Paeds Flashcards
What is the most common resp infection in infants?
Bronchiolitis
Bronchiolitis Ax
RSV
Bronchiolitis presentation
coryzal symptoms dry cough and breathlessness
Bronchiolitis Signs
Tachypnoea, chest recession
wheeze or crackles (?VIW if just wheeze)
When do you admit for bronchiolitis?
Problems with feeding Low O2 Sats <92
Bronchiolitis Ix
clinical diagnosis
Viral throat swabs
?CXR (exclude pneumonia, show hyperinflation)
Bronchiolitis Tx
O2 ?fluids ?NG tube
Pneumonia Ax
50% idiopathic
newborns : Grp B Strep
<5: RSV, strep pneumoniae, h. influenzae
>5: mycoplasma, strep. chlamydia pneumoniae
Pneumonia presenation
‘unwell’ child
resp: cough, diff breathing
General: lethargy, poor feeding, fever
Pneumonia signs
Increased RR: Tachypnoea
end inspiratory crackles
decreased O2
Pneumonia Ix
CXR nasopharyngeal aspirate
Pneumonia Tx
Amoxicillan -> co-amoxiclav
At which ages is appendicitis most and least common
Most common 10-20 Least common <3
Appendicitis Presentation
Anorexia vomiting abdo pain, central and colicky -> RIF and aggravated by movement
Appendicitis Signs
flushed face fever + McBurneys
Appendicitis Ix
urine dipstix - WBC
US - thickened non-compressable appendix with increased blood flow
Appendicitis Tx
Appendicectomy
Tonsillitis Ax
Gp A Beta-haemolytic strep Epstein-Barr Virus
Tonsillitis Presentation
throat: Sore, diff swallowing -> LOA, no voice/hoarse
sick
lethargy
earache
Tonsillitis Signs
Red tonsils white/yellow coating on tonsils
swollen glands in neck or jaw
fever
Tonsillitis Tx
- symptoms normally go in 3-4 days
- paracetamol or ibuprofen lozenges, throat spray, antiseptic solutions
When would a tonsillectomy be considered?
-recurrent tonsillitis -Peritonsillar abcess (quinsy) -obstructive sleep apnoea
Glandular Fever Ax
EBV
Glandular Fever Presentation
Fever, fatigue malaise
Sore throat: englarged tonsils, exudative, raised cervical nodes
Petechia (red/purple spots) on soft palate
Maculopapular rash
Later: Jaundice, hepato/splenomegaly
Glandular Fever Ix
-monospot test: detects heterophile abs (could have early false -ve)
Test for EBV specific abs if -ve monospot after 6w but still symptomatic
Glandular Fever Tx
Avoid contact sport 3 weeks (splenic rupture)
Avoid alcohol
Paracetamol
IV fluids
steroids if tonsils v big
What is spina bifida?
Neural tube defect, vertebral arch of spinal column either incompletely formed or absent
How does spina bifida present?
often incidental finding on X-ray
-tethered cord damage causes most symptoms
- bladder/bowel dysfunction
- pain/weakness of lower limb
-80% have skin over defect with
- hairy patch
- fatty lump
- hemangioma (red/purple spot made up of blood vessels)
- dark spot or birth mark
- skin tract or sinus
- hypopigmented spot
how is spina bifida diagnosed
Prenatal: raised AFP, 18-21 wk scan
screening bloods
X-ray, CT
What is the treatment for spina bifida?
Fetal surgery <26wks
postnatal surgery to correct in first days of life
Common causes of limp in children < 4 years old
- fracture
- osteomyelitis
- NAI
- septic arthritis
- DDH
Common causes of limp in child 4-10 years old
- fracture
- osteomyelitis
- septic arthritis
- perthes
- transient synovitis
common causes of limp in child over 10 years old
- fracture
- osteomyelitis
- septic arthritis
- perths
- chondromalacia
- SCFE
Which regions are most responsible for limp in children?
- hip
- leg
- knee
- thigh and foot
Which non MSK areas do you need to examine in the limping child and why?
- abdomen
- intra abdominal pathology can be cause
- testes
- testicular torsion can be cause
How would you diagnose trauma as the cause of a limp?
- trauma history
- X-ray
- anteroposterior and lateral views
Where would toddlers fracture generally be and how would it present? How would you treat?
- spiral tibial
- pre-school age
- unwitnessed fall
- local tenderness over tibial shaft
- Tx- immobolise
What is the most common cause of acute hip pain in children 3-10
transient synovitis
Who does transient synovitis most commonly affect and how does it present?
- boys
- acute onset (sometimes post resp infection)
- unilateral
- no pain at rest
- passive movements only painful at extreme ranges
- may refuse to walk
What investigations would be performed if transient synovitis was suspected, what would they show?
- FBC - normal or high
- ESR - normal or high
- X-Ray - can be normal
- USS - effusion
How would you treat transient synovitis?
- rest and physio
- NSAIDs can reduced duration of symptoms
- usually resolves 2/52
How does a septic arthritis history present?
- <2 years old acutely unwell
- can be after puncture wound or infected skin lesion (chicken pox)
- pain present at rest
- movement painful and resisted
- hip pain referred to knee
- one joint affected, mainly large joints
What would be in the findings from an examination of a joint affect by septic arthritis?
- red, warm, tender, decreased ROM
What investigations would be performed if septic arthritis was suspected, what would they show?
- aspiration of joint space under US for organisms and culture
- WCC and CRP - increased
- culture - +ve
- USS - effusion
- X-ray
- bony changes not evident for 14-21 days
- 28 days 90% show abnormalities
How would you treat septic arthritis?
- Abx (initally IV) Fluclox
- if deep joint or no resolution then wash out or surgical drainage
- Initially immobilise but mobilisation must follow to prevent permanent deformity
What is Kocher Criteria
Probability of septic arthritis
- Non weight bearing 1/4=3%
- Temp > 38.5 2/4= 40%
- ESR > 40 mm/hr 3/4 = 93%
- WBC >12,000 4/4 = 99%
What is Perthes disease?
Avascular necrosis of femoral head
What increases the risk of Perthes
- male
- low birth weight
- short stature
- low socio-economic class
- passive smoking
How does Perthes present?
- insidious
- unilateral limp and pain (hip or knee)
- no trauma
What would be the +ve finding on an examination of someone with Perthes?
- limited ROM
- roll test - pt supine, internally and externally rotate joint to invoke guarding or spasm (especially internally)
What investigations would be performed if Perthes disease was suspected, what would they show?
X-ray
- increased density of femoral head
- sclerosis
- fragmentation
- eventual flattening of proximal femoral head
bone scan and MRI (helpful in diagnosis)
How is Perthes managed?
- if <50% femoral head affected
- bed rest and traction (use of pulling force)
- More severe/late presentation
- femoral head needs to be covered by acetabulum then hip kept abducted by plaster or by performing femoral or pelvic osteotomy
What is SCFE?
Slipped capital femoral epiphysis
results in displacement of epiphysis of femoral head - needs prompt Tx to prevent avascular necrosis
Risk factors for SCFE
- tall and thin
- short and obese
- metabolic endocrine abnormalities
- family Hx
- usually occurs at puberty
SCFE presentation
- acute onset after minor trauma or insidious onset
- hip, thigh (maybe referred knee pain)
- painful to weight bear
- several week Hx of vague groin or thigh discomfort
What would be the positive findings in an examination of a patient with SCFE disease?
- decreased abduction and internal rotation of hip
- hip flexion often causes external rotation
- may be leg shortening
What investigations would be performed if SCFE was suspected, what would they show?
- XR
- widening and irregularity of plate of femoral epiphysis
- displacement of epiphyseal plate medial and superior
What is the treatment for SCFE?
Pinning of hip
Risk factors of DDH
- female
- breech
- c-section
- pre-mature
- 1st child
- family hx
When is neonatal screening repeated and what do you look for with DDH?
8/52
- Barlow, can hip be dislocated
- Ortolani, can hip be relocated back into acetabulum on abduction?
- asymmetrical skin creases in thigh or buttock
- USS if suspected DDH
What is the Tx for DDH?
- conservative - splint or harness
- surgery
What is a wheeze?
whistling sounds heard on expiration due to resp tree narrowing
What are the common diagnosis for recurrent wheeze?
- persistent infantile wheeze
- viral episodic wheeze
- asthma (multiple trigger wheeze)
Probably cause of wheeze age <3
Transient early wheeze
- small airways
- maternal smoking
- early virus
- pre-term
Probable cause of wheeze 3-6
viral episodic wheeze
- airway hyperactivity
- RSV/LRI
Probable cause of wheeze >6
IgE associated asthma
- airway hyperactivity
- atopy
Summarise viral episodic wheeze
- no interval symptoms
- no XS of atopy
- improves with age
Tx
- bronchodilators
- oral steriods
- No benefit from inhaled steriods
Acute asthma summary
- 02 (if needed)
- B-agonist
- prednisolone (or IV Hydrocortisone)
- IV salbutamol bolus
- amniophylline/MgS04/Salbutamol infusion
Examples of preventer inhalors
inhaled steriods - brown
- beclomethasone
- budesonide
- fluticasone
Examples of reliever inhalers
Blue - B2 agonists
- salbutamol
- torbutaline
ipratropium bromide
Examples of add on asthma therapy
LABA
- Salmeterol
- formoterol
leukotriene receptor antagonists
- monteleukast
- theophyllines
- omalizumab (anti IgE)
- protexo (high IgE)
Describe Stepwise approach to asthma mx in ages 5-12
- Inhaled SABA
- inhaled steriod (200-400mcg/day)
- +inhaled LABA and assess control
- if good continue LABA
- if middle continue LABA but increase ICS (400)
- if no response stop LABA, increase ICS (400), trial therapies
- increase ICS (800)
- maintiain ICS, + daily oral steriod tablet
Common reasons for unresponsiveness to Tx in asthma
- adherence
- rule of 3rds, adequate, partial, none
- diagnosis
- environment
- choice of drugs/devices
- bad disease
Side effects of ICS
- might cause brief slowing of growth but doesnt affect final adult height
- probably doesnt affect bones
- can suppress adrenals
What are the adrenal layers and what do they produce?
- Glomerulosa = Mineralcorticoids (aldosterone)
- Fasciculata = Glucocorticoids (cortisol)
- Reticularis = Sex Hormones (dihydrotestosterone)
(Go Find Rex, Made Good Sex)
What are the two ventral body wall defects?
- exomphalos
- gastroschisis
What is exomphalos?
abdo contents protruding through umbilical ring covered with transparent sac (amniotic membrane and peritoneum)
What is gastroschisis?
bowel protruding through defect in anterior abdo wall adjacent to umbilicus, no covering sac
risks of developing ventral body wall defects
conditions related to placental insufficiency
- maternal illness and infection
- drugs
- smoking
- alcohol
How do ventral body wall defects present?
increased alpha-fetoprotein and abnormal USS 2nd trimester
exomphalos
- 4-12cm abdo wall defect
- central epigastric hypogastric
gastroschisis
- opening >5cm
- R of umbilical cord
Ix for ventral body wall defects
- increased MSAFP (maternal serum alpha-fetoprotein)
- karyotyping
- imaging
- amniocentesis
Exomphalos Mx
- IV fluid
- surgery +/- silo
- if sac intact not much pre-op care needed
- if sac ruptured same tx as gastroschisis
Gastroschisis Mx
- plastic closure (gradual decomp of abdo contents from silo into abdo)
- primary closure
- wrap body in clingfilm to minimise fluid and heat loss
- NG tube
- gastric function should return over several weeks, reassess if not successful 6/52
ADHD features
1) attention deficit (unable to listen, sustain attention in play, follow instruction, remember simple tasks)
2) hyperactivity (squirming, fidgiting, talks incessantly, restlessness)
3) impulsivity (blurts out answers, interupts)
ADHD management
mild 1st - parent training/education -> methylphenidate ->lisdexamfetamine
severe 1st - methylphenidate -> lisdexamfetamine
Methylphenidate SE= decreased appetite dont take on weekends
Symptoms of ASD
A) Communication difficulites
- lack of desire
- literal communication
B) Social difficultlies
- lack of desire
- lack of motivation to please others
- affect when they want to be
C) imagination impaired
- repetative behaviour
- no creative play
A) impaired social interaction
- unaware of existence/feelings of others - bad at making friends
- abnormal repsonse to being hurt
- impaired imitation
- repeated play
B) impaired imagination
- little babbling
- no fantasy/pretend
C) poor range of activity/interests
- stereotyped movements
- reoccupation with parts of objects
- marked distress over change
- routines
non medical ASD management
early intensive behavioural intervention (increases IQ, enhances motor, social and living skills
±speech therapy
±special schooling
- parent training
- benefits
What is MART
Maintenance and reliever therapy
ICS and LABA in one inhaler take daily and for sx relief
(symbicort, fostair)
What ICS doses are considered low/mod/high
low: <200
mod: 200-400
high: >400
SABA example, use, MoA and SE
salbutemol
reliever
relax airway SM
SE: tremor
ICS example, use, and SE
beclometasone
preventer
SE: oral candidiasis, stunted growth
LABA example and use
salmeterol
preventers
LTRA exmaple and use
Leukotriene receptor antagonist
Monteleukast
oral preventers
Asthma spirometry results
FEV1 (vol exhaled at end of 1st second of forced expiration): significantly reduced
FVC (vol exhaled after a maximla expiration following full inspiration): normal
FEV1/FVC < 70%
Choice of Abx for tonsillitis
Phenoxymethypenicillin
(clarithromycin or erythromycin)
Facial features of a baby with Downs
Wide spaced eyes
oblique palpebral fissues
Epicanthal folds
short broad nose
deeply grooved philtrum
protruding tongue
small chin and short neck
Body features of baby with Downs
low set oval ears
excess nuchal skin
swollen oedematous dorsum of hands and feet
single palmer crease
What are later medical problems and child with Downs might encounter?
cardio: VSD, PDA
ENT: hearing loss, otitis media
Opth: cataracts, strabismus
GI: Coeliac, Duodenal atresia
Endo: hypothyroid
Neuro: learning diffs, behavioural issues, Dementia
Haem: AML, ALL
None physical neonatal features of Downs
- Hyperflexibilty
- muscular hypotonia
- transient myelosyplasia of newborn
What is the genetics of Patau?
Trisomy 13
How does Patau present?
PERC
- *P**olydactyl
- *E**ye defects and small eyes
- *R**enal malformations
- *C**left lip and palate/cardiac malformations
- *S**tructural brain defects/scalp defects
Pataus prognosis?
Mean survival 2.5 days
50% live past 1 week
5-10% 1 year survival
Pataus diagnosis?
10-14 wks: combined test (hCG PAPP-A)
11-14 weeks: CVS
>15w: aminocentesis
18-21w: physical conditions scan
Genetics of Edwards
Trisomy 18
US findings in Trisomy 18
Growth restriction
Polyhydraminos
overlapping fingers
Congential heart defects
strawberry haped cranium
Neonatal features of trisomy 18
Low birth weight
Low set ears
small jaw
cleft lip and palate
overlapping fingers
rocker bottom feet
Prognosis of Edwards
8% 1 year survival
Prevention of spina bifida?
Folic acid
- prevents occurance and reduces severity if occurs
- prenatal diagnosis and surgery
Criteria for ADHD diagnosis?
- present before 12 years old
- developmentally inappropriate
- 2 settings
- edivdence of impairment on social, academic or occupational
Croup AX
Parainfluenza virus
croup presentation
prodrome: coryzal, fever
barking cough, harsh stridor when distressed
*dont examine throat*
How do you manage a patient with croup?
mild: home
Severe: PO dexa, pred, neb steroids or adrenaline
intubate if severe
Acute epiglottitis Ax
Hib
Presentation of acute epiglottitis
child sitting upright, mouth open, drooling
high fever
stridor soft
sudden onset
How do you manage acute epiglottitis?
IV cefuroxime
intensive care, intubate
Bacterial tracheitis Ax
staph aureus
Bacterial tracheitis presentation
hours onset
older child
No prodrome
continuous stridors
Features of Kawasaki disease
5 day fever
- Mucuous membrane involvement: strawberry tongue, dry lips
- Hands and feet: odema and desquamation
- Eyes: bilat conjunctivitis
- Adenopathy: cervival lymphadenopathy
- Rash: truncal
- Temp
How do you manage Kawasaki?
IVIG in 10 days
aspirin
if persistent: immunosuppresion (infliximab, steroids, ciclosporin)
What is the most serious complication of kawasaki?
Coronary aneurysm
6 week echo follow up to detect
What is JIA?
joint inflam presenting in kids under 16 and persisting at least 6 weeks with other causes excluded
What are the subsets of JIA?
- oligoarticular JIA (<5)
- polyarticular JIA RF -Ve (>5)
- polyarticular JIA RF +ve
- Systemic onset JIA (+fever)
- Juvenile psoriatic arth
- enthesitits related arth
- undiff arthritis
Management of JIA
NSAIDS
Steroids: injection, systemic
methotrexate: subcut
surgery: joint replacement
Which JIA subtype has increased risk of uveitis?
oligoarticular
Whats the pathology of cystic fibrosis?
Autosomal recessive condition
airway: impaired ciliary function
intestine: meconium ileus
pancreas: ducts blocked by thick secretions (enzyme insufficients and malabsorption)
How does cystic fibrosis get diagnosed
antenatal: CMV, amnio
Perinatal: scenning, jaundice, haemorrhagic disease of newborn
infancy: resp infections, FTT, diarrhoea
older: resp infections, bronchiectasis, male infert
Cystic fibrosis signs
finger clubbing
cough, crackles, wheeze
obstructive FEV1 pattern
Cystic fibrosis investigations
- sweat test
- genetic testing
- sinus x-ray or CT scan: opacification
Cystic fibrosis management
mucus clearance techniques
neb dornase alpha: reduces sputum viscosity
pancreatic enzymes
high calorie intake
How do you test pancreatic function in cystic fibrosis patient?
low stool elastae
what is cerebral palsy
Movement disorder resulting from a non-progressive lesion of motor pathways
Later appearing symptoms of cerebral palsy
depend on where lesion is, symptoms appear gradually as child does not develop as expected
- learning difficulties
- epilepsy
- squint
- visual/hearing/speech and language impairment
*
Cerebral palsy causes
80% antenatal - gene deletions, infection, vascular occlusion
10% hypoxic ischaemic birth injury
10% post natal - trauma, meningitis, encephalitis
Early signs of cerebral palsy
- floppy baby
- feeding difficulties
- delayed motor milestones
- persistence of primitive symptoms
- asym hand movement (preference of hand <12m)
Patterns of sypmtoms in Cerebral palsy
- spastic - 70% - lesion in pyramidal or corticospinal tract
- dystonic - 10% - lesion in basal ganglia
- ataxic - 10% cerebellum
- mixed - 10%
Presentation of spastic cerebral palsy
UMN signs
- hemiplegic - unilat asymmetrical arm> leg
- quadriplegic - all limbs arm>leg
- diplegic - all limbs legs>arms
Cerebral palsy management
No cure
physiotherapy
splinting of affected contracted joints
botox injections - relax muscle in hyperonia, particularily for gait
SALT
Causes of spina bifida
genetic, Downs, edwards, pataus
mum: alcohol, valproate, carbamazepine, db, not taking folic acid
