Paediatrics Flashcards
1
Q
What are the three broad causes of delayed puberty?
A
Constitutional delay
Hypogonadotrophic hypogonadism
Hypergonadogrophic hypogonadism
2
Q
Give some examples of causes of hypogonadotrphic hypogonadism.
A
Hypothalamo-pituitary disorders - panhypopituitarism, intracranial tumours, kallman syndrome.
Systemic disease - anorexia nervosa, crohn’s disease, cystic fibrosis
3
Q
Give some examples of hypergonadotrophic hypogonadism.
A
Chromosomal abnormalities - klinefelter syndrome (XXY), turner syndrome (X0)
Steroid hormone enzyme deficiencies
Gonadal trauma - direct trauma, post surgery, post chemotherapy, torted testicle.
4
Q
What are the top 5 areas of concern in sexual health?
A
Age <13 years old Power imbalance in relationship Evidence of coercion Substance misuse Whether the behaviour places them at risk
5
Q
What are the top 4 risk factors for STIs?
A
Avoidance of barrier contraception
Multiple partners
Mental illness
Substance misuse
6
Q
What are the top 5 risk factors for substance misuse?
A
Conduct disorder Poor parenting Early experience of substance abuse Peer group pressure Poor social environment
7
Q
What are the top 5 negative effects of chronic illness?
A
Constitutional delay in growth and puberty Negative self-image Low mood Poor school attainment Poor peer development
8
Q
What are the top 5 factor to optimise transition to adult services for a teenager?
A
Inform the adolescent and parents early
Run specific teenage clinics
Involve the GP - continuity throughout process
Encourage the young person to take control of their health - making appointments, ordering medication, administering medication
Support and educate parents who will often struggle to let their child with a chronic medical condition to take on these adult roles.
9
Q
What are the prenatal causes of developmental impairment?
A
Genetic syndromes (Down syndrome, fragile X, Williams, Angelmanns, Rett syndrome)
Metabolic e.g. PKU
Structural e.g. tuberous sclerosis
Acquired e.g. foetal alcohol syndrome, drug exposure, rubella, infarct.
Unknown e.g. dysmorphic/brain malformation e,g. microcephaly, agenesis
10
Q
What are the perinatal causes of developmental delay?
A
Intra-ventricular haemorrhage, hypoxic ischaemic encephalopthy
11
Q
What are the post natal causes of developmental delay?
A
Post cranial radiotherapy, acquired brain injury
12
Q
What is meant by global developmental delay?
A
Affecting 2 or more areas
13
Q
When should a child be referred due to gross motor delay?
A
Failure to walk by 18 months
14
Q
What are the possible causes of gross motor delay?
A
Cerebral palsy Duchenne muscular dystrophy Antenatal insult Part of developmental impairment (Bottom shufflers - normal variant)
15
Q
What is the management of a child with speech delay?
A
Speech and language therapy referral and hearing test.
16
Q
What are the causes of speech delay?
A
Familial Hearing impairment Poor social interaction/deprivation Autistic spectrum disorder Duchenne muscular dystrophy Part of developmental impairment e.g. Down syndrome
17
Q
Which three domains do children with autism have impairments in?
A
Social interaction
Social communication
Repetitive/ritualised behaviour
18
Q
Give examples of specific issues babies with Down’s syndrome face.
A
Feeding difficulties
Congenital heart disease
Duodenal atresia
19
Q
What is the management of children with cerebral palsy?
A
Speech and language therapy.
If problems with feeding - referral to a dietician, considered for gastrostomy.
Spacticity and dyskinesia require joint medical and physio management. Consider botulinum toxin injections for local spacticity.
20
Q
What are the causes of primary bed wetting, without daytime symptoms?
A
Lack of sleep arousal
Polyuria
Bladder - small capacity/overactive
21
Q
What are the causes of primary bed wetting with day time symptoms?
A
Overactive bladder Structural abnormalities Neurological disorders Chronic constipation Urinary tract infection
22
Q
What is meant by secondary bedwetting?
A
Previously dry at night for more than 6 months.
23
Q
What are the causes of secondary bed wetting?
A
Diabetes UTI Constipation Inadequate fluid intake Psychological problems Family problems
24
Q
What are possible reasons for delay in passing meconium?
A
Cystic fibrosis
Hirschprung’s
25
What is tested for in the Guthrie test?
```
Medium-chain acyl-coenzyme A dehydrogenase deficiency (MCAD)
Sickle cell disease
Phenylketonuria (PKU)
Congenital hypothyroidism
Cystic fibrosis
Maple syrup urine disease
Isovoleic acidaemia
Homocystinuria
Glutaic aciduria type 1
```
26
Which immunisations do babies get at 8 weeks old?
```
Diptheria
Tetanus
Pertussis
Polio
Haemophilus influenza type B
Pneumococcal conjugate
Rotavirus
```
27
Which immunisations do babies get at 3 months old?
Meningococcus C
28
Which immunisations do babies get at 13 months old?
MMR
29
Which immunisations do babies get at 2 years old?
Influenza (then annually)
30
Which immunisation do children get between 12 and 14 years old?
HPV
31
What is meant by neglect?
Persistent failure to meet child's basic physical or psychological needs resulting in serious impairment of health or development.
32
What are the psychological consequences of emotional abuse?
Low self esteem
Difficulties in relationships
Difficulties in giving and accepting affection
Often impulsive and aggressive
Can be frustrated, anxious and non-compliant
33
What is the most important cause of conjugated hyperbilirubinaemia in the neonate?
Biliary atresia
34
What are the causes of unconjugated hyperbilirubinaemia in the neonate?
```
Physiological
Breast milk jaundice
Haemolytic disease (rhesus, ABO or other antibodies)
Infection (UTI, sepsis)
Congenital hypothyroidism
```
35
How is prolonged jaundice defined?
Visible jaundice lasting more than 14 days in a term infant or 21 days in a preterm infant.
36
What is the most common cause of prolonged jaundice?
Breast feeding
37
What are the top 5 reasons for respiratory distress in a newborn?
Transient tachypnoea of the newborn (first 8 hours)
Respiratory distress syndrome (surfactant deficiency)
Meconium aspiration
Pneumothorax
Respiratory infection
38
What are the top 5 causes for cyanosis in a newborn?
Any cause of respiratory distress can cause cyanosis.
Persistent pulmonary hypertension of the newborn.
Congenital cyanotic heart disease.
Tracheo-oesophageal fistula
Diaphragmatic hernia.
39
What are the risk factors for neonatal sepsis?
```
Prolonged rupture of membranes.
Premature rupture of membranes.
Maternal infection (esp. group B strep)
```
40
How will gastrointestinal disorders present in the newborn?
Poor feeding
Vomiting
Delay in passage of meconium
Abdominal distension
41
What is the differential for bile stained vomit in a newborn?
Intestinal obstruction until proven otherwise.
42
What are the main causes for gastrointestinal disorders in a newborn?
```
Meconium plug/ileus
Duodenal atresia, or other small bowel atresia
Oesophageal atresia
Malrotation with volvulus
Hirschsprung disease
```
43
What causes neural tube defects?
Maternal folic acid deficiency, especially at 3 weeks post conception.
44
What is meant by anencephaly?
Large portion of scalp, skull and cerebral hemispheres do not develop. Usually detected antenatally, always fatal. Caused by defect in closure of neural tube.
45
What is meant by encephalocele?
Neural tube defect. Protrusion of brain and meninges through midline defect in skull. Usually associated with craniofacial abnormalities and/or other cerebral abnormalities.
46
What is meant by microcephaly?
Small head due to incomplete brain development or arrest of brain growth.
47
What are the causes of microcephaly?
Usually genetic aetiology.
TORCH infections.
Maternal substance abuse.
Perinatal hypoxia.
48
What are the symptoms of microcephaly?
```
Occipito-frontal circumference crossing centiles
Shallow sloping forehead
Developmental delay
Seizures
Short stature
```
49
How frequently does a cleft lip or palate occur?
1 in 1000 live births
50
What causes a cleft lip or palate?
Failure of fusion of maxillary processes
51
At what age is a cleft lip repaired?
3 months
52
At what age is a cleft palate repaired?
6-12 months
53
What are the complications of a cleft lip or palate?
Can interfere with feeding and lead to speech problems, psychological issues and aspiration pneumonia.
54
How does a tracheo-oesophageal fistula present?
Coughing or choking during feeding, abdominal distension or recurrent chest infections.
55
How is a tracheo-oesophageal fistula diagnosed?
Bronchoscopy
| Contrast studies of the oesophagus
56
Which syndrome is dueodenal atresia often associated with?
Downs syndrome
57
What is the presentation of duodenal atresia?
Bilious vomiting shortly after birth
58
How is duodenal atresia diagnosed?
Double-bubble sign on abdominal x-ray
59
What is exomphalos/omphalococele?
Hernia into base of umbilical cord, covered by a sac
60
Which syndromes and medical conditions is exomphalos/omphalocoele often associated with?
Edward's syndrome
Patau's syndrome
Cardiac defects
61
How is gastroschisis detected?
Antenatal ultrasound
62
What is gastroschisis?
Defect in abdomen to the right of the umbilicus with protrusion of abdominal contents not covered by a sac.
The bowel is often in poor condition and may need to be resected as part of the surgical repair.
63
What is hypospadias?
Uretrhal opening on underside of penis.
64
When is surgical repair for hypospadias done?
12-18 months
65
What should parents be advised about in hypospadias?
Don't have son circumcised as foreskin is often used in repair.
66
How does an imperforate anus present?
Presents shortly after birth with failure to pass meconium, bilious vomiting and abdominal distension.
67
How are diaphragmatic hernias diagnosed?
May be detected on antenatal ultrasound.
| Present with scaphoid abdomen, apparent dextrocardia and respiratory distress at birth.
68
Which side do most diaphragmatic hernias occur on?
Left side
69
What is a common problem after surgical repair of diaphragmatic hernias?
Pulmonary hypoplasia
70
What is the presentation of achondroplasia at birth?
```
Short limbs
Large head
Flat midface
Frontal bossing
Lumbar lordosis
Trident hand
```
71
What is the incidence of Downs syndrome?
About 1 per 1000 births
72
How is Down syndrome screened for?
1st trimester blood tests beta-hCG, PAPP-A.
Age combined with above calculate risk.
Raised foetal nuchal translucency scan at first trimester also adds to risk.
Screen positive mothers offered chorionic villus sampling or amniocentesis.
Both CVS and amniocentesis carry a risk of miscarriage (1.5% and 1%).
73
What is the facial appearance of a baby with Down's syndrome?
```
Prominent epicancthic folds.
Upward slanting palpebral fissures.
Brushfield spots on iris (white spots)
Protruding tongue, with small mouth.
Small chin, flat nose, round face and small low set ears.
```
74
What is the relation between heart disease and Down's syndrome?
Up to 50% of children with Down's syndrome have congenital heart disease.
All infants with Down syndrome will have a screening echocardiogram soon after birth.
Atrioventricular septal defect is the most common congenital heart defect.
Ventricular septal defect is next most common.
Tetralogy of fallot is relatively common in Downs syndrome.
75
Which gastrointestinal defects are associated with Down's syndrome?
Increased risk of Hirschprung's disease.
Increased risk of duodenal atresia and imperforate anus.
High incidence of umbilical hernia.
High incidence of gastro oesophageal reflux.
Coeliac disease common.
76
List 5 characteristics of Down's syndrome on physical examination.
```
Generalised hypotonia.
Short neck with excess skin at nape.
Brachycephaly
Single palmar crease, short hands and fingers and a sandal toe gap in feet.
Poor growth and short stature.
```
77
List 5 neurological complications of Down's syndrome.
Learning difficulties
Hearing impairment (recurrent otitis media)
Strabismus, cataract (require regular vision and hearing checks)
Increased incidence of epilepsy
Atlanto-axial instability - affects 10-20%, may cause spinal cord compression.
78
List 5 miscellaneous potential complications in Down's syndrome.
```
Significantly raised incidence of haematological malignancy, e.g. ALL, AML.
Hypothyroidism - annual TFTs.
Recurrent respiratory infection
Obstructive sleep apnoea.
Alzheimer's disease.
```
79
Give 5 features of Edward's syndrome.
```
Microcephaly, small chin.
Low set ears.
Overlapping fingers (thumb across palm, index over middle, little over ring)
Rocker bottom feet.
Cardiac: VSD, ASD, PDA.
```
80
Give 5 features of Patau's syndrome.
```
Holoprosencephaly
Structural eye defects
Polydactyly
Cutis aplasia (skin defects)
Cardiac and renal defects.
```
81
Give 5 features of Turner's syndrome.
Downward-turned mouth, downward slanting palpebral fissures.
Webbed neck, wide spaced nipples, lymphoedema.
Coarctation of aorta.
Streak gonads, lack of secondary sexual development.
Short stature.
82
Give 5 features of Klinefelter's syndrome.
```
Infertility
Hypogonadism, microorchidism.
Gynaecomastia
Tall stature
Intelligence from normal to moderate learning difficulties.
```
83
Give 5 features of fragile X syndrome.
Long face, prominent ears, large chin.
Learning difficulty.
Macroorchidism.
Connective tissue problems such as flat feet, hyperflexible joints.
Behavioural characteristics, autistic behaviours, hand flapping, ADD
84
What are the more common intrauterine infections?
Toxoplasmosis
Rubella
Cytomegalovirus
Herpes simplex
85
What is the presentation of congenital cytomegalovirus?
```
Low birth weight
Microcephaly
Cerebral calcification.
Hepatosplenomegaly with jaundice
Petechiae
```
86
What is the treatment for congenital cytomegalovirus?
Gancyclovir
87
What are the possible complications of congenital cyclomegalovirus?
```
Hearing loss
Mental retardation
Psychomotor delay
Cerebral palsy
Impaired vision
```
88
What is the presentation of congenital rubella syndrome?
Cataracts
Microphthalmos
Sensorineural hearing loss
Thrombocytopenic purpura (blueberry muffin rash)
Cardiac: pulmonary artery stenosis or patent ductus arteriosus
Hepatomegaly
89
What are the presentations/complications of congenital toxoplasmosis?
```
Hydrocephalus or microcephaly
Chorioretinits
Cerebral calcification
Cerebral palsy
Epilepsy
```
90
List 5 features of foetal alcohol syndrome.
Microcephaly
Facial features (epicanthic folds, low nasal bridge, absent philtrum, thin upper lip, small chin)
Cardiac defects: VSD, ASD
Growth retardation, limb abnormalities
Learning difficulties and behavioural problems
91
List 5 teratogenic drugs in pregnancy.
```
Phenytoin
Sodium valproate
Lithium
Warfarin
Tetracycline
```
92
What are the potential effects of taking phenytoin in pregnancy?
Cleft lip/palate
Cardiac defects
Hypoplastic nails
Craniofacial abnormalities
93
What are the potential effects of taking sodium valproate or carbamazepine in pregnancy?
Neural tube defects
94
What are the potential effects of taking lithium in pregnancy?
Ebstein's anomaly - congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.
95
What are the potential effects of taking warfarin in pregnancy?
```
Frontal bossing
Cardiac defects
Microcephaly
Nasal hypoplasia
Epiphyseal stippling
```
96
What are the potential effects of taking tetracycline in pregnancy?
Discolouration of teeth.
97
What is the presentation of Prader Willi syndrome?
At birth - hypotonia, feeding problems, hypogonadism.
Later - failure to thrive, scoliosis.
Hyperphagia and obesity.
Developmental delay and learning difficulties.
Physical appearance: almond shaped eyes, pale skin and light hair, small hands and feet with hypogonadism.
98
Which problems are associated with prematurity?
```
Temperature control
Fluid balance, feeds and nutrition.
Lung disease
Infection
Brain haemorrhage and cysts
Retinopathy of prematurity
Hearing impairment
Developmental delay
```
99
Which problems can cause failure of respiratory adaptation (mixing of blood in heart)?
```
Transient tachypnoea
Respiratory distress syndrome
Meconium aspiration syndrome
Sepsis
Pneumothorax
```
100
What is the management of babies with hypoxic ischaemic encephalopathy?
```
Therapeutic cooling (33.5 degrees).
This significantly decreases death and disability.
```
101
What is Erb's palsy?
A brachial plexus injury
102
What is caput succedaneum?
Swelling of an infant's scalp
103
How high does bilirubin have to be for neonatal jaundice?
>85
104
What is the problem with excessively high bilirubin (>400)?
May cause kernicterus
105
How can neonatal jaundice be treated?
Phototherapy
106
What is prescribed to pregnant women for hypertension?
Labetalol
107
What conditions are implemented for resuscitation of the preterm infant?
```
Room temp >25
Plastic bags
Neopuff
CPAP
Delayed cord clamping
Intubation and surfactant
```
108
What causes respiratory distress syndrome?
Surfactant deficiency
109
Which infections are most common in preterm babies?
Group B strep
E coli
Coagulase-negative streptococcus
110
Why are preterm babies at higher risk of infection?
Poor immune function
High numbers of peripheral lines, central lines, chest drains and ET tubes.
High antibiotic usage in NICUs - can breed resistance
111
What are the risk factors for necrotising entercolitis?
Low birth weight
Prematurity
Feeding - enteral feeds. Breast milk reduces risk.
112
What is the management for necrotising entercolitis?
Nil by mouth
Total parenteral nutrition
Antibiotics
Some babies require:
Intubation and ventilation
Inotropic support
Laparotomy
113
What are the indications for therapeutic cooling in neonates?
Low apgars at 5 minutes
Metabolic acidosis
Clinical encephalopathy
Abnormal CFAM
114
What can an absent red reflex in an infant be a sign of?
Cataract
| Retinoblastoma
115
When is a heel-prick test done?
When the baby is 5 days old.
116
What are the risk factors for neonatal jaundice?
```
Family history
Breastfeeding
Infection
Antibody derived:
- rhesus disease
- ABO incompatibility
Glucose-6-phosphatase deficiency
```
117
Which hormone governs breast milk production?
Prolactin
118
What are the benefits of breastfeeding for the baby?
```
Reduced gut infection
Reduced respiratory infection
Reduced ear infection
Reduced cardiovascular disease
Reduced autoimmune conditions
Reduced sudden infant death syndrome
Improved cognitive ability
```
119
What are the benefits of breast feeding for the mother?
Reduced breast cancer
Reduced ovarian cancer
Reduced diabetes
Possibly reduced postnatal depression
120
What is the average birth weight?
3.3-3.5kg
121
Babies drop weight straight after birth, by what age should they have regained their birth weight?
By day 10-14
122
Which investigations should be carried out in cases of early puberty?
Imaging of hypothalamus with MRI in both sexes. It is usually normal in girls.
123
In a girl what age is considered precocious puberty?
<8 years
124
In a girl what age is considered early puberty?
8-10 years
125
In a girl what age is considered delayed puberty?
>13 years
126
In a boy what age is considered precocious puberty?
<9 years
127
In a boy what age is considered early puberty?
9-11 years
128
In a boy what age is considered delayed puberty?
>14 years
129
What is the function of growth hormone?
Proliferation of resting zone chondrocytes. Stimulates local IGF-1 expression.
130
What is the function of IGF-1?
Increases proliferation of resting and proliferative chondrocytes. Increases hypertrophic cell size.
131
What can cause malnutrition to result in abnormal growth?
```
Malabsorption e.g. coeliac disease
Inflammatory bowel disease
Connective tissue disease
Renal disease
Cystic fibrosis
Anorexia nervosa
Chronic infections
```
132
Which endocrine disorders can cause abnormal growth?
GH/IGF-1 axis defects, GH deficiency
Hypothyroidism
Cushing syndrome (glucocorticoid excess)
Disorders of puberty - hypogonadism, precocious puberty
133
How can chronic disease affect growth?
```
Negative energy balance - increased requirements and decreased intake.
The disease itself/chronic inflammation
Stress
Treatment: steroids, cytotoxic drugs
- suppression of hormone release
- resistance in hormone action
- pubertal delay
```
134
What are the ways in which weight can be assessed?
```
Centiles: height, weight
Height velocity
Target height
Pubertal stage
Skeletal proportion
Dysmorphic features
```
135
When should a child's short stature be investigated?
Height <3rd centile.
Height velocity low for age (and Tanner stage)
Outwith the mid-parental height range
136
What are the baseline investigations for a child who is not growing properly?
```
FBC
ESR
U&E
LFT, proteins, albumin
Bone profile
IGF-1
TSH, fT4
Coeliac abs
Bone age
Karyotype (girls, when suspicion for Turners)
```
137
Which virus is responsible for epiglottitis?
H. influenzae b
138
What the symptoms of epiglottitis?
Stridor
| Drooling
139
What are the differentials for epiglottitis?
Foreign body
Croup
Retropharyngeal abscess
Diphtheria
140
What is the age range in which children develop croup?
6 months to 3 years
141
What are the symptoms of croup?
Inspiratory stridor
Mild fever
Constitutional upset
142
What is the management for croup?
Don't distress child
Oxygen
Steroids - dexamethasone
Nebulised adrenaline 1:1000
143
What are the clinical signs of acute respiratory failure?
Restless
Agitated from hypoxia
Cyanosis
Silent chest
144
What is the presentation of acute bronchiolitis?
Cold is followed 3-5 days later by progressive cough, wheeze, difficulty in feeding.
Signs similar to asthma.
Fine inspiratory crepitations.
145
What is the typical age range for bronchiolitis?
6 weeks to 6 months old
146
Which virus is typically responsible for bronchiolitis?
Respiratory syncitial virus (RSV)
147
What are the signs of acute asthma?
```
Expiratory wheeze
Difficulty in speaking
Head extended
Nostrile flared
Chest incresaed anteroposterior diameter
Accessory muscles owrking
Rapid pulse
May have pulsus paradoxus (pulse weaker on inspiration)
Cyanosis on air
```
148
What is the management for acute asthma?
```
Nebulised salbutamol
Oxygen
Combi nebs: salbutamol/atrovent (ipratroprium bromide) (+MgSO4)
Steroids
Magnesium sulphate IV
Aminophylline IV
Salbutamol IV
```
149
Which type of pneumonia is more common in the preschool child?
Bronchopneumonia more common than lobar pneumonia.
150
What are the investigations of suspected pneumonia?
```
Chest x-ray
Hb
WBC
Throat swab
Blood culture
Mantoux
```
151
What is the management of pneumonia in young children?
Suck out secretions from airway
Give physiotherapy
Give oxygen
Nasogastric or IV feeds according to need.
Antibiotics e.g. ampicillin or gentamicin or penicillin.
Add flucloxacillin if staphylococcal pneumonia is suspected.
152
What are the symptoms of cardiac failure in infants?
```
Lethargy
Feeding problems
Breathless on feeding
Sweating
Failure to thrive
Recent excessive weight gain or oedema
Blue attacks.
```
153
What are the signs of cardiac failure in infants?
Rapid pulse and respiration
| Hepatomegaly
154
What are the investigations of cardiac failure in infants?
```
Chest x-ray
ECG
Hb
WBC
Bacteriology
U&Es
```
155
What is the management of cardiac failure in infants?
Diuretic e.g. furosemide
Digoxin
Oxygen
Morphine for agitation
Position: sitting or on an incline, head up
Treat precipitating event, i.e. anaemia or infection
Monitor weight, pulse, respirations, liver size
156
What is the initial management of cardiorespiratory arrest of a child or infant?
Airway - clear muck iwth swab round finger/suction. Meconium in newborns should be aspirated as head is delivered.
Breath - baby's nose and mouth should be covered in mouth to mouth, older children mouth only. Bag and mask.
Cardiac output - neonate, use 2 fingers on mid sternum. <1 year old, circle chest with hands, thumbs pressing down on mid sternum. >1 year old, use heel of hand on mid to lower sternum.
Rate: 1 breadth to 5 compressions at 80-100 compressions per minute.
157
What is the medical management of cardiorespiratory arrest in children?
Adrenaline/atropine/antidote
Bicarbonate
Calcium salts
Dextrose
158
What is the immediate action in the home for burns and scalds?
Scald: strip off affected clothing as it retains the hot liquid.
Scald/burn: if small immerse in cold running water, or add ice to a basin of water, until cool. Cover area in a clean dry sheet, towel or dressing.
159
What is the management of burns or scalds in the hospital?
Airway
IV access
Appropriate analgesia e.g. morphine IV
Plasma expanders (fluid) if >10% of surface affected, to prevent shock, renal failure
Weight
Hb check for early haemoconcentration and subsequent anaemia in full thickness burn
Monitor urine output, blood and urine biochemistry, beware of renal failure.
Consider NAI - history very important.
160
What are the investigations for moderate to severe cases of diarrhoea?
Hb
WBC
U&Es
Bacteriology of stool (x3), throat, urine and blood
161
What is the management for acute diarrhoea?
Oral or nasogastric feeds. In shock give plasma or 0.9% saline IV 20ml/kg over 20 minutes. If IV fluids are needed give 4% dextrose/0.18% saline for 24 hours.
Oral rehydration solution little and often.
Reintroduce diluted whole/powdered cow/s milk over 1-3 days, starches in 1-2 days.
162
What are the investigations for suspected bacterial meningitis?
CSF cells - gram stain and glucose, bacteriology, Hb, WBC, U&Es
Blood glucose
Chest x-ray
163
How is bacterial meningitis diagnosed on lumbar puncture?
CSF cloudy
Polymorphs >20/mm3
Protein/0.45.gl
Glucose <2/3
164
What is the treatment for bacterial meningitis?
Until culture and sensitivities are known:
Neonate: e.coli and group B strep likely, therefore newer cephalosporin or chloramphenicol is given with benzyl penicillin. Treat for 3 weeks.
After 3 months old: H. influenzae, meningococcus and pneumococcus likely, therefore ampicillin in high dose often with chloramphenicol in case H. influenzae is resistant. Treat for 10 days.
165
What are the complications of bacterial meningitis?
Convulsions
Cerebral oedema, subdural effusion, hydrocephalus.
Hyponatraemia from inappropriate antidiuretic hormone release.
Deafness: always screen hearing immediately on recovery.
Drug fever: rise of fever after initial fall.
Long term: mental handicap, cerebral palsy, epilepsy, deaf.
166
Which joint is often involved in osteomyelitis?
Hip
167
What are the investigations of osteomyelitis or septic arthritis?
```
Urgent aspiration with immediate microscopy and gram stain, culture and sensitivity.
Blood culture
Hb
WBC
X-rays
```
168
What is the treatment of osteomyelitis/septic arthritis?
IV antibiotics e.g. flucloxacillin plus ampicillin
Immobilise the limb
Watch.
Surgery indicated immediately in septic hip in infants and in indicated in older children if poor response to treatment after 24 hours.
169
What are the symptoms of UTI?
```
Dysuria, frequency, haematuria, smelly urine.
Bed wetting
Abdominal pain
Pyrexia
General malaise/not feeding
```
170
What are the investigations of suspected UTI?
```
Blood pressure
Hb
WBC
U&Es
Serum cretainine
Urine culture
Blood culture
Ultrasound
```
171
What is the purpose of an ultrasound in UTI?
To look for calyceal radio isotope studies for scarring, pelvic-ureteric obstruction and ureteral reflux, duplex collecting systems, bladder diverticuli/obstruction
172
What is the most commonly found organism in UTI?
E.coli
173
What are in the investigations for suspected DKA?
```
Blood glucose
Blood gas
U&E
Hb
WBC
Bacteriology
```
174
What is the management for severe ketoacidosis?
Rehydrate using 0.9% saline.
| Insulin
175
What is the management for poisoning in the home?
Induce vomiting with fingers, not salt water etc.
176
What is the management in the hospital setting for poisoning?
Establish poison, name, amount, when, how.
Check with national poisons information services centre.
Induce vomiting with ipeacac 15ml +glass fo water within 6 hours of ingestion, up to 24 hours fo salicylates. Repeat after 20 minutes if no result. Gastric lavage for the unconscious with protected airway.
Specific antidotes.
177
When is inducing vomiting contraindicated for poisoning?
Caustic
Petrol
White spirit ingestion.
178
Which investigations should be done after a first seizure?
Blood glucose
| Lumbar puncture
179
What blood glucose is considered hypoglycaemia in a child?
<2.6
180
What are the investigations for suspected volvulus?
Abdo x-ray
| Upper GI contrast
181
What is the management for volvulus?
```
Drip and suck
IV access
NG tube
IV fluids
Urgent surgical opinion
Definitive treatment is Ladd procedure.
```
182
What is intussusception often preceded by?
URTI
183
What is a complication of developmental dysplasia of the hip?
Premature hip arthritis
184
What are the risk factors for developmental dysplasia of the hip?
```
Breech after 35 weeks
Oligohydramnios
Female gender
First born
Positive family history
Torticollis
Lower limb deformity e.g. clubfoot, metatarsus adductus, congenital vertical talus
```
185
What how DDH diagnosed clinically?
Asymmetric buttock and groin creases.
Asymmetric leg length.
Range of abduction.
Barlow/Ortolani tests
186
What are the investigations for DDH?
Ultrasound
| Radiograph
187
What are the three different categories of joints?
Fibrous (sutures of the skull)
Cartilaginous (symphisis pubis)
Synovial (most skeletal joints)
188
Describe the synovial joint.
Covered by hyaline cartilage.
Joint space enclosed by synovium.
Produces synovial fluid in small amounts to lubricate the joint.
189
What happens when there is inflammation of the synovium?
Excessive synovial fluid produced, increased cellularity and altered cytokines. This environment is destructive of first hyaline cartilage and then underlying bone.
190
What are the clinical features of dermatomyositis?
Painful, proximal weakness
191
What are the clinical features of viral myositis?
Local area of painful muscles.
192
What are red flags of MSK pain?
Unable to sleep, unremitting pain.
Deep boring pain, unresponsive to simple analgesia.
Loss of function.
Unilateral.
Change in posture
Examination findings, e.g. tenderness/mass
193
What are the top 3 organisms responsible for septic arthritis?
Staphyloccocus aureus
Streptococcus pneumoniae
Haemophilus influenza
194
What is the most important indication of septic arthritis in a neonate?
Pseudoparalysis
195
Which factors differentiate septic arthritis from transient synovitis?
Pyrexia >38.5 within the last week.
Inability to weight bear through that limb.
A raised ESR >40mm/h
WBC > 12
196
What is the classic presentation of osteomyelitis?
Acutely unwell child
Pyrexia
Local erythema and tenderness
197
What has commonly preceded osteomyelitis?
Recent varicella zoster infection.
198
What is the management of osteomyelitis?
Blood cultures
Bone aspiration if an abscess is present.
High dose IV antibiotics
Splintage of the limb
199
What is the most common cause of joint swelling in children?
Reactive arthritis
200
What are the differential diagnoses of reactive arthritis?
Rheumatic fever
Reiter's syndrome
Transient synovitis of the hip
Discitis
201
What is rheumatic fever caused by?
Streptococcal infection
202
What are the features of rheumatic fever?
Carditis
Arthritis
Neurological features
Rash
203
What are the findings on investigation of rheumatic fever?
Raised ESR
ASO titre
Dnase B
204
What is the treatment of rheumatic fever?
Penicillin
| Including lifelong penicillin prophylaxis
205
What are the features of Reiter's syndrome?
Urethritis, arthritis, conjunctivitis
| +/- plantar fasciitis after gram negative infection or sexually transmitted infection
206
Give some examples of gram negative infections.
Yersinia
Shigella
Salmonella
E coli
207
What are the risk factors for Reiter's syndrome?
Boys
| HLA B27 positive
208
What is transient synovitis of the hip?
Idiopathic disorder in children, often preceded by infection. Effusion of hip. Give child analgesia and allow to rest until happy to weight bear. Should resolve within a week.
209
What are the investigations of transient synovitis of the hip?
ESR and WCC are normal or mildly raised.
| Ultrasound confirms effusion.
210
What are the clinical features of disciits?
Child (often aged 1-3 years) refusing to walk with low grade fever
211
What is found on examination in disciitis?
Examination of spine reveals well localised tenderness, usually in lumbar spine.
212
What are the clinical features of juvenile idiopathic arthritis?
Persistent joint swelling in one or more joints
Early morning stiffness
Warmth
213
Which other conditions are associated with juvenile idiopathic arthritis?
```
Chronic anterior uveitis
SLE
Dermatomyositis
Scleroderma
Vasculitis
```
214
Which two vasculitis conditions are more common in children than adults?
Henoch Schonlein Purpura
| Kawasaki disease
215
Which malignancies can have an MSK presentation?
ALL
AML
Neuroblastoma
Primary bone tumours e.g. Ewing's sarcoma and osteosarcoma
216
What is the name of the classification of growth plate injuries?
Salter-Harris Classification
217
How long do femoral fractures take to heal in chlidren?
"age in years + 1" weeks
218
What is Legg-Calve-Perthes (more commonly Perthes) disease?
Necrosis of part of the femoral capital epiphysis. A growth disturbance in the physeal and articular cartilage which can lead to deformity of the femoral head and degenerative joint disease.
219
How does Perthes disease present?
```
Groin pain
Knee pain
Limp
Reduction in hip abduction
Reduction in internal rotation.
```
220
Who is most commonly affected by perthes disease?
Boys aged 4-8 years
221
What do radiographs show in Perthes disease?
Asymmetry of the femoral capital ossific nucleus, white affected side smaller, or in more severe cases, fragmented.
222
What is the treatment for perthes disease?
Rest
Possibly casts
Possibly surgery
223
What are the risk factors for slipped upper femoral epiphysis (SUFE)?
Early adolescence (due to period of rapid growth)
Obesity
Hypothyroidism
Chronic renal failure
224
How does slipped upper femoral epiphysis present?
Insidious onset of hip pain (often referred to knee) and limp.
Affected limb is often externally rotated.
Affected limb often shortened.
225
How is diagnosis of SUFE made?
Plain raidographs, including a frog leg projection.
226
What is the treatment of SUFE?
In-situ pinning
227
Which diagnoses does DDH include?
Neonatal hip instability
Acetabular dysplasia
Frank dislocation of hip joint
228
What is the more common name for talipes equinovarus?
Club foot
229
Describe the deformity in club foot?
Heel points down and in
| Sole points medially
230
How can positional talipes be managed?
Stretching by the parents
231
How are most cases of club foot treated?
Ponseti technique:
Initially plaster casts changed weekly, most require cutting of the achilles tendon, abduction foot orthosis initially used full time and then part time until age 4.
Minority need surgery.
232
What is scoliosis?
Lateral curvature of the spine.
233
What are red flags of back pain in children?
```
Under 4 years old
Night pain
Functional disability
Postural shift
Lasting more than 4 weeks
Limitation of movement due to pain
Neurological signs
```
234
What is Osgood Schlater's syndrome?
Common overuse syndrome. Typically occurs in boys aged 11-12 who are physically active.
Pain is felt over tibial tuberosity at insertion of patellar ligament. May be accompanied by swelling and local tenderness.
235
What happens in a pulled elbow?
Radial head partially slips from the enfolding annular ligament.
236
What are the causes of rickets?
```
Vitamin D deficiency
Caclium deficiency
Hypophosphataemic
Vitamin D dependent rickets
Hypophosphatasia
```
237
Name 5 acyanotic congenital heart lesions.
```
Ventircular septal defect
Pulmonary stenosis
Atrial septal defect
Coarctation of the aorta
Patent ductus arteriosus
```
238
Name 4 cyanotic congenital heart lesions.
Tetralogy of Fallot
Transposition of the great arteries
Tricuspid atresia
Pulmonary atresia
239
What are the main effects form a large ventricular septal defect?
Left ventricular overload
| Increased pulmonary blood flow leading to cardiac failure
240
If VSD has led to heart failure what is the medical management?
```
Diuretics
ACE inhibitors
Maximise nutrition
NG feeds
Earlier surgery indicated if infant continues to fail to thrive.
```
241
What is patent ductus arteriosus associated with?
Prematurity
| Maternal rubella
242
What can be picked up clinically in a baby with patent ductus arteriosus?
Bounding femoral pulses
| Continuous murmur under left clavicle
243
What are the complications of patent ductus arteriosus?
Heart failure
| Failure to thrive
244
What is the treatment for patent ductus arteriosus?
NSAIDs
Surgical ligation
In older children device occlusion by cardiac catheterisation
245
How does coarctation of the aorta present in neonates?
As collapse, cardiac failure or weak/absent femoral pulses.
| Older children - raised blood pressure/absent femoral pulses or radio-femoral delay
246
What does chest x-ray show in coarctation of the aortra?
Cardiomegaly
| Rib notching
247
What is the treatment of coarctation of the aorta?
Surgery.
| Balloon dilatation/stenting
248
What is the commonest neonatal cyanotic condition?
Transposition of the great arteries
249
What does chest x-ray show in transposition of the great arteries?
Egg on side
250
What is the medical management of transposition of the great arteries?
Prostaglandin
251
What is the surgical management of transposition of the great arteries?
May need urgent balloon atrial septostomy to increase mixing at atrial level.
Definitive surgery - arterial switch, with good long term outcome.
252
Which 4 conditions does tetralogy of fallot encompass?
Ventricular septal defect
Right ventricular outflow tract obstruction
Aortic override of VSD
Right ventricular hypertrophy
253
What could be found on blood test that is characteristic of tetralogy of fallot?
Polycythaemia
254
What does chest x-ray show in tetralogy of fallot?
Boot shaped heart with an upturned apex
255
Which syndrome is tetralogy of fallot associated with?
Di George syndrome
256
What is the most common infective agent in endocarditis?
Strep viridans
257
How might endocarditis present?
```
Fever
Malaise
Weight loss
Arthralgia
Haematuria
Splenomegaly
Splinter haemorrhages
```
258
How is infective endocarditis diagnosed?
Blood cultures
| Echo (vegetations)
259
How is endocarditis treated?
IV antibiotics, 6 weeks.
260
What are the causes of cerebral palsy?
Antenatal - toxins, teratogens, inutero infection
Perinatal - hypoxic insult, sepsis
Postnatal - meningitis, trauma
261
What are the classifications of cerebral palsy?
```
Spastic
Dystonic
Choreoathetoid/dyskinetic
Ataxic
Mixed
```
262
What are common comorbidities in cerebral palsy?
```
Epilepsy
Learning disability
Behaviour problems
Feeding problems/reflux
Osteoporosis
```
263
How can neural tube defects be prevented?
Maternal folic acid supplementation from 1 month prior to conception
264
What will be found on examination in a child with spina bifida?
Flaccid weakness of lower limbs
Absent reflexes
Lack of sensation
265
What is myelomeningocele?
Outpouching of spinal cord and its coverings through a defect in posterior elements of vertebral arches
266
Which problems are associated with meningocele?
```
Mobility
Sensation
Bowel and bladder function
Hydrocephalus
Learning problems
```
267
Which sign is classically seen on examination of a child with muscular dystrophy?
Gowers sign
268
What is the definition of an epileptic seizure?
An epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.
269
How is epilepsy defined?
1. At least two unprovoked seizures occurring more than 24 hours apart.
2. One unprovoked seizure and a probability of further seizures similar to the
general recurrence risk after two unprovoked seizures (approximately 75% or
more).
3. At least two seizures in a setting of reflex epilepsy.
270
What is a focal epileptic seizure?
A seizure originating within networks limited to one heimsphere.
271
In what percentage of children will a febrile convulsion recur?
30%
272
What are the differential diagnosis of acute cough?
```
Upper respiratory tract infection
Croup
Bronchiolitis
Pneumonia
Acute exacerbation of asthma/viral induced wheeze
Pertussis
Inhaled foreign body
```
273
What are the differential diagnosis of a chronic cough?
Asthma
Infection (TB, recurrent aspiration)
Gastro-oesophageal reflux
Chronic illness - cystic fibrosis, kartagener syndrome (primary ciliary dyskinesia)
Rare - extrinsic compression of trachea/bronchus by enlarged heart, glands or tumour
274
What is the differential diagnosis of acute stridor?
Croup
Acute epiglottitis/bacterial tracheitis
Inhaled foreign body
Rare retropharangeal abscess
275
What is croup usually caused by?
Parainfluenza
276
What are the symptoms of croup?
Hoarse voice
Barking cough
Stridor
277
How is croup treated?
Do not upset child.
| Treat with oral dexamethasone and give nebulised adrenaline in severe cases.
278
On which days of illness is bronchiolitis worse?
Days 3-5 (but symptoms last 7-21 days)
279
What is the management of bronchiolitis?
Supportive
O2 if hypoxic
NG feeds or IV fluids if poor feeding
280
What is the pathophysiology of asthma?
Bronchial hyper-responsiveness
Smooth muscle contraction prevents normal expiration
Thickening and oedema of bronchial wall by cellular infiltration and inflammation
Mucus hypersecretion
281
In which gene is the mutation found in cystic fibrosis?
CFTR gene, chromosome 7.
| Most common mutation is delta F508.
282
What is the pathophysiology of cystic fibrosis?
When CFTR acts normally it allows chloride ions out of a mucosal cell into the lumen. If defective this results in thickened secretions which can't be cleared from the chest and infection and airway obstruction occurs.
283
If CF is suspected in somebody that didn't have it picked up on newborn screening how should it be investigated?
```
Sweat test (excess chloride in sweat)
Genetic testing
```
284
What is the management of cystic fibrosis?
Daily physiotherapy
Daily antibiotics (usually flucloxacillin prophylaxis)
Exacerbations: Double dose of prophylactic antibiotic, give planned 2nd line antibiotic, may require admission for IV antibiotic.
Portacath implantation may be required for repeated courses of IV antibiotics.
Creon
Fat soluble vitamin supplements
High calorie diet.
285
What are the acquired causes of deafness?
Prenatal - toxoplasma, rubella, CMV
Perinatal - hypoxia, jaundice (kernicterus)
Postnatal - Meningitis, head injury, ototoxic drugs (e.g. cisplatin)
286
Which gene is most commonly associated with congenital deafness?
Connexin 26 gap junction protein
287
At what age do the adenoids shrink?
After 6 years
288
What is the most common cause for sleep apnoea in children?
Physiological hypertrophy of the tonsils and adenoids.
289
In which ages is sleep apnoea most commonly a problem?
2-7 year olds
290
How is sleep apnoea diagnosed?
Sleep studies:
Overnight pulse oximetry
Full 12-channel polysomnography
291
What are the causes of amblyopia?
```
Reduced view through eye, ptosis or cataract.
Unequal focus (one eye is long or short sighted)
Misalignment of eyes (e.g. squint)
```
292
How is amblyopia treated?
Eye patch
| Atropine eye drops
293
What is the most common reason for absent red reflex?
Cataract
294
What are the top 5 causes of hepatomegaly?
```
Infection
Congestive cardiac failure
Infiltration (tumours)
Storage (fat - cystic fibrosis, glycogen storage diseases)
Idiopathic
```
295
What are the top 5 causes of splenomegaly?
Infection: malaria
Haematological: hereditary spherocytosis, sickle cells
Extramedullary haemopoesis: thallassasemia
Portal hypertension
Neoplastic
296
What are the top 5 causes of hepatosplenomegaly?
```
Infection: EBV, CMV
Portal hypertension
Infiltration: leukaemia, lymphoma
Haematological: e.g. thalassaemia
Idiopathic
```
297
What are the top 6 causes of rectal bleeding?
```
Anal fissure
Swallowed blood from epistaxis
Gastroenteritis
Acid ulceration
Intussusception
Inflammatory bowel disease
```
298
What are the risk factors for inflammatory bowel disease?
```
Family history of inflammatory bowel disease
Family history of autoimmune conditions
Parental smoking
Bottle feeding
Peri anal signs
```
299
What are the top 5 causes of haematemesis?
```
Swallowed blood
Repeated vomiting, acute gastritis
Ulceration: hiatus hernia, drugs, peptic ulcer
Bleeding disorders
Very rarely oesophageal varices
```
300
At what age does coeliac disease commonly present?
6-9 months
301
What are the clinical features of coeliac disease in an infant?
Pale, bulky stools
Distended abdomen
Buttocks wasted
302
What is the test for coeliac disease?
```
Tissue transglutaminase (TTG-IgA)
Duoedenal mucpsal biopsy is necessary in patients with moderately elevated TTG.
```
303
What would a mucosal biopsy show in coeliac disease?
Villous atrophy
Crypt hyperplasia
Increased intraepithelial lymphocytosis
304
What are the top 5 causes of acute diarrhoea?
Infection (rota and enterovirus, e. coli, salmonella, campylobacter)
Staphylococcal toxin
Response to infection e.g. pneumonia
Starvation stools (watery, green mucous)
Surgical: intussusception, pelvic appendicits, Hirschprung's
305
What are the main causes of chronic diarrhoea?
```
Toddler's diarrhoea
Constipation with overflow
Post infectious food intolerance
Inflammatory bowel disease
Malabsorption e.g. CF, coeliac
```
306
How would you investigate chronic diarrhoea?
```
Stool culture and sensitivity
Bloods - FBC, CRP, LFTs, ESR
Serum TTG
Faecal calprotectin
Peri anal insepection
```
307
What are the medical cause of acute abdominal pain?
```
Infection (e.g. gastroenteritis, mesenteric adenitis)
Constipation
Henoch-Schonlein purpura
Acute nephritis
DKA
Sickle cell crisis
```
308
What are the top 5 surgical causes of acute abdominal pain?
```
Acute appendicits
Intussusception
Volvulus
Strangulated inguinal hernia
Torsion of testis/ovary
```
309
Which virus is reponsible for most cases of gastroenteritis?
Rotavirus
310
How does renal disease commonly present?
```
Flank mass
Haematuria
Proteinuria with/without oedema
Polyuria/oliguria
Hypertension
```
311
What are the most common anomalies of the urinary tract?
Absent kidney
Multicystic dysplastic kidney (irregular cysts with no normal renal tissue)
Duplex (upper pole ureter tends to obstruct, lower pole ureter tends to reflux)
Horseshoe
Obstruction
312
What are the top 5 causes of oedema in children?
Heart failure
Nephrotic syndrome
Liver failure
Malnutrition
313
What are the pathological causes of proteinuria?
Gomerular disease (e.g. glomerulosclerosis, glomerulonephritis)
Tubular
Physiological stress e.g. exercise/cold
314
How is nephrotic syndrome defined?
Proteinuria (>1g/m2/day), Hypoalbuminaemia (<25 g/l) and oedema
315
What are the most common reasons for nephrotic syndrome?
Minimal change disease (90%)
| Focal segmental glomerulosclerosis
316
Which investigations would you carry out in a child with nephrotic syndrome?
```
FBC
U&Es
LFTs
C3/C4
Varicella status
Urine: protein creatinine ratio, culture
BP
```
317
What are the complications of nephrotic syndrome?
Hypovolaemia
Thrombosis
Infection (loss of immunoglobulin in the urine)
Hypertension
318
How is nephrotic disease treated?
Prednisolone: initially high dose with reducing course
20% Albumin + Furosemide for hypovolaemia or symptomatic
oedema
Pneumococcal Vaccination
Penicillin prophylaxis for risk of encapsulated organism
infection
Salt/fluid restriction
319
What are the non-glomerular causes of haematuria?
```
Infection (commonest)
Trauma
Stones
Sickle Cell
Coagulopathy/Bleeding disorder
Renal Vein Thrombosis Tumour
Structural abnormality (PUJ obstruction)
Munchausen by proxy
```
320
What are the glomerular causes of haematuria?
Acute or chronic glomerulonephritis
IgA nephropathy
Familial nephritis
321
What are the investigations of haematuria?
Blood: FBC, Coag, U+E’s, ASOT, ANF, Complement
Urine: MC&S, oxalate, calcium, phosphate and urate levels, calcium
creatine ratio
AXR, Renal USS, +/- Renal biopsy
322
What are the causes of hypertension in children?
```
Renin-dependent
Coarctation of the aorta
Catecholamine excess
Endocrine
Essential hypertension
Obesity
Pharmacological (e.g. steroids)
```
323
What are the investigations for hypertension?
• FBC, U&E, creatinine, albumin, bicarbonate, Ca,PO4,LFTs
• Plasma renin activity,aldosterone, plasma catecholamines
• Urinalysis, urine microscopy and culture, urinary protein to creatinine ratio,
urinary catecholamines
• Renal ultrasound with Doppler flow of the renal vessels, Echocardiography,
ECG, Chest X-ray, DMSA ( Di Mercapto Succinic Acid)
324
What are the methods of collecting urine for urinalysis?
Mid stream specimen urine
Catheter specimen urine
Suprapubic aspiration
Urine bags
325
What are the causes for acute renal failure?
```
Pre-renal
▪ Commonest
▪ Hypovolaemia
▪ Cardiac Failure
o Renal
▪ Vascular e.g. Haemolytic uraemic syndrome
▪ Tubular e.g. ATN
▪ Glomerular e.g. Glomerulonephritis
▪ Interstitial e.g. Drugs (NSAIDS)
o Post – renal – urinary obstruction
```
326
What are the indications for dialysis?
Severe volume overload
Severe hyperkalaemia Symptomatic Uraemia
Severe metabolic acidosis
Removal of toxins
327
Give modalities for renal imaging.
Ultrasound
DMSA (delineates divided function of kidneys. Identifies scars, needs to be done at least 3 months after UTI)
DTPA (dynamic scan allows assessment of drainage and obstruction)
MCUG (looks for vesicoureteric reflux, bladder outlines)
AXR - to look for stones
328
What are the top five causes for a vomiting baby?
```
Overfeeding
Possetting
Gastro-oesophageal reflux
Pyloric stenosis
Obstruction
```
329
What is the normal age of onset of pyloric stenosis?
2-6 weeks
330
What is the clinical presentation of pyloric stenosis?
Rapidly progressive projectile vomiting, without bile, soon after feeds.
331
What will be the metabolic derangements in a baby with pyloric stenosis?
Hypochloraemic, hypokalaemic metabolic acidosis
332
How is pyloric stenosis diagnosed?
```
Test feed (visible peristalsis and palpable pyloris - olive shaped mass in RUQ)
Ultrasound
```
333
What is the management of pyloric stenosis?
Correct electrolyte imabalance with IV fluids.
| Pyloromyotomy
334
What are the top 5 causes of bilious vomiting in a baby?
```
Malrotation +/- volvulus until proven otherwise
Necrotising enterocolitis
Atresia
Hirschprungs disease
Meconium ileus/plug
```
335
In normal embryological development when should rotation and fixation of the gut occur?
Between 4 and 12 weeks gestation
336
Where do parts of the gut lie after normal rotation?
DJ flexure lies to the left of the midline.
Caecum lies in right iliac fossa
Transverse colon lies anterior to the small bowel
mesentery
337
What is the commonest problem with malrotation?
Caecum lies close to the duodenojejunal flexure, resulting in abnormally narrow midgut mesentery which is liable to twist.
338
How might malrotation present?
Collapse and acidosis early due to intestinal infarction, or late with bile stained vomiting and distension.
339
How is malrotation diagnosed?
Barium contrast studies
340
How is malrotation treated?
Resuscitation
| Early laparotomy
341
What is necrotising enterocolitis?
An acute inflammatory disease occuring in the intestines of premature infants, can lead to necrosis of the bowel.
342
What are the clinical features of necrotising enterocolitis?
```
Abdominal distension
Blood in the stool
Feeding intolerance
Vomiting (often bilious)
Pyrexia
```
343
How is necrotising enterocolitis managed?
Stop feeds
IV fluids
IV antibiotics
If severe may need surgical intervention such as bowel resection and stoma formation
344
What is the most common site of atresia of the intestine?
Jejunum and ileum.
345
What percentage of infants with duodenal atresia have Down syndrome?
30%
346
What is Hirschsprungs disease?
Aganglionic section of bowel.
347
Which part of the bowel is affected by Hirschprung's disease?
Starts at the anus and progresses upwards.
348
How do most cases of Hirschprung's present?
Delayed passage of meconium
349
How does Hirschprung's present if it is a later presentation?
Abdominal distension
Constipation
Failure to thrive
Features of obstruction
350
What are the x-ray appearances of acute appendicitis?
Scoliosis due to pain
Faecolith
Absent right psoas shadow
Intraperitoneal gas indicating perforation
Abnormal caecal gas or small bowel dilatation
351
What is intussussception?
Full thickness invagination of the proximal bowel to distal intestine.
352
What is the most common site of intussusception?
Ileo-colic junction
353
What is the common cause of intussusception?
Enlarged peyer's patches secondary to preceding viral illness.
354
Which disease can predispose to intussusception?
Henoch-Schonlein purpura
Cystic fibrosis
Lymphoma
355
What is the classic triad of symptoms in intussusception?
Intermittent abdominal pain
Redcurrant jelly stools
Vomiting
356
What might be seen on abdominal x-ray in intussusception?
Absence of air in ascending colon.
| Soft tissue density in ascending colon.
357
How is intussusception diagnosed?
Ultrasound - target lesion, doughnut sign.
| Contrast enema
358
How is intussusception managed?
Air enema
| If unsuccessful operative intervention may be indicated
359
What is the commonest surgical condition in children?
Inguinal hernia
360
What are the risk factors for inguinal hernia?
Premature
| Low birth weight
361
What are the major complications of inguinal hernias?
Incarceration
| Strangulation
362
Are inguinal hernias more likely to be direct or indirect?
99% are indirect hernias
363
What is the management of umbilical hernias?
Watch and wait until 5 years of age - may then be surgically repaired if still clinically present
364
What causes a hydrocoele?
Patent processus vaginalis
365
What can make a hydrocele more noticeable?
Systemic illness
366
What is found on examination of a hydrocoele?
Swelling
Blue hue
Can get above it on examination
Transilluminates
367
What is the management of hydrocoele?
90% resolve spontaneously in first 3 years.
| If not resolved by 3 years surgery required.
368
When should undescended testis be operated on?
By 1st birthday
369
What are the differential diagnoses of testicular pain?
Testicular torsion
Torsion of the appendage (hydatid of morgagni)
Epididymo-orchitis
Hydrocoele (rarely painful)
Idiopathic scrotal oedema (rarely painful, usually bilateral)
370
What are the clinical features of epididymo-orchitis?
Swelling
Erythema
Oedema
Gradual onset
371
What is an associated symptom with epididymo-orhcitis?
Dysuria
372
What are the indications for CT scan for head injury in children?
Witnessed loss of consciousness >5 minutes
Amnesia (antegrade or retrograde) >5 minutes
Abnormal drowsiness
≥3 Discrete episodes of vomiting
Clinical suspicion of non-accidental injury
Post-traumatic seizure (no PMH of epilepsy)
GCS <14 in emergency room
(Paediatric GCS <15 if aged <1)
Suspected open or depressed skull fracture or tense fontanelle 11
Signs of base of skull fracture*
Focal neurological deficit
Aged <1 - bruise, swelling or laceration on head >5 cm
Dangerous mechanism of injury (high-speed RTA, fall from >3 m, high-speed
projectile)
373
What can cause thrombocytopaenia?
```
Malignancy
Bone marrow failure
Inherited platelet conditions
Microangiopathic haemolytic anaemia
Idiopathic thrombocytopaenia
```
374
What can cause bone marrow failure?
Aplastic anaemia
Fanconi's anaemia
Neolastic infiltration by neuroblastoma/lymphoma/Ewing's sarcoma
375
What is the presentation of idiopathic thrombocytopaenia?
Acute onset bruising, petechiae, epistaxis following a recent viral illness in a previously well child.
376
What is the typical age of onset of idiopathic thrombocytopaenia?
1-5 years
377
What will blood tests show in idiopathic thrombocytopaenia?
Platelets <20
378
What are the complications of idiopathic thrombocytopaenia?
```
Intracranial haemorrhage (rare)
Failure to resolve - becomes chronic ITP
```
379
How long does it usually take for ITP to resolve?
A few month, most have resolved by 6 months
380
What is the management of ITP?
```
Careful observation
Limit high impact activities
Platelet transfusion if bleeding (but destroyed rapidly)
IV Ig
Consider steroids
Consider splenectomy
```
381
What is Henoch Schonlein Purpura?
Vasculitis - due to deposition of IgA containing immune complexes in capillaries, arterioles and venules.
382
What is the clinical presentation of HSP?
Purpura over extensors aspects of lower limbs and buttocks.
Arthritis
Colicky abdo pain, blood and mucus on PR exam
Haematuria, proteinuria, hypertension
383
How is HSP diagnosed?
```
Clinically:
Tests to rule out other things e.g:
FBC (platelets may be raised)
CRP
ESR
Urinalysis
BP
Abdo USS
```
384
What is the prognosis of HSP?
Usually resolves spontaneously
385
What is tHE management of HSP?
```
Supportive.
Analgesia
Monitor renal function
Urinalysis
BP
Monitor for intussusception
```
386
Which vitamin can increase iron absorption?
Vitamin C
387
How long should iron supplementation be continued after Hb normalises?
3 months
388
What is the presentation of leukaemia?
```
Bone marrow failure (anaemia, pallor, dyspnoea, low WCC, increased infections, low platelets, bruising, petechiae, epistaxis)
Bone pain/limp
Lymphadenopathy
Hepatosplenomegaly
Testicular enlargement
Cranial nerve palsies, meningism
```
389
Which investigations should be done in suspected leukaemia?
```
FBC
Blood film
Bone marrow aspirate
Lumbar puncture
Coag screen
U&Es
LDH
CXR
```
390
What is the management of leukaemia?
Multi drug chemotherapy
+/- radiotherapy
+/- bone marrow transplant
391
What is deficient in haemophilia A?
Factor VIII
392
What is deficient in haemophilia B?
Factor IX
393
What is the presentation of haemophilia?
Spontaneous join/muscle bleed or due to minor trauma
| Raised lumpy bruises
394
How is haemophilia diagnosed?
Isolated prolonged APTT
| Specific factor deficiency
395
How is haemophilia treated?
Recombinant factor administration IV
396
What are the complications of haemophilia?
Progressive arthropathy
Transmission of blood borne infections
Allergic reactions
Factor antibody production
397
Which clotting factor is affected in Von Willebrand disease?
Factor VIII
398
How is Von Willebrand disease diagnosed?
Prolonged APTT
Reduced factor VIII:VWF levels
No platelet aggregation on Ristocetin co-factor assay
399
What is the presentation of von Willebrand disease?
Mucosal bleeding from GI, gums, epistaxis, menorrhagia, prolonged bleeding post trauma/surgery
400
What is the management of von Willebrand disease?
DDAVP prophylaxis
| Recombinant FVIII for bleeding episodes
401
What are the features suggestive of malignancy in children?
```
Supraclavicular, epitrochlear nodes.
Associated systemic symptoms.
Hepatosplenomegaly
Other palpable masses
Signs of bone marrow infilgration ie anaemia/bruising/petechiae
```
402
Name 5 malignant causes of lymphadenopathy?
```
Acute leukaemia
Lymphoma
Hodgkin's disease
Neuroblastoma
Rhabdomyosarcoma
```
403
What are the common infectious causes of lymphadenopathy?
```
Bacterial lymphadenitis
Viral infection
Cat scratch disease
TB
Atypical mycobacterium
```
404
Name 5 autoimmune causes of lymphadenopathy?
```
Kawasaki's disease
JIA
SLE
Sarcoidosis
Drug reactions
```
405
What are the signs of a brain tumour?
```
Raised ICP - early morning headaches, vomiting, papilloedema
Focal seizures
Neurological signs
Endocrine disturbance
Raised occipitofrontal circumference
Developmental delay/regression
```
406
What are the investigations of a suspected brain tumour?
```
Brain/spinal MRI
Tumour biopsy
Consider tumour markers
Endocrine screen - craniopharyngioma
CSF - cytology and tumour markers
```
407
What is the management of a brain tumour?
Neurosurgical referral.
Consider dexamethasone to reduce peritumour oedema
Consider chemotherapy
Consider radiotherapy
408
What are the most common paediatric malignant tumours?
Osteosarcoma
| Ewing's sarcoma
409
What is the presentation of malignant bone tumours?
```
Persistent pain
Swelling
Deformity
Pathological fractures
Systemic symptoms e.g. including fever, anorexia, weight loss
```
410
How do you diagnose a bone tumour?
Imaging of lump and distant sites
| Biopsy
411
What is the management of osteosarcoma?
Chemotherapy
| Surgery
412
What is the management of Ewing's sarcoma?
Chemotherapy
Surgery
Autologous stem cell transplant
Radiotherapy
413
What are the effects of chemotherapy?
```
Marrow suppression
Temporary hair loss
Nausea and vomiting
Hearing loss
Renal impairment
```
414
What are the late effects of chemotherapy?
Cardiac toxicity
Infertility
Risk of secondary malignancies
415
Give 7 examples of live attenuated vaccines.
```
BCG
Measles
Mumps
Rubella
Rotavirus
Influenza
Oral polio
```
416
Give 6 examples of inactivated vaccines.
```
Inactivated polio
Trivalent influenza
Diptheria & tetanus
Pertussis
HPV
MenB
```
417
What are the contraindications to vaccination?
Anaphylactic reaction to a previous dose of a vaccine containing the same antigens.
Anaphylactic reaction to another component contained in the relevant vaccine.
418
What is the incubation period for measles?
7-14 days
419
What is the infectivity period for measles?
1-2 days before symptoms to 4 days after appearance of rash.
420
What are the clinical features of measles?
Prodrome )3-5 days) of fever, coryza, cough, conjunctivitis and Koplik's spots.
Maculopapular rash starts behind ears, migrates to face and trunk and then to limbs.
Cervical lymphadeopathy
High fever.
421
What are the complications of measles?
```
Otitis media
Lymphadenitis
Interstitial pneumonitis
Secondary bacterial bronchopneumonia
Myocarditis
Post infectious demyelinating encephalomyelitis
Sub acute sclerosing panencephalitis
```
422
What is the treatment for measles?
Supportive
423
What is the incubation period for chicken pox?
14-21 days.
424
What is the infectivity period for chicken pox?
2 days before until 5 days post rash
425
What are the clinical features of chicken pox?
```
Fever
Malaise
Headache
Abdominal pain for 48 hours
Itchy crops of erythematous macules that evolve into papules then vesicles containing serous fluid. Usually start on trunk then spread to limbs.
```
426
What are the complications of chicken pox?
```
Secondary bacterial infection.
Pneumonia
Encephalitis
Progressive disseminated varicella
Cerebellar ataxia
Thrombocytopenia
Purpura fulminanas
Post-infectious encephalitis
```
427
What is the treatment for chicken pox?
Supportive
| Aciclovir in high risk patients
428
What is the post exposure prophylaxis for chicken pox in those with high risk of severe disease?
IV Ig
429
What is the incubation period for mumps?
14-21 days
430
What is the infectivity period for mumps?
1-2 days prior to parotid swelling, 9 days after.
431
What are the clinical features of mumps?
Prodrome of fever, anorexia, headache
| Painful uni/bilateral salivary +/- submandibular gland swelling
432
What are the complications of mumps?
```
Menngoencephalitis
Deafness
Orchitis
Epididymitis
Pancreatitis
Nephritis
Myocarditis
Arthritis
Thyroiditis
```
433
What is the treatment for mumps?
Supportive
434
What is the incubation period for erythema infectiosum?
4-14 days
435
What is the infectivity period for erythema infectiosum?
Not infective once rash apperas
436
What are the clinical features of erythema infectiosum?
Prodrome of low grade fever, general malaise, followed after a few days by maculopapular psots on cheeks, which coalesce to give 'slapped cheek' appearance. Fine rash extends to trunk and limbs.
437
What are the complications of erythema infectiosum?
Aplastic crisis in chronic haemolytic disease.
438
What is the incubation period for rubella?
14-21 days
439
What is the infectivity period for rubella?
1-2 days before, to 7 days after the rash appears.
440
What are the clinical features of rubella?
Prodrome of coryza, tender cervical lymphadenopathy followed by development of a fine maculopapular rash.
Starts on face from where it fades and spreads down the trunk.
arthralgia
Palatal petechiae
441
What are the complications of rubella?
Encephalitis
Thrombocytopenia
Congenital rubella syndrome if diagnosed in 1st 10 weeks of pregnancy
442
What is the incubation period of roseola infantum?
7-14 days
443
What is the infectivity period for roseola infantum?
Until fever subsides
444
What are the clinical features of roseola infantum?
Sudden onset high fever with only mild coryza.
On day 3-4 fever resolves and a maculopapular rash appears on trunk and limbs
Lasts for 1-2 days.
445
What are the complications of roseola infantum?
One of the commonest causes of febrile convulsions in 6-18 month old age group, usually happen on first day of illness.
446
What is the incubation period for petussis?
7-14 days
447
What are the clinical features of pertussis?
Catarrhal phase: Low grade fever, coryza, conjunctivits for 1-2 weeks followed by paroxysmal phase:
paroxysms of severe cough with or without whoop, vomiting. May develop cyanosis and apnoea. Paroxysmal phase lasts 2-8 weeks.
Convalescent stage: cough subsides over weeks to months.
448
What are the complications of pertussis?
Apnoea
Secondary bacterial pneumonia
Weight loss secondary to feeding difficulties
Subsequent bronchiectasis,
otitis media, seizures, encephalopathy, subconjunctival, subarachnoid or intra-ventricular
haemorrhage, umbilical and inguinal hernia, rupture of diaphragm
449
How is pertussis diagnosed?
Perinasal swab for PCR testing, culture.
| Associated lymphocytosis
450
What is the treatment for pertussis.
Supportive, low threshold for admission in neonates.
| Macrolides e.g. azithromycin may reduce complications
451
What are the most common organisms found in bacterial meningitis?
Neisseria meningitidis
| Streptococcus pneumonia
452
Which virus is commonly responsible for viral meningitis?
Enterovirus
453
In neonates what is meningitis usually caused by?
Group B strep
454
What is the clinical presentation of bacterial meningitis?
```
Fever
Headache
Nausea
Vomiting
Neck stiffness
Photophobia
Lethargy
Decreased conscious level
```
455
How is meningitis diagnosed?
Lumbar puncture
456
What will CSF analysis of lumbar puncture find in bacterial meningitis?
WCC>5 cells/mcl (>20 cells/mcl in neonates),
o Polymorphs if bacterial, after 24hrs lymphocytes if viral
• Elevated protein (>0.4g/L) & decreased glucose (<0.6 CSF:blood ratio)
o Bacterial& TB
• Organisms seen on gram staining (though negative 60% bacterial
meningitis) & cultured if bacterial, ZN/auramine stain & mycobacterial
culture if TB
• Perform PCR testing for pneumococcus/meningococcus/Hib& HSV/VZV/enterovirus
457
What is the empirical treatment for suspected bacterial meningitis?
IV cefotaxime,
add amoxicillin & gentamicin if under 6 weeks.
Over 3 months if no petechiae/purpuric lesions add dexamethasone and
continue for 2 days; reduces the risk of deafness from Hib meningitis.
458
What is the treatment for meningitis caused by N. meningitidis?
7 days IV cefotaxime/ceftriaxone
459
What is the treatment for meningitis caused by s. pneumoniae?
14 days IV cefotaxime/ceftriaxone
460
What are the public health measures around meningitis?
Refer to public health for contact tracing and chemoprophylaxis.
461
What are the possible sequlae of meningitis?
```
Hydrocephalus
Deafness
Neuromotor disorders
Seizures
Visual disorders
Speech and language disorders
Learning difficulties
Behavioural problems
```
462
What is sepsis?
A systemic inflammatory response to infection.
463
What happens in meningococcal sepsis?
Capillary leak, coagulopathy, myocardial depression, metabolic derangement.
464
Which gene do about half of severe cases of eczema have a mutation in?
Filaggrin gene
465
What is impetigo caused by?
Staph aureus
466
What are the characteristic features of impetigo?
Annular erythematous lesions with honey coloured crust and may become bullous as a result of cleaving of the peidermis by exfoliative staph.
467
What is molluscum contagiosum caused by?
DNA Pox virus
