Paeds

Question 1

Liam Hogan is a 12 year old boy who presents with a persistent dry cough, worse at night. He reports coughing fits which he finds it hard to catch his breath from and reports a multiple episodes of coughing until he vomits. You perform a nasopharyngeal swab and PCR is positive for pertussis. How long must Liam be excluded from school?

For 14 days after the onset of cough

For 28 days after the onset of cough

Until the child has received antibiotics for 24 hours

Until the child has received antibiotics for 48 hours

Until the child has received antibiotics for 5 days

Answer 1

He must be excluded from school for 21 days after the onset of the cough or until he has completed 5 days of antibiotics.

Australian Government Department of Health. Pertussis CDNA National Guidelines for Public Health Units. Updated 2015.

Question 2

Ruby is a 7 year old girl who is brought in by her Mum Sarah. Ruby is still needing to wear a pull up nappy at night due to bed wetting. Ruby is continent of urine during the day, but has never been dry overnight. Sarah says she always thought Ruby would just ‘grow out of it’, but this does not seem to be happening. Ruby has a school camp early next year where she is going to have to sleep a night away from home. She wants to be out of pull ups by the time she goes away on camp. Which management strategy for nocturnal enuresis has the best evidence for long term efficacy?

Desmopressin

Education about enuresis and the high rate of spontaneous resolution

Enuresis alarm

Fluid restriction

Motivational therapy (eg star chart)

Answer 2

Enuresis alarms have the most evidence for long term efficacy in nocturnal enuresis. Desmopressin is more effective in the short term, but has a higher relapse rate.

Question 3

Lina brings her 2 month old child, Ruby, to see you. She says that Ruby has noisy breathing, which she thinks has been present since not long after her birth. Lina notices it when she is breathing in and Ruby doesn’t seem distressed by it. Sometimes though she will get upset during breast feeding, and has been taking formula by bottle for more of her feeds recently. On examination, you note a high-pitched cog-wheel inspiratory stridor. Ruby is seen by a paediatrician and diagnosed with larynogomalacia.

Lina asks when this condition will likely resolve. Which of the following is correct? Choose one (1) option.

1 - 2 years of age

6 months of age

4 months of age

3 - 4 years of age

5 years of age

Answer 3

The correct response is: 1 - 2 years of age

As stated in eTG:

“Some children present with a chronic ‘cog-wheel’ high-pitched inspiratory stridor that has been present from birth or the first few days or weeks of life. The most common cause is laryngomalacia. The stridor resolves spontaneously at 1 to 2 years of age. Alternatively, inspiratory stridor that develops for the first time at 6 to 8 weeks of life, worsens and becomes biphasic (present in both inspiration and expiration) may be due to a subglottic haemangioma. Most cases of chronic stridor in infants need referral.”

Question 4

Leo Walker is a six year old boy who presents with a two day history of left hip pain. He denies any trauma to the hip. On examination his temperature is 38.2 degrees Celsius. Any movement of the left leg causes him pain and he cannot weight bear. What is the important diagnosis to consider in Leo?

Bone cyst

Fractured hip

Idiopathic chondrolysis of the hip

Transient synovitis

Juvenile idiopathic arthritis

Malignancy

Muscular strain

Osteoid osteoma

Osteomyelitis

Perthes disease

Septic arthritis of the hip joint

Slipped femoral epiphysis

Answer 4

Any child presenting with acute onset joint pain with reduced movement, refusal to weight bear and fever has septic arthritis until proven otherwise.

Royal Children’s Hospital Melbourne. Clinical Practice Guidelines. Osteomyelitis and septic arthritis. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Osteomyelitis_and_Septic_Arthritis/ (Accessed Jan 2020)

Question 5

Sharon Frost is a long term patient of yours, and at the end of her consult she asks if you think she should bring her 12 year old daughter in for review. Sharon is worried that her daughter has not had her first period yet, whereas all of her friends around her age have. Sharon reports that her daughter does have some breast bud development and pubertal hair growth.

At what age should a girl be evaluated for primary amenorrhoea if her menses have not occurred in the presence of normal growth and secondary sexual characteristics?

10 years old

11 years old

13 years old

15 years old

17 years old

Answer 5

Primary amenorrhoea is defined as the absence of menses at age 15 in the presence of normal growth and secondary sexual characteristics, or if menarche does not occur within 3 years of breast development.

Question 6

Jimmy is a three month of baby brought in by his parents to discuss the large birthmark on his face. They were advised by the obstetrician at birth to see you to discuss management of the lesion. Jimmy was born at term via normal vaginal delivery after an uncomplicated pregnancy. He has no medical conditions and takes no regular medications. He has no known allergies.

On examination, you note a large erythematous area over Jimmy’s left eye and cheek as pictured below.

port wine stain

What do you advise Jimmy’s parents in terms of management of the lesion?

Advise that the lesion will likely self-resolve over the next few years

Advise referral for consideration of a trial of oral propranolol under specialist guidance

Advise that the lesion will not self-resolve but is likely to become smaller and lighter with time

Advise referral for further investigation of possible associated neurological and ophthalmological abnormalities

Advise treatment with laser therapy for cosmetic reasons

Answer 6

The correct response is: Advise referral for further investigation of possible associated neurological and ophthalmological abnormalities.

Jimmy has a port wine stain (neavus flammeus) which is a capillary vascular malformation. They occur in approximately 0.3% of newborns and they tend to become darker and thicker over time. Port wine stains do not self-resolve. As Jimmy’s port wine stain affects the V1 & V2 distribution on his face, he will require further investigation including an ophthalmological examination and possible neuro-imaging to exclude associated abnormalities.

Question 7

Kelly is a 15 year old girl who has been brought in by her concerned mother because she has recently become interested in animal rights and has become vegan. Her mother is concerned about Kelly getting enough essential nutrients in her diet. Regarding dietary sources of essential nutrients, which of these is TRUE?

It is not necessary to fortify a vegan diet with calcium

Non-haem iron is found in eggs and plant foods

Vitamin B12 is found in both animal and plant products

The absorption of non-haem iron is better than haem iron.

Vitamin C reduces the absorption of haem iron

Answer 7

The correct answer is: Non-haem iron is found in eggs and plant foods

The absorption of haem iron (animal foods including red meats, fish and poultry) is better than non haem iron.

As a vegan diet does not include dairy products, it is important to fortify the diet with other calcium-rich foods or calcium supplements.

Vitamin B12 is essential for healthy blood cells and neurological function. It is only found naturally in animal products.

Vitamin C enhances the absorption of iron.

Dynan N. Helping to meet the nutritional needs of patients on a vegan diet. RACGP NewsGP. 2018

https://www1.racgp.org.au/newsGP/Clinical/Helping-to-meet-the-nutritional-needs-of-patients

Question 8

You are interrupted by the midwife during your morning ward round of your 16 bed rural hospital, which is 400km from the nearest tertiary hospital, and which provides maternity services. She has noticed that Yolanda Ling, the term baby you helped deliver yesterday evening via emergency caesarean seems jaundiced. Yolanda is otherwise well and breastfeeding normally. The mother, who already has two children, had not had any antenatal care. You organise urgent blood tests, transfer to a neonatal service, and commence phototherapy whilst awaiting transfer.

What is the most likely diagnosis to consider in this case? Choose one (1) option.

Sepsis

Physiological jaundice

Red cell haemolysis

Breast milk jaundice

Biliary atresia

Answer 8

The correct response is: Red cell haemolysis

Jaundice is a sign of elevated bilirubin levels in the blood, which occurs when there is an imbalance between bilirubin production, conjugation and elimination. It is very common in newborns, affecting 60% of term babies and 80% of preterm babies in the first week of life. Severe hyperbilirubinaemia can be a sign of a serious underlying disease, and it can also cause brain damage. Jaundice visible at less than 24 hours is always a medical emergency. The most likely causes of early onset jaundice are haemolysis (e.g. rhesus disease, ABO incompatibility, and red cell enzyme defects such as G6PD deficiency) and sepsis. However, you are told that Yolanda seems otherwise well and is breast feeding normally, so red cell haemolysis is more likely the cause of the jaundice in this clinical scenario than sepsis.

Question 9

Shaun Watson is a 22 year old man who presents with significant fatigue and sore throat that has been present for 7 days. He reports that he has also suffered with headaches, nausea and generalised body aches. He is a professional Australian Rules football player and has already missed one full week of football.

On examination, he is mildly jaundiced, his throat is congested with palatal petechiae, his tonsils are enlarged and covered with exudate, and he has cervical lymphadenopathy and splenomegaly. There is no airway compromise on examination.

Given your expected diagnosis what is the most appropriate management for Shaun? Please select one (1) answer from the following.

Oral phenoxymethylpenicillin 500mg twice per day for 10 days

Oral aciclovir 800mg five times per day for 5 days

Referral to a haematologist for further investigation of splenomegaly and lymphadenopathy

Avoid physical activity for another 2 weeks

Oral prednisolone 50mg daily for 4 days

Answer 9

The most likely diagnosis in this case is Infectious Mononucleosis (IM). This syndrome is caused by Epstein Barre Virus and most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae. Symptomatic relief is the mainstay of treatment. Glucocorticoids and antivirals do not reduce the length or severity of illness. Splenic rupture is an uncommon complication of IM. Because physical activity within the first three weeks of illness may increase the risk of splenic rupture, athletic participation is not recommended during this time. Children are at the highest risk of airway obstruction, which is the most common cause of hospitalization from IM.

Question 10

Jordan is a 17 year old male who is brought to your clinic by his mother with a rash. Jordan has been unwell recently with fevers, a very sore throat, reduced appetite and generalised abdominal discomfort. He saw another GP a week ago and was started on antibiotics for tonsillitis. This morning he has developed an intensely itchy maculopapular rash. Jordan has no significant past medical history and takes no regular medications. He has no known allergies.

On examination, Jordan appears well and his temperature is 36.5°C. He is well hydrated and non-distressed. He has a widespread blanching maculopapular rash. He has small pustules on bilateral enlarged tonsils and tender cervical lymphadenopathy. His abdominal examination is unremarkable.

What advice do you give Jordan?

Strictly avoid penicillins in the future

The rash will self-resolve without treatment

Apply topical betamethasone 0.05% ointment until the rash resolves

Commence oral prednisolone 25mg daily for three days

Strictly avoid penicillins and cephalosporins in the future

Answer 10

The correct response is: The rash will self-resolve without treatment.

This case describes a teenager with clinical features consistent with Ebstein-Barr virus. When amoxicillin, ampicillin or cephalosporins are given during the course of infectious mononucleosis (often incorrectly prescribed for presumed streptococcal tonsillitis), patients may experience an intensely itchy maculopupular or morbilliform rash seven to ten days later. This rash is not a sign of a true allergy to the antibiotic but is rather considered a ‘hypersensitivity reaction’.

Question 11

Josh, a 18 month old boy, is brought to you because his mother is worried about his development. Josh was born at term without complication and has no significant past medical history. You perform a developmental assessment.

What would you expect Josh to be able to do at this age? Choose one (1) option.

Point to body parts when asked

Undress himself

Jump on the spot

Able to name 5 body parts

Shows clear hand preference

Answer 11

The correct answer is: Point to body parts when asked.

See the reference below for a useful list of childhood developmental milestones.

Question 12

Brenda presents with her 13 month old daughter Chloe worried that Chloe is developmentally delayed. Brenda has a 3 year old son and says that he was ‘much more advanced’ at this age. Chloe is currently cruising around the consulting room holding onto her mother and the furniture but Brenda says she is concerned that she is not walking as yet as her son could at 10 months.

Which one of the following tasks would you expect Chloe to be able to do?

Turns pages in a book

Combine 2-3 clear words

Stack 2-3 blocks in a tower

Use a spoon

Wave goodbye

Answer 12

By twelve months a baby should be able to wave goodbye. The other developmental stages are more appropriate for an 18-24 month old child.

Question 13

A mother brings in her 8 year old girl with a troublesome cough for some months. It seems to be worse at night and particularly when she is playing netball. Her mother has noticed a ‘wheezing’ sound as well at those times. You suspect asthma.

What is the minimum recommended age at which spirometry can be used?

5 years old

6 years old

7 years old

8 years old

9 years old

Answer 13

Generally, spirometry cannot be performed to acceptable standards in children younger than 4–5 years.

The Australian Asthma Handbook recommends spirometry to be performed to support the diagnosis of asthma in children aged 6 years and over.

Question 14

Caroline brings in her 15 month old baby girl Georgia with an episode of choking earlier in the day after Caroline left her briefly to go to the toilet. Caroline reports that Georgia has been ok since then but she is concerned about the episode and wonders if Georgia choked on a small toy. Georgia has been well recently with no upper respiratory tract infections. She has no past medical history and takes no regular medications. Your examination of Georgia’s vital signs, ENT and respiratory systems is unremarkable.

Which of the following statements about paediatric airway foreign bodies is correct?

A chest x-ray can exclude an airway foreign body

The peak incidence of inhaled foreign bodies is children aged under 12 months

50% of children with an airway foreign body will present with no symptoms

Most children with an airway foreign body will have no history of choking or aspiration

Airway foreign bodies do not result in permanent pulmonary tissue damage

Answer 14

The correct response is: “50% of children with an airway foreign body will present with no symptoms.”

More than 80% of foreign bodies lodge in the bronchial tree, with the right main bronchus being the most common site. The peak incidence of inhaled foreign bodies is in children aged between 1 and 2 years of age. While 50% of children with present asymptomatically, more than 90% will have a history of choking or aspiration which emphasises the importance of an in-depth history from the parent / caregiver. Delays in diagnosis can result in permanent damage to pulmonary tissue and bronchiectasis. If there is a clinical suspicion of an inhaled foreign body, all children should be referred for a tertiary otolaryngology service. It is important to note that normal diagnostic imaging cannot rule out the presence of an airway foreign body.

Question 15

Harry Williams is a four year old boy brought to your clinic by his mother. Harry was climbing on the couch at home one hour ago and fell onto the tiled floor. The fall was witnessed and he hit his head and had a brief loss of consciousness. Harry’s mother reports he has vomited three times since then and has been complaining of a headache.

On examination, you note that Harry is alert and orientated but miserable and crying intermittently while sitting on his mother’s lap. You note a small haematoma on the occipital region of his scalp. His pupils are equal and reactive to light. He has no neck tenderness and is moving his neck freely. He is moving all four limbs normally and can walk normally when encouraged. He is responding appropriately to your questions and has not vomited since being at your clinic. You do not note any other abnormalities on examination.

What do you advise Harry’s mother in terms of management?

You advise Harry’s mother that he has had a minor head injury and it is safe for him to go home

You advise Harry’s mother that he needs to attend the emergency department for monitoring for up to six hours from the time of his injury

You advise Harry’s mother that he requires an urgent head CT scan and that you will review him with the results later today

You advise Harry’s mother that she can take Harry home but she will need to wake him up every hour throughout the night

You advise Harry’s mother that he needs to attend the emergency department for monitoring for twenty four hours from the time of his injury

Answer 15

The correct response is: You advise Harry’s mother that he needs to attend the emergency department for monitoring for up to six hours from the time of his injury.

According to the guidelines from the Royal Children’s Hospital, Harry has sustained a mild head injury/concussion and will require observation in an emergency department for a period of up to six hours from the time of his injury which will include 30 minutely neurological observations.

Question 16

A mother brings her three children, aged 1, 3 and 6, to see you to discuss the annual influenza vaccination. They have never been vaccinated against the flu before, but this year she thinks she would like to get the whole family immunised. She wants to know if it is recommended for her children to receive the annual influenza vaccination.

Which of the following statements regarding influenza vaccination in children is correct? Choose one (1) option.

2 doses 4 weeks apart are recommended for children aged 6 months to < 9 years who are receiving the influenza vaccine for the first time

3 doses 4 weeks apart are recommended for children aged 6 months to < 8 years who are receiving the influenza vaccine for the first time

Only children aged over 12 months with medical risk factors should be encouraged to have the annual influenza vaccine

Only children aged over 5 years with medical risk factors should be encouraged to have the annual influenza vaccine

Children aged over 6 months only require one dose of influenza vaccine each year, including in their first year of receiving the vaccine

Answer 16

The correct response is: 2 doses 4 weeks apart are recommended for children aged 6 months to < 9 years who are receiving the influenza vaccine for the first time.

All people aged 6 months or over are strongly encouraged to receive the influenza vaccine each year (unless there are contraindications).

Question 17

A 12 year old boy presents with a painful penis.

On examination he is uncircumcised and the foreskin covering the glans is hot, red and tender. There is some discharge at the opening of the foreskin.

Which one of the following is the MOST likely diagnosis?

Balanitis

Smegma collection

Dermatitis

Paraphimosis

Phimosis

Answer 17

Minor redness and/or soreness of the tip of the foreskin is common and can be managed with reassurance and avoidance of chemical/physical triggers. More extensive inflammation of the glans penis +/- foreskin is termed balanitis. Causes include:

Chemical irritation: urine trapping, soiled nappies, soap residue.
Physical trauma: forcible retraction.
Candida nappy rash in infants

Question 18

A four year old girl is brought in by her mother complaining of dysuria and urinary frequency. Urine dipstick reveals positive nitrites and leucocytes. You suspect a urinary tract infection.

Which organism is the most common cause of urinary tract infections in children? Choose one (1) option.

Enterococcus

Escherichia coli

Klebsiella

Proteus

Staphylococcus saprophyticus

Answer 18

The correct response is: Escherichia coli

Escherichia coli is the most common cause of urinary tract infections and accounts for more than 75% of cases.

Reference:

Desai D, Gilbert B and McBride C. Paediatric urinary tract infections: Diagnosis and treatment. Aust Fam Physician 2016; 45(8):558-563

https://www.racgp.org.au/afp/2016/august/paediatric-urinary-tract-infections-diagnosis-and-treatment/

Question 19

Herbert Zu, aged 4 years, presents with his mother to your GP clinic after recently moving from Canada to Australia. His mother brings his Canadian vaccination book and wants to know what immunisations Herbert requires. His last scheduled immunisations in Canada were at 18 months for diphtheria, tetanus, pertussis, poliomyelitis and haemophilus influenzae type B (as per the Canadian schedule). You notice that he has only had one measles, mumps, rubella, varicella dose at 12 months and no birth dose of hepatitis B. The remaining administered schedule matches the current Australian immunisation schedule. Herbert has no significant past medical history.

Based on the Australian Immunisation Handbook and schedule, what immunisations would you administer for Herbert today? Select one (1) option.

Herbert requires a booster of measles, mumps and rubella vaccine

Herbert requires a booster of measles, mumps, rubella and varicella, in addition to diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B and haemophilus influenzae type B vaccines

Herbert requires diphtheria, tetanus, pertussis and poliomyelitis vaccine

Herbert requires a booster of measles, mumps and rubella, in addition to diphtheria, tetanus, pertussis and poliomyelitis vaccines

Herbert requires diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B and haemophilus influenzae type B vaccines

Answer 19

The correct answer is “Herbert requires a booster of measles, mumps and rubella, in addition to diphtheria, tetanus, pertussis and poliomyelitis vaccines.”

This question reflects a common scenario of children requiring catch-up immunisations. In this scenario candidates need to be aware that there is a need for 2 doses of measles, mumps, rubella vaccine. The current guidelines in Australia are for 1 dose of varicella at 18 months, however a second dose has been shown to increase immunity. The second dose is not currently funded by the National Immunisation Program.

There is no need to catch up a missed birth dose of hepatitis B, provided a full course (i.e. 3 doses) of Hepatitis B vaccine have been provided in the first 12 months from 6 weeks of age.

Question 20

Abby Reeves is a 12 year old girl who is brought in by her Mum with a troublesome cough for some months. It seems to be worse at night and particularly when she is playing netball. Her mother has noticed a ‘wheezing’ sound as well at those times. You suspect asthma and arrange spirometry. Which of the following criteria demonstrate reversibility on spirometry?

Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 10% higher than baseline

Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 12% higher than baseline

Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 15% higher than baseline

Baseline FEV1<1.7L and post-bronchodilator FEV1 at least 100mL higher than baseline

Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 200mL higher than baseline

Answer 20

Reversibility is demonstrated by either baseline FEV1>1.7L AND post-bronchodilator FEV1 at least 12% higher than baseline

OR baseline FEV1 less than or equal to 1.7L AND post-bronchodilator FEV1 at least 200mL higher than baseline.

Question 21

Kylie, a five year old who has recently started school, is brought in by her mother after complaining of an ‘itchy bottom’ for the last few nights. It has caused her distress through the night but she has been asymptomatic throughout the day. You suspect a threadworm infection.

How would you manage Kylie’s infection? Choose the optimum treatment approach below - choose one (1) option.

7 day course of metronidazole

Reassurance - these infections are common and rarely cause morbidity

Single dose of mebendazole (Vermox)

Treat all members of the family with pyrantel (Combantrin), with repeat dosing 2 weeks later

Treat all members of the family with single dose of pyrantel (Combantrin)

Answer 21

The correct response is: Treat all members of the family with pyrantel (Combantrin), with repeat dosing 2 weeks later

Threadworm (or pinworm) infections (Enterobius vermicularis) respond to various antihelminthic drugs, including single dose mebendazole, pyrantel or albendazole. However, it is recommended that treatment is repeated after 2 weeks, including for household contacts and carers, due to the frequency of reinfection and autoinfection. eTG also recommends the following advice for patients:

“Provide advice on hygiene measures to reduce the risk of reinfection and spread of infection: wash hands regularly, avoid scratching around the anus, keep fingernails short, take a shower or bath daily, and wash clothing, towels and bed linen in hot water.”

Question 22

A 14 year old boy presents with left hip pain. His pain is poorly localised and there is no history of trauma. He is systemically well.

On examination, the boy is overweight and he appears to have a limp when walking. His left leg is slightly externally rotated and hip pain is elicited with passive internal rotation. His knee examination is unremarkable.

What is the most likely diagnosis? Choose one (1) option.

Juvenile rheumatoid arthritis

Baker’s cyst

Iliotibial band syndrome

Medial meniscal injury

Osgood Schlatter disease

Osteoarthritis

Osteochrondritis dissecans

Patellar tendonitis

Patellofemoral pain syndrome

Perthes disease

Pes anserinus tendinitis

Septic arthritis

Slipped capital femoral epiphysis

Transient synovitis/irritable hip

Answer 22

The correct response is: Slipped capital femoral epiphysis

Slipped capital femoral epiphysis (SCFE) typically occurs in late childhood / adolescence and in those > 90th percentile for weight. It can present with pain in the knee or hip and with an associated limp. Sometimes the pain is bilateral. On examination, the hip typically appears shortened and externally rotated. There is usually restricted movement, especially internal rotation.

Question 23

Janine has come to see you to get a form signed so that her 6 month old child, Caleb, doesn’t have to get immunised. She is a bit upset because her Centrelink payments have been ceased, and she cannot enrol Caleb in child care as they won’t accept an unvaccinated child without medical approval. You take a thorough history in order to determine if Caleb has a valid medical contraindication to vaccination.

Which of the following is a valid medical contraindication to vaccination?

Anaphylaxis following any component of the relevant vaccine

Mother has a history of a anaphylaxis following vaccination

Caleb has a past medical history which includes chronic medical conditions: asthma and epilepsy

Caleb has a past medical history of egg allergy

Caleb is currently unwell with an upper respiratory tract infection and has a temperature of 38.0 degree Celsius

Answer 23

The correct response is: Anaphylaxis following any component of the relevant vaccine.

See the Australian Immunisation Handbook for detailed information about medical contraindications to vaccination.

The medical basis for vaccine exemption is to be based on guidance in The Australian Immunisation Handbook. Medical contraindications include:

anaphylaxis following a previous dose of the relevant vaccine
anaphylaxis following any component of the relevant vaccine
significant immunocompromise (for live attenuated vaccines only).
A comprehensive list of false contraindications to vaccination is provided in The Australian Immunisation Handbook.

Egg allergy, even severe, is not necessarily a valid exemption for any vaccine routinely recommended for children.
Presence of a chronic underlying medical condition (apart from significant immunocompromise) is not a valid vaccine exemption.
Family history of any adverse events following immunisation is not a valid vaccine exemption.
While vaccination should be deferred in persons with acute febrile illness (current T ≥38.5°C) or other self-limiting acute systemic illness, this would usually be for short periods only and not require completion of the Immunisation medical exemption form.

References:

Australian Government Department of Human Services. Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011). Available from: https://www.humanservices.gov.au/organisations/health-professionals/forms/im011 (Accessed August 2020).

Australian Government Department of Health. Australian Immunisation Handbook: Preparing for vaccination. Available from: https://immunisationhandbook.health.gov.au/vaccination-procedures/preparing-for-vaccination (Accessed August 2020).

Question 24

Sally is a 4 year old girl, brought in by her mother because she is concerned about Sally’s seeming lack of energy. She used to spend most of her time outside, but over the last 2 months has been increasing inactive, lying down to watch television, or even going to her room for naps in the middle of the day.

On examination, Sally appears very pale, but otherwise normal. You arrange blood tests which reveal a microcytic, hypochromic anaemia, with other blood picture parameters within normal range. Which of the following are the most likely iron study results in this patient? Choose one (1) option.

Elevated Ferritin, low serum iron, low transferrin, high transferrin saturation

Low ferritin, low serum iron, low transferrin, high transferrin saturation

Normal ferritin, low serum iron, low transferrin, low transferrin saturation

Low ferritin, low serum iron, normal transferrin, low transferrin saturation

Normal ferritin, normal serum iron, normal transferrin, low transferrin saturation

Answer 24

The correct response is: Low ferritin, low serum iron, normal transferrin, low transferrin saturation

Iron deficiency is the commonest cause of anaemia in children, and will be evident by a low ferritin and serum iron, with low transferrin saturation. Differentials for microcytic anaemia, that are less common, include thalassaemia, or aplastic anaemias, including from malignancy such as leukaemia. Thalassaemia will generally present with a normal ferritin level. Aplastic anaemia will often be accompanied by abnormal white cell or platelet counts.

Question 25

Max is a 2 year old boy brought in to your GP clinic by his parents with a hoarse voice and barking cough over the past 48 hours which seems to be worse at night. There is no significant past medical history and no family history of asthma. On examination, Max’s temperature is 37.7C and his respiratory rate is 22/minute and heart rate is 110/minute. His oxygen saturations are 98% on room air. He appears non-toxic, alert, interactive and well perfused. There is audible stridor when he is active playing with the toys in your room but there is no stridor when he is resting on his father’s lap. On chest auscultation you note a slight wheeze but no focal crepitations. There is no increased work of breathing. You note a ‘barking’ cough and some rhinorrhoea. What would be your next step in managing Max? Choose one (1) option. Provide a prescription for oral prednisolone 2mg/kg for one night Provide a prescription for oral prednisolone 1mg/kg and a second dose for the next evening Provide a prescription for dexamethasone 0.3mg/kg for the next two nights Reassure Max's parents that no treatment is required at this stage but they should present to the emergency department if he develops stridor at rest Provide a prescription for dexamethasone 0.2mg/kg for the next three nights

Answer 25

The correct response is: Provide a prescription for oral prednisolone 1mg/kg and a second dose for the next evening This is a typical presentation of mild croup (laryngotracheobronchitis). Note that oral dexamethasone suspension 0.15mg/kg (single dose) can be given as an alternative to oral prednisolone but dexamethasone suspension is not available from community pharmacies (only hospital pharmacies). All parents should be advised when to urgently seek review for their child. The management of croup is outlined in the Royal Children’s Hospital clinical guidelines.

Question 26

Hugo McDonald, a 4 year old boy, presents with his mother reporting he has only opened his bowels once in the past week with a lumpy, hard stool which was painful to pass. There is no previous history of constipation and no developmental issues. He was day-time toilet trained at 3 years of age. Hugo is otherwise well. He recently started attending pre-school five days a week. On examination, his abdomen is soft, but you can palpate what you believe are faeces in the left lower quadrant. Which of the following statements regarding the management of constipation in children is correct? Choose one (1) option. Commence docusate sodium 50mg daily. Encourage toileting prior to meals, when the colon is most active. Stool softeners should not be utilised in children under 5 years of age, unless they have a diagnosis of chronic constipation. Encourage children to undertake a distraction activity while toileting, such as reading a book. Encourage good toileting behaviour, aiming for sitting on the toilet two to three times a day after meals.

Answer 26

The correct answer is: Encourage good toileting behaviour, aiming for sitting on the toilet two to three times a day after meals. Constipation is a common presentation in children. This question assesses a candidate’s knowledge of the key principles of paediatric constipation management, which is to soften the stool so as to empty the rectum, soften the stool to minimise pain and finally to encourage good toileting habits. Toileting should ideally be performed for 5 minutes 2 – 3 times per day after meals and should not be associated with distractions such as books or iPads which can prolong toileting. Toileting should be praised even when no stool is passed. A simple stool softener, such as macrogol (Movicol) is acceptable, whereas a stool stimulant, such as docusate sodium (Coloxyl) should not be used first-line. Abdominal x-rays should not be routinely performed in general practice to investigate constipation. References: eTG complete by Therapeutic Guidelines [Internet]. West Melbourne, VIC (Australia): Therapeutic Guidelines Ltd; 2019. Functional Gastrointestinal Disorders – Functional Constipation in Children; March 2016. https://tgldcdp.tg.org.au/viewTopic?topicfile=functional-gastrointestinal-disorders&guidelineName=Gastrointestinal#toc_d1e756 Waterham M, Kaufman J, Gibb S. Childhood constipation. Australian Family Physician. 2017 Dec;46(12):908. https://www.racgp.org.au/download/Documents/AFP/2017/December/AFP-2017-12-Focus-Constipation.pdf

Question 27

Jake is a 7 year old boy brought to your rural emergency department by his parents with widespread bruising, abdominal pain and leg pain. He had a ‘cold’ recently but has otherwise been well and has not suffered any trauma or injuries. Jake has had no fevers, vomiting, cough, diarrhoea, urinary symptoms or weight loss. He has no significant past medical history and takes no regular medications. His mother is not able to recall any family history of bleeding disorders. On examination, Jake’s temperature is 37.3OC, heart rate 80 / minute, respiratory rate 20 / minute, blood pressure 130/90 mmHg and oxygen saturations 98% on room air. He appears uncomfortable but is alert, orientated, non-toxic and well hydrated. He has palpable purpura on bilateral buttocks and legs. His cardiovascular, respiratory and ENT examinations are unremarkable. He has generalised mild abdominal tenderness with no signs of peritonism. Jake has tender bilateral hips and knees but there is no swelling or increased warmth on palpation. His urine dipstick is positive for blood and protein. What is the most likely diagnosis? Leukaemia Meningococcal septicaemia Idiopathic thrombocytopenia Henoch-schonlein purpura Haemophilia

Answer 27

The correct response is: Henoch-schonlein purpura The key diagnostic features in this presentation include palpable purpura over bilateral buttocks and legs, abdominal pain, arthralgia, haematuria, proteinuria and hypertension. Reference: Royal Children’s Hospital. Clinical Practice Guidelines: Henoch-schonlein purpura. https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/ (Accessed April 2020).

Question 28

Kelly brings her 2 year old daughter Sally to see you regarding some skin lesions she has noticed on Sally’s legs over the past 3 months. Sally has a history of eczema and is otherwise well and healthy. She uses topical steroid ointments as needed but otherwise takes no regular medications. Sally has no drug allergies. Her immunisations are up-to-date. You note about 10 pearly papules with central umbilication around Sally’s knees and thighs bilaterally and diagnose her with molluscum contagiosum. Kelly is keen to learn more about this condition. Which of the following pieces of advice and education do you provide Kelly, choose one (1) option. The condition can be spread by children sharing baths and towels Molluscum is caused by a bacterial infection and can be effectively treated with topical antibiotics Children with this condition need to be excluded from daycare and school The papules normally resolve within a few weeks Molluscum will not cause a flare of Sally’s eczema

Answer 28

The correct response is: "molluscum can be spread by children sharing baths and towels". Most of the time molluscum do not require any treatment and is not a reason for school or daycare exclusion. Molluscum can cause a flare of eczema. It may take more than a year for the papules to self-resolve. The Royal Children’s Hospital Melbourne. Kids Health Info Fact Sheets: Molluscum. 2018 https://www.rch.org.au/kidsinfo/fact_sheets/Molluscum/ (accessed Dec 2019).

Question 29

Luke is a 19 year old university student who presents with a 2 week history of lethargy associated with mild fever and sore throat. He has been otherwise well with no significant past history and is on no regular medications. He denies previous illicit drug use or recent excessive alcohol intake. One month ago he went on a one week holiday to Bali. On examination, he is afebrile, has diffuse cervical lymphadenopathy and is tender over the liver margin with no organomegaly. Which one of the following is the MOST likely diagnosis? Hepatitis A infection Influenza Chronic fatigue syndrome Streptococcal throat infection Infectious mononucleosis

Answer 29

Infectious mononucleosis is a common condition which typically starts with fevers, sore throat and swollen cervical lymphadenopathy. Hepatosplenomegaly occurs in approximately 10-15% of cases. Therapeutic Guidelines eTG complete. Antibiotic: Epstein-Barr virus infection 2019 https://tgldcdp.tg.org.au/viewTopic?topicfile=epstein-barr-virus&guidelineName=Antibiotic#toc_d1e47 Charles P. Infectious Mononucleosis. Aust Fam Physician 2003;32:785-788. https://www.racgp.org.au/afp/200310/17633

Question 30

A mother brings her four year old son to see you regarding concerns about his behaviour. She is concerned that he may be displaying features of autism spectrum disorder. Which of the following is a feature suggestive of autism spectrum disorder? Choose one (1) option. Deliberately annoying others Echolalia Heightened response to pain Advanced capabilities for imaginative play at a young age Intense attention to social stimuli

Answer 30

The correct response is: Echolalia Stereotyped and repetitive use of language such as echolalia is commonly seen in autism spectrum disorder. Deliberately annoying others is a symptom of oppositional defiant disorder. Children with autism spectrum disorder often have lack of response to pain, and self injurious behaviour is a common feature. Children with autism spectrum disorder will usually engage in repetitive play that lacks imagination. Older children may engage in what appears to be imaginative play, but it is usually repetition of learned activities/behaviour. Early developmental differences include failing to have an anticipatory posture, such as reaching out to be picked up, and absent or reduced visual attention to social stimuli, smiling in response to others, vocalisation and exploration of objects. Reference: Tonge B, Brereton A. Autism spectrum disorders. Aust Fam Physician 2011;40:672-677. https://www.racgp.org.au/afp/2011/september/autism-spectrum-disorders/

Question 31

Jenny brings in her four month old baby, George, to your clinic because she is concerned about the appearance of his scalp. She has noticed yellow greasy scales on his scalp which started about six weeks ago. He has been otherwise well. George was born at term and has no significant past medical history. He takes no medications and has no known allergies. You examine George’s scalp and notice yellow flaky crusts mostly over the frontal region. The underlying skin does not appear to be red or inflamed. What management advice do you give to Jenny? Source: DermNet NZ Advise skin scrapings to confirm the diagnosis Advise application of an emollient and then removal of the scales with a soft brush/comb Advise application of topical mupirocin 2% ointment 8 hourly for 5 days Advise application of topical ketoconazole 2% for 1-2 weeks Advise application of topical hydrocortisone 1% cream for 1-2 weeks

Answer 31

The correct response is: advise application of an emollient or gentle baby shampoo and then removal of the scales with a soft brush/comb. This is a classic case of mild cradle cap which is very common in infants under the age of 12 months and parents should be reassured about the benign nature of the condition. Most mild cases can be treated with application of gentle baby shampoo, liquid paraffin or an emollient. Parents can then remove the scales with a soft toothbrush or comb. Only more extensive cases require the use of low-potency topical treatments such as 1% hydrocortisone or ketoconazole 2%. DermNet NZ. Cradle cap. https://www.dermnetnz.org/topics/cradle-cap (Accessed June 2018). Su J. Common rashes in neonates. Aust Fam Physician 2012; 41(5): 280 – 286. https://www.racgp.org.au/afp/2012/may/common-rashes-in-neonates/

Question 32

Rory is a 4 year old boy who you are reviewing today. Rory has been seen at your practice twice this week already as his Mum is very concerned. He has been having high fevers for the last 5 days. He is off his food and is drinking only small amounts. You note his lips appear dry and cracked and his tongue is very red. His eyes are both red and injected, but there is no discharge. He has large tender cervical lymph nodes and the palms of his hands and soles of his feet are red and swollen. From the following list what is the most important diagnosis to consider in this case? Choose one (1) option. Roseola infantum Kawasaki Disease Rubella Henoch-Schonlein purpura Molluscum contagiosum Hand foot and mouth disease Primary Herpes Simplex infection Measles Erythema infectiosum Scarlet fever Meningococcal infection Chicken pox Impetigo

Answer 32

The correct response is: Kawasaki disease The diagnostic criteria for Kawasaki disease are: fever for 5 days or more, plus 4 out of 5 of: · polymorphous rash · bilateral (non-purulent) conjunctival injection · mucous membrane changes (e.g. reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa) · peripheral changes (e.g. erythema of the palms or soles, oedema of the hands or feet, and in convalescence desquamation) · cervical lymphadenopathy (at least one node > 15 mm diameter, usually unilateral, single, non-purulent and painful) It is the most important diagnosis to consider because patients with diagnosed or suspected Kawasaki disease should be admitted to hospital and require ongoing follow-up due to the possible sequele associated with this disease including coronary aneurysms. Reference: The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Kawasaki Disease. Updated August 2017. https://www.rch.org.au/clinicalguide/guideline_index/Kawasaki_disease/ Correct answers is: Kawasaki Disease

Question 33

Mary Su, presents with her 25 month old son Jason, after picking him up from day care. She has noticed when talking to the other parents that perhaps Jason is behind in certain aspects of his development compared with his peers. Which of the following would be considered a red flag for Jason? Choose one (1) option. Difficulty in understanding his peer’s emotions Speech occasionally difficult to understand Difficulty walking up and down stairs A vocabulary of 15 words Unable to run well

Answer 33

The correct response is: A vocabulary of 15 words A child of 2 years of age should have a vocabulary of at least 50 words. It is important that GPs are aware of developmental milestones in children. The RACGP Red Book provides a useful ‘Red flag’ early intervention referral guide on page 41. Reference: RACGP. Red Book – Guidelines for Preventative Activities in General Practice. 9th Ed. 2016. https://www.racgp.org.au/download/Documents/Guidelines/Redbook9/17048-Red-Book-9th-Edition.pdf (Accessed April 2020)

Question 34

A mother brings in her 18 month old son to see you for his routine vaccinations. The child is currently well with no significant past medical history, he was born at term and is not of Aboriginal or Torres Strait Islander descent. He tolerated his previous vaccinations without any adverse reactions, has no known contraindications to any immunisations, and has no known allergies. Which of the following vaccination combinations would you recommend for this child according to the National Immunisation Program schedule? Choose one (1) option. Measles, Mumps, Rubella (MMR) and Diptheria, Tetanus, Pertussis (DTPa) Measles, Mumps, Rubella, Varicella (MMRV) Measles, Mumps, Rubella (MMR) and Haemophilus influenza b (Hib), Meningococcal ACWY Measles, Mumps, Rubella, Varicella (MMRV) and Diptheria, Tetanus, Pertussis (DTPa) and Haemophilus influenzae type b (Hib) Measles, Mumps, Rubella, Varicella (MMRV) and Diptheria, Tetanus, Pertussis, Polio (DTPa/IPV)

Answer 34

The correct response is: Measles, Mumps, Rubella, Varicella (MMRV) and Diptheria, Tetanus, Pertussis (DTPa) and Haemophilus influenzae type b (Hib) See the National Immunisation Program schedule referenced below for details of recommended vaccinations.

Question 35

A mother is concerned that her 6 month old daughter Neve is not putting on weight appropriately. She has been unwell in the last 2 months with a bout of gastroenteritis and an episode of bronchiolitis. Neither illness required hospitalisation. Neve was 3.2kg at birth and currently weighs 6kg. In assessing Neve further for possible poor growth, which of the following would be considered a red flag? A family history of coeliac disease A history of breast feeding difficulties Signs of poor attachment between Neve and her mother Weight < 5th percentile when plotted on a growth chart Neve is not showing interest in solid foods when they have been offered to her

Answer 35

Poor growth generally describes a child whose current weight, or rate of weight gain, is significantly below that expected of similar children of the same age and sex. Adequacy of growth is best evaluated by plotting serial measurements on a centile weight chart.Serial measurements are needed to assess a child’s growth. One-off measurements show a child’s size but not their growth. Many healthy children grow on centile lines at the top or bottom of the growth chart and many healthy children have small “dips” above or below a particular centile line or growth curve. Birth weight is not necessarily representative of the genetic potential for future growth. Eg. there is no cause for concern if a baby is healthy and gaining weight but tracking along a lower centile than that of the birth weight. As per the Royal Children's Hospital Clinical Guidelines, if one or more of the following red flags are identified, involvement of a multidisciplinary team is essential. Admission to hospital should also be considered if any of the following red flags are present. Signs of abuse or neglect Poor carer understanding e.g. non-English speaking, intellectual disability Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support Signs of poor attachment Parental mental health issues Already/previously case managed by child protection services Did not attend or cancelled previous appointment/s Signs of dehydration Signs of malnutrition or significant illness

Question 36

Jordan is a 17 year old male who is brought to your clinic by his mother with a rash. Jordan has been unwell recently with fevers, a very sore throat, reduced appetite and generalised abdominal discomfort. He saw another GP a week ago and was started on antibiotics for tonsillitis. This morning he has developed an intensely itchy maculopapular rash. Jordan has no significant past medical history and takes no regular medications. He has no known allergies. On examination, Jordan appears well and his temperature is 36.5°C. He is well hydrated and non-distressed. He has a widespread blanching maculopapular rash. He has small pustules on bilateral enlarged tonsils and tender cervical lymphadenopathy. His abdominal examination is unremarkable. What advice do you give Jordan? Strictly avoid penicillins in the future The rash will self-resolve without treatment Apply topical betamethasone 0.05% ointment until the rash resolves Commence oral prednisolone 25mg daily for three days Strictly avoid penicillins and cephalosporins in the future

Answer 36

The correct response is: The rash will self-resolve without treatment. This case describes a teenager with clinical features consistent with Ebstein-Barr virus. When amoxicillin, ampicillin or cephalosporins are given during the course of infectious mononucleosis (often incorrectly prescribed for presumed streptococcal tonsillitis), patients may experience an intensely itchy maculopupular or morbilliform rash seven to ten days later. This rash is not a sign of a true allergy to the antibiotic but is rather considered a ‘hypersensitivity reaction’.

Question 37

Lina brings her 2 month old child, Ruby, to see you. She says that Ruby has noisy breathing, which she thinks has been present since not long after her birth. Lina notices it when she is breathing in and Ruby doesn't seem distressed by it. Sometimes though she will get upset during breast feeding, and has been taking formula by bottle for more of her feeds recently. On examination, you note a high-pitched cog-wheel inspiratory stridor. Ruby is seen by a paediatrician and diagnosed with larynogomalacia. Lina asks when this condition will likely resolve. Which of the following is correct? Choose one (1) option. 1 - 2 years of age 6 months of age 4 months of age 3 - 4 years of age 5 years of age

Answer 37

he correct response is: 1 - 2 years of age As stated in eTG: "Some children present with a chronic 'cog-wheel' high-pitched inspiratory stridor that has been present from birth or the first few days or weeks of life. The most common cause is laryngomalacia. The stridor resolves spontaneously at 1 to 2 years of age. Alternatively, inspiratory stridor that develops for the first time at 6 to 8 weeks of life, worsens and becomes biphasic (present in both inspiration and expiration) may be due to a subglottic haemangioma. Most cases of chronic stridor in infants need referral."

Question 38

Shaun Watson is a 22 year old man who presents with significant fatigue and sore throat that has been present for 7 days. He reports that he has also suffered with headaches, nausea and generalised body aches. He is a professional Australian Rules football player and has already missed one full week of football. On examination, he is mildly jaundiced, his throat is congested with palatal petechiae, his tonsils are enlarged and covered with exudate, and he has cervical lymphadenopathy and splenomegaly. There is no airway compromise on examination. Given your expected diagnosis what is the most appropriate management for Shaun? Please select one (1) answer from the following. Oral phenoxymethylpenicillin 500mg twice per day for 10 days Oral aciclovir 800mg five times per day for 5 days Referral to a haematologist for further investigation of splenomegaly and lymphadenopathy Avoid physical activity for another 2 weeks Oral prednisolone 50mg daily for 4 days

Answer 38

The most likely diagnosis in this case is Infectious Mononucleosis (IM). This syndrome is caused by Epstein Barre Virus and most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae. Symptomatic relief is the mainstay of treatment. Glucocorticoids and antivirals do not reduce the length or severity of illness. Splenic rupture is an uncommon complication of IM. Because physical activity within the first three weeks of illness may increase the risk of splenic rupture, athletic participation is not recommended during this time. Children are at the highest risk of airway obstruction, which is the most common cause of hospitalization from IM. Womack, J. Jimenez. Common Questions about Infectious Mononucleosis. Am Fam Physician. 2015 Mar 15;91(6):372-376. Available from: https://www.aafp.org/afp/2015/0315/p372.html (Accessed June 2020). Therapeutic Guidlines. Etg complete. Epstein Barre Virus infection. 2020. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=epstein-barr-virus#toc_d1e47 (Accessed June 2020) Paid subscription required Correct answers is: Avoid physical activity for another 2 weeks

Question 39

Mia is a four month old infant brought to the clinic by her mother with a two day history of fevers, rhinorrhoea, coughing, wheezing and reduced feeding. She has had no vomiting or diarrhoea or rashes. She was born at term via normal vaginal delivery and has no significant past medical history. On examination, you note that Mia’s temperature is 37.8C, respiratory rate 60 / minute, heart rate 170 / minute and oxygen saturations 93% on room air. You note moderate increased work of breathing with subcostal and intercostal retraction and a tracheal tug. Central capillary refill is two seconds and she has moist mucous membranes. Mia has dual heart sounds with widespread inspiratory crackles and expiratory wheeze. What do you advise Mia’s mother in terms of management advice? Amoxycillin 15mg/kg orally every eight hours for five days Prednisolone 1mg/kg orally daily for three days Referral to the emergency department for likely admission for intravenous antibiotics Immediate salbutamol 100mcg via metered dose inhaler while awaiting the arrival of the ambulance Referral to the emergency department for likely admission for supplemental oxygen and fluid management

Answer 39

The correct answer is: Referral to the emergency department for likely admission for supplemental oxygen and fluid management This case describes acute viral bronchiolitis which is common in young infants. Bronchiolitis is a clinical diagnosis and management is to support feeding and oxygenation as required. Neither corticosteroids or bronchodilators have been shown to provide benefit in reducing hospital length of stay or requirement for supplemental oxygen.

Question 40

Sally is a 4 year old girl, brought in by her mother because she is concerned about Sally's seeming lack of energy. She used to spend most of her time outside, but over the last 2 months has been increasing inactive, lying down to watch television, or even going to her room for naps in the middle of the day. On examination, Sally appears very pale, but otherwise normal. You arrange blood tests which reveal a microcytic, hypochromic anaemia, with other blood picture parameters within normal range. Which of the following are the most likely iron study results in this patient? Choose one (1) option. Elevated Ferritin, low serum iron, low transferrin, high transferrin saturation Low ferritin, low serum iron, low transferrin, high transferrin saturation Normal ferritin, low serum iron, low transferrin, low transferrin saturation Low ferritin, low serum iron, normal transferrin, low transferrin saturation Normal ferritin, normal serum iron, normal transferrin, low transferrin saturation

Answer 40

The correct response is: Low ferritin, low serum iron, normal transferrin, low transferrin saturation Iron deficiency is the commonest cause of anaemia in children, and will be evident by a low ferritin and serum iron, with low transferrin saturation. Differentials for microcytic anaemia, that are less common, include thalassaemia, or aplastic anaemias, including from malignancy such as leukaemia. Thalassaemia will generally present with a normal ferritin level. Aplastic anaemia will often be accompanied by abnormal white cell or platelet counts.

Question 41

A mother brings in her 1 year old son to see you for his routine vaccinations. The child is currently well with no significant past medical history, he was born at term and is not of Aboriginal or Torres Strait Islander descent. He tolerated his previous vaccinations without any adverse reactions, has no known contraindications to any immunisations, and has no known allergies. Based on the National Immunisation Schedule, which of the following vaccination combinations would you recommend for this child? Choose one (1) option. Measles, Mumps, Rubella, Varicella (MMRV); Haemophilus influenza b(Hib); and Meningococcal ACWY Measles, Mumps, Rubella, Varicella (MMRV); Pneumococcal; and Diptheria, Tetanus, Pertussis (DTPa) Measles, Mumps, Rubella (MMR); Pneumococcal; and Meningococcal ACWY Measles, Mumps, Rubella, Varicella (MMRV); Pneumococcal; and Meningococcal ACWY Measles, Mumps, Rubella (MMR); Meningococcal B; and Meningococcal ACWY

Answer 41

The correct response is: Measles, Mumps, Rubella (MMR); Pneumococcal; and Meningococcal ACWY These are the immunisations recommended for children at 12 months of age as per the National Immunisation Schedule. Meningococcal B is an additional vaccine recommended at 12 months for age for Indigenous children. Reference: Australian Government Department of Health. National Immunisation Program Schedule Updated July 2020. https://www.health.gov.au/resources/publications/national-immunisation-program-schedule-for-all-non-indigenous-people(Accessed July 2020).

Question 42

A 6 year old boy is brought in by his mother with an 8 hour history of fever and vomiting. He hasn't been able to keep anything down since last night. He has no localising symptoms or signs and last passed urine 4 hours ago. Which one of the following is the most appropriate next step in management? Aspirin dissolvable tablets Prochlorperazine suppositories Ibuprofen suppositories Metoclopramide injection Ondansetron wafers

Answer 42

Ondansetron is safe to give to children greater than 2 years old, but would have to be given on a private script with review of his clinical state and oral intake. Metoclopramide is best avoided in children due to the increased risk of extrapyramidal side effects. Doxycycline is contraindicated in children less than 8 years old as tetracyclines discolour teeth and cause enamel dysplasia which increases the risk of dental caries. It also deposits in bone and causes deformities and inhibits bone growth. Aspirin should be avoided in children up to the age of 16 years with fever as it has been associated with Reye's syndrome. Paracetamol would be a safer choice than ibuprofen if analgesia was required, given he has an empty stomach and is likely to be dehydrated. Rossi, S, editor. Australian Medicines Handbook 2018. Adelaide:Australian Medicines Handbook Pty Ltd;2018. https://amhonline.amh.net.au/auth Correct answers is: Ondansetron wafers

Question 43

A 2 year old boy presents with his pregnant mother with a 3 day history of fever, general malaise and reduced appetite. On examination the child has multiple vesicles on his hands and feet. There are also several blisters in his mouth. Which of these statements is true? Choose one (1) option. The child likely has parvovirus The child should be excluded from contact with pregnant women The child can excrete the virus in their faeces and saliva for several weeks The virus is spread via direct contact only The child is able to return to childcare in 3 days

Answer 43

The correct response is: The child can excrete the virus in their faeces and saliva for several weeks Based on the information provided, the child likely has hand, foot and mouth disease. He does not need to be excluded from contact with pregnant women but does need to be excluded from childcare until the blisters have dried, his fever has resolved and the rash has resolved. This condition is spread via both aerosol droplets and direct contact. The virus can be excreted for several weeks in the faeces and saliva. Reference:

Question 44

Q.25 Two young parents bring in their 12 month old boy who is refusing to walk after a fall. They report that he was climbing the stairs without them looking and then fell down the flight of stairs and was unable to get up. Examining him you notice bruises of multiple ages. You are concerned about the possibility of non-accidental injury. Which of the following bruising patterns is highly suggestive of a non-accidental cause? Choose one (1) option. Bruising on bony prominences Bruising in a child of walking age Bruising on the abdomen Bruises of multiple stages of age/resolution Bruising on the forehead

Answer 44

The correct response is: "Bruising on the abdomen" Bruises are a normal part of childhood, however some bruises should raise suspicion of non-accidental injury. Childhood accidents commonly cause bruising on the front of the body over bony prominences; toddlers frequently have accidentally acquired bruises on their foreheads and older children commonly have bruises on their knees and shins. Bruises in pre-mobile children are very uncommon. Bruises over relatively protected parts of the body such as behind the ears, neck, trunk and buttocks should raise concern about a non-accidental cause.

Question 45

A 2 year old girl is brought in to your clinic by her mother with a 2 day history of a runny nose, fever, barking cough and noisy breathing which is worse with crying. On examination, she is alert with an inspiratory stridor at rest. Her temperature is 38.2°C, pulse is 110/minute and respiratory rate is 35/minute. Tracheal tug, subcostal and intercostal recession are seen. There is a widespread wheeze on auscultation of her chest. What is the most likely diagnosis? Choose one (1) option. Allergy Aspiration pneumonia Asthma Bacterial tracheitis Chlamydia pneumoniae pneumonia Anaphylaxis Croup Cystic fibrosis Epiglottitis Foreign body inhalation Influenza Psychogenic cough Reflux Respiratory Syncytial Virus Sinusitis Streptococcal pneumoniae infection Subglottic haemangioma

Answer 45

The correct response is: Croup Croup is caused by a viral infection of the upper airway, larynx and trachea. It most commonly occurs between the ages of 6 months and 6 years. It often presents with a barking cough, inspiratory stridor, increased work of breathing, widespread wheeze, hoarse voice and/or fever. Important differential diagnoses include anaphylaxis, inhaled foreign body and bacterial tracheitis.

Question 46

Maddie Adams is a 12-year-old girl who presents with her mother and consults you regarding some worrying hair loss. Maddie’s mother wants this to be fixed urgently before an upcoming dance competition that Maddie is competing in. On examination, Maddie’s hair is tied in a bun and there is predominantly fronto-temporal hair loss with some retained hair in the area and no evidence of inflammation. Which of the following is the most likely diagnosis? Choose one (1) option. Tinea capitis Alopecia areata Traction alopecia Trichotillomania Telogen effluvium

Answer 46

The correct answer is “Traction alopecia”. The pathognomic sign of traction alopecia is the “Fringe Sign” - with alopecia along the marginal hairline and trichomalacia (thinned out hair). Traction alopecia is due to constant tension on the hair due to styling and braiding and may present due to habit or underlying psychological issues. The most common forms of alopecia in children aged under 12 years are usually benign and non-scarring.

Question 47

Jax Smith presents for his 6-week check with his mother Nikki. His mother reports an unremarkable pregnancy and delivery. Nikki has noticed that Jax only has one testicle in his scrotum. She heard in her mother’s group that she should ask for a referral to a surgeon to have this corrected and she requests a referral today. By what age, if not spontaneously corrected before this, should Jax be referred to a paediatric surgeon for orchidoplexy? Choose one (1) option. 3 months 24 months 9 months 12 months 18 months

Answer 47

The correct response is: 3 months Undescended testis refers to a testis which is not in the scrotum by 3 months of age. It is caused by a failure of normal descent. Infants with a unilateral undescended testis should be referred to a paediatric surgeon at 3 – 6 months of age, with an orchidopexy planned for between 6 and 12 months of age.

Question 48

Chloe is a 7 year old brought in by her Dad after she was sent home from school with a fever. Chloe has not been well for the last 3 days, complaining of tiredness and a sore throat. Today you notice her cheeks are red, she looks very flushed and she has a fine lacy rash over her abdomen and back. What is the most LIKELY cause of her symptoms and rash from the list below? Roseola infantum Kawasaki Disease Rubella Henoch-Schonlein purpura Molluscum contagiosum Hand foot and mouth syndrome Primary Herpes Simplex infection Measles Erythema infectiosum Scarlet fever Meningococcal infection Chicken pox Impetigo

Answer 48

The correct response is: Erythema infectiosum Erythema infectiosum is a viral infection caused by a virus called parvovirus B19. It is also called 'fifth disease' or ‘slapped cheek’. It commonly children between the ages of four and 10 years but can happen at any age, even in adulthood. The first symptoms can include fever, headache, stomach upsets, aches and pains. This is the time when the virus can be spread to others, mainly through saliva. A bright red rash appears on the cheeks from three to seven days after getting the virus. The cheeks look like they have been slapped, hence the name Slapped Cheek. It is also common for a pink lace pattern like rash to appear on the chest, back, arms and legs. The rash can come and go for several weeks, especially if the skin is exposed to sunlight or after exercise.

Question 49

Ryver Hooper is a seven year old boy who presents to you with a 24 hour history of fevers, bloody diarrhoea, vomiting and intermittent abdominal pain. He is usually well and healthy and has not travelled overseas recently. On examination he is adequately hydrated, his vital signs are within expected limits other than a fever of 38.8⁰C and his abdomen is soft and non-tender. What is the MOST likely cause of his symptoms? Campylobacter Entamoeba histolytica Adenovirus Norovirus Clostridium difficle

Answer 49

The correct answer is: Campylobacter Clinical clues that may help differentiate between viral and bacterial diarrhoea. A viral pathogen (eg rotavirus, norovirus, adenovirus, astrovirus) is more likely in the following situations: when there is a history of contact with a person who has acute infectious diarrhoea; in an outbreak with secondary cases; or with prominent upper gastrointestinal symptoms such as vomiting and nausea. In contrast, fever, tenesmus and bloody stool are commonly found in acute diarrhoea with bacterial aetiology (eg Campylobacter enteritis, Clostridium difficile infection, Salmonella enteritis, Shigella enteritis). A bacterial cause is also commonly identified in returned travellers with diarrhoea. Of the possible causes listed here, Campylobacter is the most correct answer, as the clinical stem tells you that he is usually well, so Clostridium is very unlikely as there is nothing to suggest he has been on prolonged antibiotics.

Question 50

Sophie, a 3 year old girl is brought in by her mother with 24 hours of a painful left knee, rash over her buttocks and mild cramping abdominal pain. On examination, she is afebrile. Her left knee is painful on passive movement. There is a palpable purpuric rash over her buttocks. Her abdomen is slightly tender, but soft on palpation. Urinalysis shows a trace of blood. What clinical follow up will you arrange for Sophie given your suspected diagnosis? Select one (1) from the following: Clinical review, blood pressure check and urinalysis weekly for the next one month, then fortnightly for weeks 5-12 and a single review at both 6 and 12 months Referral to a renal specialist for clinical follow up given the presence of microscopic haematuria Daily clinical review and blood pressure checks for the next one week then weekly for 6 months This condition will spontaneously resolve and no further clinical follow up is required Monthly blood pressure checks and urinalysis for the next 12 months

Answer 50

The correct response is: Clinical review, blood pressure check and urinalysis weekly for the next one month, then fortnightly for weeks 5-12 and a single review at both 6 and 12 months. Henoch-Schonlein Purpura is the most common vaculitis seen in children. It usually affects children aged 2 - 8 years of age. It can present with a palpable purpuric rash with arthritis / arthralgia, abdominal pain and/or renal involvement. The rash tends to occur over the buttocks and lower legs in ambulatory children. Follow up is critical in HSP to identify subsequent renal involvement which rarely requires a renal biopsy +/- immunosuppression. If the initial urinalysis is normal or only reveals microscopic haematuria, review clinically and check BP/early morning urinalysis at these recommended time intervals: Weekly for the first month after disease onset Fortnightly from weeks 5-12 Single reviews at 6 and 12 months Return to 1. if there is a clinical disease flare The development of hypertension, proteinuria or macroscopic haematuria at any point should prompt paediatric review with investigations (outlined above) and ongoing follow-up based on results Discussion with a Renal specialist is recommended if there is: Hypertension Abnormal renal function Macroscopic haematuria for 5 days Nephrotic syndrome Acute nephritic syndrome Persistent proteinuria UPCR >250mg/mmol for 4 weeks UPCR >100mg/mmol for 3 months UPCR >50mg/mmol for 6 months If there is no significant renal involvement plus normal urinalysis at 12 months, no further follow-up is required Reference: Royal Childrens Hospital Mebourne. Clinical Practice Guidelines: Henoch Schonlein Purpura. https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/ (Accessed June 2020). Correct answers is: Clinical review, blood pressure check and urinalysis weekly for the next one month, then fortnightly for weeks 5-12 and a single review at both 6 and 12 months

Question 51

4 week old Lara is brought in to you by her mother, who is concerned about her excessive crying throughout the day over the past week. Her mother notes that the episodes of crying are becoming more frequent and she is increasingly difficult to settle. These episodes occur throughout the day and often last for 1-3 hours. Lara is breastfed, feeding every 2-3 hours with good attachment. There is no vomiting. Urine output is normal but may be somewhat smelly. Her bowels are normal. Her physical examination is unremarkable. What is the most appropriate next step? Choose one (1) option. Commence a trial of antacid and reassess Organise a urine microscopy culture and sensitivity (MCS) and basic blood screen and review Organise urine microscopy, culture and sensitivities and review Reassure mother that infants often cry at this age and she will grow out of this in the next 2-3 months Suggest maternal restriction of dairy products for 2 weeks and reassess

Answer 51

The correct response is: Organise urine microscopy, culture and sensitivities and review As outlined in the Royal Children's Hospital guidelines, a careful history and examination needs to be performed for acute episodes of crying in order to exclude underlying medical conditions including urinary tract infection, injury such as a fracture, raised intracranial pressure, incarcerate hernia, hair torniquet and corneal abrasion. Lara should be regularly reviewed with her mother and support and education offered as needed.

Question 52

A ten week old baby is brought to the clinic by his mother. He has had a distressing cough for three days, worst today. He is otherwise well, though feeding less. On examination he is afebrile, his respiratory rate is 55, oxygen saturation 96% on room air and pulse rate 150/min. He has mild subcostal recession and appears well hydrated. Chest auscultation reveals widespread expiratory wheeze. Which one of the following is the MOST likely cause of his cough? Allergy Aspiration pneumonia Asthma Bacterial tracheitis Croup Epiglottitis Foreign body inhalation Reflux Respiratory Syncytial Virus Streptococcal pneumoniae Rhinovirus

Answer 52

Your answer is correct. General Feedback: Bronchiolitis is the most likely cause of this previously well infant's cough and wheeze worsening over three days. The most common cause of bronchiolitis is respiratory syncytial virus. Oo S and Le Souef P. The wheezing child: an algorithm. Aust Fam Physician 2015; 44(6):360-364

Question 53

Roxanne is a 31 year old who comes to see you about her daughter Annie. Annie is 3 years old and Roxanne is struggling with how to manage Annie’s behaviour. She describes Annie having the odd tantrum when she was two, but she thought now they were through the ‘terrible two’s’ that things would have got better. However, Annie is throwing food when she doesn’t like what she is given, hitting when she doesn’t get her own way, as well as having tantrums over small things like putting on her shoes to go outside. Roxanne admits she just doesn’t know how to manage Annie, and tends to give in as she is sick of struggling with her. Annie is her first child. Her husband is supportive, but works long hours, and they have no extended family close by, so most of the parenting is left up to Roxanne. Roxanne says her mood is fine, and she does not feel down or anxious, but would like some suggestions or strategies to help her manage Annie’s behaviour better. You provide Roxanne with advice regarding managing Annie’s behaviour. Which of the following is the MOST CORRECT statement when it comes to managing children with challenging behaviours? Children need clear explanations of what they did wrong at the time their behaviour occurred Withdrawing attention from all low priority behaviours send the message that this behaviour is acceptable Withdrawal of privileges is an effective way of providing consequences to toddlers with challenging behaviours Praising the child’s behaviour is more effective than praising the child If the child recommences the challenging behaviour after they have already been given a reward, this should be withdrawn immediately

Answer 53

Answer = Praising the child's positive behaviour is more effective than praising the child. Conversely, pointing out the child's bad behaviours is more effective than saying that the child is bad. Jarman, R. Finetuning behaviour management in young children. Aust Fam Physician 2015; 44(12):896-899. https://www.racgp.org.au/afp/2015/december/finetuning-behaviour-management-in-young-children/ (Accessed April 2020) Royal Children's Hospital Melbourne. Kids Health Info. Fact Sheets. Challenging Behaviours- Toddlers and Young Children. 2018. Available from: https://www.rch.org.au/kidsinfo/fact_sheets/Challenging_behaviour_toddlers_and_young_children/(Accessed April 2020).

Question 54

What are the principles of behaviour management in kids?

Answer 54

``` Stabilise routines Provide special time Praise and reward positive behaviours Prioritise difficult behaviours Ignore minor difficult behaviours Immediate consequences for major difficult behaviours Minimise talking at time of misbehaviour Debrief later when things are calm ```

Question 55

When can you give ondansetron to a child?

Answer 55

Ondansetron is safe to give to children greater than 2 years old, but would have to be given on a private script with review of his clinical state and oral intake.

Question 56

Can you give doxycycline to a child less than 8 years old?

Answer 56

Doxycycline is contraindicated in children less than 8 years old as tetracyclines discolour teeth and cause enamel dysplasia which increases the risk of dental caries. It also deposits in bone and causes deformities and inhibits bone growth.

Question 57

Can you give aspirin to a child under 16?

Answer 57

Aspirin should be avoided in children up to the age of 16 years with fever as it has been associated with Reye's syndrome. Paracetamol would be a safer choice than ibuprofen if analgesia was required, given he has an empty stomach and is likely to be dehydrated.

Question 58

What are the diagnostic criteria for HFrEF and HFpEF?

Answer 58

``` HFrEF (reduced EF) Symptoms signs of heart failure and LVEF <50%a ``` ``` HFpEF (preserved EF) Symptoms signs of heart failure and LVEF 50% and Objective evidence of: Relevant structural heart disease (LV hypertrophy, left atrial enlargement) and/or Diastolic dysfunction, with high filling pressure demonstrated by any of the following: invasive means (cardiac catheterisation) echocardiography biomarker (elevated BNP or NT proBNP) exercise (invasive or echocardiography) ```

Question 59

What are the NHYA classes of heartfailure?

Answer 59

Class I - No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc. Class II - Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. Class III - Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).Comfortable only at rest. Class IV - Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Question 60

Medical management of AAA

Answer 60

1. Smoking cessation 2. Medical management of AAA generally involves cardiovascular risk reduction, including antiplatelet therapy, statin therapy and antihypertensive therapy.

Question 61

When should you do Echo in AAA?

Answer 61

Primary presentation of a large AAA - (not incidental) - Echo to exclude a) aortic root dilatation b) bicuspid valve c) ascending arch aneurysm

Question 62

When should famillial screening in AAA?

Answer 62

Traditionally, familial screening has been recommended for primary relatives over the age of 65 years, but recent evidence suggests that this should also be extended to younger relatives in whom there is clinical evidence of a collagen, elastin or connective tissue disorder.

Question 63

When surgical intervention and surveillance of AAA?

Answer 63

Typically surgical intervention has been recommended at thresholds of 5.5cm in men, and 5.0cm in women. However, there seems to be a trend towards earlier intervention before these operative threshold in some countries. Walter may need a vascular surgeon opinion, however, this is not your top-most management priority. In general, suggested surveillance intervals have been based on rupture risk and expected growth rates, estimated from the size of the aneurysm. No surveillance guidelines have been published or endorsed by the Australian and New Zealand Society for Vascular Surgery (ANZSVS) to date. the 2007 US Society for Vascular Surgery Guidelines would recommend 10 yearly surveillance intervals for a 2.5-3cm aneurysm; while the 2010 European Society for Vascular Surgery (ESVS) Guidelines recommend 24 month surveillance intervals for a 3.0-3.9cm aneurysm.

Question 64

What foods should vegan be supplemented?

Answer 64

Calcium supplements as they dont take dairy

Question 65

How do you differentiate between viral and bacterial diarrhoea?

Answer 65

Clinical clues that may help differentiate between viral and bacterial diarrhoea. A viral pathogen (eg rotavirus, norovirus, adenovirus, astrovirus) is more likely in the following situations: when there is a history of contact with a person who has acute infectious diarrhoea; in an outbreak with secondary cases; or with prominent upper gastrointestinal symptoms such as vomiting and nausea. In contrast, fever, tenesmus and bloody stool are commonly found in acute diarrhoea with bacterial aetiology (eg Campylobacter enteritis, Clostridium difficile infection, Salmonella enteritis, Shigella enteritis). A bacterial cause is also commonly identified in returned travellers with diarrhoea.

Question 66

Signs and symptoms of molluscum?

Answer 66

At first, molluscum spots look like white pimples. They then become round, pearl-coloured lumps that have a white mark or indentation in the centre. They are usually 1–5 mm in size, but can be as big as 2 cm. Generally, molluscum spots are found on the stomach, face, arms, legs or in the nappy area. Molluscum spots are painless and usually not itchy.

Question 67

How is molluscum spread?

Answer 67

The molluscum virus is found in warm water, so children are often infected in swimming pools and baths. Sharing towels and face washers is another way to spread the virus. Molluscum can also be spread from skin-to-skin contact involving the molluscum spots. It can take weeks or even months for the spots to appear after your child has come into contact with the molluscum virus. Good personal hygiene is important to help prevent molluscum spreading. If your child has molluscum: Give your child showers instead of baths. The molluscum virus can spread to other parts of the body through the bath water. If your child does have a bath, don’t share baths with other children and avoid bath toys. The virus can be spread when drying with a towel, so try to dry areas with the molluscum spots last. Wash and dry any bath toys after use, as they can spread the virus. Do not share towels, face washers or clothing. Wash your hands thoroughly after touching your child’s molluscum spots. Most adults have been exposed to molluscum in their youth and are therefore immune, so it is not likely you will become infected by touching your child's spots.

Question 68

Molluscum treatment

Answer 68

Conservative, taping lesions, irritating solutions like imiquimod, aluminum acetate (burrows solution)

Question 69

Diagnostic criteria for Kawasakis disease?

Answer 69

The diagnostic criteria for Kawasaki disease are: fever for 5 days or more, plus 4 out of 5 of: · polymorphous rash · bilateral (non-purulent) conjunctival injection · mucous membrane changes (e.g. reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa) · peripheral changes (e.g. erythema of the palms or soles, oedema of the hands or feet, and in convalescence desquamation) · cervical lymphadenopathy (at least one node > 15 mm diameter, usually unilateral, single, non-purulent and painful)

Question 70

Kawasaki disease management?

Answer 70

patients with diagnosed or suspected Kawasaki disease should be admitted to hospital and require ongoing follow-up due to the possible sequele associated with this disease including coronary aneurysms.

Question 71

Rough Developmental milestones?

Answer 71

See the zero 0 as the “o” in tone, as the eyes for gaze, and as the mouth for strong suck The word two (months) is a combination of track and coo At four, the baby finds things funny (laughs) and pushes up on forearms to roll At six, the baby sits and makes sounds Picture the number 9 in a standing position and making a pincer grasp The w in twelve is for words and walks At 2 years old, the child has 2-word sentences and runs on 2 legs

Question 72

What are the communication and language milestones?

Answer 72

``` Communication and language milestones Average age Social smile 6 weeks Cooing 3 months Turns to voice 4 months Babbles 6–9 months ‘Mamma’/’Dadda’ (no meaning) 8–9 months ‘Mamma’/’Dadda’ (with meaning) 10–18 months Understands several words 1 year Speaks single words 12–15 months Points to body parts 14–22 months Able to name one body part 18 months Combines two words 14–24 months Speaks six or more words 12–20 months Able to name five body parts 2 years Has 50 word vocabulary 2 years Uses pronouns (me, you, I) 2 years ```

Question 73

What are the developmental milestones for tasks?

Answer 73

``` Developmental milestones (tasks) Average age Follows eyes past the midline 6 weeks Smiles 6 weeks Bears weight on legs with support 3–7 months Sits with support 4–6 months Sits without support 5–8 months Crawls 6–9 months Puts everything into mouth 4–8 months Pulls to standing position 6–10 months First tooth 6–9 months Walks holding on 7–13 months Drinks from cup 10–15 months Waves goodbye 8–12 months Climb stairs 14–20 months Turns pages 2 years Scribbles 1–2 years Uses a spoon 14–24 months Puts on clothing 21–26 months Buttons up 30–42 months Jumps on spot 20–30 months Rides a tricycle 21–36 months Bowel control 18 months – 4 years Bladder control (day) 8 months – 4 years Clear hand preference 2–5 years ```

Question 74

When should a pericarditis patient be hospitalised?

Answer 74

Patients require hospital admission if a specific treatable cause is identified, or if one of the following risk factors associated with poor prognosis is present: high fever—over 38o C subacute course—symptoms over several days without a clear-cut acute onset large pericardial effusion cardiac tamponade failure to respond within 7 days to aspirin or NSAIDs.

Question 75

Management of acute pericarditis?

Answer 75

Restriction of physical activity AND The following are recommended treatments for pericarditis as per therapeutic guidelines: Colchicine: -70 kg or more: 500 micrograms orally, twice daily for 3 months -less than 70 kg: 500 micrograms orally, once daily for 3 months PLUS EITHER: -aspirin 750 to 1000 mg orally, 8 hourly for 1 to 2 weeks, then decrease the dose by 250 to 500 mg every 1 or 2 weeks to stop OR -ibuprofen 600 mg orally, 8 hourly for 1 to 2 weeks, then decrease the dose by 200 to 400 mg every 1 or 2 weeks to stop.

Question 76

ABI testing in PVD?

Answer 76

Current RACGP guidelines for preventive activities in general practice (the ‘Red Book’) does not advocate for peripheral vascular disease screening with ankle:brachial index (ABI) in low risk or asymptomatic patients. High risk (including diabetes) or symptomatic patients would benefit from an ABI as a diagnostic test.

Question 77

Vaccine schedule for non indigenous?

Answer 77

Birth • Hepatitis B (usually offered in hospital)a H-B-Vax® II Paediatric or Engerix B® Paediatric 2 months Can be given from 6 weeks of age • Diphtheria, tetanus, pertussis (whooping cough), hepatitis B, polio, Haemophilus influenzae type b (Hib) • Rotavirusb • Pneumococcal Infanrix® hexa Rotarix® Prevenar 13® 4 months • Diphtheria, tetanus, pertussis (whooping cough), hepatitis B, polio, Haemophilus influenzae type b (Hib) • Rotavirusb • Pneumococcal Infanrix® hexa Rotarix® Prevenar 13® 6 months • Diphtheria, tetanus, pertussis (whooping cough), hepatitis B, polio, Haemophilus influenzae type b (Hib) Infanrix® hexa Additional dose for children with specified medical risk conditionsc • Pneumococcal Prevenar 13® 12 months • Meningococcal ACWY • Measles, mumps, rubella • Pneumococcal Nimenrix® M-M-R® II or Priorix® Prevenar 13® 18 months • Haemophilus influenzae type b (Hib) • Measles, mumps, rubella, varicella (chickenpox) • Diphtheria, tetanus, pertussis (whooping cough) ActHIB® Priorix-Tetra® or ProQuad® Infanrix® or Tripacel® 4 years • Diphtheria, tetanus, pertussis (whooping cough), polio Infanrix® IPV or Quadracel® Additional dose for children with specified medical risk conditionsc • Pneumococcald Pneumovax 23® Adolescent vaccination (also see influenza vaccine) 12–13 years (school programs)e • Human papillomavirus (HPV)f • Diphtheria, tetanus, pertussis (whooping cough) Gardasil®9 Boostrix® 14–16 years (school programs)e • Meningococcal ACWY Nimenrix®

Question 78

When do we give Hep B in Immu sched

Answer 78

At birth, 2, 4 and 6 months

Question 79

When do we give DTP?

Answer 79

Only ones you DONT give it is at Birth, 12 months - and then at 14-16

Question 80

When do you give Men ACWY

Answer 80

Give at 12 months and at 14-16 years

Question 81

When is gardasil given?

Answer 81

Give at 12-13 years

Question 82

When is polio given?

Answer 82

2 months, 4 months, 6 months THEN 4 years

Question 83

When is Hib given?

Answer 83

2, 4, 6, 18 months

Question 84

When is pneumococcal given?

Answer 84

2,4 and 12 months

Question 85

Paediatric foreign body? Where do most lodge?

Answer 85

80% in bronchial tree. Mainly right main bronchus. Needs referral to tertiary otolaryngology for bronch.

Question 86

Red flags for Autism - Developmental milestones

Answer 86

Does not babble or coo by 12 months of age Does not gesture (point, wave, grasp) by 12 months of age Does not say single words by 16 months of age Does not say two-word phrases on his or her own (rather than just repeating what someone says to him or her) by 24 months of age Has any loss of any language or social skill at any age

Question 87

Screening recommendations for primary aldosteronism?

Answer 87

Sustained blood pressure (BP) above 150/100 mmHg on each of three measurements obtained on different days, or Hypertension (BP >140/90 mmHg) resistant to three conventional antihypertensive drugs (including a diuretic), or Controlled BP (<140/90 mmHg) on four or more antihypertensive medications Hypertension and spontaneous or diuretic-induced hypokalaemia Hypertension and adrenal incidentaloma Hypertension and sleep apnoea Hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (<40 years) All hypertensive first-degree relatives of a patient with primary aldosteronism

Question 88

Inspiratory stridor - how would you differentiate laryngomalacia from subglottic haemangioma?

Answer 88

Some children present with a chronic 'cog-wheel' high-pitched inspiratory stridor that has been present from birth or the first few days or weeks of life. The most common cause is laryngomalacia. The stridor resolves spontaneously at 1 to 2 years of age. Alternatively, inspiratory stridor that develops for the first time at 6 to 8 weeks of life, worsens and becomes biphasic (present in both inspiration and expiration) may be due to a subglottic haemangioma. Most cases of chronic stridor in infants need referral."

Question 89

Plagiocephaly vs Craniosynostosis including red flags and referral criteria?

Answer 89

Deformational or positional plagiocephaly causes a paralellogram head shape. It has increased in incidence due to recommendations to sleep infants on their back to reduce SIDS. There is no evidence to support the use of helmets in the majority of cases. Plagiocephaly needs to be distinguished from craniosynostosis which is premature fusion of one or more cranial sutures which requires surgical treatment. Red flags for craniosynostosis include: a bony ridge along a suture line, a closed or triangular shaped anterior fontanelle and an unusual head appearance. Referral indications include if there is torticollis, any associated developmental concerns, abnormal skull x-ray or severe deformity.

Question 90

Treatment of cradle cap (seborrheic dermatitis) | Baby with yellow, greasy, flaky crusts to scalp - underlying scalp is normal

Answer 90

Most mild cases can be treated with application of gentle baby shampoo, liquid paraffin or an emollient. Parents can then remove the scales with a soft toothbrush or comb. Only more extensive cases require the use of low-potency topical treatments such as 1% hydrocortisone or ketoconazole 2%.

Question 91

HSP - when should you review and when should you refer?

Answer 91

Follow up is critical in HSP to identify subsequent renal involvement which rarely requires a renal biopsy +/- immunosuppression. If the initial urinalysis is normal or only reveals microscopic haematuria, review clinically and check BP/early morning urinalysis at these recommended time intervals: Weekly for the first month after disease onset Fortnightly from weeks 5-12 Single reviews at 6 and 12 months Return to 1. if there is a clinical disease flare The development of hypertension, proteinuria or macroscopic haematuria at any point should prompt paediatric review with investigations (outlined above) and ongoing follow-up based on results ``` Discussion with a Renal specialist is recommended if there is: Hypertension Abnormal renal function Macroscopic haematuria for 5 days Nephrotic syndrome Acute nephritic syndrome Persistent proteinuria UPCR >250mg/mmol for 4 weeks UPCR >100mg/mmol for 3 months UPCR >50mg/mmol for 6 months If there is no significant renal involvement plus normal urinalysis at 12 months, no further follow-up is required ```

Question 92

When should you be concerned about a childs growth? Red flags for Failure to thrive?

Answer 92

Poor growth generally describes a child whose current weight, or rate of weight gain, is significantly below that expected of similar children of the same age and sex. Adequacy of growth is best evaluated by plotting serial measurements on a centile weight chart.Serial measurements are needed to assess a child’s growth. One-off measurements show a child’s size but not their growth. Many healthy children grow on centile lines at the top or bottom of the growth chart and many healthy children have small “dips” above or below a particular centile line or growth curve. Birth weight is not necessarily representative of the genetic potential for future growth. Eg. there is no cause for concern if a baby is healthy and gaining weight but tracking along a lower centile than that of the birth weight. As per the Royal Children's Hospital Clinical Guidelines, if one or more of the following red flags are identified, involvement of a multidisciplinary team is essential. Admission to hospital should also be considered if any of the following red flags are present. Signs of abuse or neglect Poor carer understanding e.g. non-English speaking, intellectual disability Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support Signs of poor attachment Parental mental health issues Already/previously case managed by child protection services Did not attend or cancelled previous appointment/s Signs of dehydration Signs of malnutrition or significant illness

Question 93

BP target for CKD

Answer 93

Less than or Equal to 130/80

Question 94

Scarlet fever signs and symptoms?

Answer 94

Scarlet fever is associated with a recent strep throat or impetigo. It causes a distinctive rash (blanching, sandpapery, widespread, can spare the face) which appears 12 - 48 hours after the onset of the fever. also Strawberry tongue. It is much less common than it was a century ago. It typically affects children aged 4 -8 years of age.

Question 95

Signs of hyperkalaemia on ECG?

Answer 95

tall peaked T waves which can be a sign of hyperkalaemia. Other ECG signs of hyperkalaemia include: Prolonged PR segments Loss of P waves Bradycardia Sine wave

Question 96

Jaundice in first 24 hours of life? Ddx

Answer 96

Jaundice is a sign of elevated bilirubin levels in the blood, which occurs when there is an imbalance between bilirubin production, conjugation and elimination. It is very common in newborns, affecting 60% of term babies and 80% of preterm babies in the first week of life. Severe hyperbilirubinaemia can be a sign of a serious underlying disease, and it can also cause brain damage. Jaundice visible at less than 24 hours is always a medical emergency. The most likely causes of early onset jaundice are haemolysis (e.g. rhesus disease, ABO incompatibility, and red cell enzyme defects such as G6PD deficiency) and sepsis. However, you are told that Yolanda seems otherwise well and is breast feeding normally, so red cell haemolysis is more likely the cause of the jaundice in this clinical scenario than sepsis.

Question 97

Bruises that should be suspected for NAI in childhood?

Answer 97

Bruises are a normal part of childhood, however some bruises should raise suspicion of non-accidental injury. Childhood accidents commonly cause bruising on the front of the body over bony prominences; toddlers frequently have accidentally acquired bruises on their foreheads and older children commonly have bruises on their knees and shins. Bruises in pre-mobile children are very uncommon. Bruises over relatively protected parts of the body such as behind the ears, neck, trunk and buttocks should raise concern about a non-accidental cause.