Paediatric History Taking and Management 2 Flashcards
What is Juvenile idiopathic arthritis (JIA)?
arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks
Systemic onset JIA is also known as Still’s disease
How does Still’s disease (systemic JIA) present?
pyrexia
salmon-pink rash
lymphadenopathy
arthritis
uveitis
anorexia and weight loss
How can Still’s disease be investigated?
ANA may be positive, RF usually negative
Spot diagnosis:
Medial knee pain due to lateral subluxation of the patella
Knee may give way
Patellar sublaxation
Spot diagnosis:
Knee pain after exercise
Intermittent swelling and locking
Osteochondritis dissecans
Differentials for a limping child?
Trauma
Transient synovitis:
Acute onset, accompanies viral infections, but the child is well or has a mild fever
Mostly in boys aged 2-12 years
Septic arthritis/osteomyelitis
Unwell child, high fever
Juvenile idiopathic arthritis
Limp may be painless
Development dysplasia of the hip
diagnosed as neonate, more common in girls
Perthes disease
More common at 4-8 years, due to AVN of the femoral head
Slipped upper femoral epiphysis
10-15 years - Displacement of the femoral head epiphysis postero-inferiorly
Spot diagnosis:
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Patellar tendonitis
What is Meckel’s diverticulum?
a congenital diverticulum of the small intestine
Rule of 2s
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long
How should Meckel’s diverticulum be investigated and managed?
Ix: Meckel’s scan (technetium scan)
mesenteric arteriography may also be used in more severe cases e.g. transfusion is require
Mx: removal if narrow neck or symptomatic
How does Meckel’s diverticulum present?
abdominal pain mimicking appendicitis
rectal bleeding
intestinal obstruction
- secondary to an omphalomesenteric band (most commonly)
What is the most likely causative agent of a bacterial pneumonia in children?
What are the other causes?
streptococcus pneumoniae
Group A strep (e.g. Streptococcus pyogenes)
Group B strep: often contracted during birth as it often colonises the vagina
Staphylococcus aureus: typical chest xray findings of pneumatocoeles (round air filled cavities) and consolidations in multiple lobes
Haemophilus influenza : particularly affects pre-vaccinated or unvaccinated children
Mycoplasma pneumonia: atypical bacteria with extra-pulmonary manifestations (e.g. erythema multiforme)
What are the viral causes of pneumonia in kids?
Respiratory syncytial virus (RSV) is the most common viral cause
Parainfluenza virus
Influenza virus
How should pneumonia be managed in children?
Amoxicillin is first-line
Macrolides (e.g. erythromycin) may be added if there is no response to first line therapy / if mycoplasma or chlamydia is suspected
pneumonia associated with influenza =co-amoxiclav
How can you investigate children with recurrent LRTIs?
FBC- WCC
Serum immunoglobulins
Test IgG to previous vaccines (i.e. pneumococcus and haemophilus) -some patients are unable to convert IgM to IgG, and therefore cannot form long term immunity
Sweat test for CF
HIV test
CXR to screen for any structural abnormality in the chest or scarring from the infections
What is episodic viral wheeze? How should it be managed?
only wheezes when has a viral URTI and is symptom free inbetween episodes
Mx:
first-line is treatment with SABA (e.g. salbutamol) or anticholinergic via a spacer
next step is intermittent leukotriene receptor antagonist (montelukast), intermittent ICS, or both
What is multiple trigger wheeze? How should it be managed?
as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke
Mx: trial of either ICS or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks
parents should stop smoking
Pyloric stenosis is caused by hypertrophy of the circular muscles of the pylorus. What features does it present with?
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
What is a reflex anoxic seizure?
a syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli, occurs in children aged 6months - 3 years
Typical features
child goes very pale
falls to floor
rapid recovery
What is Roseola infantum? Features?
sixth disease
common disease of infancy caused by the human herpes virus 6 (HHV6)
Features:
high fever: lasting a few days, followed later by a
maculopapular rash
Nagayama spots: papular enanthem on the uvula and soft palate
diarrhoea and cough commonly seen
What is Scarlet fever?
Reaction to Group A haemolytic strep (usually strep pyogenes)
typically presents with:
fever: typically lasts 24 to 48 hours
malaise, headache, nausea/vomiting
sore throat
‘strawberry’ tongue
rough sandpaper rash
Describe the Scarlet fever rash
rough sandpaper like rash
‘pinhead’, appears first on the torso and spares the palms and soles
more prominent in flexures
How should Scarlet Fever be investigated and managed?
a throat swab is normally taken but antibiotic treatment should be commenced immediately, rather than waiting for the results
Management:
oral penicillin V for 10 days
penicillin allergy = azithromycin
children can return to school 24 hours after commencing antibiotics
notifiable disease
Complications of Scarlet fever?
otitis media: the most common complication
rheumatic fever: typically occurs 20 days after infection
acute glomerulonephritis: typically occurs 10 days after infection
Which joints are most commonly affected by septic arthritis?
hip, knee and ankle
What sxs and signs does septic arthritis present with?
Symptoms
joint pain
limp
fever
systemically unwell: lethargy
Signs
swollen, red joint
typically, only minimal movement of the affected joint is possible
How should septic arthritis be investigated?
joint aspiration: for culture. Will show a raised WBC
raised inflammatory markers
blood cultures
What is the diagnostic criteria for septic arthritis?
The Kocher criteria for the diagnosis of septic arthritis:
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
What are the causes of stridor in children?
Croup
Acute epiglottis
Inhaled foreign body
Laryngomalacia
What is transient synovitis? Key features?
irritable hip
acute hip pain following a recent viral infection
commonest cause of hip pain in children
Features:
limp/refusal to weight bear
groin or hip pain
a low-grade fever is present in a minority of patients
(high fever should raise the suspicion of other causes such as septic arthritis)
self limiting
Causative organisms of UTI in kids?
E. coli (80% of cases)
Proteus
Pseudomonas
Risk factors for UTI in kids?
Incomplete bladder emptying:
infrequent voiding
hurried micturition
obstruction by full rectum due to constipation
neuropathic bladder
Vesicoureteric reflux
Poor hygiene
e.g. not wiping from front to back in girls
How do UTIs present in kids?
infants: poor feeding, vomiting, irritability
younger children: abdominal pain, fever, dysuria
older children: dysuria, frequency, haematuria
features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
How should UTIs be managed in kids?
infants less than 3 months old should be referred immediately to a paediatrician
children aged more than 3 months old with an upper UTI = considered for admission to hospital OR oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI = oral antibiotics for 3 days, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin
antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. When should it be suspected?
should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough
Inspiratory whoop
Post-tussive vomiting
Undiagnosed apnoeic attacks in young infants
How can whooping cough be diagnosed?
per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back
PCR and serology
How should whooping cough be managed?
notifiable disease
infants under 6 months should be admitted
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
household contacts should be offered antibiotic prophylaxis
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
Complications of whooping cough?
subconjunctival haemorrhage
pneumonia
bronchiectasis
seizures
Who is offered the pertussis vaccine?
Women who are between 16-32 weeks pregnant
Give some ddx for acute cough in young children
Bronchiolitis (RSV) – high temperature makes this less likely
Other viral infection e.g. influenza
LRTI or pneumonia – lobar or bronchial pneumonia
Croup
Whooping cough
Laryngomalacia
Foreign body inhalation
Reflux
Heart failure
Prolonged focal seizure should make you consider what?
Encephalitis
Babies who are sleepy with reduced feeding =
sepsis until proven otherwise
How could you investigate a baby with a fever of unknown origin?
repeat temperature
look in ears for any obvious signs of ear infection
examine all over their body for any obvious rashes
listen to their chest
palpate abdomen
FBC, CRP
blood culture
capillary blood gas (lactate)
urine dipstick, MC&S
lumbar puncture
CXR
If you don’t know whether meningitis is viral or bacterial =
give aciclovir for viral cover!!!
What should you ask about in the history if suspecting neonatal herpes / herpetic meningitis ?
Is there parental hx of herpes or cold sores?
What is the most common cause of urticaria in kids?
viruses
Give some differentials for vomiting in an infant
GORD
CMPA
Intestinal malrotation
Intussuception
Pyloric stenosis
