Paediatrics Year 5 Flashcards
At her 6-hour neonatal check, a newborn infant is noted to have a flat, pink lesion on the glabella. The registrar notices that it turns darker when she cries. What is this lesion likely to be? A. Capillary hemangioma B. Nevus sebaceus C. Salmon patch D. Café-au-lait spot E. Port wine stain
Salmon patch – this is a common finding in neonates, often appearing as a flat pink or salmon- colored lesion on the eyelids, the nuchal area and the glabella. It disappears with age, although those located on the nuchal area tend to persist into adulthood. Capillary hemangioma – also known as a strawberry hemangioma are bright red. Starting off as macules that are slightly raised, they tend to grow rapidly during the first year of life. They represent a small aterio-venous malformation and can appear anywhere on the body. Treatment is not necessary as they regress spontaneously after the first year. Nevus sebaceus – (of Jadessohn) are located on the scalp. They are plaques which are hairless, yellow and resemble warts. As they have the potential to become malignant, they should be removed before adolescence. Café-au-lait spot – these are flat lesions like the salmon patch, however, as the name indicated, they are tan or light brown in color. They can occur anywhere on the body, varying in size and shape. They are sharply demarcated from the underlying skin and are often associated with neurocutaneous disorders such as neurofibromatosis. Port wine stain – this needs to be distinguished from the other more benign birthmarks. Like café- au-lait spots, it is associated with a neurological disorder – specifically Sturge-Weber syndrome. The port wine stain is unilateral, consists of dermal capillaries in the distribution of the ophthalmic division of the Trigeminal nerve (CNV1 – eyelids and upper face).
At his 6-hour neonatal check, an infant born by spontaneous vaginal delivery is noted to have a large swelling on the back of his head. It only involves the scalp and crosses the suture lines. What is this lesion likely to be? A. Cephalohematoma B. Caput succedaneum C. Subcutaneous fat necrosis D. Meningocele E. Craniosynostosis
Caput succedaneum – this is another birth injury that is due to bleeding into the scalp of the presenting part of the head. As it involves the scalp overlying the skull bones it does cross suture lines. They resolve rapidly over several days. Cephalohematoma – this is an example of a birth injury i.e. an injury occurring during labor and delivery. This particular example is a subperiosteal bleed, which doesn’t cross suture lines (Figure 1). This is due to the fact that it is limited to the bone. They can increase in size over the first few days of life and are a common cause of neonatal jaundice. They tend to persist for several months. Subcutaneous fat necrosis – this type of injury tends to occur with instrumental delivery such as forceps or Ventouse. They are firm, rubbery nodules, which can be located anywhere on the body, tending to occur on the back and lower extremities. Meningocele – this is a neural tube defect, spina bifida cystica, where the vertebral arches fail to form and a cyst containing CSF and the meninges protrudes. This condition is associated with low folic acid during pregnancy. Craniosynostosis – these are a series of conditions associated with a variety of autosomal dominant and recessive disorders where the suture lines fuse prior to cessation of brain and head growth. This results in a constellation of developmental delay and characteristic cranio-facial morphology. Craniosynostoses usually occur in association with syndromes, such as Apert and Crouzon syndrome.
A 4 week old baby presents with jaundice since the 3rd day of life. He was born at term and was of normal birth weight. He is breast fed but is not feeding well and is falling off the centiles. He has a history of bruises and mum noticed a change in the color of his stool. His mother mentions she is blood group O. What would be the most diagnostic investigation? A. Coomb’s Test B. Dipstick Urine C. Liver Function Tests D. TBIDA – radionucleotide scan E. Ultrasound Scan
Then answer is D – Infants become clinically jaundice when the bilirubin level climbs to 80 to 120μmol/L. There are three main reasons why more than 60% of infants become clinically jaundiced: (1) decreased life-span of fetal red blood cells (60 to 70 days) compared to adult red blood cells (120 days) (2) high red blood cell concentration in the neonate compared to the adult results in the physiological release of hemoglobin from the breakdown of the these cells and (3) hepatic bilirubin metabolism is immature. There are two reasons why neonatal jaundice is worrying: (1) may indicate an underlying pathology (e.g. hemolytic anemia, infection or metabolic disease) and (2) unconjugated hyperbilirubinemia put the infant at risk of kernicterus. Prolonged jaundice is that which extends beyond 3 weeks of age in a neonate, so this baby has prolonged jaundice. This is usually due to an unconjugated hyperbilirubinaemia but can also be due to liver disease – conjugated hyperbilirubinaemia. Pale stools, dark urine, bleeding/bruising and FTT suggest conjugated hyperbilirubinaemia so we need to check for liver disease. LFTs are not actually very useful for this so the best option here is TBIDA which would show liver uptake and competency of the biliary tree.
A 4 week old baby is brought in by his mother, with worsening jaundice since one week of age. He is exclusively breast-fed and growing well. Which investigation should be carried out first? A. Conjugated and unconjugated bilirubin B. Coomb’s test C. Liver Function Tests D. Septic Screen E. Thyroid stimulating hormone levels
The answer is A – conjugated and unconjugated bilirubin. This will distinguish between a hepatic cause (conjugated) vs. a systemic cause (unconjugated) such as an infection or hemolytic process. LFTs are of little diagnostic value in this case.
A baby is born at term by normal vaginal delivery. While being breast fed, the mother notices at 6 hours of age he is looking jaundiced. He was immediately placed on phototherapy. While receiving treatment for jaundice, which of the following investigations can help identify the most likely cause? A. Blood culture B. Blood film C. Coomb’s test D. G6PD level E. Urinalysis for reducing substances
The answer is C – Coomb’s Test. This child is presenting with jaundice at
The midwife bleeps you as the FY1 doctor on-call, as she is concerned about a jittery baby. The child was born at 36 weeks via emergency Caesarean section and weight 1.8 kg. He appears to be very sensitive to external stimuli when examined and appears dysmorphic with a poorly developed philtrum above his upper lip. What is the most likely diagnosis? A. Cerebral Infection B. Down’s Syndrome C. Foetal Alcohol Syndrome D. Hypocalcaemia E. Neonatal opiate withdrawal
The answer is C – Foetal Alcohol Syndrome Common causes of a ‘jittery’ neonate are: 1. Hypoglycaemia 2. Hypocalcaemia 3. Withdrawal following maternal drug and/or alcohol abuse. Of these, only foetal alcohol syndrome is associated with dysmorphism (saddle-shaped nose, maxillary hypoplasia, absent philtrum and thin upper lip). They are also growth restricted and may have cardiac defects and developmental delay.
A 15 year old boy presents to the endocrine clinic with persistent gynaecomastia. On examination he is on the 99.6th centile for height, has appropriate pubic hair growth and small testes. His parents are also concerned that he has always been below average at school. What is the most likely chromosomal abnormality? A. 45X B. 47XXY C. Fragile X D. Trisomy 13 E. Trisomy 18
The answer is B – 47XXY 47XXY (Klienfelter’s Syndrome) is characterised by micro-orchidism (small testes), tall stature, behavioural problems, gynaecomastia and speech delay. 45X = Turners is a female phenotype. Trisomy 13 (Patau’s) & 18 (Edward’s) = most die
You are the SHO on call. A two year old boy is brought in. He has been vomiting since yesterday. On examination he has dry mucous membranes; he is tachycardic with sunken eyes, with a reduced skin turgor and prolonged capillary refill time and is lethargic. You give him 20 ml/kg Bolus of 0.9% saline and he improves slightly. Assuming no further vomiting, what is his 24 hour fluid requirement if he weighs 12 kg? A. 240 ml B. 1100 ml C. 1200 ml D. 2060 ml E. 2300 ml
The answer is D – 2060ml Calculating fluid requirement: Total fluid requirement is maintenance + deficit + ongoing losses Fluid deficit in ml = % dehydration x weight (kg) x 10 Maintenance fluid = 1st 10kg: 100ml/kg 2nd 10kg: 50ml/kg >20kg: 20ml/kg First, assess the level of dehydration which in this case is severe (10%). Moderate is classified as 5% dehydration where the parameters above are not as severe and the child may be irritable but not lethargic. You can now work out the deficit: 10% x 12kg x 10 = 1200 The maintenance is: (100ml x 10kg) + (50ml x 2kg) = 1100 Total: 1200 + 1100 = 2300ml/24hrs Then minus the 20ml/kg you have already given = 240ml ….. 2300-240 = 2060mls
A 14 year old boy previously growing normally along the 2nd centile for height is now below the 0.4th centile. He has been complaining of peri-umbilical abdominal pain for the last 6 months on and off. What would be your next step? A. Full Blood Count (FBC) B. Growth Hormone Provocation Test C. Mid-parental height calculation D. Sweat test E. X-ray wrist and hands for bone age
The answer is C – mid-parental height calculation 1st step is to assess whether child is growing within his normal range: measure height and weight. Weight is not an option in this choice of answers so sensible to focus on height. The nest best step would be to work out MPH (see red book for how to do this). Then see if 2nd or 0.4th centile lie within the MPH range. This will help to work out whether he is reaching his full potential or not. If he isn’t we can then think about more investigations.
An Asian mother has brought her 8 week old son to you as her GP, for a routine child health check. He was born at 36 weeks gestation. He is exclusively breast fed and is thriving. Of the following options, which oral supplements would you advise for the mother? A. Calcium B. Folic Acid C. Iron D. Vitamin B12 E. Vitamin D
The answer is E – Vitamin D Without any further information apart from ethnicity, mum is most at risk of vitamin D deficiency due to darker skin pigmentation. The amount of vitamin D in breast milk is directly related to maternal levels, therefore increasing the risk of vitamin D deficiency in the baby if mum is not supplemented. (Babies of this age would rarely be exposed to levels of sunlight in Britain adequate enough to synthesise their own vitamin D).
A 15-year-old boy attends an outpatient paediatric clinic complaining of short stature. He has noticed over the past two years that he has become increasingly shorter than his peers. On examination he looks well. He has pre-pubertal sized testes, and sparse pubic hair. His height has fallen from the 25th to 9th centile. His father reports he was ‘a late developer’. What is the most likely cause of this boy’s short stature? A. Acquired hypothyroidism B. Coeliac Disease C. Constitutional Delay of Growth and Puberty D. Cystic Fibrosis E. Gonadotrophin Deficiency
Correct Answer: B: Constitutional Delay of Growth and Puberty In this case, there is evidence of delayed puberty, with consequent delayed pubertal growth spurt. Constitutional delay of growth and puberty is the commonest cause of delayed puberty, and there is often history of delayed puberty in the boy’s father. There was no evidence of systemic disease to suggest either celiac disease or cystic fibrosis as a cause. Isolated gonadotrophin deficiency is rare, occurring in 1 in 10,000 males, and is therefore unlikely.
A 6 six year old boy presented to the developmental clinic with difficulties fitting into school. Mother states that he has trouble sustaining prolonged conversation. He appears clumsy and has occasional tantrums but he knows the capital of every European country. Of the following options, which member of the multidisciplinary team is LEAST likely to be involved in his care? A. Community Paediatrician B. Neurologist C. Occupational Therapist D. Psychologist E. Special educational needs coordinator
Correct Answer: B: Neurologist Asperger’s syndrome is characterised by: 1. Normal intelligence 2. No delay in language development 3.Impaired social and communication skills and a narrow range of obsessional interests Many members of the multidisciplinary team are involved to help manage this disorder and improve a child’s functioning. Doctors involved primarily include neurodevelopmental and community paediatricians and GPs. There is no organic neurological problem in Asperger’s syndrome; therefore a neurologist is least likely to be involved in this child’s care.
You are the paediatric registrar working in a general out-patient clinic. You see a four year old boy whose parents are concerned that he has difficulty interacting with the neighbours’ children. The teachers in school reprimand him for being cheeky as he often repeats what they say. You notice that he has poor eye contact. What is the next most appropriate step in the management of this patient? A. Initiate Ritalin Treatment B. Reassure symptoms will resolve of their own accord C. Refer to Child Development Team for assessment D. Send the patient to child psychiatry team for assessment E. Send the patient to paediatric neurology
Correct Answer: C: Refer to Child Development Team for assessment. The child being described has features of autistic spectrum disorder. The 3 core features of autism which should be present by 3 years are: 1. Impaired social interaction 2. Impaired communication 3. Restricted, repetitive and stereotyped behaviour and interests. Management involves a wide variety of health professionals and varies greatly between different children; therefore a thorough assessment is required to assess each child’s needs. This is done by the child development team.
A 4-year-old girl is brought to the accident and emergency department after falling off her bed. Radiographic examination reveals with a right-humeral fracture. She has a past medical history of 3 previous attendances for fractures. On examination there is discolouration of the sclera and bowing of the lower limbs. Of the following, which is the most likely diagnosis? A. Achondroplasia B. NAI C. Osteogenesis imperfecta D. Osteoporosis E. Rickets
Osteogenesis imperfecta – is an autosomal recessive disorder of collagen synthesis. It typically involves blue sclera, and bowing of the legs, it would also fit to have a past medical history of fractures. Achondroplasia – is an autosomal dominant disorder which is characterized by short stature, large head and prominent forehead with a flattened nasal bridge. The limbs are short, especially the proximal aspects. Patients often have bow-legs and may present with hydrocephalus due to narrowing of the foramen magnum. These children have normal intelligence. Osteoporosis generally doesn’t affect children. Rickets – this occurs in association with vitamin D deficiency
A 5 year old boy presents with a 12 hour history of a painful left hip on movement. He is afebrile. An x-ray is normal. Ultrasound shows joint effusion in the affected hip. FBC and CXR are normal. What is the best management plan? A. Bed rest B. Joint Aspiration C. Plaster cast D. Skin traction E. Surgical intervention with pin fixation
This is transient synovitis (age range is 2-12 yr, child would be afebrile, sudden onset) for which the best treatment option is bed rest, skin traction is used but very rarely. Neutrophils and Acute Phase Reactants are also normal as are blood cultures and x-rays. Together the picture of Transient Synovitis is the opposite of septic arthritis.
A 5 year old boy is brought into A+E by his annoyed mother. She reveals that he has been constantly complaining of leg pain. On examination you notice a limp and tenderness in his right leg, but no loss of range of movement. You also notice marked bruising on his back. What is the next step in this child’s management? A. Analgesia B. Blood Film C. FBC and Clotting Studies D. Refer to child protection services E. X-ray
Correct Answer: X-ray Certain features in the history are suggestive of non-accidental injury (NAI): ‘annoyed mother, sense of delay in presentation to hospital, bruising on back. Full skeletal X-ray is useful in looking for any fractures and this is the best NEXT step. Advice from a senior colleague is always part of the management in a case like this, where NAI might be a possibility.
A new mother is attending her GP practice for a 6 week check-up for her daughter. On examination the GP notices asymmetrical skin creases around the hip joint which was also unstable. Which is the next most appropriate step for management? A. Arrange for X-ray of the hip B. Ask the Health Visitor to monitor C. Recommend the baby is put in double nappies D. Refer to orthopaedics E. Refer to physiotherapy
Correct Answer: D: Refer to orthopaedics Diagnosis is most likely to be Developmental Dysplasia of the Hips (DDH). DDH typically presents with asymmetrical skin-folds, limb abduction, shortening of affected limb and limp (if not diagnosed until child is walking). DDH needs early treatment from Orthopaedics with a Craig’s splint (hips held in abduction) or a Pavlik harness (restraining device) for several months. Therefore physiotherapy, health visitor follow-up and double nappies are inappropriate steps. IN suspected DDH the investigation of choice is an ultrasound scan of the hips, rather than an x- ray.
You are asked to see a 5-year-old boy who has been carried into the accident and emergency department by his father. His father reports that he has had a bout of the ‘flu’ over the past week and didn’t want to get out of bed this morning. There is no history of trauma. On examination, the boy is afebrile and appears well. He refuses to weight bear because it ‘hurts to walk’. What is the most likely diagnosis? A. Fracture B. Osteomyelitis C. Septic arthritis D. Slipped upper femoral epiphysis E. Transient synovitis
The answer is E – this child is refusing to weight bear following a viral illness.
A 7-year-old child is brought to the clinic by her parents to examine several bumps they have found on her body. Her parents noticed them several weeks ago on her neck and there are now several on her trunk. They say that the child has a tendency to scratch them. On examination – there are several pale-pink papules with umbilicated centers. The child is otherwise fit and well. To which family does the most likely causative viral agent of these lesions belong? A. Herpesviruses B. Poxviruses C. Flaviviruses D. Paramyxoviruses E. Retroviruses
Poxviruses – the causative agent is Molluscum contagiosum virus, which is a member of the poxvirus family. The vignette describes the classical presentation. The papules may be slightly pruritic and children tend to scratch and spread them via auto-inoculation (Koebner phenomenon). The papules eventually spontaneously resolve and no treatment is necessary. Herpesviruses – eight types of herpes virus infect humans; HSV1 and HSV2, VZV, EBV, CMV, HHV6 and HHV7 (roseola infantum / subitum – morbilliform rash appearing following fever on chest and abdomen) and HHV8 (Kaposi’s sarcoma-associated). Flaviviruses – Dengue fever and Hepatitis C virus (among others) Paramyxoviruses – Measles (rubeola – highly contagious; 7 to 14 day incubation period; fever, cough, coryza, conjunctivitis, enanthem (Koplik spots) on buccal or labial mucosa, maculopapular rash that spreads cephalocaudally). Live attenuated vaccine given (MMR) at: 12 to 15 months and a second dose age 4 to 6 years. Retroviruses – HIV virus
A 3-year-old child is brought into the emergency department. His parents are worried as he is running a fever of 38°C and has developed a rash. Examination reveals a rash at several stages of healing – some are clear 4mm vesicles on an erythematous base, while others are crusted. Which of the following complications would you worry about in an immunocompromised child? A. Secondary infection with group A streptococci B. Secondary infection with Pseudomonas aeruginosa C. Hepatic spread D. Pneumonitis E. Encephalitis
Pneumonitis – the child in the vignette has Varicella zoster virus infection (chicken pox), which is spread by respiratory droplets. It lies latent in the dorsal root ganglia and leads to herpes zoster with reactivation (shingles). Fifteen to twenty percent of immunocompromised children develop Varicella zoster pneumonitis. Secondary infection with group-A streptococci – this is the most common complication in the normal host causing scarring. Secondary infection with Pseudomonas aeruginosa – this infection commonly occurs in burns victims Hepatic spread – not a complication of Varicella zoster infection Meningitis – while Guillain-Barré syndrome, encephalitis and cerebellar ataxia all may occur in Varicella zoster, meningitis is an uncommon complication.
You are called to see a 13-month-old boy in the emergency department who over the past two days refuses to weight bear on his right side. The mother says that a week ago he had an ear infection for which the GP prescribed antibiotics. She decided not to give them as he seemed better. Which single investigation would most likely confirm your diagnosis? A. Radiograph of the right hip B. MRI of the right hip C. Blood culture D. Erythrocyte Sedimentation Rate (ESR) E. Full blood count with white blood cell differential
Blood culture – this child most likely has osteomyelitis secondary to untreated otitis media. Osteomyelitis can occur due to: (1) hematogenous spread – which is the most common mechanism in children (2) contiguous spread and (3) direct infection from a penetrating wound. Blood cultures are positive in 60% of cases. The most common cause in children aged 3 to 12 years is Staphylococcus aureus. The patient should be treated with IV antibiotics (flucloxacillin and benzyl-penicillin) for 3 weeks in hospital and then switched to oral for 1 to 3 more weeks. Radiograph of the right hip – radiographic findings appear after 10 days to two weeks. They usually show swelling of the surrounding tissue and periosteal elevation. MRI of the right hip – this is used when the diagnosis is uncertain. Erythrocyte Sedimentation Rate (ESR) – may be normal during the early stages of infection Full blood count with white blood cell differential – may be normal during the early stages of infection
You are the pediatric registrar on call in the emergency department. An 11-month-old child is brought in by her mother with irritability and several episodes of vomiting. The mother says that the child has been like this since waking and has a tactile fever. The mother adds that she is bothered by bright lights. Following a thorough history and examination, you perform a lumbar puncture. Which CSF findings would be in keeping with aseptic meningitis? A. Low glucose B. Leukocytes C. High protein D. High opening pressure E. PMNs
Leukocytes – this is the only finding listed that is a typical CSF finding in aseptic meningitis. The rest are all features of a pyogenic infection. Aseptic meningitis is typically caused by a virus, usually an enterovirus. Other viral causes include herpes viruses, adenoviruses, and paramyxoviruses. Enterovirus-associated meningitis is often seen in the summer and fall. Treatment is supportative unless herpes virus – acyclovir. The most common causes of meningitis based on age-group: Neonate to 3/12: GBS Listeria monocytogenes and Escherichia coli Over 3/12: Neisseria meningitides, Streptococcus pneumoniae and Haemophilus influenzae Children younger than 1/12 should receive ampicillin and an aminoglycoside (gentamicin to cover for Listeria) or a cephalosporin (cefotaxime). Children over 1 month should receive ceftriaxone or cefotaxime and ampicillin If Streptococcus pneumoniae is suspected, then vancomycin should be added
A four year old ‘precious child’ of an ‘alternative’ Chelsea mum presents to A+E with a maculopapular rash which began on the face and is not itchy. On examination the child complains of headache and has prominent suboccipital and post auricular lymphadenopathy. Mother is 7 weeks pregnant with her second child. What is the most appropriate management? A. Advise that the child does not attend nursery for 15 days B. Check maternal serology C. Give mother prophylaxis measles immunoglobulin D. Perform lumbar puncture E. Prescribe oral penicillin
Correct Answer: B: Check Maternal Serology The question implies that the child may not have received the MMR vaccine, and therefore the clinical history suggests measles infection. Risk of transmission to mother and foetus is high so mother’s immunity must be checked via maternal serology tests. Rubella infection during pregnancy causes foetal abnormalities such as deafness, cardiac disease, eye problems and mental retardation. The risk is higher in early pregnancy (90% at 9/40) Rubella is a live vaccine so would need to give mother maternal Ig if serology tests show she is not immune. Antibiotics would be of little use in this case as measles is a viral infection.
An 8 year old boy presented to the GP with a fever lasting 3 weeks, for which he received no medication. It was associated with a cough, loss of appetite and lesions on his lower limbs that were well defined and tender. What is the most likely cause of these symptoms? A. Drug Reaction B. Inflammatory Bowel Disease C. Mycoplasma pneumonia D. Streptococcal infection E. Tuberculosis
Correct Answer: E: Tuberculosis The leg lesions are erythema nodosum which can be associated with all of the above. The other symptoms are classically TB, particularly the anorexia and duration of symptoms. There is no indication the child is on any medication, making a drug reaction unlikely. There is also no history of diarrhoea, which would make the diagnosis of inflammatory bowel disease more likely. Streptococcal infections typically are not associated with a cough.
A mother comes into A+E with her one year old baby who has had a 4 day history of fever, irritability and a rash. The mother says that whilst stroking her child, the skin peels off. On examination purulent crusting around the eyes is noted. What is the most likely diagnosis? A. Kawasaki’s Disease B. Necrotising Cellulitis C. Pemphigoid D. Scalded Skin Syndrome E. Scarlet Fever
Correct Answer: D: Scalded Skin Syndrome Staphylococcal scalded skin syndrome (SSSS) presents with a red rash followed by diffuse separation of the epidermal skin. It is associated with fever and irritability and purulent, crusting, localised infection around the eyes, nose and mouth. Desquamation of the fingers and toes can be seen in both Kawasaki’s and scarlet fever, but it is not widespread. The key feature of necrotising cellulitis is necrosis which is not seen here. Pemphigoid is characterised by bullae, which although can be a feature of SSSS, are not mentioned in this case.
A one year old boy is brought to A+E by his parents with a history of 6 days of high fever. On clinical examination the child is irritable, has cervical lymphadenopathy, red swollen palms, red eyes and a rash. What would be the most appropriate treatment? A. Ibuprofen B. IVIG C. IV penicillin D. Steroids E. Supportive Treatment
Correct Answer: C: IVIG This is describing Kawasaki’s disease. The diagnosis is clinical: fever >5 days + 4 other features of: • conjunctival injection • red mucous membranes • cervical lymphadenopathy • rash • red and oedematous palms and soles or peeling of fingers and toes. Treatment is: • IVIG (to reduce risk of coronary artery aneurysms) • Aspirin (to reduce risk of thrombosis, but aspirin is not an option in this question) Scarlet fever (the main differential diagnosis) is treated with penicillin.
A 2 year old boy presents to Paediatric Accident and Emergency with a four day history of fever, malaise and lymphadenopathy. He saw his GP two days ago and was prescribed amoxicillin. He has since developed a widespread maculopapular rash covering 70% of his body. What is the most likely pathogen causing this presentation? A. Cytomegalovirus B. Epstein-Barr Virus C. Measles D. Human Herpes Virus-6 E. Rubella
Correct Answer: B: Epstein-Barr Virus Although all of the above can cause fever, Epstein-Barr Virus is the correct answer. When prescribed amoxicillin or ampicillin, children with EBV infection will sometimes develop a morbilliform rash, not too dissimilar to that seen in measles. The constellation of fever, malaise, lymphadenopathy in the light of this amoxicillin-associated rash should point towards a diagnosis of EBV. Always remember Kawasaki’s Disease should be considered in the differential diagnosis.
A 4-year-old girl presents to the accident-and-emergency department with a five day history of high fever and a rash. On examination, he is miserable, with a non-purulent conjunctivitis, an erythematous patchy rash and marked cervical lymphadenopathy. What is the most appropriate treatment for this girl’s condition? A. Intravenous ceftriaxone B. Intravenous dexamethasone C. Intravenous diphenhydramine D. Intravenous flucloxacillin E. Intravenous immunoglobulin
The answer is E – this child has Kawasaki’s disease.
A 10 month old boy presents with a two day history of worsening difficulty in breathing and wheeze. Prior to this he was experiencing coryzal symptoms. His 4 year old sister has recently had an upper respiratory tract infection after attending nursery. On examination there is a respiratory rate of 58, nasal flaring, tracheal tug and subcostal and intercostal recession. There is a widespread polyphonic wheeze on auscultation. Pulse oximetry reveals an oxygen saturation of 91% in room air. What is the most likely diagnosis? A. Aspiration B. Bronchiolitis C. Foreign Body inhalation D. Pneumonia E. Pneumothorax
Correct Answer: B: Bronchiolitis This is unlikely to be pneumonia as might expect focal signs such as an area of consolidation. A pneumothorax is unlikely as there is no evidence of hyper-resonant percussion notes, decreased breath sounds or asymmetrical chest expansion. With foreign body inhalation, one would expect a more sudden onset of symptoms. There is no history to suggest aspiration as cause of this respiratory distress. A widespread polyphonic wheeze and increased work of breathing, with a history of coryzal illness and close contacts with viral URTIs is a typical presentation of acute viral bronchiolitis.
A 10 month old boy presents to accident and emergency with a three day history of worsening difficulty in breathing. The boys parents report a fever of 38.5oC measured at home during this time. On examination the child is tachypnoeic and there is slightly reduced chest expansion on the right. On auscultation there is reduced air entry at the right lower zone, and also some crepitations at the right base. You also notice the child is grunting during expiration. Pulse oximetry reveals an oxygen saturation of 91% in room air. What is the most likely diagnosis? A. Aspiration B. Bronchiolitis C. Foreign Body inhalation D. Pneumonia E. Pneumothorax
Correct Answer: D: Pneumonia This is most likely to be pneumonia as there are focal signs suggestive of pneumonia. Also end expiratory grunting is often indicative of pneumonia or a lower respiratory tract infection. The grunting is due to glottal closure, which produces a positive end expiratory pressure and helps keep the lower airways patent. Grunting is also seen in infants who are acidotic.
The nurses have noted that a 2-day-old neonate is turning blue. He was born at term via C- Section. When you examine the baby, he is pale with grey lips, nasal flaring and intercostal recession. The infant is placed on 100% oxygen, but his saturation remains at 82% after 10 minutes. Of the following treatment options what is the most important next step? A. IV ceftriaxone B. IV prostaglandin C. Nebulised Salbutamol D. Oral dexamethasone E. Surfactant therapy
IV prostaglandin – failure to improve oxygen saturation in 100% oxygen suggests a cardiac rather than a respiratory problem. The neonate in the vignette most likely has cyanotic congenital heart disease. These infants need immediate treatment with IV prostaglandin to keep the ductus arteriosus patent until definitive treatment can be instituted. Some examples of cyanotic heart disease that present in the neonatal period are: transposition of the great vessels, hypoplastic left heart syndrome and truncus arteriosus. The other treatments are more likely to be useful in treating respiratory disorders (surfactant therapy is specifically useful for hyaline membrane disease).
During the first day baby check the SHO notices that the baby looks blue. There is nothing on examination of note. No murmur. ABG reveals PaO2 of 2. ECG is normal. Echo shows abnormal arterial connections. What is the best overall management? A. Blalock-Taussig Shunt B. Oxygen and morphine C. Prostaglandin infusion D. Prostaglandin infusion and surgical correction E. Surgery at 6-9 months
Correct Answer: D: Prostaglandin infusion and surgical correction Cyanotic CHD with abnormal arterial connections is most likely to be transposition of the great arteries. The treatment for this is to improve the mixing of saturated and desaturated blood and to maintain the patency of ductus arteriosus. This is done by giving a Prostaglandin infusion. Surgical arterial switch procedure is then performed in the first few days of life.
A 12 hour old 36 week infant, with an uncomplicated pregnancy is on the postnatal ward. It is suddenly noted by the mother that the baby is blue. On examination the infant is centrally cyanosed with a respiratory rate of 70 and marked subcostal and intercostal recession. There is no audible murmur, but a single second heart sound is heard. What is the most likely diagnosis? A. Meconium Aspiration B. Respiratory Distress Syndrome C. Tetralogy of Fallot D. Transient Tachypnoea of the Newborn E. Transposition of the Great Arteries
Correct Answer: E: Transposition of the Great Arteries Respiratory distress is seen in neonates less than 34 weeks gestation. Respiratory Distress Syndrome, Transient Tachypnoea of the Newborn and meconium aspiration would most likely present immediately or soon after birth, and not with a sudden onset of cyanosis at 12hrs. Tetralogy of Fallot classically presents with a loud murmur and not cyanosis in early life. Transposition of the Great Arteries has a duct-dependent circulation and usually presents on the 1st/2nd day of life with cyanosis due to ductal closure.
A 2 year old Caucasian boy presents with a six month history of poor growth and irritability along with foul-smelling, non-bloody diarrhoea. He has had no recent travel history and sweat test was negative. Select the most appropriate step in management from the following options. A. Commence antibiotic therapy B. Commence gluten-free diet C. Steroid therapy D. Substitute cow’s milk for soya milk E. Sulfasalazine
Correct Answer: B: Commence gluten-free diet Coeliac disease classically presents with poor weight gain in the 1st 2 years of life, foul smelling chronic diarrhoea, anorexia and abdominal distension. It is managed with lifelong gluten-free diet. Nothing in the history indicates either an infective cause/need for antibiotics, or a relationship to milk intake. Sulfasalazine can be used to treat inflammatory bowel disease.
A 12 year old girl presents to out-patients with a 6 month history of epigastric pain, 3 inches above the umbilicus, which wakes her up at night. She recently moved to a new secondary school as a result of her parents’ divorce. She has missed 6 weeks of school due to the pain. What is the most appropriate next step in the management of this child? A. Discharge with prophylactic pizotifen B. Reassure that the pain is non-organic and discharge C. Reassure that the pain is non-organic and review with an attendance chart for school D. Trial of treatment with Clarithromycin + Metronidazole + Omeprazole E. USS Kidneys
Correct Answer: D: Trial of treatment with Clarithromycin + Metronidazole + Omeprazole Remember Apley’s criteria: If recurrent abdominal pain is peri-umbilical, lasts no more than a few hours, doesn’t wake the child at night and has not been present for a considerable period of time, no investigation is necessary and a non-organic cause is likely. This child has epigastric pain that wakes her at night pointing to possible peptic ulcer disease; therefore a trial of treatment is the most appropriate plan. Other features in the history that suggest a diagnosis of peptic ulcer disease are the two major stressors: moving school and her parent’s divorce. The pain does not sound renal in origin therefore renal imaging is not indicated. Pizotifen can be used to treat abdominal migraine.
A four month old baby girl presents with a 3 day history of vomiting, fever and poor feeding. This is the second such episode in the last month. Examination is unremarkable with no focal signs except prolonged capillary refill time: RR 35; HR 150. What is the most likely diagnosis? A. Meningitis B. Otitis media C. Pneumonia D. Septicaemia E. UTI
Answer: E: UTI UTIs are common in female infants, and lead to dehydration, vomiting, fever and poor feeding. The recurrence is also suggestive of a UTI. Other options would have had more clinical signs: Meningitis – photophobia, neck stiffness, maybe a non-blanching rash Pneumonia – RR is very important as part of the assessment and isn’t even mentioned in the question OM – ear symptoms, maybe diarrhoea Septicaemia – systemic rash, more severe shock
Which of the following would be diagnostic of a UTI in a 5 year old presenting with fever, rigors and dysuria? A. Bacterial culture of >105 cfu of E.coli from absorbent pads in a nappy B. Bacterial culture of >106 cfu of mixed organisms from a clean catch C. Bacterial culture of >103 cfu of Pseudomonas from a clean catch D. Bacterial culture of >104 cfu of Proteus sp from a suprapubic aspirate E. Proteinuria +++ on urine dipstick from clean catch
Answer: D: Bacterial culture of >104 cfu of Proteus sp from a suprapubic aspirate Answer D is correct as a suprapubic aspirate sample is far less likely to be contaminated than either a clean catch or a sample obtained from an absorbable nappy. Proteinuria is a non-specific sign. Nitrites on urine dipstick would be more indicative of UTI.
A five year old boy was admitted to the paediatric ward after presenting to A+E with a two day history of sore knees and a purpuric rash over the buttocks and back of his legs. A full blood count is normal. Of the following options, what is the most appropriate next investigation? A. Blood clotting studies B. Blood cultures C. Joint aspirate of knees D. Lumbar puncture E. Urine dipstick
Correct Answer: E: Urine Dipstick The most likely diagnosis in this case is Henoch-Schönlein Purpura (HSP). Henoch-Schönlein purpura is an immune-mediated vasculitis. It can include: - Palpable purpura on buttocks & extensor surfaces of limbs - Arthralgia & periarticular oedema - Abdominal pain - Glomerulonephritis (leading to) haematuria >80% of children with HSP have micro- or macroscopic haematuria or mild proteinuria. This is the best next step as it is a simple non-invasive bedside test.
You are asked to see 3 year old boy who has bilateral leg, ankle and scrotal oedema. You also notice some facial oedema, which the parents report has subsided slightly since the morning. What is the next investigation you will perform? A. Anti-streptolysin O Titre B. Hepatitis B Serology C. Full Blood Count D. Urea and Electrolytes E. Urine Dipstick
Correct Answer: E: Urine Dipstick Urine dipstick is the only test from these options you can perform at the bedside and is therefore an appropriate next step, as it will be of diagnostic benefit in what sounds like the nephrotic syndrome. ASOT would be a useful test as post-streptococcal glomerulonephritis may be a cause of the nephrotic syndrome. This arises as immune-complexes containing streptococcal antigens are deposited in the glomerular basement membrane, resulting in an acute proliferative glomerulonephritis. Test for Hepatitis B antigen and antibodies may be of use as HBV-associated glomerulonephritis can also be a cause of the nephrotic syndrome. This occurs as the result of cryoglobulinaemia sometimes associated with HBV. These cryoglobulins precipitate in the glomerular basement membrane, resulting in a membranous glomerulonephritis.
A 7-year-old boy attends the GP with his parents. He has just started a new school and his parents report that he has started wetting the bed. A urine dipstick is negative or nitrites and leukocytes. How should the GP proceed at this point? A. Prescribe Amitriptyline B. Prescribe Desmopressin C. Suggest an enuresis alarm D. Explore school-related issues E. Prescribe Fluoxetine
The answer is D – this child has secondary enuresis most likely as a result of a school-related problem. The GP needs to delineate exactly what is happening before proceeding to suggest medical and non-medical management
A 14-year-old girl presents to the GP with her mother. She gives a five-week-history of recurrent headache associated with nausea, vomiting and abdominal pain. She is on no regular medications. Her mother also had similar episodes at her age. What is the most likely diagnosis? A. Benign Intracranial Hypertension B. Migraine C. Cluster headache D. Posterior Fossa Tumor E. Tension Headache
Migraine – is typically associated with nausea, vomiting, and abdominal pain. There is often a positive family history in migraine. Benign intracranial hypertension – typically affects obese young women, with a peak incidence in the 3rd or 4th decades of life. The intensity of the headache is positional – it is usually worse on waking, and relieved by standing up. Cluster headaches – these typically occur in young adult men. They tend to occur at a similar time each day, lasting several days to weeks at a time before disappearing. Posterior fossa tumor – the most common intra-cranial tumors in children are located in the posterior fossa. They typically present with a history of worsening headache over weeks to months, and may also display features secondary to cranial nerve or cerebellar compression such as strabismus (CN VI), nystagmus or ataxia. Tension headaches – these often present with a characteristic band-like distribution across the forehead or behind the eyes.
A worried mother brings her 9-year-old son to the GP. He suffered from a discrete episode of visual changes, staggering and falling yesterday. He subsequently developed a headache. This is the third time it has happened in three months. He is afebrile and cranial nerve examination is normal at the GP. What is the most likely diagnosis? A. Atonic epileptic seizure B. Benign paroxysmal vertigo C. Migraine D. Reflex anoxic seizures E. Syncope
Correct Answer: C: Migraine Child is too old for R.A.S – this is usually in infants or toddlers and follows a trigger such as cold food, head trauma, a sudden fright or a fever. BPV is associated with nystagmus and viral labyrinthitis, neither of which are mentioned. Epileptic seizure would have more details of post-ictal state and temperature would be higher. There is no mentioned trigger for syncope Best option is migraine for which this child is in the typical age range, there are also visual and abdominal symptoms and recurrence – characteristic of a migraine.
A 15 year old girl with a BMI of 29 presents with a one month history of frontal headache which is unresponsive to analgesia. The pain worsens on coughing and sneezing and is associated with nausea. A thorough history reveals she is struggling at school and has a family history of glaucoma. The most likely diagnosis is? A. Benign intracranial hypertension B. Migraine without aura C. Refractive error D. Sinusitis E. Space-occupying lesion
BIH shows the signs of an ICP but is ‘benign’ in that there is no space-occupying lesion; it is a diagnosis of exclusion and is more common in over-weight females.
Sophie, a 6 year old known epileptic, comes to A+E having been seizing for the last 35 minutes. The on-call registrar has administered one dose of rectal diazepam. However, Sophie is still seizing. IV access has been gained. Select the next most appropriate treatment. A. Lorazepam (iv) B. Midazolam (oral) C. Paraldehyde (pr) D. Phenobarbital (infusion) E. Phenytoin (iv)
Correct Answer: A: Lorazepam Once intravenous access has been gained, Lorazepam is preferential to rectal diazepam or buccal midazolam. Paraldehyde, phenytoin and phenobarbital are considered next if the child is not responding to benzodiazepines.
You are the on-call pediatric registrar in the accident-and-emergency department. A mother brings her 6-year-old son in with severe shortness-of-breath. There is some improvement in his status following administration of nebulized salbutamol and oxygen. However, the child is a known asthmatic and you feel he requires admission. The mother doesn’t wish to stay in hospital and leaves the department with the child. What is the appropriate next step? A. Contact the consultant on-call B. Call hospital security C. Call the police D. Call social services E. Respect the mother’s decision and document this in the notes
Except for choice E (respect the mother’s decision and document this in the notes) all of the above choices should be instituted. However, as the most appropriate next step is C – call the police. This is due to the fact that the mother has left the premises and the child is still at significant risk of harm. If the mother were threatening to leave the hospital, it would be appropriate to call hospital security.
A mother brings her 5-month-old infant into the accident-and-emergency department with coryzal symptoms. His weight and length are less than the fifth centile. His birth weight was 4.1kg and he is 3.6kg when the nurses weight him today. He takes an unknown amount of cows-milk-based formula per day and porridge. What is the most likely cause of his weight loss? A. Cows-milk-protein allergy B. Non-organic failure to thrive C. Celiac disease D. Inflammatory bowel disease E. Weight loss secondary to reflux
Non-organic failure to thrive – this is often seen when a child isn’t fed a sufficient amount of calories to sustain growth and development. This may occur when there is insufficient parental knowledge about feeding, substance abuse, poverty or underlying social and emotional disturbance. Presentation is variable – the child is often thin, with prominence of the bones, wasting of the buttocks (much like celiac disease) and is often developmentally delayed. There may also be evidence of physical abuse, such as a torn frenulum, burns or unusual bruises. Social services should be informed to assess the home situation and it is often necessary to hospitalize the child for nutritional assessment and unlimited feedings.
Which of these Western European countries has the highest incidence of teenage pregnancies? France Portugal Norway United Kingdom Holland
UK Becoming a teenage mother may be a positive life-choice, especially if there is considerable support from extended family. However, when the pregnancy is unintended, there can be many adverse consequences for mother and child, especially if she is unsupported or living in poverty.
Claire is 14 years old. She visits her general practitioner as she wants to go on the oral contraceptive pill. She is sexually active and has a boyfriend with whom she has been in a relationship for 6 months. Her mother is not aware she has come to see the doctor today and is also not aware she is sexually active. Claire does not want her mother knowing she is getting the oral contraceptive pill. She has no other medical problems. She has regular periods and her blood pressure is normal. What is the recommended advice to give her? You will only give her the pill if her parents are present to consent in writing You will prescribe the pill and promise not to tell her parents You will prescribe the pill and encourage her to tell her mother she is going to start the pill You will prescribe the pill but will inform her parents you are doing so She cannot have the pill as she is not legally allowed to have sex
You will prescribe the pill and encourage her to tell her mother she is going to start the pill It is usually desirable for the parents to be informed and involved in contraception management. She should be encouraged to tell them or allow the doctor to, but if the young person is competent to make these decisions for herself, in the UK the courts have supported medical management of these situations without parental knowledge.
Which of the following is the most common cause of death in adolescence in the UK? Cancer Heart disease Infection Injury and poisoning Neurological disease
Injury and Poisoning In the UK injury and poisoning account for 60% of deaths in 15–19-year-olds. Alcohol is thought to be a contributing factor in a third of those deaths.
Olivia is a 16-year-old girl who presents to the local pharmacy for ‘emergency contraception’. She has had unprotected sex with her boyfriend, who is also 16 years old. She has no other medical problems and is not currently on any medications. How long after unprotected intercourse can emergency contraception be used? 12 hours 24 hours 48 hours 72 hours 1 week
72 hours Emergency contraception is available from a pharmacist without prescription for those aged 16 years and over, and on prescription for those under 16 years. If taken within 72 hours, it has a 2% failure rate.
Sam, 16 years old, is brought to his general practitioner because his parents are worried about him. They complain that he stays locked in his room and is not doing well at school. He often refuses to get out of bed because he has a headache. You speak to Sam alone. He complains of being bored all the time, and says that there is nothing he enjoys. He feels hopeless. He no longer goes out with his friends. He complains of a headache, which is of gradual onset and like a tight band around his head. He is a fan of ‘ER’, a medical drama, where one of the characters suffered from a brain tumour. He is convinced that he also has a brain tumour. He has no other medical problems. He takes paracetamol for his headache, with good effect. Acne vulgaris Asthma Depression Epilepsy Chronic Fatigue Syndrome Anorexia Nervosa Somatic symptoms Risk-taking behaviour Pregnancy Malignancy Psychosis
Depression
Gareth is a 15-year-old boy who has become increasingly withdrawn. He frequently argues with his mother, particularly when she believes he should stay at home to do his homework rather than leaving the house to meet his new group of friends. His mother believes that this new group of friends are using drugs. She is very upset that he has even been cautioned by the police, for urinating in public whilst intoxicated. He has no other medical problems. Acne vulgaris Asthma Depression Epilepsy Chronic Fatigue Syndrome Anorexia Nervosa Somatic symptoms Risk-taking behaviour Pregnancy Malignancy Psychosis
Risk-taking behaviour Gareth is a 15-year-old boy who has become increasingly withdrawn. He frequently argues with his mother, particularly when she believes he should stay at home to do his homework rather than leaving the house to meet his new group of friends. His mother believes that this new group of friends are using drugs. She is very upset that he has even been cautioned by the police, for urinating in public whilst intoxicated. He has no other medical problems.
Bennu, an Egyptian 14-year-old girl, is sent to the school nurse by her maths teacher because she is complaining of a headache. She complains of a headache at least once a week, and often feels tired. There is no pattern to her headaches. She has no other symptoms and is doing well at school. She has lots of friends and is a sociable teenager. There are no abnormalities on examination. She has no other medical problems and is on no medications. Acne vulgaris Asthma Depression Epilepsy Chronic Fatigue Syndrome Anorexia Nervosa Somatic symptoms Risk-taking behaviour Pregnancy Malignancy Psychosis
Somatic symptoms Bennu, an Egyptian 14-year-old girl, is sent to the school nurse by her maths teacher because she is complaining of a headache. She complains of a headache at least once a week, and often feels tired. There is no pattern to her headaches. She has no other symptoms and is doing well at school. She has lots of friends and is a sociable teenager. There are no abnormalities on examination. She has no other medical problems and is on no medications.
Anika, a 15-year-old girl, presents with her mother to her general practitioner. She complains of vomiting. This is present most commonly in the morning and is associated with abdominal pain, fatigue and breast tenderness. You ask her if she has had unprotected sex, and she denies this. She has a suprapubic mass. She has no other medical problems and is not on any medications. Acne vulgaris Asthma Depression Epilepsy Chronic Fatigue Syndrome Anorexia Nervosa Somatic symptoms Risk-taking behaviour Pregnancy Malignancy Psychosis
Pregnancy Anika, a 15-year-old girl, presents with her mother to her general practitioner. She complains of vomiting. This is present most commonly in the morning and is associated with abdominal pain, fatigue and breast tenderness. You ask her if she has had unprotected sex, and she denies this. She has a suprapubic mass. She has no other medical problems and is not on any medications.
Keith, a 15-year-old boy, attends paediatric outpatient department with his mother. Over the last 6 weeks he has become increasingly aggressive, and last week was suspended from school for throwing his book at a teacher. His mother says that this behaviour is completely out of character; he was previously a kind and hard-working boy. His school performance has also deteriorated. He also complains of an occipital headache that is worse in the morning or when he bends down. His mother sometimes finds vomit in the sink. Examination is normal except for a squint. On checking his eye movements, you find that he is unable to deviate his left eye laterally. He has no other medical problems. He has tried taking paracetamol for his headache but this has not been therapeutic. Acne vulgaris Asthma Depression Epilepsy Chronic Fatigue Syndrome Anorexia Nervosa Somatic symptoms Risk-taking behaviour Pregnancy Malignancy Psychosis
Malignancy Keith, a 15-year-old boy, attends paediatric outpatient department with his mother. Over the last 6 weeks he has become increasingly aggressive, and last week was suspended from school for throwing his book at a teacher. His mother says that this behaviour is completely out of character; he was previously a kind and hard-working boy. His school performance has also deteriorated. He also complains of an occipital headache that is worse in the morning or when he bends down. His mother sometimes finds vomit in the sink. Examination is normal except for a squint. On checking his eye movements, you find that he is unable to deviate his left eye laterally. He has no other medical problems. He has tried taking paracetamol for his headache but this has not been therapeutic.
Worldwide, which of the following causes the most deaths in children under 5 years old? Neonatal problems Diarrhoea Malaria Pneumonia Injuries
Neonatal problems
Ritha, aged 3 months, is admitted to hospital with a 2-day history of mild coryza, and difficulty breathing. She has been feeding poorly for the last 3 weeks. Which clinical feature most supports her having congenital heart disease, rather than respiratory disease? Sibling with congenital heart disease Poor feeding Generalised wheeze on auscultation Marked hepatomegaly Ejection systolic murmur, grade II/VI at left sternal edge
Marked hepatomegaly. In infants, this is an important sign of heart failure, usually secondary to congenital heart disease
Nazma, aged 4 years, presents with a 1-week history of several episodes of central abdominal pain. She is of Indian ethnicity, but the family live in Kenya and are visiting relatives in the UK. She is otherwise well. Her relative’s general practitioner thinks she may be slightly pale and that her spleen is enlarged, as it is 3 cms below the costal margin. There are no other abnormalities on examination. Which of the following is the most likely cause for her enlarged spleen? Acute lymphoblastic leukaemia (ALL) Malaria Hookworm infestation Wilms tumour Sickle cell disease
Malaria. High prevalence in Kenya and may cause chronic anaemia and splenomegaly (Note - not sure if I agree with this one, as malaria would more likely present with intermittent fevers and being unwell….? However, this is the answer given in the book!)
Katie, an 18-month-old Caucasian girl, is reviewed in the paediatric clinic. She is unsteady on her feet. She walks with a limp and tends to fall to her left side. Her limb tone and reflexes are as follows: - Right arm - tone and reflexes normal - Left arm - tone increased, reflexes brisk - Right leg - tone and reflexes normal - Left leg - tone increased, reflexes brisk Which is the site of her neurological lesion? Upper motor neurone lesion Lower motor neurone lesion Cerebellar lesion Basal ganglia lesion Neuromuscular junction
The increased tone and reflexes of her left arm and leg are from an upper motor neurone lesion, most likely in the right side of her brain.
Katie, an 18-month-old Caucasian girl, is reviewed in the paediatric clinic. She is unsteady on her feet. She walks with a limp and tends to fall to her left side. Her limb tone and reflexes are as follows: - Right arm - tone and reflexes normal - Left arm - tone increased, reflexes brisk - Right leg - tone and reflexes normal - Left leg - tone increased, reflexes brisk Which of the following best describes the pattern of neurological signs? Diplegia Right hemiplegia Left hemiplegia Spastic quadriplegia Choreoathetoid cerebral palsy
Katie has a left hemiplegia due to the increased tone and reflexes on her arm and leg.
Jeremiah, a 6-year-old boy, is brought by his mother to the ophthalmology outpatient clinic. She is worried about her son’s ‘funny eyes’. You examine him using the cover test, and you find the following: - Both eyes open - right eye deviates inwards - Left eye covered - right eye fixes on stimulus What disorder does he have? Right convergent squint Right divergent squint Alternating convergent squint Left convergent squint Left divergent squint
Right convergent squint It is a convergent squint because the eye is facing inwards towards the midline. It affects the right eye when both eyes are uncovered. The uncovered left eye usually focuses on objects. But when the left eye is covered the right eye takes up a normal position and focuses.
William, a 9-year-old boy from Slovakia, presents to the rapid access paediatric clinic with a fractured tibia following a fall from a wall. He is otherwise well but has a history of shortness of breath and wheeze when running. His mother denies that he has ever needed treatment for his wheeze. He is not unwell currently. Which clinical sign is caused by long-term, poorly treated obstructive lung disease, and is seen as indentation at the lower ribcage at the costal margin? Barrel chest Pectus excavatum Pectus carinatum Harrison sulcus Sternal recession
Harrison sulcus
Ishmael, a 15-year-old boy from Pakistan, is seen in the outpatient department. He has a long history of chest infections needing recurrent courses of antibiotics. He has a productive cough. He opens his bowels once a day. On examination, he has a normal temperature, his skin and mucous membranes are pink and his heart sounds are normal. His hands look unusual. On auscultation, there are some scattered crepitations at both bases. In view of his recurrent chest infections, you had ordered a sweat test, which is negative. Explain his clubbing? Cystic fibrosis Infective endocarditis Bronchiectasis Crohn disease Tetralogy of Fallot
This child has marked clubbing of the fingers due to bronchiectasis. Although cystic fibrosis is the commonest cause, it may also be caused by other conditions.
Rob, a 9-month-old boy, presents with fever and difficulty breathing for the last 3 days. His breathing is now interfering with his feeding. Examination of his chest finds: - subcostal and intercostal recession - RR = 70/min - Scattered wheezes - Hyperinflated chest - Fine end-expiratory crackles - HR = 120/min - HS 1 + 2 + 0 Give the most likely diagnosis: Acute exacerbation of asthma Bronchiolitis Chronic asthma Cystic fibrosis Heart failure Inhaled foreign body (left side) Inhaled foreign body (right side) Pleural effusion (left-sided) Pleural effusion (right-sided) Pneumonia (left-sided) Pneumonia (right-sided) Pneumothorax (left-sided) Pneumothorax (right-sided)
Bronchiolitis
Hatem, a 3-year-old boy, presents with fever and difficulty breathing, getting worse for the last 3 days. Examination shows: - RR = 40 - Dullness on percussion in lower right zone, as well as bronchial breathing and inspiratory crepitations - HR = 120/min - HS 1 + 2 + 0 Give the most likely diagnosis: Acute exacerbation of asthma Bronchiolitis Chronic asthma Cystic fibrosis Heart failure Inhaled foreign body (left side) Inhaled foreign body (right side) Pleural effusion (left-sided) Pleural effusion (right-sided) Pneumonia (left-sided) Pneumonia (right-sided) Pneumothorax (left-sided) Pneumothorax (right-sided)
Pneumonia (right-sided)
Darren, a 3-year-old boy, was eating peanuts 2 days ago when his younger brother pushed him over. He coughed up the peanuts and was all right. Today, he has been coughing and becomes breathless as soon as he runs about. He is afebrile. Examination findings are: - RR = 36/min - Apex beat displaced to the right - Reduced air entry on the left - Percussion is normal Give the most likely diagnosis: Acute exacerbation of asthma Bronchiolitis Chronic asthma Cystic fibrosis Heart failure Inhaled foreign body (left side) Inhaled foreign body (right side) Pleural effusion (left-sided) Pleural effusion (right-sided) Pneumonia (left-sided) Pneumonia (right-sided) Pneumothorax (left-sided) Pneumothorax (right-sided)
Inhaled foreign-body (left side)
Tony, a 4-year-old boy, is admitted with pneumonia. His chest-ray shows consolidation at the right base. In spite of antibiotic therapy, he remains febrile and unwell. Examination findings are: - RR = 50 - Lower right zone is dull to opercussion, absent breath sounds, scattered inspiratory crepitations Give the most likely diagnosis: Acute exacerbation of asthma Bronchiolitis Chronic asthma Cystic fibrosis Heart failure Inhaled foreign body (left side) Inhaled foreign body (right side) Pleural effusion (left-sided) Pleural effusion (right-sided) Pneumonia (left-sided) Pneumonia (right-sided) Pneumothorax (left-sided) Pneumothorax (right-sided)
Pleural effusion (right-sided)
Jamalah, a 7-year-old girl, presents with difficulty breathing. She has had a cold for the last 2 days. This is the third time this has happened, each time when she had a cold. She has not had any other medical problems. On examination, she has an upper respiratory infection and the signs listed here: - rr = 44/min - Mild subcostal and intercostal recession - Hyper-resonance on percussion - scattered wheezes Give the most likely diagnosis: Acute exacerbation of asthma Bronchiolitis Chronic asthma Cystic fibrosis Heart failure Inhaled foreign body (left side) Inhaled foreign body (right side) Pleural effusion (left-sided) Pleural effusion (right-sided) Pneumonia (left-sided) Pneumonia (right-sided) Pneumothorax (left-sided) Pneumothorax (right-sided)
Acute exacerbation of asthma
Steven has just had his first birthday party. During his party he commando-crawled with great speed, although he cannot walk. He managed to pick off all the Smarties (round chocolate sweets) from his birthday cake. He can say two words with meaning. After his birthday party, he impressed his guests by waving goodbye. Which area of Steven’s development is delayed? Gross motor Fine motor and vision Speech and hearing Social, emotional and behavioural development None of the above
He has therefore achieved normal milestones for a 12-month-old Note also that commando crawlers and bottom-shufflers tend to decide upon walking a little later than normal crawlers
Gerald is a 16-month-old boy who has not yet said his first word, and does not babble much. His mother believes he does not hear well because he doesn’t startle when a door slams or show any response to his name. His development is otherwise normal. Which test would be best to assess Gerald’s hearing? Evoked otoacoustic emission Auditory brainstem response audiometry Distraction hearing test Visual reinforcement audiometry Speech discrimination testing
Visual reinforcement audiometry This is the most reliable test for a child Gerald’s age. The test requires an assistant to play with the child and keep their attention. Behind a soundproof window, another assistant will play sounds through a loudspeaker at particular frequencies. When the child turns around to the noise, a glass-fronted box with a toy inside that was previously dark lights up as visual reinforcement to reward the child for turning round
Evie is 10 days old and was born in London. Her health visitor reviews her and her parents at home. She is feeding well and has a normal examination except that she has a squint. The health visitor mentions to parents she will keep this under review. At what age does Evie need to be referred to an ophthalmologist if the squint is still present? 2 weeks 6 weeks 12 weeks 8 months 12 months
12 weeks A newborn may appear to squint when looking at nearby objects because their eyes over-converge. By 6 weeks, the eyes should move together when following an object, and by 12 weeks there should be no squint present
Sophie is a well 8-week-old baby who was born at term. She has come for a routine developmental check. Which of the following would you not expect her to be able to do? Raise her head when lying prone Smile Fix and follow a face or interesting object Reach out and grasp an object Quieten to a loud noise
Reach out and grasp an object An 8-week-old infant will be able to do the remaining 4 activities, but still only has a primitive grasp reflex, so will not be able to voluntarily grasp an object. She will only be able to grasp what is placed in her hand
Joanna is an active toddler. She is just being potty-trained, and has had several days where she has remained dry. She enjoys pulling her clothes off to use the potty, but cannot dress herself again. She enjoys playing by pretending to make her mother a cup of tea, but does not play well with her older siblings, as she has not yet learnt how to take turns. She is very bossy, and demands things by saying ‘give me’ or ‘me drink’. She can build a tower of six blocks, and enjoys running and climbing on furniture. What developmental age is Joanna? 12 months 18 months 24 months 2 ½ years 3 years
24 months Joanna is dry by day, can undress and has symbolic play. She is not yet playing interactively; she will learn this at about 3 years of age. She is constructing two-word sentences. She constructs a tower of six blocks and can run.
Cordelia is a 4-month-old baby who is assessed by her general practitioner because of constant crying and poor feeding. She is fed by bottle on infant formula. Her mother tearfully complains that she is finding it very difficult to cope. She also has a 20-month-old boy who has recently been referred to the speech and language therapist because of language delay. She used to work as a solicitor, and her partner is a company director who often travels abroad. Charlotte’s developmental, growth and physical examination is normal. What is the likely cause of Cordelia’s problems? An inherited genetic condition Gastro-oesophageal reflux Maternal postnatal depression and stress Pyloric stenosis Down syndrome
Maternal postnatal depression and stress This may be detrimental to Cordelia’s development, as infants are totally dependent on their main caregiver. Her older brother may have speech delay because he is not receiving enough stimulation to develop his own language skills or there may be an underlying problem causing his speech delay.
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Rosette can build a three-cube tower and can point to her nose. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
12 months
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Grace enjoys drawing. She has just learnt to copy drawing a square, and can build steps using blocks after being shown. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
4 years
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Lizzie has just started crawling. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
8 months
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Ivan can tie his shoe laces all by himself. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
5 years
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Herbert can transfer objects from one hand to the other whilst sitting without support and with a straight back. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
8 months
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Blessing’s mother is so pleased; her baby has just learnt to smile when she smiles at her! 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
6 weeks
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Rita’s father is thrilled that she has just said her first word – says ‘dada’ to her father only. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
10 months
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Anthony has a friend at nursery, and they enjoy playing with toy cars together. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
3 years
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Peace has just taken her first steps! 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
12 months
At what age will children achieve the milestones described in the scenarios (median age)? Each age can be used once, more than once, or not at all. Rinah can follow her mother’s two-step commands, such as ‘fetch your red shoes from the cupboard’. 6 weeks 6 months 8 months 10 months 12 months 18 months 2 years 3 years 4 years 5 years
3 years
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. Hearing test using audiometry Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
13 months
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. First routine immunisation with 5 in 1 immunisation - DTaP/IPV, Hib, PCV (diphtheria, tetanus, pertussis, polio, Haemophilus influenza, pneumococcal) Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
8 weeks
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. Guthrie test (biochemical screening test) Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
5-6 days
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. An orthoptist assessment for visual impairment Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
4-5 years (preschool)
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. Advice on reducing the risk of sudden infant death syndrome by ‘Back to sleep’, avoiding overheating and avoiding parental smoking Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
Newborn
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. Hearing test using evoked otoacoustic emission or auditory brainstem response audiometry Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
Newborn
At which of these ages is the following action (screening, examination, health promotion activity) taken in the child health surveillance and promotion programme in the United Kingdom? Each answer can be used once, more than once, or not at all. First MMR (measles/mumps/rubella) immunisation Newborn 5-6 days 12 days 8 weeks 3 months 4 months 8 months 12 months 13 months 2-3 years 4-5 years (pre-school) 5 years (school entry)
13 months
Jonathan is 4 years old and lives in a small village in southern England. He attends a paediatric outpatient clinic with his grandmother who is his legal guardian. She is concerned that he only seems to like to play with his toy train and insists on watching the same DVD every night before he goes to bed. He attends nursery where he plays with the toys but not with other children. His behaviour can be very difficult to manage at times. He does not say any words whereas the grandmother’s children were speaking in sentences at his age. On examination you notice he does not make eye contact with you and pushes his toy train back and forth on the floor. The rest of his examination is normal. What is the most likely diagnosis? Attention deficit hyperactivity disorder (ADHD) Autistic spectrum disorder Developmental coordination disorder (DCD, also known as dyspraxia) Asperger syndrome Expressive language disorder
Autism spectrum disorder Autism is a triad of impaired social interaction, speech and language disorder and ritualistic and repetitive behaviour.
At what age does autistic spectrum disorder usually become evident? 0–12 months 12–24 months 2–4 years 4–8 years Above 8 years
2-4 years Autistic spectrum disorder usually presents at this age because this is when language and social skills rapidly develop
At what age would you expect the clinical features of cerebral palsy to become evident? 0–12 months 12–24 months 2–4 years 4–8 years Above 8 years
0-12 months Cerebral palsy most often presents during this time when acquisition of motor skills occurs most rapidly.
Fortunate is an 8-month-old black African girl who was born at term. She is seen in the paediatric outpatient department. She can roll over. She does not crawl. She can say ‘dada’, but says it to everyone not just her father. She reaches out and grasps objects with her left hand but not with her right, and puts objects in her mouth. She smiles, but is not able to wave bye-bye. Select the option that concerns you most about Fortunate’s development. Unable to crawl Left hand preference Unable to use sounds discriminately to parents Unable to wave bye-bye None of the above
Left hand preference Fortunate has developed a preference for using her left hand at 8 months. Development of a hand preference before 1 year of age is abnormal, and she needs to be assessed for hemiplegic cerebral palsy affecting her right side.
Gloria is a 19-month-old white British girl whose health visitor is concerned because she is still only babbling and says no distinct words. She is able to walk, scribbles with crayons and feeds herself with a spoon. What is the most appropriate first action? Hearing test Assessment by a team specialising in autistic spectrum disorders Reassure the health visitor Refer to an ENT surgeon Refer to a paediatrician for a full developmental assessment
Hearing test Speech delay can be due to hearing impairment, and this should be assessed first prior to referring her to a specialist.
Andrew is 5 years old. His father feels his behaviour has deteriorated and he is worried he is not hearing him all the time. He has poor articulation of the few words that he can say. Andrew goes to the audiology department and has his hearing tested. His audiogram shows: What type of hearing loss does he have?
Mild conductive hearing loss in the right ear. The audiogram shows mild conductive hearing loss in the right ear. It is mild at 30-50dBHL and conductive as high frequency hearing is relatively preserved and bone conduction (same for both ears) is normal.
Cruz is a 2-year-old boy. He has recently moved to the UK from Mexico. He attends the audiology department as he has marked problems with his language development. Below is his audiogram:
What type of hearing loss does he have?
Mild conductive hearing loss in both ears
Severe conductive hearing loss in both ears
Mild sensorineural hearing loss in both ears
Severe sensorineural hearing loss in both ears
Mixed hearing loss in both ears
Severe sensorineural loss in both ears. The hearing loss is severe (70–90 dBHL) to profound (>90 dBHL) and sensorineural, as there is no significant air-bone gap.
Jenny is an 8-week-old girl who was born pre-term at 35 weeks’ gestation. She is seen by her general practitioner for her surveillance review. Her mother is concerned that she does not smile. Her gross motor development appears to be normal and she startles to loud noises. However, she will not follow a face nor a colourful ball. The appearance of one of her eyes is shown here. The other eye has a similar appearance. She has no other medical problems.
What is the likely underlying diagnosis?
Corneal trauma
Cataract
Conjunctivitis
Retinopathy of prematurity
Vitamin A deficiency
Cataract
This picture shows a white reflex in the eye that is caused by the clouding of the lens
You are in the acute assessment unit and see David, a 15-month-old boy who has a fever of 38.5°C. He has had a runny nose, cough and a fever for 3 days. Since this morning he has slept and has been difficult to wake. His heart rate is raised. He has a purpuric rash with lesions of variable size scattered over his legs which does not disappear with pressure.
Which of the following is the most likely diagnosis?
Non-accidental injury
Henoch–Schönlein purpura (HSP)
Idiopathic thrombocytopenia (ITP)
Acute lymphoblastic leukaemia (ALL)
Septicaemia
Septicaemia
He has a purpuric rash, with lesions of variable size. In a febrile child, meningococcal septicaemia is most likely. This may be accompanied by meningitis
You are called to see a 3-year-old boy with a high fever. The nurse is worried that he is very sleepy. As you walk into the resuscitation room he makes no spontaneous response. You try calling his name but he makes no response. On stimulation, his eyes open, he moans and he raises his hand and pushes your hand away.
What is this child’s Glasgow Coma Score?
8
9
10
11
12
9
Mohammed, aged 8 months, has been vomiting and off his feeds for two days. Initially he had episodes of crying uncontrollably, drawing his legs up into his abdomen as if in pain, and appeared fractious. His mother gave him some oral rehydration solution, but his vomiting continued and he has become lethargic. On admission to hospital he is in shock. Intussusception is suspected.
Mohammed is 8 months old and weighs 8 kg. He needs a bolus of normal saline 0.9% to treat his shock.
What volume of fluid would you give initially?
40 ml
160 ml
320 ml
680 ml
800 ml
160ml
This is 20 ml/kg initially, repeated as necessary
