Paeds resp, cardio, renal Flashcards
1
Q
What is the proper medical name for croup?
A
Viral laryngotracheobronchitis
2
Q
At what point of the year is croup most common?
A
Autumn
3
Q
What age group is affected by croup?
A
6m to 6y, peak 2y
4
Q
What is the main cause of croup?
A
Parainfluenza
5
Q
Recall 3 differentials for croup
A
Laryngomalacia, acute epiglottitis, inhaled foreign body
6
Q
Recall the signs and symptoms of croup
A
1st = coryzal symptoms, 2nd = barking cough (from vocal cord impairment) and stridor
7
Q
What investigations should be done for croup?
A
Clinical diagnosis
DO NOT EXAMINE THROAT
8
Q
How should croup be managed?
A
Westley score determines admission
Admit if RR>60, or complications
DEXAMETHOSONE TO ALL
For mild: discharge
For moderate: admit
For severe: admit and add nebulised adrenaline to dex
For impending respiratory failure: same as severe
9
Q
What is the most likely complication of croup?
A
Secondary bacterial superinfection
10
Q
What is the most common cause of acute epiglottitis?
A
Haemophilus influenza B (bacteria!!!!) hence is quite uncommon as vaccinated against
11
Q
What are the signs and symptoms of acute epiglottitis?
A
It’s a medical emergency
No cough as in croup
High-fever ('toxic-looking')
Stridor is soft inspiratory with high RR
"Hot potato" speech
Drooling as child cannot swallow
Immobile, upright and open mouth - 'tripod sign'
12
Q
How should acute epiglottitis be investigated and managed?
A
Do not lie child down or examine their throat (may precipitate a total obstruction)
- Immediately refer to ENT, paeds and anaesthetics –> transfer and secure airway
- Once airway is secured, blood culture, empirical Abx (cefuroxime) and dexamethosone
13
Q
In what age range is bronchiolitis seen?
A
1-9 months, 3-6 month peak
14
Q
What is the most common cause of bronchiolitis?
A
RSV in 80%
15
Q
What are the signs and symptoms of bronchiolitis?
A
1st = coryzal symptoms which progress to 2nd = dry, wheezy cough, SOB, grunting
16
Q
What are the examianation findings in bronchiolitis?
A
To distinguish from croup/ other ‘itis’
Auscultate: fine, bi-basal, end-inspiratory crackles
17
Q
What investigations should be done in bronchiolitis?
A
It’s a clinical diagnosis but can do an NPA to confirm
If there is significant respiratory distress + fever, do a CXR to rule out pneumonia
18
Q
What are the criteria for hospital admission in bronchiolitis?
A
Hospital admission:
If <2 months, lower threshold as they deteriorate quickly- apnoea/ cyanosis/ grunting
- Poor oral fluid intake
- SpO2 < 92% on normal room air
Supportive care: nasal O2, NG fluids/ feeds, CPAP if respiratory failure
19
Q
Over how long is bronchiolitis self-limiting?
A
2 weeks
20
Q
Describe the ‘spectrum’ of infant asthma
A
Bronchiolitis if <1y
Viral-induced wheeze (1-5y)
Asthma (>5)
21
Q
Describe the wheeze in asthma
A
End-expiratory polyphonic
22
Q
When are asthma symptoms worst?
A
Night/ early morning
23
Q
What will be seen OE in childhood asthma?
A
Hyperinflated chest + accessory muscle use
Harrisson’s sulci - depressions at base of thorax where diaphragm has grown in muscular size
24
Q
How should childhood asthma be diagnosed?
A
<5 years old = clinical diagnosis
>5 years old = spirometry, beonchodilator, PEFR variability
25
Recall the PEFR range of moderate, severe, and life-threatening asthma
Moderate: 50-75%
Severe: 33-50%
Life-threatening: <33%
26
When should you admit a child with asthma?
When they are classified as severe or life-threatening?
27
How should paediatric asthma be managed in a hospital setting?
1. Burst step
- 3 x salbutamol nebs, or up to 10 inhales on a pump
- 2 x ipratropium bromide nebs (SE of too much = shivering, vomiting)
- Involve seniors if burst therapy has failed to work
2. IV Bolus step = give one of the following: MgSO4, salbutamol, aminophylline
3. Infusion step
- IV salbutamol/ aminophylline
4. Panic step
- Intubate and ventillate
28
Recall 4 contraindications of beta-agonists/ salbutamol
Beta-blockers, NSAIDs, adenosine, ACE inhibitors
29
Recall the outpatient management of asthma in children
1. SABA
2. ICS
3. 2-16 yo LTRA
4. ICS increased dose
5. Oral steroid
30
What is the most common cause of rhinitis?
Rhinovirus
31
What is rhinitis more commonly known as?
Common cold
32
What is the general recovery time for rhinitis?
2 weeks
33
What are the possible complications of rhinitis?
Otitis media, acute sinusitis
34
What is sinusitis?
Infection of the maxillary sinuses from viral URTIs
| May lead to a secondary bacterial infection
35
How should sinusitis be managed?
If symptoms last <10 days
- no Abx, advise them that virus will take 2-3w to resolve, simple analgesia
If symptoms last >10 days, high dose nasal CS for 14 days
- this may improve symptoms but is unlikely to reduce duration of illness
- Give back up prescription of Abx
36
When should a pt be admitted to hospital for sinusitis?
Severe systemic infection
Intraorbital/ periorbital problems (eg periorbital cellulitis, diplopia)
37
Why are children particularly vulnerable to otitis media?
Eustacian tubes are short, horizontal and function poorly
38
What are the 3 most common causative organisms in otitis media?
H influenza, S. pneumoniae, RSV
39
What investigations should be done in otitis media?
Temperature, otoscopy
40
What would be seen on otoscopy in otitis media?
Bright red bulging tympanic membranes, loss of normal light reaction, perforation and pus
41
Recall 3 indications for admission in acute otitis media
Severe systemic infection
Complications (eg meningitis, mastoiditis, facial nerve palsy)
Children <3 months with a temperature >38
42
When should abx be given in otitis media?
Delayed prescription if not better after 3 days or if it gets suddenly worse
Immediate Abx prescription if systemically unwell, age <2 yo
If there is a perforation: oral amoxicillin and review in 6w to ensure healing
43
What is another name for otitis media with effusion?
Glue ear
44
What are the signs and symptoms of otitis media?
Asymptomatic apartfrom possible reduced hearing
| Can interfere with normal speech development
45
What does otoscopy show in otitis media with effusion?
Eardrum is dull and retracted, often with a fluid level visible
46
How should otitis media with effusion be investigated?
Tympanometry
| Audiometry
47
When should a referral be made to ENT in otitis media with effusion?
If persistent past 6-12 weeks
48
What is the most common complication of chronic otitis media?
Mastoiditis (chronic OM --? Honeycomb structure behind ear inflamed --> discharge + swelling behind ear)
49
What is another name for acute diffuse otitis externa?
Swimmer's ear
50
What is the cause of chronic otitis externa?
Fungal cause
51
What is necrotising otitis externa?
Life-threatening extension into mastoid and temporal bones
52
What demographic of folks are most likely to get necrotising otitis externa?
The elderly
53
How should otitis externa be investigated?
If indicated: swabs and culture
54
How should otitis externa be managed?
Topical acetic acid (only effective for 1 week)
If indicated: topical Abx (neomycin/ clioquinol)
Wicking and removal of debris
55
Recall 2 indications for abx use in otitis externa?
Cellulitis
| Cervical lymphadenopathy
56
What is tonsilitis?
Form of pharyngitis with inflammation of the tonsils and purulent exudate
57
What is the most common cause of bacterial tonsilitis?
Group A beta-haemolytic streptococcus
58
What score determines likelihood of bacterial over viral aetiology of tonsilitis? Recall it as well as the consequences of each score
```
Centor score:
+1: exudate
+1: tender anterior cervical LNs
+1: Temp >38
+1: Cough absent
+1: age 3-14
"CETTA"
1 = no abx
2/3 = rapid strep test
4/5 = rapid strep test + Abx
```
59
When should a referral for laryngoscopy be made in tonsilitis?
If persistent (>3w) and change in voice
60
When should you admit for tonsilitis/ pharyngitis/ laryngitis?
Difficulty breathing
Peri-tonsillar abscess (quinsy) or cellulitis
Suspected rare cause (eg kawasaki/ diptheria)
61
How would diptheria appear OE of the throat?
'web'/ pseudomembrane at back of throat
62
If bacterial tonsilitis is confirmed using rapid strep test, how should it be treated?
Phenoxymethylpenicillin 10 days QDS
63
What tx should be avoided in tonsilitis?
Amoxicillin in case it's EBV because then you would get a maculpapular rash
64
For how long should school be avoided in tonsilitis?
Unti 24 hours after abx have been started (in case of scarlet fever)
65
What should you advise for self-tx for tonsilitis if no abx indicated?
Paracetamol
Lozenges
Saltwater
Difflam (anaesthetic spray)
66
What is the connection between tonsilitis and scarlet fever?
GAS (s pyogenes) infection can progress from tonsilitis to scarlet fever
67
What are the signs and symptoms of scarlet fever?
Rash and erythroderma
Neck and chest --> trunk and legs
Characteristic sandpaper texture
Pastia's lines (rash prominent in skin creases)
Strawberry tongue (starts as a white tongue, then desquamates)
May progress to rheumatic fever with a week's latency
68
How should scarlet fever be managed?
Phenoxymethylpenicillin 10 days QDS
69
Upon which chromosome is the cAMP-dependent Cl channel defect in cystic fibrosis?
Chromosome 7
70
What is the incidence of cystic fibrosis in terms of number of live births?
1 in 25, 000
71
Recall some of the most important signs and symptoms of cystic fibrosis in children?
Meconium ileus
Recurring chest infections
Clubbing of fingers
72
When is cystic fibrosis screened for in children?
At birth: heel prick test
73
If cystic fibrosis screening is positive, what further tests can be done?
```
Immunoreactive trypsinogen
Sweat test (abnormally high NaCl)
Genetic tests
```
74
Recall the timeline of routine reviews in cystic fibrosis?
```
Weekly in 1st month
Every 4w in 1st year
Every 6-8w when 1-5y
Every 2-3m when 5-12yo
Then every 3-6m
```
75
What is the main method of monitoring for cystic fibrosis?
Spirometry
76
How frequent should physiotherapy be done for respiratory symptoms in CF?
twice a day
77
Recall the protocol for mucolytic therapy in cystic fibrosis
1st line = rhDNase
2nd line = rhDNase + hypertonic saline
Orkambi (lumcaftor + ivacaftor) may be effective in treating CF caused by the FGO8 mutation
78
How should recurrent infection be managed in cystic fibrosis?
Prophylactic abx - usually flucloxacillin and azithromycin
| Rescue packs given for prompt IV Abx
79
How should cystic fibrosis patients be nutritionally managed?
High calorie and high fat diet (150% of normal) and fat-soluble vitamins
Pancreatic enzyme replacemet with every meal --> CREON
80
How can liver problems in cystic fibrosis be managed?
Ursodeoxycholic acid to help bile flow
81
What is laryngomalacia?
Congenital abnormality of larynx predisposing to supraglottic collapse during inspiration
82
What are the signs and symptoms of laryngomalacia?
At 2-6w they go all noisy with their breathing (nb: not present at birth:
GORD +/- feeding difficulties, cough and choking
Normal cry
83
How should laryngomalacia be managed?
It will self-resolve within 18-24m so must conservatively manage
If airway compromise/ feeding disrupted sufficiently to prevent normal growth --> endoscopic supraglottoplasty
84
What is a breath holding attack?
When the child cries vigorously for <15s and then becomes silent
85
How should breath holding attack be managed?
They'll resolve spontaneously, nay woz
86
What will be heard on auscultation in pneumonia?
Consolidation and coarse crackles
87
How should TB be investigated if there is exposure?
Manteaux test - if neg this excludes TB
If pos --> IGRA test
If neg --> prophylaxis (isoniazid)
If pos --> treatment
88
Recall the treatment of TB pneumonia
RIPE: 6m rifampicin, 6m izoniazid, 2m pyrazinamide, 2m ethanbutol
89
How can pneumonia and bronchiolitis be differentiated clinically?
```
Bronchiolitis = fine crackles on auscultation,
Pneumonia = coarse crackles
```
90
How should pneumonia be managed?
1. Note severity using obs and examination
2. Decide on whether they need admitting or not
3. Abx (can't distinguish viral and bacterial so just go for it) - mild CAP = amoxicillin, 2nd line (severe CAP) = co-amoxiclav + macrolides
91
How should you decide whether a child with pneumonia needs to be admitted?
```
SpO2 < 92% on air
RR>60
Child <3m
OE: grunting, cyanosis, chest recession marked
Low consciousness
T>38
```
92
What is the gram status of pertussis
Gram neg
93
What are the signs and symptoms of pertussis?
1w coryzal symptoms followed by continuous coughing followed by inspiratory whoop and vomiting
In infants it is apnoea rather than a whoop
94
What investigations should be done in pertussis?
Culture and PCR per nasal swab
95
How should pertussis be managed?
Notify HPU
Decide whether to admit
<1m: clarithromycin
1+months: azithromycin
96
How do you decide whether to admit in whooping cough?
If <6m or acutely unwell
97
What is the other name for paediatric chronic lung disease?
Bronchopulmonary dysplasia
98
What would the CXR show in chronic lung disease?
Widespread opacification
99
How should chronic lung disease be managed?
If really bad - artificial ventillation/CPAP/ low-flow nasal cannula
Short course low-dose CS
100
Recall 2 differentials for a right atrium anomaly in children
Tricuspid atresia - requires ASD and VSD to remain patent to allow shunt
Ebstein's anomaly - less severe as not reliant on shunting
101
Recall 3 differentials for a right ventricle anomaly in children
Pulmonary stenosis
Pulmonary atresia
Tetralogy of Fallot
(This is what it says in Ludley's notes - bit confused about how pulmonary valve abnormalities are ventricular issues rather than atrial, so if anyone knows pls do let me know lol)
102
What is the tetralogy of fallot?
VSD, overarching aorta, right outflow tract obstruction, RV hypertrophy
103
Recall 2 differentials for a left atrium anomaly in children
Mitral stenosis
| Mitral atresia
104
Recall 4 differentials for a left ventricle anomaly in children
Hypoplastic left heart
Coarctation of aorta
Interrupted arch
Aortic stenosis
105
When does ToGA present?
When ductus arteriosus closes at 2-4days old
106
How can ToGA be managed?
Give prostaglandin infusion to keep DA open
| Need urgent surgical readjustment
107
How quickly after birth does AVSD present?
First few hours of life
108
Where is the ductus arteriosus?
Between the aorta and pulmonary artery
109
When do aortic problems (coarctation or stenosis) present?
First few weeks of life (but not within days)
110
What test is used to diagnose heart disease in a cyanosed neonate, and how is it done?
Nitrogen washout test
Give 100% oxygen for 10 mins
Measure right radial artery blood gas oxygen
If it stays low (<15kPa) = positive for CHD
111
What is a 'blue baby' presentation a red flag for?
R-L shunt
112
What is a 'breathless baby' presentation indicative of?
L-R shunt
113
Recall the 3 types of L-R shunt
VSD, ASD, PDA
114
What are the differentials for cardiac outflow obstruction and how can you clinically differentiate between them
If child is otherwise well: P or A stenosis
| If child is also in CV collapse + shock: coarctation
115
What does 'cyanotic heart disease' refer to?
Right to left shunt
116
What are the types of ASD and which is more common?
Secundum (more common): defect in atrial septum (failure of closure of foramen ovale)
Partial (AVSD) - defect of AV septum
117
What are the signs and symptoms of ASD?
Asymptomatic - but may have recurrent chest infections/ wheeze
118
What murmur is associated with ASD?
Ejection systolic murmum at ULSE
| Fixed wide splitting of S2
119
How will the different types of ASD appear on ECG?
Secundum: RBBB and RAD
Partial: superior QRS axis
120
How should the different types of ASD be managed?
Secundum: cardiac catheterisation + insertion of occlusive device
Partial: surgical correction
121
What investigation is diagnostic of ASD?
Echo
122
How are VSDs classified?
By size: small <3mm, large >3mm
123
What are the signs and symptoms of VSD?
Small: May be asymptomatic, may have a breathless 3m old baby with normal sats, poor feeding with tiredness, LOUD murmur
Large: Heart failure, SOB, recurrent chest infections, hepatomgaly
124
Describe the murmur in VSD?
Small: LOUD, Pan-systolic, LLSE
Large: SOFT pan-systolic murmur
125
How shouls small VSDs be managed?
Self-limiting - they close over time
126
What does a small VSD increase the risk of?
Endocarditis
127
What does large VSD increase the risk of?
Eisenmenger syndrome - "the process in which a long-standing left-to-right cardiac shunt caused by a congenital heart defect causes pulmonary hypertension and eventual reversal of the shunt into a cyanotic right-to-left shunt"
128
How should a large VSD be managed?
CDC
Calories (additional calorie input)
Diuretics
Captopril
Surgery is usually performed at 3-6 months to prevent permanent lung damage from pulmonary HTN and high blood flow
129
By what time should the DA usually close?
1 month postpartum
130
Describe the murmur in PDA
Continuous 'machine-like' at ULSE
131
What would be found OE in PDA?
```
Left sub-clavicular thrill
Heaving apex beat
Wide pulse pressure
Bounding, collapsing pulses
Resp symptoms from increased work
```
132
Recall the medical and surgical management of PDA
Medical: Indomethacin (NSAID) - to prompt duct closure
Surgical: at 1 year old
133
How can cyanosis be tested for?
Hyperoxia nitrogen washout test
134
How should cyanosis be immediately managed?
```
ABCs
Prostaglandin infusion (to maintain PDA patency)
```
135
Recall the timeline of presentation of the different types of cyanotic heart disease after birth
<10 mins: Tricuspid atresia
Few hours: ToGA
Up to 3 weeks: AVSD
Any age (at a few days, often): ToF
10-15 years: Eisenmenger
136
Which 2 types of cyanotic HD produce an ESM at the left sternal edge?
ToGA and ToF
137
What is Ebstein's abnormality?
Malformation of tricuspid valve leading to severe tricuspid regurgitation
138
What maternal medication is associated with Ebstein's abnormality?
Lithium
139
What would be heard on auscultation in Ebstein's abnormality?
split 1st and 2nd heart sounds
140
How should Ebstein's be managed?
Prostaglandin --> cone repair of tricuspid valve
141
What is tricuspid atresia?
Complete absence of tricuspid valve --> so LV is the only effective ventricle (right too small)
142
Describe the presentation of tricuspid atresia
Cyanosis and SOB within first 10 mins of life
143
What is the murmur in tricuspid atresia?
ESM at LSE due to VSD
144
Recall in detail the management of tricuspid atresia
1st need to maintain a secure supply of blood to the lungs
Option 1 is a Blalock-Taussig shunt insertion
Option 2 is pulmonary banding operation to reduce pulmonary blood flow
COMPLETE CORRECTIVE SURGERY NOT POSSIBLE IN MOST CASES
145
Why is ToGA not instantly fatal?
It is usually found alongside ASDs/ VSDs/PDAs etc which aid mixing
146
What is heard upon auscultation in ToGA?
Loud S2 but no murmur
147
What investigations should be done in suspected ToGA?
CXR
| Echo
148
What would a CXR show in ToGA??
Narrow upper mediastinum ('egg on side')
149
Recall the management of ToGA
Immediate prostaglandin infusion to maintain PDA patency
Balloon atrial septostomy (this tears atrial septum down to allow mixing)
Arterial surgery to switch the vessels
150
What is the most common association with AVSD?
Down's syndrome
151
How does AVSD present?
Cyanosis at 2-3w of life
152
How should AVSD be managed?
Treat heart failure medically and surgery at 3 months
153
What are the 4 characteristics of the tetralogy of fallot?
VSD
Overriding aorta (compression of PA --> )
Pulmonary stenosis (back pressure --> )
RVH
154
What would be heard on auscultation in tetralogy of fallot?
Murmur from pulmonary stenosis = loud ESM at left lower sternal border
155
What investigations should be done in suspected tetralogy of fallot?
CXR
| Echo
156
What does CXR show in tetralogy of fallot?
Boot-shaped, small heart due to RVH
157
How is tetralogy of fallot managed?
First medical, then surgery at 6 months old
Medical: PG/ alprostadil to maintain PDA and reverse severe cyanosis
Severe/ prolonged cyanosis should be managed using a BT shunt from subclavian-pulmonary artery or balloon dilatation of RV outflow
158
What is Eisenmenger syndrome?
Irreversibly raised pulmonary vascular resistance from chronically raised pulmonary arterial pressure and flow (ie from a large VSD or chronic PDA) which leads to formation of a right to left shunt
159
Recall the pathophysiology of Eisenmenger syndrome
High pulmonary flow from large L-to-R shunt untreated
Artery wall thickens
Resistance increases
Eventually shunt decreases and child becomes less symptomatic
At 10-15y the shunt reverses as a teenager and they become blue and cyanotic
160
How should Eisenmenger be managed?
Early intervention for pulmonary blood flow
| Heart transplantation not easy but can be done
161
What is the cause of congenital aortic/ pulmonary stenosis?
Partial fusion of valve leaflets
162
What are the most likely co-existent conditions with aortic/pulmonary stenosis?
Coarctation of aorta and mitral valve stenosis
163
What are the signs and symptoms of a/p stenosis?
NO CYANOSIS
AS: carotid thrill (ESM)
PS: no carotid thrill, harsh heart murmur at LSE (ESM)
164
How should a/p stenosis be managed?
Transcatheter balloon dilatation
165
When does coarctation of the aorta present?
3rd day of life --> a few weeks of life
166
Recall some signs and symptoms of coarctation of the aorta
Symptoms: asymptomatic
Signs:
1. ESM
2. High BP in arms, low BP in legs
167
How should coarctation be managed?
If sick infant: follow ABC and PG infusion guidelines
If well child --> surgical repair OR balloon angioplasty and stenting
168
Recall the signs and symptoms of hypoplastic left heart syndrome
Often the sickest of all the left-outflow presentations
| Will be cyanotic
169
How should hypoplastic left heart syndrome be managed?
1st = ABCs and PG
2nd = Blalock-Taussig (BK) shunt or Norwood Stage 1
3rd = BK shunt removal --> Glenn/ hemi-Fontan --> Fontan/ Total Cavo-Pulmonary Connection
170
What is a BK shunt?
Arterficial ductus arteriosus
171
What HR is expected in SVT?
250-300bpm
172
Recall the main symptom of SVT in neonates
Hydrops fetalis
173
What would be seen on an ECG in SVT?
Narrow complex tachycardia and T wave inversion due to ischaemia
174
How should SVT be managed?
1. Circulatory and respiratory support (correct any tissue acisosis)
2. Vagal stimulating manoevres - 80% success
3. IV adenosine
4. Electrical cardioversion with synchronised DC shock if adenosine fails
175
What is the common cause of rheumatic fever?
Group A beta-haemolytic strep
176
What age child can get rheumatic fever?
5-15 y/o
177
What is the long term risk of rheumatic fever?
Mitral stenosis
178
Describe the typical presentation of rheumatic fever
```
Latent interval of 2-6w after pharyngeal infection - polyarthritis
Pericarditis
Erythema marginatum (map-like outlines)
```
179
What are the diagnostic criteria for rheumatic fever?
Jones criteria
2 majors / 1 major and 2 minors
Major = CASES
- carditis, arthritis, SC nodules, Erythema marginatum, Sydenham's chorea
Minor = FRAPP: fever, raised ESR/CRP, Arthralgia, Prolonged PR, Previous RF
180
How should rheumatic fever be managed?
Anti-inflammatories
High dose aspirin (suppresses inflammatory responses in heart and joints)
Abx (if evidence of present infection)
Corticosteroids (if not resolved rapidly)
181
What should be done following resolution of rheumatic fever?
Prophylatic monthly injections of benzyl penicillin until age 21
May need surgical valve repair
182
Recall the signs and symptoms of infective endocarditis in a child
```
Necrotic skin lesions - from infected emboli
Splinter haemorrhages
Changing cardiac signs
Fever, aneamia, pallor
Splenomegaly
Arthritis/ arthralgia
Clubbing
```
183
How is infective endocarditis diagnosed in children?
Multiple blood cultures (before ABx) and echocardiography to identify vegetations
184
What is the most common pathogen implicated in paediatric IE?
Streptococcus viridians
185
How should infective endocarditis be managed in children?
```
6 weeks IV Abx
Strep viridians (native/prosthetic valve) = amoxicillin + gentamicin/vancomycin
```
Staph aureus (native valve) - Amoxicillin/ vancomycin/ daptomycin
Staph aureus (prosthetic valve) - nafcillin/ oxacillin
186
How is the liver affected by cardiac failure?
May see hepatomegaly
187
How is the respiratory system affected by cardiac failure?
Increased RR, recurrent chest infections
188
What basic investigations are necessary in cardiac failure?
O2 sats, BP, FBC, UandEs, calcium, BNP/ANP
189
Recall systematically the management of paediatric cardiac failure
Decrease preload: diuretics (furosemide)/ GTN
Enhance contractility: eg digoxin, dopamine, dobutamine
Reduce afterload: ACE inhibitors
Improve oxygen delivery: beta blockers (eg carvedilol)
190
How should cyanosis be managed?
Prostaglandin infusion
191
How does UTI present in an infant as compared to a child?
Infant: fever, vomiting, lethargy, poor feeding, jaundice, septicaemia
Children: dysuria, frequency, abdo pain, lethargy, anorexia, haematuria
192
How should UTI be investigated?
URINE DIP
Nitrite stick test: very specific
Leucocyte esterase: less specific than nitrites
Urine MC+S - diagnostic
Only do imaging if recurrent/ atypical UTI
193
Recall the different UTI management for different age groups
<3m: admit, IV Abx then switch to oral prophylaxis: emergency - book urgent USS
>3m, upper UTI: consider admission with IV Abx, if not --> oral Abx - again book a USS
>3m, lower UTI: oral Abx as local guidelines for 3 days (eg trimethoprim, nitrofurantoin)
194
How should recurrent UTI be managed in children?
Abx prophylaxis
USS urgently
Routine DMSA scan
195
By what age should children be dry by day?
4 years old
196
By what age should children be dry by day and night?
5 years old
197
What is 'primary bedwetting'?
Bedwetting that has not previously been resolved
198
How should primary bedwetting be managed in children <5 years old?
Reassure parents - this often resolves by 5 y/o
Educate: easy access to toilet at night, bladder emptying before bed, positive reward system
199
How should primary bedwetting be managed in children >5 years old?
If infrequent (<2 per week) then watch and see approach
If frequent: 1st line: enuresis alarm, pos reward system (eg encourage child to help change sheets)
2nd line: desmopressin (1st line for short-term control like sleepovers and school trips)
200
How should enuresis with daytime symptoms be managed?
Refer to enuresis clinic, community paediatrician
201
What causes of secondary bedwetting can be managed in primary care?
UTI and constipation
202
What causes of secondary bedwetting should be managed in secondary care?
Diabetes, psychological, LD, recurrent UTI
203
What is phimosis?
Inability to retract foreskin as it is too 'tight'
204
By what age should phimosis only be present in 10% of children who were born with it?
4 years old (it is physiological at birth)
205
How should phimosis be managed?
If <2, reassure and review in 6 months - add personal hygeine promotion
If >2 --> circumcision or topical steroid creams (depending on severity)
206
What is the name given to pathological phimosis?
Balantis Xerotica Obliterans
207
What are the signs and symptoms of BXO?
Haematuria, painful erections, recurrent UTI, weak stream, swelling
208
What is paraphimosis?
Emergency in which foreskin becomes trapped in the retracted position proximal to swollen glans
Restriction of blood flow to head of penis --> penis turns dark purple
209
How should paraphimosis be managed?
1st line: adequate analgesia, attempt to reduce foreskin (gently compresswith saline soaked swab)
2nd line - emergency referral to urologist
210
What is hypospadias?
Wrongly positioned meatus ventrally (if dorsal = epispadias)
211
What are the key features of hypospadias?
Ventral foramen
Hooded foreskin
Chordee (ventral curvature)
Foreskin not fused ventrally
212
How should hypospadias be managed?
Repair sugery after 3 months - no management required before that
213
What is balanoposthitis?
Inflamed/ purulent discharge from foreskin
214
How common is balanoposthitis?
Single attacks are common
215
How should balanthoposthitis be managed?
```
Warm baths and Abx (broad spec)
If recurrent (rare) --> circumcision
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216
What is the mean age for testicular torsion?
16 years
217
What is the appendixtestis?
Small remnant of Mullerian duct
218
How does torsion of the appendixtestis present?
Similarly to torsion but evolving over a few days
219
What is the one indication that surgery isn't needed in suspected testicular torsion?
Blue dot seen over superior pole of testes (shows it is torsion of appendixtestis)
220
Recall the signs and symptoms of torsion?
Redness, oedema, nausea and vomiting
Sudden onset pain in testis or abdomen
221
How can torsion and epididymitis be differentiated clinically?
Prehn's sign: lifting tested increases pain in torsion but decreases it in epididymitis
222
What is the surgical management of testicular torsion?
Exploratory surgery +/- BL orchidopexy +-/ orchidectomy +/- fixation ofcontralateral testes
223
What is the key window of time in which torsion needs to be fixed?
<6 hours
224
Recall the serum creatinine changes/ measurements for each stage of AKI
Stage 1: increase >26 or 1.5-1.9x reference sCr
Stage 2: 2-2.9 x reference sCr
Stage 3: >354mmol increase or >3 x the reference sCr
225
Recall the urinary output values for each stage of AKI
Stage 1: <0.5mL/kg/hr, 6-12 hours
Stage 2: <0.5mls/kg/hr, >12 hours
Stage 3: <0.3mL/kg/hr, >24 hours
226
What is the difference in clinical syndrome produced by proliferative vs non-proliferative glomerulonephritis?
Proliferative --> nephritic syndrome
Non-proliferative --> nephrotic syndrome
227
What are the 3 types of non-proliferative glomerulonephritis?
Focal segmental
Membranous glomerulonephritis
Minimal change disease
228
What are the 3 types of proliferative glomerulonephritis?
IgA nephropathy
Membranoproliferative glomerulonephritis
Post-infectious (post strep)
229
What can focal segmental glomerulonephritis be secondary to?
Obesity/ HIV
230
What can membranous glomerulonephritis be secondary to?
SLE, drugs
231
Which type of glomerulonephritis is most common in children?
Minimal change disease
232
Recall the triad of symptoms seen in IgA nephropathy
Petechiae, abdo pain, nephritic syndrome
233
What are the triad of symptoms in nephrotic syndrome?
Low albumin, peripheral oedema, proteinuria
234
What are the signs and symptoms of nephrotic syndrome?
1st = peri-orbital oedema (so often misdiagnosed as allergy)
2nd = other features of oedema (delayed) - eg leg swelling, features of underlying diagnosis
235
What % of nephrotic syndrome is steroid-sensitive?
80-95%
236
How quickly does steroid-sensitive nephrotic syndrome respond to treatment?
<6 weeks
237
How should the nephrotic syndrome be investigated?
Urine tests: dipstick, urea, U&Es, urine MC&S, urinary sodium, FBC, ESR, creatinine, albumin
Complement (C3,C4) (SLE?)
Anti-streptolysin O (recent strep throat)
HBV/HCV
238
If podocyte fusion is seen on microscopy, what is this indicative of?
Minimal change disease
239
What are the 3 main complications of nephrotic syndrome?
Risk of thrombosis
Risk of infection
Hypercholesterolaemia
240
How does the nephrotic syndrome cause hypercholesterolaemia?
Loss of albumin --> less oncotic pressure --> hepatic cholesterol synthesis
241
What are the 2 most common causes of ARF in children?
HUS and ATN
242
What is the triad of features that characterises the HUS?
Low RBC
Low platelets
AKI
243
What is the most common cause of ATN in children?
Organ failure following cardiac surgery
244
Recall the signs and symptoms of ARF in children
Oligo/anuria
Oedema (feet, legs, abdo, weight gain)
Brown discoularisation of urine
Fatigue, lethargy, N+V
245
What is the key treatent for prerenal fialure?
Fluid replacement and circulatory support
246
What is the key treatment for intrinsic renal failure?
High calorie, normal protein feed - to decrease catabolism, uraemia and hyperkalaemia
247
How should postrenal ARF be managed in children?
Assess site of obstruction - relief may be obtained by nephrostomy/ atheter
248
What is the most important investigation to do in ARF children?
Renal USS
249
What woud be seen on USS In CKD?
Small kidneys
250
What would be seen on USS in AKI?
Large, bright kidneys with loss of cortical medullary differentiation
251
In what age group is minimal change disease most common?
2-4 years old
252
In what age group is focal segmental glomerulonephritis most common?
Older children
253
How does minimal change disease affect renal function?
Renal function will be normal
254
How does FSGN affect renal funcion?
It will impair it --> HTN
255
In which age group is membranous nephropathy more common?
Adults
256
What is another name for IgA vasculitis?
Henoch-Shonlein purpura
257
Which vessels does IgA vasculitis affect?
Small vessels
258
What is the usual cause of IgA vasculitis?
Usually preceded by an URTI by 2-3 days
259
What is the pathophysiolgy of IgA vasculitis?
IgA and IgG complex and deposit in organs, activating complement
260
Recall the signs and symptoms of IgA vasculitis?
100% = purpuric rash sparing trunk - looks a bit like HUS
60-80% = arthralgia and periarticular oedema - joint pain and swelling
60% = abdominal pain - can cause intussusecption
20-60% = glomerulonephritis (within 3m of onset = 97%) with nephritic syndrome
261
What should be the first investigations ordered in IgA vasculitis?
FBC, clotting screen, urine dip and U+Es
| Urinalysis to rule out meningococcal sepsis
262
How should IgA vasculitis be managed?
Most cases resolve spontaneously within 4 weeks
For joint pain: NSAIDs
If scrotal involvement/ severe oedema/ severe abdo pain --> oral prednisolone
If renal involvement --> IV corticosteroids
263
What is another name given to nephroblastoma?
Wilm's tumour
264
In what age group is nephroblastoma most common?
<5 years old
265
Recall the common symptoms and signs of nephroblastoma
Asymptomatic abdo mass
| Painless haematuria
266
Recall some less common signs and symptoms of nephroblastoma
Abdo pain
Anaemia (from haemorrhage into the mass)
Anorexia
HTN
267
When is a biopsy indicated in suspected nephroblastoma?
Never - it may worsen the condition
268
What investigations should be done in suspected nephroblastoma?
US
| SCT/MRI
269
How is nephroblastoma managed?
Nephrectomy and chemotherapy (and neoadjuvant radiotherapy if advanced disease)
80% cure rate
