paeds Flashcards

Question

Slipped upper femoral epiphysis

Answer 1

Onset of puberty Tall and thin or short and obese Pain, leg length shortening seen on X ray

Answer 2

``` 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

Answer 3

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

Answer 4

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

Answer 5

``` Presentation Headache, often worse lying Vomiting, esp early morn Papilloedema Nystagmus Ataxia Behavioural changes Squint ``` ``` Treatment Surgical resection Radiotherapy Chemo palliative care ```

Answer 6

``` Endocrine (brain surgery) Intellectual cardiac/renal toxicity - chemo Fertility Psychological ```

Answer 7

nephroblastoma

Answer 8

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

Answer 9

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)

Answer 10

Lots of family with DM C peptide robust No antibodies for insulin Genetic testing

Answer 11

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 ```

Answer 12

4 or fewer joints involved Typically lower limb associated with chronic anterior uveitis

Answer 13

More than four joint involved More rapid bony destruction Often small joints eg hand/feet

Answer 14

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

Answer 15

Akin to ankylosing spondylitis in adults Plantar fasciitis - sore underside of feet Lower back joints sacroileus often involved

Answer 16

``` Auto-inflammatory Spiking fever Rash Lymphadenopathy Hepatosplenomegaly Fluid effusions - eg ascites ```

Answer 17

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

Answer 18

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

Answer 19

= combination of congenital cardiac conditions

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

``` Asymptomatic when younger Only if large will immediate lung effects transpire Fixed and widely split S2 sound Systolic murmur in pulmonary region Palpitations ```

Answer 24

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

Answer 25

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 ```

Answer 26

``` 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 ```

Answer 27

ASD VSD AVSD patent ductus arteriosis ``` Increase calorie intake NG feeds Diuretics ACE i Surgical or catheter device occlusion ```

Answer 28

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

Answer 29

(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

Answer 30

RV must work harder → hypertrophy → failure Ejection systolic murmur in L upper sternal edge Murmur radiates to back Heave - RV - L sternal border

Answer 31

1. VSD 2. infundibular/ muscular thickening at base of pulmonary artery - blocks outflow When severe, low o2 saturation, blood goes through VSD rather than lungs = hypercyanotic spell 3. Overriding aorta Sits on top of VSD, septum deviated towards L 4. RV hypertrophy (due to 2nd point- stenosis)

Answer 32

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 ```

Answer 33

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

Answer 34

bloods urine sample (ideally clean catch) LP

Answer 35

Pre-hospital - benzylpenicillin >3months - ceftriaxone <3months - cefotaxime + amoxicillin/ ampicillin (Group B strep cover)

Answer 36

neisseria meningitidis. Wbc engulf endotoxins → endothelial damage in blood vessels → capillary leakage

Answer 37

Prophylactic antibiotics (within 24h) -- ciprofloxacin for prolonged close contact - siblings, roomates, parents, partner (not classmates, friends, visiting family) within 7 days of illness

Answer 38

NSAIDS/ aspirin High dose corticosteroids DMARDs if corticosteroids not successful

Answer 39

``` 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) ```

Answer 40

liver / brain damage | possible effect of aspirin (in children)

Answer 41

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

Answer 42

Bugs produce air in the wall of the bowel. Then air is absorbed in veins !

Answer 43

TTN - lungs wet from C Section/grand multip -- less squeezing during birth so not prepared for lung clearance. Difficulty breathing, but resolves

Answer 44

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

Answer 45

Fluoxetine first line | Citalopram / sertraline second line

Answer 46

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)

Answer 47

``` Lack of glucose 6 phosphate dehydrogenase ⇒ haemolysis X linked (boys) ``` Presentation Acute severe haemolysis -- broad beans, prescribed drugs, infection Neonatal jaundice Chronic haemolysis

Answer 48

ALL (most common childhood cancer). good prognosis though, slightly better than the slightly less common AML

Answer 49

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)

Answer 50

Acute chest syndrome Transfusion, oxygen, antibiotics, incentive spirometry

Answer 51

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

Answer 52

No walking by 18 months - consider muscular dystrophy for boys check Creatinine Kinase should be 1 year

Answer 53

Not sitting by 1 year = worried | should be 6months

Answer 54

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?)

Answer 55

No clear words by 18 months - could be hearing problem, learning disability, autism or an isolated speech/ language problem should be 12m

Answer 56

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

Answer 57

Hand preference before 18 months - consider neurological condition such as cerebral palsy

Answer 58

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

Answer 59

No smiling by 3 months may be a sign of visual impairment, as well as autism and learning disability should be 6w

Answer 60

delay in 2 or more domains Gross motor Fine motor and vision Speech, language and vision Social interaction and self care skills

Answer 61

meningococcal septicaemia

Answer 62

1-3y mainly but 3m -5y

Answer 63

intracranial bleed

Answer 64

underlying skull fracture

Answer 65

infants 0-27d toddlers 28d - 23m children 2y-11y adolescents 12-16-18y

Answer 66

neonates - less bile acid so less fat absorption

Answer 67

unable to metabolise (no enzyme) grey baby syndrome --> vomitting, poor feeding, cyanosis, hypotension, CV and resp issues --> death so avoid or use CLOSE monitoring

Answer 68

- 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

Answer 69

Height : 3-97th centile | Height velocity : 25-75th centile

Answer 70

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

Answer 71

Height and weight problem = malabsorption issue (weight not affected by hormone issue)

Answer 72

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 ```

Answer 73

``` 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 ```

Answer 74

= rehydration attempt 5ml diarolyte given every 5 mins diarrhea/ vomitting noted reveiwed regularly

Answer 75

``` 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

Answer 76

``` 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! ```

Answer 77

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

Answer 78

Red, swollen on one side

Answer 79

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 ```

Answer 80

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

Answer 81

hypospadias (urethra opening below where it should be) | skin used to reconstruct urethra later on

Answer 82

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

Answer 83

near airway / eyes (blindness) - removal if left alone (unproblematic place), they grow, then reduce on their own (not present at birth)

Answer 84

Mostly fine Worry if >2cm in diameter Rapidly enlarging Inflamed for more than 2 weeks then May be leukaemia

Answer 85

thyroglossal cyst

Answer 86

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

Answer 87

hardly ever strangulate | so leave alone if less than 4 -5 years old (As cause more problems for adults), and less than 2 cm

Answer 88

fleshy growth on belly button | Treat with salt and water

Answer 89

Omphalitis = infected umbilicus Infection can spread centrally rapidly IV antibiotics

Answer 90

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?

Answer 91

``` Dry skin Lanugo hair Orange skin and palms Cold hands and feet Bradycardia Drop in BP on standing Oedema Week proximal muscles - squat test ```

Answer 92

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)

Answer 93

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

Answer 94

- 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?

Answer 95

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

Answer 96

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!

Answer 97

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

Answer 98

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

Answer 99

1. urgent referral - this is worrying. normally not sudden onset 2. If first few months, this may be physiological - transient newborn misalignment (reducing by 2m, stopped by 4m)

Answer 100

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

Answer 101

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 ```

Answer 102

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

Answer 103

one eye seeing better than the other even after correction of refractive error

Answer 104

unable to do this with guarding / peritoneal irritation

Answer 105

pyloric stenosis- 4w, milky malrotation- 24h, green intersussception- 6m, milky then green

Answer 106

right upper quadrant - sausage shaped mass donut usually idiopathic air enema fluid surgery sometimes