Paediatric

Question 1

Blue Zone in Paediatrics

Answer 1

Increased vigilance zone
- increase frequency of observation- clinically determined
Manage anxiety, pain and review oxygenation in consultation with nurse in charge
Consider if the observation, trends in observation or clinical assessment reflect deteroiation

Question 2

Yellow zone in paediatrics

Answer 2

• only systolic BP

=clinical review - call the home team or designated responder within 30 mins

Question 3

Red Zone

Answer 3

3 yellow zone = red zone
Mandatory call zone
Urgent response by rapid response team
Designated responder 
The right expertise 
- know about graded response
Rapid response - notes, handover, obs etc

Question 4

Altered calling criteria for kids

Answer 4

In conjunction with paediatrician
Match the criteria for patient with chronic disease
Trajectory of illness (in line with response to treatment)
Eg. day 3 of bronchiolitis = worst so change for the day
Make the trigger more sensitive

ALL altered calling criteria reviewed within 36 hours

Question 5

Na water balance in preterm babies

Answer 5

Salt water balance is modulated by ADH via osmoreceptors and baroreceptors.
There is tendency to lose sodium in urine over first weeks as the increased GFR excesses ability to reabsorb Na
High level of transepidermal loss <28/40

Respiratory related water loss can be countered with warm humidified gases

Question 6

Weight loss post birth

Answer 6

Normal is up to 10% of weight loss 
Failure to lose weight = fluid retention/overload 
>10% weight loss = assess feeding
Weight all babies at day 3
Check UEC if weight loss >12%

Question 7

Hyponatraemia in newborns

Answer 7

Causes: water overload (first weeks), maternal fluid overload, iatrogenic, sick infant (birth asphyxia, sepsis), excessive renal loss, GI loss via diarrhoea, trainable
Symptoms: irritalibity, apnea’s, seizure
Treatment: depends on underlying cause
Do not correct rapidly due to risk of neurological damage

Question 8

Hypernatremia in newborn

Answer 8

Risk of seizures if Na >150 mmol/L
Causes: water depletion, excess administration 
Two major risk groups:
1. extreme preterm infants
2. breast fed infants with poor intake

Treatment- increased fluid intake

Question 9

Hypokalemia in newborns

Answer 9

Causes: excessive losses via diarrhoea, vomiting, NG aspirate, stoma, renal diuretics or inadequate intake
Correct with supplementation: risk of arrthymia

Question 10

Hyperkalemia in newborn

Answer 10

Causes: failure to excrete K+ ie. renal failure
Treatment: myocardial stabilisation, Ca gluconate

Question 11

Causes of IUGR

Answer 11

Fetal, placental or maternal
Fetal
- fetal genetic abnormalities, fetal infection, fetal structure anomaly, Down syndrome
Maternal
- multiple gestation, maternal genetic factors., obstetric condition associated with diminished flow (pre-eclapmsia), teratogens (warfarin, metotrexate), assisted pregnancy, higher altitude, maternal age, Down syndrome
Placental
- CPM, ischemic placental disease

Question 12

Classifications of IUGR

Answer 12

Symmetrical

• 20-30%
• all organs decrease proportionally
• due to global impairment of cellular hyperplasia early in gestation
• thought to result from a pathological process manifesting early in gestation

Asymmetrical

• 70-80%
• relatively greater decrease in abdo size (liver vol and subcutaneous fat)
• asymmetrical fetal growth is capacity of fetus to adapt

Question 13

Screening for IUGR

Answer 13

Fundal height - upper edge of pubic symphysis to top of fundus
- serial
If fetus <10th percentile then monitor for growth and physiology
Sonographic estimation for fetal weight <3rd, 5th and 10th percentile

Question 14

Investigations for IUGR

Answer 14

Complete history and examination
Ultrasound biometry - biparietal dia, head circumference, abdo circumference and femur length
Fetal survey - omphalocele, gastroschisis, diaphragmatic hernia, skeletal dysphasia and congenital heart defects - because 10% of fetal growth restriction = congenital anomalies
Fetal echocardiogram- only if seems abnormal
Fetal genetic studies-
Infection workup
Plotting fetal weight 2-4 week interval to look at velocity

Question 15

What are some respiratory diseases of neonates

Answer 15

Transient at hypnoses of newborn
Pneumothorax
Congenital pneumonia
Meconium aspiration syndrome
Respiratory distress syndrome (hyline membrane disease)
Apnoea of newborn

Question 16

What is transient tachypnoea of newborn

Answer 16

Pulmonary odema caused by excess lung fluid/delayed resorption
4 hours within birth
Tachypnea >60RR, cyanosis, increased WOB “mucous” breath sounds clear
CXR- streaking with fluid in fissure, increased lung vol (flat diaphragm)
Resolves in 24 hr - supplemental oxygen, consider CPAP and ABX
RF- elective LSCS, gestational diabetes

Question 17

Pneumothorax

Answer 17

Spontaneous in 2% of births
Alveoli = hyperinflated and rupture, air then tracks into the visceral
Decreased air entry + trachea deviated
CXR- collapsed lung, lack of peripheral lung marking, ipsilateral translucency
None if asymptomatic, O2 as required, chest drain if severe
RF- lung disease, positive pressure breath (resuscitation),
Generally good prognosis

Question 18

Congenital pneumonia

Answer 18

Caused by aspiration of infected amniotic fluid - GBS, E.coli, listeria, chlamydia other gram negatives
Within the first 24 hours
Investigation: septic screen (before starting abx), CXR
Treatment: chest physio, ABX (benzyl, ampicillin and gentamicin)
RF: prolonged rupture of membrane, chorioamniotits, foetal hypoxia

Question 19

Pelvic organ prolapse

Answer 19

Anterior: cystocele
- urethrocele 
Posterior: rectocele
- enterocele
Uterine prolapse
Vaginal vault prolapse
Uterine providential- all walls of vagina and cervix 

Dx using POP-Q (The 9 measurement)
Stage 0= nil
Stage 1= >1cm above hymen
Stage II= <1cm distal to hymen
Stage III= 1-2 cm distal to hymenal plane
Stage IV = complete evertion to uterine procidentia

Question 20

De Lancy vaginal support

Answer 20

Level 1:

1. Cardinal (Mackenrodt’s)
2. Pubocervical = anterior
3. Uterosacral = posterior

Level 2

1. Pelvic fascia and paracolpops
2. Arcus trendiness fasciae pelvis (ATFP)
3. Vesicovaginal fascia and rectovaginal septum - denoviller’s fascia

Level 3

1. Peritoneal body (post)
2. Perineal transverse muscle
3. Bulbocarvenous muscle
4. Anterior pubouretheral ligament

Question 21

Colposcopy

• indications
• anatomy
• abnormalities

Answer 21

Colposcopy - is a procedure using colposcope for illuminating magnified view of the cervix, vagina and anus
Used to identify precancerous and cancerous cells

Indications

1. FU to abnormal cervical screen
2. FU to abnormal finding on gross exam
3. Evaluation of visually abnormal cervix, vagina and vulva
4. Evaluation post Rx of cervical neoplasia

No absolute contraindications

Anatomy ectocervix = squamous cell
SCJ = junction between squamous and glandular cells
Squamous = smooth pink-grey Ectocervix, glandular pink red Endocervix
Transformation = original SCJ and remaining squamous

Question 22

Jaundice in the first 24 hours of birth

Answer 22

Jaundice in the first 24 hrs is always pathological

Causes of jaundice in the first 24 hrs
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase

Jaundice in the neonate from the c. 2-14 days is common (up to 40%) and usually physiological. It is more commonly seen in breast fed babies

Question 23

Jaundice after 14 days of birth

Answer 23

If there are still signs of jaundice after 14 days a prolonged jaundice screen is performed, including:
conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
TFTs
FBC and blood film
urine for MC&S and reducing sugars
U&Es and LFTs

Causes of prolonged jaundice
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice
congenital infections e.g. CMV, toxoplasmosis

Question 24

Infantile spasms

Answer 24

Infantile spasms, or West syndrome, is a type of childhood epilepsy which typically presents in the first 4 to 8 months of life and is more common in male infants. They are often associated with a serious underlying condition and carry a poor prognosis

Features
characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
progressive mental handicap

Investigation
the EEG shows hypsarrhythmia in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)

Management
poor prognosis
vigabatrin is now considered first-line therapy
ACTH is also used

Question 25

Fragile X syndrome

Answer 25

Fragile X syndrome is a trinucleotide repeat disorder. ``` Features in males learning difficulties large low set ears, long thin face, high arched palate macroorchidism hypotonia autism is more common mitral valve prolapse ``` Features in females (who have one fragile chromosome and one normal X chromosome) range from normal to mild Diagnosis can be made antenatally by chorionic villus sampling or amniocentesis analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis

Question 26

A 2 day old baby who was born by a ventouse delivery is noted to have a swelling on the left side of his head in the parietal region. His head appeared normal immediately after delivery. On examination, the baby is well and the swelling does not cross suture lines. The fontanelles and sutures appear normal. What is the most likely diagnosis?

Answer 26

Cephalohematoma

Question 27

Cephalohematoma

Answer 27

Between periosteum and skull - remember SCALP. Most commonly in parietal region and is associated with instrumental deliveries. Swelling appears 2-3 days following delivery and does not cross suture lines Gradually resolves Jaundice may develop as complication

Question 28

Caput succadeneum

Answer 28

Caput succadeneum is commonly seen in newborns immediately after birth. It occurs due to generalised superficial scalp oedema, which crosses suture lines. It is associated with prolonged labour and will rapidly resolve over a couple of days.

Question 29

Subaponeurotic haematoma

Answer 29

Subaponeurotic haematoma is a rare condition where bleeding occurs that is not bound by the periosteum. It can be life threatening and presents as a fluctuant scalp swelling, which is not limited by suture lines.

Question 30

Craniosynostosis

Answer 30

Craniosynostosis is uncommon and is where there is premature closure of cranial sutures, causing deformity of the skull. It can be evident at birth and may be associated with genetic syndromes. The shape of the skull will depend upon which sutures are involved. Other clinical features include early closure of the anterior fontanelle and raised ridge along the fused suture.

Question 31

A baby born at 35 weeks gestations via normal vaginal delivery is found to be irritable 48 hours after birth and suffers a convulsion. There is no obvious head trauma or swellings. Which one of the following cranial injuries is most likely to have occurred?

Answer 31

Intravascular Hemorrhage

Question 32

A boy is noted to have a webbed neck and pectus excavatum

Answer 32

Noonan Syndrome Webbed neck Pectus excavatum Short stature Pulmonary stenosis

Question 33

An infant is found to have small eyes and polydactyly

Answer 33

Patau Syndrome Microcephalic, small eyes Cleft lip/palate Polydactyly Scalp lesions

Question 34

A 7-year-old boy with learning difficulties and macrocephaly

Answer 34

Fragile X ``` Learning difficulties Macrocephaly Long face Large ears Macro-orchidism ```

Question 35

Fragile X features

Answer 35

``` Learning difficulties Macrocephaly Long face Large ears Macro-orchidism ```

Question 36

Patau syndrome (trisomy 13) features

Answer 36

Microcephalic, small eyes Cleft lip/palate Polydactyly Scalp lesions

Question 37

Edward’s syndrome

Answer 37

Micrognathia (undersized jaw) Low set ears Rocker bottom feet Overlapping of fingers

Question 38

Noonan syndrom

Answer 38

Webbed neck Pectus excavatum Short stature Pulmonary stenosis

Question 39

Pierre-robin syndrome

Answer 39

Micrognathia Posterior displacement of tongue Cleft palate

Question 40

Prader-Willi syndrom

Answer 40

Hypotonia Hypogonadism Obesity

Question 41

William’s syndrom

Answer 41

``` Short stature Learning difficulties Friendly, extroverted personality Transient neonatal hypercalcaemia Supravalvular arotic stenosis ```

Question 42

Cri du chat syndrome (chromosome 5p deletion syndrome)

Answer 42

Characteristic cry Due to larynx and neurological problems Feeling difficulties and poor weight gain Learning difficulties Microcephaly and micrognathism Hypertelorism (increased distance between 2 organs like eyes)

Question 43

Avascular necrosis of femoral head in 4-8 year old. Hip pain and limp

Answer 43

Perthes disease Dx on X-ray If less than 6 = observation >6 = surgical mx

Question 44

Characteristics of innocent murmur in children

Answer 44

``` soft-blowing murmur in the pulmonary area or short buzzing murmur in the aortic area may vary with posture localised with no radiation no diastolic component no thrill no added sounds (e.g. clicks) asymptomatic child no other abnormality ```

Question 45

An 8-year-old boy presents to the emergency department severely short of breath and wheezy. He is extremely short of breath and cannot complete sentences fully. His peak expiratory flow rate is 300 l/min (40% of normal). His oxygen saturations are 93%. His pCO2 is 4.9 kPa. Which of the above is most concerning? ``` Wheeziness pCO2 (kPa) Peak expiratory flow rate Oxygen saturations Cannot complete sentences ```

Answer 45

PCO2 - because normal PCO2 in acute asthma attack indicates its life threatening

Question 46

Indications for immediate CT in head injury in paediatrics

Answer 46

* LOC > 5 minutes (witnessed) * Amnesia (antegrade or retrograde) lasting more than 5 minutes * Abnormal drowsiness * 3+ discrete episodes of vomiting * Clinical suspicion of non-accidental injury * Post-traumatic seizure but no history of epilepsy * GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department * Suspicion of open or depressed skull injury or tense fontanelle * Any sign of basal skull fracture (haemotympanum, panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign) * Focal neurological deficit * If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head * Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)

Question 47

Causes of stridor in children

Answer 47

Croup Acute epiglottis Inhaled foreign body Laryngomalacia

Question 48

Neonatal respiratory distress syndrome

Answer 48

Neonatal respiratory distress syndrome (NRDS) is primarily a disease of pre-term neonates due to surfactant deficiency. Deficiency of surfactant results in an increased alveolar surface tension, thereby resulting in decreased compliance and increased work of breathing. Natural maternal glucocorticosteroids are very important for surfactant production in the foetus, and therefore synthetic steroids are the first line agents for preventing NRDS in pregnancies at risk of pre-term birth. Tocolytics are agents that can be used to suppress pre-term labour, however they are not routinely used. Since administration of maternal steroids takes one to two days to increase surfactant levels, tocolytics can be considered in certain situations to buy time.

Question 49

Cyanotic heart disease in first few days of life

Answer 49

TGA : transposition of great arteries

Question 50

Cyanotic congenital heart disease at 1-2 months

Answer 50

TOF- tetralogy of fallout

Question 51

TOF features

Answer 51

VSD Right ventricular hypertrophy Right ventricular outflow obstruction (pulmonary stenosis) – responsible for the ESM heard Overriding aorta

Question 52

X-ray TOF

Answer 52

Boot-shaped heart

Question 53

Management of TOF

Answer 53

surgical repair is often undertaken in two parts (at 6 months) cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm

Question 54

A 5-year-old girl is brought to the GP by her mother as she has had a very loud, harsh cough for the last 2 weeks, and has been more lethargic than usual. She appears systemically well, but you witness 2 coughing fits during your consultation, in which the child appears distressed and struggles to take breaths in, making a loud harsh inspiratory noise between coughing fits. The patient has no known allergies or past medical history, but her vaccination record is unclear, having moved to the UK from abroad two years ago. Her observations reveal a fever at 37.5ºC.

Answer 54

Whooping cough- pertussis (Bordetella pertussis gram neg) Mx = azithromycin ``` Dx criteria: 14 days or more of cough Paroxysmal cough Inspiration whoop Post-tussive vomiting Undiagnosed apnoic attacks ``` Vaccination at 6 weeks, 4 months, 6 months, 18 months

Question 55

Palmer grasp

Answer 55

5-6 months

Question 56

Draws a circle

Answer 56

3 years

Question 57

Towers of 3-4 blocks

Answer 57

18 months

Question 58

Pincer grip

Answer 58

Starts at 9 months - good by 12 months

Question 59

Vertical lines

Answer 59

2 years

Question 60

Circles

Answer 60

3 years

Question 61

Cross

Answer 61

4 years

Question 62

Square and triangles

Answer 62

5 years

Question 63

Charlie is a 7 month old baby boy who presents to you with poor weight gain (50th to 10th centile), on examination he has an erythematous, blanching rash over his abdomen, colicky abdominal pain and vomiting after feeds. He has been breast feeding with top ups of 'Aptamil' formula. What is the most likely diagnosis?

Answer 63

Cow’s milk protein intolerance Multi system involvement

Question 64

Androgen insensitivity

Answer 64

Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome Features 'primary amenorrhoea' undescended testes causing groin swellings breast development may occur as a result of conversion of testosterone to oestradiol Diagnosis buccal smear or chromosomal analysis to reveal 46XY genotype Management counselling - raise child as female bilateral orchidectomy (increased risk of testicular cancer due to undescended testes) oestrogen therapy

Question 65

Marfan’s

Answer 65

Tall stature, scoliosis, pectus deformity. Aortic disease Early diastolic murmur Raised pulse pressure —> aortic regurgitation Water hammer pulse : aortic regurgitation

Question 66

Pulse associated with patent ductus arteriosus

Answer 66

Collapsing pulse

Question 67

Contraindications to MMR

Answer 67

severe immunosuppression allergy to neomycin children who have received another live vaccine by injection within 4 weeks pregnancy should be avoided for at least 1 month following vaccination immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present)

Question 68

Congenital diaphragmatic hernia

Answer 68

Hear abdo sounds in respiratory exam : tinkling sound

Question 69

Clinical presentation of foetal alcohol syndrome

Answer 69

``` microcephaly (small head) short palpebral fissures (small eye opening) hypoplastic upper lip (thin) absent philtrum reduced IQ variable cardiac abnormalities ```

Question 70

Undesceded testies referral

Answer 70

Review at 3 months and refer after 6 months

Question 71

Raised temp with rash on torso and face

Answer 71

Chickenpox: Topical calamine lotion

Question 72

``` Measles Causative Ix Mx complication ```

Answer 72

RNA paramyxovirus prodrome: irritable, conjunctivitis, fever Koplik spots before rash (white like grain of salt) on buccaneer mucosa Rash behind ear and whole body Ix: IgM antibodies Mx: mainly supportive, admit the immunosupressed and pregnant Notifiable disease Complication: Oritis media: most common complication Pneumonia : the most common cause of death Encephalitis 1-2 week following onset

Question 73

Epstein anomaly

Answer 73

Ebstein's anomaly results in low insertion of the tricuspid valve resulting in a large right atrium and small right ventricle causing tricuspid incompetence. Pan systolic murmur Linked to WPW syndrome

Question 74

Harsh vibratory noise on inspiration

Answer 74

Stridor | Croup - parainfluenza virus

Question 75

Causes of snoring in children

Answer 75

``` Obesity Nasal problem: polyps, deviated septum, hypertrophic nasal tubinates Recurrent tonsillitis Down’s syndrome Hypothyroidism ```

Question 76

The prodrome is characterised by fever, irritability and conjunctivitis

Answer 76

Measles

Question 77

May cause vesicles in the mouth and on the palms

Answer 77

Coxsackie A16 hand foot mouth

Question 78

Roseola infantum

Answer 78

Roseola infantum (also known as exanthem subitum, occasionally sixth disease) is a common disease of infancy caused by the human herpes virus 6 (HHV6). It has an incubation period of 5-15 days and typically affects children aged 6 months to 2 years. Features high fever: lasting a few days, followed later by a maculopapular rash Nagayama spots: papular enanthem on the uvula and soft palate febrile convulsions occur in around 10-15% diarrhoea and cough are also commonly seen Other possible consequences of HHV6 infection aseptic meningitis hepatitis School exclusion is not needed.

Question 79

Slapped check

Answer 79

Erythema infectosium - parovirus b19

Question 80

A 3-year-old girl with a two day history of fever and malaise. Developed a pink maculopapular rash initially on the face before spreading. Suboccipital lymph nodes are also noted

Answer 80

Rubella

Question 81

Croup treatment

Answer 81

Oral dexamethasone to all Emergency High flow o2 Neb Adr

Question 82

Mycoplasma pneumonia - lower zone consolidation Mx

Answer 82

Macrolide- erythromycin