Transcript File - Sheffield Peer Teaching Society

Pneumonia treatment
• Admit if any of these:
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Sats <93%
Signs of resp distress
Apnoea
Not feeding
Family can’t cope
Supportive measures if appropriate- painkillers, oxygen, IV fluids
Newborn- Broad spec IV abx
<5- Amoxicillin PO
>5- Amoxicillin or erythromycin PO
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Asthma
• Need to differentiate from episodic viral wheeze
Revision:
• What is the pathophysiology of asthma?
• Triggers
• What happens to the bronchi?
• Which cells are involved?
• Clinical features of asthma
– Symptoms
– Time of day
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Stepwise management
SABA (Salbutamol)
Consider anticholinergic
(Ipratropium) if infant
+ Inhaled steroid
(Beclometasone/ Budenoside)
+ LABA
(Salmeterol/Formoterol)
OR leukotriene inhibitor
(Monteleukast)
Increase inhaled steroids
Daily oral steroids
(prednisolone)
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Acute asthma
• What are the features of an asthma attack?
Moderate
Severe
Life threatening
O2 sats <92%
Too SOB to talk/feed
O2 sats <92%
Peak flow >50% predicted
Peak flow <50% predicted
Peak flow <33%
Resps >50 (age 2-5)
>30 (age >5)
Silent chest
Pulse >130 (2-5)
>120 (>5)
Cyanosis
Accessory neck muscles
Altered consciousness
Poor respiratory effort
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Acute asthma
Moderate:
– 2-4 puffs of SABA via a spacer
– Increasing by 2 puffs every 2mins to 10 puffs (if needed)
– Consider oral pred (3 days)
Severe/Life threatening
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O2
10 puffs of SABA (if life threatening- give nebs & ipratropium bromide)
Steroids- oral pred/ IV hydrocortisone
Repeat bronchodilators every 20-30 mins
Transfer to HDU or PICU if not responding
(IV salbutamol or aminophylline)
(Bolus of IV magnesium)
Discharge considerations?
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Cystic Fibrosis
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Inheritance?
Protein affected ?
Which 2 organs are mostly affected?
What is a test for CF?
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Clinical features of CF
• Newborn screening- what do they screen for?
• Most babies present at birth with CF… what are the features
of their presentation?
New born
Infancy
Young child
Adolescents
Newborn
screening
Meconium ileus
FTT
Recurrent chest
infections
Malabsorption
Bronchiectasis
Nasal polyps
Sinusitis
DM
Sterility in males
Pneumothorax
Psychological
problems
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Examination findings CF
• Chest hyperinflation
• Coarse inspiratory creps
• Established disease  finger clubbing
• Failure to thrive  name some symptoms of this
• How can pancreatic insufficiency be diagnosed?
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Meconium ileus
• 10-20% of CF infants present with this
• But nearly everyone with meconium ileus will have CF
• Thick meconium causes an obstruction
• Vomiting, abdo distension, failure to pass meconium
• Tx- gastrografin enemas. Most cases need surgery
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Management CF
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MDT approach
Prophylactic antibiotics – flucloxacillin
Persistent Sx need IV therapy to limit lung damage
Chronic Pseudomonas infections – neb antipseudomonal abx
High calorie diet – 150% of normal
Replacement of fat soluble vitamins
Pancreatic replacement therapy
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Coeliac disease
• Which part of gluten provokes the immune response?
• Jejunum biopsy = lymphocytic infiltration + villous atrophy
• villi are flattened – leading to malabsorption
• How do children present?
• What are the 2 serology screening tests?
• Dx
– +ve serology + Jejunal biopsy
• Tx – gluten free diet
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UTI
• ½ UTI – structural abnormality
• Pyelonephritis can damage the growing kidney
Infancy
Childhood
Fever, lethargy
Dysuria and frequency
V+D
Fevers +/- rigors
Poor feeding FTT
Lethargy/ anorexia
Prolonged neonatal jaundice
D+V
Septicemia
Abdo/loin pain
Febrile convulsions
Recurrence enuresis
• Collect urine sample – cleanFebrile
catch,convulsion
supra-pubic aspiration
– M+C
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Predisposing factors
• Infecting organisms
– E coli (most common)
– Proteus
– Pseudomonas
• What does proteus infection predispose to?
• Incomplete bladder emptying
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Infrequent voiding
Hurried micturition
Obstruction from constipation
Vesicoureteric reflux
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UTI
• Ix – only those who have an atypical UTI
• Atypical
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Seriously ill/ septicaemia
Poor urine flow
Abdo/bladder mass
Raised creatinine
Failure to respond to abx in 48 hrs
Infection with non e coli
• Do an USS  structural abnormalities and renal defects
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Vesicoureteric reflux
• Developmental anomaly of the vesicoureteric junction
• Ureters are displaced laterally
• Reflux with ureteric dilatation
– Urine back into bladder = incomplete emptying = encourages infection
– Pyelonephritis risk
– Renal damage
• Co-amoxiclav if unwell reduces scarring
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Nephrotic syndrome
• Heavy proteinuria, low plasma albumin, oedema
• Odematous child – test for proteinuria
• Name some clinical signs
Steroid sensitive
Steroid resistant
Congenital
85-90% of causes
Management of oedema by
diuretic and salt retention
1st 3 months of life
Don’t progress to renal failure
Common in older people
Rare
Precipitated by resp infection
Haematuria low complement
levels
Recessive inherited
1-10 years
Can cause a decline in renal
function
Unilateral nephrectomy may be
needed to control it
Normal BP, renal function,
complement, no blood
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Nephrotic syndrome
• What is the steroid regime for SS nephrotic syndrome?
• What are the complication of nephrotic syndrome?
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Acute nephritis
• What does acute nephritis usually come after?
• Restriction in glomerular blood flow leads to what?
• How do you diagnose a recent strep infection?
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Henoch-schönlein purpura- HSP
• Sx– Rash (what is the distribution?)
– Arthralgia, periarticular oedema, abdo pain,
– Glomerulonephritis (what are the renal features? )
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3- 10 years
Winter
Boys > girls
Treatment- pain relief. Steroids for abdo pain
• If renal involvement what is the required follow up?
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Congenital heart disease
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Causes of congenital heart disease
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Rubella
SLE
Maternal DM
Maternal warfarin
Fetal alcohol syndrome
Syndromes: Down’s, Edward’s, Patau’s, Turner’s
• What are the chromosomal abnormalities of these
syndromes?
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Ventricular septal defect
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Large VSDs present with HF and recurrent chest infection
Pansystolic murmur
Loud pulmonary 2nd sound
CXR- everything is BIG- heart, pulm arteries, vasc markings,
pulm oedema
• Tx- Diuretics and Captopril
– Surgery at 3-6m
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Atrial septal defect
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80% due to secundum ASD
Around 50% close on their own
Red blood flows from L atrium to R
More blood goes to lungs than normal
• Often asymptomatic in children, may present in 30s with RHF,
arrythmias, stroke (clot goes through hole), pulm htn
• Ejection systolic murmur at upper L sternal edge
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Persistent ductus arteriosus
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>1m after birth
Blood flows from aorta to pulm artery (L to R)
Continuous murmur below L clavicle
Symptoms are rare
• Tx- Closure is recommended to prevent endocarditis
– Coil or occlusion device via a catheter at 1y
– Can use ibuprofen in neonates to close it (inhibits prostaglandins)
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Coarctation of aorta
• Gets worse with age
• Systemic hypertension in R arm, radio-femoral delay, weak
femoral pulses
• Ejection systolic murmur at upper sternal edge
• Collaterals at back
• On CXR- rib notching
• Tx- Stent via cardiac catheter
– Surgical repair
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Tetralogy of Fallot
• A large VSD causing R  L blood shunt
• 4 things:
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VSD
Pulmonary stenosis
RV hypertrophy
Overriding aorta (means mixed blood)
• Cyanosis (can have spells)
• Ejection systolic murmur at L sternal edge
• Tx- Shunt, then surgery at 6m to close VSD and open PS
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Transposition of great arteries
• Aorta is connected to RV (instead of LV)
• Pulmonary artery connected to LV
• 2 separate circulations
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Blue blood is returned to body and red blood to lungs
Unless there is another defect, patient dies
Presents when ductus arteriosus closes
Tx- Prostaglandins and septostomy to keep DA and FO open
– Switch over arteries (inc. coronary arteries)
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Rheumatic fever
• Now rare in the UK still prevalent in developing countries
• Affects 5-15 y/o
• 2-6 weeks post pharyngeal infection
fever, malaise, polyarthritis
• What infection causes it?
• What is the name of the criteria for the diagnosis of RF?
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Jones criteria
• Need 2 major or 1 major and 2 minor + evidence of strep inf.
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Infective endocarditis
• RF congenital heart disease
• Suspect if there is sustained fever, malaise, raised ESR,
anaemia, haematuria
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Dx – what do you need to do before starting Abx?
What imaging should be done?
What are the common causative agents?
How do you treat bacterial endocarditis?
• Good dental hygiene is encouraged in all kids with cong. Heart
disease.
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Practice questions
Young patient with a history of asthma arrives at A&E with acute SOB and is
obviously wheezy and distressed. The doctors immediately give him a
treatment which will rapidly improve his arterial oxygenation. Which option?
The doctors then examine and investigate the patient and make the diagnosis
of acute severe asthma. They decide to prescribe the bronchodilator
treatment for initial therapy. Which option?
A. Aminophylline
B. High flow oxygen (at least 60% oxygen)
C. Magnesium infusion
D. Short acting beta 2 agonist via inhaler
E. Short acting beta 2 agonist via nebuliser
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Practice questions
14 year old boy is seen by GP with an infected throat extending to the palette,
a white membrane on the pharynx, cough, temperature of 37.8C and
generalised lymphadenopathy. Routine blood film shows white cell
population to contain 20% abnormal mononuclear cells, serology is positive
for a B cell lymphotropic virus.
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4.
What is the causative agent?
What is the name for the diagnostic test?
How do you treat this?
What should he avoid doing?
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Practice questions
1.
3 month old baby with a harsh sounding cough, poor feeding and acute
respiratory distress
2.
A 7 year old boy with clubbing, who squats to relieve period of
cyanosis
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B.
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E.
Acute asthma
Bronchiolitis
Epiglottitis
Cystic fibrosis
Tetralogy of fallot
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Practice questions
A 2 year old girl presents with smelly urine and pyrexia. Her urine dipstick
shows 3+ leucocytes and 2+ nitrites
A.
B.
C.
D.
E.
Clostridium difficile
Staphylococcus aureus
Escherichia coli
Group B Streptococcus
Pseudomonas aeruginosa
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Thank you
Any questions?
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