paeds essential conditions Flashcards

Question

Contraindications for performing an LP on someone with suspected meningitis? 6

Answer 1

- signs of raised ICP - focal neuro signs / focal seizures - shock or CV instability - evidence of coagulopathy - infection of skin at site of LP - signs of meningococcal septicaemia nb bulging fontanelle is NOT a contraindication for LP

Answer 2

BACTERIAL MENINGITIS - neutrophils = HIGH - lymphocytes = normalish - protein = HIGH - glucose = LOW - appearance = cloudy/purulent - opening pressure = HIGH VIRAL MENINGITIS - neutrophils = normalish - lymphocytes = HIGH - protein = normalish - glucose = normal - appearance = cloudy / purulent - opening pressure = normal TB MENINGITIS - neutrophils = normalish - lymphocytes = HIGH - protein = HIGH - glucose = LOW - appearance cloudy / purulent - opening pressure = high or normal nb mumps is unusual in being associated with a low glucose level in a proportion of cases. A low glucose may also be seen in herpes encephalitis

Answer 3

< 1 month - gentamicin - amoxicillin 1-3 months - cefotaxime - amoxicillin > 3 months - cefotaxime ALWAYS SAY YOU WOULD CONSULT TRUST GUIDELINES THOUGH!!! also if > 3 months - steroids (to decrease likelihood of neuro sequelae) PUBLIC HEALTH - prophylactically treat contacts / household members - inform public health

Answer 4

IMMEDIATE - sepsis - seizures - DIC - cerebral oedema - hydrocephalus (dt blockage of ventricle outlets) LONG TERM - hearing loss - focal paralysis - seizures - cerebral palsy (if under 2 years)

Answer 5

acute bacteraemia with vasculitis neisseria meninigtidis 60% also have meningitis nb subtypes of N. Men are: A/B/C/W/Y two waves of incidence: - < 5 years - adolescence

Answer 6

- fever - mottling - cold peripheries - leg pain - breathing difficulties - non-blanching rash

Answer 7

- blood cultures - urine analysis - CXR - LP (also stool culture, if loose stools) always perform in child with fever of unknown origin aged < 3 months

Answer 8

- FBC - U+E - LFT - clotting - CRP - blood cultures - VBG - glucose manage using BUFALO

Answer 9

Red/Purple non-blanching discolouration of the skin dt haemorrhage from small blood vessels under the skin PETECHIAE - < 2mm diameter PURPURA - 3-10mm fiameter ECHYMOSIS - > 1cm diameter

Answer 10

INFECTIVE - viral (most commonly enterovirus eg HFAM, coxsackie, polio) - septicaemia (most commonly meningococcal) IATROGENIC - drug reactions OTHER * Acute lymphoblastic leukaemia * Congenital bleeding disorders * Immune thrombocytopenic purpura (ITP) * Henoch-Schonlein purpura (or other vasculitis) * 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

Answer 11

nb also take full Hx and examine (don't forget joints for HSP and abdo exam/organomegaly for cancers) - BP - urine-analysis (to look for HSP) - FBC - U+E - clotting screen - blood cultures if suspect sepsis: - BUFALO - stop any potential causative drugs if diagnosis unclear, consider skin biopsy

Answer 12

INADEQUATE INTAKE - vegetarien/vegan - fussy eater - over-reliance on cow's milk MALABSORPTION - coeliac disease - parasitic disease (eg hookworm) BLOOD LOSS - meckel's diverticulum - NSAIDs - cysts / tumours - oesophagitis FORTIFIED BREAKFAST CEREALS have loads of iron in vitamin C increases absorption nb breast and cow's milik is a poor source of iron - formula feed better , but this is why should wean at 6 months

Answer 13

normally asymptomatic!! - most toddlers tolerate surprisingly low Hb - easily tired - slow feeding in infants - pallor (conjunctiva, palmar creases, tongue) - breathlessness - mood changes / irritability - reduced cognitive + psychomotor performance - PICA (eating unusual items, eg soil, chalk, gravel) also ask about blood loss and symptoms of malabsorption (eg vomiting, failure to thrive)

Answer 14

FBC - low Hb - low MCV - low MCH - low MCHC U+E - for anaemia of chronic disease, eg renal FERRITIN - low, low iron stores BLOOD FILM - microcytic hypochromic anaemia can also test for coeliac is suspect ANAEMIA IS NOT A DISEASE - IT IS A SIGN (ie look for underlying cause)

Answer 15

encourage iron-containing food - fortified formula - fortified breakfast cereals - mean - green veg - beans - egg yolk avoid prolonged cow’s milk consumption to detriment of solids intake ORAL FERROUS SULPHATE - dose depend on age and kg IF NO RESPONSE AFTER 6 MONTHS, screen for: - thalasaemmia - coeliac disease

Answer 16

Chronic airway inflammation, bronchial hyper-reactivity, reversible airway obstruction. Mucosal oedema, bronchoconstriction, hyper-secretion of mucus always ask about FHx and PNHx of atopy (ezcema, asthma, hayfever - also allergy)

Answer 17

AGE: - asthma = normally diagnosed by age 5, but hard to diagnose in infants/toddlers - viral-induced = normally under 5 (80% grow out of it) ONSET: - asthma = worse with triggers (see other flashcard) - viral-induced = symptoms associated with co-existing URTI TIMING: - asthma = interval symptoms (ie worse at night and early in morning and following triggers) - viral induced = no interval symptoms PHYSICAL EXAM FINDINGS: - asthma = wheeze found on auscultation (+ reduced PEFR) - viral-induced = clinical findings less likely FHx / PMHx - asthma = strong FHx/PMHx of atopy - viral-induced = Hx less likely Don't use steroids in acute management of viral-induced wheeze nb both are responsive to bronchodilators

Answer 18

- do parents smoke? | - any pets?

Answer 19

- wheeze - cough - difficulty breathing - chest tightness

Answer 20

- exercise - cold (or damp air) - pets - dust mites - pollen - mould - tobacco smoke - with emotions or laughter

Answer 21

- TB - URTI - recurrent aspiration - CF - congenital heart disease

Answer 22

ACUTE SEVERE ATTACK - Sats < 92% - PEFR 33-50% best or predicted - can't complete sentences in one breath (or too breathless to talk or feed) - HR >125 (if >5 years) or >140 (if 2-5 years) - RR >30 (if >5 years) or >40 (if 2-5 years) LIFE-THREATENING ATTACK - Sats < 92% - PEFR < 33% best or predicted - silent chest - poor resp effort - cyanosis - hypotension - exhaustion - confusion also look for signs of resp distress (eg accessory muscle use)

Answer 23

O SHIT ME ESCALATE EARLY! FIRST LINE - Oxygen (driven through salbutamol nebs) - Salbutamol nebs - hydrocortisone IV (or oral prednisalone) - ipraptropium bromide nebs SECOND LINE - Aminophylline IV (or IV salbutamol) - Magnesium sulphate IV

Answer 24

under, wheeze is more likely due to another aetiology - aspiration pneumonitis - pneumonia - bronchiolitis - tracheomalacia - complications of underlying conditions (eg congenital heart disease, CF)

Answer 25

ONLY TREAT IF VERY UNWELL / SYMPTOMATIC oxygen (if sats low) pMDI + spacer + mask of salbutamol consider inhaled iproatropium bromide if severe if severe, consider steroids (nb be cautious if repeated episodes as can stunt growth)

Answer 26

- stop parental smoking (if relevant) - reduce pet / animal exposure (if relevant) 1st line = salbutamol inhaler PRN 2nd line = regular inhaled steroids (start low dose and build up) OR leukotrine receptor antagonist if steroids CI 3rd line = add leukotriene receptor antagonist (or refer if under 2) 4th line = refer to resp physician NEXT LINE: if using >3 doses of SABA a week ALWAYS GIVE SPACERS!! (different ones for diff sizes) CHECK INHALER / SPACER TECHNIQUE AT EVERY APPT

Answer 27

- stop parental smoking (if relevant) - reduce pet / animal exposure (if relevant) 1st line = salbutamol inhaler PRN 2nd line = regular inhaled steroids (start low dose and build up) 3rd line = add LABA 4th line = increase dose of ICS 5th line = add steroid tablet AND refer to resp physician NEXT LINE: if using >3 doses of SABA a week ALWAYS GIVE SPACERS!! (different ones for diff sizes) CHECK INHALER / SPACER TECHNIQUE AT EVERY APPT nb children aged > 12, treat as for adults

Answer 28

- impaired growth (height, hair, feet) - adrenal suppression - altered bone metabolism - oral candidiasis

Answer 29

RSV = 70-80% winter under 2 years - peak incidence is 3-6months HIGH RISK - premature babies w chronic lung disease - children w CF - congenital heart disease ^ give these groups monoclonal antibodies (palitvizumab) before they leave hospital after birth

Answer 30

RESP - corzyal symptoms (normally precede wheeze etc - eg runny nose, sneezing) - high-pitched expiratorywheeze - fine inspiratory crackles (not always present) - dry cough - SOB OTHER - low grade fever (< 39 deg) - feeding difficulties nb symptoms peak day 3-5, though cough may continue for 3 wks nb viral induced wheeze more likely where solely wheeze and > 1 year ASK ABOUT: - bladder - bowels (incl feeding) SUSPECT BACTERIAL INFECTION IF: - focal crackles - temp > 39 deg

Answer 31

``` RR - raised HR - raised BP - norm Sats - should be norm Temp - mildly raised AVPU - A ``` RESP - nasal flaring - subcostal and intercostal recessions - harsh cough - wheeze - cyanosis! look in nappies - no wet nappies for 12 hrs is sign of dehydration look for other signs of dehydration - eg fontanelle, skin turgor, mucous membranes etc

Answer 32

CONSIDER ADMITTING TO HOSP - RR > 60 - difficulty with breastfeeding or inadequate oral intake (50-75% of normal volume) - clinical dehydration (eg no wet nappies for >12 hours) ADMIT IMMEDIATELY TO HOSP / PICU - apnoea (observed or reported) - child looks seriously unwell (dr opinion) - severe resp distress (eg grunting, marked chest recessions, RR >70) - central cyanosis - persistent sats <92% on air - milk / fluid intake drops below 50% basically the two indications for admitting someone is either: - resp distress - feeding problems

Answer 33

- humidified OXYGEN is given via a head box and is typically recommended if the sats are persistently < 92% - nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth - suction is sometimes used for excessive upper airway secretions if severe: - capillary blood gas - CXR if diagnosis uncertain: - nasal swab

Answer 34

acute viral laryngotracheobronchitis 6 months - 6 years parainfluenzae vaccination history! - to exclude epiglottitis cause by HiB

Answer 35

prodrome = coryzal symptoms - barking cough - inspiratory stridor - fever symptoms worse at night

Answer 36

WESTLEY SCORE MILD - barking cough = occasional - audible stridor = none at rest - supra and/or intercostal recession = none - behaviour = happy: can eat drink + play MODERATE - barking cough = frequent - stridor = easily audible at rest - supra and/or intercostal recession = yes - behaviour = no / little distress or agitation, child can be placated + is interested in surroundings SEVERE - barking cough = prominent - stridor = inspiratory (+ occasionally expiratory) at rest - supra and/or intercostal recession = yes, marked - behaviour = significant distress + agitation or lethargy or restlessness - tachycardia!

Answer 37

severe AND moderate (ie stridor at rest and intercostal recessions) other criteria for admission: - < 6 months of age - known upper airway abnormalities (eg laryngomalacia, down's) - uncertainty about diagnosis (see DDx flashcard) also if other reasons, eg child looks toxic / cyanosed, dehydration, social situations meaning parent is struggling to look after,

Answer 38

- ACUTE EPIGLOTTITIS (drooling present) - bacterial tracheitis - peritonsilar abscess - foreign body inhalation

Answer 39

just do obs (HR, BP, RR, sats, AVPU, temp) in addition to resp exam - is a clinical diagnosis - try to visualise back of throat - distress the child (as this may worsen symptoms)

Answer 40

single dose PO dexamethasone (or can give IM or inhaled steroid if can't take oral) if going home (ie mild): - symptoms should resolve within 48hrs - use paracetamol / ibuprofen if distressed dt fever - encourage fluid intake - check child regularly, incl at night BRING TO HOSPITAL - continuous stridor - skin between ribs is pulling in with each breath - child is restless or agitated CALL AMBULANCE - very pale, blue or grey (incl blue lips) for > few secs - unusually sleepy or not responding - real difficulty breathing (windpipe pulling in , flaring nostrils) - really agitated, uncalmable - can't talk (if applicable) - can't swallow - drooling IF ADMITTED - high flow oxygen - nebulised adrenaline (if still not work then consider intubation) remember everyone gets same single dose of steroids, regardless of severity

Answer 41

Haemophilus influenzae type B unvaccinated children

Answer 42

rapid onset - high temp, generally unwell - stridor - drooling of saliva OTHER SYMPTOMS - sore throat - odynophagia (painful swallowing) - muffled voice ('hot potato' voice) - cervical lymphadenopathy - tripoding (older kids) kids with epiglottitis rarely have a cough (helping to differentiate it from croup)

Answer 43

DON'T look in mouth! - anaesthetist - ENT Abx (once airway secured) lateral neck x-ray - thumbprint sign

Answer 44

COMMONEST = STREP PNEUMONIAE NEONATES - Group b strep - gram -ve enterococci ``` CHILDREN < 5 YEARS - VIRAL: RSV - strep pneumoniae - haem influenzae - bordetella pertussis - chlamydia trachomatis (also infrequent, but serious: staph aureus) ``` CHILDREN > 5 YEARS - strep pneumoniae - mycoplasma pneumoniae - chlamydia pneumoniae consider TB in all ages! (ask about foreign travel!) nb hard to tell difference clinically between viral and bacterial pneumonia in kids - tend to treat as bacterial (as also can't tell on CXR either) nb don't focus on learning all that much, just that strep pneumoniae is most common and organisms from mother's genital tract most common in neonates

Answer 45

RESP - dyspnoea - cough - wheeze - crackles - reduced air entry (dull percussion) - nasal flaring - inter/sub costal recessions OTHER - lethargy - poor feeding - fever - localised chest, abdo or neck pain (suggests bacterial cause)

Answer 46

amoxicillin = 1st line macrolides (norm clarithromycin) if atypical (mycoplasma or chlamydia) is suspected (or if pen allergic) co-amoxiclav if severe (or associated with flu) I WOULD LIKE TO CONSULT THE TRUST GUIDELINES - encourage oral intake (IV fluids if necessary) - maintain O2 sats above 92%

Answer 47

PHARYNGITIS: - adenovirus - enterovirus - rhinovirus - group A beta haemolytic strep TONISILITIS - ebstein-barr virus - group A beta haemolytic strep nb just learn that either viral or group A strep (strep pyogenes)

Answer 48

RESP - painful throat - wheeze - blocked nose - nasal discharge OTHER - fever - ear ache - abdo pain (mesenteric adenitis - common < 16 yrs - inflammation of abdo lymph nodes) CENTOR CRITERIA (need 3 or more): - tender cervical lymph nodes - purulent exudate on tonsils - fever - absence of cough always ask about feeding (and wet nappies) in infants

Answer 49

- encourage oral intake - analgesia (paracetamol, ibuprofen) ANTIBIOTICS: penicillin (check this) DO NOT give ampicillin or amoxicillin (as can get rash if cause is actually EBV) nb amoxicillin and ampicillin are the same thing!

Answer 50

typically under 5 MAIN TWO DDX - asthma (look at triggers, diurnal symptoms, age, hx of atopy) - foreign body inhalation (ask hx, onset) MANAGEMENT - salbutamol inhaler (if over 6 months) - oxygen, if sats < 92% nb don't gve steroids!!

Answer 51

1 in 25 are carrier if both parents carriers: - 1 in 4 will have CF - 2 in 4 will be carriers - 1 in 4 will be normal mutation in CFTR protein (chloride channels) - causes faulty exchange of chloride and sodium -> lots of mucus -> defective mucociliary clearance

Answer 52

screening: Day 5 blood spot test in all babies (tests trypsin levels) (if screening comes back +ve or any FHx of CF, do sweat test) diagnostic: sweat test (if CF, have abnormally high sweat chloride) nb there are things that cause a false positive sweat test (but don't bother learning) nb genetic test is also normally done to confirm! CXR - hyperinflation - peri-bronchial thickening - bronchiectasis (signet ring sign) lung function test = obstructive resp defect

Answer 53

1) MECONIUM ILLEUS - around 20% - can include billous vomiting - less commonly, prolonged jaundice 2) RECURRENT CHEST INFECTIONS - around 40% 3) MALABSORPTION - around 30% - failure to thrive (despite huge appetite) - steatorrhoea 4) OTHER FEATURES - around 10% - eg liver disease most are picked up on newborn screening, but 5% are diagnosed after age 18 Qs to ask - any delay in passing first meconium? - jaundice as a neonate? (or now) - number of chest infections? - growth? (weight and height - plot it!) - consistency of stools?

Answer 54

- crackles - chest deformity - nasal polyps - evidence of malnutrition - finger clubbing - firm enlarged liver + splenomegaly - delayed puberty

Answer 55

- bronchiectasis / chronic infections - nasal polyps + sinus infections - diabetes (not everyone gets it but, if they do, tend to develop it in teenage years) - nutritional deficiencies -> poor growth - liver problems - fertility problems (men infertile, women subfertile) - osteoporosis - mental health problems (secondary to living with a chronic disease)

Answer 56

- regular (at least twice daily) chest physio - high calorie diet (incl high fat intake) - fat soluble vit supplements (ADEK) - CREON (pancreatic enzymes) taken with food - prophylactic antibiotics - pneumococcal vaccine - influenza vaccine - mucolytics (nebulised enzymes, take during physio) - steroids - lumacaftor/ivacaftor - ie orkambi (now funded by NHS) - heart + lung transplant nb people w CF shouldn't meet others w CF! for risk of sharing bugs!

Answer 57

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

Answer 58

Chronic constipation most common age 2-4 whilst potty training Child should be faecally continent by age 2-3 - Abnormal if later than 5 years Encopresis: Voluntary passage of whole formed stools in inappropriate places, by child who is mature enough to be continent. – Often behavioural problem

Answer 59

following an acute illness as child may have not eaten or drunk for a few days and so may be dehydrated -> constipation always ask about any recent illnesses

Answer 60

- diet - lack of exercise - holding of stools - change in routine (incl birth of sibling, starting school) - genetics - medication

Answer 61

- 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

Answer 62

functional constipation is caused by situational, psychological, developmental or dietary issues nb 95% of constipation is functional (organic is rare) BEHAVIOURAL - young children may ignore the urge to defecate, negative feelings towards public toilets FOOD ALLERGIES - milk, egg, wheat being the most common allergies associated with constipation DIETARY FACTORS - reduced fluid and dietary fibre intake THE CYCLE - constipation -> hard stools -> anal fissure -> painful defecation -> witholding -> further constipation and harder stools (as longer in the bowel, more water is absorbed) etc ROME CRITERIA FOR FUNCTIONAL CONSTIPATION (2 or more in a child with developmental age of at least 4) - less than 3 defecations per week - at least one episode of faecal incontinence in a week - hx of painful or hard bowel movements - presence of large mass in the rectum - hx of large diameter stools that may obstruct the toilet (nb technically these criteria must be filled for at least once a week for 2 months before diagnosis)

Answer 63

- height and weight (plot on customised growth chart) - abdomen (palpable faeces, distension, bowel sounds) - anal area (examine for fissures) - spine (deep sacral cleft or tuft of hair) - neuro of LL PR is not normally required, if it is, do under GA

Answer 64

results from a documented pathological condition - ie opposite to functional - only about 5% of constipation in children is organic CAUSES - anatomical malformations - endocrine - GI diseases (eg coeliac) - neuropathic diseases - abnormal abdominal musculature (rare) - connective tissue disorders (rare) nb if hypermobility of joints, ask about GI symptoms - as often get reflux / constipation too

Answer 65

- hypercalcaemia - hypothyroidism ``` ask about FHx of any autoimmune conditions: - coeliac - hypothyroid - diabetes etc ```

Answer 66

RULE OUT - coeliac - hypothyroidism - hirschprung's (if failure to thrive or in infancy) (see later flashcard for hirschprungs)

Answer 67

delayed meconium - func = no - hirsch = common age at onset - func = after 2 years - hirsch = at birth faecal incontinence - func = common - hirsch = very rare history of fissure - func = common - hirsch = rare failure to thrive / malnutrition - func = uncommon - hirsch = possible enterocolitis - func = none - hirsch = possible abdo distension - func = rare - hirsch = common presence of stool on PR - func = palpable stool - hirsch = empty

Answer 68

- symptoms of severe constipation - overflow soiling - faecal pass palpable in abdomen (PR should only be carried out by a specialist) if found, often start management of impaction in hospital before going to outpatient - is same as for constipation but higher doses - nb symptoms may get worse before get better

Answer 69

DIET - plenty of fluids - avoid excessive cow's milk - some fibre, but not loads (need less than adult) LIFESTYLE / BEHAVIOUR - regular toileting - reward-based system MEDICATION - 1st line: movicol paediatric plan (aka polythylene glycol or PEG) - 2nd line: Senna (or other stimulant) give laxatives for at least 3-6 months - aim for one soft, easy to pass bowel motion a day - slowly taper off dose, but increase if get symptoms again nb commonest cause of treatment failure is stopping laxatives too early

Answer 70

OSMOTIC - Lactulose - PEG (aka movicol) STIMULANT - Bisacodyl - Senna STOOL SOFTENER - Coloxyl drops - Liquid parafin

Answer 71

- vomiting - diarrhoea ASK ABOUT: - consistency of stools - blood in stools - blood in vomit - appetite / food intake (% of normal) - fluid intake (what type of fluid, water or rehydration?) - abdo pain - fever TO DETERMINE CAUSE - anyone else sick? (house or nursery/school) - recent travel? - any new food in last 48hrs? (ie food poisoning)

Answer 72

normally viral - rota virus - adenovirus - norovirus less common: - salmonella, campylobacter, E. Coli O157, listeria, cholera vomiting norm: 1-2 days (most stop within 3) diarrhoea norm: 5-7 days (most stop within 2wks) commonest complication = dehydration

Answer 73

- small bowel obstruction (intussusception) - appenditicitis - food allergy - lactase deficiency - bacterial sepsis - meningitis - UTI

Answer 74

MILD (3%) - dry lips + mouth - CRT normal MODERATE (5%) - sunken eyes + fontanelle - decreased skin turgor - fewer wet nappies - CRT 2-5s SEVERE (10%) - reduced consciousness - high RR - high HR - late CRT >5s - Low BP (v. late sign) OTHER RED FLAGS - fever (temp >38 age under 3mnth, temp >39 age over 3 month) - meningism (headache, neck stiffness, photophobia) - bilious vomiting - blood or mucus in stools - severe or localised abdo pain - abdo distension - rebound tenderness

Answer 75

IF MILD - advise fluids (incl oral rehydration) - hand washing in family - stay off school/daycare until 48hrs symptoms free - safety net specific red flags to bring back in for OPTIONS IF MODERATE / SEVERE - fluids (oral if possible, or IV) - if vomiting, ondasetron - can do NG tube if need - zinc (can reduce severity of episodes in under 5s) nb can also consider vit A supplements (nb advise parents against fruit juice or fizzy drinks as this can worsen - squash is fine)

Answer 76

LISTERIA - bloody diarrhoea - fever - abdo pain CHOLERA - rice water stools - rapid dehydration

Answer 77

- bloody diarrhoea Associated with severe, large outbreaks, Infective dose is very small - Point source outbreak = likely to be E.coli - Burgers/ products with minced meat = high risk poisoning. normally just supportive treatment is required! HAEMOLYTIC URAEMIC SYNDROME associated with E.coli 157. (produces verotoxin) Triad: - Low Hb - Low platelets - High Urea Can cause AKI Early liaison with paediatric nephrology Monitor fluid balance and electrolytes Blood transfusion/ dialysis may be required.

Answer 78

GOR = effortless passage of gastric contents - aka posseting - occurs after feeds - 50% of babies have - develops before 8 wks and usually resolves by a year GORD = reflux of gastric contents with other symptoms ALWAYS ASK IF GAINING WEIGHT APPROPRIATELY (check growth chart) GORD - excessive irritability - faltering growth - persistent cough / stridor - hoarseness - recurrent pneumonia - apnoea - Brief resolved unexplained event (BRUE) (Sudden onset pain, limp, apnoea - lasts for less than 60secs)

Answer 79

- cerebral palsy (or other neuro problem) - premature babies - chronic lung problems

Answer 80

pH study - overnight oesophageal probe - though this often not done 1st LINE - small, regular feeds (though not more frequent than every 3hrs) - wind baby during feeds - keep baby upright during / following feeds (at least 25 degs) 2nd LINE - add thickener to milk or pre-thickened formula (anti-reflux milk) 3rd LINE - Ranitidine or PPIs

Answer 81

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

Answer 82

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

Answer 83

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) - bulimia - pregnancy

Answer 84

Cyclic = severe, discrete episodes of vomiting associated with pallor, lethargy +/- abdominal pain - norm a non-GI cause - idiopathic - endocrine - abdominal migraine - CNS disease

Answer 85

RED FLAGS - projectile vomiting - bile-stained - haematemesis (blood or coffee ground) - when started? (any proceeding event - think head injury) - other features of vomit: volume consistency, colour? - how many times? (getting worse?) - ever had before? - appetite - failure to thrive / weight loss (RED FLAG) - fluid intake / wet nappies? - pain (abdo, head) - diarrhoea - 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!

Answer 86

- 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

Answer 87

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)

Answer 88

- low chloride (as vomiting HCl) - low potassium ie a hypochloraemic, hypokalaemic metabolic alkalosis

Answer 89

- dehydration - electrolyte imbalance - GI bleeding - mallory weiss tear - oesophageal stricture - barret's metaplasia - aspiration - faltering growth - anaemia - damage to teeth

Answer 90

1) Intrauterine/ prenatal = most rapid phase of growth 2) Infantile 3) Childhood 4) Pubertal

Answer 91

3.3kg (7.8lbs) 35cm circum

Answer 92

150ml/kg/day until age 6 months overfeeding can -> GORD / vomiting wean at 6 months

Answer 93

1st 10kg = 100ml/kg/day 2nd 10kg = 50ml/kg/day subsequent kg = 20ml/kg/day for a child of 37kg = (10 x 100) + (10 x 50) + (17 x 20) = 1840 ml/day = 76.6 ml/hr nb Can do to decimal point in kids, esp neonates, ie don’t round up or down nb use sodium chloride 0.9%

Answer 94

0.9% sodium chloride 20 mls/kg over less than 10 mins ``` exceptions: - child in DKA - neonate (also child w HF) ^ give 10 ml/kg instead ```

Answer 95

- fatigue / lethargy - weight loss - polydipsia - polyuria "4 Ts: tired, thirsty, toilet, thin" peak presentation = 5-7 years = puberty DKA - abdo pain - vomiting - fast, deep breathing (then kussmaul) - reduced consciousness

Answer 96

serum blood glucose (random) - DM if >11.1mmol ^do this straight away as don't want to send someone away as they may go into DKA fasting glucose - DM if >7mmol nb don't do HbA1c to diagnose in kids ALL YOU NEED to diagnose a child with DM is a random blood glucose >11.1 AND signs + symptoms IF SUSPECT DKA - VBG - capillary ketones - U+Es - FBCs (any infection)

Answer 97

``` Diabetes = BM >11mmol Ketosis = ketones >3mmol Acidosis = pH <7.3 (or bicarb <18mmol) ``` KIDS - K = potassium (monitor and add to fluids if/when low) - I = Insulin (1-2 hrs post fluids) - D = Dextrose (after insulin, once BMs start to drop but acidosis still not cleared) - S = Saline (give 10ml/kg bolus first then adjust) ``` 1st = Saline 2nd = Insulin 3rd = Potassium (or when need) 4th = dextrose ``` ``` MONITOR: - BMs - blood gas (treatment guided by pH) - ECG (potassium) (also obs as well) ``` ALWAYS LOOK FOR A FOCUS OF INFECTION (esp in known diabetic!) ALWAYS FOLLOW TRUST GUIDELINES WHEN TREATING DKA

Answer 98

1) CEREBRAL OEDEMA (major cause of death) most common if: - pH <7.1 - new onset DM - long symptom duration - sodium imbalance signs - headache - agitation - reduced GCS - cushing's triad (irregular decreased resps, low HR, high BP) management: - mannitol - hypertonic saline 2) HYPOKALAEMIA - arrythmias (do ECG monitoring) 3) ASPIRATION - dt low GCS

Answer 99

- basal and bolus dosing (BD long-acting and short acting after meals) - have rapid-acting 15-20 min before food - continuous insulin pump (rapid acting insulin in this) - educate about importance of carb counting - educate how to take BMs + inject (incl rotating site) - educate about DKA and hypo, how to avoid and what signs to look out for and initial management monitoring: - capillary glucose multiple times a day - HbA1c nb low variability in BMs is associated with better outcome than good HbA1c TEENAGERS FIND IT HARD TO MANAGE! HELP THEM! - also counsel that need higher insulin doses if ill LONG TERM COMPLICATIONS: - nephropathy - neuropathy - retinopathy regularly screen for: - thyroid problems - coeliac disease

Answer 100

COMMON CAUSES - excess insulin given - not enough carbs eaten - exercise - stress - hot weather - alcohol consumption (tends to happen overnight after drinking) - D+V SYMPTOMS - feeling hungry - feeling 'shakey' - headache - nausea SIGNS - pallor - sweaty - tremor - tachycardia - drowsy / irritable - coma or convulsions Glucose < 4 mmol (nb <2.8 mmol in non-diabetics) nb common to have mild or moderate hypos even if well controlled - severe hypos (LOC, seizures) are rare

Answer 101

Conscious pt: sugary snacks (jelly baby) or ‘hypostop’ gel - RECHECK glucose after 15 mins Unconscious pt: - Hypostop gel can be rubbed into buccal mucosa. - If IV access = give 2mls/kg 10% dextrose as bolus, follow with glucose infusion. - If critically ill, then glucagon IM (parents can do this) Recheck serum glucose regularly. Within 15 mins of treatment

Answer 102

FAILURE TO THRIVE (FTT) 1) Drop in at least 2 centiles 2) less than 0.4th centile differentiate from child who is constitutionally small / short - use personalised growth charts which take into account parents height + weight

Answer 103

- Inadequate caloric intake - Inadequate nutrient absorption - Increased metabolism DON'T FORGET - genetic abnormalities, eg Turner's syndrome - medications (eg steroids)

Answer 104

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)

Answer 105

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

Answer 106

INCREASED METABOLISM - chronic lung disease of immaturity - congenital heart disease - chronic infection (eg HIV, TB) - chronic inflammation (eg asthma, IBD) - hyperthyroidism - renal failure - malignancy

Answer 107

- 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

Answer 108

BINDS - birth hx - immunisations - nutrition (incl bladder + bowel) - development - social (smoking status of parents, who at home etc) perform a FULL BODY examination (ie abdo, chest, skin for rashes etc) plot an individualised growth chart (based on parental height) blood count (and maybe ferritin) to rule out iron deficiency anaemia

Answer 109

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

Answer 110

Non-progressive brain lesion that manifests as motor or postural abnormalities - Can occur at any point between conception and 3 years of age - Injury after 3 years = acquired brain injury ANTENATAL (80%): - cerebral malformation - congenital infection (TORCH) - IUGR INTRAPARTUM (10%): - birth asphyxia/trauma POSTNATAL (10%): - intraventricular haemorrhage - hypoglycaemia - meningitis - head-trauma ONLY 1/3 HAVE AN IDENTIFIABLE CAUSE! SOOOOO IMPORTANT TO ASK ABOUT BIRTH AND ANTENATAL HX

Answer 111

TORCH T - Toxoplasmosis O - Other: - syphilis - VZV - parovirus B19 R - Rubella C - Cytomegalovirus H - HSV

Answer 112

non-progressive brain injury DEVELOPMENTAL - delayed motor milestones - early hand preference (should be ambidextrous till 18 months) - visual and hearing impairment OTHER SIGNS - poor feeding (oromotor incoordination, slow feeding, gagging + vomiting) - spasticity (abnormal tone and posturing, hypotonia) - abnormal gait, once walking achieved (toe walking) - primitive reflexes may persist - fits as a neonate - poor growth

Answer 113

- learning difficulties (60%) - epilepsy (30%) - squints (30%) - hearing impairment (20%) nb 1/3 of kids with cerebral palsy will have normal intelligence (although maybe more than this - assume that no problem) AT RISK OF: - recurrent resp infection - GORD (may be concerns about swallowing) - constipation - UTI (also at risk of FTT as use a lot of energy)

Answer 114

BY THE SITE IT AFFECTS: SPASTIC DIPLEGIA: - Bilateral spasticity - toe walking - upper motor neuron signs - 'SCISSORING' gait SPASTIC HEMIPLEGIA: - one side of the body – upper limb is usually more affected than lower limb - Hand dominance before 1 year of age - 'CIRCUMDUCTION' gait SPASTIC QUADRAPLEGIA: - all four limbs BY THE TYPE OF MOTOR DISORDER SPASTIC CEREBRAL PALSY (70%): - Velocity dependent increased muscle tone and weakness in parts of the body affected – due to a lack of cortical inhibition of the spinal reflex arcs - Spastic hemiparesis commonly associated with epilepsy DYSKINETIC (DYSTONIC) CEREBRAL PALSY: - Involuntary and uncontrollable muscle tone fluctuations, sometimes involving whole body DYSKINETIC (CHOREOATHETOID) CEREBRAL PALSY: - Small, rapid and irregularly repetitive unwanted movements - Random and jerky or long slow writhing movements ATAXIC CEREBRAL PALSY: - Impairment of cerebellum - often genetic and is rare. NB DON'T BOTHER LEARNING THE DETAILS - JUST BE AWARE THAT THERE ARE DIFFERENT TYPES!

Answer 115

- U+E - LFT - TFT - MRI brain - hearing tests - vision tests - EEG - karyotyping Severity based on Gross Motor Function Classification System (I is least severe, V most severe) - look up pictures

Answer 116

baclofen (can also use benzos, botox, and orthopods may help) - occupational therapy - physiotherapy - SALT - opthalmology (strabismus + other problems) - orthopoaedic surgeons (hip dislocation, scoliosis)

Answer 117

6 months to 6 years 3% of kids will have at least 1 strong FHx - ask if parents had febrile seizures when young - URTI - ottitis media - UTI

Answer 118

need to exclude meningitis!! Increased likelihood of meningitis if: - triggered by low-grade fever - prolonged hx (>24hrs) - young (< 1 year) - abx from GP - focal - prolonged recovery (> 30 mins) - no obvious source of infection

Answer 119

TYPICAL - generalised tonic clonic - less than 15 mins (norm 3-4 mins) - only one per febrile illness - should be complete recovery within an hour ATYPICAL - focal seizure - over 15 mins (incl status) - more than one seizure within 24hrs (or within the same febrile illness)

Answer 120

A-E approach - always check the child actually has a fever, if they don't then it is NOT a febrile convulsion - nb treat with benzos if still fitting after 5 mins - antipyretics if child irritable (won't reduce chance of fit though) NEED TO FIND SOURCE OF INFECTION: - ENT exam - urine dip - CXR - bloods - capillary glucose nb if it is a suspected bacterial cause then treat with abx as appropriate if atypical, do LP (must exclude meningitis) - also do if can't find source of infection! - tend to do if under 9months as well COUNSEL PARENTS!! (see other flashcard for exactly what to counsel parents on)

Answer 121

chance of recurrence = 1/3rd increased chance of recurrence is: - age < 18 months - FHx febrile seizures - lower temp triggering seizure - shorter duration of fever before fit - low social class IF HAPPENS AGAIN: - put in recovery position - start timer, call 999 if > 5 mins - DON'T put finger (or anything else) in mouth while fitting - make sure to find source of infection, good idea to go into walk in /GP afterwards to check okay INCREASED RISK OF EPILEPSY: - atypical febrile seizures - abnormal neurology / developmental delay prior to event - FHx of epilepsy in 1st degree relative if 0 risk factors, just population risk of epilepsy, if 3 then 50% risk DON'T BE SCARED ABOUT SAYING EPILEPSY - that's what parents will be thinking anyway!!

Answer 122

can be mistaken for rigors RIGORS - uncontrolled shivering (as opposed to rhythmic tonic clonic) - get peripheral cyanosis - not usually sleepy afterwards (no post ictal phase) nb Febrile convulsions more commonly associeted with viral infections, whereas rigors more likely to be viral or bacterial

Answer 123

neglect or lack of stimulation

Answer 124

- check their hearing!! - check how many languages are spoken at home (if 2+ may be slow to begin with but then become fluent in both) also be aware that neglect can lead to slow language also check eyesight if any problem with motor skills

Answer 125

- gross motor - fine motor and sight - speech and hearing - social interaction and play

Answer 126

- moro / startle reflex (lying on back) - parachute reflex (lying on belly) - grasp reflex (grasp finger) - sucking reflex (suck on finger) - rooting reflex (tap cheek, they turn towards it)

Answer 127

birth - When held prone knees under abdomen 6-8 wks - Briefly hold head up when held prone 3 months - HOLDS HEAD UP - loss of palmar grasp 4-5 months - reaches out for toy 6-9 months - rolls front to back (6 months) - SITS without support - CRAWLS 10-12 months - CRUISING on furniture 13 months - walks 15 months - WALKS ALONE 18 months - walks well 2 years - JUMPS with 2 feet together 3 years - up & down stairs in adult fashion - rides a tricycle 4 years - stands on one leg for 4 secs 5 years - skips

Answer 128

birth - startles to sudden noises 6-8 wks - FIXES & FOLLOWS through 90 degrees 3 months - reaches with PALMAR GRASP - holds a rattle - fixes & follows through 180 degrees 4-5 months - plays, hands together 6-9 months transfers object hand to hand 10-12 months - immature pincer 13 months - NEAT PINCER GRIP - casting (drops toys deliberately & watches them fall) 15 months - to & fro scribble 18 months - 2 block tower 2 years - towers 6-7 bricks - circular scribble 3 years - towers 9-10 bricks - copies circle - makes a train of bricks 4 years - copies a square and cross - 10 block tower 5 years - copies a triangle - draws a man with 3 parts

Answer 129

birth - quiets to voice 6-8 wks - vocalises 3 months - turns to sound at ear level 4-5 months - squeals 6-9 months - BABBLES - turns to voice 10-12 months - double-syllable babble 13 months - SINGLE WORDS 18 months - points to one body part 2 years - 2 WORD SENTENCES - 50 words - points to 2 body parts 3 years - Name, age, sex on request - 1000 words - ‘What’s that?’ - COUNTS TO 10 - 5 body parts 4 years - Tells stories - Uses past tense - Understands adverbs - Counts 1-20 5 years - knows colours, age, address

Answer 130

6-8 wks - SOCIAL SMILE 3 months - laughs 4-5 months - excited by food 6-9 months - STRANGER AWARENESS (around 9 mnths) 10-12 months - WAVES BYE - plays peek a boo - empties cupboard 13 months - UNDERSTANDS NO - gives up a toy 15 months - domestic mimicry - indicates wants 18 months - drinks from a cup - can ask for food & drink 2 years - feeds self with spoon - has difficulty sharing 3 years - MOSTLY DRY BY DAY - dresses self - understands turn taking 4 years - parallel play with other children 5 years - Names a friend - Knows what to do if lost, cold, hungry. - Comforts in distress

Answer 131

REFER IF: - not fixing and following at 6 weeks - neonatal reflexes for longer than 6 months - no sitting without support by 12 months - no babbling speech by 12 months - hand preference before 18 weeks - not walking by 18 months - exclusively toe walking - no understandable speech by 2.5 years

Answer 132

delay in more than 2 of 4 of the domains of development

Answer 133

adjust for their gestational age (up until 2 years)

Answer 134

do a gene test on all kids with autism

Answer 135

creatinine kinase

Answer 136

night and daytime continence = around 3 or 4 years ENURESIS = involuntary discharge of urine by day, night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract primary = never achieved continence secondary = child has been continent for at least 6 months before nb secondary is normally more concerning

Answer 137

TO EXCLUDE: - constipation - diabetes - UTI (if recent onset) - psychological distress OTHER CAUSES: - renal tract abnormalities - sexual abuse

Answer 138

OPERATES - onset? (ever been dry for 6 months?) - progression? (freq increasing) - exacerbating (stress?) - relieving (what have you tried? waking them up etc) - associated (see below) - timing - episodes symptom free - severity (IMPACT on life - distressing child and/or parent) ASSOCIATED SYMPTOMS - dry by day? any leakage? - constipation? - pain on urination - polydipsia - do they know when they need to pee? - do they know when they've peed? - any problems with lower limb movement / power? LIFESTYLE - what drinking? any caffeine? - how much? - when? - peeing throughout the day? - any recent changes? starting school? trauma at home etc? ALSO ASK IF ANY FHx of bed wetting!

Answer 139

FIRST LINE: - DM testing - urineanalysis OTHER - GU tract abnormality screening - psychological screening

Answer 140

7 years (hard for child to understand before then - though could start some of the behaviour stuff) TREAT CONSTIPATION, if present LIFESTYLE - increase fluid intake during the day (though not before bed) - avoid caffeine - encourage regular toilet breaks - encourage them to go to the toilet before bed - don't punish them for wet night - get them to help you tidy up in the morning (also stop using nappies and don't lift a sleeping child to the toilet) 1st line - STAR CHARTS - reward (non-food) for doing behaviours (ie drinking a lot, going to the toilet before bed etc) 2nd line - ENURESIS ALARM - alarm is triggered (auditory or vibrating) when fluid is detected - try for at least 4 weeks - more successful long-term than medications 3rd line - MEDICATIONS - 1st line is desmopression (take just before bed, only a temporary fix) - 2nd line is oxybutynin (reduces detrusor muscle instability in children with small bladder capacity + urgency) alarm and medications only if over 7!

Answer 141

- temp 38 and above - not feeding well / failure to thrive - vomiting - diarrhoea - irritable / lethargic - jaundice - strong smelling urine - haematuria ie INCREDIBLY non-specific - so do a urine test in any sick child!

Answer 142

- dysuria - haematuria - frequency - secondary enuresis - fever +/- rigor - lethargy - abdo / loin pain - vomiting - diarrhoea still quite non-specific so still just do a dipstick on most unwell children nb 1+ haematuria is normal, 3+ or more is worrying ASK IF ANY CONSTIPATION!!

Answer 143

- temp - BP (could be dt kidney abnormality) - HR ABDO EXAM - tenderness - kidney masses - size of bladder (large in boys, suspect PUV) examine for 1) spinal abnormalities (increased risk of UTI) 2) genetalia (any abnormalities? 3) any other sources of infection: throat, ear, chest, fontanelle, wounds

Answer 144

urine dipstick, if positive, send for culture nb if only leucocytes are up (and not nitrites) then may or may not be a UTI, only treat if symptoms! consider blood cultures if septic or, esp in younger children, do a full septic screen (inc LP) if not a clear source of infection

Answer 145

- clean catch (hold over a vomit bowel) - urine collection pads (which you then squeeze out - don't just use sanitary towels, cotton wall) - also this not ideal! - bag - suprapubic aspiration

Answer 146

- any signs/symptoms of a UTI - unexplained fever of >38 - with an alternative site of infection but who remain unwell so basically, vast majority of kids!

Answer 147

under 3 months - IV cef-something - norma do an LP + full septic screen as well Upper UTI (>3m) - IV / oral cef-something - 7-10 days Lower UTI (>3m) - oral nitrofurantoin / trimethoprim - 3 days I WILL CONSULT TRUST GUIDELINES! if not improving within 48 hrs then do USS

Answer 148

- ANY child under 3 months - culture grows anything other than e coli - recurrent UTIs - if not improving after 48 hrs of abx - poor urine flow - abdominal or bladder mass - raised creatinine - seriously ill / septicaemia USS (1st line) - gross abnormality of kidneys or urinary tract DMSA - isotope scan - morphology and function MCUG (micturating cystourethrogram) - picks up reflux - is a dynamic scan with contrast

Answer 149

RENAL ABNORMALITIES - neuropathic bladder (secondary to spinal probs) - vesicoureteric reflux - posterior urethral valves (only in boys - get an obstructive picture) - duplex kidneys - horseshoe kidneys ^can give these children prophylactic abx (should consider in any recurrent UTI in kids, even if can't find cause)

Answer 150

OTHER CONTRIBUTING FACTORS: - obstruction from contipation - infrequent voiding - hurried micturation - not enough water intake - wiping back to front (in girls) - nappies changed too infrequently

Answer 151

reflux of urine from bladder, up the ureters to the kidneys MCUG to diagnose monitor renal function with U+E (?any repeat scans?*) - recurrent UTIs - hydronephrosis -> scarring + CKD all get prophylactic abx surgical correction if severe (ie big impact on kidney function) most resolve spontaneously by age 5 - but renal damage may already have occurred

Answer 152

typically before 6 months - nb clears in around 50% by 5 years and 75% by 10 years - PMHx allergies, allergic rhinits, asthma - FHx atopy or allergies nb breastfeeding may reduce risk

Answer 153

INFANTS - face - trunk YOUNG CHILDREN - extensor surfaces ADOLESCENTS - flexor surfaces - skin creases of face + neck

Answer 154

- dry skin - sweating / heat - chemical irritants - allergies - emotional stress

Answer 155

- wash with emollients - use emollients (prescribe large quantities) - avoid triggers FLARE UPS - topical steroids if using emollients and steroids: emollient should be applied first, wait 30 mins, then apply steroid severe cases = ORAL CICLOSPORIN (a type of immunosuppressant DMARD) - also potentially topical tacrolimus

Answer 156

ALWAYS ADMIT CHILD <3 YEARS WITH ACUTE ONSET LIMP

Answer 157

infectious arthritis of a synovial joint 50% of all cases present in first 2 years - nb twice as common in males mechanisms of spread - from osteomyelitis - from haematogenous spread most common = staph aureaus consider neisseria gonrrhoea in adolescents (ie ask sexual hx) JOINTS - 75% lower limb - hip most common, then knee, then ankle nb knee most common in adults

Answer 158

only 50% of infants will have a fever at presentation - FEVER - systemic signs of infection - hot, red, swollen joint - reduced range of movement - NON-WEIGHT BEARING nb onset is acute

Answer 159

TRANSIENT SYNOVITIS - can present almost identically and is more common than septic arthritis, but, because septic is more dangerous, treat as septic arthritis until proven otherwise - if non-weight bearing and temp >38.5 then more likely to be septic arthritis - perthes disease - slipped upper femoral epiphysis (SUFE) - osteomyelitis - trauma - tumours - 1st presentation of juvenile idiopathic arthritis

Answer 160

JOINT ASPIRATION - send for microscopy and culture - do before start abx!! - blood cultures - FBC - ESR - CRP x-ray joints - widened joint spaces can suggest effusion - later signs: subluxation / dislocation, space narrowing, erosive changes MRI if diagnosis in doubt, to exclude osteomyelitis if septic joint with haem influenzae, do LP - as increased incidence of meningitis

Answer 161

whatever the culture is sensitive to - normally fluclox (if staph aureus) - 6-12 weeks!!!! - give analgesia - low threshold for irrigation and debridement by surgeons OTHER - splinting: improves pain, allow inflammation to settle - physio: to avoid joint stiffness recurrence up to 10% - hip joint has worst prognosis - long term follow up needed

Answer 162

55% picked up antenatally most commonly: non-dysjunction of chromosome 21 nb can also have robertsonian translocation and mosaicism but these are rare KARYOTYPE done at birth, if positive antenatal screening or dysmorphic features suggestive biggest risk factor = increased maternal age nb see obs/gyn flashcards for details of antenatal screening

Answer 163

- hypotonia - short stature HEAD + FACE - brachycephaly (flat head) - up-slanting palpebral fissures - epicanthal folds - brushfield spots (in iris) - short nose - small ears - stenotic ear canals - glossal protrusion LIMBS - single palmar crease - sandal gap CONGENITAL ABDOMINAL DEFECTS - pyloric stenosis - hirschprung's - duodenal atresia ``` CONGENITAL HEART DEFECTS (40-50%) most common: - ASD/VSD (40%) - patent ductus arteriosus (5%) - tetrology of fallot (5%) ```

Answer 164

MEDICAL CONDITIONS: - Learning difficulties - alzheimers (early onset around age 40) - repeated resp infections - hearing impairment - cataracts - acquired hypothyroidism - subfertility (males almost alway infertile, females subfertile) - atlantoaxial instability (can present w spinal cord compression) - DDH higher risk of acute lymphoblastic leukaemia (ALL)

Answer 165

- detailed cardiac assessment (main limiting factor of life expectancy - Hip USS (for DDH) audiology 1-2 yearly nb kids can go to mainstream or specialist schooling, depending on level of functioning

Answer 166

squint aka. Strabismus – misalignment of visual axis Pseudosquint = prominent epicanthal folds – create illusion of squint use corneal light reflex to test between the two

Answer 167

esotropia = inwards (aka convergent) - most common exotropia = outwards (aka divergent) hypertropia = one going upwards nb hypermetropia (long-sightedness) is different from hypertropia

Answer 168

``` PARALYTIC SQUINT - varies with gaze direction as is due to paralysis of motor nerves - rare but could be sinister = raised ICP = space-occupying lesions ``` CONCOMITANT SQUINT - due to imbalance in extra-ocular muscles - common - often corrected with glasses but may need surgery = refractive error in one or both eyes = cataracts = retinal disease / retinoblastoma CONCOMITANT TYPES: - manifest = obvious at all times - latent = found on investigation or when tired

Answer 169

GENERAL INSPECTION FIRST RULE OUT RAISED ICP - palpate fontanelle (if under 1) - opthalmascope (if can't visualise optic disc, refer to opthalmologist) RULE OUT RETINOBLASTOMA / CATARACTS - red reflex RULE OUT PARALYTIC SQUINT - H test - accommodation (if old enough) - pupillary light relfex RULE OUT DAMAGE TO OPTIC NERVE - snellen chart (use pictures for young kids - do both eyes and make sure not cheating) - or do some other form of visual acuity test RULE OUT PSEUDO SQUINT - corneal light reflex (get them to stare into distance and shine light on eye and see if reflection on same place in pupil on both eyes) FINAL TEST - cover test (ask the child to focus on a object, cover one eye, observe movement of uncovered eye, cover other eye and repeat test)

Answer 170

refer to opthalmology if still present at 3 months untreated squint can lead to amblyopia (aka lazy eye) and cortical blindness - glasses (if refractive error) - patches (over good eye) - surgery to correct rectus muscle misalignment

Answer 171

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

Answer 172

18 months - 3 years - avoid known precipitants - divert by distraction - teach control by staying calm work with parents to not give into child's demands!

Answer 173

- routine | - sleeping in own bed

Answer 174

CHILD FACTORS - temperament - illness - developmental (incl ASD etc) - disability FAMILY FACTORS - unrealistic expectations - social isolation - drug & alcohol misuse - domestic violence - parental ill health - poverty - parental unemployment CHILD-FAMILY RELATIONSHIP - relationship (incl new or disabled siblings) - attachment - neglect WIDER CIRCLE - extended family - friends - nursery / school (bullying etc)

paeds essential conditions Flashcards

(200 cards)