Passmedicine Questions Flashcards
What is bronchiolitis?
A condition characterised by bronchiolar inflammation
What is the most common pathogen causing bronchiolitis?
RSV
What is the most common LRTI in <1 year olds?
Bronchiolitis
What are the less common causes of bronchiolitis?
Mycoplasma, adenoviruses
NB there may be a secondary bacterial infection
When does bronchiolitis become more serious?
If the child has bronchopulmonary dysplasia (e.g. premature), congenital heart disease or CF
What are the features of bronchiolitis?
Coryzal + mild fever precede:
- Cough
- Increasing SoB
- Wheezing, fine inspiratory crackles
- Feeding difficulties assoc. w. dyspnoea
When does NICE recommend immediate referral for a child with bronchiolitis?
If they have any of the following:
- apnoea (observed or reported)
- child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
- central cyanosis
- persistent oxygen saturation of less than 92% when breathing air
When should clinicians consider a referral to hospital in bronchiolitis?
RR >60
Difficulty breastfeeding/inadequate oral fluid intake
Clinical dehydration
What investigations can you do for bronchiolitis?
Immunofluorescence of nasopharyngeal secretions may show RSV
How do you manage bronchiolitis?
Humidified O2 if sats <92%
NG feeding if cannot take fluid/feed by mouth
Suction sometimes used for excessive upper airway secretions
What kind of vaccine is the rotavirus?
Oral, live attenuated
How is the rotavirus vaccine given?
Orally
2 doses - one at 2 months and the second at 3 months
After what age can the rotavirus vaccine not be given after?
1st dose cannot be given after 14 weeks + 6 days
2nd dose cannot be given after 23 weeks + 6 days
Due to theoretical risk of intussception
At what age is a child presumed to be capable of consent?
16
Below the age of 16 how can a child consent?
If they are deemed capable of understanding what is involved in the decision
Can a child who is competent to consent and has refused treatment be overridden?
A parent/the court my be able to authorise investigations/treatment that are in the child’s best interests
What is Fraser’s competency?
Patients under the age of 16 can receive contraceptive advice if the young person:
- understands the professional’s advice
- cannot be persuaded to inform their parents
- is likely to begin, continue having sex with or without contraceptive
- unless they receive contraception, their mental and/or physical health are likely to suffer
- their best interests require them to receive contraceptive advice with or without parental consent
Who is croup mostly seen in ?
Infants and toddlers
What are the features of croup?
Barking cough
Stridor (due to laryngeal oedema and secretions)
What is causes croup?
Parainfluenza virus
What signs will you see in early shock?
Normal BP, tachycardia, tachypnoea, pale or mottled extremities, reduced urine output
What signs will you see in late shock?
Hypotension, bradycardia, Kussmaul breathing, blue peripheries, absent urine output
In early compensated shock how is the BP maintained?
By an increased HR and RR, redistribution of blood from venous reserve volume + diversion of BF from non-essential tissues
What is the most common cause of GE in children in the UK?
Rotavirus
How long does diarrhoea in children usually last for with rota virus?
5-7 days and stops within 2 weeks
How long does vomiting tend to last for in children with the rota virus?
1-2 days and stops within 3 days
What are the signs/symptoms of clinical dehydration?
Appears to be unwell/deterioriating Decreased urine output Skin colour unchanged Warm extremities Altered responsiveness, e.g. irritable, lethargic
Sunken eyes Dry mucous membranes Tachycardia Tachypnoea Normal peripheral pulses Normal capillary refill time Reduced skin turgor Normal BP
What are the signs and symptoms of clinical shock?
Decreased level of consciousness Cold extremities Pale or mottled skin Tachycardia Tachypnoea Weak peripheral pulses Prolonged capillary time Hypotension
What are risk factors for dehydration?
<1y old, esp <6m old
Infants who were of a LBW
Passed 6+ diarrhoeal stools in last 24h
Vomiting 3+ times in last 24h
Those not offered/unable to tolerate supplementary fluids prior to presentation
Those who have stopped breastfeeding during the illness
Those with signs of malnutrition
What features are suggestive of hypernatraemic dehydration?
Jittery movements Increased muscle tone Hyperreflexia Convulsions Drowsiness/coma
In which situations do NICE recommend you do stool cultures for a child presenting with D+V?
You suspect septicaemia
There is blood/mucous in the stool
The child is immunocompromised
In which situations do NICE recommend you consider doing a stool cultures for a child presenting with D+V?
Child has recently been abroad
Diarrhoea has not improved by day 7
You are uncertain about the diagnosis of GE
How should you manage clinical shock?
Admission + IV dehydration (crystalliods with 134-154 mmol/L Na with a bolus of 20m/kg in less than 10m, and 10-20ml/kg in less than 10m for term neonates)
How do you manage diarrhoea + vomiting in children with no clinical signs of dehydration?
Continue breastfeeding/other milk feeds
Encourage fluid intake
Discourage fruit juices + carbonated drinks
How do you manage dehydration?
50ml/kg low osmolarity oral rehydration solution over 4h + ORS for maintenance
Continue breastfeeding
Consider supplementing with usual fluids, e.g. milk or water
What vaccines can babies get at birth?
BCG if risk actors
What vaccines do babies get a 2 months?
6-in-1
Oral rotavirus
Men B
What vaccines do babies get a 3 months?
6-in-1
Oral rotavirus
PCV
What vaccines do babies get a 4 months?
6-in-1
Men B
What vaccines do babies get a 12-13 months?
Hib/Men C
MMR
PCV
Men B
What vaccine do children get annually from 2 to 8 years old?
Flu vaccine
What vaccine do children get 3-4 years old?
4-in-1 pre-school booster (diphtheria, tetanus, whooping cough, polio)
MMR
What vaccine do 12-13 year olds get?
HPV
What vaccines do 13-18 year olds get?
3-in-1 teenager booster (tetanus, diphtheria, polio)
MenACWY
Who else is able to get the MenACWY vaccine?
Those at university up to the age of 25
What are infantile spasms?
A type of childhood epilepsy
What age do infantile spasms tend to start happening?
4-8m
What causes infantile spasm?
Often associated with serious underlying condition and carry a poor prognosis
What clinical features are associated with infantile spasms?
Characteristic ‘salaam’ attacks: flexion of head, trunk, arms followed by extension of the arms (lasts 1-2s, may be repeated up to 50 times)
Become progressively mentally handicapped
What does EEG show in infantile spasms?
Hysarrhythmia
What investigations should be done for suspected infantile spasms?
CT - often shows diffuse/localised brain disease (e.g. tuberous sclerosis)
EEG
What is the management of infantile spasms?
Vigabatrin 1st line
When is the peak incidence of croup?
6m-3y
What are the features of croup?
Stridor
Barking cough (worse at night)
Fever
Coryzal symptoms
What are the features of mild croup?
Occasional barking cough
No audible stridor at rest
No/mild suprasternal/intercostal recession
Child happy and prepared to eat, drink, play
What are the features of moderate croup?
Frequent barking cough
Easily audible stridor
Suprasternal + sternal wall retraction at rest
No/little distress/agitation
Child can be placated and is interested in surroundings
What are the features of severe croup?
Frequent barkng cough
Prominent inspiratory stridor at rest
Marked sternal wall retractions
Significant distress/agitation/lethargy/restlessness (a sign of hypoxaemia)
Tachycardia occurs with more severe obstructive symptoms + hypoxaemia
What children with croup should be admitted?
Moderate/severe croup
<6m
Known airway abnormalities, e.g. Down’s, laryngomalacia
Uncertainty about diagnosis
What is the management of croup?
Single dose oral dexamethasone (0.15mg/kg)
What is involved in the emergency treatment of croup?
High flow oxygen
Nebulised adrenaline
What is Osgood-Schlatter disease?
Tibial apophysitis
= type of osteochondrosis characterised by inflammation at the tibial tuberosity
Thought to be caused by repeat avulsion of the apophysis into which the patellar tendon is inserted
How do you manage Osgood-Schlatter disease?
Supportive
What is the most common cyanotic congenital heart disease?
Tetralogy of fallot
When does ToF typically present?
1-2m
What causes ToF?
Anterior malalignment of the aorticopulmonary septum
What are the 4 characteristic features of ToF?
Overriding aorta
RV hypertrophy
VSD
Right ventricular outflow tract obstruction/pulmonary stenosis
What is the feature of ToF that makes it cyanotic?
RV outflow tract obstruction
How does ToF tend to present?
Cyanosis (due to R to L shunt)
Ejection systolic murmur (due to pulm. stenosis)
What is the classical appearance of ToF on X-Ray?
Bootshaped heart
How is ToF managed?
Surgical repair - often done in two parts
Cyanotic episodes may be helped by beta blockers which reduced infundibular spasm
Define ADHD
Inattention Hyperactivity Impulsivity That are persistent May be element of developmental delay
In which condition is ADHD 2x as common?
Autism
What are the criteria for inattention?
Does not follow through on instructions
Reluctant to engage in mentally intense tasks
Easily distracted
Finds it difficult to sustain tasks
Finds it difficult to organise tasks or activities
Often forgetful in daily activities
Often loses things necessary for tasks/activities
Often does not seem to listen when spoken directly to
What are the criteria for hyperactivity/impulsivity?
Unable to play quietly
Talks excessively
Does not wait for their turn easily
Will spontaneously leave their seat when expected to sit
Is often on the go
Often interruptive or intrusive to others
Will answer prematurely before a question has been finished
Will run and climb in situations where it is not appropriate
How is ADHD managed?
10 week watch and wait to see if symptoms persist
If persist - refer to CAMHS - try education programmes for parents, behavioural advice
Drugs therapy is last resort, methylphenidate is first line (6w trial), 2nd line is lisdexamfetamine
Who is drug treatment available for in those with ADHD?
5y+ only
What are the side effects of methylphenidate?
Abdominal pain Nausea Dyspepsia Growth and appetite suppression Insomnia Anxiety
What investigations need done every 6m with children on methylphenidate?
Height, weight (if under age 10) BP, feel pulse
Need baseline ECG before starting as it is cardiotoxic
What kind of drug is methylphenidate?
Dopamine/norepinephrine reuptake inhibitor
How many features from the inattention and hyperactivity/impulsiveness criteria are required for a diagnosis of ADHD?
<16y: 6
17y+: 5
Developmental Milestones - speech and hearing: 3 months
Quietens to parents voice
Turns towards sound
Squeals
Developmental Milestones - speech and hearing: 6 months
Double syllables
Developmental Milestones - speech and hearing: 9 months
Says mamma dada
Understands no
Developmental Milestones - speech and hearing: 12 months
Knows and responds to own name
Developmental Milestones - speech and hearing: 12-15 months
Knows 2-6 words (refer at 18m)
Understands simple commands, e.g. give it to mummy
Developmental Milestones - speech and hearing: 2 years
Combines two words
Points to parts of the body
Developmental Milestones - speech and hearing: 2.5 years
Vocabulary of 200 words
Developmental Milestones - speech and hearing: 3 years
Talks in short sentences (3-5 words)
Asks what and who questions
Identifies colours
Counts to 10
Developmental Milestones - speech and hearing: 4 years
Asks why, when and how questions
What is Perthes disease?
Degenerative condition affecting the hip joint of children usually between the age of 4 and 8
What causes Perthes disease?
Avascular necrosis of the femoral head, specifically the femoral epiphysis
Impaired blood supply to femoral head –> bone infarction
In which gender is Perthes disease most common?
5x more common in boys
What are the features of perthes disease?
Hip pain - progressive over a few wks
Limp
Stiffness + reduced RoM of hip
What X-Ray findings do you get with Perthes disease?
Widening of joint space
Later changes: decreased femoral head size/flattening
What investigations should be done for suspected Perthes disease?
Xray
Technetium bone scan or MRI if normal X-ray and symptoms persist
What complications are associated with Perthes disease?
OA
Premature fusion of the growth plates
What staging is used for Perthes disease?
Catterall staging
Stage 1 - clinical + histological features only
Stage 2 - sclerosis with or without cystic changes + preservation of articular surface
Stage 3 - Loss of structural integrity of femoral head
Stage 4 - Loss of acetabular integrity
How do you manage Perthes disease?
Keep femoral head in acetabulum with casts/braces
If <6 - observe
If >6/severe deformities - surgery
What is the prognosis of Perthes?
Tends to heal over a period of 2-3 years
What are the presenting features of cystic fibrosis?
Neonates - meconium ileus, prolonged jaundice
Recurrent chest infections
Malabsorption - steatorrhoea/FTT
Other features (10%) - liver disease
What are some other features associated with cystic fibrosis?
short stature diabetes mellitus delayed puberty rectal prolapse (due to bulky stools) nasal polyps male infertility, female subfertility
What is intussusception?
Invagination of one portion of bowel into the lumen of the adjacent bowel (usually around ileo-caecal region)
At what age does intussusception normally happen?
6-18 m
What are the clinical features associated with insussusception?
Paroxysmal abdominal colic pain
During the paroxysm the infant will characteristically draw up their knees and turn pale
Vomiting
Red current jelly stool (late sign)/blood stained stool
Sausage shaped mass in upper quadrant
What is the investigation of choice for intussusception?
USS - shows target sign
How is intussusception managed?
Pneumatic reduction under radiological control
Barium enema
If fails or signs of peritonitis - surgery
What are the key features of Patau syndrome? (trisomy 13)
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
What are the key features of Edwards syndrome? (trisomy 18)
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
What are the key features of fragile X syndrome?
Learning difficulties Macrocephaly Long face Large ears Macro-orchidism
What are the key features of Noonan syndrome?
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
What are the key features of Pierre-Robin syndrome?
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
What are the key features of Prader-Willi syndrome?
Hypotonia
Hypogonadism
Obesity
What are the key features of Williams syndrome?
Short stature Learning difficulties Friendly, extrovert personality Transient neonatal hypercalcaemia Supravalvular aortic stenosis
What are the key features of Cri du chat syndrome (chromosome 5p deletion syndrome)?
Characteristic cry (hence the name) due to larynx and neurological problems
Feeding difficulties and poor weight gain
Learning difficulties
Microcephaly and micrognathism
Hypertelorism
