Paediatrics Flashcards
1
Q
Most common cause of pneumonia in newborns
A
group B streptococcus from mothers genital tract
2
Q
most common cause of pneumonia in infants
A
RSV
3
Q
most common causes of pneumonia in children > 5
A
Mycoplasma pneumoniae, streptococcus pneumoniae and chlamydia pneumoniae
4
Q
what vaccines in the childhood immunisation protect from pneumonia
A
6 in 1 vaccines (haemophilus influenzae B)
Pneumococcal PCV vaccine (streptococcus pneumoniae)
5
Q
most important examination finding in pneumonia for paeds
A
tachypnoea
6
Q
antibiotic management of pneumonia in paediatrics
A
New-born: broad spectrum IV antibiotics
Older infants: oral amoxicillin, broad spectrum antibiotics e.g. co-amoxiclav if unresponsive
Child > 5: amoxicillin or an oral macrolide e.g. erythromycin
7
Q
main symptoms of croup
A
hoarse cry and barking cough
8
Q
main causative organism in croup
A
parainfluenza viruses 1 - 4
9
Q
peak age incidence in croup
A
2 years old
10
Q
first line management of croup
A
150mcg/kg oral dexamethasone; single dose
11
Q
list the 9 causes of wheeze in children
A
- viral induced wheeze o Atopic asthma (IgE mediated) o Non atopic asthma o Recurrent aspiration of feeds o Inhaled foreign body o Cystic fibrosus o Recurrent anaphylaxis of child with food allergies o Congenital abnormality of lungs, airway or heart o Idiopathic
12
Q
what should you not do in a child with epiglotittis
A
lie them down or use tongue depressor as it can cause total airway obstruction
13
Q
key symptoms of epiglottitis
A
acute onset unwell looking child sat upright, immobile, mouth open painful to speak and swallow (muffled voice, hoarse cry) soft stridor high temperature
14
Q
peak incidence of bronchiolitis
A
3 - 6 months
15
Q
most common causative pathogen of bronchiolitis
A
RSV
16
Q
presentation of bronchiolitis (main symptoms)
A
preceded by coryzal symptoms
persistent cough
tachypnoea and chest recession
fine inspiratory crackles and wheeze
17
Q
differential diagnosis for bronchiolitis
A
viral wheeze (esp. if no crackles) pneumonia (esp. if temperature above 39)
18
Q
risk factors for bronchiolitis
A
premature birth + bronchopulmonary dysplasia
chronic lung disease e.g. CF
congenital heart disease
severe combined immunodeficiency syndrome
19
Q
Prevention of bronchiolitis
A
monoclonal RSV antibody to those at high risk
20
Q
cystic fibrosis epidemiology
A
1 in 2500 caucasian live births
1 in 25 carriers
21
Q
cystic fibrosis pathophysiology
A
mutation in CFTR gene leads to defects in protein and abnormal ion transport. Chloride ions are not pumped out into secretions so water is not drawn in and secretions are viscous
22
Q
presentation of CF in newborns
A
screening
23
Q
presentation of CF in infants
A
meconium ileus in neonatal period prolonged neonatal jaundice failure to thrive malabsorption and steatorrhea recurrent chest infections
24
Q
presentation of CF in young children
A
bronchiectasis
nasal polyps
sinusitis
rectal prolapse
25
presentation of CF in older children and adolescence
```
allergic bronchopulmonary aspergillosis
diabetes mellitus
cirrhosis and portal hypertension
distal intestinal obstruction
pneumothorax or recurrent haemoptysis
infertility in males
```
26
diagnosis of CF is done through which test
sweat test: chloride ions > 60mmol/L on 2 occasions
27
Management of CF
multidisciplinary
annual reviews, look at FEV1 to monitor progression
respiratory: prophylactic and rescue antibiotics, physiotherapy, nebulised hypertonic saline
nutritional: high calorie, fat soluble vitamins, oral enteric coated pancreatic replacement therapy
psychological management
28
kawasaki disease peak incidence
second half of the first year of life
29
Presentation of kawasaki disease
Fever for 5 or more days + 4 of the following 5
- bilateral dry conjunctivitis
- inflammation of the lips, mouth or tongue
- non-vesicular rash
- erythrma, swelling or desquamation to skin extremities
- cervical lymphadenopathy
30
Medical Management of kawasaki disease and dose
IVIG: 2g/kg in a single infusion over 12 hours
| aspirin
31
what follow up treatment is required for kawasaki disease and why
Echocardiogram to look for cardiac artery aneurysms
32
common causes of bacterial meningitis in neonates
group b strep
E. coli
listeria monocytogenes
33
common causes of bacterial meningitis in infants and chilldren
Neisseria meningitidis, streptococcus pneumoniae, HiB
34
Common presenting features for meningitis
```
unwell child
non-blanching petechial/purpuric rash
neck stiffness
bulging fontanelle in infants
photophobia
altered mental state
kernig's and brudzinski's signs
```
35
investigations for suspected meningitis
LP - CSF analysis
Also: full blood count, CXR, Urine dipstick + culture, blood culture U+E (septic screen)
Others: glucose, blood gases, coagulation screen, whole blood PCR for N.meningitidis
36
management of meningitis overview
supportive treatment: antipyretics, antiemetics, fluids
antibiotics
treat complications
37
Management of bacterial meningitis
Primary care: IM/IV benzylpenicillin (<1 300mg, 1-9: 600mg; 10+:1200mg)
Dexamethasone if over 3 months
blind antibiotic: IV ceftriaxone (cefotaxime + amoxicillin if under 3 months)
Specific antibiotic regimen depending on pathogen
38
antibiotic management of meningococcal meningitis
IV ceftriaxone for at least 7 days; prophylactic ciprofloxacin or rifampicin for close contacts
39
most common type of leukaemia in children
acute lymphoblastic leukaemia
40
peak presentation of ALL
age 2 - 5
41
signs and symptoms of ALL
general: malaise, anorexia
bone marrow infiltration: anaemia - pallor, lethargy; recurrent infections; bruising; bone pain
reticulo-endothelial infiltration: hepatoslenomegaly, lymphadenopathy, superior mediastinal obstruction
other organ involvement: CNS - vomiting, nerve palsies, headache; testicular enlargement
42
ALL investigations
FBC, blood smear, bone marrow examination
43
ALL management
1. correct anaemia, infections, low platelet count
2. remission induction: 4 weeks of combination chemotherapy
3. consolidation + CNS protection
4. interim maintenance
5. delayed intensification
6. continued maintenance
44
ALL relapse management
high dose chemotherapy, total body irradiation, bone marrow transplant
45
poor prognostic ALL markers
```
age less than 1 or more than 10
being male
high WCC load: >50x10^9
MLL rearrangement, translocation 4,11; hypodiploidy <44
persistence after initial chemotherapy
high minimal residual disease assessment
```
46
Types of paediatric brain tumours
astrocytoma: benign to highly malignant (glioblastoma multiforme)
medulloblastoma, ependymoma
brainstem glioma
craniopharyngioma: benign, (Rathke's pouch)
47
clinical features of a brain tumour
raised intracranial pressure: headache, vomiting, behaviour and personality, seizures, visual disturbance, papilloedema
focal neuroligical signs
spinal: back pain, peripheral weakness, bladder and bowel dysfunction
48
which investigations should you perform and avoid in brain tumours
MRI
| avoid LP if signs of ICP
49
management and late effects of brain tumours
surgery, chemotherapy/radiotherapy
| late effects: neurological disability, endocrine and growth problems
50
neuroblastoma definition
cancer arising from neural crest tissue in adrenal glands and sympathetic chain
51
clinical features of neuroblastoma
weight loss, abdominal mass, hepatomegaly, bone pain, limp
52
symptoms of asthma
wheeze, chest tightness, shortness of breath, cough
53
drugs used in the management of asthma
bronchodilators: SABA (salbutamol), LABA (salmeterol), anticholinergic bronchodilators (ipratropium bromide)
inhaled corticosteroids: preventers
other therapies: leukotrine receptor antagonist, theophylline, oral prednisolone, anti IgE: omalizumab
54
step 1 of asthma management
SABA prn
| consider ipratropium bromide in young children
55
step 2 of asthma management
add inhaled steroid
| consider montelukast in under 5s if not tolerated
56
step 3 of asthma management
>5: LABA, monteleukast or theophylline if no response
| <5 montelukast
57
stage 4 of asthma management
>5 increase to maximum dose of steroids
| <5 refer to paediatrics
58
stage 5 of asthma management
paediatric referral
daily oral steroid use
immunosuppressant or immunomodulation
59
features of an innocent murmur
```
asymptomatic
soft
systolic
left sternal edge
normal heart sounds, no thrills or radiation
```
60
types of left to right shunt and their %
ventricular septal defect 30%
atrial septal defect 7%
persistent ductus arteriosis 12%
61
types of right to left shunts and %
tetralogy of Fallot 5%
| Transposition of the GA 5%
62
types of asymptomatic obstructive outflow %
pulmonary stenosis 7%
| aortic stenosis 5%
63
types of symptomatic obstructive outflow
coarctation of the aorta 5%
64
types of common mixing heart defects
atrioventricular septal defect 2%
65
which heart defects are associated with Down's syndrome
ventricular septal defect
| atrioventricular septal defect
66
which heart defects are associated with Turner's syndrome
coarctation of the aorta
| aortic stenosis
67
which heart defects are associated with foetal alcohol syndrome
VSD, ASD, TOF
68
which heart defects are associated with maternal rubella or warfarin therapy
PDA, pulmonary stenosis
69
which heart defects are associated with William's syndrome
pulmonary stenosis
| aortic stenosis
70
which heart defects are associated with Noonan's syndrome
AVSD, PS
71
VSD murmur
loud pansystolic at lower left sternal edge
72
PDA murmur
continuous murmur in left clavivle
73
ASD murmur
ejection systolic, upper left sternal edge
74
TOF murmur
harsh ejection systolic murmur at left sternal edge
75
PS murmur
Ejection systolic murmur at upper left sternal edge
76
AS murmur
Ejection systolic murmur maximal at upper right sternal edge --> neck
77
when do most cases of GORD resolve by
12 months
78
what are complications of GORD
failure to thrive from severe vomiting
oesophagitis leading to haematemesis, heartburn or anaemia
recurrent pulmonary aspiration --> recurrent pneumonia, cough, wheeze or apnoea in preterms
dystonic neck posturing (sandifer syndrome)
79
common presentation of GORD
regurgitation and vomiting
80
risk factors for severe GORD
cerebral palsy or other neurodevelopmental disorders
preterm infants (+brunchopulmonary dysplasia)
following oesophageal atresia or diaphragmatic hernia
81
investigations for gord
normally clinical
| 24hr oesophageal pH monitoring, endoscopy
82
management of gord
parental reassurance + thickening agents + head prone position 30degrees after feeds
significant gord: H2 receptor antagonists e.g. ranitidine or PPI e.g. omeprazole
surgical management for severe non-responsive cases
83
what is pyloric stenosis
hypertrophy of pyloric muscle causing gastric outlet obstruction
84
when does pyloric stenosis present
between 2 weeks and 7 weeks
85
risk factors for pyloric stenosis
being male
| maternal family history
86
clinical features of pyloric stenosis
projectile vomiting, weight loss,
signs: visible gastric peristalsis, palpable mass ('olive' RUQ), dehydration
hyponatraemic, hypochloraemic, hypokalaemic metabolic acidosis
87
investigations for pyloric stenosis
test feed
| USS
88
management of pyloric stenosis
rehydrate + restore electrolyte imbalance
| surgery
89
what is colic
set of symptoms such as aroxysmal crying/screaming, knee up-drawing and excessive flatus
usually resolves by age 4
90
DD for colic
GORD, cow's milk intolerance
91
causes of acute abdominal pain
surgical: appendicitis, obstruction, inguinal hernia, peritonitis, inflamed meckel diverticulum, pancreatitis, trauma
medical: gastroenteritis, UTI, henoch-schonlein purpura, DKA, constipation, hepatitis, IBD
extra abdominal: URTI, lower lobe pneumonia, testicular torsion, hip + spine
92
signs and symptoms of appendicitis
symptoms: anorexia, vomiting, pain
signs: flushed face, low grade fever, pain aggravated by movement, persistent tenderness + guarding (faecoliths in preschool children)
93
investigations in appendicitis
repeated observation and clinical review every few hours
WCC or organisms in urine
USS: thickened incompressible appendix with increased blood flow
94
management of uncomplicated appendicitis
appendicectomy
95
what are the features of complicated appendicitis
presence of mass, abscess or perforation
96
management of complicated appendicitis
fluid resuscitation, IV antibiotics before surgery
97
what is intussusception
invagination of proximal bowel into a distal segment
98
common area of intusussception
ileum to caecum through ileocaecal valve
99
peak age of presentation for intusussception
2 months and 2 years
100
what are complications of intusussception
venous obstruction --> bleeding from bowel mucosa, fluid loss, perforation, peritonitis and gut necrosis
101
presentation of intusussception
paroxysmal severe colicky pain, child becomes pale and draws up legs
refuse feeds, vomits (bile stained)
sausage shaped mass in abdomen
redcurrant jelly stools
abdominal distension and shock
102
investigations for intusussception
abdominal XR: distended small bowel, absence of gas in distal colon/rectum
USS
103
management
IV fluid resuscitation
rectal air insufflation if no signs of peritonitis
surgery
104
what is Meckel diverticulum and what is the prevalence
ileal remnant of vitello-intestinal duct, contains ectopic gastric mucosa or pancreatic tissue
2%
105
presentation of Meckel diverticulum
asymptomatic
severe rectal bleeding that's neither bright red or malaena
other: intusussception, volvulus, diverticulitis
106
investigations for meckel diverticulum
technetium scan
107
treatment of Meckel diverticulum
surgical resection
108
presentation of malrotation
bilous vomiting due to ladds bands across the duodenum or volvulus usually within 1st 3 days of life
abdominal pain and tenderness from peritonitis
109
investigations for malrotation
upper GI contrast study
110
treatment for malrotation
urgent surgical correction
111
IBS symptoms/presentation
positive family history
associated with stress, anxiety/GI infection
```
abdominal pain relieved by defecation
bloating
explosive, loose or mucousy stools
feeling of incomplete defecation
constipation
```
112
what is hirschsprung disease
absence of ganglion cells from myenteric and submucosal plexus part of the large bowel resulting in a narrow contracted segment. extends from rectum
113
presentation of hirschsprung's disease
failure to pass meconium within 24hrs
abdominal distension
bile stained vomiting
rectal examination: narrowed segment, withdrawal --> gush of liquid stool and flatus
later childhood: chronic constipation, abdominal distension, growth failure
114
complication of hirschsprung disease
hirschsprung enterocolitis
| due to clostridium difficile infection
115
diagnostic investigation of hirschsprung disease
suction rectal biopsy: absence of ganglion cells + large acetylcholinesterase + nerve trunks
116
management of hirschsprung disease
surgical: colostomy followed by anastomosing innervated bowel to anus
117
red flag symptoms in a child with constipation
```
failure to pass meconium in 24hrs
failure to thrive
gross abdominal distension
abnormal lower limb neurology
sacral dimple over natal cleft
abnormality of anus
perianal bruising or multiple fissures
perianal fistulae, abscess or fistulae
```
118
what is constipation
infrequent passage of dry hardened faeces accompanied by straining or pain
119
causes of constipation
secondary to other diseases e.g. hirschsprungs, hypothyroidism etc.
dehydration/reduced fluid intake
toilet training problems
120
management of chronic constipation
1. evacuate rectum: stool softeners (macrogol laxative e.g. movicol)/osmotic laxative if not toterated; 2nd line stimulant laxative; 3rd line: enema, manual excavation under GA
2. maintenance treatment: movicol (polyethylene glycol)
dietary interventions
psychological/behavioural
121
presentation of Toddler's diarrhoea
loose stools of varying consistency + undigested vegetables
122
prognosis of toddler's diarrhoea
outgrow symtoms by 5 but may have delayed faecal continence
123
management of toddler's diarrhoea
ensure diet contains enough fat and fibre
| avoid excessive consumption of fresh fruit juice
124
presentation of crohn's disease
abdominal pain, diarrhoea, weight loss
growth failure + delayed puberty
fever + lethargy
oral lesions, perianal skin tags, uveitis, arthralgia, erythema nodosum
125
investigations for crohn's
raised inflamatory markers: platelet count, ESR, CRP
iron deficency anaemia, low albumin
diagnosis: endoscopic biopsy
126
pathophysiology of crohn's
transmural, commonly affects distal ileum and proximal colon
initially: acutely inflamed, thickened bowel
subsequently: strictures of bowel + fistula
histology: non-caseating epitheliod cell granulomata
127
management of crohn's
remission induction: nutritional therapy for 6 - 8 weeks (polymeric diet); 2nd line: systemic steroids
remission: immunosupressants -e.g. azathioprine, methotrexate; anti-tumour necrosis factor agents e.g. infliximab
long term supplemental enteral nutrition e.g. overnight NG feeds to correct growth failure
surgery for complications
128
presentation of ulcerative colitis
rectal bleeding, diarrhoea + colicky pain
extra-intestinal: erythema nodosum + arthritis
129
diagnostic infection of UC
endoscopy + exclude infective colitis
| small bowel imaging to exclude Crohns
130
pathophysiology of UC
inflammation of mucosa starting from rectum and moving proximally; 90% have pan-colitis
histology: mucosal inflammation, crypt damage and ulceration
131
management of UC
Mild disease: aminosalycates (e.g. balsalazide) for remission induction + maintenance
topical steroids if confined to rectum + sigmoid colon
Aggressive disease: systemic steroids for exacerbation azathioprine for maintenance
severe fulminating disease: IV fluids + steroids; ciclosporin; colectomy (toxic megacolon complications)
132
complications of UC
toxic megacolon
| adenocarcinoma: regular colonoscopic screening after 10 years of diagnosis
133
presentation of diaphragmatic hernia
failure to respond to resuscitation or respiratory distress
134
prevalence of diaphragmatic hernia
1 in 4000 births
135
signs of diaphragmatic hernia
displaced apex beat and heart sounds to right side of chest, poor air entry in left chest
136
complications of diaphragmatic hernia
pneumothorax on vigorous resuscitation attempts
pulmonary hypoplasia
137
diagnostic investigation
x-ray chest abdomen
138
management
NG tube + suction
surgical repair once stabilised
139
what is neonatal hepatitis syndrome
prolonged neonatal jaundice and hepatic inflammation
140
causes of neonatal hepatitis syndrome
```
congenital infection
inborn errors of metabolism
alpha1-antitrypsin deficiency
type 1 tyrosinaemia
galactosaemia
cystic fibrosis
intestinal failure associated liver disease
progressive familial intrahepatic cholestasis
error of bile synthesis
```
141
symptoms of neonatal hepatitis syndrome
IUGR
| hepatosplenomegaly at birth
142
what is biliary atresia
progressive disease in which there is destruction or absence of the extrahepatic biliary tree and intrahepatic biliary ducts
143
what is wilson disease
autosomal recessive disorder
defective excretion of copper leading to accumulation of copper in liver, brain, kidney and cornea (Kayser-Fleischer rings)
144
treatment of wilson disease
penicillamine, zinc, pyridoxine
145
causes of acute liver failure in children
paracetamol overdose
| viral hepatitis: A, B, C
146
investigative findings of liver failure
elevated transaminase and alkaline phosphotase and ammonia, abnormal coagulation
EEG: acute hepatic encephalopathy
CT: cerebral oedema
147
management of liver failure
maintain blood glucose
prevent sepsis with antibiotics and anti fungals
IV fresh frozen plasma and vitamin K to prevent haemorrhage
148
biliary atresia presentation
normal birthweight --> failure to thrive
jaundice
pale stools and dark urine
hepatosplenomegaly
149
diagnostic investigation for biliary atresia
laparoscopic cholangiography
150
treatment of biliary atresia
surgical bypass of fibrotic ducts
liver transplants
151
what are choledochal cysts and what is their management
cystic dilations of extrahepatic biliary system
surgical excision of cyst
152
what is marasmus
severe protein energy malnutrition leading to a weight <70% for height
153
what is kwashiorkor
severe protein deficiency + oedema
also: flaky skin rash, angular stomatitis, diarrhoea, hypothermia, hypotension, bradycardia, distended abdomen and hepatomegaly
154
causes of failure to thrive
inadequate intake: non organic (e.g. maternal depression), organic (e.g. cleft palette, LoA)
inadequate retention: vomiting
malabsorption: CF
failure to utilise nutrients e.g. T21
increased requirements: chronic infection, CF, thyrotoxicosis
155
most common cause of gastroenteritis
rotavirus
campylobacter jejuni
other
shigella: high fever, blood, pus, tenesmus
cholera + ecoli: dehydration
156
children at higher risk of dehydration with gastroenteritis
infants < 6 months/ low birthweight
more than 5 diarrhoeal stools in 24 hrs
vomited 3+ in 24hrs
unable to tolerate feeds
157
what is clinical dehydration
5 - 10% loss of body weight
158
what is post-gastroenteritis syndrome
temporary lactulose intolerance; non absorbed sugar in stools
159
what is coeliac disease
immune response against gliadin leading to proximal small intestine damage
160
presentation of coeliac disease
abdominal distension, buttocks wasting, abnormal stools, failure to thrive, irritability, anaemia
161
histological findings in coeliac disease
intraepithelial lymphocytes
crypt hypertrophy
villous atrophy
162
management
dietary changes
| gluten challenge in later childhood
163
what is cerebral palsy
non progressive disturbances in the developing foetal or infant brain causing motor impairment
164
causes of cerebral palsy
80% antenatal: vascular occlusion, genetic syndromes, infection
10% hypoxic ischaemic injury during delivery
10% postnatal e.g. preterm infants with periventricular leucomalacia secondary to severe intraventricular haemorrhage. Also: meningitis/encephalopathy, NAI/trauma, hypoglycaemia, hyperbilirubinaemia
165
possible investigations for cerebral palsy
MRI
166
Presentation of CP
abnormal limb/trunk posture + delayed motor milestones
slowed head growth
feeding difficulties
abnormal gait
hand preference before 12 months
167
Gross motor function classification system
used in CP functional assessment
1. walks without limitations
2. walks with limitations
3. walks using hand held mobility device
4. self mobility with limitations
5. transported in manual wheel chair
168
classification of CP and regions involved
spastic: motor cortex
dyskinetic: basal ganglia
ataxic: cerebellum
169
types of spastic CP
hemiplegia
paraplegia
quadraplegia
170
features of spastic CP
hypertonia/spasticity , brisk reflexes, extensor plantar responses
tip toe walk, scissor gait
171
symptoms of dyskinetic CP
chorea: dance like movements
dystonia: contraction of agonist and antagonist muscles = twisting appearance
floppiness, poor trunk control
172
features of ataxic CP
hypotonia, delayed motor development, poor balance, ataxic gait, intention tremor, in-coordinate movement
173
pathogenic aetiology of UTI
```
e.coli
klebsiella
proteus: boys>girls; alkaline urine
pseudomonas: ~ structural abnormality
strep faecalis
```
174
risk factors for UTI
incomplete bladder emptying (infrequent voiding, neuropathic bladder, obstruction, vesicoureteric reflux)
175
atypical UTI
```
seriously ill or septicaemia
poor urine flow
abdominal or bladder mass
raised creatinine
failure to respond to suitable antibiotics in 48hrs
non-ecoli
```
176
investigations for UTI under 6 months
```
urine dipstick (>3)
clean catch urine sample for microscopy and culture
```
USS during acute infection if atypical or recurrent or 6 weeks otherwise
DMSA dimercaptosuccinic acid 4 - 6 months after in atypical or recurrent
MCUG micturating cystourethrogram if USS abnormal, atypical or recurrant
177
investigations if 6months - 3 years UTI
typical: no further investigations
atypical: USS acute; DMSA 6 months; recurrent USS in 6 weeks, DMSA
178
investigations UTI 3y+
typical: none
atypical: acute USS
recurrent: 6 month USS; DMSA
179
what do USS show in UTI
renal size, outline, congenital abnormalitis, renal calculi, hydronephrosis
180
what does MCUG show in UTI
reflux
181
what does DMSA show in UTI
renal parenchymal defects
182
management of UTI
7 - 10 days antibiotics if uper UTI
| 3 days in lower UTI
183
risk factors for recurrence in UTI
<6months
female
VUR grade 3 - 5
184
complication of UTI
renal scarring
| hypertension
185
symptoms of severe asthma
* To breathless to talk or feed
* Use of accessory neck muscles
* SPO2 <92%
* Tachypnoea and tachycardia
* Peak flow <50% predicted
186
features of life-threatening asthma
* Silent chest
* Poor respiratory effort
* Altered consciousness
* Cyanosis
* Oxygen saturations < 92%
* Peak flow < 33%
187
management of moderate asthma exacerbation
* SABA via spacer; 2 – 4 puffs
* Increase by 2 puffs every 2 minutes to 10 puffs if required
* Consider oral prednisolone
* Reassess within 1h
188
immediate management of severe/life-threatening asthma
Oxygen via face mask/ nasal prongs to achieve normal saturations
189
management of severe asthma
10 puffs of SABA via spacer or nebuliser
oral prednisolone or IV hydrocortisone
nebulised ipratropium bromide if response is poor
repeat bronchodilators every 20-30mins prn
190
management of life threatening asthma
nebulised SABA + ipratropium bromide
IV hydrocortisone
consider HDU/PICU
repeat bronchodilators every 30mins
191
management of responding asthma after exacerbation
* Continue bronchodilators 1 – 4 h prn
* Discharge when stable on 4h treatment
* Continue oral prednisolone for up to 3 days
192
management of asthma attack not responding to treatment
• Transfer to HDU or PICU and consider CXR and blood gases
• IV salbutamol or aminophylline (caution if already receiving theophyllines)
o ECG and electrolyte monitoring
o IV aminophylline – loading dose over 20 minutes followed by continuous infusion. SE: seizures, severe vomiting + fatal cardiac arrythmias (Omit loading dose if already on theophylline)
• Consider bolus of IV magnesium sulphate
193
important factors when discharging a patient after acute asthma attack
patient education
review medication and inhaler technique
personalised action plan
arrange follow up
194
3 signs of shaken baby syndrome
subdural haemorrhage
retinal haemorrhage
encephalopathy
195
what are the 3 types of child abuse
neglect
physical abuse
sexual abuse
196
what are features that should make you consider neglect
severe and persistent infestations
parents who administer essential prescribed treatment /follow up etc
failure to dress child in suitable clothing
animal bite on inadequately supervised child
197
features where you should suspect neglect
failure to seek medical advice leading to compromised child's health
child who is persistently smelly and dirty
198
features where you should consider sexual abuse
persistent dysuria or anogenital discomfort without medical explanation
gaping anus
pregnancy/STI in 13-15 year old
199
features where you should suspect sexual abuse
persistent or recurrent genital or anal symptoms + behavioural change
anal fissure + constipation with no Crohn's
STI in under 12
200
features where you should consider physical abuse
serious or unusual injury with unsuitable explanation
201
features where you should suspect physical child abuse
bruising, lacerations or burns on an immobile child
retinal haemorrhage
multiple fractures with different ages, evidence of occult fractures
202
possible presentation of childhood abuse
bruising
fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing
torn frenulum: e.g. from forcing a bottle into a child's mouth
burns or scalds
failure to thrive
sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Trichomonas
203
factors which point towards child abuse
story inconsistent with injuries
repeated attendances at A&E departments
late presentation
child with a frightened, withdrawn appearance - 'frozen watchfulness'
204
immediate complications of meningitis
```
septic shock
coma
raised ICP
cerebral oedema
seizures
septic arthritis
pericardial effusions
```
205
other complications of meningitis
subdural effusions
syndrome of inappropriate ADH secretion
sensorineural hearing loss
206
preventative measures for meningitis
vaccination: Hib, meningococcus group B and C
meningococcus ACWY
intrapartum group B strep + antibiotic prophylaxis
207
aetiology and causative pathogens for encephalitis
direct invasion by neurotoxic virus
post infectious encephalopathy
slow virus infection
enterovirus, respiratory virus, HSV
208
encephalitis presentation
fever, altered consciousness, behavioural changes and seizures
209
encephalitis management
high dose IV acyclovir until HSV is excluded
| proven HSV: 3 weeks treatment
210
clinical features of measles
cough, conjunctivitis, coryza
Koplik's spots
rash: maculopapular, downwards from ears, becomes confluent
high temperature
211
complications of measles
otitis media
encephalitis
subacute sclerosing panencephalitis
212
management of measles
* Symptomatic
* Isolate admitted children
* Antiviral drug ribavirin in immunocompromised patients
213
clinical features of chicken pox
o Lesions start on head and trunk --> peripheries
o Appear as crops of papules and vesicles with surrounding erythema --> pustules --> crusts
o New lesions appear at different times for up to 1 week (new lesions after 10 days suggestive of defective cellular immunity)
o Itching + scratching may cause permanent scar formation or secondary infection
214
complications of chicken pox
o Secondary bacteria infection: e.g. staphylococci or group A streptococci --> toxic shock syndrome, necrotising fasciitis
o CNS: cerebellitis, generalised encephalitis, aseptic meningitis
o Immunocompromised: haemorrhagic lesions, pneumonitis, progressive and disseminated infection, disseminated intravascular coagulation
215
management of chicken pox
immunocompromised/adults: oral valaciclovir
HVZ IG following contact in immunosuppressed
216
clinical features of mumps
fever, malaise, parotitis
217
complications of mumps
transient hearing loss
viral meningitis + encephalitis
orchitis in post pubertal males
218
features of rubella
low grade fever
maculopapular rash from face to entire body
suboccipital and post auricular lymphadenopathey
219
complications of rubella
o Arthritis, encephalitis, thrombocytopenia and myocarditis
220
diphteira microscopic features
cornybacterium diphtheriae Gram-positive, aerobic, non-motile, rod shaped bacterium
221
management of diptheria
erythromycin + close contacts prophylactic
immunisation
222
presentation of diptheria
nasal discharge (watery purulent blood stained), enlarged cervical lymph nodes, membranous pharyngitis + respiratory obstruction; vesicular or pustular rash in lower legs, feet and hands; cardiomyopathy or myocarditis
223
scalded skin syndrome causative organism
staphylococcus aureus
| releases a toxin that causes separation of epidermal skin through the granular cell layers
224
scalded skin syndrome differential diagnosis
Toxic epidermal necrolitis
225
scalded skin syndrome rash
vesicular
bulbous
pustular
226
presentation of SSS
fever + malaise
generalised erythema + skin tenderness
large superficial blisters commonly affecting the flexures--> Nikolsky sign positive
227
management of SSS
fluid balance
analgesia
flucloxacillin
228
whooping cough causative organism
bordella pertussis
229
clinical features of whopping gough
o 1 week of coryza (catarrhal phase) spasmodic cough + inspiratory whoop or apnoea in infants (paroxysmal phase)
o Cough is worse at night vomiting, epistaxis and subconjunctival haemorrhage
o Child may go red or blue in face
o Symptoms may last for 3 – 6 weeks
o Convalescent phase: can last for months
230
management of whooping cough
azithromycin in ist 21 days
| exclusion from school for 48hrs
231
features of TB on a CXR
hilar lymphadenopathy
Ghon complex
consolidation
232
investigations for TB
gastric washings to visualise acid fast bacilli
Mantoux test
Interferon gamma release assay
CXR
233
management of TB
Rifampicin: GI, red urine
isoniazid: peripheral neuropathy (weekly pyridoxine)
Pyrazinamide: joint pains
Ethambutol: visual impairment
TB meningitis: dexamethasone
BCG immunisation, contact tracing
234
clinical features of HIV
o Asymptomatic: routine screening
o Mild immunosuppression: lymphadenopathy or parotitis
o Moderate immunosuppression: recurrent bacterial infection, candidiasis, chronic diarrhoea and lymphocytic interstitial pneumonitis
o Severe AIDs: opportunistic infections (e.g. pneumocystis carinii pneumonia), severe failure to thrive, encephalopathy, malignancy
235
investigations for HIV
PCR HIV DNA/ antibodies
236
treatment of HIV
ART, PCP prophylaxis, co-trimoxazole
avoid BCG,
consider hep A, B and VZR vaccinations
237
coxsackie's disease/ hand foot and mouth disease
coxcackie virus
| o Painful vesicular lesions on hands, feet, mouth and tongue and buttocks; mild systemic features
238
scarlet fever causative organism
• Group A streptococci: streptococcus pyogenes
239
management of scarlet fever
penicillin V or azithromycin for 10 days; return to school after 24hrs of antibiotics
240
characteristic features of scarlet fever
sandpaper rash
| strawberry tongue
241
toxic shock syndrome presentation
```
o Fever > 39C
o Hypotension
o Diffuse erythematous macular rash
o Organ dysfunction:
Mucositis: oral, conjunctival and genital
Vomiting/ diarrhoea
Renal and liver impairment
Clotting abnormalities and thrombocytopenia
Altered consciousness
```
242
causative organisms for toxic shock syndrome
• Staphylococcus aureus and group A streptococci
243
management of toxic shock syndrome
intensive care to manage shock
surgical debridement
cefrtiaxone + clindamycin (switches off toxin production)
IVIG to neutralise circulating toxins
244
candida infection risk factors
```
hot weather
infrequent nappy changes
corticosteroid or antibiotic
poor hygiene
immunodeficiency
```
245
impetigo causative organism
staphylococcus/streptococcus
246
impetigo presentation
vesicular, bullous, pustular rash which ruptures and produces honey crusted lesions
lesions on face, neck and hands
247
management of impetigo
o Mild cases: topical antibiotics e.g. mupirocin
o Severe: systemic antibiotics e.g. flucloxacillin or co-amoxiclav
o Avoid nursery or school until lesions are dry
o Nasal carriage eradication: nasal cram with mupirocin or chlorhexidine and neomycin
248
slapped cheek syndrome rash
| and causative organism
maculopapular
| parvovirus B19
249
presentation of slapped cheek syndrome
Fever, malaise, headache + myalgia --> facial rash a week later (slapped cheek) --> lace like rash on trunk + limbs
250
complication of slapped cheek syndrome
aplastic crisis
251
tropical fevers and their management
malaria: quinine
typhoid: azithromycin
dengue fever
gastroenteritis
252
classification of immune deficiency
primary: intrinsic defect of immune system
(X-linked or autosomal recessive)
secondary: caused by another disease or treatment e.g. infection, malignancy, immunosuppressive therapy
253
presentation of immune deficiency
```
recurrent bacterial infections
severe infections
atypical presentation of infections/failure to respond to infections
opportunistic infections
failure to thrive
```
(SPUR: severe, prolonged, unusual, recurent)
254
categories of primary immune deficiency
T-cell defects: severe combined immunodeficiency, ataxia telangectasia, DiGeorge, Wiskott-Aldrich
B-cell defects
Neutrophil defects
leukocyte function defects
complement defects
255
treatment of primary immune deficiency
Antibiotic / antiviral prophylaxis
Prompt treatment of infections
Replacement immunoglobulin
Bone marrow transplant
256
investigations for primary immune deficiency
FBC : low total WBC, neutrophil or lymphocytes
Total Ig GAM +/-E
Responses to routine immunisations
Lymphocyte subsets: numbers of T and B cells
Lymphocyte function
