DAILY PEDIATRIC QUIZ: Learn Pediatric and Clear Your exams
Thursday, April 30, 2020
PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: Indications and Timing of Intervention for Common ...
PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: Indications and Timing of Intervention for Common ...: Indications and Timing of Intervention for Common Congenital Heart Diseases Atrial Septal Defect (ASD) Diagnostic work-up: Phy...
Indications and Timing of Intervention for Common Congenital Heart Diseases (ASD)
Indications and Timing of
Intervention for Common Congenital Heart Diseases
Atrial Septal Defect (ASD)
Diagnostic work-up:
Physical examination, ECG,
X-ray chest, echocardiography, and cardiac catheterization (may need in select
cases).
Types of Atrial septal defect:
Ostium secundum (~75%);
Ostium primum (15%-20%);
Sinus venosus (5%-10%); and
Coronary sinus (<1%).
Patent foramen ovale:
Small defect in fossa ovalis
region with a flap with no evidence of right heart volume overload. Diagnosed
on echocardiography, is a normal finding in newborns.
Indication for closure:
ASD with left-to-right shunt
associated with evidence of right ventricular volume overload without evidence
of irreversible pulmonary vascular disease.
Indications for ASD closure
remain the same irrespective of the method of closure.
Contraindications for closure:
Severe pulmonary arterial
hypertension or irreversible pulmonary vascular disease.
Ideal Age of Closure
Asymptomatic child:
2-4 years. For sinus venosus
defect surgery may be delayed to 4-5 years.
Symptomatic ASD: Rarely seen
in infants. Present with congestive heart failure, pulmonary arterial
hypertension. Early closure is recommended after ruling out associated lesions
such as left ventricular inflow obstruction, aortopulmonary window, total
anomalous pulmonary venous drainage, etc.
If presenting beyond ideal
age: Elective closure irrespective of age as long as there is left-to-right
shunt with right heart volume overload and pulmonary vascular resistance is
within operable range.
Method of Closure:
Surgical: Established mode.
Device: For secundum ASDs with
adequate rims and weight of child >15kg.
Recommendations for Follow-up:
Follow-up after surgical
closure: Clinical and echo in the first year only. No further follow-up
required if no residual disease, no pulmonary hypertension or arrhythmia.
Patient/guardians should be
explained about reporting to hospital in case of any cardiac symptoms, or
symptoms suggestive of arrhythmias.
Follow-up after device
closure:
(a) Anti-platelet agents for
total duration of 6 months
(b) Echocardiography: - At
discharge, 1 month, 6 months, 1 year, then every 3-5 years.
Infective endocarditis prophylaxis:
It is recommended for 6 months after device or surgical closure. However, all
patients are advised to maintain good oro-dental hygiene after this period
also.
Friday, April 17, 2020
PEDIATRICS DECISION MAKING: NEPHROTIC SYNDROME EXPLAINED IN 10 QUESTIONS AND ANSWERS
PEDIATRICS DECISION MAKING: NEPHROTIC SYNDROME EXPLAINED IN 10 QUESTIONS AND ANSWERS
Wednesday, April 15, 2020
Tuesday, April 14, 2020
Prolonged Fever: 07 Essential steps to reach the diagnosis? Blind empirical drug therapy when indicated?
Prolonged Fever
STEP # 01: Keep in mind the causes of prolonged fever
These are infections & non-infectious causes
Infections causes:
Bacterial infections
Systemic infections: Salmonellosis, brucellosis, listeriosis, leptospirosis, tularemia, tuberculosis
Hidden focal infections: Abscess (liver, perinephric, pelvic), endocarditis, pericarditis, pyelonephritis, osteomyelitis
Viral infections
Infectious mononucleosis, cytomegalovirus infection, Human immunodeficiency virus (HIV), hepatitis
Parasitic infestations
Malaria, toxoplasmosis, visceral larva migrans
Non-infectious causes:
Rheumatic diseases
Rheumatic fever, systemic rheumatoid arthritis, polyarteritis nodosa, systemic lupus erythematosus, kawasaki disease, mixed connective tissue disease
Malignancies
Leukemia, lymphoma, neuroblastoma
Immune reactions
Drug fever, serum sickness
Other causes
Factitious fever or false fever, Crohn disease, Diabetes insipidus, Anhydrotic ectodermal dysplasia, Familial Mediterranean fever
STEP # 02: Is it prolonged fever?
Prolonged fever is a fever with duration of more than 10 - 14 days. Although it is not as common as short febrile illness, it causes greater concern of both parents and doctors.
Fortunately, unlike adults, most cases of prolonged fever in children are caused by benign infections and the prognosis for ultimate recovery is generally good.
STEP # 03: Is it true prolonged fever?
Is it truly a prolonged fever?
• Is there an evident cause?
• Unexplained prolonged fever... What is the cause?
Is it truly a prolonged fever?
The complaint of prolonged fever, as any other prolonged complaint, should not be accepted without careful analysis. Parents may misinterpret normal temperature as a mild fever. Careful history may reveal that the condition represents 2 short febrile illnesses rather than a prolonged one. Documentation of fever is important in accepting the complaint as a true prolonged fever.
STEP # 04: Is there an evident cause for prolonged fever?
With documented prolonged fever, detailed history and meticulous examination may
reveal an evident cause or at least suggest a specific disease.
History and examination in children with prolonged fever
Nonspecific findings denoting significant illness
Symptoms: Anorexia, weight loss.
Signs: Toxic look, pallor, cachexia, lymphadenopathy or Hepatosplenomegaly.
Specific findings suggesting a particular disease
Symptoms related to a specific system: CNS, chest, heart, GIT, urinary.
History of contact to an adult with chronic chest disease: ? Tuberculosis.
History of eating rabbit meat: ? Tularemia.
History of medications: ? Drug fever.
Rigors: Septicemia, pyelonephritis or malaria.
Pharyngitis: Infectious mononucleosis, cytomeglovirus, tularemia, toxoplasmosis.
CNS examination May suggest meningitis.
Chest examination: May reveal pneumonia or empyema.
Cardiac examination: May reveal endocarditis or pericarditis.
Abdominal examination: Liver (hepatitis, abscess) or loin tenderness (perinephric abscess).
Skeletal examination: Arthritis or osteomyelitis (focal tenderness).
Rectal examination: Focal tenderness suggests pelvic abscess.
STEP # 05: After history and examination, did you find any cause for prolonged fever?
With clinical suspicion of any disease, investigations should be directed to confirm or exclude the suspected disease.
Unexplained prolonged fever... What is the cause?
When history and physical examination fail to reveal an evident cause or to suggest a specific disease, the term “unexplained prolonged fever” or “fever of unknown origin
(FUO)” can be used. These terms should be restricted to cases of documented fever with duration of at least 10-14 days.
STEP # 06: Whether to admit or not?
In patients with good general condition and a rather short history, simple investigations (CBC, ESR, CRP, urine analysis) can be made on an outpatient basis.
Normal laboratory findings in this group indicate that the illness is mostly a benign viral infection. Reassurance and follow-up are important.
Patients with clinical findings indicating that the illness is significant should be hospitalized and further investigated. Hospitalization is also indicated in those with abnormal results of initial simple investigations.
Hospitalization is useful for several reasons:
a. Documentation of fever: Temperature should be regularly measured by a reliable person to exclude the possibility of “factitious or false fever”.
b. Drugs should be avoided as much as possible to exclude the possibility of drug fever. In this case, fever will subside within 1-3 days of discontinuation of the responsible drug.
c. Close observation for the general condition (appetite, activity, reaction to stimulation), presence of rigors (septicemia, malaria) or appearance of new symptoms or signs. Frequently, the fever may subside spontaneously without any specific therapy and even before completing the investigations.
STEP # 06: Investigations in children with unexplained prolonged fever
Nonspecific Investigations to confirm the presence of significant illness
Complete blood count (CBC): Leukocytosis, leukopenia or eosinophilia (larva migrans).
Erythrocyte sedimentation rate (ESR): Above 30 mm (first hour).
C-reactive protein (CRP): Above 20 - 30 mg/liter.
Chest X-ray: Pneumonic consolidation or pulmonary infiltrate.
Specific investigations to identify the causative disease
Initial investigations
Blood culture (aerobic and anaerobic): May be repeated.
Urine culture.
Tuberculin test and culture of gastric washing.
Blood film for malaria.
Common serological tests: Typhoid, infectious mononucleosis (monospot), brucella.
When the above specific initial investigations are negative
Specific blood culture for listeriosis, leptospirosis, tularemia.
Specific serological tests for leptospirosis, tularemia, toxoplasmosis.
Bone marrow examination (for leukemic blast cells) and culture (bacteria).
Abdominal ultrasonography: For liver abscess, epinephric abscess.
Echocardiography: In patients with preexisting cardiac disease (infective endocarditis).
When all of above are negative
Lymph node biopsy: May reveal lymphoma.
Radioactive scanning: May reveal osteomyelitis.
Total body CT scanning or MRI: May reveal hidden tumors.
Remember: International studies showed that in 25% of cases, the cause remains unknown even after exhaustive investigations.
STEP # 07: Blind empirical drug therapy may or may not be started? When indicated?
Blind empirical drug therapy should be generally avoided as it may mask the condition and makes the diagnosis more difficult. Exceptions to this rule are:
a. Blind antibiotic therapy in patients with the clinical diagnosis of septicemia but the organism could not be isolated.
b. Blind antituberculous therapy in sick patients with cachexia and weight loss and when the possibility of tuberculosis is strongly standing in spite of the negative laboratory investigations.
Monday, April 13, 2020
SELF ASSESSMENT
SELF ASSESSMENT
A 3-year-old boy is admitted to hospital following two episodes of abnormal movements. His mother reported that on two consecutive mornings, whilst having his breakfast, the right side of his face and his right hand were twitching for about 30 s. He appeared to be conscious throughout both episodes. Afterwards, he recovered completely; although following the second episode, he fell asleep on the sofa. His twin brother used to have uncomplicated febrile convulsions in the past. Growth parameters are all on the 50th centile. Clinical examination including fundoscopy was entirely normal.
a. What other history should be sought?
b. What is your differential diagnosis?
c. What investigations would you request?
d. How would you treat this condition?
e. What would you tell his parents?
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Answer to question
Answer
a. A detailed developmental history should be taken.You want to ask about family history although this is more difficult in this case since he was adopted.
b. Benign Rolandic epilepsy of childhood or simple partial seizures.
c. Electroencephalogram (EEG).
In this case, the EEG showed left-sided centrotemporal spikes. This appearance is typical for benign Rolandic epilepsy of childhood and can also be bilateral.
A sleep EEG often intensif|es the spike activity. Further investigations like neuro-imaging are not indicated
because of the diagnostic nature of the EEG and the absence of any neurological abnormalities on clinical
examination.
d. The best treatment is not to treat! The condition is
benign and because the seizures usually occur during
sleep or on waking, it is well tolerated. If the seizures
are interfering with schooling or quality of life, carbamazepine or valproate may be used.The age of onset
is between 3 and 13 years.
e. Prognosis is excellent. Seizures commonly stop at the
age of 12 years and the EEG normalizes several years
later. There is no increased risk of seizure development
in later life. This is a genetic disorder transmitted
as an autosomal dominant trait. Forty percent of close relatives have a history of febrile convulsions
or epilepsy.
ASCITIC DRAINAGE: STEPS TO CARRY OUT IN EXAMINE
ASCITIC DRAINAGE: STEPS TO CARRY OUT IN EXAMINE
BRIEF DESCRIPTION:
Indications
•• Diagnostic – investigating a patient with ascites for the cause or when spontaneous bacterial peritonitis is suspected
•• Therapeutic – for symptomatic relief in patient with large ascites
Contraindications
•• Infection at insertion site
•• Surgical abdomen
•• Distended bowel or bowel obstruction
•• Intra-abdominal adhesions
•• Too little fluid to tap – this can be confirmed by USS in ED if available
•• Uncorrected coagulopathy is a relative contraindication; most patients with liver failure have some degree of coagulopathy and thrombocytopaenia. However if the coagulopathy is severe or platelets are lower than 40 × 109/L the procedure will normally be deferred until the abnormality is corrected.
Complications
•• Haematoma at site of procedure
•• Introduction of infection
•• Hypovolaemia leading to shock and renal failure
•• Persistent leakage of ascitic fluid from the drain site
•• Haemoperitonium (uncommon)
•• Bowel perforation (uncommon)
Common sites
•• Right or left iliac fossa
•• Ultrasound guided marking on skin where the collection is closest to the skin
Pre-procedure check
•• Drugs – local anaesthetic-1% lignocaine
•• Cleaning and preparation – skin cleaning with chlorhexidine or iodine
•• Equipment:
–– Minor dressing pack, with sterile drapes
–– 10 mL syringe and an orange and a green needle
–– 20 mL syringe
–– Bonanno pigtail catheter or other purpose-built paracentesis catheter or drip-set
–– Drainage bag
–– Dressing and suture to secure the catheter in place
–– Bottles to take samples
• Monitoring – intravenous line connected and running.
• Sterility – sterile gloves and field
Technique
Ensure all the equipment is available and easily accessible. The patient should be lying supine, preferably leaning towards the side where you plan to tap and should have an empty bladder. Percuss the abdomen and confirm dullness to percussion at the chosen site. Hands should be washed and dried before wearing sterile gloves. Clean the selected area with povidone-iodine or chlorhexidine skin solution.
Establish sterility and cover the area of the abdomen with a sterile drape leaving a window for the drain insertion.
The site for the procedure is approximately 15 cm lateral and 2–3 cm below the umbilicus. At this point the rectus and anterior abdominal wall muscles become aponeurotic. This site is also located away from the epigastric arteries. Consider using ultrasound to locate the best site.
Infiltrate an appropriate local anaesthetic at the site, first using an orange 25G needle in the skin and then using a larger 21G green needle in the abdominal wall. On advancing the needle into the peritoneal cavity one can feel a give and aspirate peritoneal fluid.
Attach a 20 mL syringe to the end of the Bonanno catheter. Insert using the so-called Z technique. Pull the skin taught and insert the needle perpendicular to the skin. Release the
skin and advance the needle obliquely in the subcutaneous tissue before advancing the needle perpendicular to the abdominal wall in the peritoneal cavity. This ensures that the holes in the skin and the abdominal wall are away from each other and therefore there is less chance of leakage of the fluid after drain removal.
Once in the peritoneal cavity, aspirate the syringe to confirm placement in the ascitic fluid. Once aspirating freely, advance the needle a few millimetres and then advance the catheter further and withdraw the needle from the catheter. If the fluid cannot be aspirated from the catheter when the needle has been withdrawn, do not re-advance the needle in the catheter. This is because the catheter is has a ‘pig-tail’ end which tends to curl up. If the
needle is advanced, it may cut through, rather than advance into the catheter.
If necessary take samples for cytology, culture, neutrophil count and albumin as required and connect the catheter to the drainage bag. Secure the catheter in place using a
suture.
Clear the sharps and other equipment appropriately. The amount of fluid to be removed and duration for which the catheter is to be left in place will depend on the situation. If the catheter is for therapeutic drainage, it is recommended for it not to remain inserted overnight.
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PEDIATRICS SHORT QUESTIONS: TEST YOUR KNOWLEDGE OF PEDIATRIC GASTROENTEROLOGY
PEDIATRICS SHORT QUESTIONS: TEST YOUR KNOWLEDGE OF PEDIATRIC GASTROENTEROLOGY
Sunday, April 12, 2020
Causes of recurrent pneumonia in Pediatrics: Pediatrics Top-ups
What are the causes of recurrent pneumonia in Pediatrics?
• Aspiration susceptibility: Oropharyngeal incoordination, vocal cord paralysis, gastroesophageal reflux, tracheoesophageal fistula
• Immunodeficiency: Congenital, acquired
• Congenital cardiac defects: Atrial septal defect, ventricular septal defect, patent ductus arteriosus
• Abnormal secretions or reduced clearance of secretions: Asthma, cystic fibrosis, ciliary dyskinesia
• Pulmonary anomalies: Sequestration, cystic adenomatoid malformation
• Airway compression or obstruction: Foreign body, vascular ring, enlarged lymph node, malignancy
• Miscellaneous: For example, sickle cell disease, sarcoidosis
Can a chest radiograph reliably distinguish between viral and bacterial pneumonia?
Can a chest radiograph reliably distinguish between viral and bacterial pneumonia?
No. Viral infections more commonly have multifocal interstitial, perihilar, or peribronchial infiltrates; hyperinflation; segmental atelectasis; and hilar adenopathy. Effusions are uncommon. However, there can be considerable overlap in features with bacterial (and chlamydophilal and mycoplasmal) pneumonia. Bacterial pneumonia more commonly results in lobar and alveolar infiltrates, but the sensitivity and specificity of this finding are not very high.
But most children with alveolar pneumonia, especially those with lobar infiltrates, have laboratory evidence of a bacterial infection. Interstitial infiltrates are seen in both viral and bacterial pneumonias.
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What is the risk for epilepsy after a simple febrile seizure?
What is the risk for epilepsy after a simple febrile seizure?
The risk depends on several variables. In otherwise normal children with a simple febrile seizure, the risk for later epilepsy is about 2%. The risk for epilepsy is higher if any of the following is present:
• There is a close family history of nonfebrile seizures.
• Prior neurologic or developmental abnormalities exist.
• The patient had an atypical or complex febrile seizure, defined as focal seizures, seizures lasting at least 15 minutes, and/or multiple attacks within 24 hours.
One risk factor increases the risk to 3%. If all three risk factors are present, the likelihood of later epilepsy increases to 5% to 10%.
PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: Why are multiple antibiotics used for the treatmen...
PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: Why are multiple antibiotics used for the treatmen...: Why are multiple antibiotics used for the treatment of TB disease? Compared with a patient with a positive test but no disease, two f...
Why are multiple antibiotics used for the treatment of TB disease?
Why are multiple antibiotics used for the treatment of TB disease?
Compared with a patient with a positive test but no disease, two features of M. tuberculosis make the organism difficult to eradicate after infection has been established. First, mycobacteria replicate slowly and may remain dormant for prolonged periods, but they are susceptible to drugs only during active replication. Second, drug-resistant organisms exist naturally within a large population, even before the initiation of therapy. These features render the organism—when it is present in significant numbers—extremely difficult to eradicate with a single agent.
PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: IRON DEFICIENCY ANEMIA: WHAT A GLOBAL PROBLEM? CLI...
PEDIATRICS MCQS, TOACS, PEARLS & UPDATES FOR MRCPCH/FCPS/MCPS EXAMS: IRON DEFICIENCY ANEMIA: WHAT A GLOBAL PROBLEM? CLI...: Question#01 As iron becomes depleted from the body, what is the progression at which laboratory tests change? For answer, click ...
IRON DEFICIENCY ANEMIA: WHAT A GLOBAL PROBLEM? CLICK BELOW TO LEARN ABOVE IRON DEFICIENCY ANEMIA.
Question#01
As iron becomes depleted from the body, what is the progression at which laboratory tests change?
For answer, click at
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-01.html
Question#02
How is the RDW useful for distinguishing causes of microcytic anemia?
For answer, click at
https://pediatricmcqsseqsbank.blogspot.com/2020/04/answer-to-question-02.html
Question#03
What is the Mentzer index?
For answer, click at
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Question#04
In a child with suspected iron-deficiency anemia, is a therapeutic trial with iron an acceptable diagnostic approach?
For answer, click at
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Question#05
After iron therapy is initiated, how early can a response be detected?
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ANSWER TO QUESTION # 05
Question#05
After iron therapy is initiated, how early can a response be detected?
ANSWER:
2 to 5 days: Increase in reticulocyte count
7 to 10 days: Increase in hemoglobin level
For patients with mild iron-deficiency anemia, the hemoglobin level should be checked after several weeks of therapy. For patients with more severe anemia, it may be useful to check the hemoglobin and reticulocyte levels after several days to make certain that the hemoglobin has not declined to dangerous levels and that the reticulocyte response is beginning.
ANSWER TO QUESTION # 04
QUESTION # 04
In a child with suspected iron-deficiency anemia, is a therapeutic trial with iron an acceptable diagnostic approach?
ANSWER:
Yes. If an infant or child is otherwise well, a therapeutic trial of 4 to 6 mg/kg/day of elemental iron can substitute for additional diagnostic testing (e.g., ferritin, transferrin saturation, free erythrocyte protoporphyrin), because dietary iron deficiency is the most likely cause of microcytic anemia. If the child is iron deficient, compliant with therapy, and there is not ongoing undetected blood loss, the hemoglobin should rise by >1 g/dL in about 2 weeks. If the hemoglobin does rise, therapy should be continued for an additional 2 months to replenish iron stores.
ANSWER TO QUESTION # 03
What is the Mentzer index?
MCV/RBC. This is one of the formulas used to distinguish the hypochromic, microcytic anemias of the thalassemia trait from iron deficiency. As a general rule, iron deficiency causes alterations in RBCs that tend to be variable, whereas thalassemia generally results in more uniformly smaller cells. In patients with the beta-thalassemia trait, the Mentzer index is usually <13; in patients with iron deficiency, it is usually >13.
ANSWER TO QUESTION # 02
Question#02
How is the RDW useful for distinguishing causes of microcytic anemia?
How is the RDW useful for distinguishing causes of microcytic anemia?
ANSWER:
The red blood cell distribution width (RDW) is a quantification of anisocytosis (variation in red-cell size). It is derived from the RBC size histogram that is measured by automated cell counters, and it is reported as a percentage. In children, normal values range from about 11.5% to 14.5% but can vary among instruments. Statistically, it is the coefficient of variation of red-cell volume distribution. When elevated in a patient with microcytosis, it suggests that iron deficiency is a more likely cause of anemia than the thalassemia trait. Children with the thalassemia trait tend to have values that overlap with normal RDW values. The combination of an RDW above the normal range with a free erythrocyte protoporphyrin level of >35 μg/dL is more sensitive and specific for iron-deficiency anemia.
Answer to Question # 01
Question#01
As iron becomes depleted from the body, what is the progression at which laboratory tests change?
ANSWER: Look at the figure
The left end of the line for each test indicates the
point at which the result deviates from its baseline. As shown in Figure, in general, the depletion of marrow, liver,
and spleen reserves (as represented by ferritin) occurs first. This is followed by a decrease
in transport iron (as represented by transferrin saturation) and finally a fall in
hemoglobin and MCV. The figure illustrates that the absence of anemia does not exclude the possibility of
iron deficiency and that iron depletion is relatively advanced before anemia develops. Tests
of soluble transferrin receptor have become of interest in patients with iron-deficiency anemia
because the elevated levels are very sensitive indicators.
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