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5th year winter semester exams > paediatric > Flashcards

paediatric Flashcards

1
Q

paediatric history

A

-patient profie (sex, name, age, DoB).
-antenatal hisotyr: mothers nutritional status, obstretic hisotry, maternal diseases/ infections/ mothers age/ gestational age. conception information/type of conception method.

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2
Q

post natal hisotry

A

first cry? -cyanosed/ apnoeic.
infections, procedures done? and basic problems-suckling, respiratory issues/swallowing. birth weight/length.

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3
Q

role of vitamin D in rickets?

A

calcium and phosphate metabolism. lack of mineralisaiton in bones due to imbalance b/w calcium and phosphate ionic ratio. bone deformity if prolonged and >18 months- 3yrs.

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4
Q

prenatal and post natal growth & development

A

prenatal: fetal placental and maternal factors.
post natal: genetic and environment.

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5
Q

developmental and growth

A

growth: increase in mass size due to multiplication and increase in intracellular substances.

development: maturation of functions due to maturation and myelination of nervous system-> achieve fine motor skills.

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6
Q

growth factors affecting prenatal/ fetus

A

IGF 1 & 2 (from liver & kidney) - 70%.
epidermal GF, TNF-A, platelet derived, nerve and fibroblast GF.

activated platelets influence leukocytes to release EGF, TGF-beta and fibroblast to make type 1 & 3 collagen.

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7
Q

growth spurts?

A

rapid- birth- 3 yrs,
slows till puberty: steady.
growth spurt at adolescent.
decrease in rate till maturation.

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8
Q

growth inhibitors

A

inhibin.
Mullerian substance (AMH)
transforming growth factor B (TGF -B),

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9
Q

fetal growth hormone prenatal?

A

predominatn in late gestation and postnatal.
insulin+ thyroxine for accretion and differentiation of tissue, glucorticoid suppports maturation of lung, liver and GIT.

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10
Q

maternal factors ?

A
  • poor nutrient, high pariy, short time between pregnances, substance misue, anaemia, recent pregnancy, gestational HTN, chronic systemic disease, TORCH infections.
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11
Q

placetAL FACTORS?

A

INCREASE VILLOUS AREA, DECREASED DIFFUSE DISTANCE, INCREASE CAPILLARY DILATUIN, DECREASE VASCULAR RESISTANCE.

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12
Q

GENETIC FACTORS

A

chromosome defect; short stature: down and turner syndrome. tall stature: klinefelt .

gene mutations: short (prader willi syndrome and noonan syndrome
tall: marfan syndrome.

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13
Q

nutreitn influence

A

macro vs micro nutreint.
micronutreint, calcum, vit A and D - fat soluble, zinc.
infections; diarrhea, recurrent RTI, TB, HIV, kala azar, chronic giardiasis, food toxins, food hygiene.malaria

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14
Q

hormones

A

GH deficiency, hypothryoidisim, growth hormone resistance.
low socio economic, poor diet, humid climate, emotional factors- broken homes, culture and religion.

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15
Q

barker hypothesis

A

IUGFR infants- DM, hypertension, hyperlipidemia later in life.

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16
Q

hormones in each phase of life

A

infant- nutrition, GH, thyroxine.
childhood: GH and thyroxine
puberty: sex steroids & GH.

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17
Q

laws f growth

A

different tisues and body growth at different rate.
brian and head rapid prenatal and post natal . 70 % in 1st tear and plateaus.
lymphoid tissuses, tonsil BM : peaks at late chilhood and declines.
reproductive (gonals) peaks at puberty.

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18
Q

prenatal period

A

ovum- 0- 1 wks.
embroy= 2-8 wkss.
fetus= 9 wks - birth.
perinatal : 23 wks >

post natal: new born from birth till 28 days ( 1 month).
infant- 1 year.
toddler- 2-3 years.
preschool- 4-6
school-7-12
and adolescent till 10- 19.

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19
Q

embronic period-

A

bi laminar, trilaminar ( 3 wks). 4 wks: human shaped, 4 cm and arm / leg buds.
5-8 wks: major organ system devleopment (maximum teratogenicity infleunce).
9 wks: fetal period begins/.
10 wks: external genitalia distinguished.
24 wks: 500 kgrams - viabilitiy. delivered be4 weeks-> immature lung maturity (low survive)
25 wks: 900 gm, 25cm.
38 wks: weight and length doubles from 25 wk.

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20
Q

athropometry:

A

weight-kg, length-cm,height HC and chest circumferences. upper to lower segment ratio, arm span.
normal birth weight-2.5 -3.5 kg
lenght: 50 cm
u: L: 1.7
hC: 33- 35
CC: 35cm
HC> CC always as time progresses.

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21
Q

postnatal growth

A

0-3 mnths: 25-30 grams/ day
4 m- 1 yr: 400 g/month
2yrs- puberty- 2/3 kg/ yr.

weight formula: wt in kg= age in years+ 4 )x2.
till 2 yrs: age in months + 9 / 2.

2x+ 8= wt for ( 2 yrs- 8 yrs).

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22
Q

height

A

wechs formula ht in cm = age in yrs x 6)= 77.
accelerated growth from 0-3 month then steady and increase 3-10 yrs.
adolescent middle rapid 8-10 cm and 3.5 kg.

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23
Q

drug precribing

A

consider in neonates: inefficient renal , deficiencies enzyme, inadequate detoxifying mechanism - high risk f toxicity.

parameters used to calculate dose - BW, SA and age.

mg/kg - consider metabolic rate and obese children.

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24
Q

complex therapies

A

drugs- etiologic pathogenetic or symptomatic therapy.
other approaches: surgical, physiotherapy, daily regular regimen, diet, monitoring.

administration of drugs not synonymous w/ good care.

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25
Q

general guidelines

A

smallest no. of drugs administered, inexpensive drugs used, dosage should be optimised, oral route preferred. adverse SE monitored. consider indication. safe dose/ overdose is even more important in infants.

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26
Q

administration

A

frequent administration, daily dose given every 6,8 or 12 hrs. calculate daily dose / 24 hrs.
routes: IM, IV or oral. SC rectal (suppositories ) or inhalation.
theophylline, phenobarbital and digoxin loading/ maintenance considered.
medical forms: capsule pills, ampoules, syrups, drops.

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27
Q

drug disposition

A

rapid/ slow.

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28
Q

physical examination of respiratory system

A

inspect, RR, note:-chest retraction, cyanosis, discharge, voice, sputum, cough & chest - shape , symmetry,
-palpation: tactile fremitus- vibrate when crying.
percussion- resonance can be normal, increased, dull ( collapse, consolidation or fluid) or decreased.

auscultation- breath sounds (vesicular-normal) , bronchial (increased) decreased or absent.

chest sounds- crackles-fluid, rhonchi, wheeze-narrowing, plural rub (friction).

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29
Q

CVD examination

A

inspection- heart hump, respiratory distress, scars.
palpation- trills, radial / femoral pulse apex beat.
BP, cyanosis, clubbing, tachy, sweats, tachypnoea, cardio/ hepatomegaly (HF features).
dextrocardia or plump children- difficult.

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30
Q

GIT.

A

throat, oral cavity (use tongue depressor) abdomen- flat/ distended, rigid/ peristaltic 10-30 seconds (supine/ warm hands).
liver- below right costal margin (soft or sharp?)
spleen.
5 f’s - fat, fluid, faeces (constipation), foetus, flatus (malabsorption, obstruction). palpate from liver-> bladder (4 quadrant) w/ parent.
tip; use their hands first.

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31
Q

GUS examination

A

inspect- labia, phimosis, kidney mass.
costovertebral angle tenderness (CVAT) - murphey punch sign - indicate pain in back percussion. observe signs for shortcoming - puberty development.

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32
Q

neurology

A

CN, reflexes, abnormal signs- tremors, chorea and athetosis- damage to basal ganglia.
meningitis- high ICP, sensory examination IQ.

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33
Q

opthalmic / ear examiantion

A

sclera-jaundice, pupils, discharge, tympanic membrane.
equipment- percussion hammer, stethoscope - small bell for infants.flashlight, therometer.

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34
Q

MSK

A

defromed bones, joint swelling,arthalgia, muscle tone.

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35
Q

rickets

A

low vitamin d3, ckd, liver failure, hypoparathyroidism, poor diet, dark skin, low sun light exposure.intestinal malabsorption (celiac and chrons).

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36
Q

metabolism of vit d

A

failure of vit d to convert to calciterol is due to enzyme deficiency.
formed in liver: 25 (0H) d3 to 1.25 (OH) d3 in liver which is active form. renal tubule resorption of calcium and bone resorption.
PTH detects low calcium, causes bone resorption and excretes po3 in urine.

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37
Q

lab result in rickets

A

high PTH, high ALP, hypocalcaemia- muscle spasm & twitching, low blood/serum phosphate. low vit D3
-xray: metaphyseal cupping, fraying and widening of plates. loose zones seen in pelvis.

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38
Q

clinical (stages) of rickets

A
  1. early stages: craniotabes, head sweating, irritability.
  2. advanced: craniotabes, genu verum, loose/fragile bones, deformities, rachitic rosary, pigeon chest, harrisons grove, delayed frontal closure, frontal bossing, abdominal protruding.
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39
Q

treatment

A

vit d3 supplement, treat underlying cause. mineral drops for neonates & infants. prophylaxis via giving maternal d3 supplies.
educate on good diet- increase fish, butter, eggs (good source), sunlight exposure.

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40
Q

rational intake nutrient

A

high caloric use in infancy from 1-3 months (1:3: 6) for protein, fat and carbs ratio. this decreases as they reach 1 yr.
water : 120-140 ml/kg/ 24hrs
roughly about 1-1.5 litres.
note type of feed (milk), frequency, characteristic, duration of feed.
fat solube vit- a, d, e , k and water souble: c,b, b2,6 and 12.
protein- essential AA for synthesis and carbohydrates.

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41
Q

breast milk for baby (+ benefit for mother).

A
  1. contains all relevant nutrients for baby: lactose ( lactobacilli), secretory IgA, other immune components. vitamins and water (88%), reduces risk of HTN, DM, IHD, lyphoma, orthodontic issues, ear infection, URTI.
    maternal benefit: uterine involution (prevent PPH), extra shed weight, reduces ovarian/ breast Ca, lactational amenorrhea (no subsequent pregnancy), reduce allergy.
    -contains omega 2,3. vitamin (fat and water soluble), galactocerebrosides, lactoalbumin, reduce solute load on kidney, PUFA for myelination of PNS. AA like cysteine and taurine for nuerotransmission.
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42
Q

food and what age to stary

A

1-4 months- strictly breast milk or formula. frequency: 6-7 times/ 24 hrs. and this reduces to 2 times till 9 mnths.
4+: veg madh.
5 months: yogurt, cereal, jelly, yolk. juice - small amount.
6 months: meat
7+: bread, cheese butter, sugar, oatmeal.
8: soup
9-12 : transition to food.

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43
Q

when to not breast feed for the mother and baby.

A

mother: chronic disease, infectious disease (HIV, untreated TB), metnal disease, pharmacotherapy -> risk to spread to baby: tetracycline , metronidazole, bromcriptine, high dose diazepam. radioactive compound.
alcohol or drug >0.5 g/kg/day.
if she doesnt want to.

baby: lack of suckling reflexes- cleft lip/ palate deformity, aspiration pneumonia, cerebro-cranial trauma, RDS, metabolic disease (galactosemia- cant metbaolise most lactose -> damage organs, lactose intolerant )

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44
Q

paediatric asthma

A

obstructive airway causing exhalation wheezing.
there’s persistent and recurrent wheezing or transient early wheezing (viral)- decreased LFT.
recurrent - igE modulated, skin prick / blood test can confirm.
atopic triad (stigmans present).

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45
Q

causes:

A

genetic predisposition or environmental.
atopy-> inflammation, bronchial hypersensitivity, narrowing (peak flow-spirometry) + clinical picture (wheezing, cough, breathless, chest tightness.

ddx:
0-1 :broncholitis, foreign body( stridor, sudden wheezing), aspration, coup, URTU, abnormal anatomy.
1-4 yrs: early asthma, CF, pneumonia.
>5: vocal cord dysufnction, allergic bronchopneuonia aspergillus, hypersensitivity pneumonitis.

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46
Q

investigations/ diagnosis

A

Albuterol efficacies + post bronchodilator response, spirometry (reduced FEF and FEV1), normal FVC peak flow meter.
consider allergy test if uncertain,
hospitalised (CXR).
clinical picture.
20% if respond to methoacholinic confirms dx.

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47
Q

treatment+ management of asthma

A

albuterol! racemic albuterol if CVD. systemic steroid (IV, IM, oral) - 2 hrs, terbutraline (tachy), avoid intubation as pneumo risk. ketamine (broncho) and other inhalation agent.

cont- ICU management, continuous nebuliser.
Q2:2 hr on meds, asthma score.
Q4: dishcarge if no longer o2 supplement, no ards, no albuterol requirement< 4 hr.

LABA’s not for acute but exercise induced trx- salmeterol. corticosteroid with inhaled LABA. systemic SE: growth , adrenal suppresion, bone isues if high dose used. beclometasone.

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48
Q

classification

A

classify asthma into intermittent (no more than 2 days a week and 2 nights per month), mild peristent (less than 1 daiy), moderate (daily) or severe episodes (LFT< 60 %) . consider no. of events and do patients experience episodes at night (cause awakening) & manage accordingly. counsel triggers (preventative measure). prevent arrest. use pulse oximeter< 92% severe- cyanosis, silent chest, peak flow< 50% poor respiratory effort.

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49
Q

cystc fibrosis definiton

A

gene mutation on chromosome 7 with CFTR protein causing defect with trasnporting Cl- across mebrame-> viscous mucus & cl- sweat (dx-electrophoresis). sodium reabsoprtion along with water-> dehydration & water cannot attract mucus.
autosomal recessive.
genetic testing confirms disease + clinical picture.

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50
Q

CF

A

thick meconium-> SBO. distended abdomen, bilious vomiting-> perforation-> sepsis. (sx: Hypo, tachypnea/ cardia).

early childhood: pancreatic insufficiency: malabsorption, failure to thrive, stearrhoea, pancreatitis (backed up enzymes), avitaminosis A.
lung -> pneumonia- gram positive and adolescent- gram -ve & p.aureginosa , bronchiectasias (permeanent dilution),

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51
Q

CF of cystic fibrosis

A

meconium ileum sbo, pancreatic insufficiency, biliary cirrhosis, stearrhoea, avitamosis, hemoptyosis broniechetasis, recurrent pneumonia,ABPA complications: hypovolemia, cardiovascular collapse,hypokalemia,contaction alkalosis.amenoorhe, subfertility in women

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52
Q

theophylline

A

used in COPD, asthma and some HF treatment. trx use bronchodilators and mucolytics (nebuuzers, n-acetyl-cysteine)/ dornase-alpha), chest physiotherapy. antibotiocs and anti-inflammatory mediatricss. CTFR modulators (lumacaftor and ivacaftor- help w/ protein functions

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53
Q

dx

A

meconium x-ray + clinical test :soap bubble/ ground glass appearance, bowel loop, PFT (obstructive pattern)- FEV1 lower, bronchiectasis (cyst shadows, tram lines,

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54
Q

forms of severe body weight anorexia

A

Forms-
◦ hypotrophy (light form), moderate
◦ marasmus (severe)
◦ kwashiorkor (severe)-sugar babies: oedema, flaky paint sin rash, hyperkeratosis, enlarged fatty liver, angular stomatis, depigmented hair, brady, hypotension, diarrhea, hypothermia, growth arrest , frequent infection

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55
Q

treatment

A

IV fluids- careful too much can lead to HF, small feeds rich in protein, Ab, nutrients treatment, correct electrolytes. bakers hypothesis- under nutrient in utero can be fixed with first 2 years of altering poor growth prognosis.

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56
Q

obesity

A

exceeds 95% percentile, RF for dyslipidemia, HTN, hyperinsulinism (DM type II) sugars lead to high insulin rise folowed by hypoglycemia
CNS and hypothalmaus- appetitie disorders, endocrine disorder, psychosocials
certain peptides like leptin decrease appetite and grelin increases hunger
tnf -A fat cells (increases insulin resistance affecting receptors)

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57
Q

RF for obesity:

A

FmHx, high birth weight, bottle feeding. positve enrgy balance and primary disorders in fat metabolism.

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58
Q

classifications of obesity

A

primary type (simple) or secondary (complicated) , diencephalon obesity- crangiopyharngeoma, hypothalamic syndromes, endocrine obesity (hypothyroidism, GH deficiency, Cushing), chromosomal obesity (downs, prader willi, turners) cerebral obesity (encephalitis, trauma).

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59
Q

dx of obesity:

A

growth curve, skin fold caliper. degree of obesity (1-4 ). body composition (lean vs fat). fat mass _ upper -> central and android -> RF for long term complications), low type (peripheral and gynecoid type ) and general (till puberty).

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60
Q

clinical

A

advanced puberty, bone age, adiomastia, flat foot (pes planus), tired & pain in limb, sweats, skin changes, acne, acanthosis nigricans, bulimia.

complications: orthopaedics, idiopathic ICP, hypoventilation syndrome- apnoea, HF, hypercapneia, Type II DM, HTN, lipid issues, increase malignant , PCO, irregular menses, early menarche,

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61
Q

labs

A

hyperinsulinism, impaired glucose tolerance, serum cholesterol, cortisol-normal or high, sexual hormones, (testerone and androgen increased).
diffiuclt management- low diet energy intake 1-2k calories. increase fibers, low rapid absorbing carbs- sweets. and more low saturated lipids- skimmed milk. increas eprotein, workit, reduce leisure.

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62
Q

acute abdomen

A

differnetial : acute appendicitis , cholecystitis, pyleonepthiris, gastroenteritis, ulcer, ectopic, ovarian / testicular torsion, ureteirc colic, peritonitis, IBD. SBo, LBO, aneurysm, MI, pancreatitis.mesenteric adenitis (common in children- confused w/ appendicitis)

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63
Q

GIT in paediatric

A

regurgitation, nausea, rumination, hemetemesis, dysphagia, vomiting, visceral v parietal (peritoneum, localised and exacerbated by movement).
hirsprung disease, mecolonium ileum, hyper amysalemia, ascites, diarrhoea faire to thrive, constipation- 2-3 day stool.
hirschprung- absence to pass meconium stool, loose stool. Aganglionic left segment - bilious vomiting,toxic megacolon. pyloric stenosis (projectile- vomiting). intussception- currant jelly stool.
midgut volvulus- emergency. bilious vomiting- emergency.

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64
Q

acute respiratory failure/ distress

A

pulmonary related or : sepsis, ingestion of toxics, metabolic acidosis, severe dehydration, HF. hypercapnia or inefficient gas exchange- tachypnea (in children-common, cant increase TVC).-> failure occurs due to overuse of inspiratory muscles.
nasal flaring- increase URT space. retraction: collapse of soft tissue- subcostal, suprasternal or intercostal retraction.

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65
Q

continuation of distress sx

A

grunting: expiraotry noise, low pitch in deep throat to maintain alveolar volume.
see-saw breathing: excess use of abdominal mm (lower airway obstruction) to help exhalation.
upper airway: supra/ sternal retractions r common.
head bobbing: to expand lung volume-> later sign, assisted ventilation if failure leaves or if uncorrected CPR
trx: supplemental o2, positioning, oor bronchospasmolytics etc.
stress sx: airhunger look, diaphoresis.

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66
Q

resporatory failure

A

definition: cannot use compensatory mechanism to exchange gas.

inadequate ventilation and oxygenation (pulse oximeter- o2 correction) (proved by ABG-cyanosis be4 arrest). o2 supplement can deceive as it saturates well.
tachycardia, hypertension, diaphoresis. hypercabia- suffocation feeling, exaggerated stress response, agitation, inability to settle.

67
Q

more info

A

solemance (drowsiness), desaturation, co2 narcosis.

68
Q

anatomical differences

A

smaller airway, reduced alveoli count, less elastic parenchyma, v/q mismatch 1:4.more resistance in URT. horizontal ribs -> limited chest expansion.
respiratory muscles: lack power/tone. < 4 yrs: obligate nose breathers.
primary pulmo disease: restrictive (impaired expansion, disease of parenchyma) vs reduced vital capacity vs narrow airways).

69
Q

causes of respiratory disease:

A

infants: pnuemnia. foreign body, CF, bronchiolitis. congential disease.
older children: pnemonia, croup, peritonsilar abscess, CNS infections, NM disease (GBS, SC injury), metabolic acidosis (hypoglycemia, dM) Anemia (SOB). salicylism- overdose of salicylates.

70
Q

CF + trx for ARF

A

tachypnea, dyspnea, stridor, cyanosis, wheezing, rhales, crackles, absent or decreased BSm altered LOC. cyanosis or tachycardia. # young pts irredponsive to bronchodilator
physiological parameter: 1-3 rd degree. if ph is below < 7.35 and pao2 is above 60 mmhg. idnciate hypercapnia and hypoxic.

labs: CXR, ABG, oxymetry CBC, ECG. intubation oxygen (face mask oxygen tent/ hood, catheter, mechanical ventilator).
dureitcs, bronchodilators, corticoseroids, AB, aspirate fluid and URT.- adrenergetic agent, cholinergic antagonist, methylxantins (10-20 PO or 5 mg/kg 20-30 min)

71
Q

acute respiraotry infection

A

children are acuqiring immunity. feedin\Qng issues as theyre obligate nose breathers. cough, snuffles, wheeze, breathless and stridors are sx.
-sinusitis, acute otitits media, sore troat, and common cold.
fever-paracetamol.
sx: discharge, blockage, earache, acute exacerbation of asthma.

72
Q

common cold

A

common infection- clea ror mucopurulemt discharge and blocked nse. viruses: rhinovirus, corona, RSVS. self limiting

73
Q

pharyngitis (sore throat)

A

pharynx and soft palate inflamed, LN tender and large.
viruses: adeno, entero and rhinovirus. older: group A strep.
tonssilitis:purulent exudate, pathogen: EBV, strep A, s. pnemonie, s,aureusm H. influenza, m. catarrhalis.
sx: odynophagia, dysphagia, trismus, malaisa, otalgia, fever.

74
Q

associated tonsilitis sx

A

-cervical, submandibular and jugulodigastric LN. exudate enlarged tonsils, strawberry tongue (scarlet fever and palatal petechiae (infectious mononucleosis).
trx: Ab -penicillin or erythromycin. 10 day trx, rest, warm saline gargle, analgesic /antypyretic. complication: rheumatic fever, GN, scarlet fever, arthritis.

75
Q

otitis media (acute)

A

jan-april. 6-12 months. infants prone due to shorter, horizontal and poorly functioning eustachian tube. etiology: s.pneumonia. same agents as tonsillitis.
pre-disposing: obstruction (carcinoma, adenoid hypertrophy and barotrauma), URTI, allergic sinusitis+ chronic.

76
Q

otoscopy examination in acute otitis media

A

recurrent infection-> effusion. fluid level visible. grommet helps to reduce fluid, to reduce conductive hearing loss. complication: TM perforation, ossicular necrosis, mastoiditis, labyrinthitis, CNS related (mengititis, abscess, CN 7 paralysis. 2-7 yr affected.
infection:10 day course of 80-90 g/kg amoxicillin and other penicillin.

77
Q

sinuisitis

A

paranasal sinus infection -> upper RTI’s. pain, swelling/ tenderness over cheek from maxillary sinus infection. Ab+ topical decongestant. frontal sinus not formed properly yet.

78
Q

influenza

A

flu, type A, B and C. coryza (catarrhal inflammation nasal membrane, myalgia (type B), fever, cough. autumn + winter.
complication: TRF- viral pneumonitis or bacteria super infection.
trx: self limiting, supportive. immunization if vulnerable

79
Q

BOS (bronchial obstructive syndrome

A

not independent dx, but complex of etiology and symptoms. cause: function (reversible ) or organic (irreversible-congential stenosis). bronchial functional patency impaired.
etiology is key!
dx: fhx (allergy), recurrent RT, genetic predisposition of atopy.
main: acute bronchitis, asthma.

80
Q

Sx of BOS & factors

A

prolonged exhaled, asthmatic fit, axillary muscle grp use, decrease in PaO2, productive cough, wheezing.
-poor immunity, early bottle feeding-rickets, malnourished, perinatal pathology, bronchia hyperactivity, prone to RT’s, passive smoking, coupled allergy hx.

81
Q

causes/ pathogenesis. groups

A

groups: RT -croup, GI, hereditary & others: bronchopulmonary dysplasia ( immature alveoli), foreign body, TB. #
GI (SOB?): achalasia, oesophagitis, GERD TE fistula, diaphragmatic hernia.

hereditary: deficiency of alpha- 1 trypsin (disease includes COPD, liver, vasculitis, panniculitis), CF.
other: parasite/ immunodeficiency.

82
Q

alpha 1 trypsinogen deficiency

A

liver-neonatal hepatitis, cirrhosis (child-Pugh classification), bronchiectasis, 2 bronchitits, copd. wt loss, tachycardia.
AAT produced in liver-> travel to lungs to protect against neutrophil elastase.

83
Q

diagnosis of BOS

A

bloods : ABG, ascultation sounds (stridoe, wheezing, ARDS, aspiration), history. ENT
CXR: atelectasis, foreign body, exclude penumonia, bronchiectasis (honey comb)
screen for neonatal clamydia, mycoplasma, allergy test,

84
Q

foreign body aspiration (upper RT obstuction)

A

partial or complete obstruction. if in glottis/sub can cause complete obstruction.
partial: gag, cough, biphasic inspiratory stridor, choke, dyspnoea, tachypnoea (high RR). unilateral wheezing (unlike asthma)
complete: unresponsive, cyanotic ,ARD’s (CPR).
dx: physical assessment, history, CXR- hyperinflation (de-inflation in ptx), infiltration and atelectasis, radiopaque object seen.
neck-AP/lateral. fluoroscopy, CT, laryngoscopy.
management: Heimlich’s manoeuvre (different for <1y (back/ chest thrusts) and >1 yr (5x abdomen).
ddx: viral -croup, laryngitis, epiglottis. trauma: collapse/haemorrhage, anaphylaxis

85
Q

management

A

priortise oxygenation (o2 supplement-> facemask non breather - 15 litres), estabilish patent airway and secure.
parent education- cut up small piece, no distraction during food. smaller diameter and child explore with object so keep eye.
parent -> CPR class,
-some children 1/2 asymptomatic.
complication: atelectasis, edema, aspiration pneumonia

86
Q

additional info

A

initial: violent paroxysmal.
asymptomatic: reflexes fatigue. subside sx.
laryngeal obstruction- croup, cough, drooling. lodge b/w VC in sagittal plane.
stridor-60% & wheezing 50%.tracheal:PA, lateral soft tissue X-ray shows abnormal in 92%. CXR: air trapping, emphysema, shifted of mediastinum to unaffected side.
obstructive emphysema, air trapping, atelectasis. lungs- R bronchi’s in 58%.
complication in 3rd stage- fever, haemoptysis, pneumonia, atelectasis.

87
Q

aspirated

A

stridor if in trachea.
unilateral ‘asthma’ if bronchial.
if total- cough, lobar pneumonia, pneumothorax etc. use bloods to rule out infection - no WBC or febrile. p.s batteries dangerous since can erode aorta

88
Q

bronchiolitis

A

inflammation due to RSV in bronchioles. in winter, common if <1yr esp in premature w/ chronic lung disease.
wheeze+ crackles, coryzal sx, ARDS, poor feeding, mild fever, aponoea’s.
sx of ARDS: SCM , abdominal, intercostal m used, nasal flaring, tracheal tugging, raised RR, grunting - against partially closed glottis to increase PEEK.

89
Q

admissions

A

< 3 months, pre-existing conditions, clinical dehydration, < 50 % feeding, moderate- severe ARDS, parent cannot manage. RR> 70, PaO2 < 92%. signs of T2RF (acidotic, hypercapnia and hypoxic)- lows cannot ventilate-> collapse.
management: supportive, saline nasal drop/ suctioning, supplemental O2, increase oral, IV or NG feeding.
ventilatory support if severe: CPAP, high-flow humidified oxygen w/ tight cannula, intubation.
capillary & arterial BG.
prophylaxis: palivizumab- monoclonal AB injection (passive and last for 1 month)

90
Q

acute and chronic bronchitis

A

non specifi brnchial inflammation- usually post viral URT’s, cough for 103 wks. oldfer children- angina.
key: exclude pnuemonia.
chronic:3 months or > for every year for 2 years. damaged epithelium-> recurrent infection -> investigate for systemic/ pulmo disorders.
dual infection of RSV & human metapnuemovirus is severe.

91
Q

investigation of respiratory Respiratory viruses.

A

PCR analysis of nasopharyngeal secretion. pulse oximeter determines concentration of humidified oxygen needed.
rarely will airway be damaged leading to bronchiolitis obliterans (stenosis/ fibrosis/ occlusion)

92
Q

acute pneumonia

A

infection of lung parenchyma- 20% overall deaths.colder monthss
LRTI’s-> deficiency in mechanism of mucocilary drainage, cell-humoral defence, cough reflex.
RF: poverty, prematurity, urban residence, smoking.
neonates: aspiration of infected amniotic fluid (GBS, ecolio).
1-3 months: RSV, infleunxa, human metapneumonvirus.
afebrile or atypical: chamydia and b. pertussis (check immunization hx).
3mont- 4 yrs: strep pneumonia, moraxella catarrhalis.
5 yrs: m. pneumonia & chalmydophilia species atypical.

93
Q

CF of pneumonia

A

non specific CF: tachypnea (specific), hypoxemia, abdominal pain, increased breathing, ARDS (neonates after birth-tachy, poor feeding, temp instability).
bacterial: greater severity, sudden onset.
atypical: progressive, sudden fever and broad spec spectrum: sore throat, malaise, prolonged cough, headache, photophobia.
afebrile: conjunctivitis, diffused rales on examination, staccato cough, rhinorrhea.
viral: gradual, preceeded via fever and upper RT (congestion, cough)

94
Q

ddx for pneumonia

A
  1. transient tachypnea of newborn, RDS, bronchopulmo dysplasia, aspiration, copd, CF, aspiration pneumonia (GERD, cleft palate, NM disorders, TE fistula, orophyarngeal dysphagia), anatomical disorder0 bronchogenic cyst, congential lobar emphysema.

Hx: nature of cough, obset of symptoms, poor appetite, lethargy and poor appetite indicate severity.
vital signs + auscultation- bacterial lobar-dullness to percussion, rales, dminished breath sound (viral -low pitched wheezig throughout), oximetry.
dx: PCR for virus (secretion/sputum culutres), if severe- CXR, blood culture and CBC, Ab, hospitalization, if AB fails and severe ARD, toxic appearance, O2 <90%.

95
Q

atreatment for pneumonia

A

< 3 months- 6 mnths-> hypoxmeia, bacteremia & deterioration-> hosptialized.
outpatient: depend on age & offending agent. if viral -> supportive.
bacterial: amoxicillin-> PO.
macrolides azithromycin: atypical pneumona.
aerythromycin-> afebrile due to chlamydia.
oseltamivir: influenza, higher risk of complication, high risk.
immunization status checked -> ampicillin IV for s. pneumonia.
inpatient: ceftriazone injection, atypical dual beta lactam+ macrolide/floroquionolones,
vancomycin (MRSA).
complication: PE, abscess, empyema. large loculated -> thoraco/ chest tube.
abscess (MRSA)- same trx.

96
Q

chronic pneumonia

A

> 3 months or recurrent for > 3 x a year. CXR: atelectasis, pneumofibrosis, heavy bronchial marking+ permeanent lung lesions.
etiology: 2 pulmo disease. school age. defect in anatomy, immune system, cogneital L-R shunt, CF. SMA (severe hypotonia)
exogenous: MV, hyaline membrane disease, cronic tonisillitis/adenositis.
klebsiella, strep/staph, pseudomonas
CF: prolonged infection/ hypoxomia: anemia, clubbing, growth resitriction, ECG changes ( P-wave -> atria), VC changes.
exacerbation: bronchiectasis cavities blocked.
dx: bronchogra,/ bronchoscopy. clinical.
trx: diet, surgical, adenotonsillectomy, Ab, postural drain, VAT??

97
Q

check for asthma and IgE mediated hypersensitivity…

A
  1. growth- food allergy, malabsorption
  2. kids treated with high dose inhaled/ nasal/ topical corticosteroid.
  3. obstructive sleep aponea.
    hyperinflated / Harrison’s sulci chest (under treated asthma).
    role: identify triggers and manage multi-system diseases.
    immunotherapy: solution of allergen is injected subcutaneous/ sublingual administration-> develop immune tolerance (3-5 yrs), UNDER SUPERVISION.
    different allergic reaction co-exist, if 1 is present, look for others.
98
Q

TB

A

asymptomatic: local inflamaotyr reaction limits disease progression-> latent. (if mantoux +ve then isonazid & rifampicin for 3 mnths).
24mm induration using PPD (purified protein derivative). if >10 mm (no BCG) and >15 mm (BCG given).
CXR: marked L. hilar LN.
syptomatic: children dont infect others. Ghon complex-> calcifies, lung lesion, LN -> spreading to LN. inhaled tuberculi failed to be contained by hosts immune system.

systemic manifestation: anorexia, wt loss cough fever, CXR changes. peribronchial LN -> obstruction. 1 infection (lungs) but cold abscess and metastic lesions occur.
post primary-> disseminated/ miliary-> gut, bones,CNS common, pericardium.

99
Q

TB manifestation in paeds population

A

TB menigitis ( emergency) if brain-> seizures.
dx: difficult to obtain sputum-> need NG gastric washes before food. urine, CSF, CXR, LN excision available.
PPD test: 0.1 ml intradermal injection-> 72 hrs in forearm (erythema/ papule).
IGRA used routinely-> specific.
trx: triple/quadriple therapy (ethambutol. pyrazinmide, rifampicin, isoniazid).
2months: rifampicin. isoniazid.
> puberty: pyrixodizine given weekly: reduce P Neuropathy assoc isoniazid.
TB menigitis: dexametheasone to reduce sequale.
uncomplicated: treat longer (6months) but disseminated then >.

100
Q

vomiting

A

posseting- normal: small amount of milk accompanied w/ return of swallowed air.
vomiting- forceful coordination expulsion of gastric content.
ddx: infection (fever & associated sx: Gastroeneteritis, UTI)
regurgitation: GERD
dysphagia: achalasia,
nasuea and epigastric pain- gastritis
early morning- neurological (ICP, headache,papilloedema meningitis).

101
Q

list DDX paediatric vomiting ?

A

neonates: / infants: pyloric stenosis, atresia, inutssception, malrotation, volvulus, hirsprung disease, hernia, otitis & other URTI’s, pertussis, inborn error of metabolism

metabolic disorder- unusual odor
Heme positive stool/melena- oesophagitis, ulcer (hemetemesis) .
virilisation in girl- congenital adrenal hyperplasia.
pregnancy, torsion of testis, coeliac disease.
flank pain- pyelonephritis, RF.
adolescent- bulimia/ eating disorder, appendicitis, coeliac, DKA, toxic ingestion, cyclic vomiting syndrome.

102
Q

types of vomit (color, appearance and associated sx) & what is indicated?

A

bile stained vomiting- intestinal obstruction.
haematemesis- oesphagus disorders- esophagitis, varices, mallory weiss, boerhave syndrome, ulcer.

projectle vomiting after feeds start- pyloric stenosis (congential)

abdominal tenderness (N+V)- acute & surgical abdomen.
distension- obstruction, strangulated hernia.
hepatosplenomegaly- chronic liver disease

blood in stool- malignancy, intussception, strangulation, vasculitis, ischemia? gastroenteritis, parasitic (giardia, amoebic dysentery).
severe dehydration- severe GIT issues, UTI, sepsis, meningitis.
bulging frontanelle/seizures- ICP
failure to thrive- GED, coeliac, other GIT conditions.

103
Q

necessary investigations to diagnose and ddx etiology of vomiting in paediatric population?

A

CBC- anemia in hemorrhage.
electrolyte- severe dehydration and vomiting causes metabolic acidosis or alkalosis (loss of stomach acid).
high BUN/ cr- dehydration or CKD?
liver enzymes -elevated.
hyperbilirubinemia- liver disease
urine culture-UTI
X-ray-air fluid level (meconium ileus and other bowel disorders).
contrast Xray- anatomic anomalie.
abdomen US- renal stone, gall stone, hydronephrosis, appendicitis. pancreatitis
endosocpy- varices, ulcer etc.
abdominal CT
head MRI- tumor, trauma, abscess etc.
pregnancy test.
physical exam & ausculation- absent peristalsis (if notheard 30 seconds indicate obstruction)
good history- bowel habits, frequency, time of vomit after feeds, assoc sx etc. signs of dehydration.

104
Q

air flud level on Xray

A

bowels have normal fluid to air level. mutliple air fluid levels, distended bowels and clinical picture keeping with acute abdomen + vomiting indicate BO.
air rises to top and fluid at the bottom.however in lungs its always PATHOLOGICAL.

105
Q

GERD

A

physiological GER up to 2 months.
LES under-developed, short intra-abdo length, horizontal lying, pre-dominantly fluid diet. crying: intragastric pressure increase.
resolve via 1 yr- LES matures/ higher tone, solid in diet, toddler sits up.
delayed gastric emptying time, impaired oesophagus motility, loss of anti-reflux barrier of diaphragm- depends on angle it enters stomach.

106
Q

CF of GERD in paediatric?

A

small multiple episode volume’s of vomiting post feeds, effortless & painless. non bilious and no blood.

107
Q

complication

A

failure to thrive if severe.
recurrent pneumonia aspiration of stomach content- apnoea, cough, whezing, pneumonia sx.
stricture, barretts, oesphagitis (acid irritate mucosa-> haemetesis, anemia.
ALTE.
sandifier (side and opitsononsis (back-arching).
older- hearburn, epigastric/chest pain.

108
Q

investigations

A

history and physical exam.
regurgitation- spitters-> physiological. but > 2x/day & >2-3 wks.
infant reflux: normal till 2 yrs.
only if FTT, pulmo sx & esophagitis -> pathological.
investigation- necessary if sx persist> 18 mnths.
GERD clinical. if atypical: 24 hr ph test monitoring to quantify degree of reflux, barium swallow, radionucleotide scanning.
barium- anomalie.
trial of empiric therapy-> if fails then investigate.

109
Q

management of GERDS in children?

A

frequent smaller feeds. minimize supine-> raise head 90 degree.
formula thickened with cereal, rice powder
if BF then mother diet avoid egg/ cow milk (consider mother milk protein intolerance).
1 hr before bedtime.
H2 blocker (ranitidine)- PPI (omeprazole)
surgery- nissen fundiplication.
formula- frisovom.
domperidone- improve motility & emptying time.

110
Q

acute abdominal pain ddx

A

acute gastroenteritis:

< 2 years: UTI, intussception, IBO, incarcerated inguinal hernia, trauma, voluvus, malrotation -> ischemia.

> 2yr: SCA (vaso-occlusion of mesentery), lower lobe pneumonia(diffuse), UTI.

adolescent: IBS, pancreatitis, diverticulum, PID, ovarian. testicular torsion, ruptured ovarian cyst, ectopic, peritonitis/appendicitis, mittelschlerimers (small blood w/ folciule rupture irritates peritonium)

111
Q

ddx by localisation

A

renal/ureteric pain- lat/posterior pain.
gastritis/GERD: epigastric/ chest.
peptic ulcer: night.
spinal/ back: lateral and over spine (movement).
liver/GBS: right hypochondrial pain.
constipation: BO relief.
gynecological: suprapubic/ iliac fossa ->
abdominal migraine-> acute attack/pallor & vomiting.
consider pyschosocial factors-abuse/bullying.
look for jaundice, color of vomits, IBS like sx,

112
Q

acute appendicitis

A

commonin adolescent >3 yrs.
etiology: lymphoid hyperplasia infection) or fecoliths (acts like diverticulum-> obstructs).
1.localised abscess/ gangrenous.
sx: N+ V, anorexia, abdo pain (periumbilical and RLQ-mcburney point), fever, pain aggravated w/ movement., low grade fever.

ddx: IBS and yersinia infection, mesentery adenitis.

113
Q

diagnosis + management

A

plain abdo xray: faecolith seen.
WBC elevated high, U/S, CT scan. thick and inflammatory changes.
pre-school: perforation due to poorly developed omentum, doesn’t surround appendix.
trx: hydrate & correct electrolyte abnormality Ab and appendectomy.
enterocutaneous fistula, perforation-> sepsis, pelvic abscess.

114
Q

acute diarrhoea :definition & casuative agent.

A

increased stool output with loss of electrolyte and fluid. etiologic: infectious vs malabsorption.
osmotic (resolve w/ fast)or secretory (doesn’t increase w/ intake).
viral: rota (common in winter-> day care0.
norwick (cruise ship).
bacteria : e.coli, shigella (reptile), salmonlela, yersinia (pet/pseudoappendicitis)).clostridium
(Ab use)

parasite: emboetic histolytica, giardia.

115
Q

features associated with each etiology.

A

rota virus: watery diarrhea 7-10 day +/- vomiting.
e.coli: daycare/nurseries.
salmonella: animal products, reptiels.
shigella: contamined food, seizures.
clostridium: Ab use significant
camylobacter: contamined food cans.
yersinia: pets, contamined food, arhtritis, rash assoc (mimick ibs/ appendicitis.
s.aureus: food posioning, 12 hr onset.

116
Q

dx + management

A

stool sample, enzyme immunofluorescent.
management: viral (supportive)+ self limiting.
bacteria:
salmonella (if <1 yr, immunocompromised or toxic looking.
shigella .salmonella: trimethoprim+ sulfamethoxazole. + azithromycin.
camylobacter: macrolides (azithromycin, erythromcyin).
parasites: metronidazole.
c.difficle: oral vancomycin/metronidazole.
Yersinia: if < 3 month, septicaemia. then consider aminoglycosides or cephalosporin 3rd generation.

117
Q

dx + management

A

stool sample, enzyme immunoflourescnet.
management: viral (supportive)+ self limiting.
bacteria:
salmonella (if <1 yr, immunocompromised or toxic looking.

118
Q

units + classification of diarrhe based on mechanism?

A

5-10 k/kg infants
children: 200 g/day.
classificiation based on mechanism:
-osmotic: presence of non -absorble solute (lactose intolerance) e.g malabsorption. water follows-> diarrhoea. trx: 2-3 fasts.
-secretory: bacterial toxin (cl- & water increase secretion) doesnt resolve w/ fasting
-malabsorptive: osmotic /secretory-> less S.A .or impaired function of stomach (Short bowel syndrome/ pancreatic insufficiency)
-inflammatory: UC/chrons. loss of proteins, plasma, blood, mucosa in feces. loss of fluid.

119
Q

classification b/w acute/chronic

A

acute:<2 wks chronic: > 2 wks. chronic causes: celiac, IBS, dietary factors. anatomic disorder/ absorption issues.
SE of antibiotics: diarrhea.
e.coli-> haemolytic uremic syndrome (HUS-> RF).
dehydration vital changes: tachy, hypotension, fever). lethargy+ distress.
emergency: dehydration sign, bilious vomiting, tender abdomen/distended/petechiae/pallor (allergy).
trx: fluid/ PO Ab-.
loperamide/IV hydration not for infants.
glucose, Na, complex carbs (75mEq/L)-> total 245 mOsm/L) start w/ small frequent uses.
100 mL/kg for moderate dehydration.

120
Q

fluid + electrolyte haemostasis

A

80% water content.
EC water (fluid+ plasma) easy to lose, not stable, depends on colloid pressure /protein (hydrostatic P)>
IC- osmotic pressure/active membrane transport.
source: exogenous (fluid+ food)/endogenous (oxidation).
loss: urine-61, stool-6 & skin loss (sweat/breathing)-33%
sweating- CF greater loss .
tachypnea-water loss
reduced fluid intake (water)

vomiting, diarrhea, polyuria, sweats- water+ electrolytes.

121
Q

dehydration degree and clinical signs?

A

degree: mild5% BW loss
moderate: 6-10% BW loss (letahry, U output reduced, lethargy.
severe- 11-15 % loss-> shock (hypovolemic, CNS sx)
CF: Wt loss, dry mucus, skin turgor, ant fontanel depressed, shock, eyeball sunken, pale/mottled skin, prolonged CR time, weak pulse, cold extremities, tearless, Decreases consciousness.

types - isotonic, hypertonic and hypotonic.

122
Q

types of dehydration?

A

isotonic- loss of proprtional quanity of water+ eelctrolyte.normal osmolarity of ECF. V+ D.
hyertonic: Na+ > 150 meq/L. water loss from cells (IC-> EC shift) hyperventilation, watery diarrhea, high fevers seen.
DKA, DI or excess hypertonic infusion fluid,sodium bicarbonate. reduced fluid intae with tube feeding.

hypotonic: below <130 mEq/L loss of Na+. EC-> IC. low serum/blood Na+. uncommon. reduced vascular volume-> shock (heat exhaustion) and cell swelling (ICP, confusion-> cns manifestation-> heat stroke).

123
Q

RF:

A

1.< 6 months or low birth weight neonates.
2.>6 stools/ 24 hrs
3. 3 or more episodes of vomiting in 24 hrs.
4.unable to tolerate extra fluids or malnutrition.

higher BM fluid requirement, greater S.A. greater insensible water loss (15-17 ml/kg per day).
immature tubular resorption (loss in urine). cannot communicate for fluid when thirsty.

124
Q

dehydration physiology-> hormones!

A

hyerposmal- H20 loss. trigger ADH-> oliguria. intracell dehydration.
isosmolal-> proprotional loss -> burns, V+D.
hyosomalirity: lack of fluid intake, trigger 2 hyperaldosteronism (adrenal cortex release hormone-> h20 and water retention and H+ excretion) pick up blood volume-> cardiac output-> arterial pressure increase-> kidney release less renin.
IC overhydrated /swollen.

125
Q

dehydration physiology-> hormones!

A

hyerposmal- H20 loss. trigger ADH-> oliguria. intracell dehydration.
isosmolal-> proprotional loss -> burns, V+D.
hyosomalirity: lack of fluid intake, trigger 2 hyperaldosteronism (adrenal cortex release hormone-> h20 and water retention and H+ excretion) pick up blood volume-> cardiac output-> arterial pressure increase-> kidney release less renin.
IC overhydrate20 d /swollen.

126
Q

treatment & rehydration

A

admit pt.
OHS-> mild dehydration w/out vomiting.
90+ 20+ 30+80+ 111.
Na,K,NaHCO3, CL-, glu.
IV infusion/24hr.
hydrating solution-0.9% saline (154 mEq/L. 134-145 mmol/L normal range.
15 % KCL- 10 ml ampouls.
5% dextrose
8.4 % NahCo3-
5% albumin/plasma.

fluid: glucose (K+ infused inside) + (Na+ )in saline.
1.pathological loss
2.daily requirement-depend on wt.
3. current loss- involuntary activity.

127
Q

calculations

A
  1. loss of water: 10x weight (KG) x % of dehydration.
    1-11 mn: age (mnth)+ 9/2
    1-6 yrs: age (yrs)+ 8.
    > 7: age in yrs + 10.
    daily requirement: 1-10 kg-> 100 ml/kg.
    11-20 + 50/kg.
    >20 kg-> +20 ml/kg

Na+-> 100 ml/6-8 mmol
K+: 100 ml 2/3 mmol.
d.l- 3mol/kg . 6.8 mmol loss

3 phases of dehydration- 1/2 volume P.L
2nd 1.2 P.L + 1/3 D.L
2/3 D.L + C.L
NG tube if vomiting. fluid deficit relacement & maintenance fluid requirement.
ondansteron: anti-emetic.
oral is best. IV is only used if AMS, ileus, circulatory shock, abnormal Na.
4:2:1
holliday -segar method
emergency: 20ml/kg over 10-15 min. normal perered, lactate ringer (contain potassium).
repeat until V.S normalise. if blood loss- alumin, plasma 10ml/kg.
seizre via hyponatremia-10-12 kg 3% NS .
hypoglycemic-10% dextrose in 2.3 ml/kg.

128
Q

malabsorption

A

FTT, specific deficiency, abnormal stool. can be either pan-malabsorption (pancrease/ intestinal) or highly specific.

1.coeliac disease: autoimmune disease->gluten-> inflammation in epithelial cell (anti-ttg/anti/ema)> rise & fa.
atrophy-> malabsorption. mouth ulcer.
dermatitis herpetiformis. type 1 DM linked.
dx: igA, endoscopy, biopsy, crypt hypetrophy, crypt atrophy.

cholestatic liver/biliary atresia- bile acid malabsopriton- fats/> stearrhoa.
short bowel-> resecteed (pan-malabsorption-> nutrient, water and electorlyte).
loss of TI (B12 , bile acid-> chrons).
exocrine-> starch, triglyceride,protein defect.
SI mucosal disease (celiac, specific enzyme),

129
Q

syndromes

A

toddlers disease, food allergy, chrons, coeliac, UC.
toddlers: 3-5 x daily diarrhea. food in stool. high fibre trigger. self resolve.
food intolerance: allergies. invetiations: igE.
enzyme deficiency: lactase deficiency.
immune mediated; coeliac (genetic). chemical irritants (chillie).

chrons: whole bowel (transmural). perianal skin tag, ulcers. dx: biopsy & colonoscopy.
biologics+ immunosuppression needed.
UC: pan colitis. bloody diarrhea mucus. left sided.
complication: toxic megacolon, colorectal Ca, hemorrhage.
dx: goblet abscess+ goblet cell in MS.
extra-intestinal : erythema nodosa, arthiritis, liver + eye lesion.

130
Q

hepatic disease

A

physical exam (firm costal edge) & auscultation for percussion (dull ) with margin of resonance above & below liver plane.
hepatomegaly: infection (radiation, toxin-drug, Kupffer cell hyperplasia), inflammation, infiltration (storage glycogen disease, DM, steatosis, Wilsons and Alpha-1 antitrypsin deficiency), excess storage, obstruction (biliary atresia, tumour, congestion (supra-hepatic, buddchari, restrictive pericardial disease, veno-occlusive in BM transplant patients).

131
Q

infiltration disease

A

-parasitic cyst, extramedullary haematopoiesis, leukemia/ lymhpoma, hepatocellular carcinoma, heangioma and other benign tumours.

hyperbilirubinemia + associated with elevated conjugated bilirubin + elevated ALT/AST-> viral hepatitis (+ autoimmune, Wilsons, toxin, drug).
liver biopsy needed.
cholestatic pattern-> US / cholangiography.
unconjugated bilirubin level+ elevated reticulocyte count-> haemolytic disease.
google conjugated vs unCJ

132
Q

age group: common disorders:

A

neonates: CHF, metabolic/ maternal disease,/ storage disease/ viral hepatits/TORCH, malnutrition, inappropriate drug metabolism.

children: anemia, biliary obstruction, CF., leukemia/ lymphoma, parasitic, obesity, systemic/sepsis.

133
Q

splenomegaly

A

physical exam detected. < 1-2 cm below left costal margin, soft and non tender but palpable (1/3 neonates).
firm -pathological.
function of spleen:filtrate defective cells+ capsulated organism. abnroal RBC may get ingesteed via macrophage in splenic cord.
-reservoir for platelets & blood component.
dx:CBC, hx, LFT.
malaria, kala azar, chronic hemolytic anaemia, HTN protal.

134
Q

patholgoical causes of splenomegaly

A

unrelated to diseases of the main organ but 2 manifestation: MPS, immunoregulation, Hemolysis disorder. neoplasia (ALL, non hodgkins), obstructive venous BF (intra/ extra hepatic aetiology), portal vein thrombosis, cirrhosis, CF, storage disease (gaucher, neimann-pick disease), abnormal lipid accumulation in splenic macrophage.
trauma-> palpable subcapsular hematoma. pseudocyst, congenital splenic cyst (6 months+ asymptomatic ).

135
Q

pathology

A

hypersplenism-> excess function. 1) excess phagocytic activity, antibody destruction, sequestration-> reduce blood circulating elements.
sequestration is emergency-> hypovolemic shock due to rapid consumption of RBC in sickle cell (CF: sudden weakness, dyspnea, L sided abdo pain)
trx: underlying cause (systemic disease). splenectomy. prophylaxis with vaccination against encapsualted organism.

136
Q

viral hepatitis (A,B,C,D,E)

A

virus target hepatocellular-> MHC 1. CD8+ recognise and cytotoxic. -> apoptosis (councilman body)-> liver damage.
sx: fever,malaise, N, hepatomegaly (pain), AST/ALThigher and last to return to normal blood).
atypcial lymphoctosis-> huge+ un/conjugted bilirubin (jaudnice0_. leak and cells cannot conjugate it.
darkurine, urobilinogen in SI (urine). chronic > 6 month (PT fibrosis)-> post necrotic cirrhosis.

137
Q

differentiation

A

hep A: travels: feco-oral transmission. only acute. serology: HAV igM (active), HAV IgG (protective-vaccination/ recovery)>
HEV: acute, uncooked food, feco -oral, serious in pregnant (fulminant hep) . no vaccination.
hep C: IV, child birth, sex (blood/fluid).
test: enzyme immunossay- igG (not specific so use recombinant immnoblot)+ HCV RNA pcr test (early 1-2 wks-RNA detected). chronic+ acute. recovery: if falls-> recovery.
HBV:
acute & chronic
liver cancer
acute/chronic
serology: same tests as HCV. surface antigen detector / core antigen. depend on age (young children-> acute).
E antigen-> active infection & replication.
igM against core Ab (police)
igG (surface)-superhero.
less contagious look healthy.
immunization.

HDV: only infect if HBV (co-super infection). HDV igM and igD indicate active infection.

138
Q

addition note for hepatitis

A

hep A: RNA vaccination for travels. cholestatic hepatitis & fulminant hepatitis. close contact pophylaxis with HNIG or vaccinated if 2 wk virus onset.

hep B: DNA , africa prevalent. chronic carriers-90%. no trx.
IGm for core antigen (anti-HBc)- acute
(HBsAg-ongoing) may have acute hepatitis.
fulminant- liver failure.
interferon trx for chronic HBV lamivudine (resistant). screen all mothers. babies relieve HB vaccination, check ab response.

HBC: HIV vertical transmission. chronic carriers-> carcinomas. RNA
trx: pegylated interferon and ribavirin (RSV)
hep D: RNA. cirrhosis likely.
HBE: considered the non- A to G hepatitis. if others aren’t confirmed in aetiology then its diagnosed. same as HBA. contaminated H20.
EBV: fulminant, asymptomatic. few jaundice.

ALF: hstory->fever, jaudncie, fatigue, D+V+ N, malignancy signs (subcut nodules), endemic traveller disease, nutrition issue, wt loss, bleeds, bruising, pruritis.
cause: infeciton/ deug/ metabolic/ autoimmune/ reye syndrome.

139
Q

investifations for liver+ spleen issues

A

CBC (anemia), speripheral smears, ESR (leukemia, SCA, parasite), reticuclocyte count
LFT: albumin, ast,ALTALp, bilirubin, raised A-fetoprotein *hepatoblastoma).
ceruloplasmin (wilson)
CXR, sweat test (CF), HBsAg -hep B
USG abdomen-cyst, tumors, liver biopsy.

140
Q

trx /approach to neonates/chidlren with hepatosplenomegaly

A

1.history, exam, screen lab test.
2.hyperbilirubinemia: fractionate (elevated direct/ indirect or mixed) .
2.1: indirect-> identify hemolysis sepsis (DIC, coagulopathy, CHF).
elevated direct bilirubin: elevated transminase-> viral serology, cerulosplasmin + liver bopsiy.

if ALp-> US/ cholangiography-> GBD obstruction.

if no hyperbilirubinemia -> check spleen.
1.1: splenomegaly: abdo US + doppler-> vascular obstruction, liver tumour, leukemia, parasite, storage disease, torch and sepsis.
no splenomegaly: DO BIOPSY/ viral hep/ obesity. primary tumours/ cyst/abscess.

141
Q

Acid and base imbalance:

A

pH is the first blood component to analyse, disruption causes cell metabolism, metabolism of drugs, contractility, response to catecholamine.

difference in venous/ arterial is 0.05.
C02-> carbonic acid (acidotic blood).
low oxygen (acidotic.
manipulate acid base if ICP high-> as Vaso - constriction needed.
Cor pulmonale (ventilation to low carbon dioxide-> vasodilate/ normal-elevated pH.

normal range bicarbonate: 22- 26 mmeq/L.
tC02 represents it, kidneys regulate. as pH raises-> excrete more.
paO2- 80-100 mmhg. hypoxia hypovolemia (R->l shunt), diffusion limitation (COPD<, pneumonoa, atelectasis,a pneumothroax).

142
Q

repsiratory acidosis

A

excess paC02-> T2RF. low ph and HC03- low-> normal or pa CO2 levels elevated.
conditons: CNS depressin (control ceners disurpted, narcotic, ansthestia, sedative (hypoventialtion).
SC< NM (diaphgramatic muscle use).
embolism-> obstrcted endotracheal tube, pain, angina, choking etc.
compensatory-> hyperventilation (compnesatory).
cellular bicarbonate buffering-> to nomrlaise pH not signifcant.
kidneys increase bicabonate reabsorption and carbonic expelled.

143
Q

chronic and fully compensated

A

adult-choronic co2 retention (copd), and infant with BPD.
sx: heaahce, letharyg, restlenes, tremor, delirium, coma, tahchy, arrythmia, /pulmo HTN, dyspnea, ARDS, shallow breathing.

interventions fail and manifest to pathology.
mechanical ventilators-> RR, vnetilator pressure.
pharmacologic: furosemide, dilators, pains killers.
CT tubes.
activities to strenghten and clear secretion-> spirometry.
Displaced Obstruction Pneumothroax tension Equipment:

144
Q

respiratory alkalosis

A

(RR)hyperventilation-anxiet, CNS , elevation, pain,, excess loss of paC02.
excess ventilation.
compensatory- mediated to lower RR+ depth. renal (slower).
decrease tidal, RR set and consider extubation.
acute anxiety- antioxyltic medications (use bag to re-breath C02).

metabolic acidosis-> high/ normal anion gap.
LA, DKA< CRF, methanol, low cardiac output, excess exercise trauma, infection, organic in toxification. diarrhoea, RTA.

145
Q

metabolic alkalosis

A

HCL through NG tube, vomiting, diuretic aggressive. (sodium, K+ loss). drugs use ammonium chloride, antiemetics, diMOX.
DX: 1)Ph 2) PC02 EXCEED 35-45 (higher than 45 its acidotic.
TCO2 (METABOLIC). HIGHER THAN 22 (ACIDOTIC). dopamine is Ianotropic.
normal anion gap because electrolytes arent affected like Na+/K+ (no replacement needed).
-long standng diarhea, RFA< NaHcO3, diamox

146
Q

mneomics

A

MUDPILERS & HARDUPS for non/anionic gap in metbaolic acidosis.
acidosis anion gap
: methanol, urenmai, DKA< paraldheyde, isoniaide ethanol renal, salicylates.

HARDUP’s: hyperalimentation, acetoazolamide, RTA, Diarrhea, uretero-elvic shunt, post-hypocapnia, spironolactone.

acute respi. acidosis-> anything causing hpoventilation.

147
Q

CLEVERPD

A

contraction, licorice, endocrine, vomiting, excess alkali, refeeding (deranged electrolyte-> phosphate and other electrolyte loss), post hypercapnia, diuretics.
CHAMPS: CNS, hypocapnia, anxiety, mech. ventilation, salicylates, sepsis.

148
Q

blood differnece in age:

A

Hb decrease from neonatal (cord blood) to adolescent via 17g/dl to 13 g/dl.
haematocrit-> decrease from mean 55 -> 38%.
leukocytes: 12-8k in adolescent, neutrophil increase, lymphocytes peak till 3 month and steadily decrease . monocyte peak at neonate, eosinophil normal.

149
Q

cardiology history / exam in infants/ neonates

A

gestational + perinatal hx?
maternal hx: healthy during preg, prenatal care, US routine. (TORCH), medications (retinoic acid warfarin, lithium, pheytoin ) -> teratogenic cardiac malformation.
TORCH (toxoplasm, others rubella , CMV, herpes).
prenet/ post natal hx: developmental miestone, feeding issues, growth curve, cyanosis, decreased exercise tolerant, syncope?, angina, palpation (extra/skipped beat).
feeding-> exercise test for neonates.
1. Fmhx-> congential Hx, sudden unexplained death (drowing-> electrical issues/ pacemaker).

150
Q

physical exam

A
  1. general appearance/ inspection.
    look mal/ well nourished,.
    breathing effect.
    palpation-> pericardium-> hyperdynamic, maximal point displaced, thrills?
    femoral and brachial pulse (peripheral)-> compare/ bounding.
    BP: upper/ lower extremity (get rid of gradient). coarctation in aorta if difference is >10mmhg (systolic).
    auscultation-> S1 (mitral and trisciupid valve closure and S2 A2 AND p2 closure. splitting is variation in S2.

widely split-> volume overload, electric delay in right bundle branch block/
narrowly split-> cor pulmonale or aortic stenosis.
enitrely single _. severe stenosis, severe pulmo HTN.

151
Q

murmurs

A

benign-> structurally normal blood moving
classification : systolic, diastolic, continuous , gallops, clicks.
grade murmurs: barely audible,
grade 2: soft but easily audible.
grade 3: mdoerate butno thrills (hand on pericardium)-> grade 6 (audible with stehtoscope off chest).
systilic murmur -> ejection /midsystolic or crescendo/ decrescendo (pulmo stenosis, aortic stenosis) , late (MT prolapse) and holosystic: triscipud , ventiricular defect.
early -> short regurgitant.

diastolic (early/ mid) -> always pathological. regurgitation of aorta/ pulmo depending on where it radiates.
higher pitched, aortic / pulmo regurgitation.
continous- venous hum (supine , neck extended louder), AV fisutla PDA (newborns), shunt post-surgery.
stills-. louder in supine.

152
Q

gallops: diluted ventricules dysfunctional

A

S3: apex. normal in children/ young adults
S4. pathological.
clicks: ejection/ mid systolic/ diastolic opening snap (mitral stenosis)

rubs: pericardial friction rub-scratching. systolic/ diastolic component-> obscure normal S1 and S2. indicate pericarditis

153
Q

physiological changes:

A

post natal alteration to extrauterine environment, rapid fall in vascular resistance, increase in f.ovale, ductus venosus (UV & V. inferior) and obliterate UA.
ductus arteriosus (functional -constriction and anatomical closure-8 wks).
heart size increase, ovale shaped, more horizontal lie, right ventricle pre-dominant as lungs. progressive function in l. ventriculi.
newborn : 140 bpm and infants 120 bpm.
BP: 76 + (mnths x2).
diastolic: 2/3 of BSP.
hx of frequent RTI’s could indicate cardiac issue.

palpation: PMI 4th IC in 6 yrs.
7 yrs- 5th IC.
thrills-> stenosis.
PDA: bounding /collapsing pulse.
aortic stenosis -low pulse. easier to find brachial P.
auscultation->
lab investigation: ECG. CXR, dopplier, Echo (note cardiothroacic ratio & pulmo vascualtures).

note: PMI, timing, radiation, duration and chnages in position.

154
Q

causes of heart failure:

A

1.pump dysfunction/ systolic-> CO reduction-> congestion
2.voluem overload (preserved/ impaired function), increase preload.
3.pressure overload (increase pressure against heart-> afterload).
cardiomyopathies-diluted/enlarged (thin ventriculi wall, regurgitation), hypertrophic (preserved size, cavity smaller), restrictive 9relaxation impaired, pressure build up-> atrium or vascular oedema)
non compaction-> embryological defect-> spongy and dysfunction.

155
Q

dysfunctional mycoardial tissue

A

myocarditis/ cardiomyopathies.
congential heatt malformation: detected within 1 yr.
l-R shunting (increased pre-laod) pDA, ASP, AVM.
volume overload-valvular dysfucntion (backload of blood-> next squeee is bigger), tachy to compensate stroke volume (increase CO).

pressure overload -> ventriculi contract against higher pressure-(r-sided) & (L-sided):aortic stenosis, co-arctation
(fixed), r-sided pulmo stenosis.

classification & staging: NYHA class 1(asx) -> 4 (most severe) present sx at rest (fatigue palpitation, dyspnoea, angina-> support/ transplant).

156
Q

ross classification

A

for neonates and children adapted.
mild- short breath, feeding.
moderate: prolonged feeding time , fft, tachpnoea.
4: marked sx even at rest (end stage- advanced therapies).
stage A; RF. chemotheraphy -> cardio toxic. echo normal.surveilance.
B:structurual/ functional HD. EJV affected. ACEi (afterload, consume less O2-> maladaptive activation paused)
C :pass failure. beta blockers, aldosterone antagonist, lose dose digoxin, direutic (sx)
D: end stage (PEEK).

157
Q

history

A

poor feeding, cachexia, ftt, diet diaphoresis, tachypnea..
chidlren: mistaken for GI pain, recurrent cough, vomiting. mistaken for asthma, viral syndrome,malaise
older children: palpitation, exercise intolerane, wheezing, edema.

physical: cold extremity, hypotension, tachypnoea, s3 (volume/ pressure overload-gallet sound).
rales/wheezing. systemic venous congestion-ascites/ abdo distension).
dx:CXR (diluted-> cardiomyopaty) increased vascular marking and bilatrial marking-> restrictive).
ECG:heart block, increased voltage (hypertrophy), decreased voltage (PE, myocarditis), ST changes.
echo-functional assessment.
blood test: CBC: hemocrit, esr, CBC, renal dysfunction, creatine, BUN, LFT, troponin, CRP, creatine kinase ,BNP (specific/ sensitive) +(inflammatory markers).
BNP-EJF (ddx respiratory).

158
Q

other tests

A

MRI: anomalies anatomical. ddx between restrictive vs constrictive, edema, RV function, fibrosis seen.
cardiac catheterization-> etiology (biopsy )direct hemodynamic pressure in heart, measure CO.
severe cases: L. outflow obstruction-> cessation of Bf out of heart (ventricular arrhythmia/ syncope).
myocarditis: viral, bacteria and rheumatological.
arrhythmogenic: supra/ventricular -> dysfunction even after cessation.
surgical repair (induced dysfunction/ bypass).
congenital: PDA, VSD, ASD, aorto-pumo window, AVSD, single ventricle circulation / unobstructed BF.

159
Q

aldosterone antagonist in heart failure

A

neuro-hormonal blockade necessary to treat systolic HF. CF: apnea periods, hepatomegaly , vein distension, catehcolamine-> sweating, grunting (dyspnea), irritability.

160
Q

therapy:

A
  1. digoxin (increase contractility,SV, BP, reduce HR. dose dependent on maintenance and total digitalising dose.
    lowest if premature 0.05 ng/kg and infant its 0.015. loading dose: 4 doses every 12 hrs (36)
    maintenance: 2 doses every 12 hrs (24 hr)
    other inotropic dobutamine (2.5-15 mcg/kg/min IV) and dopamine (5mcg/kg/min IV).
    diuretic: furosemide (hypokalemia, electrolyte disbalance) 1-3 mg/ kg IV.
    spironolactone 2-3 mg/kg.
    vasodilator systemic- captopril 1-4 mg/kg.
    diet: sedation (diazepam 2-5 mg/day) low dose and oxygen. reduce sodium chloride, increase K+). aldosterone antagonist.
161
Q

cyanotic HD (R-L shunt)

A

saturation 4-70 blue.
D-transpsition of the great arteries (normal heart-> swtich the pulmo trunk w/ the aorta) bypass lungs. ductal and atrial level mixing (shunt).
T anomalious venous congestion (TAPVC)utero_. connect with common pulmo v-> umbilico system. blood cannot leave lung (edema-> total cxr film) differentiate b/w ARDS.

ebstein anomaly: triscupid regurgitation severe, large atrial (big atrium- wall to wall CXR). r-l at atrial elvel
triscipud atresia (anomalie): never form, R. ventricule small/ non-existent).
foramen ovale-> body if DA open then to lungs. gradual hypoxemia.

pulmo stenosis/ atresia (TOF): r-> l through ovale, and some go through the DA (dificulty when that close).

162
Q

hyercyanotic spell

A

tahcypnea, cyanosis, irritiability,
emergency: knee- chest position, oxyen, diazepam 0,5 mg/kg.
CHD surgical correction.
TOF: RVOTO, septal defect. RVH, aorta overriding VSD.
cyanotic at birth, increase till 6 yrs. grade 3-6 murmor, seizure, LOV.
exam: CXR (absence of pulmo markings, boot shaped heart (small PA and RVH), echo. ABG.
surgical palliation NAD CORRECTION AT 1-3 YRS. (BLALOCK -TAUSSIG SHUNT).

163
Q

TGA

A

UNRESPONSIVE TO O2 THERAPY, severe hypoxia, acidosis and death. systolic murmurs.
dx: oval or egg shaped hsrt, icnreased lung marking. ecg (r/ axis deciation), pa o2 low).
trx: postraglandin E post birth to keep ductus open till surgery, balloon atrial septostomy to enlargge ASD and improve mixing.
total surgical correction.

5th year winter semester exams (5 decks)

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