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672 Cards in this Set
- Front
- Back
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Which level of skin differentiates between superficial burn and deep burn?
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mid dermal level
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What does a superficial burn look like?
What layer of skin is affected? |
sunburn (pale erythema)
epidermis |
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What layer of skin is burnt if it's dark blotchy erythema?
Does it blanch? |
deep dermis
no blanching |
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Burn blisters: deep or superficial burn?
Will it have a blanching base? |
Superficial
Yes - the blanching means there is blood flow so it can recover |
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Why do you get dehydrated when burned?
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burn injury is vasomodulating --> vasodilation --> protein pours through --> loss of volume from circulation --> local oedema and general hypovolaemia
the fluid carries albumin |
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What are the two most important points for first aid for burns?
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1. stop the burn
e.g remove hot clothing, stop drop roll, turn off current, brush chemical off 2. cool the burned surface Use flowing water (reduces depth of burn) |
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What do you hope to achieve by putting running water on a burn?
What temp should the water be? Start water ASAP but if you can't how long after can you start? |
flowing water reduces depth of burn
the zone of stasis no longer --> zone of necrosis 8-25 deg (causes vasconstriction) 3h |
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How long do you run water onto burn for?
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at least 20mins
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Respiratory burn:
Where in the airways will you get thermal injury? |
supraglottic
--> early obstruction |
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Respiratory burn:
Where in the airways will you get injured from chemicals? |
infraglottic
--> pneumonitis |
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Early assessment of burns is inaccurate/
How long do burns change depth for? |
48h
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Fluid resus in burns
Formula What is this formula called? What solution is used? How is it given? |
Parkland's Formula
4mL/kg/%BSA in first 24h Hartmann's Give half in first 8h after got the burn Give the 2nd half over the next 16h |
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When would you add maintenance fluids to burns resus fluids?
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child <30kg
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Do you give fluid resus to every child who's sustained a burning injury?
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No, only if over 12% of BSA is burnt
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What should urine output be in kids?
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UO: 1mL/kg/hr
Increase fluids if UO too low, and decrease if UO too high |
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After the first day, what do you wash the burn with?
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Chlorehexidine
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Should you drain and/or deroof burn blisters?
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Yes
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What prophylactic vaccine do you have to give to burns' patients?
Do you need to give ABx? |
tetanus
no |
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How often should burns dressings be changed?
What do you have to remember when doing this? |
at least once per day
PAIN RELIEF |
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What sort of surgery is gold standard for burns?
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Split skin autograft
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How do you estimate BSA burned?
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Rule of 9s
Area of hand = 1% Head of infant = 18% (for every yr up til age 10, take 1% off heads and add to leg) Leg child = 14% Arm = 9% Chest = 18% Back = 18% |
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When would you admit a burn? (3)
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if airway affected
face and peripheries, joints hands and feet (need special care) |
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When would you transfer a burn? (6)
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1. any child burn >5% TBSA
2. resp burn 3. burns of special areas 4. suspicion of child abuse 5. concomitant trauma 6. pre-existing sig disease |
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If a burn heals between ___days and ___days then it won't scar
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10-14
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If a burn heals between ___weeks and ___weeks then it can be neglected and won't contract over the joint.
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2-3
these need to be followed up |
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If a burn heals >___weeks will definitely scar. What is the mgmt?
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graft
follow-up |
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Mgmt of burns over joints?
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splint
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Dx:
jerks last 10-20s when child asleep 10-20s duration stop abruptly when child awakened What is the onset? When should it remit? |
Benign Neonatal Sleep Myoclonus
d1 - 3wks remits bu 2-7mo |
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What sort of Sz can you get from holding your breath?
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hypoxic induced Sz
(this is not epilepsy) |
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Dx:
asynchronous tonic or clonic movements, most of face, neck, extremities Some have aura 10-20s Eye deviation (can lateralise) Can be responsive No postictal period EEG: spike and sharp waves or multifocal spikes |
Simple partial sz
(aka simple Focal) |
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Dx:
impaired consciousness can respond during episode some have aura automatisms EEG: sharp waves or focal spikes What sort is it if they put their hand towards their throat as a warning? |
Complex partial sz
(aka complex focal) Temporal |
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Dx:
sudden cessation of motor activity or speech with blank stare and flickering eyes No aura <20s No postictal period, but child can't remember it EEG: 3/second spike and generalised wave d/c (3Hz) |
Generalised Absence Sz
(Petit Mal) |
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Dx:
May have aura LOC Eyes roll back, tonic contraction, apnoea Then clonic rhythmic contractions Tongue biting, loss of bladder ctl Postictal: semicomatose 2h, vomiting and H/A |
Generalised Tonic/Clonic Sz
(NB the aura indicates localisation - in this circumstance it can say where the Sz originated) |
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Dx:
Symmetric contractions of neck, trunk and extremities - looks like Moro reflex w/o stimulus Multiple episodes per day Occurs around 6mo Assoc with regression in skills EEG: hypsarrhythmia What is another term for this Sz type? |
Infantile Spasms (AKA West Syndrome)
Jack Knife |
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What is the cause and Rx for Infantile Spasms?
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increased corticotropin-releasing factor -> neuronal hyperexcitability
Rx: ACTH or steroids |
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Dx:
brief, symmetric muscle contraction, typically seen in upper arm first thing in morning loss of body tone and falling forward Presents as teenager Grow out of it 15-20yrs |
Juvenile Myoclonic Sz
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Dx:
Sz that typically occurs overnight often hypermotor; v. agitated, behave unusually v. brief (~30s) |
Frontal lobe Sz
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What do you think of with high pitched scream and bulging fontanelle?
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raised ICP
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Bile stained vomit = ______________ until proven otherwise
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bowel obstruction
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When assessing a child's airway, what does drooling mean?
What should you do? |
airway difficulty
get help! |
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Single most important way to assess circulation?
3 places where can do it What is normal? |
Capillary refill
1. sternum 2. forehead 3. base of foot <2sec = N |
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What's the acronym for assessing disability?
What does it stand for? Which one corresponds to the GCS that requires intubation? What GCS is this? |
AVPU
A = alert V = only responds to verbal stimuli P = only responds to painful stimuli (= GCS 8 --intubate) U = unresponsive |
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What does decorticate mean (GCS)?
Decerebrate? |
flexed limbs
extended limbs |
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Less than what of normal fluid intake indicates reduced intake?
Reduced urine output = <____ wet nappies in past 24h |
< half
< 4 nappies |
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What is the acronym for assessing the deteriorating child?
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A - airway
B - breathing C - circulation D - disability (AVPU) E - exposure F - fluids G - glucose |
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Hypoglycaemia
Normal BGL = ______-_____ mM BGL ____-____mM needs review BGL < 2 requires response promptly |
3-5
2-3 2 |
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Rx for hypoglycaemia
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2mL/kg of 5% dextrose
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5 x DDx for upper airways emergencies
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1. croup
2. epiglottitis 3. tracheitis 4. retropharyngeal abscess 5. FB |
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What organisms (2) cause trachietis?
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Staph
Strep |
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What part of the airway is affected in croup?
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subglottic (from cords down)
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DDx for lower airway emergencies? (4)
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1. bronchiolitis
2. asthma 3. pneumonia 4. FB |
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Most significant clinical sign in asthma?
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pulsus paradoxus
- normally when inspire, pulse drops as more and more thoracic obstruction, when expire, pulse increases does opposite in PP |
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What do you see on CXR in asthma?
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overinflation
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Define fever
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>38 degrees
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What are the causes of fever? (hint: mneumonic)
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SOURCE
Skin Osteomyelitis UTI Resp: bronchiolitis (+OM, tonsillitis) CNS Enteric |
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Septic workup (7)
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1. FBC
2. blood film 3. blood culture 4. CXR 5. UA 6. stool culture/faecal WCC 7. LP |
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Red flags for vomiting (5)
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1. bilious
2. fever >39 3. blood 4. severe abdo pain 5. very young (hydrocephalus...think congenital) |
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Two pathways that kids --> cardiac arrest
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Circulatory failure (fluid loss/maldistribution)
Respiratory failure (resp distress/depression) |
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In infants, you worry that deterioration is imminent if RR > ____
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60 (normal for <1yr = 30-40)
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Classic red flags (7)
Resuscitate, assess and treat without delay |
1. purpuric rash
2. bulging fontanelle 3. biphasic stridor 4. high pitched scream 5. bile stained vomit 6. persistent tachy 7. grunting respiration |
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Initial mgmt of the deteriorating child?
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Assess: arousal, alertness, activity, breathing, colour
ABCDEFG Give O2 Position child Call for help Insert IV |
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What are the signs for increased work of breathing? (6)
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tachypnoea
and 1. recession 2. grunting 3. nasal flair 4. accessory m use 5. head bobbing 6. cyanosis |
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What are the effects of inadequate breathing (3)?
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heart rate increases
skin colour: pallor/cyanosis mental status: agitation/exhaustion/drowsiness |
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What are the S+S of hypoglycaemia (2 groups)
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Autonomic: trembling/jittery, pounding heart, cold sweat, pallor
Neurologic: slurred speech, confusion, irritable, erratic, LOC/Sz |
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Decorticate posturing suggests a lesion ______ the brainstem
Decerebrate posturing suggests a lesion ______the brainstem |
above
below (midbrain or pontine) |
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How do you classify croup as being mod/severe instead of mild?
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stridor at rest
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Rx of severe croup (3) (incl doses)
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ADMIT
1. O2 2. dexamethasone 0.15mg/kg 3. SDNE (neb Ad) 4mL of 1:1000 |
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Rx for bronchiolitis
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Keep SaO2 >94%
fluids: mild (RR<60) - PO; IV if severe distress Trial of neb salbutamol 2.5mg or atrovent but if doesn't help, stop |
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Do you give ABx or steroids in bronchiolitis?
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No
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What level of PaO2 would you need before intubating?
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<50mmHg
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Pulse oximetry <____% in severe asthma
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93
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Nebulised salbutamol dose in severe asthma attack
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2.5-5mg/4mL with 8L/min O2 up to three times in first hour
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Dose Prednisone / Hydrocortisone in severe asthma attach
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Pred: 1-2mg/kg PO
Hydrocortisone: 5mg/kg IV |
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Dose IV salbutamol
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0.5-15ug/mg/min
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Approach to febrile infant:
Is the child toxic? What 5 signs of being toxic? |
1. lethargy
2. poor feeding 3. irritability 4. poor perfusion 5. reduced UO |
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What is the majority cause (90+%) of febrile episodes?
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viral illness
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Dx:
non-bilious vomiting ravenously hungry post-vomits weight loss reverse peristalsis hypochloraemic hypokalaemic alkalosis |
Pyloric stenosis
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Biochem changes in pyloric stenosis? (ie vomiting) (3)
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hypocholoraemia
hypokalaemia alkalosis |
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Initial mgmt of Sz (afebrile, <15min) (3)
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1. airway protection
2. semi-prone positioning 3. paracetamol Doesn't yet require Ix |
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What do you need to rule out if first Sz (afebrile) is >15mins, recurrent, focal, difficult to control fever, new neurological abnormality (6)
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1. head injury
2. meningitis 3. drugs 4. encephalitis 5. hypoglycaemia 6. SOL |
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Febrile Sz: suspect ________
Febrile Sz + altered mental state: suspect ________ |
meningitis
encephalitis |
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If a Pt has a Sz are is found to be hypoglycaemic, what is the Rx?
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10% dextrose 5mL/kg IV
OR glucagon 0.5mg (<5yr) IM/IV or 1mg (>5yr) then glucose IV or CHO feed (if conscious) |
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Emergency Rx of Sz (5)
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1. clear airway, lie on side, give O2
2. check for hypoglyaemia 3. Diazepam 0.2mg/kg IV. Repeat PRN OR 0.5mg PR 4. Phenytoin 20mg/kg or phenobarbitone 20mg/kg 5. consider Thiopentone/muscle relaxation and intubation +/- midazolam infusion |
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What usually precedes mesenteric adenitis?
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viral URTI
--> get inflammation of Peyer's Patches near ileocaecal junction = self limiting disease |
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Usual age for appendicitis?
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6-9
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Usual age for intussusception?
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<1
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What Ix for suspected appendicitis?
What do you expect to see? (5) |
FBC - WCC and differential (PMNs > 75%)
CRP UA (UTI can mimin appendix) U/S is not sensitive and not specific U/S is useful in girls if thinking ovarian cause |
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Mgmt appendicitis (5)
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1. Fluid resus 20mL/kg bolus saline + maintenance
2. Pain mgmt 3. explain to parents 4. ABx (metronidazole [covers anaerobic] + gentamycin OR cephazolin [covers aerobic]) 5. laparoscopic surgery |
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What ABx do you give when doing appendicectomy?
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Metronidazole (nitroimidazole)
plus Cephazolin (cephalosporin) or Gentamycin (aminoglycoside) |
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How does malrotation present?
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bilious vomiting
abdo pain |
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How does pyloric stenosis present?
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non-bilious vomiting
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What shape does malrotation look like when put dye down NG tube and do AXR?
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backwards S
S is for surgery! |
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What do you think of with redcurrent-jelly like stools?
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Intussusception
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What do you think of with sausage shaped mass, tender in epigastrium or RUQ?
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Intussusception
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What does intussusception look like on U/S?
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target/donut sign
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Mgmt of intussusception? (3)
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Fluid resus
Pain mgmt Send to radiology for air enema |
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Vomiting from pyloric stenosis loses Na, K, HCl and water.
When should you add K to fluids? |
after passes urine
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Major congenital malformations occur in ~___% of children within the first 5 years of life
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5
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"Morphological defect of specific anatomical structure occurring DURING organogenesis" = _______________
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malformation
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"abnormal shape/position of body part due to anomalous mechanical forces*. Usually occurs AFTER organogenesis" = >______________
*e.g co-twin, uterine fibroids, oligohydramnios |
Deformation
- loss of symmetry, distorted configuration |
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"result of a destructive process that alters structures AFTER normal foetal devpt" = _____________
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Disruption
e.g amniotic bands --> amputation of parts |
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Increased ____________ age --> higher risk for new dominant mutations
Increased ___________ age --> higher risk for chromosomal abnormalities |
father's
mother's |
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Any growth parameter measurements that deviate >____ standard deviations from each other are outside the normal range and need an explanation
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2
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Where is the deletion in Velocardiofacial syndrome?
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Chromosome 22q11
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What are the facial features of velocardiofacial syndrome? (3)
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1. high broad nasal bridge
2. alae nasi underdeveloped giving appearance of a tubular nose 3. small ears that don't have lower lobe |
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What develops abnormally in velocardiofacial syndrome?
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pharyngeal arches
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If you suspect, clinically, a genetic condition due to a very large deletion, what specialised testing can you do?
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FISH
karyotype microarray |
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Incidence of childhood cancer
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1 in 600
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True or false: kids get carcinoma
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False
Adults do |
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What sort of cancer Rx are paediatric cancers highly sensitive to?
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chemo
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What percentage of kids with cancer are cured permanently?
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75%
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What is the most common of all childhood malignancies?
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ALL
(followed by CNS tumours) |
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Presenting symptoms of ALL (9)
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1. anaemia
2. bruising 3. fever 4. bone pain 5. adenopathy 6. hepatomegaly 7. splenomegaly 8. malaise 9. anorexia |
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Which cells do you see in the blood which normally should only be in the BM in ALL?
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lymphoid blast cells
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ALL:
Which has better prognosis: Lower WCC or Higher WCC |
low
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ALL:
Which has better prognosis: B cell or T cell disease |
B
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How long do you have to have chemo for ALL?
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1 month induction
5-mo 'heavy' chemo 1.5yrs 'gentle' maintenanco chemo PO |
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Which is more serious: AML or ALL?
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AML
similar presentation to ALL different BM aspirate |
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Where are paeds brain tumours usually located?
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posterior fossa
infratentorial |
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Where would a medulloblastoma be located?
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4th ventricle
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What does an ependymoma arise from?
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ependymal lining of ventricles
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Optic nerve glioma is associated with what other condition?
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nuerofibromatosis-1
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Where is the classic site for a benign astrocytoma?
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cerebellum
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What are the risks of treating brain tumours in kids? (3)
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1. may affect neuro-cognitive fn
2. may cause hypopituitarisn (GH, pubertal derangement, thyroid) 3. carcinogenic (may cause 2ndary cancers) |
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Where would you usually find a neuroblastoma?
What cells does it arise from? What rises in the urine? |
= tumour of adrenal gland
neural crest cells HVA |
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DDx for mass in flank (3)
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1. neuroblastoma
2. Wilms' tumour 3. hydronephrosis |
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What organ would you find a Wilms' tumour in?
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kidney
(AKA nephroblastoma) |
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Are Wilm's tumours and neuroblastomas benign or malignant?
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malignant
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How does Wilm's tumour present? (2)
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1. PAINLESS abdo mass
2. haematuria |
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Which age group gets Wilms' tumours?
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young
(1-7) |
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What are 3 associated conditions of Wilms' tumour?
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1. aniridia
2. hemihypertrophy (half of body grows more) 3. GU anomalies |
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Which age group gets Hodgkin's disease?
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teenagers
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What is the diagnostic hallmark cell in Hodgkin's?
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Reed-Sternberg cell
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How does Hodgkin's present? (2)
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1. mediastinal mass
2. supraclavicular/cervical painless, firm LNs + fever, weight loss, sweats etc.... PRURITIS |
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What are three types of Non-Hodgkin's Lymphoma and how do they present?
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1. T-lymphoblastic: older, mediastinal mass, pleural effusion
2. Burkitt's (B cell): abdo disease, intussusception, mass 3. large cell NHL |
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Which virus is associated with Burkitt lymphoma?
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EBV
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Who typically gets osteosarcoma?
Why? |
adolescents
assoc with rapid bone growth |
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Where in the bones does Ewing sarcoma affect?
|
diaphyseal long bones
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Where in the bonds does osteosarcoma affect?
|
growing ends of long bones
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What is the most common soft tissue sarcomas?
What are the three most common places it's found? |
rhabdomyosarcoma
1. head and neck 2. GU tract 3. extremities |
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Which ABx do you give a child who's having chemo and has febrile neutropaenia? (2)
|
Timentum
Gentamycin (need gram +, - and pseudomonas cover) |
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Over what days does the rostral neuropore close?
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d23-26
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Over what days does the caudal neuropore close?
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d26-30
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What is the incidence of paediatric food allergy?
What is the prevalence of paediatric food allergy? For <5 year olds? |
1-3%
1 in 20 1 in 5 |
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Immunological mechanism of IgE mediated allergy
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allergen -- processed by macrophage -- presented to T cell --- communicates with B cell --- under Th2 type conditions, B cell switched from IgM/IgG production to IgE production -- circulating IgE binds to mast cells/basophils
re-exposure to allergen -- IgE bound to mast cells -- recognises allergen -- cross linking of IgE -- mast cell/basophil degranulation -- release of histamine |
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IgE mediated food allergy manisfests itself within how many hours of food ingestion?
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2
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Define mild IgE mediated food rxn
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localised facial erythema or urticaria/angioedema (e.g swollen lips)
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Define moderate IgE mediated food rxn
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Generalised urticaria/angioedema
or vomiting or both |
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Define severe IgE mediated food rxn
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Generalised urticaria/angioedema
and stridor or wheeze and/or collapse Pale/floppy in small infants |
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If your sibling is atopic, how much does your risk increase of being atopic?
And atopic parent? |
4x
10x |
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You can be allergic to any foods that contain a _________
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protein
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What are the 8 foods taht cause more than 90% of IgE mediated allergic rxns in kids?
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1. eggs
2. milk 3. peanuts 4. tree nuts and seeds 5. fish 6. shellfish 7. soy 8. wheat |
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Skin prick test:
NEGATIVE if welt <______ What would this tell you? Why would you get a welt in a positive test? |
2-3mm
A negative test means it's highly unlikely you have an allergy to that substance (i.e good NPV) pre-formed IgE |
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____% have +ve RAST or skin prick test but AREN'T clinically allergic
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50
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How does the RAST test work?
|
have the allergen bound to the test tube
put patient's serum in IgE will bind to allergen put detection anti-IgE Abs in that bind to patient's IgE wash patient's serum away detect amount of patient's IgE |
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What is skin prick test good for?
|
monitoring if grow out of allergy
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Can you use skin prick or RAST to figure out severity of allergy?
|
no
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What's a +ve skin prick test?
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greater than or = 3mm
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Skin prick tests have a fair PPV with combined with ______________ ___________
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positive Hx
of symptoms which occur as a result of exposure to the allergen |
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What does RAST stand for?
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radioallergosorbent test
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RAST has good PPV at high levels for which 3 things?
What does this mean? Can you tell severity or likelihood of anaphylaxis from RAST? |
egg, milk, peanut
if number is high on the interational units for RAST, it is likely you have the allergy No |
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Which is better for ruling out an allergy, RAST or skin prick?
|
skin prick (has better NPV)
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What do you do if your skin test is +ve but you don't know about exposure Hx? OR if you've got a grey area score for RAST
Can you tell severity of allergy from this? |
Open Food Challenge
No |
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Which 4 things which induce allergies are more likely to be outgrown?
|
1. milk
2. egg 3. soy 4. wheat |
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How do you give the Epipen?
Doses? |
"blue to the sky, orange to the thigh"
Doses: 150 for younger kids 300 if over 20kg |
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What are the major risk factors for food anaphylaxis in food allergic children? (4)
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1. older child
2. increased dose of allergen 3. presence of asthma 4. nature of allergen (nuts, shellfish, fish) |
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What are the three foods that are more likely to cause anaphylaxis?
What is #1? |
nuts (peanuts = #1)
shellfish fish |
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How soon after food ingestions do non-IgE mediated food allergies manifest?
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2-24h
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What is the best test for non-IgE mediated food allergies?
|
food elimination and rechallenge
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Is eosinophilic oesophagitis IgE mediated or non-IgE mediated?
|
non-IgE mediated
(ie presumed T cell mediated) |
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In Bx for eosinophilic oesophagitis, how many eosinophils do you see per HPF?
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>20
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Rx: eosinophilic oesophagitis? (2)
|
1. dietary modification
2. swallow fluticasone |
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What does FPIES stand for?
What usually causes it (3) |
Food protein induced enterocolitis syndrome
Rice Soy Chicken |
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Do allergic rxns typically get worse over time with more exposure?
|
no
the rxns are unpredictable |
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Are skin prick tests good for picking up non-IgE mediated food allergy?
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No
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|
Mechanism for T cell mediated allergy
What is this type of rxn called? |
allergen processed by macrophage -- presented to T cells -- Th2 environment -- allergen specific memory T cell created
Allergen re-exposure -- allergen processed by macrophage -- Ag presented to memory T cells -- activated T cell proliferation and cytokine production Delayed type hypersensitivity rxn (Type IV hypersensitivity rxn) |
|
|
What is the allergic march?
Why is it thought to happen? |
progression of atopic disease from:
eczema --> asthma --> allergic rhinoconjunctivitis caused by a regional allergic response with breakdown of the local epithelial barrier that initiates systemic allergic inflammation |
|
|
From how old can you do creatinine levels in a neonate?
Why? What is typical creatinine for a neonate? |
from day 3
before that it reflects the mother's 15-30 |
|
|
From how old can you do U/S in a neonate?
Why? |
from day 5
there's not enough urine being made to show up on U/S before this, so if there's an obstuction, you wouldn't see it |
|
|
When do you start toilet training?
|
2-3 years
|
|
|
How may kids wet the bed?
|
10% of 5 year olds
5% of 10 year olds |
|
|
What is normal GFR for a neonate?
|
30-40
|
|
|
What 4 anomalies can renal U/S show?
|
1. size
2. cysts 3. dilatation 4. stones |
|
|
What is MCUG/VCUG?
How does it work? What 3 things can you Dx with it? |
Micturating Cystourethrogram
Catheter -- contrast into bladder -- Pt voids 1. vesico-ureteric reflux 2. posterior urethral valves 3. bladder diverticulum |
|
|
What do you see on MCUG in vesico-ureteric reflux?
|
dilated renal pelvis/calyces
(depends on severity) |
|
|
What is MAG3 or DTPA renal imaging good for showing?
|
Obstruction
e.g shows one kidney emptying slower than the other |
|
|
____% of febrile children have UTI
|
~5
|
|
|
At what age are UTIs more common in boys?
|
6-12mo
|
|
|
Which organisms (5) cause UTI?
#1? #2? |
#1 E.Coli (80%)
#2 Klebsiella (10-15%) Enterobacter Proteus Pseudomonas (if abnormal urinary tract) |
|
|
Rx UTI (>12mo) (empiral ABx) (2 choices)
For how long if it's cystitis, and for pyelonephritis? |
cephalexin
or bactrim PO 3d cystitis (afebrile) 7d pyelonephritis (febrile) |
|
|
Rx severe UTI (septic, vomiting) + for all <1mo (2)
|
ampicillin
+ gentamycin IV |
|
|
What is the best specimen collection form for Dx of UTI?
|
clean catch
(in out catheter if really sick) |
|
|
What would you see on UA for Dx of UTI?
|
Nitrite +
Leukocyte + (if both then 96% sure, if just one is +ve then 70% sure) |
|
|
What do you see on urine microscopy and culture for UTI?
|
WBC > 100x10^6/L
single organism > or = 10^8 (voided) > or = 10^7 (catheter) |
|
|
By definition, if a child with UTI is febrile, what do they have?
|
pyelonephritis
|
|
|
By definition, if a child with UTI is afebrile, what do they have?
|
cystitis
|
|
|
Preventative measures for UTI (6)
|
1. regular fluids/voiding
2. avoid/treat constipation 3. avoid caffeinated drinks 4. cranberry supplements 5. correct wiping 6. ?probiotics |
|
|
True or false:
if VUR, circumcision can prevent UTI |
true
|
|
|
If an infant <6mo has a typical UTI, what other Ix do you need to do? When?
|
Ultrasound within 6wks
|
|
|
Nephrotic or nephritic:
oedema and proteinuria |
nephrotic
|
|
|
Nephrotic or nephritic:
haematuria |
nephritic
|
|
|
Nephrotic or nephritic:
HTN |
nephritic
|
|
|
Nephrotic or nephritic:
red cell casts |
nephritic
|
|
|
Nephrotic or nephritic:
raised creatinine |
nephritic
|
|
|
Most kids (80%) with nephrotic syndrome have which disease?
What age is it most common? How is it treated? |
Minimal change nephrotic syndrome
2-6 years Prednisone PO 60mg/m2 for 4wks then 40mg/m2 on alt days for 4wks wean over 1-5mo |
|
|
When would you do a renal Bx in nephrotic syndrome?
|
if after one month they haven't responded to steroids
|
|
|
Other than prednisone, what else is in the mgmt of nephrotic syndrome? (4)
|
1. fluid restrict til in remission
2. no added salt diet 3. pneumococcal vaccine 4. annual flu vaccine |
|
|
What are 4 potential complications of nephrotic syndrome?
|
1. infection (urinary loss of IgG, T cell dysfunction, decreased C') - particularly encapsulated organisms (pneumococcus)
>> At risk of sponaneous bacterial peritonitis (S. pneumoniae most common) 2. thromboembolic (increased synthesis of clotting factors, loss of coag inhibitors into urine) 3. cardiovascular (since increased cholesterol) 4. drug S.Es |
|
|
What organism usually involved in post infection GN?
What's the best test for proving an infection with this? |
GAS
anti-DNase B titre or ASOT (Ab made against streptolysin O which is a toxin produced by GAS) |
|
|
C3 is _________ in nephrotic
and __________ in nephritic |
normal
low |
|
|
DDx for acute nephritis (6)
|
1. post-infectious GN
2. IgA nephropathy 3. HSP 4. membranoproliferative GN 5. RPGN 6. SLE (ANCA +ve) |
|
|
Rx options for nephritis (3)
|
nil
diuretics (Lasix) antihypertensives |
|
|
Mgmt of ARF
(6) |
(depends on cause)
1. fluid correction 2. correction of electrolytes 3. BP mgmt 4. removal of toxins 5. drug dosage adjustment 5. dialysis |
|
|
What are 4 causes of chronic renal failure
|
1. renal dysplasia
2. obstructive uropathy 3. GN (incl FSGS) 4. reflux nephropathy |
|
|
CRF:
What happens to: urea |
increases
|
|
|
CRF:
What happens to: Potassium |
increases
|
|
|
CRF:
What happens to: BP |
increases
|
|
|
CRF:
What happens to: Calcium |
decreases
|
|
|
CRF:
What happens to: PO4 |
increases
|
|
|
CRF:
What happens to: Hb |
decreases
|
|
|
HTN in kids = SBP or DBP >_____th centile
|
95
|
|
|
Broad causes of HTN in kids (6)
|
1. renal
- parenchymal eg. GN, polycystic kidneys, scarring - obstruction 2. vascular 3. endocrine - adrenal, thyroid, parathyroid, pituitary 4. metabolic syndrome 5. central - e.g raised ICP, systemic nervous sys abNo. 6. iatrogenic - drugs, IV fluids |
|
|
What are the first Ix you get in a non-obese child or adolescent with HTN? (5)
|
1. EUC
2. CMP 3. UA 4. doppler U/S 5. ECHO |
|
|
6 symptoms of anaemia
|
1. none
2. pallor 3. lethargy 4. failure to thrive 5. jaundice 6. red urine |
|
|
Pale and jaundiced = _____________________
Pale and jaundiced and red urine = _________________ |
haemolysis
intravascular haemolysis |
|
|
4 DDx for intravascular haemolysis
|
1. G6DP def
2. paroxysmal cold haemoglobinuria 3. malaria 4. ABO incompatibility |
|
|
What do you think of in a well child, +/- recent Hx of viral infection, with sudden onset of petechiae and purpura?
|
ITP
|
|
|
How do you Rx acute ITP?
|
none normally necessary
resolves on own may need IVIG or prednisone |
|
|
What do you see on FBC in ITP?
Film? |
decreased platelets
normal or large platelets, but <20 000/mm^3 |
|
|
How long would you give iron S' for for Fe def anaemia?
|
at least 3mo
|
|
|
What two things are a marker of bone marrow stress/infiltration?
|
1. raised MCV
2. HbF |
|
|
Rx for very high WBCs
Why? |
immediate IV fluids and platelets
high WCC can --> leukostasis --> intracranial bleed |
|
|
What do you think of with anaemia, infection, bruising and gum hypertrophy?
|
AML
|
|
|
Waist:Height ratio
What's the aim? |
<0.5
(ie keep your waist to less than half your height) relatively independent of age (when >6) |
|
|
How many Australian kids are overweight or obese?
|
23%
(1 in 4) |
|
|
Are there any obesity drugs can be used in adolescence?
|
None are licenced
|
|
|
4 things in the pathology of arthritis
|
1. synovitis
2. bone erosion 3. pannus 4. cartilage degradation (joint space narrowing) |
|
|
JIA classification criteria (3)
|
1. onset <16 y/o
2. duration > or = 6wks 3. exclusion of other causes of arthritis (there is no diagnostic test) |
|
|
What do you thin kof with fever, pain, tenderness, swelling, redness of a joint?
Ix? |
Septic arthritis
joint aspirate and culture blood culture |
|
|
What do you think of wth fever and pinpoint bone tenderness?
|
Osteomyelitis
|
|
|
What is the major criteria for diagnosing Acute Rheumatic Fever?
|
"JONES" criteria
J: joints (arthritis) O: looks like a heart (carditis) N: nodules, subcutaneous E: erythema marginatum S: Sydenham's chorea (OR "SPACE": Subcut noducles, Pancarditis, Arthritis, Chorea, Erythema marginatum) |
|
|
What are the minor criteria for Acute Rheumatic Fever? (4)
|
Fever
Arthralgia Increased ESR, CRP Prolonged PR interval |
|
|
What do you need to Dx Acute Rheumatic Fever?
|
evidence of recent strep infection
+ 2 x major or 1 x major + 2 x minor |
|
|
How long after an infection do you get post-infectious/reactive arthritis?
|
1-3weeks
|
|
|
What are the causes (3) or reactive arthritis?
|
GAS
enteric (eg salmonella) viral: 'transient synovitis' |
|
|
3 causes for hip pain arranged by age
|
2-6 years old: transient synovitis
4-10: Legg-Perthe's 10-14: Slipped Epiphysis |
|
|
What is Legg-Perthe's disease?
What will you see on Xray? |
idiopathic avascular necrosis of the femoral head
flattened femoral head |
|
|
Who gets slipped capital femoral epiphysis?
|
older obese boys
|
|
|
Where does hip pain refer to?
|
knee
|
|
|
Most common organism in septic arthritis and osteomyelitis?
|
S. aureus
|
|
|
If there is joint pain and refusal to weight bear, think of.... (4)
|
1. septic arthritis/osteomyelitis
2. malignancy 3. reactive arthritis 4. pain syndromes |
|
|
If there is joint pain at night think of...(3)
|
1. malignancy
2. osteoid osteoma 3. growing pains |
|
|
What comes under the umbrella of Juvenile Idiopathic Arthritis? (6)
|
1. Systemic arthritis (Still's)
2. Oligoarthritis (< or = 4 joints) 3. Polyarthritis (> or = 5 joints) 4. Enthesitis related 5. Psoriatic arthritis 6. Unclassified |
|
|
What happens to the fever in systemic JIA?
What coincides with the fever? |
"Quotidien" fever - spikes and returns to below baseline
Salmon coloured rash |
|
|
Oligoarticular JIA:
age: which joints? Which is most common? |
<5years
large joints knee most common |
|
|
Oligoarticular JIA:
ANA: +ve or -ve? RF: +ve or -ve? |
ANA +ve in 80%
RF -ve |
|
|
What do you worry about in oligo JIA? (3)
|
1. knee flexion contracture
2. quadriceps atrophy 3. leg length discrepancy |
|
|
What else do you have to screen for in JIA, particuarly in oligo? (it's associated with ANA +ve)
|
Uveitis
(it's asymptomatic) |
|
|
RF -ve Polyarticular JIA:
which joints? ANA +ve or -ve? |
small and large joints, neck, TMJs
ANA +ve in 50% |
|
|
What do you worry about in RF -ve poly JIA? (3)
|
1. cervical spine arthritis
2. TMJ arthritis ('chipmunk') 3. growth distrubance |
|
|
RF +ve JIA:
which joints? What else do they get? |
small and large joints
rheumatoid nodules over pressure points (30%) |
|
|
Seronegative spondylarthropathies:
arthritis where? ANA and RF +ve or -ve? |
peripheral and axial arthritis
ANA and RF -ve |
|
|
What HLA type in seronegative spondyloarthropathies?
|
HLA-B27
|
|
|
Enthesitis fits into which category?
|
seronegative spondyloarthropathies
|
|
|
Is the probability of having active disease into adulthood with JIA high or low?
|
high
|
|
|
What is HSP short for?
What sized vessels does it involve? Which parts of the body does it commonly affect? (4) |
Henoch-Schonlein Purpura
= small vessel vasculitis (venules, capillaries) skin (scalp, scrotum), joints, GIT, kidneys |
|
|
What are the GI complications assoc with HSP?
|
bleeding
intussusception |
|
|
Diagnostic criteria for HSP (4)
Have to have at least ____ |
Have to have at least two of:
1. palpable purpura 2. age <20 at onset 3. bowel angina (abnormal pain after meals or bowel ischaemia usually w/ bloody diarrhoea) 4. granulocytes in walls of arterioles or venules on Bx |
|
|
DDx for HSP (4)
|
1. acute abdomen
2. acute scrotum 3. meningococcal disease 4. other vasculitis e.g PAN (Polyarteritis nodosa) |
|
|
Rx: HSP
|
symptomatic (NSAIDs)
severe abdo pain may need steroids Urine/BP needs F/U |
|
|
Dx: SLE (hint: mneumonic)
|
"MD Soap 'n Hair"
Malar rash Discoid rash Serositis (pleuritis, pericarditis) Oral ulcers Arthritis Photosensitivity Neuro disorders (Sz, psychosis) Haematologic disorder ANA positive Immunologic disorder (Lupus erythematosus prep test, anti-dsDNA, anti-Smith) Renal disorders |
|
|
What is Juvenile dermatomyositis?
What are the symptoms? |
an inflammatory myopathy of unknown cause that affects muscle, skin and blood vessels.
Photosensitive voilet coloured or dusky red rash around extensor surfaces and on face plus proximal progressive muscle weakness |
|
|
What do you see in nail fold capillaries when magnified
in Juvenile dermatomyositis? What's a complication of JD? |
tortuous capillaries
deposition of calcium in the skin (calcinosis) |
|
|
What is scleroderma?
What are the symptoms? (3) |
connective tissue disorder causing bands of thickened skin
1. thickened skin 2. Raynaud's 3. stiffness and pain in joints 4. GIT: indigestion, diarrhoea, constipation |
|
|
What is the most common cause of hip pain in a school aged child?
When should you do Ix? |
Transient synovitis (reactive arthritis from viral URTI)
Ix only if hip pain persists >10d |
|
|
What is the key sign to Perthe's disease?
|
asymmetry with ROM of hips
|
|
|
What is the Rx for Perthe's disease?
|
Rx: bisphosphonates to maintain femoral head shape so it doesn’t collapse- eventually revascularises
|
|
|
What is slipped capital femoral epiphysis?
|
proximal displacement of femoral neck
|
|
|
Which side does growing pain occur on?
|
always bilateral
|
|
|
Most common symptoms of oligoarthritis (2)
|
morning stiffness
limping |
|
|
What causes Still's disease?
|
it's an autoinflammatory disease (no autoantibodies; it's the innate immune system)
|
|
|
Most common sites of Enthesitis (4)
|
1. tibial tuberosity (achille’s tendon)
2. plantar fascia insertions on base of foot 3. insertion of glut max onto ischial tuberosities 4. anterior superior iliac spine. |
|
|
What is the HEADS interview?
|
"HEEADSSSS"
Home Education and Employment Exercise, Eating Activities - include peers and risky behaviour Drugs - including EtOH, cigarettes Sexuality Suicidality + mood Safety - from injury at school, work, home, with friends Sleep |
|
|
What ages does 'adolescence' encompass?
|
10-19
|
|
|
What is the #1 reason for female young people (age 12-24) for hospitalisation?
For male? Followed by what? |
pregnancy and childbirth
injury and poisoning #3: digestive system problems #4: mental and behavioural disorders Chronic illness also is a major cause of adolescent morbidity |
|
|
What are the developmental tasks of adolescence? (7)
|
1. est realistic body image
2. est self identity 3. achieve independence 4. integrate into peer group 5. become comfortable with own sexuality 6. acquire skills for future vocation 7. develop value system --> these tasks may be affected by illness |
|
|
How much sleep does the average 16 year old need?
Required sleep _______ during adolescence |
8.5h
declines |
|
|
Which phase of sleep is reduced in adolescence?
|
slow wave sleep
= less efficient/restorative sleep |
|
|
Adolescents sleep later and wake later. They have less efficient sleep. They do not get enough sleep.
What are the consequences of this? (6) |
1. increase risk of injury
2. poor s |
|
|
3 things used to Dx sleep disorder
|
1. sleep diary -- helps identify trends in problems of sleep/wake cycle
2. actigraphy -- worn on wrist, records motion - used with diary 3. Polysomnogram -- good when OSA suspected or symptoms can't be explained by other 2. Measures brain waves, eye movement, HR etc... |
|
|
What are 4 common sleep disorders in adolescence?
Which is most common? |
1. poor sleep hygeine (most common)
2. delayed sleep phase disorder 3. insomnia 4. sleep disordered breathing |
|
|
What are 6 things that contribute to poor sleep hygiene?
|
1.
|
|
|
What is Delayed Sleep Phase Disorder?
Mgmt? |
A circadian rhythm disturbance
-- unusually long circadian rhythm - sleep onset and wake times intractably later than desired - extreme difficulty waking in the morning Mgmt: bring sleep time 1/2h earlier each week, improve sleep hygiene, walk 20min in sun w/o sunglasses each morning, no naps, exercise, melatonin only in refractory cases |
|
|
How common is insomnia in adolescence?
|
point prev = 4-5%
|
|
|
3 causes of insomnia in adolescence?
|
1. primary (use HEADS to explore)
2. part of psych disorder 3. assoc with drugs/meds |
|
|
What causes the most burden of disease and disability in 10-14year olds? (4)
In 15-19 year olds? (3) |
1. mental health - Anx + Dep
2. chronic illness and disability 3. reducing risks for future ill health |
|
|
What are the two systems GPs most commonly treat in young people?
|
1. respiratory
2. skin (social problems is last) |
|
|
What is the prevalence of mental health problems in young people?
|
one in four
|
|
|
What supports resilience in adolescents? (4)
|
1. connections to partents, family, school,
|
|
|
Moles in kids change.
When are they a concern? |
If they're changing and the kid is not growing
|
|
|
Moles start off as ___________ ______________ which are flat and dark.
Over time progresses down into dermis to become _________________ _______________ Over time becomes less pigmented and are called _________________ _______________ |
Junctional naevi
Compound naevi Dermal naevi |
|
|
What is it called when there is a very big naevus on a baby.
Worry if it crosses midline because ________________ ____% will get melanoma before age 5 |
Bathing trunk naevus
there might be something in the spine 50% |
|
|
What surfaces do you usually get eczema on?
What is the mutation in eczema? Rx of eczema? Why? |
ventral
'Lagran' moisturise 3xday to keep skin barrier in tact so allergens don't get in May need wet dressings to help absorb if severe eczema |
|
|
Rx for eczema flare
|
as well as mois
|
|
|
Dx:
yellow and crusty usually in first 3mo of life not itchy Rx? |
Seborrheric dermatitis
Rx: moisturise and weak steroid |
|
|
How do you tell the difference between allergic contact dermatitis and periorbital cellulitis?
|
contact dermatitis: well child
periorbital cellulitis: unwell child |
|
|
A singlular annular lesion = _______________ til proven otherwise
Next step? |
TINEA
do skin scraping for fungal microscopy |
|
|
What is the name for ring worm?
From exposure to what? |
Tinea corporis
cats, guinea pigs, rabbits |
|
|
Is tinea asymmetrical/symmetrical?
Unilater/bilateral? And psoriasis? |
Tinea: asymmetrical and unilateral
Psoriasis: symmetrical and bilateral |
|
|
What is endothrix?
Ectothrix? What condition do you get it in? |
endothrix: broken off hairs at the surface of scalp= black dot tinea. spores inside hair shaft
ectothrix:hairs broken off above surface of scalp, so spores are outside hair shaft Tinea capitis |
|
|
What do you think of when you see alopecia and black dots on scalp?
It's itchy. |
tinea capitis
|
|
|
What is a Kerion?
What do you get it in? Rx? |
inflammatory response - has elevated, boggy, granulomatous mass
Tinea capitis Rx: debridement |
|
|
What do you think of with GROUPED lesions, well demarcated, SCALLOPED edge, painful. Blister.
Rx? |
HSV
Rx: IV fluids, acyclovir |
|
|
What's it called when HSV targets areas of eczema?
What do the lesions look like? |
Eczema herpeticum
('punched out' lesions with scalloped edge and grouped lesions) |
|
|
shingles
If tip of nose is affected => __________ branch of facial nerve is affected => look for ____________=> send to ___________________ Rx: ? |
opthalmic
uveitis opthalmologist IV acyclovir |
|
|
What is the causative organism for molluscum contagiosum?
how do the lesions appear? How is it spread? Rx? |
Pox virus
skin coloured, cone shaped, with central umbilication (depression in middle) spread from direct contact or in warm water Rx: Imiquimod or prick them (both simulate inflamm response) |
|
|
What do you think of with golden eruptions that look like cornflakes (honey coloured, crusted plaque)
|
Non-bullous staph impetigo
|
|
|
What do you think of with pus filled lesion?
|
Bullous impegito
|
|
|
Rx for impetigo?
|
Fluclox PO
|
|
|
What do you think of with pustules on soles of feet and on palms?
Intense pruritis. |
= SCABIES til proven otherwise
|
|
|
Rx: Scabies
|
topical PERMETHRIN 5%
treat whole family at same time on 2 consecutive nights for 2 consecutive weeks Wash all clothes and linen in hot water |
|
|
What do you think of:
in a tanned patient, get pale lesions, in a pale patient, get orangey pigmentation? What causes it? What exacerbates it? |
Pityriasis versicolor
Malassezia furfur (yeast) humid, hot weather Rx: antifungals |
|
|
What causes scabies?
|
Sarcoptes scabiei
|
|
|
What do you get if you have multiple pinna haematomas that don't heal properly?
|
Cauliflower ear
|
|
|
3 organisms assoc with otitis externa
|
1. P. aeruginosa (in water)
2. S. aureus (on skin) 3. Fungal |
|
|
Why do you get otitis externa?
|
thin skin in ear canal --> while wet, traumatise skin --> bacteria gets in
happens a lot in summer when swim a lot |
|
|
Otitis externa: what do you see?
|
swollen, macerated ear canal
|
|
|
How do you differentiate otitis externa from mastoiditis?
|
OE: hurts when pull on ear; ear canal is red and swollen and can't see ear drum
mastoiditis: doesn't hurt when pull on ear; ear drum visible and is red and bulging |
|
|
Rx: otitis externa
|
may need cleaning with microscope, wicks or packing
Topical drops/creams/ointments e.g Sofradex = combo of steroids, ABx and antifungals |
|
|
Why is otitis media common in childhood? (2)
|
Poor aeration due to less palatal muscle mechanics and strength - this leads to -ve pressure which draws fulid in and holds it there with URTIs
Poor drainage from eustachian tube due to shorter tube and horizontal axis - this keeps the fluid there (interruption of normal eustachian tube function [ventilation] by obstruction -> inflamm response -> middle ear effusion [secretions from mucous secreting cells that line the middle ear]-> infection (most with URTI) |
|
|
OM can be caused by viruses or bacteria.
What are the 3 most common bacteria? |
1. Streptococcus pneumoniae
2. Haemophilus influenzae 3. Moraxella catarrhalis |
|
|
Rx for OM
|
No systemic illness:
6mo - 2yrs - analgaesia only and r/v in 24h - if persists, give ABx 2yrs+ - as above but r/v after 48h Systemic illess or <6mo: ABx - AMOXICILLIN and analgaesia |
|
|
Otoscopic signs of OM (5)
|
1. bulging/fullness of TM
2. intense erythema 3. some degree of opacity (indicates effusion) 4. loss of light reflex 5. pneumatic otoscope: blow air in and see little to no movement of TM |
|
|
What do grommets do?
When would you put them in? |
= pressure equalising tube
lets air into middle ear space OM with effusion (if doesn't resolve after 3mo) |
|
|
What is chronic suppurative OM?
Rx? |
perforated TM with persistent drainage from middle ear
Rx: keep dry (dry mop with tissue spears = aural toilet) topical drops (Ciprofloxacin) |
|
|
What is it called when there is squamous epithelium proliferation in the middle ear?
Rx? |
Cholesteatoma
(this is the other type of chronic suppurative OM [cf tubotympanic]) Surgical Rx |
|
|
4 complications of OM
|
1. CNVII damage (facial nerve palsy) from damage to middle ear structures
2. localised abscess (mastoiditis) 3. suppurative labrynthitis (deafness, dizziness) from damage to inner ear 4. intracranial - extradural abscess, meningitis, subdural abscess, i/c abscess |
|
|
What do ears look like in mastoiditis?
|
pushed out
|
|
|
Congenital Sensorineural hearing loss
Rx? Due to damage of cochlear |
hearing aids
Cochlear implant if severe |
|
|
What area usually bleeds in the nose to cause epistaxis?
Rx? |
anterior: "LITTLE'S AREA"
= thinned, dried out mucosa Hesselbach's vessels rupture easily Cover with ointment to thicken mucosa |
|
|
2 reasons the nose can be obstructed
|
1. allergy (increases turbinates size)
2. enlarged adenoids |
|
|
Indications for tonsillectomy and adenoidectomy (2)
|
1. tonsillitis:
6x past year 4-5x past 2 yr 3x past 3 yr 2. OSA |
|
|
Complications of tonsillectomy/adenoidectomy (3)
|
1. GA
2. haemorrhage 3. palatal incompetence (causes nasal air escape which makes talking difficult) |
|
|
To avoid inhaling a FB, it is advised to avoid small foods like nuts until the age of ___
|
7
|
|
|
What do you see on CXR with FB inhalation?
|
air trapping
|
|
|
Rx: inhaled FB
|
bronchoscopy and removal
|
|
|
Three main components causing the pathophysiology of asthma
|
1. airway inflammation and oedema
2. bronchospasm 3. mucous production |
|
|
Prevalence of kids in Australia with asthma
|
10-15%
|
|
|
Are all asthmatics atopic?
|
no
(usually is though; 80%) |
|
|
Definition of asthma
|
repeated episodes of REVERSIBLE bronchoconstriction
|
|
|
What symptom MUST be present in order to Dx asthma?
|
wheeze
(but not all that wheezes is asthma - transient wheeze that usually comes on with viral infection and remits without intervention) |
|
|
What are the 6 steps in the Six Step Asthma Mgmt Plan?
|
1. assess severity
2. achieve best lung fn 3. maintain best lung fn - avoid triggers 4. maintain best lung fn - optimise meds 5. develop asthma action plan 6. educate and r/v |
|
|
What severity of acute asthma is this -
Altered consciousness: No SaO2: 90-94% Talks in: phrases PR: 100-200 Central cyanosis: Absent Wheeze: mod-loud |
Moderate
|
|
|
What severity of acute asthma is this:
Altered consciousness: agitated/drowsy/confused SaO2: <90% Talks in: words or unable to speak PR: >200 Central cyanosis: likely Wheeze: often quiet |
Severe/lifethreatening
|
|
|
What severity of acute asthma is this:
Altered consciousness: No SaO2: >94% Talks in: sentences PR: <100 Central cyanosis: absent Wheeze: variable |
Mild
|
|
|
What is asmol?
|
salbutamol
|
|
|
What is the dose of salbutamol in acute asthma mgmt?
|
<20kg:
6 puffs (600mcg) via spacer or 2.5mg via nebuliser >20kg: 12 puffs (1200mcg) via spacer or 5mg via nebuliser |
|
|
What is atrovent?
|
ipratropium bromide
(anticholinergic) |
|
|
Dose of ipratropium bromide in acute asthma mgmt?
|
<20kg:
4 puffs then q6h or 250mcg q20min x 3 via neb then q6h >20kg: 8 puffs then q6h or 500mcg q20min x 3 via neb then q6h |
|
|
In acute asthma mgmt, after giving salbutamol and ipratropium bromide, if this fails, what do you do next? (6 options in order)
|
1. IV salbutamol infusion
2. IV magnesium sulfate bolus 3. Aminophylline 4. Anaesthetic agents 5. CPAP 6. intubation and ventilation |
|
|
Who should get predisone in acute asthma?
|
those who had severe wheeze who required hospital admission
|
|
|
What is the dose for oral prednisone in acute asthma mgmt?
|
Initial dose: 2mg/kg PO (max 60mg)
Followed by: 1mg/kg PO daily for 3days |
|
|
Criteria for d/c after acute asthma?
|
Salbutamol q3h
(after having stretch the salbutamol administration) |
|
|
What should you give parents when discharging a child for acute asthma? (5)
|
1. 'reducing medication' plan
2. asthma action plan 3. d/c meds 4. F/U arrangements 5. The Children's Asthma Resource Pack for parents and carers |
|
|
How do you diagnose asthma?
|
spirometry (if mental age >4-6 y/o)
CXR (but this is not routinely done after first presentation) |
|
|
What Rx is needed for infrequent intermittent asthma?
(exacerbations < every 4-6wks, nil night time symptoms, FEV1 >80%) |
just salbutamol
|
|
|
What Rx is needed for frequent intermittent asthma?
(exacerbations >2per mo, nil night time symptoms, FEV1 >80%) |
salbutamol
+ preventer |
|
|
Can you use long acting beta2 agonists on their own in paeds?
|
NO
must use with ICS |
|
|
Preventers are prescribed twice per day, except for:
2 which are prescribed once per day. Which two? and 1 which is prescribed three times per day. Which one? |
Singulair (Montelukast)
Alvesco (Ciclesonide) Intal Forte (Sodium Cromoglycate) |
|
|
What is flixotide?
|
fluticasone
|
|
|
What is Pulmicort?
|
Budesonide
|
|
|
What is Qvar?
|
Beclomethasone
|
|
|
What is Seretide?
|
Fluticasone and Salmeterol
|
|
|
What is Symbicort?
|
Budesonide and Eformeterol
|
|
|
What is Intal Forte?
|
Sodium Cromoglycate
= preventer |
|
|
Important to note that with all preventer therapy there is the potential for _________ __________ when the child's asthma is clinically stable
|
back titration
|
|
|
What 5 things indicate good asthma control?
|
1. minimal Sx during day and night
2. minimal need fo reliever medication 3. no exacerbations 4. no limitiation to activity 5. normal lung fn: FEV1 and/or PEFR >80% pred |
|
|
Inhalation delivery devices: which would you choose for-
age <4 |
small spacer with mask
|
|
|
Inhalation delivery devices: which would you choose for-
4-6yrs old |
large or small spacer
no mask necessary |
|
|
Inhalation delivery devices: which would you choose for-
age >6 (3 choices) |
Turbuhaler
Accuhaler Autohaler |
|
|
Inhalation delivery devices: which would you choose for-
age >8 |
Puffer (no spacer - but spacer is preferred, esp for ICS)
|
|
|
Asthma action plan:
When to seek medical advice (2) |
- reliever meds every 3-4h
- given oral steroids with no/little improvement |
|
|
Max dose for reliever meds
|
<20kg: 6 puffs
>20kg: 12 puffs |
|
|
How long after having salbutamol do you wait before doing spirometry again?
|
10mins
|
|
|
What is a positive bronchodilator response on spirometry?
|
FEV1 > or = 12% and > or = 220mL
|
|
|
FEV1 for mild, mod and severe obstructive disease
(the same parameters apply for FVC when assessing restrictive disease) |
mild: >60%
mod: 40-60% severe: <40% |
|
|
Normal sleep patterns for 0-3mo
|
95% sleep during the day every day
take 0.5-1h to settle may wake up to 6 times/night, most commonly twice |
|
|
normal sleeping patterns for 1 year old
|
89% have daytime nap for 1-2h
most settle b/t 6 and 8pm 80% settle quickly 60% have night time waking requiring settling by parent, 10% wake more than 3xnight |
|
|
Normal sleeping patterns for 2 year old
|
half have daytime naps
stay up later - 1/3 sleep after 8pm 1/4 take >30min to settle 1/2 wake once during night requiring parent's attention |
|
|
Is regurgitation after a feed normal?
|
yes, 2/3 report it at 4mo
most outgrow by 12mo |
|
|
When does reflex become pathological? (4)
|
- poor growth
- blood stained (oesophagitis) - breathing difficulties, chest infection - crying, irritability |
|
|
Rx of reflux? (4)
|
1. none required for most kids
2. thickened feeds 3. PPI 4. fundoplication if severe |
|
|
What do you think of with loose frothy stools? (3)
|
1. Lactose intolerance (due to relative lactose malabsorption)
2. oversupply (advise to feed from 1 breast only for a few feeds) 3. xS CHO-rich fore-milk and not enough fat-rich hind milk: hind milk slows absorption and allows time for digestion so advise to allow baby to fully feed from one breast |
|
|
What is the most common cause of lactase def in infancy?
|
Secondary Lactase Deficiency
-- results from small bowel injury (e.g gastro) -- knocks off brush border Primary Lactase Def is the most common cause of lactose intol overall but uncommon <2years of age. This is a relative or absolute absence of lactase. |
|
|
What sort of lactose intolerance can premature babies get?
|
'Developmental lactase deficiency'
seen in <34wks gestation |
|
|
Ix for lactose intol? (6)
|
1. 2wk trial on lactose free diet and challenge
2. hydrogn breath test in subtle cases 3. stool tested for pH (low) and faecal reducing substances 4. intestinal Bx (measure lactase activity) 5. stool specimen for Giardia or cryptosporidium 6. check Ab for coeliac disease (TTG, total IgA) |
|
|
Should infants who are being breastfed and who are lactose intolerant continue to breastfeed?
|
yes
|
|
|
How common is congenital lactose intolerance?
|
very very rare
|
|
|
What weight gain should you expect to see in an infant?
|
100-200g/week
|
|
|
A toddler should be drinking no more than _____mL of cow's milk/day
|
600
|
|
|
What is the most important sign of adequate nutrition?
|
growth monitoring
|
|
|
When introducing new foods, it may take up to ____ tried before the new food is accepted
|
10
|
|
|
Define constipation
|
delay or difficulty passing stool present for >2wks
|
|
|
How often do normal babies poo?
|
First wk of life: 4xday
By age 2: 1xday |
|
|
Do breastfed or formula fed babies poo more?
|
formula
it's normal for some breast fed babies to go for several days without doing a poo |
|
|
Most common cause of constipation in kids?
Rx:? |
Functional constipation
e.g not wanting to go, forgetting Rx: <1yr: prune juice, lactulose, glycerine suppository >1yr: mineral oil, lactulose, glycerine suppository |
|
|
Do you get a fever when teething?
|
only a mildly raised fever
|
|
|
What is Positional plagiocephaly?
What side is it normally on? What exacerbates it? |
posterior skull flattening, uni or bilaterally
Ipsilateral frontal bulge forward displacement of ipsilateral ear RHS Sleeping on back |
|
|
DDx of positional plagiocephaly? (2)
|
1. craniosynostosis (has palpable ridging over prematurely fused suture)
2. congenital muscular torticollis |
|
|
Is head circumference normal or abnormal in positional plagiocephaly?
|
normal
|
|
|
What is the difference b/t Primary and Secondary nocturnal enuresis?
What causes it? |
Primary: never fry for more than few months
Secondary: was dry for >6mo and then wets again cause: ? |
|
|
Nocturnal enuresis: when should you seek professional help?
|
if still wetting >age 6
|
|
|
When is toilet training usually done?
How long does it take? |
usually successful from 2.5years
~2weeks |
|
|
In the feotal circulation, what vessel connects the umbilical vein to the inferior vena cava, and in doing so shunts 1/3 of the blood past the liver?
|
ductus venosus
|
|
|
What is the valve called in the foetal circulation that directs blood straight towards the foramen ovale?
|
euestacian valve
|
|
|
What happens to foetal circulation after a baby is born?
|
breath --> decrease in pulmonary vascular resistance --> increase in systemic vascaulr resistance --> closure of 3 foetal systemic-pulmonary shunts: DA, foramen oval, ductus venosus
|
|
|
When does the PDA close after birth?
- functionally - permanently |
w/i 10-15h
w/i 2-3wks |
|
|
When does RV dominance diminish?
|
slowly throughout childhood years
LV is dominant as an adult (the point of this is that there is a difference in normal ECG in kids with RV leads at precordium looking larger) |
|
|
At what age do you have max HR?
|
~3mo
HR initially increases after birth and then decreases after 3mo |
|
|
Kawasaki disease - AKA ___________________________
|
mucocutaneous LN syndrome
|
|
|
What cardio effects do you worry about with Kawasaki disease?
|
coronary artery aneurysms
|
|
|
What poses the highest risk for contracting endocarditis?
|
cyanotic heart diseae with posthetic shunt
|
|
|
Who gets endocarditis prophylaxis? (5)
|
1. prosthetic cardiac valves
2. previous IE 3. post cardiac Tx with cardiac valvulopathy 4. RHD with valvular pathology 5. selected CHD |
|
|
Incidence of congenital heart disease?
|
1/100
|
|
|
4 chromosomal abnormalities assoc with congenital heart disease
|
1. Down Syndrome
2. T13 3. T18 4. Turners |
|
|
Most common congenital heart disease?
|
VSD
(1/3) |
|
|
5 Genetic syndromes assoc with congenital heart disease
|
1. Velo-cardio-facial (22q11 del)
2. Marfan syndrome (Fibrillin gene) 3. Williams Syndrome (elastin gene) 4. CHARGE association 5. VACTERL association |
|
|
2 maternal diseases/infections that can --> congenital heart disease
|
1. SLE
2. rubella |
|
|
What are the 3 commonest reasons for a baby to collapse in first week of life?
|
1. - infection --> GBS
2. - obstructive left heart lesions (e.g coarctation) 3. - inborn errors of metabolism e.g hypoglycaemia |
|
|
How many children with Down Syndrome have AVSD?
|
50%
|
|
|
What do you think of with absent femoral pulse?
|
coarctation
might still be there though on day one if ductus still open |
|
|
What sign is come common than peripheral oedema in kids with RH failure
|
hepatomegaly
|
|
|
duct dependent pulmonary circulation - if closes, will --> ______________
duct dependent systemic circulation - if closes --> _______________________ |
cyanosis
shock and collapse |
|
|
Four causes for clubbing
|
1. cyanotic heart disease
2. IE 3. IBD 4. congenital familial disease |
|
|
Grades of murmurs
|
1: scarcely audible, no thrill
2: soft, no thrill 3: loud, no thrill 4: loud, faint thrill 5: very loud, easily felt thrill 6: audible without stethoscope |
|
|
Physiologically, can you hear a split S2 during....?
|
inspiration
- increased pulmonary venous return to right side of heart delays closure of pulmonary valve |
|
|
What are the features of an innocent murmur? (5)
NB there are NO symptoms |
1. systolic ejection
2. Grade 1-3 3. musical, vibratory 4. change with body position 5. augmented with illness |
|
|
4 innocent murmurs
|
1. Still's
2. pulmonary flow 3. venous hum (blood coming back into SVC) 4. carotid bruits (be sure there's no aortic pathology) |
|
|
CXR: what do you see in VSD? (2)
|
1. cardiomegaly
2. increased pulmonary vascular markings (from pulmonary venous congestion) |
|
|
CXR: TOF (3)
|
1. absent artery component
2. boot shaped heart 3. oligaemic lungs (decreased pulmonary vascular markings) |
|
|
What do you see on ECG in normal newborn vs normal adult?
|
right axis deviation
RV dominance -- big R wave in V1, small R wave in V6 adult: LV dominance -- big S wave in V1, big R wave in V6 |
|
|
4 left to right shunt diseases
what category do they fall into? |
acyanotic
1. ASD 2. VSD 3. AVSD 4. PDA |
|
|
What are the cyanotic heart diseases (5Ts!)
|
1. TOF
2. Transposition of great aa 3. Truncus arteriosus 4. Tricuspid atresia 5. Total anomalous pulmonary venous connection |
|
|
What do you worry about long term with ASD?
|
long term worry about pulmonary HTN
- LA pressure goes up because more blood coming back as more going into lungs |
|
|
CXR: ASD
|
RV and RA enlargement
|
|
|
Murmur in ASD?
|
Systolic ejection murmur - from incr pulmonary flow
Wide fixed splitting of S2 - R heart getting a bit more extra blood so R heart takes a little bi tlonger to empty and so pulmonary valve takes a bit longer to snap shut |
|
|
CXR: VSD
|
left heart enlargement
|
|
|
TOF: made up of...
|
"VORP"
VSD Overriding aorta RV hypertrophy Pulmonary and infundibular stenosis (RV outflow obstruction) |
|
|
Transposition of great aa - which two things do you need open?
|
1. PDA
2. foramen ovale (can do artificially) |
|
|
What do you give to keep PDA open?
|
PGE1
|
|
|
What happens in hypoplastic left heart syndrome when PDA closes?
What is the Rx? |
baby collapses
operation to get RV to maintain both pulmonary and systemic circulation (Norwood stage 3 procedure) |
|
|
What is a tet spell?
Rx? |
acute onset of hypoxia --> incr cyanosis --> gasping and syncope
Rx: place in lateral knee-chest position (increases systemic vascular resistance and therefore decreases R--> L shunt, give O2 |
|
|
What genetic condition is associaed with ventricular tachycardias?
|
long QT syndrome
|
|
|
What do you think of with:
epiphora and discharge of eye since birth mucocoele of lacrimal sac |
Congenital nasolacrimal duct obstruction
|
|
|
3 causes of epiphora
(xs tear production) |
1. Congenital nasolacrimal duct obstruction
2. Congential glaucoma 3. Corneal Irritation (FB or lashes) |
|
|
Rx: Congenital nasolacrimal duct obstruction
|
bathe with saline and massage over lacrimal sac
probe and irrigate if not resolved by age 1 |
|
|
4 causes of neonatal conjunctivitis
Which comes when? |
1. Gonococcal (typically presents d1)
2. viral 3. other bacteria (d4-6) (staph, strep) 3. Chlamydia (presents around d10 post NVD) |
|
|
How do you Rx neonatal conjunctivitis? (2)
|
1. topical ABx for staph/strep
2. systemic ABx for gon/chlam and remember to treat the parents! |
|
|
What do you think of with bilateral sticky eyes and eyes injected with mucopurulent d/c?
Rx? |
Bacterial conjunctivitis
(viral would have clear d/c) Rx: topical ABx |
|
|
What do you think of with vesicles involving upper and lower eyelids + watery eye
|
Herpes Simplex Blepharo-Conjunctivitis
Rx: topical acyclovir |
|
|
What do you think of with watery and irritable eye assoc with photophobia and injected eye?
Rx? |
Fluorescein
Blue-filtered light on slit lamp |
|
|
If you have an irritable eye, put fluorescein in and see an ulcer, what do you think of?
Rx? |
Herpes Simplex Keratitis
Rx: acyclovir |
|
|
How do you test visual acuity in a preverbal child (age 0-2)?
|
response to small toys - see if they fix and follow
response to 100s and 1000s |
|
|
What do you use as a screening program for visual acuity in pre-school children?
|
Sheridan Gardiner test:
matching test - points to symbol on their card that matches what you're pointing to on the screen |
|
|
From what age can you use the Snellen Chart for visual acuity?
|
5
|
|
|
What do you think of with abnormal head posture?
|
strabismus
|
|
|
What is the Hirschberg test and what's it used for?
|
Light reflex should be symmetrical in both eyes
Used for Dx of strabismus |
|
|
What do you use the cover-uncover test for in strabismus?
|
esotropia (eye turning out) - shows up at near - eyes look straight when looking into distance, and deviated when looking at something close up
exotropia - shows up at distance - eyes deviate when looking in distance but straight when looking at an object closely |
|
|
What is the term for 'lazy eye'?
|
amblyopia
|
|
|
What is the most common cause for amblyopia?
Rx of amblyopia? |
refractive errors in one eye - use good eye and ignore eye with refractive error
(can also get from strabismus - ignore one eye to avoid double vision) Rx: patch |
|
|
What do you think of with sudden onset strabismus assoc with diplopia?
|
intracranial pathology
|
|
|
DDx: leucokoria (white reflex) (2)
|
1. retinoblastoma
2. cataract |
|
|
What do you think of with leukocoria, strabismus, glaucoma and uveitis?
|
retinoblastoma
|
|
|
3 causes for congenital cataracts?
|
1. rubella
2. other TORCH infections 3. galactosaemia |
|
|
What do you think of with retinal haemorrhage?
|
NAI
|
|
|
What do you think of with 'spontaneous ecchymosis' around eyes?
|
NAI
|
|
|
What is the only intervention proven for the Rx of reading difficulties?
|
remedial intervention
|
|
|
Which sort of rash:
circumscribed, elevated lesions, i.e bumps |
Papules
|
|
|
Which sort of rash:
flat and impalpable |
macules
|
|
|
Which sort of rash:
elevated lesions containing a purulent exudate |
pustules
|
|
|
Which sort of rash:
circumscribed, elevated, fluid-filled and normally <0.5cm in diameter |
Vesicles
|
|
|
Which sort of rash:
may be flat or raised cannot be blanched small, <0.5cm caused by minor haemorrhage |
petechiae
|
|
|
Which sort of rash:
may be flat or raised cannot be blanched >0.5cm caused by minor haemorrhage |
purpura
|
|
|
Petechiae: think of which 2 things
|
1. meningococcal
2. low platelets |
|
|
What sort of rash is hand, foot and mouth?
|
vesicular
|
|
|
When does VZV stop being infectious?
|
when lesions crust (from 48h prior to onset of rash ti they crust)
|
|
|
Where are chicken pox vesicles predominantly located? (cf small pox)
|
trunk
(but they are everywhere) |
|
|
When would you give VZIG infant?>
|
if mother has it 48h before - 5d after delivery -- may cause severe neonatal disease
|
|
|
DDx for vesicular rashes (7)
|
1. VZV
2. HSV 3. hand foot and mouth 4. impetigo 5. molluscum contagiosum 6. dermatitis herpetiformis 6. Stevens-Johnson syndrome |
|
|
Who gets Rx for varicella? (3)
|
1. neonate
2. immunocompromised 3. complicated VZV |
|
|
How does neonatal HSV infection present (4)
|
1. skin, eye, mouth lesions
2. encephalitis 3. disseminated infection (looks like septicaemia) 4. pneumonitis |
|
|
What most commonly causes hand foot and mouth disease?
|
coxsackie virus 16
(enterovirus) |
|
|
How do you tell the difference between HSV infection and enterovirus (Coxsackie) in the mouth?
|
HSV: involves gingiva, more anterior
Cox: gingiva not involved, more posterior (back part of mouth + soft palate) |
|
|
DDx for maculopapular rashes (7)
|
1. measles
2. rubella 3. scarlet fever 4. |
|
|
What do you get on the inside of cheeks in measles?
|
Koplik spots
(greyish white) |
|
|
Dx: measles
|
PCR
|
|
|
What sort of rash in measles?
|
maculopapular
|
|
|
What's the difference between rubella and measles rash?
What else do you get in rubella? |
rash in rubella develops more quickly and disappears earlier than in measles
the rash is less florid LN enlargement: posterior, cervical |
|
|
What organism causes scarlet fever?
Rx:? |
GAS
Rx: Penicillin |
|
|
What do you think of with strawberry tongue?
|
scarlet fever
|
|
|
What colour is the rash in scarlet fever?
What is a distinctive feature of scarlet fever? |
dark red
circumoral pallor - rash spares area around mouth |
|
|
Kawasaki disease criteria (6)
|
Fever for at least 5d plus 4/5:
- bilateral conjunctival injection - rash - oral changes -> red mouth/pharynx/tongue and cracked lips - swelling of hands + feet then desquamation - cervical LN enlargement (at least one >1.5cm) |
|
|
What sort of rash seen in Kawasaki disease?
|
discrete red maculopapules
|
|
|
DDx for Kawasaki (2)
|
1. scarlet fever
2. staph disease |
|
|
What are the other 2 names for Slapped Cheek?
What causes it? |
Erythema infectiosum
Fifth disease Parvovirus B19 |
|
|
Rash in Fifth disease
|
starts as red cheeks
then lacy, maculopapular rash 1-2wks later mainly arms and legs |
|
|
Other than rash and fever, what else is associated with Fifth diseae?
|
joint aches
|
|
|
What causes Roseola infantum?
Where do you mainly get the rash? What sort of rash? |
HHV-6
maculopapular trunk |
|
|
What's the diff b/t the rash of roseola and measles?
|
measles: lesions become confluent
roseola: lesions are discrete |
|
|
What do you think of with high fever 3-4d then disappears and get maculopapular rash?
|
roseola infantum
|
|
|
2 presentations of meningococcal disease
|
1. meningitis
2. septicaemia |
|
|
Type of rash in meningococcal disease?
|
early on: maculopapular
then petechial/purpuric |
|
|
What is the single best test for rapidly Dx bacterial meningitis?
|
CSF gram stain
|
|
|
Meningococcus> Gram ______ ______
|
negative diplococcus
|
|
|
Common causes of bacterial meningitis in neonates? (3)
|
1. GBS
2. E. Coli 3. Listeria monocytogenes |
|
|
Common causes of bacterial meningitis in > or = 3mo - 16 years? (3)
|
1. N. meningitidis
2. Hib 3. Strep pneumoniae (any age) |
|
|
Empiric ABx for suspected bacterial meningitis: neonate
|
Ampicillin
+ Cefotaxime |
|
|
Empiric ABx for suspected bacterial meningitis: > 3mo
|
Cefotaxime
or Ceftriaxone Add vancomycin if suspect strep pneumoniae |
|
|
On CSF for bacterial meningitis, what do you expect to see for:
PMNs Lymphocytes Protein Glucose |
PMNs: increased: 100- 100 000
Lymphocytes: <100 Protein: increased >1 Glucose: decreased |
|
|
On CSF for viral meningitis, what do you expect to see for:
PMNs Lymphocytes Protein Glucose |
PMNs: <100
Lymphocytes: increased: 10-10 000 Protein: 0.4-1 Glucose: normal |
|
|
What is H1N1?
|
Swine flu
|
|
|
What is H5N1?
|
Avian flu
|
|
|
What is common in TB in aged <4 years old?
|
CNS dissemination
|
|
|
If neonate presents with any of:
fever lethargy anorexia apnoea --what should you suspect? |
infection
|
|
|
Any febrile newborn up til 3mo should have cultures of ____________, ______________ and ______________ and then should be started on empirical ABx
|
blood
CSF urine |
|
|
What is the commonest cause of congenital infection in Australia?
____% are asymptomatic. What do you worry about long term with this infection? |
CMV
90 hearing loss mental retardation |
|
|
Triad of systems in congenital rubella
|
1. eye - cataracts
2. cardiac 3. CNS - deafness, microcephalic |
|
|
Most common cause of viral gastro?
|
rotavirus
|
|
|
Dx on Hx of gastroenteritis (4)
|
1. increased watery stools
2. vomiting 3. fever 4. infectious contacts |
|
|
When looking at a fatty stool, what two things do you look for and what do they mean?
|
1. Fat globules
- lipase def (e.g CF) - liver disease 2. fatty acid crystals - mucosal disease --> do small bowel Bx for histology |
|
|
What chromosome is affected in CF?
what is the most common mutation? |
7
delta F508 |
|
|
What are the signs of CF? (5)
|
1. meconium ileus -- bilious vomiting
2. chronic diarrhoea (from pancreatic insuff) 3. FTT 4. fat sol Vit def (ADEK) 5. resp illness |
|
|
What 2 causes of chronic liver disease causes steatorrhoea?
|
1. extrahepatic biliary atresia
2. cirrhosis - decreased intraluminal bile salts - impaired fat digestion |
|
|
Who gets regular screening for Coeliac disease? (6)
|
1. Fe def anaemia
2. IgA def 3. Down Syndrome 4. Turner syndrome 5. Williams Syndrome 6. 1st degree relatives with CD |
|
|
What is the screening test for coeliac disease?
How diagnose? |
IgA antibody to TTG
check IgA too and if it's low do IgG TTG Dx: duodenal Bx |
|
|
How do you figure out the osmotic gap in stool fluid?
What do the results mean? |
serum osmolality = 280
280 - 2([Na] + [K]) >100 = osmotic diarrhoea <50 = secretory diarrhoea |
|
|
4 things that cause osmotic diarrhoa
|
1. monosaccarides
2. disaccarides 3. sorbitol 4. MgCl2 |
|
|
What in the Hx leads you to thinking of osmotic diarrhoea?
|
diarrhoea ceases when feeds are ceased
|
|
|
Monosaccharide malabsorption is rare and is _____ _________
|
life threatening
|
|
|
Congenital monosaccharide malabsorption:
What can't be absorbed and why? |
glucose/galactose
mutations in SGLT1 (recessive inheritance) |
|
|
Secretory diarrhoea: due to ____________ ____________ or ______________
(rarely due to congenital defects in electrolyte transporters) |
mucosal damage
inflammation |
|
|
Two broad classification of bloody diarrhoea
|
1. infection
2. IBD |
|
|
Presence of leukocytes on stool microscopy indicates _______________-
|
colitis
|
|
|
Why do you get diarrhoea in IBD?
|
inflamed colonic mucosa --> malabsorption of fluid and electrolytes
|
|
|
How do you measure protein lost in the stool (protein-losing enteropathy)?
|
stool alpha 1 antitrypsin levels
|
|
|
What is the main cause of acute gastroenteritis?
|
viruses (70%)
(bacterial = 15%) |
|
|
Severity of dehydration:
Dry mucous membranes Tachy Abno resp pattern Sunken eyes |
Moderate (5%)
|
|
|
Severity of dehydration:
dry mucous membranes mottled cool limbs slow cap refill tachy |
Severe (10%)
|
|
|
Severity of dehydration:
slow cap refill cool limbs mottled tachy thready peripheral pulses |
Severe: SHOCK
|
|
|
Severity of dehydration:
reduced UO thirst dry mucous membranes mild tachy |
Mild (3%)
|
|
|
When in dehydration would you do Ix?
What would you order? |
in mod-severe
EUCS (essential in every child having IV fluid), BSLs FBC stool micro/culture/virology |
|
|
Why do rehydration drinks work?
|
glucose stimulates intestinal sodium transporter
|
|
|
How do you write normal saline and half normal saline on fluid chart?
|
0.9% sodium chloride (or normal saline)+ 5% glucose
0.45% sodium chloride + 5% glucose |
|
|
When giving reydration fluid, assume ___% dehydration
|
5
|
|
|
Calculate fluids for 24h but order for first ______hrs --> r/v
What else do you check at this time? |
6-8
repeat EUCs daily weight |
|
|
Maintenance fluid regimen
|
100mL/kg for first 10kg
50mL/kg for second 10kg 20mL/kg for subsequent kg this is mL/24h |
|
|
Which fluids do you give for:
Mild dehydration? |
oral fluids
|
|
|
Which fluids do you give for:
moderate dehydration? |
IV/NG fluids:
rehydration and maintenance |
|
|
Which fluids do you give for:
severe dehydration? |
IV fluids
Bolus plus rehydration and maintenance |
|
|
Calculation for rehydration fluids
|
%dehydration (i.e 5) x weight (kg) x 10
over 24h 0.9% normal saline (assume 5% dehydration) |
|
|
Bolus calculation
|
10-20mL/kg of 0.9% sodium chloride or Hartmann's
|
|
|
How much potassium do you add to fluids?
|
20mmol for each 1000mL bag of fluid
(3mmol/kg/day) This is sufficient if inital serum potassium was normal and when urine is being passed |
|
|
How do you give fluids if the child is HYPERnatraemic?
|
Normal saline or N/2 + 2.5% glucose OVER 48 HOURS
|
|
|
After you're r/v IV fluids at 6-8h, if not improving, then ___________, if improving then _________________
|
consult
commence oral intake |
|
|
Should you continue to breast feed during gastroenteritis?
|
yes
|
|
|
Do you give antidiarrhoeal/anti-emetics to kids with gastro?
|
no
|
|
|
What are the disaccharides? (3)
|
lactose, sucrose, maltose
|
|
|
What sort of diarrhoea is cholera?
|
secretory
|
|
|
Following exposure to shiga toxin E.Coli, presenting with haemolysis and renal failure.
Dx? |
Haemolytic Uraemic Syndrome
|
|
|
What does pulsus paradoxus show?
|
severe obstruction in resp tract
|
|
|
What is the most common precipitator of asthma?
|
rhinovirus
|
|
|
Which organism causes bronchiolitis most commonly?
|
RSV
|
|
|
Which organism causes croup most commonly?
|
parainfluenza types 1,2,3
|
|
|
What are the 2 most common causes of pneumonia in kids?
|
Pneumococcus
S. aureus |
|
|
What is a non-specific cough?
Best Rx? |
following a viral infection, cough receptors can take a while to settle down
Rx: Vicks vapour rub on chest and honey |
|
|
Suppurative lung disease = chronic wet cough = __________________________
What are 4 causes of this? |
chronic bronchitis
1. secondary bacterial bronchitis 2. CF 3. primary ciliary dyskinesia 4. X-linked hypoglobulinaemia (Abs are the most important part of the immune system against bacterial infection) |
|
|
What does a psychogenic cough sound like?
|
a goose
disappears when asleep or preoccupied |
|
|
What causes epiglottitis classically?
And now? |
Hib
Streps, S. aureus, mycoplasma |
|
|
What two features are classic of epiglottitis?
|
1. drooling
2. tripod/sniffing position |
|
|
What organism causes bacterial trachietis?
S+S (3) |
S. aureus
1. high fever 2. brassy cough 3. thick purulent secretions |
|
|
When does spasmodic croup occur?
|
evening/night
|
|
|
What do you think of with respiratory distress and stridor in a child in first 2wks of life?
|
laryngomalacia (floppy airways)
- collapse of supraglottic structures during inspiration |
|
|
Bronchiolitis is typically in children aged <_______
Which days are the peak? |
1
days 3,4,5 |
|
|
What do you see on CXR in bronchiolitis? (2)
|
hyperinflation
patchy atelectasis |
|
|
Rx Bronchiolitis
|
supportive
no steroids O2 if reqd to keep sats >94% |
|
|
Signs of bronchiolitis (3)
|
1. wheezing
2. increased work of breathing 3. fine crackles |
|
|
Number 1 bacterial cause of pneumonia?
|
strep pneumoniae
|
|
|
Major pathogen in viral pneumonia?
|
RSV
|
|
|
Signs of bacterial pneumonia (3)
|
1. scattered crackles
2. marked diminished breath sounds 3. dullness to percussion |
|
|
Mode of inheritance of CF
|
autosomal recessive
|
|
|
Best test for Dx CF?
|
Sweat test
+ve result >60mEq/L |
|
|
What do you do if sweat test for CF is equivocal?
|
pancreatic fn: 72h faecal fat collection, stool for trypsin
|
|
|
What organisms do you find in sputum culture in CF Pt? (2)
|
s. aureus
P. aeruginosa |
|
|
Next step if you get a +ve newborn screen for CF?
|
sweat test
or DNA test |
|
|
Where is the disease:
Spinal muscular atrophy What is the acquired disease at this level? |
Anterior horn cell
Polio |
|
|
Where is the disease:
Charcot Marie Tooth What is the acquired disease at this level? |
Peripheral nerve
Guillain Barre |
|
|
Where is the disease:
Myasthenia gravis What is the acquired disease at this level? |
Neuromuscular junction
this can be both acquired and genetic |
|
|
Where is the disease:
Duchenne's Muscular Dystrophy What is the acquired disease at this level? |
Muscle
Myositis |
|
|
The essential Q that must be addressed is whether the infant has central hypotonia or neuromuscular disease
floppy but strong baby suggests _________ cause e.g down syndrome, sepsis, perinatal asphyxia... floppy but weak suggests _____________ cause |
central (more frequent in floppy babies)
peripheral NB: perinatal hypoxia may be secondary to a neuromuscular disorder |
|
|
Autosomal dominant = ____% recurrence risk
Autosomal recessive = _____% recurrence risk X-linked = ______% recurrence risk |
50
25 25 |
|
|
How do you tell if a hypotonic infant is from a central CNS cause, or a neuromuscular cause?
|
central: strong and normal or brisk reflexes
NM: weak and depressed or absent reflexes |
|
|
primary neuromuscular disorder or anterior horn cell disorder involves proximal or distal muscles?
|
proximal
|
|
|
peripheral neuropathies involve proximal or distal muscles?
|
distal
|
|
|
Normally, how long should it take to get up off the floor without using hands?
|
2 seconds
|
|
|
What is the manoevure called in muscular dystrophy?
What is it an objective measure of? |
Gower's
have to use arms to get up proximal muscle weakness |
|
|
What happens to calves in muscular dystrophy?
|
pseudohypertrophy
= fat and collagen Also see wasting of thigh muscles |
|
|
What do you think of with:
marked proximal weakness absent deep tendon reflexes normal intelligence tongue fasiculations bell shaped chest |
Spinal Muscle Atrophy
Bell shaped chest cos i/c mm never develop properly so chest wall doesn't develop properly |
|
|
In SMA, innervation is normal above the ________
|
tongue
|
|
|
How and when do kids with SMA type I die?
|
around age 1
resp failure as don't develop resp musculature |
|
|
EMG (electromyogram) - normal or abnormal in SMA?
Nerve conduction studies? |
abnormal: needle into muscle and get electrical equiv of fasciculations due to the fact that the muscle is denervated - see spont contraction of the muscle at the electrical level that correlates with denervation
NCS: Normal. In SMA, this is not where the pathology is cos the nn are normally formed and normally myelinated (the problem is in the anterior horn cell up near spinal cord) |
|
|
Dx: SMA (2)
|
1. EMG
2. DNA testing for SMA gene |
|
|
Sensory deficit: anterior horn cell disease or peripheral neuropathy?
|
peripheral neuropathy
|
|
|
Mode of inheritance of SMA?
|
autosomal recessive
|
|
|
Mode of inheritance of Charcot-Marie Tooth?
|
autosomal dominant
|
|
|
What do you think of with:
clumsy child pes cavus claw hand paraesthesias |
Charcot-Marie-Tooth
|
|
|
Dx of Charcot-Marie-Tooth
|
decreased Nerve Conduction Studies
Sural nerve Bx |
|
|
Mode of inheritance for DMD?
|
X-linked recessive
|
|
|
Dx: muscular dystrophy?
|
Raised CK (the muscle is leaks CK)
defective dystrophin protein from gene Xp21.2 |
|
|
How does DMD present?
|
progressive muscle weakness
|
|
|
What else can you get in DMD? (4)
|
Cardiomyopathy
Respiratory insufficiency Low IQ Contractures (dystrophin is expressed in heart and brain) |
|
|
What can happen in the spine in DMD?
|
increased lumbar lordosis/scoliosis = compensatory
|
|
|
What does dystrophin do?
|
gives muscle cell membrane support
without it, loss of structural support and so the fibre is more susceptible to normal wear and tear - holes in membrane without dystrophin -- calcium influx -- increased inflamm signals -- death of muscle cell and replacement with fibrous tissue |
|
|
If muscle weakness has a later onset and variable progression, what do you think of?
|
Becker muscular dystrophy
dystrophin decreased in size and/or amount |
|
|
What's the difference on DNA analysis between DMD and BMD?
|
DMD: out of frame deletion or nonsense mutation
BMD: inframe deletion or missense mutation |
|
|
Mgmt in DMD
|
multidisciplinary
nocturnal respiration spinal surgery STEROIDS (give early and continuously -- unknown why they help) |
|
|
What is the most common cause of death and disability in kids?
|
trauma
|
|
|
Injuries in kids are most commonly sustained by what? (3)
|
1. falls
2. sports 3. MVAs |
|
|
What is the primary survey?
|
A- airway and C-spine
B- breathing and ventilation C- circulation and control of haemorrhage D- disability and neuro exam E- exposure and environment |
|
|
How do you get children into the sniffing position to maintain airway?
|
put a rolled up towel under the shoulders
|
|
|
When would you intubate?
|
GCS <8
|
|
|
Cardiac arrest in kids: think ________________ as a cause
_________________ is the commonest cause of cardiac arrest in kids |
lungs
hypoventilation (cf heart in adults usually) |
|
|
What is the normal RR for infants?
|
40-60
|
|
|
What do you use to examine circulation in kids?
|
heart rate
(cf BP) |
|
|
How do you figure out normal systolic BP in kids?
Diastolic? |
= 80 + 2 x age (yrs)
Diastolic = 2/3 x systolic |
|
|
What is a child's blood volume?
|
80mL/kg
|
|
|
When giving boluses to improve circulation, what sort of fluid do you give?
|
crystalloid x 3
then blood |
|
|
What is normal urine output in kids?
|
< or = 1 year: 2mL/kg/hour
toddler: 1.5mL/kg/hour older child: 1mL/kg/hour (remember 1mL/kg/hour) |
|
|
What do you do as part of the 'environment' bit of primary survey?
|
warm with patient with over head warmers or warm fluids
|
|
|
For exposure, it's important to examine everywhere.
What are 5 common sites to miss injuries? |
1. scalp
2. neck 3. hands 4. back 5. pernineum |
|
|
What is involved in the secondary survey? (4)
|
1. head to foot exam
2. AMPLE Hx 3. imaging 4. think about transfer |
|
|
What is AMPle Hx?
|
Allergies
Meds Past Hx; pregnant l e |
|
|
What must you remember to do in chest trauma?
|
decompress stomach cos they swallow a lot of air
|
|
|
Spinal cord injury:
Where if - <8 years old >8 |
<8: C1-C3 (think about atlanto-axial dislocation)
>8: C7 injury |
|
|
Normal physiological values for Neonate:
Pulse RR Sys BP |
PR: 100-170
RR: 40-60 Sys BP: 50 |
|
|
Normal physiological values for 3-12mo:
Pulse RR Sys BP |
PR: 100-165
RR: 30-50 Sys BP: 50-90 |
|
|
Normal physiological values for 1-2years:
Pulse RR Sys BP |
PR: 100-150
RR: 25-35 sys BP: 80-95 |
|
|
Normal physiological values for 3-11 years:
Pulse RR Sys BP |
PR: 80-120
RR: 20-30 sys BP: 90-110 |
|
|
Normal physiological values for 12-15yrs:
Pulse RR Sys BP |
PR: 60-100
RR: 15-20 sys BP: 100-120 |
|
|
Developmental dysplasia of the hip:
more common in girls or boys? |
girls (6:1)
|
|
|
4 RFs for DDH
|
1. FHx
2. breech 3. packing ('squashed' in utero due to polyhydramnios) 4. first born |
|
|
5 clinical features of DDH
Which is the most important clinical sign? |
1. asymmetric skin creases
2. shortening 3. Limited abduction in flexion ** most important 4. Barlow's 5. Ortolani's |
|
|
Imaging for DDH
|
<6mo: ultrasound
>6mo: xray |
|
|
What is the best position for baby's hips to be in? (and hence how you brace them in DDH)
|
flexed
abducted |
|
|
3 DDx for "Irritable hip"
- hip pain, limp, stiffness What is most common? |
1. transient synovitis * most common
2. septic arthritis 3. Perthes disease |
|
|
Rx: transient synovitis
|
rest
ibuprofen |
|
|
Rx: Perthes disease?
|
Containment (brace)
|
|
|
50% of kids with Perthes disease will develop _________________ by age 40 and need a total hip replacement
50% of kids with SPFE will develop __________________ by age 50 and need a total hip replacement |
osteoarthritis
|
|
|
4 DDx for child with limp (associate with different AGES)
|
0-2yrs: DDH
2-5yrs: transient synovitis 5-10 yrs: Perthes disease 10-15 yrs: Slipped capital femoral epiphysis |
|
|
What else do kids get in slipped capital femoral epiphysis?
|
out-toeing
|
|
|
Rx: SCFE
|
pinning
|
|
|
Live or non-live:
which one stimulates both B and T cells |
Live
Non-live: B >>> T |
|
|
What do you have to do pre-vaccination?
|
have anaphylaxis kit ready - 1:1000 adrenaline
CONSENT |
|
|
What gauge needle do you use to inject immunisations?
|
23 or 25G
|
|
|
What site for immunisations?
|
<12mo -> anterolateral thigh
> or = 12mo -> deltoid |
|
|
What immunisations do you give at: Birth
|
Hep B
|
|
|
What immunisations do you give at:
2, 4 and 6mo? |
Hep B
DTPa (diptheria, tetanus, pertussis) Hib Polio Pneumococcal Rotavirus |
|
|
What immunisations do you give at:
12mo? |
Hib
Meningococcal MMR |
|
|
What immunisations do you give at:
18mo? |
Varicella
|
|
|
What immunisations do you give at:
4 years |
dTPa
Polio MMR |
|
|
What immunisations do you give at:
10-15 years |
Hep B
dTPa Varicella HPV |
|
|
Which lobe of the brain is last to mature?
|
frontal
|
|
|
Organism involved in dental caries
|
Strep mutans
|
