a. acute encephalitis T
b. dysentery T
c. pulmonary tuberculosis T
d. chicken pox F
e. Kawasaki disease F
Bacterial: anthrax, diphtheria, leptosporosis, pertussis, plague, Brucellosis, tetanus, typhus, cholera, dysentery, food poisoning, paratyphoid fever, typhoid, leprosy, tuberculosis, meningitis, meningococcal infection, ophthalmia neonatorum, erysipelas, scarlet fever.
Viral: acute encephalitis, AIDS, hepatitis B, measles, mumps,rubella, poliomyelitis, rabies, varicella (encephalitis- chickenpox isn't) , yellow fever.
Protozoal: malaria.
Chicken pox is notifiable in Scotland.
2. Theme:Causes of deafness
A Acoustic neuroma
B Alport's syndrome
C Barotrauma
D Drug induced
E Hypothyroidism
F Meningitis
G Otitis media
H Paget's disease
I Pendred's syndrome
J Radiotherapy
K Stroke
Select the most likely cause of deafness in the following cases:
-A 75-year-old male presents as he has increasing problems with deafness. He suffers from Parkinson's disease and takes l-dopa therapy.On examination, he has a pill rolling tremor and reduced mobility. There is also enlargement of the skull.
Answer: H
Although this man has Parkinson's disease, the description of a large skull suggests Paget's disease as the cause of deafness as l-dopa does not cause deafness. Paget's causes enlargement of the bone in the inner ear which can be responsible for the conductive deafness
- A 20-year-old female presents with increasing deafness. She only takes the oral contraceptive pill. On examination, there is nil of note but urinalysis reveals blood ++ and protein++.
Answer: B
Alport's syndrome is an inherited condition associated with sensorineural deafness and renal dysfunction.
- A 54-year-old female presents with a two month history of increasing deafness in the left ear. She has a history of hypertension for which she takes lisinopril and amlodipine. On examination she has decreased hearing in the left ear both through air and bone and there is loss of the corneal reflex on the left side.
Answer: A
The sensorineural deafness suggests involvement of the VIII cranial nerve and the loss of corneal reflex indicates involvement of the V cranial nerve. This would occur in the posterior fossa of the brain and hence the likely lesion is an acoustic neuroma.
3. You have been informed by the local hospital that a 4-year-old patient from your practice has been admitted with definite meningococcal sepsis. There have not been any previous cases. You need to organise appropriate prophylaxis. Which of the following is the single most appropriate group to treat?
a. All family members
b. All family members and friends who have played with the child in the last 48 hours
c. All family members and children at the same nursery
d. All household members
e. All household members and children at the same nursery
Answer: D
The following groups would be classed as close contacts and require prophylaxis:
people in the same household
people who have slept in the house during the 7 days prior to the onset of the illness
people who have spent several hours a day in the house inthe last 7 days
â€کKissing contacts’, ie boy/girlfriend
students sharing the same room or flat as the case
anyone who gave mouth-to-mouth resuscitation to the index case
Those attending the same childminder as the index case in the last 7 days.
Groups not requiring prophylaxis:
school, nursery or playgroup contacts
students on the same course or in the same hall of residence who are not in the above categories.
4. THEME: VOMITING
A Cow’s milk protein intolerance
B Gastroenteritis
C Gastro-oesophageal reflux
D Hiatus hernia
E Hirschprung’s disease
F Lactose intolerance
G Overfeeding
H Posseting
I Pyloric stenosis
J Reduced gastric motility
For each of the following clinical situations, choose the single most likely diagnosis from the list of options given above. Each option can be used once, more than once or not at all.
A 1-week-old baby is brought by his mother. He was born at home. Mum is concerned that he is vomiting and not feeding well. On questioning, his mother tells you that she cannot remember her child opening his bowels. On examination, the child appears grey, his abdomen is distended and firm. He vomits forcefully when you palpate his abdomen.
E Correct answer
Classically presents in the neonatal period with failure to pass meconium within 24 hours and features of obstruction. It is caused by aganglionosis of the distal bowel. If only a small segment of large bowel is affected children can present several years later with chronic constipation. diagnosis is made by rectal biopsy.
A 6-week-old baby is brought to see you with increasing vomiting. His mother reports that he feeds very well and is always hungry. Initially he vomited small amounts after some feeds. Over the last week, he has had large vomits after every feed. On examination, the baby is alert and hungry but appears to have lost weight.
I Correct answer
Caused by hypertrophy of the pyloric sphincter. Classically presents at 6 weeks with a preceding history of worsening vomiting as the pylorus becomes increasingly hypertrophied with use. Babies usually feed very well and are very hungry. Weight loss can be dramatic. Management includes stopping feeds, correction of electrolyte imbalance and surgical correction. The prognosis is very good.
A 6-week-old baby has a history of vomiting. His mother reports that from the age of 1 week her child has vomited after almost every feed. He is distressed when he vomits and if he is laid flat after a feed. He is thriving and examination is unremarkable.
C Correct answer
Common in infancy, due to relatively poor muscle tone. Symptoms improve with age. This is due to stronger muscle tone, introduction of dietary solids and a more upright posture for the baby. in severe cases there can be failure to thrive and feeding aversion because of the distress associated with feeds. there are several management options:
Keeping the child upright (no proved benefit)
Propping up the head of the bed (no proved benefit)
Thickening agents (proved benefit)
Antacids, eg Gaviscon (no proved benefit)
Ranitidine (proved benefit)
Omeprazole and domperidone, often used but not licensed.
A 6-week-old baby has a history of vomiting. His mother reports that he vomits after feeds, two or three times a day. He is described as a hungry baby. He takes 300 ml every 3 hours during the day, having seven feeds in 24 hours. His weight is above the 99th centile. Examination is otherwise unremarkable.
G Correct answer
Full-term babies normally require 150 ml/kg/day of milk. Particularly hungry babies might need more than this to settle them but volumes over 200 ml/kg/day are not recommended. Overfeeding is common and often results in vomiting.
An 8-month-old baby has a history of vomiting. She attends nursery 3 days per week. She has a 2-day history of vomiting after some feeds and the vomiting is worsening today. She is opening her bowels regularly and had one loose stool this morning. Examination is unremarkable, although she cries throughout.
B Correct answer
Mild, self-limiting episodes of gastroenteritis are common in this age group. Infants who attend nursery have twice the number of viral infections as those that do not.
5. THEME: JAUNDICE
A ABO incompatibility
B Biliary atresia
C Breast milk jaundice
D Galactosaemia
E Gilbert syndrome
F Hepatitis
G Hypothyroidism
H Physiological jaundice
I Rhesus incompatibility
J Sepsis
For each of the following clinical situations choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not all.
· A 20-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well and the baby’s mother has no concerns. On further questioning, she tells you that the baby’s urine is dark in colour and that the stools are the same colour as the baby’s nappy. Examination reveals no abnormality.
This is a congenital abnormality, presenting as prolonged conjugated jaundice. A history of dark urine and pale stools might also be given. This requires urgent corrective surgery. A significant number of children operated on after 6 weeks of age develop chronic hepatic failure and some require liver transplantation.
· A 10-day-old baby is noted to be jaundiced by the health visitor. The baby is breastfeeding well and gaining weight well. The jaundice was first noted on day 2 of life. The baby’s mother is concerned that her baby has a red rash in the nappy area and some small spots on the face. Examination reveals no other abnormalities.
C Correct answer
Babies who are breastfed are more likely to become jaundiced because they are taking less milk volume in the first 48 hours. The jaundice also takes longer to resolve than in formula-fed babies. This is not harmful and there is no need to stop breastfeeding.
·A 4-day-old baby is brought to your surgery by his father. He is concerned that the baby has not been feeding well for the past 24 hours. On examination, the baby is jaundiced and floppy and the heart rate is 160/minute. The father cannot give you any further history.
J Correct answer
Infection can present with jaundice in the neonatal period. Onset of jaundice in the first 24 hours of life warrants investigation for sepsis. After this time there are usually other symptoms and signs indicating infection, as in this case. In prolonged jaundice (visible after 14 days), an untreated infective cause (eg urinary tract infection) should be ruled out.
· A 6-day-old baby is brought to your surgery by her mother. She is the third baby in the family and the mother is concerned about her baby’s feeding. She describes her baby as sleepy and floppy and taking a long time to finish bottles. The mother says that the baby has been jaundiced since day 3 of life. On examination, the baby is jaundiced and floppy with a large fontanelle.
G Correct answer
Hypothyroidism can present in the neonatal period as jaundice, poor tone and poor feeding. examination is usually otherwise normal, although a large fontanelle and umbilical hernia may be features. Urgent investigation and treatment is necessary as mental retardation develops early and is irreversible. Screening for hypothyroidism is now part of the national neonatal screening programme, but the result would not be available at this stage. If there is clinical suspicion of hypothyroidism it is important to check the baby’s full thyroid function profile as the screening test only measures thyroid-stimulating hormone levels.
· You see a 6-day-old baby who is jaundiced. The baby was noted to be jaundiced on day 2 of life. Bilirubin levels were checked in the hospital and the baby did not require any treatment. Although he took a few days to start feeding, he is now breastfeeding well. The mother feels he is slightly less jaundiced than yesterday. Other than jaundice you can find no other abnormalities on examination.
In full-term babies, physiological jaundice is usually visible from day 2 or day 3, peaks at day 5, and has resolved by day 14. Treatment consists of ensuring adequate milk intake and ruling out any other causes (ie infection, rhesus or aBo incompatibility). If the bilirubin level is rising rapidly, phototherapy might be necessary but can usually be avoided if feeding issues are addressed early. Physiological jaundice in preterm infants starts sooner and usually lasts longer, up to 21 days.
6. THEME: WHEEZE
A Anaphylaxis
B Asthma
C Bronchiolitis
D Chronic lung disease
E Croup
F Cystic fibrosis
G Foreign body inhalation
H Primary ciliary dyskinesia
I Recurrent aspiration
J Virus-induced wheeze
For each of the following clinical situations, choose the single most likely diagnosis from the options given above. Each option can be used once, more than once or not at all.
· A 2-year-old child is brought to see you with sudden onset of wheeze and shortness of breath. The symptoms started when the child was at nursery this morning. She has been otherwise well. There is no significant past medical or family history. On examination, she is distressed, with mild subcostal recession; there is an audible wheeze. On auscultation, you can hear wheeze on the right side of the chest, with good air entry throughout.
A sudden onset of respiratory distress in a child of 18 months to 3 years should raise the suspicion of an inhaled foreign body. If there is a suggestive history and/or unilateral clinical signs it is an important diagnosis to rule out. Urgent paediatric assessment is required.
·A 20-month-old boy is brought to see you with respiratory distress. He has been unwell for 2 days with a runny nose, cough and reduced feeding. He is normally fit and well. On examination, the child is coryzal and has a temp of 38.1 °C. His respiratory rate is 32/minute, with mild subcostal recession. Wheeze can be heard throughout the chest with good air entry. He has a blanching maculopapular rash on his trunk
Many children aged under 3 years wheeze with viral infections. no treatment is usually necessary. a trial of salbutamol via inhaler and spacer can be given to children aged over 1 year if respiratory distress is severe or if there is a strong family history of atopy.
·A white 22-month-old boy is brought to see you by his mother. They have recently moved to the area. His mother tells you that he often needs antibiotics for his chest and that this is why she has brought him in now. On examination, the child is small and thin (weight and height are on 0.4th centile) with visible Harrison’s sulci. He has mild subcostal recession. Wheeze can be heard throughout the chest.
Recurrent lower respiratory tract infections and poor weight gain warrant further investigation. The most likely diagnosis in the white population is cystic fibrosis. Other pathologies such as immunodeficiencies, congenital lung abnormalities and rarer causes of bronchiectasis such as primary ciliary dyskinesia should be considered if cystic fibrosis tesing is negative.
·You are asked to visit a 3-year-old girl at home. She is not known to you but from her notes you see that she has diagnoses of cerebral palsy, kyphoscoliosis and severe gastro-oesophageal reflux. She is fed via a gastrostomy tube. She has symptoms of a moist cough and fever. On examination, she has a respiratory rate of 28/minute and wheeze and crepitations throughout the chest.
Children with chronic neurological conditions often have gastrooesophageal reflux and are at high risk of recurrent aspiration. Fundoplication and gastrostomy feeds can help. Infections need to be treated early and aggressively because this is the main cause of mortality in this group of patients.
· A 6-week-old baby is brought to see you with breathing difficulties. She was born at 33 weeks’ gestation and was discharged home 2 weeks ago. She has a 24-hour history of fast, noisy breathing and reduced feeding and the mother thinks that she might have stopped breathing just now in the waiting room. On examination, there is subcostal recession and wheeze is heard bilaterally.
C Correct answer
Bronchiolitis is a viral illness affecting infants aged under 1 year. It is predominantly caused by respiratory syncitial virus (rsv). Clinical features include respiratory distress, wheeze, coryzal symptoms, lowgrade temperature and reduced feeding. Treatment is supportive. Those under the age of 2 months, ex-premature babies and those with existing pathology (eg cardiac disease) are at particular risk and can develop apnoeas. Paluvizumab, a monoclonal antibody against rsv, is now available, though it is very expensive. It is currently offered to premature babies with significant lung disease and to some children with cardiac problems
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