signs of UTI in children?

A

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
23
Q

Common investigations in UTI?

A
  • 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
24
Q

Other investigations to perform in chronic UTI?

A
  • 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

25
Q

Antibiotics given in UTI?

A

<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

26
Q

Preventative advice given in UTI?

A

o Treat and prevent constipation

o Hygiene: clean perineum front to back

o Avoid nylon underwear and bubble baths

o Include fluid intake

27
Q

Define recurrent UTI? If recurrent UTI, what management can be considered?

A

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

28
Q

Define atopic eczema? Disease pattern?

A
  • 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
29
Q

Epidemiology of eczema?

A
  • UK prevalence is 20%
  • Onset usually in first year of life
  • Uncommon before 2 months
  • 1/3 of kids have asthma
30
Q

Risk factors for eczema?

A
  • Genetic susceptibility – Family history
  • Impaired epidermal barrier function
  • Immune dysregulation
  • Allergen (food and airborne) sensitization and infection
31
Q

Causes of acute exacerbation of eczema?

A
  • 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
32
Q

Symptoms and signs of eczema? Where does infant and childhood eczema affect?

A

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
33
Q

DDx of eczema?

A

1) Psoriasis
2) Contact dermatitis
3) Seborrheic dermatitis
4) Fungal infections
5) Infestations

34
Q

Investigations in eczema?

A
  • Diagnosis is made clinically
  • Elevated IgE levels
  • Skin-prick tests to specific allergens
35
Q

General management in eczema?

A

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
36
Q

Management of mild eczema?

A
  • 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

37
Q

Management of moderate eczema?

A
  • 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

38
Q

Management of severe eczema?

A
  • 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

39
Q

Preventative management in severe eczema?

A
  • 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

40
Q

Prognosis of eczema?

A
  • Usually gets better with time.

However, not all children will grow out of it, and it may get worse in teenage or adult life.

41
Q

Complications of eczema?

A
  • 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
42
Q

Definition of septic arthritis? Spread?

A
  • 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
43
Q

Epidemiology of septic arthritis?

A
  • 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
44
Q

Risk factors of septic arthritis?

A

o Increasing age, diabetes, joint damage (RA, SLE, gout), Joint prosthesis, skin infection, HIV, haemophilia

45
Q

Causative agents in septic arthritis?

A

o Staphylococcus aureus, Hib (unimmunised), group A strep (pyogenes), N gonorrhoea (sexually active)

46
Q

Symptoms of septic arthritis?

A

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

47
Q

Signs of septic arthritis?

A

o Reduced range of movement

o Pain on passive and active movement

48
Q

DDx of septic arthritis?

A
  • RA, OA, gout
  • Reactive arthritis, osteomyelitis
  • Transient synovitis
  • Cellulitis
  • Lyme Disease
49
Q

Investigations needed in septic arthritis?

A
  • 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)

50
Q

Medical management of septic arthritis?

A

o IV Abx (flucloxacillin/clindamycin), after aspirate taken, for 2-3 weeks and then oral Abx

51
Q

Surgical management of septic arthritis?

A

o Orthopaedics – irrigation and debridement of affected joint (+drainage)

52
Q

Physio in septic arthritis?

A

o Immobilise joint reduces pain and inflammation o Physiotherapy to avoid joint stiffness

53
Q

Complications of septic arthritis?

A
  • Chondrolysis, joint stiffness, avascular necrosis, bone destruction (osteomyelitis)

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