Day 6 Flashcards
Common knee joint problems in children and young adults
(6)
A 7-year-old boy is brought in to the GP surgery with an exacerbation of asthma.
On examination he has a bilateral expiratory wheeze but there are no signs of respiratory distress.
His respiratory rate is 24 / min and PEF around 60% of normal.
What is the most appropriate action with regards to steroid therapy?
3 days of prednisalone
The 2016 British Thoracic Society guidelines state the following with respect to steroid treatment in children:
Use a dose of 10 mg prednisolone for children under 2 years of age, 20 mg for children aged 2-5 years and 30-40 mg for children >5 years. Those already receiving maintenance steroid tablets
A woman brings her daughter to general practice concerned that she hasn’t started her periods yet. Her daughter is 15 years old.
On general examination, she is in the 9th percentile of height for her age, has short ring fingers, poor breast development, and a high arched palate.
On auscultation of her heart, you note a crescendo-decrescendo murmur on the upper right sternal border which radiates to the carotids.
What is the most likely diagnosis?
What type of murmur is a crescendo-decrescendo murmur?
What is the most likely cause of this murmur?
Turner’s syndrome is associated with an ejection systolic murmur due to bicuspid aortic valve
bicuspid aortic valve (15%)
coarctation of the aorta (5-10%)
Which cardiac deformity is caused by rheumatic fever?
What is the acute presentation of rheumatic fever?
Streptococcal rheumatic heart disease can cause aortic stenosis
history of polyarthritis and fever, possibly with acute cardiac involvement.
What can cause aortic stenosis?
(2)
Rheumatic heart disease - streptococcal rheumatic heart disease
William’s syndrome - This is a genetic condition caused by a deletion on chromosome seven. It is associated with aortic stenosis
What is the acute presentation of rheumatic fever?
(3)
What is a long term complication?
(1)
history of polyarthritis and fever, possibly with acute cardiac involvement
aortic stenosis
William’s syndrome features
(5)
This is a genetic condition caused by a deletion on chromosome seven.
It is associated with aortic stenosis,
patients typically present with intellectual disability, underdeveloped cheeks, short noses, broad foreheads, and a happy affect
A 13-year-old girl presents to the emergency department complaining of coryzal symptoms.
She has been experiencing a fever, runny nose, headache and a non-productive cough for several days.
She appears comfortable, alert and well hydrated.
Her mother is concerned because despite giving her paracetamol and ibuprofen, her temperature does not seem to be coming down.
She took the last dose of antipyretics one hour ago.
On examination, her temperature is 38.9ºC, her heart rate is 110bpm, her blood pressure is 90/70mmHg and her respiratory rate is 26 breaths per minute.
Her chest sounds clear, her throat is slightly red with no signs of tonsillitis.
Her ears are non-tender and otoscopy shows no abnormalities.
She does not have any rashes and shows no signs of photophobia or neck stiffness.
How should this patient be managed?
Initiate sepsis six protocol
BUFALO
Children aged over 12 have similar normal vital signs to an adult
A 4-year-old boy presents with a 2-day history of passing loose stools and non-bilious vomiting. He has passed 5 loose stools and vomited 2 times over the last 48 hours. No visible mucus or blood seen in the stool, and urine output has not changed according to his mother. He is able to tolerate oral fluid and liquid food.
He has not travelled abroad recently and there are no sick contacts. His vaccination schedule is up-to-date and there are no concerns regarding his growth and development.
On examination, he appears well and is alert and responsive. He has warm extremities and capillary refill time is <2 seconds. His vital signs are normal. Peripheral pulses are strong and regular. There is normal skin turgor and there are no sunken eyes.
How should the patient be managed?
- Introduce oral rehydrating solution (ORS)
- Do not use antidiarrhoeal medications in children under 5 years old with diarrhoea and vomiting caused by gastroenteritis
- Discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration [NICE 2009]. Fruit juice without extra water or carbonated drinks has too much sugar in it and this can draw water from the body into the gut, making the child more dehydrated.
- Do not routinely give antibiotics to children with gastroenteritis [NICE 2009] because treatment is not effective on symptoms and does not prevent complications.
Causes of chronic diarrhoea in infants
(4)
- most common cause in the developed world is cows’ milk intolerance
- toddler diarrhoea: stools vary in consistency, often contain undigested food
- coeliac disease
- post-gastroenteritis lactose intolerance
GI causes of vomiting in children
Obstructive (6)
Inflammatory (4)
CNS (4)
Obstructive (6)
- Foreign bodies
- Idiopathic Pyloric Stenosis
- Intussusception
- Indirect inguinal hernias
- Volvulus
- Appendicitis
Inflammatory (4)
- Gastroenteritis
- Hepatitis
- Peptic Ulcer Disease
- Other uncommon: pancreatitis, cholecystitis
CNS (4)
- Head injury
- migraine
- brain tumour
- CNS infection
Diagnostic criteria of migraines
(5)
Diagnosis of exclusion; usually 3 or more of:
- abdominal pain
- nausea or vomiting
- throbbing headache, unilateral location
- associated aura (usually preceding the headache)
- relief following sleep
A mother brings her 10-month-old child to the emergency department late at night due to respiratory distress. The mother states that the child did not eat dinner that night and has since started drooling at the mouth, looking very unwell and the child is now petrified of being moved. Questioning reveals that the child is late for their routine vaccinations for their age, but the mother is keen on completing the course.
The patient has a heart rate of 150 beats per minute, a temperature of 39.4ºC, blood pressure of 88/60mmHg (normal for age: ~90/60mmHg) and a respiratory rate of 28 breaths per minute.
What is the most likely diagnosis?
Which other symptoms are most likely to be found in this patient?
Acute epiglottis
Patients with acute epiglottis may adopt the ‘tripod’ position
Abrupt onset and rapid progression (within hours) of dysphagia, drooling, and distress (‘the three D’s’)
You are junior doctor at a GP practice.
Your next patient is a 3-year-old girl who is notably irritable and teary.
Her father explains that she has had a reduced appetite for the past couple of days.
On examination you note multiple vesicles over both palms and around the mouth. She is also pyrexial.
Given the likely diagnosis, what is the most appropriate next step?
Hand, foot and mouth disease requires symptomatic treatment only
You are reviewing the growth of a 4-week-old neonate. She has a length on the 35th percentile, weight on the 42nd percentile and a head circumference on the 4th percentile.
Which of the following is the most likely cause of her microcephaly?
Foetal alcohol syndrome - associated with microcephaly
A 6-year-old boy is brought for review.
You can see from his records that he has been treated for constipation in the past but is otherwise fit and well.
His mother reports that he is currently passing only one hard stool every 4-5 days.
The stool is described as being like ‘rabbit droppings’.
There is no history of overflow soiling or diarrhoea.
Examination of the abdomen is unremarkable.
What is the most appropriate first-line intervention?
Advice on diet/fluid intake + Movicol Paediatric Plain
Constipation in children: macrogols (e.g. Movicol) is first-line
A newborn is found to have a number of congenital abnormalities including an extra finger on each hand, a cleft palate and lip, microphthalmia and microcephaly.
Which of the following chromosomes is most likely to be affected in this child?
A baby is born with microcephaly, small eyes, low-set ears, cleft lip and polydactyly - Patau syndrome
Trisomy 13
Which infection commonly causes a crop of white spots on the inside of the mouth?
Measles - Koplik spots
What is the prodrome of measles? (3)
What maybe seen inside the mouth? (1)
Describe the rash distribution in measles (2)
Describe the rash appearance in measles (4)
Prodrome: irritable, conjunctivitis, fever
Koplik spots: white spots (‘grain of salt’) on buccal mucosa
Rash: starts behind ears then to whole body,
discrete, maculopapular rash becoming blotchy & confluent
Key features of mumps
(2)
Fever, malaise, muscular pain
Parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Key features of Rubella
(4)
Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
Lymphadenopathy: suboccipital and postauricular
Key features of Erythema infectiosum
(4)
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Lethargy, fever, headache
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
A 6-month-old baby who was born in Bangladesh is brought to surgery. Around one week ago he started with coryzal symptoms. His mother reports he has not been feeding well for the past two days and has started to vomit today. Her main concern is a cough which occurs in bouts and is so severe he often turns red. No inspiratory or expiratory noises are noted. Clinical examination reveals an apyrexial child with a clear chest.
\What is the most likely diagnosis?
Whooping cough (pertussis)
Diagnostic criteria
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
- Paroxysmal cough.
- Inspiratory whoop.
- Post-tussive vomiting.
- Undiagnosed apnoeic attacks in young infants.
A 5-month-old baby is admitted with poor feeding. Over the last 24 hours, they have fed 25% of their usual amount and have had significantly fewer wet nappies than usual. The baby has been particularly irritable over this time and is not settling. There is no past medical history, no known allergies, and there has been no travel outside of the UK.
On examination, the baby appears unsettled and grouchy. There are no rashes on exposure and the fontanelles appear normal.
The physical observations reveal tachycardia and a fever of 39ºC.
When you attempt to manually flex the baby’s neck you note that they also flex the hips and knees.
Which of the following is the most appropriate empirical intravenous treatment?
Ceftriaxone
Initial empirical therapy for meningitis if > 3 months of age: IV 3rd generation cephalosporin
Antibiotics
< 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
> 3 months: IV cefotaxime (or ceftriaxone)
Most common cause of croup
parainfluenza virus
How is meningitis treated in kids?
5 stages
1. Antibiotics
- < 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
- > 3 months: IV cefotaxime (or ceftriaxone)
2. Steroids
- NICE advise against giving corticosteroids in children younger than 3 months
- dexamethsone should be considered if the lumbar puncture reveals any of the following: frankly purulent, CSF, CSF white blood cell count greater than 1000/microlitre, raised CSF white blood cell count with protein concentration greater than 1 g/litre, bacteria on Gram stain
3. Fluids
- treat any shock, e.g. with colloid
4. Cerebral monitoring
- mechanical ventilation if respiratory impairment
5. Public health notification and antibiotic prophylaxis of contacts
- ciprofloxacin is now preferred over rifampicin
A baby boy is delivered by emergency caesarean section at 42 weeks and 6 days because of fetal tachycardia and thick meconium-stained amniotic fluid.
Intrapartum antibiotics were given as the mother was known to be colonised with group B streptococcus.
The baby is cyanosed and tachypnoeic with chest wall retraction.
Chest X-ray shows patchy infiltrations and atelectasis.
What is the likely diagnosis? (3)
What predisposes babies to it? (3)
- Meconium aspiration syndrome refers to respiratory distress in the newborn as a result of meconium in the trachea.
- 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.
Atelectasis definition
Atelectasis (at-uh-LEK-tuh-sis) is a complete or partial collapse of the entire lung or area (lobe) of the lung.
A 4-month-old boy is failing to gain weight and has had recurrent chest infections since birth.
On examination, he looks thin and tired.
Auscultation of the precordium reveals a continuous murmur heard loudest under the left clavicle.
What is the most likely diagnosis?
Patent ductus arteriosus
Patent ductus is associated with a continuous murmur whilst Pulmonary stenosis presents with a systolic murmur.
Patent ductus is associated with a continuous murmur is associated with which condition?
Patent ductus is associated with a continuous murmur whilst
Continuous murmur is associated with which condition?
Patent ductus arteriossis
Pulmonary stenosis presents with which murmur?
Pulmonary stenosis presents with a systolic murmur.
Which murmur are VSDs associated with?
VSDs are associated with a pansystolic murmur
Pansystolic murmur is caused by which defect?
pansystolic murmur is associated with VSD
ASDs are associated with which murmur?
ASD’s have a fixed split S2 sound due to the increased venous return overloading the right ventricle during inspiration and delaying closure of the pulmonary valve.
Charlie is a 7 month old baby boy who presents to you with poor weight gain (50th to 10th centile), on examination he has an erythematous, blanching rash over his abdomen, colicky abdominal pain and vomiting after feeds.
He has been breast feeding with top-ups of ‘Aptamil’ formula.
What is the most likely diagnosis?
(3)
The correct answer is cows’ milk protein intolerance.
- Multi-system involvement
- 7 months would suggest the new introduction of top up feeds which correlates with the symptoms
- Faltering growth along with the multi-system involvement would suggest cows’ milk protein intolerance
What is the classical age for pyloric stenosis?
2 to 8 weeks very rare above 6 months
What is the developmental cause of Hirschprung’s disease?
(3)
Craniocaudal migration of ganglion cells of the bowel
begins at 12th wk of gestation
Arrest of this migration produces an aganglionic segment
of bowel-absence of Aurbach’s & Meissener’s plexus
This aganglionic segment of bowel unable to relax &
peristaltic wave stops proximally- functional obstruction
You are called to the postnatal ward to review an 8 hour old baby born by elective caesarian section at 39 weeks gestation.
After reading the case notes you discover the use of maternal labetalol for high blood pressure.
On examination, the baby appears jittery and hypotonic.
What is the most appropriate next step?
What is the diagnosis?
(4)
A jittery and hypotonic baby may suggest neonatal hypoglycaemia.
Neonatal abstinence syndrome (also called NAS) is a group of conditions caused when a baby withdraws from certain drugs
The use of maternal labetalol is a risk factor and these babies must have their blood glucose measured.
Neonatal abstinence syndrome may also present in this way and so the use of maternal opiates or illicit drug use in pregnancy should also be ascertained.
You are the paediatrician reviewing a newborn who was delivered at 39+2 weeks vaginally and without any complications.
The child’s father has a diagnosis of achondroplasia and the parents are wondering whether their child has this condition.
Aside from measuring the child’s length, what physical feature might suggest achondroplasia in this child?
(4)
Trident hands - feature of achondroplasia
short limbs (rhizomelia)
lumbar lordosis
midface hypoplasia.
Match the genetic condition to the phenotype
Low set ears
Saddle-gap deformity
Trident hand deformity
Single palmar crease
Microcephaly
Low set ears - Fragile X syndrome
Saddle-gap deformity - Down’s syndrome
Trident hand deformity - achondroplasia
Single palmar crease - Down’s syndrome
Microcephaly - alcohol and certain drugs, chemicals and infections in the womb
Macrocephaly - achondroplasia
A newborn infant is noted to have a posterior displacement of the tongue and a cleft palate. What is the most likely diagnosis?
A baby is noted to have micrognathia and a cleft palate.
He is placed prone due to upper airway obstruction.
There is no family history of similar problems -
Pierre-Robin syndrome
Patau syndrome features (5)
- Trisomy 13
- Microcephalic, small eyes
- Cleft lip/palate
- Polydactyly
- Scalp lesions
Edward’s syndrome features
(5)
- (trisomy 18)
- Micrognathia
- Low-set ears
- Rocker bottom feet
- Overlapping of fingers
Adrenal hyperplasia
FSH and LH are both low in gonadotrophin independent precocious puberty
You have just helped deliver a 2 week premature baby and are asked to do a quick assessment of the current APGAR score.
The baby has a slow irregular cry, is pink all over, a slight grimace, with a heart rate of 140 BPM and moving both arms and legs freely.
The current APGAR score is?
A - Pink all over no cyanosis - 2 points
P - Pulse rate over 100 - 2 points
G - Grimace - 1 point
A - Activity flexed arms and legs - 2 points
R - Respiration slow irregular cry - 1 point
8 points
- A score of 0-3 is very low score
- between 4-6 is moderate low and between
- 7 - 10 means the baby is in a good state
What is this
A cephalohaematoma may occur after a spontaneous vaginal delivery or following a trauma from the obstetric forceps or the ventouse.
A haemorrhage results after the presidium is sheared from the parietal bone.
The tense swelling is limited to the outline of the bone. It reduces over a few weeks - months.
Features of a Branchial cyst (5)
- Six branchial arches separated by branchial clefts
- Incomplete obliteration of the branchial apparatus may result in cysts, sinuses or fistulae
- 75% of branchial cysts originate from the second branchial cleft
- Usually located anterior to the sternocleidomastoid near the angle of the mandible
- Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS
Infantile haemangioma features (4)
May present in either triangle of the neck
Grow rapidly initially and then will often spontaneously regress
Plain x-rays will show a mass lesion, usually containing calcified phleboliths
As involution occurs the fat content of the lesions increases
Meningitis in children < 3 months: give IV amoxicillin in addition to cefotaxime to cover for Listeria
Where are congenital diaphragmatic hernias most likely to occur?
(3)
CDH is significantly more common on the left hand side.
- 85% of cases occur on the left
- 13% on the right
- 2% bilaterally.
Congential diaphragmatic herniation of newborns features
(3)
Congenital diaphragmatic hernia (CDH) occurs in around 1 in 2,000 newborns.
It is characterised by the herniation of abdominal viscera into the chest cavity due to incomplete formation of the diaphragm.
This can result in pulmonary hypoplasia and hypertension which causes respiratory distress shortly after birth.
What are Varicoceles
Which condition are they associated with?
Varicoceles are associated with venous hypertension in the pampiniform venous plexus and are not a typical congenital defect.
Biliary atresia typically presents in the first few weeks of life with jaundice, appetite and growth disturbance
Bile duct stenosis would present in a similar way but is less common.
