Oxford summary 7 Flashcards
head lice tx
• Dimeticone- • Insecticide: effective. Four types o Melathion o Phenothrin o Permethrin o Carbaryl- prescription o Use 2 applications 7 days apart. Detector comb before and every 2 days until 2-3 after second application • Mechanical: wet-comb conditioned hair with fine-tooth comb every 3-4 days for 2 weeks
HIV 1st presentation
Primary: half are symptomatic or
o Mononucleosis- like: fever, fatigue, myalgia/ arthralgia ± lymphadenopathy
o Blotchy rash on trunk and orogenital/ perianal ulceration
o Neurological symptoms, diarrhea
HIV Tx: antiretrovirals
Entry inhibitors, II, NRTI, NNRTI, PI
Aim is undetectable viral load in <6months
Prophylaxis for opportunistic infection
HIV opportunistic infections
CD4 <200: PCP, toxoplasmosis, esophageal candidiasis
CD4 <100: MAC, cytomegalovirus
HIV Immunizations
Inactivated vaccines- influenza, pneumococcal, HBV, HAV
Live are contraindicated- (BCG, typhoid) but do give varicella, MMR to child-bearing age women CD>200
Scabies tx
permethrin 5% or malation lotion, reapply after 1 wk
Malaria Symptoms:
P/C
headache, malaise, myalgia, anorexia –> recurring high fevers, rigors, drenching sweats for 8-12h at a time
anemia, jaundice ± hepatosplenomegaly
Malaria Investigations:
malaria blood test 3x
Falciparum malaria:
can present up to 3mo later
Can be fatal in <24 hours esp if Preggo or <3 years
Malaria Complications:
cerebral malaria, hypoglycaemia, renal failure, pulmonary oedema, splenic rupture, DIC, death
Benign malaria:
P. vivax, P. ovale, P. malariae
Can px up to 18months later. Low mortality
Lie dormant in liver- viva and ovale or blood
Diphtheria: corynebacterium diphtheria
Spread by droplet or fecal contact
Px: inflammatory exudate with grey membrane in resp tract. Cutaneous form in countries with poor hygiene
Toxin affects myocardium, nervous and adrenal tissues
Tx: antitoxin, IV abx
Prevention: vaccination + booster
Orf: on hand
Solitary, red, rapidly growing papule <1cm diameter
History of close contact with sheep, cause- parapox virus
Incubation 6 days, resolve spontaneously in 2-4 weeks
Complications: 2° infection, erythema multiforme, lymphangitis
Molluscum contagioisum: on face, neck, trunk
Preschool kids, DNA pox virus spread by contact
Px: discrete pearly pink umbilicated papules 1-3mm diameter, if you squeeze= cheesy discharge
Lesions are multiple and grouped
If untreated- spontaneously resolve after 12-18moths
Can remove contents with forceps, curettage or cryotherapy
Necrotizing fasciitis
Life- threatening soft tissue infection after surgery/ trauma
Ill-defined erythema + high fever, wound becomes necrotic
Tx: admit for IV abx emergency ± surgical debridement
Wound infection
Px: swelling, erythema, tenderness ± pus
Risk: malnutrition, DM, steroids, infection, carcinomatosis
Management- swab for M,C&S
o Indurated + localized= staph: flucloxacillin 500mg qds or clarithromycin 500mg bd
o + cellulitis= strep: penicil V 500mg qds or clarithromycin
Foul smell= anaerobes- metronidazole 400mg tds
Staphylococcal whitlow (felo)
Infection that involves bulbous distal pulp of finger after trauma or extension from acute paronychia
Px: red, hot, oedematous, tender bulb. Sudden onset of pain
Management
Fluctuant: admit for drainage and abx
Non-fluctuant: elevate, apply moist head and po abx
Folliculitis
Superficial infection of hair follicle- S. aureus
Px: pustule in hairy area
Risks: obesity, DM, occlusion from clothing, topical steroids
Tx: antiseptic topical abx- fusidic acid flucloxacillin
If recurrent/ chronic tx like boil
Herpes simplex infection:
Transmission
direct contact with lesions- anywhere on body- mouth, lips, conjunctiva, cornea, genitalia
Primary HSV stomatitis: prodromal period <6h
Propromal period <6h: tingling, discomfort, itching small vesicles with erythematous base
Burt multiple, small, painful mouth ulcers
+ systemic: f, m, tender LN
Tx: analgesic mouthwash- benzydamine- healing in 8-12d. if <48 since onset= acyclovir 200mg 5x/d for 5 d
Herpes simplex Recurrent:
precipitated by too much sunlight, febrile illness, physical or emotional stress, immunosuppression.
o Less severe, more localized
o Tx; acyclovir cream 5% 5x/d for 5 d
Herpetic whitlow: HSV inoculation through skin break- HCW>
Swollen, painful, erythematous lesion of distal phalynx
o Reccurent/ chronic: swab for culture. Topical bx- naseptin qds 10d, hygiene, antiseptic in bath chlorhexidine, long-term abx- clarithromycin 500mg od
Viral warts: common and benign
Common warts: on hands
o Dome- shaped papules with papilliferous surface
o In children 30-50% go spontaneously in <6mo
Plantar warts (verrucas): on soles of feet o Pressure makes them grow into dermis, painful o Dark punctate spots on surface, group together= mosaics
Plane warts: on face and back of hands o Brown smooth, flat-topped papules o Resolve spontaneously o May show koebner phenomenon Tx: topical salicylic acid
Impetigo
Superficial infection due to S. aureus
Thin walled blister ruptures yellow crusted lesion
Most commonly on face, lesions spread and are contagious
Localized tx: topical abx- fusidic acid cream
Widespread tx: oral flucloxacillin or clarithromycin
Erysipelas and cellulitis
Acute infection of dermis. Px as flu like
Affects face/ lower leg- painful, tender erythema with well-defined border. Can be swollen and blister
Management:
Severe: admit and IB abx
Systemically unwell: flucloxacillin 500mg qds or clarithyromycin 500mg bd for 7-14d
Facial: penicillin V 500mg qds – flux if staph, clarithyromycin if allergic to penicillin
o Resurrent: prophylactic penicciln V 250mg od or bd
Boil
acute infection of hair follicle. Usually S. aureas
Hard, tender, red nodule around follicle + fever ± malaise
Can have pus and central core then heals, can scar
Carbuncle
group of hair follicles deeply infected. S. aureus
Swollen, painful with pus from several areas + fever + m
Management:
Non- fluctuant: moist heat for discomfort, help localize infection and promote drainage
Fever/ surrounding cellulitis/ facial lesion: flucloxacillin 500mg qds for 7d or clarithromycin if allergic
Large, localized, painful, fluctuant: incision and drainage
Recurrent/ chronic: swab for culture. Topical bx- naseptin qds 10d, hygiene, antiseptic in bath chlorhexidine, long-term abx- clarithromycin 500mg od
Kawasaki Disease: <5 years
Px with ≥5 of:
Fever for ≥5days
Bilateral conjunctivitis
Polymorphous rash
Lips/ mouth: red, dry, cracked lips, strawberry tongue
Extremities: red palms/ soles, oedema, peeling
Cervical lymphadenopathy >15mm, single, painful
Management: IV ig <10days after onset + aspirin
Complications: coronary arteritis + aneurysms, atherosclerosis
Scarlet fever: group A haemolytic strep
Incubation 2-4 days
Px:
fever, malaise, headache, tonsilitis, fine punctate erythematous rash sparing face, “scarlet” facial flushing+ strawberry tongue (white at first)
Tx: penicillin V 250-500mg qds for 10days
Complications: rheumatic fever and acute glomerulonephritis
Hep B Transmission: Px: Dx: Management: Prognosis:
Transmission: blood, sex, vertical, human bites
Incubation: 6-23 weeks
Px: asymptomatic or fever, malaise, fatigue, arthlagia, urticaria, pale stools, dark urine and/or jaundice
Dx: LFTS, serology
o HBsAg: 1-6mo post exposure. If >6mo later then chronic
o HBeAg: 6-3mo after acute infection = infectivity
o Anti-HBs: >10mo after infection= immunity
Management: avoid alcohol, supportive if acute. IFN + lamivudine if chronic
Prognosis: 85% recover, 10% become carrier, 5-10% chronic hepatitis cirrhosis/ carcinoma
Lyme disease: Borrelia burgdoferi
Spread: ticks from deer or sheep
Px: flu like + enlarged LN + arthralgia + splenomegaly + erythema migrans- red macule/ papule 7-10d later and expands to form ring with central clearing
Dx: serology, tx with 2-3wks of doxycycline
Hep A
Transmission via faecal- oral, infectious 2wks before being ill
Incubation 2-7weeks
Px: asymptomatic (kids), fever, malaise, anorexia, N/V, abdo pain, D, tender hepatomegaly, pale stool, dark urine, jaundice
Management: LFTs, IgM= acute, IgG=detectable life-long
Prevention: vaccinate travellers, chronic liver disease
Monovalent vaccine: Havrix
o HBV + HAV: Twinrix
o HAV + typhoid: Hepatyrix
o Passive with human Ig- protect for ≤3mo
Poliomyelitis
Spread: droplet or faecal-ral
Incubation=7d. Px 2d flu like then fever, tachycardia, headache, V, stiff neck + unilateral tremor (pre-paralytic stage)
65% with pre-paralytic state paralysis – myalgia, LMN ± RF
Management: supportive. 10% with paralysis die
Prevention
o 3 doses of 6:1 given at 2,4,6mo
o Booster in preschool and at 13-18years
Late effects: 20-30years later due to immobility
Weakness, fatigue, pain in muscles/ joints
Respiratory difficulty
Viral URTI
Coryza, runny eyes, malaise ± pyrexia, maculopapular rash
Management: exclude tonsillitis and otitis media. Self limiting
Pneumonia
Viral, bacterial (pneumococcal, HiB or staph, mycoplasma)
PC
Present with ≥1: o Fever, recurrent or persistent >38.5° o Cough o Chest and/or abdominal pain o Tachypnea, creps, BS ± bronchial breathing
Pneumonia Tx
Severe: O2 sat <92%, RR >77 if <1y or >50 if >1y, not responding to abx- admit
Less severe: fluids, amoxicillin ± macrolide if atypical, penicillin allergy or not responding
Use co-amoxiclav if a/w influenza
Prevention: pneumococcal vaccine at 2, 4, 13 months
Bronchiolitis
Occurs in epidemics- winter> in infants <1 year
Due to RSV
Px: coryza ± fever irritable cough, rapid breathing ± difficulty feeding
Ex: tachypnea, tachycardia, widespread creps ± high-pitched wheeze
Management
Mild: Paracetamol and fluids
Severe: lethargy, taking < ½ of feeds, dehydrated, intercostal recession ± nasal flaring, grunting, RR >70, cyanosis, O2 saturation <95% or apnoeid- admit
High- risk
Premature, <6weeks
Underlying lung disease, CHD or immunosuppression
Prophylaxis: palivizumab
Whooping cough: Bordetella pertussis
Incubation: 7 days
Stages
Catarrhal: 1-2wk- signs/ symptoms of URTI
Coughing: 2-6wk- severe and paroxysmal cough + spasms of coughing followed by whoop + V, cyanosis, exhaustion. Cough takes 2-3wks to improve
Examination: normal chest between bouts
Investigations: paranasal swabs- M, C and FBC
Tx: erythromycin in catarrhal stage then symptomatic
Prevention
Prophylaxis for contacts with erythromycin
Vaccination
Prevention of chickenpox
Varicella immunization 2 doses 4-8wks apart
Not contraindicated in preggos or Immunocompromised
If non-immune and exposed Vz-IG <3 after contact
Shingles
Cant be acquired by exposure to chickenpox but patients with shingles can get chicken pox
Px: unilateral pain before vesicular rash by 2-3d, crops over vesicles appear over 3-5d in dermatome distribution
Tx: oral acyclovir 800mg 5x/d if started <48h after rash
Px: shingles vaccine
Complications: post herpetic neuralgia, dissemination, eye involvement, Ramsay Hunt Syndrome
Measles 10 days Incubation: 10-14 days Early symptoms: Later sx: Com:
Early symptoms: fever, conjunctivitis, cough, coryza, LNs
Later sx: rash- maculopapular after 4days- becomes confluent, koplik’s spot- white spot on red background on buccal mucosa of cheeks
Com: bronchopneumonia, OM, stomatitis, corneal ulcers, gastroenteritis, appendicitis, encephalitis, SSPE
Rubella 10 days
Incubation: 14-21 days
Symptoms:
Complications:
Symptoms: mild- fever, LN, pink maculopapular rash for 3 days
Complications: birth defects, arthritis, thrombocytopenia, encephalitis
Mumps 10 days
Incubation: 16-21 days
Symptoms:
Complications
Symptoms: subclinical is common.
Fever, malaise, tender parotid enlargement ± submandibular
Complications:
aseptic meningitis, epididymo-orchitis, pancreatitis
Chickenpox 14 days Incubation: 10-21 days- infectious 1-2d before rash and 5d after
Sx:
Complications:
Sx: rash ± fever. Spots for 5-7d on skin/ mucous membrane. Macule papule vesicle dry and scab
Complications: eczema herpeticum, encephalitis, pneumonia, birth defects, neonatal infection
Roseola infantum 4-7 days Child <2
Symptoms:
high fever, sore throat, lymphadenopathy, macular rash after 3-4d when fever decreases
Erythema infectiosum- 5th disease/ slapped cheek
4-7 days
Parvovirus infection
Sx:
erythematous maculopapular rash starts on face,
reticular, lacy rash on trunk and limbs,
mild fever,
arthralgia
Hand, foot, mouth disease 5-7 days
Coxsackie virus infection
Symptoms:
oral blisters/ ulcers,
red-edged vesicles on hands and feet,
mild fever
Type 1 DM
Any age but more common in younger
Autoimmune ± islet cell Ig. HLA DR3/4
Prone to weight loss and ketoacidosis
Type 2 DM
Risk: >65, obesity, Fhx, impaired glucose tolerance, south Asians, Africans, gestational diabetes
Progressive and leads to impaired insulin secretion + resistance
Insidious onset and complications at dx
Latent autoimmune diabetes in adulthood (LADA)
6-10% of patients with T2DM and:
No features of metabolic syndrome
Uncontrolled hyperglycemia with medications
Other AI disease
Anti-glutamic acid decarboxylase (GAB) Ig
Higher risk of ketoacidosis and need for insulin
Maturity onset diabetes of the young (MODY)
Px <25 years with fhx. AD Gene mutations: HNF1- α, HNF1- β, HNF4-α, glucokinase- treatment different for each
DM Secondary causes
steroids, thiazides
pancreatitis, surgery, ca, haemochromatosis, CF
Endocrine: cushings, acromegaly, thyrotoxicosis, phaeochrom
glycogen storage disease, insulin R Ig
DM PC
Acute
ketoacidosis
hyperosmolar non-ketotic coma
Subacute: weight loss, polydipsia, polyuria, lethargy, irritability, infections, genital pruitis, blurred vision, tingling hands/ feet
Complications: skin changes, nephropathy, arterial/ eye prob
Asymptomatic: incidental or through risk stratification
DM Dx
Symptomatic:
Random blood glucose ≥11.1mmol/L or fasting ≥7mmol/ L
HBA1c ≥48mmol/L
Asymptomatic
RBG ≥11.1mmol/L or fasting ≥7mmol/ L x2
HBA1c ≥48mmol/L + random/fasting
Prediabetes: FBG ≥6.1 and <7mmol/L or HbA1c 42-47mmol/L
Routine diabetic review- 6monthly
Problems: live events, symptoms, difficulties with management
Review: o HbA1c, lifestyle, injection technique o Diabetes education, foot care o BG, lipid and BP therapy and results o Immunizations
Review complications: CV, nephropathy, neuropathy, eye disease, foot, erectile dysfunction
Planning: target for coming months, changes in therapy
Monitoring blood glucose DM
Fingerprick capillary glucose monitoring- need if taking insulin
HbA1c: measure 2x/year. Average BG over previous 6-8weeks
Indices of DM control
Adults FBG: 4-7 and PPBG: <9/
kids FGB: 4-8 and PPBG: <10
Urine: -ve
HbA1c: normal 20-43mmol/mol
Total cholesterol <4 and LDL <2
BMI: 25-30
BP <140/80- uncomplicated T2DM or <135/85- uncomplicated T1DM or <130/80 if any complications
Metformin
DECREASED gluconeogenesis and INCREASED peripheral utilization of glucose
Need some endogenous insulin production
Avoid in elderly, CVD, RF, LF, alcoholics= risk lactic acidosis
Hypoglycaemia not a problem
Sulfonylureas
First line if not obese, need rapid response or when met fails
Augment insulin secretion- so need endogenous insulin
SE: hypoglycaemia- take before meals and weight gain
Piogliatazone
INCREASE insulin secretion/ sensitivity, DECREASE BP and total cholesterol
No hypos, can cause weight gain, bladder ca, fluid retention, HF
Use with metformin and/ or sulfonlurea if poor control
DDP-4 inhibitors
INCREASE incretin levels. No hypos or weight gain
Use with metformin and/ or sulfonlurea if poor control
Linagliptin good for RF patients bc excreted by gall bladder
DM Treatment
Eating and exercise
THEN
First- line oral hypoglycaemics:
Biguanides: metformin 500mg-1g bd
±
Sulfonylureas: gliclazide 80-160mg bd
2nd/ 3rd line DM oral hypoglycaemics:
Pioglitazone 15mg od
DDP-4 inhibitors:
sitagliptin 100mg od, saxagliptin 5mg od, vidagliptin 5mg od/bd, linagliptin 5mg od
OTHER hypoglycaemics
Exenetide- bd/wk, lixisenatide- od, liraglutide od- obese. INCREASE insulin and DECREASE glucose absorption. Use w/ met or sulfon
Rapid acting insulin secretagogues: neteglinide, repaglinide: INCREASE insulin release. Rapid onset and short duration. Use with met if erratic lifestyle
DM Start insulin if poor control
combo with met + sulf
Types of insulin
Rapid acting
Soluble human, porcine or bovine
Intermediate/ longer actingLong- acting insulin analogues
Pre-mixed
Rapid acting insulin:
insulin lispro
Peak 0-3hours after injection, last 2-5 hours
Give prior to meals
Soluble human, porcine or bovine insulin:
actrapid- short acting
Peak 2-6 hours after injection, last 8 hours
Take 15-30 minutes before meals
Intermediate/ longer acting insulin:
humulin I
Peak 4-12 hours after injection, last 30 hours
Take alone, od/bd as background ± short acting
Long- acting insulin analogues:
insulin glardine
Last 24hours- background insulin
Lower isk of hypos
Pre-mixed insulin:
short acting + long acting
DM Cardiovascular complications
Increased risk of MI, stoke, PVD
Aspirin 75mg od as secondary prevention
Control SBP <145/90 mmHg before
DM
Statin: simvastatin 40mg or atorbastatin 20mg nocte
All T1DM with risk of arterial disease
All T2DM >75years
T2DM with any high-risk factors
T2DM >$0 with no high risk factors but 10y CVD risk >20%
Recheck lipid profile 1-3 months after starting therapy
Aim for total <4 and LDL <2
DM Fibrate: fenofibrate
If TG >4.5mmol/L- to pancreatitis risk
If doesn’t work- try omega 3 fish oil trial
DM HbA1c
<48mmol/mol: if T1 or T2DM treated with lifestyle or 1-2 meds
<58mmol/mol for everyone else
BP
T1DM
T2DM:
treat when SBP >135 or DBP >85, if proteinuria or signs of metabolic syndrome tx when SBP >130 or DBP >80
SBP ≥130 or DPB ≥80
Monitor every 4-6 months when stable
DM Renal disease complications
UTI
Can exacerbate RF and lead to renal scarring
Consider papillary necrosis if recurrent
DM Renal disease complications Nephropathy
More common in Asians and Africans
Proteinuria + HT + progressive worsening RF
Check renal function annually- first pass urine for albumin: Cr, dipstick for protein and haematuria, serum Cr and eGFR
Microalbuminuria when
o Ratio ≥2.5mg/mmol in males or ≥3.5mg/mmol in females OR
o [albumin]= ≥20mg/L without overt proteinuria or UTI
DM Renal disease complications Management
Optimize BG, monitor BP and treat
Modify diet
Microalbuminaemia or CKD with ACEI/ARB even if normal BP
DM Neuropathy types
Symmetrical sensory progressive polyneuropathy
Amyotrophy
Autonomic neuropathy
Symmetrical sensory progressive polyneuropathy
Starts distally- feet> hands- glove and stocking distribution
Px: asymptomatic or numbness, tingling, neuropathic pain
Management for pain:
- Duloxetine 60-120mg/d
- Change to amitriptyline 10-75mg taken at 5-7pm
- Change to or add pregabalin 75-300mg bd
- Change to or add tramadol 50-100mg qds
- Refer to pain clinic or endocrinology
Amyotrophy
Painful wasting of quadriceps- reverse with blood sugar control
Autonomic neuropathy
Postural hypotension: common in elderly. Increase salt intake
Fludrocortisone 100-400mcg od (SE: odema) ± flurbiprogen or ephedrine hydrochloride 30-60mg tds to relieve odema
Midodrine- α- agonist
Urinary retention
Diabetic diarrhoea: tx with 2-3 doses of tetracycline 250mg or codeine phosphate 30mg tds/qds prn
Erectile dysfunction
Gastric paresis: tx with antiemetic- domperidone 30mg tds
• Gustatory sweating: tx antimuscarinic propantheline bromide
DM Eye complications
Blurred vision: due to osmotic changes in lens
Cataract: “snowflake”- develop over days. Senile occur 10y earlier
Glaucoma
Retinopathy: most common cause of blindness
• BV get blocked, aneurysms, leaky leading to exudate formation, odeama or new vessels
• Tx: laser- photo-coagualtion to halt progression
Referral
• E: sudden LOV, rubeosis irdis, pre-retinal or vitreous haemorrhage, retinal deatachment
• U: new vessel formation
R: maculopathy, pre-proliferative retinopathy, cataract, drop in visual acuity
DM Skin changes
- Predisposition to infection
- Pruitis
- Xanthomas
- Vitilido- T1DM
- Neuropathic and/or ischaemic ulcers
- Fat atrophy/ hypertrophy at injection site
- Necrobiosis lipoidica: small, dusky red nodules with well defined borders. Single or multiple on shins. Slowly grow and turn brown. Yellow, irregular and flat. Can ulcerate
- Diabetic dermopathy: pigmented scars on shins
- Granuloma annulare: asymptomatic dermal nodules
- Diabetic cheiroarthropathy: waxy skin thickening over dorsum of hand with restricted mobility
Diabetes Mellitus
Diabetic Foot
Neuropathic Warm foot, bounding pulses, normal ABPI Found in pressure points Painless “punched out” Surrounded by callus
Vascular Cool foot, no pulses, ABPI Located at extremIties- between toes Painful Less clearly delineated
Charcot osteoarthropathy (charcot’s joint)
Neuropathic damage due to loss of pain sensation
TFTs
Thyrotoxic: low TSH, high T4
Hypothyroid: high TSH, low T4
Subclinical hypothyroid: high TSH, normal T4
Graves disease
Px:
30-50 years. Smoking and stressful life
Hyperthyroidism
Diffuse goiter ± thyroid bruit due to increased vascularity
Thyroid eye disease, pretibial myxedema, acropachy, onycholysis
`Thyroid eye disease px
Double vision, ophthalmoplegia (upward gaze>)
Exophthalmos and proptosis
Lid lag
Hypothyroidism (myxedema)
Causes: chronic AI thyroiditis
Px
Screening
Management
- Depression, fatigue, lethargy, mailaise, weight gain, constipation, hoarse voice, dry skin/ hair
- Signs: goiter, slow reflexes, non-pitting oedema
• TFT in tiredness without cause, on amiodarone, 131I, hypercholesterolaemia, infertility, turners/ downs, depression, dementia, obesity, DM, other AI
• <65: lexothyroxine 100mcg. Check TFT after 4-6wksyearly
• Elderly/ with heart disease: levothryoxin 25mg then increase every 4-6 weeks (+ propranolol bc can provoke angina)
• Overcorrection = AF and osteoporosis
Need for life time
thyroid tx β- blocker:
propranolol, atenolol for symptoms
thyroid tx Carbimazole:
inhibit synthesis of thyroid hormone
o Not for thyroiditis
o Can give short term before radioactive I or surgery
o Long- term (12-18months) to induce remission
o SE: agranulocytosis, hepatitis, aplastic anemia, SLE- like
thyroid tx 131I:
radioactive- need 3-4 months to work, TFT monitoring
o If on carbimazole, stop >4 days before and >3 after
o Avoid pregnancy for 4 months
o Risk of thyroid malignancy
thyroid tx Surgery:
partial or total thyroidectomy. Risk damage to PT, RLN
Pyloric stenosis
• Develops in first 3-6wks, failure to relax hypertrophy of adjacent pyloric muscle
• First born, boys>
• A/w fhx, Turners, PKU, esophageal atresia
• Px
o Projectile non-billous vomiting
o Failure to thrive, dehydration, constipation “rabbit pellet”
o Pyloric mass- olive palpable in right upper abdomen
o Visible peristalsis after test feed
• Management: surgical with Ramstedt’s pyloroplasty
Failure to thrive
• HC usually preserved relative to length and weight
• Weight consistently <3 centile or progressive in weight over ≥2 major centiles
• Non-organic causes:
o Lack of food due to neglect, poverty, lack of education
o Emotional neglect- family problems
• Organic causes
o Chronic infection
o GI- coeliac, chronic diarrhoes
o Heart, metabolic, respiratory (CF) disease
o Physical feeding probz: cleft palate, pyloric stenosis
• Assessment
o Amount and quantities fed
o Feeding problems, physical problems
o Full examination, look for signs of neglect, family size
• Management
o Treat reversible cause
o Refer if: no cause found, treatment not effective
Fever and acute illness in <5
Red- high risk symptoms/ signs
- Appear ill- pale, mottled, ashen or blue
- No response to social cues, doesn’t wake or stay awake
- Weak, high- pitched or continuous cry, grunting
- RR>60/min, moderate/ severe chest indrawing, T≥38C <3mo
- skin turgor, non-blanching rash
- Bulging fontanelle, neck stiffness,
- Focal neuro signs, seizures, status epilepticus
Fever and acute illness in <5
Amber- intermediate risk symptoms/ signs
- Pallor
- response to social cues, wake with excessive stimulation
- activity, no smile, nasal flaring
- RR, O2 saturation ≤95%, crackels in chest
- Tachycardia, capillary return ≥3sec, T ≥39° 3-6mo, rigors
- Dry mucous membranes, poor feeding, urine output
- Swelling of limb/joint, not using extremity
Fever and acute illness in <5
Green- low risk symptoms/ signs
- Normal color, normal skin/ eye turgor
- Respond to social cues, smiles, stays awake or waken easily
- Strong normal cry or not crying
- Moist mucous membranes
Common cause of Apyrexia
- Infections- UTI, TB, endocarditis
- Malignancy- lymphoma, leukaemia
- Immunological: stills or Kawasaki
- Drugs: Abx
- Liver/ renal disease
Temperature
<4 weeks: axilla with electronic thermometer
≥4 weeks: axilla or infared tympanic thermometer in ear
Acute illness in non-febrile kids
Can be sick without fever. Refer when:
o Red symptoms/ signs
o Persistent vomiting- > ½ of previous 3 feeds or bile stained
o Frank blood if stool or urine
o History suggestive of apneic episodes
UTI in childhood
risk factors
• Poor flow, dysfunctional voiding, enlarged bladder
• Hx of previous UTI, reccurent PUL
• Renal abnormality, fhx of vesicoureteric reflux or renal diease
Constipation, abdominal mass, spinal lesion, poor growth, HT
UTI in childhood
complications
• 5-15% renal scarring <2 years after first infection
• A/w pyelonephritis, HT, impaired renal function, RF in adults
Worse prognosis when recurrent, VUR, scarring at 1st px
UTI in childhood
PC
• Infants/ toddlers: V, irritability, fever, abdo pain, failure to thrive, prolonged jaundice
• Older: dysuria, frequency, abdo pain, haematuria, enuresis
Site: upper UTI/acute pyelonephritis: fever >38° ± loin pain
UTI in childhood
Tx
• Suspect in any child with fever >38°
• Urine testing if S/S of UTI, PUL, failure to recover from fever
o >3y: dipstick- M, C&S if +ve nitrate or leukocytes
o <3y: dipstick if acutely unwell and urent microscopy not available. Send for M, C&S
• Treatment: trimethoprim bd for 3 day for lower and 7-10 for upper. Review after 24-48hours if not better and urine M,C&S
o >3: start right away if +nitrates
<3: start right away if symptomatic
Congenital causes of childhood UTI
Horseshoe kidney
Ectopic kidney
Double ureter
Don’t affect function but predispose to UTI –> renal damage
Funny turns:
exclude fit and underlying cause- heart disease
Hx
Exam
- Ask witness about what happened
- General health
- Birth hx- problems in pregnancy, birth trauma
- Family hx- epilepsy
- Examination: full general/ neuro + developmental milestones
Funny turns DDX:
non-epileptic or epileptic- febrile or childhood epilepsy
Non-epileptic attacks DDx
Self- limiting and harmless
Simple blue breath-holding attacks: >6mo. Common due to frustration or upset
Signs: +ve valsalva, cyanosis, stiffening, coma
No tx- spontaneous recovery. Grow out by 3years
White reflex asystolic (anoxic) attacks: 6mo-2years. Due to minor injury or anxiety
Signs: vagal asystole, pallor, rapid coma, stiffening, upward eye movement ± incontinence
No tx- spontaneous recovery
Cardiac arrhythmia, hyperventilation Sleep phenomena Hypoglycaemia Benign myoclonus of infancy Benign paroxysmal vertigo
Febrile convulsions
Causes
Epileptic seizure due to fever in normal kid
Often fhx
<5min and generalized
o Viral infection
o Otitis media
o Tonsillitis
o UTI, gastroenteritis, LRTI, meningitis, post- vaccine
Febrile convulsions
Serious pathology if
> 10min
focal febrile convulsion
Not recovered within 1 hour
Febrile convulsions
Admit if
Complex, drowsy prior, irritable, systemically unwell, cause unclear
Meningitis suspected- petechial rash, abx or <18mo
Febrile convulsions
If not admitted
Reassure that they aren’t harmful
Paracetamol doesn’t prevent but symptom control
Advise to seek help if deterioration, non-blanching rash, fits again or if worried
Febrile convulsions
Outpatient referral if
Unsure if febrile convulsion
Frequent, severe and/or complex –> prophylaxis with buccal midazolam, rectal diazepam or anticonvulsants
High risk of epilepsy- fhx, coexistent neurological or developmental conditions
Asthma in Children
Diagnosis: >1 of following
Particularly if:
- Wheeze
- Cough
- Difficulty breathing
- Chest tightness
- Frequent and recurrent
- Occur without URTI
- Worse at night/ early morning
- Due to or worse after exercise and other triggers
Asthma in Children
Factors that increase likelihood:
- Atopy- +ve skin test, esoniphilia ≥4 and/ or specific IGE
- Fhx atopy and/or asthma- maternal atopy>
- Widespread wheeze, improvement of symptoms with tx
Asthma in Children
Factors that decrease likelihood:
• Symptoms only with cold, cold without wheeze or difficult breathing, moist cough
• Dizziness, light-headedness, peripheral tingling
• No chest signs, normal PEFR/ spirometry when symptomatic
No response to asthma therapy
Severe asthma in >2
- O2 saturation <92%, RR >40 in 2-5y, >30 in >5yrs
- PEFR 33-50%, cant talk, use of accessory muscles
- HR >140 in 2-5y and >125 in >5
Life threatening asthma signs in >2: O2 saturation <92% +≥1 of:
- PEFR <33%, silent chest, poor respiratory effort
* Agitation, cyanosis, altered consciousness
Significant asthma attach <2
- O2 sat <92%, resp distress, too breathless to feed, cyanosis
- Life threatening: apneoa, poor resp effort, bradycardia
childhood asthma
Exacerbations: treat early.
Prednisolone 30-40mg/d >5y or 20mg/d if 2-5y for 3-14 days.
Episodic childhood asthma
use leukotriene antagonists- start at onset of asthma/ coryzal symptoms and continue for 7 days
childhood asthma Intermediate probability (usually <5) TX
o Watchful waiting with review: mild, intermittent wheeze and/ or symptoms with viral UTIs o Trial of tx: bronchodilators and/or corticosteroids o Spirometry (usually >5): if evidence of airway obstruction, assess FEV1 change in response to tx, if of >12% = asthma. If no obstruction- test for atopic status, bronchodilator reversibility when symptomatic and/or bronchial hyper-responsiveness (exercise challenge)
childhood asthma referral
EUR
E: severe exacerbation/ URTI, unexpected clinical findings- focal signs, abnormal voice/ cry, dysphagia, stridor
U: persistent productive cough, failure to thrive, unclear dx, failure to response to >400mcg/d corticosteroid
R: excessive V, symptoms since birth/ perinatal lung problem, fhx unusual chest disease, nasal polpys, parental anxiety
childhood asthma Step management in <5
- Mild intermittent: inhaled short acting β2 agonist prn
- Regular preventer therapy:
• + inhaled beclometasone dipropionate 200-400mcg/d
• or leukotriene R antagonist if cant use steroid - Add on therapy
• 2-5y: leukotriene R antagonist, is used alone add inhaled steroid
• <2: refer to respiratory pediatrician - Persistent poor control
Selection of inhaler device
- MDI: inhale slowly and hold breath for 10s
- Show inhaler technique before prescribing and at check-ups
- Spacers and breath-activated devices if finding difficult or <5
- Dry powder alternative for older
Short acting βs agonist: salbutamol prn
- Work quickly and with fewer SE
* Poor control if using ≥2 canisters/month or >10-12 puffs/day
Inhaled corticosteroids
- Most effective preventer. Consider if:
- Exacerbations of asthma needing oral CS in last 2 years
- Using inhaled βs agonist ≥3x/week
- Symptomatic ≥3x/week or ≥1 night/week
Add on therapy:
1. Inhaled LABA:
salmeterol
1st choice in >5 - improve lung function and symptoms
Don’t use with inhaled steroids
Add on therapy:
2. Leukotriene receptor antagonist:
montelukast
decrease symptoms and exacerbations. Improve lung function
1st choice in <5
Add on therapy:
3. Theophylline or βs agonist
slow release tablets
decrease symptoms and improve lung function but SE common
Add on therapy:
Stepping down:
at ≥3mo intervals.
Lowest dose inhaled steroids.
Step management in <5
- Mild intermittent: inhaled short acting β2 agonist prn
- Regular preventer therapy:
• + inhaled beclometasone dipropionate 200-400mcg/d
• Use other preventer therapy if cant use steriods - Add on therapy
• + LABA
• Assess control of asthma
o Good: continue LABA
o Control inadequate: steroid to 400mcg/d
o No response: stop and steroid to 400mcg/d, if doesn’t respond try LRA or SR theophylline - Persistent poor control
• Increased inhaled steroids to 800mcg/day - Continuous or frequent use of oral steroids
• Use daily steroid tablet in lowest possible dose
• Keep inhaled steroid at 800mcg/d
• Refer to respiratory pediatrician
