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  • Question 1 - A child is born at term after an uneventful pregnancy and full antenatal...

    Correct

    • A child is born at term after an uneventful pregnancy and full antenatal care. The delivery is normal and the child was discharged after 48 hours. At five days old the child is jaundiced. There are no other worrying features.
      According to the National Institute for Health and Care Excellence, what is the most appropriate first-line investigation?

      Your Answer: Transcutaneous bilirubin level

      Explanation:

      Jaundice is a common condition in newborns, affecting up to 60% of term infants and 80% of preterm infants. Physiological jaundice, which is more common in breastfed babies, typically appears after the first 24 hours of life and resolves by 14 days after birth. To diagnose physiological jaundice, the National Institute for Health and Care Excellence recommends measuring the baby’s total bilirubin level within 6 hours of presentation using a transcutaneous monitor or serum blood test. If the bilirubin level is not above the phototherapy threshold, further tests are usually not necessary unless the baby becomes unwell, more jaundiced, or the jaundice persists past 10 days of age. Liver function tests may be considered if a pathological cause is suspected, but are not typically indicated for physiological jaundice. Direct Coombs’ test may be necessary if haemolysis is suspected, but this is less likely if the mother received standard antenatal care. An accurate bilirubin measurement is important to prevent the development of kernicterus, a severe neurological condition. Split bilirubin levels may be considered if the jaundice persists for more than 14 days or if the baby is unwell.

    • This question is part of the following fields:

      • Children And Young People
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  • Question 2 - A 7-year-old child is brought to the Emergency Department by his parents as...

    Incorrect

    • A 7-year-old child is brought to the Emergency Department by his parents as he is experiencing worsening breathing difficulties. The child has a history of asthma and has been hospitalized twice before due to exacerbations. During the examination, the child's oxygen saturation is at 90% on air, heart rate is 140 beats/minute, respiratory rate is 40 breaths/minute, and he is using accessory muscles to breathe. Additionally, he is having difficulty completing full sentences.

      Which aspect of the child's medical history indicates a potentially life-threatening exacerbation?

      Your Answer: Difficulty completing full sentences

      Correct Answer:

      Explanation:

      Severe asthma exacerbation is characterized by the following: difficulty in completing full sentences, use of accessory muscles, respiratory rate of 40 breaths/ min, and a heart rate of 140 breaths/ min.

      Assessing the severity of asthma attacks in children is crucial for effective management. The 2016 BTS/SIGN guidelines provide criteria for assessing the severity of asthma in general practice. These criteria include measuring SpO2 levels, PEF (peak expiratory flow) rates, heart rate, respiratory rate, use of accessory neck muscles, and other symptoms such as breathlessness, agitation, altered consciousness, and cyanosis.

      A severe asthma attack is characterized by a SpO2 level below 92%, PEF rates between 33-50% of the best or predicted, being too breathless to talk or feed, and a high heart and respiratory rate. On the other hand, a life-threatening asthma attack is indicated by a SpO2 level below 92%, PEF rates below 33% of the best or predicted, a silent chest, poor respiratory effort, use of accessory neck muscles, agitation, altered consciousness, and cyanosis.

      It is important for healthcare professionals to be familiar with these criteria to ensure prompt and appropriate management of asthma attacks in children. Early recognition of the severity of an asthma attack can help prevent complications and reduce the risk of hospitalization or death.

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      • Children And Young People
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  • Question 3 - Sophie is a 2-year-old girl who is brought in by her father. She...

    Incorrect

    • Sophie is a 2-year-old girl who is brought in by her father. She has had a fever overnight, along with a sore throat and cough. Her father is worried that she seems more tired than usual today. During the examination, you note the following:

      Temperature 38.5 degrees
      Heart rate 160 bpm
      Respiratory rate 40 / min
      Oxygen saturation 95%

      The lungs are clear, but there is inflammation and redness in the throat, and there are swollen lymph nodes in the neck.

      According to the NICE traffic light system for assessing fever in children, which of the following is considered 'amber'?

      Your Answer: Temperature 38 degrees

      Correct Answer: Heart rate 155 bpm

      Explanation:

      The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013 to provide a ‘traffic light’ system for assessing the risk of febrile illness in children under 5 years old. The guidelines recommend recording the child’s temperature, heart rate, respiratory rate, and capillary refill time, as well as looking for signs of dehydration. Measuring temperature should be done with an electronic thermometer in the axilla for children under 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer. The risk stratification table categorizes children as green (low risk), amber (intermediate risk), or red (high risk) based on their symptoms. Management recommendations vary depending on the risk level, with green children managed at home, amber children provided with a safety net or referred to a specialist, and red children urgently referred to a specialist. The guidelines also advise against prescribing oral antibiotics without an apparent source of fever and note that a chest x-ray is not necessary if a child with suspected pneumonia is not being referred to the hospital.

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      • Children And Young People
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  • Question 4 - A mother of a 9-month-old seeks guidance. Initially, she opted out of the...

    Incorrect

    • A mother of a 9-month-old seeks guidance. Initially, she opted out of the oral rotavirus vaccine for her child to limit the number of immunisations. However, due to an outbreak at her baby's daycare, she now desires the vaccine. What should she do?

      Your Answer: Advise that the vaccine is not available on the NHS and it would need to be done privately

      Correct Answer: Explain that is no longer safe to give the vaccine to her child

      Explanation:

      The oral rotavirus vaccine must be administered before 15 weeks for the first dose.

      The Rotavirus Vaccine: A Vital Tool in Preventing Childhood Mortality

      Rotavirus is a significant public health concern, causing high rates of morbidity and hospitalization in developed countries and childhood mortality in developing nations. To combat this, a vaccine was introduced into the NHS immunization program in 2013. The vaccine is an oral, live attenuated vaccine that requires two doses, the first at two months and the second at three months. It is important to note that the first dose should not be given after 14 weeks and six days, and the second dose cannot be given after 23 weeks and six days due to the theoretical risk of intussusception.

      The vaccine is highly effective, with an estimated efficacy rate of 85-90%, and is predicted to reduce hospitalization rates by 70%. Additionally, the vaccine provides long-term protection against rotavirus. The introduction of the rotavirus vaccine is a vital tool in preventing childhood mortality and reducing the burden of rotavirus-related illness.

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      • Children And Young People
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  • Question 5 - A mother brings her 10 week old baby to your morning GP clinic...

    Correct

    • A mother brings her 10 week old baby to your morning GP clinic with a three day history of noisy breathing, coryza, reduced feeding, and increased fussiness. What signs would prompt you to consider admitting the infant?

      Your Answer: Feeding less than 50% of normal

      Explanation:

      If a child with bronchiolitis displays any high risk signs, it is important to admit them for support with feeding to prevent dehydration. The NICE CKS provides a comprehensive list of these signs, which include a respiratory rate exceeding 60 per minute, intermittent apnoea, grunting, moderate or severe chest in-drawing, cyanosis, pale, ashen, mottled or blue skin color, lack of response to social cues, inability to be roused or stay awake, and appearing ill. Reduced skin turgor is also a sign of dehydration to watch out for.

      Understanding Bronchiolitis

      Bronchiolitis is a condition that is characterized by inflammation of the bronchioles. It is a serious lower respiratory tract infection that is most common in children under the age of one year. The pathogen responsible for 75-80% of cases is respiratory syncytial virus (RSV), while other causes include mycoplasma and adenoviruses. Bronchiolitis is more serious in children with bronchopulmonary dysplasia, congenital heart disease, or cystic fibrosis.

      The symptoms of bronchiolitis include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Fine inspiratory crackles may also be present. Children with bronchiolitis may experience feeding difficulties associated with increasing dyspnoea, which is often the reason for hospital admission.

      Immediate referral to hospital is recommended if the child has apnoea, looks seriously unwell to a healthcare professional, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referring to hospital if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration.

      The investigation for bronchiolitis involves immunofluorescence of nasopharyngeal secretions, which may show RSV. Management of bronchiolitis is largely supportive, with humidified oxygen given via a head box if oxygen saturations are persistently < 92%. Nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth, and suction is sometimes used for excessive upper airway secretions.

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      • Children And Young People
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  • Question 6 - A 16-year-old boy is brought to surgery by his father.
    He has symptoms...

    Correct

    • A 16-year-old boy is brought to surgery by his father.
      He has symptoms of a moderate depression and has been recommended pharmacological therapy by another health professional. You refer him to the local young people's mental health service for further treatment. His father asks about medication, as he is on citalopram himself for depression.
      What is the recommended first line antidepressant medication for adolescents with moderate depression?

      Your Answer: Fluoxetine

      Explanation:

      Treatment Recommendations for Children and Young People with Depression

      Children and young people who present with moderate to severe depression should be assessed by a CAMHS team. The first-line treatment for depression in this population is fluoxetine, as it is the only antidepressant for which the benefits outweigh the risks. According to NICE NG134, combined therapy with fluoxetine and psychological therapy should be considered as an alternative to psychological therapy followed by combined therapy for initial treatment of moderate to severe depression in young people aged 12-18 years. Patients taking St John’s wort should be advised to discontinue it when starting antidepressants. Tricyclics should not be used, and citalopram and sertraline are considered suitable second-line treatments.

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      • Children And Young People
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  • Question 7 - A 10-year-old girl is brought to the hospital after falling off her bike...

    Correct

    • A 10-year-old girl is brought to the hospital after falling off her bike and fracturing her leg. She is experiencing a lot of pain and requests pain medication.

      Which of the following analgesics is not recommended for use in pediatric patients?

      Your Answer: Aspirin

      Explanation:

      The use of aspirin as a pain reliever is not recommended for children because it can increase the risk of Reye’s syndrome. This condition is characterized by symptoms such as fever, rash, and vomiting, which can quickly progress to encephalopathy and even lead to death.

      However, aspirin is approved for use in treating Kawasaki disease and as an antiplatelet medication to prevent blood clots after surgery.

      Reye’s syndrome is a serious condition that affects children and causes progressive brain damage. It is often accompanied by the accumulation of fat in the liver, kidneys, and pancreas. The exact cause of Reye’s syndrome is not fully understood, but it is believed to be associated with the use of aspirin and viral infections. The condition is most common in children around 2 years of age and is characterized by confusion, seizures, and coma. Treatment for Reye’s syndrome is primarily supportive, and while the prognosis has improved in recent years, there is still a mortality rate of 15-25%.

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      • Children And Young People
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  • Question 8 - A 14-year-old teenage girl comes to the clinic with concerns about delayed puberty...

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    • A 14-year-old teenage girl comes to the clinic with concerns about delayed puberty as she has not yet started her menstrual cycle. She reports feeling generally well and has no significant medical history.

      During the examination, it is noted that she has a slender build and underdeveloped breasts. There is no pubic hair growth. Her abdomen is soft and non-tender, but there are small lumps in her groin area on both sides.

      What is the probable cause of this presentation?

      Your Answer: Androgen insensitivity

      Explanation:

      The classic presentation of androgen insensitivity is primary amenorrhoea, which is accompanied by groin swellings and absence of pubic hair. These symptoms suggest that the patient has undescended testes and is genetically male (46 XY) but phenotypically female due to increased oestradiol levels. Breast development is a common result of this condition, previously known as testicular feminisation syndrome.

      While non-Hodgkin’s lymphoma could also cause groin swellings, it is less likely to be the cause of delayed puberty and would typically present with systemic symptoms.

      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 gonadotrophins and low levels of testosterone. Patients with this condition often have small, firm testes, lack secondary sexual characteristics, and are infertile. They may also experience gynaecomastia, which increases their risk of breast cancer. Diagnosis is made through chromosomal analysis.

      Hypogonadotrophic hypogonadism, or Kallman’s syndrome, is a cause of delayed puberty due to low levels of sex hormones. It is usually inherited as an X-linked recessive trait and is caused by the failure of GnRH-secreting neurons to migrate to the hypothalamus. Patients with this condition may have hypogonadism, cryptorchidism, anosmia, and low sex hormone levels. However, their LH and FSH levels are inappropriately low or normal. They are typically of normal or above-average height, but may also have cleft lip/palate and visual/hearing defects.

      Androgen insensitivity syndrome is an X-linked recessive condition that causes end-organ resistance to testosterone, resulting in genotypically male children (46 XY) having a female phenotype. This condition is also known as complete androgen insensitivity syndrome or testicular feminisation syndrome. Patients with this condition 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 46 XY genotype. Management involves counselling to raise the child as female, bilateral orchidectomy to reduce the risk of testicular cancer due to undescended testes, and oestrogen therapy.

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      • Children And Young People
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  • Question 9 - The likelihood of a 34-year-old mother having a baby with Down's syndrome is...

    Incorrect

    • The likelihood of a 34-year-old mother having a baby with Down's syndrome is roughly:

      Your Answer: 1 in 1,000

      Correct Answer: 1 in 275

      Explanation:

      The risk of Down’s syndrome is 1 in 1,000 at the age of 30, and this risk decreases by a factor of 3 for every 5 years.

      Down’s Syndrome: Epidemiology and Genetics

      Down’s syndrome is a genetic disorder that is caused by the presence of an extra copy of chromosome 21. The risk of having a child with Down’s syndrome increases with maternal age, with a 1 in 1,500 chance at age 20 and a 1 in 50 or greater chance at age 45. This can be remembered by dividing the denominator by 3 for every extra 5 years of age starting at 1/1,000 at age 30.

      There are three main types of Down’s syndrome: nondisjunction, Robertsonian translocation, and mosaicism. Nondisjunction accounts for 94% of cases and occurs when the chromosomes fail to separate properly during cell division. Robertsonian translocation, which usually involves chromosome 14, accounts for 5% of cases and occurs when a piece of chromosome 21 attaches to another chromosome. Mosaicism, which accounts for 1% of cases, occurs when there are two genetically different populations of cells in the body.

      The risk of recurrence for Down’s syndrome varies depending on the type of genetic abnormality. If the trisomy 21 is a result of nondisjunction, the chance of having another child with Down’s syndrome is approximately 1 in 100 if the mother is less than 35 years old. If the trisomy 21 is a result of Robertsonian translocation, the risk is much higher, with a 10-15% chance if the mother is a carrier and a 2.5% chance if the father is a carrier.

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      • Children And Young People
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  • Question 10 - A 14-month-old boy presents with eye-rolling followed by generalised shaking of the limbs...

    Correct

    • A 14-month-old boy presents with eye-rolling followed by generalised shaking of the limbs for three minutes. He has had a cold for two days, but became very warm this morning just prior to the episode. He has no previous history of note, and had a full term normal delivery with no neonatal complications. His immunisations are up to date. There is no family history of note. On examination he is alert though febrile at 39.2°C, with flushed cheeks. He has a runny nose. Respiratory rate is 22/min and heart rate 130/min. His chest is clear and urinalysis is negative. What is the most likely diagnosis?

      Your Answer: Febrile convulsion, simple

      Explanation:
      • Febrile Convulsion, Simple:
        • Characteristics:
          • Occurs between 6 months and 5 years of age.
          • Associated with fever, often due to viral infections.
          • Generalized tonic-clonic seizure lasting less than 15 minutes.
          • No recurrence within 24 hours.
          • Rapid return to baseline consciousness.
        • In this case: The seizure lasted three minutes and was generalized, fitting the criteria for a simple febrile seizure.
      • Febrile Convulsion, Complex:
        • Characteristics:
          • Lasts longer than 15 minutes.
          • Focal (affects only part of the body) or recurrent within 24 hours.
          • May not return to baseline quickly.
        • In this case: The seizure was generalized and lasted only three minutes, making it unlikely to be a complex febrile seizure.
      • Encephalitis:
        • Characteristics:
          • Typically presents with fever, seizures, altered mental status, and focal neurological deficits.
          • Seizures may be recurrent or focal.
        • In this case: The child does not exhibit altered mental status or focal neurological signs post-seizure.
      • Meningitis:
        • Characteristics:
          • Presents with fever, irritability, poor feeding, lethargy, and possibly neck stiffness or bulging fontanelle in infants.
          • May include seizures, but other symptoms like irritability and lethargy are more pronounced.
        • In this case: The child is alert post-seizure, and there are no signs of meningismus or altered mental status.
      • Cerebral Abscess:
        • Characteristics:
          • Usually presents with focal neurological signs, headache, fever, and possibly seizures.
          • More common in children with a history of sinusitis or otitis media.
        • In this case: There is no focal neurological deficit or history suggestive of conditions leading to an abscess.

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      • Children And Young People
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  • Question 11 - A 9-year-old child is waiting in the GP's office when he suddenly experiences...

    Correct

    • A 9-year-old child is waiting in the GP's office when he suddenly experiences facial swelling and difficulty breathing. An elderly patient is snacking on a bag of cashew nuts in the waiting room. The patient is in good health and had come with his mother for her appointment. As the attending GP, you diagnose the child with anaphylaxis. What would be the appropriate dosage of adrenaline to administer?

      Your Answer: Adrenaline 300 mcg IM STAT

      Explanation:

      If a child between the ages of 6 and 11 is experiencing an anaphylactic reaction, they should be given a dose of 300 micrograms (0.3ml) of adrenaline. This dose can be repeated every 5 minutes if necessary. Based on the patient’s age of 8 years old, it is recommended to administer the adrenaline at a dose of 300 micrograms IM immediately, as stated in the BNF. It is likely that the child is having an anaphylactic reaction to the nuts they were exposed to in the GP waiting room.

      Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.

      The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.

      Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12

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  • Question 12 - You are seeing a 5-year-old boy in clinic who has a history of...

    Correct

    • You are seeing a 5-year-old boy in clinic who has a history of multiple wheezy episodes over the past 4 years and was diagnosed with asthma. He was admitted 5 months ago with shortness-of-breath and wheeze and was diagnosed with a viral exacerbation of asthma. He was prescribed Clenil (beclomethasone dipropionate) inhaler 50mcg bd and salbutamol 100 mcg prn via a spacer before discharge. His mother reports that he has a persistent night-time cough and is regularly using his salbutamol inhaler. On clinical examination, his chest appears normal.

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

      Your Answer: Add a leukotriene receptor antagonist

      Explanation:

      Managing Asthma in Children: NICE Guidelines

      The National Institute for Health and Care Excellence (NICE) released guidelines in 2017 for the management of asthma in children aged 5-16. These guidelines follow a stepwise approach, with treatment options based on the severity of the child’s symptoms. For newly-diagnosed asthma, short-acting beta agonists (SABA) are recommended. If symptoms persist or worsen, a combination of SABA and paediatric low-dose inhaled corticosteroids (ICS) may be used. Leukotriene receptor antagonists (LTRA) and long-acting beta agonists (LABA) may also be added to the treatment plan.

      For children under 5 years old, clinical judgement plays a greater role in diagnosis and treatment. The stepwise approach for this age group includes an 8-week trial of paediatric moderate-dose ICS for newly-diagnosed asthma or uncontrolled symptoms. If symptoms persist, a combination of SABA and paediatric low-dose ICS with LTRA may be used. If symptoms still persist, referral to a paediatric asthma specialist is recommended.

      It is important to note that NICE doesn’t recommend changing treatment for patients with well-controlled asthma simply to adhere to the latest guidelines. Additionally, maintenance and reliever therapy (MART) may be used for combined ICS and LABA treatment, but only for LABAs with a fast-acting component. The definitions for low, moderate, and high-dose ICS have also changed, with different definitions for children and adults.

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  • Question 13 - A father brings his twelve-year-old daughter to see you in your GP practice...

    Correct

    • A father brings his twelve-year-old daughter to see you in your GP practice as she has been struggling with sports at school. She has been complaining of steadily worsening pain, which is vaguely located above her right knee, for the past two weeks. Her father says that this has been particularly upsetting for her as she has been trying to lose weight. She is systemically well otherwise. Examination of the right knee joint is normal as is neurological examination of the lower limbs.

      What is the most crucial diagnosis to rule out?

      Your Answer: Slipped upper femoral epiphysis

      Explanation:

      Slipped capital femoral epiphysis can be difficult to diagnose as it can present insidiously and sometimes only with referred knee pain. Therefore, a high level of suspicion is necessary to avoid potential legal issues. It is crucial to rule out this condition with a hip x-ray. On the other hand, Osgood-Schlatter disease usually causes lower knee pain and tenderness over the tibial apophysis, while chondromalacia patellae typically results in anterior knee pain and can be treated conservatively with physiotherapy and non-steroidal anti-inflammatory drugs.

      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 is typically seen in children between the ages of 10 and 15 years. It is more common in obese children and boys. This condition is characterized by the displacement of the femoral head epiphysis postero-inferiorly, which may present acutely following trauma or more commonly with chronic, persistent symptoms.

      The features of slipped capital femoral epiphysis include hip, groin, medial thigh, or knee pain, as well as loss of internal rotation of the leg in flexion. In 20% of cases, a bilateral slip may occur. To diagnose this condition, AP and lateral (typically frog-leg) views are used.

      The management of slipped capital femoral epiphysis involves internal fixation, typically with a single cannulated screw placed 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 can cause significant pain and discomfort in children. Early diagnosis and management are crucial to prevent complications and ensure a good outcome.

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  • Question 14 - A 6-year-old boy is brought to the clinic by his father who reports...

    Correct

    • A 6-year-old boy is brought to the clinic by his father who reports that he has been experiencing nocturnal coughing for the past three months. The father has observed that his son frequently wakes up at night due to coughing fits. Despite two previous rounds of antibiotics, the cough has not improved. The child is generally healthy, has a good appetite, and has met all developmental milestones for his age. On examination, there are no notable findings. What would be your plan of action?

      Your Answer: Monitored initiation of metered dose inhaler (short acting beta agonist ) with spacer

      Explanation:

      Managing Suspected Asthma in Children

      Asthma is a possible diagnosis in children with a family history of atopy. If a child cannot perform spirometry, management options depend on their symptoms. Asymptomatic children may be monitored, while symptomatic children may be offered a carefully monitored trial of treatment. Oral bronchodilators and cough suppressants are not effective, and further antibiotics are futile. Nebulised bronchodilators are only appropriate during an acute attack. A trial of inhaled bronchodilators (MDI with spacer) may be justified, but establishing the diagnosis should be the top priority. It is unlikely that a four-year-old child would be able to perform spirometry successfully with reversibility.

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  • Question 15 - A 5-year-old boy is brought to the emergency room by his mother. He...

    Incorrect

    • A 5-year-old boy is brought to the emergency room by his mother. He was playing on the monkey bars at the playground and fell off, landing on his right arm. He started crying and complained that his right elbow hurt. He is now reluctant to move the elbow and holds it slightly flexed and pronated with the forearm held against the abdomen. There is no tenderness, swelling, bruising or deformity at the elbow.
      Which is the MOST LIKELY diagnosis?

      Your Answer: Supracondylar fracture of the humerus

      Correct Answer: Radial head subluxation

      Explanation:

      Common Elbow Injuries in Children and Adults

      Radial head subluxation is a frequent injury in children under the age of 6 years. The rounded end of the radial head is still made of cartilage and can easily slip out of the encircling annular ligament when the arm is pulled. There is usually no history of trauma, but there may be a history of axial traction by a pull on the hand or wrist. Tenderness at the head of the radius may be present. Imaging is only necessary when a fracture is suspected. Manipulation can be done in the GP surgery by immobilizing the elbow with one hand and with the other hand applying axial compression while supinating the forearm and flexing the elbow. Alternatively, it can be done while pronating the forearm. A click indicates success.

      Supracondylar fracture of the humerus is most commonly seen in children and usually results from a fall on to an outstretched arm. The patient usually has elbow swelling and pain.

      Lateral epicondylitis (tennis elbow) is a chronic condition that peaks between 40 and 50 years of age. It is thought to be an overload tendon injury.

      Radial neck fracture occurs due to trauma such as a fall onto the outstretched arm. The median age is 9–10 years. There is pain, swelling, and tenderness over the lateral side of the elbow.

      In cases of suspected non-accidental injury, the explanation should be consistent with the injury, and in the absence of other features, non-accidental injury is unlikely.

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  • Question 16 - A toddler boy is now 2 years old, having been born at 34...

    Incorrect

    • A toddler boy is now 2 years old, having been born at 34 weeks’ gestation. You see his mother during a follow-up appointment and she expresses concerns about potential complications of prematurity during early childhood.
      Which of these problems is MOST LIKELY to be a complication of preterm (premature) birth during early childhood?

      Your Answer: Developmental dysplasia of the hip

      Correct Answer: Blindness

      Explanation:

      Health Risks Associated with Premature Birth

      Premature birth, defined as birth before 37 weeks of gestation, can lead to a range of health problems for the newborn. These include cerebral palsy, blindness, deafness, learning disabilities, motor function problems, and speech and language problems. Premature infants are also at an increased risk of having special educational needs. The risk of these health problems is higher for infants born at earlier gestational ages and with lower birthweights.

      One specific visual problem that premature infants may experience is retinopathy of prematurity, a vascular disorder of the immature retina. Additionally, premature infants are at an increased risk of developing chronic kidney disease during adulthood, although the reason for this is not clear.

      However, not all health problems are associated with premature birth. Cystic fibrosis, for example, is caused by an autosomal-recessive gene and is not more prevalent in premature infants. Similarly, congenital adrenal hyperplasia is caused by several autosomal-recessive genes and is not more prevalent in premature infants. Developmental dysplasia of the hip, while more common in infants with neuromuscular disorders, is not commonly associated with prematurity.

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  • Question 17 - A 20-year-old male visits his GP clinic as he is preparing to start...

    Incorrect

    • A 20-year-old male visits his GP clinic as he is preparing to start university in a few months. His friends have advised him to get vaccinated before he begins. He is of 'White British' ethnicity, has a clean medical history, and will be studying English at the University of Manchester. Which vaccine should he receive as part of the standard NHS immunisation program?

      Your Answer: Human papillomavirus

      Correct Answer: Meningitis ACWY

      Explanation:

      Due to a recent surge in meningitis W cases, the NHS is now advising all incoming students to receive the meningitis ACWY vaccine.

      The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at specific intervals. At 12-13 months, the Hib/Men C, MMR, PCV, and Men B vaccines are given. At 3-4 years, the ‘4-in-1 Preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

      It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine is also offered to new students up to the age of 25 years at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine, while students going to university or college for the first time should contact their GP to have the vaccine before the start of the academic year.

      The Men C vaccine used to be given at 3 months but has now been discontinued as there are almost no cases of Men C disease in babies or young children in the UK. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

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  • Question 18 - A 6-year-old girl is brought in by her father. She was feeling a...

    Incorrect

    • A 6-year-old girl is brought in by her father. She was feeling a bit sick yesterday with a fever, tiredness, and a sore throat. Today, her father is concerned as he has noticed 'blisters' in and around her mouth and she is refusing to eat or drink. During the examination, the child appears unhappy but not seriously ill, her temperature is 38.2ºC and she has a combination of shallow ulcers and red papules scattered over her hard palate, tongue, and lips. Upon further examination, a few red maculopapular lesions are also visible along the sides of her fingers, around her left heel, and over her buttocks. What is the most probable diagnosis?

      Your Answer: Chickenpox

      Correct Answer: Hand, foot and mouth disease

      Explanation:

      Hand foot and mouth disease is the correct answer. The patient’s history reveals a mild illness with symptoms such as systemic upset, sore throat, and fever, followed by the appearance of oral ulcers and lesions on the hands and feet. It is worth noting that the lesions may also be present in the groin or buttocks area. The rash is characterized by scattered erythematous macules and papules, usually with a central greyish vesicle measuring around 25 mm.

      Hand, Foot and Mouth Disease: A Contagious Condition in Children

      Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.

      The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.

      Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.

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  • Question 19 - A worried father brings his 14 month old child into the clinic, concerned...

    Correct

    • A worried father brings his 14 month old child into the clinic, concerned that he is not walking. He says that many other children his age in his playgroup are already walking but his child is still crawling.

      At what age would you consider referring a child who is not yet walking?

      Your Answer: 18 months

      Explanation:

      Further assessment should be sought if a child is unable to walk without support by the age of 18 months.

      Gross Motor Developmental Milestones

      Gross motor developmental milestones refer to the physical abilities that a child acquires as they grow and develop. These milestones are important indicators of a child’s overall development and can help parents and healthcare professionals identify any potential delays or concerns. The table below summarizes the major gross motor developmental milestones from 3 months to 4 years of age.

      At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to pull themselves to a sitting position and roll from front to back. At 9 months, they should be able to crawl and pull themselves to a standing position. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. Finally, at 4 years, they should be able to hop on one leg.

      It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. By monitoring a child’s gross motor developmental milestones, parents and healthcare professionals can ensure that they are meeting their developmental goals and identify any potential concerns early on.

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  • Question 20 - A 5-year-old girl is brought in for surgery. Her mother reports that her...

    Correct

    • A 5-year-old girl is brought in for surgery. Her mother reports that her stools have always been firm and for the past two weeks, she has been taking a combination of lactulose (10ml bd) and senna (2 tablets od) prescribed by a colleague. However, she is still only passing a hard stool every 2-3 days. The clinical examination shows no abnormalities. What is the best course of action to take next?

      Your Answer: Switch the lactulose for a macrogol (Movicol Paediatric Plain)

      Explanation:

      Understanding Constipation in Children

      Constipation is a common problem in children, and its frequency varies with age. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the diagnosis and management of constipation in children. A diagnosis of constipation is suggested by two or more symptoms, including infrequent bowel movements, hard stools, and symptoms associated with defecation. The vast majority of children have no identifiable cause, but other causes include dehydration, low-fiber diet, medications, anal fissure, over-enthusiastic potty training, hypothyroidism, Hirschsprung’s disease, hypercalcemia, and learning disabilities.

      After making a diagnosis of constipation, NICE suggests excluding secondary causes. If no red or amber flags are present, a diagnosis of idiopathic constipation can be made. Prior to starting treatment, the child needs to be assessed for fecal impaction. NICE guidelines recommend using polyethylene glycol 3350 + electrolytes as the first-line treatment for faecal impaction. Maintenance therapy is also recommended, with adjustments to the starting dose.

      It is important to note that dietary interventions alone should not be used as first-line treatment. Regular toileting and non-punitive behavioral interventions should also be considered. For infants not yet weaned, gentle abdominal massage and bicycling the infant’s legs can be helpful. For weaned infants, extra water, diluted fruit juice, and fruits can be offered, and lactulose can be added if necessary.

      In conclusion, constipation in children can be effectively managed with proper diagnosis and treatment. It is important to follow NICE guidelines and consider the individual needs of each child. Parents can also seek support from Health Visitors or Paediatric Continence Advisors.

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  • Question 21 - Which patient among these needs diagnostic evaluation? ...

    Incorrect

    • Which patient among these needs diagnostic evaluation?

      Your Answer: A 15-year-old girl with primary amenorrhea who doesn't have secondary sexual characteristics

      Correct Answer: A 15-year-old girl with primary amenorrhea who has normal secondary sexual characteristics

      Explanation:

      Puberty and Menarche

      Puberty typically starts around the age of 10, with menarche occurring between 11 and 15 years old. If there are no signs of secondary sexual characteristic development by the age of 14, it may be necessary to investigate. However, if other secondary sexual characteristics are developing normally, it is reasonable to wait until the age of 16 before considering further investigation.

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  • Question 22 - What immunizations are advised for a child between the ages of 14 and...

    Incorrect

    • What immunizations are advised for a child between the ages of 14 and 16?

      Your Answer: MMR

      Correct Answer: Haemophilus influenza B

      Explanation:

      Recommended Vaccinations for Adolescents

      A booster vaccination for tetanus and diphtheria is required for adolescents between the ages of 14 and 16. It is recommended that these boosters be administered every 10 years thereafter. In some countries, a second dose of the MMR vaccine is given at age 12. The BCG vaccine is not routinely given, but is offered to individuals who are at risk. It is important for adolescents to stay up-to-date on their vaccinations to protect themselves and those around them from preventable diseases.

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  • Question 23 - A father requests access to his 16-year-old son's medical records. He is in...

    Correct

    • A father requests access to his 16-year-old son's medical records. He is in the process of separating from his son's mother, and they have been married for twenty-five years.

      What is the most appropriate action in this case?

      Your Answer: Seek consent from the son, and if he is competent, disclose only information that is not prejudicial to a third party with his consent

      Explanation:

      Confidential Medical Records for Adolescents

      When it comes to disclosing confidential medical records of a 15-year-old adolescent, it is important to consider their maturity level. If they are deemed ‘Gillick’ competent, then their decision to disclose or withhold their medical record should be respected. However, practitioners must carefully review any third-party information and any information that may cause harm to an individual’s physical or mental health. If necessary, this information can be withheld under the Data Protection Act 1998. It is crucial to handle confidential medical records with care to protect the privacy and well-being of adolescents.

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  • Question 24 - A mother brings in her 8 week old baby girl and reports that...

    Correct

    • A mother brings in her 8 week old baby girl and reports that she has noticed that the lips of her baby's vagina appear 'sewn' together. She has also noticed that since birth the baby always cries when urinating. On examination you note that the child has a normal vagina, however it appears that the labia minora are fused together.

      What would be your next step in management?

      Your Answer: Trial of topical oestrogen cream

      Explanation:

      In infant girls, the labia minora may fuse together due to low levels of estrogen. This typically doesn’t cause any symptoms, but in some cases, it may lead to discomfort or pain during urination. Fortunately, labial adhesions usually resolve on their own during puberty and do not have any lasting effects. Treatment is typically unnecessary unless there is pain or discomfort, in which case a brief course of topical estrogen cream may be beneficial.

      Labial Adhesions: Causes, Symptoms, and Treatment

      Labial adhesions refer to the fusion of the labia minora in the middle, which is commonly observed in girls aged between 3 months and 3 years. This condition can be treated conservatively, and spontaneous resolution usually occurs around puberty. It is important to note that labial adhesions are different from an imperforate hymen.

      Symptoms of labial adhesions include problems with urination, such as pooling in the vagina. Upon examination, thin semitranslucent adhesions covering the vaginal opening between the labia minora may be seen, which can sometimes cover the vaginal opening completely.

      Conservative management is usually appropriate for most cases of labial adhesions. However, if there are associated problems such as recurrent urinary tract infections, oestrogen cream may be tried. If this fails, surgical intervention may be necessary.

      In summary, labial adhesions are a common condition in young girls that can cause problems with urination. While conservative management is usually effective, medical intervention may be necessary in some cases.

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  • Question 25 - For which children is it necessary to defer their polio vaccination and refer...

    Incorrect

    • For which children is it necessary to defer their polio vaccination and refer them to a child specialist for additional guidance?

      Your Answer: A child with a family history of epilepsy

      Correct Answer: A child with uncontrolled epilepsy

      Explanation:

      Polio Vaccination and Neurological Conditions

      The Department of Health’s ‘Green Book’ provides guidelines for polio vaccination and neurological conditions. According to the book, stable pre-existing neurological conditions such as spina bifida and congenital brain abnormalities do not prevent polio vaccination. However, if a child has an unstable or deteriorating neurological condition, vaccination should be deferred, and the child should be referred to a specialist for further assessment and advice. This includes children with uncontrolled epilepsy.

      It is important to note that a family history of seizures or epilepsy doesn’t prevent immunization. However, if there is a personal or family history of febrile seizures, there is an increased risk of these occurring after any fever, including post-immunization. In such cases, immunization should proceed as recommended, with advice on the prevention and management of fever beforehand.

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  • Question 26 - A 6-year-old girl with Down's syndrome who has a congenital heart defect has...

    Correct

    • A 6-year-old girl with Down's syndrome who has a congenital heart defect has been prescribed furosemide by the paediatric cardiologists. Her parents have come to get a refill. Looking at the prescription, she has been prescribed furosemide at a dose of 0.5 mg/kg twice daily. Her current weight is 16 kg. Furosemide oral solution is available at a concentration of 20 mg/5 ml. What is the appropriate amount in millilitres to prescribe?

      Your Answer: 2 ml BD

      Explanation:

      Dosage Calculation for Furosemide Oral Solution

      To calculate the correct dosage for furosemide oral solution, the patient’s weight and prescribed dose must be taken into account. For example, if the patient weighs 16 kg and the prescribed dose is 0.5 mg/kg BD, then the total daily dose would be 8 mg BD (16 kg x 0.5 mg/kg).

      The furosemide oral solution comes in a concentration of 20 mg in 5 ml, which means there is 4 mg in 1 ml. To determine the correct dosage, we can use the conversion factor of 8 mg = 2 ml. Therefore, the patient should take 2 ml of the furosemide oral solution twice a day. Proper dosage calculation is crucial to ensure the patient receives the correct amount of medication for their condition.

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  • Question 27 - A 6-year-old child presents clinically with mumps and has not been immunised.

    Which statement...

    Correct

    • A 6-year-old child presents clinically with mumps and has not been immunised.

      Which statement is true of notifiable diseases?

      Your Answer: Notification is a statutory duty

      Explanation:

      Disease Notification and Surveillance

      The notification of diseases has a long history, dating back to the great epidemics of the past. With improvements in hygiene and vaccination, infectious diseases have become less common, and many GP disease notification returns are inconsistent. However, it is still a legal obligation to report diseases. It is also essential that hospitals are informed of potential infectious diseases when patients are referred. The government uses various data sources for disease surveillance and increasingly relies on electronic data returns. Mumps remains a risk to unimmunised populations.

      Mumps: Epidemiology, Surveillance, and Control

      Mumps is a viral infection that can cause swelling of the salivary glands, fever, and headache. It is still a risk to unimmunised populations. To control the spread of mumps, it is essential to have effective epidemiology, surveillance, and control measures in place. This includes reporting cases to health authorities, monitoring outbreaks, and promoting vaccination. With the help of electronic data returns and other surveillance methods, it is possible to track the spread of mumps and take appropriate action to prevent further transmission. By working together, we can reduce the impact of mumps and other infectious diseases on our communities.

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  • Question 28 - A 5-year-old girl comes to your clinic after her mother notices a lump...

    Correct

    • A 5-year-old girl comes to your clinic after her mother notices a lump in her abdomen while getting her dressed. During the examination, you find a mass in her left upper quadrant. You collect a urine sample, which shows positive results for blood on dipstick testing. Other than that, she appears to be healthy.
      What is the probable diagnosis? Choose ONE answer only.

      Your Answer: Wilms’ tumour

      Explanation:

      Distinguishing Childhood Abdominal Malignancies: Wilms’ Tumour, Hodgkin’s Lymphoma, and More

      Wilms’ tumour, also known as nephroblastoma, is the most common abdominal malignancy in children. It arises from undifferentiated mesodermal cells and typically presents as an asymptomatic abdominal mass in children under five years old. However, it can also occur in adults. Other symptoms may include abdominal pain, haematuria, urinary infection, hypertension, or pyrexia. With treatment, over 90% of children with Wilms’ tumour survive into adulthood.

      Hodgkin’s lymphoma, on the other hand, is a rare malignancy in children. It typically presents with lymphadenopathy, most commonly in the cervical region, but hepatosplenomegaly may also occur.

      Constipation, hepatoblastoma, and splenomegaly are not likely diagnoses in this scenario. Constipated children typically have infrequent stools and a palpable faecal mass in the lower left abdomen. Hepatoblastoma is a rare malignancy that presents with a mass on the right side of the abdomen, and splenomegaly is not typically associated with haematuria.

      In summary, distinguishing between childhood abdominal malignancies such as Wilms’ tumour and Hodgkin’s lymphoma requires careful consideration of the presenting symptoms and physical examination findings.

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  • Question 29 - A 9-year-old boy comes to see you with his father; they have returned...

    Incorrect

    • A 9-year-old boy comes to see you with his father; they have returned from a holiday to Egypt and the father is very concerned as his son is lethargic, tired and has most recently become jaundiced, with dark urine. He is nauseated all the time and hardly able to eat.

      On examination he is pyrexial 38.2°C, with jaundice and evidence of scratch marks on his skin.

      Investigations show:

      Haemoglobin 118 g/L (135 - 180)

      WCC 8.2 ×109/L (4 - 10)

      Platelets 190 ×109/L (150 - 400)

      Sodium 140 mmol/L (134 - 143)

      Potassium 4.7 mmol/L (3.5 - 5.0)

      Creatinine 105 µmol/L (60 - 120)

      Bili 142 (<26)

      ALT 680 (<36)

      Which one of the following is true of his condition?

      Your Answer: Fulminant liver failure may occur in up to 20% of patients

      Correct Answer: You can reassure her mother that she will almost certainly make a full recovery

      Explanation:

      Hepatitis A in North Africa

      This child is suffering from hepatitis A, a common condition in North Africa where most people are exposed to it and develop immunity as children. However, children from the United Kingdom are not immune and may become infected while on holiday through the faeco-oral route.

      Fortunately, supportive care is all that is needed, including bed rest, proper nutrition, fluid intake, and pain relief. Only a small percentage of patients progress to fulminant hepatic failure.

      To prevent infection, it is recommended to get vaccinated for hepatitis A before traveling to areas where exposure is likely.

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  • Question 30 - A 2-year-old boy is brought to surgery with a fever and poor appetite....

    Correct

    • A 2-year-old boy is brought to surgery with a fever and poor appetite. Upon examination, his temperature is 38.5ºC and there is no clear source of infection. The mother was able to collect a urine sample using a collection pad, which tested positive for both leucocytes and nitrites. As a result, the child was started on a course of trimethoprim and the urine sample was sent for culture. After three days, the urine culture results reveal the growth of Pseudomonas aeruginosa. What is the most appropriate course of action?

      Your Answer: Arrange abdominal ultrasound + outpatient referral for consideration of further imaging

      Explanation:

      The presence of Pseudomonas infection in a child’s urinary tract indicates the possibility of an underlying structural abnormality. This is considered an atypical feature of a urinary tract infection and warrants uroimaging. According to NICE guidelines, if such an infection is detected, an ultrasound should be performed while the infection is still acute.

      Urinary tract infections (UTIs) in children require investigation to identify any underlying causes and potential kidney damage. Unlike in adults, the development of a UTI in childhood may indicate renal scarring. The National Institute for Health and Care Excellence (NICE) recommends imaging the urinary tract for infants under six months who present with their first UTI and respond to treatment, within six weeks. Children over six months who respond to treatment do not require imaging unless there are features suggestive of an atypical infection, such as being seriously ill, having poor urine flow, an abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to antibiotics within 48 hours, or infection with non-E. coli organisms.

      Further investigations may include a urine microscopy and culture, as only 50% of children with a UTI have pyuria, making microscopy or dipstick of the urine inadequate for diagnosis. A static radioisotope scan, such as DMSA, can identify renal scars and should be done 4-6 months after the initial infection. Micturating cystourethrography (MCUG) can identify vesicoureteric reflux and is only recommended for infants under six months who present with atypical or recurrent infections.

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  • Question 31 - A 6-year-old boy complaining of acute abdominal pain is brought to see you...

    Incorrect

    • A 6-year-old boy complaining of acute abdominal pain is brought to see you by his mother. His mother tells you that he has been having bouts of abdominal pain for the last few days that she thought would settle with time. In addition, she tells you that he has also developed a rash on his legs and has been complaining that his knees and ankles are sore. He is opening his bowels normally and passing urine normally. Prior to the last few days he has been entirely well. He has no significant past medical history and is not on any regular medications.

      You examine him and he is afebrile and alert. His blood pressure is 118/82 mmHg. There is no significant lymphadenopathy. His abdomen is soft with no masses. He has some mild tenderness on deep palpation around the umbilicus and lower abdomen. There is an obvious purpuric rash over the extensor surfaces of his legs and buttocks. You also notice a few similar lesions on the extensor surfaces of his arms. His trunk is unaffected by the rash.

      He has full range of movements in his joints which are not inflamed, however there is discomfort when manipulating his knees and ankles and his ankles appear slightly puffy.

      Which of the following tests is most useful in guiding further management of this patient?

      Your Answer: Throat swab

      Correct Answer: Urine dipstick

      Explanation:

      Henoch-Schönlein Purpura (HSP) in Children

      Henoch-Schönlein purpura (HSP) is a vasculitic condition that commonly affects children between the ages of 3 and 10. The core clinical features of HSP include a characteristic skin rash, joint pain, periarticular oedema, renal involvement, and abdominal pain. The skin rash, known as ‘palpable’ purpura, typically affects the buttocks and extensor surfaces of the legs and arms. Renal involvement can lead to hypertension, haematuria, and proteinuria, which can result in nephrotic and nephritic syndromes.

      Urine dipstick testing is essential in making a clinical diagnosis and guiding management and follow-up. Regular follow-up is necessary during the convalescent period as HSP can lead to chronic renal problems in some patients. Therefore, early detection and management of renal manifestations are crucial in preventing long-term complications. If left untreated, HSP can cause significant morbidity and mortality in children.

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  • Question 32 - A mother brings her 2-year-old daughter into surgery complaining that she is having...

    Incorrect

    • A mother brings her 2-year-old daughter into surgery complaining that she is having trouble passing urine. She describes 'ballooning' of the labia when she urinates. She doesn't complain of any pain, is well in herself and has no past medical history. You examine her and find that her labia doesn't separate. What is the next most appropriate plan of management?

      Your Answer: Application of steroid cream

      Correct Answer: Expectant approach and reassure

      Explanation:

      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 may be necessary.

      It is important to note that treatment should only be considered in cases where the child is experiencing discomfort or complications. Forcing the foreskin to retract can cause pain and damage to the penis, so it is best to wait and monitor the situation. If the child is experiencing symptoms, a doctor should be consulted to determine the best course of action. With proper care and attention, most cases of phimosis can be resolved without the need for medical intervention.

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  • Question 33 - A 30-year-old woman brings her 4-year-old daughter to the surgery. According to both...

    Correct

    • A 30-year-old woman brings her 4-year-old daughter to the surgery. According to both the family and the nursery she attends for day care, her left eye has become increasingly amblyopic, and she has developed a divergent squint. It appears also that she has become increasingly clumsy and has difficulty using stereoscopic vision to play with her lego.

      She was born two months premature but has achieved normal milestones since and has had all of her planned vaccinations.

      Which of the following is the most appropriate next step?

      Your Answer: Check for red reflex

      Explanation:

      Importance of Red Reflex Assessment in Diagnosing Retinoblastoma

      In cases where a patient presents with loss of the red reflex, it is crucial to rule out the development of a retinoblastoma. This is because retinoblastoma is the most common intraocular malignancy of childhood, and delay in diagnosis can have negative prognostic implications. Therefore, urgent referral to an ophthalmologist is necessary.

      Diagnosis of retinoblastoma is typically confirmed through indirect dilated ophthalmoscopy under anaesthetic. Referral to a community optician or non-urgent referral to an ophthalmologist can result in significant delays in diagnosis, making both options inappropriate. While referral to an optician may seem like a viable option, testing the red reflex is a quick and easy procedure that a GP can perform themselves.

      Re-examining the patient in six weeks is not a suitable course of action as it will only delay diagnosis. In situations where loss of the red reflex is present, reassurance is not appropriate, and urgent referral for further assessment is necessary. Therefore, it is essential to prioritize red reflex assessment in diagnosing retinoblastoma.

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  • Question 34 - Sophie is a 12-week-old infant who has been brought in by her mother...

    Correct

    • Sophie is a 12-week-old infant who has been brought in by her mother due to recurrent episodes of regurgitation after feeds and frequent crying during feeding for the past week. She is otherwise well.

      Sophie was born at term and is formula-fed. Her mother explains that each feed is around 180ml and she has 5-6 feeds over a 24 hour period. Sophie's current weight is 5.5kg.

      After a full assessment, you suspect that this is gastro-oesophageal reflux disease.

      What is the most appropriate next step?

      Your Answer: Reduce the total volume of feeds to 900 ml over 24 hours

      Explanation:

      According to NICE guidelines, formula-fed infants with GORD should undergo a stepped care approach starting with a review of their feeding history. If the volume of feeds is excessive for the child’s weight, the next step is to reduce it to a total of 150 mL/kg body weight over 24 hours (6-8 times a day). Currently, Bobbie is consuming 1200-1400 ml over 24 hours, which is more than the recommended amount of 900 ml for his weight of 6kg. Therefore, his feeds should be reduced to 900 ml over 24 hours while maintaining the current frequency of 6-7 times a day. Decreasing the volume of each feed to 100ml would result in an insufficient total intake of 600-700ml over 24 hours. Reducing the frequency of feeds is not recommended for GORD, as smaller, more frequent feeds are more effective in improving symptoms. If reducing feed volume and frequency doesn’t significantly improve symptoms, a trial of feed thickeners or alginate therapy added to formula can be considered as options in the stepped care approach.

      Gastro-oesophageal reflux is a common cause of vomiting in infants, with around 40% of babies experiencing some degree of regurgitation. However, certain risk factors such as preterm delivery and neurological disorders can increase the likelihood of developing this condition. Symptoms typically appear before 8 weeks of age and include vomiting or regurgitation, milky vomits after feeds, and excessive crying during feeding. Diagnosis is usually made based on clinical observation.

      Management of gastro-oesophageal reflux in infants involves advising parents on proper feeding positions, ensuring the infant is not overfed, and considering a trial of thickened formula or alginate therapy. However, proton pump inhibitors (PPIs) are not recommended as a first-line treatment for isolated symptoms of regurgitation. PPIs may be considered if the infant experiences unexplained feeding difficulties, distressed behavior, or faltering growth. Metoclopramide, a prokinetic agent, should only be used with specialist advice.

      Complications of gastro-oesophageal reflux can include distress, failure to thrive, aspiration, frequent otitis media, and dental erosion in older children. If medical treatment is ineffective and severe complications arise, fundoplication may be considered. It is important for healthcare professionals to be aware of the risk factors, symptoms, and management options for gastro-oesophageal reflux in infants.

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  • Question 35 - A 4-year-old boy from a traveller community family is brought to the surgery...

    Correct

    • A 4-year-old boy from a traveller community family is brought to the surgery by his mother.

      She informs you that he began with what appeared to be a severe catarrhal cold, but now experiences intense paroxysms of coughing, causing him to turn completely red in the face and struggle to catch his breath. Upon examination, he has no fever.

      What feature on history, examination, or investigation, although not conclusive, is consistent with the presence of whooping cough?

      Your Answer: Lack of pyrexia

      Explanation:

      Whooping Cough: Symptoms and Risk Factors

      The incubation period for whooping cough, also known as pertussis, typically lasts seven to 10 days but can extend up to 21 days. Patients with this condition often experience a paroxysmal cough with an inspiratory whoop, and lymphocytosis is commonly observed. While extensive consolidation is uncommon, pockets of lower respiratory tract infection may occur due to atelectasis. Notably, a lack of fever is a strong indication of whooping cough.

      Children from travelling families may be at a higher risk of contracting whooping cough if they have missed the standard vaccination schedule. It is important to be aware of the symptoms and risk factors associated with this condition to ensure prompt diagnosis and treatment.

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  • Question 36 - A 4-year-old girl, Lily, has a febrile convulsion at home. She has been...

    Correct

    • A 4-year-old girl, Lily, has a febrile convulsion at home. She has been suffering from Chickenpox. This is her third febrile convulsion, the last one was six months ago and was during a viral gastroenteritis. The convulsion quickly terminates within a minute and Lily recovers promptly at home. Mum asks for medication to prevent further febrile convulsions. What advice should the GP give her?

      Your Answer: Tell her that no preventative treatment is required for Jonny's febrile convulsions

      Explanation:

      It is not recommended to use preventative treatment for febrile convulsions as the risks of regular anti-epileptic medications outweigh the benefits. There is no evidence that regular use of paracetamol or ibuprofen during an illness can prevent febrile convulsions. While antipyretics may provide comfort to a febrile child, they do not reduce the risk of febrile convulsions.

      If a parent witnesses their child having a febrile seizure, they should take steps to prevent the child from harming themselves. Placing the child in the recovery position during the seizure is recommended. Seizures that last longer than 5 minutes require medical treatment, and parents should call for an ambulance. If the child experiences regular febrile convulsions, parents may keep PR diazepam at home to administer if the seizure lasts longer than 5 minutes.

      Febrile convulsions are seizures that occur in otherwise healthy children when they have a fever. They are most common in children between the ages of 6 months and 5 years, affecting around 3% of children. Febrile convulsions usually occur at the onset of a viral infection when the child’s temperature rises rapidly. The seizures are typically brief, lasting less than 5 minutes, and are usually tonic-clonic in nature.

      There are three types of febrile convulsions: simple, complex, and febrile status epilepticus. Simple febrile convulsions last less than 15 minutes and are generalised seizures. Complex febrile convulsions last between 15 and 30 minutes and may be focal seizures. Febrile status epilepticus lasts for more than 30 minutes. Children who have had their first seizure or any features of a complex seizure should be admitted to paediatrics.

      Following a seizure, parents should be advised to call an ambulance if the seizure lasts longer than 5 minutes. Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring. If recurrent febrile convulsions occur, benzodiazepine rescue medication may be considered, but this should only be started on the advice of a specialist, such as a paediatrician. Rectal diazepam or buccal midazolam may be used.

      The overall risk of further febrile convulsions is 1 in 3, but this varies depending on risk factors for further seizure. These risk factors include age of onset under 18 months, fever below 39ºC, shorter duration of fever before the seizure, and a family history of febrile convulsions. Children with no risk factors have a 2.5% risk of developing epilepsy, while those with all three risk factors have a much higher risk of developing epilepsy, up to 50%.

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  • Question 37 - You see a 7-year-old boy with his mother. He has had a productive...

    Incorrect

    • You see a 7-year-old boy with his mother. He has had a productive cough for 2 weeks. His vital signs are within normal range for his age. On examination, there are no signs of respiratory distress, but you hear crackles in the left base.

      He is normally fit and well. He is not on any regular medications. He has no known drug allergies.

      What is the most suitable course of action to take next in managing this patient?

      Your Answer: Chest X ray

      Correct Answer: Amoxicillin

      Explanation:

      NICE Guidelines for Children with Pneumonia Symptoms

      According to the National Institute for Health and Care Excellence (NICE), children who show symptoms of pneumonia but are not admitted to the hospital should not undergo a chest X-ray as a routine procedure. Instead, the first line of treatment for such cases is amoxicillin, which is safe to use in children without any drug allergies. It is important to follow these guidelines to ensure the best possible care for children with pneumonia symptoms.

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  • Question 38 - A 12-week-old baby is brought to the clinic with persistent regurgitation that causes...

    Incorrect

    • A 12-week-old baby is brought to the clinic with persistent regurgitation that causes significant distress. The infant is exclusively breastfed and appears otherwise healthy. The baby was born a week before the due date through a normal vaginal delivery. The mother experienced significant blood loss during delivery and required overnight observation. She was found to be slightly anemic and was given ferrous sulfate supplementation. What initial treatment would you suggest for this baby?

      Your Answer: Reduce feeding time

      Correct Answer: Alginate therapy

      Explanation:

      When breastfed infants display symptoms of gastro-oesophageal reflux, it is important for a qualified individual to conduct a breastfeeding assessment. Simply observing the infant without providing any treatment is not appropriate, as the reported distress of the infant must be taken into consideration. While a proton pump inhibitor is a viable treatment option, an alginate is preferred due to its lower risk of side effects, provided it is effective. Alginates can be administered to breastfed infants by mixing them with cooled boiled water or expressed breast milk.

      Gastro-oesophageal reflux is a common cause of vomiting in infants, with around 40% of babies experiencing some degree of regurgitation. However, certain risk factors such as preterm delivery and neurological disorders can increase the likelihood of developing this condition. Symptoms typically appear before 8 weeks of age and include vomiting or regurgitation, milky vomits after feeds, and excessive crying during feeding. Diagnosis is usually made based on clinical observation.

      Management of gastro-oesophageal reflux in infants involves advising parents on proper feeding positions, ensuring the infant is not overfed, and considering a trial of thickened formula or alginate therapy. However, proton pump inhibitors (PPIs) are not recommended as a first-line treatment for isolated symptoms of regurgitation. PPIs may be considered if the infant experiences unexplained feeding difficulties, distressed behavior, or faltering growth. Metoclopramide, a prokinetic agent, should only be used with specialist advice.

      Complications of gastro-oesophageal reflux can include distress, failure to thrive, aspiration, frequent otitis media, and dental erosion in older children. If medical treatment is ineffective and severe complications arise, fundoplication may be considered. It is important for healthcare professionals to be aware of the risk factors, symptoms, and management options for gastro-oesophageal reflux in infants.

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  • Question 39 - A 7-year-old boy has developed involuntary movements of his arms and face over...

    Correct

    • A 7-year-old boy has developed involuntary movements of his arms and face over the last few days. Some of these he converts into apparently purposeful movement by pushing back his hair or scratching his nose. There is reduced tone in the limbs, and he is unsteady. He seems unconcerned and intermittently giggles. His mother tells you that he had a sore throat four weeks previously.
      What is the most likely diagnosis?

      Your Answer: Sydenham’s chorea

      Explanation:

      Understanding Sydenham’s Chorea: A Common Cause of Acute Chorea Worldwide

      Sydenham’s chorea, also known as St Vitus’ dance, is a neurological manifestation of rheumatic fever and remains the most common cause of acute chorea worldwide. While it was commonly seen in the 1930s, it occurs less frequently in the UK today. This condition can occur with or without symptoms of rheumatic fever and is usually self-limiting. Improvement occurs over about two weeks, but total recovery can take up to nine months, and may recur in some patients.

      In this scenario, the short time course of the chorea and the girl’s age are useful diagnostically. It is important to note that psychological changes may precede or accompany the choreiform movements, as demonstrated by the girl’s emotional lability.

      It is important to consider other potential causes of chorea, such as cerebral tumour, cerebrovascular accident, Guillain–Barré syndrome, and Huntington’s chorea. However, in this case, these conditions are unlikely as they do not fit with the girl’s symptoms and age.

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  • Question 40 - A 6-month-old boy is scheduled for his routine immunisations. He has received all...

    Incorrect

    • A 6-month-old boy is scheduled for his routine immunisations. He has received all previous immunisations according to the routine schedule and has no medical history. What vaccinations should he receive during this visit?

      Your Answer: '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) + PCV

      Correct Answer: '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) + Men B

      Explanation:

      PCV in addition to the 6-1 vaccine (which includes protection against diphtheria, tetanus, whooping cough, polio, Hib, and hepatitis B).

      The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at specific intervals. At 12-13 months, the Hib/Men C, MMR, PCV, and Men B vaccines are given. At 3-4 years, the ‘4-in-1 Preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

      It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine is also offered to new students up to the age of 25 years at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine, while students going to university or college for the first time should contact their GP to have the vaccine before the start of the academic year.

      The Men C vaccine used to be given at 3 months but has now been discontinued as there are almost no cases of Men C disease in babies or young children in the UK. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

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