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4th Year > Paediatrics > Flashcards

Paediatrics Flashcards

Paediatrics core conditions questions

1
Q

Definition of chronic constipation

A

2 or more of the following in last 8 weeks:

  • Less than 3 bowel movements a week
  • 1 episode of incontinence a week
  • Stools blocking toilet
  • Stool palpable in abdomen
  • Retentive posturing/ with-holding behaviours
  • Painful defecation
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2
Q

What percentage of children are affected by constipation?

A

5-30%

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3
Q

What percentage of constipation is idiopathic?

A

90%

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4
Q

Red flags for constipation- action taken

A

Don’t treat constipation, refer

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5
Q

Red flags for constipation

A
  • Failure to pass meconium within 48h of birth
  • ‘Ribbon stools’ suggests anal stenosis
  • Failure to thrive
  • Gross abdominal distension
  • Lower limb neurology
  • Urinary incontinence
  • Signs of spina bifida (sacral dimple, naevi, hairy patch)
  • Abnormal anorectal anatomy
  • Perianal bruising/ fissures (?sexual abuse)
  • Perianal fistulae/ abscesses
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6
Q

Amber flags for constipation: action performed

A

Treat constipation and initiate further relevant Ix

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7
Q

Amber flags for constipation

A

Faltering growth
? Maltreatment
Peri-anal streptococcal infection

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8
Q

When should a referral be made for constipation not responding to treatment

A 
4 weeks (under 1s)
3 months (older children)
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9
Q

First line treatment for constipation

A

Polyethylene glycol 3350 + Electrolytes (Movicol Paediatric Plain)

Dose escalation over 2 weeks if impaction

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10
Q

Second-line add-ins for constipation

A

Stimulant laxatives e.g. Sodium picosulfate, Bisacodyl, Senna, Docusate

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11
Q

Which medications should only be added for impaction when everything else has failed?

A

Rectal medications/ enemas e.g. Sodium citrate

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12
Q

Signs suggesting hypernatraemic dehydration in Gastroenteritis

A 
Jittery movements
Increased muscle tone
Hyperreflexia
Convulsions
Drowsiness or coma
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13
Q

When may stool MC+S be indicated in gastroenteritis?

A 
Sepsis
Blood or mucous in stools
Immunocompromised
Caught abroad
Not improving within 7 days
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14
Q

When are antibiotics indicated for gastroenteritis?

A 
Septicaemia
Salmonella ( under 6 months)
C. difficile
giardiasis
dysenteric shigellosis
dysenteric amoebiasis cholera
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15
Q

Dose of Oral Rehydration Solutions

A

50ml/kg over 4 hours + maintenance

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16
Q

How long does gastroenteritis last?

A

diarrhoea usually lasts for 5–7 days, and in most it stops within 2 weeks

vomiting usually lasts for 1–2 days, and in most it stops within 3 days

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17
Q

Important investigations in gastroenteritis

A

Glucose (children at much higher risk of hypoglycaemia)

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18
Q

Risk factors for Gastro-oesophageal reflux

A 
Cerebral palsy
Neurodevelopmental disorders
Obesity
Family history
Congenital atresia
Pyloric stenosis
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19
Q

Why are infants at a high-risk of reflux?

A
  • Short, narrow oesophagus,
  • Delayed gastric emptying
  • Immature lower oesophageal sphincter that is slightly above rather than below the diaphragm
  • Liquid diet
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20
Q

Indications for investigation in Gastro-oesophageal reflux?

A 
Unexplained feeding difficulties
Distressed behaviours
FTT
Chronic cough
Hoarseness
Pneumonia
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21
Q

Complications of GOR

A 
Oesophagitis
Recurrent aspiration/ pneumonia
Sandifer Syndrome (Dystonic neck posturing)
Frequent OM
Dental erosion
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22
Q

What is posseting

A

Milk coming out of the babies mouth after feeding (only a small amount)

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23
Q

Thickeners for GOR in bottle fed babies

A

rice starch, corn-starch, locust bean gum or carob bean gum

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24
Q

Indications for 4 week trial of a PPI/ H2 antagonist in GOR

A
  • unexplained feeding difficulties (refusing feeds, gagging or choking)
  • distressed behaviour
  • faltering growth
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25
Q

A common complication of viral gastroenteritis

A

Transient lactose intolerance

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26
Q

Extra-abdominal causes of acute abdominal pain in children

A

Lower lobe pneumonia
URTI
Testicular torsion
Hip and spine

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27
Q

Meckel’s diverticulum as a cause of acute abdominal pain- rule of 2’s

A

Is the most common congenital abnormality of the GI tract. Presentation includes PR bleeding, obstruction, volvulus, intussusception, inflammation, perforation

2% of population affected
2% of these are symptomatic
Lesions are 2cm long
Normally 2 feet from the Ileocaecal valve
2/3 have ectopic tissue, of which there are two types (gastric and pancreatic)

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28
Q

In what percentage of children is a structural cause of recurrent abdominal pain identified?

A

10%

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29
Q

Symptoms that suggest organic disease in recurrent abdominal pain

A 
Epigastric pain at night (peptic ulceration)
Jaundice
Haematemesis
Diarrhoea
Weight loss
FTT
Vomiting
Dysuria/ secondary eneuresis
Billous vomiting
Abdominal distension
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30
Q

Abdominal migraine

A

Abdominal pain associated with headaches
Midline pain, vomiting, facial pallor
Common in families with FH of migraine

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31
Q

IBS in children

A

Common when family history or psychosocial issues

  • Abdominal bloating relieved by defecation
  • Explosive stools
  • Feeling of incomplete empyting
  • Constipation alternating with normal stools
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32
Q

Risk factors for Coeliac disease in children

A

T1DM
Thyroid disease
Turner’s syndrome
Family history

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33
Q

Protective factors against coeliac disease in children

A

Breastfeeding alongside gluten introduction

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34
Q

Investigations for Coeliac disease

A

Antibody testing whilst eating gluten:

  • Tissue Transglutaminase (tTGA) antibodies
  • IgA Endomysial antibodies (EMA)

Less reliable in children under 18 months

Other tests:
Endoscopy (villous atrophy)
Ferritin, B12, Hb blood tests

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35
Q

Presentation of colic

A

Paroxysmal crying with legs pulled up, occurring 3+ hours for 3+ days of the week

Suggests:

  • Feeding difficulties
  • Inadequate milk supply
  • Hungry baby
  • Relationships/ bonding issues
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36
Q

Management of colic

A

Advice and reassurance on:

  • Stress reduction with feeding
  • Low allergen diet
  • Allow baby to finish first breast first before beginning second breast
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37
Q

Presentation of a strangulated hernia

A

Vomiting
Irritability
Tachycardia
Oedematous/erythematous skin

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38
Q

Management of umbilical hernias

A

96% will close by 3 months if less than 0.5cm

If still present aged 3-5, unlikely to close so will be repaired surgically for cosmetic reasons

9X more common in black than caucasian children

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39
Q

Presentation of intussusception

A

Paroxysmal SEVERE colicky pain and pallor (particularly around mouth).
Drawing up of the legs
Early profuse vomiting which becomes bile-stained quickly
Refusal of feeds
Dehydration ± shock and pyrexia
Mucoid and ‘redcurrant jelly’ bloody stools (later sign)

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40
Q

Signs of Intussusception

A

Target sign on USS

Dance’s Sign (absence of bowel in right lower quadrant)

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41
Q

Why is jaundice rare in older infants

A

Most causes are detected upon the Guthrie test

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42
Q

Liver causes of jaundice in children

A
  • CF
  • Wilson’s disease
  • Post-viral hepatitis
  • IBD
  • Primary sclerosing cholangitis
  • A1 antitrypsin deficiency
  • Bile duct lesions
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43
Q

Causes of conjugated jaundice in children

A
  • Biliary atresia
  • Urinary Tract Infection
  • Hypothyroidism
  • Neonatal Hepatitis Syndrome
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44
Q

Mesenteric adenitis presentation and management

A

Abdominal pain (commonly central or in RIF) following a viral infection

  • Fever, malaise, nausea and diarrhoea all common
  • Preceded by viral or bacterial infection ? coryzal symptoms

Treat with PRN analgesia but may require surgical opinion

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45
Q

Risk factors for Pyloric stenosis development

A 
Family history
Primips
Boys
Erythromycin exposure
Prematurity
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46
Q

ABG findings in pyloric stenosis with dehydration

A

Metabolic alkalosis with hypochloraemia and hypokalaemia

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47
Q

USS findings in pyloric stenosis

A

Muscle thickness >4mm
Muscle length > 18mm
Absence of fluid passage past the sphincter, despite gastric peristalsis

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48
Q

Which side is more commonly affected in testicular torsion

A

Left

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49
Q

Why might hormonal injections be used in undescended testes?

A

HCG injections can detect presence of impalpable testes as it induces a rise in serum testosterone

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50
Q

Hepatitis A in children

A

Follows close contact or travel to an endemic area

  • Asymptomatic or mild self-limiting illness with full recovery in 2-4 weeks
  • Symptomatic treatment ± - Human Normal Immunoglobulin (HNIG) prophylaxis for close contacts
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51
Q

Hepatitis B and C in children

A

May be acquired in travel to areas with high-prevalence e.g. Sub-Saharan africa, South america, Far east
- May be acquired from maternal infection, blood products

Hep B is normally self resolving in older children. In younger children it may symptomatic but risk of chronic disease is 90%

Hep C is slower and more chronic however 75% will inherit chronic disease

  • Pharmacological management reduces the risk of cirrhosis and hepatocellular carcinoma and liver failure.
  • Pegylated Interferon alpha-2a (blocks viral protein synthesis) or antivirals (Lamivudine)
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52
Q

Autoimmune Hepatitis

A

May present as an acute or chronic hepatitis, or in a similar way to cirrhosis. Corticosteroid management is needed. Some children may need a liver transplant.

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53
Q

Fulminant hepatitis

A

Associated most commonly with paracetamol overdose causing necrosis and loss of liver function. LFTs and clotting are deranged, cerebral oedema occurs. Treat by managing blood glucose, haemorrhage (Vit K, FFP, Cryoprecipitate), and preventing sepsis

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54
Q

Medical conditions associated with diabetes in children

A 
Family History- PATERNAL > maternal
HLA-DR3/4 genes
Hypothyroidism
Addison’s Disease
Coeliac Disease
Rheumatoid Arthritis
Cystic Fibrosis
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55
Q

Maturity-Onset Diabetes of the Young (MODY)

A

Represents 5% of all diabetes in white children
Is an autosomal-dominant presentation
MODY3 most common subtype and is similar to T2DM

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56
Q

Blood glucose diagnosis of Type 1 diabetes

A

Random >11 mmol/L

Fasting > 7 mmol/L

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57
Q

Blood glucose control targets in T1DM

A

4-7 mmol/L before meals/ waking
5-9 mmol/L after meals

HbA1c 48mmol/mol (6.5%)

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58
Q

Basis of insulin calculations for T1DM

A
  • 1U reduces blood glucose by 5mmol/L when over 7mmol

- 1U accounts for 10g of carbohydrates consumed

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59
Q

Important complications of DKA in children

A 
Cerebral oedema
Leucocytosis
Infection
Creatinine
Hyponatraemia
Ketonuria
Hypokalaemia
VTE
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60
Q

Growth adjustment considerations to make in premature babies

A

Should reach normality in:
HC at 18 months
Weight at 24 months
Height at 40 months

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61
Q

Weight change in first week of life

A

Babies may lose up to 10% weight in first week of life

Normally re-gained by 3 weeks

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62
Q

NICE recommendations for identifying faltering growth/ FTT:

A
  • Fall across 1+ weight centiles if birth weight below 9th centile
  • Fall across 2+ weight centiles if birth weight between 9th and 91st centiles
  • Fall across 3+ weight centiles if birth weight above 91st centile
  • Current weight below 2nd centile regardless of birth weight
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63
Q

When should children be admitted for FTT?

A

If under 6 months and severe FTT

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64
Q

Most common enzyme deficiency in Congenital Adrenal Hyperplasia

A

21 Hydroxylase (needed for cortisol synthesis; leads to elevated ACTH and testosterone production)

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65
Q

Metabolic disturbances in Congenital Adrenal Hyperplasia

A 
Raised 17⍺ Hydroxyprogesterone
Low Na+
High K+
Metabolic Acidosis
Hypoglycaemia
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66
Q

Acute Adrenocortical Crisis

A

Vomiting, dehydration, abdominal pain, lethargy

Treat with hydrocortisone, saline, glucose, fludrocortisone

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67
Q

Presentation and Management of Congenital Adrenal Hyperplasia

A

Female genital virilisation
Penis enlargement and precocious puberty in boys
Tall stature (non-salt losers)
muscular build, adult body odour, pubic hair

Requires lifelong glucocorticoid treatment to suppress ACTH and surgical correction of ambiguous genitalia

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68
Q

Which gene promotes formation of male genitalia (and if not present, female genitalia are formed)?

A

SRY gene

Production of Anti-Mullerian hormone occurs

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69
Q

Causes of Disorders of Sexual Development/ Ambiguous genitalia in genetic females

A

CAH- virilisation

May have:
Clitoral hypertrophy of any degree
Vulva with single opening

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70
Q

Causes of Disorders of Sexual Development/ Ambiguous genitalia in genetic males

A

Androgen insufficiency
Gonadotrophin insufficiency e.g. Prader-Willi, Congenital Hypopituitarism, Ovotesticular disorder

May have:
Severe hypospadias with bifid scrotum
Undescended testes with hypospadias
Bilaterally non-palpable testes in a full-term male infant

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71
Q

Definition of precocious puberty

A

Puberty beginning before:

  • 8 in girls
  • 9 in boys
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72
Q

Path of puberty in males

A

Testicular enlargement first sign
Growth spurt 18 months later
Pubic hair development

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73
Q

Puberty in females

A

Breast development first sign
Menarche follows ~2.5 years after breast development (at stage 4 most commonly)
Pubic hair development

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74
Q

Causes of Gonadotrophin-Dependent precocious puberty

A

90% idiopathic due to premature activation of Hypothalamic - Pituitary axis

Rare causes: CNS tumours/ pathology

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75
Q

Causes of Gonadotrophin-Independent precocious puberty

A 
Production of sex hormones from excess steroids
Familial or Idiopathic (usual cause in females)
Gonadal tumour in males
Stress
CNS tumours
Craniopharyngioma
Thyroid disorders
Meningoencephalitis
21-Hydroxylase Deficiency (CAH)
McCune Albright Syndrome
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76
Q

Delayed puberty definition

A

Absence of puberty features by:
- 14 in girls
15 in boys

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77
Q

What is Tanner Stage 1 of puberty?

A

No puberty occurred

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78
Q

Low gonadotrophin causes of Delayed puberty (hypogonadotropic hypogonadism)

A 
o	CF
o	Severe asthma
o	Crohn’s Disease
o	Organ failure
o	Anorexia nervosa
o	Starvation
o	High exercise levels
o	Panhypopituitarism
o	IC tumours
o	Kallmann Syndrome
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79
Q

High gonadotrophin causes of (hypergonadotropic hypogonadism)?

A

Klinefelter’s Syndrome
Turner Syndrome
Gonadal damage

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80
Q

Foetal thyroid function

A

Reverse T3 production (largely inactive)

Surge in TSH leads to high T3 and T4 at birth

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81
Q

Features of acquired hypothyroidism specific to children

A

Growth Failure
Delayed puberty
Slipped upper femoral epiphysis
Learning difficulties

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82
Q

Conditions associated with acquired hypothyroidism

A

Down’s and Turner’s Syndromes

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83
Q

Features of Congenital Hypothyroidism specific to children

A 
Failure to thrive and delayed development
Feeding problems
Constipation
Reduced crying
Prolonged jaundice
Coarse facies
Umbilical hernia
Cold, mottled dry skin
Narrow palpebral fissures
Depressed nose bridge
Swollen eyelids
Large fontanelles
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84
Q

Biochemical defect in Phenylketonuria (PKU)

A

High phenylalanine due to deficiency of Phenylalanine Hydroxylase enzyme or its Biopterin co-factor

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85
Q

Features of phenylketonuria

A

Fair hair, eczema, musty odour, developmental delay, mental impairment, fits, eczema, microcephaly

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86
Q

Foods to avoid/ restrict in phenylketonuria

A

Meat, dairy, rice, pasta, aspartame

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87
Q

Definition of short stature

A

Height 2SD below age-adjusted mean- often below 2nd or 3rd centile

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88
Q

Most common cause of short stature

A

Constitutional (80%)

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89
Q

Indications for Somatropin (Synthetic Growth hormone in Short stature

A

Somatropin increases growth VELOCITY to 50% of baseline within first year of treatment

o Have GH deficiency
o Have Turner’s
o Have Prader-Willi
o Have CKD
o SFGA with subsequent growth failure at 4 or older
o Short stature homeobox-containing gene deficiency

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90
Q

NICE definitions of obesity

A
  • BMI >91st centile – Overweight
  • > 98th centile – Obese
  • > 99.6th centile – severely obese
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91
Q

Consequences of obesity in children

A

Slipped Upper Femoral Epiphyses
Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs)
Musculoskeletal pains
Poor self-esteem, bullying
sleep apnoea
benign intracranial hypertension
increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease

etc.

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92
Q

Indications for drug treatment of obesity in children (Orlistat)

A

Over 12, significant physiological or psychological co-morbidities

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93
Q

Age which febrile seizures occur

A

6 months to 6 years

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94
Q

Features of a Simple febrile seizure

A 
Isolated tonic-clonic rhythmic seizure activity
Lasts LESS than 15 minutes
Complete recovery within 1 hour
No recurrence in 24 hours
No recurrence in the same illness
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95
Q

Features of a Complex febrile seizure

A

Any of:

Lasts longer than 15 minutes
Focal seizure activity
Incomplete recovery within 1 hour
Recurrence within 24 hours
Recurrence within the same illness
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96
Q

Symptoms seen in a simple febrile seizure

A 
Lasts 2 -3 minutes
Rolling back of the eyes
Foaming at the mouth
SOB, pallor, cyanosis
Post-ictal drowsiness lasting less than 1 hour
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97
Q

Fever- temperature in febrile seizures

A

38 degrees

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98
Q

Reasons to consider hospital admission after febrile seizure

A 
First febrile seizure 
Seizure lasting over 15 mins 
Focal seizure 
Seizure recurring within same febrile illness within 24 hours 
Incomplete recovery after one hour 
Child under 18 months
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99
Q

Antenatal risk factors for cerebral palsy

A

Chorioamnionitis
Maternal respiratory/ urinary infection
TORCH infection
Preterm birth (risk of periventricular leukomalacia)

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100
Q

Perinatal risk factors for cerebral palsy

A 
Placental abruption
Hypoxic-Ischaemic birth injury
Neonatal encephalopathy
Neonatal sepsis
Low birth weight
Low APGAR score at birth
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101
Q

Postnatal risk factors for cerebral palsy

A 
Meningitis/ Encephalitis
Head Trauma
Hypoglycaemia
Hydrocephalus
Hyperbilirubinaemia
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102
Q

General features of Spastic Cerebral palsy

A 
Most common types
UMN lesions (pyramidal, corticospinal)
Brisk tendon reflexes and extensor plantar responses
Velocity-dependent tone
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103
Q

Hemiplegic spastic cerebral palsy

A

Affects either hand or leg (monoplegia), or both unilaterally

  • Tiptoes walking
  • Circumduction gait
  • Growth arrest in extremities
  • Pronated forearm and fisting
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104
Q

Diplegic spastic cerebral palsy

A

Commonly caused by periventricular leukomalacia
All four limbs affected but to a lesser extent than with quadriplegia
- Arm deficits are greater with functional use
- Scissoring gait

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105
Q

Quadriplegic spastic cerebral palsy

A

The most severe spastic CP

  • Microcephaly with poor head control
  • Seizures
  • Opisothonus
  • Moderate to severe intellectual impairment
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106
Q

Ataxic cerebral palsy

A

Early trunk and limb hypotonia
Impaired force, rhythm and accuracy of movements
Delayed motor and intellectual development
Behavioural and communication problems
Bladder and bowel dysfunction

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107
Q

Dyskinetic cerebral palsy

A 
Features abnormal recurring movement disorders
Commonly caused by HIE and Kernicterus
- Floppiness
- Poor trunk control
- Delayed motor development

3 patterns: Athetosis, Dystonia, Chorea

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108
Q

Chorea-pattern cerebral palsy

A
  • Irregular sudden non-repetitive movements

- Reduced tone

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109
Q

Dystonic-pattern cerebral palsy

A

Involuntary and sustained muscle contractions

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110
Q

Athetosis- pattern cerebral palsy

A

Slow ‘writhing’ distal movements e.g. finger fanning

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111
Q

Childhood Absence Epilepsy

A

Common between 5 and 12 years of age
May be triggered by hyperventilation
Automatisms common e.g. lip smacking, eyelid flickering, staring
Episodes lasting 5-20 seconds

Usually remit in adolescence without treatment

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112
Q

Juvenile Myoclonic Epilepsy

A

Most common in teenage girls
Common early morning
Tonic-clonic seizures, absence seizures

40% are photosensitive, also triggered by sleep deprivation and alcohol

Rx: Usually requires lifelong antiepileptics

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113
Q

Infantile spasms and West Syndrome

A

Infantile Spasms:
Common at around 5 months of age
Head nodding and arm-jerk attacks
Occur every 3-30 seconds

West Syndrome:
As above, plus motor regression and typical EEG pattern

Rx: Prednisolone 1st line, Vigabatrin 2nd line

114
Q

Childhood Epilepsy with Centro-Temporal Spikes (CECTS)/ BECTS/ Benign Rolandic Seizures

A

Peak at 9-13 years
Are nocturnal
Typically last less than 5 minutes
Hemifacial paralysis and paraesthesia, salivation/ drooling

115
Q

Medications available for migraines

A

Simple analgesia
Anti emetics in over 12s (Domperidone, Prochlorperazien)
Triptans in over 6
Prophylactic Propanolol, Topiramate, Pizotifen

116
Q

Pharmacological treatment options for Tics (and short-term for Tourette’s)

A

Risperidone, Clonidine

117
Q

Inheritance pattern of Duchenne Muscular Dystrophy

A

X Linked Recessive

Deficiency of Dystrophin protein

118
Q

When is daytime continence usually achieved

A

24-48 months

119
Q

When is night continence achieved

A

3-4 years

120
Q

Over what age may Enuresis alarms be considered

A

7 years

Continue use until 2 dry weeks

121
Q

Asymptomatic bacteruria

A

10^5 Colony Forming Units/mL without any symptoms of UTI

122
Q

What is a MCUG- when used

A

Micturating Cysturethrogram

Used in under 1s to diagnose Vesico-ureteric reflux in recurrent UTI. The child is catheterised and given prophylactic antibiotics; scanned with contrast whilst urinating

Commonly only performed in under 1’s

123
Q

What is a DMSA scan

A

Di-mercaptousuccinic acid Scintigraphy Scan

Normally performed 6 months after acute infection, it detects renal scarring damage by injection of radioisotope and then scanning.

124
Q

What is the most common cause of AKI in children

A

Haemolytic Uraemic Syndrome

125
Q

Most common causes of HUS

A

Gastroenteritis- E coli 0157 or Shigella

126
Q

Triad of features in HUS

A

AKI
Thrombocytopaenia
Microangiopathic Haemolytic Anaemia (Coomb’s Negative)

127
Q

What is an early sign of HUS

A

High blood LDH

128
Q

Key signs of HUS

A

Profuse, Bloody Diarrhoea

Followed by Fever, Abdo pain, vomiting, Oliguria

129
Q

Triad of features in Nephrotic Syndrome

A

Proteinuria
Oedema
Hyperlipidaemia

130
Q

Most common cause of Nephrotic Syndrome

A

Minimal change nephropathy

131
Q

Symptoms of Nephrotic syndrome

A 
Peri-orbital oedema
Limb/ scrotal/ vulval oedema
Ascites
SOB
Cloudy urine with protein casts
132
Q

Indications for renal biopsy in children with haematuria

A

Normal renal function
Significant persistent proteinuria
Recurrent macroscopic haematuria
Abnormal complement levels

133
Q

Definition of haematuria

A

10 RBCs per high power field

134
Q

Diagnostic criteria for eczema

A

Itching plus 3 from:

  • Age appropriate distribution
  • Personal hx/ 1st degree FH if under 4
  • Dry skin in last 12 months
  • Asthma or allergic rhinitis
  • Onset under 2
135
Q

Treatment of impetigo

A

Fusidic acid/ Mupirocin

Oral e.g. flucloxacillin if severe/ Bullous

136
Q

What condition is Gower’s Sign associated with

A

Duchenne Muscular Dystrophy

Patient has to use arms to ‘walk up’ their body- its a sign of proximal muscle weakness

137
Q

Common precipitants of Stevens-Johnson Syndrome

A 
Allopurinol
Anticonvulsants
Sulphonamides
NSAIDs
Penicillins
Imidazole
Antifungals
Sertraline
138
Q

Most common organisms of septic arthritis in neonates

A

Group B Streptococci

Streptococcus pyogenes

139
Q

Most common organism of septic arthritis in older children

A

Staphylococcus aureus

Haemophilus influenzae

140
Q

Antibiotics for Septic Arthritis: empirical prescribing

A

Flucloxacillin 2 weeks IV
Clindamycin if penicillin allergic

Vancomycin: MRSA involved
Ceftriaxone/ Cefotaxime: Gonococcal or gram negative infection

141
Q

Kocher Criteria for septic arthritis

A

Non- Weight Bearing
ESR >40
Temperature 38.5+
WCC 12000 cells/mm3 +

1 present: 3% risk
2 present: 40% risk
3 present: 93% risk
4 present: 99% risk

142
Q

Barlow Manoeuvre

A

Detects an unstable hip by DISLOCATING it (Barlow Breaks)

Hip dislocated inferiorly with the thumb and usually clicks if positive

143
Q

Ortolani Manouevre

A

Relocates a subluxed or partially dislocated hip

Test is negative if dislocation is irreducible

144
Q

Which babies require an ultrasound at 6-8 weeks for DDH

A 
Those which are still breech by 36 weeks
First degree relative with hip problems as a child
Breech presentation at 36 weeks
Twins
Prem
Hip feels unstable
145
Q

Management of DDH

A

Bracing with a Pavlik Harness for children under 6 months

Surgery/ open reduction thereafter, or if the bracing fails

146
Q

Joints most commonly affected by septic arthritis in children

A

Knee > Hip > Ankle

147
Q

Common precipitating infections for Transient Synovitis/ Irritable hip

A

Viral URTIs

Gastroenteritis

148
Q

Osteochondritis dissecans

A

Cracks in the cartilage due to AVN

  • Pain and swelling of joint
  • Locking during movement
149
Q

Chondromalacia patellae

A

Overuse cartilage injury

- Runner’s Knee

150
Q

Osgood- Schlatter Disease

A

Inflammation of the patellar ligament at the tibial tuberosity

  • Painful bump below the knee, worse with activity (running, jumping)
  • Most commonly males 10-15
151
Q

Red flags of a limping child

A
  • Pain waking at night (malignancy)
  • Redness, swelling or stiffness of the joint or limb (infection or inflammatory joint disease)
  • Weight loss, anorexia, fever, night sweats or fatigue (malignancy, infection or inflammation)
  • Unexplained rash or bruising
  • Limp and stiffness worse in the morning
  • Severe pain, anxiety and agitation after a traumatic injury (compartment syndrome)
152
Q

Management of Perthe’s Disease

A

Conservative if Under 8 or bone age <6

Otherwise: surgery- osteotomy
Physio and strengthening

153
Q

Reactive arthritis

A

Transient joint swelling following an enteric infection e.g. Salmonella, campylobacter etc.

  • Low fever plus joint swelling
  • NSAIDs
154
Q

XR findings in Slipped Upper Femoral Epiphysis (SUFE)

A

Widening of the growth plate (posteriorly)

155
Q

XR findings in Perthe’s Disease

A

Reduction in epiphysis size and lucency
Fragmentation and destruction
Joint space widening
Loss of shenton’s lines

156
Q

What does a high ANA predict in JIA

A

Uveitis risk

157
Q

Features of Oligoarticular JIA

A

Most common (50%)
1-4 joints affected (called extended if more are subsequently affected)
Knee and ankle most common
Normally girls, under 6

158
Q

Features of Polyarticular JIA

A

5+ joints affected

It may be RF positive or negative

159
Q

Features of Systemic JIA

A 
Arthritis with 2+ weeks of daily fever
Other Sx:
- Rash
- Lymphadenopathy
- Hepatosplenomegaly
- Serositis
- Salmon pink rash
160
Q

Features of Psoriatic JIA

A

Arthritis then Psoriasis
Dactylitis, onycholysis
Normally asymmetrical

161
Q

Features of Enthesitis Related JIA

A

Inflammation at tendon/ ligament sites

162
Q

Features of Iron Deficiency

A

anaemia and fatigue, impaired cognitive development and reduced growth

163
Q

Features of Zinc Deficiency

A

Immune deficiency, acrodermatitis, increased childhood illness and death

164
Q

Features of Iodine Deficiency

A

Causes Goitre, hypothyroidism, growth restriction

165
Q

Features of Vitamin A deficiency

A

Night blindness, immune deficiency, increased childhood illness and death

166
Q

Bloods findings in Ricketts

A

Increased Alk Phos and PTH

Low Calcium and Phosphorus

167
Q

Guthrie Test- what’s included

A
  • Cystic Fibrosis
  • Sickle Cell Disease
  • Congenital Hypothyroidism
  • Phenylketonuria (PKU)
  • Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
  • Maple-Syrup Urine Disease
  • Isovaleric Acidaemia
  • Glutaric Aciduria Type 1
  • Homocystinuria (pyridoxine unresponsive) (HCU)
168
Q

Features of DiGeorge Syndrome (CATCH-22)

A 
C: Cardiac Abnormalities
A: Abnormal face
T: thymic hypoplasia
C: Cleft Palate
H: Hypocalcaemia

22: 22q11 microdeletion

169
Q

What percentage of Down’s Syndrome is due to Meiotic Non-Disjunction

A

94%

170
Q

Which chromosome is normally implicated in a T21 Translocation?

A

Chr 14

171
Q

Most common cardiac issues in Down’s Syndrome

A

VSD or Secundum ASD
Tetralogy of Fallot
Isolated PDA

172
Q

What is a concomitant squint

A

A non-paralytic squint

  • Normally an esotropia
  • Refractive error in one or both eyes, commonly due to a neurodevelopmental delay
173
Q

What is a paralytic squint

A
  • Motor nerve paralysis e.g. due to a SOL

- Squint varies with gaze

174
Q

What is a manifest squint

A
  • Grossly present on observation
175
Q

What is a latent squint

A

A squint that isn’t visible on inspection and is produced by the cover test

176
Q

Which type of squint are more severe

A

Tropias are more severe than phorias

177
Q

Medical conditions associated with Autism development

A

Fragile X
Neurofibromatosis Type 1
Tuberous sclerosis
Phenylketonuria

178
Q

What age must autism be diagnosed before

A

36 months

179
Q

Three domains of Autism

A

Social Interaction Impairment
Language and Communication Skills
Rigidity of Thinking

180
Q

Mainstay of autism treatment

A

Applied Behavioural Analysis (ABA)

  • Stops ritualistic behaviours
  • Improves sleep and social contact
  • Requires 25-30hrs a week to be successful
181
Q

What is Retinopathy of Prematurity associated with

A

High flow O2 use in premature babies

Treated with laser therapy

182
Q

Which conditions are associated with cataracts in children

A

Trisomy 21
Turner’s Syndrome
Neurofibromatosis Type 2

Juvenile cataracts

183
Q

Screening for developmental delay

A
  • Birth Neonatal Examination: Eyes (red reflex), heart, hips, automated screening of hearing
  • Guthrie Screen at 1 Week (PKU, Hypothyroidism, CF, Hb-opathies, Acylcarnitine)
  • 8 week general GP examination
  • 4-5 years (orthoptist)
  • School Entry: Height and weight, hearing
184
Q

Which medication may be offered short term for Conduct Disorder or ODD in children?

A

Risperidone

185
Q

Monitoring and side effects of Methylphenidate

A

Initial BP, height and weight, ECG

SEs: Growth restriction (1%), loss of appetite

186
Q

When is attachment behaviour maximal

A

18-36 months

187
Q

Average birth weight of a child

A

3.3kg

188
Q

Average head circumference (HC) of a child at birth

A

35 cm

189
Q

VACTERL Conditions

A 
Vertebral
Anorectal
Cardiac
Tracheo-Oesophageal
Renal
Limb
190
Q

Symptoms of anxiety in children

A 
Dizziness
Fainting
Rapid Breathing
Butterflies
Nausea
Sweating
Palpitations and Tachycardia
Recurrence of thought
191
Q

T waves on paediatric ECG

A

Upright for first week of life

Inverted until adolescence

192
Q

Axis of paediatric ECG

A

May be Right axis deviation

193
Q

QRS complex in paediatric ECG

A

Dominant R waves V1-V3
Shorter QRS

Dominant RV means that if V6 overlaps V5, there is a chance of LVH

194
Q

Features of an Innocent Murmur

A
  • Asymptomatic patient
  • Soft blowing murmur
  • Systolic murmur only
  • Sternal edge (left)
  • Sensitive to position e.g. standing up
  • Small (doesn’t radiate)
  • Single (no associated clicks or gallops)
195
Q

What is Eisenmenger’s Syndrome

A

When the pressure of the Pulmonary artery exceeds the LVH, blood begins to shunt back the other way. Usually appears 9 months after development, and the only treatment is a complete heart-lung transplant.

196
Q

Murmur associated with ASD

A

Systolic murmur and fixed split S2

At upper left sternal edge

197
Q

Murmur associated with VSD

A

Systolic murmur

At lower left sternal edge

198
Q

Murmur associated with PDA

A

Machinery like murmur

199
Q

Murmur associated with coarctation of the aorta

A

Ejection systolic murmur

200
Q

Murmur associated with TGA

A

No murmur, but loud S2

201
Q

Which congenital heart abnormality is associated with Turner’s Syndrome

A

Coarctation of the aorta

202
Q

Which genetic conditions are associated with tetralogy of fallot?

A

Digeorge Syndrome
Foetal alcohol syndrome
Phenylketonuria
22q11 microdeletion syndrome

203
Q

Common causes of neonatal jaundice in first 24 hours

A

Infection (TORCH, sepsis)
ABO incompatibility (developed countries)
Rhesus incompatibility (developing countries)
Hypothyroidism
Hereditary spherocytosis
G6PD deficiency

204
Q

Persistent neonatal jaundice after 2 weeks- most common cause

A

Biliary atresia

205
Q

Physiological jaundice causes

A

Cephalohaematoma
Prematurity
Breastfeeding jaundice/ breastmilk jaundice

206
Q

Kernicterus symptoms

A

High bilirubin levels (360+) where bilirubin crosses the BBB

Lethargy, poor feeding, hypertonicity, opisthonus

207
Q

Investigations of pathological jaundice

A

Transcutaneous Bilirubin first

Serum bilirubin if:

  • 250+ on transcutaneous BR
  • Under 24 hours old
  • Gestational age under 35 weeks
208
Q

Indications for IVIG in jaundice

A

ABO or Rh incompatibility

Rapidly rising serum BR

209
Q

Birth asphyxia typical criteria

A

Cord Blood pH <7.05
APGAR 0-5 at 10 minutes
Hypoxic ischaemic encephalopathy

210
Q

Treament for infantile haemangioma

A

Propanolol (reduces blood flow to the lesion)

211
Q

Treatments for Birth Asphyxia/ HIE

A

Monitor/ manage seizures with CFAM
Therapeutic hypothermia
Fluids (careful of renal impairment)

212
Q

ABO blood group incompatibility

A

Mother usually O, baby A
Can’t be detected antenatally
Do Direct coomb’s test

213
Q

Bronchopulmonary Dysplasia (BPD)

A

Complication of Respiratory Distress Syndrome
Due to pressure/ volume trauma from oxygen therapy

Defined as needing oxygen support past 36 weeks gestational age

214
Q

TORCH infection

A 
Toxoplasmosis
Other- Syphilis, VZV, Parovirus B19
Rubella
Cytomegalovirus
Herpes
215
Q

Talipes Equinovarus features

A

Inversion
Adduction of the forefoot
Inability to evert/ dorsiflex
Equinus deformity

216
Q

Live Vaccines

A
  • Measles (part of MMR)
  • Rotavirus
  • Polio (IPV)
  • Tuberculosis (BCG)
  • (Yellow Fever)
217
Q

Infective organisms of sepsis in children

A

Neonates: Group B streptococcus, Listeria, E. coli

All: Meningococcus, Pneumococcus

218
Q

Amber (intermediate) criteria for assessing illness in children

A

Decreased activity and not responding to normal cues
Nasal flaring
Tachypnoea, increased RR, crackles, reduced O2 sats
Tachycardia
Cap refill 3+ seconds
Reduced urine output
Poor feeding
Dry mucous membranes
Fever, rigors
Limb or joint swelling, on non-weight bearing
Temp 39+ in children 3-6 months

219
Q

Red criteria for assessing illness in children

A 
Pale/ mottled/ ashen/ blue
Not responding to cues
Grunting
Tachypnoea 60+, chest indrawing
Reduced skin turgor
Seizures
Focal neurology
Status epilepticus
Neck stiffness
Bulging fontanelles
Temp 38+ in children under 3 months
220
Q

Key indications for an LP in septic children

A

Infants under 1 month

Infants 1-3 months who appear unwell, or with a WCC <5 or 15+

221
Q

Petechia/ purpura definitions

A

Petechiae: less than 2mm
Purpura: 2-10 mm
Echymosis: 10mm+

222
Q

Idiopathic Thrombocytopenic Purpura: key features

A

2-10 year olds, follows 1-2 weeks after a viral infection

Easy bruising, and a petechial/ purpuric rash over bony prominences
Gum/ nose bleeding

Low platelets (<40 x 10^9/L)

Normally self-resolves but treat if low platelets/ chronic (20%).
- Oral steroids ± IV Ig and venous anti-D

223
Q

Henoch Schonlein Purpura: key features

A

4-6 year olds, follows after infection (mycoplasma, EBV, Strep)

Purpuric rash distributed to buttocks, legs and ankles; becomes raised within 24 hours
Arthritis and arthralgia
Abdominal pain ± GI bleeding
Scrotal pain
Glomerulonephritis

Diagnosis normally clinical but may need to r/o sepsis

Predominantly supportive treatment (NSAIDs and fluids), consider steroids if severe
- Children should ideally get follow up 6-12 months later to detect renal complications (25%)

224
Q

Chickenpox- viral features

A

Incubation 10-21 days
Infectious 1-2 days before rash
Infectious until lesions crusted over (exclude from school until then)

225
Q

Most common cause of Ophthalmia neonatorum; treatment

A

Chlamydia

Treat with saline bathing

226
Q

Features of IgE mediated food allergies

A

Acute with rapid onset

Urticaria, angioedema, colic, rhinorrhoea, cough, bronchospasm

227
Q

Features of Non-IgE mediated food allergies e.g. Cow’s Milk Protein Allergy

A 
Atopic eczema
Reflux
Colic
Loose mucosal/ bloody stools
Constipation
228
Q

Investigations for Infectious mononucleosis

A

Over 12’s:
FBC- differential WCC shows 20%+ atypical lymphocytes
Monospot test
EBV serology

229
Q

Criteria for Kawasaki Disease

A

Fever (39+, for 5 days, plus):

  • Bilateral non-exudative conjunctivitis
  • Cervical lymphadenopathy
  • Mucous Membrane changes (cracked lips, strawberry tongue, mouth/ pharyngeal inflammation)
  • Polymorphous rash
  • Extremity changes (arthralgia, palmar erythema, swelling)
230
Q

Investigations and Management of Kawasaki Disease

A

Echocardiogram (detect Coronary A. aneurysm)
Bloods (raised platelets, bilirubin, AST)
Urinalysis- sterile pyuria/ proteinuria

High-dose aspirin for 6 weeks (then antiplatelet dose)
IVIG within 10 days if possible

231
Q

Measles: clinical features

A

Cough, coryza and conjunctivitis; plus Koplik’s spots
Incubation period of 10 days

Maculopapular rash starts behind ears and spreads over the body- becoming blotchy and confluent

No school 4 days from rash onset

232
Q

Complications of measles

A 
Subacute sclerosing panecephalitis (SSPE)
Encephalitis
Pneumonia
Otitis Media
Diarrhoea
Myocarditis
233
Q

Mumps features

A

infective 7 days before and 9 days after parotid swelling starts
incubation period = 14-21 days

Fever, malaise and muscular pain
Parotid swelling
Orchitis

Supportive management but notifiable disease
No school 5 days from swollen glands

234
Q

Congenital rubella infection features

A 
Sensorineural deafness
Congenital heart disease
Cataracts
Growth retardation
Hepatosplenomegaly
Cerebral palsy
Microphthalmia
235
Q

Rubella: clinical features

A

Incubation 14-21 days
Infectious 5 before to 5 after

Fever with maculopapular rash on face spreading to whole body; lymphadenopathy

No school 4 days from rash onset

236
Q

3 main categories of causes of Iron deficiency anaemia

A

Inadequate intake (diet, cow’s milk, low Vitamin C)
Malabsorption
Blood loss

237
Q

Values for Iron deficiency anaemia, and when does it become symptomatic

A

Neonate – Hb <140g/l
1-12 months – Hb <100g/l
1-12 years – Hb <110g/l

Symptomatic below 60-70

238
Q

Key symptoms of Fe def anaemia

A

Fatigue
Slow feeding
Poor behaviour and intellectual function
Conjunctival/ tongue/ palmar crease pallor

239
Q

Sickle Cell Anaemia: typical symptoms and complications

A

Anaemia ± jaundice
Infection susceptibility
Splenomegaly

Delayed puberty/ growth restriction
Cognitive impairment
Tonsillar hypertrophy
Cardiac enlargement
Heart failure
Renal dysfunction
Gallstones
Leg ulcers
240
Q

Vaso-Occlusive crisis in SCA

A

May be exacerbated by cold, dehydration, stress, hypoxia

  • Dactylitis
  • Mesenteric ischaemia
  • Stroke
  • Acute chest syndrome (respiratory distress)

Fluids, exchange transfusion

241
Q

Thalassaemia clinical features

A

Major is most severe, intermediate less so and minor/ trait is normally asymptomatic. Presentation is:

  • FTT
  • Extramedullar haemopoiesis
  • Skull bossing
  • Osteopaenia
  • Endocrine failure

Treatments: regular transfusions, splenectomy, bone marrow transplant, iron chelators

242
Q

Haemophilias

A

X-Linked Recessive
Haemophilia A more common, F8 deficiency

Higher F8/9 : C ratio indicates a better prognosis

Treatments: Recombinant F8 or F9 ± Desmopressin/ ddAVP for Haemophilia A

Von Willebrands: Autosomal dominant, diagnosed in adolescence. Treat as for haemophilia A

243
Q

Most common childhood brain tumours

A

Astrocytoma (40%)
Medulloblastoma (20%)- cerebellar usually

MRI first line
Surgical excision ± adjunct chemotherapy

244
Q

Neuroblastoma

A

Neural Crest cell tumour

  • Abdominal mass
  • Appetite and weight loss
  • Bone pain
  • Hypertension
  • Skin mets (Blueberry muffin baby)

Ix: USS then CT and MIBG bone scans, Urinary catecholamine levels

245
Q

Wilm’s Tumour

A

Presents before age 5, FH, Edward’s Syndrome, Beckwith- Wiedemann syndrome

  • Abdominal mass ± pain
  • Anorexia
  • Anaemia
  • Haematuria
  • Hypertension

Requires nephrectomy then chemo.

246
Q

Most common leukaemia type in children and its differentiating factors

A

Acute Lymphoblastic Leukaemia (80%)

  • Faster onset
  • Younger children
  • Males affected more (poorer prognosis)
  • No Auer rods
  • Low platelets and prolonged Prothrombin time
247
Q

Leukaemia clinical features

A

Main signs:

  • Anaemia (tiredness, pallor, fever)
  • Thrombocytopaenia
  • Hepatosplenomegaly
  • Lymphadenopathy

Others:

  • Petechiae, purpura, bruising
  • Headaches and vomiting
  • Testicular enlargement
  • Bone pain
248
Q

Hodgkin’s Lymphoma

A

Presence of Reed-Steenberg cells

  • EBV, smoking, immunosuppression, HIV
  • Adolescents

Painless lymphadenopathy plus:

  • B symptoms
  • Cough (airway obstruction)
  • Alcohol induced pain

High ESR carries a poor prognosis

249
Q

Non-Hodgkin’s Lymphoma

A

No Reed-Steenberg cells

  • 5x more common
  • Younger children

Lymphadenopathy plus:
- Palpable abdominal masses (hepatosplenomegaly)
- SOB
Pancytopaenia

250
Q

Moderate acute asthma

A

PEFR 50% + of expected
Saturations under 92%
Able to talk in sentences
Age-related tachycardia and tachypnoea

251
Q

Severe Acute Asthma

A

PEFR 33-50% of expected
Saturations under 92%
Unable to talk in full sentences
Higher tachycardia and tachypnoea

252
Q

Life-threatening Asthma

A 
PEFR <33% of predicted
Saturations under 92%
Cyanosis
Hypotension
Exhaustion
Silent Chest
Tachycardia
253
Q

When can an asthmatic child be discharge

A

Using 6 puffs 4-hourly

Go home with a wheeze plan

254
Q

Most common organism in Bronchiolitis

A

RSV

255
Q

Clinical features of Bronchiolitis

A

Aged 3-6 months peak but can occur under 12 months
Coryzal prodrome 1-3 days

High-pitched cough, tachypnoea, cracles
Fever and poor feeding

256
Q

Indications for admission/ referral in Bronchiolitis

A

RR 60+
Clinically dehydrated
Inadequate intake 50-75%
Saturations <92%

Can consider NG feeding, nasal cannula with humidified oxygen

257
Q

Most common organisms in croup

A

Parainfluenza virus

  • Type 3 most common
  • Type 1 most severe
258
Q

Clinical features of Croup

A

Coryzal phase of rhinorrhoea, ST, cough and fever

Barking cough and stridor, often worse at night

259
Q

Aspects of Westley Score for croup

A 
Chest wall retractions
Stridor
Cyanosis
Level of consciousness
Air entry

Under 3: optimal
8+: severe, consider ICU

260
Q

Management of Croup

A

Dexamethasone/ Budesonide weight-adjusted

Adrenaline 1 in 1000 if severe

261
Q

Causative organism in Epiglottitis

A

Haemophilus influenzae type B

262
Q

Epiglottitis clinical features

A 
Acute onset
Soft whispering stridor with a muffled voice
High fever
Drooling of saliva/ no fluids
Scared
263
Q

XR findings in Epiglottitis

A

Thumb print sign

264
Q

Common organisms in Tonsilitis/ pharyngitis

A

Group A beta-haemolytic streptococci
EBV
Influenzae
Rhinovirus, adenovirus, HSV1, coronavirus

265
Q

When to offer an antibiotic for Tonsilitis

A

Centor score 3+

  • Phenoxymethylpenicillin (Penicillin V)
  • Corticosteroids
266
Q

Indications for a tonsillectomy in children

A

3+ episodes of tonsilitis a year for 3 years
5+ episodes of tonsilitis a year for 2 years
7+ episdoes in a year
Recurrent OM with effusion
Obstructive sleep apnoea

267
Q

Organism for whooping cough

A

Bordatella pertussis

268
Q

Clinical features and management of whooping cough

A

Spasmodic cough (worse at night) with inspiratory whoops
Epistaxis, subconjunctival haemorrhage
Apnoea

Treat with erythromycin in commenced early
Exclude from school for 3 weeks
Vaccinate mothers

269
Q

Best signs of pneumonia in children

A 
High fever (39+)
Tachypnoea

Others: poor feeding, pleurisy, bronchial breathing, prodromal URTI, respiratory distress

270
Q

Antibiotics for pneumonia in children

A

Amoxicillin 1st line
Co-Amoxiclav in neonates

Macrolide if mycoplasma

271
Q

Antibiotic of choice for AOM

A

Amoxicillin

272
Q

Key Neonatal features of cystic fibrosis

A

Meconium ileus (not passed within 48 hours)
FTT
Prolonged jaundice
Distended bowel loops on AXR

273
Q

Features of CF in childhood

A 
Frequent respiratory infections
Bronchiectasis
Persistent loose cough with sputum production
Clubbing
Chest hyperinflation
Nasal polyps
Rectal prolapse
Steatorrhoea
274
Q

Longer term complications of Cystic Fibrosis

A 
Male infertility
Diabetes
Chronic liver disease
Osteoporosis
Vitamin deficiencies
Urinary stress incontinence
275
Q

Sweat test diagnosis of Cystic Fibrosis

A

60 mmol/L +
- Need to be 3-4kg

Other causes of false positives:

  • Eczema
  • Adrenal insufficiency
  • Hypothyroidism
  • Malnutrition
276
Q

What does the Guthrie test detect with regards to CF

A

Immuno-Reactive Trypsinogen

277
Q

CT findings in cystic fibrosis

A

Signet rings (bronchioles are larger than adjacent blood vessels)

278
Q

Infective organisms in cystic fibrosis

A 
S. aureus
H. influenzae
Pseudomonas aueruginosa
Klebsiella
Burkholderia cepacian
Non tuberculous mycobacteria (once get to this stage, can't transplant)
279
Q

Chance of a foreign body passing if below the diaphragm

A

80%

280
Q

Presentation of inhaled foreign body in children

A 
Choking
SOB
Wheeze
Stridor
Refusal to eat
Drooling

4th Year (7 decks)

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