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  • Question 1 - A 9-month-old girl is presented to the clinic. About 5 days ago, she...

    Correct

    • A 9-month-old girl is presented to the clinic. About 5 days ago, she became feverish after being fussy the day before. The fever subsided after approximately 3 days, but she developed a rash afterwards, which prompted her mother to bring her to the clinic. She is consuming about 80% of her usual feeds, has wet nappies, and has had three instances of loose stools. On examination, she is alert, has a temperature of 37.2ÂșC, and has clear lungs and unremarkable ears/throat. There are several blanching, rose pink macules on her trunk. What is the most probable diagnosis?

      Your Answer: Roseola infantum

      Explanation:

      Roseola infantum is a condition characterized by the occurrence of a fever, which is later followed by the appearance of a rash.

      Understanding Roseola Infantum

      Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.

      In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.

      It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 2 - Which of the following is not a characteristic of Tetralogy of Fallot? ...

    Incorrect

    • Which of the following is not a characteristic of Tetralogy of Fallot?

      Your Answer: Ventricular septal defect

      Correct Answer: Atrial septal defect

      Explanation:

      Understanding Tetralogy of Fallot

      Tetralogy of Fallot (TOF) is a congenital heart disease that results from the anterior malalignment of the aorticopulmonary septum. It is the most common cause of cyanotic congenital heart disease, and it typically presents at around 1-2 months, although it may not be detected until the baby is 6 months old. The condition is characterized by four features, including ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular outflow tract obstruction, and overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

      Other features of TOF include cyanosis, which may cause episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract. These spells are characterized by tachypnea and severe cyanosis that may occasionally result in loss of consciousness. They typically occur when an infant is upset, in pain, or has a fever, and they cause a right-to-left shunt. Additionally, TOF may cause an ejection systolic murmur due to pulmonary stenosis, and a right-sided aortic arch is seen in 25% of patients. Chest x-ray shows a ‘boot-shaped’ heart, while ECG shows right ventricular hypertrophy.

      The management of TOF often involves surgical repair, which is usually undertaken in two parts. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm. However, it is important to note that at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. Understanding the features and management of TOF is crucial for healthcare professionals to provide appropriate care and treatment for affected infants.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 3 - A 25-year-old male patient visits the GP clinic complaining of left ear pain...

    Incorrect

    • A 25-year-old male patient visits the GP clinic complaining of left ear pain that has been present for 3 days. The patient is new to the clinic and there is no medical history available on the system. Upon examination, you observe the patient's facial features, which include upslanting palpebral fissures, prominent epicanthic folds, low-set ears, and a protruding tongue. Otoscopy examination of the left ear reveals a bulging tympanic membrane. What is the probable diagnosis?

      Your Answer: Otitis media with effusion

      Correct Answer: Acute otitis media

      Explanation:

      Acute otitis media can be indicated by a bulging tympanic membrane, which is a common occurrence in individuals with Down’s syndrome. Lesions in the attic area of the tympanic membrane are typically associated with cholesteatoma. Otitis externa does not typically result in a bulging otitis media, while otitis media with effusion is characterized by a retracted tympanic membrane and a feeling of fullness in the ear.

      Vision and Hearing Issues in Down’s Syndrome

      Individuals with Down’s syndrome are prone to experiencing vision and hearing problems. In terms of vision, they are more likely to have refractive errors, which can cause blurred vision. Strabismus, a condition where the eyes do not align properly, is also common in 20-40% of individuals with Down’s syndrome. Cataracts, both congenital and acquired, are more prevalent in this population, as well as recurrent blepharitis, an inflammation of the eyelids. Glaucoma, a condition that damages the optic nerve, is also a potential issue.

      Regarding hearing, otitis media and glue ear are very common in individuals with Down’s syndrome, which can lead to hearing problems. Otitis media is an infection of the middle ear, while glue ear is a buildup of fluid in the middle ear that can cause temporary hearing loss. It is important for individuals with Down’s syndrome to receive regular vision and hearing screenings to detect and address any potential issues.

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      • Paediatrics
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  • Question 4 - A 5-year-old boy is brought to the Emergency Department by his parents with...

    Correct

    • A 5-year-old boy is brought to the Emergency Department by his parents with a 3-day history of diarrhoea; he has also vomited twice today. He is alert and responsive and his observations are within normal limits.
      On examination, he has moist mucous membranes, normal skin turgor, normal skin colour, normal peripheral pulses and a normal capillary refill time. His abdomen is soft and nontender and his peripheries are warm.
      What is the most appropriate initial management option for this patient?

      Your Answer: Oral rehydration solution (ORS)

      Explanation:

      Management of Dehydration in Children with Gastroenteritis

      Gastroenteritis is a common illness in children that can lead to dehydration if not managed properly. Oral rehydration solution (ORS) is the first-line treatment for children at increased risk of dehydration, including those who have vomited more than twice in the last 24 hours or have other risk factors such as age less than one year, low birth weight, or signs of malnutrition. However, if a child is clinically dehydrated and not responding to ORS, intravenous (IV) fluids may be necessary.

      It is important to encourage fluid intake in children with gastroenteritis, but carbonated drinks and fruit juices should be avoided as they can worsen diarrhea. If a child is unable to drink, an NG tube may be considered, but ORS should be attempted first. A bolus of IV fluids is only indicated in cases of suspected or confirmed shock.

      Overall, prompt recognition and management of dehydration in children with gastroenteritis can prevent serious complications and improve outcomes.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 5 - A 4-month-old girl presents with vomiting, yellowing of the skin and dehydration. Tests...

    Correct

    • A 4-month-old girl presents with vomiting, yellowing of the skin and dehydration. Tests show low potassium levels and metabolic alkalosis.
      What is the best initial course of action?

      Your Answer: Correction of metabolic derangements

      Explanation:

      Management of Infantile Pyloric Stenosis: Correction of Metabolic Derangements

      Infantile pyloric stenosis is a common condition in newborns, characterized by a hypertrophied pylorus that causes projectile vomiting and hungry feeding. The electrolyte abnormality associated with this condition is hypokalaemic hypochloraemic alkalosis. Before undergoing surgery, it is crucial to correct these metabolic abnormalities in consultation with a pediatrician and anesthetist. Ramstedt’s pyloromyotomy is the definitive surgical treatment for infantile pyloric stenosis. Upper GI endoscopy is not necessary for diagnosis if the clinical presentation is clear. Feeding jejunostomy and total parenteral nutrition are not appropriate initial management options. During surgery, the umbilicus should be excluded from the operative field to prevent staphylococcus aureus infection.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 6 - A 6-year-old girl is brought to her General Practitioner by her mother. She...

    Correct

    • A 6-year-old girl is brought to her General Practitioner by her mother. She reports that her daughter has been complaining of abdominal pain and has had loose stools for the past three weeks. Her weight was previously on the 75th centile but has now dropped to the 50th centile. She appears fatigued, pale and has a bloated abdomen.
      Which of the following is the most appropriate initial investigation?

      Your Answer: Blood tests for immunoglobulin A (IgA) tissue transglutaminase antibody (tTG) and total IgA

      Explanation:

      Diagnostic Tests for Coeliac Disease

      Coeliac disease is a condition that affects the small intestine and is caused by an intolerance to gluten. There are several diagnostic tests that can be performed to confirm a diagnosis of coeliac disease.

      Initial Blood Tests
      The initial blood tests for coeliac disease are immunoglobulin A (IgA) tissue transglutaminase antibody (tTG) and total IgA. Total IgA is tested because IgA deficiency is associated with coeliac disease and can cause a false-negative tTG-IgA. It is important for patients to be eating a diet containing gluten when they have the blood test to avoid a false-negative result.

      Endoscopy and Duodenal Biopsy
      An endoscopy with a duodenal biopsy may be required to confirm the diagnosis in secondary care. However, guidelines state that children may be diagnosed without a biopsy if they have tTG-IgA levels over ten times the upper limit of normal and positive endomysial antibodies (EMA-IgA) in a second blood test.

      HLA-DQ2 and HLA-DQ8 Blood Tests
      HLA-DQ2 and HLA-DQ8 are associated with coeliac disease. This blood test may be performed in secondary care but is not an initial investigation.

      C13 Urea Breath Test
      The C13 urea breath test is used in the diagnosis of Helicobacter pylori and has no role in the diagnosis of coeliac disease.

      In conclusion, a combination of blood tests and endoscopy with a duodenal biopsy may be required to confirm a diagnosis of coeliac disease. It is important for patients to continue eating a gluten-containing diet before undergoing diagnostic tests.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 7 - A mother brings in her 2-day-old baby girl to the GP surgery. She...

    Incorrect

    • A mother brings in her 2-day-old baby girl to the GP surgery. She expresses concern about some white discharge from the baby's vagina. Upon examination, a small amount of mucoid white discharge is observed at the entrance of the vagina. The external appearance of the genitalia is otherwise normal. What is the recommended next step in management?

      Your Answer: Refer to paediatric team for further investigation

      Correct Answer: Reassure the mother that it is normal at this age

      Explanation:

      It is common for newborn girls to experience a mucoid white vaginal discharge, which typically resolves by the age of 3 months. Reassurance is the most suitable course of action, and there is no need to refer to paediatrics or suspect sexual abuse. Arranging a transvaginal ultrasound for these symptoms is not necessary.

      Gynaecological Problems in Children

      In children, gynaecological problems are not uncommon. However, it is important to note that vaginal examinations and vaginal swabs should not be performed. Instead, referral to a paediatric gynaecologist is appropriate for persistent problems. One of the most common gynaecological disorders in girls is vulvovaginitis. This condition can be caused by bacterial or fungal organisms and is often associated with poor hygiene, tight clothing, lack of labial fat pads protecting the vaginal orifice, and lack of protective acid secretion found in the reproductive years. In some cases, vulvovaginitis may be a result of sexual abuse, which can present as bloody discharge.

      It is important to manage vulvovaginitis appropriately. Advising children about hygiene is crucial, and soothing creams may be useful. Topical antibiotics or antifungals may also be prescribed. In resistant cases, oestrogen cream may be recommended. It is important to note that most newborn girls have some mucoid white vaginal discharge, which usually disappears by three months of age.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 8 - A 10-year-old girl is brought to the emergency room due to worsening asthma...

    Correct

    • A 10-year-old girl is brought to the emergency room due to worsening asthma symptoms over the past 48 hours. Her parents are worried that her breathing is not improving with the usual inhaled salbutamol treatment. What signs indicate a potentially life-threatening asthma attack?

      Your Answer: Quiet breath sounds on auscultation

      Explanation:

      The absence of bilateral wheezing and presence of quiet breath sounds in a child with asthma is a concerning sign, as it may indicate a severe asthma attack that could be life-threatening.

      Assessing Acute Asthma Attacks in Children

      When assessing the severity of asthma attacks in children, the 2016 BTS/SIGN guidelines recommend using specific criteria. These criteria can help determine whether the attack is severe or life-threatening. For a severe attack, the child may have a SpO2 level below 92%, a PEF level between 33-50% of their best or predicted, and may be too breathless to talk or feed. Additionally, their heart rate may be over 125 (for children over 5 years old) or over 140 (for children between 1-5 years old), and their respiratory rate may be over 30 breaths per minute (for children over 5 years old) or over 40 (for children between 1-5 years old). They may also be using accessory neck muscles to breathe.

      For a life-threatening attack, the child may have a SpO2 level below 92%, a PEF level below 33% of their best or predicted, and may have a silent chest, poor respiratory effort, agitation, altered consciousness, or cyanosis. It is important for healthcare professionals to be aware of these criteria and to take appropriate action to manage the child’s asthma attack. By following these guidelines, healthcare professionals can help ensure that children with asthma receive the appropriate care and treatment they need during an acute attack.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 9 - A 10-year-old boy presents to you with his mother, reporting pain in his...

    Correct

    • A 10-year-old boy presents to you with his mother, reporting pain in his left hip. He is typically healthy, but he recently saw another doctor for a viral upper respiratory tract infection. The pain began two days ago, and he is hesitant to put weight on his left leg.

      What is the probable underlying condition?

      Your Answer: Transient synovitis of the hip

      Explanation:

      A possible diagnosis for a child experiencing hip pain, limp, and a recent infection could be transient synovitis.

      Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.

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      • Paediatrics
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  • Question 10 - A 22-month-old toddler presents to the GP with a barking cough and fever...

    Incorrect

    • A 22-month-old toddler presents to the GP with a barking cough and fever for 3 days. The fever has been responding to regular paracetamol. The child's parent reports that the toddler is eating and drinking normally and has been urinating regularly. During playtime, the parent has noticed some increased breathing sounds, but they disappear when the child is at rest. There have been no febrile convulsions, rash, or drowsiness reported.
      Upon examination, the toddler has a clear chest with no signs of increased work of breathing. An occasional barking cough is heard.
      What is the most appropriate management for this toddler?

      Your Answer: Inhaled or nebulised salbutamol

      Correct Answer: Oral dexamethasone

      Explanation:

      For this infant with mild croup, the recommended treatment is a single dose of oral dexamethasone (0.15 mg/kg body weight) regardless of the severity of symptoms. This should be taken immediately to reduce upper airway inflammation and alleviate the occasional barking cough and stridor. Delayed antibiotic prescription, immediate oral antibiotics, humidified oxygen, and inhaled or nebulised salbutamol are not appropriate options for croup management. Antibiotics are ineffective against viruses, which are the most common cause of croup, while humidified oxygen and inhaled or nebulised salbutamol are used for other respiratory conditions.

      Understanding Croup: A Respiratory Infection in Infants and Toddlers

      Croup is a type of upper respiratory tract infection that commonly affects infants and toddlers. It is characterized by a barking cough, fever, and coryzal symptoms, and is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses are the most common cause of croup. The condition typically peaks between 6 months and 3 years of age, and is more prevalent during the autumn season.

      The severity of croup can be graded based on the presence of symptoms such as stridor, cough, and respiratory distress. Mild cases may only have occasional barking cough and no audible stridor at rest, while severe cases may have frequent barking cough, prominent inspiratory stridor at rest, and marked sternal wall retractions. Children with moderate or severe croup, those under 6 months of age, or those with known upper airway abnormalities should be admitted to the hospital.

      Diagnosis of croup is usually made based on clinical presentation, but a chest x-ray may show subglottic narrowing, commonly referred to as the steeple sign. Treatment for croup typically involves a single dose of oral dexamethasone or prednisolone, regardless of severity. In emergency situations, high-flow oxygen and nebulized adrenaline may be necessary.

      Understanding croup is important for parents and healthcare providers alike, as prompt recognition and treatment can help prevent complications and improve outcomes for affected children.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 11 - At what point in the childhood immunisation schedule is the Meningitis B vaccine...

    Correct

    • At what point in the childhood immunisation schedule is the Meningitis B vaccine administered?

      Your Answer: 2, 4, and 12 months

      Explanation:

      The most prevalent cause of meningococcal disease in children in the UK is currently Meningitis B. In 2015, the Meningitis B vaccination was added to the NHS routine childhood immunisation schedule. It is administered at 2, 4, and 12 months of age, in conjunction with other immunisations in the schedule. If given at a different time, doses must be spaced at least 2 months apart. For children over one year old, only two doses are necessary.

      Meningitis B Vaccine Now Part of Routine NHS Immunisation

      Children in the UK have been vaccinated against meningococcus serotypes A and C for many years, leaving meningococcal B as the most common cause of bacterial meningitis in the country. However, a new vaccine called Bexsero has been developed to combat this strain. Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero due to a cost-benefit analysis. However, the decision was eventually reversed, and the vaccine has been added to the routine NHS immunisation schedule.

      The vaccine is administered in three doses at 2 months, 4 months, and 12-13 months. Additionally, Bexsero will be available on the NHS for individuals at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. This new vaccine is a significant step in protecting children and vulnerable individuals from meningitis B.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 12 - A 6-year-old boy comes to the doctor's office with a continuous fever and...

    Incorrect

    • A 6-year-old boy comes to the doctor's office with a continuous fever and rash that has been present for the past 4 days. During the examination, the doctor observes that the boy has chapped, parched lips and flaking hands and fingers. Despite administering regular doses of paracetamol, the mother is worried as there has been no improvement. What is the probable diagnosis?

      Your Answer: Viral urticaria

      Correct Answer: Kawasaki's disease

      Explanation:

      Kawasaki disease is characterized by a high fever that lasts for more than 5 days, along with red palms, desquamation, and a strawberry tongue. It is crucial to diagnose and treat this condition promptly to minimize the risk of cardiac complications. Without early treatment with IV immunoglobulins, up to 20% of patients may develop coronary artery aneurysms, which can result in heart attack and sudden death.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

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      • Paediatrics
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  • Question 13 - A 3-year-old boy is brought to the paediatric urology clinic due to recurrent...

    Incorrect

    • A 3-year-old boy is brought to the paediatric urology clinic due to recurrent urinary tract infections. A renal ultrasound revealed dilatation of the ureters. The boy's father remembers having a similar issue with a valve in his ureters during childhood, resulting in urine flowing back towards the kidneys. What is the most suitable test to assess the severity of the probable underlying cause?

      Your Answer: Dimercaptosuccinic acid (DMSA) scan

      Correct Answer: Micturating cystography

      Explanation:

      Vesicoureteral reflux (VUR) is a likely cause of recurrent urinary tract infections (UTIs) in children under 6 years old. The family history, age of the patient, and abnormal ultrasound findings suggest VUR as the underlying issue. To determine the severity of VUR, a voiding cystourethrogram (micturating cystography) is necessary. This test involves injecting dye into the bladder via a catheter and taking x-ray images while the child urinates. Early detection of VUR is crucial to prevent kidney scarring (reflux nephropathy).

      Bladder ultrasound is not an appropriate method for grading VUR severity. While ultrasound imaging of the urinary tract, including the kidneys, can be useful, it cannot grade VUR severity.

      A CT abdomen is not necessary and would expose the child to unnecessary radiation.

      A dimercaptosuccinic acid (DMSA) scan can assess renal parenchymal defects resulting from VUR and is typically performed within six months of an acute infection in children with recurrent UTIs. However, it cannot grade the severity of VUR.

      Understanding Vesicoureteric Reflux

      Vesicoureteric reflux (VUR) is a condition where urine flows back from the bladder into the ureter and kidney. This is a common urinary tract abnormality in children and can lead to urinary tract infections (UTIs). In fact, around 30% of children who present with a UTI have VUR. It is important to investigate for VUR in children following a UTI as around 35% of children develop renal scarring.

      The pathophysiology of VUR involves the ureters being displaced laterally, which causes a shortened intramural course of the ureter. This means that the vesicoureteric junction cannot function properly. VUR can present in different ways, such as hydronephrosis on ultrasound during the antenatal period, recurrent childhood UTIs, and reflux nephropathy, which is chronic pyelonephritis secondary to VUR. Renal scarring can also produce increased quantities of renin, which can cause hypertension.

      To diagnose VUR, a micturating cystourethrogram is usually performed. A DMSA scan may also be done to check for renal scarring. VUR is graded based on the severity of the condition, with Grade I being the mildest and Grade V being the most severe.

      Overall, understanding VUR is important in preventing complications such as UTIs and renal scarring. Early diagnosis and management can help improve outcomes for children with this condition.

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  • Question 14 - A 3-year-old child presents to the emergency department with a 3 day history...

    Correct

    • A 3-year-old child presents to the emergency department with a 3 day history of left knee pain and irritability. The child had recently recovered from a viral respiratory tract infection and is currently asymptomatic and without fever. Upon examination, the joint is painful to move but not hot or red, and the child is able to bear weight. Laboratory results reveal a hemoglobin level of 140 g/L (male: 135-180, female: 115-160), platelet count of 450 * 109/L (150-400), white cell count of 11.5 * 109/L (4.0-11.0), CRP of 29 mg/L (<5), and ESR of 32 mm/hr (0-10). What is the most likely diagnosis?

      Your Answer: Transient synovitis

      Explanation:

      Understanding Septic Arthritis in Children

      Septic arthritis is a condition that affects children and can lead to permanent joint damage and systemic infection if not treated promptly. It has an incidence of around 4-5 per 100,000 children and is more common in boys, with a M:F ratio of 2:1. The hip, knee, and ankle are the most commonly affected joints. Symptoms of septic arthritis include joint pain, limp, fever, and lethargy. Signs of the condition include a swollen and red joint, with minimal movement possible.

      To diagnose septic arthritis, joint aspiration is necessary to culture the affected area. This will show a raised white blood cell count. Inflammatory markers in the blood will also be raised, and blood cultures will be taken. The Kocher criteria are used to diagnose septic arthritis and include a fever of over 38.5 degrees Celsius, non-weight bearing, raised erythrocyte sedimentation rate (ESR), and raised white cell count (WCC).

      Understanding septic arthritis in children is crucial for prompt diagnosis and treatment to reduce the risk of permanent joint damage and systemic infection.

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      • Paediatrics
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  • Question 15 - A 4-week-old infant is referred by the health visitor for failure to thrive....

    Correct

    • A 4-week-old infant is referred by the health visitor for failure to thrive. The infant's weight has dropped from the 50th to the 9th centile on the growth chart. The parents disclose that the infant vomits after every meal, sometimes even hitting the wall. The mother had a normal pregnancy with regular antenatal scans, and the infant was delivered vaginally without complications. The newborn examination did not reveal any abnormalities. What is the probable diagnosis?

      Your Answer: Pyloric stenosis

      Explanation:

      The probable diagnosis is pyloric stenosis.

      Understanding Pyloric Stenosis

      Pyloric stenosis is a condition that usually occurs in infants between the second and fourth weeks of life. However, in rare cases, it may present later, up to four months. This condition is caused by the thickening of the circular muscles of the pylorus. Pyloric stenosis is more common in males, with an incidence of 4 per 1,000 live births. It is also more likely to affect first-borns and infants with a positive family history.

      The most common symptom of pyloric stenosis is projectile vomiting, which usually occurs about 30 minutes after a feed. Other symptoms may include constipation, dehydration, and a palpable mass in the upper abdomen. Prolonged vomiting can lead to hypochloraemic, hypokalaemic alkalosis, which can be life-threatening.

      Diagnosis of pyloric stenosis is typically made using ultrasound. Management of this condition involves a surgical procedure called Ramstedt pyloromyotomy. This procedure involves making a small incision in the pylorus to relieve the obstruction and allow for normal passage of food. With prompt diagnosis and treatment, infants with pyloric stenosis can make a full recovery.

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      • Paediatrics
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  • Question 16 - A 35-year-old primip has a stillborn baby at 34 weeks gestation. The infant...

    Correct

    • A 35-year-old primip has a stillborn baby at 34 weeks gestation. The infant presents with microcephaly, micrognathia, and club feet. What is the diagnosis?

      Your Answer: Trisomy 18

      Explanation:

      Edward’s syndrome is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. The baby affected by this syndrome will have experienced slow growth in the womb and will have a low birthweight. Unfortunately, around half of those who survive to birth will pass away within two weeks, and only one in every five will live for at least three months. The survival rate beyond one year is only one in every 12 babies born with Edwards’ syndrome. This information is according to NHS Choices.

      Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.

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  • Question 17 - A 7-year-old girl visits her GP clinic with her mother who is worried...

    Correct

    • A 7-year-old girl visits her GP clinic with her mother who is worried about her continued bedwetting at night. They had visited the clinic 4 weeks ago and have seen no improvement despite following general management advice and a basic reward system. The girl is healthy otherwise and has no history of constipation or daytime incontinence. She does not complain of any issues at home or school. Physical examination reveals no abnormalities.
      What additional treatment options would you suggest for her?

      Your Answer: Enuresis alarm

      Explanation:

      When general management advice has not been effective for nocturnal enuresis, an enuresis alarm is typically the first-line recommendation. This device detects urine moisture and triggers an alarm (either through sound or vibration) to wake the child and prompt them to use the toilet. Enuresis alarms have a high success rate when used consistently, and a review is typically conducted after four weeks to assess progress. Bladder training and retention control training are not recommended by NICE guidelines due to limited evidence and concerns about promoting voiding dysfunction. Desmopressin, a vasopressin analogue that reduces urine production, may be considered if the family is not receptive to or finds an enuresis alarm ineffective. However, an enuresis alarm should be offered first. Desmopressin can provide short-term control, but it can cause hyponatremia. Desmopressin plus oxybutynin may be helpful if there are daytime symptoms or if desmopressin alone does not improve the condition. As not all anticholinergic medications have UK marketing authorization for bedwetting treatment, a healthcare professional with appropriate expertise should manage this combination, often requiring a specialist referral and further investigations.

      Nocturnal enuresis, or bedwetting, is when a child involuntarily urinates during the night. Most children achieve continence by the age of 3 or 4, so enuresis is defined as the involuntary discharge of urine in a child aged 5 or older without any underlying medical conditions. Enuresis can be primary, meaning the child has never achieved continence, or secondary, meaning the child has been dry for at least 6 months before.

      When managing bedwetting, it’s important to look for any underlying causes or triggers, such as constipation, diabetes mellitus, or recent onset UTIs. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Reward systems, like star charts, can also be helpful, but should be given for agreed behavior rather than dry nights.

      The first-line treatment for bedwetting is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up to use the toilet. If short-term control is needed, such as for sleepovers, or if the alarm is ineffective or not acceptable to the family, desmopressin may be prescribed. Overall, managing bedwetting involves identifying any underlying causes and implementing strategies to promote continence.

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      • Paediatrics
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  • Question 18 - A 7-year-old boy is presented for surgery due to recurring headaches. What is...

    Incorrect

    • A 7-year-old boy is presented for surgery due to recurring headaches. What is the primary reason for headaches in children?

      Your Answer: Refractive errors

      Correct Answer: Migraine

      Explanation:

      In children, primary headache is most commonly caused by migraine.

      Understanding Headaches in Children

      Headaches are a common occurrence in children, with up to 50% of 7-year-olds and 80% of 15-year-olds experiencing at least one headache. Migraine without aura is the most common cause of primary headache in children, with a strong female preponderance after puberty. The International Headache Society has produced criteria for diagnosing pediatric migraine without aura, which includes headache attacks lasting 4-72 hours, with at least two of four specific features and accompanying symptoms such as nausea and vomiting.

      When it comes to acute management, ibuprofen is considered more effective than paracetamol for pediatric migraine. Triptans may be used in children over 12 years old, but follow-up is required, and only sumatriptan nasal spray is licensed for use in young people. However, oral triptans are not currently licensed for those under 18 years old, and side effects may include tingling, heat, and pressure sensations.

      Prophylaxis for pediatric migraine is limited, with no clear consensus guidelines. Pizotifen and propranolol are recommended as first-line preventatives, while valproate, topiramate, and amitriptyline are considered second-line preventatives. Tension-type headache is the second most common cause of headache in children, with diagnostic criteria including at least 10 previous headache episodes lasting from 30 minutes to 7 days, with specific pain characteristics and the absence of nausea or vomiting.

      In summary, headaches in children are common, and migraine without aura is the most common primary headache. Acute management includes ibuprofen and triptans, while prophylaxis is limited. Tension-type headache is also a common cause of headache in children. It is important to seek medical advice if headaches are frequent or severe, or if there are any concerning symptoms such as neurological deficits or changes in behavior.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 19 - A 9-year-old boy with asthma is brought into the GP surgery with a...

    Incorrect

    • A 9-year-old boy with asthma is brought into the GP surgery with a cough and shortness of breath. Examination reveals a respiratory rate of 34 breaths/min, apyrexial, wheeze throughout his chest and a peak expiratory flow rate (PEFR) of half his predicted value.
      Which of the following treatments is the best option?

      Your Answer: Outpatient management with antibiotics

      Correct Answer: Inpatient management with nebuliser salbutamol and oral steroids

      Explanation:

      Managing Acute Asthma Exacerbations in Children: Treatment Options and Guidelines

      When a child experiences an acute asthma exacerbation, prompt and appropriate management is crucial to prevent further complications. Here are some treatment options and guidelines to consider:

      Inpatient Management with Nebuliser Salbutamol and Oral Steroids
      For severe asthma exacerbations, hospital transfer is necessary. Inpatient management should include nebulised bronchodilators in combination with early oral steroids. A 3-day steroid course is usually sufficient.

      Manage as Outpatient with Inhaled Salbutamol via Spacer
      Mild to moderate acute asthma can be managed with salbutamol via a spacer. Oral steroids should be considered in all children with an acute exacerbation of asthma. However, all children with features of severe or life-threatening asthma should be transferred to a hospital.

      Outpatient Management with Antibiotics
      Antibiotics would be inappropriate for acute asthma exacerbations unless there are clues in the history to suggest a bacterial infection as the cause of exacerbation.

      Continue Current Medications with No Changes
      In severe acute asthma, urgent treatment with nebulisers and transfer to a hospital is necessary.

      IV Salbutamol
      IV salbutamol is second line and considered only if the symptoms have responded poorly to nebulised therapy.

      British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidance suggests that all children with features of severe or life-threatening asthma should be transferred to a hospital. The severity of acute asthma in children over 5 can be determined using the BTS severity scoring.

      By following these guidelines and treatment options, healthcare professionals can effectively manage acute asthma exacerbations in children and prevent further complications.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 20 - A 6-year-old girl presents to the emergency department with a 5-day history of...

    Correct

    • A 6-year-old girl presents to the emergency department with a 5-day history of fever and lethargy. She has no significant medical history and is up to date with her childhood vaccinations.

      During the examination, the girl appears drowsy and has a temperature of 39.2ÂșC. Her heart rate is 155 beats/min and respiratory rate is 46 breaths/min. She has a maculopapular rash on her torso and upper limbs, and her lips are cracked and erythematous. Additionally, her conjunctivae are inflamed. Kernig's sign is negative.

      What is the most appropriate management for this patient, given the likely diagnosis?

      Your Answer: Aspirin

      Explanation:

      High-dose aspirin therapy is the recommended treatment for Kawasaki disease, despite it typically being contraindicated in children.

      Aspirin is the appropriate treatment for this patient’s diagnosis of Kawasaki disease, as evidenced by their persistent fever, conjunctivitis, maculopapular rash, and cracked and erythematous lips. This disease is vasculitic in nature, and current guidelines advise the use of high-dose aspirin therapy as the initial treatment.

      Intravenous aciclovir is not indicated for Kawasaki disease, as it is used to treat viral conditions such as viral meningitis or encephalitis.

      Intravenous ceftriaxone is not appropriate for the treatment of Kawasaki disease, as it is reserved for significant bacterial infections like Neisseria meningitidis. Additionally, the negative Kernig’s sign makes meningitis less likely.

      Oral phenoxymethylpenicillin is not the recommended treatment for Kawasaki disease, as the mucosal changes and conjunctivitis are more indicative of this disease rather than scarlet fever, which is treated with oral phenoxymethylpenicillin.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

    • This question is part of the following fields:

      • Paediatrics
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SESSION STATS - PERFORMANCE PER SPECIALTY

Paediatrics (12/20) 60%
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