Short Notes: Prostaglandin Analogs in Obstetrics & Gynaecology

For Final Year MBBS OBGyn University Exam

1. MISOPROSTOL (Cytotec)

• Binds prostaglandin receptors on uterine smooth muscle → stimulates uterine contractions
• Relaxes and softens cervix (collagenase effect on cervical stroma)
• Also acts on parietal cell PG receptors → ↓ gastric acid secretion + ↑ mucus/bicarbonate (cytoprotection)

• Inexpensive
• Stable at room temperature (no cold chain required — important in developing countries)
• Multiple routes of administration
• Fewer systemic side effects at obstetric doses

• Diarrhea, abdominal cramps (most common)
• Nausea, vomiting
• Uterine tachysystole / hyperstimulation → fetal distress
• Pyrexia (less than dinoprostone)

• Previous uterine scar (relative CI for induction — risk of uterine rupture)
• Prior classical cesarean section
• Hypersensitivity to prostaglandins

Exam Point: Misoprostol is NOT FDA-approved for obstetric indications but is widely used off-label. Recognized by WHO as an essential medicine for PPH prevention.

2. DINOPROSTONE (PGE₂ — Cervidil, Prepidil)

• Binds EP receptors → stimulates uterine smooth muscle contractions throughout pregnancy
• Directly acts on cervical collagenase → cervical softening, effacement, and dilation (cervical ripening)
• Effect potentiated by oxytocin as pregnancy progresses
• Metabolized locally and on first pass through lungs (~95%); plasma half-life = 2.5–5 minutes; metabolites excreted in urine

1. Cervical ripening for induction of labor at or near term
2. Induction of labor (when cervix unfavorable)
3. Second-trimester abortion (20 mg vaginal suppository)
4. Missed abortion / intrauterine fetal death
5. Benign hydatidiform mole evacuation

• Removable in case of uterine hyperstimulation
• Lower GI side effects (<1% vs 5.7% with gel)

• Fever (characteristic — more than misoprostol)
• Nausea, vomiting, diarrhea
• Uterine hyperstimulation
• Headache, chills

• Previous cesarean or uterine scar
• Asthma, glaucoma, myocardial infarction (caution)
• Non-reassuring fetal status
• Active genital herpes
• Hypersensitivity to prostaglandins

Exam Point: Dinoprostone is the only prostaglandin FDA-approved for cervical ripening. The controlled-release insert (Cervidil) can be removed if hyperstimulation occurs — this is its key clinical advantage.

3. CARBOPROST (Hemabate)

The 15-methyl group prolongs duration of action compared to natural PGF₂α.

• Stimulates uterine smooth muscle contractions (powerful oxytocic)
• Causes bronchoconstriction (PGF₂α effect on bronchial smooth muscle)
• Strong GI smooth muscle stimulation

• IM injection: 250 mcg (0.25 mg)
• Repeated every 15–90 minutes as needed
• Maximum total dose: 2 mg (8 doses)

1. Postpartum hemorrhage (refractory uterine atony) — primary OBGyn indication; used when oxytocin fails; success rate ~80%
2. Second-trimester abortion induction
3. Mid-trimester pregnancy termination

• M — Methylergonovine
• A — (after oxytocin)
• C — Carboprost
• E — —

• Diarrhea and vomiting (very common — GI smooth muscle stimulation)
• Bronchoconstriction (important!)
• Transient fever (in ~1/8 patients)
• Flushing, headache

• Asthma (absolute — causes bronchoconstriction)
• Cardiovascular disease (use with great caution)
• Active cardiac, pulmonary, renal, or hepatic disease

Exam Point: Carboprost is contraindicated in asthma — this is the most tested fact. Use misoprostol (rectal) instead in asthmatics with refractory PPH.

Comparative Summary Table

High-Yield Exam Points

1. Misoprostol = PGE₁; cheapest, heat-stable, multipurpose; used for PPH, induction, abortion; off-label for obstetrics but WHO-recommended.
2. Dinoprostone = PGE₂; only FDA-approved cervical ripening agent; Cervidil (insert) is removable — key safety advantage.
3. Carboprost = 15-methyl PGF₂α; contraindicated in asthma; used for refractory PPH when oxytocin fails; IM 250 mcg, max 8 doses.
4. All three cause uterine hyperstimulation — monitor for fetal distress.
5. Dinoprostone is most associated with fever; carboprost with bronchoconstriction; misoprostol with diarrhea.
6. In resource-limited settings: misoprostol is the preferred uterotonic because no cold chain required.

Respiratory Disease in Paediatrics: Clinical Posting Study Guide

SECTION 1: HISTORY-TAKING IN PAEDIATRIC RESPIRATORY DISEASE

Framework: SOCS-PAMPER

Age-Specific History Points

• Is stridor associated with swallowing, crying, or movement? (suggests laryngomalacia or subglottic stenosis)
• Is the stridor worse with feeding in the first 4 weeks of life? (suggests vascular ring or tracheo-oesophageal fistula)
• Is the cry weak or abnormal? (suggests vocal fold palsy)
• Any failure to thrive / poor weight gain? (chronic respiratory compromise)
• Birth history: prematurity, need for intubation, oxygen requirement at birth

• Sudden onset of choking or stridor? (foreign body aspiration - "was the child playing with/eating small objects?")
• Barking cough with hoarse voice? (croup)
• Drooling + inability to swallow + high fever? (epiglottitis — do NOT examine throat)
• Night-time worsening of symptoms?

• Recurrent episodes of wheeze/cough? (asthma)
• Exercise-induced symptoms?
• Seasonal pattern or allergen triggers?
• Smoking history (passive/active)

SECTION 2: DIFFERENTIATING UPPER vs. LOWER RESPIRATORY TRACT DISEASE

Anatomical Landmark

• Upper Respiratory Tract (URT): nose, nasopharynx, oropharynx, laryngopharynx, larynx
• Lower Respiratory Tract (LRT): trachea, bronchi, bronchioles, alveoli

Differential Features Table

Quick Differentiator: Croup vs. Epiglottitis vs. Bacterial Tracheitis

SECTION 3: STRIDOR - ANALYSIS OF THE SYMPTOM

Definition

"Because of the small airway diameter in infants and children, even small and subtle abnormalities can cause stridor and obstruct the airway." - Textbook of Family Medicine 9e

Classification by Phase of Breathing (Key Diagnostic Clue)

Causes: Congenital vs. Acquired

• Laryngomalacia (most common congenital cause)
• Laryngeal web / cyst
• Vocal cord paralysis (unilateral or bilateral)
• Subglottic stenosis
• Tracheomalacia
• Vascular ring

• Viral croup (laryngotracheobronchitis) - most common acute cause in children
• Acute epiglottitis
• Bacterial tracheitis
• Retropharyngeal / peritonsillar abscess
• Angio-oedema / anaphylaxis

• Inhaled foreign body
• Post-intubation subglottic stenosis / laryngeal trauma

• Laryngeal papillomatosis (benign, HPV-related)
• Laryngeal or tracheal tumours

History Points to Analyse Stridor

1. Onset: Sudden (foreign body, anaphylaxis) vs. gradual (croup, laryngomalacia)?
2. Age at onset: At birth / first weeks of life (congenital) vs. acquired after weeks to years?
3. Phase: Inspiratory / expiratory / biphasic?
4. Precipitating factors: Associated with feeding? Crying? Exercise? URTI?
5. Associated symptoms:
   • Drooling + high fever → epiglottitis (emergency!)
   • Barking cough + hoarse voice → croup
   • Weak cry + present at birth → vocal cord palsy or laryngomalacia
   • Choking episode → foreign body
6. Positional change: Does stridor improve in prone position? (laryngomalacia often improves prone)
7. Fever: Suggests infective cause
8. Progression: Getting worse rapidly = emergency
9. Immunisation status: Hib vaccination reduces epiglottitis markedly
10. Previous intubation: Risk of subglottic stenosis

Assessment of Severity

Critical Rule: If a child is stridulous, drooling, and sitting forward (tripod) - do NOT examine the throat; do NOT lay the child down; call senior help immediately and secure the airway in theatre.

SECTION 4: DOCUMENTATION & PRESENTATION OF RESPIRATORY TRACT INFECTION IN PAEDIATRICS

How to Document a Clinical Case (SOAP Format)

• Patient: [Name/initials], [Age], [Sex], [Weight]
• Informant: Mother/Father/Guardian — history appears reliable/unreliable

"A [age]-year-old [sex] child presented with a [duration]-day history of [symptoms]. The cough is [barking/productive/dry]. There is associated [fever: grade, pattern] / [runny nose, onset __days] / [wheeze/stridor]. The child is [feeding well/refusing feeds]. [No/Yes] drooling. [No/Yes] cyanosis episodes. Symptoms began after [URI contact/sibling illness/school exposure]. The child has [received/not received] age-appropriate vaccinations."

• Previous similar episodes: Yes / No
• Hospital admissions: Yes / No
• Birth: Term / Preterm at __ weeks, required intubation: Yes/No
• Chronic illness: Asthma / recurrent wheeze / GERD

• Temperature: __ °C
• RR: __ /min (age-appropriate norms: neonate >60, infant >50, child >40 = tachypnoea)
• HR: __ /min
• SpO₂: __ % on room air
• Weight: __ kg

• Inspection: Chest wall movement symmetrical/asymmetrical. Recession (subcostal / intercostal / sternal / suprasternal / nasal flaring). Expiratory grunting. Use of accessory muscles.
• Palpation: Trachea central/deviated. Tactile fremitus.
• Percussion: Resonant / dull / hyperresonant.
• Auscultation: Air entry equal bilaterally. Added sounds: wheeze (inspiratory/expiratory), crackles (fine/coarse), stridor, reduced breath sounds.

1. Epiglottitis
2. Bacterial tracheitis
3. Foreign body aspiration

• Pulse oximetry (continuous)
• CXR AP + lateral (steeple sign in croup; thumbprint sign in epiglottitis)
• FBC, CRP (if bacterial cause suspected)
• Blood culture (if febrile + toxic)
• Throat swab for culture (do NOT attempt if epiglottitis suspected)
• Nasopharyngeal swab for viral PCR (RSV, parainfluenza, influenza)

• Position: Upright, in parent's lap (reduces distress and obstruction)
• Oxygen: If SpO₂ <92% — via mask or nasal prongs
• Nebulised adrenaline (epinephrine): 0.5 mL/kg of 1:1000 (max 5 mL) — for moderate-severe croup
• Dexamethasone: 0.15-0.6 mg/kg oral/IM — cornerstone of croup management; reduces subglottic oedema
• Antibiotics: Only for bacterial cause (ceftriaxone for epiglottitis; IV nafcillin/vancomycin for bacterial tracheitis)
• Avoid: Throat examination / laying down child / sedation if epiglottitis suspected
• Fluid management: IV fluids if unable to feed orally
• Escalation plan: If deteriorating → call anaesthetics/ENT for emergency airway management

Westley Croup Score (Document This in Notes)

High-Yield Summary for Clinical Posting Exam

1. Always take history from caregiver - document reliability of source
2. Ask about feeding difficulties, cyanosis episodes, failure to thrive in all respiratory presentations
3. Stridor = localise to phase of breathing → pinpoints level of obstruction
4. Inspiratory stridor + barking cough + hoarse voice = CROUP → treat with dexamethasone ± nebulised adrenaline
5. Inspiratory stridor + drooling + toxic + tripod posture = EPIGLOTTITIS → do NOT examine throat; call senior/ENT immediately
6. Age of peak incidence matters: croup peaks at 1-2 years; epiglottitis peaks at 6-12 years
7. Hib vaccination has dramatically reduced epiglottitis - always check immunisation status
8. RSV is the most common cause of bronchiolitis (LRT) in infants <2 years
9. CXR in croup: Steeple sign (subglottic narrowing on AP view)
10. CXR in epiglottitis: Thumbprint sign (epiglottis on lateral view) - do NOT delay airway management for X-ray

• The Harriet Lane Handbook (Johns Hopkins, 23rd ed.) - a clinical handbook
• Red Book 2021 (AAP Committee on Infectious Diseases)

1. Re-do the previous notes using Harriet Lane - it's excellent for paediatric clinical protocols, drug doses, and respiratory management algorithms.
2. Supplement with Red Book 2021 for the infectious disease/RTI section (causative organisms, treatment guidelines).
3. The content from the previous response is already sourced from Tintinalli's, Bailey & Love, Rosen's, and Barash - these are all high-quality, exam-appropriate references.

• Redo the notes using Harriet Lane + Red Book from the library?
• Add specific drug dosing (dexamethasone, nebulised adrenaline for croup) from Harriet Lane?
• Expand any specific section (e.g., bronchiolitis, pneumonia, or asthma in children) from the available books?

What the Library Has in Paediatrics

What's NOT in the Library

What This Means for Your Study

• Tintinalli's Emergency Medicine - has a dedicated paediatric stridor chapter, croup/epiglottitis comparison table
• Rosen's Emergency Medicine - detailed croup, epiglottitis, bacterial tracheitis
• Bailey & Love - stridor in children section with history-taking protocol
• Barash Clinical Anesthesia - paediatric airway management

Your Options

1. Use Harriet Lane (which IS in the library) - excellent for drug doses and clinical decision algorithms in paediatrics - to add to / verify the previous notes?
2. Use Red Book 2021 to expand the RTI section specifically - pathogens, antibiotic choices, treatment durations?
3. Proceed with the notes as written - the content is clinically accurate and exam-appropriate?

For Indian MBBS Paediatrics

• Ghai's Essential Paediatrics (Piyush Gupta) — primary Indian UG text
• Nelson's — for deeper reading
• IAP (Indian Academy of Pediatrics) guidelines — these sometimes differ from AAP/WHO on doses and protocols
• NMC (National Medical Commission) competency-based curriculum

1. IAP guidelines take precedence over AAP where they differ (e.g., vitamin A in measles, ORS formulation, immunisation schedule follows India's UIP — Universal Immunisation Programme)
2. Common Indian pathogens get highlighted — e.g., TB as a differential is always relevant, typhoid, malaria co-existing with respiratory illness
3. Drug doses I'll quote in mg/kg as used in Indian practice
4. Exam format — Indian university exams love:
   • Short notes (5-10 marks)
   • Long essays with "enumerate + discuss" format
   • Clinical case write-ups for viva
5. NMC competency codes — I can tag relevant competencies if useful for your logbook

• The topic you need
• Whether it's for written exam, viva, or clinical posting
• Marks allocation if known (e.g., "5 mark short note" vs. "10 mark long answer")

PAEDIATRIC RESPIRATORY DISEASE

Clinical Posting Guide — Indian MBBS

HOW THIS GUIDE IS ORGANISED

1. Take the history from the mother/caregiver
2. Examine the child and document findings
3. Present the case to your resident/professor
4. Write the case sheet

PART 1: TAKING THE HISTORY

Who Gives the History?

• Always from the mother or primary caregiver
• Start your case sheet with: "History given by mother, appears reliable"
• Note the language used (vernacular vs. English) and whether an interpreter was needed

Opening Question (say this to the mother)

"Aapke bachche ko kya takleef hai?" / "What problem has brought you here today?"

The 7 Core Symptoms to Ask About in Respiratory Disease

1. COUGH

• "Khansi kab se hai?" — Since when?
• Character: Dry / wet / barking / whooping / nocturnal
• Productive: Any sputum? What colour?
• Timing: Worse at night? Early morning? After feeds?
• Triggers: Cold air, exercise, smoke, dust?

2. DIFFICULTY BREATHING (Dyspnoea)

• "Saans lene mein taklif hai?"
• Onset — sudden or gradual?
• At rest or only on exertion / crying / feeding?
• Getting worse or better?

3. NOISY BREATHING / STRIDOR

• "Saans lene mein awaz aati hai?"
• When: Breathing in (inspiratory) or breathing out (expiratory)?
• Since when: Birth (congenital) or new onset (acquired)?
• Associated with: Feeding? Crying? URTI?

4. FEVER

• Duration, pattern (continuous / intermittent / remittent)
• Highest recorded temperature at home
• Response to paracetamol?
• Associated rigors / chills?

5. FEEDING DIFFICULTY

• "Bachcha doodh pee raha hai?" — Is the child feeding?
• Reduced feeds = sign of moderate-severe illness in infants
• Refusal to swallow / drooling = suspect epiglottitis

6. CYANOSIS

• "Hont ya nakhun neele ho jaate hain?"
• Central (lips, tongue) vs. peripheral (fingers, toes)
• Episodic or persistent?

7. ASSOCIATED SYMPTOMS

• Runny nose, ear pain, sore throat (suggests URTI)
• Wheeze (LRT disease)
• Rash (measles → croup; chickenpox)
• Diarrhoea / vomiting (dehydration worsens respiratory illness)

Essential Background History (Always Ask)

Indian-specific: Always ask about biomass fuel exposure (a major risk factor for recurrent RTI in Indian children), TB contact history, and malnutrition (worsens RTI outcome significantly).

PART 2: UPPER vs. LOWER RESPIRATORY TRACT — WHAT TO LOOK FOR

At the Bedside — Quick Differentiator

Common Diseases — What to Expect on Each Ward Patient

UPPER RTI — CROUP (Laryngotracheobronchitis)

• Who: 6 months to 3 years; peaks at 1-2 years
• Cause: Parainfluenza virus (most common in India)
• History: 1-3 days runny nose → then barking cough + hoarse voice + inspiratory stridor
• Worse at: Night
• X-ray finding: "Steeple sign" — subglottic narrowing on AP view (show this to your professor!)
• Treatment: Dexamethasone 0.15-0.6 mg/kg oral/IM + nebulised adrenaline if moderate-severe

UPPER RTI — EPIGLOTTITIS

• Who: School-age children (6-12 years); now rare due to Hib vaccine
• Cause: Streptococcus pneumoniae, S. aureus, H. influenzae
• History: Sudden onset, HIGH fever, toxic child, drooling, dysphagia, muffled voice, tripod posture
• ⚠ DO NOT examine throat — do not lay child flat
• X-ray: "Thumbprint sign" — thickened epiglottis on lateral view
• Treatment: Secure airway in theatre; IV ceftriaxone

LOWER RTI — BRONCHIOLITIS

• Who: Infants <2 years; peaks at <6 months
• Cause: RSV (most common), parainfluenza, rhinovirus
• History: 2-3 days URTI → then wheeze + respiratory distress + poor feeding
• Signs: Tachypnoea, subcostal recession, diffuse wheeze and crackles, hyperinflation
• X-ray: Hyperinflation, peribronchial thickening
• Treatment: Supportive — oxygen if SpO₂ <92%, adequate feeds/IV fluids; no routine antibiotics or bronchodilators
• High risk for deterioration: Prematurity, congenital heart disease, age <6 weeks

LOWER RTI — PNEUMONIA

• Who: Any age
• Cause:
  • <2 months: GBS, E. coli, Klebsiella (neonatal organisms)
  • 2 months - 5 years: Strep. pneumoniae (#1), H. influenzae

  • 5 years: Strep. pneumoniae, Mycoplasma pneumoniae ("walking pneumonia")

• History: Fever + cough + fast breathing + chest pain (older child)
• WHO criteria for fast breathing (tachypnoea):
  • <2 months: RR >60/min
  • 2-12 months: RR >50/min
  • 1-5 years: RR >40/min
• Signs: Dull percussion, bronchial breathing, crackles (localized)
• X-ray: Lobar / segmental consolidation
• Treatment (IAP):
  • Non-severe: Oral amoxicillin 40-45 mg/kg/day × 5 days
  • Severe: IV ampicillin + gentamicin (first line in India for <5 years)
  • Very severe: IV ceftriaxone + oxygen + hospitalization

PART 3: STRIDOR — HOW TO ANALYSE IT AT THE BEDSIDE

Question 1: When does the sound occur?

Question 2: How old is the child?

Question 3: Are there any danger signs?

Bedside Rule: Stridulous child + drooling = do NOT examine throat, do NOT put child flat, call senior NOW.

PART 4: HOW TO WRITE YOUR CASE SHEET

Standard Format for Paediatric Respiratory Case

CHIEF COMPLAINTS

1. Cough — .... days
2. Fever — .... days
3. Difficulty breathing — .... days
4. Noisy breathing — .... hours

HISTORY OF PRESENTING ILLNESS

"Master/Miss [initials], a [age]-year-old [male/female] child, resident of [place], was brought by the mother with complaints of cough for [X] days, fever for [X] days, and noisy breathing for [X] hours. The cough is [barking/wet/dry], [productive/non-productive]. Fever is [high-grade/low-grade], [continuous/intermittent], documented up to [temperature] at home, relieved partially with paracetamol. The child has been having noisy breathing which is [inspiratory/expiratory/biphasic], [present at rest/only on crying]. There is [no/associated] drooling. The child is [feeding well/taking reduced feeds/refusing feeds]. [No/Yes] episodes of cyanosis. There was [no] history of choking episode or foreign body ingestion. The child had a running nose [X] days prior to this illness. There is [no/a] contact history of tuberculosis at home."

PAST HISTORY

• Similar complaints in the past: Yes / No
• Previous hospitalisation: Yes / No
• Known case of asthma / recurrent wheeze: Yes / No
• Surgical history: Nil

BIRTH HISTORY

• Gestational age: Term / Preterm (......weeks)
• Mode of delivery: Normal / LSCS / Instrumental
• Birth weight: ...... kg
• Cry at birth: Immediate / Delayed / Absent
• NICU admission: Yes / No; Duration: ......
• Required intubation / oxygen: Yes / No

DEVELOPMENTAL HISTORY

IMMUNISATION HISTORY

DIETARY HISTORY

• Breastfed: Yes / No / Exclusive till 6 months
• Complementary feeding started at: ...... months
• Current diet: ......

FAMILY HISTORY

• Similar illness in siblings: Yes / No
• TB in family: Yes / No
• Asthma / atopy: Yes / No
• Smoking / biomass fuel at home: Yes / No

SOCIOECONOMIC HISTORY

• Modified BG Prasad scale: Class ......
• Housing: Pucca / Kachcha / Overcrowded
• Water source / Sanitation: ......

GENERAL EXAMINATION

• Child is: Well / Ill-looking / Toxic / Lethargic
• Pallor / Icterus / Cyanosis / Clubbing / Lymphadenopathy / Oedema: Present / Absent
• Nutritional status: Well-nourished / Mild-moderate-severe malnutrition
  • Weight: ...... kg (......th centile)
  • Height: ...... cm
  • MUAC: ...... cm

VITAL SIGNS

SYSTEMIC EXAMINATION

• Shape of chest: Normal / Barrel-shaped / Harrison's sulcus
• Movement: Symmetrical / Asymmetrical
• Recession: Subcostal / Intercostal / Sternal / Suprasternal / Nasal flaring
• Expiratory grunting: Present / Absent
• Use of accessory muscles: Present / Absent

• Trachea: Central / Deviated to ......
• Tactile vocal fremitus: Normal / Increased / Decreased

• Resonant / Dull over ...... / Hyperresonant

• Air entry: Equal bilaterally / Decreased over ......
• Breath sounds: Vesicular / Bronchial over ......
• Added sounds: Wheeze (inspiratory/expiratory) / Fine crackles / Coarse crackles / Stridor / Absent

• Throat: Hyperaemia / Tonsillar enlargement (Grade ......) / Exudate / Peritonsillar bulge
• Ears: TM normal / Congested / Perforated
• Cervical lymph nodes: Not palpable / Enlarged

PROVISIONAL DIAGNOSIS

"This is a [age]-year-old child presenting with [duration] history of [symptoms], with [signs on examination], likely suffering from [diagnosis] — [e.g., Viral croup (Laryngotracheobronchitis), mild-moderate severity] / [Severe community-acquired pneumonia, right lower lobe] / [Acute bronchiolitis with moderate respiratory distress]."

1. ......
2. ......

INVESTIGATIONS ADVISED

• Pulse oximetry (continuous)
• CXR PA / AP + lateral
• FBC with differential
• CRP (if bacterial cause suspected)
• Blood culture (febrile + toxic child)
• Nasopharyngeal swab for viral PCR / rapid antigen test (RSV, influenza)
• Mantoux test (if TB suspected)
• RBS, electrolytes (if sick infant)

MANAGEMENT PLAN

• Position: Upright / semi-recumbent in mother's lap
• Oxygen: Via nasal prongs / mask if SpO₂ <92%
• IV access if unable to feed
• Monitor: SpO₂, RR, HR 4-hourly; document on observation chart

FOLLOW-UP / DISCHARGE CRITERIA

• SpO₂ ≥95% on room air
• Feeding well
• No recession at rest
• Afebrile for 24 hours
• Caregiver counselled on danger signs to return

KEY THINGS YOUR PROFESSOR WILL ASK DURING VIVA ON THE WARD

1. "What is the respiratory rate of this child and is it normal?" — Know WHO age norms by heart
2. "What type of stridor does this child have?" — Answer: Inspiratory/expiratory/biphasic + what level that implies
3. "Why won't you examine the throat in this child?" — Because drooling + toxic = epiglottitis risk; examining may cause complete obstruction
4. "What does the steeple sign mean?" — Subglottic narrowing on AP CXR; pathognomonic of croup
5. "What is the immunisation status and what does it tell you?" — Hib vaccine coverage reduces epiglottitis
6. "Name the causes of stridor in a neonate" — Laryngomalacia (#1), vocal cord palsy, subglottic stenosis, vascular ring
7. "What is the most common cause of bronchiolitis?" — RSV