paeds Flashcards

Question

prevention of chronic lung disease of prematurity

Answer 1

give corticosteroid (eg betamethasone) to mothers <36wks gestationw ith premature labour once babies born give it: - CPAP (rather than I&V) - caffeine

Answer 2

1. thick pancreatic and biliary secretions 2. low volume thick airway secretions 3. congenital bilateral absence of vas deferens

Answer 3

1. newborn blood spot testing 2. sweat test 3. genetic testing fro CFTR gene (during pregnancy via amniocentesis or CVS)

Answer 4

long term nebulised antibiotics such as tobramycin oral ciprofloxacin separate clinic rooms to prevent spread to other children with CF

Answer 5

sputum cultures screening for diabetes, osteoporosis, vitamin D deficiency, liver failure

Answer 6

Kartagners syndrome

Answer 7

paranasal sinusitis bronchiectasis situs inversus

Answer 8

Persistent or bilious vomiting Severe chronic diarrhoea Fever Rectal bleeding Weight loss or faltering growth Dysphagia (difficulty swallowing) Nighttime pain Abdominal tenderness

Answer 9

central abdominal pain lasting more than 1 hour can be associated with: - N&V - anorexia - pallor - headache - photophobia - aura

Answer 10

pizotifen (serotonin antagonist) propanolol (non-selective beta-blocker) cyroheptadine (antihistamine) Flunarazine (CCB)

Answer 11

Encopresis is the term for faecal incontinence. This is not considered pathological until 4 years of age. It is usually a sign of chronic constipation where the rectum becomes stretched and looses sensation. Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.

Answer 12

- not passing meconium - neurological signs - vomting - ribbon stool - abnormal anus - abnormal lower back or buttocks - failure to thrive - acute severe abdominal pain and bloating

Answer 13

Correct any reversible contributing factors, recommend a high fibre diet and good hydration Start laxatives (movicol is first line) Faecal impaction may require a disimpaction regimen with high doses of laxatives at first Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts. Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.

Answer 14

Small, frequent meals Burping regularly to help milk settle Not over-feeding Keep the baby upright after feeding (i.e. not lying flat)

Answer 15

Gaviscon mixed with feeds Thickened milk or formula (specific anti-reflux formulas are available) Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate

Answer 16

rare conditions leading to brief episodes fo abnromal movement associated with reflux 1. torticollis 2. dystonia usually resolves as reflux resolves but should refer to specialist to rule out serious causes,

Answer 17

first few weeks of life = failure to thrive - pale - thin - hungry 'projectile vomiting' firm, round mass in upper abdomen 'feels like a large olive'

Answer 18

hypochloric (low chloride) metabolic alkalosis

Answer 19

Lactose intolerance Irritable bowel syndrome Reactive arthritis Guillain–Barré syndrome

Answer 20

Failure to thrive in young children Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia secondary to iron, B12 or folate deficiency Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen

Answer 21

Check total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies: 1. Raised anti-TTG antibodies (first choice) 2. Raised anti-endomysial antibodies Endoscopy and intestinal biopsy show: 1. “Crypt hypertrophy” 2. “Villous atrophy”

Answer 22

N- No blood or mucus E - Entire GI Tract S - 'skip lesions' on endoscopy T - terminal ileum most affected and transmural inflammation S - smoking is a risk factor also : weight loss, structures and fistulas

Answer 23

C - continuous inflammation L - limited to colon and rectum O - Only superficial mucosa affected S - Smoking is protective E - Excrete blood and mucus U - Use aminosalicylates P - PSC

Answer 24

Finger clubbing Erythema nodosum Pyoderma gangrenosum Episcleritis and iritis Inflammatory arthritis Primary sclerosing cholangitis (ulcerative colitis)

Answer 25

Faecal calprotectin is released by the intestines when inflamed. It is a useful screening test and is more than 90% sensitive and specific for IBD in adults. Endoscopy (OGD and colonoscopy) with biopsy is the gold standard investigation for diagnosis of IBD. Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.

Answer 26

1st line > steroids (oral prednisolone or IV hydrocortisone) 2nd > azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab

Answer 27

First line: Azathioprine Mercaptopurine Alternatives: Methotrexate Infliximab Adalimumab

Answer 28

Mild to moderate disease First line: aminosalicylate (e.g. mesalazine oral or rectal) Second line: corticosteroids (e.g. prednisolone) Severe disease First line: IV corticosteroids (e.g. hydrocortisone) Second line: IV ciclosporin

Answer 29

Aminosalicylate (e.g. mesalazine oral or rectal) Azathioprine Mercaptopurine

Answer 30

remove the colon (panproctocolectomy) - permanent ileostomy OR - ileo-anal anastamosis (J-pouch)

Answer 31

blie duct is narrowed or absent leasing to cholestasis. ie the excretion of conjugated bilirubin

Answer 32

persistent jaundice lasting more than 14 days in term babies and 21 days in premature babies

Answer 33

"Kasai Portoenterostomy" attaching small intestine to the opening of the liver. Often require a full liver transplant to fully resolve condition.

Answer 34

Meconium ileus Hirschsprung’s disease Oesophageal atresia Duodenal atresia Intussusception Imperforate anus Malrotation of the intestines with a volvulus Strangulated hernia

Answer 35

Persistent vomiting. This may be bilious, containing bright green bile. Abdominal pain and distention Failure to pass stools or wind Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.

Answer 36

The initial investigation of choice is an abdominal xray. This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be absence of air in the rectum.

Answer 37

refer to paediatric surgical unit as emergency nil by mouth insert NG tube to drain stomach and stop vomiting IV fluids to correct dehydration and electrolyte imbalances

Answer 38

Hirschsprung’s disease is a congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum. The myenteric plexus, also known as Auerbach’s plexus, forms the enteric nervous system. It is the brain of the gut.

Answer 39

acute intestinal obstruction shortly after birth or more gradually developing symptoms: Delay in passing meconium (more than 24 hours) Chronic constipation since birth Abdominal pain and distention Vomiting Poor weight gain and failure to thrive

Answer 40

Hirschsprung-associated enterocolitis (HAEC) is inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease. It typically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis. It is life threatening and can lead to toxic megacolon and perforation of the bowel. It requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel.

Answer 41

abdo XR rectal biospy if unwell > fluid resus and management of intestinal obstruction definitive management is surgical removal of aganglionic bowel.

Answer 42

bowel 'invaginates' or 'telescopes' into itself. Leads to palpable mass in abdomen and obstruction. typically occurs in infants 6mnhts- 2 years. more common in boys

Answer 43

Severe, colicky abdominal pain Pale, lethargic and unwell child “Redcurrant jelly stool” Right upper quadrant mass on palpation. This is described as “sausage-shaped” Vomiting Intestinal obstruction

Answer 44

Diagnosis is made mainly by ultrasound scan or contrast enema. Therapeutic enemas can be used to try to reduce the intussusception. Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position. Surgical reduction may be necessary if enemas do not work. If the bowel becomes gangrenous (due to a disruption of the blood supply) or the bowel is perforated, then surgical resection is required.

Answer 45

This typically starts as central abdominal pain, that moves down to the right iliac fossa (RIF) over time and eventually becomes localised in the RIF. On palpation of the abdomen there is tenderness in McBurney’s point. This is a localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus.

Answer 46

Loss of appetite (anorexia) Nausea and vomiting Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF) Guarding on abdominal palpation Rebound tenderness is increased pain when quickly releasing pressure on the right iliac fossa Percussion tenderness is pain and tenderness when percussing the abdomen Rebound tenderness and percussion tenderness suggest peritonitis, caused by a ruptured appendix.

Answer 47

Diagnosis is based on the clinical presentation and raised inflammatory markers. Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An ultrasound scan is often used in female patients to exclude ovarian and gynaecological pathology. When a patient has a clinical presentation suggestive of appendicitis but investigations are negative, the next step is to perform a diagnostic laparoscopy to visualise the appendix directly. The surgeon can then proceed to an appendicectomy during the same procedure if indicated.

Answer 48

Bleeding, infection, pain and scars Damage to bowel, bladder or other organs Removal of a normal appendix Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism)

Answer 49

25-50% present in DKA remaining present with triad of hyperglycaemia - polyuria - polydipsia - weight loss less common - secondary enuresis - recurrent infections

Answer 50

Baseline bloods including FBC, renal profile (U&E) and a formal laboratory glucose Blood cultures should be performed in patients with suspected infection (i.e. with fever) HbA1c can be used to get a picture of the blood sugar over the previous 3 months. This gives an idea of how long they have been diabetic prior to presenting. Thyroid function tests and thyroid peroxidase antibodies (TPO) to test for associated autoimmune thyroid disease Tissue transglutaminase (anti-TTG) antibodies for associated coeliac disease Insulin antibodies, anti-GAD antibodies and islet cell antibodies to test for antibodies associated with destruction of the pancreas and the development of type 1 diabetes

Answer 51

"lantus" a long-acting insulin in the evening "Actrapid" a short acting insulin 3x day before meals and according to number of carbohydrates consumed during snacking

Answer 52

if cannula in situ IV dextrose - 10% dextrose 2mg/ kg bolus followed by 5mg/kg/hr infusion or IM glucagon

Answer 53

glucose level of the interstitial fluid in the subcutaneous tissue. There is a 5 minute lag behind blood glucose. The sensor records the glucose readings at short intervals so you get a really good impression of what the glucose levels are doing over time

Answer 54

ketoacidosis - due to liver converting fatty acids into ketones due to lack of insulin and so no glucose available for cells. dehydration - due to osmotic diuresis potassium imbalance - insulin normally drives K into cells so without it there's high K in the blood. However kidneys balance blood potassium by excreting more K in the urine leading to low total body K. Therefore, when Insulin treatment started and K is driven into the cells this can lead to low blood K.

Answer 55

In DKA dehydration and hyperglycaemia lead to water moving intra to extra cellular spaces in the brain. When this is corrected with IV fluids causes a rapid shift of fluid back into the cells leads to swelling of the brain. leads to cell destruction and death

Answer 56

hyperglycaemia (>11mmol/l in blood) Ketosis (>3mmol/l in blood) acidosis (pH <7.3)

Answer 57

1. Correct dehydration evenly over 48 hours. This will correct the dehydration and dilute the hyperglycaemia and the ketones. Correcting it faster increases the risk of cerebral oedema. 2. Give a fixed rate insulin infusion. This allows cells to start using glucose again. This in turn switches off the production of ketones.

Answer 58

adrenal glands have been damaged, resulting in reduced secretion of cortisol and aldosterone. This is also called primary adrenal insufficiency. The most common cause is autoimmune.

Answer 59

inadequate ACTH stimulating the adrenal glands, resulting in low levels of cortisol being released. This is the result of loss or damage to the pituitary gland. This can be due to congenital underdevelopment (hypoplasia) of the pituitary gland, surgery, infection, loss of blood flow or radiotherapy.

Answer 60

inadequate CRH release by the hypothalamus. This is usually the result of patients being on long term oral steroids (for more than 3 weeks) causing suppression of the hypothalamus. When the exogenous steroids are suddenly withdrawn the hypothalamus does not “wake up” fast enough and endogenous steroids are not adequately produced

Answer 61

hyponatraemia hyperkalaemia hypoglycaemia

Answer 62

Primary: Low cortisol High ACTH Low aldosterone High renin secondary: Low cortisol Low ACTH Normal aldosterone Normal renin

Answer 63

The short synacthen test can be used to confirm adrenal insufficiency. It is ideally performed in the morning when the adrenal glands are the most “fresh”. The test involves giving synacthen, which is synthetic ACTH. The blood cortisol is measured at baseline, 30 and 60 minutes after administration. The synthetic ACTH will stimulate healthy adrenal glands to produce cortisol. The cortisol level should at least double in response to synacthen. A failure of cortisol to rise (less than double the baseline) indicates primary adrenal insufficiency (Addison’s disease).

Answer 64

hydrocortisone fludrocortisone steroid card and emergency ID tag dose increases during acute illness close monitoring by specialist

Answer 65

The dose of steroid needs to be increased and given more regularly until the illness has completely resolved. Blood sugar needs to be monitored closely and they need to eat foods containing carbohydrates regularly. With diarrhoea or vomiting, they need an IM injection of steroid at home and likely required admission for IV steroids.

Answer 66

Reduced consciousness Hypotension Hypoglycaemia, hyponatraemia and hyperkalaemia

Answer 67

Intensive monitoring if they are acutely unwell Parenteral steroids (i.e. IV hydrocortisone) IV fluid resuscitation Correct hypoglycaemia Careful monitoring of electrolytes and fluid balance

Answer 68

Congenital adrenal hyperplasia is caused by a congenital deficiency of the 21-hydroxylase enzyme. This causes underproduction of cortisol and aldosterone and overproduction of androgens from birth. It is a genetic condition that is inherited in an autosomal recessive pattern. In a small number of cases it is caused by a deficiency of 11-beta-hydroxylase rather than 21-hydroxylase.

Answer 69

Aldosterone is the main mineralocorticoid hormone. It is released by the adrenal gland in response to renin. Aldosterone acts on the kidneys to increase sodium reabsorption into the blood and increase potassium secretion into the urine. Therefore, aldosterone acts to increase sodium and decrease potassium in the blood.

Answer 70

21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol. Progesterone is also used to create testosterone, but this conversion does not rely on the 21-hydroxylase enzyme. In CAH, there is a defect in the 21-hydroxylase enzyme. Therefore, because there is extra progesterone floating about that cannot be converted to aldosterone or cortisol, it gets converted to testosterone instead. The result is a patient with low aldosterone, low cortisol and abnormally high testosterone.

Answer 71

Female patients with CAH usually presents at birth with virilised genitalia, known as “ambiguous genitalia” and an enlarged clitoris due to the high testosterone levels. Patients with more severe CAH present shortly after birth with hyponatraemia, hyperkalaemia and hypoglycaemia. This leads to signs and symptoms: Poor feeding Vomiting Dehydration Arrhythmias

Answer 72

Patients who are less severely affected present during childhood or after puberty. Their symptoms tend to be related to high androgen levels. Female patients: Tall for their age Facial hair Absent periods Deep voice Early puberty Male patients: Tall for their age Deep voice Large penis Small testicles Early puberty

Answer 73

Cortisol replacement, usually with hydrocortisone, similar to treatment for adrenal insufficiency Aldosterone replacement, usually with fludrocortisone Female patients with “virilised” genitals may require corrective surgery

Answer 74

Insulin-like growth factor 1 (IGF-1)

Answer 75

Growth hormone deficiency may present at birth or in neonates with: Micropenis (in males) Hypoglycaemia Severe jaundice Older infants and children can present with: Poor growth, usually stopping or severely slowing from age 2-3 Short stature Slow development of movement and strength Delayed puberty

Answer 76

Growth hormone stimulation tests involve measuring the response to medications that normally stimulate the release of growth hormone. Examples of these medications include glucagon, insulin, arginine and clonidine. Growth hormone levels are monitored regularly for 2-4 hours after administering the medication to assess the hormonal response. In growth hormone deficiency there will be a poor response to stimulation.

Answer 77

Daily subcutaneous injections of growth hormone (somatropin) Treatment of other associated hormone deficiencies Close monitoring of height and development

Answer 78

Congenital hypothyroidism is screened for on the newborn blood spot screening test. Where it is not picked up a birth, patients can present with: Prolonged neonatal jaundice Poor feeding Constipation Increased sleeping Reduced activity Slow growth and development

Answer 79

All children under 3 months with a fever should start immediate IV antibiotics (e.g. ceftriaxone) and have a full septic screen, including blood cultures, bloods and lactate. A lumbar puncture should also be considered.

Answer 80

All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks Children with atypical UTIs should have an abdominal ultrasound during the illness

Answer 81

diagnose using micturating cystourethrogram (MCUG) mx: - avoid constipation - avoid excessively full bladder - prophylactic antibiotics - surgical input form paeds urology

Answer 82

Vulvovaginitis refers to inflammation and irritation of the vulva and vagina. It is a common condition often affecting girls between the ages of 3 and 10 years. can cause leukocytes but no nitries on dipstick and often misdiagnosed as UTI. Mx is conservative If severe experienced paediatrician may recommend oestrogen cream

Answer 83

Low serum albumin High urine protein content (>3+ protein on urine dipstick) Oedema

Answer 84

high dose prednisolone for 4 weeks then gradually weaned over 8 weeks. - 80% respond and recover although 80% of these children relapse - steroid dependence if unable to wean due to relapse - steroid resistant if not affective (ACEi and immunosuppressants may be used)

Answer 85

Post-streptococcal glomerulonephritis occurs 1 – 3 weeks after a β-haemolytic streptococcus infection, such as tonsillitis caused by Streptococcus pyogenes. Immune complexes made up of streptococcal antigens, antibodies and complement proteins get stuck in the glomeruli of the kidney and cause inflammation. This inflammation leads to an acute deterioration in renal function, causing an acute kidney injury. Mx supportive 80% make full recovery

Answer 86

IgA nephropathy is also known as Berger’s disease. This condition is related to Henoch-Schonlein Purpura, which is an IgA vasculitis. IgA deposits in the nephrons of the kidney causes inflammation (nephritis). When a renal biopsy is taken the histology will show “IgA deposits and glomerular mesangial proliferation”. It usually presents in teenagers or young adults. Management involves supportive treatment of the renal failure and immunosuppressant medications such as steroids and cyclophosphamide to slow the progression of the disease.

Answer 87

Microangiopathic haemolytic anaemia Acute kidney injury Thrombocytopenia (low platelets)

Answer 88

E. coli O157 and Shigella cause gastroenteritis. Diarrhoea is the first symptom, which turns bloody within 3 days. Around a week after the onset of diarrhoea, the features of HUS develop: Fever Abdominal pain Lethargy Pallor Reduced urine output (oliguria) Haematuria Hypertension Bruising Jaundice (due to haemolysis) Confusion

Answer 89

Stool culture is used to establish the causative organism. HUS is a medical emergency and requires hospital admission and supportive management with treatment of: Hypovolaemia (e.g., IV fluids) Hypertension Severe anaemia (e.g., blood transfusions) Severe renal failure (e.g., haemodialysis) It is self-limiting, and most patients fully recover with good supportive care.

Answer 90

2 years old in daytime 5 years old at nighttime

Answer 91

Urinary tract infection Constipation Type 1 diabetes New psychosocial problems (e.g. stress in family or school life) Maltreatment

Answer 92

Secondary nocturnal enuresis is where a child begins wetting the bed when they have previously been dry for at least 6 months

Answer 93

Cystic enlargement of the renal collecting ducts Oligohydramnios, pulmonary hypoplasia and Potter syndrome Congenital liver fibrosis

Answer 94

underdeveloped ear cartilage, low set ears, a flat nasal bridge and abnormalities of the skeleton

Answer 95

one kidney made up of many cysts while other kidney is normal (if both this way = death) abnormal kidney usually atrophies before aged 5 and child lives normally inc. risk of UTI, hypertension and CKD no treatment

Answer 96

1/3 die in neonatal period 1/3 survive until adulthood

Answer 97

Consider a Wilms tumour in a child under the age of 5 years presenting with a mass in the abdomen. The parents may have noticed the mass, or they may present with signs and symptoms of: Abdominal pain Haematuria Lethargy Fever Hypertension Weight loss

Answer 98

The initial investigation is an ultrasound of the abdomen to visualise the kidneys. A CT or MRI scan can be used to stage the tumour. Biopsy to identify the histology is required to make a definitive diagnosis.

Answer 99

surgical excisim and nephrostomy +- adjuvatn chemotherapy or radiotherapy

Answer 100

A posterior urethral valve is where there is tissue at the proximal end of the urethra (closest to the bladder) that causes obstruction of urine output. It occurs in newborn boys. The obstruction to the outflow of urine creates a back pressure into the bladder, ureters and up to the kidneys, causing hydronephrosis. A restriction in the outflow of urine prevents the bladder from fully emptying, leading to a reservoir of urine that increases the risk of urinary tract infections.

Answer 101

Severe cases may be picked up on antenatal scans as oligohydramnios and hydronephrosis. To investigate cases presenting after birth, for example young boys presenting with urinary tract infections: Abdominal ultrasound may show an enlarged, thickened bladder and bilateral hydronephrosis Micturating cystourethrogram (MCUG) shows the location of the extra urethral tissue and reflux of urine back into the bladder Cystoscopy involves a camera inserted into the urethra to get a detailed view of the extra tissue. Cystoscopy can be used to ablate or remove the extra tissue.

Answer 102

Family history of undescended testes Low birth weight Small for gestational age Prematurity Maternal smoking during pregnancy

Answer 103

Watching and waiting is appropriate in newborns. In most cases the testes will descend in the first 3 – 6 months. If they have not descended by 6 months they should be seen by a paediatric urologist. Orchidopexy (surgical correction of undescended testes) should be carried out between 6 and 12 months of age.

Answer 104

Hypospadias is a condition affecting males, where the urethral meatus (the opening of the urethra) is abnormally displaced to the ventral side (underside) of the penis, towards the scrotum. This might be further towards the bottom of the glans (in 90% of cases), halfway down the shaft or even at the base of the shaft

Answer 105

Epispadias is where the meatus is displaced to the dorsal side (top side) of the penis

Answer 106

Hypospadias requires referral to a paediatric specialist urologist for ongoing management. It is important to warn parents not to circumcise the infant until a urologist indicates this is ok. Mild cases may not require any treatment Surgery is usually performed after 3 – 4 months of age Surgery aims to correct the position of the meatus and straighten the penis

Answer 107

Ultrasound is a useful investigation for confirming the diagnosis and excluding other causes. Simple hydroceles will usually resolve within 2 years without having any lasting negative effects. Parents can be reassured and followed up routinely. They may require surgery if they are associated with other problems, such as a hernia. Communicating hydroceles can be treated with a surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis

Answer 108

- warm the baby - calculate APGAR - stimulate breathing - inflation breaths - chest compressions (if HR <6obpm despite inflation breaths. 3:1 ratio with ventilation breaths) - escalation (IV drugs and intubation, babies near or at term may benefit from therapeutic hypothermia to prevent hypoxic-ischaemic encephalopathy)

Answer 109

to get blood from placenta into fetus (known as umbilical transfusion). In healthy babies this leads to improved haemoglobin, iron stores and BP. Reduction of intraventricular haemorrhage and necrotising enter-colitis. uncompromised neonates should have a delay of 1 minute.

Answer 110

- Skin to skin - Clamp the umbilical cord - Dry the baby - Keep the baby warm with a hat and blankets - Vitamin K - Label the baby - Measure the weight and length

Answer 111

Sickle cell disease Cystic fibrosis Congenital hypothyroidism Phenylketonuria Medium-chain acyl-CoA dehydrogenase deficiency (MCADD) Maple syrup urine disease (MSUD) Isovaleric acidaemia (IVA) Glutaric aciduria type 1 (GA1) Homocystin

Answer 112

taken on day 5 (day 8 latest) results take 6-8wks

Answer 113

The examination is performed within the first 72 hours after birth. It is repeated at 6 – 8 weeks by their GP.

Answer 114

measuring O2 sats before and after ductus arteriosus - pre-ductal > right wrist - post-ductal > either foot normal sats are above 96%. There should be no greater difference than 2%. This could suggest patent ductus arteriosus

Answer 115

positional is when muscles are slightly tight around the ankle but bones are unaffected. refer to physiotherapist. structural is when the bones of the foot and ankle are affected. refer to ortho.

Answer 116

Galeazzi > putting babys legs with feet flat and knees bent to look at differences in height between both knees. Barlow maneuver > The examiner gently applies pressure to the infant's thigh near the hip to dislocate the femoral head from the acetabulum. If the hip is dislocatable, a clunk may be felt. Ortolani maneuver > The examiner abducts the hip and applies gentle pressure to the proximal thigh from behind to relocate a dislocated femoral head back into the acetabulum.

Answer 117

injury to C5/6 nerves associated with forceps delivery, shoulder dystocia, large birth weight. weakness of shoulder abduction and external rotation, arm flexion and finger extension = 'waiters tip" appearance. Usually returns to normal within few months.

Answer 118

caput succedaneum - fluid collection on scalp outside the periosteum. - crosses suture lines. - causes very mild discolouration of skin. - resolves in a few days. cephalohaematoma - blood between skull and perosteum - does not cross suture lines. - can cause discoloration os skin. - resolves within few months. - risk of anaemia and jaundice if blood breaks down

Answer 119

assoc. with shoulder dystocia, instrumental delivery, large birth weight. feat: - noticeable lack of movement - asymmetry of shoulders - pain and distress on movement of arm confirm via USS or XR Sometimes needs immobilisations but usually heals well

Answer 120

Group B streptococcus (GBS) Escherichia coli (e. coli) Listeria Klebsiella Staphylococcus aureu

Answer 121

Vaginal GBS colonisation GBS sepsis in a previous baby Maternal sepsis, chorioamnionitis or fever > 38ºC Prematurity (less than 37 weeks) Early (premature) rupture of membrane Prolonged rupture of membranes (PROM)

Answer 122

Fever Reduced tone and activity Poor feeding Respiratory distress or apnoea Vomiting Tachycardia or bradycardia Hypoxia Jaundice within 24 hours Seizures Hypoglycaemia

Answer 123

- If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours - If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics - Antibiotics should be started if there is a single red flag - Antibiotics should be given within 1 hour of making the decision to start them - Blood cultures should be taken before antibiotics are given - Check a baseline FBC and CRP - Perform a lumbar puncture if infection is strongly suspected or there are features of meningitis (e.g. seizures)

Answer 124

- Confirmed or suspected sepsis in the mother -Signs of shock - Seizures - Term baby needing mechanical ventilation - Respiratory distress starting more than 4 hours after birth - Presumed sepsis in another baby in a multiple pregnancy

Answer 125

1 > Benzylpenicillin and gentamycin If low risk Cefotaxime alternative

Answer 126

Check the CRP again at 24 hours and check the blood culture results at 36 hours: Consider stopping the antibiotics if the baby is clinically well, the blood cultures are negative 36 hours after taking them and both CRP results are less than 10. Check the CRP again at 5 days if they are still on treatment: Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days. Consider performing a lumbar puncture if any of the CRP results are more than 10.

Answer 127

events that could lead to hypoxia during the perinatal or intrapartum period, acidosis (pH < 7) on the umbilical artery blood gas, poor Apgar scores, features of mild, moderate or severe HIE (see below) or evidence of multi organ failure.

Answer 128

maternal shock intrapartum haemorrhage prolapsed cord nuchal cord

Answer 129

within first 24hrs of life More than 14 days in full term babies More than 21 days in premature babies

Answer 130

Full blood count and blood film for polycythaemia or anaemia Conjugated bilirubin: elevated levels indicate a hepatobiliary cause Blood type testing of mother and baby for ABO or rhesus incompatibility Direct Coombs Test (direct antiglobulin test) for haemolysis Thyroid function, particularly for hypothyroid Blood and urine cultures if infection is suspected. Suspected sepsis needs treatment with antibiotics. Glucose-6-phosphate-dehydrogenase (G6PD) levels for G6PD deficiency

Answer 131

phototherapy (blue light shone on baby which converts unconjugated bilirubin into isomers which are excreted in the urine)

Answer 132

Under 28 weeks: extreme preterm 28 – 32 weeks: very preterm 32 – 37 weeks: moderate to late preterm

Answer 133

Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality IV Magnesium sulphate: can be offered before 34 weeks gestation and helps protect the baby’s brain Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby

Answer 134

Neonatal units attach apnoea monitors to premature babies. These make a sound when an apnoea is occurring. Tactile stimulation is used to prompt the baby to restart breathing. Intravenous caffeine can be used to prevent apnoea and bradycardia in babies with recurrent episodes.

Answer 135

Retinal blood vessel development starts at around 16 weeks and is complete by 37 – 40 weeks gestation. The blood vessels grow from the middle of the retina to the outer area. This vessel formation is stimulated by hypoxia, which is a normal condition in the retina during pregnancy. When the retina is exposed to higher oxygen concentrations in a preterm baby, particularly with supplementary oxygen during medical care, the stimulant for normal blood vessel development is removed. When the hypoxic environment recurs, the retina responds by producing excessive blood vessels (neovascularisation), as well as scar tissue. These abnormal blood vessels may regress and leave the retina without a blood supply. The scar tissue may cause retinal detachment.

Answer 136

Babies born before 32 weeks or under 1.5kg should be screened for ROP. Screening is performed by an ophthalmologist. Screening starts at: 30 – 31 weeks gestational age in babies born before 27 weeks 4 – 5 weeks of age in babies born after 27 weeks Screening should happen at least every 2 weeks and can cease once the retinal vessels enter zone 3, usually at around 36 weeks gestation.

Answer 137

Inadequate surfactant leads to high surface tension within alveoli. This leads to atelectasis (lung collapse), as it is more difficult for the alveoli and the lungs to expand. This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress.

Answer 138

antenatal steroids given in preterm labour. once born: - intubation and ventilation if severe - endotracheal surfactant - CPAP - supplementary oxygen (maintain sats of 91-95%)

Answer 139

- very low birth weight or very premature - formula feeds - respiratory distress and assisted ventilation - sepsis - patent ductus arteriosus and other congenital heart disease

Answer 140

- nil by mouth with IV fluids - Total parenteral nutrition - antibiotics - NG tube - surgical referral

Answer 141

3-72hrs - opiates - diazepam - SSRI - alcohol 24 hrs - 21 days - methadone and other benzodiazepines

Answer 142

Mothers that are known to use substances should have an alert on their notes so that when they give birth the neonate can have extra monitoring and management of NAS. Babies are kept in hospital with monitoring on a NAS chart for at least 3 days (48 hours for SSRI antidepressants) to monitor for withdrawal symptoms. A urine sample can be collected from the neonate to test for substances. The neonate should be supported in a quiet and dim environment with gentle handling and comforting.

Answer 143

- oral morphine sulphate - oral phenobarbitone

Answer 144

Intracranial calcification Hydrocephalus Chorioretinitis

Answer 145

Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye and the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy

Answer 146

Prematurity Low birth weight Smoking during pregnancy Male baby (only slightly increased risk)

Answer 147

Put the baby on their back when not directly supervised Keep their head uncovered Place their feet at the foot of the bed to prevent them sliding down and under the blanket Keep the cot clear of lots of toys and blankets Maintain a comfortable room temperature (16 – 20 ºC) Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes). Avoid co-sleeping, particularly on a sofa or chair If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers

Answer 148

exclusive breast feeding for first 6 months of life

Answer 149

It is acceptable for breast fed babies to loose up to 10% and formula fed babies to loose up to 5% of their body weight by day 5 of life. They should be back at their birth weight by day 10. If they loose more weight than this or do not regain their birth weight by two weeks, they need admission to hospital and assessment for possible causes.

Answer 150

~6 months by 1 year of age should resemble diet of older child

Answer 151

First 2 years: rapid growth driven by nutritional factors From 2 years to puberty: steady slow growth During puberty: rapid growth spurt driven by sex hormones

Answer 152

A fall in weight across: - One or more centile spaces if their birthweight was below the 9th centile - Two or more centile spaces if their birthweight was between the 9th and 91st centile - Three or more centile spaces if their birthweight was above the 91st centile

Answer 153

(height of mum + height of dad) / 2.

Answer 154

Boys: (mother height + fathers height + 14cm) / 2 Girls: (mothers height + father height – 14cm) / 2

Answer 155

variant of normal. Short as a child but normal stature as an adult. A key feature of CDGP is delayed bone age. It is possible to estimate the age of a child using xray images of their wrist and hand by assessing the size and shape of the bones and the growth plates

Answer 156

Puberty starts age 8 – 14 in girls and 9 – 15 in boys. It takes about 4 years from start to finish. threshold for investigation is no evidence of pubertal changes in girls aged 13 or boys aged 14

Answer 157

Kallman syndrome is a genetic condition causing hypogonadotrophic hypogonadism, resulting in failure to start puberty. It is associated with a reduced or absent sense of smell (anosmia).

Answer 158

11-14 weeks gestation by combining USS and maternal blood tests. USS - nuchal translucency >6mm Maternal Blood Tests - high Beta-human chorionic gonadotrophin (beta-HCG) low Pregnancy- associated plasma protein-A (PAPPA)

Answer 159

Beta-HCG. A higher result indicates greater risk. Alpha-fetoprotein (AFP). A lower result indicates a greater risk. Serum oestriol (female sex hormone). A lower result indicates a greater risk. + Inhibin-A (high + greater risk)

Answer 160

- Regular thyroid checks (2 yearly) - Echocardiogram to diagnose cardiac defects - Regular audiometry for hearing impairment - Regular eye checks

Answer 161

males with 47 XXY feat: - Taller height - Wider hips - Gynaecomastia - Weaker muscles - Small testicles - Reduced libido - Shyness - Infertility - Subtle learning difficulties (particularly affecting speech and language)

Answer 162

females with 45 X0 Feat: - Short stature - Webbed neck - High arching palate - Downward sloping eyes with ptosis - Broad chest with widely spaced nipples - Cubitus valgus Underdeveloped ovaries with reduced function - Late or incomplete puberty - Most women are infertile

Answer 163

Autosomal dominant condition affecting FIbrillin (connective tissue) feat: Tall stature Long neck Long limbs Long fingers (arachnodactyly) High arch palate Hypermobility Pectus carinatum or pectus excavatum Downward sloping palpable fissures

Answer 164

variety of genes inherited in autosomal dominant way. Feat: - Short stature - Broad forehead - Downward sloping eyes with ptosis - Hypertelorism (wide space between the eyes) - Prominent nasolabial folds - Low set ears - Webbed neck - Widely spaced nipples

Answer 165

X-linked (unclear whether recessive or dominant). Involving the fragile X mental retardation 1 gene (FMR1) feat: Intellectual disability Long, narrow face Large ears Large testicles after puberty Hypermobile joints (particularly in the hands) Attention deficit hyperactivity disorder (ADHD) Autism Seizures

Answer 166

loss of functional genes on proximal arm of chromosone 15 inherited from the father. fear: Constant insatiable hunger that leads to obesity Poor muscle tone as an infant (hypotonia) Mild-moderate learning disability Hypogonadism Fairer, soft skin that is prone to bruising Mental health problems, particularly anxiety Dysmorphic features Narrow forehead Almond shaped eyes Strabismus Thin upper lip Downturned mouth

Answer 167

loss of function of the UBE3A gene inherited from the mother. feat: - Delayed development and learning disability - Severe delay or absence of speech development - Coordination and balance problems (ataxia) - Fascination with water - Happy demeanour - Inappropriate laughter - Hand flapping - Abnormal sleep patterns - Epilepsy - Attention-deficit hyperactivity disorder - Dysmorphic features - Microcephaly - Fair skin, light hair and blue eyes - Wide mouth with widely spaced teeth

Answer 168

deletion of material on one copy of chromosome 7, usually random. Feat: - Broad forehead - Starburst eyes (a star-like pattern on the iris) - Flattened nasal bridge - Long philtrum - Wide mouth with widely spaced teeth - Small chin - Very sociable trusting personality - Mild learning disability

Answer 169

Focal seizures start in the temporal lobes. They affect hearing, speech, memory and emotions. There are various ways that focal seizures can present: - Hallucinations - Memory flashbacks - Déjà vu - Doing strange things on autopilot 1> carbamazepine or lamotrigine 2> sodium valproate or levetiracetam

Answer 170

Absence seizures typically happen in children. The patient becomes blank, stares into space and then abruptly returns to normal. During the episode they are unaware of their surroundings and won’t respond. These typically only lasts 10 to 20 seconds. Most patients (more than 90%) stop having absence seizures as they get older. 1> sodium valproate or ethosuximide

Answer 171

Atonic seizures are also known as drop attacks. They are characterised by brief lapses in muscle tone. These don’t usually last more than 3 minutes. They typically begin in childhood. They may be indicative of Lennox-Gastaut syndrome. Management is: 1> sodium valproate 2> lamotrigine

Answer 172

Myoclonic seizures present as sudden brief muscle contractions, like a sudden “jump”. The patient usually remains awake during the episode. They occur in various forms of epilepsy but typically happen in children as part of juvenile myoclonic epilepsy. Management is: 1> sodium valproate 2> lamotrigine, levetiracetam or topiramate

Answer 173

This is also known as West syndrome. It is a rare (1 in 4000) disorder starting in infancy at around 6 months of age. It is characterised by clusters of full body spasms. There is a poor prognosis: 1/3 die by age 25, however 1/3 are seizure free. 1> Prednisolone or Vigabatrin

Answer 174

The first seizure is in children under 2 years Focal seizures There is no response to first line anti-epileptic medications

Answer 175

- Put the patient in a safe position (e.g. on a carpeted floor) - Place in the recovery position if possible - Put something soft under their head to protect against head injury - Remove obstacles that could lead to injury - Make a note of the time at the start and end of the seizure - Call an ambulance if lasting more than 5 minutes or this is their first seizure.

Answer 176

It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.

Answer 177

1. Secure the airway 2. Give high-concentration oxygen 3. Assess cardiac and respiratory function 4. Check blood glucose levels 5. Gain intravenous access (insert a cannula) 6. IV lorazepam, repeated after 10 minutes if the seizure continues If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin. At this point intubation and ventilation to secure the airway needs to be considered, along with transfer to the intensive care unit if appropriate.

Answer 178

Simple febrile convulsions are generalised, tonic clonic seizures. They last less than 15 minutes and only occur once during a single febrile illness. Febrile convulsions can be described as complex when they consist of partial or focal seizures, last more than 15 minutes or occur multiple times during the same febrile illness.

Answer 179

1.8% for the general population 2-7.5% after a simple febrile convulsion 10-20% after a complex febrile convulsion

Answer 180

Spastic: hypertonia (increased tone) and reduced function resulting from damage to upper motor neurones Dyskinetic: problems controlling muscle tone, with hypertonia and hypotonia, causing athetoid movements and oro-motor problems. This is the result of damage to the basal ganglia. Ataxic: problems with coordinated movement resulting from damage to the cerebellum Mixed: a mix of spastic, dyskinetic and/or ataxic features

Answer 181

1. hemiplegic or diplegic gait 2. UMN signs > good muscle bulk, inc. tone, brisk reflexes, slightly reduced power 3. extramyrpymidal signs 4. cerebellar signs

Answer 182

Must be before age 8 Occlusive patch to cover good eye and force the weaker eye to develop. Or Atropine drops in good eye to cause blurring of vision.

Answer 183

aqueductal stenosis aka stenosis of the aqueduct between the third and fourth ventricle.

Answer 184

defective gene for dystrophin on the x-chromosome. X-linked recessive.

Answer 185

25-35 years

Answer 186

Anaemia (low haemoglobin) Leucopenia (low white cell count) Thrombocytopenia (low platelets) Hypokalaemia (low potassium – due to vomiting or excessive laxatives)

Answer 187

Hypomagnesaemia (low serum magnesium) Hypokalaemia (low serum potassium) Hypophosphataemia (low serum phosphate) Fluid overload (due to water following the extra sodium into the extracellular space)

Answer 188

- Slowly reintroducing food with limited calories - Magnesium, potassium, phosphate and glucose monitoring - Fluid balance monitoring - ECG monitoring in severe cases Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine

Answer 189

around or after 5 yrs

Answer 190

- Habit reversal training - Exposure with response prevention - Medications may be tried in very severe cases, usually with antipsychotic medications

Answer 191

Fetal haemoglobin (HbF) has two alpha and two gamma subunits. Adult haemoglobin (HbA) has two alpha and two beta subunits. this means fetal Hb has higher affinity for O2 than adult Hb.

Answer 192

Hydroxycarbamide

Answer 193

T – Thalassaemia A – Anaemia of chronic disease I – Iron deficiency anaemia L – Lead poisoning S – Sideroblastic anaemia

Answer 194

A – Acute blood loss A – Anaemia of Chronic Disease A – Aplastic Anaemia H – Haemolytic Anaemia H – Hypothyroidism

Answer 195

- Hb low - Ferritin low or normal (especially if ongoing inflammation) - TIBC and transferrin high

Answer 196

ALL peaks aged 2 – 3 years AML peaks aged under 2 years

Answer 197

NICE recommend referring any child with unexplained petechiae or hepatomegaly for immediate specialist assessment. If leukaemia is suspected based on the non-specific signs above, NICE recommend a very urgent full blood count within 48 hours.

Answer 198

Full blood count, which can show anaemia, leukopenia, thrombocytopenia and high numbers of the abnormal WBCs Blood film, which can show blast cells Bone marrow biopsy Lymph node biopsy

Answer 199

The overall cure rate for ALL is around 80%, but prognosis depends on individual factors. The outcomes are less positive for AML.

Answer 200

Idiopathic thrombocytopenic purpura (ITP) is a condition characterised by idiopathic (spontaneous) thrombocytopenia (low platelet count) causing a purpuric rash (non-blanching rash). ITP is caused by a type II hypersensitivity reaction. It is caused by the production of antibodies that target and destroy platelets. This can happen spontaneously, or it can be triggered by something, such as a viral infection.

Answer 201

Idiopathic thrombocytopenic purpura usually present in children under 10 years old. Often there is a history of a recent viral illness. The onset of symptoms occurs over 24 – 48 hours: Bleeding, for example from the gums, epistaxis or menorrhagia Bruising Petechial or purpuric rash, caused by bleeding under the skin

Answer 202

The condition can be confirmed by doing an urgent full blood count for the platelet count. Other values on the FBC should be normal. Other causes of a low platelet count should be excluded, for example heparin induced thrombocytopenia and leukaemia. The severity and management depends on how low the platelet count falls. Usually no treatment is required and patients are monitored until the platelets return to normal. Treatment may be required if the patient is actively bleeding or severe thrombocytopenia (platelets below 10): - Prednisolone - IV immunoglobulins - Blood transfusions if required - Platelet transfusions only work temporarily

Answer 203

- Low threshold for admission to hospital - Treating infections that may have triggered the crisis - Keep warm - Good hydration (IV fluids may be required) - Analgesia (NSAIDs should be avoided where there is renal impairment)

Answer 204

red blood cells block flow within the spleen = enlarged & painful spleen. Can lead to severe anaemia and hypovolaemic shock. Mx > supportive, blood transfusions and fluid resus splenectomy in recurrent cases

Answer 205

temporary absence of creation of new red blood cells triggered by parovirus B19. Leads to significant anaemia. Mx supportive +- blood transfusions. Usually resolves spontaneously within a week

Answer 206

vessels supplying lungs become clogged by RBC. Acute chest syndrome presents with fever, SOB, chest pain, cough and hypoxia. CXR shows pulmonary infiltrates. Mx > - Analgesia - IV fluids - Antibiotics / antivirals if infection suspected - Blood transfusions - Incentive spirometry - Respiratory support

Answer 207

Crizanlizumab (targets P-selectin)

Answer 208

Thalassaemia is related to a genetic defect in the protein chains that make up haemoglobin. Normal haemoglobin consists of 2 alpha and 2 beta globin chains. Defects in the alpha globin chains lead to alpha thalassaemia. Defects in the beta globin chains lead to beta thalassaemia. Both conditions are autosomal recessive. This causes RBC to become more fragile and breakdown more easily.

Answer 209

Microcytic anaemia (low mean corpuscular volume) Fatigue Pallor Jaundice Gallstones Splenomegaly Poor growth and development Pronounced forehead and malar eminences

Answer 210

faulty creation of red blood cells, recurrent transfusions and increased absorption of iron in the gut in response to anaemia.

Answer 211

Hereditary spherocytosis is a condition where the red blood cells are sphere shaped, making them fragile and easily destroyed when passing through the spleen. It is the most common inherited haemolytic anaemia in northern Europeans. It is an autosomal dominant condition.

Answer 212

Jaundice Anaemia Gallstones Splenomegaly can also present with haemolytic crisis triggered by infection or aplastic crisis often triggered by parovirus.

Answer 213

Hereditary spherocytosis is diagnosed by family history and clinical features, along with spherocytes on the blood film. The mean corpuscular haemoglobin concentration (MCHC) is raised on a full blood count. Reticulocytes will be raised due to rapid turnover of red blood cells.

Answer 214

Treatment is with folate supplementation and splenectomy. Removal of the gallbladder (cholecystectomy) may be required if gallstones are a problem. Transfusions may be required during acute crises.

Answer 215

deficiency in G6PD enzyme found in all cells in body. Particularly important in RBC, without it RBC undergo haemolysis. Inherited in X-linked recessive pattern (usually affects males) Mediterranean, Middle Eastern and African patients

Answer 216

Heinz bodies (blobs of denatured Hb within RBCs)

Answer 217

Patient should avoid triggers to acute haemolysis where possible. This includes avoiding fava beans and certain medications. Medications that trigger haemolysis and should be avoided include: Primaquine (an antimalarial) Ciprofloxacin Nitrofurantoin Trimethoprim Sulfonylureas (e.g gliclazide) Sulfasalazine and other sulphonamide drugs

Answer 218

IgE antibodies to a specific allergen trigger mast cells and basophils to release histamines and other cytokines. This causes an immediate reaction. Typical food allergy reactions, where exposure to the allergen leads to an acute reaction, range from itching, facial swelling and urticaria to anaphylaxis

Answer 219

IgG and IgM antibodies react to an allergen and activate the complement system, leading to direct damage to the local cells. Examples are haemolytic disease of the newborn and transfusion reactions.

Answer 220

Immune complexes accumulate and cause damage to local tissues. Examples are autoimmune conditions such as systemic lupus erythematosus (SLE), rheumatoid arthritis and Henoch-Schönlein purpura (HSP)

Answer 221

Cell mediated hypersensitivity reactions caused by T lymphocytes. T-cells are inappropriately activated, causing inflammation and damage to local tissues. Examples are organ transplant rejection and contact dermatitis.

Answer 222

admit child to paediatric unit for assessment and observation. In case of biphasic reactions. Confirm anaphylaxis by measuring the serum mast cell tryptase within 6hrs. education and follow-up with family and child. referral for training on how to use an adrenalin auto-injector.

Answer 223

Non-sedating antihistamines include cetirizine, loratadine and fexofenadine Sedating antihistamines include chlorphenamine (Piriton) and promethazine

Answer 224

skin prick testing can support diagnosis but is not always needed.

Answer 225

- Breast feeding mothers should avoid dairy products - Replace formula with special hydrolysed formulas designed for cow’s milk allergy every 6 months or so infants should try consuming small quantities of milk and working up the "milk ladder" to see if resolved

Answer 226

age 3 (often earlier)

Answer 227

in cows milk intolerance you get same GI symptoms as allergy but no allergic feat (cough, rasg, angio-oedema, sneeze etc) Infants with cow’s milk intolerance will grow out of it by 2 – 3 years. They can be fed with breast milk, hydrolysed formulas and weaned to foods not containing cow’s milk. After one year of age they can be started on the milk ladder.

Answer 228

Severe combined immunodeficiency (SCID) is the most severe condition causing immunodeficiency. Children with SCID have almost no immunity to infections. It is a syndrome caused by a number of different genetic disorders that result in absent or dysfunctioning T and B cells.

Answer 229

SCID is fatal unless successfully treated. Management should be in a specialist immunology centre. Management involves treating underlying infections, immunoglobulin therapy, minimising the risk of new infections with a sterile environment, avoiding live vaccines and performing haematopoietic stem cell transplantation

Answer 230

<3 months with temperature >38 degrees

Answer 231

The causative pathogens are recognised by macrophages, lymphocytes and mast cells. These cells release vast amounts of cytokines, such as interleukins and tumor necrosis factor, to alert the immune system to the invader. These cytokines activate other parts of the immune system. This immune activation leads to further release of chemicals such as nitrous oxide that causes vasodilation. The immune response causes inflammation throughout the body. Many of these cytokines cause the endothelial lining of blood vessels to become more permeable. This causes fluid to leak out of the blood into the extracellular space, leading to oedema and a reduction in intravascular volume. The oedema around blood vessels creates a space between the blood and the tissues, reducing the amount of oxygen that reaches the tissues. Activation of the coagulation system leads to deposition of fibrin throughout the circulation, further compromising organ and tissue perfusion. It also leads to consumption of platelets and clotting factors, as they are being used up to form the blood clots. This leads to thrombocytopenia, haemorrhages and an inability to form clots and stop bleeding. This is called disseminated intravascular coagulopathy (DIC). Blood lactate rises as a result of anaerobic respiration in the hypo-perfused tissues with an inadequate oxygen. A waste product of anaerobic respiration is lactate.

Answer 232

when sepsis leads to cardiovascular dysfunction. Arterial BP falls > organ hypo-perfusion > rise in blood lactate as organs begin anaerobic respiration.

Answer 233

Colour: normal colour versus cyanosis, mottled pale or ashen Activity: active, happy and responsive versus abnormal responses, drowsy or inconsolable cry Respiratory: normal breathing versus respiratory distress, tachypnoea or grunting Circulation and hydration: normal skin and moist membranes versus tachycardia, dry membranes or poor skin turgor Other: other concerning signs, such as fever > 5 days, non blanching rash, seizures or high temperatures < 6 months

Answer 234

Under 1 month presenting with fever 1 to 3 months with fever and are unwell Under 1 year with unexplained fever and other features of serious illness

Answer 235

stat injection of Benzylpenicillin (IM or IV). Giving antibiotics should not delay transfer.

Answer 236

LP before startign Abx send blood for meningococcal PCR if this is suspected. Under 3 mnths > cefotaxime plus Amoxicillin Above 3 mnths > Ceftriaxone add vancomycin is risk of penicillin resistant pneumococcal infection eg recent foreign traval or prolonged antibiotic exposure steroids given if LP suggestive of bacterial meningitis to prevent hearing loss (dexamethasone 4x day for 4 days) notify public health

Answer 237

single dose of Ciprofloxacin ideally within 24 hrs of diagnosis

Answer 238

appearance > cloudy protein > high glucose > low WCC > high (neutrophils) culture > bacteria isolated

Answer 239

Hearing loss is a key complication Seizures and epilepsy Cognitive impairment and learning disability Memory loss Cerebral palsy, with focal neurological deficits such as limb weakness or spasticity

Answer 240

Ganciclovir

Answer 241

develop an itchy maculopapular rash

Answer 242

Splenic rupture Glomerulonephritis Haemolytic anaemia Thrombocytopenia Chronic fatigue EBV infection is associated with certain cancers, notable Burkitt’s lymphoma.

Answer 243

Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml Caesarean sections are considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml

Answer 244

Low risk babies, where mums viral load is < 50 copies per ml, should be given zidovudine for 4 weeks High risk babies, where mums viral load is > 50 copies / ml, should be given zidovudine, lamivudine and nevirapine for 4 weeks

Answer 245

HIV can be transmitted during breastfeeding, even if the mother’s viral load is undetectable. Breastfeeding is never recommended for mothers with HIV, however if the mum is adamant and the viral load is undetectable, sometimes it is attempted with close monitoring by the HIV team.

Answer 246

HIV viral load test at 3 months. If this is negative, the child has not contracted HIV during birth and will not develop HIV unless they have further exposure. HIV antibody test at 24 months. This is to assess whether they have contracted HIV since their 3 month viral load, for example through breast feeding. If the 3 month test is negative and they are not breastfed, this should be negative.

Answer 247

Surface antigen (HBsAg) – active infection E antigen (HBeAg) – marker of viral replication and implies high infectivity Core antibodies (HBcAb) – implies past or current infection Surface antibody (HBsAb) – implies vaccination or past or current infection Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load

Answer 248

Within 24 hrs of birth give: 1. Hep B vaccine 2. Hep B immunoglobulin infusions additional vaccines at 1 and 12 months and 3x more as part of normal 6-in-1 childhood vaccine schedule Tested for HBsAg at 1 year ro see if they've contracted Hep B

Answer 249

tested at 18 months of age.

Answer 250

A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present: 1. Fever over 38ºC 2. Tonsillar exudates 3. Absence of cough 4. Tender anterior cervical lymph nodes (lymphadenopathy)

Answer 251

score of 2 – 3 gives a 34 – 40% probability and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis: Fever during previous 24 hours P – Purulence (pus on tonsils) A – Attended within 3 days of the onset of symptoms I – Inflamed tonsils (severely inflamed) N – No cough or coryza

Answer 252

Penicillin V (phenoxymethylpenicillin) 1o days. clarithromycin if allergic

Answer 253

Group A Strep (Streptococcus Pyogenes)

Answer 254

refer as inpatient under ENT for incision and drainage under GA. ABx e.g. Co-Amoxiclav Sometimes add steroids to reduce inflammation

Answer 255

7 or more in 1 year 5 per year for 2 years 3 per year for 3 years Other indications are: - Recurrent tonsillar abscesses (2 episodes) - Enlarged tonsils causing difficulty breathing, swallowing or snoring

Answer 256

1. Call the ENT registrar and get them involved early 2. Get IV access and send bloods including a FBC, clotting screen, group and save and crossmatch 3. Keep the child calm and give adequate analgesia 4. Sit them up and encourage them to spit the blood rather than swallowing 5. Make the child nil by mouth incase an anaesthetic and operation is required 6. IV fluids for maintenance and resuscitation as required if less severe can try: - hydrogen peroxide - adrenaline soaked swab applied topically

Answer 257

streptococcus pneumoniae other - Haemophilus influenzae - moraxella catarrhalis - staphylococcus aureus

Answer 258

Consider prescribing antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised. Children less than 2 years with bilateral otitis media and children with otorrhoea (discharge) are more likely to benefit from antibiotics.

Answer 259

The first line choice of antibiotic is amoxicillin for 5 days. Alternatives are erythromycin and clarithromycin.

Answer 260

- Referral for audiometry to help establish the diagnosis and extent of hearing loss. - Glue ear is usually treated conservatively, and resolves without treatment within 3 months. - Children with co-morbidities affecting the structure of the ear, such as Down’s syndrome or cleft palate may require hearing aids or grommets.

Answer 261

Grommets are tiny tubes inserted into the tympanic membrane by an ENT surgeon. This allows fluid from the middle ear to drain through the tympanic membrane to the ear canal. Usually grommets are inserted under general anaesthetic as a day case procedure. The procedure is relatively safe with few complications. Grommets usually fall out within a year, and only 1 in 3 patients require further grommets to be inserted for persistent glue ear.

Answer 262

automated otoacoustic emission test. If uncelar results offer a second test known as a automated auditory brainstem response test

Answer 263

They originate from Kiesselbach’s plexus, which is also known as Little’s area.

Answer 264

Sit up and tilt the head forwards. Tilting the head backwards is not advised as blood will flow towards the airway. Squeeze the soft part of the nostrils together for 10 – 15 minutes Spit any blood in the mouth out rather than swallowing

Answer 265

When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, from both nostrils or they are unstable, patients may require admission to hospital.

Answer 266

1. Nasal packing using nasal tampons or inflatable packs 2. Nasal cautery using a silver nitrate stick After treating a nosebleed consider prescribing naseptin (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.

Answer 267

malformation of the lymphatic system resulting in a cyst filled with lymphatic fluid. most common in the posterior triangle on the left side.

Answer 268

Cystic hygromas most commonly present in the neck or armpit. They: - Can be very large - Are soft - Are non-tender - Transilluminate To transilluminate the cystic hygroma, hold a pen torch flat against the skin and watch as the whole thing lights up like a bulb.

Answer 269

Treatment varies based on the size, location and complications. Watching and waiting can be appropriate as it is a benign condition. They do not resolve spontaneously, but can show some regression. Aspiration (giving temporary improvement), surgical removal and sclerotherapy are treatment options.

Answer 270

persistence of an anatomical structure present in normal development called a thyroglossal duct. This fills with fluid forming a cyst. found in front of the trachea.

Answer 271

Thyroglossal cysts usually occur in the midline of the neck. They are: - Mobile - Non-tender - Soft - Fluctuant Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue.

Answer 272

Ultrasound or CT scan can confirm the diagnosis. Thyroglossal cysts are usually surgically removed to provide confirmation of the diagnosis on histology and prevent infections. The cyst can reoccur after surgery unless the full thyroglossal duct is removed.

Answer 273

abnormality arising from the second brachial cleft. leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This can fill with fluid. present as round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.

Answer 274

Salter-Harris Classification: Use the SALTR mnemonic to remember the types: Type 1: Straight across Type 2: Above Type 3: BeLow Type 4: Through Type 5: CRush

Answer 275

when only one side of bone fractures

Answer 276

when bone buldges out without breaking

Answer 277

Child under 3 years Fever Waking at night with pain Weight loss Anorexia Night sweats Fatigue Persistent pain Stiffness in the morning Swollen or red joint

Answer 278

Child under 3 years Child older than 9 with a restricted or painful hip Not able to weight bear Evidence of neurovascular compromise Severe pain or agitation Red flags for serious pathology Suspicion of abuse

Answer 279

3 to 6 weeks

Answer 280

Managed in primary care if limp present for less than 48hrs. Need to give clear safety netting advice to attend A&E immediately if not resolving or develop a fever. Follow up after 48hrs and 1 week to ensure symptoms have fully resolved.

Answer 281

IN mild-mod manage conservatively: - bed rest - traction - crutches - analgesia physiotherapy regular XR surgery if severe, older children and not healing.

Answer 282

patients prefer to keep hip in external rotation as restricted internal rotation.

Answer 283

surgery to correct position of the femoral head and prevent it slipping further.

Answer 284

- Open bone fracture - Orthopaedic surgery - Immunocompromised - Sickle cell anaemia - HIV - Tuberculosis

Answer 285

Xrays are often the initial investigation, but can be normal in osteomyelitis. MRI is the best imaging investigation for establishing a diagnosis. A bone scan is an alternative. Blood tests will show raised inflammatory markers (CRP and ESR) and white blood cells in response to the infection. Blood culture is important in establishing the causative organism. A bone marrow aspiration or bone biopsy with histology and culture may be necessary.

Answer 286

Treatment requires extensive and prolonged antibiotic therapy. They may require surgery for drainage and debridement of the infected bone.

Answer 287

most common > femur other > tibia & humerus

Answer 288

NICE guidelines recommend a very urgent direct access xray within 48 hours for children presenting with unexplained bone pain or swelling. If the xray suggests a possible sarcoma they need very urgent specialist assessment within 48 hours XR show "fluffy" appearance of bone. Periosteal reaction (irritation of the bone lining) known as "Sun-burst" appearance. Blood tests > raised ALP

Answer 289

Management involves surgical resection of the lesion, often with a limb amputation. Adjuvant chemotherapy is used alongside surgery to improve outcomes.

Answer 290

main > persistent bone pain, particularly worse at night. May disturb or wake up from sleep. other> - bone swelling - palpable mass - restricted joint movements

Answer 291

manipulat foot towards a normal position and apply cast to fold in position. repeat until foot in correct position. + achilles tenotomy to release tension in achilles tendon performed in clinic. brace then used to hold feet in correct position when not walking until child aged 4.

Answer 292

- First degree family history - Breech presentation from 36 weeks onwards - Breech presentation at birth if 28 weeks onwards - Multiple pregnancy

Answer 293

Treatment typically involves a Pavlik harness if the baby presents at less than 6 months of age. The Pavlik harness is fitted and kept on permanently, adjusting for the growth of the baby. The aim is to hold the femoral head in the correct position to allow the hip socket (acetabulum) to develop a normal shape. This harness keeps the baby’s hips flexed and abducted. The child is regularly reviewed and the harness is removed when their hips are more stable, usually after 6 – 8 weeks. Surgery is required when the harness fails or the diagnosis is made after 6 months of age. After surgery is performed, an hip spica cast is used to immobilises the hip for a prolonged period.

Answer 294

- Bowing of the legs, where the legs curve outwards - Knock knees, where the legs curve inwards - Rachitic rosary, where the ends of the ribs expand at the costochondral junctions, causing lumps along the chest - Craniotabes, which is a soft skull, with delayed closure of the sutures and frontal bossing - Delayed teeth with under-development of the enamel

Answer 295

Serum calcium may be low Serum phosphate may be low Serum alkaline phosphatase may be high Parathyroid hormone may be high

Answer 296

The achondroplasia gene, fibroblast growth factor receptor 3 (FGFR3), is on chromosome 4. Achondroplasia results from either a sporadic mutation or inheritance of an abnormal copy of this gene. The condition is inherited in an autosomal dominant pattern. Homozygous gene mutations, meaning two abnormal gene copies with one from each parent, is fatal in the neonatal period. Therefore, patients with achondroplasia have one normal gene and one abnormal gene. Mutations in the FGFR3 gene causes abnormal function of the epiphyseal plates (growth plates). This restricts the bone growth in length, leading to short bones and short stature.

Answer 297

- Recurrent otitis media, due to cranial abnormalities - Kyphoscoliosis - Spinal stenosis - Obstructive sleep apnoea - Obesity - Foramen magnum stenosis can lead to cervical cord compression and hydrocephalus

Answer 298

It typically occurs in patients aged 10 – 15 years, and is more common in males. Osgood-Schlatter disease is usually unilateral, but it can be bilateral.

Answer 299

Osteogenesis imperfecta is a genetic condition that results in brittle bones that are prone to fractures. It is also knowns as brittle bone syndrome. It is caused by a range of genetic mutations that affect the formation of collagen. Collagen is a protein that is essential is maintaining the structure and function of bone, as well as skin, tendons and other connective tissues. There are 8 types of osteogenesis imperfecta depending on the underlying genetic mutation, and they vary in their severity

Answer 300

recurrent and inappropriate fractures assoc. feat: - Hypermobility - Blue / grey sclera (the “whites” of the eyes) - Triangular face - Short stature - Deafness from early adulthood - Dental problems, particularly with formation of teeth - Bone deformities, such as bowed legs and scoliosis Joint and bone pain

Answer 301

bisphosphates Vit D Supplements MDT team

Answer 302

at 4-6 wks if: - baby born in breech position - FHx of childhood hip problems

Answer 303

autoimmune inflammation of the joints without any other cause for more than 6 weeks under the age of 16.

Answer 304

a systemic illness occurring throughout childhood (and adulthood). idiopathic inflammatory conditions. Feat: - subtle salmon-pink rash - high swinging fevers - enlarged lymph nodes - weight loss - joint inflammation and pain - splenomegaly - muscle pain - pleuritis and pericarditis key complication is macrophage activation syndrome (MAS) > DIC, anaemia, thrombocytopenia, bleeding, non-blanching rash.

Answer 305

1. hypermobile ehlers-danlos 2. classical ehlers-danlos 3. vascular ehlers-danlos 4. kyphoscoliotic ehlers-danlos

Answer 306

maximum score of 9 > Place their palms flat on the floor with their straight legs (scores only 1) Hyperextend their elbows Hyperextend their knees Bend their thumb to touch their forearm Hyperextend their little finger past 90 degrees

Answer 307

Henoch-Schonlein Purpura (HSP) is an IgA vasculitis that presents with a purpuric rash affecting the lower limbs and buttocks in children. Inflammation occurs in the affected organs due to IgA deposits in the blood vessels. It affects the skin, kidneys and gastro-intestinal tract. The condition is often triggered by an upper airway infection or gastroenteritis. It is most common in children under the age of 10 years.

Answer 308

Purpura (100%), Joint pain (75%), Abdominal pain (50%) Renal involvement (50%)

Answer 309

- Meningococcal septicaemia - Leukaemia - Idiopathic thrombocytopenic purpura - Haemolytic uraemic syndrome

Answer 310

Abdominal pain usually settles within a few days. Patients without kidney involvement can expect to fully recover within 4 to 6 weeks. A third of patients have a recurrence of the disease within 6 months. A very small proportion of patients will develop end stage renal failure.

Answer 311

Kawasaki disease is also known as mucocutaneous lymph node syndrome. It is a systemic, medium-sized vessel vasculitis. It affects young children, typically under 5 years. There is no clear cause or trigger. It is more common in Asian children, particularly Japanese and Korean children. It is also more common in boys. A key complication is coronary artery aneurysm.

Answer 312

A key feature that should make you consider Kawasaki disease is a persistent high fever (above 39ºC) for more than 5 days. Children will be unhappy and unwell. The key skin findings are a widespread erythematous maculopapular rash and desquamation (skin peeling) on the palms and soles. Other features include: - Strawberry tongue (red tongue with large papillae) - Cracked lips - Cervical lymphadenopathy - Bilateral conjunctivitis

Answer 313

There are two first line medical treatments given to patients with Kawasaki disease: 1. High dose aspirin to reduce the risk of thrombosis 2. IV immunoglobulins to reduce the risk of coronary artery aneurysms Patients will need close follow up with echocardiograms to monitor for evidence of coronary artery aneurysms.

Answer 314

Acute rheumatic fever is an autoimmune condition triggered by Grp A streptococcus bacteria. It is caused by antibodies created against the streptococcus bacteria that also target tissues in the body. It is a multi-system disorder that affects the joints, heart, skin and nervous system. It is rare in the UK due to early treatment of streptococcus with antibiotics. Type 2 hypersensitivity reaction 2-4 wks after initial infection.

Answer 315

A diagnosis of rheumatic fever can be made when there is evidence of recent streptococcal infection, plus: Two major criteria OR One major criteria plus two minor criteria The mnemonic for the Jones criteria is JONES – FEAR. Major Criteria: J – Joint arthritis O – Organ inflammation, such as carditis N – Nodules E – Erythema marginatum rash S – Sydenham chorea Minor Criteria: Fever ECG Changes (prolonged PR interval) without carditis Arthralgia without arthritis Raised inflammatory markers (CRP and ESR)

Answer 316

Patients with clinical features of rheumatic fever should be referred immediately for specialist management. Management involves medications and follow up: - NSAIDs (e.g. ibuprofen) are helpful for treating joint pain - Aspirin and steroids are used to treat carditis - Prophylactic antibiotics (oral or intramuscular penicillin) are used to prevent further streptococcal infections and recurrence of the rheumatic fever. These are continued into adulthood. - Monitoring and management of complications

Answer 317

The simplified pathophysiology is that eczema is caused by defects in the barrier that the skin provides. Tiny gaps in the skin barrier provide an entrance for irritants, microbes and allergens that create an immune response, resulting in inflammation and the associated symptoms.

Answer 318

Thin creams: E45 Diprobase cream Oilatum cream Aveeno cream Cetraben cream Epaderm cream Thick, greasy emollients: 50:50 ointment (50% liquid paraffin) Hydromol ointment Diprobase ointment Cetraben ointment Epaderm ointment

Answer 319

Mild: Hydrocortisone 0.5%, 1% and 2.5% Moderate: Eumovate (clobetasone butyrate 0.05%) Potent: Betnovate (betamethasone 0.1%) Very potent: Dermovate (clobetasol propionate 0.05%

Answer 320

mild - oral flucloxacillin severe - admit for IV antibiotics

Answer 321

A typical presentation is a patient who suffers with eczema that has developed a widespread, painful, vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes).

Answer 322

oral or IV aciclovir

Answer 323

Guttate psoriasis is the second most common form of psoriasis and commonly occurs in children. It presents with many small raised papules across the trunk and limbs. The papules are mildly erythematous and can be slightly scaly. Over time the papules in guttate psoriasis can turn into plaques. Guttate psoriasis is often triggered by a streptococcal throat infection, stress or medications. It often resolves spontaneously within 3 – 4 months.

Answer 324

Auspitz sign refers to small points of bleeding when plaques are scraped off Koebner phenomenon refers to the development of psoriatic lesions to areas of skin affected by trauma Residual pigmentation of the skin after the lesions resolve

Answer 325

Topical steroids Topical vitamin D analogues (calcipotriol) Topical dithranol Topical calcineurin inhibitors (tacrolimus) are usually only used in adults Phototherapy with narrow band ultraviolet B light is particularly useful in extensive guttate psoriasis

Answer 326

- Macules are flat marks on the skin - Papules are small lumps on the skin - Pustules are small lumps containing yellow pus - Comedomes are skin coloured papules representing blocked pilosebaceous units - Blackheads are open comedones with black pigmentation in the centre - Ice pick scars are small indentations in the skin that remain after acne lesions heal - Hypertrophic scars are small lumps in the skin that remain after acne lesions heal - Rolling scars are irregular wave-like irregularities of the skin that remain after acne lesions heal

Answer 327

- No treatment may be acceptable if mild - Topical benzoyl peroxide reduces inflammation, helps unblock the skin and is toxic to the P. acnes bacteria - Topical retinoids (chemicals related to vitamin A) slow the production of sebum (women of childbearing age need effective contraception) - Topical antibiotics such as clindamycin (prescribed with benzoyl peroxide to reduce bacterial resistance) - Oral antibiotics such as lymecycline - Oral contraceptive pill can help female patients stabilise their hormones and slow the production of sebum

Answer 328

First disease: Measles Second disease: Scarlet Fever Third disease: Rubella (AKA German Measles) Fourth disease: Dukes’ Disease Fifth disease: Parvovirus B19 Sixth disease: Roseola Infantum

Answer 329

Erythema multiforme is an erythematous rash caused by a hypersensitivity reaction. leads to 'target lesions'. Doesn't usually affect mucus membranes (although can cause a sore mouth). The most common causes are viral infections and medications. It is also notably associated with the herpes simplex virus (causing coldsores) and mycoplasma pneumonia.

Answer 330

Patients should be kept off school and avoid pregnant women and immunocompromised patients until all the lesions are dry and crusted over. This is usually around 5 days after the rash appears.

Answer 331

- generalised, self-limiting rash with an unknown cause - prodomal symtpoms > headache, tiredness, anorexia, flu - starts with a HERALD PATCH (~2cm) - 2 or more days after rest of rash appears can take on a CHRISTMAS TREE fashion following the lines of the ribs heals in ~3 mnths usually requires no treatment

Answer 332

Seborrhoeic dermatitis is an inflammatory skin condition that affects the sebaceous glands. The sebaceous glands are the oil producing glands in the skin. It affects areas that have a lot of these glands, such as the scalp, nasolabial folds and eyebrows. It causes erythema, dermatitis and crusted dry skin. In infants it causes a crusted dry flaky scalp, often called cradle cap. It is thought that Malassezia yeast colonisation has a role to play in the development of seborrhoeic dermatitis, and the condition improves with anti-fungal treatment.

Answer 333

Affecting the scalp> - ketoconazole shampoo Affecting the face and body> - clotrimazole (up to 4 wks)

Answer 334

Signs that would point to a candidal infection rather than simple nappy rash are: - Rash extending into the skin folds - Larger red macules - Well demarcated scaly border - Circular pattern to the rash spreading outwards, similar to ringworm - Satellite lesions, which are small similar patches of rash or pustules near the main rash Check for oral thrush with a white coating on the tongue, as this is likely to indicate a fungal infection in the nappy area.

Answer 335

Dimeticone 4% lotion can be applied to the hair and left to dry. This is left on for 8 hours (i.e. overnight), then washed off. This process is repeated 7 days later to kill any head lice that have hatched since treatment. Special fine combs can be used to systematically comb the nits and lice out of the hair. They can be used for detection combing to check the success of treatment. NICE clinical knowledge summaries recommend The Bug Buster kit.

Answer 336

antiseptic cream (hydrogen peroxide 1% cream) first line rather than antibiotics for localised non-bullous impetigo.

Answer 337

1. erythemous patches that look thin and wrinkled. Then formation of bullae which burst and leave sore, erythematous skin below. Looks like a scald! 2. NIKOLSY SIGN pos. > when gently rubbing skin it peals away. 3. systemic symptoms

Answer 338

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are a spectrum of the same pathology, where a disproportional immune response causes epidermal necrosis, resulting in blistering and shedding of the top layer of skin. Generally, SJS affects less that 10% of body surface area whereas TEN affects more than 10% of body surface area.

Answer 339

spectrum of severity. Usually starts with non-specific symptoms then develops into a purple or red rash that spreads across skin and starts to blister. Skin starts to shed and reveasl raw tissue. Can also affect mucous membranes eg eyes become inflammed and ulcerated.

Answer 340

medical emergency! admit to dermatology or burns unit. Supportive care > nutrition, antiseptics, analgesia, opthamology input. treat> steroids, immunoglobulins, immunosupressants

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