Miscellaneous Questions Flashcards
(106 cards)
1
Q
A 4 year old presents with 2 week history of increasing oedema with scrotal swelling and now periorbital swelling. He has proteinuria 4+, his BP and renal function are normal. The most likely diagnosis is:
- Henoch-Schonlein Purpura
- SLE
- Angioneurotic-oedema
- Glomerulonephritis resulting in nephrotic syndrome
- Post streptococcal glomerulonephritis
A
Answer: 4. Glomerulonephritis resulting in nephrotic syndrome.
The presentation is of nephrosis, which has many causes so the generic answer is 4. (It could be caused by 1, 2 or 5 but there is not enough info in the question to say this).
2
Q
This 2 year old has a 6 day history of a fever; very irritable, no cough or runny nose; there are >1cm cervical lymph nodes and non-purulent conjunctivitis. No improvement with broad spectrum antibiotics. Platelets are 1,150,000 and ESR 120. What is the most likely diagnosis?
- Measles
- Rheumatic fever
- Scarlet fever
- Kawasaki’s disease
- Staphyloccocal toxic shock syndrome (TSS)
A
Answer: 4. Kawasaki’s disease
The features alongside a very high platelet count makes Kawasaki’s most likely.
Scarlet fever usually responds to antibiotics, measles presents with a cough/ URTI.
3
Q
A 5 year old, just emigrated from Australia 10 days ago has a 1 week history of high grade fevers and a cough, with no response to iv cefuroxime. The most likely organism is?
- Haemophilus
- Strep pneumoniae
- Moxarella
- Staph. aureus
- Mycobacterium TB
A
Answer: Staph. aureus
Australia has one of the lowest incidences int he world for TB- so very unlikely to be TB.
4
Q
Which is the most appropriate treatment for an acutely wheezy, alert 18 month old in A&E: RR 40/min, HR 120/min, Sats 90% on 100% oxygen?
- 6 puffs of salbutamol via a turbohaler
- 10 puffs of salbutamol via an MDI + aerochamber
- 6 puffs of salbutamol via an MDI
- 5mg of salbutamol via nebuliser
- 2.5mg of salbutamol via nebuliser
A
Answer: 2
10 puffs of salbutamol via an MDI and spacer
A nebuliser is reserved for life threatening wheeze or failure to tolerate spacer; even if the child requires oxygen (in non life threatening wheeze), remove the nebuliser temporarily to give salbutamol via spacer.
5
Q
2 year old child had his first febrile convulsion, which was a very prolonged one resulting in intubation. For the next febrile illness, the parents are best advised to:
- Give prophylactic neurofen and paracetamol to reduce risk of a convulsion
- Tepid sponge and place in a warm (not cold) bath
- Apply a cool fan to the child
- Give rectal diazepam if he starts fitting and call 999
- Always seek medical attention to have the child examined
A
Answer: 4
Give rectal diazepam and call 999 if he starts fitting
There is no evidence that prophylactic neurofen and paracetamol will work to prevent febrile convulsions (Option 1). Options 2 and 3 are not advisable and there is no need to always have the child examined for a fever alone.
6
Q
A 5 year old has a sudden onset painful left testes for the past 3 hours. No reported trauma. On examination the testis is swollen and tender. What should the first line management be?
- Ultrasound of the scrotum
- Admission for further assessment
- IV antibiotics
- Discharge with NSAIDs and review in 24 hours
- Arrange for an immediate exploration in theatre
A
Answer: 5
Arrange for immediate exploration in theatre.
Time is paramount if this is testicular torsion - do not waste time by doing other investigations.
7
Q
An 8 month old with a mild infantile eczema has a 24 hour history of red, vesicular rash with crusting and exudates. Which treatment option is the most appropriate?
- IV aciclovir
- IV aciclovir and IV flucloxacillin
- IV benzyl penicillin and flucloxacillin
- Oral acyclovir, penicillin V and flucloxacillin
- Topical fucidin, antiseptic baths and emollients
A
Answer: 2
IV acyclovir and IV flucloxacillin
With this vesicular rash with crusting and exudates, one has to consider both Staph aureus and Herpes simplex. Flucloxacillin covers Staph aureus and Aciclovir covers Herpes simplex.
The rash is actually eczema herpeticum with secondary staph infection. Do not use topical antibiotics for infected eczema.
NB: There is a widespread myth that using penicillin to treat Strep, plus flucloxacillin to treat Staph is good practice. In fact, flucloxacillin is a semi-synthetic penicilin and when given in appropriate doses iv is just as effective at treating Strep as penicillin. It is unnecessary to duplicate the cover, and simply costs more in terms of nursing time, and may reduce the half life of peripheral cannulae by doubling the number of drug doses given intravenously.
8
Q
A 10 month old baby had a mild allergic reaction to egg and developed a rash subsequently. What should happen with his MMR vaccination?
- Admit for MMR under hospital observation
- Do not give him the MMR vaccine
- Single jabs in community setting
- Single jabs under hospital observation
- MMR in community setting
A
Answer: 5
MMR in community setting
The MMR vaccine is cultured in fibroblasts derived from chick embryos and not on egg, therefore the amount of egg protein is negligible. Studies on large number of egg-allergic children show there is no increased risk of severe allergic reaction to the MMR vaccine. The Immunisation Against Infectious Diseases (Green book) advises that all children with egg allergy should receive the MMR vaccine as a routine procedure in primary and there is no need to admit for hospital admission.
You never ever give single MMR jabs!!
9
Q
What is the most appropriate management strategy for an alert, well oxygenated 3 year old with a 24 hour history of barking cough, increasing (moderate) stridor and fever >40 degrees and riggers. No drooling. She is being given oxygen.
- Adrenaline nebuliser stat and call ENT and anaesthetic teams
- Oral dexamethasone and lateral neck X-ray
- IV cefuoxime and flucloxacillin after blood cultures
- Budesonide nebuliser
- Oral dexamethasone, IV cefuroxime and flucloxacillin after blood cultures and review.
A
Answer: 3
IV cefuroxime and flucloxacillin (after taking blood cultures)
Whilst the history suggests viral croup, the high grade fever with riggers also suggest the possibility of bacterial tracheitis, for which antibiotics are required.
In this case, adrenaline is not yet needed unless she deteriorates, at which you would need to call ENT and anaesthetists.
Never perform a lateral neck X-ray.
Oral dexamethasone is first line for viral croup, although you can give budesonide nebuliser instead.
10
Q
A 14 month old child presents with a 2 weeks history of increased bruising and a few nose bleeds; no recent history except MMR 2 weeks ago. No family history, examination was normal (no lymph nodes, no enlargement of the liver or spleen), lots of bruises over contact points.
FBC shows Hb 11.9, WCC 7.8 with normal differentials, Plts 8,000 and blood film normal. What is the most likely diagnosis?
- Acute lymphoblastic leukaemia
- Idiopathic thrombocytopenia purport
- Henoch Schonlein Purpura
- MMR associated thrombocytopenia
- Aplastic anaemia
A
Answer: 4
MMR associated thrombocytopenia
This child most likely has an immune thrombocytopenia so 2 or 4 is correct, but given the MMR history, 4 is the best answer.
11
Q
A bright 9 year old presents with primary nocturnal enuresis. Parents tried pad and alarm, which have failed. They have also tried lots of self-help remedies to no avail. Which is the most useful first line approach?
- Start DDAVP tablets for 3 months and review
- Give imipramine for 3 months as a trial
- Encourage lifting at midnight and reduction in oral fluids at night
- Commence behavioural approach
- Do nothing, just reassure
A
Answer: 4
Commence behavioural approach
Medications have a very limited role (short term use of DDAVP occasionally use to support behavioural approach or for sleepovers); Imipramine is almost never used nowadays. Lifting at night will delay continence; doing nothing is not an option at this age!
12
Q
An 8 year old with asthma has persistent cough and wheeze at night and on exertion. She is requiring regular salbutamol. What is the next step to optimise her asthma management?
- Montelukast 5mg orally once daily
- Low dose inhaled steroids via turbohaler
- Lowe dose inhaled steroids via MDI
- Salmeterol and low dose steroid combination via MDI and spacer
- Low dose inhaled steroids via MDI and aerochamber
A
Answer: 5
Low dose inhaled corticosteroid via MDI and spacer
A trial of Montelukast is indicated if child is <5 years.
Inhaled corticosteroid via MDI must be used with a spacer!!
13
Q
What would be the most appropriate immediate response in a situation where a child with severe acute asthma is being removed from the ED by their carers prior to treatment?
- Accept parental wishes
- Prevent child from leaving, by force if necessary
- Ask security to intercept and rescue the child
- Call social services and ask them to of to court for an emergency protection order
- Call the police
A
Answer: 5
Call the police
The only correct immediate option is 5, so that you can get the child back to start immediate treatment. This can be done without parental consent in the best interests of the child. Meanwhile you will then pursue 4 (calling social services).
Security cannot use force as this would be assault.
14
Q
A 15 year old takes an overdose of tricyclic antidepressants and is comatose, GCS 6. The most appropriate first line management is?
- Ipecac forced emesis
- Activated charcoal via an NG tube
- Gastric washout, then activated charcoal via an NG tube
- Oxygen, suction and intubation
- Contact psychiatrist
A
Answer: 4
The only safe option is 4 as she has an unsafe airway, then you would consider 3 followed by 5.
There is no role for forced emesis!
15
Q
Which of the following statements about the Swine influenza A/H1N1, 2009 is correct?
- This novel virus was the result of a genetic shift, combining pig, avian and human viral characteristics
- The first wave was associated with higher paediatric mortality than normal seasonal influenza
- There was good evidence from RCTs that oseltamivir (Tamiflu) reduced mortality and morbidity in children
- RSV was not a co-factor in more severe illness phenotype
- Schools were not advised to close during a school outbreak, during the initial national containment phase.
A
Answer: 1
This novel virus was the result of a genetic shift, combining pig, avian and human viral characteristics.
The first wave had very low mortality rates compared to seasonal flu.
There are no RCTS on tamiflu (oseltamivir); RSV can certainly worsen the clinical picture.
The containment phase was the phase when all attempts to stop spread of disease occurred including shutting schools during outbreaks. This all stopped in July 09 once disease was widespread and the containment phase ended.
16
Q
A healthy 18 month old, has a 3 month history of writhing movements of her thighs whilst strapped in the high chair or car seat. She is always alert and happy throughout these, and the episodes can be stopped by parents. Normal development milestones. Normal neuro examination. Video confirms the above history. What would you do?
- Arrange baseline EEG and MRI
- Refer to the paediatric neurologist
- Arrange an ECG, ECHO and 24 hr holter tape
- Admit for observation
- Reassure this is likely to be normal toddler masturbation
A
Answer: 5
All the clues point to 5; it is normal and there is nothing to worry about.
17
Q
In a 6 month old with a 2 week history of persisting diarrhoea (watery, no blood, 6-8 times a day) after an initial bout of vomiting and fever; with no travel or drug history, the most appropriate management would be:
- 24 hours of diarolyte instead of all other fluids
- Perform a coeliac screen, stool cultures and refer to a paediatric gastroenterologist
- Send stool cultures and start ciprofloxacin
- Stop all dairy products and substitute with a hydrolysed formula; also send stool cultures
- Send stool cultures and start metronidazole
A
Answer: 4
Please see “Diarrhoea and vomiting in under 5’s”, (nice.org.uk); Approach is 4.
If giardia was found, Rx with metronidazole can be considered but there are very few other indications to use antibiotics in children with infective gastroenteritis (other than with possible sepsis)
18
Q
A 6 wk old breast fed infant with a 2 week history of worsening vomiting after feeds, with poor weight gain and constipation. The chloride is 90 mmol/L.
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
A
Answer: A. pyloric stenosis
Poor weight gain as the infant is vomiting all the feed. Low chloride due to vomiting up gastric acid (HCl)
19
Q
A 1 week old with vomiting, lethargy, increasing jaundice and on exam a 3 cm liver is felt and cataracts are noted.
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
A
Answer: E - Galactosaemia
20
Q
3 yr old with acute onset abdominal pain for 4 hrs (3 similar episodes in the past, all self resolved), but this time with bile stained vomiting
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
A
Answer: J. Malrotation
21
Q
6 month old breast fed infant, vomiting since early on, not resolved with anti-reflux medication; also has eczema hard to control and constipation
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
A
Answer: K
Cow’s milk protein intolerance
NB: CMP intolerance can occur in breast fed infants as small amounts of CMP fragments may be found in the breast milk of mothers who have not excluded milk from their own diet.
22
Q
2 week old boy with frequent vomiting, lethargy, no fevers. The abdomen is soft and non tender. U&E’s show Na 122, K+ 6.4
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
A
Answer: G
Congenital adrenal hyperplasia
23
Q
A 5 yr old with 1 week of severe left sided headaches, analgesic unresponsive. Having high fevers, vomiting, and earache, on oral amoxicillin for otitis media. Aside from a red left TM, nothing to find on examination.
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
A
Answer: C Intracranial abscess
24
Q
Acute onset severe right sided headaches in 7 yr old, with left sided weakness lasting an hour then full recovery. Several similar episodes in the past but getting worse; weakness is taking longer to resolve each time and more severe.
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
A
Answer: I. Arterio-venous malformation
25
3 yr old with 2 week history of waking with headaches and vomiting; becoming unsteady on feet and presents with a sudden squint of left eye, with diplopia on looking to the left.
```
A. Tension type headaches
B. Posterior fossa tumour
C. Intracranial abscess
D. Migraine
E. Idiopathic intracranial hypertension
F. Hypertension
G. Mastoiditis
H. Chronic sinusitis
I. Arterio-venous malformation
J. Right hemispheric tumour
```
Answer: B. Posterior fossa tumour
26
9 yr old with 6-12 months of continuous daily frontal and vertex headaches; unresponsive to analgesia; does not wake from sleep; no interruption with ADL’s. No other symptoms. Examination was normal, including normal BP and fundi.
```
A. Tension type headaches
B. Posterior fossa tumour
C. Intracranial abscess
D. Migraine
E. Idiopathic intracranial hypertension
F. Hypertension
G. Mastoiditis
H. Chronic sinusitis
I. Arterio-venous malformation
J. Right hemispheric tumour
```
Answer: A. Tension type headaches
27
14 yr old girl, 6 weeks worsening headaches, early morning with vomiting; grossly blurred fundi, CT scan normal
```
A. Tension type headaches
B. Posterior fossa tumour
C. Intracranial abscess
D. Migraine
E. Idiopathic intracranial hypertension
F. Hypertension
G. Mastoiditis
H. Chronic sinusitis
I. Arterio-venous malformation
J. Right hemispheric tumour
```
Answer: E. Idiopathic intracranial hypertension
28
5 yr old recently returned Nigeria; has had 3 day history of swinging high fevers, also urine is noted to be dark red. On exam has enlarged liver, otherwise nil else. Dipstick positive for blood +++.
```
A. UTI
B. Hereditary spherocytosis
C. Schistosomiasis
D. Malaria
E. G6PD deficiency
F. Wilm’s tumour
G. Nephrotic Syndrome
H. Acute glomerulonephritis
I. Polycystic kidneys
J. Von Willebrand’s
```
Answer: D. Malaria
29
2 year old with frank haematuria, some abdominal pain, rigors. Urine nitrite and blood +++.
```
A. UTI
B. Hereditary spherocytosis
C. Schistosomiasis
D. Malaria
E. G6PD deficiency
F. Wilm’s tumour
G. Nephrotic Syndrome
H. Acute glomerulonephritis
I. Polycystic kidneys
J. Von Willebrand’s
```
Answer: A. UTI
30
6 month old brought in by parents as they noted blood in the nappy; well infant; history of constipation last 6 weeks; exam, right sided abdominal mass palpable; urine blood ++++.
```
A. UTI
B. Hereditary spherocytosis
C. Schistosomiasis
D. Malaria
E. G6PD deficiency
F. Wilm’s tumour
G. Nephrotic Syndrome
H. Acute glomerulonephritis
I. Polycystic kidneys
J. Von Willebrand’s
```
Answer: F. Wilm’s tumour
31
A 3 yr old with urine noted to be very dark by parents; Has had puffy eyes and been generally unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. BP 110/65.
```
A. UTI
B. Hereditary spherocytosis
C. Schistosomiasis
D. Malaria
E. G6PD deficiency
F. Wilm’s tumour
G. Nephrotic Syndrome
H. Acute glomerulonephritis
I. Polycystic kidneys
J. Von Willebrand’s
```
Answer: H. Acute glomerulonephritis
32
A 6 yr old male, UK born, of Iraqi parents, develops sudden onset very dark red urine, no pain. He has a current viral infection. On exam, slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice.
```
A. UTI
B. Hereditary spherocytosis
C. Schistosomiasis
D. Malaria
E. G6PD deficiency
F. Wilm’s tumour
G. Nephrotic Syndrome
H. Acute glomerulonephritis
I. Polycystic kidneys
J. Von Willebrand’s
```
Answer: E. G6PD deficiency
33
A 5-year-old girl is brought to A+E after school by her mother and school teacher with central abdominal pain.
The best history is likely to be obtained by talking to:
a. Her mother
b. Her mother and her school teacher
c. Her school teacher
d. The A+E triage nurse
e. The girl herself and her mother
Answer: E. The girl herself and her mother
The girl is the one experiencing the pain. The mum can provide details of her PMH and birth/ antenatal history.
34
A two-year-old boy is seen in Paediatric Outpatients with a 6 month history of diarrhoea and parental concern about his nutritional status. The best way to assess these concerns would be to:
a. Assess his weight for height
b. Calculate his Body Mass Index (BMI)
c. Measure his height and weight in clinic
d. Measure his upper arm circumference
e. Review and plot serial weights and heights
Answer: E. Review and plot serial weights and heights
35
A previously healthy 2-year-old child presents with a 24 hour history of diarrhoea and vomiting. Which of the following is the single, most accurate method for assessing the degree of dehydration?
a. Assess skin turgor
b. Assess the fontanelle
c. Calculate the difference between the current weight and the predicted weight from the child’s growth records
d. Examine the mucous membranes
e. Measure the heart rate and blood pressure
Answer: C. Calculate the difference between the current weight and the predicted weight from the child’s growth records
36
A 3-year-old boy attends the Paediatric A+E Department because he has developed an itchy rash whilst at a birthday party. Of the following features, which requires immediate treatment with 0.01 ml/kg of 1:1000 adrenaline i.m.?
a. Blood pressure of 88/50
b. Generalised urticaria
c. Lip swelling
d. Respiratory rate of 22/minute
e. Wheeze on auscultation
Answer: E. Wheeze on auscultation
37
A 3-year-old boy has just started fitting in A+E. You are the F1 doctor. The nurses are all busy with other children. Of the following actions which should you do first?:
a. Administer rectal diazepam
b. Gain iv access
c. Give him high-flow oxygen
d. Measure his blood sugar
e. Do a blood gas
Answer: C. Give him high-flow oxygen
38
One evening a 4-month-old boy is brought into A+E by his step-father because of a prolonged nose bleed. This has now stopped. The examination is normal apart from some irregular bruising on his abdomen and small, well circumscribed marks on his back. The next most appropriate step from the options below would be to:
a. Admit him and arrange a full skeletal survey, clinical photographs and clotting studies
b. Check his full blood count and clotting studies, and discharge him if they are normal for follow up in OPD
c. Discharge him and discuss the case the next day with the child protection team
d. Discuss the case with the child protection team now
e. Reassure the step-father that since the nose bleed has stopped, no further treatment is required
Answer: D. Discuss the case with the child protection team now.
39
A 2-month-old, ex-26 week gestation boy establishing feeding on the neonatal unit has developed a distended abdomen and bile-stained vomiting, and has an increasing oxygen requirement. The most likely diagnosis is:
a. Appendicitis
b. Gastro-oesophageal reflux
c. Hirschsprung’s disease
d. Intussusception
e. Necrotising enterocolitis
Answer: E. Necrotising enterocolitis
Risk factor: prematurity
40
A 5-month-old boy has been brought to A+E 2 hours previously with a 12 hour history of very high fever and vomiting. Examination does not reveal a clear source of infection so a blood culture is taken and lumbar puncture is performed. Of the following options, which method reflects current clinical practice when an urgent urine sample is required prior to starting antibiotics?
a. Fixing a sterile bag and waiting for a sample
b. Performing an in-out urinary catheterisation with aseptic technique
c. Placing a sterile pad in the nappy and waiting for a sample
d. Placing and leaving a urinary catheter in situ
e. Waiting for the parents to ‘catch’ a mid-stream urine sample in a bowl
Answer: B. Performing an in-out urinary catheterisation with aseptic technique
41
A 2-week-old boy is brought to A+E by his mother who has noticed that he has become increasingly jaundiced. She reported that he had not been breast-feeding as well as previously, and also commented that his stools looked like “off-white chewing gum”. The most likely diagnosis is:
a. Breast-milk jaundice
b. Congenital gall stones
c. Extra-hepatic biliary atresia
d. Glucose 6-phosphate dehydrogenase deficiency
e. Rhesus incompatibility
Answer: C. Extra-hepatic biliary atresia
42
A 4-month-old girl is brought into A+E Resus by paramedics with a widespread, progressing, non-blanching purpuric rash on both lower limbs. She has cold peripheries with a capillary refill time of 5 seconds, has a heart rate of 180/min and her blood pressure is unrecordable. The most likely diagnosis is:
a. Anaphylaxis
b. Erythema infectiosum
c. Group B streptococcal infection
d. Henoch-Schonlein purpura (HSP)
e. Neisseria meningitidis infection
Answer: E. Neisseria meningitidis infection
She has signs of septicaemia and shock (prolonged capillary refill time, tachycardia and hypotension).
43
A 12-year-old boy has presented to A+E unable to weight-bear on his right leg due to pain in the hip. He grazed his thigh 6 days ago whilst playing football, and for the last 48 hours has had high fevers. Bloods taken today show a CRP of 240 and a WCC of 24.5. A hip x-ray shows a periosteal reaction in the proximal femur but no fracture or joint effusion. The most likely diagnosis is:
a. Osteomyelitis
b. Perthe’s disease
c. Septic arthritis
d. Slipped upper femoral epiphysis
e. Transient synovitis
Answer: Osteomyelitis
Signs of infection- high grade fever; predisposing injury of grazing his thigh (route of entry for pathogen).
44
A 2-year-old boy presented to A+E with a 4 week history of intermittent high fever and misery. The parents have noticed a widespread evanescent salmon-pink rash. In the last 48 hours he has been unwilling to weight bear. Laboratory tests reveal markedly raised acute phase markers. The most likely diagnosis is:
a. Chronic listeria infection
b. Dermatomyositis
c. Duchenne muscular dystrophy
d. Juvenile idiopathic arthritis
e. Systemic lupus erythematosus
Answer: D. Juvenile idiopathic arthritis
45
A 14-month-old boy, with normal growth is referred to you due to his mother complaining that he is a difficult feeder. He refuses most solids and meal times are a battle, but he likes drinking cows’ milk and has about 1 litre per day. Which of the following would you do next?
a. No need to test for deficiency in the absence of clinical signs
b. Test for iron deficiency
c. Test for vitamin B12 deficiency
d. Test for folic acid deficiency
e. Test for calcium deficiency
Answer: B. Test for iron deficiency
46
A 15-month-old Muslim girl is not meeting her gross motor developmental milestones and is generally very irritable. She was growing on the 50th centile, but is now on the 25th. She has 2-hourly breast feeds and consumes minimal solids with no additional dairy products. What is the most likely diagnosis?
a. Failure to thrive
b. Iron Deficiency
c. Phosphate deficiency
d. Nutritional Rickets
e. Vitamin A deficiency
Answer: D. Nutritional Rickets
Breast milk is deficient in vitamins?
47
A 15 year old girl attends the Emergency Department with her boyfriend, also 15, requesting the morning-after pill following a condom accident the previous evening. She reveals that four months ago she was circumcised during a family trip to Somalia. She understands your advice and the implications of her decisions to engage in sexual activity. She refuses to inform her parents. The couple are using condoms regularly. What is the appropriate management?
a. Decline to prescribe the morning-after pill and refer the patient back to her GP
b. Decline to prescribe the morning-after pill and inform her parents so that they can support her
c. Prescribe the morning-after pill and recommend that the girl informs her parents
d. Prescribe the morning-after pill and immediately alert the safeguarding children's team
e. Prescribe the morning-after pill, give contraceptive advice and inform her parents
Answer: C. Prescribe the morning-after pill and recommend that the girl informs her parents.
Since she understands your advice and the implications of her decisions to engage in sexual activity, she is deemed to have Gillick competence, thus you cannot go against her wishes and break confidentiality by informing her parents. You can only encourage that she discloses with her parents.
48
An 8-year-old girl is referred to outpatient department with a 3-month history of acne, breast development and fine pubic hair. She is otherwise healthy and has had no known illnesses, nor is she on any long term medication. Examination is otherwise normal. What is the most likely aetiology?
a. a feminising ovarian tumour
b. a gonadotropin producing tumour
c. congenital adrenal hyperplasia, late onset
d. Premature adrenarche
e. Early onset of normal puberty
Answer: E. Early onset of normal puberty
49
A 13-year-old boy presents to his GP for a routine physical prior to participation in competitive sports. He has had no recent illnesses and no past medical history of note. His height and weight are on the 75th centile for his age. Cardiovascular examination reveals a grade 2/6 ejection systolic murmur heard loudest at the left lower sternal border. It is low pitched and musical but does not radiate. Which of the following is the most likely diagnosis?
a. atrial septal defect
b. ventricular septal defect
c. vibratory innocent murmur
d. tricuspid regurgitation
e. mitral stenosis
Answer: C. vibratory innocent murmur
50
An 8-week-old exclusively breastfed baby boy was born at 38 weeks gestation after an uneventful pregnancy. Which of the following findings would require a prompt referral to a paediatric surgeon?
a. bilateral nontender scrotal swellings which transilluminate
b. a right testis which can be manipulated to the base of the scrotal sac
c. an acute episode of balanitis
d. glandular hypospadias
e. an irreducible firm lump which extends from the inguinal canal to the scrotum
Answer: E. an irreducible firm lump which extends from the inguinal canal to the scrotum
Inguinal hernia- at risk of strangulation.
51
A healthy 4-year-old girl develops acute onset of petechiae and epistaxis. Laboratory findings include haemoglobin = 12g/dL; white cell count = 5.5 with normal differential; and platelet count = 15. Of the following investigations, which would you do next?
a. blood film
b. bone marrow aspirate
c. check the bleeding time
d. clotting studies
e. platelet antibody tests
Answer: A. blood film
52
The laboratory calls you to inform you that a baby who is now 10 days old has an elevated TSH on their Guthrie Card test. If this condition is left untreated, which of the following signs is the baby most likely to demonstrate in the first few months of life?
a. hyperphagia
b. prolonged jaundice
c. diarrhoea
d. hyperirritability
e. hyperreflexia
Answer: B. prolonged jaundice
```
Due to congenital hypothyroidism.
Other signs include:
- hypotonia
- excessive sleepiness
- constipation
- reduced interest in feeding
```
53
A 2-week-old boy is admitted with a 3-day history of vomiting and increasing lethargy. Physical examination is normal except for increased pigmentation of the areolar and nipples bilaterally. Laboratory findings include plasma sodium = 126 mmol/L; plasma potassium = 6.8 mmol/L; and plasma glucose = 5.9 mmol/ L. What is the most likely diagnosis?
a. pyloric stenosis
b. gastroenteritis
c. hyperaldosteronism
d. panhyperpituitarism
e. congenital adrenal hyperplasia
Answer: E. congenital adrenal hyperplasia
In classic 21-hydroxylase deficiency, laboratory studies will show:
- hypoglycemia (due to hypocortisolism)
- hyponatremia (due to hypoaldosteronism)
- hyperkalemia (due to hypoaldosteronism)
- elevated 17α-hydroxyprogesterone
54
A 15-year-old basketball player complains of pain in his knees. Clinical examination reveals, in addition to tenderness, a swollen and prominent tibial tubercle. X-rays of the knee are unremarkable. What is the most likely diagnosis?
a. Osgood-Schlatter's disease
b. Popliteal cyst
c. Slipped capital femoral epiphysis
d. Legg-Calve-Perthes disease
e. Gonococcal arthritis
Answer: A. Osgood-Schlatter's disease
apophysitis of the tibial tubercle, is inflammation of the patellar ligament at the tibial tuberosity. It is characterized by a painful bump just below the knee that is worse with activity and better with rest. Episodes of pain typically lasts a few months. One or both knees may be affected and flares may reoccur.
Risk factors include overuse, especially sports which involve running or jumping. The underlying mechanism is repeated tension on the growth plate of the upper tibia. Diagnosis is typically based on the symptoms. A plain X-ray may be either normal or show fragmentation in the attachment area.
55
Two infants are born at 36 weeks’ gestation. One infant weighs 2600g at birth and an unrelated second infant weighs 1600g. Which of the following conditions is the second baby more likely to have?
a. congenital malformations
b. low haematocrit
c. hyperglycaemia
d. surfactant deficiency
e. occipito-frontal (head) circumference that is small compared to body weight
Answer: A. Congenital malformations
Intrauterine growth restriction (IUGR) leading to low birth weight for gestational age.
56
A ten-year-old girl presents with recurrent abdominal pain. Of the following symptoms, which is most suggestive of an organic aetiology?
a. Periumbilical location
b. She has lost touch with her friends at school
c. She wakes from sleep with pain at night
d. The pain has persisted intermittently for more than three months
e. The pain is so severe that she cannot attend school
Answer: C. She wakes from sleep with pain at night
All the other signs are suggestive of abdominal pain somatisation (related to psychological causes such as anxiety and stress).
57
A 16 month old boy is not yet walking unaided. He has "bottom shuffled" from the age of 10 months. His vision, hearing and fine motor skills are within normal limits. He has an older brother who had normal milestones. What is the best action to take next?
a. measure his creatine kinase (CK) level
b. refer him for physiotherapy
c. review him in 3 months
d. send blood for chromosomal analysis
e. refer him for assessment by the Child Development Team
Answer: C. review him in 3 months
If he does not walk unaided by 18 months, then there is a delay in reaching this milestone. So review in 3 months, to see if he has met this milestone.
58
A 3-month-old breast-fed girl presents with a 3 day history of increasing breathlessness and difficulty with feeding. On examination she is tachypnoeic / hypoxic with no crepitations or wheeze and no abnormal upper airway signs. Her mother declined antenatal blood tests. What is the most likely underlying cause of this child’s respiratory illness?
```
A. Meningococcal sepsis
B. Bacterial meningitis
C. Respiratory syncitial virus
D. Malaria
E. Tuberculosis
F. HIV/AIDS
G. Chicken pox
H. Mumps
I. Influenza
J. Measles
```
Answer: F. HIV
59
A 6-year-old South African boy, domiciled in the UK, has just returned from visiting his family in Cape Town during July and August. He has a high fever with rigors, is coughing and is complaining of muscular aches.
```
A. Meningococcal sepsis
B. Bacterial meningitis
C. Respiratory syncitial virus
D. Malaria
E. Tuberculosis
F. HIV/AIDS
G. Chicken pox
H. Mumps
I. Influenza
J. Measles
```
Answer: I. Influenza
He has a cough (as well as fever and rigors with muscular pain).
60
A 14-year-old girl presents with a 5 day history of abdominal pain, submandibular and parotid gland enlargement, low grade fever and severe headaches. She has not received any antibiotics. On examination she is photophobic with neck stiffness, but is well perfused. She has no rash. On lumbar puncture the cerebrospinal fluid has normal protein and glucose, 50 WBC/ml (95% lymphocytes) and no RBC.
```
A. Meningococcal sepsis
B. Bacterial meningitis
C. Respiratory syncitial virus
D. Malaria
E. Tuberculosis
F. HIV/AIDS
G. Chicken pox
H. Mumps
I. Influenza
J. Measles
```
Answer: H. Mumps
61
A 6-year-old caucasian boy has a three-week history of fevers, not responding to oral antibiotics in the first and second weeks, increasing drowsiness and now presents with confusion. On examination he has a mildly stiff neck and his Glasgow Coma Score is 12. A lumbar puncture revealed raised protein (2.1 g/l.) in the cerebrospinal fluid, decreased glucose, 710 WBC/ml, no RBC and no organisms seen on Gram stain.
```
A. Meningococcal sepsis
B. Bacterial meningitis
C. Respiratory syncitial virus
D. Malaria
E. Tuberculosis
F. HIV/AIDS
G. Chicken pox
H. Mumps
I. Influenza
J. Measles
```
Answer: E. Tuberculosis
62
A 5-year-old girl who never received MMR was exposed to chicken pox last week at school. She now presents with a 12 hour history of rash and abdominal pain and is reluctant to walk. On examination, she is unwell with cold hands and feet, and a widespread blanching maculopapular rash with spots of different sizes sparing the head and neck.
```
A. Meningococcal sepsis
B. Bacterial meningitis
C. Respiratory syncitial virus
D. Malaria
E. Tuberculosis
F. HIV/AIDS
G. Chicken pox
H. Mumps
I. Influenza
J. Measles
```
Answer: A. Meningococcal sepsis
'Cold hands and feet' >> signs of shock which you wouldn't get in chicken pox.
63
A 5-week-old boy presented with a 5 day history of vomiting after feeds. He has always tended to posset. In the last 24 hours he appears anxious when feeding. The Red Book confirms a weight loss of 200g since he was weighed two weeks ago.
```
A. Cerebral palsy
B. Giardia lamblia infection
C. Acquired immune deficiency (AIDS)
D. Congenital hypothyroidism
E. Iron deficiency anaemia
F. Pyloric stenosis
G. Cystic fibrosis
H. Coeliac disease
I. Gastro-oesophageal reflux
J. Hyperthyroidism
```
Answer:
64
A 10-month-old girl has grown along the 50th centile for weight until around 6 months but is now on the 25th centile. The mother has noticed a distended abdomen and says her stools are more frequent and bulky.
```
A. Cerebral palsy
B. Giardia lamblia infection
C. Acquired immune deficiency (AIDS)
D. Congenital hypothyroidism
E. Iron deficiency anaemia
F. Pyloric stenosis
G. Cystic fibrosis
H. Coeliac disease
I. Gastro-oesophageal reflux
J. Hyperthyroidism
```
Answer:
65
A 7-month-old girl adopted from an orphanage in Nepal is below 0.4th centile for length and weight. The birth history was apparently normal, apart from prolonged jaundice postnatally. She is not yet sitting. On examination she is hypotonic and flaccid. The lower limb reflexes are hard to elicit.
```
A. Cerebral palsy
B. Giardia lamblia infection
C. Acquired immune deficiency (AIDS)
D. Congenital hypothyroidism
E. Iron deficiency anaemia
F. Pyloric stenosis
G. Cystic fibrosis
H. Coeliac disease
I. Gastro-oesophageal reflux
J. Hyperthyroidism
```
Answer:
66
A 5-year-old-girl has recently arrived in the UK from Ukraine. She has a recent history of persistent loose stools associated with growth faltering. She has intermittent bloating and abdominal discomfort but on examination there are no other abnormal findings. Investigations reveal a negative Ttg test.
```
A. Cerebral palsy
B. Giardia lamblia infection
C. Acquired immune deficiency (AIDS)
D. Congenital hypothyroidism
E. Iron deficiency anaemia
F. Pyloric stenosis
G. Cystic fibrosis
H. Coeliac disease
I. Gastro-oesophageal reflux
J. Hyperthyroidism
```
Answer:
67
A 2-year-old boy from a socially disadvantaged family presents with dental caries and frequent upper respiratory tract infections. He is a very fussy eater. On examination he has chronic suppurative otitis media but is avidly sucking from a bottle of cow’s milk. He is continuing to grow along the 25th centile for height and weight.
```
A. Cerebral palsy
B. Giardia lamblia infection
C. Acquired immune deficiency (AIDS)
D. Congenital hypothyroidism
E. Iron deficiency anaemia
F. Pyloric stenosis
G. Cystic fibrosis
H. Coeliac disease
I. Gastro-oesophageal reflux
J. Hyperthyroidism
```
Answer:
68
A 6-week-old breast-fed infant presents with a prolonged history of vomiting after feeds. He is growing along the 0.4th centile for weight. A pyloric mass is not palpable during a test feed. The plasma chloride is 102 mmol/l (NR 96-110).
```
A. Meningitis
B. Galactosaemia
C. Pyloric stenosis
D. Gastro-oesophageal reflux
E. Malrotation
F. Lactose intolerance
G. Encephalitis
H. Food allergy
I. Urinary tract infection
J. Congenital adrenal hyperplasia
```
Answer:
69
A 3-year-old child presents with acute onset abdominal pain for 4 hours. She has had 3 similar episodes in the past, which were all self-resolving. This time the vomiting is bile-stained.
```
A. Meningitis
B. Galactosaemia
C. Pyloric stenosis
D. Gastro-oesophageal reflux
E. Malrotation
F. Lactose intolerance
G. Encephalitis
H. Food allergy
I. Urinary tract infection
J. Congenital adrenal hyperplasia
```
Answer:
70
A 6-month-old breast-fed infant has developed vomiting since early life, which has not resolved with anti-reflux medication. He also has eczema, which is hard to control.
```
A. Meningitis
B. Galactosaemia
C. Pyloric stenosis
D. Gastro-oesophageal reflux
E. Malrotation
F. Lactose intolerance
G. Encephalitis
H. Food allergy
I. Urinary tract infection
J. Congenital adrenal hyperplasia
```
Answer:
71
A 15-month-old girl presents with a 3-day history of intermittent fevers and vomiting and poor feeding. On examination her temperature is 38.6 C but there are no localising signs.
```
A. Meningitis
B. Galactosaemia
C. Pyloric stenosis
D. Gastro-oesophageal reflux
E. Malrotation
F. Lactose intolerance
G. Encephalitis
H. Food allergy
I. Urinary tract infection
J. Congenital adrenal hyperplasia
```
Answer:
72
A 5 year old who has recently returned from Nigeria, has had 3 days of swinging high fevers. His urine is noted to be dark red. On examination he has enlarged liver, but no other abnormal findings. A dipstick is positive for blood +++.
```
A. 24 hour urine protein quantification
B. G6PD level, now and in one month's time
C. Urine M, C & S
D. PT and APTT
E. Blood cultures
F. Von Willebrand’s factor assay
G. Thin and thick film
H. Complement C3 and C4 levels
I. Ultrasound scan of abdomen
J. Urinary schistosomiasis antigen
```
Answer: Thin and thick film
Test for Malaria
73
A 2 year old presents with frank haematuria, some abdominal pain and rigors.
```
A. 24 hour urine protein quantification
B. G6PD level, now and in one month's time
C. Urine M, C & S
D. PT and APTT
E. Blood cultures
F. Von Willebrand’s factor assay
G. Thin and thick film
H. Complement C3 and C4 levels
I. Ultrasound scan of abdomen
J. Urinary schistosomiasis antigen
```
Answer: Urine M, C & S
74
A 6 month old is examined by the GP because of parental concern about constipation over the last 6 weeks. On examination he is well and thriving and has a palpable right sided abdominal mass. He has microscopic haematuria.
```
A. 24 hour urine protein quantification
B. G6PD level, now and in one month's time
C. Urine M, C &S
D. PT and APTT
E. Blood cultures
F. Von Willebrand’s factor assay
G. Thin and thick film
H. Complement C3 and C4 levels
I. Ultrasound scan of abdomen
J. Urinary schistosomiasis antigen
```
Answer: Ultrasound scan of abdomen
75
A 3 year old girl's parents have noted that her urine has gone very dark and she has had puffy eyes. She has been unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. BP 110/65.
```
A. 24 hour urine protein quantification
B. G6PD level, now and in one month's time
C. Urine M, C & S
D. PT and APTT
E. Blood cultures
F. Von Willebrand’s factor assay
G. Thin and thick film
H. Complement C3 and C4 levels
I. Ultrasound scan of abdomen
J. Urinary schistosomiasis antigen
```
Answer: Complement C3 and C4 levels
76
A 6 yr old male, UK born, of Iraqi parents, develops sudden onset very dark red urine, no pain. He has a current viral infection. On exam, slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice.
```
A. 24 hour urine protein quantification
B. G6PD level, now and in one month's time
C. Urine M, C & S
D. PT and APTT
E. Blood cultures
F. Von Willebrand’s factor assay
G. Thin and thick film
H. Complement C3 and C4 levels
I. Ultrasound scan of abdomen
J. Urinary schistosomiasis antigen
```
Answer: B. G6PD level, now and in one month's time
During an acute illness, you can get a false negative result when testing for G6PD, (cells with low G6PD are undergoing haemolytic) so you would need to retest it again.
77
A 2-year-old-boy presents to A&E with a generalised itchy rash, stridor and tingling of his mouth one hour after eating a Snickers bar.
```
A. Procyclidine
B. i.v. Salbutamol
C. Atropine
D. Prednisolone orally
E. Adrenaline (epinephrine)
F. N-acetylcysteine
G. Desferrioxamine
H. No treatment - admit for observation
I. Paraldehyde
J. Aminophylline
```
Answer: E. Adrenaline (epinephrine)
78
A 15 year-old girl was brought to the A&E after disclosing to her teacher at school that she had taken about 40 tablets the evening before. On arrival she was alert but complaining of nausea and right upper quadrant abdominal pain. Bloods taken on arrival at A&E showed a raised ALT and AST and abnormal coagulation studies.
```
A. Procyclidine
B. i.v. Salbutamol
C. Atropine
D. Prednisolone orally
E. Adrenaline (epinephrine)
F. N-acetylcysteine
G. Desferrioxamine
H. No treatment - admit for observation
I. Paraldehyde
J. Aminophylline
```
Answer: F. N-acetylcysteine
Abnormal LFTs and coagulation studies confirmed paracetamol overdose. Antidote for paracetamol overdose is N-acetylcysteine.
79
A 7 year old girl with severe wheeze, a peak expiratory flow rate of 40% and a heart rate of 120 bpm presented to A+E an hour ago. She has been treated with burst therapy using Salbutamol and Ipratroprium Bromide but has had no response.
```
A. Procyclidine
B. i.v. Salbutamol
C. Atropine
D. Prednisolone orally
E. Adrenaline (epinephrine)
F. N-acetylcysteine
G. Desferrioxamine
H. No treatment - admit for observation
I. Paraldehyde
J. Aminophylline
```
Answer: B. iv salbutamol
80
A 3-year-old boy with diarrhoea and vomiting was given metoclopromide and loperamide. He presents to A&E with torticollis and an intermittent convergent squint and upward deviation of both eyes.
```
A. Procyclidine
B. i.v. Salbutamol
C. Atropine
D. Prednisolone orally
E. Adrenaline (epinephrine)
F. N-acetylcysteine
G. Desferrioxamine
H. No treatment - admit for observation
I. Paraldehyde
J. Aminophylline
```
Answer:
81
A 3 year old girl has been brought into A+E after drinking about 100 ml of Ibuprofen (100 mg/5 ml) suspension.
```
A. Procyclidine
B. i.v. Salbutamol
C. Atropine
D. Prednisolone orally
E. Adrenaline (epinephrine)
F. N-acetylcysteine
G. Desferrioxamine
H. No treatment - admit for observation
I. Paraldehyde
J. Aminophylline
```
Answer:
82
A term infant delivered by elective Caesarian section develops tachypnoea, grunting and recession at 30 minutes of age. A CXR shows flattened diaphragms with fluid in the right horizontal fissure and well-aerated lung fields. The infant improves after 4 hours and no longer requires oxygen.
```
A. Meconium aspiration
B. Respiratory distress syndrome
C. Transient tachypnoea of the newborn
D. Bacterial pneumonia
E. Bronchiolitis
F. Primary pulmonary hypertension
G. Asthma
H. Pulmonary interstitial emphysema
I. Pneumothorax
J. Chronic lung disease
```
Answer: C. Transient tachypnoea of the newborn
83
A post-term infant is delivered by emergency Caesarian section for a moderate placental abruption. On examination the infant’s oxygen saturation is 85% in air and has marked respiratory distress. A CXR reveals bilateral patchy infiltrates.
```
A. Meconium aspiration
B. Respiratory distress syndrome
C. Transient tachypnoea of the newborn
D. Bacterial pneumonia
E. Bronchiolitis
F. Primary pulmonary hypertension
G. Asthma
H. Pulmonary interstitial emphysema
I. Pneumothorax
J. Chronic lung disease
```
Answer: A. Meconium aspiration
84
An infant of 31 weeks gestation was born via an emergency section because of foetal decelerations noted on CTG. The birth weight was 1100g and the infant required intubation but was difficult to ventilate. A CXR shows diffuse whiteout of both lungs with an air bronchogram.
```
A. Meconium aspiration
B. Respiratory distress syndrome
C. Transient tachypnoea of the newborn
D. Bacterial pneumonia
E. Bronchiolitis
F. Primary pulmonary hypertension
G. Asthma
H. Pulmonary interstitial emphysema
I. Pneumothorax
J. Chronic lung disease
```
Answer: B. Respiratory distress syndrome
85
A preterm infant is now 7 weeks old. She has been extubated for 10 days but is still oxygen dependent. Her CXR now shows patchy infiltrates with areas of lucency. She is currently on diuretics.
```
A. Meconium aspiration
B. Respiratory distress syndrome
C. Transient tachypnoea of the newborn
D. Bacterial pneumonia
E. Bronchiolitis
F. Primary pulmonary hypertension
G. Asthma
H. Pulmonary interstitial emphysema
I. Pneumothorax
J. Chronic lung disease
```
Answer:
86
A term baby is born normally at 38 weeks gestation at 2.3 kg. Labour was difficult with prolonged rupture of membranes. At 35 minutes of age the infant was noted to have an increasing oxygen requirement with grunting and respiratory distress. On examination he was floppy with an oxygen saturation of 95% in 2L/min of oxygen. A CXR showed reticulonodular shadowing.
```
A. Meconium aspiration
B. Respiratory distress syndrome
C. Transient tachypnoea of the newborn
D. Bacterial pneumonia
E. Bronchiolitis
F. Primary pulmonary hypertension
G. Asthma
H. Pulmonary interstitial emphysema
I. Pneumothorax
J. Chronic lung disease
```
Answer: D. Bacterial pneumonia
Prolonged rupture of membranes (PROM) is a risk factor for neonatal infection.
Note: this baby is small for gestational age (<2.5kg).
87
A 4-month-old boy who is well and thriving has blood test results positive for HIV antibodies. What is the most likely immunological mediator?
```
A. IgA antibodies
B. Eosinophils
C. C1 esterase inhibitor
D. Neutrophils
E. T cells
F. IgG antibodies
G. IgM antibodies
H. IgE antibodies
I. Complement C3
J. Complement C4
```
Answer: F. IgG antibodies
IgG antibodies can cross the placenta
88
A 14-year-old girl is stung by a bee and develops urticaria within 20 minutes of the sting. What is the most likely immunological mediator?
```
A. IgA antibodies
B. Eosinophils
C. C1 esterase inhibitor
D. Neutrophils
E. T cells
F. IgG antibodies
G. IgM antibodies
H. IgE antibodies
I. Complement C3
J. Complement C4
```
Answer: H. IgE antibodies
89
An 18-month-old boy is seen with a history of recurrent oral candidiasis. He developed tetany in the newborn period and had cardiac surgery for a complex heart defect.
```
A. IgA antibodies
B. Eosinophils
C. C1 esterase inhibitor
D. Neutrophils
E. T cells
F. IgG antibodies
G. IgM antibodies
H. IgE antibodies
I. Complement C3
J. Complement C4
```
Answer: E. T cells
90
An 8-year-old girl is seen with second episode of cervical abscess in 3 months. The first culture grew Klebsiella pneumoniae. On this occasion Staphylococcus aureus was cultured. What is the most likely immunological mediator?
```
A. IgA antibodies
B. Eosinophils
C. C1 esterase inhibitor
D. Neutrophils
E. T cells
F. IgG antibodies
G. IgM antibodies
H. IgE antibodies
I. Complement C3
J. Complement C4
```
Answer: D. Neutrophils
Neutrophils >> pus >> abscess
91
A 12-year-old boy has had seven episodes of spontaneous lip swelling and bilateral periorbital oedema in the last 3 years. His father also had similar episodes in childhood. What is the most likely immunological mediator?
```
A. IgA antibodies
B. Eosinophils
C. C1 esterase inhibitor
D. Neutrophils
E. T cells
F. IgG antibodies
G. IgM antibodies
H. IgE antibodies
I. Complement C3
J. Complement C4
```
Answer: C1 esterase inhibitor deficiency
This child has hereditary angioedema. There is a family history (autosomal dominant) and this is characterised by spontaneous angioedema, which is not associated with urticaria or itching that you may get with an allergic reaction.
92
A four year old boy presents with chronic cough, poor weight gain, loose stools and finger clubbing.
```
A. Lobar Pneumonia
B. Obstructive sleep apnea
C. Viral Croup
D. Epiglotittis
E. Chronic asthma
F. Gastro oesophagus reflux
G. Pulmonary TB
H. Tracheo-oesophageal fistula
I. Pertussis
J. Cystic Fibrosis
```
Answer: J. Cystic Fibrosis
93
A five week old girl presents with a history of recurrent coughing and choking during and after feeds. Pregnancy was complicated by polyhydramnios.
```
A. Lobar Pneumonia
B. Obstructive sleep apnea
C. Viral Croup
D. Epiglotittis
E. Chronic asthma
F. Gastro oesophagus reflux
G. Pulmonary TB
H. Tracheo-oesophageal fistula
I. Pertussis
J. Cystic Fibrosis
```
Answer: H. Tracheo-oesophageal fistula
94
An eight year old boy presents with nocturnal cough and early morning tiredness. He has a past history of serous otitis media. On examination, he has noisy breathing, is overweight and is inattentive during consultation.
```
A. Lobar Pneumonia
B. Obstructive sleep apnea
C. Viral Croup
D. Epiglotittis
E. Chronic asthma
F. Gastro oesophagus reflux
G. Pulmonary TB
H. Tracheo-oesophageal fistula
I. Pertussis
J. Cystic Fibrosis
```
Answer: B. Obstructive sleep apnea
This would cause his noisy breathing and his tiredness, resulting in his inattentiveness during the consultation. Being overweight is a risk factor for OSA.
95
A five month old baby boy presents with a three week history of persistent cough with no wheeze. Sometimes he vomits after coughing. He has had two doses of the primary immunisations.
```
A. Lobar Pneumonia
B. Obstructive sleep apnea
C. Viral Croup
D. Epiglotittis
E. Chronic asthma
F. Gastro oesophagus reflux
G. Pulmonary TB
H. Tracheo-oesophageal fistula
I. Pertussis
J. Cystic Fibrosis
```
Answer:
96
A three year old girl presents with a two day history of fever of 37.8ºC and stridor. She has vomited twice prior to being seen in Accident & Emergency.
```
A. Lobar Pneumonia
B. Obstructive sleep apnea
C. Viral Croup
D. Epiglotittis
E. Chronic asthma
F. Gastro oesophagus reflux
G. Pulmonary TB
H. Tracheo-oesophageal fistula
I. Pertussis
J. Cystic Fibrosis
```
Answer:
97
A two year old boy is brought into A+E by ambulance having a generalised tonic-clonic seizure. Over the last 24 hours he has had a slightly runny nose, and his mum has been giving him regular Paracetamol for a low grade fever. Mum also comments that she herself had a cold sore recently. On arrival at A+E he is still having the seizure. What would be the most appropriate immediate action?
```
A. give intravenous phenytoin
B. start ceftriaxone
C. organise an EEG
D. organise neuro-imaging
E. give sodium valproate
F. do a blood gas
G. start aciclovir
H. reassure the parents
I. do a lumbar puncture
J. give buccal midazolam
```
Answer: J. Give buccal midazolam
98
A three month old baby has been admitted to the ward with a history of fever and a two minute generalised, self-terminating tonic-clonic seizure. She has had a lumbar puncture that shows white blood count 850 per mm3 (80% polymorphs), protein 1.2 g/l, glucose 1.7 mmol/l (blood glucose 5.1 mmol/l). What would be the most appropriate immediate action?
```
A. give intravenous phenytoin
B. start ceftriaxone
C. organise an EEG
D. organise neuro-imaging
E. give sodium valproate
F. do a blood gas
G. start aciclovir
H. reassure the parents
I. do a lumbar puncture
J. give buccal midazolam
```
Answer: B. Start (intravenous) ceftriaxone
99
a 3 year old girl is brought into A+E by her parents. She is usually fit and well. Her mum says that half an hour ago she ran into a table, and banged her head on the corner. She went pale and fell to the floor, and then had two or three twitching movements before starting to cry. She is now back to her normal self and is running round A+E. Clinical examination is normal. What is the most appropriate action?
```
A. give intravenous phenytoin
B. start ceftriaxone
C. organise an EEG
D. organise neuro-imaging
E. give sodium valproate
F. do a blood gas
G. start aciclovir
H. reassure the parents
I. do a lumbar puncture
J. give buccal midazolam
```
Answer: H. Reassure the parents
100
A seven year old girl who has previously been fit and well presents in A+E. Over the last few weeks her school teacher has commented that she has not been doing as well as normal. She has also been complaining of headaches. Today at school she had a left-sided seizure that lasted approximately three minutes.
```
A. give intravenous phenytoin
B. start ceftriaxone
C. organise an EEG
D. organise neuro-imaging
E. give sodium valproate
F. do a blood gas
G. start aciclovir
H. reassure the parents
I. do a lumbar puncture
J. give buccal midazolam
```
Answer: D. Organise neuro-imaging
101
A four year old known epileptic is admitted to the ward for observation as he has been vomiting. He is on regular sodium valproate. You are called urgently to the ward to see him. An hour ago he had his regular sodium valproate but vomited soon afterwards. He is now having a seizure and has been fitting for about six minutes. A fingerprick blood glucose is 4.7 mmol/l. What is the most appropriate initial action?
```
A. give intravenous phenytoin
B. start ceftriaxone
C. organise an EEG
D. organise neuro-imaging
E. give sodium valproate
F. do a blood gas
G. start aciclovir
H. reassure the parents
I. do a lumbar puncture
J. give buccal midazolam
```
Answer: J. Give buccal midazolam
102
A term neonate is cyanotic and tachypnoeic at birth. There is a soft pan systolic murmur at the lower sternal edge. An antenatal scan had shown a VSD, overriding aorta and infandibular stenosis.
```
A. rheumatic fever
B. infective endocarditis
C. interruption of the aortic arch
D. aortic coarctation
E. tetralogy of Fallot
F. ASD
G. PDA
H. innocent murmur
I. VSD
J. transposition of the great arteries
```
Answer: E. Tetralogy of Fallot
103
A one week old term baby presents to A+E. He is tachypnoeic, tachycardic and has an enlarged liver. Feeding and weight gain have been poor. On examination the infact is acyanotic with a quiet systolic murmur best heard at the upper left sternal edge. The second heart sound is widely split, the split not varying with respiration.
```
A. rheumatic fever
B. infective endocarditis
C. interruption of the aortic arch
D. aortic coarctation
E. tetralogy of Fallot
F. ASD
G. PDA
H. innocent murmur
I. VSD
J. transposition of the great arteries
```
Answer:
104
A ten year old girl is seen in the endocrine clinic for short stature. On examination she is noted to have widely spaced nipples, a webbed neck, cubitus valgus and an ejection systolic murmur at the upper sternal edge.
```
A. rheumatic fever
B. infective endocarditis
C. interruption of the aortic arch
D. aortic coarctation
E. tetralogy of Fallot
F. ASD
G. PDA
H. innocent murmur
I. VSD
J. transposition of the great arteries
```
Answer:
She has Turner syndrome (45XO)
105
A two year old ex-preterm child, who recently arrived from Bhutan, has been admitted with pneumonia. He has had three episodes of lower respiratory tract infection in the past year. On examination a continuous murmur is heard beneath his left clavicle.
```
A. rheumatic fever
B. infective endocarditis
C. interruption of the aortic arch
D. aortic coarctation
E. tetralogy of Fallot
F. ASD
G. PDA
H. innocent murmur
I. VSD
J. transposition of the great arteries
```
Answer:
106
A six year old child with a known VSD has had episodes of fever following a dental procedure. On examination she is febrile with a loud pan systolic murmur and a thrill. Her spleen tip is palpable. Her urine dipstick reveals haematuria.
```
A. rheumatic fever
B. infective endocarditis
C. interruption of the aortic arch
D. aortic coarctation
E. tetralogy of Fallot
F. ASD
G. PDA
H. innocent murmur
I. VSD
J. transposition of the great arteries
```
Answer:
