Paediatrics Flashcards by Andy Taylor

December, 6 month old with coryza, SoB, cough, increased work of breathing and decreased feeds.
Wheeze and inspiratory crackles on examination, hypoxic.
Diagnosis and cause?

Bronchiolitis - lower airway infection
RSV
(mycoplasma, parainfluenza, adenovirus)

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Bronchiolitis management?

Supportive:
Oxygen
Nasogastric feeds
Respiratory support - high flow, CPAP, ventilation

Not routine:
Adrenaline nebs +-dexamethosone
Hypertonic saline
Heliox
Abx

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October, 3.5 year old boy. Stridor last 2 days - now soft stridor at rest, drowsy, cyanosed, barking cough, hoarse voice, coryza, no fever.
Diagnosis and management?

Severe croup (laryngotracheobronchitis)
Parainfluenza virus 1,2,3
(RSV, measels rarely)
Subglottic oedema, inflammation, exudate

KEEP CHILD CALM
ABC
O2
Dexamethosone/prednisolone PO stat
Adrenaline nebs - repeat if necessary ==> ITU
Intubation occasionally

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November, 5 year old girl. Coryzal, stridor 2/7 when exerting herself, hoarse voice, nose flaring, increased work of breathing, alert, well perfused, no fever.
Diagnosis and management?

Mild croup
(laryngotracheobronchitis)
Parainfluenza virus 1,2,3
(RSV, measels rarely)
Subglottic oedema, inflammation, exudate

ABC +-O2
KEEP CHILD CALM
Dexamethosone/prednisolone PO stat
Send home if settled

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7 year old boy in hospital with stridor for 5/7 has developed fever and is not responding to steroids or adrenaline nebs. Respiratory distress, barking cough and tracheal tenderness. Stridor is now soft, continuous and biphasic.
Diagnosis and management?

Bacterial tracheitis

Secure airway/ intubation, frequent suctioning and high air humidity to maintain patency.
Broad spectrum IV antibiotics - Cefotaxime, flucloxacillin
Hydrocortisone

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Epiglottitis signs and management?

Sudden onset, continuous, soft stridor.
Drooling of secretions.
Muffled voice
Feverish and toxic e.g.>39*

ABC
DO NOT APPROACH OR UPSET
DO NOT EXAMINE THROAT
Theatre for inhalation anaesthesia and EUA
Small diameter endotracheal tube
Tracheostomy if completely obstructed
Cefotaxime (h influenzae b)

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4 year old girl with fever, malaise, poor feeding, tachypnoea, cyanosis, recession, grunting, accessory muscles, pleural pain, bronchial breathing.
Diagnosis and management?

Pneumonia
(pneumococcus, mycoplasma, haemophilus, staph, TB, viral)
CXR/FBC/blood and sputum cultures if severe

ABC
Admit if SpO2<92%/respiratory distress
If symptoms mild, omit antibiotics - viral more common
Amoxicillin 1st line
(coamoxiclav, azithromycin, clarithromycin)
Monitor TPR, SpO2

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Cystic fibrosis presentation? Early vs later?

As neonate: 
Meconium ileus - failure to pass stool/ vomitting in first 2 days of life, distended bowel loops, firm mass of meconium (nasogastric drainage and washout enemas (gut excision))
Later: 
Recurrent pneumonia+- clubbing
Failure to thrive
Slow growth

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Cystic fibrosis investigations?

Sweat Cl- test >60mmol/L
False positives/negatives can occur e.g. eczema, hypothyroidism, dehydration. Oedema gives false negatives.
Immunoreactive trypsinogen IRT
DNA test: 2 mutations associated with severe disease

CXR: hyperinflation, increased AP diameter, bronchial dilation, cysts, linear shadows, infiltrates.
Malabsorption screen
Random glucose
Spirometry: Obstructive pattern, decreased FVC, increased lung volume
Sputum culture if deteriorating: Mycobacterial colonisation in 20%

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Cystic fibrosis treatment?

Respiratory including abx
GI
Endocrine

Respiratory (staph aureus, h influenzae, strep pneumoniae, chronic pseudomonas aeruginosa in 90%):
Physio, percussion+postural drainage, forced expiration techniques
Treat acute infections with double doses for prolonged periods. Ticarcillin+gentamycin/ ceftazidime.
Ticarcillin+tobramycin nebs at home prevent admissions.

GI:
Increased energy needs, high calorie, high protein (malabsorption+chronic lung inflammation)
Nasogastric feeding if weight cannot be maintained.
Pancrex enzyme replacement
Pancrelipase/Creon in older children
If creon inadequate/ dehydrated obstruction can occur
Increase duodenal pH helps absorption (PPI omeprazole OR H2 antagonists ranitidine)
Vitamins A+D or multivitamins for older children

Endocrine
Screen with OGTT yearly from 12yo
Optimise diet, insulin, oral hypoglycaemics (metformin, sulphonylureas, glitinides, glitizones) only if nutrition is satisfactory.

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Cystic fibrosis complications?

Haemoptysis
Pneumonia
Pneumothorax
Pulmonary osteoarthropathy
Diabetes mellitus
Cirrhosis
Cholesterol gallstones
Fibrosing colonopathy
Male infertility

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4 year old boy presents with facial swelling, peripheral oedema and recurrent infections. Sometimes urine is frothy.
Investigations and diagnosis?

Dipstick proteinuria
Serum albumin < 25

Nephrotic syndrome
(most commonly minimal change disease)
(other causes include glomerulosclerosis/nephritis, infection, sickle cell anaemia, diabetes, lupus)

Other investigations:
FBC, U&amp;Es, LFTs
Immunoglobulins
Complement levels
Varicella titres
Blood pressure
Consider:
Autoantibodies
Hepatits B serology
Renal USS
Renal biopsy

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Nephrotic syndrome treatment?

Prednisolone
(cyclophosphamide, cyclosporin alternatively)
Fluid restriction/balance
Diet control, no added salt
Diuretics for oedema if no hypovolaemia
Albumin infusion if severe/ symptomatic hypovolaemia
Penicillin prophylaxis

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5 newborn screening conditions

Cystic fibrosis IRT
Congenital hypothyroidism
Sickle cell disease

phenylketonuria (PKU)
medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
maple syrup urine disease (MSUD) 
isovaleric acidaemia (IVA) 
glutaric aciduria type 1 (GA1) 
homocystinuria (pyridoxine unresponsive) (HCU)

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Features of phenylketonuria?

Autosomal recessive - PAH gene chromo 1
Buildup of phenylalanine==>phenylketones - cognitive impairment
Lack of tyrosine - neurotransmitter deficit e.g. dopamine

Learning difficulties
Musty urine
Microcephaly
Seizures
Fair hair
Eczema

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Phenylketonuria management?

Diet control, low phenylalinine diet, tyrosine enrichment.

Amino acid drinks

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Down syndrome characteristics?

Trisomy 21

Flat occiput
Wide, flat nasal bridge
Epicanthic folds
Upslanting mongoloid eyes
Iris brushfield spots
Low set small ears
Single palmer crease
Wide sandal gap
Clinodactyly
Hypotonia

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Downs syndrome associated conditions?

Moderate to severe Learning Disabilities
Congenital heart disease – atrioventricular septal defect
Duodenal atresia
Hirschprung’s disease
Hypothyroidism 
Coeliac disease
Hearing impairment from secretory otitis media
Obstructive Sleep Apnoea 
Visual impairment from cataracts, squints, myopia (short-sightedness)
Delayed motor milestones
Short stature
↑ susceptibility to infection
↑ risk of leukaemia and testicular tumours
↑ risk of atlanto-axial instability 
Epilepsy
Alzheimer’s Disease
Infertility

18 month old boy with fever for 5/7. Also has bilateral conjunctivitis, R sided cervical lymphadenopathy, truncal polymorphic rash, dry lips, strawberry tongue, palmar erythema.
Diagnosis and main complications?

Kawasakis vasculitic syndrome

Coronary aneurysms, digital desquamation, thrombocytosis, conjunctival injection (weeks 4-6/subacute phase 2)

2yo girl with fever for 6/7. Also has bilateral conjunctivitis, pharyngeal injection/inflammation, truncal polymorphic rash, arthralgia.
Investigations and treatment?

FBC==> Raised platelets
Raised CRP/ESR
Raised bilirubin
Raised AST, a1 antitrypsin
Echocardiogram
MRA

IVI immunoglobulin
IVIG+prednisolone if non resposive
Aspirin PO

Premature neonate 24 hours after birth. Labile temperature, poor feeding, respiratory distress. Mum has a fever.
Likely diagnosis and management?

Early onset sepsis

ABC
Ventilation, volume expansion, inotropes
Bloods ==> FBC, CRP, glucose
Blood cultures
CXR
LP for culture, glucose, protein count, WCC, gram stain
After 24 hours ==> stool virology, throat swab, herpes serology, urine CMV culture, VDRL

Abx
Broad ==> benzylpenicillin + gentamycin
Meningitis ==> Cefotaxime
Listeria (purulent conjunctivitis/maternal infection) ==> ampicillin/ amoxicillin

Early onset vs late onset neonatal sepsis antibiotic management?

Early ==> <48 hours
Broad ==> benzylpenicillin + gentamycin
Meningitis ==> Cefotaxime
Listeria (purulent conjunctivitis/maternal infection) ==> ampicillin/ amoxicillin

Late ==> .48 hours
Broad ==> Flucloxacillin + gentamycin
Meningitis ==> Cefotaxime
CVP line ==> vancomycin (coag neg staph)

Cyanosed baby with harsh ejection systolic murmur over LLSE. Hypoxic.
Diagnosis and pathology?
Treatement?

Tetralology of fallot
Large VSD
Overriding aorta
Subpulmonary stenosis
RV Hypertrophy
R ==> L shunt, decreased pulmonary blood flow, hypoxia.
Risk of MI and stroke

Surgical closure of VSD
Palliative shunts (e.g. subclavian==>pulmonary artery) are of use as an interim measure

Cardiac differentials for the breathless child?

Left to right shunts
VSD
Persistent ductus arteriosus
ASD

(Complete AVSD causes common mixing and a breathless/blue picture)

Cardiac differentials for the blue child?

``` Tetralogy of Fallot Transposition of the great arteries Truncus Arteriosus Tricuspid Atresia Total Anomalous Pulmonary Venous Connection ```

Circulatory collapse/ shock cardiac cause?

Coarctation of the aorta | aortic narrowing

Asymptomatic murmur most common causes?

Pulmonary stenosis | Aortic stenosis

Outline circulatory changes at birth.

Closure of ductus arteriosus in first few hours or days. Foramen ovale closes as left atrial pressure increases (decreased pulmonary resistance = increased pulmonary blood flow) and right atrial pressure falls (placenta excluded from circulation)

Hallmarks of an innocent murmur?

Soft blowing aSymptomatic Systolic only left Sternal edge

3 day old collapsed suddenly and is pale with grey lips. On examination, child is tachycardic and a systolic heart murmur can be heard, liver is enlarged. Femoral pulses are not palpable. Diagnosis and possible causes? Treatment?

Obstructive left heart failure. Aortic coarctation/stenosis. Prostaglandin - alprostadil - infusion maintains ductal patency. Stenting/surgery by 5yo to avoid pulmonary HTN and end organ damage.

6 week old with poor feeding/weight gain, wheezing/breathlessness for 2 weeks. On examination she is tachypnoeic with sternal and intercostal recession. Normal pulses. Thrill and loud pansystolic murmur @LLSE. Liver enlarged. Diagnosis and probable cause?

Left heart failure - L=>R shunting VSD ==> small ones close spontaneously ``` Upright O2 NG feeds Diuretics - furosemide, spironolactone ACE-i, e.g. captopril Surgical closure @ 3-6 months ```

Investigations for congenital heart disease?

Chest radiograph ECG Echocardiography is diagnostic Doppler USS

6yo boy had a pharyngeal infection 3 weeks ago. Now has mild fever, malaise and polyarthritis. On examination a murmur is heard. Patient has raised ESR/CRP. Diagnosis and management? Long term prophylaxis?

Rheumatic fever Rest High dose aspirin with serum monitoring Prednisolone if needed - particularly in sydenhams chorea. Phenoxymethylpenicillin for residual infection. One preceding dose of benzylpenicillin. Long term - monthly benzathine penacillin injections (Or oral penicillin, erthyromycin is an alternative) Prevention of acute episodes is vital to limit valvular disease.

List major criteria for rheumatic fever.

Polyarthritis Pancarditis Sydenhams chorea (involuntary movements+emotional lability) Erythema marginatum (early, uncommon, fading centre, pink outline, map appearance) Subcutaneous nodules (rare)

List minor criteria for rheumatic fever.

``` Fever Arthralgia History of rheumatic fever Raised ESR/CRP/leucocytes Prolonged PR interval ```

2 year old with history of VSD has fever, malaise, raised ESR, unexplained anaemia. On closer inspection, child has developed splinter haemorrages. Investigations and diagnosis? Treatment?

Multiple blood cultures (time and location) Echocardiography for vegetations. Infective endocarditis IV Benzylpenicillin+gentamycin usually for bacterial endocarditis Oral hygeine advice

Give likely differentials when the following features accompany vomitting: 1. Bile-stained 2. Haematemesis 3. Projectile, in first few weeks of life 4. Following paroxysmal coughing 5. Abdominal tenderness/pain on movement 6. Distension 7. Hepatosplenomegaly 8. Bloody stool 9. Severe dehydration/shock 10. Bulging fontanelle/seizures 11. Failure to thrive

1. Intestinal obstruction 2. Oesophagitis, peptic ulceration, oral/nasal bleeding 3. Pyloric stenosis 4. Whooping cough 5. Surgical abdomen 6. Intestinal obstruction (particularly distal), strangulated inguinal hernia 7. Chronic liver disease 8. Intussusception, gastroenteritis (salmonella, campylobacter) 9. Severe GE, systemic infection (UTI, meningitis), diabetic ketoacidosis 10. Raised ICP 11. Gastro-oesophageal reflux, coeliac, chronic conditions

3yo boy with apnoea, bouts of coughing causing vomitting, worse at night. Started 1 week ago. Mum says he sometimes makes strange noises and she is really worried he can't breath properly. Investigations/diagnosis and management?

Nasal swab PCR FBC = lymphocytosis Whooping cough ==> Bordatella pertussis Clarithromycin if within first 3 weeks to prevent spread. Can take months for symptoms to go away.

Severe GORD investigations and management?

24hr oesophageal pH/impedence monitoring Endoscopy/biopsy (oesophagitis identification) Sit upright after feeds Antacid + sodium/magnesium alginate (e.g. infant gaviscon) Carobel feed thickener Domperidone D2 antagonist (antiemetic, gastroprokinetic) Omeprazole PPI/ranitidine H2 Fundoplication for unresolved after 9 months/ failure to thrive/ severe oesophagitis/ apnoea/ bleeding

Infant with frequent regurgitation, failure to thrive and recurrent chest infections. Some recent vomits contained blood. Diagnosis?

GORD + oesophagitis

4 week old first born boy with worsening vomitting, now occasionally projectile. Baby is always hungry and now has dry mouth and lips and is irritable. Also has sunken fontanelle. Mum thinks she knows what the diagnosis is and is worried baby won't gain weight as he's not keeping anything down. Diagnosis and management?

Pyloric stenosis. Mum had the same as a child. Test feed pyloric olive mass and visible left to right peristalsis. USS can confirm. Air can be released with nasogastric tube. Usually hypo-natraemia, kalaemia, and hypochloraemic alkalosis. Correct fluid/electrolyte balance (0.45% saline and 5% dextrose with potassium supplements). Pyloromyotomy

5 yo abdominal pain worse when moving. Vomitted last night, not eating. Mild fever, flushed face. Weeing lots. No cough. Tummy tender on examination. Increased pulse rate. Supporting investigations & diagnosis?

FBC - neutrophilia Urine dip Ultrasound - thickened, non compressible appendix with increased blood flow; abcesses, perforation, masses Sometimes laparoscopy Appendicitis

Appendicitis management?

Apendicectomy If complicated, fluid resuscitation and IV antibiotics before laparotomy. If palpable mass in RIF, can give IV antibiotics for several weeks before appendicectomy. If symptoms worsen ==> laparotomy.

8 month old with sudden severe collicky pain. Pale, particularly around the mouth. Lethargic, not feeding, vomitted a few times, most recently bile stained. On examination a mass can be felt in the abdomen. Tummy looks slightly distended. Diagnosis, investigations, management?

Intussusseption Abdominal xray => distended small bowel, absence of gas in distal colon Ultrasound Palpable mass is a sausage Fluid resuscitation Rectal air insufflation ==> surgery if necessary