Respiratory, GI, Growth, Metabolic Flashcards
1
Q
Key investigations for asthma
A
PEFR
Spirometry + Reversibility testing
FeNO test
2
Q
Respiratory symptoms/signs increasing the likelihood of asthma over other resp diseases
A
Cough and Wheeze
Hx atopy
Wheeze on auscultation
Responsive to therapy
3
Q
Features of acute severe asthma exacerbation
A
SpO2<92% PEFR 33-50% Tachycardia and Tachypnoea Can't complete sentences in one breath Too SoB TO SPEAK
4
Q
Features of life-threatening asthma
A
SPO2<92% PEFR<33% Silent, poor effort, exhaustion Hypotension Confusion Normal or raised PCO2 Cyanosis
5
Q
For mild asthma exacerbation what can you give?
A
6-8 puffs of salbutamol inhaler
1puff= 100mcg
If tolerated then go home on this for 48 hours
6
Q
What is the maximum number of salbutamol puffs recommended for home in ?Acute asthma
A
2-4 puffs
6+ then they need to come hospital
7
Q
Acute asthma management (>5 years)
A
Nebulised salbutamol 5mg BTB
Nebulised ipratropium 250mcg every 5 mins
Prednisolone 30-50mg 3 days (or hydracortisone 100mg IV)
MGSO4 added to Salbutamol
Aminophylline or IV salbutamol
8
Q
What time between inhalers after an acute exacerbation of asthma would indicate it is safe to discharge
A
> 4 hours apart
9
Q
Aims of asthma control
A
No waking at night
No need for reliever therapy
No limitations on activity
Step down therapy once objectives are achieved
10
Q
How many uses of SABA a week would suggest asthma therapy needs to be intensified
A
> /=3
11
Q
BTS Asthma guidelines
A
1) SABA
2) Low dose ICS
LTRA if <5
3) Increase ICS or add LTRA or LABA
4)Oral steroids, theophylline
12
Q
NICE Asthma guidelines
A
SABA-> + ICS low dose -> +LTRA -> Stop LTRA IF NOT HELPING -> +LABA/MART
If <5 years then SABA + 8 WEEK TRIAL of ICS then consider LTRA
13
Q
Example of a LTRA
A
Monteleukast
14
Q
Example of a low dose ICS
A
Clenil Modulite
15
Q
What is Maintenance and Reliever Therapy
A
LABA and ICS In one inhaler
16
Q
Indications for starting an asthmatic child on both SABA and ICS (According to NICE)
A
If symptoms > 3X a week or waking at night
17
Q
Peak age for Bronchiolitis
A
3-6 months
18
Q
Cause of Bronchiolitis
A
RSV (Maybe other viruses)
Inflammation and narrowing of airways in lungs because of infection
19
Q
Presentation of bronchiolitis
A
Harsh cough, Fever, High pitched wheeze bilaterally, Fine inspiratory crackles, SOB, Poor feeding
YOUNG <2 Years
20
Q
When do the symptoms of Bronchiolitis peak
A
4-5 days from onset
21
Q
Indications for admission of bronchiolitis
A
THINK FEEDING OR OXYGEN SUPPORT
Dehydration- No wet nappy for 12 hours Marked recessions/grunting Apnoeic Milk/Fluids<50% normal Exhausted Spo2<92%
22
Q
Management of moderate Bronchiolitis
A
NG feed
Nasal cannula-> CPAP-> Intubate
+/- Fluids
23
Q
Management of severe Bronchiolitis
A
HDU/PICU
CPAP/Ventilation/IV fluids
24
Q
Severe bronchiolitis
A
Worsening respiratory distress Respiratory acidosis Apnoea Dehydration Risk Factors
25
Palivizumab
MAb to RSV
Passive immunity provided to at risk babies: Premature/CF/Congential HD/Lung disease
Reduces INFECTIONS
IM monthly for 6/12
26
Safety netting for Bronchiolitis when sending a mild case home
```
Struggling to breath or irregular breathing
Blue lips
Unresponsive
No wet nappy >12 hours
Pauses in breathing
```
27
Peak age for croup
6 months to 6 years
28
Causes of croup
Parainflueza virus mostly
| Can be other viruses like RSV/Adeno/Influenza
29
What is Croup
Acute viral Layngotracheobronchitis (URTI)
30
Presentation of croup
```
~Acute abrupt onset
Stridor
Barking cough
Respiratory distress
Worse at night
IC recessions
```
31
Commonest cause of stridor in children
Croup
32
What is contraindicated in Croup
Throat exam as can potentiate airway obstruction
33
Epiglottitis vs Croup
In Epiglottitis there is drooling, mouth open with muffled voice and they cannot drink
ONSET IS VERY RAPID mins- hrs
Croup has barking cough and no drooling
34
Indications for admission in croup
< 6 months old
Poor oral intake
Severe obstruction
Immunocompromised
35
Mild vs Moderate croup presentation
Mild has occassional barking but no stridor and no Resp Distress
Barking and stridor is intermittent in moderate croup, chest wall retraction
36
Signs of severe croup
Frequent barking
Severe RDS
Stridor is prominent and there at rest
Tiredness and confusion
37
Treatment of croup
```
Keep upright
Oral Dexamethasone 0.15mg/kg (or Neb Budesonide or IM Dex)
Neb Adrenaline if Mod-Sev
HF O2 if severe
ENT help?
```
38
How do you assess the severity of Croup
```
Stridor
Recessions
Air entry
02 sats
Conscious level
```
39
What is Pneumonia
Inflammation of the lungs primarily affecting the alveoli
| Induced by infection
40
Bacterial causes of pneumonia
1) Neonates
2) Infants
3) Children
Viral causw
1) GBS, E.coli, Listeria, Chlamydia
2) S.Pneum, H.Influ, Pertussis
3) S.Pneum, H.Influ, GAS, Mycoplasma
RSV, PIV, AV, Rhino (1/3rd are viral!)
41
Presentation of Pneumonia?
What abdominal sign is important not to forget?
```
Recent URTI
Cough +/- Sputum
Respiratory distress
Feeding is reduced
Pleuritic chest pain
Wheeze, crackles, reduced AE, Bronchial Breathing
```
UPPER ABDO TENDERNESS
42
Investigations for Pneumonia?
When is a CXR indicated?
FBC, U&Es, CRP, Sputum ?Blood culture
?Septic screen
CXR if not responding to treatment or complications are suspected
43
Admission of pneumonia
If Moderate to severe
| - Respiratory distress, Poor fluid intake, Dehydration, Diffuse chest signs, RR>70 infants, RR>50 Children
44
Treatment of Mild Pneumonia
CXR follow up?
Send home, fluids advice and temp control
Oral Amoxicillin +/- Macrolides
NO CXR follow up
45
Treatment of mod-sev pneumonia
0xygen support to maintain sats >92%
IV Co-Amoxiclav +/- Cefotaxime/Cefuroxime
Fluids
46
Follow up CXR in Pneumonia
Not routinely indicated in paediatrics
Unless: Atelectasis, Volume loss, Lymphadenopathy
47
What signs indicate a bacterial tonsillitis
Tender Cervical Lymphadenopathy
| Purulent exudate on tonsils (ESPECIALLY GAS)
48
Common causes of pharyngitis
Viral- Adeno, Entero, Rhino
GAS can be a cause in older children
49
Centor Criteria
>3= Bacterial likely
Tonsillar exudate, Tender anterior cervical lymphadenopathy, Hx feverm No cough
50
URTI advice
Should only last a week
Ibuprofen and paracetamol
Lots of fluids
51
Abx indications for URTI
> 3 centor
Immunodeficiency
Rheumatic fever
Marked systemic upset
1st line is Phenoxymethylpenicillin 7-10 days or erythromycin if allergic
52
Amoxicillin and EBV
Causes a rash
53
Complications of tonsillitis
Otitis media
Quinsy
Post-strep glomerulonephritis
54
Tonsillectomy indications
> 5 episodes a year
Disabling
Quinsy
Obstructive- Apnoea, Dysphagia
55
Viral induced wheeze
URTI associated
< 5 years
No Hx of atopy
May have had it before but admission unlikely
56
Wheeze vs Stridor
Wheeze- High-pitched largely expiratory breath sound; intrathoracic airway narrowing
Stridor- Upper airway obstruction, arises acutely and paitent is in respiratroy distress, Inspiratory noise
57
Treatment of wheeze
Ensure it isnt stridor
| SABA or Anticholinergic via spacer +/- LTRA/ICS
58
Different modalities of airway compression that can cause wheeze
Extrinsic- Lung parenchyma, Vascular, Lymphatic
Intrinsic- CF, Bronchiolitis, Polyps
Intraluminal- Aspiration, Reflux
59
Genetics and pathophysiology of CF
Autosomal recessive
| CFTR defect, codes Cl- channel
60
Neonatal features of CF
Meconium ileus= Obstruction (Distended coils of bowel on CXR)
Prolonged jaundice
61
GI manifestations of CF
```
Failure to thrive
Bulky, pale, offensive stools
Wx loss
Rectal prolapse
DM- PANCREATIC INSUFFICIENCY
```
62
Respiratory manifestations of CF
Bronchiectasis
Recurrent infections
Chest deformity
Crackles on auscultation
63
Key complications of CF
```
Subfertility +/- Delayed puberty
Bone disease
Malabsorption
DM
Liver disease as sluggish bile flow induces Portal HTN
Excess salt loss
```
64
Gold standard test for CF
Sweat test- Cl- >60mmols
| Need 2 abnormal tests
65
False -ve sweat tests for CF
Skin oedema, adrenal/thyroid problems, Nephrogenic DI
66
Newborn screening for CF
Heel prick
| Increased immunoreactive trypsinogen on newborn bloodspot card
67
CF on a CXR
Dilated TRAMLINE airways
Lymphadenopathy
Interstitial pattern because of scarring
Mottled ground glass appearance
68
MDT management of CF
```
6-8 week outpatient appointment
Specialist nurses
Pysiotherapy- 2X daily with Neb DNAase
High calorie diet + Vit ADEK + Salt (Dietician)
Isolate from other CF patients
?Sputum sample if infections + Dilators + Abx
PORTACATH
Fertility/Endocrine support
```
69
Best measure of the progression of CF
| Prognosis
Lung function tests
| Half live to at least 48 years
70
What enzyme supplementation are CF patients given
Creon with all meals
71
Causes of a chronic cough >8 weeks
```
Tonsillitis
Post-nasal Drip
GORD
Pertussis
TB
Bronchiectasis
PCD
Tourette's
Psychogenic
```
72
Cough red flags
```
Haemoptysis
Dyspnoea
Pleuritic chest pain
Stridor
Respiratory distress
Cyanosis
Hypoxia
```
73
Classification of the causes of SoB
```
Pulmonary
-Hypoxia
-Obstruction
-Abnormal lung mechanisms
Cardiac
```
74
Larynx obstruction
Hoarseness, Cough, Stridor, SOB, Cyanosis
| Apnoea= complete
75
Oesophageal obstruction
Drooling, Dysphagia, Vomiting, Tracheal compression
76
Otitis Media causes
S.Pneum/H.Influ/RSV/Other viruses
+/- Eustachian tube dysfunction
77
Causes of Eustachian Tube Dysfunction
Results from many URTIs
Obstruction from large adenoids
Cleft palate and Down's increase risk
78
Tympanic membrane in Otitis Media
Red, Inflamed, Bulging, Purulent discharge Loss of light refelx
79
Otitis media with effusion (GLUE EAR)
Peak 2 years
Thick middle ear exudate
Tympanic Membrane changes- Thick, Retracted, no light reflex
Hearing loss +/- Speech and language delay
80
Treatment of Glue Ear
Grommets (VENTILATION TUBES)
Lasts months to years
Indicated if language delay
81
Treatment of simple otitis media
Try Paracetamol for 72 hours- Spontaneous resolution
> 4 days/Systemic upset/immunocompromised/Bil + <2 years/Perforated drum= AMOXICILLIN 5/7
82
Mastoiditis
Can be secondary to OM
| Otalgia, Swelling, Erythema, Tenderness, External ear protrudes forwards
83
Number one cause of stridor in neonates
Laryngomalacia
84
Presentation of Layngomalacia
Presents at birth and resolves by 12-18 months
Symptoms are increased when lying flat/eating
Otherwise well
85
Causes of Stridor
```
Layngomalacia
Epiglottitis (esp 2-4 years)
Sinusitis/Rhinitis
Choanal atresia
Layngeal web/cleft
Croup 6 months to 6 years
Abscess/Cyst
Tracheomalacia
Fistula
```
86
Where is TB endemic
Asia, Latin America, Eastern Europe, Africa
87
Cause of TB
Mycobacterium tuberculosis
Acid fast bacilii
Induces a T4 Hypersensitivity reaction (Delayed and T-cell response)
Adults not children usually infectious
88
Presentation of TB
Cough, Fever, Wx loss, Night sweats, Haemoptyisis
< 4 years= Meningitis
Hilar lymphadenopathy +/- Bronchial obstruction
89
BCG vaccine
Parent/Guardian from high risk area
| Then offered to Babies up to 1 year of age
90
Whooping cough classical presentation
Paradoxical expiratory cough spasms followed by a sharp inspiratory breath (Whooping)
Apnoeas/Post-tussive vomiting/Coryzal symptoms
Insp. whoop may be absent in younger patients
91
Diagnosis of Whooping Cough/Pertussis
Clinical
Ask immunisation status (6 in 1 vaccine)
Per-nasal swab culture if within 2/52 of cough
?Serum PCR
92
FBC in whooping cough
Significant lymphocytosis
93
Management of Whooping cough
Within 3/52 of onset= Give Abx
1) > 1month old= Azithromycin
< 1month = Claithromycin
Pregnant= Erythromycin
< 6months= Admit
94
Whooping cough and school exclusion
Avoid 48 hours post Abx
| 3 weeks if no treatment
95
Constipation- Acute vs Chronic
Acute- < 3 complete stools a week
Chronic if 6-8 weeks particularly abnormal if > 5 years old, incidence peaks at 2-4 years
96
Feacal impaction
No bowel movement in days, large faecal mass compacted in rectum
Overflow soiling
Severe constipation
97
Soiling
Faecal staining of underwear as there is leakage around impaction
Mistaken for diarrhoea
Abnormal of > 4 years!
98
Encopresis
Involuntary passage of whole stools
Overflow or Psych
CHILD MUST BE MATURE ENOUGH TO BE CONTITNENT
99
Presentation of constipation
```
Excessive straining- Back arching, straight legs, tiptoed
Pain
Soiling
Overflow incontinence
Neuro exam may be abnormal...
```
100
Constipation reg flags
```
Present from birth
Thin Ribbon stools (?Anal stenosis)
Delayed meconium (>48 hours)
Abd distension and vomiting
Leg weakness, locomotor delay
Abnromal leg reflexes
Sacral dimple, Gluteal agenesis
Perianal fistula/Abscess
Bruising around anus
(FTT is amber flag)
```
101
Causes of constipation
Number 1= IDIOPATHIC
Dehydration, Low fibre diet, Opiates, Learning difficulties, Post-illness, Abuse, Hypothyroidism, Hypercalcaemia, Routine change, Hirschsprungs's, Coeliac's
Toilet training is a precipitant
102
ROME criteria for constipation
2 or fewer defecations per week
At least 1 episode of weekly faecal incontinence
Hx of excessive stool retention
Need at least 2 for Dx
103
Hirschsprung's disease
Absence of ganglion cells in the bowel wall plexus
| Increased in Boys and Down's syndrome
104
Hirschsprung's disease presentation and Dx
Newborn + Delayed meconium + Distension
Dx= Biopsy
105
Pharmacological Management of idiopathic constipation
Disimpaction with Movicol for at least 2 weeks (may increase soiling and pain initially)
Then switch to Maintenance therapy with movicol (lower dose)
If disimpaction doesn't work then + Senna Stimulant or + Laculose softner
106
Advice for constipation
```
Always use advice + Laxative
Increase water, Limit squash/fizzy drinks/Caffeine
Increase fibre, fruit, beans, nuts
Non-punitive regular toileting
Regular set toilet times- sit 20 mins 1-3x a day
Footrest
Bowel diary
?Reward system
Massage abdomen if not weaned
```
107
Examples of osmotic, Stimulant and softener laxatives
Osmotic- Movicol
Stimulant- Senna, Bisacodyl
Softener- Lactulose
108
Length of Laxative maintenance therapy for constipation
3-6 months and keep them on it for weeks after resumption of normal bowel movements
109
NICE clinical features of Gastroenteritis
Diarrhoea 5-7/7
Worrying if > 2 weeks
Vomiting 1-2/7 stops within 3 days
+/- Fever, Abdo pain, Nausea
110
Causes of Gastroenteritis
ROTAVIRUS most common, also Adeno/Norovirus
Salmonella, Shigella, Campylobacter, E.Coli 0157
111
Bacterial vs Viral Gastroenteritis
Viral is watery smelly stools
Bacterial is usually bloody mucous stained stools
Not infallible
112
When is a stool sample indicated in gastroenteritis
```
Blood and mucous in stools
?Sepsis
Immunocompromised
Recently abroad
Diarrhoea not improving by D7
```
113
Key DDx for Gastroenteritis
INTUSSUSCEPTION
Associated with viral gastroenteritis
Episodic screaming, vomiting, paroxysmal drawing up of legs, shock, sausage shaped mass in RUQ, Jelly stool
114
Signs of Clinical dehydration 6-10%
```
Sunken eyes
Sunken Fontanelle
Decreased Skin turgor
Tachycardia, Tachypnoea
CRT normal, Warm extremities,Normal periph pulses
Irritable, Lethargic
```
115
Signs of shock/10+% Dehydration
```
Decreased Consciousness
Col peripheries
Pale, Mottled
HR/RR inc + Acidotic
Hypotension (Late)
Central CRT >5s
```
116
When are Bloods indicated in gastroenteritis (especially urea and electrolytes)
If IV fluids needed
| ?Hypernatraemia (Won't look dehydrated)
117
Hypernatraemic dehydration presentation and management
Jittery, Increased tone, Hyperreflexia, Convulsions, Coma
Senior input, replace fluids slowly over 48 hours
118
Management of dehydration with nil/Mild dehydration
Continue feeding
Discourage fruit juices and carbonated drinks
Oral challenge 5 mls every 5 mins +/- ORS if high risk
Can try oral fluids 2ml/kg/10 mins slow and steady if dehydrated
Home and safety net
119
Management of clinical dehydration (6-10%) secondary to gastroenteritis
50ml/Kg ORS over 4 hours
Continue breastfeeding
?NGT if vomiting or not tolerating drinks
120
Indications for escalating ORS therapy to IV therapy when treating dehydration
```
Deterioration in state
Decreasing responsiveness
Decreasing skin turgor
Persistent vomiting
Adverse haemodynamic changes
```
121
Management of clinical shock (10+% dehydration)
1) Rapid IV bolus NaCl 0.9% 20ml/kg
2) Repeat
3) Then ?PICU
If resolution then switch to IV maintenance therapy
122
IV fluid maintenance therapy for dehydration
0/9% Saline + 5% Dextrose
1st 10kg= 100ml/kg/24rs
2nd 10kg= 50ml/kg/24hrs
>20kg= 20ml/kg/24hrs
+ 100ml/kg/24hrs if shocked
OR +50ml/kg/24hrs if clinically dehydrated
+ Zn if malnourished +K once potassium known (20mmol/l)
Continue breastfeeding
123
Switching from IV maintenance fluids to ORT
Gradually introduce ORT early and if tolerated then switch
124
Signs of late decompensated shock
```
Hypotension
Bradycardia
Acidotic
Kussmal Breathing
Blue
Absent UO
```
125
Indications for Abx in Gastroenteritis
```
C.Diff
Cholera
Giardiasis
Septicaemia
< 6/12 + Salmonella
Malnourished
Immunosuppressed
```
126
Triad seen in Haemolytic Uraemic Syndrome
Consumption thrombocytopenia
Acute renal failure
Microangiopathic haemolytic anaemia
127
Causes of HUS
Often follows bloody diarrhoea after E.Coli 0157
Shiga toxin damages Renal endothelium, leads to platelet aggregation, occlusion of micro-circulation and shredding of red cells
128
HUS on a blood film
Schistocytes (Fragmented RBCs)
129
Complications of Gastroenteritis
```
Metabolic acidosis as Bicarb is lost
HUS
Guillain-Barre syndrome
Reactive arthropathy
Haemorhaggic colitis
Paralytic Ileus as K+ is lost
Post-GE syndrome
```
130
Post-Gastroenteritis syndrome
Introduction of a normal diet leads to diarrhoea
Temporary lactose intolerance
24 hour return to ORS then try normal diet again
Increasing yoghurt may help to increase lactase
131
Significant abnormalities in height as depicted by centiles
<0.4th centile
>99.6th centile
or Markedly discrepant from weight
132
The 4 phases of growth that determine adult height
Fetal 30%- Uterine
Infant- 15% Nutrition, Happiness, Thyroid
Childhood 40%- Genes, Happiness, Growth & Thyroid hormones
Pubertal 15%- Tes, Oes, Growth hormones
133
A drop in how many centile lines is worrying when reviewing growth
>2
134
Causes of short stature
Familial
IUGR/Prematurity
Constitutional delay of growth and puberty
Endo (Hypothyroidism, GH deficiency, Steroid excess, IGF-1 deficiency)
Nutritional/GI (Crohn's, Coeliacs)
Turner's
Skeletal Dysplasia
135
How does an endocrine cause of growth delay look on a growth chart?
Fall off height centile
Wx> Height centile
Delayed bone age
136
How does a nutritional/GI cause of growth delay look on a growth chart?
Fall of height centiles
Height centile> Wx centile (unlike endo causes!)
Delayed bone age
137
Familial and constitutional causes of reduced growth on a growth chart
Will follow a growth centile likely <0.4th
| Rate may drop off if delayed puberty
138
Measuring the Height of a baby
Baby supine
| Head to Heel
139
What age does GORD usually begin in children?
Likely <8 weeks
| V common!
140
Colic presentation
< 3 months of age
Pulls legs up, Arches back, Screams POST FEED
3 hrs a day, 3 times a day
Inconsolable
141
Advice for colic
Reassure- BENIGN
| ?Anti-flatulents ?Venting pole on bottle
142
Colic vs spasms in presentation
In infantile spasms there is distress in-between the spasms whereas in colic child is usually fine in-between episodes
143
GORD presentation
Non-forceful vomiting/regurgitation post-feed
Coughing
Sleep disturbance
Refuses feed + Post-feed irritability/resistance
Inconsolable crying
Apnoea
144
GOR vs GORD
```
GORD= Reflux + Significant symptoms
GOR= Reflux + No Pain + No FTT
```
145
Diagnosis of GORD
Clinical +/- FBC
+/- 24hr PH study if not responding initially
+/- Barium Swallow +/- Endoscopy
146
Red flags in ?GORD
```
FTT
Lethargy
Onset > 6 months
Carries on beyond 12 months
Fever
```
147
When does GOR/GORD typically resolve by?
12-18 months
148
Step-wise Management of GORD
Reassure- most gone by 18 months
1) Small regular feeds, wind baby during, keep upright 30 degrees, Add thickeners or anti-reflux milk
2) Stop thickeners and 4 week trial of Gaviscon
3) Omeprazole/Ranitidine
4) Nissen's Fundoplication
149
Causes of Bilious vomiting in Neonates
```
Duodenal atresia
Malrotation with volvulus
Jejunal/Ileal Atresia
Meconium Ileus
NEC
```
150
Feeding requirement for a Infant
150mls/kg/day
151
Causes of Acute vomiting
```
Infection
Pyloric Stenosis
Obstruction
Aresia
Adverse food reaction
Raised ICP
Endocrine
Poisoning
Overfeeding
```
152
When would Duodenal Atresia typically present? What is the X-ray sign?
Few hours post-birth
Bubble sign
153
When would Malrotation typically present
3-5 days post-birth
154
Key causes of Meconium Ileus
Hirschsprung's
| CF
155
Mesenteric Adenitis
Lymph glands swollen in abdo
Recent Viral illness, not peritonitic, Pain mimics Appendicitis
156
Abdo pain causes
Adenitis, Appendicitis, UTI, Pneumonia, Constipation, DKA, Calculi, HSP, Malrotation, NEC, IBD, Intussusception, Obstruction
157
At what age is appendicitis common and uncommon?
Common > 5 years
| Uncommon if < 4 years, Very rare < 1 year
158
McBurney's Triad of symptoms common in appendicitis
Associated symptoms
RIF pain, Low grade fever N&V
Constipation, reduced appetite, reluctance to move
MAY BE ATYPICAL IF YOUNG
159
Blood results seen in Appendicitis?
Indications for a USS/CT in ?Appendicitis
Leucocytosis, Neutrophilia but WCC may be normal
Diagnosis uncertain or ?Abscess
160
Treatment of Appendicitis
Appendectomy
| +/- IV Abx if unwell with perforation/Abscess
161
Diagnosis of a Appendicitis induced perforation
Abdominal lavage
162
Common age of Coeliac's presentation
Before 2 years
163
Pathophysiology of Coeliac's
Repeated Gluten exposure induces a non-IGE mediated immune response that causes vilious atrophy and malabsorption
Not Atopy because atopy is IGE specific
164
1st choice investigation to diagnose Coeliac's
Tissue Transglutaminase antibody (TTG)
Coeliac anti-endomysial Ab also useful
DEFINITIVE= Subtotal vilious atrophy in jejunal biopsy with crypt hyperplasia
165
Presentation of Coeliac's
```
FTT
Anorexia
Vomiting, Diarrhoea, Pain, Fatigue
Distension, Wasted buttocks, Pallor
PALE FOUL SMELLING STOOL- Steatorrhoea
```
166
Description of stools in Coeliac's
Pale and Foul smelling (Steatorrhoea)
167
Management of Coeliac's
Gluten free diet induces a quick resolution of symptoms
The diet is continued indefinitely
Pneumococcal vaccine
Check for Iron deficiency anaemia
Gluten rechallenge can be considered after 2 years
168
What 4 causes are important to consider when a child presents with feeding problems
Quantity of food
Kind of food- e.g milk changing
Technique
Congential problem e.g cleft palate
169
Complications of GORD
```
Aspiration Pneumonia
Oesophagitis
Bronchiectasis
FTT
Frequent Otitis Media
DYSTONIC NECK POSTURING/SANDIFER SYNDROME
```
170
Managing feeding problems
Food diary
Turn off TV, 1 meal for whole family, Offer child only 2 choices, Allow them to help in preparation
Present food at pre-agreed time and then remove
Ignore -ves and Praise +ves
171
Weaning advice
Start from 6 months
Puree fruit/veg or baby rice then Mashed food then gradually mash up less
Use alongside milk until 8 months
Cow's milk and normal food at 12 months
Spoon feeding -> Finger feeding -> Feeding themselves
A mess is okay, small helpings, eat together, do not pressure them into eating
Remember that eating habits may be unpredictable could switch from eating huge amounts to little
172
Advice about foods to avoid when weaning
| When do you start certain foods?
Avoid: Low fat sugary salty foods, soft cheese
Honey and Cow's milk fine AFTER 12 months
Full fat milk until 5 years, can switch to semi at 2 if needed
Nuts okay if ground but allergies are common
Shellfish allergies also common
No soya before 12 months
173
Presentation of Inguinal hernia
Swelling likely right inguinal region +/- Groin
Increases when crying
Painless (unless incarcerated)
NO TRANSILLUMINATION
Testis palpable and distinct from swelling
Reducible
174
Risk factors for inguinal hernia
Male
| Preterm
175
Most common type of inguinal hernia
Indirect
| Direct is rare
176
Key complications of inguinal hernias
Incarceration +/- Strangulation +/- Obstruction
| Testicular infarction
177
Indications for an urgent surgical referral for a inguinal hernia
Irreducible, Hard, Tender, Vomiting
This indicates incarceration and strangulation
178
Management of an inguinal hernia
Surgery within weeks of diagnosis because the incarceration risk is high
This risk decreases after age of 1 year
179
Management of an umbillical hernia
Fixed around 4/5 years for cosmetic reasons
| Note People of Black ethnicity are at increased risk
180
Hydrocele
Painless testicular swelling that Transilluminates
Not reducible
Spontaneously resolves by 12 months
181
Epidemiology of intussusception
Infants 6-18 months
Peak is at 9 months
Males 2x more at risk
182
Causes of intussusception
Proximal bowel telescopes into distal bowel, likely Ileum/Caecum
Common post-viral illness as Peyer's patches become inflammed
Polyps and Meckel's can cause this in older children
183
Presentation of Intussusception
Episodic screaming- Cycles from agony to sleep
Paroxysmal drawing up of legs and knees
Pallor, Vomiting, Lethargy
May appear well inbetween episodes
Red current jelly stools
Sausage shaped mass in midline RUQ
HX of recent viral illness or vaccinations
184
Diagnosis of Intussusception
USS- Target sign usually RLQ
185
Management of Intussusception
Fluid resus, Abx and Analgesia
Air insufflation under radiological control then barium enema if this fails
Laparotomy if Peritonitis or above fails
186
Causes of increased unconjugated bilirubin
Haemolysis- Spherocytosis, G6PD deficiency, SC anaemia, Thalass, HUS
Defective conjugation- Gilbert's
187
Causes of cholestatic jaundice (Raised conjugated fraction)
```
Biliary atresia
Choledochal cyst
CF
Cholangitis
Cholecystitis
Tumours/Cysts
```
188
Presentation of Kernicterus
Irritability, High pitched cry, Coma, Athetoid CP
189
Causes of Intrahepatic cholestasis
Infection, Toxins, Wilson's AATD, Biliary hypoplasia, RHF, Budd-Chiari
190
Epidemiology of Pyloric stenosis
Mostly 2-8 weeks old with 6 weeks being the peak
Newborn infants
Uncommon
191
Presentation of Pyloric stenosis
Recurrent projectile post-feed vomiting increasing in intensity
Infant hungry
Wx loss, Dehydration, Small for age, Irritable
Hard, olive shaped right epigastric mass
Visible peristaltic waves over stomach
192
Diagnosis of Pyloric stenosis
USS showing thickened elongated pyloric muscle
193
Blood results seen in Pyloric stenosis
Hypochloremic hypokalaemic metabolic alkalosis
194
Management of Pyloric stenosis
Consider a test feed
Rehydration in preparation for surgery
Pyloromyotomy- Ramstedt's procedure (Open) or Laparoscopic
195
Presentation of testicular torsion
```
Sudden severe scrotal pain +/- Referred to the lower abdomen
Testis are retracted upwards
Red and Oedematous skin
No Cremasteric reflex
Elevation does not ease pain
'Walk like a cowboy'
```
196
Epididymitis vs Testicular Torsion
Epidid= +ve Cremasteric reflex, Urinary symptoms and elevation relieves pain (Prehn's +ve)
197
Management of Testicular Torsion
Immediate scrotal exploration and fixing of testis
Treat contralateral as torsion risk is 50%
6 hrs from seeing there must be untangling!
If necrotic then remove
198
Torted Hyatid
Like torsion but blue dot seen
< 10 years
Remanent of obliterated Mullerian ducts
199
Classification of Crpytorchidism
Palpable undescended testis 70%- Can still descend
Impalpable 30%- Intra-abdomen, Inside canal or absent
200
Complications of Crpytorchidism
Malignant deterioration especially if intra-abdominally
| Increased Testicular cancer risk
201
Risk factors for Crpytorchidism
Preterm
FHx
Low birth Wx
202
Management of Crpytorchidism
Consider referral from 3 months, should be seen by a urology surgeon by 6 months corrected gestational age
If Bilateral and Non-palpable then 24hr urgent referral for Endo/Genetic evaluation alongside an examination under Anaesthesia-> THEN ORCHIOPEXY
Major surgeries usually done around 1 year
203
Biliary atresia presentation
Persistent jaundice >14 days
Conjugated Hyperbilirubinaemia developing over several weeks
Pale, Chalky stools, Dark urine
Bruising and Hepatomegaly
204
Biliary atresia Management
Urgent referral
| Hepatoportoenterostomy if detected within 6 weeks
205
Causes of Hepatitis
TORCHES, Hepatitis virus (esp. if mum Hep B Ag +ve, Hep is is Faecal Oral)
206
Presentation of Hirschsprung's
```
Usually in the newborn period
- Delayed meconium >48 hrs
-Distension and vomiting
FTT
Constipation
```
207
What is Hirschsprung's disease
Congential aganglionosis in bowel walls
Neural crest cells fail to migrate
Averbach and Meissner Plexuses fail
Inc in boys and those with Down's syndrome
208
Diagnosis of Hirschsprung's disease
Rectal biopsy is definitive
209
Hirschsprung's disease on an AXR
Faecal loading, Dilated bowel loops, Air fluid levels
210
Management of Hirschsprung's disease
Resection of abnormal bowel and end to end anastamoses
Removal of aganglionic segment + Colostomy bag
Management of symptoms
211
Crohn's vs UC
Crohn's is mouth to anus, UC is Colon
UC- Nothing inflammed beyond the submucosa, Inflammation seen in all layers in Crohn's
212
Toddler's diarrhoea
```
6 months to 5 years
Food particles in stool
Excessive fruit juice consumption
Child is generally well
Child must be thriving
```
213
What is a volvulus
Torsion of the mal-rotated intestine around its mesenteric axis
More common in males
214
What age is a volvulus most common?
6- 36 months
Rare in < 3 months
215
Presentation of volvulus
Bilious vomiting
Acutely unwell, Haemodynamically unstable and collapse
Scaphoid abdomen (Malnutrition)
Peritonitic
216
Volvulus Diagnosis
Upper GI contrast (Drink water with soluble contrast) showing corkscrew jejunum and DJ flexure to the right of the midline
(AXR also gasless)
217
Management of a volvulus
Urgent surgery- Laparotomy- Ladd's procedure to twist volvulus and treat underlying malrotation
218
What congential conditions are associated with volvulus
Congential diaphragmatic gernia and exomphalos are associated with malrotation and thereby volvulus
219
Average birth weight
3.3kg/7 pounds 4 ounces
| Doubles by 5/12 and triples by 12/12
220
Average head circumference at birth
35cm
221
Immediate management of an infant with faltering growth
High energy 120mls/kg/day formula
| ?Admit for NG feeding
222
When do teeth develop?
```
Primary= 6/12- 2 years
Permanents= 6-12 years
Molars= 20 years
```
223
How do you plot the weight of preterm babies on a growth chart?
Corrected Gestational Age until 2 years
| Actual Age - Number of weeks the baby was preterm
224
What constitutes a Failure to Thrive?
Lack of progress in Growth, Emotionally and Developmentally
| During the 1st 3 years of life
225
Causes of FTT
Psychological (most common)- Problems at home, abuse, eating difficulties
Malabsorption- Coeliac's, CF
Chronic illness
Familial- ?Constitutionally small
226
Peaks of T1DM
5-7 years
Puberty
Both as the body's insulin requirements increase
227
Diagnosis of T1DM
Random Blood Glu >11.1mmol/l + Symptoms
or...
6 hr Fasting Glu> 7mmol/l
or...
OGTT 2hr level >11.1mmol/l
228
Basal Bolus insulin regime for T1DM
Fixed dose of long acting insulin lasting 24 hrs
Pre-meal short acting insulin with onset 20-30mins
Carb counting
THIS IS THE BASAL BOLUS REGIME
229
Advice to parents in reference to insulin therapy in T1DM
Check sugars 4x/day before meals and bed
Increase checking if frequent hypos
Explain significance of taking insulin
Illness- Never stop insulin, ?More, Frequent drinks, check ketones, sip fizzy drinks if poor appetite
230
Blood glucose targets for T1DM
FBG 4-7mmol/l
HBA1C<48 mmol/l (check every 3-6 months)
231
Insulin pumps
Use rapid acting insulin
Improve compliance by decreasing need for injections
Expensive and technical issues though
232
Diagnosis of DKA
1) +ve Glucose on dipstick
2) Ketones >3 on monitor or 3+ on dipstick
3) PH <7.3 (Bicarb<18) <7.1 is severe
233
Indications for an NG tube when a patient is acutely unwell
Decreased GCS
| Aspiration risk
234
Fluid bolus in DKA when a patient is shocked
10ml/kg 0.9% NaCl + 20mmol/l K+
Then start maintenance
235
Fluid resuscitation in a non-shocked DKA patient
```
<10kg= 2ml/kg/hr
10-40kg= 1ml/kg/hr
40+kg= 40ml/hr
```
+ REPLACE DEFICITS (%Deficit X Wx X 10)- NOTE PH<7.1 IS SEVERE SO 10% Deficit (5% if PH>7.1)
+ 40mmol/l K+ given
236
In DKA what is done after fluid Resuscitation
0.05-0.1 UI/kg/hour IV insulin
237
Injection sites for insulin
Upper arms, Outer thighs, Abdomen
238
Definition of hypoglycaemia
Technically when Blood glucose is <3mmol/l but pathology appears when <2.6mmol/l
239
Causes of hypoglycaemia
D&V, Miscalculate insulin (common when just starting), Alcohol, Exercise, Stress, Puberty, Illness
240
Symptoms of hypoglycaemia
How does this present in a Neonate
Faint/Dizzy, Sweaty, Lethargy, Seizure, Coma
Neonate= Jittery, Hypotonic
241
In hospital when would you treat hypoglycaemia
Any glucose <4mmol/l + Symptoms
242
Management of hypoglycaemia
Try Glucogel (E.G 15g in 85ml H20 for a 50kg child), Sugary drinks and bread then recheck in 15 minutes
If symptoms then: IV Glucose or IM glucagon
243
Transient hypoglycamia if the newborn
Common if MDM
Monitor and encourage feeding
If CBG is <2 mmol/l on 2x readings despite the above then IV dextrose
244
MODY
Very strong FHx
Monogenetic AD gene defect
Relatively thin, Recurrent infection, Frequent urination, Polydipsia, Wx loss
245
When do you screen for T2DM
FHx, High risk ethnicity (S.Asian), HTN, PCOS, Acanthosis Nigricans
246
T2DM presentation
Insidious onset
Polyuria, Polydipsia, Skin changes (Acanthosis Nigricans), Infection, Lethargy, Glycosuria
247
Management of T2DM
Exercise and lifestyle changes
Then Try Metformin
248
Causes of Primary Acquired Hypothyroidism
Hashimoto's, Thyroiditis, Iodine deficiency, drugs
249
Congenital hypothyroidism
How is it screened for?
Thyroid dysgenesis= Prolonged jaundice, Constipation, Hypotonia + other hypo symptoms
Picked up by Heel Prick in 1st few days of life and then USS to establish dysgenesis
250
Causes of secondary hypothyroidism
Pituitary/Hypothalamic dysfunction
| Intracranial masses. RT, Surgery
251
Blood results for primary and secondary hypothyroidism
Primary Raised TSH and Low T3/4
Secondary Low everything
252
Presentation of hypothyroidism
SHORT STATURE AND DEVELOPMENTAL DELAY OR DROP IN SCHOOL PERFORMANCE
Constipation, Pubertal delay, Wx gain, Fatigue, Slipped upper femoral epiphysis (Limp/Hip pain), Delayed bone age
253
Management of hypothyroidism
Lifelong levothyroxine
TFTs every 4-6 months
Monitor growth and neurodevelopment
Good prognosis
254
What BMI percentile chart indicates overweight or obesity?
>85th centile= Overweight
91-98th= Obese
255
Lifestyle changes for obesity
1hr/day of exercise for 7 days a week
3 meals a day with healthy snacks
Decrease calorie intake
Education and behavioural change
256
Indications for checking glucose tolerance
```
>98th centile on BMI percentile chart
PCOS
HTN
FHx
Symptoms of DM
```
257
PKU pathophysiology
Defect in Phenylalanine hydroxylase so cannot convert phenylalanine to tyrosine
AR chr 12 gene
If left untreated it causes impaired brain development
258
Presentation of PKU
6 months= DEVELOPMENTAL DELAY
Fair haired and blue eyed + FHx
Learning difficulties, Eczema, Seizures, musty odour to sweat
259
Guthrie test
Day 5-9 Heel Prick
| PKU, Congential Hypothyroidism, CF
260
Management of PKU
Avoid Meat, Eggs and Dairy, Aspartame
High-tyrosine dietary substitution
Regularly assess plasma phenylalanine levels to reflect treatment response
261
Leading cause of pseudo-hermaphroditism
Congential Adrenal Hyperplasia
262
Congential Adrenal Hyperplasia
Likely 46xx karyotype but absence of 2-1-hydroxylase commonly leads to male phenotype
Inadequete cortisol production = Inc ACTH and adrenal hyperplasia and androgen overproduction (=Ambiguous Genitalia)
263
Causes of Ambiguous Genitalia
Congential Adrenal Hyperplasia (MOST COMMON)
Androgen Insensitivity syndrome (46xy)
5-Alpha Reductase Deficiency
264
Androgen Insensitivity syndrome
46XY Male Genotype; Female Phenotype
Testes there but external genitalia are ambiguous
No uterus, Tes/Oes/LH all raised
265
5-Alpha Reductase Deficiency
46XY
AR disease
Cannot convert Testosterone to Dihydrotestosterone leading to ambiguous genitalia and hypospadias
266
Definition of Precocious Puberty
Female <8 years (Idiopathic/Familial)
| Male <9 years (Uncommon, Organic cause)
267
Hypothalamic-Pituitary-Gonadal axis
Hypothalamus release GnRH
Anterior Pituitary then release FSH/LH
This acts on the testis and ovaries to induce Testosterone and/or Oestrogen release
This then induces a negative feedback loop
268
Gonadotrophin dependent Precocious Puberty
Central/True- FSH/LH raised
Can be caused by intracranial pathology
Testicular enlargement will be bilateral
Gonadotrophin agonists to treat via negative feedback
269
Gonadotrophin independent Precocious Puberty
Peripheral/False- FSH/LH low
Adrenal/Testicular/Ovarian pathology
Unilateral testicular enlargement if gonadal, Small Testes if Adrenal
Ketoconazole or Cyproterone to treat
270
Definition of delayed puberty
Female>13 yrs
| Male>14 yrs
271
Functional causes of Delayed Puberty
Constitutional delay
Malnutrition
Excessive exercise
272
Causes of Delayed puberty with short stature
Turners (45XO)
Prader-Wili
Noonan's
273
Causes of Delayed puberty with normal stature
PCOS
Kallmann's (Hypogonadotrophic hypogonadism)
Kilnefelters (47xxy)
Androgen insensitivity
274
Delayed Puberty- Kallmann's syndrome
| Hypogonadotrophic Hypogonadism
X linked recessive pattern of inheritance
GNRH neurones fail to migrate to hypothalamus LH/FSH/Tes low
Small gonads, Poor smell, Cryptorchidism, Delayed puberty
275
Precocious puberty- Androgen insensitivity
X-linked recessive
46xy but female phenotype
Primary Amenorrhoea, Bilateral Orchidectomy, Raise as female
276
Precocious Puberty- Klinefelter's
```
47xxy
No secondary sexual characteristics
Small firm testis and Gyaecomastia
Tall
Raised LH, Low Testosterone
```
277
Short stature Definition
>2 SDs below the 2nd centile
| Height, Weight and Head circumference
278
Investigating short stature
Biochemistry- FBC, TFTs, U&Es, VitD,Ca, Fe, B12, Folate, Coeliacs screen, GH levels post glucagon stimulation
Karyotype?
Dex suppression test, Synacthen test (prim adrenal)
Growth chart- Normal velocity= Healthy short
X-ray wrist for bone age
Uterus/ovary USS
279
Turner's syndrome (45XO)
No pubertal signs B/C Gonadal dysgenesis
Neck webbing, low set ears, Hypertelorism, shield chest, low hairline, short 4th metacarpal
Biscuspid Aortic valve and coarctation of aorta
280
Presentation of congential diaphragmatic hernia
Born in respiratory distress alongside pulmonary HTN
Can be detected later
Postero-lateral most common
281
Exompholos
Abd contents in sac at umbillicus
Carefully and gradually put back in
282
Gastroschisis
Uncovered abdominal contents outside cavity at umbillicus
| Atresia risk as bowel thickens
283
When is surgery considered for an umbilical hernia?
>2 years old if symptomatic
if <1 cm most close by age 5 (>1.5cm ?Repair)
284
X-ray changes in CF
Dilated tramline airways
Lympthadenopathy
Interstitial pattern because of scars
