paeds Flashcards
Meckel’s Diverticulum
2 rule
gastric/ pancreatic mucosa which can bleed -painless
Technectium scan
resection if symptomatic otherwise leave
comp is intusussception
Littre’s hernia
vitello-intestinal ducton
Coarctation of the aorta
loudest between scapulae, loud brachial
may present with leg pain and dizziness if mild
angioplastic/ balloon stent
give prostaglandins while waiting for surgery
hypertension may be complication esp after surgery = give antihypertensives
VSD
the smaller the louder
<3mm - loud pan systolic, poor gain and feeding
spontaneously resolve, no risk of IE after closure
>3mm - may have HF, surgery at 3-6 months, softer pan systolic
echo is diagnostic
ASD - heart
foramen ovale fails to close
cardiac catheterisation at 3 years
ESM fixed splitting of S2
Haemangioma
Infantile and congenital
congenital: non-involuting or involuting (12-18 months) - may do embolisation if causing problems
laryngeal haemangioma –> ENT referral, ulcerated
medical photography and review in 3 months
preterm, IVF, bleeding in pregnancy
superficial, deep, mixed
USS/ MRI
PHACES and LUMBAR syndromes
Juvenile dermatomyositis
Heliotrope rash on eyelids and malar rash
raised ESR and creatinine kinase
Proximal weakness
Nappy rash
Irritant, candida, seborrhoeic
candida: superficial pustules, satellite spots, check oral
seborrhoeic: flaking, salmon pink patches, cradle cap
hgih absorbency, disposable, fragrance free nappy wipes
topical imidazole for candida, fluclox for bacterial, if eczema - hydrocortisone
Tinea
Kerion and hair loss (alopecia) immediate derm referral
topical terbinafine, moderate = + hydrocortisone, severe = oral
Skin scrapings and wood’s lamp
Hypothyroidism
Downs and Turners
Jaundice, constipation, lethargy, developmental delay, poor feeding, umbilical hernia, macroglossia
<2 = neuro, >2 = short stature (cretinism)
TFTs monitored
every few weeks until TSh stabilise, every month until puberty, then annually
Thyrotoxicosis
Grave’s, de Quervain’s, Hashimotos, post-partum
foetal high CTG and goitre on USS
neutropenia - warn about fever/ sore throat - come back
Neuroblastoma
neural crest tissue of adrenal glands
abdominal mass and distension
orbital ecchymoses
bone pain
biopsy, check BM fx (mets)
Epiglottitis
do not lie down
cefuroxime and dexamethosone after ENT, paeds, anaes support
rifampicin for household contacts
Epistaxis
10-15 mins bleed stop
cautery + Naseptin application
if not then nasal packing
Meconium aspiration
GA >42 weeks
if no GBS infection then observe
if signs of infection = IV gentamicin and ampicillin and O2 support if needed
Meconium ileus
gastrograffin enema
billous vomiting
biliary atresia and cf
Encopresis
soiling after age of potty training 4 years
psych stressors - school, travel, diet, malabsorption, medication changes, food intolerance
Vitamin D
phsophate loss - Fanconi’s
looser’s zones/ pseudofractures
formula feed
calcium carbonate and chole/ergocalciferol
Wilm’s
abdominal mass not crossing midline
painless haematuria
hypertension
flaws
CT abdo/ pelvis
resection, chemo, radio
GS: renal biopsy - small round blue cells
Beckwith Weidemann syndrome
Hernias
6 weeks = 2 days
6 months = 2 weeks
6 years = 2 months
if large/ symptomatic >1 = 2/3 surgery, if small = 4/5
process vagialis
if strangulated/ obstructed = emergency laparotomy with cephalosporin
VZV
head and trunk then spread
IV aciclovir in imunocompromised
bacterial infection (fluclox and aciclovir), NSAIDS = necrotising fasciitis, purpura fulminans (protein C and S inactivation), encephalitis = cerebellar signs, shingles
EBV
Paul Bunnel and Monospot
white exudate on tonsils
Roseola Infantum
Nagayama spots
febrile seizures
diarrhoea and cough
Measles
4 days before and after
prodrome of fever, malaise, conjunctivitis
otitis media, subacute sclerosing panencephalitis - 7 years after
encephaltis after couple weeks
notifiable - HPU
Mumps
Orchitis, encephalitis, sensorineural loss, amylase
9 days after swelling starts infective
salivary IgM, amylase
Rubella
spares limbs unlike measles
Forcheimer spots
thrombocytopenia and encephalitis
5 days after
Retinoblastoma
leukocoria
strabismus
visual problems
no biopsy
examination under anaesthetic
enucleation, chemo, laser therapy
secondary malignancy e.g. osteosarcoma
autosomal dominant
Otitis Media
haemophilus, strep, RSV
<2 + bilateral, <3 months, immunocompromised, perforation
can give delayed if has not improved in 3 days
breastfeeding is protective
passive smoking
cleft palate, down;s
ENT emergency if mastoiditis - CT
meningitis, brain abscess, facial nerve palsy, labyrintitis
if perfroation, amoxicillin oral for 5 days then review in 6 weeks
check speech and developmental milestones
Otitis media with effusion
if cleft palate or Down’s –> immediate ENT referral
speech and development, poor performance in school
two pure audiometry tests 3 months apart
non-surgical: hearing aids - active monitor for 3 months
surgical: grommets
otorrhoea is SE of myringotomy and grommets
Brain tumours
cranial nerve palsies, seizures, medulloblastoma, ependyoma - hydrocephalus, cranipharyngeoma, pituitary adenoma
CLIC sargent - cancer and leukaemia in children social worker
Benign IC hypertension -papilloedema but normal everything else, obesity - LP with manometry
MRI > CT
Infantile spasms
clusters
hypsarrhythmias
Torch screen, lactate, ammonia, hypoglycaemia
tuberous sclerosis, hypoxic brain injury
can cause developmental delay and development of epilepsy
poor prognosis
triad of infantile spasms, hypsarrhythmias and encephalopathy - regression/ plateau in development
triggered by feeding and noise
steroids and vigabatrin (can cause irreversible visual field defects)
Bone tumours
Ewing’s: onion skinning, t(11;22)
osteosarcoma: mets to lung, Rb gene
sarcoma specilaist team, limb sparing surgery +/- amuputation + chemo +radio
Nephrotic and nephritic
Antithrombin loss = procoagulant
strep titre even minimal associated
lipid profile
shifting dullness
steroids
neprhitic: can give prophylactic trimetoprim
reduce steroid dose after 4 weeks
JIA
like RA - swan neck deformity
NSAIDs, steroids, DMARDs
morning stiffness
uveitis
persistent joint swelling > 6 weeks
reactive arthritis
gonorrhoea, chlamydia, yersinia,
sterile pyuria
NSAIDs because after infection
fractures
greenstick - distal radial
normal: distal radial, elbow, clavicle, tibia
NAI: humerus, femoral, radial
femoral
· Neonates (0-28 days) – padded splints or Pavlik’s harness
· <18 months – Gallows traction
· 1-6 years – straight leg skin traction
>4 years – intramedullary nail (+ more support if >11y)
radial = k=wire
pain management: intranasal midazolam/ ketamine
Ottawa’s ankle and knee rule
spinal muscular atrophy
poor feeding
cant stand and NG tube in type 2
gastroschisis and omphacoele
omph: umbilical cord attached, chromosomal disorders, Beckwith-Wiedemenn syndrome
gastro: vaginal then theatre within 4 hours to correct
more gradual staged repair for omph
omphacoele assoc w/ syndromes
gastroschisis with smoking young age alcohol
congenital diaphragmatic hernia
due to incomplete diaphram formation
USS during preg
CXR - displaced mediastinum, loops of bowel in chest, collapsed left lung)
NG tube and suction then surgery to re-expand lungs and ventilatory support
Bochdhalek hernia in left lung
barrel shaped chest and scaphoid abdomen
Intussusception
Dance’s sign = RLQ
Peyer’s patches
think recurrent = Meckel’s diverticulum, polyps
sausage shaped mass in RUQ
teelscoping of proximal into distal
rectal air insufflation
Whooping cough
catarrhal –> spasmodic –> convalesecent
can last 10-14 weeks
worse at night and after feeds
Abx need to be given within 21 days
seizures, subconjunctival, pneumonia
admit if <6 months, severe breathing difficulty, seizures
<1 month = clarithro, >1 month = erythro
Neonatal resus
1) dry baby
2) asses HR and breathing
3) 5 inflation breaths if not breathing/ gasping
4) reassess if chest not moving 2 person airway control and repeat inflation breaths
5) if chest moving - ventilation 30 seconds
6) if HR < 60 - 3:1 chest compressions
7) check HR every 30 seconds
if still not IV access and give drugs
Duchenne’s and Becker’s
resp problems
mother reports child slipping through hands
Becker’s more milder form, wheelchair later, cardiaomyopathy, scapula winging and waddling gait (shoulder and pelvic girdle weakness)
lung function tests - decreased vital capacity
air stacking and insufflation
glucocorticoids may strengthen muscles over time
proximal to distal
geneitc testing is GS
Tetralogy of Fallot
overriding aorta, RVOTO - determinant of severity of cyanosis, RVH, VSD
tet spells
ejection systolic at lower left sternal border
Acutely: lie babies on their back and bend their knees. In hospital, oxygen should also be provided
otherwise: prostaglandin infusion, BT shunt and then 6 months surgery to correct RVOTO and close VSD
RDS
ground glass appearance
IV fluids, antibiotics, intratracheal surfactant
if looks well and comfortable = nasal cannulae
if >30 weeks/ looks well + acidosis = nCPAP
if <30 weeks/ looks unwell + acidosis = positive pressure ventilation
diabetic mothers
Cerebral palsy
causes: antepartum - TORCH, peripartum - HIE, preterm, postpartum - meningitis, PVL
hand preference before 1 year, tip toe walking (refer anyone with persistent)
MRI
clasp knife, tip toe in spastic
chorea, dystonia, athetosis - fanning of fingers in dyskinetic
hypotonia in ataxic
follow up with MDT for 2 years
red flags for other neuro conditions: progressive, MRI not keeping with CP, lost attained abilities/ skills
SCOPE disability charity
feeding difficulties
Sepsis
<30 mins - ST4 or above reg, <1 hr = consultant
Lp if <1 month unwell between 1 and 3 months, WCC count really low/ high between 1 and 3 (5 and 15)
procalcitonin good marker of bacterial sepsis
continuous monitoring and review
if. failed IV then IO
deep ear swab
IV fluid bolus if shock
sepsis 6 within 1 hour
prolonged rupture of membranes
early onset: benzylpenicillina and gentamicin (GEL)
late: fluclox + gentamicin (staph epidermitis)
ceftriaxone for gram -ve cover if needed
seizures, resp distress > 4 hours
P U on AVPU
Gastroenteritis
CHESS + listeria = dysentery
rotavirus most common
* Complications → dehydration → shock (increased risk if…)
* <6m old
* >5 diarrhoeal stools in <24hrs
* >2 vomits in <24hrs
Cannot tolerate extra fluids or malnourished
can do oral rehydration solution
no antidiarrhoels
no sugary/ carbonated drinks
Antibiotic treatment for slamonella <6 months or immunocompromised
sepsis
extra intetsinal spread
c.diff
post-infectious IBS, HUS, transient lactose intolerance
- Children ≤ 5 years: Rehydration with ORS at 50mL/kg over 4 hours
Children > 5 years: Rehydration with 200mL ORS after each loose stool (in addition to normal fluid intake) in clinical dehydration not shock + maintenance
Infantile spasms
encephalopathy - regression of developmental skills, hypsarrythmia on EEG, salaam attacks = West’s syndrome
ammonia, lactate, glucose, torch screen, EEG does not exclude
tuberous sclerosis: ash leaf spots, angiofibroma on the nose,
steroids and vigabatrin
poor prognosis, development of learning disabilities and epilepsy
symmetrical
triggered by noise and feeding
in clusters
UTI
if <3 months admit and give IV co-amox
if >3 months and lower UTI = PO trimethoprim for 3 days F, 5 days M
if > 3 months and upper + vomtiing = IV co amox and admit
if upper and no vomiting = PO cefalexin
if recurrent consider long term prophylaxis before MCUG if no VUS then stop
if < 6 months and atypical = urgent USS and DMSA in 4-6 months + MCUG
if first presenation = USS within 6 weeks, can consider MCUG
if >6 months + < 3 years and atypical = urgent USS (if non-E.coli and responding well then within 6 weeks)
if recurrent: USS within 6 weeks and DMSA +/- MCUG (FHx pf VUR, poor urine flow, dilation on USS)
if >3 years: atypical = same as above but no need for MCUG
recurrent UTI = >= 2 upper, 1 upper and lower or >3 lower
atypical: very unwell, not E.coli, not responding to Abx for 48 hours
precocious puberty
<8 and <9
boobs, pubes, grow and flow
Tanner’s and Prader’s orchidometer (> 4ml)
flat, budding, rounded, mens within 2 years, more rounded and only nipple raised
gonadotrophin depended: tumour, hydrocephalus, meningitis
independent: McCune Albright (thyroid, cushings, acromegaly), CAH, gonadal tumours, leydig cell tumour
premature thelarche and adrenarche
refer to paeds endo
if atrophic testes = CAH
if bilateral enlarge: gonadrotrophin dependent
if unilateral: tumour
dependent: GnRH analogues and GH
but no tx if no underlying pathology
independent: ketoconazole
gold standard diagnosis: GnRH stimulation test
Down’s
ASVD
hypothyroidism
Hirschsprungs
Infertility
Glue ear
ALL
ASD
Alzheimer’s
annual thyroid, opthalmic and hearing checks up to 5 years then every 2 years
local DS clinic and parent support groups
Epicanthal folds in addition to upslanting palpebral fissures
meiotic non-dysjunction
Enuresis
primary: not ever had a dry period for longer than 6 months
secondary: after 6 month dry period
constipation, neuropathic bladder, reduced bladder sensation, detrusor instability, emotional upset, UTI, diabetes
> 5 years when should have sensation
if wetting on getting up and dry at night with girls = ectopic ureter
>7 = desmopressin first line
>5 = enuresis alarm
4 weeks follow up after alarm continue after better until 14 consecutive dry nights
if not responded to 2 courses of Tx = community paeds referral/ enuresis clinic/ secondary care
status epilepticus
convulsing more than 5 minutes without gaining consciousness
in community - buccal midazolam after 5 minutes if not recovered call ambulance
in patient: buccal midazolam/ rectal diazepam –> IV lorazepam x2 –> anaesthetic support and Iv phenytoin –> rapid sequence induction with sodium theopenthone
CAH
21 hydroxylase def –> 17a-OH progesterone build up
USS on internal genitalia in neonates
IV hydrocortisone, dextrose and fluids
lifelong is hydrocortisone but give fludro as well if salt losing
metabolic acidosis
monitor 17a-OH progesterone, androgens, skeletal growth, androgens
5a-reductase def = XY, feminisation, male organs
21 = XX, no male or female organs
androgen insensitivity = XY, female phenotype
17a = XY, feminisation, hypertensive
double dose if ill
enlarged penis small testes
Testicular torsion
undescended testes is a rf
if presented within 4-6 hours greater testicular viability
urine dip to rule out epididymo-orchitis
duplex USS - increased in orchitis and decreased in torsion
if surgery not available in 6 hours, then manual detortion
orchidoplexy but may need orchidectomy
bell clapper testis
pain relief and anti-emetics
Chronic asthma
Pectus excavatum and carinatum
Harrison’s sulci
FEV1/FVC <70 and 12% improvement with bronchodilator in >5
<5 = clinical diagnosis
FeNO >30 = inflammation
how much school missed
use spacer?
<5:
SABA –> SABA + moderate dose ICS (8 weeks trial) if recurred within 4 weeks of stopping = low dose if beyong 4 weeks of stopping = moderate –> SABA + LTRA + low dose ICS –> refer to specialist
>5:
SABA –> SABA + low dose ICS –> SABA + low dose ICS + LTRA(review in 4-8 weeks) –> SABA + low dose ICS + LABA –> SABA + MART (moderate dose ICS) –> specialist
if good asthma control can step down to lowest steroid dose
Acute Asthma
every 20-30 mins for an hour
if at home every 10-20 mins
consider quadrupling ICS dose for next 14 days if cant can give PO pred for 3-7 days
1-2-3-4 hourly, >94% sats, >75% PEFR then discharge
follow up within 2 days in hosp and week in GP
if on MgSO4 use ECG
Iv salb/ aminophylline
transfer to ICU
5 tidal breaths per puff
Atrovent
salb overdose = vomiting, shviering
paco2 rising = near fatal
Duodenal atresia
blind end to duodenum
Down’s
double bubble sign
duodenoduodenostomy
polyhydramnios
DDD - downs, double bubble, duodenodudeno
Hypospadias
three features: hooded prepuce, ventral meatus, curvature of shaft (chordee)
baso urethra not at tip of penis
important not to be circumscised before surgery at 12 months as need skin
Normal dehydration
Different to DKA
Bolus is same
shocked = 20ml/kg over 15 mins
non-shocked = 10ml/kg over 60 mins
but deficit is not according to pH but weight loss
no clinical dehydration = <5%
clinical = 5-10%
shock = >10%
1% = 200ml as deficit
maintenance is with 5% dextrose unlike DKA
4,2,1 calculation
first 10kg, next 10kg and rest = 4 x – + 2 x ___ + 1 x ___
oral rehydration solution in clinical dehydration (has glucose in it)
continue breastfeeding, avoid sugary drinks, advise fluid intake before and after
FOFSALT and SALTLOSS
signs of clinical undectable are baso nromal, in clinical dehydr - red urine output, lethargy, dry mucous membranes, shock = cold peipeheries and other symps
Perthes
4-8 year
short stature and hyperactivity (think ADHD)
Catterall staging - 1= no changes, 2 = cystic changes ona rticular surface, 3 = femoral head changes to integrity, 4 = acetabulum integrity
<6 = obs, pain relief, physio, splints
>6 = osteotomy
limb shortening
roll test = guaridng
MRI if persistent pain despite normal x-rays
should raise suspicion of this if > 4weeks
Persistent pulmonary hypertension
fluoxetine can cause
think HF so may need CXR, urgent echo
absent heart murmurs and signs of HF
O2 and inhaled inotropes, may need ventilation
Kwashiokor and marasmus
Kwashiokor - proteins
Marasmus - fat and proteins
think like nephrotic so oedema, muscle wasting
in marasmus get more weight loss, dry wrinkled skin
Impetigo
Staph aureus/ strep
warm weather, scratching
incubation period 4-10 days
non bullous, local = hydrogen peroxide cream then topical fusidic acid
non bullous, wide spread - topical fusidic/ oral fluclox
widespread bullous = oral fluclox
school exclusion until healed and crusted over or 48 hours after starting Abx
what is considered as DKA being resolved
bicarbonate >15
ketones <0.6
pH > 7.3
Delayed puberty
13 not starting breast devlopment, 15 for periods
infection, trauma, chemo, intracranial tumours, hypothryoidism, testicular torsion
>=75th = drop by 3
25-75th = drop by 2
<25th = drop by 1
wrist x-ray = constitutional delay
prolactin TSH
orchidometer <=4ml
charting of parents
IM test for 3-6 months, 6 weekly
transdermal oestrogen for 3-6 months
monitor for overdevelopment of breasts and early fusion of epiphyses then give progesterone once established
Kleinfelters
sparse axillary and pubic hair
47XXY
tall stature
gynaecomastia
small firm testes
Kallman’s
X-linked recessive
failure of GnRH neurones to migrate to hypothalamus
anosmia
hypogonadotrophic hypogonadism
Tonsilitis
tonsillectomy: 7 in 1, 5 in 2 , 3 in 3
sandpaper rash, amox rash, change in voice
ibuprofen, difflam, fluids
centor: fever, anterior cervical lymph, absence of cough, lymph exudate (3/4)
feverpain: FASTI (inflamed tonsils, symptoms within 3 days) - 4,5 , 2,3 = consider
admit: difficulty breahing, dehydration, quinsy, systemically ill
lemierre’s syndrome: septic emboli and internal jugular vein inflam - high dose benzylpen + debridement
Laryngomalacia
supraepiglottic collapse - baso voice box
FTT, poor feeding
GOR symps
onset within 2 weeks of birth (2-6 weeks)
worse lying down
coughing
Ix: flexible laryngoscopy
usually resolves within 18-24 months
thicked feeds for GOR
if failure to grow and rlly impacting then epiglottic supraglottoplasty
hypotonia, Down’s
normal cry as vocal cords not affected
mesenteric adenitis
diagnosis of exclusion - mainly appendicitis on clinical suspicion
may have to do USS and bloods
always inc in PACES differentialsI
ITP
avoid activities, contact sport which result in trauma
<20 = IVIG, steroids, anti-RhD
if life-threatening haemorrhage then transfusion
1-2 weeks after vaccine/ infection
reoslve in 6-8 weeks
Threadworms
Enterobius Vermicularis
<6 months - 6 weeks hygiene
cut nails, no scrtahcing, change linen, handwashing
mebendazole and 2 weeks measures
Epilepsy
lamotrigine not for myoclonic
ethosuximide for absence
MDT
ECG
benign rolandic epilepsy - during sleep and hypersalivation - younger children
juvenile myoclonic epilepsy - waking up - older children
progressive - deteriorates overtime
school
weight gain in valproate
rash in carb and lam
carb and lam for focal