Paediatrics

Question 1

4 month old presents with mottled skin, irritable and photophobia.

1) Likely diagnosis
2) Skin change and causative organism
3) Septic screen and initial investigations
4) Diagnostic inx and what is seen in bacterial infection
5) Management for <3 months and > 3 months

Answer 1

1) Meningitis
2) Non-blanching purpuric rash (N. Meningitidis)
3) FBC, U/E, CRP, Clotting, venous gas + lactate, urine dipstick + cultures/sens. Blood cultures/sens
4) Lumbar Puncture. Protein raised, glucose low, Neutrophils raised, leucocytes slightly raised
5) <3 months = cefotaxime + amoxicillin. >3 months = ceftriaxone

Question 2

4 Causative organisms in Meningitis and which one affects neonates

Answer 2

Listeria (Neonates/ <3 months) (gram pos, anaerobe)
Group B strep (<3 months) (gram positive, strep)
N. Meningitidis (gram pos, diplococcus)
S. Pneumonia
H. Influenzas (Gram neg coccus)

Question 3

Complication of N Meningitidis and mx

Answer 3

hearing loss

dexamethasone 10mg every 6h (QDS) until cultures return and N Meningitidis rules out. Or continue.

Question 4

Patient presents with 2 month hx of reduced weight baring on leg, Malaise and a salmon pink rash.

1) Likely diagnosis
2) Other symptoms
3) Inx and results
4) ANA status in specific diseases
5) Management

Answer 4

1) Juvenile Ideopathic arthritis
2) Lymphadenopathy, Weight loss, splenomegaly, Joint pain, muscle pain.
3) CRP, ESR, Ferratin, Platelets. All raised
4) Systemic disease = ANA and RF neg
Oligoarticular disease = ANA positive
5) Ibuprofen, Steroids, DMARDS

Question 5

Patient presents with cracking lips, 5 days of fever and strawberry tongue.
1) Other possible symptoms that may be present.
Type of rash
2) Diagnosis
3) Inx
4) 2 Complications and management

Answer 5

1) Swollen hands and feet. Desquamination of skin on fingers, Maculopapular rash
2) Kawasaki
3) Anaemia, Leucocytosis, thrombocytosis, Hypoalbuminaemia, Raised liver enzymes.
4) Coronary artery aneurysm (IV immunoglobulin)
Thrombosis (High dose aspirin)

Question 6

3yo presents with stridor, barking cough, fever and 2-3 days of coryza.

1) Likely differential and why.
2) Other symptoms specific to this disease
3) Infective causes
4) Management

Answer 6

1) Croup - 2-3 days of coryza and presence of cough
2) Low grade fever, horse voice, decreased feeding
3) Parainfluenza, influenza, RSV
4) Dex 150mcg/kg. If deteriorate then Nebulised adrenaline and oxygen

Question 7

1) 3 differences between croup and epiglottitis
2) Cause of epiglottitis
3) Management of epiglottitis

Answer 7

1) Croup has a cough, develops over 2-3 days (not hours). Patients can still feed. Harsh and loud stridor
2) H. Influenza B (hib)
3) IV Ceftiaxone. Dex. Intubation and anaesthetist ready

Question 8

Patient presents with difficulty breathing and eating. Low grade fever. Hyperinflated chest.

1) 3 signs of severe disease on examination
2) Admission criteria
3) Causative organism and time of year most common
4) Management

Answer 8

1) Chest recessions, mottled skin. Grunting. Floppy.
2) <3months. 50% reduction in feeding volume. Visible dehydration. RR>70. sats<90
3) RSV - october - February
4) Supportive. Encourage re-feeding. IV/NG tube

Question 9

1) Moderate asthma attack criteria
2) Severe asthma attack criteria
3) Life-threatening asthma attack criteria

Answer 9

1) Peak flow >50%. non of the below features
2) Peak flow <50%. sats <92. Unable to complete sentences/eat. Signs of resp distress. RR > 40 in 1-5 years and > 30 in > 5 years. HR > 140 in 1-5 years and > 125 in > 5 years
3) Peak flow <33% sats < 92%. Silent chest. Low GCS. Exhaustion. Cyanosis.

Question 10

1-4 Management stages of asthma in child <5

Answer 10

1) SABA
2) low dose ICS for 8 weeks, then stop, see if symptoms get worse. If they do = asthma.
3) Add one of either, LRA (Monteleukast) or ICS.
4) refer to specialist

Question 11

1-4 management stages for asthma for child 5-12

Answer 11

1) SABA
2) ICS + SABA
3) ICS + SAMA + SABA (only cont sama if it works
4) Increase ics dose, add LAMA (theophylline).

Question 12

1) How does cystic fibrosis present in new borns
2) How does CF present in older children.
3) Differential for CF - and what to ask in the family history?
4) Gold standard test for CF.
5) Management of CF.

Answer 12

1) Meconium ileus. Or picked up on newborn blood spot test
2) Failure to thrive, recurrent chest infections, pancreatitis. Steatorrhoea
3) Primary ciliary dyskinesia. “Is you mum your brother?” - those exact words. (Consanguineous parentage more commonly leads to PCD)
4) Sweat test
5) Daily chest physio. CREON tablets. Nedulised DNAse. Hypertonic saline nebs. Prophylactic fluclox. Genetic counselling. Fertility support. High calorie diet.

Question 13

1) Congential heart defects risked by maternal rubella infection
2) 2 Cyanotic congenital heart conditions.
3) Patient presents with webbed neck, short stature, and weak femoral pulses. Likely condition?
4) Drug used to maintain patience of ductus arteriosus. When might this be needed
5) Arrhythmia associated with Ebstein’s anomaly

Answer 13

1) Tetralogy of fallot. PDA.
2) Ebsteins anomaly. ToF.
3) Turners syndrome –> Coactation of aorta
4) Prostoglandin E - Coarctation of aorta. ToF
5) Wolf-Parkinson-White syndrome

Question 14

6 week old presents with FTF and poor feeding. SOB. On Auscultation there is loud machinery murmur

1) Likely diagnosis
2) how else can this disease present
3) Drug used to close PDA and when

Answer 14

1) PDA
2) Recurrent chest infections
3) Indamethacin - 1 week if no closure,

Question 15

1) Definition of neonatal hypoglycaemia

2) Management options (2)

Answer 15

1) Not technically. But unofficial is <2.6mmol/mol
2) If well - encourage oral feeding.
If symptomatic - admit to neonates for 10% IV dextrose

Question 16

Inx required for all babies born in breach presentation

Answer 16

USS pelvis and hips (hip dysplasia)

Question 17

4yo boy presents with 3/52 hx of weight loss and polyuria and polydipsia. Now complaining of abdominal pain. Taken to ED with GCS 8.

1) What would you expect to see on the blood gas, given the likely diagnosis.
2) What initial management approach would you take + what fluids would you prescribe - would you have to do anything differently?
3) Complication of DKA in paeds. And management of this
4) Insulin infusion dosage

Answer 17

1) Metabolic acidosis. High Bicarb, high base excess. Possibly low CO2.
2) A-E approach. Resuscitation fluids at 10mL/kg in <10 min. (normal resuscitations fluids in paeds are 20mL/kg in <10min). Caution of cerebral oedema. Only give more fluid if clinically dry.
3) Cerebral oedema - low GCS, headache, bradycardia.
4) 0.1U/kg/hr. Once Blood glucose <14mmol.mol add dextrose 5% to fluids.

Question 18

What are the paediatric maintenance fluids doses.

Answer 18

100mL/kg/24h for first 10kg
50mL/kg/24h for next 10kg
20mL/kg/24h for everything over 20kg.

Question 19

1) 3 Causes for congenital TSH and aetiology.
2) Screening test for these, and the other diseases tested for.
3) Mx of Congenital hypothyroidism

Answer 19

1) Mal-descent of thyroid gland (developed world). Dyshormonogenesis (consanguineous parents). Iodine deficiency (most common world wide)
2) Guthrie test: CF, Sickle cell, Hypothyroid, inherited metabolic disease.
3) Levothyroxine 10mcg/kg then 5mcg/kg.

Question 20

Unwell neonate has a blood test. Report shows hyponatraemia and hyperkalaemia and acidosis.

1) Likely cause?
2) presentation in a) neonate b) young child
3) Acute management and long term management

Answer 20

1) Adrenal insufficiency (addisons)
2) A) committing, lethargy, collapse, poor feeding. B) Abdo pain, cramps, pigmentation, Hypoglycaemia. TFT.
3) Acute management with fluids, fludrocortisone and hydrocortisone.
Long term management with hormonal replacement. + corrective surgery may be needing in women

Question 21

1) Pathophysiology of congenital adrenal hyperplasia.
2) Presentation of a) neonate b) male c) female)
3) Management

Answer 21

1) Deficiency of 21-hydroxylase enzyme
2a) poor feeding, von, dehydration, arrhythmias
b) Tall, deep voice, big cock, small balls, early puberty.
c) Tall, oligomenorrhoea, early puberty.
3) Hormone replacement. Fludrocortisone and hydrocortisone

Question 22

Causes of TFT

Answer 22

Low nutritional intake - maternal malnourished. neglect.
Difficulting feeding - cleft lip, pyloric stenosis
Malabsorption - CF, Coeliac, cows milk intolerance
Increased energy requirement - CHD, hyperthyroidism.
Metabolic disease

Question 23

1) when to investigate UTIs in paediatrics. and what investigation.
2) How to inx damage post recurrent or atypical UTI.

Answer 23

1) Recurrent UTI (6 weeks post infection)
Any UTI under 6 months (within 6 weeks)
Atypical/proteus infection (during infection)
2) DMSA scan. 4-6 months post infection to assess damage

Question 24

Causes of diarrhoea in children (8)

Answer 24

Overflow from chronic constipation 
coeliac 
IBS
IBD
Gastroenteritis 
Meckels diverticulum 
Cows milk intolerance 
Hyperthyroidism

Question 25

Management of overflow diarrhoea/ constipation (3 steps)

Answer 25

1) Osmotic agent (Movicol)
2) Senna/picosulphate
3) Specialist involvement

Question 26

1) Criteria for nephrotic syndrome + 3 additional symptoms
2) Most common cause of nephrotic syndrome in paeds. What is seen on urinalysis
3) Management of above and dosage
4) Indication for steroid use and dosage

Answer 26

1) Hypoalbuminaemia. Oedema. Proteinurea (+++). Also hypertension. High cholesterol. Hyper coagulable state.
2) Minimal change disease. Hyaline casts on urinalysis.
3) Albumin infusion. Abx prophylaxis. Diuretics. Prednisolone (60mg/m^2 for 4 weeks then 40mg OD of alt days)
4) Age 1-10. No haematuria. Normal BP. Normal complement. Normal renal function.

Question 27

How is cows milk protein intolerance managed

Answer 27

Fomulae feeds. Most children grow out of it by 5 years

Question 28

7 yo girl presents with hip pain, decreased weight baring and a low grade fever.

1) Likely diagnosis, and DD to RULE OUT,
2) Likely recent illness to cause diagnosis
3) Management

Answer 28

1) Transient synovitis. rule out septic arthritis
2) URTI. Coryzal symptoms
3) Safety net for septic arthritis.

Question 29

3 common causes of neonatal sepsis

Answer 29

Group B strep
E coli
Listeria

Question 30

Antibiotics used to treat meningitis in <3mo. Why?

Answer 30

Ceftriaxone (standard)

Amoxicillin (Listeria)

Question 31

1) Most common and second most common Leukemias in children. And their peak presentation
2) Risk factors for leukaemia in children (3)
3) When should you urgently admit/refer a patient with suspected Leukemia
4) At least 8 symptoms of Leukemia

Answer 31

1) ALL - 2-3 years. AML <2 years
2) Downs, Kleinfeldern, Noonans, Fanconis
3) Hepato-splenomegaly + petecchia/bruising
4) Fatigue, fever, night sweats, anaemia, bruising, bone pain, lymphadenopathy, weight loss, TFT.

Question 32

Drug to manage cyanosis in TOF

Answer 32

Beta blockers

Prevent infundibular spasm

Question 33

How to determine admission of feverish child to hospital

Answer 33

NICE traffic light scoring system

Question 34

Green, Orange and Red criteria/summary for NICE feverish child traffic light system

Answer 34

GREEN 
Pretty much normal - not red or orange
ORANGE - F2F then ?hospital
Nasal flaring. RR>40. O2<95
HR>160 (140 if older)
Not responding to social cues 
RED - emergency admission 
Blue/mottled
grunting RR>60
Rash or meningism 
Chest recession  
Decreased consciousness

Question 35

Mother with bipolar disorder was never taken off lithium during pregnancy. What congenital heart condition is most likely

Answer 35

Ebsteins anomaly