Paediatrics Flashcards

Question

stridor

Answer 1

Background: Noise heard on inspiration, from partial obstruction at the larynx or large airways More common in children as their airways are narrower and more flexible than adults, meaning obstruction occurs more dramatically and faster. Pathology: Partial obstruction of the larynx or large airways causing whistling high pitch notes on inspiration due to the decreased diameter of the airway passage. Aetiology: Infective - croup (laryngotracheobronchitis), bacterial tracheitis, epiglottitis, laryngitis Non-infective - congenital (laryngomalacia, web/stenosis, vascular rings), anaphylaxis, haemangiomas or papillomas, thermal or chemical trauma, foreign body or vocal cord paralysis.

Answer 2

High pitched, wheezing, musical sound on inspiration Other signs of respiratory distress: Swallowing difficulty/drooling pale/cyanosed Accessory muscle breathing Nasal flaring Subcostal retraction/recession (indrawing of the abdomen just below rib cage, belly breathing) Downward plunging of trachea with respiration (tracheal tug)

Answer 3

infective: croup epiglottitis bacterial tracheitis retropharyngeal abscess non-infective: inhaled foreign body subglottic haemngioma C1 esterase inhibitor deficiency (hereditary angioedema) hypoglycaemia ``` investigations ABCDE examination Vital signs - temp, RR, HR, breathing Respiratory examination Bloods - U+Es, Ca, FBC ```

Answer 4

Background: Leading cause of stridor with a barking cough Most severe in children under 3 years old (typically 6 months - 2 years) Pathology: Viral upper respiratory tract infection causing inflammatory oedema involving the larynx, causing a hoarse voice and barking cough and partial airways obstruction leading to stridor. Aetiology: 95% viral - parainfluenza, influenza, adenovirus, respiratory syncytial virus (RSV), measles etc. Bacterial - klebsiella, diphtheria (rare, can lead to epiglottitis) Fungal - rare Risk factors: Ages 6 months - 2 years

Answer 5

Presentation: Stridor and barking cough with no drooling - almost always croup Increased work of breathing Barking cough occurring in clusters of coughing episodes Hoarse voice Stridor Low grade fever Steeple sign - tapering trachea seen on XR ``` Investigation/diagnosis: ABCDE examination Respiratory examination Vital signs CXR ``` Management: Mild Generally self-limiting, within 48 hours should improve (parainfluenza viral infection especially), Supportive treatments (fluids and rest), sit them up during coughing and comfort, avoid school while ill and vulnerable people. Good hygiene to avoid spreading. Any child under 6 months with signs of difficulty breathing or dehydration must be admitted to hospital Moderate - severe - admit to hospital Dexamethasone (prednisolone in GPs) 150 mcg/kg can be given orally and repeated again in 12 hours PRN Supportive oxygen Nebulised budesonide 2 mg Nebulised adrenaline (failure to improve with steroids or adrenaline - consider bacterial tracheitis) Intubation and ventilation

Answer 6

Background: Pseudomembranous necrotising tracheitis Most serious in young children due to relatively small sized trachea, easily blocked by swelling. A severe bacterial infection of the trachea capable of producing airways obstruction Usually considered part of the lower respiratory tract however can produce upper airway obstruction if severe. Pathology: Thick mucopurulent exudate and tracheal mucosal sloughing (pseudomembrane) that is not able to be cleared with coughing and risks occluding airway Defects in the cartilage leads to inability to support the trachea, collapse of the trachea due to hacking or barking cough Aetiology: Most commonly staph aureus Often follows recent viral URTI

Answer 7

``` Presentation: Often history of a recent URTI with an acute deterioration Toxic appearance Barking cough with thick sputum Inspiratory stridor Scratchy feeling in throat Tracheal tenderness Chest pain Fever Earache, headache, dizziness Increased effort to breathe (accessory muscle use, stridor, grunting, nasal flaring) ``` Investigation/diagnosis: ABCDE assessment Respiratory examination - rule out croup and epiglottitis Bronchoscopy for direct vision of exudates or pseudomembrane on trachea CXR - subglottic narrowing Vital monitoring ECG monitoring during treatment

Answer 8

Severe: IV antibiotics (broad spectrum) ITU/ICU admission for intubation and supportive ventilation ECG monitoring, oxygen saturation, capnography, BP monitoring

Answer 9

Background: Rare but has high mortality rate due to risk of respiratory arrest Medical emergency Pathology: Bacterial URTI leading to inflammation and swelling of the epiglottis This can potentially cause airway obstruction Aetiology: Haemophilus influenzae type B most commonly Strep pyogenes Risk factors: M:F 3:1 Peak age of infection is 2-7 years

Answer 10

``` Presentation: Often acute history of infection Sore throat Drooling (head forward, tongue out) Prefer to sit, leaning forward (tripod position) Fever Dyspnoea Stridor Hot potato muffled voice Dysphagia Tender anterior neck Enlarged anterior neck nodes Voice hoarseness Thumb sign seen on lateral XR of neck ``` Investigation/diagnosis: ABCDE assessment Vitals examination Lateral neck XR - thumb sign + exclude foreign body Nasopharyngeal intubation by anaesthetist to diagnose Bloods - culture Epiglottis culture DO NOT EXAMINE THE THROAT - CAUSES RESP> ARREST

Answer 11

Management: Prevention - vaccine programme against haemophilus DO NOT DISTRESS PATIENT - can cause airway closure ITC admission, alert senior paediatrician and anaesthetist to secure airway Oxygen by mask until anaesthetist arrives Nebulised adrenaline IV dexamethasone Nasopharyngeal intubation by anaesthetist to diagnose IV pen G + ceftriaxone 2g/12 hourly Antipyretic (ibuprofen) Cricothyrotomy in emergency Prognosis: Most recover without intubation Those that are intubated often recover fully within a few days Common complication is epiglottic abscess, collection of pus around the epiglottis which also threatens the airways. Treatment is similar to epiglottitis.

Answer 12

Background: Chronic relapsing inflammatory condition of the skin Complications - lichenification, secondary infection, refractory eczema Pathology: Excessive skin growth leading to immature keratocytes on outer skin layers and improper laying of keratocytes leads to improper skin barrier formation Leads to excess loss of water and skin buried defects allowing pathogens etc. to enter This leads to skin inflammation and easy irritation The itch, scratch cycle is when inflammation causes itching, the patient scratches the area and this leads to further histamines release in the tissues causing increased itch and so on. Aetiology: Unknown Triggers - heat, allergens, infection, sweating, severe stress Risk factors: Personal history of atopic conditions - asthma, hay fever, eczema Familial history of atopy

Answer 13

``` Presentation: Itchy Erythematous Dry, scaly patches May weep Nail pitting and ridging Commonly on extensor aspects (INFANTS) or flexor aspects (CHILDREN and ADULTS) ``` Investigation/diagnosis: Clinical - itch + history of atopy, general dry skin, visible eczema rash, onset in first 2 years of life Management: Avoid triggers, keep nails short and avoid scratching (educate on itch scratch cycle) Apply emollient liberally (thin creams - e45, aveeno, thick creams - 50:50 ointment, hydromol, cetraben ointment) Topical hydrocortisone 7 days for flares Antihistamines Antibiotics (flucloxacillin) for secondary infection Later life - tacrolimus (ages 2+) or pimecrolimus (ages 2-16) Phototherapy and immunosuppressants for severe cases

Answer 14

Mild = hydrocortisone Mod = eumovate Potent = betnovate Very potent = dermovate

Answer 15

Background: Very common in young children wearing nappies Common complication is secondary yeast infection with candida species Severe long standing nappy rash can lead to erosions and ulcerations Pathology: Contact dermatitis +/- secondary candida infection Inflammation of the skin in response to urine and faeces contact Aetiology: Prolonged wearing of soiled nappies ``` Risk factors: Most common between ages 9-12 months Not regularly changing infant Not washing or drying well/using talcum powder Tight fitted nappies ```

Answer 16

``` Presentation: Sore, itchy Erythematous Spread around the nappy region only (perianal, genital region) Tends to spare the skin creases Worsened after wearing nappies Improves with less nappy use Candida - rash extending into skin folds, well demarcated scaly border, circular pattern to rash, satellite lesions near main rash. ``` Investigation/diagnosis: Clinical Swab for resistance or uncertainty Management: Leave nappies off for as long as possible Change regularly, use barrier emollient creams liberally Talcum powder after washing to help properly dry the area Loose fitting nappies to avoid irritation Mild hydrocortisone cream for 7-14 days for inflammation Daktacort cream (miconazole + hydrocortisone) or antifungal cream for suspected candida infection 2-3x daily for 7-10 days after the rash clears

Answer 17

Background: Viral herpes simplex or VZV skin infection in those with atopic dermatitis Pathology: Atopic dermatitis leads to poor skin barriers in some areas making contact with viral lesions easier for spreading and causes more widespread severe skin flare up Aetiology: Most commonly HSV-1 or VZV Risk factors: Atopic dermatitis

Answer 18

``` Presentation: Widespread, painful, vesicular rash - affects any area Pus filled vesicles, sometimes itchy After bursting, leave punched out ulcers with red base Fever Lethargy Irritability Reduced oral intake LAP ``` Investigation/diagnosis: Clinical diagnosis Viral swabs to confirm Management: Aciclovir (oral for mild-mod or IV if severe) Complications - bacterial superinfection needing antibiotics

Answer 19

Background: Complications - dehydration, bacterial superinfection, encephalitis Pathology: Incubation usually 3-5 days Viral infection transmitted via lesion contact or respiratory droplets Aetiology: Coxsackie A virus Presentation: URTI - fatigue, sore throat, dry cough, fever After 1-2 days small mouth ulcers appear followed by blistering red spots across the hands, feet and mouth mostly Painful ulcers, particularly on the tongue May be itchy

Answer 20

Investigation/diagnosis: Clinical diagnosis Dehydration status Management: Supportive - good fluid intake, simple analgesia and antihistamines if itchy or painful Spontaneously resolves within 7-10 days Educate on high transmission - avoid sharing towels, bedding, wash hands regularly especially when handling dirty nappies

Answer 21

Background: Complication: chickenpox induced pneumonia, bacterial superinfection, dehydration, conjunctival lesions, encephalitis/ataxia Do NOT use NSAIDs as this worsens the rash and symptoms Pathology: Highly contagious, spread via direct contact with lesions or infected respiratory droplets Patients become symptomatic 10 days - 3 weeks after exposure Stops being contagious after lesions have crusted over After viral infection presents, virus can lay dormant in sensory dorsal root ganglion cells and cranial nerves which can reactivate later in life as shingles or ramsay hunt syndrome Aetiology: VZV infection

Answer 22

Presentation: Vesicular, raised rash, widespread Erythematous Blistering lesions Usually starts on the trunk or face and spreads outwards over 2-5 days Eventually lesions scab over and stop being contagious Fever Itch General fatigue and malaise In pregnancy <28 weeks can cause congenital varicella syndrome In pregnancy around time of delivery can cause life threatening VZV infection

Answer 23

Investigation/diagnosis: Clinical Management: In neonates - IV acyclovir Usually no treatment in otherwise healthy children Aciclovir in immunocompromised patients 14 years + presenting within 24 hours. Calamine lotion and chlorpheniramine (antihistamine) for itching Avoid school and pregnant women and immunocompromised patients until lesions dry and crust over (5 days usually) Prevention: Ig VZV given to unexposed pregnant women

Answer 24

Background: Very common in teenagers and young adults Generalised self limiting rash with unknown cause NOT contagious - no need to keep off school Pathology: Not fully understood Aetiology: May be caused by HHV-6 or HHV-7 but no definitive cause is known Risk factors: More common in women More common in ages 10-35

Answer 25

Presentation: Prodromal - headache, fatigue, loss of appetite, general malaise Rash begins with large Herald patch - faint pink/red scaly patch usually >2cm on the torso 2 days after the rest of the rash spreads - faint red/pink, slightly scaly and oval shaped lesions usually <2cm Can form characteristic ‘christmas tree’ pattern on ribs or torso Dark skin - lesions can be grey coloured or darker in colour than skin Itchy Investigation/diagnosis: Clinical diagnosis Management: Resolves spontaneously within 3 months Can leave skin discolouration for an additional few months Educate on course and that it is NOT contagious Symptomatic relief (emollients, topical steroids, antihistamines) for itching

Answer 26

Background: AKA slapped cheek/5th disease Very common childhood infection occurring between the ages of 3-15 years Pathology: Spread via droplet transmission, blood/bone marrow transplant or vertical transmission (mum-baby) Typically takes 4-20 days incubation Lifelong immunity after being exposed to the virus Aetiology: Parvovirus B19 Risk factors: Most common in children

Answer 27

Presentation: Asymptomatic in 25% of infections Non-specific coryza symptoms Headaches Rhinitis Sore throat Low grade fever Typically 7 days after being symptoms free develop facial rash - slapped cheek red face rash Can spread to the rest of the body 2-3 days after appearing on the face Arthropathy (more common in adults than children) Differentials: Rubella: very similar rash over the whole body Measles: check for Koplik spots Scarlet fever: look for strawberry tongue Roseola: similar rash Drug eruption: new medications?

Answer 28

Investigation/diagnosis: Clinical diagnosis If uncertain/pregnant - PCR test for parvovirus B19 Bloods - specific to IgM and IgG checking for immunity and current infection Management: Self limiting viral infection Regular OTC analgesia, symptomatic management Avoid any immunocompromised or pregnant people Do NOT need to avoid school, but do need to make anyone pregnant at the school aware Pregnancy: 30% chance of passing infection onto baby Baby fatality 10% if infected, higher in the first trimester Can cause congenital abnormality If been in contact with someone infected, must be investigated (ask if any previous history of parvovirus in childhood, bloods and PCR) If they have active infection: refer to foetal medicine unit to check for foetal infection

Answer 29

Background: Contagious infection, should keep children off school during Classified into bullous (always caused by staph. aureus) and non-bullous Complications - cellulitis, sepsis, scarring, post. Strep glomerulonephritis, staph. Scalded skin syndrome, scarlet fever. Pathology: Superficial bacterial skin infection Occurring when bacteria enter via break in skin barrier Bullous impetigo - staph. Aureus bacteria produce epidermolytic toxins that break down proteins holding the skin together. Causes fluid filled vesicles to form under the skin Aetiology: Most commonly staph. Aureus bacteria Less commonly strep. pyogenes Risk factors: Eczema or dermatitis Bullous - more common in neonates and children <2 years

Answer 30

Non-bullous - typically around the nose/mouth. Exudate dries into ‘GOLDEN CRUST’. Often do NOT cause systemic symptoms Bullous - 1-2 cm vesicular lesions that grow in size then burst. Exudate dries forming ‘GOLDEN CRUST’. Heal without scarring. Lesions can be painful and itchy. More common for systemic symptoms to occur (fever, malaise) and this is called staphylococcal scalded skin syndrome.

Answer 31

Investigation/diagnosis: Clinical diagnosis Swab of lesions to confirm Management: Fusidic acid (topical) for localised non-bullous impetigo Antibiotics (flucloxacillin) for widespread or more severe impetigo Advice on good hand hygiene, not touching lesions, avoiding sharing face towels and cutlery, must be kept off school while unwell until lesions heal or have been treated with antibiotics for at least 48 hours.

Answer 32

Background: Common infection of the skin next to the nail Chronic paronychia - infection/inflammation for >6 weeks Pathology: Infection of the skin besides the nail fold Aetiology: Bacterial (staph. aureus) or fungal infection (candida) Risk factors: Hands in water for long periods of time (cleaners, bartenders, beauticians etc.) Injury to the skin around the nail (nail biting, eczema or splinters) Artificial nails Gloves for prolonged period of time

Answer 33

``` Presentation: Collection of pus Swelling Erythema Painful and tender Nail may become infected or damaged ``` Investigation/diagnosis: Clinical diagnosis Swab for uncertain species and treatment Management: Fusidic acid and warm water soaks, simple analgesia 1st line Flucloxacillin or erythromycin for bacterial infection Pus drainage Chronic paronychia - keep hands warm and dry, avoid triggers, wear comfortable shoes (toenails), treat underlying skin conditions, hydrocortisone for inflammation, clotrimazole cream or terbinafine oral antifungals. Operation to open infected area and allow drainage and healing

Answer 34

Background: Associated with bacterial meningitis, all non-blanching rash is treated as meningococcal sepsis until proven otherwise Pathology: Large purple rash from haemorrhage/bleeding under the skin from blood vessel leaking into skin tissue Petechiae - Small <3mm, non-blanching red/purple spots from burst capillaries Purpura - larger 3-10mm non-blanching, red/purple, macules or papules from leaking blood vessels under the skin Aetiology: Bacterial meningitis (meningococcal septicemia) henoch-Schonlein purpura (HSP) Idiopathic thrombocytopenic purpura (ITP) Acute leukaemias Haemolytic uraemic syndrome (HUS) Mechanical cause - strong coughing, vomiting, breath holding Traumatic - tight pressure on the skin e.g. non-accidental injury Viral illness - influenza and enterovirus typically

Answer 35

Non-blanching rash Purpura HPS - rash on legs and buttocks, may have associated abdominal or joint pains ITP - develops over several days in otherwise well child Acute leukaemias - gradual development of petechiae, anaemia, LAP and hepatosplenomegaly HUS - rash with oliguria and anaemia often recent diarrhoea Mechanical - petechiae around the ‘superior vena cava distribution’ above the neck and most prominent around the eyes Traumatic - specific areas only

Answer 36

Investigation/diagnosis: Exclude meningitis, HUS, leukaemias, HSP etc. Bloods - FBC, U+Es, CRP, ESR, coagulation, ESR, blood cultures, Meningococcal PCR LP BP - HTN associated with HSP and HUS and hypotension with septic shock Urine dipstick - proteinuria and haematuria suggest HUS Safeguarding Management: Urgent referral and investigation in secondary care unless there is a clear unconcerning cause Manage underlying cause

Answer 37

Background: Tinea capitis - affecting the scalp Tinea pedis - affecting the foot (athletes foot) Tinea cruris - of the groin or leg Tinea corporis - of the torso/body Onychomycosis - fungal nail infection Tinea incognito - more extensive fungal skin infection resulting from use of steroids on the area. Often occurs when misdiagnosed as dermatitis, accelerates growth of fungus by weakening the immune system via steroid use Pathology: Spread via contact with infected individual, animal or soils More likely to occur in areas with sweaty, moist, damp environments such as changing rooms Aetiology: Ringworm - tinea fungal infection of the skin Most common fungus causing ringworm is trichophyton

Answer 38

Risk factors: Tinea capitis - more common in children Presentation: Itchy, erythematous and scaly rash Well demarcated Often one or several rings/circular shaped areas that spread outwards Edge is more prominent than the centre Tinea capitis - associated with hair loss, itching, dryness and erythema of the scalp Athletes foot (tinea pedis) - white/red flakey, cracked, itchy patches between the toes. May split and bleed. Onychomycosis - thickened, discoloured and deformed nails Tinea incognito - fewer scales, less well-demarcated border

Answer 39

Investigation/diagnosis: Clinical diagnosis Scraping for microscopy and culture to confirm Management: Antifungal creams - clotrimazole and miconazole Antifungal shampoos - ketoconazole (tinea capitis) Oral antifungal medications - fluconazole, griseofulvin and itraconazole Nail infection - amorolfine nail lacquer for 6-12 months or oral terbinafine if this fails (needs LFTs before and whilst taking) Daktacort for mild itching Lifestyle advice: Loose, breathable clothing Keep affected area clean and dry Avoid sharing towels, clothes and bedding Use separate towel for feet (tinea pedis) Avoid scratching and spreading to other areas Wear clean dry socks every day

Answer 40

Background: Benign epidermal neoplasms Over 100 subtypes of HPV and different subtypes associated with different clinical lesions Types: (examples not exhaustive list) Common warts: dome shape nodules, common on hands, may have fine digit like projections caused by HPV 2, 27 and 57 Plane warts: smooth, flat topped papules common on the face, may have brownish colour and caused by HPV 3 and 10 Plantar warts: found on soles of feet, can be painful and scaly, may have dark punctate spots caused by HPV 1, 2, 4, 27 and 57 Anogenital warts: occur on genitals and spread through sexual contact. May be small or coalesce into larger lesions called condylomata acuminata caused by HPV 6 and 11 Filiform warts: eye or face typically have fingerlike projections Epidermodysplasia verruciformis: rare genetic condition of chronic cutaneous infection starting out as flat warts then developing into skin cancer Pathology: Spread via direct contact with lesion or sharing towels, damp environment like pools etc. ``` Aetiology: Human papillomavirus (HPV) ```

Answer 41

Presentation: Infections of mucous membranes like URT can cause respiratory papillomatosis causing voice changes and high pitched breath sounds if the larynx is infected Anal and genital infections tend to be skin coloured, range in size and have califlower like surface. Typically painless, can be itchy, burning local pain or bleeding

Answer 42

Investigation/diagnosis: Clinical diagnosis Mucous membrane infections may need endoscopy (if URT suspected) or regular pap or acetic acid tests of cervix after 21 years old even if symptoms are subclinical Cervical smears detect HPV virus after 25 years old every 3 years until age 50 when becomes every 5 years Definite diagnosis needs biopsy microscopy confirmation Prevention: HPV vaccine nationally against HPV 16 and 18 Now switched to protect against HPV 16, 18, 6 and 11 so is also protective against genital warts

Answer 43

Black tape method: cut a piece of duct tape as close to the size of the wart as possible. Leave tape on wart in place for 6 days (if falls off, replace) after 6 days remove the tape and soak the area in water. Repeat the process until the wart is gone or for up to 2 months. Most resolve without treatment: watch and wait if not painful Topical salicylic acid first line: pared down wart prior to application then daily treatment for at least 12 weeks Cryotherapy: 2 wkly liquid nitrogen given by clinician. May be painful and cause bleeding. Avoid in young children Anogenital: may resolve spontaneously, remain same or increase in size. Need to be referred to a sexual health clinic for diagnosis, STI screening and management. There is a very long latent period of HPV so reassure pt it does not mean infidelity Podophyllotoxin cream/solution self application for soft, non-keratinised external warts for 3 days BD Imiquimod 5% for keratinised lesions and non-keratinised external lesions apply 3 x weekly until resolution or for up to 4 months Surgical removal All treatments cause burning, itch and pain Condoms not reliably protective 95% genital warts not associated with high risk neoplasm transformation however types 16 and 18 are high risk of anogenital cancers

Answer 44

Background: Acute (<3 weeks) Chronic (>3months) Very common and more than 1% of people will be diagnosed with the conditions each year Affects all ages but incidence peaks between ages 7-12 Complications can include abscess, inflammation of tympanic membrane, malignant otitis Pathology: Inflammation of the external ear canal +/- infection Aetiology: Bacterial infection Disturbing/damaging cell lining of the ear canal e.g. excessive cotton bud use or hot tubs causing inflammation Risk factors: Diabetes or radiotherapy to the head/neck increase the risk of malignant otitis

Answer 45

Presentation: Ear pain, itching, discharge and hearing loss Swollen, red or eczematous ear canal and/or external ear Usually systemically well and not bothered by infection Ear may leak fluids, look wet and crusty and may smell Investigation/diagnosis: History/clinical diagnosis Ear examination Ear swab for persistent or recurrent symptoms

Answer 46

Paracetamol or ibuprofen (codeine for severe pain up to 60mg) analgesia Topical preparation (Otomize spray) containing dexamethasone and neomycin. Also can use steroid eye drops for simple otitis externa cases. Use for 7 days but up to 14 if symptoms persist, 2-3 drops 3-4x daily. Tilt ear up and back (or back and down if child <3 years), press tragus and keep head tilted to the side for a few moments to help keep fluid in the ear Do NOT prescribe steroids if there is a perforation ! NO OTOMIZE SPRAY https://www.safemedication.com/how-to-use-medication/ear-drops General advice to keep ears clean, dry, avoid using cotton buds, moisturising any eczema etc. Follow up recommended for those with severe otitis externa, chronic OE, diabetes or are immunocompromised Suspected malignant otitis - urgent admission Chronic otitis externa: If fungal infection is suspected - clotrimazole or other antifungal prep used. 7-14 days T/QDS. Irritation suspected - prescribe corticosteroid prep Unknown cause - topical corticosteroid without antibiotic, can prescribe acetic acid spray alongside Inadequate response - continue steroid but reduce strength Still no response - consider trial of antifungal drug e.g. clotrimazole

Answer 47

Background: Very common in children Complications - otitis media with effusion (glue ear), hearing loss, perforation, recurrent infection, mastoiditis, abscess Pathology: Infection of the middle ear (between tympanic membrane and inner ear, where the cochlea, vestibular apparatus and nerves are located) Bacteria enter through the throat via the eustachian tube Often preceded by viral URTI Aetiology: Commonly viral infection Strep. Pneumoniae most commonly for bacterial infection

Answer 48

Presentation: Ear pain Reduced hearing Fever Cough Coryzal symptoms Sore throat General malaise Fever, vomiting, irritability and lethargy or poor feeding especially in younger children Bright red, inflamed tympanic membrane with bulging appearance due to fluid build up Perforation - allows discharge to travel through Investigation/diagnosis: ENT examination

Answer 49

Severely unwell or uncertain diagnosis or in those <3 months with temperature 38 or those aged 3-6 months with temp 39+ - urgent paediatric referral Mostly self limiting within 3 days but can last up to a week Simple analgesia and supportive care (fluids) Antibiotics for those <2 YOs with bilateral otitis media, with otorrhea (discharge) Delayed prescription for if not cleared up within 3 days or if condition worsens Amoxicillin 1st line for 5 days, erythromycin and clarithromycin for allergy

Answer 50

Background: Otitis media with effusion Pathology: Middle ear is inflamed (otitis media) with fluid and causes hearing loss in affected ear Eustachian tube becomes blocked and causes middle ear secretions to build up within the middle ear space Possibility of secondary bacterial infection due to fluid stasis Aetiology: Eustachian tube blockage Risk factors: Otitis media Presentation: Hearing reduction Dull tympanic membrane with air bubbles or visible air fluid level but can look normal Otitis media if infection present Investigation: ENT exam Audiometry to establish hearing loss Management: Spontaneously resolves within 3 months Hearing aids or grommets if other comorbidities or not healing

Answer 51

Background: Very common with URTIs Peak age between 5-10 and 15-20 YOs Complications - chronic tonsillitis, quinsy, otitis media, scarlet fever, rheumatic fever, post. Strep GN, post strep. Reactive arthritis Pathology: Inflammation of the tonsils Waldeyer’s tonsillar ring - ring of lymphoid tissue making up the adenoid, tubal, palatine and lingual tonsils. The palatine tonsils are typically affected in tonsillitis Aetiology: Viral infection most commonly Bacterial infection (strep. A and strep pyogenes most often)

Answer 52

``` Fever Sore throat Odynophagia Poor oral intake Headache Vomiting Abdominal pain Swollen, bilaterally enlarged tonsils +/- white exudate ``` Investigation/diagnosis: Centor criteria Fever pain score - fever in 24 hours, purulence, attended within 0-3 days onset, inflamed tonsils, no cough or coryza Exclude red flags for quinsy, meningitis and encephalitis Management: Viral tonsillitis - supportive Mx only, good fluid intake, analgesia for pain and fever Safety net for persistent fever above 38.3 degrees, worsening condition Consider delayed prescription in those with fever pain score of 2-3 Antibiotics (penicillin V/phenoxymethylpenicillin 10 day course, clarithromycin in allergy) for score 4+

Answer 53

Background: Often follows tonsillitis Common in teens and young adults as well as children Pathology: Trapped pus forming an abscess within a region of the tonsils Aetiology: Bacterial infection causing pus and abscess formation - most commonly strep. pyogenes , staph aureus and H. influenzae ``` Presentation: Unilaterally enlarged tonsils Difficult to differentiate tonsils Deviated uvula Sore throat Hot potato voice Trismus - unable to open mouth LAP and tender lymph nodes Neck pain Odynophagia ``` Investigation/diagnosis: Throat exam Clinical diagnosis Management: Referral to secondary ENT care for incision and drainage under GA Antibiotics (co-amoxiclav) Dexamethasone to settle inflammation and help recovery in some cases

Answer 54

Background: Complication can include bacterial superinfection rarely Pathology: Spread through direct contact or sharing items like towels or bedsheets Aetiology: Poxvirus - molluscum contagiosum virus Presentation: Small, flesh coloured papules with characteristic central dimple Typically appear in crops of multiple lesions in a local area Investigation/diagnosis: Clinical diagnosis Management: Avoid sharing towels/flannels Avoid picking and scratching as can cause secondary infection or scarring Self resolving within 18 months and skin returns to normal after this Treat any secondary bacterial infection - fusidic acid or antibiotics Specialist referral for extensive lesions or in problematic areas like eyelids, anogenital areas etc.

Answer 55

Background: Common, acute inflammatory response of skin to exposure to UV radiation Pathology: UVR causes vasodilation and release of mast cell mediators leading to inflammatory response Less intense or short duration exposure leads to increase skin pigmentation which provides further protection against UVR induced damage Aetiology: UV radiation exposure ``` Risk factors: Duration of UVR exposure Height of sun (midday = worst) Type of UVR - UVB more potent Increasing altitude Environmental reflection Lack of sun cream or protective clothing Lighter skin pigmentation Moist skin Face, neck and torso skin is less resistant Areas of vitiligo more prone to burn Photosensitivity - SLE, acne medication (EPIDUO) Sunbed use ```

Answer 56

``` Presentation: Red and hot skin Blanches on pressure Painful and tender Usually 2-6 hours post exposure Peaks 12-24 hours after onset Vesicles and bullae may form Headache, chills, malaise, N+V if more severe ``` ``` Investigation/diagnosis: Assess area and degree of burn Assess for dehydration Assess for degree of pain Heat Stroke or exhaustion signs - high body temp, fatigue, weakness, dizziness, LOC, headache, N+V, rapid pulse, myalgia, altered behaviour ``` Management: SAFE SUN EXPOSURE - sun creams and covering clothing Refer deep dermal and full thickness burns, all circumferential burns, superficial burns with >3% total body surface area in those aged 16+ or >2% in those under 16. Refer those involving hands, feet, perineum, genitalia or flexures, suspected dehydration, heat stroke, shock or sepsis. Safeguard for non-accidental injury or neglect. Majority resolves spontaneously - good fluid intake, aloe vera after sun to soothe symptoms, emollients, simple analgesics

Answer 57

Background: Most individuals are infected with HSV-1 by 1-2 years of age (1 = above waist) HSV-2 tends to be with onset of sexual activity (2 = below waist) Usually is asymptomatic Most contagious when virus filled lesions are present but can also be shed when asymptomatic In individuals with atopic dermatitis can present with very severe herpes virus blistering in these areas due to weakness of skin barriers (eczema herpeticum) and also can have very similar severe viral blisters in those with burn injuries. Complications include meningitis or encephalitis if viral infection reaches the brain (typically in the TEMPORAL LOBE) Pathology: Primary infection occurs through a break in the mucous membranes of the mouth, throat, eyes, genitals or skin abrasions. Can also be spread via vertical transmission Virus internalised in cells then begins lytic cycle of proliferation Cells burst and virus spreads to other cells Can also infect sensory neurons and lays latent there in the trigeminal ganglia (oral herpes) or sacral ganglia (genital warts) and lies dormant until an immunocompromised state allows for the virus to travel back down the neurons and infect the cells Triggers include stress, skin damage and viral illness. Aetiology: HSV-1 and HSV-2 Enveloped, double stranded DNA viruses Risk factors: Triggers include stress, skin damage and viral illness.

Answer 58

``` Oral: Often asymptomatic Tingling or burning sensation Blisters appearing on the sides of the mouth, heal within a few weeks and often painful Lesions on palate, lip, gums, tongue LAP Pharyngitis ``` ``` Investigation/diagnosis: Clinical diagnosis PCR viral DNA Viral cultures Viral antibodies ``` ``` Management: Usually self limiting Topical or systemic antivirals within prodromal phase to help speed up recovery Topical analgesic OTC for oral lesions Acyclovir, famciclovir or valacyclovir ```

Answer 59

Background: Acute - 10-15% occurs suddenly and normally spontaneously Chronic - 85% is a steady slippage occurring progressively Typically seen in ages 10-13, adolescence Stable - can walk Unstable - unable to walk (10% case) and is high risk of osteonecrosis Pathology: A slippage between the neck and head (capital epiphysis) of the femur Physis (growth plate) of the femur is weak and unstable during the growth phase before ossification and is supported by the perichondrial ring helping resist shearing forces holding the head and neck together. Weakness in the proximal femoral physis/perichondrial ring or factors inducing stress to the hip joint at the growth plate during growth periods leads to displacement of the capital femoral epiphysis The metaphysis (neck of the femur) is displaced anteriorly and superiorly leads to slipped state If severe can cut off blood supply causing avascular osteonecrosis

Answer 60

Mechanical - local trauma, obesity Hormonal - testosterone weakening the physis Hypothyroidism Radiotherapy and chemotherapy to the hip

Answer 61

Uni or bilateral (usually unilateral) Discomfort in the hip, groin, medial thigh or knee during walking Limping Pain accentuated in running and jumping Limited hip motion especially internal rotation When flexed the hip externally rotates Mild-moderate shortening of the affected leg in chronic cases

Answer 62

Investigation/diagnosis: Clinical XR using Kline’s line or trethowan’s sign using frog leg lateral XR view Management: Immobilise limb, non-weight bearing Analgesia and orthopaedic referral Surgery to stabilise the joint via percutaneous pin fixation

Answer 63

Background: Common cause of knee pain in adolescents More common in boys during periods of rapid growth Pathology: Repeated pulling on the tendons on the growth plate of the tibia causing repeated microtrauma, inflammation of the apophysis resulting in apophysitis during fast growth of the bones

Answer 64

Knee pain over the tibial tuberosity during activity like running or jumping Usually unilateral but can be bilateral Localised pain worse with exercise improves with rest Swollen and tender tibial tuberosity No effusion

Answer 65

Investigation/diagnosis: Knee examination and hip examination (referred pain) Management: Usually settles over weeks or months but can persist for 1-2 years Simple analgesia Intermittent ice pack application especially after activity Patients may continue normal activity but may need to modify the duration, frequency or intensity (limiting running or jumping)

Answer 66

Background: AKA irritable hip The most common cause of limp in children Often follows a viral infection or after a fall/injury Most common in ages 3-10 Self resolving Pathology: Inflammation of the synovial lining of the joint (usually the hip joint) Cross immune inflammation resulting in inflammation of the joints following a viral infection aetiology: viral infection trauma or injury

Answer 67

``` New onset limp Pain in hip, knee, groyne or thigh Refusal to weight bear Usually unilateral Systemically well but may follow recent viral infection ```

Answer 68

Investigation/diagnosis: Hip examination R/O septic arthritis, juvenile arthritis Management: Self-resolving condition Rest - should begin to improve within 3 days and better within 2 weeks NSAIDs analgesia Avoid sports and strenuous activity until they are completely better

Answer 69

Refers to condition affecting children and adolescents where autoimmune inflammation occurs in the joints Diagnosed where there is arthritis without any other cause lasting >6 weeks in patient under the age of 16 Key features are joint pain, swelling and stiffness ``` Subtypes: Systemic Polyarticular Oligoarticular Enthesisits related Juvenile psoriatic ```

Answer 70

AKA still’s disease Systemic illness that can occur throughout childhood Typical features are subtle salmon pink rash, high swinging fevers, enlarged lymph nodes, weight loss, joint inflammation and pain, splenomegaly, muscle pain, pleurisy and pericarditis Antinuclear antibodies and RFs typically negative but inflammatory markers CRP, ESR, platelets and serum ferritin are raised Key complication is macrophage activation syndrome with severe immune system activation and massive inflammatory response. Acutely unwell child with disseminated intravascular coagulation, anaemia, thrombocytopenia, bleeding and non-blanching rash. Life threatening emergency - key investigation is finding low ESR

Answer 71

In 5 joints or more Tends to be symmetrical and can affect small joints of hands and feet as well as large joints Minimal systemic symptoms (mild fever, anaemia, reduced growth) RF -ve usually described as seronegative; seropositive patients tend to be older children/adolescents and disease more similar to rheumatoid arthritis in adults

Answer 72

Involves 4 joints or less Usually only affects single joint (monoarthritis) Tends to be larger joints and more common in girls under age 6 Classic feature is anterior uveitis (must be referred to ophthalmologist) Tend not to have systemic symptoms and inflammatory markers are normal/mild ANAs often positive but RF usually negative

Answer 73

More common in male children over age 6 Thought of as a paediatric version of seronegative spondyloarthropathy conditions (ankylosing spondylitis, psoriatic arthritis, reactive arthritis and inflammatory bowel disease-related arthritis. Patients have inflammatory arthritis in the joints as well as enthesitis) MRI can demonstrate enthesitis but cannot distinguish cause (stress or autoimmune) Majority of patients are HLA B27 positive Prone to anterior uveitis and should be referred to ophthalmologist even if asymptomatic Tender to localised palpation of entheses: commonly in IP, wrist, greater trochanter, quad insertion at ASIS, quad/patella tendon, achilles, MCP areas

Answer 74

Seronegative arthritis associated with psoriasis Pattern of joint involvement varies but associated with several skin signs: psoriasis, nail pitting, onycholysis (separation of nail from bed), dactylitis, enthesitis

Answer 75

``` Paediatric rheumatology referral and MDT NSAIDs Steroids (oral, IM, intra articular) DMARDs (methotrexate) TNF inhibitors (etanercept, infliximab) ```

Answer 76

Background: Perthes' disease is a degenerative condition affecting the hip joints of children Typically between the ages of 4-8 years. Around 10% of cases are bilateral Pathology: It is due to avascular necrosis of the femoral head, specifically the femoral epiphysis. Impaired blood supply to the femoral head causes bone infarction. Risk factors: Perthes' disease is 5 times more common in boys.

Answer 77

Presentation: hip pain: develops progressively over a few weeks limp stiffness and reduced range of hip movement x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening Investigation/diagnosis: plain x-ray technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist Management: To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities Prognosis Most cases will resolve with conservative management. Early diagnosis improves outcomes. Complications osteoarthritis premature fusion of the growth plates

Answer 78

Background: EBV AKA human herpesvirus 4 is widespread and one of the most common human viruses worldwide Member of the herpes virus family Most people are infected with EBV at some point in their lives Most common cause of infectious mononucleosis (85-90% of cases) Pathology: Spread commonly through bodily fluids (saliva) Infects B lymphocytes and epithelial cells Can cause infectious mononucleosis in roughly 50% of primary infections Also associated with tumours such as Burkitt’s lymphoma, Hodgkin’s disease, B-lymphoproliferative disease Nasopharyngeal carcinomas and oral hairy leukoplakia can also be associated. In congenital infection can cause X linked lymphoproliferative syndrome Can also play a role in autoimmune diseases like SLE, RA and MS but pathology is unknown. Primary infection is often mild or asymptomatic or causes mumps. After primary infection the virus becomes latent however in immunocompromised individuals may reactivate Aetiology: HHV-4/EBV viral infection Risk factors: Immunocompromised - risk of reactivation of latent infection

Answer 79

``` Fatigue Fever Inflamed throat Lymphadenopathy Hepatosplenomegaly Rash ```

Answer 80

``` Clinical diagnosis (difficult due to vague presentation) PCR and viral antibodies (MONOSPOT test - looks for heterophile antibodies) Bloods - FBC (WCC and monospot test), LFTs (raised ALT) ``` prevention: good hygiene, avoid kissing or sharing bodily fluids, personal items such as drinks

Answer 81

Usually self limiting within 2-4 weeks, fatigue can last for longer Do not need to isolate from school (with infectious mononucleosis) Arrange hospitalisation for signs of dehydration, stridor or complication such as ruptured spleen Avoid exercise for at least one month after recovery due to risk of splenic rupture Fluid intake Rest Avoiding kissing, sharing personal items, drinks Regular analgesia as needed Treat immunocompromised states

Answer 82

Background: Abnormal backflow of urine from the bladder into the ureter and kidney. Relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI) Found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI Pathophysiology: ureters are displaced laterally, entering the bladder in a more perpendicular fashion than at an angle therefore shortened intramural course of the ureter vesicoureteric junction cannot, therefore, function adequately Aetiology: Developmental anomaly Presentations antenatal period: hydronephrosis on ultrasound recurrent childhood urinary tract infections reflux nephropathy term used to describe chronic pyelonephritis secondary to VUR commonest cause of chronic pyelonephritis renal scar may produce increased quantities of renin causing hypertension Investigation/diagnosis: VUR is normally diagnosed following a micturating cystourethrogram a DMSA scan may also be performed to look for renal scarring The table below summarises the grading of VUR Grade I - Reflux into the ureter only, no dilatation II - Reflux into the renal pelvis on micturition, no dilatation III - Mild/moderate dilatation of the ureter, renal pelvis and calyces IV - Dilation of the renal pelvis and calyces with moderate ureteral tortuosity V - Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity Complications: Pyelonephritis Recurrent UTI

Answer 83

Background: Febrile convulsions are seizures provoked by fever in otherwise normal children. They typically occur between the ages of 6 months and 5 years and are seen in 3% of children. Clinical features: usually occur early in a viral infection as the temperature rises rapidly seizures are usually brief, lasting less than 5 minutes are most commonly tonic-clonic

Answer 84

Simple - <15 mins - generalised seizures (tonic clonic most commonly) - typically no recurrence within 24 hours - should have complete recovery within an hour Complex - 15-30 minutes - focal seizures - may have repeat seizures within 24 hours Febrile status epilepticus - > 30 minutes

Answer 85

Management following a seizure children who have had a first seizure OR any features of a complex seizure should be admitted to paediatrics Prognosis the overall risk of further febrile convulsion = 1 in 3. However, this varies widely depending on risk factors for further seizure. These include: age of onset < 18 months, fever < 39ºC, shorter duration of fever before seizure and a family history of febrile convulsions If there are recurrences, try teaching parents how to use rectal diazepam or buccal midazolam. Parents should be advised to phone for an ambulance if the seizure lasts > 5 minutes regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring

Answer 86

risk factors for developing epilepsy include a family history of epilepsy, having complex febrile seizures and a background of neurodevelopmental disorder children with no risk factors have 2.5% risk of developing epilepsy if children have all 3 features the risk of developing epilepsy is much higher (e.g. 50%)

Answer 87

Background: One of the most common life threatening autosomal recessive conditions 1 in 2000 live births 1 in 25 people carry a copy of the faulty gene (carriers) All UK babies undergo screening programme Pathology: Mutations in the CF transmembrane conductance regulator (CFTR) gene on chromosome 7 Deranged transport of chloride and/or other ions, such as Na and bicarbonate Leads to an alteration in viscosity and tenacity of mucous produced at the epithelial surfaces and to increased salt content in sweat gland secretions The changes in the composition of airway surface liquid predispose the lung to chronic pulmonary infections and bronchiectasis. The lungs of babies born with CF are structurally normal at birth, frequent respiratory infections soon develop and are the presenting feature. The resultant inflammatory response damages the airway, leading to progressive bronchiectasis, airflow limitation and eventually respiratory failure. 20% develop ABPA (allergic bronchopulmonary aspergillosis). Mycobacterial colonisation affects up to 20% of children, making a rapid deterioration of condition. In the newborn, thick tenacious intestinal secretions cause small bowel obstruction (meconium ileus), an early manifestation of CF.

Answer 88

Aetiology: Mutations in the CF transmembrane conductance regulator (CFTR) gene on chromosome 7 Risk factors: Caucasian Family history

Answer 89

``` Meconium ileus [obstruction due to impaction of thick meconium] FTT (Failure to thrive) Rectal prolapse Fatty stool Cyanosis Finger clubbing Bilateral lung crackles ```

Answer 90

``` Respiratory: cough, wheeze, recurrent infections, bronchiectasis, pneumothorax, haemoptysis, respiratory failure, cor pulmonale - nasal polyps, sinusitis Bilateral lung crackles Fatty stool Cyanosis Finger clubbing ``` GI: Pancreatic insufficiency (DM, Steatorrhoea), Malabsorption Intestinal obstruction (content impaction), Gallstones, Cirrhosis, GORD, … Other Male Infertility Osteoporosis, Arthritis, Hypertrophic pulmonary osteoarthropathy (HPOA) Vasculitis

Answer 91

Usually based on sweat test and genetic assessment Sweat test - sweat Na and Cl >60mmol/L (1st line) Genetic blood DNA analysis screening and counselling Faecal elastase - exocrine pancreatic dysfunction Bloods - FBC, U+Es, LFT, clotting screen, vitamins A, D and E, glucose tolerance test annually from 12 years Sputum culture CXR - hyperinflation Abdominal USS - fatty liver, cirrhosis, chronic pancreatitis DEXA bone scan - osteoporosis Spirometry - obstructive lung disease

Answer 92

``` Holistic management (psychosocial + physical wellbeing): MDT: physician, GP, physiotherapist, specialist nurse, and dietician ``` Chest: Respiratory Physiotherapy (postural drainage, airway clearance techniques). Abx (Antibiotics) for acute infective exacerbations and prophylactically. Mucolytics, Bronchodilators Chronic Pseudomonas infection is an important predictor of survival. Annual CXR surveillance GI Pancreatic enzyme replacement, vitamin supplements (A, D, E, K) … ``` Other: Mx of CF-related DM Screening (DEXA scan) >> treatment of osteoporosis Advanced lung disease: Oxygen Diuretics (cor pulmonale) Non-invasive ventilation Lung or heart/lung transplantation ```

Answer 93

Complications: Pseudomona Lung damage associated with persistent infection with P. aeruginosa is a major cause of morbidity and mortality in patients with CF. Nebulized antipseudomonal antibiotic therapy, e.g. Tobramycin, improves lung function, slows the rate of respiratory decline and decreases the risk of infective exacerbations and hospitalisation in these patients. Regular sputum culture for Pseudomonas allows early detection and treatment. Prognosis: Today: Median survival is now ~ 41yrs in the UK. In future: A baby born today would expect to live longer. Post-lung-transplant survival = 5 years.