Paediatrics

Question 1

What questions should be asked about the presenting illness?

Answer 1

When and how did it start?
Was he/she well before?
How did it develop?
What aggravates or alleviates it?
Has there been contact with infections?
Has the child been overseas recently?
Have the carers sought medical attention before now?
Which treatments have been tried?
Especially in infants, wet and dirty nappies, alertness and weight gain

Question 2

What questions should be asked around PMH?

Answer 2

In utero: Any problems (abnormal bleeding, infections, Rh disease), medications, alcohol, drug use, US normal?
At birth: Gestation, mode of delivery, birth weight, resuscitation required, birth injury, malformations
As a neonate: Jaundice, fits, fevers, bleeding, special care baby unit? - How long? Later illnesses, operations, accidents, screening tests, drugs, allergies, immunisations, travel. Check red book.

Question 3

What are the 6 week developmental milestones?

Answer 3

smiles

follows eyes past midline

Question 4

What are the 4-6 month milestones?

Answer 4

sits with support
rolls
reaches out for objects
starts babbling

Question 5

What are the 6-9 month milestones?

Answer 5

crawls
sits without support
pulls to stand
gives toy on request
turns head to name
responds to 'bye bye'
gestures with babbling
first tooth

Question 6

What are the 7-12 month milestones?

Answer 6

develops pincer grasp
plays ‘peek-a-boo’
walks with a hand held
waves goodbye

Question 7

What are the 12-15 month milestones?

Answer 7

single words
listens to stories
drinks from cup

Question 8

What are the 18 month milestones?

Answer 8

speaks 6 words
able to walk up steps
names pictures
walks independently
scribbles
builds with blocks

Question 9

What are the 1.5-2 year milestones?

Answer 9

kicks/throws a ball
runs
2 word sentences
follows a 2 step command
stacks 5-6 blocks
turns pages
uses a spoon
helps with dressing

Question 10

What are the steps in the physical examination?

Answer 10

General health
Vital signs
Respiratory system
Cardiovascular system
GI system
GU system
MSK system
ENT
Anything else parents would like to be checked?
Height, weight and head circumference

Question 11

What information can be gained in physical examination surrounding general health?

Answer 11

Is the child well or ill? Alert, lethargic, or uncomfortable / in pain? Playing is a good sign. If crying, is it high pitched or normal? Behaving normally and interacting with the parents? Any jaundice, cyanosis, rashes, anaemia, or dehydration? Neck stiffness is a rare sign in infants

Question 12

What do you look for during the respiratory examination?

Answer 12

Is the shape of the chest normal?
Any intercostal, subcostal or sternal recession, or nasal flaring?
Use of accessory muscles?
Is there grunting or any other audible noise breathing in (stridor) or breathing out (wheeze)?
Percuss the chest for dullness
Auscultate the chest, listening for breath sounds, fine crackles, rhonchi, wheeze and pleural rub

Question 13

What do you look for during the CV examination?

Answer 13

Check for peripheral and central cyanosis
Look for clubbing and peripheral oedema
Compare strength of femoral and right brachial pulse
Is the apex beat displaced?
Auscultate the heart with the child sitting and lying down
Listen over the apex, 2nd intercostal space left of stermum (pulmonary valve), and right of sternum (aortic valve), 4th intercostal space over the sternum (tricuspic)

Question 14

What is fixed splitting of the second heart sound indicative of?

Answer 14

Atrial septal defect

Question 15

What is a galloping rhythm suggestive of?

Answer 15

Congestive cardiac failure

Question 16

What do you look for during the GI examination?

Answer 16

Child should be supine and relaxed, with knees bent
Look for distension, visible peristalsis, and hernias
Listen for bowel sounds and percuss for hepatosplenomegaly and ascites
Palpate looking for tenderness and masses (during inspiration and deep expiration)
If relevant look for anal patency, fissures and prolapse

Question 17

What do you look for during the GU examination?

Answer 17

If relevant, examine external genitalia for evidence of ambiguity, congenital abnormality and size
Examine once only using a chaperone

Question 18

What do you look for during MSK examination?

Answer 18

Watch the child walk and play
Examine all limbs and digits for congenital anomaly
Symmetrical skin creases on both thighs?
If <6 months check for congenital hip dislocation
Inspect the spine for dimples, hair tufts, masses or cysts at the base
Is there any abnormal curvature or posture?

Question 19

What do you look for during ENT examination?

Answer 19

(best left until the end)
Evidence of otitis externa?
Post-auricular rash is a sign of measles, rubella and eczema
Look at the tympanic membrane - noting colour and lucency - is it perforated?
Use a spatula to check the tonsils, as well as inspecting the teeth and oral mucosa (plaques, white patches, spots, ulcers)
Can the child breathe through both nostrils
Is there a runny nose?
Check for neck lumps and lymphadenopathy

Question 20

What is makes up ‘red’ on the traffic light system?

Answer 20

Pale, mottled, ashen blue. Doesn’t stay awake when roused. Reduced consciousness (not engaging, apathy, coma), reduced skin turgor. Any GRUNTING signs?

Question 21

What are GRUNTING signs?

Answer 21

Grunting; weak or continuous high pitched cry; tachypnoea
Rib recession; Retraction of sternomastoid, nasal flaring, wheeze, stridor
Unequal or Unresponsive pupils; focal CNS signs, fits, marked hypotonia
Not using limbs / lying still; odd or rigid posture decorticate (flexed arms, extended legs); or decerebrate (arms and legs extended)
Temperature > or = 38 if < 6 months or >/=39 especially if cold or shutdown peripheries
I have a bad feeling about this baby
Neck rigidity, non-blanching rash, meningism, bulging fontanelle, etc.
Green bile in vomit (may = bowel obstruction, e.g. atresia, volvulus, intussusception)

Question 22

What are common symptoms in infancy?

Answer 22

Crying
Colic
Cows' milk protein allergy
Nappy rash/diaper dermatitis
Sleep problems

Question 23

What is the definition of colic?

Answer 23

Paroxysmal crying with pulling up of the legs, for >3h on >/= 3days/week. There is an association with feeding difficulties.

Question 24

What advice would you give to parents with a baby with colic?

Answer 24

Movement (carry-cot on wheels) is often tried and may help
Let the baby finish the first breast first (hindmilk is easier to digest)
If breastfeeding, a low allergen diet may help, as may probiotics
Reassure strongly, reduce stress, grandparent involvement

Question 25

How might Cows' milk protein allergy present?

Answer 25

Separate entity to colic - IgE or non-IgE mediated. | It causes colic symptoms, but also GORD, blood/mucus in the stools, and may result in faltering growth

Question 26

What are the four types of nappy rash?

Answer 26

1. Common 'ammonia dermatitis'. Red desquamating rash, sparing skin folds. 2. Candida / thrush. Satellite spots beyond the main rash 3. Seborrhoeic dermatitis. Diffuse, red, shiny rash extends into skin folds (occiput - cradle cap) 4. Isolated, psoriasis-like scaly plaques

Question 27

What are the differential diagnoses for vomiting?

Answer 27

``` Posseting Vomiting between feeds (ask about carpets) GORD, Gastritis Over-feeding Pyloric stenosis (projectile, at ~8 weeks old) Any infection e.g. UTI Adverse food reaction Infective gastroenteritis ``` ``` Rarer causes: Pharyngeal pouch Poisoning Raised ICP Metabolic conditions i.e. DKA Almost all other conditions Bilious (green) vomiting: get urgent help ```

Question 28

What are the differentials for an ill and feverish child?

Answer 28

Self-limiting viral infection Pneumonia UTI Meningitis

Question 29

What are some problems facing babies on NICU?

Answer 29

``` Hypothermia Hypoxia Hypoglycaemia Respiratory distress syndrome Infection IVH (25% of = 1500g birthweight - delayed cord clamping may reduce risk) Apnoea Necrotizing enterocolitis Retinopathy of prematurity (screen) ```

Question 30

Describe what happens with the first breath, and what can go wrong

Answer 30

Pulmonary vascular resistance falls, and there is a rush of blood to the lungs. Partly mediated by endogenous NO. Initiates changes from fetal to adult circulation. Process may be interrupted in various conditions e.g. meconium aspiration, pneumonia, respiratory distress syndrome, diaphragmatic hernia, group B strep infection, pulmonary hyperplasia. Pulmonary hypertension results as a consequences of these adverse events may also be primary (hypertrophy of muscular layer of pulmonary arteries.

Question 31

What are some types of non-invasive ventilation for neonates?

Answer 31

CPAP (continuous positive airways pressure) NIPPV (nasal intermittent positive pressure ventilation) HFNC (high-flow nasal cannula)

Question 32

What are some types of invasive ventilation for neonates?

Answer 32

TCPL (time cycled pressure limited ventilation) PTV (patient-triggered ventilation) HFV (high-frequency ventilation)

Question 33

What might be the presentation of neonatal sepsis?

Answer 33

Signs may be non-specific and subtle. Labile temperature, lethargy, poor feeding, respiratory distress, collapse, DIC.

Question 34

How would you manage suspected neonatal sepsis?

Answer 34

ABC Supportive (ventilation, volume expansion, inotropes) Bloods for FBC, CRP, glucose Blood cultures (results take 48h) CXR Lumbar puncture for culture, glucose, protein count, WCC and Gram stain Failure to responsd within 24h investigate further with stool sample for virology, throat swab, serology for herpes virus, urine CMV culture, VDRL (syphyllis)

Question 35

What antibiotics would you give in early-onset neonatal infection?

Answer 35

Broad spectrum i.e. benzylpenicillin + gentamicin until culture results are available. Stop if well and cultures negative. Continue treatment for 7 days if +ve cultures. In meningitis suspected then give cefotaxime

Question 36

What antibiotics would you give in late-onset neonatal infection?

Answer 36

Broad spectrum e.g. flucloxacillin + gentamicin until cultures available Cefotaxime if meningitis is likely Coagulase -ve Staph is more likely in a preterm infant with CVP line - give vancomycin + discuss removal of line

Question 37

What are the risk factors for early onset neonatal sepsis

Answer 37

Prolonged rupture of membranes >18h Maternal infection; maternal pyrexia, chorioamnionitis, UTI Mother carrier of Group B strep (GBS) from vagina or urine, or previous infant affected by it Preterm labour Fetal distress Breaks in neonatal skin or mucosa (caused by organisms acquired from the mother)

Question 38

What are the risk factors for late-onset neonatal sepsis?

Answer 38

Central lines and catheters Congenital malformations e.g. spina bifida Severe illness Malnutrition Immunodeficiency (tends to be caused by environmental organisms)

Question 39

How common are neonatal seizures?

Answer 39

~4/1000 births - most occur 12-48h after birth. May be generalised or focal, tonic, clonic or myoclonic

Question 40

What are the causes for neonatal seizures?

Answer 40

Hypoxic-ischaemic encephalopathy (due to antenatal or intrapartum hypoxia/ respiratory distress) Infection (meningitis/encephalitis) Intracranial haemorrhage / infarction Structural CNS lesions (focal cortical dysplasia/tuberous sclerosis) Metabolic disturbance (hypoglycaemia, hypocalcaemia, hypo/hypernatraemia, hypomagnesium) Metabolic disorders (urea cycle disorders / amino acid metabolism) Neonatal withdrawal from maternal drugs or substance abuse Kernicterus (hyperbilirubinaemia) Idiopathic seizures e.g. benign 5th day fits

Question 41

How would you treat a neonatal seizure?

Answer 41

ABC - Help Rule out and treat reversible causes i.e. hypoglycaemia Start empirical antibiotics IV access and take blood for FBC, U+E, LFTs, calcium, magnesium, glucose and blood gas If available, start CFAM Consider cranial US and MRI Specialist tests include toxicology screening, serum ammonia, urine organic acids, serum amino acids, karyotype and TORCH screen. Treat cause

Question 42

What is hypoxic-ischaemic encephalopathy (HIE)?

Answer 42

A clinical syndrome of brain injury secondary to a hypoxic-ischaemic insult

Question 43

What are the causes of HIE?

Answer 43

Antenatal, intrapartum up postpartum causes e.g. cord prolapse, placental abruption, maternal hypoxia (any cause) or inadequate postnatal cardiopulmonary circulation.

Question 44

What are the causes of shock in a neonate?

Answer 44

``` Blood loss (placental haemorrhage, twin-twin transfusion, IVH, lung haemorrhage) Capillary plasma leaks (sepsis, hypoxia, acidosis, necrotizing enterocolitis) Fluid loss (D&V, inappropriate diuresis) Cardiac causes (hypoxia, left to right shunts, valve disease, coarctation) ```

Question 45

What should you ask before examining a neonate if not taking a history?

Answer 45

Birthweight normal? Birth and pregnancy normal? Mother Rh-ve? Enlist mothers help, explain aims and listen if mother talks

Question 46

What do you look for when examining the head of a neonate?

Answer 46

Circumference Shape (odd shapes from a difficult labour quickly resolve) Fontanelles (tense or sunken) Eyes - red reflex, corneal opacities, conjunctivitis Ears - shape, position, low set? tip of the nose in white babies when pressed will be jaundiced. Shut the mouth to test breathing through the nose (choanal atresia). Oto-acoustic screening done? Complexion - cyanosed, pale, jaundiced, or ruddy (polycythaemia)? Mouth - Look inside, insert a finger: palate intact? suck good? does baby's face look normal?

Question 47

What do you look for when examining the arms and hands of a neonate?

Answer 47

Single palmar creases? (normal or trisomy 21) Does baby look like the parents? Waiter's tip sign of Erb's palsy of C5 and 6 trunks Number of fingers Clinodactyly (5th finger curved towards ring finger (normal or trisomy 21)

Question 48

What do you look for when examining the thorax of a neonate?

Answer 48

``` Watch respirations Not grunting, recessions Palpate the precordium and apex beat Listen to the heart and lungs Inspect the vertebral column for neural tube defects ```

Question 49

What do you look for when examining the abdomen of a neonate?

Answer 49

Expect to feel the liver. Any other masses? Inspect the umbilicus, is it healthy? Assess skin turgor Inspect genitalia and anus, are the orifices patent? Ensure in the first 24hr baby passes urine (if not consider posterior urethral valves in boys) and stool (if not consider Hirschprung's, CF, Hypothyroidism) Is the urinary meatus misplaced, are both testes descended? Neonatal clitoris looks large, if very large consider CAH Bleeding PV may be a normal variant following maternal oestrogen withdrawal

Question 50

What do you look for when examining the legs of a neonate?

Answer 50

Test for development dysplasia of the hip Avoid repeated tests as it hurts, and may induce dislocation Feel femoral pulses to 'rule out' coarctation Note talipes Toes - too many, too few, too blue?

Question 51

What do you look for when examining the buttocks/sacrum of a neonate?

Answer 51

Is there an anus? Are there 'mongolian spots'? Tufts of hair +/- dimples suggest bifida occulta - if you can't see the bottom of a dimple, arrange US Any pilonidal sinus?

Question 52

What do you look for when assessing the CNS of a neonate?

Answer 52

Assess posture and handle the baby Intuition can be most helpful in deciding if the baby is ill or well Is he jittery (hypoxia, ischaemia, encephalopathy, hypoglycaemia, infection, hypocalcaemia)? There should be some control of the head Do limbs move normally? Is the tone floppy, or spastic? Are responses absent on one side (hemiplegia)? Moro reflex Stroke palm to elicit grasp reflex Is the baby post-mature, small for dates, or premature?

Question 53

What are the signs of pneumonia?

Answer 53

Raised temperature Malaise Poor feeding Respiratory distress: tachypnoea, cyanosis, grunting, intercostal recession, use of accessory muscles (older children may have typical lobar signs - pleural pain, crackles, bronchial breathing)

Question 54

When should you admit for pneumonia?

Answer 54

If SpO2 is <92%; signs of respiratory distress

Question 55

What tests should you order when suspecting pneumonia?

Answer 55

CXR Bloods: FBC/ blood and sputum cultures if severe Not required in community acquired pneumonia if a child is going home

Question 56

How would you treat pneumonia?

Answer 56

Amoxicillin is 1st line | Alternatives: co-amoxiclav, axithromycin, clarithromycin

Question 57

Which bacteria typically cause pneumonia?

Answer 57

Pneumococcus, Mycoplasma, Haemophilus, Staphlycoccus, (Tb, Viral)

Question 58

What are the signs of croup?

Answer 58

Stridor, Barking cough, Hoarseness from obstruction in the region of the larynx

Question 59

What is the typical epidemiology of croup?

Answer 59

<6yrs but can be recurrent in older, atopic children | Autumn

Question 60

What are the causes of croup?

Answer 60

Parainfluenza virus (1, 2, 3) Respiratory syncitial virus Measles (rare)

Question 61

What is the pathology of croup?

Answer 61

Subglottic oedema, inflammation and exudate

Question 62

What is mild croup?

Answer 62

Minimal recession / stridor, no cyanosis, alert child, good air entry Can be sent home if settles w/ Tx

Question 63

How would you treat mild croup?

Answer 63

Dexamethasone (0.15mg/kg PO) or prednisolone 1-2mg/kg

Question 64

If there is a poor response to treatment in a child with croup, what should you do?

Answer 64

Adrenaline via nebuliser 1:1000 (400mcg/kg up to 5ml) | If poor response again, repeat and take to ITU

Question 65

If there is failure to improve with steroids/nebulised adrenaline in croup what should you consider?

Answer 65

Bacterial tracheitis

Question 66

How would you manage epiglottitis?

Answer 66

Avoid approaching child, don't examine throat, don't cannulate. Senior help. Inhalation induction and EUA if necessary Cause may be Haemophilus influenzae type B (Hib) - treat with cefotaxime, 25-50mg/kg/8h IV

Question 67

What is the differential for stridor in babies?

Answer 67

``` Viral croup Bacterial tracheitis Epiglottitis Inhaled foreign body Laryngomalacia ```

Question 68

Define asthma

Answer 68

Reversible airway obstruction (peak flows vary by >20%) +/- wheeze, dyspnoea or cough (10% of the population is affected)

Question 69

What risk factors exist for asthma?

Answer 69

``` Low birthweight FHx Bottle fed Atopy Male Pollution Past lung disease ```

Question 70

What gene causes susceptibility to asthma?

Answer 70

ADAM33

Question 71

What are some triggers for asthma?

Answer 71

``` Pollen House dust mite Feathers Fur Exercise Viruses Chemicals Smoke Traffic ```

Question 72

What is the differential diagnosis of asthma?

Answer 72

``` Foreign body Pertussis Croup Pneumonia / TB (do CXR) Hyperventilation Aspiration CF (wet cough, starting at birth, failure to thrive) ```

Question 73

How should you treat asthma exacerbations?

Answer 73

Treat early - rescue prednisolone 30-40mg/day if >5yrs or 20mg/day if 2-5 years for 5 days

Question 74

What should be the general management of a child with asthma?

Answer 74

Annual review of symptoms, exacerbations, oral steroid use, and time off school or nursery, check inhaler technique and medication adherence, make a personalised self-management action plan, advice regarding tobacco smoke exposure, record height and weight on centile charts

Question 75

What is the first line drug therapy for asthma?

Answer 75

Occasional Beta-agonist via pMDI e.g. salbutamol 100mcg - use spacer

Question 76

What is the second step in drug therapy for asthma?

Answer 76

Add inhaled steroid e.g. beclometasone - 50mcg use up to 200mcg / 12hr (i.e. 4 times in 12 hrs)

Question 77

When should you add the second step of treatment to a patient with asthma?

Answer 77

If beta-agonist is needed >3 times per week (also if >5yrs and many exacerbations, or asthma wakes from sleep >once per week)

Question 78

If first two steps of asthma treatment are not working, what should you do next?

Answer 78

Review diagnosis. Check inhaler use/concordance. Eliminate triggers. Monitor height. If <5yrs: Add 1 evening dose of Montelukast 4mg If >5yrs: Consider respiratory review. Can try salmeterol (LABA). If symptomatic then increased inhaled steroid and try motelukast 5my or theophylline

Question 79

How should you treat severe asthma acutely?

Answer 79

Sit up - high flow 100% oxygen Salbutamol: 5mg O2 nebulised in 4ml saline with ipratropium bromide 0.25mg Hydrocortisone or prednisolone Consider one IV dose of magnesium sulphate 40mg/kg over 20 mins Aminophylline 5mg/kg IV over 20 mins

Question 80

What is classed as a near fatal / life threatening acute asthma exacerbation?

Answer 80

``` Respiratory acidosis and/or requiring mechanical ventilation with increased ventilation pressures Any one of the following: PEFR <33% predicted Sats < 92% Silent chest Cyanosis Feeble respiratory effort Bradycardia, dysrhythmia, hypotension Exhaustion, confusion, coma ```

Question 81

What is classed as an acute severe asthma exacerbation?

Answer 81

``` Any one of: PEFR 33-50% predicted RR: 2-5yrs > 40/min ; 5-12 yrs >30/min ; >12yrs >25/min Pulse: >140bpm, >125, >110 Inability to complete sentences Use of accessory muscles ```

Question 82

What is classed as a moderate asthma exacerbation?

Answer 82

Increasing symptoms PEFR 50-70% best or predicted No features of severe asthma

Question 83

What is classed as brittle asthma?

Answer 83

Type 1: wide variability in PEFR despite intensive therapy | Type 2: sudden severe attacks despite apparently well controlled asthma

Question 84

What is the commonest lung infection in infants?

Answer 84

Acute bronchiolitis

Question 85

What are the features of acute bronchiolitis?

Answer 85

``` Coryza preceds cough Fever (sometimes) Tachypnoea Wheeze Inspiratory crackles Apnoea Intercostal recession +/- cyanosis +/- fever ```

Question 86

What are the causes of acute bronchiolitis?

Answer 86

Typically - Respiratory syncytial virus (RSV) | Others - Mycoplasma, parainfluenza, adenoviruses.

Question 87

Who is most at risk in acute bronchiolitis?

Answer 87

<6 months old | underlying conditions

Question 88

What signs in acute bronchiolitis should prompt admission?

Answer 88

Inadequate feeding Respiratory distress Hypoxia

Question 89

If the acute bronchiolitis is severe, what should you do?

Answer 89

CXR to exclude pneumothorax or lobar collapse Blood gases/ SpO2 FBC

Question 90

How would you treat acute bronchiolitis?

Answer 90

Oxygen (stop when SpO2 >/=92%) Nasogastric feeds 5% of those need respiratory support (mostly CPAP) (mortality roughly 1%; 33% if symptomatic congenital heart disease)

Question 91

What can be given to immunocompromised children to try and prevent bronchiolitis?

Answer 91

Ribavirin

Question 92

What is viral-induced wheeze?

Answer 92

Cough and wheeze. Too young for diagnosis of asthma to be made confidently. These infants often end up being treated with escalating bronchodilator therapy with frequent courses of antibiotics against uncultured organisms. Non-atopic disorder. RSV more often than haemophilus. Spectrum.

Question 93

What is at the lower and upper end of viral induced wheeze severity?

Answer 93

Lower end is 'happy wheezers' i.e. undistressed | Upper end is CF in those with loose stools and failure to thrive

Question 94

What gene mutation causes CF?

Answer 94

Mutations of the transmembrane conductance regulator gene (CFTR) on chromosome 7, which codes for a cyclic AMP-regulated sodium/chloride channel.

Question 95

Broadly, what are the problems / pathology in CF?

Answer 95

Varying severity of exocrine gland function. Meconium ileus in neonates (and its equivalent in children), lung disease akin to bronchiectasis, pancreatic exocrine insufficiency, raised Na+ sweat level - in 85% of mutations.

Question 96

How do you diagnose CF?

Answer 96

All newborns are screened looking for an abnormally raised immunoreactive trypsinogen, and 29 CFTR mutations on the Guthrie card (85% coverage). 10% present with meconium ileus as neonates Later presentation is with: - Recurrent pneumonia - Failure to thrive - Slow growth - Fatty, oily, pale stools are reflective of steatorrhoea

Question 97

What is a positive finding in the sweat test for CF?

Answer 97

<40mmol/L is normal. >60mmol/L supports the diagnosis. Intermediate results are suggestive but not diagnostic.

Question 98

What can cause false positive results in the sweat test?

Answer 98

``` Up to 25% of normal newborns show a sweat sodium concentration >65mmol/L (rapidly declines on the 2nd day after birth) Atopic eczema Adrenal insufficiency Ectodermal dysplasia Some types of glycogen storage disease Hypothyroidism Dehydration Malnutrition ```

Question 99

What can cause false negative results in the sweat test?

Answer 99

Oedema | Poor technique when testing

Question 100

What is meconium ileus and how is it managed?

Answer 100

Presents with failure to pass stool or vomiting in the first 2 days of life. Distended loops of of bowel are seen through the abdominal wall. A plug of meconium may show in one of the loops. NG tube drainage / washout enemas / excision of gut containing meconium

Question 101

How should you manage respiratory problems in CF?

Answer 101

Physiotherapy 3x per day Educate parents - teach percussion and postural drainage Older children learn forced expiration techniques

Question 102

What respiratory infections can occur in CF?

Answer 102

``` Staph aureus H. influenzae (rarer) Strep pneumoniae (younger children) Aspergillosis (in adolescents) Eventually >90% are chronically infection with pseudomonas aeruginosa ```

Question 103

What GI problems do CF patients experience?

Answer 103

Energy needs rise by ~130% due to malabsorption and chronic lung inflammation Most need enzymes for pancreatic insufficiency Omeprazole helps absorption by increasing duodenal pH Vitamins needed Diet should be high protein / high calorie

Question 104

What is the prognosis for CF patients?

Answer 104

Death from pneumonia or cor pulmonale. Most survive to adulthood. Median survival is >31 years, and possibly >50 for those born after 2000

Question 105

How does acute otitis media present?

Answer 105

Rapid onset pain Fever +/- irritability Vomiting (often after a viral URTI)

Question 106

What are some common organisms that cause otitis media?

Answer 106

Pneumoccocus Haemophilus Moraxella Other streps and staphs

Question 107

What causes pain in acute otitis media?

Answer 107

Bulging tympanic membrane which is relieved if it perforates

Question 108

How should you treat acute otitis media?

Answer 108

Analgesia Resolves in >60% within 24hours without antibiotics Consider immediate antibiotics if systemically unwell, immunocompromised or no improvement in >4 days Amoxicillin for 5 days if required

Question 109

What are some complications of otitis media?

Answer 109

Mastoiditis | Petrositis, labrynthitis, meningitis, abscess etc (rare)