Day 4 Flashcards
A mother comes to surgery with her 6-year-old son. During the MMR scare she decided not to have her son immunised. However, due to a recent measles outbreak she asks if he can still receive the MMR vaccine.
What is the most appropriate action?
Give MMR with repeat dose in 3 months.
The Green Book recommends allowing 3 months between doses to maximise the response rate.
A period of 1 month is considered adequate if the child is greater than 10 years of age.
In an urgent situation (e.g. an outbreak at the child’s school) then a shorter period of 1 month can be used in younger children.
Contraindications to MMR
(5)
severe immunosuppression
allergy to neomycin
children who have received another live vaccine by injection within 4 weeks
pregnancy should be avoided for at least 1 month following vaccination
immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present)
Adverse effects of the MMR
(2)
Malaise, fever and rash may occur after the first dose of MMR.
This typically occurs after 5-10 days and lasts around 2-3 days
When are children given the MMR?
(2)
Children in the UK receive two doses of the Measles, Mumps and Rubella (MMR) vaccine before entry to primary school.
This currently occurs at 12-15 months and 3-4 years as part of the routine immunisation schedule
You are asked to attend a preterm delivery. The neonate is born at 36 weeks gestation via emergency Caesarean section. The neonate has difficulty initiating breathing and requires resuscitation.
- They are dyspnoeic and tachypnoeic at a rate of 85 breaths/min.
- On auscultation of the chest, there is reduced breath sounds bilaterally.
- Heart sounds are displaced medially.
- The abdominal wall appears concave.
What is the most likely diagnosis?
Congenital diaphragmatic hernia presents with scaphoid abdomen, due to herniation of the abdominal contents into the cleft
Congenital diaphragmatic hernia can present with dyspnoea and tachypnoea at birth. The auscultation findings are due to pulmonary hypoplasia and compression of the lung due to the presence of abdominal contents in the thoracic cavity.
Prompt treatment and respiratory support are required.
A 2-month-old baby is rushed into the emergency department by her parents who discovered her limp and blue in her cot.
- On assessment, she is found to not be breathing and has no femoral pulses.
Paediatric life support is commenced and 5 rescue breaths are given.
What is the most appropriate technique for in-hospital chest compressions in a paediatric patient of this age?
The two-thumb encircling technique at a compression: breath ratio of 15:2 is the correct answer according to the paediatric life support algorithms.
In an in-hospital environment where intermediate/advanced life support is being used, a ratio of 15:2 should be used for compressions: breaths.
Once a definitive airway has been established, compressions should then be continuous.
A 2-year-old boy with meningococcal septicaemia arrests on the ward.
You are the first person to attend. After confirming cardiac arrest and following paediatric BLS protocol, what is the rate you should perform chest compressions at?
The UK Resuscitation Council’s Paediatric Basic Life Support guideline states that chest compressions for children of all ages must be performed at a rate of 100-120 per minute. Compressions should depress the sternum by at least a third of the depth of the chest.
A 6-year-old boy comes to see you with his mother.
He reports that he has pain in his knees and calves bilaterally at night which has been ongoing for the past 6 months.
These pains are worse if he has played football in the daytime. He describes that these pains can cause him to wake up at night time around 1-2 times per month.
Examination of the knee is unremarkable. He is otherwise fit and well.
Which one of the following is the most likely diagnosis?
Growing pains are a common complaint in children aged 3-12 years.
These usually present with children complaining of pains in their legs.
When seeing children who are presenting with these symptoms it is important to check that there are no ‘red flags’
Features of growing pains
(7)
- never present at the start of the day after the child has woken
- no limp
- no limitation of physical activity
- systemically well
- normal physical examination
- motor milestones normal
- symptoms are often intermittent and worse after a day of vigorous activity
Features of JRA
(4)
Juvenile rheumatoid arthritis usually presents as:
fever, rash, symmetrical joint pain and swelling
Features of Osteosarcoma
(3)
Features of osteosarcoma include:
an unexplained lump
unexplained bone pain
unexplained swelling.
Features of Osteochondritis
(4)
Osteochondritis dissecans is a joint disorder in which cracks form in the articular cartilage and underlying subchondral bone.
This results in joint pain, locking and swelling.
What is the triad of shaken baby syndrome?
(3)
Retinal haemorrhages
subdural haematoma
encephalopathy
What is shaken baby syndrome?
(2)
Subdural haematomas are the most common and classical intracranial feature of Shaken Baby Syndrome.
The bridging cerebral veins are fragile in infants and the theory is that these vessels are torn when a child is shaken, leading to subdural haematomas.
A 9-year-old boy is diagnosed as having Attention Deficit Hyperactivity Disorder and started on methylphenidate.
What is monitored during treatment?
(2)
Growth
ECG at the start of treatment
At what age would the average child acquire the ability to sit without support?
The answer (6-8 months) includes the 6 months as stated in the MRCPCH Development Guide. Most other sources suggest a slightly later age of 7-8 months.
A 3-year-old boy, Lionel, is brought into the general practitioner by his mother.
She is worried about an umbilical hernia which Lionel has had since birth.
She was advised that this would likely self-resolve, however, it has not yet resolved.
The general practitioner performs an examination which identifies a 1cm umbilical hernia which is easily reducible.
His mother would like to know how this should be managed. Which one of the following is the most appropriate management plan?
(2)
Umbilical hernias: Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age.
If small and asymptomatic peform elective repair at 4-5 years of age.
A 2-day-old baby is brought to the Emergency Department after his mum noticed that he has became floppier, more irritable, and not feeding properly over the past 24 hours.
Lumbar puncture confirms meningitis.
Which is the most likely causative organism in this case?
Group B streptococcus
Neonates are at a greater risk of meningitis, with greater risks associated with low birth weight, prematurity, traumatic delivery, fetal hypoxia and maternal peripartum infection.
A 2-year-old child has a history of chronic constipation for the past year and chronic abdominal distention with vomiting for three months. It is suspected that the child may have Hirschsprung’s disease.
Which investigation from the list below offers the most definitive diagnosis for this condition?
Rectal biopsy is the gold standard for diagnosis of Hirschsprung’s disease
A 3-year-old boy is brought to the emergency department with difficulty breathing. Since this morning, he has developed a fever (38.3ºC) and become progressively short of breath. On examination, he appears unwell with stridor and drooling. His past medical history is otherwise unremarkable.
Given the likely diagnosis, which of the following is the most likely causative organism?
(2)
Acute epiglottitis is characterised by rapid onset fever, stridor and drooling
Haemophilus influenzae B
A 13-month-old girl is referred to paediatrics by her GP due to concerns that she is still not attempting to ‘pull to stand’. She was born at 29 weeks by emergency cesarean section due to foetal bradycardia and weighed 1.1kg at birth.
On examination, she appears healthy and engaged. She responds to her name and has 7 meaningful words. She can drink from a cup using both hands. When put on the floor, she commando crawls to move around. Upper limb tone is normal however lower limb tone is significantly increased.
Based on this patient’s symptoms, in which part of the brain/nervous system has damage occurred?
(2)
Spastic cerebral palsy results from damage to upper motor neurons
Upper motor neurons in the periventricular white matter
A neonate is born at 32 weeks gestation via spontaneous vaginal delivery. There was no meconium staining of the liquor. Shortly after delivery he develops cyanosis, tachypnoea, grunting and sternal recession.
What is the most likely diagnosis?
It is important to be aware of risk factors when answering questions like these. Prematurity is the major risk factor for NRDS. Caesarean section is the major risk factor for tachypnoea of the newborn (TTN). Meconium staining is the major risk factor for aspiration pneumonia.
A 6-year-old boy attends the emergency department with acute shortness of breath. His parents report that he has had a cold for a few days but today has been struggling more with his breathing. He has had several prior admissions for wheeze and has had exertional breathlessness and nighttime cough for the past year.
His observations show a respiratory rate of 30/min, heart rate 130/min, saturations 94% and temperature of 37.4ºC. He has intercostal and subcostal recession and a global expiratory wheeze but responds well to salbutamol.
What acute medication/medications should he be prescribed on discharge?
Steroid therapy should be given to all children who have an asthma attack
While a formal diagnosis has not been made, this acute presentation combined with interval symptoms (exertional breathlessness and nighttime cough) suggests that this patient has suffered an acute exacerbation of asthma. For this, a salbutamol inhaler + 3 days prednisolone PO are the correct acute medications to prescribe on discharge. For all children suffering an acute exacerbation of asthma 3-5 days of oral prednisolone should be given. It is important to ensure that all patients have an adequate supply of their salbutamol inhaler with advice on when and how to use it.
A 4-day-old girl who was diagnosed prenatally with Down’s syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium.
What is the most likely diagnosis?
Failure or delay to pass meconium is common presentation of Hirschprung’s disease
A boy is noted to have a webbed neck and pectus excavatum
What is the diagnosis?
Noonan syndrome
An infant is found to have small eyes and polydactyly
What is the most likely diagnosis?
Patau’s Syndrome
A 7-year-old boy with learning difficulties and macrocephaly
What is the most likely diagnosis?
Fragile X
A 2-year-old child is referred by the GP for treatment-resistant chronic constipation.
Which of the following features in the history is a red flag for a diagnosis of Hirschsprung’s disease?
Passage of meconium after 48 hours is a red flag
Which mutation is associated with HIrchsprungs?
Hirschsprung’s disease is associated with MEN 2A/B and not MEN1
What is the most common cause of nephrotic syndrome in children?
(2)
Minimal change glomerulonephritis
Minimal change glomerulonephritis nearly always presents as nephrotic syndrome, accounting for 80% of cases in children and 25% in adults. The majority of cases are idiopathic and respond well to steroids
What is the nephritis triad?
Nephrotic syndrome is classically defined as a triad of
- proteinuria (> 1 g/m^2 per 24 hours)
- hypoalbuminaemia (< 25 g/l)
- oedema
A 7-year-old girl presents to her GP as she has been suffering from daily epistaxis for the last week.
On examination, her legs are covered with petechiae and bruises.
She is otherwise well and has no other symptoms. Blood tests show low platelets, with no other abnormalities.
On follow-up, the symptoms have completely resolved after 4 months.
What would you expect to precede these symptoms?
The condition described is idiopathic thrombocytopenic purpura (ITP), whereby low platelet count can result in symptoms such as epistaxis and unexplained bruising/petechiae. This is often self-limiting and may resolve within 12 months.
Idiopathic thrombocytopenic purpura may be preceded by a self-limiting viral infection
Features suggestive of hypernatraemic dehydration:
(5)
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
An 8-month-old unwell baby is brought to the paediatric emergency department with discolouration over her left arm. Her parents say the arm was ‘initially red and warm but now has black patches’. On examination, these black areas are consistent with skin necrosis. She was diagnosed with chickenpox one week ago.
Her observations are:
Heart rate: 180 beats per minute (normal 80-140)
Respiratory rate: 42 breaths per minute (normal 30-40)
Temperature: 38.1º (>37.5º)
What is the most likely causative organism?
Streptococcus pyogenes which is a group A streptococcus and is the most common cause of invasive skin infections following chickenpox.
Chickenpox is a risk factor for invasive group A streptococcal soft tissue infections including necrotizing fasciitis
A 9-year-old boy who is having an asthma attack is brought to the surgery.
Which findings would categorise the asthma attack as life-threatening, rather than just severe, according to the British Thoracic Society guidelines?
(6)
- SpO2 <92%
- PEF <33% best or predicted
- Silent chest
- Poor respiratory effort
- Agitation
- Altered consciousness
- Cyanosis
A 15-year-old boy from Germany presents with chronic diarrhoea for the past 9 months. He also reports foul smelling stools. He has a past medical history of recurrent chest infections from a young age and diabetes mellitus.
What is the most likely diagnosis?
CF
A 3-day-old male is admitted to the neonatal unit with bilious vomiting and reduced feeding. He was born at 30 weeks gestation via an uncomplicated delivery. An abdominal X-ray is requested that shows intramural gas. Oral feeding is stopped and he is started on broad-spectrum antibiotics.
Which of the following is the most likely diagnosis?
Necrotising enterocolitis
Pneumatosis intestinalis is a hallmark feature of necrotising enterocolitison AXR
What are the x-ray signs of necrotising enterocolitis?
(7)
Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
- dilated bowel loops (often asymmetrical in distribution)
- bowel wall oedema
- pneumatosis intestinalis (intramural gas)
- portal venous gas
- pneumoperitoneum resulting from perforation
- air both inside and outside of the bowel wall (Rigler sign)
- air outlining the falciform ligament (football sign)
You are called to review a female baby born 22 hours ago, at 33 weeks gestation, as the nurse is worried about her.
After conducting a thorough examination, and noting that the mother was positive for group B streptococcus, you provisionally diagnose the baby with neonatal sepsis and initiate treatment.
Which of the following options is the most common finding with regards to this diagnosis?
Grunting and other signs of respiratory distress are the most common presentation of neonatal sepsis
A three-year-old girl presents with her parents to the accident and emergency department. The parents are concerned that they’ve noticed a new widespread rash on her abdomen. The parents deny any history of trauma or recent infection.
On examination you note a petechial rash covering the anterior abdomen and to a lesser extent the posterior right forearm. The child looks pale and is not playing with the toys set out. You also find hepatosplenomegaly and cervical lymphadenopathy.
While waiting for blood results you dip her urine which proves unremarkable and take a tympanic temperature reading of 36.6º.
What is the most likely diagnosis?
Acute lymphoblastic leukaemia may present with haemorrhagic or thrombotic complications due to DIC.
A 6-year-old is brought in by his mother who is concerned that he has been experiencing pain in his right hip for the past 6 weeks.
She reports the pain has been progressively worsening and is waking him up at night.
For the last week, she has noticed a slight limp and difficulty getting in or out of the car and the bath.
What is the most likely diagnosis?
Perthes disease is caused by avascular necrosis of the femoral head - it presents with progressive hip pain, limp and stiffness
What is the cause of Perthe’s disease?
Perthes disease is caused by avascular necrosis of the femoral head
it presents with progressive hip pain, limp and stiffness
children age 4-8 years
A man with glucose-6-phosphate dehydrogenase deficiency asks for advice regarding his son.
Given the x-linked recessive inheritance of the condition, what is the chance his son will also develop the disease?
X-linked recessive conditions - no male-to-male transmission
A 13-year-old girl presents to clinic with right knee pain. She is a keen hockey player but has had no recent injuries.
On examination there is a painful swelling over the tibial tubercle. What is the most likely diagnosis?
(2)
Osgood-Schlatter disease
(tibial apophysitis)Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
Features of Osteochondritis dissecans
(2)
- Pain after exercise
- Intermittent swelling and locking
Features of Patellar tendonitis
(3)
- More common in athletic teenage boys
- Chronic anterior knee pain that worsens after running
- Tender below the patella on examination
A 3-week-old boy is rushed to the emergency department by ambulance following a reported episode of unconsciousness. The patient’s mum explains that the patient was crying and suddenly started to breathe quickly. He then turned blue in the face and became unresponsive. He woke prior to ambulance arrival.
On examination, the patient appears well and is interacting with their mum. An ejection systolic murmur is noted, loudest in the left 2nd intercostal space. The examination is otherwise normal.
What is the most likely diagnosis?
(2)
Tetralogy of Fallot - infants may experience episodic hypercyanotic ‘tet’ spells that can result in loss of consciousness
This scenario describes a baby with cyanosis and loss of consciousness following a period of upset, in addition to an examination finding of an ejection systolic murmur. These combined suggest a diagnosis of a ‘tet’ spell, which is associated with tetralogy of Fallot. Due to a reduction in right ventricular outflow, when a patient with tetralogy of Fallot is upset, cyanosis can occur.
Features of tetralogy of Fallot
(4)
The four characteristic features are:
- ventricular septal defect (VSD)
- right ventricular hypertrophy
- right ventricular outflow tract obstruction, pulmonary stenosis
- overriding aorta
A 6-month-old boy is brought into your practice by his adoptive parents, complaining of an unusual pattern of movements recently in their son.
They were able to catch this on camera, and on watching the video you notice subtle symmetrical contracting of his neck and drawing up of his legs, followed by extending of his arms.
He repeats this movement around 50 times before stopping.
What is the most likely diagnosis in this case?
Infantile spasms - classically characterised by repeated flexion of head/arms/trunk followed by extension of arms