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P a e d a ric s finaocus@gmail.com EveRos-eahy @finaocusf @finaocusfIn tro d u ctio n : /media/documents/mla-content-map-_pdf-85707770.pdf the University of Bristol and junior doctorsdents at Monday night revision series on Zooms, via a weekly up to date with our revision scheduleCQs and to stay the slides! fill in the feedback form in order to receiveQuestion 1: 11-month-old girl brought into GP with coryzal symptoms and a mild fever. Dad reports she has been breathing fast and just isn’t herself. Which of the following features of this She is breastfed and is feeding as much as presentation is the most concerning and would lead to consider referring this usual and has a normal number of wet child to hospital? nappies. There is no significant PMH but dad reports there is a family history of asthma. A. Family history of asthma On examination there are signs of mild B. Nasal flaring respiratory distress with nasal flaring. There C. Fever are no signs of clinical dehydration. On D. Age under 24 months auscultation of the chest there is mild E. RR 60 wheeze and crackles. Obs are as follows: RR 60, HR 140, Sats 94% on RA, temp 37.9.Bronchiolitis • Very common in winter. Often caused by RSV. • Most common up to 1 year old. But can occur up to 24 months. • Presents with : o Coryzal symptoms o signs of respiratory distress o Tachypnoea o poor feeding and dehydration o wheeze and crackles. • Most infants can be managed at home with advice on when to seek further help. • Needs referring to hospital/admitting when concerning features present. • The management in hospital is largely supportive: o Oxygen supplementation o Maintaining adequate intake o Suctioning where needed o Ventilatory support – high flow humidified oxygenKey Points for Resp • Know the signs of respiratory distress • Having a knowledge of different ranges for different age children – no need to learn off by heart but a vague idea will help. • Don’t forget to assess dehydration – and ask about feeding and wet nappies. • Other resp conditions to revise: Croup, Epiglottitis, Asthma, Viral wheeze Croup Epiglottitis Viral Induced Wheeze • URTI causing oedema of • Inflammation + swelling of • Acute wheezy illness caused by larynx epiglottis caused by infection – viral infection • Barking cough + stridor typically Haemophilus influenza • Children 3 and under usually • Classic exam cause of croup • Life threatening emergency • Epriorce of viral illness 1-2 days = parainfluenza virus • Exam presentation – • SOB, signs of resp distress, • Oral dexamethasone unvaccinated child with fever, expiratory wheeze • Age 6 months – 2 years sore throat, difficulty • Management the same as acute swallowing that is sitting asthma in children forward and drooling. • DO NOT EXAMINE, alert senior paediatrician and anaesthetistFever in the under 5sQuestion 2: 2 day old baby boy is brought into Paeds ED by Mum with vomiting and abdominal distention. Given the most likely diagnosis, what is the gold standard investigation to Mum describes the vomit as green in confirm this? colour. When questioned she does not think baby has passed meconium yet. A. Abdo XR B. Rectal Biopsy Baby boy has been irritable and hard to C. Abdominal ultrasound console. He was born at 39 weeks with D. CT scan an uncomplicated vaginal birth. E. clinical diagnosis - no specific Pregnancy was unremarkable. investigationHirschsprung’ s This newborn demonstrates a classic Management: • Abdo XR for obstruction presentation of Hirschsprung's disease. It can • Rectal biopsy to confirm diagnosis present with acute intestinal obstruction • Unwell children and those with shortly after birth or present more gradually: • Delay in passing meconium (more than 24 enterocolitis will need fluid hours) resuscitation and management of • Chronic constipation since birth the obstruction. • Definitive management is removal • Abdominal pain and distention of the aganglionic section of bowel. • Vomiting • Poor weight gain and failure to thrive Hirschsprung-Associated Enterocolitis • Inflammation and obstruction of the intestine • Occurs in 20% of neonates with Hirschsprung’s disease. What is Hirschsprung’s? • Typically presents within 2-4 weeks of birth with fever, • Congenital condition where the nerve cells of abdominal distention, diarrhoea (often with blood) and the myenteric plexus are absent in the distal features of sepsis. bowel and rectum • Life threatening and can lead to toxic • The key pathophysiology = absence of megacolon and perforation of the bowel. It requires urgent antibiotics, fluid parasympathetic ganglion cells. resuscitation and decompression of the obstructed bowel.Paediatric Abdo General Pointers Common paediatric abdo presentations: Red flag symptoms to look out • Constipation for for Hirschsprung’s: • Abdominal Pain • Vomiting • Delay in passing meconium (>48 hours in a full term • Thorough history and examination is vitally infant) important. • Symptoms of constipation • Determine whether the child is dehydrated. appearing from birth or in •– look for red flags.al pain is very common the first few weeks of life. • The key consideration in acute abdominal • Abdominal distention with pain is the differentiation between conditions vomiting which require specific or urgent management, particularly surgical management • Family history of Hirschsprung's. !! Conditions requiring urgent medical or surgical management Other common causes Neonates • Intussusception • Dietary protein allergy • Necrotising enterocolitis • GORD • Volvulus • Testicular torsion • Hirschsprung associated enterocolitis Infants and children • Abdo trauma • Constipation • Appendicitis • Gastroenteritis • Foreign body ingestion • UTI • Intussusception • Mesenteric adenitis • Pyloric Stenosis • Epididymitis • Volvulus • Henoch-Schlonlein Purpura • Testicular torsion • Hip pathology • Ovarian torsion • Migraine • Incarcerated hernia • Respiratory tract infection • DKA • Hepatitis • Malignancy • Meckel’s diverticulum Adolescents • Abdo trauma • Constipation • Appendicitis • Gastroenteritis • Ectopic pregnancy • UTI • Ovarian cyst rupture or torsion • Cholecystitis • DKA • Cholelithiasis • Testicular torsion • Pancreatitis • Hepatitis • IBD • PID • Renal calculi • Epididymitis • Hip pathology • MigraineQuestion 3: 2 year old girl presents to ED after parents witnessed a seizure at home. They report that she has been unwell for 24 hours previously with a fever. What is the most appropriate They have not noticed any rashes. There has been an management at this stage? URTI going around her nursery. They report the seizure lasted around 2 minutes and A. Refer to paediatric epilepsy clinic describe it as stiffening and jerking of her arms and legs. B. Give rectal diazepam She did not injure herself during the episode.e. C. Reassure parents and give advice On examination she is alert and happy in mums' arms. for potential future seizures She has a snotty nose and a cough. She is a bit hot and D. MRI head sweaty. There are no added sounds on auscultation of the chest, and no other obvious sources of infection. No E. EEG rashes and no focal neuro signs. Observations are all within normal range except her temperature which is 38.9.Febrile Convulsions • Febrile convulsions are a type of seizure that Management: occurs in children with a high fever. • Identify and manage the underlying source of infection and control fever with analgesia e.g • They are not caused by epilepsy or other paracetamol, ibuprofen. underlying neurological pathology, such as • Simple febrile convulsions do not require meningitis or tumours. further investigations. • Complex febrile convulsions may need further • Febrile convulsions occur only in children investigation. between the ages of 6 months and 5 years. • Give parents advice on managing a seizure if a further episode occurs: • To make a diagnosis, other neurological o Stay with the child pathology must be excluded such as epilepsy, o Put the child in a safe place, for example on a carpeted o Place them in the recovery position and away from neurological infection (meningitis, potential sources of injury encephalitis), space occupying lesions, Non- o Don’t put anything in their mouth accidental injury, electrolyte abnormalities. o Call an ambulance if the seizure lasts more than 5 minutes o The first seizure should always result in a trip to hospital for assessment, however if parents are confident in subsequent events and can safely manage the child at home then they can visit their GP at the next available opportunity.Question 4: A new mum comes into her GP practice for her 6-week baby check and asks for advice about what Which of the following is a red flag that developmental milestones to look out may suggest developmental delay? for and when to be concerned. A. 12 month old unable to sit independently B. 14 month old not walking independently C. 4 month old unable to grasp object with thumb and fingers D. 18 month old using only 5-10 words E. 4 weeks old not smiling yetDevelopmental Milestones • Key part of paeds, commonly assessed by paediatricians. Also something parents worry about. Red Flags: • Broken down into gross motor , • Lost developmental milestones fine motor , language and personal • Not able to hold an object at 5 and social. months • Lots to remember so may be • Not sitting unsupported at 12 months easiest to learn red flags • Not standing independently at 18 • There can be normal variations in months development • Not walking independently at 2 years • Not running at 2.5 years • No words at 18 months • No interest in others at 18 monthsQuestion 5 3-year-old girl brought into GP by Gran who reports a new rash. She reports the patient has been a bit unwell with a fever, coryzal symptoms and a cough 3 days prior. The rash then started yesterday first on the face and spread to the rest of the body. Gran is unsure of the patient's vaccination What is the most likely diagnosis? history. A. Viral exanthem B. Measles On examination you can see an erythematous, C. Chickenpox maculopapular rash on the face and body. In the oral cavity you can see small white spots on D. Rubella the mucous membranes. She is currently E. Scarlet Fever afebrile. Bonus question – how is it managed? A: supportively – rest, analgesia, fluidsMeasles • One of the most highly communicable infectious illnesses • Prodromal stage: onset of fever, malaise, coryza, conjunctivitis and cough • Rash is erythematous (on darker skin tones it can appear more as hyperpigmentation) and maculopapular, starting at the head and spreading to the trunk and limbs over three to four days • Koplik spots (small red spots with blueish- white centres) may appear on the mucous membranes of the mouth one to two days before the rash appears and may be seen for a further one to two days afterwardsCommon Paediatric Rashes Acute Urticaria Scarlet Fever Impetigo Chicken Pox (Varicella) • sore throat then general erythema • usually takes the form of itchy – Itchy, blotchy raised red • Vesicular rash and fever (classically with perioral sparing), lesions with macules, vesicles, rash • Highly contagious viral • followed by confluent petechiae in bullae, pustules and gold- – Described as wheals infection skin folds (Pastia's sign) coloured crusts caused – Short history • Itchy red papules progressing • Strawberry tongue (initially white, – May be a precipitating to vesicles on stomach, back then red). by Staphylococcus aureus. factor and face • Skin desquamation (peeling) frequently follows the rash. • ’sandpaper rash’ Atopic Eczema • typically involves itching Rubella Hand, foot and mouth erythematous patches, • Pink macules and papules starting on the • Lesions may be papules, papules and plaques with forehead and spreading to the face, moist crusted erosions on trunk and extremities on the first day vesicles, blisters or ulcers, the face, neck and upper occurring typically on the trunk and also the elbows • Petechiae on soft palate before rash oral mucosa , hands and feet. and knees. • Coxsackie virusQuestion 6 A four-year-old girl is sent to the emergency department after her GP found a profound, isolated Which drug should be prescribed to minimise proteinuria. complications from her likely On examination she has marked underlying diagnosis? oedema with facial involvement. Her blood results are as follows: A. Prednisolone B. Low molecular weight heparin Na: 142 (135-14K: 4.8 (3.5-5.0)0) C. Albumin Urea: 4.0 (2.5-ALT: 27 (0-29) CRP < 5 (< 5) Albumin: 10 (35-50) D. Trimethoprim E. Ciclosporin WCC: 9 (3-10x109) Cr: 40 (13-39) Bili: 4 (< 17)Nephrotic Syndrome • Nephrotic syndrome occurs when the basement Most common cause is minimal change disease. Causes membrane in the glomerulus becomes highly over 90% of cases of nephrotic syndrome in under 10s. • Can also be secondary to intrinsic kidney disease – permeable to protein, allowing proteins to leak from o Focal Segmental glomerulosclerosis the blood into the urine. o Membranoproliferative glomerulonephritis • Or to underlying systemic illness – • Most common between the ages of 2 and 5 years. o Henoch Schonlein Purpura o Diabetes • Presents with frothy urine, generalised o Infection oedema and pallor. Management: • Nephrotic syndrome should be managed by • Nephrotic syndrome features a classic triad of: experienced paediatricians with input from renal o Low serum albumin specialists. o High urine protein content (>3+ protein on urine dipstick) • General management is with: o Oedema o High dose steroids (i.e. prednisolone) o Low salt diet • There are three other features that occur in patients o Diuretics may be used to treat oedema with nephrotic syndrome: o Albumin infusions may be required in severe o Deranged lipid profile hypoalbuminaemia o High blood pressure o Antibiotic prophylaxis may be given in severe o Hyper-coagulability casesQuestion 7 At her 6-week baby check, Mum reports her new baby has not been feeding well. What is the most likely diagnosis at She describes her seeming out of breath when feeding, and when this stage? recently weighed by the health visitor A. Tetralogy of Fallot she had failed to gain weight. B. Coarctation of the Aorta C. Ventricular Septal Defect D. Transposition of the great arteries On examination baby is acyanotic. A E. Patent ductus arteriosus pan-systolic murmur is heard, loudest at the lower left sternal edge.Acyanotic Congenital Heart Defects Left to right shunts - non-cyanotic - still going through the pulmonary circulation Management: • Treatment should be coordinated by – Atrial septal defects a paediatric cardiologist. – Ventricular septal defects • Depends on the size of the defect – – Persistent ductus arteriosus either watch and wait or surgical intervention – Tend to cause heart failure/arrythmias Congenital Defect murmurs: •Atrial septal defect: ejection systolic murmur best heard at the left sternal edge •Small Ventricular septal defect: pansystolic murmur at lower left sternal edge •Large ventricular septal defect: apical mid- diastolic murmur •Patent ductus arteriosus = continuous crescendo-descendo murmur under the left clavicleCyanotic Congenital Heart Defects • Tetralogy of Fallot = four defects that affect Right to left shunts - cyanotic - as blood bypasses the pulmonary circulation - the heart: usually presents as cyanotic or collapsed o Ventricular Septal Defect in the first week of life o pulmonary Stenosis o Right Ventricular Hypertrophy – Tetralogy of Fallot o Overriding Aorta – Transposition of the great arteries • Transposition of the great arteries = pulmonary artery and aorta swapped round. Presentation: - Cyanotic Murmurs: - Tet spells - Poor feeding •Tetralogy of Fallot: loud harsh ejection systolic murmur at the left sternal edge - Both are usually picked up antenatally from day 1 of life •Transposition of the great arteries: usually Management: Prostaglandins (maintains no murmur but the second heart sound is a patent ductus arteriosus) and often loud and single ultimately corrective surgeryMLA content map Thankou! focus@gmail.com @focussinf