Paediatrics Flashcards
1
Q
What are the main 3 types of anaemia? State the mass of the RBC in each
A
Microcytic: <80
Normocytic: 80-100
Macrocytic: >100
2
Q
State the causes of microcytic anaemia
A
Fe2+ deficient anaemia
Anaemia of chronic disease
Thalassemia
3
Q
State the causes of normocytic anaemia
A
Increased reticulocytes: haemolytic anaemia, blood loss
Decreased reticulocytes: bone marrow disorder
4
Q
State the causes of microcytic anaemia
A
Megaloblastic: Vitamin B12/folate deficiency
Non-megaloblastic: alcohol abuse/chronic liver disease, hypothyroidism
5
Q
State the 3 main groups of causes of anaemia in infants + children
A
- Impaired RBC production inc. red cell aplasia + ineffective erytropoiesis
- Increased RBC destruction (haemolysis)
- Blood loss
6
Q
State 4 causes of increased RBC destruction
A
- RBC membrane disorders: inherited spherocytosis
- RBC enzyme disorders: G6PD
- Haemoglobinopathies: SCA
- Immune [neonates]
7
Q
State some common serious bacterial infections causing fever in children/infants
A
Sepsis Pneumonia Meningitis UTI Osteomyelitis
8
Q
State some common less serious infections causing fever in children/infants
A
Otitis media
Tonsilitis
Lower RTIs
Gastroenteritis
9
Q
What other infectious conditions can cause fever in children?
A
HIV
TB
Malaria
Typhoid
10
Q
State 5 non-infectious causes of fever
A
AI/inflammatory disorders: SLE, JIA, Kawasaki’s disease, vasculitides
Malignancy: leukaemia, lymphoma
11
Q
An infant under 3 months presents with a fever. What series of tests must you perform?
A
FULL SEPTIC SCREEN
12
Q
What investigations are performed under a septic screen?
A
FBC U&Es Blood cultures Urine MC&S CXR Lumbar puncture
13
Q
Why would you do a urine MC&S for a child with a fever?
A
RULE OUT UTI
14
Q
Why might you do a blood gas in a child with a fever?
A
Indicate respiratory compromise + sepsis (acidosis)
15
Q
What ABx would you commence in a neonate with suspected meningitis?
A
IV CEFTRIAXONE + AMOXICILLIN [listeria cover]
16
Q
What ABx would you commence in an infant/child with suspected meningitis?
A
IV CEFTRIAXONE
17
Q
What ABx would you commence in an infant >3months with suspected uncomplicated UTI ?
A
Trimethoprim or
Nitrofurantoin
18
Q
What is a UTI?
A
Bacterial colonisation of the urinary tract
>10*5 CFU/ml of urine
19
Q
What is the most common cause of UTI?
A
E.coli
20
Q
State some other causative pathogens of UTI in children
A
Klebsiella
Proteus mirabilis [boys]
Pseudomonas [structural abnormality]
Strep.faecalis
21
Q
What is the most common way for bacteria to colonise the UT?
A
Bowel flora ascend up the urethra
22
Q
State some of the features of an atypical UTI
A
Sepsis/IV ABx No response to treatment within 48hrs Non-E.coli cause Increased creatinine/decreased GFR Poor urine flow Abdominal/bladder mass
23
Q
Why are UTIs potentially significant in children?
A
High risk of recurrence
50% have structural abnormality
Long-term complications e.g. CKD
Acute illness
24
Q
State 3 risk factors for UTI
A
Female
Previous UTI
Vesico-ureteric reflux
Anatomical abnormality
25
How do infants typically present with UTIs?
Non-specific symptoms
| FEVER, vomiting, lethargy, irritability, poor feeding, offensive smelling urine, septicaemia
26
How do children typically present with UTIs?
```
Older the child, more specific the UTI symptoms
Abdominal/loin pain
Dysuria
Frequency
Haematuria
Fever
Foul smelling urine
+ non-specific symptoms
```
27
What is the screening investigation for a UTI?
Urine dipstick
28
What is the gold-standard screen for UTI?
Urine microscopy, culture + sensitivity with clean catch urine sample
29
What is the outcome if the dipstick is leucocyte esterase + nitrite positive?
Treat as UTI, commence ABx
30
What is the outcome if the dipstick is leucocyte esterase + nitrite negative ?
Unlikely to be UTI
31
What is the outcome if the dipstick is leucocyte esterase positive + nitrite negative?
Send urine sample for MC&S
32
What is the outcome if the dipstick is leucocyte esterase negative + nitrite positive?
Treat as UTI, commence ABx
| Send urine sample for MC&S
33
What are the indications for further testing with an USS? What can you see from this?
<6 months old, atypical or recurrent UTI
| Structural abnormalities + urinary obstruction
34
If abnormalities are found on the USS, what other investigations might be performed?
1. Micturating Cystourethrogram (MCUG): illustrates vesicle-ureteric reflux
2. DMSA: perform 3-6 months after UTI, illustrates renal scarring
35
What is the management of an infant <3months with a UTI?
Paediatric referral
| IV Amoxicillin + Gentamycin (swap to PO when temperature decrease)
36
What is the management of an infant/child >3months with an uncomplicated UTI?
PO Trimethoprim/Nitrofurantoin
37
What is the management of a child > 3months with suspected acute pyelonephritis?
PO CEFALEXIN/CO-AMOXICLAV
38
What is croup?
Infectious paediatric emergency characterised by inflammation of the trachea + larynx. Mucosal inflammation + increased secretions
39
What is the most common cause of croup?
Parainfluenza
40
What cohort of PTs does croup often affect? During what time of year?
6months-6yo children
| Spreads during autumn most commonly
41
Give an overview of the onset of croup
Onset over 1-2 days starting with prodromal phase:
- Nasal congestion + discharge)
- Fever (low-grade)
42
What are the 3 characteristic clinical features of croup?
BARKING COUGH
INSPIRATORY STRIDOR
HOARSE VOICE/CRY
43
What may indicate a case of mild croup is worsening?
Tachypnoea/dyspnoea
Chest recessions
Tachycardia
44
What may indicate a case of croup is very severe and potentially life-threatening?
Severe tachypnoea/dyspnoea
Cyanosis
Head bobbing
Bradycardia
45
A child presents with symptoms of croup. He has good air-entry and is alert. No recessions or stridor evident. How will you manage this PT?
PO DEXAMATHASONE
| If PT improves, manage PT at home
46
A child presents with a barking cough, hoarse cry and severe chest recessions. He appears short of breath. You diagnose croup. How will you manage this PT?
Hospitalise PT
OXYGEN THERAPY
PO DEXAMETHASONE
If PT does not improve give NEBULISED ADRENALINE
47
What must you not do to a PT with acute upper AWs obstruction?
Examine throat
48
When might you consider intubation in a child with severe croup?
Severe respiratory distress e.g. cyanosis/head-bobbing/bradycardia/altered mental status
49
What is acute epiglottitis?
Rapidly progressive inflammation of the epiglottis resulting in respiratory obstruction
Paediatric emergency
50
What is the main cause of acute epiglottitis?
Haemophilus influenza type B (HiB)
51
Who does acute epiglottitis tend to affect?
PI: 1-6yo
Remember: can also affect adults
52
What are the main symptoms of epiglottitis?
Drooling
Dysphagia
Painful throat
Fever (high-grade)
53
State some of the signs you might expect in a PT with acute epiglottitis
TOXIC/VERY ILL DISTRESSED CHILD
Tripod position
Struggle to speak
Inspiratory stridor
54
What is mean by a tripod posture? What condition does it often present it?
Acute epiglottitis
| PT sits upright, leaning forward with mouth open
55
A child presents drooling and unable to swallow or speak. He is in the classic "tripod position". How do you manage him?
EMERGENCY, DO NOT DELAY TREATMENT
ITU + secure airway
Blood cultures
IV CEFTRIAXONE
56
A child with acute epiglottitis has two brothers. They have not been immunised against HiB. What might you give them as prophylaxis?
RIFAMPICIN
57
What is bronchiolitis?
Infection + subsequent inflammation of the bronchioles (lower RT)
Viral LRTI
58
What is the main cause of bronchiolitis? Compare this to croup
```
Bronchiolitis = RSV
Croup = Parainfluenza
```
59
Who does bronchiolitis tend to affect?
Children < 2yo
| PI: 3-6 months
60
Give an overview of the progression of symptoms in bronchiolitis
Day 1-2: coryzal/prodromal phase, virus has infects epithelia of upper respiratory tract
Day 3-5: symptoms + signs are worst at this time, virus has infected lower AW epithelia
Day 6: child will improve
61
State 3 risk factors for severe bronchiolitis
1. Prematurity
2. CF
3. Heart/lung disease
4. Immunodeficiency
62
Give an overview of the pathophysiology of bronchiolitis
Inflammation of SM+ mucus build up--> AW obstruction
Air diffuses into blood--> AW collapse
Air trapped by obstruction
63
What symptoms may a PT experience in the coryzal phase of bronchiolitis?
```
Fever (low-grade)
Runny nose (rhinorrhoea)
```
64
3 days into bronchiolitis the RSV starts to colonise the lower AW. What symptoms would the PT experience?
Dry, sharp COUGH
DYSPNOEA
POOR FEEDING
65
What signs may a PT with bronchiolitis present with?
```
Tachypnoea
Wheeze
Inspiratory crackles
Hyperinflation
Respiratory distress
```
66
What is the main investigation used to diagnose bronchiolitis?
Nasal swab + PCR (nasopharyngeal secretions)
67
Give some indications for admitting a PT with bronchiolitis
1. Oxygen sats <92%
2. Apnoea
3. Comorbidity: lung/heart disease, premature
4. Severe respiratory distress
5. Inadequate fluid intake
68
A 1yo girl presents with a dry cough and shortness of breath. They have chest recessions and nasal flaring. You suspect bronchiolitis + this is confirmed by nasal swab. How do you manage this PT?
SUPPORTIVE MANAGEMENT
- IV fluids
- NG feeds
- High-flow humidified oxygen
- CPAP (if respiratory failure)
69
What might you give to high risk PTs as prophylaxis against RSV?
IM PALIVIZUMAB
70
What is epilepsy?
Recurrent tendency to experience intermittent, spontaneous abnormal electrical activity in brain, manifested as seizures
71
What is generalised epilepsy?
Electrical discharge arises from both hemispheres
72
What is focal epilepsy?
Electrical discharge arises from one or part of one hemisphere
73
State the different types of generalised epilepsy
1. Tonic clonic
2. Absence
3. Myoclonic
4. Atonic
5. Tonic
74
State the different types of focal epilepsy
1. Simple: no loss of consciousness
| 2. Complex: loss of consciousness
75
Who might you expect to present with absent epilepsy? How would they present?
Children (4-10yo)
| Suddenly cease activity + stare into space, child has no recall missed something
76
How might an individual with generalised tonic-clonic seizure present?
Tonic phase: suddenly become stiff, rigid + fall to floor
| Clonic phase: generalised, bilateral muscle jerking
77
What other features may you want to establish to diagnose tonic clonic seizures?
Tongue biting
Eyes open
Loss of continence
Post-ictal confusion/drowsiness
78
How does juvenile myoclonic epilepsy present?
Typically in adolescence-adulthood
Sudden onset jerking of limb, trunk or face
"throwing cereal about in morning"
Often in morning
79
Who tends to present with West syndrome? How do they present?
West syndrome = epilepsy syndrome seen in very young (4-6 months)
Flexor spasms of head, neck + limbs followed by extension of arms
Spasms last 1-2 seconds + occur in clusters
80
How would you treat west syndrome (epilepsy)?
Corticosteroids
| Vigabatrin
81
How is epilepsy diagnosed?
CLINICAL DIAGNOSIS: 2 or more unprovoked seizures >24hrs apart
82
What investigations might support a diagnosis of epilepsy?
EEG + video telemetry
| CT head: important if neurological signs, focal seizures or to rule out underlying cause
83
What is 1st line anti-epileptic drug for generalised tonic clonic in children?
Valporate, Carbemazepine
84
What is 1st line anti-epileptic drug for absence seizures?
Valporate, Ethosuximide
85
What is 1st line anti-epileptic drug for myoclonic seizures?
Valporate
86
What is the 2nd line anti-epileptic medication for all generalised epilepsy?
Lamotrigine
87
State some 1st line medications for focal seizures in children
Valporate
Carbemazepine
Lamotrigine
88
A child is brought to A&E after having a seizure for 35 minutes with no sign of stopping. How do you manage the child initially?
ABCD
Check AW
Check glucose <3 give glucose
89
A child is brought to A&E after having a seizure for 35 minutes with no sign of stopping. You do not have IV access, what medication do you give? There is no response to this or second dose, what do you now give?
Either buccal midazolam or PR diazepam
IV phenytoin + PR paraldehyde in meantime
90
A child is brought to A&E after having a seizure for 35 minutes with no sign of stopping. You have IV access, what medication do you give?
IV LORAZEPAM
91
In a girl >12yo with abdominal pain, what test is mandatory?
Pregnancy test
92
What is the most common cause of appendicitis in children?
Lymphoid tissue hyperplasia--> Lumen of appendix obstructed
93
Describe the main symptom that a children with appendicitis will be experiencing
ABDOMINAL PAIN
| Initially peri-umbilical + localises to RIF (McBurney's point), constant + worsens, worse on movement
94
State two signs that may indicate appendicitis
McBurney's sign: rebound tenderness
Guarding of RIF
Rovsing's signs
Psoas sign
95
What two clinical features may indicate a perforated appendix?
High grade fever
| Generalised guarding
96
What symptoms are expected in acute appendicitis?
Abdominal pain
N&V
Anorexia
Low-grade fever
97
How is appendicitis diagnosed?
Clinical diagnosis with history + examination
| Support with lab studies
98
State two findings on blood results that would be expected in a child with appendicitis
```
Raised WCC (neutrophils)
Raised CRP
```
99
You suspect a child has non-complicated appendicitis, how do you manage this child?
Appendicetomy + prophylactic ABx (IV Piperacillin/ Tazobactam 24hrs)
100
A child with suspected appendicitis develops a high-grade fever and generalised guarding. How might you manage this child?
Fluid resus, IV ABx
| Appendicetomy + prophylactic IV ABx (5-10 days)
101
State some red flags for child with constipation
Failure to pass meconium in 1st 24hrs: CF/HD
Abdominal distension: HD
Failure to thrive/grow: coeliac disease, hypothyroidism
Lower limb neurology + urinary incontinence: lumbosacral pathology
102
State 4 clinical features of a child with constipation
```
Abdo pain/bloating
Difficulty passing stool
Infrequent passage
Over-flow diarrhoea
Involuntary soiling
Decreased appetite
Blood in stool (fissures)
```
103
What is encopresis? In what situation does it occur?
Involuntary defecation at age where continence expected
| Occurs in chronic constipation
104
Why does encopresis occur in chronic constipation?
For 2 reasons:
1. Faecal matter retained causing secondary overflow incontinence
2. Large bolus of faeces difficult to pass, rectal dilatation + loss of awareness of emptying rectum
105
When a child presents with constipation, what are the key differential diagnosis to consider?
```
Hirschprung's disease
Bowel obstruction
Spinal cord compression
Hypothyroidism
Coeliac disease
```
106
A well-looking child presents with mild abdominal discomfort, loss of appetite and you palpate an abdominal mass in LIF on examination. What is the most likely diagnosis?
Idiopathic constipation
107
What is constipation?
Infrequent passage of stool associated with pain and difficulty/straining
108
State some factors that may increase a child's risk of idiopathic constipation
Low fibre diet
Lack of mobility/exercise
FH of reduced colonic motility
109
A child presents with mild constipation and otherwise looks well. How will you manage them?
```
Encourage fluids
Balanced diet (inc. fibre)
Possibility maintenance laxative (polyethylene glycol)
```
110
A child has had chronic constipation and was tried for 2wks on movicol. What is the next treatment you would suggest?
Senna (stimulant laxative), this follows movical (stool softener)
111
If Senna + lactulose does not relieve a child of their constipation, what are the options?
```
Enema (+/- sedation)
Manual evacuation (GA)
```
112
What is intussusception?
Invagination of proximal part of bowel into distal segment--> Bowel obstruction
113
What demographic of PTs does intussusception often affect?
2months- 2yo
114
Where is the most common place in the bowel for intussusception to occur?
Ileo-caecal valve
115
What is the classic presentation of intussusception?
Bilious vomiting + triad:
1. Abdo pain
2. Red-currant jelly stool
3. Sausage-like abdominal mass
116
What is the gold-standard diagnosis for intussusception?
USS abdomen- target sign
| Shows 2 concentric circles indicating 2 loops of bowel
117
Before any investigation, if you suspect intussusception, what must you do? If they are in shock e.g. hypovolaemic what do you do?
Secure IV access
| IV fluids inc. 20ml/kg NaCl bolus
118
A patient has suspected intussusception, how do you manage them? They do not appear in shock
Secure IV access--> USS diagnosis--> IV fluids + ABx--> Surgery (insufflation or manual reduction)
119
State 3 complications of intussusception
Ischaemia + necrosis
Perforation
Peritonitis
Haemorrhage (hypovolaemic shock)
120
Give two classic signs seen in PT with intussusception
DRAWING UP OF LEGS
| Pallor
121
What is the most common cause of gastroenteritis in infants/children?
Viruses specifically ROTAVIRUS
122
Explain how a PT with gastroenteritis may present
Sudden onset DIARRHOEA + VOMITING
| Headaches, lethargy, weight loss, abdominal pain, blood stools, fever
123
What is the main aim of treatment in gastroenteritis?
Prevent or correct dehydration
124
How would you work out the degree of dehydration in a child with gastroenteritis?
Degree of weight loss indicates severity of dehydration
<5% loss = no clinically detectable dehydration
5-10% weight loss = clinical dehydration
>10% = shock, identify + correct without delay
125
Give 3 factors that put an infant at increased risk of dehydration
```
Low birth weight
Diarrhoea > 6 times 24hrs
Vomiting >3 times 24hrs
Infants > 6 months
Unable to tolerate fluids
Malnutrition
```
126
What are the three types of dehydration?
1. Hyponatraemic dehydration: greater net loss of Na+ than water, children drink loss of water
2. Isonatraemic dehydration: loss of Na+ is proportional to water loss
3. Hypernatraemic dehydration: water loss exceeds sodium loss, often due to insensible water loss
127
What is the problem with correcting hypernatraemic dehydration?
DO NOT REPLACE FLUIDS TOO FAST
| Rapid decrease in Na+ osmolality--> Shift water into cerebral cells--> Cerebral oedema
128
At what rate should you be aiming to reduce plasma concentration of Na+ in hypernatraemic dehydration?
0.5mmol/L/hr over 48hrs
129
Under what's conditions might you take a stool sample and culture in gastroenteritis?
1. Sepsis
2. Suspect unusual pathogen/travel abroad
3. Blood/mucus in stool
4. No improvement over 7 days
5. Immunocompromised child
130
Give 3 clinical features of a patient with clinical dehydration
```
Appears unwell
Lethargic/irritable
Eyes sunken
Tachycardic
Urine output decreased
```
131
Give 3 clinical features of a patient with shock caused by dehydration
```
Cold extremities
CRT > 2secs
Dry mucosal membranes
Pale, mottled skin
Decreased level of consciousness
```
132
A 2 year old boy has developed sudden onset diarrhoea and vomiting over the last 48hrs. He looks reasonably well but his mum is concerned he is dehydrated. How do you manage this child assuming there is <5% weight loss? He has vomited 4 times in the past 24hrs
<5% weight loss--> No clinically detectable dehydration
Encourage oral intake of fluid
Vomiting >3 times in past 24hrs puts him at increased risk of dehydration so give ORAL REHYDRATION SOLUTION
133
What fluid deficit replacement amount do you give in a child who is clinically dehydrated but showing no signs of shock?
50ml/kg over 4hrs
134
What fluid deficit replacement amount do you give in a child who is showing signs of shock from dehydration?
100ml/kg over 4hrs
135
What is ulcerative colitis?
Chronic relapsing-remitting inflammatory disease of the bowel, characterised by involvement of colonic mucosa
136
State some macroscopic features of UC
1. Mucosa looks inflamed + reddened, bleeds easily
2. Ulcerations/pseudopolyps
3. Begins at bowel + extends proximally
4. Affects up to ileo-caecal valve
5. Circumferential + continuous inflammation
137
State some microscopic features of UC
1. Mucosal + sub-mucosal inflammation
2. Decreased goblet cells
3. Increased crypt abscesses
138
Who does ulcerative colitis typically present in?
Adolescents + young adults
139
State 3 important symptoms of ulcerative colitis
1. BLOODY DIARRHOEA (+/-mucus)
2. Abdominal pain (colicky, LIF)
3. Faecal urgency
4. Tenesmus: painful urge to pass stool even when rectum empty
140
Name 3 extra-intestinal features associated with ulcerative colitis
Arthritis
PSC
Uveitis
141
State some different types of ulcerative colitis
1. Ulcerative proctitis: inflammation limited to rectum
2. Left-sided colitis: inflammation does not extend proximally to splenic flexure
3. Extensive colitis: spreads proximally to splenic flexure. Including pancolitis
142
What is the gold-standard investigation for suspected UC?
Colonoscopy + biopsy
| Histology will show decreased goblet cells, increased crypt abscesses, ulceration + mucosal inflammation
143
State some other investigations that might indicate ulcerative colitis
Faecal calprotectin
+ve pANCA
Barium imaging
CT/MRI
144
What is the management for mild-moderate UC?
Mesalazine (used for remission and maintenance)
145
What treatment might you use in an adolescent with moderate-severe UC?
Oral prednisolone (only for remission, not maintenance)
146
State some immunomodulators that could be used in the maintenance of UC, or in treatment of resistant active disease
Azathioprine
Ciclosporin
Infliximab
147
What surgical options are there for ulcerative colitis?
Colectomy + ileostomy
| Ileo-rectal pouch
148
What is toxic megacolon?
Complication of IBD whereby there is acute dilatation of the colon, can result in sepsis + perforation
149
What is Crohn's disease?
Chronic inflammation of the GI tract characterised by transmural granulomatous inflammation, any where from mouth to anus
150
State some macroscopic features of Crohn's disease
Skip lesions (discontinuous)
Cobblestone appearance: ulcers and tissues in mucosa
Thickened/narrowed bowel
151
State some microscopic features of Crohn's disease
Non-caseating granulomas
Transmural inflammation
Normal glands + goblet cells
Less crypt abscesses
152
What is a volvulus? Which types if most common in infants/children?
Twisting of intestine and surrounding mesentery on its axis
| Midgut volvulus most common in children due to malrotation during development
153
A volvulus causes two major problems, what are they?
1. Bowel ischaemia: twisting of mesentery containing blood vessels compromises blood supply
2. Bowel obstruction: mechanical obstruction as bowel twists on itself
154
Give 3 key clinical features a PT with a midgut volvulus might present with
1. Bilious vomiting
2. Tender abdomen
3. Distended abdomen
4. Constipation
5. Generally unwell/irritable
155
You suspect a child has a midgut volvulus, they are constipation and having been vomiting green liquid. What investigations will confirm this?
AXR: will show bowel obstruction
| Barium contrast: show dilatation of intestine e.g. duodenum
156
State 5 differential diagnosis for bilious vomiting
1. Intussusception
2. Hirschprung's disease
3. Malrotation + volvulus
4. Duodenal/intestinal atresia
5. Meconium ileum
6. Ano-rectal malformation
157
How will you manage suspected volvulus?
SURGICAL EMERGENCY
Aggressive fluid resuscitation, NG drainage + IV ABx
Laparotomy: Ladd's procedure to untwist volvulus
158
What is the main complication of a midgut volvulus?
Intestinal ischaemia + infarction--> Sepsis
| Perforation + peritonitis follow--> Death
