00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 28-year-old woman who is 20 weeks pregnant visits the GP clinic to...

    Correct

    • A 28-year-old woman who is 20 weeks pregnant visits the GP clinic to inquire about the whooping cough vaccine. She mentions that her friend, who also sees the same GP, received the vaccine at 32 weeks of pregnancy. She wants to know if she can get the vaccine at this stage of her pregnancy.

      Your Answer: She can have the vaccine now

      Explanation:

      Pregnant women at 16-32 weeks are given the option to receive the pertussis vaccine.

      Whooping Cough: Causes, Symptoms, Diagnosis, and Management

      Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.

      Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.

      Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.

      To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.

      Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.

      Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and

    • This question is part of the following fields:

      • Paediatrics
      28.5
      Seconds
  • Question 2 - A mother brings her 14-year-old daughter to the general practice with concerns about...

    Correct

    • A mother brings her 14-year-old daughter to the general practice with concerns about her delayed onset of periods. During the examination, the daughter is found to be in the 9th percentile for her age in terms of height, has short ring fingers, poor breast development, and a high arched palate. While listening to her heart, a crescendo-decrescendo murmur is heard on the upper right sternal border that radiates to the carotids. What is the probable cause of this murmur?

      Your Answer: Bicuspid valve

      Explanation:

      A 16-year-old girl presents with symptoms of shortness of breath, chest pain, and fatigue. Upon examination, a heart murmur is detected in the aortic region, which is described as a crescendo-decrescendo murmur. The possible causes of this murmur are considered, including aortic stenosis, aortic valve calcification, rheumatic heart disease, and Tetralogy of Fallot. However, based on the patient’s age and symptoms, aortic stenosis is the most likely diagnosis.

      Understanding Turner’s Syndrome

      Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.

      The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.

      In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Paediatrics
      39.8
      Seconds
  • Question 3 - A 6-week-old girl is brought to the pediatrician by her father with symptoms...

    Incorrect

    • A 6-week-old girl is brought to the pediatrician by her father with symptoms of vomiting and diarrhea for the past 5 days. She has also developed a new rash that is bothering her and has a runny nose. The father denies any weight loss, fever, or other family members being sick.

      Upon further questioning, the father reveals that he has recently introduced formula milk as he is planning to return to work soon and wants the baby to get used to it. The pediatrician suspects that the infant may have an intolerance to cow's milk protein.

      What would be the most appropriate alternative feed to try for this baby?

      Your Answer: Amino acid based formula

      Correct Answer: Extensively hydrolysed formula

      Explanation:

      Formula options for infants with different types of intolerance vary. For infants with cow’s milk protein intolerance, a partially hydrolysed formula is recommended as it contains proteins that are less allergenic. Amino acid-based formula is suitable for infants with severe intolerance, although it may not be as palatable. High protein formula is used for pre-term infants, but recent studies suggest that it may increase the risk of obesity in the long-term. Lactose-free formula is appropriate for infants with lactose intolerance, which is characterized by gastrointestinal symptoms rather than rash and runny nose.

      Understanding Cow’s Milk Protein Intolerance/Allergy

      Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects around 3-6% of children, typically presenting in the first 3 months of life in formula-fed infants. Both immediate and delayed reactions can occur, with CMPA used for immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms include regurgitation, vomiting, diarrhea, urticaria, atopic eczema, colic symptoms, wheeze, chronic cough, and rarely, angioedema and anaphylaxis. Diagnosis is often clinical, with investigations including skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein.

      Management for formula-fed infants includes using extensive hydrolyzed formula (eHF) milk as the first-line replacement formula for mild-moderate symptoms and amino acid-based formula (AAF) for severe CMPA or if no response to eHF. Around 10% of infants are also intolerant to soya milk. For breastfed infants, mothers should eliminate cow’s milk protein from their diet and consider prescribing calcium supplements to prevent deficiency. eHF milk can be used when breastfeeding stops until at least 6 months and up to 12 months of age.

      The prognosis for CMPI is usually good, with most children becoming milk tolerant by the age of 3-5 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur. It is important to refer infants with severe symptoms to a pediatrician for management. Understanding CMPI/CMPA and its management can help parents and healthcare providers provide appropriate care for affected children.

    • This question is part of the following fields:

      • Paediatrics
      40.1
      Seconds
  • Question 4 - What is a factor that leads to cyanotic congenital heart disease? ...

    Correct

    • What is a factor that leads to cyanotic congenital heart disease?

      Your Answer: Transposition of the great arteries

      Explanation:

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

    • This question is part of the following fields:

      • Paediatrics
      10.6
      Seconds
  • Question 5 - You are a senior doctor in the paediatrics department. A fifteen year-old whose...

    Correct

    • You are a senior doctor in the paediatrics department. A fifteen year-old whose parents are devout Jehovah's witnesses requires a blood transfusion. Both parents state that they do not wish their child to have a potentially life saving transfusion. The fifteen year-old herself understands the risks and benefits of a transfusion and wishes to have the transfusion regardless.

      Which of the following is correct?

      Your Answer: The blood can be transfused without the parents consent

      Explanation:

      Once a child reaches the age of 16, they are considered competent to provide consent for treatment. In this case, the 16-year-old child can provide consent for the blood transfusion, but cannot refuse it. Therefore, the blood can be given as the child has provided consent. If the child were to refuse the treatment, the blood could still be given in their best interests without the consent of the child or their parents, using the Children Act 1989 and a High Court Order. However, in this particular case, such an order is not necessary. While some Jehovah witnesses may accept certain blood products, such as fresh frozen plasma or albumin, they may decline a complete blood transfusion. However, this is not appropriate in this situation. It may be advisable to contact the hospital liaison representative, but as the child is of age and understands the situation, they are able to provide consent for the treatment.

      Understanding Consent in Children

      The issue of consent in children can be complex and confusing. However, there are some general guidelines to follow. If a patient is under 16 years old, they may be able to consent to treatment if they are deemed competent. This is determined by the Fraser guidelines, which were previously known as Gillick competence. However, even if a child is competent, they cannot refuse treatment that is deemed to be in their best interest.

      For patients between the ages of 16 and 18, it is generally assumed that they are competent to give consent to treatment. Patients who are 18 years or older can consent to or refuse treatment.

      When it comes to providing contraceptives to patients under 16 years old, the Fraser Guidelines outline specific requirements that must be met. These include ensuring that the young person understands the advice given by the healthcare professional, cannot be persuaded to inform their parents, is likely to engage in sexual activity with or without treatment, and will suffer physical or mental health consequences without treatment. Ultimately, the young person’s best interests must be taken into account when deciding whether to provide contraceptive advice or treatment, with or without parental consent.

      In summary, understanding consent in children requires careful consideration of age, competence, and best interests. The Fraser Guidelines provide a useful framework for healthcare professionals to follow when providing treatment and advice to young patients.

    • This question is part of the following fields:

      • Paediatrics
      27.1
      Seconds
  • Question 6 - A father is worried about a swelling he has noticed on his two-day-old...

    Incorrect

    • A father is worried about a swelling he has noticed on his two-day-old baby's head. The baby was delivered using forceps due to a prolonged second stage of labor. Upon examination, there is a swelling in the parietal region that does not cross the suture lines. The doctor informs him that it may take several weeks to resolve. What type of head injury is most likely responsible for this?

      Your Answer: Caput succedaneum

      Correct Answer: Cephalohaematoma

      Explanation:

      A cephalohaematoma is a swelling that appears on a newborn’s head, usually a few hours after delivery. It is caused by bleeding between the skull and periosteum, with the parietal region being the most commonly affected site. This condition may lead to jaundice as a complication and can take up to three months to resolve.

      In comparison to caput succedaneum, which is another type of swelling that can occur on a newborn’s head, cephalohaematoma is more localized and does not cross suture lines. Caput succedaneum, on the other hand, is a diffuse swelling that can cross suture lines and is caused by fluid accumulation in the scalp tissue. Both conditions are usually harmless and resolve on their own, but medical attention may be necessary in severe cases.

    • This question is part of the following fields:

      • Paediatrics
      17.8
      Seconds
  • Question 7 - A 2-year-old girl is brought to the GP by her mother due to...

    Correct

    • A 2-year-old girl is brought to the GP by her mother due to a new rash. The mother is worried as the rash appeared suddenly just 1 day ago. The child had a cold with a high fever 3 weeks ago, but has since recovered. Apart from that, the child is healthy and active.

      During the examination, an erythematous rash is observed on the child's trunk and limbs. The rash does not seem to be causing any itching and disappears when pressure is applied.

      What is the most probable diagnosis?

      Your Answer: Roseola infantum

      Explanation:

      What is the classical history of roseola infantum and how does it differ from other childhood rashes?

      Roseola infantum is a common viral illness that typically affects children between 6 months and 2 years of age. It is characterized by a high fever that is followed 1-2 weeks later by an erythematous rash across the trunk and limbs. Febrile seizures are also common with this illness.

      Measles, on the other hand, presents with an erythematous rash that starts behind the ears and spreads to the rest of the body. It is associated with fever, conjunctivitis, coryzal symptoms, and white koplik spots on the inside of the mouth.

      Parvovirus B19, also known as slapped cheek disease, is characterized by a rash that first appears on the cheeks before spreading to the trunk and arms. It is usually preceded by 2-5 days of mild fever and non-specific viral symptoms.

      Rubella presents with an erythematous rash that starts on the face and spreads to the rest of the body. It is associated with mild fever, sore throat, and lymphadenopathy.

      Understanding Roseola Infantum

      Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.

      In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.

      It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.

    • This question is part of the following fields:

      • Paediatrics
      51.9
      Seconds
  • Question 8 - A newborn boy is born via emergency caesarean section at 42 weeks and...

    Correct

    • A newborn boy is born via emergency caesarean section at 42 weeks and 5 days due to fetal tachycardia and thick meconium-stained amniotic fluid. The mother received intrapartum antibiotics as she was known to be colonized with group B streptococcus. The infant presents with cyanosis, tachypnea, and chest wall retraction. A chest X-ray reveals patchy infiltrates and atelectasis. What is the probable diagnosis?

      Your Answer: Meconium aspiration syndrome

      Explanation:

      Transient tachypnoea of the newborn does not exhibit cyanosis or chest X-ray changes. Preterm deliveries are usually associated with surfactant deficiency.

      Understanding Meconium Aspiration Syndrome

      Meconium aspiration syndrome is a condition that affects newborns and causes respiratory distress due to the presence of meconium in the trachea. This condition typically occurs in the immediate neonatal period and is more common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks. The severity of the respiratory distress can vary, but it can be quite severe in some cases.

      There are several risk factors associated with meconium aspiration syndrome, including a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking, or substance abuse. These risk factors can increase the likelihood of a baby developing this condition. It is important for healthcare providers to be aware of these risk factors and to monitor newborns closely for signs of respiratory distress.

      Overall, meconium aspiration syndrome is a serious condition that requires prompt medical attention. With proper management and treatment, however, most babies are able to recover fully and go on to lead healthy lives. By understanding the risk factors and symptoms associated with this condition, healthcare providers can help ensure that newborns receive the care they need to thrive.

    • This question is part of the following fields:

      • Paediatrics
      55.3
      Seconds
  • Question 9 - A 3-week-old Somali male infant was brought to the paediatric Emergency Department by...

    Incorrect

    • A 3-week-old Somali male infant was brought to the paediatric Emergency Department by his mother who recently arrived in the UK. Due to inadequate antenatal care in their home country, the baby has been experiencing rapid breathing, poor feeding, and weight loss for the past 3 weeks. During examination, the baby displayed upslanting palpebral fissures, prominent inner epicanthal folds, a protuberant tongue, and single palmar creases. Additionally, an atypical murmur was heard. An urgent echocardiogram was performed, and the diagnosis was revealed. What is the most likely congenital cardiac abnormality in this baby?

      Your Answer: Ventricular septal defect

      Correct Answer: Atrioventricular septal defect

      Explanation:

      The most frequent congenital cardiac abnormality found in individuals with Down’s syndrome is atrioventricular septal defects. This baby, who displays typical syndromic features of Down’s syndrome, was not diagnosed during pregnancy due to inadequate antenatal care in Somalia. In the first few weeks of life, dyspnoea, failure to thrive, poor weight gain, and cyanosis can be common presentations. Although Tetralogy of Fallot can occur in Down’s syndrome, it is not the most common. Ventricular and atrial septal defects can also occur, but they are not as prevalent and do not align with the severity of this baby’s symptoms.

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      33.2
      Seconds
  • Question 10 - A mother brings her 3-year-old child to you, complaining of frequent respiratory infections,...

    Correct

    • A mother brings her 3-year-old child to you, complaining of frequent respiratory infections, a persistent cough, and poor weight gain. The child is currently at the 3rd percentile for their age. The parents are of Romanian descent and have recently moved to the UK. What test should be performed to confirm the suspected diagnosis?

      Your Answer: Sweat test

      Explanation:

      Cystic fibrosis is a genetic disorder that affects the lungs and is inherited in an autosomal recessive manner. In the United Kingdom, newborns are screened for cystic fibrosis on the sixth day of life using a dried blood spot collected on a Guthrie card.

      Understanding Cystic Fibrosis and the Organisms that Affect Patients

      Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. This condition is caused by a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates chloride channels. In the UK, 80% of CF cases are due to delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

      CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.

    • This question is part of the following fields:

      • Paediatrics
      58.7
      Seconds
  • Question 11 - A 3-month-old baby boy is brought to the hospital with suspected meningitis. His...

    Incorrect

    • A 3-month-old baby boy is brought to the hospital with suspected meningitis. His parents report that he has been feverish and lethargic for the past day. During the examination, his temperature is recorded as 39.5ÂșC, heart rate is 165/min, and respiratory rate is 52/min. The anterior fontanelle is visibly swollen, but no petechial rash is observed. Apart from cefotaxime, what other intravenous antibiotic should be administered?

      Your Answer: Clarithromycin

      Correct Answer: Amoxicillin

      Explanation:

      To ensure coverage for Listeria, it is recommended to administer IV amoxicillin along with cefotaxime when treating meningitis in children under 3 months of age.

      Investigation and Management of Meningitis in Children

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      50.6
      Seconds
  • Question 12 - A 1-month-old infant presents with low-set ears, rocker bottom feet, and overlapping of...

    Correct

    • A 1-month-old infant presents with low-set ears, rocker bottom feet, and overlapping of fingers. What is the probable diagnosis?

      Your Answer: Edward's syndrome

      Explanation:

      Edward’s syndrome is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers, which are present at birth.

      Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.

    • This question is part of the following fields:

      • Paediatrics
      12.3
      Seconds
  • Question 13 - A 7-week-old male infant was presented to the GP clinic by his anxious...

    Correct

    • A 7-week-old male infant was presented to the GP clinic by his anxious mother. She complains of a 2-week history of inadequate feeding and weight gain, accompanied by fast breathing, especially during feeding. The mother became extremely worried when she observed a bluish tint on her baby's skin this morning.
      What is the probable diagnosis?

      Your Answer: Tetralogy of Fallot

      Explanation:

      TOF is the primary reason for cyanotic congenital heart disease, which usually manifests at 1-2 months of age. While transposition of the great arteries is also a significant cause of this condition, it typically presents within the first 24 hours of life. Ventricular septal defect and atrioventricular septal defect are not associated with cyanotic congenital heart disease.

      Understanding Tetralogy of Fallot

      Tetralogy of Fallot (TOF) is a congenital heart disease that results from the anterior malalignment of the aorticopulmonary septum. It is the most common cause of cyanotic congenital heart disease, and it typically presents at around 1-2 months, although it may not be detected until the baby is 6 months old. The condition is characterized by four features, including ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular outflow tract obstruction, and overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

      Other features of TOF include cyanosis, which may cause episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract. These spells are characterized by tachypnea and severe cyanosis that may occasionally result in loss of consciousness. They typically occur when an infant is upset, in pain, or has a fever, and they cause a right-to-left shunt. Additionally, TOF may cause an ejection systolic murmur due to pulmonary stenosis, and a right-sided aortic arch is seen in 25% of patients. Chest x-ray shows a ‘boot-shaped’ heart, while ECG shows right ventricular hypertrophy.

      The management of TOF often involves surgical repair, which is usually undertaken in two parts. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm. However, it is important to note that at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. Understanding the features and management of TOF is crucial for healthcare professionals to provide appropriate care and treatment for affected infants.

    • This question is part of the following fields:

      • Paediatrics
      21.1
      Seconds
  • Question 14 - A boy of 7 presents with a unilateral painless limp. Examination shows limitation...

    Incorrect

    • A boy of 7 presents with a unilateral painless limp. Examination shows limitation of rotation and extension at the affected hip joint, and a radiograph shows a dense flattened and fragmented femoral head on the affected side.
      Which of the following is the most likely diagnosis?

      Your Answer: Slipped upper femoral epiphysis

      Correct Answer: Perthes' disease

      Explanation:

      Perthes’ Disease: Avascular Necrosis of the Proximal Femoral Head in Children

      Perthes’ disease is a condition that results from avascular necrosis of the proximal femoral head, which is caused by a compromised blood supply. It typically affects children aged 4-10, with boys being affected more frequently than girls. The disease presents with a painless limp and limited range of motion of the affected hip, followed by hip pain as necrosis develops.

      The diagnosis of Perthes’ disease is suspected clinically, and radiographs may be normal initially or show only a non-specific effusion. As the condition progresses, the joint space between the ossified femoral head and acetabulum widens, and narrowing or collapse of the femoral head causes it to appear widened and flattened. Eventually, femoral head collapse may ensue.

      Other conditions that may present similarly to Perthes’ disease include slipped upper femoral epiphysis, septic arthritis, juvenile rheumatoid arthritis, and congenital dislocation of the hip. However, each of these conditions has its own unique features and diagnostic criteria.

      Overall, Perthes’ disease is a generalised disorder of cartilage development that predisposes children to repeated episodes of infarction in the proximal femoral epiphysis. The most significant factors determining prognosis are onset in the older child, epiphyseal protrusion, extensive involvement of the epiphysis, and arrest of subcapital growth.

    • This question is part of the following fields:

      • Paediatrics
      32.8
      Seconds
  • Question 15 - A 14-year-old girl comes to the clinic complaining of right knee pain. She...

    Correct

    • A 14-year-old girl comes to the clinic complaining of right knee pain. She is an avid hockey player but has not experienced any recent injuries. During the examination, a painful swelling is observed over the tibial tubercle. What is the probable diagnosis?

      Your Answer: Osgood-Schlatter disease

      Explanation:

      Common Knee Problems in Children and Young Adults

      Knee problems are common in children and young adults, especially those who are active in sports.
      Chondromalacia patellae is a condition that is more common in teenage girls. It is characterized by the softening of the cartilage of the patella, which can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. This condition usually responds well to physiotherapy.

      Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle.

      Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking of the knee.

      Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella. The knee may also give way.

      Patellar tendonitis is more common in athletic teenage boys. It causes chronic anterior knee pain that worsens after running. On examination, the area below the patella is tender. It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis.

    • This question is part of the following fields:

      • Paediatrics
      10.5
      Seconds
  • Question 16 - A newborn girl born 4 hours ago has an APGAR score of 10....

    Correct

    • A newborn girl born 4 hours ago has an APGAR score of 10. She is not cyanosed, has a pulse of 150, cries on stimulation, her arms and legs resist extension and she has a good cry. However, she appears jaundiced. What should be done in this situation?

      Your Answer: Measure and record the serum bilirubin level urgently.

      Explanation:

      Jaundice in newborns can occur within the first 24 hours of life and is always considered pathological. The causes of jaundice during this period include rhesus and ABO haemolytic diseases, hereditary spherocytosis, and glucose-6-phosphodehydrogenase deficiency. On the other hand, jaundice in neonates from 2-14 days is common and usually physiological, affecting up to 40% of babies. This type of jaundice is due to a combination of factors such as more red blood cells, fragile red blood cells, and less developed liver function. Breastfed babies are more likely to develop this type of jaundice.

      If jaundice persists after 14 days (21 days for premature babies), a prolonged jaundice screen is performed. This includes tests for conjugated and unconjugated bilirubin, direct antiglobulin test, thyroid function tests, full blood count and blood film, urine for MC&S and reducing sugars, and urea and electrolytes. Prolonged jaundice can be caused by biliary atresia, hypothyroidism, galactosaemia, urinary tract infection, breast milk jaundice, prematurity, and congenital infections such as CMV and toxoplasmosis. Breast milk jaundice is more common in breastfed babies and is thought to be due to high concentrations of beta-glucuronidase, which increases the intestinal absorption of unconjugated bilirubin. Prematurity also increases the risk of kernicterus.

    • This question is part of the following fields:

      • Paediatrics
      26.5
      Seconds
  • Question 17 - A healthy toddler is 18 months old and was born in the breech...

    Incorrect

    • A healthy toddler is 18 months old and was born in the breech position. The toddler's mother is concerned about developmental dysplasia of the hip (DDH), as she has heard that this can be associated with breech delivery.
      Which of the following is the most appropriate investigation for this toddler?

      Your Answer: Ultrasound scan of the hips only if they are found to be unstable at the 6-week baby check

      Correct Answer: Ultrasound scan of the hips before six weeks of age

      Explanation:

      An ultrasound scan of the hips is recommended for all babies born in the breech position after 36 weeks of pregnancy, even if they are not born in the breech position. It is also necessary for babies born before 36 weeks in the breech position or those with a family history of hip problems in early life. This is to detect developmental dysplasia of the hip (DDH) early, which can be treated with a Pavlik harness before six months of age. Surgery may be required if non-operative treatment is not successful. An ultrasound scan should be performed before six weeks of age to ensure early diagnosis and treatment. If a baby is found to have an unstable hip joint during their newborn examination, they should have an ultrasound of the hip before two weeks of age. X-rays are not recommended for detecting DDH in infants, and ultrasound is the preferred imaging modality.

    • This question is part of the following fields:

      • Paediatrics
      31.2
      Seconds
  • Question 18 - A 6-week-old infant is brought to the GP clinic by her mother for...

    Correct

    • A 6-week-old infant is brought to the GP clinic by her mother for a check-up. The mother is concerned about her daughter's occasional fever and wants to have her checked. The baby appears active and healthy, breathing comfortably with a central capillary refill of less than 2 seconds. She has no rashes and is of normal color.

      The following observations and growth measurements are recorded:
      - Heart rate: 140 beats per minute (normal range: 115-180)
      - Oxygen saturation: 99% on room air
      - Respiratory rate: 42 breaths per minute (normal range: 25-60)
      - Temperature: 38.7ÂșC
      - Weight: 75th percentile
      - Height: 50th percentile
      - Head circumference: 75th percentile

      What would be the most appropriate course of action?

      Your Answer: Refer to the paediatric emergency department

      Explanation:

      If an infant is under 3 months old and has a fever over 38ÂșC, it is crucial to consider the possibility of a serious infection. In this case, it is not appropriate to assess the infant in a GP clinic. Instead, they should be immediately referred to a paediatric emergency department for monitoring and potential investigations, such as urine, chest X-ray, blood cultures, or lumbar puncture, depending on the progression of symptoms. Keeping the infant in the GP clinic for observations is not recommended, as they may deteriorate rapidly and become difficult to manage in that setting. Reassurance and review are usually appropriate for a febrile infant with an obvious infective focus, but not for an infant under 3 months old with no apparent focus of infection. Similarly, an urgent referral to an outpatient paediatrician is not appropriate, as it may take too long to organise and may not be able to manage sudden deterioration.

      The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer.

      The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.

    • This question is part of the following fields:

      • Paediatrics
      48.7
      Seconds
  • Question 19 - What is the most frequent cause of nephrotic syndrome in pediatric patients? ...

    Correct

    • What is the most frequent cause of nephrotic syndrome in pediatric patients?

      Your Answer: Minimal change disease

      Explanation:

      Understanding Nephrotic Syndrome in Children

      Nephrotic syndrome is a medical condition that is characterized by three main symptoms: proteinuria, hypoalbuminaemia, and oedema. This condition is most commonly seen in children between the ages of 2 and 5 years old. In fact, around 80% of cases in children are caused by a condition called minimal change glomerulonephritis. Fortunately, this condition has a good prognosis, with approximately 90% of cases responding well to high-dose oral steroids.

      Aside from the main symptoms, children with nephrotic syndrome may also experience hyperlipidaemia, a hypercoagulable state, and a higher risk of infection. These additional features are caused by the loss of antithrombin III and immunoglobulins in the body.

      Overall, understanding nephrotic syndrome in children is important for parents and healthcare professionals alike. With proper treatment and management, most children with this condition can recover and lead healthy lives.

    • This question is part of the following fields:

      • Paediatrics
      23
      Seconds
  • Question 20 - A 36-year-old woman has been diagnosed with pertussis. She came to the doctor's...

    Correct

    • A 36-year-old woman has been diagnosed with pertussis. She came to the doctor's office after a child at her workplace daycare tested positive for whooping cough. She has been experiencing an on-and-off cough with occasional vomiting for the past 18 days. Assuming the patient has no allergies, what is the best course of treatment for this diagnosis?

      Your Answer: Azithromycin

      Explanation:

      Azithromycin or clarithromycin are recommended as first-line antibiotics for non-pregnant adults with whooping cough if the cough onset is within 21 days. Erythromycin can be used for pregnant adults. Co-amoxiclav and doxycycline are not recommended, and co-trimoxazole can be used off-label if macrolides are contraindicated or not tolerated. Antibiotics are preferred over supportive treatment within 21 days of presentation.

      Whooping Cough: Causes, Symptoms, Diagnosis, and Management

      Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.

      Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.

      Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.

      To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.

      Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.

      Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and

    • This question is part of the following fields:

      • Paediatrics
      30.5
      Seconds
  • Question 21 - A newborn is delivered at term via vaginal delivery with no complications, however...

    Incorrect

    • A newborn is delivered at term via vaginal delivery with no complications, however she is not showing signs of breathing at one minute. Her heart rate is >110bpm, but she is floppy and has a blue colouration. What is the most appropriate next step?

      Your Answer: 5 mouth-to-mouth rescue breaths

      Correct Answer: 5 breaths of air via face mask

      Explanation:

      Performing airway suction should be avoided unless there is clear evidence of thick meconium causing obstruction, as it may lead to reflex bradycardia in infants. Chest compressions are not necessary if the heart rate (HR) is above 100 beats per minute (bpm). CPR should only be initiated if the HR drops below 60 bpm. If there are no signs of breathing due to fluid in the lungs, administering five breaths through a 250ml ambu bag is a more effective and hygienic approach than using mouth-to-mouth resuscitation in a hospital setting.

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

    • This question is part of the following fields:

      • Paediatrics
      41.1
      Seconds
  • Question 22 - You are requested to assess a premature infant born at 34 weeks, 48...

    Incorrect

    • You are requested to assess a premature infant born at 34 weeks, 48 hours after delivery without any complications. During the examination, you observe a continuous 'machinery-like' murmur and a left subclavicular thrill. Additionally, you notice a bounding pulse and a widened pulse pressure. There are no indications of cyanosis or crackles on auscultation. The mother confirms that there were no complications during pregnancy, and antenatal scans and screening did not reveal any abnormalities. There is no family history of significant illnesses. What would be the most appropriate management option for this probable diagnosis?

      Your Answer: Give prostaglandin E1 to the neonate

      Correct Answer: Give indomethacin to the neonate

      Explanation:

      To promote closure of patent ductus arteriosus (PDA), indomethacin or ibuprofen is administered to the neonate. This is the correct course of action based on the examination findings. The ductus arteriosus typically closes naturally with the first breaths, but if it remains open, prostaglandin synthesis can be inhibited with medication. Administering indomethacin to the mother would not be effective. Prostaglandin would have the opposite effect and maintain the PDA’s patency, which is not desirable in this scenario. Involving surgeons or monitoring the baby without treatment would also not be appropriate. If left untreated, PDA can lead to serious complications such as pulmonary hypertension or Eisenmenger’s syndrome.

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

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

    • This question is part of the following fields:

      • Paediatrics
      77.3
      Seconds
  • Question 23 - A 9-month-old boy is presented to the GP with a 4-week history of...

    Correct

    • A 9-month-old boy is presented to the GP with a 4-week history of rash. He has no significant medical history and is meeting developmental milestones appropriately. He has received all of his scheduled immunizations, has no known allergies, and is feeding and urinating well. Upon examination, there is a symmetrical, poorly defined erythematous rash on his elbows and knees. What is the most probable diagnosis?

      Your Answer: Eczema

      Explanation:

      Atopic eczema commonly appears in children before the age of 2, with symptoms often affecting the face and extensor surfaces of the body. This patient’s visible dermatitis in the extensor aspects of her body suggests a diagnosis of atopic eczema based on clinical presentation. Impetigo, pemphigus vulgaris, and psoriasis are unlikely diagnoses given the patient’s symmetrical dry rash involving the extensor aspects of the limbs.

      Eczema in Children: Symptoms and Management

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      23.3
      Seconds
  • Question 24 - As a foundation doctor on the neonatal ward, you examine a two hour...

    Correct

    • As a foundation doctor on the neonatal ward, you examine a two hour old baby delivered via cesarean section. The baby presents with intercostal recession and a respiratory rate of 55/min. However, they have good tone and color and are apyrexial. You suspect transient tachypnoea of the newborn and order a chest x-ray as part of your assessment. What is the probable result of the chest x-ray?

      Your Answer: Hyperinflation and fluid in the horizontal fissure

      Explanation:

      Transient tachypnoea of the newborn may be indicated by hyperinflation and fluid in the horizontal fissure on a chest x-ray. However, it is important to note that even if this condition is suspected, the baby should still be screened and treated for sepsis. This is because transient tachypnoea of the newborn is the most common cause of respiratory distress in neonates, but it typically resolves within 24-48 hours. Other conditions may present with different x-ray findings, such as ground glass appearance and low volume lungs in respiratory distress syndrome, or asymmetric patchy opacities in meconium aspiration syndrome. Additionally, a pneumothorax may be associated with mechanical ventilation but should be carefully evaluated in all chest x-rays.

      Understanding Transient Tachypnoea of the Newborn

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

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

    • This question is part of the following fields:

      • Paediatrics
      41.1
      Seconds
  • Question 25 - A 6-year-old boy is brought to the Emergency Department by his parents. He...

    Incorrect

    • A 6-year-old boy is brought to the Emergency Department by his parents. He has been feeling unwell for 6 days with diarrhoea and is now lethargic and pale. Despite drinking enough fluids, he has not urinated in over 14 hours. The child has no medical history and has received all of his vaccinations. His symptoms began 3 days after he ate a chicken burger at a fair. During the examination, the doctor noticed multiple petechiae on his torso and limbs, and his feet were swollen. What is the likely diagnosis, and what is the organism responsible for this patient's illness?

      Your Answer: Shigella species

      Correct Answer: Escherichia coli

      Explanation:

      This child’s symptoms, including oliguria, peripheral edema, petechial bruising, and pallor, suggest the possibility of hemolytic uremic syndrome (HUS). HUS is often associated with diarrheal illnesses and is characterized by normocytic anemia, thrombocytopenia, and acute kidney injury. The most common cause of HUS is Shiga-toxin producing Escherichia coli, which can be contracted from undercooked meat, such as a chicken burger from a carnival. While Campylobacter jejuni is a common cause of acute diarrhea, it is not typically associated with HUS. Clostridium perfringens can cause acute diarrhea and vomiting but is not associated with HUS. Salmonella species can also cause diarrheal illnesses, but they are not a common cause of HUS. In this case, Escherichia coli is the most likely causative organism.

      Understanding Haemolytic Uraemic Syndrome

      Haemolytic uraemic syndrome (HUS) is a condition that primarily affects young children and is characterized by a triad of symptoms, including acute kidney injury, microangiopathic haemolytic anaemia, and thrombocytopenia. The majority of cases are secondary and caused by Shiga toxin-producing Escherichia coli (STEC) 0157:H7, also known as ‘verotoxigenic’ or ‘enterohaemorrhagic’. Other causes of HUS include pneumococcal infection, HIV, systemic lupus erythematosus, drugs, and cancer. Primary HUS, also known as ‘atypical’, is caused by complement dysregulation.

      To diagnose HUS, doctors may perform a full blood count to check for microangiopathic hemolytic anaemia and thrombocytopenia. A fragmented blood film may also be done to look for schistocytes and helmet cells. Additionally, a stool culture may be performed to check for evidence of STEC infection, and PCR for Shiga toxins may be done.

      Treatment for HUS is supportive and may include fluids, blood transfusion, and dialysis if required. Antibiotics are not recommended, despite the preceding diarrhoeal illness in many patients. Plasma exchange may be considered for severe cases of HUS not associated with diarrhoea, while eculizumab, a C5 inhibitor monoclonal antibody, has shown greater efficiency than plasma exchange alone in the treatment of adult atypical HUS.

      Overall, understanding the causes, symptoms, and management of HUS is crucial for healthcare professionals to provide appropriate care for patients with this condition.

    • This question is part of the following fields:

      • Paediatrics
      32.3
      Seconds
  • Question 26 - A 6-month-old baby girl starts to experience frequent vomiting after feedings. Prior to...

    Incorrect

    • A 6-month-old baby girl starts to experience frequent vomiting after feedings. Prior to this, she had been growing at a steady rate. What is the probable diagnosis?

      Your Answer: Hirschsprung’s disease

      Correct Answer: Pyloric stenosis

      Explanation:

      Common Neonatal Gastrointestinal Disorders

      There are several common gastrointestinal disorders that can affect newborns. These include pyloric stenosis, necrotising enterocolitis (NEC), congenital duodenal atresia, Hirschsprung’s disease, and tracheoesophageal fistula (TOF).

      Pyloric stenosis is characterised by hypertrophy of the circular pyloric muscle, and typically presents with non-bilious, projectile vomiting in the third or fourth week of life. Constipation and dehydration may also occur, and biochemistry may show hypokalaemic metabolic alkalosis. Boys are more likely to be affected, especially if born into a family with affected girls.

      NEC is a condition primarily seen in premature infants, where portions of the bowel undergo necrosis. Symptoms include bilious vomiting, distended abdomen, and bloody stools, with late signs including bowel perforation and multi-organ failure.

      Congenital duodenal atresia is a congenital absence or complete closure of a portion of the lumen of the duodenum, and presents with bile-stained vomiting, abdominal distension, and inability to pass meconium.

      Hirschsprung’s disease is characterised by the failure of ganglion cells to migrate into the hindgut, leading to functional intestinal obstruction. Symptoms include abdominal distension, bile-stained vomiting, and failure to pass meconium.

      TOF refers to a communication between the trachea and oesophagus, usually associated with oesophageal atresia. Symptoms include choking, coughing, and cyanosis during feeding, excess mucus, and recurrent lower respiratory tract infections. Other congenital anomalies may also be present.

      Overall, early recognition and management of these neonatal gastrointestinal disorders is crucial for optimal outcomes.

    • This question is part of the following fields:

      • Paediatrics
      31.8
      Seconds
  • Question 27 - As a foundation doctor on the postnatal ward, you conduct a newborn examination...

    Correct

    • As a foundation doctor on the postnatal ward, you conduct a newborn examination on a two-day-old baby girl. She was delivered normally and in good condition. During the hip examination, you notice that the left hip can be relocated, which raises concerns. What is the next appropriate step in management?

      Your Answer: Urgent referral for hip ultrasound

      Explanation:

      The Ortolani manoeuvre was performed on a newborn to relocate the femoral head after dislocation caused by the Barlow manoeuvre. The result was abnormal, indicating a need for urgent assessment to check for potential developmental dysplasia of the hip. The best imaging option is ultrasound, which avoids radiation and provides optimal visualization of the hip’s development. Referring the child for routine assessment would cause unnecessary delay in treatment, and providing reassurance would be inappropriate given the abnormal screening result.

      Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

    • This question is part of the following fields:

      • Paediatrics
      22.3
      Seconds
  • Question 28 - A 7-year-old boy comes to the clinic with his father, complaining of a...

    Incorrect

    • A 7-year-old boy comes to the clinic with his father, complaining of a rash. The father reports that his son has been feeling unwell for approximately 6 days. Three days ago, he noticed some red rash behind his son's ears and it has now spread to his face and body. He also observed some white spots in his son's mouth before the rash appeared. During examination, there is a widespread maculopapular rash with regions of confluence.

      What is the probable diagnosis?

      Your Answer: Rubella

      Correct Answer: Measles

      Explanation:

      The symptoms of measles include prodromal symptoms, Koplik spots, and a maculopapular rash that starts behind the ears. Kawasaki’s disease is identified by a fever lasting more than five days, along with conjunctivitis, cervical lymphadenopathy, a strawberry tongue, rash, and desquamation of digits. Chickenpox is characterized by the presence of vesicles, while scarlet fever is identified by a sandpaper rash and a strawberry tongue.

      Measles: A Highly Infectious Viral Disease

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

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      16
      Seconds
  • Question 29 - You are consulted by the parents of a 5-year-old girl. She has a...

    Incorrect

    • You are consulted by the parents of a 5-year-old girl. She has a lifelong history of bedwetting at night, and they are becoming increasingly concerned that the problem is not getting any better. She never has accidents in the day and opens her bowels at least once a day. She has been potty-trained since the age of two. Apart from hay fever, there is no relevant family history. Physical examination is normal. Urinalysis reveals no abnormality. Things have come to a head as she is starting school in two weeks’ time, and they do not want her to wet the bed.
      What is the most appropriate management plan?

      Your Answer: Give general advice on enuresis, reassure the parents that he is almost certain to grow out of the problem and commence treatment with an enuresis alarm to prepare him for his camping trip and advise to restrict fluid from 1600 h to prevent bedwetting during the camping trip

      Correct Answer: Give general advice on enuresis, reassure the parents that he is almost certain to grow out of the problem and prescribe desmopressin to be taken during the camping trip to prevent bedwetting

      Explanation:

      Managing Primary Enuresis in Children: Advice and Treatment Options

      Primary enuresis, or bedwetting, is a common condition affecting 15-20% of children. It is characterized by nocturnal wetting without daytime symptoms and is thought to be caused by bladder dysfunction. Parents of children with primary enuresis may be reassured that their child is likely to grow out of the problem by age 15, with only 1% of patients continuing to have symptoms into adulthood.

      Treatment options for primary enuresis include the use of an enuresis alarm combined with a reward system to teach and reward good habits. Fluid should not be restricted. In children over the age of 5, short-term control can be achieved with a prescription of desmopressin to prevent enuresis during sleepovers or school trips.

      It is important to involve the child in the management plan and explore family habits. Referral to a paediatric urologist may be necessary for children with primary enuresis and daytime symptoms or for those who have failed two complete courses of treatment with an enuresis alarm or desmopressin.

      Managing Primary Enuresis in Children: Advice and Treatment Options

    • This question is part of the following fields:

      • Paediatrics
      60.3
      Seconds
  • Question 30 - A father brings in his 3-week-old baby boy to the pediatrician's office as...

    Correct

    • A father brings in his 3-week-old baby boy to the pediatrician's office as he's noticed that the baby bruises very easily. This is his first child, who was born in Canada following an uncomplicated pregnancy by natural vaginal delivery. Exclusive breastfeeding was commenced immediately following delivery and the baby has been feeding well otherwise and gaining weight steadily. You order the following blood test.

      International normalised ratio (INR) 4

      What could be the possible reasons for the baby's symptoms?

      Your Answer: Exclusive breastfeeding

      Explanation:

      Breastfed infants may be susceptible to vitamin K deficiency, as breast milk lacks sufficient amounts of this nutrient. The baby in question is likely experiencing idiopathic vitamin K deficiency, with breastfeeding being the only known risk factor. It is possible that the baby did not receive a vitamin K injection at birth, as they were born in Ukraine. Gender, age, vaginal delivery, and birth order are not associated with an increased risk of vitamin K deficiency.

      Haemorrhagic Disease of the Newborn: Causes and Prevention

      Newborn babies have a relatively low level of vitamin K, which can lead to the development of haemorrhagic disease of the newborn (HDN). This condition occurs when the production of clotting factors is impaired, resulting in bleeding that can range from minor bruising to intracranial haemorrhages. Breast-fed babies are particularly at risk, as breast milk is a poor source of vitamin K. Additionally, the use of antiepileptic medication by the mother can increase the risk of HDN in the newborn.

      To prevent HDN, all newborns in the UK are offered vitamin K supplementation. This can be administered either intramuscularly or orally. By providing newborns with adequate levels of vitamin K, the risk of HDN can be significantly reduced. It is important for parents and healthcare providers to be aware of the risk factors for HDN and to take steps to prevent this potentially serious condition.

    • This question is part of the following fields:

      • Paediatrics
      27.1
      Seconds
  • Question 31 - A mother who refused regular prenatal check-ups delivers a male infant. During delivery,...

    Correct

    • A mother who refused regular prenatal check-ups delivers a male infant. During delivery, a defect is observed on the side of the belly button, revealing the intestines.
      What could be the possible diagnosis?

      Your Answer: Gastroschisis

      Explanation:

      Gastroschisis is a bowel condition where the intestines are exposed and not encased by a sac. It is not associated with cardiac and kidney diseases, unlike exomphalos. It can be diagnosed through routine ultrasound, but may be missed if the mother does not engage in antenatal care. It is not a normal variant and is not necessarily associated with prematurity.

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      25.8
      Seconds
  • Question 32 - What is the most effective examination to detect the potential complications of Kawasaki...

    Correct

    • What is the most effective examination to detect the potential complications of Kawasaki disease in children?

      Your Answer: Echocardiogram

      Explanation:

      An echocardiogram should be performed to screen for coronary artery aneurysms, which can be a complication of Kawasaki disease.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

    • This question is part of the following fields:

      • Paediatrics
      7.7
      Seconds
  • Question 33 - A mother brings in her 4-week old male baby who was born at...

    Correct

    • A mother brings in her 4-week old male baby who was born at 30 weeks. He was discharged from neonatal intensive care unit 2 weeks ago. She reports that for the last 4 days, he has been refusing feed. This morning she noticed that he passed some bloody stools. On examination, the baby has a distended abdomen.
      What is the probable diagnosis?

      Your Answer: Necrotising enterocolitis

      Explanation:

      Feeding intolerance, abdominal distension, and bloody stools are among the early signs of necrotising enterocolitis, which is a high risk for preterm babies. Gastroesophageal reflux disease (GORD) does not cause abdominal distension and bloody stools, while duodenal atresia typically presents with bilious vomiting within the first day of life and does not cause bloody stools. Although hospital-acquired infection is a possibility, given the clinical picture and preterm status, ruling out necrotising enterocolitis should be the priority.

      Understanding Necrotising Enterocolitis

      Necrotising enterocolitis is a serious condition that is responsible for a significant number of premature infant deaths. The condition is characterized by symptoms such as feeding intolerance, abdominal distension, and bloody stools. If left untreated, these symptoms can quickly progress to more severe symptoms such as abdominal discolouration, perforation, and peritonitis.

      To diagnose necrotising enterocolitis, doctors often use abdominal x-rays. These x-rays can reveal a number of important indicators of the condition, including dilated bowel loops, bowel wall oedema, and intramural gas. Other signs that may be visible on an x-ray include portal venous gas, pneumoperitoneum resulting from perforation, and air both inside and outside of the bowel wall. In some cases, an x-ray may also reveal air outlining the falciform ligament, which is known as the football sign.

      Overall, understanding the symptoms and diagnostic indicators of necrotising enterocolitis is crucial for early detection and treatment of this serious condition. By working closely with healthcare professionals and following recommended screening protocols, parents and caregivers can help ensure the best possible outcomes for premature infants at risk for this condition.

    • This question is part of the following fields:

      • Paediatrics
      97.6
      Seconds
  • Question 34 - A 7-year-old girl visits her GP clinic with her mother who is worried...

    Correct

    • A 7-year-old girl visits her GP clinic with her mother who is worried about her continued bedwetting at night. They had visited the clinic 4 weeks ago and have seen no improvement despite following general management advice and a basic reward system. The girl is healthy otherwise and has no history of constipation or daytime incontinence. She does not complain of any issues at home or school. Physical examination reveals no abnormalities.
      What additional treatment options would you suggest for her?

      Your Answer: Enuresis alarm

      Explanation:

      When general management advice has not been effective for nocturnal enuresis, an enuresis alarm is typically the first-line recommendation. This device detects urine moisture and triggers an alarm (either through sound or vibration) to wake the child and prompt them to use the toilet. Enuresis alarms have a high success rate when used consistently, and a review is typically conducted after four weeks to assess progress. Bladder training and retention control training are not recommended by NICE guidelines due to limited evidence and concerns about promoting voiding dysfunction. Desmopressin, a vasopressin analogue that reduces urine production, may be considered if the family is not receptive to or finds an enuresis alarm ineffective. However, an enuresis alarm should be offered first. Desmopressin can provide short-term control, but it can cause hyponatremia. Desmopressin plus oxybutynin may be helpful if there are daytime symptoms or if desmopressin alone does not improve the condition. As not all anticholinergic medications have UK marketing authorization for bedwetting treatment, a healthcare professional with appropriate expertise should manage this combination, often requiring a specialist referral and further investigations.

      Nocturnal enuresis, or bedwetting, is when a child involuntarily urinates during the night. Most children achieve continence by the age of 3 or 4, so enuresis is defined as the involuntary discharge of urine in a child aged 5 or older without any underlying medical conditions. Enuresis can be primary, meaning the child has never achieved continence, or secondary, meaning the child has been dry for at least 6 months before.

      When managing bedwetting, it’s important to look for any underlying causes or triggers, such as constipation, diabetes mellitus, or recent onset UTIs. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Reward systems, like star charts, can also be helpful, but should be given for agreed behavior rather than dry nights.

      The first-line treatment for bedwetting is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up to use the toilet. If short-term control is needed, such as for sleepovers, or if the alarm is ineffective or not acceptable to the family, desmopressin may be prescribed. Overall, managing bedwetting involves identifying any underlying causes and implementing strategies to promote continence.

    • This question is part of the following fields:

      • Paediatrics
      24.3
      Seconds
  • Question 35 - A 6-year-old girl is brought to your clinic by her father. She has...

    Correct

    • A 6-year-old girl is brought to your clinic by her father. She has a history of asthma and has been using salbutamol as needed. However, her father reports that her symptoms have become more severe lately, with a persistent nighttime cough that disrupts her sleep and affects her performance during physical activities at school. Upon examination, there are no notable findings. What is your recommended course of action?

      Your Answer: Add an inhaled steroid

      Explanation:

      As per current clinical practice, the child is not using an inhaled corticosteroid. However, the 2016 British Thoracic Society guidelines suggest that all children and adults should be prescribed an inhaled corticosteroid upon diagnosis. The previous approach of using only a short-acting beta agonist as the initial step has been eliminated. Therefore, the best course of action would be to introduce a ‘very low’ dose inhaled corticosteroid.

      Managing Asthma in Children: NICE Guidelines

      Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.

      It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.

    • This question is part of the following fields:

      • Paediatrics
      29.5
      Seconds
  • Question 36 - A mother of a 5-year-old child with cystic fibrosis (CF) visits the clinic...

    Correct

    • A mother of a 5-year-old child with cystic fibrosis (CF) visits the clinic to inquire about the likelihood of having another child with CF. She is still with the same partner as before. What is the probability of them having another child with CF?

      Your Answer: 25%

      Explanation:

      Understanding Autosomal Recessive Inheritance

      Autosomal recessive inheritance is a genetic pattern where a disorder is only expressed when an individual inherits two copies of a mutated gene, one from each parent. This means that only homozygotes, individuals with two copies of the mutated gene, are affected. Both males and females are equally likely to be affected, and the disorder may not manifest in every generation, as it can skip a generation.

      When two heterozygote parents, carriers of the mutated gene, have children, there is a 25% chance of having an affected (homozygote) child, a 50% chance of having a carrier (heterozygote) child, and a 25% chance of having an unaffected child. On the other hand, if one parent is homozygote for the gene and the other is unaffected, all the children will be carriers.

      Autosomal recessive disorders are often metabolic in nature and can be life-threatening compared to autosomal dominant conditions. Understanding the inheritance pattern of autosomal recessive disorders is crucial in genetic counseling and family planning.

    • This question is part of the following fields:

      • Paediatrics
      32.5
      Seconds
  • Question 37 - Which of the following conditions is not screened for in the blood spot...

    Incorrect

    • Which of the following conditions is not screened for in the blood spot screening test for infants?

      Your Answer: Sickle cell disease

      Correct Answer: Galactosaemia

      Explanation:

      Neonatal Blood Spot Screening: Identifying Potential Health Risks in Newborns

      Neonatal blood spot screening, also known as the Guthrie test or heel-prick test, is a routine procedure performed on newborns between 5-9 days of life. The test involves collecting a small sample of blood from the baby’s heel and analyzing it for potential health risks. Currently, there are nine conditions that are screened for, including congenital hypothyroidism, cystic fibrosis, sickle cell disease, phenylketonuria, medium chain acyl-CoA dehydrogenase deficiency (MCADD), maple syrup urine disease (MSUD), isovaleric acidaemia (IVA), glutaric aciduria type 1 (GA1), and homocystinuria (pyridoxine unresponsive) (HCU).

    • This question is part of the following fields:

      • Paediatrics
      11.9
      Seconds
  • Question 38 - You perform a routine examination on a 6-month-old baby with newly diagnosed Down...

    Correct

    • You perform a routine examination on a 6-month-old baby with newly diagnosed Down syndrome. The mother mentions 'white speckles on his eyes'. Upon examination, you find a bilateral red reflex and no abnormalities. What is the mother describing?

      Your Answer: Brushfield spots

      Explanation:

      Brushfield spots, which are small grey or brown spots found on the outer edge of the iris, are commonly observed in individuals with Down syndrome. Cataracts, on the other hand, involve clouding of the lens and are not likely present in this patient as their red reflex appears normal. Coloboma, a congenital defect that causes a gap in the lens, iris, or retina, is associated with Patau syndrome rather than Down syndrome. While there have been links between Down syndrome and congenital glaucoma, the patient’s history does not suggest this condition. A squint, or deviation in the gaze of an eye, is a separate issue altogether.

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      17
      Seconds
  • Question 39 - A 30-year-old man is advised on the genetics of Huntington's disease. What is...

    Correct

    • A 30-year-old man is advised on the genetics of Huntington's disease. What is the best explanation for the concept of anticipation?

      Your Answer: Earlier age of onset in successive generations

      Explanation:

      Trinucleotide repeat disorders exhibit earlier onset in successive generations due to anticipation, which is often accompanied by an escalation in symptom severity.

      Trinucleotide repeat disorders are genetic conditions that occur due to an abnormal number of repeats of a repetitive sequence of three nucleotides. These expansions are unstable and can enlarge, leading to an earlier age of onset in successive generations, a phenomenon known as anticipation. In most cases, an increase in the severity of symptoms is also observed. It is important to note that these disorders are predominantly neurological in nature.

      Examples of trinucleotide repeat disorders include Fragile X, Huntington’s, myotonic dystrophy, Friedreich’s ataxia, spinocerebellar ataxia, spinobulbar muscular atrophy, and dentatorubral pallidoluysian atrophy. Friedreich’s ataxia is unique in that it does not demonstrate anticipation.

    • This question is part of the following fields:

      • Paediatrics
      30.6
      Seconds
  • Question 40 - As a second-year foundation doctor in the emergency department, you come across a...

    Correct

    • As a second-year foundation doctor in the emergency department, you come across a thirteen-year-old patient complaining of right hip pain and a limp. The patient has a mild fever, but all other observations and blood tests are normal. An X-ray also shows no abnormalities. What is the probable diagnosis?

      Your Answer: Transient synovitis

      Explanation:

      Transient synovitis, also known as irritable hip, is a common childhood condition that presents with sudden onset pain and limping. It is diagnosed by ruling out other possible causes and typically resolves on its own within 1-2 weeks. While trauma or non-accidental injury may be a factor, this would likely be revealed in the patient’s medical history. However, doctors should remain vigilant for signs of non-accidental injury. Although septic arthritis is a possibility, it is unlikely in cases where blood tests are normal. Slipped Upper Femoral Epiphysis (SUFE), which causes groin pain and a waddling gait, can be ruled out based on its characteristic x-ray findings.

      Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.

    • This question is part of the following fields:

      • Paediatrics
      20.8
      Seconds
  • Question 41 - A 6-year-old boy comes to the doctor's office with a continuous fever and...

    Correct

    • A 6-year-old boy comes to the doctor's office with a continuous fever and rash that has been present for the past 4 days. During the examination, the doctor observes that the boy has chapped, parched lips and flaking hands and fingers. Despite administering regular doses of paracetamol, the mother is worried as there has been no improvement. What is the probable diagnosis?

      Your Answer: Kawasaki's disease

      Explanation:

      Kawasaki disease is characterized by a high fever that lasts for more than 5 days, along with red palms, desquamation, and a strawberry tongue. It is crucial to diagnose and treat this condition promptly to minimize the risk of cardiac complications. Without early treatment with IV immunoglobulins, up to 20% of patients may develop coronary artery aneurysms, which can result in heart attack and sudden death.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

    • This question is part of the following fields:

      • Paediatrics
      16
      Seconds
  • Question 42 - Which of the following examples of infant jaundice from the list below is...

    Correct

    • Which of the following examples of infant jaundice from the list below is the most concerning?

      Your Answer: Jaundice which develops on the day of delivery

      Explanation:

      Jaundice that appears within the first 24 hours after delivery is always considered to be pathological. Physiological jaundice typically develops 2-3 days after delivery and should resolve within 14 days. The risk of developing jaundice is higher in pre-term infants. In cases of physiological jaundice, bilirubin levels typically do not exceed 200 ÎŒmol/L.

      Jaundice in newborns can occur within the first 24 hours of life and is always considered pathological. The causes of jaundice during this period include rhesus and ABO haemolytic diseases, hereditary spherocytosis, and glucose-6-phosphodehydrogenase deficiency. On the other hand, jaundice in neonates from 2-14 days is common and usually physiological, affecting up to 40% of babies. This type of jaundice is due to a combination of factors such as more red blood cells, fragile red blood cells, and less developed liver function. Breastfed babies are more likely to develop this type of jaundice.

      If jaundice persists after 14 days (21 days for premature babies), a prolonged jaundice screen is performed. This includes tests for conjugated and unconjugated bilirubin, direct antiglobulin test, thyroid function tests, full blood count and blood film, urine for MC&S and reducing sugars, and urea and electrolytes. Prolonged jaundice can be caused by biliary atresia, hypothyroidism, galactosaemia, urinary tract infection, breast milk jaundice, prematurity, and congenital infections such as CMV and toxoplasmosis. Breast milk jaundice is more common in breastfed babies and is thought to be due to high concentrations of beta-glucuronidase, which increases the intestinal absorption of unconjugated bilirubin. Prematurity also increases the risk of kernicterus.

    • This question is part of the following fields:

      • Paediatrics
      9.2
      Seconds
  • Question 43 - A 3 day old infant who was delivered via ventouse presents with a...

    Correct

    • A 3 day old infant who was delivered via ventouse presents with a swelling on the left parietal region of the head. The swelling was not present immediately after birth and the baby is otherwise healthy. Upon examination, the swelling does not cross suture lines and the fontanelles and sutures appear normal. What is the probable diagnosis?

      Your Answer: Cephalohaematoma

      Explanation:

      A cephalohaematoma is a swelling caused by bleeding between the skull and periosteum, typically seen in the parietal region of newborns delivered with instruments. It usually appears 2-3 days after birth and does not cross suture lines, resolving over several weeks.

      Caput succadeneum is a common condition in newborns immediately after birth, caused by generalised scalp oedema that crosses suture lines. It is associated with prolonged labour and resolves quickly within a few days.

      Subaponeurotic haematoma is a rare and potentially life-threatening condition where bleeding occurs outside the periosteum, causing a fluctuant scalp swelling that is not limited by suture lines.

      Craniosynostosis is a rare condition where cranial sutures close prematurely, leading to skull deformities that may be evident at birth and associated with genetic syndromes. The shape of the skull depends on which sutures are involved, and other clinical features include early closure of the anterior fontanelle and a raised ridge along the fused suture.

      A cephalohaematoma is a swelling that appears on a newborn’s head, usually a few hours after delivery. It is caused by bleeding between the skull and periosteum, with the parietal region being the most commonly affected site. This condition may lead to jaundice as a complication and can take up to three months to resolve.

      In comparison to caput succedaneum, which is another type of swelling that can occur on a newborn’s head, cephalohaematoma is more localized and does not cross suture lines. Caput succedaneum, on the other hand, is a diffuse swelling that can cross suture lines and is caused by fluid accumulation in the scalp tissue. Both conditions are usually harmless and resolve on their own, but medical attention may be necessary in severe cases.

    • This question is part of the following fields:

      • Paediatrics
      21.8
      Seconds
  • Question 44 - A 6-year-old girl is presented with a worsening of her asthma symptoms. Upon...

    Incorrect

    • A 6-year-old girl is presented with a worsening of her asthma symptoms. Upon examination, she exhibits bilateral expiratory wheezing, but there are no indications of respiratory distress. Her respiratory rate is 24 breaths per minute, and her PEF is approximately 50% of normal. What is the best course of action regarding steroid treatment?

      Your Answer: Double his usual beclometasone dose

      Correct Answer: Oral prednisolone for 3 days

      Explanation:

      According to the 2016 guidelines of the British Thoracic Society, children should be given a specific dose of steroids based on their age. For children under 2 years, the dose should be 10 mg of prednisolone, for those aged 2-5 years, it should be 20 mg, and for those over 5 years, it should be 30-40 mg. Children who are already taking maintenance steroid tablets should receive a maximum dose of 60 mg or 2 mg/kg of prednisolone. If a child vomits after taking the medication, the dose should be repeated, and if they are unable to retain the medication orally, intravenous steroids should be considered. The duration of treatment should be tailored to the number of days required for recovery, and a course of steroids exceeding 14 days does not require tapering.

      Managing Acute Asthma Attacks in Children

      When it comes to managing acute asthma attacks in children, it is important to assess the severity of the attack and take appropriate action. For children between the ages of 2 and 5, those with severe or life-threatening asthma should be immediately transferred to the hospital. For moderate attacks, children should have a SpO2 level above 92% and no clinical features of severe asthma. However, for severe attacks, children may have a SpO2 level below 92%, be too breathless to talk or feed, have a heart rate above 140/min, and use accessory neck muscles. For life-threatening attacks, children may have a SpO2 level below 92%, a silent chest, poor respiratory effort, agitation, altered consciousness, and cyanosis.

      For children over the age of 5, it is recommended to attempt to measure PEF in all cases. For moderate attacks, children should have a SpO2 level above 92%, a PEF level above 50% best or predicted, and no clinical features of severe asthma. For severe attacks, children may have a SpO2 level below 92%, a PEF level between 33-50% best or predicted, and be unable to complete sentences in one breath or too breathless to talk or feed. For life-threatening attacks, children may have a SpO2 level below 92%, a PEF level below 33% best or predicted, a silent chest, poor respiratory effort, altered consciousness, and cyanosis.

      For children with mild to moderate acute asthma, bronchodilator therapy should be given via a beta-2 agonist and spacer (or close-fitting mask for children under 3 years old). One puff should be given every 30-60 seconds up to a maximum of 10 puffs. If symptoms are not controlled, the beta-2 agonist should be repeated and the child should be referred to the hospital. Steroid therapy should also be given to all children with an asthma exacerbation for 3-5 days, with the usual prednisolone dose varying based on age and weight.

    • This question is part of the following fields:

      • Paediatrics
      33
      Seconds
  • Question 45 - A 4-week-old baby boy is brought to the Emergency Department with a two-week...

    Correct

    • A 4-week-old baby boy is brought to the Emergency Department with a two-week history of vomiting after every feed and then appearing very hungry afterwards. His weight has remained at 4 kg for the past two weeks, and for the past two days, the vomiting has become projectile. His birthweight was 3.6 kg. He is exclusively breastfed. A small mass can be palpated in the right upper quadrant of his abdomen.
      What is the most likely diagnosis?

      Your Answer: Pyloric stenosis

      Explanation:

      Differential diagnosis of vomiting and poor weight gain in infants

      Vomiting and poor weight gain are common symptoms in infants, but they can be caused by different conditions that require specific management. One possible cause is pyloric stenosis, which results from an enlarged muscle at the outlet of the stomach, leading to projectile vomiting, dehydration, and failure to thrive. Another possible cause is gastro-oesophageal reflux disease (GORD), which may also involve vomiting, but not projectile, and may respond to conservative measures such as frequent feeds and upright positioning, or medication such as GavisconÂź or proton pump inhibitors. Cow’s milk protein allergy is another potential cause, which may present with a range of symptoms, including vomiting, but not projectile, and may require an exclusion diet for the mother if breastfeeding. Gastroenteritis is a common cause of vomiting and diarrhoea in infants, but it usually resolves within a few days and does not cause an abdominal mass. Finally, volvulus is a rare but serious condition that involves a twisted bowel, leading to acute obstruction and ischaemia, which requires urgent surgical intervention. Therefore, a careful history, examination, and investigations, such as ultrasound or blood tests, may help to differentiate these conditions and guide appropriate treatment.

    • This question is part of the following fields:

      • Paediatrics
      20.4
      Seconds
  • Question 46 - A four-year-old boy is brought to the emergency department by his parents due...

    Correct

    • A four-year-old boy is brought to the emergency department by his parents due to a new rash on his abdomen. The parents deny any recent infections or injuries. Upon examination, you observe a widespread petechial rash on the anterior abdomen and right forearm. The child appears pale and uninterested in the toys provided. Additionally, you note hepatosplenomegaly and cervical lymphadenopathy. While waiting for blood test results, you perform a urinalysis, which is unremarkable, and record a tympanic temperature of 36.6Âș. What is the most probable diagnosis?

      Your Answer: Acute lymphoblastic leukaemia

      Explanation:

      DIC can cause haemorrhagic or thrombotic complications in cases of acute lymphoblastic leukaemia.

      While a petechial rash can be a result of trauma, it is unlikely to be the case with this child given the other significant symptoms present. The non-blanching rash may initially suggest meningococcal disease, but the absence of fever and a clear source of infection makes this less likely. Additionally, the lesions associated with Henoch-Schonlein purpura typically appear on specific areas of the body and are accompanied by other symptoms such as haematuria or joint pain, which are not present in this case.

      Acute lymphoblastic leukaemia (ALL) is a type of cancer that commonly affects children and accounts for 80% of childhood leukaemias. It is most prevalent in children between the ages of 2-5 years, with boys being slightly more affected than girls. Symptoms of ALL can be divided into those caused by bone marrow failure, such as anaemia, neutropaenia, and thrombocytopenia, and other features like bone pain, splenomegaly, and hepatomegaly. Fever is also present in up to 50% of new cases, which may indicate an infection or a constitutional symptom. Testicular swelling may also occur.

      There are three types of ALL: common ALL, T-cell ALL, and B-cell ALL. Common ALL is the most common type, accounting for 75% of cases, and is characterized by the presence of CD10 and a pre-B phenotype. Poor prognostic factors for ALL include age less than 2 years or greater than 10 years, a white blood cell count greater than 20 * 109/l at diagnosis, T or B cell surface markers, non-Caucasian ethnicity, and male sex.

    • This question is part of the following fields:

      • Paediatrics
      48
      Seconds
  • Question 47 - An infant develops bile-stained vomiting; an abdominal X-ray shows a ‘double bubble’ appearance....

    Correct

    • An infant develops bile-stained vomiting; an abdominal X-ray shows a ‘double bubble’ appearance. The infant is also hypotonic with brachycephaly.
      Which of the following is the most likely diagnosis?

      Your Answer: Trisomy 21

      Explanation:

      Genetic Disorders and Associated Phenotypic Features

      Trisomy 21: Down Syndrome and Duodenal Atresia
      Neonates with Down syndrome have an increased risk of duodenal atresia, accounting for around a third of cases. Prenatal imaging can detect this condition, which presents with bilious vomiting within hours of birth. Down syndrome is also characterized by distinct physical features such as brachiocephaly, upward slanting palpebral fissures, and joint hyperflexibility.

      45,XO: Turner Syndrome and Cardiac Defects
      Turner syndrome affects females with a genetic complement of 45XO. It is characterized by short stature, webbed neck, and lymphoedema. Cardiac defects, including coarctation of the aorta, may also be present.

      Fragile X: Learning Disability and Autism
      Fragile X is a common X-linked form of learning disability and autism. Physical features are difficult to detect in infancy, but delayed motor milestones and speech and language delay may be present. Macro-orchidism is almost universal post-puberty, and cardiac defects, including mitral valve prolapse, may occur.

      Trisomy 18: Edwards’ Syndrome and Neonatal Hypotonia
      Trisomy 18, or Edwards’ syndrome, is characterized by neonatal hypotonia, apnoea, and seizures. There is severe psychomotor and growth retardation, microcephaly, and microphthalmia. Over 90% have cardiac defects, commonly VSD, as well as anomalies in most organ systems.

      47,XXY: Klinefelter’s Syndrome and Infertility
      Klinefelter’s syndrome affects males with a genetic complement of either 47,XXY or 48,XXXY. It is a random mutation, not inherited, and is characterized by tall stature, poorly developed testes or cryptorchidism, and gynaecomastia. Infertility is common. Physical features are not obvious in infancy.

    • This question is part of the following fields:

      • Paediatrics
      16.1
      Seconds
  • Question 48 - Sophie, a 9-month-old with a confirmed non-IgE mediated allergy to cow's milk protein,...

    Correct

    • Sophie, a 9-month-old with a confirmed non-IgE mediated allergy to cow's milk protein, is seen in your allergy clinic. Her parents are worried about her long-term milk avoidance. At present, she is not consuming any milk-based products. What recommendations would you provide for treatment?

      Your Answer: Initiate the milk ladder starting with malted milk biscuits

      Explanation:

      Non IgE mediated cows milk protein allergy tends to resolve at a younger age compared to IgE mediated allergies in children.

      The milk ladder is a common approach for introducing milk into the diet of children with cows milk protein allergy, with gradual steps starting from malted milk biscuits and progressing to chocolate and yoghurt.

      It is not advisable to use Chlorpheniramine (piriton) as it can cause drowsiness in this age group. Additionally, an epipen is not necessary for non IgE mediated allergy.

      Understanding Cow’s Milk Protein Intolerance/Allergy

      Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects around 3-6% of children, typically presenting in the first 3 months of life in formula-fed infants. Both immediate and delayed reactions can occur, with CMPA used for immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms include regurgitation, vomiting, diarrhea, urticaria, atopic eczema, colic symptoms, wheeze, chronic cough, and rarely, angioedema and anaphylaxis. Diagnosis is often clinical, with investigations including skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein.

      Management for formula-fed infants includes using extensive hydrolyzed formula (eHF) milk as the first-line replacement formula for mild-moderate symptoms and amino acid-based formula (AAF) for severe CMPA or if no response to eHF. Around 10% of infants are also intolerant to soya milk. For breastfed infants, mothers should eliminate cow’s milk protein from their diet and consider prescribing calcium supplements to prevent deficiency. eHF milk can be used when breastfeeding stops until at least 6 months and up to 12 months of age.

      The prognosis for CMPI is usually good, with most children becoming milk tolerant by the age of 3-5 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur. It is important to refer infants with severe symptoms to a pediatrician for management. Understanding CMPI/CMPA and its management can help parents and healthcare providers provide appropriate care for affected children.

    • This question is part of the following fields:

      • Paediatrics
      21.9
      Seconds
  • Question 49 - A 10-year-old boy presents to you with his mother, reporting pain in his...

    Correct

    • A 10-year-old boy presents to you with his mother, reporting pain in his left hip. He is typically healthy, but he recently saw another doctor for a viral upper respiratory tract infection. The pain began two days ago, and he is hesitant to put weight on his left leg.

      What is the probable underlying condition?

      Your Answer: Transient synovitis of the hip

      Explanation:

      A possible diagnosis for a child experiencing hip pain, limp, and a recent infection could be transient synovitis.

      Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.

    • This question is part of the following fields:

      • Paediatrics
      14.8
      Seconds
  • Question 50 - A 6-month-old infant is presented to the emergency department by their caregiver. The...

    Incorrect

    • A 6-month-old infant is presented to the emergency department by their caregiver. The infant is exhibiting a fever, lethargy, and decreased muscle tone. Additionally, a non-blanching rash is observed on the right arm of the infant. What is the best course of treatment?

      Your Answer: IV cefotaxime + amoxicillin

      Correct Answer: IV ceftriaxone

      Explanation:

      For an unwell child with suspected meningitis who is over 3 months old, the recommended initial empirical therapy is IV 3rd generation cephalosporin, such as ceftriaxone. IV cefuroxime, a 2nd generation cephalosporin, is not recommended for this purpose. IV cefotaxime + amoxicillin is recommended for babies at risk of jaundice, but as the child in this case is 4 months old, this is not necessary. IV co-amoxiclav and piperacillin do not provide adequate coverage for meningitis and are not suitable for central nervous system infections.

      Investigation and Management of Meningitis in Children

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      16.8
      Seconds
  • Question 51 - A young girl from a nomadic group has been diagnosed with measles. What...

    Incorrect

    • A young girl from a nomadic group has been diagnosed with measles. What is the potential immediate complication she may face following the initial infection?

      Your Answer: Pancreatitis

      Correct Answer: Pneumonia

      Explanation:

      Pneumonia is a possible complication of measles, while subacute sclerosing panencephalitis may develop 5-10 years after the illness. Mumps infection may lead to pancreatitis and infertility.

      Measles: A Highly Infectious Viral Disease

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

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      22.9
      Seconds
  • Question 52 - Which one of the following statements regarding croup is true? ...

    Correct

    • Which one of the following statements regarding croup is true?

      Your Answer: Most commonly caused by parainfluenza viruses

      Explanation:

      The majority of croup cases are caused by parainfluenza virus, and it is recommended to avoid throat examination as it may lead to airway obstruction.

      Understanding Croup: A Respiratory Infection in Infants and Toddlers

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

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      27
      Seconds
  • Question 53 - Sarah, a 5-year-old child visits the allergy clinic with her parents. She has...

    Correct

    • Sarah, a 5-year-old child visits the allergy clinic with her parents. She has a confirmed milk protein allergy and her parents are interested in using the milk ladder to manage it. Which food item would be suitable to gradually introduce?

      Your Answer: Malted milk biscuits

      Explanation:

      Children with cows milk protein allergy can use the milk ladder to reintroduce milk protein after they turn 6 months old.

      To gradually introduce milk, the milk ladder starts with cooked or baked milk. The process begins with malted milk biscuits and then progresses in a step-by-step manner towards pasteurised milk.

      Understanding Cow’s Milk Protein Intolerance/Allergy

      Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects around 3-6% of children, typically presenting in the first 3 months of life in formula-fed infants. Both immediate and delayed reactions can occur, with CMPA used for immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms include regurgitation, vomiting, diarrhea, urticaria, atopic eczema, colic symptoms, wheeze, chronic cough, and rarely, angioedema and anaphylaxis. Diagnosis is often clinical, with investigations including skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein.

      Management for formula-fed infants includes using extensive hydrolyzed formula (eHF) milk as the first-line replacement formula for mild-moderate symptoms and amino acid-based formula (AAF) for severe CMPA or if no response to eHF. Around 10% of infants are also intolerant to soya milk. For breastfed infants, mothers should eliminate cow’s milk protein from their diet and consider prescribing calcium supplements to prevent deficiency. eHF milk can be used when breastfeeding stops until at least 6 months and up to 12 months of age.

      The prognosis for CMPI is usually good, with most children becoming milk tolerant by the age of 3-5 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur. It is important to refer infants with severe symptoms to a pediatrician for management. Understanding CMPI/CMPA and its management can help parents and healthcare providers provide appropriate care for affected children.

    • This question is part of the following fields:

      • Paediatrics
      8.9
      Seconds
  • Question 54 - A 6-year-old girl with known sickle cell disease presents with pallor, back pain...

    Correct

    • A 6-year-old girl with known sickle cell disease presents with pallor, back pain and a 6-cm tender, enlarged spleen. She is anaemic with a raised reticulocyte count, and is moderately jaundiced.
      Which one of the following is the most likely diagnosis?

      Your Answer: Splenic sequestration crisis

      Explanation:

      Differentiating Sickle Cell Disease Complications: A Guide

      Sickle cell disease is a genetic disorder that affects the shape of red blood cells, leading to a range of complications. Here is a guide to differentiating between some of the most common complications:

      Splenic Sequestration Crisis: This occurs when sickled red blood cells become trapped in the spleen, leading to abdominal pain, splenomegaly, and signs of anemia. It is most common in children aged 5 months to 2 years and may be associated with infection. Treatment involves fluid resuscitation and transfusion, with splenectomy advised for recurrent cases.

      Haemolytic Crisis: Chronic haemolysis is a feature of sickle cell disease, but worsening haemolysis may accompany acute deteriorations. This leads to a reduction in haemoglobin and an increase in unconjugated bilirubin. However, isolated haemolysis would not lead to abdominal pain and splenomegaly.

      Aplastic Crisis: This is a temporary cessation of red blood cell production, often associated with parvovirus B19 infection. Patients present with fatigue, pallor, shortness of breath, and low reticulocyte counts.

      Girdle Syndrome: This rare complication is characterised by an established ileus, with vomiting, distended abdomen, and absent bowel sounds. It is often associated with bilateral basal lung consolidation, but this patient does not exhibit these features.

      Painful Crisis: This is the most common reason for hospital admission in sickle cell disease patients. It is characterised by recurrent attacks of acute severe pain, triggered by sickling and vaso-occlusion. Splenomegaly is not a feature of painful crisis.

    • This question is part of the following fields:

      • Paediatrics
      18.6
      Seconds
  • Question 55 - A 7-year-old boy comes to his General Practitioner with his mother, having just...

    Correct

    • A 7-year-old boy comes to his General Practitioner with his mother, having just woken up from a nap and experienced twitching of the left side of his mouth. He complains of a ‘buzzing’ sensation in his lips. His speech is unclear and he drooled from the left side of his mouth. His symptoms resolved within two minutes and he remained conscious throughout the episode.
      What is the most probable diagnosis?

      Your Answer: Benign rolandic epilepsy (BRE)

      Explanation:

      Types of Epilepsy: Characteristics and Differences

      Epilepsy is a neurological disorder characterized by recurrent seizures. There are different types of epilepsy, each with its own set of clinical features and diagnostic criteria. Here are some of the most common types of epilepsy and their distinguishing characteristics:

      Benign Rolandic Epilepsy (BRE)
      BRE, also known as childhood epilepsy with centrotemporal spikes, is characterized by seizures that often occur during sleep or just before waking. Children may experience paraesthesia of their lips, tongue, or the inside of their mouth, which can interfere with speech and cause drooling. Twitching of one side of the mouth or face often develops, followed by twitching in the limbs on the same side. Seizures typically last less than two minutes, and the child remains conscious.

      Absence Seizures
      Absence seizures are a form of generalized epilepsy that impairs consciousness. Children are most commonly affected, and the seizures usually last only a few seconds but may occur many times a day. During the absence, the child stops activity and stares blankly, not responding to questions. There may be lip-smacking or facial tics. An EEG will reveal a characteristic spike-and-wave activity.

      Temporal Lobe Epilepsy (TLE)
      TLE is characterized by partial and/or focal seizures that may be simple or complex, with some loss of awareness. The clinical features of TLE reflect the function of the temporal lobe, primarily speech, taste, smell, and memory. Presentations may include déjà vu, gastrointestinal disturbance, amnesia during an attack, olfactory or gustatory hallucinations, and abnormal sensations crawling up the body. Repetitive vocalizations, automatism, and lip-smacking may be seen.

      Juvenile Myoclonic Epilepsy (JME)
      JME describes generalized epilepsy that impairs consciousness. JME usually presents in later childhood, with a peak onset at 10–16 years. The defining seizure is myoclonic and usually occurs in the first hour after waking. These seizures occur as sudden jerks, which commonly involve the arms and/or trunk. However, any muscle may be affected. The patient is generally conscious while myoclonic jerks are occurring. Generalized tonic-clonic seizures often accompany myoclonic seizures in JME, which may lead to reduced consciousness.

      Infantile Spasms
      Infantile spasms develop in the first year of life, with peak

    • This question is part of the following fields:

      • Paediatrics
      19.5
      Seconds
  • Question 56 - A 5-year-old is brought by his father for abnormal stool patterns. He has...

    Incorrect

    • A 5-year-old is brought by his father for abnormal stool patterns. He has just started kindergarten and the staff note he does not go to the toilet when at the kindergarten. He returns home and has been trying to pass stool with difficulty and pain. His father is worried because he now passes frequent small stools at home and is not sure what to do.

      What is the initial management option for this child?

      Your Answer: Lactulose daily

      Correct Answer: Macrogol daily

      Explanation:

      For a child experiencing functional constipation and showing signs of faecal impaction, the recommended first-line treatment is macrogols like Movicol. Docusate and senna are not the initial options but can be added if disimpaction is not achieved within two weeks. Lactulose is also a suitable osmotic laxative, but macrogols are more effective and therefore preferred as the first-line treatment. Liquid paraffin may be used as a lubricating laxative, but macrogols are more effective and should be used first. Psyllium husk is not appropriate for treating faecal impaction and may worsen the situation, so disimpaction should be achieved before increasing fibre intake.

      Understanding and Managing Constipation in Children

      Constipation is a common problem in children, with the frequency of bowel movements decreasing as they 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 associated distress or pain. Most cases of constipation in children are idiopathic, but other causes such as dehydration, low-fiber diet, and medication use should be considered and excluded.

      If a diagnosis of constipation is made, NICE recommends assessing for faecal impaction before starting treatment. Treatment for faecal impaction involves using polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) as the first-line treatment, with the addition of a stimulant laxative if necessary. Maintenance therapy involves a similar regime, with adjustments to the starting dose and the addition of other laxatives if necessary.

      It is important to note that dietary interventions alone are not recommended as first-line treatment, although ensuring adequate fluid and fiber intake is important. Regular toileting and non-punitive behavioral interventions should also be considered. For infants, extra water, gentle abdominal massage, and bicycling the legs can be helpful for constipation. If these measures are not effective, lactulose can be added.

      In summary, constipation in children can be managed effectively with a combination of medication, dietary adjustments, and behavioral interventions. It is important to follow NICE guidelines and consider the individual needs of each child.

    • This question is part of the following fields:

      • Paediatrics
      26.5
      Seconds
  • Question 57 - A 10-year-old child receives primary immunisation against hepatitis B. What should be checked...

    Correct

    • A 10-year-old child receives primary immunisation against hepatitis B. What should be checked four months later to ensure an adequate response to immunisation?

      Your Answer: Anti-HBs

      Explanation:

      While a minimum of 10 mIU/ml is considered sufficient to provide protection against infection, it is recommended to attain anti-HBs levels exceeding 100 mIU/ml.

      Interpreting hepatitis B serology is an important skill that is still tested in medical exams. It is crucial to keep in mind a few key points. The surface antigen (HBsAg) is the first marker to appear and triggers the production of anti-HBs. If HBsAg is present for more than six months, it indicates chronic disease, while its presence for one to six months implies acute disease. Anti-HBs indicates immunity, either through exposure or immunization, and is negative in chronic disease. Anti-HBc indicates previous or current infection, with IgM anti-HBc appearing during acute or recent hepatitis B infection and persisting IgG anti-HBc. HbeAg is a marker of infectivity and HBV replication.

      To illustrate, if someone has been previously immunized, their anti-HBs will be positive, while all other markers will be negative. If they had hepatitis B more than six months ago but are not a carrier, their anti-HBc will be positive, and HBsAg will be negative. However, if they are now a carrier, both anti-HBc and HBsAg will be positive. If HBsAg is present, it indicates an ongoing infection, either acute or chronic if present for more than six months. On the other hand, anti-HBc indicates that the person has caught the virus, and it will be negative if they have been immunized.

    • This question is part of the following fields:

      • Paediatrics
      20.1
      Seconds
  • Question 58 - A 3-month-old girl is brought to the morning clinic by her father. Since...

    Correct

    • A 3-month-old girl is brought to the morning clinic by her father. Since yesterday she has been taking reduced feeds and has been 'not her usual self'. On examination the baby appears well but has a low-grade temperature of 38.2ÂșC. What is the most suitable course of action?

      Your Answer: Admit to hospital

      Explanation:

      The latest NICE guidelines classify any infant under 3 months old with a temperature exceeding 38ÂșC as a ‘red’ feature, necessitating immediate referral to a paediatrician. While some seasoned GPs may opt not to adhere to this recommendation, it is crucial to stay informed about recent examination guidelines.

      The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer.

      The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.

    • This question is part of the following fields:

      • Paediatrics
      16.6
      Seconds
  • Question 59 - As a foundation doctor on the neonatal ward, you conduct a newborn examination...

    Incorrect

    • As a foundation doctor on the neonatal ward, you conduct a newborn examination on a six hour old infant. The baby was delivered vaginally at 38 weeks with no risk factors for sepsis and no maternal concerns. The baby was born in a healthy condition, with good tone. However, you observe cyanosis in the peripheries, while the rest of the examination appears normal. Pre and post ductal oxygen saturations are at 97%. What is the probable diagnosis?

      Your Answer: Hypothermia

      Correct Answer: Acrocyanosis

      Explanation:

      Cyanosis, a bluish discoloration of the skin, is a common occurrence in newborns. Peripheral cyanosis, which affects the hands and feet, is often seen in the first 24 hours of life and can be caused by crying or illness. Central cyanosis, on the other hand, is a more serious condition that occurs when the concentration of reduced hemoglobin in the blood exceeds 5g/dl. To differentiate between cardiac and non-cardiac causes of central cyanosis, doctors may use the nitrogen washout test, which involves giving the infant 100% oxygen for ten minutes and then measuring arterial blood gases. A pO2 of less than 15 kPa indicates cyanotic congenital heart disease, which can be caused by conditions such as tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia.

      If cyanotic congenital heart disease is suspected, initial management involves supportive care and the use of prostaglandin E1, such as alprostadil, to maintain a patent ductus arteriosus in ductal-dependent congenital heart defects. This can serve as a temporary measure until a definitive diagnosis is made and surgical correction is performed.

      Acrocyanosis, a type of peripheral cyanosis, is a benign condition that is often seen in healthy newborns. It is characterized by bluish discoloration around the mouth and extremities, such as the hands and feet, and is caused by vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction. Unlike other causes of peripheral cyanosis that may indicate significant pathology, such as septic shock, acrocyanosis occurs immediately after birth in healthy infants and typically resolves within 24 to 48 hours.

    • This question is part of the following fields:

      • Paediatrics
      26.6
      Seconds
  • Question 60 - A 6-month-old baby girl is brought to her General Practitioner by her mother....

    Correct

    • A 6-month-old baby girl is brought to her General Practitioner by her mother. She had a runny nose for two days and has had a cough for three days. She has not been feeding as much as usual.
      On examination, her temperature is 38.2 °C. Her respiratory rate is slightly raised. On auscultation of the chest, she has a widespread wheeze and crepitations. Her other observations are within normal limits.
      What is the most likely diagnosis?

      Your Answer: Bronchiolitis

      Explanation:

      Distinguishing between respiratory illnesses in children: A guide

      When a child presents with respiratory symptoms, it can be difficult to determine the underlying cause. Here, we will discuss the key features of several common respiratory illnesses in children and how to differentiate between them.

      Bronchiolitis is characterized by coryzal symptoms followed by a persistent cough, tachypnea, chest recession, and wheezing or crepitations on auscultation. A low-grade fever and reduced feeding may also be present.

      Croup is a viral upper airway infection that causes a barking cough, predominantly inspiratory stridor, hoarse voice, intercostal or sternal indrawing, fever, and coryzal symptoms.

      Asthma typically presents with shortness of breath, cough, wheeze, and chest tightness, and is more common in children over two years old.

      Acute epiglottitis is an insidious but rapidly progressive airway emergency that causes fever, sore throat, odynophagia, muffled voice, dysphagia, dyspnea, respiratory distress, dysphonia, and stridor. The child may sit in a tripod position to maximize airway opening.

      A viral upper respiratory tract infection may cause coryzal symptoms, cough, and fever, but crepitations on auscultation would not be expected.

      By understanding the key features of these respiratory illnesses, healthcare providers can make a more accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Paediatrics
      19.2
      Seconds
  • Question 61 - What is a risk factor for the development of surfactant deficient lung disease...

    Incorrect

    • What is a risk factor for the development of surfactant deficient lung disease in a neonate?

      Your Answer: Female sex

      Correct Answer: Maternal diabetes mellitus

      Explanation:

      Surfactant Deficient Lung Disease in Premature Infants

      Surfactant deficient lung disease (SDLD), previously known as hyaline membrane disease, is a condition that affects premature infants. It occurs due to the underproduction of surfactant and the immaturity of the lungs’ structure. The risk of SDLD decreases with gestation, with 50% of infants born at 26-28 weeks and 25% of infants born at 30-31 weeks being affected. Other risk factors include male sex, diabetic mothers, Caesarean section, and being the second born of premature twins.

      The clinical features of SDLD are similar to those of respiratory distress in newborns, including tachypnea, intercostal recession, expiratory grunting, and cyanosis. Chest x-rays typically show a ground-glass appearance with an indistinct heart border.

      Prevention during pregnancy involves administering maternal corticosteroids to induce fetal lung maturation. Management of SDLD includes oxygen therapy, assisted ventilation, and exogenous surfactant given via an endotracheal tube. With proper management, the prognosis for infants with SDLD is generally good.

    • This question is part of the following fields:

      • Paediatrics
      14.2
      Seconds
  • Question 62 - A 4-week-old infant is referred by the health visitor for failure to thrive....

    Correct

    • A 4-week-old infant is referred by the health visitor for failure to thrive. The infant's weight has dropped from the 50th to the 9th centile on the growth chart. The parents disclose that the infant vomits after every meal, sometimes even hitting the wall. The mother had a normal pregnancy with regular antenatal scans, and the infant was delivered vaginally without complications. The newborn examination did not reveal any abnormalities. What is the probable diagnosis?

      Your Answer: Pyloric stenosis

      Explanation:

      The probable diagnosis is pyloric stenosis.

      Understanding Pyloric Stenosis

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      26.5
      Seconds
  • Question 63 - A 12-year-old girl has excessive bleeding after an adenotonsillectomy for recurrent tonsillitis. Physical...

    Incorrect

    • A 12-year-old girl has excessive bleeding after an adenotonsillectomy for recurrent tonsillitis. Physical examination reveals no abnormalities. The girl's grandmother died of a postoperative bleeding complication at a young age.
      Which of the following is the most important investigation to establish a diagnosis?

      Your Answer: Prothrombin time/INR (international normalised ratio)

      Correct Answer: Factor VIII assay

      Explanation:

      Diagnostic Tests for Haemophilia: Factor VIII Assay, Prothrombin Time/INR, Platelet Count, Bone Marrow Examination, and Blood Film

      Haemophilia is an X-linked bleeding disorder caused by deficiency of clotting factor VIII (haemophilia A) or factor IX (haemophilia B). Patients may present with bruising, inadequate clotting with mild injury, or spontaneous haemorrhage. To diagnose haemophilia A, a factor VIII assay is necessary. Other diagnostic tests include prothrombin time/INR, platelet count, bone marrow examination, and blood film. The prothrombin time and platelet count are normal in haemophilia, while bone marrow sampling carries a risk of significant bleeding. A blood film is not useful in the diagnosis as red blood cells and platelet count are normal.

    • This question is part of the following fields:

      • Paediatrics
      30.4
      Seconds
  • Question 64 - A 6-year-old boy is brought to the Emergency Department by his mother with...

    Correct

    • A 6-year-old boy is brought to the Emergency Department by his mother with complaints of right iliac fossa pain for the past two days. He has no previous medical history except for a cough and sore throat in the last week. He has had a high fever for the past two days and has lost his appetite but denies any other symptoms.
      On examination, his temperature is 38.9 °C, and his pulse is 130 beats per minute. Bilateral enlarged submandibular and cervical lymph nodes are palpable and slightly tender. Chest examination is clear, with transmitted sounds from the upper airways. Abdominal examination reveals marked tenderness in the right iliac fossa with no guarding.
      Urine dipstick reveals 2+ of ketones and 1+ of protein.
      Blood test results for his full blood count (FBC) are as follows:
      Investigation Result Normal value
      Haemoglobin (Hb) 145 g/l 135–175 g/l
      White cell count (WCC) 14.3 × 109/ 4.0–11.0 × 109/l
      Platelets (PLT) 425 × 109/l 150–400 × 109/l
      What is the most likely clinical diagnosis for this 6-year-old boy?

      Your Answer: Mesenteric adenitis

      Explanation:

      Possible Diagnoses for a Child with Right Iliac Fossa Pain and High Temperature

      When a child presents with right iliac fossa pain and high temperature, several possible diagnoses should be considered. One of them is mesenteric adenitis, which is characterized by abdominal pain resulting from mesenteric lymphadenopathy and often accompanied by enlarged neck nodes and a recent history of viral upper respiratory tract infection. Appendicitis is another possibility, but it tends to present with a low-grade fever and peritoneal irritation that causes involuntary muscle spasm in the abdominal wall. Meckel’s diverticulitis, which is clinically indistinguishable from appendicitis, is an intra-operative or radiological diagnosis and can cause gastrointestinal bleeding, obstruction, inflammation, or umbilical discharge. Retroperitoneal appendix abscess is an uncommon type of infection that presents with fever, back pain, and abdominal pain, but it can also cause other symptoms such as gastrointestinal bleeding, poor wound healing, chest pain, general discomfort, urinary frequency, and haematuria. Finally, urinary tract infection (UTI) is unlikely if there are no nitrites or leukocytes on urine dipstick, but it can cause non-specific symptoms such as vomiting/diarrhoea, mild abdominal pain, dysuria, frequency, and enuresis, especially in infants.

    • This question is part of the following fields:

      • Paediatrics
      87.2
      Seconds
  • Question 65 - A 6-year-old girl is brought to her General Practitioner by her mother. She...

    Correct

    • A 6-year-old girl is brought to her General Practitioner by her mother. She reports that her daughter has been complaining of abdominal pain and has had loose stools for the past three weeks. Her weight was previously on the 75th centile but has now dropped to the 50th centile. She appears fatigued, pale and has a bloated abdomen.
      Which of the following is the most appropriate initial investigation?

      Your Answer: Blood tests for immunoglobulin A (IgA) tissue transglutaminase antibody (tTG) and total IgA

      Explanation:

      Diagnostic Tests for Coeliac Disease

      Coeliac disease is a condition that affects the small intestine and is caused by an intolerance to gluten. There are several diagnostic tests that can be performed to confirm a diagnosis of coeliac disease.

      Initial Blood Tests
      The initial blood tests for coeliac disease are immunoglobulin A (IgA) tissue transglutaminase antibody (tTG) and total IgA. Total IgA is tested because IgA deficiency is associated with coeliac disease and can cause a false-negative tTG-IgA. It is important for patients to be eating a diet containing gluten when they have the blood test to avoid a false-negative result.

      Endoscopy and Duodenal Biopsy
      An endoscopy with a duodenal biopsy may be required to confirm the diagnosis in secondary care. However, guidelines state that children may be diagnosed without a biopsy if they have tTG-IgA levels over ten times the upper limit of normal and positive endomysial antibodies (EMA-IgA) in a second blood test.

      HLA-DQ2 and HLA-DQ8 Blood Tests
      HLA-DQ2 and HLA-DQ8 are associated with coeliac disease. This blood test may be performed in secondary care but is not an initial investigation.

      C13 Urea Breath Test
      The C13 urea breath test is used in the diagnosis of Helicobacter pylori and has no role in the diagnosis of coeliac disease.

      In conclusion, a combination of blood tests and endoscopy with a duodenal biopsy may be required to confirm a diagnosis of coeliac disease. It is important for patients to continue eating a gluten-containing diet before undergoing diagnostic tests.

    • This question is part of the following fields:

      • Paediatrics
      37.5
      Seconds
  • Question 66 - A mother brings her 10-month-old baby to the doctor because of a diaper...

    Incorrect

    • A mother brings her 10-month-old baby to the doctor because of a diaper rash. During the examination, the doctor observes a red rash with flexural sparing. What is the probable reason for this?

      Your Answer: Candida infection

      Correct Answer: Irritant dermatitis

      Explanation:

      Understanding Napkin Rashes and How to Manage Them

      Napkin rashes, also known as nappy rashes, are common skin irritations that affect babies and young children. The most common cause of napkin rash is irritant dermatitis, which is caused by the irritant effect of urinary ammonia and faeces. This type of rash typically spares the creases. Other causes of napkin rash include candida dermatitis, seborrhoeic dermatitis, psoriasis, and atopic eczema.

      To manage napkin rash, it is recommended to use disposable nappies instead of towel nappies and to expose the napkin area to air when possible. Applying a barrier cream, such as Zinc and castor oil, can also help. In severe cases, a mild steroid cream like 1% hydrocortisone may be necessary. If the rash is suspected to be candidal nappy rash, a topical imidazole should be used instead of a barrier cream until the candida has settled.

      Understanding the different types of napkin rashes and their causes is important in managing them effectively. By following these general management points, parents and caregivers can help prevent and alleviate napkin rashes in babies and young children.

    • This question is part of the following fields:

      • Paediatrics
      31.5
      Seconds
  • Question 67 - You are a junior doctor working in pediatrics. You are preparing cases for...

    Correct

    • You are a junior doctor working in pediatrics. You are preparing cases for the morbidity and mortality meeting. What is the time frame that defines infant mortality?

      Your Answer: Any death in pregnancy, labour or in the six weeks post partum

      Explanation:

      The investigation of maternal deaths in the UK is carried out by the Confidential Enquiry into Maternal Deaths, which encompasses deaths occurring during pregnancy, labour, and up to six weeks after delivery. Post partum haemorrhage (PPH) is a leading cause of maternal mortality. A stillbirth is defined as the loss of a fetus after twenty weeks gestation, while any loss prior to this is classified as a miscarriage.

      Perinatal Death Rates and Related Metrics

      Perinatal mortality rate is a measure of stillbirths and early neonatal deaths within seven days per 1,000 births after 24 weeks of gestation. In the UK, this rate is around 6 per 1,000 births. This figure is usually broken down into 4 per 1,000 stillbirths and 2 per 1,000 early neonatal deaths.

      Maternal mortality rate, on the other hand, is calculated by dividing the number of deaths during pregnancy, labor, and six weeks after delivery by the total number of maternities and multiplying the result by 1000. Meanwhile, the stillbirth rate is determined by dividing the number of babies born dead after 24 weeks by the total number of births (live and stillborn) and multiplying the result by 1000. Lastly, the neonatal death rate is computed by dividing the number of babies who died between 0-28 days by the total number of live births and multiplying the result by 1000.

      These metrics are important in assessing the quality of perinatal care and identifying areas for improvement. By monitoring these rates, healthcare providers can work towards reducing perinatal deaths and improving maternal and neonatal outcomes.

    • This question is part of the following fields:

      • Paediatrics
      27.2
      Seconds
  • Question 68 - A 16-year-old complains of left knee pain that has been present for the...

    Correct

    • A 16-year-old complains of left knee pain that has been present for the last 4 weeks. No injury history is reported. The pain is located in the front of the joint and is aggravated when ascending or descending stairs. Physical examination reveals no significant findings. What is the probable diagnosis?

      Your Answer: Chondromalacia patellae

      Explanation:

      Common Knee Problems in Children and Young Adults

      Knee problems are common in children and young adults, especially those who are active in sports.
      Chondromalacia patellae is a condition that is more common in teenage girls. It is characterized by the softening of the cartilage of the patella, which can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. This condition usually responds well to physiotherapy.

      Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle.

      Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking of the knee.

      Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella. The knee may also give way.

      Patellar tendonitis is more common in athletic teenage boys. It causes chronic anterior knee pain that worsens after running. On examination, the area below the patella is tender. It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis.

    • This question is part of the following fields:

      • Paediatrics
      35.4
      Seconds
  • Question 69 - A 4-year-old child is presented to your allergy clinic by anxious parents. The...

    Correct

    • A 4-year-old child is presented to your allergy clinic by anxious parents. The child has a previous medical record of a mild non-IgE mediated egg allergy. What course of action would you suggest?

      Your Answer: Gradual reintroduction of egg based products using the egg ladder

      Explanation:

      The egg ladder can be used to reintroduce egg in children with non-IgE mediated allergy, starting with baked egg in biscuits. Chlorpheniramine and adrenaline pen are not appropriate choices.

      Identifying and Managing Food Allergies in Children and Young People

      Food allergies in children and young people can be categorized into IgE-mediated and non-IgE-mediated allergies. It is important to note that food intolerance is not caused by immune system dysfunction and is not covered by the 2011 NICE guidelines. Symptoms of IgE-mediated allergies include skin reactions such as pruritus, erythema, urticaria, and angioedema, gastrointestinal symptoms like nausea, colicky abdominal pain, vomiting, and diarrhea, and respiratory symptoms such as nasal itching, sneezing, rhinorrhea, congestion, cough, chest tightness, wheezing, and shortness of breath. Non-IgE-mediated allergies may present with symptoms like gastro-oesophageal reflux disease, loose or frequent stools, blood and/or mucus in stools, abdominal pain, infantile colic, food refusal or aversion, constipation, perianal redness, pallor and tiredness, and faltering growth.

      If the history suggests an IgE-mediated allergy, skin prick tests or blood tests for specific IgE antibodies to the suspected foods and likely co-allergens should be offered. On the other hand, if the history suggests a non-IgE-mediated allergy, the suspected allergen should be eliminated for 2-6 weeks and then reintroduced. It is recommended to consult a dietitian with appropriate competencies about nutritional adequacies, timings, and follow-up. By identifying and managing food allergies in children and young people, we can prevent severe allergic reactions and improve their quality of life.

    • This question is part of the following fields:

      • Paediatrics
      36
      Seconds
  • Question 70 - Samantha is a 28-year-old who comes to your GP clinic seeking information about...

    Correct

    • Samantha is a 28-year-old who comes to your GP clinic seeking information about cystic fibrosis. She is in a committed relationship and wants to start a family. Samantha mentions that her partner's family has a history of cystic fibrosis and she wants to know more about it. She has already done some research and knows that cystic fibrosis is caused by mutations in the CF transmembrane conductance regulator gene (CFTR) on chromosome 7. Samantha asks you to explain how cystic fibrosis is inherited.

      Can you help her understand the inheritance pattern of cystic fibrosis?

      Your Answer: Autosomal recessive inheritance

      Explanation:

      Cystic fibrosis is a genetic disorder that follows an autosomal recessive pattern of inheritance. The carrier frequency is estimated to be 1 in 25 individuals, while the prevalence of the disease is 1 in 2500 newborns. Having a positive family history is the only known risk factor for CF, and parents should receive appropriate counseling before conception or during pregnancy if they are carriers.

      Understanding Cystic Fibrosis and the Organisms that Affect Patients

      Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. This condition is caused by a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates chloride channels. In the UK, 80% of CF cases are due to delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

      CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.

    • This question is part of the following fields:

      • Paediatrics
      12.7
      Seconds
  • Question 71 - During a routine check-up, a 7 week-old baby boy is seen. His mother...

    Correct

    • During a routine check-up, a 7 week-old baby boy is seen. His mother has a history of asthma and used inhaled steroids while pregnant. He was delivered via planned Caesarian at 39 weeks due to breech presentation and weighed 3.1kg at birth. What condition is he at a higher risk for?

      Your Answer: Developmental dysplasia of the hip

      Explanation:

      If a baby was in a breech presentation, it is important to ensure that they have been referred for screening for developmental dysplasia of the hip (DDH) as it is a risk factor for this condition. The Department of Health recommends that all babies who were breech at any point from 36 weeks (even if not breech at birth), babies born before 36 weeks who were in a breech presentation, and all babies with a first degree relative who had a hip problem in early life, should undergo ultrasound screening for hip dysplasia. If one twin was breech, both should be screened. Some hospitals also refer babies with other conditions such as oligohydramnios, high birth weight, torticollis, congenital talipes calcaneovalgus, and metatarsus adductus for screening. For more information on screening for DDH, please refer to the link provided.

      Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

    • This question is part of the following fields:

      • Paediatrics
      14.4
      Seconds
  • Question 72 - A 6-week-old baby is observed to have rocker-bottom feet, microcephaly and a small...

    Correct

    • A 6-week-old baby is observed to have rocker-bottom feet, microcephaly and a small retracted chin. The mother is a refugee from Syria who gave birth recently but could not attend antenatal screening. What is the probable syndrome?

      Your Answer: Edwards' syndrome

      Explanation:

      Understanding Genetic Conditions: Trisomy 18 (Edwards’ Syndrome)

      Trisomy 18, also known as Edwards’ syndrome, is a genetic condition that results in a range of physical and developmental abnormalities. Neonates with trisomy 18 often present with neonatal hypotonia, apnoea, and seizures, as well as severe psychomotor and growth retardation. Other common features include microcephaly, microphthalmia, microstomia, micrognathia, clenched fingers, and rocker-bottom feet. Over 90% of individuals with trisomy 18 have cardiac defects, commonly ventricular septal defect (VSD), as well as anomalies in most organ systems. Unfortunately, many fetuses will die in utero, and neonates born with trisomy 18 have a 40% chance of survival to 1 month.

      It is important to note that an Edwards’ syndrome diagnosis should be made in the prenatal period. Low levels of AFP (α-fetoprotein), estradiol, and hCG (human chorionic gonadotrophin) on triple test biochemistry are suggestive, and the diagnosis can be confirmed on ultrasonography.

      Other genetic conditions, such as Pierre-Robin syndrome, Down’s syndrome, Fragile X syndrome, and Noonan’s syndrome, have their own distinct features and should be differentiated from trisomy 18. Understanding these conditions and their unique characteristics can aid in early diagnosis and appropriate management.

    • This question is part of the following fields:

      • Paediatrics
      7.2
      Seconds
  • Question 73 - A 22-month-old toddler presents to the GP with a barking cough and fever...

    Correct

    • A 22-month-old toddler presents to the GP with a barking cough and fever for 3 days. The fever has been responding to regular paracetamol. The child's parent reports that the toddler is eating and drinking normally and has been urinating regularly. During playtime, the parent has noticed some increased breathing sounds, but they disappear when the child is at rest. There have been no febrile convulsions, rash, or drowsiness reported.
      Upon examination, the toddler has a clear chest with no signs of increased work of breathing. An occasional barking cough is heard.
      What is the most appropriate management for this toddler?

      Your Answer: Oral dexamethasone

      Explanation:

      For this infant with mild croup, the recommended treatment is a single dose of oral dexamethasone (0.15 mg/kg body weight) regardless of the severity of symptoms. This should be taken immediately to reduce upper airway inflammation and alleviate the occasional barking cough and stridor. Delayed antibiotic prescription, immediate oral antibiotics, humidified oxygen, and inhaled or nebulised salbutamol are not appropriate options for croup management. Antibiotics are ineffective against viruses, which are the most common cause of croup, while humidified oxygen and inhaled or nebulised salbutamol are used for other respiratory conditions.

      Understanding Croup: A Respiratory Infection in Infants and Toddlers

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

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      19.1
      Seconds
  • Question 74 - You assess a neonate who is 2 hours old and was delivered via...

    Correct

    • You assess a neonate who is 2 hours old and was delivered via caesarean section. The mother had an elective caesarean section at 38-weeks due to an active herpes infection. During examination, the infant has a respiratory rate of 62 breaths per minute. A chest x-ray reveals hyperinflation and fluid in the horizontal fissure. What would be your management plan for this patient, considering the probable diagnosis?

      Your Answer: Observation and supportive care

      Explanation:

      Transient tachypnoea of the newborn can be identified through a chest x-ray which may reveal hyperinflation and fluid in the horizontal fissure. The appropriate management for this condition is observation and supportive care, including the administration of supplemental oxygen if necessary. Symptoms typically resolve on their own within a few days. The use of IV ceftriaxone, IV steroids, or urgent blood transfusion is not indicated in this case and therefore, incorrect.

      Understanding Transient Tachypnoea of the Newborn

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

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

    • This question is part of the following fields:

      • Paediatrics
      22.2
      Seconds
  • Question 75 - What is a risk factor for developmental dysplasia of the hip in infants?...

    Correct

    • What is a risk factor for developmental dysplasia of the hip in infants?

      Your Answer: Oligohydramnios

      Explanation:

      Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

    • This question is part of the following fields:

      • Paediatrics
      28.7
      Seconds
  • Question 76 - Which one of the following drugs is safe to use while breastfeeding? ...

    Correct

    • Which one of the following drugs is safe to use while breastfeeding?

      Your Answer: Ceftriaxone

      Explanation:

      The use of cephalosporins during breastfeeding is deemed to be safe.

      Breastfeeding has some contraindications that are important to know, especially when it comes to drugs. Antibiotics like penicillins, cephalosporins, and trimethoprim are safe for breastfeeding mothers, as are endocrine drugs like glucocorticoids (in low doses) and levothyroxine. Epilepsy drugs like sodium valproate and carbamazepine, asthma drugs like salbutamol and theophyllines, and hypertension drugs like beta-blockers and hydralazine are also safe. Anticoagulants like warfarin and heparin, as well as digoxin, are also safe. However, some drugs should be avoided, such as antibiotics like ciprofloxacin, tetracycline, chloramphenicol, and sulphonamides, psychiatric drugs like lithium and benzodiazepines, aspirin, carbimazole, methotrexate, sulfonylureas, cytotoxic drugs, and amiodarone. Other contraindications include galactosaemia and viral infections, although the latter is controversial in the developing world due to the increased risk of infant mortality and morbidity associated with bottle feeding.

    • This question is part of the following fields:

      • Paediatrics
      17.9
      Seconds
  • Question 77 - A 9-year-old boy with asthma comes to the clinic with his mother, who...

    Correct

    • A 9-year-old boy with asthma comes to the clinic with his mother, who is worried about his breathing problems. He has an oxygen saturation of 90%, his chest is slightly wheezy, but there is weak inspiratory effort, and his lips are pale.
      What is the probable classification of the acute asthma exacerbation?

      Your Answer: Life-threatening acute asthma

      Explanation:

      The child is experiencing life-threatening acute asthma, which is a medical emergency. This is defined as having any of the following features: SpO2 below 92%, peak expiratory flow below 33% of the best or predicted, silent chest, cyanosis, poor respiratory effort, hypotension, exhaustion, or confusion. Therefore, 999 should be called immediately. This is not moderate or mild acute asthma, nor is it acute severe asthma, as the child is showing signs of cyanosis. Acute severe asthma is defined as having any of the following: SpO2 between 33-50% of the best or predicted, inability to complete sentences in one breath or too breathless to talk or feed, heart rate above 125 beats/min (for ages over 5) or above 140 beats/min (for ages 1-5), or respiratory rate above 30 breaths/min (for ages over 5) or above 40 breaths/min (for ages 1-5).

    • This question is part of the following fields:

      • Paediatrics
      16.8
      Seconds
  • Question 78 - A mother brings her 10-month-old child to surgery, worried that he is not...

    Incorrect

    • A mother brings her 10-month-old child to surgery, worried that he is not meeting developmental milestones compared to her friends' children. Upon observation, the child is able to sit without support but shows minimal interest in exploring his surroundings. He has a basic pincer grip, seems hesitant to engage with others, and only says mama. How would you describe his developmental progress?

      Your Answer: Global developmental delay

      Correct Answer: Normal development

      Explanation:

      Common Developmental Problems and Possible Causes

      Developmental problems can manifest in various ways, including referral points such as not smiling at 10 weeks, inability to sit unsupported at 12 months, and failure to walk at 18 months. Fine motor skill problems may also arise, such as abnormal hand preference before 12 months, which could indicate cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, as they can also be caused by environmental deprivation or general development delay.

      It is important to recognize these developmental problems early on and seek appropriate interventions to address them. By doing so, children can receive the necessary support to reach their full potential and overcome any challenges they may face. With proper care and attention, many children with developmental problems can go on to lead happy and fulfilling lives.

    • This question is part of the following fields:

      • Paediatrics
      41.9
      Seconds
  • Question 79 - A father brings his 5-year-old daughter to the clinic. Despite not getting the...

    Correct

    • A father brings his 5-year-old daughter to the clinic. Despite not getting the MMR vaccine during the recent scare, he now wants to know if it's still possible to have her immunised due to the current measles outbreak. What should be done in this situation?

      Your Answer: Give MMR with repeat dose in 3 months

      Explanation:

      According to the Green Book, it is recommended to have a 3-month gap between doses for optimal response rate. However, if the child is over 10 years old, a 1-month gap is sufficient. In case of an emergency, such as an outbreak at the child’s school, younger children can have a shorter gap of 1 month.

      The MMR Vaccine: Information on Contraindications and Adverse Effects

      The Measles, Mumps and Rubella (MMR) vaccine is given to children in the UK twice before they enter primary school. The first dose is administered at 12-15 months, while the second dose is given at 3-4 years old. This vaccine is part of the routine immunisation schedule.

      However, there are certain contraindications to the MMR vaccine. Children with severe immunosuppression, allergies to neomycin, or those who have received another live vaccine by injection within four weeks should not receive the MMR vaccine. Pregnant women should also avoid getting vaccinated for at least one month following the MMR vaccine. Additionally, if a child has undergone immunoglobulin therapy within the past three months, there may be no immune response to the measles vaccine if antibodies are present.

      While the MMR vaccine is generally safe, there are some adverse effects that may occur. After the first dose of the vaccine, some children may experience malaise, fever, and rash. These symptoms typically occur after 5-10 days and last for around 2-3 days. It is important to be aware of these potential side effects and to consult with a healthcare professional if any concerns arise.

    • This question is part of the following fields:

      • Paediatrics
      23.7
      Seconds
  • Question 80 - A 5-year-old girl is discovered collapsed and unresponsive. Upon examination, there are no...

    Incorrect

    • A 5-year-old girl is discovered collapsed and unresponsive. Upon examination, there are no apparent obstructions in her airway. There are no signs of life and no indication of any respiratory efforts being made. Emergency assistance has been summoned and is en route.
      What is the most suitable course of action to take next in her treatment?

      Your Answer: Start chest compressions at a ratio of 15:2

      Correct Answer: Give 5 rescue breaths

      Explanation:

      The correct initial step for paediatric basic life support (BLS) is to give 5 rescue breaths immediately, even before checking for a pulse. This is because respiratory causes are the most common in children. Checking for a femoral pulse is not necessary to determine the need for chest compressions, as palpation of the pulse is not a reliable indicator of effective circulation. Giving 2 rescue breaths is incorrect for children, as they require 5 rescue breaths to mitigate hypoxia. The correct ratio of chest compressions to rescue breaths is 15:2, but the first step in paediatric BLS is always to give 5 rescue breaths.

      Paediatric Basic Life Support Guidelines

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

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      22
      Seconds
  • Question 81 - A 3-year-old boy is brought to the paediatric urology clinic due to recurrent...

    Correct

    • A 3-year-old boy is brought to the paediatric urology clinic due to recurrent urinary tract infections. A renal ultrasound revealed dilatation of the ureters. The boy's father remembers having a similar issue with a valve in his ureters during childhood, resulting in urine flowing back towards the kidneys. What is the most suitable test to assess the severity of the probable underlying cause?

      Your Answer: Micturating cystography

      Explanation:

      Vesicoureteral reflux (VUR) is a likely cause of recurrent urinary tract infections (UTIs) in children under 6 years old. The family history, age of the patient, and abnormal ultrasound findings suggest VUR as the underlying issue. To determine the severity of VUR, a voiding cystourethrogram (micturating cystography) is necessary. This test involves injecting dye into the bladder via a catheter and taking x-ray images while the child urinates. Early detection of VUR is crucial to prevent kidney scarring (reflux nephropathy).

      Bladder ultrasound is not an appropriate method for grading VUR severity. While ultrasound imaging of the urinary tract, including the kidneys, can be useful, it cannot grade VUR severity.

      A CT abdomen is not necessary and would expose the child to unnecessary radiation.

      A dimercaptosuccinic acid (DMSA) scan can assess renal parenchymal defects resulting from VUR and is typically performed within six months of an acute infection in children with recurrent UTIs. However, it cannot grade the severity of VUR.

      Understanding Vesicoureteric Reflux

      Vesicoureteric reflux (VUR) is a condition where urine flows back from the bladder into the ureter and kidney. This is a common urinary tract abnormality in children and can lead to urinary tract infections (UTIs). In fact, around 30% of children who present with a UTI have VUR. It is important to investigate for VUR in children following a UTI as around 35% of children develop renal scarring.

      The pathophysiology of VUR involves the ureters being displaced laterally, which causes a shortened intramural course of the ureter. This means that the vesicoureteric junction cannot function properly. VUR can present in different ways, such as hydronephrosis on ultrasound during the antenatal period, recurrent childhood UTIs, and reflux nephropathy, which is chronic pyelonephritis secondary to VUR. Renal scarring can also produce increased quantities of renin, which can cause hypertension.

      To diagnose VUR, a micturating cystourethrogram is usually performed. A DMSA scan may also be done to check for renal scarring. VUR is graded based on the severity of the condition, with Grade I being the mildest and Grade V being the most severe.

      Overall, understanding VUR is important in preventing complications such as UTIs and renal scarring. Early diagnosis and management can help improve outcomes for children with this condition.

    • This question is part of the following fields:

      • Paediatrics
      28.8
      Seconds
  • Question 82 - A 15-year-old girl comes to the clinic with concerns about not having started...

    Incorrect

    • A 15-year-old girl comes to the clinic with concerns about not having started her periods yet. She is shorter than most girls her age. She has gone through adrenarche but has not yet experienced thelarche. Her mother and sister both began menstruating at age 12. The following are her blood test results:
      - FSH: 60 IU/L (normal range: 0-10)
      - LH: 40 IU/L (normal range: 0-16)
      - Oestradiol: 6.4 pmol/L (normal range: 73-407)
      - Thyroid stimulating hormone (TSH): 5.0 mU/L (normal range: 0.5-5.5)
      - Free thyroxine (T4): 12 pmol/L (normal range: 9.0-18)
      - Prolactin: 323 mIU/L (normal range: <700)

      Based on the patient's symptoms and test results, what is the most likely cause of her amenorrhoea?

      Your Answer: Constitutional delay

      Correct Answer: Turner's syndrome

      Explanation:

      Understanding Turner’s Syndrome

      Turner’s syndrome is a genetic disorder that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is denoted as 45,XO or 45,X.

      The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (15%), coarctation of the aorta (5-10%), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially feet), and elevated gonadotrophin levels. Hypothyroidism is much more common in Turner’s syndrome, and there is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn’s disease.

      In summary, Turner’s syndrome is a chromosomal disorder that affects females and can cause a range of physical features and health issues. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Paediatrics
      48
      Seconds
  • Question 83 - A 9-year-old girl comes to the clinic with a one-month history of unusual...

    Correct

    • A 9-year-old girl comes to the clinic with a one-month history of unusual facial movements noticed by her father. Her father reports that he first noticed her having twitching of left eye and face as well as drooling of saliva. This happens about twice a week, always at night. Each episode lasts for 1-2 minutes and after each episode, the girl is unable to speak properly for around 5 minutes. The girl is aware of these occurrences but reports unable to control them. The father reports that his daughter is otherwise normal with normal development.
      What is the diagnosis?

      Your Answer: Benign rolandic epilepsy

      Explanation:

      Benign rolandic epilepsy is identified by the occurrence of partial seizures during the night.

      The child displays typical indications of benign rolandic epilepsy, which is distinguished by partial seizures that occur during the night. Reflex anoxic seizures are caused by anoxia and typically manifest as syncope and subsequent convulsions in very young children. Panayiotopoulos syndrome is characterised by seizures, often prolonged, with predominantly autonomic symptoms such as nausea and retching. Idiopathic childhood occipital epilepsy of Gastaut is mainly characterised by visual hallucinations. Night terrors are a sleep disorder that causes feelings of dread or terror, typically during REM sleep.

      Benign rolandic epilepsy is a type of epilepsy that usually affects children between the ages of 4 and 12 years. This condition is characterized by seizures that typically occur at night and are often partial, causing sensations in the face. However, these seizures may also progress to involve the entire body. Despite these symptoms, children with benign rolandic epilepsy are otherwise healthy and normal.

      Diagnosis of benign rolandic epilepsy is typically confirmed through an electroencephalogram (EEG), which shows characteristic centrotemporal spikes. Fortunately, the prognosis for this condition is excellent, with seizures typically ceasing by adolescence. While the symptoms of benign rolandic epilepsy can be concerning for parents and caregivers, it is important to remember that this condition is generally not associated with any long-term complications or developmental delays.

    • This question is part of the following fields:

      • Paediatrics
      16.6
      Seconds
  • Question 84 - A 9-year-old boy with asthma is brought into the GP surgery with a...

    Correct

    • A 9-year-old boy with asthma is brought into the GP surgery with a cough and shortness of breath. Examination reveals a respiratory rate of 34 breaths/min, apyrexial, wheeze throughout his chest and a peak expiratory flow rate (PEFR) of half his predicted value.
      Which of the following treatments is the best option?

      Your Answer: Inpatient management with nebuliser salbutamol and oral steroids

      Explanation:

      Managing Acute Asthma Exacerbations in Children: Treatment Options and Guidelines

      When a child experiences an acute asthma exacerbation, prompt and appropriate management is crucial to prevent further complications. Here are some treatment options and guidelines to consider:

      Inpatient Management with Nebuliser Salbutamol and Oral Steroids
      For severe asthma exacerbations, hospital transfer is necessary. Inpatient management should include nebulised bronchodilators in combination with early oral steroids. A 3-day steroid course is usually sufficient.

      Manage as Outpatient with Inhaled Salbutamol via Spacer
      Mild to moderate acute asthma can be managed with salbutamol via a spacer. Oral steroids should be considered in all children with an acute exacerbation of asthma. However, all children with features of severe or life-threatening asthma should be transferred to a hospital.

      Outpatient Management with Antibiotics
      Antibiotics would be inappropriate for acute asthma exacerbations unless there are clues in the history to suggest a bacterial infection as the cause of exacerbation.

      Continue Current Medications with No Changes
      In severe acute asthma, urgent treatment with nebulisers and transfer to a hospital is necessary.

      IV Salbutamol
      IV salbutamol is second line and considered only if the symptoms have responded poorly to nebulised therapy.

      British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidance suggests that all children with features of severe or life-threatening asthma should be transferred to a hospital. The severity of acute asthma in children over 5 can be determined using the BTS severity scoring.

      By following these guidelines and treatment options, healthcare professionals can effectively manage acute asthma exacerbations in children and prevent further complications.

    • This question is part of the following fields:

      • Paediatrics
      35.9
      Seconds
  • Question 85 - At what point in the childhood immunisation schedule is the Meningitis B vaccine...

    Incorrect

    • At what point in the childhood immunisation schedule is the Meningitis B vaccine administered?

      Your Answer: 2, 3, and 4 months

      Correct Answer: 2, 4, and 12 months

      Explanation:

      The most prevalent cause of meningococcal disease in children in the UK is currently Meningitis B. In 2015, the Meningitis B vaccination was added to the NHS routine childhood immunisation schedule. It is administered at 2, 4, and 12 months of age, in conjunction with other immunisations in the schedule. If given at a different time, doses must be spaced at least 2 months apart. For children over one year old, only two doses are necessary.

      Meningitis B Vaccine Now Part of Routine NHS Immunisation

      Children in the UK have been vaccinated against meningococcus serotypes A and C for many years, leaving meningococcal B as the most common cause of bacterial meningitis in the country. However, a new vaccine called Bexsero has been developed to combat this strain. Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero due to a cost-benefit analysis. However, the decision was eventually reversed, and the vaccine has been added to the routine NHS immunisation schedule.

      The vaccine is administered in three doses at 2 months, 4 months, and 12-13 months. Additionally, Bexsero will be available on the NHS for individuals at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. This new vaccine is a significant step in protecting children and vulnerable individuals from meningitis B.

    • This question is part of the following fields:

      • Paediatrics
      17.4
      Seconds
  • Question 86 - When is the infant blood spot screening test typically performed in the United...

    Correct

    • When is the infant blood spot screening test typically performed in the United Kingdom?

      Your Answer: Between fifth and ninth day of life

      Explanation:

      Neonatal Blood Spot Screening: Identifying Potential Health Risks in Newborns

      Neonatal blood spot screening, also known as the Guthrie test or heel-prick test, is a routine procedure performed on newborns between 5-9 days of life. The test involves collecting a small sample of blood from the baby’s heel and analyzing it for potential health risks. Currently, there are nine conditions that are screened for, including congenital hypothyroidism, cystic fibrosis, sickle cell disease, phenylketonuria, medium chain acyl-CoA dehydrogenase deficiency (MCADD), maple syrup urine disease (MSUD), isovaleric acidaemia (IVA), glutaric aciduria type 1 (GA1), and homocystinuria (pyridoxine unresponsive) (HCU).

    • This question is part of the following fields:

      • Paediatrics
      20.6
      Seconds
  • Question 87 - Which of the following neonatal complications is least frequently observed in pregnancies of...

    Correct

    • Which of the following neonatal complications is least frequently observed in pregnancies of women with diabetes?

      Your Answer: Microsomia

      Explanation:

      Macrosomia is more likely to occur in individuals with diabetes than microsomia.

      Complications of Diabetes during Pregnancy

      Diabetes during pregnancy can lead to various complications for both the mother and the baby. Maternal complications may include polyhydramnios, which occurs in 25% of cases and may be due to fetal polyuria. Preterm labor is also a common complication, occurring in 15% of cases and often associated with polyhydramnios.

      Neonatal complications may include macrosomia, although diabetes can also cause small for gestational age babies. Hypoglycemia is another potential complication, which can occur due to beta cell hyperplasia. Respiratory distress syndrome may also occur, as surfactant production is delayed. Polycythemia, which leads to more neonatal jaundice, is also a possibility.

      Malformation rates may increase 3-4 fold, with sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy) being some of the potential risks. Stillbirth is also a possibility. Hypomagnesemia and hypocalcemia may occur, and shoulder dystocia may cause Erb’s palsy.

    • This question is part of the following fields:

      • Paediatrics
      13.3
      Seconds
  • Question 88 - A mother visits the GP clinic seeking information on the hearing tests conducted...

    Incorrect

    • A mother visits the GP clinic seeking information on the hearing tests conducted during school entry. She is anxious about the hearing screening tests as her sister had a language delay caused by hearing impairment that went unnoticed. Her daughter is 4 years old and is about to start preschool. What kind of hearing screening test will be provided to her?

      Your Answer: Speech discrimination tests

      Correct Answer: Pure tone audiometry

      Explanation:

      In the majority of regions in the UK, pure tone audiometry is conducted when children start school. Newborns and infants undergo an Auditory Brainstem Response test if the otoacoustic emission test yields abnormal results. The newborn hearing screening programme includes an otoacoustic emission test. Health visitors perform a distraction test on infants between 6-9 months old. A speech discrimination test is administered after children reach 2.5 years of age.

      Hearing Tests for Children

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      34.1
      Seconds
  • Question 89 - Which of the following is not a characteristic of Tetralogy of Fallot? ...

    Correct

    • Which of the following is not a characteristic of Tetralogy of Fallot?

      Your Answer: Atrial septal defect

      Explanation:

      Understanding Tetralogy of Fallot

      Tetralogy of Fallot (TOF) is a congenital heart disease that results from the anterior malalignment of the aorticopulmonary septum. It is the most common cause of cyanotic congenital heart disease, and it typically presents at around 1-2 months, although it may not be detected until the baby is 6 months old. The condition is characterized by four features, including ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular outflow tract obstruction, and overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

      Other features of TOF include cyanosis, which may cause episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract. These spells are characterized by tachypnea and severe cyanosis that may occasionally result in loss of consciousness. They typically occur when an infant is upset, in pain, or has a fever, and they cause a right-to-left shunt. Additionally, TOF may cause an ejection systolic murmur due to pulmonary stenosis, and a right-sided aortic arch is seen in 25% of patients. Chest x-ray shows a ‘boot-shaped’ heart, while ECG shows right ventricular hypertrophy.

      The management of TOF often involves surgical repair, which is usually undertaken in two parts. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm. However, it is important to note that at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. Understanding the features and management of TOF is crucial for healthcare professionals to provide appropriate care and treatment for affected infants.

    • This question is part of the following fields:

      • Paediatrics
      9
      Seconds
  • Question 90 - A 6-year-old girl presents to the emergency department with a 5-day history of...

    Correct

    • A 6-year-old girl presents to the emergency department with a 5-day history of fever and lethargy. She has no significant medical history and is up to date with her childhood vaccinations.

      During the examination, the girl appears drowsy and has a temperature of 39.2ÂșC. Her heart rate is 155 beats/min and respiratory rate is 46 breaths/min. She has a maculopapular rash on her torso and upper limbs, and her lips are cracked and erythematous. Additionally, her conjunctivae are inflamed. Kernig's sign is negative.

      What is the most appropriate management for this patient, given the likely diagnosis?

      Your Answer: Aspirin

      Explanation:

      High-dose aspirin therapy is the recommended treatment for Kawasaki disease, despite it typically being contraindicated in children.

      Aspirin is the appropriate treatment for this patient’s diagnosis of Kawasaki disease, as evidenced by their persistent fever, conjunctivitis, maculopapular rash, and cracked and erythematous lips. This disease is vasculitic in nature, and current guidelines advise the use of high-dose aspirin therapy as the initial treatment.

      Intravenous aciclovir is not indicated for Kawasaki disease, as it is used to treat viral conditions such as viral meningitis or encephalitis.

      Intravenous ceftriaxone is not appropriate for the treatment of Kawasaki disease, as it is reserved for significant bacterial infections like Neisseria meningitidis. Additionally, the negative Kernig’s sign makes meningitis less likely.

      Oral phenoxymethylpenicillin is not the recommended treatment for Kawasaki disease, as the mucosal changes and conjunctivitis are more indicative of this disease rather than scarlet fever, which is treated with oral phenoxymethylpenicillin.

      Understanding Kawasaki Disease

      Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications, such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days and is resistant to antipyretics. Other symptoms include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

      Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms, rather than angiography.

      Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

    • This question is part of the following fields:

      • Paediatrics
      48.9
      Seconds
  • Question 91 - A 35-year-old primip has a stillborn baby at 34 weeks gestation. The infant...

    Correct

    • A 35-year-old primip has a stillborn baby at 34 weeks gestation. The infant presents with microcephaly, micrognathia, and club feet. What is the diagnosis?

      Your Answer: Trisomy 18

      Explanation:

      Edward’s syndrome is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. The baby affected by this syndrome will have experienced slow growth in the womb and will have a low birthweight. Unfortunately, around half of those who survive to birth will pass away within two weeks, and only one in every five will live for at least three months. The survival rate beyond one year is only one in every 12 babies born with Edwards’ syndrome. This information is according to NHS Choices.

      Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that is characterized by microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, also known as trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is characterized by learning difficulties, macrocephaly, long face, large ears, and macro-orchidism. Noonan syndrome is characterized by a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome is characterized by hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, friendly, extrovert personality, and transient neonatal hypercalcaemia. Cri du chat syndrome, also known as chromosome 5p deletion syndrome, is characterized by a characteristic cry, feeding difficulties and poor weight gain, learning difficulties, microcephaly and micrognathism, and hypertelorism. It is important to note that Treacher-Collins syndrome is similar to Pierre-Robin syndrome, but it is autosomal dominant and usually has a family history of similar problems.

    • This question is part of the following fields:

      • Paediatrics
      16.7
      Seconds
  • Question 92 - You are called to attend a premature delivery. The neonate is born at...

    Correct

    • You are called to attend a premature delivery. The neonate is born at 34 weeks gestation via emergency Caesarean section. The neonate is having trouble starting to breathe and needs resuscitation. They are dyspnoeic and tachypnoeic at a rate of 85 breaths/min. Upon listening to the chest, there is decreased breath sounds on both sides. Heart sounds are displaced towards the middle. The abdominal wall looks sunken. What is the probable diagnosis?

      Your Answer: Congenital diaphragmatic hernia

      Explanation:

      The appearance of a scaphoid abdomen is a common presentation of congenital diaphragmatic hernia, which occurs when abdominal contents protrude into the chest cavity. This condition can cause breathing difficulties and rapid breathing in newborns. The characteristic auscultation findings are caused by underdeveloped lungs and compression due to the presence of abdominal organs in the chest. Immediate medical attention and respiratory support are necessary. It is important to note that this specific concave abdominal appearance is not seen in any other conditions mentioned.

      Understanding Congenital Diaphragmatic Hernia

      Congenital diaphragmatic hernia (CDH) is a rare condition that affects approximately 1 in 2,000 newborns. It occurs when the diaphragm, a muscle that separates the chest and abdominal cavities, fails to form completely during fetal development. As a result, abdominal organs can move into the chest cavity, which can lead to underdeveloped lungs and high blood pressure in the lungs. This can cause respiratory distress shortly after birth.

      The most common type of CDH is a left-sided posterolateral Bochdalek hernia, which accounts for about 85% of cases. This type of hernia occurs when the pleuroperitoneal canal, a structure that connects the chest and abdominal cavities during fetal development, fails to close properly.

      Despite advances in medical treatment, only about 50% of newborns with CDH survive. Early diagnosis and prompt treatment are crucial for improving outcomes. Treatment may involve surgery to repair the diaphragm and move the abdominal organs back into their proper position. In some cases, a ventilator or extracorporeal membrane oxygenation (ECMO) may be necessary to support breathing until the lungs can function properly. Ongoing care and monitoring are also important to manage any long-term complications that may arise.

    • This question is part of the following fields:

      • Paediatrics
      26.5
      Seconds
  • Question 93 - As a foundation doctor on the postnatal ward, you conduct a newborn examination...

    Correct

    • As a foundation doctor on the postnatal ward, you conduct a newborn examination on a two-day-old baby girl. She was delivered normally and in good condition. During the hip examination, you observe that the left hip can be dislocated. What is the name of the examination you have conducted?

      Your Answer: Barlow

      Explanation:

      The Barlow manoeuvre is a technique used to try and dislocate a newborn’s femoral head. If successful, the Ortolani manoeuvre can then be used to relocate the dislocated femoral head. The Thomas test is not appropriate for neonates and is used to identify hip flexion contractures in older patients. The Denis Brown bar is an orthotic device used in conjunction with the Ponseti method to correct a fixed talipes.

      Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

    • This question is part of the following fields:

      • Paediatrics
      16.7
      Seconds
  • Question 94 - A 6-year-old girl presented to the paediatric emergency department with a 4-day history...

    Correct

    • A 6-year-old girl presented to the paediatric emergency department with a 4-day history of fever, and watery diarrhoea for the previous 8 days. After initial management, she now appears well hydrated and is drinking as usual. Her observations are normal. The child's stool culture result returns positive for Salmonella spp.
      Which of the following is the most appropriate next step in your management?

      Your Answer: Discharge home with no antibiotic treatment

      Explanation:

      Management of Salmonella Infection in Children: Discharge Home with No Antibiotic Treatment

      Salmonella infection is a common cause of gastroenteritis in children. The mainstay of treatment is oral rehydration for correction of dehydration and prevention of further fluid losses. Most children with salmonella infection do not need any specific treatment, and symptoms usually improve in a few days. Unless symptoms are severe, children with salmonella can usually be cared for at home. Infection with Salmonella spp. is a notifiable disease in the UK. Antibiotics should be considered in children with salmonella gastroenteritis who are aged < 6 months, malnourished or immunocompromised. However, in this case, the child is well hydrated and drinking as usual, and therefore, discharge home with no antibiotic treatment is the correct management approach.

    • This question is part of the following fields:

      • Paediatrics
      30.4
      Seconds
  • Question 95 - A 9-year-old girl is brought to the emergency department by her father who...

    Correct

    • A 9-year-old girl is brought to the emergency department by her father who is worried about a non-blanching petechial rash on her arms and legs. The child had a cold recently but currently has normal observations and seems to be in good health. What is the probable diagnosis?

      Your Answer: Immune thrombocytopaenic purpura (ITP)

      Explanation:

      ITP is a possible diagnosis for a child who presents with petechiae and no fever, while HUS and meningitis are unlikely. HSP may also be considered, but the child in the question has not experienced other symptoms of HSP. Non-accidental injury should also be considered as a differential for any petechial rash. However, ITP is more likely as it is often preceded by a viral illness and presents with isolated thrombocytopenia, causing the classic petechial rash. Blood results are needed to confirm the diagnosis.

      Understanding Immune Thrombocytopenia (ITP) in Children

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

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

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

    • This question is part of the following fields:

      • Paediatrics
      38.5
      Seconds
  • Question 96 - A 3-day-old infant is presented to the Emergency Department due to increased irritability,...

    Correct

    • A 3-day-old infant is presented to the Emergency Department due to increased irritability, poor feeding, and decreased muscle tone as observed by the mother in the last 24 hours. Meningitis is confirmed through lumbar puncture. What is the probable causative agent in this scenario?

      Your Answer: Group B streptococcus

      Explanation:

      Meningitis poses a higher risk to neonates, particularly those with low birth weight, prematurity, traumatic delivery, fetal hypoxia, and maternal peripartum infection. The initial symptoms are usually vague and may include elevated body temperature, respiratory distress, apnea, episodes of bradycardia, low blood pressure, difficulty feeding, irritability, and decreased activity.

      Organisms causing meningitis in children

      Meningitis is a serious condition that can affect children of all ages. The organisms that cause meningitis vary depending on the age of the child. In neonates up to 3 months old, Group B Streptococcus is the most common cause, which is usually acquired from the mother during birth. E. coli and other Gram-negative organisms, as well as Listeria monocytogenes, can also cause meningitis in this age group.

      From 1 month to 6 years old, Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus), and Haemophilus influenzae are the most common organisms that cause meningitis. In children over 6 years old, Neisseria meningitidis and Streptococcus pneumoniae are the most common causes.

      It is important for parents to be aware of the signs and symptoms of meningitis, such as fever, headache, stiff neck, and sensitivity to light. If a child is showing these symptoms, they should be taken to a doctor immediately for evaluation and treatment. Early diagnosis and treatment can help prevent serious complications and improve outcomes.

    • This question is part of the following fields:

      • Paediatrics
      17.2
      Seconds
  • Question 97 - You assess a 10-month-old infant with parents of Jamaican descent. The parents have...

    Correct

    • You assess a 10-month-old infant with parents of Jamaican descent. The parents have observed a minor bulge near the belly button. The child is healthy and falls on the 50th percentile. During the examination, you observe a small umbilical hernia that is less than 1 cm in size and can be reduced. What is the best course of action for this situation?

      Your Answer: Reassure the parents that the vast majority resolve by the age of 4-5 years

      Explanation:

      Abdominal wall hernias occur when an organ or the fascia of an organ protrudes through the wall of the cavity that normally contains it. Risk factors for developing these hernias include obesity, ascites, increasing age, and surgical wounds. Symptoms of abdominal wall hernias include a palpable lump, cough impulse, pain, obstruction (more common in femoral hernias), and strangulation (which can compromise the bowel blood supply and lead to infarction). There are several types of abdominal wall hernias, including inguinal hernias (which account for 75% of cases and are more common in men), femoral hernias (more common in women and have a high risk of obstruction and strangulation), umbilical hernias (symmetrical bulge under the umbilicus), paraumbilical hernias (asymmetrical bulge), epigastric hernias (lump in the midline between umbilicus and xiphisternum), incisional hernias (which may occur after abdominal surgery), Spigelian hernias (rare and seen in older patients), obturator hernias (more common in females and can cause bowel obstruction), and Richter hernias (a rare type of hernia that can present with strangulation without symptoms of obstruction). In children, congenital inguinal hernias and infantile umbilical hernias are the most common types, with surgical repair recommended for the former and most resolving on their own for the latter.

    • This question is part of the following fields:

      • Paediatrics
      15.3
      Seconds
  • Question 98 - A 20 year-old with no notable medical history enrolls at a new GP...

    Incorrect

    • A 20 year-old with no notable medical history enrolls at a new GP clinic upon moving to a different city. The clinic checks his immunization records and sends him an invite to get vaccinated. What vaccination should he get if he hasn't received it before?

      Your Answer: Influenza

      Correct Answer: Men ACWY

      Explanation:

      The Meningitis ACWY vaccine is being gradually introduced and is recommended for all children during their 9th or 10th year of school. Instead of the Men C booster, they should receive this vaccination. The catch-up program is currently targeting individuals under the age of 25 who are starting university for the first time. It is recommended that they receive the vaccine a few weeks before beginning their studies.

      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 certain intervals. At 12-13 months, the Hib/Men C, MMR, and PCV vaccines are given, along with Men B. At 3-4 years, the ‘4-in-1 pre-school 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 will also be 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. Students going to university or college for the first time as freshers, including overseas and mature students up to the age of 25, should contact their GP to have the Men ACWY vaccine, ideally before the start of the academic year.

      It is worth noting that the Men C vaccine used to be given at 3 months but has now been discontinued. This is because the success of the Men C vaccination programme means there are almost no cases of Men C disease in babies or young children in the UK any longer. 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.

    • This question is part of the following fields:

      • Paediatrics
      39.3
      Seconds
  • Question 99 - What is the likelihood of a 44-year-old mother having a child with Down's...

    Correct

    • What is the likelihood of a 44-year-old mother having a child with Down's syndrome?

      Your Answer: 1 in 50

      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 occurs when there is an extra copy of chromosome 21. The risk of having a child with Down’s syndrome increases with maternal age. At 20 years old, the risk is 1 in 1,500, but by 45 years old, the risk increases to 1 in 50 or greater. To remember this, one can start with a risk of 1/1,000 at 30 years old and divide the denominator by 3 for every extra 5 years of age.

      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. The risk of recurrence is 1 in 100 if the mother is under 35 years old. Robertsonian translocation occurs when part of chromosome 21 attaches to another chromosome, usually chromosome 14. This accounts for 5% of cases and has a higher risk of recurrence if the mother or father is a carrier. Mosaicism accounts for 1% of cases and occurs when there are two genetically different populations of cells in the body.

      In summary, Down’s syndrome is a genetic disorder that is more common with increasing maternal age. The risk of recurrence depends on the type of Down’s syndrome and whether the parents are carriers. It is important for individuals to understand the genetics and epidemiology of Down’s syndrome to make informed decisions about family planning.

    • This question is part of the following fields:

      • Paediatrics
      5.6
      Seconds
  • Question 100 - A grandfather visits you as his grandson has been diagnosed with hypospadias. He...

    Correct

    • A grandfather visits you as his grandson has been diagnosed with hypospadias. He wants to know what treatment options are available and if there are any measures he can take to prevent the condition from worsening.

      Your Answer: Corrective surgery at around 12 months of age is required and children should not be circumcised

      Explanation:

      The usual age for performing hypospadias surgery is approximately 12 months.

      Understanding Hypospadias: A Congenital Abnormality of the Penis

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

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

    • This question is part of the following fields:

      • Paediatrics
      35.3
      Seconds
  • Question 101 - A 12-year-old boy has been under the care of the Paediatrics Team since...

    Correct

    • A 12-year-old boy has been under the care of the Paediatrics Team since birth and is attending the Paediatric Clinic for a follow-up appointment. His mother reports that he is struggling at school due to his learning and behavioural difficulties. He has a large jaw, hyper-extensible joints and macroorchidism.
      Which of the following is the most likely syndrome?

      Your Answer: Fragile X syndrome

      Explanation:

      Genetic Conditions and Their Phenotypic Features

      Fragile X Syndrome, Down Syndrome, Edwards Syndrome, Noonan Syndrome, and Pierre-Robin Syndrome are genetic conditions that have distinct phenotypic features. Fragile X Syndrome is an X-linked form of learning disability and autism that mainly presents after puberty. Down Syndrome is characterized by brachycephaly, prominent epicanthal folds, and small nose and mouth with protruding tongue, among others, and is usually diagnosed at birth. Edwards Syndrome has a life expectancy of days to weeks and is characterized by neonatal hypotonia, apnea, and seizures. Noonan Syndrome is inherited in an autosomal-dominant pattern and is characterized by distinctive facial features, congenital heart defects, and skeletal malformations. Pierre-Robin Syndrome results in facial abnormalities, respiratory and feeding difficulties, and cleft palate. Understanding the phenotypic features of these genetic conditions is crucial for early diagnosis and management.

    • This question is part of the following fields:

      • Paediatrics
      29.3
      Seconds
  • Question 102 - Which one of the following statements regarding the HPV vaccine is incorrect? ...

    Incorrect

    • Which one of the following statements regarding the HPV vaccine is incorrect?

      Your Answer: The second dose is given at 3-4 years

      Correct Answer: Children who received another live vaccine 2 weeks ago can safely have MMR

      Explanation:

      The MMR Vaccine: Information on Contraindications and Adverse Effects

      The Measles, Mumps and Rubella (MMR) vaccine is given to children in the UK twice before they enter primary school. The first dose is administered at 12-15 months, while the second dose is given at 3-4 years old. This vaccine is part of the routine immunisation schedule.

      However, there are certain contraindications to the MMR vaccine. Children with severe immunosuppression, allergies to neomycin, or those who have received another live vaccine by injection within four weeks should not receive the MMR vaccine. Pregnant women should also avoid getting vaccinated for at least one month following the MMR vaccine. Additionally, if a child has undergone immunoglobulin therapy within the past three months, there may be no immune response to the measles vaccine if antibodies are present.

      While the MMR vaccine is generally safe, there are some adverse effects that may occur. After the first dose of the vaccine, some children may experience malaise, fever, and rash. These symptoms typically occur after 5-10 days and last for around 2-3 days. It is important to be aware of these potential side effects and to consult with a healthcare professional if any concerns arise.

    • This question is part of the following fields:

      • Paediatrics
      25.8
      Seconds
  • Question 103 - A 7-year-old girl presents to you with her father. She complains of bilateral...

    Correct

    • A 7-year-old girl presents to you with her father. She complains of bilateral knee and calf pain at night for the past 6 months. The pain worsens after playing soccer during the day and can cause her to wake up 1-2 times per month. Knee examination is normal, and she is otherwise healthy. What is the most probable diagnosis?

      Your Answer: Growing pains

      Explanation:

      Children between the ages of 3 and 12 often experience growing pains, which typically involve leg pain. However, it is crucial to check for any potential warning signs when examining these children. One such warning sign is osteosarcoma, a rare but significant diagnosis that should be ruled out. Symptoms of osteosarcoma include an inexplicable lump, bone pain, or swelling. Another condition to consider is juvenile rheumatoid arthritis, which typically presents with fever, rash, and symmetrical joint pain and swelling.

      Understanding Growing Pains in Children

      Growing pains are a common complaint among children aged 3-12 years. These pains are often attributed to ‘benign idiopathic nocturnal limb pains of childhood’ in rheumatology, as they are not necessarily related to growth. Boys and girls are equally affected by growing pains, which are characterized by intermittent pain in the legs with no obvious cause.

      One of the key features of growing pains is that they are never present at the start of the day after the child has woken up. Additionally, there is no limp or limitation of physical activity, and the child is systemically well with normal physical examination and motor milestones. Symptoms may worsen after a day of vigorous activity.

      Overall, growing pains are a benign condition that can be managed with reassurance and simple measures such as massage or heat application. However, it is important to rule out other potential causes of leg pain in children, especially if there are any worrying features present.

    • This question is part of the following fields:

      • Paediatrics
      32.2
      Seconds
  • Question 104 - Which of the following is the least probable cause of snoring in adolescents?...

    Correct

    • Which of the following is the least probable cause of snoring in adolescents?

      Your Answer: Kallman's syndrome

      Explanation:

      Snoring is not a symptom of Kallman’s syndrome, which is a condition that leads to delayed puberty due to hypogonadotrophic hypogonadism.

      Snoring in Children: Possible Causes

      Snoring in children can be caused by various factors. One of the common causes is obesity, which can lead to the narrowing of the airways and difficulty in breathing during sleep. Another possible cause is nasal problems such as polyps, deviated septum, and hypertrophic nasal turbinates, which can also obstruct the airways and cause snoring. Recurrent tonsillitis can also contribute to snoring, as the inflamed tonsils can block the air passages.

      In some cases, snoring in children may be associated with certain medical conditions such as Down’s syndrome and hypothyroidism. These conditions can affect the structure and function of the respiratory system, leading to snoring and other breathing difficulties.

      It is important to identify the underlying cause of snoring in children and seek appropriate treatment to prevent potential health complications. Parents should consult a healthcare professional if their child snores regularly or experiences other symptoms such as daytime sleepiness, difficulty concentrating, or behavioral problems.

    • This question is part of the following fields:

      • Paediatrics
      25
      Seconds
  • Question 105 - A 9-month-old girl is presented to the clinic. About 5 days ago, she...

    Incorrect

    • A 9-month-old girl is presented to the clinic. About 5 days ago, she became feverish after being fussy the day before. The fever subsided after approximately 3 days, but she developed a rash afterwards, which prompted her mother to bring her to the clinic. She is consuming about 80% of her usual feeds, has wet nappies, and has had three instances of loose stools. On examination, she is alert, has a temperature of 37.2ÂșC, and has clear lungs and unremarkable ears/throat. There are several blanching, rose pink macules on her trunk. What is the most probable diagnosis?

      Your Answer: Measles

      Correct Answer: Roseola infantum

      Explanation:

      Roseola infantum is a condition characterized by the occurrence of a fever, which is later followed by the appearance of a rash.

      Understanding Roseola Infantum

      Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpes virus 6 (HHV6). This disease has an incubation period of 5-15 days and is typically seen in children aged 6 months to 2 years. The most common symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms may include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea.

      In some cases, febrile convulsions may occur in around 10-15% of children with roseola infantum. While this can be concerning for parents, it is important to note that this is a common occurrence and typically resolves on its own. Additionally, HHV6 infection can lead to other possible consequences such as aseptic meningitis and hepatitis.

      It is important to note that school exclusion is not necessary for children with roseola infantum. While this illness can be uncomfortable for infants, it is typically not serious and resolves on its own within a few days.

    • This question is part of the following fields:

      • Paediatrics
      66
      Seconds
  • Question 106 - A 3-year-old child presents to the emergency department with a 3 day history...

    Correct

    • A 3-year-old child presents to the emergency department with a 3 day history of left knee pain and irritability. The child had recently recovered from a viral respiratory tract infection and is currently asymptomatic and without fever. Upon examination, the joint is painful to move but not hot or red, and the child is able to bear weight. Laboratory results reveal a hemoglobin level of 140 g/L (male: 135-180, female: 115-160), platelet count of 450 * 109/L (150-400), white cell count of 11.5 * 109/L (4.0-11.0), CRP of 29 mg/L (<5), and ESR of 32 mm/hr (0-10). What is the most likely diagnosis?

      Your Answer: Transient synovitis