Paediatrics Flashcards
Social history
What to ask parents of all neonates/infants/toddlers/children presenting with parent? (7)
1. Have they reached developmental milestones?
2. Have they ever had social care input?
3. Have they had all of their vaccinations?
4. Questions regarding birth - Method, Extra-support requirements after birth?
5. Are there other children at home? - are they well?
6. Elicit home situation - partner present? pick up on cues for abuse (avoidance, shying away, apprehension etc.)
7. Parent coping - how are you managing
Special Considerations in consultations with older children?
(Extra questions/ things to offer)
Would you like to speak to me without parent present?/ Offer them an appointment at a later date if this seems appropriate (UTI, STI concerns)
General Paediatric History Structure
PC - SOCRATES
HPC - NOTEPAD (Nature, onset, timing, exacerbating, patient factors, alleviating factors, disability)
ICE!!
Have you given anything yet?
PMH - Ask about birth history, specifically about vaccinations, development, growth, medical and surgical history
SR EARLY! - Weight loss, Wet Nappies (Should be 6 a day roughly), Urinary Sx, Bowel Sx, Vomiting, Fever, Rash, Lethargy, Cough, Fits etc.
DH - And allergies
FH - Ask about siblings too, genetic conditions - kidneys, diabetes, early history of death, potentially ask about consanguinuity (if strange syndromic features)
SH - Breast/Bottle fed? When were they weaned? School? How’s Home? Partner?
Management:
Coeliac’s Disease
Hx
Dx
Rx and discussion with patient
Hx
- Loose Stools/ Altered Stool pattern
- FTT/ Wasted buttocks
- Rash (blistering rash aka. dermatitis herpetiformis)
Dx
- Anti-TTG (best antibody test 90% Sens / 90% Spec). Anti- EMA and Anti- Gliadin
- FBC, B12/Folate, Haemitinics, Faecal Calprotectin (Rule out IBD), Inflammatory Markers (Rule out IBD)
- Gold Standard - Duodenal Biopsy
Rx
- I would consider a referral to paeds gastro and a dietitian
Anti - gluten diet and monitoring of height/weight (give patient graph to plot at home) - Anything grain containing - cereals, beer, bread, oats, pasta, cakes.
- okay to eat dairy food, eggs, fruits and potatoes. Explain there are gluten free options available commercially
Re-inforce the importance of sticking to the diet to avoid complications of coeliac’s and to improve development
Refer to dietician
Management:
IBD
Dx:
Mx:
Dx:
FBC, Faecal Calprotectin, Inflamattory Markers (CRP/ESR), B12/Folate, LFT (PSC in UC)
Gold Standard- Colonscopy: Crohn’s - Transmural, Non caseating granuloma, skip lesions, cobble stone, anywhere in GI tracts. UC - confluent from rectus upwards. confined to mucosa.
Mx:
Avoidance of triggers - can be gluten etc.
Crohn’s: Protein Modulated Diet.
Steroids - for treatment and remission
can use immune modulation for remission - AZT, 5-ASA?
UC: Mild -Steroids +5 ASA,
Mod- Oral steroids + Rectal steroids,
Severe - NBM, IV Steroids
Remision - Aminosalicylates
Extra questions for resp
Think about FH/ PMH: atopy, asthma
Think about: Allergen exposure - dust, pets, pollen, smoking
Ask about - Rash, joint pain
Diabetes
Questions
Rx
Questions - Assess mood, Ask for a BM chart, Check for compliance, Check for alcohol intake, Check for inappetance/ anorexia, Check for current illness
Rx - Usually on Evening base bolus + Short acting before meals. Continuous pump. One/Two/Three injections with mix of short/rapid or intermediate
Consider - Increasing frequency of diabetic team/nurse visits to optomise to control if adherence is poor.
Family therapy/ motivational interviewing
Childhood Mood
Young Children
Look for parental discord
family trouble - alcohol, drug abuse, Low SES
Learning difficulties
Co-moborbidities
change of school
Considerations
may be atypical - hypersomnia, hyperphagia, hyperreactive mood, substance buse
or typical:
ask about school performance, school truancy, social isolation
What should you do when a child presents alone?
Ask where parents are
Autism Spectrum Disorder
Key Features, Hx and Diagnosis:
Mx:
Rx:
Key features: S&L Problems, Social Reciprocicity, Ritualistic Behaviours
Hx: Seizures, Developmental Delay, Family history of congenital illness, consanguinity, childhood questions
Dx: Clinical+ Exclusion + Questionnaires (CHAT and MCHAT)
- TO exclude haring problems, LD, Blood tests (metabolic screen + Organic acidurias screen). To consider in congenital abnormalities - MRI/CT - for Tuberous Sclerosis and other structural anomalies, Genetic testing (Cri du chat, Fragile X etc.)
Extra questions: Screen for parental mental health,substance abuse
Mx: Teams involved: GP, CAMHS - (Psychiatric care plan), SALT, Occupational Therapy, Social Services, School (educational health care plan ) , Disability Allowance, safety net, psychological support groups for the parents
Rx: Mainly psychosocial. Potentially (SSRis & Atypical antipsychotics for agitated children and when going to high stress environments)
Seizure
Hx
Dx
Mx
Hx:
Has this happened before? Diabetic?
Before
Fever? Illness? Aura? Drug use? Where were they?
Anyone around? Breath holding? Trauma? Headache? Focal Neurology?
During - How long?
Generalised - Tonic Clonic.
Did one thing move first then spread? - Complex partial
Myoclonic - Jerks
Atonic - Jerk then loss of tone
Absence, Temporal lobe (aura differentiates from absence)
LOC? Incontinence? Tongue biting?
After
Post-Ictal? Injuries? Possibility of head trauma?
Headache? Fever? Illness? Vomiting?
HPC - Raised ICP screen, Headache screen, Endocrine Screen
Dx -
Seizure termination protocol - Rectal/bucal midazol/diazepam –> Lorazepam (alert anaesthetics) –> rectal paredlayhde –> phen/ phenarb –> Rapid induction with thiopentone
ABCDE - BM!!!
Temperature, FBC, WCC, CRP, ESR, Prolactin, Urine dip, Urinary Drug Screen
Extra- Consider CT/MRI (injury, ICP, concerns of structural abnormality - LD etc. ). EEG, Sleep deprived eeg, ambulatory EEG,
Funduscopy
Neuro exam
ENT - OM, discharge, pharyngitis
Mx
Emergency
To take away - rectal/buccal for parents/school
Epilepsy = more than 2 with no identifiable cause. Valproate for generalised. Lamotrigine/Carbamezapine for - partial. Valproate + ethosuximide for - Absence. Vigabatrin for - Infantile spasms
Video the next one
Seizure free for >1 year to drive, or >3 years if only having at night.
Advise against - unsupervised swimming
Liaise with school
NB- status epilepticus is seizure for more than 5 minutes or more than 1 seizure within 5 minutes if no regaining of consciousness
Pyloric Stenosis
Hx
Dx
Mx
Hx: <8 weeks, Projectile vomiting, FTT, Hungry after vomiting, Anxiety when going to feed. Less wet nappies
Bowel habits, Lethargy, Meconium passage? (screen for hirschprungs/ cooeliac)
Food undigested in vomit. If bile - think about duodenal atresia
Dx: Clinical, Abdo examination (olive shaped mass), Urine dip (ketones), Test feed (visible/ palpable), USS (thickened pylorus >3mm muscle thickenss, >15-17mm longitudinal, >13mm diameter )
Hypocholoraemia Hypokalaemic metabolic acidosis
Capillary Blood Gas - Good one for management plan (quick)
Mx - ABCDE, IV fluid resuscitation, correct the acid base anomaly.
Prepare for surgery - Ramstedt’s pyloromotomy (small cut in the pyloric muscle)
Long term prognosis is good - will need follow up by the paediatric surgical team
Respiratory complaint
Hx
DDx
Dx
Hx: Cough, coryzal symptoms, SOB, pain, pleuritic pain, wheeze, Temperature
Extra questions:
Frequent URTI/ LRTI? (Primary immunodeficiency/ kartageners/ CF/ A1AT)
Conscious state?
Feeding? (<50% is cause for admission)
Wet nappies (<3 a day is bad news)
Exercise related or at rest?
Any Rx given? (Calpol)
Any vomiting? (bordatella)
HPC - Atopy, Smoking, Allergens, Pet, exercise, cold, rash, joint pain, urethritis
SR - Bowel, Abdominal pain, Urinary
DH - allergies (penicillin)
FH - atopy, allergy, serious illness
SH - smoking, alcohol, drug abuse, neglect
DDx: Viral induced wheeze, Multiple trigger wheeze, Bronchiolitis, Croup, Whooping Cough, Pneumonia, Pneumothorax, CF, A1AT, Kartagener’s, Heart Failure (most common cauase of chronic lung disease in young children), Asthma (>5),
