🤔 MEDIUM

A classic problem we’ve all had.  You’ve bought something tasty, you enjoy eating it … but a few short hours later you don’t feel right.  Have fun with this quiz of a classic vignette of infective gastroenteritis.  Bring your BNF and good luck! 

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paed CBH 2

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Question 1
After a BBQ, a 4 year old male reports to his GP surgery with 2 days of diarrhoea and vomiting. His mother is concerned because she purchased “ORT” from the pharmacy and he twice vomited it back up. He had “a dodgy burger” at the event. On examination he had umbilical abdominal pain and appeared dehydrated. He had a low fever and was nauseated.

What is the most common cause of traveller’s diarrhoea?
A
Campylobacter
B
E coli
C
Entamoeba histolytica
D
Salmonella
E
Shigella
Question 1 Explanation: 
Despite all the exotic locations, and causative organisms, the prevalence of E coli means this bug is the most common cause by far! Source: BMJ Best Practice, 2021.
Question 2
Which of the following should be undertaken next?
A
Abdominal X-ray
B
Admit to hospital
C
FBC
D
Renal function test
E
Stool culture
Question 2 Explanation: 
The patient requires admission to hospital. They are not tolerating fluids per oral, and have signs of systemic infection/dehydration. In the paediatric patient, this cluster triggers admission for monitoring/IV fluids etc. Source: NICE CKS, 2021.
Question 3
At admission, the patient is given FBC, renal function and electrolytes alongside microscopy and culture of stools. Which of the following justifies sending for full blood counts (choose ALL appropriate answers)?
A
A marker of acute phase proteins
B
A marker of dehydration
C
A marker of GI blood loss
D
A marker of thrombocytopenia
E
This should not be ordered first-line
Question 3 Explanation: 
Full blood count can be used to measure risk of iron deficiency anaemia, or decreased haemoglobin (GI bleeding), dehydration markers and platelet count. All are red flags for either bleeding ± haemolytic uraemic syndrome - for which you should always think of microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury.
Question 4
The culture is returned as an enterotoxigenic species of E. coli. Which of the below is not a classic sign of haemolytic uraemic syndrome? Select all which may apply.
A
Bloody diarrhoea
B
<5 year old onset
C
>7 year old onset
D
Shiga breakout infection
E
Thrombocytopenia
Question 4 Explanation: 
The patient with low platelets, anaemia bloods, blood in stool, of a young onset with a region of Shiga toxin breakout is most at risk of HUS (described briefly above).
Question 5
The patient is given a fluoroquinolone first line. Which of the below is the best fit to this regimen?
A
Azithromycin
B
Ceftriaxone
C
Ciprofloxacin
D
Meropenem
E
Vancomycin
Question 5 Explanation: 
Azithromycin is a macrolide, ceftriaxone is a third-generation cephalosporin (beta-lactam inhibitor), ciprofloxacin is a fluoroquinolone, meropenem is a carbapenem (beta-lactam inhibitor), vancomycin is a glycopeptide. All are different - important - classes of antibiotic.
Question 6
Which region of the gastrointestinal tract refers to the periumbilical region more commonly?
A
Distal duodenum
B
Gastric corpus
C
Gastric fundus
D
Oesophagus
E
Proximal duodenum
Question 6 Explanation: 
The periumbilical region (T9-10/11) dermatomes receive referred pain from the midgut. This is the portion of the alimentary system from distal duodenum to two-thirds along the transverse colon.
Question 7
For which reason is loperamide held from the patient’s regimen?
A
Can cause significant escalation of nausea
B
Increase enteric nervous output
C
Reacts negatively with ciprofloxacin
D
Risks colonic dilatation
E
Would make it difficult to travel
Question 7 Explanation: 
Loperamide is contraindicated in diarrhoea (except in traveller’s diarrhoea where it is still not desirable). The opiate risks toxic dilation of the colon.
Question 8
The physician adds a bismuth to the drug chart. What is the rationale for this addition?
A
Analgesic
B
Anti-diarrhoeal
C
Antiemetic
D
Antitussive
E
Pro-motile
Question 8 Explanation: 
Bismuth subsalicylate can be given to reduce diarrhoea - and is especially handy in paediatric populations.
Question 9
The next day the patient is discharged as he passes an oral fluid challenge. He is given advice by the nurse before leaving. Select the most appropriate options from the list below (choose all that may apply).
A
Continue drinking fluids regularly
B
Eat when you are able to - avoid nothing
C
If the diarrhoea persists, buy an over-the-counter antidiarrheal
D
Fruit juice can be a useful alternative to encourage drinking
E
Aspirin is a useful analgesia for the patient
Question 9 Explanation: 
NHS.uk states that you should rest, stay at home, and drink plenty of fluids (plain, without fruit juice). You should demand feed, and not restrict diet if you feel able to eat it. Paracetamol is a fine analgesic in this group (but - due to Reye’s syndrome - avoid aspirin). Anti-diarrhoeal should not be given to children unless under specialist guidance. Source: https://www.nhs.uk/conditions/diarrhoea-and-vomiting/
Question 10
On leaving, the doctor is asked “how long until Timmy can go back to school?”
A
He can return immediately
B
One day after symptoms cease
C
Two days after symptoms cease
D
Three days after symptoms cease
E
Four days after symptoms cease
Question 10 Explanation: 
The NHS advise that, as a core part of the management of GE, patients should refrain from being in work/school until at least 2 days after the cessation of vomiting/diarrhoea. This is a key fact to remember. Source: https://www.nhs.uk/conditions/diarrhoea-and-vomiting/
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