Paeds #1 Flashcards
You are called acutely to the postnatal ward to see a 48-hour-old baby girl.
She was seen the day before by your colleague who performed her
baby-check and found no abnormalities. On arrival you find a baby who
is grunting and cyanotic. All pulses are palpable and there is no murmur
on auscultation of the chest. You transfer her to the neonatal unit where
you find her oxygen saturations are 55% in air.
Which of the following congenital cardiac lesions would be consistent with
these findings?
A. Coarctation of the aorta
B. Eisenmenger’s syndrome
C. Patent ductus arteriosus
D. Tetralogy of Fallot
E. Transposition of the great arteries
E – Transposition of the great arteries
This neonate is clearly unwell. With these features you should be very suspicious
of congenital sepsis or pneumonia so your priority would be to perform blood
cultures, CRP, FBC and chest X-ray. Empirical antibiotics (e.g. amoxicillin and
gentamicin) should be commenced without delay.
These features are also suspicious of a cardiac lesion. Tetralogy of Fallot would
usually not present so early in life and would usually be associated with a pulmonary
stenosis murmur. In transposition of the great arteries the great
vessels are reversed (transposed) with the aorta coming off the right ventricle
and the pulmonary artery off the left ventricle. Affected children are therefore
dependent on the ductus arteriosus to supply oxygenated blood to the systemic
circulation (‘duct dependent’). As the duct closes after birth the baby will
become profoundly cyanotic and acidotic. Chest X-ray shows a characteristic
narrow mediastinum with an egg-on-side appearance of the heart shadow.
The ‘switch operation’ (surgical swapping of the pulmonary artery and aorta)
is required as definitive management.
Coarctation of the aorta also often presents when the ductus closes but this is
not a cyanotic disease and the baby would usually present with shock, poor perfusion
of the limbs distal to the lesion and absent femoral pulses. Eisenmenger’s
syndrome is a cyanotic heart lesion that occurs later in life with reversal of flow
across septal defects due to right ventricular hypertrophy. A patent ductus arteriosus
presents with a loud machinery-like murmur in a child with heart failure.
A 12-year-old boy with a history of type-1 diabetes is seen in the emergency
department. His blood sugar is high and he is breathing much harder than
usual. An arterial blood gas is taken (on air):
pH 7.19
PaCO2 2.8 kPa
Base excess –9
PaO2 14.6 kPa
Normal reference ranges for arterial blood gases:
pH 7.36–7.44
PaCO2 4.7–6.0 kPa, 35–45 mmHg
Base excess +2
PaO2 .10.6 kPa, .80 mmHg (in air)
Which of the following is your interpretation of this blood gas?
A. Metabolic acidosis (uncompensated)
B. Metabolic acidosis with some respiratory compensation
C. Mixed metabolic and respiratory acidosis
D. Respiratory acidosis (uncompensated)
E. Respiratory acidosis with some metabolic compensation
B – Metabolic acidosis with some respiratory compensation
This boy is most likely in diabetic ketoacidosis (DKA) and has a metabolic
acidosis with respiratory compensation. However you do not have a result for
ketones therefore you cannot technically diagnose DKA. He will need aggressive
management as DKA is a life-threatening complication of type-1 diabetes.
Interpretation of blood gas results
pH (the power of hydrogen) is an inverse logarithmic scale. That is, rather than
following a linear pattern, each unit of pH is a 10-fold representation of Hþ
concentration. Therefore a shift from 7.5 to 6.5 is a 10-fold increase in Hþ
concentration. The body normally controls serum pH within a tight range. A
normal intracellular pH is required for the functioning of many enzyme
systems. When blood becomes profoundly acidotic (pH ,7) then cellular
function becomes impossible and death ensues.
An excellent method for interpreting blood gases can be found in the advanced
paediatric life support manual. Three questions should give you the interpretation
of any blood gas.
1. What is the pH?
Assess the pH. Is it acidotic or alkalotic? This is the overall status of the patient,
regardless of compensation.
2. What is the PaCO2
The Henderson-Hesselbach equation tells us that if you mix carbon dioxide
(CO2) with water, acid (Hþ) will be produced. CO2 is a good indicator of ‘ventilation’
and if the pH corresponds with the pCO2 then the anomaly is caused by
a respiratory problem (i.e. a high pCO2 with a low pH is a respiratory acidosis). If
the CO2 does not account for the pH then it is compensating for a metabolic
abnormality.
3. Confirm your findings by assessing the base excess/bicarbonate?
The base excess (i.e. an excess of base HCO3
2) indicates metabolic status. If the
base excess provides a cause for the abnormal pH then this is a metabolic picture
(i.e. a high pH and positive base excess is a metabolic alkalosis).
As a final tip always remember to assess the conditions of the blood gas, i.e.
what inspired oxygen concentration was the patient in, what type of sample
was it (arterial, venous, capillary), was it taken correctly and do the results fit
with the patient’s condition. Also, remember that you can have a ‘mixed’
blood gas, i.e. a mixed metabolic/respiratory acidosis where both the CO2
and the bicarbonate are low (a compensated respiratory acidosis would have
a high bicarbonate).
A 7-year-old girl is referred to the paediatrician as she has started showing
signs of puberty. On examination, she has some breast tissue and sparse
pubic hair, as well as axillary hair. She is growing well and appears to be
starting a growth spurt. Her mother is worried as no one else in her class
has any signs of puberty and she is being teased. She has not started to
menstruate yet. She has no other symptoms and there is nothing else of
note on examination.
What is the most likely cause of her precocious puberty?
A. Congenital adrenal hyperplasia
B. Hypothyroidism
C. Idiopathic
D. McCune–Albright syndrome
E. Pituitary tumour
C – Idiopathic
This girl has true precocious puberty and it is most likely to be idiopathic. Precocious
puberty is defined as the start of puberty in girls under the age of 8 and in
boys under the age of 10. It can be divided into true and pseudo.
In true precocious puberty the course of puberty occurs in a normal synchronous
manner, as in this case, suggesting an intact hypothalamic–pituitary
axis. It is more common in girls and is idiopathic in 80–90% of cases. Other
causes of true precocious puberty include: intracranial pathology such as
tumours (although pituitary tumours are more likely to be associated with
delayed puberty), haemorrhage, hydrocephalus, neurofibromatosis, cerebral
palsy and primary hypothyroidism. Although true precocious puberty is less
common in boys, if it does occur there is more likely to be a central cause and
therefore should be investigated. This would normally involve a brain MRI,
gonadotrophin levels and sex steroid levels.
In pseudo (false) precocious puberty the course of puberty occurs in an abnormal
manner. For example, axillary and pubic hair with a growth spurt is seen in
females but there is no breast budding. Boys may show features of puberty but
still have prepubertal-sized testes. Pseudo precocious puberty is gonadotrophinindependent
and usually extracranial. Causes include adrenal virilizing tumours,
congenital adrenal hyperplasia, Cushing’s syndrome, testicular or ovarian malignancy,
and gonadotrophin-secreting tumours, e.g. hepatoblastoma.
McCune–Albright syndrome is a sporadic genetic condition characterized by
precocious puberty (due to primary ovarian cysts secreting oestradiol), cafe´-
au-lait spots and polyostotic fibrous dysplasia (where normal bone is replaced
by cystic bone growth).
A 9-month-old boy has gastroenteritis. He is febrile and tachycardic. On
examination, he has a normal capillary refill time, a slight reduction in
skin turgor and dry mucous membranes. He is not wetting his nappies as
much as usual.
What percentage of weight do you expect to be lost from dehydration in
this case?
A. 0%
B. 5%
C. 10%
D. 15%
E. 20%
C – 10%
Approximately 70–80% of a child’s body is made up of water. Children with
fever should be assessed for signs of dehydration, such as1:
† Prolonged capillary refill time
† Abnormal skin turgor
† Abnormal respiratory pattern
† Weak pulse
† Cool extremities
A 3-year-old is in clinic and your consultant asks you to assess his
development. You find he demonstrates normal development in all areas.
Which of the following would you expect him not to be able to do?
A. Build a tower of five bricks
B. Copy a circle
C. Feed with a fork
D. Hop on one leg
E. Know his first and last name
D – Hop on one leg
A 3-year-old would be expected to be able to pedal a tricycle but not be able to
hop until they are 4 years old. In fine motor and vision development, a 3-yearold
should be able to copy a circle and build a tower of nine bricks. Languagewise
they would be speaking in at least three-word sentences and would know
their first and last names. They would not be expected to be able to count until
they were 4. Socially 3-year-olds play make-believe, can eat with a fork and can
brush their teeth. They should be being potty-trained and be dry during the day.
A 4-year-old boy presents to the emergency department with tachypnoea
and a fever. He has been vomiting and is passing only small amounts of
dark urine. On examination he is not clinically dehydrated and may even
be a little oedematous around his eyes. He is unable to tolerate oral antibiotics
so you insert a peripheral cannula. Because he is vomiting you
perform routine electrolyte studies while inserting the cannula. A chest
X-ray shows right lower lobe consolidation.
You receive the following blood results:
Na 129 (135–145 mmol/L) K 4.2 (3.5–5.0 mmol/L) Urea 3.2 (1.5–4.5 mmol/L) Creatinine 83 (40–110 mmol/L) pH 7.37 (7.35–7.45) Glucose 4.2 (3.4–5.5 mmol/L)
Which of the following is the most likely cause of the electrolyte
disturbance?
A. Conn’s syndrome
B. Diabetes insipidus
C. Hypovolaemic hypernatraemia
D. Hypovolaemic hyponatraemia
E. Syndrome of inappropriate ADH secretion
E – Syndrome of inappropriate ADH secretion
This child has pneumonia associated with syndrome of inappropriate antidiuretic
hormone (SIADH). Though he is producing small volumes of concentrated
urine this is because of water retention rather than hypovolaemia. In
addition, if he was dehydrated, we may expect a raised urea.
A normal plasma sodium concentration is 135–145 mmol/L. Hyponatraemia is
usually defined as plasma Na ,130 mmol/L and hypernatraemia defined as
plasma Na .150 mmol/L.
You are at a wedding next to your 4-year-old nephew. He is eating a sausage
and suddenly starts coughing vigorously. He is very agitated and continues
to cough. He has been coughing for over a minute and he is now crying
between coughs.
You suspect an inhaled foreign body, which of the following would be your
next course of action?
A. Encourage coughing
B. Five back blows
C. Five chest thrusts
D. Heimlich manoeuvre
E. Rescue breaths
A – Encourage coughing
You may not become a paediatrician but an inhaled foreign body is relatively
common. As a general practitioner, parent or wedding guest you could instantly
become a hero! The vast majority of deaths occur in preschool-aged children.
Food is the most common object but almost anything can cause an obstruction.
If a foreign body is directly visible and accessible within the mouth then it can be
removed but great care has to be taken not to push it further into the airway.
Blind finger sweeps should never be performed.
If a child is coughing, such as in this case, then they should be encouraged as a
spontaneous cough is more likely to be effective than externally imposed
manoeuvres at relieving the obstruction. No further intervention should be
made unless the cough becomes ineffective. An effective breath is defined as
one in which the child is able to speak, cry or take breaths between coughs.
Though appearing much more distressing, it at least confirms a partially open
airway. Performing any kind of procedure may move the foreign object making
a partial obstruction a complete obstruction. If coughing then the child
should be continuously reassessed and never left alone
A 6-month-old girl born in India is referred to you by her general practitioner
as she is not growing along the centiles. She was born on the
50th centile and has now dropped below the 2nd centile despite a good
intake. She has had two chest infections but has never needed to be hospitalized.
On examination, she looks thin but is not pale. Her abdomen is not
distended and is soft on palpation.
What investigation is most likely to give you a cause for her failure
to thrive?
A. Full blood count
B. IgA
C. No investigation necessary
D. Sweat test
E. Thyroid function test
D – Sweat test
This girl is likely to have cystic fibrosis, which is diagnosed with a sweat test. She
was not born in the UK and so would have missed out on the neonatal screening.
A common presentation of cystic fibrosis is failure to thrive (FTT) along with
a history of chest infections.
FTT can be caused by numerous problems:
Non-organic FTT results from various environmental and psychosocial factors:
† Inadequate provision or intake of food
† Family dysfunction, lack of support and difficult parent–child interactions
† Children who are subject to neglect
Organic FTT:
† Prenatal causes
W Premature babies, intrauterine growth retardation
W Maternal infection
W Fetal alcohol syndrome
W Chromosomal abnormalities
† Inadequate intake
W Lack of appetite, seen in iron deficiency anaemia, and chronic infection
W Mechanical problems such as a poor suck or swallow secondary to
hypotonia
W Excessive vomiting caused by metabolic, renal or neurological disease,
or gastroesophageal reflux leading to oesophagitis can lead to food
refusal
† Poor absorption or utilization of metabolites
W Cystic fibrosis due to the lack of pancreatic enzymes
W Coeliac disease causes malabsorption but is unlikely in this case as there
are no other signs such as a distended abdomen or diarrhoea
W Hypothyroidism, diabetes mellitus, inborn errors of metabolism, renal
failure
† Increased metabolic demand
W Hyperthyroidism, congenital heart disease, chronic lung disease, renal
failure
W Malignancy
FTT must be distinguished from constitutionally delayed growth, a variation of
normal growth. Children with short stature resulting from constitutional delay
have a deceleration of growth in the first 2 years that can be confused with
FTT, but then grow parallel to but below the third percentile. In reality children
with failure to thrive would have more than one investigation and you would
most likely include a full blood count, thyroid function tests and a coeliac
screen. However in this case a sweat test is most likely to reveal the cause as
there are no other signs of hypothyroidism, coeliac disease or iron deficiency
anaemia.
A 28-year-old woman has asked the community midwife if it is appropriate
for her to breastfeed.
Which of the following is a contraindication to breastfeeding?
A. Cosmetic breast surgery
B. Mastitis
C. Maternal digoxin therapy
D. Maternal HIV in a developed country
E. Maternal HIV in a developing country
D – Maternal HIV in a developed country
The contraindications to breastfeeding are:
† Breast cancer
† Maternal infection
† HIV in developed country
† Active tuberculosis
† Hepatitis B
† Hepatitis C
† Active herpes infection of the breast
† Infantile galactosaemia
† Maternal medication, e.g. lithium, antimetabolite chemotherapies (not
digoxin)
† Maternal intravenous drug user
Unicef states that ‘Without preventive interventions, approximately one-third of
infants born to HIV-positive mothers contract HIV through mother-to-child
transmission, becoming infected during their mothers’ pregnancy, childbirth
or breastfeeding. The risk of HIV-infection has to be compared with the risk of
morbidity and mortality due to not breastfeeding. Breastfeeding is protective
against death from diarrhoea, respiratory and other infections, particularly in
the first months of life.’ It is for this reason that breastfeeding is recommended
in developing countries despite maternal HIV infection.
A physician needs to understand the benefits of breastfeeding in order to decide
if the benefits of breastfeeding are outweighed by the risks.
The advantages of breastfeeding to the baby are a reduced risk of infections (as
breast milk provides secretory IgA, lactoferrin, peroxidases and lysozymes),
reduced risk of sudden infant death syndrome and less diarrhoeal illnesses.
Advantages to the mother include the fact it is free, it aids the bonding
process, it provides a contraceptive effect (due to high prolactin levels) and
there is a reduced risk of premenopausal breast and ovarian cancers. Babies
fed with artificial feeds are more at risk of necrotizing enterocolitis, urinary
tract infections, gastrointestinal infections, respiratory infections, ear infections,
asthma, eczema and type-1 diabetes
A 12-year-old boy presents to the emergency department with worsening
shortness of breath and a wheeze. You suspect an acute exacerbation of
asthma.
Which of the following peak expiratory flow rates (best or predicted) would
suggest a severe exacerbation of asthma?
A. 75–100%
B. 50–75%
C. 33–50%
D. ,33%
E. ,20%
C – 33–50%
The peak expiratory flow rate (PEF) is often used to help guide diagnosis and
management of asthma. The levels of severity of acute exacerbations of
asthma have been defined by the British Thoracic Society, as follows:
Near fatal asthma Raised PaCO2 and/or requiring mechanical
ventilation with raised inflation pressures
Life-threatening asthma Anyone of the following in a patient with severe asthma: † PEF ,33% best or predicted † SpO2 ,92% † PaO2 ,8 kPa † Normal PaCO2 (4.6–6.0 kPa) † Silent chest † Cyanosis † Feeble respiratory effort † Bradycardia † Dysrhythmia † Hypotension † Exhaustion † Confusion † Coma
Severe asthma Any one of: † PEF 33–50% of best or predicted † Tachypnoea (dependent on age) † Tachycardia (dependent on age) † Inability to complete sentences in one breath
Moderate asthma † Increasing symptoms
† PEF 50–75% of best or predicted
† No features of acute severe asthma
A 4-year-old boy, who was previously fit and well, developed some petechial
spots on his legs after climbing a tree. A few days later, the rash had spread
over his entire body. He had not been any more lethargic than normal and
was eating well. On examination, you note a large bruise on his hip and a
black eye which his mother could not give any explanation for.
Which of the following investigation would be likely to confirm the
diagnosis?
A. Bone marrow biopsy
B. Clotting screen
C. Full blood count
D. Skeletal survey
E. No investigation required
C – Full blood count
This boy most likely has idiopathic thrombocytopenia (ITP) which is diagnosed
by a very low platelet count (,40 109/L) with no evidence of anaemia and a
normal white cell count. Unexplained or extensive bruising in any child is
worrying.
Causes of bruising include:
† Trauma (accidental or non-accidental)
† Clotting disorders
† Platelet disorders
† Malignancy
Non-accidental injury cannot be fully ruled out in this case as the bruises are not
accounted for and a thorough history would need to be taken. It is unusual to
have a widespread petechial rash with physical abuse, although one may be
seen over the face and neck from strangulation. A diagnosis of non-accidental
injury should certainly not be made until other causes had been ruled out.
Leukaemia and other malignancies can present with unexplained bruising,
however the child in this case is very well and there are no other symptoms
that would suggest an underlying malignancy.
A 5-year-old girl has suffered from arthritis for the last 6 months. It only
affects her knees and elbows, and she has never had sacroiliac tenderness
or nail problems. She has no rash or fever, but she does have regular ophthalmology
follow-up due to her increase risk of developing uveitis.
Blood tests reveal that she is antinuclear antibody positive but rheumatoid
factor negative.
What type of arthritis is she most likely to have?
A. Enthesitis
B. Oligoarticular juvenile idiopathic arthritis
C. Polyarticular juvenile idiopathic arthritis
D. Psoriatic arthritis
E. Systemic juvenile idiopathic arthritis
B – Oligoarticular juvenile idiopathic arthritis
Juvenile idiopathic arthritis (JIA) is defined as arthritis of unknown aetiology
beginning before the 16th birthday and persisting for at least 6 weeks where
other known conditions are excluded. JIA is categorized into:
† Systemic JIA
† Oligoarticular JIA
† Polyarticular JIA
† Psoriatic arthritis
† Enthesitis-related arthritis
Oligoarthritis affects four joints or fewer, accounts for 60% of all JIA and is seen
most commonly in girls below 6 years. It affects the medium-sized joints such as
the elbows and knees, and is associated with anterior uveitis (inflammation of
the middle eye) as well as having the highest association with the antinuclear
antibody (ANA).
Polyarticular JIA affects five or more joints and often affects the small joints of the
hands and feet. This girl is unlikely to have polyarticular arthritis as it is seen more
commonly in older girls and rheumatoid factor is often positive. The cervical
spine and temporomandibular joints can also be affected.
An 8-year-old boy presents to the emergency department with abdominal
pain, fever, nausea and some diarrhoea. The pain is poorly localized,
although on palpation you feel he is most tender in the right lower quadrant
and he demonstrates guarding over this area. There are no obvious
swellings.
What is the most likely cause for his abdominal pain?
A. Appendicitis
B. Gastroenteritis
C. Inguinal hernia
D. Mesenteric adenitis
E. Torsion of the testis
A – Appendicitis
Appendicitis is common in children and is caused by inflammation and swelling
of the appendix. The lumen to the appendix becomes blocked and the appendiceal
wall subsequently becomes oedematous and inflamed. Initially, the pain is
poorly defined and periumbilical, but moves to the right iliac fossa (RIF) due to
inflammation of the peritoneum over the appendix. Nausea, anorexia, vomiting
and a low grade fever may also be present. The child with appendicitis typically
lies still and there is usually tenderness and guarding over the McBurney’s point
(one-third of the way between the anterior superior iliac spine and the umbilicus).
There are a number of other signs suggesting peritoneal irritation in
the RIF:
Rovsing’s sign ! pain in the RIF in response to left-sided palpation
Cough sign ! pain in the RIF after a voluntary cough
Obturator sign ! pain on internal rotation of the flexed right thigh
caused by an inflammatory mass overlying the
psoas muscle
Perforation is a complication of appendicitis and is more common in younger
children because of the non-classical presentation and late diagnosis. Appendicitis
can present differently to the symptoms given above. The pain may be elsewhere
in the abdomen or, in children who are very young, abdominal pain is
often not obvious. Loose stools occur in 10% of cases due to a pelvic or retrocaecal
appendix. Urinary symptoms may also be present if the appendix is in
the pelvis. Dysuria occurs in 10% of cases with an excess of leucocytes in the
urine.
A 3-year-old girl presents to the emergency department with a 3-day history
of diarrhoea and vomiting. Her mother is worried as she has blood in her
stool. On examination, she appears mildly dehydrated and pale but is
otherwise well. You perform some blood tests and a urine dipstick.
Bloods: Hb 7.2 g/dL WCC 8.0 g/dL Platelets 69 109/L Na 145 mmol/L K 6.1 mmol/L Urea 32 mmol/L Creatinine 219 mmol/L Urine dipstick: Protein 3þ Blood Negative Leucocytes Negative Nitrites Negative
What is the most likely diagnosis?
A. Glomerulonephritis
B. Haemolytic uraemic syndrome
C. Henoch–Scho¨nlein purpura
D. Leukaemia
E. Pyelonephritis
B – Haemolytic uraemic syndrome
This girl is anaemic, thrombocytopenic and is in acute renal failure. The most
likely diagnosis is haemolytic uraemic syndrome (HUS).
HUS is characterized by acute renal failure, microangiopathic anaemia and
thrombocytopenia (with a normal clotting time). It is commonly seen after gastroenteritis
caused by Escherichia coli (the verotoxin-producing O157:H7 strain),
Salmonella, Shigella or Campylobacter. Children present with vomiting and diarrhoea
(which is often bloody) and acute renal failure occurs soon after. This form
of HUS is known as the epidemic/typical version and is seen more commonly in
younger children and in the summer months. It usually has a good outcome and
permanent renal damage is uncommon. However the rarer type (‘sporadic
type’) is seen in older children and renal damage is more severe. Drugs and
malignancy can also all cause HUS, and there is a hereditary form. A blood
film is diagnostic, showing a microangiopathic haemolytic anaemia.
Complications of HUS include abdominal pain, myocarditis, encephalitis-like
features, hepatitis, pancreatitis and retinal haemorrhages. Renal damage can
lead to hypertension. Treatment is conservative and symptomatic, and includes
careful fluid and electrolyte balance, treatment of renal failure with dialysis and
transfusion of blood and platelets as required.
Henoch–Scho¨nlein purpura (HSP) is a vasculitis which affects the whole body. It
classically presents with a purpuric rash over the back of the legs and buttocks. It
is not associated with anaemia or thrombocytopenia but can lead to nephritis
and thus haematuria and proteinuria. Arthritis is a common feature and HSP
can also affect the abdomen, leading to abdominal pain and occasionally
melaena. Glomerulonephritis may present in a number of ways: nephrotic or
nephritic syndrome, acute renal failure or asymptomatic haematuria and/or proteinuria.
It does not normally present with anaemia and thrombocytopenia.
Leukaemia is unlikely in this situation as, although the child has anaemia and
thrombocytopenia, she is otherwise well. Acute renal failure can be a presenting
feature of malignancies if there is tumour lysis syndrome, but it is unlikely in a
child that is otherwise well.
A newborn baby has a heel-prick blood test taken for Guthrie card
screening.
Which of the following is not screened for on the newborn Guthrie card?
A. Congenital hypothyroidism
B. Cystic fibrosis
C. Diabetes mellitus
D. Phenylketonuria
E. Sickle cell disease
C – Diabetes mellitus
The national newborn screening programme was introduced in 1969 for phenylketonuria
(PKU) and in 1981 congenital hypothyroidism (CHT) was added.
Currently all babies in the UK will have a Guthrie card to screen for:
† PKU
† CHT
† Cystic fibrosis
† Sickle cell disease and thalassaemia
Medium Chain Acetyl Co-A Dehydrogenase Deficiency (MCADD – an inborn
error of metabolism where fat cannot be broken down, resulting in low
energy and hypoglycaemic episodes) screening has now also been approved
and will hopefully soon be nationalized.
The Wilson criteria describe the features of a good screening tool:
† The condition should be an important health problem
† The natural history should be understood
† There should be a recognizable latent or early symptomatic stage
† There should be an accepted treatment recognized for the disease
† Treatment should be more effective if started early
† There should be a policy on who should be treated
† Diagnosis and treatment should be cost-effective
The test/tool should be:
† Easy to perform and interpret
† Acceptable
† Accurate, reliable, sensitive and specific
† Case-finding should be a continuous process
A 10-year-old boy falls from a lower branch of a tree while playing with his
brother at home. There was no loss of consciousness at the time but he now
has a headache and is feeling sick. He is brought to the emergency
department 20 minutes later. On examination there is no focal neurology.
Which of the following is an indication for an immediate CT scan?
A. Amnesia of the event and the preceding 4 hours
B. Glasgow Coma Score of 14 on admission
C. Obvious tender swelling to the side of the head
D. One episode of vomiting in the department
E. Previous head injury 2 years previously
A – Amnesia of the event and the preceding 4 hours
Initial assessment of any head injury follows A-B-C. Cervical spine evaluation is
performed in conjunction with airway assessment. C-spine immobilization is
appropriate if any of the following apply: Glasgow Coma Scale (GCS) ,15,
neck tenderness or pain, any focal neurological deficit, paraesthesia or other
clinical suspicion of a cervical spine injury. Immobilization should be maintained
until a full risk assessment including clinical assessment (and imaging if necessary)
indicates removal is safe.
If GCS ,8, an anaesthetist should secure the airway by means of tracheal intubation
and ventilation. A full skeletal survey should also be performed to assess
any other injuries.
Indications for CT head scanning in patients under 16 years are as follows:
† Witnessed loss of consciousness lasting .5 minutes
† Amnesia (anterograde or retrograde) lasting .5 minutes
† Abnormal drowsiness
† Three or more discrete episodes of vomiting
† Clinical suspicion of non-accidental injury
† Post-traumatic seizure but no history of epilepsy
† Age .1 year: GCS ,14 on assessment in the emergency department
† Age ,1 year: GCS (paediatric) ,15 on assessment in the emergency
department
† Suspicion of open or depressed skull injury or tense fontanelle
† Sign of basal skull fracture
W Haemotympanum (blood behind the tympanic membrane)
W Raccoon eyes
W Cerebrospinal fluid otorrhoea/rhinorrhoea
W Battle’s sign (blood at the mastoid)
† Focal neurological deficit
† Age ,1 year: presence of bruise, swelling or laceration .5 cm on the head
† Dangerous mechanism of injury (high-speed road traffic accident either as
a pedestrian, cyclist or vehicle occupant, fall from .3 m, high-speed
injury)
A 13-month-old boy presents to the general practitioner. He has a 24-hour
history of irritability. His mother reports he has been ‘tugging’ at his left ear.
His temperature is 38.28C. On examination of the left ear, there is a bulging
red tympanic membrane.
Which of the following describes the appropriate management of this case?
A. Five-day course of oral antibiotics
B. Insertion of oil to the external ear canal
C. No action required
D. Oral analgesia
E. Oral antihistamine
D – Oral analgesia
Acute otitis media (AOM) is a purulent middle ear process. Earache is the single
most important symptom. Other ear-related symptoms include tugging and
rubbing of the ear, irritability, restless sleep and fever. Non-specific symptoms
such as cough and rhinorrhoea may also be present. Examination with an otoscope
may reveal a bulging tympanic membrane with loss of the normal landmarks,
a change in colour (red or yellow) and poor mobility.
In this case it would be entirely reasonable to use paracetamol for control of discomfort
and as an antipyretic.
The following guidance is given by the Scottish Intercollegiate Guidelines
Network regarding the management of AOM1:
† Children with AOM should not routinely be prescribed antibiotics as the
initial treatment
† If an antibiotic is to be prescribed, the conventional 5-day course is recommended
at dosage levels indicated in the British National Formulary
† Delayed antibiotic treatment (antibiotic to be collected at parents discretion
after 72 hours if the child has not improved) is an alternative approach
which can be applied in general practice
† Parents should give paracetamol for analgesia and be advised of the
potential danger of overuse
† Children with AOM should not be prescribed decongestants or
antihistamines
† Insertion of oils should not be prescribed for reducing pain in children with
AOM
A 4-year-old boy presents with a 10-month history of cough. This occurs
most nights and he is usually symptom-free during the day. He has had
two episodes of wheeze, the first at 9 months of age associated with bronchiolitis,
the second when he was 3 years old when he had a viral upper respiratory
tract infection.
Which of the following would you like to perform?
A. Chest X-ray
B. Peak expiratory flow rate before and after
bronchodilator
C. pH study
D. Sweat test
E. Trial of therapeutic bronchodilators
E – Trial of therapeutic bronchodilators
Asthma is the most common chronic respiratory disease in children. It is defined
as ‘a chronic inflammatory disorder of the airways in susceptible individuals.
Inflammatory symptoms are usually associated with widespread but variable
airflow obstruction and an increase in airway response to a variety of stimuli.
Obstruction is often reversible, either spontaneously or with treatment’.
Chronic cough is a common problem in paediatrics and general practice. The
differential diagnosis includes:
† Asthma (cough exacerbated by exercise, frequent nocturnal cough, atopic
family history)
† Gastroesophageal reflux (associated with feeding reflux symptoms)
† Inhaled foreign body
† Inhaled irritants
† Allergic rhinitis (sneezing, itchy eyes, watery rhinorrhoea)
† Sinusitis (prolonged nasal discharge)
† Post-infectious cough syndrome
† Habit cough (a cough not responsive to treatment which only occurs
during waking hours)
† Tuberculosis
† Cystic fibrosis (now picked up more frequently on Guthrie card and so
many do not develop symptoms before the diagnosis is made)
† Immune deficiency (frequent upper respiratory tract infections)
† Bronchiectasis
Asthma is the most common cause of recurrent cough in children. It is usually
associated with wheeze and/or breathlessness, and triggered by exercise, cold
or dust. In many children a nocturnal cough may be the only presenting clinical
feature.
An 8-year-old girl has recently been diagnosed with type-1 diabetes.
Her current insulin regimen is 10 units of Mixtard 30 in the morning and
7 units of Mixtard 30 in the evening. Her recent blood glucose monitoring
is shown below:
Time of day Blood glucose
Pre-breakfast 5 mmol/L
Pre-lunch 10 mmol/L
Pre-tea 19 mmol/L
Pre-bedtime 8 mmol/L
How should she change her insulin regimen?
A. Change evening dose to 7 units Mixtard 20
B. Change morning dose to 11 units Mixtard 20
C. Increase evening insulin to 8 units Mixtard 30
D. Increase morning insulin to 11 units Mixtard 30
E. Increase morning insulin to 11 units Mixtard 30 and evening dose
to 8 units Mixtard 30
D – Increase morning insulin to 11 units Mixtard 30
This girl is on a twice daily insulin regimen. The insulin she takes is a mixture of a
short-acting and medium/long-acting insulin. For example, Mixtard 30 contains
30% short-acting insulin and 70% medium-acting insulin. When a child is
initially diagnosed an estimate of 0.5–1.0 units/kg/day insulin is often used to
start with. This is usually split 2/3 at breakfast time and 1/3 at teatime. Monitoring
of diabetes is done by measuring blood sugars daily. Preprandial (before
food) blood glucose should aim to be between 4 and 8 mmol/L and postprandial
to be 10 mmol/L. When morning glucose levels are high this suggests the
medium-acting evening insulin needs to be increased. If pre-lunch glucose
levels are high the short-acting breakfast dose needs to be increased.
It is best to only adjust one insulin dose at any time and allow a few days to assess
the outcome. It is also useful to check blood sugar more regularly when changing
insulin regimens. The amount to increase or decrease the dose by varies,
but a rough estimate of 10% either way is often used.
In this case the girl’s glucose level is high pre-lunch and pre-tea, though the prelunch
level is not excessively high. Her morning blood sugars however appear
well controlled. This would imply she needs her morning medium-acting
insulin increased. You could do this by either increasing the Mixtard 30 dose
or by increasing the amount of medium-acting insulin in her morning dose,
i.e. change her to Mixtard 20 (20% short acting and 80% long acting).
However it is best not to adjust the dose and the type of insulin together as it
is difficult to know which was effective. Therefore sticking with Mixtard 30
but increasing the morning dose is the most optimal management in this case
A 5-year-old boy presents to the emergency department with a red, nonblanching
rash over his trunk and peripheries. His mother says that he
has been complaining of a headache. He is crying but is limp in his
mother’s arms. He is cool to touch and has a central capillary refill time
of 4 seconds.
The child has an oxygen mask before you arrive. Which of the following
would be your first course of action?
A. Give a bolus of antibiotic
B. Give a fluid bolus of 10 mL/kg
C. Give a fluid bolus of 20 mL/kg
D. Intubation and ventilation
E. Perform a lumbar puncture
C – Give a fluid bolus of 20 mL/kg
In children under 3 years of age the classical signs of neck rigidity, photophobia,
headache and vomiting are often absent making clinical diagnosis of meningitis
harder.
Signs of possible meningitis in children under 3 years are:
† Coma
† Drowsiness
† High-pitched cry or irritability
† Poor feeding
† Unexplained pyrexia
† Convulsions with or without fever
† Apnoea or cyanotic attacks
† Purpuric rash
A purpuric rash in an ill child with a headache should raise a strong suspicion of
meningitis associated with sepsis. The most common organism responsible for
causing septicaemia in infants and children is meningococcus (Neisseria meningitidis).
Group B streptococcus is also common in infants. The Advanced Paediatric
Life Support manual (the gold standard for acute care) states that all children
who are acutely unwell should be approached in an ABC fashion. This includes
meningitis. In this case the patient is crying therefore we know that the airway is
intact and the child is breathing. It would be useful to assess the respiratory rate,
monitor blood saturations and apply some facial oxygen to minimize tissue
hypoxia. Though intubation and ventilation may become necessary it is not
required at this point.
Capillary refill time (CRT) is a measure of perfusion. It is performed by applying
cutaneous pressure on the centre of the sternum (central) or digit (peripheral)
for 5 seconds. The ‘refill’ or return of colour should occur within 2 to 3
seconds. CRT is a very useful sign in early septic shock when the child may be
otherwise well. In this case, as the perfusion is poor, your first action would be
to site a peripheral cannula (taking a blood sugar, blood culture, full blood
count, C-reactive protein, venous blood gas and polymerase chain reaction
for organisms) and then give a fluid bolus (20 mL/kg is the recommended
first bolus). This is to improve the perfusion to maximize the distribution of antibiotics
which should be given immediately after the fluid bolus. Antibiotics
should not be delayed for a lumbar puncture
