Paediatric History Taking and Management Flashcards
How can you structure a paediatric history?
Confirm full name and DOB
Presenting Complaint
How long have they been in hospital for? What brought them in? How have they been progressing? What treatment are they receiving – is it helping?
PDF BINDS
Past medical and surgical hx
Drug hx
Family hx
Birth history – how was the pregnancy? How many weeks were they born at? Mode of delivery? Birth weight? Complications after birth? SCBU stay?
Immunisations
Nutrition- how much do they eat and drink? Wet/dirty nappies?
Development
Social and sexual hx – including any previous social services input
How could you explore a presenting complaint of a child with a seizure?
Is there anything the parent thinks might have triggered it?
How were they leading up to the seizure? Any temperature? Complaining of a headache? Stiff neck? Any new rashes? N+V? Change in waterworks/bowel habit?
How did they look when they were seizing? One part of their body shaking or all of it? Was the child aware of what was happening? Tongue biting? Incontinence?
Eye rolling during the seizure?
How long did it last? How did it stop? How were they afterwards?
How would you investigate a child with a seizure?
measure their glucose and oxygen sats immediately
bloods for reversible causes e.g. electrolyte derangement
suspecting meningitis / encephalitis: inflammatory markers, viral PCR/ nasopharyngeal aspirates, blood cultures, LP, neuroimaging
ECG for arrythmia
EEG
DDx for a child with a seizure?
Febrile convulsions
Roseola infantum (can cause febrile convulsions)
Hypoglycaemia / hypoxia
Epilepsy
Meningitis
Encephalitis (e.g. herpes simplex)
SOL
How would you explain febrile convulsions and their management to a parent?
Explain that when some children run a temperature that their brain isn’t used to it and it may cause a seizure, occurs commonly in children from 6 months - 5 years
If they have had one febrile convulsion they are more likely to have another, but most children grow out of it by 5/6 years
Can give paracetomol to bring down the temperature but this doesn’t reduce the risk of them occuring
Safety netting advice: if seizing, clear obstacles, put cushion under head, call ambulance if lasting more than 5 mins
Explain that they don’t increase risk of epilepsy unless they are complicated / prolonged
How can non-blanching rashes be described?
Petechiae : < 5mm diameter
Purpura: 5-10mm diameter
Ecchymoses: >1cm diameter
What can cause non- blanching rashes in kids?
Meningococcal sepsis
Henoch-Schönlein purpura
Haemolytic uraemic syndrome
Idiopathic thrombocytopaenic purpura
Leukaemia
Forceful coughing/vomiting
Non-accidental injury
What features would you expect in the history and examination for a child with menigococcal sepsis?
Fever
Neck stiffness
Headache
Photophobia
Confusion and/or seizures
OE:
Kernig’s sign (pain and resistance on passive knee extension with hips fully flexed)
Brudzinski’s sign (knees and hips flex on bending the head forward)
Non-blanching rash
How could you investigate meningococcal sepsis?
MUST NOT DELAY TX
Baseline bloods (FBC, WCC CRP, U&E, clotting): inflammatory markers may be raised
Blood cultures
Pharyngeal swab: to screen for Neisseria meningitides in the pharynx
do not do lumbar puncture if signs of sepsis or rapidly evolving rash
How would you manage meningococcal sepsis?
GP: IM Benzylpenicillin
Hospital:
Intravenous cefotaxime and amoxicillin in patients under 3 months.
Intravenous ceftriaxone (and consider steroids) in patients over 3 months old.
What are the 5 key components of meningitis management in children?
Antibiotics
Steroids
Fluids
treat any shock, e.g. with colloid
Cerebral monitoring
mechanical ventilation if respiratory impairment
Public health notification and antibiotic prophylaxis of contacts - ciprofloxacin
Complications of untreated meningococcal sepsis?
Seizures
Raised intracranial pressure and hydrocephalus
Disseminated intravascular coagulation
What is Henoch-Schönlein purpura (HSP)?
IgA mediated vasculitis usually triggered by group A strep
peaks at 4-6 years
A prodromal URTI or GI infection
Generalised abdominal pain
N+V, sometimes bloody diarrhoea
Joint pain
IgA nephropathy - haematuria
Symmetrical rash on the back of the legs, buttocks and arms
What is an important differential for HSP?
intussusception : also presents as bloody diarrhoea and abdominal pain
Intussusception can also be a complication secondary to HSP
How can HSP be investigated?
Urinalysis: to test for the presence of haematuria or proteinuria
monitor blood pressure (renal involvement)
Baseline blood tests :FBC, clotting profile, (bc bleeding) U&Es, LFTs (bc diarrohea) CRP
Skin biopsy: can be considered if there is doubt surrounding the origin of the rash
Can do USS if worried about intussuception
How can HSP be managed?
Complications?
supportive care, analgesia, excellent prognosis (usually gone in a few weeks)
Complications:
recurs in 1/3 of patients
Nephrotic or nephritic syndrome
Renal failure
Intussusception
What is ITP? How does it present?
development of a purpuric rash in those with low circulating platelets with the absence of any clear cause
viral illness
followed by epistaxis / new rash
How could you investigate ITP?
Baseline blood tests (FBC) and blood film: thrombocytopenia
Bloodborne virus screen (HIV, hepatitis C): to exclude secondary cause of ITP
Bone marrow biopsy: only required if there are atypical features e.g.
lymph node enlargement/splenomegaly, high/low white cells, failure to resolve/respond to treatment
How can ITP be managed?
self limiting, ITP resolves in around 80% of children with 6 months
medical management:
avoid contact sports
if very low platelets or significant bleeding can consider steroids and platelet transfusion
What is Haemolytic Uraemic Syndrome?
follows infection with the Shiga toxin, commonly associated with E.coli 0157
peaks at 6 months to 5 years
Triad of:
Microangiopathic haemolytic uraemia
Acute kidney injury
Thrombocytopaenia
How will HUS present in the history?
Diarrhoea, which typically turns bloody around day three
Abdominal pain
Fever
Vomiting
make sure you ask about recent exposure to farm animals
What examination findings might there be for HUS?
Abdominal tenderness
Hypertension secondary to acute kidney injury
Small petechiae on the skin can occur due to low platelet count
How may you investigate HUS?
FBC, U&E, CRP, clotting: may show thrombocytopenia, raised WCC, anaemia and acute kidney injury
Urinalysis: to screen for haematuria and proteinuria
Stool cultures: to screen for the presence of E.Coli O157
How can HUS be managed?
supportive care, consider fluids
notifiable disease
How can you differentiate clinically between HSP and HUS?
both present with fever, abdo pain, bloody diarrhoea and a non blanching rash
purpuric rash over extensor surfaces and buttocks in HSP V widespread small petechial rash in HUS
joint pain and haematuria in HSP V not present in HUS
How could you explore a non-blanching rash in a history?
Rash - when did it come on, has it changed over time, is it itchy or sore?
triggers? have they been poorly recently?
high temperature, headache, photophobia, neck stiffness?
abdominal pain, N+V, diarrhoea (bloody? from onset or did it turn bloody?), joint pain? blood in urine?
nose bleeds? (ITP)
any recent exposure to farm animals? (HUS)
B symptoms - ALL!!!
Biliary atresia presents in the first few weeks of life with what symptoms and signs ?
Jaundice extending beyond the physiological two weeks
Dark urine and pale stools
Appetite and growth disturbance, (however, may be normal in some cases)
Hepatomegaly with splenomegaly
Cardiac murmurs if associated cardiac abnormalities present
How should biliary atresia be investigated?
Serum bilirubin : Total bilirubin may be normal, whereas conjugated bilirubin is abnormally high
LFTs including serum bile acids and aminotransferases : usually raised but cannot differentiate causes of neonatal cholestasis
Serum alpha 1-antitrypsin: Deficiency may be a cause of neonatal cholestasis
Sweat chloride test: check for CF
Ultrasound of the biliary tree and liver: May show distension and tract abnormalities
How can biliary atresia be managed? Complications?
Surgical intervention is only definitive tx
Medical intervention includes antibiotic coverage and bile acid enhancers following surgery
Complications :
Unsuccessful anastomosis formation
Progressive liver disease
Cirrhosis with eventual hepatocellular carcinoma
What is Bronchiolitis? Offending pathogen? Presenting features?
acute bronchiolar inflammation
Usually RSV (respiratory syncytial virus)
other causes: mycoplasma, adenoviruses
may be secondary bacterial infection
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles
feeding difficulties
In which patients is bronchiolitis more likely to be severe?
bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis
How can bronchiolitis be investigated and managed?
immunofluorescence of nasopharyngeal secretions may show RSV
Management is largely supportive:
humidified oxygen is given via a head box
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
Chickenpox is caused by primary infection with varicella zoster virus. How does it present?
fever initially
itchy rash starting on head/trunk before spreading - macular then papular then vesicular
systemic upset is usually mild
infectivity = 4 days before rash, until 5 days after the rash first appeared
How can chickenpox be managed?
keep cool, trim nails
calamine lotion
school exclusion: until lesions have crusted over (usually about 5 days after the onset of the rash)
immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG)
If chickenpox develops then IV aciclovir should be considered
Complications of chickenpox?
Secondary bacterial infection of the lesions - NSAIDs may increase risk, group A strep may cause necrotising fasciitis
pneumonia
encephalitis (cerebellar involvement may be seen)
disseminated haemorrhagic chickenpox
What are the causes of constipation in children?
Idiopathic - most common
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung’s disease
hypercalcaemia
learning disabilities
What red flags might suggest an underlying condition as opposed to idiopathic constipation?
Reported from birth or first few weeks of life
Passage of meconium > 48 hours
‘Ribbon’ stools
Abdominal distension
Faltering growth is an amber flag
Previously unknown or undiagnosed weakness in legs, locomotor delay
Signs of maltreatment
Prior to starting treatment for constipation, the child needs to be assessed for faecal impaction. Factors which suggest faecal impaction include:
symptoms of severe constipation
overflow soiling
faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)
How can children with constipation be managed?
If faecal impaction is present
polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
Can add a stimulant laxative after 2 weeks if needed
consider regular toileting and non-punitive behavioural interventions
consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents
