Paediatric History Taking and Management 2

Question 1

What is Juvenile idiopathic arthritis (JIA)?

Answer 1

arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks

Systemic onset JIA is also known as Still’s disease

Question 2

How does Still’s disease (systemic JIA) present?

Answer 2

pyrexia
salmon-pink rash
lymphadenopathy
arthritis
uveitis
anorexia and weight loss

Question 3

How can Still’s disease be investigated?

Answer 3

ANA may be positive, RF usually negative

Question 4

Spot diagnosis:
Medial knee pain due to lateral subluxation of the patella
Knee may give way

Answer 4

Patellar sublaxation

Question 5

Spot diagnosis:
Knee pain after exercise
Intermittent swelling and locking

Answer 5

Osteochondritis dissecans

Question 6

Differentials for a limping child?

Answer 6

Trauma

Transient synovitis:
Acute onset, accompanies viral infections, but the child is well or has a mild fever
Mostly in boys aged 2-12 years

Septic arthritis/osteomyelitis
Unwell child, high fever

Juvenile idiopathic arthritis
Limp may be painless

Development dysplasia of the hip
diagnosed as neonate, more common in girls

Perthes disease
More common at 4-8 years, due to AVN of the femoral head

Slipped upper femoral epiphysis
10-15 years - Displacement of the femoral head epiphysis postero-inferiorly

Question 7

Spot diagnosis:
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination

Answer 7

Patellar tendonitis

Question 8

What is Meckel’s diverticulum?

Answer 8

a congenital diverticulum of the small intestine

Rule of 2s
occurs in 2% of the population
is 2 feet from the ileocaecal valve
is 2 inches long

Question 9

How should Meckel’s diverticulum be investigated and managed?

Answer 9

Ix: Meckel’s scan (technetium scan)
mesenteric arteriography may also be used in more severe cases e.g. transfusion is require

Mx: removal if narrow neck or symptomatic

Question 10

How does Meckel’s diverticulum present?

Answer 10

abdominal pain mimicking appendicitis
rectal bleeding
intestinal obstruction
- secondary to an omphalomesenteric band (most commonly)

Question 11

What is the most likely causative agent of a bacterial pneumonia in children?

What are the other causes?

Answer 11

streptococcus pneumoniae

Group A strep (e.g. Streptococcus pyogenes)
Group B strep: often contracted during birth as it often colonises the vagina
Staphylococcus aureus: typical chest xray findings of pneumatocoeles (round air filled cavities) and consolidations in multiple lobes
Haemophilus influenza : particularly affects pre-vaccinated or unvaccinated children
Mycoplasma pneumonia: atypical bacteria with extra-pulmonary manifestations (e.g. erythema multiforme)

Question 12

What are the viral causes of pneumonia in kids?

Answer 12

Respiratory syncytial virus (RSV) is the most common viral cause

Parainfluenza virus

Influenza virus

Question 13

How should pneumonia be managed in children?

Answer 13

Amoxicillin is first-line

Macrolides (e.g. erythromycin) may be added if there is no response to first line therapy / if mycoplasma or chlamydia is suspected

pneumonia associated with influenza =co-amoxiclav

Question 14

How can you investigate children with recurrent LRTIs?

Answer 14

FBC- WCC

Serum immunoglobulins
Test IgG to previous vaccines (i.e. pneumococcus and haemophilus) -some patients are unable to convert IgM to IgG, and therefore cannot form long term immunity

Sweat test for CF

HIV test

CXR to screen for any structural abnormality in the chest or scarring from the infections

Question 15

What is episodic viral wheeze? How should it be managed?

Answer 15

only wheezes when has a viral URTI and is symptom free inbetween episodes

Mx:
first-line is treatment with SABA (e.g. salbutamol) or anticholinergic via a spacer
next step is intermittent leukotriene receptor antagonist (montelukast), intermittent ICS, or both

Question 16

What is multiple trigger wheeze? How should it be managed?

Answer 16

as well as viral URTIs, other factors appear to trigger the wheeze such as exercise, allergens and cigarette smoke

Mx: trial of either ICS or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks
parents should stop smoking

Question 17

Pyloric stenosis is caused by hypertrophy of the circular muscles of the pylorus. What features does it present with?

Answer 17

‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting

Question 18

What is a reflex anoxic seizure?

Answer 18

a syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli, occurs in children aged 6months - 3 years

Typical features
child goes very pale
falls to floor
rapid recovery

Question 19

What is Roseola infantum? Features?

Answer 19

sixth disease
common disease of infancy caused by the human herpes virus 6 (HHV6)

Features:
high fever: lasting a few days, followed later by a
maculopapular rash
Nagayama spots: papular enanthem on the uvula and soft palate
diarrhoea and cough commonly seen

Question 20

What is Scarlet fever?

Answer 20

Reaction to Group A haemolytic strep (usually strep pyogenes)

typically presents with:
fever: typically lasts 24 to 48 hours
malaise, headache, nausea/vomiting
sore throat
‘strawberry’ tongue
rough sandpaper rash

Question 21

Describe the Scarlet fever rash

Answer 21

rough sandpaper like rash
‘pinhead’, appears first on the torso and spares the palms and soles
more prominent in flexures

Question 22

How should Scarlet Fever be investigated and managed?

Answer 22

a throat swab is normally taken but antibiotic treatment should be commenced immediately, rather than waiting for the results

Management:
oral penicillin V for 10 days
penicillin allergy = azithromycin
children can return to school 24 hours after commencing antibiotics
notifiable disease

Question 23

Complications of Scarlet fever?

Answer 23

otitis media: the most common complication
rheumatic fever: typically occurs 20 days after infection
acute glomerulonephritis: typically occurs 10 days after infection

Question 24

Which joints are most commonly affected by septic arthritis?

Answer 24

hip, knee and ankle

Question 25

What sxs and signs does septic arthritis present with?

Answer 25

Symptoms joint pain limp fever systemically unwell: lethargy Signs swollen, red joint typically, only minimal movement of the affected joint is possible

Question 26

How should septic arthritis be investigated?

Answer 26

joint aspiration: for culture. Will show a raised WBC raised inflammatory markers blood cultures

Question 27

What is the diagnostic criteria for septic arthritis?

Answer 27

The Kocher criteria for the diagnosis of septic arthritis: fever >38.5 degrees C non-weight bearing raised ESR raised WCC

Question 28

What are the causes of stridor in children?

Answer 28

Croup Acute epiglottis Inhaled foreign body Laryngomalacia

Question 29

What is transient synovitis? Key features?

Answer 29

irritable hip acute hip pain following a recent viral infection commonest cause of hip pain in children Features: limp/refusal to weight bear groin or hip pain a low-grade fever is present in a minority of patients (high fever should raise the suspicion of other causes such as septic arthritis) self limiting

Question 30

Causative organisms of UTI in kids?

Answer 30

E. coli (80% of cases) Proteus Pseudomonas

Question 31

Risk factors for UTI in kids?

Answer 31

Incomplete bladder emptying: infrequent voiding hurried micturition obstruction by full rectum due to constipation neuropathic bladder Vesicoureteric reflux Poor hygiene e.g. not wiping from front to back in girls

Question 32

How do UTIs present in kids?

Answer 32

infants: poor feeding, vomiting, irritability younger children: abdominal pain, fever, dysuria older children: dysuria, frequency, haematuria features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness

Question 33

How should UTIs be managed in kids?

Answer 33

infants less than 3 months old should be referred immediately to a paediatrician children aged more than 3 months old with an upper UTI = considered for admission to hospital OR oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days children aged more than 3 months old with a lower UTI = oral antibiotics for 3 days, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs

Question 34

Whooping cough (pertussis) is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. When should it be suspected?

Answer 34

should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features: Paroxysmal cough Inspiratory whoop Post-tussive vomiting Undiagnosed apnoeic attacks in young infants

Question 35

How can whooping cough be diagnosed?

Answer 35

per nasal swab culture for Bordetella pertussis - may take several days or weeks to come back PCR and serology

Question 36

How should whooping cough be managed?

Answer 36

notifiable disease infants under 6 months should be admitted an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread household contacts should be offered antibiotic prophylaxis school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )

Question 37

Complications of whooping cough?

Answer 37

subconjunctival haemorrhage pneumonia bronchiectasis seizures

Question 38

Who is offered the pertussis vaccine?

Answer 38

Women who are between 16-32 weeks pregnant

Question 39

Give some ddx for acute cough in young children

Answer 39

Bronchiolitis (RSV) – high temperature makes this less likely Other viral infection e.g. influenza LRTI or pneumonia – lobar or bronchial pneumonia Croup Whooping cough Laryngomalacia Foreign body inhalation Reflux Heart failure

Question 40

Prolonged focal seizure should make you consider what?

Answer 40

Encephalitis

Question 41

Babies who are sleepy with reduced feeding =

Answer 41

sepsis until proven otherwise

Question 42

How could you investigate a baby with a fever of unknown origin?

Answer 42

repeat temperature look in ears for any obvious signs of ear infection examine all over their body for any obvious rashes listen to their chest palpate abdomen FBC, CRP blood culture capillary blood gas (lactate) urine dipstick, MC&S lumbar puncture CXR

Question 43

If you don’t know whether meningitis is viral or bacterial =

Answer 43

give aciclovir for viral cover!!!

Question 44

What should you ask about in the history if suspecting neonatal herpes / herpetic meningitis ?

Answer 44

Is there parental hx of herpes or cold sores?

Question 45

What is the most common cause of urticaria in kids?

Answer 45

viruses

Question 46

Give some differentials for vomiting in an infant

Answer 46

GORD CMPA Intestinal malrotation Intussuception Pyloric stenosis