Paediatrics

Question 1

What are some differential diagnoses for Purpura in a child? What are some relevant questions you should ask?

Answer 1

Main DDx:

• HSP - henoch Scholein Pupura
• Viral Exanthem
• Streptococcal sepsis

Rule out:

• meningitis - non-blanching, neck stiffness, photophobia
• Kawasaki’s - strawberry tongue, conjunctivitis, lyphadenopathy
• anaphylaxis - angioedema, diffuse rash, shock
• viral exanthems (roseola, coxsackie, parvovirus, HSV, molluscum)
• ITP - blurred vision (low platelet count), blood in urine/stools

Ask:

• VACCINATION Hx

Question 2

What questions can you ask in a heads check? Give 2 for each category?

Answer 2

Home:

• who lives with you at home?
• is there someone you can chat to if you are stressed?

Education/Employment:

• whats school like?
• is school a safe place?
• what are your future study/employment plans?

Eating:

• does your body shape stress you?
• have you ever tried going on a diet or altering the way you eat?

Activities:

• what do you do for fun?
• how many hours of screen time do you get?

Drugs?

• any of your friends or family use tobacco? alcohol?
• have you ever used some? (CAGE)

Sexuality?

• attracted to anyone? interested in boys/girls?
• what does the term ‘safer sex’ mean to you?

Suicide?

• do you feel stressed or down more than usual?
• thought about hurting yourself?

Safety?

• ever seriously injured?
• drunk driving?
• met anyone online?

Question 3

Talk through the steps to a surgical abdominal examination in a child, what are you looking for?

Answer 3

• HELP
  
  • HI - introduce, consent, explain, wash hands
  • E - exopsure
  • L - lighting
  • P - positioning
• general inspection
• close inspection - point to where the pain is worst, cough/flex neck.
• ausculatation
• percussion (‘do you play the drums?’
• light palpation/deep palpation (feet towards bottom to relax muscles, talk while palpating
  
  • McBurney’s point,
  • Rosvings,
  • Psoas (raise right leg against pressure or roll onto left and extend)
  • Obturator sign (flex then internally rotate at hip)
• liver and spleen (palpation, percussion) and kidneys
• shifting dullness if distended
• lymph nodes
• vitals and hydration (pulse, RR, temp, sunken eyes, fontanelles, conjunctival pallor)
• DRE - inguinoscrotal exam and resp. (pneumonia/mesenteric adenitis)

Question 4

What are some differentials for a febrile convulsion?

Answer 4

• FC
  
  • 6mths- 6 years - temp more susceptible to fit
  • tonic clonic, last several minutes - time it. call ambulance if >5mins, child >1hr to recover, focal symptoms. See GP <5mins.
  • no increased risk of developing epilepsy
  • treat with panadol - doesn’t fix the FC though
• breath holding spells
  
  • can happen after minor accident, fright, frustrated, or upset
  • turn red then blue (can go pale) - may have a fit or twitch.
  • 1-2 year old toddlers, grow out of it by 6.
  • not harmful, Mg similar to FC.
  • do not punish them for it or make a big fuss.
  • see doctor if you’re having frequent attacks
• reflex anoxic seizure (vaso-vagal)
• epilepsy
• precipitators - hypoglycemia, head trauma, meningitis
• mimics:
  
  • jerks in sleep
  • tantrum
  • parasomnia (sleepwalking)
  • psychogeni

Question 5

What things should you always do in an Asthma history?

Answer 5

• Type:
  
  • episodic (symptom free period)
    
    • frequenct - viral infection triggers, need pred
    • infrequent
  • persistent (has symptoms all the time) - preventer
    
    • nocturnal cough
• definition:
  
  • <1year = bronchiolitis
  • 1-2 years = viral induced wheeze
  • >2 = virus + wheeze responds to ventolin = asthma (>1 attack but with atopy, eczema = diagnosis)
    
    • no ventolin response = viral pneumonitis (give roxythromycin and pred)
  • >4 do spirometry
• Action plan
  
  • reliever medications (ventolin/bricanyl (if teenagers don’t want big one)
  • pred for acute exacerbations if needed (frequent episodic)
  • instructions for sport
  • factsheet, read up on it
• Instructions on how to give:
  
  • mask
  • no mask 5+
  • wash 1x a week if regular, soapy dish water no rinse
• Prevention:
  
  • fluvax
  • smoking
  • triggers
• hospital care - 6 every 20minutes (3 rounds in an hour), 12 for >6years.

Question 6

What is the initial management and investigations for asthma?

Answer 6

• OSHIT MAN (acute)
  
  • oxygen
  • salbutamol
  • hydrocortisone (predisolone)
  • ipratropium
  • theophylline (aminophylline)
  • magnesium sulphate
• 6 puffs if <6 years 12 puffs if >6years
• mild 1 after 20mins, pred no response,
• moderate (O2 <92%), burst 1 dose every 20mins for 1 hour (review), prednisolone for 1-2 days.
• severe - as above but ipratropium, MgSO4, aminophylline, IV salbutamol, intubate
• discharge on regular pred, SABA and follow-up.

Question 7

What is relevant to a paediatric cardiovascular examination?

Answer 7

• HELP
• ask for vitals and growth chart (FTT)
• general inspection:
  
  • well/unwell
  • cyanosis - oedema, respiratory effort)
• hands (pallor, cap refill)
• pulse (radial, femoral, character) and delay (radio-radial, radiofemoral)
• eyes - pallor/jaundice, mouth (high arch/cyanosis)
• carotid pulse
• close inspection of the chest
• capillary refill
• heaves/thrills
• ausculatation - 4 areas and back + manoeuvres (inspiration/expiration, radiation to neck/axilla, lying on side, leaning forward)
  
  • Loud P2 = pulmonary HTN
  • fixed splitting = ASD
  • clicks after S1: apex = ASD or bicuspid aortic, LSE + PS
• auscultate lung bases, peripheral oedema, pedal pulses

Question 8

What are some innocent murmurs?

Answer 8

• Still’s murmur
  
  • short, mid systolic vibratory
  • mid-left sternal edge - soft when standing loud when supine
• pulmonary flow murmur
  
  • soft, blowing ejection murmur in pulmonary area radiating to the axilla
• carotid bruit
  
  • rough ejection systolic murmur at carotid
• venous hum - continous at sternoclavicular junction,

Question 9

What are some pathological murmur features?

Answer 9

• diastolic
• pansystolic
• late systolic
• harsh/high pitched, split S2
• symptomatic

Question 10

Talk through ASD, VSD and TOP.

Answer 10

• VSD
  
  • large - LHF, soft systolic murmur, apical diastolic
  • small - pnasystolic LSE, harsh/high pitched
• PDA
  
  • continous with no variation with posture
  • LHF if severe
• TOF
  
  • appears late in infancy, clubbing, harsh ESM (LSE or pulmonary), radiating to the back, hypoxic tet spells.

Question 11

A teenager is having seizures recently, having been diagnosed with epilepsy as a child. What should you include in history?

Answer 11

• consider types:
  
  • focal
    
    • simple (movements, tingling, numbness, hearing/smell)
    • complex (clumsy actions, automatisms (chewing/swallowing/picking)
  • generalised (tonic clonic, urinary, tongue)
  • provoked/unprovoked
• predisposing
  
  • stress (HEEADSSS
  • sleep deprivation
  • medication compliance
  • alcohol
  • illicit drugs
  • hypoglycemia
  • fever
• Counsel
  
  • triggers:
    
    • lights/sleep deprivation
  • driving/swimming/heavy machinery
  • seizure diary
  • prescription and aim of medication
  • inform school/childcare/clubs
  • call ambulance if >5mins, LOC afterwards, injury
  • any questions - pamphlet
• DIAMOCAP (Dx, Ix, Admissions, Mg, complications, prognosis)
• Other:
  
  • ketogenic diet
  • vagus nerve stimulation
  • epilepsy surgery

Question 12

Talk through the respiratory examination.

Answer 12

• HELP
• inspection
  
  • WOB - nasal flare, tracheal tug, head bobbing, abdo excursion, sub/inter-costal recession, suprasternal retraction, noises
• hands (cap refill, nails, palms)
• vitals
• eyes
• tracheal deviation
• close inspection of chest (symmetry, expansion)
• pecrussion, auscultation, fremitus
• lymph nodes

‘I would also like to do peak flow, O2 sats, an ENT, CVD and hepatomegaly exam’

Question 13

How can you rank asthma severity?

Answer 13

• mild - normal, no increase WOB, talks
• moderate - increased WOB, accessory muscles, tachycardia, limitation of speech
• severe - marked WOB, limitation of speech, distressed
• critical - drowsy, maximal, silent chest, unable to talk, exhaustion

Question 14

What questions would you ask for a child who has neonatal jaundice?

Answer 14

• types:
  
  • unconjugated
    
    • physiological - after 24 hours improves at 2 weeks
    • hemolytic (rhesus or G6PD deficiency)
    • non-hemolytic - cephalohematoma, hypothyroid
  • conjugated
    
    • intrahepatic (infection, genetic, drugs)
    • post-hepatic - Biliary atresia, GIT obstruction
• Confirm age, characterise jaundice (timecourse)
• kernicterus symptoms:
  
  • phase 1 - lethagy, poor feeding, hypotonia (reversible)
  • phase 2 - fever, hypertonia, back arching
  • phase 3 - athetosis (writhing movements - irreversible)
  • LT - upward gaze palsy, sensorineural deafness, CP
• Hx:
  
  • antenatal
    
    • isoimmunization
    • TORCH
    • TFT
    • polycythaemia (DM/TTTS)
  • perinatal
    
    • infections
    • PROM
    • Instrumental
    • delayed cord clamping
  • Post-natal
    
    • newborn screen
    • feeding
    • drugs
  • FHx
• DDx:
  
  • sepsis
  • post-hepatic (pale stool, dark urine)
• Tx:
  
  • 60% newborn babies within 1 week of life.
  • phototherapy - fluid, hydration, weight, electrolytes
  • Bhutani nomogram (phototherapy vs exchange transfusion)

Question 15

What are some differentials for a vomiting child? What features would each have?

Answer 15

• gastroenteritis:
  
  • diarrhoea, contacts, food, travel
• mesenteric adenitis
  
  • pain, abdo tender, fever, malaise, flu-like
• appendicitis
  
  • 10-12y.o. abdo pain >4 hours, diarrhoea, lies still
• intussusception
  
  • 3mth-3year old, red current jelly, lethargy, pallor, colic (legs drawn up)
• Malrotation with volvulus
  
  • bile stained vomit, feeding, late - PR bleed, distension, tenderness
• Pyloric stenosis
• Septicemia (UTI, pneumonia, meningitis)
• Testicular torsion

Question 16

Perform Immunization counselling in a child who is coming in for the 12 month vaccines but the mother has concerns.

Answer 16

• clarify what they know:
  
  • good idea:
    
    • stop illness
    • herd immunity
  • side effects:
    
    • redness
    • lump
    • tender (2-3 days)
    • fever
    • fainting
    • MMR - 1 rash 1 week post, varicella - vesicles, rotovirus - diarrhoea
  • pre-immunization Hx:
    
    • allergies (egg or vaccines (Flu, yellow, Q fever)
    • PHx - immunodeficiencies, vaso-vagal
    • contraindications: fever, pregnant, immunosuppressed, evolving neuro illness

Question 17

What are different rankings of dehydration that you can observe on exam?

Answer 17

• mild - no signs
• moderate - CRT >2secs , RR, frontanelles, tissue turgor
• Severe - CRT >3 seconds, mottled skin, shock (increase HR, lowered BP)

Question 18

What are some differentials for Colic? What would you ask about for each?

Answer 18

• common causes:
  
  • excessive tiredness (frowning, clenched hands, jerking arms, crying)
  • hunger (frequent feeds <3hourly), poor weight gain, inadequate supply
• DDx:
  
  • cow milk/soy protein allergy
    
    • comiting, blood, mucus in diarrhoea
    • poor weight gain
    • feeding problems
    • FHx of atopy (eczema/Wheezing)
  • GORD
    
    • frequent >4x/day
    • secondary to cow milk
  • lactose overload/malabsorption (rare)
    
    • frothy watery diarrhoea with perianal excoriation
    • mucosal injury secondary to allergy?
• acute crying
  
  • UTI/OM - Urine micro and culture
  • Raised ICP
  • eyes - fluoroscein stain (if history suggestive)
  • hair tourniquet
• Always ask about PND and Edinburgh postnatal depression scale.

Question 19

Counsel a mother whose baby has colic.

Answer 19

PURPLE (pain, unexpected, resist soothing, peak 6-8weeks, long lasting, evening)

• crying is normal - peaks at 6-8weeks
• 2-3hrs per 24 hours, usually worse at night
• may look in pain

No identifiable medical cause. But understandably its distressing.

• establish feeding pattern, settling, sleep.
• avoid excessive stimulation
• rocking/patting
• give yourself a break (help?)
• medication is not recommended.
• REFER

Question 20

What questions would you want to ask in a failure to thrive station?

Answer 20

• Questions:
  
  • breastfeeding
  • formula feeding
  • introduction of solids
  • volume over 24 hours
  • illness? complications OH
  • birth weight?
  • social supports

Differentials:

• Intake
  
  • malnutrition
  • technique
  • structural
  • vomiting
• Malabsorption
  
  • coeliacs
  • CF
  • food intolerance
• Metabolism
  
  • chronic disease
  • DM
  • hyperthyroidism
  • chronic infection
• Psychosocial
  
  • behaviour disorder
  • abuse/neglect
  • parental MH
  • coercive feeding
• Other
  
  • genetic disease
  • inborn errors of metabolism

Question 21

What is involved in a newborn examination?

Answer 21

• length, weight, head circumference
• general (posture/behaviour)
• CVD exam (S1/S2 murmur, pulses)
• Resp exam - WOB
• Head - frontanelles, sutures
• eyes - red reflex
• face - dysmorphic features, i.e. overfolded helix, slanted palpable fizzures, flattened nasal bridge, cleft palate
• abdomen - hepatosplenomegaly
• neurological examination - tone, movements, reflexes
• back - sacral pits, lipoma, hemangioma
• inguinoscrotal - 2 descended testis, presence of anus
• hips - ortolani/barlow’s

Question 22

What would you do for a hip examination. What is the management of DDH?

Answer 22

• general inspection, then do one side at a time
  
  • barlow - stabilise pelvix, flex hips and push posteriorly (subluxion/dislocation)
  • ortolani - flex/abduct the hip and push anteriorly (listen and feel for a clunk -reduction of the hip)
• RFs:
  
  • 4Fs - first born, female, FHx, breech
  • less space (oligohydramnios, multiple pregnancies, macrosomia, congenital)
• Galazetti test - 90 degree see if they are the same length.
• management:
  
  • prevention - avoid swaddling with straight legs
  • splint with pavlik harness for 1-2mths (<3mths)
  • >3mths need cast
  • walking = open reduction surg

Question 23

Counsel a parent who has had a child come in with anaphylaxis, what advice should you give them?

Answer 23

Allergy (mild-mod rxn):

• Rash, angioedema, swollen eyes, tingling, abdominal pain within minutes
• Action Plan:
  
  • Avoid trigger
  • Again - stay with person, give meds, contact family
  • Watch for anaphylaxis
  • Call ambulance, lay flat
• Anaphylaxis (severe):
  
  • Definition need CVD, Resp involvement:
    
    • SOB
    • Wheeze
    • Cough
    • Hoarse voice
    • Swollen tongue
    • Conscious state (hypotension)
    • Pale
  • Action plan:
    
    • Locate epipen (blue sky shake into thigh) - check its not expired. Hold for 10seconds and massage the site.
      
      • >20kg epipen,
      • <20kg epipen Jr, really young seek advice
    • Ambulance
    • Lay flat
    • Another epipen if no response