Paeds Flashcards
what are 3 characteristic signs of pneumonia on examination?
bronchial breath sounds
focal coarse crackles
dullness to percussion
what is the most common cause of pneumonia in children?
streptococcus pneumonia
what is the most common viral cause of pneumonia?
respiratory syncytial virus (RSV)
what is the typical x-ray finding in s. aureus pneumonia?
pneumatocoeles (round air filled cavities) and multilobe consolidation
what are 2 bacteria that are more likely to cause pneumonia in pre/un-vacinated children?
GBS
Haemophilus influenza
which bacterial pneumonia can cause extrapulmonary manifestations and what are they?
Mycoplasma pneumonia
Can cause erythema multiforme
what is the management of pneumonia?
1st - amoxicillin
+/- macrolide (erythro, clarithro, azithro) for atypicals or allergy
what is the name of the condition where people cannot convert IgM to IgG so cannot form long term immunity?
immunoglobulin class-switch recombination deficiency
VACCINES DONT WORK!
what age group is typically affected by croup?
6 months - 2years
what is the pathophysiology of croup?
upper resp tract Ix causing oedema of the larynx
what is the most common pathogenic cause of croup?
parainfluenza virus
what are 2 key features of croup caused by parainfluenza virus?
improves in <48 hours
responds well to dexamethasone
what are 3 other common pathogenic causes of croup
influenza
adenovirus
RSV
what is a possible cause of croup especially in pre/unvaxinated children?
diphtheria - leads to epiglottitis!!! high mortality!
what are 5 symptoms of croup?
increased work of breathing
barking cough in clusters
hoarse voice
stridor
low grade fever
what is the treatment for croup?
supportive
oral dexamethasone - single dose 150 mcg/Kg (can repeat at 12 hours)
what is the stepwise management of severe croup?
oral dexamethasone
O2
Neb budesonide
Neb adrenaline
Intubation and ventilation
what age is virally induced wheeze typical in?
<3 years
what is the pathophysiology of viral induced wheeze?
viral infection causes inflammation and oedema which reduces space for air flow in a greater proportion due to small size of child’s airways- Poiseuilles law
what is the management of viral induced wheeze?
same as acute asthma
what kind of wheeze is heard in asthma and viral wheeze?
expiratory wheeze throughout
what is moderate asthma?
peak flow >50% predicted
normal speech
otherwise well
what is severe asthma? (6)
peak flow <50% predicted
sats <92%
unable to complete sentences
signs of respiratory distress
RR >40 1-5years, >30 5+ years
HR >140 1-5 years, >125 5+ years
what is life threatening asthma?
peak flow <33% predicted
sats <92%
exhaustion and poor resp effort
hypotension
silent chest
cyanosis
altered consciousness/confusion
what is a physical finding on the chest wall in severe chronic asthma?
harrison sulus - indentation in chest wall along 6th rib can be bilateral or unilateral
what is the acute management of asthma/viral wheeze?
Escalating Bronchodilators - Salbutamol, ipratropium bromide, magnesium sulphate, aminophylline
PLUS - Steroids - prednisone (oral) or Hydrocortisone IV
ABx - if suspected
what is the stepwise progression of bronchodilators in acute asthma?
IHR/Neb salbutamol (10 puffs every 2 hours or repeat nebs every 20-30 mins)
IHR/Neb ipratropium bromide
IV magnesium sulphate
IV aminophylline
what on spirometry suggests an obstructive picture?
reversibility
FEV1 <80%, FEV1:FVC <0.7
what are 4 investigations for asthma?
spirometry
direct bronchial challenge
fractional exhaled nitric oxide
peak flow variability
what is the long term management of asthma over 5?
Reliever - SABA (salbutamol)
Preventer
1 - ICS
2 - ICS + LTRA (leukotriene receptor antagonist - montelukast)
3 - ICS + LABA (-LTRA)
4 - MART (maintenance and reliever therapy, steroid + (S)LABA)
which LABA can be used as a short acting agonist also?
folmeterol
can ICS cause restricted growth?
can reduced adult hight with long term use by up to 1cm . dose dependent effect
what is the most common cause of bronchiolitis?
Respiratory syncytial virus (RSV)
in what age group does bronchiolitis occur?
<1 year, most common <6 months can be up to 2 years
what are 8 typical signs of bronchiolitis?
coryzal symptoms - URTI
signs of resp distress
dyspnoea
tachypnoea
poor feeding
mild fever
apnoea
wheeze and crackles
what are 8 signs of respiratory distress?
raised RR
use of accessory muscles
intercostal and subcostal recession
nasal flaring
head bobbing
tracheal tugging
cyanosis
abnormal airway noise
what is the typical course of RSV bronchiolitis?
coryzal symptoms
chest symptoms 1-2 days later
worst day 3-4
symptoms usually last 7-10 days
what are reasons for admission in bronchiolitis?
<3 months, pre-existing conditions
<50-70% of normal milk intake
clinical dehydration
RR >70
O2 <92%
resp distress
apnoea
parent not able to manage/access medical help at home
what is the management of bronchiolitis?
ensure adequate intake - NG, IVs
saline nasal drops, nasal suctioning
O2
ventilation support
2 signs of poor ventilation of a cap gas?
rising pCO2
falling pH
what can be given as prevention of RSV infection?
Palivizumab
monthly injection as prevention of bronchiolitis caused by RSV given to high risk babies. Provides passive protection
what age does laryngomalacia occur at?
infants peaking at 6 months - inspiratory stridor exacerbated by lying, feeding, upset => no coinciding resp distress
problem resolves as larynx matures - around 1.5 years
what chromosome is CF carried on?
chromosome 7
mutations on what gene causes CF?
Cystic fibrosis transmembrane conductance regulatory gene
what channels are affected in CF?
chloride channels
what is often the first sign of CF?
meconium ileus - not passing meconium in 24 hours, abdo distention, vomiting
what are 7 causes of clubbing in children?
hereditary
cyanotic heart disease
infective endocarditis
CF
TB
IBD
Liver cirhosis
what is the diagnostic chloride concentration on sweat test for CF?
> 60 mmol/L
which are 2 bacteria which are especially difficult to treat in CF?
pseudomonas aeruginosa
Burkholderia cepacia
what Abx can be used to treat pseudomonas?
tobramycin nebs or oral ciprofloxacin
what is the management of CF?
multidisciplinary
chest physio
exercise
high calorie diet
CREON tablets - for pancreatic insufficiency
prophylactic flucloxacillin
Tx chest infections
bronchodilators
DNase nebs - help clear secretions
hypertonic saline nebs
vaccinations
what is the average life expectancy for CF?
47 years
what infection typically causes epiglottitis?
HiB
what are 8 symptoms of epiglottitis?
sore throat/pain swallowing
stridor
drooling
tripod position
high fever
muffled voice
scared and quiet
septic and unwell
what investigation can be done in suspected epiglottitis?
lateral xray of neck
what is the management of epiglottitis?
alert senior paediatrician and anaesthetist
ABx - cefriaxone
steroids - dexamethasone
what is a complication of epiglottitis?
epiglottic abscess
what is chronic lung disease of prematurity (bronchopulmonary dysplasia)?
typically <28 weeks gestation suffer from resp distress syndrome and require O2 or intubation and ventilation at birth. Diagnosed on CXR when infant required O2 >36 weeks gestational age
what are 5 features of chronic lung disease of prematurity?
low O2 sats
increased work of breathing
poor feeding and weight gain
crackles and wheeze
increased susceptibility to infection
what can reduce risk of chronic lung disease of prematurity?
corticosteroids (betamethasone) in premature labour mothers <36 weeks
CPAP rather than intubation
Caffeine to stimulate resp effort
avoid over-oxygenating
what is the most common pathogen of otitis media?
strep pneumoniae
what is the typical presentation of otitis media?
ear pain
reduced hearing
symptoms of URTI
what is the first line Abx for otitis media?
1 - amoxicillin 5 days
erythro, clarithro
what is glue ear?
otitis media with effusions - middle ear become full of fluid due to a blockage in the eustacion tube causing loss of hearing
what can be seen on otoscopy in glue ear?
dull tympanic membrane with air bubbles or a visible fluid level
can look normal
what is the natural course of glue ear?
usually resolves within 3 months without treatment
how long does it usually take grommets to fall out?
1 year
what are 3 common congenital causes of deafness?
maternal rubella or CMV
genetic deafness
associated syndromes - downs
what are 2 common perinatal causes of deafness?
prematurity
hypoxia during or after birth
what are 4 common post natal causes of deafness?
jaundice
meningitis and encephalitis
otitis media or glue ear
chemo
what is the range of normal hearing on an audiogram?
all readings between 0-20 dB
what are 3 symptoms additional to tonsillitis symptoms that can indicate quinsy?
trismus - unable to open mouth
change in voice (hot potato voice)
swelling and erythema surrounding tonsils
what is the most common pathogen in quinsy?
strep pyogenes (A) and Haemophilus influenzae
what is the management of quinsy?
drainage and Abx (co-amox)
?dex
what is preorbital cellulitis?
infection of upper and lower eyelid which causes red how skin swelling around eyelid and eye - distinguish from orbital cellulitis with CT scan
usually no pain or reduction in eye movements, no change in vision or abnormal pupillary response
what is the management of preorbital cellulitis?
systemic Abx
what is squint also known as?
strabismus - misalignment of the eyes causing double vision
what are 5 causes of squint?
idiopathic
hydrocephalus
cerebral palsy
space occupying lesion
trauma
what are 2 tests for squint?
cover test
herschberg’s test
what is the management of squint?
occlusive patch or atropine drops in good eye
what are the 3 foetal circulation shunts?
ductus venosus
foramen ovalae
ductus arteriosus
what is the ductus venosus?
shunt connecting umbilical vein to inferior vena cava allowing foetal blood to bypass liver
what is the foramen ovale?
shunt connecting R to L atrium which allows blood to bypass R ventricle and pulmonary circulation
what is the ductus arteriosus?
shunt connecting pulmonary artery and aorta which allows blood to bypass the pulmonary circulation
are atrial septal defects cyanotic?
no - unless R sided pressure becomes so great due to pulmonary hypertension the shunt reverses - EISENMENGER SYNDROME
what is eisenmenger syndrome?
when a shunt reverses due to pulmonary HTN causing R sided pressure > L sided pressure leading to pulmonary circulation bypass and cyanosis. develops after 1-2 years with large shunts and in adulthood with small
what are 4 complications of atrial septal defects?
stroke - with DVT - clot bypasses lungs
AF or atrial flutter
Pulmonary hypertension and r sided HF
Eismenger syndrome
what are 3 types of atrial septal defect?
Ostium secondum
patent foramen ovale
ostium primum - tend to causes Av valve defects also
what is the murmur in ASD?
mid systolic crescendo-decrescendo murmur loudest at upper left sternal border with a fixed split second heart sound
what are 5 typical ASD symptoms?
SOB
difficulty feeding
poor eight gain
LRTIs
complications - heart failure, stroke
what can be seen on examination in eisenmengers syndrome?
cyanosis
clubbing
dyspnoea
plethoric complection (due to polycythaemia)
what is the management of eisenmengers syndrome?
Heart lung transplant
Management of pulmonary HTN, polycythaemia and thrombosis
what genetic conditions are associated with VSDs?
Downs and turners
what 3 defects can cause eisenmenger’s syndrome?
ASD
VSD
patent duct arteriosus
what is the murmur is VSD?
pan-systolic more prominent at left lower sternal border in 3/4 intercostal space. May be systolic thrill
what are the 3 causes of pan-systolic murmur?
VSD
mitral regurg
tricuspid regurg
how long does it usually take for the ductus arteriosus to close?
1-3 days to stop functioning, 2-3 weeks to fully close
what kind of shunt is patent duct arteriosus?
left to right - from aorta to pulmonary vessels
what murmur is heard in patent duct arteriosus?
continuous crescendo -decrescendo machinery murmur
what causes an ejection systolic murmur? (3)
aortic stenosis
pulmonary stenosis
hypertrophic obstructive cardiomyopathy
what 2 conditions that cause cyanotic heart disease?
transposition of the great arteries
Tetralogy of fallot
Eisenmengers transformation
what condition is coarctation of the aorta associated with?
turners syndrome
what is the presentation of coarctation of the aorta?
weak femoral pulses - upper limb BP higher than lower limb
Systolic murmur below left clavicle
tachypnoea
poor feeding
grey, floppy baby
what is the management of coarctation of the aorta?
surgery
in high risk - prostaglandin E to keep ductus arteriosus open till surgery
what cardiac condition causes cyanosis at birth?
transposition of the great arteries
what is the management of transposition of the great arteries?
prostaglandins - maintain ductus arteriosus
Balloon septostomy - insert balloon catheter into foramen ovale to create largeASD
open heart surgery - arterial switch
what are the 4 pathologies in tetralogy of fallot?
Pulmonary valve stenosis
Right ventricular hypertrophy
Overriding Aorta
VSD
PROVe
what kind of shunt is there in tetralogy of fallot?
left to right - cyanotic
what are 4 risk factors for tetralogy of fallot?
rubella infection
increased age of mother
alcohol in pregnancy
diabetic mother
what investigations can be used for septal defects?
echo + doppler flow studies
what can be seen on chest x-ray in tetralogy of fallot?
boot shaped heart due to right ventricular hypertrophy
what are 6 manifestations of tetralogy of fallot?
cyanosis
clubbing
poor feeding
poor weight gain
ejection systolic murmur loudest in pulmonary area
tet spells
what are tet spells?
seen in tetralogy of fallot where shunt becomes temporarily worse causing cyanotic episode - usually during waking, exertion, crying
what is the management of tet spells?
squatting or pulling knees to chest - increases systemic vascular resistance
O2
beta blockers - relax R ventricle
IV fluids
morphine - decrease resp drive
sodium bicarb - buffer metabolic acidosis
phenylephrine infusion - increase systemic vascular resistance
what is the management of tetralogy of fallot?
Prostaglandins - maintain ductus arteriosus
surgery
what is ebstein’s anomaly?
R tricuspid valve lower than normal causing R ventricle to be smaller causing poor flow to pulmonary vessels - usually presents after closing of ductus arteriosus
what 4 conditions are associated with pulmonary valve stenosis?
tetralogy of fallot
william syndrome
noonan syndrome and turners syndrome
congenital rubella syndrome
what is rheumatic fever?
autoimmune condition triggered by antibodies to group A beta-haemolytic strep - typically strep pyogenes causing tonsilitis. The process usually occurs 2-4 weeks after initial infection
what is the presentation of rheumatic fever? (7)
fever
joint pain - migratory of large joints
erythema marginatum rash
shortness of breath
chorea
firm painless nodules
carditis - tachy/brady, murmurs, pericardial rub, heart failure
what are 3 investigations for rheumatic fever?
throat swab and culture
Anti streptococcal antibodies (ASO) titres
ECHO, ECG, CXR
what criteria is used to diagnose rheumatic fever?
jones criteria
what is the jones criteria?
for diagnosing rheumatic fever
TWO of JONES
Joint arthritis
Organ inflammation (carditis)
Nodules
Erythema marginatum rash
Sydenham chorea
OR
One JONES and TWO FEAR
Fever
ECG changes (prolonged PR)
Arthralgia
Raised inflammatory markers
what is the management of rheumatic fever?
Abx - Benzathine benzylpenicilin or phenoxymethylpenicillin
NSAIDs or salicates (joint pain)
Aspirin and steroids - carditis
Heartfailure - Diuretics +/- ACEi
Chorea - carbamazepine
what are 3 complications of rheumatic fever?
recurrence
valvular heart disease - mitral stenosis
chronic heart failure
what are 6 signs of problematic reflux in babies?
chronic cough
hoarse cry
distress after feeding
reluctance to feed
pneumonia
poor weight gain
what advice can be given for GORD in babies?
small frequent meals
burping regularly
not overfeeding
keep baby upright after feeding
what kind of vomiting is present in GORD?
effortless mainly after feeding
what 3 treatments can be given in babies with GORD?
gaviscon mixed with feeds
thickened milk or anti-reflux formula
PPIs
what is a key feature of pyloric stenosis?
projectile vomiting
when does pyloric stenosis present?
first few weeks (4-6 weeks) of life baby failing to thrive with projectile vomiting
what 3 things can be found on examination of a baby with pyloric stenosis?
observation of stomach peristalsis
firm round ‘olive like’ mass in upper abdomen
hypochloric (low Cl-) metabolic alkalosis on blood gas
how is pyloric stenosis dianosed?
Abdo USS
what is the management of pyloric stenosis?
laparoscopic pyloromyotomy - Ramstedt’s operation
what are 2 common viral causes of gastroenteritits?
rotavirus
norovirus
which e.coli produces shiga toxin?
E.coli 0157
what does shiga toxin cause?
abdo cramps, bloody diarrhoea, vomiting - can lead to haemolytic uraemic syndrome
what is the most common cause of bacterial gastroenteritis?
campylobacter jejuni
where does campylobacter come from?
raw/improperly cooked poultry
untreated water
unpasteurised milk
what is the treatment of campylobacter?
azithromycin or ciprofloxacin
which bacteria causes gastroenteritis after food has not been refrigerated quickly (rice)?
bacillus cereus - diarrhoea resolving in 24 hours
what is the treatment of Giardiasis?
metronidazole
what are 4 possible complications of gastroenteritis?
lactose intolerance
IBS
reactive arthritis
GBS
what is toddlers diarrhoea?
chronic watery diarrhoea in well <5 year olds which can often be helped by changes in diet
what are the 4fs of toddler’s diets?
fat - shouldnt have low fat diet
Fluid - not sugary drinks, not too much water
Fruit + fruit juice - gut cannot absorb fructose or sorbitol easily
Fibre - 12-18g per day
what is persistent diarrhoea?
> 2 weeks
what is chronic diarrhoea?
> 4 weeks
what is encopresis?
foecal incontinence
what are 5 causes of faecal incontinence?
spina bifida
hirschprungs disease
cerebral palsy
overflow incontenence - stress, abuse
Constipation with overflow
what are 5 lifestyle factors that may contribute to constipation in children?
habitual not opening bowels
low fibre diet
poor fluid intake
sedentary lifestyle
psychosocial problems
what are 8 secondary causes of constipation in children?
hirschprungs disease
CF
Hypothyroid
Spinal cord lesions
sexual abuse
Intestinal obstruction
anal stenosis
cow milk intolerance
what is the first line laxative in children?
movicol
when is the peak incidence of apendicitis?
10-20 years
where is McBurney’s point?
one third of the way from the anterior superior iliac spine and the umbilicus
what is rovsing’s sign?
for apendicitis
when palpation in LIF causes pain in RIF
what are 6 classical features of apendicitis?
loss of appetite
nausea and vomiting
rovsing’s sign
guarding
rebound tenderness
percussion tenderness
what are 5 key differentials for apendicitis?
ectopic pregnancy
ovarian cysts
meckel’s diverticulum
mesenteric adenitis
appendix mass
what is meckel’s divertculum?
malformation of distal ileum present in 2% of population that can bleed, become inflamed, rupture or cause volvutus, intussusception or obstruction
what are 5 complications of apendicectomy?
bleeding, infection, pain, scars
damage to bowel or bladder
removal of normal appendix
anaesthetic risks
VTE
what are the 5 key features of Crohn’s? (mneumonic)
NESTS
No blood or mucus (less than UC)
Entire GI tract
Skip lesions
Terminal ileum most affected + Trans mural
Smoking risk factor
weight loss, strictures, fistulae
what are the 7 key features of UC? (mneumonic)
CLOSEUP
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa
Smoking protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosing cholangitis
what are extra-intestinal manifetations of IBD?
finger clubbing
erythema nodosum
pyoderma gangrenosum
episcleritis and iritis
inflammatory arthritis
primary sclerosing cholangitis (UC)
what is one stool test that can be used for IBD but only in adults?
faecal calprotectin
what is the acute management of crohn’s?
1 - steroids (oral pred or IV hydrocortisone)
+ immunosuppression under specialist - azathioprine, mercaptopurine, methotrexate, infliximab
what is the long term management of crohn’s?
1 - azithioprine or mercaptopurine
what is the management of mild-moderate acute UC?
1 - aminosalcylates - mesalazine
2 - corticosteroids
what is the management of severe acute UC?
1 - IV corticosteroids (hydrocortisone)
2 - IV ciclosporin
what is the long term management of UC?
aminosalicylate - mesalazine
or azathioprine or meraptopurine
what is the name of surgery to remove the colon and rectum sometimes used in UC?
panproctocolectomy
what is the most common congenital abnormality of the small bowel?
meckel’s diverticulum
when do people usually present with meckel’s diverticulum?
<2 years
what are 2 antibodies in coeliac disease?
anti-tissue transglutaminase (anti-TTG)
anti-endomysial (anti-EMA)
What skin manifestation can be a sign of coeliac disease?
dermatitis herpetiformis - itchy blistering skin rash usually on abdomen
what are 3 neurological signs associated with celiac disease?
peripheral neuropathy
cerebellar ataxia
epilepsy
what are 2 findings on endoscopy in coeliac disease?
crypt hypertrophy
villous atrophy
what are 6 conditions associated with coeliac?
T1DM
thyroid disease
autoimmune hepatitis
primary billiary cirrhosis
primary sclerosing cholangitis
downs syndrome
what are 7 complications of untreated coeliac disease?
vitamin deficiency
anaemia
osteoporosis
ulcerative jenunitits
enteropathy associated t-cell lymphoma
non-hodgekin lymphoma
small bowl adenocarcinoma
what is faltering growth?
fall in weight across:
1+ centiles if birth weight below 9th
2+ centiles if birth weight between 9th-91st
3+ centiles if birth weight 91+ centiles
what are 5 causes of failure to thrive?
inadequate nutritional intake
difficulty feeding
malabsorption
increased energy requirements
inability to process nutrition
what are 5 causes of inadequate nutritional intake in children failing to thrive?
maternal malabsorption if breastfeeding
IDA
family or parental problems
neglect
availability of food
what are 4 causes of difficulty feeding?
poor suck (cerebral palsy)
cleft lip/palate
genetic conditions w/ abnormal face structure
pyloric stenosis
what are 5 causes of malabsorption in children failing to thrive?
CF
coeliac disease
cows milk intolerance
chronic diarrhoea
IBD
what are 4 causes of increased energy requirements in children failing to thrive?
Hyperthroidism
chronic disease - CF, CHD
malignancy
chronic infections - HIV, immunodeficiency
what are 2 causes of inability to process nutrients in children failing to thrive?
inborn errors of metabolism
T2DM
how do you calculate mid-parental height?
average of parents height
what is anthropometry?
in nutritional assessment - includes weight, height mid-upper arm circumference and skinfold thickness
what is marasmus?
severe malnutrition due to inadequate energy intake in all forms. More common <1 year olds and causes muscle wasting and loss of subcutaneous fat but no oedema
what is kwashiorkor?
Severe malnutrition due to protein deficiency but with adequate energy intake. Leads to oedema, ascites and enlarged liver with fatty infiltrates
what is Hirschprungs disease?
congenital condition where nerve cells of the myenteric (auerbach’s) plexus are absent causing a lack of peristalsis of the large bowel
what is the key pathopysiology of hirschprungs disease?
absence of parasympathetic ganglion cells in the colon
what are 4 syndrome that can be associated with hirschprung’s?
downs
neurofibromatosis
waardenburg syndrome
multiple endocrine neoplasia type II
what are 5 presentations of hirschprungs disease?
delay in passing meconium
chronic constipation since birth
abdo pain and distention
vomiting
poor weight gain and failure to thrive
what is hirschsprung associated enterocolitis?
inflammation and obstruction of the intestines in 20% of neonates with hirschprungs presenting usually between 2-4 weeks with fever, abdo distension, diarrhoea (w/ blood usually) and features of sepsis
what is the management of hirschsprungs associated enterocolitis?
Abx
fluid resuscitation
decompression of obstruction
how is hirschsprungs disease diagnosed?
rectal biopsy + histology for absence of ganglionic cells
what is the management of hirschsprungs disease?
surgical resection of aganglionic bowel
what age group does intussusception occur most commonly in?
6 months - 2 years
more common in boys
what is intussusception?
when the bowel invaginates into itself causing bowel obstruction
what 5 things are risk factors for intussusception?
concurrant viral illness
henoch-schonlein purpura
CF
intestinal polyps
meckel diverticulum
what are 6 presentations of intussusception?
sever colicky abdo pain
pale, lethargic unwell child
redcurrant jelly stool
sausage shaped RUQ mass
vomiting
intestinal obstruction
what is the first line investigation for intussusception?
USS