Pediatrics Flashcards
(121 cards)
1
Q
Acute kidney injury
findings?
investigation?
management?
A
oliguria
hypotension
elevated creatinine
STOP AKI
- septic screen
- Toxic medications?
- Optimise volume status
- Prevent harm - relieve obstructions, treat complications e.g hyperkalemia
pre renal (mostly caused by hypovolemia)
- fluid resus
-Noradrenaline if severe hypotension
renal
- Glomerulonephritis, thrombotic microangiopathy, acute tubular injury
- furosemide if volume overloaded
post renal
- urology referral
2
Q
Acute epiglottis
diagnosis?
management?
A
respiratory distress, tripod positioning, DROOLING, high fever. Thumbprint sign on X-ray
Caused by H influenzae type B, rare due to vaccinations
do not examine throat due to risk of airway collapse.
Secure airway - intubation = 1st line
IV ceftriaxone
Oxygen
Rifampicin prophylaxis to close contacts!!
3
Q
Appendicitis
A
abdominal pain, nausea and vomiting, RLQ pain
Ultrasound in children
supportive treatment (nil by mouth IV fluids analgesia) + appendicectomy
4
Q
Eczema management?
A
emollients - cetraben, diprobase
topical steroids if not sufficient -> start with weakest = topical hydrocortisone
moderate strength = betamethasone
strong = mometasone
(eumovate, dermovate)
if uncontrolled with steroids = topical tacrolimus
infected = flucloxacillin
5
Q
Biliary Atresia
diagnosis?
management?
A
neonatal jaundice
pale stools
elevated direct bilirubin
- no end stage liver disease = hepatoportoenterostomy (Kasai procedure!! - create pathway of bile flow directly from liver to small intestine). + antibiotics for 1 year
liver disease = liver transplant
- ursodeoxycholic acid to promote bile flow
- fat soluble vitamins for nutrition
6
Q
Bronchiectasis (dilation of bronchi)
diagnosis?
management?
A
Chronic cough with sputum production, recurrent pulmonary infection
Finger clubbing
Intermittent hemoptysis
Wheeze
50% idiopathic
chest CT - signet ring sign
sweat chloride test
screen for antibody deficiency = IgM, IgA, IgG
Bronchoscopy
treat CF if cause
vaccinations for strep pneumo and seasonal influenza
antibiotics for exacerbations if NO CF diagnosis
7
Q
bronchiolitis
diagnosis?
management?
A
cough, wheezing, tachypnea, runny nose
LRTI in a child < 1 years old - suspect bronchiolitis!!!
RFs: chronic lung disease, CHD, preterm
supportive care, usually self limiting
admit to hospital if severe resp distress.
sats below 92% if < 6 weeks old
Sats less than 90% if 6 weeks or over
Or if apnoea occurs
pavalizumab prophylaxis in preterm infants - Monoclonal antibody to RSV
8
Q
Cellulitis
diagnosis?
management?
A
flucloxacillin
Cellulitis + VZV = flucloxacillin + amoxicillin
erysipelas presents similarly BUT is well demarcated and is treated with penicillin V
9
Q
coeliac disease
diagnosis?
management?
A
diarrhea, abdominal pain, anemia, dermatitis
igAtTG, endomysial antibody
gluten free diet
calcium and vitamin D tablets
iron only if deficient
10
Q
cystic fibrosis
diagnosis?
management?
A
failure to pass meconium
failure to thrive
recurrent infection/cough/sinusitis
genital abnormalities in males
sweat test, genetic test
meconium ileus = water-soluble contrast enema + oral osmotic agents
respiratory infection = oral antibiotic eg amoxicillin
GI disease = optimising nutrition. pancreatic replacement if necsssary, ursodeoxycholic acid for liver disease
flucloxacillin as prophylaxis for s.aureus pneumonia
lumacaftor/ivacaftor
Chronic infection with Pseudomonas and Bulkholderia in CF are associated with increased morbidity and mortality
11
Q
Intussuception
symptoms
diagnosis
management
A
abdominal pain
vomiting (abdominal obstruction - unopened bowels)
currant jelly red stool - late sign -blood may be seen rectal exam
RUQ mass may be palpable
abdominal ultrasound = 1st line - target like mass
AXR - can show obscured liver edge w paucity of air in RUQ, dilated proximal bowel loops
Ng tube and IV fluids may be needed
reduction using air or barium enema = 1st line - perforation risk
surgery if fails or signs of peritonitis
consider broad spectrum antibiotics - clindamycin and gentamicin
associated with HSP, lymphoma, CF, viral infection
12
Q
Hirschprungs disease
symptoms
diagnosis
management
Complications?
A
failure to pass meconium
abdominal distention and vomiting may occur
AXR - dilated loops
rectal biopsy with barium enema = confirmatory
bowel irrigation + surgery
complications:
Hirschprungs enterocolitis = proximal colonic dilatation secondary to obstruction + bacterial overgrowth -> fever, abdominal distention, bloody diarrhea -> antibiotics, ng TUBE, surgery
13
Q
Acute gastroenteritis
organism diffferential if blood in stool?
HUS signs? treatment?
A
ecoli
salmonella - if chicken or egg ingestion
Thrombocytopenia - blood count
Microangiopathic haemolytic anaemia - jaundice
Acute renal failure - renal and electrolytes
AVOID antibiotics
IV isotonic crystalloids
14
Q
Pyloric stenosis
symptoms?
investigation?
management?
A
projectile’ non bilious vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in RUQ
Blood gas - hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
ultrasound abdomen - target/dougnut sign
IV fluid resucitation = 1st line (including correction of potassium)
then Ramstedt pyloromyotomy
15
Q
Hepatospleenomegaly differentials in child
A
- leukemia - high white cell count
- malaria
- thalassemia
- Gauchers
- EBV - low wcc
16
Q
Parvovirus B19
symptoms
RF
investigation
complication in pregnancy?
A
slapped cheek rash
Sickle cell, HIV
Parvovirus serology
hydrops fetalis in pregnant woman
17
Q
Hemophilia A (x linked recessive)
symptoms
investigation
management
complications
A
excessive bruising, bleeding, hemarthrosis
aPTT time - prolonged. everything else is normal!
avoid NSAIDS
early management of trauma
chronic arthropathy, compartment syndrome, hematuria, hep B infection
18
Q
HSP (IgA vasculitis)
symptoms
RFs
diagnosis
management
complications
A
tetrad of rash, abdominal pain, arthritis/arthralgia, and glomerulonephritis.
History of Upper respiratory tract infection
FBC & clotting screen - normal, used to exclude other causes such as ITP and sepsis which can cause low platelet and abnormal coagulation)
renal function, and urine dipstick
most cases resolve in 4 weeks
joint pain/abdo pain = ibuprofen
nephritis/ proteinuria = oral corticosteroids, IV if moderate. IV cyclophosphamide if severe
Intussusception
Acute renal impairment
Arthritis/arthralgia, typically involving ankles and knees
Pancreatitis
19
Q
Acute lymphoblastic leukemia
symptoms
diagnosis
management
complications and how to treat?
A
- hepatospleenomegaly
- high white cell count
(more common than AML) BUT neutropenia (frequent infections),
Thrombocytopenia (petechiae/ echymoses), anemia
fever
FBC
Blood smear
- rehydration
- alluprinol - prevent tumour lysis s
- platelet transfusion
- bone marrow aspirate
- chemotherapy once definite diagnosis
tumour lysis syndrome -Potassium, phosphate, uric acid, LDH are all like to be high. -> renal failure risk
febrile neutropenia -> Piptazobactam and gentamicin prophylaxis
20
Q
Acute myeloid leukemia
symptoms
diagnosis
management
complications
A
Anemia, thrombocytopenia, neutropenia
Lymphadenopathy, hepatospleenomegaly
Blood smear - diagnostic, blasts and auer rods
- if no auer rods, immunophotyping to distinguish AML from ALL
- if aleukemic lukemia suspected = bone marrow aspirate
Chemo
21
Q
Slipped upper femoral epiphyses
symptoms
RFs
diagnosis
management
complications
A
external rotation of leg
Restricted range of motion
hip pain, referred pain to knee or groin
Trendelenburgs gait
Obesity, endocrine disorders, puberty
most common cause of limp/hip symptom in children aged 12-14. Presents in adolescence
Perthes more common in 4-7 years
pelvic Xray - DIAGNOSTIC - widening of growth plate/ physis. klein line does not intersect femoral head (shows displacement)
internal pinning and fixation of epiphysis
avascular necrosis, limb length discrepancy
22
Q
DDH
symptoms
diagnosis
management
complications
A
Toe walking
abnormal positioning of leg,
Limb length discrepancy
Trendelenburgs gait
NO PAIN
+ ortolani (hip abduction) and barlow (hip adduction) test, trendelenburg
RFs:
- breech presentation
- family history
- female sex
- birth weight > 5 kg
- oligohydramnios
can be associated with Talipes
USS hips at 6 weeks for breech babies at or after 36 weeks gestation, or babies with family history
if the infant is > 4.5 months then x-ray is the first line investigation
<6months is observation, Pavlik harness
>6 months with dislocation = closed reduction, cast
DDH is hip abnormality seen in newborns and infants 0-4
Perthes/ transient synovitis = 4-10
SCFE = 10 -16
23
Q
Developmental milestones
Gross motor
A
6 weeks - head control begins
6 months - no head lag, sitting
1 year - cruises, walks
18 months - walks well, runs
2 years - climbs stairs, kicks ball
36 months - stands on one leg
Exam May ask what developmental milestones group is affected, or what the developmental age of child is
24
Q
Developmental milestones
Fine motor vision
A
6 weeks - fixes and follows
6 months - full hand grip
1 year - mature pincer, pointing
18 months - build tower of 3, hand preference, scribbles
2 years - build tower of 7, circular scribbles
36 months - draws circle, imitates bridge
25
Developmental milestones
language hearing
6 weeks - stills to sound
6 months - turn to sound, babble
1 year - first word, response to name
18 months - 6-12 words, follow simple instructions
2 years - 2 words sentence
36 months - speaks in sentences
26
Developmental milestones
social skill
self-care
6 weeks - smiles
6 months - laughs and squeals
1 year - waves, peekaboo, drinks from cup
18 months - spoon feeding, symbolic play
2 years - toilet training, remove garment
36 months - parallel play, interactive play, sharing
27
whooping cough
symptoms
diagnosis
management
cattarrhal phase - viral infection symptoms
coughing - worse after feeds, associated with vomiting
INSPIRATORY whoop
APNEA periods in infants
Per nasal swab
Significant lymphocytosis w low or normal neutrophils - bloods
infants under 6 months with suspect pertussis should be admitted
+ an oral macrolide!! (e.g. clarithromycin, azithromycin or erythromycin)
Erythromycin prophylaxis to close contacts
School exclusion till 48 hours after starting antibiotics
28
croup
symptoms
diagnosis
management
complications
bark like /seal like cough
Worse at night
clinical diagnosis
Clinical or steeple sign on CXR (viral laryngotracheobronchitis)
6 months to 6 years main occurrence. Peak at 2 years old!
Parainfluenza is a key cause
never perform throat examination due to risk of airway obstruction
Oral dexamethasone (0.15mg/kg)
*bacterial tracheitis is differential - same sounds, but high fever, thick airway secretions, more severe, usually caused by staph aureus. can cover w IV cefuroxime and Flucloxacillin
if severe = marked sternal wall retractions/resp distress/stridor = oxygen + nebulised adrenaline!!
29
Congenital CMV signs?
hearing loss, low birth weight, petechial rash, microcephaly and seizures, periventricular calcifications
+/- blueberry muffin rash
urine or salivary PCR test
oral valganciclovir
30
Congenital Toxoplasmosis signs?
chorioretinitis, hydrocephalus, intracranial calcifications
+/- blueberry muffin rash
31
Congenital Rubella signs?
sensorineural deafness, eye abnormalities (e.g. retinopathy and cataracts) and congenital heart disease (especially pulmonary artery stenosis and patent ductus arteriosus).
+/- blueberry muffin rash
if infection as an infant: pink macules and papules at head, moves down, post-auricular lymphadenopathy. athralgia
supportive care
encephalitis, thrombocytopenia
32
Congenital Herpes signs?
vesicular rash, very low birth weight, microcephaly, microphthalmia and preterm
encephalitis, herpetic lesions
33
Congenital varicella zoster signs?
hypertrophic scars, limb defects, ocular defects (such as cataracts and microphthalmia).
34
congenital syphilis
notched teeth, saddle nose, saber shins
35
Measles symptoms
diagnosis
management
complications
rash beginning at head then spreading
cough conjuctivitis, koplik spots, coryza
measles-specific IgM and IgG serology
supportive care - paracetamol/ibuprofen
consider vitamin A
otitis media is most common complication
36
HHV 6/ roseola symptoms
fever then rose coloured macules on body. siezures
37
Prevention of HIV transmission to baby?
babies born should recieve zidovudine for 6 weeks
38
Epilepsy
management
complications/ side effects drugs
recurrent febrile siezures =rectal diazepam or buccal midazolam)
tonic clonic:
- sodium valproate 1st line
- lamotrigine if child bearing age
absence:
- ethusuximide
- sodium valproate
myoclonic:
- valproate
Focal:
- carbamezepine
- lamotrigine if child bearing age
treatment not given for childhood rolandic epilepdy
39
Epididymitis and orchitis
symptoms
diagnosis
management
complications
scrotal pain and swelling
unilateral
may be hot and erythematous
sexual health RF
gram stain urethral secretions
NAAT test urethral secretions
gonorrhea/chlamydia = ceftriaxone and doxycyline
enteric organisms = levofloxacin
M genitalium = moxifloxacin
idiopathic or viral eg mumps = supportive measures
tuberculous = tb meds
underlying vasculitis = rheumatologist referral
scrotal elevation
40
Neonatal Hypoglycemia
symptoms
diagnosis
management
complications
< 2.6 mmol/L
transient hypoglycemia in first hours after birth is normal - monitor blood glucose
RF for persisitent = preterm, gestational diabetes, inborn errors of metabolism
'jitteriness', irritable, tachypnoea
pallor
poor feeding/sucking, weak cry, drowsy, hypotonia, seizures
- asymptomatic
encourage normal feeding (breast or bottle)
monitor blood glucose
- symptomatic or very low blood glucose <1.5
admit to the neonatal unit, intravenous infusion of 10% dextrose
41
treatment for child with hypoglycemia?
mild/moderate = fast acting glucose by mouth + Carbs
severe = IV 10% glucose or IM glucagon/ concentrated oral glucose if not in hospital
42
Kawasaki disease
symptoms
diagnosis
management
complications
rash
conjuctival injection
enlarged cervical lymph nodes
strawberry tongue
desquamation of palms and soles (late sign)
Fever - at least 5 days, conjunctivitis can help differentiate from scarlet fever. Kawasaki uncommon in child > 8 years
Scarlet fever differential - will have runny nose, cough, sore throat
FBC - anemia, Thrombocytosis!! leukocytosis!!
1. IVIG infusion = 1st line
(inflixmab + corticosteroids if resistant to IVIG)
2. high dose aspirin to reduce thrombosis risk for first 72 hours then low dose for 8 weeks
coronary artery aneurysms
43
Down syndrome
symptoms
diagnosis
management
complications
44
Mumps
complications
swelling of parotid gland - clinical diagnosis
self limiting, rest, paracetamol
7 days away from school
seek help if meningitis or
epididymo-orchitis develops
deafness
45
Volvulus
symptoms
diagnosis
management
twisting of bowel causing obstruction
bilious vomiting
abdominal pain
upper GI contrast - done if vomiting, lights up, allows you to follow the orientation of the bowel the whole way through, shows abnormal positioning of vowel
CT abdomen with contrast -> done when theres no vomiting and low concern of malrotation
emergency surgery = Ladd procedure with open laparotomy
suppportive care: NG tube if obstruction, antibiotics, IV fluids
46
Perthes disease
symptoms
investigations
management
complications
caused by avascular necorosis of femoral epiphysis
hip pain can radiate to knee, worse during activities
limp
reduced range of movement in hip
more common in boys
trendelenburg sign may be present
plain x ray - femoral head collabse and fragmentation, subchondral fracture. widening of epiphyses = early sign
Conservative:
- NSAIDS, monitor if less than 5 years
cast/braces
- if over 7 years - surgical containment
osteoarthritis, premature fusion of growth plates
47
Idiopathic thrombocytopenic purpura
symptoms
diagnosis
management
complications
bruising
petechial or purpuric rash
bleeding is less common and typically presents as epistaxis or gingival bleeding
follows viral illness typically
full blood count - isolated thrombocytopenia
blood film
asymptomatic or minor bleeding: - self resolving 6-8 weeks
avoid activities that can cause trauma
severe bleeding/platelet count (e.g. < 10 * 109/L) =
- IVIG + corticosteroid + platelet transfusion
chronic/persistent disease =
mycophenolate/rituximab/
eltrombopag. splectomy 2nd line
48
Congenital diaphragmatic hernia
tinkling bowel sounds on chest auscultation
respiratory distress
1st line = intubate and ventilate
THEN - surgical repair of diaphragm
49
Bacterial meningitis
symptoms
diagnosis
management
<3 Months = IV ampicillin/amoxicillin + cefotaxime
> 3 months = IV ceftriaxone
presenting in primary care = IM/IV benzylpenicillin
recent foreign travel - add vancomycin
dexamethasone my play a role but AVOID in menigococcal septicemia and children under 3 months
review of child by pediatrician in 4-6 weeks, hearing assessment
contacts give ciprofloxacin
50
Osteosarcoma
pain in long bones - arms/ legs near growth areas (metaphysis), including around the knees.
- systemic symptoms: weight loss or fever and
wide surgical resection and reconstruction
51
Duchenne MD
delayed motor milestones
ambulatory difficulties
calf hypertrophy
gowers sign
genetic testing - 1st line
elevated CK
DMD = corticosteroid + physiotherapy + exercise
spinal muscular atrophy = psychosocial and neuropalliative care
52
Sickle cell disease
symptoms
diagnosis
management
complications
persistent pain in skeleton, chest or abdomen
dactylitis
bone pain
jaundice may occur
electrophoresis
blood smear
fbc and reticulocyte count
prophylaxis: immunisation against encapsulated organisms, daily oral penicillin and folic acid
Acute crisis:
- oral and IV analgesia
acute chest syndrome, priaprasm or stroke:
- exchange tranfusion
chronic problems:
- consider hydroxycarbamide in children
- spleenectomy
- bone marrow transplant
53
Testicular torsion
testicular pain/swelling/erythema
high riding testicle
absent cremasteric reflex
no pain relief upon elevation of scrotum
orchiectomy/orchidopexy
fixation of contralateral testes
54
Retinoblastoma
symptoms
diagnosis
management
complications
leukocoria - white pupillary reflex
fundoscopy
Gross vitreous seeding (tumour cells floating within vitreous cavity)
- enucleation 1st line
- adjuvant chemo if infiltration of iris, ciliary body, sclera, optic nerve
minimal or no seeding:
systemic chemotherapy
+ cryotherapy or laser ablation = tumour > 2 disc diameters in size
laser ablation only = tumour <2 disc diameters
55
Reactive Arthritis
symptoms
diagnosis
management
complications
arthritis
conjuctivitis or iritis
preceeding chlamydia or GI infections
clinical diagnosis
NSAIDS - 1st line
persistent = sulfasalzine (DMARD)
56
eczema herpeticum treatment
eczema staph infection treatment?
IV aciclovir
IV flucloxacillin
57
Asthma
Dry cough, wheeze, SOB
Typical triggers
Personal/family history of atopy
Wheeze on auscultation
step 1 = SABA
step 2 = Low dose inhaled steroids via MDI and aerochamber
step 3 =
*any sudden deterioration in a patient with a lung condition, eg marked respiratory distress, hypoxia and HTN, think Tension pneumothorax!
If the wheeze only related to cough or colds -> it might be a viral induced wheeze instead
Severe asthma - can’t complete sentences in one breath, too exhausted to talk, use of accessory muscles. Give SABA + prednisolone or hydrocortisone. Consider ipatropium bromide
Life threatening - hypotension, cyanosis, silent chest, poor respiratory effort, confusion Give SABA + prednisolone or hydrocortisone + ipatropium bromide
58
conjuctivitis
viral - self limiting, clean with saline, wash hands to prevent spread
bacterial - usually self limiting but can treat with azithromycin/erythromycin
gonorrhea - IV ceftriaxone
chlamydia - oral arithromycin or doxy
^ both cause purulent discharge
allergic - artificial tears, antihistamine
59
dehydration
> or = 5% weight loss
> 10 = Shock
treatment = ORS 75mL/kg every 4 hours
IV fluids only indicated for Shock, deterioration, or persistent vomiting
60
Allergic Rhinitis
Sneezing
Nasal pruritus, discharge, congestion
Eye redness/itching
Mild/intermittent
= allergen avoidance + intranasal non sedating antihistamine
Persistent/ moderate - severe
Allergen avoidance + intranasal antihistamine + intranasal corticosteroid (beclometasone, budesonide, fluticasone)
Ineffective therapy still:
sublingual or subcutaneous immunotherapy
61
Cows protein milk allergy
62
Food allergy
exclusion of offending foods
mild reaction = non-sedating antihistamines
severe w cardio/laryngeal or bronchial involvement = IM adrenaline (epipen) + salbutamol if bronchospasm occurs
- provide epipens
- food challenge after 6-12 months symptom free
63
Anaphylaxis
symptoms
management
breathing difficulty - SOB, wheeze, stridor
airway swelling
Hypotension
urticaria
tachycardia
ABCDE assesment - if unresponsive and in cardiorepiratory arrest :
- start CPR
if not:
remove trigger
lie patient flat
IM adrenaline 1:1000, asses response after 5 min and repeat in intervals until adequate response
high flow oxygen
IV fluids
give antihistamine after initial resus:
(IV chlorphenamine 10mg + IV hydrocortisone 200mg??)
referral to allergy clinic
future management - epipen
64
Urticaria
management
1st line = trigger avoidance
severe =
- certirizine OR other non-sedating antihistamine eg fexofenadine, loratidine
- prednisolone
If occurs with angioedema that involves airway=
- adrenaline injection 1st line
- IV dypenhydramine
65
Lactose intolerance management
avoid dairy products
calcium and vitamin D supplementation
66
Mesenteric adenitis
Symptoms
Investigations
Management
enlarged mesenteric lymph nodes caused by viral infection)
Abdominal pain, tenderness, fever
Nausea or vomiting
Typically due to viral infection - sore throat, cold prodrome
Clinical diagnosis
Self limiting, pain killers if needed
67
Hemangioma
Diagnosis
Management
Doppler ultrasound -> distinguish infantile haemangioma from vascular malformations (e.g., venous malformations, arteriovenous malformations, lymphatic malformations)
Asymptomatic = reassurance
Functional impairment/cosmetic disfigurement
= propanolol (or corticosteroids)
Consider surgical excision
68
Subarachnoid hemorrhage
Causes
Diagnosis
Management
Rupture of saccular aneurysm- main
AVMs
Non contrast CT head
GCS 8 or lower = cardiopulmonary support
Consider nimodipine
Endovascular coiling, surgical clipping = definitive
69
Subdural hemorrhage
Management
Consider NAI due to shaking
Small = conservative
GCS<9 with large hematoma or midline shift = surgical
Antiepileptics
70
Peptic ulcer disease and gastritis
abdominal pain - often related to eating and nocturnal
endoscopy - if bleeding
h pylori breath test or stool test
bleeding ulcer:
- endoscopy +/- blood transfusion
- PPI
- Surgery or ablation
non bleeding, H pylori negative:
- PPI, treat underlying cause
non bleeding, H pylori +ve
- PPI + clarithromycin + amoxicillin (triple therapy)
treat children with PPI, if it doesnt work, do an endoscopy, if it is normal = Functional dyspepsia diagnosis
71
Periorbital and orbital cellulitis
Redness and swelling of eye
Decreased vision, proptosis
Periorbital - superficial injury eg insect bite
Orbital - usually due to underlying bacterial sinusitis
CT sinus and orbit with contrast
WBC count
IV antibiotics eg cefotaxime
Hospital admission
72
Cerebral Palsy
Risk Factors
Symptoms
Diagnosis
What anatomical structure is most likely affected?
Management
when would you be worried about a neurological disorder instead?
antenatal: maternal illnesses (e.g., chorioamnionitis, TORCH infections,
perinatal: prematurity, birth asphyxia (due to placental abruption, rupture of the uterus, prolonged/obstructed labour, instrumental delivery), brain malformation, neonatal sepsis, neonatal siezures
postnatal: meningitis, head trauma prior to 3 years
others: metabolic/genetic disorders,thyroid disease, iodine deficiency, thrombotic disorders) severe hyperbilirubinaemia, periventricular haemorrhage, respiratory distress, teratogen exposure
abnormal motor development - spasticity (80%), dystonia, chorea, ataxia, athetosis, hypotonia
delayed motor milestones:
- not sitting by 8 months
- not walking by 18 months
- hand preference before 1 year
- late head control, rolling and crawling
toe walking/knee hyperextension
delay in speech and cognition may occur
MRI Brain -periventricular leukomalacia, congenital malformation, stroke or haemorrhage, cystic lesions
Affects motor cortex!!!
occupational therapy, physiotherapy and speech therapy
for children at risk, follow up programme with MDT up till 2 years
symptomatic medicines:
stiffness - baclofen
sleeping - melatonin
constipation - laxatives
drooling - anticholinergic
- absence of risk factors
- family history of neurological disorders
- loss of already attained cognitive and developmental abilities
- different MRI findings
- focal neurological signs
73
Juvenile idiopathic arthritis
Symptoms
Diagnosis
Management
Swelling, warmth, painful limited movement
Tenderness may occur
Arthritis in 1 or more joints for at least 6 weeks before age 16
Clinical diagnosis
ESR CRP ANA RF may be elevated
Polyarticular/ 5 or more joints:
= methotrexate
Specialist rheumatologist management
4 or less
=intraarticular corticosteroids eg triamcinolone or methyl prednisolone
NSAIDS for sacroilitis and enthesitis
74
Pneumothorax
Symptoms
Diagnosis
Management
pleuritic chest pain
dyspnea
ipsilateral reduced breath sounds
CXR - absent lung markings
small = observation + 02 for 1-2 hours
needle decompression - if child at risk of respiratory failure
chest drain - for all tension pneumothoraces or ventilated or preterm infants that deteriorate
75
Malaria
Symptoms
Diagnosis
Management
Headache
Myalgia
Arthralgia
Fever
Diarrhoea
Jaundice and siezures may occur
Non specific symptoms in children <5
history of travel to endemic area/inadequate prophylaxis
FBC - thrombocytopenia, anemia
Blood smear - parasites
Rapid diagnostic test
p falciparum:
- oral artemisinin combination
- if severe parental artesunate for 24 hours then artemisinin combination
non falciparum
- artemisinin combination
notifiable
76
Hypoxic Ischemic Encephalopathy
77
Obstructive sleep apnea
breathing through an open mouth
snoring, gasping, choking while asleep
HTN
Polysomnography = diagnostic
Adenotonsillectomy = 1st line
CPAP = 2nd line
Treatment of precipitating conditions: reflux, obesity
78
Hyperthyroidism
symptoms
diagnosis
management
complications
heat intolerance, weight loss, palpitations, tremor
Graves disease most common cause in child - orbitopathy, pretibial myxedema, TSH receptor antibodies
- thyroid nodules and thyroiditis may also cause
- neonatal graves disease - transplacental passage of maternal TSIs
elevated T4.T3, Suppressed TSH
Carbimazole or propylthiouracil = 1st line. risk of neutropenia - medical attention if fever or sore throat
radioiodine or surgery = 2nd line
can use beta blockers for symptomatic relief - anxiety, tremor, tachycardia
thyroid storm -> high temp, changes in mental status
78
Peripheral nerve palsies
Erbs palsy - lateral traction on neck during delivery
klumpke pasly = upward force on arm during delivery
winged scapula
physiotherapy, occupational therapy
79
Raised intracranial pressure
infant: increased head size, tight fontanelle
other: morning headache, headache waking from sleep, vomiting, visual disturbance, fluctuating conciousness, siezure, ataxia or other motor disturbance
1. trauma
2. brain tumour
3. Hydrocephalus - chiari malformation? spina bifida? arachnoid cysts? - treated with shunt
4. meningitis
80
Nephrotic Syndrome
list different causes in child
Minimal change disease
symptoms
investigations
management
complications
1. minimal change disease - often idiopathic or triggered by infection, immunization, drugs eg NSAIDs. may be secondary to lymphoma. MCD = MAIN cause in child
2. FSGS - may be secondary to sickle cell, HIV, or congenital malformations (single kidney, kidney removal)
3. membranous nephropathy
MCD symptoms:
facial/generalised edema
no HTN or hematuria
recent viral illness
urine protein/creatine ratio
24 hour urine protein
management:
oral prednisolone = 1st line
+ fluid restriction + low salt diet
advanced MCD = albumin and furosemide
81
Nephritic syndrome/glomerulonephritis
symptoms
management
symptoms
investigations
management
complications
hematuria, proteinuria, fatigue
mild=
treat underlying cause eg. phenoxymethylpenicillin for post-strep GN
moderate =
ACE inhibitor or ARB
treat underlying cause
Severe =
prednisolone and immunosuppresant eg Rituximab (give prophylactic trimethoprim for immunosuppression)
RPGN - treatment depends on subtype but may involve prednisolone and cyclophosphamide. give prophylactic trimethoprim
82
Hodgkins Lymphoma
symptoms
diagnosis
management
complications
Painless cervical and or supraclavicular lymphadenopathy
B symptoms may occur - fevers, nights sweats, weight loss
PET/CT - shows extent of disease
Lymph node biopsy - diagnostic = reed stern berg cells
FBC - low Hb and platelets; WBC count may be high or low
ABVD combination chemo - adriamycin, bleomycin, vinblastine, dacarbazine
+ 2 cycles ABVD + radiotherapy if favourable
+ 4 cycles of ABVD + medium radiation if unfavourable
Refractory or relapse disease = chemo + ASCT. Brentoximab vedotin if ASCT fails. Nivolumab, Pembrolizumab as last line
83
Diabetic Ketoacidosis
symptoms
diagnosis
management
complications
nausea, vomiting, abdomina pain, hyperventilation, acetone smell on breath
typically in Type 1 diabetes - history of weight loss, polydipsia, polyuria
venous blood gas - metabolic acidosis
blood ketones - elevated
blood glucose - elevated
oral fluids and SC insulin if alert child
not alert = IV fluids and IV insulin
fluids = 0.9% saline, add on 5% glucose after glucose drops below 14mmol/l
all fluids administered to children must contain 40mmol/L potassium chloride unless child has renal failure
IV insulin should commence 1-2 hours after starting fluids
monitor with ECG for hypokalemia
complications:
1. cerebral oedema - from replacing fluids too quickly causing hyponatremia - watch for neurological symptoms: headache, deacreased HR, increased BP, agitation - treat with mannitol or hypertonic sodium chloride
2. hypokalemia - consider stoping insulin
84
Diabetes mellitus type 1
symptoms
management
polyuria, polydipsia
random glucose> 11.1
fasting glucose>7
elevated HBA1C
absence of ketoacidosis, presence of obesity, acanthosis nigricans, +ve family history, suspect type 2 -> confirmed with negative autoantibody tests
therapy options;
1.multiple daily injection basal bolus
2. continuous subcutaneous insulin infusion
3. 1,2, or 3 insulin injections per day
type 2 = metformin and lifetsyle modifications
85
Cardiac Arrest
management
5 rescue breaths
15 chest compressions, 2 rescue breaths
shockable rhythms:
- CPR +defibrillator
- + adrenaline
86
Brain tumours
Pilocytic astrocytoma = most common in child, usually in cerebellum
Medullobalstoma = most common malignant brain tumour in child. hydrocephalus risk
ependymoma
craniopharyngioma - bitemporal hemianopia
Pinealoma
surgery-> treat hydrocephalus, tissue diagnosis and resection. radiotherapy and chemo depending on tumour
87
Downs syndrome
complications
hypothyroidism, dementia, leukaemia, and seizures, atlanto-axial instability (always screen for in patients that play sports)
sandal gap between big and first toe
brushfield spots on iris
etc
88
HPV infection
respiratory papillomatis -> infection of true vocal cords
warts - sertypes 1,2,6,11
89
Pneumonia
symptoms
diagnosis
investigations
management
Fever, breathing difficulty, increased RD
Abdominal pain
decreased breath sounds, dullness to percussion, wheeze, consolidation on X-ray
chest xray - consolidation
pulse oximeter
hospital admission if:
02 <92%
grunting, marked chest recession, RR>60/min
cyanosis
child looks seriously unwell, does not wake or stay awake
temp >38 in child <3 months
Amoxicillin = 1st line
if hospital admission not needed:
amoxicillin or clarithromycin if allergic
co-amoxiclav for high severity pneumonia, add clarithromycin if atypical organisms suspected
90
Crohns disease
symptoms
diagnosis
investigations
management
complications
abdominal pain - may be RLQ
diarrhea - may be bloody
weight loss
extraintestinal manifestations
colonoscopy with biopsy
inducing remission : corticosteroid monotherapy for first presentation or first exacerbation in 12 months
maintaining remission :
azothioprine or methotrexate
patient on immunosppresants should not have live vaccines
educate about features of flares - eg weight loss
malabsorption, colon cancer
91
Ulcerative Colitis
symptoms
diagnosis
investigations
management
diarrhea
abdominal pain
blood in stool
extraintestinal manifestations
colonoscopy
mild = 5ASA topical or oral
moderate = oral prednisolone
severe = surgery
92
DIC
symptoms
diagnosis
investigations
management
widespread clotting factor consumption
petechiae, echhymosis, oozing, hematuria
signs of systemic collapse my be seen - oliguria, hypotension, tahcycardia
RFs; tumours, Hematological malignancies, trauma, burn, sepsis/infection
increased PT and PTT
decreased platelets, increased BT
decreased fibrinogen
treat underlying cause
+ platelets and coagulation factors if high risk of bleeding
93
Cushings Syndrome
symptoms
diagnosis
management
complications
growth retardation in children
weight gain
abdominal striae
hypertension
hyperglycemia and insulin resistance
ammennorhea
step 1
- increased 24 hour urinary cortisol or late night salivary cortisol
- OR failure to suppress dexamethasone
= cushings syndrome. now distinguish cause in step 2
step 2 measure ACTH
low
= adrenal tumour - adrenal ct - resection
= exogenous glucocorticoids
high:
- do CRH stimulation test (inferior petrosal sinsus sampling)
- Increased ACTH and cortisol = cushings disease (pituitary dependent) - do MRI pituitary - transphenoidal surgery
- no increase in ACTH and cortisol = ectopic ACTH secretion - CT chest, abdomen and pelvis - surgical resection
94
Hepatitis
hep A = supportive for pain, itch, rash, vaccinate close contacts
hep B =
supportive
+ antivirals eg entecavir
hep C =
only treat if > 3 years
antivrals
treatment faliure - combine antivirals or add oral ribavirin
95
patent ductus arteriosus
symptoms
diagnosis
management
complications
Patent ductus arteriosus:
- continous machine like murmur - left infraclavicular region and left sternal border
- left to right shunt can cause RVH
- late cyanosis in lower extremities NOT whole body
widened pulse pressure
echo = diagnostic
- manage with indomethacin
- surgical ligation or percutaneous catheter device closure may be used if other methods unsuccessful
96
Pulmonary stenosis
symptoms
diagnosis
management
complications
Systolic murmur ejection murmur over left sternal border
mild = observation
echo with doppler
moderate to severe = percutaneous balloon valvuloplasty
97
Atrial septal defect
symptoms
diagnosis
management
complications
wide fixed SPLIT S2
ejection systolic murmur in upper left sternal edge
small = observation
large =
transcatheter closure - Ostium secundum ASD
open heart surgery - Ostium primum ASD
98
Ventricular septal defect
symptoms
diagnosis
management
complications
holosystolic murmur in tricuspid area
shortness of breath
small:
observation = 1st line, for closure
prophylactic amoxicillin to prevent endocarditis
Large VSD -> corrective closure, pre operative furosemide to control HF symptoms
99
Tetralogy of Fallot
symptoms
diagnosis
management
complications
whole body cyanosis - most common cause
hypercyanosis - tet spells
systolic ejection murmur
1. systolic ejection murmur which improves on squatting -> pulmonary stenosis
2. RVH -> boot shaped heart on xray. tet spells when crying or exercise due to worsening of RV outflow tract obstruction
3. Overriding aorta
4. VSD
echo = definitive
severe or worsening cyanosis:
prostaglandin E1 (alprostadil) - maintain patency of ductus arteriosus
shunt between subclavian and pulmonary artery
surgery/closure of VSD = definitive
100
Transposition of great arteries
symptoms
diagnosis
management
complications
= separation of aortic and pulmonary circulations
whole body cyanosis
PGE1
heparin bolus then balloon atrial septostomy
atrial switch procedure in 1st 2 weeks
101
Tricuspid atresia
symptoms
diagnosis
management
complications
absence of tricuspid valve and hypoplastic RV. requires ASD and VSD for viability
whole body cyanosis
PGE1 - maintain PDA
surgery with the first stage being
shunt between subclavian and pulmonary arteries
102
Coarctation of aorta
symptoms
diagnosis
management
complications
HTN in upper extremities
weak/delayed pulse in lower extremities (BP Difference) - eg femoral pulse
notched appearance of intercostal arteries on CXR
associated with bicuspid aortic valve and Turner Syndrome
murmur may be heard at back
claudication with walking may occur
98% in distal left subclavian artery
most common presentation is at 48 hours once PDA closes
PGE1 - alprostadil - maintain PDA = 1st line
surgery -> arch reconstruction
103
cyanosis in newborn causes
Cardiac
-5Ts are main causes:
- Transposition of great arteries
- tetralogy of fallot
- tricuspid atresia
- truncus arteriosus
- total anomalous pulmonary venous return
pulmonary
- examples include RDS, pneumonia, congenital diaphragmatic hernia , pulmonary edema
104
congenital cyanotic heart disease
105
gastroesophageal reflux
106
constipation
107
hypothyoidism
108
osteomyelitis
fever, tenderness/pain, reluctance to weight bear, swelling and erythema may occur
- X-ray - May show signs or May be normal
- take a blood culture, THEN give IV antibiotics
- analgesia
- if child deteriorates -> urgent surgical drainage/debridement
109
Explain and classify causes of neonatal jaundice
give examples for causes of early jaundice and prolonged jaundice
High bilirubin in first 24 hours of life is always pathological. common causes of early jaundice:
1. hemolytic disease of newborn - ABO, rhesus!!
2. hemolytic anemia - G6PD
3. Gilberts, Rotor, Crigler-Naijar syndrome etc
3. Sepsis!!!/congenital TORCH infections
4. difficult deliveries -> hematoma formation
if in days 2, 3 jaundice develops or bilirubin is raised but doesnt reach a certain threshold, in otherwise normal baby you put it down as physiological such as decreased UGT/ impaired liver ability to excrete bilirubin, shorter life span of neonatal rbcs. may have to give phototherapy
however, if after 14 days (21 in preterm), bilirubin is still slighlty elevated/child is still jaundiced, or after 2 days it shoots up quickly, need to rule out causes of prolonged jaundice
prolonged jaundice causes:
1. biliary atresia = most feared, rule out
2. breast milk jaundice = most common
3. hepatitis
4. congenital hypothyroidism
110
neonatal jaundice history taking points
Gestational age <38 weeks
Previous sibling with neonatal jaundice requiring phototherapy
Mother’s intention to breastfeed exclusively
Visible jaundice in the first 24 hours of life
Other important areas to cover in the history include:9
Family history: a history of inherited diseases (e.g. G6PD deficiency or liver disease) or previous sibling with jaundice (suggests a higher chance of haemolytic disease of the newborn)
Pregnancy history: congenital infections, diabetes (increases the risk of jaundice), maternal drugs (e.g. sulfonamides interfere with bilirubin-albumin binding), maternal blood group and any known antibodies
Labour and delivery history: birth trauma (e.g. bruising or cephalohaematoma)
Feeding history: breastfeeding or formula feeding, intake (poor intake causes delayed or infrequent stooling which increases enterohepatic circulation of bilirubin), vomiting (may be a sign of sepsis or galactosaemia)
111
investigations for neonatal jaundice?
management?
measure bilirubin -> TCB, serum bilirubin
tests specific to suspected cause
liver ultrasound, fbc, blood film, G6PD Levels, blood urine and CSF if signs of infection
phototherapy, if bilirubin level is really high, exchange transfusion
112
causes of Respiratory distress in newborn?
TTN (transient tachypnea of newborn) - most common
RDS - premature babies, mothers with diabetes
chronic lung disease of prematurity
congenital pneumonia - eg GBS, mum has chorioaminionitis
meconium aspiration
113
What forms part of prolonged jaundice screen?
- Conjugated bilirubin
- LFTs
- FBC - rule out a missed hemolytic anemia
- Look at stools - May be pale
- Thyroid function
114
Explain breast milk jaundice
How is it Managed?
How does breast feeding failure jaundice differ?
Breast milk jaundice
Typically caused by:
* Factors in a mother's milk that help a baby absorb bilirubin from the intestine
* Factors that keep certain proteins in the baby's liver from breaking down bilirubin
Breastfeeding can continue as normal
Use bilirubin to guide management
Breast feeding failure jaundice (baby does not get enough breast milk)
115
common causes of neonatal aneamia?
Hemolytic disease of newborn
G6PD deficiency - has breastfeeding mother taken relevant drugs or eaten fava beans?. other congenital hemolytic anemias
maternal parvovirus infection - passed across placenta?
fetomaternal hemorrhage
116
Celiac disease
Symptoms
Investigations
Management
Celiac Disease
- Abdominal pain, bloating, diarrhoea/constipation
- test for anti TTG antibodies which attack coeliac disease
- Small bowel endoscopy and Biopsy!! = Gold standard to confirm diagnosis = villous atrophy, intra-epithelial lymphocytes
- Damage to intestine, difficulty absorbing - iron and B12 deficiency. FBC important
Gluten free diet
117
Fluids maintenance option for 2 year old boy with diarrhoea and vomiting, decreased food and fluid intake, 3% dehydrated and blood glucose of 6 mmol/L?
0.9% sodium chloride + 5% glucose
OR
Plasmalyte + 5% glucose
Glucose is important as can’t eat, and you need to try and avoid Ketoacidosis
118
Child with 4 weeks smelly discharge from left nostril, sometimes tinged with blood. More recently she has had a persistent sneeze. Most likely diagnosis?
Foreign body!! - clue is blood tinged
Nasal polyp - asymptomatic in Children
Rhinitis and sinusitis = bilateral
119
Scarlet fever
Symptoms
RFs
Diagnosis
Management
Sore throat, fever, rash
Strawberry tongue
cervical lymphadenopathy
Group A strep
Clinical diagnosis
Phenoxymethylpenicillin!!!
120
7 year old girl acute asthma. 95% sats, mild increased work of breathing.
Management?
Inhaled salbutamol multidose via spacer
You would only give nebulised salbutamol if you need to deliver oxygen at the same time
