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  • Question 1 - A 6-year-old girl walks with a limp due to right hip pain, which...

    Incorrect

    • A 6-year-old girl walks with a limp due to right hip pain, which is relieved by rest and made worse by walking or standing. Her vital signs are normal. The Trendelenburg sign presents when she stands on her right leg.
      X-rays reveal periarticular right hip swelling in soft tissue. A bone scan reveals reduced activity in the anterolateral right capital femoral epiphysis.
      What is the most likely diagnosis?

      Your Answer: Epiphyseal dysplasia

      Correct Answer: Legg-Calvé-Perthes disease

      Explanation:

      Understanding Legg-Calvé-Perthes Disease and Differential Diagnoses

      Legg–Calvé–Perthes disease is a condition that occurs due to vascular compromise of the capital epiphysis of the femur. The exact cause of this self-limiting disease is unclear, but it may be related to developmental changes in the hip’s blood supply. The compromised blood flow leads to ischaemic necrosis of the epiphysis. The retinacular arteries and their branches are the primary source of blood to the head of the femur, especially between the ages of 4 and 9 when the epiphyseal plate is forming. During this time, the incidence of Legg-Calvé-Perthes disease is highest.

      Differential diagnoses for this condition include a slipped capital femoral epiphysis, septic arthritis, and epiphyseal dysplasia. A slipped capital femoral epiphysis would be visible on hip radiography, which is not the case in this scenario. Septic arthritis would cause systemic inflammatory responses, which are not present in this case. Epiphyseal dysplasia is a congenital defect that would typically present when the child starts to walk.

      In addition to Legg-Calvé-Perthes disease, there is radiological evidence of synovitis and hip joint effusion in this scenario. However, synovitis is a non-specific sign and not a specific diagnosis. Understanding these differential diagnoses can help healthcare professionals provide accurate diagnoses and appropriate treatment plans for patients with hip joint issues.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 2 - Which one of the following is not included in the Apgar score for...

    Incorrect

    • Which one of the following is not included in the Apgar score for evaluating a neonate?

      Your Answer: Tone

      Correct Answer: Capillary refill time

      Explanation:

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

    • This question is part of the following fields:

      • Paediatrics
      67.9
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  • Question 3 - A 5-year-old boy is brought to the emergency department with a fever, sore...

    Incorrect

    • 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: Cricothyroidotomy

      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.

    • This question is part of the following fields:

      • Paediatrics
      118
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  • Question 4 - A 3-month-old boy is brought to the emergency department by his mother. She...

    Incorrect

    • A 3-month-old boy is brought to the emergency department by his mother. She reports a 3 hour history of a non-blanching rash all over his body. She also mentions that he has been more fussy than usual and has been refusing to eat.
      Upon examination, the baby has a temperature of 38.9ºC and a non-blanching petechial rash with overall hypotonia. The anterior fontanelle is also bulging.
      Based on the likely diagnosis and appropriate investigation, what would be the most suitable initial management option?

      Your Answer: IV amoxicillin and IV dexamethasone

      Correct Answer: IV cefotaxime and IV amoxicillin

      Explanation:

      When dealing with suspected or confirmed bacterial meningitis in children under 3 months old, it is not recommended to use corticosteroids. Instead, the most appropriate treatment option would be a combination of IV cefotaxime and IV amoxicillin. IV cefotaxime is effective in covering for pneumococcal and haemophilus influenzae, but since children under 3 months are at risk of listeria monocytogenes as a cause of bacterial meningitis, amoxicillin is necessary to provide adequate coverage. It is important to note that IV dexamethasone is typically given to patients with bacterial meningitis to reduce the risk of neurological complications, but this is not recommended for children under 3 months old.

      Investigation and Management of Meningitis in Children

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

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

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

    • This question is part of the following fields:

      • Paediatrics
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  • Question 5 - An 18-year-old girl visits her GP with worries about not having started her...

    Correct

    • An 18-year-old girl visits her GP with worries about not having started her menstrual cycle yet. Apart from that, she feels healthy. During the examination, she appears to be of average height and has developed breasts, but has minimal pubic hair growth. The doctor can feel two lumps in her groin area upon examination of her abdomen. Her external genitalia seem normal. What is the probable diagnosis?

      Your Answer: Androgen insensitivity syndrome

      Explanation:

      The patient’s presentation is consistent with androgen insensitivity, which is a genetic condition where individuals with XY chromosomes have female physical characteristics due to a lack of testosterone receptors in their tissues. This disorder is X-linked and often results in undescended testes. Congenital adrenal hyperplasia is unlikely as it typically causes early puberty and virilization, while Kallmann syndrome does not explain the presence of groin masses. Polycystic ovarian syndrome usually results in secondary amenorrhea or oligomenorrhea and is accompanied by other symptoms such as acne and hirsutism. Turner’s syndrome, which causes primary amenorrhea, is characterized by short stature, webbed neck, heart defects, and abnormal breast development, and does not involve undescended testes.

      Disorders of sex hormones can have various effects on the body, as shown in the table below. Primary hypogonadism, also known as Klinefelter’s syndrome, is characterized by high levels of LH and low levels of testosterone. Patients with this disorder often have small, firm testes, lack secondary sexual characteristics, and are infertile. They may also experience gynaecomastia and have an increased risk of breast cancer. Diagnosis is made through chromosomal analysis.

      Hypogonadotrophic hypogonadism, or Kallmann syndrome, is another cause of delayed puberty. It is typically inherited as an X-linked recessive trait and is caused by the failure of GnRH-secreting neurons to migrate to the hypothalamus. Patients with Kallmann syndrome may have hypogonadism, cryptorchidism, and anosmia. Sex hormone levels are low, and LH and FSH levels are inappropriately low or normal. Cleft lip/palate and visual/hearing defects may also be present.

      Androgen insensitivity syndrome is an X-linked recessive condition that causes end-organ resistance to testosterone, resulting in genotypically male children (46XY) having a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome. Patients with this disorder may experience primary amenorrhoea, undescended testes causing groin swellings, and breast development due to the conversion of testosterone to oestradiol. Diagnosis is made through a buccal smear or chromosomal analysis to reveal a 46XY genotype. Management includes counseling to raise the child as female, bilateral orchidectomy due to an increased risk of testicular cancer from undescended testes, and oestrogen therapy.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 6 - A 5-year-old girl is brought in by ambulance. Her parents explain that she...

    Incorrect

    • A 5-year-old girl is brought in by ambulance. Her parents explain that she has had cold symptoms for the last 24 hours but is generally well. They describe her walking towards them in the park when she suddenly went floppy and all four limbs started shaking. This lasted for around 1 minute, during which time she did not respond to her name and her eyes were rolled back. She remained drowsy for the next 30 minutes or so in the ambulance but is now well, alert and active, moving all limbs normally.
      What is the most likely diagnosis?

      Your Answer: Epilepsy

      Correct Answer: Febrile convulsion

      Explanation:

      Differential diagnosis of a seizure in a young child

      Febrile convulsion, reflex anoxic seizure, meningitis, epilepsy, and hypoglycaemia are among the possible causes of a seizure in a young child. Febrile convulsions are the most common type of seizure in this age group, occurring during a febrile illness and lasting less than 15 minutes. They are usually benign and do not require long-term treatment, but there is a risk of recurrence and a small risk of developing epilepsy later in life. Reflex anoxic seizures are syncopal episodes triggered by a minor head injury, resulting in a brief loss of consciousness and some convulsive activity. Meningitis is a serious infection of the central nervous system that presents with fever, headache, neck stiffness, and a non-blanching rash. Epilepsy is a chronic neurological disorder characterized by recurrent seizures, but it cannot be diagnosed based on a single episode. Hypoglycaemia is a metabolic condition that can cause seizures in diabetic patients, typically accompanied by symptoms like sweating, shakiness, tachycardia, nausea, and vomiting. A careful history, physical examination, and laboratory tests can help differentiate these conditions and guide appropriate management.

    • This question is part of the following fields:

      • Paediatrics
      117.2
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  • Question 7 - A 2-year-old child is brought in for a routine check-up, with concerns from...

    Incorrect

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

      Your Answer: Pulmonary stenosis

      Correct Answer: Atrial septal defect

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Paediatrics
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  • Question 8 - What is the typical distribution of atopic eczema in a 12-month-old child? ...

    Incorrect

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

      Your Answer: Scalp and arms

      Correct Answer: Face and trunk

      Explanation:

      Eczema in Children: Symptoms and Management

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

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

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

    • This question is part of the following fields:

      • Paediatrics
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  • Question 9 - When do most infants begin to smile? ...

    Incorrect

    • When do most infants begin to smile?

      Your Answer: 4 months

      Correct Answer: 6 weeks

      Explanation:

      The table summarizes developmental milestones for social behavior, feeding, dressing, and play. Milestones include smiling at 6 weeks, using a spoon and cup at 12-15 months, and playing with other children at 4 years.

    • This question is part of the following fields:

      • Paediatrics
      260
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  • Question 10 - A 2-day-old baby has her heel prick test done, and it comes back...

    Incorrect

    • A 2-day-old baby has her heel prick test done, and it comes back that she has a raised level of immunoreactive trypsinogen (IRT).
      What is the most suitable subsequent test for this infant?

      Your Answer: Blood film

      Correct Answer: Sweat test

      Explanation:

      At day 5 of life, newborns undergo a heel prick test to check for various metabolic diseases including cystic fibrosis (CF), sickle cell disease, and congenital hypothyroidism. A positive result for CF is indicated by elevated levels of immunoreactive trypsinogen (IRT) and requires a sweat test to confirm the diagnosis. If the sweat test is also positive, the baby is diagnosed with CF.

      Diagnosis of Cystic Fibrosis through Sweat Test

      Cystic fibrosis (CF) is a genetic disorder that affects the respiratory, digestive, and reproductive systems. One of the most reliable ways to diagnose CF is through a sweat test. This test measures the amount of chloride in a patient’s sweat, which is abnormally high in those with CF. A normal value is less than 40 mEq/l, while a value greater than 60 mEq/l indicates CF.

      However, there are some causes of false positive results, such as malnutrition, adrenal insufficiency, glycogen storage diseases, nephrogenic diabetes insipidus, hypothyroidism, hypoparathyroidism, G6PD, and ectodermal dysplasia. On the other hand, false negative results can occur due to skin edema, which is often caused by hypoalbuminemia or hypoproteinemia resulting from pancreatic exocrine insufficiency.

      In conclusion, the sweat test is a reliable method for diagnosing CF, but it is important to consider the potential causes of false positive and false negative results. Proper interpretation of the test results can help ensure accurate diagnosis and appropriate treatment for patients with CF.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 11 - A 6-year-old boy visits his GP with a productive cough and wheeze. During...

    Incorrect

    • A 6-year-old boy visits his GP with a productive cough and wheeze. During the examination, a 1/6 intensity systolic murmur is detected in the second intercostal space lateral to the left sternal edge. The murmur is not audible when the child lies flat. What is the most probable diagnosis?

      Your Answer: Pulmonary stenosis

      Correct Answer: Innocent murmur

      Explanation:

      The innocent murmur is the correct answer. It is characterized by being soft, systolic, short, symptomless, and varying with position when standing or sitting. In contrast, coarctation of the aorta produces an ejection systolic murmur that can be heard through to the back and does not change with position. This condition is also associated with hypertension in the upper extremities and a difference in blood pressure between the arms and legs. Ventricular septal defect presents as a pansystolic murmur, while atrial septal defect is an ejection systolic murmur that is often accompanied by fixed splitting of the 2nd heart sound.

      Innocent murmurs are common in children and are usually harmless. There are different types of innocent murmurs, including ejection murmurs, venous hums, and Still’s murmur. Ejection murmurs are caused by turbulent blood flow at the outflow tract of the heart, while venous hums are due to turbulent blood flow in the great veins returning to the heart. Still’s murmur is a low-pitched sound heard at the lower left sternal edge.

      An innocent ejection murmur is characterized by a soft-blowing murmur in the pulmonary area or a short buzzing murmur in the aortic area. It may vary with posture and is localized without radiation. There is no diastolic component, no thrill, and no added sounds such as clicks. The child is usually asymptomatic, and there are no other abnormalities.

      Overall, innocent murmurs are not a cause for concern and do not require treatment. However, if a child has symptoms such as chest pain, shortness of breath, or fainting, further evaluation may be necessary to rule out any underlying heart conditions.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 12 - A 5-year-old girl is brought to the GP by her mother for an...

    Incorrect

    • A 5-year-old girl is brought to the GP by her mother for an asthma review. She was diagnosed with asthma eight months ago. Since then, she has been using a low-dose clenil (beclomethasone 100 μg BD) inhaler and salbutamol inhaler as needed, both inhaled via a spacer. She has been experiencing a nocturnal cough and has been using her salbutamol inhaler 3–4 times per day due to the cold weather, with good results. On examination, there are no signs of respiratory distress, her oxygen saturation is 98%, and her chest is clear.
      What would be the next step in managing this patient?

      Your Answer: Refer to paediatrician

      Correct Answer: Add montelukast

      Explanation:

      Treatment Approach for Suspected Asthma in Children Under Five Years Old

      When a child under five years old is suspected to have asthma, the diagnosis can be challenging as they cannot perform objective lung function tests. Therefore, a low threshold for referral is recommended if treatment fails to control symptoms.

      The first step in treatment is a trial of a moderate-dose inhaled corticosteroid (ICS) for eight weeks. If symptoms persist, adding a leukotriene receptor antagonist (LTRA) is recommended. However, if the asthma is still poorly controlled, referral to a paediatrician is advised.

      It is not appropriate to change the short-acting beta agonist (SABA) inhaler, but increasing the dose of the ICS should only be done under specialist advice. If the child needs to use a SABA inhaler regularly, the ICS should be stopped for four weeks, and if symptoms recur, the inhaler should be restarted at a low dose.

      In summary, a stepwise approach is recommended for treating suspected asthma in children under five years old, with a low threshold for referral to a specialist if treatment fails to control symptoms.

      Treatment Approach for Suspected Asthma in Children Under Five Years Old

    • This question is part of the following fields:

      • Paediatrics
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  • Question 13 - A 36-month-old girl is brought to the paediatric clinic. She is an orphaned...

    Incorrect

    • A 36-month-old girl is brought to the paediatric clinic. She is an orphaned refugee who recently arrived in the United Kingdom and has no medical history.

      Her foster parents have brought her to the clinic as they have noticed that she becomes easily breathless on exertion or after a bath and squats down to catch her breath. During these times, they notice that her lips turn blue.

      Upon examination, you find that she is on the 10th centile for height and weight, her lips are slightly dusky, she has good air entry bilaterally in her chest, and she has a normal heart rate at rest with a loud ejection systolic murmur at the upper left sternal edge with an associated thrill.

      A chest x-ray reveals decreased vascular markings and a normal-sized heart. Electrocardiography (ECG) shows sinus rhythm with right axis deviation and deep S waves in V5 and V6.

      What is the most likely diagnosis?

      Your Answer: Ventricular septal defect

      Correct Answer: Tetralogy of Fallot

      Explanation:

      Tetralogy of Fallot (TOF) is a common cyanotic congenital heart condition characterized by four abnormalities. Symptoms are determined by the degree of shunting of deoxygenated blood from right to left, which is influenced by the degree of right ventricular outflow tract obstruction (RVOTO) and other ways blood can get to the lungs. Squatting can relieve cyanotic episodes by increasing peripheral vascular resistance. The child in question has a loud ejection systolic murmur at the upper left sternal edge in keeping with the turbulent flow of blood across the stenosed RVOT. Isolated pulmonary stenosis is a possible differential diagnosis, but the history of squatting is highly suggestive of TOF.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 14 - As a paediatrician, you are reviewing a 1-month-old who was delivered at 39+2...

    Correct

    • As a paediatrician, you are reviewing a 1-month-old who was delivered at 39+2 weeks vaginally and without any complications. The parents of the child have a concern that their child might have achondroplasia as the child's father has been diagnosed with this condition. Apart from measuring the child's length, what other physical characteristic should you look for to determine if the child has achondroplasia?

      Your Answer: Trident hand deformity

      Explanation:

      Identifying physical features of congenital conditions is crucial for exam purposes and diagnosis. One such feature of achondroplasia is trident hands, characterized by short, stubby fingers with a gap between the middle and ring fingers. Other physical features include short limbs (rhizomelia), lumbar lordosis, and midface hypoplasia. Fragile X syndrome is associated with low set ears, while Down’s syndrome is characterized by saddle-gap deformity and a single palmar crease. It is important to note that achondroplasia is characterized by macrocephaly with frontal bossing, not microcephaly.

      Understanding Achondroplasia

      Achondroplasia is a genetic disorder that is inherited in an autosomal dominant manner. It is caused by a mutation in the fibroblast growth factor receptor 3 (FGFR-3) gene, which leads to abnormal cartilage development. This results in short stature, with affected individuals having short limbs (rhizomelia) and shortened fingers (brachydactyly). They also have a large head with frontal bossing and a narrow foramen magnum, midface hypoplasia with a flattened nasal bridge, ‘trident’ hands, and lumbar lordosis.

      In most cases, achondroplasia occurs as a sporadic mutation, with advancing parental age at the time of conception being a risk factor. There is no specific therapy for achondroplasia, but some individuals may benefit from limb lengthening procedures. These procedures involve the application of Ilizarov frames and targeted bone fractures, with a clearly defined need and endpoint being essential for success.

      Overall, understanding achondroplasia is important for individuals and families affected by this condition. While there is no cure, there are treatment options available that can improve quality of life for those living with achondroplasia.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 15 - A 5-year-old boy comes to his pediatrician with a complaint of daily nosebleeds...

    Correct

    • A 5-year-old boy comes to his pediatrician with a complaint of daily nosebleeds for the past week. During the examination, the doctor notices petechiae and bruises on the child's legs. Apart from these symptoms, the child appears to be healthy and does not report any other issues. Blood tests reveal low platelet count, but no other abnormalities are detected. The child's symptoms disappear entirely after four months. What is the likely precursor to these symptoms?

      Your Answer: Glandular fever

      Explanation:

      ITP, a condition characterized by low platelet count and symptoms such as epistaxis and unexplained bruising/petechiae, may be preceded by a viral infection that is self-limiting and can resolve within a year. The correct answer to the question is glandular fever, as constipation, epileptic fits, asthma attacks, and stress have not been linked to triggering ITP.

      Understanding Immune Thrombocytopenia (ITP) in Children

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

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

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

    • This question is part of the following fields:

      • Paediatrics
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  • Question 16 - Should all infants undergo hearing screening by their health visitor as part of...

    Correct

    • Should all infants undergo hearing screening by their health visitor as part of the 'Infant Hearing Screening Programme'? And if the results are abnormal, what is the next hearing test they will have?

      Your Answer: Auditory Brainstem Response test as a newborn/infant

      Explanation:

      When a newborn baby’s hearing test at birth shows an abnormal result, they are recommended to undergo an auditory brainstem response test as a newborn or infant. Prior to being discharged from the hospital, all newborns should have an acoustic emission test, which involves placing a soft earpiece in the baby’s ear and playing quiet clicking sounds to detect inner ear responses. If this test yields abnormal results, the auditory brainstem response test is conducted using three sensors placed on the baby’s head and neck, along with soft headphones to play sounds and analyze the brain and hearing nerve responses. At 6-9 months of age, a distraction test is performed, and most areas in the UK conduct pure tone audiometry at school entry.

      Hearing Tests for Children

      Hearing tests are important for children to ensure that they are developing normally. There are several tests that may be performed on children of different ages. For newborns, an otoacoustic emission test is typically done as part of the Newborn Hearing Screening Programme. This test involves playing a computer-generated click through a small earpiece and checking for the presence of a soft echo, which indicates a healthy cochlea. If the results of this test are abnormal, an Auditory Brainstem Response test may be done.

      For infants between 6-9 months, a Distraction test may be performed by a health visitor with the help of two trained staff members. For children between 18 months to 2.5 years, a Recognition of familiar objects test may be used, which involves using familiar objects like a teddy or cup and asking the child simple questions like where is the teddy? For children over 2.5 years, Performance testing and Speech discrimination tests may be used, such as the Kendall Toy test or McCormick Toy Test. Pure tone audiometry is typically done at school entry in most areas of the UK for children over 3 years old.

      In addition to these tests, there is also a questionnaire for parents in the Personal Child Health Records called Can your baby hear you? It is important for parents to be aware of these tests and to have their child’s hearing checked regularly to ensure proper development.

    • This question is part of the following fields:

      • Paediatrics
      12
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  • Question 17 - A 5-year-old girl is brought to the pediatrician by her father who reports...

    Incorrect

    • A 5-year-old girl is brought to the pediatrician by her father who reports a 'barking' cough that has occurred a few times daily for the past two days. The child's appetite and behavior remain unchanged. Upon examination, the pediatrician finds no abnormalities. What is the recommended first-line treatment for mild croup?

      Your Answer: Oral prednisolone

      Correct Answer: Oral dexamethasone

      Explanation:

      Regardless of severity, a single dose of oral dexamethasone (0.15 mg/kg) should be taken immediately for mild croup, which is characterized by a barking cough and the absence of stridor or systemic symptoms.

      Understanding Croup: A Respiratory Infection in Infants and Toddlers

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

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

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

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

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  • Question 18 - An emergency call is made for a 10-year-old boy who has collapsed in...

    Incorrect

    • An emergency call is made for a 10-year-old boy who has collapsed in the waiting room. The receptionists have already called 999. After 10 seconds, there are no signs of respiration and the boy does not respond to stimulation. There is no apparent foreign object in his mouth. What should be the next appropriate action?

      Your Answer: Start chest compressions/ventilations at a ratio of 30:2

      Correct Answer: Give 5 rescue breaths

      Explanation:

      The current guidelines for paediatric basic life support still prioritize rescue breaths, despite the shift in focus for adult cases. This is because most cases of paediatric cardiac arrest are caused by issues with the airway or breathing. It is recommended to administer 5 rescue breaths if the child shows no signs of breathing during initial assessment.

      Paediatric Basic Life Support Guidelines

      Paediatric basic life support guidelines were updated in 2015 by the Resuscitation Council. Lay rescuers should use a compression:ventilation ratio of 30:2 for children under 1 year and between 1 year and puberty, a child is defined. If there are two or more rescuers, a ratio of 15:2 should be used.

      The algorithm for paediatric basic life support starts with checking if the child is unresponsive and shouting for help. The airway should be opened, and breathing should be checked by looking, listening, and feeling for breaths. If the child is not breathing, five rescue breaths should be given, and signs of circulation should be checked.

      For infants, the brachial or femoral pulse should be used, while children should use the femoral pulse. Chest compressions should be performed at a ratio of 15:2, with a rate of 100-120 compressions per minute for both infants and children. The depth of compressions should be at least one-third of the anterior-posterior dimension of the chest, which is approximately 4 cm for an infant and 5 cm for a child.

      In children, the lower half of the sternum should be compressed, while in infants, a two-thumb encircling technique should be used for chest compressions. These guidelines are crucial for anyone who may need to perform basic life support on a child, and it is essential to follow them carefully to ensure the best possible outcome.

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      • Paediatrics
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  • Question 19 - A father brings his 10-month-old daughter to the emergency department due to a...

    Incorrect

    • A father brings his 10-month-old daughter to the emergency department due to a rash that has developed. Upon further inquiry, the father explains that the rash started behind her ears two days ago and has since spread. Prior to the rash, the baby had a fever and cough. Although she is up to date with her vaccinations, the father has not yet scheduled her next appointment. During the examination, the baby appears irritable, has white spots in her mouth, and inflamed eyes. What is the most likely diagnosis, and what is the potential risk for the baby?

      Your Answer:

      Correct Answer: Otitis media

      Explanation:

      Otitis media is the most frequent complication that arises from measles, which typically presents with an initial prodrome of cough, coryza, and the appearance of white spots on the buccal mucosa known as koplik spots. The rash usually emerges between day 3 and 5, starting behind the ears and spreading down the body.

      Measles: A Highly Infectious Viral Disease

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

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

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

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

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  • Question 20 - A 4-year-old girl is brought to the emergency department by her father with...

    Incorrect

    • 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:

      Correct 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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  • Question 21 - You are a Foundation Year 2 (FY2) doctor in the Emergency Department. You...

    Incorrect

    • You are a Foundation Year 2 (FY2) doctor in the Emergency Department. You are asked to see a 7-year-old girl. She has been brought in by her grandmother with a wrist injury following a fall from a swing while staying with her mother. Her grandmother reports that this is the third time in the past four months that she has been injured while staying with her mother. On examination, she has several bruises on her arms and legs. You are concerned about the welfare of the child.
      What is the most appropriate immediate action for you to take?

      Your Answer:

      Correct Answer: Discuss the case with the safeguarding lead in the department

      Explanation:

      Dealing with Safeguarding Concerns as an FY2 Doctor

      As an FY2 doctor, it is important to know how to handle safeguarding concerns appropriately. If you have any concerns about a patient’s welfare, it is crucial to follow the correct protocol to ensure their safety. Here are some options for dealing with safeguarding concerns:

      1. Discuss the case with the safeguarding lead in the department. It is always best to seek advice from someone with more experience in this area.

      2. Contact the police if you are concerned about the current safety of a patient. However, if the child is in the department, they can be considered to be in a place of safety.

      3. Do not investigate the allegations yourself. This could put the child at increased risk. Instead, follow the correct protocol for dealing with safeguarding concerns.

      4. If you have concerns regarding a child’s welfare, ensure you have followed the correct protocol and be confident that it is safe to discharge them. Always discuss your concerns with the safeguarding lead.

      5. If you are going to make a referral to social services, try to gain consent from the parent or patient. If consent is refused, the referral can still be made, but it is important to inform the patient or parent of your actions.

      Remember, as an FY2 doctor, you are still inexperienced, and it is important to seek advice and guidance from more experienced colleagues when dealing with safeguarding concerns.

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  • Question 22 - You are requested to assess a 35-year-old man who has presented to the...

    Incorrect

    • You are requested to assess a 35-year-old man who has presented to the emergency department complaining of shortness of breath, fever, and unusual breathing sounds for the past twelve hours. He reports having a sore throat for the past few days, which has rapidly worsened. He has no significant medical history.

      Upon examination, his vital signs are as follows: respiratory rate 30/min, pulse 120 bpm, oxygen saturation 96%, temperature 39.0ºC, blood pressure 110/60 mmHg. From the end of the bed, you can observe that he is visibly struggling to breathe, has a hoarse voice, and is drooling into a container. You can hear a high-pitched wheeze during inspiration.

      What would be the most appropriate course of action at this point?

      Your Answer:

      Correct Answer: Call the on-call anaesthetist to assess the patient for intubation

      Explanation:

      In cases of acute epiglottitis, protecting the airway is crucial and may require endotracheal intubation. Symptoms such as high fever, sore throat, dyspnoea, change in voice, and inspiratory stridor indicate a potential airway emergency. While other treatments may be necessary, securing the airway should be the top priority, following the ABCDE management steps. IV dexamethasone can help reduce laryngeal oedema, but an anaesthetic assessment should be arranged before administering any medication. Nebulised salbutamol is ineffective in treating laryngeal narrowing caused by epiglottitis. X-rays of the neck may be used, but they can take time to organise and delay urgent airway management. Attempting to visualise the larynx without appropriate senior support and intubation capabilities is dangerous in cases of acute epiglottitis. Flexible nasendoscopy should only be performed with the presence of trained personnel who can secure the airway if necessary.

      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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  • Question 23 - A 4-year-old girl, Lily, is taken to the pediatrician by her father. He...

    Incorrect

    • A 4-year-old girl, Lily, is taken to the pediatrician by her father. He is concerned about an umbilical hernia that Lily has had since birth. He was told that it would likely go away on its own, but it has not yet resolved. The pediatrician conducts an examination and finds a 1.5 cm umbilical hernia that is easily reducible. What is the most suitable course of action for managing this, according to the guidelines?

      Your Answer:

      Correct Answer: Delaying referral for elective outpatient surgical repair until 5 years of age, if still unresolved

      Explanation:

      According to medical guidelines, umbilical hernias in children usually close on their own by the age of 4-5. However, if the hernia persists beyond this age or is large and causing symptoms, surgical repair is recommended. In the case of a small hernia in a 3-year-old child, observation is appropriate until the age of 5. If the hernia becomes incarcerated, it should be manually reduced and surgically repaired within 24 hours. The use of compression therapy after surgery is not recommended. Waiting for the hernia to self-resolve after the age of 5 is not advised as it is unlikely to happen and could lead to incarceration. These recommendations are based on BMJ Best Practice guidelines.

      Umbilical Hernia in Children: Causes and Treatment

      Umbilical hernias are a common occurrence in children and are often detected during the newborn examination. This condition is characterized by a bulge or protrusion near the belly button, caused by a weakness in the abdominal muscles. While umbilical hernias can occur in any child, they are more common in Afro-Caribbean infants and those with Down’s syndrome or mucopolysaccharide storage diseases.

      Fortunately, in most cases, umbilical hernias in children do not require treatment and will resolve on their own by the age of three. However, if the hernia persists beyond this age or becomes painful, surgery may be necessary to repair the abdominal wall. It is important to monitor the hernia and seek medical attention if there are any changes in size or symptoms.

      In summary, umbilical hernias are a common condition in children that typically resolve on their own without treatment. However, certain factors such as ethnicity and underlying medical conditions may increase the likelihood of developing an umbilical hernia. Parents should be aware of the signs and symptoms of umbilical hernias and seek medical attention if necessary.

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  • Question 24 - A 10-year-old boy comes to the GP with his father, complaining of right-sided...

    Incorrect

    • A 10-year-old boy comes to the GP with his father, complaining of right-sided hip pain that has been present for the past 3 weeks. The pain has gradually worsened over time. When asked to point to the location of the pain, he indicates his right hip and groin area. Upon examination, his heart rate is 71 bpm and temperature is 37.3ºC. He is able to walk, but with moderate discomfort and an antalgic gait that causes him to out-toe. Passive movement of the hip reveals a loss of internal rotation of the right leg in flexion. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Slipped capital femoral epiphysis

      Explanation:

      Slipped capital femoral epiphysis is a possible diagnosis for a boy aged 10-15 years old presenting with hip pain and a key examination finding of limited internal rotation of the leg in flexion. Other diagnoses such as septic arthritis, juvenile idiopathic arthritis, and Perthe’s disease are less likely based on the absence of certain symptoms and age range. Further investigation and imaging should be done to confirm the diagnosis.

      Slipped Capital Femoral Epiphysis: A Rare Hip Condition in Children

      Slipped capital femoral epiphysis, also known as slipped upper femoral epiphysis, is a rare hip condition that primarily affects children between the ages of 10 and 15. It is more commonly seen in obese boys. This condition is characterized by the displacement of the femoral head epiphysis postero-inferiorly, which may present acutely following trauma or with chronic, persistent symptoms.

      The most common symptoms of slipped capital femoral epiphysis include hip, groin, medial thigh, or knee pain and loss of internal rotation of the leg in flexion. In some cases, a bilateral slip may occur. Diagnostic imaging, such as AP and lateral (typically frog-leg) views, can confirm the diagnosis.

      The management of slipped capital femoral epiphysis typically involves internal fixation, which involves placing a single cannulated screw in the center of the epiphysis. However, if left untreated, this condition can lead to complications such as osteoarthritis, avascular necrosis of the femoral head, chondrolysis, and leg length discrepancy.

      In summary, slipped capital femoral epiphysis is a rare hip condition that primarily affects children, especially obese boys. It is characterized by the displacement of the femoral head epiphysis postero-inferiorly and can present with various symptoms. Early diagnosis and management are crucial to prevent complications.

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  • Question 25 - A 12-year-old girl comes to the emergency department with a headache. During the...

    Incorrect

    • A 12-year-old girl comes to the emergency department with a headache. During the examination, she mentions that the lights are bothering her eyes and the doctor observes a purpuric rash on her chest. Her respiratory rate is 22/min, heart rate is 140/min, and blood pressure is 80/60 mmHg. Which of the following tests should be avoided in this patient?

      Your Answer:

      Correct Answer: Lumbar puncture

      Explanation:

      Performing a lumbar puncture is not recommended for patients with meningococcal septicaemia, which is a contraindication. In cases of suspected meningitis and sepsis, a coagulation screen and blood glucose may be ordered in secondary care, while blood cultures and serum lactate are typically included in the sepsis 6 protocol.

      Investigation and Management of Meningitis in Children

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

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

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

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  • Question 26 - A 4-week-old infant boy born at 37 weeks gestation by caesarian section is...

    Incorrect

    • A 4-week-old infant boy born at 37 weeks gestation by caesarian section is presented to his pediatrician for a routine check-up. The pediatrician observes that the neonate's urethral meatus is situated on the ventral aspect of the penile shaft, instead of the distal glans penis. What other congenital anomaly is this neonate more likely to have?

      Your Answer:

      Correct Answer: Cryptorchidism

      Explanation:

      Hypospadias is often accompanied by cryptorchidism in neonates, indicating a potential issue with embryological urogenital migration that may be linked to endocrine disruptions during pregnancy, such as low serum androgens. Imperforate anus, obstructive uropathy with a patent urachus, and posterior urethral valve are not associated with hypospadias and would present with different symptoms or complications.

      Understanding Hypospadias: A Congenital Abnormality of the Penis

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

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

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  • Question 27 - A mother brings her 18-day old baby to the emergency department with visible...

    Incorrect

    • A mother brings her 18-day old baby to the emergency department with visible jaundice and distress. The baby has been feeding poorly since yesterday. Upon examination, hepatomegaly and splenomegaly are observed. The newborn jaundice screen shows no infection, normal thyroid function tests, raised conjugated bilirubin, liver transaminases, and bile acids. Reducing substances are absent in the urine. What is the initial management option for the most probable diagnosis?

      Your Answer:

      Correct Answer: Surgical intervention

      Explanation:

      Biliary atresia is diagnosed when a newborn presents with prolonged jaundice, hepatomegaly, splenomegaly, abnormal growth, and cardiac murmurs. Surgery is the preferred treatment, specifically a hepatoportoenterostomy (HPE), also known as Kasai portoenterostomy. This procedure removes the blocked bile ducts and replaces them with a segment of the small intestine, restoring bile flow from the liver to the proximal small bowel. Ursodeoxycholic acid may be given as an adjuvant after surgery to facilitate bile flow and protect the liver. However, it should not be given if the total bilirubin is >256.6 micromol/L (>15 mg/dL). Frequent monitoring is not sufficient, urgent action is required. Liver transplant is not the first-line treatment, but may be considered if HPE is unsuccessful or if there are signs of end-stage liver disease, progressive cholestasis, hepatocellular decompensation, or severe portal hypertension.

      Understanding Biliary Atresia in Neonatal Children

      Biliary atresia is a condition that affects the extrahepatic biliary system in neonatal children, resulting in an obstruction in the flow of bile. This condition is more common in females than males and occurs in 1 in every 10,000-15,000 live births. There are three types of biliary atresia, with type 3 being the most common. Patients typically present with jaundice, dark urine, pale stools, and abnormal growth.

      To diagnose biliary atresia, doctors may perform various tests, including serum bilirubin, liver function tests, serum alpha 1-antitrypsin, sweat chloride test, and ultrasound of the biliary tree and liver. Surgical intervention is the only definitive treatment for biliary atresia, and medical intervention includes antibiotic coverage and bile acid enhancers following surgery.

      Complications of biliary atresia include unsuccessful anastomosis formation, progressive liver disease, cirrhosis, and eventual hepatocellular carcinoma. However, the prognosis is good if surgery is successful. In cases where surgery fails, liver transplantation may be required in the first two years of life. Overall, understanding biliary atresia is crucial for early diagnosis and effective management in neonatal children.

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  • Question 28 - A 7-year-old girl is brought to the pediatrician's office by her father. She...

    Incorrect

    • A 7-year-old girl is brought to the pediatrician's office by her father. She has been experiencing nighttime itching around her bottom and has mentioned to her father that she has seen small white strands moving in her stool. She is not constipated and is generally healthy. No one else in the household has reported similar symptoms. The girl lives with her father and her two-year-old brother.

      What should be the next course of action?

      Your Answer:

      Correct Answer: Mebendazole and hygiene measures for the patient and his parents, as his sister is too young

      Explanation:

      It is recommended to treat asymptomatic household contacts of patients with threadworms, even if they show no symptoms. In the case of this boy with threadworms, the appropriate course of action would be to administer Mebendazole and advise on hygiene measures for both the patient and his parents. It is not necessary to send a sample to the laboratory for confirmation as empirical treatment is recommended. Advising on hygiene and fluid intake alone would not be sufficient to treat the infection. It is important to note that Mebendazole should not be given to children under six months old, so treating the patient’s three-month-old sister is not appropriate. Permethrin is not a suitable treatment for threadworms as it is used to treat scabies.

      Threadworm Infestation in Children

      Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.

      The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.

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  • Question 29 - A 2-day-old baby girl is presented to the emergency department by her parents...

    Incorrect

    • A 2-day-old baby girl is presented to the emergency department by her parents with complaints of decreased oral intake and fussiness. The parents also report that the baby has been vomiting green liquid and has not had a bowel movement since passing meconium, although she has had wet diapers. The baby was born vaginally at 39 weeks without any complications during pregnancy or delivery. An upper gastrointestinal contrast study revealed intestinal malrotation. What is the most appropriate definitive treatment option?

      Your Answer:

      Correct Answer: Ladd’s procedure

      Explanation:

      A newborn with symptoms of bowel obstruction and bilious vomiting is suspected to have paediatric intestinal malrotation with volvulus. An upper gastrointestinal contrast study confirms the diagnosis. The most appropriate management option is a Ladd’s procedure, which involves division of Ladd bands and widening of the base of the mesentery. If vascular compromise is present, an urgent laparotomy is required. IV antibiotics are not indicated as there are no signs of infection. NEC may require antibiotics, but it presents differently with feeding intolerance, abdominal distension, and bloody stools, and is more common in premature infants.

      Paediatric Gastrointestinal Disorders

      Pyloric stenosis is more common in males and has a 5-10% chance of being inherited from parents. Symptoms include projectile vomiting at 4-6 weeks of life, and diagnosis is made through a test feed or ultrasound. Treatment involves a Ramstedt pyloromyotomy, either open or laparoscopic.

      Acute appendicitis is uncommon in children under 3 years old, but when it does occur, it may present atypically. Mesenteric adenitis causes central abdominal pain and URTI, and is treated conservatively.

      Intussusception occurs in infants aged 6-9 months and causes colicky pain, diarrhea, vomiting, a sausage-shaped mass, and red jelly stool. Treatment involves reduction with air insufflation.

      Intestinal malrotation is characterized by a high caecum at the midline and may be complicated by the development of volvulus. Diagnosis is made through an upper GI contrast study and ultrasound, and treatment involves laparotomy or a Ladd’s procedure.

      Hirschsprung’s disease occurs in 1/5000 births and is characterized by delayed passage of meconium and abdominal distension. Treatment involves rectal washouts and an anorectal pull through procedure.

      Oesophageal atresia is associated with tracheo-oesophageal fistula and polyhydramnios, and may present with choking and cyanotic spells following aspiration. Meconium ileus is usually associated with cystic fibrosis and requires surgery to remove plugs. Biliary atresia causes jaundice and increased conjugated bilirubin, and requires an urgent Kasai procedure. Necrotising enterocolitis is more common in premature infants and is treated with total gut rest and TPN, with laparotomy required for perforations.

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  • Question 30 - You are an FY1 on the neonatal ward round with your consultant. Whilst...

    Incorrect

    • You are an FY1 on the neonatal ward round with your consultant. Whilst seeing a newborn that has been admitted with respiratory distress, the consultant you're with decides to quiz you on the pathophysiology.
      'What is the most likely organism to cause respiratory distress syndrome in premature infants?

      Your Answer:

      Correct Answer: Parainfluenza virus

      Explanation:

      The majority of croup cases are caused by the parainfluenza virus, while bronchiolitis is commonly caused by RSV. Pseudomonas aeruginosa is associated with pseudomonas, and Streptococcus pneumoniae is a common cause of pneumonia.

      Understanding Croup: A Respiratory Infection in Infants and Toddlers

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

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

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

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

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  • Question 31 - A 3-week-old baby girl is brought to the emergency department due to continuous...

    Incorrect

    • A 3-week-old baby girl is brought to the emergency department due to continuous vomiting. According to the mother, the baby's vomiting is like a fountain. What is the most suitable investigation to confirm the suspected diagnosis?

      Your Answer:

      Correct Answer: US Abdomen

      Explanation:

      Ultrasound is the key investigation for pyloric stenosis, as other methods such as abdominal x-ray, CT scans, TTG antibodies, and upper GI contrast study are less useful or not applicable for young children with this condition. The classic symptom of pyloric stenosis is forceful projectile vomiting.

      Understanding Pyloric Stenosis

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

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

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

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      • Paediatrics
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  • Question 32 - You are evaluating the growth of a 6-week-old infant. Her length is at...

    Incorrect

    • You are evaluating the growth of a 6-week-old infant. Her length is at the 35th percentile, weight at the 42nd percentile, and head circumference at the 4th percentile. What is the probable reason for her microcephaly?

      Your Answer:

      Correct Answer: Foetal alcohol syndrome

      Explanation:

      Microcephaly is often linked to foetal alcohol syndrome, which also presents with other physical characteristics such as a smooth philtrum, hypoplastic upper lip, and epicanthic folds. Conditions like Thalassaemia, Turner’s syndrome, and cerebral palsy do not typically impact head size, while Achondroplasia is associated with macrocephaly and frontal bossing, not microcephaly. Recognizing the distinct physical features of congenital conditions is crucial for both exams and accurate diagnosis.

      Understanding Fetal Alcohol Syndrome

      Fetal alcohol syndrome is a condition that occurs when a pregnant woman consumes alcohol, which can lead to various physical and mental abnormalities in the developing fetus. At birth, the baby may exhibit symptoms of alcohol withdrawal, such as irritability, hypotonia, and tremors.

      The features of fetal alcohol syndrome include a short palpebral fissure, a thin vermillion border or hypoplastic upper lip, a smooth or absent philtrum, learning difficulties, microcephaly, growth retardation, epicanthic folds, and cardiac malformations. These physical characteristics can vary in severity and may affect the child’s overall health and development.

      It is important for pregnant women to avoid alcohol consumption to prevent fetal alcohol syndrome and other potential complications. Early diagnosis and intervention can also help improve outcomes for children with fetal alcohol syndrome. By understanding the risks and consequences of alcohol use during pregnancy, we can work towards promoting healthier pregnancies and better outcomes for children.

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      • Paediatrics
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  • Question 33 - You are requested to assess a preterm neonate in the neonatal unit. During...

    Incorrect

    • You are requested to assess a preterm neonate in the neonatal unit. During the examination of the palate, you observe a white nodule on the roof of the mouth. The baby is alert and active, and there is no interference with feeding. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Epstein's pearl

      Explanation:

      Epstein’s pearls, which are located in the middle of the posterior hard palate, can be mistaken for neonatal teeth. However, unlike neonatal teeth, Epstein’s pearls do not need any treatment. Bohn’s nodules, on the other hand, are situated on the inner labial aspect of the maxillary alveolar ridges. Dermoid cysts, which may contain teeth, are not commonly found in the oral cavity. Oral candida infection can manifest as white patches on the interior of the mouth.

      Understanding Epstein’s Pearl

      Epstein’s pearl is a type of cyst that is present in the mouth from birth. It is commonly found on the hard palate, but can also be seen on the gums, which may be mistaken for a tooth eruption. The good news is that no treatment is usually required as these cysts tend to disappear on their own within a few weeks.

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      • Paediatrics
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  • Question 34 - A 7-month-old infant is brought to the emergency department with symptoms of vomiting,...

    Incorrect

    • 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:

      Correct 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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  • Question 35 - A premature neonate is born at 32 weeks’ gestation and is noted to...

    Incorrect

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

      Your Answer:

      Correct Answer: Long-standing bipolar disorder therapy

      Explanation:

      Potential Risks and Management of Medical Conditions and Medications During Pregnancy

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

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

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

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

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

      Managing Medical Conditions and Medications During Pregnancy

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  • Question 36 - A 35-year-old woman delivers a male infant who presents with low muscle tone...

    Incorrect

    • A 35-year-old woman delivers a male infant who presents with low muscle tone and is later diagnosed with Down's syndrome. Which of the following features is the least probable in this case?

      Your Answer:

      Correct Answer: Rocker-bottom feet

      Explanation:

      Understanding the features of Down’s syndrome is crucial for clinical practice and final examinations. The correct answer to this question is option 4. While rocker-bottom feet are a characteristic of trisomy 18 or Edward’s syndrome, they are not typically observed in individuals with Down’s syndrome.

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

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

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

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      • Paediatrics
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  • Question 37 - A 14-year-old boy comes to the GP complaining of left groin pain and...

    Incorrect

    • A 14-year-old boy comes to the GP complaining of left groin pain and a limp that has been gradually developing over the past 5 weeks. He has no medical or family history and his right leg is unaffected. Upon examination, there is a noticeable decrease in internal rotation of the left leg, but no swelling or warmth around the joints. The patient's vital signs are normal, and his height is in the 50th percentile while his weight is in the 95th percentile. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Slipped capital femoral epiphysis

      Explanation:

      Slipped capital femoral epiphysis is more likely to occur in obese boys aged 10-15, as obesity is a risk factor for this condition. It is caused by a weakness in the proximal femoral growth plate, which can also be due to endocrine disorders or rapid growth. Loss of internal rotation of the affected leg is a common finding during examination. Perthes’ disease can also cause groin pain, but it typically affects children aged 4 to 8 years old. Being male and having a lower socioeconomic status are also risk factors for this condition. Septic arthritis is unlikely in this case as the child’s vital signs are normal, and it usually presents with a hot and swollen joint and systemic illness. Developmental dysplasia of the hip is usually detected during routine hip examinations in the first year of life, using Barlow/Ortolani tests and assessing hip abduction.

      Slipped Capital Femoral Epiphysis: A Rare Hip Condition in Children

      Slipped capital femoral epiphysis, also known as slipped upper femoral epiphysis, is a rare hip condition that primarily affects children between the ages of 10 and 15. It is more commonly seen in obese boys. This condition is characterized by the displacement of the femoral head epiphysis postero-inferiorly, which may present acutely following trauma or with chronic, persistent symptoms.

      The most common symptoms of slipped capital femoral epiphysis include hip, groin, medial thigh, or knee pain and loss of internal rotation of the leg in flexion. In some cases, a bilateral slip may occur. Diagnostic imaging, such as AP and lateral (typically frog-leg) views, can confirm the diagnosis.

      The management of slipped capital femoral epiphysis typically involves internal fixation, which involves placing a single cannulated screw in the center of the epiphysis. However, if left untreated, this condition can lead to complications such as osteoarthritis, avascular necrosis of the femoral head, chondrolysis, and leg length discrepancy.

      In summary, slipped capital femoral epiphysis is a rare hip condition that primarily affects children, especially obese boys. It is characterized by the displacement of the femoral head epiphysis postero-inferiorly and can present with various symptoms. Early diagnosis and management are crucial to prevent complications.

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  • Question 38 - A 5-year-old girl comes to the GP with her father. He reports that...

    Incorrect

    • A 5-year-old girl comes to the GP with her father. He reports that she has had a fever and a sore throat for the past 3 days and now has a rash all over her trunk and legs. During the examination, the child appears lethargic, flushed, and has a rough-textured erythematosus rash on her trunk and legs. The doctor observes a swollen red tongue and cervical lymphadenopathy during throat examination. What is the diagnosis?

      Your Answer:

      Correct Answer: Scarlet Fever

      Explanation:

      The child’s symptoms are consistent with scarlet fever, which is characterized by a sandpaper-like rash, swollen tongue, and lymphadenopathy. Treatment with a 10-day course of penicillin V is recommended, and the child should stay home from school for 24 hours after starting antibiotics. Public health should also be notified. Kawasaki disease, rubella, and parvovirus are unlikely diagnoses based on the child’s presentation.

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

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

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  • Question 39 - A toddler with macrosomia has had a difficult delivery, owing to shoulder dystocia....

    Incorrect

    • A toddler with macrosomia has had a difficult delivery, owing to shoulder dystocia. The obstetrician pulled the child’s head downwards towards the floor to disengage the anterior shoulder from below the pubic bones. When the child is having a check-up prior to discharge, the paediatrician notes that the left upper limb is adducted and medially rotated, with extension at the elbow joint. When questioned, the mother admits that the child has not been moving it.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Erb–Duchenne palsy due to trauma to the upper trunk of the brachial plexus

      Explanation:

      Differentiating Brachial Plexus Injuries: Causes and Symptoms

      The brachial plexus is a network of nerves that originates from the spinal cord and supplies the upper limb. Trauma to this network can result in various types of injuries, each with its own set of symptoms. Here are some of the common types of brachial plexus injuries and their distinguishing features:

      Erb-Duchenne Palsy: This injury occurs due to trauma to the upper trunk of the brachial plexus, typically during obstructed labor or delivery. The affected muscles include those supplied by the musculocutaneous, radial, and axillary nerves, resulting in adduction and medial rotation of the arm, wrist drop, and sensory loss along the posterolateral aspect of the limb.

      Isolated Radial Nerve Injury: This type of injury is associated with paralysis of the wrist and digital extensors, as well as the triceps. However, medial rotation of the humerus is not affected.

      Klumpke’s Palsy: This injury is caused by trauma to the lower trunk of the brachial plexus, often during difficult delivery or sudden upward stretching of the upper limb. It results in claw hand due to damage to T1, causing paralysis of the short muscles of the hand.

      Isolated Axillary Nerve Injury: With this type of injury, the wrist extensors function normally.

      Isolated Musculocutaneous Nerve Injury: This injury is not associated with wrist drop.

      In summary, understanding the specific symptoms associated with each type of brachial plexus injury can aid in accurate diagnosis and treatment.

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  • Question 40 - A 28-year-old woman has just had her 34 week check. The patient reported...

    Incorrect

    • A 28-year-old woman has just had her 34 week check. The patient reported reduced fetal movements 3 days ago, but they are now back to normal. An ultrasound was performed to investigate any potential issues. The obstetrician informs her that a defect in the abdominal wall has been detected and the baby's intestines are outside the body but enclosed in a membrane. Despite this, the baby is healthy. What is the best course of action for this patient?

      Your Answer:

      Correct Answer: Plan a caesarean section at 37 weeks

      Explanation:

      If the unborn baby has exomphalos, it is recommended to opt for a caesarean section to minimize the chances of sac rupture. The presence of a membrane containing the abdominal content suggests that the baby is likely to have exomphalos. While vaginal delivery is possible, a caesarean section is the safest delivery option. There is no need for an emergency caesarean section as the baby is not experiencing any distress. Inducing labor for vaginal delivery is not advisable, and a caesarean section is a better option. Additionally, IM corticosteroids are not necessary as there is no risk of premature delivery at present. These steroids are typically used when women are at risk of or experience premature labor.

      Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocoele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.

      When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.

      Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.

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  • Question 41 - A 4-year-old girl comes to the doctor's office with a diffuse, blanching, erythematosus...

    Incorrect

    • A 4-year-old girl comes to the doctor's office with a diffuse, blanching, erythematosus rash all over her trunk, arms, and legs. She has been running a fever and feeling generally cranky and tired for about a week. Additionally, she has been experiencing abdominal discomfort for the past few days. During the examination, the doctor notices that the skin on her palms and soles is peeling, and her tongue is red with a white coating. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Kawasaki disease

      Explanation:

      Kawasaki disease can be identified by a combination of symptoms, including a high fever lasting more than five days, red palms with peeling skin, and a strawberry tongue. If a fever lasts for more than five days and is accompanied by desquamation and strawberry tongue, it is likely to be Kawasaki disease. Scarlet fever also causes skin peeling and strawberry tongue, but the fever is not as prolonged. Meningitis causes a non-blanching rash and more severe symptoms, while Henoch-Schonlein purpura presents with a non-blanching rash, abdominal pain, joint pain, and haematuria.

      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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  • Question 42 - Which of the following features is not typically associated with patent ductus arteriosus?...

    Incorrect

    • Which of the following features is not typically associated with patent ductus arteriosus?

      Your Answer:

      Correct Answer: Bisferiens pulse

      Explanation:

      A collapsing pulse is linked to PDA.

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

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

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  • Question 43 - A 3-day-old infant is presenting with increased work of breathing. The baby was...

    Incorrect

    • A 3-day-old infant is presenting with increased work of breathing. The baby was born via elective caesarean section at 38 weeks gestation and the pregnancy was uncomplicated. On examination, the infant has a respiratory rate of 70 breaths per minute (normal: 30-60) and an oxygen saturation of 94% (normal: >90%). Nasal flaring is also observed. A chest x-ray reveals hyperinflated lung fields and a line of fluid in the horizontal fissure of the left lung. Based on the likely diagnosis, what is the most appropriate course of action?

      Your Answer:

      Correct Answer: Supportive care

      Explanation:

      The primary treatment for uncomplicated transient tachypnoea of the newborn is observation and supportive care, which may include oxygen supplementation if necessary. In this case, the symptoms and chest x-ray results suggest a diagnosis of transient tachypnoea of the newborn, which is caused by excess fluid in the lungs due to caesarean delivery. This condition is not life-threatening and can be managed with careful monitoring and appropriate care. Corticosteroids are not recommended for newborns with this condition, and humidified oxygen and nebulised salbutamol are not necessary in this case.

      Understanding Transient Tachypnoea of the Newborn

      Transient tachypnoea of the newborn (TTN) is a common respiratory condition that affects newborns. It is caused by the delayed resorption of fluid in the lungs, which can lead to breathing difficulties. TTN is more common in babies born via caesarean section, as the fluid in their lungs may not be squeezed out during the birth process. A chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure.

      The management of TTN involves observation and supportive care. In some cases, supplementary oxygen may be required to maintain oxygen saturation levels. However, TTN usually resolves within 1-2 days. It is important for healthcare professionals to monitor newborns with TTN closely and provide appropriate care to ensure a full recovery. By understanding TTN and its management, healthcare professionals can provide the best possible care for newborns with this condition.

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  • Question 44 - A 6-year-old girl with Down syndrome is seen by her general practitioner (GP)....

    Incorrect

    • A 6-year-old girl with Down syndrome is seen by her general practitioner (GP). She has been complaining of ear pain for a few days. She has not had any problems with her ears in the past, and her mother has no concerns about her hearing. On examination, she is found to have otitis media with effusion.
      What is the most appropriate management plan for this patient?

      Your Answer:

      Correct Answer: Refer to ear, nose and throat (ENT)

      Explanation:

      Management of Otitis Media with Effusion in Children with Down Syndrome or Cleft Palate

      Children suspected to have otitis media with effusion (OME) and Down syndrome or cleft palate should be referred for specialist assessment to avoid any delays that may impact their overall development, especially speech development. OME is the presence of fluid in the middle ear space, which can lead to conductive hearing loss and speech delay in some children. While OME can be self-limiting, it can become chronic, and failure of treatment may cause complications, particularly in children with low immunity due to Down syndrome.

      Amoxicillin 500 mg three times daily for five days is not recommended for children with Down syndrome or cleft palate. Instead, a period of active observation is recommended for 6-12 weeks, unless a referral is indicated. The use of corticosteroids or decongestants, such as fluticasone or xylometazoline nasal spray, respectively, is not supported by evidence and is not advised by the National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS).

      In summary, early referral for specialist assessment is crucial for children with Down syndrome or cleft palate suspected to have OME to prevent any delays in their development. Active observation is recommended for other children with OME, and the use of antibiotics, corticosteroids, or decongestants is not supported by evidence and is not advised by NICE CKS.

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  • Question 45 - A 6-week old infant is seen by the health visitor. She was born...

    Incorrect

    • A 6-week old infant is seen by the health visitor. She was born via breech caesarean section at 36+2 weeks gestation due to suspected chorioamnionitis and received antibiotics post-partum. Her hospital newborn physical examination (NIPE) was normal. She is currently thriving and following the 60th centile. What further assessments should the health visitor arrange for this infant based on her medical history?

      Your Answer:

      Correct Answer: Ultrasounds of pelvis in 2 weeks

      Explanation:

      An ultrasound of the pelvis in 2 weeks is the correct answer. This is because infants born in a breech position have an increased risk of DDH and require screening at 6 weeks to ensure there is no hip laxity. Vaginal swabs for group B streptococcus are not necessary if the mother is asymptomatic. Reviewing the infant’s progress along the centiles once or twice weekly is too frequent, as infants are usually weighed no more than once a month up to 6 months of age unless there are concerns about development. A full blood count is unnecessary for a well-looking infant without signs of anaemia or infection.

      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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  • Question 46 - A 2-year-old toddler is brought to the GP by concerned parents who have...

    Incorrect

    • A 2-year-old toddler is brought to the GP by concerned parents who have noticed swelling of the foreskin during urination and inability to retract it. What is the most appropriate initial approach to manage this condition?

      Your Answer:

      Correct Answer: Reassure parents and review in 6-months

      Explanation:

      Forcible retraction should be avoided in younger children with phimosis, as it can lead to scar formation. It is important to note that phimosis is normal in children under the age of 2 and typically resolves on its own over time. Therefore, there is no urgent need for referral to paediatrics or paediatric surgeons. While lubricant is not helpful in managing phimosis, topical steroids have been found to be beneficial.

      Phimosis in Children: When to Seek Treatment

      Phimosis is a condition where the foreskin of the penis cannot be retracted. In children under two years old, this may be a normal physiological process that will resolve on its own. The British Association of Paediatric Urologists recommends an expectant approach in such cases, as forcible retraction can lead to scarring. However, personal hygiene is important to prevent infections. If the child is over two years old and experiences recurrent balanoposthitis or urinary tract infections, treatment can be considered.

      It is important to note that parents should not attempt to forcibly retract the foreskin in young children. This can cause pain and scarring, and may not even be necessary. Instead, parents should focus on teaching their child good hygiene habits to prevent infections. If the child is experiencing recurrent infections or other symptoms, it may be time to seek medical treatment. By following these guidelines, parents can help their child manage phimosis and maintain good health.

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  • Question 47 - An infant, born to a 25-year-old woman immigrant who did not receive prenatal...

    Incorrect

    • An infant, born to a 25-year-old woman immigrant who did not receive prenatal care, is found to have a midline lesion on his lower back. Examination reveals a fluid-filled cystic mass that is continuous with the spinal canal.
      With which one of the following could this anomaly have been prevented by supplementation?

      Your Answer:

      Correct Answer: A vitamin necessary in nucleic acid synthesis

      Explanation:

      The Importance of Vitamins in Various Biological Processes

      Vitamins play a crucial role in various biological processes, including nucleic acid synthesis, high-energy electron carrier synthesis, pyruvate dehydrogenase function, prevention of keratinised squamous metaplasia, and fatty acid synthesis.

      Insufficient maternal folate, a vitamin necessary in nucleic acid synthesis, can cause spina bifida, a neural tube defect. Supplementation with folate prior to conception can prevent such defects. Vitamin B3 is necessary for the synthesis of a high-energy electron carrier, while vitamin B1 is necessary for pyruvate dehydrogenase function. Vitamin A prevents keratinised squamous metaplasia and maintains specialised epithelium, but its supplementation is contraindicated during pregnancy. Finally, pantothenic acid or vitamin B5 is necessary for fatty acid synthesis, and its deficiency is rare.

      In conclusion, vitamins are essential for various biological processes, and their deficiency can lead to severe health issues. It is crucial to maintain a balanced diet and ensure adequate vitamin intake to prevent such deficiencies.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 48 - A baby born to a 28-year-old woman has ambiguous genitalia on examination; the...

    Incorrect

    • A baby born to a 28-year-old woman has ambiguous genitalia on examination; the rest of the physical examination is normal. Genotype is determined to be XY. The testes are retained within the abdominal cavity, and the internal reproductive tracts exhibit the normal male phenotype.
      What could be the possible cause of this abnormal development?

      Your Answer:

      Correct Answer: 5α-reductase deficiency

      Explanation:

      There are several conditions that can affect the development of male reproductive organs. 5α-reductase deficiency is a congenital absence of 5α-reductase, which is necessary for the production of dihydrotestosterone. Without dihydrotestosterone, the external genitalia may not develop properly, resulting in feminization. Testicular dysgenesis can also lead to poor development of the testes and decreased secretion of testosterone, which can cause feminization of the external genitalia and female-type internal tracts. 17α-hydroxylase deficiency prevents the synthesis of testosterone, leading to feminization of the external genitalia and degeneration of the Wolffian ducts. Complete androgen resistance results in feminization of the external genitalia, but neither male nor female internal tracts develop. Sertoli-only syndrome occurs when only Sertoli cells are present, leading to absent spermatogenesis and increased FSH levels. This can result in both male and female internal tracts due to the absence of the Müllerian regression factor, but normal testosterone secretion allows for the development of male-type external genitalia.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 49 - A 2-year-old girl is brought to the pediatrician by her father due to...

    Incorrect

    • A 2-year-old girl is brought to the pediatrician by her father due to concerns about her breathing. The father reports that she has had a fever, cough, and runny nose for the past three days, and has been wheezing for the past 24 hours. On examination, the child has a temperature of 37.9ºC, a heart rate of 126/min, a respiratory rate of 42/min, and bilateral expiratory wheezing is noted. The pediatrician prescribes a salbutamol inhaler with a spacer. However, two days later, the father returns with the child, stating that the inhaler has not improved her wheezing. The child's clinical findings are similar, but her temperature is now 37.4ºC. What is the most appropriate next step in management?

      Your Answer:

      Correct Answer: Oral montelukast or inhaled corticosteroid

      Explanation:

      Child has viral-induced wheeze, treat with short-acting bronchodilator. If not successful, try oral montelukast or inhaled corticosteroids.

      Understanding and Managing preschool Wheeze in Children

      Wheeze is a common occurrence in preschool children, with around 25% experiencing it before they reach 18 months old. Viral-induced wheeze is now one of the most frequently diagnosed conditions in paediatric wards. However, there is still ongoing debate about how to classify wheeze in this age group and the most effective management strategies.

      The European Respiratory Society Task Force has proposed a classification system for preschool wheeze, dividing children into two groups: episodic viral wheeze and multiple trigger wheeze. Episodic viral wheeze occurs only during a viral upper respiratory tract infection and is symptom-free in between episodes. Multiple trigger wheeze, on the other hand, can be triggered by various factors, such as exercise, allergens, and cigarette smoke. While episodic viral wheeze is not associated with an increased risk of asthma in later life, some children with multiple trigger wheeze may develop asthma.

      To manage preschool wheeze, parents who smoke should be strongly encouraged to quit. For episodic viral wheeze, treatment is symptomatic, with short-acting beta 2 agonists or anticholinergic via a spacer as the first-line treatment. If symptoms persist, a trial of intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both may be recommended. Oral prednisolone is no longer considered necessary for children who do not require hospital treatment. For multiple trigger wheeze, a trial of inhaled corticosteroids or a leukotriene receptor antagonist (montelukast) for 4-8 weeks may be recommended.

      Overall, understanding the classification and management of preschool wheeze can help parents and healthcare professionals provide appropriate care for children experiencing this common condition.

    • This question is part of the following fields:

      • Paediatrics
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  • Question 50 - You are a junior doctor in paediatrica and have been asked to perform...

    Incorrect

    • You are a junior doctor in paediatrica and have been asked to perform a newborn exam. Which statement is true regarding the Barlow and Ortolani manoeuvres?

      Your Answer:

      Correct Answer: It relocates a dislocation of the hip joint if this has been elicited during the Barlow manoeuvre

      Explanation:

      Understanding the Barlow and Ortolani Manoeuvres for Hip Dislocation Screening

      Hip dislocation is a common problem in infants, and early detection is crucial for successful treatment. Two screening tests commonly used are the Barlow and Ortolani manoeuvres. The Barlow manoeuvre involves adducting the hip while applying pressure on the knee, while the Ortolani manoeuvre flexes the hips and knees to 90 degrees, with pressure applied to the greater trochanters and thumbs to abduct the legs. A positive test confirms hip dislocation, and further investigation is necessary if risk factors are present, such as breech delivery or a family history of hip problems. However, a negative test does not exclude all hip problems, and parents should seek medical advice if they notice any asymmetry or walking difficulties in their child.

    • This question is part of the following fields:

      • Paediatrics
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