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Y4 Paediatrics > Child Health SAQs and SBAs > Flashcards

Child Health SAQs and SBAs Flashcards

1
Q

What investigations should be considered in a well child with suspected ADHD?

A

none needed

Blood testing can be considered once a patient has been diagnosed with ADHD and the management plan is to start stimulant medication. The side-effects of stimulant medication can lead to leucopoenia, pancytopenia and hepatic coma, and so it can be useful to show baseline normal function (FBC, LFTs).

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2
Q

3 main impairments in ADHD?

A

Attention deficit, hyperactivity and impulsivity

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3
Q

Give some screening tools that can be used in the assessment of ADHD

A

Conners Questionnaire
Dundee Difficult Times of the Day Scale (D- DTODS)
SNAP – IV
Strengths and Difficulties questionnaire

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4
Q

If this patient had a family history sudden death in a first-degree relative under 40 years of age suggesting a cardiac disease, what would you do prior to starting possible ADHD medication?

A

24-hour ECG tape monitoring, ECG with calculation of QTc
Blood pressure measurement
Echocardiogram

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5
Q

What should be monitored in a child on stimulant medication?

A

height, weight, pulse and BP

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6
Q

What clinical features suggets a bacterial cause of CAP?

A

Age < 2 years
Absence of rhinorrhoea
Absence of wheeze
Temperature > 38.5°C
Presence of localised pain

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7
Q

What features suggest severe CAP in an infant?

A

RR > 70/min
CRT > 2 sec
Nasal flaring
Intermittent apnoea
Grunting
Unable to feed

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8
Q

What features suggest severe CAP in an older child?

A

RR >50/min
CRT > 2 sec
Unable to complete sentences
Severe recessions
Nasal flaring
Signs of dehydration

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9
Q

Spot diagnosis: young infant child with acute onset cough and respiratory distress following a short coryzal prodrome (runny nose) and with clinical signs of fine crepitations audible in all areas

A

bronchiolitis

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10
Q

Evidence based tx options for bronchiolitis?

A

supplemental oxygen where needed (SpO2 ≤ 93%) and help with feeds/fluids (NG feeds or IV fluids). Nebulised 3% saline may improve symptoms of mild to-moderate bronchiolitis and reduce hospital stay.

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11
Q

An acute onset of CAP (without a coryzal prodrome) in a toxic child suggests what?

A

bacterial origin

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12
Q

Give 3 causes of acute onset stridor

A

anaphylaxis
epiglottitis
inhaled foreign body

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13
Q

Why is epiglottitis decreasing in prevalence in the UK?

A

due to widespread uptake of the Hemophilus influenzae vaccine

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14
Q

Besides nephrotic syndrome, what can cause oedema in kids?

A
  1. Increased hydrostatic pressure from sodium and water retention – heart failure, acute glomerulonephritis, renal failure and drugs (antihypertensives).
  2. Increased capillary pressure from obstruction - venous obstruction, cirrhosis.
  3. Decreased capillary oncotic pressure – protein malnutrition, protein losing enteropathy.
  4. Lymphatic obstruction.
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15
Q

What baseline investigations may be done for suspected minimal change disease?

A

Urinalysis for blood and protein
Protein:creatinine ratio
(early morning sample if possible)

Full blood count
Electrolytes, urea and creatinine
Bone profile (including albumin)
Varicella zoster immunity status

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16
Q

Give 3 steps in the mx of an acutely oedematous child with nephrotic syndrome

A
  1. admit to paeds ward
  2. Oral penicillin V should be prescribed as antibiotic 3. prophylaxis to protect against pneumococcal infection
    oral prednisolone to induce remission
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17
Q

Give 2 recognised complications of nephrotic syndrome

A

Peritonitis : Depressed immunity predisposes children with NS to infections with encapsulated bacteria such as streptococcus pneumonia. Antibiotic prophylaxis and pneumococcal vaccination are recommended.

Thrombosis: hypercoagulable state due to urinary loss of antithrombin III, exaggerated by steroid therapy and increased blood viscosity from the raised haematocrit

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18
Q

Give the criteria for renal USS in a child with a UTI

A

Criteria for renal ultrasound are as follows:

  1. Infant <6 months old. Renal US within 6 weeks
  2. Atypical UTI as defined by:
    * Seriously ill.
    * Poor urine flow.
    * Abdominal/bladder mass.
    * Raised creatinine.
    * Septicaemia.
    * Failure to respond to antibiotics within 48 hours.
    * Infection with non-E. coli organism
  3. Recurrent UTI
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19
Q

How will you monitor the efficacy of a new asthma treatment in a 4 year old?

A

Clinic review after 6 weeks, symptom diary

spirometry and peak flow measurements are unreliable in children under 5 years old and can therefore not be used to monitor asthma management

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20
Q

What should you do for an asthmatic child with a new night-time cough despite previously being well-controlled?

A

Check concordance
Check inhaler technique
Exclude other concomitant cause of cough
Increase asthma preventer treatment

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21
Q

The risk factors for severe (or life-threatening) asthma are:

A

Previous near-fatal asthma e.g. previous ventilation or respiratory acidosis.
Previous admissions for asthma, especially in the last year
Requiring three or more classes of asthma medication.
Heavy use of SABA.
Repeated attendances at ED for asthma care, especially in the past year.
Brittle asthma.

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22
Q

A 11-year-old boy presents to ED because his urine has changed colour (now rusty like CocaCola). He has no other urinary symptoms, nor any associated fever, rash, abdominal pain or weight loss. He was previously well although did have peri-oral impetigo about 3 weeks ago. There is no family history of medical significance.

On examination the only abnormal findings are an elevated blood pressure and oedema of his feet and ankles. His urine dipstick shows 3+ of protein and 4+ of blood.

Which is the most likely diagnosis? What test would help to confirm this?

A

Post-streptococcal glomerulonephritis

Anti-streptolysin O titre (ASOT)

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23
Q

What would suggest a glomerular cause of haematuria?

A

Red cell casts visible on urine microscopy
Raised blood pressure - as a consequence of decreased glomerular filtration and sodium and water retention.
Rusty coloured urine - secondary to red cell damage by glomerular filtration

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24
Q

If haematuria is associated with abdominal pain, which conditions should be considered in the differential diagnosis?

A

Henoch-Schonlein purpura

Nephrolithiasis: Renal stones or calculi are uncommon in children, but should be considered in those with abdominal pain, loin pain and haematuria. Renal ultrasound is the first investigation

Urinary tract infection

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25
Q

Define CKD in children

A
  1. Structural abnormalities of the kidney seen on imaging,
  2. Functional abnormalities within the kidney e.g. elevated urea or creatinine.
  3. Abnormal GFR (<60ml/min/1.73m2)
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26
Q

Give complications of CKD in children

A

Anaemia: due to decreased erythropoietin production by the kidneys (normocytic normochromic)

Hyperuricaemia: due to decreased urinary excretion. Raised levels are also independent risk factor for the progression of the disease

Bleeding tendency: increase in urea results in abnormal platelet adhesion and aggregation

Electrolyte abnormalities. Metabolic acidosis with low sodium and increased potassium

Intellectual impairment, Growth impairment

Cardiovascular disease. Due to the presence of dyslipidaemia and hypertension

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27
Q

What questionnaire can be used to assess for autism?

A

GARS questionnaire

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28
Q

What additional information might be helpful when considering a diagnosis of autism?

A

Family history of Autism
Parental views about a diagnosis
School report
Speech and language therapy assessment
Educational psychology assessment

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29
Q

What other co-morbid issues can be associated with having a diagnosis of Autism?

A

ADHD
Anxiety issues
Epilepsy
Learning difficulties
Sleep problems

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30
Q

What is the rule of 2’s for lymphadenopathy?

A

Investigate if:
>2 LN palpable for >2 weeks
>2cm in size
2 or more regions affected

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31
Q

What is the general approach to supraclavicular lymphadenopathy?

A

it often reflects mediastinal disease and should
always prompt investigation

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32
Q

Lymph nodes of variable size and consistency should make you consider what?

A

TB

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33
Q

Red flags sxs with lymphadenopathy?

A

Fever, weight loss and night sweats with lymphadenopathy should trigger prompt referral for early biopsy

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34
Q

Which areas are essential in your examination of a child with a limp?

A

Abdomen - Abdominal pathology like appendicitis can cause referred hip pain

Axilla and groin - lymphadenopathy, hepatosplenomegaly

Hips - Knee pain can be referred from the hip, and thigh pain can be referred from the spine or sacroiliac joints

Scrotum
Spine

35
Q

What are common pitfalls and missed diagnoses in the assessment of hip pain?

A

Failure to recognise previous limping issues
suggestive of chronic rather than acute disease - DDH, Perthes disease and JIA

Not correctly localising the source of the
pain e.g. incorrectly diagnosing knee pain
rather than hip pain - SUFE

Not identifying bone pain as source of pain
or tenderness - haematological or bone
tumours

Not checking for lymphadenopathy or hepatosplenomegaly - cancer

Not examining the abdomen - Appendicitis

Not examining the scrotum - testicular torsion

36
Q

A 12 year old boy who is systemically well presents with an acute onset limp. What are the likely ddx?

A

SUFE
Trauma

transient synovitis (irritable hip) and Perthe’s disease affect younger children
JIA and septic arthritis would cause the child to be systemically unwell

37
Q

How can slipped upper femoral epiphysis be investigated?

A

X-ray of the hip

Klein’s line is drawn along the superior border of the femoral neck and should intersect with the growth plate. Failure to do so suggests early SUFE.

38
Q

A boy aged 3 years, presents to ED. He woke this morning complaining of pain in his right leg. He was able to walk but with a limp, but now is refusing to stand and weight bear or sit down preferring to lie. His presentation is consistent with a diagnosis of either transient synovitis or acute septic arthritis.

Which clinical features are more suspicious of septic arthritis?

A

fever >38.5°C, inability to weight bear, CRP >20 and white cell count >12x109/L

39
Q

Which investigations are recommended for suspected septic arthritis of the hip?

A

Blood culture
CRP
USS - helps to identify joint effusion
X-ray - always done as a baseline

40
Q

What is a limp?

A

used to describe a shortened’ stance phase’ in the gait cycle
where an individual ‘hurries’ off one leg to offload a source of pain – better described as an antalgic gait.

41
Q

Which conditions are associated with haemolytic anaemia in children?

A

Glucose-6-phosphatase dehydrogenase (G6PD)
deficiency
Beta-thalassaemia trait
Megaloblastic anaemia
Sickle cell disease

42
Q

What is a Direct Coombs test (DCT)?

A

used to determine whether the haemolysis is immune (positive - mediated by antibodies IgM or IgG) or non-immune (negative)

It must be requested in patients who present with haemolysis

43
Q

Apart from G6PD, name 2 conditions associated with haemolytic anaemia that present with a negative DCT.

A

Disseminated Intravascular Coagulation
Haemolytic Uraemic Syndrome

44
Q

Outline the pathophysiology of DIC

A

DIC is a microangiopathic haemolytic anaemia. The endothelial layer of small vessels is damaged with resulting fibrin deposition and platelet aggregation.

As red blood cells travel through these damaged
vessels, they are fragmented resulting in intravascular haemolysis. The resulting schistocytes are also increasingly targeted for destruction by the reticuloendothelial system in the spleen

45
Q

Outline the pathophysiology of haemolytic uraemic syndrome

A

HUS is a microangiopathic haemolytic anaemia. The Shiga toxin which is produced by Escherichia coli results in damage of the small vessels and haemolytic anaemia. Associated features include low platelets and renal failure with raised blood pressure

46
Q

Give some non-immune (DCT negative) causes of haemolytic anaemia

A

Abnormal haemoglobin: Sickle-cell anaemia, Thalassaemias.
Red cell enzyme defects: G6PD deficiency, pyruvate kinase deficiency.
Red cell membrane defects: Hereditary spherocytosis, elliptocytosis.
Haemolytic uraemic syndrome.
Thrombotic thrombocytopaenic purpura.
Micro-angiopathic anaemias: prosthetic valves, haemangiomas, DIC

47
Q

Give some Immune (DCT positive) causes of haemolytic anaemia

A

Rhesus incompatibility
ABO incompatibility
Autoimmune (warm, cold antibody)
SLE, Rheumatoid arthritis
Infections: mycoplasma, CMV, EBV
Drugs, malignancy
Paroxysmal cold haemoglobinuria

48
Q

Most common cause of macrocytic anaemia in children?

A

use of certain medication, such as anticonvulsants, zidovudine and immunosuppressant medications

49
Q

Give 5 causes of macrocytosis in children

A

Aplastic anaemia
Blackfan-Diamond syndrome
Hypothyroidism
Liver disease
Vitamin B12 deficiency

50
Q

Give some causes of microcytic anaemia

A

TAILS

Thalassemia
Anaemia of chronic disease
IDA
Lead poisoning
Sideroblastic anaemia

51
Q

Presence of jaundice and pallor is typical of what type of anaemia?

A

haemolytic anaemia

52
Q

In what conditions would you find target cells?

A

post-splenectomy, haemoglobinopathy, severe iron deficiency

53
Q

In what conditions would you find Anisocytosis?

A

iron deficiency anaemia, beta-thalassaemia, megaloblastic anaemia

54
Q

In what conditions would you find Howell-Jolly bodies?

A

Beta-thalassaemia, megaloblastic anaemia, post-splenectomy

55
Q

In what conditions would you find Poikilocytosis?

A

Beta-thalassaemia, severe iron deficiency

56
Q

In what conditions would you find Heinz bodies?

A

Red cell enzyme defects

57
Q

In what conditions would you find spherocytes?

A

Hereditary spherocytosis, immune haemolytic anaemia, severe burns, post transfusion

58
Q

In what conditions would you see Basophilic stippling?

A

Lead poisoning, beta-thalassaemia

59
Q

What would you see on blood film post splenectomy?

A

Howell-Jolly bodies, acanthocytes, target cells, schistocytes

60
Q

What are the contraindications to a child receiving a live vaccine?

A

Previous anaphylaxis to a vaccine or vaccine component (e.g. neomycin, gelatine)

Primary or acquired immunodeficiency

Immunosuppressive therapy

Contact with individuals with immunodeficiency or current/recent immunosuppressive
therapy

61
Q

When might a vaccine be temporarily deferred?

A

Acutely unwell e.g. with fever >38.5°C. Postpone immunisation until well.
* Immunoglobulin therapy. May interfere with immune response of live vaccines.

62
Q

Which of the routine vaccines in the UK are live?

A

rotavirus, MMR, nasal flu ± BCG

63
Q

Adverse events following immunisation (AEFI) are common - true or false?

A

true - 1/10 children

64
Q

AEFIs are more likely where there is a family history of AEFIs - true or false?

A

false

65
Q

AEFI can be vaccine specific and differ between individual vaccines - true or false?

A

true

66
Q

Systemic AEFIs like fever and irritability do not contraindicate further vaccination - true or false?

A

true

67
Q

‘Vaccine hesitancy’ or ‘delay or refusal to vaccinate in the presence of services’ is the main reason for children being under vaccinated. True of false?

A

false

68
Q

Which children are at risk of undervaccination?

A

Children in large families.
Children with lone or single parents.
Looked after children.
Children in mobile families.
Migrant/asylum seeking children.
Children with disabling or chronic conditions.
Children in ethnic minority groups.

69
Q

Causes of a waddling gait?

A

Hip pain e.g. DDH, SUFE, Perthes disease
Proximal myopathy e.g. Duchenne MD

70
Q

Give some causes of a foot drop ‘ high steppage’ gait?

A

Common peroneal nerve palsy
Peripheral neuropathy

71
Q

How can a child with suspected cerebral palsy be investigated?

A

An MRI Brain and spine would be needed to identify any obvious underlying insults of the child’s brain.

In a child born very prematurely with a difficult neonatal course and clinical signs of possible cerebral palsy, a common finding is of periventricular leukomalacia (PVL), an abnormality of the white matter of the brain.

72
Q

A child with cerebral palsy is provided with insoles, splints and supportive footwear but still continues to encounter difficulties due to the position of his feet. This is adversely affecting his gait, causing pain and localised friction from his splints.

What are your options now?

A

Analgesia

Contact orthotics to review splints

Refer to orthapaedics:
Botox therapy
Serial casting

73
Q

A baby is born a 28-weeks’ gestation. The pregnancy was unremarkable until spontaneous rupture of membranes at 28-weeks’ gestation.
At this gestational age the baby is at high risk of respiratory distress syndrome because of surfactant deficiency.

Which antenatal treatment (administered to the mother) would be the best option to help the baby?

A

Antenatal steroids followed by infusion of magnesium during labour

Magnesium now given as routine in preterm deliveries to improve the neurodevelopmental outcome of the baby

74
Q

Is saturations of 91% at one minute a sign of RDN?

A

not necessarily - Oxygen saturations can take up to 10
minutes to achieve adult levels

75
Q

What would be the best intervention to start in a baby with RDN?

A

CPAP has been shown to improve the outcome if started early

76
Q

What is the prognosis of tension pneumothorax following RDN?

A

Approx. 80% chance of survival. Chance of moderate disability around 10%

77
Q

With regards to bruising, which of the following scenarios would cause you to be suspicious of non-accidental injury (NAI)?

Bruising on the elbows
Bruising on the face
Bruising on the pinna of the ear
Bruising on the shins
Circular bruising on the chest

A

Bruising on the face
Bruising on the pinna of the ear
Circular bruising on the chest

78
Q

Give some risk factors for child abuse

A
  1. Child
    failure to meet parental expectations and aspirations, e.g. disabled, ‘wrong’ gender, ‘difficult’ child.
    born after rape or commercial sex
  2. Parent/carer
    mental health problems
    parental indifference, intolerance, or over-anxiousness
    alcohol, drug abuse
  3. Family
    step-parents
    domestic violence.
    multiple/closely spaced births.
    social isolation or lack of social support.
    young parental age.
    poverty, poor housing.
79
Q

Give 4 fractures that raise suspicion of NAI

A

Metaphyseal corner fractures
Posterior rib fractures
Spiral fracture of the humerus
Spiral fracture of the femur

80
Q

Give some investigations are considered first-line in a child who presents with a fracture due to suspected NAI?

A

FBC - malabsorption disorders that reduce bone strength
Alkaline phosphatase
Calcium and phosphate
Skeletal survey

81
Q

What is the genetic abnormality that causes Down’s syndrome?

A

Non-disjunction trisomy 21

82
Q

Give 3 risk factors for Down’s syndrome

A

A parent with a translocation mutation of chromosome 14 and 21
Advancing maternal age
Having already had a child with DS

83
Q

A baby girl with DS is kept in hospital for a couple of days under the paediatric team to complete some important screening investigations before she is discharged.

Which screening investigations should be completed before discharge?

A

FBC
TFT
Hearing screen

84
Q

Which cardiac abnormality is commonest in DS?

A

Atrioventricular septal defect

Y4 Paediatrics (17 decks)

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