paeds common / serious presentations Flashcards
(101 cards)
1
Q
FEVER DDx
- infective? (4 groups of causes)
- autoimmune? 4
- other? 5
A
INFECTIVE
- bacterial (incl atypical)
- TB
- viral
- parasites (eg malaria)
AUTOIMMUNE
- kawasaki
- thyroidoxicosis
- JIA
- SLE
OTHER
- haem cancers
- solid tumours
- dehydration
- post-immunisation (also post-surgery)
- factitious (eg thermometer in tea)
nb if acute fever almost always infection, if prolonged or can’t find site of infection, start to consider other causes!
2
Q
If you suspect an infective cause of fever, what locations should you think of? 9
and what hx/exam/investiagtions might you consider for each ‘location’
what investigations should you consider for all children with suspected infection? regardless of cause
A
EAR
- ear pain / tugging
- examine ear
THROAT
- examine throat + tonsils
- feel for cervical lymphadenopathy
- throat swab for strep
CHEST
- resp exam (incl auscultate lungs AND heart)
- CXR
GI TRACT
- hx of diarrhoea/vomiting (esp blood)
- (consider stool sample)
URINARY
- hx of urinary symptoms (freq, pain, new nocturnal enuresis) and/or abdo pain
- urine dip / culture
SKIN (rash or wound)
- hx of any rashes or wounds
- examine body for rashes or wounds
JOINTS
- hx of any painful joints or limp
- MSK exam (general or specific to one joint)
BLOOD
- listen to heart
- blood cultures
CNS
- hx of meningism, sick contacts
- brief neuro exam (incl conciousness, fontanelle, mengism signs)
- lumbar puncture
BLOODS FOR ALL
- FBC
- CRP
3
Q
RED FLAGS FOR FEVER ON HX/EXAM/OBS
- colour? 1 (exam)
- activity? 4 (1 exam, rest mixed)
- resp? 3 (all exam)
- circulation/hydration? 1 (exam)
- other? 6 (mainly neuro, mainly exam)
- red/orange flags for degree of fever with respect to age? 2
ORANGE FLAGS FOR FEVER ON HX/EXAM/OBS
- colour? 1 (hx)
- activity? 4 (all hx)
- resp? 4 (all exam/obs)
- circulation/hydration? 5 (1 obs, 2 exam, 2 hx)
- other? 4 (1 hx, 3 exam)
A
RED EXAM / OBS:
- pale / mottled / ashen / blue
- no response to social cues
- appears ill to a health professional
- does not wake or, if aroused, does not stay awake
- weak, high pitched or continuous cry
- grunting
- tachypnoea (RR>60)
- moderate/severe chest indrawing
- reduced skin turgor
- non-blanching rash
- bulging fontnelle
- neck stiffness
- status epilepticus
- focal neuro signs
- focal seizures
AGE
- age < 3 months with temp >/= 38
- age 3-6 months with temp >/= 39
ORANGE EXAM / OBS
- pallor reported by parent / carer
- not responding normally to social cues
- no smile
- wakes only with prolonged stmulation
- decreased activity
- nasal flaring
- tachypnoea (RR>50 age 6-12m, RR>40 age >12m)
- O2 sats <95
- crackles in chest
- tachycardia (look up individual age ranges)
- CRT >/= 3sec
- dry mucous membranes
- poor feeding in infants
- reduced urine output
- fever for 5 days or longer
- rigors
- swelling of limb or joint
- non-weight-bearing limb/not using an extremity
nb so GREEN flags for fever (ie low risk) are absence of any red/amber incl:
- normal colour
- responds normally to social cues
- content / smiles
- stays awake or wakens quickly
- strong normal cry / not crying
- normal skin + eyes
- moist mucous membranes
nb this all comes from NICE traffic light system - look it up!
4
Q
What are the constituents of a ‘septic screen’:
- bedside? (2, 2 others to consier)
- bloods? 5
- imaging? 1
also what 2 obs and 1 clinical test are expecially important to do in every child?
A
- urine dip + culture
- LP (esp if under a year)
- stool sample (if stool present)
- throat swab (i tonsilitis)
- FBC
- U+E
- blood gas
- CRP
- blood cultures
- CXR
ALWAYS DO:
- HR
- RR
- cap refill
5
Q
What specific questions should you ask (in addition to norm hx Qs) in these sections of a hx in a child presenting with fever:
- PMHx? 1
- BINDS? (which 2 especially important)
- SHx? 2
A
PMHx
- any predisposition to infection (eg steroids, immunodeficiency)
BINDS
- birth Hx
- Immunisation Hx
SHx
- Hx of foreign travel
- any sick contacts
6
Q
groups of DDx for ‘collapse’? (3 groups come round from, 6 groups may still be altered level of consciousness when arrive in A+E) - 9 overall
(nb one of these is ‘fit mimics’ - list 5 examples)
A
SYNCOPE
- vaso-vagal
- cardiac (long QT most common in children)
SEIZURE
- lots of diff types
- incl prolonged febrile convulsion
FIT MIMICS
- anoxic attacks
- breatholding spells
- migraine
- non-epileptic seizures
- “faking it”
INFECTION
- meningitis
- encephalitis
RAISED ICP
- space-occupying lesion
HEAD INJURY
- sub-dural/extradural haematoma
- diffuse axonal injury
- NAI
ACUTE ASPHYXIA
- near miss cot-death (SIDS)
- CV accident (rare in kids)
METABOLIC
- hypoglycaemia
- DKA
- inborn errors of metabolism
DRUG OVERDOSE
- intentional / deliberate
nb another way of dividing up is ‘structural’ (tumour, haematoma, abscess, hydrocephalus) to ‘non-structural’ (infection, metabolic, poisoning)
- structural tend to have focal neuro signs, non-structural tend not to - though infection sometimes can
7
Q
Way to structure a history of ‘collapse’? 3
- specific questions to especally ask (in addition to normal HPC/PMH/DH/SH) ? 6
A
BEFORE
- possibility of drug ingestion (deliberate or accidental)
- any prodromal illness (incl fever + personality change) or contact with serious infection
- any head trauma
- any Hx of seizures
- any developmental concerns prior to this
DURING
- assess posibility of NAI
AFTER
nb also ask all the obvious stuff like what they were doing before it happened, any tongue biting/incontinenece, how long they were ‘out’ for, any drowsiness afterwards etc
8
Q
EXAMINATION OF COLLAPSE
- what could brady cardia indicate in this setting? 1
- what could tachy cardia indicate in this setting? 3
- what should you be searching for to rule in/out one group of causes?
- what examination to do? which ‘add on’ part of this examination should you always do?
A
BRADY
- could mean raised ICP
TACHY
- infection
- ingestion of drugs
- anaphylaxis (or other cause of shock)
look for SOURCE OF INFECTION
NEURO EXAM
- must include looking at PUPILS (PEARL)
also:
- abnormal posture (decordiate or decerebrte posture)
- GCS
9
Q
possible investigations for ‘collapse’ and when you would use them:
- bedside? 5
- bloods? 5
- imaging? 3
A
BEDSIDE
- capillary glucose (always)
- urine dip (if suspect infection)
- LP (if suspect infection, not if non-blanching rash though)
- ECG (if cardiac syncope possible)
- opthalmascope (if any neuro/raised ICP signs)
BLOODS
- blood glucose
- blood gases (metabolic or resp acidosis)
- FBC (infection, acute blood loss)
- blood culture (if suspect infection)
- U+E (dehydration incl DKA, ingestion of drugs)
IMAGING
- CXR (infection)
- CT/MRI (focal pathology: tumour, haemorrhage, abscess)
- skeletal survey (if suspect NAI)
10
Q
Two definitions of failure to thrive?
main intervention used in diagnosing FTT?
what important to differentiate it from? how to prevent this?
A
FAILURE TO THRIVE (FTT)
1) Drop in at least 2 centiles
2) less than 0.4th centile
plot GROWTH CHARTS!
differentiate from child who is constitutionally small / short
- use personalised growth charts which take into account parents height + weight
11
Q
DDx of failure to thrive:
what are the three main groups of causes?
other main two groups of causes that doesn’t fit into any of these 3?
what is the commonest cause of FTT? describe it
A
- Inadequate caloric intake
- Inadequate nutrient absorption
- Increased metabolism
DON’T FORGET
- genetic abnormalities, eg Turner’s syndrome
- medications (eg steroids)
COMMONEST CAUSE = environmental / psychological
- weight nor affected first, then head circum + height
- eating difficuolties are common
- disturbed maternal-child interaction may be present
- maternal depression/mental health problem may be present
- neglect may be a factor
12
Q
DDx OF FAILURE TO THRIVE due to:
- Inadequate caloric intake? (4 infants, 4 any age)
by ‘infants’ I mean either only happens in infants or is normally present from birth/early infancy
A
INADEQUATE CALORIC INTAKE:
- inadequate breast milk supply or poor latching
- incorrect formula preparation
- mechanical feeding difficulties (eg cleft lip/palate)
- reflux
- poor oral neuromotor coordination
- poor eating habits (‘fussy’)
- neglect or abuse
- mental health conditions (in parent or child)
13
Q
DDx OF FAILURE TO THRIVE due to:
- Inadequate nutrient absorption? (4 infant, 3 any age)
by ‘infants’ I mean either only happens in infants or is normally present from birth/early infancy
A
INADEQUATE NUTRIENT ABSORPTION
- biliary atresia
- cystic fibrosis
- inborn errors of metabolism
- milk protein allergy
- coeliac disease (growth chart shows fall off in growth when gluten introduced into diet)
- chronic GI conditions (eg IBD)
- anaemia / iron deficiency
14
Q
DDx OF FAILURE TO THRIVE due to:
- Increased metabolism? (2 infant, 5 any age)
nb some of these may be groups of causes
by ‘infants’ I mean either only happens in infants or is normally present from birth/early infancy
A
INCREASED METABOLISM
- chronic lung disease of immaturity
- congenital heart disease
- chronic infection (eg HIV, TB)
- chronic inflammation (eg asthma, IBD)
- hyperthyroidism
- renal failure
- malignancy
15
Q
RED FLAGS FOR FAILURE TO THRIVE? 8 (ie when to suspect a medical cause)
nb 2 are hx, 6 are exam findings
A
- cardiac findings suggesting congenital heart disease (eg murmur, oedema, jugular venous distension)
- developmental delay
- dysmorphic features
- failure to gain weight despite adequate caloric intake
- organomegaly
- lymphadenopathy
- recurrent or severe resp or urinary infection
- recurrent vomiting, diarrhoea or dehydration
16
Q
What specific questions to raise in a child presenting with FTT:
- review of systems? 7
- Birth Hx? 3
- nutritional Hx? 2
- developmental Hx? 2
- FHx? 2
- SHx? 2
A
REVIEW OF SYSTEMS
- vomiting
- diarhoea
- colic
- irritability
- fatigue
- chronic cough
- SOB when feeding (think cardiac)
BIRTH Hx
- prenatal probs
- birth WEIGHT (+ gestation)
- postnatal probs / stays in NICU
also ask if any recurrent or chronic conditions
NUTRITIONAL Hx
- dietary hx (ideally a food diary)
- any feeding difficulties (when start: birth, weening, toddler - think about whether these are a cause or result of FTT)
DEVELOPMENTAL Hx
- any concerns? (esp loss of acquired skills)
- ask about age-relevant milestones for each of 4 domains
FHx
- any FHx of genetic problems / short stature / FTT
- any maternal/paternal mental health problems
SHx
- any problems at home? incl financial difficulties
- ever had any involvement with social care
17
Q
What potential underlying cause of failure to thrive might each of these exam findings suggest:
- poor parent-child interaction 1
- mental status change 2
- pale 1
- dysmorphic changes 1
- hair colour / texture change 1
- wasting 2
- rash, skin changes, bruising 2
- heart murmur 1
- respiratory compromise 1
- hepatomegaly 3
- peripheral oedema 2
A
poor parent-child interaction
- depression / social stress
mental status change
- cerebral palsy
- poor social bonding
pale
- iron deficiency anaemia
dysmorphic changes
- genetic abnormality / undiagnosed syndrome
hair colour / texture change
- zinc deficiency
wasting
- cerebral palsy
- cancer
rash, skin changes, bruising
- cow’s milk allergy
- abuse
heart murmur
- anatomical cardiac defect
respiratory compromise
- cystic fibrosis
hepatomegaly
- infection
- chronic illness
- malnutrition
peripheral oedema
- renal disease
- liver disease
18
Q
INVESTIGATIONS FOR FTT:
- first thing to do?
- what documentation to always look at?
- when to do investigations?
- bedside test to consider? 2
- bloods to consider? 7
- imaging to consider? 1
A
PLOT INDIVIDUALISED GROWTH CHART
SEE RED BOOK!!!
- loads of info in there from health visitor about living conditions etc
LET HX + EXAM GUIDE INVESTIGATIONS
- probs do a FBC in everyone for anaemia but apart from that only do investogations which match with hx/exam
- urine dipstick / culture
- sweat test (if suspect CF)
- FBC
- U+E
- LFT
- ESR/CRP
- TFTs
- coeliac antibodies
- chromosomes (in girls, for turners)
- echo (if suspect cardiac cause)
19
Q
Causes of short stature:
- steady but poor growth? (3 common, 2 rare)
- fall-off in growth across centiles? (3 common, 2 rare)
describe features which may indicate each
A
STEADY BUT POOR GROWTH
CONSTITUTIONAL
- short parents
- normal hx + exam
- no delay in bone age
MATURATIONAL DELAY
- delayed onset of puberty
- FH x of delay
- delayed bone age
IUGR
- low birth weight
- the underlying reason for IUGR (eg maternal alcohol, genetic syndrome) may be evident
TURNER’S (rare)
- features of turner’s (not always present)
- XO karyotype
- no pubertal signs
- no delay in bone age
SKELETAL DYSPLASIAS (rare)
- body disproportion with shortened limbs
- achondroplasia is most common cause
FALL OFF IN GROWTH ACROSS CENTILES
PSYCHOSOCIAL
- neglected appearance
- behavioural problems
- catch-up growth occurs when child removed from home
CHRONIC ILLNESS
- usually identified on hx + exam
- crohns andf kidney disease may be occult
- some delay in bone age occurs
ACQUIRED HYPOTHYROIDISM
- clinical features of hypothyroidism
- goitre may be present
- low T4, high TSH + thyroid antibodies
- delayed bone age
CUSHING’S (rare)
- cushingoid features
- usually iatrogenic dt prescribed steroids
- delayed bone age
GROWTH HORMONE DEFICIENCY (rare)
- congenital or acquired
- may occur with other hormone deficiencies
- delayed bone age
20
Q
DDx for fatigue/lethargy in an acute presentation:
- infective? 5
- non-infective? 4
A
INFECTIVE
- viral URTI infection
- UTI
- gastroenteritis
- meningitis
- septicaemia
NON-INFECTIVE
- DKA
- hypoglycaemia
- brain tuymour
- hypothyroid
nb viral URTI is by far the most common cause, but exclude others
21
Q
DDx for fatigue/lethargy in a chronic/insidious presentation:
- psychosocial? 4
- infections? 3
- metabolic/endocrine? 3
- other chronic diseases? 7
ones with = sign are most common
A
PSYCHOSOCIAL = depression/anxiety = sleep problems (incl sleep apnoea if obese) = neglect / difficulties at home/school - chronic fatigue
INFECTIONS
= post-viral fatigue
- EBV infection
- TB or other occult infection
METABOLIC / ENDOCRINE
= iron-deficiency anaemia (incl from periods)
= diabetes
- hypothyroidism
OTHER CHRONIC DISEASES
- coeliac disease
- crohns
- liver disease
- cardiac disease
- renal failure
- leukaemia
- solid malignancies
(also other rarer chronic diseases such as JIA, SLE, addisons etc)
also always consider pregnancy in adolescent girl!
22
Q
Red flags for lethargy/fatigue? 9
A
- weight loss/FTT
- non-blanching rash
- easy bruising
- fever with no identifiable infection focus
- night sweats
- swollen joints or MSK pain
- widespread and/or concerning lymphadenopathy
- hepatosplenomegaly
- any palpable non-tender lumps (eg kidney, bone)
23
Q
Initial investigation if chronic presentation of fatigue / lethargy? 1
A
FBC
- can reveal iron deficiency anaemia
- can show high WCC if ongoing infection
- can show abnormalities in leukaemia
then do whatever investigations are indicated by
24
Q
DDx for acute dyspnoea in children:
- resp non-infective? 2
- resp infective? 6
- cardiac? 1
- other? 4
A
RESP
= asthma attack
- inhaled foreign body
= viral URTI (incl viral-induced wheeze)
= croup
= bronchiolitis
= pneumonia
- TB
- whooping cough
CARDIAC
- heart failure
OTHER
- DKA
- sepsis
- ingestion of toxins
- panic attack
25
BREATHLESSNESS Hx:
- associated symptoms to ask about in HPC? 8
- important conditions to ask about in PMHx? 3
- important conditions to ask about in FHx? 3
nb also ask about onset and, if really uddne ask about likelihood of foreign body or panic attack
ASSOCIATED SYMPTOMS
- cough (productive or not)
- wheeze
- any stridor or whooping
- fever
- lethargy / behaviour change (DKA, sepsis, dehydration)
- rashes or sign changes (sepsis)
- eating + drinking?
- wet nappies / urinating?
PMHx
- any atopic conditions
- any underlying conditions (esp heart disease
- prematurity?
FHx
- any atopic conditions
- TB
- CF
26
What two clinical signs make pneumonia more likely in bronchiolitis?
- high-grade fever (>38.5)
| - persistent focal crackles on auscultation
27
RESP EXAM FOR CHILD WHO IS SOB:
- noises to listen for? 4
- signs of resp distress to look for? 8
- sign indicative of epiglottitis?
- possible findings on persussion / auscultation?
- what else to always examine in child with resp symptoms? 6
NOISES
- grunting
- stridor
- wheeze
- whooping
RESP DISTRESS
- high RR (for age)
- grunting
- nasal flaring
- inter/subcostal recession
- tracheal tug
- central cyanosis
- child can't talk in full sentences
- restlessness or reduced GCS
new drooling = epiglotittis until proven otherwise
AUSCULTATION (nb tend not to do percussion - though do in osce)
- reduced air entry
- crackles
- wheeze
nb signs are often not focal in young children
ALWAYS EXAMINE
- ears
- nose
- throat
- heart
- abdomen
- skin for rashes
28
INVESTIGATIONS FOR SOB
- first line blood? (and finding)
- bloods if very unwell? 2
- first line imaging?
- three types of resp swab and what each looks for?
- bedside test if suspect asthma?
- test if suspect TB?
obvs always keep an eye on obs too (esp O2 + temp)
FBC
- high neutrophils in bacterial pneumonia
- high lymphocytes in pertussis
if ill
- blood culture
- blood gases
SWABS
- sputum culture (causative organisms, incl acid fast bacilli in TB)
- nasopharyngeal aspirate (viral immunoflurescence for bronchiolitis)
- per nasal swab (for bordella pertussis)
PEFR for asthma
Mantoux test if suspect TB
29
two main indications for doing a bronchoscopy for SOB child?
- inhaled foreign body likely
| - diagnostic bronchioalvelar lavage
30
DDx for chronic cough without breathlessness? 9
- GOR
- post nasal drip
- tracheo-oesophageal fistula ('TOF cough')
- passive smoking
- cystic fibrosis
- retained or recurrent aspirations
- variant asthma
- pertussis
(also post-viral cough)
- tic / habit cough
also may just be recurrent infections, normal for age group (if REALLY frequent then may be immunocompromised but kids do just get a LOT of infections!)
31
DDx for wheeze in children:
- widespread? 3
- focal? 2
WIDESPREAD
- asthma
- viral-induced wheeze
- bronchiolitis
FOCAL
- pneumonia
- foreign body
(see essential core condition flaschards for how to differentiate between viral-induced wheeze + asthma)
32
DDx for cyanosis:
- peripheral? 4
- central? 5
nb acronym for this, two words - 1st word is causes of peripheral, 2nd word is central
also one other cause that isn't in this pneumonic!
COLD PALMS
PERIPHERAL
```
C = Cold
O = Obstruction
L = LVF and shock
D = Decreased cardiac output
```
CENTRAL
```
P = Polycythaemia
A = Altitude
L = Lung disease
M = Methemoglobinaemia (see on blood gas)
S = Shunt (R -> L - ie cyanotic heart disease)
```
Also DON'T FORGET breath holding spells too!!!
Lung diseases include basically anything but especially:
- asthma
- pneumonia
- inhaled foreign body
- meconium aspioration at birth
- congenital lung conditions / prematurity
33
INNOCENT MURMUR:
- eight features? (all start with the same letter)
- what often triggers or exacerbates them?
- safety net?
8 S's
- Soft (also quiet)
- Short
- Systolic
- Site - heard over small area (left Sternal edge)
- Sitting + standing - Change with movement or position (decreases in intensity when stand)
- symptom-free
- Signs - none present (incl no FTT and no thrills)
- Special tests normal (radiograph, ECG normal)
tend to get / exacerbate in:
- febrile / intercurrent illness
- anaemia
also because heart is small there is just more turbulence
- can be heard in 30% of children at some point
If child is acutely unwell and has a murmur then wait until they are better again to listen for murmur again - normally it’s gone when they’re well again
nb, on the other hand, pathological murmurs are:
- pansystolic or diastolic (or may be systolic)
- harsh or long
- loud
- may radiate + have palpable thrill
- may involve cardiac sympotms (esp fatigue, cyanosis)
34
Differential diagnosis for murmur:
- innocent? 3
- pathological? 7 (basically most of thecongenital heart conditions)
describe features / location of each? 7
INNOCENT
VENOUS HUM
- blowing continuous murmur in systole + diastole
- heard below the clavicles
- disappears on lying down
PULMONARY FLOW MURMUR
- brief high-pitched murmur at second left intercostal space
- best heard with child lying down
SYSTOLIC EJECTION MURMUR
- short systolic murmur at left sternal edge or apex
- musical sound
- changes with child's position
- intensified by fever, exercise and emotion
PATHOLOGICAL
AORTIC STENOSIS
- soft systolic ejection murmur at right upper sternal border
- radiates to neck and down left sternal border
- causes dizziness + LOC in older children
PULMONARY STENOSIS
- short systolic ejection murmur in upper left chest
- conducted / radiated to back
- thrill in pulmonary area
ATRIAL SEPTAL DEFECT
- soft systolic murmur at 2nd left intercostal space
- wide fixed splitting of second sound
- may first be detected at school entry
VENTRICULAR SEPTAL DEFECT
- harsh pan systolic murmur at lower left sternal border
- radiates all over chest
- signs of heart failure may be present
TETROLOGY OF FALLOT
- ejection systolic murmur
- cyanotic
PATENT DUCTUS ARTERIOSUS
- continuous 'machinery' murmur
- below left clavicle
- also get collapsing pulses
- especially common in premature infants
COARACTATION OF AORTA
- systolic murmur on left side of chest
- heard in the back
- absent / weak / delayed femoral pulses
- nb murmur sometimes not heard, change in femoral pulses is more sensitive sign
nb transposition of arteries don't tend to have a murmur
35
ACUTE ABDO PAIN in children:
- three most common causes? (nb all GI)
- other GI causes? 5
- urinary system? 2
- other important? 3
- other important in teenagers? 4
MOST COMMON
- constipation
- mesenteric adenitis
- gastroenteritis
OTHER GI
- appendicitis
- intusssuception
- bowel obstruction (incl volvulus in neonates, also meckel's)
- peptic ulcer (pain at night, relief with milk)
- inflammatory bowel disease
(also cholecystitis + pancreatitis are rare but can happen)
URINARY
- pyelonephritis / UTI
- henoch schonlein purpura
```
OTHER
- lower-lobe pneumonia
- DKA
- anxiety / stress / migraine
(- sickle cell)
```
TEENS
- ectopic pregnancy
- ovarian cyst
- pelvic inflam disease
- ovarian / testicular torsion
nb could also be an acute presentation of a chronic problem - always ask if had before!
36
Qs to ask about acute abdo pain? 8
red flags to ask about? 5
associated symptoms to ask about:
- GI? 4
- urinary? 3
- other local? 3
- systemic? 7
what should you never forget to check in / simple test for:
- anyone with abdo pain?
- any teenage girl w abdo pain?
SOCRATES!
- site
- onset (incl any viral illness before)
- character
- radiation (incl to testes)
- associated symptoms
- timing (does it wake from sleep)
- exacerbating / relieving factors
- severity
RED FLAGS
- bilious vomiting
- blood in stool or vomit
- pain waking up child at night
- haemodynamic instability / shock
- peritonitis / guarding
GI
- nausea
- vomiting (blood? green?)
- diarrhoea / constipation (ask re freq + consistency)
- blood in stools
URINARY
- pain on urination
- new nocturnal enuresis (DM or UTI)
- blood in urine
- polyuria (also polydipsia)
OTHER
- girls: periods started? painful? heavy?
- vaginal / penile discharge (think STI)
- resp symptoms (incl SOB, cough)
- joint pain / swelling (HSP, IBD))
SYSTEMIC - AW FS FIN
- appetite loss (often get in appendicitis, or gain if DM)
- weight loss
- fatigue
- sleep
- fever
- itch (incl jaundice, RASH, skin probs)
- night sweats
ANY CHILD = check glucose
ANY TEENAGE GIRL = pregnancy test
37
Investigations for acute abdo pain:
- bedside? (2 always, 2 sometimes)
- bloods (2 always, 5 to consider)
- two main imaging used?
= urine dip
= capillary blood glucose
- urine culture
- pregnancy test
```
BLOODS
= FBC
= CRP
- U+E (HSP, UTI, dehydration)
- LFT (jaundice)
- ESR (IBD)
- blood gas (if unwell)
- amylase (pancreatitis)
```
- abdo x-ray
- abdo USS
(see other flashcard for when use what)
38
What is 1st line imaging for suspected:
- appendicitis
- biliary atresia
- constipation / bowel obstruction
- duodenal atresia
- intussception
- malrotation + volvulus
- necerotising enterocolitis
- pyloric stenosis
way of remembering which is which?
- appendicitis = USS
- biliary atresia = USS
- constipation / bowel obstruction = X-RAY
- duodenal atresia = X-RAY ('double bubble' sign)
- intussception = USS
- malrotation + volvulus = X-RAY
- necerotising enterocolitis = X-RAY
- pyloric stenosis = USS
nb if obstruction / bile stained vomit then x-ray - generally the rest is USS
- nb duodenal atresia is only exception to this
39
CHRONIC/RECURRENT ABDO PAIN IN CHILDREN:
- non-organic causes? 4
- organic GI causes? 4
- other relatively common causes? 2
- rare causes? 18 (5 GI, 3 gynae, 2 urinary, 3 neuro, 5 other)
(don't worry if don't get all of these rare causes)
- RECURRENT ABDO PAIN OF CHILDHOOD
- Irritable bowel syndrome
- non-ulcer dyspepsia
- abdominal migraine
- constipation
- GORD / oesophagitis
- IBD
- coeliac disease
- recurrent UTIs (could be dt anatomical problem or ureteric reflux)
- dysmenorrhoea / endometriosis
RARE
- eosinophilic oesophagitis
- h. pylori infection / peptic ulcer disease
- hiatal hernia
- pancreatitis
- giardiasis
- mittelschmertz
- ovarian cyst
- pelvic inflammatory disease
- ureteropelvic junction obstruction
- kidney stones
- nerve entrapment
- spinal tumour
- transverse myelitis
- porphyria
- familial meditierranean fever
- lead posioning
- lymphoma
- sickle cell disease
40
What red flags should you always ask about for recurrent / chronic abdo pain to see if organic? 11
- red flag signs on exam? 3
RED FLAGS ON HX
- pain that is not-central
- wake child at night?
- any GROWTH FAILURE/weight loss?
- diarrhoea or vomiting?
- any GI blood loss?
- dysuria?
- secondary nocturnal enuresis
- unexplained fever
- joint inflammation
- skin rashes
- FHx of IBD
RED FLAGS ON EXAM
- any perianal or oral lesions
- palpable mass / organomegaly (incl kidneys)
- jaundice
41
Investigations to CONSIDER if organic cause of recurrent / chronic abdo pain is suspected:
- bedside? 4
- bloods? 6
- imaging? 4
- more invasive test? 1
what are you looking for for each one?
BEDSIDE
- urine dip (UTI, renal probs)
- urine culture (UTI)
- stool (for ova + parasites)
- stool for occult blood (IBD, peptic ulcer)
BLOODS
- FBC (anaemia, eosinophilia, high WCC)
- U+E (kidney failure)
- LFT (liver dysfunction)
- amylase (pancreas)
- ESR (IBD)
- coeliac screen
IMAGING
- ABDO/PELVIC USS (urinary obstruction, organomegaly, abscess, pregnancy, ovarian cyst, torsion)
- ABDO XRAY (constipation, renal calculi, lead poisoning)
- BARIUM SWALLOW + FOLOW THROUGH (oesophagitis, reflux, peptic ulcer, crohns, congenital malformations of gut)
- BARIUM ENEMA (ulcerative colitis)
ENDOSCOPY (oesophagitis, reflux, peptic ulceration, colitis, coeliac)
42
ACUTE VOMITING DDx
- three most common causes (all GI)
- other GI? 6
- other? 8
MOST COMMON
= overfeeding
= GO-reflux
= gastroenteritis
OTHER GI
- protein intolerance (eg CMPA)
- appendicitis
- obstruction
- pyloric stenosis
- malrotation with volvulus
- small bowel atresia
OTHER
- viral infection (esp from coughing)
- acute otitis media
- UTI
- sepsis
- meningitis
- poisoning
- endocrine / metabolic problem (eg DKA)
- raised ICP
also nb other things like ovarian torsion can also cause vomiting
43
Causes of bilious vomiting in neonates? 5
describe for each:
- cause?
- age at presentation?
- investigation?
- management?
DUODENAL ATRESIA
- Few hours after birth
- AXR shows double bubble sign, contrast study may confirm
= Duodenoduodenostomy
JEJUNAL / ILEAL ATRESIA
- norm caused by vascular insufficiency in utero
- Usually within 24 hours of birth
- AXR will show air-fluid levels
= Laparotomy with primary resection and anastomosis
MALROTATION WITH VOLVULUS
- caused by incomplete rotation during embryogenesis
- Usually 3-7 days after birth, volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability
- Upper GI contrast study may show DJ flexure is more medially placed, USS may show abnormal orientation of SMA and SMV
= Ladd's procedure
MECONIUM ILEUS
- 15-20% of babies with cystic fibrosis, otherwise 1 in 5000
- Typically in first 24-48 hours of life with abdominal distension and bilious vomiting
- Air - fluid levels on AXR, sweat test to confirm cystic fibrosis
= Surgical decompression, serosal damage may require segmental resection
NECROTISING ENTEROCOLITIS
- risks increased in prematurity, low birth weight and inter-current illness
- Usually second week of life
- Dilated bowel loops on AXR, pneumatosis and portal venous air
- Conservative and supportive (incl abx) for non-perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
44
CHRONIC VOMITING DDx
- four most common? (all GI)
- other GI? 2
- other? 5 (last 2 think adolescents)
ie low-grade daily pattern of vomiting
```
MOST COMMON:
= GO-reflux
= overfeeding
= cows milk protein intolerance
= food allergy
```
OTHER GI
- coeliac disease
- recurernt obstruction
OTHER
- space occupying lesion
- psychogenic / behavioural (esp in younger children)
- migraine
- bulimia
- pregnancy
45
VOMITING: Qs for Hx:
- red flag features of the vomit? 3
- other HPC questions (excl associated symp)? 4
- associated symptoms? 8
- PMHx to specifically ask about? 1
- additional Hx to do in adolescents? 1
(obvs do full PMHx, DHx, FHx, BINDS, SHx as well)
RED FLAGS
- projectile vomiting
- bile-stained
- haematemesis (blood or coffee ground)
OTHER HPC
- when started? (any proceeding event - think head injury)
- other features of vomit: volume consistency, colour?
- how many times? (getting worse?)
- ever had before?
ASSOCIATED SYMPTOMS
- appetite
- failure to thrive / weight loss (RED FLAG!)
- fluid intake / wet nappies?
- food intake? how much (overfeeding/bulimia)
- pain (abdo, head)
- diarrhoea / constipation
- haedache (raised ICP, migraine)
- fever
(do full systems review in kids: eg any resp symptoms, more drowsy, weakness etc)
any PMHx of diabetes?
HEADSS HX in adolescents - this may be bulimia!
46
EXAMINATION FOR VOMITING:
- what to examine to assess fluid status? 5
- finding on abdo exam in pyloric stenosis? 2
- sign to look for which indicates obstruction?
- what to always do on abdo exam (regardless of age)?
- aside from abdo exam, what else should you examine / measure in children under 5? 3
- abdo exam end pieces / bedside tests to consider in children? 6 (acronym - diff to adult one)
- what examination should you do if no obvious cause?
- fontanelle (under a year)
- eyes
- mucous membranes
- CRT
- weight
pyloric stenosis
- olive mass
- visible peristalsis
look for ABDO DISTENSION for obstruction
- ask parents if they think look more distended than normal!
LISTEN FOR BOWEL SOUNDS
- ear exam
- throat exam
- head circumference (under 2)
END PIECES - SHUGGG
- Stool sample
- hernial orifices
- urine sample
- external Genetalia
- GROWTH CHART
- capillary Glucose
(nb in adults, tend not to do glucose or growth chart, but would do rectal exam - ie SHRUG)
DO NEURO EXAM (incl papilloedema, meningism signs) if no obvious cause of vomiting
47
VOMITING INVESTIGATIONS:
- blood to do if suspect dehydration?
- blood to do if suspect pyloric stenosis?
- options to investigate GORD? 2
- investigation in all cases of bile-stained vomit? why?
suspect dehydration
= U+E
pyloric stenosis
= blood gas (venous or capillary) - assess degree of metabolic acidosis
GORD
- pH monitoring
- barium swallow
bile-stained vomit = upper GI contrast study (to exclude malrotation)
48
DDx CHRONIC / RECURRENT DIARRHOEA:
- three most common causes?
- other causes? 6
nb all causes are GI
MOST COMMON
= constipation with overflow
= toddler's diarrhoea
= food allergy
OTHER CAUSES
- coeliac disease
- IBD
- cows milk protein intolerance / allergy
- secondary lactose intolerance (eg following gastroenteritis)
- parasites: giardia
- other malabsorption (eg CF, other pancreatic insufficiency)
49
Hx of CHRONIC / RECURRENT DIARRHOEA
- what potential triggers to ask about? 3
- specific questions to ask about the diarrhoea? 4 (which 2 are red flags)
- associated symptoms? 4 (which of these is a BIG red flag)
- conditions to ask if FHx of? 3
ANY TRIGGERS?
- weaning (CMPA, coeliac)
- specific foods (allergy / intolerance)
- recent gastroenteritis (lactose)
DIARRHOEA
- what does it look like/consistency?
- how frequent?
- blood? (RED flag)
- mucus? (RED flag)
(nb odour + 'flushability' not helpful)
ASSOCIATED SYMPTOMS
- abdo pain
- weight loss / FTT (RED FLAG)
- any skin changes or rashes (CMPA, IBD, coeliac)
- any resp symptoms (CF, CMPA)
FHX
- atopy (for CMPA)
- IBD
- CF
50
EXAM for recurrent/chronic DIARRHOEA:
- most important thing to do?
- other features to look for during general exam? 4
- other features to look for during abdo exam? 2
MEASURE + PLOT WEIGHT + HEIGHT (+head circum)!! = most important
GENERAL
- pallor
- hydration status
- skin changes / rashes
- clubbing
ABDO
- distension
- tenderness
51
INVESTIGATIONS TO CONSIDER FOR RECURRENT / CHRONIC DIARRHOEA
- bedside? 3
- bloods? 3
- more invasive investigation?¡
- when should you NOT do investigations?
nb don't forget to measure height, weight and head circum and plot on growth chart first
stool sample
- ova + parasites
- occult blood (CMPA, IBD)
- sweat test (for CF)
(could consider doing urine dipstick for UTI too)
BLOODS
- FBC (anaemia if blood loss, malabsorption, poor diet - eosinophilia if parasites or atopy)
- ESR (IBD)
- coeliac antibodies
ENDOSCOPY (+/- biopsy)
- coeliac
- IBD
no investigations needed if there is no effect on growth and no other signs/symptoms except the diarrhoea
- can just remove food from diet if suspect allergy/intolerance
52
DDx for acute diarrhoea:
- infective? 3
- non-infective? 2
INFECTIVE
- viral gastroenteritis
- bacterial gastroenteritis (shigella, e.coli., salmonella, campylobacter)
- any acute infection
NON-INFECTIVE
- antibiotic induced
- food poisoning (toxins)
53
MAIN CAUSES OF ACUTE CONSTIPATION? 2
FLUID DEPLETION
- norm secondary to dehydration from a viral illness
- may require laxatives
- may lead to chronic constipation if not treated
BOWEL OBSTRUCTION
- much rarer
- norm due to congenital gut malformations
- usually presents as an acute abdomen but can present as constipation w vomiting + abdo pain
54
CHRONIC CONSTIPATION:
- by far the most common cause? 1
- other causes to rule out? 5 (incl how to rule out/in hx/exam/investigations)
FUNCTIONAL CONSTIPATION = commonest cause
HIRSCHPRUNGS
- when pass meconium?
- almost always have FTT
- constipation from infancy
- empty ampulla on DRE
- rectal biopsy to diagnose
HYPERCALCAEMIA
- do U+E and calcium bloods
HYPOTHYROIDISM
- ask about thyroid symptoms, incl FTT
- TFT bloods
COELIAC DISEASE
- FBC + coeliac antibodies
NEURO PROBLEMS
- eg spina bifida, spinal cord compression
- any urinary problems or leg weakness
- do LL neuro exam
- MRI if suspect
55
Constipation:
- first thing to ask?
- normal frequency of bowel movement?
- what to ask about the stool appearance? 2
- what to ask the child about opening their bowels? 2
- what posture to ask parents about?
- (in summary of above points, what 6 things do you want to know about the constipation)
- what does overflow soiling look like?
- apart from bowels, what else GI/urinary-related should you ask about in hx? 7
WHEN STARTED
- any triggers?
- illness/dehydration?
- weaning?
- life change?
frequency varies hugely from 3 times a day to 3 times a week
- is not that helpful as an indicator (consistency more important) but still ask anyway
ask about:
- consistency - how hard (show them bristol stool chart)
- any blood?
ask child if it hurts when they go for a poo? and if they ever try to 'hold a poo in'?
typical retentive posturing: typically straight legged, tiptoed, back arching posture
so want to know:
- frequency
- consistency
- blood
- pain
- retentive behaviour
can also ask parents about if they notice any abdo BLOATING
Overflow soiling = commonly very loose, very smelly, stool passed without sensation
ALSO ASK ABOUT:
- nutrition (content of diet)
- appetite
- weight gain / loss
- fluid intake
- urinary function
- nausea + vomiting
- any diarrhoea
56
CONSTIPATION:
- what conditions to ask about in PMHx? 2
- What conditions to ask about in FHx? 3
- what med to ask about in DHx? 1
- what is two most important things to ask about in BINDS? 2
- inportant Qs in social Hx? 2
PMHx
- any spinal / neuro probs
- any developmental delya (incl learning difficulties - have a higher prevelence of functional constipation)
FHx
- thyroid problems (+ other autoimmune)
- calcium problems
- coeliac disease
DHx
- iron tablets (can cause constipation)
- also ask if tried any laxatives
BINDS
- when pass meconium?
- diet + fluids (ie nutrition)
SHx
- any changes in life (new school, new sibling)
- exercise
57
What 4 examinations to do if constipation?
1) abdo exam
2) inspect anus for fissures (rarely do PR)
3) LL neuro exam
4) measure height + weight + plot on GROWTH CHART
58
Red flags for constipation? 9
- failure to pass meconium as a newborn (ie it took >48 hours)
- Reported from birth or first few weeks of life
- failure to thrive / faltering growth
- ribbon stools
- abdominal distension
- absence of witholding manouveres
- bladder dysfunction
- abnormal neuro findings (lower limb weakness, sacral dimple)
- empty rectal ampulla on PR
59
Investigations to consider for constipation:
- bloods to rule out non-functional causes? 4
- imaging to consider if bad?
- invasive test to consider?
- imaging if suspect a neuro cause?
BLOODS
- FBC
- coeliac screen
- TFTs
- calcium
consider abdo x-ray
rectal biopsy - if suspect hirschprungs (nb have FTT with this)
consider spinal MRI if neuro signs
60
Causes of (true) seizures:
- neuro? 3
- infective? 3
- metabolic? 5
= is the 3 most common causes of the above
NEURO
= epilepsy
- brain tumour / raised ICP
- head injury (incl NAI)
INFECTIVE
= febrile convulsion
= meningitis
- encephalitis
METABOLIC
- hypogylcaemia
- inborn errors of metabolism
- hypocalcaemia
- hyponatraemia
- poisoning (accidental, self-harm or deliberate by parents)
nb examples of things which can cause hypoglycaemia:
- exogenous insulin
- congenital adrenal hyperplasia
- ketotic hypoglycaemia
- liver disease
- glycogen storage disorders
- galactosaemia
- other inborn errors of metabolism
61
History of seizure:
- how to structure hx? 3
- recent PMHx/triggers to ask about? 3
- questions to ask about the seizure itself? 7 (obvs if ongoing then just look for these things yourself)
- more general conditions to ask about in PMHx? 2
- questions to ask in FHx? 2
- important sections of BINDS not to forget? 2
- before
- during
- after
RECENT PMHx / TRIGGERS
- unwell or pyrexial beforehand, incl menigism (febrile, meningitis, encephalitis)
- head injury
- any possibility of drug ingestion (accidental or deliberate)
THE SEIZURE
- what happened?
- all four limbs?
- eye flickering?
- tongue biting?
- incontinence?
- HOW LONG did it last?
- how long to recover?
GENERAL PMHx
- epilepsy (or previous seizures)
- diabetes
FHx
- epilepsy
- what medications are other people in household on (accidental poisoning)
BINDS, esp:
- developmental Hx (epilepsy)
- any contact w social services (NAI)
62
Examination following a seizure:
- if suspect febrile convulsion? 2
- if suspect meningitis or raised ICP?
- if suspect secondary epilepsy?
- bedside test to do in EVERY CHILD?
nb obvs also do all the obs too (esp temp, HR, RR - for febrile seizures and meningitis)
- source of infection (general exam: ENT, chest, abdo)
- brief developmental exam
- GCS
- examine pupils
- any signs of head injury (incl retina!)
- look at skin for non-blanching rash
- look at skin for cafe au lait or maple leaf lesions indicative of neurodematoses conditions (also developmental exam)
CAPILLARY GLUCOSE in ALL!!
nb also examine for / ask about any injuries caused by the seizure
63
INVESTIGATIONS FOR A SEIZURE:
- bedside to do in everyone? 1
- bedside to consider? when? 3
- bloods to consider?
- imaging to consider? 2
nb obvs do obs in everyone
CAPILLARY GLUCOSE in ALL!!
BEDSIDE TO CONSIDER
- urine toxicology (drug ingestion/overdose)
- urine dip (focus of infection)
- throat swab (focus of infection)
BLOODS
- FBC (infection)
- U+E (electrolyte abnormality)
- blood gases (electrolytes)
- blood culture (infection)
- CT/MRI if hx of trauma or focal neuro signs suggesting space occupying lesion
- CXR (look for focus of infection)
64
STATUS EPILEPTICUS:
- definition? incl when to treat?
- management algorithm?
- additional investigations (2) + management (2) to consider if suspect metabolic / eectrolyte cause?
STATUS EPILEPTICUS
One continuous seizure (>30 mins) or combination of seizure without full recovery of conciousness
- Actually now TREAT AT 5 MINS FOR GENRALISED and TREAT AT 10 MINS FOR FOCAL as we know that damage starts to happen after 5 mins
MANAGEMENT OF STATUS
1) Wait 5 mins (attach monitors, administer facial O2 and suction excretions)
2) Give first dose benzo (IV lorazepam or buccal midazolam)
3) Wait 10 mins
4) Give 2nd dose benzo
5) Wait 10 mins
6) Phenytoin infusion (can do IO access if no IV access)
7) Wait 20 mins
8) Rapid sequence induction (with thiopentone) and PICU transfer
ONLY GIVE MAX TWO DOSES OF BENZOS!!
```
INVESTIGATIONS
- capillary blood glucose
- blood gases
MANAGEMENT
- give dextrose if hypoglycaemic
- coprrect an electrolyte abnormality
```
65
What should you always consider when a child presents with a head injury?
How do you rule this in/out?
other questions to ask about in head injury:
- symptoms to ask about? 7
- What PMHx to ask about? 1
- what examinations to do? 3
whether it could be a non-accidental injury (NAI)
by taking a thorough history from child + parents and making sure the story and mechanism matches with the symptoms + signs found on exam
- also any signs of a delay in presentation may also make you suspicious (if any delay, ask why!)
- mechanism of injury?
- any LOC? (if witnessed, how long?)
- any seizures? (if so, ask about epilepsy hx)
- any amnesia? (how long)
- abnormal drowsiness
- vomiting? (how many
discrete episodes)
- any blood or fluid from ears or nose?
- ANY INJURIES TO ANYWHERE ELSE?
PMHx
- Any bleeding disorders
EXAMS
- full neuro exam
- opthalmascope to see funds (also check pupils)
- examine whole head for bruising, size, fontanelle etc
66
When to perform a CT head scan on a child presenting with a head injury:
- if have any of these risk factors, how fast should a CT scan be done?
- mechanism of injury?
- symptoms following the injury?
- GCS score?
- other findings on exam? (incl 2 just for age under 1 year)
- which of these are indications for immediate CT on their own and which need 2 or more? if latter, how long do they need to be observed for?
perform CT scan within an hour (and provisionally report within an hour of scan being done)
MECHANISM
= suspicion of non-accidental injury (NAI)
- dangerous mechanism of injury (see definition below)
dangerous mechanism:
- high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant
- fall from a height of greater than 3 metres
- high-speed injury from a projectile or other object
SYMPTOMS
= post-traumatic seizure (with no PMHx of epilepsy)
- LOC lasting more than 5 mins (witnessed)
- abnormal drowsiness
- three or more discrete episodes of vomiting
- Amnesia (antegrade or retrograde) lasting more than 5 minutes (assessment of amnesia will not be possible in preverbal children and is unlikely to be possible in children aged under 5 years)
GCS
= GCS <14 on initial assessment in ED (or <15 for infants under 1)
= GCS <15 at 2 hours after the injury
OTHER FINDINGS ON EXAM
= suspected open or depressed skull fracture
= any signs of basal skull fracture (see other flashcard)
= tense fontanelle
= for children under 1, presence of bruise, swelling or laceration of >5cm on head
= focal neurological deficit
For risk factors with '=', just need one to do an urgent CT, for risk factors with '-' need 2 or more, if only 1, observe in ED for 4 hours and if, during observation, you see:
- GCS <15
- further vomiting
- further episode of abnormal drowsiness
then order urgent CT
nb don't learn this totally off by heart (if in ED etc, google nice head injury guidelines) but good to be aware - and ask these questions in a Hx
67
What are the signs of a possible basal skull fracture? 5
- blood from ears (haemotympanum)
- CSF from ears
- CSF from nose
- 'panda' eyes
- battle's sign (bruising behind ear)
68
'SHAKEN BABY SYNDROME'
- aka?
- triad of features? 3
- what investigation should you also do if you find this?
abusive head trauma (AHT)
1) encephalopathy (eg reduced GCS)
2) SUBDURAL haematoma
3) retinal haemorrhages
do a skeletal survey (and another 2 weeks later) to look for other signs of trauma
69
Primary headaches in children? 2 (which is most common)
Common secondary causes of headaches in children? 4
rare, but serious, secondary causes of headaches in children? (3 more acute in onset, 2 more insidious)
PRIMARY
- stress / tension
= migraine
migraine without aura is most common cause of primary headache in children
- aura is rare in children!
COMMON SECONDARY
- eye strain
- dental problems
- sinusitis
- analgesic headache (overuse: esp in teens)
nb headaches are rare in younger children!
RARE SECONDARY
ACUTE:
= meningitis (only get in older kids)
= trauma
- carbon monoxide posioning
INSIDIOUS
- space occupying lesion
- hypertension (esp overweight teenagers)
70
Hx of HEADACHE
- always ask if there is a recent hx of what? 1
- specific exacerbating features to ask about (while doing socrates)? 6
- associated symptoms? 9
any recent hx of HEAD TRAUMA? (in last 3 months)
obvs ask whole of SOCRATES!!!
EXACERBATING FACTORS
- stress
- light (photophobia)
- sound
- worse in morn (also ask if wake at night)
- worse when lying
- worse when cough / laugh / exercise
ASSOCIATED SYMPTOMS
- nasal congestion (chronic sinusitis)
- visual aura (halos, zig zag lines - migraine w aura)
- vomiting
- blurred vision
- fever
- non-blanching rash
- neck stiffness
- impaired consciousness
- developmental regression or personality change
71
Examination for headaches in children:
- why important to do basic obs?
- four exams to do?
to look for cushing's triad (also temp)
EXAMS
- cranial nerve (incl fundoscopy for papilloedema)
- UL neuro
- LL neuro
- ENT (dental carries, sinus tenderness etc)
72
RED FLAGS FOR HEADACHES IN CHILDREN:
- features of headache? 5 (incl exacerbating features)
- associated symptoms? 6
- findings on exam? 4
- PMHx? 3
- what to consider doing if find these?
- acute onset of severe pain
- pain wakes child at night
- pain present on waking or worse in early morning
- pain worse on lying
- pain worse on coughing, sneeze, exercise
ASSOCIATED SYMPTOMS
- blurred vision
- vomiting
- fever (with worsening headache)
- non-blanching rash
- impaired consciousness
- developmental regression or personality change
nb neck stiffness and photophobia may indicate meningitis but, in kids the former could just indicate a viral infection, and the latter a migraine
SIGNS:
- HTN
- papilloedema
- increasing head circumference
- focal neuro signs
PMHx
- hx of head trauma (in last 3 months)
- hx of seizures
- bleeding disorder
consider head imaging if suggestive of raised ICP
- consider investigation (eg LP) + management of meningitis if suspect that
73
CUSHINGS TRIAD:
- three features?
- what does it indicate?
- high systolic BP
- low HR
- low/irregular RR
significantly raised ICP
this triad is more sensitive of acutely raised ICP than papilloedema (which develops over time) is
74
FOCAL NEURO SIGNS THAT INDICATE LESION IN:
- cerebellum? 6 (acronym)
- cerebral? 8
- pituatory? 2
Cerebellum = DANISH
- Dysdiadochokinesia
- Ataxia
- Nystagmus
- Intention termor
- Staccato / slurred speach
- Hypotonia
CEREBRAL
- cranial nerve lesions
- focal seizures
- personality change (temporal)
- pronator drift
- spasticity / increased muscle tone
- focal weakness / paralysis
- brisk reflexes
- clonus
^basically UMN signs
PITUATORY:
- endocrine dysfunction
- visual field defects (hetronymous hemianopia - loose lateral aspects of vision in both eyes)
75
BRUISING DDx? 3
how to tell the difference between these?
- investigations that should always do? 2
- accidental trauma
- NAI
- bleeding problems (congenital or acquired, eg ALL)
do a thorough Hx and exam
- does the story / mechanism of injury / developmental age match with injury?
to rule out bleeding problems always do:
- FBC
- clotting
do skeletal survey if suspect NAI
- also very deatiled documentation
76
Causes of purpura / non-blanching rash in children:
- infective? 2
- iatrogenic? 1
- other causes? 5
INFECTIVE
- viral (most commonly enterovirus eg HFAM, coxsackie, polio)
- septicaemia (most commonly meningococcal)
IATROGENIC
- drug reactions
OTHER
* Acute lymphoblastic leukaemia (ALL)
* Congenital bleeding disorders
* Immune thrombocytopenic purpura (ITP)
* Henoch-Schonlein purpura (nb platelets normal in HSP)
* Non-accidental injury (or accidental trauma)
nb raised superior vena cava pressure (e.g. secondary to a bad cough) may cause petechiae in the upper body but would not cause purpura
77
Dscribe these different types of rashes / skin lesions AND give examples of common causes:
- desquamation 2
- vesicles 1
- wheals 1
- papules 1
- macules 3
- maculopapular 2
- petechiae / purpura 4
numbers are the numbers of examples
DESQUAMATION
- loss of epidermal cells producing a scaly eruption
= post scarlet fever
= kawasaki's
VESICLES
- raised fluid-filled lesions <0/5cm in diameter (if bigger called bullae)
= chicken pox
WHEALS
- raised lesions with a flat top + pale centre
= urticaria
PAPULES
- solid palpable projections above skin surface
= insect bite
```
MACULES
- lesions that are flat to the skin
= rubella
= roseola
= cafe au lait spot
```
MACULOPAPULAR
- mixture of macules and papules, tend to be confluent
= measles
= drug rash
```
PETECHIAE / PURPURA
- purple lesions caused by small haemorrhages, do not fade with pressure (petechiae are small purpura)
= meningococcaaemia
= HSP
= ITP
= leukaemia
```
nb scarlet fever has a distinctive fine punctuate rash with a 'sandpaper' feel, which blanches on pressure (esp in neck, axilla + groin - also strawberry tongue)
nb hand foot and mouth get oral lesions and macular/maculpapular/vesicle lesions on hands and feet - and sometimes perineum)
78
Hx of child with RASH:
- How to structure HPC? and questions to ask within this? 3
- associated symptoms? (4 local, 2 systemic)
- relevant Q in PMHx? 1
- relevant Qs in DHx? 2
- most relevant Q in SHx? 1
- most relevant Q in BINDS? 1
CHRONOLOGICALLY:
- what happened first? (child unwell with fever? any new medications / foods?)
- where did rash start? where is it now?
- decribe the rash?
ASSOCIATED SYMPTOMS
- any lesions in the mouth?
- rash itchy?
- any conjunctivitis / eye changes?
- any resp symptoms (cough, SOB)
- fever
- lethargy
nb also ask about joint + abdo pain if purpuric rash (HSP)
PMHx
- what rashes had before? (eg chicken pox)
DHx
- any new meds recently (esp antibiotics - also esp amoxicillin/ampicillin with EBV)
- any ALLERGIES?
SHx
- any infectious contacts?
BINDS
- immunisations esp important
79
examination of rash:
- acronym of how to describe it? 5
- which locations in the body should you always remember to check for lesions? 4
- what other clinical signs should you look for? 2
what type of rash need further investigations? 1 (ie is not just a clinical diagnosis)
SCALD (get scalded if you don't describe correctly)
- S = Size
- C = Colour
- A = Arrangement
- L = Lesion morphology (vesicle, maculopapular etc)
- D = Distribution
1) Hair
2) Mouth (+ other mucous membranes)
3) Nails
4) in between fingers + toes
ALSO LOOK FOR:
- lymphadenopathy
- fever
nb always do a general exam too: lungs, heart, ENT
Most rashes are clinical diagnoses based on hx + exam EXCEPT PURPURA - which need bloods etc for to find out cause!
80
Main DDx for generalised 'puffiness'
- renal causes of oedema? 3
- other causes of oedema? 4
- systemic conditions which could mimic generalised oedema? 3
RENAL CAUSES OF OEDEMA
= nephrotic syndrome
- glomerulonephritis
- acute or chronic renal failure
OTHER CAUSES OF OEDEMA
- congestive heart failure
- malnutrition (ie kwashiokor)
- liver disease
- urticaria / angioedema
OTHER CAUSES OF 'PUFFINESS'
- obesity
- cushings
- hypothyroidism
81
DDx of 'pallor'
- acute onset? 2
- more insidious onset? (3 causes of hypochromic microcytic anaemia, 4 other insidious causes of pallor)
ACUTE ONSET
- syncope
- shock (incl septic, anaphylactic etc)
MORE INSIDIOUS ONSET
hypochromic microcytic anaemia
= iron deficiency (incl coeliac)
- thalassaemia trait
- lead poisoning
- leukaemia
- other malignancies
- chronic infection
- chronic renal failure
82
PALLOR:
- Red flag associated symptoms to ask about? 2
- what is the most important aspect of BINDS to ask about?
- relevant FHx to ask about? 2
- four red flags on exam?
RED FLAG SYMPTOMS
- fever (or acutely unwell)
- easy bleeding/bruising/purpura
BINDS
- esp NUTRITION
- iron deficiency is by far the most common cause of pallor
- ask about diet (esp how much milk consume)
FHx
- any cosanguity (hhaemoglobinopathies)
- ethnic origin (thalassaemias)
RED FLAGS ON EXAM
- fever (or acutely unwell)
- easy bleeding/bruising/purpura
- HEPATOSPLENOMEGALY (or other palpable masses)
- concerning lymph nodes
83
PALLOR:
- 1st line blood for everyone?
- when do trial of treatment?
- additional bloods to consider for insidious cause? 3
- additional invasive investigation to consider? 1
- additional group of investigations to consider if acutely unwell?
FBC (+/- ferritin) for all
- if shows hypochromic microcytic anaemia (and no red flags on hx/exam) then do trial of treatment with iron before investigating further
TO CONSIDER
- U+E (renal failure)
- haemoglobin electrophoresis (haemoglobinopathies)
- lead levels
bone marrow biopsy (if suspect leukaemia)
SEPTIC SCREEN IF ACUTELY UNWELL
- FBC
- CRP
- blood cultures
- Urine dip
- CXR
- LP
84
DDx of LIMP:
- under 3 years? 2
- 3-10 years? 4
- 10-18 years? 3
- any age? 4
- rarer groups of causes? 4
UNDER 3 YEARS
- DDH
- septic arthritis
3-10 YEARS
- transient synovitis
- septic arthritis
- JIA
- perthes disease
10-18 YEARS
- slipped upper femoral epiphysis (SUFE)
- osgood-schlatter disease
- JIA
ANY AGE
- fracture or soft tissue injury (?NAI esp if under 3)
- osteomyelitis (nb may not show on x-ray initially)
- malignancy (sarcoma, lymphoma, leukaemia)
- Reactice arthritis (mumps, rubella, imms)
RARER CAUSES:
- HAEM conditions (eg sickle cell)
- METABOLIC (rickets)
- NEUROMUSCULAR diseases (cerebral palsy, spina bifida, muscular dystrophy)
- OTHER (HSP, rheumatic fever)
85
Hx of a child with limp:
- features of HPC? (operates - incl 2 Qs about what may have proceeded in onset)
- associated symptoms? (3 local, 7 systemic)
(see other flashcard for rest of hx Qs)
O
- when came on / duration (also sudden or gradual onset)
- any trauma?
- preceding viral illness?
P
- getting worse?
E
- worse in morning? (morning stiffness)
- can they weight bear?
R
- tried anything to make it better?
A
- joint pain
- joint swelling / redness / heat
- muscle weakness
AW FS FIN
- appetite
- weight loss
- fatigue
- sleep - waking up at night?
- fever
- itch / rash
- night sweats
if joint pain, do socrates of the pain!!
T / E
- there all the time? is more worrying
S
- impact on life
86
Hx of child presenting with limp:
- PMHx? 2
- BINDS (what specifically to look for risk factors for)
- FHx? 3
- SHx? 4
nb did HPC in prev flashcard
PMHx
- ever had before?
- any autoimmune conditions?
BIRTH HX
- risk factors for DDH (breech, FHx of DDH, multiple pregnancy)
- any ischaemic damage (cerebral palsy)
IMMS - up to date
NUTRITION (rickets)
DEVELOPMENT
- any delays in walking? (DDH, muscular dystrophy)
- any other delays?
SOCIAL SERVICES Hx
- previous injuries
- child protection concerns
FHx
- autoimmune conditions
- joint problems
- DDH
SHx - ASD OHA DOT
- diet (ricketts)
- exercise (osgood-schlatter)
- who live with
- how interfering with life
87
EXAMINATION OF CHILD WITH A LIMP:
- what initial exams to do? 2
- other things to examine / look for on exam? 5
EXAM OF AFFECTED JOINT
- swelling, erythema, tenderness
- range of motion
pGALS
- knee pain can be referred from the spine
- sacro-iliac joints and spine in joint assessment - look for pain on flexion and/or midline tenderness which may be present in discitis
- Hip ABDUCTION and INTERNAL ROTATION are often the most restricted movements in hip pathology
nb also get them to run - it may exagerrate a limp!
GENERAL INSPECTION
- septic / temp
BRIEF NEURO EXAM
- look for ataxia, weakness
FEEL FOR LYMPHADENOPATHY
- viral infection
- haem / onc cause
FEEL FOR ORGANOMEGALY
LOOK AT SKIN
- extensive bruising or bruising in unusual place may indicate: NAI, haem
88
RED FLAGS FOR CHILD WITH LIMP:
- age of child?
- history? 7
- exam? 5
what could each indicate?
AGE UNDER 3 YEARS
- septic arthritis more common in this age
Pain waking the child at NIGHT
- ?malignancy.
? malignancy, infection, inflamm
- anorexia / appetite loss
- weight loss
- fatigue
- sleep (waking at night)
- fever
- night sweats
Limp and stiffness WORSE in the MORNING
- ?inflammatory joint disease.
SYSTEMICALLY UNWELL
- ?infection
SEVERE PAIN, anxiety, and agitation after a traumatic injury (also reduced peripheral pulses or muscle weakness
- ? evolving compartment syndrome
Signs of REDNESS, SWELLING, or stiffness of the joint or limb
- ?infection or inflammatory joint disease
Unexplained rash or BRUISING
- ?haematological or inflammatory joint disease, or NAI
HEPATOSPLENOMEGALY
- ?oncology
89
Investigations for child with limp:
- 1st line blood? 1
- 1st line imaging?
- possible investigations if swollen joint? 2
FBC
- high WCC in infection + malignancy
X-RAY OF JOINT
- bone tumours
- trauma
- perthes
- SUFE
SWOLLEN JOINT
- USS
- aspirate fluid (if can't tell if transient synovitis or septic)
90
EARLY FEEDING PROBLEMS:
- what should you always monitor?
- what symptoms/signs may they also present with?
- most difficulties with feeding arise from one or more of which three factors?
- who to refer to?
GROWTH CHART
- weigh and measure accurately
MAY PRESENT WITH:
- vomiting
- disturbed bowel habit
- unsatisfactory weight gain
- crying
1) QUANTITY of food
- both under and over-feeding may lead to vomiting and crying
- bottle fed babies are often over fed
- CHECK how parents are making up the formula
2) KIND of food
- early mixed feeding may lead to vomiting, diarrhoea + crying
- introduce solids slowly and gradually
3) feeding TECHNIQUE
- watch how baby is bottle or breast fed, may be in wrong position, teet too small or large
REFER TO DIETITICIAN!
91
Examination of infant with feeding problems:
- describe the examination you would do / what you're looking for? 7
nb is a given that you've already measured weight and length
GENERAL APPEARANCE
- jaundice / pale?
- muscle wasting
FACE
- test suck reflex (with gloved finger)
- check for tongue tie
CHEST ABDO
- listen heart (murmurs)
- listen chest
- feel abdo (for lumps/organomegaly)
92
DDx for neonatal jaundice:
< 24 hrs
- unconjugated? 2
- conjugated? 4
24hrs - 2 wks
- unconjugated? 3
- conjugated? 4
> 2 wks
- unconjugated? 4
- conjugated? 3
nb unconjugated is much more common!!
< 24 hrs UNCONJUGATED
- haemolytic disease (eg rhesus, HBO incompatibility, hereditary spherocytosis, G6PD deficiency)
- neonatal sepsis
< 24 hrs CONJUGATED (ie neonatal hepatitis)
- hepatitis A or B (also a1-antitrypsin)
- TORCH infections
- Inborn errors of metabolism (eg galactosaemia)
- CF
24hrs - 2wks UNCONJUGATED
- PHYSIOLOGICAL
- hypothyroidism
- haemolysis/sepsis
24hrs - 2wks CONJUGATED
- (as above - ie hep, torch, metabolism, CF)
> 2wks UNCONJUGATED
- breast milk jaundice (but should have resolved by now)
- haemolysis
- sepsis
- hypothyroidism
> 2wks CONJUGATED
- BILIARY ATRESIA
- choledochal cyst
- neonatal hepatitis
JAUNDICE IN FIRST 24hrs IS NEVER PHYSIOLOGICAL!
93
NEONATAL JAUNDICE Hx
- most important question? (and two red flag answers to this)
- prenatal Qs to ask? 2
- Qs to ask about labour? 7 (which 3 of these are risk factors for neonatal sepsis)
- Qs to ask about post-natal? 6 (incl feeding, bowels etc)
- conditions to ask if FHx of? 2
- other FHx to ask? 2
AT WHAT AGE DID THE JAUNDICE DEVELOP?
- <24hrs = red flag
- >2wks = red flag
PRENATAL
- full antenatal care received? (if not may have missed rhesus or other screening etc)
- get any infections in pregnancy? (or in contact with anyone - list torch)
INTRAPARTUM
- gestation born?
- method of delivery?
- any trauma to baby during delivery? (bruising/forceps etc)
- how long mebranes ruptured for? (>12hrs sepsis)
- any fever? (sepsis)
- any high foetal HR? (sepsis)
- have to stay in NICU for any period?
POST NATAL
- general behaviour (active/alert or lethargic/needing to be woken)
- how fed? (breast or bottle)
- any feeding difficulties?
- when pass meconium (>48 hrs could be CF)
- How stools been since (pale, chalky = red flag for biliary atresia)
- wet nappies (lack of could mean infection/dehydration)
FHx
- any previous children (any problems)
- cosanguinity? (inborm errors)
- CF
- spherocytosis
94
Exam for NEONATAL JAUNDICE:
| - what looking for? 10
nb you effectively do a full NIPE exam! (maybe minus the hips)
- is baby alert / well
- how handle / tone (hypothyroid)
- extent of jaundice (norm spreads from head towards feet)
- does it blanch to pressure? (hard to see if non-white)
ANY SIGNS OF DEHYDRATION
- mucous membranes
- dry nappy
- sunken FONTANELLE)
ANY FEATURES OF TORCH
- petechiae
- anaemia
- hepatosplenomegaly
95
What four things can exacerbate physiological jaundice?
- bruising
- polycythaemia
- dehydration (eg caused by poor feeding)
- prematurity
96
Investigations for neonatal jaundice:
- initial test for all?
- initial bloods? 4
- other tests to consider to help find cause? 4
- what further tests should be done if infant still jaundiced after 14 days? 2
Measure trans-cutaneous bilirubin (nb can only do after 24hrs, if earlier than that, just do LFTs)
if high, need to find cause:
- FBC (shows anaemia, low or high WCC)
- LFTs (esp proportion conjugated or not)
- Group + save (compare w mothers)
- COOMBS TEST
OTHER TESTS
- TORCH screen
- Septic screen
- TFTs
- Urine metabolic scvreen (inborn errors)
IF STILL JAUNDICE AFTER 14 DAYS (look for biliary atresia)
- liver USS
- liver isotope scan
97
NEONATAL JAUNDICE:
- three symptomatic management options? when use each?
- what other management is needed?
1) DO NOTHING
- if unconjugated bilirubin is lower than line for phototherapy
- reasssure parents that it is self-limiting AND safety net
- encourage feeding if struggling
2) PHOTOTHERAPY
- if unconjugated bilirubin above line for phototherapy
- baby lies under UV light with eyes protected
- have breaks for feeding, changing nappies etc
- measure bilirubin every 4-6 hours during phototherapy
- stop phototherapy once levels of bilirubin have dropped to at least 50micromol/L below threshold for treatment
3) EXCHANGE TRANSFUSION
- if unconjugated bilirubin above line for exchange transfusion (though can try phototherapy first)
REMEMBER JAUNDICE <24hrs is ALWAYS pathological and needs further investigation
FIND AND TREAT UNDERLYING CAUSE!
- unless just physiological!
98
PREMATURITY:
- definition?
- at what gestation are most problems seen though?
birth before 37 wks gestation (8%)
most problems seen in infants born <32 wks (2%)
99
If an infant is born prematurely, what full history should be taken?
- risk factors for prematurity? 11 (as identified in the hx)
- what percentage of premature births are idiopathic? (ie have no risk factors)
TAKE FULL OBSTETRIC Hx
RISK FACTORS:
- young maternal age
- previous premature birth
- cervical incompetence
- multiple pregnancies
- gestational HTN / pre-eclampsia
- antepartum haemorrhage
- congenital infection (TORCH)
- certain medications during pregnancy
- maternal smoking
- maternal alcohol
- domestic violence
40% have no known risk factors
100
COMPLICATIONS ASSOCIATED WITH PREMATURITY:
- CNS? 4
- metabolic? 4
- blood? 2
- cardiovascular? 2
- respiratory? 3
- GI? 5
- other? 2
- later? 4
CNS
- intraventricular haemorrhage (bleeding into ventricular system, can lead to cerebral palsy)
- periventricular leukomalacia (white matter surrounding ventricle deprived of blood and oxygen -> softening)
- cerebral palsy
- retinopathy of prematurity (ROP)
101
CRYING BABY:
- common, benign causes? 6
- red flag associated symptoms of crying which should make you suspect an underlying cause? 7
COMMON
- hunger
- tired
- wind
- colic
- reflux
- teething
RED FLAGS
- inconsolable for >2hours (though if this only red flag then likely colic)
- temperature (over 38 under 3 months, less strict if older)
- won't eat / drink
- bile-stained or projectile vomit
- not weeing
- not pooing (or blood in stools)
- bulging fontanelle
