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Phase 3a > Paediatrics > Flashcards

Paediatrics Flashcards

1
Q

Acute epiglottitis

What is the most common causative organism?

A

Haemophilus Influenzae Type B (HIB)

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2
Q

Acute epiglottitis

What are the signs and symptoms?

A

Intense swelling of epiglottis and surrounding tissues
Very acute onset (few hours)
High fever >38.5C
Immobile child, sitting propped up with mouth open
Child unable to speak or swallow, often drooling
Absent/slight cough
No preceding coryza

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3
Q

Acute epiglottitis

What is the management?

A

IV or oral (if tolerated) antibiotics - cefuroxime for 3-5 days
Intubation
Blood cultures
Rifampicin prophylaxis for close contacts

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4
Q

Nephrology

What are the 3 main renal causes of oedema in children?

A

Nephrotic syndrome
Nephritic syndrome
Henoch Scholein Purpura (HSP)

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5
Q

Nephrology

What causes increased interstitial fluid?

Pathophysiology

A

Lymph drainage (lymphoedema)
Venous drainage and pressure (obstruction e.g., venous thrombosis)
Lowered oncotic pressure - low albumin/protein (malnutrition, decreased production or increased loss)
Salt and water retention (in the kidney due to impaired GFR or due to heart failure)

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6
Q

Nephrology

How does nephrotic syndrome cause oedema?

A

Increased loss of albumin/protein in the kidneys –> low oncotic pressure –> oedema

Heavy proteinuria and hypoalbuminaemia

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7
Q

Nephrology

What are the three types of nephrotic syndrome?

A

Congenital NS (<1 year old)
Steroid sensitive NS
Steroid resistant NS

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8
Q

Nephrology

What are the features in the clinical presentation of steroid sensitive nephrotic syndrome?

A
  • normal BP
  • no macroscopic haematuria
  • normal renal function
  • no features suggesting nephritis
  • responds to steroids
  • “minimal change” on histology
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9
Q

Nephrology

What are the features in the clinical presentation of steroid resistant nephrotic syndrome?

A
  • elevated BP
  • haematuria
  • renal function may be impaired
  • features may suggest nephritis
  • failure to respond to steroids
  • histology - various, underlying glomerulopathy, basement membrane abnormality
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10
Q

Nephrology

What is the peak age of onset for steroid sensitive nephrotic syndrome?

A

2-5 years old

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11
Q

Nephrology

What gender is steroid sensitive nephrotic syndrome most common in?

A

Male

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12
Q

Nephrology

What ethnicity has a higher incidence of steroid sensitive nephrotic syndrome?

A

Asian sub-continent

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13
Q

Nephrology

What is the prognosis of nephrotic syndrome?

A
  • recurrent relapses common, about 5% continue into adult life
  • normal renal function steroid responsive
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14
Q

Nephrology

What is the treatment of steroid sensitive nephrotic syndrome?

A

For first episode:
- prednisolone 60mg/m^2 for 4 weeks
- prednisolone 40mg/m^2 on alternate days for 4 weeks

Consider: sodium and water moderation, diuretics, Pen V, measles and varicella immunity, pneumococcal immunisation

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15
Q

Nephrology

What is the clinical presentation of acute glomerulonephritis?

A
  • haematuria (often macroscopic)
  • proteinuria (varying degree)
  • impaired GFR
  • rising creatinine
  • salt and water retention - hypertension and oedema
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16
Q

Nephrology

What is the most common cause of acute glomerulonephritis?

A

Group A B-haemolytic streptococcus, nasopharyngeal or skin infections e.g., tonsillitis

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17
Q

Nephrology

What is the underlying pathophysiology of acute post-streptococcal glomerulonephritis?

A

Antigen-antibody complexes in the glomerulus and complement activation

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18
Q

Nephrology

How does acute post-streptococcal glomerulonephritis present?

A

Presents 10 days after the infection with clinical nephritis
* haematuria
* swelling
* decreased urine output
* oedema
* hypertension
* signs of cardiovascular overload

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19
Q

Nephrology

What is the management of acute post-streptococcal glomerulonephritis?

A

Fluid balance: measurement of input/output, fluid moderation, diuretics, salt restriction

Correction of other imbalances: potassium, acidosis

Dialysis if needed.

Penicillin for streptococcal infection.

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20
Q

Nephrology

What is the prognosis of acute post-streptococcal glomerulonephritis?

A

95% make a full recovery
Not recurrent
No long term implication for renal function if full recovery

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21
Q

Nephrology

What investigations are performed for acute post-streptococcal glomerulonephritis?

A

FBC - mild normocytic, normochromic anaemia

U&Es - increased urea and creatinine, hyperkalaemia, acidosis

Immunology - raised ASOT/antiDNAse B titre, low C3 and C4

Throat/other swabs

Urinalysis - haematuria (macroscopic usually), proteinuria (dipstick, protein:creatinine ratio), microscopy (RBC cast)

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22
Q

Nephrology

What is Henoch-Schonlein Purpura?

A

It is a vasculitis of the skin, joints, gut and kidneys

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23
Q

Nephrology

What is the renal presentation of Henoch-Schonlein Purpura nephritis?

A

Variable
* haematuria/proteinuria
* nephrotic syndrome
* acute nephritis
* renal impairment
* hypertension

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24
Q

Nephrology

What are the differences between nephritic and nephrotic syndrome?

A

Nephritic: acute onset, decreased GFR, reduced urine output, haematuria, hypertension, some proteinuria, normal/slightly low albumin, high creatinine, red cell casts

Nephrotic: more insidious onset, decreased or normal GFR, normal urine output, little/no haematuria, normal BP, high proteinuria, hypoalbuminaemia, hyperlipidemia

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25
Q

Nephrology

What are the long term complications of a UTI?

A

Kidney scarring, hypertension and chronic kidney disease

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26
Q

Nephrology

What are the signs and symptoms of a UTI in a child under 3 months old?

A

Most common on top:
* fever
* vomiting
* lethargy
* irritability
* poor feeding
* failure to thrive
* abdominal pain
* jaundice
* haematuria
* offensive urine

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27
Q

Nephrology

What are the signs and symptoms of a UTI in a child older than 3 months old that is pre-verbal?

A

Most common on top:
* fever
* abdominal pain
* loin tenderness
* vomiting
* poor feeding
* lethargy
* irritability
* haematuria
* offensive urine
* failure to thrive

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28
Q

Nephrology

What are the signs and symptoms of a UTI in a child older than 3 months old that is verbal?

A

Most common on top:
* frequency
* dysuria
* dysfunctional voiding
* changes to continence
* abdominal pain
* loin tenderness
* fever
* malaise
* vomiting
* haematuria
* offensive urine
* cloudy urine

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29
Q

Nephrology

When should you request a urine sample?

A

When a child presents with:
* symptoms and signs of UTI
* an unexplained fever of 38C or higher
* an alternative site of infection but remains unwell

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30
Q

Nephrology

What is the initial management of a child <3 months old with a UTI?

A

Any infant under 3 months old with a suspected UTI should be referred to paediatric specialist care and urine should be sent for urgent microscopy and culture

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31
Q

Nephrology

What is the most common causative organism for UTIs in girls?

A

E. coli

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32
Q

Nephrology

Which causative organism of UTIs is more commonly found in boys?

A

Proteus

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33
Q

Nephrology

Which causative organism of UTIs may indicate structural abnormalities?

A

Pseudomonas

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34
Q

Nephrology

What is the management of a UTI in infants under 3 months old?

A

Minimum 2-4 days IV abx followed by oral

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35
Q

Nephrology

What is the management of a UTI in a systematically well child, no significant fever and no systemic features?

A

3 days oral abx
Advise to return if no better at 24-48hrs

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36
Q

Nephrology

What is the management of a UTI in a systematically unwell child, fever >38C +/- loin pain?

A

7-10 days oral abx
Consider IV abx

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37
Q

Nephrology

What is the management of a UTI in a systematically well child, no significant fever and no systemic features?

A

3 days oral abx
Advise to return if no better at 24-48hrs

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38
Q

Nephrology

What is classed an atypical UTI?

A

When it involves:
* septacaemia
* requires IV abx
* poor urine flow
* abdominal mass/bladder mass
* raised creatinine
* failure to respond to treatment with suitable abx within 48hrs

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39
Q

Nephrology

What is classed as a recurrent UTI?

A

2+ episodes of UTI, at least one episode included systemic symptoms or signs
OR
3+ episodes of UTI without systemic symptoms/signs

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40
Q

Nephrology

What investigations are performed in a UTI?

A

Ultrasound renal tract
Micturating cystourethrogram
DMSA scan

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41
Q

Nephrology

What investigation is performed when vesicoureteric reflux is suspected?

A

Micturating cystourethrogram

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42
Q

Nephrology

What is vesicoureteric reflux?

A

Retrograde flow of urine from bladder into ureter/pelvicalyceal system/intrarenal system

It is associated with UTIs

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43
Q

Nephrology

Which investigation is done to look for renal scarring?

A

DMSA scan

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44
Q

Diabetes

At what age is Type 1 Diabetes most commonly diagnosed in children?

A

2 peaks: 4-5 years and 10-11 years

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45
Q

Diabetes

What is the pathophysiology of Type 1 diabetes?

A

Autoimmune destruction of the insulin-producing pancreatic Beta cells

Associated with HLA types DR3 and DR4

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46
Q

Diabetes

What are the presenting features of type 1 diabetes in children?

A

Polyuria
Polydipsia (extreme thirst)
Weight loss
Tiredness

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47
Q

Diabetes

What conditions is type 2 diabetes associated with in children, on presentation?

A

Hypertension - 44% have it on presentation
Kidney disease - 25% have it on presentation

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48
Q

Diabetes

What are the risk factors for type 2 diabetes in children?

A

Obesity, girls, non-white ethnicity and deprivation

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49
Q

Diabetes

What is the pathophysiology of type 2 diabetes?

A

Diminished response to insulin –> insulin resistence

It is initially countered by an increase in insulin production to try to maintain glucose homeostasis.

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50
Q

Diabetes

How is type 2 diabetes diagnosed?

A

Oral glucose tolerance test

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51
Q

Diabetes

What are the criteria for a diagnosis of diabetes?

A

Diabetes symptoms AND:
* a random venous plasma glucose of at least 11.1 mmol/L OR
* a fasting plasma glucose of at least 7.0 mmol/L OR
* who hour plasma glucose of at least 11.1mmol/L two hours after 75g anhydrous glucose in an OGTT

HbA1c of 48mmol/mol or more, but a lower value does not exclude

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52
Q

Diabetes

What is the management of type 1 diabetes?

Not in DKA

A

Insulin:
* started on 0.5-0.8 units/kg/day
* 50% long acting and 50% short acting for meals
* pen therapy to start with, pump later if needed
* blood glucose testing at least 5 times a day

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53
Q

Diabetes

How does diabetic ketoacidosis (DKA) present?

A
  • nausea and vomiting
  • abdominal pain
  • hyperventilation
  • dehydration
  • reduced level of consciousness
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54
Q

Diabetes

How is the severity of diabetic ketoacidosis graded?

A

Mild = pH <7.3 or plasma bicarbonate <15 mmol/L
Moderate = pH <7.2 or plasma bicarbonate <10 mmol/L
Severe = pH <7.1 or plasma bicarbonate <5 mmol/L

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55
Q

Diabetes

How is diabetic ketoacidosis managed?

A

Fluids
Insulin - slow 0.05-0.1 units/kg/hr
Monitor glucose hourly
Monitor electrolytes, especially K+ and ketones
Very strict fluid balance
Hourly neuro obs

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56
Q

Diabetes

What are the possible complications of diabetic ketoacidosis?

A

Cerebral oedema, shock, hypokalaemia, vomit aspiration, thrombus

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57
Q

Diabetes

What is the initial management of type 2 diabetes?

A

**Metformin +/- insulin **
Consider GLP-1 agonists: Liraglutide (>10 years), semaglutide (>18 years)
Diet: calorie/carb reduction and weight loss
Lifestyle: physical activity, sleep, screentime

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58
Q

Diabetes

What are the autonomic symptoms of hypoglycaemia?

A
  • irritable
  • hungry
  • shaky
  • anxious
  • sweaty
  • palpitations
  • pallor
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59
Q

Diabetes

What are the neuroglycopenic symptoms of hypoglycaemia?

A
  • confused
  • drowsy
  • hearing or visual problems
  • headache
  • slurred speech
  • unusual behaviour/moodiness
  • coma
  • seizures
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60
Q

Diabetes

What is the management of mild-moderate hypoglycaemia?

A

Check blood glucose

Glucose tablets, gel, glucose containing food or drink (not chocolate)

Check glucose in 15 minutes

Follow up with longer acting carb (bread or a biscuit)

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61
Q

Diabetes

What is the management of severe hypoglycaemia?

A

Glucagon injection

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62
Q

Diabetes

What are the short term complications of diabetes?

A

Hypo/hyperglycaemia
DKA

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63
Q

Diabetes

What are the long term complications of diabetes?

A

Microvascular: albuminuria, retinopathy
Macrovascular: hypertension, hypercholesterolaemia

Blindness, kidney failure, heart disease, stroke, amputations

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64
Q

Disability

What are the five types of impairments?

A

Physical
Sensory
Learning
Neurodevelopmental
Emotional/Behavioural

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65
Q

Disability

What is WHODAS?

A
  • A generic assessment instrument for health and disability
  • Used across all diseases inc., mental, neurological and addictive disorders
  • A tool to produce standardised disability levels and profiles
  • Directly linked at the level of the concepts to the International Classification of Functioning, Disability and Health (ICF)
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66
Q

Disability

What six domains of functioning does WHODAS 2.0 cover?

A

Cognition - understanding and communication
Mobility - moving and getting around
Self-care - hygiene, dressing, eating and staying alone
Social - interacting with other people
Life activities - domestic responsibilities, leisure, work and school
Participation - joining in community activies

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67
Q

Disability

What is the definition of quality of life?

A

The degree to which a person enjoys the important possibilities of his/her life

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68
Q

Disability

What are the three B’s of quality of life?

A

Being - who one is
Belonging - how one fits into the environment
Becoming - how to have purposeful activities in order to achieve one’s goals

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69
Q

Limping child

What are the 4 modified Kocher’s criteria used when assessing for likelihood of septic arthritis?

A

Modified Kocher’s criteria:
* Fever >38.5C
* Inability to weight bear
* CRP > 20mg/L
* WBC >12

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70
Q

Limping child

What is the pathophysiology of Perthe’s disease?

A

Avascular necrosis of the femoral head

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71
Q

Limping child

What are the common causes of a limp in a child under 3 years old?

A

Septic arthritis/osteomyelitis
Transient synovitis
Fracture/soft tissue injury
Developmental dysplasia of the hip
Toddler fracture
Non-accidental injury

Others:
* malignancy e.g., leukaemia
* non-malignant haematological disease e.g., haemophilia/sickle cell
* metabolic disease e.g., rickets
* neuromuscular disease e.g., cerebral palsy, spina bifida
* limb abnormality e.g., length discreptancy

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72
Q

Limping child

What are the common causes of a limp in a child between 3-10 years old?

A

Transient synovitis
Septic arthritis/osteomyelitis
Fracture/soft tissue injury
Perthe’s disease

Others:
* malignancy e.g., leukaemia
* non-malignant haematological disease e.g., haemophilia/sickle cell
* metabolic disease e.g., rickets
* neuromuscular disease e.g., cerebral palsy, spina bifida
* limb abnormality e.g., length discreptancy
* inflammatory joint or muscle disease e.g., JIA

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73
Q

Limping child

What are the common causes of a limp in a child older than 10 years old?

A

Septic arthritis/osteomyelitis
Slipped upper femoral epiphysis
Perthe’s disease
Fracture/soft tissue injury

Others:
* malignancy e.g., leukaemia
* non-malignant haematological disease e.g., haemophilia/sickle cell
* metabolic disease e.g., rickets
* neuromuscular disease e.g., cerebral palsy, spina bifida
* limb abnormality e.g., length discreptancy
* inflammatory joint or muscle disease e.g., JIA

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74
Q

Limping child

What are the ACR criteria for the diagnosis of juvenile idiopathic arthritis?

A
  • age at onset <16 years
  • arthritis in one or more joints
  • duration >/= 6 weeks
  • exclusion of other forms of juvenile arthritis
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75
Q

Limping child

What are the three types of juvenile idiopathic arthritis and how do they present?

A

Polyarthritis: 5 or more inflamed joints, usually medium-sized joints (knees, ankles, elbows)
Oligoarthritis: <5 inflamed joints
Systemic: arthritis with characteristic fever

Morning stiffness, gradual resolution of pain with activity. Painful or decreased range of motion, especially in internal rotation if hip affected.

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76
Q

Limping child

What are the features associated with systemic juvenile idiopathic arthritis?

A
  • Pyrexia
  • Salmon-pink rash
  • Lymphadenopathy
  • Arthritis
  • Uveitis
  • Anorexia and weight loss
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77
Q

Limping child

How does septic arthritis/osteomyelitis present?

A
  • Usually febrile
  • Most common <4 years old
  • Pain
  • Inability to weight bear
  • Child often looks unwell
  • Swollen, red joint in septic arthritis
  • Passive movement of the joint is incredibly painful
  • Femoral osteomyelitis presents similarily but there is some passive range of motion unless the infection has extended into the joint
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78
Q

Limping child

What investigations should be performed when you suspect osteomyelitis?

A

MRI

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79
Q

Limping child

How is osteomyelitis managed?

A

IV cefuroxime for 6 weeks first-line
If known staph. auerus then flucloxacillin for 6 weeks OR clindamycin if penicillin-allergic

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80
Q

Limping child

What investigations should be performed for septic arthritis?

A

Joint aspiration for culture, also shows raised WBC
CRP and ESR raised
Blood cultures
FBC: raised WCC

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81
Q

Limping child

When should you suspect septic arthritis rather than transient synovitis?

A

When the child has a high fever and/or is systematically unwell

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82
Q

Limping child

How does transient synovitis present?

A
  • Typically acute onset following a viral infection
  • No systemic upset
  • Age 3-8 years old, peak at 5/6 years
  • More common in boys
  • No pain at rest and passive movement is only painful at the extreme range of movement
  • Limp/refusal to weight bear
  • Low-grade fever in minority of patients
  • Recurs in up to 15% of children
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83
Q

Limping child

How is transient synovitis managed?

A

It is a self-limiting condition, requires only oral analgesia

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84
Q

Limping child

How does Perthe’s disease present?

A
  • 5 times more common in boys
  • Peak age 4-8 years old
  • Around 10% of cases are bilateral
  • Hip pain: develops progressively over a few weeks
  • Limp
  • Stiffness and reduced range of movement
  • Widened joint space on x-ray, later changes include decreased femoral head size/flattening
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85
Q

Limping child

How is Perthe’s disease diagnosed?

A

Using a plain x-ray
Technetium bone scan or MRI if normal x-ray and symptoms persist

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86
Q

Limping child

What are the complications of Perthe’s disease?

A

Osteoarthritis and premature fusion of the growth plates

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87
Q

Limping child

How does slipped upper femoral epiphysis (SUFE) present?

A
  • Usually 11-14 years
  • More common in obese children and boys
  • Bilateral in 20-40%
  • X-ray shows displacement of the femoral head epiphysis posterio-inferiorly
  • May present acutely following trauma or more commonly with chronic, persistent symptoms
  • Hip, groin, medial thigh or knee pain
  • Loss of internal rotation of the leg in flexion
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88
Q

Limping child

What investigation should be performed for slipped upper femoral epiphysis (SUFE)?

A

AP and lateral views - diagnostic

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89
Q

Limping child

How is slipped upper femoral epiphysis managed?

A

Internal fixation - single cannulated screw placed in the centre of the epiphysis

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90
Q

Limping child

What are the complications associated with slipped upper femoral epiphysis?

A

Osteoarthritis, avascular necrosis of the femoral head, chondrolysis, leg-length discrepancy

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91
Q

Spots and rashes

What is a macular rash?

A

A non-palpable rash with colour changes in limited areas

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92
Q

Spots and rashes

Give two causes of a macular rash

A

Measles, rubella

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93
Q

Spots and rashes

What is a papular rash?

A

A palpable rash with raised, solid lesions and colour changes in limited areas up to 0.5cm

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94
Q

Spots and rashes

What can cause a papular rash?

A

Pityriasis rosea

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95
Q

Spots and rashes

What is a vesicular rash?

A

Elevated lesions that are filled with clear fluid <0.5cm

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96
Q

Spots and rashes

Give three causes of a vesicular rash

A

Chicken pox, herpes simplex, herpes zoster

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97
Q

Spots and rashes

What is an ulcer?

A

A skin or mucous membrane lesion occuring as a result of the loss of superficial tissue, usually involving an inflammatory process

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98
Q

Spots and rashes

What is a plaque?

A

A differentiated area on a flat skin surface area or a mucous membrane

99
Q

Spots and rashes

Give an example of a plaque

A

Urticarial plaque

100
Q

Spots and rashes

What is a nodule?

A

A circumscribed swelling or an elevated lesion

101
Q

Spots and rashes

What is petechiae?

A

A small red or purple spot that is not elevated and does not blach when pressure is applied
Usually the result of haemorrhages from tiny blood vessels in the skin

102
Q

Spots and rashes

What can cause a petechial rash?

A

Meningococcal sepsis

103
Q

Spots and rashes

What are crusts?

A

Hard outer layer of lesions which may be due to dried serum or pus from ruptured vesicles

104
Q

Spots and rashes

What can cause crusts?

A

Impetigo

105
Q

Spots and rashes

What are blisters?

A

A fluid-filled structure within the epidermis or under the dermis

106
Q

Spots and rashes

What can cause blisters?

A

Bullous impetigo, bullous pemphagoid

107
Q

Spots and rashes

What are café au lait spots and how do they present?

A

Birthmark
* flat patches on the skin
* light brown but can darken with exposure to the sun
* more common in African Americans
* usually present at birth
* tend do persist, life-long

108
Q

Spots and rashes

What skin lesion is associated with neurofibromatosis?

A

Cafe-au-lait patch - more than 5 is suggestive of neurofibromatosis

109
Q

Spots and rashes

How do strawberry naevi/marks (infantile/capillary haemangiomas) present?

A
  • Not at birth, develop rapidly in the first month of life
  • Increase in size until 6-9 months old, then regress over few years
  • Erythematous, raised and multilobed tumours
  • Common sites: face, scalp, back
  • Present in around 10% of white infants
  • Risk factors: female, prematurity, mother undergone chorionic villous sampling
110
Q

Spots and rashes

What are the complications of strawberry naevus?

A

Mechanical e.g., obstructing visual field or airway
Bleeding
Ulceration
Thrombocytopenia

111
Q

Spots and rashes

What is the management of strawberry naevi?

A

Normally self limiting, 95% resolve before 10 years old
If treatment required due to complications, propranolol

112
Q

Spots and rashes

What are port wine stains/naevus flammeus and how do they present?

A

Birth marks
* often unilateral
* deep red or purple in colour
* do not spontaneously resolve, darken and become raised over time
* female predisposition
* 65% on head and neck
* may be associated with glaucoma

113
Q

Spots and rashes

What is the management of port wine stains?

A

Pulsed dye laser or cosmetic camouflage

114
Q

Spots and rashes

What are Mongolian blue spots/congenital dermal melanocytosis and how do they present?

A

Birth marks
* appear at or shortly after birth
* bruise-like, flat skin markings
* commonly at the base of spine, buttocks, back and shoulders
* seen in children with darker skin
* usually fade before adolescence

115
Q

Spots and rashes

What are milia/milk spots?

A

Small, benign, keratin-filled cysts that are common in newborns and often found around the nose and cheeks

116
Q

Spots and rashes

What is erythema toxicum neonatorum and how does it present?

A

Blotchy, red rash with small bumps that can be filled with fluid
Not infectious, self limiting
Occurs in up to 50% of all babies born at term
Usually between days 2-5 of life

117
Q

Spots and rashes

What organism is chickenpox caused by?

A

Varicella zoster virus

118
Q

Spots and rashes

How does chickenpox present?

A
  • Small, itchy blisters
  • Start on the chest, back and face then spreads
  • Fever
  • Tiredness
  • Headaches
  • Symptoms last 5-7 days
119
Q

Spots and rashes

How does chickenpox spread?

A

Through airborne droplets 1-2 days prior to rash starting, as well as contact with blisters
Infectious until all the lesions have crusted over (about 5 days from rash onset)

120
Q

Spots and rashes

What is the management of chickenpox?

A
  • keep cool, trim nails
  • calamine lotion
  • school exclusion until lesions have crusted over
  • if immunocompromised, or newborn with peripartum exposure –> varicella zoster immunoglobulin (VZIG), if chickenpox develops then consider IV aciclovir
121
Q

Spots and rashes

What are the complications of chickenpox?

A

Secondary bacterial infection of the lesions most common, NSAIDs may increase the risk

Other:
* pneumonia
* encephalitis
* disseminated haemorrhagic chickenpox
* arthritis, nephritis, pancreatitis (very rare)

122
Q

Spots and rashes

How does measles present?

A

CCCK: cough, conjuctivitis, coryza, Koplik’s spots

  • infective prodrome until 4 days after rash starts: irritability, conjuctivitis and fever
  • Koplik’s spots (white spots on buccal mucosa) develop before the rash
  • rash starts behind ears then spreads to the whole body
  • rash = discrete maculopapular rash, becomes blotchy and confluent
  • desquamation of the rash that spares palms and soles may occur after a week
  • diarrhoea in about 10%
123
Q

Spots and rashes

What investigation is performed for measles?

A

IgM antibodies - detected within a few days of rash onset

124
Q

Spots and rashes

How is measles managed?

A

Mainly supportive management
Admission if immunosuppressed or pregnant
Notifiable disease so inform PHE

125
Q

Spots and rashes

What are the complications of measles?

A
  • Otitis media = most common
  • Pneumonia = most common cause of death
  • Encephalitis = normally 1-2 weeks following the onset of illness
  • Subacute sclerosing panencephalitis = very rare, may present 5-10 years following illness
  • Febrile convulsions
  • Keratoconjunctivitis, corneal ulceration
  • Diarrhoea
  • Increased incidence of appendicitis
  • Myocarditis
126
Q

Spots and rashes

How does rubella present?

A
  • non-photogenic rash that starts on face and spreads
  • rash is vague, lacy, ill-defined and not itchy
  • rash lasts for 3 days
  • lymphadenopathy
  • fever
  • sore throat
  • fatigue
127
Q

Spots and rashes

What are the complications of rubella?

A
  • Bleeding problems
  • Testicular swelling
  • Nerve inflammation
  • In congenital rubella syndrome: miscarriage, cataracts, deafness, problems with heart and brain
128
Q

Spots and rashes

How does slapped cheek syndrome/erythema infectiosum present?

A
  • mild feverish illness, headache and coryza
  • rash appears after a few days - bright red cheeks, may spread to rest of the body but rarely involves palms and soles
  • child begins to feel better as the rash appears
  • no school exclusion
  • common in 5-15 years old
  • rash lasts 1-3 weeks
129
Q

Spots and rashes

What organism causes slapped cheek syndrome?

A

Parvovirus B19

130
Q

Spots and rashes

What are the complications of slapped cheek syndrome?

A
  • Suppresses erythropoiesis
  • Pancytopenia in immunosuppressed patients
  • Aplastic crises in sickle-cell disease
  • Hydrops fetalis (crosses placenta in pregnant women, causes severe anaemia –> heart failure –> accumulation of fluid in fetal serous cavities, treated with intrauterine blood transfusions)
131
Q

Spots and rashes

How does roseola infantum/exanthem subitum present?

A
  • usually 6 months - 2 years old
  • high fever lasting a few days before the rash
  • rash is maculopapular, starts on torso then spreads to face, neck and arms, fades within 2 days
  • nagayama spots = papular enanthem on the uvula and soft palate
  • febrile convulsions in 10-15%
  • diarrhoea and cough
  • child feels better as rash appears
132
Q

Spots and rashes

What organism causes roseola infantum/exanthem subitum?

A

Human herpes virus 6

133
Q

Spots and rashes

How does hand, foot and mouth disease present?

A

Start with fever and feeling unwell, sore throat and oral ulcers
Rash appears 1-2 days later = vesicles on hands, feet and mouth

134
Q

Spots and rashes

What is the management of hand, foot and mouth disease?

A

Symptomatic: hydration and analgesia
No school exclusion as long as the child is well

135
Q

Spots and rashes

What organisms commonly cause hand, foot and mouth disease?

A

Coxsackie A16 and enterovirus 71

136
Q

Spots and rashes

How does mumps present?

A
  • high fever
  • malaise, muscular pain
  • parotitis - unilateral initially then bilateral in 70%
  • headache
  • joint pain
137
Q

Spots and rashes

What is the management of mumps?

A

Rest, paracetamol and notify PHE

138
Q

Spots and rashes

What are the complications of mumps?

A
  • orchitis - 4/5 days after the start of parotitis
  • hearing loss - usually unilateral and transient
  • meningoencephalitis
  • pancreatitis
  • can be associated with a fall in fertility
139
Q

Spots and rashes

How does molloscum contagiosum present?

A
  • often 1-4 years old
  • common in children with atopic eczema
  • after contact with contaminated surfaces e.g., shared towels
  • characteristic pinkish/pearly white papular with a central umbilication, up to 5mm
  • lesions in clusters anywhere other than palms and soles
140
Q

Spots and rashes

How is molloscum contagiosum managed?

A

Self-care advice
* reassurance
* self-limiting within 18 months
* discourage scratching, consider emollient or mild topical conticosteroid to allieviate itch

141
Q

Spots and rashes

How does impetigo present?

A
  • more common in warm weather
  • golden, crusted skin lesions typically around the mouth
  • very contagious
142
Q

Spots and rashes

What is the management of impetigo?

A
  • hydrogen peroxide 1% if not systematically unwell or at risk of complications
  • topical antibiotic creams: fusidic acid (first line), mupirocin
  • extensive disease: oral flucloxacillin, oral erythromycin is penicillin-allergic
  • school exclusion until lesions crusted over or 48 hours after starting antibiotics
143
Q

Spots and rashes

What organisms cause impetigo?

A

Staphylococcus aureus or streptococcus pyogenes

144
Q

Spots and rashes

How does scalded skin syndrome present?

A

Peeling skin over large parts of the body
Skin looks like scalded/burned

145
Q

Spots and rashes

What organism causes scalded skin syndrome?

A

Staphylococcus aureus

146
Q

Spots and rashes

How does orbital cellulitis present?

A
  • age 7-12 years old
  • redness/swelling around eye
  • severe ocular pain
  • visual disturbance
  • proptosis
  • ophthalmoplegia
  • eyelid oedema and ptosis
147
Q

Spots and rashes

What organisms cause orbital cellulitis?

A

Staphylococcus aureus, Haemophilus influenzae B (not common due to vaccine), Streptococcus (less common than staph)

148
Q

Spots and rashes

How does scarlet fever present?

A
  • 2-6 years old
  • fever for 24-48 hours
  • malaise, headache, nausea/vomiting
  • sore throat
  • strawberry tongue
  • rash: fine punctuate erythema (pinhead), first on torso then spreads, rough sandpaper texture, desquamination later on around fingers and toes, perioral sparing
149
Q

Spots and rashes

What is the management of scarlet fever?

A

Oral penicillin V for 10 days or azithromycin if allergic
School exclusion until 24 hours after starting antibiotics
Notify PHE

150
Q

Spots and rashes

What are the complications of scarlet fever?

A

Otitis media (most common)
Rheumatic fever - usually 20 days after infection
Acute glomerulonephritis - usually 10 days after infection

151
Q

Spots and rashes

What is the pathophysiology of scarlet fever?

In terms of causative organisms

A

Reaction to erythrogenic toxins produced by Group A haemolytic streptococci, usually streptococcus pyogenes

152
Q

Spots and rashes

How does acanthosis nigricans present?

A

Symmetrical, brown, velvety plaques found on the neck, axilla and groin

153
Q

Spots and rashes

What are the causes of acanthosis nigricans?

A
  • Type 2 DM
  • Gastrointestinal cancer
  • Obesity
  • Polycystic ovarian syndrome
  • Acromegaly
  • Cushing’s disease
  • Hypothyroidism
  • Familial
  • Prader-Willi syndrome
  • Drugs: combined oral contraceptive pill, nicotinic acid, steroids, insulin
154
Q

Spots and rashes

What is tinea capitis and how does it present?

A

Fungal infection of the scalp (scalp ringworm)
* scarring alopecia
* if untreated, a raised, pustular, spongy/boggy mass (kerion) may form

155
Q

Spots and rashes

What is tinea corporis/ringworm and how does it present?

A

Fungal infection of the trunk, legs or arms
* may be after contact with cattle
* well-defined, annular, erythematous lesions with pustules and papules

156
Q

Spots and rashes

How is tinea capitis managed?

A

Oral antifungals (terbinafine or griseofulvin) and topical ketoconazole shampoo

157
Q

Spots and rashes

How is tinea corporis/ringworm managed?

A

Oral fluconazole

158
Q

Spots and rashes

What is tinea pedis and how does it present?

A

Athlete’s foot
Itchy, peeling skin between toes

159
Q

Metabolic bone diseases

What are the criteria for diagnosing osteoporosis in children?

A

1 or more vertebral fractures
OR
Size adjusted bone density <-2.0 SDS plus one of:
* 2 or more long bone fractures by age 10
* 3 or more long bone fractures by age 19

160
Q

Metabolic bone diseases

What are the inherited/congenital causes of osteoporosis?

A

Osteogenesis imperfecta
Inborn errors e.g., galactosemia
Haematological problems
Idiopathic

161
Q

Metabolic bone diseases

What are the acquired causes of osteoporosis?

A

Drug-induced - especially steroids
Major endocrinopathies
Malabsorption
Immobilisation
Inflammation

162
Q

Metabolic bone diseases

What is the mode of inheritance of osteogenesis imperfecta?

A

Usually (85-90%) autosomal dominant, there are some rare recessive genes

163
Q

Metabolic bone diseases

How does osteogenesis imperfecta present?

A
  • Bone fragility, fractures and deformity
  • Bone pain
  • Impaired mobility (ligamentous laxity and sarcopenia)
  • Poor growth
  • Deafness, hernias, valvular prolapse
  • May have blue sclera
  • Bones also brittle
164
Q

Metabolic bone diseases

What is the pathophysiology of osteogenesis imperfecta?

A

Abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

165
Q

Metabolic bone diseases

Describe the first 4 types of osteogenesis imperfecta in terms of severity

A

I - mild
II - lethal
III - progressively deforming, severe
IV - moderate

166
Q

Metabolic bone diseases

What medication is used to treat osteogenesis imperfecta and what does it do?

A

Bisphosphonates
* increases bone mass
* reduces fracture frequency
* increases vertebral height
* suppresses bone markers
* reduces pain
* increases mobility
* does not affect growth

167
Q

Metabolic bone disease

What is rickets?

A

A condition characterised by inadequately mineralised bone in developing and growing bones, resulting in soft and easily deformed bones

168
Q

Metabolic bone diseases

What is rickets caused by?

A

Vitamin D deficiency

169
Q

Metabolic bone diseases

What are the risk factors for rickets?

A

Dietary deficiency of calcium
Prolonged breastfeeding
Unsupplemented cow’s milk formula
Lack of sunlight

170
Q

Metabolic bone diseases

How does rickets present?

A
  • Aching bones and joints
  • Lower limb abnormalities (toddlers: genu varum/bow legs, older children: genu valgum/knock knees)
  • Rickety rosary - swelling at the costochondral junction
  • Kyphoscoliosis
  • Craniotabes - soft skull bones in early life
  • Harrison’s sulcus
171
Q

Metabolic bone diseases

What does vitamin D do?

A

It makes calcium more available by increasing calcium absorption from the gut and increasing calcium release from the bone

Maternal vitamin D influences bone size and mass in childhood

It has a role in immune function/tolerance

172
Q

Metabolic bone diseases

What are the complications of vitamin D deficiency in newborns?

A

Severe, life threatening:
* cardiomyopathy
* hypocalcaemic convulsions

Severe:
* clinically apparent rickets e.g., metaphyseal swelling, bony deformity

Moderate:
* radiological or biochemical changes

173
Q

Metabolic bone diseases

What biochemical disturbances are seen in rickets?

A

Low PO4 (fasting)
Serum calcium variable
Raised serum alkaline phosphate
In vitamin D deficiency: raised PTH and low 25 OH-D

174
Q

Microbiology

What is the most common causative organism of a UTI?

A

E. coli

175
Q

Microbiology

What is the first line treatment for a UTI in neonates or infants who are acutely ill, have suspected pyelonephritis or are vomiting?

A

IV cefuroxime for 7 days
Oral switch trimethoprim

176
Q

Microbiology

What type of bacteria is E. coli?

Gram staining and cocci/bacillus

A

Gram negative rods/bacilli

177
Q

Microbiology

What type of bacteria is Staphylococcus aureus?

Gram staining and cocci/bacilli

A

Gram positive cocci

178
Q

Microbiology

What is the antibiotic management of bacterial meningitis/meningococcal sepsis?

A

First line: IV cefotaxime

179
Q

Microbiology

What investigations should be performed for suspected bacterial meningitis/meningococcal sepsis?

A

Blood clutures, EDTA blood for PCR, CSF

180
Q

Microbiology

What are the most common causative organisms of meningitis in children 0-3 months old?

A

Group B streptococcus (most common cause in neonates)
E.coli
Listeria monocytogenes

181
Q

Microbiology

What are the most common causative organisms of meningitis in children 3 months-6 years old?

A

Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

182
Q

Microbiology

What are the most common causative organisms of meningitis in children >6 years old?

A

Neisseria meningitidis
Streptococcus pneumoniae

183
Q

Microbiology

What antibiotics should you use for prophylaxis of contacts with a child who has been diagnosed with meningitis?

A

Ciprofloxacin or rifampicin

184
Q

Microbiology

What type of bacteria is streptococcus pneumoina/pneumococcus?

Gram staining and cocci/bacilli

A

Gram positive cocci in pairs

185
Q

Microbiology

What is the most common cause of lobar pneumonia?

A

Streptococcus pneumonia/pneumococcus

186
Q

Microbiology

What is the management of streptococcus pneumoniae pneumonia?

A

IV benzylpenicillin if severe
PO amoxicillin if mild

187
Q

Faltering growth

Define faltering growth

A

Failure to gain adequate weight or achieve adequate growth during infancy or early childhood

Significant interruption in the expected rate of growth compared with other children of similar age and sex during early childhood

Fall across 2 centiles on the growth chart

188
Q

Faltering growth

What are the concerning features of a child with faltering growth?

A
  • 10% loss of their birthweight in a newborn
  • No return to birthweight by 3 weeks of age
  • Fall across >1 centile, if birthweight was below 9th centile
  • Fall across >2 weight centiles, if birthweight was between 9th-91st centiles
  • Fall >3 weight centiles, if birthweight was above 91st centile
  • Weight is <2nd centile for age, independent of birthweight
189
Q

Faltering growth

What are the 4 types of causes of faltering growth?

A

Poor intake
Malabsorption
Excessive expenditure
Abnormal appetite/growth and psychosocial

190
Q

Faltering growth

What are the causes of poor intake?

A

Breast-feeding poorly
Bottle feeds too dilute
Juice drinker
Exclusion diets
Cleft palate
Neuromuscular disorder
Vomiting
Eating disorder

191
Q

Faltering growth

What are the symptoms of GORD?

Respiratory, oesophagitis, regurgitation and neurobehavioural

A

Respiratory:
* aspiration pneumonia
* bronchospasm, wheezing
* apnoeas, cyanotic episodes
* cough, stridor, hoarseness
* otitis media, glue ear

Oesophagitis:
* chest and epigastric pain
* irritability
* anaemia, haematemesis
* dysphagia
* peptic stricture causing obstruction

Regurgitation:
* poor weight gain
* nausea, vomiting

Neurobehavioural:
* infant spells (including seizure-like events)
* Sandifer’s syndrome

192
Q

Faltering growth

What are the causes of malabsorption?

A

Enteropathy, liver disease and pancreatic disease

193
Q

Faltering growth

What are the causes of pancreatic insufficiency?

A
  • Cystic fibrosis
  • Schwachmann-Diamond syndrome
  • Isolated enzyme deficiency
  • Chronic pancreatitis and failure
194
Q

Faltering growth

What is the presentation of pancreatic insufficiency?

A

Fatty, greasy stools that smell foul and float, diffiuclt to flush

195
Q

Faltering growth

What investigations should be performed for pancreatic insufficiency?

A

Check faecal elastase, formal pancreatic function studies and trial of Creon

196
Q

Faltering growth

What are the causes of diarrhoea?

A

Allergic, coeliac, infective, post-infective

197
Q

Faltering growth

How does cow’s milk protein allergy present?

A

IgE mediated - rapid onset, anaphylactic type symptoms
* Constipation
* Iron deficiency anaemia
* Vomiting
* Smelling of lips or eye lids
* Asthma
* Wheezing and coughing
* Eczema
* Skin rash
* Colic
* Diarrhoea
* Refusal to feed
* Blood in faeces

198
Q

Faltering growth

What are the infective causes of diarrhoea?

A

Enteroviruses: rotavirus, adenovirus, picornavirus
Bacterial:
* toxins - clostridium difficile, staphylococcal
* secretagogues - cholera
* inflammatory - salmonella, campylobacter
Parasitic: giardia, entamoeba histolytica
Others: TB, opportunistic in immunocompromised, herpes, CMV, HIC

199
Q

Faltering growth

How is post-infective diarrhoea caused?

A

Infection-related mucosal disintegrity –> immunological antigen exposure –> mucosal (allergic) inflammation –> secondary disaccharidase deficiency –> diarrhoea

200
Q

Faltering growth

How does coeliac disease cause faltering growth?

A

Prximal small intestine damage due to tissue transglutaminase –> malnutrition and malabsorption

201
Q

Faltering growth

How does coeliac disease present?

A
  • Fatigue
  • Iron deficiency anaemia
  • Osteopenia/osteoporosis
  • Mouth ulcers
  • Dental enamel defects
  • Failure to thrive
  • Short stature
  • Delayed puberty
  • Nausea and vomiting
  • Abdominal pain
  • Bloating
  • Diarrhoea
  • Constipation
  • Hepatitis
  • Weakness
  • Parasthesia
  • Dermatitis herpetiformis
  • Behavioural changes
  • Subfertility and recurrent miscarriages
  • Malnutrition
202
Q

Faltering growth

How do you test for lactose intolerance?

A

Lactose hydrogen breath tests
Trial off milk

203
Q

Faltering growth

How does inflammatory bowel disease present?

A

Long history of faltering growth of weight loss, pain, loose stools, frequency and urgency, PR bleeding, FE deficiency anaemia

204
Q

Faltering growth

What investigations should be performed for IBD?

A

CRP
ESR
FBC - anaemia and thrombocytosis
Albumin
Faecal calprotectin

205
Q

Faltering growth

What are the causes of excessive energy expenditure?

A
  • Congenital heart disease
  • Chronic renal failure
  • Chronic respiratory disease e.g., CF
  • Chronic inflammation
  • Tumours
  • Other catabolic states
206
Q

Faltering growth

What are non-organic causes of faltering growth?

A
  • Poor parental understanding
  • Low income
  • Poor social support
  • Deliberare starvation
  • Maternal anorexia
  • Parental psychiatric illness
  • Emotional neglect
207
Q

ENT

What causes acute otitis media?

A

Normally preceded by a viral URTI which disrupt the microbiome and allow bacteria to grow
Bacterial causes: Streptococcus pneumoniae, Haemophilus influenza

208
Q

ENT

How tos otitis media present?

A
  • Otalgia (pain)
  • Some children may tug/rub their ear
  • Fever in about 50%
  • Hearing loss
  • Recent viral URTI symptoms
  • Ear discharge if tympanic membrance perforates
209
Q

ENT

What might you find on otoscopy in otitis media?

A
  • bulging tympanic membrane
  • opacification or erythema of the tympanic membrane
  • perforation with purulent otorrhoea
  • decreased mobility if using a pneumatic otoscope
210
Q

ENT

What is the management of otitis media?

A

Self limiting, analgesia

Antibiotics (amoxicillin or erythromycin/clarithromycin):
* symptoms >4 days and not improving
* systematically unwell but not requiring admission
* immunocompromise or high risk of complications
* younger than 2 years with bilateral otitis media
* perforation and/or discharge in the canal

211
Q

ENT

What is glue ear?

A

Otitis media with an effusion

212
Q

ENT

How does glue ear present?

A
  • Peaks at 2 years of age
  • Hearing loss on 2 occasions 3 months apart
213
Q

ENT

How is glue ear managed?

A

Conservative
Grommet insertion
Adenoidectomy
Hearing aids

214
Q

ENT

What are the causes of epistaxis?

A

Nose picking, inflammation, foreign body, trauma, bleeding diathesis

215
Q

ENT

How is epistaxis managed?

A

ABCDE
Medical: topical naseptin, silver nitrate cautery
Surgical: electrocautery

216
Q

ENT

What is laryngomalacia and how does it present?

A

Congenital abnormality of the larynx
* infants present at 4 weeks old with a stridor
* stridor worse on feeding and exertion, also when supine
* normal voice
* failure to thrive
* increased work of breathing

217
Q

ENT

What is the management of laryngomalacia?

A
  • Close monitoring
  • Monitor weight
  • Antireflux
  • NG tube
  • Surgery
  • Normally self limiting, stridor lessens and is gone by 2 years old
218
Q

ENT

How does croup present?

A
  • peak incidence 6 months - 3 years
  • more common in autumn
  • stridor
  • barking cough (worse at night)
  • fever
  • coryzal symptoms
  • increased work of breathing
219
Q

ENT

What is the management of croup?

A

Single dose of oral dexamethasome (or prednisolone)
Emergnecy: high-flow oxygen, nebulised adrenaline

220
Q

ENT

What is the most common causative organism of croup?

A

Parainfluenza viruses

221
Q

ENT

What is the most common causative organism of tonsillitis?

A

Streptococcus pyogenes

222
Q

ENT

How does tonsillitis present?

A

Swollen, red tonsils, pus may be present, may have a fever

223
Q

ENT

What is the management of tonsillitis?

A

If bacterial suspected, penicillin-like antibiotics

224
Q

Neurology

What is cerebral palsy?

A

A group of motor impairment syndromes secondary to non-progressive lesions or anomalies in the brain, arising in the early stages of development

225
Q

Neurology

How does cerebral palsy cause undernutrition?

A

Inadequate intake as a result of self-feeding inadequacy and/or oro-motor coordination difficulties

Dystonia:
* extensor patterns, limiting oral movements becoming stereotyped and abnormal
* tactile hypersensitivity may be greatest around the mouth

Postural deformity: control of head/trunk/compression abdomen
Drug treatment: baclofen/diazepam/tone/sedation, anticonvulsants/sedation have an effect on appetite
Impaired hand function
Immobility
Vision impairment
Deafness
GORD

226
Q

Neurology

What are the consequences of undernutrition in cerebral palsy?

A

Poor growth
Reduced muscle strength
Poor circulation due to reduced activity
Increased susceptibility to infection

227
Q

Neurology

What are the causes of cerebral palsy?

A

Antenatal (80%): cerebral malformation, congenital infections (rubella, toxoplasmosis, CMV)
Intrapartum (10%): birth asphyxia/trauma
Postnatal (10%): intraventricular haemorrhage, meningitis, head trauma

228
Q

Neurology

How does cerebral palsy present?

A
  • abnormal tone early infancy
  • delayed motor milestones
  • abnormal gait
  • feeding difficulties
  • learning difficulties
  • epilepsy
  • squints
  • hearing impairments
229
Q

Gastroenterology

How does malrotation/volvulus present?

A
  • Neonate (3-7 days old)
  • Bilious vomiting, abdominal distension
230
Q

Gastroenterology

How is malrotation diagnosed?

A

Upper GI contrast study

231
Q

Gastroenterology

How does Hirschsprung’s disease present?

A
  • More common in males
  • Associated with Down’s syndrome
  • Failure or delay to pass meconium in the neonatal period
  • Constipation or abdominal distension in older children
232
Q

Gastroenterology

What investigations should be performed for Hirschsprung’s disease?

A

Abdominal XR
Gold standard for diagnosis = rectal biopsy (aganglionic segment of the bowel)

233
Q

Gastroenterology

What is the management of Hirschsprung’s disease?

A

Rectal washouts and bowel irrigation
Surgery to affected segment of the colon

234
Q

Gastroenterology

How does meconium ileus present?

A

Delayed passage of meconium and abdominal distension
Majority have cystic fibrosis

235
Q

Gastroenterology

How does necrotising enterocolitis present?

A

usually pre-term infant
abdominal distension
bilious vomiting

236
Q

Immunisation schedule

What immunisations are given at 2 months old?

A

6 in 1
Oral rotavirus
Men B

237
Q

Immunisation schedule

What immunisations are given at 3 months old?

A

6 in 1
Oral rotavirus
PCV

238
Q

Immunisation schedule

What immunisations are given at 4 months old?

A

6 in 1
Men B

239
Q

Immunisation schedule

What immunisations are given at 12-13 months old?

A

HiB/Men C
MMR
PCV
Men B

240
Q

Immunisation schedule

What immunisations are given at 2-8 years?

A

Annual flu vaccine

241
Q

Immunisation schedule

What immunisations are given at 3-4 years?

A

4 in 1
MMR

242
Q

Immunisation schedule

What immunisations are given at 12-13 years?

A

HPV

243
Q

Immunisation schedule

What immunisations are given at 13-18 years?

A

3 in 1
Men ACWY

Phase 3a (10 decks)

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