Urology, Dermatology & Surgery Flashcards
What are the reccomended doses on the WHO pain ladder for pain management?
Paracetamol 20ml/kg -4-6hrly
Ibuprofen 10mg/kg 8hrly
Weak opioid-codeine not recommended in <12
Strong opioid
What are the sentinel signs in children that imply there is something significant going on?
FEED REFUSAL
BILE VOMITS
COLOUR (grey is bad)
TONE
TEMPERATURE
What is an example of classical presentation of APPENDICITIS?
- 2 day Hx of abdo pain
- Vomited
- Pain was initially periumbilical but is now in RIF
- Temp 37.8, flushed
- Tender RIF with guarding
What should be considered in an abdo pain Hx?
- ‘closer to umbilicus, less chance of pathology’
- Colic vs constant (constant implies peritonitis)
- Movement (car trip)-sore on movement think peritonitis
Vomiting=increases significance and bile is important (green NOT yellow)
If you have a retro-ileal/retrocolic appendix what can you get?
Diarrhoea as the bowel is irritated
Tenesmus in pelvic appendix
What investigations are done for abdo pain?
None but all get a urine
FBC only if diagnostic doubt
Electrolytes only if sick/very dry
Xrays-rarely unless have obstruction
In what age group is appendicitis unusual?
<4years
Can be a difficult diagnosis
- Clues= Moderate temp, vomiting and looks unwell
What is murphy’s triad for appendicitis?
PAIN
VOMITING
FEVER
Tenderness over what point is indicative of appendicitis?
Mc Burney’s point (1/3 of way between umbilicus & ASIS)
What are the complications of appendicitis?
Abscess
Mass
Peritonitis
How is appendicitis managed?
- ANALGESIA-oral paracetamol is best option
- SURGERY
What are the features of NSAP (non specific abdo pain)?
short duration
central
constant
not made worse by movement
no GI disturbance
no temperature
site & severity of tenderness vary
Who is more likely to present with NSAP and what can it mimic?
Girls>boys
Often recurrent
Can mimic early appendicitis
What are the differential diagnoses of NSAP?
Mesenteric adenitis
- high temperature
- URTI often
- not “unwell”
Pneumonia
- clue “sicker than abdominal signs”
- usually Right Lower Lobe
(CXR makes diagnosis)
What is the investigation done in a child presenting with bile vomiting?
Upper GI contrast study ASAP
Diagnosis until proven otherwise is MALROTATION & VOLVULUS
What is the management of MALROTATION & VOLVULUS?
LAPAROTOMY
How does INTUSSUSCEPTION present?
6-18 month baby
3 day history of viral illness then intermittent COLIC and DYING SPELLS
bilious vomiting
bloody mucous PR (redcurrant jelly stool)
on admission – 4 seconds capillary refill (prolonged)
How is INTUSSUSCEPTION investigated and managed?
Investigations
- USS abdomen
- “target sign”
Management
- pneumostatic reduction (air enema)
- laparotomy
How does Umbilical Hernia present?
8 month baby
umbilical swelling
present from about 4 days old
worse with crying
easily reducible
What is the rule for spontaneous closure of umbilical hernia?
4 years is rule
Complications are rare
When would you repair an umbilical hernia?
- Complications
- Relative- persistence >4years, large defect, aesthetic
How do you distinguish umbilical hernia from paraumbilical hernia?
Above umbilicus
When out points towards feet whereas umbilical hernias point straight up in the air
What are 2 abdominal wall defects that can present?
Gastroschisis
Exomphalos
How does Gastroschisis present and how is it managed?
abdominal wall defect-gut eviscerated and exposed
10% associated atresia
Management:
delayed closure
TPN
Survival:
90%+
short gut-catastrophic risk
How does exomphalos present and how is it managed?
Umbilical defect with covered viscera
Management=primary / delayed closure
Outcome=post natal mortality - 25%
What are the associated anomalies with exomphalos?
Associated anomalies:
25% cardiac
25% chromosomal - Trisomy13, 18, 21
15% renal, neurological
Beckwith-Weideman syndrome
How does inguinal hernia present?
GROIN swelling
2% boys
boys 9:1 girls
increase risk with prematurity
< 1 year 33% incarcerate!
How are inguinal hernias managed in <1 years, >1 years and incarcerated?
< 1 year
URGENT referral
repair - no place for observation
> 1 year
elective referral and repair
Incarcerated
reduce and repair on same admission
What is a SCROTAL swelling that is very common in new borns and how does it present and how is it managed?
HYDROCELE
Painless
Increases with crying, straining, evening
Bluish colour
Management=conservative until 5 yrs of age
What is Cryptorchidism (undescended testis)?
Any testis that cannot be manipulated into the bottom half of the scrotum
True undescended testis
Retractile testis
(ascending testis)
What are indications for orchidopexy?
Fertility
- 1% loss germs cells / month undescent……
Malignancy
- RR 3 x (probably intra-abdominal only)
- lifetime risk - <1%
Trauma
Torsion
Cosmetic
How does a normal non retractile foreskin present?
“4 year old boy with non retractile foreskin”
“recurrent balanitis”
o/e “pinhole meatus”
Normal development
How does BXO (Balinitis Xerotica Obliterans) present?
“14 year old boy with non retractile foreskin”
“struggling to pass urine”
o/e “scarred foreskin, narrow meatus”
What is an absolute indication for circumcision?
BXO
(use ultrapotent steroid cream before)
What is a relative indication for circumcision?
Balanoposthitis
Religious
UTI (abnormal Urinary tract)
What are the disadvantages of circumcision?
Painful
Complications:
- bleeding
- meatal stenosis
- fistula
- cosmetic
“14 year old boy with 4 hour history of right sided testicular pain”
o/e scrotum red, asymmetry, acutely tender to touch
What is this?
TESTICULAR TORSION
(Around 6 hrs to salvage testis)
How does Torsion Appendix Testis present?
“14 year old boy with 4 hour history of right sided testicular pain”
o/e scrotum red, NO Asymmetry, blue spot seen, tender to touch
What are the differential diagnosis for acute scrotum (age related(ish))?
Torsion testis, torsion appendix testis,
RARELY epididymitis
Trauma, haematocele, incarcerated inguinal hernia
What should you do in a case where in doubt of acute scrotum?
Explore
6-8hrs to recover testis
Why are UTIs investigated?
Prevent renal scarring
- reflux nephropathy and chronic renal failure
Prevent hypertension
Who to investigate?
NICE guideline on UTI=all <6/12, atypical, recurrent
Why are UTIs investigated?
Prevent renal scarring
- reflux nephropathy and chronic renal failure
Prevent hypertension
Who to investigate?
NICE guideline on UTI=all <6/12, atypical, recurrent
What is the definition of UTI and when is it less significant?
pure growth bacteria > 105
pyuria
systemic upset-fever, vomiting
mixed growth bacteria, no pyuria, no systemic symptoms=less significant
How is UTI assessed?
H&E=FH, bowel habit, voiding dysfunction
USS=number, size, position, shape, hydronephrosis
Renography
- MAG3 - drainage, function, reflux
- DMSA - function, scarring
Micturating cystourethrogram (MCUG) (Gold standard for picking up reflux)
How is VUR managed?
Conservative=voiding advice, constipation, fluids
Antibiotic prophylaxis:
? until toilet trained?
Trimethoprim (2mg/kg nocte)
STING=mild/moderate with symptoms
Ureteric reimplantation
What are Hypospadias?
Urethral meatus on the VENTRAL aspect of the penis
Classification (anterior, middle or posterior)
What are associated anomalies with Hypospadias and how are hypospadias investigated and managed?
Associated anomalies
- upper tract
- (ambiguous genitalia)
Investigations: US, Karyotype only if severe
Management=one stage or 2 stages procedure
How does eczema (dermatitis) present and what are the different types?
Red , dry itchy skin eruption
- Flares & settles intermittently
- Familial tendency
Atopic – ‘genetic barrier dysfunction’
Seborrheoic – face/scalp – scale associated
Discoid – annular/circular patches
Pomphylx – vesicles affecting palms/soles
Varicose – oedema/venous insufficiency
Contact allergic dermatitis
Contact irritant dermatitis
Photoaggravated
What is the commonest type of eczema particularly in children?
ATOPIC ECZEMA
Widespread diffuse scaly red eruption
Itchy ++
Onset anytime in childhood
Fluctuates in severity
Commonest pattern is early onset and settles by school age
If prior to 3 months raises suspicion of CMPA
What is the atopic march?
Atopic march – tendency to 3 commonly linked conditions, ECZEMA, ASTHMA and HAYFEVER
Atopy = overactive immune response to environmental stimuli
How is atopic eczema distributed in infancy compared to older children?
Infancy:
Typically starts on the face/neck (cheeks common), can spread more generally
Older children:
Flexural pattern predominates (antecubital fossae, popliteal fossae, wrists, hands, ankles)
What is the cause of atopic eczema?
Inherited abnormalities in the skin – the skin “barrier defect”
Abnormality in filaggrin expression.
Filaggrin proteins bind the keratin filaments together. Also play a role in producing a natural moisturising factor.
How does loss of skin barrier function lead to atopic eczema?
Loss of water
Irritants may penetrate (soap, detergent, solvents, dirt)
Allergens may penetrate (pollens, dust-mite antigens, microbes)
Increased risk of irritation and sensitization
What can flares of childhood eczema be associated with?
Infections/viral illness
Environment: central heating, cold air
Pets: if sensitised/allergic
Teething
Stress
Sometimes no cause for flare found
Where and who does Seborrheoic dermatitis usually affect and what is it associated with?
- Mainly scalp and face
- Often babies under 3 months, usually resolves by 12 months
Associated with proliferation of various species of the skin commensal Malassezia in its yeast form.
Associated cradle cap in infants
- Emollients - to loose scale
- Daktocort ointment
- Protopic ointment
(Emollients, antifungal creams,
antifungal shampoos, mild topical steroids)
What type of eczema scattered annular/circular patches itchy eczema that can occur in this pattern as part of atopic eczema or in isolation?
DISCOID ECZEMA
- Requires potent topical steroid, often in combo with antibacterial component
- E.g. Betnovate C ointment
What is Pomphylx eczema?
Hand and foot eczema
Characterised by vesicles
Can be intensely itchy
What is exogenous eczema?
Allergic eczema –sensitised to allergen
- Type IV hypersensitivity - patch testing helpful.
Irritant eczema – repeated contact; water and soaps, touching irritant foods; citrus, tomatoes, chemical irritants.
Eczema = Dermatitis?
Eczema = Dermatitis
Important to remember eczema has many causes and allergy is only one possible cause
Do all children with eczema need allergy testing?
Majority of children with mild eczema do not need allergy testing
80% of childhood eczema is mild
What are the immediate and late reactions to a food allergy?
Immediate reactions (Type 1 reaction) Lip swelling, facial redness/itching, anaphylactoid symptoms
Late reactions (Type IV hypersensitivity)
worsening of eczema 24/48 hours after ingestion
GI problems
Failure to thrive
Severe eczema unresponsive to treatment
Severe generalised itching – even when the skin appears clear
What are the tests for immediate vs late reactions of food allergy?
For immediate reaction
Blood test for specific IgE antibodies (RAST)
Skin prick testing
Beware of false positive tests and limitations of allergy testing
Commonest: milk, soy, peanuts, eggs
Airborne allergens - house dust mite, pet dander, pollens
For Late Reaction- there is NO test
Dietary restrictions/eliminations 6-8 weeks
Eliminate one food at a time
What are the treatments for eczema?
Emollients (lotions, cream, gel & ointments)
Topical steroids (skin thinning in prolonged use)
Calcineurin inhibitors (e.g protopic – steroid sparing topical agents)
UVB light therapy
Immunosuppressive medication
What are the different strengths of topical steroids (topical steroid ladder?
Very potent (Dermovate)600x
Potent (Betnovate)100x
Moderate (Eumovate) 25x
Mild (Hydrocortisone)
What is the mainstay of eczema management?
Topical steroids
What is the mainstay of eczema management?
Topical steroids
Moisturiser (emollient) to help symptomatically with itch
(Soap substitute use for washing to prevent use of soap)
What are finger tip units guided by?
Age
How should topical steroids be applied?
Once daily for 1-2 weeks
If improvement then use alternate days for a few more days
Then if stubborn/persistent areas can use twice weekly in these areas
If at any point the eczema starts flaring, go back to daily applications
(Use ointment rather than cream-less preservatives, greasier preparations)
Can you use topical steroid on face if so how?
Yes but is more sensitive an area so need to limit steroid use
Mild or moderate steroid for 3-5 days & then stop & repeat as needed
If needing to use regularly, can introduce topical tacrolimus-protopic ointment (improves skin barrier)
What can untreated eczema impact on?
QoL & can lead to faltering growth
What can be used if topical steroid doesn’t help with eczema?
Think about triggers-allergy, photoaggravation
- Steroid sparing agents-protopic ointment or Elidel cream
- Phototherapy UVB
- Immunosuppression
- Biologics - Dupilomab (IL4 inhibitor)
What can be used if topical steroid doesn’t help with eczema?
Think about triggers-allergy, photoaggravation
- Steroid sparing agents-protopic ointment or Elidel cream
- Phototherapy UVB
- Immunosuppression
- Biologics - Dupilomab (IL4 inhibitor)
What is impetigo and what organism can cause it?
Common acute superficial bacterial skin infections
Pustules and HONEY COLOURED CRUSTED EROSIONS
Staph aureus
How is impetigo treated?
Topical antibacterial (Fucidin)
Oral Abx (Flucloxacillin) if not responding or unwell
What does Molluscum contagiosum look like and what is it caused by?
Common benign self limiting infection
Molluscipox virus
2 wk - 6 month incubation
Transmission to close direct contacts
Pearly papules, umbilicated centre
Can take up to 24 months to clear
Reassurance.
(5% potassium hydroxide can help to speed up resolution)
Viral warts are a benign self limiting viral condition: what are they caused by and how are they transmitted?
Common non-cancerous growths of the skin caused by infection with human papillomavirus (HPV)
(Sole foot – verruca)
Transmitted by direct skin contact
How are viral warts treated?
No treatment
Stimulate own immune system to respond
Topical treatments such as salicylic acid and paring
Cryotherapy
Oral zinc
90 % resolve in 24 months
Viral exanthems is common and often seen with an associated viral illness (fever, malaise, headache), what is it caused by?
Either reaction to a toxin produced by the organism, damage to the skin by the organism, or an immune response.
Chicken pox
Measles
Rubella
Roseola (herpes virus 6)
Erythema infectiosum (Parvovirus B19, slapped cheek )
What causes Chicken pox and what does it present with?
Highly contagious disease caused by primary infection with the varicella-zoster virus.
One infection is thought to confer lifelong immunity.
Immunocompromised individuals are susceptible to the virus at all times.
Red papules (small bumps) progressing to vesicles (blisters) often start on the trunk.
Itchy
Associated with viral symptoms.
What is the incubation period and contagious period of chicken pox and how is it managed?
Incubation period 10-21 days
Contagious 1-2 days before rash appears and until lesions have crusted
Self limiting.
Infection control – nursery
Rarely associated pneumonia, encephalitis.
Parvovirus (slapped cheek) is fifth disease/erythema infectiosum: How does it present?
Incubation 7-10 days.
Viral symptoms.
Erythematous rash cheeks initially and then also lace like network rash (trunk and limbs). Can take 6w to fully fade.
Usually a mild self limiting illness
Virus targets red cells in bone marrow.
Parvovirus is usually self limiting but what can it very rarely cause?
Aplastic crisis (if haemolytic disorders)
Risk to pregnant women (spontaneous abortion, intrauterine death, hydrops fetalis)
What enterovirus usually causes hand foot and mouth?
Coxsackie virus A16
(can also be due to enterovirus 71 & other coxsackivirus types)
How does hand foot and mouth present and how is it treated?
Blisters on the hands,feet & mouth. Viral symptoms
Epidemics late summer or autumn months
Self limiting, treatment supportive
How does eczema coxsackium present?
- Associated viral symptoms
- Hx of eczema
- Flared sites picks out areas of eczema
- Self limiting
How does eczema herpeticum present and how is it treated?
Unwell child
History of eczema
Monomorphic punched out lesions
Withold steroids for 24 hours
Aciclovir- oral or IV
Opthalmology review if near eye
How does eczema herpeticum present and how is it treated?
Unwell child
History of eczema
Monomorphic punched out lesions
Withold steroids for 24 hours
Aciclovir- oral or IV
Opthalmology review if near eye
How does orofacial granulomatosis present and what can you do to start to manage it?
Lip swelling and fissuring
Oral mucosal lesions: ulcers and tags, cobblestone appearance
Can be associated with Crohn’s Disease
Check faecal calprotectin if GI symptoms
Consider patch testing
Benzoate and cinnamate free diet
What are the clinical features of erythema nordosum?
Painful, erythematous subcutaneous nodules
Over Shins; sometimes other sites
Slow resolution - like bruise, 6-8 weeks
(NSAIDs, Topical steroids-may not be helpful)
What are the causes of erythema nordosum?
Infections – Streptococcus, Upper respiratory tract
Inflammatory bowel disease
Sarcoidosis
Drugs – OCP, sulphonamides, Penicillin
Mycobacterial Infections
Idiopathic
What is a rare but persistent immunobullous disease that has been linked to coeliac disease?
DERMATITIS HERPETIFORMIS
Itchy blisters can appear in clusters
Often symmetry
Scalp, shoulders, buttocks, elbows and knees
How to manage dermatitis herpetiformis?
Detailed history
Coeliac screening
Skin biopsy
Emollients, gluten free diet, topical steroids, dapsone
What is urticaria and what can it be associated with?
Wheals/hives
Associated angioedema (10%)
Areas of rash can last from few minutes up to 24 hours
Acute <6 wks
Chronic >6 wks
What are the causes of urticaria?
Many causes:
Viral infection
Bacterial infection
Food or drug allergy
NSAIDS, OPIATES,
Vaccinations
Chronic urticaria – idiopathic
How is urticaria treated?
Consider possible triggers including medication and withdraw
Antihistamines:
Newer generation e.g desloratadine
3 x daily (off licence doses)
Ranitidine
Montelukast
Omalizumab
Ciclosporin
What is infantile haemangioma?
Very common vascular birth mark-not present on skin at birth
Proliferative phase between 6 weeks up to 8 months-Then starts to involute
Can be superficial or deep
There is no treatment for infantile haemangioma as it will resolve but what can be used on it?
B blockers can speed up the process of involution
- Topical-Timolol
- Oral-propranolol solution
Typically reserved for:
- Rapidly enlarging
- Central face or cosmetically sensitive site
- Ulcerating (Buttocks or genitals, posterior shoulder)
What is PHACES (syndrome)?
Pituitary fossa abnormality
Haemangioma
Arterial anomalies
Cardiac anomalies or coarctation of aorta
Eyes
Sternal cleft
(Low dose propranolol can result in good improvement of segmental haemangioma)
