Paediatrics Flashcards
A two-month-old female, Lila, presents to the paediatric emergency department in the morning with her father. The father reports that Lila has felt quite hot since last night and has been feeding poorly. Lila’s birth was uncomplicated and all of her immunisations are up to date. Her vital signs are as follows: temperature 38.8oc, HR 160, RR 40 and SpO2 98% on room air. Lila is mildly lethargic, but examination is otherwise unremarkable.
If this child is found to have a serious bacterial infection (SBI), which of the following is the most likely cause?
UTI
To begin with, you should know that infants under 3 months are of particularly high risk for SBI and that the two most prevalent SBIs are urinary tract infections (UTIs) and pneumonia. In the absence of localising chest signs, a UTI is epidemiologically the most likely diagnosis in this case. In one study, 7.5% of children presenting with fever had an SBI, and 45% of them had a UTI. Another factor that affects your consideration of the epidemiology is that Lila is female as 6.5% of girls will have a UTI in the first year of life.
Name the disease:
Early features: leg pain, diarrhoea, abnormal skin colour, cold peripheries and breathing difficulties.
Late features: non-blanching haemorrhagic rash, meningism and impaired consciousness
Meningococcal septicaemia.
Caused by: Neisseria meningitidis, a Gram-negative diplococcus
Management:
- immediate admission to hospital
- start antibiotics (IV Ceftriaxone in those over 3 months of age)
Name the condition:
(Itchy) Vesicular rash on head/neck/trunk
+ pyrexia, headache, malaise and abdominal pain
Chicken Pox
Caused by: Varicella-zoster virus
NB: shingles (VZV reinfection) has a dermatomal distribution
Management: conservative
Name the condition:
Prodrome: fever, malaise, loss of appetite
followed by: conjunctivitis, cough and coryza + Koplik spots (blue-white spots inside the mouth)
followed by: rash - face + trunk + extremities (disappears and leaves behind brownish discolouration)
Measles:
Caused by: acute infection caused by a single-stranded RNA Morbillivirus from the paramyxovirus family
Management: conservative
Name the condition:
honey-coloured crusted plaques that tend to be under 2 cm in diameter (on face/extremities)
+ enlargement of regional lymph nodes
Impetigo
Caused by: Staphylococcus aureus or Streptococcus pyogenes.
Management:
- infection control
- topical antibiotic: mupirocin and fusidic acid.
- if infection is extensive: flucloxacillin
Name the condition:
The initial patch (known as a “herald patch”) typically measures 2-5 cm in diameter and is oval or round with a central, wrinkled, salmon-coloured area, separated from a dark-red peripheral zone by fine scales. The secondary rash is symmetrical and localised mostly to the trunk, with some involvement of the neck and proximal limbs. The lesions of the secondary rash are smaller versions of the original herald patch, with two red zones separated by a scaling ring. The lesions are pruritic in about half of cases.
Pityriasis rosea:
The disease is most common in those aged between 10-35 years and it is more common in women. It occurs most often during the spring and autumn. The cause is not fully understood, however various drugs (ACEi / NSAIDs / Metronidazole) and viruses are associated (herpesviruses 6/7). The disease is not infectious.
Name the condition:
Extremely tender flaccid bullae (large superficial blisters) develop within 48 hours and commonly affect the flexures. The bullae enlarge and rupture easily to reveal a moist erythematous base, which gives rise to the scalded appearance.
clinical features: fever, generalised erythema, and skin tenderness.
[Prodrome: sore throat, conjunctivitis]
Staphylococcal scalded skin syndrome (SSSS)
Caused by: the release of two exotoxins (epidermolytic toxins A and B) from toxigenic strains of the bacteria Staphylococcus aureus.
Mainly occurs in children <5
Management:
- hospital admission
- manage fluid balance
- administer IV fluxcloxacillin
Which of the following medications is recommended for the initial management of children in presumed status epilepticus?
Lorazepam
NICE recommends a benzodiazepine as the first-line management of acute status epilepticus. IV lorazepam is usually used, assuming that you are able to gain IV access.
A concerned mother brings her 1-year-old son to A&E. She explains her son has been having sudden bouts of crying, during which he draws up his legs, for the past 12 hours. He is also not feeding and appears pale but is afebrile. This morning he passed stool that appeared red in colour.
What is the most appropriate initial investigation for this child?
Abdominal USS
The best initial investigation is an abdominal USS. The patient’s mother has described symptoms typical of intussusception. Intussusception is the invagination of the proximal bowel into more distal bowel. It commonly presents with paroxysmal abdominal pain in which the child draws up his or her legs, pallor, poor feeding, vomiting, an abdominal mass and “red-currant jelly” (blood-stained) stools. The red-currant jelly stools are a late sign.
An abdominal USS can confirm this diagnosis by showing a “target sign” and is a quick and simple bedside investigation.
An abdominal MRI would also show intussusception, but is not quickly available and therefore not the best option.
When is the 6-in-1 vaccine given to children in the UK?
The 6-in-1 vaccine is given to children in the 8th, 12th and 16th week of life.
The vaccine protects against Diphtheria, Tetanus, Whooping cough, Polio, Haemophilus Influenza Type B (Hib) and Hepatitis B.
Whilst walking past the A&E waiting room, you recognise a young patient and his father as you had treated the child for a case of mild gastroenteritis 2 days ago. Now, little Jonny represents complaining of a severe stomach ache and that his legs hurt. When you examine his legs, you notice a purpuric rash which spreads up the back of Jonny’s legs to his buttocks. A urine dipstick is quickly ordered which shows haematuria and proteinuria.
What is the most common progressive complication?
IgA nephritis
Jonny has Henoch-Schonlein purpura, a type of vasculitis which is commonly triggered by an upper respiratory infection or gastroenteritis. 50% of HSP cases have kidney involvement due to IgA nephritis.
A 4-year-old child is admitted to the Emergency Department with acute shortness of breath and wheeze. He has a diagnosis of asthma and is under the care of respiratory consultant. His parents reports that they have been giving him salbutamol regularly at home for the past two days, but he has become increasingly wheezy and distressed over the past few hours.
Which signs would suggest an acute severe exacerbation in a child of this age?
child aged between 1 and 5 years:
HR > 140
Peak flow predicted 33-50% best
Oxygen sat <92%
Resp rate >40
NB: children 5+
HR > 125
RR > 30
10-year-old Billy Glue-Ear presents to general practice accompanied by his mother, who is concerned that she has to call his name repeatedly before he seems to notice. The problem has been worsening recently and is no longer limited to times when he is engrossed by the television. He has a past history of recurrent ear infections, and currently has purulent yellow discharge leaking from the right ear.
On otoscopic examination, there is a considerable defect in the tympanic membrane and purulent debris in the auditory canal. You place the hilt of a ringing 256Hz tuning fork in the centre of Billy’s head, and he reports hearing it in the right ear. When the hilt of the tuning fork is placed on his right mastoid he can hear it, but when the tips are held close to his external acoustic meatus he hears nothing.
How would you summarise the findings of this examination?
Right conductive deafness: Rinne’s Negative; Weber’s lateralising to the right.
Weber’s test:
Place a ringing 256Hz or 512Hz tuning fork in the midline of the patient’s forehead and ask which ear they hear the ringing in.
Normal subjects will hear the sound symmetrically in both ears
- in conductive deafness the sound localises to the deaf ear as it is conducted to the sensory apparatus through the cranium and is the only sound ‘heard’ on the affected side. It is heard less clearly on the unaffected side as it may be lost to ambient noise
- In unilateral sensorineural hearing loss (see below), the patient has impaired or absent ability to perceive sound in the affected ear no matter how intact the conductive system, and so the sound localises to the normal side.
Rinne’s Test
Place the base of a ringing 256Hz or 512Hz tuning fork on the patient’s mastoid process and ask them to indicate when the sound dies out. When they can no longer hear the tone, bring the tips of the fork close to the external acoustic meatus and the patient should hear the sound again, demonstrating that air conduction is better than bone.
This test works on the proviso that air conduction of sound to the inner ear should be more effective than bone conduction.
- A normal Rinne’s test is described as positive.
In conductive hearing loss, bone conduction to the sensory apparatus is the most reliable route and is better than air conduction. This is an abnormal, negative result.
Toby Robertson is a 15-year-old boy who attends the GP practice with his mother who is concerned that he appears to be developing breasts. He has no significant past medical history but he does receive support at school for learning difficulties.
Findings on examination include:
Tall stature Elongated arms and legs Reduced facial and body hair Wide hips Gynaecomastia Small testicles Which of the following is the most likely diagnosis?
Klinefelter’s syndrome
47XXY syndrome where a male has an extra copy of the X chromosome (XXY). Those with Klinefelter’s syndrome have a number of characteristic features including tall stature, sparse facial/body hair, gynecomastia, infertility, learning difficulties and small testicles (due to hypogonadism).
Name the condition:
loss or abnormality of the second X chromosome in at least one cell line in a phenotypic female. Clinical features are vary widely but can include pubertal delay, ovarian failure, learning difficulties, neck webbing, low set ears and epicanthic folds.
Turner syndrome
Name the condition:
repeat DNA expansion disorder. Typical features include learning difficulties, delayed developmental milestones, high forehead, large testicles, facial asymmetry, large jaw and long ears.
Fragile X syndrome
Name the condition:
gonadotropin-independent precocious puberty in which boys experience early onset of puberty, sometimes from the age of 1 year old. It is an autosomal dominant condition caused by a mutation in the LH receptor leading to the production of large quantities of sex steroids. In addition to all the symptoms of puberty, the patient may also have a shortened spinal length due to premature epiphyseal
maturation.
Familial male-limited precocious puberty
Samantha Hayes, 18, has scheduled a GP consultation to discuss an itchy vesicular rash on her forearms. Whilst reading her notes, you learn that she was in the lowest growth decile as a child, and has recurrent bouts of diarrhoea, queried gastroenteritis, over the past year. She currently takes iron tablets and vitamin D.
What is the most likely diagnosis?
Coeliac disease
Coeliac disease is caused by a sensitivity to a protein in gluten. It most commonly presents in the 2nd and 6th decades of life, but may manifest in children as ‘failure to thrive’.
Symptoms include intermittent or chronic diarrhoea, with grey, oily faeces that smell especially foul. Patients may also experience abdominal pain, nausea, weight loss and dermatitis herpetiformis (described here). Iron and vitamin D deficiencies are common complication caused by villous atrophy and consequent malabsorption. The former causes anaemia and the latter may even predispose to osteoporosis or osteomalacia.
Sally is a 15-year-old girl is brought to the GP surgery by her parents, with symptoms of reflux. She has some mild facial swelling, bilaterally in the cheek area. She also complains of pain in this area, as well as under her jaw. Her weight is within the normal range.
You perform an abdominal examination with a chaperone present, but there are no significant findings.
On her hands, you notice koilonychia (spoon-shaped nails) and calluses on her knuckles.
What is the most likely diagnosis?
Bulimia Nervosa
(BN) is an eating disorder, typically characterised by “binge-eating” followed by episodes of “purging.” This can take the form of using laxatives or vomiting in order to prevent calorific absorption through food or drink.
Often patients with BN have a normal/slightly fluctuating weight. Due to the recurrent presence of stomach acid contents (including hydrochloric acid) in the upper gastrointestinal tract, patients may develop erosion of their teeth and oral mucosa, mouth ulcers, GI irritation or reflux. Recurrent vomiting also leads to dehydration, perhaps one of the reasons for the swollen and painful salivary glands (including parotid gland in her cheek and submandibular area).
A rare, but characteristic feature may be the calluses on her knuckles, which is called Russell’s sign and develops due to her knuckles being scraped across her teeth. This is one of the ways that vomiting may be induced. Koilonychia is a sign of anaemia, perhaps due to poor absorption of iron in her diet.
A 12-year-old Caucasian girl was admitted with a two-day history of lower abdominal pain and blood-stained diarrhoea. Two days later, she complained of pain in her ankles and right elbow associated with nausea. On examination, a purpuric rash affecting the arms and legs, periorbital oedema and a blood pressure of 150/90 mmHg were found. Investigations were performed, the reports are as follows:
Hb 100 g/L WCC 12x109/L Platelets 135,000 /L MCV 70 fL ESR 35 mm/h PT 13 s APTT 34 s Sodium 138 mmol/l Potassium 5.9 mmol/l Creatinine 130 mol/l Urinalysis: Blood ++ Protein ++ What is the most likely diagnosis for this patient?
Henoch–Schönlein purpura
Lower abdominal pain, bloody diarrhoea, purpuric rash, and nephritis in a young patient point to the diagnosis of Henoch–Schönlein purpura, which is an IgA small-vessel vasculitis occurring most often in kids. Patients may often also present with buttock wasting, PR bleeding, arthralgia, and a rash over the lower limbs and buttocks.
Complications include intestinal perforation, haemorrhage, intussusception and acute renal failure.
Investigations;
- Abdominal USS indicated in patients with severe abdominal pain. It can detect increased bowel wall thickness, hematomas, peritoneal fluid, and intussusception
Name the condition:
Systemic necrotizing vasculitis that typically affects medium-sized muscular arteries, with occasional involvement of small muscular arteries. Presents with systemic symptoms (fatigue, weight loss, weakness, fever, arthralgias) and signs (skin lesions, hypertension, renal insufficiency, neurologic dysfunction, abdominal pain) of multisystem involvement. No bloody diarrhoea
Polyarteritis nodosa
Name the condition:
recurrent hematuria following tonsillitis or a viral upper respiratory infection
+/- proteinuria, flank pain and low grade fever
IgA nephritis
