Paeds 3B

Question 1

What murmur is associated with ASD?

Answer 1

ejection systolic murmur (due to increased stroke volume of the right ventricle through the pulmonary outflow tract), widely split heart sound (because of increased stroke volume)

Question 2

What murmur is associated with VSD?

Answer 2

Loud pansystolic murmur at the lower left sternal edge, quiet pulmonary second heart sound

Question 3

Which defects require surgical correction in tetralogy of Fallot?

Answer 3

Close the VSD
Relive the right ventricular outflow obstruction

Question 4

How may hypercyanotic spells in tetralogy of Fallot be treated?

Answer 4

place patient in knee-to-chest position

administer oxygen

Insert IV line and give phenylephrine, morphine sulphate and propranolol (reduce infundibular muscle contractility and therefore improves blood flow out of RVOT towards lungs) 
IV fluids (improve pulmonary blood flow)

refer to cardiac centre

Question 5

Which temporary life-saving procedure may be performed for patients with transposition of the great arteries to enhance mixing of the blood?

Answer 5

Balloon atrial septostomy - this is a temporary measure to buy time for definitive surgery (arterial switch)

Question 6

How is tricuspid atresia treated?

Answer 6

initial management: prostaglandin e1 transfusion

surgical = Blalock-Taussig shunt (bt subclavian and pulmonary arteries)

Question 7

How is aortic stenosis treated?

Answer 7

Balloon valvulotomy (valvuloplasty)
Aortic valve replacement

NOTE: same for pulmonary stenosis

Question 8

How is SVT managed?

Answer 8

If haemodynamically stable:

1 - vagal manoeuvres
2 - IV adenosine
3 - one of the following: DC cardioversion, amiodarone, procainamide, flecainide

If hemodynamically unstable:

attempt vagal manouevres and adenosine as above but do not delay cardioversion

catheter ablation is recommended if recurrent/acessory pathway

90% of children have no further attacks

Question 9

How is acute rheumatic fever treated?

Answer 9

Bed rest and anti-inflammatory agents (e.g. aspirin)
Penicillin V if evidence of persistent infection

Question 10

What is the most effective prophylaxis for rheumatic fever?

Answer 10

Monthly injections of benzathine penicillin (not the same as benzyl;enicillin)
Alternative: oral penicillin OD

NOTE: prophylaxis recommended for 10 years after last episode of rheumatic fever or until 21 years old

Question 11

How is infective endocarditis treated?

Answer 11

Beta-lactam (benzylpenicillin, ampicillin, ceftriaxone, amoxicillin) and gentamicin

Usually for 6 weeks

Question 12

How would you treat an umbilical granuloma?

Answer 12

Regular application of salt to the wound (draws water out and causes it to shrink)
Cauterise with silver nitrate (to burn off tissue)

Question 13

List some contraindications for MMR ( a live attenuated vaccine)

Answer 13

Severe immunosuppression (high dose steroids leave you immunocompromised for 3 months)

Allergy to neomycin (additive in MMR)

Received another live vaccine by injection within 4 weeks

Pregnancy should be avoided for at least 1 month afterwards (you dont want pregnant women getting infected so just want to be safe you ask them to not get pregnant for long enough to make sure theyre definitely ok)

Question 14

How should neonates, infants and <6 weeks with a UTI be managed?

Answer 14

Admit to hospital immediately after a full septic screen
IV antibiotics ampicillin and gentamicin or co-amoxiclav for at least 5-7 days

oral therapy after clinical response and blood/csf culture being negative

Question 15

Which clinical features are suggestive of an upper UTI?

Answer 15

Bacteriuria + fever
Bacteriuria + loin pain

Question 16

How should an upper UTI be treated?

Answer 16

Consider admission

Oral antibiotics for 7-10 days - CEFALEXIN or CO-AMOXICLAV

If oral cannot be used, give IV antibiotics

Question 17

How should simple cystitis/lower uti be treated?

Answer 17

Oral antibiotics (e.g. trimethoprim) for 3 days

Question 18

Which children should have an ultrasound after a UTI?

Answer 18

Children who have had an atypical UTI (seriously unwell, not caused by ecoli, sepsis etc)

Children who have had a recurrent UTI
Children < 6 months

Question 19

Which children should have a DMSA and MCUG after a UTI?

Answer 19

infant <6 months with a standard UTI would need an USS

child any age presenting with atypical UTI (non ecoli, seriously ill, sepsis, abdominal mass, failure to respond to antibiotics, basically anything that isnt a classic UTI) : USS + dimercaptosuccinic acid scan (DMSA) + micturating cystourethrogram (MCUG)

recurrent UTI = same as atypical UTI

Question 20

How should enuresis in < 5 year olds be managed?

Answer 20

Reassure that this usually resolves without investigation
Ensure easy access to the toilet at night
Encourage bladder emptying before bed

Question 21

How should enuresis in > 5 year olds be managed?

Answer 21

If infrequent (< 2 per week) reassure and watch-and-wait

1st line if < 7: enuresis alarm and positive reward system
2nd line: desmopressin

Desmopressin may be used first line if rapid short-term control is necessary, or if > 7 years old

Question 22

List some causes of secondary enuresis.

Answer 22

UTI

Constipation

Diabetes

Psychological/Family problems

Question 23

How is nephrotic syndrome treated?

Answer 23

fluid restrict and low salt diet

Oral prednisolone for 4 weeks

Wean and stop after 4 weeks

very advanced minimal change disease may need albumin and furosemide

If the child does not respond or has atypical features, consider renal biopsy

Question 24

List some complications of nephrotic syndrome.

Answer 24

Hypovolaemia

Thrombosis

Infection due to loss of IgG

Hypercholesterolaemia

Question 25

How is Henoch-Schonlein purpura managed?

Answer 25

Most resolve spontaneously within 4 weeks

Joint pain can be managed with paracetamol/ibuprofen

IV corticosteroids are recommended for nephrotic-range proteinuria or declining renal function

Oral prednisolone may be given for severe scrotal oedema or abdominal pain