Paediatrics Flashcards
How is a diagnosis of bronchiolitis confirmed?
Nasopharyngeal aspiration
What requires admission in bronchiolitis?
Rib recession
Apnoea
>50 RR
Dehydration
Poor feeding
Patient or parental exhausation
What shows on an X-ray in bronchiolitis?
Hyperinflation of lungs
Flattening of the diaphragm
Increased hilarity bronchiole markings
What are the symptoms of croup?
Barking cough
Hoarseness
Stridor
What is given in severe croup?
Nebulised adrenaline
What are signs of severe croup?
Respiratory distress
Restlessness
Cyanosis
Rising pulse
Rising RR
Lethargy
Where do you feel for mass in pyloric stenosis?
Lateral border of the rectus in the RUQ
What are the four parts of the stomach?
Cardia
Fundus
Body
Pylorus
What is the age range for SUFE?
10-17
What is the cartilage that makes up the epiphysis?
Hyaline cartilage
What is found on examination in SUFE?
Limp on walking
External rotation of limb
Hip motion is limited (flexion abduction and medial rotation)
What are causes of jaundice within the first 24 hours?
Rhesus haemolytic disease
ABO incompatability
Herpes
G6PD deficiency
Hereditary spherocytosis
Haematomas
Toxoplasmosis
Syphilis
Rubella
CMV
Hepatitis
What investigations can be performed on a baby presenting with jaundice in first 24 hours of life?
FBC
Blood groups
Direct Coombs’ test
Blood film
TORCH screen
Urine dipstick/microscopy
What condition would you suspect with prolonged jaundice, pale stools and a raised conjugated bilirubin level?
Biliary atresia
What are two methods of treating neonatal jaundice?
Phototherapy
Exchange transfusion
What are signs of cyanotic congenital heart disease?
Poor feeding
Dyspnoea
Tachycardia
Weak pulse
Cold peripheries
Hepatomegaly
Engorged neck veins
Sweating
Gallop rhythm (third heart sound)
What are risk factors for infant respiratory distress syndrome?
Prematurity
C section
Second twins
Males
Hypothermia
FH
Perinatal asphyxia
What cells in the lungs produce surfactant?
Type II pneumocytes
How does infant respiratory distress syndrome present on a CXR?
Diffuse granular shadowing/ground glass shadowing
When are febrile convulsions classed as complex febrile convulsions?
Focal signs
>15 minutes
Recurrence within 24 hours
Incomplete recovery within 1 hour
What is cerebral palsy?
A chronic disorder of movement and posture due to non progressive brain abnormalities occurring before the brain is fully developed
What are the subtypes of cerebral palsy based on movement disorder?
Spastic
Athetoid
Ataxic
Mixed
Aside from motor complications, what are other signs of cerebral palsy?
Delayed milestones
Failure to thrive
Epilepsy
Urinary incontinence
Constipation
Drooling
Sleep disturbance
Contractures
What medications can be used for muscle spasm in CP?
Baclofen
Diazepam
Dantolene
What is the pathophysiology of intussusception?
One segment of bowel telescopes into a distal segment of bowel, causing obstruction
What are X-ray findings in intussusception?
Right lower quadrant opacity
Dilated gas-filled proximal bowel with absence of gas distally
Multiple fluid levels
Perforation
What is the non-surgical management of intusussception?
Reduction by enema
What is the most common cause of pseudomembranous croup?
Staph aureus (most common)
Strep A
Haemophilus
How is epiglottis treated?
IV cefuroxime/ceftriaxone
What is prophylaxis for epiglottis?
Rifampicin
What are notifiable diseases?
Whooping cough
Mumps
How is whooping cough tested for?
Per nasal swab for PCR
What is the prophylaxis for bronchiolitis in at risk babies?
Palivizumab
Monoclonal antibody to RSV given monthly IM
What are the phases of whooping cough?
Catarrhal
Paroxysmal
Convalescent
What is heard on examination in bronchiolitis?
Find end inspiratory crackles and prolonged expiration
High pitched wheeze expiratory
What is asthma?
Chronic inflammatory airway disease leading to variable airway obstruction
The smooth muscle in the airways is hypersensitive and responds to stimuli by constricting and causing airflow obstruction
What is a severe asthma attack?
Sats <92
Peak flow <50%
Unable to complete sentences
RR >= 25 in adult >40 in 1-5 and >30 in >5
HR >= 110, >140 in 1-5 and >125 in >5
What is a life threatening asthma attack?
Peak flow <33%
Sats <92
Exhaustion and poor respiratory effort
Hypotension
Silent chest
Cyanosis
Altered consciousness/confusion
Normal CO2
PaO2 <8
What is the management of acute asthma?
Salbutamol inhaler 10 puffs every 2 hours
Salbutamol/ipratropium bromide nebuliser
Oral prednisolone (3days)/IV hydrocortisone
IV magnesium sulphate
IV salbutamol
IV aminophylline
How does salbutamol work?
Smooth muscle relaxant
What inhaler usage can a child be discharged on?
6 puffs 4 hourly
How is asthma investigated?
Spirometry with reversible bronchial testing
Fractional exhaled nitric oxide (if above negative)
Direct bronchial challenge with histamine or metacholine
Peak flow varaibility
How do SAMA and LAMA work?
Block the muscarinic effects of acetylcholine
How does ICS work?
Suppress airway inflammation
What is an example of a LAMA?
Tiotropium bromide
What is an example of a SAMA?
Ipratropium, glycopyrronium
What are the consequences of CF?
Thick pancreatic and biliary secretions that cause blockage of the ducts resulting in a lack of digestive enzymes such as pancreatic lipase)
Low volume thick airway secretions that reduce airway clearance, resulting in bacterial colonisation and susceptibility to airway infections
Congenital bilateral absence of the vas deferens
What are the significant bacteria that colonise in CF?
Staphylococcus aureus
Pseudomonas aeurginosa
How is cystic fibrosis inherited?
Autosomal recessive
Cystic fibrosis transmembrane conductance regulatory gene on chromosome 7
What is often the first sign of CF?
Meconium ileus
What are signs of CF on examination?
Clubbing
Nasal polyps
Crackles and wheeze
Abdominal distension
Low weight or height
How is cystic fibrosis investigated?
Newborn blood spot test
Sweat test (chloride >60 is diagnostic)
Genetic testing
What is the management of cystic fibrosis?
Chest physiotherapy several times a day
Exercise
High calorie, low fat diet
CREON
Prophylactic flucloxacillin
Bronchodilators
Nebulised DNase (dornase alfa, makes secretions less thick)
Nebulised hypertonic saline
Vaccinations including pneumococcal, influenza, varicella
What does CF affect?
Mucous glands
What are the complications of CF?
Pancreatic insufficiency
CF-related diabetes
Liver disease
Infertility in males
What presents similarly to CF?
Primary ciliary dyskinesia (aka Kartagener’s syndrome)
What are the features of primary ciliary dyskinesia?
Affects the motile cilia of various cells:
Build up of mucus in lungs
Affects cilia in Fallopian tubes and in the tails (flagella) of sperm
How is primary ciliary dyskinesia inherited?
Autosomal recessive
What is the triad for primary ciliary dyskinesia?
Paranasal sinusitis
Bronchiectasis
Situs invertus
What is heard on examination in pneumonia?
Bronchial breath sounds
Focal coarse crackles
Dullness to percussion
What is first line treatment in pneumonia/
Amoxicillin + erythromycin (cover atypical)
What is immunoglobulin class-switch recombinant deficiency?
Cannot convert IgM to IgG
What is Poiseuille’s law?
Flow rate is proportional to the radius of the tube to the power of 4
What are the 5 criteria for Kawasaki disease?
Cracking of lips or strawberry tongue
Nonpurulent conjunctivitis
Rash
Erythema and oedema of hands and feet (desquamation)
Large unilateral cervical lymphadenopathy
What is Kawasaki disease?
Systemic, medium sized vessel vasculitis
What are the phases of Kawasaki disease?
Acute: most unwell. 1-2 weeks
Subacute phase: acute symptoms settle, desquamation and arthralgia occur, risk of coronary artery aneurysm forming. 2-4 weeks
Convalescent stage: 2 -4 weeks
What is the major complication of Kawasaki disease?
Coronary artery aneurysm
What is the treatment of Kawasaki?
High dose aspirin to decrease risk of thrombosis
IV Immunoglobulin to reduce the risk of coronary artery disease
What do blood tests show in Kawasakia?
FBC: anaemia, leukocytosis, thrombocytosis
LFTs: hypoalbuminaemia, elevated LFTs
Raised inflammatory markers, particularly ESR
Urinanalysis: high WCC without infection
What triggers rheumatic fever?
Strep bacteria, usually 2-4 weeks after infection
Usually group A strep (strep pyogenes)
What type of hypersensitivity reaction is rheumatic fever?
Type 2
Antibodies against strep bacteria also match antibodies in the body e.g on the myocardium
What are the main organs involved in rheumatic fever?
Heart: carditis, mitral valve disease, pericardial rub on auscultation
Joint: migratory arthritis affecting large joints, hot, swollen and painful joints
Skin: subcutaneous nodules, erythema marginatum rash
Nervous system: chorea (Sydenham chorea)
How is rheumatic fever investigated?
Throat swab for bacterial culture
Anti-strep antibodies titre
Echocardiogram, ECG, CXR
Which criteria is used in making the diagnosis of rheumatic fever?
Jones Criteria
Major:
J oint arthritis
O rgan inflammation e.g. carditis
N odules
E rythema marginatum rash
S ydenham chorea
Minor:
F ever
E CG changes (prolonged PR but no carditis)
A rthralgia without arthritis
R raised inflammatory markers
What is given after rheumatic fever?
Prophylactic antibiotics (oral or IM penicillin) to prevent further strep infections and recurrence
What is the most notable valve disease in rheumatic fever?
Mitral stenosis
What is the most common B strep cause in meningitis?
Strep agalactiae
Why is amoxicillin added in bacterial meningitis for < 3 months?
To cover for listeria in pregnancy
Why is dexamethasone used in bacterial meningitis management?
Reduce the frequency and severity of hearing loss
Which vertebral level is a LP inserted into?
L3/L4
What are the viral causes of encephalitis?
Herpes simplex (most common)
Varicella zoster
CMV
EBV
When is a LP contraindicated?
GCS <9
Haemodynamically unstable
Active seizures
Post-ictal
What is the management of encephalitis?
IV Aciclovir for HSV or VZV
IV ganciclovir for CMV
Other viral causes are just supportive management
When is septic shock diagnosed?
When sepsis has led to cardiovascular dysfunction. The arterial BP falls resulting in organ hypoperfusion which leads to a rise in lactate
For what aged children is the traffic light system used?
< 5
What are the red flags on the traffic light system?
Colour: pale/mottled/ashen/blue
Activity: no response to social cues, appears ill, does not wake, weak high-pitched or continuous cry
Respiratory: grunting, RR >60, moderate or severe chest indrawing
Circulation: reduced skin turgor
Other: <3 months with >=38 degrees, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurological signs, focal seizures
What is the IV fluid bolus for children?
10ml/kg bolus of normal saline
Which age group and temperature need urgent treatment for sepsis?
< 3 months with temperature >= 38 degrees
What investigation is ordered if meningococcal disease is supsected?
Meningococcal PCR
What are the signs of infectious mononucleosis?
Lymphadenopathy
Tonsillar enlargement
Splenomegaly and splenic rupture
What are the investigations for infectious mononucleosis?
Monospot test
Paul-Bunnell test
Looking for heterophiles antibodies which are produced in infectious mononucleosis but can take up to 6 weeks for these to be produced
What are lifestyle measures for infectious mononucleosis?
Avoid alcohol as EBV impacts the ability of the liver to process alcohol
Avoid contact sport due to risk of splenic rupture
Which malignancy is associated with infectious mononucleosis?
Burkitt’s lymphoma
What are the complications of mumps?
Pancreatitis (abdominal pain)
Orchitis (testicular pain and swelling)
Meningitis or encephalitis (confusion, neck stiffness and headache)
Sensorineural hearing loss
How is mumps investigated?
PCR testing on a saliva swab
Blood or saliva testing for antibodies
What is the pathophysiology of Hirschsprung’s disease?
Loss of parasympathetic ganglion cells from the myenteric plexus in the distal bowel and rectum
The aganglionic section of colon does not relax, causing it to become constricted which leads to loss of movement of faeces and obstruction in the bowel
This stops peristalsis of the large bowel
Proximal to the obstruction, the bowel becomes distended and full
Which diseases are Hirschsprung’s associated with?
Down’s syndrome
Neurofibromatosis
MEN type II
What is the diagnostic investigation for Hirschsprung’s disease?
Rectal biopsy
Absence of ganglionic cells
What is an immediate complication of Hirschsprung’s disease?
Hirschsprung associated enterocolitis (toxic megacolon and perforation of the bowel)
Where is conjugated bilirubin excreted?
In the bile
What is biliary atresia?
Congenital condition where a section of the bile duct is either narrowed or absent
This results in cholestasis where the bile cannot be transported from the liver to the bowel
When should biliary atresia be suspected?
Persisten jaundice (>14 days in term babies and >21 days in prep babies)
What is the management of biliary atresia?
Kasai portoenterostomy: involves attaching a section of the small intestine to the opening of the liver where the bile duct normally attaches
Often require a full liver transplant to resolve the condition
How does intestinal obstruction show on X-ray?
Dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction
Absence of air in the rectum
What is the pathophysiology of pyloric stenosis?
Hypertrophy of the pyloric sphincter (ring of smooth muscle that forms the canal between the stomach and the duodenum)
This causes narrowing of the pyloric sphincter
This prevents food travelling from the stomach to the duodenum as usual
After feeding, there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum and it eventually becomes so powerful that it ejects food into the oesophagus and projectile
What is seen on examination in pyloric stenosis?
Peristalsis observed in the abdomen after feeding
Firm, round mass like a large olive felt in the upper abdomen
What is shown on a blood gas in pyloric stenosis?
Hypochloraemic, hypokalaemic metabolic acidosis
What is the diagnostic investigation for pyloric stenosis?
Abdominal US
What is the management of pyloric stenosis?
Laparoscopic pyloromyotomy (Ramstedt’s pyloromyotomy)
When does intussusception typically occur?
6 months - 2 years
What is found on examination in intussusception?
RUQ mass on palpation, described as sausage shaped
What are the features of intestinal obstruction?
Vomiting
Absolute constipation
Abdominal distension
What is the management of intussusception?
Therapeutic enemas (with contrast, water or air)
Surgical reduction if enemas do not work
Surgical resection if the bowel becomes gangrenous
What are preventative medications for abdominal migraine?
Pizotifen (serotonin agonist)
Propranolol
Cyproheptadine (antihistamine)
Flunarizine (CCB)
What is the pathophysiology of coeliac disease?
Autoimmune condition where autoantibodies created in response to the gluten target the epithelial cells of the intestine and lead to inflammation
Which part of the bowel is affected by coeliac disease?
Small bowel, particularly the jejunum
What is shown on biopsy in coeliac disease?
Crypt hyperplasia
Villous atrophy
What should be tested first in coeliac disease?
Total IgA levels (if total IgA is low then the test will be negative even if they have the condition)
If IgA levels are low, test for the IgG version of the antibodies
What conditions is coeliac disease associated with?
T1DM
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
What is the rash associated with coeliac disease?
Dermatitis herpetiformis (itchy blistering rash on the abdomen)
What are the types of lymphoma associated with coeliac?
Enteropathy associated T cell lymphoma of the intestine
Non-Hodgkin lymphoma
What are the most common viral causes of gastroenteritis?
Rotavirus
Norovirus
Adenovirus
What are the bacterial causes of gastroenteritis?
E.Coli
Campylobacter jejuni
Shigella
Salmonella
Bacillus cereus
Yersinia Enterocolitica
Staph aureus toxin
Giardiasis (parasite, treated with metronidazole)
Why do you avoid antibiotics in E.Coli gastroenteritis?
Increases the risk of haemolytic uraemic syndrome
What is the most common bacterial cause of gastroenteritis worldwide?
Campylobacter jejuni
Which bacterial causes of gastroenteritis can cause haemolytic uraemic syndrome?
E.Coli and Shigella due to producing the Shiga toxin
What is a transient complication of gastroenteritis?
Lactose intolerance
What are post-gastroenteritis complications?
Dehydration
Transient lactose intolerance
IBS
Reactive arthritis
GBS
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