Paeds 5

Question 1

How is chondromalacia patellae managed?

Answer 1

Physiotherapy for quadriceps strengthening

Question 2

How is osteochondritis dissecans managed?

Answer 2

Pain relief
Rest and quadriceps exercise
Occasionally need surgery

Question 3

How is subluxation of the patella treated?

Answer 3

Reduction and immobilisation

Rehab

Question 4

Outline the treatment of Perthes disease.

Answer 4

o Acute Pain - supporting care with simple analgesia

o < 5 years
• Mobilisation and monitoring (healing potential is good at this age)
• Non-surgical containment using splints

o 5-7 years
• Mobilisation and monitoring
• Surgical containment

o 7-12 years
• Surgical containment
• Salvage procedure (remodel the acetabulum)

o 12+ years
• Salvage procedure
• Replacement arthroplasty

Question 5

How is septic arthritis treated?

Answer 5

Antibiotics (initially IV for 2 weeks, followed by 4 weeks oral)

Suspected Gram-positive
Vancomycin + joint aspiration
2nd line = clindamycin or cephalosporin + joint aspiration

Suspected Gram-negative
3rd generation cephalosporin (e.g. ceftriaxone) + joint aspiration
2nd line = IV ciprofloxacin + joint aspiration

Affected joints should be aspirated to dryness as often as required (through closed needle aspiration or arthroscopically)

Question 6

What are the aspects of managing juvenile idiopathic arthritis?

Answer 6

Multidisciplinary team
Physiotherapist and occupational therapist 
NSAIDs
Corticosteroids 
DMARDs (methotrexate is first-line)

Question 7

How is vitamin D deficiency/Rickets treated?

Answer 7

Calcium and ergocalciferol OR cholecalciferol

NOTE: pseudovitamin D deficiency is treated with alfacalcidol or calcitriol

Question 8

How might you investigate a patient presenting with migraines?

Answer 8

Headache diary for 8 weeks to help identify triggers

Question 9

Outline the steps in the acute management of a migraine.

Answer 9

Step 1: simple analgesia
Step 2: nasal sumatriptan
Step 3: nasal sumatriptan and NSAID/paracetamol
Step 4: consider adding prochlorperazine or metoclopramide

Question 10

Which medications are used to prevent migrianes?

Answer 10

Topiramate and propranolol

Question 11

How should you manage a febrile convulsion during the seizure?

Answer 11

Protect them from injury

Do not restrain

When the seizure stops, check the airway and place in the recovery position

If > 5 mins –> rectal diazepam (can be done twice) or buccal midazolam (only one dose)

An ambulance should be called if the seizure continues

Question 12

What should be tested in all children who have a seizure?

Answer 12

Blood glucose

Question 13

Which children who have had a febrile convulsion require hospital assessment by a paediatrician?

Answer 13

First febrile convulsion
Diagnostic uncertainty about the cause of the seizure
Focal features of the seizure
Seizure recurs within the same febrile illness (or within 24 hours)
< 18 months old
Parents are anxious
No apparent focus of infection

Question 14

What is the recurrence rate of febrile convulsions?

Answer 14

1 in 3

Question 15

What are some cardinal features of childhood rolandic epilepsy?

Answer 15

Unilateral facial sensorimotor symptoms
Oropharyngeal ictal manifestations
Arrest of speech
Hypersalivation

NOTE: this is not usually treated and children will grow out of it (around 14-18 years)

Question 16

What is the first-line AED for generalised seizures?

Answer 16

Valproate

NOTE: ethosuximide can be used for absence seizures

Question 17

Name some antiepileptics that can worsen certain forms of epilepsy.

Answer 17

Lamotrigine - worsens myoclonic

Carbamazapine - worsens absence

Question 18

What is the first-line AED for focal seizures?

Answer 18

Carbamazepine or lamotrigine

Question 19

What advice should you give to parents with regards to activities that may be dangerous with epilepsy?

Answer 19

Avoid situations where having a seizure could lead to injury or death (e.g. swimming unsupervised)
Driving is allows only after 1 year free of seizures
The school should be made aware of the diagnosis

Question 20

How is Guillain-Barre syndrome managed?

Answer 20

Supportive
Respiratory support
IVIG
Plasma exchange

Question 21

Which milestones would you expect the average child to have reached by 7 months?

Answer 21

Gross Motor: sits without support
Fine Motor: transfers objects from hand to hand
Hearing, Speech and Language: turns to voice, polysylabic babble
Social/Emotional: finger feeds, fears strangers

Question 22

Which milestones would you expect the average child to have reached by 1 year?

Answer 22

Gross Motor: stand independently
Fine Motor: pincer grip (10 months), points
Hearing, Speech and Language: 1-2 words, understands name
Social/Emotional: drinks from cup, waves

Question 23

Which milestones would you expect the average child to have reached by 15-18 months?

Answer 23

Gross Motor: walks independently
Fine Motor: immature grip of pencil, random scribble
Hearing, Speech and Language: 6-10 words, points to 4 body parts
Social/Emotional: feeds self with spoon, beginning to help with dressing

Question 24

Which milestones would you expect the average child to have reached by 2.5 years?

Answer 24

Gross Motor: runs and jumps
Fine Motor: draws
Hearing, Speech and Language: 3-4 word sentences, understands 2 commands
Social/Emotional: parallel play

Question 25

List the median ages for gross motor development milestones.

Answer 25

6-8 weeks: raises head to 45 degrees when prone 6-8 months: sits without support (first with round back, then straight back) 8-9 months: crawling 10 months: cruising 12 months: walks unsteadily 15 months: walks steadily

Question 26

List the median ages for vision and fine motor milestones.

Answer 26

6 weeks: follows moving object or face by turning head 4 months: reaches out for toys 4-6 months: palmar grasp 7 months: transfers toys from one hand to another 10 months: mature pincer grip 16-18 months: makes marks with a crayon, tower of 3 3 years: draws a circle

Question 27

List the median ages for hearing, speech and language development.

Answer 27

3-4 months: vocalises alone or when spoken to, coos and laughs 7 months: turns to soft sound out of sight 10 months: sounds used discriminately to parents (mama/dada) 12 months: 2-3 words other than mama or dada 18 months: 6-10 words, shows two parts of the body 20-24 months: use 2 or more words to make simple phrases 2.5-3 years: talks constantly in 3-4 word sentences

Question 28

List the median ages for social, emotional and behavioural development.

Answer 28

``` 6 weeks: smiles responsively 6-8 months: puts food in mouth 10-12 months: waves bye bye, plays peek-a-boo 12 months: drinks from cup 18 months: uses spoon 18-24 months: symbolic play 2 years: dry by day 2.5-3 years: parallel play, takes turns ```

Question 29

How is paracetamol overdose managed?

Answer 29

Measure plasma paracetamol concentration at 4 hours and plot on normogram Treat with IV N-acetylcysteine if necessary

Question 30

How is carbon monoxide poisoning treated?

Answer 30

Presents with headache, nausea, confusion and drowsiness High-flow oxygen Hyperbaric oxygen therapy may be considered

Question 31

How is salicylate poisoning treated?

Answer 31

Presentation: vomiting, tinnitus, respiratory alkalosis Measure plasma salicylate concentration at 2-4 hours Alkalinisation of urine with sodium bicarbonate increases urinary excretion Consider haemodialysis

Question 32

How is TCA overdose treated?

Answer 32

Treat arrhythmias and give sodium bicarbonate | Support ventilation

Question 33

How is ethylene glycol poisoning treated?

Answer 33

Presentation: intoxication, tachycardia, metabolic acidosis Fomepizole inhibits the production of toxic metabolites (ethanol can also be used)

Question 34

How is iron overdose treated?

Answer 34

Presentation: vomiting, diarrhoea, haematemesis, late drowsiness/coma/shock/hypoglycaemia Serum iron level 4 hours after ingestion is the best measure of severity IV desferoxamine chelates iron

Question 35

How is organophosphorus pesticide poisoning treated?

Answer 35

``` Supportive Atropine (large dose) Pralidoxime (reactivates actylcholinesterase) ``` NOTE: presentation is mainly cholinergic features

Question 36

What is a port wine stain?

Answer 36

Capillary malformation in the dermis that is present from birth and persists for life If in the trigeminal nerve distribution, some children may have Sturge-Weber syndrome and should have an MRI

Question 37

Describe the appearance and progression of cavernous haemangiomas.

Answer 37

Appears within the first month of life | Grows before shrinking and disappearing (before 5 years)

Question 38

Describe the inheritance pattern of von Willebrand disease.

Answer 38

Type 1 and 2 = autosomal dominant | Type 3 = autosomal recessive

Question 39

How should bladder outflow obstruction be investigatd?

Answer 39

MCUG

Question 40

What are the two different types of polycystic kidney disease and how do they differ?

Answer 40

Autosomal Dominant - mainly in older children/adults, cysts are large Autosomal Recessive - presents in childhood with bilateral renal masses, respiratory distress due to pulmonary hypoplasia and congenital hepatic fibrosis with pulmonary hypertension

Question 41

What are the aspects of managing Duchenne muscular dystrophy?

Answer 41

``` Physiotherapy to prevent contractions Exercise and psychological support Surgery (e.g. tendoachilles lengthening) CPAP for nocturnal hypoxia Glucocorticoids may slow degeneration ```

Question 42

What's the main difference between Duchenne and Becker muscular dystrophy?

Answer 42

Duchenne - no dystrophin - severe symptoms (LE: 20-30 years) | Becker - abnormal dystrophin - milder symptoms

Question 43

What are some consequences of neural tube defects?

Answer 43

Paralysis and muscle imbalance (needs physiotherapy) Sensory loss (can lead to accidental damage) Neuropathic bladder Bowel denervation Scoliosis Hydrocephalus

Question 44

How is hydrocephalus treated?

Answer 44

Ventriculoperitoneal shunt

Question 45

Outline the management of idiopathic intracranial hypertension.

Answer 45

``` Eliminate causal factors Weight-reduction Low-sodium diet and fluid restriction Acetazolamide Analgesia VP shunt ```

Question 46

List some clinical features of a child at high-risk of sepsis.

Answer 46

``` Behaviour: • No response to social cues • Appears ill • Does not wake, or if roused does not stay awake • Weak, high-pitched and continuous cry ``` Heart Rate: • Tachycardia (different at different ages) • < 60 bpm at any age ``` Respiratory Rate • Tachypnoea (different at different ages) • Grunting • Apnoea • SpO2 < 90% on air ``` ``` Mottled or ashen appearance Cyanosis of the skin, lips or tongue Non-blanching rash Aged < 3 months with temperature > 38 degrees Temperature < 36 degrees ```

Question 47

Which investigations constitute a septic screen?

Answer 47

``` FBC Blood culture CRP Urinalysis LP CXR ``` Also do a VBG NOTE: if < 1 month, all children should have an LP

Question 48

Outline the role of a VBG in managing a child with moderate to high risk of sepsis.

Answer 48

> 2 mmol/L or evidence of AKI --> treat as high-risk | < 2 mmol/L = repeat assessment at least hourly, ensure review by senior clinician, identify a cause and manage it

Question 49

Outline the non-pharmacological steps taken in the management of high risk sepsis.

Answer 49

``` Immediate review by senior clinician VBG (gas, glucose, lactate, FBC, U&E, creatinine, clotting) Broad spectrum antibiotics immediately Monitor continuously Monitor mental state using GCS or AVPU ```

Question 50

Outline how the lactate guides treatment in high risk sepsis.

Answer 50

> 4 mmol/L = IV fluid bolus without delay, refer to critical care 2-4 mmol/L = IV fluid bolus without delay < 2 mmmol/L = consider IV fluids