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PAEDIA TRICTEACHING (CARDIOLOGY ,RESPIRATOR Y, GASTROENTEROLOGY)-OSCE MBBS (Hons)herafat Specialised Foundation Programme –East Midlands Currentlyworking in Paediatrics DepartmentPaediatric Cardiology (1) • Heart diseases in children mostly congenital. • 8 per 1000 liveborn infants have significant cardiac malformation. • Most common cardiac abnormalities are explained in the next slide (mainly classified based on flow direction of blood)Left to Right Shunts (Breathless) (1) • Ventricular Septal Defect (30%) • PersistentArterial Duct (12%) • Arterial Septal Defect ( 7%) Figure 1)VSD (2) Figure 2) PersistentArterial Duct (3) Figure 3)Arterial Septal Defect (4).Right to Left Shunts (Blue) (1) • Tetralogy of Fallot (5%) • Transposition of the GreatArteries (5%) Figure 5)Transposition of the GreatArteries(6). Figure 4)Tetralogy of Fallot (5)CommonMixing (Breathless and Blue) (1) • Atrioventricularseptaldefect(complete)(2%) Figure 6)Atrioventricularseptal defect (7)Obstruction of Outflow in a well child (1) • Pulmonary Stenosis (7%) • Aortic Stenosis (5%) Figure 7) Pulmonary Stenosis (8). Figure 8)Aortic Stenosis (9).Obstruction of Outflow in a well child (1) • Coarctation ofAorta (5%) Figure 9) Coarctation ofAorta (10)Aetiology (1) • Genetic causes affecting whole chromosomes,point mutations or microdeletions (1) • Risk of having a subsequent child with congenital heart diseases doubled if a previous child had congenital heart diseases (1). • External teratogens can cause a small proportionof congenital heart defects. Presentation of Congenital Heart defects (1) • Diagnosis before birth by Ultrasound Scan • Heart murmur detection at routine baby checks after birth • Poor feeding and weight gain • Breathless baby • Signs of peripheral cyanosis • Signs of Shock • Other signs of heart failure such as hepatomegaly,tachypnoea,enlarged heart and cool peripheriesDiagnosis of Congenital Heart Disease (1) • If there is a clinical suspicion of congenital heart disease :Chest X-ray,ECG and ECHO are amongst the required investigations. • Refer to specialist Paediatric CardiologyCentre for further managementManagement of Congenital Heart Disease (1) • Minimally invasive procedures • Insertion of shunts • Surgical repair (various time frames) • Medical management of heart failure • Poorly managed (delayed management) congenital heart disease can result in pulmonary hypertension and irreversible damage to pulmonary vessels. • Children with congenital heart disease are at an increased risk of developing infective endocarditis at any age.Have a low threshold for investigations if a child with background of heart defects presented with fever,malaise,anaemia,etc.OSCE Scenario • History taking (mainly focus on symptoms of heart failure and family history) • Simulation dummies can be used to ask about murmurs (be familiar with the grading system and describe the murmur as diastolic,systolic,continuous machinery or pansystolic inVSD).Use the grading system below for murmurs. Figure 10) Murmurgrading system (11).Kawasaki Disease (1) • Mainly affects children 6 months-4 years • SystemicVasculitis • Diagnosis based on clinical findings • Clinical features include:fever> 5 days ;Conjunctivitis,Mucous Membrane changes (Cracked lips and strawberry tongue),peeling of fingers and toes,Cervical lymphadenopathy and rash. • Investigations :HighWBC (neutrophils), High Platelets,High ESR/CRP • Request ECHO to investigate for coronary artery aneurysms • Treat with high dose aspirin and IVIG • Follow-upPaediatric Respiratory (1) • More than 750,000 deaths worldwide in children due to respiratory conditions. • 25% of acute paediatric admissions to hospitals in the UK are due to respiratory conditions • The most common childhood disease isAsthma • Upper respiratory presentations :coryza,sore throat,earache,noisy breathing (stridor),congestion and sinusitis • Lower respiratory presentations :shortness of breath,wheeze, cough and respiratory distressStridor vs wheeze • Narrowingof the airwayoften happensdueto inflammation. • If the narrowing affectsupperairways,a harsh inspiratorynoiseknown as "stridor"appears such as in croup. • If the narrowing affectslower airways,expiratorynoise known as "wheeze" appearssuch as in Bronchiolitis. • Course lobarcrepitations/wheeze can be noted in lobarpneumonia. • ***ImportantforOSCEs to describethe noise***URTI (1) - Common cold (coryza) - Pharyngitis/tonsilitis (Sore throat) - Otitis media (middle ear infection) - Sinusitis - Majority of these infections are viral.However,a secondary bacterial infection can develop.In your OSCEs,use your clinical skills to decide if it sounds more bacterial or viral and explain to parents (actor) if antibiotics are indicated or not. Scoring systems such as Centor may help as well.Centor Criteriato assess likelihood of bacterial pharyngitis Figure 11) Centor Criteria (12).Otitis media (1) • Complications such as Otitis Media with effusion may develop • Recurrentotitis media with effusion can develop • Referto ENT for Glue ear as insertion of Grommets may be required. Figure 12) otitis media with effusion (13) Figure 13)Grommet inserted (small ventilation device)(14).Causes of Stridor (1) CommonCause • Viral Laryngotracheobronchitis(croup);treat with oral dexamethasone Uncommonbutlife-threatening • Epiglottitis(Particularlyif not immunisedfor H.Influenza anddrooling)-Call theAnaesthetistimmediately • BacterialTracheitis(similarpresentationto EpiglottitistypicallybyStaphAureus) • Laryngealor Oesophagealforeign body • Retropharyngealabscess • Severe lymph nodeswelling inTB ,EBV or maliganacy • DiphtheriaSigns of respiratory distress on Inspection • Tracheal tug • Head bobbing • Nasal flaring • Subcostal Recessions • Intercostal recessions • Posture of baby • Use ofAccessory muscles • Silent chest • Peripheral cyanosis (late sign)Causes of acute respiratory distress in an infant (1) • Bronchiolitis • Viral wheeze • Pneumonia • Heart Failure • Severe anaemia • Anaphylaxis • Foreign body • Pneumothorax or pleural effusion • Metabolic acidosisBronchiolitis • Mainly due to RSV infection affecting infants (under 1) • Usually,supportive care at home should be fine • Can get worse on day 4-5 before getting better • Safety-nettingadvice would be key in OSCE!! • Sometimeswe admit them mainly to support feeding and supply oxygen • Can potentially get unwell and requireHDU/ITU support.Asthma Figure 14) Management of acute asthma in children as per BTS/SIGN 2011 (15)Figure 15) asthma treatmentin children (16)Pneumonia Can develop as a secondary infection in children following a viral illness Can be life-threatening. Requiresantibiotics for management. Unwell children may requireadmission to receiveIV antibiotics,IV fluids and oxygen. Figure 16)Lobar pneumonia (17)Paediatric Gastroenterology • Faltering growth • Cow's Milk allergy • Reflux • Celiac disease ***commonly encountered conditions- we will cover in more details in the next session***Surgical conditions • Inguinal hernias • Umbilical hernias • Necrotising enterocolitis • Intussusception • Pyloric stenosis • ***we will cover in more details in the next session***Next session on 14th March 2023!!! References 1-Lissauer,T.,& Clayden,G.(2012).Illustratedtextbook of paediatrics.Mosby. 2-American HeartAssociation.(2019). Ventricular Septal Defect(VSD).Www.heart.org.https://www.heart.org/en/health- topics/congenital-heart-defects/about-congenital-heart-defects/ventricular-septal-defect-vsd 3-American HeartAssociation. (2010).Patent Ductus Arteriosus(PDA).Www.heart.org.https://www.heart.org/en/health- topics/congenital-heart-defects/about-congenital-heart-defects/patent-ductus-arteriosus-pda 4-American HeartAssociation.(2019). Atrial Septal Defect(ASD).Www.heart.org.https://www.heart.org/en/health- topics/congenital-heart-defects/about-congenital-heart-defects/atrial-septal-defect-asd 5-American HeartAssociation.(2010). Tetralogyof Fallot.Www.heart.org.https://www.heart.org/en/health-topics/congenital- heart-defects/about-congenital-heart-defects/tetralogy-of-fallot 6-l-Transpositionof the GreatArteries.(n.d.).Www.heart.org.https://www.heart.org/en/health-topics/congenital-heart- defects/about-congenital-heart-defects/l-transposition-of-the-great-arteries 7-CompleteAtrioventricularCanal defect (CAVC).(2019).Www.heart.org.https://www.heart.org/en/health-topics/congenital- heart-defects/about-congenital-heart-defects/complete-atrioventricular-canal-defect-cavc8-PulmonaryValve Stenosis.(2019).Www.heart.org.https://www.heart.org/en/health-topics/congenital-heart- defects/about-congenital-heart-defects/pulmonary-valve-stenosis 9- AorticStenosis.(n.d.).Norton Children’s.RetrievedMarch 8,2023,from https://nortonchildrens.com/services/cardiology/conditions/congenital-heart-disease/aortic-stenosis/ 10-Coarctation of theAorta.(n.d.).Www.nationwidechildrens.org. https://www.nationwidechildrens.org/conditions/coarctation-of-the-aorta 11-Houghton,A.R.(2016,May 10).Andrew R.Houghton:Making sense of murmurs:The Levine scale.AndrewR. Houghton. https://arhcardio.blogspot.com/2016/05/making-sense-of-murmurs-levine-scale.html 12- Lee,H.,Kim,J.T.,Lee,J.Y.,Shin,J.-M.,Kim,J.W.,Lee,B.,& Hwang,K.(2018).Usefulness of Centor Score to Diagnosis of Group a StreptococcalPharyngitis and Decision Making ofAntibiotics Use. Korean Journal of Otorhinolaryngology-Headand Neck Surgery.https://www.semanticscholar.org/paper/Usefulness-of-Centor- Score-to-Diagnosis-of-Group-a-Lee-Kim/4f183f9faf65504466d07c29a9c007c40c43f80c/figure/0 13- Otitis media with effusion.(n.d.). Entsho.com.RetrievedMarch 9,2023,from https://entsho.com/otitis- media-with-effusion14- Grommets | MESHGuides.(n.d.).Www.meshguides.org.RetrievedMarch 9,2023,from http://www.meshguides.org/guides/node/1118 15- BPJ 42:Asthma in children.(n.d.).Bpac.org.nz. https://bpac.org.nz/bpj/2012/february/asthma.aspx 16-StepwiseTreatmentofAsthma in Children 5–11Years ofAge |Time of Care.(2019,June 4). https://www.timeofcare.com/stepwise-treatment-of-asthma-in-children-5-11-years-of-age/ 17-Rad_doc.(n.d.). Childhood pneumonia | Radiology Case | Radiopaedia.org.Radiopaedia.RetrievedMarch 9,2023,from https://radiopaedia.org/cases/childhood-pneumonia-1?lang=gb