Paeds am ks teach surgical revision weekend

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  • 1. + Paediatrics for the AMK By Dr Eva Wooding

2. + Learning Objectives Revise key Indicative Presentations for the AMK including Paediatric emergencies (what would you do first?) Common inherited conditions Community Paediatrics (normal development, vaccinations) Common childhood infections and their management Fractures and common injuries 3. + Q: Febrile Child A mother from Totnes brings her 22 month old daughter to ED. She has been off colour for 5 days and visibly unwell for 48 hours with a coryzal illness, pyrexia and lethargy. She had Calpol 2 hours ago. O/E: HR 165, RR 35, Sats 97% on air, BP 90/60, Cap Refill 3 secs,Temp 37.6oC. A maculopapular rash visible on the face, mild cervical lymphadenopathy and conjunctivitis.The child has not had any regular vaccinations. She is looked after at home, but attended a playgroup until 2 weeks ago. Whats your primary diagnosis? A: Bacterial Meningitis B: Kawasaki Disease C: Fifth Disease D: Chickenpox E: Rubella 4. + Q: Febrile Child A mother from Totnes brings her 22 month old daughter to ED. She has been off colour for 5 days and visibly unwell for 48 hours with a coryzal illness, pyrexia and lethargy. She had Calpol 2 hours ago. O/E: HR 165, RR 35, Sats 97% on air, BP 90/60, Cap Refill 3 secs,Temp 37.6oC. A maculopapular rash visible on the face, mild cervical lymphadenopathy and conjunctivitis.The child has not had any regular vaccinations. She is looked after at home, but attended a playgroup until 2 weeks ago. Whats your primary diagnosis? A: Bacterial Meningitis B: Kawasaki Disease C: Fifth Disease D: Chickenpox E: Rubella 5. + Common Childhood Infections Meningitis Rash associated with bacterial septicaemia (non-blanching, maculopapular). Expect higher fever Immediate Management? Rubella Respiratory spread, 14-21 day incubation. Fever, then spreading maculopapular rash (face to trunk) which fades in 3-5 days. !! Pregnancy !! Fifth Disease Aka Slapped Cheek caused by Parvovirus. Painless rash on one/both cheeks. Mild fever, usually self-limiting. Peak incidence April/May Chickenpox Respiratory spread. 10-21 day incubation. Clusters of vesicles over head/neck/trunk. Intensely itchy. Papule Vesicle Pustule Crust + Scratch marks Kawasakis (vasculitis) Fever >5 days + Strawberry tongue, peeling skin (desquamation) , cervical lymphadenopathy, bilateral conjunctivitis. Complications: myocardial ischaemia and sudden death 6. + Rashes of Childhood Diseases 7. + Normal Reference Ranges in Children They are different! 8. + Q: Abdominal Pain A 2 year old boy is brought to his GP with intermittent screaming and pain, followed by periods where he is quiet and withdrawn. He has had one loose, jelly-like stool passed today. O/E there is a mass palpable in his abdomen. A: Meckels Diverticulum B: Gastroschisis C: Intussusception D: Sigmoid volvulus E: Appendicitis 9. + Q: Abdominal Pain A 2 year old boy is brought to his GP with intermittent screaming and pain, followed by periods where he is quiet and withdrawn. He has had one loose, jelly-like stool passed today. O/E there is a mass palpable in his abdomen. A: Meckels Diverticulum B: Gastroschisis C: Intussusception D: Sigmoid volvulus E: Appendicitis 10. + Paediatric Acute Abdomen Intussusception Cause of 25% of acute abdomen in children 6 days Impaired immunity Chemo/RadioRx in last 6 wks Bone marrow transplant in last 6 months Immunosuppression with cytotoxic drugs 23. + Q: Mobility Problems A 4 year old boy attends Paediatric Outpatient Clinic with difficulty walking, and trips. Developmentally, he sat up by 9 months and was walking by 20 months. His mother has noticed a limp. O/E he has unsteady gait and poor balance. The doctor diagnoses Muscular Dystrophy. How is this inherited? A: Autosomal Dominant B: X-linked Recessive C: Autosomal Recessive D: Polygenic Inheritance E: X-linked Dominant 24. + Q7: Mobility Problems A 4 year old boy attends Paediatric Outpatient Clinic with difficulty walking, and trips. Developmentally, he sat up by 9 months and was walking by 20 months. His mother has noticed a limp. O/E he has unsteady gait and poor balance. The doctor diagnoses Muscular Dystrophy. How is this inherited? A: Autosomal Dominant B: X-linked Recessive C: Autosomal Recessive D: Polygenic Inheritance E: X-linked Dominant 25. + Heritance Patterns Autosomal Dominant Familial hypercholesterolaemia 1 in 500 Polycystic kidney disease 1 in 1250 Marfan Syndrome 1 in 4000 Huntington Disease 1 in 15 000 X-Linked (recessive) Red-Green colour-blindness Duchennes and Beckers Muscular Dystrophies Fragile X syndrome Haemophilia A and B Autosomal Recessive Sickle cell disease 1 in 625 (Black African-Caribbeans) Cystic fibrosis 1 in 2500 (Caucasians) Tay-Sacs disease 1 in 3000 (Ashkenazi Jews) Others X-linked (Dominant):Vitamin D resistance Ricketts Mitochondrial (passed by mother) Polyfactorial (congenital or acquired) e.g. Diabetes, Epilepsy 26. + Punnett Square Which/who is the? Heterozygote Homozygote Dominant allele? Affected child? Unaffected? What type of heritance is this? 27. + Bonus Question What are the names of the two hip tests we carry out to look for congenital hip disorders in neonates? 28. + Congenital Hip Malformations Ortolanis Flex hip to 90o then move hips OUT Tests for posterior disclotion Barlows Move hips inwards Tests for posterolateral dislocation 29. + Q: Managing Epilepsy A 7 year old child with known Epilepsy is having a seizure in a GPs waiting room.You are called to assess them.This seizure has continued for 5 minutes.What should you do first? A: Secure the airway B: Call an ambulance C: Remove objects from around the child e.g. chairs D: Give Midazolam E: Give Diazepam 30. + Q: Managing Epilepsy A 7 year old child with known Epilepsy is having a seizure in a GPs waiting room.You are called to assess them.This seizure has continued for 5 minutes.What should you do first? A: Secure the airway B: Call an ambulance C: Remove objects from around the child e.g. chairs D: Give Midazolam E: Give Diazepam 31. + Seizures and their management Emergency Management for seizures lasting >5 mins: Call 999 Give buccal Midazolam in the community, IV Lorazepam if IV access available (or PR Diazepam) Status Epilepticus = seizure (or cluster of seizures) lasting >10 mins. Treated with Benzodiazepines Phenobarbitol Phenytoin 32. + Summary and Top Tips If its obvious, go for it; theyre probably not trying to trick you! Read the vignettes carefully looking for key words. Bring a highlighter if that helps Write things out if that works for you, especially for genetics questions If the question asks what youd do FIRST its probablyhigh flow oxygen Dont get too bogged down with details, remember the big stuff and the common stuff and youll be fine! 33. + Some Key Words/Phrases Strawberry tongue and desquamation of palms = Kawasakis Redcurrant jelly stool/sausagey mass = Intussusception Sick child sat forward and drooling = epiglottitis Barking cough = Croup Spiral fracture = Non-accidental injury 34. + Learning Objectives Revise key Indicative Presentations for the AMK including Paediatric emergencies (what would you do first?) Common inherited conditions Community Paediatrics (normal development, vaccinations) Common childhood infections and their management Fractures and common injuries 35. + Thank you! Any questions? evawooding@nhs.net 36. + Further Reading and References Etheridge, L (ed.) Oxford Assess and Progress: Clinical Specialties 2010 OUP: Oxford. Core Clinical Cases in Paediatrics 2nd ed. Ewer A, Gupta R, Barrett T, Gupta J. 2011 Hodder Arnold: London. Orekunrin O, Chaplin H. Revision Questions for Paediatrics. 2010 Radcliffe: Oxford. Patient UK, 2013. Accessed online: http://www.patient.co.uk/doctor/Paediatric-Examination.htm (accessed 08/10/13). University of Texas, 2013. Accessed online: http://www.utmb.edu/pedi_ed/CORE/Abuse/page_08.htm (accessed 08/10/13). Almost A Doctor: Mind Maps, 2013. Accessed online: http://almostadoctor.co.uk/sites/all/MindMaps/409.pdf (accessed 08/10/13) 37. + Picture References Pictures are copyright and royalty free unless referenced Chickenpox http://www.theintellectualdevotional.com Kawasakis disease:http://en.wikipedia.org/wiki/File:Kawasaki_symptoms_B.jpg Meningococcal septicaemia: http://www.wales.nhs.uk/sites3/page.cfm?orgId=457&pid=32261 Spiral Fracture: http://www.utmb.edu/pedi_ed/CORE/Abuse/page_08.htm https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/204061/DoH_Imm_schedule_poster_A4_2013_07_accessible.p df Punnett Square: http://upload.wikimedia.org/wikipedia/commons/2/22/Punnett_Squar e.svg Ortolani/Barlows Manoeuvre http://www.cssd.us/body.cfm?id+512