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Phase 4 Question Knowledge > Paediatrics > Flashcards

Paediatrics Flashcards

1
Q

Resp distress Px

A
  • Increased RR
  • Tripod pos
  • Stridor / wheeze / grunting
  • Tracheal tug
  • Accessory muscle use - SCM…
  • Supraclavicular / suprasternal / intercostal / substernal / subcostal recession
  • Abdominal breathing (see-saw)
  • Head bobbing
  • Nasal flaring
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2
Q

Term neonate maintenance fluids

A

Use 10% dextrose

Birth-D1 - 50-60ml/kg/d
D2 - 70-80
D3 - 80-100
D4 - 100-120
D5-28 - 120-150

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3
Q

Child >28d maintenance fluids

A

0.9%NaCl + 5% glucose

100ml/kg/d for first 10kg
50ml/kg/d for next 10kg
20ml/kg/d for every kg over 20kg

(4,2,1ml/kg/hr)

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4
Q

Paeds replacement fluid

A

0.9% NaCl + 5% glucose + K replacement if needed

% dehydration = (well weight-current weight)/well weight x 100

deficit (ml) = % dehydration x weight (kg) x 10

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5
Q

Paeds resus fluids

A

Bolus 0.9% NaCl 10ml/kg over 10 mins

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6
Q

Developmental milestones

A

GO OVER THIS AGAIN

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7
Q

Milestones concerns

A

Gross motor
Not sitting by 1yo
Not walking by 18mo

Fine motor
Hand preference before 18mo

Speech + language
Not smiling by 3mo
No clear words by 18mo

Social development
No response to carers by 8wks
Not interested in playing with peers by 3yo

RED FLAGS
regression
poor health / growth
significant FHx
Examination - microcephaly, dysmorphic features
safeguarding indicators

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8
Q

Shaken baby syndrome

A

Intentional shaking of child 0-5yo

retinal haemorrhages
subdural haematoma
encephalopathy

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9
Q

Bronchiolitis

A

Acute infection of bronchioles

RSV

<1yo, mostly <6mo - in winter

RFs
prem, SGA, <12wks, congenital HD, nursery…

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10
Q

RSV course

A

URTI (coryza)
50% get better
50% chest sx in 1-2d
Worse d3-4, lasts 7-10d, max 2-3wks

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11
Q

Bronchiolitis Px

A

Coryza
Cough, SOB, increased RR, reduced feeding, irritable
Mild fever
Apnoeas
Wheeze / crackles bilaterally

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12
Q

Bronch Ix

A

Immunofluorescence of nasopharyngeal secretions may show RSV

Clinical dx
NPA - nasopharyngeal aspirate
Blood gases if severe, CXR

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13
Q

Bronch reasons for admission

A

<3mo, pre-existing condition, reduced feeding, dehydrated, increased RR, resp distress, low sats, apnoeas, parents struggling to manage

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14
Q

Bronch Mx

A

Supportive - calpol, feeds, nasal suctioning, O2

Ventilatory support - high flow O2, CPAP, intubation

Palivizumab - MAb for prevention - for high risk, prem…

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15
Q

Viral-induced wheeze

A

Acute wheeze from viral infection

RSV / rhinovirus commonly

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16
Q

Viral induced wheeze Px

A

SOB
Coryza
Fever
Resp distress
Global wheeze

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17
Q

Viral induced wheeze Mx

A

Salbutamol nebs
Pred
Mg
Monteleukast
Inhaled corticosteroids later on

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18
Q

Croup

A

URTI - inflammation of larynx

Acute laryngotracheobronchitis

6mo-6yo, peak 2yo

Parainfluenza

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19
Q

Croup Px

A

Coryza
Barking cough
Stridor, resp distress
Drowsy, lethargic, cyanosis

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20
Q

Croup Ix

A

Clinical Dx

XR - steeple sign

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21
Q

Croup Mx

A

Oral dexamethasone 0.15mg/kg oral, rpt dose after 12hrs if needed

O2, nebulised budesonide / adrenaline, intubate

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22
Q

Epiglottitis

A

Inflammation of epiglottis

H influenzae B

Vaccine against

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23
Q

Epiglottitis Px

A

Sore throat
Stridor
Drooling
Tripod
High fever
Dysphagia
Muffled voice
Unwell

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24
Q

Epiglottitis Ix

A

lateral neck XR - thumb sign

Laryngoscopy is dx

Throat swab / culture

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25
Q

Epiglottitis Mx

A

Do not distress

Anaesthetist / ENT

IV ceftriaxone once airway secure

Rifampicin to household contacts

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26
Q

Whooping cough

A

URTI from Bordetella pertussis (G-)

Resp droplet spread

Stay off school for 21d after sx onset, or 48hrs after abx

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27
Q

Whooping cough Px

A

2-3d coryza
Coughing fits
Loud inspiratory whoop
Faint, vomit, PTX, epistaxis…
Apnoeas

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28
Q

Whooping cough Ix

A

Nasal swab PCR

Anti-pertussis toxin IgG

Bloods - WCC raised

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29
Q

Whooping cough Mx

A

Notify PHE (equivalent)

Supportive / admit

Macrolide within 21d - clarithromycin / azithromycin / erythromycin (ery if pregnant)

Co-trimoxazole alternative

Prophylactic abx for vulnerable contacts - pregnant, unvaccinated

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30
Q

Acute asthma

A

chronic inflammation + reversible obstruction of airways

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31
Q

Acute asthma px

A

SOB
Wheeze
cough
nocturnal cough
tight chest
Sx are intermittent, variable, worse at night, triggered

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32
Q

Acute asthma severity

A

Mild/moderate
PEF>50%
normal speech

Severe
SOB to talk/feed
Deranged obs
sats <92%
PEF <50%

Life-threatening
Cyanosis, pallor
silent chest
poor resp effort
reduced GCS
sats <92%
PEF <33%

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33
Q

Acute asthma Mx

A
  • O2
  • Salbutamol inhaler 4-6 puffs every 4hrs / 10 puffs every 2hrs
  • Nebulised salbutamol + ipratropium
  • 3d oral prednisolone
  • IV Mg
  • IV salbutamol
  • IV aminophylline
  • Monitor K

Discharge when child well on 6 puffs 4hrly

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34
Q

Chronic asthma

A

Chronic inflammatory airway disease, reversible obstruction

Atopic

Omalizumab - potential tx - anti IgE

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35
Q

Chronic asthma px

A

episodix dx, intermittent exacerbations
diurnal variability - worse at night / early morning
dry cough
wheeze
SOB
triggers
Hx of atopy

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36
Q

Chronic asthma Ix

A
  • Clinical dx after 5yo
  • Spirometry + reversibility testing
  • Direct bronchial challenge - histamine / methacholine
  • FeNO
  • Peak flow variability
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37
Q

Chronic asthma Mx <5yo

A
  1. salbutamol
  2. low dose ICS / montelukast
  3. other step 2 option
  4. refer to specialist
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38
Q

Chronic asthma Mx 5-12yo

A
  1. Salbutamol
  2. Low dose ICS
  3. Salmeterol
  4. medium dose ICS, ?montelukast / theophylline
  5. High dose ICS
  6. refer
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39
Q

Chronic asthma Mx >12yo

A
  1. salbutamol
  2. ICS low dose
  3. salmeterol
  4. medium dose ICS, ?montelukast / theophylline / tiotropium
    5 . high dose ICS, add other option 4 options, refer
  5. Oral daily steroids
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40
Q

Pneumonia

A

Lung infection - inflammation of lungs, exudate production

Bacterial - Strep pneumonia, GAS, GBS, S aureus, H influenza, M pneumonia

Viral - RSV, parainfluenza, influenza

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41
Q

Pneumonia Px

A

cough
fever >38
raised RR, HR
IWOB
Sepsis
focal coarse creps
Bronchial breath sounds

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42
Q

Pneumonia Ix

A

Bloods
CXR - consolidation
Sputum culture
Throat swabs

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43
Q

Pneumonia Mx

A

Amoxicillin / benpen
Add macrolide if atypical / mycoplasma / chlamydia
Co-amox
O2

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44
Q

Laryngomalacia

A

Floppy larynx -> partial obstruction

Tissue around supraglottic larynx is softer -> stridor

Px
Stridor, intermittent
Worse when feeding, upset, lying on back

Mx
usually grow out of it
Rarely - tracheostomy, surgery to alter larynx

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45
Q

Chronic lung disease of prematurity (CLDP)

A
  • Bronchopulmonary dysplasia
  • Occurs in prem babies <28wks, suffer resp distress syndrome, need I+V at birth
  • CXR changes later, infant may need O2 after 36wks

Px
Low sats, IWOB
Poor feeding/weight gain
Crackles / wheeze
Increased infections

Mx
Home O2, wean
Pavilizumab for RSV prevention

Prevention
steroids in prem labour
CPAP > intubation after birth
Caffeine for apnoeas

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46
Q

Cystic fibrosis

A

Autosomal recessive multi-organ disease

Mutation in CFTR gene -> thickened secretions - (low Cl secretion, increased Na resorption, high sodium sweat…)

Resp disease, concentrated bile, water deficiency in bowel, pancreatic insufficiency

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47
Q

CF Px

A

Neonates
Failure to thrive
Meconium ileus
Rectal prolapse

Resp
Cough, thick mucus, wheeze, recurrent infections, bronchiectasis, sinusitis, nasal polyps, spon PTX, haemoptysis, SOB

Malabsorption, DM, steatorrhoea, gallstones, infertility, clubbing, osteoporosis

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48
Q

CF Ix

A
  • Screen with newborn spot test
  • Sweat test - high Na + Cl
  • Genetic testing
  • Pulmonary function tests
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49
Q

CF Mx

A

Chest physio
Exercise
High calorie diet
Abx
Dornase alfa nebs - mucolytic
Salbutamol nebs
Nebulised hypertonic saline
CREON tablets
Vit ADEK
Ursodeoxycholic acid
Fertility Tx
Lung / liver transplant

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50
Q

Primary ciliary dyskinesia / Kartagner’s syndrome

A

Cilia affected, autosomal recessive - consanguinity

Frequent LRTIs, reduced fertility

Kartagner’s triad
Paranasal sinuses
Bronchiectasis
Situs invertus

Chest physio, high calorie diet, abx

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51
Q

Bacterial tracheitis

A

Infection of trachea
Pseudomonas

IV cefotaxime, fluclox

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52
Q

Congenital HD

A

Acyanotic
VSD, ASD, PDA, coarc, AS

Cyanotic
TOF, TGA, tricuspid atresia

Mx at birth of cyanotic
Supportive
Prostaglandin E1 (alprostadil) - keeps PDA open

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53
Q

Innocent murmurs

A

Venous hums - turbulent blood flow in great veins - continuous blowing noise below clavicles

Still’s murmur - low-pitched sound heard at L lower sternal edge

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54
Q

PDA

A
  • Patent ductus arteriosus
  • L->R shunt (aorta -> pulm artery)
  • fetus pulm vascular resistance high, shunt R->L to bypass lungs (also flows from RA->LA through foramen ovale)
  • resistance decreases at birth, duct closes due to decreased resistance
  • may stay open - genetics, prem, maternal rubella
  • Leads to pulm HTN, Eisenmengers, RVH, RHF, eventually LHF

Px
- continuous machinery murmur
- SOB, difficulty feeding

Ix
- ECHO

Mx
- Indomethacin - prostaglandin inhibitor
- Transcatheter / surgical repair
- monitor for 1yr with ECHOs

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55
Q

ASDs

A

Hole in septum between atria
L-R shunt
Then RHF, pulm HTN, Eisenmengers, R->L, cyanotic

Px
Mid systolic murmur (from increased flow across pulm valve due to more blood in R heart
Fixed split S2
SOB, difficulty feeding, URTIs

Ix
ECHO

Mx
Can w+w
Transvenous / surgical closure

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56
Q

VSDs

A

Hole in septum between ventricles
Downs, Turners association
L-R, becomes R-L with Eisenmenger’s

Px
- pan-systolic murmur
- SOB, poor feeding, failure to thrive, cyanosis

Ix
- ECHO

Mx
- w+w if small, may close spontaneously
- Surgical / transvenous closure

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57
Q

AVSD

A

Hole in centre of heart - involves ventricular, atrial septum, mitral, tricuspid valves

Down’s association

Px
SOB neonate
Poor weight gain / feeding
Eisenmenger’s over time

Mx
surgical repair

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58
Q

Eisenmenger’s syndrome

A

Reversal of L-R shunt in congenital HD due to pulm HTN

In L-R - high pressure pulm flow - damage to pulmonary vasculature, increased resistance through lungs -> pulm HTN, reverse shunt to R-L, cyanotic pt

associated with ASD, VSD, PDA

Px
Original murmur may disappear
Cyanosis
Clubbing
RVF
Haemoptysis

Mx
Heart-lung transplant
Tx pulm HTN

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59
Q

Coarctation of aorta

A
  • Congenital narrowing of aortic arch, usually around ductus arteriosus
  • Turner’s association
  • Collateral vessels grow

Px
- weak femoral pulses
- high BP in head, neck, R arm, low BP in lower limbs
- systolic murmur
- radiofemoral delay
- SOB, poor feeding, grey/floppy

Ix
- USS, CT angio

Mx
- if severe, prostaglandin E to keep duct open
- surgical correction

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60
Q

Aortic stenosis

A
  • Congenital narrowing of aortic valve
  • bicuspid aortic valve

Px
- fatigue, SOB, dizzy, faint
- HF at birth
- ejection systolic murmur in aortic area
- slow rising pulse, narrow pulse pressure

Ix
- ECHO

Mx
- percutaneous balloon aortic valvuloplasty
- surgical valvotomy
- valve replacement

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61
Q

Pulmonary stenosis

A
  • congenital narrowing of pulmonary valve
  • associations - TOF, William, Noonan, congenital rubella

Px
- SOBOE, dizzy, faint
- RHF
- Ejection systolic murmur in pulmonary area

Ix
- ECHO

Mx
- Balloon valvuloplasty
- valve replacement

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62
Q

Tetralogy of Fallot

A
  • VSD, PS, RVH, overriding aorta (allowing blood from both ventricles in)
  • R->L (stenosis of RV outflow means R pressure >L - cyanotic

RFs
- rubella, older mother, alcohol in pregnancy, diabetic mother

Px
- picked up on scans
- central cyanosis
- clubbing
- low birth weight + growth
- SOB
- ejection systolic murmur

Ix
- ECHO
- CXR - boot shaped heart

Mx
- prostaglandin infusion
- surgery

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63
Q

Tet spells

A
  • cyanotic episode, R-L shunt worsened
  • when pulm vasc resistance increases, or systemic resistance decreases
  • eg exertion (CO2 is vasodilator), crying

Px
- low sats

Mx
- squat
- knees to chest
- O2
- IV fluids - increase preload, increase vol to pulm vessels
- Morphine - reduce resp drive - more effective breathing
- sodium bicarb - acidosis
- phenylephrine infusion - increase SVR

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64
Q

Ebstein’s anomaly

A
  • Congenital - tricuspid valve lower, big RA, small RV
  • poor flow to pulm vessels, poor flow from RA-RV
  • associated with ASD, WPW

Px
- HF, oedema
- S3,4
- cyanosis, SOB, collapse
- worse when duct closes, a few days after birth (blood could flow from aorta -> pulm vessels to get oxygenated)

Ix
- ECHO

Mx
- Tx arrhythmias, HF
- Surgery

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65
Q

Transposition of great arteries

A
  • Attachments of aorta / pulmonary trunk swapped
  • increased risk in diabetic mothers
  • RV pumps into aorta, LV into pulmonary vessels - 2 separate circulations - cyanosis
  • survival depends on PDA (or ASD / VSD if present)

Px
- detected on antenatal scans
- cyanosis at birth, raised RR
- shunt compensates to begin
- resp distress, tachycardia, poor feeding, sweat

Ix
- CXR - egg on side appearance

Mx
- prostaglandin infusion
- balloon septostomy - make ASD
- open heart surgery

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66
Q

HF

A

Causes
- malformation, cardiomyopathy, pericardial effusion, myocarditis, arrhythmias

Px
- poor feeding, failure to thrive
- sweaty
- SOB - during feeding
- raised RR, HR
- Gallop rhythm, rapid weight gain, enlarged liver

Ix
- CXR, ECG, ECHO, BP (upper/lower limbs), sats (on pre/post ductal limbs)

Mx
- Sit up, NG feed, O2
- Furosemide + spironolactone
- Monitor K

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67
Q

Arrhythmias

A

SVT
- SOB, poor feeding, HF, pallor, palpitations
- ECG, cardiac monitoring
- A-E, DC shock if shocked, vagal manoeuvres (diving reflex, carotid massage, valsalva), adenosine, flecainide / amiodarone

VT
- much the same
- shock, amiodarone, Mg

Brady
- A-E, o2
- adrenaline bolus + infusion
- atropine

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68
Q

Constipation causes

A

Idiopathic, poor fluid/fibre intake
Hirschsprung’s
CF
Hypothyroid
Spinal cord lesions
Sexual abuse, safeguarding
Intestinal obstruction
Anal stenosis
Cow’s milk intolerance

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69
Q

Encopresis

A

faecal incontinence >4yo - overflow past impaction - rectum desensitised

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70
Q

Constipation red flags

A

meconium ileus
neuro sx
vomiting
abdo pain
abnormal anus
failure to thrive

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71
Q

Constipation Mx

A

Hydrate, fibre

Disimpaction
Movicol
After 2wks if no disimpaction, add senna / docusate
Can use lactulose if movicol not tolerated

Maintenance
Movicol

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72
Q

Faltering growth causes

A

Not enough in
ineffective feeding, GORD, feed refusal
Mx - NG feed, gastrostomy

Not absorbed
anaemia, biliary atresia, coeliac, infections, IBS, CF, CMPA

Too much used up
chronic infections (HIV, TB), CLDP, con HD, hyperthyroid, asthma, malignancy, IBD

abnormal central control
GH, thyroid, psychosocial influence, avoidant/restrictive food intake disorder

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73
Q

GORD

A

reflux of stomach contents via LOS - immature in babies

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74
Q

Causes of vomiting

A

overfeeding
GORD
pyloric stenosis - projectile
gastritis / GE
appendicitis
infections - UTI, tonsillitis, meningitis
intestinal obstruction
bulimia

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75
Q

GORD Px

A

Reflux after larger feeds
vomiting
chronic cough
hoarse cry
unsettled after feeds
reluctant to feed
poor weight gain

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76
Q

GORD red flags

A

bile
projectile
blood
reduced GCS
blood in stools
rash - eg CMPA
?aspiration

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77
Q

GORD Mx

A
  • small meals
  • Gaviscon, thickened milk
  • omeprazole / ranitidine if nothing else works
  • severe - barium meal, endoscopy, surgical fundoplication
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78
Q

Sandifer’s syndrome

A

torticollis / dystonia with GORD - refer for assessment

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79
Q

Pyloric stenosis

A

hypertrophy + thickening of pyloric sphincter

prevents food moving from stomach to duodenum

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80
Q

Pyloric stenosis Px

A

~1mo
failure to thrive
projectile vomiting - milky
see peristalsis in abdo
palpate pylorus - olive

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81
Q

Pyloric stenosis Ix

A

Blood gas - high pH, low Cl, low H, low K - metabolic alkalosis

Abdo USS

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82
Q

Pyloric stenosis Mx

A

Laparoscopic pyloromyotomy (Ramstedt’s operation)

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83
Q

Gastroenteritis

A

infection of intestines

Viral - rotavirus, norovirus, adenovirus

Bacterial - E coli, campylobacter, shigella, salmonella ….

Px
N+V+D
abdo pain
fever
blood in stools

Ix
stool sample
bloods
assess hydration

Mx
off school
fluids, dioralyte
maintain feed
no-antiemetic / anti-diarrhoea

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84
Q

Coeliacs

A

Autoimmune reaction to gluten - inflammation in SI - villous atrophy and malabsorption - jejunum mostly

Associations
T1DM, thyroid, PBC, PSC, Down’s, autoimmune hep

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85
Q

Coeliacs Px

A

Asym
Failure to thrive
diarrhoea
fatigue
wt loss
mouth ulcers
anaemia - iron, B12, folate
Dermatitis herpetiformis
Neuro sx - neuropathy, ataxia, epilepsy

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86
Q

Coeliac Ix

A
  • raised anti-TTG
  • raised anti-EMA
  • check total IgA - exclude deficiency (would show false negative for ABs)
  • endoscopy + biopsy - crypt hypertrophy + villous atrophy
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87
Q

Coeliac Mx

A

gluten free diet

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88
Q

Biliary atresia

A

Bile duct narrowed / absent -> cholestasis, build up of conjugated bilirubin

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89
Q

Biliary atresia Px

A
  • jaundice after birth >14d (>21 if prem)
  • dark stools, pale urine
  • failure to thrive
  • HSM
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90
Q

Biliary atresia Ix

A
  • LFTs, bilirubin, serum A1AT
  • USS biliary tree
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91
Q

Biliary atresia Mx

A

Surgery - Kasai portoenterostomy

May need liver transplant

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92
Q

Duodenal atresia

A

Downs, Vacterl association

Blind end to duodenum

Bilious vomiting

USS - double bubble sign

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93
Q

Small bowel atresia

A

may have multiple
…..

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94
Q

Intestinal obstruction causes

A

Meconium ileus
Hirschsprung’s
oesophageal atresia
intussusception
imperforate anus
malrotation + volvulus

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95
Q

Obstruction Px

A

vomiting, bilious
abdo pain, distension
not passing wind / stools
abnormal BS

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96
Q

Obstruction Ix

A

Abdo XR - dilated loops proximal, collapsed loops distal

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97
Q

Obstruction Mx

A

Surgery - laparotomy
NBM, NG tube, IV fluids

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98
Q

Hirschsprung’s disease

A

congenital - absence of nerve cells in myenteric plexus (Auerbach’s) in distal bowel / rectum

Aganglionic cells do not relax - bowel remains constricted, obstructs faeces

Hirschsprung-associated enterocolitis (HAEC)
- infection with hirschsprung’s

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99
Q

Hirschsprung’s Px

A

depends how much bowel affected
acute intestinal obstruction after birth
delay passing meconium >24hrs
chronic constipation, abdo pain, distension
failure to thrive

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100
Q

Hirschsprung’s Ix

A

AXR - obstruction

Rectal biopsy

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101
Q

Hirschsprung’s Mx

A

IV fluids
IV abx in HAEC
Bowel washouts
Surgery to remove affected bowel - pull through op / stoma

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102
Q

Intussusception

A

Bowel telescopes
Commonly ileocaecal
6mo-2yo,
obstructs faeces

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103
Q

Intussusception Px

A

Colicky abdo pain - draw legs up
pale, lethargic, unwell
redcurrant jelly stool - late
sausage RUQ mass
vomiting - milky, then green
Obstruction

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104
Q

Intussusception Ix

A

USS - target like mass

Contrast enema

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105
Q

Intussusception Mx

A

Enema - air insufflation

surgery - laparotomy - reduction +/- resection

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106
Q

Meckel’s diverticulum

A
  • diverticulum of ASI - remnant of a duct
  • 2% of pop, 2ft from IC valve, 2in long

Px
- abdo pain
- painless PR bleed (may be massive)
- obstruction

Ix
- Meckel’s scan…
- CT angio if severe

Mx
- surgical removal

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107
Q

Appendicitis

A

inflammation of appendix

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108
Q

Appendicitis Px

A
  • Abdo pain - central, moving to RIF, tender in McBurney’s point (1/3 from ASIS to umbilicus)
  • Anorexia
  • N+V
  • Rovsing’s sign - palpation of LIF causes pain in RIF
  • Guarding
  • Rebound tenderness, percussion tenderness
  • Although - children more likely to present atypically
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109
Q

Appendicitis Ix

A

Bloods, inc CRP

?CT

USS

Diagnostic laparoscopy

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110
Q

Appendicitis Mx

A

Laparoscopic appendicectomy

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111
Q

IBD

A

UC / Crohns - inflammation of walls of GIT - remission / exacerbation

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112
Q

Crohn’s features

A
  • Entire GI tract
  • Skip lesions on endoscopy
  • Terminal ileum most affected
  • Full thickness of wall affected - transmural
  • Less commonly blood / mucus
  • Associated with wt loss, strictures, fistulas
  • Granuloma, fissures, fistula, abscesses, strictures
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113
Q

UC features

A
  • Continuous inflammation, colon and rectum only
  • Only superficial mucosa
  • Smoking protects
  • Blood + mucus
  • Primary sclerosing cholangitis associated
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114
Q

IBD Px

A

Diarrhoea
Abdo pain
bleeding
wt loss
anaemia
fever, malaise, dehydration

finger clubbing, erythema nodosum, episcleritis, iritis, arthritis, PSC

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115
Q

IBD Ix

A

Bloods

Faecal calprotectin

OGD + colonoscopy

Imaging - USS / CT / MRI

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116
Q

Crohn’s Mx

A

Induce remission
- oral pred / IV hydrocortisone
- immunosuppressants

Maintain remission
- azathioprine / mercaptopurine

Surgery
- remove affected bowel, strictures, fistulas

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117
Q

UC Mx

A

Induce remission
- mild/mod - mesalazine, then pred
- severe - IV hydrocortisone, IV ciclosporin

Maintain remission
- mesalazine, azathioprine, mercaptopurine

Surgery
remove bowel

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118
Q

Colic

A

Inconsolable crying, 1wk-3/4mo
R/o other causes - eg GI motility….

Mx
reassure
soothing strategies
support - health visitor, friends

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119
Q

Toddler’s diarrhoea

A

1-5yo
stool - foul smelling, watery, mucus, undigested veg
Short mouth->anus transit time
No failure to thrive
Balanced diet to mx

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120
Q

congenital diaphragmic hernia

A

herniation of abdo viscera into chest - incomplete formation of diaphragm

can lead to pulmonary hypoplasia, resp distress after birth

Ix
USS, fetal MRI, CXR

Mx
Surgery

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121
Q

Gastroschisis

A

Bowel out of abdo, through defect in abdo wall, no covering

Mx
May attempt vaginal delivery
Surgery ASAP after

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122
Q

Exomphalos / omphalocele

A

Abdo contents protrude through anterior abdo wall, covered by sac

Mx
C-section birth
staged repair - infant needs to grow to fit bowel

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123
Q

Hernias

A

Umbilical
common
Typically resolve by 3 years of age
If large or symptomatic- elective repair age 2-4
If small and asymptomatic perform repair at 5 years old

Inguinal
indirect in children, urgent in neonates
can’t get above it, doesn’t transilluminate

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124
Q

Necrotising enterocolitis (NEC)

A

prem babies, necrotic bowel, perforation, peritonitis

Px
not feeding
vomit, green bile
unwell
distended abdo, shock

Ix
Bloods
AXR - dilated bowel loops, bowel wall oedema, pneumatosis intestinalis (gas in bowel wall)

Mx
NBM, IVF, TPN, abx, surgery to resect

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125
Q

Malrotation + volvulus

A

anomaly of rotation of midgut (occurs in 1st trim)

Px
24hrs old
Green vomit, bile
abdo distention
blood / mucus in stools / bowels not opening
pale
not feeding

Ix
AXR, USS

Mx
IVF, laparotomy (Ladd’s - division of Ladd bands, widen mesentry base)

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126
Q

Hepatoblastoma

A

Malignant liver ca

Px
asym
abdo mass
poor appetite, wt loss, fever, vomit, jaundice

Ix
raised alpha-fetoprotein
CXR, USS, CT / MRI
Biopsy

Mx
Surgical resection
chemo
transplant

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127
Q

Kwashiorkor

A

malnutrition - reduced protein

Px
oedema (reduced albumin)
Enlarged liver (fatty)
hair thinning, teeth loss
anorexia, muscle atrophy, distended abdo

Ix
clinical dx

Mx
feed

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128
Q

Marasmus

A

Malnutrition of all food groups

Px
wasting, loss of fat, hypothermia, pyrexia, anaemia, dehydration, dry skin, brittle hair

Mx
refeed slowly

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129
Q

Choledochal cyst

A

Bile duct cyst -> obstruction + retention of bile

Px
intermittent abdo pain, jaundice, RUQ mass
jaundice, vomiting, enlarged liver
pale stools, dark urine

Ix
bloods, USS, CT, MRCP

Mx
Surgery

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130
Q

Vaccines at birth

A

BCG if RFs present

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131
Q

2mo

A

6 in 1 (diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type B (Hib), hep B)

Oral rotavirus vaccine

Meningitis B

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132
Q

3mo

A

6 in 1 vaccine

Oral rotavirus vaccine

Pneumococcal conjugate vaccine (PCV)

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133
Q

4mo

A

6 in 1 vaccine

Meningitis B

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134
Q

12-13mo

A

Hib / Men C - one jab

MMR

PCV

Men B

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135
Q

2-10yo

A

Flu (annual)

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136
Q

3yr4mo

A

4 in 1 (diphtheria, tetanus, pertussis, polio)

MMR

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137
Q

12-13yo

A

Human papillomavirus (HPV) - 2 jabs 6-24mo apart

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138
Q

14yo

A

3 in 1 (diphtheria, tetanus, polio)

Men ACWY

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139
Q

Vaccination schedule

A

6in1 - 2mo, 3mo, 4mo
4in1 - 3yr4mo
3in1 - 14yo
Oral rotavirus - 2mo, 3mo
menB - 2mo, 4mo, 12mo
PCV - 3mo, 12mo
Hib/menC - 12/13mo
MMR - 12mo, 3y4mo
HPV - 12-13yo
menACWY - 14yo

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140
Q

NICE Febrile Child Traffic Light Red Flags

A
  • pale, mottled, ashen, blue
  • no response to social cues
  • appears ill to healthcare professional
  • unarousable
  • weak, high-pitched, continuous cry
  • grunting
  • RR>60
  • moderate / severe chest indrawing
  • reduced skin turgor
  • <3mo T>38
  • non-blanching rash
  • bulging fontanelle
  • neck stiffness
  • status epilepticus
  • focal neurological signs
  • focal seizures
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141
Q

Fever causes

A

Meningitis
Encephalitis
Pneumonia
UTI
Septic arthritis
GE
Kawasaki

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142
Q

Fever Ix

A
  • hydration status, obs, travel abroad
  • Sepsis bloods, urine dip + culture, CXR, NPA, stool culture
  • LP - if <1mo, 1-3mo + unwell, >3mo with red flag sx
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143
Q

Fever Mx

A
  • A-E
  • Abx (if <1mo, or 1-3mo unwell) - cefotaxime, ceftriaxone (add amoxicillin for listeria if <3mo)
  • fluid bolus - 10-20ml/kg
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144
Q

Infectious mononucleosis (IM)

A

EBV infection

2-3wk acute illness, chronic fatigue, saliva spread

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145
Q

IM Px

A

fever, sore throat, fatigue, lymphadenopathy, enlarged tonsils
splenomegaly (rupture risk)
itchy rash after amoxicillin

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146
Q

IM Ix

A
  • Heterophile ABs - not specific to EBV Ags
  • Monospot test - ABs react with RBCs from horses
  • Paul-Bunnell test - RBCs from sheep
    ….

Specific AB tests - IgM/IgG

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147
Q

IM Mx

A

Self limiting
Avoid alcohol
Avoid contact sports

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148
Q

Mumps

A

Viral infection, spread by resp droplets
14-25d incubation, lasts 1wk
MMR 80% protection

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149
Q

Mumps Px

A

Flu prodrome
Parotid swelling - uni/bilateral
Earache, pain on eating
fever, myalgia, lethargy, reduced appetite, headache

Cx sx
abdo pain - pancreatitis
testicular pain/swelling - orchitis
confusion, neck stiffness, headache - meningoencephalitis
sensorineural hearing loss

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150
Q

Mumps Mx

A

Saliva PCR
Test blood / saliva for ABs
PHE notifiable
Supportive - rest, fluids

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151
Q

Meningitis

A

infection of meninges

Orgs by age group
<3mo - GBS, E coli, listeria
1mo-6yo - N meningitidis, S pneumoniae, H influenzae
>6yo - N meningiditis, S pneumoniae

Meningococcal septicaemia - bacterial infection in bloodstream

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152
Q

Meningitis Px

A

Fever, neck stiffness, headache, photophobia, reduced GCS, seizures, non-blanching rash, Kernig’s/Brudzinski’s

Hypotonia, poor feeding, lethargy, hypothermia, bulging fontanelle

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153
Q

Meningitis Ix

A

sepsis bloods, meningococcal PCR

LP
- <1mo + fever, 1-3mo unwell + fever, >1yo unexplained fever
- bacteria - high protein, low glucose, high neutrophils
- viral - normal protein, normal glucose, raised lymphocytes
- CI with raised ICP - eg focal neurology, papilloedema, bulging fontanelles, DIC

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154
Q

Meningitis Mx

A

Community / non-blanching rash - IM benzylpenicillin

Abx
- <3mo - cefotaxime + amoxicillin
- >3mo - ceftriaxone or cefotaxime

Dexamethasone >3mo - reduce hearing loss

Acyclovir - if viral

Ciprofloxacin - single dose for close contacts- PH notification

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155
Q

Encephalitis

A

infection of brain

Tends to be viral - HSV, VZV, EBV

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156
Q

Encephalitis Px

A

altered consciousness
focal neuro sx
focal seizures
fever

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157
Q

Encephalitis Ix

A

LP (not if GCS<9, BP low, active seizures)
CT / MRI
EEG maybe
Swabs
HIV test

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158
Q

Encephalitis Mx

A

acyclovir

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159
Q

Chickenpox

A

primary VZV infection

resp spread / shingles
contagious for 4d before -> 5d after rash / pustules crust over
10-21d incubation

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160
Q

Chickenpox Px

A

1-2d prodrome
pruritic rash 6d - macular -> papular -> vesicular - on scalp, trunk, face, extremities
fever, malaise, headache

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161
Q

Chickenpox Ix

A

Clinical dx

Tzanck smear - shows multinucleated giant epithelial cells

PCR

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162
Q

Chickenpox Mx

A

Supportive, trim nails

Calamine lotion - for itch

VZV Ig - for immunocompromised / newborns with peripartum exposure

IV acyclovir if needed

be aware secondary bacterial infection

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163
Q

Impetigo

A

Superficial bacterial skin infection

S aureus, S pyogenes

may be bullous - fluid filled lesions

direct contact spread, 4-10d incubation

No school until all lesions healed / 48hrs after abx

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164
Q

Impetigo Px

A

Usually where not covered by clothing - face, neck, hands, flexures

erythematous -> macule -> vesicular/pustular -> rupture causes honey-crusted lesions

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165
Q

Impetigo Ix

A

Clinical dx

Swab exudate for MC+S

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166
Q

Impetigo Mx

A

hydrogen peroxide 1st line

fusidic acid topical abx

oral flucloxacillin if bullous / extensive

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167
Q

Hand, foot and mouth (HFM) disease

A

viral infection

Coxsackie A16 commonly

V contagious

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168
Q

HFM Px

A

Sore throat
fever
oral ulcers
vesicles on palms /soles of feet

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169
Q

HFM Mx

A

Hydrate, analgesia

Keep off school until feeling better

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170
Q

Measles

A

RNA virus, spread by aerosol

infective from prodrome until 4d after rash starts

10-14d incubation

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171
Q

Measles Px

A
  • Prodrome - irritable, conjunctivitis, fever
  • Koplik spots - white spots on buccal mucosa
  • Rash - behind ears -> whole body, maculopapular, blotchy/confluent, desquamation of palms/soles
  • diarrhoea
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172
Q

Measles Ix

A

serum IgM ABs

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173
Q

Measles Mx

A

Notifiable
Sx relief
Vaccine for unvaccinated contacts

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174
Q

Measles Cx

A

Otitis media
pneumonia
encephalitis
…

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175
Q

Rubella

A

Viral infection, german measles

Droplet spread / direct contact

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176
Q

Rubella Px

A
  • rash - face/neck -> body, pink, maculopapular, itchy, 3-5d
  • lymphadenopathy
  • arthritis
  • fever, headache, malaise, nausea, URTI, conjunctivitis
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177
Q

Rubella Ix

A

Lab ix to confirm….

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178
Q

Rubella Mx

A
  • Notifiable
  • rest, sx control, off school for >5d after rash starts
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179
Q

Diphtheria

A

G+ bacteria, vaccine to prevent

releases exotoxin

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180
Q

Diphtheria Px

A
  • visit to high risk country
  • sore throat + diphtheric membrane - grey
  • cervical lymphadenopathy - bull neck
  • systemic spread
  • diaphragm paralysis
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181
Q

Diphtheria Ix

A

Throat swab culture

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182
Q

Diphtheria Mx

A

IM penicillin
Diphtheria antitoxin

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183
Q

Scarlet fever

A

Reaction to GAS toxins (often S pygenes)

spread by resp droplets

risk of invasive GAS (iGAS) - extremes of age, immunocompromised, IVDU…

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184
Q

Scarlet fever Px

A
  • 2-4d incubation, infectious for 2-3wks w/o tx
  • fever (24-48hrs), malaise, headache, N+V
  • sore throat
  • strawberry tongue
  • sandpaper rash - fine, punctate erythema - torso -> everywhere - spares palms, soles - then desquames
  • cervical lymphadenopathy
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185
Q

Scarlet fever Ix

A

Throat swabs / blood test - not routine

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186
Q

Scarlet fever Mx

A

Pen V 10d (azithromycin if allergy)

Off school for 24hrs after starting abx

Notifiable

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187
Q

Scarlet fever Cx

A

Otitis media
Rheumatic fever
Glomerulonephritis
iGAS

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188
Q

Slapped cheek syndrome

A

Aka erythema infectiosum / fifth disease

Parvovirus B19

resp spread

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189
Q

Slapped cheek Px

A
  • asym
  • prodrome - fever, malaise, headache, myalgia
  • diffuse rash develops
  • arthralgia
190
Q

Slapped cheek Ix

A

If immunocompromsed - bloods to confirm Dx

191
Q

Slapped cheek Mx

A

Rash can come + go
Sx relief
not infectious after 1d rash

risk of fetal death <20wks gestation

192
Q

Staphylococcal scalded skin syndrome (SSSS)

A

type of S aureus produces epidermolytic toxins - causes separation of epidermal skin

193
Q

SSSS Px

A
  • erythema patches
  • bullae - blisters
  • rubbing skin causes peeling
  • fever, irritable, lethargy, malaise
194
Q

SSSS Mx

A
  • admit
  • IV abx
  • fluids
  • analgesia
195
Q

Polio

A

poliovirus, faeces / resp spread

Vaccine to prevent

Px
- sore throat, fever, fatigue, nausea, headache, abdo pain
- sx 2-5d
- poliomyelitis - paralysis

196
Q

Candida

A

fungal infection

Px
- oral thrush
- candida oesophagitis
- systemic - fever, sepsis, rash, pain, headache, neuro sx

Ix
- KOH smear test
- blood / tissue culture
- endoscopy
- Blood Ag detection - candida

Mx
- topical clotrimazole
- fluconazole - topical / vaginal
- systemic - IV caspofungin

197
Q

Toxic shock syndrome

A

severe systemic reaction to exotoxins

S aureus, strep pyogenes

Px
- fever >39
- hypotension
- diffuse erythematous maculopapular rash
- >3 organ systems involved
- desquamation after 1-2wks of palms, soles

Mx
- remove infection focus (eg tampon, surgical debridement)
- IV fluids
- IV abx
- IV Ig maybe

198
Q

Molluscum contagiosum

A

virus, skin infection

direct contact spread

resolve alone

Px
- small, flesh coloured papules, central dimple
- appear in crops

Mx
- dont share towels
- if bacterial superinfection - abc, topical fusidic acid / oral fluclox
- specialist tx - topical KOH, benzoyl peroxide, surgical removal

199
Q

Head lice

A

Pediculus capitis

direct head-to-head contact

Dx
seen on fine tooth combing of hair

Mx
- malathion, wet combing, dimeticone……

200
Q

Hearing loss

A

Causes
- congenital - rubella, CMV, genetic, Down’s
- perinatal - prem, hypoxia
- post-natal - jaundice, meningoencephalitis, OM, chemo

Px
Not hearing

Ix
OAE at birth
Response to sound
Audiometry if older

Mx
MDT - hearing aids, SALT, …

201
Q

Cleft lip + palate

A

Cleft lip - split section of upper lip

Cleft palate - defect in hard/soft palate at roof of mouth

Cx
problems feeding, swallowing, speech…

Mx
Refer to cleft lip + palate services
Teats to eat/drink
Surgery
- cleft lip 3mo
- cleft palate 6-12mo

202
Q

Tongue tie

A

baby born with short frenulum - cannot latch onto breast

Px
poor feeding - noticed by mum / midwife

Mx
frenotomy

203
Q

Cystic hygroma

A

Cyst filled with lymphatic fluid

Px
Posterior triangle of left neck (pos. SCM)
large, soft, painless
transilluminates
hypoechoic

Mx
w+w
aspiration
surgery

204
Q

Thyroglossal cyst

A

persistence of thyroglossal duct (where thyroid travelled down in development) - fluid filled

Px
midline neck, below hyoid
painless, soft
moves with tongue
painful if infected
anechoic

Ix
USS / CT

Mx
surgical removal

205
Q

Branchial cyst

A

malformation of 2nd branchial cleft

Px
Anterior triangle (ant SCM)
non-tender, smooth, round
no movt on swallowing
no transillumination

Ix
US, aspiration

Mx
Conservative
Surgery if recurrent infections

206
Q

Dermoid cyst

A

teratoma of cystic nature

Px
midline of neck, above hyoid

Ix
heterogenous on imaging

207
Q

Infantile hemangioma

A

Either triangle of neck
grow rapidly.

XR - mass lesion, fat…..

208
Q

Periorbital cellulitis

A

infection of soft tissues anterior to orbital septum - eyelids, skin, subcut tissue

Orbit / septum not affected

From breaks in skin, sinusitis, RTIs - S aureus, Staph epidermis, Strep, anaerobic bacteria

209
Q

Periorbital cellulitis Px

A

Red, swollen, painful eye, acute onset
fever
erythema of eyelid / skin
ptosis
normal eye movt, vision, reflexes

210
Q

Periorbital cellulitis Ix

A

Bloods - raised CRP
Swab discharge
Contrast CT - to see if peri/orbital

211
Q

Periorbital cellulitis Mx

A

Refer to ophthal
Drain abscesses
Oral co-amox

212
Q

Orbital cellulitis

A

infection of fat / muscles posterior to orbital septum, within orbit, not involving globe

after URTI of sinuses

213
Q

Orbital cellulitis Px

A

As periorbital +
visual disturbance
absent light reflex
proptosis
ophthalmoplegia
drowsy

214
Q

Orbital cellulitis Ix

A

Orbital cellulitis Ix

215
Q

Orbital cellulitis Mx

A

Admit
IV abx

216
Q

Squint

A

misalignment of eyes, aka strabismus

Pt experiences double vision

lazy eye -> becomes passive, reduced function -> amblyopia

Concomitant squint - imbalance in extra-ocular muscles, convergent more common than divergent
Paralytic squint - paralysis in extra-ocular muscles (rare)

Esotropia - inward squint (affected eye in)
Exotropia - outward squint (affected eye out)

Hypertropia - upward moving affected eye
Hypotropia - downward moving affected eye

Manifest strabismus - there all the time
Latent strabismus - appears when each eye covered

217
Q

Squint causes

A

Idiopathic
Refractive error
Hydrocephalus
CP
SOL - retinoblastoma
Trauma

218
Q

Squint examination

A

Eye movts, fundoscopy, acuity

Hirschberg’s test / corneal light reflection test
- shine pen torch at pt 1m away, look for symmetrical + central reflection of light source - normal

Cover test
- cover one eye, ask pt to focus on object in front, move cover to opposite eye - if first eye moves inwards, it was exotropia when covered, if it moves outwards, it was esotropia when covered

219
Q

Squint Mx

A

Start tx <8yo

Occlusive patch

Atropine drops - blur vision in good eye

Glasses

220
Q

Retinoblastoma

A

ocular malignancy, autosomal dominant

Avg age 18mo at dc

Px
absent red-reflex - white pupil
strabismus
visual problems

Mx
enucleation - remove whole eye
external beam radiation therapy, chemo, photocoagulation

221
Q

UTIs

A

infections in urethra, bladder, ureters, kidneys

pyelo -> scarring, reduction in function

<3mo M>F, >3mo F>M

Causes
E coli, proteus, pseudomonas

222
Q

Atypical UTIs

A

Seriously ill
Poor urine flow
Abdo / bladder mass
Raised creatinine
Septicaemia
Failure to respond to abx in 48hrs
Non-E coli organisms

223
Q

Recurrent UTI

A
  • 2+ episodes of UTI with pyelonephritis
  • 1 episode pyelonephritis + lower UTI
  • 3+ episodes lower UTI
224
Q

UTI Px

A

Fever

Babies - lethargy, irritable, vomiting, poor feed, urinary frequency

Older children - suprapubic pain, vomiting, dysuria, urinary frequency, incontinence, new bedwetting

Dark cloudy smelly urine, haematuria, abdo pain, shivers

225
Q

UTI Ix

A

Septic screen - if unwell

Urine dipstick (clean catch)
- N + L = UTI
- N = UTI
- L = maybe UTI, tx if sx
- neither = no UTI
MC+S if either present

Renal USS - look at anatomy
For <6mo with UTI, recurrent / atypical

DMSA scan - dimercaptosuccinic acid
After 4-6mo to assess for scarring

MCUG - micturating cystourethrogram
Look for VUR

226
Q

UTI Mx

A

Pyelonephritis
<3mo - IV abx
>3mo - oral cefalexin, co-amoxiclav - cefuroxime / ceftriaxone / gentamicin if needed

Lower UTI
<3mo - IV cefuroxime
>3mo - trimethoprim / nitrofurantoin, amoxicillin / cefalexin second line

227
Q

Vesico-ureteric reflux (VUR)

A

abnormal backflow of urine from bladder into ureter / kidney

Malfunction of VUJ

Px
Recurrent UTIs
Hydronephrosis on USS antenatal
Reflux nephropathy - chronic pyelo, scarring

Ix
MCUG
DMSA

Mx
Surgery

228
Q

Nephrotic syndrome

A

Podocyte damage - GBM permeable to proteins

2-5yo

Triad - low albumin <25g/L, >3+ protein on dipstick, oedema

Steroid sensitive / resistant

Also - high cholesterol, increased BP, hypercoagulable, infections

229
Q

Nephrotic syndrome causes

A

Minimal change disease
Most commonly
No underlying condition, no abnormality on biopsy

intrinsic kidney disease
FSGS
MPG

Systemic illness
HSP, DM, HIV, hepatitis, malaria

230
Q

Nephrotic syndrome Px

A

Frothy urine
generalised oedema - face - gravitational
pallor

231
Q

Nephrotic syndrome Ix

A
  • Urine dip - 3+ protein
  • Urine protein:creatinine ratio
  • Serum albumin <20-25
  • U/E, bone profile, FBC, VZV immunity
  • BP
  • assess CV status - fluid overload, hypovolaemia
232
Q

Nephrotic syndrome Mx

A
  • Prednisolone - 4ks high dose, 8wks weaning, 80% respond
  • No added salt diet
  • Furosemide + spironolactone - for oedema
  • severe - albumin infusion
  • Pen V abx prophylaxis
  • Pneumococcal vaccine
  • ACEi for HTN
  • Immunosuppressants if steroid resistant
233
Q

Nephrotic syndrome Cx

A

Hypovolaemia
Thrombosis - loss of factors that prevent clotting
Infection - loss of Igs
Renal failure
RAAS activated
High cholesterol - liver in overdrive
Relapse

234
Q

Haemolytic uraemic syndrome (HUS)

A

Thrombosis in small vessels

Triggered by shiga toxin - E coli -157, shigella

Triad of:
- microangiopathic haemolytic anaemia - RBCs churned by clots
- AKI - retain urea
- thrombocytopenia - low platelets

235
Q

HUS Px

A

GE, then HUS sx ~5d later
Fever
Reduced UO
Haematuria, dark-brown urine
Abdo pain
Lethargy, irritability
Confusion
Oedema
HTN
Bruising
Jaundice (from haemolysis)

236
Q

HUS Ix

A

FBC - anaemia, negative Coombs

Blood film - schistocytes, helmet cells

U/E - AKI

Stool culture - look for shigella, PCR for toxins

237
Q

HUS Mx

A

Self-limiting

Renal dialysis

anti-HTN, fluids, blood if needed

Eculizumab maybe

238
Q

Enuresis

A

Involuntary urination

Nocturnal enuresis - bedwetting at night, normally controlled by 7(?)yo

Diurnal enuresis - wetting during day, normally controlled by 2yo

239
Q

Primary nocturnal enuresis

A

child has never been dry at night

Causes
- normal development
- overactive bladder
- fluids before bed
- stress, pressure at home
- chronic constipation, UTI, LD, CP

Ix
- diary of toileting, fluid intake, bed wetting

Mx
- +ve reinforcement
- Enuresis alarms
- desmopressin (ADH analogue)
- oxybutynin - anticholinergic
- imipramine - TCA, relaxes bladder

240
Q

Secondary nocturnal enuresis

A

Child wets bed after being dry for >6mo - ?illness

Causes
UTI, constipation, T1DM, new psychological stress, maltreatment / abuse

Mx
Tx cause

241
Q

Diurnal enuresis

A

Urinary incontinence during day, F>M

Stress / urge incontinence

Recurrent UTIs, psychosocial issues, constipation

242
Q

Wilm’s tumour

A

Nephroblastoma - common childhood malignancy, typically <5yo

Px
- Abdo mass
- painless haematuria
- flank pain
- anorexia, fever, wt loss
- HTN, lethargy
- 95% unilateral
- mets in 20% (commonly lung)

Ix
- USS, CT, MRI, biopsy

Mx
- nephrectomy
- chemo
- radiotherapy

243
Q

Hypospadias

A

congenital penis abnormality

  • ventral urethral meatus
  • hooded prepuce (foreskin)
  • chordee (ventral curvature of penis)

associated with cryptorchidism

Px
see on newborn baby check
abnormal urine stream

Mx
surgery at 1yo
do not circumcise child - foreskin used in correction

244
Q

Phimosis

A

Non-retractile foreskin

<2yo normal - physiological phimosis
Normally can retract by 10yo

Pathological phimosis - from recurrent foreskin infection

Px
Ballooning during micturition
painful erections
haematuria
recurrent UTIs
swelling, red, tender

Ix
Can take swab

Mx
Reassure, clean
Topical steroids
Surgery - divide frenulum / circumcision

245
Q

Paraphimosis

A

Foreskin retracted, unable to be replaced

RFs
Tight foreskin, scarring, vigorous sexual activity, piercing, catheter insertion

Px
oedema, pain on erection, irritable, eventually necrotic

Mx
gentle compression with saline-soaked swab
Manual reduction
Ice, squeezing, 50% dextrose
Refer to urology

246
Q

Balanitis xerotica obliterans (BXO)

A

Lichen sclerosis of male genitalia - chronic inflammation + scarring

Px
ballooning during micturition
scarring
irritation
dysuria
white, fibrotic, scarred preputial tip

Mx
circumcision
send foreskin to histopathology to confirm dx

247
Q

Cryptorchidism

A

Undescended testes

5% babies at birth, 25% cases bilateral

RFs
Prem, low birth weight, hypospadias, FHx, maternal smoking in pregnancy

Correct to reduce infertility risk, avoid testicular torsion

Px
no testis on palpation of scrotum
Testes in inguinal canal or elsewhere

DDx
hormonal - AIS, disorders of sex development
retractile testes

Mx
- w+w - most descend by 3-6mo - review at 6-8wks, then again at 3mo - see surgeon before 6mo
- try to move down if in inguinal canal
- orchidopexy - surgical correction, 6-12mo
- if bilateral undescended - senior paeds review in 24hrs

248
Q

Torsion of appendix of testis

A

Hydatid of Morgagni

Mimics testicular torsion

Pain not as severe

Blue dot sign

NSAIDs to tx

249
Q

Febrile convulsions

A
  • Seizure + high fever - 6mo-5yo
  • simple - generalised tonic clonic <15mins
  • complex - partial / focal, >15mins

Ix
- exclude DDx - epilepsy, meningoencephalitis, SOL, syncope, electrolyte abnormalities, trauma
- find infection source - chest, GI, UTI, ears, throat

Mx
- paracetamol / ibuprofen
- tx infection source

250
Q

Cerebral palsy (CP)

A

disorder of movt + posture due to non-progressive lesion of motor pathways

permanent neurological sx resulting from damage to brain around time of birth

sx manifest during growth + development

251
Q

CP causes

A

Antenatal
- Maternal infections, eg rubella, toxoplasmosis, CMV
- Trauma during pregnancy

Perinatal
- Birth asphyxia
- Pre-term birth

Postnatal
- Meningitis
- Severe neonatal jaundice
- Head injury

252
Q

CP Types

A

Spastic / pyramidal
- Damage to UMN, hypertonia, reduced function
- Patterns - monoplegia (one limb), hemiplegia (one side), diplegia (4 limbs, mostly legs), quadriplegia (4 limbs severely affected + seizures, speech disturbance etc)

Dyskinetic / athetoid / extrapyramidal
- Problems controlling movt …muscle tone - hypertonia + hypotonia
- Athetoid movts (slow, involuntary writhing), oro-motor problems
- Damage to basal ganglia + substantia nigra

Ataxic
- Damage to cerebellum - problems with coordinated movt

Mixed
- Mix of all

253
Q

CP Px

A
  • milestone failure
  • abnormal tone
  • hand preference <18mo
  • problems with coordination, speech, walking, feeding, swallowing
  • LDs
  • tiptoeing gait
  • scissoring gait
  • Epilepsy, squint, hearing impairment
254
Q

CP Ix

A
  • neuro exam
  • CT / MRI
  • EEG, EMG, bloods
255
Q

CP Mx

A
  • MDT - OT/PT, SALT, dieticians, orthopaedics (lengthen tendons, release contractures)
  • meds - oral diazepam, baclofen, AEDs, glycopyrronium, botox
256
Q

Breath holding spells

A

Involuntary episodes of holding breath, outgrow by 4-5yo

cyanotic breath holding spells
- upset, worked up, crying, stop breathing, LOC 1min, then breathe

Reflex anoxic seizures
- startled - vagus -> drop HR
- LOC, seizure like
- 30s, regain consciousness

  • exclude DDx, reassure
257
Q

Childhood epilepsy

A

Transient episodes of abnormal electrical activity in the brain

Ix
- EEG, bloods, MRI brain, ECG, genetic / AB testing if needed

258
Q

Generalised tonic clonic

A
  • LOC, tonic + clonic
  • tongue biting, incontinence, groaning, irregular breathing
  • post-ictal

Mx
- sodium valproate - boys
- lamotrigine / levetiracetam - girls / 2nd line for boys

259
Q

Focal seizures

A
  • tend to start in temporal lobes
  • hearing, speech, memory, emotions affected

Px
- hallucinations, memory flashbacks, deja vu, autopilot

Mx
- 1st - lamotrigine / levetiracetam
- 2nd - carbamazepine

260
Q

Absence seizures

A
  • stare into space, blank, unresponsive 10-20s

Ix
- EEG - bl synchronous/symmetrical 3Hz spike + wave discharges

Mx
- ethosuximide
- sodium valproate (2nd line for boys)
- lamotrigine / levetiracetam (3rd line)

If absence seizures + other types
- valproate - 1st line boys
- lamotrigine / levetiracetam - 1st line girls
- then other 1st line drugs not tried
- then ethosuximide add on

261
Q

Atonic seizures

A
  • drop attacks - lapse in muscle tone
  • may indicate Lennox-Gestaut syndrome

Mx
- valproate - 1st line M
- lamotrigine - 1st line F, 2nd line M
- clobazam - 2nd line F

262
Q

Myoclonic seizures

A
  • sudden brief muscle contractions, pt awake
  • may indicate juvenile myoclonic epilepsy - within 1-2hrs waking - clumsy mornings

Mx
- valproate - 1st M
- Levetiracetam - 1st F, 2nd M
- clobazam…..2nd F

263
Q

Infantile spasms

A
  • West syndrome
  • often associated with tuberous sclerosis - serious

Px
- salaam attack - flexion of head, trunk, arms, extension of arms
- lasts 1-2s, repeated <50x
- developmental delay

Ix
- sleep EEG - hypsarrhythmia
- CT head

mx
- vigabatrin
- pred if not TS

264
Q

Benign Rolandic epilepsy

A
  • 4-12yo

Px
- seizures at night
- facial paraesthesia, can develop into secondary tonic clonic

Ix
- EEG - centro-temporal spikes

Mx
- lamotrigine / levetiracetam if needed
- good prognosis

265
Q

Lennox-Gastaut syndrome (LGS)

A
  • an epileptic encephalopathy, onset 3-5yo
  • different seizure types, intellectual delay, behavioural problems

Mx
- valproate - for all
- lamotrigine 2nd line

266
Q

Dravet syndrome

A
  • frequent myoclonic + myoclonic-atonic seizures

Mx
- levetiracetam / sodium valproate
- ketogenic diet

267
Q

AEDs

A
  • Sodium valproate - teratogenic - only for use in boys, girls <10 who are unlikely to need tx when older, women who cannot have children
  • Carbamazepine - agranulocytosis
  • Phenytoin - folate / vit D deficiency
  • Ethosuximide - night terrors
  • Lamotrigine - Stevens-Johnson syndrome
268
Q

Tension headache

A

Triggers
- stress, skipping meals, dehydration, infection

Px
- last 30mins - 7d
- symmetrical ache, like band around head
- no visual changes

Mx
- analgesia, hydrate, avoid stress / triggers

269
Q

Migraines

A
  • most common headache in children

Px
- 4-72hr attack
- unilateral, pain, throbbing, aura, photophobia, phonophobia, N+V

Mx
- paracetamol / ibuprofen
- sumatriptan >12yo
- domperidone antiemetic
- prophylaxis - propranolol (avoid asthmatics), pizotifen (drowsiness), topiramate (teratogenic), valproate

270
Q

Cluster headaches

A

uncommon in children

as for adults

271
Q

Hydrocephalus

A

Build up of CSF in brain / spinal cord

From overproduction / reduced absorption / drainage

272
Q

Hydrocephalus congenital causes

A
  • cerebral aqueduct stenosis - narrow, doesn’t drain
  • arachnoid cysts - block CSF outflow
  • Arnold-Chiari malformation
  • chromosomal / congenital malformations
273
Q

Hydrocephalus Px

A
  • increased head circumference
  • bulging anterior fontanelle
  • poor feeding, vomiting
  • poor tone
  • sleepiness
274
Q

Hydrocephalus Mx

A

VP shunt

275
Q

Brain tumours

A
  • tend to be primary in paeds
  • pilocytic astrocytoma, medulloblastoma, ependymoma

Px
- headache, worse lying down
- vomiting
- papilloedema
- squint, nystagmus, ataxia
- personality change

Ix
- CT / MRI

Mx
- surgical resection
- VP shunt
- Chemo (many drugs don’t cross BBB)
- radio

276
Q

Neuroblastoma

A

Tumour of neural crest tissue of adrenal medulla and sympathetic NS

Px
- abdo mass
- pallor, wt loss, bone pain, hepatomegaly
- paraplegia
- proptosis
- lung mets - resp sx

DDx
- hepatoblastoma, Wilms, lymphoma/leukaemia, sarcoma, PKD

Ix
- raised urinary VMA + HVA levels
- AXR (calcification), CT, biopsy

Mx
- surgery
- chemo / radio

277
Q

Craniosynostosis

A
  • skull sutures close early - abnormal head shapes, restricts brain growth - leads to raised ICP

Px
- abnormal head shape, small
- anterior fontanelle closed by 1yo

Ix
- Skull XR, CT head

Mx
- mild - monitor
- severe - surgical recon

278
Q

Plagiocephaly and brachycephaly

A

plagio - flattening of one area of head

Brachy - flattening at back of head

Mx
- reassure
- place on other side

279
Q

Duchenne muscular dystrophy (DMD)

A
  • x-linked recessive - dystrophin genes affected - weakening + wasting of muscles

Px
- progressive proximal muscle weakness from 3-5yo
- calf pseudohypertrophy
- gower’s sign - use arms to stand from seated
- intellectual impairment

Ix
- CK raised
- genetic testing - definitive (replaced muscle biopsy)

Mx
- supportive
- OT/PT
- wheelchairs / braces
- ?oral steroids

280
Q

Spinal muscular atrophy (SMA)

A
  • autosomal recessive - progressive loss of motor neurons - muscular weakness
  • LMNs in spinal cord affected -> LMN signs

Mx
- MDT
- OT/PT
- splints, braces, wheelchair
- resp support, PEG….

281
Q

Down’s syndrome

A

3 copies of c21 - trisomy 21

282
Q

Down’s screening

A

Offer to all women - to indicate if further invasive tests needed

Combined test
11-14wks - first line
- Combine USS / maternal blood tests
- high nuchal translucency, high bhCG, low PAPPA

Triple test
- 14-20wks - only maternal bloods
- high bhCG, low AFP, low oestriol

Quadruple test
- as above + high inhibin A

283
Q

Down’s antenatal testing

A

Chorionic villus sampling (CVS)
- US-guided biopsy of placental tissue, <15wks - karyotype fetal cells

Amniocentesis
- US-guided aspiration of amniotic fluid - later in pregnancy - karyotype fetal cells

Non-invasive pre-natal testing (NIPT)
- blood test from mother - not definitive

284
Q

Down’s Px

A
  • Face - upslanting palpebral fissures (gaps between lower and upper eyelid), epicanthic folds (folds of skin covering medial portion of eye and eyelid), Brushfield spots in iris, protruding tongue, small low-set eats, round / flat face
  • Flat occiput - brachycephaly
  • Single palmar crease, pronounced ‘sandal gap’ between big and next toe
  • Hypotonia
  • Congenital heart defects (40-50%)
  • Duodenal atresia
  • Hirschsprung’s disease
285
Q

Down’s Ix

A
  • TFTs every 2yrs
  • ECHO
  • regular audiometry
  • regular eye checks
286
Q

Down’s Mx

A
  • MDT
  • eg SALT, OT/PT, dietician, paediatrician, GP…..
287
Q

Down’s Cx

A
  • Cardiac - 1/3 - ASD, VSD, TOF, PDA
  • subfertility
  • LDs
  • Myopia, strabismus, cataracts
  • repeated resp infections
  • hearing impairment from recurrent OM
  • ALL
  • hypothyroid, Alzheimers
  • atlantoaxial instability
288
Q

Patau syndrome

A
  • trisomy 13
  • microcephaly, small eyes, cleft L+P, polydactyly, scalp lesions, LD
  • 90% die <1yo - neuro/heart defects
289
Q

Edward’s syndrome

A
  • trisomy 18
  • micrognathia, low-set ears, rocker bottom feet, overlapping fingers, small baby, LD
  • 95% do not result in live birth
  • 50% do not survive past 1wk
290
Q

Fragile X syndrome

A
  • trinucleotide repeat disorder - mutation in FMR1 -> lack of cognitive development
  • x-linked
  • LD, macrocephaly, long face, large ears, macro-orchidism, ADHD, autism
291
Q

Noonan syndrome

A
  • male Turner’s - caused by a number of genes
  • webbed neck, pectus excavatum, short stature, PS, downward sloping eyes, ptosis, widely spaced nipples
292
Q

Pierre-Robin syndrome

A
  • micrognathia, posterior tongue displacement, cleft palate
293
Q

Prader-Willi syndrome

A
  • loss of genes on arm of c15
  • hypotonia, hypogonadism, obesity, dysmorphic, LD, anxiety
294
Q

William’s syndrome

A
  • deletion of genes on c7 - random (not inherited)
  • short, LD, friendly + extroverted, transient neonatal hypercalcaemia, supravalvular AS, starburst eyes,
295
Q

Cri du chat

A
  • cry, feeding difficulties, LD, microcephaly, micrognathia….
296
Q

Klinefelter syndrome

A
  • male has additional X - 47XXY

Px
- taller, wide hips, gyne, weaker muscles, smaller testicles, lower libido, shy, infertile, subtle LDs

Ix
- high gonadotrophins, low testosterone
- karyotype for dx

Mx
- testosterone injections
- IVF for infertility
- breast reduction

297
Q

Turner syndrome

A
  • female with one X - 45XO

Px
- short, webbed neck, broad chest, wide nipples, cubitus valgus, underdeveloped ovaries, late / incomplete puberty, infertile, downward sloping eyes, ptosis

Mx
- GH replacement
- oestrogen + progesterone replacement
- fertility tx

298
Q

Marfan syndrome

A
  • autosomal dominant - fibrillin affected - abnormal connective tissue

Px
- tall, long neck/limbs/fingers (arachnodactyly), high arch palate, hypermobile, pectus carinatum/excavatum, downward palpable fissures, pes planus

Associations
- eye issues, joint dislocations, scoliosis, PTX, GORD, aortic aneurysm/dissection, aortic regurg

Ix
- thumb across palm
- fingers around wrist

Mx
- avoid cardiac cx - exercise, caffeine, give BB/ACEi
- physiotherapy
- yearly echo / ophthal review

299
Q

Angelmann syndrome

A
  • loss of function of gene (?deletion)
  • LD, speech dev delay, ataxia, happy, laughing, abnormal sleep, epilepsy, wide mouth, widely-spaced teeth, short broad skull
300
Q

T1DM

A

pancreas stops producing insulin

may be genetic / triggered by virus

301
Q

T1DM Px

A
  • DKA
  • Polyuria, polydipsia, weight loss
  • Secondary enuresis (bedwetting in previously dry child)
  • Recurrent infections
  • 4 Ts - toilet, thirsty, tired, thinner
302
Q

T1DM Ix

A

Bloods
- FBC, U/E, lab glucose, blood cultures (if fever), HbA1c,
- TFTs and thyroid peroxidase antibodies (TPO) for autoimmune thyroid disease
- anti-TTG (coeliac)
- insulin ABs, anti-GAD ABs and islet cell ABs (check for destruction of pancreas)

303
Q

T1DM Mx

A

S/C insulin
- basal/bolus
- Lantus long acting, once nightly
- actrapid short acting 30 mins before carbs
- insulin pump alternative

304
Q

T1DM monitoring

A
  • HbA1c every 3-6mo
  • BMs on waking, at each meal, before bed
  • Flash glucose monitoring, eg FreeStyle Libre
305
Q

T1DM Cx

A

Lipodystrophy
Hypos
Hypers, DKA
Macrovascular / microvascular
Infections etc

306
Q

DKA

A

high ketones, hyperglycaemia, acidosis

First px, or miss insulin dose

307
Q

DKA Px

A

vomiting, abdo pain, reduced GCS, dehydration, pear drop breath, Kussmauls

308
Q

DKA Ix

A

Bloods - BM, ketones, gas, FBC, U/E, lab BM, CRP, cultures, LFTs, HbA1c, TFTs, coeliac screen

309
Q

DKA classification

A

pH 7.2-7.29 +/- bicarb <15 - mild DKA - 5% fluid deficit

pH 7.1-7.19 +/- bicarb <10 - moderate DKA - 7% fluid deficit

pH <7.1 +/- bicarb <5 - severe DKA - 10% fluid deficit

310
Q

DKA Mx

A

A-E

Fluids
- 0.9% NaCl 20ml/kg bolus if shocked (up to 2x further 10ml/kg boluses if needed)
- not shocked, but needs fluids - 10ml/kg over 60 mins (subtract from deficit)
- Deficit (ml) - %dehydration x weight (kg) x 10 - over 48hrs
- maintenance - 100/50/20 rule - over 24hrs
- Add deficit and maintenance (x2) - for total requirement over 48hrs

Insulin
- 1-2hrs after IV fluids
- 50 units actrapid in 50ml 0.9%NaCl rate of 0.05-0.1units/kg/hr
- change to S/C once ketones <1
- continue long-acting insulin during

Monitoring
- fluid chart, BMs, ketones, obs, neuro obs
- 2x daily weights….

311
Q

DKA Cx

A

cerebral oedema - hypertonic saline / mannitol

312
Q

Adrenal insufficiency (AI)

A

adrenal glands do not produce enough steroid hormones - cortisol / aldosterone

313
Q

AI causes

A

Primary - adrenal glands damaged
- TB
- Autoimmune - Addisons

Secondary - low ACTH, low cortisol
- Congenital hypoplasia of pituitary gland
- surgery, infection….

Tertiary - lack of CRH from hypothalamus
- long term steroids - suppresses axis

314
Q

AI Px

A

Babies
- lethargy, vomiting, poor feeding, hypoglycaemia, jaundice, failure to thrive

Older children
- N+V, poor weight gain, weight loss, anorexia, abdo pain, muscle weakness/cramps, dev delay, bronze pigmentation (Addison’s)

315
Q

AI Ix

A
  • U/E - low Na, high K
  • BMs - hypoglycaemia
  • Primary AI - low cortisol, high ACTH, low aldosterone, high renin
  • Secondary AI - low cortisol, low ACTH, normal aldosterone, normal renin
  • Short synacthen test - failure of rise in cortisol in response to synacthen - primary AI
316
Q

AI Mx

A

Hydrocortisone

Fludrocortisone

Increase dose if sick

317
Q

Addisonian crisis

A
  • acute severe px of addisons - eg triggered by infection, trauma
  • Px - reduced GCS, hypotension, low BM, low Na, high K
  • Mx - A-E, IV hydrocortisone, IV fluids, correct BMs
318
Q

Congenital adrenal hyperplasia (CAH)

A
  • deficiency in 21-hydroxylase enzyme -> low aldosterone, low cortisol, high testosterone
  • enzyme converts progesterone -> aldosterone + cortisol - therefore lack of these
  • progesterone only converted into testosterone - high
319
Q

CAH Px

A

Severe
- ambiguous genitalia - F have virilised genitalia (large clitoris)
- low Na, high K, low BMs
- poor feeding, dehydration, vomiting, arrhythmias

Mild
- px after puberty
- F - tall for age, facial hair, absent periods, deep voice, early puberty
- M - tall, deep voice, large penis, small testicles, early puberty
- hyperpigmentation - high ACTH

320
Q

CAH Ix

A

High serum 17-hydroxyprogesterone
….

321
Q

CAH Mx

A
  • refer to paeds endo
  • hydrocortisone, fludrocortisone
  • surgery for genitalia
322
Q

GH deficiency

A

due to pathology at hypothalamus / pituitary

Causes
- congenital - mutation
- empty sella syndrome - underdeveloped / damaged pit gland
- acquired - trauma, infection….

Patho
- may have other pituitary hormone deficiencies

323
Q

GH deficiency Px

A
  • birth - micropenis, hypoglycaemia, severe jaundice
  • poor growth, short, slow movt/strength dev, delayed puberty
324
Q

GH deficiency Ix

A
  • GH stimulation tests - lack of GH rise in response to meds that stimulate release (eg glucagon, insulin)
  • ix for thyroid / adrenal issues
  • MRI brain, genetic testing
  • XR wrist / DEXA san - bone age
325
Q

GH deficiency Mx

A

Daily S/C somatropin (GH)

monitor H+W

326
Q

Hypothyroidism

A

underactive thyroid

congenital - not formed, doesn’t make enough, or from pit/hypo problem - screen for on newborn blood spot

acquired - autoimmune

327
Q

Hypothyroidism Px

A

Congenital
- prolonged neonatal jaundice
- poor feeding, constipation, sleepy, reduced activity, slow growth
- short, hypotonia, puffy face, macroglossia

Acquired
- fatigue, poor growth, wt gain, poor school performance, constipation, dry skin/hair loss

328
Q

Hypothyroidism Ix

A

TFTs - TSH, T3/4

Bloods for thyroid ABs

Thyroid USS

Heel-prick screening

329
Q

Hypothyroidism Mx

A

Levothyroxine OD

330
Q

Obesity

A
  • use BMI centile charts

causes
poor diet, lack of exercise, low SES, GH deficiency, hypothyroid, Down’s, Cushing’s, Prader-Willi

Assessment
- explore lifestyle / stress
- urine dip, protein/glucose, check BP, measure lipids / HbA1c

Mx
- weight maintenance / reduction of rate of gain
- diet + exercise
- cognitive approach
- no orlistat

331
Q

Pica

A
  • eat non-food

Cause
- many factors
- maybe iron-deficiency anaemia

Px
- eating non-food
- watch for sx of poisoning, cx

Ix
- bloods, maybe AXR, endoscopy

Mx
- remove substances, psych review

332
Q

Short stature

A
  • <2nd centile for age/sex

Causes
- familial
- constitutional delay
- malnutrition, chronic disease, endo, Down’s, achondroplasia, low GH

Ix
- XR L wrist
- bloods
- Cushing’s ix, GH provocation tests

Mx
- reassure, tx causes

333
Q

Craniopharyngioma

A
  • pituitary gland brain tumour

Px
- bitemporal hemianopia, headache, vomit, low GH, low growth, low ACTH, diabetes insipidus (lack of ADH)

Ix
- CT / MRI

Mx
- Neurosurgery
- chemo / radio

334
Q

Normal puberty

A

Girls
- starts 8-14yo
- earlier growth spurt
- breast buds, then pubic hair, menarche

Boys
- 9-15yo
- testicle development (>4ml), then penis, scrotum darkening, pubic hair, deeper voice

335
Q

Male genitals Tanner staging

A

I - testicles <1.5ml, small prepubertal penis

II - testicles 1.6-6ml, scrotum skin thins, reddens, enlarges

III - testicles 6-12ml, scrotum enlarges, penis lengthens

IV - testicles 12-20ml, scrotum enlarges, darkens, penis lengthens

V - testicles >20ml, adult scrotum + penis

336
Q

Female breasts Tanner staging

A

I - no glandular tissue, areola follows skin contours of chest (prepubertal)

II - breast bud, areola widens

III - breast elevated, extends beyond borders of areola, remains in contour

IV - increased breast size and elevation, areola and papilla form secondary mound projecting from contour of breast

V - adult size breast, areola returns to contour of surrounding breast with projecting central papilla

337
Q

Pubic hair (M+F) tanner stages

A

I - no hair (prepubertal)

II - small amount of long, downy hair, slight pigmentation at base of penis / scrotum or on labia majora

III - hair more coarse + curly, begins to extend laterally

IV - adult-like hair, across pubis, spares medial thighs

V - hair extends to medial surface of thighs

338
Q

Hypogonadism

A

Lack of sex hormones (oestrogen, testosterone) -> delay in puberty

339
Q

Hypogonadotrophic hypogonadism

A
  • Low FSH + LH leading to sex hormone deficiency
  • due to pit/hypo pathology
  • eg damage, low GH, hypothyroid, high prolactin, Kallman
340
Q

Hypergonadotrophic hypogonadism

A
  • gonads fail to respond to FSH / LH
  • high FSH / LH
  • gonads damaged - eg torsion, cancer, congenital (Kleinfelter’s, Turner’s)
341
Q

Delayed puberty Ix/Mx

A
  • Ix if no puberty changes by 13yo (F), 14yo (M)
  • H/E, FBC, ferritin, U/E, anti-TTG, early morning FSH/LH, TFTs, IGF-1, prolactin, genetics, XR L wrist, pelvic USS, MRI brain
  • Tx cause, replace sex hormones if needed
342
Q

Delayed puberty causes by stature

A

With short stature
- Turner’s syndrome
- Prader-Willi syndrome
- Noonan’s syndrome

Normal stature
- Polycystic ovarian syndrome
- Androgen insensitivity
- Kallman’s syndrome
- Klinefelter syndrome

343
Q

Precocious puberty

A
  • dev of 2ndary sex characteristics <8yo (F), <9yo (M)
  • thelarche - first breast development
  • adrenarche - first pubic hair

Gonadotrophin dependent
- premature activation of HPG axis - raised FSH + LH
- idiopathic, CNS abnormalities, congenital, Turner’s, high thyroid,

Gonadotrophin independent
- due to excess sex hormones - FSH + LH low
- adrenal disorders, gonadal tumours, exogenous

344
Q

McCune-Albright syndrome

A

Due to random, somatic mutation in GNAS gene

Px
Precocious puberty
Café-au-lait spots
Polyostotic fibrous dysplasia
Short stature

345
Q

Kallman syndrome

A
  • X-linked recessive hypogonadotropic hypogonadism -> delayed puberty
  • failure of GnRH-secreting neurones to migrate to hypo -> lack of GnRH -> lack of sex hormones

Px
- delayed puberty, hypogonadism, small testis, micropenis, anosmia

Ix
- testicular volume
- bloods / hormones - sperm, GnRH stimulation test, wrist XR, DEXA scan

Mx
- HRT - tes/oes/prog
- FSH / LH replacement
- GnRH pulsatile therapy

346
Q

Androgen insensitivity syndrome (AIS)

A
  • X-linked recessive - end-organ resistance to testosterone
  • genotypically male (46XY) children grow up phenotypically female

Type - depends on degree of genital masculinisation
- complete - female genitalia
- partial - ambiguous
- mild - male

Px
- “primary amenorrhoea”
- undescended testes (groin swellings)
- breast dev - testosterone converted into oestradiol

Ix
- buccal smear - chromosomal analysis

Mx
- counselling
- bl orchidectomy - risk of cancer
- oestrogen HRT
- sex assignment / genitoplasty

347
Q

Haemolytic disease of the newborn

A
  • Rh negative mother previously sensitised to Rh positive cells
  • Transplacental passage of ABs
  • Haemolysis of Rh positive fetal cells

Px
- Severe anaemia
- Neonatal jaundice
- Hepatosplenomegaly

Mx
- Prevent sensitisation with Rh immunoglobulin
- Intrauterine transfusion of affected fetuses

348
Q

Osteogenesis imperfecta

A
  • autosomal dominant - brittle bones - collagen affected -> osteoporosis

Px
- recurrent fractures, hypermobile, blue/grey sclera, triangle face, short, early deafness, bowed legs, scoliosis, joint/bone pain

Ix
- clinical dx, XR, genetic testing

Mx
- bisphosphonates, vit D, OT/PT, MDT

349
Q

Rickets

A
  • soft/deformed bones due to low minerals - vit D / Ca

Px
- bone pain, swollen wrists, poor growth, weak, abnormal fractures, deformities - leg bowing, knock knees, delayed teeth, kyphoscoliosis…

Ix
- Bloods - low Ca, phosp, vit D, high ALP/PTH….
- XR

Mx
- ergocalciferol (vit D) + Ca supplements

350
Q

Transient synovitis

A

3-8yo, recent URTI, inflammation of synovial membrane

Recent viral infection

Commonest cause of hip pain in children

351
Q

Transient synovitis Px

A
  • acute / gradual
  • recent viral illness
  • limp, cannot weight bear
  • groin / hip pain
  • mild fever
352
Q

Transient synovitis Mx

A
  • analgesia
  • self-limiting
  • needs review to r/o ddx

High grade fever = urgent specialist assessment

353
Q

Septic arthritis

A
  • infection in joint
  • most common <4yo
  • S aureus, N gonorrhoea, GAS…
354
Q

Septic arthritis Px

A
  • single joint - hip, knee, ankle
  • rapid onset, hot red swollen, painful
  • not weight bearing
  • stiff, reduced ROM
  • fever, lethargy, sepsis
355
Q

Septic arthritis Ix

A
  • bloods, inc cultures
  • joint aspiration, for MC+S
356
Q

Kocher Criteria - distinguish septic arthritis from transient synovitis - each point raises % chance

A

Non-weight bearing
Temp >38.5
Raised ESR
Raised WCC

357
Q

Septic arthritis Mx

A

IV abx - IV cefuroxime

Surgical drainage / washout

358
Q

Osteomyelitis

A
  • infection of bone / bone marrow - typically metaphysis

Px
- not weight bearing
- pain, swelling, tender
- low fever

Ix
- XR normal
- MRI, bone scan
- Bloods, inc culture
- Bone marrow aspirate / bone biopsy

Mx
- IV cefuroxime
- drainage / debridement

359
Q

Perthes disease

A
  • avascular necrosis of femoral head
  • 4-12yo, M>F
  • risk of early OA
360
Q

Perthes Px

A
  • slow onset
  • pain in hip, groin
  • limp, may be painless
  • stiff, reduced ROM
  • no trauma hx
361
Q

Perthes Ix

A
  • XR (may be normal)
  • Bloods
  • MRI / technetium bone scan
362
Q

Perthes Mx

A
  • younger / less severe - conservative, keep in position - bed rest, traction, crutches, analgesia
  • physio, regular XR
  • severe / not healing - surgery
363
Q

Slipped upper femoral epiphysis (SUFE)

A
  • head of femur slips along growth plate
  • M>F, 8-15yo, commonly obese pt, 20% bilateral
364
Q

SUFE Px

A
  • hx of minor trauma
  • pain out of proportion
  • hip, groin, thigh, knee pain
  • restricted ROM, esp int rotation
  • painful limp
  • hip externally rotated, shortened
365
Q

SUFE Ix

A
  • XR - AP + lateral (frog leg)
  • Bloods
  • technetium bone scan
  • CT / MRI
366
Q

SUFE Mx

A

surgery

367
Q

Discoid meniscus

A
  • thicker disc shaped meniscus - congenital

Px
- anterior / lateral knee pain
- clunk at terminal flexion - “snapping knee syndrome”
- pain, reduced ROM, effusion
- locking / clicking

Ix
- XR
- MRI - bow tie sign

Mx
- surgical - reshape meniscus
- physio

368
Q

Toddler’s fracture

A

undisplaced, spiral fracture of distal tibia in toddlers

low-energy rotational trauma

369
Q

Osgood-schlatter’s

A
  • inflammation at tibial tuberosity at patella tendon insertion
  • 10-15yo
  • multiple small avulsion #’s from running / jumping at same time as growth -> lump -> tender then non-tender

Px
- gradual onset
- lump at tibial tuberosity
- pain anterior knee
- worsened by physical activity, kneeling

Mx
- reduce activity
- NSAIDs
- physio

370
Q

Developmental dysplasia of the hip (DDH)

A
  • abnormal dev -> unstable hips, prone to dislocate

Picked up on NIPE, or later when child px with hip asymmetry, reduced ROM, limp

371
Q

DDH RFs

A

7 Fs - first born, female, fat (macrosomia), fair (caucasian), feet first (breech), fluid (oligohydramnios), FHx

Multiple pregnancy

372
Q

DDH screening

A
  • At NIPE, and 6-8wks
  • look for symmetry in - hips, leg length, skin folds, hip movts

Barlow
- push knees back, dislocate posteriorly

Ortolani
- abduct hips, pressure behind legs, reduce hips anteriorly

373
Q

DDH Ix

A

USS

XR - esp if older >4.5mo

374
Q

DDH Mx

A
  • most unstable hips spontaneously stabilise by 3-6wks
  • Pavlik harness if <6mo
  • surgery if harness fails
375
Q

Scoliosis

A
  • spine twists

causes
- idiopathic, congenital, CP, muscular dystrophy, degenerative

Mx
- babies tend to grow out of it
- back brace / surgery

376
Q

Congenital muscular torticollis

A
  • neck deformity - SCM tight + thick - head to one side
  • r/o acquired - look for infective / neuro sx
  • USS hips to r/o DDH (RF)
  • passive stretching / physio to mx
377
Q

Talipes

A
  • aka club foot - inverted / plantarflexed foot
  • mostly idiopathic

Mx
- ponseti method - manipulation + progressive casting
- achilles tenotomy in 85%
- boots + bars
- surgery if ponseti method not effective

378
Q

Achondroplasia

A
  • autosomal dominant - short stature
  • FGFR-3 gene mutation
  • abnormal cartilage, abnormal function of epiphyseal plates

Px
- short, proximal limbs short, short fingers, large head, frontal bossing, trident hands, bow legs

Associations
- obesity, otitis media, OSA

Mx
- MDT
- ?limb lengthening
- ?nothing

379
Q

Benign bone tumours

A

Osteoma
- Benign overgrowth of bone

Osteochondroma
- cartilage capped bony projection on external surface of bone

Giant cell tumour
- tumour of multinucleated giant cells in fibrous stroma
- XR - double bubble appearance

380
Q

Osteosarcoma

A
  • most common primary malignant bone tumour, 10-20yo
  • tends to be metaphyseal regions of long bones
  • pagets / radio - RFs

Px
- bone pain, worse at night, bone swelling, mass

Ix
- urgent XR <48hrs - fluffy bone, poorly defined lesion, Codman triangle, sunburst appearance
- bloods - raised ALP
- CT / MRI / PET / bone scan
- bone biopsy

Mx
- surgery
- chemo

381
Q

Ewing’s sarcoma

A
  • Small round blue cell tumour
  • pelvis + long bones - severe pain
  • XR - onion skin appearance
382
Q

Chondrosarcoma

A
  • malignant tumour of cartilage
  • axial skeleton
  • more common middle aged
383
Q

Juvenile idiopathic arthritis (JIA)

A
  • autoimmune inflammation in joints -> joint pain, swelling, stiffness

Mx
- MDT
- NSAIDs
- Steroids (oligo)
- DMARDs (methotrexate, sulfasalazine…)
- TNF inhibitor - infliximab, etanercept
- ophthal review for anterior uveitis

384
Q

Systemic JIA

A
  • Still’s disease
  • systemic illness

Px
- salmon pink rash
- high fever
- large lymph nodes
- wt loss, splenomegaly, pleuritis, pericarditis
- joint pain, inflammation, muscle pain

Ix
- Bloods - ANA, RF (normally -ve), raised CRP, ESR, platelets, ferritin

Cx
- macrophage activation syndrome (MAS) - massive immune system activation, inflammatory response

385
Q

Polyarticular JIA

A
  • 5+ joints, symmetrical, small / large joints
  • minimal systemic sx - mild fever, anaemia, reduced growth
  • RA in kids
  • RF -ve
386
Q

Oligoarticular JIA

A
  • <4 joints, usually 1 - larger joints (knee/ankle)
  • associated with anterior uveitis, no systemic sx
  • ANA+, RF-
387
Q

Enthesitis-related arthritis

A
  • paeds version of seronegative sponyloarthropathies (AS, PsA, ReA, IBD-related)
  • inflammation of joints + entheses
  • HLA B27

Px
- tender entheses - eg IPJ in hand, wrist, greater trochanter, quad at ASIS, base of achilles….
- ?psoriatic plaques, nail pitting, diarrhoea, PR bleed
- uveitis - visual blurring, red eye, pain

388
Q

Juvenile psoriatic arthritis

A
  • seronegative arthritis + psoriasis
  • symmetrical, small joints, or asymmetrical of large joints
  • psoriatic plaques, nail pitting, onycholysis, dactylitis, enthesitis
389
Q

Ehlers-Danlos syndrome (EDS)

A
  • genetic conditions -> collagen defects -> joint hypermobility

Types
- hypermobile
- classical
- vascular
- kyphoscoliotic

390
Q

EDS Px

A
  • joint pain, hypermobile
  • dislocations
  • bleeding, bruising
  • soft stretchy skin
  • headaches, dizziness, syncope
  • GORD, abdo pan, IBS
  • menorrhagia, dysmenorrhoea, TMJ dysfunction, myopia, SAH, aortic regurg, mitral prolapse, dissection……
391
Q

EDS Ix - Beighton score for hypermobility

A

To assess extent of hypermobility - one point for each side of body, max score 9
- Palms flat on floor with straight legs (score 1)
- Elbows hyperextend
- Knees hyperextend
- Thumb can bend to touch forearm
- Little finger hyperextends past 90 degrees

392
Q

EDS DDx

A

Marfan syndrome - hypermobility, high arch palate, arachnodactyly, arm span

393
Q

EDS Mx

A
  • OT/PT
  • exercise
  • no cure
394
Q

EDS Cx -postural orthostatic tachycardia syndrome (POTS)

A
  • autonomic dysfunction
  • no SVR increase when standing - tachycardia, hypotension, syncope
395
Q

Henoch-Schonlein purpura (HSP)

A
  • IgA vasculitis - purpuric rash on lower limbs / buttocks
  • triggered by URTI / GE - commonly GAS
  • IgA deposits -> leaking from vessels
396
Q

HSP Px

A
  • purpura (100%) - red/purple, palpable under skin
  • arthralgia (75%) - knees/ankles - painful, swollen, reduced ROM
  • abdo pain (50%) - if severe - GI bleed, intussusception, infarction
  • IgA nephritis (50%) - micro/macroscopic haematuria, proteinuria (if 2+ protein - nephrotic)
397
Q

HSP Dx

A

EULAR/PRINTO/PRES criteria for dx
Need palpable purpura (not petechiae) and at least one of:
- Diffuse abdo pain
- Arthritis / arthralgia
- IgA deposits on biopsy
- Proteinuria / haematuria

398
Q

HSP Ix

A
  • bloods - FBC, blood film, renal function, serum albumin, CRP, cultures, urine dip, urine protein:creatinine ratio, BP….
399
Q

HSP Mx

A
  • supportive
  • ?steroids
  • monitor urine dip + BP
400
Q

Kawasaki disease

A
  • medium vessel vasculitis - young children

Disease course
- acute phase - 1-2wks - unwell, fever, rash, lymphadenopathy
- subacute phase - 2-4 wks - desquamation, arthralgia, coronary artery aneurysm
- convalescent stage - 2-4 wks - everything settles

401
Q

Kawasaki Px

A

fever >5d and 4/5 of:
- Bl non-exudative conjunctivitis
- Erythematous polymorphous rash
- Strawberry tongue, dry cracked lips
- Red swelling + desquamation of hands + feet
- Tender cervical lymphadenopathy, unilateral

May also have - D+V, fatigue, abdo pain, arthralgia, dysuria

402
Q

Kawasaki Ix

A
  • Bloods - FBC, LFTs, ESR
  • urinalysis
  • ECHO
403
Q

Kawasaki Mx

A
  • high dose aspirin - risk of Reye’s
  • IVIg - risk of haemolytic anaemia
  • corticosteroids in high risk pts
404
Q

Kawasaki Cx

A
  • coronary artery aneurysm - ECHO after 6-8 wks to screen
405
Q

Rheumatic fever

A
  • autoimmune condition triggered by ABs to strep bacteria
  • caused by GAS - strep pyogenes (tonsillitis)
  • T2 hypersensitivity - IgM/G - immune system attacks body’s cells
406
Q

Rheumatic fever Px

A
  • 2-4wks after strep infection, eg tonslilitis
  • fever, joint pain, rash, SOB, chorea, nodules
  • joint pain is migratory - hot, swollen, painful
  • heart - peri/myo/endocarditis, tachy/brady, murmur, pericardial rub, HF
  • skin - nodules, pink rash
  • neuro - chorea
407
Q

Rheumatic fever - Jones criteria for Dx

A

Dx made when evidence of strep infection plus 2 major criteria OR 1 major and 2 minor

Major (JONES)
- Joint arthritis
- Organ inflammation (eg carditis)
- Nodules
- Erythema marginatum rash
- Sydenham chorea

Minor (FEAR)
- Fever
- ECG changes (PR prolongation) w/o carditis
- Arthralgia w/o arthritis
- Raised CRP and ESR

408
Q

Rheumatic fever Ix

A
  • throat swab - culture
  • Anti-streptococcal ABs (ASO) titres
  • ECHO, ECG, CXR
409
Q

Rheumatic fever Mx

A
  • tx infection - pen V 10d
  • NSAIDs - joint pain
  • aspirin + steroids - cardio
  • prophylactic abv - penicillin - for further infections
410
Q

Allergic rhinitis

A
  • IgE T1 hypersensitivity to environmental allergens -> nasal inflammation
  • eg hayfever, home dust mites, atopy association

Px
- runny, blocked nose, sneezing, itchy red swollen eyes

Ix
- clinical dx on hx
- skin prick testing

Mx
- avoid trigger
- antihistamines - non-sedating (cetirizine, loratadine, fexofenadine), sedating (chlorphenamine, promethazine)
- nasal corticosteroid sprays
- nasal antihistamines

411
Q

Cow’s milk protein allergy (CMPA)

A
  • non/IgE mediated hypersensitivity to protein in cow milk
  • typically <3yo, outgrow after
412
Q

CMPA Px

A
  • usually <1yo, eg when weaned from breast to formula
  • bloating, wind, abdo pain, D+V
  • urticaria, angioedema, cough, wheeze, sneezy, watery eyes, eczema, anaphylaxis
413
Q

CMPA DDx

A

Lactose intolerance

Cow’s milk protein intolerance (CMPI)
no allergic sx - will grow out of it

414
Q

CMPA Ix

A
  • skin prick testing
  • total IgE, specific IgE (RAST) for cows milk protein
415
Q

CMPA Mx

A

If formula fed
- extensive hydrolysed (eHF) milk
- then amino acid formula (AAF)

If breastfed
- continue
- avoid dairy in maternal diet
- eHF when breastfeeding stops

  • try progressing up milk ladder
416
Q

Eczema

A

-chronic atopic condition - skin inflammation

Px
- itchy, erythematous rash
- face + trunk in infants
- extensor surfaces younger children
- flexor surfaces, creases of face/neck - older children

Mx
- emollients
- topical steroids
- antihistmaine if severe itch
- wet wrapping
- oral ciclosporin - severe
- flucloxacillin for infections

417
Q

Eczema herpeticum

A
  • viral skin infection from HSV / VZV
  • HSV-1 commonly

Px
- widespread painful vesicular rash - punched out ulcers
- fever, lethargy, irritable, lymphadenopathy

Ix
- viral swab of vesicles

Mx
- acyclovir

418
Q

Urticaria

A
  • hives - histamine release from mast cells in skin - allergic / autoimmune

Mx
- fexofenadine
- oral steroids for flares
- if problematic - montelukast, omalizumab (IgE MAb), ciclosporin

419
Q

Nappy rash

A
  • usually contact (irritant) dermatitis (urine / faeces contact) - can lead to bacterial / candida infection

Types
- irritant - creases spared
- candida - flexures, macules, scaly border, satellite lesions
- seborrhoeic - red, flakes, scalp rash -> baby shampoo / hydrocortisone
- psoriasis - red + scaly
- atopic - also affects other areas of skin

Px
- red, inflamed ski in nappy area
- check for oral thrush

Mx
- barrier cream
- mild steroid cream
- topical imidazole - candida
- topical fusidic acid / oral fluclox - bacterial

420
Q

Seborrhoeic dermatitis

A
  • inflammatory skin condition affecting sebaceous glands - Malassezia yeast

Px
- cradle cap - crusty flaky scalp
- red, flaky, crusted, itchy skin - eyelids, nasolabial folds, ears, upper chest, back

Mx
- cradle cap - baby oil, brush, wash, clotrimazole cream
- older pts - ketoconazole shampoo
- face + body - antifungal clotrimazole cream, hydrocortisone if inflammed

421
Q

Ringworm

A
  • fungal infection, tinea:
  • capitis (scalp), pedis (feet), cruris (groin), corporis (body), onychomycosis (fungal nail infection)

Px
- itchy rash, red, scaly, demarcated, rings, pedis between toes

Ix
- clinical dx
- scrape + send for MC+S

Mx
- antifungals - clotrimazole cream, ketoconazole shampoo, oral fluconazole….
- steroids for inflammation

Tinea incognito
- steroids dampen immune response - once stopped fungus returns worse

422
Q

Scabies

A
  • tiny mites burrow + lay eggs under skin

Px
- itchy, small red spots, track marks
- finger webs

Mx
- permethrin cream - whole body, leave 8-12hrs, then wash off, rpt 1wk later
- malathion 2nd line
- wash bedding / clothing, tx all household members
- oral ivermectin - severe (crusted) scabies - massive infection

423
Q

Roseola infantum

A
  • aka sixth disease - HHV6
  • 5-12d incubation, school exclusion not needed

Px
- high fever for a few days
- then maculopapular rash
- Nagayama spots
- diarrhoea, cough, sore throat

Ix
- clinical dx
- PCR to confirm

Mx
- self-limiting

424
Q

Birthmarks

A

see notes

425
Q

Primary immunodeficiency

A

genetic defects in immune system -> infection risk

Types
- AB deficiency
- combined - eg severe combined immunodeficiency (SCID)
- phagocytic cell deficiency
- complement deficiency
- immune dysregulation
- autoinflammatory

426
Q

Primary immunodeficiency Px

A
  • failure to thrive
  • severe / frequent infections
  • low lymphocyte count
    …..
427
Q

Primary immunodeficiency Ix

A
  • FBC - low WCC
  • total Ig G/A/M +/-E
  • HIV aBs
428
Q

Primary immunodeficiency Mx

A
  • abx/antiviral prophylaxis
  • tx infections
  • Ig replacement
  • bone marrow transplant
429
Q

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

A
  • severe/disproportionate immune response -> epidermal necrosis
  • SJS <10% body SA
  • TEN >10%

Causes
- penicillin, sulfonamides, NSAIDs, lamotrigine…..infections….

Px
- fever, cough, sore throat/mouth/eyes, itchy skin, arthralgia
- rash - maculopapular, target lesions, vesicles, bullae
- affect urinary tract, lungs

Mx
- admit to derm / burns
- supportive
- steroids, Igs, immunosuppression

430
Q

Erythema multiforme

A
  • erythematous rash, from hypersensitivity reaction
  • eg viral infections, meds, HSV, mycoplasma pneumonia

Px
- widespread itchy erythematous rash
- target lesions
- does not affect mucous membranes
- sore throat
- fever, arthralgia, myalgia

Ix
- clinical dx
- CXR for mycoplasma

Mx
- resolves alone
- severe - admit, IV fluids, analgesia, steroids, abx/antivirals

431
Q

Erythema nodosum

A
  • red lumps on shins - rom hypersensitivity
  • caused by inflammation of subcut fat - panniculitis

Causes
- strep throat infections, GE, mycoplasma, TB, pregnancy, meds, IBD….

Px
- red, inflamed, subcut nodules across both shins - raised, tender
- may settle - bruises

Ix
- ESR, CRP
- throat swab for strep
- CXR - mycoplasma, TB, sarcoidosis, lymphoma
- stool MC+S
- faecal calprotectin - IBD

Mx
- tx cause
- rest, steroids, analgesia
- resolve in 6wks

432
Q

Actions after birth

A
  • skin-to-skin, clamp cord (after it stops pulsating), dry baby, keep baby warm, IM vit K, label baby, measure weight + height
  • feed as soon as alert enough, NIPE <72hrs, blood spot tests d5, OAE test
433
Q

Blood spot test conditions

A

Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Phenylketonuria
Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
Maple syrup urine disease (MSUD)
Isovaleric acidaemia (IVA)
Glutaric acidura type 1 (GA1)
Homocystin

434
Q

Caput succedaneum

A
  • fluid on scalp, outside periosteum, instrumental delivery
  • crosses suture lines, no skin discolouration
  • resolves in a few days
435
Q

Cephalohaematoma

A
  • blood between skull + periosteum
  • does not cross suture lines, skin discolouration
  • anaemia + jaundice risk
436
Q

Facial paralysis

A
  • damage to nerve, forceps delivery
  • normally resolves in a few months
  • neurosurg input if not
437
Q

Erb’s palsy

A
  • C5/6 injury in brachial plexus after birth
  • associated with shoulder dystocia, traumatic/instrumental delivery
  • weakness of shoulder abduction, external rotation, arm flexion, finger extension - waiters tip
  • resolves in a few months, neurosurg if not
438
Q

Fractured clavicle

A
  • associated with shoulder dystocia, large birth weight…
  • lack of movt, asymmetry, pain / distress
  • USS / XR
  • Immobilise to tx
439
Q

Neonatal life support

A
  • cut cord, dry baby, stimulate
  • 5 inflation breaths (can use air)
  • if no chest movt, manage airway, repeat inflation breaths
  • 15 ventilation breaths (for 30s, every 2s)
  • if HR <60 -> 3:1 compressions (increase O2 to 100%)
  • reassess every 30s
440
Q

APGAR

A

1, 5, 10 mins

0-3 is low, 4-6 moderately low, 7-10 is good state

  • appearance / colour
  • pulse
  • grimace
  • activity / tone
  • respiration
441
Q

Hypoxic-ischaemic encephalopathy (HIE)

A
  • brain damage from hypoxia at birth -> CP, death
  • eg maternal shock, intrapartum haemorrhage, prolapsed cord, nuchal cord (wrapped around neck)

Sarnat staging
Mild - poor feeding, irritable, resolves <24hrs
Moderate - poor feeding, lethargic, hypotonia, seizures, 40% develop CP
Severe - reduced consciousness, apnoeas, flaccid, <50% mortality

Mx
- optimise ventilation, feeds
- ICU therapeutic cooling
- MDT…

442
Q

Respiratory distress syndrome

A
  • prem neonates -> surfactant deficienct
  • alveolar collapse -> inadequate gas exchange
  • can lead to CLDP, ROP

Px
- resp distress, raised RR
- intercostal recession, grunting, cyanosis

Ix
- XR - ground glass appearance

Mx
- dex for mother
- intubation + ventilation
- endotracheal surfactant
- CPAP, O2

443
Q

Transient tachypnoea of the newborn (TTN)

A
  • delayed resorption of fluid in the lungs, common during c-sections

Px
- raised RR, resp distress

Ix
- CXR - hyperinflation of lungs, fluid in horizontal fissure

Mx
- observe, support, O2

444
Q

Meconium aspiration

A
  • aspiration of meconium -> resp distress, airway obstruction, hypoxia, infection

Dx
- meconium-stained amniotic fluids, meconium in airways
- resp distress
- pneumonia

Mx
- supportive, O2, ventilate, suction, abx, NICUNeonatal sepsis

445
Q

Neonatal sepsis

A
  • infection in neonatal period - early onset <72hrs, late onset 7-28d

Common orgs
- GBS, E coli, listeria, klebsiella, S aureus

446
Q

Neonatal sepsis RFs

A
  • vaginal GBS
  • GBS sepsis in prev baby
  • maternal sepsis, chorioamnionitis, fever >38
  • prematurity (IgG transfer in last 3mo gestation, baby doesn’t make own ABs until a few months old)
  • early ROM
  • PROM
447
Q

Neonatal sepsis Px

A
  • fever / hypothermia
  • reduced tone / feeding
  • resp distress, apnoea
  • vomiting
  • tachy/bradycardia
  • jaundice <24hrs
  • hypoglycaemia
  • neuro sx, seizures
448
Q

Neonatal sepsis Ix

A
  • cultures, FBC, CRP, gas, urine dip, MC+S
  • LP
449
Q

Neonatal sepsis Mx

A
  • benpen + gent
  • cefotaxime in lower risk
  • repeat CRP / cultures
450
Q

Neonatal jaundice

A
  • increased bilirubin
  • <24hrs - pathological - neonatal sepsis, haemolytic disease…
  • > 14d in term / >21d preterm - pathological -
  • from fetal Hb breakdown, immature liver
  • breastfed babies more likely to be jaundiced, prem babies worse
451
Q

Neonatal jaundice causes

A

Increased production
- haemolytic disease of newborn, ABO incompatibility, haemorrhage, cephalohaematoma, sepsis, DIC, G6PD deficiency

Decreased clearance
- prem, breastfed, neonatal cholestasis, biliary atresia, low thyroid, low pituitary, Gilbert

452
Q

Neonatal jaundice Ix

A
  • FBC, blood film
  • conjugated bilirubin
  • Blood type for mother + baby
  • Direct antiglobulin test (DAT) - Coombs
  • TFTs
  • blood / urine cultures
  • G6PD levels
453
Q

Neonatal jaundice Mx

A
  • plot bilirubin levels on chart
  • phototherapy
  • exchange transfusion
454
Q

Neonatal jaundice Cx

A

Kernicterus
- brain damage caused by excessive unconjugated bilirubin - crosses BBB, damages CNS

Px - floppy, drowsy baby, poor feeding

Can lead to CP, LDs, deafness

455
Q

Neonatal hypoglycaemia

A
  • transient <24hrs - normal
  • <2.6 defined as neonatal hypo

Causes of persistent hypo
- prem, maternal DM, IUGR, hypothermia, sepsis…

Px
- jittery baby, irritable, pallor
- poor feeding, weak cry, drowsy, low tone
- apnoea, hypothermia

Mx
- asym - encourage feeds
- sym - NICU, IV dextrose 10%

456
Q

Neonatal hepatitis syndrome

A
  • early liver inflammation
  • eg CMV, rubella, hepatitis

Px
- jaundice, dark urine
- failure to thrive
- HSM
- liver cirrhosis, bruising

DDx
- biliary atresia - no splenomegaly
- neonatal jaundice - no dark urine

Ix
- bloods - inc LFTs
- USS
- biopsy

Mx
- tx cause
- vit supplements
- liver transplant

457
Q

Prematurity

A
  • born <37wks
  • associated with - smoking, alcohol, maternal comorbidities….

Mx before birth
- vaginal progesterone / cerclage to discourage
- tocolysis + nifedipine
- corticosteroids <35wks
- Mg <34wks - protect brain

458
Q

Apnoeas of prematurity

A
  • immaturity of autonomic NS -> recurrent apnoeas
  • desaturations, bradycardia

Mx
- apnoea monitor
- tactile stimulation
- IV caffeine

459
Q

Retinopathy of prematurity (ROP)

A
  • abnormal dev of blood vessels in retina -> scarring, retinal detachment, blindness
  • excessive vascularisation from early O2 exposure, abnormal vessels, scar tissue, VEGF
  • screen evert 2wks if <32wks / <1/5kg

Mx
- laser therapy
- cryotherapy
- VEGF inhibitors

460
Q

Neonatal abstinence syndrome (NAS)

A
  • withdrawal in neonate from maternal substance use - opiates, cocaine, meth, nicotine

Px
- 3-72hrs for opiates, diazepam, SSRI, alcohol
- 1-21d for methadone, other benzos
- irritable, increased tone, high cry, tremor, seizure
- yawning, sweaty, unstable temp, fever, increased RR
- poor feeding, vomiting, low BMs, loose stools

Mx
- NAS chart
- urine sample - test for substances
- morphine sulfate - for opiate withdrawal
- oral phenobarbitone - non-opiate withdrawal

461
Q

Haemorrhagic disease of the newborn (HDN)

A
  • low vit K in newborn babies -> risk of haemorrhage
  • give IM vit K at birth (can give oral)

Intraventricular haemorrhage (IVH)
- <72hrs
- USS to dx
- supportive mx, shunt for raised ICP

462
Q

Cystic periventricular leukomalacia

A

death of white matter near lateral ventricles -> CP

more common in prem babies

463
Q

Fetal alcohol syndrome

A

microcephaly, thin upper lip, smooth philtrum, short palpebral fissure, LDs, CP, cardiac malformations

464
Q

Congenital rubella syndrome

A

congenital cataracts, PDA, AS, LD, hearing loss (sensorineural)

465
Q

Congenital varicella syndrome

A

IUGR, LD, scars, skin changes, limbs not developed, eye damage

466
Q

Congenital CMV

A

IUGR, hearing / vision loss, LD, seizures

467
Q

Congenital toxoplasmosis

A

Intracranial calcification + hydrocephalus + chorioretinitis

468
Q

Congenital zika syndrome

A

microcephaly, IUGR, ventriculomegaly, cerebellar atrophy

469
Q

TORCH

A
  • congenital infection
  • Toxoplasmosis, Other agents, Rubella, CMV, HSV
  • also syphilis, zika, parvovirus B19

Px
- HSM, fever, lethargy, reduced feeding, anaemia, jaundice

Ix
- IgM, IgG

Mx
- tx infection in mother / fetus

470
Q

Sudden infant death syndrome (SIDS)

A
  • unexplained death in infant (cot death)

RFs
- prematurity, low birth weight, smoking during pregnancy, sleeping prone, bed sharing

Minimise risk
- baby on back, head uncovered, nothing by head, 16-20 degree room temp, no co-sleeping, no smoking

Support
- The lullaby trust
- Bereavement services

CONI - care of next infant

471
Q

VACTERL association

A
  • association of birth defects, tend to co-occur

Vertebral defects

Anal atresia / malformations
- no anal opening
- surgery, colostomy first, then 6mo repair

Cardiac defects
- ASD, VSD, TOF, also truncus arteriosus, TGA

Tracheoesophageal fistula
- abnormal connection between oesophagus + trachea
- Px - choking, coughing, vomiting, cyanosis with feeding
- Mx - surgery, NICU, stomach tube feed

(O)Esophageal atresia
- oesophagus not connected to stomach - unable to feed, surgery

Renal abnormalities
- defects, kidney failure
- transplant / correction

Limb abnormalities
- eg thumbs, polydactyly, syndactyly, radial aplasia….

Phase 4 Question Knowledge (30 decks)

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