Quesmed wrong answers

Question 1

What is eczema herpeticum?

Answer 1

Eczema herpeticum is a viral skin infection caused by the herpes simplex virus (HSV) or varicella zoster virus (VZV). It was previously known as Kaposi varicelliform eruption (don’t confuse this with Kaposi sarcoma, which occurs in late stage HIV).

Herpes simplex virus 1 (HSV-1) is the most common causative organism, and may be associated with a coldsore in the patient or a close contact. It usually occurs in a patient with a pre-existing skin condition, such as atopic eczema or dermatitis, where the virus is able to enter the skin and cause an infection.

Question 2

What are the presenting features of eczema herpeticum?

Answer 2

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).

The Rash
The rash is usually widespread and can affect any area of the body. It is erythematous, painful and sometimes itchy, with vesicles containing pus. The vesicles appear as lots of individual spots containing fluid. After they burst, they leave small punched-out ulcers with a red base.

Question 3

How is eczema herpeticum managed?

Answer 3

Viral swabs of the vesicles can be used to confirm the diagnosis, although treatment is usually started based on the clinical appearance.

Treatment is with aciclovir. A mild or moderate case may be treated with oral aciclovir, whereas more severe cases may require IV aciclovir.

(Caused by herpes simplex 1)

Question 4

What is the complication of eczema herpeticum?

Answer 4

Children with eczema herpeticum can be very unwell. When not treated adequately it can be a life threatening condition, particularly in patients that are immunocompromised.

Bacterial superinfection can occur, leading to a more severe illness. This needs treatment with antibiotics.

Question 5

What is Rickets and what are the causes?

Answer 5

Rickets is a paediatric skeletal disorder caused by a deficiency or impaired metabolism of vitamin D, calcium, or phosphate. It results in an inability to adequately mineralise the bone matrix of growing bone, causing soft and deformed bones.

Rickets typically presents in infancy or childhood. While it is less prevalent in developed countries due to improved nutritional awareness and public health measures, it remains common in some regions of Asia and Africa. In Asia, contributing factors include a lack of sunlight and vegetarian diets low in meat, which is a source of dietary vitamin D. In Africa, higher incidences can be attributed to darker skin pigmentation, which reduces vitamin D synthesis upon sunlight exposure.

The primary cause of rickets is a prolonged deficiency in vitamin D. This vitamin is crucial for the absorption of calcium and phosphorus from food in the intestines. Causes of this deficiency may include:
- Poor nutrition
- Insufficient sun exposure, which aids in vitamin D synthesis
- Malabsorption syndromes in which the intestines do not adequately absorb vitamins

Question 6

What are the features of rickets?

Answer 6

Patients with rickets may exhibit the following signs and symptoms:
- Bowed legs or knock knees
- Bone pain
- Stunted growth
- Dental deformities
- Skeletal deformities such as pigeon chest or spinal curvature
- Muscle weakness
- In severe cases, bone fragility and fractures
- Hypocalcaemia, which may cause seizures and intellectual disability

Question 7

What are the differentials for rickets?

Answer 7

When diagnosing rickets, other conditions with similar presenting signs and symptoms should be considered. These may include:
- Osteomalacia: Presenting with bone pain, muscle weakness, and increased fracture risk, but typically seen in adults.
- Hypophosphatasia: Characterised by bone pain, dental issues, and muscle weakness, but often associated with low levels of alkaline phosphatase.
- Osteogenesis imperfecta: Exhibits bone fragility and fractures, but also characterised by blue sclera and hearing loss.

Question 8

How is rickets diagnosed?

Answer 8

The diagnosis of rickets involves a combination of clinical examination, laboratory testing, and radiological imaging.
- Laboratory testing: Includes blood tests for calcium, phosphate, and alkaline phosphatase levels, and sometimes 25-hydroxyvitamin D levels. Urinalysis can be used to assess calcium and phosphate excretion.
- Radiological imaging: X-rays of the affected bones can show typical changes such as cupping, fraying, and metaphyseal widening.

Question 9

How is rickets managed?

Answer 9

The management of rickets aims to correct the underlying deficiency and relieve symptoms.
1. Supplementation: Vitamin D, calcium, and phosphorus supplements are commonly prescribed.
2. Diet and Lifestyle Modifications: Ensuring adequate sun exposure and a diet rich in vitamin D, calcium, and phosphorus.
3. Orthopaedic intervention: In severe cases with significant bone deformities, orthopaedic surgery may be required.

Question 10

What is Perthes disease and how is it thought to manifest?

Answer 10

Perthes disease refers to idiopathic avascular necrosis of the femoral head in children aged 4-8. This condition arises due to disruption in blood flow to the femoral head, which subsequently leads to ischemia.

Perthes disease tends to manifest predominantly in males, with a male to female ratio of 5:1. Furthermore, approximately 10% of the cases present bilaterally.

The exact cause of Perthes disease remains unknown. However, it’s thought to be multifactorial involving genetic factors, potential trauma, and other environmental factors. There is a disruption in the blood supply to the femoral head which leads to avascular necrosis. This blood flow disruption could be due to clot formation, increased pressure within the bone, or damage to the vessels.

Question 11

What are the features of Perthes disease?

Answer 11

The cardinal symptoms of Perthes disease include:

1. Gradual onset of limp
2. Hip pain, which may also be referred to the knee

It is important to note that pain persisting for more than 4 weeks raises the suspicion for Perthes disease, as pain from conditions such as transient synovitis typically resolves within 2 weeks.

Question 12

What are the differentials for Perthes disease?

Answer 12

1. Transient synovitis: Presents with hip pain and a limp, but typically resolves within 2 weeks.
2. Septic arthritis: Characterised by acute onset of severe hip pain, fever, and inability to bear weight.
3. Slipped capital femoral epiphysis (SCFE): Presents in older, often overweight children, with knee pain, limping, and decreased hip motion.
4. Juvenile idiopathic arthritis (JIA): Presents with chronic joint pain and swelling, morning stiffness, and possible systemic features.

Question 13

How is Perthes disease diagnosed?

Answer 13

The primary diagnostic tool for Perthes disease is a hip X-ray. This investigation reveals:

• Sclerosis and fragmentation of the epiphysis
• In some cases, initial X-rays may appear normal, necessitating a repeat X-ray if clinical suspicion persists

Question 14

How is Perthes disease managed?

Answer 14

The management approach to Perthes disease depends on the extent of necrosis.
- If less than 50% of the femoral head is involved, conservative measures such as bed rest, non-weight bearing, and traction can lead to resolution. In these cases, the prognosis is generally favourable.
- If more than 50% of the femoral head is involved, management may necessitate the use of a plaster cast to keep the hip abducted or even an osteotomy. Unfortunately, this scenario is associated with poorer outcomes and a higher risk of degenerative arthritis in later life.

Question 15

What is Rubella and how is it transmitted?

Answer 15

Rubella, also known as German measles, is a contagious viral illness. It is caused by the rubella togavirus and transmitted through respiratory droplets.

Rubella is now less common due to widespread vaccination. The most vulnerable population is unvaccinated individuals, particularly unvaccinated pregnant women due to the risk of congenital rubella syndrome.

Rubella is caused by the rubella togavirus, which is transmitted via respiratory droplets or aerosols. Children are routinely vaccinated for Rubella as part of the MMR vaccine starting at 12 months of age.

Question 16

What are the features of rubella?

Answer 16

Rubella presents with nonspecific symptoms and signs such as:
- Fever
- Coryza
- Arthralgia
- A rash that typically begins on the face and moves down to the trunk, sparing the limbs. Pink/red spots which may merge to form evenly coloured patches. Takes 2-3 weeks to appear after being infected
- Lymphadenopathy, classically post-auricular

Question 17

What are the differentials for rubella?

Answer 17

The main differential diagnoses for rubella and their key signs and symptoms include:
1. Measles: Fever, cough, conjunctivitis, coryza, Koplik spots, and a rash that typically begins at the hairline and moves downwards to involve the entire body, including the limbs.
2. Scarlet fever: Sudden onset of fever, sore throat, “strawberry” tongue, and a fine, sandpaper-like rash, most often on the neck, underarm, and groin.
3. Fifth disease (Erythema infectiosum): A mild illness that might cause a “slapped cheek” rash on the face and a lacy red rash on the trunk and limbs, often after a few days of mild fever or cold-like symptoms.

Question 18

How is rubella diagnosed and managed?

Answer 18

Diagnosis of rubella is primarily confirmed with serological testing. This includes detecting rubella-specific IgM or a significant rise in rubella-specific IgG in acute and convalescent serum samples.

Management
Management of rubella is supportive, focused on relieving symptoms such as fever and joint pain. Antipyretics and analgesics may be used. It is crucial to isolate diagnosed individuals to prevent spread, particularly among vulnerable populations such as unvaccinated pregnant women.

Question 19

What is the main complication of rubella infection?

Answer 19

Rubella poses a serious risk to unvaccinated pregnant women. Congenital rubella infection (especially in the first 20 weeks of pregnancy) can lead to congenital rubella syndrome, which can cause severe fetal abnormalities such as:
- Cataracts
- Deafness
- Patent ductus arteriosus
- Brain damage/Learning disability

The risk is highest during the first 3 months of pregnancy. Women planning to become pregnant should ensure they have had the MMR vaccine. If in doubt they can be tested for rubella immunity. If they do not have antibodies to rubella they can be vaccinated with 2 doses of the MMR 3 months apart.
Pregnant women should not receive the MMR vaccination, as this is a live vaccine. Non-immune women should be offered the vaccine after giving birth.

Question 20

Which is the best scan for confirming the diagnosis of Meckel’s diverticulum?

Answer 20

A Technetium scan.

Uses radioactive metastable technetium-99, will highlight ectopic gastric mucosa in a symptomatic Meckels’ diverticulum.

Question 21

What is Kawasaki’s disease and what is the theorised cause?

Answer 21

Kawasaki disease is defined as a medium-vessel vasculitis predominantly affecting children. Despite extensive research, its exact mechanisms and triggers remain unclear.

Aetiology
The aetiology of Kawasaki disease is not fully understood. It’s thought to be multifactorial, potentially involving genetic factors, an infectious trigger, and a subsequent abnormal immune response.

Question 22

What are the features of Kawasaki’s disease?

Answer 22

The diagnosis of Kawasaki disease is based on the presence of high-grade fevers persisting for more than five days, accompanied by four out of five ‘CREAM’ features:
Conjunctivitis (bilateral, non-exudative)
Rash (any non-bullous rash)
Edema/Erythema of hands and feet
Adenopathy (cervical, commonly unilateral and non-tender)
Mucosal involvement (strawberry tongue, oral fissures etc)

Children with Kawasaki disease typically appear very unwell, often ‘flat’ - more so than with most other febrile illnesses they may have experienced.

Question 23

What are the differentials for Kawasaki’s disease?

Answer 23

The main differential diagnoses for Kawasaki disease, along with their key signs and symptoms include:
- Scarlet Fever: Characterized by a high fever, “strawberry tongue,” and a red rash with a sandpaper-like texture.
- Measles: Presents with fever, cough, coryza, conjunctivitis, and a maculopapular rash.
- Drug Reactions: These can cause similar skin manifestations and fever, but are often associated with the onset of a new medication.
- Juvenile Rheumatoid Arthritis: This can cause fever and rash, as well as joint pain and swelling.
- Toxic Shock Syndrome: This typically includes fever, rash, hypotension, and multisystem involvement.

Question 24

How is Kawasaki’s disease investigated?

Answer 24

The primary investigation for Kawasaki disease is an echocardiogram due to the risk of coronary aneurysms. Additional investigations may include blood tests looking for elevated inflammatory markers, such as CRP and ESR.

Question 25

How is Kawasaki’s disease treated?

Answer 25

The mainstay of treatment for Kawasaki disease includes:
- Intravenous immunoglobulin (IVIg) and high-dose aspirin to reduce inflammation and prevent coronary artery aneurysms.
- Regular echocardiograms for ongoing surveillance of coronary artery aneurysms.
- Patients should be closely monitored as recovery from the acute episode can take several weeks.

Question 26

What are the common issues with breastfeeding?

Answer 26

• Cracked/sore nipples: pain, discomfort, visible cracks or sores on nipples.
• Blocked duct and breast engorgement: pain, swelling, warmth, redness, lump in the breast.
• Mastitis/abscess: fever, intense breast pain, red, swollen, warm breast, malaise, pus or discharge from the nipple.
• Thrush: white patches on the tongue or inside of the mouth, pain, discomfort, and difficulty feeding.
• Insufficient milk: slow weight gain, fewer than six wet diapers a day, persistent hunger.

Question 27

Which antibiotics are safe and which are cautioned during breastfeeding?

Answer 27

• Antibiotics that are safe to use in breastfeeding mothers include: penicillin-based antibiotics, beta-lactam antibiotics, trimethoprim, azithromycin, cephalosporins, clarithromycin, erythromycin
• IV gentamicin and meropenem can also be given
• Tetracyclines although previously contraindicated - may be given in short courses, however caution is advised
  = Most antibiotics can produce excessively loose motions in the baby, with the appearance of diarrhoea. Some infants appear more unsettled with tummy aches or colic. These effects are not clinically significant and do not require treatment.
• Antibiotics which are cautioned or **contra-indicated ** include: ciprofloxacin (potential joint problems), nitrofurantoin (G6PD deficiency), teicoplanin, clindamycin (antibiotic-associated colitis), co-trimoxazole.

Question 28

Which analgesia is safe and which isn’t during breastfeeding?

Answer 28

Paracetamol and ibuprofen form the basis for safe analgesics for breastfeeding mothers. NSAIDs are safe to use in breastfeeding mothers.

Stronger drugs are available but should be taken with caution and babies observed for drowsiness.

Dihydrocodeine is the preferred opiate analgesic if mothers need stronger painkillers. This is because it has a cleaner metabolism than codeine and is less associated with adverse effects in the baby. It is frequently used as the drug after caesarean section.

Aspirin as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections.

Codeine is no longer recommended as routine medication for breastfeeding mothers with particular caution where the mother has never taken the drug before or has found that the drug causes her to be drowsy, dizzy or experience severe constipation.

Question 29

What is the risk of HIV, HepB and HepC transmission during breastfeeding?

Answer 29

• An HIV infected mother can pass HIV to her infant during pregnancy and delivery
• Anti-retroviral drugs reduce the risk of transmission of HIV through breastfeeding
• However, current recommendations advise that HIV-infected mothers should refrain from breastfeeding

Hepatitis B and C transmission
There is no risk for mother to child transmission of Hepatitis B provided the infant has received appropriate HBV immunoprophylaxis

Question 30

What are the features that point towards complex febrile seizures?

Answer 30

Any one of:
-Focality
-Duration of longer than 15 minutes
- Recurrence within a 24-hour period

Question 31

What are the features of intussusception?

Answer 31

• Paroxysmal, severe colicky pain, often causing the child to draw up his legs
• Lethargy and decreased activity between pain episodes
• Refusal of feeds
• Vomiting, which may be bile-stained depending on the location of the intussusception
• Passage of a ‘redcurrant jelly’ stool, which consists of blood-stained mucus
• Abdominal distension
• Palpation may reveal a sausage-shaped mass in the abdomen

Question 32

How is intussusception diagnosed?

Answer 32

Abdominal ultrasound is the primary investigation method for intussusception. The classic ‘target’ sign, represented by concentric echogenic and hypoechogenic bands, is often seen. Ultrasound can also reveal complications such as free abdominal air or the presence of gangrene.

Question 33

How is intussusception managed?

Answer 33

The management of intussusception varies based on the child’s stability and the presence of complications:

Initial management typically involves rectal air insufflation or a contrast enema, but these should only be performed if the child is stable.
Operative reduction is indicated in the following scenarios:
- Non-operative management has failed.
- The child presents with peritonitis or perforation.
- The child is haemodynamically unstable.

Question 34

How can the presence of EBV be confirmed?

Answer 34

Positive heterophile antibody test (‘Paul Bunnell’)

Question 35

How is hydrocephalus investigated?

Answer 35

• A cranial ultrasound through the anterior fontanelle, typically conducted during the first few months of life when the fontanelle is still open
• MRI or CT of the brain, offering detailed images to assess ventricular size and identify potential underlying causes such as tumours or haemorrhages

Question 36

What are the normal gross motor milestones for: 6 weeks, 6 months, 9months, 12 months, 18 months, 2 years, 2.5 years, 3 years, 4 years?

Answer 36

Six weeks: Good head control - raises head to 45 degrees when on tummy

Six months: Sit without support - rounded back; rolls tummy (prone) to back (supine) - vice versa slightly later.

9 months: Stands holding on

12 months: Walks alone (12-18m). 18 months is threshold for concern.

18 months: Runs

2 years: Runs on tiptoes; walks up stairs - 2 feet per step

2.5 years: Kicks ball

3 years: Hops on one foot for 3 steps; walks up stairs 1 foot per step but still 2 feet per step on the way down.

4 years: Walks up and down stairs in an adult fashion

Question 37

What is the limit age for a baby sitting unsupported?

Answer 37

9 months

Question 38

What are the common causes of respiratory tract infections in patients with cystic fibrosis?

Answer 38

Notably Pseudomonas aeruginosa

Other common pathogens include staph aureus and Haemophilus influenzae

Question 39

What are the common side effects of vaccinations in children?

Answer 39

Vaccinations are generally very safe and effective. Any vaccination can cause side effects from a local and systemic immune response:

• Locally, there may be tenderness and aches around the injection site
• Systemically, the patient may have a fever and feel unwell for a few hours
• Fever is particularly common with the meningococcal vaccine; parents should be asked to give prophylactic paracetamol to their child and warned that a fever is very likely. This will help to reduce unnecessary worry, A&E attendance and unnecessary investigations.

Question 40

What are the rare side effects of rotavirus vaccination and MMR vaccination?

Answer 40

• Rotavirus vaccination can rarely cause intussusception.
• The MMR vaccine can cause seizures (1/1000 doses) and ITP (idiopathic thrombocytopenic purpura) (1/24,000 doses).

Question 41

What are the possible contraindications to vaccinations?

Answer 41

1. Egg allergy
   - children with egg allergy should not receive yellow fever vaccination
   - the standard preparation of the influenza vaccine is only contraindicated in children who have been admitted to PICU as a result of their egg allergy. All other cases of children with egg allergy can safely have the standard vaccine in primary care settings.
   - The MMR vaccine is safe for children with an egg allergy. It is a common misconception that it contains components from eggs.
2. Previous proven anaphylaxis to vaccine components - children with serology confirming allergy to vaccine components should not receive further doses of that particular vaccine.
3. Immunosuppression - children with immunosuppression (e.g. from confirmed severe primary immunodeficiencies, chemotherapy or other immunosuppressive medications, or radiotherapy) should not receive live attenuated vaccines, such as the MMR vaccine, inhaled influenza vaccine or the varicella vaccine.
4. Intussusception - children with a history of intussusception cannot have the rotavirus vaccination

Question 42

What are the common causes of cellulitis?

Answer 42

The most common causative organisms are Streptococcus and Staphylococcus species, with Streptococcus pyogenes (Group A Streptococcus) being the most common. The bacteria gain entry through breaches in the skin barrier, such as trauma, ulcers, or other skin conditions.

Question 43

What are the features of periorbital cellulitis and what is the most important investigation?

Answer 43

• Erythema and oedema around one eye,
• fever,
• reduced visual acuity, double vision and limited eye movements
• The most common antecedent to orbital cellulitis is bacterial sinusitis (headache, fever and copious yellow snot).

The most important investigation in suspected orbital cellulitis is a CT of the orbit to assess the depth of infection and if there are any abscesses or risk for invasion of the CNS

Question 44

What are the possible causes of testicular torsion?

Answer 44

Testicular torsion is a urological emergency characterized by the twisting of the testicle around the spermatic cord due to inadequate attachment of tissues within the scrotum. This situation leads to the obstruction of blood flow to the affected testicle, which if not promptly treated, can result in testicular necrosis. Testicular torsion is most commonly observed in males aged 12-18 years but can occur at any age.

Aetiology
The primary cause of testicular torsion is the lack of adequate tissue attachment around the testicle, allowing it to freely rotate within the scrotum. This is often associated with the following risk factors:
- Bell-Clapper deformity: An anomaly where the testis is inadequately fixed, allowing it to rotate freely.
- Undescended testicle: Testicles that have not descended fully into the scrotum may be more prone to torsion.
- Trauma: Physical injury may precipitate torsion, although it often occurs spontaneously.
- Prior intermittent torsion: Those who have previously experienced episodes of intermittent torsion may be at higher risk.

Question 45

What are the features of testicular torsion?

Answer 45

Testicular torsion primarily presents with the following clinical features:
- Sudden onset, severe pain in one testicle
- The event often follows minor trauma
- The affected testicle may be high riding in the scrotum
- Unilateral loss of cremaster reflex
- Persistent pain despite elevation of the testicle (negative Prehn’s sign)

Question 46

What are the differentials for testicular torsion?

Answer 46

• Epididymitis: Characterized by a slower onset of pain, presence of urethral discharge, urinary symptoms, and relief with testicular elevation (positive Prehn’s sign).
• Orchitis: This condition usually presents with systemic symptoms like fever, along with testicular pain and swelling.
• Trauma: Testicular rupture or hematoma may present with acute pain, but history will typically reveal a significant traumatic event.
• Inguinal Hernia: Presents with groin pain, a bulge in the inguinal area, and potential bowel symptoms but without the acute onset of testicular pain.

Question 47

How is testicular torsion investigated and managed?

Answer 47

While the diagnosis of testicular torsion primarily relies on clinical features, further investigations can help confirm the diagnosis and rule out differential diagnoses:
1. Doppler ultrasound: Demonstrates reduced or absent blood flow to the affected testicle.
2. Urinalysis: Can rule out infection or urinary tract inflammation.

Management
The management of testicular torsion is primarily surgical:
- Urgent surgical exploration: This is crucial to confirm the diagnosis and to attempt to salvage the testicle.
- Bilateral orchidopexy: Fixation of both testicles is performed to prevent future torsion.

Question 48

What are the complications of untreated testicular torsion?

Answer 48

Without immediate treatment, testicular torsion can lead to:
- Testicular necrosis: Lack of blood flow can cause tissue death, requiring surgical removal.
- Impaired fertility: Loss or damage to a testicle can affect overall fertility.

Question 49

What is the screening test for cystic fibrosis in neonates and what constitutes a positive test?

Answer 49

Cystic fibrosis is initially screened for on the neonatal blood spot test within the first few days of life through the identification of raised blood immunoreactive trypsinogen.

If cystic fibrosis is suspected, further tests, such as genetic testing or a sweat test, are done to confirm the diagnosis.

Question 50

What are the 5 risk factors for developmental dysplasia of the hip?

Answer 50

1. Female: The condition is more prevalent in females.
2. Firstborn: Firstborn children have a higher risk.
3. Family history: DDH often runs in families.
4. Frank breech presentation (previously referred to as ‘Fanny first’): Babies presenting buttocks or feet first in the womb have a higher risk.
5. Fluid: Low amniotic fluid levels (oligohydramnios) can increase the risk.

Question 51

What are the clinical features of developmental dysplasia of the hip?

Answer 51

Clinical presentation may vary based on age. In infants, key signs include:
- Limited hip abduction, especially when the hip is flexed.
- Asymmetry of gluteal and thigh skinfolds.
- Apparent limb length discrepancy.

In older children, the following signs may be present:
- Walking difficulties or a limp.
- Delayed walking.
- Waddling gait in bilateral cases.

Question 52

What are the tests for developmental dysplasia of the hip?

Answer 52

Barlow (tests for posterior dislocation) and Ortolani (tests for relocation on hip abduction) manoeuvres are primary screening tools.

If DDH is clinically suspected, hip ultrasonography should be ordered for confirmation, especially in infants less than 6 months of age. For older infants and children, pelvic radiography may be more suitable.

Question 53

How is developmental dysplasia of the hip managed?

Answer 53

The management approach is largely dependent on the severity and age at diagnosis:
- In mild cases or those detected early, the condition may be self-limiting within the first few months of life.
- A Pavlik harness may be used to maintain the hip in a flexed and abducted position.
- More severe cases, or those not responding to non-operative management, may necessitate surgical intervention for reduction and stabilization.

Question 54

When is hip ultrasound indicated?

Answer 54

Public Health England recommends hip ultrasound for any child with an abnormal hip examination (Barlow and Ortolani test) or any hip risk factors (including first-degree family history and breech presentation).

Question 55

Which antibiotic should be used in neisseria meningitidis infection? How are contacts treated?

Answer 55

3rd generation cephalosporins including ceftriaxone or cefotaxime

All household or close contacts should receive ciprofloxacin or rifampicin as post-exposure prophylaxis.
Infections caused by Neisseria Meningitidis are notifiable diseases

Question 56

How is meningococcal infection transmitted and how does it cause disease?

Answer 56

Meningococcal infection is a disease caused by the Neisseria meningitidis bacterium, a gram-negative intracellular diplococcus. It resides in the nasopharynx of many children and young adults, with some strains having the potential to invade the bloodstream and cause fatal septicaemia.

The disease is transmitted via respiratory droplet spread.

The pathological process begins when the bacteria enter the circulation, initiating inflammatory processes that result in capillary leakage and intravascular thrombosis.

Question 57

What are the clinical features of infection with Neisseria Meningitidis?

Answer 57

Infection with Neisseria meningitidis may present as:
- Meningococcaemia (septicaemia)
- Meningitis, with non-specific signs such as lethargy, headache, fever, rigors, and vomiting.
- A combination of the two, often associated with a rapidly developing purpuric skin rash.
- Hypovolaemic shock, demonstrated by cold peripheries, poor capillary refill time, tachycardia, and decreased urine output.
- In rare cases, massive adrenal haemorrhage and septic shock may occur, a condition known as Waterhouse-Friderichsen syndrome.

Question 58

How is meningococcal infection diagnosed?

Answer 58

• Confirmation of meningococcal infection is achieved through cultures of blood or cerebrospinal fluid (CSF), as appropriate.
• Polymerase chain reaction (PCR) testing for Neisseria meningitidis is highly sensitive and is another key investigative tool.

Neisseria Meningitidis is a gram-negative diplococcus

Question 59

How is meningococcal infection managed?

Answer 59

• Early antibiotic treatment should be administered when meningococcal infection is suspected. Initial therapy will typically involve broad-spectrum IV antibiotics until the pathogen is identified, at which point antibiotics may be adjusted to penicillin-based treatment if sensitivities permit.
• Empirical choice is 3rd generation cephalosporins (ceftriaxone or cefotaxime)
• Patients with severe septicaemia may require admission to the Intensive Care Unit (ICU).
• Infections caused by Neisseria meningitidis are notifiable diseases, meaning cases must be reported to public health authorities.

Question 60

What are the possible causes of hydrocephalus in children?

Answer 60

Hydrocephalus can be categorised into non-communicating (obstructive) and communicating types, each with its own causes:
1. Non-communicating Hydrocephalus: An obstruction in the ventricular system disrupts the flow of CSF, potentially resulting from:
- Congenital malformations such as stenosis of the aqueduct or a Chiari malformation
- A tumour or vascular malformation in the posterior fossa
- An intraventricular haemorrhage (premature infants are particularly at risk)

1. Communicating Hydrocephalus: In these cases, CSF is not adequately reabsorbed due to damage to the arachnoid villi. Potential causes include:
   - Meningitis
   - Subarachnoid haemorrhage

Question 61

What are the clinical features of hydrocephalus?

Answer 61

• An enlarged head circumference, noticeable upon inspection or when tracking their growth
• Bulging of the anterior fontanelle
• Distention of scalp veins
• ‘Sunsetting’ of the eyes, a late sign where upward gaze is limited due to raised intracranial pressure

Question 62

How is hydrocephalus diagnosed in children?

Answer 62

1. A cranial ultrasound through the anterior fontanelle, typically conducted during the first few months of life when the fontanelle is still open
2. MRI or CT of the brain, offering detailed images to assess ventricular size and identify potential underlying causes such as tumours or haemorrhages

Question 63

What are the features of benign rolandic seizures?

Answer 63

Benign rolandic seizures primarily affect children aged 3-10 years and almost exclusively occur during sleep. Children may experience a tonic seizure overnight, which could be noticed by parents or inferred from disrupted bedding or the child found sleeping on the floor in the morning.

The diagnosis is based on history and characteristic EEG findings during sleep of centro-temporal spikes. The prognosis is generally excellent, with most children outgrowing the condition around puberty.

Question 64

What is west syndrome?

Answer 64

West Syndrome, or infantile spasms, starts between 4-8 months of age. The primary symptom is myoclonic jerking, termed ‘jack knife’ spasms, which usually occur in clusters. This syndrome is often associated with developmental regression and high morbidity. Diagnosis is typically made based on the characteristic EEG findings of hypsarrhythmia.

First line treatments are prednisolone and vigabatrin

Question 65

What is the definition of precocious puberty and what are the two main types?

Answer 65

Precocious puberty is defined as the onset of secondary sexual characteristics before the age of 8 in females and before the age of 9 in males, which is earlier than the normal age of puberty onset.

Types:
1. Gonadotrophin-dependent precocious puberty (GDPP):
- Idiopathic (>90% of cases)
- Brain tumours
- Cranial radiotherapy
- Structural brain damage, such as:
- Hydrocephalus
- Post-infection (e.g., meningitis)
- Traumatic head injury

2. Gonadotrophin-independent precocious puberty (GIPP):
   - Gonadal tumours
   - Adrenal or liver tumours (which may cause virilisation)
   - Congenital adrenal hyperplasia

Question 66

How should precocious puberty be investigated?

Answer 66

• Measurement of oestradiol/testosterone levels
• Measurement of adrenal androgens
• Brain MRI
• Pelvic ultrasound
• Intra-abdominal imaging if an adrenal or hepatic tumour is suspected
• Bone age assessment

Question 67

How is precocious puberty managed and what are the complications?

Answer 67

Management of precocious puberty primarily involves use of GnRH analogues to suspend the progression of puberty. However, the approach may vary depending on the underlying cause of the condition.

Complications
If precocious puberty is left untreated, it can lead to:
- Accelerated skeletal development and premature fusion of bone growth plates, which can result in a reduced final adult height.
- Early onset of physical changes can significantly impact the affected child’s psychological wellbeing.

Question 68

What is the major complication of glandular fever?

Answer 68

Splenic rupture
There is splenomegaly from white blood cell sequestration and the enlarged spleen is at risk of rupture in severe cases

Question 69

What are the outstanding features of a near-fatal asthmatic episode?

Answer 69

Near-fatal asthmatic episodes are characterised by a rising carbon dioxide level on a blood gas and altered consciousness.

Question 70

What are the outstanding features of a life-threatening acute asthmatic episode?

Answer 70

A life-threatening acute asthmatic episode is characterised by CHEST 92 33:
- Cyanosis
- Hypotension
- Exhaustion
- Silent chest
- Tachycardia
- Saturations < 92%
- PEFR < 33% of predicted

Question 71

What are the outstanding features of a severe acute episode (not life-threatening or near-fatal)?

Answer 71

• Respiratory distress: use of accessory muscles of respiration, breathlessness resulting in inability to complete sentences, tachypnoea
• Tachycardia
• Peak expiratory flow rate 33-50% of predicted

Question 72

How are maintenance fluids calculated in paeds?

Answer 72

1000ml for first 10kg
500ml for next 10kg (50ml/kg if less than 20kg)
20ml per kg for weight over 20kg

Question 73

Which investigation is contraindicated in meningococcal septicaemia (with meningitis symptoms)?

Answer 73

Lumbar puncture due to the risk of coning. (i think due to hypotension and

Question 74

When is Lumbar puncture contraindicated?

Answer 74

Raised ICP
Focal neurological signs
Coagulation disorder
Cardiovascular instability
If antibiotic administration will be delayed

Question 75

What are the features of Patau’s syndrome?

Answer 75

• Holoprosencephaly (failure of the cerebral hemispheres to divide)
• Microcephaly
• Cleft lip and palate
• Polydactyly
• Congenital heart disease

(Trisomy 13)

Question 76

What are the features of Edward’s syndrome?

Answer 76

• Low-set ears
• Micrognathia
• Microcephaly
• Overlapping 4th and 5th fingers
• Rocked bottomed feet
• Congenital heart disease

Question 77

What are the features of Down’s syndrome?

Answer 77

• Flat facial features: Small head, flattened face, and protruding tongue.
• Upward slanting eyes: Often with a skin fold that comes out from the upper eyelid and covers the inner corner of the eye.
• Small ears: The ears may be set low on the head.
• Small hands and short fingers: The fingers may be short and the hands broad. A single crease across the palm (palmar crease) is common.
• Hypotonia: Poor muscle tone or loose joints.
• Short stature: Affected individuals are often shorter than their peers.
• Intellectual disability: Varying degrees of cognitive impairment, from mild to moderate.
• Congenital heart defects: Up to half of all children with Down’s syndrome have some form of heart defect.
• Digestive problems: Including blockage of the intestines (duodenal atresia) or other issues with the digestive tract.
• Increased susceptibility to infection: Particularly respiratory infections.
• Hearing and vision problems: Including a higher risk of developing cataracts.
• Thyroid conditions: Both hypothyroidism and hyperthyroidism are more common in individuals with Down’s syndrome.
• Sleep apnea: Obstructive sleep apnea is a common condition among children with Down’s syndrome.
• Leukemia: Children with Down’s syndrome have an increased risk of developing leukemia.

Question 78

What are the key investigations for the trisomy disorders?

Answer 78

Karyotyping: To confirm the presence of the extra chromosome.
Ultrasound scanning: For prenatal detection of potential physical anomalies.

Question 79

How are the trisomy disorders generally managed?

Answer 79

1. Supportive care: Addressing feeding difficulties, cardiac complications, respiratory problems, and other associated issues.
2. Genetic counselling: Providing information and support to families.
3. Multidisciplinary approach: Involving paediatricians, cardiologists, surgeons, speech therapists, occupational therapists, and physiotherapists.

Question 80

At what age would you expect the moro reflex to have disappeared by?

Answer 80

Usually disappears around 3-4 months, and should no longer be elicited past 6 months of age

Question 81

What is plagiocephaly?

Answer 81

Plagiocephaly is a change in shape of a baby’s head (flatter at the back) due to babies sleeping on their back.

Question 82

What are the steps in paediatric BLS?

Answer 82

1. Open airway
2. If not breathing normally, 5 rescue breaths
3. If no signs of life, 15 chest compressions followed by 2 rescue breaths
4. Continue repetition of compressions and breaths at a 15:2 ratio

Question 83

Which airway positions are used in infants, young children and older children in paediatric BLS?

Answer 83

1. Infants: neutral
2. Young children: ‘sniffing the morning air’ - a very slight extension of the neck
3. Older children: head tilt, chin lift. Followed by a jaw thrust if necessary.

Question 84

How are chest compressions performed in paediatric BLS?

Answer 84

• Rate: 100-120 compressions a minute
• There must be full recoil of the chest

A rough guide on how to perform compressions:
- Infants: 2 fingers from one hand (digits 2 and 3) or using both thumbs
- Small children: one handed compressions using the heel of your hand
- Larger children: two-handed compressions with interlocking fingers - just like compressions on an adult
Note: with larger young children, you may need to use the two-handed technique especially if you are small

Compression depth:
- Babies and young children: 2/3 of chest depth
- Adult-sized children: 5 cm

Question 85

What is roseola infantum?

Answer 85

Roseola, also known as roseola infantum or sixth disease, is a common viral infection in infants and young children caused by the Human herpes virus 6.

Roseola is most common in infants and young children, typically affecting those between the ages of 6 months to 2 years. However, it can also occur in older children and adults.

The pathogen responsible for roseola is the Human herpes virus 6.

Question 86

What are the features of roseola infantum?

Answer 86

The clinical presentation of roseola includes:
- Initial febrile phase lasting for up to 5 days, with high fevers that can reach up to 40 degrees Celsius, accompanied by lethargy.
- As the fever subsides, a blanching, rose-pink macular rash erupts, predominantly over the trunk but may also spread to the face and limbs.

Question 87

What are the differentials for roseola infantum?

Answer 87

While roseola is distinctive, it can be mistaken for other febrile illnesses with rash, including:
1. Measles: Characterized by high fever, cough, coryza, conjunctivitis, and a maculopapular rash starting at the hairline and descending downwards. Koplik’s spots may be present.
2. Rubella (German Measles): Mild fever and lymphadenopathy followed by a pink maculopapular rash that begins on the face and spreads downward.
3. Scarlet Fever: Presents with high fever, sore throat, “strawberry tongue,” and a fine sandpaper-like rash.

Question 88

How is roseola infantum managed?

Answer 88

Management of roseola is primarily supportive, involving:
- Fever control with antipyretics such as paracetamol or ibuprofen.
- Hydration and nutrition support as needed.
- Monitoring for complications, such as febrile seizures.

Question 89

What is discoid eczema?

Answer 89

Discrete circular lesions with an erythematous border accompanied with pruritus is classical of discoid eczema. Eczema generally is a pruritic condition, however discoid eczema is even more pruritic. It is managed using the same therapies and principles as eczema

Question 90

How is whooping cough managed?

Answer 90

Management of pertussis involves:

1. Macrolide antibiotics as first-line therapy. These not only help alleviate symptoms in the patient but also reduce transmission to others. eg Clarithromycin, Azithromycin, Erythromycin. (Co-trimoxazole is used if macrolides are contraindicated)
2. Late initiation of antibiotics may not alter the course of the disease for the patient but can help minimise transmission to others.
3. Pertussis is a notifiable disease, meaning that healthcare providers are required to report diagnosed cases to local health authorities.

Question 91

Which factors make a child at high risk of sepsis?

Answer 91

Risk factors for sepsis include age less than 1 year, impaired immune function (e.g. diabetes, splenectomy, immunosuppressant medication, cancer treatment), recent surgery in the last six weeks, breach of skin integrity (burns/cuts/skin infections) and presence of an indwelling catheter or line

Question 92

What is a hydrocele and how does it develop?

Answer 92

A hydrocele is a pathological accumulation of serous fluid in a sac-like cavity specifically around the testicle. It typically presents as an enlarged scrotum.

During normal fetal development, the testes develop in the abdomen and descend into the scrotum along the pathway of the processus vaginalis, usually before birth. The processus vaginalis should typically obliterate after the descent. If it doesn’t close completely, fluid from the abdomen can gradually accumulate in the scrotum, causing a hydrocele.

Question 93

What are the features of a hydrocele?

Answer 93

1. Scrotal swelling: This is the most common symptom. The swelling is usually painless and can be on one or both sides.
2. Discomfort: Though usually painless, some men might experience discomfort due to the increased size of the scrotum.
3. Pain or redness: In rare cases, a hydrocele can cause pain or redness in the scrotum. This is often a sign of infection or other underlying conditions, such as testicular torsion or epididymitis.

Question 94

What are the differentials for a hydrocele?

Answer 94

1. Inguinal Hernia: Characterized by a bulge in the groin or scrotum, discomfort or pain in the area, and possible nausea and vomiting if strangulation occurs.
2. Varicocele: Signs and symptoms may include a “bag of worms” feeling in the scrotum, scrotal swelling, and discomfort. It’s commonly detected on the left side.
3. Testicular Torsion: Presents with sudden severe testicular pain, often with nausea and vomiting. A high-riding testis may also be present.
4. Epididymitis: Symptoms include testicular pain and tenderness, often with fever and urinary symptoms.
5. Testicular Cancer: Presents with a hard, painless lump in the testicle, often with scrotal enlargement. May also have symptoms such as lower abdominal pain.

Question 95

How is a hydrocele investigated and managed?

Answer 95

The primary diagnostic tool for a hydrocele is an ultrasound scan, which can show simple fluid accumulation around the testicle. Additional tests may be required if infection or malignancy is suspected.

Management -
The initial approach to managing hydroceles is observation as most will spontaneously resolve by 12 months of age. If the hydrocele persists past 1 year or if it causes discomfort, surgical correction may be indicated. This is primarily due to the significantly increased risk of an indirect inguinal hernia.

Question 96

How is asthma diagnosed from spirometry?

Answer 96

Diagnosis of asthma from spirometry can be defined as a significant post-bronchodilator response, ie. increase in FEV1 ≥ 200 ml and 12% improvement from baseline after inhalation of short-acting beta2-agonists.

Question 97

What is the characteristic LFT finding in biliary atresia?

Answer 97

Abnormally high levels of conjugated bilirubin is a characteristic finding in biliary atresia.

Question 98

What is biliary atresia?

Answer 98

This is the correct answer. Biliary atresia is a paediatric condition where the bile ducts become progressively fibrosed and obliterated, which obstructs the flow of bile and presents as cholestasis in the first few weeks of life. Abnormally high levels of conjugated bilirubin is a characteristic finding in biliary atresia. The spleen becomes palpable in the 3rd-4th week of life (LUQ mass), with the liver also becoming enlarged (RUQ mass).

Prolonged neonatal jaundice with a raised conjugated bilirubin fraction, is biliary atresia until proven otherwise

Question 99

What are the next steps in asthma management after a SABA and ICS in children under 5 years and children over 5 years?

Answer 99

Under 5 - Addition of a LTRA
Over 5 - Addition of LTRA or LABA

Question 100

What are the stepped treatments for an acute exacerbation of asthma?

Answer 100

Maintain oxygen saturations between 94-98% with high flow oxygen if necessary.

1. Administer inhaled salbutamol
2. Proceed to nebulised salbutamol if necessary
3. Add nebulised ipratropium bromide
   If O2 saturations remain <92%, add magnesium sulphate
4. Add intravenous salbutamol if no response to inhaled therapy
   - If severe or life-threatening acute asthma is not responsive to inhaled therapy, add aminophylline

All patients should receive steroids, given IV only if the patient is unable to take the dose orally
If the patient is not responding to salbutamol or ipratropium, consult with a senior clinician

Question 101

What is the newborn resuscitation protocol?

Answer 101

• Birth
• Dry baby and perform initial check- assess tone, breathing and heart rate
• If gasping or not breathing- open airway, give five inflation breaths and consider oxygen and ECG monitoring
• Reassess- look for improvement and response in heart rate and chest movement during inflation
• If chest not moving- optimise airway control, repeat inflation breaths, give oxygen (if not given already), consider ECG monitoring (if not already doing so) and look for a response
• If no increase in heart rate at this point, re-assess for chest movement and repeat above steps if necessary
• When chest is moving- if heart rate <60 bpm, ventilate for 30 seconds
• At this point, reassess heart rate- if heart rate still <60 bpm, commence chest compressions at a rate of 3:1
• Continue this process, re-assessing every 30 seconds- if heart rate remains <60 bpm, consider venous or osseous access and administering drugs
• Throughout process: Keep the parents updated, and keep a record of time and timings of interventions

Question 102

What medication can be used to manage a patent ductus arteriosus?

Answer 102

Initial management is oral indomethacin or ibuprofen

(Catheter device closure is used second line after a trial of medical management - rarely done in premature babies)
(Surgical ligation involves tying or clipping off the open duct - used in larger ducts or in smaller infants)

Question 103

Where does the rash spread in scarlet fever?

Answer 103

12-48hrs after fever, coryza, lymphadenopathy

Starts on the chest and tummy then spreads, can also have rash on both cheeks

Question 104

What is the antibiotic of choice in scarlet fever?

Answer 104

Phenoxymethylpenicillin

Question 105

How is a chronic tic disorder distinguished from Tourette’s syndrome?

Answer 105

A chronic tic disorder can be distinguished from Tourette’s Syndrome by the presence of either a motor of phonic tic, but not both.

Question 106

When is APGAR score assessment done after birth?

Answer 106

1 and 5 and 10 minutes post birth

(Appearance, Pulse, Grimace, Activity and Respiration - scores from 0-2)

Question 107

What are the components of the APGAR score?

Answer 107

There are 5 components to the APGAR score: Appearance, Pulse, Grimace, Activity, Respiration.

1. Appearance relates to the colour of the child.
   - 2 is for a pink baby
   - 1 if the baby is blue peripherally but pink centrally
   - 0 if the baby is blue all over
2. Pulse:
   - 2 for >100 beats per minute
   - 1 for <100 beats per minute
   - 0 for a non-detectable heart rate
3. Grimace:
   relates to the response to stimulation
   - 2 for crying on stimulation scores
   - 1 for a grimace
   - 0 for no response
4. Activity:
   - 2 for flexed limbs that resists extension
   - 1 for some flexion
   - 0 for a floppy baby
5. Respiration:
   - 2 for a strong cry
   - 1 for a weak cry
   - 0 for no respiratory effort

Question 108

What is roseola infantum?

Answer 108

Roseola, also known as roseola infantum or sixth disease, is a common viral infection in infants and young children caused by the Human herpes virus 6.

Roseola is most common in infants and young children, typically affecting those between the ages of 6 months to 2 years. However, it can also occur in older children and adults.

Question 109

What are the features of roseola infantum?

Answer 109

The clinical presentation of roseola includes:
- Initial febrile phase lasting for up to 5 days, with high fevers that can reach up to 40 degrees Celsius, accompanied by lethargy.
- As the fever subsides, a blanching, rose-pink macular rash erupts, predominantly over the trunk but may also spread to the face and limbs.

Question 110

How is roseola infantum managed?

Answer 110

Management of roseola is primarily supportive, involving:
- Fever control with antipyretics such as paracetamol or ibuprofen.
- Hydration and nutrition support as needed.
- Monitoring for complications, such as febrile seizures.

Question 111

What dose of IM adrenaline is used for anaphylactic reactions in children?

Answer 111

300 microg in children 6-12
500microg for >12 and adults

Question 112

What is meconium aspiration syndrome?

Answer 112

Meconium aspiration syndrome refers to respiratory distress in the newborn as a result of meconium in the trachea. It occurs in the immediate neonatal period. It is more common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks. It causes respiratory distress, which can be severe. Higher rates occur where there is a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse.

Question 113

What can happen when amoxicillin is taken for infective mononucleosis?

Answer 113

A widespread maculopapular rash due to a type 4 hypersensitivity reaction (1-2 weeks after abx are taken)

Question 114

What are the maintenance fluid requirements in children?

Answer 114

1st 10kg of bodyweight at 100ml/kg/day
2nd 10kg of bodyweight at 50ml/kg/day
Remaining bodyweight at 20ml/kg/day

The fluid type routinely used is 0.9% sodium chloride + 5% dextrose. Potassim is added as required depending on their U&Es.

Question 115

What are paediatric electrolyte requirements?

Answer 115

Sodium: 2-4mmol/kg/day
Potassium: 1-2mmol/kg/day

Question 116

What are the features of DKA?

Answer 116

Fruity-smelling breath (due to the presence of acetone)
Vomiting
Dehydration
Abdominal pain
Deep, sighing respiration (Kussmaul respiration)
Signs of hypovolaemic shock
Altered mental status, including drowsiness or coma

Question 117

How is DKA investigated?

Answer 117

Diagnosis of DKA involves assessment of clinical features along with:

Blood glucose (>11.1mmol/L)
Blood ketones (>3mmol/L)
Urea and electrolytes
Blood gas analysis
Urinary glucose and ketones
Blood cultures (if evidence of infection)
Cardiac monitoring/ECG (for any ischaemic changes or changes secondary to hypokalaemia)
Note that hyperglycaemia may not always be present in DKA.

Question 118

How is DKA managed?

Answer 118

Management of DKA varies based on the patient’s condition:

• If the patient is alert, not significantly dehydrated, and can tolerate oral intake without vomiting, encourage oral intake and administer subcutaneous insulin.
• If the patient is vomiting, confused, or significantly dehydrated, provide IV fluids (initial bolus of 10ml/kg 0.9% NaCl, then discuss with a senior) and insulin infusion at 0.1 units/kg/hour 1 hour after starting IV fluids. If there is evidence of shock, the initial bolus should be 20ml/kg.
• In the case of a shocked or comatose patient, follow the ABCDE approach for emergency resuscitation.

It’s important to note that the intravenous insulin infusion should not be stopped until 1 hour after subcutaneous insulin has been given.

Question 119

What is the coombs test?

Answer 119

Antiglobulin testing, also known as the Coombs test, is an immunology laboratory procedure used to detect the presence of antibodies against circulating red blood cells (RBCs) in the body, which then induce hemolysis