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Question 1
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When should the pneumococcal conjugate (PCV) vaccine be given to a healthy individual based on the UK immunisation schedule?
Your Answer: 8 weeks and 12 weeks
Explanation:Understanding the Pneumococcal Vaccine
The pneumococcal vaccine is an important immunization that helps protect against pneumococcal disease, which can cause serious illnesses such as pneumonia, meningitis, and blood infections. However, it’s important to note that there are two types of pneumococcal vaccines – the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV).
The PCV vaccine is given to children under the age of 2, with a booster at 1 year old. On the other hand, the PPV vaccine is given to individuals over the age of 2, particularly those who are 65 years old and above. It’s important to know which vaccine to administer, as the immune response to each vaccine is different.
Aside from the recommended age groups, individuals with certain medical conditions are also eligible for the pneumococcal vaccine. These include those with asplenia or splenic dysfunction, cochlear implants, chronic respiratory or heart disease, chronic neurological conditions, diabetes, chronic kidney disease stage 4/5, chronic liver disease, immunosuppression due to disease or treatment, and complement disorders.
In summary, understanding the pneumococcal vaccine and its different types and recommended age groups is crucial in ensuring proper administration and protection against pneumococcal disease.
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This question is part of the following fields:
- Children And Young People
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Question 2
Correct
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A 4-year-old boy is brought in by his father. His father reports that he has been eating less and refusing food for the past few weeks. Despite this his father has noticed that his abdomen is distended and he has developed a 'beer belly'. For the past year he has opened his bowels around once every other day, passing a stool of 'normal' consistency. There are no urinary symptoms. On examination he is on the 50th centile for height and weight. His abdomen is soft but slightly distended and a non-tender ballotable mass can be felt on the left side. His father has tried lactulose but there has no significant improvement. What is the most appropriate next step in management?
Your Answer: Speak to a local paediatrician
Explanation:The evidence for the history of constipation is not very compelling. It is considered normal for a child to have a bowel movement of normal consistency every other day. However, the crucial aspect of this situation is identifying the abnormal examination finding – a palpable mass accompanied by abdominal distension. While an adult with such a red flag symptom would be expedited, it is more appropriate to consult with a pediatrician to determine the most appropriate referral pathway, which would likely involve a clinic review within the same week.
Wilms’ Tumour: A Common Childhood Malignancy
Wilms’ tumour, also known as nephroblastoma, is a prevalent type of cancer in children, with a median age of diagnosis at 3 years old. It is often associated with Beckwith-Wiedemann syndrome, hemihypertrophy, and a loss-of-function mutation in the WT1 gene on chromosome 11. The most common presenting feature is an abdominal mass, which is usually painless, but other symptoms such as haematuria, flank pain, anorexia, and fever may also occur. In 95% of cases, the tumour is unilateral, and metastases are found in 20% of patients, most commonly in the lungs.
If a child presents with an unexplained enlarged abdominal mass, it is crucial to arrange a paediatric review within 48 hours to rule out Wilms’ tumour. The management of this cancer typically involves nephrectomy, chemotherapy, and radiotherapy if the disease is advanced. Fortunately, the prognosis for Wilms’ tumour is good, with an 80% cure rate.
Histologically, Wilms’ tumour is characterized by epithelial tubules, areas of necrosis, immature glomerular structures, stroma with spindle cells, and small cell blastomatous tissues resembling the metanephric blastema. Overall, early detection and prompt treatment are essential for a successful outcome in children with Wilms’ tumour.
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This question is part of the following fields:
- Children And Young People
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Question 3
Correct
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A 29-year-old woman undergoes antenatal haemoglobinopathy screening and is found to have sickle cell trait. The father of the child agrees to further screening and is found to have the HbAS genotype. What is the probability of their offspring having sickle cell disease?
Your Answer: 25%
Explanation:Understanding Autosomal Recessive Inheritance
Autosomal recessive inheritance is a genetic pattern where a disorder is only expressed when an individual inherits two copies of a mutated gene, one from each parent. This means that only homozygotes, individuals with two copies of the mutated gene, are affected. Both males and females are equally likely to be affected, and the disorder may not manifest in every generation, as it can skip a generation.
When two heterozygote parents, carriers of the mutated gene, have children, there is a 25% chance of having an affected (homozygote) child, a 50% chance of having a carrier (heterozygote) child, and a 25% chance of having an unaffected child. On the other hand, if one parent is homozygote for the gene and the other is unaffected, all the children will be carriers.
Autosomal recessive disorders are often metabolic in nature and are generally more life-threatening compared to autosomal dominant conditions. It is important to understand the inheritance pattern of genetic disorders to provide appropriate genetic counseling and medical management.
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This question is part of the following fields:
- Children And Young People
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Question 4
Correct
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A concerned mother of a toddler attends your clinic seeking advice on how to reduce the risk of accidents in her child.
Which of the following pieces of advice is supported by the best evidence?Your Answer: Avoid soft mattresses
Explanation:Best Evidence for Reducing the Risk of SIDS
Cot death, also known as Sudden Infant Death Syndrome (SIDS), is a rare but devastating occurrence that affects approximately 1 in 1500 babies per year. It is more common in male infants and during the winter months. While there are several risk factors for SIDS, including multiple pregnancies, low birth weight, and lower social class, the best evidence suggests that avoiding prone sleeping is the most effective intervention.
Other interventions that have been suggested to reduce the risk of SIDS include using a dummy (pacifier) and ensuring a smoke-free environment. However, the evidence for these interventions is not as strong as the evidence for avoiding prone sleeping.
It is important for parents and caregivers to be aware of the risk factors for SIDS and to take steps to reduce the risk. By following the best available evidence, we can help to prevent this tragic and heartbreaking event from occurring.
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This question is part of the following fields:
- Children And Young People
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Question 5
Correct
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A 5-year-old girl, who has been wetting the bed at night attends surgery today with her father, as her mother is at work. Her father is worried because it was also an issue for her older sister, who is 10-years-old and she is prescribed desmopressin. The girl in front of you is otherwise well and her bowels open regularly. An examination is unremarkable and she has a soft non-tender abdomen.
What recommendations would you make?Your Answer: Reassurance and general advice
Explanation:Reassurance and advice can be provided to manage nocturnal enuresis in children under the age of 5 years.
Managing Nocturnal Enuresis in Children
Nocturnal enuresis, also known as bedwetting, is a common condition in children. It is defined as the involuntary discharge of urine during sleep in children aged 5 years or older who have not yet achieved continence. There are two types of nocturnal enuresis: primary and secondary. Primary enuresis occurs when a child has never achieved continence, while secondary enuresis occurs when a child has been dry for at least 6 months before.
When managing nocturnal enuresis, it is important to look for possible underlying causes or triggers such as constipation, diabetes mellitus, or recent onset urinary tract infections. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Lifting and waking techniques and reward systems, such as star charts, can also be effective.
The first-line treatment for nocturnal enuresis is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up when they start to wet the bed. If an enuresis alarm is not effective or not acceptable to the family, desmopressin can be used for short-term control, such as for sleepovers. It is important to note that reward systems should be given for agreed behavior rather than dry nights, such as using the toilet to pass urine before sleep. By following these management strategies, children with nocturnal enuresis can achieve continence and improve their quality of life.
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This question is part of the following fields:
- Children And Young People
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Question 6
Correct
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Which genetic condition is a result of a trinucleotide repeat expansion?
Your Answer: Huntington's disease
Explanation:Trinucleotide repeat disorders are genetic conditions that occur due to an abnormal number of repeats of a repetitive sequence of three nucleotides. These expansions are unstable and may enlarge, leading to an earlier age of onset in successive generations, a phenomenon known as anticipation. In most cases, an increase in the severity of symptoms is also observed. It is important to note that these disorders are predominantly neurological in nature. Examples of such disorders include Fragile X, Huntington’s, myotonic dystrophy, Friedreich’s ataxia, spinocerebellar ataxia, spinobulbar muscular atrophy, and dentatorubral pallidoluysian atrophy. It is interesting to note that Friedreich’s ataxia is an exception to the rule and doesn’t demonstrate anticipation.
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This question is part of the following fields:
- Children And Young People
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Question 7
Correct
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A mother brings her 4-year-old child in to receive the DTP booster. Which one of the following would make it inappropriate to give the vaccination today?
Your Answer: Recent onset of a seizure disorder currently being investigated
Explanation:Guidelines for Safe Immunisation
Immunisation is an important aspect of public health, and the Department of Health has published guidelines to ensure its safe administration. The guidelines, titled ‘Immunisation against infectious disease’, outline general contraindications to immunisation, situations where vaccines should be delayed, and specific contraindications to live vaccines.
General contraindications include confirmed anaphylactic reactions to previous doses of a vaccine containing the same antigens or to another component in the relevant vaccine, such as egg protein. Vaccines should also be delayed in cases of febrile illness or intercurrent infection.
Live vaccines should not be administered to pregnant women or individuals with immunosuppression. In the case of the DTP vaccine, vaccination should be deferred in children with an evolving or unstable neurological condition.
However, there are several situations where immunisation is not contraindicated. These include asthma or eczema, a history of seizures (unless associated with fever), being breastfed, a previous history of natural infection with pertussis, measles, mumps, or rubella, a history of neonatal jaundice, a family history of autism, neurological conditions such as Down’s or cerebral palsy, low birth weight or prematurity, and patients on replacement steroids.
Overall, these guidelines aim to ensure the safe administration of vaccines and protect individuals from infectious diseases.
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This question is part of the following fields:
- Children And Young People
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Question 8
Incorrect
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A 7-year-old boy is brought to the clinic by his father. He has a history of asthma and is prescribed salbutamol 100 mcg prn and Clenil (beclomethasone dipropionate) 100 mcg bd via a spacer. Despite the steroid inhaler, he is having to use salbutamol on a daily basis, especially in the morning or after physical activity. Today, his chest examination is normal.
What would be the most suitable course of action for further management?Your Answer: Add a slow release theophylline preparation
Correct Answer: Add a leukotriene receptor antagonist
Explanation:For children between the ages of 5 and 16 who have asthma that is not being controlled by a combination of a short-acting beta agonist (SABA) and a low-dose inhaled corticosteroid (ICS), it is recommended to add a leukotriene receptor antagonist to their asthma management plan.
Managing Asthma in Children: NICE Guidelines
The National Institute for Health and Care Excellence (NICE) released guidelines in 2017 for the management of asthma in children aged 5-16. These guidelines follow a stepwise approach, with treatment options based on the severity of the child’s symptoms. For newly-diagnosed asthma, short-acting beta agonists (SABA) are recommended. If symptoms persist or worsen, a combination of SABA and paediatric low-dose inhaled corticosteroids (ICS) may be used. Leukotriene receptor antagonists (LTRA) and long-acting beta agonists (LABA) may also be added to the treatment plan.
For children under 5 years old, clinical judgement plays a greater role in diagnosis and treatment. The stepwise approach for this age group includes an 8-week trial of paediatric moderate-dose ICS for newly-diagnosed asthma or uncontrolled symptoms. If symptoms persist, a combination of SABA and paediatric low-dose ICS with LTRA may be used. If symptoms still persist, referral to a paediatric asthma specialist is recommended.
It is important to note that NICE doesn’t recommend changing treatment for patients with well-controlled asthma simply to adhere to the latest guidelines. Additionally, maintenance and reliever therapy (MART) may be used for combined ICS and LABA treatment, but only for LABAs with a fast-acting component. The definitions for low, moderate, and high-dose ICS have also changed, with different definitions for children and adults.
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This question is part of the following fields:
- Children And Young People
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Question 9
Incorrect
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A 9-month-old baby presents with a brief history of cough and difficulty breathing. During the examination, the infant has a temperature of 38.6°C and a respiratory rate of 37. The baby appears distressed, and there are widespread crackles and wheezing sounds when listening to the chest. The pulse rate is 170 BPM. What is the most probable diagnosis?
Your Answer: Lower lobe pneumonia
Correct Answer: Bronchiolitis
Explanation:Acute Bronchiolitis in Children
This child is experiencing acute bronchiolitis and needs to be admitted to the hospital for supportive care. Ribavirin may also be necessary. The child is showing clear signs of respiratory distress. The most common cause of acute bronchiolitis is respiratory syncytial virus, but adenoviruses and parainfluenza viruses can also be responsible.
Acute bronchiolitis is a common respiratory illness in young children, especially those under the age of two. It is characterized by inflammation and narrowing of the small airways in the lungs, making it difficult for the child to breathe. Symptoms include coughing, wheezing, and shortness of breath. Treatment typically involves supportive care, such as oxygen therapy and fluids, and may also include antiviral medications like ribavirin.
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This question is part of the following fields:
- Children And Young People
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Question 10
Correct
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An apprehensive mother has called the clinic to report that her family had significant contact with a confirmed case of measles yesterday. Her husband believes he had measles when he was younger, but their three children, aged 6 months, 5 years, and 11 years, have not received the MMR vaccine. You are contemplating administering post-exposure prophylaxis with the MMR vaccine.
What is the minimum age requirement for the MMR vaccine to be effective as post-exposure prophylaxis?Your Answer: 1 month
Explanation:MMR Vaccine Administration Guidelines
The MMR vaccine can be administered at any age, but it is recommended to consult with your local Health Protection Team if the child is under 1 year of age. In case of exposure to measles, mumps, or rubella, most individuals can receive post-exposure prophylaxis with the MMR vaccine within three days, provided that the vaccine is not contraindicated. However, the response to MMR vaccine in infants under 6 months of age is not optimal, and it is not recommended as post-exposure prophylaxis in this age group.
For children under 6 months of age, pregnant women, and immunocompromised individuals, human normal immunoglobulin should be considered if the MMR vaccine cannot be given. It is important to follow the recommended guidelines for MMR vaccine administration to ensure the best protection against these diseases.
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This question is part of the following fields:
- Children And Young People
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Question 11
Correct
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A 7-year-old boy presents with a viral upper respiratory tract infection. On examination, you hear a heart murmur that has not been noted previously.
Which of the following features is most indicative of an innocent murmur?Your Answer: The murmur is short and systolic in nature
Explanation:Understanding Innocent Murmurs in Children
Innocent murmurs are common in children and are usually harmless. They are short in duration, soft, systolic, and typically located at the left sternal border. Innocent murmurs may change with the child’s position or respiration, but they do not usually radiate and are without symptoms in the patient.
It is important to note that a grade 4/6 murmur is loud with a thrill and is usually pathological. Murmurs that are only diastolic in nature or pansystolic in nature are also usually pathological. The presence of abnormal heart sounds is another indication of a pathological murmur.
If an innocent murmur is suspected, it should disappear when the child has recovered from a febrile illness. If the murmur persists when the child is well, further investigation is warranted.
Understanding the characteristics of innocent murmurs can help healthcare professionals differentiate between harmless murmurs and those that require further investigation.
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This question is part of the following fields:
- Children And Young People
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Question 12
Correct
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A 7-month-old infant born in Bangladesh is presented for surgery. The mother reports that the baby has been experiencing coryzal symptoms for the past week and has not been feeding well for the last two days. Today, the baby has started vomiting. The mother is particularly worried about the baby's cough, which comes in bouts and is so severe that the baby turns red. There are no inspiratory or expiratory noises. Upon clinical examination, the baby is found to have a clear chest and no fever. What is the most probable diagnosis?
Your Answer: Pertussis
Explanation:It is rare for patients of this age to exhibit the inspiratory ‘whoop’.
A vaccination programme for pregnant women was introduced in 2012 to combat an outbreak of whooping cough that resulted in the death of 14 newborn children. The vaccine is over 90% effective in preventing newborns from developing whooping cough. The programme was extended in 2014 due to uncertainty about future outbreaks. Pregnant women between 16-32 weeks are offered the vaccine.
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This question is part of the following fields:
- Children And Young People
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Question 13
Incorrect
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You are asked to see a 3-day-old newborn baby who was born by normal vaginal delivery without any complications. The parents report that the baby has suddenly become ill and deteriorated over the last few hours. The child is drowsy and lethargic, has a bulging fontanelle, and a high fever. You suspect meningitis and call for immediate transfer to the hospital.
What is the most probable causative agent for this condition?Your Answer: Escherichia coli
Correct Answer: Group B Streptococcus
Explanation:Newborn Meningitis: Signs, Causes, and Consequences
Sepsis in newborns can cause nonspecific signs of unwellness, such as apnoeic episodes, drowsiness, lethargy, and irritability. However, meningitis in newborns may present differently, with a bulging fontanelle being a late and sometimes absent finding. The most common cause of meningitis in newborns is group B streptococcus (GBS), which is often transmitted vertically during labor and delivery. In some cases, infection may be delayed for up to one month.
Meningitis as a whole has significant morbidity and mortality rates, with a mortality rate of 5-15% in infants. Even those who survive may experience learning difficulties, speech problems, visual impairment, and neural deafness. Recently, NICE has issued guidance on the prehospital care of patients with a clinical diagnosis of meningitis. It is crucial to recognize the signs of meningitis in newborns and seek prompt medical attention to prevent severe consequences.
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This question is part of the following fields:
- Children And Young People
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Question 14
Correct
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Which one of the following statements regarding vaginal problems in adolescents is incorrect?
Your Answer: Vaginal swabs should be taken by the GP to guide treatment
Explanation:Gynaecological Problems in Children: Vulvovaginitis
In children, gynaecological problems are not uncommon, and vulvovaginitis is the most prevalent disorder. This condition is often caused by poor hygiene, tight clothing, lack of labial fat pads protecting the vaginal orifice, and lack of protective acid secretion found in the reproductive years. Bacterial or fungal organisms may be responsible for the infection, and in rare cases, sexual abuse may present as vulvovaginitis. If there is a bloody discharge, it is essential to consider a foreign body.
It is not recommended to perform vaginal examinations or vaginal swabs on children. Instead, referral to a paediatric gynaecologist is appropriate for persistent problems. Most newborn girls have some mucoid white vaginal discharge, which usually disappears by three months of age.
The management of vulvovaginitis includes advising the child about hygiene, using soothing creams, and applying topical antibiotics or antifungals. In resistant cases, oestrogen cream may be necessary. It is crucial to seek medical attention if the symptoms persist or worsen.
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This question is part of the following fields:
- Children And Young People
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Question 15
Correct
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An anxious mother has called the clinic because she suspects that her unimmunised 4-year-old has measles. The child has been feeling unwell for a few days and has now developed a red rash. The mother is worried about the likelihood of measles. Typically, where does the rash begin with measles?
Your Answer: Head and neck
Explanation:Understanding Measles
Measles is a highly contagious disease that is characterized by a rash with maculopapular lesions. The onset of the disease is marked by a prodromal phase, which includes symptoms such as fever, malaise, loss of appetite, cough, rhinorrhea, and conjunctivitis. This phase typically lasts for one to four days before the rash appears.
The rash usually starts on the head and then spreads to the trunk and extremities over a few days. The fever usually subsides once the rash appears. The rash itself lasts for at least three days and then fades in the order of appearance. In some cases, it can leave behind a brownish discoloration and may become confluent over the buttocks.
It is important to note that measles is a serious disease that can lead to complications such as pneumonia, encephalitis, and even death. Vaccination is the best way to prevent measles and its complications.
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This question is part of the following fields:
- Children And Young People
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Question 16
Correct
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Jane, age 14, comes to morning surgery requesting the contraceptive pill. She looks a lot older than her age. You have to decide whether to prescribe or not.
The Sexual Offences Act 2003 considers children under what age as too young to give consent to sexual activity?Your Answer: Under 13 years
Explanation:Child Protection and Sexual Offences
The Sexual Offences Act 2003 states that children under the age of 13 are not capable of giving consent to sexual activity. Any sexual offence involving a child under 13 should be treated with utmost seriousness. Health professionals should consider referring such cases to social services under the Child Protection Procedures. It is advisable to seek advice from designated child protection professionals in the first instance.
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This question is part of the following fields:
- Children And Young People
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Question 17
Correct
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A 15-year-old girl came to the clinic with her older sister, complaining of foul-smelling vaginal discharge. Upon taking a detailed medical history, it was revealed that the discharge started three weeks ago, after she returned from a trip to Sudan where she had a celebration to mark her transition into womanhood. Initially hesitant to undergo a vaginal examination, she eventually agreed after her sister's persuasion. During the examination, you observe indications that suggest female genital mutilation (FGM). You discover that she has a younger sister at home. What would be the most appropriate next step to take?
Your Answer: Call the police to make a report, refer all children urgently to social services and treat the infection
Explanation:If you come across a case of Female Genital Mutilation (FGM) in a female under the age of 18, it is important to report it to the police immediately. FGM is considered a form of child abuse and violence, and is illegal in England and Wales. This can be reported either by the child themselves or through physical examination.
It is crucial to take action as doing nothing is not an option when it comes to child abuse and the safety of other children. A safeguarding alert alone is not sufficient, as there is a mandatory reporting duty for healthcare professionals who encounter a confirmed case of FGM.
There is no need to contact the parents for further information as physical evidence has already been observed. It is also not appropriate to advise the child to call the police, as they are vulnerable and it is the duty of healthcare professionals to provide assistance.
Understanding Female Genital Mutilation
Female genital mutilation (FGM) is a practice that involves the partial or total removal of the external female genitalia or other forms of injury to the female genital organs for non-medical reasons. This practice is classified into four types by the World Health Organization (WHO). Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while Type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.
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This question is part of the following fields:
- Children And Young People
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Question 18
Incorrect
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Johnny is an 8-year-old boy who presents with a mild fever, rash on the hands and feet, and oral ulcers. You inform his parents that he is likely suffering from hand, foot & mouth disease. They inquire about how long he should stay home from school?
Your Answer: Keep out of school until 48 hours after symptoms resolve
Correct Answer: No restriction
Explanation:Children with hand, foot and mouth disease do not need to be excluded from childcare or school.
Hand, Foot and Mouth Disease: A Contagious Condition in Children
Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.
The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.
Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.
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This question is part of the following fields:
- Children And Young People
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Question 19
Correct
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A 6-year-old girl presents with a rash and joint pain. The rash has developed over the past few days, with the joint pain starting today. She also reports intermittent abdominal pain that has been occurring since before the rash appeared. On examination, she is afebrile with a blood pressure of 110/70 mmHg. There is a symmetrical purpuric rash over the extensor surfaces of her arms and legs and over her buttocks, while her trunk is unaffected. The child complains of pain in her knees and ankles, which appear slightly swollen. Her abdomen is soft with mild periumbilical tenderness on palpation. Which test would be most helpful in guiding further management of this patient?
Your Answer: Urine dipstick
Explanation:Henoch-Schonlein Purpura (HSP)
Henoch-Schonlein purpura (HSP) is a vasculitic condition that commonly affects children between the ages of 3 and 10. The core clinical features of HSP include a characteristic skin rash, joint pain, periarticular oedema, renal involvement, and abdominal pain. Renal involvement can lead to hypertension, haematuria, and proteinuria, which can result in nephrotic and nephritic syndromes. Therefore, urine dipstick testing is crucial in aiding the clinical diagnosis and guiding management and follow-up. Regular follow-up is necessary in the convalescent period as HSP can lead to chronic renal problems in some patients. PatientPlus provides HSP guidelines that offer a comprehensive overview of the clinical features, patient assessment, and management.
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This question is part of the following fields:
- Children And Young People
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Question 20
Correct
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Sophie is a 2-year-old girl who is brought in by her father. She has had a fever overnight, along with a sore throat and cough. Her father is worried that she seems more tired than usual today. During the examination, you note the following:
Temperature 38.5 degrees
Heart rate 160 bpm
Respiratory rate 40 / min
Oxygen saturation 95%
The lungs are clear, but there is inflammation and redness in the throat, and there are swollen lymph nodes in the neck.
According to the NICE traffic light system for assessing fever in children, which of the following is considered 'amber'?Your Answer: Heart rate 155 bpm
Explanation:The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013 to provide a ‘traffic light’ system for assessing the risk of febrile illness in children under 5 years old. The guidelines recommend recording the child’s temperature, heart rate, respiratory rate, and capillary refill time, as well as looking for signs of dehydration. Measuring temperature should be done with an electronic thermometer in the axilla for children under 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer. The risk stratification table categorizes children as green (low risk), amber (intermediate risk), or red (high risk) based on their symptoms. Management recommendations vary depending on the risk level, with green children managed at home, amber children provided with a safety net or referred to a specialist, and red children urgently referred to a specialist. The guidelines also advise against prescribing oral antibiotics without an apparent source of fever and note that a chest x-ray is not necessary if a child with suspected pneumonia is not being referred to the hospital.
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This question is part of the following fields:
- Children And Young People
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Question 21
Correct
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You are requested by the practice nurse to assess a mother who has brought in her 12-week-old baby who appears unwell. The mother is concerned because the baby seems to have a fever.
Upon examination, you observe that the baby has an upper respiratory tract infection. The family members have recently had a cold. Although the baby is pyrexial at 37.8°C, you cannot detect any indications of lower respiratory tract infection.
What is the appropriate course of action for managing this baby?Your Answer: The mother should be advised to give the child paracetamol for as long as it appears distressed
Explanation:Fever Management in Children
A fever over 38°C is an indication for admission. However, antipyretics should only be administered if the child appears distressed by the fever, rather than for the sole aim of reducing body temperature. It is important to note that antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. When using paracetamol or ibuprofen in children with fever, it is recommended to continue only as long as the child appears distressed and to consider changing to the other agent if the distress is not alleviated. It is not recommended to give both agents simultaneously, and only consider alternating these agents if the distress persists or recurs before the next dose is due.
In most cases, fever of this nature is viral in origin, and specific antibacterial intervention is not required. Cold sponging is also not effective in reducing fever. It is important to note that while a significant percentage of children suffer from febrile fits, these do not usually predispose the patient to the development of epilepsy later. The risk is very small, one to two in one hundred in the general population and one in fifty for the febrile convulsion group. Proper management of fever in children is crucial to ensure their well-being and prevent any unnecessary complications.
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This question is part of the following fields:
- Children And Young People
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Question 22
Correct
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You come across a pair of patients who are both under your care and are interested in starting a family. They are worried because their niece has Fragile X syndrome (FXS). They require additional details about it and would like a recommendation to a geneticist.
What is the characteristic linked with Fragile X syndrome?Your Answer: Macroorchidism
Explanation:Macroorchidism is a common feature of Fragile X syndrome, which also presents with delayed developmental milestones and learning difficulties (typically with an IQ less than 70). Physical characteristics include a high forehead, facial asymmetry, a large jaw, and long ears. Diagnosis is often made by age 3 due to developmental delays. Life-threatening cardiovascular issues and full lips are not associated with FXS, but are seen in William’s syndrome. Down’s syndrome is characterized by decreased muscle tone and hypothyroidism.
Fragile X Syndrome: A Genetic Disorder
Fragile X syndrome is a genetic disorder caused by a trinucleotide repeat. It affects males more severely than females, with symptoms including learning difficulties, large low set ears, a long thin face, high arched palate, macroorchidism, hypotonia, and a higher likelihood of autism. Mitral valve prolapse is also common in males with this syndrome. Females who have one fragile chromosome and one normal X chromosome may have a range of symptoms from normal to mild.
Diagnosis of fragile X syndrome can be made antenatally through chorionic villus sampling or amniocentesis. Analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot analysis is also used to diagnose this disorder. Proper diagnosis and management can help individuals with fragile X syndrome lead fulfilling lives.
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This question is part of the following fields:
- Children And Young People
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Question 23
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A father brings his 15-month-old daughter into surgery. Since yesterday she seems to be straining whilst passing stools. He describes her screaming, appearing to be in pain and pulling her knees up towards her chest. These episodes are now occurring every 15-20 minutes. This morning he noted a small amount of blood in her nappy. She is taking around 50% of her normal feeds and vomiting 'green fluid' every hour. On examination, she appears irritable and lethargic but is well hydrated and apyrexial. On examination, her abdomen seems distended but no discrete mass is found.
What is the most likely diagnosis?Your Answer: Intussusception
Explanation:Understanding Intussusception
Intussusception is a medical condition where one part of the bowel folds into the lumen of the adjacent bowel, usually around the ileocecal region. This condition is most common in infants between 6-18 months old, with boys being affected twice as often as girls. Symptoms of intussusception include severe, crampy abdominal pain, inconsolable crying, vomiting, and bloodstained stool, which is a late sign. During a paroxysm, the infant will draw their knees up and turn pale, and a sausage-shaped mass may be felt in the right upper quadrant.
To diagnose intussusception, ultrasound is now the preferred method of investigation, which may show a target-like mass. Treatment for intussusception involves reducing the bowel by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema. If this method fails, or the child has signs of peritonitis, surgery is performed. Understanding the symptoms and treatment options for intussusception is crucial for parents and healthcare professionals to ensure prompt and effective management of this condition.
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This question is part of the following fields:
- Children And Young People
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Question 24
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Which one of the following statements regarding Chickenpox in adults is incorrect?
Your Answer: Children are infectious once rash begins until all lesions have scabbed over
Explanation:Chickenpox is a viral infection caused by the varicella zoster virus. It is highly contagious and can be spread through respiratory droplets. The virus can also reactivate later in life and cause shingles. Chickenpox is most infectious from four days before the rash appears until five days after. The incubation period is typically 10-21 days. Symptoms include fever and an itchy rash that starts on the head and trunk before spreading. The rash goes through stages of macular, papular, and vesicular. Management is supportive, with measures such as keeping cool and using calamine lotion. Immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin. Complications can include secondary bacterial infection of the lesions, pneumonia, encephalitis, and rare complications such as disseminated haemorrhagic Chickenpox.
One common complication of Chickenpox is secondary bacterial infection of the lesions, which can be increased by the use of NSAIDs. This can manifest as a single infected lesion or small area of cellulitis. In rare cases, invasive group A streptococcal soft tissue infections may occur, resulting in necrotizing fasciitis. Other rare complications of Chickenpox include pneumonia, encephalitis (which may involve the cerebellum), disseminated haemorrhagic Chickenpox, and very rarely, arthritis, nephritis, and pancreatitis. It is important to note that school exclusion may be necessary, as Chickenpox is highly infectious and can be caught from someone with shingles. It is advised to avoid contact with others until all lesions have crusted over.
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This question is part of the following fields:
- Children And Young People
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Question 25
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A toddler has had a seizure. He has been unwell for a few hours and has a temperature of 38.2°C. There are no concerning features in his previous medical history.
Which of the following is most compatible with a diagnosis of ‘simple febrile seizure’?Your Answer: Age of child 18 months
Explanation:Febrile seizures are most common in children between 6 months and 6 years old, with the highest incidence at 18 months. They are associated with fever and affect 2-4% of European children. While tonic-clonic movements are typical during febrile seizures, complex febrile seizures may present with focal or myoclonic features. If a seizure lasts longer than 15 minutes, it is considered complex and may require hospitalization. Signs of meningeal irritation, such as neck stiffness and Kernig’s sign, suggest a possible CNS infection and require further evaluation. Recurrence of seizures within 24 hours or during the same illness may indicate a complex febrile seizure.
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This question is part of the following fields:
- Children And Young People
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Question 26
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A 7-year-old girl is brought in by her worried parent who has observed a significant space between her ankles and is anxious as her knees seem to be close together while standing. The parent mentions that the girl has a balanced diet and gets enough exposure to sunlight and is healthy otherwise.
What would be the most suitable course of action to manage this situation?Your Answer: Reassure the parent that knock knees are a usual variant and usually resolve by the age of 8 years
Explanation:Genu valgum, commonly known as knock knees, is a typical condition that typically resolves on its own by the age of 8 years. As such, there is no need to refer the patient to an orthopaedic clinic or provide specific physiotherapy. Supportive shoes or leg braces are not recommended.
Common Variations in Lower Limb Development in Children
Parents may become concerned when they notice what appears to be abnormalities in their child’s lower limbs. This often leads to a visit to the primary care physician and a referral to a specialist. However, many of these variations are actually normal and will resolve on their own as the child grows.
One common variation is flat feet, where the medial arch is absent when the child is standing. This is typically seen in children of all ages and usually resolves between the ages of 4-8 years. Orthotics are not recommended, and parental reassurance is appropriate.
Another variation is in-toeing, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. In most cases, these will resolve on their own, but severe or persistent cases may require intervention such as serial casting or surgical intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.
Bow legs, or genu varum, are typically seen in the first or second year of life and are characterized by an increased intercondylar distance. This variation usually resolves by the age of 4-5 years. Knock knees, or genu valgum, are seen in the third or fourth year of life and are characterized by an increased intermalleolar distance. This variation also typically resolves on its own.
In summary, many variations in lower limb development in children are normal and will resolve on their own. However, if there is concern or persistent symptoms, intervention may be appropriate.
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This question is part of the following fields:
- Children And Young People
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Question 27
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What is the suggested amount of prednisolone for kids aged 3-17 years who experience a worsening of their asthma symptoms?
Your Answer: 1-2 mg/kg od for 3-5 days
Explanation:For the treatment of asthma in children, the recommended dose of prednisolone is 1-2 mg/kg once daily for a period of 3-5 days.
The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.
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This question is part of the following fields:
- Children And Young People
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Question 28
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A 16-year-old male with a history of cystic fibrosis comes for his yearly check-up. What is the most suitable recommendation for his diet?
Your Answer: High calorie and high fat with pancreatic enzyme supplementation for every meal
Explanation:Managing Cystic Fibrosis: A Multidisciplinary Approach
Cystic fibrosis (CF) is a chronic condition that requires a multidisciplinary approach to management. Regular chest physiotherapy and postural drainage, as well as deep breathing exercises, are essential to maintain lung function and prevent complications. Parents are usually taught how to perform these techniques. A high-calorie diet, including high-fat intake, is recommended to meet the increased energy needs of patients with CF. Vitamin supplementation and pancreatic enzyme supplements taken with meals are also important.
Patients with CF should try to minimize contact with each other to prevent cross-infection with Burkholderia cepacia complex and Pseudomonas aeruginosa. Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation. In cases where lung transplantation is necessary, careful consideration is required to ensure the best possible outcome.
Lumacaftor/Ivacaftor (Orkambi) is a medication used to treat CF patients who are homozygous for the delta F508 mutation. Lumacaftor increases the number of CFTR proteins that are transported to the cell surface, while ivacaftor is a potentiator of CFTR that is already at the cell surface. This combination increases the probability that the defective channel will be open and allow chloride ions to pass through the channel pore.
In summary, managing cystic fibrosis requires a comprehensive approach that involves a range of healthcare professionals. Regular chest physiotherapy, a high-calorie diet, and vitamin and enzyme supplementation are essential components of CF management. Patients with CF should also take steps to minimize contact with others with the condition to prevent cross-infection. Finally, the use of medications such as Lumacaftor/Ivacaftor can help improve outcomes for patients with CF.
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This question is part of the following fields:
- Children And Young People
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Question 29
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You are working in a Saturday morning clinic and a mother brings in her 10-year-old daughter who has developed new pustular, honey-coloured crusted lesions over her chin. She is otherwise healthy with normal vital signs and no evidence of lymphadenopathy on examination. She has no known allergies to any medications and is usually in good health.
You diagnose localised non-bullous impetigo.
The daughter is scheduled to go on a field trip to the zoo the next day and is very excited about it. The mother asks if it is safe for her daughter to go on the field trip.
What is your plan for managing this situation?Your Answer: Prescribe topical hydrogen peroxide 1% cream and advise them that the child should be excluded from school until the lesions are crusted and healed
Explanation:Referral or admission is not necessary for this straightforward primary care case, even if there is suspicion or confirmation of fusidic acid resistance. However, prescribing topical antibiotics is an option. It is important to advise the patient that he cannot attend school or go on his school trip until 48 hours after starting antibiotic treatment or until the lesions have crusted and healed.
The Health Protection Agency has provided guidance on when children should be excluded from school due to infectious conditions. Some conditions, such as conjunctivitis, fifth disease, roseola, infectious mononucleosis, head lice, threadworms, and hand, foot and mouth, do not require exclusion. Scarlet fever requires exclusion for 24 hours after commencing antibiotics, while whooping cough requires exclusion for 2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are taken. Measles requires exclusion for 4 days from onset of rash, rubella for 5 days from onset of rash, and Chickenpox until all lesions are crusted over. Mumps requires exclusion for 5 days from onset of swollen glands, while diarrhoea and vomiting require exclusion until symptoms have settled for 48 hours. Impetigo requires exclusion until lesions are crusted and healed, or for 48 hours after commencing antibiotic treatment, and scabies requires exclusion until treated. influenza requires exclusion until the child has recovered for 48 hours.
Regarding Chickenpox, Public Health England recommends that children should be excluded until all lesions are crusted over, while Clinical Knowledge Summaries suggest that infectivity continues until all lesions are dry and have crusted over, usually about 5 days after the onset of the rash. It is important to follow official guidance and consult with healthcare professionals if unsure about exclusion periods for infectious conditions.
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This question is part of the following fields:
- Children And Young People
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Question 30
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A 25-year-old nanny, Sarah, cares for 5 different children during the week. What is a concerning sign to look out for in one of her charges?
Your Answer: Sarah aged 10 months preferentially uses her right hand to pick up toys
Explanation:Red flags in child development serve as warning signs that can indicate a possible developmental delay. The following table outlines some common red flags to look out for:
Age Red Flags
Birth-3 months Consistent clenching of fists before 3 months of age, rolling over before 3 months
4-6 months Lack of smiling by 10 weeks, failure to reach for objects by 5 months
6-12 months Persistence of primitive reflexes after 6 months
12-24 months Demonstrating hand dominance before 12 months may be a red flag for hemiparesis, inability to walk independently by 18 months, and difficulty using a spoon, which typically develops between 12-15 months.Common Developmental Problems and Their Causes
Developmental problems can manifest in various ways, including referral points, fine motor skill problems, gross motor problems, and speech and language problems. Referral points may include a lack of smiling at 10 weeks, inability to sit unsupported at 12 months, and inability to walk at 18 months. Fine motor skill problems may be indicated by abnormal hand preference before 12 months, which could be a sign of cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, but other causes may include environmental deprivation and general developmental delay. It is important to identify and address these developmental problems early on to ensure the best possible outcomes for the child’s future.
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This question is part of the following fields:
- Children And Young People
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