Passmedicine Flashcards
First sign of puberty in boys and when does it occur?
Testicular growth around 12 years
range =10-15 years
What testicular volume indicates that puberty has begun?
Testicular volume >4ml
When do boys have their maximum growth spurt?
Maximum growth spurt age 14
First sign of puberty in girls and when does it occur?
Breast development around age 11.5 (range = 9-13)
Maximum height spurt in girls?
Maximum growth spurt at 12 (before menarche)
Only about 4% of growth after menarche
When does menarche begin in girls?
Age 13 (range 11-15)
Which viruses cause hand, foot and mouth disease?
Coxsackie A16
Enterovirus 71
Clinical features of hand, foot and mouth disease?
And management
Mild systemic upset - sore throat, fever
Oral ulcers
Followed later by vesicles on the palms and soles of the feet
Management:
- general advice about hydration and analgeis
- reassurance no link to cattle disease (comes from a different virus)
- advise child to stay off school until symptom free - ask parent what school policy is on when child can return after illness
Your child is most contagious in the first 7 days. But the virus can stay in her body for days or weeks after symptoms go away and it could spread through her spit or poop. The best way to prevent that is to wash hands thoroughly. That applies to you, too, after you change a diaper or wipe a runny nose.
What is the rate you should perform chest compressions at for a child?
100-120 compressions per minute
Compressions should depress the sternum by at least a third of the depth of the chest
Those trained in paediatric CPR should use a ratio of 15:2 (not trained people just use adult 30:2)
First line investigation for DDH
Ultrasound scan is first line, except if the child is over 4.5 months as by then the femoral head will have ossified and x-ray will be better to visualise the joint
Risk factors for DDH
- female sex
- first born child
- premature
- breech presentation
- oligohydramnios
- positive family history
- baby >5kg
- congenitcal calcaneovalgus foot deformity
Which hip is DDH more common in?
Slightly more common in left hip
Around 20% of cases occur bilaterally
Treatment of DDH
- most unstable hips will spontaneously stabilise within 3-6 weeks of age
- Pavlik harness in children younger than 4-5 months
- older children may require surgery
Pneumonic for the causes of meningitis in a child <3 months
GEL
Group B strep
E. coli
Listeria
Group B strep and e. coli can colonise the maternal reproductive tract and during birth, the baby can acquire these pathogens and become unwell
Listeria meningitis can occur if a women eats food contaminated with listeria while pregnant, as the infection can be transmitted from mother to foetus
Pneumonic for causes of meningitis in children aged 1 month to 6 years
NHS
Neisseria meningitides
Haemophilus influenza
Strep pneumonia
(after age 6, haemophilus influenza is not a significant cause of meningitis)
When should you intervene/assess for comorbidities in obese children?
Consider a tailored clinical intervention if BMI at 91st centile or above
Consider assessing for comorbidities if 98th centile or above
Causes of obesity in children
- growth hormone deficiency
- hypothyroidism
- Down’s syndrom
- Cushing’s syndrome
- Prader willi syndrome
Why is it bad to be a morbidly fat kid
-orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
Psychological consequences: poor self-esteem, bullying
Sleep apnoea
Benin intracranial hypertension
Long term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease
This rash typically starts with a high grade fever, which usually resolves before the onset of the rash
Roseola infantum
- usually starts on trunk and spreads to limbs
- maculopapular rash and not itchy
Mouth sign of measles
Koplik spots
Where does measles rash usually begin?
Usually begins on the face and spreads to other parts of the body
What causes erythema multiforme macules in children?
Erythema multiforme is a hypersensitivity reaction to herpes 7 virus
Which virus is responsible for hand, foot and mouth disease?
Coxsackie A6 virus
Which virus causes roseola infantum
Herpes virus 6
herpes 7 causes erythema multiforme
Features of roseola infantum
High grade fever for several days, when fever resolves you suddenly get massive maculopapular rash
Febrile convulsions in 10-15%
Diarrhoea and cough are commonly seen
Delayed passage of meconium (>2 days)
Bilious vomiting
Abdominal distension
Hirschprungs disease (do rectal biopsy to confirm)
A 4-year-old boy was discharged from the hospital six weeks ago after an episode of viral gastroenteritis. He now has 4-5 loose stools each day which has been present for the past four weeks
Post-gastroenteritis lactose intolerance
remove lactose from diet and then gradually reintroduce to solve the problem
Which virus causes Roseola infantum?
Human herpes virus 6 (HHV6)
What is MART therapy
MART is a form of combined ICS and LABA treatment (its a single inhaler with both your steroid and LABA in it and its used for maintenance and for relief)
(beclametasone and formoterol)
MART is only available in combinations where the LABA has a fast acting component (e.g. formoterol)
What constitutes paediatric low/medium/high dose steroids?
Paediatric low dose = <200 micrograms (budesonide or equivalent)
Paediatric moderate dose = 200-400 micrograms (budesonide or equivalent)
> 400 micrograms = paediatric high dose (budesonide or equivalent)
Difference between episodic and multiple trigger wheeze, and treatment for them?
Episodic viral wheeze = child only wheezes when has an upper respiratory tract infection and is symptom free between episodes
Multiple trigger wheeze = as well as viral URTIs, other factors appear to trigger the wheeze, such as exercise, allergens and cigarette smoke
Treatment for episodic = give SABA or anticholinergic via a spacer (if this doesn’t work then give oral leukotriene receptor antagonist or inhaled corticosteroid)
If multiple trigger then start with inhaled SABA or a leuoktriene receptor antagonist, typically for 4-8 weeks
Most common cause of hypothyroidism in children in the UK
Autoimmune thyroiditis
(iodine deficiency is the most common cause in the developing world)
Other causes: post total-body irradiation (e.g. in a child previously treated for acute lymphoblastic leukaemia)
Child less than 3 months old with a temperature >38 degrees
ADMIT TO HOSPITAL
What is a bisferiens pulse and when might you see it?
It is a biphasic pulse (so it occurs in a cardiac cycle with two peaks -a small one followed by a broad and strong one)
It is a sign of problems with the aortic valve, including aortic stenosis and aortic regurgitation etc
What kind of babies are most likely to get patent ductus arteriosus?
Premature babies
Babies born at higher altitude or maternal infection in the first trimester
Treatment for patent ductus arteriosus
Indomethacin closes the connection in the majority of cases
Cardiac examination features of patent ductus arteriosus?
Left subclavicular thrill Continuous machinery murmur Large volume, bounding, collapsing pulse Wide pulse pressure Heaving apex beat
Most common cause of hypothyroidism in children in the UK
Autoimmune thyroiditis
(iodine deficiency is the most common cause in the developing world)
Other causes: post total-body irradiation (e.g. in a child previously treated for acute lymphoblastic leukaemia)
How does giardiasis present?
Watery stools, nausea and fever
What conditions might you see a strawberry tongue in?
Kawasaki disease and scarlet fever
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
Osgood schlatters
Treatment for chondromalacia patellae?
Physiotherapy
Describe chondromalacia patellae and who it is most likely to affect?
- Most likely to occur in teenage girls
- Due to softening of the patellar cartilage
- Typically anterior knee pain when walking up and down stairs/rising from prolonged sitting
- Usually responds to physiotherapy
Osteochondritis dissecans
- Caused by cracks in the cartilage
- pain after exercise
- Intermittent swelling and LOCKING
Medial knee pain
May give way
Patellar subluxation (caused by lateral subluxation of the patella)
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Patellar tendonitis
People with increased risk of umbilical herniation
- Down’s syndrome
- Afro-carribean
- Mucopolysaccarhide storage disease
When should you share information about children and sexual activity?
You should usually share information about sexual activity in children under 13, who are considered in law to be unable to consent (GMC)
Who gets x-linked recessive disorders and what is the one exception?
Males get X-linked recessive disorders as they only have 1 X chromosome
The exception is Turner’s syndrome where the female only has 1 X chromosome
Which clotting factor is missing in haemophilia A?
Clotting factor VII
eight = Aight
Which clotting factor is missing in haemophilia B?
Clotting factor IX
Inheritance pattern of haemophilia?
X-linked recessive
Risk factors for surfactant deficient lung disease
- preterm babies
- male sex
- being the second born of premature twins
- caesarean section
- diabetic mothers
Chest x-ray findings of surfactant deficient lung disease
Ground glass appearance and indistinct heart border
How should you investigate renal scarring in a child?
Radionucleotide scan with dimercaptosuccinic acid (DMSA)
Investigation for vesicoureteric reflux and for renal scarring
Investigate VUR using micturating cystourethrogram
Investigate scarring with radionucleotide scan with DMSA
When is the heel prick test performed?
Between days 5 and 9
Treatment of croup
Regardless of severity give single dose of oral dexamethasone at 0.15mg/kg (NICE)
Give oxygen if saturations are <92%
(emergency treatment =high flow oxygen and nebulised adrenaline)
(prednisolone is fine if dexamethasone isn’t available)
Which viruses are responsible for croup?
Parainfluenza viruses are responsible for the majority of cases
Chest x-ray shows a “boot shaped heart”
Tetralogy of fallot
Central causes of hypotonia in a child/neonate
Down’s syndrome
Prader-willi syndrome
Hypothyroidism
Cerebral palsy (hypotonia may precede the development of spasticity)
Management of a child <3years with acute limp
All children <3 with an acute limp should be urgently assessed in secondary care:
- they are at a higher risk of septic arthritis
- high risk of child maltreatment
Acute onset
Usually accompanies viral infections, but the child is well or has mild fever
More common in boys aged 2-12 (average age 5-6)
Transient synovitis
quite rare in really young children- average age of onset 5-6
How does juvenile idiopathic arthritis present
Presents with a limp - may be painless (although could be painful in acute phase)
What is perthes disease and which age group is it more common in?
Avascular necrosis of the femoral head, more common in 4-8 years old
Causes of prolonger jaundice in neonates?
Biliary atresia Hypothyroidism Galactosaemia Urinary tract infection Breast milk jaundice Congenital infection (e.g. CMV, toxoplasmosis)
Tests you’d want to do if a baby still has jaundice after 2 weeks
Conjugated and unconjugated bilirubin (this is the most important test as raised conjugated bilirubin could indicate biliary atresia, which requires urgent surgical intervention) Direct antiglobulin test (Coombs' test) TFTs FBC and blood film Urine for MC&S and reducing sugars U&Es and LFTs
What do you need to assess and record in febrile children?
Temperature
Heart rate
Respiratory rate
Capillary refill time
Child under 3 months with temperature >38C what do you do?
High risk illness - refer to paediatrics
What is the best practice for giving neonatal vitamin K?
Once off IM injection (given shortly after birth)
-Better than giving orally as means parents won’t forget it and babies won’t vomit it up
Why do you need to give babies vitamin K shortly after birth?
They are relatively deficient and you want to prevent against haemorrhagic disease of the newborn (if babies don’t have enough vitamin K then they might not be able to produce enough clotting factors)
Non-bilious vomiting
Pyloric stenosis
Is pyloric stenosis more common in males or females?
Pyloric stenosis more common in males
How does pyloric stenosis present
Projectile NON-bilious vomiting at 4-6 weeks of life
How do you diagnose pyloric stenosis?
By test feed or USS
Treatment for pyloric stenosis?
Ramstedt pyloromyotomy (open or laparoscopic)
Central abdominal pain and URTI?
Mesenteric adenitis
Mesenteric adenitis management?
Conservative management
Where does intussusception usually occur?
Proximal to or at the level of, the ileocaecal valve
When does intussusception usually occur?
6-9 months of pain
How does intussusception present?
Presents with colicky pain, diarrhoea, vomiting, SAUSAGE SHAPED MASS AND RED JELLY STOOL
Treatment for intussusception?
Air insufflation
High caecum at the midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
Malrotation
How do you diagnose malrotation?
Upper GI contrast study and USS
Treatment for malrotation
Laparotomy
Majority of patients with meconium ileus have which disease?
Cystic fibrosis
Associated with tracheo-oesophageal fistula and polyhydraminos
Oesophageal atresia
Treatment for meconium ileus
PR contrast studies may dislodge meconium plugs.
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Treatment for Hirschprung’s disease?
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
May present with choking and cyanotic spells following aspiration?
Oesophageal atresia
VACTERL associations
Oesophageal atresia
What does VACTERL stand for?
Vertebral defects Anal atresia Cardiac defects Tracheo-esophageal fistula Renal anomalies Limb abnormalities
Treatment for biliary atresia?
Urgent kasai procedure
Jaundice >14 days
Increased conjugated bilirubin
Biliary atresia
How does biliary atresia present?
Jaundice >14 days
Increased conjugated bilirubin
Main risk factor for necrotising enterocolitis?
Prematurity
Abdominal distension and passage of bloody stools
Necrotising enterocolitis
How does necrotising enterocolitis present?
Distended abdomen and passage of bloody stools
Treatment for necrotising enterocolitis?
Total gut rest and TPN (babies with perforations will require laparotomy)
Treatment for threadworms
Single dose mebendazole for child and all the members of the household
Biggest risk factor for TTN?
Caesarian section (because the fluid in the lungs doesn’t get squeezed out after birth)
Drug treatment for whooping cough
Azithromycin or clarithromycin
Which bacteria causes whooping cough?
Bordatella pertussis
Does whooping cough immunisation work?
No, neither infection nor immunisation results in lifelong protection
How does whooping cough present?
And blood findings
2-3 days of coryza then cough
Cough usually worse at night and after feeding
May end by vomiting and associated with central cyanosis
Inspiratory whoop - not always present (caused by forced inspiration against a closed glottis)
Persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope and seizures
Marked lymphocytosis
Symptoms may last 10-14 weeks and tend to be more severe in infants
How to diagnose whooping cough
Nasal swab culture for bordatella pertussis
Whooping cough complications
Subconjunctival haemorrhage
Pneumonia
Bronchiectasis
Seizures
What is an umbilical granuloma?
An umbilical granuloma is an overgrowth of tissue which occurs during the healing process of the umbilicus. It is most common in the first few weeks of life. On examination, a small, red growth of tissue is seen in the centre of the umbilicus. It is usually wet and leaks small amounts of clear or yellow fluid.
How do you treat umbilical granuloma?
Treat with regular application of salt to the wound
If this does not help then cauterise with silver nitrate
What is gastroschisis?
Gastroschisis is a congenital condition which is characterised by a defect in the anterior abdominal wall through which the abdominal contents protrude.
What is omphalitis?
Omphalitis or umbilical cellulitis is a bacterial infection of the umbilical stump which presents as a superficial cellulitis, usually a few days after birth.
First line treatment for nocturnal enuresis for children <7?
Enuresis alarm
First line treatment for nocturnal enuresis for children >7?
Desmopressin
How does patellar tendonitis present?
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
