Neurology, Renal, Dermatology Flashcards
1
Q
Cerebral Palsy Definition
A
Non-progressive insult to the brain between Conception-3 years
2
Q
Classification of Cerebral Palsy
A
Spastic- Hypertonia and abnormal reflexes (+/-Dyskinetic- Abnormal involuntary movement)
Ataxic- Loss of coordination and balance (Abnormal force, Rhythm and accuracy)
Athetoid- Jerky limbs, Hyperkinesia
OR… MIXED
3
Q
Distribution pattern of Cerebral Palsy symptoms
A
Paraplegia- Both lower limbs Hemiplegia- One sided Diplegia- Corresponding parts of the body on both sides Quadriplegia- All 4 limbs Monoplegia- One limb
4
Q
Circumduction gait vs Scissoring gait in Cerebral Palsy
A
Circumduction gait occurs in Hemiplegia
Scissoring gait occurs in Diplegia
5
Q
Aetiology of Cerebral Palsy
A
80% because of in utero insult (TORCHES, Chr, Leukomalacia, IVH etc)
Perinatal- Birthy Asphyxia
Post-delivery- Brain injury, Meningitis etc
2/3rds unknown
6
Q
Key Features of Cerebral Palsy
A
Movement and posture abnormalities
Delayed motor milestones- Sitting (>8/12), Walking (<18/12), Early asymmetry of hand preference (<1 yr)
Early on= Fidgety/Hypotonia/Stiff/Dystonia/Late head control
7
Q
Associated features of Cerebral Palsy
A
Learning Disability IQ<70 Epilepsy Comm difficulties Behavioural difficulties E.G. ADHD Visual and Hearing impairment Constipation/Vomiting/GORD/Incontinence/Recurrent UTIs Pain and sleep disturbance FTT B/C eating problems
8
Q
MDT approach to managing Cerebral Palsy
A
Developmental Assessment Anticonvulsants Anti-spasticity drugs Ortho/surgical involvement ?Dorsal Rhizotomy Physio/Occupational Therapist Speech and Language therapist Education= Special Needs Teaching
9
Q
Complications of Cerebral Palsy
A
Contractures Feeding difficulties... Malnutrition Drooling, Dressing problems, sleep problems Scoliosis, Hip dislocation Epilepsy Recurrent Resp infections
10
Q
Epidemiology of Febrile Fit
A
6 months to 6 years
Commonest seizure disorder of childhood
Potentiated by a rapid increase in temperature induced by a likely viral infection
11
Q
Presentation of a Simple Febrile Fit
A
< 15 mins Fever >38 Generalised Seizure- Tonic-Clonic- STIFF THEN SHAKE Complete recovery within 1 hr No recurrence within 24 hours
12
Q
Presentation of Complex Febrile Fit
A
15-30 minutes (+ Fever)
Focal or Aura
+/- Repeated seizures within 24 hours
Not always rousable for >1 hour after
13
Q
Febrile Status Epilepticus
A
Febrile seizure lasting >30 minutes
NOTE YOU TREAT IT AFTER 5 MINUTES
14
Q
Managing Febrile Fits
A
A to E Assessment
Admit for 6 hour monitoring if 1st episode
Rule out meningitis
> 5 mins= IV Lorazepam 0.1mg/kg
(Alt= Buccal Midazolam/Rectal Diazepam 0.5 mg/kg)
15
Q
Advice to parents for a child with febrile fits
A
Reassure
During another fit- Time, Do not restrain
> 5 mins= Ambulance <5 mins= GP appointment
Antipyretics won’t prevent but can give if child is unwell
Keep Hydrated
16
Q
Prognosis and Epilepsy risk in febrile fits
A
30% Recurrence risk during another febrile episode
Epilepsy risk 1-2/100 in general population, Febrile fit increases it to 1/50
Elevated risk if (1/20):
1- Neuro abnormalities/Developmental delay
2- FHx of Epilepsy
3- Complex febrile seizure
17
Q
Concerning recovery time after a febrile fit
A
> 30 minutes
18
Q
Blue Breath Holding attacks
A
Cries- Goes silent- Breath held on expiration- Cannot inhale- Blue & LoC for < 1 min- Collapses- Floppy or stiff
+/- Post-ictal tiredness
6 months- 6 years
Provoked by temper/frustration
19
Q
Explaining Blue Breath Holding Attacks to parents
A
Involuntary, not dangerous, no brain damage
Not a sign of poor parenting
Improves with age
Can use a pacemaker if very severe
20
Q
Reflex Anoxic Seizures
A
6 months to 3 years
Pain or fear induces transient involuntary bradycardia
Opens mouth, pale, LoC, +/- Tonic-Clonic seizure
Likely to grow out of it
21
Q
Action to take after a Breath Holding Attack or Reflex Anoxic Seizure
A
Take them to the GP- ECG, Bloods
Stay calm, if happens again lie them on their side, don;t make a fuss
If severity or frequency is increasing or stiffness/shaking >1 min then take back to GP
22
Q
Key Diangostic Criteria for Breath Holding Attacks/Reflec Anoxic Seizure
A
Onset with crying or breath holding
No post-ictal phase only some minor tiredness
No associated behavioural problems
Quick Recovery
23
Q
Key investigations to do after a seizure
A
BP. BM, ECG, Urine toxicology
Vital signs
24
Q
Generalised Tonic-Clonic Epilepsy Symptoms
A
Tonic phase- Sudden LoC, Extend limbs, Back arhces, Teeth Clench, Breathing stops, Bitten tongue, eyes roll back
Clonic phase- Intermittent jerking,Irregular breathing +/- Urination and salivation
~15 mins post-ictal drowsiness/tiredness
25
Absence Seizures
Fleeting 5-20s impairment of consciousness
/Daydreaming/Staring
4-8 years
10-15 times a day with a quick recovery and no involuntary movement
EEG shows 3 per second spike and wave
26
Treatment for absence seizures
Sodium Valproate or Ethosuximide
NOT CBZ
27
Infantile Spasms/West's syndrome presentation
4-6 months
Generalised myoclonic seizure- Symmetrical flexion spasms then arms extend
Lasts seconds in clusters
Hypsarrhythmia on EEG
28
Prognosis of West's syndrome
Poor
| Associated with developmental delay and brain disease
29
Treatment of West's syndrome
Steroids and Vigabatrin
30
Actions following 1st seizure in ? Epilepsy
EEG +/- MRI
Then start antiepileptics following 2nd seizure
31
Management of Epilepsy
Only start after 2nd seizure
```
Generalised= Sodium Valproate (?Lamotrigine)
Partia= CBZ then Valproate
```
Advice: Don't lock bathrooms, helmet when on bike, tell lifeguards, 1 yr free before driving
32
Managing an Acute Seizure/Status Epilepticus
Recovery position
Oxygen and suction (Remember to check glucose)
1) MAX 2 BZD doses= Iv Loraz 0.1mg/kg or Buccal mid 0.5mg/kg
2) Phenytoin (takes 15 mins to prepare) or phenobarbital
3) RSI- Thipentone from anaesthetist + Observation
33
Complex Partial Epilepsy
```
Impaired consciousness
Usually Isolated unilateral jerking
Strange sensations
Chewing/Sucking
Post-ictal phase
```
34
Myoclonic epilepsy
Shock like jerks that cause sudden falls can be early morning
More common if known neurological disability
Increased by alcohol and sleep deprivation
35
Causes of syncope in children
Vasovagal
Long QT syndrome
Daydreamng, self gratification
Dissociative seizures in Teenagers (PSYCH)
36
Headache red flags
```
Worse on lying
Systemic symptoms- Vomiting, HTN, Papilloedema
Focal neurology- Visual, Motor
Increased head circumference
Developmental regression
Personality change
Photo/Phonophobia
```
37
Diagnostic criteria for tension headache
10+ episodes
No N&V and No Photophobia/Phonophobia
Lasts 30 mins- 7 days
Band like non-pulsating bilateral pain
38
Number one cause of primary headache in children
Migraine without aura
39
Diagnostic criteria for migraine without aura
>/= 5 attacks lasting 2-72 hours
2 of: Inhibits activity/Throbbing/Worsened by activity
1 of: N+V/Photophobia/Phonophobia
40
Management of migraine without aura
1) NSAIDS
2) Nasal Triptans if >12
3) Propanolol or Pizotifen
41
Diagnostic criteria for migraine with aura
2 attacks with at least 3 of:
Headache onset <60mins post aura
One or more fully reversible aura symptoms
>1 aura symptom develops over >4 mins
42
Examples of aura symptoms
Changes in the following domains:
| Visual/Motor/Sensory/Speech/Language/Cognitive impairment/LoC/Vertigo/Ophthalmoparesis
43
What features would make a headache likely secondary to raised ICP
```
Worse on morning and lying
Vomiting
Papilloedema
Focal Neurology- Weakness, visual, motor
Cushing's reflex- HTN and low HR/RR
```
44
Analgesia headache
High NSAIDs use in teenagers
45
Important history points when a child presents with head injury
Event details
Condition Before vs After (crying? LoC? Vomiting? Dizzy? Headache?)
History of fits? Bleeding disorder? Diabetic?
46
Indications for an immediate CT following head injury
```
LoC or Amnesia lasting > 5 mins
> 2 discrete episodes of vomiting
Post-traumatic seizure with no Hx of epilepsy
Abnormally drowsy
GCS<14
? Open or depressed Skull injury
Basal skull fracture- Otto/Rhinorrhoea, Panda eyes, Battle's
Focal neurology
Dangerous mechanism
Swelling/Bruising > 5cm if < 1 yr
```
47
What cases of head injury would you admit for observation?
Continuing signs and symptoms
Skull fracture
Serious trauma as indicated by mechanism
48
Advice for parents if discharging a child with head injury
Supervision
Rest, Avoid computer games, Plenty of fluids, Avoid noise/stress, pain relief
Safety netting: Headache worsens, vomiting, seizures, Alertness decreases, Visual changes, Walking changes, Weakness
49
Causes of obstructive hydrocephalus
Aqueduct stenosis
Posterior fossa tumour
Other tumours
50
Causes of Non-obstructive hydrocephalus
Meningitis
SAH
IVH
51
Diagnosis of hydrocephalus
CT/MRI
LP may be done for diagnostic and therapeutic purposes only in non-obstructive causes
52
Presentation of hydrocephalus
Older children= Headache, N&V, Papilloedema
Babies= Developmental delay, increased head circumference especially if sutures haven't fused
Macrocephaly and bulging fontanelle
Sunsetting of the eyes
53
Management of hydrocephalus
Neurosurgical referral
54
Food/Drinks to avoid in migraine
Cheese, Chocolate, Citrus Fruit, Nuts, Caffeine
55
Plaigocephaly
Flat spot on the top or side of the head
Caused by remaining supine for too long or a lack of amniotic fluid in the womb
No impact on the brain!
56
Management of Plaigocephaly
Tummy time and sleep pattern change
Alter positioning of the toys
Alleviate head pressure when in car seat etc
Majority improve as child grows because they adopt a more upright position
57
What increases tics?
What are risk factors?
Stress
Excitement
Boredom
Tiredness
Smoking, FHx and being male increases risk
58
What decreases tics?
Concentration, Exercise, Distraction, Sleep
59
Tourette's syndrome diagnosis
Both motor and 1+ vocal tics
Many times a day, Most days, >1 year
No 3 month tic free period
Isolated Vocal or Motor tics is NOT Tourette's but a chronic (>1 year) tic disorder, can also be transient (<1 year)
60
Management of Tics/Tourette's
Do not punish child for tics and do not try to stop them doing it
Try to ignore the tics and just reassure the child
Try to educate other children at school etc
Screen for co-morbid mental health problems
If they interfere with functioning then ?Baclofen/Anti-epileptics/Alpha Adrenergic Agonists
61
Genetics of muscular dystrophy
X-linked recessive disorder
Deletion of dystrophin gene leads to myofibre necrosis
DMD worse than BMD
62
DMD vs BMD
DMD onset ~5 years and loss of ambulation by 10-14 yrs, LE early 20s
BMD onset ~11 years and loss of ambulation by late 20s, LE middle/old age
63
Presentation of DMD/BMD
```
Gower's sign- turn prone to rise then crawl up own legs with arms
Difficulty walking
Clumsy
Waddling gait
Toe walking
Incontinence
Delayed motor milestones
Enlarged calves because of fatty infiltration
Intellectual disability (30%)
```
64
Key blood test that could indicate DMD/BMD
Raised CK
| Especially if done in boys not walking by 18/12
65
Management of DMD/BDM
```
Ventilator support in DMD by ~25 years
Overnight CPAP or NI-PAP to alleviate nocturnal hypoxia
Physiotherapy
Surgery
Corticosteroids if ambulant?
```
66
Different forms of Spina Bifida
Myelomeningocele (Most common)
Spina Bifida Occulta
Meningocele
67
Myelomeningocele
Spinal cord and meninges exposed - Most severe and most common form
Visible overlying sac
68
Spina Bifida Occulta
```
Minor defects in lumbar vertebrae
No visible overlying sac
Naevus/Lipoma/Hair at location
Bone fails to develop over spinal cord but skin does
Can be clinically insignificant
```
69
Presentation of spina bifida
```
Swelling over the spine at any level
Exposed spinal cord
Paralysis below lesion
Sudden death
HYDROCEPHALUS- Rapid head growth and bulging fontanelle
Urinary and faecal Incontinence
```
70
What maternal test can detect most spina bifida
Maternal serum alpha-fetoproteins
71
Managment of spina bifida
Surgery- High risk
Conservative- Poor life expectancy
5mg folic acid up to 12 weeks in future pregnancies
72
Classifications of Enuresis
Primary- Nocturnal or Diurnal
Secondary (Previously been dry for 6/12)
73
When do children reach day/night continence?
| When should you refer/intervene?
3/4 years= majority
| 5+ then refer ?Intervene
74
Causes of primary enuresis
```
Decreased bladder awareness
Stress
UTI/DM/Renal pathology
Decreased ADH production
Psych problems
```
75
Investigations for enuresis
DM- random and fasting blood glucose
Urinalysis if symptoms or recent onset
GU tract screening?
76
Management of enuresis
5-7 years= Advice + Alarm
- No drinking 90 mins before bed, avoid caffeine/fizzy drinks, treat constipation
- Reinforcing behaviour chart (dont punish)
- Alarm sounds when wet but takes weeks-months
7+
Desmopressin- Lasts 8 hours, short term assess 4/52 and continue 3/12
77
Causes of UTI
Infection (90% E.Coli)
Obstruction, VUR, Poor habits, Constipation, Neuropathic bladder
78
Vesico-ureteric reflex
Ureters at a perpendicular angle to bladder
Increased UTI risk
Hydronephrosis
MCUS to Dx
79
Methods of collecting urine in UTI
Clean catch if possible
| Catching bag, sterile pad, catheter, suprapubic stab
80
Interpretation of urinalysis in ?UTI
+ve leuko and +ve nitrates= likely UTI
If one +ve and one -ve then send off for culture and treat as a UTI
-ve nitrates make UTI less likely but does not rule it out
81
MC&S in UTI
Microscopy, culture and sensitivity
| 10^5 colony forming units/ml of single organism
82
Definition of recurrent UTIs
>/= 2 + symptoms
>/=3 + No symptoms
83
Guidelines on imaging in UTI
< 6 months= Always do USS (Usually 6 weeks after)
<6 months + atypical= USS, DMSA, MCUS
> 3 yrs= USS if atypical
<3 years >6 months= DMSA/USS if atypical
84
DMSA
Dimercapto Succinic Acid
| IV Isotope injected and taken up by kidneys to assess renal scarring
85
MCUS
Micturating cysto-urethrography
Contrast dye injected through catheter
Assesses whether it refluxes e.g VUR
86
Features in a UTI which would suggest atypical and require imaging
Frequent UTIs
Nil response to treatment within 46 hours
Non-E.coli (Psuedomonas= ?Tract abnormality)
Poor flow, Mass, Deranged U&Es
Systemically unwell
87
UTI history in an infant
Non-specific
```
Fever, fits, septic
Irritable
Lethargic
Vomiting
Poor feeding
FTT
+/- Jaundice
```
88
Management of UTI in <3 months
Admission
| IV Cefotaxime or Gent
89
Management of Pyelonephritis
Admit
| IV Cefuroxime 2-4/7 then 10/7 oral abx like Co-Amox
90
Management of UTI without prophylaxis
3 days oral Trime/Nitro/Ceph/Amox
Good hygiene
Fluids
Prompt toileting
91
VUR management
Prophylactic Abx
| Surgical correction
92
Causes of Hamaturia
```
Post-strep Glomerulonephritis
Polycystic Kidneys
Renal stone
Renal tumour
UTI
Sickle cell disease
HSP
Rifampicin
```
93
Investigating haematuria
Urine MC+S
Bloods
Urinalysis of parents to ?Hereditary cause
US tract
No resolution in 6/12 then referral to nephrology
94
Haematuria in the presence of what would indicate a likely more serious cause?
Proteinuria
| Impaired function
95
HUS triad
Microangiopathic Haemolytic anaemia (LOW HB)
Acute kidney Failure (Uraemia)
Thrombocytopenia (LOW PLATELETS)
96
HUS causes
```
Post-dysentry (E.COLI 0157 or Shigella)
Pregnancy
Tumours
HIV
Lupus
Chemotherapy/Ciclosporin
```
97
FBC in HUS
Anaemia
Thrombocytopenia
Fragmented blood film
98
Investigations in HUS
FBC, U&Es, Stool culture
99
HUS presenting symptoms
Bloody diarrhoea
Abdo pain and N&V
No fever
Painless rash
100
How do you safety net bloody diarrhoea for HUS?
Check for painless rash and oliguria
101
Management of HUS
Fluids, Blood transfusion, ?Dialysis
Monitor electrolytres
No role for Abx
Plasma exchange?
102
Complications of HUS
Encephalopathy
| Renal failure
103
Diagnostic features of Nephrotic syndrome
Proteinuria >1g/m^2 per 24 hours
Hypoalbuminaemia <25g/l
Oedema
THINK PROTEIN LOSS AND OEDEMA
104
Most common cause of Nephrotic syndrome
Minimal change glomerulonephritis
105
Presentation of Nephrotic syndrome
2-5 years old
```
Puffy face and limb oedema
Ascites and pleural effusion as hypoalbuminaemia
Frothy urine
Look unwell
Recent UTI or UTI symptoms
```
106
Investigations and results in Nephrotic syndrome
Urine dip- Albumin +ve, Protein +ve, Hyaline Casts and NO BLOOD
FBC/U&Es- Albumin <25g/L, Inc cholesterol and triglycerides
107
Management of Nephrotic syndrome
```
Admit
6 weeks corticosteroids (high dose)
Low sodium diet
Fluid restrict
Diuretics
Prophylactic penicillin until proteinuria cleared
```
108
Fluids in Nephrotic syndrome
RESTRICT
| Give diuretics to remove!`
109
NAPHROTIC Mnemonic in nephrotic syndrome
```
Na- LOW
Albumin- Low
Proteinuria >3.5g/day
Hyperlipidaemia/HTN
Renal vein thrombosis
Orbital oedema
Thromboembolism
Infection B/c Ig loss
Coagulability B/c Antithrombin 3 loss
```
110
3 key features of Nepritic syndrome
Haematuria
Oliguria
HTN
111
Key presenting features of Glomerulonephritis
Haematuria- 1-2/52 Post-throat infection
or 3-6/52 post-skin infection
Malaise, Oedema, Loin pain, Headache
Oliguria
112
Glomerulonephritis on urinalysis
Gross haematuria
Granular and red cell casts
Often proteinuria
113
Management of glomerulonephritis
Admission for fluid balance
Treat hyperkalaemia, acidosis and HTN
10 days penicillin
114
Features of Hypospadias
```
Ventral urethral meatus
Bend in penis
Foreskin doesn't wrap all the way around therefore only the top half is covered
Inc UTI risk and sexual dysfunction
Difficult to urinate when standing
```
115
Management of hypospadias
Surgery < 2 years old
| Essential that they aren't circumcised before this procedure as foreskin is used in reconstruction
116
Vulvovaginitis features
Most common between 3-10 years
irritated by heat and humidity
Itching, redness, soreness, yellow/green discharge +/- offensive
117
Cause of vulvovaginitis
Bacteria from Gut/Bowel/Nose/Mouth get into VV area
118
Management of vulvovaginitis
Wash in bath- no shampoo, soap, sanitary wear etc
Wipe front to back
Non-soap cleanser
No spermicidally lubricated condoms
+/- Emollients +/- Topical antihistamine
+/- Low dose corticosteroids
119
What precipitates eczema flare ups
```
Dry skin
Irrritants
Infection
Sweating
Heat
Emotional stress
Allergies
```
120
Different location of eczema rash by age
Infants- Cheeks, Trunk
Childhood- Flexural, wrists, ankle
Adolescents- Flexural, H&N, Nipples, Palms/Soles
121
Describe the rash in eczema
Intensely itchy, red, dry, scaly and thick
Can weep if infected
122
Common causes of secondary infection in eczema
Staph
| Herpes Zoster
123
Emollient and steroid advice regarding use in eczema
```
Emolient: Steroid= 10:1
Apply emollient 30mins before steroid
Oil based emolients better for dry areas; water based better for wet
"Apply until they shine"
Must apply emollients after bathing
Use spoon if in tub
```
124
General advice in eczema
Avoid soaps
Wet wraps can reduce scratching
Keep nails short
Sedative antihistamine use if >2 years to help with sleep
125
Steroid ladder
Hydrocortisone
Betamethasone 0.025% -> 0.1%
Clobetasol propionate 0.1% is potent <50g week
126
Advice on steroid use in eczema
Indicated in severe cases of eczema
1 finger tip= 2X palmar aspect of hand
Symptom improvement in 3-6 days
Keep use short term <3 months
127
Side effects of topical steroids in eczema
Skin thinning, Depigmentation, Striae, Dermatitis, Acne, Telangectasia
Adrenal suppression, Cushing's, decreased growth!
128
Eczema herpeticum
Herpes on top of eczema
Sequela: Blindness and Encephalitis
Give IV Aciclovir +/- Flucloxicillin
129
Impetigo classification
Bullous (Staph)
Non-bullous
130
Causes and pathophysiology of impetigo
Highly contagious bacterial skin infection
Spread via direct contact with discharges from scabs
Increased risk if underlying skin condition
131
Presentation of impetigo
Facial areas mainly
Sticky, honey coloured crusts
+/- Lympthadenopathy +/- Fever
132
Management of impetigo
Exclusion until healed over/scabbed or Abx 48 hours
PO Macrolide like erythromycin (penicillin also good)
IF MRSA THEN MUPIROCIN
Bathe in cetrimide and fusidic acid cream
Don't share towels and reduce face touching
133
Staphylococcal scaled skin syndrome
Life threatening
tender Bullae that rupture easy and scale (Nikolsky +ve)
Accompanying erythema unlike in Bullous impetigo
134
Different causes of nappy rash
Ammoniacal (Most common)
Candida
psoriatic
Seborrhoeic
135
Differentiating between the different causes of nappy rash
Ammoniacal will spare skin folds
Candida is bright red and clearly demarcated with satellite lesions beyond border and worse in flexures
Seborrhoeic will have pink greasy lesions with a yellow scale
136
Treating nappy rash
Ammoniacal- Wash and change regularly, expose to air, sudocrem to stop secondary infection
Candida- Topical imidazole
Seborrhoeic- Mild topical corticosteroids, Baby shampoo and oil will spont resolve in 8/12
137
Presentation of SJS
Flu like symptoms progress to painful purple rash that spreads and blisters
Nikolsky's sign positive- sloughing upon pressure
Target lesions
Blistering mucosae- eyes, oral, Genital (Polymorphic erythema)
138
Erythema Nodosum
Inflammation of the subcutaneous fat
Tender erythematous nodular lesions >0.5cm usually on the skin of shins resolving over 3-6 weeks
Nodules are red
Accompanying GI, Occular or limb involvement
139
Pathophysiology of scabies
Sarcoptes Scabei burrows into skin and lays eggs in stratus corneum
Delayed T4 HSN reaction ~30 days post-infection leading to pruritis
140
Presentation of scabies
```
Itchy papular rash with visible linear burrows
Excoriations
Eczematisation
Infection
Urticaria
Impetigo
```
141
Treatment of scabies
Treat whole household
Permethrin cream 5% 12 hour topic application all areas
or 24 hour malathion liquid 0.5%
Avoid close contact, wash bedding
Calamine lotion or antihistamines for itch
Weak corticosteroids if nodules
142
When is phimosis normal
< 2 years
143
Symptoms of phimosis
Itchy when physiological separation is occurring
| Swelling when urinating although this helps separate the glans from the foreskin
144
Balanitis xerotica obliterans
Splitting and scarring of the skin upon foreskin separation
| Requires surgery
