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  • Question 1 - You witness the sudden arrival of a baby in one of the cubicles...

    Incorrect

    • You witness the sudden arrival of a baby in one of the cubicles within the Emergency Department. Your consultant evaluates the newborn one minute after birth and notifies you that:
      The limbs appear bluish, while the body has a pink hue.
      The heart rate measures 110 beats per minute.
      The baby responds with cries upon stimulation.
      There is noticeable flexion in the limbs.
      The baby's cry is strong and robust.
      What is the Apgar score of the neonate at one minute?

      Your Answer: 7

      Correct Answer: 8

      Explanation:

      The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

      Appearance
      Pulse rate
      Grimace
      Activity
      Respiratory effort

      The Apgar score criteria are as follows:

      Score of 0:
      Appearance (skin color): Blue or pale all over
      Pulse rate: Absent
      Reflex irritability (grimace): No response to stimulation
      Activity: None
      Respiratory effort: Absent

      Score of 1:
      Appearance (skin color): Blue at extremities (acrocyanosis)
      Pulse rate: Less than 100 per minute
      Reflex irritability (grimace): Grimace on suction or aggressive stimulation
      Activity: Some flexion
      Respiratory effort: Weak, irregular, gasping

      Score of 2:
      Appearance (skin color): No cyanosis, body and extremities pink
      Pulse rate: More than 100 per minute
      Reflex irritability (grimace): Cry on stimulation
      Activity: Flexed arms and legs that resist extension
      Respiratory effort: Strong, robust cry

    • This question is part of the following fields:

      • Neonatal Emergencies
      13.5
      Seconds
  • Question 2 - You are present for the unexpected delivery of a baby in one of...

    Correct

    • You are present for the unexpected delivery of a baby in one of the cubicles in the Emergency Department. Your consultant evaluates the newborn one minute after birth and informs you that:
      The hands and feet appear bluish in color
      The heart rate is 110 beats per minute
      There is no response to stimulation
      There is slight bending of the limbs
      The cry is feeble, and the baby is gasping for breath
      What is the Apgar score of the newborn at one minute?

      Your Answer: 5

      Explanation:

      The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

      Appearance
      Pulse rate
      Grimace
      Activity
      Respiratory effort

      The Apgar score criteria are as follows:

      Score of 0:
      Appearance (skin color): Blue or pale all over
      Pulse rate: Absent
      Reflex irritability (grimace): No response to stimulation
      Activity: None
      Respiratory effort: Absent

      Score of 1:
      Appearance (skin color): Blue at extremities (acrocyanosis)
      Pulse rate: Less than 100 per minute
      Reflex irritability (grimace): Grimace on suction or aggressive stimulation
      Activity: Some flexion
      Respiratory effort: Weak, irregular, gasping

      Score of 2:
      Appearance (skin color): No cyanosis, body and extremities pink
      Pulse rate: More than 100 per minute
      Reflex irritability (grimace): Cry on stimulation
      Activity: Flexed arms and legs that resist extension
      Respiratory effort: Strong, robust cry

    • This question is part of the following fields:

      • Neonatal Emergencies
      34.8
      Seconds
  • Question 3 - A 12-day-old baby girl is brought to the Emergency Department by the community...

    Correct

    • A 12-day-old baby girl is brought to the Emergency Department by the community midwife. She has been having difficulty with feeding, and her mother reports that she has been vomiting after most meals. Her diaper is stained with dark urine, and her mother mentions that her stools have been pale and chalky. She has some bruises on her arms and legs. The midwife has arranged for a heel prick test, which has revealed a total serum bilirubin of 208 mmol/l, with 80% being conjugated.

      What is the SINGLE most likely diagnosis?

      Your Answer: Biliary atresia

      Explanation:

      This infant is displaying prolonged jaundice and failure to thrive. Prolonged jaundice is defined as jaundice that persists beyond the first 14 days of life. Neonatal jaundice can be divided into two categories: unconjugated hyperbilirubinemia, which can be either physiological or pathological, and conjugated hyperbilirubinemia, which is always pathological.

      Causes of prolonged unconjugated hyperbilirubinemia include breast milk jaundice, infections (particularly urinary tract infections), haemolysis (most commonly rhesus haemolytic disease), hypothyroidism, hereditary disorders (such as Crigler-Najjar syndrome), and galactosemia.

      Causes of prolonged conjugated hyperbilirubinemia include biliary atresia, choledochal cysts, and neonatal hepatitis. Conjugated hyperbilirubinemia often presents with symptoms such as failure to thrive, easy bruising or bleeding tendency, dark urine, and pale, chalky stools.

      In this case, the jaundice is clearly conjugated, and the only cause of prolonged conjugated hyperbilirubinemia listed is biliary atresia. To evaluate conjugated hyperbilirubinemia, an ultrasound of the bile ducts and gallbladder should be performed. If dilatation is observed, it may indicate the presence of choledochal cysts, which should be further investigated with a cholangiogram. If the bile ducts and gallbladder appear normal or are not visualized, a radionuclide scan is often conducted. The absence of excretion on the scan is consistent with biliary atresia.

      Biliary atresia is a condition characterized by progressive destruction or absence of the extrahepatic biliary tree and intrahepatic biliary ducts. It is a rare condition, occurring in approximately 1 in 10-15,000 live births in the western world. Infants with biliary atresia typically exhibit jaundice early on, and their stools are pale while their urine is dark starting from the second day of life. If left untreated, the condition will progress to chronic liver failure, leading to portal hypertension and hepatosplenomegaly. Without treatment, death is inevitable.

    • This question is part of the following fields:

      • Neonatal Emergencies
      54
      Seconds
  • Question 4 - A 12 month old is brought into the emergency department by worried parents....

    Incorrect

    • A 12 month old is brought into the emergency department by worried parents. The child has been experiencing diarrhea and has been eating poorly for the past 48 hours. Upon examination, the patient appears alert but shows signs of trembling and excessive sweating. The initial observations are as follows:

      Pulse: 150 bpm
      Respirations: 32 bpm
      Temperature: 37.5ºC
      Oxygen Saturations: 98% on air
      Capillary glucose: 2.2 mmol/l
      Urinalysis: NAD

      What would be the most appropriate next step in managing this patient?

      Your Answer: Administer 10% dextrose solution via intravenous infusion at 2.5 mL/kg over five minutes

      Correct Answer: Squeeze glucogel® into child’s mouth between the patients lower cheek and gum

      Explanation:

      Diabetes Mellitus:
      – Definition: a group of metabolic disorders characterized by persistent hyperglycemia caused by deficient insulin secretion, resistance to insulin, or both.
      – Types: Type 1 diabetes (absolute insulin deficiency), Type 2 diabetes (insulin resistance and relative insulin deficiency), Gestational diabetes (develops during pregnancy), Other specific types (monogenic diabetes, diabetes secondary to pancreatic or endocrine disorders, diabetes secondary to drug treatment).
      – Diagnosis: Type 1 diabetes diagnosed based on clinical grounds in adults presenting with hyperglycemia. Type 2 diabetes diagnosed in patients with persistent hyperglycemia and presence of symptoms or signs of diabetes.
      – Risk factors for type 2 diabetes: obesity, inactivity, family history, ethnicity, history of gestational diabetes, certain drugs, polycystic ovary syndrome, metabolic syndrome, low birth weight.

      Hypoglycemia:
      – Definition: lower than normal blood glucose concentration.
      – Diagnosis: defined by Whipple’s triad (signs and symptoms of low blood glucose, low blood plasma glucose concentration, relief of symptoms after correcting low blood glucose).
      – Blood glucose level for hypoglycemia: NICE defines it as <3.5 mmol/L, but there is inconsistency across the literature.
      – Signs and symptoms: adrenergic or autonomic symptoms (sweating, hunger, tremor), neuroglycopenic symptoms (confusion, coma, convulsions), non-specific symptoms (headache, nausea).
      – Treatment options: oral carbohydrate, buccal glucose gel, glucagon, dextrose. Treatment should be followed by re-checking glucose levels.

      Treatment of neonatal hypoglycemia:
      – Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
      – Initial stat dose of 2 mL/kg over five minutes may be required for severe hypoglycemia.
      – Mild asymptomatic persistent hypoglycemia may respond to a single dose of glucagon.
      – If hypoglycemia is caused by an oral anti-diabetic drug, the patient should be admitted and ongoing glucose infusion or other therapies may be required.

      Note: Patients who have a hypoglycemic episode with a loss of warning symptoms should not drive and should inform the DVLA.

    • This question is part of the following fields:

      • Neonatal Emergencies
      100.2
      Seconds
  • Question 5 - A 2 year old toddler is brought into the resuscitation bay after collapsing...

    Incorrect

    • A 2 year old toddler is brought into the resuscitation bay after collapsing and having a seizure. A capillary blood glucose test shows a reading of 0.9 mmol/L. Your consultant instructs you to initiate an intravenous glucose infusion. What is the most suitable dosage?

      Your Answer: 20 mL/kg/hour of 20% dextrose

      Correct Answer: 5 mL/kg/hour of 10% dextrose

      Explanation:

      Diabetes Mellitus:
      – Definition: a group of metabolic disorders characterized by persistent hyperglycemia caused by deficient insulin secretion, resistance to insulin, or both.
      – Types: Type 1 diabetes (absolute insulin deficiency), Type 2 diabetes (insulin resistance and relative insulin deficiency), Gestational diabetes (develops during pregnancy), Other specific types (monogenic diabetes, diabetes secondary to pancreatic or endocrine disorders, diabetes secondary to drug treatment).
      – Diagnosis: Type 1 diabetes diagnosed based on clinical grounds in adults presenting with hyperglycemia. Type 2 diabetes diagnosed in patients with persistent hyperglycemia and presence of symptoms or signs of diabetes.
      – Risk factors for type 2 diabetes: obesity, inactivity, family history, ethnicity, history of gestational diabetes, certain drugs, polycystic ovary syndrome, metabolic syndrome, low birth weight.

      Hypoglycemia:
      – Definition: lower than normal blood glucose concentration.
      – Diagnosis: defined by Whipple’s triad (signs and symptoms of low blood glucose, low blood plasma glucose concentration, relief of symptoms after correcting low blood glucose).
      – Blood glucose level for hypoglycemia: NICE defines it as <3.5 mmol/L, but there is inconsistency across the literature.
      – Signs and symptoms: adrenergic or autonomic symptoms (sweating, hunger, tremor), neuroglycopenic symptoms (confusion, coma, convulsions), non-specific symptoms (headache, nausea).
      – Treatment options: oral carbohydrate, buccal glucose gel, glucagon, dextrose. Treatment should be followed by re-checking glucose levels.

      Treatment of neonatal hypoglycemia:
      – Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
      – Initial stat dose of 2 mL/kg over five minutes may be required for severe hypoglycemia.
      – Mild asymptomatic persistent hypoglycemia may respond to a single dose of glucagon.
      – If hypoglycemia is caused by an oral anti-diabetic drug, the patient should be admitted and ongoing glucose infusion or other therapies may be required.

      Note: Patients who have a hypoglycemic episode with a loss of warning symptoms should not drive and should inform the DVLA.

    • This question is part of the following fields:

      • Neonatal Emergencies
      18.8
      Seconds
  • Question 6 - Following a postnatal home visit, the community midwife refers a newborn baby with...

    Correct

    • Following a postnatal home visit, the community midwife refers a newborn baby with jaundice. The pediatric team conducts an assessment and investigations, revealing unconjugated hyperbilirubinemia. The suspected underlying cause is extrinsic hemolysis. Which of the following is the most likely diagnosis?

      Your Answer: Haemolytic disease of the newborn

      Explanation:

      Neonatal jaundice is a complex subject, and it is crucial for candidates to have knowledge about the different causes, presentations, and management of conditions that lead to jaundice in newborns. Neonatal jaundice can be divided into two groups: unconjugated hyperbilirubinemia, which can be either physiological or pathological, and conjugated hyperbilirubinemia, which is always pathological.

      The causes of neonatal jaundice can be categorized as follows:

      Haemolytic unconjugated hyperbilirubinemia:
      – Intrinsic causes of haemolysis include hereditary spherocytosis, G6PD deficiency, sickle-cell disease, and pyruvate kinase deficiency.
      – Extrinsic causes of haemolysis include haemolytic disease of the newborn and Rhesus disease.

      Non-haemolytic unconjugated hyperbilirubinemia:
      – Breastmilk jaundice, cephalhaematoma, polycythemia, infection (particularly urinary tract infections), Gilbert syndrome.

      Hepatic conjugated hyperbilirubinemia:
      – Hepatitis A and B, TORCH infections, galactosaemia, alpha 1-antitrypsin deficiency, drugs.

      Post-hepatic conjugated hyperbilirubinemia:
      – Biliary atresia, bile duct obstruction, choledochal cysts.

      By understanding these different categories and their respective examples, candidates will be better equipped to handle neonatal jaundice cases.

    • This question is part of the following fields:

      • Neonatal Emergencies
      44.5
      Seconds
  • Question 7 - You evaluate a teenager with tetralogy of Fallot in a pediatric cardiology clinic.
    Which...

    Incorrect

    • You evaluate a teenager with tetralogy of Fallot in a pediatric cardiology clinic.
      Which of the following is NOT a characteristic of tetralogy of Fallot?

      Your Answer: Ventricular septal defect

      Correct Answer: Left ventricular hypertrophy

      Explanation:

      Tetralogy of Fallot (TOF) is the most prevalent cause of cyanotic congenital heart disease. It is characterized by four distinct features: pulmonary infundibular stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. TOF is often associated with various congenital syndromes, including DiGeorge syndrome (22q11 microdeletion syndrome), Trisomy 21, Foetal alcohol syndrome, and Maternal phenylketonuria.

      Nowadays, many cases of TOF are identified during antenatal screening or early postnatal assessment due to the presence of a heart murmur. Initially, severe cyanosis is uncommon shortly after birth because the patent ductus arteriosus provides additional blood flow to the lungs. However, once the ductus arteriosus closes, typically a few days after birth, cyanosis can develop.

      In cases where TOF goes undetected, the clinical manifestations may include severe cyanosis, poor feeding, breathlessness, dyspnea on exertion (such as prolonged crying), hypercyanotic spells triggered by activity, agitation, developmental delay, and failure to thrive. A cardiac examination may reveal a loud, long ejection systolic murmur caused by pulmonary stenosis, a systolic thrill at the lower left sternal edge, an aortic ejection click, and digital clubbing. Radiologically, a characteristic finding in TOF is a ‘boot-shaped’ heart (Coeur en sabot).

      Treatment for TOF often involves two stages. Initially, a palliative procedure is performed to alleviate symptoms, followed by a total repair at a later stage.

    • This question is part of the following fields:

      • Neonatal Emergencies
      73.2
      Seconds
  • Question 8 - A 6-month-old infant is referred by the community pediatrician following a well-child visit...

    Incorrect

    • A 6-month-old infant is referred by the community pediatrician following a well-child visit with a rash. After an assessment by the dermatology team and subsequent investigations, the infant is discovered to have a localized skin infection. The underlying cause is thought to be bacterial in nature.

      Which of the following is the SINGLE most likely diagnosis?

      Your Answer: Hereditary spherocytosis

      Correct Answer: Alpha 1-antitrypsin deficiency

      Explanation:

      Neonatal jaundice is a complex subject, and it is crucial for candidates to have knowledge about the different causes, presentations, and management of conditions that lead to jaundice in newborns. Neonatal jaundice can be divided into two groups: unconjugated hyperbilirubinemia, which can be either physiological or pathological, and conjugated hyperbilirubinemia, which is always pathological.

      The causes of neonatal jaundice can be categorized as follows:

      Haemolytic unconjugated hyperbilirubinemia:
      – Intrinsic causes of haemolysis include hereditary spherocytosis, G6PD deficiency, sickle-cell disease, and pyruvate kinase deficiency.
      – Extrinsic causes of haemolysis include haemolytic disease of the newborn and Rhesus disease.

      Non-haemolytic unconjugated hyperbilirubinemia:
      – Breastmilk jaundice, cephalhaematoma, polycythemia, infection (particularly urinary tract infections), Gilbert syndrome.

      Hepatic conjugated hyperbilirubinemia:
      – Hepatitis A and B, TORCH infections, galactosaemia, alpha 1-antitrypsin deficiency, drugs.

      Post-hepatic conjugated hyperbilirubinemia:
      – Biliary atresia, bile duct obstruction, choledochal cysts.

      By understanding these different categories and their respective examples, candidates will be better equipped to handle neonatal jaundice cases.

    • This question is part of the following fields:

      • Neonatal Emergencies
      17.7
      Seconds
  • Question 9 - A 6-week-old baby girl is brought in to the Emergency Department by her...

    Correct

    • A 6-week-old baby girl is brought in to the Emergency Department by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can palpate a small mass in the upper abdomen. A venous blood gas is performed.
      What metabolic picture would you anticipate observing on the venous blood gas?

      Your Answer: Hypochloraemic metabolic alkalosis

      Explanation:

      Infantile hypertrophic pyloric stenosis is a condition characterized by the thickening and enlargement of the smooth muscle in the antrum of the stomach, leading to the narrowing of the pyloric canal. This narrowing can easily cause obstruction. It is a relatively common condition, occurring in about 1 in 500 live births, and is more frequently seen in males than females, with a ratio of 4 to 1. It is most commonly observed in first-born male children, although it can rarely occur in adults as well.

      The main symptom of infantile hypertrophic pyloric stenosis is vomiting, which typically begins between 2 to 8 weeks of age. The vomit is usually non-bilious and forcefully expelled. It tends to occur around 30 to 60 minutes after feeding, leaving the baby hungry despite the vomiting. In some cases, there may be blood in the vomit. Other clinical features include persistent hunger, dehydration, weight loss, and constipation. An enlarged pylorus, often described as olive-shaped, can be felt in the right upper quadrant or epigastric in approximately 95% of cases. This is most noticeable at the beginning of a feed.

      The typical acid-base disturbance seen in this condition is hypochloremic metabolic alkalosis. This occurs due to the loss of hydrogen and chloride ions in the vomit, as well as decreased secretion of pancreatic bicarbonate. The increased bicarbonate ions in the distal tubule of the kidney lead to the production of alkaline urine. Hyponatremia and hypokalemia are also commonly present.

      Ultrasound scanning is the preferred diagnostic tool for infantile hypertrophic pyloric stenosis, as it is reliable and easy to perform. It has replaced barium studies as the investigation of choice.

      Initial management involves fluid resuscitation, which should be tailored to the weight and degree of dehydration. Any electrolyte imbalances should also be corrected.

      The definitive treatment for this condition is surgical intervention, with the Ramstedt pyloromyotomy being the procedure of choice. Laparoscopic pyloromyotomy is also an effective alternative if suitable facilities are available. The prognosis for infants with this condition is excellent, as long as there is no delay in diagnosis and treatment initiation.

    • This question is part of the following fields:

      • Neonatal Emergencies
      40.7
      Seconds
  • Question 10 - A 3-day old, extremely low birth weight baby develops respiratory distress and symptoms...

    Incorrect

    • A 3-day old, extremely low birth weight baby develops respiratory distress and symptoms of sepsis. The baby was born prematurely at 32 weeks gestation. A diagnosis of neonatal pneumonia is suspected.
      What is the SINGLE most probable causative organism?

      Your Answer:

      Correct Answer: Escherichia Coli

      Explanation:

      Pneumonia in newborns is typically caused by organisms that inhabit the mother’s genital tract. Despite the widespread use of chemoprophylaxis to prevent maternal carriage, Group B haemolytic Streptococcus remains a common culprit in early-onset infections in full-term and near-term infants aged less than three days. Among very low birth weight infants, Escherichia Coli is the most frequently encountered bacterial strain. Additionally, neonatal pneumonia can be caused by other bacteria such as Chlamydia trachomatis, Listeria monocytogenes, and Haemophilus influenzae.

    • This question is part of the following fields:

      • Neonatal Emergencies
      0
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SESSION STATS - PERFORMANCE PER SPECIALTY

Neonatal Emergencies (4/9) 44%
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