Paeds 2 Flashcards
1
Q
What is the most common organism causing paediatric UTI? What are some others and what would you have to do if a little child had infection with them?
A
E.coli
Klebsiella, proteus, pseudomonas- they would need imaging (US renal tract)
2
Q
How would you investigate if you suspected a child had a UTI?
A
Bedside: Urinalysis- dipstick and MC&S
Bloods: FBC, U&E, CRP
Imaging only if septic, atypical UTI, not responding to Abx: US, DMSA, MCUG
3
Q
A 2 month old has confirmed UTI. How are you going to treat?
A
Admission to hospital and IV antibiotics eg. co-amoxiclav for any child with UTI <3 years old
4
Q
A 1 year old has confirmed cystitis. How are you going to treat?
A
Oral trimethoprim or nitrofurantoin
5
Q
A 7 month old has confirmed pyelonephritis. How are you going to treat?
A
Oral cefalexin or co-amoxiclav borad spectrum and narrow with results. If vomiting- IV co-amox
6
Q
A little boy comes in to practice as he has had recurrent UTIs now, he is having one every other month. He needs some investigating due to this. You have done a scan which shows grossly dilated ureters and kidneys. What is the likely diagnosis and what scan would have been done?
A
Vesico-ureteric reflex
Micturating cystogram
7
Q
What is the pathophysiology behind vesico-ureteric reflex and how does it cause kidney damage?
A
Ureters enter the bladder laterally and more directly so causes retrograde flow of urine from bladder to kidneys. This occurs during voiding and due to the urinary stasis it predisposes to recurrent UTIs. Additionally causes renal damage from infection but also the high pressure of bakckflow of urine when voiding
8
Q
A 9 year old boy has been brought in by his mother due to recurrent episodes of bed wetting. He has been having these episodes for many months now and has gradually been increasing in frequency. He is now wetting the bed every night. He says he is enjoying school and mum says there are no issues with bullying etc in school. Family life is good at home. PMH: Constipation- he is on lactulose which isnt helping. No other medications. Examination is unremarkable. Given the likely diagnosis, what are some options for initial treatments? What investigation might you do?
A
Primary enuresis
Conservative measures:
- No drinking before bed
- Increase the dose/add senna to treat constipation
-Star charts
- Bladder training- using toilet just before bed
-Small alarm triggered by wee.
May do urine dip and MC&S to rule out UTI
9
Q
The 9 year old who was diagnosed with enuresis and given conservative measures comes back 3 months later for review. Mum says there has been no improvement in his urinary symptoms and he is still bed wetting every night. He also has a school trip to Paris coming up and is not wanting to go for fear of embarrassment. His constipation is under control now though. What treatment can you offer now?
A
Desmopressin- particularly useful for school trips and sleepovers.
10
Q
A 7 year old boy presents to clinic with his mother. His mum says she’s noticed his face has been swollen, particularly around his eyes as well as his legs. Also she has noticed his urine has been frothy but there is no blood, burning or stinging. Dipstick shows no protein 3+, no haematuria.
Given the likely diagnosis, what treatment are you going to offer?
A
Minimal change disease - nephrotic syndrome
Treatment: prednisolone
11
Q
What is the triad of symptoms in nephrotic syndrome?
A
Hypoalbuminaemia <25g/L
Oedema- peripheral, orbital, scrotal
Proteinuria >3g loss
12
Q
Investigations required in nephrotic syndrome are relatively few what are most important ones?
A
FBC, U&E- kidney function, LFTs, CRP
Urine albumin: creatinine ratio
Urine dip- proteinuria
Renal biopsy- if not responding to steroids
13
Q
What do you see on light and electron microscopy in minimal change disease?
A
Light- nothing
Electron- podocyte effacement –> leaky glomerular b.m
14
Q
How would you manage minimal change disease- treatment and monitoring?
A
Prednisolone- usually responds well
Fluid restrict and low salt diet. and monitor their fluid balance daily.
15
Q
What are some of the complications that can develop with minimal change disease and how would you treat them?
A
Hypovolaemia- become intravascularly dry. Give IV albumin
Infections- give prophylactic penicillin and treat infections promptly
Thrombosis- monitor for any signs of stroke/PE etc.
16
Q
What are the clinical features of glomerulonephritis/nephritic syndrome?
A
Haematuria Oliguria RBC casts in urine Hypertension Oedema
17
Q
What are the causes of glomerulonephritis/nephritic syndrome?
A
Post strep GN IgA nephropathy SLE HSP Granulomatosis with polyangiits
18
Q
A 8 year old boy presents with his mum to GP with what she describes as ‘cola coloured’ urine. It began a last week and has not been getting better. She says it’s also a bit frothy. She says he is going to the toilet less even though she’s drinking the same amount of fluid. You ask if he’s been well recently and she says he had a sore throat and fever about 2.5 weeks ago but that has settled now with some penicillin by the other GP. Observations show a raised BP. What is the likely diagnosis?
A
Post-strep glomerulonephritis - 2-3 weeks post strep infection
19
Q
What is the difference between post-strep glomerulonephritis and IgA nephropathy?
A
Post-strep glomerulonephritis- 2-3 weeks post strep infection
IgA nephropathy- 2-3 days after strep infection
20
Q
What is the causative organism of Post-strep glomerulonephritis?
A
Group A beta haemolytic strep
21
Q
How would you investigate and manage Post-strep glomerulonephritis?
A
Ix:
Bedside: urinaylsis- urine dipstick- proteinuria, RBC casts and haematuria and MC&S
Bloods: FBC, U&E- kidney function, ESR, ASOT
Tx:
Fluid balance, salt restriction, may need diuretics
Treat HTN
Treat step infection if still present
22
Q
A 10 year old boy comes to A&E as he has developed this new onset rash. It is slightly raised and is on his buttocks and back of his legs. His mum is really worried because the glass test has not caused it to blanch. He also have some abdominal pain and his legs are really achy too. He has recently had a bad chest cold that is settling now. What is your diagnosis but what do you also need to rule out?
A
HSP
Rule out menigoccal sepsis, DIC , ITP, leukaemia - non blanching rash
23
Q
What is the triad of symptoms in HSP? What else might you get?
A
Arthritis + Purpura + Abdo pain- colicky
Haematuria
Proteinuria
24
Q
How do you treat HSP- mild and severe- with worsening gFR
A
Mild: supportive and give prednisolone to help oedema, joint pain and abdo pain
Severe with worsening eGFR- cyclophosphamide
25
A young boy comes to A&E with his dad because he has been suffering from bad abdominal pain for a few days and this morning had an episode of bloody diarrhoea. He also has noticed his child hasn't been the toilet to urinate for a few hours now which is unlike him. Bloods tests have showed low platelets, low Hb and raised reticulocytes and massively raised urea and creatinine. What is the likely diagnosis and cause?
Haemolytic uraemic syndrome: low Hb with shistocytes (MAHA) + thrombocytopenia (low platelets) + AKI
Caused by E.coli- bloody diarrhoea
26
How do you treat Haemolytic uraemic syndrome?
Supportive: fluids - IV if not drinking
May need blood transfusion for anaemia
may need dialysis
27
What complications can develop from CKD?
Anaemia- may need EPO
Renal osteodystophy- from secondary hyperparathryodism - may need bisophosphates and vitamin d supplements
Hypertension- strict BP control
Acidosis- may need bicarbonate
Oedema: may need fluid restriction and furosemide
28
A 2 year old comes to clinic with his mum. He has been well recently apart from some non-specific abdominal pain. On palpation of the abdomen you feel a mass in the left side that is painless. What condition do you need to rule out?
Wilms tumour - nephroblastoma
29
What investigations do you need to do for a patient with a Wilms tumour?
Bedside: urinalysis- urine dipstick and MC&S
Bloods: FBC, U&Es, LFTs, clotting.
Imaging: US abdomen, confirm with CT/MRI pelvis
30
A teenage boy presents with a painless lump in his scrotum. On questioning he says it feels like there are worms in his scrotum and is achy but not painful. What is the likely diagnosis and what are the treatment options for a small and big one?
Varicocele
Small: reassurance and supportive underwear
Large: surgery
31
An infant boy presents with a painless lump in his scrotum. He says it feels like a balloon. On palpation you feel a diffuse swelling in the testes that is fluctuant and it transilluminates with a pen torch. What is the likely diagnosis and treatment?
Hydrocele
| Treatment: conservative and monitoring. If gets large and uncomfy: surgical excision
32
What tests/signs can differentiate testicular torsion from epididymo-orchtiis?
Testicular torsion: cremasteric reflex absent, Prehn's sign negative (lifting testicle doesn't relieve pain)
Epididymo-orchitis: cremasteric reflex present, Prehn's sign positive + fever
33
You are doing the newborn baby check on little Jake. You notice he has undescended testes. What is the management?
Nothing- reassure
34
You are doing a review of a 5 month old James. You notice he has undescended testes. What is the management?
Refer to surgeons if >6m for orchiopexy
35
What are some complications that can develop from undescended testes?
Testicular torsion
Testicular malignancy
Infertility
36
A little boy comes to A&E as his mother has noticed he has difficulty urinating. It sprays backwards and is getting all over their bathroom floor. On examination of the external genitalia you cannot see the urethral meatus at the tip of the penis and the penis is pulled down. What is the likely diagnosis?
Hypospadias- urethral meatus is on the underside (ventral) side of the penis
Chordee pulls penis down- tightening of tissue on underside of penis.
37
How do you treat hypospadias?
Surgical: use the foreskin to create a new urethral meatus
38
What is phimosis?
Tight foreskin that cannot retract around glans
39
How might phimosis present?
Painful and ballooning of foreskin during urination
40
How might you treat phimosis?
Circumcision
41
What are the complications of phimosis?
Paraphimosis - foreksin retracts and gets stuck causing necrosis
Balanitis
Urethritis
Cystitis
42
A teenage girl comes into practice because she has been suffering with bad headaches recently. She says the headache throbs in the front of her head and she usually feels very sick with it and has to go lie down in her bed with the lights off. The pain doesnt wake her from sleep and is not worse on posture. She notices it gets worse around her period. What is the likely diagnosis and what first line treatment can you offer as this is her first episode?
Migraine- without aura most common in kids
Treatment:
-Conservative: avoid triggers, cold/warm pads
-Acute attacks: NSAIDs, triptan , anti-emetics: cyclising
43
The teenage girl you diagnosed with migraines comes back next month having had 3 more attacks all of the same nature. What can you now prescribe?
Beta blockers eg. propranolol or pizotifen (NA channel blocker)
44
A 3 year old girl, Janie, has come to A&E with her very worried mum. Mum says Janie has been a bit unwell since yesterday with a cough, cold and a high fever which she was managing at home with paracetamol. However, this morning Janie had a fit where she went quite stiff and then her arms shook. The episode lasted 1 minute. She hasn't had another episode since and looks well now apart from a fever when the nurse takes her obs. Bloods are all normal and you do a CT to rule out meningitis and encephalitis which is also normal. What is the likely diagnosis and what will you tell mum?
Simple febrile seizure
Can happen in young children when they have a viral illness. Will settle itself with paracetamol to treat the viral infection.
Safety net for any signs of meningitis/encephalitis
45
You have diagnosed Janie with a febrile seizure and want to discharge her. Mum wants to know if this will happen again and whether it means she will have epilepsy?
It might happen again- fairly common in young children but doesnt cause brain damage.
Risk of epilepsy is similar to all other children.
46
Janie comes back 6 months later with her mum again. This time , mum is extremely worried as Janie has been ill for 3 days again with a simple fever and cough but has had 3 fits in that time that are lasting over 5 minutes. What is the likely diagnosis now and what will you tell mum about the epilepsy risk?
Complex febrile seizures - slightly increased risk
47
What happens in breath holding attacks?
Toddlers- get angry and hold their breath when upset. They may pass out and may turn blue but make full recovery.
48
What are the features of syncope?
Faint - triggers include hot temperature, fear, standing for long periods
full recovery after
may twitch
49
A little toddler has come in with his mum. Mum says he had a fitting episode today. He had banged into the table and hurt his knee which was fine but then he went very pale and fell to the floor. She says his arms and legs went stiff and shaky but he recovered within a couple of minutes. On examination he looks absolutely fine and is running around the waiting room. What might have happened?
Reflex anoxic seizure- triggers of pain, fear, cold foods, minor trauma. Fall to the ground, pale and GTC seizure.
Child recovers quickly
50
You see a child who has had two fits in the last month. On further questioning mum tells you he falls to the ground, goes very stiff and then shakes. It often takes him an hour or two to come around afterwards as he still feels disorientated. He has lost incontinence in both episodes. Given the likely diagnosis, what is the first line treatment?
Epilepsy : >2 attacks
Involve epilepsy nurses for lifestyle advice
Medication: sodium valproate is first line.
51
What are the main side effects of sodium valproate?
Weight gain, nausea and vomiting
52
Another child comes to clinic as his mum is saying his school teachers have been noticing him daydreaming more often than not. He has multiple episodes where he looks like he's just staring and sometimes his eyes roll up. He has no preceding symptoms and no symptoms afterwards. He is meeting his developmental milestones. Hyperventilating has elicited the episode in clinic. What is the likely diagnosis and first line treatment?
Childhood absence epilepsy
Involve epilepsy nurses
Tx: 1. ethosuximide, 2. valproate
53
What are the main side effects of ethosuximide?
nausea and vomiting
54
A 13 year old comes to clinic with his dad. He is describing episodes of fits. Initially he gets these jerky movements of his arms causing him to drop objects all the time and then he falls to the ground and goes stiff and shakes. It has not been affecting his development or learning. What is the likely diagnosis and first line treatment?
Juvenile myoclonic epilepsy
| First line: sodium valproate
55
What important investigations will you do when a child presents with a seizure?
Bedside: ECG !- rule out arrhythmia
Bloods- FBC, U&E, GLUCOSE, CRP, Calcium
Imaging: EEG, CT/MRI if suspect SOL
56
A 5 month old child presents to clinic with his mother. She has been noticing he is having these episodes where his head twitching and his arms jerk and extend out. It lasts a couple of seconds but he is having them every 30 seconds. He is fine in between and has not had any other symptoms. He has not been meeting his developmental milestones though. What is the likely diagnosis and what is might you see on EEG?
West syndrome- infantile spasms
| EEG: hypsarrythmia - disorganised brain activity
57
What are the treatment options for focal seizures? What investigation should you do?
Carbamazepine and lamotragine
| CT/MRI head
58
What are the main side effects of Carbamazepine and lamotrigine?
Rash- both
| Neutropenia- carbamazepine
59
A little girl has come into A&E and is having a seizure. You get a quick collateral history from the mum who said this has been going on for almost 10 minutes now and they've rushed to A&E as quickly as possible. She has PMH of epilepsy. What is your immediate management? and the stepwise process after?
ABCDE - control airway and high flow oxygen
IV access and get bloods- FBC, U&E, CRP, glucose
IV lorazepam if got IV access (otherwise= buccal midazolam or rectal diazepam)
After 10 minutes: another dose of IV lorazepam
Another 10 mins: IV phenytoin (or phenobarbital if on phenytoin)
Another 10: Call anaesthetics- needs RSI
60
A 2 year old child has come into practice with her mum. Mum says over the past few months, Jackie has been doing some abnormal jerky movements with her arms and legs on the left side. Jackie has not been meeting her developmental milestones- she is unable to walk. When mum has been carrying her, she has noticed her arms and legs on that side feel incredibly stiff too. On examination- you notice some spasticity along with brisk reflexes and muscle weakness, most marked on the left side. What could be the cause of this and is this UMN or LMN?
Spastic cerebral palsy- UMN lesion - damage to the pyramidal tract
MOTOR symptoms only
61
What are some associated problems in those with cerebral palsy? Apart from motor symptoms
Epilepsy
Speech and language problems
Poor growth
Intellectual impairment
62
What are some causes of cerebral palsy? prenatal, perinatal or postnatal
Prenatal: cerebral malformations during gestation, TORCH infections
Perinatal: hypoxic-ischaemic injury, metabolic disturbances
Postnatal: stroke, head trauma, infection- meningitis/encephalitis
63
How do you manage cerebral palsy?
```
MDT approach
Physiotherapists- strengthening
Baclofen for spasticity and bot tox if v severe
SALT team involvement
Treat symptoms as they come
```
64
A little boy presents to clinic as mum describes him having these uncontrolled movements. These come on suddenly. One happens while in clinic and looks like a dystonia causing the child to twist into abnormal postures. He struggles to sit up by himself although he should be by know and his muscle tone is very poor on examination. Mum says birth was slightly complicated and he was very yellow and drowsy in his first few days of life. What is the likely diagnosis?
Cerebral palsy -dyskinetic type . Associated with bilirubin encephalopathy
Basal ganglia lesion
65
What are the signs/symptoms of motor neurone disease?
```
UMN + LMN
Weakness of muscles
Wasting of muscles
Fasiculations
Increased tone
Brisk reflexes
No sensory symptoms
```
66
What happens in spinal muscular atrophy?
AR: Genetic mutation in motor neurone gene
Get gradual muscle wasting and weakness
Limbs- won't be able to sit/stand, floppy limbs
Bulbar- swallowing difficulties
Resp- breathing difficulties
67
What happens in Charcot-Marie Tooth disease?
Motor and sensory peripheral neuropathy
| Autosomal dominant
68
What symptoms might you get in Charcot-Marie Tooth disease?
```
Motor and sensory predominantly in legs
Muscle wasting
Sensory disturbance
Bilateral foot drop might cause tripping
Loss of reflexes
```
69
What investigations might you do in a patient with Charcot-Marie Tooth disease?
Nerve conduction studies- shows demyelination and hypertrophy
Nerve biopsy- 'onion'- collagen layers due to hypertrophy
70
A teenager has come into clinic with his parents. He describes a new onset muscle weakness in his legs mainly but his arms too. They feel quite sore as well. He is also describing some tingling and numbness in his feet in particular. Mum tells you he had a bit of a viral infection 2 weeks ago but he has been well otherwise and takes no medication. Given the likely diagnosis, how are you going to treat?
GBS
Supportive- monitor respiratory symptoms and intubate if need
Plasma exchange or IV immunoglobulin
71
What investigations might you do in GBS?
Bedside: spirometry - check lung function
Bloods: FBC, U&E, CRP, LFTs
Nerve conduction studies- slow conduction - demyelination
LP- CSF protein raised
72
Is Bell's palsy UMN or LMN?
LMN palsy of facial nerve (CN 7)
73
What symptoms might you get in a Bell's palsy?
Unilateral facial weakness and drooping (opposite side of facial nerve palsy)
Unable to raise eyebrows on affected side
Unable to close eye on affected side
Assymetrical smile- unable to raise lips on affected side
74
How would you treat Bell's palsy?
Steroids- prednisolone high dose
| Opthal input if can't close eye- may need patch, lubricating eye drops
75
A 13 year old comes to clinic with his mum. Jimmy is complaining of this new weakness in his arms and in his face. He says he has noticed when eating meals he gets tired chewing by the end of his meals and his arms are getting a lot more tired quickly when he's exercising. He says they don't feel weak and tired when he's resting though. You notice some ptosis on examination too and Jimmy complains of double vision when you test movements of his eyes. Given the likely diagnosis, what autoantibody is implicated?
Myasthenia gravis
| Due to anti-acetylcholine receptor antibodies
76
What is an important investigation to do when you see someone with Myasthenia gravis?
CT thymus- commonly associated with a thymoma
77
How will you treat Myasthenia gravis?
Anticholinesterase inhibitors- pyridostigmine or neostigmine
Thymectomy
78
A 5 year old boy comes in to practice with his mother. She has noticed he is struggling to walk and waddles when he does. He often falls over though and can't stand up for much time. He is a lot slower than his friends and struggles very much to climb up the stairs. Mum has been noticing he uses his hands to walk up his body in order to stand up. He is also struggling in school. What is the likely diagnosis and the sign mentioned in the history?
Muscular dystrophy -Duchenne
| Sign: Gower's sign
79
What is the pathophysiology behind muscular dystrophy?
Deletion in the dystrophin gene, causes muscle wasting and tissue to be replaced by fat. Also causes fat necrosis due to free radicals.
80
What inheritance pattern is muscular dystrophy?
X linked recessive
81
What investigations will you do in a child with suspected muscular dystrophy?
Bedside: spirometry- respiratory muscles affected
Bloods: FBC, U&E, clotting, ESR, CREATININE KINASE is raised
Muscle biopsy
82
How do you manage muscular dystrophy?
MDT approach
Physios- to help with muscle strengthening
Prednisolone - maintain strength
Ortho: may have scoliosis
Resp: may need CPAP if respiratory failure
83
What is the key feature of myotonic dystrophy?
Delayed muscle relaxation after sustained contraction eg. struggle to release after a handshake
84
What is Friedrich's ataxia?
AD condition - degenerative disease affecting neurological and cardio
Neuro: ataxia, dysarthria, muscle wasting
Cardiomyopathy
85
A child comes in with his mother who is saying Jacob is struggling to walk. She has noticed he has been off balance and walks very clumsily. He is not meeting his motor milestones either. On examination you see thin red blood vessels all across his chest, face and neck. He has poor coordination on neurological examination and his speech is quite slow. What is the likely diagnosis?
Ataxia telangiectasia
86
What malignancy is associated with ataxia telangiectasia?
Acute lymphoblastic leukaemia
87
You are clerking in A&E. A toddler has been brought in by the police because the neighbours had seen the parents vigorously shaking their toddler and called the police. The child looks drowsy saying 'my head hurts' and on neurological examination you notice some weakness. Given the likely diagnosis, what might you see on CT?
Subdural haemorrhage
| Crescent shaped on CT scan
88
What is the cause of subdural haemorrhage?
Tearing of the bridging veins
89
How do you treat subdural haemorrhage?
IV fluids, clot evacuation in surgery
90
What is the cause of extradural haemorrhage and how do you treat it?
Tear of the middle meningeal artery
| IV fluids and Burr holes- evacuate clot
91
What is given to mothers and at what dose to reduce the risk of neural tube defects in babies?
Folic acid
0.4mg - normal
5mg - high risk
92
You attend the labour to help assess the child. The child is born without a skull vault and his eyes look bulging. He dies within a few minutes. What is the diagnosis?
Anencephaly- failure of the skull vault and cranium
93
What is the encephalocele?
Midline skull defect causing protrusion of cranium and meninges
94
A child comes to clinic with her mother. Mother says she has noticed a tuft of hair on the lower back of her child. It has been there for a while now and is not disappearing. She has no other symptoms and has been well recently. On questioning about pregnancy, mum said she missed a few appointments and took some of the vitamins but not all. Birth was uncomplicated. What is the likely diagnosis and does it need treatment?
Spina bifida occulta- failure of closure of spinal cord
Ix: X ray = incidentally
Tx: asymptomatic= no treatment. if tethering occurs- neurological sx= surgical
95
You attend the labour to do the newborn assessment of the child. On delivery, the baby has a large head, looks drowsy and is vomiting. On examination, there is herniation of the meninges of the spine which is covered by skin. On neurological examination, the baby has flaccid paralysis of lower limbs and areflexia. What is the likely diagnosis?
Spina bifida cystica- meningocele
Meninges protrude through a defect in the spinal cord but is covered by skin.
Hydrocephalus + sensory loss + paralysis + areflexia
96
How do you treat meningocele?
Surgical repair of the lesion
| May need help with walking- physio, walking aids
97
You attend the labour to do the newborn assessment of the child. On delivery, the baby has a large head, looks drowsy and is vomiting. On examination, there is herniation of the meninges of the spine through the skin and a cyst that contains neural tissue. On neurological examination, there is severe weakness, hypotonia and areflexia. What is the likely diagnosis and treatment?
Spina bifida cystica- myelomeningocele
Meninges protrude through defect in spinal cord NOT covered by skin.
Cystic mass- can see neural tissue in it
Tx: surgery
98
An infant presents to A&E with his mother as she has noticed his head is growing very big and his head circumference is quite large for his age. She also says that the soft spot on his head looks a bit swollen. On examination, you see the bulging fontanelle. What is the likely diagnosis?
Hydrocephalus
99
What are the two types of hydrocephalus?
Communicating- failure to absorb CSF or increased CSF production.
Non-communicating- obstruction so CSF cannot flow between the ventricles or between ventricles and sub arachnoid space
100
What are the causes for communicating and non-communicating hydrocephalus?
Communicating: sub arachnoid haemorrhage, meningitis, choroid plexus tumour- produces CSF
Non-communicating: chiari malformation, aqueduct stenosis
101
What signs may you see in a child with hydrocephalus?
Infant - bulging fontanelle
Downward gaze of eyes
Older: raised ICP- vomiting, headache worse on lying down, drowsy, papilloedema
102
How would you investigate and manage hydrocephalus?
Ix: MRI scan
Tx: VP shunt
103
A 8 year old boy has come to A&E with his mum. She says he has suddenly become quite drowsy, is complaining of a severe headache and has vomited a couple of times. You can see papilloedema when you look in his eyes. How are you going to manage him acutely?
ABCDE
Oxygen
Elevate the head
IF shocked: careful IV fluids
Intubate and ventilate- call anaesthetics
Hypertonic saline and dexamethasone
Will need CT scan and ix for case eg. LP if meningitis/encephalitis
104
What is the most common brain tumour in kids?
Brainstem astrocytoma - CN palsies, hemiparesis, associated with neurofibromatosis 1
105
A 14 year old is brought to clinic with his mother. He describes about 15 of these flat brown patches on his skin and a couple of hard bumps on his arms. You do a full examination and you notice freckles in his armpit as well. He has had some blurred vision recently as well and on opthlamoscopy you see Lisch nodules. Mum says his father had the same when he was younger. What is the likely diagnosis?
Neurofibromatosis 1
106
What is the inheritance pattern of Neurofibromatosis 1 ?
AD
107
What is the main association of Neurofibromatosis 1 and Neurofibromatosis 2?
NF1- brainstem astrocytoma
| Nf2- bilateral acoustic neuromas- present with deafness
108
What are features of tuberous sclerosis?
```
Seizures
Ash leaf macules- depigmented areas
Shagreen patches- roughened areas
Learning disability and autism
Cardiac tumour
Renal cysts
```
109
What is an esotropia?
Manifest squint- present on examination
| One eye turned inwards- convergent squint . commonest
110
What is an exotropia?
Manifest squint- present on examination
| One eye turned outwards- divergent squint
111
What is a hypertropia?
Manifest squint- present on examination
| One eye turned upwards
112
What is a hypotropia?
Manifest squint- present on examination
| One eye turned donwards
113
What is an esophoria?
Latent squint- only comes up on swinging test
| Corneal reflection turns in on shining light and eye turns in
114
What is an exophoria?
Latent squint- only comes up on swinging test
| Corneal reflection turns out on shining light . normal
115
What could cause strabismus?
```
Congenital
Uncorrected hypermetropia- long disntace
Ambylopia- lazy eye
Loss of vision in 1 eye
Neurological conditions eg. cerebral palsy
```
116
You are testing a child's eye as you suspect a manifest squint. You can see the child's left eye is turned inwards. On covering the right eye, the left eye moves out. What is the diagnosis?
Left convergent squint- left esotropia.
| Moves out to take up fixation
117
You are testing a child's eye as you suspect a manifest squint. You can see the child's left eye is turned outwards. On covering the right eye, the left eye moves in. What is the diagnosis?
Left divergent squint- left exotropia.
| Moves in to take up fixation
118
You are testing a child's eye as you suspect a latent squint/phoria. You do the swinging test and notice the right eye moves out. What is the likely diagnosis?
Right esophoria
| If move out- they had a tendency to look in
119
You are testing a child's eye as you suspect a latent squint/phoria. You do the swinging test and notice the right eye moves in. What is the likely diagnosis?
right exophoria
| if move in- they had a tendency to point out
120
What test can you do to differentiate between strabismus and psueostrabismus?
Corneal reflection- will fall asymmetrically in strabismus and symmetrically in psudostrabismus
121
How do you manage strabismus?
3 O's- optical, orthoptic, operation
Optical- glassess/contacts. Eye patch of good eye. Orthoptic exercises of affected eye.
Operation: recession- weakening muscle and resection.- strengthening muscle
Botulin toxin injections
122
A child has a right divergent squint - right exotropia. He has tried glasses and orthoptic exercises and all the conservative measures. He now needs surgery. Which muscle will you do recession on and which will you do resection on?
His eye is turning out
Weaken the lateral rectus - recession
Strengthen the medial rectus - resection
OR bilateral lateral rectus recession = both eyes
123
A child has a right convergent squint - right esotropia. He has tried glasses and orthoptic exercises and all the conservative measures. He now needs surgery. Which muscle will you do recession on and which will you do resection on?
His eye is turning in
Medial rectus recession- weaken MR
Lateral rectus resection- strengthen LR
OR weaken both medial rectus - both eyes
124
A child has a right divergent squint - right exotropia. He has tried glasses and orthoptic exercises and all the conservative measures. His parents don't want surgery and want the botulinum toxin injections instead. Into which muscle will you inject?
His eye is turning out
| Inject bot toxin into lateral rectus- weakness it
125
A child has a right convergent squint - right esotropia. He has tried glasses and orthoptic exercises and all the conservative measures. His parents don't want surgery and want the botulinum toxin injections instead. Into which muscle will you inject?
His eye is turning in
| inject botox into medial rectus - weaken it
126
What are some causes of ambylopia- lazy eye?
Strabismus
Refractive error- having one prescription v high and one low (they use the lower eye to see and higher one becomes unused and lazy) OR high prescription in both eyes
Astigmatism
Ptosis in one eye causing covering of pupil
127
How do you treat ambylopia- lazy eye?
Eye patch of better eye, glasses
| Atropine drops to occlude vision in better eye
128
A boy presents with a down and out eye. What nerve is affected?
CN3- oculomotor
129
A boy presents with a eye that is upwards and outwards and difficulty walking down the stairs due to double vision. What nerve is affected?
CN4- trochlear
130
A boy presents with a eye pointing inwards. What nerve is affected?
CN6- abducens- can't look out due to palsy of lateral rectus
131
What MSK condition would you think of if a boy aged 7 presents with new sudden onset hip pain and limp and recent URTI?
Transient synovitis
132
What MSK condition would you think of if a boy aged 6 presents with gradually worsening hip and knee pain and limp. Internal and external rotation is painful.
Perthe's disease- gradual onset
133
What MSK condition would you think of if a 12 year old obese boy presents with hip and groin pain and a limp . He is lying with his leg externally rotated on the bed.
Slipped upper/capital femoral epiphysis
134
What MSK condition would you think of if a 12 year old presented with gradually worsening pain and stiffness in his knees. He struggles to walk up stairs and the stiffness is worse after resting. On examination you see a pink rash on his torso.
JIA- salmon rash, uveititis, morning stifness/stifness after rest, can't walk up stairs
135
What MSK condition would you think of if a 15 year old boy presents with new onset knee pain. He is very athletic and plays football rugby and runs for county level. His knee pain is worse on activity. On examination you see swelling below the patella at the tibial tubersosity.
Osgood-Schlatter disease
136
What bone tumour is found in the metaphysis of long bones in kids?
Osteosarcoma
137
What bone tumour is found in the diaphysis of long bones in kids and has an onion ring appearance on X ray
Ewing's sarcoma
138
What MSK condition would you think of if a child came into clinic with repeated fractures of his legs, bone pain and was affecting his mobility. You see blue sclera in his eyes.
Osteogenesis imperfecta
139
What MSK condition would you think of if a child presented with difficulty walking and waddled, repeated fractures to his legs, and his knees would bang together when he walked. His growth has been affected.
Rickets
140
What cardiac conditions are associated with Marfan's?
Aortic dissection
Aortic regurgitation
Mitral regurgitation
141
What is Perthe's disease?
Avascular necrosis of the femoral head
142
What is SUFE?
Fracture through the epiphyseal plate (growth plate) causing it to become displaced
143
How do you treat SUFE?
Surgically - pin
144
What complications of JIA can occur?
```
Anterior uveitis
Growth failure
Anaemia of chronic disease
Oesteoporosis
Hepatosplenomegaly
Pericarditis
Pleuritis
```
145
What are the treatment options for JIA?
NSAIDS and analgesics
Steroid injections- first line for oligo
Methotrexate- good for poly
Systemic steroids- avoid if poss tho
146
What investigations will you do in osteomyelitis?
Bedside: obs
Bloods: FBC, U&E, CRP, blood cultures
Imaging: X ray- may be normal, MRI!
147
What happens in Osgood -Schlatter?
Inflammation of patellar ligament at tibial tuberosity
148
How do you treat Osgood-Schlatter?
Self-resolving- rest, NSAIDs, physio , ice
149
What might you see on X ray in osteoid osteoma?
Radiolucent nidus- bright white spot surrounded by sclerotic bone
150
What happens in osteogenesis imperfecta?
Disorder of collagen metabolism leading to brittle bones and bone fragility and easy fractures and bending.
151
How do you treat osteogenesis imperfecta?
Bisphosphonates
152
What might you see in the bloods and on X ray in rickets?
Bloods: raised PTH, low phosphate, raised alk phosph
| X ray- splaying of the metaphysis, bowed legs
153
How do you treat rickets?
Vitamin D supplementation
Calcium supplementation
Anaglesia
