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Question 1
Correct
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A 10-day-old preterm neonate is having difficulty tolerating cow's milk feeds administered by the nurses in the special care baby unit. During the most recent feed, the neonate vomited and the nurse observed bile in the vomit. Although the stools are of normal consistency, the last stool contained fresh red blood. Upon examination, the neonate appears to be well hydrated, but the abdomen is significantly distended. An urgent abdominal x-ray is ordered, which reveals distended loops of bowel with thickening of the bowel wall. What is the next course of action in managing this situation?
Your Answer: Commence broad spectrum antibiotics
Explanation:The infant in this scenario is likely suffering from bacterial necrotising enterocolitis, given their prematurity and symptoms. Immediate administration of broad spectrum antibiotics is necessary due to the severity of the condition. Therefore, the correct answer is option 2. While changing feeds may be helpful in preventing necrotising enterocolitis in bottle-fed infants, it is not useful in treating the condition once it has developed. While IV fluids are important for maintaining hydration, they are not as urgent as antibiotics in this case. Antenatal administration of erythromycin is intended to prevent necrotising enterocolitis, but it is not effective in treating the condition once it has developed.
Understanding Necrotising Enterocolitis
Necrotising enterocolitis is a serious condition that is responsible for a significant number of premature infant deaths. The condition is characterized by symptoms such as feeding intolerance, abdominal distension, and bloody stools. If left untreated, these symptoms can quickly progress to more severe symptoms such as abdominal discolouration, perforation, and peritonitis.
To diagnose necrotising enterocolitis, doctors often use abdominal x-rays. These x-rays can reveal a number of important indicators of the condition, including dilated bowel loops, bowel wall oedema, and intramural gas. Other signs that may be visible on an x-ray include portal venous gas, pneumoperitoneum resulting from perforation, and air both inside and outside of the bowel wall. In some cases, an x-ray may also reveal air outlining the falciform ligament, which is known as the football sign.
Overall, understanding the symptoms and diagnostic indicators of necrotising enterocolitis is crucial for early detection and treatment of this serious condition. By working closely with healthcare professionals and following recommended screening protocols, parents and caregivers can help ensure the best possible outcomes for premature infants at risk for this condition.
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This question is part of the following fields:
- Paediatrics
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Question 2
Incorrect
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A ten-year-old boy with a history of asthma and eczema visits the urgent GP clinic due to a cough. Upon entering the room, he appears to be in good health and is able to speak in complete sentences. His oxygen saturation level is 97% in air, peak expiratory flow is 60% of expected, heart rate is 115/min, and respiratory rate is 28/min. During chest examination, widespread wheezing is observed. What is the appropriate course of action for this patient?
Your Answer: Salbutamol via a spacer: one puff every 30-60 seconds to a maximum of 10 puffs
Correct Answer: Oral prednisolone and salbutamol via a spacer: one puff every 30-60 seconds to a maximum of 10 puffs
Explanation:His respiratory rate and heart rate are both within normal limits, with a respiratory rate of less than 30 breaths per minute and a heart rate of less than 125 beats per minute. The appropriate treatment for his asthma attack is oral prednisolone and salbutamol via a spacer, with one puff administered every 30-60 seconds up to a maximum of 10 puffs. It is important to administer steroid therapy to all children experiencing an asthma attack. The use of high flow oxygen and a salbutamol nebuliser is not necessary, as his SP02 is already at 97%.
Managing Acute Asthma Attacks in Children
When it comes to managing acute asthma attacks in children, it is important to assess the severity of the attack and take appropriate action. For children between the ages of 2 and 5, those with severe or life-threatening asthma should be immediately transferred to the hospital. For moderate attacks, children should have a SpO2 level above 92% and no clinical features of severe asthma. However, for severe attacks, children may have a SpO2 level below 92%, be too breathless to talk or feed, have a heart rate above 140/min, and use accessory neck muscles. For life-threatening attacks, children may have a SpO2 level below 92%, a silent chest, poor respiratory effort, agitation, altered consciousness, and cyanosis.
For children over the age of 5, it is recommended to attempt to measure PEF in all cases. For moderate attacks, children should have a SpO2 level above 92%, a PEF level above 50% best or predicted, and no clinical features of severe asthma. For severe attacks, children may have a SpO2 level below 92%, a PEF level between 33-50% best or predicted, and be unable to complete sentences in one breath or too breathless to talk or feed. For life-threatening attacks, children may have a SpO2 level below 92%, a PEF level below 33% best or predicted, a silent chest, poor respiratory effort, altered consciousness, and cyanosis.
For children with mild to moderate acute asthma, bronchodilator therapy should be given via a beta-2 agonist and spacer (or close-fitting mask for children under 3 years old). One puff should be given every 30-60 seconds up to a maximum of 10 puffs. If symptoms are not controlled, the beta-2 agonist should be repeated and the child should be referred to the hospital. Steroid therapy should also be given to all children with an asthma exacerbation for 3-5 days, with the usual prednisolone dose varying based on age and weight.
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This question is part of the following fields:
- Paediatrics
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Question 3
Incorrect
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A 5-year-old boy is brought to the emergency department with a fever, sore throat, and difficulty swallowing that started yesterday and has gotten worse. During the examination, he appears anxious and leans forward with his hands on his knees, drooling. His temperature is 38ºC, oxygen saturation is 96% on air, heart rate is 100 beats per minute, respiratory rate is 24 breaths per minute, and blood pressure is 100/60 mmHg.
Despite receiving intravenous dexamethasone and inhaled budesonide, the child's condition continues to deteriorate. He now has audible stridor, and the on-call anaesthetist is paged. What intervention should be considered next?Your Answer: Continuous positive airway pressure (CPAP)
Correct Answer: Endotracheal intubation
Explanation:Oxygen that has been humidified
Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B. It is important to recognize and treat it promptly as it can lead to airway obstruction. Although it was once considered a disease of childhood, it is now more common in adults in the UK due to the immunization program. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine. Symptoms include a rapid onset, high temperature, stridor, drooling of saliva, and a tripod position where the patient leans forward and extends their neck to breathe easier. Diagnosis is made by direct visualization, but x-rays may be done to rule out a foreign body.
Immediate senior involvement is necessary, including those who can provide emergency airway support such as anaesthetics or ENT. Endotracheal intubation may be necessary to protect the airway. It is important not to examine the throat if epiglottitis is suspected due to the risk of acute airway obstruction. The diagnosis is made by direct visualization, but only senior staff who are able to intubate if necessary should perform this. Treatment includes oxygen and intravenous antibiotics.
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This question is part of the following fields:
- Paediatrics
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Question 4
Correct
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A 5-year-old girl is brought in by ambulance after her parents awoke in the middle of the night to a harsh coughing episode and noted she had difficulty breathing. She has been coryzal over the last 2 days but has never had any episodes like this before. The paramedics have given a salbutamol nebuliser, to some effect, but she continues to have very noisy breathing. Oxygen saturations are 94% on air, with a respiratory rate of 50.
What is the most likely diagnosis?Your Answer: Croup
Explanation:Pediatric Respiratory Conditions: Croup and Acute Epiglottitis
Croup is a common upper respiratory tract infection in children caused by the parainfluenza virus. It leads to laryngotracheobronchitis and upper airway obstruction, resulting in symptoms such as a barking cough, stridor, and difficulty breathing. Treatment involves a single dose of oral dexamethasone or inhaled budesonide, oxygen, and inhaled adrenaline in severe cases.
Viral-induced wheeze and asthma are unlikely diagnoses in this case due to the lack of wheeze and minimal improvement with salbutamol. Inhalation of a foreign body is also unlikely given the absence of a history of playing with an object.
Acute epiglottitis is a rare but serious condition that presents similarly to croup. It is caused by inflammation of the epiglottis, usually due to streptococci. Symptoms develop rapidly over a few hours and include difficulty swallowing, muffled voice, drooling, cervical lymphadenopathy, and fever. The tripod sign, where the child leans on outstretched arms to assist with breathing, is a characteristic feature.
In conclusion, prompt recognition and appropriate management of pediatric respiratory conditions such as croup and acute epiglottitis are crucial to prevent complications and ensure optimal outcomes.
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This question is part of the following fields:
- Paediatrics
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Question 5
Incorrect
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A 4-year-old girl is admitted to the paediatric ward with suspected Kawasaki disease. Upon arrival at the emergency department, she had a fever lasting for 8 days, dry cracked lips, bilateral conjunctivitis, and peeling of her fingers and toes. What additional symptom would support the diagnosis?
Your Answer: Abdominal tenderness
Correct Answer: Cervical lymphadenopathy
Explanation:Kawasaki disease is a rare condition that typically affects children under the age of 5. The diagnosis is based on the presence of a fever lasting for at least 5 days, accompanied by at least 4 of the following symptoms: dry and cracked lips, bilateral conjunctivitis, peeling of the skin on the fingers and toes, cervical lymphadenopathy, and a red rash over the trunk. It is crucial to be aware of the diagnostic criteria for this disease, as the vascular complications can be severe. Additionally, this topic may be tested on final exams.
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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This question is part of the following fields:
- Paediatrics
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Question 6
Correct
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A 4-year-old girl is brought to the emergency department by her father with bruising after a fall. During assessment, it is noted that she has a global developmental delay. She walks with difficulty, has some fine motor skills, and is playing with toys during the consultation. There are bruises on her back, right elbow, and right thigh, at different stages of healing.
Her father reports that these bruises are from her being clumsy for the past few months and he himself once had bruising which required oral steroids and thinks she has developed the same condition.
What would be the most appropriate next step in her management?Your Answer: Immediately contact safeguarding lead
Explanation:The presence of multiple bruises at different stages of healing in an infant who has been brought a few months after the injuries occurred should raise suspicion of non-accidental injury. This is because it is unlikely for a child to have so many bruises from clumsiness alone. A delayed presentation may also suggest non-accidental injury. Therefore, the correct course of action is to immediately contact the safeguarding lead. While coagulation screen and coagulopathy testing may be performed later, they are not the first priority. Similarly, oral prednisolone is not the first-line treatment for children with immune thrombocytopenia (ITP) and is not relevant in this case. The priority is to assess the infant for non-accidental injury.
Recognizing Child Abuse: Signs and Symptoms
Child abuse is a serious issue that can have long-lasting effects on a child’s physical and emotional well-being. It is important to be able to recognize the signs and symptoms of child abuse in order to intervene and protect the child. One possible indicator of abuse is when a child discloses abuse themselves. However, there are other factors that may point towards abuse, such as an inconsistent story with injuries, repeated visits to A&E departments, delayed presentation, and a frightened, withdrawn appearance known as frozen watchfulness.
Physical presentations of child abuse can also be a sign of abuse. These may include bruising, fractures (especially metaphyseal, posterior rib fractures, or multiple fractures at different stages of healing), torn frenulum (such as from forcing a bottle into a child’s mouth), burns or scalds, failure to thrive, and sexually transmitted infections like Chlamydia, gonorrhoeae, and Trichomonas. It is important to be aware of these signs and symptoms and to report any concerns to the appropriate authorities to ensure the safety and well-being of the child.
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This question is part of the following fields:
- Paediatrics
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Question 7
Incorrect
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A 6-year-old boy is brought to the GP surgery by his mother. He has a two-year history of asthma which has previously been controlled with a salbutamol inhaler twice daily and beclomethasone 50 micrograms bd. He has an audible wheeze that has been gradually worsening over the last few weeks and has not responded to additional doses of salbutamol. His mother also reports that he has a night-time cough for the past 6 weeks.
What is the most appropriate next step in management?Your Answer: Increase the beclomethasone to 100 micrograms bd
Correct Answer: Add a trial of a leukotriene receptor antagonist
Explanation:If a child under the age of 5 has asthma that is not being controlled by a short-acting beta agonist (SABA) and a low dose of inhaled corticosteroids (ICS), then a leukotriene receptor antagonist should be added to their asthma management plan.
Managing Asthma in Children: NICE Guidelines
Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.
It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.
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This question is part of the following fields:
- Paediatrics
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Question 8
Correct
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A 15-year-old boy presents to the Emergency Department with hypotension following a rugby injury. During the game, he was tackled from the side and experienced intense pain in his left lower rib cage. On examination, the patient has a pulse of 140 bpm and a blood pressure of 80/40 mmHg. There is visible bruising over the left flank and tenderness upon palpation. What is the probable diagnosis?
Your Answer: Splenic rupture
Explanation:High Impact Injuries to the Left Flank
High impact injuries to the left flank can result in damage to the spleen or kidney, as well as the ribs and soft tissue. If the patient experiences fractured ribs and hypotension, it is important to suspect a spleen rupture. Fluid resuscitation can be used to determine if the patient responds positively, and a CT scan can be arranged to confirm the diagnosis. Based on the injury grade and physical parameters, a decision can be made to either manage the injury conservatively or operate.
Observation should be conducted in a High Dependency Unit (HDU) setting initially to ensure that any deterioration in haemodynamic parameters can be addressed promptly. CT scans are also useful in trauma cases to rule out other injuries, such as hollow visceral injuries that would require a laparotomy. Renal trauma typically does not cause hypotension unless other organs are also injured, and aortic dissection would require more force.
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This question is part of the following fields:
- Paediatrics
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Question 9
Correct
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A five-year-old boy has been brought to the clinic by his worried mother due to an unusual walking pattern and lower limb weakness. After conducting a thorough medical history, physical examination, and further tests, the child is diagnosed with Duchenne muscular dystrophy. What is the prevailing cardiac pathology linked to this disorder?
Your Answer: Dilated cardiomyopathy
Explanation:Dilated cardiomyopathy is the most common heart condition linked to Duchenne muscular dystrophy, while acute myocardial infarctions, atrioventricular septal defects, and coronary aneurysms are not associated with this condition. Atrioventricular septal defects are, however, associated with Down syndrome, while coronary aneurysms are a complication of Kawasaki disease. Dilated cardiomyopathy is a rapidly progressive complication that typically starts in adolescence for individuals with Duchenne muscular dystrophy, an X-linked recessive condition characterized by progressive muscle wasting and weakness.
Understanding Duchenne Muscular Dystrophy
Duchenne muscular dystrophy is a genetic disorder that is inherited in an X-linked recessive manner. It affects the dystrophin genes that are essential for normal muscular function. The disorder is characterized by progressive proximal muscle weakness that typically begins around the age of 5 years. Other features include calf pseudohypertrophy and Gower’s sign, which is when a child uses their arms to stand up from a squatted position. Approximately 30% of patients with Duchenne muscular dystrophy also have intellectual impairment.
To diagnose Duchenne muscular dystrophy, doctors typically look for elevated levels of creatinine kinase in the blood. However, genetic testing has now replaced muscle biopsy as the preferred method for obtaining a definitive diagnosis. Unfortunately, there is currently no effective treatment for Duchenne muscular dystrophy, so management is largely supportive.
The prognosis for Duchenne muscular dystrophy is poor. Most children with the disorder are unable to walk by the age of 12 years, and patients typically survive to around the age of 25-30 years. Duchenne muscular dystrophy is also associated with dilated cardiomyopathy, which can further complicate the management of the disorder.
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This question is part of the following fields:
- Paediatrics
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Question 10
Incorrect
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A 5-day-old infant presents with feeding difficulties for the past day. The baby was born at 38 weeks, induced 48 hours after pre-labor spontaneous rupture of membranes. Following observation, there were no concerns and the baby was discharged. The infant is breastfed every 1-2 hours, but over the past 24 hours, has been less interested in feeding, occurring every 3-4 hours, sometimes being woken to feed. The baby appears uncomfortable during feeding and frequently pulls away. The mother also reports an unusual grunting sound after the baby exhales. Based on this information, what is the most likely diagnosis?
Your Answer: Gastro-oesophageal reflux disease
Correct Answer: Neonatal sepsis
Explanation:Neonatal Sepsis: Causes, Risk Factors, and Management
Neonatal sepsis is a serious bacterial or viral infection in the blood that affects babies within the first 28 days of life. It is categorized into early-onset (EOS) and late-onset (LOS) sepsis, with each category having distinct causes and common presentations. The most common causes of neonatal sepsis are group B streptococcus (GBS) and Escherichia coli, accounting for approximately two-thirds of cases. Premature and low birth weight babies are at higher risk, as well as those born to mothers with GBS colonization or infection during pregnancy. Symptoms can vary from subtle signs of illness to clear septic shock, and diagnosis is usually established through blood culture. Treatment involves early identification and use of intravenous antibiotics, with duration depending on ongoing investigations and clinical picture. Other important management factors include maintaining adequate oxygenation and fluid and electrolyte status.
Neonatal Sepsis: Causes, Risk Factors, and Management
Neonatal sepsis is a serious infection that affects newborn babies within the first 28 days of life. It can be caused by a variety of bacteria and viruses, with GBS and E. coli being the most common. Premature and low birth weight babies, as well as those born to mothers with GBS colonization or infection during pregnancy, are at higher risk. Symptoms can range from subtle signs of illness to clear septic shock, and diagnosis is usually established through blood culture. Treatment involves early identification and use of intravenous antibiotics, with duration depending on ongoing investigations and clinical picture. Other important management factors include maintaining adequate oxygenation and fluid and electrolyte status.
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This question is part of the following fields:
- Paediatrics
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Question 11
Incorrect
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Which condition is frequently associated with plethoric lung fields on radiological imaging?
Your Answer: Coarctation of the aorta
Correct Answer: A large ventricular septal defect (VSD)
Explanation:Types of Congenital Heart Defects and Pulmonary Blood Flow
Congenital heart defects can be classified into different types based on their effects on pulmonary blood flow. Coarctation is a type of defect that is associated with normal pulmonary blood flow. On the other hand, most other types of defects, such as tetralogy of Fallot, pulmonary atresia, and tricuspid atresia, are associated with reduced pulmonary blood flow. The only exception to this is a large ventricular septal defect (VSD), which can also be associated with normal pulmonary blood flow. the different types of congenital heart defects and their effects on pulmonary blood flow is important for proper diagnosis and treatment. Proper management of these defects can help improve the quality of life and outcomes for individuals with congenital heart defects.
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This question is part of the following fields:
- Paediatrics
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Question 12
Incorrect
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A toddler is brought to the emergency room with breathing difficulties. The medical team wants to evaluate the child's condition.
At what point should the APGAR score be evaluated?Your Answer: 1 and 10 minutes of age
Correct Answer: 1 and 5 minutes of age
Explanation:According to NICE, it is recommended that APGAR scores are regularly evaluated at both 1 and 5 minutes after a baby is born. The APGAR score is a measure of a newborn’s overall health, based on their pulse, breathing, color, muscle tone, and reflexes. A higher score indicates better health, with scores ranging from 0-3 (very low), 4-6 (moderately low), and 7-10 (good). If a baby’s score is less than 5 at 5 minutes, additional APGAR scores should be taken at 10, 15, and 30 minutes, and umbilical cord blood gas sampling may be necessary. It is important to note that the correct time for assessing APGAR scores is at 1 and 5 minutes after birth, and none of the other options are accurate.
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.
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This question is part of the following fields:
- Paediatrics
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Question 13
Correct
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A 7-month-old infant is brought to the emergency department with symptoms of vomiting, blood in stools, and irritability. During the physical examination, the baby's abdomen is found to be tense, and he draws his knees up in response to palpation.
What would be the most suitable course of action for this baby?Your Answer: Refer to paediatric surgeons
Explanation:Intussusception in Children: Diagnosis and Treatment
Intussusception is a medical condition that occurs when one part of the intestine slides into another part, causing a blockage. Children with this condition may experience severe abdominal pain, vomiting, and bloody stools. If left untreated, intussusception can lead to bowel perforation, sepsis, and even death. Therefore, it is crucial to diagnose and treat this condition promptly.
When a child presents with symptoms of intussusception, the most appropriate course of action is to refer them immediately to a paediatric surgical unit. There, doctors will attempt to relieve the intussusception through air reduction, which involves pumping air into the intestine to push the telescoped section back into place. If this method fails, surgery may be necessary to correct the blockage.
Several risk factors can increase a child’s likelihood of developing intussusception, including viral infections and intestinal lymphadenopathy. Therefore, parents should seek medical attention if their child experiences any symptoms of this condition. With prompt diagnosis and treatment, most children with intussusception can make a full recovery.
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This question is part of the following fields:
- Paediatrics
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Question 14
Incorrect
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A 6-year-old boy is discovered to have an incidental murmur. He is healthy and progressing normally. The first heart sound is regular, but the second heart sound appears to be broadly split, and this splitting is unchanging regardless of inhalation or exhalation. A faint mid-systolic murmur is heard over the pulmonary region. The electrocardiogram (ECG) reveals an rSr' pattern in V1 and prominent P waves. What is the probable diagnosis?
Your Answer: Innocent murmur with normal variant ECG
Correct Answer: Atrial septal defect
Explanation:Atrial septal defects (ASDs) are often asymptomatic and produce fixed splitting of the second heart sound. They are of three types and are often picked up during auscultation. The rSr change on the ECG can be caused by ASDs, right ventricular hypertrophy, or pulmonary embolus. The mechanism resulting in splitting of the heart sounds in ASDs is due to the difference in compliance between the left and right ventricles. The extra flow through the right side due to an ASD causes the splitting to be widened, and the lack of variation with ventilation suggests an intra-atrial connection is the cause. ASDs can lead to right ventricular failure and paradoxical embolisation of venous clots into the systemic circulation.
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This question is part of the following fields:
- Paediatrics
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Question 15
Incorrect
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A 3-month-old previously healthy boy is brought into the pediatrician's office by his father who is concerned about a change in his behavior. The father suspects his child has a fever. During the examination, the baby is found to have a temperature of 38.5 ºC but no other notable findings.
What should be the next course of action?Your Answer: Reassure the mother and ask to return if the fever doesn't settle in the next two days
Correct Answer: Urgent referral for paediatric assessment at the hospital
Explanation:If a child under 3 months old has a fever above 38ºC, it is considered a high-risk situation and requires urgent assessment. This is a crucial factor to consider when evaluating a child with a fever. The NICE guidelines use a traffic light system to categorize the risk level of children under 5 with a fever, taking into account various factors such as the child’s appearance, activity level, respiratory function, circulation, hydration, and temperature. If the child falls under the green category, they can be managed at home with appropriate care advice. If they fall under the amber category, parents should be given advice and provided with a safety net, or the child should be referred for pediatric assessment. Children in the red category must be referred urgently to a pediatric specialist. In children under 3 months with fever, NICE recommends performing various investigations such as blood culture, full blood count, c-reactive protein, urine testing for urinary tract infections, stool culture if diarrhea is present, and chest x-ray if there are respiratory signs. Lumbar puncture should be performed in infants under 1 month old, all infants aged 1-3 months who appear unwell, and infants aged 1-3 months with a white blood cell count (WBC) less than 5 × 109/liter or greater than 15 × 109/liter. NICE also recommends administering parenteral antibiotics to this group of patients.
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.
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This question is part of the following fields:
- Paediatrics
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Question 16
Incorrect
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A 14-year-old high school student comes to your office with symptoms of depression. During the consultation, she reveals that she has been bullied for having sex with an 18-year-old boy in the same school. The sexual encounter was consensual and occurred only once, without the influence of drugs or alcohol.
What is the best immediate step to take?Your Answer: You must contact the patient's mother as she is the legal guardian
Correct Answer: You should disclose that this girl has been sexually active to the relevant authority
Explanation:When it comes to sexual issues involving young people, the topics of consent and confidentiality can be challenging. However, in this particular case, there is no ambiguity. Legally, individuals under the age of 13 are incapable of giving consent for sexual activity. Therefore, it is typically necessary to disclose this information. If there is a decision to withhold this information, it should be discussed with a designated doctor for child protection and documented appropriately. This is an uncommon occurrence. As the patient is under 13, she is unable to provide consent for sexual activity. While it may be necessary to discuss the situation with the patient’s mother, this is not the most urgent responsibility. The primary duty is to report the incident to the appropriate authority, and it cannot be left in the hands of the patient.
Guidelines for Obtaining Consent in Children
The General Medical Council has provided guidelines for obtaining consent in children. According to these guidelines, young people who are 16 years or older can be treated as adults and are presumed to have the capacity to make decisions. However, for children under the age of 16, their ability to understand what is involved determines whether they have the capacity to decide. If a competent child refuses treatment, a person with parental responsibility or the court may authorize investigation or treatment that is in the child’s best interests.
When it comes to providing contraceptives to patients under 16 years of age, the Fraser Guidelines must be followed. These guidelines state that the young person must understand the professional’s advice, cannot be persuaded to inform their parents, is likely to begin or continue having sexual intercourse with or without contraceptive treatment, and will suffer physical or mental health consequences without contraceptive treatment. Additionally, the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.
Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children. However, rumors that Victoria Gillick removed her permission to use her name or applied copyright have been debunked. It is important to note that in Scotland, those with parental responsibility cannot authorize procedures that a competent child has refused.
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This question is part of the following fields:
- Paediatrics
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Question 17
Correct
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You are working in the Neonatal Intensive Care Unit and currently assessing a 3-day-old boy with respiratory distress due to meconium aspiration. The mother is visibly upset and asks if there was anything she could have done to prevent this.
After reviewing the medical history, you find that the baby was conceived through in vitro fertilization, there were no complications during the pregnancy, but he was delivered via C-section at 41 weeks with a birth weight of 2.6kg.
What is the most significant risk factor for meconium aspiration in this particular case?Your Answer: Post-term delivery
Explanation:Post-term delivery is a major risk factor for meconium aspiration, which is why women are induced following term. Placental insufficiency, not low birth weight, is a consequence of meconium aspiration. The sex of the child and assisted reproduction are not considered independent risk factors. While meconium aspiration may cause distress during labor and potentially result in a Caesarean section, it is not a risk factor on its own.
Understanding Meconium Aspiration Syndrome
Meconium aspiration syndrome is a condition that affects newborns and causes respiratory distress due to the presence of meconium in the trachea. This condition typically occurs in the immediate neonatal period and is more common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks. The severity of the respiratory distress can vary, but it can be quite severe in some cases.
There are several risk factors associated with meconium aspiration syndrome, including a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking, or substance abuse. These risk factors can increase the likelihood of a baby developing this condition. It is important for healthcare providers to be aware of these risk factors and to monitor newborns closely for signs of respiratory distress.
Overall, meconium aspiration syndrome is a serious condition that requires prompt medical attention. With proper management and treatment, however, most babies are able to recover fully and go on to lead healthy lives. By understanding the risk factors and symptoms associated with this condition, healthcare providers can help ensure that newborns receive the care they need to thrive.
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This question is part of the following fields:
- Paediatrics
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Question 18
Correct
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A mother takes her four-week-old daughter to visit her pediatrician. The baby has been throwing up white substance after feeds, particularly when laid down afterwards. The mother reports that the baby also frequently cries during breastfeeding. The baby was born at 36 weeks through vaginal delivery and has been meeting developmental milestones. There are no other siblings. There have been no instances of bloody stools or diarrhea. What is the probable diagnosis?
Your Answer: Gastro-oesophageal reflux
Explanation:The most probable diagnosis for an infant under eight weeks who is experiencing milky vomits after feeds, particularly when laid flat, and excessive crying during feeds is gastro-oesophageal reflux. This is supported by the risk factor of preterm delivery in this case. Coeliac disease is an unlikely diagnosis as the child is exclusively breastfed and would typically present with diarrhoea and failure to thrive when introduced to cereals. Cow’s milk protein intolerance/allergy is also unlikely as it is more commonly seen in formula-fed infants and would typically present with additional symptoms such as atopy and diarrhoea. Duodenal atresia, which causes bilious vomiting in neonates a few hours after birth, is also an unlikely diagnosis for a six-week-old infant experiencing white vomitus.
Understanding Gastro-Oesophageal Reflux in Children
Gastro-oesophageal reflux is a common cause of vomiting in infants, with around 40% of babies experiencing some degree of regurgitation. However, certain risk factors such as preterm delivery and neurological disorders can increase the likelihood of developing this condition. Symptoms typically appear before 8 weeks of age and include vomiting or regurgitation, milky vomits after feeds, and excessive crying during feeding. Diagnosis is usually made based on clinical observation.
Management of gastro-oesophageal reflux in children involves advising parents on proper feeding positions, ensuring the infant is not being overfed, and considering a trial of thickened formula or alginate therapy. Proton pump inhibitors are not recommended unless the child is experiencing unexplained feeding difficulties, distressed behavior, or faltering growth. Ranitidine, previously used as an alternative to PPIs, has been withdrawn from the market due to the discovery of carcinogens in some products. Prokinetic agents should only be used with specialist advice.
Complications of gastro-oesophageal reflux in children include distress, failure to thrive, aspiration, frequent otitis media, and dental erosion in older children. In severe cases where medical treatment is ineffective, fundoplication may be considered. It is important for parents and caregivers to understand the symptoms and management options for gastro-oesophageal reflux in children to ensure the best possible outcomes for their little ones.
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This question is part of the following fields:
- Paediatrics
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Question 19
Incorrect
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A 9-month-old boy is brought to the emergency department by his father. His father reports that over the past 4 hours, his son has had episodes of shaking and is less responsive than usual.
On examination, the boy is drowsy and does not respond to voice. You note he has some bruising around his torso. You suspect that the baby may have been shaken.
Which triad of symptoms is consistent with this diagnosis?Your Answer: Retinal haemorrhages + extradural haematoma + encephalopathy
Correct Answer: Retinal haemorrhages + subdural haematoma + encephalopathy
Explanation:Understanding Shaken Baby Syndrome
Shaken baby syndrome is a condition that involves a combination of retinal haemorrhages, subdural haematoma, and encephalopathy. It occurs when a child between the ages of 0-5 years old is intentionally shaken. However, there is controversy among physicians regarding the mechanism of injury, making it difficult for courts to convict suspects of causing shaken baby syndrome to a child. This condition has made headlines due to the ongoing debate among medical professionals.
Shaken baby syndrome is a serious condition that can cause long-term damage to a child’s health. It is important to understand the signs and symptoms of this condition to ensure that children are protected from harm. While the controversy surrounding the diagnosis of shaken baby syndrome continues, it is crucial to prioritize the safety and well-being of children. By raising awareness and educating the public about this condition, we can work towards preventing it from occurring in the future.
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This question is part of the following fields:
- Paediatrics
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Question 20
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A 35-year-old woman attends an ultrasound scan at 36 weeks due to gestational hypertension. This shows a breech presentation. She has a successful external cephalic version (ECV) at 37 weeks and her baby is born vaginally at 40+5 weeks. On the initial postnatal check, both Ortolani's and Barlow's tests are negative. Mums' blood pressure returns to normal after birth.
What investigations will be necessary?Your Answer: Ultrasound hips of baby at 6 weeks
Explanation:At 6 weeks, the mother will undergo a 2-hour oral glucose tolerance test (OGTT) with a glucose load of 75g.
Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.
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This question is part of the following fields:
- Paediatrics
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