Paediatrics Flashcards
Main things covered in hx?
hild’s age, nature of the problem and observation
HPC for hx?
parent/child accounts; ADLs affected and how parents taken action; why referred and parent worries; to check – general health, normal growth, E+D and behaviour change; wet/dirty nappies
PMH for hx?
maternal obstetric complications; birthweight; perinatal problems (jaundice, fits, fever, bleeding, feeding); immunisations and past illnesses; medication, alcohol, drugs
SH for hx?
family (normal SH that you would take but for family members); child happy at home/school; impact of illness on carers and benefits, same father of kids; siblings; play, eating, sleeping, pets; who looks after child; hopes, fears, expectations of parents for child in hospital
Development covered in paeds overview?
parental concerns, developmental milestones, previous child health surveillance checks, enuresis, child behaviour, sleeping problems, progress at school; use ABCD for consciousness if needed; faltering growth = red flag; plot weight, height and head circumference for infants on chart
How to stage puberty?
Tanner staging
Define low birthweight?
under 2500g, very low = under 1500g and extremely low is under 1000g
What is small for gestational age?
low weight under 10th percentile for age
2 types of IUGR?
symmetrical = fetus affected from early pregnancy; asymmetrical = foetus affected later e.g. pre-eclampsia; most catch up to height/weight in 2 years but adults slightly shorter; coronary HD and obesity
Behavioural problems in kids?
food refusals, overeating (comfort), pica (eating things which aren’t food)
Causes of prematurity?
smoking, poverty, malnutrition, PMH, GU infection, chorioamnionitis, pre-eclampsia, DM, polyhydramnios, closely spaced pregnancies, multiple, uterine, malformations, placenta praevia (placenta covers cervix causing bleeding during pregnancy), abruption, premature membrane rupture
S+Ss mastitis?
tender, hot reddened area of breast with/out fever; can’t breastfeed
Ages for normal pulses?
110-160 <1; 95-150 2-5; 80-120 5-12
Causes of HT in children?
renal parenchymal disease or essential mainly; same treatment as adults but only if symptomatic
Problems from HT crisis and treatment in children?
cerebral oedema, HF, seizures, pulmonary oedema, renal failure; use nifedipine, labetol or sodium nitroprusside
S+Ss HF in children?
poor feeding, sweating, tachypnoea, tachycardia, gallop rhythm, cardio/hepatomegaly
Describing HS in children?
describe timing, duration, loudness, radiation and site of max intensity; 3rd HS is normal
Signs for severely ill children (GRUNTING)?
Grunting, weak/continuous high-pitched cry, tachypnoea; Rib recession, nasal flaring, sternocleidomastoid retraction, stridor; Unequal/unresponsive pupils, hypotonia, focal CN; Not using limbs/lying still, odd posture, decerebrate (arms and legs extended); Temp >38 (6 months) or 39; I have a bad feeling (judgement); Neck rigidity, non-blanching rash, meningism; Green bile in vomit
4 fields considered during normal child development?
gross motor, vision/fine motor, hearing/speech/language and social/emotional/behavioural
Advice for parents with crying babies?
peaks at 6-8 wks and subsides by 4 months; support parents so preventing post-natal blues, reduce their stress (take it in turns); teach that this normal and say techniques to deal (rocking, singing, hungry or tired, hugging); colic (paroxysmal crying with legs up – hunger)
What are the median and limit ages for milestones in development?
- Take into account median age (MA) for each milestone
* Limit ages (LA) – when child should have reached milestone
List main child development milestones in the first 5 years?
o Unsupported walking – 12 months, 18 months (later more likely to be hypermobile)
o Sat up – 6 months
o Crawling – 8-9 months (bottom shufflers later)
o Motor development follows CNS development
o 3-4 word sentences – 2.5-3
o Interactive play – 2.5-3
o Drink from cup – 12 months
o Vision/fine motor >1
o Hearing/speech/language from 18 months
o Social from 2.5
o Respond to name and familiar words – 12 months
o Orthoptist screening age 5
When is developmental correction intervention needed?
• Correction not required til after 2 (cognitive problems appear later than developmental)
Tests for development in child assessment?
Denver developmental screening test; Griffiths and Bailey developmental scales; IQ tests; cultural backgrounds (for cognitive); parents’ evaluation of developmental status; ages and stages questionnaire; Brigance screens II, modified checklist for autism in toddlers
How to assess hearing in newborns?
optoacoustic emission or auditory brainstem response audiometry
What is amblyopia?
cataract interfering with optic pathway development
Define delay with respect to development?
slow acquisition of all skills in a field
Define disorder with respect to development?
maldevelopment of a skill
Define impairment with respect to development?
loss/abnormality of a function
Failure to thrive definition and tests?
poor weight gain in infancy; MSU, coeliac serology, U+E, glucose, LFT, calcium, igs, CRP, TSH, FBC, sweat, urinary aas, stools, CXR, US renal/CNS
Failure to thrive short stature definition and causes?
height <3rd percentile; hypopituitarism, low GH (arginine stimulation test – use somatotrophin to treat)
Causes of tallness?
thyrotoxic, precocious puberty, Marfan’s, homocystinuria
Causes of abnormal heaviness?
snacks, low exercise, hypothyroidism, Cushing’s, Prader-Willi, Bardet-Biedl, Cohen syndrome, polycystic ovary syndrome
Abnormal motor signs in children?
head control, rolling, sitting, walking balance, gait, involuntary movements
Causes of developmental delay in children?
central motor deficit, congenital myopathy, spinal cord lesions, global developmental delay
Define cerebral palsy?
oo Permanent disorder of movement, posture or motor function from non-progressive abnormality in brain development under the age of 2
What is affected in cerebral palsy?
cognition, communication, vision, perception, sensitisation, behaviour, seizure and secondary MSK problems; abnormal posture, feeding difficulties, gait, asymmetrical head function
What are the causes of cerebral palsy?
80% antenatal = CV haemorrhage, structural maldevelopment, TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex); intra-partum = hypoxic-ischaemic brain injury; postnatal = meningitis, head trauma, hypoglycaemia, hydrocephalus, hyperbilirubinaemia
Diagnosis for cerebral palsy?
clinical exam; posture, tone, hand function and gait; infection screen; CT/MRI head; EEG/NCS; TFTs, FBC, U+Es, bone chemistry, blood gases
Spastic changes in cerebral palsy?
UMN damage; unilateral limbs only (facial sparing); 4-12 months = fisting of hand affected, flexed arm, hand function, toe pointing when lifted, extensor posturing, poor head control, low central tone, seizures, microcephaly
Dyskinetic changes in cerebral palsy?
involuntary, uncontrolled, stereotyped movements; more evident with movement/stress; chorea, athetosis (slow writhing movements) and dystonia; intellect can be unimpaired; floppiness; signs from basal ganglia damage; hypoxic-ischaemic encephalopathy (brain damage after hypoxic-ischaemic event, resp depression at birth, low pH
Treatment for dyskinesia in cerebral palsy?
resus, avoid hyperthermia, exclude other causes, treat seizures)
Ataxic changes in cerebral palsy?
genetic; trunk and limb hypotonia, poor balance and delayed motor development
Treatment for ataxia in cerebral palsy?
botox, intrathecal baclofen and DBS (for hypotonia)
Examples of speech and language delay?
hearing loss, global developmental delay, anatomical deficit, environmental deprivation and familial pattern; disorders of expression, comprehension, speech intelligibility, pragmatics and social skills; hearing tests and SALT; symbolic toy test and Reynell test
S+Ss of dyspraxia?
disorder of motor planning; no findings on neuro exam; features like handwriting, dressing, literacy, copying, drawing, messy eating
Types of hearing impairment in children?
sensorineural presents soon after birth and irreversible; microtia (undeveloped external ear) and meatal atresia can be helped with bone conduction hearing aids; conductive hearing loss from middle ear mild-moderate (chronic otitis media); Down’s, cleft palate, atopy prone to middle ear loss
Management of hearing impairment in children?
impedence audiometry tests (pressure in middle ear) determine functioning; long term abx or decongestants; grommets sometimes
S+Ss visual impairment?
ocular malformations; not smiling responsively by 6 weeks, poor visual response, nystagmus, squint
Causes of visual impairment?
retinoblastoma = life threatening; squint = retinal reflexes checked (corneal light reflex test and cover test) and over 3 months refer to ophthalmologists (commonly refractive error but can be retinoblastoma); paralytic = rare, concomitant (common); corneal light reflex test and cover test; hypermetropia = most common refractive error (long-sigthedness); myopia (near-sightedness) in adolescence; astigmatism common; patch good eye to improve bad eye
Sick children treated at home and conservatively?
• Usually mild and can be treated at home; hosp admission rate increased = lower threshold, lack of instant test to rule out serious illness, repeated admission for children with complex illnesses; parents can stay overnight with them; consider psychosocial factors if treated at home
Treatment of general pain in children?
observation and parent input; distractions used and topical anaesthetics; use NO, mild sedatives or hypnotics, opioids and post-op analgesics; nerve-blocks used; IM drug injections should be avoided; aspirin not given under 16 as Reye syndrome (encephalopathy and liver failure); OD high from longer half-life and low renal excretion
Normal resp rate in kids?
30-40 in infants, 25-35 in young children and 20-25 in older children
Normal bp in kids?
80-90 in infants, 85-100 in young children and 90-110 in older children
Exam in those with resp/neuro/circ failure?
look for history, O/E, trauma, rash, smell, scars and medicalert bracelets; more likely to resp/hypoxia than cardiac failure; disinterested and not alert
Treatment for shockable VF/VT?
after 3rd shock give adrenaline and amiodarone
Causes of resp failure?
lungs can’t give good gas exchange; causes = alveolar hypoventilation, v/q ventilation, diffusion impairment and intrapulmonary shunting; less than 92% O2 sats give O2
Treatment for resp failure?
can give CPAP or biphasic positive airways pressure; intubation for = progressive hypoxaemia, reduced consciousness, progressive neuromuscular weakening, tiring
S+Ss resp failure?
tachycardia, resp>50, nasal flaring, accessory muscle use, head retraction cyanosis, unable to feed, tired and sats <92%
Why low fluid in kids and compensated and decompensated shock?
higher BMR means need more fluids; lose from = no oral, fever, diarrhoea, burns, capillary leak; dehydration shock = metabolic acidosis, low BP; compensated shock = tachycardia, tachypnoea, low skin turgor, delayed cap refill, pale and mottled skin; decompensated = acidotic breathing, bradycardia, confusion, blue peripheries, no urine output, hypotension
Treatment for compensated/decompensated shock?
PICU if IV fluids not helping; can have renal support and inotropic support
Problems and treatment for septic shock?
fluid maldistribution with cap leak; may need central venous monitoring and catheterisation; clotting derangements, pulmonary oedema, DIC, myocardial dysfunction, tilt head 20-30 seconds to reduce ICP risk and mannitol, early abx
Risks in babies emergency medicine?
gestation <32 weeks, duration >1 minute, repeat event, CPR, concerning history, abnormal O/E, SIDS = 2-4 months (unexpected cot death;
Tests for babies in emergency care?
obs, ECG, swab for pertussis, sats
Prevention of SIDS?
sleep supine, stop overheating [16-20 degrees in room] and no smoking, use a grow bag so baby can’t move, not too much bedding; baby must have a post-mortem; CONI programme, grief counselling for parents
What is involved in children coma scale?
motor = 6carrying out request, 5localised pain response, 4withdraw to pain, 3flexor pain response, 2extensor posturing to pain, 1no response; verbal = 5orientated, 4crying but consolable, 3inconsistently inconsolable, 2inconsolable crying, 1no response; eye opening = 4spontaneous, 3from speech, 2to pain, 1none
Treatment and management of traumatic accidents?
always try to maintain brain blood supply if head injury and evacuate haemorrhage (otherwise get brain injury); liver and spleen rupture apparent immediately; pneumothorax and haemopericardium from blunt trauma; ECG for electrical burns and do burn size and depth (fluids if >10% body size)
Causes of poisonings?
accidental, iatrogenic, deliberate or intentional
Prevention of poisonings?
child resistant containers, low packet number of analgesia
S+Ss poisoning?
behavioural changes, hyperactivity, developmental delay, chronic lead nephropathy, abdo pain, headache, lethargy, vomiting, seizures
Poisoning treatment?
chelation effective; activated charcoal (not for iron and pesticides); Iv acetylcysteine for paracetamol; Iv desferrioxamine for iron (gives red-orange urine); intubation if low GCS; supportive management; haemodialysis for salicylates; TCAs for sodium bicarb and ventilation; blood glucose and ventilate for alcohol; IV desferoxamine for iron; atropine and pralidoxime for pesticides
Specific antidotes for poisons?
beta-blockers = atropine (bradycardia) with glucagon and sometimes adrenaline/dopamine; CO = high flow O2, mannitol for cerebral oedema; digoxin = atropine, digoxin specific antibody; opioids = IV naxolone; methanol/ethylene glycol = fomepizole; sulfonylureas = octreotide
Child abuse categories?
physical, emotional, sexual, neglect and fabricated illness (suffocate, give poisons, OD); witnessing intimate partner violence and FGM serious
Define neglect?
persistent failure to meet child’s physical and psychological needs
Risks for child neglect?
failure to meet parent’s expectations, born after forced sex, mental health problems, substance misuse, step-parents, domestic violence, closely spaced births, social isolation and poverty, disability
Factors to consider in child protection?
age, hx from child, plausibility of injury, background, injury reporting delay, inappropriate reaction of caregiver
Examples of neglect?
child miss appts, lack of immunisations, dirty, hungry, inadequate clothes, substance misuse, caregiver indifferent to child, child ‘wrong-gender’, partner separation, babies non-demanding, toddlers fearful/violent, school children violent/wetting/antisocial, adolescents self-harm
Sexual abuse examples?
porno, pregnant, STI, vaginal bleeding, itching, discharge, rectal bleeding, sexual acting out, self-harm, aggression, poor school performance; need to exclude other causes; can swab for perp or full radio skeleton under 30 months
Management for abuse?
does child need immediate protection; safety of other siblings; hosp or foster care; social workers
What is trisomy 18?
Edward’s syndrome
Edward’s syndrome S+Ss?
(small and bad heart and kidneys); low birth weight, prominent occiput, small mouth and chin, short sternum, flexed overlapping fingers, cardiac/renal malformations
What is trisomy 13?
Patau syndrome
Patau syndrome S+Ss?
(wrong with head, face, heart and kidneys), structural brain defects, scalp defects, small eyes, cleft palate, polydactyly and cardiac/renal malformations; amniocentesis and chromosomal analysis
S+Ss turner syndrome?
45X; early miscarriage, US foetal oedema; (lots of hormone problems and fluid) lymphoedema of hands and feet, koilonychia, short stature, neck webbing, wide nipples, CHD, delayed puberty, ovarian dysgenesis, hypothyroidism, renal abnormalities, pigmented moles, recurrent otitis media, normal intellect
Treatment of turner syndrome?
growth hormones therapy and oestrogen replacement
Klinefelter syndrome S+Ss?
– (tall and low sexually) infertility, hypogonadism, gynaecomastia, normal puberty, tall stature, normal intelligence; chorionic villus or amniocentesis
AD inheritance diseases?
achondroplasia, familial hypercholesterolaemia, Huntington’s, marfan’s, myotonic dystrophy
AR diseases?
congenital adrenal hyperplasia, CF, Friedreich’s ataxia, glycogen storage disorders, sickle cell (increased by consanguinity – inbreeding)
X-linked diseases?
colour blindness; fragile X; haemophilia; DMD/BMD (only males affected)
Prader-Willi S+Ss?
hypotonia, faltering growth, obesity, learning difficulties and hypogonadism
Nooan syndrome S+Ss?
mild learning difficulties, short webbed neck, pectus excavatum, short stature, congenital heart disease
Williams disease S+Ss?
short stature, congenital heart disease, mild-moderate learning difficulties
Glucocorticoids for neonates?
better lung maturity and surfactant production (better lungs)
Management for preterm labour?
antibiotics, corticosteroids, tocolysis (anti-contractions/labour), magnesium sulfate
Multiple birth problems?
preterm, IUGR (intrauterine growth restriction), congenital abnormalities, twin-twin transfusion
Problems with maternal DM?
more likely for polyhydramnios (too much amniotic fluid in sac) and pre-eclampsia (basically problems with too much fluid – osmosis); risks = macrosomia (large baby), IUGR, congenital abnormalities
Neonatal common problems?
hypos, resp distress, HCM, polycythaemia; foetal thrombocytopenia = risk of intracerebral haemorrhage; epidural can cause maternal pyrexia; oxytocin can cause foetal hypoxia; taxoplasmosis = bad news bears
Mask ventilation overview?
no breath, HR<100 and HR<60 = chest compressions
Non-invasive venitlation (CPAP) definition?
continuous positive airway pressure = air always into lungs to keep airways and alveoli open (no collapse) but can cause pneumothorax, reflux, feed intolerance and nasal trauma; NIPPV (nasal intermittent positive pressure ventilation); HFNC (high flow nasal cannula)
Invasive ventilation overview?
TCPL (time-cycled pressure limited ventilation) continuous heated and humidified gas through endotracheal tube; PTV (patient-triggered ventilation) like TCPL but triggered by a sensor detecting spontaneous breaths; HFV (high frequency ventilation); give sedation before (opiate with muscle relaxant e.g. morphine with suxamethonium); if giving pain relief give up to 50mcg/kg 5
Problems with acidotic infants inhaling meconium?
meconium aspiration syndrome – foetal faeces in bowel [meconium] is passed in utero so amniotic fluid is that colour); preterms prone to hypothermia; airway obstruction, surfactant dysfunction, pulmonary vasoconstriction, infection, chemical pneumonitis
What are Barlow’s and Ortolani’s?
how to check for developmental dysplasia of hip; risks = grils, positive FH, breech presentation, neuromuscular disorder
Examination of newborn?
birthweight, gestational age, head circ, fontanelle (where the skull plates meet), face, eyes (red reflex), palate, breathing, heart, abdo, femoral pulses, genitalia, anus, muscle tone, back, primitive reflexes, hips (everything)
Normal progression in neonates but can be seen as pathological?
neonatal urticaria 2/3 yrs; milia (white pimples on face); ubilical hernia resolves 2/3yrs; port-wine stain normal; strawberry naevus in 1st month
What is hypoxic ischaemic encephalopathy?
significant labour event (failure gas exchange, interruption of umbilical blood flow, inadequate maternal placental perfusion; leading to cardioresp depression then hypoxia/hypercarbia/metabolic acidosis)
Management of hypoxic ischaemic encephalopathy?
may need resp support = treatment of seizures, fluid restriction, hypotension treat, monitor hypos
Worrying signs with newborns?
not pink and crying (antenatal hist and check gestation); check not expanding; HR <60; use ventilation, resus and sometimes adrenaline; suck out meconium if needed
Some minor problems in newborns?
strawberry naevus (increase in size then disappear, bleed and ulcer); milia (pearly white papules from keratin retention in dermis); erythema toxicum (neonatal urticaria); stork mark (capillary dilation over eyelids, head and neck); swollen breasts; sticky eye (blocked tear duct but exclude chlamydia); feeding anxieties (turning blue, adjust feeding technique); red stained nappy (blood from cord/vagina/urinary urates); sneezing to clear amniotic fluid; harlequin colour change (transient, episodic demarcation erythema with contralateral blanching)
Birth injuries?
caput succedaneum (bruising and oedema), cephalhaematoma, chignon (bruising and oedema from ventouse), bruising to face, abrasions to skin, forcep marks; breech problems (brachial nerve palsy, humerus and femur fracture)
S+Ss preterm infant?
resp depression = alveolar collapse from surfactant deficiency; commoner in <28wks boys; S+Ss = tachypnoea (>60), wall recession, expiratory grunting, cyanosis
Treatment for preterm infants?
O2 (SEE PAGE 7 OF PAED NOTES FOR WHAT TYPE OF O2), surfactant therapy, CPAP; apnoea, bradycardia, desaturation treated with caffeine and CPAP
How to close patent ductus arteriosus?
prostaglandin synthetase inhibitor (indomethacin/ibuprofen used)
Fluids for preterm?
60-80l/kg, 150-180l/kg day 5; <35 wks = nasogastric; ill = PIC line; minerals for bone development
S+Ss necrotising enterocolitis?
inflammatory bowel necrosis; signs = feed tolerance, bile stained vomit, abdo distended, blood in stool, shock, tenderness
Risk for necrotising enterocolitis?
Cow’s milk
Treatment for necrotising enterocolitis?
stop oral feeding and broad spectrum abx, resp/circ support; can get bowel perforation, culture faeces
Causes intraventricular haemorrhage?
more in low birthweight and early birth as underdeveloped vessels and stress of birthing
Problems with IVH?
impair CSF drainage (hydrocephalus); ventricular tap used; if dilation happens can get cerebral palsy
Treatment for child retinopathy?
vascular proliferation of retina and laser therapy used and can be from early oxygen exposure
Treatment and causes of bronchopulmonary dysplasia?
damage from pressure from artificial ventilation/oxygen toxicity/infection; O2 requirement after 36 wks
Pathophysiology of jaundice?
half of newborns from release of Hb from RBCs
Kernicterus causes?
encephalopathy from deposition unconjugated in basal ganglia and brainstem nuclei
S+Ss kernicterus?
athetoid movements (slow, involuntary, writhing), deafness, and low IQ if not treated; lethargy, poor feeding; can develop choreoatheoid cerebral palsy, learning difficulties, sensorineural deafness
Causes of haemolysis?
jaundice in 24 hours (abnormal = ABO compatibility – coomb’s test, rhesus haemolytic disease, red cell anomalies); congenital infection can cause, breastfed, dehydration, UTI, hypothyroidism, biliary atresia, neonatal hepatitis syndrome, galactosaemia (prolonged jaundice), hypterbilirubinaemia (higher bilirubin from low RBC lifespan, decreased conjugation from hepatic immaturity, breastfeeding, no gut flora to remove bile pigment); bruising and polycythaemia exacerbate
Treatment of jaundice in children?
phototherapy (UV converts bilirubin to excretable products – eye damage, loss of fluids and diarrhoea), exchange transfusion (must be heated)
Causes of resp distress in neonates?
transient tachypnoea (most common), infection, mechanical obstruction, chemical pneumonitis (meconium), pneumothorax (vigorous resus/ventilation), diaphragmatic herniation (bowel sounds in one hemithorax), premature, low weight, low surfactant (leads to atelectasis)
Complications of resp distress?
hypoxia leading to renal failure, low CO, hypotension and acidosis
Treatment of resp distress?
CPAP, high flow nasal cannula, mechanical vent., circ support, caffeine and corticosteroids (beclomethasone) in mother as increases surfactant for preterm baby and inositol promotes surfactant maturation, delay cord clamping to increase blood to baby, sats 85-93% aim; if deterioration check DOPE (Displaced ET tube, Obstruction, Pneumothorax, Equipment failure)
Causes and treatment of pneumonia?
rupture of membranes, chorioamnionitis, low weight; broad spectrum abx
Causes of persistent pulmonary hypertension?
birth asphyxia, meconium aspiration, septicaemia, RDS; cyanosed
What is bronchopulmonary dysplasia?
persistent hypoxia with difficult ventilator weaning; treat same as resp distress
What is retinopathy of prematurity?
abnormal fibrovascular proliferation/retinal vessels = retinal detachment/visual loss
Causes of retinopathy of prematurity?
premature, low weight, supplement O2
Treatment of retinopathy of prematurity?
Diode laser therapy
Causes of sepsis?
bacteria from birth canal into amniotic fluid
S+Ss sepsis?
pneumonia and secondary bacteraemia; resp distress and temp instability
Investigations and treatment of sepsis?
sepsis screen (supportive, bloods, cultures, CXR, LP); treat with benzylpenicillin, amoxicillin and gentamicin; late onset usually staph epidermis and give flucloxacillin and gentamicin; resistance = vancomycin; group B strep, risk are same as pneumonia and give prophylactic abx
Listeria causes and S+Ss?
rare but from unpasteurised milk, soft cheese and undercooked poultry; flu-like, bacteraemia, widespread rash, meconium stained liquor
Treatment for conjunctivitis?
clean with saline; neomycin to treat redness; discharge can lead to gonococcal infection; stop before vision loss; chlamydia with purulent discharge and eye swelling and use erythromycin
S+Ss herpes simplex?
4 wks with local herpetic lesions and encephalitis; acyclovir for systemic
S+Ss hypoglycaemia?
irritability, apnoea, lethargy, drowsiness, seizures (like adult);
Prevention and treatment of hypos?
early milk and regular feeding prevent; glucose>2.6 IV needed and if not work then glucagon
What is a cleft lip?
no fusion frontonasal and maxillary processes
What is a cleft palate?
palatine processes and nasal septum
Repair of cleft palate/lip?
3 months; feeding tricky, secretory otitis media common
What is Pierre Robin and treatment?
micrognathia, posterior displacement of tongue and midline cleft of soft palate; mother to quit smoking and take folic acid
S+Ss small bowel obstruction?
persistent vomiting (bile stained); meconium passed; abdo distension if more distal
Causes of small bowel obstruction?
from duodenal atresia, congenital malformations, volvulus, meconium ileus
Treatment of small bowel obstruction?
Surgery
What happens in Hirschsprung’s?
absence of ganglion cells on myenteric and submucosal plexuses in large bowel, narrowed segment; explosive faeces and wind; use rectal suction biopsy of aganglionic bit
Treatment for large bowel obstruction?
nasogastric tube passed and aspirated; IV fluids
What is examphalos?
abdo contents through umbilical ring
What is gastroschisis?
bowel through defect in anterior abdo wall
What are the 4 phases of growth?
foetal, infantile, childhood and pubertal growth spurt
What is the foetal growth phase?
size of mother and placental nutrient supply; severe IUGR = permanent short stature
What is the infantile growth phase?
18 months from nutrition, thyroid and good health; 15% of final height
What is the childhood phase of growth?
slow and steady; pituitary GH dependent (IGF-1 at epiphyses); can be decreased by chronic unhappiness; testosterone and oestradiol increase; measure = height, weight, head circ, BMI
Overview of puberty for women?
breast development (8.5-12.5yrs), pubic hair growth, menarche (2.5 yrs after puberty start)
Overview of male puberty?
testicular enlargement, pubic hair growth, rapid height
Overview of join male and female puberty changes?
acne, axillary hair, BO, mood changes; measure bone age and pelvic US if early/late
Definition of short stature?
height below 2nd centile; should be a year apart (measuring velocity = growth failure indicator)
What is the height centile?
mean of mother and father’s height +7 for boys and -7 for girls
What is constitutional delay?
variation of normal growth but still end up the same; GH treatment if insufficient growth by 4yrs
Causes of short stature?
low nutrition; coeliacs, crohns, CKD, CF and CHD; physical and emotional deprivation; hypothyroidism, GH deficiency, IGF1 deficiency, steroid excess, Cushings; GH low from primary or secondary to pituitary dysfunction (craniopharyngioma, hypothalamic tumour, head injury, meningitis)
How to identify short stature?
sitting height, subischial leg length (sitting-normal height), limited radiographic skeletal survey
Definition of micro and macrocephaly?
microcephaly = below 2nd centile, macro = above 98th centile
Causes of high ICP?
hydrocephalus, meningoencephalitis, head injury, sub/extradural bleeds, hypoxia, ketoacidosis, tumours, thrombosis
Other problems with the head in neonates?
), subdural haematoma, tumour; plagiocephaly (parallelogram head) is from babies on back and hypotonia; premature fusion of sutures = head distortion
Definition of premature sexual development?
<8yrs for girls and <9 for boys is abnormal
S+Ss premature sexual development?
precocious puberty, thelarche (breasts – between 6 months and 2yrs), pubarche, isolated premature menarche; gonadotrophin independent = excess androgens or adrenal tumours; gonadotrophin dependent = pituitary adenoma; GDPP common in girls; teste enlargement = GDPP but if only one bigger then gonadal tumour; prepubertal testes = independent
Causes of premature pubertal development?
hypothalamic hamartoma, LH receptor gene mutations, sporadic, familial male gonadotrophin-independent precocious puberty
Hx of premature sexual development?
polyuria, polydipsia, obesity, sleep, temp, high ICP, visual disturbance
Treatment of premature sexual development?
reduce rate of skeletal maturation, address psych and behavioural concerns and sometimes GnRH analogues to suppress by -ve feedback; can use inhibitors of androgens/oestrogen sometimes for independent (sometimes spironolactone)
o Differentiate adrenal hyperplasia from pubarche by urinary steroid profile, levels of blood androgens and bone age – more likely to have polycystic ovary syndrome
Treatment of delayed puberty in men?
oral oxandrolone used or IV testosterone in older boys
When need most nutrition?
1st 6 months
Why is breastfeeding good?
protective against necrotising enterocolitis and DM2 and breast/ovarian cancer for mum
Recommended intake for water, energy, protein, carbs?
• Water = 180mL/kg/day; energy = 130kal/day; protein = 2.5-3.1g/100kcal; 4.7-9g/kg; carbs = 7-14g/100kcal
Dehydration treatment?
dioralyte, IV fluids if needed using the calc (moderate to severe), use intraosseous route; pre-existing deficit = %dehydration x kg x 10
Dehydration S+Ss?
mild = 5%, moderate 10 and severe >10; weight loss, less skin turgor, tenting, shock, hypotension, high pulse, low cap refill, lethargy; careful of sudden changes in sodium levels
What is intraosseus transfusion for?
venous access (cv arrest, severe burns, prolonged status epilepticus, hypovolaemia, septic shock)
When no to use intraosseus transfusion?
don’t use for brittle bones (osteogenesis imperfecta, osteoporosis, infection, fracture at sight); goes into BM
Timeline for food in babies?
• COLOSTRUM – 1st few days of milk and more Igs; cow’s milk after 12 months and full fat until 5yrs; solid foods from 6 months
Hx for weight of babies?
week 1, 8, 12, 16 and 1 year; to ask = history of milk feeding, age of weaning, range of food, mealtime routine, 3-day food diary, weight centiles to assess weight faltering
At risk to malnutrition?
o Long-term illness most at risk; anorexia, malabsorption, increased energy requirements
Tests for malnutrition?
asked to keep 7 day food diary; nutritional assessment = anthropometry (physical proportions), labs (albumin and V+M), immunodeficiency
When to give enteral feeding?
when GI tract works; give continuously overnight
What is parenteral feeding?
all basic energy and vitamins given as solution
What to give parenteral feeding for?
for short bowel syndrome, enteropathies, motility disorder
Marasmus S+Ss?
(lack of calories – more than 3 standard deviations below weight-height ratio) = child wasted, withdrawn and apathetic
Kwashiorkor S+Ss?
(recurrent infection – low protein and aas) = generalised oedema and wasting, can develop acute infection like measles/gastroenteritis
General severe protein-calorie malnutrition?
flaky skin rash, abdo distension, angular stomatitis, sparse hair, diarrhoea, low plasma, glucose and electrolytes; often from breast milk before 12 months
Treatment of severe malnutrition?
stop hypos, hypothermia, dehydration; correct electrolytes; treat infection; micronutrient support and initiate feeds; sensory stimulation and emotional support
Problems with vit D deficiency?
rickets, osteomalacia, hypocalcaemia
Rickets and osteomalacia S+Ss?
both problems in mineralisation but rickets growing and the other one grown, when triggers hyperparathyroidism to normalise serum calcium but brittle bones; phosphate excreted and low serum so less absorption of calcium into bones
Hypocalcaemia S+Ss?
seizures, neuromuscular irritability, apnoea and cardiomyopathy); <2yrs more common and adolescence
Risks to increase vit D deficiency?
intestinal malabsorption, northern, dark skin, strict diets and prolonged PN
Diagnosis and S+Ss rickets?
in wrists, occipital/parietal bones, ankles, horizontal depression of chest, legs bowed; diagnose = diet hist, bloods, x-ray of wrist
Treatment of rickets?
D3 and correct other factors
Problems associated with obesity?
changes in bones, hypoventilation syndrome, NAFLD, gallbladder disease, DM2, HT, abnormal blood lipids and psych problems
Causes of obesity?
diet, exercise, low sleep = low leptin and high ghrelin, socioeconomic, meds; BMI>91st centile and obese >98th; <3yrs = genetics
Management of obesity?
change lifestyle (diet and exercise); change fam perceptions, orlistat (causes steatorrhoea)
Causes of childhood caries?
poor diet and oral health; psychosocial factors; streptococcus mutans and sobrinus
Prevention of childhood caries?
mouthwash, avoid sharing utensils, oral health edu, drink from own cup, wean from bottle 12-14 months, daily brushing, fluoridated water
What is posseting?
small amounts of milk with air brought up (not quite regurgitation and this isn’t quite as strong as vomiting which is forceful ejection of gastric contents); usually benign and sometimes mild GORD
Causes of vomiting?
bilous/prolonged/systemically unwell/faltering growth = RTI/UTI, pyloric stenosis, intestinal obstruction
S+Ss GORD?
regurg, distress after feeds, apnoea, pneumonia, failure to thrive, anaemia; inappropriate relaxation of LOS (fluid, diet, horizontal posture, short intraabdo length); most resolves in 12 months; common in cerebral palsy, preterm, surgery for oesophageal atresia (polyhydramnios, small stomach, cough, airway obstruction, lots of secretions, blowing bubbles, distended abdo, cyanosis, aspiration, can’t pass catheter to stomach)
Investigations of GORD?
24 hour oesophageal pH monitoring, impedance monitoring and endoscopy (biopsies)
Treatment of GORD?
thickening agents and smaller, frequent feeds; severe = H2 antagonists and PPIs then surgery; alginates
S+Ss pyloric stenosis?
vomiting after feeds (no bile and large volume) and hunger after it, dehydration and weight loss, no diarrhoea; hypo (K+, Na+ and Cl-)
Diagnosis of pyloric stenosis?
test feed, pyloric mass RUQ, US
Treatment of pyloric stenosis?
IV fluids, pyloromyotomy
Causes of abdo distension?
air = faecal impaction, air swallowing, malabsorption; ascites = nephrosis, hypoprotinaemia, cirrhosis; solid masses = wilms tumour, neuroblastoma, adrenal tumour; cysts = polycystic kidneys, hepatic, dermoid, pancreatic
S+Ss colic?
paroxysmal; inconsolable crying, drawing up knees, lots of flatus
Causes of colic?
if severe could be cow’s milk allergy; acute = appendicitis
Tests for colic?
o Check – testes, hernial orifices, hip joints, lower lobe pneumonia, DKA, UTI and pancreas
S+Ss acute appendicitis?
anorexia, vomiting, abdo pain, fever, pain from movement, guarding at McBurney’s point; faecoliths in schoolchildren; perforations high in <5yrs
Treatment of acute appendicitis?
fluid resus and abx; symptoms progress = surgery
What is intussusception?
invagination of proximal bowel into distal; usually ileum into caecum through valve; most common cause of kid GI obstruction; 3 months-2 yrs
Complications of acute appendicitis?
stretching and constricting mesentery; venous obstruction, bowel bleeding, perforation, peritonitis, gut necrosis
S+Ss appendicits?
paroxysmal colicky pain, pallor, refuse feeds, vomiting, sausage shaped mass, red jelly stool, abdo distension; abdo US and Xray
Treatment of intussusception?
IV fluids; rectal air insufflation; surgery for rest
Complications from intussuception?
could be volvulus or diverticulitis or Meckels diverticulum; green vomit need to check upper GI for malrotation
Definition of recurrent abdo pain?
interrupts ADLs and 3 months+
S+Ss recurrent abdo pain?
periumbilical; constipation = most common; others = anxiety, anal fissures, growth, GI/UTI infection (urine microscopy and culture), coeliac/crohns, thyroid, IBS (non-specific bloating, feeling of incomplete defecation, epigastric pain), abdo migraine (abdo and head pain – use triptans), duodenal/peptic ulcers (PPIs/abx for H.Pylori)
What is eosinophilic oesophagitis and treatment?
inflammatory from eosinophil activation in mucosa; atopy; use oral corticosteroids
Causes of gastroenteritis?
mainly rotavirus, others = noro, astro and adenovirus; also campylobacter jejuni (severe abdo pain), shigella (blood and pus in stool with tenesumus), cholera and e.coli (severe diarrhoea – dehydration), protozoan with giardia or cryptosporidium; normal diet after this can cause watery stool
Risks of dehydration?
<6 months with low weight, >6 stools in 24 hours, >3 vomits in 24 hours, malnutrition, can’t tolerate fluids
S+Ss hyponatraemia?
seizures
S+Ss hypernatraemia?
jittery movements, increased tone, altered consciousness, seizure, small multiple haemorrhages
o Diarrhoea in developing countries could be low zinc
o Prevent with good hygiene and education
Causes of diarrhoea?
secretory = low absorption or high secretion (watery); osmotic = watery, acidic and +ve for reducing substances; motility disorders, increased = thyrotoxicosis, decreased = intussusception; inflammatory = bloody stool
What is gastroschisis?
paraumbilical defect with evisceration (viscera extrudes) of abdo contents; find with US
Treatment of gastroschisis?
cover exposed bowel with clingfilm and keep baby warm and hydrated at birth; surgery; may take a while for GI function to resume (few weeks)
What is exampholos/omphalocele?
ventral defects of umbilical ring with abdo viscera herniation; small might only have meckel’s diverticulum but larger = stomach, liver, bladder
Treatment of exampholos/omphalocele?
protect, keep hydrated, keep warm, gastric decompression, prevent sepsis, keep CV healthy, surgical closure
S+Ss and causes of malabsorption?
abnormal stools, poor weight gain, specific nutrient deficiencies; usually 8-24 months; other signs = faltering growth, abdo distension, buttock wasting, abnormal stools, general irritability; could be coeliacs (6 weeks plus serology and endoscope with villous atrophy – enteropathy from gluten), short bowel syndrome
S+Ss persistent loose stools?
chronic non-specific diarrhoea, IBD, Crohn’s (looks like anorexia)
Diagnosis persistent loose stools?
raised inflammatory, iron deficiency anaemia, low serum albumin, endoscope
Treatment of persistent loose stools?
diet, steroids, immunosuppressants (azathioprine, mercaptopurine), anti-TNF, surgery if complications
S+Ss UC?
rectal bleeding, diarrhoea, colicky pain, weight loss, growth failure; colonoscopy diagnosis
Treatment UC?
mesalazine (mild), steroids, immunomodulation and infliximab/ciclosporin (resistant disease); 10 years colonoscopy after diagnosis
S+Ss constipation?
<3 stools per week, large and hard, rabbit droppins, distress/strain/bleeding, abdo pain, masses, overflow soiling, megarectum, anorexia
Causes of constipation?
hirschsprung’s (can’t pass meconium in 1st 24 hours, intestinal obstruction, chronic constipation, abdo distension, growth failure), coeliac, hypercalcaemia, anorectal abnormalities, hypothyroidism, diet, poor fluid, fibre intake
Treatment of constipation?
stool softeners (polyethene glycol, electrolytes), stimulant laxatives (senna), osmotic laxatives (lactulose), rehydrate with movicol; sometimes enemas
Causes of allergies?
• 40% have allergic rhinitis/asthma/eczema, 6% have food allergy; IgE (early phase and late phase response – more severe) or non-IgE mediated (delayed onset and varying clinical course); eczema and food usually in infancy and rest at primary school age
S+Ss allergies?
mainly resp) mouth breathing, allergic salute (rubbing itchy nose), pale/swollen inferior nasal turbinates, hyperinflated chest, atopic eczema on limb flexures, allergic conjunctivitis; growth checked
Causes of food allergies?
usually IgE; normally react on 1st exposure; milk, peanuts, eggs (can resolve); older = nuts and fish
IgE mediated allergies S+Ss?
urticaria, facial swelling, anaphylaxis (classic allergy reaction); skin prick test and IgE levels
Non-IgE mediated allergies S+Ss?
diarrhoea, vomiting, abdo pain, faltering growth (more like gastro problem), blood in stools in first weeks of life; intestinal biopsy and endoscopy; double-blind placebo-controlled food challenge
Management of allergies?
avoidance, training and education, non-sedating antihistamines, epinephrine for severe
Treatment of anaphylaxis?
resus; pt on back with legs raised/in position of comfort; ABCDE (e = exposure of skin); adrenaline; repeat with high flow O2 and crystalloid; salbutamol for bronchoconstriction; may have to give epi pen afterwards and always record
Causes of eczema?
atopic or non-atopic; impairment of skin barrier function; 40% in infants have IgE food allergy; skin test
Causes allergic rhinitis?
atopic or non-atopic; intermittent, persistent or mild; can be seasonal; post-nasal drip, chronically blocked nose
S+Ss rhinoconjunctivitis?
urticaria can lead to angioedema, anaphylaxis
Treatment rhinoconjunctivitis?
non-sedating antihistamines or omalizumab; topical corticosteroid nasal/eye preparations, cromoglycate eye drops, leukotriene receptor antagonists, nasal decongestants, allergen immunotherapy
Tests for child with temp >37.5 degrees?
4 weeks = axilla thermometer and after this tympanic; septic screen (blood culture, FBC/WBC, CRP and urine [UTI], blood gas, glucose) and broad spectrum abx (unless cause found); CSF = CXR, LP, rapid antigen screen, meningococcal/pneumococcal/virus PCR
Risks to increase chance of febrile child?
= ill fam, illness in community, low immunisations, recent travel, animal contact and immunodeficiency, prolonged membrane rupture, maternal carrier of group B strep, preterm labour, fetal distress, breaks in skin/mucosa, chorioamnionitis, central lines and catheters
Red flags for febrile child?
fever >38, pale/cyanosed, reduced GCS, neck stiffness, neuro signs, resp distress, bile-stained vomit and severe dehydration
Treatment for febrile child?
PN abx (broad spectrum until blood cultures confirm e.g. benzylpenicillin and gentamicin) for seriously unwell (cefotaxime), ampicillin for <1 month for listeria and antipyretics
S+Ss bacterial meningitis?
mainly <16; can have neuro impairment from it, irritable, abnormal cry, lethargy, difficulty feeding; cerebral oedema, raised ICP, decreased cerebral blood flow, fibrin deposits lower CSF absorption (hydrocephalus); meningeal signs (after septic = high temp, cold peripheries, limb/join pain, odd behaviour, skin colour change, rash) = Brudzinski and Kernig signs; LP contraindicated if cardioresp instability, raised ICP and focal neuro signs
S+Ss high ICP?
listless, irritable, drowsy, headache, diplopia, vomiting, tense fontanelle, low GCA (pupil changes, abnormal posturing), cushing’s triad (imminent coning – slow pulse, high bp, breathing abnormal)
Management of high ICP?
ABC, tilt head elevated 25 degrees, treat symptoms (seizures and high temp with O2), intubate, mannitol, dexamethasone, fluid restriction, send to neurosurgery
Types of abx used for serious infections?
Cephalosporins
Investigations bacterial meningitis?
cloudy CSF with polymorphs, increased protein and decreased glucose (TB same but lymphocytes instead of polymorphs)
Organisms causing bacterial meningitis?
Neisseria meningitis, H influenzae, strep pneumoniae, E coli, group B haemolytic strep, listeria monocytogenes, TB
Causes of viral meningitis?
mumps, echo, herpes, polio
Tests for viral meningitis?
clear CSF, lymphocytes and normal protein/glucose
Cerebral complications from meningitis?
hearing impairment, local vasculitis, subdural effusion, hydrocephalus, cerebral abscess; prophylaxis for fam = rifampicin/ciprofloxacin
Treatment for meningitis?
ceftriaxone
What is encephalitis?
direct invasion of brain by neurotoxic virus (HSV – herpes is most treatable - and enteroviruses), delayed brain swelling, slow virus infection, delayed brain swelling after dysregulated neuroimmunological response
S+Ss encephalitis?
fever, altered consciousness, seizures
Treatment of encephalitis?
HSV give acyclovir; EEG and CT/MRI
Causes of toxic shock syndrome?
S.aureus and group A strep
S+Ss toxic shock syndrome?
= fever >39, hypotension, diffuse erythematous rash, organ dysfunction and impaired consciousness
Treatment of toxic shock syndrome?
intensive care, IV ceftriaxone/clindamycin and IV ig
Treatment for meningococcal infection?
usually full recovery, early penicillin and inotropes may be needed, rifampicin prophylaxis for contacts; septicaemia = purpura rash
What can S.pneumoniae cause?
pharyngitis, otitis media, conjunctivitis, sinusitis and meningitis (basically all neck/face swellings)
S+Ss impetigo?
localised, highly contagious skin infection, staph/strep, common in eczema, lesions on face/hands (honey-crusted)
Treatment of impetigo?
topical abx in mild and flucloxacillin in severe
What is a boil?
staph aureus infection of hair follicles/sweat glands
Treatment of boils?
systemic abx and excision
S+Ss periorbital cellulitis?
fever, erythema, tenderness and oedema of eyelid
Abx for periorbital cellulitis?
ceftriaxone
S+Ss orbital cellulitis?
proptosis, reduced visual acuity, painful ocular movement
What is staphylococcal scalded skin syndrome?
separation of epidermal skin; fever, malaise, localised infection (eyes, nose, mouth)
Treatment of staphylococcal scalded skin syndrome?
manage with IV flucloxacillin, analgesia and fluid balance
Types of HSV?
type 1 = skin and lip lesions, 2 = genitals
Complications of HSV?
blepharitis (eyelid) or conjunctivitis, pneumonia and disseminated infection in immunocompromised; eczema herpeticum (widespread lesions on eczema, can get herpetic whitlows)
Treatment of HSV?
acyclovir
S+Ss roseola infantum?
gives high temp, maculopapular rash, uvulo-palatoglossal ulcers
S+Ss gingivostomatitis?
10m-3y with vesicular lesions on lips and gums, tongue and hard palate; ulceration and bleeding (painful E+D), dehydration
S+Ss varicella zoster?
; lesions on head and trunk to peripheries; infect = 4 days before rash then all lesions scabbed, droplet spread; spots blackish/blueish/coalescing then ITU and no ibuprofen
Complications varicella zoster?
= staph infection, encephalitis, purpura fulminans
Treatment serious varicella zoster?
; IV acyclovir for serious and immunocompromised with antivaricella-zost igs; use calamine lotion to soothe; shingles/herpes zoster uncommon but usually after 1st year
Complications in baby with mother with herpes zoster?
microcephaly, severe chicken pox, convulsions, cerebral hypoplasia etc
S+Ss EBV?
oral spread; older = fever, malaise, tonsillitis, lymphadenopathy, petechiae on soft palate, splenomegaly, maculopapular rash, jaundice
Diagnosis EBV?
atypical lymphocytes, positive monospot test or seroconversion
CMV mode of transition?
saliva, genital secretions, breastmilk
CMV immunocompromised S+Ss?
retinitis, pneumonitis, bone marrow failure, encephalitis, hepatitis, oesophagitis, enterocolitis; high fever and malaise for few days then generalised macular rash
Treatment for CMV?
ganciclovir
S+Ss human parvovirus B19?
slapped cheek syndrome and in spring; respiratory secretions transmission; asymptomatic or fever, malaise, headache and myalgia; aplastic crisis in chronic haemolytic anaemia; sometimes hydrops fetalis
S+Ss enteroviruses?
loose stools, vomiting, rash non-blanching then ceftriaxone unless sepsis excluded; can cause myocarditis/pericarditis
Mode of admission for enteroviruses?
faecal-oral or resp droplets
What is herpangina?
painful lesions causing tricky swallowing and fever
What is pleurodynia?
fever, pleuritic chest pain, muscle tenderness
S+Ss measles?
(7-12 days incubation) = fever, runny nose (coryza), cough, conjunctivitis, marked malaise, Koplik spots and maculopapular rash
Complications of measles?
otitis media, encephalitis and subacute sclerosing panencephalitis (7-13yrs after = behaviour changes, myoclonus, choreoatheotosis, dystonia, dementia, coma)
Treatment of measles?
isolation, supportive and ribavirin in immunocompromised
S+Ss mumps?
; incubation 15-24 days; fever (stops after 3-4 days), malaise
Parotitis S+Ss?
(infective 7 days before and 9 days after), E+D difficult; plasma amylase high and orchitis common
Rubella S+Ss?
mild illness, low grade fever, maculopapular rash on face (fades 3-5 days – infective 5 days before and after rash), suboccipital lymphadenopathy; incubation 15-20 days; resp route; diagnosis serology
S+Ss and overview kawasaki?
systemic vasculitis (coronary artery aneurysm), Japanese mainly; high inflammatory markers and platelets rise in 2nd week; conjunctivitis, red mucous membranes, cervical lymphadenopathy, red palms, eyes and soles, lips and peeling of skin later, high fever
Treatment kawasaki?
IV ig to lower aneurysm risk, aspirin or warfarin; inflammation and fever use corticosteroids, infliximab or ciclosporin
Tests for HIV in babies?
> 18 months = ab test but <18 month = DNA PCR as get mother’s IgGs from breast milk so false positives
S+Ss HIV in kids?
mild = lymphadenopathy, parotid enlargement; moderate = recurrent bacterial infections, candidiasis, diarrhoea, thrombocytopenia, hepatospleomegaly; lymphocytic interstitial pneumonia
Treatment of HIV?
HAART (antiretroviral therapy) but before this use PENTA, HIV viral load, CD4 count, prophylaxis of PCP with cotrimoxazole, vaccines, weight/development/clinical monitoring
Factors reducing maternal transmission of HIV?
ART in pregnancy, PEP after birth, no breastfeeding, C-section
S+Ss lyme disease?
= erythema migrans and expanding lesion (bullseye), fever, headache, malaise, myalgia, arthralgia, lymphadenopathy; dissemination = rare (2+ colonised sites) but can cause CN palsies, meningitis, arthritis, carditis
Treatment of lyme disease?
> 12 use doxycycline and amoxicillin
S+Ss URTI?
difficulty feeding, febrile seizures, acute asthma exacerbations, nasal discharge and blockage
Common URTIs?
rhinovirus, coronavirus, resp syncytical virus, group A beta-haemolytic, enterovirus, adenovirus
Treatment URTIs?
paracetamol/ibuprofen
What is pharyngitis?
pharynx and soft palate with lymphadenopathy
What is tonsillitis?
pharyngitis with exudate and intense inflammation
S+Ss tonsillitis?
headache, abdo pain, white exudate, cervical lymphadenopathy (bacterial)
Treatment tonsillitis?
10 day course abx
S+Ss scarlet fever?
group a strep, 5-12 yrs, fever before tonsillitis, headache, sandpaper maculopapular rash
Causes of acute otitis media?
RSV, rhinovirus, pneumococcus, H.influenzae, Moraxella catarrhalis
S+Ss acute otitis media?
bright red and bulging on otoscope; decreased hearing, eardum dull and retracted, fluid; conductive hearing loss
Treatment otitis media?
anaesthesia with P+I
Causes of stridor?
most common from laryngeal and tracheal infection (mainly viral croup and sometimes parainfluenza), foreign body, bacterial tracheitis, epiglottitis
Severity of stridor assessed?
stridor character and degree of chest retraction also cyanosis and ABCD
S+Ss complete resp obstruction?
central cyanosis, drooling, reduced consciousness
Causes of acute stridor with no infection?
anaphylaxis/foreign body; if nothing works then think bacterial tracheitis (mucosal sloughing that can’t be cleared and exudate)
S+Ss croup?
6 months-6 yrs; autumn; coryza (catarrh) and fever then hoarseness, barking cough, harsh stridor, worse at night, subglottic oedema, inflammation ad exudate
Treatment of croup?
oral dexamethasone/prednisolone and severe = nebulised adrenaline and O2
S+Ss epiglottitis?
intense swelling with septicaemia; emergency; from Hib; 1-6yrs; high fever, ill, painful throat, soft inspiratory stridor, resp difficulty, sitting immobile
Treatment epiglottitis?
don’t lie down/spatula in throat; intubate, blood culture, IV abx (cefuroxime) 3-5 days, rifampicin for fam, may need tracheostomy if occluded too much
S+Ss diphtheria?
usually starts with tonsillitis and sometimes membrane over fauces (back of mouth leading to pharynx); can get polyneuritis mainly with CNs, shock from myocarditis, toxaemia or cardiac conduction system involvement; other signs = dysphagia, muffled voice, bronchopneumonia, brassy cough then airway obstruction
Diagnosis diphtheria?
swab culture of below pseudomembrane
Treatment diphtheria?
diphtheria antitoxin and erythromycin for 7 days
Causes of wheeze?
mucosal inflammation, swelling and mechanical obstruction
S+Ss bronchiolitis?
1-9months – LRTI, coryza, cough, fever, tachypnoea, wheeze, inspiratory crackles, apnoea sometimes cyanosis
What is RSV?
respiratory syncytial virus
Wheeze S+Ss?
coryzal, dry wheezy cough, SOB, feeding tricky, recurrent apnoea (serious in young), tachypnoea/cardia, chest hyperinflation, sub/intercostal recession, fine end inspiratory crackles, high-pitched wheezes
Treatments wheeze?
O2 sats and CXR; give steroids and nebulised adrenaline and only ribavirin for immunocompromised
When to refer to a specialist with wheeze?
apnoea, <90% sats, low fluid intake, severe resp distress; give humidified O2, NG/IV fluids, CPAP and MV sometimes, reduce infectivity; most recover in 2 wks, RSV v infective, permanent damage sometimes in adenovirus
S+Ss viral wheezing?
episodic wheezing, multiple trigger wheeze and asthma
S+Ss asthma?
– polyphonic and diurnal variation; not usually hyperinflation unless attack
Treatment for asthma?
LABAs effective for 12 hours; prednisolone/beclametasone; salbutamol = spacers in kids; ipratropium bromide (anticholinergic bronchodilator) after other bronchodilators don’t work; motelukast/theophylline = leukotriene receptor antagonists; anti-IgE with omalizumab in severe
When to hospitalise in asthma?
hospitalise if no improvement after high bronchodilator dose, exhausted, silent chest, cyanosis, hypotension, PEFR <33%, <50% peak flow, <92% sats = bronchodilators, steroids, O2, IV mg sulfate/salbutamol/aminophylline; if emergency use all the above treatments and consider CPAP
RFs TB?
Overseas contacts and HIV?
S+Ss TB?
anorexia, low fever, failure to thrive, malaise, cough common
Diagnosis TB?
tuberculin tests, blood, ziehl-neelson stain of sputum; miliary spread rare but dangerous
Treatment of TB with RIPE?
rifampicin, isoniazid, pyrazinamide, ethambutol; co-trimoxazole prophylaxis if with HIV for pneumocystitis
Indications of a dry cough with prolonged expiratory phase?
narrowing of small-moderate sized airways
Indications from a barking cough?
tracheal inflammation
Indications from a moist cough?
LRTI
Define a whooping cough, cough?
paroxysmal/spasmodic cough (worse at night and can be vomit) followed by inspiratory whoop
S+Ss whooping cough?
paroxysm = goes red and blue and mucous out mouth, sometimes epistaxis and conjunctival haemorrhages (3 months); cough only last 25 days and if after might be lobar collapse; pneumonia, seizures and bronchiectasis can happen but rare
Diagnosis whoopin cough?
perinasal swab, PCR, marked lymphocytosis
Prevention of whooping cough?
close contacts get macrolide prophylaxis (also for treat), vaccination, no parental smoking
Causes of pneumonia?
newborns = group B strep and gram -ve enterococci; infants = RSV, strep pneumoniae, H.influenzae; 5+ = mycoplasma pneumoniae
S+Ss pneumonia?
fever, cough, tachypnoea, lethargy, poor feeding, unwell; pleural irritation (bacterial), crackles; sometimes empyema
Diagnosis pneumonia?
CXR, nasopharyngeal aspirate, cultures if bad
Treatment of pneumonia?
O2 if <92%, analgesia, new-borns = broad spectrum abx, older = amoxicillin, chronic = high dose co-amoxiclav with physio
Pathophysiology CF?
defective CF transmembrane conductance regulator (CFTR gene – chromosome 7); bad ion transport across epithelium, impaired cilia function, retention of mucopurulent secretions; pancreatic ducts blocked, low defence against infections and dysregulated inflammatory response; pancreatic enzyme blocked so malabsorption (steatorrhea)
S+Ss CF?
nasal polyps and sinusitis, failure to thrive and slow growth, meconium ileus (can’t pass stool in 1st 2 days of life; older = DM, cirrhosis, pneumothorax and sterility in males, chest infections
Screening infants for CF?
immunoreactive trypsinogen, low faecal elastase (pancreatic insufficiency), sweat test for chloride (can have false +ve if really young, some diseases or false -ve if oedema), spirometry, 95% die of resp failure; older = spirometry
Treatment CF?
reg = no symptoms; physio twice/day, exercise, continuous prophylactic abx, nebulised DNase or hypertonic solution (reduces sputum viscosity), azithromycin, lung transplant sometimes, high calorie diet and enzymes (pancrex) and omeprazole increases absorption, gastrotomy overnight, if infection gentamicin with ticarcillin
What is primary ciliary dyskinesia?
abnormal cilia function/structure; low mucociliary clearance, lots of URTI/LRTI
S+Ss primary ciliary dyskinesia?
recurrent productive cough, purulent nasal discharge, chronic ear infections, ½ have dextrocardia, obstructive sleep apnoea
Assessment of primary ciliary dyskinesia?
O2 sats, electrophysical assessment
Normal HSs in paeds?
asymptomatic, soft blowing murmur systolic and left sternal edge, Still’s murmur; no symptoms of cardiac abnormalities
HF S+Ss?
SOB, sweating, poor feeding, recurrent chest infections, poor weight gain, tachypnoea/cardia, murmur, cardiomegaly, hepatomegaly, cold peripheries, acidosis
Investigations HF?
FBC, CXR, paO2, ECG, ECHO, cardiac catheter
Management of HF?
sit-up; o2; ng feed; diuretics (furosemide with/out spironolactone); alprostadil for duct dependent cyanosis
Causes of HF/CHD?
neonates = hypoplastic left heart syndrome, aortic stenosis, coarctation of the aorta, interruption of aortic arch; infants = VSD, ASD and ductus arteriosus; older = cardiomyopathy, Eisenmenger and RHD; usually starts off as left-right shunt (pulmonary oedema and SOB) then to Eisenmenger’s syndrome (irreversible and raised pulmonary vascular resistance, cyanosis); congenital HD = chest radiograph and ECG; shock happens in severe left heart obstruction
ASD types (atrial septal defects)?
secundum (defect involving foramen ovale) and partial (defect of AV septum – bottom of atrial septum, AV valves); usually asymptomatic
ASD S+Ss?
ejection systolic murmur, fixed/wide 2nd HS, pansystolic murmur, cardiomegaly, enlarged pulmonary arteries, increased vascular markings
VSD S+Ss?
small = symptomatic; large = loud pansystolic murmur at left sternal edge with quiet P2, tachypnoea/cardia, hepatomegaly, active precordium, soft pansystolic, apical mid-diastolic murmur, loud P2, cardiomegaly, enlarged pulmonary arteries, increased vascular markings, pulmonary oedema, ventricular hypertrophy
Treatment of VSD?
diuretics (captopril), more calories, pulmonary HT 3-6 months
What is patent ductus arteriosus (PDA)?
haven’t closed by 1 month then constrictor mechanism defect
PDA S+Ss and treatment?
continuous murmur below left clavicle, collapsing pulse, HF and pulmonary HT, thrill, collapsing pulse, pneumonia, loud S2; closure to abolish risk of bacterial endocarditis
Types of right-left heart shunts?
tetralogy of Fallot, translocation of the great arteries
Right-left heart shunts S+Ss?
cyanosis in 1st week; nitrogen washout test in cyanosed, 100% O2 for 10 mins and right radial artery PaO2 low then HD
Management of cyanosis?
ABC, prostaglandin infusion
S+Ss tetralogy of fallot?
large VSD, overriding aorta, subpulmonary stenosis, RVH; older = loud ejection systolic at left sternal edge, clubbing; ECG normal, CXR = small heart, untilted apex, decreased vascular markings
Treatment fallot?
surgery at 6 months; hypercyanotic spells = sedation, pain relief, IV propranolol, IV volume administration, bicarbonate, artificial ventilation; TOGA = aorta connected to RV and PA to LV and do atrial switch surgery and balloon atrial septostomy
Common mixing defects in the heart?
AVSD (in Down’s) and complex congenital HD
AVSD and complex congenital HD S+Ss?
cyanosis/HF at 2wks, no murmur, ECG superior axis
AVSD and complex congenital HD treatment?
surgical repair at 3-6 months (blalock-Taussig shunt insertion if cyanosed)
Outflow obstruction types?
– aortic stenosis (ass. with mitral stenosis), pulmonary stenosis, coarctation of aorta
AS S+Ss?
reduced exercise tolerance, chest pain, syncope, slow rising pulse, carotid thrill, ejection systolic murmur, delayed soft S2; exercise symptoms
Treatment aortic stenosis?
balloon valvotomy or replacement
PS S+Ss?
asymptomatic, some cyanosis, ejection systolic, RV heave
PS treatment?
transcatheter balloon dilation
CoA S+Ss and treatment?
worsens over time, ejection systolic, radio-femoral delay; stent may be inserted; arterial duct tissue constricts aorta, blocks LVO; acute circulatory collapse 2 days; S+Ss = sick baby, HF, no femoral pulse, severe metabolic acidosis, cardiomegaly; surgical management
Outflow obstruction complications?
HF and shock; ABC, prostaglandin and cardiac centre referral
Interruption of arch S+Ss?
no connection between proximal aorta and distal to arterial duct so R-L shunt gives CO; S+Ss = VSD, shock in neonate
Interruption of arch treatment?
treat with VSD closure and surgical repair of arch
What is hypoplastic left heart syndrome and S+Ss?
left side underdeveloped, CoA, no flow through left side and CV collapse, peripheral pulse weakness
Treatment hypoplastic left heart syndrome?
Norwood procedure
SVT complications?
most common childhood arrhythmia; HR 250-300, poor CO, pulmonary oedema, HF, hydrops foetalis (oedema/fluid in at least 2 foetal compartments) and intrauterine death; narrow complex tachycadia
Treatment SVT?
circ/resp support, vagal manoeuvres, IV adenosine, electrical cardioversion (last line), flecainide/sotalol maintenance; relapse = ablation; complete heart block = pacemaker
Cardiac syncope S+Ss?
symptoms in exercise, FH of sudden death, palpitations; acute rheumatic fever = short-lived, multisystem and after group A beta-haemolytic strep, 2-6 weeks = polyarthritis, carditis, erythema marginatum, subcut nodules, sydenham’s chorea, malaise and fever, mitral stenosis (Jone’s diagnostic criteria)
Treatment cardiac syncope?
use aspirin and corticosteroids and treat HF with diuretics and ACEi; pericardial effusions = pericardiocentesis, monthly benzathine penicillin prophylaxis
Infective endocarditis S+Ss?
sustained fever, malaise, raised ESR, unexplained anaemia, haematuria, clubbing, splinter haemorrhages, oslers nodes, Janeway lesions
Diagnosis infective endocarditis?
blood cultures, ECHO, usually strep viridans
Treatment of infective endocarditis?
bacterial treatment = high dose penicillin with aminoglycoside (benzylpenicillin with gentamicin) for 6 weeks; prophylaxis = good oral hygiene
What is PANDAS?
(paediatric autoimmune neuropsychiatric disorders associated with strep infections) – tics and OCD sometimes anorexia
Treatment PANDAS?
abx and risperidone tried
Diagnosis dilated CM?
HF and cardiomegaly; diagnose = ECHO
Treatment dilated CM?
diuretics, ACEi and carvediol
Cardiac S+Ss kawasaki disease?
ECHO = pericardial effusion, myocardial disease, endocardial disease, coronary disease, aneurysm
Pulmonary HT S+Ss?
large post tricuspid shunt, high pulmonary flow, low resistance
Treatment pulmonary HT?
bosentan, heparin, aspirin or warfarin given so transplant delayed
Abnormal findings in antenatal US kidneys?
absence of kidneys, multicystic dysplastic kidney (no functioning tissue and not connected to bladder), Potter syndrome (intrauterine compression from oligohydramnios from low foetal urine – facial deformity, pulmonary hypoplasia, postural deformities)
ADPKD childhood S+Ss?
HT; ass with cerebral aneurysms, mitral valve prolapse; cystic dilations of collecting ducts with biliary dysgenesis and periorbital fibrosis
What is bladder exstrophy?
bladder through defect in abdo wall
What is abnormal caudal migration of kidneys?
horseshoe kidney (silent/obstructive uropathy with/out renal infections), infection, obstruction; can get 2 ureters if premature division of ureteric bud
Types of obstruction of urine flow?
pelvi-ureteric, vesicoureteric junction, bladder neck or posterior urethra
S+Ss obstruction of urine flow?
can cause dysplastic kidney; posterior urethral valves = progressive bilateral hydronephrosis, poor renal growth, low liquor volume, pulmonary hypoplasia
S+Ss UTI?
cystitis = no fever; ½ pts = abnormality, pyelonephritis, scarring leading to CKD; S+Ss = fever, vomiting, lethargy, poor feeding, jaundice, febrile seizure, septicaemia (all in infants, if in children similar to adults)
Diagnosis UTI?
urine culture in <3yrs, temp >38; KEEPS organisms; pseudomonas more common in abnormalities/catheters, urine dipstick with nitrites/+ve WCCs
Causes of incomplete emptying?
– infrequent voiding, vulvitis, incomplete micturition, obstruction from loaded rectum, neuropathic bladder, vesicoureteric reflux (VUR)
What is VUR?
anomaly from laterally displaced ureter enter bladder directly; familial; mild-severe, increased risk of scarring, resolves with age
S+Ss atypical VUR?
seriously ill, poor urine flow, abnormal bladder mass, high creatinine, no abx in 48hours, atypical organisms
Treatment of urinary obstruction outflow?
MCUG used; infants <3 = IV abx 5-7 days, infants/children with pyelonephritis = oral abx 7 days; cystitis = nitrofurantoin/trimethoprim/co-amoxiclav for 3 days; abx used = amoxicillin and gentamicin or cephalosporin with ampicillin
Prevention of urine obstruction outflow?
high fluid intake, complete bladder emptying, treat constipation, good perineal hygiene, probiotic, abx prophylaxis; recurrent/scarring/reflux = urine dipstick, low dose abx prophylaxis, circumcision, anti-VUR, bp check, urinalysis (proteinuria), assess renal function/growth
Causes of enuresis?
lack of attention to bladder sensation, detrusor instability, bladder neck weakness, neuropathic bladder (S2-4), UTI, constipation, ectopic ureter (girls dry at night and wet getting up), emotional upset, UTI, polyuria
Investigations enuresis?
urine microscopy, US, urodynamic studies, XR and MRI
Treatment of enuresis?
star charts, bladder training, pelvic floor exercises, anticholinergics (oxybutynin)
What is encopresis?
repeated passage of soiling into wrong area >4yrs (faecal incontinence = soiling due to physical lesion, overflow incontinence from chronic constipation and lose sensation of defecation); voluntary or involuntary
Treatment encopresis?
; rule out sexual abuse; enemas, dietary fibre, stool softeners, daily toilet sittings after eating, behaviour therapy (can be psych problems – depression)
Causes proteinuria?
orthostatic proteinuria, nephrotic syndrome (corticosteroids; oedema, proteinuria, albumin low, hypercholesteremia sometimes; usually minimal change and sometimes steroid resistant
S+Ss proteinuria?
oedema periorbital then general, frothy albumin urine, oliguria), Henoch-Schonlein purpura; S+Ss = periorbital oedema, scrotal/vulval/leg/ankle oedema, SOB (pleural effusion), infection; common in Asians, boys, atopy; renal biopsy if don’t respond to steroids in 4-6wks
Risks for proteinuria?
hypovolaemia (IV fluids), thrombosis, infection, hypercholesteremia
Treatment of proteinuria?
steroid-sparing therapies (immunomodulators and alkylating agents – cyclophosphamide if don’t work with steroids, cyclosporin = nephrotoxic), diuretics, salt restriction, ACEi, NSAIDs, sometimes unilateral nephrectomy or dialysis
S+Ss glomerular haematuria?
glomerular = brown urine, deformed red cells, casts; UTI most common form
Glomerular causes of haematuria?
acute GN, IgA nephropathy, familial nephritis
Non-glomerular causes haematuria?
infection, trauma, UT/kidneys stones, tumours, SCD, bleeding disorders, hypercalciuria, renal vein thrombosis
Investigations of haematuria?
microscopy, calcium/protein excretion, renal US, U+Es, FBC, coagulation screen; biopsy if persistent proteinuria, macroscopic haematuria, abnormal renal function
Causes of acute nephritis?
post-infection, vasculitis, IgA nephropathy, antiglomerular basement disease
Treatment of acute nephritis?
fluid/electrolyte balance, diuretics, immunosuppression sometimes
What is Henoch-Schonlein purpura?
skin rash (buttocks and extensors), arthralgia (knees and ankles), periarticular oedema, colicky abdo pain, glomerular nephritis, have previous resp infection; 3-10yrs boys
RFs for CKD in paeds?
heavy proteinuria, oedema, HT, deteriorating renal function, Alport syndrome (X-linked recessive – nerve deafness and ocular defects), polyarteritis nodosa, granulomatosis with polyangiitis, SLE; ANCA
CKD treatment?
corticosteroids, plasma exchange and IV cyclophosphamide
Causes of HT generally?
renal, cardiac and endo causes
S+Ss HT?
vomiting, facial palsies, headaches, hypertensive retinopathy, convulsions, proteinuria, faltering growth, HF; abdo mass US
Causes of kidney stones?
phosphate with proteus infection (most common), calcium (high calcium/oxalate)
Fanconi syndrome S+Ss?
excessive loss of aas, glucose, phosphate, bicarb, sodium, calcium, potassium, mg, from heavy metals, vit D deficiency or drugs
Emergency treatment of HT?
Sodium nitroprusside
Acute renal failure causes?
haemolytic uraemic syndrome and acute tubular necrosis (from crush, burn, dehydration, shock, sepsis, malaria)
Management acute renal failure?
circ and fluid balance monitored (may need diuretics); US; may need nephrostomy or bladder catheter; good prognosis
S+Ss acute renal failure?
Rapid rise in creatinine or development of oliguria/anuria; potassium, creatinine, urea high and calcium, sodium, chloride low
RIFLE criteria?
grading = risk, injury, failure, loss of renal function and end-stage renal failure
Reasons for dialysis?
conservative management fails, hyperkalaemia, sever hyponatraemia, pulmonary oedema, HT, severe metabolic acidosis, multisystem failure
Treatment acute renal failure?
causes; use salbutamol or polystyrene sulfonate resins and calcium gluconate for hyperkalaemia
S+Ss haemolytic uraemic syndrome (HUS)?
acute renal failure, microangiopathic haemolytic anaemia and thrombocytopenia, typical with diarrhoea; rare; usually secondary to GI infection with E.coli or shigella; brain, pancreas and heart involved
Treatment of HUS?
Eculizumab
S+Ss glomerulonephritis?
acute = haematuria and oliguria from autoimmune, also periorbital oedema, fever, GI disturbance and loin pain
Complications of glomerulonephritis?
hypertensive encephalopathy, uraemia and cardiac failure/abnormal rhythms
Investigations glomerulonephritis?
= FBC, U+E, complement, ANA, ANCA, syphilis, culture, virology (blood and MSU check blood cells); can get poststreptococcal type
Treatment for glomerulonephritis?
penicillin but if encephalopathy give nitroprusside
Causes of CKD?
congenital dysplastic kidneys, pyelonephritis, recurrent infection, reflux nephropathy, glomerulonephritis
S+Ss CKD?
stage 4-5 = anorexia, lethargy, polydipsia, polyuria, faltering growth, bony deformities, HT, proteinuria, unexplained normochromic normocytic anaemia, vomiting
Treatment of CKD?
prevent metabolic abnormalities, allow normal growth and maintain current renal function
Risks from CKD?
phosphate retention and hypocalcaemia means secondary hyperparathyroidism
Treatment for secondary hyperparathyroidism?
improve nutrition, phosphate restriction, bicarb supplements, EPO, GH, dialysis, transplant; prevent renal osteodystrophy (poor mineralisation from renal failure – like rickets/osteomalacia) and anaemia from low EPO
Hx for genital disorders?
testosterone, progesterone, phenytoin, aminoglutethimide; past neonatal deaths; penis size, urethra; fused labia; gonads descended (34wks should have)
S+Ss inguinal hernias?
– 5% of boys; lump in groin to scrotum (lateral to pubic tubercle), visible on straining, tender and may vomit, can be reduced by taxis (gentle compression in canal) with good analgesia; can sometimes have intestinal obstruction
Treatment inguinal hernias?
ligation and division of processus vaginalis; hydrocele = asymptomatic and transilluminate, usually resolve
S+Ss varicocele?
15% boys in puberty; more common left side and asymptomatic, dull ache, can be blueish and bag of worms
Treatment varicocele?
occlusion of gonadal veins by surgical ligation
What are posterior urethral valves?
bladder mucosa folds in male block outflow causing outflow obstruction
S+Ss hydrocele?
processus vaginalis; fluid from peritoneal cavity; should stop by age 2; if next to spermatic cord (encysted hydrocele) or wide so hernia then action needed
S+Ss undescended testes?
can be palpable but usually incidental finding (external inguinal ring out of scrotum); may be retractile but can be manipulated into scrotum
Treatment undescended testes?
orchidopexy = placement of testis in scrotum (cosmetics, lower torsion risk, fertile, reduce malignancy)
Torsion causes?
commonly post-pubertal (testicular appendage/Mullerian remnant)
S+Ss torsion?
pain groin/lower abdo, redness, oedema of scrotal skin; distinguished from incarcerated hernia
Treatment of testicular torsion?
treated soon so no testicular loss (fixation of contralateral testis), analgesia; if in perinatal then loss inevitable
S+Ss epididymo-orchitis?
infants and urological/anorectal malformations; doppler US, urine sample; S+Ss = redness, swelling beyond scrotum to thigh, perineum, suprapubic area
Treatment of epididymo-orchitis?
analgesia, trauma uncommon but explore and debride/repair if so; think of sexual abuse
S+Ss balanoposthitis and treatment?
redness more extensive and purulent discharge, infection bacterial, topical corticosteroids
What is phimosis?
balanitis xerotica obliterans gives scarring to glans and urethra; older boys and adults
Treatment phimosis?
circumcise, topical corticosteroids and sometimes just wait as normal in most young kids to not be able to retract foreskin
What is paraphimosis?
postpuberty and retracted foreskin so glans swells and low blood supply
Treatment of paraphimosis?
circumcision and GA
S+Ss hypospadias?
failure of development of ventral tissues of penis; features = ventral urethral meatus, ventral curvature of shaft and hooded appearance of foreskin
Treatment of hypospadias?
surgery
Causes of vulvovaginitis?
vulvovaginitis = from nappy rash and infective from candida
S+S vulvovaginitis?
vaginal discharge, fusion of labia minora (irritating)
Treatment vulvovaginitis?
Topical corticosteroids if symptomatic
S+Ss biliary atresia?
fibrosis and obliteration of biliary tree
S+Ss chronic liver failure?
death within 2 years; mild jaundice and pale stools, raised conjugated bilirubin, abnormal LFTs
Diagnosis and treatment chronic liver failure?
ERCP and biopsy; palliative surgery (kasai hepatoportoenterostomy) and liver transplant
S+Ss choledochal cysts?
cystic dilations of extrahepatic biliary system; jaundice, abdo pain, mass, cholangitis
Diagnosis and treatment choledochal cysts?
diagnose = US, MRCP; surgical excision
S+Ss neonatal hepatitis syndrome?
low birthweight, faltering growth
S+Ss alagille syndrome?
rare AD inheritance; pruritus, faltering growth, triangular facies, skeletal abnormality, HD
S+Ss and treatment progressive familial intrahepatic cholestasis?
jaundice, intense pruritus, faltering growth, rickets; transplant needed
S+Ss alpha 1 antitrypsin deficiency?
AR inheritance; protein accumulation in hepatocytes; emphysema in adults; neonatal bleeding/jaundice from vit K low; hepatomegaly, splenomegaly, cirrhosis, portal HT
S+Ss galactosaemia?
rare, poor feeding, vomiting, jaundice, hepatomegaly (all when fed milk); liver failure, cataracts, developmental delay if untreated; galactose in urine
S+Ss viral hepatitis?
= N+V, abdo pain, lethargy, jaundice, hepatomegaly, splenomegaly
Treatment viral hepatitis?
treat with ribavirin and pegylated interferon
S+Ss acute liver failure?
massive necrosis with liver loss; uncommon but high mortality; infection/metabolic; S+Ss = jaundice, coagulopathy, encephalopathy, hypos, electrolyte disturbance, cerebral oedema, haemorrhages, sepsis
Investigations acute liver failure?
LFTs, ALP and ammonia raised, acid-base balance, bg and coagulation monitored
Treatment of acute liver failure?
treat the S+Ss; IV dextrose, broad spectrum abx, IV vit K, H2 blocking drugs, fluid restriction
Common liver diseases in older children?
common = HBV, HCV, AI hepatitis but exclude Wilson’s and sclerosing cholangitis
S+Ss AI and sclerosing cholangitis?
7-10yrs, girls; skin rash, arthritis, haemolytic anaemia/nephritis
Diagnosis AI and sclerosing cholangitis?
hypergammaglobulinaemia, positive autoantibodies, low serum C4, histology
Treatment AI and sclerosing cholangitis?
prednisolone, azathioprine, SC = ursodeoxycholic acid, optimise nutritional support, liver transplant sometimes
Wilson’s S+Ss?
– AR inheritance; hepatic dysfunction in childhood, neuropsych with extrapyramidal SEs, renal tubular dysfunction (vit D resistant rickets), Kayser-Fleischer rings (>7), low serum caeruloplasmin and copper
Diagnosis Wilson’s?
elevated copper in liver
Treatment Wilson’s?
penicillamine, zinc, pyridoxine (peripheral neuropathy), liver transplant
S+Ss congenital hepatic fibrosis and treatment?
> 2yrs, hepatomegaly, abdo distension, portal HT, cystic renal disease, NAFLD; liver transplant and weight loss targeted
Complications of chronic liver disease?
o Lacking = protein (medium chain triglyceride with milk needed if cholestatic)
o Encephalopathy – protein restricted; causes = GI haemorrhage, sepsis, sedatives, renal failure, electrolyte imbalance, irritable, sleepy, mood change, intellect lower, ammonia high
o Pruritus – loose cotton clothing, moisturising skin, phenobarbital and cholestyramine
o Cirrhosis – secondary to hepatocellular disease/chronic bile obstruction; signs = jaundice, palmar erythema, telangiectasia, spider naevi, malnutrition and hypotonia
Investigations for chronic liver disease?
screening for chronic liver disease, upper GI endoscopy, abdo US, liver biopsy
Treatment of acute bleeds?
transfusions, H2 blockers; persists = octreotide infusion, vasopressin analogues, endoscopic ligation, scleropathy
Causes of ascites?
hypoalbuminaemia, sodium retention, renal impairment, fluid redistribution
S+Ss spontaneous bacterial peritonitis?
abdo pain, fever, tenderness, unexplained decrease in renal/liver
Reason for liver transplant?
severe malnutrition, complications with management, failure of growth, poor quality of life
Diagnoses for malignant diseases?
VMA and HVA useful tumour markers in neuroblastoma, high alpha fetoprotein in germ cell tumours, bone marrow histology for leukaemia or biopsy for solid
Treatment for malignant diseases?
chemo = primary curative in ALL, primary/mets before surgery and micromets; allogenic transplant in high-risk/relapsed leukaemia; autologous stem cell support in solid tumours with poor prognosis; with fever and neutropenia = broad spectrum abx; fertility preservation and central venous catheters
Examples of opportunistic infections?
PCP, aspergillosis, candidiasis, coagulase-negative staphylococcal infections
SEs of chemo?
doxorubicin = cardiotoxicity; cisplatin = renal failure and deafness; vincristine = neuropathy; cyclophosphamide = haemorrhagic cystitis
S+Ss leukaemia?
from disseminated disease (BM and organ infiltration by leukaemic blast cells) over weeks; FBC normal, low Hb, thrombocytopenia, malaise, anorexia, N+V, lethargy, bruising, infection and bone pain, lymphadenopathy
Investigations leukaemia?
BM examination, clotting screen (for DIC), LP and CXR; B or T cells, normochromic normocytic anaemia; csf
Prognostic factors for leukaemia?
age, WCC at presentation, cytogenetics and treatment response; if have Philadelphia chromosome then very high risk
Treatment for leukaemia?
before = anaemia, thrombocytopenia, infection, hydration and allopurinol (for renal) should be managed; intense chemo and intrathecal for no CNS relapse, or moderate over 3 yrs; cotrimoxazole for PCP prophylaxis; high chemo and transplant for relapse; induction therapy, then consolidation phase then maintenance
Remission of leukaemia?
eradication of leukaemic blast cells and restoration of marrow function
Complications of leukaemia?
neutropenic sepsis, hyperuricaemia, cancer elsewhere
Management of neutropenic pts?
anything suspect infection; test and treat = piptazobactum (tazocin) +/- gentamicin or imipenem (teicoplanin); usually gram +ve bacteria
Types of brain tumours?
always primary, 60% infratentorial, 40% astrocytoma, 20% medullablastoma, 8% ependymoma, 6% glioma, 4%craniopharyngioma
S+Ss brain tumours?
high ICP, focal neuro deficits, back pain, peripheral weakness, bladder/bowel dysfunction
Investigations and treatment of brain tumours?
MRI, LP and surgery
S+Ss lymphomas?
non-hodgkin common in kids = painless lymphadenopathy (usually neck), last months, systemic uncommon, usually T-cell
Investigations for lymphomas?
lymph node biopsy, radio assess nodes, BM biopsy, examine CSF
Treatment of lymphomas?
combination chemo with/without radio; PET to monitor
What are Burkitt lymphomas?
B-cell NHL (more mature than ALL), either endemic (malaria from EBV), sporadic (EBV) and immunodeficient (HIV) associated
S+Ss neuroblastoma?
neural crest tissue in adrenal medulla and sympathetic NS; ganglioneuroma to neuroblastoma spectrum; <5yrs; signs = usually abdo mass with adrenal origin (can envelop major vessels and lymph nodes), can have nerve compression from paravertebral, bone pain, BM suppression, weight loss, malaise
Treatment neuroblastoma?
surgery (without mets), chemo, autologous stem cell rescue, radio, relapse high
S+Ss Wilm’s tumour/nephroblastoma?
from embryonal renal (mesoderm) tissue; usually <5; asymptomatic other than large abdo mass but fever, flank pain, anorexia, anaemia, haematuria, HT sometimes; can be associated with beckwith-Wiedemann syndrome (enlargement of most organs), Aniridia (no iris) GU malformations, Retardation; staging from US/CT/MRI
Treatment Wilm’s tumour?
chemo (vincristine and actinomycin), delayed nephrectomy, 80% cured
S+Ss rhabdomyosarcoma?
most common soft tissue in kids; primitive mesenchymal tissue; symptoms = proptosis, nasal obstruction, GU tumours, mets
Treatment for rhabdomyosarcoma?
multimodal
S+Ss osteosarcoma?
more common than Ewing’s and more common in prepubertal boys; symptoms = limbs, persistent bone pain, use XR, MRI, bone scan, BM and chest CT for mets and diagnosis
Treatment osteosarcoma?
combo chemo before surgery and amputation
Retinoblastoma S+Ss?
severe visual impairment, if bilateral then hereditary, <3yrs; MRI useful
Treatment retinoblastoma?
based on ophthalmology and chemo then laser treatment or radio in advanced
S+Ss primary hepatic malignant tumours?
hepatoblastoma or HCC; abdo distension and mass, elevated alpha fetoprotein, most cured
What is rhesus haemolytic disease?
RHD-ve mother gives +ve baby and then makes anti-D rhd abs
S+Ss rhesus haemolytic disease?
= hydrops fetalis (severe oedematous lunged foetus – need to ventilate with high pressure, find cause, drain ascites, vitamin K to lower haemorrhage, furosemide, limit fluids, 90% die in utero), hypoalbuminaemia, thalassaemia, infection
Treatment of rhesus haemolytic disease?
regular US and anti-D titre should be lower <4u/mL and Hb should be above 7g/dL; give mums anti-D IgG, phototherapy and exchange transfusion for below 7g/dL
Tropical causes of haemolytic diseases?
malaria, bacteraemia, worms, HIV, low B12, low G6DP, low iron, sickle cell
Hb normal values in children?
neonate <140, 1-12 months <100, 1-12yrs <110
Causes of reduced red cell production?
(MCV <70fL) – ineffective erythropoiesis (iron deficiency – inadequate uptake, malabsorption (coeliac), blood loss, delay in mixed feeding, asymptomatic unless Hb <70, tiredness, slow feeding; microcytic, hypochromic anaemia, low serum ferritin), abnormal MCV (low in IDA and high folic acid), normal reticulocyte count
Treatment of reduced red cell production?
ferrous fumarate syrup
Causes of a high MCV?
> 100fL – low folate, low B12; absorption, intake, breast milk from veggie, pernicious anaemia
Causes of red cell aplasia?
either congenital, transient erythroblasopenia of childhood or parvovirus B19, Diamon-Blackfan = rare
Diagnosis red cell aplasia?
low reticulocytes, normal bilirubin, negative Coomb’s, absent red cell precursors on BM
Treatment red cell aplasia?
steroids, monthly RBC transfusions, stem cell transplant
Causes of haemolytic anaemia?
normocytic) – reduced RBC lifespan; RBCs destroyed in liver/spleen, BM can’t compensate; causes = membrane disorders (spherocytosis – AD inheritance, SEE PHASE 2A NOTES, jaundice, anaemia, splenomegaly, aplastic crisis and gallstones), enzyme disorders (G6PD deficiency – common in central Africa, x-linked, neonatal jaundice, acute haemolysis increased by infection, fava beans, naphthalene, normal blood between episodes), haemoglobinopathies
Diagnosis haemolytic anaemia?
hepato/splenomegaly, anaemia, high unconjugated bilirubin, high urinary urobilinogen, high reticulocytes, abnormal RBC shape, positive Coomb’s, high RBC precursors, blood film, autoimmune excluded by Coomb’s
Treatment haemolytic anaemia?
oral folic acid, splenectomy sometimes, aplastic crisis = 2 blood transfusion
What is haemoglobinopathy?
reduced HbA or low production from deletions; sickle cell anaemia, HbSC and sickle beta thalassaemia; sickle = lower lifespan and stuck in microcirc, HbSS is most severe
S+Ss haemoglobinopathies?
anaemia, infection, painful crisis, acute anaemia, priapism (painful and sustained erection), splenomegaly, stroke, cognitive problems, HF, renal dysfunction, gallstones, leg ulcers, psychosocial problems, confusion
Treatment haemoglobinopathies?
folic acid; avoid cold, dehydration, high exercise and stress; can use morphine if in a lot of pain
Treatment of painful anaemic crises?
oral/IV analgesia, good hydration and exchange transfusion; recurrent = hydroxycarbamide (monitor WBC suppression); can have older retinopathy; beta thalassaemia in India and middle-east; major (need blood with SC iron chelation and desferrioxamine so no iron overload) and intermedia forms
What is severe alpha thalassaemia major?
4 alpha globulin deletions; diagnose from liquid chromatography or Hb electrophoresis
What is haemolytic disease of the newborn?
abs against blood group antigens; causes = feto-maternal haemorrhage, twin-twin transfusion and blood loss in delivery
Causes of anaemia of prematurity?
inadequate epo, reduced RBC lifespan, frequent blood sampling, iron/folic acid deficiency
Causes of aplastic anaemia?
BM failure; gives peripheral blood pancytopenia; inherited or acquired (viruses, drugs like sulphonamides or chemo, toxins)
S+Ss aplastic anaemia?
anaemia, infection and bruising/bleeding
S+Ss Fanconi syndrome?
inherited and most common; S+Ss = short stature, abnormal thumbs, renal malformations, BM failure at 5/6yrs, can become ALL
Treatment Fanconi syndrome?
BM transplant
Screening tests for bleeding disorders?
screening = FBC, PT, APTT, thrombin time (low fibrinogen), quantitative fibrinogen assay, D-dimers, biochemical screen, don’t forget autoimmune thrombocytopenia
S+Ss haemophilia A and B?
x-linked; A (more common) = factor 8 and B = factor 9 deficient; severe = spontaneous bleeding into muscles, joints (arthritis) at end of 1st yr
Haemophilia A and B treatment?
recombinant factor 8/9 in bleeding IV, may need to use central venous catheter, desmopressin
What to avoid with bleeding disorders?
IM injections, NSAIDs, aspirin
What is von Willebrand disease?
von willebrand factor aids platelet adhesion to damaged endothelium and in this case is deficient; type 1 more common
S+Ss VWD?
bruising, excessive post-surgery bleeding, mucosal bleeding
Treatment of VWD?
desmopressin and if severe = plasma-derived factor 8 concentrate
Causes of acquired bleeding disorders?
vit K deficiency (prolonged PT, from inadequate intake, malabsorption, vit K antagonists), liver disease
o Immune thrombocytopenia - pt <150
S+Ss acquired bleeding disorders?
bruising, petechiae, purpura, mucosal bleeding; destruction of pts from antiplatelet IgG autoantibodies; exclude if = anaemia, infection, lymphadenopathy, hepatomegaly (SLE)
Treatment of acquired bleeding disorders?
oral prednisolone, IV anti-D or IV Ig, rituximab sometimes, splenectomy if all fails
What is DIC?
coagulation pathway activation giving diffuse fibrin deposition in microvasc
Causes of DIC?
Severe sepsis or shock
S+Ss DIC?
bruising, petechiae, haemorrhage, thrombocytopenia, prolonged PT and APTT, low fibrinogen, haemolytic anaemia, low natural anticoagulants
Treatment of DIC?
intensive care needed, plasma/cryoprecipitate, vit K
Causes of thrombosis in paeds?
most from underlying disorders; congenital thrombophilia disorders = C/S deficiency, antithrombin deficiency, factor 5 Leiden; screen in unanticipated VT with FH of neonatal purpura fulminans
Causes of primary ab deficiencies?
primary hypogammaglobulinaemia or bruton’s agammaglobulinaemia
S+Ss primary ab deficiencies?
infections, bronchiectasis, sinusitis, failure to thrive, nodular lymphoid hyperplasia, absent tonsils, enteropathy, hepatosplenomegaly, anaemia, arthrology, lymphopenia, low total serum protein; count lymphocytes involved in ab production, FH
Treatment of primary ab deficiencies?
ig replacement via iv, use hydrocortisone and antihistamine if reaction; can use stem cells and harmless retrovirus to replace gene
Hx for child mental health?
from parents ask how affects child, child and adversity, how did problems start, what was happening at the time, how do people respond, ask what child thinks about problem, any worries, when is it better, what already doing about it, child development
Risks for child mental health problems?
anger in fam, parental mental health, bereavement, divorce, intrusive overprotection, lack of parental authority, abuse, emotional rejection, unpredictable discipline, inappropriate responsibilities for child
Prevention of child mental health problems?
time spent as a fam (meals – meal refusal = problem), regular exercise, regular sleep (tell child to go to bed and lie there for hour if can’t sleep, night terrors 1.5 hours into sleep), absence of bullying
Analysing tantrums?
analysed by ABC (antecedents, behaviour, consequences)
Night soiling causes?
abnormal >4yrs; with/without loaded rectum, constipation, inhibition of defecation from fear/punishment, anxiety about toilet
Somatic symptoms in paeds?
common and increase with stress, depression, anxiety; abdo pain, headache; older = limb pain, aching muscles, fatigue, neuro; hx identifies causes and use pain-coping skills
S+Ss chronic fatigue syndrome?
high levels of subjective persisting fatigue, rapid exhaustion on minimal exercise; sometimes recent infection; myalgia, migratory arthralgia, headache, insomnia, poor conc, irritability normal; stomach pains, scalp tenderness, eye pain, photophobia, depression sometimes
Drug abuse in children?
– intoxication, unexplained truancy, mixing with users, high rates of stealing, possession of equipment for drug use, medical complications; solvent abuse = cardiac dysrhythmias, BM suppression, renal failure; ecstasy = hyperthermia, dehydration, death
Investigation of drug abuse in children?
urine drug screen, exclusion of medication, dementia
Bullous impetigo treatment?
severe blistering and given systemic abx
S+Ss malignant melanoma?
congenital pigmented naevi increase risk; macule = small flat area of different colour/texture; papule = small raised lesion; nodule = larger raised and deeper component; purpura = bleeding into skin/mucosa
RF malignant melanoma?
prolonged sun (use SPF30), positive FH, melanocytic naevi, far skin, repeated sunburn, hot climate
S+Ss albinism?
defect in biosynthesis and melanin distribution; could be oculocutaneous, ocular or partial; pendular nystagmus, photophobia, severe visual impairment
What is epidermolysis bulosa?
– rare genetic, blistering skin (after trauma or spontaneously) and mucous membranes; AR more severe (digit fusion, limb contracture)
Management of epidermolysis bulosa?
avoid injury and treat infections, nutrition and analgesia
S+Ss irritant dermatitis?
most common nappy rash (don’t change enough or diarrhoea); eruption on bum, perineal area, lower abdo, top of thighs; erythematous; not in flexures unless candida
Treatment of irritant dermatitis?
protective emollient, severe, change nappies = topical corticosteroids; if candida then topical antifungal and hydrocortisone
S+Ss infantile seborrheic dermatitis?
first 3 months; diffuse, red, shiny, erythematous scaly scalp then to face/behind ears; risk of atopic eczema
Treatment irritant dermatitis?
mild with emollients and severe with topical corticosteroids/antibac agents
S+Ss atopic eczema?
1st year of life; FH, 1/3 get asthma; most resolve by 16; exclude immunodeficiency if severe; S+Ss = pruritus, erythematous excoriated areas that weep and crust, dry skin, lichenification if scratch, flare-ups with staph/strep infections, regional lymphadenopathy
What to avoid in atopic eczema?
soap and biological detergents, nails short
Treatment of atopic eczema?
emollients, ointments when skin dry, topical corticosteroids, >2yrs short term tacrolimus ointment when steroids fail, occlusive bandages to stop scratching and oral antihistamine, abx with hydrocortisone for infection but if eczema herpeticum then acyclovir
Common allergies associated with atopic eczema?
Eggs and cow’s milk
S+Ss viral warts?
small, skin coloured papules) from HPV disappear over months/yrs
Treatment for viral warts?
use cryotherapy and sometimes topical abx, glutaraldehyde solution/salicylic acid and lactic acid paint daily
S+Ss scabies?
parasite burrowing into epidermis and severe pruritus after 2-6wks, worse in warm conditions and night, older = fingers, toes, axilla, penis, bum, other fam (treat all fam), analyse skin scrapings
Treatment of scabies?
permethrin cream and wash off after 8-12 hours and malathian lotion for 12 hours
S+Ss headlice?
scalp itching, may have secondary bacterial infection
Treatment headlice?
dimeticon lotion into hair and left overnight, wetcomb with fine-tooth comb
S+Ss psoriasis?
usually >2yrs; guttate type most common in kids; attacks 3-4months and recur in next 3-5yrs
Treatment psoriasis?
bland ointments, calcipotriol for plaque = coal tar preparations; can develop psoriatic arthritis
S+Ss pityriasis rosacea?
acute, benign, viral; rash follows ribs
Treatment of pityriasis rosacea?
None but should resolve in 4-6wks
What is alopecia areata?
common form of hair loss
S+Ss granuloma annulare?
ringed, raised flesh-coloured non-scaling over bony prominences on hands and feet; disappear spontaneously
S+Ss acne vulgaris?
1-2yrs before puberty; risk = menstruation and emotional stress
Treatment acne vulgaris?
benzyl peroxide, sunshine, topical abx and severe = oral tetracyclines
Systemic disease causing skin rashes?
SLE, Hennoch-Schonlein purpura, erythema nodosum, Steven-Johnson syndrome (systemic rash reactions to sepsis/medications – severe bullous form of erythema multiforme starting with URTI)
What is urticaria?
flesh-coloured wheals; popular urticarial = delayed hypersensitivity on legs after bite
Triggers for TIDM?
triggers for type 1 = enteroviruses, cow’s milk; association with other autoimmune disorders (autoimmune destruction of beta pancreatic cells)
S+Ss DM?
triad = polydipsia, polyuria and weight loss, weight loss, infection, poor growth, ketosis; DKA = change in breath, vomiting, dehydration, abdo pain, hypervent, hypovolaemia, drowsiness, coma
Diagnosis DM?
symptoms, randomly raised bg >11.1 or 7mmol/l fasting, autoantibodies, type 2 = FH in obese of insulin resistance; monitor blood ketones and check HbA1c 4x per annum
Tests for DKA?
intensive educational programme, glucose >11.1, ketones >3.0, U+Es (dehydration), ABG (metabolic acidosis), ECG (t wave change in hypokalaemia),
S+Ss DKA?
cerebral oedema (mannitol), weight, infection, hyponatraemia, acidosis, leukocytosis; S+Ss = listless, confused, vomiting, polyuria, polydipsia, weight loss, abdo pain, kussmaul resps, dehydration, shock, drowsy, coma
Treatment DKA?
ABC, fluids, IV insulin after 1 hour of fluids, stop insulin after ketones under 1
Types of insulin?
human insulin analogues, short-acting soluble human regular insulin, intermediate-acting; can be given as continuous rapid acting; most have long and short; aim for 4-7mmol/L before meals; encourage healthy diet and carb counting
Risks increasing consequences of DM?
menstruation, GH, illness, corticosteroids, sex hormones, stress, sugary snacks, infrequent blood testing, illness, exercise, eating disorders, family disruption, inadequate family motivation
Conservative management DM?
exercise, alcohol, drugs, anxiety, hot weather
S+Ss and treatment hypoglycaemia?
hunger, stomach ache, sweaty, faint, dizzy can lead to seizures and coma; glucose usually but glucagon if severe
Hx to ask for DM?
hypos, absence from school, HbA1c, insulin regimen, lipohypertrophy, diet
Regular checks for child with DM?
normal growth, BP, renal disease, circ, eyes, feet, screen for coeliac/thyroid, annual flu vaccine
S+Ss maturity onset diabetes of the young?
– AD, non-ketotic, children or young-adults; impaired beta cell function and insulin secretion; only single gene defects (unlike DM)
Define neonatal hypoglycaemia?
Glucose <2.6mmol/L
S+Ss hypoglycaemia?
sweating, irritability, headache, seizures and neuro problems if not fixed; don’t starve infant for >4 hours; check bg if sepsis, prolonged seizure, altered state of consciousness; unknown cause = lab readings, urine
Causes of hypoglycaemia?
hepatomegaly could be glycogen store disorder, DM, beta cell tumours, drug-induced, autoimmune, Beckwith syndrome, liver disease, ketotic hypo, hormonal deficiency, congenital error of metabolism
Treatment of hypoglycaemia?
don’t overload glucose otherwise cerebral oedema risk, can use IM glucagon
Causes of hypothyroidism?
can have severe LD if untreated
o Hypothyroidism = autoimmune; causes = maldescent of thyroid, dyshormonogenesis, iodine deficiency, TSH deficiency, athyreosis, premature, hashimoto’s thyroiditis, down’s, hypopituitarism
S+Ss hypothyroidism?
faltering growth, feeding problems, prolonged jaundice, constipation, dry skin, large tongue, goitre, delayed development, hypotonia, delayed puberty, short
Diagnosis hypothyroidism?
routine biochemical screen (high TSH but low T4), low Hb, low I uptake
Treatment hypothyroidism?
levothyroxine before 2-3wks, lifelong treat
Hyperthyroidism S+Ss?
eye signs less obvious, tremor, palpitations, anxiety, tachycardia, low TSH and high T4, exophthalmos, D, weight loss, diarrhoea, sweating, goitre
Treatment hyperthyroidism?
carbimazole or PTU (neutropenia SE), beta blockers for anxiety
Causes hypoparathyroidism?
usually due to congenital abnormality (DiGeorge syndrome with thymic aplasia, cardiac defects, facial abnormalities), older = autoimmune disorder, Addison’s
S+Ss hypoparathyroidism?
hypocalcaemia, constipation, anorexia, lethargy, behaviour change
Treatment hypoparathyroidism?
IV calcium gluconate with hypocalcaemia, chronic is with oral calcium and high doses of vit D analogues
S+Ss congenital adrenal hyperplasia?
(insufficient cortisol – foetal ACTH production so overproduction of adrenal androgens, virilisation of external genitals, penis enlargement/scrotal pigmentation, salt-losing adrenal crisis (Na and K), tall stature, psychosexual problems, vomiting, dehydration); can give adrenocortical crisis (N+V, abdo pain, lethargy, hypotension; use hydrocortisone, saline, glucose and fludrocortisone)
Diagnosis congenital adrenal hyperplasia?
high 17-alphahydroxyprogesterone, low sodium, high potassium, metabolic acidosis, hypos
Management congenital adrenal hyperplasia?
lifelong gluco and mineralcorticoids, monitor growth/skeletal maturity and additional hormone replacement
S+Ss Addison’s?
rare in kids; S+Ss = salt-losing crisis, hypotension, hypos, fatigue, pigmentation
Diagnosis Addison’s?
hyponatraemia, hyperkalaemia, metabolic acidosis, hypos, ACTH test
Treatment Addison’s?
crisis (IV saline, glucose, hydrocortisone), parents taught to inject hydrocortisone (reduced height and osteopenia)
S+Ss and investigations and treatment of Cushing’s?
short, growth failure, red cheeks, hirsutism, bruising, carb intolerance, osteopenia, psych problems, muscle wating and weakness; 24-hour free urinary cortisol high; pituitary adenoma releasing ACTH with transsphenoidal resection; adrenal tumours unilateral
Causes of disorders of sexual development?
secondary to virilisation in female from excessive androgens, inadequate androgen action, gonadotrophin insufficiency, ovotesticular DSD
What is an inborn error of metabolism?
• Disorder of enzyme reactions (degrade, synthesise, interconvert molecules in cells); disorders of intoxication, energy metabolism, complex organelles
S+Ss inborn errors of metabolism?
severe presentation of common illness, diarrhoea, significant metabolic acidosis, unexplained resp alkalosis, hypos, HF, hepatomegaly, unexpected drowsiness, early onset seizures, dysmorphic features, developmental regression, sudden unexplained death
Hx for inborn errors of metabolism?
FH of IEoM, sudden unexplained death, epilepsy, LD, consanguinity; examine skin, MSK, eyes; usually AR inheritance
Management of inborn errors of metabolism?
medication (symptomatic therapies, specific therapies and enzyme replacement therapy), dietary manipulation (supplying deficient product, preventing accumulation of toxic substrate, prevention catabolism, ketogenic diet); more likely if acidosis too much with clinical picture, abnormalities persist even when managed (raised anion gap – usually 10-16mmol/L)
S+Ss infection for those with inborn errors of metabolism?
common trigger; ammonia measured if unexplained encephalopathy, resp alkalosis, recurrent vomiting, unexplained severe illness, unexplained seizures
Treatment of inborn errors of metabolism with infection?
stop feeds, 10% dextrose, IV ammonia scavengers and arginine
What is a glycogen storage disorder?
hepatic (hypos), muscular, cardiac; degradation in enzymes needed for glycogen storage and synthesis
S+Ss glycogen storage disorders?
poor feeding, hepatomegaly, raised lactate, neutropenia 1b, stiffness and myalgia after exercise
Types of glycogen storage disorders?
von gierke, pompe’s, cori, Anderson, mcardle, hers, tauri
Diagnosis glycogen storage disorders?
= low levels of lactate and pyruvate in venous blood post exercise and low phosphorylase muscle staining
Treatment glycogen storage disorders?
= no extreme exercise and glucose/fructose can help
What is a lysosomal storage disorder?
can’t break down chemical (accumulate);
Diagnosis lysosomal storage disorder?
urinary glycosaminoglycan screen, oligosaccharide screen, WCC testing
S+Ss lysosomal storage disorder?
supportive treatment; most common = Gaucher disease and familial hypercholesteraemia is most common inherited
Treatment lysosomal storage disorder?
low fat diet, statin, ezetimibe
S+Ss PKU?
mutation of phenylalanine hydroxylase gene; mental impairment, fair hair, fits, eczema, musty urine
Treatment PKU?
expert help and diet low in phenylalanine but high in tyrosine
General MSK leg problems in kids?
• Most kids have tibiae bowing but if pathological then rickets; varus usually resolves; flat feet common in hypermobile and toddlers (if painful then tendo-Achilles contracture or JIA); toe-walking common in kids
In-toeing causes of abnormal gait?
metatarsus varsus (from being flat-footed), medial tibial torsion and persistent anteversion of femoral neck
Causes of abnormal posture?
talipes (club foot – inverted and supinated, equinovarus = complication) from intrauterine compression, passive exercises useful, can be bilateral, calf and leg smaller
Treatment of abnormal posture?
plaster cast and bracing
What is vertical talus?
foot is stiff and rocker-bottom shape; diagnose with XR and surgery needed
What is talipes calcaneovalgus?
dorsiflexed and everted foot
Tarsal coalition definition?
bones of foot more rigid as more fused; surgery
S+Ss DDH (developmental dysplasia of the hip)?
dysplasia, subluxation and dislocation of hip; limb or abnormal gait
S+Ss scoliosis?
lateral curvature in frontal plane of spine; mild, pain-free, cosmetic but can cause CV failure
Causes scoliosis?
idiopathic, congenital structure defect, neuromuscular imbalance, connective tissue disorder
Causes of torticollis?
sternocleidomastoid tumour; mobile, non-tender nodule, restriction in head-turning; later causes = muscular spasm from ENT infections/spinal tumour/C-spine arthritis
S+Ss painful limb, knee, back?
growing pains common, 3-12 yrs, symmetrical limb pain, after start of day, physical activity and exam normal
Causes and S+Ss hypermobility?
MSK pain after exercise; local or general; causes = chromosome abnormalities, collagen disorders; S+Ss = hyperaesthesia, allodynia, bizarre posturing, if diffuse then widespread pain, disturbed sleep, exhausted in day
What is osteomyelitis?
infection of metaphysis of long bones; distal femur and proximal tibia; spread from staph, strep, H.influenzae and sometimes TB in immunocompromised
S+Ss osteomyelitis?
painful, immobile limb, febrile illness, infection is erythematous and warm, blood culture positive, high CRP and WCC
What to rule out for bone pain, swelling and fx?
osteoid osteoma = benign affecting adolescents in long bones in leg and spine (pain at night improves with NSAIDs)
What is Osgood-Schlatter disease S+Ss?
osteochondritis of patellar tendon in adolescent males; physically active, knee pain after exercise, localised tenderness, swelling
Treatment of Osgood-Schlatter disease?
reduce exercise and physio, knee immobiliser splint
What is chondromalacia patellae?
softening of articular cartilage of patella in adolescent females
Treatment of chondromalacia patellae?
physio
Osteochondritis dissecans S+Ss?
persistent knee pain in physically active adolescent; tenderness over femoral epicondyles; from avascular necrosis
Treatment osteochondritis dissecans?
rest and quad exercises
Things to rule out with back pain?
if in younger then pathological (mechanical, tumour, vertebral osteomyelitis/discitis, spinal cord/nerve entrapment and Scheuermann disease, spondylosis and CRPS)
S+Ss transient synovitis?
acute hip pain with decreased movement and referred knee pain, 2-12yrs with virus, can develop to Perthes disease
Treatment transient synovitis?
bed rest and skin traction
What is Perthes disease?
avascular necrosis of capital femroal epiphyses of femoral head from blood supply interruption then revascularisation, mainly boys
Diagnosis perthes disease?
bone scan, MRI
Treatment pertes disease?
rest, physio, plaster casts, surgery; slipped capital epiphyses need to be treated before avascular necrosis, restricted abduction and internal hip rotation
S+Ss acute arthritic pain in kids?
pain, swelling, heat, redness, restricted movement
Causes of arthritis in kids?
reactive arthritis is most common form (ankles, knees after extra-articular infection), enteric bacteria in children with virus and STIs in adolescents; septic, JIA, HSP
Septic arthritis S+Ss and diagnosis?
<2yrs; common = staph aureus; S+Ss = erythematous, warm, acutely tender joint with lack of movement, infants hold limb still, joint effusion detectable, WCC and CRP high, blood cultures, US shows effusion, joint aspirate = diagnostic
Treatment septic arthritis?
IV abx, washout and surgical drainage
S+Ss JIA?
common chronic inflammatory joint disease in kids; persistent joint swelling >6wks in <16 with no infection; S+Ss = gelling (stiffness after rest), morning joint stiffness and pain, intermittent limp, behaviour/mood deterioration, antinuclear factor may be present
Complications JIA?
chronic anterior uveitis (low sight from cataract), flexion joint contracture, growth failure, anaemia of chronic disease, delayed puberty, osteoporosis and amyloidosis
Treatment JIA?
NSAIDs, analgesics, joint injections, methotrexate, systemic corticosteroids, cytokine modulators
S+Ss hennoch-Schonnlein purpura?
most common vasculitis of kids; S+Ss = purpuric rash on legs and bum, abdo pain (use steroids), haematuria, proteinuria, arthralgia, severe nephropathy sometimes, scrotal oedema sometimes and sometimes intussusception
S+Ss juvenile dermatomyositis?
malaise, progressive weakness, facial rash, muscle pain, resp failure and aspiration pneumonia can happen
S+Ss achondroplasia?
AD inheritance; features = short stature, large head, frontal bossing, depression of nasal bridge, lumbar lordosis and hydrocephalus
S+Ss thanatophoric dysplasia?
stillbirth, large head, short limbs; XR and antenatal US
S+Ss arthrogryposis?
stiffness and contracture of joints, marked flexion contractures, muscle atrophy over joints; association with oligohydramnios
Treatment arthrogryposis?
physio and correction of deformities
Osteogeneis imperfecta S+Ss (type 1 and 2)?
disorder of collagen metabolism; S+Ss = bone fragility, bowing, frequent fx; type 1 = AD, fx in kids and blue sclera, less severe, treat with bisphosphonates; type 2 = severe
S+Ss osteopetresis?
bones dense and brittle, faltering growth, recurrent infection, hypocalcaemia, anaemia, thrombocytopenia
Treatment osteopetresis?
BM transplant
S+Ss and complications Marfans?
AD, tall stature, long thing digits, hyperextensible joints and eye lenses, CV aneurysms and valvular incompetence
Types of febrile seizures?
fever and no intracranial infection; small chance of epilepsy (focal, generalised, tonic/conic [grand mal – limbs stiffen which is clonic and then jerk which is tonic], absences [brief 10 sec pauses, unaware], infantile spasms/west syndrome [clusters of head nodding and arm jerks – use prednisolone])
Causes of febrile seizures?
hypoxic-ischaemic encephalopathy, infection, intracranial haemorrhage, CNS lesions, metabolic disturbance/disorders, withdrawal, kernicterus (rare brain damage from jaundice), idiopathic
S+Ss febrile seizures?
toddlers have blue breath holding spells (after anger/crying), blue, stiff, limp, apnoea, lip-smacking, limb-cycling, eye-deviation and then recover, reflex asystolic syncope after sudden surprising pain (stop breathing, pale, stiff, brief convulsions, rapid recovery), EEG, lasts <15 min, >1 in 24 hrs
Treatment of febrile seizures?
ketogenic diet, vagal nerve stimulation, surgery, treat causes, empirical abx, IV access for invest, cerebral function analysis monitoring; prolonged seizure 3-5 min = phenobarbital and if not then phenytoin, others = midazolam, clonazepam, paraldehyde, lorazepam, diazepam; treat fever with antipyretics, parental education
What is a positive gower’s sign?
proximal weakness and inability to stand unaided from supine
Emergency treatment of epilepsy?
0-5min = ABC, 5-15 = lorazepam or buccal midazolam, 15-20 = phenytoin or phenobarbital and call PICU/anaesthetist, 20-40 = PICU
Drug management of epilepsy?
carbamazepine, sodium valproate, ethosuximide, lamotrigine, vigabatrin, levetiracetam, diet, education
S+Ss reflex anoxic attacks?
paroxysmal, self-limiting, asystole, fear and pain triggers; S+Ss = hypotonia, rigidity, upward eye deviation, clonic, incontinent urine; drugs rarely needed
S+Ss panayiotopoulos syndrome?
benign focal seizure disorder, 5yrs peak, autonomic symptoms; vomiting and eye deviation before seizure, at night; no drugs as recover in 2yrs
What is ohtahara syndrome?
tonic spams with/out clustering
Treatment of ohtahara syndrome?
chloral hydrate
What does ohtahara syndrome develop into?
west syndrome then lennox-gas-taut syndrome
S+Ss rolandic?
benign, brief, infrequent, unilateral facial/oropharyngeal and rarely speak; no treatment needed
S+Ss migraine?
severe bilateral or frontal 1-48 hours, N+V either 2 of photophobia, phonophobia, visual, sensory aura; aggravated by activity, daily then chronic, CHOCOLATE aggravators
Treatment migraine?
paracetamol, ibuprofen, domperidone for nausea and sumatriptan if doesn’t work
Prophylaxis for migraine?
avoid triggers, pizotifen if not then propranolol and amitryptilline
What is craniostenosis and its complications?
premature closure of skull’s fibrous sutures by ossification (should be 3-9 months for frontal and 22-39 months for rest – can mean brain diesn’t have enough growth room = high ICP, sleep loss, eating problems, visual loss, low IQ)
Investigations for myopathy?
plasma CK, muscle biopsy, DNA testing, US/MRI muscles
S+Ss spinal muscular atrophy?
AR, degeneration of anterior horn cells; S+Ss = tongue fasciculation, symmetrical flaccid paralysis, absent deep tendon reflexes, intercostal recession, weakness of bulbar muscles, death from resp failure in 12 months
S+Ss dermatomyositis?
5-10yrs; S+Ss = symmetrical muscle weakness, sometimes with pharynx, purple rash on eyelids, periorbital oedema
Treatment dermatomyositis?
physio, corticosteroids, immunosuppressants
S+Ss Freidrich ataxia?
AR; S+Ss = worsening ataxia, dysarthria, wasting in lower limbs, absent reflexes, pes carvus, kyphoscoliosis, DM, cardiomyopathy, death at 40-50yrs
S+Ss ataxia telengiectasia?
AR condition of DNA repair; delay in motor movement, complex eye movement disorder, cerebellar ataxia, dysarthria, susceptibility to infection, malignant disorder, progressive pulmonary disease
What is anencephalopathy?
failure of development of cranium and brain (myelocele); most stillborn
Types of myelodysplasia?
neuroectoderm defect (no fused tube = myelocele, double neural tube = diplomyelia, herniation through bony defect = meningocele and meningomyelocele if cord as well)
Prevention of myelodysplasia?
folic acid to mother
What is spina bifida occulta?
failure of vertebral arch fusion
S+Ss meningocele?
variable paresis of lower limb, muscle imbalance, sensory loss, bladder/bowel denervation, scoliosis, hydrocephalus
Treatment of meningocele?
physio, indwelling catheter, checks for HT/RF/UTI, laxatives, suppositories, surgical treatment
Treatment of hydrocephalus in kids?
cranial US in young and CT/MRI in kids with head circ, use a ventriculoperitoneal shunt
S+Ss type 1 neurofibromatosis?
AD, mutation in neurofibromin-1 gene; S+Ss = >6 café-au-lait spots, neurofibroma on periphery nerves, axillary freckling, optic glioma, bony lesions, 1st degree relative with condition; sometimes megalencephaly with LD and epilepsy
S+Ss type 2 neurofibromatosis?
AD, present in adolescence, bilateral acoustic neuromata, present with deafness and cerebellopontine angle syndrome, multiple endocrine neoplasia syndromes
S+Ss tuberous sclerosis?
AD, mutations in TSC1/2 genes; S+Ss = depigmentation patches, roughened skin over lumbar spine, angiofibromata (over nose-bridge), developmental delay, epilepsy, LD, fibromata under nails, dense white areas on retina, rhabdomyata on heart, angiomyolipomas, polycystic kidneys, lung cysts
S+Ss Sturge-Weber syndrome?
sporadic, port-wine stain in trigeminal distribution, epilepsy, LD, contralateral hemiplegia, ophthalmic nerve always involved
Treatment Sturge-Weber syndrome?
laser treatment to reduce ipsilateral glaucoma risk
S+Ss foetal alcohol spectrum disorder?
microcephaly, short palpebral fixtures, hypoplastic upper lip, small eyes, low IQ, cardiac mmalformations
S+Ss x-linked adenoleukodystrophy (ALD)?
peroxisomal defects and neonatal (feeding problems, seizures, hypotonia), X-linked (adrenal glands, brain cells and myelin), childhood cerebral (boys 4-12yrs, low academic performance, regression, ataxia, adrenal insufficiency), adrenomyeloneuropathy (slowly progressive spastic paraparesis, dorsal column sensory disturbance)
HEADS for taking a psychosocial hx in adolescents?
Home life, Education, Activities, Driving drugs and diet, Sexual health sleep suicide and safety
What are the 4 points of child rights?
survival rights (food, shelter, access to healthcare), developmental rights (achieve full potential in education, play, thoughts, religion), protection rights (against all forms of abuse), participation rights (active role in the community)
Top 5 causes of death in children worldwide?
pneumonia, diarrhoea, HIV, malaria and measles
Systems review in child?
general rashes, fever; resp (cough, wheeze, breathing problems); ENT (throat infections, snoring, noisy breathing); CV (murmur, cyanosis, exercise tolerance); GI (D+V, constipation, abdo pain); GU (dysuria, frequency, bed-wetting); neuro (seizures, headaches, abnormal movements); MSK (gait, limb pain, swelling)
What is fogg’s test?
walk on heels, inside and outside of feet to assess gait
Give the primitive reflexes in infants?
moro (sudden head extension causes extension then arm flexion – similar to startle reflex but this dwindles after multiple times), grasp, rooting (head turns to stimulus when touches near mouth), stepping response, asymmetrical tonic neck reflex (when lying supine head turns to side and arm outstreteched)
Give the postural reflexes in infants?
labyrinthine righting (head moves opposite to way head tilted), postural support (when held upright legs take support), lateral propping (arm extends to way child falls), parachute (arms extend when held upside down)
What is developmental screening?
checking children at set ages for milestones and formal process
What is developmental assessment?
detailed analysis of particular areas if development to follow up any concerns for diagnosis and formulating a management plan
What is the healthy child programme?
screening tests, development reviews, health promotion from 0-19yrs
What is optoacoustic emission?
use earphone to produce a sound from the ear if cochlear working
What is auditory brainstem response audiometry?
computer analysis of EEG from auditory stimuli
What is visual reinforcement audiometry?
Turn head to stimulus with different frequencies
What is performance and speech discrimination testing?
Can visibly understand the content of what is being said (asked to pick up a toy etc)
Give the gross motor function classification?
level 1 = walks without limitations, 2 = walks with limitations, 3 = use handheld mobility advice, 4 = self-mobility with limitations (may need powered mobility), 5 = in manual wheelchair
What is amblyopia?
potentially permanent loss of visual acuity in eye/lazy eye
What is involved with the common assessment framework (for special needs)?
multidisciplinary sharing of diagnosis, assessment of functional skills, provision of therapy, regular review, coordinated approach to care
Flowchart progression for evidence based paeds practice?
Frame question, search for evidence, appraise the evidence and make a decision and evaluate your performance
S+Ss compensated shock?
tachypnoea, tachycardia, low skin turgor, sunken eyes and fontanelle, delayed cap refill, mottled/pale/cold skin, core-peripheral temp gap >4degrees, decreased urine output
S+Ss decompensated shock?
acidotic breathing, bradycardia, confusion, blue peripheries, absent urine output, hypotension
S+Ss sepsis?
fever, tachycardia, tachypnoea, purpuric rash (meningococcal shock), poor feeding, irritable, focal infection, multi-organ failure, shock
Causes of life threatening events?
infections (RSV and pertussis), GORD, seizures, upper airway obstruction
Investigations of life threatening events?
blood glucose, blood gas, O2 sats, cardioresp monitoring, EEG, oesophageal pH, barium swallow, FBC, U+Es, lactate, urine (culture, toxicology, microscopy, metabolic), ECG, CXR, LP
What chelating agents used for lead posioning?
D-penicillamine or EDTA if severe
2 types of birth defects?
single-system or sequence
4 causes of dysmorphology?
malformation (primary structural defect in development of organ), deformation (abnormal uterine force distorting normal formed structure), disruption (destruction of part that was formed normally), dysplasia (abnormal cells/organisation of tissue)
Genetic testing methods?
PCR, FISH, aCGH, GWAS
When to consider DOPE and what it is?
When intubating newborn isn’t working; displaced airway, obstructed airway, patient (airway disorders, shock, birth asphyxia etc), equipment failure
What to give all newborns to stop haemorrhaging?
Vit K
What is the guthrie/heel prick/newborn screening test for in newborns?
biochemical screening from blood; for checking if have phenylketonuria, hypothyroidism, haemoglobinopathies, CF, MCAD
Why is hypothermia a problem in preterm infants and how is it prevented?
thinner walls, less fat, large SA to V ratio; put in incubators, cover and keep dry
What is the cause of transient tachypnoea in the newborn?
delay in resorption of lung liquid
How to prevent left to right shunting in persistent pulmonary hypertension of the newborn?
use NO or sildenafil to dilate vessels
Main cause of pulmonary hypoplasia in newborn?
Diaphragmatic hernia
Neonatal seizures S+Ss?
unstimulated, repetitive, rhythmic clonic movements
Neonatal seizures treatment and investigations?
use EEG and check for hypoglycaemia/meningitis, head US, use MRI to check for stroke
What is the fastest growth period?
Foetal
What is failure to thrive?
Inability to grow in infantile growth stage
What is craniosynostosis?
premature fusion of the skull sutures leading to head shape distortion
When does the brain dveelop the most?
Last trimester of pregnancy and first 2yrs of life
Problems with breastfeeding?
o Can transmit drugs or infection (hep B, HIV), jaundice, less flexible, vit K if breast milk is deficient
Mechanism for breastfeeding?
baby uses rooting, sucking and swallowing reflex, tactile receptors in nipple activated, hypothalamus sends impulses to anterior (prolactin secretion for milk secretion from cuboidal cells) and posterior pituitary (oxytocin for contraction for ‘let down’ reflex in myoepithelial cells)
When should be weaning of pureed food be introduced?
After 6 months (don’t give wheat, eggs, fish) and no honey til 1yr to prevent infantile botulism
Causes of failure to thrive?
organic (impaired suck/swallow reflex, cleft palate, Crohn’s, chronic renal failure, CF, liver disease, coeliac, cow’s milk intolerance, chromosomal disorders) or non-organic (psychosocial and environmental deprivation), undernutrition for both
History taking in failure to thrive?
diet, feeding details, energy levels, diarrhoea, vomiting, cough, premature/IUGR, growth of other family, development normal, psychosocial, HF, dysmorphia
How is vit D3 activated?
hydroxylated by liver from oral/sun intake or from bone by parathyroid hormone
Earliest sign of rickets?
craniotabes (ping pong sensation in skull)
Pathophysiology of vit A deficiency?
aka retinol, complication of fat malabsorption
S+Ss and complications of Vit A deficiency?
S+Ss = rare other than can’t adapt to dark light; complications = eye damage (xerophthalmia), night blindness from corneal ulceration and scarring, susceptible to infection
S+Ss Meckels diverticulum?
ectopic gastric mucosa/pancreatic tissue, S+Ss = severe rectal bleeding, volvulus, diverticulitis
Aetiology and S+Ss volvulus?
mesentery unfixed at duodenojejunal flexure/ileocaeal region and obstruction with/out compromised blood supply, dark green bilious vomiting, abdo pain from peritonitis/ischaemia
Treatment for diarrhoea in kids?
fluids (isotonic), abx (don’t try to use anti-diarrhoea/anti-emetics) then give good nutrition post-infection
SS and aetiology of coeliacs?
AI against gluten to lead to villous atrophy, anaemia, failure to thrive and abdo distension
Difference between UC and crohns?
only after ileum and crohn is skip lesions and anywhere from mouth to anus
What is used to treat EBV in kids if not serious?
Amoxicillin/ampicillin with symptomatic management (airway management)
TB S+Ss in kids?
fever, malaise, anorexia, weight loss, focal infection signs
Tests for TB?
Mantoux, interferon gamma release assays (best one) and tuberculin tests
RIPE treatment for TB?
rifampicin, isoniazid, pyrazinamide, ethambutol
Vaccine prevention TB?
BCG
Sinusitis in paeds S+Ss?
mainly paranasal sinuses with tenderness, swelling
Treatment for sinusitis?
acute give abx, analgesia and topical decongestants
Indications for tonsillectomy or adenoidectomy?
recurrent tonsillitis, OSA, peritonsillar abscess
Differences between croup and epiglottitis?
croup over days rather than hours, no coryza in epiglottitis before, severe coughing/barking, can’t drink in epiglottitis, drooling in epiglottitis, higher fever and more unwell in epiglottitis, harsher stridor in croup
Vaccines against the pathogens causing pneumonia?
Prevenar and Hib
What is global developmental delay in children?
delay in more than 2 areas of development – mild, moderate and severe determined against children of their age
What test and why would you do in a boy 18 months old and not walking?
CK for muscular dystrophy
Dx diagnosis of testicular torsion?
testicular appendage/Mullerian remnant is torsion of appendix testis and mimics testicular torsion
Dx of lumps in neck?
thyroglossal cyst on front of neck (surgical removal), cervical lymph nodes swelling (viral infection but if >2cm for 2wks then maybe lymphoma etc), brachial fistula
What is omphalitis?
infection of umbilicus, can form sepsis quite easily so needs immediate treatment
Consequences of tricuspid atresia?
mixing of blood and difficult to treat surgically as right atria not working, relies on venous pressure to pump blood to lungs, palliation, chronic cyanosis that worsens
Tests of kidney function in children?
plasma creatinine conc, eGFR, inulin/EDTA filtration rate, plasma urea conc
Consequences of acute nephritis?
hypertension, oedema, proteinuria, haematuria, decreased urine output, volume overload
Normal conditions in young boys in the genitals?
preputial adhesions (foreskin partially adherent to glans) and trapped epithelial squames looking like white pearls under foreskin
Indications for circumcision?
recurrent balanoposthitis, recurrent complicated UTIs, phimosis
Treatment for vulvovaginitis and fusion of labia minora firstline?
Topical oestrogen
Warning signs for jaundice in neonates needing treatment?
• Prolonged neonatal jaundice (with pale stools, dark urine, bleeding tendency, failure to thrive)
Main S+Ss of liver failure?
encephalopathy, jaundice, epistaxis, pale stools, dark urine, bleeding tendency, failure to thrive, ascites, hypotonia, peripheral neuropathy, rickets, varices of portal hypertension, spider naevi, muscle wasting, bruising, petechiae, splenomegaly, hypersplenism, hepatorenal failure, liver palms, clubbing
Diagnosis of billiary atresia?
operative cholaniography
How to treat billiary atresia?
Kasai procedure/hepatoportoenterostomy
Causes of chronic liver disease?
hep B and C, AI hepatitis, nitrofurantoin/NSAIDs, IBD, primary sclerosing cholangitis, Wilson’s, alpha 1 antitrypsin, CF, neonatal liver disease, bile duct lesions
Treatment of ascites?
Diuretcis and fluid and sodium restriction
Treatment of spontaneous bacterial peritonitis?
Broad spectrum abx
Vitamins given in liver failure?
ADEK
3 indicators of malignancy in general?
localised mass, disseminated disease (bone infiltration etc), pressure from mass on local structures
SEs of chemo?
Allopecia, GI damage, N+V
Name of the cells in Hodgkin’s lymphoma to diagnose?
Reed-sternberg
Most common way retinoblastoma picked up?
White reflex instead of red reflex
S+Ss of langerhans cell histiocytosis?
technically not cancer; S+Ss = seborrheic rash, widespread soft tissue infiltration, bone pain/swelling, diabetes insipidus
5 factors involved in blood clotting homeostasis and how they do it?
coagulation factors (vessel injury and from liver), coagulation inhibitors (stop widespread coagulation), fibrinolysis (limits fibrin deposition to just site of injury), platelets (aggregate at site of injury for fibrin), blood vessels (initiate and limit coagulation, intact release prostaglandin I2 and NO for vasodilation and inhibition platelet aggregation; damaged releases tissue factor and procoagulants [VWF and collagen])
Are haemangiomas ok?
not good in mouth as obstruction, eye and use beta blockers
What are mongolian blue spots (on bottom)?
not bruises btu fine and should go away
What is coxsackie?
hand, foot and mouth disease
Molluscum contagiosum S+Ss?
red warts all over skin
What causes impetigo and therefore what should you use to treat it?
from staph aureus and use flucloxacillin
DKA CO2 and pH and HCO3 values?
pH = 7.06, CO2 = 2.8 and HCO3 = 13
What happens after 6 months of ITP?
Becomes chronic and should screen for SLE
What age do babies get upset about removal from their main caregiver?
6-8 months
What is the triphasic acute separation reaction?
mounting fear mother doesn’t reappear; then child becomes withdrawn from play, food and speech; child eventually cheers up but now indifferent to the mother (detachment)
What does the PATHOS mneumonic stand for in assessing suicide risk?
Problems for longing than a month?, Alone in the house at the time?, plan the OD for longer than Three hours?, feeling HOpeless about the future?, feeling Sad most of the time before OD?
Main psych treatment for emotional and behavioural problems?
explanation and reassurance, counselling of child/parents, parenting groups, behavioural therapy, family therapy, cognitive therapy, individual or group dynamic psychotherapy
What is a collodion baby and how to treat?
baby comes out dry and scaly skin; use emollients and moisturisers
S+Ss ringworm?
when dermophyte fungi invade dead keratinous skin, scalp from dogs and cats, UV light can show yellow infected hairs
Treatment ringworm?
Topical antifungals
What is pediculosis?
Headlice
Long-term risks from diabetes?
stunted growth, delayed puberty, HT, renal disease, retinopathy, peripheral neuropathy (feet), type 1 associated with coeliac, thyroid disease and other AI diseases
Definition of hypoglycaemia?
BG below 2.6mmol/L
Main cause of hyperthyroidism in children?
Grave’s disease
Causes of failure of treatment?
ADECB = adherence, diagnosis, environment, choice of drugs/device, bad disease
Definition of UTI?
at least 10^5 organisms in urine
Types of strabismus?
eye deviation/strabismus = esotropia (eye deviates in), exotropia (eye out), hypertropia (up) and hypotropia (down); others = deviation when covered esophoria, exophoria, hyperphoria, hypophoria
What is anisometropia?
difference in refractive error (associated with strabismus and amblyopia)
How to detect a strabismus?
Corneal reflective test, cover test using corneal reflection
Treatment of amblyopia?
refractive adaptation (glasses), occlusion of the better seeing eye, atropine drops to paralyse the good eye
Management of strabismus?
glasses, orthoptic exercises, prisms, surgery or botox in extraocular muscles
What are the three factors a disability is defined by?
functioning, activity and ability to participate
WHODAS 6 domains of functioning covered in assessing a disability?
cognition, mobility, self-care, social, life activities, participation
Problems with prematurity?
chronic lung disease of prematurity, inadequate neural development (LD), apnoea of prematurity (baby forgets to breath, give phosphodiesterase inhibitor and caffeine, CPAP), ventricular haemorrhage (not usually long-term consequences unless massive), cystic periventricular leukomalacia (worst type of premature brain injury – end up with some kind of plegia [hemi, para, tetra]), 22-25 wks very high likelihood of death
Who automatically has parental responsibility?
• Unless married, the mother has parental responsibility of the child’s care
Factors to cover when thinking about when to apply fraser guidelines (and Gillick competency)?
girl understand advice, cannot persuade to tell parents about contraceptive advice, likely to keep having sex, unless she has contraceptive advice physical and mental health suffer, best interests to give contraceptive advice
Cause of transient tachypnoea of the newborn?
C section
Origin of cause for inspiratory stridor?
Laryngeal
Origin of cause for biphasic stridor?
subglottis/trachea
Origin of cause of expiratory stridor?
bronchi
ENT causes of stridor?
laryngomalacia, cysts, papilloma, haemangiomas, clefts, post intubation subglottis stenosis, tracheobronchomalacia
Diagnosis of OSA?
Polysomnography and management from hx and examination (large adenoids need removal with tonsils)
Which side does foreign body tend to fall into in lung?
Right side
Red flag sign causes for high fever?
Pneumonia, UTI, bone/joint infection, kawasaki, flu, meningitis and meningococcal septicaemia
S+Ss meningococcal sepitcaemia?
Fever, rigors, mottled, rash (non-blanching), bulging fontanelle, febrile, tachypnoea, tachycardia, cold peripheries, delirium, arthralgia
What is a vesicle?
blistering like in chicken pox/herpes simplex
What is a pustule?
pus in a vesicle
What is petechiae?
smaller spots of purpura (below 2mm)
What is urticaria?
raised, itchy red rash usually from reaction and looks like nettle sting
What is eczema?
dry itchy skin and can be red
What is the mnemonic and what it stands for for emergency management of a seriously ill child?
ABCDENT TT - airway, breathing, circulation, ENT, temperature, tummy
Thalidomide ADR?
fetal congenital abnormalities
Surfactant ADR?
pulmonary haemorrhage
Chloramphenicol (eyedrops abx) ADR?
grey baby syndrome
Ceftriaxone ADR?
calcium precipitation
Sulphonamides ADR?
kernicterus
Aniline dye from nappies ADR?
methaemoglobinaemia
Sodium valproate ADR?
liver toxicity
Propofol ADR?
metabolic acidosis
Lamotrigine ADR?
serious skin reactions
What does more protein in CSF mean?
Bacterial CNS infection
Sepsis 6 for child?
High flow oxygen, inotropic support, IV/IO access and bloods, IV/IO abx, involve senior clinicians
SEs of rifampicin?
Nausea, thrombocytopenia, liver problems and reduces efficacy of the pill
Management of septic child?
sepsis 6, fluid management (20ml per kilo), 3x bolus then intubate if not stable, metabolic disturbances found and corrected, catheterise
Give 2 DMARDs?
methotrexate/sulfasalzine
My HEART mnemonic for kawasaki S+Ss?
mucosal involvement like dry lips and strawberry tongue, Hands and feet with desquamation and oedema, Eyes non-purulent bilateral conjunctivitis, adenopathy of cervical lymph nodes, rash usually truncal and pleomorphic, temperature for at least 5 days
Treatment for kawasaki?
Aspirin and IVIg
Fluid management for DKA (values for shocked and not shocked)?
shock = 1st bolus 20ml/kg 0.9% NaCl, further use 10ml/kg; not shocked = 10ml/kg 0.9% over 1 hour
The MISFITS and NEOSECRETS causes acronyms for collapsed child?
o T: Trauma, tumor, thermal
o H: Heart disease, hypovolemia, hypoxia
o E: Endocrine (CAH, DM, thyroid)
o M: Metabolic disturbances (electrolyte imbalance)
o I: Inborn errors of metabolism
o S: Seizures or CNS abnormalities
o F: Formula dilution or over-concentration leading to hypo/hypernatremia
o I: Intestinal catastrophe (intussusception, volvulus, NEC)
o T: Toxins (including home remedies such as baking soda for burping)
o S: Sepsis
o N: iNborn errors of metabolism o E: Electrolyte abnormalities o O: Overdose o S: Seizures o E: Enteric emergencies o C: Cardiac abnormalities o R: Recipe (formula, additives) o E: Endocrine crisis o T: Trauma o S: Sepsis
What medication to give for high risk of RSV (immunodeficient/CF)?
Prophylactic palivizumab every month
Longterm management for HF with septal defects?
ACEi, diuretics
Causes of faltering growth categories?
Intake decreased, increased metabolism/requirements, decreased absorption
Stool softeners examples for faecal impaction?
Movicol and lactulose
Stimulant laxative example?
Senna
What are TORCH and when are they referred to?
toxoplasmosis, rubella, cytomegalovirus, herpes simplex; antepartum infections
EEG for absence seizure?
3 spikes
First line treatment drugs for paeds epilepsy?
sodium valproate, ethosuximide
What type of seizure tends to happen in the morning and what type of epilepsy can it develop from?
Myoclonic from absence seizures
Cause of resp distress in premature baby?
Choanal atresia, IVH, sepsis, surfactant dysfunction, congenital heart defect, congenital pulmonary defect, pneumonia (strep B), sepsis (treat with benzylpenicillin, amoxicillin and gentamicin)
Treatment amount for sepsis in premature baby of benzylpenicillin?
25mg/kg
How does jaundice tend to progress?
From the eyes craniocaudally downwards
Obstructive jaundice signs?
pale stools and dark urine
S+Ss and aetiology of medium chain acyl CoA dehydrogenase deficiency (MCADD)?
fat breakdown; infections, fasting, diarrhoea, vomiting with encephalopathy with death if untreated
Treatment of MCADD?
IV/enteral glucose before BMs decrease
mnemonic PAMGU for main illnesses in kids?
pneumonia, acute otitis media, meningitis, gastroenteritis and uti
BINDS mnemonic for PMC?
Birth hx, immunisations, neonatal, development hx, shx
VITAMIN CDE for differentials?
vascular, infectious/inflammatory, traumatic/toxic, autoimmune, metabolic, iatrogenic/idiopathic, neoplastic, congenital, degenerative, endocrine
O SHIT for asthma management in severe attacks and IV treatment after this?
oxygen, salbutamol (nebulised and IV), hydrocortisone, ipratropium bromide, theophylline
IV = magnesium sulfate and then salbutamol
Give a tocolytic?
Atosiban
