Paediatric OSCE's Flashcards

Question

Syncope in Adolescents and children?

Answer 1

Serious Diagnoses - Structural heart disease (HOCM, RHD, Kawasakis and CHD) - Ahrythmogenic heart disease (long and short QT, Brugada, ARVD, WPW) - Heat stroke/Trauma - Hypoglycaemia - Anaphylaxis - Seizures/Epilepsy - Sepsis/Acute myocarditis - Illicit/prescription drugs - CNS cause (SAH, migraine, tumour) - Abdominal catastrophe (ruptured ectopic, aneurysm etc) Common diagnoses - Vasovagal - Orthostatic hypotension - Breath holding spells Red Flags - Unexplained deaths family - SOBOE/chest pain/syncope with exertion - Recurrent syncope - FHx known syndromes (ie Brugada) History - Previous episodes - Injury prior to or from syncope - Exactly what happened - Seizure acitivty/post ictal phase, tongue biting, incontinence - Recent illness, medications, injuries - Postural symptoms, occurring when standing, lying or sitting? - Noxious stimuli - Prodromal symptoms vs sudden - Palpitations/chest pain - PAIDEMS - Preceded by headache? Abdominal pain? Exam - Life threats (ABC approach) - Vitals, postural blood pressures (drop >10mmHg or Hr increase >20) - Postural symptoms - Heaves, bruits, murmurs - Radio-femoral pulse deficit - HOCM murmur louder post Valsalva or post postural change from lying>sitting or standing - HOCM murmur quieter during valsalva or during squatting - Rales, gallop rhythm, hepatomegaly ECG - WPW (short PR, long QRS, D wave) - HOCM (large complexes, dagger Q waves in inferolateral leads, TWI) - ARVC (Epsilon wave ie uptick at end of QRS/start T wave in V1-3, TWI V2-4) Other investigations - BSL if shortly post - Pregnancy test in adolescent girls - FBE if anaemia suspected - Targeted tests based on Hx/Ex

Answer 2

Acute chest syndrome basics - Vaso-occlusive crisis in the lungs - New opacity on Xray combined with fever and respiratory symptoms including chest pain - More prone to atypical infections (chlamydia, mycoplasma, salmonella) - The commonest cause of death in sickle cell patients Acute chest syndrome precipitants - Infection (pneumonia, sepsis) - Sedation (surgery, opioids etc) - Dehydration - Hypoxia (asthma, pulmonary oedema, atelectasis etc) - Pain (other VO crisis, injury etc) Acute Chest syndrome DDx - DDx Pneumonia/sepsis, MI, PE, decompensated chronic cor pulmonale, splenic sequestration, line infection (Port in situ) Acute Chest Syndrome Mx - See picture - Consider bronchodilators if possible underlying asthma - Cover for atypicals (azithromycin and Ceftriaxone) Vaso-Occlusive Crises Acute splenic sequestration - Defined as splenic enlargement with acute drop 20g/L - Transfuse aiming for Hb 50-60 and haemodynamic stability - 10-20ml/kg saline bolus while awaiting blood - Raising Hb too quickly can cause hyperviscosity and stroke (not more than 30g/L rise) - Cover with antis Priapism - Early Uro/Haem contact - 02, analgesia, IV fluids - Empty bladder - Warm pack, take a shower and do some light exercise - May need exchange transfusion Aplastic crisis - Acutely unwell, drop in Hb and massively reduced reticulocytes (<1%), often from Parvovirus - IV antis - Maintain hydration - Aim Hb 50-60g/L Stroke - Treat as per stroke normally but with caveats - Transfuse if needed to 50-60g/L - NO CONTRAST (worsens viscosity) - May need red cell exchange

Answer 3

Basics - Autosomal recessive - Exclusively in european (caucasian) populations - More common in cosanguinous parent relationships - Tested for on early screening, usually diagnosed in 1st weeks of life - A key differential for failure to thrive - Main cause of mortality is progressive pulmonary disease Organs affected Lungs - Bronchiectasis - Pseudomonas/Staph infections - Recurrent chest infections as a child - Haemoptysis and pneumothorax - Pulmonary hypertension and cor pulmonale (late signs) Pancreas - T1DM, exocrine enzyme deficiency - Steatorrhoea Bowel - Meconium ileus, constipation, diarrhoea - Failure to thrive, malabsorption - Bowel obstruction, rectal prolapse Liver - Cirrhosis, portal hypertension Endocrine Glands - Salty sweat, vulnerable in the heat, can become hyponatraemic - Azoospermia in men SInuses - Sinusitis - Nasal polyps

Answer 4

ECG changes - Superior axis (AVL and AVR up, all else down) if AVSD present (see ECG attached) - RAD (RVH with pHTN) Common Issues - Epilepsy (8%) - 50% have congenital heart diease! AVSD/AVCD is most common and varies in severity - Atlantoaxial subluxation (risk factor for intubation) - Leukaemia (1/300 chance, can present atypically, harder to treat) - Relative immune deficiency - Diabetes mellitus (1%) - Hirschsprungs (2%) and Duodenal stensosis/atresia - Hearing loss mainly from recurrent OM and CSOM - Glaucoma and cataracts - Coeliac disease Down syndrome intubation - Atlantoaxial subluxation - pHTN and cardiac defects - Larger tongues - Otherwise smaller airways - OSA - Hypotonia with early desaturation - Excessive secretions, need more suctioning than usual

Answer 5

Causes - Simple muscular spasm (wry neck, most common cause, 7-10 days) - Neck trauma - Atlantoaxial subluxation/fixation - Infection (Retropharyngeal abscess, cervical lymphadenitis, CNS, other neck or spine infections) - Inflammation (JIA) - Neoplasms (bone, brain) - Dystonic reactions - Ocular dysfunction, benign paroxysmal torticollis Red Flags - Neck trauma - Neurological symptoms - Fevers - Drooling Hx - Time course - New medications - Awkward neck positioning - Infective symptoms - Previous episodes Exam - Neck ROM, midlne tenderness - Focal area of tenderness - Neuro/ophthal exam - Neck swelling/nodes - ENT and chest exams IX - Lateral neck xray for retropharyngeal abscess - CTB/C-spine for trauma or neurological symptoms - Infective bloods Mx - Depends on underlying cause - Heat pack, massage, simple analgesia - Diazepam can help with spasm

Answer 6

Risk Factors for NAI - Age <1 - Prematurity - Mental/physical disability - Poor social supports - DV at home - FHx mental health issues or substance abuse Bucket Handle (metaphyseal corner fractures) - <24 months - Often in the proximal tibia but can occur in other parts of the limbs - Usually from shaking mechanism with shearing forces Posterior rib fractures - Spiral Humeral Fractures - Ten 4 Faces(p) - Bruising in children <4yrs - See picture Examination - A/B/C approach - Look for life threats first - Consider co-existent abdominal injuries and intracranial injuries - Ophthalmoscopy for retinal haemorrhages (ophthalmologist) - Consider CT brain and abdomen, skeletal survery, ultrasound etc Management - Always screen for other injuries - Look at previous imaging if available (ie CXR for previous pneumonia etc) - Discussion with paediatrics and VFPMS, if indicated after this needs referral to DHS - Police and child protection - Skeletal survey +/- bone scan - Targeted CT/MRI as needed Governance - Missed or near-miss NAI should be brought up at M&M and consider a VHIMS/SAC 1 or 2 report - Ie previously missed Xray findings, particularly if missed by radiology Differentials for NAI - osteogenesis imperfecta - Menkes disease - Ehlers-Danlos syndrome - Congenital insensitivity to pain - Alternative medicine and practices (cupping, medications etc)

Answer 7

Definitiion - BGL < 3.3 for paeds - BGL <2.6 neonates Accelerated starvation - The most common cause in paeds >2yo - Period of fasting usually in context of mild illness - Hypoglycaemia with associated ketonaemia and ketonuria - Resolves with feeding Other differentials - see picture History Red flags - Anxiety, sweating - Hypothermia, confusion, coma, seizures, irritability, lethargy (symptoms of severe hypoBGL) - in neonates <48hrs (apnoea, jitteriness, hypotonia, poor feeding, high pitched cry) Extended history - Previous hypoglycaemia episodes - seizures - GI surgery or disorders - Dietary intake and type (inadequate intake, food allergies) - Toxin exposure (alcohol, sulfonylureas, BB's, aspirin etc) - Screen for sepsis/shock/trauma - FHx cosanguinity, hormonal deficiencies, hyperinsulinism, unexplained infant deaths Exam - A/B/C - Fevers and hypothermia - Dysmorphic - Hepatomegaly and hypotonia (inborn error of metabolism) Treatment - If conscious give glucose gel (0.2gm/kg up to 15gm) - 2ml/kg of 10% glucose IV - IM glucagon 0.1mg/kg or 1 unit if >25kg's - Collapsed neonate protocol if appropriate (Fluids, ABX, glucose, hydrocort, prostaglandin) Investigations - Targeted to specific cause (ie sepsis, trauma etc) - BSL and ketones - Lactate, ammonia (IEM) - VBG/electrolytes (adrenal crisis) - Cortisol, insulin, c-peptide - Fatty acids, carnitine etc

Answer 8

Infants DDx - Volvulus - NEC (neonates) - Colic - Intussusception - Hirschsprungs - Incarcerated hernia Paeds DDx - intussusception - Constipation - Gastro - HSP - Pancreatitis - Sickle cell crisis - Pneumonia Adolescents DDx - Appendicitis - Pregnancy - STI and UTI and PID - ovarian/testicular torsion - Gastritis - Psychochenic/Munchausen - SBO - Billiary tract disease Age independent DDx - NAI - Tox ingestion - Trauma - DKA Appendicits on ultrasound - See pic - Good for ruling in but can't rule rule out appendicitis - CT scan >95% but radiation risk Paediatric Appendicitis Score - 0-3 is low risk (discharge and safety netting) - 4-6 is intermediate risk (scans, bloods and observation) - Score 7 or higher is high risk (admit surgery, likely theatre) - All points are 1 marks, except those with asterisk are 2 marks Scoring points on PAS - Tenderness to RLQ * - RLQ Pain to cough, percussion or hopping * - Pain migrates to RLQ - Anorexia - Fever (>38C) - N/V - WBC >10,000 - Neuts (ANC) >7500

Answer 9

**Indications for psychiatric vs Medical admission** - See pic - eGFR <60 or dropping (med) - Albumin mildly low (Psych) or <30 (medical) - LFT's mildly deranged (Psych) or ALT/AST > 500 (Med) - Neuts <1.5 (psych) or <1.0 (med) - SI/self harm or significant distress are indications for psych admit Life threats - Hypovolaemic shock - Cardiac failure, cardiogenic and arrhythmogenic shock - Septic shock (relative immunosuppression) - PE with obstructive shock - Booerhaves syndromes - Respiratory failure from muscle atrophy or refeeding syndrome - Seizures/encephalopathy from hypoglycaemia and metabolic derangement - Severe anaemia with high output cardiac failure - Acute liver failure, severe electrolyte derangement DDx for Cachexia - Eating disorders - Malignancies - Endocrine disorders (hyperthyroid, diabetes mellitus) - Malabsorption (coeliac, short gut syndrome etc) - Inflammatory bowel disease (any chronic inflammation) - Chronic infections (TB most common) History - SI and self harm, psychotic/mania and depression symptoms - Weight loss amount (current and pre-morbid), percentage and time frame - Menarche and menses Hx - HEADSS screen - heart failure symptoms, syncope, palpitations, light headedness - B symptoms, thyroid symptoms, fevers, lumps/bumps - FHx AN and mental health Exam - Weight, height, BMI - Postural BPs and HR - Temp (hypothermic) - cachexia, oedema, murmurs, heart failure signs Investigations - BSL, VBG - ECG - FBE (anaemia) - UEC/CMP (hypoelectrolytes and risk of re-feeding) - LFT's (High ALT/AST, low alb) - Nutritional (ADEK, B12, folate, zinc) - BHCG if female - If first presentation then coeliac, ESR and TFT's) Treatment - Adress ABC's - slow correction of all electrolytes and BSL as rapid replacement may precipitate arrhythmias and refeeding syndrome - IV or oral replacement Mag + K + Ca + Po4 - Postural hypotension give fluid aiming BP <15mmHg drop - IV thiamine 300mg - Admit med/psych, may need cardiac monitoring - May need NG - Atropine for unstable bradycardia, myocardium irritable and other inotropes may cause malignant arrhythmias

Answer 10

**Most common causes** IGA nephropathy - Commonest GN overall - Preceding viral or GAS infection, but usually only days prior - Flank pain, fever, loin pain - AKI and nephritic or nephrotic syndrome Post-strep GN - GAS infection 2-3 weeks prior - Nephritic - HTN, haematuria, WCC casts in urine, loin pain - Treat with LA Bicillin - Fluid and sodium restriction - Nifedipine for HTN Haemolytic Uraemic Syndrome - Usually post infectious Gastro (E.coli 0157 etc) - Anuria/haem or proteinuria - Hypertension with possible crisis - MAHA (schistocytes) and thrombocytopaenia - LDH and platelets up, Coombs -ve Hypertensive crisis management - Attend to ABCDEFG's - if urgency then give or Nifedipine - If emergency then IV Labetalol bolus 0.5mg/kg (max 40mg) then infusion 0.5mg/kg/hr titrated to effect - Aim for 25% drop in BP in first 8hrs - Further medications include Hydralazine and SNP

Answer 11

Bleeding *Primary* - Within 24hrs of the surgery - Usually a surgical complication - 10% of bleeds *Secondary* - Usually around days 5-10 - When the fibrin clot separates as mucosa is growing inwards - Highest risk time for bleeding - 90% of bleeds Other complications *Airway obstruction* - Usually from clots, sometimes from tonsillar tissue or retained surgical equipment - Risk of negative pressure APO - Manage as per FB *Infection* - Suppurative lymphadenitis, tonsillar bed infection, Lemierres syndrome General History - Date of surgery, issues in surgery - Episodes of bleeding, visible clot? - PO intake, hydration, UO - Fevers, neck stiffness - Vomiting - Difficulty breathing - Cooperation level and age of patient - Coffee ground emesis? - PHx, particularly bleeding diathesis - Jehova's witness status, able to have blood products, issues with transfusions - Analgesia needs, medications taken Exam - "Blackberry sign" Dark clot on the tonsillar bed, high risk of rupture - Hydration status (often poor oral intake and dehydrated) - Fevers, neck stiffness, Lemierres syndrome in neck Investigations - FBE and coags +/- TEG/ROTEM - Group and hold + cross match - UEC and CMP (dehydration, at risk of hyponatraemia) - CRP (infection) Secondary bleed treatment - Rinse mouth with cold water, lignocaine with adrenaline, and TXA - Possible to use silver nitrate on oozing slow bleed - Larger bleed use direct pressure with mcagills forceps and gauze saturated with epinephrine (pressure laterally, not posteriorly) - Consider IV TXA 15mg/kg and DDAVP 0.3mcg/kg - MTP as needed - Intubation with soiled airway plan