Paediatrics

Question 1

Diagnostic criteria for Kawasaki disease

Answer 1

Non remitting fever for at least 5 day and 4 or more of the following:
Bilaterally injected conjunctiva
Polymorphic rash, blanching
Edema and erythema of hands and feet
Adenopathy - usually cervical unilateral and more that 1.5cm in size
Mucus membrane involvement such as injected tonsils and strawberry tongue and fissured lips (fissured lips help differentiate between other diseases such as scarlet fever and measles which do not have this feature)
CREAM
Atypical Kawasaki is fever with 2-3 of these symptoms

Question 2

Management of Kawasaki disease

Answer 2

IV immunoglobulins 2g/kg as a single dose. Occasionally a second dose is indicated
High dose aspirin 7.5mg/kg qds and then low dose aspirin, potentially for life
Baseline echo as soon as diagnosis made and then follow up echo and 2 and 6 weeks (check f/u echo may also be 4 weeks)
May also require steroids
Infliximab can be used if iv immunoglobulins are contraindicated
May need coagulation

Question 3

Investigations for Kawasaki disease

Answer 3

CBC - high white cells, low platelets or high platelets usually low initially and then elevate)
UEs - hyponatraemia. Some research suggests this can help determine severity.
LFTs - low albumin, elevated ALT
ECHO - to look for coronary aneurysms

Kawasaki is a clinical diagnosis. Bloods help to build a clinical picture but not specific to Kawasaki.

Question 4

What is Kawasaki disease

Answer 4

A vasculitis affecting small to medium arteries and has a tendency towards coronary arteries.
Eitiology is unknown but usually has a prior illness to trigger

Question 5

Patient presents with a murmur what other associated features would concern you?

Answer 5

Infants:
Poor feeding tolerance, failure to thrive, respiratory symptoms or cyanosis
Older children:
Chest pain, syncope, exercise intolerance, syncope, family history of sudden death

Question 6

Features of innocent murmurs in children

Answer 6

Usually systolic,
asymptomatic
No radiation
No associated thrill

Question 7

4 most common, innocent murmurs in children

Answer 7

1. Stills murmur (mid systolic mid left sterna border - Erbs point)
2. Pulmonary flow murmur (mid systolic upper left eternal border 2nd intercostal space)
3. Venous hum (diastolic heard over jugular venous area)
4. Supraclavicular systolic murmur

Question 8

Diagnostic criteria for rheumatic fever

Answer 8

Evidence of streptococcal infection plus 2 major criteria or 1 major and 2 minor criteria

Question 9

Major criteria for diagnosis of rheumatic fever

Answer 9

Carditis usually manifests as mitral regurgitation
Poly arthritis
Erythema merginatum 
Subcutaneous nodules
Chores

Question 10

Minor criteria for diagnosis of rheumatic fever

Answer 10

Arthralgia
Fever
High esr 
High crp 
Prolonged QR interval

Question 11

symptoms of shigellosis

Answer 11

watery stools with mucus and blood
pain
fever
dehydration
seizures (?febrile vs. complication of shigellosis

Question 12

symptoms of cryptosporidium

Answer 12

self limiting watery diarrhoea sometimes mucoid rarely blood or leukocytes

Question 13

symptoms of vibrio

Answer 13

abdominal pain or cramps
nausea
vomiting
fevers and chills 
stools watery up to 15+ a day sometimes bloody

Question 14

symptoms of rotavirus

Answer 14

watery non-bloody diarrhoea, vomiting

low grade fever and abdominal cramps

Question 15

symptoms of giardias

Answer 15

abdominal cramps
bloating
nausea
watery diarrhoea
NOT associated with fever

Question 16

Nikolsky’s sign

Answer 16

Stapyhlococcal scalded skin syndrome - intact blisters extend laterally with gentle pressure.

Question 17

what is SSSS

Answer 17

staphylococcus scalded skin syndrome - characterised by bull and epidermal sloughing as well as systemic features such as malaise, fevers and chills.

Question 18

steven-Johnson rash

Answer 18

begins as macule that develop into papule, vesicles, bullae and urticarial plaques or confluent erythema.

Question 19

risk factors for development of VSD

Answer 19

maternal diabetes, phenylketonuria and alcohol during pregnancy.
genetic risk factors

Question 20

what is hyperbilirubinaemia

Answer 20

> 170umol/L

Question 21

When is hyperbilirubinaema pathologic?

Answer 21

when it presents in the first 24 hours of life and is higher than 291 umol/L or rises by more than 85umol/L/day or signs and symptoms present suggesting disease.

Question 22

when should phototherapy by initiated for hyperbilirubinaemia?

Answer 22

bili level >256umol/L 29-48 hours old
308umol/L 49-72 hours
342umol? infants older than 72 hours

Question 23

second line treatment for hyperbilirubinaemia

Answer 23

exchange transfusion

Question 24

prevalence of congenital heart disease

Answer 24

1%

Question 25

why does VSD usually require early surgical closure compared with ASD

Answer 25

higher pressure gradient between the ventricles
pulmonary vascular resistance
pulmonary hypertensions
Eisenmenger’s syndrome are all more likely to occur in VSD

Question 26

What is Eisenmenger’s syndrome

Answer 26

R to L shunt

symptoms include: cyanosis, Pulmonary hypertension, and erythrocytosis.

Question 27

Risk factors for cerebral palsy

Answer 27

10% intrapartum asphyxia
10% post natal insult
associated with low birth weight

Question 28

Spastic cerebral palsy

characteristics and area of brain involvement

Answer 28

Truncal hypotonia in first yr
Increased tone, increased reflexes, clonus
monoplegia, hemiplegia, diplegia, or quadriplegia

UMN of pyramidal tract
Diplegia associated with periventricular
leukomalacia in premature babies
Quadriplegia associated with HIE
(asphyxia), higher incidence of intellectual
disability

Question 29

Athetoid/ dyskinetic cerebral palsy characteristics and area of brain involved

Answer 29

Athetosis (involuntary writhing movements)
± chorea (involuntary jerky movements)
Can involve face, tongue (results in dysarthria)

Basal ganglia (may be associated with
kernicterus)

Question 30

Ataxic cerebral palsy characteristics and area of brain involved

Answer 30

Poor coordination, poor balance (wide based gait)
Can have intention tremor

Cerebellum

Question 31

mixed cerebral palsy characteristics

Answer 31

multiple motor patterns and accounts for 10-15% of cases

Question 32

febrile seizure

Answer 32

a convulsion in the presence of a temperature over 38 with the absence of inter cranial pathology or electrolyte imbalance which usually settle by the age of 6.
commonly caused by URTI and viruses
most common neurological condition in children

Question 33

chance of having a second febrile seizure

Answer 33

30-50%

Question 34

simple febrile seizure

Answer 34

generalised seizures lasting less than 15 minutes and do not recur within 24 hours

Question 35

Complex febrile seizures

Answer 35

focal
over 15 minutes
multiple within 24 hours

Question 36

criteria for febrile seizure

Answer 36

• convulsion associated with fever over 38
• older than 6 months, younger than 6 years
• absence of CNS infection or inflammation
• absence of acute systemic metabolic abnormality
• no history of afebrile seizures

Question 37

managing a febrile seizure

Answer 37

appropriate to put child into prone position
A- E monitoring circulation and respiration
if longer than 5 minutes - should be treated (IV Lorazepam)

Question 38

risk of developing epilepsy after febrile seizure

Answer 38

9% if there are other risk factors

2% if typical febrile seizures compared to 1% of general population