Pediatrics

Question 1

meningococcal sepsis suspected

Answer 1

• blood cultures
• immediate iv cephalosporin (alternatively benzyl penicillin), if unable to obtain iv access im is alternative, witholding can be fatal.
• warn parents it is very sever illness and that 1/3 have fulminant course (rapidly developing and severe)
• look for rash, fever, pallor and cold extremities, there might not be neck stiffness
• dd is H influenzae but less common after vaccinations and ofcourse other septic causes
• in subacute stage organise profylactic antibiotics for close contacts

Question 2

First diagnosis Asthma to explain and symptoms

Answer 2

• inquire about smoking of parents and advise
• can be chronic cough
• spirometry
• may be triggered by B-blocker, aspirin, NSAID
• causes: viral URTI, allergens/irritants, cold air, excersize,
• classical symptoms wheezing, coughing (mostly night), chest tightness, SOB

Question 3

MDI/spacer

Answer 3

Metered dose in haler:
- from 8 + onwards, adults that can comply
- shake well 1-2 sec
- mouth piece between theeth (do not bite), close lips around
- breath out relaxed
- tilt head back slightly and chin up a bit
- at start breathing in slowely press inhaler once continue to breath in through mouth for 3-5 sec as deep as possible and hold breath for 10 sec
- repeat after 1 minute if required
Spacer:
- small spacer + face mask under 2
- large volume spacer 2-7
Refer to asthma nurse for proper use

Question 4

Asthma treatment

Answer 4

Aim:

• symptom free, optimal lung function, < 3 time reliever = bronchodilator
• very mild: < weekly episode , < 2/month night symptoms –> B2-agonist (salbutamol) PRN
• more frequent –> add inhaled corticosteroid
• if still not enough control further treatment available
• Attack: 4 puffs, repeat after 4 minutes, call ambulance if no effect

Question 5

Jaundice in infant, eatiology and treatment

Answer 5

• 50% of babies gets jaundice
• physiological, usually day 2 - 7 or 10
• < 24 hours usually pathological and needs to be excluded
• eg haemolytic most common eg ABO incompatibility,hereditairy spherocytosis, G6PD, Rh isoimmunisation
• prolonged divide in unconjugated and conjuganted (last more severe eg biliary atresia)
• unconjugated prolonged in well baby is breasmill jaundice

inv: direct coombs test, blood film, hb, conjugated and unconjugated bili

phototherapy: only if sleeping, can be done in room with parents, eyes protected, can have green/black bowel motions, start from +/- > 240 in healthy term baby
exchange therapy: start from

Question 6

Breast milk Jaundice

Answer 6

• unconjungated
• well baby
• diagnosis of exclusion
• bowel motions and urine normal colour
• exclude hypothyroidism
• benign
• stop breastfeeding for few days to confirm diagnosis (keep expressing) than restart
• milk is not harmful for babies, reasure mother that stopping is only to confirm diagnosis

Question 7

febrile convulsion

Answer 7

• 3% of population
• can be running in family
• do not cause brain injury or epilepsy
• 30% recurrence in first 24 hours
• tepid sponging and paracetamol
• 3% will develop epilepsy, mainly from high risk group (family history epilepsy, prolonged convulsion, focal element, abnormal development before seizure)
• rectal diazepam only reserved for special circumstances

Question 8

ADHD

Answer 8

Exclude: brain injury (old or new), neonatal problems, congenital, home circumstances, visual or auditoiry problems, problem adapting to school, 
ask:
- hyperactivity and associated problems
- school progress
- home situation
-family history
- pregnancy
- past medical history

Management:

• little evidence for exclusion diets but support if wished
• psychologist/child psychiatrist
• behavioural interventions
• stimulant medication only last recourse

Question 8

post streptococcal glomerulonephritis

• exam
• invx
• management

Answer 8

# BP, postural hypotension, temp, pulse, oedema, ascites, pleural effusion, CVS, hepatosplenomegaly, optic fundi, ENT, 
# invx: urine dipstick, EUC, ESR, WCC, CRP, C3, C4, ASOT, DNAase, urine microscopy and culture, FE
# hospital, strict fluid balance restrict intake, test all urine, 4 hourly obs, daily weight, low protein, low salt, antihypertensive treatment, penicillin not essential, renal biopsy if in doubt, Peads!
# after admission, weekly/monthly/quarterly BP, EUC and urine check
# long term prognosis is exellent

Question 9

Tonsillitis, exam, invx and management

Answer 9

# appearance including posture and drooling, ENT, LN including elsewhere, neck stiffness, hepatosplenomegaly, rash, obs and temp
# swab, if typical nothing else required, if not typical WCC, CRP, CMV, EBV and what else indicated
# pain medication and fever control. penicillin if mononucleosis not suspected, other wise erythromycin. 

• exudate and fever help distinguish viral and bacterial but often not really possible clinically. Waiting for swab acceptable if not too sick as 2 days delay in treatment does not increase risk of rheumatic heart disease
• Group A-B haemolytic streptococcus common organism

Question 10

Teething

Answer 10

order:

• 4-6 months: central lower incisors
• 1-2 months later: upper central and lateral incisors
• followed by bottom lateral incisors
• 1 year: first molars
• 18 months: canines
• 2-3 years: second molars

symptoms expected

• nothing to
• swollen, red tender gums; irritability, cranky, drooling, chewing on things, irritation of skin around mouth –> rash and chapped skin, pain, disturbed sleeping, eating less, diarrhoea, low grade fever (NEVER high temperature), pulling ears

Management

• reassure parents
• gentle massage of gum with finger
• soothing gels like bonjela or oro-sed
• wipe face often to prevent rash (and thus 2nd bacterial infection)
• chewing on pacifier or cold teething ring
• chilled foods
• panadol, antihistamines at night