12.10.01 Notes
Jaundice
Up to 70% of neonates
Pathological if appears in first 24 hr
Starts in the head and moves down
Appearance below the waist is a warning sign
Kernicterus
Etymology
"Kern" or kernel plus "icterus" or yellow
Due to yellow staining of basal ganglia
Acute diagnosis
Abnormalities of tone
Hypertonia, or hypotonia, or variation between the two
Lethargy
High pitched cry
Arching the back and spine (retrocollis or opisthotonus)
Fever
Consequences
Hearing loss or deafness
Athetoid cerebral palsy
Refers to the slow, writhing involuntary movements that occur
Impairment of eye movements especially upward gaze
Dystonia
Hyperimmunoglobulin E syndrome
Association with deep tissue infection?
FATED
Coarse facies
Cold staph abscesses
Retained primary teeth
Increased IgE
Dermatologic problems [eczema]
Antipsychotic side effects
Tardive dyskinesia
Characterized by repetitive, involuntary, purposeless movements
From neuroleptic-induced dopamine supersensitivity in the nigrostriatal pathway, with the D2 dopamine receptor being most affected
Neuroleptic malignant syndrome
Muscle cramps and tremors, fever, symptoms of autonomic nervous system, alterations in mental status
Iincreased muscular activity and rhabdomyolysis => raised CPK
Common variable immunodeficiency
Group of approximately 150 primary immunodeficiencies (PIDs)
Common set of features but different underlying causes
Most commonly encountered primary immunodeficiency
Features:
Hypogammaglobulinemia
Poor titer response to vaccination with polysaccharide and protein antigens
Recurring infections involving the ears, eyes, sinuses, nose, bronchi, lungs, skin, GI tract, joints, bones, CNS, parotid glands, etc.
Viral infections that usually respond to antivirals
Enlarged lymph nodes, spleen
Fatigue
Otitis media
AKA glue ear
Organisms:
Streptococcus pneumoniae (most common)
Pseudomonas aeruginosa, nontypeable Haemophilus influenzae, Moraxella catarrhalis
Haemophilus influenzae in older adolescents/adults
Azithromycin
Macrolide antibiotic
Derived from erythromycin
Used to treat or prevent middle ear infections, strep throat, pneumonia, typhoid, sinusitis
Also as prophylaxis for those with impaired immunity (e.g. immunodeficiency)
Vitamin D deficiency
Signs
Brittle nails
Wide wrist
Prominent forehead
Causes
NOT just insufficient intake
e.g. Renal, liver, receptor problems
=> Do a full bloods workup when checking Vit D levels to exclude secondary causes
Naevi
Melanocytic
Derived from melanocytes
e.g. Your standard mole; Mongolian spot
Epidermal
Derived from keratinocytes
Connective tissue
Derived from connective tissue cells like adipocyte and fibroblasts
V. rare
Vascular
Derived from structures of the blood vessels
e.g. Haemangioma
Headache history
Characteristics
Location
Uni or bilateral region
Character
Pulsating, pressing
Severity and effect on ability to carry out daily activities
Frequency and duration
Including number of days missed from school
Triggers
Fatigue/sleep deprivation, caffeine (including cola), specific foods, hunger, stress, exercise, menses, motion sickness, perfume
Aggravating and relieving factors
Associated symptoms
Constitutional symptoms suggestive of underlying systemic pathology
Fever, rash, decreased or fluctuating level of consciousness, irritability, confusion, hallucinations, seizures, possibility of unobserved head trauma
Symptoms suggestive of migraine
Nausea and vomiting, photophobia and phonophobia, osmophobia
Symptoms suggestive of aura
Visual, sensory, cognitive or motor manifestations which may precede headache onset, occur concomitantly with it or occur after the headache
Autonomic symptoms
Pallor, flushing, syncope, tachycardia
Symptoms suggestive of complicated migraine or migraine variant
Can be specifically enquired about but these syndromes are rare in children and are usually diagnoses of exclusions
Past medical history and social/emotional factors
Co-existing medical disorders
In particular conditions associated with immune dysfunction (increasing probability of systemic disorder with secondary headache)
Emotional and social factors which may precipitate TTH
Social turmoil, academic failure, bullying etc
Symptoms of depression
Family and treatment history
Family history of migraine, especially maternal
FHX positive in 70 per cent
Medication previous tried
Dose, frequency, effect
History of excessive medication use?
Suggestive of analgesic induced headache or rebound headache
Physical examination
Vital signs, including blood pressure
Growth parameters, including head circumference
General examination
Specifically assessing for evidence of underlying systemic disease
Neurological examination
To look for any clinical evidence of underlying neurological pathology
Should include:
neurocutaneous lesions
cranial bruit
meningism
fundoscopy: papilloedema, retinal haemorrhages
spine: deformity suggesting occult spinal dysraphism
signs of unobserved head trauma
Notes
Isotretinoin
AKA roacutane
Induces apoptosis in sebaceous gland cells (and lots of other places!)
Retinoid
cf Teratogenic
Used primarily for severe cystic acne
Levetiracetam
Anticonvulsant for epilepsy
Monotherapy for partial seizures / adjunct for others
AKA Kepra
Less bone marrow side effects than carbamazepine etc.
Dopamine pathways
Nigrostriatal
Mesocortical
Mesolimbic
Tuberoinfundibular
Anterior fontanelle: 9-18 months
Anaemia => Splenomegaly
Sacral pit
Quite common
If you can see the bottom, don't worry
If not, needs investigation
c.f. spina bifida occulta
Anaemia is a CAUSE as well as a consequence of decreased appetite
Too much iron causes haemosiderosis
Don't confuse with haemochromatosis :)
Don't forget to consider CENTRAL causes of nausea/vomiting
ADH secretion from posterior pituitary craniopharyngioma
Frontal (as well as cerebellar) lesions can cause ataxia
Headache:
Changes in handwriting?
Clumsy?
Mood/personality changes?
Tuberous sclerosis
Non-malignant tumors grow in the brain, as well as kidneys, heart, eyes, lungs, skin
Symptoms may include seizures, developmental delay, behavioral problems, skin abnormalities, lung and kidney disease