Paediatrics Flashcards
What questions should be asked about the presenting illness?
When and how did it start? Was he/she well before? How did it develop? What aggravates or alleviates it? Has there been contact with infections? Has the child been overseas recently? Have the carers sought medical attention before now? Which treatments have been tried? Especially in infants, wet and dirty nappies, alertness and weight gain
What questions should be asked around PMH?
In utero: Any problems (abnormal bleeding, infections, Rh disease), medications, alcohol, drug use, US normal?
At birth: Gestation, mode of delivery, birth weight, resuscitation required, birth injury, malformations
As a neonate: Jaundice, fits, fevers, bleeding, special care baby unit? - How long? Later illnesses, operations, accidents, screening tests, drugs, allergies, immunisations, travel. Check red book.
What are the 6 week developmental milestones?
smiles
follows eyes past midline
What are the 4-6 month milestones?
sits with support
rolls
reaches out for objects
starts babbling
What are the 6-9 month milestones?
crawls sits without support pulls to stand gives toy on request turns head to name responds to 'bye bye' gestures with babbling first tooth
What are the 7-12 month milestones?
develops pincer grasp
plays ‘peek-a-boo’
walks with a hand held
waves goodbye
What are the 12-15 month milestones?
single words
listens to stories
drinks from cup
What are the 18 month milestones?
speaks 6 words able to walk up steps names pictures walks independently scribbles builds with blocks
What are the 1.5-2 year milestones?
kicks/throws a ball runs 2 word sentences follows a 2 step command stacks 5-6 blocks turns pages uses a spoon helps with dressing
What are the steps in the physical examination?
General health Vital signs Respiratory system Cardiovascular system GI system GU system MSK system ENT Anything else parents would like to be checked? Height, weight and head circumference
What information can be gained in physical examination surrounding general health?
Is the child well or ill? Alert, lethargic, or uncomfortable / in pain? Playing is a good sign. If crying, is it high pitched or normal? Behaving normally and interacting with the parents? Any jaundice, cyanosis, rashes, anaemia, or dehydration? Neck stiffness is a rare sign in infants
What do you look for during the respiratory examination?
Is the shape of the chest normal?
Any intercostal, subcostal or sternal recession, or nasal flaring?
Use of accessory muscles?
Is there grunting or any other audible noise breathing in (stridor) or breathing out (wheeze)?
Percuss the chest for dullness
Auscultate the chest, listening for breath sounds, fine crackles, rhonchi, wheeze and pleural rub
What do you look for during the CV examination?
Check for peripheral and central cyanosis
Look for clubbing and peripheral oedema
Compare strength of femoral and right brachial pulse
Is the apex beat displaced?
Auscultate the heart with the child sitting and lying down
Listen over the apex, 2nd intercostal space left of stermum (pulmonary valve), and right of sternum (aortic valve), 4th intercostal space over the sternum (tricuspic)
What is fixed splitting of the second heart sound indicative of?
Atrial septal defect
What is a galloping rhythm suggestive of?
Congestive cardiac failure
What do you look for during the GI examination?
Child should be supine and relaxed, with knees bent
Look for distension, visible peristalsis, and hernias
Listen for bowel sounds and percuss for hepatosplenomegaly and ascites
Palpate looking for tenderness and masses (during inspiration and deep expiration)
If relevant look for anal patency, fissures and prolapse
What do you look for during the GU examination?
If relevant, examine external genitalia for evidence of ambiguity, congenital abnormality and size
Examine once only using a chaperone
What do you look for during MSK examination?
Watch the child walk and play
Examine all limbs and digits for congenital anomaly
Symmetrical skin creases on both thighs?
If <6 months check for congenital hip dislocation
Inspect the spine for dimples, hair tufts, masses or cysts at the base
Is there any abnormal curvature or posture?
What do you look for during ENT examination?
(best left until the end)
Evidence of otitis externa?
Post-auricular rash is a sign of measles, rubella and eczema
Look at the tympanic membrane - noting colour and lucency - is it perforated?
Use a spatula to check the tonsils, as well as inspecting the teeth and oral mucosa (plaques, white patches, spots, ulcers)
Can the child breathe through both nostrils
Is there a runny nose?
Check for neck lumps and lymphadenopathy
What is makes up ‘red’ on the traffic light system?
Pale, mottled, ashen blue. Doesn’t stay awake when roused. Reduced consciousness (not engaging, apathy, coma), reduced skin turgor. Any GRUNTING signs?
What are GRUNTING signs?
Grunting; weak or continuous high pitched cry; tachypnoea
Rib recession; Retraction of sternomastoid, nasal flaring, wheeze, stridor
Unequal or Unresponsive pupils; focal CNS signs, fits, marked hypotonia
Not using limbs / lying still; odd or rigid posture decorticate (flexed arms, extended legs); or decerebrate (arms and legs extended)
Temperature > or = 38 if < 6 months or >/=39 especially if cold or shutdown peripheries
I have a bad feeling about this baby
Neck rigidity, non-blanching rash, meningism, bulging fontanelle, etc.
Green bile in vomit (may = bowel obstruction, e.g. atresia, volvulus, intussusception)
What are common symptoms in infancy?
Crying Colic Cows' milk protein allergy Nappy rash/diaper dermatitis Sleep problems
What is the definition of colic?
Paroxysmal crying with pulling up of the legs, for >3h on >/= 3days/week. There is an association with feeding difficulties.
What advice would you give to parents with a baby with colic?
Movement (carry-cot on wheels) is often tried and may help
Let the baby finish the first breast first (hindmilk is easier to digest)
If breastfeeding, a low allergen diet may help, as may probiotics
Reassure strongly, reduce stress, grandparent involvement
How might Cows’ milk protein allergy present?
Separate entity to colic - IgE or non-IgE mediated.
It causes colic symptoms, but also GORD, blood/mucus in the stools, and may result in faltering growth
What are the four types of nappy rash?
- Common ‘ammonia dermatitis’. Red desquamating rash, sparing skin folds.
- Candida / thrush. Satellite spots beyond the main rash
- Seborrhoeic dermatitis. Diffuse, red, shiny rash extends into skin folds (occiput - cradle cap)
- Isolated, psoriasis-like scaly plaques
What are the differential diagnoses for vomiting?
Posseting Vomiting between feeds (ask about carpets) GORD, Gastritis Over-feeding Pyloric stenosis (projectile, at ~8 weeks old) Any infection e.g. UTI Adverse food reaction Infective gastroenteritis
Rarer causes: Pharyngeal pouch Poisoning Raised ICP Metabolic conditions i.e. DKA Almost all other conditions Bilious (green) vomiting: get urgent help
What are the differentials for an ill and feverish child?
Self-limiting viral infection
Pneumonia
UTI
Meningitis
What are some problems facing babies on NICU?
Hypothermia Hypoxia Hypoglycaemia Respiratory distress syndrome Infection IVH (25% of = 1500g birthweight - delayed cord clamping may reduce risk) Apnoea Necrotizing enterocolitis Retinopathy of prematurity (screen)
Describe what happens with the first breath, and what can go wrong
Pulmonary vascular resistance falls, and there is a rush of blood to the lungs. Partly mediated by endogenous NO. Initiates changes from fetal to adult circulation. Process may be interrupted in various conditions e.g. meconium aspiration, pneumonia, respiratory distress syndrome, diaphragmatic hernia, group B strep infection, pulmonary hyperplasia. Pulmonary hypertension results as a consequences of these adverse events may also be primary (hypertrophy of muscular layer of pulmonary arteries.
What are some types of non-invasive ventilation for neonates?
CPAP (continuous positive airways pressure)
NIPPV (nasal intermittent positive pressure ventilation)
HFNC (high-flow nasal cannula)
What are some types of invasive ventilation for neonates?
TCPL (time cycled pressure limited ventilation)
PTV (patient-triggered ventilation)
HFV (high-frequency ventilation)
What might be the presentation of neonatal sepsis?
Signs may be non-specific and subtle. Labile temperature, lethargy, poor feeding, respiratory distress, collapse, DIC.
How would you manage suspected neonatal sepsis?
ABC
Supportive (ventilation, volume expansion, inotropes)
Bloods for FBC, CRP, glucose
Blood cultures (results take 48h)
CXR
Lumbar puncture for culture, glucose, protein count, WCC and Gram stain
Failure to responsd within 24h investigate further with stool sample for virology, throat swab, serology for herpes virus, urine CMV culture, VDRL (syphyllis)
What antibiotics would you give in early-onset neonatal infection?
Broad spectrum i.e. benzylpenicillin + gentamicin until culture results are available. Stop if well and cultures negative. Continue treatment for 7 days if +ve cultures.
In meningitis suspected then give cefotaxime
What antibiotics would you give in late-onset neonatal infection?
Broad spectrum e.g. flucloxacillin + gentamicin until cultures available
Cefotaxime if meningitis is likely
Coagulase -ve Staph is more likely in a preterm infant with CVP line - give vancomycin + discuss removal of line
What are the risk factors for early onset neonatal sepsis
Prolonged rupture of membranes >18h
Maternal infection; maternal pyrexia, chorioamnionitis, UTI
Mother carrier of Group B strep (GBS) from vagina or urine, or previous infant affected by it
Preterm labour
Fetal distress
Breaks in neonatal skin or mucosa
(caused by organisms acquired from the mother)
What are the risk factors for late-onset neonatal sepsis?
Central lines and catheters
Congenital malformations e.g. spina bifida
Severe illness
Malnutrition
Immunodeficiency
(tends to be caused by environmental organisms)
How common are neonatal seizures?
~4/1000 births - most occur 12-48h after birth. May be generalised or focal, tonic, clonic or myoclonic
What are the causes for neonatal seizures?
Hypoxic-ischaemic encephalopathy (due to antenatal or intrapartum hypoxia/ respiratory distress)
Infection (meningitis/encephalitis)
Intracranial haemorrhage / infarction
Structural CNS lesions (focal cortical dysplasia/tuberous sclerosis)
Metabolic disturbance (hypoglycaemia, hypocalcaemia, hypo/hypernatraemia, hypomagnesium)
Metabolic disorders (urea cycle disorders / amino acid metabolism)
Neonatal withdrawal from maternal drugs or substance abuse
Kernicterus (hyperbilirubinaemia)
Idiopathic seizures e.g. benign 5th day fits
How would you treat a neonatal seizure?
ABC - Help
Rule out and treat reversible causes i.e. hypoglycaemia
Start empirical antibiotics
IV access and take blood for FBC, U+E, LFTs, calcium, magnesium, glucose and blood gas
If available, start CFAM
Consider cranial US and MRI
Specialist tests include toxicology screening, serum ammonia, urine organic acids, serum amino acids, karyotype and TORCH screen.
Treat cause
What is hypoxic-ischaemic encephalopathy (HIE)?
A clinical syndrome of brain injury secondary to a hypoxic-ischaemic insult
What are the causes of HIE?
Antenatal, intrapartum up postpartum causes e.g. cord prolapse, placental abruption, maternal hypoxia (any cause) or inadequate postnatal cardiopulmonary circulation.
