Day 4 Flashcards
1
Q
A mother comes to surgery with her 6-year-old son. During the MMR scare she decided not to have her son immunised. However, due to a recent measles outbreak she asks if he can still receive the MMR vaccine.
What is the most appropriate action?
A
Give MMR with repeat dose in 3 months.
The Green Book recommends allowing 3 months between doses to maximise the response rate.
A period of 1 month is considered adequate if the child is greater than 10 years of age.
In an urgent situation (e.g. an outbreak at the child’s school) then a shorter period of 1 month can be used in younger children.
2
Q
Contraindications to MMR
(5)
A
severe immunosuppression
allergy to neomycin
children who have received another live vaccine by injection within 4 weeks
pregnancy should be avoided for at least 1 month following vaccination
immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present)
3
Q
Adverse effects of the MMR
(2)
A
Malaise, fever and rash may occur after the first dose of MMR.
This typically occurs after 5-10 days and lasts around 2-3 days
4
Q
When are children given the MMR?
(2)
A
Children in the UK receive two doses of the Measles, Mumps and Rubella (MMR) vaccine before entry to primary school.
This currently occurs at 12-15 months and 3-4 years as part of the routine immunisation schedule
5
Q
You are asked to attend a preterm delivery. The neonate is born at 36 weeks gestation via emergency Caesarean section. The neonate has difficulty initiating breathing and requires resuscitation.
- They are dyspnoeic and tachypnoeic at a rate of 85 breaths/min.
- On auscultation of the chest, there is reduced breath sounds bilaterally.
- Heart sounds are displaced medially.
- The abdominal wall appears concave.
What is the most likely diagnosis?
A
Congenital diaphragmatic hernia presents with scaphoid abdomen, due to herniation of the abdominal contents into the cleft
Congenital diaphragmatic hernia can present with dyspnoea and tachypnoea at birth. The auscultation findings are due to pulmonary hypoplasia and compression of the lung due to the presence of abdominal contents in the thoracic cavity.
Prompt treatment and respiratory support are required.
6
Q
A 2-month-old baby is rushed into the emergency department by her parents who discovered her limp and blue in her cot.
- On assessment, she is found to not be breathing and has no femoral pulses.
Paediatric life support is commenced and 5 rescue breaths are given.
What is the most appropriate technique for in-hospital chest compressions in a paediatric patient of this age?
A
The two-thumb encircling technique at a compression: breath ratio of 15:2 is the correct answer according to the paediatric life support algorithms.
In an in-hospital environment where intermediate/advanced life support is being used, a ratio of 15:2 should be used for compressions: breaths.
Once a definitive airway has been established, compressions should then be continuous.
7
Q
A 2-year-old boy with meningococcal septicaemia arrests on the ward.
You are the first person to attend. After confirming cardiac arrest and following paediatric BLS protocol, what is the rate you should perform chest compressions at?
A
The UK Resuscitation Council’s Paediatric Basic Life Support guideline states that chest compressions for children of all ages must be performed at a rate of 100-120 per minute. Compressions should depress the sternum by at least a third of the depth of the chest.
8
Q
A 6-year-old boy comes to see you with his mother.
He reports that he has pain in his knees and calves bilaterally at night which has been ongoing for the past 6 months.
These pains are worse if he has played football in the daytime. He describes that these pains can cause him to wake up at night time around 1-2 times per month.
Examination of the knee is unremarkable. He is otherwise fit and well.
Which one of the following is the most likely diagnosis?
A
Growing pains are a common complaint in children aged 3-12 years.
These usually present with children complaining of pains in their legs.
When seeing children who are presenting with these symptoms it is important to check that there are no ‘red flags’
9
Q
Features of growing pains
(7)
A
- never present at the start of the day after the child has woken
- no limp
- no limitation of physical activity
- systemically well
- normal physical examination
- motor milestones normal
- symptoms are often intermittent and worse after a day of vigorous activity
10
Q
Features of JRA
(4)
A
Juvenile rheumatoid arthritis usually presents as:
fever, rash, symmetrical joint pain and swelling
11
Q
Features of Osteosarcoma
(3)
A
Features of osteosarcoma include:
an unexplained lump
unexplained bone pain
unexplained swelling.
12
Q
Features of Osteochondritis
(4)
A
Osteochondritis dissecans is a joint disorder in which cracks form in the articular cartilage and underlying subchondral bone.
This results in joint pain, locking and swelling.
13
Q
What is the triad of shaken baby syndrome?
(3)
A
Retinal haemorrhages
subdural haematoma
encephalopathy
14
Q
What is shaken baby syndrome?
(2)
A
Subdural haematomas are the most common and classical intracranial feature of Shaken Baby Syndrome.
The bridging cerebral veins are fragile in infants and the theory is that these vessels are torn when a child is shaken, leading to subdural haematomas.
15
Q
A 9-year-old boy is diagnosed as having Attention Deficit Hyperactivity Disorder and started on methylphenidate.
What is monitored during treatment?
(2)
A
Growth
ECG at the start of treatment
16
Q
At what age would the average child acquire the ability to sit without support?
A
The answer (6-8 months) includes the 6 months as stated in the MRCPCH Development Guide. Most other sources suggest a slightly later age of 7-8 months.
17
Q
A 3-year-old boy, Lionel, is brought into the general practitioner by his mother.
She is worried about an umbilical hernia which Lionel has had since birth.
She was advised that this would likely self-resolve, however, it has not yet resolved.
The general practitioner performs an examination which identifies a 1cm umbilical hernia which is easily reducible.
His mother would like to know how this should be managed. Which one of the following is the most appropriate management plan?
(2)
A
Umbilical hernias: Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age.
If small and asymptomatic peform elective repair at 4-5 years of age.
18
Q
A 2-day-old baby is brought to the Emergency Department after his mum noticed that he has became floppier, more irritable, and not feeding properly over the past 24 hours.
Lumbar puncture confirms meningitis.
Which is the most likely causative organism in this case?
A
Group B streptococcus
Neonates are at a greater risk of meningitis, with greater risks associated with low birth weight, prematurity, traumatic delivery, fetal hypoxia and maternal peripartum infection.
19
Q
A 2-year-old child has a history of chronic constipation for the past year and chronic abdominal distention with vomiting for three months. It is suspected that the child may have Hirschsprung’s disease.
Which investigation from the list below offers the most definitive diagnosis for this condition?
A
Rectal biopsy is the gold standard for diagnosis of Hirschsprung’s disease
20
Q
A 3-year-old boy is brought to the emergency department with difficulty breathing. Since this morning, he has developed a fever (38.3ºC) and become progressively short of breath. On examination, he appears unwell with stridor and drooling. His past medical history is otherwise unremarkable.
Given the likely diagnosis, which of the following is the most likely causative organism?
(2)
A
Acute epiglottitis is characterised by rapid onset fever, stridor and drooling
Haemophilus influenzae B
21
Q
A 13-month-old girl is referred to paediatrics by her GP due to concerns that she is still not attempting to ‘pull to stand’. She was born at 29 weeks by emergency cesarean section due to foetal bradycardia and weighed 1.1kg at birth.
On examination, she appears healthy and engaged. She responds to her name and has 7 meaningful words. She can drink from a cup using both hands. When put on the floor, she commando crawls to move around. Upper limb tone is normal however lower limb tone is significantly increased.
Based on this patient’s symptoms, in which part of the brain/nervous system has damage occurred?
(2)
A
Spastic cerebral palsy results from damage to upper motor neurons
Upper motor neurons in the periventricular white matter
22
Q
A neonate is born at 32 weeks gestation via spontaneous vaginal delivery. There was no meconium staining of the liquor. Shortly after delivery he develops cyanosis, tachypnoea, grunting and sternal recession.
What is the most likely diagnosis?
A
It is important to be aware of risk factors when answering questions like these. Prematurity is the major risk factor for NRDS. Caesarean section is the major risk factor for tachypnoea of the newborn (TTN). Meconium staining is the major risk factor for aspiration pneumonia.
23
Q
A 6-year-old boy attends the emergency department with acute shortness of breath. His parents report that he has had a cold for a few days but today has been struggling more with his breathing. He has had several prior admissions for wheeze and has had exertional breathlessness and nighttime cough for the past year.
His observations show a respiratory rate of 30/min, heart rate 130/min, saturations 94% and temperature of 37.4ºC. He has intercostal and subcostal recession and a global expiratory wheeze but responds well to salbutamol.
What acute medication/medications should he be prescribed on discharge?
A
Steroid therapy should be given to all children who have an asthma attack
While a formal diagnosis has not been made, this acute presentation combined with interval symptoms (exertional breathlessness and nighttime cough) suggests that this patient has suffered an acute exacerbation of asthma. For this, a salbutamol inhaler + 3 days prednisolone PO are the correct acute medications to prescribe on discharge. For all children suffering an acute exacerbation of asthma 3-5 days of oral prednisolone should be given. It is important to ensure that all patients have an adequate supply of their salbutamol inhaler with advice on when and how to use it.
24
Q
A 4-day-old girl who was diagnosed prenatally with Down’s syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium.
What is the most likely diagnosis?
A
Failure or delay to pass meconium is common presentation of Hirschprung’s disease
25
A boy is noted to have a webbed neck and pectus excavatum
What is the diagnosis?
Noonan syndrome
26
An infant is found to have small eyes and polydactyly
What is the most likely diagnosis?
Patau's Syndrome
27
A 7-year-old boy with learning difficulties and macrocephaly
What is the most likely diagnosis?
Fragile X
28
A 2-year-old child is referred by the GP for treatment-resistant chronic constipation.
Which of the following features in the history is a red flag for a diagnosis of Hirschsprung's disease?
Passage of meconium after 48 hours is a red flag
29
Which mutation is associated with HIrchsprungs?
Hirschsprung's disease is associated with **MEN 2A/B** and not MEN1
30
What is the most common cause of nephrotic syndrome in children?
(2)
**Minimal change glomerulonephritis**
Minimal change glomerulonephritis nearly always presents as nephrotic syndrome, accounting for 80% of cases in children and 25% in adults. The majority of cases are idiopathic and respond well to steroids
31
What is the nephritis triad?
Nephrotic syndrome is classically defined as a triad of
* proteinuria (\> 1 g/m^2 per 24 hours)
* hypoalbuminaemia (\< 25 g/l)
* oedema
32
A 7-year-old girl presents to her GP as she has been suffering from daily epistaxis for the last week.
On examination, her legs are covered with petechiae and bruises.
She is otherwise well and has no other symptoms. Blood tests show low platelets, with no other abnormalities.
On follow-up, the symptoms have completely resolved after 4 months.
What would you expect to precede these symptoms?
The condition described is **idiopathic thrombocytopenic purpura** (ITP), whereby low platelet count can result in symptoms such as epistaxis and unexplained bruising/petechiae. This is often self-limiting and may resolve within 12 months.
Idiopathic thrombocytopenic purpura may be preceded by a self-limiting viral infection
33
Features suggestive of hypernatraemic dehydration:
(5)
## Footnote
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
34
An 8-month-old unwell baby is brought to the paediatric emergency department with discolouration over her left arm. Her parents say the arm was 'initially red and warm but now has black patches'. On examination, these black areas are consistent with skin necrosis. She was diagnosed with chickenpox one week ago.
Her observations are:
Heart rate: 180 beats per minute (normal 80-140)
Respiratory rate: 42 breaths per minute (normal 30-40)
Temperature: 38.1º (\>37.5º)
What is the most likely causative organism?
**Streptococcus pyogenes** which is a group A streptococcus and is the most common cause of invasive skin infections following chickenpox.
Chickenpox is a risk factor for invasive group A streptococcal soft tissue infections including necrotizing fasciitis
35
A 9-year-old boy who is having an asthma attack is brought to the surgery.
Which findings would categorise the asthma attack as life-threatening, rather than just severe, according to the British Thoracic Society guidelines?
(6)
* SpO2 \<92%
* PEF \<33% best or predicted
* Silent chest
* Poor respiratory effort
* Agitation
* Altered consciousness
* Cyanosis
36
A 15-year-old boy from Germany presents with chronic diarrhoea for the past 9 months. He also reports foul smelling stools. He has a past medical history of recurrent chest infections from a young age and diabetes mellitus.
What is the most likely diagnosis?
CF
37
A 3-day-old male is admitted to the neonatal unit with bilious vomiting and reduced feeding. He was born at 30 weeks gestation via an uncomplicated delivery. An abdominal X-ray is requested that shows intramural gas. Oral feeding is stopped and he is started on broad-spectrum antibiotics.
Which of the following is the most likely diagnosis?
Necrotising enterocolitis
Pneumatosis intestinalis is a hallmark feature of necrotising enterocolitison AXR
38
What are the x-ray signs of necrotising enterocolitis?
(7)
Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
* dilated bowel loops (often asymmetrical in distribution)
* bowel wall oedema
* pneumatosis intestinalis (intramural gas)
* portal venous gas
* pneumoperitoneum resulting from perforation
* air both inside and outside of the bowel wall (Rigler sign)
* air outlining the falciform ligament (football sign)
39
You are called to review a female baby born 22 hours ago, at 33 weeks gestation, as the nurse is worried about her.
After conducting a thorough examination, and noting that the mother was positive for group B streptococcus, you provisionally diagnose the baby with neonatal sepsis and initiate treatment.
Which of the following options is the most common finding with regards to this diagnosis?
Grunting and other signs of respiratory distress are the most common presentation of neonatal sepsis
40
A three-year-old girl presents with her parents to the accident and emergency department. The parents are concerned that they've noticed a new widespread rash on her abdomen. The parents deny any history of trauma or recent infection.
On examination you note a petechial rash covering the anterior abdomen and to a lesser extent the posterior right forearm. The child looks pale and is not playing with the toys set out. You also find hepatosplenomegaly and cervical lymphadenopathy.
While waiting for blood results you dip her urine which proves unremarkable and take a tympanic temperature reading of 36.6º.
What is the most likely diagnosis?
Acute lymphoblastic leukaemia may present with haemorrhagic or thrombotic complications due to DIC.
41
A 6-year-old is brought in by his mother who is concerned that he has been experiencing pain in his right hip for the past 6 weeks.
She reports the pain has been progressively worsening and is waking him up at night.
For the last week, she has noticed a slight limp and difficulty getting in or out of the car and the bath.
What is the most likely diagnosis?
**Perthes disease** is caused by avascular necrosis of the femoral head - it presents with progressive hip pain, limp and stiffness
42
What is the cause of Perthe's disease?
Perthes disease is caused by **avascular necrosis of the femoral head**
it presents with progressive hip pain, limp and stiffness
children age 4-8 years
43
A man with glucose-6-phosphate dehydrogenase deficiency asks for advice regarding his son.
Given the x-linked recessive inheritance of the condition, what is the chance his son will also develop the disease?
X-linked recessive conditions - no male-to-male transmission
44
A 13-year-old girl presents to clinic with right knee pain. She is a keen hockey player but has had no recent injuries.
On examination there is a painful swelling over the tibial tubercle. What is the most likely diagnosis?
(2)
**Osgood-Schlatter disease**
(tibial apophysitis)Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
45
Features of Osteochondritis dissecans
| (2)
* Pain after exercise
* Intermittent swelling and locking
46
Features of Patellar tendonitis
| (3)
* More common in athletic teenage boys
* Chronic anterior knee pain that worsens after running
* Tender below the patella on examination
47
A 3-week-old boy is rushed to the emergency department by ambulance following a reported episode of unconsciousness. The patient's mum explains that the patient was crying and suddenly started to breathe quickly. He then turned blue in the face and became unresponsive. He woke prior to ambulance arrival.
On examination, the patient appears well and is interacting with their mum. An ejection systolic murmur is noted, loudest in the left 2nd intercostal space. The examination is otherwise normal.
What is the most likely diagnosis?
(2)
Tetralogy of Fallot - infants may experience episodic hypercyanotic 'tet' spells that can result in loss of consciousness
This scenario describes a baby with cyanosis and loss of consciousness following a period of upset, in addition to an examination finding of an ejection systolic murmur. These combined suggest a diagnosis of a 'tet' spell, which is associated with tetralogy of Fallot. Due to a reduction in right ventricular outflow, when a patient with tetralogy of Fallot is upset, cyanosis can occur.
48
Features of tetralogy of Fallot
| (4)
**The four characteristic features are:**
* ventricular septal defect (VSD)
* right ventricular hypertrophy
* right ventricular outflow tract obstruction, pulmonary stenosis
* overriding aorta
49
A 6-month-old boy is brought into your practice by his adoptive parents, complaining of an unusual pattern of movements recently in their son.
They were able to catch this on camera, and on watching the video you notice subtle symmetrical contracting of his neck and drawing up of his legs, followed by extending of his arms.
He repeats this movement around 50 times before stopping.
What is the most likely diagnosis in this case?
Infantile spasms - classically characterised by repeated flexion of head/arms/trunk followed by extension of arms
50
Investigations for infantile spasms
| (2)
Investigation
* the EEG shows hypsarrhythmia in two-thirds of infants
* CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
51
Features of infantile spasms
| (3)
Features
* characteristic 'salaam' attacks: flexion of the head, trunk and arms followed by extension of the arms
* this lasts only 1-2 seconds but may be repeated up to 50 times
* progressive mental handicap
52
Management of infantile spasms
| (3)
Management
* poor prognosis
* vigabatrin is now considered first-line therapy
* ACTH is also used
53
Features of Chondromalacia patellae
* Softening of the cartilage of the patella
* Common in teenage girls
* Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
* Usually responds to physiotherapy
54
55
You have been asked by a midwife to complete a newborn examination on a 12-hour old neonate. The parents have noticed that his penis looks abnormal and ask if you could please have a look at this. On examination, you note his urethral meatus is located on the ventral aspect of the glans and he has a hooded prepuce. He has passed urine with a good stream observed by the midwife earlier in the day.
How should the doctor proceed?
Hypospadias surgery is typically performed at around 12 months of age
56
You are asked to assess a baby presenting with an increased work of breathing. The baby was delivered 12 hours ago by emergency Caesarean section at 35 weeks gestation. On examination, they are tachypnoeic with a respiratory rate of 55 breaths per minute. A chest x-ray shows hyperinflated lung fields and the presence of fluid in the horizontal fissure.
What is the most likely cause of the baby's increased work of breathing?
Chest x-ray in **transient tachypnoea** of the newborn may show hyperinflation and fluid in the horizontal fissure
57
A 3-year-old girl is found unresponsive. You shout for help and ask a colleague to phone the arrest team. You open the airway by performing a head tilt and chin lift and note the patient's only respiratory activity is occasional irregular gasps.
What is the next step that should be performed?
5 rescue breaths
58
A two-week-old preterm baby girl is brought into the paediatric assessment unit by her mother, who is concerned that over the last 3 days she is becoming increasing lethargic and refusing to feed.
Observations are respiratory rate 66 breaths/min, oxygen saturations 95% on air, heart rate 178bpm, blood pressure 64/48 mmHg and temperature 36.5ºC.
Examination is unremarkable except for lethargy and signs of dehydration.
What is the most likely diagnosis?
Neonatal sepsis should be considered in infants with vague signs such as poor feeding, grunting, lethargy
59
A 5-month-old girl is seen in the paediatric urology clinic with recurrent urinary tract infections. She has had a renal ultrasound that showed dilatation of the ureters. Her mother recalls that when she was a child herself there was a problem with the valve in her ureters, with some backflow of urine from the bladder up towards the kidneys.
Given the likely underlying cause, what test is most appropriate to grade the severity?
**Micturating cystography** is the investigation of choice for **reflux nephropathy**
60
A 3-year-old girl is brought in by her mother. Her mother reports that she has been eating less and refusing food for the past few weeks. Despite this her mother has noticed that her abdomen is distended and she has developed a 'beer belly'. For the past year she has opened her bowels around once every other day, passing a stool of 'normal' consistency. There are no urinary symptoms. On examination she is on the 50th centile for height and weight. Her abdomen is soft but slightly distended and a non-tender ballotable mass can be felt on the left side. Her mother has tried lactulose but there has no significant improvement.
What is the most appropriate next step in management?
The history of constipation is not particularly convincing. A child passing a stool of normal consistency every other day is within the boundaries of normal. The key point to this question is recognising the abnormal examination finding - a ballotable mass associated with abdominal distension. Whilst an adult with such a 'red flag' symptom/sign would be fast-tracked it is more appropriate to speak to a paediatrician to determine the best referral pathway, which would probably be clinic review the same week.
Wilms' nephroblastoma is one of the most common childhood malignancies. It typically presents in children under 5 years of age, with a median age of 3 years old.
61
A 5-day-old baby has her heel prick test done, and it comes back that she has a raised level of immunoreactive trypsinogen (IRT).
What does this indicate?
What is the most appropriate next test for this baby?
Newborns with a positive heel prick for **CF**, i.e. they have a raised immunoreactive trypsinogen (IRT) result, get a sweat test, which will be high if they have CF
Sweat test
62
A 13-year-old boy presents to the GP with gradual onset right groin pain and a limp. He is otherwise well, with no past medical or family history. On examination, there is a restricted range of motion of the right leg, which appears shortened and externally rotated. There is no swelling or warmth felt over the joints. His notes document normal vital signs, height in the 50th percentile and weight in the 90th percentile.
Which of the following is the most appropriate first-line investigation?
The correct option is to perform a plain X-ray of both hips (AP and frog-leg views) as the most likely condition is slipped upper femoral epiphysis (SUFE).
Factors suggesting this include being male, aged 10-15, obese and an externally rotated leg.
Plain X-rays should be requested for all patients with suspected SUFE.
The diagnosis can be confirmed and graded if Klein's line (drawn along the superior edge of the femoral neck) intersects less of the femoral head.
63
A 2-week-old old baby girl is brought to the emergency department by her mother after losing consciousness at home. The mother explains that she was feeding her baby before this episode occurred and that her baby quickly recovered afterwards.
The mother also mentions that she noticed her baby's face had developed a deep blue tone shortly before she lost consciousness.
On examination, a harsh ejection systolic murmur is heard. A chest X-ray is normal.
What is the most likely underlying diagnosis?
Tetralogy of Fallot - infants may experience episodic hypercyanotic 'tet' spells that can result in loss of consciousness
This baby is presenting with tetralogy of Fallot, a congenital heart defect characterised by hypercyanotic episodes that may be associated with a loss of consciousness. The patient may also have an ejection systolic murmur due to the pulmonary stenosis that occurs in this condition.
64
An 18-month old girl is brought to see her GP with a two-day history of a runny nose and fever. She developed a cough yesterday, which worsened overnight. Her parents report that she had a cough a few weeks ago at the start of September but it had improved on its own and was not as severe.
On examination, there is hoarseness, a barking cough, and stridor.
Her observations are as follows:
Heart rate: 150 beats per minute (normal 80-130)
Respiratory rate: 35 breaths per minute (normal 20-30)
Temperature: 38.1º (\>37.5º)
What is the most likely cause of the child's symptoms?
Croup is more common in autumn months
In children, the most common infectious cause of stridor is croup. **Parainfluenza viruses are responsible for the majority of cases of croup**. Other croup symptoms include a barking cough (worse at night), coryzal symptoms and fever. NICE recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children with croup regardless of severity.
65
A 4-week old infant is reviewed by the health visitor. She was delivered via breech caesarean section at 36+2 weeks gestation due to suspected chorioamnionitis. Post-partum, she required antibiotics due to the suspected infection. Her notes indicate hospital newborn physical examination (NIPE) was unremarkable. She appears to be well and is progressing steadily along the 60th centile.
What follow-up should be arranged by the health visitor due to this infant's history?
Ultrasounds of pelvis in 2 weeks
All breech babies at or after 36 weeks gestation require USS for DDH screening at 6 weeks regardless of mode of delivery
66
You are called by the mother of an 18-month-old boy.
He has been unwell with a suspected viral upper respiratory tract infection for the past few days.
His mother reports that he has just had a seizure.
Three months ago he had a confirmed febrile convulsion following a similar illness.
You arrange to see the child that morning.
Which factor should prompt referral to paediatrics?
The child still being drowsy 2 hours after the seizure.
A child still being drowsy after 1 hour is not consistent with a 'simple' febrile convulsion.
A tonic-clonic seizure is typical and not a worrying feature.
Having a confirmed focus of infection (otitis media) is reassuring, rather than a reason to admit the child.
67
A 36-week gestation newborn is rushed into the neonatal intensive care unit in respiratory distress.
He was delivered by cesarean section 30 minutes ago due to concerns surrounding reduced foetal movements and a non-reassuring cardiotocograph trace.
On examination, he has subcostal and intercostal recession with head bob, grunting and tracheal tug. Respiratory rate is 80/min, heart rate 200/min and saturations 97%. He is afebrile.
A chest X-ray shows hyperinflation and fluid in the horizontal fissure.
What is the most likely diagnosis?
Chest x-ray in transient tachypnoea of the newborn may show hyperinflation and fluid in the horizontal fissure
Transient tachypnoea of the newborn is the correct answer here. This is a breathing disorder seen shortly after birth in early term or late preterm babies. It is more commonly seen in babies born by caesarean section and is due to delayed absorption of foetal lung fluid following delivery. Hyperinflation and fluid in the horizontal fissure are classic chest x-ray findings. Unlike meconium aspiration or neonatal respiratory distress syndrome, hypoxia is less common. It is generally a benign, self-limiting condition that typically requires only supportive treatment.
68
A 28-year-old woman is found to have sickle cell trait on antenatal haemoglobinopathy screening. The father of the child consents for further screening and he is found to have the genotype, HbAS.
What is the likelihood of their child having sickle cell disease?
For autosomal recessive conditions, if both parents are carriers (heterozygote) there is a 25% chance of having an affected (homozygote) child
69
The ward doctor is asked to review a 12-hour-old neonate, born at 34 weeks gestation to a healthy mother during an otherwise-uncomplicated vaginal delivery.
On examination, the neonate looks comfortable.
A continuous 'machinery-like' murmur is noted on auscultation of the heart, as well as a left-sided thrill.
The apex beat appears to be heaving on palpation.
A widened pulse pressure is noted.
There is no visible cyanosis.
An echocardiogram is subsequently performed which confirms the diagnosis and rules out any other cardiac problems.
Given the likely diagnosis, what is the most appropriate management at this stage?
Patent ductus arteriosus: indomethacin is given to the neonate in the postnatal period, not to the mother in the antenatal period
70
What is the most likely diagnosis?
A 4-year boy presents with an abnormal gait.
He has a history of recent viral illness.
His WCC is 11 and ESR is 30.
Transient synovitis
Viral illnesses can be associated with transient synovitis. The WCC should ideally be \> 12 and the ESR \> 40 to suggest septic arthritis.
71
A 6-year-old boy presents with an groin pain. He is known to be disruptive in class. He reports that he is bullied for being short.
On examination, he has an antalgic gait and pain on internal rotation of the right hip.
What is the most likely diagnosis?
Perthes disease
This child is short, has hyperactivity (disruptive behaviour) and is within the age range for Perthes disease. Hyperactivity and short stature are associated with Perthes disease.
72
An obese 12-year-old boy is referred with pain in the left knee and hip. On examination he has an antaglic gait and limitation of internal rotation. His knee has normal range of passive and active movement.
What is the most likely diagnosis?
Slipped upper femoral epiphysis
Slipped upper femoral epiphysis is commonest in obese adolescent males. The x-ray will show displacement of the femoral epiphysis inferolaterally. Treatment is usually with rest and non weight bearing crutches.
73
A 16-year-old female presents with chronic left knee pain. The pain is typically felt after jogging. There is also intermittent swelling and locking of the same joint. What is the most likely diagnosis?
Osteochondritis dissecans
74
An 8-year-old boy presents to the emergency department severely short of breath and wheezy.
He is extremely short of breath and cannot complete sentences fully.
His peak expiratory flow rate is 300 l/min (40% of normal).
His oxygen saturations are 93%. His pCO2 is 4.9 kPa.
Which of the above is most concerning?
A normal pCO2 in an acute asthma attack indicates it is life-threatening
A normal pCO2 is indicative of reduced respiratory effort in asthma as is, therefore, a life-threatening sign. Normal pCO2 is 4.8-6 kPa.
75
A 6-year-old boy is noted to have pectus excavatum and pulmonary stenosis during a cardiorespiratory exam.
What is the most likely diagnosis?
A young boy is noted to have a webbed neck, pulmonary stenosis, ptosis and short stature.
The karyotype is normal - Noonan syndrome
76
A 20-month-old child has been admitted following a massive rectal bleed requiring transfusion. The child is settled and does not appear to be in pain.
What is the most likely diagnosis?
Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
Meckel's diverticulum is a congenital disorder causing malformation in the small intestine. There is an out-pouching from the small intestine, formed by the remnant of the umbilical cord. Often this disorder is asymptomatic, however, it can release acid, ulcerating the small intestine. Consequently, this condition is the most common cause of gastrointestinal bleeding requiring transfusion in under 2-year-olds, presenting with bright red rectal bleeding, constipation, nausea and vomiting, and abdominal pain.
77
A mother brings her 14-month-old daughter into surgery as she is concerned about her hearing. For a child born in the United Kingdom, at what age would their hearing first be formally assessed?
Otoacoustic emission test is used to screen newborns for hearing problems
78
You are seeing a 5-year-old girl that has been brought in by her father with a sudden onset of fever and a sore throat this morning.
Her father informs you that she is prone to tonsillitis and would like some antibiotics as they had worked well previously.
On examination she is alert, sitting upright and unaided with a slight forward lean.
She has a temperature of 38.3 ºC, heart rate of 140/min, respiratory rate is normal.
There is no cyanosis or use of accessory muscles, but you do note a mild inspiratory fine-pitched stridor.
What would be the most appropriate next course of action?
(3)
Do not examine the throat if acute epiglottis is suspected
The correct answer is to 'contact the paediatrician on call and arrange a same-day review and admission to hospital'.
This history is suggestive of acute epiglottitis (acute onset, relatively normal respiratory rate, forward lean and stridor), a potentially life-threatening condition that requires urgent assessment and treatment in secondary care. Hospital transfer should be by blue light ambulance.
79
A 9-year-old boy is brought to surgery with recurrent headaches.
What is the most common cause of headaches in children?
Migraine is the most common cause of primary headache in children
80
A teenager attends the sexual health clinic experiencing pain on urinating and some penile discharge. He is concerned he has a sexually transmitted infection.
On closer questioning you discover that he is only 11 years old, despite looking older.
You enquire about his partner, but the boy will not give you any further information.
He doesn't want you to tell his parents or anyone else about this encounter. What is the best course of action?
Explain why you are unable to keep it a secret and tell him you will have to inform social services and his parents
81
A 14-year-old girl attends the GP with her mother, concerned that her periods have yet to start. On examination, she has normal female genitalia but is noted to have bilateral inguinal hernias. Breast buds and sparse pubic and axillary hair are also present. The girl is a normal weight and IQ for her age.
Which of the below is the most likely underlying cause of her complaint?
Androgen insensitivity - classic presentation is 'primary amenorrhoea'
Complete androgen insensitivity is the correct answer. The key detail of this question is that the girl is demonstrating primary amenorrhoea, the failure of ever starting menses, and the other choices are typical causes of secondary amenorrhoea, the cessation of regular menses. Complete androgen insensitivity leads to phenotypically female genitalia in a genetic male, caused by failure of androgen masculinisation of genitalia in-utero. Gonads in these patients are testes rather than ovaries and up to 90% develop inguinal hernias containing the immature testes. Signs of apparent female puberty such as breast bud development and sparse pubic hair occur due to the action of aromatase on androgens; primary amenorrhoea occurs due to the inherent absence of ovaries and a uterus.
82
A 5-year-old child presents to the emergency department complaining of right iliac fossa pain. On examination there is no rebound tenderness or guarding. Urine dipstick and routine bloods come back as normal. The mother reports that her daughter had a viral infection a few days ago.
What's the most likely diagnosis?
**Mesenteric adenitis** is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
* Appendicitis would present with abdominal tenderness and guarding.
* Pyelonephritis wouldn't have a negative urine dipstick.
* Intussusception is more likely in babies less than 9 months and causes a severe colic pain.
* Meckel's diverticulum would present similarly to appendicitis with severe pain and most commonly affects children aged 2.
83
A mother and her 5-year-old son come into your Child and Adolescent Mental Health Service (CAMHS) clinic, as he has just received a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). She has already completed an evening education programme on ADHD. She is quite distraught as he is a challenge to manage at home and has heard that there are some medicines that can help.
Bearing in mind the interventions previously tried, what would be next most appropriate treatment for his ADHD?
ADHD: first-line treatment is methylphenidate
84
A 15-year-old boy from Birmingham is brought to surgery by his mother complaining of abdominal pains for the past two days.
On examination there is a clinical suspicion of appendicitis and a referral to hospital is planned.
On discussing this with the patient he refuses to be admitted as he had planned to go to a party tonight.
He is able to understand all information you give him and repeat it, including the serious nature of untreated appendicitis.
What is the most appropriate course of action?
* His mother may overrule his wishes
* In England and Wales a child has the ability to consent to, but not refuse, treatment. Whether a child has demonstrated capacity (as per the Fraser guidelines) is not the relevant issue.
85
What is the first sign of puberty in boys?
| (3)
first sign is testicular growth at around 12 years of age (range = 10-15 years)
testicular volume \> 4 ml indicates onset of puberty
maximum height spurt at 14
86
What is the first sign of puberty in females?
(4)
Females
* first sign is breast development at around 11.5 years of age (range = 9-13 years)
* height spurt reaches its maximum early in puberty (at 12) , before menarche
* menarche at 13 (11-15)
* there is an increase of only about 4% of height following menarche
87
You review a 4-year-old boy in clinic.
He has been diagnosed with asthma after having multiple wheezy episodes over the past 3 years.
Around 4 months ago he was admitted with shortness-of-breath and wheeze and was diagnosed as having a viral exacerbation of asthma by the paediatric team.
Prior to his discharge he was given a Clenil (beclometasone dipropionate) inhaler 50mcg bd in addition to salbutamol 100mcg prn via a spacer.
His mother reports that he has a persistent night-time cough and is regularly having to use his salbutamol inhaler.
Clinical examination of his chest today is normal.
What is the most appropriate next step in management?
Add a leukotriene receptor antagonist
Child aged \< 5 years with asthma not controlled by a SABA + paediatric low-dose ICS - asthma management in children \< 5 years - add a leukotriene receptor antagonist
88
Which vaccines do young people usually receive between the ages of 13 - 18 years?
13-18 years immunisations: DT + IPV + Men ACWY
89
How are head lice diagnosed?
How are they treated?
**_Diagnosis_**
* fine-toothed combing of wet or dry hair
**_Management_**
* treatment is only indicated if living lice are found
* a choice of treatments should be offered - malathion, wet combing, dimeticone, isopropyl myristate and cyclomethicone
* household contacts of patients with head lice do not need to be treated unless they are also affected
90
You are an F1 doctor who has just started working on a paediatric ward. During the ward round, you see an 8-year-old boy with his parents, he suffers from West syndrome and has been involved in a research trial which involves regular EEG recordings. Although his parents have consented to him being involved in the trial, the boy interrupts saying he hates the 'horrible head stickers' and becomes visibly distressed when the trial is mentioned. What is the most appropriate course of action?
Raise your concerns with your consultant about the child's obvious objections in being involved with the trial
Ignoring your concerns over the patient's involvement in the trial is unprofessional. It would be an overreaction to remove the child from the trial, especially as an F1 doctor, as it would be to contact the GMC before consulting a senior colleague about your concerns. Exploring the parents' understanding of the trial would be a good idea, however, as an F1 doctor, it would perhaps be more appropriate to approach your consultant first who will likely have more knowledge of the trial and research they are conducting. The GMC guidance below also states that 'Children and young people should not usually be involved in research if they object or appear to object in either words or actions, even if their parents consent.'
91
A 15-month-old child is brought into the emergency department after feeling generally unwell and being off food. The child's mother informs you that he has also been bleeding from his back passage. There are no reports of nausea or vomiting. On examination, you note that the patient is tender in the right lower quadrant and appears in evident distress. There were no masses felt in the abdomen on palpation. His heart rate is 170 beats per minute, respiratory rate is 32 breaths per minute, blood pressure is 68/37 mmHg and temperature is 36.2 ºC. His medical records show no known medical conditions and regular medications.
What is the most likely diagnosis?
Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
92
A paediatrician is called to review a 2-day-old neonate born at 37+2 weeks gestation due to concerns in the newborn physical examination. The neonate has absent fundal reflexes bilaterally and a loud machinery murmur is heard on auscultation. Automated otoacoustic emission is suggestive of sensorineural deafness.
The mother recently arrived from overseas where she was unable to access antenatal care. She shows a photo of an exanthematous rash on her trunk in the first trimester, though the pregnancy was otherwise unremarkable.
Given this information, what is the neonate's likely diagnosis?
Congenital rubella
## Footnote
sensorineural deafness
congenital cataracts
93
Congenital rubella
sensorineural deafness
congenital cataracts
94
Features of growing pains
| (7)
Features of growing pains
1. never present at the start of the day after the child has woken
2. no limp
3. no limitation of physical activity
4. systemically well
5. normal physical examination
6. motor milestones normal
7. symptoms are often intermittent and worse after a day of vigorous activity
95
Developmental red flags
Referral points
* doesn't smile at 10 weeks
* cannot sit unsupported at 12 months
* cannot walk at 18 months
96
A 23 month old boy presents to your GP practice with what you suspect is a viral URTI.
During the consultation you become concerned about his development.
**Which of the following would make you most concerned?**
* Unable to say 6 individual words with meaning
* Not toilet trained
* Unable to stand on one leg
* Started to walk independently at 17 months
* Plays alone
Unable to say 6 individual words with meaning
By 23-24 months most children would have a vocabulary of between 20-50 words and will be able to join 2 words with meaning.
97
The consultant asks you to examine a 3-week-old girl on the neonatal ward.
She was born prematurely at 27 weeks gestation.
She is pink in colour and warm to touch, developing well and gaining weight appropriately.
She is currently saturating well on oxygen and her lungs sound clear.
On auscultation of her heart, you detect a continuous machinery murmur over the upper left sternal edge.
The murmur does not vary with position or radiate.
Which of the following is this murmur most likely to reflect?
Patent ductus arteriosus: machinery murmur at the upper left sternal edge
98
Patent ductus arteriosus features (2)
machinery murmur
at the upper left sternal edge
99
A baby is born at term via vaginal delivery with no complications, however he is still not showing signs of breathing at one minute. Heart rate is \>100bpm, but he is floppy and cyanosed. What is the most appropriate next step in management?
**5 breaths of air via face mask**
Airway suction should not be performed unless there is obviously thick meconium causing obstruction, as it can cause reflex bradycardia in babies.
Chest compressions are not indicated, as the HR in this case is \>100bpm. CPR should only be commenced at a HR \< 60bpm.
In cases where there are no signs of breathing and this is thought to be due to fluid in the lungs, five breaths should be given via a 250ml bag via face mask.
This is a more effective and more hygienic method than using mouth-to-mouth in a hospital setting.
100
An 18 month old child attends the paediatric assessment unit with his mother.
He has been brought in as he has had a fever, barking cough and difficulty breathing at night.
He has been diagnosed with croup and you have been asked to see him to review.
After history and assessment you are confident there is no stridor or respiratory distress.
What would your next step in management be?
Croup - A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity
101
Which organism is responsible for causing scarlet fever?
Group A haemolytic streptococci
102
A 2 month old baby is brought in to hospital with a fever. The child is pyrexial, with nil respiratory signs on examination and no diarrhoea. Which of the following would be part of your initial investigations?
**Perform the following investigations in infants younger than 3 months with fever:**
* Full blood count
* Blood culture
* C-reactive protein
* Urine testing for urinary tract infection
* Chest radiograph only if respiratory signs are present
* Stool culture, if diarrhoea is present
103
A 12-hour-old newborn, born at 34 weeks to a healthy mother, is currently undergoing a check whilst on the ward. The baby appears healthy on general inspection and the mother reports no concerns so far. On examination, a large volume, collapsing pulse is noted, and a heaving apex beat, as well as a left subclavicular thrill. On auscultation of heart sounds, the doctor notes a continuous 'machinery-like' murmur.
The doctor arranges an urgent echocardiogram, which confirms her suspected diagnosis. No other abnormalities or defects are demonstrated on the echo.
Given the findings and likely diagnosis, what would be the most appropriate initial management?
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
104
You are reviewing a 6-month-old child with suspected bronchiolitis. Which one of the following should prompt the consideration of a hospital referral?
* Oxygen saturations of 96%
* The child being below the 10th centile for weight
* Feeding 50% of the normal amount
* Respiratory rate 54 / min
* Crackles on auscultation
Consider referring children with bronchiolitis to hospital if they have any of the following:
* a respiratory rate of over 60 breaths/minute
* difficulty with breastfeeding or inadequate oral fluid intake (50–75% of usual volume, taking account of risk factors [see recommendation 1.3.3] and using clinical judgement)
* clinical dehydration
105
A 4-year-old boy is brought to the GP by his mother who states that she has noted a 'barking' cough a few times every day for the last two days. There has been no change to his appetite and his behaviour has not changed. The GP does not find any abnormalities on examination.
Given the likely diagnosis of mild croup, what would be the first-line treatment?
Croup - A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity
106
A 5-year-old male presents to his general practitioner accompanied by his mother. He has been recently having some trouble falling asleep at night, because of an itchy bottom.
The child looks healthy and well. He regularly attends school and enjoys playing in the garden with other children. He visits the doctor only for his vaccinations, for which he is up to date.
Given the most likely diagnosis, which one of the following is the first-line management for this child?
Mebendazole is first line therapy for treatment of threadworm
107
A 2-month-old baby girl is admitted to hospital with suspected meningitis. Her parents describe her becoming pyrexial and drowsy over the past 24 hours. On examination her temperature is 39.2ºC, heart rate is 160/min and respiratory rate is 50.min. Her anterior fontanelle is bulging. No petechial rash is seen. In addition to cefotaxime, what antibiotic should be given intravenously?
Meningitis in children \< 3 months: give IV amoxicillin in addition to cefotaxime to cover for Listeria
108
The midwife has asked you to perform a newborn examination on a 1-day-old baby boy.
He was born in good condition by vaginal delivery at 38+6 weeks gestation weighing 3400 grams.
You take a brief antenatal history and are told the antenatal scans were normal and it was a low-risk pregnancy.
There is no family history of congenital disorders.
You proceed with your examination, and on examining the external genitalia you notice a ventral urethral meatus.
What condition is associated with the above findings?
Cryptorchidism is present in around 10% of patients with hypospadias
109
A 2-year-old boy is seen by his GP with an enlarging neck swelling that has been present for the past year. On examination you note a smooth midline lesion which is round and located just below the hyoid bone. It measures 2.5 cm x 2 cm and rises on protrusion of the tongue.
What is the most likely diagnosis?
Thyroglossal cysts are located in the anterior triangle, and are usually in the midline and below the hyoid. Typically, the cyst rises on protrusion of the tongue as well as on swallowing.
110
Precocious puberty in males may be defined as the development of secondary sexual characteristics before:
Definition
## Footnote
'development of secondary sexual characteristics before 8 years in females and 9 years in males'
more common in females
111
You are working as a FY1 in the emergency department when you attend a mother and her 4-year-old child.
She complains that her child has had a sore throat which has rapidly become worse over the last 3 hours, a high fever and has begun drooling from the sides of his mouth.
His mother admits he has missed some of his vaccinations as she read a story on their negative effects, but is unsure which were omitted.
On examination the child is sitting on the examination couch leaning forward and refusing to move.
He is pyrexial (38.1C) with overt drooling from the sides of his mouth.
He is refusing to talk and a soft high pitched sound is just audible on inspiration.
What is the most likely causative agent underlying this child's condition?
**Acute epiglottitis** is caused by **Haemophilus influenzae type B**
This child is presenting with a classic case of acute epiglottitis, which is more likely considering there is a chance he has not been vaccinated against Haemophilus influenza type B. This is the most common cause of this condition, with other less common causes being Streptococcus pyogenes and Streptococcus pneumoniae. Parainfluenza virus is the cause of croup, and RSV is the cause of bronchiolitis in children.
112
You are asked to review a neonate born pre-term at 35 weeks, 36-hours after delivery with no complications.
On examination, you find a left subclavicular thrill and notice a continuous 'machinery-like' murmur. You also discover a bounding pulse and note a widened pulse pressure.
There is no evidence of cyanosis, nor crackles on auscultation.
Upon reviewing the notes and history with the mother, there were no problems during the pregnancy, nor any abnormal findings on antenatal scans or screening. There is no family history of any significant disease.
Given the likely diagnosis, what would be the most appropriate management option?
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
113
You are a foundation doctor working in the emergency department. A senior doctor has seen a child with a severe cough and asks you to go to examine them for your own learning. However, they warn you not to examine this child's throat due to risk of airway obstruction. What is the most likely diagnosis?
Never perform a throat examination on a patient with croup due to risk of airway obstruction
114
You are asked to review a term neonate on the postnatal wards.
On examination of the palate, you notice a white-coloured nodule at the roof of the mouth.
This is not interfering with feeding and baby is alert and active. What is the most likely diagnosis?
Epstein's pearls are found in the posterior hard palate, along the midline. They do not require treatment.
## Footnote
A congenital cyst found in the mouth. They are common on the hard palate, but may also be seen on the gums where the parents may mistake it for an erupting tooth. No treatment is generally required as they tend to spontaneously resolve over the course of a few weeks.
115
A mother of a 10-week-old baby reports that he has not been himself for the past 24 hours; he is not smiling as much and is having 25% less breastfeeds. He was born term without complication, has been thriving well and is up to date with his immunisations. Examination is unremarkable apart from a temperature of 38.5ºC. What would be the most appropriate initial step in management?
A child aged \< 3 months with a fever \> 38ºC should be assessed as high risk of serious illness
116
Which one of the following is a cause of cyanotic congenital heart disease?
* Atrial septal defect
* Ventricular septal defect
* Transposition of the great arteries
* Coarctation of the aorta
* Patent ductus arteriosus
* Transposition of the great arteries
117
Cyanotic congenital heart diseases:
(3)
* tetralogy of Fallot
* transposition of the great arteries (TGA)
* tricuspid atresia
118
Acyanotic congential heart diseases
| (5)
* ventricular septal defects (VSD) - accounts for 1/3rd
* atrial septal defect (ASD)
* patent ductus arteriosus (PDA)
* coarctation of the aorta
* aortic valve stenosis
119
On auscultation, the neonate has no murmur but a **loud single S2**. On palpation, there is a **prominent ventricular pulse**.
What is the most likely diagnosis?
**Transposition of the great arteries** presents with no murmur but typically a loud single S2 is audible and a prominent right ventricular impulse is palpable on examination
120
What is transient synovitis?
| (3)
* Transient synovitis is an inflammation in the hip joint that causes pain, limp and sometimes refusal to bear weight.
* This occurs in pre-pubescent children and is the most common cause of hip pain.
* It occurs when a viral infection, such as an upper respiratory infection, moves to and settles in the hip joint.
121
A 1-year-old boy presents with bilious vomiting, abdominal distension and has been constipated since birth and did not pass meconium until he was 3 days old.
Height and weight are at the fifth percentile.
On examination, the abdomen is distended and a PR examination causes stool ejection. What is the likely diagnosis?
**Hirschsprung disease** is a congenital bowel disease, which is **five times more likely to occur in boys than girls**.
It usually presents with bilious vomiting, abdominal distension, constipation and failure to pass meconium in the first 48 hours.
Hirschsprung disease may not present until childhood or adolescence.
Colon biopsy demonstrates an aganglionic segment of bowel.
122
An 18 year-old with no significant medical history registers at a new GP practice when he moves to University. The practice reviews his immunisation history and sends him an invitation to have a vaccination. Which of the following vaccinations should he receive if he has not had it previously?
The **Meningitis ACWY** vaccine is being rolled out over several years. All children should receive the vaccination in school year 9 or 10 (in place of the Men C booster). The catch-up program is currently being aimed at students starting University for the first time (aged 25 and under only) and should ideally be given a few weeks before they begin.
123
