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  • Question 1 - A preterm baby is admitted to the hospital with signs of heart failure...

    Correct

    • A preterm baby is admitted to the hospital with signs of heart failure shortly after birth. The infant is experiencing poor feeding, excessive sweating, and fatigue, resulting in inadequate weight gain. The parents also report irritability and episodes of apnea. During the examination, a continuous machinery murmur and bounding peripheral pulses are detected. An echocardiogram reveals left ventricular enlargement and a shunt between two of the great vessels, indicating a possible patent ductus arteriosus (PDA). What non-surgical intervention can be utilized to manage this patient?

      Your Answer: Indomethacin

      Explanation:

      To promote duct closure in patent ductus arteriosus, indomethacin or ibuprofen is used.

      The incomplete closure of the ductus arteriosus after birth is known as patent ductus arteriosus (PDA), which is causing the patient’s symptoms. During fetal development, this vessel allows blood to bypass the immature fetal lungs. However, if the duct remains open after birth, a large amount of blood can bypass the functioning lungs, resulting in reduced oxygen saturation and a murmur.

      Prostaglandin E2 maintains the ductus arteriosus, so medications like indomethacin or ibuprofen, which inhibit prostaglandin synthesis, can be effective in closing the duct. However, in some cases, surgery may be necessary to close particularly large PDAs.

      Patent ductus arteriosus is a type of congenital heart defect that is typically classified as ‘acyanotic’. However, if left untreated, it can eventually lead to late cyanosis in the lower extremities, which is known as differential cyanosis. This condition is caused by a connection between the pulmonary trunk and descending aorta that fails to close with the first breaths due to increased pulmonary flow that enhances prostaglandins clearance. Patent ductus arteriosus is more common in premature babies, those born at high altitude, or those whose mothers had rubella infection during the first trimester of pregnancy.

      The features of patent ductus arteriosus include a left subclavicular thrill, a continuous ‘machinery’ murmur, a large volume, bounding, collapsing pulse, a wide pulse pressure, and a heaving apex beat. To manage this condition, indomethacin or ibuprofen is given to the neonate, which inhibits prostaglandin synthesis and closes the connection in the majority of cases. If patent ductus arteriosus is associated with another congenital heart defect that is amenable to surgery, then prostaglandin E1 is useful to keep the duct open until after surgical repair.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 2 - A 2-year-old child is brought in for a routine check-up, with concerns from...

    Incorrect

    • A 2-year-old child is brought in for a routine check-up, with concerns from the parents that the child is smaller than expected for their age. The parents mention that the child has difficulty with eating and mainly consumes milk and soft foods. The child appears healthy upon examination, but is found to be on the 3rd percentile for weight. During a cardiac examination, a systolic murmur is detected in the pulmonary area and a fixed splitting to the second heart sound is heard. All pulses are palpable and within normal range. What is the most likely diagnosis?

      Your Answer: Patent ductus arteriosus

      Correct Answer: Atrial septal defect

      Explanation:

      Most children with atrial septal defects (ASDs) do not show any symptoms. However, if these heart defects are not detected before birth, children with severe ASD may experience shortness of breath, fatigue, poor appetite and growth, and increased susceptibility to respiratory infections. During a physical examination, a doctor may detect an ejection systolic murmur and fixed splitting of the second heart sound.

      Other congenital heart defects can be identified by the following murmurs:
      – Ventricular septal defect: A pansystolic murmur in the lower left sternal border
      – Coarctation of the aorta: A crescendo-decrescendo murmur in the upper left sternal border
      – Patent ductus arteriosus: A diastolic machinery murmur in the upper left sternal border

      Congenital heart disease can be categorized into two types: acyanotic and cyanotic. Acyanotic heart diseases are more common and include ventricular septal defects (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, and aortic valve stenosis. VSD is the most common acyanotic heart disease, accounting for 30% of cases. ASDs are less common than VSDs, but they are more frequently diagnosed in adult patients as they tend to present later. On the other hand, cyanotic heart diseases are less common and include tetralogy of Fallot, transposition of the great arteries (TGA), and tricuspid atresia. Fallot’s is more common than TGA, but TGA is the more common lesion at birth as patients with Fallot’s generally present at around 1-2 months. The presence of cyanosis in pulmonary valve stenosis depends on the severity and any other coexistent defects.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 3 - A 5-year-old girl presents to the emergency department with a fever and a...

    Incorrect

    • A 5-year-old girl presents to the emergency department with a fever and a blotchy rash. According to her mother, the rash started behind her ears and has now spread all over her body. During the examination, you observe clusters of white lesions on the buccal mucosa. The child has not received any vaccinations. What is the potential complication that this child may face?

      Your Answer: Otitis externa

      Correct Answer: Pneumonia

      Explanation:

      Pneumonia is a common complication of measles and can be fatal, especially in children. The measles virus can damage the lower respiratory tract epithelium, which weakens the local immunity in the lungs and leads to pneumonia. Other complications of measles include otitis media, encephalitis, subacute sclerosing panencephalitis, keratoconjunctivitis, corneal ulceration, diarrhea, increased risk of appendicitis, and myocarditis. Treatment for measles involves rest, fluids, and pain relief. It is important to inform the local Health Protection Team (HPT) and avoid school or work for at least four days after the rash appears. Mumps can cause complications such as orchitis, oophoritis, pancreatitis, and viral meningitis. Symptoms of mumps include fever, headache, swelling of the parotid glands, and general malaise. Kawasaki disease, on the other hand, can lead to coronary artery aneurysm and presents with symptoms such as high fever, rash, conjunctival injection, red and cracked hands, feet, and lips, and swollen lymph glands. It is important to note that otitis media, not otitis externa, is a complication of measles.

      Measles: A Highly Infectious Viral Disease

      Measles is a viral disease caused by an RNA paramyxovirus. It is one of the most infectious known viruses and is spread through aerosol transmission. The disease has an incubation period of 10-14 days and is infective from the prodromal phase until four days after the rash starts. Measles is now rare in developed countries due to immunization programs, but outbreaks can occur when vaccination rates drop, such as during the MMR controversy of the early 2000s.

      The disease is characterized by a prodromal phase, which includes irritability, conjunctivitis, fever, and Koplik spots. The latter typically develop before the rash and are white spots on the buccal mucosa. The rash starts behind the ears and then spreads to the whole body, becoming a discrete maculopapular rash that may become blotchy and confluent. Desquamation may occur after a week, typically sparing the palms and soles. Diarrhea occurs in around 10% of patients.

      Measles is mainly managed through supportive care, and admission may be considered in immunosuppressed or pregnant patients. The disease is notifiable, and public health should be informed. Complications of measles include otitis media, pneumonia (the most common cause of death), encephalitis (typically occurring 1-2 weeks following the onset of the illness), subacute sclerosing panencephalitis (very rare, may present 5-10 years following the illness), febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis.

      If an unimmunized child comes into contact with measles, MMR should be offered within 72 hours. Vaccine-induced measles antibody develops more rapidly than that following natural infection.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 4 - As an F1 in the emergency department, you receive a 15-year-old girl who...

    Correct

    • As an F1 in the emergency department, you receive a 15-year-old girl who has been brought in from her high school due to complaints of abdominal pain and nausea. Upon examination, you discover that she is septic and can only provide a brief medical history before becoming drowsy. The surgical team suspects that she may have a perforated appendicitis and requires immediate surgery. Unfortunately, the patient's parents cannot be reached with the contact numbers provided by the school, and the patient is not in a state to provide consent for the operation. What would be the most appropriate course of action in this situation?

      Your Answer: Take the patient to surgery immediately

      Explanation:

      According to GMC, it is permissible to administer emergency treatment to a child or young person without their consent in order to save their life or prevent their health from seriously deteriorating. This means that obtaining consent from their parents, seeking permission from others, or obtaining a court order is not required.

      Understanding Consent in Children

      The issue of consent in children can be complex and confusing. However, there are some general guidelines to follow. If a patient is under 16 years old, they may be able to consent to treatment if they are deemed competent. This is determined by the Fraser guidelines, which were previously known as Gillick competence. However, even if a child is competent, they cannot refuse treatment that is deemed to be in their best interest.

      For patients between the ages of 16 and 18, it is generally assumed that they are competent to give consent to treatment. Patients who are 18 years or older can consent to or refuse treatment.

      When it comes to providing contraceptives to patients under 16 years old, the Fraser Guidelines outline specific requirements that must be met. These include ensuring that the young person understands the advice given by the healthcare professional, cannot be persuaded to inform their parents, is likely to engage in sexual activity with or without treatment, and will suffer physical or mental health consequences without treatment. Ultimately, the young person’s best interests must be taken into account when deciding whether to provide contraceptive advice or treatment, with or without parental consent.

      In summary, understanding consent in children requires careful consideration of age, competence, and best interests. The Fraser Guidelines provide a useful framework for healthcare professionals to follow when providing treatment and advice to young patients.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 5 - A mother brings her child to the pediatrician's office concerned about her child's...

    Correct

    • A mother brings her child to the pediatrician's office concerned about her child's development. Her child is 20 months old and has been slow to meet all developmental milestones. Her health visitor advised that she come to see you. You learn that the child has experienced feeding difficulties throughout her life.

      During the examination of the child, you observe that she is drooling and is making lots of slow, writhing movements of her hands and feet. The mother tells you that this is common and that her daughter struggles to hold onto objects such as toys.

      What is the probable diagnosis?

      Your Answer: Dyskinetic cerebral palsy

      Explanation:

      The child in the stem is displaying symptoms of dyskinetic cerebral palsy, which is a subtype of cerebral palsy characterized by athetoid movements and oro-motor problems. The slow writhing movements of the child’s hands and feet and difficulty in holding objects are indicative of athetoid movements, while drooling is a sign of oro-motor problems. Ataxic cerebral palsy, Duchenne’s muscular dystrophy, and hydrocephalus are incorrect diagnoses as they do not match the symptoms presented in the stem.

      Understanding Cerebral Palsy

      Cerebral palsy is a condition that affects movement and posture due to damage to the motor pathways in the developing brain. It is the most common cause of major motor impairment and affects 2 in 1,000 live births. The causes of cerebral palsy can be antenatal, intrapartum, or postnatal. Antenatal causes include cerebral malformation and congenital infections such as rubella, toxoplasmosis, and CMV. Intrapartum causes include birth asphyxia or trauma, while postnatal causes include intraventricular hemorrhage, meningitis, and head trauma.

      Children with cerebral palsy may exhibit abnormal tone in early infancy, delayed motor milestones, abnormal gait, and feeding difficulties. They may also have associated non-motor problems such as learning difficulties, epilepsy, squints, and hearing impairment. Cerebral palsy can be classified into spastic, dyskinetic, ataxic, or mixed types.

      Managing cerebral palsy requires a multidisciplinary approach. Treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopedic surgery, and selective dorsal rhizotomy. Anticonvulsants and analgesia may also be required. Understanding cerebral palsy and its management is crucial in providing appropriate care and support for individuals with this condition.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 6 - A mother gives birth to her first baby. The baby begins vomiting persistently...

    Incorrect

    • A mother gives birth to her first baby. The baby begins vomiting persistently during the fourth week of life. The paediatrician performs a physical examination of the baby and feels a small mass about the size of an olive in the epigastrium.
      Which of the following is this child likely to exhibit?

      Your Answer: Biliary stenosis

      Correct Answer: Pyloric stenosis

      Explanation:

      Pediatric Gastrointestinal Disorders: Pyloric Stenosis, Pancreas Divisum, Biliary Stenosis, and Duodenal Atresia

      Pyloric Stenosis: A newborn presenting with non-bilious vomiting during the third week of life and an ‘olive’ in the epigastrum on physical examination is indicative of pyloric stenosis. This condition occurs when the pylorus, the region of the stomach that serves as the junction between the stomach and the duodenum, becomes obstructed, preventing duodenal material from traveling to more proximal structures.

      Pancreas Divisum: Pancreas divisum is a condition in which the ventral and dorsal anlage of the pancreas fail to fuse during embryology, leading to pancreatitis and pancreatic insufficiency. This occurs because the pancreatic duct fails to form, forcing pancreatic secretions through two smaller dorsal and ventral ducts that cannot support the required flow of secretions. Pancreatic juices accumulate and dilate the smaller ducts, leading to pancreatitis.

      Biliary Stenosis: Biliary stenosis can lead to digestion problems, as the narrow biliary tree prevents bile from reaching the duodenum. Patients with this condition may experience cramping pain when ingesting fatty foods, and fat-soluble vitamin deficiency can develop.

      Duodenal Atresia: Duodenal atresia refers to a blind-ended duodenum, which causes bilious vomiting shortly after beginning to feed. This condition is associated with trisomy 21, but there is no evidence of trisomy 21 in this scenario, and the vomiting has begun after the third week of life.

      Overall, these pediatric gastrointestinal disorders have distinct presentations and require different diagnostic approaches. It is important for healthcare providers to consider all possible conditions when evaluating a patient with gastrointestinal symptoms.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 7 - A 4-week-old girl is brought to the paediatric emergency department with a fever,...

    Incorrect

    • A 4-week-old girl is brought to the paediatric emergency department with a fever, vomiting and reduced appetite for the past 48 hours. The baby's growth and development have been normal so far. During the examination, the baby appears lethargic and fussy, with a respiratory rate that is faster than normal and a temperature of 39ºC. Blood pressure and pulse rate are within the normal range, and there are no signs of raised intracranial pressure. The medical team suspects bacterial meningitis and performs a lumbar puncture. What should be done while waiting for the lumbar puncture results?

      Your Answer: Start recombinant bacterial permeability-increasing protein therapy and empirical antibiotics therapy

      Correct Answer: Start empirical antibiotics only

      Explanation:

      It is not recommended to use corticosteroids in children under 3 months of age who have suspected or confirmed bacterial meningitis. The most common organisms causing bacterial meningitis vary depending on the age of the child. For neonates up to 3 months old, Group B streptococcus, E.coli, and Listeria monocytogenes are the most common. For children between 1 month and 6 years old, Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae are the most common. For children over 6 years old, Neisseria meningitidis and Streptococcus pneumoniae are the most common. In older children with bacterial meningitis, dexamethasone may reduce the risk of hearing loss, particularly in those with Hib meningitis. However, it should be avoided in children under 3 months old with suspected or confirmed bacterial meningitis, as well as those with certain central nervous system abnormalities or nonbacterial meningitis. Activated protein C and recombinant bacterial permeability-increasing protein should not be used in children and young people with meningococcal septicaemia. Treatment should not be delayed for a CT scan, as bacterial meningitis is a medical emergency. Intravenous immunoglobulins are not currently recommended for the management of meningitis.

      Investigation and Management of Meningitis in Children

      Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcal should be obtained instead.

      The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.

      It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 8 - A 2-week-old infant is presented to the clinic for evaluation. The baby was...

    Incorrect

    • A 2-week-old infant is presented to the clinic for evaluation. The baby was delivered at 38 weeks and has been breastfeeding without any issues. The mother reports that the baby seems excessively fatigued. During the assessment, a history is obtained, and some basic observations are documented. What would be an alarming observation?

      Your Answer: Temperature of 37.2 Celsius

      Correct Answer: Heart rate 90 beats per minute and regular

      Explanation:

      For infants to be considered healthy, their respiratory rate should fall within the range of 30-60 breaths per minute. Additionally, their pulse should be regular and fall between 100-160 beats per minute for newborns. Their body temperature should be around 37 Celsius, and they should have regular bowel movements and urination.

      Child Health Surveillance in the UK

      Child health surveillance in the UK involves a series of checks and tests to ensure the well-being of children from before birth to preschool age. During the antenatal period, healthcare professionals ensure that the baby is growing properly and check for any maternal infections that may affect the baby. An ultrasound scan is also performed to detect any fetal abnormalities, and blood tests are done to check for neural tube defects.

      After birth, a clinical examination of the newborn is conducted, and a hearing screening test is performed. The mother is given a Personal Child Health Record, which contains important information about the child’s health. Within the first month, a heel-prick test is done to check for hypothyroidism, PKU, metabolic diseases, cystic fibrosis, and medium-chain acyl Co-A dehydrogenase deficiency (MCADD). A midwife visit may also be conducted within the first four weeks.

      In the following months, health visitor input is provided, and a GP examination is done at 6-8 weeks. Routine immunisations are also given during this time. Ongoing monitoring of growth, vision, and hearing is conducted, and health professionals provide advice on immunisations, diet, and accident prevention.

      In preschool, a national orthoptist-led programme for preschool vision screening is set to be introduced. Overall, child health surveillance in the UK aims to ensure that children receive the necessary care and attention to promote their health and well-being.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 9 - As a doctor, you have been requested by a midwife to conduct a...

    Correct

    • As a doctor, you have been requested by a midwife to conduct a newborn examination on a 24-hour old infant. During the examination, the parents express concern about their baby's penis appearing abnormal and request your assistance. Upon inspection, you observe that the urethral meatus is situated on the ventral aspect of the glans and the prepuce is hooded. However, the baby has already passed urine with a strong stream, as noted by the midwife earlier in the day. What should be the doctor's next course of action?

      Your Answer: Refer to a specialist for possible surgery around 12 months of life

      Explanation:

      It is recommended to refer a child with hypospadias to a specialist for possible surgery around the age of 12 months. This timing is considered optimal, taking into account various factors such as developmental milestones, tolerance of surgery and anesthesia, and the size of the penis. It is important to refer the child to a specialist at the time of diagnosis. Referring a child for surgery within the first month of life or within four hours is not necessary, as this is not an urgent or life-threatening issue. Hypospadias always requires a specialist referral, even if it is mild, and it is the specialist’s responsibility, along with the parents, to decide whether surgery is necessary. It is crucial to advise parents not to circumcise their child with hypospadias, as the prepuce may be used during corrective surgery.

      Understanding Hypospadias: A Congenital Abnormality of the Penis

      Hypospadias is a condition that affects approximately 3 out of 1,000 male infants. It is a congenital abnormality of the penis that is usually identified during the newborn baby check. However, if missed, parents may notice an abnormal urine stream. This condition is characterized by a ventral urethral meatus, a hooded prepuce, and chordee in more severe forms. The urethral meatus may open more proximally in the more severe variants, but 75% of the openings are distally located. There appears to be a significant genetic element, with further male children having a risk of around 5-15%.

      Hypospadias most commonly occurs as an isolated disorder, but it can also be associated with other conditions such as cryptorchidism (present in 10%) and inguinal hernia. Once hypospadias has been identified, infants should be referred to specialist services. Corrective surgery is typically performed when the child is around 12 months of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease, no treatment may be needed. Understanding hypospadias is important for parents and healthcare providers to ensure proper management and treatment of this condition.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 10 - A 3-month-old girl is brought to the morning clinic by her father. Since...

    Correct

    • A 3-month-old girl is brought to the morning clinic by her father. Since last night she has been taking reduced feeds and has been 'not her usual self'. On examination the baby appears well but has a temperature of 38.5ºC. What is the most suitable course of action?

      Your Answer: Admit to hospital

      Explanation:

      The latest NICE guidelines classify any infant under 3 months old with a temperature exceeding 38ºC as a ‘red’ feature, necessitating immediate referral to a paediatrician. While some seasoned GPs may opt not to adhere to this recommendation, it is crucial to stay informed about recent examination guidelines.

      The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infrared tympanic thermometer.

      The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. The table includes categories such as color, activity, respiratory, circulation and hydration, and other symptoms. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 11 - You are requested to assess a 3-month-old infant who has a significant, solitary...

    Incorrect

    • You are requested to assess a 3-month-old infant who has a significant, solitary ventricular septal defect (VSD). What clinical manifestation might be observed?

      Your Answer: Quiet P2 component

      Correct Answer: Laterally displaced apex beat

      Explanation:

      Painless haematuria, or blood in the urine, is the most common symptom reported by individuals with bladder cancer.
      This should be taken seriously and prompt a thorough history and examination, with a view for urgent referral to urology.
      Other indicators include smoking, a palpable mass, and occupational exposure to aniline dyes.
      However, the latter is becoming increasingly rare.
      Age is also a factor, with men over the age of 50 having a greater risk.

      It is important to note that alcohol intake is not linked to bladder cancer, but smoking has a very strong association.
      In terms of occupation, those who work with aniline dyes and rubber are more predisposed to bladder cancer.
      On the other hand, urinary frequency is a non-specific symptom that can occur in prostate conditions and urinary tract infections, and therefore would not in isolation point to bladder cancer.

      In summary, the indicators of bladder cancer is crucial in identifying and treating the disease early on.
      Painless haematuria, smoking, a palpable mass, and occupational exposure to aniline dyes are all factors to consider, while age and alcohol intake are less significant.
      It is important to seek medical attention if any of these symptoms are present.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 12 - You are asked to evaluate a 3 day-old neonate who was born 2...

    Incorrect

    • You are asked to evaluate a 3 day-old neonate who was born 2 weeks premature after a premature rupture of membranes. The infant has not passed meconium in the first 24 hours and has started vomiting. During the examination, you observe one episode of vomiting that is green in color, indicating bile. The baby appears irritable with a visibly distended abdomen, but has normal oxygen saturation and no fever. Palpation of the abdomen causes further discomfort, but no discrete mass is detected. What is the most probable underlying condition?

      Your Answer: Intussusception

      Correct Answer: Cystic fibrosis

      Explanation:

      The presented history indicates a possible case of meconium ileus, where the thickened meconium caused a blockage in the small intestine due to cystic fibrosis. The neonate is likely to have a swollen abdomen and may not pass meconium. Vomiting may contain bile, which is different from pyloric stenosis that does not have bile. Additionally, there is no indication of intussusception or pyloric stenosis mass.

      Cystic Fibrosis: Symptoms and Characteristics

      Cystic fibrosis is a genetic disorder that affects various organs in the body, particularly the lungs and digestive system. The symptoms of cystic fibrosis can vary from person to person, but there are some common features that are often present. In the neonatal period, around 20% of infants with cystic fibrosis may experience meconium ileus, which is a blockage in the intestine caused by thick, sticky mucous. Prolonged jaundice may also occur, but less commonly. Recurrent chest infections are a common symptom, affecting around 40% of patients. Malabsorption is another common feature, with around 30% of patients experiencing steatorrhoea (excessive fat in the stool) and failure to thrive. Liver disease may also occur in around 10% of patients.

      It is important to note that while many patients are diagnosed with cystic fibrosis during newborn screening or early childhood, around 5% of patients are not diagnosed until after the age of 18. Other features of cystic fibrosis may include short stature, diabetes mellitus, delayed puberty, rectal prolapse (due to bulky stools), nasal polyps, male infertility, and female subfertility. Overall, the symptoms and characteristics of cystic fibrosis can vary widely, but early diagnosis and treatment can help manage the condition and improve quality of life.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 13 - A 24-hour-old neonate requires a detailed examination on the Postnatal Ward. It was...

    Incorrect

    • A 24-hour-old neonate requires a detailed examination on the Postnatal Ward. It was a forceps delivery at 41+3 weeks’ gestation. The detailed examination is normal, except you notice slight reduced tone in the right leg and reduced Moro reflex on the right. The leg is resting in a slightly extended position. The examination is otherwise normal.
      What is the most appropriate management?

      Your Answer: Refer to Paediatric Neurology

      Correct Answer: Refer to physiotherapy

      Explanation:

      Assessing Erb’s Palsy in a Neonate: Appropriate Management and Investigations

      Erb’s palsy is a neurological condition that commonly presents as reduced tone and movement in one arm, often due to shoulder dystocia during birth. In neonates, this can be identified by reduced Moro reflex and the arm resting in a waiter’s tip position. While Erb’s palsy is self-resolving, physiotherapy is recommended to strengthen the affected arm.

      If there are no other neurological deficits, referral to a Paediatric Neurologist is not necessary. Cranial ultrasound and head MRI are also not appropriate investigations as they do not provide relevant information for this condition. Similarly, a shoulder X-ray is not necessary as the issue is neurological in nature. Overall, appropriate management and investigations for Erb’s palsy in a neonate involve physiotherapy and observation for resolution.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 14 - You are working in a district general hospital and are asked to perform...

    Correct

    • You are working in a district general hospital and are asked to perform a routine check on a 6-month-old infant. You're part of the paediatric team and haven't had any access to the previous medical records.
      On examination, the infant appears healthy with appropriate weight for age and has a strong cry. There are no signs of respiratory distress and no abnormal heart sounds on auscultation. However, you notice a cleft palate. What is the most likely association with this finding?

      Your Answer: Maternal anti-epileptic use in pregnancy

      Explanation:

      The use of anti-epileptic medication by expectant mothers can lead to the development of orofacial clefts in their babies. Orofacial clefts are a common birth defect that can be caused by various factors, including smoking, benzodiazepine use, anti-epileptic medication, and rubella infection during pregnancy. Treatment for orofacial clefts requires a team of specialists, including plastic and orthodontic surgeons, paediatricians, and speech therapists. It is important to note that congenital heart disease does not increase the risk of orofacial clefts.

      Understanding Cleft Lip and Palate

      Cleft lip and palate are common congenital deformities that affect approximately 1 in every 1,000 babies. These conditions can occur as isolated developmental malformations or as a component of over 200 birth defects. The most common variants of cleft lip and palate are isolated cleft lip, isolated cleft palate, and combined cleft lip and palate.

      The pathophysiology of cleft lip and palate involves polygenic inheritance and an increased risk for babies whose mothers use antiepileptic medication. Cleft lip occurs when the fronto-nasal and maxillary processes fail to fuse, while cleft palate results from the failure of the palatine processes and nasal septum to fuse.

      Children with cleft lip and palate may experience problems with feeding and speech. Orthodontic devices can be helpful for feeding, while speech therapy can help 75% of children develop normal speech. Babies with cleft palate are at an increased risk of developing otitis media.

      Management of cleft lip and palate involves repairing the cleft lip earlier than the cleft palate. The timing of repair varies, with some practices repairing the cleft lip in the first week of life and others waiting up to three months. Cleft palates are typically repaired between 6-12 months of age.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 15 - A 6-week-old baby and their mum come to the hospital for their postnatal...

    Correct

    • A 6-week-old baby and their mum come to the hospital for their postnatal baby check. The infant has an asymmetrical skinfold around their hips. The skin folds under the buttocks and on the thighs are not aligning properly.
      What is the most suitable test to confirm the diagnosis?

      Your Answer: Ultrasound scan of the hip

      Explanation:

      Diagnostic Tests for Developmental Hip Dysplasia

      Developmental hip dysplasia is a condition that must be detected early for effective treatment. Clinical tests such as Barlows and Ortolani’s manoeuvres can screen for the condition, but an ultrasound scan of the hips is the gold standard for diagnosis and grading of severity. Asymmetrical skinfolds, limited hip movement, leg length discrepancy, and abnormal gait are also clues to the diagnosis. Isotope bone scans have no place in the diagnosis of developmental hip dysplasia. X-rays may be used in older children, but plain film X-rays do not exclude hip instability. Early detection and treatment with conservative management can prevent the need for complex surgery.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 16 - A 5-month-old baby presents with symptoms of shortness of breath and difficulty taking...

    Incorrect

    • A 5-month-old baby presents with symptoms of shortness of breath and difficulty taking feeds. During examination, a systolic murmur is heard at the left lower sternal edge, and a thrill is felt in the pulmonary area. A rough ejection systolic murmur is best heard in the same area. An ECG shows right ventricular hypertrophy with right axis deviation, and the liver is palpable. The baby's oxygen saturation intermittently drops to 88%, causing cyanotic spells. What is the most probable diagnosis?

      Your Answer: Ventricular septal defect (VSD)

      Correct Answer: Tetralogy of Fallot

      Explanation:

      Understanding Congenital Heart Disorders: Tetralogy of Fallot and Other Conditions

      Congenital heart disorders are conditions that affect the heart’s structure and function from birth. One such disorder is Tetralogy of Fallot, which is characterized by several abnormalities, including right ventricular hypertrophy, pulmonary stenosis, VSD, and an overriding aorta. Symptoms usually appear at birth or within the first year of life and are caused by a right-to-left shunt, leading to systemic hypoxemia.

      Cyanotic spells are common in Tetralogy of Fallot and can cause marked desaturation due to a decrease in systemic vascular resistance or an increase in pulmonary resistance. In some cases, a left-to-right shunt may initially be present, leading to pulmonary hypertension and eventually causing a right-to-left shunt and heart failure.

      Other congenital heart disorders include VSD, which may not manifest until childhood or adulthood, transposition of the great vessels, which presents at birth with severe hypoxemia, ASD, which may not manifest until later in life, and coarctation of the aorta, which typically does not present until later in life unless extremely severe.

      Understanding these congenital heart disorders and their symptoms is crucial for early diagnosis and treatment, which can improve outcomes and quality of life for affected individuals.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 17 - A 35-year-old woman presents at 16+4 weeks gestation for amniocentesis due to a...

    Correct

    • A 35-year-old woman presents at 16+4 weeks gestation for amniocentesis due to a high-risk combined screening test, which revealed trisomy 21. What is a potential late complication associated with this condition?

      Your Answer: Alzheimer's disease

      Explanation:

      Alzheimer’s disease is a late complication of Down syndrome. This is due to the extra copy of chromosome 21 that people with Down syndrome are born with, which produces an excess of amyloid precursor protein (APP). The buildup of beta-amyloid plaques in the brain, caused by too much APP protein, is a major risk factor for developing Alzheimer’s disease. By the age of 40, most people with Down syndrome have these plaques, as well as tau tangles, which further increase the risk of developing Alzheimer’s disease.

      Chronic myeloid leukemia is not a late complication of Down syndrome, but acute lymphoblastic leukemia is. Symptoms of ALL may include frequent infections, bleeding, night sweats, bone and joint pain, and easy bruising.

      Hirschsprung disease is a birth defect that can occur in babies with Down syndrome, but it is considered an early complication. It results from missing nerve cells in parts of the large intestine, causing severe constipation and sometimes intestinal obstruction.

      Hypothyroidism is another late complication of Down syndrome, often caused by an autoimmune reaction. Hyperthyroidism is rare in people with Down syndrome.

      Down’s syndrome is a genetic disorder that is characterized by various clinical features. These features include an upslanting of the palpebral fissures, epicanthic folds, Brushfield spots in the iris, a protruding tongue, small low-set ears, and a round or flat face. Additionally, individuals with Down’s syndrome may have a flat occiput, a single palmar crease, and a pronounced sandal gap between their big and first toe. Hypotonia, congenital heart defects, duodenal atresia, and Hirschsprung’s disease are also common in individuals with Down’s syndrome.

      Cardiac complications are also prevalent in individuals with Down’s syndrome, with multiple cardiac problems potentially present. The most common cardiac defect is the endocardial cushion defect, also known as atrioventricular septal canal defects, which affects 40% of individuals with Down’s syndrome. Other cardiac defects include ventricular septal defect, secundum atrial septal defect, tetralogy of Fallot, and isolated patent ductus arteriosus.

      Later complications of Down’s syndrome include subfertility, learning difficulties, short stature, repeated respiratory infections, hearing impairment from glue ear, acute lymphoblastic leukaemia, hypothyroidism, Alzheimer’s disease, and atlantoaxial instability. Males with Down’s syndrome are almost always infertile due to impaired spermatogenesis, while females are usually subfertile and have an increased incidence of problems with pregnancy and labour.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 18 - A 16-year-old known type 1 diabetic presents with vomiting, abdominal pain, and drowsiness....

    Incorrect

    • A 16-year-old known type 1 diabetic presents with vomiting, abdominal pain, and drowsiness. During the examination, you detect a distinct smell of pear drops on her breath. Despite the severity of her condition, she insists on leaving to attend a friend's birthday party. After discussing the potential consequences of leaving, she appears to comprehend the risks and can articulate her decision. However, her parents believe she should remain for treatment. What course of action should you take?

      Your Answer: Make the patient sign a self-discharge form

      Correct Answer: Admit the patient for treatment, seeking legal advice if she continues to refuse treatment

      Explanation:

      This person is below the age of 16 but is considered to have the ability to make decisions. As a result, they have the right to consent to treatment without the need for parental approval. However, if they choose to decline treatment, their best interests must be taken into account. In this case, the patient is suffering from diabetic ketoacidosis, and leaving without treatment would likely result in death. Therefore, it would be reasonable to conclude that it is in their best interests to receive treatment.

      According to the General Medical Council’s ethical guidelines, parents cannot override the competent consent of a young person when it comes to treatment that is deemed to be in their best interests. However, if a child lacks the capacity to consent, parental consent can be relied upon. In Scotland, parents are unable to authorize treatment that a competent young person has refused. In England, Wales, and Northern Ireland, the laws regarding parents overriding a young person’s competent refusal are complex.

      When a young person refuses treatment, the harm to their rights must be carefully weighed against the benefits of treatment to make decisions that are in their best interests. This is outlined in paragraphs 30-33 of the GMC’s ethical guidance for individuals aged 0-18 years.

      Understanding Consent in Children

      The issue of consent in children can be complex and confusing. However, there are some general guidelines to follow. If a patient is under 16 years old, they may be able to consent to treatment if they are deemed competent. This is determined by the Fraser guidelines, which were previously known as Gillick competence. However, even if a child is competent, they cannot refuse treatment that is deemed to be in their best interest.

      For patients between the ages of 16 and 18, it is generally assumed that they are competent to give consent to treatment. Patients who are 18 years or older can consent to or refuse treatment.

      When it comes to providing contraceptives to patients under 16 years old, the Fraser Guidelines outline specific requirements that must be met. These include ensuring that the young person understands the advice given by the healthcare professional, cannot be persuaded to inform their parents, is likely to engage in sexual activity with or without treatment, and will suffer physical or mental health consequences without treatment. Ultimately, the young person’s best interests must be taken into account when deciding whether to provide contraceptive advice or treatment, with or without parental consent.

      In summary, understanding consent in children requires careful consideration of age, competence, and best interests. The Fraser Guidelines provide a useful framework for healthcare professionals to follow when providing treatment and advice to young patients.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 19 - A 6-year-old girl comes to the emergency department with a 4-day history of...

    Correct

    • A 6-year-old girl comes to the emergency department with a 4-day history of fever. She has no medical history, allergies, is developing normally and is up-to-date on her immunizations.

      Vital signs:
      - Respiratory rate: 18
      - SpO2: 97%
      - Heart rate: 95
      - Cap. refill time: 2 sec
      - BP: 112/80 mmHg
      - AVPU: Alert
      - Temperature: 39.2ºC

      During the examination, a rough-textured maculopapular rash is found to be widespread. Her tongue is swollen, red, and covered with white papillae, and her tonsils are erythematosus. All other system examinations are normal.

      What is the most likely diagnosis based on these findings?

      Your Answer: Scarlet fever

      Explanation:

      Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more prevalent in children aged 2-6 years, with the highest incidence at 4 years. The disease spreads through respiratory droplets or direct contact with nose and throat discharges, especially during sneezing and coughing. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, nausea/vomiting, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. The rash has a rough ‘sandpaper’ texture and desquamation occurs later in the course of the illness, particularly around the fingers and toes.

      To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be initiated immediately, rather than waiting for the results. Management involves administering oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after commencing antibiotics, and scarlet fever is a notifiable disease. Although usually a mild illness, scarlet fever may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications such as bacteraemia, meningitis, or necrotizing fasciitis, which may present acutely with life-threatening illness.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 20 - A 3-year-old girl presents to the Emergency Department with a 2-day history of...

    Correct

    • A 3-year-old girl presents to the Emergency Department with a 2-day history of diarrhoea and vomiting. She has only had small amounts to drink and is becoming increasingly lethargic. She has had five bowel movements but has only urinated once today. She is typically healthy. Her 5-year-old sister had similar symptoms a few days ago but has since recovered. On examination, she appears restless with sunken eyes, dry mucous membranes, and a CRT of 2 seconds. She is also tachycardic with a heart rate of 150 bpm. What is your assessment of her clinical fluid status?

      Your Answer: Clinical dehydration

      Explanation:

      Understanding Dehydration in Children: Symptoms and Management

      Dehydration is a common concern in children, especially when they are suffering from illnesses like gastroenteritis. Children have a higher percentage of body weight consisting of water, making them more susceptible to dehydration. It is important to understand the different levels of dehydration and their corresponding symptoms to manage it effectively.

      Clinical dehydration is characterized by restlessness and decreased urine output. Signs of clinical dehydration include irritability, sunken eyes, dry mucous membranes, tachycardia, and normal capillary refill time (CRT). On the other hand, a euvolaemic child will have a normal general appearance, moist tongue, and tears, with a normal CRT and no tachycardia.

      Children without clinically detectable dehydration do not show any signs or symptoms of dehydration and can be managed with oral fluids until the symptoms of gastroenteritis subside. However, children who are severely dehydrated may experience clinical shock, which is characterized by a decreased level of consciousness, pale or mottled skin, cold extremities, tachycardia, tachypnea, hypotension, weak peripheral pulses, and a prolonged CRT. These children require immediate admission and rehydration with intravenous fluid and electrolyte supplementation to normalize the losses.

      It is crucial to identify the level of dehydration in children and manage it accordingly to prevent complications. Parents and caregivers should monitor their child’s fluid intake and seek medical attention if they suspect dehydration. With proper management, most cases of dehydration in children can be resolved without any long-term effects.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 21 - A worried father brings his 12-month-old son to the GP because he is...

    Correct

    • A worried father brings his 12-month-old son to the GP because he is worried about his development.

      You conduct a developmental evaluation.

      What results in the child would be worrisome?

      Your Answer: Picks up objects with a pincer grip, with a preference for the right hand

      Explanation:

      Hand preference before the age of 12 months may indicate a potential issue such as cerebral palsy. It is not typical for a child to strongly favor one hand over the other at this age. However, it is encouraging for a 10-month-old to have a vocabulary of at least three words. It is normal for children to play alone at this age and they are not expected to share toys until they are around 3 years old. It is also normal for children to enjoy casting bricks until they are 18 months old, but if this behavior continues beyond that age, it may be a cause for concern. Finally, independent walking should develop between 9 and 18 months, with 18 months being the age at which parents may want to seek medical advice if their child is not yet walking independently.

      Common Developmental Problems and Possible Causes

      Developmental problems can manifest in various ways, including referral points such as not smiling at 10 weeks, inability to sit unsupported at 12 months, and failure to walk at 18 months. Fine motor skill problems may also arise, such as abnormal hand preference before 12 months, which could indicate cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, as they can also be caused by environmental deprivation or general development delay.

      It is important to recognize these developmental problems early on and seek appropriate interventions to address them. By doing so, children can receive the necessary support to reach their full potential and overcome any challenges they may face. With proper care and attention, many children with developmental problems can go on to lead happy and fulfilling lives.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 22 - A father attends his GP to discuss concerns he has about his 12-year-old...

    Incorrect

    • A father attends his GP to discuss concerns he has about his 12-year-old daughter. Since the age of three, she has had a lot of routines, such as how she organizes her toys and which way she walks to school, and is very rigid about following them. She does not cope at all well with changes to the routine. She struggles to make friends and seems very uncomfortable in social situations. Apart from going to school, she avoids meeting children; she has been to a few birthday parties, but she was very clingy to her father and demanded to be taken home after a few minutes. On examination, the GP is unable to build a rapport with the girl, as she refuses to speak and will not maintain eye contact. She appears fidgety and gets up and down out of her chair on several occasions to try and leave the room. You suspect a diagnosis but advise her father that more assessment will be needed to confirm a diagnosis.

      The sign to support the diagnosis is the child's rigid adherence to routines and difficulty coping with changes to the routine, as well as their struggles with social situations and avoidance of meeting other children.

      Your Answer: Separation anxiety from parents or carers at age ten months

      Correct Answer: Less than ten spoken words by age two years

      Explanation:

      Developmental Milestones and Red Flags in Early Childhood

      By the age of two years, children should be using 50 or more words. If they do not meet this milestone, there may be a social, speech or hearing issue that needs to be assessed by a paediatric team. Lack of spoken words could be a sign of autistic spectrum disorder (ASD).

      A lack of social smile by age three months is considered abnormal and could indicate a social, visual, or cognitive problem. However, it may also signal ASD in some cases.

      Parallel play is normal behavior for two-year-olds. They will happily play next to each other but rarely play with each other. It isn’t until the age of three when they usually start to involve other children in playing.

      Separation anxiety from parents or carers at age ten months is normal behavior. Children can become upset if they are not with their parents or carer until the new person becomes more familiar to them, usually between the ages of six months and three years.

      Temper tantrums at age 18 months are normal behavior. However, if these tantrums persist into later childhood, it could indicate a social or developmental problem.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 23 - A 6-month-old Caucasian baby girl is brought to her general practitioner, as her...

    Incorrect

    • A 6-month-old Caucasian baby girl is brought to her general practitioner, as her parents are concerned about a skin lump that has appeared on the left side of her neck. It is non-tender and does not seem to bother her, but it is growing in size. She is feeding well and is otherwise healthy. On examination, there is a 2 x 2 cm, firm and well-demarcated lesion in the left posterior triangle of the neck, with visible telangiectasia. There are no other skin lesions. The abdomen is soft, without masses.
      What would be the next step in management?

      Your Answer: Surgery

      Correct Answer: Medical photography and review again in 3 months

      Explanation:

      This child has an infantile haemangioma, a benign lesion caused by abnormal vessel growth in the skin and deeper structures. These lesions usually appear shortly after birth and can grow rapidly in the first 3 months of life, peaking around the fifth month before regressing spontaneously. The haemangioma in this case is located in the posterior neck triangle and is asymptomatic, so medical photography will be taken and the child will be reassessed in 3 months. Treatment is only necessary if the haemangioma is troublesome, symptomatic, or affecting deeper structures. The first-line treatment is oral propranolol, but topical b blockers can be used if necessary. Surgery is reserved for rapidly evolving haemangiomas that are compressing vital structures or affecting essential functions. Topical timolol can also be used with caution if oral b blockers are not tolerated.

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      • Paediatrics
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  • Question 24 - A 4-year-old girl presents with multiple petechiae and excessive bruising on her arms....

    Correct

    • A 4-year-old girl presents with multiple petechiae and excessive bruising on her arms. She had been healthy until two weeks ago when she had a viral upper respiratory tract infection and was only given paracetamol by her doctor. Her mother noticed her symptoms half an hour ago and she has no fever. Blood tests show thrombocytopenia with all other parameters within normal range.
      What is the most probable diagnosis?

      Your Answer: Idiopathic thrombocytopaenic purpura (ITP)

      Explanation:

      Understanding Immune Thrombocytopenia (ITP) in Children

      Immune thrombocytopenic purpura (ITP) is a condition where the immune system attacks the platelets, leading to a decrease in their count. This condition is more common in children and is usually acute, often following an infection or vaccination. The antibodies produced by the immune system target the glycoprotein IIb/IIIa or Ib-V-IX complex, causing a type II hypersensitivity reaction.

      The symptoms of ITP in children include bruising, a petechial or purpuric rash, and less commonly, bleeding from the nose or gums. A full blood count is usually sufficient to diagnose ITP, and a bone marrow examination is only necessary if there are atypical features.

      In most cases, ITP resolves on its own within six months, without any treatment. However, if the platelet count is very low or there is significant bleeding, treatment options such as oral or IV corticosteroids, IV immunoglobulins, or platelet transfusions may be necessary. It is also advisable to avoid activities that may result in trauma, such as team sports. Understanding ITP in children is crucial for prompt diagnosis and management of this condition.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 25 - A premature neonate is born at 32 weeks’ gestation and is noted to...

    Correct

    • A premature neonate is born at 32 weeks’ gestation and is noted to have low Apgar scores following birth. During a comprehensive review by the neonatology team, an echocardiogram demonstrates very poor right ventricular function. The mother has a history of hypertension and bipolar disease requiring lithium therapy.
      Which one of the following maternal medical complications may have contributed to the infant’s condition?

      Your Answer: Long-standing bipolar disorder therapy

      Explanation:

      Potential Risks and Management of Medical Conditions and Medications During Pregnancy

      Ebstein’s Anomaly and Lithium Use:
      Ebstein’s anomaly, a condition where the tricuspid valve is displaced towards the apex of the right ventricle, is often associated with lithium use. Management includes procainamide and surgical options. It is important to discuss the risk of lithium transmission through breast milk if a patient is taking lithium.

      Maternal Hypertension and Captopril Use:
      Captopril use during pregnancy can affect the fetal renal system and lead to oligohydramnios. It is important to monitor maternal hypertension and consider alternative medications if necessary.

      Heavy Tobacco Use:
      Smoking during pregnancy is associated with growth retardation and placental abruption. It is important to encourage smoking cessation and provide support for patients who are struggling to quit.

      Prior Deep Venous Thrombosis and Warfarin Use:
      Warfarin use during pregnancy is associated with bone abnormalities such as epiphyseal stippling and nasal hypoplasia. Alternative anticoagulation options should be considered during pregnancy.

      Pelvic Inflammatory Disease and Doxycycline Use:
      Doxycycline and other tetracyclines are contraindicated in pregnancy due to their effects on fetal tooth development. However, they have no impact on cardiac development. It is important to consider alternative antibiotics for the treatment of pelvic inflammatory disease during pregnancy.

      Managing Medical Conditions and Medications During Pregnancy

    • This question is part of the following fields:

      • Paediatrics
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  • Question 26 - Which one of the following statements regarding osteosarcoma is true? ...

    Correct

    • Which one of the following statements regarding osteosarcoma is true?

      Your Answer: More than 90% of children survive to adulthood

      Explanation:

      Retinoblastoma is a prevalent type of eye cancer that is commonly found in children, with an average age of diagnosis at 18 months. It is caused by a loss of function of the retinoblastoma tumor suppressor gene on chromosome 13, which is inherited in an autosomal dominant pattern. About 10% of cases are hereditary. The most common presenting symptom is the absence of red-reflex, which is replaced by a white pupil (leukocoria). Other possible features include strabismus and visual problems.

      When it comes to managing retinoblastoma, enucleation is not the only option. Depending on how advanced the tumor is, other treatment options include external beam radiation therapy, chemotherapy, and photocoagulation. The prognosis for retinoblastoma is excellent, with over 90% of patients surviving into adulthood.

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      • Paediatrics
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  • Question 27 - You have just assisted with the normal vaginal delivery of a baby boy,...

    Correct

    • You have just assisted with the normal vaginal delivery of a baby boy, during the delivery there was a large amount of meconium. On observation of the baby just after the birth, what signs would indicate the need for the neonatal team to evaluate the baby?

      Your Answer: Respiratory rate 75/minute

      Explanation:

      The Apgar score is a tool used to evaluate the health of a newborn baby. It is recommended by NICE to be assessed at 1 and 5 minutes after birth, and again at 10 minutes if the initial score is low. The score is based on five factors: pulse, respiratory effort, color, muscle tone, and reflex irritability. A score of 0-3 is considered very low, 4-6 is moderate low, and 7-10 indicates that the baby is in good health. The score helps healthcare professionals quickly identify any potential issues and provide appropriate care.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 28 - A 10-week-old baby is admitted to the Paediatric Ward by her General Practitioner...

    Incorrect

    • A 10-week-old baby is admitted to the Paediatric Ward by her General Practitioner (GP). She was born at term via normal vaginal delivery after an uncomplicated pregnancy. Her birthweight was 2900 g. Her 20-week anomaly scan was unremarkable. Her parents inform you that a heart murmur was noted at her 8-week check, for which she is awaiting routine outpatient assessment. Her parents report that, over the last week, she has had episodes of going blue during feeds and friends have remarked that she looks ‘off colour’. She had a similar episode while with her GP, and oxygen saturation was recorded at 88% peripherally. As a result, the GP called 999 and transferred her to hospital. She is growing along the 25th centile. On examination, she is alert with normal vital signs. Heart sounds reveal a loud systolic murmur at the lower left sternal edge; she had palpable femoral pulses bilaterally and very slight cyanosis. Her chest is clear, without recession or signs of distress. Her liver is not enlarged.
      What is the most likely diagnosis?

      Your Answer: Ventricular septal defect (VSD)

      Correct Answer: Tetralogy of Fallot

      Explanation:

      Tetralogy of Fallot is a common congenital heart disease that affects around 3-6 out of every 10,000 births. It is characterized by four heart abnormalities that can cause symptoms such as cyanosis, difficulty with feeding, failure to thrive, and Tet spells. Diagnosis is typically made through echocardiography, and surgical correction is usually performed within the first two years of life.

      Cyanotic heart disease can be divided into two groups: those that present in the first week of life and those that present after the first week. Examples of conditions that present in the first week include total pulmonary atresia, tricuspid atresia, and transposition of the great arteries. Examples of conditions that can present after the first week include tetralogy of Fallot, total anomalous pulmonary venous drainage, and tricuspid regurgitation with right-to-left shunt via atrial septal defect.

      Transposition of the great arteries is a cyanotic congenital heart condition where the aorta arises from the right ventricle and the pulmonary arteries from the left ventricle. It typically presents with central cyanosis within the first day or two of life and is managed with intravenous prostaglandin E1 and balloon atrial septostomy.

      Total pulmonary atresia is a congenital heart abnormality where the pulmonary valve fails to develop, resulting in disrupted blood flow from the right ventricle to the pulmonary trunk. It can occur with or without a ventricular septal defect and is associated with tetralogy of Fallot.

      Ventricular septal defect is a congenital heart defect located in the interventricular septum that allows mixing of blood between the two sides of the heart. Symptoms depend on the size of the defect and can range from asymptomatic to signs of heart failure.

      Patent ductus arteriosus is the failure of closure of the fetal connection between the descending aorta and pulmonary artery. It is not a cyanotic congenital heart defect and can be treated with intravenous indomethacin, cardiac catheterization, or ligation. Symptoms may include decreased exercise tolerance, pulmonary congestion, a cardiac murmur, or heart failure.

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      • Paediatrics
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  • Question 29 - A 10-year-old girl is brought to the Accident and Emergency department by her...

    Incorrect

    • A 10-year-old girl is brought to the Accident and Emergency department by her parents. On a background of high-grade fever and lethargy over the last 12 hours, the child had an episode of jerking of the limbs, frothing at the mouth and incontinence of urine. She has failed to recover full consciousness after the episode. At presentation, she is poorly responsive to name-calling, but responsive to pain. She is however maintaining her airway and oxygen saturation is 95% on air. Limited neurological examination is unremarkable. Non-contrast computerised tomography (CT) scan of the brain is normal. Lumbar puncture is performed and reveals a slightly raised opening pressure, moderately increased cerebrospinal fluid (CSF) protein, CSF lymphocytosis and normal glucose.
      What is the most important step in management?

      Your Answer: IV cefotaxime

      Correct Answer: IV acyclovir

      Explanation:

      The child in question is suffering from viral encephalitis, which is typically treated with IV acyclovir. The recommended dosage is 5 mg/kg every 8 hours for 5 days, or 10 mg/kg every 8 hours for at least 14 days in cases of encephalitis. Encephalitis should be suspected when a patient presents with altered behavior, decreased consciousness, focal neurology, or seizures, along with a viral prodrome of fever and lethargy. The most common cause of encephalitis is the herpes simplex virus-1 (HSV-1), with other common causes including cytomegalovirus (CMV), Epstein-Barr virus (EBV), and Japanese encephalitis. Diagnostic tests should include a full blood count, urea and electrolytes, inflammatory markers, blood glucose, blood cultures, and serum for viral polymerase chain reaction (PCR). A CT scan of the brain is necessary to rule out structural brain lesions and raised intracranial pressure. Lumbar puncture is then performed. Mortality in untreated viral encephalitis is high, so IV acyclovir should be started within 30 minutes of the patient arriving. Intubation and ventilation may be necessary in severe cases, but in this case, acyclovir is the most appropriate treatment. While MRI may aid in diagnosis, CSF analysis is sufficient, and IV cefotaxime and IV mannitol are not the most urgent steps in management.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 30 - What is the typical distribution of atopic eczema in a 12-month-old child? ...

    Incorrect

    • What is the typical distribution of atopic eczema in a 12-month-old child?

      Your Answer: Nappy area and flexor surfaces of arms and legs

      Correct Answer: Face and trunk

      Explanation:

      Eczema in Children: Symptoms and Management

      Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The symptoms of eczema include an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, it typically occurs on the extensor surfaces. In older children, the rash is more commonly seen on the flexor surfaces and in the creases of the face and neck.

      To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams are absorbed into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.

      In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. Overall, managing eczema in children involves a combination of avoiding irritants, using emollients, and potentially using topical steroids or other medications in severe cases.

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      • Paediatrics
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