Paeds Flashcards
Good questions to ask for constipation
- when passed meconium
- any walking/ lower limb difficulties that are recently onset
Differentials for constipation in a child (not neonate)
Normal constipation- could be anxiety, diet, water intake
Hirschprung
Obstruction
Questions for neonate with just a fever
How long for
Have measured
Seem unwell/not self?
Breathing difficulty? Noises?
Wees and poos?
Skin changes?
Travel?
Anyone else ill that you know of?
How manage an infant with fever
Obs
Examine
- ears
- throat
- in head to toe
Urine dip and MUS
Bloods
- FBC
- U&E
- LFTs
- CRP
- Blood cultures
CXR
LP
Stool sample
What does a fever suggest about UTI
That it is probably upper UTI
In the presence of bacteriuria this confirms it
When do CT in case of acute meningitis
Focal neuro
Signs of ICP
If none just do LP straight away unless contraindicated
How to assess patient who comes in with first time asthma presentation
Obs
Examine chest
Peak flow
Treat with 10 puffs of salbutamol
Questions for child in ambulatory clinic/GP presenting with asthma (non-urgent)
Triggers for cough
- cold
- exercise
- animals
- smoking
- worse at night
History of haye fever and eczema or allergies
People live with smoke?
How to counsel a parent over asthma
Explain what it is
- certain triggers such as the cold, dust can cause our airways to become smaller
It is a very common condition that affects millions of people who go on to live completely normal lives. To help you cope with this we can give you a personalised asthma action plan which involves some drugs, specificadvice on how to manage some triggers which cause you to get your symptoms and then regular follow ups
The drugs available are inhalers which provide a drug into the lungs which causes the airways to open up and become wider
On top of this there are things you mentioned which can trigger your sx such as….. therefore when …. important to have inhaler on you
Additionally mention about how if smoke then need to encourage quitting
Talk about drugs which must be avoided
What we can do is follow you up in about 2 months and assess how getting on, in the meantime keep using your inhaler when you need however be careful if after a few puffs of it you find its not working it is important to come to hospital
Questions for abdo pain in a child
SOCRATES
Vomiting
Diarrhoea/constipation
Blood
Urinary sx
Jaundice and any skin changes
How should DKA be counselled
Explain that this is the first manifestation of type 1 diabetes
This is a condition where your body is unable to produce enough insulin, which is the hormone that is responsible for controlling blood glucose levels
This can lead to blood glucose levels being higher than normal
This can be dangerous in the long run because it can damage blood vessels and nerves in various important organs
The good thing is that it’s a very well-known disease with well-established management options
The condition that is ongoing in called diabetic ketoacidosis – it’s a condition that arises when a lack of insulin in the patient leads to very high glucose levels and high levels of another chemical called ketones which leads to all the symptoms Jonny has been suffering
Our main priority is to deal with the DKA now and make sure that Jonny is feeling better
Then we can discuss the long-term management of diabetes
There are some good fact sheets about DKA and diabetes on diabetes.org
Questions for vomiting in an infant
How much
What look like
Ever red or yellow/green in it
Forceful
Related to food?
Diarrhoea
Skin discolouration
Assessment of vomiting patinet
Obs
Examination- abdo, hydration satus
Weight and height and plot
Urine dip
Bloods
- FBC
- U&es
- LFTs
- glucose
- VBG
Counselling a parent on CF
Explain that it is likely to be cystic fibrosis, a condition that Hamza was born with and has been responsible for his regular chest infections, poor growth and bowel problems
The rectal prolapse is likely the result of frequent coughing
It results from a genetic mutation that leads to secretions being much thicker than usual (this affects several parts of the body including the lung (most commonly), GI tract, pancreas and testes)
Lung symptoms are most common (difficulty breathing, coughing, recurrent infections) and can be managed with physiotherapy, prophylactic antibiotics and some agents to loosen the mucus
This is a chronic condition and there is no cure but with the help of the specialist MDT, Hamza will be able to live a very fulfilling life
It is caused by two gene mutations, both of which are required for the gene to manifest (1 from father, 1 from mother)
If planning on having another child or when her other son is thinking about starting a family, may want to consider genetic testing beforehand
Management consists of dealing with lung symptoms, nutrition, infection and psychological issues
Management of bronchiolitis in hospital
Obs
If O2 less than 92 give oxygen
If signs of resp distress- grunting, marked chest recession, RR over 70 admit to ward
If severely preterm, cyanotic heart condition give pavlizumab
If have teenager with chronic condition what is important thing to do
Screen for depression and assess impact on mental health/social life
In counselling talk about things can do for mental health support
Managing someone with IBD
Obs
Examination- abdo, DRE
Bloods
- FBC
- U&Es
- LFT
- CRP
Stool sample for caeruplasmin
Refer to gastro for colonoscopy
Managing a first febrile seizure
If at GP send to A&E
If in hospital
Obs
Exam
Bloods
- FBC
- U&Es
- LFTs
- CRP
- VBG
- glucose
Septic screen
- urine dip
- CXR
- LP
Questions for a seizure in a child
What happened before?
- seemed off?
- what doing?
During
- hit head?
- shake?
- for how long?
After
- LOC
- return to normal
Has this happened before?
Fever recently?
Been unwell?- cough, SOB, rash, toilets?
Counselling for a febrile seizure
We think that alfie has had what we call a febrile seizure
These tend to occur while people have a viral infection and can be caused by the rise in temperature
Short ones such as what he has had can be very distressing as a parent but have no long term consequences
Talk about how this is not epilepsy
If ask there is a marginally increased risk compared to the rest of population
Is risk of happening again- if does protect their head but do not try to restrain their movements at all
If happens for longer than 5 mins then call ambulance
Specialist assessment if
- under 18 months
- first presentation
- focal neurology
Questions for joint pain
SOCRATES
- when hurt
- sport
How long
Happened before
Swollen
Limp
Functional impairment
Tender
Ill recently
Fever
Skin changes
Differentials for joint pain in a child
Reactive arthritis
Trauma
Juvenile idiopathic arthritis
SUFE
Perthes and osgood schlatters
Septic arthritis
Cancer
Growing pain
Management of a blue baby on post natal ward
Immediately set up IV prostaglandins
Senior support
Paediatrics surgeons in loop
Obs
Examination
ECG and cardiac monitor
Can do hyperoxia test where give 100% oxygen and reassess saturations
CXR
Echo- gold standard
When is suspicion of NAI what need to do
Obs
Examination head to toe including fundoscopy
Admit to ward
Skeletal survey
Contact seniors and safeguarding leads
Differentials for a drowsy baby
Sepsis
Intracranial pathology
- bleed
- enceph/meningitis
Hypoglycaemia including poor feeding technique
ELectrolyte abnormalities
NAI
Counselling for enuresis
Bedwetting is a common thing we see in children a lot and it is important to remember that at some point all children will be able to achieve continence. It is no ones fault as it happens when the volume of urine becomes too much for the bladder and as is the case in your child this sensation is not being felt by them
There are a few things that we can do
- remember to remain neutral as i said its no ones fault so remember not to punish them
- things like drinking all of your fluid in the day a few hours before bed can really help and making sure they go to wee before bed can go a long way to stopping it from happening so often
in the cases does this is important to reward these behavioiurs and not having a dry night
How to manage GORD in primary care
Obs
Examine- signs of dehydration
Measure weight and height
Refer if signs of faltering growth, no response to medical treatment, avoiding feeding
Counselling on GORD
Very common cause of vomiting, caused by slower development of what we call the sphincter at the bottom of your feeding tube which goes into the stomach. It acts as valve and as its not working yet it is hard to keep the food in the stomach
Differentials for cough in a child
Croup
Pneumonia
Inhaled foreign object
Bronchiolitis
Pertussis
Cough in an infant
Bronchiolitis
Inhaled foreign object
Croup
Pneumonia
GORD
Pertussis
Questions for cough
Dry?
Blood?
How long?
Is it always there?
Infrequent bouts?
Vomiting at all?
Investigations and management in acute asthma
A- if needed
B- oxygen, nebulised salbutamol
C- fluids
PEFR
DKA management
A-E
If shocked then give bolus over 10 minutes and oxygen
If not give bolus over 30 mins
Repeat until no longer shocked
Insulin 0.05-0.1 units/Kg
Add potassium if needed
Add dextrose when glucose below 5%
Long term DM management
2 main insulin regimes
- continuous pump-programmable pump and insulin storage reservoir that gives a regular or continuous amount of insulin
- multiple short and long acting injections- long acting give baseline protection and short action to cover for when eat
Done in diabetes clinic
Will see dietician and community nurse who can liase with for any concerns
Investigations for first time seizures
Bedside
- neuro examination
- ECG
Bloods
- glucose
- U&Es
Imaging
- EEG within 72 hours
- MRI if focal
First time seizure counselling
An abnormal sudden burst of electrical activity in the brain which can cause your symptoms
In meantime going to refer you to first fit clinic who are specialists in treating people with seizures
Here they will carry out a thorough assessment and carry out some more investigations and give you a detailed management plan- can talk about likely plan if want?
In the meantime until then it is important to know what to do if suffers another seizure in meantime
So firstly it is important to make sure in a safe environment- so make sure ndangerous objects in vicinity where could hit head or hurt themselves
Place them on their side and make sure they are able to breathe so if got any tight clothings around enck remove or loosen these
Also important to as soon as it starts, start watch and time it- if this lasts over 5 then it is important you call ambulance as soon as possible. Other things that are important are that if afterwards they are extremely drowsy or just do not smm right then call ambulance or bring them in to A and E
Headache differentials in a child
Tension
Migraine
Myopia / hypermetropia
Post-ictal
Meningitis / encephalitis / abscess
Sinusitis
Idiopathic intracranial hypertension
Raised intracranial pressure / space occupying lesion
Questions for heache
SOCRATES
Include
- morning
- triggers- chocolate,cheese
Bright lights and neck stiffness
Abdo pain
Vomiting
Been themselves
Fever
Coryzal
Neuro symptoms- vision, fits, weakness
Investigations for tension and migraines
A-E
Neuro examination
BMI
Headache diaries
Abdo pain in kids differentials
Common
- mesenteric adenitis
- appendicits
- UTI
- constipation
- somatisation
Less common
- pneumonia
- DKA
- HSP
- Hep A
- SCD
How to measure temperature in kids
Temp dot in axilla <4 weeks
Tympanic membrane >4 weeks
Global developmental delay
Common
- understimulation
- neglect
- IDA
- CP
Less common
- congenital hypothyroidism
- inherited metabolic disorder
How to explain phototherapy to a parent
A special type of light shines on the skin,
which alters the bilirubin into a form that
can be more easily broken down by the liver
Management of meningococcal sepsis
In primary care
- IM benzylpenicillin
- call 999
Secondary care
- abx
- fluids
- steroids if needed
- public health notification- ciprofloxacin
Long term management= hearing loss, learning difficulties and CP
Vaccine counselling- MMR
The MMR is a vaccine which contains weakened versions of live measles, mumps rubella viruses.
Why and when is it given?
It is given to a child soon after their first birthday when they are most at risk of getting infected by the viruses (because natural immunity fades from maternal antibodies).
The vaccine helps protect your child from experiencing the full blown symptoms of the viruses, if any at all.
The vaccine is very effective and is recommended as part of the UK Immunisation Schedule.
Vaccine counselling - What are measles, mumps and rubella vaccines
Mumps is caused by a virus which causes headache, fever and large neck lumps. Measles and rubella present similarly with a rash which starts on the face and then spreads downwards- flu like symptoms, lots of long term complications- infertility and deafness in mumps. measles can lead to long term brain complications. rubella has severe effects on pregnant women
Vaccine counselling- side effects
As with any medical intervention there are some side effects
The most common occurs in about 1 in 10 children who may experience a bit of a fever
There is a very small risk of about 1 in 1000 children who may have a fitcaused by a fever, which is called a ‘febrile convulsion’. However, to put this into context, if a child has not been immunised and gets measles they are
five times more likely to get a fit (1 in 200).
Vaccine counselling- autism link
There has been some speculation in 1998 that the MMR was associated with Autism and that subsequently received quite a bit of publicity. However, since then there have been numerous scientific papers written
which show absolutely no risk associated
The WHO have categorically stated there is no risk.
The MMR is given at the same sort of time as the symptoms of autism appear
The doctor who published the paper Dr Andrew Wakefield has subsequently, been struck off the medical register. Dr Wakefield had shares in a pharmaceutical company that was trying to market an alternative MMR
vaccine. The papers have also subsequently been retracted.
Management of NAI
Investigations- full head to toe examinations, skeletal survey, head CT
Management- ontact on call social services and Child Protection team
Inform senior paediatrician
Deal with injury/fracture
Document everything in the notes
Liaise with social services – consider Child Protection Case Conference
Obesity in kids measurements
If under 12 use weight centiles
- overweight above 91st centile
- obese above 98th centile
- severe above 99.6 centile
If over 12 use BMI
- overweight above 25
- obese above 30
Investigations for obesity in a child
Bedside
- phyiscal examination
- BMI
- BP
Bloods
- TSH
- cortisol
- HbA1c
What can use if desmopressin does not work in enuresis
Imipramine or oxybutynin
Important questions for enuresis
I understand it can be frustrating, how do you react to it? Do you ever discipline him?
Causes of obesity in a child
Tall( typically above 50th centile)
- simple obesity
Short
Prader willi
- endocrine; hypothyroidism, cushings, PCOS
Causes of learning difficulty/slow school progress
Common
Hearing impairment
Visual impairment
Low IQ
Rarer
Specific learning impairments
Investigations for short stature GP
Bedside
- full examination
- BMI
- urine dip
Bloods
- FBC, U&E, TFTs, GH, HbA1c
Secondary care investigations for short stature
Karyotyping
Bone X ray
Questions for motor delay
Have they lost any skills
Hand dominance
Appear floppy or muscles are tense
Crawling or bottom shuffling?
Counselling for failure to thrive
What we can see by plotting his weight is that he really has not been growing as we would expect and is not putting on weight at the rate we would expect
Counselling for any development history
Safety net about red flags
- losing their progress
- floppiness
- hand dominance
Failure to thrive differentials
Cystic fibrosis
Metabolic disorder
Diabetes
Bowel disease
Chronic illness- sickle cell and IDA
Malnourishment
Neglect
Endocrine- hypothyroidism, GH
CKD
Investigations for FTT
Bedside
- observations
- head to toe examination
- stool sample- calprotectin, elastase
- sweat test
Bloods
- FBC, U&Es, LFTs, Hb electrophoresis, iron screen, vitamins
- coeliac antibodies
Causes of short stature
Familial normal variant
IUGR or extreme prematurity
Delayed puberty (normally familial)
Endocrine causes- cushings syndrome, IGF-1 or GH deficiency, hypothyroidism
Chronic illness
Nutritional deficit
- GI diseases
- insufficient food
Chronic disease
- crohns
- coeliac
- CF
- CKD from renal tubular acidosis
Psychosocial deprivation
What does height centile greater than weight centile suggest in short stature
Nutritional cause or chronic illness
Investigations for short stature
Bloods
- FBC
- U&Es
- calcium and phosphate
- TSH
- CRP
- coeliac hormones
- GH provocation, IGF-1, dexamethasone provocation test
If neuro symptoms MRI
X ray of wrist and hand
Causes of delayed motor development
CP
Congenital myopathy
Spinal chord lesions
Spina bifida
Part of global delay
Varied initial moving- commando crawl or bottom shuffling
Classify causes of global developmental delay
Prenatal
- genetic conditions- downs, fragile X
- metabolic (hypothyroidism, inborn errors of metabolism)
- congenital infections
Perinatal
- prematurity linked IVH
- HIE
- hypoglycaemia
- kernicterus
Postnatal
- meningitis/encephalitis
- anoxia
- trauma
How to counsel NAI
So we have done an examination of timmy and during this we have found some signs which suggest that Timmy may have been physically hurt which is of concern to us because his safety is our top priority
It is important to state at this point that we are not accusing anyone of this just that this is what we have found and that we are going to need to investigate what has happened- do you have any idea how this may have happened
In the meantime what we are going to do is admit him to hospital where he is in a safe place and the proper investigation can be done. we have contacted the safeguarding team who are going to come and figure out what is best for him as that is their speciality
How to counsel neglect
From the history what were most concerned is that your sons basic needs are not being met which worries us because these things are necessary for him to thrive and develop as a healthy young boy
We are unsure what has been going on here and are not accusing anyone however what we need to do is to contact the safeguarding team who are going to figure out what is best for him
Counselling on ADHD
Today you have described thse behaviours of restlessness and having lots of energy
In people with these behaviours what we consider as a diagnosis is ADHD. Have you heard of this before
Yes so there are 2 main parts the first of which is attention deficit where people struggle to concentrate and remain focussed on something
The second part is hyperactivity where people are full of energy and struggle to sit still
What causes?
- no one is at fault for this, it is not a disease that is caused by the environment that they have grown up in, instead we have seen that is does run in families and is due to changes in the area of the brain involved in controlling impulses
Describing family therapy for ADHD
Parent training programmes which help you learn specific ways of talking to your child and working with them to improve their attention and behaviour
NIPE what to do- face to chest
Weigh
General inspection- posture, colour and jaundice
Head
- measure
- shape and fontanelles
Face
- asymmetry
- nose
- skin
Eyes
- red reflex and look in eyes
Ears
- insepct pinna and tags- will undergo hearing test before discharge
Mouth
- palate
- tongue tie
Neck and clavicles
- fracture
- lumps
Arms
- tone
- number of fingers
- 2 palmar creases
Chest
- resp rate
- work of breathing
- listen to lungs
- listen to heart
- pulse oximetry
NIPE abdomen to
Abdomen
- inspection and palpation
Genitalia
Lower limps
- tone
- club foot
- number of toes
Hips
- barlow= bring hip in while applying pressure on knee which is flexed
- ortolani= bringing it back out (abduction)
Turn over
- back scoliosis and inspection
- anus check patency
Reflexes
- check a couple of these
Primitive reflexes
MORO- hand on back of head and let fall backwards
SUCKLING- if something touches roof of mouth will suckle
Rooting- turn its head if stroke mouth
Palmar grasp- touch hand and will close fingers
Stepping- if feet touch floor then will put 1 foot in front of other
