Paeds1

Question 1

Before performing 6 week well baby check what should you consider?

Answer 1

Consider: Family centred care with parental involvement/cultural background - interpreter or INdigenous liaison needed?/Infection control/Does infant personal health record need updating

Question 2

What does the six week well baby check involve?

Answer 2

REVIEW HISTORY - medical, obstetric, foetal investigations and results, meds, family and social history

• mode of birth, resus?, meds, observations, feeding since birth, urine and faecal output since birth
• ask about any parental concerns

EXAMINE:

• General appearance - skin colour, integrity, anomalies/rash, alertness, posture, activity, range of spontaneous movement, muscle tone
• Growth status - head circ, length, weight (PLOT)
• Head/face/neck - shape/size, scalp fontanelles, sutures, eyes (red reflex), nose, ears position, mouth/palate, tongue, jaw size
• Clavicles,arms and hands - length, proportions, symmetry and digits

Chest - size, shape, symmetry, movement, breast tissue, nipples, heart sounds, heart rate, breath sounds, RR

Abdo- size, shape, symmetry - umbilicus, palpate for hepatosplenomegaly

Genitourinary - anal position, patency, passage of urine and stool

• male: check for formed penis, foreskin, testes (descended) , check for hypospadias/urethral position
• female: check for clitoris, labia, hymen

Hips. legs and feet: Ortolani and Barlow, leg length, proportions, symmetry, digits

Back: spinal column, skin, symmetry of scapulae and buttocks

NeuroL assess posture, behaviour, spontaneous movements, tone, cry, reflexes (Moro, rooting, suck, grasp, stepping/walking)

Discuss with parents:

Screening tests for neonatal hearing (Discuss finding with parents)

Ensure the infant personal health record is completed and discussed with parents

Immunisation

Consider hip ultrasound for possible developmental dysplasia of the hip (DDH) in female breech babies

Question 3

DDx for sudden onset abdominal pain in child?

Answer 3

Testicular torsion

Intussusception

Volvulus

Perforated viscous

Hernia

Question 4

DDx for bloody diarrhoea in child?

Answer 4

IBD

Gastro

HUS

Question 5

Billious vomiting in a child DDx

Answer 5

Volvulous

Bowel obstruction

Question 6

Jaundice and abdominal pain in a child? likely Dx

Answer 6

Hepatitis

Question 7

Episodic/Colicky abdo pain in a child - Ddx?

Answer 7

Constipation

Gastroenteritis

Itussusception

Mesenteric adenitis

Question 8

Dull the increasing severity and localisation of abdominal pain in a child?

Answer 8

Appendicitis

Epidydimitis

Question 9

Abdo pain with Vomiting and diarrhoea in a child - likely dx

Answer 9

Gastroenteritis

Question 10

Abdo pain with cough and fever in a child - likely dx

Answer 10

pneumonia

Question 11

Abdo pain with dysuria/frequency/ fever

Answer 11

UTI

Pyelo

Question 12

Sudden painful distension and bloody diarrhoea in a child with CF or Hirsprungs disease

Answer 12

Enterocolitis

Can rapidly deteriorate with dehydration, electrolyte disturbance, systemic toxicity and risk of colonic perforation.

Question 13

What is a dangerous cause of abdominal pain in kids with a history of:

Liver disease and/or ascites

Nephrotic syndrome

Splenectomy

VP shunt

Answer 13

Primary bacterial peritonitis

Question 14

Potential cause of abdo pain in kids who are taking:

Chemotherapy

On immunosuppressants

PEG / NG / NJ fed

Answer 14

Pancreatitis

Question 16

A dangerous cause of abdominal pain in kids with a history of:

Inflammatory bowel disease (especially if concurrent Clostridium difficile)

Immunocompromised

Answer 16

Toxic megacolon

Question 17

Child with Abdominal pain - findings on examination?

Answer 17

Observe the child’s movements, gait, position and level of comfort

Examine the abdomen for:

focal vs generalised tenderness

rebound tenderness*

guarding or rigidity*

abdominal masses

distension

palpable faeces

Assess for non-abdominal causes as above

*Peritonism:

Child will often not want to move in the bed and will be unable to walk or hop comfortably, and will have abdominal tenderness with percussion, internal rotation of the right hip can irritate an inflamed appendix

Rectal or vaginal examination is rarely indicated in a child,

Question 18

How do you assess for peritonism in a child

Answer 18

Child will often not want to move in the bed and will be unable to walk or hop comfortably, and will have abdominal tenderness with percussion, internal rotation of the right hip can irritate an inflamed appendix

Question 19

When would you order an ultrasound in a child with abdo pain

Answer 19

It is not clinically indicated for testicular torsion and may delay time critical surgery

May be appropriate in suspected ovarian torsion

Useful if the history is suggestive of intussusception, even if examination is normal

Question 20

Would you order an AXR in a child with constipation

Answer 20

NO. not indicated

Question 21

Prior to transferring infants or children with possible surgical conditions - considerations?

Answer 21

ensure the child has adequate analgesia, venous access and intravenous fluids

Question 22

When would you consider transfering a child with abdominal pain to hospital

Answer 22

Consider consultation with local paediatric / surgical team when

Surgical cause suspected

Severe pain not responding to analgesia

Child requiring admission

Consider transfer when

Child requires care beyond the comfort level of the local hospital

Question 23

What is the classic symptomology of Acute appendicitis

Answer 23

Anorexia and periumbilical pain FOLLOWED by nausea –> vomiting.

RUQ and vomiting only in 50%

Fever is a late sign.

Patients often lie down, flex knees and draw knees up to reduce movements and thereby reduce pain.

Later pain can migrate with worsening nausea and vom.

Question 24

Vomiting that precedes abdominal pain in a child?

Answer 24

need to consider intestinal obstruction

Question 25

What is considered a fever in a child?

Answer 25

37.8 degrees Celsius

Question 26

Child with fever under 3 months of age?

Answer 26

Send to ED

Question 27

Child with fever 3 months to 3 year?

Answer 27

Focus on examination and history? manage accordingly If no focus found and fever ongoing for 2 days - FBE/CRP/ESR + Urine M/C/S Plus or minus chest xray

Question 28

Blue-grey discolouration of skin over lower back and sacrum of babies of east asian and other dark skinned backgrounds?

Answer 28

Mongolian spot No clinical significance usually disappear by age of 4

Question 29

What is the usual time course of hydrocele in a child?

Answer 29

Majority resolve by 12-18months of age Surgical r/v if not resovled by 2 years

Question 30

When should you consider abuse in a non ambulant infant?

Answer 30

BRUISING - is suspicious in a non ambulant infant. Falls from change table/bed/cot - rarely bruise ACCIDENTAL bruising occurs at bony prominences and the front of the body. Think of non accidental bruising in the following areas: - back, buttock, forearms, face, neck, ears,abdomen, feet, hands

Question 31

What circumstances are suggestive of non accidental injury in a child?

Answer 31

* Delay in seeking medical treatment for significant injury * Explanation of injury cause changes over time without apparent reason * Explanation of injury cause differs between caregivers without apparent reason * Explanation offered is inconsistent with child’s developmental capabilities * Possible impairments to caregivers’ capacity to supervise and protect the child

Question 32

What fractures are more often seen in Non accidental injury?

Answer 32

• Classic metaphyseal lesions • Rib, especially posterior • Scapular • Sternal

Question 33

What bruising patterns are suggestive of Non Accidental injury

Answer 33

Bruising in a child \<9 months of age or nonmobile child * Bruising away from bony prominences * Bruising to the ears, face, abdomen, arms, back, buttocks and hands * Multiple bruises in clusters * Multiple bruises of uniform shape (eg. opposing arc from a bite) • Bruising that has the shape of an object or a ligature (eg. tram track from a rod shaped object)

Question 34

Management goals for NAI

Answer 34

managing the child’s immediate injuries, ## Footnote assessing the child’s (and any other cohabiting children’s) immediate safety and reporting the suspected abuse to the local authorities. **Report suspected child abuse to their statutory child protection agency as per local legislation.** The long term ongoing family support and monitoring of the child’s wellbeing are also important roles for the GP.

Question 36

What is idiopathic scrotal oedema? What age group does it affect?

Answer 36

Idiopathic scrotal oedema usually affects boys aged 3 - 7 years with rapid onset. The child appears well and the oedema is not painful. The condition usually resolves over 1 - 2 days and no intervention is required.

Question 37

HOw does abdominal migraine present?

Answer 37

Abdominal migraine is defined by episodes of dull midline abdominal pain associated with nausea, vomiting, anorexia, headache and pallor. It is an underdiagnosed condition and typically affects children aged 3 - 10 years of age. Most patients with this condition have a personal or family history of migraine.

Question 40

Common cause of painless rectal bleeding in child under 5?

Answer 40

**Meckel's diverticulum** is the most common congenital abnormality of GI tract, occurring in about 2% of people. Most people with Meckel's diverticulum are asymptomatic, however a small percentage develop complications which may include: bleeding, obstruction, diverticulitis and perforation. Bleeding is the most common presentation in children aged \<5, where they usually present with episodes of intermittent painless rectal bleeding. Obstruction can occur at any age, but is more common in older children and adults. In children, obstruction is most likely a result of intussesception of the diverticulum.

Question 41

What do you call a febrile seizure that has lasted longer than 10 minutes? What age group is affected by FC's?

Answer 41

A febrile seizure lasting more than 10 minutes is classified as a **complex febrile seizure.** Febrile convulsions occur in children **between 6 months and 5 years of age.** Older children with a first episode of a simple febrile convulsion are less likely to have further episodes than those who have their first episode at a younger age. Paracetamol has not been shown to reduce the risk of further febrile convulsions. Febrile convulsions occur in around 3% of healthy children.