Paeds 2 Flashcards
What is the most common organism causing paediatric UTI? What are some others and what would you have to do if a little child had infection with them?
E.coli
Klebsiella, proteus, pseudomonas- they would need imaging (US renal tract)
How would you investigate if you suspected a child had a UTI?
Bedside: Urinalysis- dipstick and MC&S
Bloods: FBC, U&E, CRP
Imaging only if septic, atypical UTI, not responding to Abx: US, DMSA, MCUG
A 2 month old has confirmed UTI. How are you going to treat?
Admission to hospital and IV antibiotics eg. co-amoxiclav for any child with UTI <3 years old
A 1 year old has confirmed cystitis. How are you going to treat?
Oral trimethoprim or nitrofurantoin
A 7 month old has confirmed pyelonephritis. How are you going to treat?
Oral cefalexin or co-amoxiclav borad spectrum and narrow with results. If vomiting- IV co-amox
A little boy comes in to practice as he has had recurrent UTIs now, he is having one every other month. He needs some investigating due to this. You have done a scan which shows grossly dilated ureters and kidneys. What is the likely diagnosis and what scan would have been done?
Vesico-ureteric reflex
Micturating cystogram
What is the pathophysiology behind vesico-ureteric reflex and how does it cause kidney damage?
Ureters enter the bladder laterally and more directly so causes retrograde flow of urine from bladder to kidneys. This occurs during voiding and due to the urinary stasis it predisposes to recurrent UTIs. Additionally causes renal damage from infection but also the high pressure of bakckflow of urine when voiding
A 9 year old boy has been brought in by his mother due to recurrent episodes of bed wetting. He has been having these episodes for many months now and has gradually been increasing in frequency. He is now wetting the bed every night. He says he is enjoying school and mum says there are no issues with bullying etc in school. Family life is good at home. PMH: Constipation- he is on lactulose which isnt helping. No other medications. Examination is unremarkable. Given the likely diagnosis, what are some options for initial treatments? What investigation might you do?
Primary enuresis
Conservative measures:
- No drinking before bed
- Increase the dose/add senna to treat constipation
-Star charts
- Bladder training- using toilet just before bed
-Small alarm triggered by wee.
May do urine dip and MC&S to rule out UTI
The 9 year old who was diagnosed with enuresis and given conservative measures comes back 3 months later for review. Mum says there has been no improvement in his urinary symptoms and he is still bed wetting every night. He also has a school trip to Paris coming up and is not wanting to go for fear of embarrassment. His constipation is under control now though. What treatment can you offer now?
Desmopressin- particularly useful for school trips and sleepovers.
A 7 year old boy presents to clinic with his mother. His mum says she’s noticed his face has been swollen, particularly around his eyes as well as his legs. Also she has noticed his urine has been frothy but there is no blood, burning or stinging. Dipstick shows no protein 3+, no haematuria.
Given the likely diagnosis, what treatment are you going to offer?
Minimal change disease - nephrotic syndrome
Treatment: prednisolone
What is the triad of symptoms in nephrotic syndrome?
Hypoalbuminaemia <25g/L
Oedema- peripheral, orbital, scrotal
Proteinuria >3g loss
Investigations required in nephrotic syndrome are relatively few what are most important ones?
FBC, U&E- kidney function, LFTs, CRP
Urine albumin: creatinine ratio
Urine dip- proteinuria
Renal biopsy- if not responding to steroids
What do you see on light and electron microscopy in minimal change disease?
Light- nothing
Electron- podocyte effacement –> leaky glomerular b.m
How would you manage minimal change disease- treatment and monitoring?
Prednisolone- usually responds well
Fluid restrict and low salt diet. and monitor their fluid balance daily.
What are some of the complications that can develop with minimal change disease and how would you treat them?
Hypovolaemia- become intravascularly dry. Give IV albumin
Infections- give prophylactic penicillin and treat infections promptly
Thrombosis- monitor for any signs of stroke/PE etc.
What are the clinical features of glomerulonephritis/nephritic syndrome?
Haematuria Oliguria RBC casts in urine Hypertension Oedema
What are the causes of glomerulonephritis/nephritic syndrome?
Post strep GN IgA nephropathy SLE HSP Granulomatosis with polyangiits
A 8 year old boy presents with his mum to GP with what she describes as ‘cola coloured’ urine. It began a last week and has not been getting better. She says it’s also a bit frothy. She says he is going to the toilet less even though she’s drinking the same amount of fluid. You ask if he’s been well recently and she says he had a sore throat and fever about 2.5 weeks ago but that has settled now with some penicillin by the other GP. Observations show a raised BP. What is the likely diagnosis?
Post-strep glomerulonephritis - 2-3 weeks post strep infection
What is the difference between post-strep glomerulonephritis and IgA nephropathy?
Post-strep glomerulonephritis- 2-3 weeks post strep infection
IgA nephropathy- 2-3 days after strep infection
What is the causative organism of Post-strep glomerulonephritis?
Group A beta haemolytic strep
How would you investigate and manage Post-strep glomerulonephritis?
Ix:
Bedside: urinaylsis- urine dipstick- proteinuria, RBC casts and haematuria and MC&S
Bloods: FBC, U&E- kidney function, ESR, ASOT
Tx:
Fluid balance, salt restriction, may need diuretics
Treat HTN
Treat step infection if still present
A 10 year old boy comes to A&E as he has developed this new onset rash. It is slightly raised and is on his buttocks and back of his legs. His mum is really worried because the glass test has not caused it to blanch. He also have some abdominal pain and his legs are really achy too. He has recently had a bad chest cold that is settling now. What is your diagnosis but what do you also need to rule out?
HSP
Rule out menigoccal sepsis, DIC , ITP, leukaemia - non blanching rash
What is the triad of symptoms in HSP? What else might you get?
Arthritis + Purpura + Abdo pain- colicky
Haematuria
Proteinuria
How do you treat HSP- mild and severe- with worsening gFR
Mild: supportive and give prednisolone to help oedema, joint pain and abdo pain
Severe with worsening eGFR- cyclophosphamide
A young boy comes to A&E with his dad because he has been suffering from bad abdominal pain for a few days and this morning had an episode of bloody diarrhoea. He also has noticed his child hasn’t been the toilet to urinate for a few hours now which is unlike him. Bloods tests have showed low platelets, low Hb and raised reticulocytes and massively raised urea and creatinine. What is the likely diagnosis and cause?
Haemolytic uraemic syndrome: low Hb with shistocytes (MAHA) + thrombocytopenia (low platelets) + AKI
Caused by E.coli- bloody diarrhoea
How do you treat Haemolytic uraemic syndrome?
Supportive: fluids - IV if not drinking
May need blood transfusion for anaemia
may need dialysis
What complications can develop from CKD?
Anaemia- may need EPO
Renal osteodystophy- from secondary hyperparathryodism - may need bisophosphates and vitamin d supplements
Hypertension- strict BP control
Acidosis- may need bicarbonate
Oedema: may need fluid restriction and furosemide
A 2 year old comes to clinic with his mum. He has been well recently apart from some non-specific abdominal pain. On palpation of the abdomen you feel a mass in the left side that is painless. What condition do you need to rule out?
Wilms tumour - nephroblastoma
What investigations do you need to do for a patient with a Wilms tumour?
Bedside: urinalysis- urine dipstick and MC&S
Bloods: FBC, U&Es, LFTs, clotting.
Imaging: US abdomen, confirm with CT/MRI pelvis
A teenage boy presents with a painless lump in his scrotum. On questioning he says it feels like there are worms in his scrotum and is achy but not painful. What is the likely diagnosis and what are the treatment options for a small and big one?
Varicocele
Small: reassurance and supportive underwear
Large: surgery
An infant boy presents with a painless lump in his scrotum. He says it feels like a balloon. On palpation you feel a diffuse swelling in the testes that is fluctuant and it transilluminates with a pen torch. What is the likely diagnosis and treatment?
Hydrocele
Treatment: conservative and monitoring. If gets large and uncomfy: surgical excision
What tests/signs can differentiate testicular torsion from epididymo-orchtiis?
Testicular torsion: cremasteric reflex absent, Prehn’s sign negative (lifting testicle doesn’t relieve pain)
Epididymo-orchitis: cremasteric reflex present, Prehn’s sign positive + fever
You are doing the newborn baby check on little Jake. You notice he has undescended testes. What is the management?
Nothing- reassure
You are doing a review of a 5 month old James. You notice he has undescended testes. What is the management?
Refer to surgeons if >6m for orchiopexy
What are some complications that can develop from undescended testes?
Testicular torsion
Testicular malignancy
Infertility
A little boy comes to A&E as his mother has noticed he has difficulty urinating. It sprays backwards and is getting all over their bathroom floor. On examination of the external genitalia you cannot see the urethral meatus at the tip of the penis and the penis is pulled down. What is the likely diagnosis?
Hypospadias- urethral meatus is on the underside (ventral) side of the penis
Chordee pulls penis down- tightening of tissue on underside of penis.
How do you treat hypospadias?
Surgical: use the foreskin to create a new urethral meatus
What is phimosis?
Tight foreskin that cannot retract around glans
How might phimosis present?
Painful and ballooning of foreskin during urination
How might you treat phimosis?
Circumcision
What are the complications of phimosis?
Paraphimosis - foreksin retracts and gets stuck causing necrosis
Balanitis
Urethritis
Cystitis
A teenage girl comes into practice because she has been suffering with bad headaches recently. She says the headache throbs in the front of her head and she usually feels very sick with it and has to go lie down in her bed with the lights off. The pain doesnt wake her from sleep and is not worse on posture. She notices it gets worse around her period. What is the likely diagnosis and what first line treatment can you offer as this is her first episode?
Migraine- without aura most common in kids
Treatment:
-Conservative: avoid triggers, cold/warm pads
-Acute attacks: NSAIDs, triptan , anti-emetics: cyclising
The teenage girl you diagnosed with migraines comes back next month having had 3 more attacks all of the same nature. What can you now prescribe?
Beta blockers eg. propranolol or pizotifen (NA channel blocker)
A 3 year old girl, Janie, has come to A&E with her very worried mum. Mum says Janie has been a bit unwell since yesterday with a cough, cold and a high fever which she was managing at home with paracetamol. However, this morning Janie had a fit where she went quite stiff and then her arms shook. The episode lasted 1 minute. She hasn’t had another episode since and looks well now apart from a fever when the nurse takes her obs. Bloods are all normal and you do a CT to rule out meningitis and encephalitis which is also normal. What is the likely diagnosis and what will you tell mum?
Simple febrile seizure
Can happen in young children when they have a viral illness. Will settle itself with paracetamol to treat the viral infection.
Safety net for any signs of meningitis/encephalitis
You have diagnosed Janie with a febrile seizure and want to discharge her. Mum wants to know if this will happen again and whether it means she will have epilepsy?
It might happen again- fairly common in young children but doesnt cause brain damage.
Risk of epilepsy is similar to all other children.
Janie comes back 6 months later with her mum again. This time , mum is extremely worried as Janie has been ill for 3 days again with a simple fever and cough but has had 3 fits in that time that are lasting over 5 minutes. What is the likely diagnosis now and what will you tell mum about the epilepsy risk?
Complex febrile seizures - slightly increased risk
What happens in breath holding attacks?
Toddlers- get angry and hold their breath when upset. They may pass out and may turn blue but make full recovery.
What are the features of syncope?
Faint - triggers include hot temperature, fear, standing for long periods
full recovery after
may twitch
A little toddler has come in with his mum. Mum says he had a fitting episode today. He had banged into the table and hurt his knee which was fine but then he went very pale and fell to the floor. She says his arms and legs went stiff and shaky but he recovered within a couple of minutes. On examination he looks absolutely fine and is running around the waiting room. What might have happened?
Reflex anoxic seizure- triggers of pain, fear, cold foods, minor trauma. Fall to the ground, pale and GTC seizure.
Child recovers quickly
You see a child who has had two fits in the last month. On further questioning mum tells you he falls to the ground, goes very stiff and then shakes. It often takes him an hour or two to come around afterwards as he still feels disorientated. He has lost incontinence in both episodes. Given the likely diagnosis, what is the first line treatment?
Epilepsy : >2 attacks
Involve epilepsy nurses for lifestyle advice
Medication: sodium valproate is first line.
What are the main side effects of sodium valproate?
Weight gain, nausea and vomiting
Another child comes to clinic as his mum is saying his school teachers have been noticing him daydreaming more often than not. He has multiple episodes where he looks like he’s just staring and sometimes his eyes roll up. He has no preceding symptoms and no symptoms afterwards. He is meeting his developmental milestones. Hyperventilating has elicited the episode in clinic. What is the likely diagnosis and first line treatment?
Childhood absence epilepsy
Involve epilepsy nurses
Tx: 1. ethosuximide, 2. valproate
What are the main side effects of ethosuximide?
nausea and vomiting
A 13 year old comes to clinic with his dad. He is describing episodes of fits. Initially he gets these jerky movements of his arms causing him to drop objects all the time and then he falls to the ground and goes stiff and shakes. It has not been affecting his development or learning. What is the likely diagnosis and first line treatment?
Juvenile myoclonic epilepsy
First line: sodium valproate
What important investigations will you do when a child presents with a seizure?
Bedside: ECG !- rule out arrhythmia
Bloods- FBC, U&E, GLUCOSE, CRP, Calcium
Imaging: EEG, CT/MRI if suspect SOL
A 5 month old child presents to clinic with his mother. She has been noticing he is having these episodes where his head twitching and his arms jerk and extend out. It lasts a couple of seconds but he is having them every 30 seconds. He is fine in between and has not had any other symptoms. He has not been meeting his developmental milestones though. What is the likely diagnosis and what is might you see on EEG?
West syndrome- infantile spasms
EEG: hypsarrythmia - disorganised brain activity
What are the treatment options for focal seizures? What investigation should you do?
Carbamazepine and lamotragine
CT/MRI head
What are the main side effects of Carbamazepine and lamotrigine?
Rash- both
Neutropenia- carbamazepine
A little girl has come into A&E and is having a seizure. You get a quick collateral history from the mum who said this has been going on for almost 10 minutes now and they’ve rushed to A&E as quickly as possible. She has PMH of epilepsy. What is your immediate management? and the stepwise process after?
ABCDE - control airway and high flow oxygen
IV access and get bloods- FBC, U&E, CRP, glucose
IV lorazepam if got IV access (otherwise= buccal midazolam or rectal diazepam)
After 10 minutes: another dose of IV lorazepam
Another 10 mins: IV phenytoin (or phenobarbital if on phenytoin)
Another 10: Call anaesthetics- needs RSI
A 2 year old child has come into practice with her mum. Mum says over the past few months, Jackie has been doing some abnormal jerky movements with her arms and legs on the left side. Jackie has not been meeting her developmental milestones- she is unable to walk. When mum has been carrying her, she has noticed her arms and legs on that side feel incredibly stiff too. On examination- you notice some spasticity along with brisk reflexes and muscle weakness, most marked on the left side. What could be the cause of this and is this UMN or LMN?
Spastic cerebral palsy- UMN lesion - damage to the pyramidal tract
MOTOR symptoms only
What are some associated problems in those with cerebral palsy? Apart from motor symptoms
Epilepsy
Speech and language problems
Poor growth
Intellectual impairment
