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Year 3- placement > Paediatrics- respiratory and ENT > Flashcards

Paediatrics- respiratory and ENT Flashcards

1
Q

Mild croup

A
  • Occasional barking cough
  • No audible stridor at rest
    *No or mild suprasternal and/or intercostal recession
  • The child is happy and is prepared to eat, drink, and play
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2
Q

Moderate croup

A
  • Frequent barking cough
  • Easily audible stridor at rest
  • Suprasternal and sternal wall retraction at rest
  • No or little distress or agitation
  • The child can be placated and is interested in its surroundings
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3
Q

Severe croup

A
  • Frequent barking cough
  • Prominent inspiratory (and occasionally, expiratory) stridor at rest
  • Marked sternal wall retractions
  • Significant distress and agitation, or lethargy or restlessness (a sign of hypoxaemia)
  • Tachycardia occurs with more severe obstructive symptoms and hypoxaemia
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4
Q

Croup- when to admit to hospital

A
  • Moderate or severe croup
  • <6 months of age
  • Known upper airway abnormalities i.e. Laryngomalacia, Down’s syndrome
  • Uncertainty about diagnosis
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5
Q

Croup- investigations

A
  • the vast majority of children are diagnosed clinically
  • however, if a chest x-ray is done: a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’. In contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
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6
Q

Tonsilitis- causes and symptoms

A

Inflammation of palatine tonsils (often due to infection)
* Causes: Viruses (rhinovirus, coronavirus, RSV, EBV); bacteria (mainly group A beta-haemolytic streptococci = ‘strep throat’)
*Symptoms: Throat pain; odynophagia; referred ear pain; hoarse voice(esp. if associated laryngitis); headache; small children may have abdominal pain
* Signs: Red, swollen tonsils +/- exudate; fever; cervical lymphadenopathy

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7
Q

Tonsillitis- investigations and when to refer

A
  • Investigations: Usually not needed; sepsis 6 if septic; consider throat swab (esp. for streptococci)
  • Refer: Difficulty breathing; dehydration; systemic illness/possible sepsis; peritonsillar/retropharyngeal abscess
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8
Q

Tonsilitis- centor criteria

A
  • Exudate on tonsils (1 point)
  • Tender anterior cervical lymph nodes (1 point)
  • Absence of cough (1 point)
  • Fever >38 degrees (1 point)
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9
Q

Tonsilitis- management

A
  • Conservative: Explanation and reassurance, ‘delayed prescription’
  • Medical: Analgesia/antipyretics (paracetamol/ibuprofen); topical analgesia (benzydamine spray); consider antibiotics if Centor score >3 (10 days penicillin V/clarithromycin)
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10
Q

Interpreting centor score

A
  • A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus.
  • A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.

A Centor criteria score of 3/4 would warrant prescribing antibiotics or evidence of systemic upset/immunosuppression

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11
Q

Antibiotics prescribed in tonsilitis

A
  • 1st line: Penicillin V 500mg PO QDS for 5-10 days
  • Alternative in penicillin allergy: Clarithromycin/Erythromycin 250-500mg PO BD for 5 days
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12
Q

Surgical management of tonsillitis

A
  • Tonsillectomy if recurrent episodes (3 yearly for 3 years; 5 for 2 years or 7 in 1 year)
  • Also indicated for obstructive sleep apnoea from enlarged tonsils/adenoids
  • Admit for drainage if peritonsillar abscess forms
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13
Q

Otitis media- symptoms

A

Bacteria transfer more easily in children from the nasopharynx due to a shallower Eustachian tube angle

Signs and symptoms
* Symptoms: ear pain (young children may pull at affected ear), fever, coryza, vomiting
* Signs: fever, red eardrum, if discharging (suppurative) suggests perforation, sometimes red pinna

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14
Q

Types of otitis media

A
  • Benign chronic otitis media: dry tympanic membrane perforation without chronic infection
  • Chronic secretory otitis media (glue ear): presents as persistent pain, lasting a couple of weeks after the initial episode. The drum looks abnormal and shows reduced mobility of the membrane
  • Chronic Suppurative Otitis Media: diagnosed when there is persistent purulent drainage through the perforated tympanic membrane
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15
Q

Management of otitis media

A
  • Investigations: usually none (swab if recurrent/grommets in situ)
  • Conservative: reassurance, ‘delayed prescription’, safety net advice
  • Medical: simple analgesia/antipyretics. 5 days amoxicillin/erythromycin IF systemically unwell/AOM for > 4 days/ comorbidities (e.g/ congenital heart disease/chronic lung disease/immunocompromise)
  • Surgical: refer to ENT surgeon if recurrent episodes or complications
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16
Q

Otitis media- when to admit

A
  • Admit any children under 3 months with a temperature of 38 or more, or children with suspected acute complications of otitis media such as meningitis, mastoiditis or facial nerve palsy.
  • Consider admitting any children who are very systemically unwell.
  • Otherwise, treat pain and fever with paracetamol or ibuprofen
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17
Q

Otitis media: complications

A
  • Extra-cranial: Facial nerve palsy, Mastoiditis, Petrositis, Labrynthitis
  • Intra-cranial: Meningitis, Sigmoid sinus thrombosis, Brain abscess
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18
Q

Glue ear

A

Build up of middle ear fluid causing hearing loss in affected ear (often self limiting). No acute inflammation, often follows AOM.

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19
Q

Glue ear- presentation

A
  • Presentation: ear fullness/popping/pain; hearing loss (loud TV, poor communication, speech/language delay, difficulty at school)
  • Signs: yellow, retracted tympanic membrane, fluid level/bubbles behind it, loss of light reflex
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20
Q

Glue ear- investigation

A
  • Hearing test: audiometry/McCormick toy test if preschool repeat in 3 months
  • McCormick toy test: the child is shown 7 pairs of toys whose names sound similar (e.g. tree and key, plane and plate) and asked at different volumes to indicate a particular toy
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21
Q

Glue ear- management

A
  • Conservative: reassure parents that majority self-resolve, safety net, advice to speak loudly/clearly, face child, turn off competing sounds
  • Medical: no evidence for antihistamines, decongestants or antibiotics
22
Q

Glue ear: surgery

A

Children may benefit from grommet insertion if
* Bilateral OME for >3 months
* Hearing loss >25 dB in better ear
* Hearing loss and social/educational or developmental difficulties

23
Q

Inhaled foregin body- management

A
  • If presenting with choking symptoms assess level of obstruction: If ineffective cough, signs of choking, cyanosis, reduced consciousness then immediately begin choking algorithm
  • If in respiratory distress then leave comfortable and contact ENT and anaesthetic teams
  • If no respiratory distress then organise X Ray to find location of foreign body
  • Ultimately, treatment is removal (in theatre, sometimes endoscopy/bronchoscopy)
  • NB: button battery inhalation/ingestion is an emergency and MUST be removed within 6 hours due to risk of erosion
24
Q

Identifying hearing loss in children

A
  • Newborn screening: at birth if in hospital, can be done up to 3 months before
  • Further hearing tests when starting school at around 4 or 5 years old
25
Q

Conductive hearing loss

A
  • Abnormality of external or middle ear
  • E.g. otitis media with effusion or “glue ear” (OME)
  • Important to pick up as early as possible in children as can affect language development
26
Q

Sensorineural hearing loss

A
  • Abnormality of inner ear or nerves carrying impulses to brain – (cochlear branch of vestibulocochlear nerve)
  • E.g. Congenital (1 in 1000, can be genetic); infection during pregnancy (e.g. rubella, CMV); Meningitis
27
Q

Hearing loss: audiogram

A
  • Horizontal axis is frequency (pitch) in hertz (Hz) whilst the vertical axis is sound intensity (loudness) in decibels (dB)
  • Quietest sounds are at the top
  • Normal adult hearing is between 0 to 25dB across the frequency range, children’s are normal between 0 to 15 dB across the frequency range
  • Bone conduction is normal in conductive hearing loss, reduced in sensorineural
28
Q

Food allergy/tolerance: Investigations

A
  • Offer skin prick test and blood tests for specific IgE antibodies in food
  • Skin prick tests should only be done where there are facilities to deal with an anaphylactic reaction
  • If non-IgE-mediated food allergy is suspected, trial elimination of the suspected allergen (normally for between 2–6 weeks) and reintroduce after the trial
29
Q

Food allergy/tolerance: symptoms

A
  • The skin: Pruritus, Erythema, Acute urticaria, acute angioedema
  • The gastrointestinal system: Angioedema (lips, face and eyes), oral pruritis, nausea, colicky abdominal pain, vomiting, diarrhoea
  • Respiratory: nasal itching, sneezing, rhinorrhoea or congestion, cough, chest tightness, wheezing, shortness of breath
30
Q

Food allergy/tolerance: Management

A
  1. Avoidance – dietetic advice helpful. Can continue to have egg as baked ingredient as tolerated previously.
  2. Antihistamine to use in case of allergic reaction – chlorphenamine for children under 1 year of age, cetirizine in older children.
  3. Adrenaline pens- if history of anaphylaxis or asthma

Most children with milk and egg allergies outgrow it

31
Q

Anaphylaxis: Management

A
  • ABCDE, oxygen
  • IM (intramuscular) adrenaline
  • Can repeat IM adrenaline after 5 minutes if needed
  • Consider IV fluid bolus
  • Can give salbutamol nebuliser if wheezy, and consider oral prednisolone if has asthma exacerbation, but priority is adrenaline!
  • Don’t give IV hydrocortisone and IV chlorphenamine acutely.
  • Once anaphylaxis has resolved and stabilised, then can give oral cetirizine.
32
Q

UTI: causative organisms and predisposing factors

A

Causative organisms: E.coli (80%), Proteus, Pseudomonas

Predisposing factors
* Incomplete bladder emptying: infrequent voiding, hurried micturition, obstruction by full rectum due to constipation, neuropathic bladder
* Vesicoureteric reflux: a development anomaly found in 35% of children with a UTI
* Poor hygiene

33
Q

UTI- epidemiology

A

More common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood

34
Q

UTI- presentation in childhood

A

Depends on age:
* infants: poor feeding, vomiting, irritability
* younger children: abdominal pain, fever, dysuria
* older children: dysuria, frequency, haematuria
* features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness

35
Q

UTI: NICE guidelines for checking urine samples in a child

A
  • if there are any symptoms or signs suggestive or a UTI
  • with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
  • with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
36
Q

Urine collection method

A
  • clean catch is preferable
  • if not possible then urine collection pads should be used
  • cotton wool balls, gauze and sanitary towels are not suitable
  • invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
37
Q

Treatment for UTI- special cases

A
  • infants less than 3 months old should be referred immediately to a paediatrician
  • children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
  • children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
38
Q

UTI management

A
  • antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
  • Lower UTI’s are usually treated with nitrofurantoin, upper UTI’s are usually treated with cephalosporin
39
Q

Investigations following UTI

A
  • Renal ultrasound- only if they have an atypical UTI
  • Micturating cystourethragram- to assess for abnormal bladder function
  • DMSA scan- 4 to 6 months after acute infection to detect renal parenchymal defects
40
Q

Special tests for a UTI

A

What investigations are recommended for children under 6 months after a first atypical urine infection or recurrent UTI?- Renal ultrasound, DMSA and MCUG.

Gold standard for renal cortical scarring: DMSA

41
Q

Atypical UTI

A

A UTI is classed as atypical if any of the following are present:
* Poor urine flow
* Abdominal or bladder mass
* Raised creatinine
* Septicaemia
* Failed to respond to treatment with suitable antibiotics within 48 hours
* Infection with non E.coli organisms

42
Q

Clinical features of a UTI

A
  • Under 3 months: fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, offensive urine
  • 3-12 months: fever, poor feeding, abdominal pain, vomiting
  • Above 1 year: frequency, dysuria, abdominal pain
43
Q

UTI: diagnosis

A
  • Positive leukocytes and nitrites on urine dip
  • Positive urine culture with appropriately collected urine (clean catch; non-contaminated collection pad/catheter sample/suprapubic aspirate)
44
Q

Nephrotic syndrome

A

Defined as a tetrad of
* proteinuria (> 1 g/m^2 per 24 hours)
* hypoalbuminaemia (< 25 g/l)
* oedema
* Hyperlipidaemia (hypercholesteralaemia

45
Q

Nephrotic syndrome: symptoms

A
  • Most patients have periods of remission and relapses
  • Swelling- around the eyes and lower legs
  • Susceptibility to infections
  • Frothy urine and reduced output
  • Increased risk of blood clots
46
Q

Nephrotic syndrome: causes and other features

A

Causes= glomerulosclerosis, glomerulonephritis, HIV/Hepatitis, lupus, diabetes, sickle cell anaemia, certain types of cancer i.e. leukaemia.

Other features include hyperlipidaemia, a hypercoagulable state (due to loss of antithrombin III) and a predisposition to infection (due to loss of immunoglobulins)

47
Q

Nephrotic syndrome: main cause

A
  • In children the peak incidence is between 2 and 5 years of age.
  • Around 80% of cases in children are due to a condition called minimal change glomerulonephritis.
  • Means the kidneys will look fine under a microscope.
  • The condition generally carries a good prognosis with around 90% of cases responding to high-dose oral steroids.
48
Q

Nephrotic syndrome: Effect of steroid treatment

A
  • Short term: behaviour change (irritability, mood swings), increased appetite, gastric irritation
  • Long term: changes to facial appearance, weight gain, hypertension, hyperglycaemia, osteopenia, immunosuppression
49
Q

Nephrotic syndrome: Pathophysiology

A
  • Podocytes are damaged within the glomerulus, this causes proteins to pass through into the nephrons tubule and joins the urine.
  • Can also cause haematuria, antibodies can also be lost.
  • The liver then detects the loss of proteins and causes more cholesterol and albumin production.
  • There is also a reduction in plasma oncotic pressure causing oedema and decreased venous return.
  • There is then decreased GFR and renin production
50
Q

Nephrotic syndrome: signs and symptoms

A
  • Xanthelasma: deposits of cholesterol around the eye
  • Fatigue
  • Leukonychia: changes to the nail bed
  • Periorbital oedema, ascites, peripheral oedema
  • Breathlessness: pulmonary oedema, pleural effusion
51
Q

Nephrotic syndrome: Investigations

A
  • Urine dipstick, MSU
  • FBC, U&E, LFT, Ca+2, CRP, glucose
  • Serum and urine immunoglobulins
  • Autoimmune screen
  • Hep B&C, HIV
  • Chest x-ray: to show pleural effusion
  • Ultrasound of the kidneys, renal biopsy

Year 3- placement (34 decks)

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