Paediatrics Flashcards
What are the components of a newborn examination
Cardiac/resp Red reflex Fontanelle Face and mouth Abdomen Nappy area Hips Limbs Prone Reflexes
What are the components of a newborn cardiac/resp exam
Listen to 4 areas over the chest, including with the bell- less than 200 bpm is pathologic
- May have innocent murmurs due to flow velocity change in different sized vessels
Anterior resp auscultation is enough in absence of signs
More than 60 breaths is pathologic
Can auscultate abdomen here but low yield
- Inspect and palpate chest after auscultation
What are the components of a newborn red reflex exam
- Baby needs to be awake and in a dimmed room, looking through ophthalmoscope with both eyes
- Looking for asymmetry or whitening
- Could indicate congenital cataract/glaucoma or retinoblastoma
Describe the anatomy of a fontanelle
Sutures are coronal, saggital, metopic and lambdoid
Describe the components of a fontanelle exam
Feel along sutures and both ant and post fontanelles
May initially feel as if they overlap due to pressure from birth
ABNORMAL if no suture or ridge feeling- may be due to pressure from early fusion (craniosynostosis)
Widening within the saggital suture may be due to trisomy 21
If wormian bones are present they will feel like cracked eggshell
Describe components of neonatal face and mouth exam
Look for any abnormalities in skull shape and facial symmetry (but check the parents!)
Palate- look at uvula and feel/look at palate for cleft
Describe component of neonatal abdominal exam
Inspect and palpate for masses and discoloration
Check umbilical cord for erythema- oomphalitis
Quick feel
Check for liver and spleen, starting in RIF for both
- You can palpate liver and spleen in a normal neonate
Kidneys are low yield
Describe the components of the neonatal nappy area exam
Femoral pulses
Fingers into medial hip creases to part labia in girls
Boys- fingers right behind scrotum to check for testes, feeling down
Lift legs up to examine anus
Describe the components of the neonatal hip examination
Barlow and ortolani’s test
Describe barlow’s test
Can it dislocate?
Femur adducted, press down and out
Describe the ortolani test
Can the hip go back in?
Abduct femur, press in and up
Describe the limb exam for the neonate
Count and assess fingers and toes
Check for palmar creases (glyphs)- only one crease in down syndrome
Describe the components of the prone neonatal exam
Hold baby prone perpendicular to arm- does baby hold itself rigid for a couple of seconds? Indicates normal tone
Check for sacral dimple/tufts of hair/port wine stain- indicates possible spinal bifida occulta
Skin changes- peau d’orange, masses, rashes
Describe the neonatal reflexes to check
Grasp
Root
Suck
Pull to sit- hold baby forearms, lift up- at past 80 degrees head should fall forward
Moro- hold baby’s head in palm, drop arm down from 80-20 degrees quickly
- Normal response is symmetric arm abduction and extension, then back to midline
- Abnormal may suggest brachial plexus palsy (Erb’s/clumpkies) or clavicle plexus
Causes of acute abdominal pain
IBD Appendicitis Henoch-Schonlein purpura UTI Constipation Bowel obstruction Gastroenteritis Intussusception Diabetes Lower lobe pneumonia Peptic Ulcer Renal stone Ovarian torsion/cyst/ectopic Volvulus
Causes of recurrent abdominal pain (categories)
Hepatitis Gastrointestinal Urinary Pancreatitis Gynaecological Psychogenic Abdo migraine Sickle cell disease
Features of IBD on history
Acute abdo pain
Blood or mucus in stools
Weight loss and poor stools
FHx of diarrhoea
Features of acute apendicitis
Acute abdo pain Anorexia Pain localises to RIF Peritonism in RIF Tachycardia Low grade fever Vomiting and diarrhoea
Features of Henoch-Schonlein purpura
Acute abdo pain
Purpuric rash on legs
Joint pain
Features of UTI on history
Abdo pain Dysuria and frequency Bedwetting Back pain Vomiting MSU/microscopy is positive
Features of constipation on history
Abdo pain
hard or infrequent stools
Mass in LIF
Faecal loading on radiograph
Features of intestinal obstruction on history
Abdo pain
Bile stained vomiting
Abdo distension
Consider volvulus
Features of gastroenteritis on history
Abdo pain
Vomiting and diarrhoea
Features of renal calculi on history
Abdo pain
Hydronephrosis
Features of peptic ulcer on history
Abdo pain
Pain at night
Relief with milk
Helicobacter pylori
Features of lower lobe pneumonia on history
Abdo pain
Signs of pneumonia
Referred abdominal pain
Features of diabetes on history
Abdo pain
Diabetic ketoacidosis
Features of intussusception on history
Abdo pain Intermittent screaming/colic Shock/pallor Redcurrant jelly stool is a late sign 3-24mo old Often following a viral infection Palpable sausage shaped mass
Ix for appendicitis
Bloods- leukocytosis, neutrophilia
Urine to exclude UTI
CT if in doubt
Mx for appendicitis
Laparoscopic appendectomy
If perforation- may be adhesions etc.
ABX
Ix for intussusception
- Abdominal radiograph- may show proximal bowel obstruction, edge of intussusception against gas filled lumen
- USS- Shows ‘donut sign’
Mx for intussusception
- Often reduced by air or barium enema
- If evidence of peritonitis- laparotomy
Features of volvulus
Torsion of malrotated intestine
Severe abdo pain and bilious vomiting
Urgent surgery to untwist
Mechanism of mesenteric adenitis
Enlarged mesenteric nodes cause acute pain but no peritonism or guarding
Mx of mesenteric adenitis
Simple analgesia
Types of chronic abdo pain due to GI causes
IBS Oesophagitis Peptic ulcer IBD Constipation Malabsorption Giardiasis
Types of chronic abdo pain from urinary tract
Lower UTI
Pyelonephritis
Types of chronic abdo pain from gynaecological
Dysmenorrhoea
PID
Haematocolpos
Ovarian cyst
Features of IBS
Recurrent abdo pain
Bloating
Altered bowel habit
May have alternating diarrhoea and constipation
Dx of IBS
Symptoms must be present for 6mos
Requires an organic cause to be excluded
Mx of IBS
Acute symptoms resolve
May need re-evaluation of diagnosis
Smooth muscle relaxants may help spasms
Causes of vomiting
Overfeeding GORD Pyloric stenosis Whooping cough SBO Constipation Systemic infection Early pregnancy (older females) Ingestion of toxins Raised ICP Migraine Gastroenteritis
Features of overfeeding causing vomiting
Feeding >200mL/kg/day
Features of GORD causing vomiting
Due to lax GO sphincter and may see positional vomiting
May lead to oesophagitis or aspiration pneumonia
Can see apnoea or failure to thrive
Features of pyloric stenosis causing vomiting
4-6 weeks old Projectile vomits after feeding Hungry after vomiting Less frequent stools Palpable pyloric mass
Features of whooping cough causing vomiting
Paroxysmal cough, red or blue colour change and then vomit
Features of SBO causing vomiting
Bile stained vomit
Presents soon after birth
May show a distended abdomen
Causes of diarrhoea in children
Toddler's Diarrhoea Nonspecific Diarrhoea Cystic fibrosis Coeliac disease Secondary lactose intolerance Overflow diarrhoea UC Lactose intolerance Crohn's disease Giardia
Features of toddler’s diarrhoea on history
- Thriving toddler
- Loose stools containing undigested food
- May have large fluid intake
- Fast gut transit time
Features of nonspecific diarrhoea on history
Loose watery stools
Thriving child, may follow after acute gastro
Features of giardia infection
Weight loss and abdominal pain
Watery stools
Common in nurseries
Features of crohn’s disease on history
Late childhood/adolescence
Weight loss and abdominal pain
Anorexia and fatigue
Exacerbations and remissions
Features of cows milk protein intolerance
Occurs in babies
Watery stools that may be bloody
May also show urticaria, stridor, bronchospasm or eczema
Features of UC on history
Late childhood and adolescence
Bloody stools and abdominal pain
Exacerbations and remission
Features of overflow diarrhoea in constipation
Soiling rather than diarrhoea
Constipated stool may be palpable abdominally or rectally
Features of secondary lactose intolerance on history
Baby or toddler
Follows acute gastro
Watery stools with low pH and reducing substances
Features of coeliac disease on history
Failure to thrive with irritability, muscle wasting, abdo distension
Often presents after introduction of wheat into diet
Fatty stools
Diagnosed on jejunal biopsy
Features of cystic fibrosis on history
Starts in infancy
Failure to thrive with chest infections
Fatty stools
Diagnosed with sweat test
Mx of secondary lactose intolerance
Empirical formula change to soy or lactose free milk
Revert to cows milk after symptom resolution
Ix for coeliac disease
Iron deficiency anaemia
Steatorrhea
IgA tTGA2 present in blood
Definitive diagnosis with villous atrophy on jejunal biopsy
Mx of coeliac disease
Gluten free diet indefinitely
Repeat challenge and biopsy at 2 years
Assoc with coeliac disease
Diabetes
Down syndrome
Dx of crohns disease
Endoscopic biopsy
Mx of crohns disease
Elemental diet Immunodulator drugs Anti- TNF-a (infliximab) Steroids Surgical resection if localised
Mx of UC
Oral or rectal mesalazine or steroid enemas
May require immunosuppression, infliximab or colectomy if severe
Dx of giardia
Microscopic stool examination over 3 seperate specimens
May also have eosinophilia on bloods
Mx of giardia
Metronidazole
