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Paediatrics Flashcards

1
Q

Describe the components of a paediatric clinical history

A

Name
Age
PC
HPC - origin, duration, progress
Birth hx - full term, normal delivery, weight, SCBU
Feeding hx - breast/bottle, weaned, weight gain
Immunisation hx - up to date
Developmental hx - milestones, concerns, school performance
SH - nursery/school, home environment, travel
FH - conditions, genogram, consanguinity

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2
Q

Describe relevant questions in a systems review

A

Cardioresp - tachypnoea, grunting, wheeze, cyanosis, smokers in family, cough (barking/whooping)
GI - appetite, vomiting, feeding, jaundice, bleeding, weight, passed meconium
Genitourinary - wet nappies, smell, haematuria
ENT - noisy breathing, ear infections, hearing
Skin - rash, birthmarks

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3
Q

Describe the components of a paediatric examination

A

Vital signs - temp. O2 sats, HR, RR, cap. refill,

Plot and interpret growth chart

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4
Q

Describe the components of a paediatric respiratory examination

A

Observation - respiratory distress (nasal flaring, recession, accessory muscle use, wheeze, stridor, grunting), restless, drowsy, cyanosis, finger clubbing
Palpation - expansion, trachea (central), apex beat, chest deformity, percussion
Auscultation - air entry, breath sounds, expiratory wheeze, transmission of upper airway sounds

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5
Q

Describe the components of a paediatric ENT examination

A

Ear - grey, shiny/red, bulging/dull, retracted
Nose - inflammation, obstruction, polyps
Throat - enlarged, red tonsils

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6
Q

Describe the components of a paediatric cardiology examination

A

Observation - central cyanosis, breathless/pale/sweaty, finger clubbing, failure to thrive
Palpation - apex beat, RVH, thrills, hepatomegaly, pulse (radial/femoral)
Auscultation - murmurs (diastolic = pathological), BP, CRT

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7
Q

Describe the components of a paediatric abdominal examination

A

Observation - nutritional status (BMI, upper arm circumference), jaundice, pallor, abdominal distension, wasting of buttocks (coeliac), genitalia (hypospadias, undescended testes, hydrocele, hernia)
Palpation - tenderness, organomegaly (spleen, kidneys), masses
Auscultation - bowel sounds

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8
Q

Describe the components of a paediatric neurological examination

A

Observation - conscious level, posture, movement, gait, limb deformity, contractures, growth, head circumference, shoes (unequal wear)
Tone - hypotonia, spasticity (toe walking)
Power
Sensation
Reflexes - *plantar reflex is up until ~8mo
Coordination
Developmental exam

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9
Q

Describe the NICE guidelines on fever in children

A

Green = normal colour, responds normally to social cues, smiles, stays awake, not crying/strong cry. normal skin and eyes, moist mucous membranes

Amber = pale, not responding normally to social cues, no smile, wakes only with prolonged stimulation, decreased activity, nasal flaring, tachypnoea, tachycardia, CRT >3s, dry mucous membranes, poor feeding, low urine output, temp. >38, rigors, fever >5 days, non weight bearing limb

Red = pale/mottled/ashen/blue, no response to social cues, appears ill to HCP, does not wake, weak high pitched continuous cry, grunting, reduced skin turgor, age <3mo with temp. >38, non blanching rash, bulging fontanelle, neck stiffness, focal neurology

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10
Q

Define the terms prematurity, extremely premature, low birth weight, very low birth weight, extremely low birth weight and small for gestational age

A 
Prematurity = <37 weeks
Extremely premature = <28 weeks
Low birth weight = <2.5kg
Very low birth weight = <1.5kg
Extremely low birth weight <1kg
SGA = <10th centile
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11
Q

List risk factors for prematurity

A

Maternal - smoking, alcohol, pre-eclampsia, young age
Uterine - structural abnormality, cervical incompetence
Fetal - multiple, distress, infection, chromosomal abnormality
Placental - praevia, abruption, insufficiency

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12
Q

Describe the APGAR score

A

Appearance - pink/blue/white (2/1/0)
Pulse - >100/<100/absent
Grimace (reflex to suction) - cough or sneeze/grimace/none
Activity (floppy) - good flexion/some flexion/limp
Respiration - strong cry/irregular/absent
*normal score at 1 min = 7/10

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13
Q

List and describe the management of some common newborn respiratory problems

A

TTN - often in C-section baby –> dry and give oxygen
RDS - surfactant deficiency, ground glass appearance on CXR –> dexamethasone, surfactant
Apnoea - not breathing for >20s –> caffeine
Bronchopulmonary dysplasia - chronic oxygen requirement for >28 days or 36 weeks corrected
Meconium aspiration syndrome - seen on Xray –> suction

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14
Q

List and describe the management of some common newborn cardiac problems

A

PDA –> NSAIDs (indomethacin), ligation

Hypotension –> ITU

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15
Q

List and describe the management of some common newborn haematology problems

A

Anaemia - iatrogenic (multiple blood tests), underdeveloped kidneys producing low EPO –> iron tablets, transfusions

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16
Q

List and describe the management of some common newborn gastrointestinal problems

A

NEC - breast milk is protective, abdominal distension, bloody stools –> ABx, NBM, surgery if perforated
Inguinal hernia –> surgery due to strangulation risk

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17
Q

Describe causes and management of neonatal jaundice

A

<24h - Rh/ABO incompatibility, G6PD, spherocytosis, sepsis
24h-2 weeks - breastfeeding, physiological, dehydration
>2 weeks - biliary atresia, hypothyroidism, pyloric stenosis
Mx = watch and wait/phototherapy/exchange transfusion (*risk of kernicterus)

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18
Q

What precautions must be taken when a neonate undergoes phototherapy

A

Cover eyes

Ensure adequate fluids (IV)

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19
Q

Describe the clinical presentation and management of biliary atresia

A

CFs - jaundice, yellow urine, chalky, white stool, splenomegaly
Ix - HIDA scan
Mx - surgery (Kasai procedure), liver transplantation

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20
Q

List different causative agents for neonatal infection

A 
Early onset (<48h) - GBS, listeria (maternal infection/PROM)
Late onset (>48h) - staph aureus, E. coli (central line, catheter infection)
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21
Q

List and describe the management of some common newborn endocrine/metabolic problems

A

Jaundice
Hypoglycaemia (BM <2.6) –> IV 2mls/kg of 10% dextrose
Thermoregulation –> incubator box
Osteopenia

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22
Q

List and describe the management of some common newborn neurological problems

A 
Intraventricular haemorrhage (IVH) - cranial USS, increased cerebral palsy risk
Hypoxic ischaemic encephalopathy - cord blood pH <7.0 --> therapeutic hypothermia (cooling to 33.5 for 72h)
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23
Q

Describe causes and management of retinopathy of the newborn

A

Screen neonates <1.5kg or born <32 weeks
Caused by high oxygen - keep neonate at <92% sats
Mx = laser ablation

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24
Q

List benefits of breastfeeding

A

Maternal - bonding, lower risk of PPH (oxytocin release), lowers risk of breast/ovarian cancer, contraceptive effect, low cost
Fetal - receive maternal IgG, lowers risk of NEC, long term health benefits

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25
List some negatives of breastfeeding
Cracked nipples Increased sodium loss --> dehydration Higher costs (formula)
26
List contraindications of breastfeeding
HIV +ve mother Active TB (+ treatment) Illicit drug use
27
List medications that are contraindicated in breastfeeding
``` Amiodarone Antineoplastic (e.g. methotrexate) Chloramphenicol Lithium Tetracyclines ```
28
List signs of a healthy breastfed baby
Wet nappies Pooing regularly Gaining weight (30-40g/day)
29
What is the NIPE?
Newborn and Infant physical examination - performed within 72h of delivery General - weight, length, head circumference, tone, reflexes Skin - jaundice, pallor, cyanosis, erythema toxicum rash, birthmarks Head - anterior fontanelle, chignon Eyes - red reflex, jaundice, coloboma Mouth - cleft lip/palate, tongue tie Chest - heart murmur, respiratory distress Abdomen - distention, defects, organomegaly Hips/limbs - pulses, barlow & ortolani, clubfoot Genitalia/anus - ambiguity, undescended testes Spine - spina bifida
30
Describe clinical presentation, investigations and management of bronchiolitis
<1 year, viral (RSV, parainfluenza, rhinovirus), lasts 7-10 days CFs - wheeze, crackles, fever, poor feeding, <92% sats Ix - CXR (hyperinflation, collapse/consolidation) Mx - supportive (oxygen, feeding)
31
List the admission criteria for bronchiolitis
Apnoea <92% sats RR >70 Decreased oral intake
32
Describe the clinical presentation, management and long term advice given in cystic fibrosis
Cystic fibrosis = genetic disorder causing defect in CFTR chloride channel --> thick mucus CFs - Guthrie heel prick (screening), sweat test (>60mmol/L Cl-), meconium ileus, failure to thrive, (recurrent chest) infections Ix - CXR (overinflation, hilar enlargement, ring shadows) Mx - ABx, steroid therapy, nebulised DNAse, regular bronchodilators, chest physiotherapy Long term advice - prophylactic ABx, immunisations (pneumococcal, influenza)
33
List common organs affected in cystic fibrosis
Lungs - recurrent infections Pancreas - malabsorption, pancreatic failure (requires vitamins ADEK, pancreatic enzymes), diabetes Liver - cirrhosis Gallbladder - biliary disease Reproductive - sub fertility (absence of vas deferens in men)
34
Describe clinical presentation, investigations and management of croup
Croup = swelling of trachea 6mo-6 years, viral (RSV, parainfluenza) CFs - seal like barking cough, stridor, sternal recession, agitation, lethargy, coryza illness, usually self limiting Mx = dexamethasone oral/IV
35
Describe clinical presentation, investigations and management of epiglottitis
Epiglottitis = inflammation of epiglottis 1-6 years, haemophilus influenza B bacteria (*immunisation history) CFs - 4Ds (drooling, dysphonia, dyspnoea, distress) Ix - DO NOT EXAMINE Mx - intubate, IV ABx, steroids
36
Describe clinical presentation, investigations and management of tonsilitis
Tonsilitis = inflammation of tonsils Often viral (adenovirus, rhinovirus), bacterial (group A b-haemolytic streptococcus) CFs - sore throat, red swollen tonsils, odynophagia, fever, malaise, lymphadenopathy Mx - supportive (paracetamol, ibuprofen) or ABx (penicillin V), tonsillectomy
37
Describe the Fever PAIN score
``` Predicts likelihood of strep. throat: Fever in past 24h Purulent tonsils (exudate) Attend rapidly (symptoms <3 days) Inflamed tonsils No cough ``` ``` 0-1 = no ABx 2-3 = delayed ABx\ >4 = ABx ```
38
Describe the NICE guidelines regarding tonsillectomy
Sore throat is due to acute tonsillitis The episodes of sore throat are disabling and prevent normal functioning >7 in one year OR 5 in two years OR 3 in three years
39
Describe clinical presentation, investigations and management of whooping cough
Whooping cough = highly infectious bacterial (bordella pertussis) infection *infants not fully vaccinated CFs - paradoxical coughing spasms during expiration followed by a sharp intake of breath, apnoea Ix - mostly clinical, lymphocytosis, nasal swab culture Mx - supportive, ABx (erythromycin) *advise cough may continue for months
40
List cyanotic heart defects
Transposition of the Great Arteries (TGA) | Tetralogy of Fallot (ToF)
41
List acyanotic heart defects
VSD PDA Coarctation of the aorta (CoA)
42
Describe clinical presentation, investigations and management of Transposition of the Great Arteries
TGA = two parallel unconnected circulations (*only viable if ASD/PDA/VSD = bidirectional shunting) CFs - cyanosis in 24h, tachypnoea, tachycardia, failure to thrive (3-6 weeks), prominent right ventricular heave, systolic murmur (if VSD), no respiratory distress Ix - blood gas (metabolic acidosis, lactate), ECHO, CXR (egg on a string = narrowed mediastinum, cardiomegaly) Mx - PG infusion (keeps duct patent), correct metabolic acidosis, surgery (<4 weeks)
43
List some maternal risk factors for fetal TGA
``` Age >40 Diabetes mellitus Rubella infection Poor nutrition Alcohol ```
44
Describe clinical presentation, investigations and management of Tetralogy of Fallot
ToF = VSD + pulmonary stenosis + RVH + overriding aorta CFs - asymptomatic until age 1-3 (mild), cyanosis, respiratory distress recurrent chest infections, failure to thrive (moderate - severe), marked respiratory distress, cyanosis (extreme), central cyanosis, clubbing, thrill/heave, murmur, hepatosplenomegaly Ix - ECG (RAD, RVH), CXR (boot shaped heart), ECHO Mx - squatting, PG infusion, definitive surgery (3mo-4years)
45
Describe clinical presentation, investigations and management of VSD
VSD = hole in the septum separating left and right ventricles CFs - exercise intolerance, dizziness, chest pain, blue-ish complexion, clubbing, undernourished, sweaty, tachypnoea, blowing pan systolic murmur Ix - ECG, bloods, CXR, ECHO Mx - diuretics, ACEi, surgical repair
46
What is Eisenmenger's syndrome?
Pressure in RV > LV --> shunt reversal --> cyanotic patient
47
List some maternal risk factors of fetal VSD
``` Maternal diabetes Rubella Alcohol FH (Fetal Down's syndrome/trisomy 18) ```
48
Describe clinical presentation, investigations and management of PDA
PDA = ductus arteriosus fails to close after birth (common in preterm babies - prevent with indomethacin, *associated with IVH, NEC) CFs - systolic/continuous machinery like murmur, full bounding pulses Ix - ECHO, CXR (cardiomegaly) Mx - ibuprofen, surgical closure
49
Describe clinical presentation, investigations and management of Coarctation of the Aorta
CoA = narrowing of descending aorta CFs - shock (if closure of PDA), weak/absent femoral pulses, BP in arms > legs Mx - PGs (keep duct open), surgical repair
50
Describe clinical presentation, investigations and management of gastro-oesophageal reflux disease
GORD = passage of gastric contents into the oesophagus causing symptoms or complications CFs - distressed behaviour, feeding difficulties, chronic cough, pneumonia, faltering growth, alleviated when held upright Mx - reassurance (*usually resolves by 1 year of age), alginate (Gaviscon) + water, lower feed volume and higher frequency, feed thickener/alginate added to formula, PPI (omeprazole), H3 antagonist (ranitidine), domperidone, fundoplication
51
List reasons neonates are more likely to experience GORD
Lower tone of lower oesophagus Short narrow oesophagus Delayed gastric emptying High ratio of gastric volume:oesophageal volume
52
List some risk factors of GORD
``` Prematurity Obesity Hx of congenital diaphragmatic hernia Hx of oesophageal atresia Neurodisability ```
53
Describe clinical presentation, investigations and management of cow's milk protein intolerance/allergy
IgE (acute, rapid onset, skin signs, angioedema) vs non IgE (non acute, delated onset, faltering growth) mediated allergy Ix - clinical, IgE blood test (RAST) Mx - cow's milk avoidance (baby + mother) for >6mo, nutritional counselling, growth monitoring, extensively hydrolysed formula/amino acid formula *NOT soya based formula due to oestrogenic effects
54
List some risk factors for CMPI
Atopy (asthma, eczema, allergic rhinitis, other food allergies) FH of atopy
55
Describe clinical presentation, investigations and management of Coeliac Disease
CD = lifelong gluten (wheat, barley, rye) sensitive autoimmune disease CFs - failure to thrive, abdominal distension, buttock wasting, diarrhoea, anaemia, osteoporosis, dermatitis herpetiformis Ix (if on gluten diet) - serology testing, duodenal biopsy Mx - gluten free diet, iron supplementation
56
What is the diagnostic criteria of Coeliac Disease?
Positive serology - IgA for anti-endomyseal, anti TTG On biopsy - increased intraepithelial lymphocytes, villous atrophy, crypt hypertrophy Resolution of symptoms on gluten free diet and catch up growth
57
List some risk factors for Coeliac Disease
Autoimmune conditions (T1DM, thyroid, RA), Down's syndrome, Turner's syndrome
58
Describe clinical presentation, investigations and management of gastroenteritis
Viral (rotavirus, norovirus, adenovirus) or bacterial (campylobacter, E.coli) CFs - sudden onset diarrhoea +/- vomiting, abode pain, mild fever, dehydration Ix - stool sample, bloods (Na+/K+, urea, creatinine, glucose) Mx - continue feeds, encourage fluid intake, offer rehydration solution (if dehydrated), oral therapy or NG tube *IV therapy if shock/red flags/lots of vomit
59
List some complications of gastroenteritis
Haemolytic uraemic syndrome Toxic megacolon Acquired lactose intolerance
60
State the paediatric maintenance fluid calculation formula
1st 10kg - 100ml/kg/day 2nd 10kg - +50ml/kg/day >20kg - +20ml/kg/day
61
Calculate the maintenance fluids of a 35kg child
1800ml/day
62
State how to correct for dehydration in children
%dehydration x 10 x weight
63
Describe clinical presentation, investigations and management of Hirshsprung's Disease
HD = absence of ganglionic cells from plexuses in large bowel, association with trisomy 21 CFs - no meconium >48h, obstruction, abdominal distension, bilious vomit, chronic constipation, faltering growth Ix - full thickness rectal biopsy, barium enema Mx - rectal washout, anorectal pullthrough
64
Describe clinical presentation, investigations and management of intussusception
= telescoping of one part of bowel into another, 3mo-2 years, commonly ileum --> caecum, caused by enlarged lymphatics (post viral, polyp, lymphoma) CFs - episodic abdo pain, screaming, drawing up legs, pallor, passage of blood/mucus (red current jelly stool), palpable sausage mass Ix - AXR (rounded edge of intussusception against gas filled lumen, proximal bowel obstruction), abdominal USS (target/doughnut sign) Mx - fluid, IV ABx, reduction enema, laparotomy
65
Describe clinical presentation, investigations and management of mesenteric adenitis
= inflammation of intraabdominal lymph nodes following URTI/gastroenteritis CFs - abdo (RIF) pain, no peritonism/guarding, evidence of infection Mx - analgesia (normally self limiting), otherwise appendicectomy
66
Describe clinical presentation, investigations and management of Meckel's diverticulum
= congenital out-pouching leftover from umbilical cord releases acid, rule of twos (2% population, 2% symptomatic, 2 inches, 2 feet from ileocaecal valve) *intussusception risk, appendicitis risk, volvulus risk Ix - AXR, USS, faecal sample, Meckel's scan, laparoscopy
67
Describe clinical presentation, investigations and management of malrotation
= failure of duodenojejunal flexure to rotate around superior mesenteric vessels --> mesentery is not fixed, presents in first few days of life CFs - obstruction +/- ischaemic bowel, blood stained bilious vomit Ix - upper GI contrast study (corkscrew sign) Mx - surgical correction
68
Describe clinical presentation, investigations and management of pyloric stenosis
= hypertrophy of pylorus muscle, 2-8 weeks, first born male CFs - non bilious projectile vomiting (immediately after feed), constipation, hungry baby, failure to thrive, prominent peristaltic wave, palpable epigastric mobile mass Ix - USS (thickened, elongated pyloric muscle), bloods (hypochloraemic hypokalaemia metabolic acidosis) Mx - rehydration + correction of electrolytes/acidosis), Ramstedt's pyloromyotomy
69
Describe clinical presentation, investigations and management of congenital diaphragmatic hernia
CFs - respiratory distress in neonate, not responsive to resuscitation, displaced apex beat, poor air entry to left lung Ix - X-ray (bowel loops in chest) Mx - NG with suction (to decompress bowel), intubation, surgical repair
70
Describe clinical presentation, investigations and management of tracheoesophageal fistula/oesophageal atresia
CFs - polyhydramnios, not feeding, cyanosis on feeding Ix - CXR (air in stomach) Mx - NG with suction, surgical repair
71
List some causes of nephritic syndrome
= inflammation --> haematuria Post streptococcal glomerulonephritis - red cells, casts, HTN, group A strep, 1-2 weeks post throat/2-6 weeks post skin, penicillin 10 day course Vasculitis - SLE, Wegener's granulomatosis, HSP IgA nephropathy (Berger's disease) Goodpasture's syndrome (anti GBM) Alport's syndrome (X-linked recessive, sensorineural deafness + ESRD) Sickle cell disease PCKD (recessive --> infancy, dominant --> adolescence)
72
List some causes and complications of nephrotic syndrome
= inflammation --> proteinuria, oedema, hypoalbuminaemia, hyperlipidaemia Minimal change glomerulonephritis - oedema, URTI hx, fluid restriction, low salt diet, steroids (renal biopsy +/- cyclophosphamide if steroid resistant), penicillin (pneumococcal peritonitis risk) Focal segmental glomerulosclerosis - rule of 1/3 (resolve/infrequent relapse/frequent relapse) Complications - hypovolamia, thrombotic disease, hypercholesterolaemia
73
List different causes of UTI in a child
``` Pelviureteric obstruction - due to abnormal tissue/external compression at point of renal pelvis joining ureter Vesicoureteric reflux (VUR) - retrograde flow of urine from bladder into ureters due to abnormally short and straight insertion of ureters into bladder, Mx - monitor, ABx prophylaxis ```
74
List some causes of anaemia in a child
Impaired RBC production: - Red cell aplasia - parvovirus B19, leukaemia, aplastic anaemia - Ineffective erythropoiesis - chronic renal failure, folic acid deficiency - Iron deficiency anaemia - blood cells, malabsorption, low intake Increased RBC destruction: - Haemolytic anaemia (hereditary sperocytosis, G6PD, sickle cells) Blood loss: - ITP - post viral infection, mucocutaneous bleed, Mx = steroid) - Haemophilia A - joint bleeds, F8 deficiency, raised APTT - DIC - raised D dimer, PT/APTT, trauma, metastatic cancer, sepsis - von Willebrand's - raised APTT, mucosal bleeding, Mx = desmopressin
75
Describe the features of Kawasaki Disease
``` Conjunctivitis Rash Adenopathy (cervical) Strawberry tongue Hand/feet reddening Fever for >5 days *risk of coronary artery aneurysms ```
76
Describe the features of Henloch Shonlich Purpura (HSP)
Rash on buttocks, extensor surfaces Arthralgia Abdo pain Nephritis (haematuria/proteinuria)
77
Describe risk factors, investigations and management of Developmental Dysplasia of the Hip (DDH)
= abnormal relationship of femoral head to acetabulum RFs - female, FHx, breech, oligohydramnios, positive screening (Barlow&Ortolani) CFs - painless limp Ix - USS if <6mo/XR hip if >6mo Mx - pavlik harness if <6mo, closed reduction if >6mo, ORIF if unsuccessful
78
Describe clinical presentation, investigations and management of septic arthritis
CFs - hot, swollen, painful joint +/- erythema, severely reduced ROM, non weight bearing Ix - USS joint (effusion) *never aspirate Mx - urgent IV ABx, surgical washout
79
Define Kocher's criteria
``` Likelihood of septic arthritis WBC >12 ESR >40 Temp >38.3 Non weight bearing ```
80
Describe clinical presentation, investigations and management of transient synovitis
Similar to septic arthritis but inflammatory markers normal, hx of viral illness Self limiting *if >18mo = septic arthritis
81
Describe clinical presentation, investigations and management of Perthes' disease
= idiopathic osteonecrosis of femoral head, peak 4-7 years CFs - painless limp *rule out sickle cell Ix - radiography/MRI Mx - symptom control, surgery --> THR in adult life
82
Describe clinical presentation, investigations and management of SUFE
= salter halter 1 fracture, adolescents, overweight/obese CFs - gradual onset groin/knee pain Ix - X-ray hip + frog leg lateral Mx - surgical (prophylaxis vs. damage control)
83
List red flags for a limping child
``` Child <3y Unable to weight bear Fever Systemic illness >9y with a hip problem ```
84
List red flags for development
``` Regression Plateau Hyper/hypotonia Not holding an object by 5mo Can't sit unsupported by 10mo No speech by 18mo Not pointing by 2y ```
85
List red flags of gross motor development
Primitive reflexes >6mo Unable to sit unsupported >10-12mo Can't walk >18mo
86
List red flags for fine motor development
Hand preference <6mo
87
List red flags for speech and language development
No sounds >10mo <6 words at 18mo Not responding to commands >2y
88
List red flags for social development
Not smiling responsively >10weeks | Little interest in others >6mo
89
List important development milestones
4-6 weeks - fixes to face, smiles responsively 6-7 months - sits unsupported 9 months - gets to sitting position 10 months - pincer grasp, waves bye bye 12 months - walks unsupported, 2-3 words 18 months - feeds self with spoon, throws a ball 2y - 2-3 word sentences, runs, kicks a ball

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