Q&A COUNT: 48* (includes 9 questions from WALRI)
*For undergraduates, both ARI and WALRI can be kept as short cases
*For undergraduates, both ARI and WALRI can be kept as short cases
HISTORY:
Causes of RIGOR + Fever:
Causes of RIGOR + Fever:
- Malaria
- Filaria
- UTI
- Follicular Tonsillitis
Age required to produce RIGOR?
3-6 months
*This answer varies between different faculties. Some say that the age to develop is around 3 years. Kindly be cautious when commenting on rigor.
*This answer varies between different faculties. Some say that the age to develop is around 3 years. Kindly be cautious when commenting on rigor.
Types of Fever?
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| This picture is taken from Aruchamy textbook of Paediatrics |
Causes for evening rise in temperature?
1. TB
2. Typhoid
3. Malaria
4. UTI
Practically, all fevers have evening rise in temperature. This is due to physiological diurnal variation in cortisol levels (peak in morning)
2. Typhoid
3. Malaria
4. UTI
Practically, all fevers have evening rise in temperature. This is due to physiological diurnal variation in cortisol levels (peak in morning)
What is recurrent Respiratory Tract infection? (or) Tell criteria to say it is recurrent RTI
6-8 episodes of Respiratory Infection in every year
Age from which expectoration is possible
5-6 years
5-6 years
Types of discharge?
Purulent, Mucoid, Watery, Serous
Purulent, Mucoid, Watery, Serous
Types of Cough
1. Whooping cough
2. Barking cough - epiglottis involvement
3. Brassy cough - Intrathoracic space occupying lesions
4. Bovine cough - loss of explosive nature due to tumors pressing on recurrent laryngeal nerve
5. Whooping or paroxysmal cough - Whooping cough
6. Short cough - common cold
7. Productive cough - Suppurative lung disease, chronic bronchitis, pulmonary TB
8. Dry cough - Pleural disorder, Interstitial lung disease, mediastinal lesion
2. Barking cough - epiglottis involvement
3. Brassy cough - Intrathoracic space occupying lesions
4. Bovine cough - loss of explosive nature due to tumors pressing on recurrent laryngeal nerve
5. Whooping or paroxysmal cough - Whooping cough
6. Short cough - common cold
7. Productive cough - Suppurative lung disease, chronic bronchitis, pulmonary TB
8. Dry cough - Pleural disorder, Interstitial lung disease, mediastinal lesion
Cough during sleeping - causes
1. Asthma
2. Sinusitis
3. GERD
2. Sinusitis
3. GERD
What is persistent cough?
Cough existing 8 weeks or more
EXAMINATION
External markers for TB
a) Scrufuloderma (side of neck)
b) Phlyctens (eyes)
c) Lupus vulgaris (face/neck)
d) Tinea versicolor
e) Erythema nodosum (shin)
f) Coroid tubercle (fundus)
g) Nimbus (spine)
h) Epididymo orchitis
DISCUSSION:
EXAMINATION
External markers for TB
a) Scrufuloderma (side of neck)
b) Phlyctens (eyes)
c) Lupus vulgaris (face/neck)
d) Tinea versicolor
e) Erythema nodosum (shin)
f) Coroid tubercle (fundus)
g) Nimbus (spine)
h) Epididymo orchitis
Normal Respiratory Rate at various ages:
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| This picture is taken from Aruchamy textbook of Paediatrics |
If you observe Tachypnoea cut offs - you can see it correlates with IMNCI values for fast breathing*
How to draw?
- Bronchial breathing - (a)
- Vescicular breathing - (b)
- Broncho vescicular breathing - (c)
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| This picture is taken from Aruchamy textbook of Paediatrics |
How to differentiate viral and bacterial pneumonia from history and findings?
Bacterial - Sudden onset, Crepts can be heard, Toxic nature of child
Viral - Gradual onset, spreads easily within families (any similar history in family), wheeze can be heard, no signs of consolidation
MANAGEMENT
What is IMNCI?
Integrated Management of Neonatal and Childhood Illnesses
IMNCI module of ARI (2 months to 5 years)
Viral - Gradual onset, spreads easily within families (any similar history in family), wheeze can be heard, no signs of consolidation
What is IMNCI?
Integrated Management of Neonatal and Childhood Illnesses
IMNCI module of ARI (2 months to 5 years)
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| This picture is taken from OP Ghai textbook of Paediatrics |
Amoxycillin - dose
30-50 mg/kg/day in 3 divided doses
Amoxycillin - Formulation
Amoxycillin - Formulation
Syrup formulation for less than 1 year (1 ml contains 25 mg)
Tablet or Capsule formulation for more than 1 year (1 tab contains 125 mg, 1 capsule contains 250 mg)
Paracetamol - Dose
15 mg/kg per dose QDS (6th hourly) (note that it is calculated per dose* - not per day)
Formulations (forms) of Paracetamol
1. Tablets
2. Capsules
3. Syrups
4. Suppositories
Syrup formulation for less than 1 year (1 ml contains 25 mg)
Tablet formulation for more than 1 year (1 tab contains 500 mg)
Routes of Paracetamol
1. Oral
2. Rectal suppositories
3. IV
Dosage and formulation of Cotrimoxazole
Trimethoprim is taken for child dose
6-8 mg/kg body weight/day in 2 divided doses
Forms of Cotrimoxazole
1. Tablet
2. Syrup
INVESTIGATIONS: (Mantoux Test)
Syrup formulation for less than 1 year (1 ml contains 8 mg)
Tablet formulation for more than 1 year (1 tab contains 80 mg)
Dosage of CPM (Chlorpheninramine)
0.1 mg/kg/dose TDS*
Formulation - Tablet (1 tab contains 4 mg)
IV Antibiotics - dosage
IV Cefotaxime 100-200 mg/kg/day TDS
IV Ceftriaxone 75-100 mg/kg/day OD or BD
Remember: 1 vial of both drugs contains 1 gram of them
Dosage of CPM (Chlorpheninramine)
0.1 mg/kg/dose TDS*
Formulation - Tablet (1 tab contains 4 mg)
IV Antibiotics - dosage
IV Cefotaxime 100-200 mg/kg/day TDS
IV Ceftriaxone 75-100 mg/kg/day OD or BD
Remember: 1 vial of both drugs contains 1 gram of them
INVESTIGATIONS: (Mantoux Test)
About Mantoux test
Dosage - 0.1 ml of Purified Protein Derivative (PPD) injected intra-dermally
After 24-48 hours
Measure vertical INDURATION (not horizontal erythema - as lymphatic spread is possible)
Induration measurement:
>10 mm - Definite TB
6-9 mm - Possible TB
5 mm or less - TB ruled out
Dosage - 0.1 ml of Purified Protein Derivative (PPD) injected intra-dermally
After 24-48 hours
Measure vertical INDURATION (not horizontal erythema - as lymphatic spread is possible)
Induration measurement:
>10 mm - Definite TB
6-9 mm - Possible TB
5 mm or less - TB ruled out
False positive Manxtoux test - conditions:
a) Prior BCG vaccination
b) Atypical mycobacteria infection
c) Hypersensitivity (Allergy)
a) Prior BCG vaccination
b) Atypical mycobacteria infection
c) Hypersensitivity (Allergy)
False negative Manxtoux test - conditions:
a) Malnutrition
b) Steroids
c) Sarcoidosis
d) Infectious Mononucleosis
e) AIDS
f) Hodgkin's disease
b) Steroids
c) Sarcoidosis
d) Infectious Mononucleosis
e) AIDS
f) Hodgkin's disease
Complications of pneumonia
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| This picture is taken from Davidson's Textbook of Medicine |
Causes of Recurrent Respiratory Tract Infection (or) Pneumonia
Non Respiratory Causes:
- HIV
- Measles* (Measles virus binds to secretory IgA in respiratory tract and decreases local immunity in both GIT and RS tract)
- Malnutrition (SAM)
- Nephrotic syndrome
- Down's syndrome
- Leukemias
- Primary Immunodeficiency (ex: SCID)
- Congestive Cardiac Failure - due to pulmonary congestion*
*Except for CCF, all others given above can cause both ADD and ARI. CCF can cause only ARI - not ADD
Respiratory Causes:
- Asthma
- Infections - Bacterial, Viral, TB, Parasitic, Loeffler's syndrome, Atypical pneumonia - Mycoplasma, Chlamydia
- Bronchiectasis - Cystic Fibrosis, Primary Ciliary dyskinesia
- Environmental irritants inhalation
- Foreign body aspiration
- Congenital malformations (Laryngo-tracheal cleft)
*Note that 4 of our cases - SAM, Down's syndrome, Nephrotic syndrome, CCF can cause Recurrent LRI or Pneumonia
Investigations done for "recurrent" pneumonia?
1. Complete Blood Count
2. Peripheral smear
3. Imaging - CT, CXR
2. Peripheral smear
3. Imaging - CT, CXR
4. Blood gas analysis
5. PFT
6. Bronchoscopy
7. Sweat Chloride
8. HIV Serology
9. Echocardiogram - for Congenital heart diseases
10.RFT, Urine albumin
8. HIV Serology
9. Echocardiogram - for Congenital heart diseases
10.RFT, Urine albumin
When will you suspect Staphylococcal pneumonia?
- Skin infections are associated
- Presence of PNEUMATOCOELES or air filled cavity in X ray (Pneumatocoeles rupture to cause Pneumothorax)
Drugs for Staphylococcus
Penicillin group of drugs - Coamoxiclav, Cloxacillin, Ceftriaxone
If no response..
Vancomycin or Teicoplanin or Linezolid is used.
RNTCP latest FDC regimen for Paediatric Tuberculosis and Adult Tuberculosis
BCG:
If no response..
Vancomycin or Teicoplanin or Linezolid is used.
RNTCP latest FDC regimen for Paediatric Tuberculosis and Adult Tuberculosis
BCG:
What to do when BCG scar is not seen in a baby?
If child is normal.. repeat BCG
If child is ill.. do Mantoux test
What to do when BCG injection causes a swelling of lymph node?
When BCG adenitis develops (mostly in axillary node), it can be normal reaction.
So wait and watch!
It can resolve spontaneously!
If there is no resolution, do Mantoux test after 6 months of age*. If it proves to be positive, give INH 10 mg/kg for 6 months
Mechanism of BCG scar
A pustule will form after injection of BCG injection around 2-3 weeks, due to cellular hypersensitivity
It will enlarge and rupture to form a healed scar around 6-8 weeks
BCG Vaccine Complications
1. Disseminated BCG infection
2. Osteomyelitis (more possible in preterm baby)
3. Keloid
4. Fever, rash, anaphylaxis (as in any vaccine)
Risk of putting BCG vaccine in a PRETERM CHILD
There will be no adequate subcutaneous tissue. So, there are chances of disseminated BCG due to invasion of periosteum
Wheeze Associated Acute Respiratory Infection: (9)
What is WALRI?
Wheeze Associated Lower Respiratory Infection
Causes of Wheezing in Paediatrics
1. Wheeze associated LRI or viral infection with wheeze
2. Bronchiolitis
3. Bronchial Asthma
4. Tropical eosinophilia
5. Loeffler syndrome
6. Hypersensitivity pneumonitis
7. Inhaled foreign bodies
8. Enlarged mediastinal nodes (TB or neoplasm)
9. Anomalous left pulmonary artery compressing right main bronchus
10. Cystic Fibrosis
11. Pulmonary hemosiderosis
12. Mediastinal cysts
What is GINA?
Global Initiative for Asthma
What is Bronchiolitis?
Affects child upto 2 years
One of the most common types of acute LRI caused by Respiratory synctitial virus, parainfluenza, influenza virus and rarely M.pneumoniae
It involves inflammation of bronchiolar mucosa leading to edema and spasm
Presents like Bronchial asthma, but poor response to bronchodilators*
Clinically: URI (initial) --> high fever + rapid breathing + crepts/rhonchi - can lead to respiratory distress & death (usually self limiting by 3-7 days)
CXR: Hyperinflation and infiltrates
Treatment: Moist oxygen, head elevation to 30-40°, no antibiotics
Classification of Asthma based on severity
What is WALRI?
Wheeze Associated Lower Respiratory Infection
Causes of Wheezing in Paediatrics
1. Wheeze associated LRI or viral infection with wheeze
2. Bronchiolitis
3. Bronchial Asthma
4. Tropical eosinophilia
5. Loeffler syndrome
6. Hypersensitivity pneumonitis
7. Inhaled foreign bodies
8. Enlarged mediastinal nodes (TB or neoplasm)
9. Anomalous left pulmonary artery compressing right main bronchus
10. Cystic Fibrosis
11. Pulmonary hemosiderosis
12. Mediastinal cysts
What is GINA?
Global Initiative for Asthma
What is Bronchiolitis?
Affects child upto 2 years
One of the most common types of acute LRI caused by Respiratory synctitial virus, parainfluenza, influenza virus and rarely M.pneumoniae
It involves inflammation of bronchiolar mucosa leading to edema and spasm
Presents like Bronchial asthma, but poor response to bronchodilators*
Clinically: URI (initial) --> high fever + rapid breathing + crepts/rhonchi - can lead to respiratory distress & death (usually self limiting by 3-7 days)
CXR: Hyperinflation and infiltrates
Treatment: Moist oxygen, head elevation to 30-40°, no antibiotics
Classification of Asthma based on severity
Nebulization dosage in Paediatrics
Two types of Nebulization are given
1. Salbutamol Nebulization
Frequency - 2nd hourly
Given if there is wheeze present
Usual dose used is 2.5 mg (0.5 ml) of Salbutamol solution mixed with 3.5 ml of Normal saline
Total 4 ml
2. Saline Nebulization
Given to relieve mechanical obstruction due to mucus
Hypertonic saline 3% (4 ml) solution used
Given 2nd hourly
Salbutamol dosage in Paediatrics
Tablet:
0.1 to 0.15 mg/kg/dose TDS
Formulation - Tablet (1 tab contains 4 mg)
Note that this dosage is almost same as CPM*
Metered Dose Inhaler:
100 microgram per puff use
Total 200 times can be used
Total dose in the Inhaler - 20 mg
Stepwise Treatment of Asthma
Step 1 - Intermittent: Short acting Beta 2 agonist whenever symptomatic
Step 2 - Mild persistent: Short acting Beta 2 agonist whenever symptomatic + Low dose inhaler steroids
Step 3 - Moderate persistent: Long acting Beta 2 agonist + Low dose inhaler steroids
Step 4: Severe persistent: Long acting Beta agonist + High dose inhaler steroids
Treatment of Asthma based on age:
1. <4 years - Metered Dose Inhaler with spacer with face mask
2. 4-12 years - Metered Dose Inhaler with spacer
3. >12 years - Metered Dose Inhaler with or without spacer
Two types of Nebulization are given
1. Salbutamol Nebulization
Frequency - 2nd hourly
Given if there is wheeze present
Usual dose used is 2.5 mg (0.5 ml) of Salbutamol solution mixed with 3.5 ml of Normal saline
Total 4 ml
2. Saline Nebulization
Given to relieve mechanical obstruction due to mucus
Hypertonic saline 3% (4 ml) solution used
Given 2nd hourly
Salbutamol dosage in Paediatrics
Tablet:
0.1 to 0.15 mg/kg/dose TDS
Formulation - Tablet (1 tab contains 4 mg)
Note that this dosage is almost same as CPM*
Metered Dose Inhaler:
100 microgram per puff use
Total 200 times can be used
Total dose in the Inhaler - 20 mg
Stepwise Treatment of Asthma
Step 1 - Intermittent: Short acting Beta 2 agonist whenever symptomatic
Step 2 - Mild persistent: Short acting Beta 2 agonist whenever symptomatic + Low dose inhaler steroids
Step 3 - Moderate persistent: Long acting Beta 2 agonist + Low dose inhaler steroids
Step 4: Severe persistent: Long acting Beta agonist + High dose inhaler steroids
Treatment of Asthma based on age:
1. <4 years - Metered Dose Inhaler with spacer with face mask
2. 4-12 years - Metered Dose Inhaler with spacer
3. >12 years - Metered Dose Inhaler with or without spacer