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Flashcards in Paediatrics Deck (20):
1

A 14-year-old girl comes to see you as she has not had her periods yet. You note that her breasts are stage II and her nipples are set lateral to the mid-clavicular line. She has no pubic hair. Her weight is on the 50th centile but height is on the 9th centile. Her parents are both of average height. What is the most likely diagnosis?

a) Turner's syndrome
b) Polycystic ovarian syndrome
c) Anorexia
d) Constitutional delay
e) Underlying undiagnosed chronic illness

A

Turner's syndrome (45, XO) often goes undiagnosed in women. It is associated with neonatal hand and foot lymphoedema, webbing of the neck, short stature, wide-spaced nipples, congenital heart defects (co-arctation of the aorta), delayed or absent puberty, and infertility.

PCOS is unlikely as she hasn't started puberty.

Constitutional delay is more common in males and is the isolated finding of delayed skeletal growth (e.g. height).

2

A 2-year-old child is referred to you by the GP because he has not started walking. His mother says that he can stand but cries to be picked up or sits down shortly. His older sister was walking by 14 months. You note that he is talking well with short two to three word phrases. He is able to build a tower of six blocks. What is your management plan?

a) Advise mum to work harder at giving him independence and follow up in 4 months
b) Request blood tests including a creatinine kinase
c) Refer for physiotherapy
d) Reassure and discharge as his development is normal
e) Refer to orthopaedics

B

At 2 years old, this is delay in gross motor skills without other delays. Muscular dystrophy is suspected. This usually presents with clumsiness, and a waddling gait.

If CK is raised, a muscle biopsy can confirm the diagnosis.

Diagnosis should be confirmed before referral to PT. Referral to orthopaedics would be appropriate in developmental dysplasia of the hip, but this should be confirmed first with USS.

3

You see a boy in outpatients whose parents are concerned he is not talking yet. You do a developmental assessment and find he is walking well and able to build a tower of three blocks. He will scribble but does not copy your circle. He is able to identify his nose, mouth, eyes, and ears, as well as point to mummy and daddy. You do not hear him say anything but his parents say he will say a few single words at home such as mummy, daddy, cup, and cat. He is a happy, alert child. Parents report him to be starting to feed himself with a spoon and they have just started potty training but he is still in nappies. What is the child's most likely age?

a) 12 months
b) 15 months
c) 18 months
d) 2 years
e) 2.5 years

C

This child is scoring 18 months old in all areas.

Gross motor: steady walking

Fine motor: scribbling

Speech and language: identifies four body parts, at least 10 words

Social and behavioural: feeds himself with a spoon, starting to potty train

4

A one-and-a-half-year-old Caucasian child is referred to paediatrics for failure to thrive. On examination, he is a clean, well-dressed child who is quite quiet and withdrawn. He is pale and looks thin with wasted buttocks. His examination is otherwise unremarkable.
His growth chart shows good growth along the 50th centile until 6 months followed by weight down to the 9th, height down to the 25th and head circumference now starting to falter at 1.5 years. What is the most likely cause of this child's growth failure?

a) Coeliac disease
b) Neglect
c) Constitutional delay
d) Normal child
e) Beta thalassaemia

A

Coeliac disease is most likely as growth was normal until the age of weaning, 6 months. Wasted buttocks are also a classic sign of coeliac disease, as is his anaemia and malnutrition.

Neglect would require MDT input to diagnose, and physical illness should always be ruled out.

Constitutional delay is common in males, and is the isolated finding of skeletal growth delay (e.g. height).

Dropping centiles is never normal.

Beta thalassaemia is uncommon in Caucasians, and also should present around 6 months of age. Without transfusions, he'd unlikely survive to one-and-a-half years.

5

A 12-year-old boy presents to his GP with left-sided unilateral breast development at stage III. He is very upset as he is being bullied at school. His mother is worried as her friend's sister has just been diagnosed with breast cancer and wants to know if he could have breast cancer. What is the management?

a) Refer for a breast ultrasound
b) Test sex hormone levels
c) Test alpha foetoprotein
d) Reassure and explain that this is a normal part of puberty; it will resolve but the other breast may enlarge transiently as well
e) Do a fine needle aspirate on his left breast

D

Normal puberty in boys starts from 9 to 13 years. Testicular volume increases above 4mL, followed by penis enlargement, pubic hair growth, and lastly the growth spurt. Transient gynaecomastia is common, and doesn't require treatment unless it doesn't resolve.

6

You see a baby for the first baby check at 6 weeks. Mum reports no problems and he is feeding well. On examination you are unable to palpate the testicles on either side and do not feel any lumps in the groin area. He has a normal penis with no hypospadias and the anus is patent. He is otherwise a normal baby on examination. What is the most important diagnosis to rule out?

a) Klinefelter's syndrome
b) Congenital adrenal hyperplasia
c) Undescended testicles
d) Virilised female infant
e) Testicular cancer

B

CAH is most commonly due to 21-hydroxylase deficiency. They often have ambiguous genitalia or bilateral undescended testes. They are at risk of a salt-losing adrenal crisis around 1 to 3 weeks of age, with vomiting, weight loss, and floppiness. If suspected, U and E, chromosomal analysis, and pelvic USS should be done.

Klinefelter's syndrome (47XXY) typically presents as tall stature, delayed puberty, and mild learning difficulties; not undescended testes.

Undescended testicles are important to identify, but are only worrying if undescended by 2 years of age, as this increases risk of testicular cancer.

This could be a virilised female infant, but this would be secondary to another cause (e.g. CAH).

7

You see an 8-year-old boy in A and E who fell off his bike 3 days ago and scraped his left calf. The cuts are now angry, red, and painful. You note he is a big boy and plot his growth: his weight is on the 99th centile and his height is on the 75th centile. You note mild gynaecomastia and stretch marks on his abdomen, which are normal skin colour. His past medical history is unremarkable except for mild asthma. What is the most likely cause of his large size?

a) Cushing's syndrome secondary to pituitary adenoma
b) Cushing's syndrome secondary to becotide inhaler use
c) Obesity
d) His size is within the normal range and is a variant of normal
e) Liver failure

C

Advice concerning diet and exercise should be given. Children should eat a normal healthy diet (not restricted), and exercise regularly, to decrease weight as they grow.

Cushing's syndrome would usually present with growth failure, but this boy is above average height, which is more in keeping with obesity.

8

A 16-year-old boy is brough to the GP by his parents. They are concerned he is the shortest boy in his class. He is otherwise well. His height and weight are on the 9th centile. His father plots the 75th centile and his mother on the 50th centile for adult height. On examination, his testicular volume is 8mL, he has some fine pubic and axillary hair. The rest of the physical examination is normal. On further questioning, you elicit from his father that he was a late bloomer and did not reach his full height until he was at university. What is the most likely cause of the boy's short stature?

a) The 9th centile is a normal height and weight so there is nothing wrong with him
b) Growth hormone deficiency
c) Constitutional delay of growth and puberty
d) Underlying chronic illness should be sought
e) Anorexia

C

Constitutional delay is more common in males, runs in the family, and often presents with delayed puberty and growth spurt. It is an isolated skeletal growth delay.

This is not normal height for him given his parents' height centiles.

This boy has started puberty, and is progressing normally, so it is unlikely to be growth hormone deficiency

9

A mother comes to see you with her 2-year-old daughter, Stacey, out of frustration that her daughter is so ill behaved. She does not know how to make her listen and is worried that she is going to get hurt. Yesterday she ran ahead and did not stop when her mother called to her. She ran into the street and was hit by a cyclist, but fortunately he was OK and Stacey had only a few cuts and scrapes and seems alright. On questioning, you hear other stories of a naughty child. She is active and eats well, feeding herself a lot now, but her mother does say she gets frequent coughs and colds. Her mother says that Stacey only says about 5-10 words and only she can understand what Stacey says. What is the best next management?

a) Ask the health visitor to visit mum for parenting advice and support
b) Order blood tests for full blood count to check for leukaemia as she has recurrent coughs and colds
c) Give Stacey a tetanus shot to cover her after her fall the day before
d) Refer for a hearing test
e) Tell Stacey that she needs to listen to her mother and not have any more accidents

D

Stacey has isolated speech delay. This, combined with her poor attentiveness, suggests hearing difficulty.

Commonly, this is because of glue ear, which is supported by her recurrent coughs and colds. These coughs and colds are not worrying, as they are not severe, and most children have on average 8 illnesses a year, so she doesn't need testing for immune deficiencies.

10

An older mother books in to see you after attending the health visitor for a weight check at 2 months for her first child. She and her husband have had a hard time coming to terms with their daughter's diagnosis of Down's syndrome. She is relieved that the appointment with the cardiologists went well and the heart is normal, however they have a lot of trouble getting her to take the whole bottle. She was slow to regain her birth weight, and, looking at the plotted weight yesterday, she is not growing along her birth centile. The mother is worried she is not doing a good enough job She is not vomiting except for small possets after she feeds, is passing urine, and opening her bowels. The red book growth chart shows the weight to be falling off centiles. What is the most appropriate management?

a) Contact the cardiologists in light of the poor feeding and slow weight gain for a second opinion, because babies with Down's syndrome are at high risk of heart problems and they may have missed it
b) Refer to the dietician for nutritional support
c) Replace the growth chart in their red book with a Down's syndrome growth chart, reassure mum by re-plotting her growth and explain she is normal but arrange to review again
d) Tell the mother to try a different milk and come back in 2 weeks
e) Advise the mother to change to a faster flow teat for their bottles so that she takes her feed better

C

Children with Down's syndrome have different growth patterns to other children.

Even if there was a lack of weight gain, it's unlikely that this is to do with cardiology if they've given the all clear.

Dietician advice is warranted if there is still failure to thrive on the Down's syndrome growth charts, but should be given with appropriate investigations for a cause.

Different milks are unlikely to help as there doesn't appear to be an intolerance.

A faster teat could make things worse, as Down's syndrome is associated with hypotonia and swallowing difficulties.

11

Which child should be moved to the resuscitation area for urgent management in A and E?

a) A miserable 2-year-old with fever and vomiting; temperature 38.5C, HR 150bpm, RR 42/m, CRT 2 - 3s; alert and clinging onto his father; just been given paracetamol and started on a fluid challenge with oral rehydration salts 5m ago by the triage nurse
b) A quiet 4-year-old brought in with an asthma attack, sitting upright with a RR 25/m, HR 1662bpm, CRT 3s, subcostal recessions, and poor air entry on chest auscultation following a salbutamol nebuliser
c) An 8-year-old, known diabetic, brought in vomiting wh her glucose reader saying HI. She is able to tell you her history and has a HR 120bpm, RR 25/m, CRT <2s
d) An alert 3-year-old who has had a cough and cold for the past 3 days which is keeping him up at night, and mum noticed a rash on his neck and face which did not disappear when she pressed a glass tumbler against it. His temperature is 37.8C, HR 110bpm, RR 30/m, CRT <2s.
e) A 15-year-old, known to social services for a family history of domestic abuse, brought into A and E by her best friend after she admitted taking 20 paracetamol tablets 4 hours ago. She is alert but does not make eye contact, her HR is 98bpm, RR 20/m, CRT <2s

B

12

A 4-year-old child has been losing weight recently and has been vomiting for the past 24 hours, unable to eat anything. His mother has brought him into A and E out of concern as he seems confused. The triage nurse has taken him to the resuscitation room and asked for your help. On examination he is drowsy, has a HR 150bpm, RR 60/m, CRT 5s. He has subcostal recessions and good air entry bilaterally with no added sounds. He moans when you examine his abdomen, but there are no masses. You put in a cannula and take bloods. The venous blood gas shows:

pH 7.12
PCO2 2.3kPa
PO2 6.7kPa
HCO3 15.3 mmol/L
BE -8.6
Glucose 32.4mmol/L

What is the most likely diagnosis and what is the first management step?

a) Diabetic ketoacidosis, start an insulin infusion
b) Diabetic ketoacidosis, give a fluid bolus
c) Pneumonia, start IV co-amoxiclav
d) Ruptured appendix, give a fluid bolus and book the emergency operating theatre
e) Gastroenteritis with severe dehydration, give a fluid bolus

B

13

An 8-year-old known asthmatic is brought into A and E by ambulance as a 'blue call'. He has been unwell with an upper respiratory tract infection for the past 2 days. For the past 24h, his parents have given him 10 puffs of salbutamol every 4 hours, his last dose being 90m ago. The ambulance staff have given him a nebuliser, but he remains agitated with a HR 155bpm, RR 44/m, and sub- and intercostal recessions. On auscultation, there is little air movement heard bilaterally. Saturations in air are 85%. He is started on 'back to back' nebulisers with high flow oxygen. How sever is his asthma exacerbation, and what other bedside test would support this?

a) Moderate, venous blood pH 4.4, gas PCO2 3.1kPa
b) Severe, peak flow <33% expected
c) Severe, venous blood pH 4.4, gas PCO2 3.1kPa
d) Life-threatening, peak flow <33% expected
e) Life-threatening, venous blood pH 4.4, gas PCO2 3.1kPa

D

14

The A and E triage nurse asks you to look at a 3-year-old child with a short history of waking up this morning unwell with a cough and fever. She looks unwell, HR 165bpm, RR 56/m, sats 96%, temperature 39.3C, CRT 4s. She has a mild headache but no photophobia or neck stiffness and you notice a faint macular rash on her torso and wonder if one spot is non-blanching. You ask the triage nurse to move her to the resuscitation area and call your senior to review her. Fifteen minutes later your senior arrives and the spot you saw on the abdomen is now non-blanching and there is another spot on her knee. What are the three most important things to give her immediately?

a) High flow oxygen, IV fluid bolus, IV ceftriaxone
b) IV fluid bolus, IV ceftriaxone, IV methylprednisolone
c) High flow oxygen, IV ceftriaxone, IV fresh frozen plasma
d) IV fluid bolus, IV ceftriaxone, IV fresh frozen plasma
e) High flow oxygen, IV ceftriaxone, IV methylprednisolone

B

15

A 9-year-old boy is brought in by ambulance having been hit by a car while playing football in the street. You have been assigned to do the primary survey in resus when the ambulance arrives The patient is receiving oxygen, crying for his mummy and holding his right arm, but able to move over from the stretcher to the bed when asked. Which is the correct examination procedure?

a) The trachea is deviated to the right. On auscultation you hear decreased air entry on the left. Percussion note is hyper-resonant on the left. He is tachycardic and his heart sounds are muffled, heard loudest at the right lower sternal edge. You ask for a left-sided thoracocentesis.
b) You introduce yourself and tell him that you will be gently but need to check that he is okay. You see his left wrist is deformed and swollen, and check the fingers, which are cool, and note the CRT is 4s. He is able to feel you touching him and moans when you examine the wrist. You call for an x-ray to assess the probable fracture in the wrist.
c) You introduce yourself and tell him that you will be gentle but need to check if he is okay. You listen for equal air entry and think there is decreased air entry on the left, but there is air entry on the right. He is tachypnoeic and has a pulse which is tachycardic. His CRT is 4s. You expose his abdomen and notice bruising and grazes to the left side. He moans as you palpate the left upper quadrant and has guarding. You ask for an IV cannula or IO needle and a 20m/kg fluid bolus while organising an urgent CT chest and abdomen.
d) You introduce yourself and tell him that you will be gentle but need to check if he is okay. He is tachypnoeic. The trachea is deviated to the right. On auscultation you hear decreased air entry on the left. Percussion note is hyper-resonant on the left. He is tachycardic and his heart sounds are muffled, heard loudest at the right lower sternal edge. You ask for a left-sided thoracocentesis.
e) You listen for equal air entry and think there is decreased air entry on the left but there is air entry on the right. He is tachypnoeic and has a pulse which is tachycardic. His CRT is 4s. You expose his abdomen and notice bruising and grazes to the left side. he moans as you palpate in the left upper quadrant and has guarding. You ask for an IV cannula or IO needle and a 20mL/kg fluid bolus while organising an urgent CT chest and abdomen.

C

16

A 6-year-old boy with a history of anaphylaxis to peanuts is brought in by ambulance unconscious. He was attending a children's birthday party. His mother says there was a bowl full of candy and he may have eaten a Snickers bar but she is not sure and she did not have his EpiPen with her. His face and lips are swollen and erythematous. He is still breathing, but weakly, and there is wheeze. His pulse is tachycardic and thready. Which type of shock is this?

a) Hypovolaemic
b) Distributive
c) Septic
d) Cardiac
e) Obstructive

E

17

A 13-month-old is brought in having had a blue floppy episode at home lasting 1 minute. While you are taking a history from the mother, you notice the baby has gone blue again and seems to be unconscious in her arms. You call for help and place the baby on the examination table. There is no obvious work of breathing. The nurses bring the crash trolley and give you a bag valve mask, which they are connecting to the oxygen. You give two inflation breaths but do not see the chest rise. You reposition the airway and this time the breaths go in. You feel for a pulse and there is none. When asked to do CPR, the nurse asks for direction on how many breaths and compressions you both need to do.

a) Two inflation breaths per 30 compressions
b) Two inflation breaths per 15 compressions
c) Continuous inflation breaths about 10-12 per minute and compressions 100-120 per minute
d) One inflation breath per five compressions
e) Two inflation breaths per five compressions

B

18

A 10-year-old child is brought in by abulance with seizure activity. His mother reports it starting 30 minutes ago in his right arm and quickly became generalised tonic clonic jerking. She have him his buccal midazolam after the first 5 minutes and called an ambulance when he did not respond after another 5 minutes. The ambulance crew gave him rectal diazepam on arrival at 15 minutes into the seizure. He is receiving high flow oxygen via face mask and continues to convulse. The mother tells you that he was weaned from his long-term seizure medication, phenytoin, 2 weeks ago and that he has had a cold for the past 2 days. What is the next step in management?

a) Gain IV or IO access and administer lorazepam
b) Gain IV or IO access and administer ceftriaxone
c) Repeat the rectal diazepam
d) Gain IV or IO access and start a phenytoin infusion
e) Gain IV or IO access and start a phenobarbital infusion

A

19

A 3-year-old boy is brought in by ambulance fitting. You are assigned to get the history from the father. Harry is normally fit and well with no significant past medical history or allergies. He is up to date with his immunisations and has been growing and developing normally. His behaviour has been difficult for the past 2 weeks since the birth of his little sister. Mum has been unwell as she developed HELLP syndrome and was in hospital for a week following the delivery. Yesterday, he was quite unwell with a tummy bug, vomiting and had black diarrhoea. That evening they found a mess he had made in the bathroom with all of his mum's things strewn over the floor including her tablets from the hospital. By hat time, Harry was getting better so they did not think anything of it. Today he has been acting strangely and has been difficult to understand. He then became lethargic at about 4pm and started fitting 15m ago. What is the most likely diagnosis?

a) Paracetamol overdose
b) Aspirin overdose
c) Tricyclic antidepressant overdose
d) Bleach intoxication
e) Iron overdose

C

20

A 6-year-old boy with a history of asthma and eczema is brought in to A and E from a local restaurant. He is on high flow facial oxygen with significant facial oedema and generalised erythema. On auscultation there is widespread wheeze for which the ambulance crew gave a salbutamol nebuliser. What is the next step in management?

a) Insert an IV line and give 10mg slow IV antihistamine
b) Insert an IV line and give 100mg slow IV hydrocortisone
c) Insert an IV line and give 200ug of 1:10,000 IV adrenaline
d) Give IM 1:1000 adrenaline, 250ug
e) Repeat the salbutamol nebuliser and call for an anaesthetist for intubation

D