November 2024 Flashcards
Most common complications of Hypertension (5)
- CV disease (stroke)
- CHD, LVH, AF.
- Renal disease: Focal segmental glomerulosclerosis (FSGE)
- HT Retinopathy.
- Peripheral vascular disease (Aortic aneurism/dissection)
Clinical features of Aortic Dissection
- Diastolic murmur if Aortic Regurgitation occurred
- Abrupt chest pain, sharpen,
migrating / irradiating to the
back. - Unequal or absent pulses.
- Difference of BP in arms (more than 20mmHg).
Aortic Dissection Types
- Type A: Ascending aorta.
- Type B: Descending aorta.
Aortic Dissection FIRST Investigation
Transesophageal Echocardiogram
Aortic Dissection BEST Investigation
CT angiogram
Aortic Dissection Treatment
- Beta blockers (to reduce shear stress)
- Immediate Qx for type A
(ascending aorta)
ABI values
> 1.4: Calcification → Refer
1-1.4: Normal
0.9-1: Acceptable
0.8-0.9: Mild Arterial disease → treat risk factors
0.5-0.8: Moderate Arterial disease →
- Treat risk factors
- Refer if signs of gangrene or pain on rest.
< 0.5: Severe → Refer
Aortic dissection/aneurysm vs myocardial infarction investigation
Check if patient stable
if stable:
Initial: ECG
Best: CT angio
If unstable: fast US
Cardiac Tamponade classic quartet
- Hypotension
- Increased JVP
- Tachycardia
- Pulsus paradoxus ( ↓ BP after inhalation)
Beck’s triad
- Hypotension
- Increased JVP
- Muffled heart sounds
Main cause of dysphagia
achalasia
most common oesophageal disorder
achalasia
Dysphagia to solids and liquids + Heartburn unresponsive to PPI + Retained food in the oesophagus on upper endoscopy + Unusually increased esophagogastric junction sphincter tone + failure of muscle relaxation + weight loss + regurgitation getting worse at night/lying down
Achalasia
Achalasia diagnostic feature
Dysphagia for both solids and liquids
Achalasia initial investigation
Plain X -ray
- air fluid levels to see absence of gastric bubble
Barium swallow
- Birds beak/rat tail appearance
OGD endoscopy
- exclude other causes of dysphagia
Achalasia best investigation
oesophageal manometry
- increased tension in lower end of oesophagus
Achalasia complications
- strictures
- oesophageal cancer
Achalasia management
Mild symptoms
- CCB (Nifedipine)
- nitrates
Young px
- Endoscopic Pneumatic dilation of LES
Old px
- Botulinum injection (may need to be repeated every 3 - 12 months) + mild symptoms management
Best
- Laparoscopic Myotomy (Heller’s)
dysphagia + hoarseness + hx of achalasia + thoracic inlet mass
Oesophageal cancer
Progressive dysphagia + Weight loss >10% + Elderly
Rule out Oesophageal cancer
Oesophageal cancer features
▪ Dysphagia progressive continuous - first solids then liquids → odynophagia
▪ Striking unintentional weight loss ( >10%)
▪ Hiccoughs (early sign – phrenic nerve irritation)
▪ Hoarseness and cough (upper 1/3 cancer – recurrent
laryngeal nerve irritation – vocal cord palsy)
▪ Progressive chest discomfort or pain in locally invasive cancer
Oesophageal cancer types
▪ SCC (most common)
▪ Adenocarcinoma
Oesophageal cancer risk factors
SCC:
▪ Smoking & OH → Triple S
(smoking - spirits – SCC)
Adeno:
▪ Barrett’s oesophagus & smoking
Oesophageal cancer investigation
1st test: Barium swallow to locate lesion
▪ Narrowing of oesophagus
▪ Irregular oesophageal borders
▪ apple core appearance
THEN
Endoscopy w/biopsies
Oesophagogastroduodenoscopy
Oesophageal cancer ddx
Dysphagia intermittent = Achalasia
Hoarseness and cough = also in Pancoast tumour but Horner is present and no GI symptoms
Complete oesophageal rupture causes
▪ Iatrogenic - 56% due to an endoscopy or
paraesophageal surgery
▪ Boerhaave’s syndrome- 10%
▪ Spontaneous perforation include:
- Caustic ingestion
- Pill esophagitis
-Barrett’s oesophagus
-Infectious ulcers in AIDS patients
- oesophageal strictures dilation
dysphagia + iron deficiency anaemia + glossitis ‘rings’ (oesophageal webs)
Plummer Vinson Syndrome/Syderopenic dysphagia
Eosinophilic oesophagitis causes
history of atopy (genetic tendency to develop allergic diseases):
- eczema
- asthma
- rhinitis
- hay fever
- cow’s milk allergy
- dietary allergens or aeroallergens
- chronic, immune-mediated esophageal inflammation
Plummer Vinson Syndrome/Syderopenic dysphagia biggest risk factor
Oesophageal SCC
Oesophageal varices management
- Prophylaxis: Beta blocker (propranolol or nadolol)
- Endoscopic variceal/band ligation
- If failed endoscopic or medical management TIPS (trans-jugular intrahepatic portosystemic shunt)
- Active bleeding: Octreotide
What is the major cause of morbidity and mortality in patients with cirrhosis?
Oesophageal varices 30%-60%
Abdominal aortic aneurysm (AAA) size screening
3-3.9cm = 2 yearly US
4-4.5cm = 1 yearly US
4.6-5cm = 6m US
> 5cm = 3m US
> 5.5cm (male) = surgical intervention
Abdominal aortic aneurysm (AAA) screening
- family history 20%
- >50 years US
Abdominal aortic aneurysm (AAA) investigation
- >50 years fast US
- CT angiogram (before elective surgical repair)
Acute limb ischaemia causes
- Cardiac/arterial embolus (eg, AF, LV thrombus, IE)
- Local thrombosis from disruption of a preexisting atherosclerotic plaque (PAD)
- Iatrogenic/blunt trauma
Arterial emboli origin
Cardiac
Acute limb ischemia requiring surgical treatment
- Paralysis
- Paraesthesia
- Rest pain
Abdominal aortic aneurysm (AAA) mortality rate
- 80%
Abdominal aortic aneurysm (AAA) surgical intervention
- Rapid growth > 1cm yearly
- Males > 5.5cm
- Females > 5cm
- Symptomatic (abdominal/back pain, tenderness, distal embolization)
Acute limb ischemia treatment
embolectomy
Acute limb ischaemia reperfusion syndrome
not enough oxygen causes muscles to die releasing potassium outside the cell but restricted to the limb.
When restoriung blood flow all the potassium will get into circulation causing hyperkalaemia in the heart and px dies due to AF/VF
The same thing happens with the myoglobin gets into the circulation and gets into the kidneys causing blockage leading to AKI. Px doesn’t pass any urine.
Patients with PAD and intermittent claudication have the risk of developing which diseases in the future?
- nonfatal myocardial infarction and stroke in the next 5 years (20%)
- death due to cardiovascular causes in the next 5 years (15%—30%)
- The risk rises exponentially PAD progression 1-year risk of cardiovascular mortality in patients with critical limb ischemia (25%)
Acute limb ischemia reperfusion injury features
– Metabolic acidosis
– Acute renal failure
– Hyperkalaemia.
– Myoglobinemia.
– CK elevation
Acute limb ischemia most common cause
Thrombosis
- lower limbs 80%
Abdominal aortic aneurysm (AAA) symptoms
Triad:
1. abdominal and/or back pain
2. pulsatile abdominal mass
3. hypotension
Acute limb ischemia clinical features/symptoms
- Context of a patient with: Thrombosis (most common cause) or Embolus from AF.
- Pain (progressive)
- Calf: Common femoral art / Superficial femoral art (MC site of occlusion).
- Buttock: Common iliac/external iliac Thrombosis. - Paralysis - Foot drop = Peroneal nerve paralysis - Most reliable sign requiring Emergency Qx intervention
- Pulselessness
- Paraesthesia
- Pallor
- Poikilothermia
Acute limb ischemia investigation
- Measure ABI
- Doppler US
- CT angiogram (gold standard) for surgical
intervention
Acute limb ischaemia initial treatment
Golden time: 4 hrs
1. IV Unfractionated Heparin: 5000 IU then 1250IU/hour. APTT guides further adjustment.
- Surgical treatment: Embolectomy - Can cause reperfusion injury (HyperK, metabacid, myoglobinuria, increased CK). Keep pt hydrated and perfused.
- Arterial bypass is helpful if it is chronic limb ischemia.
- Amputation is required only if there are irreversible ischemic changes. - After acute, give warfarin for 3m
Angioplasty/Catheter
Acute limb ischaemia reperfusion syndrome heart management
If Potassium >= 5.5:
- Stop all K+ supplementation
- Stop medication causing hyperK+
- Cardiac monitoring
If px asymptomatic + normal EKG + K >= 5.5 <= 6:
- Consider if treatment necessary.
- ± Salbutamol Neb
- ± Polystyrene sulfonate PR or oral
- ± Bicarbonate IV if metabolic acidosis
Patient Asymptomatic and Normal ECG and K+ >6 <=7mmoI/L:
- Salbutamol NEB
- Insulin/Glucose perfusion IV
- ± Resonium PR or oral
- Bicarbonate IV if metabolic acidosis
Patient unstable or Symptomatic or Clearly abnormal ECG or K+>7mmoI/L:
- Discuss dialysis
- Consider transfer to tertiary centre.
↓
- Calcium IV
- Salbutamol Neb
- Insulin / Glucose IV
- Bicarbonate IV if metabolic
acidosis - ± Resonium PR or oral
Aortic dissection (AD) confirmation investigation
CT angio
Aortic dissection/aneurysm vs myocardial infarction
Check if patient stable
if stable:
Initial: ECG
Best: CT angio
If unstable: fast US
Acute limb ischemia LMWH vs UFH
- Preceding surgery/renal impairment: UFH
- Medical Mangement only: LMWH (enoxaparin)
Pseudoaneurysm management
Ultrasound-guided thrombin injection
Pseudoaneurysm complication
femoral artery catheterization 7.5%
Clinical features of Chronic Lower Limb Ischemia
- Claudication (pain w/ exercise and relieved by rest)
- if pain at rest: 🚩🚩🚩
- Shiny hairless legs
- Muscles atrophied
Chronic limb ischemia diagnostic symptoms
- Poor pulses (hallmark)
- Shiny, hyperpigmented skin.
-Hair loss & ulceration on the legs
-Thickened nails.
-Muscle atrophy.
-Vascular bruits.
Chronic limb ischemia symptoms that require surgical intervention
– Rest Pain
– Ischemic ulceration
– Gangrene
– Claudication symptoms limiting day to day life & work, no improvement with risk factor modifications, exercises, medical management > 6 months
Chronic Lower Limb Ischaemia MEDICAL Treatment
Measure ABI:
1-1.4: Normal
0.9: Borderline. Nothing
<0.9: Manage risk factors
- Smoke cessation
- Antiplatelets (aspirin or clopidogrel) ONLY if clinically evident CVD
- Statins (even in the absence of dyslipidemia)
- ACE Inhibitors or ARBs.
- Supervised exercise program.
beta-blockers should be avoided until and unless they are commenced for cardioprotection(sys/dia cardia insufficency).
For mixed ulcers (Do not use compression bandage if ABI <0.8)
<0.4: Urgent referral
Chronic Lower Limb Ischaemia SURGICAL Treatment
– Endovascular angioplasty or stenting
– Open surgical reconstruction by bypass or endarterectomy
Chronic Lower Limb Ischaemia initial investigation
- Measure ABI
- Duplex US (often the only imaging required to plan endovascular interventions)
Chronic Lower Limb Ischaemia BEST investigation
CT Angiography w/contrast (Contraindicated in RF)
Exposure to what can trigger an asthma attack?
Sulphites
Prophylactic treatment of asthma in children?
Inhaled corticosteroids ICS : Fluticasone
NOTE: Sodium cromoglycate in some cases
Asthma best initial treatment
Short-acting β2 agonist (salbutamol)
Asthma treatment progression
Oxygen and short-acting beta-2 agonists (salbutamol)
- 6 puffs for children 0-5 and up to 12 puffs for 6 years
- wait 20 mins
If the attack does not subside, up to 6 puffs can be given every 20 minutes for one hour.
If the attack still does not subside, ipratropium bromide
- 4 puffs by MDI + mask or 250 mcg by nebuliser for children 0-5 years
- 8 puffs by MDI + mask or 500 mcg by nebuliser for children > 6 years
Oral prednisolone 1 mg/kg for first 3 days after the asthma attack (prophylactic)
Asthma in children definitive dx
- 2 and 5 years
-Bilateral wheezing - viral wheezing, pre-school wheeze, episodic viral wheeze and multiple
trigger wheeze
Chronic cough cause in children
asthma
most common
allergens that can cause allergy and asthma
dust mites 90%
sheepskin 2nd most common
Asthma LABA
Infrequent Intermittent asthma in children
- less than one episode of asthma in 6
weeks and no symptoms in between the flare-ups - inhaled short-acting beta2 agonist
(SABA)
indications for preventer therapy in asthma
symptoms at night
>1 canister b2 agonists every 3 months
using beta 2 agonists >2days /week
asthma attacks >2/month
infrquent asthma attacks but severe
spirometry with reversible airflow obstruction
Raised JVP is a feature of
Right heart failure
Cardiac tamponade in terms of heart pathogenesis
fluid accumulation in the pericardial cavity → ↑intrapericardial pressure > diastolic ventricular pressure
↓
This restricts venous return to the heart and lowers right and left ventricular filling →
↓preload ↓stroke volume ↓cardiac output.
Pericarditis Clinical Features
Chest pain + SOB+ viral infection
Kussmaul sign.
S4 Gallop: Cardiac Tamponade
Continuous Murmurs List
◦ Patent Ductus Arteriosus – Paeds
Has a harsh, machinery-like quality (Gibson murmur)
◦ Pericardial friction rub: Pericarditis or pericardial effusion. Not a real murmur. Has scratchy, scraping quality
Pericarditis Initial Investigations
- ECG:
- ST elevation except in AVR & V1
- Reciprocal PR - CXR:
- Pericardial fluid
- Pulmonary congestion - Echocardiogram: Is diagnostic! Chest FAST scan should be done ASAP.
- Cardiac CT
Pericarditis Causes
- Viral infection: Coxsackie B, CMV, influenza, EBV, COVID, HIV
- After a major heart attack or heart surgery: Dressler syndrome.
- Systemic inflammatory disorders: Lupus, rheumatoid arthritis.
- Trauma
Pericarditis Best Investigation
Echocardiogram with drainage and culture (Pericardiocentesis)
Pericarditis Complications
Constrictive pericarditis.
Cardiac tamponade
Pericarditis Medical Treatment
Mild to moderate Pericarditis
- AAS/Ibuprofen (7 to 10 days)
- Colchicine x 3 months. Indication: Recurrent symptoms (Side Effects: Diarrhea, abd pain)
- Prednisone
If infection: ATBs and drainage
Pericarditis Surgical Treatment
Severe Pericarditis, include admision
- Cardiac tamponade: Pericardiocentesis
- Severe, Recurrent or Constrictive:
Pericardiectomy
Pericarditis Pathophysiology
Restrictive Cardiomyopathy
Diastolic Dysfunction with impaired filling – relaxation
Normal Ejection fraction + S4 gallop
Dressler’s Syndrome risk factors
- Young age
- B-negative blood type
- Prior history of pericarditis
- Prior treatment with prednisone
Dressler’s Syndrome Treatment
1st LINE: NSAIDs in high doses (aspirin, ibuprofen, naproxen) tapered over 4 to 6 weeks.
2nd LINE: Corticosteroids (prednisone) tapered over a 4-week period
3rd LINE: Colchicine.
Dressler’s Syndrome investigations
Gold Standard: Echocardiogram
UNSTABLE patient: bedside ultrasonographic (E-FAST)
ECG: Same pattern as pericarditis (global ST segment elevation and T wave inversion)
Dressler’s Syndrome COMPLICATION
Cardiac Tamponade
Pericarditis Duration: Acute & Chronic timeline
Acute (<6w)
Chronic (>6w).
Kussmaul sign physical exam
Paradoxical: ↑ JVP with insp and ↓ JVP with exp)
Means: constrictive and/or cardiac tamponade.
Dressler’s Syndrome definition
Pericarditis in the context of major heart attack or heart surgery
Takotsubo Cardiomyopathy ECG:
STEMI or pericarditis pattern.
Cardiac Tamponade is an early complication of which surgical procedure post-op?
coronary artery bypass grafting
painless + elderly + recurrent pneumonia + dysphagia + solids & liquids undigested food regurgitation + coughing immediately after eating + halitosis
Zenker’s diverticulum (pharyngeal pouch)
Zenker’s diverticulum investigation (pharyngeal pouch)
Initial: Barium swallow/Contrast oesophagography
Best: Upper gastrointestinal endoscopy
Zenker’s diverticulum management (pharyngeal pouch)
Surgery: cricopharyngeal myotomy ± diverticulectomy
Laparoscopic surgery
acquired bleeding disorders other causes
- malignancy
- infection
- liver disease
- DIC
Autosomal dominant haemotological diseases
- spherocytosis
- hemorrhagic telangiectasia
- Von Willebrand disease
Autosomal recessive haemotological diseases
- Factor 5 diseases
- Fanconi’s anaemia
- haemochromatosis
Coagulation issue + low platelet
Immunocompromised - suspect HIV
delayed bleeding in trauma is due to
coagulation factor deficiency
DIC causes
- Sepsis
- Transfusion reactions
- Neoplasm (adenocarcinoma, leukemia).
- Trauma.
- Obstetric complications (placental abruption, preeclampsia, septic abortion, retained dead fetus).
DIC management
Treat underlying disorder (see causes)
Platelets
Packed RBC
FFP
Cryoprecipitate
Consider IV heparin for thrombotic complications.
DIC physical symptoms
Epistaxis
Petechiae purpura
Bleeding from venipuncture site or incisional wounds
Haematemesis
Tachycardia
Tachypnoea
Respiratory failure
drugs to avoid in haemophilia
aspirin
warfarin
heparin
early beeding in trauma is due to
platelet issue
Haemophilia features
X - linked recessive = only males affected (1 in 5000)
Factor VIII/IX deficiency
Physical symptoms:
Haemarthroses + muscle bleeds + delayed bleeding.
haemoarthrosis: especially knees, ankles, elbows
* Mild/moderate bleeding: after major trauma or surgery.
* Severe: spontanaeous bleeding
Haemophilia management
Recombinant factor VIII/IX concentrates infusion
Henoch Schonlein Purpura management
Supportive – bed rest and analgesia.
* Corticosteroids – may reduce the duration of abdominal pain, but it is uncertain if they significantly affect other features.
* Refer to a specialist if renal dysfunction, hypertension or surgical complications develop
Henoch Schonlein Purpura features
- Onset 2–8 years most common.
- lgA—mediated small vessel vasculitis
- Post URTI
- Large joint migratory arthritis of variable duration and severity.
- Fever and fatigue
- Non-TP
- Evolving crops of palpable purpura (buttocks and legs)
- Abdominal pain (occasionally melaena) may precede rash.
- High risk of Intussusception
- Nephritis w/ oedema: dorsum of the feet and hands, acute scrotal swelling and bruising
Henoch Schonlein Purpura investigation
- Full blood examination (NO thrombocytopenia).
- Urinalysis: haematuria/proteinuria.
- Renal function: urea/creatinine and urinary protein estimation.
ITP adult features
- Nearly always chronic
- Duration > 14 days
- 50% associated with HIV, SLE, CLL
- Rarely recovers without treatment
- Splenectomy usually required
ITP child features
- Acute onset
- Follows viral infection or drug hx
- Nearly always self limiting (90%)
- 10% pass onto chronic ITP
ITP investigation
Exclude ALL/AML
Bone marrow aspiration: increased megakariocytes
ITP management
Conservative management:
- platelet count > 20 x 109/L
- no active bleeding
- isolated brusiing and petechiae
- without mucousal, GI or renal tract bleeding
Inpatient management:
- Prednisolone for 2 weeks
- IV Ig
- Splenectomy in chronic cases
Most common cause of acquired bleeding disorder
drug therapy (nsaids, anticaogulants)
Prolonged aPTT causes
Increased aPTT only:
- Haemophilia A
- Haemophilia B
- Von Willebrand
Increased aPTT + PT:
- DIC
- Heparin/Warfarin
- Vit K deficiency
Prolonged aPTT is due to which pathway deficiency?
intrinsic pathway deficiency
Factors:
VIII
IX
XI
XII
prolonged PT causes
- Heparin/Warfarin
- DIC
- Vit K deficiency
- Liver disease
Prolonged PT is due to which pathway deficiency?
extrinsic pathway deficiency
Factors:
II
VII
IX?
X
TTP causes
- ADAMTS 13 deficiency
- bleeding disorders: Von Willebrand
- cocaine
- chronic rhinitis/sinusitis
- nasal cavity ulcers/ perforation
- nasal polyps
TTP investigation
Blood film:
- Prolonged bleeding time
- schistocytes (helmet cells)
- High creatinine
- Normal coagulation profile
FBC:
- anaemia
- thrombocytopenia.
TTP management
- Platelet transfusion is contraindicated.
- Plasma exchange transfusion
- FFP (maybe)
TTP symptoms
Clinical symptoms:
- Easy bleeding/epistaxis
- Neurological symptoms: confusion, seizures, headache
- Thrombosis
- Renal dysfunction
On examination:
- Fever
- Pallor
- Purpura/petechiae
- Jaundice
- Splenomegaly
TTP triggers
ADAMTS 13 deficiency
▪ Haemolytic uraemic syndrome
▪ Drugs (quinine, ticlopidine, clopidogrel,cyclosporine).
▪ SLE
▪ Infections
▪ AIDS
▪ Malignancies
Vit K deficiency management
IV Vit K
Severe bleeding: FFP
Vit K deficiency physical symptoms
Easy bruising.
Oozing from nose or gums.
Excessive bleeding from wounds, injection or surgical sites.
Heavy menstrual periods.
Bleeding from the gastrointestinal (GI)tract.
Blood in the urine and/or stool.
Vit K deficiency required for & assiciated with
Required for the function of factors II, VII, IX, X, protein C, protein S.
Associated with malabsorption, cholestatic disease.
Von Willebrand disease features
- Autosomal dominant
- Most common in girls (although genders equal)
- vWF defect resulting in decreased factor VIII + platelet adhesion to each other/ blood vessel wall
- Impaired platelet-endothelial binding
- bleeding exacerbated by NSAIDs/aspirin
- PT normal
-aPTT prolonged
Physical symptoms:
- minor surgical bleeding: dental, incisions
- epistaxis (common)
- menorrhagia
- bruising
- gingival bleeding
Von Willebrand best investigation
Ristocetin co-factor assay (best test)
Von Willebrand treatment
SURGERY
- A single dose of DDAVP (Desmopressin)
- vWF concentrate
- Menorrhagia: Tranexamic acid
DENTAL EXTRACTION:
- Tranexamic acid preoperatively and continue for 1-5 days.
- Single dose of DDAVP or/and single dose of vWF concentrate
X-linked recessive
Haemophilia A
Haemophilia B
- Glucose-6-phosphate dehydrogenase deficiency
fever + maculopapular rash+ serum AST, bilirubin and alkaline phosphatase elevation post transplant
Graft-versus-host disease
B12 deficiency conditions
- Autoimmune gastritis
- Terminal ileum disease
- Gastrectomy
- Metformin therapy
- Coeliac disease
- H.pyelori infection
- Crohn disease
- Postgastrectomy
B12 deficiency causes what type of anaemia
pernicious anaemia
fever + thrombocytopenia + low haemoglobin + acute renal failure + hallucination + haemolytic anaemia
Thrombotic thrombocytopenic purpura (TTP)
Thrombotic thrombocytopenic purpura (TTP) treatment
- replacement fluid
- fresh frozen plasma
decreased serum albumin + hypercalcaemia + normocytic anaemia + bony lytic lesions/osteoporosis
Multiple myeloma
Multiple myeloma investigation
Initial: & diagnostic: serum and urinary
electrophoresis
haemochromatosis investigation
Serum transferrin saturation
- >60% men
- 50% women
haemophilia A in pregnancy
- measure Factor 8 level at 1st antenatal
visit and at 32 weeks - majority develop normal level of factor 8 and do not require replacement
congenital developmental anomalies + progressive pancytopenia
Fanconi’s anaemia
-Malaise and pallor + Recurrent infection + Gingival hypertrophy + Fever, night sweats + -Normocytic normochromic anaemia + Thrombocytopenia + myeloblasts more than 20%
acute myeloid leukaemia (AML)
fatigue + prolonged PT/active PTT + hypofibrinogenemia + and easy bruising + pancytopenia + coagulopathy + elevated lactate dehydrogenase
Acute Promyelocytic myeloid leukaemia (APML)
vegan vegetarian deficiency
B12 deficiency
Fanconi anaemia investigation
Diagnostic: Chromosome fragility test
Most common nutrition al deficiency in children?
Iron deficiency anaemia
Most common cause of iron deficiency anaemia in developed countries?
Occult blood loss
rise in platelet count causes
– Polycythemia vera.
– Hyposplenism due to splenectomy.
– Iron deficiency anemia.
– Correction of vitamin B12 and folic acid deficiency
pruritis on hot bath + vertigo + tinnitus + headache + visual disturbances + hypertension + facial plethora + transient ischemic strokes
Polycythaemia vera
Polycythaemia Vera lab findings
- JAK2 mutation positive
- Increased blood viscosity
- Elevated haemoglobin
- Leucocytosis & thrombocytosis
- Low erythropoietin level
Polycythaemia Vera treatment
- Phlebotomy
- Hydroxyurea (if ↑ risk of thrombus)
acute haemolysis following ingestion of cotrimoxazole/trimethoprim-sulfamethoxazole, nitrofurantoin, primaquine
Glucose-6-phosphate dehydrogenase deficiency
sudden onset of jaundice + pallor, +
dark urine + with or without abdominal and back pain + fall in the haemoglobin concentration + “bite” cells
Glucose-6-phosphate dehydrogenase deficiency
The outcome of splenectomy in a patient with spherocytosis
1- Spherocytosis persists after splenectomy, the cells survive longer in the circulation.
2-Decrease in reticulocytosis.
3- RBC fragility remains high resulting short life span of red blood cells
4- Fall in elevated bilirubin
5- In severely affected patients, life-threatening anaemia
Fanconi anaemia congenital abnormalities
- Hand and arm anomalies (misshapen,missing or extra thumbs or abnormalities of
the radius) - Skeletal anomalies of the hips, spine or ribs
- Skin discolouration (café au lait spots, hypopigmentation)
- Small head or eyes
- Low birth weight and subsequent short stature
- Missing or horseshoe kidney
- Gastrointestinal abnormalities including abnormal development of the
oesophagus
Fanconi’s anaemia treatment
Hematopoietic stem cell transplant
Spherocytosis gene defect
spectrin
ancyrin
protein 4.1
CRAB
C - hypercalcaemia 13%
R - renal impairment 20–40%
A - anaemia 70%
B - bony lesions
hepatomegaly + weakness+ hyperpigmentation + atypical
arthritis + diabetes + impotence + unexplained chronic abdominal pain + cardiomyopathy + Decreased production of FSH and LH + gynaecomastia + 90% are C282Y homozygotes
haemochromatosis
Vitamin B12 bsorbed by binding to
intrinsic factor
conditions which can lead to the development of AML
-Trisomy 21 noted in Down syndrome.
-Fanconi anaemia.
-Ataxia-telangiectasia.
-Myeloproliferative syndromes.
urticaria + stridor + hypotension during blood transfusion+ hx of recurrent infections
Immunoglobulin A deficiency
> 60y/o + fatigue and weakness, dyspnea, and pallor + dysplasia + Anaemia with/o f bi- or
pancytopenia+ Macrocytosis + absolute neutropenia
Myelodysplasia
common feature of autoimmune thrombocytopenia in
childhood
Antecedent viral illness
microcytic anemia + increased concentration of hemoglobin A2
β-Thalassemia
weakness + fatigue + dizziness + palpitations + exercise intolerance + craving of ice/clay
Iron deficiency
increased MCV + neutropenia + thrombocytopenia + history of alcohol abuse + hypersegmentation of
the neutrophils + taking phenytoin
Folate deficiency
Causes of macrocytic anemia
High MCV
megaloblastic anemias
- Vitamin B12 (cobalamin)
- folate deficiency
- vigorous reticulocytosis
- hypothyroidism
- chronic liver disease
- myelodysplastic syndrome
Common causes of microcytic anaemia
Low MCV
iron deficiency
thalassemia,
anaemia of chronic disease
sideroblastic anaemia (Vitamin B6 (pyridoxine) deficiency)
Iron studies in microcytic anaemia
Cause | MCV | Iron | TIBC | Ferritin | Transferrin Saturation
Iron Deficiency | ↓ | ↓ | ↑ | ↓ | ↓
Thalassemia | ↓↓ | ↑ | ↓ | ↑ | ↑↑
Anaemia of |Normal/↓ | ↓ | ↓ | Normal/↑ | Normal/↓
chronic disease
microcytic anaemia + . Seizures + peripheral neuritis + dermatitis + isoniazid
Vitamin B6 (pyridoxine) deficiency
Pyridoxine anaemia lab findings
hypochromic and normochromic RBC’s
cheilosis (welling and fissuring of the lips) + glossitis+ a variety of ocular problems + hx of biliary atresia/hepatitis
Folate deficiency
pallor + sweats + weight loss + bilateral axillary lymphadenopathy + massive Spleen and liver megaly
Chronic lymphocytic leukaemia (CLL)
mature lymphocytes with the presence of smudge cells means
Chronic lymphocytic leukaemia (CLL)
Most common manifestation of cardiac
involvement in hemochromatosis
Congestive cardiac failure
difference between haemolytic anaemia vs anaemia of chronic disease
Low haptoglobin
Glucose-6-phosphate dehydrogenase deficiency dx
Heinz Bodies
decreased red cell, white cell and platelets counts
pancytopenia/aplastic anemia
aplastic anaemia causes
- NSAIDs
- Sulphonamides.
– Gold.
– Anti-epileptic drugs (carbamazepine, valproic acid, phenytoin).
– Nifedipine.
– Chloramphenicol.
sickle cell anaemia how to reduce iron overload
- Subcutaneous deferoxamine
- Splenectomy
- Erythrocytopheresis
Sickle cell anaemia maintenance management
- Vaccination
- Penicillin (until age 5)
- Folic acid supplementation
- Hydroxyurea (for patients with recurrent vaso-occlusive crises)
Sickle cell anaemia pain crisis management
- Hydration
- Analgesia
- +/- Transfusion
Sickle cell anaemia first line medication
Hydroxyurea
NOTE: side-effect is myelosuppression
neutropenia, anaemia, thrombocytopenia
poor prognosis of multiple myeloma
- higher levels of beta-2 microglobulin
- lower levels of albumin
px around 70 + fatigue + tiredness + macrocytic anaemia
myelodysplasia
myelodysplasia investigation
Bone marrow biopsy
generalised weakness, low-grade fever and sore throat + normal haemoglobin + low neutrophil + low platelets + thyroid medicatiob
agranulocytosis
spherocytosis clinical features
1-Haemolytic Anaemia and jaundice.
2-Splenomegaly.
3- elevated mean corpuscular hemoglobin
concentration (MCHC)
4-Positive family history of anaemia, jaundice, or gallstones.
5-Spherocytosis with increased reticulocytes.
6-Increased osmotic fragility.
7-Negative direct antiglobulin test (DAT).
most common causes of death in hemochromatosis
- Liver disease
- cardiomypathy
most profound adverse effect of chronic
transfusional iron overload in children with thalassemia?
Progressive hepatic cirrhosis
Long-standing history of prolonged bleeding after trauma and history of menorrhagia in an otherwise healthy woman
Von Willebrand disease
earliest complication of sickle cell disease
Bone infarction (can lead to avascular necrosis)
progressive, painless lymphadenopathy + fever, night sweats + weight loss + elevated LDH
non-Hodgkin lymphoma
non-Hodgkin lymphoma features
GI tract most common site
- 3% of all malignant gastric tumors
- Surgery alone can be considered adequate treatment that does not infiltrate beyond the submucosa
-
β-Thalassemia investigation
diagnostic: hemoglobin electrophoresis
incidence of thrombosis and bleeding in patients with myeloproliferative neoplasms?
- typically mucocutaneous
- Bleeding is usually less severe and less frequent than thrombosis
- Arterial
thromboses are more common than venous thrombosis - Strokes are more frequent followed by myocardial infarction and peripheral arterialocclusion
best test to monitor heparin therapy
Activated partial thromboplastin time (aPTT)
DVT in the presence of thrombocytopenia
heparin induced thrombocytopenia
types of heparin induced thrombocytopenia
Type 1 : first 2 days after exposure, platelet count normalizes with continued heparin therapy. non-immune
Type 2: typically occurs 4-10 days after
exposure, immune-mediated disorder
- Venous limb gangrene
- Bilateral adrenal hemorrhagic infarction
- Skin lesions at injection sites
- Acute systemic reactions following an i- ntravenous heparin bolus
heparin induced thrombocytopenia management
discontinue and avoid all heparin products immediately
CLL management
1st line: corticosteroids such as prednisolone
chemotherapy if needed
immediate haemolytic reaction secondary to a blood transfusion investigation
Positive Coombs test
helmet cells + Artificial (mechanical) valves placemenent
schistocytes Hemolytic anemia
schistocytes Hemolytic anemia lab findings
Decreased serum haptoglobin level
Renal failure reflected by oliguria and abdominal pain following invasive diarrhoea
hemolytic uremic syndrome (HUS).
Preceding bloody diarrhoea + Fatigue, pallor + Bruising, petechiae + Oliguria, oedema + Decreased platelet count
Haemolytic uremic syndrome (HUS)
respiratory distress + hypotension + bilateral pulmonary infiltrates minutes to hours after blood transfusion
Transfusion-related acute lung injury (TRALI)
age 15-35 & >60 + fever, night sweats, weight loss + painless generalized lymphadenopathy which becomes painful after alcohol consumption + Mediastinal mass
Hodgkin lymphoma (HL)
Hodgkin lymphoma epidemiology
- Bimodal peak incidence: age 15-35 & > 60
- Association with EBV in the immunosuppressed
Hodgkin lymphoma (HL) physical symptoms
- Painless lymphadenopathy
- Mediastinal mass
- Fever, sweats, weight loss
- Pruritus
Hodgkin lymphoma (HL) highest risk of malignancy
Supraclavicular lyphadenopathy
Hodgkin lymphoma (HL) diagnostic investigation
Lymph node excision biopsy
- Reed-Sternberg cells on histology
Normal pH
7.35-7.45
CURB-65 Score
– Confusion of new onset.
– Urea greater than 7 mmol/l.
– Respiratory rate of 30 breaths per minute or higher.
– Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg
or less.
– Age 65 or older
CURB-65 score equal or >3, an
inpatient treatment for community acquired pneumonia is necessary.
Treatment for community acquired pneumonia
IV benzyl penicillin and azithromycin
periodontal disease + cough + foul-smelling sputum + immobilised (hiatal, post-op)
Aspiration pneumonia
Aspiration pneumonia treatment
1st line: ampicillin-sulbactam (1.5 to 3 g IV every 6 hours)
Aspiration pneumonia pathogen
oral streptococci
Bronchiectasis treatment
IV ticarcillin-clavulanate
pigmentation of skin + lung mass + hypokalaemia + hirsutism
Small cell lung carcinoma
-Ectopic production of adrenal corticotropin (ACTH)
Small cell lung carcinoma complication
Ectopic production of ACTH can lead to Cushing’s syndrome
- hypokalaemia
Most common causes pulmonary hypertension and cor-pulmonale
- COPD
- Emphysema
cough + mucopurulent sputum lasting for months to years + finger clubbing
bronchiectasis
Bronchiectasis investigation of choice
High-res CT
best bed-side measure to assess the severity of asthma
Use of accessory muscles upon inspiration
abdominal / trans-thoracic procedure post-op + cough and fever + within 48 hours
Postoperative atelectasis
Postoperative atelectasis management
- Removal of impacted secretions by coughing, managed by physiotherapists, and involves active chest percussion and breathing exercises.
- oxygen supplementation
- Passive postural drainage.
- bronchoscopy if px still hypoxic
FEV1/FVC ratio
0.75-0.85
FEV1/FVC ratio > 0.85
Restrictive airway disease
FEV1/FVC ratio < 0.75
Obstructive airway disease
dyspnea + cough + fever + productive sputum +
occasionally pleuritic chest pain
pneumonia
Small cell lung carcinoma treatment
chemotherapy and radiation
pleural fluid analysis
- pH always below 7.30
- Pleural/serum protein ratio greater than 0.5
- Pleural/Serum lactic dehydrogenase ratio of greater than 0.6
- Glucose concentration (30-50 mg/dL)
- Bloody pleural fluid is strongly suggestive of malignancy
High altitude pulmonary oedema cause
Hypoxic pulmonary vasoconstriction
clubbing of nails can be found in
– Cystic fibrosis.
– Interstitial pulmonary fibrosis.
– Lung cancer
– Interstitial lung disease
- bronchiectasis
middle/older age + high grade fever + dry cough + severe headache + diarrhoea/vomiting/confusion + hyponatremia + deranged liver function tests
Legionnaires disease
recurrent asthma exacerbations + patchy opacities + central bronchiectasis + eosinophilia+ elevated immunoglobulin E
allergic bronchopulmonary aspergillosis
latent tuberculosis (LTB) treatment
Isoniazid (5mg/kg up to a maximum 300mg daily) for 9 months
superior vena cava syndrome investigation
chest CT angiogram
cough + weight loss + lung nodule in X-ray
adenocarcinoma
adenocarcinoma investigation
FNAC gold standard
Difference between crackles associated with alveolar fluid vs interstitial lung disease
Egophony
smoker + pulmonary nodule + hypercalcemia (increased thirst, abdominal pain, constipation, and polyuria)
squamous cell carcinoma
(fever, malaise, cough + acute SOB + bilateral crackles + asymptomatic between exacerbations
hypersensitivity pneumonitis (alveolitis)
IV drug abuse + dyspnoea + bilateral pleuritic chest pain + multiple partners sex hx + hypoxemic
Pneumocystis jiroveci pneumonia
family hx of emphysema/liver disease + + weight loss, + jaundice + dyspnoea
Alpha-1 antitrypsin (AAT) deficiency
idiopathic pulmonary fibrosis (IPF) treatment
Antifibrotic therapy
black + 20-30 years + erythema nodosum + arthritis + hilar lymphadenopathy
Sarcoidosis Lofgren syndrome
Unprocessed raw cotton + bacterial endotoxin
Byssinosis
doesn’t cause COPD
Normal PaO2
75-100 mmHg
Normal PaCO2
35-45 mmHg
Normal HCO3
22-26 meq/L
black + 20-30 years + fever + parotid gland enlargement + uveitis + facial palsy
Sarcoidosis
pneumothorax in the absence of trauma and no history of lung disease
Primary spontaneous pneumothorax (PSP)
Pneumothorax management
PSP < 15%: observation
PSP > 15%: needle aspiration
SSP: mechanical ventilation (can’t put needle into an already damaged lung)
Symptomatic SSP: Catheter drainage/water sealed thorcostomy
Pneumothorax as well as other lung disease is labelled as
Secondary spontaneous pneumothorax (SSP)
Most common symptom in pleural effusion
Dyspnoea
Most effective preventative therapy for asthma
ICS
- fluticasone
- beclomethasone
- budesonide
Montelukast if ICS contraindicated
NOTE: Montelukast is associated with nightmares in children
X-ray pleural thickening + significant weight loss + pleural effusion
mesothlioma
when to add preventer
using preventer if they use salbutamol more than 3x week
Residual lung volume increased
obstructive disease
Residual lung volume decreased
restrictive disease
Asthma causes
emotional changes
gord
allergies
pregnancy
occupational hazards
dust mites
List of restrictive diseases
- pulmonary fibrosis
- pneumothorax
List of obstructive diseases
- asthma
- COPD
Asthma dx
triad: dyspnoea + wheeze + cough
fev1/fevc ratio < 75
PEF: improvement in fev1 more > 12% after medication (salbutamol)
- prolonged expiration
- resonant
- expiratory wheeze
respiratory acidosis
Types of asthma
mild:
moderate:
severe:
4 hallmark indicators of severe asthma
- <94% oxygen saturation
- altered mental state
- effort on breathing
- struggling to talk
role of oral steroids in asthma
can only be used in exacerbation, not for long term
prolonged use of oral steroids (prednisolone):
- Cushing syndrome,
- osteoporosis,
- immunosuppression
Exercised induced asthma management
Cromolyn
physical symptoms that are not indicated in assessing severe asthma
- wheezing
- respiratory rate
fever + malaise + hepatosplenomegaly + exudative pharyngitis + cervical lymphadenopathy
Infectious mononucleosis
Indications for splenectomy
- Trauma
- Spontaneous rupture (mononucleosis)
- Hypersplenism (ITP)
- Neoplasia
Infectious mononucleosis cause
EBV
Infectious mononucleosis inv
Initial: FBC - Atypical lymphocytosis (>50%)
- ESR: Differentiate between IM (elevated) & Strep pharynitis (normal)
Diagnostic: Positive heterophile antibody (Monospot) test
Transient hepatitis
Infectious mononucleosis management
- Supportive treatment: rest, fluids, analgaesia
- Symptoms resolve within 1-2 weeks
- Avoid sports due to risk of splenic rupture
Symptoms 1-2 weeks after exposure + Fever + skin rash + polyarthralgia + urticaria
Serum sickness
Serum sickness sensitivity type
type III
Serum sickness management
- Remove/avoid offending agent
- Supportive care
- Steroids or plasmapheresis if severe
Malar rash (butterfly rash),
- highly specific for
the diagnosis of SLE - flat, scaly, non-pruritic and
characteristically spares the nasolabial fold
metacarpophalangeal joint + wrists are warm and tender + swollen
RA
SLE investigation
(ANA) is indicated as the best initial screening test.
The dsDNA is 90% specific
highest specificity for rheumatoid arthritis
Anti-citrullinated peptide antibody
Anti-CCP
SLE clinical features
- Anaemia, leukopenia, thrombocytopenia
- most common presentation of this arthritis is symmetrical polyarthritis affecting the hands, wrist and knees.
- affects women in high oestrogen period
- more common in females of African American, Hispanic, and Asian descent
- weight loss
- malar rash and oral ulcers
Thrombotic thrombocytopenic purpura
- thrombotic microangiopathy
- severely reduced activity of the von Willebrand factor-cleaving protease
ADAMTS13 - small-vessel platelet-rich thrombi that cause thrombocytopenia, microangiopathic hemolytic anemia, and sometimes organ
damage
colchicine contraindications
1- Renal insufficiency.
2-Cytopenias.
3-Abnormal liver functions.
4-Sepsis.
Bradycardia in a patient with SLE antibody
Anti-Ro
Acute rheumatic fever clinical features
- Peak incidence: age 5-15
- Twice as common in girls
- Major symptoms: JONES
*Joints (migratory arthritis) - ❤️ (Carditis)
- Nodules (subcutaneous)
- Erythema marginatum
- Sydenham chorea
- Minor symptoms: FEAP
- Fever
- Arthralgias
- Elevated ESR/CRP
- Prolonged PR interval
Acute rheumatic fever late sequelae
Mitral regurgitation/stenosis
Acute rheumatic fever diagnosis
group A streptococcal infection along with 2 major
or
1 major plus 2 minor (J❤️NES)
ARF can also present with
carditis
chorea
elevated ESR
Coxsakie virus also known as
Hand foot and mouth disease
coxsackie can lead to what condition?
myocarditis
Coxsackie seasonal onset
late summer early autumn
fever + lesions on hands/feet + oral sores/ulcerations
Coxsackie (HFM)
Rinne test in relation to AC/BC
AC>BC = Normal/SNHL
BC>AC= CHL
Development of pubic hair
Girls: 8 years
Boys: 9 years
SIADH in children
- hyponatremia
- excessive amount of ADH from hypothalamus-pituitary
Hyponatremia in children
Dehydration: hypernatremia
Cardiac: Pseudohyponatremia
Addisons:
- Low aldosterone
- Hyperkalaemia
- hypotension
SIADH in children symptoms
- nausea and vomiting
- headache
- problems with balance
- mental changes (confusion, memory problems)
- seizures or worst case, coma
SIADH in children causes
- type 2 DM medication:
- antiepileptic
- antidepressant
- surgery under general anaesthesia
- brain disorders, injury, infections, stroke
- lung disease (pneumonia, tuberculosis, cancer, chronic infections)
- cancer of lung, small intestine, brain, leukaemia
Weber’s test
Normal = lateralizes equally to both ears
CHL= lateralizes to abnormal ear
SNHL= lateralizes to the normal ear
Acute Otitis media risk factors
- Age (6-18 months)
- Lack of breastfeeding
- Day care attendance
- Smoke exposure
Pathogens that give arise to acute otitis media
- Streptococcus pneumoniae (most common)
- Nontypeable (?) Haemophilus influenzae
- Moraxella catarrhali
Complications of Otitis media
Acute mastoiditis
Acute mastoiditis initial treatment
sample from the ear discharge should be taken for culture DONE BY ENT
flucloxacillin + a third-generation cephalosporin
Acute otitis media treatment
- Amoxicillin 1st choice (used for 1 week)
- 2nd line: amoxicillin-clavulanate
Acute otitis media treatment px that’s allergic to penicillin
- clindamycin
- azithromycin
Chronic suppurative otitis media treatment
Assess if tympanic membrane intact or perforated:
If intact: ciprofloxacin ear drops to treat on going infection
If perforated: initial treatment ear toilet with povidone-iodine solution, followed by
dry mopping with rolled toilet papers2 to 3 times a day using 20ml syringe with plastic tubing. In addition, ciprofloxacin ear drops
Untreated a tympanic membrane perforation secondary to chronic otitis media
- Marginal perforation with discharge
- Perforation that is surrounded by granulation tissue
- Continuously discharging central perforation
- Perforation associated with a cholesteatoma
Cholesteatoma risk factors
- history of recurrent acute otitis media
- chronic middle ear effusion
- tympanostomy tube placement
- history of cleft palate
Lymph nodes red flags
Weight loss
Sustained fever
Night sweats Generalized lymphadenopathy
Signs and symptoms of pancytopenia
Mass persisting> 6 weeks
Lymph node> 3 cm
Thyroid mass
Supraclavicular mass
Hard, irregular mass
Fixed mass
1 standard deviation above/below the 50th percentile
Weight: overweight/underweight
2 standard deviation above/below the 50th percentile
Weight: obese/severely underweight
Marfan’s syndrome (MFS) features
- autosomal dominant connective tissue
disorder (FBN1) - affects height
- does not affect weight
- aortic aneurysm
dissection, aortic regurgitation (Decrescendo high-pitched diastolic murmur at the left sternal edge) - Myopia and ectopic ocular lens.
Most common neurological symptoms in children with cancer
- Nausea
- Vomiting
Most common neurological cancers in children
Lymphadenopathy in children
viral upper respiratory tract infection
TB, Infectious
mononucleosis cytomegalovirus infection
Cat scratch disease
haematological and nonhematological malignancies, Kawasaki
disease.
Growing pains
Growing pains refers to pain in the lower
extremities of growing active children.
children between 2 and 12 years with the peak
incidence in preschool children.
mostly felt in the thighs, calves and
behind the knee.
intermittent and in mostly present in the afternoon and evening after activity during the day.
Pain may also wake up the child at night.
Perthes
- avascular necrosis of the femoral head.
4 -8 years of age
associated with hip pain and intermitent limp.
Transient synovitis
- 3-8 years
- URTI hx
- sudden onset unilateral hip or groin pain most common sx
- medial thigh or knee
pain 2nd common sx
Arthralgia and arthritis secondary to synovium inflammation - no fever, or only a mild fever
Features of Epiglottitis
– H. influenzae
High fever, sore throat,
dysphagia, odynophagia,
drooling due to inability to swallow the saliva because swallowing
is painful and difficult.
child miserable adopts a tripod position with a hyperextended neck to maintain the airway open. Muffled voice (hot potato voice)
Lungs are clear on auscultation initiallt later expiratory stridor (ominous sign.)
age of epiglottitis
more common between
ages 2 and 4 years;
Foreign body
U/L wheeze
Asthma in children definitive dx
- 2 and 5 years
-Bilateral wheezing - viral wheezing, pre-school wheeze, episodic viral wheeze and multiple
trigger wheeze
CXR in bronchiolitis
B/L perihilar infiltrates
Croup management
mild: no treatment
moderate/severe:
-Dexamethasone 0.3 mg/kg orally (first-line);
- Prednisolone 1mg/kg orally, or
- Budesonide 2mg by nebulizer
most severe with significant airway obstruction/fatigue: Adrenaline 1% (1:100, 10mg/ml) solution 0.05ml/kg/dose
Cervical masses in children
- Congenital
- Inflammatory/ infective
- Neoplastic
Posterior triangle of the neck mass
CCP
- Cystic hygroma
- Cervical rib
- Pancoast tumour
- (Naso/oropharyngeal squamous cell carcinomas)
Cervical masses in neonatal period
- thyroglossal duct cyst (TDC)
- teratomas
- sternocleidomastoid tumours of infancy
- vascular or lymphatic malformations.
Anterior triangle of the neck mass
BCC
- Branchial cyst
- Carotid body tumour
- Carotid aneurysm
Midline of the neck mass
**TTD **
- Thyroid nodule
- Thyroglossal cyst
- Dermoid cyst
Acute rheumatic fever high risk population (JONES)
Major criteria:
- Carditis
-Polyarthritis
-Chorea.
-Subcutaneous nodules.
-Erythema marginatum
- Polyarthritis or aseptic mono-arthritis or
polyarthralgia
Minor criteria
-Fever more than 38c
-Previous rheumatic fever
-Arthralgia
-Raised ESR/CRP more than 30
-ECG shows prolonged PR interval
Perthes features
- Normal Caucasian boy
- 4 and 10 years, peak incidence at 5 to 7 years
- 15% bilateral
- widening of joint hip space
Hip pain result of necrosis of the involved bone
-pain may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. - The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip may develop adduction flexion contracture
- antalgic gait with limited hip motion, or a Trendelenburg gate (abductor lurch).
- Pain may be present with passive range of motion and
limited hip movement, especially internal rotation and abduction
Features of Acute rheumatic fever (ARF)/ erythema marginatum.
2 major and 2 minor criteria
- history of sore throat 3 weeks
-migratory arthralgia/arthritis
- Erythema marginatum - well demarcated bright red/pink macules rash
Treatment of Perthes disease
Conservative: Splinting
Surgery: osteotomy
Initial ARF dx
2 major criteria OR one major and two minor criteria + Evidence of preceding GAS infection
recurrent attack of ARF dx
Two major criteria OR one major and two minor criteria OR three minor criteria + Evidence of preceding GAS infection
ARF dx
Cultures for GAS are the gold standard (Throat swab)
Most common cause of vaginal bleeding in children
vaginal foreign body
Causes of vaginal bleeding in children
- Vaginal foreign body
- Severe vulvovaginitis
- Trauma (including straddle injury and sexual
abuse) - Excoriation associated with threadworms
- Onset of first menstruation
- Haematuria
- Urethral prolapse
Complications of thyroglossal duct cyst (TDC)
-
Infection
-Malignancy 1% - Overgrowth and pressure of the underlying
structures. - Rupture and fistula formation
nonspecific vulvovaginitis
- caused by chemical
irritants such as bubble baths or by poor hygiene - stop bubble baths and use only cotton underwear
Enuresis management in children
- Spontaneous resolution <5 years (84%)
- Bed wetting alarms >5 years and conservative methods (fluid
intake, toileting, reward system) failed + wetting >2 per week - nasal desmopressin alternative bed wetting alarm.
Gastroenteritis in children causes
- Norovirus 95% aus
- faecal–oral route
- Contaminated food and water (cold meats)
- 12 to 24/48 hour incubation period
- noninflammatory, nonbloody, non-mucoid
Norovirus Gastroenteritis in children dx
PCR stool
Gastroenteritis in children clinical features
Common:
- Nausea
- Vomiting
- Diarrhoea
- Abdominal cramps
Not common:
- Headache
- Low-grade fever
- Chills
- Muscle aches
- Malaise
Gastroenteritis in children management
Symptomatic
Proteinuria in children investigation protocol
> 1+ protein on urine dipstick exam
- perform urinalysis for confirmation
Causes of obesity in children
- Hypothyroidism (check TSH)
- Excessive caloric intake
- Cushing’s disease (ACTH, cortisol)
Acute mastoiditis pathogen
Streptococcus pneumoniae
Autistic disorder features
- preoccupations with activities
- objects
- delayed speech language development
- Aggression and irritability
- poor communication with friends and avoiding eye contact
Characteristic features of autistic disorder
- Onset during infancy and early childhood
- Lack of socila interactions
least two of the following:
- No awareness of the feelings of others
- No or abnormal comfort seeking in
response to distress
- No imitation
- No social play
- cannot socialize, (no eye contact )
3- Impaired communication
least one of the following:
- No babbling, gesture, mime or spoken
language
No non-verbal
communication
- abnormal form of
speech
- inability to make conversation
-abnormal speech
4- Restricted or repetitive activities, interests and
imaginative development, shown in at least one of
the following:
- stereotyped body movements
- persistent preoccupations and
rituals with objects or activities
- gets troubled over changes in routine or
surroundings
- No imaginative and symbolic play
5- Behavioral problems:
- tantrums
- hyperactivity
- risk-taking activity
kidney scarring features in children
- one kidney smaller than the other
nutshell diagnosis of autistic disorder requires
the presence of core features by the
age of 3 years:
- Impairment of social interaction
- Impairment of communication
- Restricted, repetitive and stereotyped patterns of activities, behavior and interest
kidney scarring investigation of choice in children
DMSA (gold standard)
- Clinical suspicion of renal injury
- Reduced renal function
- Suspicion of VUR
- Suspicion of obstructive uropathy on ultrasound in older toilet-trained children
Encoperesis
voluntary or involuntary passageof stools
- place
other than the toilet
- >1/month for 3months
- >4years
Social & emotional developmental milestones
Emotional development milestones
Cognitive development milestones
Language development milestones
2 years child expected to
- walking upstairs
- Scribbling
- points to body part
- knowing 2 pronouns
-Toilet trained - self feeding by spoon/cup
8 months
- sits without support
- repeats syllables ‘mama/dada’
- enjoys peekaboo
9 months
- crawls
- stranger anxiety
12 months
- ‘Cruises’
-thumb grasp - imitates speech with meaning
- waves goodbye
14 months
- pulls string on toy
15 months
- neat pincer grasp
18 months
- walks without support
- can build 2 tower blocks
- say 3 words
- drinks from cup
2.5 years
- runs/jumps
- throws ball
- build 4 blocks
- 2 word sentences
3 years
- ride tricycle
- copes vertical line/ circle
- can use scissors
- 3-word sentences
4 years
- learns bicycle
-copies square - first and last name
- dress with supervision
5 years
- hops on one foot
- draw a person with 3 parts triangles
- knows colours
- dress without supervision
Types of encoperesis
primary- child has never been
continent
secondary- previously
continent.
With constipation and overflow
Incontinence:
<3/week bowel movements
-stool partially emptied remaining
- stool leak out, often during the child’s daily
activities.
- if constipation resolves encoperesis resoleves
Encoperesis with No constipation overflow Incontinence:
there’s no constipation, and the child’s faeces have normal consistency. Unlike in cases associated with constipation and overflow, soiling of this type is intermittent. Feces may be emitted in
a prominent location (e.g., as an act of defiance) or
may be an unintentional consequence of anal selfstimulation (e.g., a variety of masturbation).
Encopresis without constipation and overflow
incontinence is less common than the first type of
encopresis, and is often associated with
oppositional defiant disorder and conduct disorder.
It has been estimated that 3% of children with
psychiatric issues may have encopresis.
Oppositional Defiant Disorder (ODD) in Children
- 10-12 years
Conductive disorder
- 12-18
Bilateral sensorineural deafness in children
Congenital sensorineural deafness.
‘hand, foot
and mouth (HFM) disease’
- Self-limiting
- Coxsackie A virus. - Erythematous macular rash,
progressing to gray
vesicles
vesicles seen in buccal mucosa,
gums and tongue. - doesn’t involve the buttocks and the genitalia
- no scarring.
School Exclusion: until lesions dried up
Features of partial seizures
- no loss of consciousness
- no pos ictus
vertigo in children
- CNS tumours (medulloblastoma)
- temporal lobe epilepsy
Absent seizures in children
- loss of consciousness
- pos ictus
- 30-60s duration
Temporal lobe seizures in children
Features of infantile spasms
- 3-7 months
sudden bending of the trunk and flexion of upper limbs - 1st line: Corticosteroids (prednisolone) for 8 to 10 week. Vigabatrin
- Clonazepam for acute presentation?
BPPV child
- variant of migraine
preceeds - migraine in future
Roseola infantum
exanthem subitum/sixth disease/three-day
fever
Roseola infantum features
3 to 5 days of high
fever may exceed) 40°C.
fever resolves abruptly
macular papular rash (trunk extremities) after 3 days
Roseola infantum causes
human herpes virus 7 (HHV-7),
enteroviruses (coxackievirus A and B, echovirus),
adenovirus, and parainfluenza virus type 1.
Features of diarrhoea
- opposite of vomiting
Austin-Flint murmur
mid-diastolic
rumbling murmur best heard over the apex.
In Severe Aortic Regurgitation
In MFS
MFS treatment
1st -beta blockers
2nd- verapamil, ACEinhibitors
Marfan’s syndrome (MFS) investigation
echocardiogram
most
common cause of failure to breastfeed?
Reduced frequency of
breastfeeding.
ureteropelvic junction (UPJ)
obstruction features
- most common cause
of paediatric hydronephrosis - periodic abdominal pain with vomiting
- exacerbation on UPJ can also lead to pelvic distention, flank pain or even tenderness
COUGH
acute (<3 weeks),
subacute (3-8 weeks)
chronic or persistent (>8
weeks).
ureteropelvic junction (UPJ)
obstruction diagnosis
US during painful episode
Isolated thrombocytopenia features
- following an URTI
- acute (~90%) or chronic (~10%)
- no pallor, lymphadenopathy
or hepatosplenomegaly. - if platelets > 20 x 109/L: bed rest
- if platelets < 20 x 109/L: oral steroids (prednisolone)
Colon polyp
- benign hamartomas
- ages 2 and 8 years, peak at 3 to 4 years
- mostly painless
rectal bleeding
palpable polyp
on rectal examination >60%
anal fissure
- most common cause of painful rectal bleeding in children
- associated with constipation
- bright blood on the
surface of stool, on the nappy or toilet paper
retinoblastoma
- most common intraocular tumor in children
- Leukocoria (white cornea or Cat’s eye)
-strabismus - initial: US (intraocular calcification)
- best dilated indirect
ophthalmoscopic examination under anesthesia
Chronic cough cause in children
asthma
acute or subacute cause of cough
Post viral cough
diagnosis and staging of the VUR.
Voiding cystoureterogram
Bordetella pertussis (whooping cough) hospital admission
- Infants less than 6 months of age
- Any child with complications (i.e. apnoea,
cyanosis, pneumonia, encephalopathy, pneumothorax)
Bordetella pertussis (whooping cough) school exclusion
3 weeks start of symptoms
2 weeks start of cough
<5 days of antibiotics
Choanal atresia features
- failure of canalization of the bucconasal membrane.
CHARGE SYNDROME - coloboma
- heart defect,
- atresia choanae
- retarded growth
- genital abnormality
- ear abnormality
CHARGE SYNDROME
-bilateral choanal atresia
coloboma
- heart defect,
- atresia choanae
- retarded growth
- genital abnormality
- ear abnormality
Choanal atresia dx
pass nasogastric tube (also managment)
no use in giving oxygen
Choanal atresia management
Mild hypoxemia: nasogastric tube
Severe hypoxemia: intubation and ventilation
Noonan’s (Male Turner’s) syndrome features
- Affects males
- An autosomal disorder involving mutation in chromosome 11
- Pulmonary valve stenosis
- Webbed neck
- Abnormalities in cardiac conduction and rhythm
- flat nasal bridge
- single palmar crease
- protruding tongue
- eyes that are apart more than usual
- low set ears
Perthes disease management
- refer to surgeon
Surgeon will make call on conservative or surgical
- conservative: brace
- surgical: osteotomy/femoral head fixation, hip replacement worst case
Transient synovitis
- NSAIDs 48 hours
- bed rest
Developmental dysplasia (DDH) of the hip features
- neonates from breech delivery
- Female 6xt more likely
- unilateral or bilateral (positive family hx)
- Diminished abduction in flexion of the
affected hip - Apparent inequality of legs: affected
leg being shortened and externally rotated - Asymmetrical skin creases of the groin and
thigh - ‘clicking’ on hip movements
Developmental dysplasia (DDH) of the hip dx
Barlow test —‘telescoping’ movements in the long axis of the flexed and abducted thighs.
Ortolani test — flexed hips are abducted. thighs are the grasped between the thumbs in front and other fingers behind. The child’s knees are flexed and hip flexed to a right
angle. **positive sign makes audible and palpable ‘jerk’ or ‘clunk’ (not a click). **
- Ortolani and Barlow tests but is usually negative after two months
- Ultrasound is excellent especially up to 3-4 months
vesicoureteral reflux (VUR)
Grade I: Reflux into the nondilated ureter
2. Grade II — Reflux into the ureter and renal calyces without dilation
3. Grade III — Reflux with mild to moderate dilation
and minimal blunting of the fornices
4. Grade IV — Reflux with moderate ureteral
tortuosity and dilation of pelvis and calyces
5. Grade V — Reflux with gross dilation of ureter,
pelvis and calyces, loss of papillary impressions,
and ureteral tortuosity NEED SURGERY
cyanosed baby + No murmur at birth
Transposition of great vessels
vesicoureteral reflux (VUR) management
management depends on grading:
Grade I-IV: continuous antibiotics
Grade V: Surgery
Tetralogy of Fallot (TOF)
4 defects
- blood going from left to right ( acyanotic)
- all have VSD (systolic murmur)
- pulmonary stenosis
- right ventricle hypertrophy
- overriding aorta
Patent ductus arteriosus. (PDA)
-acyanotic
- pansystolic machinery murmur (harsh) at the left sternal border
- wide pulse pressure.
- Definite treatment surgical closure
cyanosed baby + murmur at birth
Tetrology of fallot
cyanosed baby + No murmur at 2-7 days of life
Hypoplastic left heart
Ventricular septal defect (VSD)
- holosystolic murmur at left sternal border
- acyanotic
Atrial Septal Defect (ASD)
- acyanotic
- mid-systolic murmur at the pulmonary area, a split-second heart sound and a loud P2
2 main types:
- Ostium Primum: most dangerous type, can lead to pulmonary hypertension and heart failure, Prophylactic antibiotics recommended
- Ostium Secundum: most common type, e hole is higher in the septum, not serious, symptoms uncommon in infancy
Transposition of the great arteries (TGA)
- central cyanotic after 10-12 hours
Aorta and pulmonary arteries are reversed - no murmur as there is no hole
- prescribe PG e1
- definite treatment: surgery to correct the transposition
Drugs closing ductus arteriosus
NSAIDS
Drug keeping the ductus arteriosus open or patent
PGE2
Idiopathic (immune) thrombocytopenic purpura (ITP)
- preceding viral infection
- s frequently < 20,000/μL
- ## other lab tests normal
Innocent murmur
7S
-soft
- systolic
- short duration
- sounds (S1 &S2)
- symptomless
- Special tests normal (X-ray, ECG)
- Standing/Sitting changes (not fixed) (increased when supine)
Pathological murmurs
Family hx of sudden cardiac death or
congenital heart disease
- in utero exposure to certain medications (lithium) or
alcohol
- Maternal diabetes mellitus
- History of rheumatic fever
- History of Kawasaki disease
- Grade 3/6 or higher murmurs
- Harsh quality
- Abnormal S2
- The presence of a systolic click
- Increased intensity with decreased venous
return (e.g., when the patient stands) - The patient has any symptoms that could be
related to a cardiac condition (e.g. shortness
of breath, chest pain, poor feeding, etc.)
murmurs that increase in
intensity when the venous return to the heart is
decreased:
- hypertrophic obstructive
cardiomyopathy (HOCM) - mitral valve prolapse
- venous hum (low-pitched continuous
murmurs produced by blood returning from
the great veins to the heart)
most common
allergens that can cause allergy and asthma
dust mites 90%
sheepskin 2nd most common
Duodenal atresia features
- Neonate w/ vomiting (after first feeds)
- Down syndrome 5%
distal obstruction to the papilla of Vater 80%
-bilious vomiting - M > F
-X-ray: ‘double-bubble’ - drooling
- abdominal distension (very late symptom)
2 months
social smile 6 weeks
3 months
- hold the neck
- recognize mother’s face
6 months
- Sits without support
- Rolls from prone to supine vice versa
- palmar grasp
- hand to hand transfer
- turns head to loud noise
- understands bye bye and no
- puts object to mouth (stops at 1 year)
- shakes rattle
reaches for bottle/breast - Ability to explore things by holding, looking at them and putting them in mouth
separation anxiety in child features
- Want to stay at home with parents
- Get upset about going to school
aches or headaches, or do
not feel well without a physical cause -Do not have any serious behavior problems - Do not try to hide their wish regarding not going to school from their parents
- Are more likely to be the youngest memberof a family
Bordetella pertussis (whooping cough) investigation
Children: Nasopharyngeal aspiration
Adults: nasopharyngeal swab
Lobar Pneumonia in children
- streptococcus pneumoniae
- high fever
-
chest auscultation
deceitfully normal
-high fever - pallor
-respiratory distress
Oxygen saturation in children
- > 93%
- RR 50
Bronchiolitis
- acute LRTI <12 months (2 weeks to 9 months)
- respiratory syncytial virus (RSV)
- irritating cough and rhinorrhoea
- distressed wheezing breathing
- Hyper-inflated chest (barrel-shaped)
- Use of accessory muscles and subcostal
recession - fine inspiratory crackles
- supportive with oxygen and hydration
- bilateral perihilar congestion on X-ray (not necessary)
Laryngomalacia in children
- congenital softening of the tissues of the larynx
- **noisy breathing ** worsens when agitated, feeding, crying or sleeping
on back - High pitched sound
- symptoms present at
birth, can become more obvious within the first
few weeks - outgrow by 18 to 20 months
expiratory stridor
inspiratory
stridor
suggests obstruction above the glottis.
most common cause of failure to thrive
inadequate caloric intake
Lobular (atypical) Pneumonia in children
- fever is not often that high.
- insidious onset
- prodromal
state
Pneumonia in children investigation
initial step: chest X-ray (to see consolidation)
Bronchiolitis management
100% oxygen via nasal prongs.
- severe bronchiolitis and requires rehydration
using intravenous fluids or nasogastric tube.
tonsillectomy in children
- Hemorrhage common complication, also life thereatening
- bleeding may occur in the early post-operative
period or may be as delayed as 5 to 10 days - bleeding secondary to tonsillar fossae infection
post-tonsillectomy haemorrhage management
- Resuscitation - 2 large bore cannula with
bloods - Reservation of cross-matched packed red
cells - IV antibiotics: with 1.2g Benzyl Penicillin, 6-hourly + 500mg of metronidazole, 12-hourly
- NSAIDs
- Hydrogen peroxide gargle - 20mls of
hydrogen peroxide diluted with water in a
ratio of 1:6.
Hirschsprung disease (HD)
- 15-20 % of newborn intestinal obstructions
- 80% in the first 6 weeks of life
- male > female
- congenital anomaly by absence of ganglia in a segment of colon and paralysis of this aganglionic segment
-starts at the anus and progresses up
the rectum towards the colon. (Delayed meconium passage) - Failure to pass meconium in the first 24 hours but w/ gradual
onset of abdominal distension of days to weeks. - Persistent and progressive constipation
-Vomiting late
Hirschsprung disease (HD) complication
enterocolitis
Hirschsprung disease (HD) Dx
Rectal suction biopsy – Gold standard
Hirschsprung Disease (HD) Mx
- Laxatives (mild cases)
- Surgery
UTI in children investigation
- suspect vesicoureteric reflux
- < 3 years (2-36 months) US of the kidney, ureter & bladder
- If US normal then voiding cystoureterogram (VCU)
Renal scarring in children
- Recurrent urinary tract infections (more than
2 times during childhood) - Dimercaptosuccinic acid scintigraphy (DMSA) - Gold Standard
DMSA indications
- Clinical suspicion of renal injury
- Reduced renal function
- Suspicion of VUR
- Suspicion of obstructive uropathy on ultrasound in older toilet-trained children
UTI hospital admission indication
- Most of children less than 3 months.
- Children who are seriously unwell such as
those with toxic appearance or
dehydration. - Oral antibiotics cannot be tolerated.
UTI in children
- Fever, nausea, vomiting
- abdominal pain
- Leukocytes and nitrites on urinalysis
slipped capital femoral
epiphysis (SCFE)
- Overweight adolescent of 10 to15 years
- bilateral in 20%
- Limp and irritability of hip on movement
- Knee pain — referred from the affected hip
- On flexion of the hip, it rotates externally. Hip
is often in external rotation on walking. - Most movements restricted, especially
internal rotation.
slipped capital femoral epiphysis (SCFE) management
- Cease weight-bearing and refer urgently.
- lf acute slip, gentle reduction via traction is
better than manipulation for prevention of
later avascular necrosis. - Once reduced, perform pinning
Henoch-Schönlein purpura (HSP) in children
- Autumn, winter and spring months
- IgA mediated vaculitis
- anaphylactoid purpura
- arthralgia (not arthritis),
- non-thrombocytopenic purpura (the purpura is vascular due to leukocratic activity)
-typical symmetrical distribution over legs and buttock. - colicky abdominal pain 2 to 4 weeks
- melena
- ankle swelling
- nephritis
Henoch-Schönlein purpura (HSP) in children Dx
-Clinical presentation + urinalysis for nephritis
What Vitamin is given to babies after birth?
- Vitamin K IM injection to avoid intercranial haemorrhage
Aboriginal Australians are deficient in what vitamin
Vitamin D
Abnormal UA in children
- Asymptomatic microscopic hematuria
- Repeat UA after fever settles if no UTI (2 positive UA)
umbilical granuloma
- most common umbilical mass
- overgrowth of tissue during the healing process
- soft pink or red lump
- leaks small amounts of clear or yellow fluid
- presence of non-purulent discharge
umbilical granuloma management
topical silver nitrate
- cauterisation may need to be repeated at 3-day intervals if drainage persists
Asthma short-acting beta2 agonist SABA
salbutamol
Asthma LABA
Infrequent Intermittent asthma in children
- less than one episode of asthma in 6
weeks and no symptoms in between the flare-ups - inhaled short-acting beta2 agonist
(SABA)
intestinal malrotation with volvulus
- 6 months
-bilious vomiting - crampy abdominal pain
- abdominal distention
- bloody, mucoid stool
3 months
- hold the neck
- recognize mother’s face
4 months
- eye contact with people
- look for mother when she speaks
- happy or settled most of the time
-follow activities with eyes
Hypertrophic Pyloric Stenosis features in children
- 2 and 6 weeks of age
- gastric outlet narrowing
- projectile vomiting a few minutes after feeding
- non bloody, non bilious vomiting
- delayed capillary refill > 2 seconds
Hypertrophic Pyloric Stenosis risk factors in children
-Formula feeding
-Male
-Caucasian background
-Firstborn
-Maternal smoking during pregnancy
-Positive family history
-Both erythromycin and azithromycin < 2weeks
Bacterial conjunctivitis in children
- gonorrhoea: fast and aggressive (3 and 7 days after birth)
- chlamydia: slow and less aggressive (end of 1st week - 1 month after birth)
congenital adrenal
hyperplasia (CAH)
- ## 21-hydroxylase deficiency
congenital adrenal
hyperplasia (CAH) dx
Palpable gonads:
-Pelvic ultrasound
-Testosterone and dihydrotestosterone (DHT) ratio.
-LH and FSH.
-ACTH stimulation test.
-hCG stimulation test
No palpable gonads:
- markedly elevated 17-hydroxyprogesterone 90%
-Serum electrolytes.
-Plasma renin activity
Hereditary angioedema
- recurrent angioedema without pruritis in:
- upper respiratory tract
- gastrointestinal tract
- subcutaneous tissues
- autosomal dominant reduced C-1 esterase
inhibitor levels (HAE type I) or poorly functional (HAE type II)
post-streptococcal Glomerulonephritis (PSGN) in children symptoms
- hypertension 50-90%
- haematuria 30-50%
- oedema 60%
- Decreased complement (C3) levels
post-streptococcal Glomerulonephritis (PSGN) management
- Fluid restriction
- Loop diuretics/dialysis
- Steroids (caution, could be wrong)
Meningitis management in children
CSF analysis/Lumbar puncture FIRST:
- turbidity
- low glucose (less than 1.7 mmol/L)
- elevated proteins
- elevated white cells (20 to 30 cells/microL)
- Gram stain may be negative 60%
> 7 days E. Coli most
common
IF signs of ICP (seizure, papilledema) then CT head
Minimal Change Disease (MCD) in Children
- nephrotic syndrome
- <6 years
- Absence of hypertension
Absence of hematuria by Addis count - Normal complement levels
- Normal renal function
Nephrotic disease management
- Corticosteroid (Prednisolone)
Minimal Change Disease (MCD) in Children dx
1. Nephrotic range proteinuria-urinary protein excretion greater than 50 mg/kg per
day.
2. Hypoalbuminemia-serum albumin
concentration less than 30 g/L.
3. Edema.
4. Hyperlipidaemia
Aortic coarctation in children
- 90% of blood is shunted across ductus arteriosus (well tolerated)
- low cardiac output and shock once the ductus arteriosus closes
Aortic coarctation symptoms in children
- hypotension,
- cyanosis,
- respiratory distress,
- **shock with normal or weak upper extremity pulses **
- absent femoral pulses
- Metabolic acidosis is seen as compensation to respiratory alkalosis
- prostaglandin E1 infusion to maintain a patent ductus
arteriosus and surgical repair
Kawasaki disease features
- acute onset of fever more than 39C
-inadequate response to paracetamol - sole, palm and tongue erythema
- desquamation of fingertips (vasculitis)
- tender mass in the right hypochondrium
- elevated CRP and ESR
Kawasaki disease in children management
- aspirin and immunoglobulins
-Steroids must be avoided
Kawasaki disease in children complications
- vasculitis leading to coronary artery aneurysm 17-31% (second week and second month
of illness)
-
incidence of congenital heart disease in children
1 child: 2% to 6%
2 children: 20% to 30%
most common congenital heart disease in infants?
Ventricular Septal Defect (VSD) 1 in 100 Australian infants
Hepatoblastoma
-<5 years
- mass in right upper quadrant
- abdominal distension
- right-sided abdominal pain
- familial adenomatous polyposis high risk
- lost appetite and weight
- vomiting and jaundice (very rare)
most common cause of sinus bradycardia in
neonates
secondary to Respiratory failure and hypoxia
anal fissure management in children
- anusol cream (lignocaine)
- pain for anal fissure is under control, laxatives and fibre diet
anal fissure features
- passage of hard stools
Most common allergy in children
Food allergy 80%
most common cause of short stature in children
Constitutional delay of growth and puberty
- lack of breast development-thelarche in girls above 13 years
- testicular volume less than 4ml by the age of 14 years
Chronological age and bone age
-should be equal
- difference <2 years = normal (reassure)
- difference > 2 years = constitutional delay
Unknown seizures
- resistant to
treatment with
intravenous calcium - test Serum magnesium level
Febrile seizures/ convulsions
Simple:
- duration of less than 15 minutes
- do not occur more than once in 24 hours
Complex seizures:
- MAY last for longer than 15 minutes
- recur in
the course of 24 hours
6 weeks
- good head control
- head stabilises when sitting
- track objects
- startes at loud noise
- social smile
indications for preventer therapy in asthama
symptoms at night
>1 canister beta 2 aginists every 3mon
using beta 2 agonists >2days /week
asthma attacks >2/month
infrquent asthma attacks but severe
spirometry with reversible airflow obstruction
Acute lymphoblastic leukemia Epidemiology
- Most common childhood cancer
- Peak age: 2-5 years
- Male > female
Most common childhood cancer
Acute lymphoblastic leukemia
Acute lymphoblastic leukemia clinical features
- Nonspecific systemic symptoms
- Bone pain
- Lymphadenopathy
- Hepatosplenomegaly
- Pallor (from anemia)
- Petechiae (from thrombocytopenia)
Acute lymphoblastic leukemia dx
Bone marrow biopsy with >25% lymphoblasts
Acute lymphoblastic leukemia treatment
Multidrug chemotherapy
Lymphoblastic leukaemia in children contraindication
- Live-attenuated vaccines contraindicated (MMRV, rotavirus, yellow fever)
Guillain-Barré syndrome in children
- immune mediated demyelination
- Campylobacter infection
- 10 days after a nonspecific viral illness
- acute polyneuropathy
- progressive, mostly symmetric muscle weakness (days or weeks) beginning in the lower
extremities and progressing toward the trunk - absent or depressed deep
tendon reflexes
Guillain-Barré syndrome dx in children
- spinal fluid protein measurement (elevated protein 2x normal)
- glucose and cell counts are normal
- Nerve conduction studies (NC)
- needle electromyography (EMG)
Guillain-Barré syndrome management in children
- observation (24-48 hours)
- intravenous immunoglobulin
- steroids
- plasmapheresis (respiratory failure)
Guillain-Barré syndrome complication
Neuromuscular respiratory failure (30%)
- order spirometry after dx
Charcot-Marie-Tooth disease in children
- peroneal and intrinsic foot muscle atrophy (strange feet)
- extending to the intrinsic hand muscles and proximal leg
Fragile X syndrome in children
- inherited disorder
- Fragile X Mental Retardation 1 (FMR1) gene expansion
- associated primary ovarian
insufficiency & tremor ataxia syndrome - All males with the full mutation
- Relative macrocephaly
- Strabismus
*Pale blue irises
*Midface hypoplasia with sunken eyes
*Arched palate
*Mitral valve prolapse (seemingly benign)
*Joint hyperlaxity (particularly of the thumbs, fingers, and wrists)
*Hypotonia
*Doughy skin over the dorsum of hands
*Flexible flat feet
Tay Sachs disease in children features
- 2 to 6 months
- Retinal cherry red spots 90%
- progressive weakness and loss of motor skills
- with hypotonia
- hyperreflexia
- retinal ganglion cells become distended with glycolipid
Mumps meningitis in children
- occurs in the post-pubertal male 25%, usually unilateral
- Paramyxovirus isolated from CSF,
saliva and nasopharynx - fever,
- lethargy,
- bilateral parotid swelling
- parasternal oedema
Mumps meningitis in children complications
- Aseptic meningitis
- testes causing orchitis, usually unilateral,
most common cause of hyponatremia in children
- diarrhoea
hyponatremia in children
-Gastrointestinal fluid losses.
-Administration of hypotonic fluids.
-Severe infections-meningitis, encephalitis, pneumonia, bronchiolitis, sepsis etc can lead to SIADH
persistent hyponatremia in children
– Congenital Adrenal Hyperplasia.
– Addison’s Disease.
– Psychogenic polydipsia.
– Obstructive uropathy
Thumb sign in X-ray
Acute epiglottitis
- intubation at hospital
Tics in children
- also known as habit spasms
- individually recognisable, intermittent movements
- aware in the urge to perform the movement
- blinking,
- facial grimacing,
- shoulder shrugging,
- head jerking
best method of anaesthesia for neonatal circumcision
Dorsal penile nerve block
Tetanus vaccinations in children
- 3 vaccinations at 2,4 and 6 months
- 1st booster at 4 years
- 2nd booster between 12-17 years
Clean laceration tetanus
- no immunoglobulins required
- check to see vaccination status and vaccinated in indicated
Dirty laceration tetanus
- immunoglobulins required
Oral polio vaccine (OPV) in children
Preterm babies should not get vaccinated until after leaving hospital (might spread the live vaccine virus to other babies in the hospital)
- inactivated polio vaccine can be used instead
Epiglottitis treatment
- supplemental oxygen
- intubate
Hydrocele in children
- scrotal swelling
- A bluish discoloration of the skin if the hydrocele is large.
- Fluctuation in the size of the swelling (mainly in infants).
- The area of the hydrocoele is clearly defined.
- Hydroceles are not painful but may cause discomfort if they are large.
Hydrocele in children management
- wait until 18 months (resolve spontaneously)
- surgery if not resolved after 18 months
Hydrocele in children investigation
positive transillumination test
Hyponatraemic seizures in children
- increasing irritability
- increasing lethargy, - increasing tonic-clonic generalised
seizures - respond poorly to conventional anticonvulsants (phenytoin, phenobarbitone)
- address hyponatraemia by 3% NaCl solution
cystic fibrosis in children
- autosomal recessive
- 1:3700
- Sweat chloride test
- DNA testing (CFTR) diagnostic 72%
Kernicterus in children
pathogenic sign of bilirubin staining of the brain stem nuclei and
cerebellum
– Athetoid cerebral palsy with or without seizures.
– Developmental delay.
– Hearing deficit.
– Oculomotor disturbances including paralysis of upward gaze.
– Dental dysplasia.
– Intellectual impairment.
Febrile seizures/ convulsions management
If seizure is of short duration and doesn’t reoccur = reassurance
if the following situations:
1. A child with a pattern of prolonged seizures (usually longer than ten mins.) which
have previously responded to intravenous or rectal diazepam.
2. A child with clusters of repeated seizures in whom oral treatment is inappropriate.
3. A child with severe epilepsy who is remote from emergency services.
=
Rectal diazepam
Duchenne’s muscular dystrophy in children
- X-linked recessive trait
- after
- deficiency of dystrophin
beginning to walk features become more evident - Pseudohypertrophy limited to the calf muscle
- hip girdle weakness at 2 years
- Gower sign (use of the hands to “climb up” the legs in order to assume the upright position) at 3-5 years
- use of a wheelchair after 12 years
- mental impairment and cardiomyopathy
- Death respiratory failure, heart failure, pneumonia, or aspiration
Neonatal hypoglycaemia features
- Mid-line defects (Congenital pituitary deficiency)
- Hepatomegaly (glycogen storage diseases and fatty acid oxidation
disorders) - Micro penis (congenital gonadotropin deficiency, possible pituitary, cortisol deficiency)
abnormalities - Macrosomia (maternal history of
gestational diabetes)
benign haemangioma
- strawberry naevus
- around 1 to 4 weeks of age, then get bigger, for a few months
- stop growing between 6-12 months
- gradually disappear over the next few years
- if naevus at eyes, nose, ears or trachea then laser therapy
- If anywhere else, then observation
most common cause of jaundice in a neonate
within 24 hours after birth?
Haemolysis due to ABO incompatibility
- always pathological
bronchiolitis high risk of airway compromise
- Infants younger than 3 months of age
- Preterm or low birth weight infants.
– Infants with chronic lung disease.
– Infants with congenital acyanotic heart disease.
Brain tumours in children
- account for 25% -
30% of all paediatric malignancies - 1 to 10 years infratentorial (posterior fossa)
- After 10 years of age, supratentorial tumour’s (eg, diffuse astrocytoma)
bacterial balanitis ( bacterial infection of the
foreskin) treatment
- topical antibiotics mupirocin
- mild inflammation without pus or other signs of cellulitis = topical
steroids
infratentorial tumours in children
cerebellar and brainstem tumours (medulloblastoma, cerebellar astrocytoma)
- ICP
- nausea
- vomiting,
- ataxia,
- vertigo,
- papilloedema
- Cranial nerve VI to X palsies
supratentorial tumours in children
Seborrheic dermatitis in children
- Erythema toxicum 50% of term newborns
- commonly greasy, scaly, and erythematous rash
- face, neck, axilla, and diaper area
Mongolian spot in children
- a bluish-grey lesion over
buttocks, lower back, and occasionally extremities extensor surfaces - blacks, Asians, and Latin Americans
- tend to disappear by
1 to 2 years
Meningitis in children features
- < 1 month old
- fever
- poor feeding
- jaundice
- bulging fontanelle
- seizures
- nuchal rigidity
- irritability/lethargy
- Usually GBS
Sickle cell anaemia in children
- pneumonia,
- pulmonary thromboemboli
- sepsis
NOTE: with sickle-cell anaemia, these can be rapidly progressive and quickly fatal
- require hospitalisation
Sickle cell anemia what would be seen in peripheral smear?
Howell-Jolly bodies
Bacterial conjunctivitis in children school exclusion
- Excluded until discharge has resolved
Hypernatremia in children
- “doughy” skin
- Isotonic (normal) saline for an initial bolus
Diaphragmatic hernia in children
- Mortality 50%
- transmittal of abdominal contents across a
congenital or traumatic defect in the diaphragm - profound respiratory distress
- birth at a tertiary-level
centre - scaphoid abdomen
- bowel sounds in the chest
Diaphragmatic hernia in children management
- high-frequency oscillatory ventilation
- extracorporeal membrane oxygenation (ECMO)
Addison’s disease in children
- hyponatraemia with hyperkalaemia
- 21-hydroxylase deficiency
- Dehydration, hypotension, and shock
Opioid intoxication in children
maternal analgesic narcotic drug (meperidine)
- depression of the newborn via crossing of the placenta
- administration
of naloxone, 0.1 mg/kg, IM, IV, or endotracheal
Rickets in children
- failure of bone mineralization
- Vitamin D deficiency
- a flattened occiput
- prominent forehead
-significant dental caries, - bumpy ribs
- bowed extremities
Tay Sachs disease in children investigation
Fundoscopy: retinal cherry red spots in 90%
Tay Sachs disease in children blood test
Hexosaminidase A & B enzyme
Down syndrome in children
- short stature
- microcephaly
- centrally placed hair whorl
- small ears
- redundant skin on the nape of the neck
- flat nasal bridge
- Cardiac lesions 30% to 50% (endocardial cushion defect, VSD, tetralogy of Fallot (all 30%)
- Duodenal atresia
Vitamin C deficiency
- irritability
- low-grade fever
- swelling
- tachypnoea
- and poor appetite
- impaired wound healing
- diffuse tenderness, worse in legs
Idiopathic (immune) thrombocytopenic purpura (ITP) in children management
- If not bleeding: monitoring/observation
- If bleeding: IVIG and corticosteroids (prednisone)
Pulmonary hypoplasia
- Oligohydramnios
- Kidney US (bilateral renal agenesis)
Turner Syndrome features
- Affects females
-Madelung deformity - short stature,
- webbed neck
- low-set ears
- low hairline at the back of the neck
- epicanthal folds
prominent ulnar head and apparent volar subluxation of the wrist on the forearm
Madelung deformity
Turner Syndrome complications
- aortic coarctation
- Complete atrioventricular septal defect (CAVSD) – 37 percent
- Ventricular septal defect (VSD) – 31 percent
- ASD – 15 percent
- Partial atrioventricular septal defect (PAVSD) – 6 percent
- Tetralogy of Fallot (TOF) – 5 percent
- PDA – 4 percent
DTPa minimum dose
duration
4 weeks
- booster doses 10 years and 20 years after primary course
Klumpke paralysis
- C7, C8 & T1 injury
- affects elbow
- hand palsy
Vitamin A deficiency
night blindness
drying of the conjunctivas and sclera
dry skin
Poor growth and impaired cognition
Acute disseminated encephalomyelitis (ADEM)
autoimmune-demyelinating
<10 years of age
preceeding URTI
high-dose corticosteroids to treat
Neurocysticercosis (NCC)
- raw meat consumption
- Tapeworm Taenia solium
- MRI single focal white matter lesions
- Blood test serology
- Albendazole
ABO hemolytic disease in this infant
positive direct Coombs test
Coombs test
Direct = autoimmune haemolytic anaemia
Indirect = antibodies in blood to see if there’s reaction to blood transfusion
Phenylketonuria,
- autosomal recessive
- absence of an enzyme that metabolizes
phenylalanine to tyrosine
mental retardation - Treatment consists of a diet that maintains phenylalanine at levels low enough to
prevent brain damage but adequate to support normal physical and mental
development.
Galactosemia in children
- galactose-l-phosphate uridyl transferase enzyme deficiency
- ## serious damage to liver, brain, and eyes after being fed lactose milk
Galactosemia in children symptoms
-lethargy,
vomiting and diarrhoe,
-hypotonia,
-hepatomegaly
- jaundice (liver failure)
-failure to thrive
- cataracts
Biotinidase
autosomal
recessive trait
dermatitis, alopecia, ataxia,
hypotonia, seizures, developmental delay, deafness, immunodeficiency, and
metabolic acidosis
Treatment is lifelong administration of free biotin.
Galactosemia in children treatment
- elimination
of lactose-containing milk from the diet - exclusion of foods that contain casein, dry milk solids, whey, or curds
Holt-Oram syndrome
hypoplastic radii, thumb abnormalities, and cardiac anomalies.
pectoralis major muscle is missing
Edwards syndrome in children
- Mortality is 50% in the first week and 90% in the first year
- low-set ears,
- a prominent
occiput, - a short sternum,
- a closed hand with overlapping fingers,
- cardiac defects,
rocker-bottom (rounded) feet, - cleft lip and/or palate
maternal infection with mumps or rubella virus
may produce aqueductal stenosis hydrocephalus
Müllerian agenesis
- Female gonads do not secrete Müllerian-inhibiting factor (MIF)
- Male testes secrete MIF
- empty scrotum
- testes are impalpable in inguinal canal
Pseudohematuria
beets, blackberries, and rhubarb
chloroquine
metronidazole
phenytoin
rifampinsulfasalazine
Night terrors
- 5 and 7 years
- awaken suddenly, appear frightened and unaware of surroundings
- cannot recall the
event in the morning - Sleepwalking is common
- reassurance
Prader willi syndrome
- hypotonia, hypogonadism
- hyperphagia after the newborn period - hypomentia
- obesity
- deletion of a
portion of chromosome 15 - Feeding difficulties and failure to thrive in 1st year
- defect in the satiety center in the hypothalamus.
- Stringent caloric
restriction is the only known treatment
Tonsillitis management
- Perform throat swab+ start antibiotics
- If swab+ve = continue antibiotics
- if swab-ve = discontinue antibiotics
Retropharyngeal abscess
- inflamed prevertebral soft tissue
- inability to extend the neck
- lateral neck film demonstrates a widened prevertebral soft tissue strip
- typically not present with airway compromise and hypoxia
Staphylococcal scalded skin syndrome
known as Ritter disease
commonly in children less than 5 years of age
fever,
irritability, erythema,tender skin
Circumoral
erythema
crusting of the eyes, mouth, and nose
blisters on the skin
Postive Nikolsky sign- Peeling of the epidermis in
response to mild shearing forces
Abetalipoproteinemia in children
- Microsomal triglyceride transfer protein (MTP) gene mutation
- impaired VLDL formation
- decreased
vitamin E delivery to PNS/CNS
-
Tanner stages
I:
- 0–15 years
- None
II:
- Commencement of puberty
-8–15
- Pubic hair first, along with breast budding
- Scrotal/Testicular growth, penis growth after a year
III:
- Increase in hair and pigmentation
Parvovirus B19
- Fifth disease (erythema infectiosum)
-
Low haemoglobin patients with
haemolytic conditions (such as sickle-cell anaemia) thus develop a transient aplastic
crisis - poorly functioning bone marrow (for a week or more)
Laurence-Moon-Biedl syndrome
- autosomal
recessive
-Obesity - mental retardation
- hypogonadism
- retinitis
pigmentosa with night blindness - polydactyly
Fröhlich syndrome
- adiposogenital dystrophy
- obesity associated with a hypothalamic tumour
Pseudohypoparathyroidism
(low serum calcium and high serum phosphorus
levels
- high
levels of endogenous parathyroid hormone
short,round-faced, and mildly retarded.
- Metacarpals and metatarsals are shortened
- subcutaneous and basal ganglia -
- calcifications
- cataracts can be present.
- Treatment: large doses of vitamin D and reduction of the
phosphate load.
Duchenne dystroph
- Pseudohypertrophy routinely is limited to the calf muscles
- lordotic posture as weakness evolves in the hip girdle
musculature - ## waddling gait
normal infants show the following
- Coarse, tremulous movements accompanied by ankle
clonus - harlequin color change (a
transient, longitudinal division of a body into red and pale halves)
softness of
parietal bones at the vertex (craniotabes)
a liver that is palpable down to 2 cm
below the costal margin
septic arthritis in children
- S aureus
- joint aspiration
congenital motor neuron disease in newborn/infant
Werdnig-Hoffmann disease
hypotonia, and muscle atrophy
Anterior horn cell
disease
congenital motor neuron disease in older children
Kugelberg-Welander disease
Anterior horn cell
disease
hypotonia, and muscle atrophy
Wiskott-Aldrich syndrome
- X-linked recessive
- Thrombocytopenia
- Eczema
- Increased susceptibility to infection
- bloody diarrhea and easy bruising
- impaired humoral
immunity - low serum IgM and a normal or slightly low IgG
- low T cells and lymphocyte
- Few live past their teens, frequently succumbing to malignancy caused by
EBV infection.
Adenosine deaminase (ADA)
deficiency
- Type of severe combined immunodeficiency (SCID)
- Lymphopenia from birth
- Platelets are not affected
Autosomal dominant
Most are affected: males and femailes
Autosomal recessive
A few are affected: males and females
X- linked recessive
A few are affected: only males
Toxic shock syndrome (TSS) in children
- S aureus
- “menstrual” TSS (associated with
intravaginal devices like tampons, diaphragms, and contraceptive sponges) - “nonmenstrual” TSS associated with pneumonia
- skin infection
- bacteremia
- osteomyelitis
List of autosomal dominant diseases
D -dystrophy myotonia
O - osteogenisis imperfecta
M - Marfan’s
I - intermittent porphyria
N - Noonan’s
A - achondroplasia, familial adenomatous polyposis (FAP)
N - neurofibromatosis
T - Tuberous sclerosis
V- Von Willebrand
H - Huntington’s HNPCC
H - hereditary spherocytosis
H- familial hypocholesteraemia
R - retinoblastoma
List of autosomal recessive diseases
A - albinism
B - thalassaemia
C - cystic fibrosis
D - deafness
E - emphysema
F - Friederich’s ataxia (trinucleotide test, repeat GAA)
G - Gaucher’s disease
H Hemochromatosis, homocystinuria
S - sickle cell
P - phenylketonuria
N - Wilson’s
X - xeroderma pigmentosa
List of X-linked recessive diseases
D- diabetes insipidus
D - Duchenne’s
C - colour blindness
C - chronic granulomatous disease (membranous type)
F - Fabry’s disease (alpha- glucosidase deficiency)
F - fragile X syndrome (Martin Bell Syndrome)
2 blood - haemophilia. G6PD
2 syndrome Lesch Nylon syndrome, Wiskots Aldrich yndrome
Toxic shock syndrome (TSS) in children treatment
Antibiotics against S aureus (penicillin)
Epstein-Barr virus (EBV) in children
PE:
- diffuse adenopathy
- tonsillar enlargement
- enlarged spleen
- small haemorrhages on the soft palate
- periorbital swelling
Blood:
- predominance of atypical lymphocytes with at least 10%
- heterophil antibodies present (may not be present in young
children)
Epstein-Barr virus (EBV) in children management
- Self-limiting symptomatic management
- avoid contact sports to protect spleen
VATER/VACTERL
V- vertebral defect,
A- anal atresia,
C- cardiac defects,
TE- tracheoesophageal fistula
-R renal/radial defect
L- limb defects
Undescended testes
descend into the scrotum during the
first two weeks of life
- the descent is unlikely to take place after the age of 1year
- 20 percent of premature males
- Orchidopexy is best performed by 12-18 month
- 5-10 times greater risk of developing a malignancy
Hx of travel to South Asia + fever + dry cough + dull frontal headache + gastroenteritis
Salmonella Typhi
Acute rheumatic fever treatment
- benzathine penicillin IM
-Roxithromycin if allergic to penicillin/NSAIDs
Autism treatment
Atypical antipsychotics (Risperidone)
tachycardia + sunken eyes + >3 sec capillary resuscitation
severe dehydration
severe dehydration management
10-20ml/kg boluses of 0.9% normal saline
inguinal hernia ‘6-2’ rule
birth to 6 weeks, surgery is recommended within 2 days, 6 weeks to 6 months-surgery within 2 weeks and over 6 months surgery within 2 months
Most common organism causing ophthalmia neonatorum
Chlamydia trachomatis
- notifiable disease
ophthalmia neonatorum treatment
oral erythromycin and sulfacetamide eye drops
< 6 months + > 7 days fever + systemic
inflammation but no other explanation for febrile illness
Atypical Kawasaki
Salmonella Typhi treatment
- South/South East Asia: azithromycin 1 g (child: 20 mg/kg up to 1 g)
Not India: ciprofloxacin 500 mg
infant < 2 years + low-grade fever + abdominal distension + loss of appetite + limb pain + abdominal mass that crosses the midline
Neuroblastoma
- originates from adrenal glands
3-4 years of age + kidney claw sign + abdominal mass does not cross midline
nephroblastoma (Wilm’s tumour)
Early onset neonatal sepsis risk factors
– Maternal group B streptococcus colonization in current pregnancy.
– A previous baby with GBS infection.
Late onset neonatal sepsis risk factors
– Artificial ventilation with an endotracheal tube.
– Extreme prematurity.
– Total parenteral nutrition.
- Central catheter
Coeliac disease assessment
gluten challenge for 4-6 weeks and then should have coeliac serology performed
Hypoglycaemia IV infusion
2ml/kg of 10% dextrose IV
Diabetic ketoacidosis in a young patient
- type 1 diabetes mellitus
- autoimmune (diseases celiac, autoimmune thyroiditis)
HPV contraindications
- egg and yeast allergy
adolescent + fever >38.5C + ↑WBC, ESR, CRP + Acute painful, tender and warm joint + limited movement + refusal to bear weight
Septic arthritis
septic arthritis management
- Joint drainage & debridement
- IV antibiotics
- orthopaedic surgeon referral
UTI in children Managment
1st line: trimethoprim
cephalexin
Hypertrophic Pyloric Stenosis in children mananament
Initial: Fluid resuscitation
Best: Ramstedts Pyloromyotomy
Indication for urgent referral in children
- Green vomiting: gangrene of
the bowel
male adolescent athlete + pain below the knee + tenderness
Osgood-Schlatter disorder
Osgood-Schlatter disorder management
Gentle quadriceps stretching exercises
- self limiting up to 12 months
NOTE: Corticosteroids are absolutely contraindicated
Growth investigations to consider prior to referral
- FBC
- urea & electrolytes
- ESR
- Coeliac serology
NOTE: GH is pulsatile therefore not diagnostic
strawberry like red mass on cheek
infantile haemangioma
infantile haemangioma management
reassure
-Gradual regress in size
Immediate management of acute meningitis in chidren
-Airway, Breathing, Circulation, Disability, Exposure (Primary Survey).
-Obtain immediate intravenous access (an intraosseous needle may be required).
-Administer intravenous dexamethasone (0.15 mg/kg).
-Intravenous ceftriaxone (100 mg/kg).
-Take blood cultures.
causes of iron deficiency anaemia in
children
– Excessive intake of cow’s milk.
– Prematurity.
– Low birth weight.
– Coeliac disease.
– Lead poisoning.
< 8 girl + tall + pubic hair & breast development Tanner stage 3 + inappropriate sexual behaviour
Precocious puberty
Precocious puberty investigation
- serum FSH & LH estradiol
- MRI
- Bone age
UTI in infants < 1 year
- 1st: US
- micturating cystourethrogram (MCU): rule out vesicoureteric reflux
vulvovaginitis management in children
no voiding difficulties: reassure
voiding difficulties: topical oestrogen or oestradiol cream applied twice daily
severe obstruction to urinary flow with retention or recurrent infections: Manual or surgical separation
Neisseria gonorrhoea infection in a child
Vaginal non-bloody pus-like discharge 95%
dry eyes and mouth + low urine output + dilated pupils + decreased bowel sounds/constipation + sinus tachycardia + QRS interval
prolongation
anticholinergic toxicity (TCA)
anticholinergic toxicity (TCA) managment
Sodium bicarbonate Sodium bicarbonat
Most common long-term complication of streptococcus pneumonia meningitis in children
Deafness 11%
Intellectual disability (mental retardation)-4%.
-Spasticity and/or paresis-4 %.
-Seizure disorder-4 %
Expiratory wheeze + RSV URTI + barking cough
Croup
Relationship between ADHD & ODD
In more than 50% of px with ADHD, ODD is also a part of the clinical picture
Oppositional Defiant Disorder (ODD) in Children Treatment
1st line: Antipsychotics (risperidone)
2nd line: mood stabilisers (sodium valproate) SSRIs
Henoch-Schönlein purpura (HSP) in children complication
Intussusception (due to intestinal oedma and bleeding)
Eye Discharge
1st day - chemical irritation
6 days - Gonorrhoea
14 days- Chlamydia
IgA deficiency
increased frequency
* bronchitis,
* chronic diarrhoea,
* conjunctivitis
* otitis media in children
Babies are at increased risk of contracting meningitis or septicaemia
(a)they are low birth weight.
(b)premature.
(c)born after prolonged labour.
(d)premature rupture of membrane.
Streptococcus B Group
Erythema infectiosum
Fifth disease
Parvo B 19
slapped cheek
macular papular rash
Myalgia / Arthralgia
Primary adrenal insufficiency aetiology
- Most common: Autoimmune adrenalitis
- Infection (tuberculosis)
- Metastatic infiltration (primary tumours of the lung, breast, kidney, and skin)
Primary adrenal insufficiency clinical features
- Fatigue, weakness, anorexia/weight loss
- Nausea, vomiting, abdominal pain
- Salt craving, postural hypotension
- Hyperpigmentation
Acute adrenal crisis: confusion, hypotension/shock
Primary adrenal insufficiency lab findings
- Hyponatremia, hyperkalaemia, eosinophilia
- Low morning cortisol, high ACTH
Primary adrenal insufficiency treatment
Glucocorticoids (eg, hydrocortisone, prednisone)
Mineralocorticoids (eg, fludrocortisone)
persistent hypotension + hyperpigmentation + hyponatremia + hyperkalaemia
Aldosterone/adrenal insufficiency (Addison’s)
Aldosterone/adrenal insufficiency management
Known dx: parenteral administration of corticosteroids (Hydrocortisone)
Previous dx:
dexamethasone
Severe hypertension resistant to 3 antihypertensive drugs + Hypokalaemia + Adrenal mass/A family history of early onset hypertension or cerebrovascular events less than 40 years
Primary aldosteronism (Conn’s)
vitamin D normal serum value
75-250 nanomole/L
Back pain around the anus, scrotum or vagina
saddle anaesthesia
- investigate by MRI
Back pain without neurological symptoms
pulled muscle/muscle spasm
- analgesia + normal activity
pain in the distal interphalangeal joints + carpometacarpal joints + hard/bony swelling + evening stiffness
Osteoarthritis (OA)
pain in the proximal interphalangeal joints + carpometacarpal joints + soft/tender swelling + morning stiffness > 30 minutes
Rheumatoid arthritis (RA)
Bisphosphonates prerequisites
Vitamin D level (symptomatic hypocalcaemia)
renal function test (creatinine > 35mL)
Bisphosphonates side-effects
- oesophagitis
- jaw osteonecrosis
Scaphoid fracture
- proximal pole fracture 20%
- Distal pole fractures are 10%
- Most common site of fracture is waist of the bone 70%
Scaphoid fracture prognosis
distal pole fractures is better than proximal pole because of low risk of vascular compromise
- may take up to 1-2 weeks to become visible radiologically
Scaphoid fracture investigation
CT scan
Back pain diagnosis
chronic back pain persisting longer than 3 months, have to exclude:
- central canal stenosis
- nerve root compression
Back pain classification
1- Acute low back pain lasts less than 6 weeks.
2- Sub-acute low back pain lasts between 6 and 12 weeks.
3- Chronic low back pain persists for more than 12 weeks.
asymmetrical large joint monoarthritis/oligoarthritis + rash + uveitis + enthesitis
Reactive arthritis
Distal interphalangeal joints are most commonly seen in
Psoriatic arthritis
septic arthritis
septic arthritis management
- IV antibiotics (flucloxacillin) for 2 weeks
- Oral antibiotics after 6 weeks
Developmental dysplasia of the hip risk factors
- female
- breech presentation
- positive family history of hip dysplasia
Osteoarthritis not responding to pain
Severe
- orthopaedic consult for knee replacement
subluxed, dislocated femoral heads + knees are at unequal heights when hips and knees are flexed + asymmetric skin folds + limited abduction
Developmental dysplasia of the hip
athlete + overuse apophysitis of the tibial tubercle + pain upon quadriceps contraction
Osgood-Schlatter disease
4-10 years + avascular necrosis of the femoral head
Legg-Calve-Perthes Disease
sclerosis of sacroiliac joint
sacroiliitis
sacroiliitis ddx
– Psoriasis.
– Reactive arthritis.
– Ankylosing spondyloarthropathy.
– Arthritis related to inflammatory bowel disease
sacroiliitis causes
1-HLA-B27
2-Chlamydia and Gonorrhoea serology
3-RA factor, anti-ccp to rule out Rheumatoid arthritis
4-Inflammatory markers such as ESR and C-reactive protein
Absolute contraindication to total knee
replacement
Septic knee
most useful test for evaluation of osteoporosis
- DEXA
- 25-hydroxy vitamin D
‘pop’ at time of knee injury + severe pain + effusion (hemarthrosis) + instability of the knee changing direction
anterior cruciate ligament (ACL) injury
hx of type 2 DM + severe global passive movement restriction affecting all planes of movement + bilateral pain
Adhesive capsulitis (Frozen shoulder)
Adhesive capsulitis management
prednisolone 30 mg daily for 3 weeks
- wean after 6 weeks
lower limbs trauma or surgery + 24 to 72 hours after injury + altered mental state + dyspnoea + petechiae + eye/torso haemorrhage
fat embolism
serious complication after cast application
compartment syndrome
Hip pain management
- walking stick on the contralateral hand
compartment syndrome diagnostic symptom
throbbing pain increasing after wiggling fingers/toes
compartment syndrome complications
permanent nerve damage or loss of limb due to decreased circulation and oxygen to the tissue
Paget’s disease management
IV Zoledronic acid
Bisphosphonate, Alendronate
- paracetamol, NSAIDs
- vitamin D and calcium supplementation (prevent hypocalcaemia and secondary hyperparathyroidism)
Developmental dysplasia of the hip screening
- < 6 months: Hip examination (Ortolani), US
- > 6 months: X-ray
Osteoporosis risk factors
– Menopause
– Age over 70
– Corticosteroid use longer than three months
– Rheumatoid arthritis
– Alcoholism
– Smoking
– Anorexia nervosa.
– Inflammatory Bowel Disease
hip joint degeneration affected movement
Internal rotation
injuries warranting knee X-ray in children
– Isolated patellar tenderness.
– Tenderness at the head of the fibula.
– Inability to flex at 90 degrees.
– Inability to bear weight immediately after trauma and in an emergency
‘twinge’ or sudden pain + Medial Joint line tenderness + able to continue activity with some discomfort
Medial meniscus tear
Medial meniscus tear investigation
- barefooted with the knee flexed to 20 degrees and rotates the body
and knee three times internally and externally (Thessaly test) most useful
Flexion/rotation test (McMurray test) for screening
volleyball and baseball injury + flexion deformity + inability to actively extend finger
Mallet finger
posterolateral buttock + posterior thigh + lateral leg +
L5 radiculopathy
posterolateral buttock + posterior thigh + lateral leg posterior calf + lateral foot + diminished Ankle jerk
L5-S1 radiculopathy
shooting radiating pain through the posterior thigh and posterior leg to little toe + anterior + posterior motor symptoms
Sciatica
pain radiates through posterior buttock + posterior calf +
lateral foot + diminished Ankle jerk
S1 radiculopathy
pain radiating to the hip + anterior thigh + medial aspect of knee + calf + diminished knee jerk
L4 radiculopathy
Overweight adolescent + limping + hip stiffness + hip pain radiating to antero-medial thigh and knee
Slipped capital femoral epiphysis
sudden onset of severe calf pain + limping + absent plantar reflex
Achilles tendon rupture
Achilles tendon rupture investigation
Thompson Test
- absent plantar reflex
prominent acromion + loss of deltoid contour + slightly abducted and externally rotated
anterior shoulder dislocation
severe burning pain between the third and fourth toe + gets better walking barefoot + gets worse on weight bearing + localised tenderness
Morton Neuroma
anterior shoulder dislocation nerve injury
Axillary nerve
Mallet finger management
Maintain hyper-extension of the distal interphalangeal joint for 6-8 weeks
treatment for plantar fasciitis
- stretching exercises for the plantar fascia and calf muscles
- Avoid flat shoes and barefoot walking
- arch supports
and/or heel cups - Decreasing causative or aggravating exercise
- NSAIDs
- glucocorticoids and a local anesthetic
Osteoporosis treatment
- Alendronate, risedronate and zoledronic acid: first-line therapy in **postmenopausal osteoporosis **
and prevent vertebral, Non-vertebral and hip fractures. - bisphosphonates: primary prevention of fractures in px who never had minimal trauma fracture, secondary prevention of fractures
- Strontium ranelate: primary prevention of osteoporosis in women
- bisphosphonates and raloxifene: secondary prevention of fractures in women who have had minimal trauma fractures
Osteoporosis treatment not going to plan, what to do
- BMD T-score of =<-3
- > 1 symptomatic new
fracture after at least 12-months of
continuous therapy - > 2 minimal trauma fractures despite being on sufficient doses of bisphosphonates.
switch to teriparatide for 18 months
Paget’s most common location
Pelvis 70%
Slipped capital femoral epiphysis management
Percutaneous pin fixation
Normal BMD T-score
> -1
Ankylosing spondylitis features
- Sacroilitis is the earliest manifestation
- In only 5% cases, onset is after the age of 40 years
- Median age of onset is 23 years of age
- More than 40% patients present with unilateral ocular pain, lacrimation and
photophobia - Limited chest expansion
- Limitation of movement of lumbar spine in both sagital and frontal planes
- inflammatory back pain
Gout investigation
Diagnostic: joint aspiration
Adhesive capsulitis features
- bilateral 20%
- Diabetic 80%
- painful freezing phase, adhesive phase and a recovery phase 6months-2years
Adhesive capsulitis management
– 1st line: NSAIDS.
– 2nd line: - Intra-articular steroids
- Physiotherapy /Occupational Therapy
– Oral steroids (prednisolone) if NSAIDs not working
bilateral leg pain + worse on erect posture + responds to exercise
Spinal stenosis
osteopenic BMD T-score
-1 to -2.5
Osteoporotic BMD T-score
< -2.5
osteomyelitis in children
- S aureus
- secondary to deep cellulitis
-MRI investigation
child + fever + limp + raised ESR
Acute osteomyelitis
positive rhomboid-shaped birefringent crystals
Pseudogout
Negative needle shaped birefringent crystals
Gout
Winging of the scapula nerve impingmeent
Long thoracic nerve
pain and numbness in the fingers + HIV + multiple loose bodies in the ulnar bursal fluid
Mycobacterial tenosynovitis due to Mycobacterium avium complex
Scaphoid fracture complication
– Non-union.
– Avascular necrosis.
– Carpal instability.
– Osteoarthritis.
by trauma, as a result of a fall, or by the direct pressure and friction of repetitive kneeling
Acute prepatellar bursitis (housemaid’s knree)
Acute prepatellar bursitis management
- NSAIDs
- glucocorticoid injection
most common joint affected in diabetic neuropathy
tarsus and tarsometatarsal joints(midfoot)
Heel pain + medial tuberosity tenderness + worse getting out of bed + relieved by walking
Plantar Fasciitis
Most common pelvic bone tumour in young adult
Metastatic tumor
Gout causes
- Alcohol (increase urate)
Paget’s disease features
-Elevated alkaline phosphatase (early finding)
- bone pain (most common symptom)
osteoporosis most common site fracture
Vertebrae
bone pain + tibia bowing + enlarged skull with frontal bossing
Paget’s disease
Ankylosing spondylitis management
1st line: NSAIDs
2nd: TnF alpha inhibitors
- Infliximab
- Adalimumab
- rituximab
weakness of eversion and dorsiflexion + sensory loss of dorsum of foot + hc of colon cancer surgery
Common peroneal nerve damage
thickened fascia of 4th digit + joint stiffness + a loss of full extension
Dupuytren’s contracture
Dupuytren’s contracture management
depends on severity
low/moderate: Steroid injection
severe: Open fasciectomy
NEXUS Criteria
Dupuytren’s contracture cause
- Alcohol
- DM
- epilepsy
- male
corticosteroid use in osteoporosis
at least 3 months
lateral epicondylitis management
Band support below the elbow
pain worsens on thumb and wrist + grasping + tenderness on proximal to radial styloid
De Quervain tenosynovitis
Finkelstein’s test is used to determine
De Quervain tenosynovitis
Thompsons test is used to determine
Achilles tendon lesion/rupture
Lachmans test is used to determine
ACL
Drawers test is used to determine
anterior: ACL
posterior: PCL
Bulb sign is used to determine
Posterior dislocation of shoulder
Most common elbow fracture in children
supracondylar fracture
most serious complication of supracondylar fractures
Volkmann ischemic contracture
- permanent damage to nerves and muscles of the forearm leading to contractures
non-healing diabetic foot ulcer concern
osteomyelitis
- Do MRI
wrist movements is most likely to reproduce the pain in a patient with lateral epicondylitis
Resisted extension
Muishaft humeral fracture will cause what nerve injruy
radial nerve
Radial nerve injury
wrist drop
- decreased or absent thumb extension and abduction
- Decreased sensation over dorsum of the hand (thumb, index, middle and half of the ring fingers)
Acute herniation of an intervertebral disk that will require emergency surgery
crushed cauda equina
Signs of cauda equina compression
- loss of bladder
- loss of bowel control
- paraparesis/paraplegia
Tinel sign is used to determine
Carpal tunnel syndrome
Calcaneal fracture can give rise to what injury
spinal injury
- do Spinal x-ray series
shoulder pain + shoulder abduction weakness + external roation weakness
suprascapular nerve entrapment (SNE)
- shoulder abduction (supraspinatus)
- external rotation (infraspinatus)
medial deviation of the forefoot with a normal neutral position of the hindfoot
Metatarsus adductus (MA)
- corrects spontaneously;
rigid positioning + medial/upward deviation of forefoot & hindfoot + hyperplantar flexion of foot
congenital clubfoot
congenital clubfoot management
serial manipulation and casting
-surgery if dire
Median nerve injury
- Colles fracture
- acute carpal tunnel syndrome
- impaired thumb abduction
- paraesthesia
Colles fracture nerve injury
median nerve
age 3-8 + viral illness + acute hip/thigh Pain + limp + hip decreased range decreased range of motion
transient synovitis transient synovitis (TS),
transient synovitis transient synovitis (TS) management
ibuprofen
weakness of foot plantar flexion + inversion
Tibial nerve
Colles fracture cast management
the wrist should be in 10° flexion and 10° ulnar deviation 4-6 weeks
earliest complication of Colles fracture
Ischemic Volkmann contracture
most common complication of Colles
fracture
Malunion
Fromenr’s sign is used to determine
Ulnar nerve injury
blood supply to the scaphoid
distal to proximal
Most common type of scaphoid fracture
proximal pole fracture 20%
Diagnosis of rheumatoid arthritis (RA)
-Persistent joint pain and swelling affecting at least three joint areas
2-Symmetrical involvement of the MCP or MTP joints
3-Morning stiffness lasting more than 30 minutes.
(if there’s a rash: Psoriatic arthritis)
Rheumatic arthritis treatment
NSAIDs + DMARDS
Osteoarthritis treatment
symptomatic pain treatment
adhesive capsulitis movement restriction
all planes of movement but especially internal rotation
knee X-ray is required when a child presents after an injury
– Isolated patellar tenderness.
– Tenderness at the head of the fibula.
– Inability to flex at 90 degrees.
– Inability to bear weight immediately after trauma and in an emergency.
Major Branches of Brachial Plexus
- MUSCULOCUTANEOUS NERVE ( C5,C6,C7) - REMEMBER IT SUPPLIES- BICEPS
BRACHII, BRACHIALIS - AXILLARY NERVE ( C5,C6)- it wraps around the neck of humerus. REMEMBER DELTOID AND REGIMENTAL BADGE SIGN
- MEDIAN NERVE ( C5-T1)- REMEMBER - ALL FLEXORS OF FOREARM EXCEPT 1.5
- RADIAL NERVE (C5-T1) - REMEMBER ALL THE EXTENSORS
- ULNAR NERVE (C8-T1)- 1.5 FLEXORS + ALL THE INTRICATE MUSCLES OF THE Hand
Tonic clonic seizure 1st line treatment
Kids/adults: Sodium Valproate
Child bearing age woman: Leveltiracetam
Tonic clonic seizures 2nd line management
- Phenytoin
- Lamotrigine
Absence seizure 1st line management
- Ethosuximide
- Valproate
Absence seizure 2nd line management
- Clonazepam
-Lamotrigine
Juvenile Myoclonic 1st line therapy
- Sodium Valproate
Juvenile Myoclonic 2nd line therapy
- Clonazepam
- Lamotrigine
Focal Partial 1st line therapy
Carbamazepine
Focal Partial 2nd line therapy
- Phenytoin
- Valproate
- Phenobarbitone
- lamotrigine
Infantile spasm – West Syndrome 1st line therapy
- prednisolone
- Tetracosactin
Infantile spasm 2nd line therapy
- Clonazepam
- Vigabatrin
What is West Syndrome
Infantile spasm
Myocardial Infarction management
M- monitor
O - oxygen
V - vein/troponin
E - ECG
M - morphine
O - oxygen
N - Nitrates/nitroglycerin
A - aspirin
B - beta blockers
C - clopidogrel
H - heparin
Left vs Right side MI management
