Paeds - Aimee / Lydia

Question 1

Streptococcus pneumonae on a microscope? Possible severe illness caused ?

Answer 1

Gram positive
Alpha haemolytic
Facultative anaerobic

Meningitis
Invasive pnemococcal disease - pneumonia with septicaemia

Question 2

What might cause you to admit a URTI?

Answer 2

Poor feeding
Parental concern
Unknown diagnosis

Question 3

Viruses causing coryzal sx?

Answer 3

Rhinovirus
Coronavirus
RSV

Question 4

When is tonsillectomy an option?

Answer 4

Recurrent severe tonisilitis
Quincy
Obstructive sleep apnea

Question 5

Which bacteria can cause tonsillitis in older children? Usual viral causes?

Answer 5

B haemolytic strep

Adenovirus, enterovirus, rhinovirus

Question 6

What criteria can you use to determine if tonsillitis is likely bacterial?

Answer 6

Centor criteria

Age 5-15 
Season Late autumn, early spring, winter 
Fever >38.3 
Cervical lymphadenopathy 
Pharyngeal erythema, oedema or exudate 
No cough 

If 5 -> 50%, 6->75% likelihood of bacterial

Question 7

Laryngeal / tracheal infection seen in?

Answer 7

Croup
Bacterial tracheitis
Acute epiglottis

Question 8

Croup is what? Onset over? Cause? Age? Treat of moderate? Severe?

Answer 8

Laryngotracheobronchitis - onset over days
95% viral - parainfluenza, RSV
6month-6years

Moderate - PO dexamethosone, PO prednisolone, Nebulised steroids

Severe - Nebulised adrenaline + O2, anaesthetist incase airway lost

Question 9

What causes psuedomembranous croup? Sx? Mx?

Answer 9

Staph aureus - bacterial tracheitis

High fever, toxic, rapidly progressing airway obstruction by thick secretions

IV Abx
Intubation and ventilation if required

Question 10

Onset of acute epiglotits?
Cause?
Signs it has progressed to septicaemia ?
Management?

Answer 10

Hours (age 1-6)
H influenza type B

Septicaemia -> swelling of epiglottis and soft tissues -> airway obstruction
High fever, toxic child
Painful throat - no speaking + drooling
Soft inspiration stridor -> increasing respiratory difficulty

Immobile child with extended neck

Mx
Anaesthetist, ENT surgeon, paediatrician
Secure airway then blood cultures
Transfer to ICU

Rifampicin to household contacts

Question 11

Basic management principles for child with laryngeal / tracheal infections?

Answer 11

Keep calm 
Quiet room 
DO NOT examine 
Observe for hypoxia 
Call anaesthetist 
Nebulised adrenaline

Question 12

Pertussis 
Sx? 
How long? 
Ix?
Treat? 
Prophylaxis?
Complications?

Answer 12

Epidemic every 3-4y
1 wk coryza → paroxysmal cough → insp whoop (apnoea in infants)
Cough WORSE AT NIGHT. May → vomiting
Lasts 3-6 wks

Per-nasal swab – culture or PCR
Treat: erythromycin – eases symptoms if started in coryzal phase
Prophylaxis : erythromycin or vaccination
Complications: pneumonia, convulsions, bronchiectasis

Question 13

What important DD with pneumonia? Usual crackle in pneumonia ?

Answer 13

TB

End-inspiratory coarse crackles

Question 14

4 S’s of innocent murmurs

Answer 14

aSymtomatic patient
Soft blowing murmur
Systolic murmur only
Left Sternal edge

Question 15

Features of a large VSD? O/e? CXR? Mx?

Answer 15

> 1wk: HF, breathlessness, failure to thrive, recurrent chest infections, tachypnea, hepatomegaly

Soft murmur
Apical mid diastolic murmur (bilateral from lungs across mitral valve)
Loud pulmonary 2nd sound

CXR
Cardiomegaly
Enlarged pulmonary artery
Pulmonary oedema

Diuretics + captopril
Surgery to prevent eisenmenger syndrome

Question 16

When should a PDA close ? Shunt? What happens if it is large?

Answer 16

1 month
L->R
HF, pulmonary HTN

Question 17

Most common ASD? 
Sx? 
Murmur? 
CXR? 
ECG?

Mx?

Answer 17

Secundum (usually due to foramen ovale) - 80% of ASD

Can be aSx
Recurrent chest infections , arrhythmia (4th decade +)

Ejection systolic murmur at left sternal edge (pulmonary valve)

CXR : cardiomegaly, ↑pulmonary arteries, ↑pulmonary vascular markings
ECG : partial R bundle branch block R axis deviation
Echo
Cardiac catheterisation (carotid angiography) @ 3-5y

Question 18

What is ASD primum also called? What happens? Murmur?
CXR?
ECG?

Mx?

Answer 18

Partial AVSD
Communication between atria and valves
Leaky 3 leaved mitral valve → regurg
Apical pansystolic murmur from valve regurg
CXR : cardiomegaly, ↑pulmonary arteries, ↑pulmonary vascular markings
ECG : -ve AVF = superior QRS
Echo

Surgical repair

Question 19

Murmur in TOF ?

Answer 19

Loud, harsh ejection systolic at L sternal edge

Question 20

When would AS lead to HF and shock? Associations? What does it lead to? Auscultation? What other feature?

Answer 20

If it is duct dependant
Mitral valve stenosis & coarctation of the aorta

LVH

Carotid thrill
Small -> slow rising pulse

Question 21

O/e of coarctation of aorta

Answer 21

Systemic HTN in right arm
Radiofemoral delay
Weak femoral pulses

Question 22

PS and AS lead to respectively?

Answer 22

RVH

LVH

Question 23

Causes of outflow obstruction with well baby ?

Answer 23

AS
PS
CoA

Question 24

Outflow obstruction but sick baby causes? Features?

Answer 24

Aortic interruption
Very sick babies - VSD / Duct dependent
Absent peripheral pulses

Coarctation of the aorta
Circulatory collapse at 2 days old
Absent femoral pulses

Hypo-plastic left heart syndrome
100% duct dependant

Question 25

``` Infective endocarditis features? RFs? Diagnosis based on? Usual causes? Treatment? - what marker for monitoring? Prophylaxis? Complications? ```

Answer 25

Sustained fever, malaise, raised ESR, anaemia / haematuria -splinter haemorrhages, clubbing, arthralgia RF - VSD, CoA, PDA, prosthetic valves Diagnosis - blood cultures, echo A-haemolytic strep: strep Viridans IV penicillin + aminoglycoside for 6/52 -use acute phase protein levels to monitor treatment Prophylaxis - good dental hygiene Complications - infected emboli & infarcts -retinal, pulmonary, neuro

Question 26

Which cardiomyopathy is risk of sudden death in young athletes? Features?

Answer 26

Hypertrophic LVH Diastolic dysfunction

Question 27

Most common cardiomyopathy? Features?

Answer 27

Dilated Enlargement of all heart chambers Systolic dysfunction

Question 28

What happens in restrictive cardiomyopathy ?

Answer 28

Rigid ventricular walls Diastolic dysfunction [least common]

Question 29

Rf/ Mx of cardiomyopathy?

Answer 29

FH, infection Large heart Diuretics + ACEi

Question 30

``` What common complication of rheumatic fever? Usual cause? Criteria for diagnosis? Treatment? Prophylaxis? ```

Answer 30

Mitral stenosis Group A B-haemolytic strep Jones criteria - 2 major OR 1 major and 2 minor Major Pericarditis , polyarthritis, Sydenham chorea, erythema marginatum, subacute nodules Minion Fever, polyarthlargia, Hx RF, raised acute phase proteins, raised p-r interval ``` Treatment Bed rest Anti-inflammatory - high dose aspirin Steroids if not resolving Treat HF ``` Prophylaxis Benzathine penicillin IM for 1 month

Question 31

Triad in nephrotic syndrome? Other sx? What is the usual cause?

Answer 31

Oedema -periorbital, scrotal / vulval, leg Hypoalbuminaemia Proteinuria -throthy urine ±ascities, breathlessness Minimal change disease - not much to see on histological examination

Question 32

Ix in nephrotic syndrome?

Answer 32

``` Urine dipstick MSU C+S U&E, creatinine Albumin FBC, ESR Complement C3 and C4 levels Anti-Dnase B titre/throat swab (for strep) ```

Question 33

Usual mx of nephrotic syndrome? Dose? What happens if it is resistant to this?

Answer 33

``` Steroid sensitive (90%)-> Prednisolone 60mg/m2 /day for 4 weeks, then 40mg/m2 alternate days 4 weeks ``` Steroid resistant -> immunosuppression (cyclophosphamide, cyclosporin) diuretics, ACE inhibitor, salt restriction, NSAIDs

Question 34

Bar minimal change what are the other rare causes of nephrotic syndrome?

Answer 34

Focal segmental glomerulosclerosis Mesangiocapillary glomerulonephritis Membranous nephropathy

Question 35

Congenital nephrotic syndrome genetics? Mx?

Answer 35

Recessive ‘Finnish type’ Nephrectomy

Question 36

Complications of nephrotic syndrome?

Answer 36

``` Hypovolaemia Thrombosis Infection Hypercholesterolaemia Spontaneous peritonitis! Strep pneumoniae ```

Question 37

Features of nephritis ? What would brown vs red urine indicate?

Answer 37

Haematuria Reduced urine output - oliguria Proteinuria Brown-> glomerular bleeding Red - lower tract defect and is uncommon in children

Question 38

Causes of nephritis ?

Answer 38

Post-infectious -> normally group A strep Hx of sore throat (1-3w ago) Anti-Dnase B, throat swab IgA nephropathy Goodpasteur’s syndrome Lung symptoms Vasculitis HSP, SLE, PAN, Wegener’s

Question 39

Nephritis IX?

Answer 39

``` Dipstick, MSU U&E, albumin, creatinine C3/C4 levels Anti-Dnase B. Throat swab Biopsy Blood pressure ```

Question 40

What is henoch-schonlein purpura? Follows what? Triad? What is often involved?

Answer 40

Acute, immune complex-mediated vasculitis Follows URTI Classic triad: Purpura on buttocks, extensor surfaces, lower legs Abdominal pain Arthritis/arthralgia Renal involvement

Question 41

Ix in HSP? Mx? Complication?

Answer 41

``` Raised ESR Raised IgA Urinalysis – proteinuria Antistreptolysin O (ASO) titer [test for antibodies against a substance produced by group A strep] U+E BP Abdo US to exclude intussusception ``` Steroids may help. Most recover spontaneously. Risk of chronic renal failure

Question 42

What is haemolytic uraemic syndrome? Features? Risk of? Usually follows? What treatment may be required?

Answer 42

Acute microangiopathic haemolytic anaemia AKI Thrombocytopenia Anaemia Renal failure Typically follows E.coli 0157 dysentery -> history of bloody diarrhoea Dialysis

Question 43

Possible complication of UTI ? What type of uti can be ASx? | Congenital causes of uti?

Answer 43

Renal scaring -> renal failure and hypertension Bacteriuria - often asx Structural abnormality

Question 44

Presentation of UTI infant? Toddler?

Answer 44

Infants - collapse, septicaemia, poor feeding Toddler - vomiting, FTT, colic

Question 45

When would you investigate a UTI? What ix?

Answer 45

Complicated / atypical -seriously ill, abdo mass, raised creatinine, failure to repond to Abx <48hrs, non-E. Coli Dipstick all urine -nitrates and WCC -> likely for all UTIs MSU ‘clean catch’ USS DMSA scan - radioactive isotope injected to scan kidneys (CT / X-RAY)

Question 46

Treatment of a UTI in <3months? >3months? With pyelonephritis? When would you start treatment? Who would you give prophylaxis to and what would you give?

Answer 46

<3months - IV amoxicillin + gentamicin >3months [uncomplicated] - 3days PO trimethoprim / nitrofuantoin / co-amoxiclav Pyelonephritis -> gentamicin Treat immediately without waiting for culture Prophylaxis for those with renal abnormalities / recurrent UTI -> trimethoprim

Question 47

Usual cause of vesicouretic reflux? What happens?

Answer 47

Developmental abnormality of the vesicouretic junction Ureters displaced laterally Urine reflexes up into ureters ->pyelonephritis and renal damage