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