Paediatrics Flashcards
(166 cards)
1
Q
Symptoms of mild-moderate allergic reaction?
A
- Angioedema (swelling of lips, face, eyes).
- Itchy / tingling mouth.
- Sudden change in behaviour.
- Hives or itchy skin rash.
- Abdominal pain or vomiting.
2
Q
Signs of anaphylactic reaction?
A
- Airway: swelling, hoarseness, stridor, difficulty swallowing.
- Breathing: tachypnoea, wheeze, fatigue (use of accessory muscles or indrawing of intercostal muscles), cyanosis, SpO2 <92%, confusion.
- Circulation: pale, clammy, hypotension, faint, drowsy, coma.
3
Q
What does of adrenaline should be administered IM to a child over 12 in anaphylaxis?
A
500 micrograms (0.5mL - i.e. the same as an adult).
4
Q
What dose of adrenaline should be administered IM to a child 6-12 years old who is in anaphylaxis?
A
300 micrograms (0.3mL).
5
Q
What dose of adrenaline should be administered IM to a child less than 6 years old who is in anaphylaxis?
A
150 micrograms (0.15mL).
6
Q
How would you fluid challenge a child after administering IM adrenaline for anaphylaxis?
A
IV crystalloid 20mL/kg.
If crystalloid is cause of anaphylaxis then stop the IV
7
Q
What advice would you give to the parents of a child with a new diagnosis of asthma with regards to bathing?
A
- Don’t use soap, bubble bath or shower gel.
- Use an emollient soap substitute instead.
- Minimise the amount of time shampoo spends in contact with skin.
8
Q
Describe what an emollient is in layman’s terms.
A
Used to moisturise the skin, they can be used liberally and often - which is when they work best.
9
Q
Explain how to use an emollient for eczema.
A
- wash hands prior to using.
- if using a tub without a dispenser - use a spoon to take it out the tub (reduces risk of infection).
- use 1-2x day applying in the direction of hair growth (downward) and avoiding rubbing back and forth.
- continue to use even when skin looks okay.
10
Q
What warnings should you advise parents of when using emollients for eczema?
A
ointments containing white soft paraffin and emulsifying ointment are easily ignited - avoid flame and smoking and warn friends/ relatives to be careful.
11
Q
What advice should you give to parents when using topical steroids for eczema?
A
- Apply only on affected areas i.e. itchy, red, rough skin.
- Use once daily and only when needed.
- One fingertip unit (i.e. from finger top to first joint) is enough to cover an area the size of two adult hands.
12
Q
Explain why steroids are used in eczema in layman’s terms.
A
Steroids act on affected areas to reduce the inflammation of the skin. They are safe when used correctly and benefits outweigh risks.
13
Q
What is physical abuse?
A
Causing physical harm to a child or young person (e.g. hitting, shaking, burning, suffocating, poisoning, fabricating or inducing illness).
14
Q
What is emotional abuse?
A
Persistent emotional neglect or ill treatment that has a severe and persistent adverse effect on a child’s emotional development.
15
Q
What is sexual abuse?
A
Any act that involves the child in any activity for the sexual gratification of another person regardless of the child’s consent or assent.
16
Q
What is neglect?
A
Persistent failure to meet a child’s basic physical and/or psychological needs - likely to result in serious impairment of the child’s health or development.
17
Q
Name child-specific factors that make children more vulnerable to physical abuse?
A
- First child in a family.
- Unwanted pregnancy.
- Male.
- Disabled or congenital abnormality.
- <2 years old.
- History of neglect.
18
Q
Name familial factors that make children more vulnerable to physical abuse?
A
- Low socioeconomic status.
- Family insecurity or instability.
- Mental health problems in family.
- Illicit drug abuse.
- History of violence in family.
19
Q
What investigations might be arranged to investigate non-accidental injury?
A
- CT brain.
- Skeletal survey.
- Ophthalmology review to look for retinal haemorrhages.
- Full clotting screen.
20
Q
Who can report concerns to child protection?
A
ANYONE. You do not have to be certain but you are expected to explain why you are concerned.
21
Q
How does a healthcare professional refer suspected abuse to child protection?
A
Usually by phone to the duty social worker and then follow up in writing.
If there is concern the child is in immediate danger, the police should be contacted.
22
Q
If you suspect a child is in immediate danger, what should you do as a healthcare professional?
A
Contact police.
23
Q
As a medical student, if you suspect physical abuse while on placement, what should you do?
A
Speak to supervisor and block supervisor.
24
Q
As a medical student, if you suspect physical abuse while NOT on placement, what should you do?
A
Contact the public child protection line.
25
Which features of bruising would raise suspicion of non-accidental injury?
- Child not yet independently mobile e.g. infants.
- Multiple bruises in one area of similar size and shape (fingertip-gripping, blunt force trauma, crushing).
- Bruises in the shape of a pattern or object.
- Bruising of a soft, non-bony area e.g. abdomen, bum, back, soft parts of arms, thighs.
- Head, ears, neck.
26
Bruising usually occurs as a result of?
- Blunt force impact e.g. a blow.
- Falling.
- Crushing.
- Pinching.
27
What kind of object would cause a tramline bruise?
Blunt, thin linear object e.g. mop handle, hairbrush handle, rod.
28
When does tramline bruising occur?
- When a linear object hits the skin it causes blood vessels either side of the object to stretch, tear and leak blood.
- The vessels underneath the object are compressed and so do not leak.
> Linear bruising with an area of central clearing.
29
How do a burn and a scald differ?
- Burn results from dry heat e.g. fire, iron, radiator.
| - Scald results from wet heat e.g. hot oil, steam, boiling water.
30
Which tends to be more severe, burns or scalds?
Burns.
- Severity of which is measured by depth and extent.
Scalds tend to be less severe and often show blistering.
31
What features of a burn or a scald would raise suspicion of non-accidental injury?
- Child not yet mobile.
- On an area not normally coming into contact with hot objects e.g. dorsum of hands, feet, legs, buttock.
- Shape or patterned e.g. cigarette burns.
- Glove and stocking distribution on limbs or on buttocks, suggesting immersion scald.
32
Differentials for non-accidental injury?
- Bleeding disorders: clotting screen.
33
An abrasion superimposed on a bruise is likely to have been caused by what?
A blow with or a fall onto a blunt object.
34
Which type of rib fractures are especially associated with non-accidental injury?
Posterior rib.
35
What is a skeletal survey?
- Series of x-rays taken in a child with suspected NAI.
- Designed to detect occult fractures.
- Compulsory in suspected NAI of children <2 y/o.
36
What features of a skeletal survey would make you suspicious of NAI?
- Rib fractures (especially posterior).
- Metaphyseal corner fractures (bucket handle fracture - often caused by shaking).
- Skull fracture (especially if non-parietal).
- Any fractures in a non-mobile child.
- Multiple fractures.
- Fractures of different ages / stages of healing.
37
What is cradle cap?
Fungal infection in infants causing itching and scaling of the scalp.
38
When is a CT head indicated in suspected NIA?
Acute presentations if there are signs suggestive of intracranial injury or in infants <1 year old.
39
What is the "classic triad" of symptoms in a shaken child (NAI)?
- Bilateral retinal haemorrhages.
- Subdural haemorrhage.
- Encephalopathy.
40
Signs of non accidental head injury?
- Skull fracture.
- Extradural haemorrhage.
- Confusion and decreased consciousness.
- Bilateral retinal haemorrhages.
- Subdural haemorrhage.
- Encephalopathy.
41
True or false? Short distance accidental falls are commonly associated with skull fracture and intracranial injury.
False.
- Rarely cause skull fracture.
- Even more rarely cause intracranial injury.
42
A fracture occurring as a result of a short distance accidental fall would have what features?
Simple and linear with no depression and confined to one bone.
43
When do abrasions occur?
When the skin is crushed or scraped.
44
What kind of injury would be associated with being dragged along the carpet?
Abrasion - tangential contact with the floor is likely to scrape off parts of the epidermis.
45
How can you tell from an abrasion, in which direction someone was being dragged?
The more severe part of the abrasion suggests this part was leading and the less severe part suggests this part was following - giving us direction.
46
The presence of an abrasion indicates what about the timescale?
It is likely to have occurred recently.
| They are superficial, heal quickly and don't scar
47
What is a crush abrasion?
Abrasions which may leave a pattern depicting the object used.
48
What is a scrape abrasion?
Abrasion leaving skin tags and lines showing the direction of the injury.
49
What features of abrasions would make you suspicious of NAI?
- Presence on a non-mobile child.
- Symmetrical.
- On areas usually covered by clothing e.g. chest, back, axilla.
- On areas unlikely to be hit during play e.g. ears, eyes.
- Around ankles or wrists (e.g. possible ligature marks).
- Patterns or shapes.
50
What is the normal resting heart rate in an infant <1 y/o?
110-160bpm.
51
What is the normal resting heart rate in an infant 1-2 y/o?
100-150bpm.
52
What is the normal resting heart rate in a child 2-5 y/o?
95-140bpm.
53
What is the normal resting heart rate in a child 5-12 y/o?
80-120bpm.
54
What is the normal resting heart rate in a child >12 y/o?
60-100bpm.
55
What is the normal respiratory rate in an infant <1 y/o?
30-40 / min.
56
What is the normal respiratory rate in an infant 1-2 y/o?
25-35 / min.
57
What is the normal respiratory rate in a child 2-5 y/o?
25-30 / min.
58
What is the normal respiratory rate in a child 5-12 y/o?
20-25 / min.
59
What is the normal respiratory rate in a child >12 y/o?
15-20 / min.
60
What is the normal systolic blood pressure (mmHg) in an infant <1 y/o?
70-90 mmHg.
61
What is the normal systolic blood pressure (mmHg) in an infant 1-2 y/o?
80-95 mmHg.
62
What is the normal systolic blood pressure (mmHg) in a child 2-5 y/o?
80-100 mmHg.
63
What is the normal systolic blood pressure (mmHg) in a child 5-12 y/o?
90-110 mmHg.
64
What is the normal systolic blood pressure (mmHg) in a child >12 y/o?
100-120 mmHg.
65
Describe the head of an infant.
- Infants have a relatively large head (in comparison to their body) and a prominent occiput.
- Large surface area compared to volume.
66
What is the blood volume of a child?
80ml/kg.
67
What is foetal haemoglobin (HbF)?
α2γ2 - main oxygen carrying protein in human foetus persisting in circulation until infant is around 2-4months old.
68
Commonest cause of acute illness in children?
Sepsis.
69
Although arrhythmias are rare in children, which is the most common?
Supraventricular tachycardia.
70
Which signs indicate effortful breathing in a child?
- Recession (intercostal).
- High (or low) respiratory rate.
- Accessory muscle use.
- Nasal flare.
- Inspiratory stridor, expiratory wheeze, grunting.
71
How do you assess efficacy of breathing in a child?
- Chest expansion.
- Air entry.
- Oxygen saturations.
72
How do you assess effects of breathing (effort, efficacy, effects)?
- Heart rate.
- Skin colour.
- Mental status.
73
How do you assess circulatory signs of shock?
- Pulse (rate and volume).
- Capillary refill.
- Blood pressure.
HYPOTENSION IS A PRE-TERMINAL SIGN.
74
How do you assess the effects of circulatory inadequacy?
- Respiratory rate.
- Skin temperature / colour.
- Mental status.
75
How do you assess potential central neurological failure?
- Conscious level.
- Pupils.
- Posture (decorticate / decerebrate posturing).
76
What does AVPU stand for?
Alert, Voice, Pain, Unresponsive.
77
What are we assessing in exposure in an acutely ill child?
- Temperature.
- Rash.
- Bruising.
78
What congenital heart defect is associated with trisomy 21?
- ventricular septal defect.
| - atrial septal defect.
79
What congenital heart defect is associated with trisomy 18 (Edwards)?
- VSD.
- Double outlet right ventricle (DORV).
(ventricular septal defect ALWAYS occurs with DORV).
80
What other congenital heart defect always occurs in association with double outlet right ventricle (DORV)?
- Ventricular septal defect.
81
What congenital heart defect is associated with trisomy 13 (Patau)?
- Ventricular septal defect.
| - Double outlet right ventricle.
82
What is double outlet right ventricle (DORV)?
Both the Great Arteries i.e. the aorta and the pulmonary artery originate from the RV (deoxygenated).
83
What congenital heart defect is associated with Turner's syndrome?
Coarctation of the aorta.
84
What congenital heart defect is associated with DiGeorge syndrome?
- Truncus arteriosus.
- Interrupted aortic arch.
- Tetralogy of fallot.
- Ventricular septal defect.
85
What is tetralogy of fallot?
Four congenital abnormalities:
1. VSD.
2. Pulmonary valve stenosis.
3. Misplaced aorta.
4. Right ventricular hypertrophy.
86
Symptoms of cardiac disease in an infant?
- Breathlessness.
- Difficulty feeding or poor weight gain.
- Sweating with feeding.
- Cyanosis.
87
Risk factors for cardiac disease in an infant?
- Prematurity.
| - Other anomalies or a syndrome (e.g. Trisomy 13 / 18 / 21, Turner's, Di George).
88
What is trisomy 13?
Patau
89
What is trisomy 18?
Edwards
90
What is the first heart sound?
Mitral and tricuspid valves.
91
What is the second heart sound?
Aortic and pulmonary valves - typically split.
92
What is acrocynaosis and is it pathological?
Acrocyanosis is blue hands and feet, potentially also perioral blueness.
- Common in young children - NOT a sign of cardiac disease.
93
Describe the cyanosis associated with cyanotic heart disease?
Most cyanotic heart disease makes children blue all the time.
94
Children can be intermittently cyanotic without cyanotic heart disease (e.g. acrocyanosis). Which feature would suggest tetralogy of fallot in addition to intermittent central cyanosis?
- Murmur.
95
What is a grade 1 murmur?
Faint murmur heard with concentration.
96
What is a grade 2 murmur?
Faint murmur heard immediately.
97
What is a grade 3 murmur?
Murmur easily heard immediately.
98
What is a grade 4 murmur?
Murmur loud with palpable thrill.
99
What is a grade 5 murmur?
Loud - heard with stethoscope just touching the chest and likely accompanied by a palpable thrill.
100
What is a grade 6 murmur?
Extremely loud, heard with stethoscope off the chest.
101
What findings would suggest an innocent paediatric murmur?
- Short systolic.
- Asymptomatic.
- Soft i.e. Grade 3/6 or
102
What findings would suggest a pathological paediatric murmur?
- Diastolic or pansystolic murmur.
- Symptomatic.
- Palpable thrill.
- Grade 4/6 or >.
103
Cyanotic types of congenital heart disease?
- Tetralogy of Fallot.
| - Transposition of the Great Arteries.
104
Acyanotic types of congenital heart disease?
- VSD.
- ASD.
- Pulmonary stenosis.
- PDA.
- Aortic stenosis.
- Coarctation of the aorta.
105
The presence of cyanosis is suggestive of which congenital heart diseases?
- Tetralogy of Fallot.
- Transposition of the Great Arteries.
- Pulmonary atresia with intact septum.
106
Describe systemic duct-dependent lesions.
- Severe obstruction of blood out of the left side of the heart.
- Systemic circulation is therefore dependent on the PDA - which must remain open until palliative or curative procedure can be performed.
107
Describe cyanotic duct-dependent lesions.
- Obstruction to pulmonary blood flow OR lack of oxygenation of systemic blood.
- Patient relies on PDA > keep duct open until adequate mixing is secured e.g. atrial septostomy.
108
What is an atrial septal defect?
Oxygenated blood from left atrium shunts via defect into right atrium > enlargement of atria, RV and pulmonary artery.
109
What is a ventricular septal defect?
Oxygenated blood from LV shunts via defect into RV (L>R) > enlargement of ventricles and pulmonary artery.
Also exposes the right ventricle and pulmonary arteries to abnormally high pressure.
110
What are important causes of vomiting to consider in a child?
- Infection e.g. meningitis.
| - Surgical causes e.g. malrotation, pyloric stenosis.
111
What features of vomiting in an infant would suggest a chronic rather than acute cause e.g. infection?
- Present since birth.
112
Features of Gastro-oesophageal reflux in an infant?
- Frequent vomiting associated with discomfort (e.g. whining or uncomfortable during feeds or may draw legs up or arch back or cry).
- Improvement of symptoms when in upright posture.
- Gaining weight normally (if severe there may be poor weight gain).
- No signs of dehydration.
- Milky vomit.
113
What other congenital defect occurs in association with oesophageal atresia (and vice versa)?
Tracheo-oesophageal fistula.
114
Congenital anomalies of the foregut?
- Oesophageal atresia.
- Duodenal atresia.
- Extrahepatic biliary atresia.
- Annular pancreas.
115
Congenital anomalies of the midgut?
- Exomphalos.
- Umbilical hernia.
- Gastroschisis.
- Malrotation.
- Ileal diverticulum (Meckel's diverticulum).
- Stenosis, atresia and duplications.
116
Congenital anomalies of the hindgut?
- Imperforate anus.
- Fistulae: rectum to urethra / bladder / vagina.
- Hirschsprung's disease.
117
Oesophageal atresia and tracheo-oesophageal fistula may be associated with which chromosomal abnormalities?
- Down's syndrome ( Trisomy 21).
- Edward's syndrome (Trisomy 18).
- VACTERL (vertebral, rectal, cardiac, tracheo-oesophageal, renal and limb (especially radial) anomalies - group often presenting together).
118
Which antenatal finding may suggest a diagnosis of oesophageal atresia?
- Polyhydramnios on antenatal ultrasound.
119
What findings in a neonate may suggest oesophageal atresia or tracheo-oesophageal fistula?
- Pooling of saliva in mouth.
| - Choking or dusky episodes (cyanosis) when feeding > milk pours into lung.
120
What finding in a child may suggest tracheo-oesophageal fistula?
- Recurrent chest infections.
| - i.e. isolated (without atresia) narrow "H-type" fistula.
121
How is diagnosis of oesophaeal atresia made postnatally?
- If an NG tube cannot be passed into the stomach.
- No stomach bubble present on CXR in isolated atresia.
- Presence of stomach bubble suggests distal tracheo-oesophageal fistula.
122
How is diagnosis of an isolated tracheo-oesophageal fistula made?
- Contrast swallow radiograph.
123
How is tracheo-oesophageal fistula and oesophageal atresia managed?
- Nil by mouth until reanastomosis surgery (usually within 24h).
- Continuous suction of oropharynx to prevent saliva aspiration.
124
What complications of oesophageal atresia / tracheo-oesophageal fistula commonly occur despite (or because of) management?
- Gastro-oesophageal reflux.
| - Strictures leading to dysphagia (surgical complication).
125
What is the difference between gastroschisis and exomphalos?
Both are defects of the anterior abdominal wall that allow herniation of the bowel.
- Gastroschisis: only intestine herniates, usually to the right of the umbilicus.
- Exomphalos: intestine and or liver may herniate, but is covered by peritoneal membrane.
126
What conditions are associated with gastroschisis?
Rarely associated with:
- Cleft lip and palate.
- Heart defects:
- Intestinal atresia.
127
Conditions associated with exomphalos?
Common (50%):
- Beckman-Weidermann syndrome.
- Trisomy 13, 18, 21.
128
What is Hirschsprung's disease?
Lack of parasympathetic innervation of the distal colon > constant contraction of affected bowel segment.
129
What part of the bowel is always involved in Hirschsprung's disease?
- Internal anal sphincter.
130
What causes Hirschsprung's disease?
Failure of neural cells to migrate to the bowel muscle.
131
Typical Hirschsprung presentation?
- Newborn fails to pass meconium within 48 hours of birth.
- Distended abdomen.
- Vomiting.
132
What findings on PR exam may indicate Hirschsprung's disease?
Withdrawing of finger can result in explosive passage of stool.
133
Volvulus presents with?
- bilious vomiting (especially in neonates).
134
What is malrotation?
Fixed abnormal rotation of the small bowel.
135
How may malrotation present in older children?
Rarely presents as intermittent abdominal pain.
136
Volvulus is a surgical emergency because?
Bowel can become necrotic due to occluded blood supply from mesentery.
137
Hirschsprung's disease is diagnosed by?
- Abdominal radiograph showing distended loops of bowel.
| - Confirmed by a lack of ganglionic nerve cells in rectal biopsy.
138
Hirschsprung's disease is managed by?
- Surgical resection of aganglionic section and anastomosis of colon to anal canal.
(Can be done in one operation or a colostomy can be formed with anastomosis at a later date).
139
The most common form of bowel atresia is?
Duodenal atresia.
140
Duodenal atresia is associated (30% of cases) with which chromosomal abnormality?
Trisomy 21 i.e. Down's syndrome.
141
Symptoms of bowel atresia include?
- Vomiting (bilious if atresia distal to hepatopancreatic duct).
- Failure to pass flatus and faeces.
142
Bowel atresia is confirmed by?
Abdominal radiograph illustrating dilated bowel loops proximal to atresia.
143
This finding on abdominal radiograph is typical of duodenal atresia.
- "Double bubble".
| (Air distends stomach and first part of duodenum proximal to atresia > two bubbles and a lack of air in distal bowel.
144
Biliary atresia is the?
- Rare condition of atresia of the CBDs or hepatic ducts.
| - Bile produced is unable to be secreted into small intestine > inflammation of bile ducts and liver.
145
Biliary atresia typically presents as?
- Prolonged jaundice in the first few weeks after birth (i.e. >14 days in a term infant).
- Pale stools.
- Dark urine.
- Poor weight gain.
146
Bloods taken in investigation of biliary atresia, typically show?
- Conjugated hyperbilirubinaemia (conjugate bilirubin fraction >20% of total).
- Deranged LFTs.
147
Diagnosis of biliary atresia is confirmed by?
Radioisotope scans showing no excretion of radioisotope-labelled bile from the liver.
148
Biliary atresia is managed by?
- Hepatoportoenterostomy (Kasai's procedure).
- This is not curative and many require a liver transplant at a later time.
- Higher success the earlier it is performed.
149
Causes of persistent vomiting in children include?
- Gastro-oesophageal reflux.
- Pyloric stenosis.
- Malrotation and partial obstruction.
- Cow's milk protein allergy,
- UTI.
- Increased ICP.
- Renal failure.
- Renal tubular acidosis.
- Adrenal failure.
150
Physiological reflux occurs in infants because?
- They have an immature lower oesophageal sphincter (allows easy passage of stomach contents into oesophagus).
- Liquid diet until weaned (6 months).
- Most often in the supine position.
151
Groups of children and infants at higher risk of gastro-oesophageal reflux include?
- Premature babies.
| - Children with severe neurodevelopmental problems.
152
Common exacerbating factors in babies with reflux include?
- Overfeeding (particularly if formula fed)
- Lying flat after feeds.
- Large volumes of milk at one time.
153
Treatment options for gastro-oesophageal reflux in babies includes:
- feed thickeners.
- alginate therapy.
- antacids (H2-receptor antagonist or PPI).
154
In children with severe neurodisability and gastro-oeosphageal reflux, surgical management may be considered in the form of?
- fundoplication to prevent aspiraiton.
155
Pyloric stenosis is caused by?
Hypertrophy of pyloric muscle (proximal to hepatopancreatic duct) > prevents emptying of gastric contents by peristalsis.
156
Factors known to increase risk of pyloric stenosis include?
- Caucasians of Northern European descent (uncommon in black, asian or indian descent).
- Male sex (4:1 of boys:girls).
- Unknown cause but thought to have genetic link.
157
Babies with pyloric stenosis tend to present?
- At 3-8 weeks with projectile non-bilious vomiting.
- Hungry and dehydrated.
- Poor weight gain.
158
Clinical signs of dehydration in an infant include?
- Sunken fontanelle.
- Mottled skin.
- Cold hands and feet.
- Sunken eyes.
- Dry mucous membranes.
- Cap refill <2s.
- Tachycardia,
- Lethargy.
159
Examination findings suggestive of pyloric stenosis include?
- Peristaltic waves across abdomen after test-feeding.
| - Small firm lump i.e. "olive" may be felt in epigastric region.
160
Blood tests supporting a diagnosis of pyloric stenosis may show?
- Hypokalaemic hypochloraemic metabolic alkalosis (due to loss of HCl from stomach).
161
A diagnosis of pyloric stenosis is confirmed by?
Abdominal ultrasound.
162
Pyloric stenosis is managed by?
Surgery - Ramstedt's pyloromyotomy (pylorus muscle cut to mucosal layer).
163
Appendicitis is acute inflammation of the appendix caused by?
Obstruction of the appendix lumen by faecoliths.
164
Appendicitis typically presents with?
- Decreased appetitie.
- Central abdominal pain later migrating to right iliac fossa.
- Vomiting.
- Fever.
165
Examination findings in support of a diagnosis of appendicitis include?
- Localised tenderness and guarding over the right iliac fossa.
- Rebound tenderness.
166
Which examination finding would suggest perforation of the appendix?
Generalised rigidity is present in peritonitis secondary to appendix perforation.
