rando

Question 1

non accidental injury red flags

Answer 1

any # in immobile child, multiple #s of different ages, spiral #s brusing in shape of hand or object, on neck, around wrists, buttocks any burn in non mobile child always do a full development assessment to see if child is able to do what parent said child did

Question 2

non accidental injury investigations

Answer 2

full skeletal survey

Question 3

bruising differentials

Answer 3

NAI trauma coagulation disorders ALL Mongolian blue spot (back of thigh and buttocks)

Question 4

differentials

Answer 4

NAI osteogenesis imperfecta

Question 5

presyncopal symptoms?

Answer 5

faint dizzy feeling nausea feeling hot/ cold/ sweaty rushing noise in the ears

Question 6

risk factors predisposing to vasovagal syncope?

Answer 6

tired hungry stressed crowded place frightened unwell anaemic dehydrated standing suddenly

Question 7

2 month immunisations?

Answer 7

6 in 1: DTaP/IPV(polio)/Hib/HepB + Rotavirus (oral) + MenB

Question 8

3 month immunisations?

Answer 8

6 in 1: DTaP/IPV(polio)/Hib/HepB + Rotavirus (oral) + PCV

Question 9

4 month immunisations?

Answer 9

6 in 1: DTaP/IPV(polio)/Hib/HepB + MenB

Question 10

12-13 month immunisations?

Answer 10

Hib/MenC + MMR + PCV + MenB

Question 11

preschool immunisations? aka 3-4 years

Answer 11

4 in 1 (Diphtheria, tetanus, pertussis, polio) + MMR

Question 12

14 year immunisations?

Answer 12

Td/IPV(polio) booster + Men ACWY

Question 13

immunisations given to only those at high risk? + live

Answer 13

BCG

Question 14

Fraser guidelines?

Answer 14

UPSSI understands advice cannot be persuaded to tell parents likely to continue having sex physical or mental health likely to suffer in the young persons best interests

Question 15

consent in children

Answer 15

patients less than 16 years old may consent to treatment if they are deemed to be competent (an example is the Fraser guidelines, previously termed Gillick competence), but cannot refuse treatment which may be deemed in their best interest between the ages of 16-18 years it is presumed patients are competent to give consent to treatment patients 18 years or older may consent to treatment or refuse treatment

Question 16

Causes of neonatal jaundice presenting within 24 h of life

Answer 16

ALWAYS pathological! Haemolytic disease of newborn (rhesus/ ABO incompatibility), G6PD deficiency, Hereditary spherocytosis, pyruvate kinase deficiency. Congenital infection e.g. CMV, rubella, toxoplasmosis

Question 17

Causes of neonatal jaundice that occurs after 24 h of life but is not yet prolonged (under 2 wks)

Answer 17

physiological, breast milk jaundice, dehydration, infection e.g. UTI, haemolytic disorders, bruising, polycythaemia

Question 18

why do neonates become jaundiced physiologically?

Answer 18

High [Hb] at birth which undergo marked breakdown in the following days red cell life span markedly shorter than adult RBCs (70 days) hepatic bilirubin metabolism less efficient in the first few days of life.

Question 19

causes of prolonged neonatal jaundice (>2 wks)

Answer 19

unconjugated - breast milk jaundice, infection esp UTI, hypothyroidism, haemolytic anaemia, Crigler-Najjar conjugated - biliary atresia, bile duct obstruction by cyst, neonatal hepatitis e.g. by congenital infection, inborn errors of metabolism, etc. intrahepatic biliary hypoplasia

Question 20

Biliary Atresia - presentation - Ix -mx

Answer 20

progressive disease, destruction or absence of extrahepatic biliary tree and intrahepatic biliary ducts -> chronic liver failure and death unless surgery is performed. pale stools dark urine. FTT. neonatal jaundice hepatosplenomegaly - secondary to portal HTN Ix: Fasting Abdo USS may show absent/ contracted gallbladder Liver biopsy shows features of extrahepatic biliary obstruction. Diagnosis confirmed at laparotomy by operative cholangiography Tx- Kasai procedure. if surgery unsuccessful, consider liver transplantation

Question 21

mx of hepatitis A

Answer 21

supportive: rest and hydration close contacts given prophylaxis with human normal Ig or vaccinated within 2 wks of illness onset Admit if severe vomiting and dehydration, deranged liver function (abnormal clotting) and hepatic encephalopathy

Question 22

Hep A presentation

Answer 22

acute mild illness, jaundice, gastroenteritis, abdo discomfort some may develop prolonged cholestatic hepatitis (self limiting) or fulminant hepatitis diagnosis confirmed by detecting IgM antibody to the virus

Question 23

Tx of Hep C infection in children

Answer 23

Pegylated IFNa and ribavarin success rate depends on viral genotype tx not undertaken before 4 years, as it may resolve spontaneously following vertically acquired infections

Question 24

Tx of Hep B infection in children

Answer 24

all babies born to HBsAg+ mother should receive a course of hep B vaccination. Pegylated IFNa usually taken for 48 wks

Question 25

To perform a jejunal biopsy on a suspected coeliac patient who is on a gluten free diet, what is the recommendation?

Answer 25

recommendation is to eat some gluten in more than one meal every day for at least 6 weeks before testing.

Question 26

causes of acute liver failure (fulminant hepatitis) in children

Answer 26

viral: Hep A, B, C poisons/ drugs - paracetamol, isoniazid metabolic - wilsons, reye syndrome, Autoimmune hepatitis

Question 27

presenting within hours / weeks with jaundice, encephalopathy, coagulopathy, hypoglycaemia, electrolyte imbalance. encephalopathy may present as alternating periods of irritability and confusion w drowsiness.

Answer 27

Acute liver failure *impt to monitor acid-base balance (ABG/ VBG), blood glucose and coagulation times

Question 28

acute liver failure diagnosis

Answer 28

LFTS: transaminases greatly elevated. ALP increased Clotting abnormal Plasma ammonia elevated. EEG shows acute hepatic encephalopathy and CT may demonstrate cerebral oedema

Question 29

Complications of Acute liver failure

Answer 29

cerebral oedema haemorrrhage from gastritis or coagulopathy sepsis and pancreatitis

Question 30

Mx of acute liver failure

Answer 30

maintain blood glucose >4 with IV dextrose, prevent sepsis w abx and antifungal prophylaxis, preventing haemorrhage with FFP, cryoprecipitate, Vit K, and PPI or H2 blocking drugs, treat cerebral oedema by fluid restriction and mannitol diuresis, URGENT transfer to specialist liver unit.

Question 31

where is gluten commonly found?

Answer 31

wheat, barley and rye

Question 32

retinal haemorrhages in an infant?

Answer 32

shaken baby syndrome caused by intentional shaking of a child. Triad of retinal haemorrhages, subdural haematoma, and encephalopathy.

Question 33

large abdo mass often found incidentally. may sometimes be accompained by abdo pain, anorexia, anaemia (haemorrhage into mass), haematuria and hypertension.

Answer 33

wilms tumour nephroblastoma.

Question 34

Ix of suspected wilms tumour

Answer 34

USS or CT/MRI then staging for metastases (usually lung), initial tumour resectability and function of other kidney

Question 35

pulmonary hypoplasia - what are some common causes?

Answer 35

oligohydramnios + congenital diaphragmatic hernia. It is believed that oligohydramnios decreases the size of the intrathoracic cavity, thus preventing foetal lung growth

Question 36

Mx of wilms tumour

Answer 36

initial chemo followed by delayed nephrectomy. Radiotherapy restricted to those w advanced disease

Question 37

persistent localised bone pain, commonly in limbs. - likely diagnosis? - investigations? - mx?

Answer 37

osteosarcoma Plain Xray followed by MRI and bone scan Xray shows codmans triangle - lifted periosteum and destruction of bone. In Ewings’ there is often a substantial soft tissue mass. CXR for lung mets and BM sampling to exclude BM involvement. Mx in Osteosarcoma (& Ewings) - combination chemo before surgery. if resection is impossible or incomplete e.g. pelvic or axial skeleton, radiotherapy used for local disease in Ewings

Question 38

Retinoblastoma presentation

Answer 38

red reflex absent/ squint IX- MRI and examination under anaesthetic. Tx- to cure, yet preserve vision. enucleation of eye may be necessary for more advanced disease. Chemo used (esp if bilateral) to shrink the tumour followed by local laser to the retina. Radiotx may be used in advanced, but more often reserved for tx of recurrence.

Question 39

most common type of solid tumour in children?

Answer 39

CNS tumours e.g. astrocytoma (40%), medulloblastoma (20%), ependymoma (8%), brainstem glioma (6%), craniopharyngioma (4%)

Question 40

most common type of CNS tumour in child?

Answer 40

astrocytoma ranges from benign to highly malignant (glioblastoma multiforme)

Question 41

clinical features of CNS tumour

Answer 41

raised ICP + focal neuro signs dependent on site of tumour. headache, vomiting, behaviour/ personality change, visual disturbance and papilloedema. Infants- vomiting, tense fontanelle, increased head circumference, head tilt, developmental delay

Question 42

medical indications for circumcision?

Answer 42

phimosis - inability to retract foreskin. whitish scarring of the foreskin. due to localised skin disease known as balanitis xerotica obliterans. Recurrent balanoposthitis - redness + inflammation of foreskin, sometimes w dischage. Recurrent UTI

Question 43

sudden onset severe pain in groin/ lower abdomen/ scrotum. *cremasteric reflex absent

Answer 43

testicular torsion testis always tender if testicular torsion. must be relieved within 6-12 h for there to be good chance of testicular viability.

Question 44

testicular torsion mx?

Answer 44

surgical exploration. if confirmed, fixation of contralateral testis is essential because there may be anatomical predisposition to torsion.

Question 45

what increases risk of testicular torsion and risk of delayed diagnosis?

Answer 45

cryptorchidism

Question 46

epididymitis

Answer 46

feverish, +/- freq/ dysuria. Prehn’s sign: tenderness relieved by elevating the scrotum.

Question 47

most common cause of acute scrotum in child. pain, testicle red/ swollen. blue dot sign on transillumination

Answer 47

torsion of hydatid of Morgagni. aka torsion of testicular appendage.

Question 48

cryptorchidism risk factors

Answer 48

more common in preterm infants because testicular descent through inguinal canal occurs in 3rd trimester. may descend in the first 3 months of life.

Question 49

classification of cryptorchidism

Answer 49

retractile - can be manipulated to the bottom but subsequently retracts, pulled up by the cremasteric muscle. with age, testis resides permanently in scrotum but follow up is advisable. Palpable - testes can be palpated but not manipulated into scrotum. Impalpable - no testis felt. may be in the inguinal canal, intra abdo or absent.

Question 50

IX of cryptorchidism

Answer 50

USS - to verify internal pelvic organs Hormonal - inject hCG for rise of testosterone to confirm presence of testicular tissue Laparoscopy - investigation of choice for impalpable testes.

Question 51

Mx of cryptorchidism

Answer 51

surgical placement of testis in scrotum (orchidopexy) for: fertility- optimal temp for spermatogenesis. malignancy- increased malignancy risk. scrotal testes more easily examinable and can be picked up earlier. Cosmetic and psyschological reasons. *if bilateral impalpable testes, usually sterile. if unilat, fertility close to normal.

Question 52

intermittent swelling in groin or scrotum on crying or straining. swelling may become visible on raising intra abdo pressure by gently pressing abdo. may also present as irreducible lump which is firm and tender.

Answer 52

inguinal hernia. due to patent processus vaginalis.

Question 53

mx of inguinal hernia

Answer 53

incarcerated- emergency surgery irreducible but stable- opioid analgesia + sustained gentle compression may be able to reduce hernia. surgery delayed for 24-48 h to allow resolution of oedema

Question 54

acute renal failure (uraemia), thrombocytopenia, MAHA. usually secondary to GI infection. prodrome of bloody diarrhoea

Answer 54

Haemolytic Uraemic Syndrome early supportive therapy including dialysis. follow up is necessary as there may be persistent proteinuria and HTN and declining renal function in subsequent years.

Question 55

if metabolic acidosis due to acute renal failure- mx?

Answer 55

sodium bicarbonate

Question 56

if hyperphosphataemia due to acute renal failure- mx?

Answer 56

calcium carbonate + dietary restriction

Question 57

if hyperK due to acute renal failure- mx?

Answer 57

calcium gluconate, salbutamol, glucose+ insulin, dietary restriction, dialysis

Question 58

when is dialysis indicated?

Answer 58

failure of conservative mx, hyperK, severe acidosis, severe hypo/hyperNa, pulmonary oedema or HTN, multisystem failure,

Question 59

Staging of Perthes Disease

Answer 59

Stage 1: clinical and histological features only Stage 2: sclerosis with or without cystic changes and preservation of the articular surface Stage 3: loss of structural integrity of the femoral head Stage 4: loss of acetabular integrity.

Question 60

monitoring of growth of children below 0.4 gentile for height

Answer 60

should be reviewed by a paediatrician

Question 61

monitoring of growth of children below 2nd centile

Answer 61

reviewed by GP

Question 62

1st hearing test in newborn

Answer 62

automated otoacoustic emissions test’ or ‘evoked otoacoustic emissions test’

Question 63

if automated otoacoustic emissions test is +ve, what test do you do?

Answer 63

automated auditory brainstem response test

Question 64

what hearing test may be performed on a 6-9 month old?

Answer 64

distraction test

Question 65

what hearing test may be performed in those >3 yrs

Answer 65

pure tone audiometry

Question 66

congenital diaphragmatic hernia

Answer 66

birth defect of the diaphragm. malformation of the diaphragm allows the abdominal organs to push into the chest cavity, hindering proper lung formation. -> pulmonary hypoplasia and pulmonary HTN

Question 67

Choanal atresia

Answer 67

congenital disorder where the back of nasal passage is blocked. may present as cyanosis while baby is feeding, because the oral air passages are blocked by the tongue. cyanosis may improve when the baby cries, as the oral airway is used at this time. - may require resuscitation. assoc w other congenital malformations e.g. coloboma babies w bilateral disease are obligate mouth breathers. tx w fenestration procedures designed to restore patency.

Question 68

intraventricular haemorrhage

Answer 68

Intraventricular haemorrhage is a haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together the with the delicate neonatal CNS.

Question 69

Tx of intraventricular haemorrhage

Answer 69

Is largely supportive, therapies such as intraventricular thrombolysis and prophylactic CSF drainage have been trialled and not demonstrated to show benefit. Hydrocephalus and rising ICP is an indication for shunting.

Question 70

Mx of croup

Answer 70

Oral dexamethasone 0.15mg/ kg (or prednisolone) Emergency tx if severe: high flow O2, nebulised adrenaline.

Question 71

The mother of a 6-week-old baby girl born at 32 weeks gestation asks for advice about immunisation. What should happen regarding the first set of vaccines?

Answer 71

Give as per normal timetable.

Question 72

recommended period to be kept away from school for chickenpox

Answer 72

5 days from start of eruption. but all lesions should be crusted over by then.

Question 73

the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’.

Answer 73

This is a normal variant and runs in families

Question 74

1st line for constipation in children

Answer 74

movicol paediatric plain

Question 75

Mx for constipation in children

Answer 75

first-line: Movicol Paediatric Plain add a stimulant laxative (Senna) if no response substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce dose gradually

Question 76

constipation in breast fed infants

Answer 76

unusual and organic causes should be considered

Question 77

social hx in paeds?

Answer 77

social services?

who lives at home?

coping?

smoking in the household?

if older child: ask about school/ any problems

Question 78

progressive weight loss, constipation, muscular atrophy, loss of skin turgor, hypothermia and possible, oedema.

in advanced disease, affected infants are lethargic and can have starvation diarrhoea, with small, mucus-containing stools.

these children appear emaciated and cachetic.

Answer 78

marasmus

(infantile atrophy)

due to inadequate caloric intake that can be linked w factors such as insufficient food resources, poor feeding techniques, metabolic disorders and congenital anomalies.

Question 79

autosomal dominant disorder, distinctive white forlock, heterochromia irides, unilateral or bilateral congenital deafness and lateral displacement of the inner canthi.

Answer 79

waardenburg syndrome

Question 80

autosomal dominant, tall stature, long slender limbs, hypermobile joints, lens subluxation and myopia, and mitral valve prolapse.

aortic dilatation and dissection are potential complications.

Answer 80

Marfans syndrome

Question 81

iron toxicity in infants

Answer 81

as few as 3 tablets can cause severe symptoms and as few as 10 can be lethal.

symptoms occur in two phases: GI symptoms such as bloody vomiting or diarhhoea and abdo pain, followed by a

latent period of up to 12h or more and terminating w CV collapse.

Desferrioxamine given

Question 82

sacral agenesis assoc w ?

Answer 82

maternal diabetes mellitus

also higher risk of cardiac defects e.g. TGA, VSD, renal defects

and anencephaly

Question 83

use of antivconvulsants phenytoin and valproate during pregnancy assoc w?

Answer 83

fetal hydantoin syndrome

IUGR, hypoplasia of distal phalanges and nails, alterations in CNS performance.

with valproate, increased risk of neural tube defects in the first trimester

Question 84

neonatal lupus erythematosus

Answer 84

skin lesions

AV block (permanent) -> heart block*

TGA

valavular and septal defects.

Question 85

scabies in children tx

Answer 85

permethrin 5% cream

Question 86

what vit should be given to all children w measles?

in communities where this vit deficiency is prtevalent

Answer 86

vit A.

Question 87

What Vit is given to newborns to prevent haemorrhagic disease of the newborn?

Answer 87

Vit K

lack of free Vitamin K in the mother and the absence of bacterial intestinal flora that synthesizes vit K result in a transient deficiency in vit k depenedent factors.

Question 88

what is short stature defined as?

and when is it abnormal?

Answer 88

height below the 2nd or 0.4th centile.

abnormal if child is falling across centile lines.

Height velocity should be calculated.

height must be compared to weight centile and estimate of genetic target centile, which is calculated as mean of fathers and mothers height, with 7cm added for boy and 7cm subtracted for a girl.

Question 89

how to calculate height velocity?

Answer 89

2 accurate measurements of height velocity at least 6 months (but preferably 1 year) apart.

calculated as cm/ year.

If height velocity is persistently below 25th centile -> abnormal and child will eventually be short.

Question 90

causes of short stature

Answer 90

familial- short parents

IUGR - born w severe IUGR or extremely preterm (GH tx may be indicated)

Endocrine - hypothyroid, GH deficiency, steroid excess (usually weight centile > height centile)

Constitutional delay

Chronic illness (e.g. coeliac)

restricted diet, psychosocial deprivation

chromosomal abnormalities

Question 91

Ix of short stature

Answer 91

Growth charts

with clinical features usually allows diagnosis.

Bone age may be indicated. (X ray of hand and wrist for bone age)

Question 92

Constitutional delay

presentation

Answer 92

more common in males.

often familial.

variation of normal timing of puberty.

may also be due to dieting or excessive excercise.

will have delayed sexual changes compared to peers, and bone age would show moderate delay. (legs will be long in comparison to back).

Eventually target height is reached.

Question 93

Ix of constitutional delay

Answer 93

If puberty abnormally late,

bone age measurement from hand/ wrist Xray - usually delayed.

in females: pelvic USS can help determine uterine size and endometrial thickness.

Question 94

Mx of constitutional delay

Answer 94

onset of puberty can be induced w short course of androgens or oestrogens.

Question 95

what syndromes may cause tall stature?

Answer 95

marfan, homocystinuria, klinefelters.

Question 96

when is puberty considered to be delayed in females? and males?

Answer 96

>14 for females

>16 for males

Question 97

Causes of pubertal delay

Answer 97

constitional delay of puberty and growth

hypogonadotrophic hypogonadism-

e.g. kallmanns, congenital hypopituitarism, isolated LH/FSH deficiency, intracranial tumours, anorexia nervosa, excessive exercise, chronic illness.

Primary gonadal failure-

chromosomal, LH resistance, chemotherapy, gonadal irradiation/ infection/ trauma

Question 98

examination for delayed puberty

Answer 98

height, weight, HC - growth charts

measure parents heights and midparental height

puberty staging

Question 99

Ix in delayed puberty

Answer 99

LH, FSH. oestrogen/ testosterone levels

karyotype if any dysmorphic features or suspicion.

TFTs, routine biochemistry and CRP/ESR.

Bone age xray, Pelvic USS for ovarian morphology or intra abdo testes.

Question 100

specific test to measure for levels of testosterone?

Answer 100

hCG stimulation test

• measurement of testosterone pre and post HCG

Question 101

special test for LH and FSH in delayed puberty?

Answer 101

GnRH test

• measurement of basal LH/FSH and post GnRH to measure gonadal function.

Question 103

Abx for upper UTI?

Answer 103

Cefotaxime

if <3 months: IV for sure.

>3 mths: IV/ Oral for 10 days

if >3 months: ceftriaxone / co-amoxiclav.

Question 104

Abx for lower UTI?

Answer 104

oral 3 day course

trimethoprim, nitrofuratoin, cefotaxime.

Question 105

what is McBurney’s point?

Answer 105

found 1/3 of the way between the ASIS and the umbilicus

pain over mcburneys point seen in appendicitis

Question 106

What is the Rovsing’s sign?

Answer 106

palpation over the LIF causes pain in RIF

Seen in acute appendicitis

Question 107

common causes of mesenteric adenitis

Answer 107

inflammation of mesenteric lymph nodes

commonly following viral URTI, or with tonsillitis/ otitis media.

Question 108

symptoms of DKA

Answer 108

poyluria, polydipsia

lethargy

weight loss

abdo pain

n+v

laboured breathing (resp compensation for the acidosis)

Question 109

what does a full septic screen involve?

Answer 109

blood cultures, urine cultures, lumbar puncture for CSF

CXR

FBC, U+Es + glucose

usually for <3 months with high fever

Question 110

Complications of gastro oesophageal reflux

Answer 110

apnoea

failure to thrive

aspiration

oesophagitis -> Pain, bleeding, iron deficiency

Sandifer’s syndrome -> dystonic movements of head and neck and arching of back that resembles seizures

Question 111

ABC DEFG

Answer 111

ABC

dont ever forget glucose

Question 112

neonatal hypoglycaemia

symptoms

Answer 112

may be asymptomatic

or jittery, convulsions, hypotonia, lethargy, apnoea

Question 113

Risk factors for neonatal hypoglycaemia

Answer 113

preterm (<37), babies <2.5kg, IUGR

babies of mothers with GDM/ on BB for preeclampsia

prolonged, symptomatic hypoglycaemia can cause permanent neurological disability.

Question 114

Signs of shaken baby syndrome

Non accidental injury

Answer 114

retinal haemorrhages

skull fractures

swelling of the brain

subdural haematomas

rib and long bone fractures

bruises around the head, neck, or chest

torn frenulum

Question 115

Live attenuated vaccine given intradermally to at risk infants

Answer 115

BCG

Question 116

inactivated virus given at 2, 3, 4 months, preschool booster and again at 13-18 yrs

to prevent muscle paralysis.

Answer 116

Polio

(Salk)

Question 117

When is Men C given to children?

Answer 117

12-13 months

with Hib Vaccine

+ MMR + PCV + MenB

Question 118

when are Men B + PCV given?

Answer 118

2, 4 and 12-13 months

Question 119

Pertussis - when is the vaccine given?

Answer 119

2, 3, 4 months, preschool booster.

Question 120

vaccine that is given 2, 3, 4 months, preschool and again at 13-18 yrs to prevent disease that causes thick gray coating in the back of throat/ nose (‘pseudomembrane’)

Answer 120

Diphtheria

thick gery-white coating at back of throat

high fever

malaise

sore throat

headache

swollen cervical LNs

difficulty breathing and swallowiing

cutaneous - pus filled blisters, large ulcers

Question 121

what factors should initiate a higher level of suspicion of non accidental injury?

Answer 121

discrepancy between injury/ presentation and hx given

change in hx over time or between different ppl

delay in presentation

unusual reaction to the injury

repeated injuries

hx of NAI/ suspicious injury in sibling

other signs of neglect / FTT

Question 122

osteogenesis imperfecta

features

Answer 122

bony fragility -> recurrent fractures and deformity

wormian bones may be seen on skull Xray

(irregular, isolated bones found within skull sutures- not fractures)

sclerae are blue

assoc w conductive hearing deafness and

aortic valve regurgitation - Diastolic mumur

Question 123

e.g.s of short acting beta2 agonists for asthma

Answer 123

salbutamol

terbutaline

Question 124

e.g.s of inhaled steroid

in asthma

Answer 124

budesonide

fluticasone

Question 125

how to administer leukotriene receptor antagonists in children w asthma

Answer 125

oral

can be sprinkled onto foods such as yoghurt or cereal

Question 126

eg. of long acting b2 agonist in asthma

Answer 126

salmeterol

formoterol

Question 127

features of severe asthma

Answer 127

pt too breathless to talk or feed

PEF <50% predicted or best

RR >50

Pulse >140

Question 128

Features of life threatening exacerbation of asthma

Answer 128

silent chest

poor resp effort

PEF <33% predicted or best

decreasing consciousness

fatigue/ exhaustion

Question 129

Mx of life threatening asthma

Answer 129

Oxygen

Nebulised salbutamol (back to back + cardiac monitoring)

oral/ Iv steroids

may need IV salbutamol +/- IV aminophylline

or transfer to ITU

if >5 yrs, IV mg so4 can be used

Question 130

Gold standard for how to get a urine sample in a child

Answer 130

clean catch urine

Question 131

learning difficulties, progressive visual impairment due to retinal changes, polydactyly and syndactyly, hypogenitalism and nephropathy

Answer 131

Laurence Mood Biedl syndrome

Question 132

coarse facial features, large tongue, hoarse cry, hypotonia, lethargy, umbilical hernia, constipation and prolonged jaundice

Answer 132

congenital hypothyroidism

rarely made as a clinical diagnosis now due to screening using the Guthrie card

Question 133

pansystolic murmur in the 5th intercostal space, left of the sternum

Answer 133

VSD

murmur caused by shunting of blood from the high pressure L ventricle to the low pressure R ventricle

Question 134

Mitral stenosis murmur

Answer 134

end diastolic in the 5th intercostal space, left side (apex)

almost always caused by rheumatic fever

Question 135

ejection systolic murmure

Upper Right Sternal Edge

Answer 135

Aortic stenosis

If critical, HF will ensue rapidly after birth.

there may be an ejection click and radiation to the carotids

Question 136

ejection systolic murmur

upper left sternal edge

Answer 136

pulmonary stenosis

critical stenosis will present rapidly when the ductus arteriosus closes

mx is w dilatation of stenosis w balloon or surgical correction

Question 137

machinery murmur (in both systolic and diastolic)

inferior to left clavicle

Answer 137

patent ductus arteriosus

Question 138

first line mx in bacterial gastroenteritis

Answer 138

Oral rehydration.

Question 139

toddlers diarrhoea

Answer 139

common between 1-5 yrs

often description of food in the diarrhoea

in otherwise well child

Question 140

e.g.s of osmotic laxatives

Answer 140

movicol (a macrogol- polyethylene glycol)

lactulose

Question 141

signet ring inclusions

Answer 141

malaria

Question 142

Mx of incarcerated inguinal hernia

Answer 142

treat the severe dehydration

reduction of hernia and possible resection of necrotic bowel

Question 143

what is an antacid we can use in gastrooesophageal reflux?

Answer 143

gaviscon

Question 144

what is a promotility drug we can use in gastrooesophageal reflux

Answer 144

erythromycin

domperidone

metoclopramide

Question 145

Proton pump inhibitors we can use in gastrooesophageal reflux

Answer 145

omeprazole

Question 146

H2 receptor antagonists that we can use in gastrooesophageal reflux

Answer 146

ranitidine

Question 147

double bubble sign on abdo xray

• presence of air in the stomach and proximal duodenum only, and not in the distal intestines

Answer 147

Duodenal atresia

about 1/3 have Downs

present at birth w bilious vomiting and abdo distension

tx by duodeno-duodenostomy

Question 148

gastroschisis

Answer 148

defect in ant abdo wall adjacent to umbilicus

abdo contents can herniate through this defect, but there is no sac covering the contents

Mx: immediately covering the exposed viscera w cling film, followed by surgical repair.

Question 149

Exomphalos

Answer 149

herniation of abdo contents through umbilicus

herniated viscera surrounded by a sac and this structure known as an omphalocele

surgical closure is required.

assoc w other congenital malformations such as trisomies and cardiac defects

Question 150

Meckel’s diverticulum

Answer 150

congenital diverticulum that contains gastric-type mucosa

usually found 2 feet proximal to ileocaecal junction, 2 inches in length and occurs in 2% of population

most common presentation- painless rectal bleeding

some may present w acute inflammation similar to acute appendicitis.

Dx by technetium-99m scan

Tx by resection if required.

Question 151

complications of septic arthritis

Answer 151

joint destruction leading to arthritis

spread of infection to bone - osteomyelitis

ankylosis- bony fusion across the joint

Question 152

talipes equinovarus

= clubfoot

Answer 152

foot is inverted and plantar flexed

talipes is the most common congenital abnormality

half of the cases are bilateral.

may be secondary to intrauterine compression (oligohydramnios) or a neuromuscular disorder (such as spina bifida)

mx: passive stretching and strapping.

if deformity is severe, then corrective surgery required.

Question 153

genu varus

Answer 153

bowlegs

Question 154

congenital disorder w lymphoedema of hands and feet in the neonatal period, coarctation of the aorta (femoral pulses hard to palpate)

Answer 154

45XO turners syndrome

Question 155

Stills diseae

Answer 155

systemic form of Juvenile arthritis

autoimmune

intermittent high pyrexia and salmon pink rash w aches and pains of the joints and muscles

+ hepatosplenomegaly, lymphadenopathy and pericarditis.

CRP raised.

Mx includes physiotherapy, resting splints, NSAIDs, DMARDs e.g. methotexate, ciclosporin, and steroids.

Question 156

why does rheumatic fever occur following strep infections?

Answer 156

ususally 2-4 wks after group A strep

in susceptible individuals, antibodies formed against the bacterial carbohydrate cell wall cross react w antigens in the heart, joints and skin in a process known as molecular mimicry,

Question 157

Diagnosis of Rheumatic fever

Answer 157

2 major or 1 major + 2 minor + evidence of strep infection

Major:

Pancarditis - myocarditis, pericarditis, endocarditis

Polyarthritis

Sydenhams chorea (St vitus’ dance)

erythema marginatum

subcutaneous nodules

Minor:

fever

arthralgia

high ESR/ WCC

heart block

Serial ASOT titres

Question 158

what are the major criteria for rheumatic fever

Answer 158

Pancarditis - myocarditis, pericarditis, endocarditis

Polyarthritis

Sydenhams chorea (St vitus’ dance)

erythema marginatum

subcutaneous nodules

Question 159

Minor criteria for Rheumatic fever

Answer 159

fever

arthralgia

high ESR/ WCC

heart block

Question 160

Pancarditiis in rheumatic fever can present w?

Answer 160

murmurs - incl mitral stenosis, mitral regurgitation, aortic regurgitation

Carey Coombs murmur (soft mid diastolic murmur tt ocurs due to nodule development on mitral valve leaflets)

pericarditis

myocarditis

endocarditis

Question 161

Mx of rheumatic fever

Answer 161

Penicilliin

analgesia

NSAIDs

bed rest

if severe, steroids

following acute phase, patients require prophylactic abx prior to invasive procedures such as tooth extraciton in order to protect against bacteraemia and subsequent bacterial endocarditis.

Question 162

TORCH screen?

Answer 162

Toxoplasmosis

Other - Syphilis

Rubella

CMV- most common

HSV

Question 163

Mx of patent ductus arteriosus w subsequent heart failure

Answer 163

HF should be treated w duretics, such as frusemide and spironolactone

patent ductus arteriosus then plugged via catheter inserted into the femoral artery.

only if this fails should open cardiothoracic surgery be performed

Question 164

same presentation as coeliac

biopsy shows villous atrophy and motile trophozoites

Answer 164

Giardiasis

chronic infection causes malabsorption, particularly of carbohydrates and fat

deficiency of fat soluble Vit A D E K

stool cultures may be taken to look for cysts

tx - oral metronidazole

Question 165

tx of giardiasis

Answer 165

oral metronidazole

Question 166

haematuria after vigorous forms of exercise?

Answer 166

stress haematuria

aka

exercise induced haematuria

painless and of short duration

later repeated samples will be clear

Question 167

IgA nephropathy

Answer 167

assoc w Henoch schonlein purpura

causes haematuria 2 days after an URTI

Question 168

Triad of glomerual BM degeneration, sensorineual deafness, and ocular abnormalities

Answer 168

Alports syndrome

second most common inherited cause of chronic renal failure (after polycystic disease)

an x linked mutation causes degeneration of type IV collagen, found in the BM, cochlea and eye

Question 169

haematuria after prolonged surgery?

Answer 169

rhabdomyolysis

• breakdown of muscle fibres w release into the blood of myoglobiin which is excreted into the urine.

tx w IV rehydration to aid excretion of myoglobin and prevent renal failure.

Question 170

Immediate mx of Crohns with anal fissure and anal tags?

Answer 170

Tx underlying constipation w laxatives.

2nd line: topical preparations that relax the anal sphincter can be used, such as glyceryl trinitrate or diltiazem pastes.

Question 171

pica

nervous, GI and haem systems affected

abdo pain, constipation, headaches

encephalopathic signs

hypochromic microcytic anaemia

blood film demonstrates basophilic stippling

Answer 171

Lead poisoning

examination may reveal a bluish line along the gums.

lead found in paint.

Ix: measure blood lead levels

tx: chelation of lead using EDTA (ethylenediamine tetraacetic acid)

Question 172

meconium ileum in CF

mx?

Answer 172

initial mx is with gastrograffin enema, which is both diagnostic and therapeutic.

if child is peritonitic -> gastrograffin enema is contraindicated and a laparotomy and bowel resecetion should be performed

start immediately on prophylactic flucloxacillin to protect lung function

Question 173

Diagnosis of sickle cell disease

Answer 173

blood film appearance,

haemoglobin electrophoresis

Question 174

Mx of inhalation of foreign body

Answer 174

CXR may locate the foreign object

but needs to removed by rigid bronchoscopy under anaesthesia.

Question 175

retropharyngeal abscess

presentation

Answer 175

fever, drooling, dysphagia, stridor

similar to acute epiglottitis but air entry still fine.

occasionally, head tilted to one side and neck may be stiff (torticollis)

Mx: abscess needs to be drained with antibiotic cover

Question 176

what age would a child be walkinging alone, feet apart, arms assisting balance?

Answer 176

15 months

Question 177

at what age would a child be able to draw squares and triangles?

Answer 177

5 years

Question 178

at what age will a child be able to walk on a narrow line?

Answer 178

5 yrs

Question 179

at what age can a child fix and follow 180 through the horizontal plane?

and fix and follow 90?

Answer 179

180 degrees- 3 months

90 degrees- 6 wks

Question 180

at what age can a child hop on one foot?

Answer 180

4 years

Question 181

hereditary angioedema

• what deficiency?

Answer 181

C1 esterase inhibitor deficiency

C1 esterase inhibitor acts as a mediator of complement proteins of the immune system. Lack of this protein -> complement system goes unchecked + accumulation of vasoactive inflammatory mediators.

Question 182

Angioedema

• presentation

Answer 182

intermittent itchy swelling of the face, lips, pharynx and limbs, along with abdo pain, vomiting and diarrhoea.

attacks of herediatry angioedema can be mistaken for anaphylaxis.

there is often no identifiable trigger for attacks of hereditary angioedema, although recognized precipitators include minor trauma and strenuous exercise.

laryngeal oedema is the most concerning complication, and can be fatal

Question 183

Mx of acute episode of angioedema

Answer 183

IV C1 esterase inhibitor concentrate

long term mx with anabolic steroids e.g. danazol

helps promote synthesis of C1 esterase inhibitor.

Question 184

Nephrotic syndrome complications

Answer 184

ascites -> can become infected (peritonitis)

pulmonary oedema

loss of immunoglobulins in the urine-> high risk of pneumococcal and haemophilus infections

Question 185

Mx of nephrotic syndrome

Answer 185

prednisolone to induce remission

salt restriction and replacement of fluids with human albumin solution may be required.

Prophylactic penicillin.

Question 186

Congenital adrenal hyperplasia

• enzyme deficiency
• what accumulates?

Answer 186

21 hydroxylase (autosomal recessive deficiency)

excess 17-hydroxyprogesterone

Question 187

Mx of SIADH

Answer 187

restrict total intake of fluids

monitor daily - electrolytes, serial serum and urine osmolality

in severe cases: hypertonic saline and concurrent furosemide.

Question 188

CXR - boot shaped heart, where the normally convex-shaped pulmonary artery on the L heart border becomes a concavity.

Answer 188

tetralogy of fallot

Question 189

neonatal teeth mx

Answer 189

neonatal teeth are often removed, as there is a risk of aspiration and they can cause problems w breastfeeding.

Question 190

infantile colic

Answer 190

description of a baby who cries for more than a total of 3 h in any 3 days of 3 consecutive wks

tx is supportive, and the baby w colic usually settles by the fourth month of life.

Question 191

Mx of tetany

Answer 191

anti tetanospasmin Immunoglobulins

Question 192

Fever, malaise, pharyngitis, tonsillitis, lymphadenopathy.

Petechiae on the soft palate, jaundice, splenomegaly and hepatomegaly

Administration of amoxicillin/ ampicillin causes widespread maculopapular rash.

Answer 192

Infectious mono (glandular fever)

Caused by EBV

Diagnosis via monospot test/ Paul Bunnell test

Tx is symptomatic.

*Administration of amoxicillin/ ampicillin in infectious mono causes widespread maculopapular rash.

This rash can scar.

Better to administer penicillin instead if wanting to tx for bacterial tonsillitis but cannot rule out Infectious mono.

Question 193

Ddx of acute epiglottitis

Answer 193

Retropharyngeal abscess

Often preceded by an URTI

Presents w fever, drooling, dysphagia and stridor.

Head may be tilted to one side and neck may be stiff.

Question 194

unvaccinated child

flu-like illness associated w muscle pain, flaccid paralysis and areflexia.

cranial n dysfunction-> deafness, blindness, dysarthria and dysphagia.

Answer 194

Poliomyelitis

acute disorder of the anterior horn cells caused by the highly contagious RNA poliovirus.

affects lower motor neurones.

paralysis of the resp muscles warrant mx w non invasive negative pressure ventilator.

Question 195

Severe dysphagia, earache and trismus (lockjaw)

Inspection of the pharynx shows a unilateral bulge of the soft palate, w deviation of the uvula to the opposite side.

Tonsils inflamed + halitosis

Answer 195

Peritonsillar Abscess (Quinsy)

Collection of pus outside the tonsil – complication of tonsillitis

Question 196

White plaques in mouth

May be immunosuppressed/ recently used antibiotics

Dysphagia, odynophagia and hoarse voice

Answer 196

Candida.

Oesophageal candidiasis can be treated w antifungals such as fluconazole, nystatin or amphotericin.

Question 197

skin lesions of TB

Answer 197

erythema nodosum - painful inflamed rash on the lower limbs

lupus vulgaris - painful, nodular, disfiguring lesions, predominantly on the face

Question 198

recurrent fevers on uncertain origin + erythema nodosum

Answer 198

TB

Question 199

wound on the back of hand there for 7-14 days

painful, hot, regional lymphadenitis and flu like symptoms.

fever

if severe, altered mental state and convulsions

Answer 199

cat scratch fever

infection w gram negative bacterium bartonella henselae

tx w antibiotics.

Question 200

Prader- Willi syndrome

Angelman syndrome

• inheritance pattern?

Answer 200

imprinting

• gene required for normal function comes from only one parent

syndrome ensues when gene is deleted or both genes come from the other parent (uniparental disomy)

Question 201

williams syndrome

short stature, elf like faces, transient hypercalcaemia as infants, supravalvular aortic stenosis and mild to moderate learning difficulties

inheritance pattern?

Answer 201

microdeletion

at chr 7q11

Question 202

Tx of acute sinusitis

Answer 202

antibiotics if bacterial infection is suspected

analgesia

vasoconstricting nose drops (1% ephedrine) aid drainage of the sinus

Question 203

Labial Adhesions

Answer 203

relatively common in prepubertal girls

caused by recurrent irritation, trauma or infection

prepubescent labia are prone to adhesions due to lack of oestrogenized epithelium.

bleeding and dysuria are common.

most cases will require no tx

tx required if pt is symptomatic w dysuria or freq vulval or vaginal infections.

most cases respond w topical oestrogen tx.

if unsuccessful, symptomatic cases need surgical intervention.

Question 204

Mx of phimosis

Answer 204

No treatment needed

Only if prepuce remains non retractile or he has UTI/ balanitis secondary to phimosis, should surgical correction be performed.

Question 205

Mx of paraphimosis

Answer 205

Administer local anaesthetic ring block to the glans followed by simultaneous squeezing of the glans and reduction of the foreskin.

After paraphimosis, formal circumcision should be performed to prevent recurrence.

urological emergency. Paraphimosis is caused by retraction of a tight foreskin over the glans. The foreskin then acts as a tight band, making it more difficult to reduce the skin. may cause necrosis/ gangrene.

Question 206

Petechiae vs purpura?

Answer 206

Petechiae are pinpoint, flat, red lesions that do not blanch on pressure. Caused by capillary bleeding into the skin.

Purpura comprises larger lesions that are red, brown or purple. They do not blanch w pressure, are raised and may be palpable.

Question 207

Henoch Schonlein purpura

What features?

Answer 207

Often preceded by URTI esp strep infections

Non thrombocytopenic palpable purpura (usually on buttocks and extensor surfaces of lower limbs), arthralgia, periarticular oedema, colicky abdo pain and glomerulonephritis.

Rash is initially uritcarial, rapidly becoming purpuric.

Tx is symptomatic.

Question 208

Why may a child w pertussis cause petechiae in the upper limbs/ face?

Answer 208

Both coughing and vomiting can cause increased pressure in the SVC region, resulting in bleeding from the superficial capillaries into the skin.

Question 209

thick yellow scale and crust on the scalp of a young child

Answer 209

seborrhoeic dermatitis

Question 210

prophylactic tx for migraines in children?

Answer 210

topiamate and propranolol

(>12 yrs old)

CKD does not recommend preventative tx in primary care unless the HCP has a specialist interest in headaches (consider expert advice/ referral).

Question 211

what is given alongside iv antibiotics in bacterial meningitis, to reduce the incidence of neuorlogical complications?

Answer 211

IV dexamethasone

Question 212

1st thing to do when a premature infant is born?

Answer 212

put a hat on the babys head and a plastic bag over his body

Question 213

what are oesophageal atresias assoc with?

Answer 213

92% assoc w tracheo-oesophageal fistula

Question 214

catch-up growth for weight in early childhood is a risk factor for obesity

Answer 214

e.g. when a child is in 0.4th centile at term birth but then 50th centile at 2 yrs old.

Question 215

Answer 215

strawberry naevus

bright red and irregular

enlarge in size initially and then shrink and disappear by the age of 4 to 5 years.

Question 216

Answer 216

epstein pearls

seen in over half of newborns and caused by entrapment of fluid during development of the palate

they disappear within a few wks and are harmless.

Question 217

erythema toxicum neonatorum

Answer 217

baby acne

seen in about half of newborns and despite the name, is completely harmless.

classically, there are small pustule like spots on a red base and the fleeting nature is characteristic.

Question 218

white flecks on the iris in Downs

Answer 218

brushfield spots

Question 219

newborn with macroglossia, macrosomia, microcephaly, midline abdominal wall defects (omphalocele/ exomphalos, umbilical hernia), ear creases, nenonatal hypoglycemia

Answer 219

Bechwith-Wiedemann syndrome

Question 220

a 10 yr old boy with T1DM has recurrent abdo pain, oily loose stools and recurrent episodes of hypoglycemia.

what is the cause of the abdo pain?

Answer 220

coeliac disease

T1DM is an autoimmune condition and there is an increased risk of other immune-mediated diseases, such as coeliac disease, which is characterized by features of malabsorption.

Question 221

3 month old boy has had severe gastroenteritis, for which he has required intravenous rehydration. On reintroduction of feeds, his diarrhoea has worsened and he has increasing abdominal discomfort and distension and borborygni.

what is the cause of abdo pain?

Answer 221

transient lactose intolerance

following gastroenteritis, the gut can take some time to heal completely, and there may be a transient lactose intolerance.

this will cause symptoms of malabsorption.

Question 222

orange-red stains in nappy

Answer 222

urate crystals

may be noticed in the first couple of days after birth.

often mistaken for blood.

a sign of overconcentrated urine.

if there is any doubt, the red area can be eluted into some water in a specimen pot and tested with a urine dipstick. it will be negative if urate crystals are the cause,

Question 223

episodes that occur on waking

tingling on one side of the mouth, and then makes a gurgling noise and cannot speak properly.

he finally makes small jerking movements, which spread from his arm to his leg on the left side.

afterwards he is sleepy for several hours.

Answer 223

beinign rolandic epilepsy

Question 224

Answer 224

double bubble sign

duodenal atresia

Question 225

which feature of downs syndrome occurs most frequently?

Answer 225

intellectual impairment

Question 226

In the U.K., the perinatal mortality rate is approximately 6 per 1000 births. The World Health Organization (WHO) defines the Perinatal mortality rate as

Answer 226

The number of stillbirths (of at least 22 completed weeks of gestation) plus the number of neonatal deaths within the first 7 days of life per 1000 births.

Question 227

nephrotic syndrome ix?

Answer 227

lipids: cholesterol and triglyceride levels (elevated in nephrotic syndrome)

ASOT titre + C3/4 levels (post strep GN)

ANA (vasculitides e.g. SLE)

Hep B antibodies of at risk population - rare cause of nephrotic syndrome

measles and VZ antibodies (impt to know as children on immunosuppressive therapy such as steroids are more vulnerable to these conditions)

blood culture if febrile

Urine- Dip + MCS + Spot Protein.creatinine ratio (should be >2 in nephrotic syndrome)

Question 229

mx of nephrotic syndrome

Answer 229

prednisolone as a single morning dose for 4 wks follwed by a prolonged reducing regime.

+ prophylactic penicillin (due to increased risk of bacterial infections- immunosuppression + loss if Ig in the urine)

assess fluid balance of child, esp if hypoabluminaemia or vomting/ diarrhoea.

if hypovolaemic -> IV fluids, or IV albumin

Question 230

what % of patients w nephrotic syndrome will relapse again?

Answer 230

70%

Question 231

Complications of nephrotic syndrome

Answer 231

• hypovolaemia -> iv fluids/ albumin
• bacterial sepsis - most common strep pneumoniae and bacterial peritonitis.
• thromboembolic events due to hyperviscosity e.g. PE/ DVT/ renal vein thrombosis

Question 232

examination of a bedwetter

Answer 232

gentalia and spine inspected for abnormalities,

assess lower limb neurology

Question 233

DDx of primary nocturnal enuresis

Answer 233

lack of arousal from sleep - enuresis alarm w star chart

bladder instability - bladder retraining, anticholinergic medication

low functional bladder capacity

Question 234

most common cause of hypertension in pubertal children?

Answer 234

essential (idiopathic) HTN - usually assoc w obesity.

*if prepubertal- there is often a cause

Question 235

Idiopathic HTN Mx

Answer 235

BP repeated at least 3 x at weekly intervals

• to determine if elevation is sustained.

plot BP on centile chart.

Lifestyle changes.

referral to dietician + advice about low salt/ low fat diet

total of 1 hr of exercise a day is recommended

if the raised BP is confirmed, a BB/ CCB may be used.

Question 236

causes of HTN

CREED

Answer 236

Cardiological - e.g. coarctation of the aorta

Renal - e.g. GN, renal artery stenosis

Essential

Endocrine e.g. Cushings, thyrotoxicosis, phaeochromocytoma

Drugs e.g. steroids, COCP, amphetamines

Question 237

Ix of HTN in an adolescent

Answer 237

24 hr ambulatory BP monitoring to confirm diagnosis

renal USS - renal disease?

ECG - cardiac pathology?

Fasting Glucose (to rule out T2DM- potential consequence of obesity)

Lipids: cholesterol and triglyceride levels

Question 238

complications of measles

Answer 238

pneumonia

suppurative otitis media

corneal ulceration

gastroenteritis

febrile convulsions

encephalomyelitis

encephalitis

subacute sclerosing panencephalitis

Question 239

lymph node features in bacterial vs viral vs TB infection?

Answer 239

bacterial infections -

overlying skin is usually erythematous and lump is warm and tender.

occasionally, the swelling may become fluctuant and this is indicative of pus formation and an abscess -> referral to surgeon for incision and drainage.

viral infections-

nodes are tender but not usually warm/ erythematous.

TB infection

lump usually cold and non tender

lymphoma-

non tender, tends to be firmer than inflammatory nodes and may be adherent to the overlying skin or underlying structures.

Question 240

characteristic Xray features of osteosarcoma

Answer 240

bone destruction

gross swelling

elevation of the periosteum w creation of codmans triangle

sunray spicules of new bone visible in the muscle and subcut tissues.

Question 241

Mx of osteosarcoma

Answer 241

a senior paediatrician should break the news to the girl and her family.

onward referral to specialist paediatric oncology centre

MDT care- oncology, specialist nurses

first step- analgesia.

screened for metastases - Chest CT scan and bone scan + MRI scan of shoulder to guide future surgery.

Biopsy should be taken

Initial chemo to reduce tumour bulk

then surgery

then further chemotx

Question 242

what factors contribute to increased risk of infection in children w cancer?

Answer 242

neutropenia

mucositis - following chemo/ radiotx (poor mucus protection_

indwelling central lines

frequent hospital admissions

poor nutrition

generalized immunosuppression.

Question 243

Ix of temperature in neutropenic chemo kid?

Answer 243

blood cultures, FBC, WCC, CRP, U+Es

swabs from any suspected sites of infection

+ urine/ stool samples

CXR if resp signs

Question 244

Mx of fever in neutropenic chemo kid?

Answer 244

gram -ve sepsis is the real threat.

febrile neutropenia in an immunocompromised child is a medical emergency.

admit and immediate IV Abx broad-sepctrum.

careful monitoring and frequent re evaluation, changing the regimen according to response and culture results.

if still febrile and neutropenic after 5 days, add antifungal agents.

may need blood/ platelet transfusions if active bleeding or v low numbers.

Question 245

Endocrine associations of Downs syndrome

Answer 245

Hypothyroidism

Addisons

T1DM

Question 246

Ocular assoc w Downs

Answer 246

cataracts

Question 247

IBD in a younger child more likely to be?

Answer 247

Crohns

Question 248

Mx of epileptic fit worsened due to concurrent febrile illness

Answer 248

IV fluids.

IV ceftriaxone, clarithromycin, aciclovir. (empirical abx/ antivirals if high temp and cant rule out meningitis/ encephalitis)

antipyretics if temp v high.

measure blood glucose to rule out hypoglycaemia.

Question 249

when performing examination of large head, what to consider?

Answer 249

shape of head, size/ shape/ patency of the fontanelles and cranial sutures.

dysmorphic features, or other congenital abnormalities.

full neuro/ developmental assessment.

plot weight/ heigh and head circumferences on centile chart.

Question 250

causes of macrocephaly

Answer 250

familial

hydrocephaly -> tense fontanelle, distended scalp veins

SOL - tumour, vascular malformations, subdural haematoma (NAI)

fragile X syndrome -> large ears, developmental delay

overgrowth syndrome e.g. developmental delay, large hands/ feet

neurofibromatosis - cafe au lait patches, axillary freckles

Question 251

DDx of coma in children

Answer 251

hypoxic ischaemic brain injury

epileptic seizure/ post ictal state

trauma e.g. intracranial haemorrhage, cerebral oedema

infections e.g. meningitis, encephalitis, abscess

metabolic - renal and hepatic failure, hypoglycemia, DKA, inborn errors

poisoning

vascular lesions e.g. stroke

Question 252

mx of subdural haemorrhage causing raised intracranial pressure in infant

Answer 252

urgent transfer to neurosurgical unit/ PICU.

sitting infant at 30 degree angle

restricting fluids to two thirds maintenance

elective intubation and ventilation

control oxygenation/ maintain normoglycaemia

urgent discussion w regional neurosurgical centre

decrease ICP - can be done w mannitol/ hypertonic saline

arrange for urgent neurosurgical assessment to determine whether surgery required to evacuate the haematoma.

contact social services and follow child protection procedures.

Question 253

causes of delayed walking

Answer 253

generalized developmental delay: e.g. downs syndrome, fragile X

neuromuscular cause: cerebral palsy, Duchenne muscular dystrophy

MSK: DDH

normal late walker: majority of cases

Question 254

contributing factors in learning difficulties?

Answer 254

hearing impairment

visual impairment

chronic medical condition

epilepsy

autism spectrum disorder

dyspraxia

neglect

Question 255

commonest cause of acute childhood stroke

Answer 255

sickle cell disease

Question 256

causes of acute stroke in childhood

Answer 256

haem- sickle cell, polycythaemia, leukaemia

cardiac- embolic, kawasaki

infection- meningitis

intracerebral vascular- ruptured aneurysm, arteriovenous malformation

autoimmune- JIA, SLE

metabolic- homocystinuria

trauma

Question 257

Ix of Stroke

Answer 257

CT/MRI head

• to distinguish between ischaemia/ haemorrhagic

all children w arterial ischaemic stroke:

MRI angiography of the cervical and proximal intracranial arterial vasculature

cardiac echo

ix for prothrombic tendency e.g. protein C deficiency

if intracerebral haemorrhage:

clotting studies and pl count

Question 258

mx of stroke in childhood

Answer 258

refer to neurology

regular neuro observations

urgent scanning/ admission to PICU if there is deterioration.

if ischaemic stroke and haemorrhage / SCD excluded- start aspirin

long term mx involves MDT

Question 259

features of common migraine

Answer 259

recurrent headache w symptom-free intervals

unilateral, typically throbbing, n+v

abdo pain is common

over 90% have family history

auras: visual, small areas of visual loss in a visual field (scotoma) and brilliant white zig zag lines

Question 260

DDx of chronic headaches

Answer 260

tension headache

sinusitis

refractive errors - check vision

raised ICP - pain worse on lying down/ change in behaviour, papilloedema

solvent/ drug abuse

HTN- blood pressure must be checked

Question 261

mx of migraine

Answer 261

migraine diary - identify possible triggers (common stress/ tiredness/ anxiety)

reassurance that there is no serious intracranial pathology

lifestyle changes

avoid blanket exclusion diets

explore social stressors- e.g. bullying

if all else fails, school attendance is affected, migraines are unacceptably intrusive, prevention w drugs. e.g. propranolol, pizotifen, topiramate but all have side effects

Question 262

Bells palsy

Answer 262

lower motor neurone palsy of the facial n

whole side of the face is weak.

taste on the anterior 2/3 of the tongue on the involved side may be lost

+ facial numbness

Question 263

lower vs upper motor neuron lesion of facial n

how to differentiate

Answer 263

in upper motor neurone facial n palsies:

preserved facial power and eye closure

Question 264

why may bells palsy occur following infection

Answer 264

occurs due to oedema of the facial n as it crosses the facial canal in the temporal bone

it may occur 2 wks after a viral infection

herpes simplex and varicella zoster are causative + EBV, lyme disease and mumps

Question 265

causes of acute bells palsy

Answer 265

HSV

VZV

EBV

lyme disease

mumps

Question 266

consider chronic cases of bells palsy

Answer 266

otitis media

HTN

tumours

leukaemia

trauma

Question 267

mx of bells palsy

Answer 267

if presenting within 1 wk:

steroid tx with prednisolone for 7 days

eye care impt - if child cannot close eye, tx w artificial tears such as hypromellose eye drops and taping of the eye at night

most pts recover within a few wks

10% left with mild facial weakness

5% are left w permanent significant facial weakness

recovery may take up to 6 months

Question 268

DDx of back pain in children

Answer 268

developmental abnormalities - spondylolysis, scoliosis

traumatic- verterbral stress fractures, muscle spasm due to overuse e.g. in athletes/ gymnasts, prolapsed intervertebral disc

neoplastic - metastases

infection - discitis, verterbral osteomyelitis

rheumatological - ank spond, psoriatic arthritis

Question 269

back pain in child- screen for?

Answer 269

persistent or worsening pain

systemic features: FLAWS

neuro symptoms/ signs

sphincter dysfunction

young age

Question 270

mx of back pain in child

with neuro signs: hypotonia/ absent reflexes

Answer 270

medical emergency

urgent investigation and intervention to reduce cord compression

MRI

refer immediately to a paediatric neurosurgery centre

spinal cord tumours: intramedullary, extramedullary intradural, extramedullary extradural

Question 271

west syndrome

Answer 271

epilepsy syndrome characterized by infantile spasms, developmental regression and hypsarrhythmia on EEG

usually starts in first year of life and can have a variety of underlying causes including structural brain abnormalities, neurometabolic disease, neurocutaneous syndromes and acquired brain injury

Question 272

causes of developmental regression

Answer 272

acquired brain injury: hypoxia, meningitis

seizure disorders: west syndrome

neurodegenerative: mitochondrial disorders, Tay-Sachs disease

toxic substances: lead poisoning

infectious: subacute sclerosing panencephalitis, prion disease

pervasive developmental disorder: autism, rett’s syndrome

Question 273

Ix of developmental regression

Answer 273

MRI scan

EEG - seizure disorder?

FBC, renal function, liver function tests, U+Es, lactate/ ammonia

urine for urine amino and organic acids

Question 274

depigmented patches on skin?

Answer 274

possible ash leaf macules

tuberous sclerosis

Question 275

tuberous sclerosis presentation

Answer 275

hamartomas in multiple organs including brain, skin, eyes, kidneys, heart.

ash leaf macules

seizures common.

Question 276

chronic otitis media w effusion

‘glue ear’

presentation and signs

Answer 276

conductive hearing loss

snoring (partial upper airway obstruction)

tympanic membranes have dull retracted appearance w loss of light reflex and some bubbles visible behind the membrane

Question 277

why are children w Downs particularly vulnerable to Otitis media w effusion?

Answer 277

large adenoids, small nasopharynx and narrow eustachian tubes

making aeration of the middle ear less efficient.

Question 278

mx of conductive hearing loss

Answer 278

causes: glue ear, congenital ear abnormalities

conservative

use grommets

Question 279

sensorineural deafness

causes

Answer 279

genetic

infection: congenital/ postnatal

birth asphyxia

head injury

Question 280

Mx of sensorineural hearing loss

Answer 280

hearing aid

cochlear implant

Question 281

mx of downs syndrome w glue ear

Answer 281

refer to paediatric audiology clinic + regular follow up

hearing assessment

tympanometry to confirm negative middle ear pressures typical of OME

if pt has sleep apnoea -> may necessitate an adenotonsillectomy

Question 282

what is a convergent squint?

Answer 282

appearance of one eye not looking in the same direction as the other

ie. right convergent squint means that the right eye is turned in towards the nose when the left eye is looking directly at the target

Question 283

squint: types

Answer 283

paralytic or concomitant

paralytic squints are caused by dysfunction of the motor nerves controlling eye movements (III, IV, VI) -> may be the 1st sign of a brain tumour/ neuro disorder

concomitant squints are common - usually due to extraocular muscle imbalance in infants, or refractive errors after infancy.

Question 284

what simple assessment to assess for squint?

Answer 284

testing corneal light reflex-

looking at position of reflection on each eye.

Question 285

Ix of squint

Answer 285

corneal light reflex

visual fields

range of eye movement tested

red reflexes tested w ophthalmoscope - absence of the red reflex indicates ocular pathology such as cataract or retinoblastoma

cover test: when fixing eye is covered, the squinting eye will move to take over fixation

Question 286

Mx of squint

Answer 286

refer to paediatric Opthalmology

aim to detect any serious underlying pathology and to prevent development of amblyopia.

in the developing brain- the image from the squinting eye is suppressed to avoid diplopia.

in untreated squint- leads to irreversible suppression of the visual pathways, visual impairment in that eye and possible blindness. (amblyopia)

correction of refractive errors w glasses

patching of good eye to force use of the other eye

surgery on the extraocular muscles

Question 287

triad in autism

Answer 287

impairment of social communication, social interaction and rigidity of thought and behaviour

Question 288

what comorbidities to consider with autism?

Answer 288

hearing difficulties

learning disability

Question 289

assessment of suspected autism spectrum disorder?

Answer 289

refer to CAMHS for assessment or paediatrician w interest in autism spectrum disorders

usually involves a clinical psychologist + MDT

hearing test arranged

detailed developmental, medical, family and social histories taken

social skills, communication and behaviour observed in a standardized way

Question 290

criteria for ADHD

Answer 290

inattention, hyperactivity, impulsiveness

excessive for the childs developmental age and cause significant social/ academic problems

present in more than one setting

begun < 7 yrs of age

present for > 6months

Question 291

causes of injury to fetal brain:

antenatal (80%)

Answer 291

vascular occlusion

structural maldevelopment of the brain

genetic syndromes

congenital infection

Question 292

causes of injury to fetal brain

perinatal

Answer 292

hypoxic ischaemic injury during delivery

Question 293

causes of postnatal brain injury (10%)

Answer 293

meningitis

encephalitis

encephalopathy

head trauma

hypoglycaemia

hydrocephalus

kernicterus

neonatal stroke

Question 294

clinical presentation of cerebral palsy

Answer 294

abnormal limb/ trunk posture and tone

delayed motor milestones

feeding difficulties w oromotor incoordination

abnormal gait once walking

asymmetric hand function < 12 months

primitive reflexes may persist and become obligatory

Question 295

diagnosis of cerebral palsy

Answer 295

clinical examination of posture/ tone/ hand function and gait

Question 296

Hemiplegic Spastic Cerebral Palsy

Answer 296

increased spasticity with brisk deep tendon reflexes and extensor plantar responses.

unilateral arm and leg affected.

arm more affected/ face spared.

flexed arm, pronated forearm, asymmetric hand function, tiptoe walk on affected side (due to contracted calf)

Question 297

Quadriplegic spastic cerebral palsy

Answer 297

increased spasticity with brisk deep tendon reflexes and extensor plantar responses.

all 4 limbs affected, often severely.

trunk - extensive posturing

poor head control

low central tone

more severe- seizures, microcephaly, intellectual impairment

may have hx of perinatal HIE

Question 298

diplegic spastic cerebral palsy

Answer 298

increased spasticity with brisk deep tendon reflexes and extensor plantar responses.

all 4 limbs affected, but legs much more.

hand fn releatively normal but abnormal gait.

assoc w preterm birth due to periventricular brain damage

Question 299

dyskinetic cerebral palsy

Answer 299

involuntary, uncontrolled movements

variable muscle tone

primitive reflexes predominated

chorea, athetosis and dystonia

signs are due to basal ganglia/ extrapyramidal injury

commonest cause: HIE at term/ kernicterus

Question 300

ataxic (hypotonic) cerebral palsy

Answer 300

most genetically determined

early trunk and limb hypotonia, poor balance

delayed motor development

incordinate movements

intention tremor

ataxic gait

Question 301

mx of cerebral palsy

Answer 301

MDT approach - SALT, physio, OT to support child development + neurologists

stretching exercises, orthoses etc for posture/ movement

surgery last resort

communication - speech aids/ therapy

cognition and learning- special education

tx for spasticity: oral diazepam, oral/ intrathecal baclofen, etc

Question 302

paediatric emergency

Answer 302

ABCDE protocol

AVPU/ GCS score

BLS to resuscitate seriously ill child

fluid requirements: first 10 kg - 4ml/kg/hr

subsequent 10kg - 2 ml/kg/hr

subsequent 10 kg - 1ml/kg/hr

Bolus - 0.9% saline, 20ml/kg

Question 303

1st line treatment for seizure if IV access alr established

Answer 303

IV lorazepam

• in hospital setting.

can give twice

Question 304

advice regarding prevention of sudden infant death syndrome

Answer 304

put to sleep on back

avoid overheating by heavy wrapping

Question 305

immediate mx for premature baby birth

Answer 305

immediately dried and covered (head + body), or placed in a plastic bag under a radiant heater

assess APGAR

airway positioned optimally

baby will need resp support, which may be CPAP or intubation

surfactant may need to be delivered

transfer to neonatal unit

Question 306

complications of premature birth

Answer 306

lungs- RDS, apnoea, pneumothorax

brains - periventricular haemorrhage, periventricular leukomalacia

heart- PDA

GI - NEC, GORD

infection

metabolic- hypoglycaemia, jaundice

Question 307

Answer 307

Vesicoureteric reflux (VUR) is the abnormal backflow of urine from the bladder into the ureter and kidney. It is relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI

perform DMSA scan to identify renal scarring

Question 308

maternal labetalol may lead to what in a neonate?

Answer 308

neonatal hypoglycaemia

measure blood glucose

Question 309

elfin like facies, v friendly and social, learning difficulties, supravalvular aortic stenosis

Answer 309

williams syndrome

diagnosis by FISH

Question 310

signs of achondroplasiatrident hand deformity (short, stubby fingers with separation between the middle and ring fingers), other physical features include: short limbs (rhizomelia), lumbar lordosis and midface hypoplasia.

Answer 310

short limbs (rhizomelia) with shortened fingers (brachydactyly)

large head with frontal bossing and narrow foramen magnum

midface hypoplasia with a flattened nasal bridge

‘trident’ hands

lumbar lordosis

Question 311

fetal risk if SSRI use during third trimester?

Answer 311

persistent pulmonary hypertension of the newborn

Question 312

by what age can a child squat to pick up a toy?

Answer 312

18 months

Question 313

term neonate

VBG: severe metabolic acidosis

absence of risk factors/ signs of sepsis

lethargic baby

strong odour

ketones +++ in urine

lactate 2.1 glucose 5.2

Answer 313

inborn error of metabolism

e.g. organic acidurias

isovaleric acidaemia, maple syrup urine disease

Question 314

mx of baby w severe metabolic acidosis from inborn error of metabolism

Answer 314

call for help from senior paediatrician

stop feeds and start infusion of 10% dextrose

may need intubation and ventilation

sodium bicarb to correct the acidosis

blood should be sent for ammonia, plasma ammino acid profile and urine for amino and organic acid profiles.

transfer to regional metabolic unit

Question 315

what are dysmorphic features

Answer 315

abnormal body characteristics

Question 316

characteristic dysmorphic features of t21

Answer 316

hypotonia

flat face

upward slanting palpebral fissures

epicanthic folds

white speckles on iris (brushfield spots)

short broad hands

single palmar and plantar fissures (simian crease)

Question 317

ix in one with downs syndrome

Answer 317

chromosomal analysis - to confirm diagnosis, look for mosaicism (that might alter the prognosis), to exclude a translocation

cardiac echo - even if no murmurs are heard

Question 318

breaking bad news about downs syndrome

Answer 318

should be done by senior paediatrician and midwife who knows them well

discussion needs to take place in a private room w plenty of time allowed

avoid jargon and use diagrams to help explanations.

expect distress/ anger - any emotion

written material is available from downs syndrome charities and their websites

Question 319

approach to a fitting child

Answer 319

ABC

give high flow oxygen

place on cardiac monitor

obtain intravenous access

send relevant tests

check blood glucose

in a neonate, though it may seem unlikely- give iv broad spectrum abx to cover for sepsis

control the seizure with anticonvulsants

Question 320

what anticonvulsant to use in a neonate

Answer 320

usually a loading dose of phenobarbital

followed by- if necessary- maintenance

Question 321

causes of hypoCa in infancy

Answer 321

prematurity

hypoxic ischaemic encephalopathy

hypoPTH (e.g. diGeorges)

hypoMg - Mg facilitates release of PTH

exchage trnafusion - citrate in transfused blood chelates ca to prevent clotting

maternal hyperCa- suppresses fetal PTH

maternal vit D deficiency

Question 322

what does the Xray show

Answer 322

Xray shows a mid shaft spiral fracture of the left femur.

spiral fracture suggests a twisting injury - unlikely in a non weight bearing infant.

Question 323

NAI Ix

Answer 323

Full skeletal survey

Brain CT scan - exclude any injuries such as subdural haemorrhage

if there is bruising -> FBC, clotting screen

Question 324

mx of spiral fracture in child

Answer 324

admit to manage the fracture and as place of safety

pain relief and immobilization in traction

check child protection register

document, date, sign hx, examination, investigations

inform senior paediatrician, who will confirm the findings and explain openly and non judgmentally why there are concerns, what is going to happen next and who will be involved

refer immediately to social care/ safeguarding lead

aim is to act in childs best interest

Question 325

vulvovaginitis

causes

Answer 325

due to UTI

poor perineal hygiene - often after girls have started self toileting

masturbation

pinworms - assoc w perianal itching, esp at night (20% assoc vulvovaginitis)

herpes infection

possibility of sexual abuse

Question 326

advice on hygiene for vulvovaginitis

Answer 326

cleaning oneself from front to back after bowel motion

use loose fitting cotton knickers

having daily baths/ showers using simple soaps

allowing area to dry

Question 327

what is this?

Answer 327

positional plagiocephaly

occurs when asymmetricael pressure on the developing occiput/ skull base results in oblique flattening of the posterior skull.

Question 328

plagiocephaly causes

Answer 328

asymmetrical sleeping position

• may be normal or may have underlying neuromuscular disorder

torticollis

cervical spine abnormalities

Question 329

typical presentation of positional plagiocephaly

Answer 329

baby born with/ develops an abnormal head shape sometime after birth

which then improves with time

as mobility increases, the likelihood of persistent asymmetrical pressure decreases, and in most cases head shape will return to normal.

Question 330

threadworms presentation

Answer 330

perianal itching, particularly at night

girls may have vulval symptoms

asymptomatic in around 90% of cases

Infestation with threadworms (Enterobius vermicularis, sometimes called pinworms) is extremely common amongst children in the UK.

occurs after swallowing eggs that are present in the environment.

Question 331

diagnosis of threadworms

Answer 331

apply sellotape to perianal area

send to lab for microscopy to visualize eggs

However, most patients are treated empirically and this approach is supported in the CKS guidelines.

Question 332

mx of threadworms

Answer 332

CKS recommend a combination of anthelmintic with hygiene measures for all members of the household

1st line for >6 month old: mebendazole

Question 333

newborn with growth retardation, sensorineual deafness, purpuric skin lesions, seizures

Answer 333

CMV

characteristic features: growth retardation/ purpuric skin lesions

other features: hepatosplenomegaly, jaundice, anaemia, pneumonitis, cerebral palsy

rubella: SHE, purpuric skin lesions and ‘salt and pepper’ chorioretinitis

Question 334

DDx of plagiocephaly

Answer 334

craniosynostosis

Question 335

what is craniosynositis?

Answer 335

premature fusion of one or more sutures of the skull, resulting in abnormal skull shape.

deformity often present at birth, is progressive and does not improve spontaneously.

can result in raised ICP and developmental delay

Question 336

atlantoaxial instability assoc w?

Answer 336

Downs

neck instability

Question 337

precocious puberty + cafe au lait spots + polyostotic fibrous dysplasia

Answer 337

mcCune-Albright syndrome

Question 338

what atrial septal defect is most common in Downs

Answer 338

secundum ASD

Question 339

at what age is the average child able to draw a staight line

Answer 339

2.5 years

Question 340

at what age can a child build a tower of 6 blocks

Answer 340

2 years

Question 341

at what age has an average child developed a pincer grip

Answer 341

9/10 months

Question 342

at what age does early babbling start - with double syllables?

Answer 342

6 months

Question 343

at what age can a child turn towards sound

Answer 343

3 months

Question 344

at what age can a child understand no

Answer 344

9 months

Question 345

at what age does a child know and respond to own name

Answer 345

1 year

Question 346

what type of ovarian tymour is assoc with Meigs syndrome

Answer 346

fibroma

triad of ascites, pleural effusion and benign ovarian tumour)

Question 347

complications of craniosynositis

Answer 347

increased ICP

developmental delay

permanent abnormal head shape

Question 348

sagittal synostosis results in what appearance?

Answer 348

narrow head with enlarged anteroposterior dimension

Question 349

lambdoid synostosis

appearance?

Answer 349

similar to plagiocephaly

unilateral flattening of the occiput but less frontal asymmetry (compared to plagiocephaly)

resulting in rhomboid head shape

also, ear ipsilateral to flattened occiput is displaced posteriorly and inferiorly

a ridge may be palpable in the area of the fused suture

Question 350

differentiating between plagiocephaly and lambdoid craniosynostosis

Answer 350

plagiocephaly: parallelogram head shape, unilateral flattening of occipital area with ipsilateral bossing of the frontal and parietal bones

Lambdoid synostosis: rhomboid shape, unilat flattening of occiput but less frontal asymmetry

ear

plagiocephaly: ear ipsilateral to flattened occiput is displaced anteriorly

lambdoid synostosis: ear is displaced poisteriorly and inferiorly

in craniosynostosis, ridge often palpable on area of fused suture

imaging

CXR/ CT scan can be used to assess sutures

Question 351

mx of plagiocephaly

Answer 351

will improve spontaneously

even if it does not completely return to normal, hair growth will disguise much of the abnormal appearance

if problem is severe or continues to worsen then tx may be indicated.

helmet moulding may have some benefit by rebalancing growth of skull

it most severe cases- surgical intervention may be warranted

Question 352

mode of action of emergency contraception levonorgestrel

Answer 352

inhibits ovulation

Question 353

what heart defects assoc w turners syndrome?

Answer 353

bicuspid aortic valve (15%)

coartaction of the aorta (5-10%)

Question 354

when is a child able to build a tower of 3-4 blocks

Answer 354

18 months

Question 355

mode of action of desogestrel POP

Answer 355

inhibits ovulation

+ thickens cervical mucus

Question 356

classical history for iron toxicity

Answer 356

iron is corrosive to GI mucosa -> abdo pain, nausea, vomiting, diarrhoea w haematemesis and bloody diarrhoea (dark) in more severe toxicity

interlude w apparent recovery for abour 8-16h

third stage: progressive systemic involvement due to vasodilator effects of iron and mitochondrial poisoning

Question 357

mx of iron poisoning

Answer 357

Oxygen and IV fluids to manage poor perfusion

treat hypoglycaemia

send family to check for missing drugs - identify other possible drug toxicity

Abdo Xray- can confirm ingestion of iron tables which are radio opaque

if taken with 1 hr of presentation or tablets visible in stomach on xray -> consider gastric lavage with wide bore tube

measure serum Iron urgently- it may be spuriously low if taken >8h post ingestion

discuss w national poisons info service to discuss tx w desferrioxamine

discuss w specialist liver unit

Question 358

at what age does a child wave bye bye

Answer 358

1 year

same time they know and respond to their own name

and develop a good pincer grip

Question 359

inheritance of retinoblastoma

Answer 359

autosomal dominant

Question 360

by what age should a child be able to smile

Answer 360

6 weeks

Question 361

when to intubate a child?

Answer 361

airway of any child w GCS <8 is at risk

an anesthetist should be called urgently to monitor airway/ breathing

and potentially may need to be intubated.

Question 362

alcohol poisoning

unconscious teen

ix?

Answer 362

blood alcohol level

blood glucose

U+Es, LFTs, Blood gas

CT head - may have sustained head injury

Question 363

Mx of alcohol poisoning

Answer 363

ABC

maintenance IV fluids (0.45% saliine, 5% dextrose)

hourly GCS observations

social services

contact childs family

consider doing urine toxicology

may need further psychiatric/ social work input and follow up

Question 364

Questions to ask in social history when considering neglect?

Answer 364

who else is at home?

does the mother have a partner? is the partner father of child?

is there hx of drug/ alcohol abuse?

are there other children?

is family known to social care?

Question 365

Pica is assoc w?

Answer 365

iron deficiency anaemia and

lead poisoning - basophilic stippling

Question 366

symptoms of lead poisoning

Answer 366

colicky abdo pain

constipation

headache

drowsiness

fits

coma -> lead encephalopathy

Question 367

mx of lead poisoning

Answer 367

urgent referral to hospital

measure blood lead

seek advice from national posions info service about need for chelating agents

check blood ferritin and haemoglobinathy screen

measure bone biochemistry and vit D -> tx w Vit D to minimize lead absorption

Question 368

mx of neglect

Answer 368

referral to social care for multidisciplinary assessment of whole family

referral to child and family therapy service for behaviour management

Question 369

emergency mx of anaphylaxis

Answer 369

IM adrenaline 1:1000

ABC

high flow oxygen

nebulized salbutamol

(if stridor does not improve- call for anaesthetist)

IV fluids: Bolus 20ml/kg + maintenance

dose of antihistamine e.g. chlorpheniramine

Question 370

Mx of anaphylaxis?

Answer 370

find culprit food

skin prick testing and or total IgE/ RAST to specific foods

lifelong exclusion

epipen on him at all times + family taught how to use it + supply of oral antihistamine

referral to dietician

Question 371

to determine whether a relationship presents a risk that needs referral to social care and or police:

GP needs to consider?

Answer 371

whether pt is competent to understand and consent to sexual activity (ALL children <13 not competent to consent)

power imbalances - difference in age/ development e.g. teacher/ youth worker

aggression/ manipulation/ bribery - use of drugs/ alcohol

attempts to secure unreasonable secrecy

whether partner is known by agencies to have worrying relationships w other young ppl

evidence of parental neglect/ lack of supervision in child <13

grooming behaviour? sexual exploitation

Question 372

what does advanced paediatric life support involve?

Answer 372

asystole in child

->

ventilate w high concentration O2

intubation

IV access -> give IV 1:10000 adrenaline

4 min CPR

consider 4 Hs:

hypothermia, hypovolaemia, hypoxia, hypoK/hyperK

consider 4 Ts:

cardiac tamponade, tension pneumothorax, toxic substances, thromboemolic phenomena

consider giving IV bicarb

Question 373

mx of sudden infant death syndrome

Answer 373

refer to coroner

baby by law requires postmortem

police automatically informed

child protection register check

bereavement counselling offered

Question 374

ix in patients with suspected chronic fatigue syndrome

Answer 374

investigations to rule out active infection, inflammation, endocrine problems, malignancy

FBC, WCC, CRP, ESR

Blood film

Ur, Cr

Glucose and U+Es

Liver function, thyroid function

urine dipstick

Question 375

Mx of chronic fatigue syndrome

Answer 375

MDT approach:

support w physiotherapy, occupational therapy and CAMHS

assessment of baseline fn using activity diary

supportive tx- allieviate symptoms, improve nutrition and sleep patterns

graded programme of return to activity

occasionally - inpatient mx required

Question 376

fabricated or induced illness

Answer 376

perpertrator may

• fabricate medical hx
• cause symptoms by repeatedly exposing child to toxin, medication, infectious agent, physical trauma
• alter lab samples/ temp measurements

consider in children who have recurrent unexplained symptoms

• almost always the mother. sadly the disturbed parent seems to obtain a perverse satisfaction from the close association w hospital care and staff.

Question 377

mx of suspected fabricated/ induced illness

Answer 377

obtain second opinion from another consultant paediatrician

referred to social care

child protection register check

health visitor contacted for further info

Question 378

3 day history of puffy eyes, unwell with coryzal illness last wk.

O/E generalized oedema and scrotal oedema.

tachycardic + cool peripheries

diagnosis?

Answer 378

nephrotic syndrome with hypovolaemia

tachycardia and cool peripheries suggest hypovolaemia, due to increased interstitial fluid collection due to reduced oncotic pressure.

Question 379

how to diagnose posterior urethral valves?

Answer 379

micturating cystourethrogram

post urethral valves may cause vesicoureteric reflux

Question 380

NSAIDs e.g. diclofenac in renal impairment?

Answer 380

Do not use

as it is nephrotoxic

Question 381

inheritance pattern of PCKD that presents in childhood with bilateral renal masses?

and of PCKD that presents in older children/ adults.

Answer 381

auto recessive- presents in childhood w bilateral renal masses, resp distress due to pulmonary hypoplasia and chronic hepatic fibrosis w pulmonary HTN.

due to tubular dilation of the distal collecting system. Renal function is impaired and progressively deteriorates, requiring renal replacement therapy (dialysis/ transplant).

the auto dominant type presents in older child/ adult. the cysts are grossly dilated nephrons which compress normal renal tissue. it affects renal, liver and cerebral vasculature.

Question 382

what is considered a mild Learning disability?

Answer 382

IQ 50-70

Question 383

moderate learning disability?

Answer 383

IQ 35-50

Question 384

severe learning disability?

Answer 384

20-35

Question 385

mx of umbilical hernia

if small and asymptomatic

Answer 385

perform elective repair at 4-5 yrs of age.

Umbilical hernias are relatively common in newborn children, and in 80% will spontaneously close by 4-5 years of age.

after this age, it should be managed due to risk of incarceration.

Question 386

mx of large (>1.5cm) or symptomatic umbilical hernia

Answer 386

elective repair at 2-3 yrs of age

hernias may cause pain/ intermittent symptoms of incarceration.

Question 387

mx of incarcerated umbilical hernia

Answer 387

should be manually reduced with pressure and surgically repaired within 24 hours.

if it can’t be reduced, an emergency operation is required.

Question 388

how does ovarian cancer spread

Answer 388

by local invasion

Question 389

what is considered a raised CA125

Answer 389

35 IU/mL or greater

Question 390

what is infantile colic?

Answer 390

Infantile colic describes a relatively common and benign set of symptoms seen in young infants.

typically occurs in infants < 3 months old

characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening

cause unknown

occurs in up to 20% of infants

Question 391

what investigations do you perform in infant < 3m w fever?

Answer 391

Full blood count

Blood culture

C-reactive protein

Urine testing for urinary tract infection

Chest radiograph only if respiratory signs are present

Stool culture, if diarrhoea is present

Question 392

when can a child ask what and who questions?

Answer 392

3 years

Question 393

when can a child count to 10

Answer 393

3 years

Question 394

when can a child ask why when and how qns

Answer 394

4 years

Question 395

most common fractures assoc w child abuse

Answer 395

radial

humeral

femoral

Question 396

when can a child start to play alongside, but not interacting with, other children? (parallel play)

Answer 396

2 years

Question 397

when does a child start to laugh and enjoy friendly handling?

Answer 397

3 months

Question 398

when does a child start to be shy and take everything to the mouth

Answer 398

9 month

Question 399

Lactational Amenorrhoea method

what % of the babys feeds have to be from moms breastfeeding?

Answer 399

85% feeds from breast milk

Question 400

mx of seborrhoeic dermatitis

Answer 400

regular washing of scalp w baby shampoo followed by gentle brushing w soft brush

softening scales w baby oil first then gentle brushing and washing off w baby shampoo

if simple measures not effective: topical imidazole cream.

Question 401

features of growing pains

Answer 401

never present at the start of the day after the child has woken

no limp

no limitation of physical activity

systemically well

normal physical examination

motor milestones normal

symptoms are often intermittent and worse after a day of vigorous activity

Question 402

normal heart rate in infants <1

Answer 402

110-160

Question 403

normal resp rate in infants <1

Answer 403

40

Question 404

toddlers 1-2 yrs normal heart rate

Answer 404

100-150

Question 405

toddlers 1-2 yrs normal resp rate

Answer 405

35

Question 406

preschool 3-4 yrs normal heart rate

Answer 406

95-140

Question 407

preschool 3-4 yrs normal resp rate

Answer 407

30

Question 408

5-11 yr olds normal heart rate

Answer 408

80-120

Question 409

5-11 yr olds normal resp rate

Answer 409

25

Question 410

how to estimate weight in child 1 yr and over?

Answer 410

(age +4) x2

Question 411

tricuspid valve leaflets are attached to the walls and septum of the right ventricle

resulting in a large atrium and small ventricle.

Answer 411

ebsteins anomaly

Question 412

mx of pertussis in child < 1 month of age

Answer 412

clarithromycin

Question 413

mx of pregnant woman with pertussis

Answer 413

erythromycin

Question 414

complications of pertussis

Answer 414

subconjunctival haemorrhage

pneumonia

bronchiectasis

seizures

Question 415

in infants with GORD who do not respond to alginates/thickened feeds and who have 1. feeding difficulties, 2. distressed behaviour or 3. faltering growth

mx?

Answer 415

proton pump inhibitor (PPI) or H2 receptor antagonists (H2RA) e.g ranitidine

Question 416

painless fluid filled lesion posterior to the sternocleidomastoid

Answer 416

cystic hygroma

Question 417

atopic eczema in infant

what areas are often affected

Answer 417

face and trunk

Question 418

what type of vaccine is the rotavirus?

Answer 418

oral, live attenuated vaccine

Question 419

scaphoid abdomen and bilious vomiting

Answer 419

intestinal malrotation and volvulus

Question 421

When does moro reflex disappear?

Answer 421

from birth to around 3-4 months

Question 422

when does grasp reflex disappear?

Answer 422

from birth to 4-5 months of age

Question 423

when does stepping reflex disappear?

Answer 423

birth til 2 months

Question 424

when does rooting reflex disappear?

Answer 424

from birth til around 4 months

Question 425

mx of any chidld <2 w acute limp

Answer 425

urgent hospital assessment

as they are at higher risk of septic arthritis and child maltreatment

Question 426

what term is used to describe the fetal head in relation to the ischial spine

Answer 426

station

0 - directly at lvl of the ischial spines

-2 -> 2cm above the ischial spines

+2 -> 2 cm below the ischial spines

Question 427

molar pregnancy

what do you expect of BHCG, TSH and T4 levels

Answer 427

BHCG high

TSH low

T4 High

Question 428

What is Kocher’s criteria?

Answer 428

Non-weight bearing - 1 point

Fever >38.5ºC - 1 point

WCC >12 * 109/L - 1 point

ESR >40mm/hr

Question 429

What is Kocher’s criteria used for?