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Year 5 - specialties > Paeds resp, cardio, renal > Flashcards

Paeds resp, cardio, renal Flashcards

1
Q

What is the proper medical name for croup?

A

Viral laryngotracheobronchitis

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2
Q

At what point of the year is croup most common?

A

Autumn

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3
Q

What age group is affected by croup?

A

6m to 6y, peak 2y

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4
Q

What is the main cause of croup?

A

Parainfluenza

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5
Q

Recall 3 differentials for croup

A

Laryngomalacia, acute epiglottitis, inhaled foreign body

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6
Q

Recall the signs and symptoms of croup

A

1st = coryzal symptoms, 2nd = barking cough (from vocal cord impairment) and stridor

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7
Q

What investigations should be done for croup?

A

Clinical diagnosis

DO NOT EXAMINE THROAT

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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

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9
Q

What is the most likely complication of croup?

A

Secondary bacterial superinfection

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10
Q

What is the most common cause of acute epiglottitis?

A

Haemophilus influenza B (bacteria!!!!) hence is quite uncommon as vaccinated against

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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'
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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)

  1. Immediately refer to ENT, paeds and anaesthetics –> transfer and secure airway
  2. Once airway is secured, blood culture, empirical Abx (cefuroxime) and dexamethosone
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13
Q

In what age range is bronchiolitis seen?

A

1-9 months, 3-6 month peak

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14
Q

What is the most common cause of bronchiolitis?

A

RSV in 80%

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15
Q

What are the signs and symptoms of bronchiolitis?

A 
1st = coryzal symptoms which progress to
2nd = dry, wheezy cough, SOB, grunting
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16
Q

What are the examianation findings in bronchiolitis?

A

To distinguish from croup/ other ‘itis’

Auscultate: fine, bi-basal, end-inspiratory crackles

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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

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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

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19
Q

Over how long is bronchiolitis self-limiting?

A

2 weeks

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20
Q

Describe the ‘spectrum’ of infant asthma

A

Bronchiolitis if <1y
Viral-induced wheeze (1-5y)
Asthma (>5)

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21
Q

Describe the wheeze in asthma

A

End-expiratory polyphonic

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22
Q

When are asthma symptoms worst?

A

Night/ early morning

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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

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24
Q

How should childhood asthma be diagnosed?

A

<5 years old = clinical diagnosis

>5 years old = spirometry, beonchodilator, PEFR variability

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25
Q

Recall the PEFR range of moderate, severe, and life-threatening asthma

A

Moderate: 50-75%
Severe: 33-50%
Life-threatening: <33%

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26
Q

When should you admit a child with asthma?

A

When they are classified as severe or life-threatening?

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27
Q

How should paediatric asthma be managed in a hospital setting?

A
  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
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28
Q

Recall 4 contraindications of beta-agonists/ salbutamol

A

Beta-blockers, NSAIDs, adenosine, ACE inhibitors

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29
Q

Recall the outpatient management of asthma in children

A
  1. SABA
  2. ICS
  3. 2-16 yo LTRA
  4. ICS increased dose
  5. Oral steroid
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30
Q

What is the most common cause of rhinitis?

A

Rhinovirus

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31
Q

What is rhinitis more commonly known as?

A

Common cold

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32
Q

What is the general recovery time for rhinitis?

A

2 weeks

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33
Q

What are the possible complications of rhinitis?

A

Otitis media, acute sinusitis

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34
Q

What is sinusitis?

A

Infection of the maxillary sinuses from viral URTIs

May lead to a secondary bacterial infection

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35
Q

How should sinusitis be managed?

A

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
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36
Q

When should a pt be admitted to hospital for sinusitis?

A

Severe systemic infection

Intraorbital/ periorbital problems (eg periorbital cellulitis, diplopia)

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37
Q

Why are children particularly vulnerable to otitis media?

A

Eustacian tubes are short, horizontal and function poorly

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38
Q

What are the 3 most common causative organisms in otitis media?

A

H influenza, S. pneumoniae, RSV

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39
Q

What investigations should be done in otitis media?

A

Temperature, otoscopy

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40
Q

What would be seen on otoscopy in otitis media?

A

Bright red bulging tympanic membranes, loss of normal light reaction, perforation and pus

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41
Q

Recall 3 indications for admission in acute otitis media

A

Severe systemic infection
Complications (eg meningitis, mastoiditis, facial nerve palsy)
Children <3 months with a temperature >38

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42
Q

When should abx be given in otitis media?

A

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

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43
Q

What is another name for otitis media with effusion?

A

Glue ear

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44
Q

What are the signs and symptoms of otitis media?

A

Asymptomatic apartfrom possible reduced hearing

Can interfere with normal speech development

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45
Q

What does otoscopy show in otitis media with effusion?

A

Eardrum is dull and retracted, often with a fluid level visible

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46
Q

How should otitis media with effusion be investigated?

A

Tympanometry

Audiometry

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47
Q

When should a referral be made to ENT in otitis media with effusion?

A

If persistent past 6-12 weeks

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48
Q

What is the most common complication of chronic otitis media?

A

Mastoiditis (chronic OM –? Honeycomb structure behind ear inflamed –> discharge + swelling behind ear)

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49
Q

What is another name for acute diffuse otitis externa?

A

Swimmer’s ear

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50
Q

What is the cause of chronic otitis externa?

A

Fungal cause

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51
Q

What is necrotising otitis externa?

A

Life-threatening extension into mastoid and temporal bones

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52
Q

What demographic of folks are most likely to get necrotising otitis externa?

A

The elderly

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53
Q

How should otitis externa be investigated?

A

If indicated: swabs and culture

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54
Q

How should otitis externa be managed?

A

Topical acetic acid (only effective for 1 week)
If indicated: topical Abx (neomycin/ clioquinol)
Wicking and removal of debris

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55
Q

Recall 2 indications for abx use in otitis externa?

A

Cellulitis

Cervical lymphadenopathy

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56
Q

What is tonsilitis?

A

Form of pharyngitis with inflammation of the tonsils and purulent exudate

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57
Q

What is the most common cause of bacterial tonsilitis?

A

Group A beta-haemolytic streptococcus

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58
Q

What score determines likelihood of bacterial over viral aetiology of tonsilitis? Recall it as well as the consequences of each score

A 
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
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59
Q

When should a referral for laryngoscopy be made in tonsilitis?

A

If persistent (>3w) and change in voice

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60
Q

When should you admit for tonsilitis/ pharyngitis/ laryngitis?

A

Difficulty breathing
Peri-tonsillar abscess (quinsy) or cellulitis
Suspected rare cause (eg kawasaki/ diptheria)

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61
Q

How would diptheria appear OE of the throat?

A

‘web’/ pseudomembrane at back of throat

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62
Q

If bacterial tonsilitis is confirmed using rapid strep test, how should it be treated?

A

Phenoxymethylpenicillin 10 days QDS

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63
Q

What tx should be avoided in tonsilitis?

A

Amoxicillin in case it’s EBV because then you would get a maculpapular rash

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64
Q

For how long should school be avoided in tonsilitis?

A

Unti 24 hours after abx have been started (in case of scarlet fever)

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65
Q

What should you advise for self-tx for tonsilitis if no abx indicated?

A

Paracetamol
Lozenges
Saltwater
Difflam (anaesthetic spray)

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66
Q

What is the connection between tonsilitis and scarlet fever?

A

GAS (s pyogenes) infection can progress from tonsilitis to scarlet fever

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67
Q

What are the signs and symptoms of scarlet fever?

A

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

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68
Q

How should scarlet fever be managed?

A

Phenoxymethylpenicillin 10 days QDS

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69
Q

Upon which chromosome is the cAMP-dependent Cl channel defect in cystic fibrosis?

A

Chromosome 7

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70
Q

What is the incidence of cystic fibrosis in terms of number of live births?

A

1 in 25, 000

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71
Q

Recall some of the most important signs and symptoms of cystic fibrosis in children?

A

Meconium ileus
Recurring chest infections
Clubbing of fingers

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72
Q

When is cystic fibrosis screened for in children?

A

At birth: heel prick test

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73
Q

If cystic fibrosis screening is positive, what further tests can be done?

A 
Immunoreactive trypsinogen 
Sweat test (abnormally high NaCl)
Genetic tests
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74
Q

Recall the timeline of routine reviews in cystic fibrosis?

A 
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
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75
Q

What is the main method of monitoring for cystic fibrosis?

A

Spirometry

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76
Q

How frequent should physiotherapy be done for respiratory symptoms in CF?

A

twice a day

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77
Q

Recall the protocol for mucolytic therapy in cystic fibrosis

A

1st line = rhDNase
2nd line = rhDNase + hypertonic saline
Orkambi (lumcaftor + ivacaftor) may be effective in treating CF caused by the FGO8 mutation

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78
Q

How should recurrent infection be managed in cystic fibrosis?

A

Prophylactic abx - usually flucloxacillin and azithromycin

Rescue packs given for prompt IV Abx

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79
Q

How should cystic fibrosis patients be nutritionally managed?

A

High calorie and high fat diet (150% of normal) and fat-soluble vitamins
Pancreatic enzyme replacemet with every meal –> CREON

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80
Q

How can liver problems in cystic fibrosis be managed?

A

Ursodeoxycholic acid to help bile flow

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81
Q

What is laryngomalacia?

A

Congenital abnormality of larynx predisposing to supraglottic collapse during inspiration

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82
Q

What are the signs and symptoms of laryngomalacia?

A

At 2-6w they go all noisy with their breathing (nb: not present at birth:
GORD +/- feeding difficulties, cough and choking
Normal cry

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83
Q

How should laryngomalacia be managed?

A

It will self-resolve within 18-24m so must conservatively manage
If airway compromise/ feeding disrupted sufficiently to prevent normal growth –> endoscopic supraglottoplasty

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84
Q

What is a breath holding attack?

A

When the child cries vigorously for <15s and then becomes silent

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85
Q

How should breath holding attack be managed?

A

They’ll resolve spontaneously, nay woz

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86
Q

What will be heard on auscultation in pneumonia?

A

Consolidation and coarse crackles

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87
Q

How should TB be investigated if there is exposure?

A

Manteaux test - if neg this excludes TB
If pos –> IGRA test
If neg –> prophylaxis (isoniazid)
If pos –> treatment

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88
Q

Recall the treatment of TB pneumonia

A

RIPE: 6m rifampicin, 6m izoniazid, 2m pyrazinamide, 2m ethanbutol

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89
Q

How can pneumonia and bronchiolitis be differentiated clinically?

A 
Bronchiolitis = fine crackles on auscultation, 
Pneumonia = coarse crackles
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90
Q

How should pneumonia be managed?

A
  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
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91
Q

How should you decide whether a child with pneumonia needs to be admitted?

A 
SpO2 < 92% on air
RR>60
Child <3m
OE: grunting, cyanosis, chest recession marked
Low consciousness
T>38
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92
Q

What is the gram status of pertussis

A

Gram neg

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93
Q

What are the signs and symptoms of pertussis?

A

1w coryzal symptoms followed by continuous coughing followed by inspiratory whoop and vomiting

In infants it is apnoea rather than a whoop

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94
Q

What investigations should be done in pertussis?

A

Culture and PCR per nasal swab

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95
Q

How should pertussis be managed?

A

Notify HPU
Decide whether to admit
<1m: clarithromycin
1+months: azithromycin

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96
Q

How do you decide whether to admit in whooping cough?

A

If <6m or acutely unwell

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97
Q

What is the other name for paediatric chronic lung disease?

A

Bronchopulmonary dysplasia

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98
Q

What would the CXR show in chronic lung disease?

A

Widespread opacification

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99
Q

How should chronic lung disease be managed?

A

If really bad - artificial ventillation/CPAP/ low-flow nasal cannula
Short course low-dose CS

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100
Q

Recall 2 differentials for a right atrium anomaly in children

A

Tricuspid atresia - requires ASD and VSD to remain patent to allow shunt
Ebstein’s anomaly - less severe as not reliant on shunting

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101
Q

Recall 3 differentials for a right ventricle anomaly in children

A

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)

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102
Q

What is the tetralogy of fallot?

A

VSD, overarching aorta, right outflow tract obstruction, RV hypertrophy

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103
Q

Recall 2 differentials for a left atrium anomaly in children

A

Mitral stenosis

Mitral atresia

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104
Q

Recall 4 differentials for a left ventricle anomaly in children

A

Hypoplastic left heart
Coarctation of aorta
Interrupted arch
Aortic stenosis

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105
Q

When does ToGA present?

A

When ductus arteriosus closes at 2-4days old

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106
Q

How can ToGA be managed?

A

Give prostaglandin infusion to keep DA open

Need urgent surgical readjustment

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107
Q

How quickly after birth does AVSD present?

A

First few hours of life

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108
Q

Where is the ductus arteriosus?

A

Between the aorta and pulmonary artery

109
Q

When do aortic problems (coarctation or stenosis) present?

A

First few weeks of life (but not within days)

110
Q

What test is used to diagnose heart disease in a cyanosed neonate, and how is it done?

A

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
Q

What is a ‘blue baby’ presentation a red flag for?

112
Q

What is a ‘breathless baby’ presentation indicative of?

113
Q

Recall the 3 types of L-R shunt

A

VSD, ASD, PDA

114
Q

What are the differentials for cardiac outflow obstruction and how can you clinically differentiate between them

A

If child is otherwise well: P or A stenosis

If child is also in CV collapse + shock: coarctation

115
Q

What does ‘cyanotic heart disease’ refer to?

A

Right to left shunt

116
Q

What are the types of ASD and which is more common?

A

Secundum (more common): defect in atrial septum (failure of closure of foramen ovale)
Partial (AVSD) - defect of AV septum

117
Q

What are the signs and symptoms of ASD?

A

Asymptomatic - but may have recurrent chest infections/ wheeze

118
Q

What murmur is associated with ASD?

A

Ejection systolic murmum at ULSE

Fixed wide splitting of S2

119
Q

How will the different types of ASD appear on ECG?

A

Secundum: RBBB and RAD
Partial: superior QRS axis

120
Q

How should the different types of ASD be managed?

A

Secundum: cardiac catheterisation + insertion of occlusive device
Partial: surgical correction

121
Q

What investigation is diagnostic of ASD?

122
Q

How are VSDs classified?

A

By size: small <3mm, large >3mm

123
Q

What are the signs and symptoms of VSD?

A

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
Q

Describe the murmur in VSD?

A

Small: LOUD, Pan-systolic, LLSE

Large: SOFT pan-systolic murmur

125
Q

How shouls small VSDs be managed?

A

Self-limiting - they close over time

126
Q

What does a small VSD increase the risk of?

A

Endocarditis

127
Q

What does large VSD increase the risk of?

A

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
Q

How should a large VSD be managed?

A

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
Q

By what time should the DA usually close?

A

1 month postpartum

130
Q

Describe the murmur in PDA

A

Continuous ‘machine-like’ at ULSE

131
Q

What would be found OE in PDA?

A 
Left sub-clavicular thrill
Heaving apex beat
Wide pulse pressure
Bounding, collapsing pulses 
Resp symptoms from increased work
132
Q

Recall the medical and surgical management of PDA

A

Medical: Indomethacin (NSAID) - to prompt duct closure
Surgical: at 1 year old

133
Q

How can cyanosis be tested for?

A

Hyperoxia nitrogen washout test

134
Q

How should cyanosis be immediately managed?

A 
ABCs
Prostaglandin infusion (to maintain PDA patency)
135
Q

Recall the timeline of presentation of the different types of cyanotic heart disease after birth

A

<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
Q

Which 2 types of cyanotic HD produce an ESM at the left sternal edge?

A

ToGA and ToF

137
Q

What is Ebstein’s abnormality?

A

Malformation of tricuspid valve leading to severe tricuspid regurgitation

138
Q

What maternal medication is associated with Ebstein’s abnormality?

139
Q

What would be heard on auscultation in Ebstein’s abnormality?

A

split 1st and 2nd heart sounds

140
Q

How should Ebstein’s be managed?

A

Prostaglandin –> cone repair of tricuspid valve

141
Q

What is tricuspid atresia?

A

Complete absence of tricuspid valve –> so LV is the only effective ventricle (right too small)

142
Q

Describe the presentation of tricuspid atresia

A

Cyanosis and SOB within first 10 mins of life

143
Q

What is the murmur in tricuspid atresia?

A

ESM at LSE due to VSD

144
Q

Recall in detail the management of tricuspid atresia

A

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
Q

Why is ToGA not instantly fatal?

A

It is usually found alongside ASDs/ VSDs/PDAs etc which aid mixing

146
Q

What is heard upon auscultation in ToGA?

A

Loud S2 but no murmur

147
Q

What investigations should be done in suspected ToGA?

148
Q

What would a CXR show in ToGA??

A

Narrow upper mediastinum (‘egg on side’)

149
Q

Recall the management of ToGA

A

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
Q

What is the most common association with AVSD?

A

Down’s syndrome

151
Q

How does AVSD present?

A

Cyanosis at 2-3w of life

152
Q

How should AVSD be managed?

A

Treat heart failure medically and surgery at 3 months

153
Q

What are the 4 characteristics of the tetralogy of fallot?

A

VSD
Overriding aorta (compression of PA –> )
Pulmonary stenosis (back pressure –> )
RVH

154
Q

What would be heard on auscultation in tetralogy of fallot?

A

Murmur from pulmonary stenosis = loud ESM at left lower sternal border

155
Q

What investigations should be done in suspected tetralogy of fallot?

156
Q

What does CXR show in tetralogy of fallot?

A

Boot-shaped, small heart due to RVH

157
Q

How is tetralogy of fallot managed?

A

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
Q

What is Eisenmenger syndrome?

A

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
Q

Recall the pathophysiology of Eisenmenger syndrome

A

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
Q

How should Eisenmenger be managed?

A

Early intervention for pulmonary blood flow

Heart transplantation not easy but can be done

161
Q

What is the cause of congenital aortic/ pulmonary stenosis?

A

Partial fusion of valve leaflets

162
Q

What are the most likely co-existent conditions with aortic/pulmonary stenosis?

A

Coarctation of aorta and mitral valve stenosis

163
Q

What are the signs and symptoms of a/p stenosis?

A

NO CYANOSIS
AS: carotid thrill (ESM)
PS: no carotid thrill, harsh heart murmur at LSE (ESM)

164
Q

How should a/p stenosis be managed?

A

Transcatheter balloon dilatation

165
Q

When does coarctation of the aorta present?

A

3rd day of life –> a few weeks of life

166
Q

Recall some signs and symptoms of coarctation of the aorta

A

Symptoms: asymptomatic
Signs:
1. ESM
2. High BP in arms, low BP in legs

167
Q

How should coarctation be managed?

A

If sick infant: follow ABC and PG infusion guidelines

If well child –> surgical repair OR balloon angioplasty and stenting

168
Q

Recall the signs and symptoms of hypoplastic left heart syndrome

A

Often the sickest of all the left-outflow presentations

Will be cyanotic

169
Q

How should hypoplastic left heart syndrome be managed?

A

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
Q

What is a BK shunt?

A

Arterficial ductus arteriosus

171
Q

What HR is expected in SVT?

A

250-300bpm

172
Q

Recall the main symptom of SVT in neonates

A

Hydrops fetalis

173
Q

What would be seen on an ECG in SVT?

A

Narrow complex tachycardia and T wave inversion due to ischaemia

174
Q

How should SVT be managed?

A
  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
Q

What is the common cause of rheumatic fever?

A

Group A beta-haemolytic strep

176
Q

What age child can get rheumatic fever?

177
Q

What is the long term risk of rheumatic fever?

A

Mitral stenosis

178
Q

Describe the typical presentation of rheumatic fever

A 
Latent interval of 2-6w after pharyngeal infection - polyarthritis
Pericarditis
Erythema marginatum (map-like outlines)
179
Q

What are the diagnostic criteria for rheumatic fever?

A

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
Q

How should rheumatic fever be managed?

A

Anti-inflammatories
High dose aspirin (suppresses inflammatory responses in heart and joints)
Abx (if evidence of present infection)
Corticosteroids (if not resolved rapidly)

181
Q

What should be done following resolution of rheumatic fever?

A

Prophylatic monthly injections of benzyl penicillin until age 21
May need surgical valve repair

182
Q

Recall the signs and symptoms of infective endocarditis in a child

A 
Necrotic skin lesions - from infected emboli
Splinter haemorrhages
Changing cardiac signs
Fever, aneamia, pallor
Splenomegaly
Arthritis/ arthralgia
Clubbing
183
Q

How is infective endocarditis diagnosed in children?

A

Multiple blood cultures (before ABx) and echocardiography to identify vegetations

184
Q

What is the most common pathogen implicated in paediatric IE?

A

Streptococcus viridians

185
Q

How should infective endocarditis be managed in children?

A 
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
Q

How is the liver affected by cardiac failure?

A

May see hepatomegaly

187
Q

How is the respiratory system affected by cardiac failure?

A

Increased RR, recurrent chest infections

188
Q

What basic investigations are necessary in cardiac failure?

A

O2 sats, BP, FBC, UandEs, calcium, BNP/ANP

189
Q

Recall systematically the management of paediatric cardiac failure

A

Decrease preload: diuretics (furosemide)/ GTN

Enhance contractility: eg digoxin, dopamine, dobutamine

Reduce afterload: ACE inhibitors

Improve oxygen delivery: beta blockers (eg carvedilol)

190
Q

How should cyanosis be managed?

A

Prostaglandin infusion

191
Q

How does UTI present in an infant as compared to a child?

A

Infant: fever, vomiting, lethargy, poor feeding, jaundice, septicaemia

Children: dysuria, frequency, abdo pain, lethargy, anorexia, haematuria

192
Q

How should UTI be investigated?

A

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
Q

Recall the different UTI management for different age groups

A

<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
Q

How should recurrent UTI be managed in children?

A

Abx prophylaxis
USS urgently
Routine DMSA scan

195
Q

By what age should children be dry by day?

A

4 years old

196
Q

By what age should children be dry by day and night?

A

5 years old

197
Q

What is ‘primary bedwetting’?

A

Bedwetting that has not previously been resolved

198
Q

How should primary bedwetting be managed in children <5 years old?

A

Reassure parents - this often resolves by 5 y/o

Educate: easy access to toilet at night, bladder emptying before bed, positive reward system

199
Q

How should primary bedwetting be managed in children >5 years old?

A

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
Q

How should enuresis with daytime symptoms be managed?

A

Refer to enuresis clinic, community paediatrician

201
Q

What causes of secondary bedwetting can be managed in primary care?

A

UTI and constipation

202
Q

What causes of secondary bedwetting should be managed in secondary care?

A

Diabetes, psychological, LD, recurrent UTI

203
Q

What is phimosis?

A

Inability to retract foreskin as it is too ‘tight’

204
Q

By what age should phimosis only be present in 10% of children who were born with it?

A

4 years old (it is physiological at birth)

205
Q

How should phimosis be managed?

A

If <2, reassure and review in 6 months - add personal hygeine promotion

If >2 –> circumcision or topical steroid creams (depending on severity)

206
Q

What is the name given to pathological phimosis?

A

Balantis Xerotica Obliterans

207
Q

What are the signs and symptoms of BXO?

A

Haematuria, painful erections, recurrent UTI, weak stream, swelling

208
Q

What is paraphimosis?

A

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
Q

How should paraphimosis be managed?

A

1st line: adequate analgesia, attempt to reduce foreskin (gently compresswith saline soaked swab)
2nd line - emergency referral to urologist

210
Q

What is hypospadias?

A

Wrongly positioned meatus ventrally (if dorsal = epispadias)

211
Q

What are the key features of hypospadias?

A

Ventral foramen
Hooded foreskin
Chordee (ventral curvature)
Foreskin not fused ventrally

212
Q

How should hypospadias be managed?

A

Repair sugery after 3 months - no management required before that

213
Q

What is balanoposthitis?

A

Inflamed/ purulent discharge from foreskin

214
Q

How common is balanoposthitis?

A

Single attacks are common

215
Q

How should balanthoposthitis be managed?

A 
Warm baths and Abx (broad spec) 
If recurrent (rare) --> circumcision
216
Q

What is the mean age for testicular torsion?

217
Q

What is the appendixtestis?

A

Small remnant of Mullerian duct

218
Q

How does torsion of the appendixtestis present?

A

Similarly to torsion but evolving over a few days

219
Q

What is the one indication that surgery isn’t needed in suspected testicular torsion?

A

Blue dot seen over superior pole of testes (shows it is torsion of appendixtestis)

220
Q

Recall the signs and symptoms of torsion?

A

Redness, oedema, nausea and vomiting

Sudden onset pain in testis or abdomen

221
Q

How can torsion and epididymitis be differentiated clinically?

A

Prehn’s sign: lifting tested increases pain in torsion but decreases it in epididymitis

222
Q

What is the surgical management of testicular torsion?

A

Exploratory surgery +/- BL orchidopexy +-/ orchidectomy +/- fixation ofcontralateral testes

223
Q

What is the key window of time in which torsion needs to be fixed?

224
Q

Recall the serum creatinine changes/ measurements for each stage of AKI

A

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
Q

Recall the urinary output values for each stage of AKI

A

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
Q

What is the difference in clinical syndrome produced by proliferative vs non-proliferative glomerulonephritis?

A

Proliferative –> nephritic syndrome

Non-proliferative –> nephrotic syndrome

227
Q

What are the 3 types of non-proliferative glomerulonephritis?

A

Focal segmental
Membranous glomerulonephritis
Minimal change disease

228
Q

What are the 3 types of proliferative glomerulonephritis?

A

IgA nephropathy
Membranoproliferative glomerulonephritis
Post-infectious (post strep)

229
Q

What can focal segmental glomerulonephritis be secondary to?

A

Obesity/ HIV

230
Q

What can membranous glomerulonephritis be secondary to?

A

SLE, drugs

231
Q

Which type of glomerulonephritis is most common in children?

A

Minimal change disease

232
Q

Recall the triad of symptoms seen in IgA nephropathy

A

Petechiae, abdo pain, nephritic syndrome

233
Q

What are the triad of symptoms in nephrotic syndrome?

A

Low albumin, peripheral oedema, proteinuria

234
Q

What are the signs and symptoms of nephrotic syndrome?

A

1st = peri-orbital oedema (so often misdiagnosed as allergy)

2nd = other features of oedema (delayed) - eg leg swelling, features of underlying diagnosis

235
Q

What % of nephrotic syndrome is steroid-sensitive?

236
Q

How quickly does steroid-sensitive nephrotic syndrome respond to treatment?

237
Q

How should the nephrotic syndrome be investigated?

A

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
Q

If podocyte fusion is seen on microscopy, what is this indicative of?

A

Minimal change disease

239
Q

What are the 3 main complications of nephrotic syndrome?

A

Risk of thrombosis
Risk of infection
Hypercholesterolaemia

240
Q

How does the nephrotic syndrome cause hypercholesterolaemia?

A

Loss of albumin –> less oncotic pressure –> hepatic cholesterol synthesis

241
Q

What are the 2 most common causes of ARF in children?

A

HUS and ATN

242
Q

What is the triad of features that characterises the HUS?

A

Low RBC
Low platelets
AKI

243
Q

What is the most common cause of ATN in children?

A

Organ failure following cardiac surgery

244
Q

Recall the signs and symptoms of ARF in children

A

Oligo/anuria
Oedema (feet, legs, abdo, weight gain)
Brown discoularisation of urine
Fatigue, lethargy, N+V

245
Q

What is the key treatent for prerenal fialure?

A

Fluid replacement and circulatory support

246
Q

What is the key treatment for intrinsic renal failure?

A

High calorie, normal protein feed - to decrease catabolism, uraemia and hyperkalaemia

247
Q

How should postrenal ARF be managed in children?

A

Assess site of obstruction - relief may be obtained by nephrostomy/ atheter

248
Q

What is the most important investigation to do in ARF children?

249
Q

What woud be seen on USS In CKD?

A

Small kidneys

250
Q

What would be seen on USS in AKI?

A

Large, bright kidneys with loss of cortical medullary differentiation

251
Q

In what age group is minimal change disease most common?

A

2-4 years old

252
Q

In what age group is focal segmental glomerulonephritis most common?

A

Older children

253
Q

How does minimal change disease affect renal function?

A

Renal function will be normal

254
Q

How does FSGN affect renal funcion?

A

It will impair it –> HTN

255
Q

In which age group is membranous nephropathy more common?

256
Q

What is another name for IgA vasculitis?

A

Henoch-Shonlein purpura

257
Q

Which vessels does IgA vasculitis affect?

A

Small vessels

258
Q

What is the usual cause of IgA vasculitis?

A

Usually preceded by an URTI by 2-3 days

259
Q

What is the pathophysiolgy of IgA vasculitis?

A

IgA and IgG complex and deposit in organs, activating complement

260
Q

Recall the signs and symptoms of IgA vasculitis?

A

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
Q

What should be the first investigations ordered in IgA vasculitis?

A

FBC, clotting screen, urine dip and U+Es

Urinalysis to rule out meningococcal sepsis

262
Q

How should IgA vasculitis be managed?

A

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
Q

What is another name given to nephroblastoma?

A

Wilm’s tumour

264
Q

In what age group is nephroblastoma most common?

A

<5 years old

265
Q

Recall the common symptoms and signs of nephroblastoma

A

Asymptomatic abdo mass

Painless haematuria

266
Q

Recall some less common signs and symptoms of nephroblastoma

A

Abdo pain
Anaemia (from haemorrhage into the mass)
Anorexia
HTN

267
Q

When is a biopsy indicated in suspected nephroblastoma?

A

Never - it may worsen the condition

268
Q

What investigations should be done in suspected nephroblastoma?

A

US

SCT/MRI

269
Q

How is nephroblastoma managed?

A

Nephrectomy and chemotherapy (and neoadjuvant radiotherapy if advanced disease)
80% cure rate

Year 5 - specialties (10 decks)

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