Michael Grant\'s Paediatrics Notes PDF

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PaediatricsMichael GrantNotes based on QUB online Med Portal lectures, QUB student manual, NICE Guidelines,Oxford Clinical handbook and various external online resourcesA) Four Basic Paediatric Skills: How to pick up and hold a baby Taking a paediatric history (different emphasis to adults) Introduc...

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Paediatrics Michael Grant

Notes based on QUB online Med Portal lectures, QUB student manual, NICE Guidelines, Oxford Clinical handbook and various external online resources

Michael Grant

Paediatrics: Page 2 of 78

A) Four Basic Paediatric Skills: • How to pick up and hold a baby • Taking a paediatric history (different emphasis to adults) Introduce yourself – name / role Confirm patient details – name / DOB Explain the need to take a history Gain consent to take a history Ensure the patient is comfortable Presenting complaint Give the patient time to explain the problem/symptoms they’ve been experiencing. In a paediatric history this may well be a collateral history from a parent. It’s important to use open questioning to elicit the patient’s or parent’s presenting complaint. “So what’s brought your child in today?” or “What’s brought you in today?” This can sometimes be difficult when talking to children and you may need to adopt an approach involving more direct questioning. So instead of saying “Tell me about the pain” you may need to ask a series of questions requiring only yes or no answers. “Is the pain in your tummy?” “Is the pain in your back?” Allow the patient time to answer and do not interrupt. History of presenting complaint Onset – when did the symptom start? / was the onset acute or gradual? Duration – minutes / hours / days / weeks / months / years Severity – e.g. if symptom is shortness of breath – are they able to talk in full sentences? Course – is the symptom worsening, improving, or continuing to fluctuate? Intermittent or continuous? – is the symptom always present or does it come and go? Precipitating factors – are there any obvious triggers for the symptom? Relieving factors – does anything appear to improve the symptoms e.g. an inhaler Associated features – are there other symptoms that appear associated e.g. fever / malaise Previous episodes – has the patient experienced this symptoms previously? Key paediatric questions Feeding – volume of intake / frequency of feeding Vomiting – frequency / volume / timing – projectile? / bilious? / blood? Fever – confirmed using thermometer vs subjectively feeling hot? Wet nappies / urine output – number of wet nappies a day – ↓ in dehydration Stools – consistency / steatorrhoea? (biliary obstruction) / red currant jelly (intussusception) Rash – any obvious trigger? / distribution? / blanching? Behaviour – irritability / less responsive Cough – productive? / associated increased work of breathing? Rhinorrhoea – often associated with viral upper respiratory disease Weight gain or loss – check baby book if the parent has it with them Sleeping pattern – more sleepy than usual? Unwell contacts – often children become infected from unwell siblings Localising symptoms – tugging at an ear/ holding tummy Pain – if pain is a symptom, clarify the details of the pain using SOCRATES ◦ Site – where exactly is the pain / where is the pain worst ◦ Onset – when did it start? / did it come on suddenly or gradually? ◦ Character – what does it feel like? (sharp stabbing / dull ache / burning?) ◦ Radiation – does the pain move anywhere else? (e.g. chest pain with left arm radiation) ◦ Associations – any other symptoms associated with the pain (e.g. chest pain with SOB) ◦ Time course – does the pain have a pattern (e.g. worse in the mornings) ◦ Exacerbating / relieving factors – anything make it particularly worse or better? ◦ Severity – on a scale of 0-10, with 0 being no pain & 10 being the worst pain you’ve ever felt Ideas, Concerns & Expectations – often addressed to parents Ideas – what are the patient’s / parent’s thoughts regarding their symptoms? Concerns – explore any worries the patient / parent may have regarding the symptoms Expectations – gain an understanding of what the patient / parent is hoping to achieve from the consultation Summarising Summarise what the patient / parent has told you about the presenting complaint. This allows you to check your understanding regarding everything the patient/parent has told you. It also allows the patient/parent to correct any inaccurate information & expand further on certain aspects. Once you have summarised, ask the patient/parent if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history. Michael Grant

Paediatrics: Page 3 of 78 Signposting Signposting involves explaining to the patient/parent: ◦ What you have covered – “Ok, so we’ve talked about the symptoms”” ◦ What you plan to cover next – “Now I’d like to discuss any previous medical history” Past medical history Antenatal period – illnesses or complications during gestation – e.g. rubella Birth – delivery complications / prematurity / birth weight Neonatal period – illness /admission to special care baby unit (SCBU)? Medical conditions Previous hospitalisation – when and why? Previous surgery Accidents & injuries – remain vigilant for signs of non accidental injury Developmental history Current weight and height – weight is required to calculate drug doses Developmental milestones (are they on track for their given age?): ◦ e.g. sitting up, crawling, walking, talking, toilet training, reading Family history Family history of disease – e.g. coeliac / T1DM Genetic conditions – e.g. cystic fibrosis Family tree – useful to draw out if considering genetic disease Drug history Regular medication – e.g. inhalers for asthma Over the counter medication ALLERGIES Immunisations - Is the child up to date with their immunisations? Social history Living situation + Social services – accommodation / main carer / who lives with child? Second hand smoke exposure – risk factor for otitis media / asthma / SIDS Dietary history • Type of food? – formula / breast milk / solids • Intake – e.g. how many ounces of milk? • Frequency of feeding – reduced or increased? • Special dietary requirements? – cow’s milk intolerance / coeliac disease Parents occupation Pets – important when considering allergies / asthma triggers Schooling – stage of learning / any issues? Foreign travel – may be important when considering certain diagnoses e.g. TB Systemic enquiry Top to bottom: CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence Musculoskeletal – Bone and joint pain / Muscular pain Dermatology – Rashes / Skin breaks / Ulcers

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Clinical examination - gaining maximum information with minimum upset (including normal neonate, infant, dysmorphic child, developmental assessment, ENT, eyes for squint). How to modify systematic examination of CVS, RS, GIT, CNS, PNS in light of child’s age, ability to understand and co-operate, and the relevance of signs at different ages.

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Learn to: o Understand the anxieties and worries parents have about their ill children. o develop the ability to show parents that you understand and grasp what they perceive to be the problem. o develop communication skills that will allay fears or convey information in a way that is understood by parents and by children. Michael Grant

Paediatrics: Page 4 of 78

Child Abuse and Neglect Physical abuse: Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Factors to consider in the presentation of a physical injury are: • The history given by the child (if they can communicate) • The child’s age and stage of development • The plausibility and/or reasonableness of the explanation for the injury • Any background, e.g. previous child protection concerns, multiple attendances to A&E or general practitioner • Delay in reporting the injury • Inconsistent histories or reactions from caregiver (e.g. vague, evasive, aggression) Investigations: • X-rays o If under 30 months, full radiographic skeletal survey with oblique views – esp. posterior ribs o Repeat x-ray at 1-2 weeks later • Bruising: o Rule out coagulation disorders o Be aware of Mongolian blue spots on back or thighs o The age of a bruise cannot be accurately estimated o Can be hard to detect on dark skinned children • Fractures: o Exclude osteogenesis imperfecta – type 1 causes #, autosomal dominant, blue sclerae, wormian bones in skull sutures • Scalds and cigarette burns o Exclude bullous impretigo (Staph aureus scalded skin syndrome) • Head and neck trauma: o Extra dural (direct trauma) Subdural (shearing, shaking trauma +/- retinal haemorrage) or subarachnoid (retinal bleeds, aneurysm) bleeds o Retinal haemorrhages or injury to the eye in a child if there is no major confirmed accidental trauma • RECORDING: o Make sure to clearly document any injuries, the histories and – if consenting – photographic evidence o Discuss with senior paediatrician Sexual abuse: Involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, or non!contact activities, such as involving children in looking at or producing pornographic material. • Recognition can occur when: child informs someone, becomes pregnant (automatically sexual absuse if girl >13 years), STI with no clear reason (although they can be contracted from mother during birth) • Physical symptoms: vaginal/rectal bleeding • Behaviour symptoms: soiling, secondary enuresis, self harm, sexualised behaviours, poor school performance • Signs: o Can be difficult to find as gential area heals very quickly in young children o STI screening o Forensic swabs of body, clothing, bedding for semen Emotional abuse: Is the persistent emotional maltreatment of a child resulting in severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. This may arise form the fact the child is seen as the “wrong” gender, born at a time of parental separation or violence, r is seen as unduly difficult. • Clues come from child’s behaviour: o Babies: § Apathetic, delayed development, non!demanding Michael Grant

Paediatrics: Page 5 of 78 o o o

§ Described by the mother as ‘spoiled, attention seeking, in control, not loving her’. Toddlers and preschool children: § Violent, apathetic, fearful. School children: § Wetting, soiling, relationship dif culties, non!attendance, anti!social behaviour. Adolescents: § Self!harm, depression, oppositional, aggressive and delinquent behaviour

Neglect: Is the persistent failure to meet a child’s basic physical and/or psychological needs; i.e. food, clothing, shelter, supervision Consider the possibility of neglect when the child: • Consistently misses important medical appointments • Lacks needed medical or dental care, immunisations or glasses • Seems ravenously hungry • Is dirty • Is wearing inadequate clothing for weather Or if parent: • Appears to be indifferent to the child • Seems apathetic or depressed • Behaves irrationally or in a bizarre manner • Is abusing alcohol or other drugs. Fabricated or induced illness: Refers to parents (or carers), but usually the mother (>80%), which cause harm to children. It fulfils the parents (or carers) own needs. Organic illness may coexist clouding the picture but clues include frequent unexplained illnesses and multiple hospital admissions with symptoms that only occur in the carer’s presence and are not substantiated by clinical findings. It may consist of; • Verbal fabrication – parents fabricate (i.e. invent) symptoms and signs in the child, telling a false story to healthcare professionals • Induction of illness may involve: suffocation, poisoning (drugs, ordinary substances e.g. salt) Management: • Any injuries or medical findings should be carefully noted, measured, recorded and drawn on a body map and photographed • If abuse is suspected or confirmed, a decision needs to be made as to whether the child needs immediate protection from further harm – this can be achieved by hospital admission – occasionally this will require legal enforcement • If treatment is not necessary but felt to be unsafe for the child to return home, a placement may be found in a foster home •

The safety of any other siblings or children at home must be considered

Cardiology Important Presenting Symptoms and Signs in Cardiology You should be able to list the 3-4 commonest causes of these symptoms/signs at various ages and be able to differentiate these (by features and investigations): Tachycardia Murmurs Cyanosis Heart failure The Spectrum of Clinical Conditions in Cardiology You should be able to describe - aetiology, presentation, natural history, signs, diagnosis and basic management of an infant/toddler/older child with: ◦ Congenital heart disease - describe anatomical and physiological basis for pathology and physical signs ◦ Heart failure ◦ Innocent versus pathological asymptomatic murmurs ◦ SBE ◦ Rheumatic fever ◦ Kawasaki syndrome ◦ Cardiomyopathy Practical skills You should be able to list the 3-4 commonest causes of these symptoms/signs at various ages and be able to differentiate these (by features and investigations): ◦ Cardiovascular examination ◦ Blood pressure measurement ◦ Recognise heart sounds/murmurs ◦ Recognise signs of heart failure

Michael Grant

Paediatrics: Page 6 of 78

Genetic conditions affecting the heart: • Trisomies: o 21 – Down’s sundrome – 40% with cardiac abnormalities § Atrioventricular septal defect, VSD o 13 (Patau’s), 18 (Edward’s) - >50% with cardiac abnormalities • Turner’s syndrome (Monosomy 45 – XO) – left heart problems; bicuspid aortic valve and coarctation of •

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the Aorta 22q11 deletion (DiGeorge syndrome) – dominant inheritance o Cardiac abnormality (commonly interrupted aortic arch, truncus arteriosus [embryological structure known as the truncus arteriosus fails to properly divide into the pulmonary trunk and aorta] and tetralogy of Fallot [Pulmonary Infundibular Stenosis, overriding aorta, VSD, right ventricular hypertropy) o Abnormal facies o Thymic aplasia o Cleft palate o Hypocalcemia/Hypoparathyroidism Noonan’s syndrome is one of the most common causes of cardiac defects o Autosomal dominant congenital disorder o The principal features include congenital heart defect (typically pulmonary valve stenosis; also atrial septal defect and hypertrophic cardiomyopathy), short stature, learning problems, pectus excavatum, impaired blood clotting, and a characteristic configuration of facial features including a webbed neck and a flat nose bridge

Fetal circulation: • Oxygenated blood form the placenta enters umbilical vein and mostly bypasses the liver using the ductus venosus • From here it enters the vena cava and travels into the heart where it mostly bypasses the pulmonary circulation via the foramen ovale – into the left atrium • Blood that does enter the pulmonary artery from the

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right ventricle also passess though the ductus arteriosus to reenter systemic circulation Deoxygenated blood returns to the placenta via the umbilical arteries that branch off from the internal iliac Michael Grant

Paediatrics: Page 7 of 78

Transitional from fetal to baby circulation: • Pulmonary vascular resistance decreases (first few breaths x6 blood flow) while systemic vascular resistance increases - Causes closure of: o Ductus arteriosus, to ligamentum arteriosum o Ductus venosus to ligamentum to venosum o Foramen ovale closes as left atrial pressure increases, becoming the fossa ovalis Cardiac malformations: These can be abnormal connections, holes or obstructions that are described as either cyanotic or acyanotic: Cyanotic (right to left) conditions produce blue babies that can be remembered by the 5 T’s: • Transposition of the great arteries (TGA) o Due to ventriculo‐atrial discordance, with the aorta arising from the right ventricle and the pulmonary trunk arising from the left ventricle. The pulmonary and systemic circulations are thereby completely separate and without some form of septal defect to allow mixing of oxygenated and deoxygenated blood, the condition is rapidly fatal Maintaining the patency of the ductus arteriosus with a prostaglandin infusion (PGE2, 5-20 ng/kg per min) is mandatory o Correct acidosis o If the infant does not have an ASD, VSD, PFO or PDA, the cardiologists will perform an emergency balloon atrial septostomy to create a large ASD and allow the blood to mix. o Definitive anatomical correction is the surgery of choice (arterial switch operation) o Egg on a string appearance on x-ray Tetralogy of fallot o Characterised by a VSD, aortic overriding of the septal defect, right ventricular outflow tract obstruction (which may be sub, supra or valvular) and consequent right ventricular hypertrophy § Extreme form know as pulmonary atresia, pulmonary valve is not open or does not form § At birth, some infants do not show signs of cyanosis, but they may later develop episodes of bluish pale skin during crying or feeding (ie, "Tet" spells) – they may squat to compensate (increases PVR and thus reduces right to left shunting) § Cyanosis of the lips and nail bed is usually pronounced at birth; after age 3-6 months, the fingers and toes show clubbing § CXR shows a boot shaped heart (severe RVH) with apex lifted off diaphragm with dark lung fields from reduced pulmonary blood flow o

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Maintaining the patency of the ductus arteriosus with a prostaglandin infusion (PGE2, 5-20 ng/kg per min) is mandatory § Correct acidosis § If the infant does not have an ASD, VSD, PFO or PDA, the cardiologists will perform an emergency balloon atrial septostomy to create a large ASD and allow the blood to mix. • Total anomalous pulmonary venous drainage (TAPVD) o A form of congenital cyanotic heart disease, whereby the pulmonary veins drain into venous structures other than the left atrium o Location of anomalous drainage can be supracardiac, intracardiac or infracardiac o Oxygenatied blood drains into right side of heart • Trunus arteriosus o Failure of separation between pulmonary artery and aorta, resulting in a common truck o Typically overlies a ventricular septal defect causing mixing of blood • Tricuspid atresia o Tricuspid valve doesn’t form meaning that blue blood from the right side must cross atrial septum into left atrium o Only the left ventricle is effective, the right being small and non!functional. o A Blalock–Taussig shunt insertion (between the subclavian and pulmonary artery) in children who are severely cyanosed, acts as artificial ductus artriosus o Pulmonary artery banding operation to reduce pulmonary blood flow if breathless. Acyanotic (Left to right) produce breathless babies: • VSD/ASD o Secundum atrial septal defect: §

Michael Grant

Paediatrics: Page 8 of 78 Very well tolerated and often not detected until late in life Arises from an enlarged foramen ovale, inadequate growth of the septum secundum, or excessive absorption of the septum primum § Left to right flow from atria causes gradual enlargement of right atrium, ventricle and pulmonary artery § Heard as slight ESM and pronounced AP split due to increased length of time for drainage of right side (that doesn’t not vary with respiration) Ventricular septal defect (up to 5% of new borns) § Typically cause increase flow from left ventricle into pulmonary artery, thus increase pulmonary venous return that can lead to left side hypertrophy § Large VSD cause cardiac decompensation or heart failure – not due to pump failure – but due to high output state that circulates significant amount of blood right back into left side § Pansystolic murmur as both in systole and diastole there is a gradient in pressure between the ven...