Paeds

Question 1

Gross motor milestones

3 months

Answer 1

Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve

Question 2

Gross motor milestones

6 months

Answer 2

Lying on abdomen arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back

Question 3

Gross motor milestones

7-8m

Answer 3

Sits without support

Refer at 12m

Question 4

Gross motor milestones

9 months

Answer 4

Pulls to standing

Crawls

Question 5

Gross motor milestones

12m

Answer 5

Cruises

Walks with one hand held

Question 6

Gross motor milestones

13-15m

Answer 6

Walks unsupported

Refer at 18m

Question 7

Gross motor milestones

2y

Answer 7

Runs

Walks upstairs and downstairs holding onto rail

Question 8

Pyloric stenosis presentation:

Answer 8

Pyloric stenosis typically presents in the second
to fourth weeks of life with vomiting, although
rarely may present later at up to four months. It
is caused by hypertrophy of the circular
muscles of the pylorus

Question 9

Features of Py Sten

Answer 9

‘projectile’ vomiting, typically 30 minutes after
a feed
constipation and dehydration may also be
present
a palpable mass may be present in the upper
abdomen
hypochloraemic, hypokalaemic alkalosis due to
persistent vomiting

Question 10

Dx of py sten

Answer 10

USS

Question 11

Ramstedt pylorotomy

Answer 11

Used in management of py sten
Excision of the hypertrophied circular muscles
of the pylorus

Question 12

Def intussuception

Answer 12

Intussusception describes the invagination of
one portion of bowel into the lumen of the
adjacent bowel, most commonly around the
ileo-caecal region.
Intussusception usually affects infants between
6-18 months old. Boys are affected twice as
often as girls

Question 13

Features of intussuception

Answer 13

paroxysmal abdominal colic pain
during paroxysm the infant will
characteristically draw their knees up and turn
pale
vomiting
blood stained stool - 'red-currant jelly'
sausage-shaped mass in the right lower
quadrant

Question 14

Ix intussuception

Answer 14

uss

Question 15

Mx of intussuception

Answer 15

Air insuffation under radiological control
If the child has signs of peritonitis or the air
insufflation fails, Sx

Question 16

A 2-month-old boy is brought to the afternoon
surgery by his mother. Since the morning he
has been taking reduced feeds and has been
‘not his usual self’. On examination the baby
appears well but has a temperature of 38.7ºC.
What is the most appropriate management?
Advise regarding antipyretics, to see if not
settling
IM benzylpenicillin
Advise regarding antipyretics, booked
appointment for next day
Admit to hospital
Empirical amoxicillin for 7 days

Answer 16

Any child less than 3 months old with a
temperature > 38ºC is regarded as a ‘red’
feature in the new NICE guidelines, warranting
urgent referral to a paediatrician. Although
many experienced GPs may choose not to
strictly follow such advice it is important to be
aware of recent guidelines for the exam

Question 17

Assessment of febrile children?

Answer 17

T: electronic thermometer in the axilla if <4w or
with infra-red tympanic thermometer
HR
RR
CRT
Signs of dehydration: skin turgor

Question 18

Mx of child at “green” on risk stratificiation for

feverish illness?

Answer 18

Managed at home with appropriate care

advice, including when to seek further help

Question 19

Mx of child at “amber” on risk stratificiation for

feverish illness?

Answer 19

Safety net or refer to paediatric specialist for
further assessment
Safety net: verbal/written info about warning
symptoms and how to access further care

Question 20

Mx of child at “red” on risk stratificiation for

feverish illness?

Answer 20

Admit to hospital

Question 21

A 3-year-old girl is brought in by her mother.
Her mother reports that she has been eating
less and refusing food for the past few weeks.
Despite this her mother has noticed that her
abdomen is distended and she has developed a
‘beer belly’. For the past year she has opened
her bowels around once every other day,
passing a stool of ‘normal’ consistency. There
are no urinary symptoms. On examination she
is on the 50th centile for height and weight.
Her abdomen is soft but slightly distended and
a non-tender ballotable mass can be felt on the
left side. Her mother has tried lactulose but
there has no significant improvement. What is
the most appropriate next step in
management?
Switch to polyethylene glycol 3350 +
electrolytes (Movicol Paediatric Plain) and
review in two weeks
Speak to a local paediatrician
Reassure normal findings and advise Health
Visitor review to improve oral intake
Prescribe a Microlax enema
Continue lactulose and add ispaghula husk
sachets

Answer 21

The history of constipation is not particularly
convincing. A child passing a stool of normal
consistency every other day is within the
boundaries of normal. The key point to this
question is recognising the abnormal
examination finding - a ballotable mass
associated with abdominal distension. Whilst
an adult with such a ‘red flag’ symptom/sign
would be fast-tracked it is more appropriate to
speak to a paediatrician to determine the best
referral pathway, which would probably be
clinic review the same week.

Question 22

Wilms’ tumour

Answer 22

Wilms’ nephroblastoma is one of the most
common childhood malignancies. It typically
presents in children under 5 years of age, with
a median age of 3 years old

Question 23

Features of Wilm’s tumour

Answer 23

Abdominal mass (most common PC)
Painless haematuria
Flank pain
Anorexia, fever
Unilateral in 95%
Mest found in 20%

Question 24

Mx of Wilm’s

Answer 24

Management
nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate

Question 25

Features of pertussis

Answer 25

Caused by Bordetella pertussis 10-14d incubation Infants rountely immunised at 2,3,4m and 3-5y. Pregnant women also immunised

Question 26

Clinical features of pertussis

Answer 26

Coughing bouts: usually worse at night and after feeding, may be ended by vomiting and associated central cyanosis inspiratory whoop (not always present), caused by forced inspriration against a closed glottis Persistent coughing may cause subconjunctival haemorrhages or anorexia, leading to syncope and seizures Symptoms may last 10-14w and tend to be more severe in infants Lymphocytosis

Question 27

Dx of pertussis

Answer 27

Per nasal swab culture for B. pertussis | PCR and serology may also be used

Question 28

Mx of pertussis

Answer 28

Oral erythromycin to eradicate organism and reduce spread Has not been shown to alter the course of the illness

Question 29

A mother presents to your GP surgery with her six month old daughter. She has been struggling to feed her daughter, and her health visitor found that she was small for her age. Her mother is exhausted as she says her daughter sleeps poorly. On examination, the baby is just below the 3rd centile in length. She has epicanthic folds and low set ears. Her neck appears short and she has micrognathia. You hear an ejection systolic murmur on auscultation. What is the most likely diagnosis? Fragile X syndrome Down's syndrome Patau syndrome Klinefelter's syndrome Turner's syndrome

Answer 29

Turner's syndrome is a genetic condition due to a loss or abnormality of one X chromosome. In infancy, children often have difficulty with feeding which contributes to poor weight gain, although the often have short stature too when older. Babies with Turner's syndrome often have multiple dysmorphic features, but a webbed neck is often classical. It is also associated with cardiac abnormalities, in this question aortic stenosis although others are also common. Chromosome analysis would be needed to confirm the diagnosis. While Down's syndrome babies would have many of the dysmorphic features, they would not usually have a webbed neck or micrognathia. They may have loose skin at the nape of the neck but not webbing. It is caused by Trisomy 21. Klinefelter's syndrome is caused by having an extra X chromosome. They are often tall in stature with small testes and gynaecomastia. They do not tend to have the dysmorphic features. Fragile X syndrome is due to a CGG repeat on the X chromosome. They tend to have learning difficulties, long ears, mitral valve prolapse and a large forehead and jaw. Patau's syndrome is caused by trisomy 13. They do tend to have intrauterine growth restriction leading to low birth weight, and can have congenital heart defects and ear abnormalities. However, they do not have webbing of the neck, and eye dysmorphic features tend to be microphthalmia or anophthalmia. They typically have rocker bottom feet and polydactyly

Question 30

9 | Features of Turner's syndrome

Answer 30

``` 45XO Short stature Shield chest, widely spaced nipples Webbed neck Cardiac: bicuspid aortic valve, coarctation Primary amenorrhoea Cystic hygroma High-arched palate Short fourth metacarpal Multiple pigmented naevi Lymphoedema Increased incidence of autoimmune disease: thyroiditis and Crohn's especially ```

Question 31

A 2 year old boy presents to the GP with his mother. She is worried that he is not growing at the same rate as the other children at his play group. His mother describes foul smelling diarrhoea about 4-5 times a week, accompanied by abdominal pain. On examination he has a bloated abdomen and wasted buttocks. He has dropped 2 centile lines and now falls on the 10th centile. ``` What is the most appropriate initial investigation? Stool sample IgA TTG antibodies Hydrogen breath test Endoscopy Abdominal xray ```

Answer 31

The most likely diagnosis here is coeliac disease, diagnosed using IgA TTG antibodies, as explained below. A stool sample would be diagnostic for gastroenteritis, in order to dictate which antibiotic should be used. The hydrogen breath test is used to diagnose irritable bowel syndrome or some food intolerances. Endoscopy is more commonly used in adults where cancer is suspected. An abdominal X-ray may be useful where obstruction is suspected. Coeliac disease is a digestive condition which is becoming increasingly common, and describes an adverse reaction to gluten. gluten is a protein found in wheat, barley and rye.

Question 32

Features of coeliac in children?

Answer 32

``` May coincide with the introduction of cereals FTT Diarrhoea Abdominal distension Older children may present with anaemia May not be dxed until adulthood ```

Question 33

Hirschprung's features

Answer 33

Hirschsprung's disease is caused by an aganglionic segment of bowel due to a developmental failure of the parasympathetic Auerbach and Meissner plexuses. Although rare (occurring in 1 in 5,000 births) it is an important differential diagnosis in childhood constipation ``` Possible presentations neonatal period e.g. failure or delay to pass meconium older children: constipation, abdominal distension Associations 3 times more common in males Down's syndrome ```

Question 34

Erb's palsy

Answer 34

Erb's palsy occurs due to damage to the upper brachial plexus most commonly from shoulder dystocia. Damage to these nerve roots results in a characteristic pattern: adduction and internal rotation of the arm, with pronation of the forearm. This classic physical position is commonly called the 'waiter's tip'.

Question 35

Klumpke's palsy

Answer 35

Klumpke's palsy occurs due to damage of the lower brachial plexus and commonly affects the nerves innervating the muscles of the hand.

Question 36

A male child from a travelling community is diagnosed with measles. Which one of the following complications is he at risk from in the immediate aftermath of the initial infection? Arthritis Pancreatitis Infertility Subacute sclerosing panencephalitis Pneumonia

Answer 36

Subacute sclerosing panencephalitis is seen but develops 5-10 years following the illness. Pancreatitis and infertility may follow mumps infection Pneumonia

Question 37

Measles clinical features

Answer 37

Prodrome: irritable, conjunctivitis, fever Koplik spots: grains of salt, on buccal mucosa Rash: starts behind ears, then to whole body, discrete maculopapular rash becoming blotchy and confluent

Question 38

Cxs of measles

Answer 38

encephalitis: typically occurs 1-2 weeks following the onset of the illness) subacute sclerosing panencephalitis: very rare, may present 5-10 years following the illness febrile convulsions giant cell pneumonia keratoconjunctivitis, corneal ulceration diarrhoea increased incidence of appendicitis myocarditis

Question 39

Mx of measles contacts

Answer 39

if a child not immunized against measles comes into contact with measles then MMR should be offered (vaccine-induced measles antibody develops more rapidly than that following natural infection) this should be given within 72 hours

Question 40

Def: nephrotic syndrome

Answer 40

``` Nephrotic syndrome is classically defined as a triad of proteinuria (> 1 g/m^2 per 24 hours) hypoalbuminaemia (< 25 g/l) oedema ```

Question 41

Nephrotic syndrome in children

Answer 41

In children the peak incidence is between 2 and 5 years of age. Around 80% of cases in children are due to a condition called minimal change glomerulonephritis. The condition generally carries a good prognosis with around 90% of cases responding to high-dose oral steroids. Other features include hyperlipidaemia, a hypercoagulable state (due to loss of antithrombin III) and a predisposition to infection (due to loss of immunoglobulins)

Question 42

Features of acute epiglottitis

Answer 42

Acute epiglottitis is rare but serious infection caused by Haemophilus influenzae type B. Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis was generally considered a disease of childhood but in the UK it is now more common in adults due to the immunisation programme. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine

Question 43

Clinical features of epiglottit

Answer 43

``` Features rapid onset high temperature, generally unwell stridor drooling of saliva ```

Question 44

A 7-year-old boy is brought in to the GP surgery with an exacerbation of asthma. On examination he has a bilateral expiratory wheeze but there are no signs of respiratory distress. His respiratory rate is 36 / min and PEF around 60% of normal. What is the most appropriate action with regards to steroid therapy? Oral prednisolone for 3 days Admit for intravenous steroids Give a stat dose of oral dexamethasone Double his usual beclometasone dose Do not give steroids

Answer 44

Oral prednisolone for 3 days

Question 45

Mx of mild-moderate acute asthma

Answer 45

Bronchodilator: Beta-2 agonist via a spacer (<3y use a closefitting mask) 1 puff every 15-30secs, up to a maximum of 10 puffs, repeat dose after 10-20 mins if necessary If symptoms are not controlled, repeat beta-2 and refer to hospital Steroid therapy: should be given to all children with asthma exacerbation Treatment for 3-5d

Question 46

``` A 9-year-old boy is brought to surgery with recurrent headaches. What is the most common cause of headaches in children? Migraine Depression Refractive errors Tension-type headache Cluster headache ```

Answer 46

Migraine

Question 47

Features of Hand foot and mouth disease?:

Answer 47

Hand, foot and mouth disease is a self-limiting condition affecting children. It is caused by the intestinal viruses of the Picornaviridae family (most commonly coxsackie A16 and enterovirus 71). It is very contagious and typically occurs in outbreaks at nursery Clinical features mild systemic upset: sore throat, fever oral ulcers followed later by vesicles on the palms and soles of the feet

Question 48

Mx of hand foot and mouth?

Answer 48

Management general advice about hydration and analgesia reassurance no link to disease in cattle children do not need to be excluded from school* *The HPA recommends that children who are unwell should be kept off school until they feel better. They also advise that you contact them if you suspect that there may be a large outbreak.

Question 49

Features of Croup?

Answer 49

Croup is a form of upper respiratory tract infection seen in infants and toddlers. It is characterised by stridor which is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses account for the majority of cases. Epidemiology peak incidence at 6 months - 3 years more common in autumn Features stridor barking cough (worse at night) fever coryzal symptoms

Question 50

Mx of croup

Answer 50

``` Single dose of oral dexamethasone (0.15mg/kg) Emergency: High flow O2 Nebulised adrenaline ```

Question 51

The parents of a 14-month-old girl present to their GP. They have noticed that in some photos there is no 'red eye' on the left hand side. When you examine the girl you notice an esotropic strabismus and a loss of the redreflex in the left eye. There is a family history of a grandparent having an enucleation as a child. What is the most likely diagnosis? Congenital hypertrophy of the retinal pigment epithelium Uveal malignant melanoma Neuroblastoma Retinoblastoma Congenital cataract

Answer 51

A congenital cataract may cause a loss of the red-reflex but is likely to have been detected at birth or during the routine baby-checks. It would also not explain the family history of enucleation. Retinoblastoma

Question 52

Features of retinoblastoma

Answer 52

``` Retinoblastoma is the most common ocular malignancy found in children. The average age of diagnosis is 18 months. Pathophysiology caused by a loss of function of the retinoblastoma tumour suppressor gene on chromosome 13 around 10% of cases are hereditary Possible features absence of red-reflex, repalced by a white pupil (leukocoria) - the most common presenting symptom strabismus visual problems ```

Question 53

Mx of retinoblastoma

Answer 53

Management enucleation is not the only option depending on how advanced the tumour is other options include external beam radiation therapy, chemotherapy and photocoagulation Prognosis excellent, with > 90% surviving into adulthood

Question 54

What differentiates between NRDS and TTN?

Answer 54

Neonates with NRDS usually present with respiratory distress shortly after birth which usually worsens over the next few days. In contrast, TTN usually presents with tachypnoea shortly after birth and often fully resolves within the first day of life. A chest radiograph can be useful

Question 55

CXR in NRDS?

Answer 55

Diffuse ground glass lungs Low volumes Bell shaped throax

Question 56

CXR in TTN

Answer 56

``` Heart failure type pattern Intersitital oedema PLeural effusions But normal heart size in contrast to congenital heart disease ```

Question 57

Features of Surfactant lung disease?

Answer 57

Surfactant deficient lung disease (SDLD, also known as respiratory distress syndrome and previously as hyaline membrane disease) is a condition seen in premature infants. It is caused by insufficient surfactant production and structural immaturity of the lungs The risk of SDLD decreases with gestation 50% of infants born at 26-28 weeks 25% of infants born at 30-31 weeks Other risk factors for SDLD include male sex diabetic mothers Caesarean section second born of premature twins Clinical features are those common to respiratory distress in the newborn, i.e. tachypnoea, intercostal recession, expiratory grunting and cyanosis Chest x-ray characteristically shows 'groundglass' appearance with an indistinct heart border

Question 58

Mx of SDLD?

Answer 58

Management prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation oxygen assisted ventilation exogenous surfactant given via endotracheal tube

Question 59

What timing indicates idiopathic constipation?

Answer 59

Starts after a few weeks of life Obvious precipitating factors coinciding with the start of symptoms: fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines

Question 60

Mx of feacal impaction

Answer 60

Polyethylene glycoe 3350 + electroyles (using an escalating dose) is first line Stimulant laxative can be addied if first line does not lead to disimpaction after 2 weeks. Subsititue a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric plan is not tolerated. Inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain

Question 61

General points in Mx of constipation?

Answer 61

do not use dietary interventions alone as firstline treatment although ensure child is having adequate fluid and fibre intake consider regular toileting and non-punitive behavioural interventions for all children consider asking the Health Visitor or Paediatric Continence Advisor to help support the parents.

Question 62

Mx of infants not yet weaned with | constipation

Answer 62

bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs breast-fed infants: constipation is unusual and organic causes should be considered

Question 63

Features of: | Chickenpox

Answer 63

Fever initially Rash starting on head/trunk before spreading Initially macular, then papular, then vessciular Normally mild systemic upset

Question 64

Features of mumps

Answer 64

Fever, malaise, muscular pain Parotitis initially unilateral becoming bilateral in 70%

Question 65

Features of measles

Answer 65

Prodrome: irritable, conjuncitivits, fever Koplik spots Rash starting behind ears, spreading to the whole body Initially discrete maculopapular rash that becomes blotchy and confluent

Question 66

Features of Rubella

Answer 66

Pink maculopapular rash initially on face before spreading to the whole body, usually faind by the 3-5th day Suboccipital and postauricular lymphadenopathy

Question 67

Features of erythema infectiosum

Answer 67

``` AKA slapped cheek syndrome Caused by parvovirus B19 Lethargy, fever, headache Slapped cheek rash spreading to proximal arms and extensor surfaces ```

Question 68

Features of Scarlet fever

Answer 68

``` Reaction to erythrogenci toxins produced by group A haemolytic strep Fever, malaise, tonsilitis Strawberry tongue Fine punctate erythema sparing face ```

Question 69

Features of hand, foot and mouth disease

Answer 69

Caused by coxsackie A16 virus Mild systemic upset: sore throat, fever Vesciles in the mouth and on the palms and soles of the feet

Question 70

Scarlet fever features

Answer 70

Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes). It is more common in children aged 2 - 6 years with the peak incidence being at 4 years. Scarlet fever has an incubation period of 2-4 days and typically presents with: fever malaise tonsillitis 'strawberry' tongue rash - fine punctate erythema ('pinhead') which generally appears first on the torso and spares the face although children often have a flushed appearance with perioral pallor. The rash often has a rough 'sandpaper' texture. Desquamination occurs later in the course of the illness, particularly around the fingers and toes

Question 71

Dx of scarlet fever

Answer 71

Throat swab usually taken but antibiotic | treatment should be commenced immediately

Question 72

Mx of scarlet fever

Answer 72

Oral penicillin V (penallergic: azithromycin) Children can return to school 24h after commencing antibiotics Notifiable disease

Question 73

Cx of Scarlet fever?

Answer 73

Otitis media: most common Rheumatic fever: typically 20d after infection Acute GN

Question 74

Characteristic symptoms in ADHD?

Answer 74

Extreme restlessness Poor concentration Uncontrolled activity Impusliveness

Question 75

Patau syndrome (trisomy 13)

Answer 75

Microcephalic, small eyes Cleft lip/palate Polydactyly Scalp lesions

Question 76

Edward's syndrome (trisomy 18)

Answer 76

Micrognathia Low-set ears Rocker bottom feet Overlapping of fingers

Question 77

Fragile X

Answer 77

``` Learning difficulties Macrocephaly Long face Large ears Macro-orchidism ```

Question 78

Noonan syndrome

Answer 78

Webbed neck Pectus excavatum Short stature Pulmonary stenosis

Question 79

Prader-Willi syndrome

Answer 79

Hypotonia Hypogonadism Obesity

Question 80

William's syndrome

Answer 80

``` Short stature Learning difficulties Friendly, extrovert personality Transient neonatal hypercalcaemia Supravalvular aortic stenosis ```

Question 81

What Ixs should be performed in infants <3m | old with fever?

Answer 81

``` FBC Blood culture CRP Urine dip CXR if respiratory signs are present Stool culture if diarrhoea is present ```

Question 82

What are hte criteria for admission in | bronchiolitis?

Answer 82

Apnoea (observed or reported) Persistent oxygen saturation of <92% in air Inadequate oral fluid intake (<50% of normal fluid intake) Persisting severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute.

Question 83

Mx of RSV

Answer 83

Admit if fulfils criteria Deliver humidifed oxygen best through head box. Level can be determiend with pulse oximetry. Fluids and feed may need to be given by NG tube or IV. Only 5% require venitlation.

Question 84

A 2-year-old girl is brought to her GP because her mother has noticed she is constantly itching her bottom at night. Her mother says she has noticed some strange looking white bits when she wipes her daughters bottom following a bowel motion. What is the most appropriate management option? Prescribe 14 days of daily miconazole for whole household and issue hygiene advice. Issue hygiene advice only. Prescribe a single dose of mebendazole for the daughter and issue hygiene advice. Prescribe a single dose of mebendazole for the whole household and issue hygiene advice

Answer 84

This child is highly likely to have a threadworm infection with symptoms of perianal itching that is worse at night. It is also possible to see threadworms, described as small threads of slowly-moving white cotton either around the anus or in the stools. The risk of transmission in families is as high as 75%, and asymptomatic infestation is common. For this reason an anthelmintic drug (mebendazole) should be given as a single dose to all household members.

Question 85

64 | Features of threadworm infection

Answer 85

Asymptomactic in 90% Perianal itching, particulrly at night. Girls may have vulval symptoms. Dx can be made by applyoing sellotape to the perianal area and sending it to the laboratory for microscopy to identify the eggs.

Question 86

A mother comes to surgery with her 6-year-old son. During the MMR scare she decided not to have her son immunised. However, due to a recent measles outbreak she asks if he can still receive the MMR vaccine. What is the most appropriate action? Arrange for measles immunoglobulin to be given Cannot vaccinate at this age as live vaccine Give separate measles vaccine Give MMR with repeat dose in 3 months Give MMR with repeat dose in 5 years

Answer 86

The Green Book recommends allowing 3 months between doses to maximise the response rate. A period of 1 month is considered adequate if the child is greater than 10 years of age. In an urgent situation (e.g. an outbreak at the child's school) then a shorter period of 1 month can be used in younger children.

Question 87

Transient synovitis

Answer 87

Acute onset Usually accompanies viral infections, but the child is well or has a mild fever More common in boys, aged 2-12 years

Question 88

Septic arthritis/osteomyelitis

Answer 88

Unwell child, high fever

Question 89

Development dysplasia of the hip

Answer 89

Usually detected in neonates | 6 times more common in girls

Question 90

Perthes disease

Answer 90

More common at 4-8 years | Due to avascular necrosis of the femoral head

Question 91

myotonic dystrophy

Answer 91

Myotonic dystrophy (dystrophia myotonica, myotonia atrophica) is a chronic, slowly progressing, highly variable, inherited multisystemicdisease. It is an autosomaldominant disease.It is characterized by wasting of the muscles (muscular dystrophy), cataracts, heart conduction defects, endocrine changes, and myotonia.[1] There are two main types of myotonic dystrophy. Myotonic dystrophy type 1 (DM1), also called Steinert disease, has a severe congenital form and an adult-onset form. Myotonic dystrophy type 2 (DM2), also called proximal myotonic myopathy (PROMM) is rarer than DM1 and generally manifests with milder signs and symptoms. Myotonic dystrophy can occur in people of any age. Both forms of the disease display an autosomal-dominant pattern of inheritance. Both "DM1" and "DM2" have adult-onset forms.

Question 92

Which one of the following statements regarding scabies is false? All members of the household should be treated Typically affects the fingers, interdigital webs and flexor aspects of the wrist in adults Scabies causes a delayed type IV hypersensitivity reaction Patients who complain of pruritus 4 weeks following treatment should be retreated Malathion is suitable for the eradication of scabies

Answer 92

It is normal for pruritus to persist for up to 4-6 | weeks post eradication

Question 93

Features opf Scabies

Answer 93

Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults. The scabies mite burrows into the skin, laying its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.

Question 94

Clinical features of scabies

Answer 94

Widespread prutirus Linear burrows on the side of fingers, interdigital webs and flexor aspects of hte wrist. Infants the face and scalp may be affected. 2o features are due to scratching excoriation, infection

Question 95

Mx of scabies

Answer 95

Permethrin 5% is first line Malathion is second line. Guidance on use. Pruritus persists 4-6w post eradication

Question 96

When is crusted scabies seen? | Mx

Answer 96

Crusted scabies is seen in patients with suppressed immunity, especially HIV. The crusted skin will be teeming with hundreds of thousands of organisms. Ivermectin is the treatment of choice and isolation is essentia

Question 97

A 3-year-old girl presents with a 3 day history of fever and bloody diarrhoea. Over the past 24 hours she has had 5 episodes of loose bloody stools. On examination she has a temperature of 39.6ºC, a heart rate of 175 bpm and her abdomen is soft with generalised tenderness. It is also noted that she has a reduced urinary output. Blood tests show a haemolytic anaemia and raised urea. What is the most likely diagnosis? Campylobacter gastroenteritis Salmonella gastroenteritis Norovirus Rotavirus Escherichia coli gastroenteritis

Answer 97

A short history of bloody diarrhoea is very suggestive of haemorrhagic gastroenteritis which can occur due to a variety of pathogens including Campylobacter, Salmonella and Escherichia coli. In this case, the haemolytic anaemia and raised urea suggest haemolytic uraemic syndrome. Haemolytic anaemia and renal failure form two parts of the classic triad of haemolytic uraemic syndrome. The third part of the triad is thrombocytopenia. It is usually caused by Escherichia coli subtype 0157. Treatment is supportive as antibiotics are contraindicated.

Question 98

A 9 year old boy is brought to the emergency department by ambulance. For approximately 24 hours he has had nausea and vomiting. However, he has now developed acute abdominal pain and when he arrives in the emergency department his breathing is laboured, deep and of a gasping nature. He is usually fit and well and is not prescribed any medication. Blood results show the following: Na+130 mmol/l K+3.5 mmol/l HCO3-19 mmol/l What is the likely cause? Sepsis Rotavirus Intestinal obstruction Meningitis Diabetic ketoacidosis

Answer 98

The patient in this scenario has developed diabetic ketoacidosis (DKA). The important pieces of information to consider when answering this question are his acute presentation and the blood results. This patient has presented to the emergency department with nausea, vomiting and acute abdominal pain. These are all symptoms of diabetic ketoacidosis. Furthermore, the laboured, deep breathing that is mentioned is Kussmaul's breathing, which is witnessed in DKA and metabolic acidosis. Kussmaul's breathing occurs whereby excess CO2 is exhaled as a compensatory mechanism for an increased blood pH. The recognition of Kussmauls breathing in this question is one of the major factors in getting this question correct, as you would not expect to see this phenomenon in the other 4 possible answers. The blood results are concurrent with a diagnosis of DKA. Bloods will often show a hyponatraemia, low bicarbonate and a hypokalaemia in severe cases. The low bicarbonate in this question gives the indication that there is an acidosis in this patient, which helps in deriving the correct answer. Taking into account all other answers, they each could explain some of the symptoms of this child. However, the low bicarbonate, his symptoms and Kussmaul's respirations should lead to a working diagnosis of diabetic ketoacidosis in this patient.

Question 99

Features of DKA

Answer 99

Abdo pain Polyuria, polydipsia, dehydration Kussmaul respiration Acetone smelling breath

Question 100

A baby boy born 6 hours ago has an APGAR score of 10. He is not cyanosed, has a pulse of 140, cries on stimulation, his arms and legs resist extension and he has a good cry, He appears jaundiced. What is the most appropriate action? Encourage the mother to sit with the baby in sunlight Arrange a blood transfusion Start phototherapy Prescribe intravenous immunoglobulin Measure and record the serum bilirubin level urgently

Answer 100

Measure and record the serum bilirubin level urgently (within 2 hours) in all babies with suspected or obvious jaundice in the first 24 hours of life since this is likely to be pathological rather than physiological jaundice. NICE CG98

Question 101

Causes of jaundice in the first 24h

Answer 101

Rhesus disease ABO disease Hereditary spherocytosis G6PDD

Question 102

Jaundice <24h y/o

Answer 102

Always pathological

Question 103

Jaundice 2-14d

Answer 103

Common and usually physiological, commonly | seen in breast fed babies

Question 104

Causes of prolonged jaundice (>14d)

Answer 104

``` Biliary atresia Hypothyroidism Galactosaemia HTI Breast milk jaundice Congenital infections e.g. CMV, toxoplasmosis ```

Question 105

Daniel is a newborn who is having his baby check done by nurse Karen, who notices that he has microcephaly with a prominent occiput, low set ears, micrognathia, palpebral fissures ``` and wide spaced eyes. What genetic disorder are these features suggestive of? Edward's syndrome Down's syndrome Turner's syndrome Noonan syndrome Angelman syndrome ```

Answer 105

``` The correct answer for this question is Edward's syndrome. All of the aforementioned characteristics can be present in Edward's syndrome. Furthermore, individual's with Edward's syndrome can also have: Ptosis Rocker bottom feet Undescended testes ```

Question 106

Features of kawasaki's disease

Answer 106

``` High-grade fever which lasts >5d and is characteristically resistant to antipyretics Conjunctival injection Bright red, cracked lips Strawberry tongue Cervical lymphadenopathy Red plams of the hands and the soles of the feet which alter peel ```

Question 107

Mx of kawasaki

Answer 107

High dose aspirin IVIG Echocardiogram as screening test for coronary artery aneurysm

Question 108

Cx of kawasaki

Answer 108

Coronary artery aneurysm

Question 109

An 8-year-old boy presents with increasing jaundice over the past week. He was recently treated with nitrofurantoin for a simple urinary tract infection. On examination he is obviously jaundiced, and he is looking pale and breathless. Investigation results are as follows: Hb58 g/l Platelets250 * 109/l WBC6.5 * 109/l A blood films demonstrates red cell fragments and Heinz bodies. What is the most likely diagnosis? Pyruvate kinase deficiency Sickle cell disease Glucose-6-phosphate dehydrogenase deficiency Beta-thalassaemia Hereditary spherocytosis

Answer 109

Glucose-6-phosphate dehydrogenase deficiency is an X linked disorder affecting red cell enzymes. It results in a reduced ability of the red cells to respond to oxidative stress. Therefore, red cells have a shorter life span and are more susceptible to haemolysis, particularly in response to drugs (e.g. nitrofurantoin), infection, acidosis and certain dietary agents (e.g. fava beans). The red cell fragments, Heinz bodies and anaemia confirm a haemolytic anaemia.

Question 110

Features of G6PD

Answer 110

``` Features neonatal jaundice is often seen intravascular haemolysis gallstones are common splenomegaly may be present Heinz bodies on blood films ```

Question 111

A 6-year-old boy is reviewed in clinic due to nocturnal enuresis. His mother has tried using a star-chart but unfortunately this has not resulted in any significant improvement. Of the following options, what is the most appropriate initial management strategy? Enuresis alarm Trial of oral desmopressin Trial of imipramine Trial of intranasal desmopressin Restrict fluids in the afternoon and evening

Answer 111

Restricting fluids is not recommended advice - Clinical Knowledge Summaries suggest: 'Do not restrict fluids. The child should have about eight drinks a day, spaced out throughout the day, the last one about 1 hour before bed.' Enuresis alarm

Question 112

Mx of Nocturnal enuresis

Answer 112

Look for possible underlying causes/triggers: constipation, DM, UTI Advise on fluid intake Reward systems e.g. star charts Enuresis alarm for children <7 Desmopressin may be used if >7y particulalry if ST control is needed or an enuresis alarm has been ineffective

Question 113

Henry is a 29 week premature baby who was born 2 weeks ago. Over the past week it has been noted that he has had bloody stool, abdominal distension and has not been feeding well. Physical examination reveals an increased abdominal girth with reduced bowel sounds. Abdominal X-ray shows dilated asymmetrical bowel loops and bowel wall oedema. What is the likely diagnosis? Intussusception Inflammatory bowel disease Pyloric stenosis Hirschsprung's disease Necrotising enterocolitis

Answer 113

The correct answer for this question is | necrotising enterocolitis.

Question 114

You see a worried mum with her 6 month old baby boy. She is concerned that his skull shape is not normal. His development and birth have been normal and there are no conditions in the family. On examination his head circumference is at the 40th centile with his height and weight at the 30th centile. His occiput is flattened on the left, his left ear mildly protruding forward and his left forehead more prominent than the right. No other abnormality is detected. What is the most appropriate management? Urgent referral to neurosurgery Suggest buying an infant helmet Arrange an MRI scan Routine referral to community child health clinic Reassurance

Answer 114

Plagiocephaly is more common since there have been campaigns to encourage babies to sleep on their back to reduce the risk of sudden infant death syndrome (SIDS). Plagiocephaly is a skull deformity producing unilateral occipital flattening, which pushes the ipsilateral forehead ear forwards producing a 'parrallelogram' appearance. The vast majority improve by age 3-5 due to the adoption of a more upright posture. Helmets are not usually recommended as there was no significant difference between groups in a randomised controlled trial. Turning the cot around may help the child look the other way and take the pressure off the one side. Other simple methods include giving the baby time on their tummy during the day, supervised supported sitting during the day, and moving toys/ mobiles around in the cot to change the focus of attention. Ensure all advice is in line with prevention of SIDS

Question 115

A 4-year-old boy was discharged from the hospital six weeks ago after an episode of viral gastroenteritis. He now has 4-5 loose stools each day which has been present for the past four weeks. What is the most likely diagnosis? Coeliac disease Inflammatory bowel disease Secondary bacterial infection Lactose intolerance Clostridium difficile infection

Answer 115

Transient lactose intolerance is a common complication of viral gastroenteritis. Removal of lactose from the diet for a few months followed by a gradual reintroduction usually resolves the problem.

Question 116

A 1-year-old girl is investigated for recurrent urinary tract infections. A micturating cystourethrogram is ordered: What does this image demonstrate? ``` Vesicoureteric reflux Horseshoe kidney Paediatric urolithiasis Duplex collecting system Isolated right-sided hydronephrosis ```

Answer 116

This image demonstrates grade V vesicoureteric reflux - gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity. A DMSA scan is needed to identify renal scarring.

Question 117

A 15-year-old boy presents to his GP complaining of knee pain for one week. He has no significant past medical history. Which of the following would make a diagnosis of Osgood-Schlatter disease more likely? Bilateral knee pain. Sudden onset of symptoms and acutely painful. Knee pain isolated to the posterior aspect of the knee joint. Pain relieved by rest and made worse by kneeling and activity, such as running or jumping. Locking of the knee on movement

Answer 117

Osgood-Schlatter disease may be diagnosed on the basis of clinical features alone. This age group (adolescent) is the most likely age to suffer from this condition and is localized to the tibial tuberosity. Typically, pain is: Unilateral (but may be bilateral in up to 30% of people). Gradual in onset and initially mild and intermittent, but may progress to become severe and continuous. Relieved by rest and made worse by kneeling and activity, such as running or jumping.

Question 118

A 2-year-old boy is brought to the surgery by his mother with earache and pyrexia. On examination of the precordium a murmur is heard. Which one of the following characteristics is not consistent with an innocent murmur? Short buzzing murmur in the aortic area Soft-blowing murmur in the pulmonary area Varies with posture Diastolic murmur Continuous blowing noise heard just below the clavicles

Answer 118

Diastolic murmur

Question 119

``` Which one of the following types of glomerulonephritis is most characteristically associated with streptococcal infection in children? Focal segmental glomerulosclerosis Diffuse proliferative glomerulonephritis Membranous glomerulonephritis Mesangiocapillary glomerulonephritis Rapidly progressive glomerulonephritis ```

Answer 119

Diffuse proliferative glomerulonephritis

Question 120

A mother brings her 3-year-old child in to receive the DTP booster. Which one of the following would make it inappropriate to give the vaccination today? Being below the 2nd centile for weight Family history of allergy to DTP Recent onset of a seizure disorder currently being investigated Planned general anaesthesia in 2 weeks time Being born at 29 weeks gestation

Answer 120

DTP: vaccination should be deferred in children with an evolving or unstable neurological condition

Question 121

16-year-old boy presents to the emergency room with a history of groin pain for the past three hours. He has associated nausea and has vomited three times. He reports that he recently had unprotected vaginal sex. On examination there is tenderness and swelling of the scrotum and left testicle, with absence of the cremaster reflex on the left side. Elevation of the affected testicle causes increased pain. What is the most likely diagnosis? Torsion of the hydatid of Morgagni Strangulated inguinal hernia Epididymitis Testicular torsion Hydrocoele

Answer 121

Testicular torsion occurs when the testis turns on the remnant of the processus vaginalis thereby restricting blood flow. It usually presents with acutely severe testicular pain often with associated nausea and vomiting. There may be swelling of the testis with overlying erythema. The cremaster reflex may also be absent on the affected side. Elevation of the testicle often results in worsening of the pain. Although this patient recently had unprotected sex, the history is less suggestive of epididymitis. With epididymitis we would expect urinary symptoms. In addition, elevation of the testes often relieves the pain (Prehn's sign positive).

Question 122

You are called to the post natal ward to review an 8 hour old baby born by elective caesarian section at 39 weeks gestation. After reading the case notes you discover the use of maternal labetalol for high blood pressure. On examination the baby appears jittery and hypotonic. What is the most appropriate next step? Record temperature and ensure adequately wrapped Perform full septic screen Measure blood glucose levels Start empirical antibiotics for early onset sepsis Re-examine after next feed

Answer 122

A jittery and hypotonic baby may suggest neonatal hypoglycaemia. The use of maternal labetalol is a risk factor and these babies must have their blood glucose measured. Neonatal abstinence syndrome may also present in this way and so the use of maternal opiates or illicit drug use in pregnancy should also be ascertained.

Question 123

On routine antenatal swabs, a mother is found to be colonised with Group B Streptococcus. However, she did not receive adequate intrapartum antibiotic prophylaxis and she delivers a healthy baby girl by vaginal delivery. Her baby does not require any resuscitation and remains well in the post natal ward. The mother is eager for discharge home. What is the most appropriate course of action with regards to her child? Intravenous antibiotics for 24 hours Check C-Reactive protein levels and take blood cultures Discharge if no suspicion of infection Perform routine 6 hour post natal check and discharge with community midwife follow up. Regular observations for 24 hours

Answer 123

Maternal colonisation with group B streptococcus is a minor risk factor for early onset sepsis in the newborn. Newborns with only one minor risk factor for early onset sepsis should remain in hospital for at least 24 hours with regular observations. Two or more minor risk factor or one red flag warrant empirical antibiotic therapy with Benzylpenicillin and Gentamicin and a full septic screen.

Question 124

A 9-year-old girl is brought to surgery as her mother is concerned that she is too fat. This has now been a problem for over two years and mum feels this is holding her back at school. What is the most appropriate method to ascertain how obese she is? Body mass index Body mass index percentile adjusted to age and gender Weight plotted on percentile chart Mother's perception Waist circumference

Answer 124

Defining obesity is more difficult in children than adults as body mass index (BMI) varies with age. BMI percentile charts are therefore needed to make an accurate assessment. Recent NICE guidelines suggest to use 'UK 1990 BMI charts to give age- and gender-specific information'

Question 125

A newborn male baby is found to have an undescended right testicle during the routine 6-8 week examination. It is neither palpable in the scrotum or inguinal canal. What is the most appropriate management? Outpatient referral to urology to be seen within 4 weeks Review at 3 months Immediate referral to urology Arrange ultrasound abdomen and scrotum Review at 12 months

Answer 125

Undescended testicle - wait 6 months prior to referral If the testicle has not descended by around 3 months then referral should be considered for orchidopexy.

Question 126

A 6-week-old term infant has difficulty feeding due to increased breathlessness. As the on-call doctor you are called to review this baby. You witness the baby feeding and note she is pink and well perfused but sweating profusely with and increased respiratory rate. On examination you hear a soft pan-systolic murmur at the lower left sternal border. What is the most likely underlying pathology? Transient tachypnoea of the newborn Acute respiratory distress syndrome Heart failure Eisenmenger syndrome Infantile pneumonia

Answer 126

Heart failure typically presents in infants with symptoms of breathlessness worse on exertion (e.g. feeding), sweating, poor feeding and recurrent chest infections. On examination you should: examine the growth charts (?failure to thrive), examine for tachycardia, tachypnoea, murmurs and pre and post-ductal saturations. Heart failure may be due to duct dependant systemic circulations (<2 weeks old) e.g. coarctation of the aorta or left-to-right shunts (>2 weeks old) e.g. VSD as the pulmonary vasculature resistance begins to fall. In this case the baby has a large VSD causing decompensated heart failure. Cardiac lesions can be missed during the foetal anomaly scan and this baby would need a detailed foetal echocardiogram and discussion with the cardiac team on management strategies.

Question 127

An 18 month old child attends the paediatric assessment unit with his mother. He has been brought in as he has had a fever, barking cough and difficulty breathing at night. He has been diagnosed with croup and you have been asked to see him to review. After history and assessment you are confident there is no stridor or respiratory distress. What would your next step in management be? Give antibiotics Give oxygen Full ENT exam Give nebulised adrenaline Give oral dexamethasone

Answer 127

This child has mild croup, the severity of croup is based upon; respiratory rate, respiratory distress, heart rate, O2 saturations and exhaustion. Treatment of mild croup is oral dexamethasone 0.15mg/kg single dose and review. Systemic dexamethasone and nebulised adrenaline 5ml of 1:1000 are used in severe croup, alongside oxygen administration. Antibiotics should not be given unless an underlying bacterial infection is suspected. You should not perform an ENT exam due to the possibility of an epiglottis diagnosis.

Question 128

A mother notices that her newborn boy has small eye openings, a small body and low-set ears. On examination the paediatrician also notes a flat philtre, a sunken nasal bridge, short palpebral fissures and a thin upper lip. What is the most likely cause? Diabetes Maternal alcohol abuse Group B Streptococcal infection Maternal Listeria Maternal opioid abuse

Answer 128

Fetal alcohol syndrome Maternal alcohol abuse during pregnancy. Presentation: IUGR, microcephaly, midfacial hypoplasia, micrognathia, smooth philtrum, microphthalmia, short palpebral fissures, thin upper lip, irritability, ADHD.

Question 129

A 2 day old baby who was born by a ventouse delivery is noted to have a swelling on the left side of his head in the parietal region. His head appeared normal immediately after delivery. On examination, the baby is well and the swelling does not cross suture lines. The fontanelles and sutures appear normal. What is the most likely diagnosis? Subaponeurotic haematoma Caput succedeneum Craniosynostosis Skull fracture Cephalohaematoma

Answer 129

A cephalohaematoma appears as a swelling due to bleeding between the periosteum and the skull. It is most commonly noted in the parietal region and is associated with instrumental deliveries. The swelling usually appears 2-3 days following delivery and does not cross suture lines. It gradually resolves over a number of weeks.

Question 130

A 9-year-old boy who has recently arrived from India presents with fever. On examination a grey coating is seen surrounding the tonsils and there is extensive cervical lymphadenopathy. What is the most likely diagnosis? Dengue fever Typhoid Paratyphoid Actinomycosis Diphtheria

Answer 130

Diphtheria

Question 131

A baby born at 35 weeks gestations via normal vaginal delivery is found to be irritable 48 hours after birth and suffers a convulsion. There is no obvious head trauma or swellings. Which one of the following cranial injuries is most likely to have occurred? Caput succedaneum Cephalohaematoma Subaponeurotic haemorrhage Intraventricular haemorrhage Extradural haemorrhage

Answer 131

Caput succedaneum is caused by pressure on the fetal scalp during the birthing process. It results in a large oedematous swelling and bruising over the scalp. Treatment is not required as the swelling reduces over a few days. A cephalohaematoma may occur after a spontaneous vaginal delivery or following a trauma from the obstetric forceps or the ventouse. A haemorrhage results after the presidium is sheared from the parietal bone. The tense swelling is limited to the outline of the bone. It reduces over a few weeks - months. A Subaponeurotic haemorrhage, also known as a subgaleal haemorrhage is rare and is due to a traumatic birth. It may result in the infant losing large amounts of blood. An intracranial haemorrhage refers to subarachnoid, subdural or intraventricular haemorrhages. Subarachnoid haemorrhages are common and may cause irritability and even convulsions over the first 2 days of life. Subdural can following the use of forceps. Intraventricular haemorrhage mostly affects pre-term infants and can be diagnosed by ultrasound examinations. Extradural haemorrhage is unlikely to occur during the birthing process.

Question 132

You are an FY1 on the paediatric ward round with your consultant. Whilst seeing a child that has been admitted with croup, the consultant you're with decides to quiz you on the pathophysiology. 'What is the most likely organism to cause croup?' Respiratory syncytial virus (RSV) Parainfluenza virus Pseudomonas aeruginosa Streptococcus pneumoniae Bordetella pertussis

Answer 132

Parainfluenza

Question 133

A 2-year-old boy presents with a harsh cough and pyrexia. His symptoms worsened overnight and on examination stridor is noted. Which one of the following interventions may improve his symptoms? Codeine linctus Humidified oxygen Nebulised salbutamol Oral erythromycin Oral dexamethasone

Answer 133

Oral dexamethasone

Question 134

A 5-year-old girl attends your GP surgery with her mother. She reports a five day history of a sore throat and fever. On examination you note a bright red tongue, flushed face and a rough dry erythematous rash on her neck. What is the most likely diagnosis? Measles Rubella Bordetella pertussis Kawasaki disease Scarlet fever

Answer 134

A strawberry tongue can be seen in both scarlet fever and Kawasaki disease. However given the history a diagnosis of scarlet fever is more likely.

Question 135

An 8-year-old boy presents with weakness and purple striae on his abdomen. On examination he is obese with a central fat distribution and is found to have facial plethora. He is also found to have a blood pressure of 130/85 mmHg and facial plethora. What is the most likely underlying cause? ``` ACTH-secreting pituitary tumour Adrenal carcinoma Craniopharyngioma Congenital adrenal hyperplasia Ectopic adrenocorticotropin-producing tumour ```

Answer 135

The history is suggestive of Cushing's syndrome. In an 8-year old boy the commonest cause of Cushing's would be iatrogenic use of glucocorticoids. Out of the options above the most likely answer is an ACTH-secreting pituitary tumour.

Question 136

589 A 2-year-old child with a history of atopic eczema is brought to the local GP surgery. Her eczema is usually well controlled with emollients but her parents are concerned as the facial eczema has got significantly worse overnight. She now has painful clustered blisters on both cheeks, around her mouth on her neck. Her temperature is 37.9ºC. What is the most appropriate management? Advise paracetamol + emollients and reassure Admit to hospital Add hydrocortisone 1% Oral flucloxacillin Topical fusidic acid

Answer 136

Eczema herpeticum is a serious condition that | requires IV antivirals

Question 137

A baby is born at term via vaginal delivery with no complications, however he is still not showing signs of breathing at one minute. Heart rate is >100bpm, but he is floppy and cyanosed. What is the most appropriate next step in management? Call for anaesthetist to intubate the baby 5 mouth-to-mouth rescue breaths 5 breaths of oxygen via face mask Start chest compressions Suction airways

Answer 137

Airway suction should not be performed unless there is obviously thick meconium causing obstruction, as it can cause reflex bradycardia in babies. Chest compressions are not indicated, as the HR in this case is >100bpm. CPR should only be commenced at a HR < 60bpm. In cases where there are no signs of breathing and this is thought to be due to fluid in the lungs, five breaths should be given via a 250ml bag via face mask. This is a more effective and more hygienic method than using mouth-to-mouth in a hospital setting.

Question 138

A 14-year-old male being investigated for irondeficiency anaemia is found to have numerous polyps in his jejunum. On examination he is also noted to have pigmented lesions on his palms and soles. What is the likely diagnosis? Hereditary non-polyposis colorectal carcinoma Gardner's syndrome Familial adenomatous polyposis Peutz-Jeghers syndrome Hereditary haemorrhagic telangiectasia

Answer 138

Hereditary haemorrhagic telangiectasia is associated with mucocutaneous lesions and iron-deficiency anaemia but intestinal polyps are not a feature

Question 139

You see a 6 week-old baby boy for his routine baby check and note a small, soft, umbilical hernia on examination. What should you do? ``` Advise parents to tape a coin over the area Refer for surgery Refer for ultrasound Watch and wait Arrange emergency admission ```

Answer 139

Small umbilical hernias are common in babies and tend to resolve by 12 months of age. Parents should be reassured no treatment is usually required but to be aware of the signs of obstruction or strangulation such as vomiting, pain and being unable to push the hernia in - this is rare in infants. Advise the parents to present the child at around 2 years of age if the hernia is still present to arrange referral to a surgeon. Attempts to treat the hernia by strapping or taping things over the area are not helpful and can irritate the skin.

Question 140

A 12-year-old female from Bulgaria presents to the surgery. She reports being unwell for the past 2 weeks. Initially she had a sore throat but she is now experiencing joint pains intermittently in her knees, hips and ankles. On examination there are some pink, ring shaped lesions on the trunk and occasional jerking movements of the face and hands. What is the most likely diagnosis? Lyme disease Infective endocarditis Polyarticular juvenile idiopathic arthritis Rheumatic fever Still's disease

Answer 140

Rheumatic fever

Question 141

You are reviewing a 9-month-old child with suspected bronchiolitis. Which one of the following features should make you consider other possible diagnoses? Fine inspiratory crackles Rhinitis Feeding difficulties Temperature of 39.7ºC Expiratory wheeze

Answer 141

A low-grade fever is typical in bronchiolitis. SIGN guidelines advise that the presence of high fever should make the clinician carefully consider other causes before making the diagnosis.

Question 142

After birth which of the following happens in the foetus? The foramen ovale opens allowing blood to circulate into the pulmonary artery Haemoglobin A is replaced by Haemoglobin F, which has a lower affinity for oxygen and may lead to physiological jaundice in the newborn The umbilical veins and arteries remain open for several days The ductus arteriosus closes The first few breaths force lung fluid into the fetal alveoli

Answer 142

After birth, the foramen ovale, ductus arteriosus and umbilical vessels close within a few hours. After a few days Haemoglobin F is replaced by Haemoglobin A, which has a lower affinity for oxygen and may lead to physiological jaundice in the newborn, due to the breakdown of fetal blood cells. The first few breaths force lung fluid out of the fetal alveoli.

Question 143

An 18-month-old boy is brought to the GP by his mother as she is concerned about his breathing. Three days ago he started with fever, cough and rhinorrhoea. For the past 24 hours his mother reports that he has been 'wheezy'. On examination his temperature is 37.9ºC, heart rate 126/min, respiratory rate 42/min and a bilateral expiratory wheeze is noted. You prescribe a salbutamol inhaler along with a spacer. Two days later the mother represents noting the inhaler has made little difference to the wheeze. Clinical findings are similar, although his temperature today is 37.4ºC. What is the most appropriate next step in management? Inhaled long-acting beta agonist Oral prednisolone Add in regular ipratropium bromide Oral montelukast or inhaled corticosteroid Oral amoxicillin

Answer 143

This child is likely to have a viral-induced wheeze, also known as episodic viral wheeze. First-line treatment is short-acting bronchodilator therapy. If this is not successful then either oral montelukast or inhaled corticosteroids should be tried.

Question 144

``` What is the most common cause of hypertension in children? Renal vascular disease Congenital adrenal hyperplasia Renal parenchymal disease Coarctation of the aorta Phaeochromocytoma ```

Answer 144

Renal parenchymal disease

Question 145

It is December and you are the paediatric foundation doctor. A five month old baby is admitted through the paediatric observation unit with tachypnoea, tachycardia and fever. On examination there is evidence of increased work of breathing with sub costal and diaphragmatic recession. There is widespread wheeze. You discuss the patient with your senior and a diagnosis of bronchiolitis is established. Oxygen is started but it is not deemed appropriate to begin intravenous fluids at this time. Which investigation is important to conduct in the management of this patient? Glucose Full blood count Nasopharyngeal aspirate Urea and electrolytes Arterial blood gas

Answer 145

Nasopharyngeal aspirate are recommended during the winter months to ascertain which children are suffering with respiratory syncitial virus positive bronchiolitis. By diagnosing these patients it helps with ward management of patients, placing RSV negative patients on a ward and RSV positive patients in a side room. Urea and electrolytes would only be appropriate if the patient was on IV fluids.

Question 146

Charlie is a 7 month old baby boy who presents to you with poor weight gain (50th to 10th centile), on examination he has an erythematous, blanching rash over his abdomen, colicky abdominal pain and vomiting after feeds. He has been breast feeding with top ups of 'Aptamil' formula. What is the most likely diagnosis? Pyloric stenosis Eczema Infantile colic Cows' milk protein intolerance Reflux

Answer 146

The correct answer is cows' milk protein intolerance. The following clues in the history would suggest the diagnosis of cows' milk protein intolerance: Multi-system involvement 7 months would suggest the new introduction of top up feeds which correlates with the symptoms Faltering growth along with the multi-system involvement would suggest cows' milk protein intolerance Charlie is older than the classical age of presentation for pyloric stenosis (2 to 8 weeks ``` very rare above 6 months) The presentation is unusual for eczema, infantile colic and reflux due to the multisystem involvement in the history making cows' milk protein intolerance more likely. ```

Question 147

A newborn is found to have a number of congenital abnormalities including an extra finger on each hand, a cleft palate and lip, microphthalmia and microcephaly. Which of the following chromosomes is most likely to be affected in this child? 9 12 13 18 21

Answer 147

Patau syndrome is a chromosomal abnormality resulting in an extra full copy of chromosome 13 (trisomy 13). Like many of the chromosomal defects, physical and mental disability is common, in this case key distinguishing features to separate Patau's from other trisomy disorders include polydactyly, cleft lips and palates, microcephaly and microphthalmia. Many children die before within a year of birth but those who survive will often go on to show intellectual and motor disability.

Question 148

``` 14-year-old boy is brought in by his mother who noticed her child had repeated episodes of slurred speech and gait abnormalities. On musculoskeletal examination, you notice muscle weakness, dysdiadochokinesis and spinal scoliosis. What is the mode of inheritance of this condition? X-linked recessive Autosomal dominant Point mutation X-linked dominant Autosomal recessive ```

Answer 148

Firedrich's ataxia | AR

Question 149

``` A 6-year-old boy is diagnosed as having nephrotic syndrome. A presumptive diagnosis of minimal change glomerulonephritis is made. What is the most appropriate treatment? Cyclophosphamide Albumin infusion Plasma exchange Renal biopsy followed by prednisolone Prednisolone ```

Answer 149

A renal biopsy is only indicated if response to | steroids is poor

Question 150

A 29-week-old baby is born premature and shortly after birth experiences tachypnoea and tachycardia along with chest wall retractions. The paediatrician notes that the neonate has a blue discolouration of the skin and commences continuous positive airway pressure (CPAP) and intravenous fluids before explaining to the parents that the lungs lack surfactant, a compound that helps people breathe. Which of the following cells are responsible for surfactant production? Microfold cells Alveolar macrophage Type 1 pneumocytes Type 2 pneumocytes Paneth cells

Answer 150

Type 1 pneuomcytes are involved in the process of gas exchange between the alveoli and the blood and type 2 pneumocytes produce pulmonary surfactant

Question 151

A mother brings her son in to surgery as she suspects he has a squint. She thinks his right eye is 'turned inwards'. You perform a cover test to gather further information. Which one of the following findings would be consistent with a right esotropia? On covering the left eye the right eye moves medially to take up fixation The cover test could not be used to identify this type of defect On covering the left eye the right eye moves laterally to take up fixation On covering the right eye the left eye moves laterally to take up fixation On covering the right eye the left eye moves medially to take up fixation

Answer 151

On covering the left eye in this example the right eye moves laterally from the nasal (esotropic) position to take up fixation.

Question 152

A neonate who was born prematurely at 35 weeks gestation is registered at the Practice. He was very well after delivery, without any notable complications such as respiratory problems. How should his routine childhood immunisations be given? Adjust schedule for gestational age Give according to chronological age Refer to the hospital to receive first immunisations Start immunisations at 3 months old Delay until weight reaches 3.5kg

Answer 152

Babies who were born prematurely should receive their routine vaccinations according to chronological age; there should be no correcting for gestational age. Babies who were born prior to 28 weeks gestation should receive their first set of immunisations at hospital due to risk of apnoea.

Question 153

A 14-year-old attends surgery. She was diagnosed with having migraines three years ago and requests advice about options for treating an acute attack. Which one of the following medications is it least suitable to recommend? Aspirin Paracetamol + prochlorperazine Paracetamol + codeine Ibuprofen Paracetamol

Answer 153

Avoid aspirin in children < 16 years as risk of Reye's syndrome Aspirin should be avoided in children due to the risk of Reye's syndrome. Codeine would also be a poor choice as it has limited benefit in migraine.

Question 154

You are reviewing a 11-month-old baby with a viral upper respiratory tract infection. She is clinically well but at the end of the consultation her mother asks you about her development. You notice that she points and babbles 'mama' and 'dada' but has no other words. She is shy and cries when you try to examine her. There is an early pincer grip and she can roll from front to back but she cannot yet sit without support. How would you describe her development? Normal development Global developmental delay Isolated delay in gross motor skills Delay in speech + social skills, possibly early autism Isolated delay in fine motor skills

Answer 154

Most babies can sit without support at 7-8 months so this probably represents a delay in gross motor skills. If still present at 12 months she should be considered for referral to a paediatrician. The other development features are normal for her age.

Question 155

Meera brings her 5 year old daughter Reena to the surgery who is being treated for acute lymphoblastic leukaemia (ALL) for review as Reena's classmate has been sent home from school with chickenpox. Reena is asymptomatic currently. Meera is unclear if Reena has suffered with chicken pox previously. What would be the correct management? Admit urgently Send home and come back if symptomatic Prescribe aciclovir Prescribe varicella zoster immunoglobulin Urgent bloods for varicella zoster antibodies

Answer 155

'People who have had a significant exposure to chickenpox and who are immunocompromised should be tested for varicella-zoster antibody, regardless of their history of chickenpox. Test for varicella-zoster immunoglobulin G (IgG) antibodies in primary care if test results can be available within 2 working days of first exposure. If this is not possible, urgently seek specialist advice because testing in secondary care and/or varicella-zoster immunoglobulin prophylaxis may be needed.'

Question 156

A newborn baby has their blood glucose measured on the post natal ward as part of the neonatal hypoglycaemia protocol due to low birthweight. It measures 2.9mmol/L. The midwife asks you what you want to do next? Admit to the Special Care Baby Unit (SCBU) for NG feeding Offer additional feed if willing Administer 100 mls intravenous 20% glucose Measure blood glucose again in three hours time Take blood sample for a formal glucose measurement

Answer 156

Neonatal hypoglycaemia is a common medical problem affecting neonates. This usually represents adaption to extrauterine life as opposed to any significant underlying medical problems. In the neonate blood glucose levels of >2.5mmol/L are usually regarded as normal. Formal measurements may be needed to confirm readings of either extreme as they are more reliable. If measurements are consistently >2.5mmol/L then monitoring can be stopped.

Question 157

Which one of the following statements regarding absence seizures is incorrect? Typical age of onset of 3-10 years old Sodium valproate and ethosuximide are firstline treatments Seizures may be provoked by a child holding their breath There is a good prognosis The EEG characteristically shows a bilateral, symmetrical 3Hz spike and wave pattern

Answer 157

Seizures are characteristically provoked by | hyperventilation

Question 158

``` A 4-year-old boy is admitted after developing a haemarthrosis in his right knee whilst playing in the garden. The following blood results are obtained: Platelets220 * 109/l PT12 secs APTT78 secs Factor VIIIc activityNormal What is the most likely diagnosis? Antithrombin III deficiency Von Willebrand's disease Antiphospholipid syndrome Haemophilia A ``` Haemophilia B

Answer 158

A grossly elevated APTT may be caused by heparin therapy, haemophilia or antiphospholipid syndrome. A normal factor VIIIc activity points to a diagnosis of haemophilia B (lack of factor IX). Antiphospholipid syndrome is a prothrombotic condition

Question 159

6-week-old infant is referred from the health visitor due to failure to thrive. The infant has fallen from the 50th to 9th centile on growth chart for weight. On further questioning, the parents reveal the infant vomits following each meal, which have on occasions 'hit the wall.' The mother's pregnancy was unremarkable, with normal antenatal scans, and the infant was born by an uncomplicated vaginal delivery. There were no abnormal features noted at the newborn baby examination. What is the most likely diagnosis? Intussusception Infantile colic Cow's milk protein intolerance Galactosaemia Pyloric stenosis

Answer 159

In this question the most likely diagnosis is pyloric stenosis. Pyloric stenosis typically presents around 2-6 weeks of age. Infants tend to have projectile vomiting following feeds and remain hungry after vomiting. There may be an olive shaped mass in the right upper quadrant due to hypertrophy of the pylorus, and 'waves of peristalsis' may be seen following a test feed.

Question 160

A man brings his 18 month old daughter to your GP clinic. She has had coryzal symptoms for the last 2 days. Last night, she started with a barking cough and a mild temperature of 37.8º. On examination, there is a mild stridor when mobilising, with no recessions visible. Chest sounds clear with good air entry bilaterally. Temperature today remains at 37.8º, but all other observations are normal. What is the appropriate management? Admit to hospital Give nebulised adrenaline Give a stat dose of dexamethasone 150 micrograms/kg PO Give a salbutamol inhaler Start antibiotics

Answer 160

This is a child who has croup. This is an illness that usually starts with coryzal symptoms, and the child then develops a seal like, barking cough. The first stage is to work out how serious a case of croup this child has. Generally recommendations include: Mild croup: Occasional barking cough with no stridor at rest No or mild recessions Well looking child Moderate croup: Frequent barking cough and stridor at rest Recessions at rest No distress Severe croup: Prominent inspiratory stridor at rest Marked recessions Distress, agitation or lethargy Tachycardia In this case, the child would have mild croup. Admission to hospital is only considered for moderate or severe croup, or if an alternative severe diagnosis like epiglottitis is suspected. It would not be appropriate in this case. Nebulised adrenaline would only be used for children who were distressed, or who had a severe stridor. It would be not be used in this case as this child is well at rest with only a mild stridor on movement. A salbutamol inhaler would only help if the child had wheeze, which she does not in this case. It would not give her any benefit. Antibiotics are not indicated in croup as it is a viral illness. Systematic reviews have shown that steroids can ease symptoms within a few hours. They also lead to fewer reattendances and fewer hospital admissions. Mild croup will resolve on its own, but Dexamethasone has been shown to be of some benefit.

Question 161

BB. A 5-year-old girl is brought to A+E after school by her mother and school teacher with central abdominal pain. The best history is likely to be obtained by talking to: Answers: a. Her mother b. Her mother and her school teacher c. Her school teacher d. The A+E triage nurse e. girl herself and her mother

Answer 161

girl herself and mother

Question 162

BB. A two-year-old boy is seen in Paediatric Out-Patients with a 6 month history of diarrhoea and parental concern about his nutritional status. The best way to assess these concerns would be to: a. Assess his weight for height b. Calculate his Body Mass Index (BMI) c. Measure his height and weight in clinic d. Measure his upper arm circumference e Review and plot serial weights and heights

Answer 162

e | Review and plot serial weights and heights

Question 163

BB A previously healthy 2-year-old child presents with a 24 hour history of diarrhoea and vomiting. Which of the following is the single, most accurate method for assessing the degree of dehydration? a. Assess skin turgor b. Assess the fontanelle c. Calculate the difference between the current weight and the predicted weight from the child’s growth records d. Examine the mucous membranes e. Measure the heart rate and blood pressu

Answer 163

c. | Calculate the difference between the current weight and the predicted weight from the child’s growth records

Question 164

BB. A 3-year-old boy attends the Paediatric A+E Department because he has developed an itchy rash whilst at a birthday party. Of the following features, which requires immediate treatment with 0.01 ml/kg of 1:1000 adrenaline i.m.? a. Blood pressure of 88/50 b. Generalised urticaria c. Lip swelling d. Respiratory rate of 22/minute e. Wheeze on auscultatio

Answer 164

e. | Wheeze on auscultatio

Question 165

BB A 3-year-old boy has just started fitting in A+E. You are the F1 doctor. The nurses are all busy with other children. Of the following actions which should you do first?: a. Administer oral midazolam b. Do a blood gas c. Gain iv access d. Give him high-flow oxygen e. Measure his blood sugar

Answer 165

d. | Give him high-flow oxygen

Question 166

BB A 15-month-old girl presents with a 3-day history of intermittent fevers and vomiting and poor feeding. On examination her temperature is 38.6 C but there are no localising signs. What is the most likely cause? a. Bronchiolitis b. Encephalitis c. Meningitis d. Pyloric stenosis e. Urinary tract infection

Answer 166

UTI

Question 167

BB A three year old girl presents with a two day history of fever of 37.8º and inspiratory stridor. She has a loud barking cough which is worse in the night. What is the most likely diagnosis? a. Acute exacerbation of asthma b. Bacterial tracheitis c. Croup d. Epiglottitis e. Pneumonia

Answer 167

Croup

Question 168

BB A term neonate is cyanotic and tachypnoeic at birth. There is soft pan systolic murmur at the lower sternal edge. An antenatal scan had shown a VSD, overriding aorta and infundibular stenosis. What is the most likely diagnosis? a. Ebstein anomaly b. Tetralogy of Fallot c. Total anomalous pulmonary venous return d. Transposition of the great arteries e. Truncus arteriosus

Answer 168

b. | Tetralogy of Fallot

Question 169

BB A 6 yr old male born in the UK to Iraqi parents, develops sudden onset very dark red urine with no dysuria. He has a intercurrent viral infection. On exam, slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice. Which investigation is most likely to reveal the underlying diagnosis? a. Blood film b. G6PD level, now and in one month's time c. Hb electrophoresis d. Liver function tests e. Urine M,C&S

Answer 169

b. | G6PD level, now and in one month's time

Question 170

BB A twelve year old boy has had seven episodes of spontaneous lip swelling and bilateral periorbital oedema in the last three years. His father also had similar episodes in childhood. What is the most likely immunological mediator? a. C1 esterase inhibitor b. Complement C4 c. Eosinophils d. Histamine e. IgE antibodies

Answer 170

a. | C1 esterase inhibitor

Question 171

BB One evening a 4-month-old boy is brought into A+E by his step-father because of a prolonged nose bleed. This has now stopped. The examination is normal apart from some irregular bruising on his abdomen and small, well circumscribed marks on his back. The next most appropriate step from the options below would be to: a. Admit him and arrange a full skeletal survey, clinical photographs and clotting studies b. Check his full blood count and clotting studies, and discharge him if they are normal for follow up in OPD c. Discharge him and discuss the case the next day with the child protection team d. Discuss the case with the child protection team now e. Reassure the step-father that since the nose bleed has stopped, no further treatment is required

Answer 171

d. | Discuss the case with the child protection team now

Question 172

BB An eight year old boy presents with nocturnal cough and early morning tiredness. He has a past history of serous otitis media. On examination, he has noisy breathing, is overweight and is inattentive during consultation. What is the most likely diagnosis? a. Asthma b. Chronic bronchitis c. Obstructive sleep apnoea d. Pertussis e. Pulmonary tuberculosis

Answer 172

c. | Obstructive sleep apnoea

Question 173

BB A term baby is born normally at 38 weeks gestation at 2.3 kg. Labour was difficult with prolonged rupture of membranes. At 35 minutes of age the infant was noted to have an increasing oxygen requirement with grunting and respiratory distress. On examination he was floppy with an oxygen saturation of 95% in 2L/min of oxygen. A CXR showed reticulonodular shadowing. What is the most likely diagnosis? a. Bacterial pneumonia b. Bronchiolitis c. Chronic lung disease d. Persistent pulmonary hypertension e. Respiratory distress syndrome

Answer 173

a. | Bacterial pneumonia

Question 174

BB A 2-month-old, ex-26 week gestation boy establishing feeding on the neonatal unit has developed a distended abdomen and bile-stained vomiting, and has an increasing oxygen requirement. The most likely diagnosis is: a. Appendicitis b. Gastro-oesophageal reflux c. Hirschsprung’s disease d. Intussusception e. Necrotising enterocolitis

Answer 174

e. | Necrotising enterocolitis

Question 175

An 18 month old boy is seen with a history of recurrent oral candidiasis. He developed tetany in the newborn period and had cardiac surgery for a complex heart defect. What is the most likely immunological deficiency? a. B-cells b. Complement C3 c. Neutrophils d. NK cells e. T-cells

Answer 175

e. T-cells T cells - de George's syndrome. Tetany - hypocalcaemia, parathyroid deficient, absence of thymus.

Question 176

A 5-year-old girl who never received MMR was exposed to chicken pox last week at school. She now presents with a 12 hour history of rash and abdominal pain and is reluctant to walk. On examination, she is unwell with cold hands and feet, and a widespread blanching maculopapular rash with spots of different sizes sparing the head and neck. What is the most likely diagnosis? ``` a. Chicken pox (Varicella zoster) ``` b. Measles c. Meningococcal sepsis d. Roseola infantum e. Rubella

Answer 176

c. Meningococcal sepsis Rash doesn't have to be non blanching. Cold hands and feet - think seriously about sepsis. Rosella - fever, fever, fever, rash comes after.

Question 177

BB A ten-year-old girl is seen in the endocrine clinic for short stature. On examination she is noted to have widely spaced nipples, a webbed neck, cubitus valgus and an ejection systolic murmur at the upper sternal edge. What is the most likely diagnosis? a. Aortic valve anomaly b. Innocent murmur c. Patent ductus arteriosus d. Pulmonary stenosis e. Tetralogy of Fallot

Answer 177

a. Aortic valve anomaly - coarctation of the aorta... Outflow Obs in Well Child Adult – Type Coarctation of Aorta Not duct dependent – more severe over years. - Asymptomatic. - Systemic HT in R arm. - ESM at upper sternal edge. - Collaterals heard – continuous murmur at back. - Radio-femoral delay. CXR – rib notching – collateral intercostal arteries. 3 sign – visible notch, in descending aorta at site coarctation. ECG – LVH. Rx - Stent Outflow Obs in Unwell Child Coarctation of Aorta Arterial duct tissue encircling the aorta, at point of insertion of duct. Duct closes – aorta constricts = severe obstruction to LV outflow. ``` Circulatory collapse – 2 days. - HF. - Absent femoral. - Severe metabolic acidosis. CXR – cardiomegaly ECG – normal. Rx – surgery. Prostaglandin infusion. ```

Question 178

BB A 5-month-old boy has been brought to A+E 2 hours previously with a 12 hour history of very high fever and vomiting. Examination does not reveal a clear source of infection so a blood culture is taken and lumbar puncture is performed. Of the following options, which method reflects current clinical practice when an urgent urine sample is required prior to starting antibiotics? a. Fixing a sterile bag and waiting for a sample b. Performing an in-out urinary catheterisation with aseptic technique c. Placing a sterile pad in the nappy and waiting for a sample d. Placing and leaving a urinary catheter in situ e. Waiting for the parents to ‘catch’ a mid-stream urine sample in a bowl

Answer 178

b. | Performing an in-out urinary catheterisation with aseptic technique

Question 179

BB A four year old, known epileptic is admitted to the ward for observation as he has been vomiting. He is on regular sodium valproate. You are called urgently to the ward to see him. An hour ago he had his regular sodium valproate but vomited soon afterwards. He is now having a seizure and has been fitting for about six minutes. A fingerprick blood glucose is 4.7 mmol/l. What is the most appropriate initial action? Answers: a. Give an anti-emetic b. Give buccal midazolam c. Give IV dextrose d. Give IV phenytoin e. Start a sodium valproate infusion

Answer 179

b. | Give buccal midazolam

Question 180

BB A 3 year old girl's parents have noted that her urine has gone very dark and she has had puffy eyes. She has been unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. BP 110/65. Which investigation is most likely to indicate the underlying diagnosis? a. 24-hour urine protein quantification b. Blood culture c. Complement C3 and C4 levels d. Ultrasound scan of the abdomen e. Urine M,C&S

Answer 180

c. Complement C3 and C4 levels Post strep glomerulonephritis - complement C3 and C4 levels - indicate underlying diagnosis.

Question 181

BB A 4-month-old girl is brought into A+E Resus by paramedics with a widespread, progressing, non-blanching purpuric rash on both lower limbs. She has cold peripheries with a capillary refill time of 5 seconds, has a heart rate of 180/min and her blood pressure is unrecordable. The most likely diagnosis is: a. Anaphylaxis b. Erythema infectiosum c. Group B streptococcal infection d. Henoch-Schonlein purpura (HSP) e. Neisseria meningitidis infection

Answer 181

e. | Neisseria meningitidis infection

Question 182

BB A 3-year-old child presents with acute onset abdominal pain for 4 hours. She has had 3 similar episodes in the past, which were all self-resolving. This time the vomiting is bile-stained. What is the most likely cause? a. Food allergy b. Intussusception c. Malrotation d. Pyloric stenosis e. Strangulated inguinal hernia

Answer 182

c. Malrotation

Question 183

BB A 5 year old who has recently returned from Nigeria, has had 3 days of swinging high fevers. His urine is noted to be dark red. On examination he has an enlarged liver, but no other abnormal ndings. A urine dipstick is positive for blood +++. Which investigation is most likely to reveal the underlying diagnosis? a. Blood culture b. G6PD level, now and in one month's time c. Hb electrophoresis d. Thick and thin blood lm e. Urine M,C&S

Answer 183

d. Thick and thin blood film

Question 184

BB A 2-year-old boy presented to A+E with a 4 week history of intermittent high fever and misery. The parents have noticed a widespread evanescent salmon-pink rash. In the last 48 hours he has been unwilling to weight bear. Laboratory tests reveal markedly raised acute phase markers. The most likely diagnosis is: ``` Answers: a. Chronic listeria infection b. Dermatomyositis c Duchenne muscular dystrophy c. Duchenne muscular dystrophy d. Juvenile idiopathic arthritis e. Systemic lupus erythematosus ```

Answer 184

d. Juvenile idiopathic arthritis

Question 185

BB A 7 year old girl with severe wheeze, a peak expiratory flow rate of 40% and a heart rate of 120 bpm presented to A+E an hour ago. She has been treated with burst therapy using Salbutamol and Ipratroprium Bromide but has had no response. What is the next most appropriate treatment a. Adrenaline (epinephrine) subcutaneously b. Aminophylline infusion c. Magnesium sulphate orally d. Prednisolone orally e. Salbutamol iv

Answer 185

e. Salbutamol iv

Question 186

BB A 14-month-old boy, with normal growth is referred to you due to his mother complaining that he is a dicult feeder. He refuses most solids and meal times are a battle, but he likes drinking cows’ milk and has about 1 litre per day. Which of the following would you do next? ``` a. No need to test for deciency in the absence of clinical signs b. Test for calcium deciency c. Test for folic acid deciency d. Test for iron deciency e. Test for vitamin B12 deciency ```

Answer 186

d. Test for iron deciency

Question 187

BB A 14-year-old girl presents with a 5 day history of abdominal pain, submandibular and parotid gland enlargement, low grade fever and severe headaches. She has not received any antibiotics. On examination she is photophobic with neck stiness, but is well perfused. She has no rash. On lumbar puncture the cerebrospinal fluid has normal protein and glucose, 50 WBC/ml (95% lymphocytes) and no RBC. What is the most likely diagnosis? a. Bacterial meningitis b. HIV infection c. Measles d. Mumps e. Tuberculosis

Answer 187

Mumps

Question 188

BB A 15-month-old Muslim girl is not meeting her gross motor developmental milestones and is generally very irritable. She was growing on the 50th centile, but is now on the 25th. She has 2-hourly breast feeds and consumes minimal solids with no additional dairy products. What is the most likely diagnosis? a. Failure to thrive b. Iron Deciency c. Nutritional Rickets d. Phosphate deciency e. Vitamin A deciency

Answer 188

c. Nutritional Rickets should be eating... 15 month old - milk, in morn, eve. 3 meals a day plus snacks.

Question 189

BB A 6 month old is examined by the GP because of parental concern about abdominal distension over the last 6 weeks. On examination he is well and thriving and has a palpable right sided abdominal mass. He has microscopic haematuria. Which investigation is most likely to reveal the underlying diagnosis? a. Blood lm b. Clotting studies c. Ultrasound scan of the abdomen d. Urine M,C&S e. Urine protein:Creatinine ratio

Answer 189

. Ultrasound scan of the abdomen

Question 190

BB A 15 year old girl attends the Emergency Department with her boyfriend, also 15, requesting the morning-after pill following a condom accident the previous evening.  She reveals that four months ago she was circumcised during a family trip to Somalia.  She understands your advice and the implications of her decisions to engage in sexual activity.   She refuses to inform her parents.  The couple are using condoms regularly.   What is the appropriate management? a. Decline to prescribe the morning-after pill and inform her parents so that they can support her b. Decline to prescribe the morning-after pill and refer the patient back to her GP c. Prescribe the morning-after pill and immediately alert the safeguarding children's team d. Prescribe the morning-after pill and recommend that the girl informs her parents e. Prescribe the morning-after pill, give contraceptive advice and inform her parents

Answer 190

c. Prescribe the morning-after pill and immediately alert the safeguarding children's team

Question 191

A 7-month-old girl adopted from an orphanage in Nepal is below 0.4th centile for length and weight. The birth history was apparently normal, apart from prolonged jaundice postnatally. She is not yet sitting. On examination she is hypotonic and accid. The lower limb reexes are hard to elicit. What is the most likely underlying condition? a. Cerebral palsy b. Congenital hypothyroidism c. Down syndrome d. Muscular dystrophy e. Myasthenia gravis

Answer 191

b. Congenital hypothyroidism

Question 192

BB A three year old girl is brought into A+E by her parents.   She is usually fit and well.   Her mum says that half an hour ago she ran into a table and banged her head on the corner.   She went pale and fell to the floor, and then had two or three twitching movements before starting to cry.  She is now back to her normal self and is running round A+E.  Clinical examination is normal.   What is the most appropriate action? a. Organise an ECG b. Organise an EEG c. Organise neuro-imaging d. Reassure the parents e. Teach parents how to give buccal midazolam if this recurs

Answer 192

d. Reassure the parents

Question 193

BB A 6-year-old caucasian boy has a three-week history of fevers, not responding to oral antibiotics in the first and second weeks, increasing drowsiness and now presents with confusion. On examination he has a mildly stiff neck and his Glasgow Coma Score is 12. A lumbar puncture revealed raised protein (2.1 g/l.) in the cerebrospinal fluid, decreased glucose, 710 WBC/ml, no RBC and no organisms seen on Gram stain. What is the most likely underlying cause? a. Bacterial meningitis b. HSV encephalitis c. Meningococcal sepsis d. Toxoplasmosis e. Tuberculosis

Answer 193

e. Tuberculosis WBC = increased. normal 0.5mm^3 normal protein = 0.15-0.4 g/L TB meningitis. Bcg - very good against TB meningitis.

Question 194

BB An 8-year-old girl is referred to outpatient department with a 3-month history of acne, breast development and ne pubic hair. She is otherwise healthy and has had no known illnesses, nor is she on any long term medication. Examination is otherwise normal. What is the most likely aetiology? a. A feminising ovarian tumour b. A gonadotropin producing tumour c. Congenital adrenal hyperplasia, late onset d. Early onset of normal puberty e. Premature adrenarche

Answer 194

d. Early onset of normal puberty

Question 195

BB A 2-year-old boy from a socially disadvantaged family presents with dental caries and frequent upper respiratory tract infections. He is a very fussy eater. On examination he has chronic suppurative otitis media but is avidly sucking from a bottle of cow’s milk. He is continuing to grow along the 25th centile for height and weight. What is the most likely underlying condition? a. Acquired immune deciency (AIDS) b. Cystic brosis c. IgA deciency d. Iron deciency anaemia e. Vitamin D deciency

Answer 195

d. Iron deciency | anaemia

Question 196

BB A 15 year-old girl was brought to the A&E after disclosing to her teacher at school that she had taken about 40 tablets of paracetamol the evening before. On arrival she was alert but complaining of nausea and right upper quadrant abdominal pain. Bloods taken on arrival at A&E showed a raised ALT and AST and abnormal coagulation studies. What is the most appropriate treatment? a. Activated charcoal b. Desferrioxamine c. Gastric lavage d. N-acetylcysteine e. No treatment - admit for observation

Answer 196

d. N-acetylcysteine

Question 197

BB A 3-year-old boy with diarrhoea and vomiting was given metoclopromide and loperamide. He presents to A&E with torticollis and an intermittent convergent squint and upward deviation of both eyes. What is the most appropriate treatment? a. Atropine b. Bromocriptine c. Buccal midazolam d. No treatment - admit for observation e. Procyclidine

Answer 197

e. Procyclidine - anticholinergic drug, used to treat drug0induced parkinsonism, akathisia, acute dystonia, parkinsons. Dystopia reaction. Procycline.

Question 198

BB A 13-year-old boy presents to his GP for a routine physical prior to participation in competitive sports. He has had no recent illnesses and no past medical history of note. His height and weight are on the 75th centile for his age. Cardiovascular examination reveals a grade 2/6 ejection systolic murmur heard loudest at the left lower sternal border. It is low pitched and musical but does not radiate. Which of the following is the most likely diagnosis? a. Atrial septal defect b. Mitral stenosis c. Tricuspid regurgitation d. Ventricular septal defect e. Vibratory innocent murmur

Answer 198

e. Vibratory innocent murmur

Question 199

BB A seven year old girl who has previously been fit and well presents in A+E following a left-sided seizure that lasted approximately three minutes at school.   Over the last few weeks she has been complaining of headaches.   She has not had any fever.   What is the most appropriate next step in her management? a. Do a lumbar puncture b. Organise and EEG c. Organise neuro-imaging d. Start IV acyclovir e. Start IV ceftriaxone

Answer 199

c. Organise neuro-imaging

Question 200

BB A five week old girl presents with a history of recurrent coughing and choking during and after feeds.  Pregnancy was complicated by polyhydramnios.  What is the most likely diagnosis? Answers: a. Epiglottis b. Gastro-oesophageal reux c. Laryngomalacia d. Tongue-tie e. Tracheo-oesophageal fistula

Answer 200

e. Tracheo-oesophageal fistula

Question 201

BB An 8-week-old exclusively breastfed baby boy was born at 38 weeks gestation after an uneventful pregnancy. Which of the following findings would require a prompt referral to a paediatric surgeon? a. A right testis which can be manipulated to the base of the scrotal sac b. An acute episode of balanitis c. An irreducible firm lump which extends from the inguinal canal to the scrotum d. Bilateral nontender scrotal swellings which transilluminate e. Glandular hypospadias

Answer 201

An irreducible firm lump which extends from the inguinal canal to the scrotum

Question 202

``` BB An infant of 31 weeks gestation was born via an emergency section because of foetal decelerations noted on CTG. The birth weight was 1100g and the infant required intubation but was difficult to ventilate. A CXR shows diuse whiteout of both lungs with air bronchograms. What is the most likely diagnosis? a. Bacterial pneumonia b. Chronic lung disease c. Meconium aspiration d. Respiratory distress syndrome e. Transient tachypnoea of the newborn ```

Answer 202

d. Respiratory distress syndrome

Question 203

BB A healthy 4-year-old girl develops acute onset of petechiae and epistaxis. Laboratory ndings include haemoglobin = 12g/dL; white cell count = 5.5 with normal dierential; and platelet count = 15. Of the following investigations, which would you do next? a. Blood film b. Bone marrow aspirate c. Check the bleeding time d. Clotting studies e. Platelet antibody tests

Answer 203

a. Blood film ITP - most likely. Platelets - whole fillers for capillaries, them fibrin cascades and fixes them. Not bleeding time - wouldn’t cut a child. Haemophilia - haemarthrosis is main worrying. Blood film - make sure it's not leukaemia.

Question 204

``` BB A 6-year-old South African boy, domiciled in the UK, has just returned from visiting his family in Cape Town during July and August. He has a high fever with rigors, is coughing and is complaining of muscular aches. What is the most likely cause of this infection? a. Dengue b. Influenza virus c. Malaria d Meningococcal sepsis d. Meningococcal sepsis e. Tuberculosis ```

Answer 204

b. Influenza | virus

Question 205

``` BB A four month old boy who is well and thriving has blood test results positive for HIV antibodies.  What is the most likely immunological mediator of the positive result in this child? a. B lymphocytes b. CD4+ T lymphocytes c. IgG antibodies d. NK cells e. Tranplacental maternal lymphocytes ```

Answer 205

c. IgG antibodies

Question 206

BB A 10-month-old girl has grown along the 50th centile for weight until around 6 months but is now on the 25th centile. The mother has noticed a distended abdomen and says her stools are more frequent and bulky. What is the most likely underlying condition? a. Coeliac disease b. Congenital hypothyroidism c. Cystic brosis d. Giardia lamblia infection e. Toddler's diarrhoea

Answer 206

a. Coeliac disease | you start weaning at 6 months - thats why her centile dropped then

Question 207

BB A 2-week-old boy is brought to A+E by his mother who has noticed that he has become increasingly jaundiced. She reported that he had not been breast-feeding as well as previously, and also commented that his stools looked like “off-white chewing gum”. The most likely diagnosis is a. Breast-milk jaundice b. Congenital gall stones c. Extra-hepatic biliary atresia d. Glucose 6-phosphate dehydrogenase deciency e Rhesus incompatibility

Answer 207

c. Extra-hepatic biliary atresia

Question 208

BB The laboratory calls you to inform you that a baby who is now 10 days old has an elevated TSH on their Guthrie Card test. If this condition is left untreated, which of the following signs is the baby most likely to demonstrate in the first few months of life? a. Diarrhoea b. Hyperirritability c. Hyperphagia d. Hyperreexia e. Prolonged jaundice

Answer 208

e. Prolonged jaundice

Question 209

BB A three month old baby has been admitted to the ward with a history of fever and a two minute generalised, self-terminating tonic-clonic seizure.  She has had a lumbar puncture that shows white blood count 850 per mm3 (80% polymorphs), protein 1.2g/l, glucose 1.7 mmol/l (blood glucose 5.1 mmol/l).  What would be the most appropriate next step in her management? a. Organise and EEG b. Organise neuro-imaging c. Request a paediatric neurology opinion d. Start IV aciclovir e. Start IV ceftriaxone

Answer 209

e. Start IV ceftriaxone ``` WBC = very raised n = 0.5 viral = lymphocytes raised (inital may be polymorphs) bac = polymorphs, very raised ``` protein is very raised (N - 0.14-0.4) bac = vr, viral n/r glucose (n - >50% of blood) bac = vl viral = n/l

Question 210

BB A 2-week-old boy is admitted with a 3-day history of vomiting and increasing lethargy. Physical examination is normal except for increased pigmentation of the areolar and nipples bilaterally. Laboratory ndings include plasma sodium = 126 mmol/L; plasma potassium = 6.8 mmol/L; and plasma glucose = 5.9 mmol/ L. What is the most likely diagnosis? a. Congenital adrenal hyperplasia b. Gastroenteritis c. Hyperaldosteronism d. Panhyperpituitarism e. Pyloric stenosis

Answer 210

a. Congenital adrenal hyperplasia

Question 211

BB A 6-week-old breast-fed infant presents with a history of vomiting after feeds since birth. He is growing along the 0.4th centile for weight. A pyloric mass is not palpable during a test feed. The plasma chloride is 102 mmol/l (NR 96-110). What is the most likely cause? a. Cow's milk protein allergy b. Duodenal atresia c. Gastro-esophageal reux d. Malrotation e. Pyloric stenosis

Answer 211

c. Gastro-esophageal reux

Question 212

BB A 15-year-old basketball player complains of pain in his knees. Clinical examination reveals, in addition to tenderness, a swollen and prominent tibial tubercle. X-rays of the knee are unremarkable. What is the most likely diagnosis? a. Gonococcal arthritis b. Legg-Calve-Perthes disease c. Osgood-Schlatter's disease d. Popliteal cyst e. Slipped capital femoral epiphysis

Answer 212

c. Osgood-Schlatter's disease

Question 213

BB A 12-year-old boy has presented to A+E unable to weight-bear on his right leg due to pain in the hip. He grazed his thigh 6 days ago whilst playing football, and for the last 48 hours has had high fevers. Bloods taken today show a CRP of 240 and a WCC of 24.5. A hip x-ray shows a periosteal reaction in the proximal femur but no fracture or joint eusion. The most likely diagnosis is: a. Osteomyelitis b. Perthe’s disease c. Septic arthritis d. Slipped upper femoral epiphysis e. Transient synovitis

Answer 213

a. Osteomyelitis

Question 214

BB A post-term infant is delivered by emergency Caesarian section for a moderate placental abruption. On examination the infant’s oxygen saturation is 85% in air and there is marked respiratory distress. A CXR reveals bilateral patchy inltrates. What is the most likely diagnosis? a. Bacterial pneumonia b. Bronchiolitis c. Congenital heart disease d. Meconium aspiration e. Respiratory distress syndrome

Answer 214

d. Meconium aspiration

Question 215

``` BB A 14 year old girl is stung by a bee and develops urticaria within 20 minutes of the sting.  What is the most likely immunological mediator? a. Arachidonic acid b. Eosinophils c. IgE antibodies d. Macrophages e. T-cells ```

Answer 215

c. IgE antibodies

Question 216

BB Two infants are born at 36 weeks’ gestation. One infant weighs 2600g at birth and an unrelated second infant weighs 1600g. Which of the following conditions is the second baby more likely to have? a. Congenital malformations b. Hyperglycaemia c. Low haematocrit d. Occipito-frontal (head) circumference that is small compared to body weight e. Surfactant deciency

Answer 216

a. Congenital malformations - causing the low BW

Question 217

BB A 2 year old presents with frank haematuria, some abdominal pain and rigors. Which investigation is most likely to reveal the underlying diagnosis? a. 24-hour urine protein quantication b. Blood culture c. Renal biopsy d. Ultrasound scan of the abdomen e. Urine M,C&S

Answer 217

e. Urine M,C&S

Question 218

BB A 3-month-old breast-fed girl presents with a 3 day history of increasing breathlessness and diculty with feeding. On examination she is tachypnoeic and hypoxic with no crepitations or wheeze and no abnormal upper airway signs. Her mother declined antenatal blood tests. What is the most likely underlying cause of this child’s respiratory illness? a. Group B streptococcal infection b. HIV infection c. Inuenza virus d. Respiratory syncitial virus e. Viral meningitis

Answer 218

b. HIV infection

Question 219

BB A ten-year-old girl presents with recurrent abdominal pain. Of the following symptoms, which is most suggestive of an organic aetiology? Selected Answer: Answers: a. Periumbilical location b. She has lost touch with her friends at school c. She wakes from sleep with pain at night d. The pain has persisted intermittently for more than three months e. The pain is so severe that she cannot attend school

Answer 219

c. She wakes from sleep with pain at night

Question 220

BB A term infant delivered by elective Caesarian section develops tachpnoea, grunting and recession at 30 minutes of age and is hypoxic.  A CXR shows flattened diaphragms with fluid in the right horizontal fissure and well-aerated lung fields. The infant improves after four hours and no longer requires oxygen.  What is the most likely diagnosis Answers: a. Meconium aspiration b. Patent ductus arteriosus c. Primary pulmonary hypertension d. Respiratory distress syndrome e. Transient tachypnoea of the newborn

Answer 220

e. Transient tachypnoea of the newborn

Question 221

BB A two year old boy is brought into A+E by ambulance having a generalised tonicclonic seizure.  Over the last 24 hours he has had a slightly runny nose, and his mum has been giving him regular Paracetamol for a low grade fever.  Mum also comments that she herself had a cold sore recently.  On arrival at A+E he is still having the seizure.  What would be the most appropriate immediate action? Selected Answer: [None Given] Answers: a. Do a lumbar puncture b. Give buccal midazolam c. Give IV acyclovir d. Give IV phenytoin e. Organise a CT head

Answer 221

b. Give buccal midazolam