paeds Flashcards
causes of dehydration main categories
reduced intake
increased loss
causes of dehyrdration
REDUCED INTAKE
- dysphagia /neurodisability (cleft palate, developmental delay, cerebral palsy)
- vomitting (gastroenteritis, GORD, URTI, chemo)
- behavioural/ psych (food refusal, anorexia)
- child neglect
INCREASED LOSS
- gut (gastroenteritis, IBD, stoma)
- kidneys (renal tubular disease, nephrogenic diabetes insipidus, renal dysplasia)
- lungs (cystic fibrosis, cardio/resp diseases)
- skin (burns, cystic fibrosis, sepsis/fever)
signs of dehydration - mild (5% water loss), moderate, severe (10%)
thirst
dry lips
restless, irritable
sunken eyes
reduced skin turgor
decreased urine output
anuria
cold, mottled peripheries, hypotension
reduced conciousness
dehydration complications
constipation
developmental delays
UTI
failure to thrive, malnutrition
managment principles of rehydration for different levels of dehydration
Not dehydrated (eg elective surgery) = maintenance Dehydrated = maintenance + correct deficit Shocked = maintenance + correct deficit + bolus (C as part of ABCDE - part of their resuscitation)
maintaince of hydration formula
first 10kg = 100ml/kg (10x100)
second 10kg = 50ml/kg
all other kg = 20ml/kg
this = daily total. so divide by 24 for hourly amount
how to calculate estimated weight
Estimated weight (kg) = (age +4 ) x2
defecit correction for hydration formula
Deficit % x 10 x weight (kg)
Over 24h or 48h
fluid bolus for dehydration amount
20mls/kg of 0.9%
Sometimes 10ml/kg more
Sometimes less than 20 – give 10ml/kg of 0.9%
- Trauma
- DKA
what is monitored in dehydration
BP HR O2 sat RR Capillary refill Temperature Appearance and behaviour - Lips dry - Sunken eyes - Skin turgor - Restless - Reduced consciousness U/Es Urine output
ondasteron =
prevents vomitting. try in dehydrated, esp gastroentiris
when are fluids given orally/ IV for dehydration
flexible but generally 5% (mild) - oral; 10% severe - IV
toddlers diarrhea
Foul smelling, watery. May contain mucus or undigested material
No other thriving problems in baby
Exclusion diagnosis (infection, malabsorption)
extra things to ask in paeds history
Feeding /hydration
- How often
- How much
- How long on breast
- Fed overnight
- Wet nappy - how many, how much wetness (heaviness of nappy)
- Bowels opening - diarrhea
Fever
- If checking temperature, how – Under arm best, What reading, Since when
- Any action eg paracetamol
Rashes
- inc Non-blanching -septicaemia
Behaviour
- Are they their usual selves
- How happy - have you seen them smile today
Contacts
- Who lives at home? Are they well?
- Anyone ill at school
- Been abroad?
Ask about birth history
- How many weeks
- Mode of birth (vaginal, elective, emergency, instrumental)
- Any time in neonatal unit after birth
- Feeding
Development
- “Have you got any concerns about development?”
- Ask about milestones - independent walking etc
- Growth
vaccination history
- Are they up to date
- Flu
- Any extra?
- Preterm have additional winter vaccines
extra things to ask in paeds history
Feeding /hydration
- How often
- How much
- How long on breast
- Fed overnight
- Wet nappy - how many, how much wetness (heaviness of nappy)
- Bowels opening - diarrhea
Fever
- If checking temperature, how – Under arm best, What reading, Since when
- Any action eg paracetamol
Rashes
- Non-blanching -septicaemia
Behaviour
- Are they their usual selves
- How happy - have you seen them smile today
Contacts
- Who lives at home? Are they well?
- Anyone ill at school
- Been abroad?
Ask about birth history
- How many weeks
- Mode of birth (vaginal, elective, emergency, instrumental)
- Any time in neonatal unit after birth
- Feeding
Development
- “Have you got any concerns about development?”
- Ask about milestones - independent walking etc
- Growth
vaccination history
- Are they up to date
- Flu
- Any extra?
- Preterm have additional winter vaccines
kawasaki presentation / diagnosis
Fever (Essential)
4 out of 5 of:
- Skin rash - diffuse
- Conjunctivitis - red eyes
- Periphery change - Peeling of fingers / swelling / red / pain
- Cracked lips, Swollen red tongue
- Swollen neck lymph gland - painful, solitary, large
non blanching rash- what are you thinking of
meningitis septicaemia
also could be ITP and HSP
if just face/neck/conjunctival petichiae - may be due to retching/ vomitting –> pressure
ASD triad
Rituals
- Certain order in bedroom, fixed on daytimes
- rigid, resist change
Unusual /delayed language
- May have seen speech and language therapist, language may appear stilted
Social difficulty
- Lack of theory of mind, can’t read others
- Lack of understanding unspoken social rules, idioms, body language
PTSD triad
Intrusive sensations, memories/ flashbacks
Avoidance
- Of places, of talking/ thinking about it
Anxiety
kocher’s criteria
Kocher's criteria Fever >38.5 CRP>20 ESR >40 in first hr Cannot bear weight WBC >12
for septic arthritis (limping child)
also - pain often at rest
any age
most common UTI cause. treat with what
e coli
cefcefotaxime
If unresponsive to this, meropenem (a carbapenem) (broader)
flucoxycylin good for what
staph aureus
perthes disease
3-10y Self limiting Ischaemia → necrosis of femoral head Unilateral Seen on X ray Pain, effusion, limited range of motion
Transient synovitis
3-10y
Usually following resp infection (but the effusion is sterile!)
Usually no pain at rest/passive movements
Slipped upper femoral epiphysis
Onset of puberty
Tall and thin or short and obese
Pain, leg length shortening
seen on X ray
what could cause limping
Toxic synovitis = most common - Benign, self limiting Infection - osteomyelitis, septic arthritis - systemically unwell, prev infection Fracture Tumour - Pain, tender, mass possibly Arthritis Slipped upper femoral epiphysis - Onset of puberty - Tall and thin or short and obese - Pain, leg length shortening Perthes disease - Self limiting - Ischaemia → necrosis of femoral head - Unilateral - Pain, effusion, limited range of motion
could be foot, leg, thigh, hip, knee, spine, testiclar or abdomen
presentation of malignancy (general)
Localised mass
- Lymphadenopathy
- Organomegaly
- Soft tissue or bony mass
- Airway obstruction as a result
Disseminated disease → infiltrates bone marrow → anaemia → infections, bruising
Headaches, increase ICP signs (brain tumour)
Fever, weight loss, fatigue
leukaemia
- commonness
- symptoms
- investigations
Leukaemia is common esp ALL
Fatigue Fever Frequent infections Lymphadenopathy hepato/splenomegaly Anaemia - pale, bruising Bone/ joint pain
Blood film - see blastocyte Serum chemistry CXR Bone marrow aspirate Lumbar puncture
Chemo
Haemopoetic stem cell transplant
CNS tumours presentation and treament
Presentation Headache, often worse lying Vomiting, esp early morn Papilloedema Nystagmus Ataxia Behavioural changes Squint
Treatment Surgical resection Radiotherapy Chemo palliative care
negative long term effects of cancer treatment
Endocrine (brain surgery) Intellectual cardiac/renal toxicity - chemo Fertility Psychological
wilms =?
nephroblastoma
ADHD criteria
3 key symptoms = inattention, hyperactivity, impulsivity
6 symptoms of inattention
- Lack of attention to detail, careless mistakes
- Difficulty sustaining attention
- Does not seem to listen when spoken to directly
- Fails to finish tasks
- Difficulty organizing
- Avoids or dislikes tasks that require sustained mental effort
- Often loses things needed for tasks
- Easily distracted by extraneous stimuli
- Forgetful in daily activities
OR 6 symptoms of hyperactivity or impulsivity
- fidgets/taps hands/legs / squirms in seat
- Leaves seats when expected to stay in seat (school, eating, activity)
- runs/ climbs in inappropriate situations
- Unable to play/ leisure quietly
- “On the go”
- Talks excessively
- Blurts out answer before question finished
- Difficulty waiting their turn
- Interrupts or intrudes
Present before 12y
Present in 2 or more settings
Must affect functioning
No better diagnosis
ADHD treatment
Nonpharmalogical
- Parent management and training = 1st line
- —Plan for day, routine
- —Positive reinforcement
- —Brief, specific instructions
- —Incentives eg star chart
- —Keep social interactions with others short and sweet
- —Regular exercise
- —Regular and healthy diet
- —Support from school
- CBT
Pharmacological
- Not advised for pre-school children
- Stimulant
- —Increase dopamine in brain
- —Ritalin (short acting)
- —Delmosart (long acting)
- —Lisdexamfetamine
- Non stimulant
- —Reduce norepinephrine breakdown
- —SNRI - atomoxetine
- —Guanfacine
- Combined therapy
- Side effects
- —Anxiety
- —Reduced appetite
- —Hypertension
- —Psychosis (rare)
MODY
- what might make you suspcious that t1dm is acc mody
- diagnosis
Lots of family with DM
C peptide robust
No antibodies for insulin
Genetic testing
JIA
- commonnes
- when
- diagnosis
- features
Most common inflammatory condition
Juvenile = Onset before 16th birthday
Idiopathic = no other identified cause- diagnosis of exclusion
Rule out:
- Reactive arthritis (following other infection)
- Malignancies inc blood born ones like leukaemia
- Non accidental injury
- Septic arthritis
Arthritis = joint swelling (or painful restriction of movement) - lasting 6w Features - Persistent joint swelling - Joint stiffness - esp morning - Loss of range of movement - Pain - Warmth - Colour change - Joint deformity - Accelerated bone growth - if one leg longer
oligoarticular JIA
4 or fewer joints involved
Typically lower limb
associated with chronic anterior uveitis
polyarticular JIA
More than four joint involved
More rapid bony destruction
Often small joints eg hand/feet
Psoriatic JIA
May be before / after / same time as joint problems
Family link common
Dactylitis , nail pitting - can diagnose it even if child has not yet developed psoriasis
often associated with chronic anterior uveitis
Enthesitis -related JIA
Akin to ankylosing spondylitis in adults
Plantar fasciitis - sore underside of feet
Lower back joints sacroileus often involved
systemic arthitis JIA
Auto-inflammatory Spiking fever Rash Lymphadenopathy Hepatosplenomegaly Fluid effusions - eg ascites
chronic anterior uveitis
Silent - no signs/ symptoms
Can cause blindness
Often present in JIA, so all children with JIA/suspected JIA are screened several times a year
Especially connected to oligoarticular and psoriatic JIA
what should you screen for when you see dysmorphic features
cardiac conditions
Trisomy 21
- VSD
- AVSD
- Tetralogy of fallot
Turners syndrome
- Coarctation of aorta
- Bicuspid aortic valves
- Aortic stenosis
- Aortic dissection (later in life)
Noonans
22q11p.2 deletion syndrome
complex congenital cardiac conditions
= combination of congenital cardiac conditions
pulmonary vascular resistance pre and post birth
High pulmonary vascular resistance (alveoli closed) so blood bypasses lungs
After birth, baby takes breaths, alveoli open, so pulmonary vascular resistance falls, so blood goes to lungs rather than to L side of body
physiological fetal circulation shunt closing and why
After birth, baby takes breaths, alveoli open, so pulmonary vascular resistance falls, so blood goes to lungs rather than to L side of body
Oxygen presence also reduces prostaglandins so ductus arteriosus tissue contracts and closes (first shunt to close)
Then L side pressure increases so less foramen ovale activity so closes
The umbilicus is cut - so no blood from placenta to umbilical vein and ductus venosus - so this shunts closes too
types of ASD
Ostium secundum - in middle of septum
Ostium primum - at bottom of atrial septum, closer to AV valves, associated with AVSD
Sinus venosus defect - at top of septum - rare and hard to pick up with echo
ASD presentation
Asymptomatic when younger Only if large will immediate lung effects transpire Fixed and widely split S2 sound Systolic murmur in pulmonary region Palpitations
VSD presentation
Pulmonary oedema (Pulmonary artery blood is mixed. High pressure → increased pulmonary blood flow)
Infection of IE around defect
Asymptomatic often until pulmonary vascular resistance falls
Poor feeding
Failure to thrive
Tachypnoea
Gallop rhythm, 3rd heart stand, thrill
Pan systolic murmur, best heart in lower left sternal edge, radiating to axilla and upper sternal edge
Hepatomegaly
Oedema
AVSD
=?
Presentation
Atrial and septal septum defect, involving the crux of the heart and leaflets (so worse than ASD +VSD)
Common in trisomy 21
So important to look for dysmorphism in cardiac examination
Poor feeding Failure to thrive Tachypnoea Gallop rhythm, 3rd heart stand, thrill Can lead to to pulmonary vascular disease rapidly Murmur arises from valvular regurgitation Hepatomegaly Oedema
patent ductus arteriosus presentation
Preterm Pulmonary oedema (High pressure blood into lungs from aorta to pulm artery) Poor feeding Failure to thrive Tachypnoea Easily palpable femoral pulses Gallop rhythm (3rd heart sound), thrill Continuous machinery murmur Hepatomegaly Oedema
types of L–>R shunts
management
ASD
VSD
AVSD
patent ductus arteriosis
Increase calorie intake NG feeds Diuretics ACE i Surgical or catheter device occlusion
coarctation of aorta signs
Weak femoral pulses– Compare to brachial
Pre and post ductal difference in o2 saturations - IF duct is open (Open aids survival - bypasses coarctation )
4 limb BP - upper/lower limb discrepancy
If ductus arteriosus closing/ closed - collapsed and acidotic
Murmur over back if older child
aortic stenosis signs
(aortic valve narrowing)
LV must work harder → hypertrophy → failure
Weak pulses upper and lower limb (less volume ejected from LV)
Thrill in suprasternal region and carotid area
Ejection systolic murmur in aortic area
If critical → collapsed and acidotic
pulmonary stenosis signs
RV must work harder → hypertrophy → failure
Ejection systolic murmur in L upper sternal edge
Murmur radiates to back
Heave - RV - L sternal border
tetraolgy of fallot features
- VSD
- infundibular/ muscular thickening at base of pulmonary artery - blocks outflow
When severe, low o2 saturation, blood goes through VSD rather than lungs = hypercyanotic spell - Overriding aorta
Sits on top of VSD, septum deviated towards L - RV hypertrophy (due to 2nd point- stenosis)
tetralogy of fallot
presentation
investigations
management
Cyanosis
Acidosis
Collapse /death
Investigations
Check for 22q deletion (genetic)
Management Managing hypercyanotic spells - Propranolol - BT shunt (Blood taken from head and neck arteries to lungs) Surgical repair - 6-9m
Transposition of great arteries
=?
presentation
management
Aorta not connected to L as planned, but the R. and visa versa with pulmonary artery
Deoxygenated blood from body goes to body → central cyanosis
Oxygenated blood form pulmonary veins into L heart then back to lungs
Foramen ovale helps - allows some mixing of blood. If and when this closes … :
Cyanosis
Acidosis
Collapse /death
Management
Atrial septostomy - mixing of circulations via hole in foramen ovale being widened
what is in septic screen
bloods
urine sample (ideally clean catch)
LP
meningococcal antibiotics
- pre hospital
- <3 m
- > 3m
Pre-hospital - benzylpenicillin
>3months - ceftriaxone
<3months - cefotaxime + amoxicillin/ ampicillin
(Group B strep cover)
meningococcal purpura cause
neisseria meningitidis. Wbc engulf endotoxins → endothelial damage in blood vessels → capillary leakage
meningococcal prophylaxis for close contacts
Prophylactic antibiotics (within 24h) – ciprofloxacin
for prolonged close contact - siblings, roomates, parents, partner (not classmates, friends, visiting family) within 7 days of illness
systemic JIA tx
NSAIDS/ aspirin
High dose corticosteroids
DMARDs if corticosteroids not successful
kawasaki tx
Aspirin - Painkiller - Anti-inflammatory - Anti-platelet - High dose until fever goes, then low dose for 6-8w IV immunoglobulin - gamma globulin - Reduces heart risk and fever - If ineffective → corticosteroids Fluids Monitor heart (aneurysm (rupture, MI, HF), myocarditis, tachy, pleural effusions)
what is reyes syndrome
liver / brain damage
possible effect of aspirin (in children)
broncholitis xray and clinical presentation
thickened airways - air struggles to leave so wheeze and hyperinflated chest
diaphragm level at more than 6 ribs visible
cant breath out, exhausted form breathing effort - maybe on ventilator
NEC pathophysiology
Bugs produce air in the wall of the bowel. Then air is absorbed in veins !
TTN causes and pathophysiology
TTN - lungs wet from C Section/grand multip – less squeezing during birth so not prepared for lung clearance. Difficulty breathing, but resolves
where does diaphragm normally lie (xray)
Diaphragm at 3/4th rib with expiration
And this gives a more consolidated picture so important to rule out poor inflation
Diaphragm at 5/6th rib with inspiration
If overinflated, could be bronchiolitis
first/ second line for antidepressants
Fluoxetine first line
Citalopram / sertraline second line
why is iron deficiency common in children
investigation results
treatment
Children have poor intake and increased demand
Especially with breastfeeding (over cow’s milk), picky toddlers, growth and infection increases requirement
Adults get most of their iron from recycled red blood cells whereas children need to get more from their diet
Low ferritin, low serum iron, increased total iron binding capacity (TIBC) as compensation, high ZPP
minimum 3 months oral iron (compliance is challenging) and also address cause (change diet)
G6PD presentation and cause
Lack of glucose 6 phosphate dehydrogenase ⇒ haemolysis X linked (boys)
Presentation
Acute severe haemolysis – broad beans, prescribed drugs, infection
Neonatal jaundice
Chronic haemolysis
which is more common ALL or AML
ALL (most common childhood cancer). good prognosis though, slightly better than the slightly less common AML
what should you prevent in sickle cell patients
pain / crises (hydration, warmth, transfusion)
infection – aplastic crisis often precipitated by parvovirus (slapped cheek virus) - rbc production switched off temporarily but this has large effects as their rbc lifespan is shorter (anaemia with low reticulocyte count)
sickle cell patient develops Pain, hypoxia, fever, sometimes CXR signs …
- diagnosis
- tx
Acute chest syndrome
Transfusion, oxygen, antibiotics, incentive spirometry
normal and abnormal gross motor development
- newborn
- 3months
- 6 months
- 6-8months
- 9 months
- 1 yr
- 2 yr
- 3 yr
- 4yr
- 5yr
Newborn
Flexed arms and legs
Equal movements in all limbs
Head lag, floppy
3 months
Start pushing up on arms, lift head when on tummy
Turn head side to side
Minimal head lag
6 months Hands on ground, with head up whilst on tummy Rolls - Front to back - 4-6m - Back to front - 6m Crawling 6-9m
6-8m
Tripod sitting, supported sitting, Rounded back, arms in front of their legs
9 months Pull up on furniture → standing Sit unsupported (SOME SAYS 6M, SO TRIPOD BEFORE?) - Not sitting by 1 year = worried Cruising
1 year
Walking
- No walking by 18 months - consider muscular dystrophy for boys (check Creatinine Kinase)
2 years
Steps
Throw ball overarm
3 years
Jumps
Ride tricyle
4 years
Hops
Use bat
5 years
Ride a bike
when worried about no walking
No walking by 18 months - consider muscular dystrophy for boys
check Creatinine Kinase
should be 1 year
when worried about no sitting unsupported
Not sitting by 1 year = worried
should be 6months
speech and language and hearing and abnormal landmarks
3m 9m 1y 2y 3y 4y 5y
3 months
Laughs and squeals
Turn to sound
9 months
‘mama’/’dada’
1 year
One word
- No clear words by 18 months - could be hearing problem, learning disability, autism or an isolated speech/ language problem
2 years
2 words joined together
Name body parts x10
3 years
Short sentences, mainly understandable
Can follow 2 - step commands
4 years
Colours
Count to 5 objects
Fluent in 4 word sentences
5 years
Knows meanings of words (e.g. what is a lake?)
when worried by no words
No clear words by 18 months - could be hearing problem, learning disability, autism or an isolated speech/ language problem
should be 12m
normal and abnormal fine motor/ vision landmarks
8w 2-3m 4m 6m 8m 1y 1.5y 2y 3y 4 5 6 7 10
8w
Follow movement in horizontal plane
2-3 months Hands not closed anymore Blink at bright lights Hold gaze of caregivers Follow movement in all planes
4 months
Palmar grasp of object, both hands
Hand regard- Stare at hands, in midline, understand they are theirs
6 months
Transfer object one hand to other
Foot regard
Object permanence
8 months
Take object in each hand
- Hand preference before 18 months - consider neurological condition such as cerebral palsy
1 year
Scribbles with crayon
Basic pincer grip
Casting
1.5 years
2 cube tower
2years
Horizontal scribble
3 years 8 cube tower Draw circle Bridge/train out of blocks Colour matching Red green colour blindness recognisable at this point
4 years
Cross drawing
Steps out of cube blocks
5
Square drawing
6
Triangle drawing
7
Diamond drawing
10
Cube drawing
hand preference is worrying at what age
Hand preference before 18 months - consider neurological condition such as cerebral palsy
normal/ abnormal social interaction and self care landmarks
6w 2m 6m 9m 1y 2y 3y 4y
6 weeks
Spontaneous smile
No smiling by 3 months may be a sign of visual impairment, as well as autism and learning disability
2m
Coo
6 months
Finger feeds
object permanece
9 months
Wave goodbye
Stranger anxiety, upset when caregivers leave
1 year
Finger feeds
2 years
Help dress self
Feed a doll
3 years
Play with others, name a friend
Worried if not interested in playing with friends by 3
Dress self
4 years
dress/ undress without help
Simple board game
Cultery use
at what age should children be playing with peers
3y
at what point do we worry about lack of smile
No smiling by 3 months may be a sign of visual impairment, as well as autism and learning disability
should be 6w
global impairment defined as what
delay in 2 or more domains
Gross motor
Fine motor and vision
Speech, language and vision
Social interaction and self care skills
sore legs may suggest
meningococcal septicaemia
what age is consistent with febrile convulsions
1-3y mainly but 3m -5y
unequal pupils associated with?
intracranial bleed
boggy head swelling indicates
underlying skull fracture
classification of infants toddlers children adolescents
infants 0-27d
toddlers 28d - 23m
children 2y-11y
adolescents 12-16-18y
which age category can have less fat soluble drugs
neonates - less bile acid so less fat absorption
chloramphenicol and babies
unable to metabolise (no enzyme)
grey baby syndrome –> vomitting, poor feeding, cyanosis, hypotension, CV and resp issues –> death
so avoid or use CLOSE monitoring
rashes + the following
- abdo pain
- recent burn
- bleeding gums
- cough / sore eyes
- red eyes
- joint pains
- abdo pain - HSP
- recent burn - toxic shock syndrome
- bleeding gums/ nose bleeds - leukaemia
- cough / sore eyes - measles
- red eyes - kawasaki
- joint pains - meningioccal sepsis, HSP, JIA, leukaemia
which centiles are considered the outer ranges of normal for
- height
- height velocity
Height : 3-97th centile
Height velocity : 25-75th centile
early/ delayed puberty ages for boys and girls. and what is the marker for puberty
Girls - breast
13 = delayed
8= early
Boys - testes
14 = delayed
9= early
Late is more common and okay for boys. Early is more common and okay for girls
how do you distinguish hormonal vs malnutrtion issue in regards to growth
Height and weight problem = malabsorption issue (weight not affected by hormone issue)
test to distinguish true and pseudo precicious puberty
GnRH test
Test between true and pseudo precocious puberty
LH, FSH measured and remeasured after GnRH injection
True = levels rise Pseudo = levels stay low
True = central (cause = hypothalamus/pit - early HPG axis maturation) - more internal charactherisitcs ? eg testes size and periods? maybe not though Pseudo = peripheral (induced by sex steroids, gonadatrophin /HPG axis independant) - more secondary characteristics? eg pubic hair. maybe not though
discuss 2 chromosomal hypogonadic conditions
- name
- chromosomal tagline
- features
Klinefelter syndrome 47XXY Primary hypogonadism Gynacomastia Azzospermia Reduced secondarys sexual characteristics Small testicular volume <5mls Lower IQ Tall
Turners 45XO Hypergonadotropic hypogonadism Short stature, neck webbing, low posterior hairline, prominent ears CV and renal malformations Recurrent ear infections
what is a fluid challenge
= rehydration attempt
5ml diarolyte given every 5 mins
diarrhea/ vomitting noted
reveiwed regularly
acute scrotum pain differential diagnosis
investigations
testicular torsion (main one) Torsion of hydatid aka appendix testis Trauma Epididymo-orchitis Acute hydrocele Idiopathic scrotal oedema UTI
Examination !
Urine dip !
Surgery exploration
NOT US - doesn’t rule out testicular torsion
testicular torsion
- when does it happen
- symptoms inc late signs
- how long until death of testicle
- tx/diagnosis
Neonatal / puberty - main times Pain often so severe → vomit Tender all over 6h from onset until ischaemia/death Redness and swelling are LATE signs Surgery needed- This is the diagnosis too!
Torsion of hydatid aka appendix testis
- what is that
- symptoms (compared to dif diagnosis)
- tx
Remnant of mullerian duct
Pain less severe, more localised to upper testicle (compared to testicular torsion)
Can sometimes see blue dot - as infarct through skin
Surgery not necessary
Idiopathic scrotal oedema presentation
Red, swollen on one side
non retractile foreskin
- worrying?
Up until puberty, this is normal
- Reassurance
- may have …. Mysterious swelling
- Smegma = skin secretions trapped due to non-rectralie foreskin – also Reassurance , will get better when foreskin retracts
Unless BXO (balanitis xerotica obliterans) (Then worrying!): White scarred appearance of foreskin inc when retracted (unlike pink/red = healthy) Circumcision needed
hypospadias
- what is this
- what should you check and why
- tx
Urethra opening is below where it should be (along shaft/ at base)
Don’t circumcised - skin used to reconstruct urethra later on
Check testicles are palpable
Undescended may indicate sex disorder - congenital adrenal hyperplasia - unusual hormone synthesis
XX but exposed to hormones during pregnancy. Clitoromegaly rather than glans. Virilized genitalia
when should you def not circumcise someone
hypospadias (urethra opening below where it should be)
skin used to reconstruct urethra later on
groin swelling differential diagnosis
investigations to distinguish
Inguinal hernias
- Boys more- testicular descent opens up canal more
- Priority to younger - more complications eg strangulation of hernia
Hydroceles
- Often left alone, unless large or hasn’t subsided for ages
- Hydroceles transilluminate (less so for pediatric – skin and bowel thinner so bowel hernias also transilluminate)
- Hernias may have cough impulse
- Swelling just in scrotum = hydrocele, but swelling between testicle and superficial inguinal ring = hernias
when capillary haemoangiomas cant be left
normal course of action
near airway / eyes (blindness) - removal
if left alone (unproblematic place), they grow, then reduce on their own (not present at birth)
when do you worry about lymphadenopathy
Mostly fine
Worry if
>2cm in diameter
Rapidly enlarging
Inflamed for more than 2 weeks
then May be leukaemia
what neck swelling moves when tongue stuck out
thyroglossal cyst
undescended testis
- how long til worry
- investigations
Do nothing for first 6 months, as most sort themselves out
Often palpable along line of descent - important to palpate (may indicate congenital adrenal hyperplasia- sex disorder- XX but exposed to hormones during pregnancy. Clitoromegaly rather than glans. Virilized genitalia )
Investigations
Examination under anaesthetic if unable to palpate - laparoscopy
umbilical hernias
- worry?
hardly ever strangulate
so leave alone if less than 4 -5 years old (As cause more problems for adults), and less than 2 cm
umbilicus granuloma
- looks like what
- tx
fleshy growth on belly button
Treat with salt and water
omphalitis =?
tx
Omphalitis = infected umbilicus
Infection can spread centrally rapidly
IV antibiotics
anorexia screening
SCOFF
S- do you make yourself Sick because you’re
uncomfortably full?
C- do you worry that you’ve lost Control over how much
you eat?
O- have you recently lost more than 6 kilograms
(about One stone) in three months?
F- do you believe you’re Fat when others say you’re thin?
F- would you say that Food dominates your life?
anorexia clinical signs
Dry skin Lanugo hair Orange skin and palms Cold hands and feet Bradycardia Drop in BP on standing Oedema Week proximal muscles - squat test
faltering growth definition
description (not diagnosis) of inadequate weight gain/ growth
1 + centile drop if birth weight below 9th centile
2+ centile drop if birth weight 9-91st centile
3+ centile drop if birth weight above 91st centile
weight below 2nd centile (regardless of birthweight)
newborn weight loss
- what is normal
- what is concerning
- investigations
drop is normal up until 4th day of life, this is normally recovered by 3w
Be worried if losing more than 10% of birth weight
assess feeding (discussion/ observation)
feeding support
monitoring
faltering growth investigations
- monitor height/length and weight regularly (Measure more often if more concerned and if younger)
- Measure parents - work out mid-parental centile (2 centiles below may suggest undernutrition of growth disorder
- assess feeding
- If 2y+, BMI centile
- Nutritional blood tests - any supplementation needed?
faltering growth causes (in categories)
Not enough in
- Ineffective suckling/ bottle feeding
- Feeding aversion (problems with parental interaction, GORD (avoid pain))
- Physical disorder to disturb feeding eg tongue tied
- neglect
- anorexia
Not absorbed
- Anaemia
- Billiary atresia
- Cystic fibrosis
- Inborn errors of metabolism
- Coeliac
- Infections
- Cows milk allergy CMA
Too much used up
- Prematurity
- Chronic infections / illness
- – HIV, TB
- – Asthma
- – Hyperthyroidism
- – IBD
- – Malignancy
- – Renal failure
- – Congenital heart disease
Abnormal central control of growth / appetite
gower’s manoevre
for duchenne’s (m)/ beckers (f, milder)). or hip girdle weakness
Lie on their back. How quickly can they stand up
Long time from lying to sitting then crawl themselves up legs to wide based stance
due to proximal weakness
Creatine kinase test next step!
types of strabismus
Manifest = obvious deviation of one eye
- Esotropia = one eye straight ahead, one eye turned inwards
- Exotropia = one eye straight ahead, one eye turned outwards
- Hypertropia one eye straight ahead, one eye turned upwards
- Hypotropia = one eye straight ahead, one eye turned downwards
Latent = when one eye close / occluded under a cover, then the eye deviates
- Esophoria = one eye straight ahead, one eye turned inwards
- Exophoria = one eye straight ahead, one eye turned outwards
- Hyperphoria one eye straight ahead, one eye turned upwards
- Hypophoria = one eye straight ahead, one eye turned downwards
strabismus aetiology
Genetic component
Refractive error - need of glasses
- Long sighted - hypermetropia
- Anisotropia - difference in refractive error of each eye → amblyopia (one eye seeing better than the other even with correction of refractive error)
Neurological defects eg cerebral palsy
what about…
- sudden onset strabismus
- strabismus in first few months
- urgent referral - this is worrying. normally not sudden onset
- If first few months, this may be physiological - transient newborn misalignment (reducing by 2m, stopped by 4m)
strabismus examination (inc what refers to what strabismus)
Corneal reflection
- With pen torch, looking for white dot reflection
In pupil and slightly nasal but central, and symmetrical. if white dot is displaced - strabismus
Cover test
- Light + Get child to focus on something 33cm away and then 6m away
- Eye not covered moves position when cover on other eye put on/removed
- One at a time with gap between → manifest
- One after the other straight away → latent
Measure visual acuity – each eye separately!!
- V young- Whether they look towards stripes or not (levelled)
- Picture based - either at top or bottom of card, point/ eye movements
- Snellen / picture naming
strabismus tx
Better prognosis if caught earlier
Glasses Prisms Eye exercises Surgery - on extraocular muscles by weakening/strengthening them Botox injected into muscles - but wears off - Would need repeating - Can be diagnostic tool
what is pseudostrabismus and why might this occur
Eyes are straight, and are being used normally but appear unusual:
- Broad epicanthus (nose bridge) - wide interpupillary distance
- Or narrow! ^
- Facial asymmetry eg Unilateral ptosis
- Deep set eyes
Amblyopia = ?
one eye seeing better than the other even after correction of refractive error
jump/ hop test and blowing out/sucking in tummy in abdo exam
unable to do this with guarding / peritoneal irritation
classic age of presentation and colour of vomit:
pyloric stenosis
malrotation
intersussception
pyloric stenosis- 4w, milky
malrotation- 24h, green
intersussception- 6m, milky then green
where is intersussception mass ususally felt
USS appearance
cause
treatment
right upper quadrant - sausage shaped mass
donut
usually idiopathic
air enema
fluid
surgery sometimes
