Paediatrics Flashcards
Main things covered in hx?
hild’s age, nature of the problem and observation
HPC for hx?
parent/child accounts; ADLs affected and how parents taken action; why referred and parent worries; to check – general health, normal growth, E+D and behaviour change; wet/dirty nappies
PMH for hx?
maternal obstetric complications; birthweight; perinatal problems (jaundice, fits, fever, bleeding, feeding); immunisations and past illnesses; medication, alcohol, drugs
SH for hx?
family (normal SH that you would take but for family members); child happy at home/school; impact of illness on carers and benefits, same father of kids; siblings; play, eating, sleeping, pets; who looks after child; hopes, fears, expectations of parents for child in hospital
Development covered in paeds overview?
parental concerns, developmental milestones, previous child health surveillance checks, enuresis, child behaviour, sleeping problems, progress at school; use ABCD for consciousness if needed; faltering growth = red flag; plot weight, height and head circumference for infants on chart
How to stage puberty?
Tanner staging
Define low birthweight?
under 2500g, very low = under 1500g and extremely low is under 1000g
What is small for gestational age?
low weight under 10th percentile for age
2 types of IUGR?
symmetrical = fetus affected from early pregnancy; asymmetrical = foetus affected later e.g. pre-eclampsia; most catch up to height/weight in 2 years but adults slightly shorter; coronary HD and obesity
Behavioural problems in kids?
food refusals, overeating (comfort), pica (eating things which aren’t food)
Causes of prematurity?
smoking, poverty, malnutrition, PMH, GU infection, chorioamnionitis, pre-eclampsia, DM, polyhydramnios, closely spaced pregnancies, multiple, uterine, malformations, placenta praevia (placenta covers cervix causing bleeding during pregnancy), abruption, premature membrane rupture
S+Ss mastitis?
tender, hot reddened area of breast with/out fever; can’t breastfeed
Ages for normal pulses?
110-160 <1; 95-150 2-5; 80-120 5-12
Causes of HT in children?
renal parenchymal disease or essential mainly; same treatment as adults but only if symptomatic
Problems from HT crisis and treatment in children?
cerebral oedema, HF, seizures, pulmonary oedema, renal failure; use nifedipine, labetol or sodium nitroprusside
S+Ss HF in children?
poor feeding, sweating, tachypnoea, tachycardia, gallop rhythm, cardio/hepatomegaly
Describing HS in children?
describe timing, duration, loudness, radiation and site of max intensity; 3rd HS is normal
Signs for severely ill children (GRUNTING)?
Grunting, weak/continuous high-pitched cry, tachypnoea; Rib recession, nasal flaring, sternocleidomastoid retraction, stridor; Unequal/unresponsive pupils, hypotonia, focal CN; Not using limbs/lying still, odd posture, decerebrate (arms and legs extended); Temp >38 (6 months) or 39; I have a bad feeling (judgement); Neck rigidity, non-blanching rash, meningism; Green bile in vomit
4 fields considered during normal child development?
gross motor, vision/fine motor, hearing/speech/language and social/emotional/behavioural
Advice for parents with crying babies?
peaks at 6-8 wks and subsides by 4 months; support parents so preventing post-natal blues, reduce their stress (take it in turns); teach that this normal and say techniques to deal (rocking, singing, hungry or tired, hugging); colic (paroxysmal crying with legs up – hunger)
What are the median and limit ages for milestones in development?
- Take into account median age (MA) for each milestone
* Limit ages (LA) – when child should have reached milestone
List main child development milestones in the first 5 years?
o Unsupported walking – 12 months, 18 months (later more likely to be hypermobile)
o Sat up – 6 months
o Crawling – 8-9 months (bottom shufflers later)
o Motor development follows CNS development
o 3-4 word sentences – 2.5-3
o Interactive play – 2.5-3
o Drink from cup – 12 months
o Vision/fine motor >1
o Hearing/speech/language from 18 months
o Social from 2.5
o Respond to name and familiar words – 12 months
o Orthoptist screening age 5
When is developmental correction intervention needed?
• Correction not required til after 2 (cognitive problems appear later than developmental)
Tests for development in child assessment?
Denver developmental screening test; Griffiths and Bailey developmental scales; IQ tests; cultural backgrounds (for cognitive); parents’ evaluation of developmental status; ages and stages questionnaire; Brigance screens II, modified checklist for autism in toddlers
How to assess hearing in newborns?
optoacoustic emission or auditory brainstem response audiometry
What is amblyopia?
cataract interfering with optic pathway development
Define delay with respect to development?
slow acquisition of all skills in a field
Define disorder with respect to development?
maldevelopment of a skill
Define impairment with respect to development?
loss/abnormality of a function
Failure to thrive definition and tests?
poor weight gain in infancy; MSU, coeliac serology, U+E, glucose, LFT, calcium, igs, CRP, TSH, FBC, sweat, urinary aas, stools, CXR, US renal/CNS
Failure to thrive short stature definition and causes?
height <3rd percentile; hypopituitarism, low GH (arginine stimulation test – use somatotrophin to treat)
Causes of tallness?
thyrotoxic, precocious puberty, Marfan’s, homocystinuria
Causes of abnormal heaviness?
snacks, low exercise, hypothyroidism, Cushing’s, Prader-Willi, Bardet-Biedl, Cohen syndrome, polycystic ovary syndrome
Abnormal motor signs in children?
head control, rolling, sitting, walking balance, gait, involuntary movements
Causes of developmental delay in children?
central motor deficit, congenital myopathy, spinal cord lesions, global developmental delay
Define cerebral palsy?
oo Permanent disorder of movement, posture or motor function from non-progressive abnormality in brain development under the age of 2
What is affected in cerebral palsy?
cognition, communication, vision, perception, sensitisation, behaviour, seizure and secondary MSK problems; abnormal posture, feeding difficulties, gait, asymmetrical head function
What are the causes of cerebral palsy?
80% antenatal = CV haemorrhage, structural maldevelopment, TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes simplex); intra-partum = hypoxic-ischaemic brain injury; postnatal = meningitis, head trauma, hypoglycaemia, hydrocephalus, hyperbilirubinaemia
Diagnosis for cerebral palsy?
clinical exam; posture, tone, hand function and gait; infection screen; CT/MRI head; EEG/NCS; TFTs, FBC, U+Es, bone chemistry, blood gases
Spastic changes in cerebral palsy?
UMN damage; unilateral limbs only (facial sparing); 4-12 months = fisting of hand affected, flexed arm, hand function, toe pointing when lifted, extensor posturing, poor head control, low central tone, seizures, microcephaly
Dyskinetic changes in cerebral palsy?
involuntary, uncontrolled, stereotyped movements; more evident with movement/stress; chorea, athetosis (slow writhing movements) and dystonia; intellect can be unimpaired; floppiness; signs from basal ganglia damage; hypoxic-ischaemic encephalopathy (brain damage after hypoxic-ischaemic event, resp depression at birth, low pH
Treatment for dyskinesia in cerebral palsy?
resus, avoid hyperthermia, exclude other causes, treat seizures)
Ataxic changes in cerebral palsy?
genetic; trunk and limb hypotonia, poor balance and delayed motor development
Treatment for ataxia in cerebral palsy?
botox, intrathecal baclofen and DBS (for hypotonia)
Examples of speech and language delay?
hearing loss, global developmental delay, anatomical deficit, environmental deprivation and familial pattern; disorders of expression, comprehension, speech intelligibility, pragmatics and social skills; hearing tests and SALT; symbolic toy test and Reynell test
S+Ss of dyspraxia?
disorder of motor planning; no findings on neuro exam; features like handwriting, dressing, literacy, copying, drawing, messy eating
Types of hearing impairment in children?
sensorineural presents soon after birth and irreversible; microtia (undeveloped external ear) and meatal atresia can be helped with bone conduction hearing aids; conductive hearing loss from middle ear mild-moderate (chronic otitis media); Down’s, cleft palate, atopy prone to middle ear loss
Management of hearing impairment in children?
impedence audiometry tests (pressure in middle ear) determine functioning; long term abx or decongestants; grommets sometimes
S+Ss visual impairment?
ocular malformations; not smiling responsively by 6 weeks, poor visual response, nystagmus, squint
Causes of visual impairment?
retinoblastoma = life threatening; squint = retinal reflexes checked (corneal light reflex test and cover test) and over 3 months refer to ophthalmologists (commonly refractive error but can be retinoblastoma); paralytic = rare, concomitant (common); corneal light reflex test and cover test; hypermetropia = most common refractive error (long-sigthedness); myopia (near-sightedness) in adolescence; astigmatism common; patch good eye to improve bad eye
Sick children treated at home and conservatively?
• Usually mild and can be treated at home; hosp admission rate increased = lower threshold, lack of instant test to rule out serious illness, repeated admission for children with complex illnesses; parents can stay overnight with them; consider psychosocial factors if treated at home
Treatment of general pain in children?
observation and parent input; distractions used and topical anaesthetics; use NO, mild sedatives or hypnotics, opioids and post-op analgesics; nerve-blocks used; IM drug injections should be avoided; aspirin not given under 16 as Reye syndrome (encephalopathy and liver failure); OD high from longer half-life and low renal excretion
Normal resp rate in kids?
30-40 in infants, 25-35 in young children and 20-25 in older children
Normal bp in kids?
80-90 in infants, 85-100 in young children and 90-110 in older children
Exam in those with resp/neuro/circ failure?
look for history, O/E, trauma, rash, smell, scars and medicalert bracelets; more likely to resp/hypoxia than cardiac failure; disinterested and not alert
Treatment for shockable VF/VT?
after 3rd shock give adrenaline and amiodarone
Causes of resp failure?
lungs can’t give good gas exchange; causes = alveolar hypoventilation, v/q ventilation, diffusion impairment and intrapulmonary shunting; less than 92% O2 sats give O2
Treatment for resp failure?
can give CPAP or biphasic positive airways pressure; intubation for = progressive hypoxaemia, reduced consciousness, progressive neuromuscular weakening, tiring
S+Ss resp failure?
tachycardia, resp>50, nasal flaring, accessory muscle use, head retraction cyanosis, unable to feed, tired and sats <92%
Why low fluid in kids and compensated and decompensated shock?
higher BMR means need more fluids; lose from = no oral, fever, diarrhoea, burns, capillary leak; dehydration shock = metabolic acidosis, low BP; compensated shock = tachycardia, tachypnoea, low skin turgor, delayed cap refill, pale and mottled skin; decompensated = acidotic breathing, bradycardia, confusion, blue peripheries, no urine output, hypotension
Treatment for compensated/decompensated shock?
PICU if IV fluids not helping; can have renal support and inotropic support
Problems and treatment for septic shock?
fluid maldistribution with cap leak; may need central venous monitoring and catheterisation; clotting derangements, pulmonary oedema, DIC, myocardial dysfunction, tilt head 20-30 seconds to reduce ICP risk and mannitol, early abx
Risks in babies emergency medicine?
gestation <32 weeks, duration >1 minute, repeat event, CPR, concerning history, abnormal O/E, SIDS = 2-4 months (unexpected cot death;
Tests for babies in emergency care?
obs, ECG, swab for pertussis, sats
Prevention of SIDS?
sleep supine, stop overheating [16-20 degrees in room] and no smoking, use a grow bag so baby can’t move, not too much bedding; baby must have a post-mortem; CONI programme, grief counselling for parents
What is involved in children coma scale?
motor = 6carrying out request, 5localised pain response, 4withdraw to pain, 3flexor pain response, 2extensor posturing to pain, 1no response; verbal = 5orientated, 4crying but consolable, 3inconsistently inconsolable, 2inconsolable crying, 1no response; eye opening = 4spontaneous, 3from speech, 2to pain, 1none
Treatment and management of traumatic accidents?
always try to maintain brain blood supply if head injury and evacuate haemorrhage (otherwise get brain injury); liver and spleen rupture apparent immediately; pneumothorax and haemopericardium from blunt trauma; ECG for electrical burns and do burn size and depth (fluids if >10% body size)
Causes of poisonings?
accidental, iatrogenic, deliberate or intentional
Prevention of poisonings?
child resistant containers, low packet number of analgesia
S+Ss poisoning?
behavioural changes, hyperactivity, developmental delay, chronic lead nephropathy, abdo pain, headache, lethargy, vomiting, seizures
Poisoning treatment?
chelation effective; activated charcoal (not for iron and pesticides); Iv acetylcysteine for paracetamol; Iv desferrioxamine for iron (gives red-orange urine); intubation if low GCS; supportive management; haemodialysis for salicylates; TCAs for sodium bicarb and ventilation; blood glucose and ventilate for alcohol; IV desferoxamine for iron; atropine and pralidoxime for pesticides
Specific antidotes for poisons?
beta-blockers = atropine (bradycardia) with glucagon and sometimes adrenaline/dopamine; CO = high flow O2, mannitol for cerebral oedema; digoxin = atropine, digoxin specific antibody; opioids = IV naxolone; methanol/ethylene glycol = fomepizole; sulfonylureas = octreotide
Child abuse categories?
physical, emotional, sexual, neglect and fabricated illness (suffocate, give poisons, OD); witnessing intimate partner violence and FGM serious
Define neglect?
persistent failure to meet child’s physical and psychological needs
Risks for child neglect?
failure to meet parent’s expectations, born after forced sex, mental health problems, substance misuse, step-parents, domestic violence, closely spaced births, social isolation and poverty, disability
Factors to consider in child protection?
age, hx from child, plausibility of injury, background, injury reporting delay, inappropriate reaction of caregiver
Examples of neglect?
child miss appts, lack of immunisations, dirty, hungry, inadequate clothes, substance misuse, caregiver indifferent to child, child ‘wrong-gender’, partner separation, babies non-demanding, toddlers fearful/violent, school children violent/wetting/antisocial, adolescents self-harm
Sexual abuse examples?
porno, pregnant, STI, vaginal bleeding, itching, discharge, rectal bleeding, sexual acting out, self-harm, aggression, poor school performance; need to exclude other causes; can swab for perp or full radio skeleton under 30 months
Management for abuse?
does child need immediate protection; safety of other siblings; hosp or foster care; social workers
What is trisomy 18?
Edward’s syndrome
Edward’s syndrome S+Ss?
(small and bad heart and kidneys); low birth weight, prominent occiput, small mouth and chin, short sternum, flexed overlapping fingers, cardiac/renal malformations
What is trisomy 13?
Patau syndrome
Patau syndrome S+Ss?
(wrong with head, face, heart and kidneys), structural brain defects, scalp defects, small eyes, cleft palate, polydactyly and cardiac/renal malformations; amniocentesis and chromosomal analysis
S+Ss turner syndrome?
45X; early miscarriage, US foetal oedema; (lots of hormone problems and fluid) lymphoedema of hands and feet, koilonychia, short stature, neck webbing, wide nipples, CHD, delayed puberty, ovarian dysgenesis, hypothyroidism, renal abnormalities, pigmented moles, recurrent otitis media, normal intellect
Treatment of turner syndrome?
growth hormones therapy and oestrogen replacement
Klinefelter syndrome S+Ss?
– (tall and low sexually) infertility, hypogonadism, gynaecomastia, normal puberty, tall stature, normal intelligence; chorionic villus or amniocentesis
AD inheritance diseases?
achondroplasia, familial hypercholesterolaemia, Huntington’s, marfan’s, myotonic dystrophy
AR diseases?
congenital adrenal hyperplasia, CF, Friedreich’s ataxia, glycogen storage disorders, sickle cell (increased by consanguinity – inbreeding)
X-linked diseases?
colour blindness; fragile X; haemophilia; DMD/BMD (only males affected)
Prader-Willi S+Ss?
hypotonia, faltering growth, obesity, learning difficulties and hypogonadism
Nooan syndrome S+Ss?
mild learning difficulties, short webbed neck, pectus excavatum, short stature, congenital heart disease
Williams disease S+Ss?
short stature, congenital heart disease, mild-moderate learning difficulties
Glucocorticoids for neonates?
better lung maturity and surfactant production (better lungs)
Management for preterm labour?
antibiotics, corticosteroids, tocolysis (anti-contractions/labour), magnesium sulfate
Multiple birth problems?
preterm, IUGR (intrauterine growth restriction), congenital abnormalities, twin-twin transfusion
Problems with maternal DM?
more likely for polyhydramnios (too much amniotic fluid in sac) and pre-eclampsia (basically problems with too much fluid – osmosis); risks = macrosomia (large baby), IUGR, congenital abnormalities
Neonatal common problems?
hypos, resp distress, HCM, polycythaemia; foetal thrombocytopenia = risk of intracerebral haemorrhage; epidural can cause maternal pyrexia; oxytocin can cause foetal hypoxia; taxoplasmosis = bad news bears
Mask ventilation overview?
no breath, HR<100 and HR<60 = chest compressions
Non-invasive venitlation (CPAP) definition?
continuous positive airway pressure = air always into lungs to keep airways and alveoli open (no collapse) but can cause pneumothorax, reflux, feed intolerance and nasal trauma; NIPPV (nasal intermittent positive pressure ventilation); HFNC (high flow nasal cannula)
Invasive ventilation overview?
TCPL (time-cycled pressure limited ventilation) continuous heated and humidified gas through endotracheal tube; PTV (patient-triggered ventilation) like TCPL but triggered by a sensor detecting spontaneous breaths; HFV (high frequency ventilation); give sedation before (opiate with muscle relaxant e.g. morphine with suxamethonium); if giving pain relief give up to 50mcg/kg 5
Problems with acidotic infants inhaling meconium?
meconium aspiration syndrome – foetal faeces in bowel [meconium] is passed in utero so amniotic fluid is that colour); preterms prone to hypothermia; airway obstruction, surfactant dysfunction, pulmonary vasoconstriction, infection, chemical pneumonitis
What are Barlow’s and Ortolani’s?
how to check for developmental dysplasia of hip; risks = grils, positive FH, breech presentation, neuromuscular disorder
Examination of newborn?
birthweight, gestational age, head circ, fontanelle (where the skull plates meet), face, eyes (red reflex), palate, breathing, heart, abdo, femoral pulses, genitalia, anus, muscle tone, back, primitive reflexes, hips (everything)
Normal progression in neonates but can be seen as pathological?
neonatal urticaria 2/3 yrs; milia (white pimples on face); ubilical hernia resolves 2/3yrs; port-wine stain normal; strawberry naevus in 1st month
What is hypoxic ischaemic encephalopathy?
significant labour event (failure gas exchange, interruption of umbilical blood flow, inadequate maternal placental perfusion; leading to cardioresp depression then hypoxia/hypercarbia/metabolic acidosis)
Management of hypoxic ischaemic encephalopathy?
may need resp support = treatment of seizures, fluid restriction, hypotension treat, monitor hypos
Worrying signs with newborns?
not pink and crying (antenatal hist and check gestation); check not expanding; HR <60; use ventilation, resus and sometimes adrenaline; suck out meconium if needed
Some minor problems in newborns?
strawberry naevus (increase in size then disappear, bleed and ulcer); milia (pearly white papules from keratin retention in dermis); erythema toxicum (neonatal urticaria); stork mark (capillary dilation over eyelids, head and neck); swollen breasts; sticky eye (blocked tear duct but exclude chlamydia); feeding anxieties (turning blue, adjust feeding technique); red stained nappy (blood from cord/vagina/urinary urates); sneezing to clear amniotic fluid; harlequin colour change (transient, episodic demarcation erythema with contralateral blanching)
Birth injuries?
caput succedaneum (bruising and oedema), cephalhaematoma, chignon (bruising and oedema from ventouse), bruising to face, abrasions to skin, forcep marks; breech problems (brachial nerve palsy, humerus and femur fracture)
S+Ss preterm infant?
resp depression = alveolar collapse from surfactant deficiency; commoner in <28wks boys; S+Ss = tachypnoea (>60), wall recession, expiratory grunting, cyanosis
Treatment for preterm infants?
O2 (SEE PAGE 7 OF PAED NOTES FOR WHAT TYPE OF O2), surfactant therapy, CPAP; apnoea, bradycardia, desaturation treated with caffeine and CPAP
How to close patent ductus arteriosus?
prostaglandin synthetase inhibitor (indomethacin/ibuprofen used)
Fluids for preterm?
60-80l/kg, 150-180l/kg day 5; <35 wks = nasogastric; ill = PIC line; minerals for bone development
S+Ss necrotising enterocolitis?
inflammatory bowel necrosis; signs = feed tolerance, bile stained vomit, abdo distended, blood in stool, shock, tenderness
Risk for necrotising enterocolitis?
Cow’s milk
Treatment for necrotising enterocolitis?
stop oral feeding and broad spectrum abx, resp/circ support; can get bowel perforation, culture faeces
Causes intraventricular haemorrhage?
more in low birthweight and early birth as underdeveloped vessels and stress of birthing
Problems with IVH?
impair CSF drainage (hydrocephalus); ventricular tap used; if dilation happens can get cerebral palsy
Treatment for child retinopathy?
vascular proliferation of retina and laser therapy used and can be from early oxygen exposure
Treatment and causes of bronchopulmonary dysplasia?
damage from pressure from artificial ventilation/oxygen toxicity/infection; O2 requirement after 36 wks
Pathophysiology of jaundice?
half of newborns from release of Hb from RBCs
Kernicterus causes?
encephalopathy from deposition unconjugated in basal ganglia and brainstem nuclei
S+Ss kernicterus?
athetoid movements (slow, involuntary, writhing), deafness, and low IQ if not treated; lethargy, poor feeding; can develop choreoatheoid cerebral palsy, learning difficulties, sensorineural deafness
Causes of haemolysis?
jaundice in 24 hours (abnormal = ABO compatibility – coomb’s test, rhesus haemolytic disease, red cell anomalies); congenital infection can cause, breastfed, dehydration, UTI, hypothyroidism, biliary atresia, neonatal hepatitis syndrome, galactosaemia (prolonged jaundice), hypterbilirubinaemia (higher bilirubin from low RBC lifespan, decreased conjugation from hepatic immaturity, breastfeeding, no gut flora to remove bile pigment); bruising and polycythaemia exacerbate
Treatment of jaundice in children?
phototherapy (UV converts bilirubin to excretable products – eye damage, loss of fluids and diarrhoea), exchange transfusion (must be heated)
Causes of resp distress in neonates?
transient tachypnoea (most common), infection, mechanical obstruction, chemical pneumonitis (meconium), pneumothorax (vigorous resus/ventilation), diaphragmatic herniation (bowel sounds in one hemithorax), premature, low weight, low surfactant (leads to atelectasis)
Complications of resp distress?
hypoxia leading to renal failure, low CO, hypotension and acidosis
Treatment of resp distress?
CPAP, high flow nasal cannula, mechanical vent., circ support, caffeine and corticosteroids (beclomethasone) in mother as increases surfactant for preterm baby and inositol promotes surfactant maturation, delay cord clamping to increase blood to baby, sats 85-93% aim; if deterioration check DOPE (Displaced ET tube, Obstruction, Pneumothorax, Equipment failure)
Causes and treatment of pneumonia?
rupture of membranes, chorioamnionitis, low weight; broad spectrum abx
Causes of persistent pulmonary hypertension?
birth asphyxia, meconium aspiration, septicaemia, RDS; cyanosed
What is bronchopulmonary dysplasia?
persistent hypoxia with difficult ventilator weaning; treat same as resp distress
What is retinopathy of prematurity?
abnormal fibrovascular proliferation/retinal vessels = retinal detachment/visual loss
Causes of retinopathy of prematurity?
premature, low weight, supplement O2
Treatment of retinopathy of prematurity?
Diode laser therapy
Causes of sepsis?
bacteria from birth canal into amniotic fluid
S+Ss sepsis?
pneumonia and secondary bacteraemia; resp distress and temp instability
Investigations and treatment of sepsis?
sepsis screen (supportive, bloods, cultures, CXR, LP); treat with benzylpenicillin, amoxicillin and gentamicin; late onset usually staph epidermis and give flucloxacillin and gentamicin; resistance = vancomycin; group B strep, risk are same as pneumonia and give prophylactic abx
Listeria causes and S+Ss?
rare but from unpasteurised milk, soft cheese and undercooked poultry; flu-like, bacteraemia, widespread rash, meconium stained liquor
Treatment for conjunctivitis?
clean with saline; neomycin to treat redness; discharge can lead to gonococcal infection; stop before vision loss; chlamydia with purulent discharge and eye swelling and use erythromycin
S+Ss herpes simplex?
4 wks with local herpetic lesions and encephalitis; acyclovir for systemic
S+Ss hypoglycaemia?
irritability, apnoea, lethargy, drowsiness, seizures (like adult);
Prevention and treatment of hypos?
early milk and regular feeding prevent; glucose>2.6 IV needed and if not work then glucagon
What is a cleft lip?
no fusion frontonasal and maxillary processes
What is a cleft palate?
palatine processes and nasal septum
Repair of cleft palate/lip?
3 months; feeding tricky, secretory otitis media common
What is Pierre Robin and treatment?
micrognathia, posterior displacement of tongue and midline cleft of soft palate; mother to quit smoking and take folic acid
S+Ss small bowel obstruction?
persistent vomiting (bile stained); meconium passed; abdo distension if more distal
Causes of small bowel obstruction?
from duodenal atresia, congenital malformations, volvulus, meconium ileus
Treatment of small bowel obstruction?
Surgery
What happens in Hirschsprung’s?
absence of ganglion cells on myenteric and submucosal plexuses in large bowel, narrowed segment; explosive faeces and wind; use rectal suction biopsy of aganglionic bit
Treatment for large bowel obstruction?
nasogastric tube passed and aspirated; IV fluids
What is examphalos?
abdo contents through umbilical ring
What is gastroschisis?
bowel through defect in anterior abdo wall
What are the 4 phases of growth?
foetal, infantile, childhood and pubertal growth spurt
What is the foetal growth phase?
size of mother and placental nutrient supply; severe IUGR = permanent short stature
What is the infantile growth phase?
18 months from nutrition, thyroid and good health; 15% of final height
What is the childhood phase of growth?
slow and steady; pituitary GH dependent (IGF-1 at epiphyses); can be decreased by chronic unhappiness; testosterone and oestradiol increase; measure = height, weight, head circ, BMI
Overview of puberty for women?
breast development (8.5-12.5yrs), pubic hair growth, menarche (2.5 yrs after puberty start)
Overview of male puberty?
testicular enlargement, pubic hair growth, rapid height
Overview of join male and female puberty changes?
acne, axillary hair, BO, mood changes; measure bone age and pelvic US if early/late
Definition of short stature?
height below 2nd centile; should be a year apart (measuring velocity = growth failure indicator)
What is the height centile?
mean of mother and father’s height +7 for boys and -7 for girls
What is constitutional delay?
variation of normal growth but still end up the same; GH treatment if insufficient growth by 4yrs
Causes of short stature?
low nutrition; coeliacs, crohns, CKD, CF and CHD; physical and emotional deprivation; hypothyroidism, GH deficiency, IGF1 deficiency, steroid excess, Cushings; GH low from primary or secondary to pituitary dysfunction (craniopharyngioma, hypothalamic tumour, head injury, meningitis)
How to identify short stature?
sitting height, subischial leg length (sitting-normal height), limited radiographic skeletal survey
Definition of micro and macrocephaly?
microcephaly = below 2nd centile, macro = above 98th centile
Causes of high ICP?
hydrocephalus, meningoencephalitis, head injury, sub/extradural bleeds, hypoxia, ketoacidosis, tumours, thrombosis
Other problems with the head in neonates?
), subdural haematoma, tumour; plagiocephaly (parallelogram head) is from babies on back and hypotonia; premature fusion of sutures = head distortion
Definition of premature sexual development?
<8yrs for girls and <9 for boys is abnormal
S+Ss premature sexual development?
precocious puberty, thelarche (breasts – between 6 months and 2yrs), pubarche, isolated premature menarche; gonadotrophin independent = excess androgens or adrenal tumours; gonadotrophin dependent = pituitary adenoma; GDPP common in girls; teste enlargement = GDPP but if only one bigger then gonadal tumour; prepubertal testes = independent
Causes of premature pubertal development?
hypothalamic hamartoma, LH receptor gene mutations, sporadic, familial male gonadotrophin-independent precocious puberty
Hx of premature sexual development?
polyuria, polydipsia, obesity, sleep, temp, high ICP, visual disturbance
Treatment of premature sexual development?
reduce rate of skeletal maturation, address psych and behavioural concerns and sometimes GnRH analogues to suppress by -ve feedback; can use inhibitors of androgens/oestrogen sometimes for independent (sometimes spironolactone)
o Differentiate adrenal hyperplasia from pubarche by urinary steroid profile, levels of blood androgens and bone age – more likely to have polycystic ovary syndrome
Treatment of delayed puberty in men?
oral oxandrolone used or IV testosterone in older boys
When need most nutrition?
1st 6 months
Why is breastfeeding good?
protective against necrotising enterocolitis and DM2 and breast/ovarian cancer for mum
Recommended intake for water, energy, protein, carbs?
• Water = 180mL/kg/day; energy = 130kal/day; protein = 2.5-3.1g/100kcal; 4.7-9g/kg; carbs = 7-14g/100kcal
Dehydration treatment?
dioralyte, IV fluids if needed using the calc (moderate to severe), use intraosseous route; pre-existing deficit = %dehydration x kg x 10
Dehydration S+Ss?
mild = 5%, moderate 10 and severe >10; weight loss, less skin turgor, tenting, shock, hypotension, high pulse, low cap refill, lethargy; careful of sudden changes in sodium levels
What is intraosseus transfusion for?
venous access (cv arrest, severe burns, prolonged status epilepticus, hypovolaemia, septic shock)
When no to use intraosseus transfusion?
don’t use for brittle bones (osteogenesis imperfecta, osteoporosis, infection, fracture at sight); goes into BM
Timeline for food in babies?
• COLOSTRUM – 1st few days of milk and more Igs; cow’s milk after 12 months and full fat until 5yrs; solid foods from 6 months
Hx for weight of babies?
week 1, 8, 12, 16 and 1 year; to ask = history of milk feeding, age of weaning, range of food, mealtime routine, 3-day food diary, weight centiles to assess weight faltering
At risk to malnutrition?
o Long-term illness most at risk; anorexia, malabsorption, increased energy requirements
Tests for malnutrition?
asked to keep 7 day food diary; nutritional assessment = anthropometry (physical proportions), labs (albumin and V+M), immunodeficiency
When to give enteral feeding?
when GI tract works; give continuously overnight
What is parenteral feeding?
all basic energy and vitamins given as solution
What to give parenteral feeding for?
for short bowel syndrome, enteropathies, motility disorder
Marasmus S+Ss?
(lack of calories – more than 3 standard deviations below weight-height ratio) = child wasted, withdrawn and apathetic
Kwashiorkor S+Ss?
(recurrent infection – low protein and aas) = generalised oedema and wasting, can develop acute infection like measles/gastroenteritis
General severe protein-calorie malnutrition?
flaky skin rash, abdo distension, angular stomatitis, sparse hair, diarrhoea, low plasma, glucose and electrolytes; often from breast milk before 12 months
Treatment of severe malnutrition?
stop hypos, hypothermia, dehydration; correct electrolytes; treat infection; micronutrient support and initiate feeds; sensory stimulation and emotional support
Problems with vit D deficiency?
rickets, osteomalacia, hypocalcaemia
Rickets and osteomalacia S+Ss?
both problems in mineralisation but rickets growing and the other one grown, when triggers hyperparathyroidism to normalise serum calcium but brittle bones; phosphate excreted and low serum so less absorption of calcium into bones
Hypocalcaemia S+Ss?
seizures, neuromuscular irritability, apnoea and cardiomyopathy); <2yrs more common and adolescence
Risks to increase vit D deficiency?
intestinal malabsorption, northern, dark skin, strict diets and prolonged PN
Diagnosis and S+Ss rickets?
in wrists, occipital/parietal bones, ankles, horizontal depression of chest, legs bowed; diagnose = diet hist, bloods, x-ray of wrist
Treatment of rickets?
D3 and correct other factors
Problems associated with obesity?
changes in bones, hypoventilation syndrome, NAFLD, gallbladder disease, DM2, HT, abnormal blood lipids and psych problems
Causes of obesity?
diet, exercise, low sleep = low leptin and high ghrelin, socioeconomic, meds; BMI>91st centile and obese >98th; <3yrs = genetics
Management of obesity?
change lifestyle (diet and exercise); change fam perceptions, orlistat (causes steatorrhoea)
Causes of childhood caries?
poor diet and oral health; psychosocial factors; streptococcus mutans and sobrinus
Prevention of childhood caries?
mouthwash, avoid sharing utensils, oral health edu, drink from own cup, wean from bottle 12-14 months, daily brushing, fluoridated water
What is posseting?
small amounts of milk with air brought up (not quite regurgitation and this isn’t quite as strong as vomiting which is forceful ejection of gastric contents); usually benign and sometimes mild GORD
Causes of vomiting?
bilous/prolonged/systemically unwell/faltering growth = RTI/UTI, pyloric stenosis, intestinal obstruction
S+Ss GORD?
regurg, distress after feeds, apnoea, pneumonia, failure to thrive, anaemia; inappropriate relaxation of LOS (fluid, diet, horizontal posture, short intraabdo length); most resolves in 12 months; common in cerebral palsy, preterm, surgery for oesophageal atresia (polyhydramnios, small stomach, cough, airway obstruction, lots of secretions, blowing bubbles, distended abdo, cyanosis, aspiration, can’t pass catheter to stomach)
Investigations of GORD?
24 hour oesophageal pH monitoring, impedance monitoring and endoscopy (biopsies)
Treatment of GORD?
thickening agents and smaller, frequent feeds; severe = H2 antagonists and PPIs then surgery; alginates
S+Ss pyloric stenosis?
vomiting after feeds (no bile and large volume) and hunger after it, dehydration and weight loss, no diarrhoea; hypo (K+, Na+ and Cl-)
Diagnosis of pyloric stenosis?
test feed, pyloric mass RUQ, US
Treatment of pyloric stenosis?
IV fluids, pyloromyotomy
Causes of abdo distension?
air = faecal impaction, air swallowing, malabsorption; ascites = nephrosis, hypoprotinaemia, cirrhosis; solid masses = wilms tumour, neuroblastoma, adrenal tumour; cysts = polycystic kidneys, hepatic, dermoid, pancreatic
S+Ss colic?
paroxysmal; inconsolable crying, drawing up knees, lots of flatus
Causes of colic?
if severe could be cow’s milk allergy; acute = appendicitis
Tests for colic?
o Check – testes, hernial orifices, hip joints, lower lobe pneumonia, DKA, UTI and pancreas
S+Ss acute appendicitis?
anorexia, vomiting, abdo pain, fever, pain from movement, guarding at McBurney’s point; faecoliths in schoolchildren; perforations high in <5yrs
Treatment of acute appendicitis?
fluid resus and abx; symptoms progress = surgery
What is intussusception?
invagination of proximal bowel into distal; usually ileum into caecum through valve; most common cause of kid GI obstruction; 3 months-2 yrs
Complications of acute appendicitis?
stretching and constricting mesentery; venous obstruction, bowel bleeding, perforation, peritonitis, gut necrosis
S+Ss appendicits?
paroxysmal colicky pain, pallor, refuse feeds, vomiting, sausage shaped mass, red jelly stool, abdo distension; abdo US and Xray
Treatment of intussusception?
IV fluids; rectal air insufflation; surgery for rest
Complications from intussuception?
could be volvulus or diverticulitis or Meckels diverticulum; green vomit need to check upper GI for malrotation
Definition of recurrent abdo pain?
interrupts ADLs and 3 months+
S+Ss recurrent abdo pain?
periumbilical; constipation = most common; others = anxiety, anal fissures, growth, GI/UTI infection (urine microscopy and culture), coeliac/crohns, thyroid, IBS (non-specific bloating, feeling of incomplete defecation, epigastric pain), abdo migraine (abdo and head pain – use triptans), duodenal/peptic ulcers (PPIs/abx for H.Pylori)
What is eosinophilic oesophagitis and treatment?
inflammatory from eosinophil activation in mucosa; atopy; use oral corticosteroids
Causes of gastroenteritis?
mainly rotavirus, others = noro, astro and adenovirus; also campylobacter jejuni (severe abdo pain), shigella (blood and pus in stool with tenesumus), cholera and e.coli (severe diarrhoea – dehydration), protozoan with giardia or cryptosporidium; normal diet after this can cause watery stool
Risks of dehydration?
<6 months with low weight, >6 stools in 24 hours, >3 vomits in 24 hours, malnutrition, can’t tolerate fluids
S+Ss hyponatraemia?
seizures
S+Ss hypernatraemia?
jittery movements, increased tone, altered consciousness, seizure, small multiple haemorrhages
o Diarrhoea in developing countries could be low zinc
o Prevent with good hygiene and education
Causes of diarrhoea?
secretory = low absorption or high secretion (watery); osmotic = watery, acidic and +ve for reducing substances; motility disorders, increased = thyrotoxicosis, decreased = intussusception; inflammatory = bloody stool
What is gastroschisis?
paraumbilical defect with evisceration (viscera extrudes) of abdo contents; find with US
Treatment of gastroschisis?
cover exposed bowel with clingfilm and keep baby warm and hydrated at birth; surgery; may take a while for GI function to resume (few weeks)
What is exampholos/omphalocele?
ventral defects of umbilical ring with abdo viscera herniation; small might only have meckel’s diverticulum but larger = stomach, liver, bladder
Treatment of exampholos/omphalocele?
protect, keep hydrated, keep warm, gastric decompression, prevent sepsis, keep CV healthy, surgical closure
S+Ss and causes of malabsorption?
abnormal stools, poor weight gain, specific nutrient deficiencies; usually 8-24 months; other signs = faltering growth, abdo distension, buttock wasting, abnormal stools, general irritability; could be coeliacs (6 weeks plus serology and endoscope with villous atrophy – enteropathy from gluten), short bowel syndrome
S+Ss persistent loose stools?
chronic non-specific diarrhoea, IBD, Crohn’s (looks like anorexia)
Diagnosis persistent loose stools?
raised inflammatory, iron deficiency anaemia, low serum albumin, endoscope
Treatment of persistent loose stools?
diet, steroids, immunosuppressants (azathioprine, mercaptopurine), anti-TNF, surgery if complications
S+Ss UC?
rectal bleeding, diarrhoea, colicky pain, weight loss, growth failure; colonoscopy diagnosis
Treatment UC?
mesalazine (mild), steroids, immunomodulation and infliximab/ciclosporin (resistant disease); 10 years colonoscopy after diagnosis
S+Ss constipation?
<3 stools per week, large and hard, rabbit droppins, distress/strain/bleeding, abdo pain, masses, overflow soiling, megarectum, anorexia
Causes of constipation?
hirschsprung’s (can’t pass meconium in 1st 24 hours, intestinal obstruction, chronic constipation, abdo distension, growth failure), coeliac, hypercalcaemia, anorectal abnormalities, hypothyroidism, diet, poor fluid, fibre intake
Treatment of constipation?
stool softeners (polyethene glycol, electrolytes), stimulant laxatives (senna), osmotic laxatives (lactulose), rehydrate with movicol; sometimes enemas
Causes of allergies?
• 40% have allergic rhinitis/asthma/eczema, 6% have food allergy; IgE (early phase and late phase response – more severe) or non-IgE mediated (delayed onset and varying clinical course); eczema and food usually in infancy and rest at primary school age
S+Ss allergies?
mainly resp) mouth breathing, allergic salute (rubbing itchy nose), pale/swollen inferior nasal turbinates, hyperinflated chest, atopic eczema on limb flexures, allergic conjunctivitis; growth checked
Causes of food allergies?
usually IgE; normally react on 1st exposure; milk, peanuts, eggs (can resolve); older = nuts and fish
IgE mediated allergies S+Ss?
urticaria, facial swelling, anaphylaxis (classic allergy reaction); skin prick test and IgE levels
Non-IgE mediated allergies S+Ss?
diarrhoea, vomiting, abdo pain, faltering growth (more like gastro problem), blood in stools in first weeks of life; intestinal biopsy and endoscopy; double-blind placebo-controlled food challenge
Management of allergies?
avoidance, training and education, non-sedating antihistamines, epinephrine for severe
Treatment of anaphylaxis?
resus; pt on back with legs raised/in position of comfort; ABCDE (e = exposure of skin); adrenaline; repeat with high flow O2 and crystalloid; salbutamol for bronchoconstriction; may have to give epi pen afterwards and always record
Causes of eczema?
atopic or non-atopic; impairment of skin barrier function; 40% in infants have IgE food allergy; skin test
Causes allergic rhinitis?
atopic or non-atopic; intermittent, persistent or mild; can be seasonal; post-nasal drip, chronically blocked nose
S+Ss rhinoconjunctivitis?
urticaria can lead to angioedema, anaphylaxis
Treatment rhinoconjunctivitis?
non-sedating antihistamines or omalizumab; topical corticosteroid nasal/eye preparations, cromoglycate eye drops, leukotriene receptor antagonists, nasal decongestants, allergen immunotherapy
Tests for child with temp >37.5 degrees?
4 weeks = axilla thermometer and after this tympanic; septic screen (blood culture, FBC/WBC, CRP and urine [UTI], blood gas, glucose) and broad spectrum abx (unless cause found); CSF = CXR, LP, rapid antigen screen, meningococcal/pneumococcal/virus PCR
Risks to increase chance of febrile child?
= ill fam, illness in community, low immunisations, recent travel, animal contact and immunodeficiency, prolonged membrane rupture, maternal carrier of group B strep, preterm labour, fetal distress, breaks in skin/mucosa, chorioamnionitis, central lines and catheters
Red flags for febrile child?
fever >38, pale/cyanosed, reduced GCS, neck stiffness, neuro signs, resp distress, bile-stained vomit and severe dehydration
Treatment for febrile child?
PN abx (broad spectrum until blood cultures confirm e.g. benzylpenicillin and gentamicin) for seriously unwell (cefotaxime), ampicillin for <1 month for listeria and antipyretics
S+Ss bacterial meningitis?
mainly <16; can have neuro impairment from it, irritable, abnormal cry, lethargy, difficulty feeding; cerebral oedema, raised ICP, decreased cerebral blood flow, fibrin deposits lower CSF absorption (hydrocephalus); meningeal signs (after septic = high temp, cold peripheries, limb/join pain, odd behaviour, skin colour change, rash) = Brudzinski and Kernig signs; LP contraindicated if cardioresp instability, raised ICP and focal neuro signs
S+Ss high ICP?
listless, irritable, drowsy, headache, diplopia, vomiting, tense fontanelle, low GCA (pupil changes, abnormal posturing), cushing’s triad (imminent coning – slow pulse, high bp, breathing abnormal)
Management of high ICP?
ABC, tilt head elevated 25 degrees, treat symptoms (seizures and high temp with O2), intubate, mannitol, dexamethasone, fluid restriction, send to neurosurgery
Types of abx used for serious infections?
Cephalosporins
Investigations bacterial meningitis?
cloudy CSF with polymorphs, increased protein and decreased glucose (TB same but lymphocytes instead of polymorphs)
Organisms causing bacterial meningitis?
Neisseria meningitis, H influenzae, strep pneumoniae, E coli, group B haemolytic strep, listeria monocytogenes, TB
Causes of viral meningitis?
mumps, echo, herpes, polio
Tests for viral meningitis?
clear CSF, lymphocytes and normal protein/glucose
Cerebral complications from meningitis?
hearing impairment, local vasculitis, subdural effusion, hydrocephalus, cerebral abscess; prophylaxis for fam = rifampicin/ciprofloxacin
Treatment for meningitis?
ceftriaxone
What is encephalitis?
direct invasion of brain by neurotoxic virus (HSV – herpes is most treatable - and enteroviruses), delayed brain swelling, slow virus infection, delayed brain swelling after dysregulated neuroimmunological response
S+Ss encephalitis?
fever, altered consciousness, seizures
Treatment of encephalitis?
HSV give acyclovir; EEG and CT/MRI
Causes of toxic shock syndrome?
S.aureus and group A strep
S+Ss toxic shock syndrome?
= fever >39, hypotension, diffuse erythematous rash, organ dysfunction and impaired consciousness
Treatment of toxic shock syndrome?
intensive care, IV ceftriaxone/clindamycin and IV ig
Treatment for meningococcal infection?
usually full recovery, early penicillin and inotropes may be needed, rifampicin prophylaxis for contacts; septicaemia = purpura rash
What can S.pneumoniae cause?
pharyngitis, otitis media, conjunctivitis, sinusitis and meningitis (basically all neck/face swellings)
S+Ss impetigo?
localised, highly contagious skin infection, staph/strep, common in eczema, lesions on face/hands (honey-crusted)
Treatment of impetigo?
topical abx in mild and flucloxacillin in severe
What is a boil?
staph aureus infection of hair follicles/sweat glands
Treatment of boils?
systemic abx and excision
S+Ss periorbital cellulitis?
fever, erythema, tenderness and oedema of eyelid
Abx for periorbital cellulitis?
ceftriaxone
S+Ss orbital cellulitis?
proptosis, reduced visual acuity, painful ocular movement
What is staphylococcal scalded skin syndrome?
separation of epidermal skin; fever, malaise, localised infection (eyes, nose, mouth)
Treatment of staphylococcal scalded skin syndrome?
manage with IV flucloxacillin, analgesia and fluid balance
Types of HSV?
type 1 = skin and lip lesions, 2 = genitals
Complications of HSV?
blepharitis (eyelid) or conjunctivitis, pneumonia and disseminated infection in immunocompromised; eczema herpeticum (widespread lesions on eczema, can get herpetic whitlows)
Treatment of HSV?
acyclovir
S+Ss roseola infantum?
gives high temp, maculopapular rash, uvulo-palatoglossal ulcers
S+Ss gingivostomatitis?
10m-3y with vesicular lesions on lips and gums, tongue and hard palate; ulceration and bleeding (painful E+D), dehydration
S+Ss varicella zoster?
; lesions on head and trunk to peripheries; infect = 4 days before rash then all lesions scabbed, droplet spread; spots blackish/blueish/coalescing then ITU and no ibuprofen
Complications varicella zoster?
= staph infection, encephalitis, purpura fulminans
Treatment serious varicella zoster?
; IV acyclovir for serious and immunocompromised with antivaricella-zost igs; use calamine lotion to soothe; shingles/herpes zoster uncommon but usually after 1st year
Complications in baby with mother with herpes zoster?
microcephaly, severe chicken pox, convulsions, cerebral hypoplasia etc
S+Ss EBV?
oral spread; older = fever, malaise, tonsillitis, lymphadenopathy, petechiae on soft palate, splenomegaly, maculopapular rash, jaundice
Diagnosis EBV?
atypical lymphocytes, positive monospot test or seroconversion
CMV mode of transition?
saliva, genital secretions, breastmilk
CMV immunocompromised S+Ss?
retinitis, pneumonitis, bone marrow failure, encephalitis, hepatitis, oesophagitis, enterocolitis; high fever and malaise for few days then generalised macular rash
Treatment for CMV?
ganciclovir
S+Ss human parvovirus B19?
slapped cheek syndrome and in spring; respiratory secretions transmission; asymptomatic or fever, malaise, headache and myalgia; aplastic crisis in chronic haemolytic anaemia; sometimes hydrops fetalis
S+Ss enteroviruses?
loose stools, vomiting, rash non-blanching then ceftriaxone unless sepsis excluded; can cause myocarditis/pericarditis
Mode of admission for enteroviruses?
faecal-oral or resp droplets
What is herpangina?
painful lesions causing tricky swallowing and fever
What is pleurodynia?
fever, pleuritic chest pain, muscle tenderness
S+Ss measles?
(7-12 days incubation) = fever, runny nose (coryza), cough, conjunctivitis, marked malaise, Koplik spots and maculopapular rash
Complications of measles?
otitis media, encephalitis and subacute sclerosing panencephalitis (7-13yrs after = behaviour changes, myoclonus, choreoatheotosis, dystonia, dementia, coma)
Treatment of measles?
isolation, supportive and ribavirin in immunocompromised
S+Ss mumps?
; incubation 15-24 days; fever (stops after 3-4 days), malaise
Parotitis S+Ss?
(infective 7 days before and 9 days after), E+D difficult; plasma amylase high and orchitis common
Rubella S+Ss?
mild illness, low grade fever, maculopapular rash on face (fades 3-5 days – infective 5 days before and after rash), suboccipital lymphadenopathy; incubation 15-20 days; resp route; diagnosis serology
S+Ss and overview kawasaki?
systemic vasculitis (coronary artery aneurysm), Japanese mainly; high inflammatory markers and platelets rise in 2nd week; conjunctivitis, red mucous membranes, cervical lymphadenopathy, red palms, eyes and soles, lips and peeling of skin later, high fever
Treatment kawasaki?
IV ig to lower aneurysm risk, aspirin or warfarin; inflammation and fever use corticosteroids, infliximab or ciclosporin
Tests for HIV in babies?
> 18 months = ab test but <18 month = DNA PCR as get mother’s IgGs from breast milk so false positives
S+Ss HIV in kids?
mild = lymphadenopathy, parotid enlargement; moderate = recurrent bacterial infections, candidiasis, diarrhoea, thrombocytopenia, hepatospleomegaly; lymphocytic interstitial pneumonia
Treatment of HIV?
HAART (antiretroviral therapy) but before this use PENTA, HIV viral load, CD4 count, prophylaxis of PCP with cotrimoxazole, vaccines, weight/development/clinical monitoring
Factors reducing maternal transmission of HIV?
ART in pregnancy, PEP after birth, no breastfeeding, C-section
S+Ss lyme disease?
= erythema migrans and expanding lesion (bullseye), fever, headache, malaise, myalgia, arthralgia, lymphadenopathy; dissemination = rare (2+ colonised sites) but can cause CN palsies, meningitis, arthritis, carditis
Treatment of lyme disease?
> 12 use doxycycline and amoxicillin
S+Ss URTI?
difficulty feeding, febrile seizures, acute asthma exacerbations, nasal discharge and blockage
Common URTIs?
rhinovirus, coronavirus, resp syncytical virus, group A beta-haemolytic, enterovirus, adenovirus
Treatment URTIs?
paracetamol/ibuprofen
What is pharyngitis?
pharynx and soft palate with lymphadenopathy
What is tonsillitis?
pharyngitis with exudate and intense inflammation
S+Ss tonsillitis?
headache, abdo pain, white exudate, cervical lymphadenopathy (bacterial)
Treatment tonsillitis?
10 day course abx
S+Ss scarlet fever?
group a strep, 5-12 yrs, fever before tonsillitis, headache, sandpaper maculopapular rash
Causes of acute otitis media?
RSV, rhinovirus, pneumococcus, H.influenzae, Moraxella catarrhalis
S+Ss acute otitis media?
bright red and bulging on otoscope; decreased hearing, eardum dull and retracted, fluid; conductive hearing loss
Treatment otitis media?
anaesthesia with P+I
Causes of stridor?
most common from laryngeal and tracheal infection (mainly viral croup and sometimes parainfluenza), foreign body, bacterial tracheitis, epiglottitis
Severity of stridor assessed?
stridor character and degree of chest retraction also cyanosis and ABCD
S+Ss complete resp obstruction?
central cyanosis, drooling, reduced consciousness
Causes of acute stridor with no infection?
anaphylaxis/foreign body; if nothing works then think bacterial tracheitis (mucosal sloughing that can’t be cleared and exudate)
S+Ss croup?
6 months-6 yrs; autumn; coryza (catarrh) and fever then hoarseness, barking cough, harsh stridor, worse at night, subglottic oedema, inflammation ad exudate
Treatment of croup?
oral dexamethasone/prednisolone and severe = nebulised adrenaline and O2
S+Ss epiglottitis?
intense swelling with septicaemia; emergency; from Hib; 1-6yrs; high fever, ill, painful throat, soft inspiratory stridor, resp difficulty, sitting immobile
Treatment epiglottitis?
don’t lie down/spatula in throat; intubate, blood culture, IV abx (cefuroxime) 3-5 days, rifampicin for fam, may need tracheostomy if occluded too much
S+Ss diphtheria?
usually starts with tonsillitis and sometimes membrane over fauces (back of mouth leading to pharynx); can get polyneuritis mainly with CNs, shock from myocarditis, toxaemia or cardiac conduction system involvement; other signs = dysphagia, muffled voice, bronchopneumonia, brassy cough then airway obstruction
Diagnosis diphtheria?
swab culture of below pseudomembrane
Treatment diphtheria?
diphtheria antitoxin and erythromycin for 7 days
Causes of wheeze?
mucosal inflammation, swelling and mechanical obstruction
S+Ss bronchiolitis?
1-9months – LRTI, coryza, cough, fever, tachypnoea, wheeze, inspiratory crackles, apnoea sometimes cyanosis
What is RSV?
respiratory syncytial virus
Wheeze S+Ss?
coryzal, dry wheezy cough, SOB, feeding tricky, recurrent apnoea (serious in young), tachypnoea/cardia, chest hyperinflation, sub/intercostal recession, fine end inspiratory crackles, high-pitched wheezes
Treatments wheeze?
O2 sats and CXR; give steroids and nebulised adrenaline and only ribavirin for immunocompromised
When to refer to a specialist with wheeze?
apnoea, <90% sats, low fluid intake, severe resp distress; give humidified O2, NG/IV fluids, CPAP and MV sometimes, reduce infectivity; most recover in 2 wks, RSV v infective, permanent damage sometimes in adenovirus
S+Ss viral wheezing?
episodic wheezing, multiple trigger wheeze and asthma
S+Ss asthma?
– polyphonic and diurnal variation; not usually hyperinflation unless attack
Treatment for asthma?
LABAs effective for 12 hours; prednisolone/beclametasone; salbutamol = spacers in kids; ipratropium bromide (anticholinergic bronchodilator) after other bronchodilators don’t work; motelukast/theophylline = leukotriene receptor antagonists; anti-IgE with omalizumab in severe
When to hospitalise in asthma?
hospitalise if no improvement after high bronchodilator dose, exhausted, silent chest, cyanosis, hypotension, PEFR <33%, <50% peak flow, <92% sats = bronchodilators, steroids, O2, IV mg sulfate/salbutamol/aminophylline; if emergency use all the above treatments and consider CPAP
RFs TB?
Overseas contacts and HIV?
S+Ss TB?
anorexia, low fever, failure to thrive, malaise, cough common
Diagnosis TB?
tuberculin tests, blood, ziehl-neelson stain of sputum; miliary spread rare but dangerous
Treatment of TB with RIPE?
rifampicin, isoniazid, pyrazinamide, ethambutol; co-trimoxazole prophylaxis if with HIV for pneumocystitis
Indications of a dry cough with prolonged expiratory phase?
narrowing of small-moderate sized airways
Indications from a barking cough?
tracheal inflammation
Indications from a moist cough?
LRTI
Define a whooping cough, cough?
paroxysmal/spasmodic cough (worse at night and can be vomit) followed by inspiratory whoop
S+Ss whooping cough?
paroxysm = goes red and blue and mucous out mouth, sometimes epistaxis and conjunctival haemorrhages (3 months); cough only last 25 days and if after might be lobar collapse; pneumonia, seizures and bronchiectasis can happen but rare
Diagnosis whoopin cough?
perinasal swab, PCR, marked lymphocytosis
Prevention of whooping cough?
close contacts get macrolide prophylaxis (also for treat), vaccination, no parental smoking
Causes of pneumonia?
newborns = group B strep and gram -ve enterococci; infants = RSV, strep pneumoniae, H.influenzae; 5+ = mycoplasma pneumoniae
S+Ss pneumonia?
fever, cough, tachypnoea, lethargy, poor feeding, unwell; pleural irritation (bacterial), crackles; sometimes empyema
Diagnosis pneumonia?
CXR, nasopharyngeal aspirate, cultures if bad
Treatment of pneumonia?
O2 if <92%, analgesia, new-borns = broad spectrum abx, older = amoxicillin, chronic = high dose co-amoxiclav with physio
Pathophysiology CF?
defective CF transmembrane conductance regulator (CFTR gene – chromosome 7); bad ion transport across epithelium, impaired cilia function, retention of mucopurulent secretions; pancreatic ducts blocked, low defence against infections and dysregulated inflammatory response; pancreatic enzyme blocked so malabsorption (steatorrhea)
S+Ss CF?
nasal polyps and sinusitis, failure to thrive and slow growth, meconium ileus (can’t pass stool in 1st 2 days of life; older = DM, cirrhosis, pneumothorax and sterility in males, chest infections
Screening infants for CF?
immunoreactive trypsinogen, low faecal elastase (pancreatic insufficiency), sweat test for chloride (can have false +ve if really young, some diseases or false -ve if oedema), spirometry, 95% die of resp failure; older = spirometry
Treatment CF?
reg = no symptoms; physio twice/day, exercise, continuous prophylactic abx, nebulised DNase or hypertonic solution (reduces sputum viscosity), azithromycin, lung transplant sometimes, high calorie diet and enzymes (pancrex) and omeprazole increases absorption, gastrotomy overnight, if infection gentamicin with ticarcillin
What is primary ciliary dyskinesia?
abnormal cilia function/structure; low mucociliary clearance, lots of URTI/LRTI
S+Ss primary ciliary dyskinesia?
recurrent productive cough, purulent nasal discharge, chronic ear infections, ½ have dextrocardia, obstructive sleep apnoea
Assessment of primary ciliary dyskinesia?
O2 sats, electrophysical assessment
Normal HSs in paeds?
asymptomatic, soft blowing murmur systolic and left sternal edge, Still’s murmur; no symptoms of cardiac abnormalities
HF S+Ss?
SOB, sweating, poor feeding, recurrent chest infections, poor weight gain, tachypnoea/cardia, murmur, cardiomegaly, hepatomegaly, cold peripheries, acidosis
Investigations HF?
FBC, CXR, paO2, ECG, ECHO, cardiac catheter
