Paediatric History Taking and Management Flashcards

Question

How can you differentiate clinically between HSP and HUS?

Answer 1

both present with fever, abdo pain, bloody diarrhoea and a non blanching rash purpuric rash over extensor surfaces and buttocks in HSP V widespread small petechial rash in HUS joint pain and haematuria in HSP V not present in HUS

Answer 2

Rash - when did it come on, has it changed over time, is it itchy or sore? triggers? have they been poorly recently? high temperature, headache, photophobia, neck stiffness? abdominal pain, N+V, diarrhoea (bloody? from onset or did it turn bloody?), joint pain? blood in urine? nose bleeds? (ITP) any recent exposure to farm animals? (HUS) B symptoms - ALL!!!

Answer 3

Jaundice extending beyond the physiological two weeks Dark urine and pale stools Appetite and growth disturbance, (however, may be normal in some cases) Hepatomegaly with splenomegaly Cardiac murmurs if associated cardiac abnormalities present

Answer 4

Serum bilirubin : Total bilirubin may be normal, whereas conjugated bilirubin is abnormally high LFTs including serum bile acids and aminotransferases : usually raised but cannot differentiate causes of neonatal cholestasis Serum alpha 1-antitrypsin: Deficiency may be a cause of neonatal cholestasis Sweat chloride test: check for CF Ultrasound of the biliary tree and liver: May show distension and tract abnormalities

Answer 5

Surgical intervention is only definitive tx Medical intervention includes antibiotic coverage and bile acid enhancers following surgery Complications : Unsuccessful anastomosis formation Progressive liver disease Cirrhosis with eventual hepatocellular carcinoma

Answer 6

acute bronchiolar inflammation Usually RSV (respiratory syncytial virus) other causes: mycoplasma, adenoviruses may be secondary bacterial infection coryzal symptoms (including mild fever) precede: dry cough increasing breathlessness wheezing, fine inspiratory crackles feeding difficulties

Answer 7

bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis

Answer 8

immunofluorescence of nasopharyngeal secretions may show RSV Management is largely supportive: humidified oxygen is given via a head box nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth suction is sometimes used for excessive upper airway secretions

Answer 9

fever initially itchy rash starting on head/trunk before spreading - macular then papular then vesicular systemic upset is usually mild infectivity = 4 days before rash, until 5 days after the rash first appeared

Answer 10

keep cool, trim nails calamine lotion school exclusion: until lesions have crusted over (usually about 5 days after the onset of the rash) immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin (VZIG) If chickenpox develops then IV aciclovir should be considered

Answer 11

Secondary bacterial infection of the lesions - NSAIDs may increase risk, group A strep may cause necrotising fasciitis pneumonia encephalitis (cerebellar involvement may be seen) disseminated haemorrhagic chickenpox

Answer 12

Idiopathic - most common dehydration low-fibre diet medications: e.g. Opiates anal fissure over-enthusiastic potty training hypothyroidism Hirschsprung's disease hypercalcaemia learning disabilities

Answer 13

Reported from birth or first few weeks of life Passage of meconium > 48 hours ‘Ribbon' stools Abdominal distension Faltering growth is an amber flag Previously unknown or undiagnosed weakness in legs, locomotor delay Signs of maltreatment

Answer 14

symptoms of severe constipation overflow soiling faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)

Answer 15

If faecal impaction is present polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment Can add a stimulant laxative after 2 weeks if needed consider regular toileting and non-punitive behavioural interventions consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents

Answer 16

Infants not yet weaned (usually < 6 months) bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs breast-fed infants: constipation is unusual and organic causes should be considered Infants who have or are being weaned offer extra water, diluted fruit juice and fruits if not effective consider adding lactulose

Answer 17

regurgitation and vomiting diarrhoea urticaria, atopic eczema 'colic' symptoms: irritability, crying wheeze, chronic cough rarely angioedema and anaphylaxis

Answer 18

Diagnosis is often clinical (e.g. improvement with cow's milk protein elimination) Ix: skin prick/patch testing total IgE and specific IgE (RAST) for cow's milk protein Mx: Management if formula-fed = extensive hydrolysed formula (eHF) milk is the first-line replacement formula Management if breastfed = continue breastfeeding eliminate cow's milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers

Answer 19

also known as laryngotracheitis URTI characterised by stridor which is caused by a combination of laryngeal oedema and secretions Usually caused by parainfluenza virus typically affects children aged 6 months to 2 years

Answer 20

stridor barking cough (worse at night) fever coryzal symptoms

Answer 21

single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity high-flow oxygen nebulised adrenaline

Answer 22

Features may coincide with the introduction of cereals (i.e. gluten) failure to thrive diarrhoea abdominal distension older children may present with anaemia many cases are not diagnosed to adulthood

Answer 23

jejunal biopsy showing subtotal villous atrophy and crypt hyperplasia First line blood tests: Total IgA levels (to exclude IgA deficiency) Anti-tissue transglutaminase antibodies (anti-TTG) (anti-endomysial and anti-gliadin antibodies are also useful)

Answer 24

Down's syndrome autoimmune thyroid disease IDDM

Answer 25

Nutritional deficiencies Anaemia Osteoporosis Hyposplenism Ulcerative jejunitis Enteropathy-associated T-cell lymphoma (EATL) Non-Hodgkin lymphoma Small bowel adenocarcinoma

Answer 26

Raised respiratory rate Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles Intercostal and subcostal recessions Nasal flaring Head bobbing Tracheal tugging Cyanosis (due to low oxygen saturation) Abnormal airway noises

Answer 27

a monoclonal antibody that targets the respiratory syncytial virus A monthly injection is given as prevention against bronchiolitis caused by RSV to high risk babies, such as ex-premature and those with congenital heart disease

Answer 28

diarrhoea usually lasts for 5-7 days and stops within 2 weeks vomiting usually lasts for 1-2 days and stops within 3 days

Answer 29

Appears to be unwell or deteriorating Decreased urine output Altered responsiveness (for example, irritable, lethargic) Sunken eyes Dry mucous membranes Tachycardia Tachypnoea Reduced skin turgor Normal peripheral pulses, cap refill and bp

Answer 30

Decreased level of consciousness Cold extremities Pale or mottled skin Tachycardia Tachypnoea Weak peripheral pulses Prolonged capillary refill time Hypotension

Answer 31

jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma

Answer 32

you suspect septicaemia or there is blood and/or mucus in the stool or the child is immunocompromised consider when: the child has recently been abroad or the diarrhoea has not improved by day 7 or you are uncertain about the diagnosis of gastroenteritis

Answer 33

give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts continue breastfeeding consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)

Answer 34

most common cause in the developed world is cows' milk intolerance toddler diarrhoea: stools vary in consistency, often contain undigested food coeliac disease post-gastroenteritis lactose intolerance

Answer 35

It is thought that some children may have a fast gut transit time (the time it takes for the food to move through the bowel). As part of the role of the bowel is to absorb water, if things more through too quickly, a lot of the fluid remains in the poo. avoid sugary drinks and fruit squashes as they can irritate the gut need enough fat in their diet - slows down movement in the gut, things like rice pudding and full fat milk

Answer 36

Gastro-oesophageal reflux

Answer 37

advise regarding position during feeds - 30 degree head-up ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds a trial of thickened formula a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents

Answer 38

distress failure to thrive aspiration frequent otitis media in older children dental erosion may occur

Answer 39

coxsackie A16 and enterovirus mild systemic upset: sore throat, fever oral ulcers followed later by vesicles on the palms and soles of the feet symptomatic mx reassurance no link to disease in cattle children do not need to be excluded from school

Answer 40

Migraine without aura

Answer 41

ibuprofen triptans may be used in children >= 12 years but follow-up is required

Answer 42

invagination of one portion of the bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region Features: intermittent, crampy, progressive abdominal pain inconsolable crying during paroxysm the infant will characteristically draw their knees up and turn pale vomiting bloodstained stool - 'red-currant jelly' - is a late sign sausage-shaped mass in the right upper quadrant

Answer 43

Ix: USS: target like mass Mx: reduction by air insufflation under radiological control , peritonitis = surgery

Answer 44

a prolonged jaundice screen is performed: urine for MC&S FBC, U&Es and LFTs TFTs conjugated and unconjugated bilirubin: look for biliary atresia Direct antiglobulin test (Coombs' test) Blood film

Answer 45

prematurity ( immature liver function) congenital infections e.g. CMV, toxoplasmosis biliary atresia breast milk jaundice (jaundice is more common in breastfed babies) galactosaemia hypothyroidism UTI

Answer 46

Phototherapy is usually adequate to correct neonatal jaundice. Extremely high levels may require an exchange transfusion.

Answer 47

high-grade fever which lasts for > 5 days conjunctival injection bright red, cracked lips strawberry tongue cervical lymphadenopathy red palms of the hands and the soles of the feet which later peel complication : coronary artery aneurysm

Answer 48

FBC: anaemia, leukocytosis and thrombocytosis LFTs: hypoalbuminemia and elevated liver enzymes Inflammatory markers (particularly ESR) are raised Urinalysis can show raised WCC Echocardiogram can demonstrate coronary artery pathology

Answer 49

High dose aspirin to reduce the risk of thrombosis IV immunoglobulins to reduce the risk of coronary artery aneurysms

Answer 50

seen in infants - the supraglottic larynx is structured in a way that allows it to cause partial airway obstruction. This leads to a chronic stridor on inhalation, when the larynx flops across the airway as the infant breathes in may resolve on its own or rarely requires tracheostomy

Answer 51

disposable nappies are preferable to towel nappies expose area to air when possible apply barrier cream (e.g. Zinc and castor oil) mild steroid cream (e.g. 1% hydrocortisone) in severe cases management of suspected candidal nappy rash is with a topical imidazole. Cease the use of a barrier cream until the candida has settled

Answer 52

abdo x-ray dilated bowel loops (often asymmetrical in distribution) bowel wall oedema pneumatosis intestinalis (intramural gas) portal venous gas pneumoperitoneum resulting from perforation air both inside and outside of the bowel wall (Rigler sign) air outlining the falciform ligament (football sign)

Answer 53

Grunting and other signs of respiratory distress are the most common presentation Early-onset neonatal sepsis is most commonly caused by group B streptococcus Late- onset can be caused by Staphylococcus epidermidis, Pseudomonas aeruginosa, Klebsiella and Enterobacter

Answer 54

Ix: * Urine MCS * FBC, CRP * Blood culture * Blood gases: metabolic acidosis is particularly concerning for neonatal sepsis, particularly a base deficit of ≥10 mmol/L * LP Mx: IV benzylpenicillin with gentamicin

Answer 55

M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic)

Answer 56

High caecum at the midline bilious vomiting and obstruction (volvulus) Ix: upper GI contrast study and USS Mx: laparotomy, if volvulus is present (or at high risk of occurring) then a Ladd's procedure is performed

Answer 57

typically obese male adolescents pain is often referred to the knee limitation to internal rotation Bed rest and non-weight bearing internal fixation: typically a single cannulated screw placed in the centre of the epiphysis

Answer 58

degenerative condition affecting the hip joints of children (typically 4-8 years) , due to avascular necrosis of the femoral head hip pain: develops progressively over a few weeks limp stiffness and reduced range of hip movement x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Answer 59

osteoarthritis premature fusion of the growth plates

Answer 60

To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities

Answer 61

Chondromalacia patellae

Answer 62

Osgood-Schlatter disease (tibial apophysitis)

Answer 63

Irritant dermatitis most common cause, irritant effect of urinary ammonia and faeces, creases are characteristically spared Candida dermatitis erythematous rash which involve the flexures and has characteristic satellite lesions Seborrhoeic dermatitis erythematous rash with flakes, may be coexistent scalp rash Psoriasis erythematous scaly rash also present elsewhere on the skin Atopic eczema Other areas of the skin will also be affected

Answer 64

otitis media: the most common complication pneumonia: the most common cause of death encephalitis: typically occurs 1-2 weeks following the onset of the illness)

Answer 65

Ix: IgM antibodies Mx: mainly supportive notifiable disease → inform public health

Answer 66

prodromal phase: irritable, conjunctivitis, fever Koplik spots: typically develop before the rash white spots (‘grain of salt’) on the buccal mucosa rash: starts behind ears then to the whole body discrete maculopapular rash becoming blotchy & confluent desquamation that spares the palms and soles may occur after a week

Answer 67

RNA paramyxovirus infective from prodrome until 4 days after rash starts incubation period = 10-14 days

Answer 68

MMR within 72 hours

Answer 69

Any signs of raised ICP: focal neurological signs papilloedema significant bulging of the fontanelle DIC signs of cerebral herniation meningococcal septicaemia:blood cultures and PCR for meningococcus instead

Answer 70

orchitis - occurs four or five days after the start of parotitis hearing loss - usually unilateral and transient meningoencephalitis pancreatitis

Answer 71

Ix: PCR testing on a saliva swab. The blood or saliva can also be tested for antibodies to the mumps virus Mx: rest paracetamol for high fever/discomfort notifiable disease

Answer 72

fever malaise, muscular pain parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70%

Answer 73

14-21 days