Paeds Ix/Mx Flashcards

Question

What advice should be offered to parents of a child with febrile convulsions?

Answer 1

30% chance of recurrence Call ambulance if lasts >5 mins Usually self-limiting Majority of children have normal growth and development One in three will have another febrile convulsion, Future risk of epilepsy is low Increased future epilepsy risk if • Complex seizure • Positive FH of epilepsy • Neuro abnormality or delayed development

Answer 2

ABCDE approach Obs - Fever, HR, RR, BP Physical exam: infection focus, exclude rash, neuro exam (normal), CV to rule out arrhytmia + any injuries sustained by seizure Glucose

Answer 3

``` Initial: • Examination, signs of resp distress • Obs including oxygen sats, temp • PEFR if >5 • ABG • Sputum sample if productive cough, Consider CXR ``` Determine severity of attack Confirmatory tests of asthma diagnosis e.g. spirometry, FEV1 reversibility with bronchodilator, FeNO, asthma diary with diurnal variation of PEFR, skin prick for allergies, bloods (eosinophilia, IgE)

Answer 4

- Foreign body inhalation - Multiple trigger wheeze - Resp infection - Hyperventilation due to anxiety: normal PEFR, no wheeze

Answer 5

Mx as OP = inhaled SABA through spacer One puff of Salbutamol, every 30 seconds, max 10 puffs Consider oxygen if sats <94%

Answer 6

1. Oxygen if sats <94% usually nasal cannulae + BURST therapy: back to back nebulisers a. Salbutamol 5mg, every 20 mins 2. If refractory: add nebulisers w/ salbutamol if that doesn’t work nebulizers w/ Ipratropium bromide 3. Steroids: oral prednisolone for 3 days 4. IV Hydrocortisone – if this doesn’t work SENIOR HELP 5. Monitor PEFR, oxygen sats 6. Monitor ECG (tachycardia) and electrolytes (low K with bronchodilators) 7. If not responding, 2nd line i. Senior help ii. IV MgSO4 – also acts as anti-HTN so monitor BP over 20 minutes iii. IV salbutamol iv. IV aminophylline (not given if pt already on theophylline) v. ITU and intubation (call ITU, anesthetics and ENT – if requirement for Cricothyrotomy)

Answer 7

After inhaled bronchodilators • Severe or life-threatening attack • No adequate clinical response: still SOB, tachypnoea • Signs of exhaustion e.g. normalising / rising CO2 • Reduced oxygen sats <92% • Also if premature or significant medical hx Discharge when • Stable on using inhaled SABA less than 4 hourly (continue at home) • PEFR >75% • Oxygen >94%

Answer 8

* Antibiotics if infection * Follow up with GP within 2 days: inhaler technique, asthma action plan for school * Advise about PEFR monitoring and to seek advice if worsening = safety net * Inhaler technique, which types to use when * If parental smoking: advise about stopping

Answer 9

Dry cough, worse at night SOB, wheeze Precipitants: cold, exercise, recent illness, travel Previous exacerbations, ITU admissions Current meds, recent meds, adherence Smoking, pets, allergies, atopy Effect on school, play, sleep Family history

Answer 10

* Cardioresp exam * Basic obs * Nasopharyngeal aspirate or nasopharyngeal swab – PCR testing / bacterial culture to confirm infection <3w

Answer 11

Admit if: • < 6 months old or acutely unwell • Significant breathing difficulties (e.g. apnoea, severe paroxysms, cyanosis) • Significant complications e.g. seizures, pneumonia Macrolide antibiotic: azithromycin or clarithromycin (2nd line – Co-trimoxazole) Advice = Rest, adequate fluid intake + paracetamol / ibuprofen for symptomatic relief, avoid school for 48h after abx or 21d after cough started if not treated Supportive: fluids, paracetamol, rest + macrolide prophylactically for close contacts Notifiable disease

Answer 12

Cough, sputum SOB Wheezy sounds Runny nose, fever Eating and drinking Passing urine, stools Playing as usual / more drowsy ``` Risk factors: • Prematurity, RDS • Underlying lung disease e.g. CF • Congenital heart defects • Down’s syndrome ```

Answer 13

Viral induced wheeze = whenever get virus, causes wheeze • Same as bronchiolitis • But in Bronch: children usually <1 and unresponsive to steroids/dilators Pneumonia

Answer 14

ABCDE approach Physical exam, resp, look for signs of dehydration, resp distress (raised RR, intercostal and subcostal recessions, nasal flaring or cyanosis) Obs especially oxygen sats + Consider CXR and blood gas if resp failure suspected Test for RSV via nasopharyngeal swab and PCR if child 1-2 (possibly VIW) Consider CXR and blood gas if resp failure suspected

Answer 15

Admit if: • Apnoea • Feeding 50-75% of normal • Persistent sats <92% on air • Severe resp distress / central cyanosis (E.g. grunting, marked recession, tachypnoea >60) • Lower threshold for admission if (<3m, CLD + premature <32w) Supportive management: • Regular obs • Paracetamol / ibuprofen for fever • Oxygen if <92% - Consider optiflow (nasal), CPAP if impending resp failure • Adequate intake – Oral or NG / orogastric tube if poor feeding Infection control = isolate

Answer 16

Usual course: 3-5 days worsening, 3 days same, 3 days getting better, most will fully recover in 2w Encourage regular fluid intake – small + frequent Viral cause: RSV, consider parainfluenza, influenzae Prophylaxis: Palivizumab for preterm high risk babies (preterm, downs, congenital HD)

Answer 17

- Conduct disorder - Depression, anxiety - Mania

Answer 18

This is likely to be ADHD but I’d like to refer patient to specialist for diagnosis Assessment by child psychiatrist, paediatrician and educational psychologist Questionnaires: • Strength and Difficulties Questionnaire • Conner’s Rating Scale • Completed by child, parents and teachers Info from school: reports, interview teachers ``` Physical exam • Height, weight, BMI • BP • Motor coordination Lipids, ECG = before meds ``` Consider hearing test

Answer 19

MDT approach including OT Bio-psycho-social approach <5y: •Psycho-education w/ dietary advice (10w watchful waiting + food diary to see what influences hyperactivity) •Referral to ADHD focused parent training group (Webster Stratton) – can be done whilst waiting on diagnosis  Behavioural mx (praise + reward + rules w/ realistic expectations) •Making environmental modifications to reduce distractions >5y: •Psycho-education w/ dietary advice (10w watchful waiting + food diary to see what influences hyperactivity) •Referral to ADHD focused parent training group (Webster Stratton) – can be done whilst waiting on diagnosis  Behavioural mx (praise + reward + rules w/ realistic expectations) •Making environmental modifications to reduce distractions eg. teaching assistants at school + regular breaks when doing work •Meds: •Stimulants e.g. Methylphenidate (Ritalin), first line o Can cause appetite suppression → weight loss, insomnia o Long term: weight gain, obesity o Monitoring – Height (6m), weight (3m <10y then 6m), HR + BP (6m) •Atomoxetine, second line o Can cause appetite suppression and ECG abnormalities Improve concentration and reduce impulsivity Drug holidays recommended to prevent growth retardation Consider CBT if medication helps but there is still significant morbidity

Answer 20

* Does the child act the same at home and in school? * School performance including concentration, dyslexia, learning disability * Social interactions and friends * Fidgety * Tics/twitches, aggression, antisocial behaviour * Disobedience * Reckless / risky behaviours like crossing road without looking * Clumsy, accident-prone

Answer 21

* Faltering growth * Abdo distension * Vomiting: contents, blood * Change in stools: diarrhoea / constipation, blood, mucus, steatorrhoea (pale, smelly) * Adequate hydration and passing urine * Irritability, fatigue: not playing as normal * Rash * Diet and weaning * Specific triggers / foods * Breastfed / formula * Development milestones * FH of coeliac (strong genetic component) * Social history: known to social worker

Answer 22

* Coeliac * Hypothyroidism * Neglect * Chronic diarrhoea: toddler’s diarrhoea (preschool child, undigested veg, improves with age), Giardia infection * Lactose intolerance

Answer 23

Bedside: • Physical exam: buttock wasting, abdo distension • Growth chart to identify growth stunting • Obs Bloods: FBC, Ferritin, U+E, TFT (assc w/ thyroid disease), LFTs, B12 + D, Ca, glucose (assc w/ T1DM) Serology: • Antibodies: anti-TTG IgA, anti-endomysial IgA - if positive then arrange biopsy • Measure IgA to ensure no false negatives Stool: • MCS to exclude infectious causes, ova and cysts for Giardia • Faecal fat tests Definitive: duodenal biopsy on and off gluten diet (Villous atrophy, crypt hyperplasia, increased lymphocytes)

Answer 24

MDT: Paediatric gastroenterologists, GP, refer to dietician, School nurses, school and psychologists Diet advice: no gluten = wheat, rye, barley Warn about risks: malabsorption, cancer Consider calcium, vitamin D and iron supplements Screen for associated autoimmune diseases e.g. thyroid, type 1 diabetes GP: monitoring • Weight, height, BMI • Anti-TTG every 3 months then yearly once normalised Consider bone scan for osteomalacia / osteoporosis Dapsone topical antibiotic for dermatitis herpetiformis