Medical conditions

Question 1

Clinical features of malrotation?

Can you also name some late signs?

Answer 1

Clinical features

• Normal baby with feeding difficulties
• Bile stained vomiting
  
  • Grassy green (bilirubin > biliverdin via stomach acid)
• Mostly present within first month, nearly all present within first year of life
• Late signs
  
  • PR bleeding
  • Abdominal distension
  • Abdominal tenderness

Investigation

• Investigate with a contrast swallow - look at the duodenum
  
  • C shape = conservative management
  • Screw shape = surgery

Question 2

How does pyloric stenosis present?

Why does this rule out sepsis?

What would we expect to see in a blood test?

Answer 2

• Non bilious vomiting, pattern is projectile
  
  • Stomach is a strong muscle, with the outlet blocked
  • They will be hungry after they vomit, will imply not sepsis
• Metabolic derangement
  
  • Hypochloremic, hypokalemic, metabolic alkalosis
    
    • Vomit out double HCL, NaCl, and K
    • No hyponatremia because hte body conserves it very well
  • Kids have a paradoxic aciduria
    
    • They’re trying to retain sodium so its a Na/H+ exchanger that results in loss of H+
  • Need fluid resus before surgery
    
    • Kids will die on the table otherwise

Question 3

7 month old presents to ED with green vomitus, what do you do?

Answer 3

Green vomit = bile stained vomit = malrotation until proven otherwise

Investigate with contrast studies (upper GI)

Immediate surgical referral

Question 4

What are 3 DDx for non-bilious vomiting?

Answer 4

1. Pyloric stenosis
2. Sepsis
   
   • Meningitis
   • UTI
3. Reflux
4. Overfeeding

Question 5

What age does pyloric stenosis commonly present?

Answer 5

3-6 weeks

Question 6

Management plan for kid with pyloric stenosis?

Presents with non-bilious projectile vomiting after every feed, scrawny and dehydrated, palpable olive in epigastrium.

Answer 6

1. Resuscitate dehydrated infant
2. Correct electrolytes
   
   • 150ml/kg/day normal saline + 5% dextrose +/- 20mmol/L KCL after confirming K levels
3. Replace ongoing fluid loss
4. Surgical division of hypertrophic muscle

Question 7

Age range of intususseption?

Peak? Why?

Answer 7

• 3m - 3y, peaks at 6m
• What happens at 6m? Immune system changes (loss of maternal immunity)
  
  • Parental fatigue no longer sterilising
    
    • Send to creche or grandparents, huge antigenic exposure
  • Huge increase in mucosal associated lymphoid tissue, so it grows
  • Theory is that lymph nodes get bigger, bowel picks some up and think its poo and pushes it along, and this snowballs

Question 8

Clinical features of intususseption?

Investigation of choice?

Treatment?

Answer 8

CFt

1. Colicky abdominal pain, every 3 to 5 mins (rate or persistalsis)
   
   • Pale, sweaty, hot feel like crap for 30 seconds then it seems to resolve for a bit
   • As an adult you go down into the fetal position, a 6m old can’t do that so they pull their legs up while they’re in pain then they relax
2. Vomit
3. Mass is an early sign
   
   • They back up with gas and it becomes hard to feel
4. Red current jelly stools in 40%
   
   • Bit of blood in the mucus

Ix

• Plain XR - look for absence of gas in caecal region
• US - gold standard
  
  • Look for target sign

Rx

• Gas enema

Question 9

Match the CFt with the appendicitis presentation

1. Vague non-localizing RIF pain with deep RIF tenderness (no guarding)
2. Periumbilical pain with shift to RIF +/- N/V. Lying still, pale, low grade fever, guarding
3. Generalised peritonitis
4. Lower abdominal pain and tenderness, urinary symptoms, small volume diarrhoea

• ‘Medical student’ presentation
• Retrocaecal appendicitis
• Pelvic appendicitis
• Perforated appendicitis

Answer 9

1. Retrocecal
2. Medical student style
3. Perforated appendicitis
4. Pelvic appendicitis

Question 10

Patient presents with appendicitis, how do you manage?

Answer 10

1. Stabilise the patient
   
   • Correct dehydration and electrolyte disturbance - most important step
2. Appendicectomy

Question 11

Define anaphylaxis clinically

Answer 11

• Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema) PLUS
• Respiratory and/or cardiovascular and/or persistent severe GI symptoms

Question 12

What are 7 signs of IgE anaphylaxis?

Answer 12

1. Tachy- / brady- cardia
2. Hypotension
3. Lower airway signs
   
   • Cough, chest tightness, dyspnea, hoarse voice
4. Difficult/noisy breathing
5. Swollen tongue
6. Swelling/tight throat/difficulty swallowing
7. Hoarse voice
8. Wheeze or persistent cough
9. Persistent dizziness or collapse
10. Pale and floppy infant/young child

Question 13

Name 3 key risk factors for developing anaphylaxis

Answer 13

1. History of anaphylaxis
2. Multiple food and drug allergy
3. Poorly controlled asthma
4. Underlying lung disease
5. Beta-blockers/ACE inhibitors
6. Older age

Question 14

Describe the key 3 investigations used to detect allergy.

Answer 14

• Skin prick test (SPT)
  
  • Measure wheal at 15 mins
    
    • Controls - histamine = +ve and saline = -ve
    • +ve = SPT >/= 3mm (L+W/2) above saline control
  • Before the test
    
    • No antihistamines for 3-4 days
    • SPT > 6 weeks after any anaphylaxis
    • Issues with dermatographism (saline causes wheal)
  • Correlate results with history
    
    • +ve test and +ve history = allergy as more SPT +ve than allergic
• Serum specific IgE (previously RAST)
  
  • Detects free antigen specific IgE in serum, results usually concordant with SPT
• Food challenges (gold standard)
  
  • Confirms diagnosis of food allergy
    
    • Non-IgE mediated reaction
      
      • The only way to test
    • IgE food reaction BUT
      
      • Uncertain history with +ve RAST/SPT
      • Good history but -ve RAST/SPT

Question 15

What is food protein induced enterocolitis syndrome (FPIES)?

How does it normally present?

Management strategy?

Answer 15

1. A type of non IgE mediated food allergy, mostly outgrown by ages 3-4
2. Acutely unwell baby
   
   • Vomiting 2-4 hours after allergen ingestion
   • Bloody diarrhoea
   • Can get CV collapse
     
     • Redistributed body fluids > hypotension, pallor, floppiness
     • May need IV resus
3. Avoid allergen, challenge with an alternative (eg. soy milk), re-challenge when appropriate (age dependent)

Question 16

What are the 4 key innocent murmurs?

Answer 16

These murmurs are clinically minimal, softer when erect adn vary with respiration. Typically heard at left sternal edge with minimal radiation.

1. Still’s murmur (most common)
2. Pulmonary flow murmur
3. Branch pulmonary stenosis
4. Venous hum

Question 17

1. What are the two congenital heart diseases that cause a left to right shunt?
2. What is the key difference between the two?
3. Which causes fixed S2 splitting, why?

Answer 17

1. VSD, and ASD (secundum septum)
2. VSD causes volume l oading on the left heart, while ASD loads teh right heart
3. ASD because we get L > R shunting, which delivers preload to the right atrium and therefore ventricle, delaying closure of P2 thus causing fixed splitting.

Question 18

Why do some children with PDA/coarctation present with shock?

How can we reopen the duct? Why do this?

Answer 18

Coarctation occurs distal to left subclavian. Organs below the diaphragm become hypoperfused.

Prostaglandins open the duct, indomethacin closes the duct. Opening the duct can cause the abnormal tissue to retract a bit, widening the stenosis

Question 19

1. What causes hand foot and mouth disease?
2. How do we treat?

Answer 19

1. Coxsackie A16
2. Just symptomatic management

Question 20

Patient presents with high fever, strawberry tongue, and a sunburn like rash that started after 24 hours. Dx (organism)

Answer 20

Scarlet fever due to group A strep

Question 21

Spot dx these vaccinated diseases

1. Sore throat leads to membrane that progressively covers the pharynx causing obstruction
2. Chronic cough, apnoeic and cyanosed during coughing fits. Rx?
3. Can cause epiglotitis, periorbital cellulitis, and meningitis. Rx?
4. Permanent flaccid paralysis
5. Swollen parotid glands
6. Conjunctivitis, coryza, cough, koplik spots + maculopapular truncal rash

Answer 21

1. Diphtheria
2. Pertussis - azythromycin
3. HiB - cefotaxime
4. Polio
5. Mumps
6. Measles

Question 22

Name 6 side effects of vaccines

Answer 22

• Local
  
  • Swelling, pain, redness
• Generalized
  
  • Mild fever, irritability, crying
  • Drowsiness
  • Muscle aches
• Specific to live vaccines
  
  • MMR, varicella, rotavirus
  • Can get a rash that shows up a week later due to latency period

Question 23

What are the live vaccines?

Who should get them, who should not get them?

Do you give them all at once?

Answer 23

• MMR, varicella, rotavirus
• If you’re living with someone who is immunosuppressed get the live vaccine
  
  • Negligible risk of passing it on
• Do NOT give to
  
  • Immunosuppressed
  • Pregnancy
  • Previous live vaccine or immunoglobulin recipient
• Have to give all at once, or separate by at least a month

Question 24

Name some causes of HTN in kids

Answer 24

• White coat HT
• Organic: Renal, cardiac, endocrine, other
• Lifestyle/ familial

Question 25

Minimal change disease * Affects _ - _ year olds * _____ disease process * Triggered by \_\_\_\_\_\_\_ * 90% respond to \_\_\_\_\_\_ * Relapse rate \_\_\_\_\_\_

Answer 25

* Affects 2-10 year olds * Atopic disease process * Triggered by infection * 90% respond to steroids * Relapse rate high

Question 26

Classic nephritic syndrome causes GN of any sort eg. ____ or \_\_\_\_ * Classic childhood cause = \_\_\_\_\_\_\_\_\_ * Post = __ - __ weeks * Diagnose with \_\_\_\_\_\_\_ * Main risk = ____ and \_\_\_\_ * Rx = \_\_\_\_\_\_\_

Answer 26

Classic nephritic syndrome causes GN of any sort eg. SLE or IgA * Classic childhood cause = Post - strep GN * Post = 2- 4 weeks * Diagnose with strep serology eg. Anti-Streptolysin O titre * Main risk = HTN and hypokalemia * Rx = Frusemide

Question 27

1. What is HUS? 2. What causes it? 3. What are the classic features? 4. What organs are affected? 5. How do we investigate it?

Answer 27

1. Thrombotic microangiopathy * Results from mechanical destruction of red cells and platelets in microvasculature 2. Toxin mediated * Shigella producing E.Coli * Uncooked meat * Outbreaks 3. Classic features * Often afebrile * Anaemia * Thrombocytopaenia 4. Affected organs * CNS * Pancreatitis * Myocarditis * AKI 5. Investigate with * Blood film * Fragmented red cells * INR * Normal, raised fibrinogen * Can get DIC * Direct Coombs Test (antiglobulin test) negative * No autoimmune haemolytic anaemia present

Question 28

What is Henoch Schonlein purpura (other name)? What is the classic symptom triad? Management?

Answer 28

1. Small vessel vasculitis, also known as 'IgA vasculitis' * Can present as IgA nephropathy with haematuria 2. Symptom triad = * Rash * Palpable purpuric/petechial rash over buttocks and lower extremities (ankles) * Arthritis * Large joints wiht painful subcutaneous oedema * Can include scrotum, hands, feet, sacrum * Abdominal pain * Can also have bloody diarrhoea * Higher risk of intussusception and spontaneous bowel perforation 3. Manage with watchful waiting, symptoms can be managed with

Question 29

What are the main complications of CKD?

Answer 29

* Anaemia * Bone disease (hyperparathyroidism) * Growth impairment * Others = electrolyte disturbance, acid/base etc

Question 30

Kid presents with lump, what is your Dx sieve?

Answer 30

A lump will be 1 of 3 things 1. Congenital 2. Inflammatory 3. Neoplastic

Question 31

4yrs M. Chronic wet cough, day and night for last 5 months. Episodes of coughing for last 2 years, several ear infections in past. Thriving. 1. Likely Dx? 2. Common causes? 3. Rx?

Answer 31

1. Protracted Bacterial Bronchitis (PBB) - most common cause of chronic cough 2. Predisposing viral illness \> impaired mucociliary clearance \> bacterial infection \> biofilm -- usual culprits are H. Influenzae, S. Pneumo, Moraxella catarrhalis 3. Prolonged (4-6 weeks) course of ABx=

Question 32

**Cystic fibrosis** 1. What organs does it affect? 2. What is the main principle of pathophysiology?

Answer 32

1. Any organ with ducts that can get clogged 2. ENaC not inhibited \> increased sodium absorption, and Cl not secreted \> increased Na, Cl, and water absorption. This all results in a decreased airway surface liquid * This all results in absence of lubrication \> mucous plaque build up, and poor ciliary beating

Question 33

1. What are the key clinical features of bronchiolitis? 2. What age group? 3. How do we diagnose it? Any valid investigations? 4. Management protocol?

Answer 33

1. Clinical features 1. Cough - dry to wet to groupy 2. Wheeze - bilateral wheeze and crackles 3. Increased WOB - retraction, grunting, nasal flaring 4. Tachypnoea, reduced feeds, fever 2. \< 3y 3. Clinical diagnosis, only real Ix you should do is pulse oximetry 4. Management is * Respiratory support * Only provide oxygen if sats are \< 90% persistently * Hydration * Oral is first, NG tube if having difficulty * If IV is used, do 2/3 maintenance if very severe * Medication * Not indicated

Question 34

1. What is the most common cause of stridor in infants? 2. What is the pathophysiology? 3. What is the management?

Answer 34

1. Laryngomalacia 2. Epiglottic folds collapse inwards 3. Self corrects at 12-18 months

Question 35

What defines an epileptic seizure from other seizures?

Answer 35

Must be recurrent (2 or more), unprovoked (afebrile), epileptic seizures

Question 36

**Febrile seizure** 1. What are the two most common causes 2. What age group (inc peaks) is primarily affected? 3. What is the common seizure type, and duration? How long before status epilepticus? 4. Management?

Answer 36

1. Roseola (HHV-6), Influenza A 2. 6m-6y with peak at 12-24m 3. Generalised tonic clonic lasting up to 15 mins. If \> 30mins it is status epilepticus 4. Reassurance for parents, consult neurologist, give antipyretic + anticonvulsant (diazepam)

Question 37

**General seizure management** 1. What immediate Ix do you take for someone having a seizure? 2. What immediate management? 3. What do you do if a seizure isn't stopping?

Answer 37

1. Bloods - glucose, and calcium (hypocalcaemia) 2. Oxygen, IV access 3. Benzodiazepine

Question 38

What are the most common causes of constipation in a kid? Can you name some uncommon causes for bonus points?

Answer 38

**Most common** * Functional constipation * Painful defaecation leads to apprehension, retention, and passage of hard stool * The passage of hardstool is often painful and leaves to a cycle * Young children may ignore the urge to defecate * This can cause a build-up of large hard bowel actions **Less common causes** * Medical * Cow milk allergy * Coeliac disease * Hypercalcaemia, hypothyroidism * Surgical * Hirschsprung disease * Meconium ileus * Anatomic malformation of the anus * Spinal cord abnormalities

Question 39

Eczema management plan ## Footnote *Day to day, flares, infection*

Answer 39

* Day to day 1. Reduce dryness 1. Use bath oils or washes instead of soap 2. Use lots of emollients 2. Reduce heat (itch) 1. Heaters, hot rooms, activity etc 3. Manage allergies 1. Food allergies in babies etc can cause urticarial rash * Flares * Steroid creams * Face - sigmacort * Body - elocon (stronger) * Wet dressings - wet chux with crepe bandage wrapped over * Cool compress * Bleach bath to kill bacteri a on the skin - also reduces allergic reaction to them * Infection * Remove crusts in bath with wet towel * Bleach bath * Steroids with emollient once crusts removed * +/- o ABx

Question 40

What is the best first line management for haemangioma? What are some possible complications of haemangioma? What do you do with a haemangioma near the eye?

Answer 40

* Propranolol * Complications - AEIOU's * A- Aesthetic * E- Exsanguination * Direct * Kasabach Merritt * I - Infection * O - Obstruction and pressure * Eye * Larynx (subglottic) * U - Ulceration * S - Systemic * Heart (CCF) * Brain (PHACES) * Hypothyroidism, spinal dysraphism, other (dissimeniated neonatal hemangiomatosis) * Don't have to worry about unless it is approproaching the eye * It is usually a strawberry haemangioma * It will eventually just go away

Question 41

1. When do children start eating solids? 2. When should they be eating modified family meals? 3. Avoid bottle feeding beyond __ months

Answer 41

1. 4-6 months 2. 12 months 3. 18 months

Question 42

1. How do you determine FTT vs. just being normally small? 2. What is a good way to determine FTT? 3. What is a good way to categorise causes of FTT?

Answer 42

1. FTT is usually below the 3rd centile, or dropping two centile tracks. Normal is typically 2. Before even looking at charts, look at the child. They should have good muscle bulk, good subcut fat, and normal activity/development. 3. System 1. Divide into pre and post-natal. 2. Divide the post natal into organic and inorganic 1. For organic causes try to consider anything that would affect inadequate intake, poor absorption, or increased metabolic demand. Do this for each system, eg. CV, metabolic, GI 2. Non-organic causes can be neglect, poverty, poor feeder etc

Question 43

Determine the difference between asthma severities Mild vs. moderate Moderate vs. severe Severe vs. critical

Answer 43

**Mild** * Normal mental state * Normal work of breathing **Moderate** * Normal mental state * Mildly increased work of breathing **Severe** * Agitated mental state * Moderately-markedly increased work of breathing **Critical** * Confused or drowsy mental state * Work of breathing may be maximally increased, or exhausted