Paeds: crib list Flashcards
Respiratory distress
Vitals - RR, SpO2 (likely if on oxygen), HR
Inspection (and A-E) - recessions, nasal flaring, cyanosis, tiring, drowsiness,
Auscultation - grunting, silent chest, crackles, (stridor, wheeze)
Reflexes
a) Primitive (MRS BAPS) - up to ~ 6 months
b) Postural (LLPP)
a) Moro, rooting, sucking, Babinksi, ATNR, palmar grasp, stepping
b) Landau, Lateral propping, parachute, positive support
Causes of short stature
a) 4 categories
b) ABCDEFG
a) Reduced intake, malabsorption, increased requirement, dysregulation
b) Alone (neglect), Bone dysplasia, Chromosomal (Turner, Down), Endocrine (GH, T4), Familial (genetics, constitutional delay), Gastro (coeliac, IBD, CF)
Congenital hypothyroidism: features
a) Vitals
b) Appearance/signs on examination
c) Symptoms
a) Bradycardia, low temperature
b) Jaundice, hypotonia, large fontanelles, Myxoedema (coarse features), Macroglossia, Umbilical hernia, Goitre, SHORT STATURE
c) Feeding difficulties, Somnolence, Lethargy, Low frequency of crying, Constipation, cretinism
Puberty:
a) Girls - normal, precocious, delayed
b) Boys - normal, precocious, delayed
c) Causes of precocious
d) Causes of delay
a) Normal (8-13)
- Precocious (<8)
- Delayed (>13 without breast development or >15 amenorrhoea with normal breasts)
b) Normal (9-14)
- Precocious (<9)
- Delayed (>14 without testicular development)
c) Usually idiopathic (in girls), CAH
d) CDGP, chronic disease, gonadal dysgenesis
Neonatal jaundice:
a) What 3 groups to screen (timing, duration)
b) Screening tests (BLITH)
a) Onset <24h, onset >2 weeks, duration > 10 days
b) Bilirubin (serum if <24h, transcutaneous otherwise)
Liver function tests
Infection screen (TORCH, surface swabs, septic screen)
Thyroid function test
Haemolytic tests (FBC, Blood group and Rh, Reticulocyte count., Coombs, blood film, Hb electrophoresis and red cell enzyme essays for G6PD deficiency, pyruvate kinase deficiency)
Imaging USS if required
Heart murmurs:
a) Innocent characteristics
b) VSD - characteristics, other features, Ix
c) VSD investigations
d) VSD management
a) Soft, Systolic, Short, Symptomless (no WOB, no HF, no cyanosis, normal femorals), Small (no radiation), Single (no associated sounds), Sensitive (varies with posture)
b) Harsh pansystolic, LLSB, signs of heart failure
c) Investigate using CXR, ECG, Echo (diagnostic).
d) Treat with high energy feeds, diuretics, ACE +/-digoxin
Cyanotic CHD
- 1, 2, 3, 4, 5
- Caused by…?
1 - Persitent truncus arteriosus 2 - TGA 3 - Tricuspid atresia 4 - ToF 5 - TAPVR (oxygenated blood returns into R atrium, rather than L atrium)
Caused by mixing of ox/deox blood (right to left shunts) causing deox blood to be pumped to the body
Duct-dependent lesions:
a) Explain the 2 basic types
b) Presentation
c) DDx: cardiac and non-cardiac
d) How to differentiate cardiac vs pulmonary causes
e) Ix
f) Rx
a) - Duct-dependent systemic lesions: systemic circulation dependent on R-L flow through patent DA
- Duct-dependent pulmonary lesions: pulmonary blood flow is dependent on L-R shunting from the aorta to the pulmonary arteries through the patent DA
(DA closure in both cases can be catastrophic)
b) Difficulty feeding, SOB, Cyanosis, Acute cardiorespiratory collapse with shock (weak femorals).
c) Cardiac.
- Duct-dependent systemic circulation: critical AS, hypoplastic left heart, CoA
- Duct-dependent pulmonary circulation: pulmonary atresia, Critical pulmonary stenosis, TGA, Tricuspid atresia, ToF
Non Cardiac. - Persistent Pulmonary Hypertension of the Newborn (PPHN) - Primary pulmonary disease (Lobe collapse, pneumothorax, IRDS, etc.) - Sepsis, Metabolic disorders
d) Hyperoxic test (if improved oxygenation: respiratory)
e) CXR, ECG, Echo
f) - ABDCE (airway, oxygen and breathing support, monitor pre+post-ductal sats, fluid resuscitation if needed, dopamine if needed, monitor BP in all 4 limbs)
- PGE2 to keeps duct open - give before oxygen as oxygen is a systemic vasoconstrictor
Classifying babies with suspected CHD
a) Blue, femoral pulses present, murmur - 4 DDs
b) Blue, femoral pulses present, NO murmur - 3 DDs
c) Blue/pink, femoral pulses ABSENT
d) Pink, femorals present
a) Cyanotic CHD: ToF, AVSD, TA
b) - Cyanotic CHD: TGA, TAPVR
- Persistent pulmonary HTN
c) Duct-dependent systemic lesions: CoA, critical AS, hypoplastic left heart, interrupted arch
d) VSD, ASD, AS
Persistent pulmonary hypertension of the newborn
a) Pathophys
b) Causes
c) Presentation
d) Ix
e) Rx
a) Normally - first breath leads to pulmonary vasodilatation and reduction in pulmonary blood pressure.
- In PPHN, this doesn’t happen, causing persisting pulmonary hypertension
b) Meconium aspiration, infection, diaphragmatic hernia
c) Blue baby, normal femorals, hypoxic, respiratory distress, poor feeding
d) CXR, ECG, Echo, pre+post-ductal sats
e) ABC (oxygen and ventilation, feeding support, fluids and antibiotics, dopamine if necessary),
- Nitric oxide (NO) may be useful as a vasodilator
Asthma vs. viral wheeze
DR BANT
Dry cough Recurrent/persistent Bronchodilator response Atopy Nocturnal symptoms Triggers
Asthma/wheeze management
a) Indications for step-up asthma management (3)
b) Management of exacerbation: O SHIT ME
c) Step-wise (< 5 years)
d) Step-wise (> 5 years) - differences
a) Salbutamol (>2/week), sleep disturbance (1/week), Exacerbation in previous 2 years requiring admission
b) Oxygen, Salbutamol, Hydrocortisone (or pred), Ipratroprium, Theophylline, Magnesium, Escalate
c) Conservative (triggers, diet, exercise, educate, monitor, review, asthma action plan), Step 1 (B2 agonist), Step 2 (Preventer ICS or LTRA), Step 3 (ICS and LTRA), Step 4 (referral to paeds, note: refer under 2s at step 3)
d) Step 3: add LABA, or increase ICS. If still not controlled, add LTRA or theophylline
Step 4: increase ICS again. Step 5 (requiring regular oral steroids): refer to paeds)
Fluids and resus and traffic light system
Covered in separate deck
Collapsed child
WET FLAG
Weight: (age + 4) x 2 Energy: (age/4) + 4 Tube (NG) Fluids - 20ml/kg (or 10 - neonates, DKA, trauma) Lorazepam Adrenaline/dopamine (and escalate) Glucose
Development
a) By age 6m
b) By 1 year
c) By 18m
d) By 2 years
e) By 3 years
f) By 4 years
g) By 5 years
a) Sit without support, roll onto back, palmar grasp, reach for toys, babbling, put food in mouth
b) First steps, pincer grip, transfer objects, scribble, one word sentences, drink from a cup
c) Walking confidently, tower of 2 cubes
d) Walk up two steps, tower of 6 cubes, draw line, 2-word sentences, cooperates with dressing
e) Jump, tower of 8 cubes, draw circle, speech mostly understandable, names a friend
f) Hop and skip, draw square, knows colours, dress without help, toileting
g) Ride bike, knows meaning of words
Developmental red flags
Gross Motor
- Not sitting by 1 year
- Not walking at 18 months
Fine Motor
- Hand preference before 18 months
Speech and language
- Not smiling by 3 months
- No clear words by 18 months
Social development
- No response to carers interactions by 8 weeks
- Not interested in playing with peers by 3 years
THE MISFITS
- the main 4
Trauma Heart Endocrine Metabolic Inborn errors Seizures/neuro Formula Intestinal Toxins Sepsis
Main 4:
- Sepsis
- CHD
- NAI
- Metabolic
Septic screen
a) Under 1 month
b) 1 - 3 months
c) Over 3 months - green, amber, red
a) FUCC LP (FBC, Urine, CRP, Culture, LP)
b) FUCC (only add LP if unwell/raised WCC)
c) - Green (urine)
- Amber (FUCC, + LP if under 1 year, + CXR if fever and raised WCC)
- Red (FUCC + LP + Gas + CXR depending on clinical picture)
Immunisation schedule
a) Four at 8, 12 and 16 weeks (largely the same)
b) Four at 1 year
c) Two at 3 years (pre-school)
d) Seasonal for 2 - 8 year olds
e) 3 for teenage girls (2 for teenage boys)
f) Optional/at-risk groups
a) 6-in-1 (Dip, polio, tetanus, pertussis, Hib, Hep B),
PCV, Rotavirus, Men B
b) MMR, PCV, Men B, Hib/Men C
c) MMR booster, 4-in-1 pre-school booster (DTaPP)
d) Nasal flu vaccine
e) HPV, 3-in-1 teenage booster (DTaP), Men ACWY
f) Flu, BCG, Chickenpox, Hep B
Paediatric sepsis 6
a) Suspect in patients with 2 or more of what 4 features? (PATT)
b) Lower threshold in what groups?
c) 6 actions
a) Poor peripheral perfusion/increased CRT, Altered mental state, Tachycardia, Temperature <36/ >38.5C
b) < 3 months, recent surgery, ID
c) - Administer high-flow oxygen
- IV/IO access and do septic screen (FUCC, blood gas and lactate)
- Administer IV/IO antibiotics
- Consider fluid resuscitation (20ml/kg)
- Involve senior support
- Give 2nd and 3rd fluid bolus then inotropes
- HDU/ICU (invasive monitoring, dialysis, mechanical ventilation, etc.)
Kawasaki
- Fever for 5 days + at least 4 out of…HEART
- other features
H - Hands and feet erythema, oedema and desquamation
E - eye (bilateral conjunctival injection without exudate)
A - adenopathy (15mm cervical, usually unilateral)
R - rash polymorphic
T - tongue strawberry and chapped lips
Coronary artery aneurysms - do an ECHO
Increased ESR and platelet count
Treat with aspirin and IVIG
UTI in children
a) Atypical
b) Recurrent
c) Urine dip vs MSU
a) Seriously unwell/septic, reduced urine output, abdominal mass, non-e.coli, raised serum creatinine, poor response to ABx in 48 hours
b) 2 or more Upper UTIs. 3 or more lower UTIs
c) < 3 months (MSU only)
- 3m - 3y (Dip: treat if leukocyte or nitrite positive, send for culture)
- >3y (Dip: treat only if nitrite positive, send for culture if leukocyte positive)
UTI imaging in children
a) MCUG - only needed in…?
b) USS during infection
c) USS within 6 weeks (1 group only)
d) DMSA
a) < 6 months if atypical/recurrent UTI or abnormality on USS in normal UTI
b) Atypical at any age, recurrent < 6 months
c) Normal UTI in < 6 months
d) Recurrent UTI at any age, atypical UTI < 3 years
Treatment for:
a) Early-onset neonatal sepsis
b) Empirical sepsis under 3 months
c) Empirical sepsis over 3 months
d) Suspected meningococcus in GP surgery
e) Suspected meningitis over 3 months
f) Intrapartum antibiotic prophylaxis for women with confirmed GBS/previous baby with GBS
a) Benpen + Gent
b) Cef + Amox
c) Cef
d) Benpen
e) Cef + dexamethasone
f) IV Benpen (mother)
Meningitis on CSF (Opening pressure, colour, cells, gram stain, protein, glucose): a) Viral b) Bacterial c) TB/Fungal
a) Normal pressure, clear, lymphocytes, normal protein, normal glucose
b) Increased pressure, turbid, neutrophils, raised protein, low glucose (< 50% serum glucose)
c) Normal pressure, mainly lymphocytes, raised protein, low glucose (< 50% serum)
Safety-netting
a) General
b) Dehydration
c) Infection (e.g. gastroenteritis) prevention
a) Recognising red flag symptoms, How to get help, Follow-up
b) - Continue breast-feeding/eating and drinking,
- Discourage juices/carbonated drinks, ORS supplements PRN
- Red flags (thirsty, tired, sunken fontanelle, dry mouth, pale, SOB, drowsy, confused)
c) Hand-washing (especially before/ after contact, if in contact with stool/secretions, before and after food), Wash and don’t share towels, Keep from school until clear of D&V for 48 hours, barriers
Monitoring renal function
a) 3 main tests
a) BP, urinalysis, eGFR
Febrile convulsions:
a) Requirements - age, cause, temperature
b) Emergency treatment - explain
c) 2 reasons to LP
d) If home care - advice for parents
a) Occur in 6 months to 5 years, associated with fever, without other underlying cause such as CNS infection or electrolyte imbalance (if suspected meningitis: treat with cefotaxime)
b) ABCD (airway, breathing, circulation, glucose check) If > 5 mins, rectal diazepam
c) Under the age of 18 months. Complex seizure. Severe infection (red flags, e.g. reduced GCS)
d) Educate, how to treat fever, spotting red flags (rash, drowsiness, dehydration, not eating/drinking, fever > 5 days), call 999 if longer than 5 minutes seizure or any red flags
Dysmorphic features
JT SMELSS
Jaw small Thin upper lip Smooth philtrum Microcephaly Epicanthic folds Low nasal bridge Short nose Short stature
Downs features
a) Eyes - 3
b) Face - 4
c) Body - 4
d) Diseases
a) Epicanthic folds, oblique palpebral fissures, Brushfield spots (iris speckles)
b) Protruding tongue, high arched palate, brachcephaly, low set ears, flat nasal bridge
c) Sandal gap, single palmar crease, short and incurved little finger, short hands, hypotonia, hyperflexibility
d) Leukaemias (ALL especially), duodenal atresia, hypothyroidism, AVSD, Alzheimer’s, myelodisplasia
If child has a breath-holding spell (blue or reflex anoxic), what treatment may help?
Iron supplements
Limping child:
a) Kocher’s criteria
b) Differentials
c) SALTR
a) Fever > 38.5C, ESR > 40, WCC > 12,000, unable to weight bear (3 or 4: Septic Arthritis very likely)
b) Transient synovitis (3-8), septic arthritis, Perthes (5-10), SCFE (10-13), malignancy (ALL, osteo, Ewing’s), JIA, OM, Osgood-Schlatter, growing pains (exclusion), TB
c) Slipped, Above, Lower, Through, Rammed
Centor criteria
Temp > 38C
Anterior cervical nodes swollen/tender
Cough absent
Tonsils swollen/exudative
IRDS.
a) Management (SOS CpAp)
b) Appearance on CXR
a) - Surfactant via ETT
- Oxygen (target sats: 91 - 95%)
- Supportive care: nutrition (NG feed), temperature, glucose and hydration control
- CPAP (non-invasive) or IPPV (invasive)
- Antibiotics to cover for infection (discontinue if cultures negative)
b) Ground glass appearance
Cyanosed neonate.
- What features would help to give diagnosis?
- What examinations would you do?
- What investigations would you do?
- SOB, recessions, cough, fever, scaphoid abdomen (diaphragmatic hernia - may cause PPHN)
- Vitals: SpO2 (pre and post ductal), HR, RR,
- CV (hepatomegaly, femorals, cool peripheries), resp (crackles, wheeze)
- Ix: hyperoxic test, CXR, ECG, Echo, blood gas (lactic acidosis in CHD and sepsis)
Collapsed neonate: how would you manage…?
a) General
b) Duct-dependent cardiac lesion
c) TGA operation
a) Airway and breathing (intubate, ventilate, NG tube) circulation (IV/IO access, fluid bolus 10ml/kg, inotropes), disability (glucose 10%, prevent hypothermia).
b) Prostaglandin infusion
c) Atrial septostomy
Investigations and management of:
a) Volvulus
b) Intusussception
c) NEC
d) Pyloric stenosis
e) HSP
f) Hirschsprung’s
a) - UGI contrast studies
- Rx: ABC, correct any fluid and electrolyte imbalance
- Surgical Rx: Ladd’s procedure
b) - USS (donut sign) and barium enema
- Rx: NG tube and IV fluids (drip and suck), followed by air enema reduction.
- Laparotomy if 5 Ps (peritonitis, perf, prolonged, poor response to enema, pathological lead point likely)
c) - Bloods (to indicate severity via Bells staging criteria): lactic acidosis, thrombocytopenia, coagulopathy
- AXR (loops of bowel, Football sign, thickened bowel wall, intramural gas)
- Rx: ABC (intubate, ventilate, fluids and inotropes if shocked), NBM and TPN feeding, drip and suck
- Antibiotics (gentamicin and metronidazole)
- Surgery if air under the diaphragm/necrotic bowel
d) - Blood gas (metabolic alkalosis)
- UEs (hypokalaemia, hypochloraemia)
- USS to confirm. (also olive shaped mass in epigastrium)
- Rx: correct fluid/electrolyte imbalance and…
- Pyloromyotomy
e) - Monitor for renal involvement
- Urinalysis (haematuria and proteinuria)
- U+E and creatinine, eGFR, Blood pressure.
- If nephrotic: fluid and salt restrict, diuretics, penicillin V prophylaxis and PCV vaccine.
- If suspect intussusception, manage as above
f) - Bloods (WCC raised in enterocolitis - fever, foul smelling and bloody diarrhoea),
- AXR (obstruction), anal manometry, rectal biopsy (definitive)
- Rx in acute obstruction (NBM, drip and suck)
- Rx in enterocolitis (broad spec ABx)
- Surgical Rx: resection and end-to-end anastamosis
Management of:
a) Bronchiolitis
b) Croup
a) Supportive: fluids, feeding (NG if necessary), temperature control, high-flow oxygen +/- CPAP
b) Oral dexamethasone (+ 2nd dose if needed after 12 hours), keep child calm, don’t examine throat
- Nebulised adrenaline if severe.
- General: fluids, temperature control, adequate nutrition, oxygen if required
DKA: immediate management (ABCDE)
Airway:
- intubate and pass NG tube if necessary
Breathing:
- Kussmaul resps,
- ventilate if necessary, 100% high-flow oxygen
Circulation:
- IV access and take bloods (glucose, ketones, blood gas, electrolytes),
- fluid bolus 10ml/kg 0.9% NaCl (may give 3 max),
- attach cardiac monitor,
- maintenance fluids of 0.9% NaCl with 20 mmol KCl
Disability:
- AVPU/GCS, pupils, temperature control, fundoscopy
Exposure
DKA: further management (glycaemic control)
- After 1 - 2 hours of 0.9% NaCl with 20 mmol KCl, you can add IV insulin (0.1 U/kg/hour).
- Once BM = 12 - 15, swap fluid from 0.9% NaCl to 0.45% NaCl and 5% glucose (still include 20 mmol KCl)
- If glucose rises, reduced dextrose and increase insulin if necessary
- Once BM < 14 or pH > 7.3, can reduce insulin dose (but don’t stop till clinically well)
DKA: further management (monitoring)
- if cerebral oedema suspected?
Vitals and ABCD (including GCS) Fluid input and output ECG Blood glucose, ketones and electrolytes Blood gas (acidosis)
Cerebral oedema - mannitol, ICU transfer, intubate and ventilate as necesary
CAH: investigations and management
UEs (hyponatraemia, hyperkalaemia)
Glucose (hypoglycaemia)
Blood gas (met alkalosis)
17-hydroxyprogesterone raised in serum
Management:
- A-E (including glucose correction, fluid bolus if shocked 10ml/kg 0.9% NaCl, IV/IO access and bloods as above, IV antibiotics)
- IV hydrocortisone acute
- Fludrocortisone long-term
- NaCl supplements (first 6 - 12 months)
Pavalizumab
- Who? (3 groups)
- How and when?
CLD of prematurity
CHD
SCID
IM monthly injections during winter season
CF diagnosis
a) Measured on newborn heelprick
b) If raised, what 2 tests?
a) IRT
b) Genetic testing and sweat test (raised chloride with chloride higher than sodium on 2 occasions)
Nephrotic syndrome: investigations and management
a) Ix
b) Rx
a) Urine dipstick and 24h urine collection
FBC, UEs, CRP, albumin and total protein levels (calculate albumin: creatinine ratio)
ASOT, glucose, IGs, auto-antibodies
Lipids, clotting screen
b) - Fluid restrict, diuretics
- Corticosteroids (If resistant: tacrolimus, cyclophosp)
- Consider: Penicillin V (not routinely recommended) and PCV jab
Cerebral palsy: investigations
Note: clinical diagnosis
To exclude differentials:
- Thyroid studies
- Chromosomal analysis
- Pyruvate and lactate levels (mitochondrial)
- Amino acid and organic acid levels (inborn errors)
To confirm diagnosis/damage if unclear:
- CT/MRI head
- EEG
For complications:
- Audiology
- Ophthalmology
HCPs involved in CP management
Child developmental services
Multidisciplinary and Multiagency working
Community Paediatrician +/- Neurologist/ Specialists
Specialist Nurse-epilepsy Physiotherapist/Occupational therapist/Psychologist/Dietician
Ophthalmology/ Audiology/ENT/SALT
Orthopaedic surgeon
Social services
Education
Anatomical landmark in GI tract determining bilious or non-bilious vomiting
Ampulla of vater
Signs of NEC on AXR
Football sign
Thickened bowel wall
Intramural gas
Dilated loops of bowel
Differentials for…
a) Bilious vomiting
b) Projectile vomiting
a) Volvulus, NEC, duodenal atresia, meconium ileus (all distal to ampulla of vater)
b) Pyloric stenosis
Patau syndrome - feature
Polydactyly
VACTERL association
Vertebral defects Anorectal anomalies Cardiac defects Tracheo-oesphageal fistula/oesophageal atresia Renal abnormalities Limb abnormalities
CHARGE association
Colomboma (pupil defect) Heart defect Choanal Atresia (blockage of nasal passage) Retardation of growth / development Genital hypoplasia Ear anomalies
Cleft lip/palate complications
Poor feeding, milk aspiration, speech delay, conductive hearing loss
DDH: tests
Barlow’s = dislocation Ortolini = relocation
(Orto - relocates, because Ortho is all about relocating and fixing things)
Hemiplegic vs. diplegic CP
Diplegic: Bilateral leg > arm spasticity, knock-knee gait, most common CP phenotype
Hemiplegic: Unilateral arm > leg spasticity, tiptoe gait and dystonic posture
NAI
a) History
b) Injuries
a) History incompatible with injury / unclear history, delay seeking medical attention
b) Multiple fractures (Metaphyseal corner fracture!!!)
Retinal haemorrhage, torn frenulum
Injury in a non-ambulatory / totally dependent child
Neuroblastoma:
a) Presentation - 4 common symptoms, 4 common signs
b) Possible eye abnormality
c) Investigations - bloods? Urine? Imaging?
d) Metastases common to where? Scan indicated?
e) Management - low-risk? High-risk?
f) Complications
a) - Loss of appetite, vomiting, weight loss, abdominal pain, periorbital bruising;
- Signs - abdominal distention, Horner’s, hypertension, fever, blueberry muffin baby
b) Opsoclonus-myoclonus
c) - Raised ESR, raised LFTs;
- urinary catecholamine metabolites;
- CT TAP (or MRI if worried about cord compression)
d) Bone - MIBG bone scan
e) Resection; adjuvant chemoradiotherapy
f) Cord compression, hypertension, renal failure
Osteosarcoma
a) Most common sites
b) Metastasises rapidly to…?
c) XR appearance
d) Management
a) Around the knee (75%) and humeral shaft
b) Lungs
c) Bone destruction and formation (Sunburst appearance)
d) Surgery + chemo
Ewing’s sarcoma
a) Tumour type
b) Presentation - main symptom? Other symptoms?
c) Imaging
d) On bloods - what 2 things indicate mets and poor prognosis?
e) Treatment
a) PNET
b) Mass or swelling in long bones of the arms and legs, pelvis or chest but also in the skull and flat bones of the trunk.
Other: pain, redness, malaise, anorexia, weight loss, fever, cord compression symptoms (e.g. weakness, tingling, incontinence)
c) XR: onion-skin appearance of bone formation. Also do bone scintigraphy and CT to assess spread
d) Anaemia and raised LDH
e) Chemotherapy: vincristine, ifosfamide, doxorubicin and etoposide (VIDE).
- Also combine with radiotherapy and surgery
Wilms tumour
a) May coexist with what syndromes (in 10%)
b) Onset - age, site
c) Presentations
d) Management
a) Overgrowth syndromes (macroglossia, nehpromegaly) or non-overgrowth (WAGR, Edwards)
b) 95% unilateral, 97% under age of 5
c) Asymptomatic abdominal mass.
- Others: abdo pain, haematuria, UTIs
d) Nephrectomy + chemo (e.g. vincristine, dactinomycin and doxorubicin, cyclophosphamide) +/- RT
