ICSM Paeds Mock

Question 1

At her 6-hour neonatal check, a newborn infant is noted to have a flat, pink lesion on the glabella. The registrar notices that it turns darker when she cries. What is this lesion likely to be?

A. Capillary hemangioma

B. Nevus sebaceus

C. Salmon patch

D. Café-au-lait spot

E. Port wine stain

Answer 1

C. Salmon patch

Salmon patch – this is a common finding in neonates, often appearing as a flat pink or salmon-colored lesion on the eyelids, the nuchal area and the glabella. It disappears with age, although those located on the nuchal area tend to persist into adulthood. Café-au-lait spot – these are flat lesions like the salmon patch, however, as the name indicated, they are tan or light brown in color. They can occur anywhere on the body, varying in size and shape. They are sharply demarcated from the underlying skin and are often associated with neurocutaneous disorders such as neurofibromatosis.

Question 2

At his 6-hour neonatal check, an infant born by spontaneous vaginal delivery is noted to have a large swelling on the back of his head. It only involves the scalp and crosses the suture lines. What is this lesion likely to be?

A. Cephalohematoma

B. Caput succedaneum

C. Subcutaneous fat necrosis

D. Meningocele

E. Craniosynostosis

Answer 2

B. Caput succedaneum

Caput succedaneum – this is another birth injury that is due to bleeding into the scalp of the presenting part of the head. As it involves the scalp overlying the skull bones it does cross suture lines. They resolve rapidly over several days.

Question 3

A 4 week old baby presents with jaundice since the 3rd day of life. He was born at term and was of normal birth weight. He is breast fed but is not feeding well and is falling off the centiles. He has a history of bruises and mum noticed a change in the color of his stool. His mother mentions she is blood group O. What would be the most diagnostic investigation?

A. Coomb’s Test

B. Dipstick Urine

C. Liver Function Tests

D. TBIDA – radionucleotide scan

E. Ultrasound Scan

Answer 3

D. TBIDA – radionucleotide scan

Then answer is D – Infants become clinically jaundice when the bilirubin level climbs to 80 to 120μmol/L. There are three main reasons why more than 60% of infants become clinically jaundiced: (1) decreased life-span of fetal red blood cells (60 to 70 days) compared to adult red blood cells (120 days) (2) high red blood cell concentration in the neonate compared to the adult results in the physiological release of hemoglobin from the breakdown of the these cells and (3) hepatic bilirubin metabolism is immature. There are two reasons why neonatal jaundice is worrying: (1) may indicate an underlying pathology (e.g. hemolytic anemia, infection or metabolic disease) and (2) unconjugated hyperbilirubinemia put the infant at risk of kernicterus.

Question 4

A 4 week old baby is brought in by his mother, with worsening jaundice since one week of age. He is exclusively breast-fed and growing well. Which investigation should be carried out first?

A. Conjugated and unconjugated bilirubin

B. Coomb’s test

C. Liver Function Tests

D. Septic Screen

E. Thyroid stimulating hormone levels

Answer 4

A. Conjugated and unconjugated bilirubin

The answer is A – conjugated and unconjugated bilirubin. This will distinguish between a hepatic cause (conjugated) vs. a systemic cause (unconjugated) such as an infection or hemolytic process. LFTs are of little diagnostic value in this case.

Question 5

A baby is born at term by normal vaginal delivery. While being breast fed, the mother notices at 6 hours of age he is looking jaundiced. He was immediately placed on phototherapy. While receiving treatment for jaundice, which of the following investigations can help identify the most likely cause?

A. Blood culture

B. Blood film

C. Coomb’s test

D. G6PD level

E. Urinalysis for reducing substances

Answer 5

C. Coomb’s test

The answer is C – Coomb’s Test. This child is presenting with jaundice at

Question 6

The midwife bleeps you as the FY1 doctor on-call, as she is concerned about a jittery baby. The child was born at 36 weeks via emergency Caesarean section and weight 1.8 kg. He appears to be very sensitive to external stimuli when examined and appears dysmorphic with a poorly developed philtrum above his upper lip. What is the most likely diagnosis?

A. Cerebral Infection

B. Down’s Syndrome

C. Foetal Alcohol Syndrome

D. Hypocalcaemia

E. Neonatal opiate withdrawal

Answer 6

C. Foetal Alcohol Syndrome

The answer is C – Foetal Alcohol Syndrome Common causes of a ‘jittery’ neonate are:
1. Hypoglycaemia
2. Hypocalcaemia
3. Withdrawal following maternal drug and/or alcohol abuse
Of these, only foetal alcohol syndrome is associated with dysmorphism (saddle-shaped nose, maxillary hypoplasia, absent philtrum and thin upper lip). They are also growth restricted and may have cardiac defects and developmental delay.

Question 7

A 15 year old boy presents to the endocrine clinic with persistent gynaecomastia. On examination he is on the 99.6th centile for height, has appropriate pubic hair growth and small testes. His parents are also concerned that he has always been below average at school. What is the most likely chromosomal abnormality?

A. 45X

B. 47XXY

C. Fragile X

D. Trisomy 13

E. Trisomy 18

Answer 7

B. 47XXY

The answer is B – 47XXY 47XXY (Klienfelter’s Syndrome) is characterised by micro-orchidism (small testes), tall stature, behavioural problems, gynaecomastia and speech delay. 45X = Turners is a female phenotype. Trisomy 13 (Patau’s) & 18 (Edward’s) = most die

Question 8

You are the SHO on call. A two year old boy is brought in. He has been vomiting since yesterday. On examination he has dry mucous membranes; he is tachycardic with sunken eyes, with a reduced skin turgor and prolonged capillary refill time and is lethargic. You give him 20 ml/kg Bolus of 0.9% saline and he improves slightly. Assuming no further vomiting, what is his 24 hour fluid requirement if he weighs 12 kg?

A. 240 ml

B. 1100 ml

C. 1200 ml

D. 2060 ml

E. 2300 ml

Answer 8

D. 2060 ml

The answer is D – 2060ml

Calculating fluid requirement:

Total fluid requirement = maintenance + deficit + ongoing losses

Fluid deficit in ml = % dehydration x weight (kg) x 10

Maintenance fluid = 1st 10kg: 100ml/kg

2nd 10kg: 50ml/kg

> 20kg: 20ml/kg

Question 9

A 14 year old boy previously growing normally along the 2nd centile for height is now below the 0.4th centile. He has been complaining of peri-umbilical abdominal pain for the last 6 months on and off. What would be your next step?

A. Full Blood Count (FBC)

B. Growth Hormone Provocation Test

C. Mid-parental height calculation

D. Sweat test

E. X-ray wrist and hands for bone age

Answer 9

C. Mid-parental height calculation

The answer is C – mid-parental height calculation 1st step is to assess whether child is growing within his normal range: measure height and weight. Weight is not an option in this choice of answers so sensible to focus on height. The nest best step would be to work out MPH (see red book for how to do this). Then see if 2nd or 0.4th centile lie within the MPH range. This will help to work out whether he is reaching his full potential or not. If he isn’t we can then think about more investigations

Question 10

An Asian mother has brought her 8 week old son to you as her GP, for a routine child health check. He was born at 36 weeks gestation. He is exclusively breast fed and is thriving. Of the following options, which oral supplements would you advise for the mother?

A. Calcium

B. Folic Acid

C. Iron

D. Vitamin B12

E. Vitamin D

Answer 10

E. Vitamin D

Without any further information apart from ethnicity, mum is most at risk of vitamin D deficiency due to darker skin pigmentation. The amount of vitamin D in breast milk is directly related to maternal levels, therefore increasing the risk of vitamin D deficiency in the baby if mum is not supplemented. (Babies of this age would rarely be exposed to levels of sunlight in Britain adequate enough to synthesise their own vitamin D).

Question 11

A 15-year-old boy attends an outpatient paediatric clinic complaining of short stature. He has noticed over the past two years that he has become increasingly shorter than his peers. On examination he looks well. He has pre-pubertal sized testes, and sparse pubic hair. His height has fallen from the 25th to 9th centile. His father reports he was ‘a late developer’. What is the most likely cause of this boy’s short stature?

A. Acquired hypothyroidism

B. Coeliac Disease

C. Constitutional Delay of Growth and Puberty

D. Cystic Fibrosis

E. Gonadotrophin Deficiency

Answer 11

C. Constitutional Delay of Growth and Puberty

In this case, there is evidence of delayed puberty, with consequent delayed pubertal growth spurt. Constitutional delay of growth and puberty is the commonest cause of delayed puberty, and there is often history of delayed puberty in the boy’s father. There was no evidence of systemic disease to suggest either celiac disease or cystic fibrosis as a cause. Isolated gonadotrophin deficiency is rare, occurring in 1 in 10,000 males, and is therefore unlikely.

Question 12

A 6 six year old boy presented to the developmental clinic with difficulties fitting into school. Mother states that he has trouble sustaining prolonged conversation. He appears clumsy and has occasional tantrums but he knows the capital of every European country. Of the following options, which member of the multidisciplinary team is LEAST likely to be involved in his care?

A. Community Paediatrician

B. Neurologist

C. Occupational Therapist

D. Psychologist

E. Special educational needs coordinator

Answer 12

B. Neurologist

Asperger’s syndrome is characterised by:
1. Normal intelligence
2. No delay in language development
3. Impaired social and communication skills and a narrow range of obsessional interests
Many members of the multidisciplinary team are involved to help manage this disorder and improve a child’s functioning. Doctors involved primarily include neurodevelopmental and community paediatricians and GPs. There is no organic neurological problem in Asperger’s syndrome; therefore a neurologist is least likely to be involved in this child’s care.

Question 13

You are the paediatric registrar working in a general out-patient clinic. You see a four year old boy whose parents are concerned that he has difficulty interacting with the neighbours’ children. The teachers in school reprimand him for being cheeky as he often repeats what they say. You notice that he has poor eye contact. What is the next most appropriate step in the management of this patient?

A. Initiate Ritalin Treatment

B. Reassure symptoms will resolve of their own accord

C. Refer to Child Development Team for assessment

D. Send the patient to child psychiatry team for assessment

E. Send the patient to paediatric neurology

Answer 13

C. Refer to Child Development Team for assessment

The child being described has features of autistic spectrum disorder. The 3 core features of autism which should be present by 3 years are:
1. Impaired social interaction
2. Impaired communication
3. Restricted, repetitive and stereotyped behaviour and interests.
Management involves a wide variety of health professionals and varies greatly between different children; therefore a thorough assessment is required to assess each child’s needs. This is done by the child development team.

Question 14

A 4-year-old girl is brought to the accident and emergency department after falling off her bed. Radiographic examination reveals with a right-humeral fracture. She has a past medical history of 3 previous attendances for fractures. On examination there is discolouration of the sclera and bowing of the lower limbs. Of the following, which is the most likely diagnosis?

A. Achondroplasia

B. NAI

C. Osteogenesis imperfecta

D. Osteoporosis

E. Rickets

Answer 14

C. Osteogenesis imperfecta

Osteogenesis imperfecta – is an autosomal recessive disorder of collagen synthesis. It typically involves blue sclera, and bowing of the legs, it would also fit to have a past medical History of fractures.

Question 15

A 5 year old boy presents with a 12 hour history of a painful left hip on movement. He is afebrile. An x-ray is normal. Ultrasound shows joint effusion in the affected hip. FBC and CXR are normal. What is the best management plan?

A. Bed rest

B. Joint Aspiration

C. Plaster cast

D. Skin traction

E. Surgical intervention with pin fixation

Answer 15

A. Bed rest

This is transient synovitis (age range is 2-12 yr, child would be afebrile, sudden onset) for which the best treatment option is bed rest, skin traction is used but very rarely

Question 16

A 5 year old boy is brought into A+E by his annoyed mother. She reveals that he has been constantly complaining of leg pain. On examination you notice a limp and tenderness in his right leg, but no loss of range of movement. You also notice marked bruising on his back. What is the next step in this child’s management?

A. Analgesia

B. Blood Film

C. FBC and Clotting Studies

D. Refer to child protection services

E. X-ray

Answer 16

E. X-ray

Certain features in the history are suggestive of non-accidental injury (NAI): ‘annoyed mother, sense of delay in presentation to hospital, bruising on back. Full skeletal X-ray is useful in looking for any fractures and this is the best NEXT step. Advice from a senior colleague is always part of the management in a case like this, where NAI might be a possibility.

Question 17

A new mother is attending her GP practice for a 6 week check-up for her daughter. On examination the GP notices asymmetrical skin creases around the hip joint which was also unstable. Which is the next most appropriate step for management?

A. Arrange for X-ray of the hip

B. Ask the Health Visitor to monitor

C. Recommend the baby is put in double nappies

D. Refer to orthopaedics

E. Refer to physiotherapy

Answer 17

D. Refer to orthopaedics

Diagnosis is most likely to be Developmental Dysplasia of the Hips (DDH). DDH typically presents with asymmetrical skin-folds, limb abduction, shortening of affected limb and limp (if not diagnosed until child is walking). DDH needs early treatment from Orthopaedics with a Craig’s splint (hips held in abduction) or a Pavlik harness (restraining device) for several months. Therefore physiotherapy, health visitor follow-up and double nappies are inappropriate steps.

Question 18

You are asked to see a 5-year-old boy who has been carried into the accident and emergency department by his father. His father reports that he has had a bout of the ‘flu’ over the past week and didn’t want to get out of bed this morning. There is no history of trauma. On examination, the boy is afebrile and appears well. He refuses to weight bear because it ‘hurts to walk’. What is the most likely diagnosis?

A. Fracture

B. Osteomyelitis

C. Septic arthritis

D. Slipped upper femoral epiphysis

E. Transient synovitis

Answer 18

E. Transient synovitis

The answer is E – this child is refusing to weight bear following a viral illness.

Question 19

A 7-year-old child is brought to the clinic by her parents to examine several bumps they have found on her body. Her parents noticed them several weeks ago on her neck and there are now several on her trunk. They say that the child has a tendency to scratch them. On examination – there are several pale-pink papules with umbilicated centers. The child is otherwise fit and well. To which family does the most likely causative viral agent of these lesions belong?

A. Herpesviruses

B. Poxviruses

C. Flaviviruses

D. Paramyxoviruses

E. Retroviruses

Answer 19

B. Poxviruses

Poxviruses – the causative agent is Molluscum contagiosum virus, which is a member of the poxvirus family. The vignette describes the classical presentation. The papules may be slightly pruritic and children tend to scratch and spread them via auto-inoculation (Koebner phenomenon). The papules eventually spontaneously resolve and no treatment is necessary

Question 20

A 3-year-old child is brought into the emergency department. His parents are worried as he is running a fever of 38°C and has developed a rash. Examination reveals a rash at several stages of healing – some are clear 4mm vesicles on an erythematous base, while others are crusted. Which of the following complications would you worry about in an immunocompromised child?

A. Secondary infection with group A streptococci

B. Secondary infection with Pseudomonas aeruginosa

C. Hepatic spread

D. Pneumonitis

E. Encephalitis

Answer 20

D. Pneumonitis

Pneumonitis – the child in the vignette has Varicella zoster virus infection (chicken pox), which is spread by respiratory droplets. It lies latent in the dorsal root ganglia and leads to herpes zoster with reactivation (shingles). Fifteen to twenty percent of immunocompromised children develop Varicella zoster pneumonitis.

Question 21

You are called to see a 13-month-old boy in the emergency department who over the past two days refuses to weight bear on his right side. The mother says that a week ago he had an ear infection for which the GP prescribed antibiotics. She decided not to give them as he seemed better. Which single investigation would most likely confirm your diagnosis?

A. Radiograph of the right hip

B. MRI of the right hip

C. Blood culture

D. Erythrocyte Sedimentation Rate (ESR)

E. Full blood count with white blood cell differential

Answer 21

C. Blood culture

Blood culture – this child most likely has osteomyelitis secondary to untreated otitis media. Osteomyelitis can occur due to (1) hematogenous spread – which is the most common mechanism in children (2) contiguous spread and (3) direct infection from a penetrating wound. Blood cultures are positive in 60% of cases. The most common cause in children aged 3 to 12 years is Staphylococcus aureus. The patient should be treated with IV antibiotics (flucloxacillin and benzyl-penicillin) for 3 weeks in hospital and then switched to oral for 1 to 3 more weeks.

Question 22

You are the pediatric registrar on call in the emergency department. An 11-month-old child is brought in by her mother with irritability and several episodes of vomiting. The mother says that the child has been like this since waking and has a tactile fever. The mother adds that she is bothered by bright lights. Following a thorough history and examination, you perform a lumbar puncture. Which CSF findings would be in keeping with aseptic meningitis?

A. Low glucose

B. Leukocytes

C. High protein

D. High opening pressure

E. PMNs

Answer 22

B. Leukocytes

Leukocytes – this is the only finding listed that is a typical CSF finding in aseptic meningitis. The rest are all features of a pyogenic infection. Aseptic meningitis is typically caused by a virus, usually an enterovirus. Other viral causes include herpes viruses, adenoviruses, and paramyxoviruses. Enterovirus-associated meningitis is often seen in the summer and fall. Treatment is supportative unless herpes virus – acyclovir.

Question 23

A four year old ‘precious child’ of an ‘alternative’ Chelsea mum presents to A+E with a maculopapular rash which began on the face and is not itchy. On examination the child complains of headache and has prominent suboccipital and post auricular lymphadenopathy. Mother is 7 weeks pregnant with her second child. What is the most appropriate management?

A. Advise that the child does not attend nursery for 15 days

B. Check maternal serology

C. Give mother prophylaxis measles immunoglobulin

D. Perform lumbar puncture

E. Prescribe oral penicillin

Answer 23

B. Check maternal serology

The question implies that the child may not have received the MMR vaccine, and therefore the clinical history suggests measles infection. Risk of transmission to mother and foetus is high so mother’s immunity must be checked via maternal serology tests. Rubella infection during pregnancy causes foetal abnormalities such as deafness, cardiac disease, eye problems and mental retardation. The risk is higher in early pregnancy (90% at 9/40) Rubella is a live vaccine so would need to give mother maternal Ig if serology tests show she is not immune. Antibiotics would be of little use in this case as measles is a viral infection.

Question 24

An 8 year old boy presented to the GP with a fever lasting 3 weeks, for which he received no medication. It was associated with a cough, loss of appetite and lesions on his lower limbs that were well defined and tender. What is the most likely cause of these symptoms?

A. Drug Reaction

B. Inflammatory Bowel Disease

C. Mycoplasma pneumonia

D. Streptococcal infection

E. Tuberculosis

Answer 24

E. Tuberculosis

The leg lesions are erythema nodosum which can be associated with all of the above. The other symptoms are classically TB, particularly the anorexia and duration of symptoms. There is no indication the child is on any medication, making a drug reaction unlikely. There is also no history of diarrhoea, which would make the diagnosis of inflammatory bowel disease more likely. Streptococcal infections typically are not associated with a cough.

Question 25

A mother comes into A+E with her one year old baby who has had a 4 day history of fever, irritability and a rash. The mother says that whilst stroking her child, the skin peels off. On examination purulent crusting around the eyes is noted. What is the most likely diagnosis?

A. Kawasaki’s Disease

B. Necrotising Cellulitis

C. Pemphigoid

D. Scalded Skin Syndrome

E. Scarlet Fever

Answer 25

D. Scalded Skin Syndrome

Correct Answer: D: Scalded Skin Syndrome Staphylococcal scalded skin syndrome (SSSS) presents with a red rash followed by diffuse separation of the epidermal skin. It is associated with fever and irritability and purulent, crusting, localised infection around the eyes, nose and mouth. Desquamation of the fingers and toes can be seen in both Kawasaki’s and scarlet fever, but it is not widespread. The key feature of necrotising cellulitis is necrosis which is not seen here. Pemphigoid is characterised by bullae, which although can be a feature of SSSS, are not mentioned in this case.

Question 26

A one year old boy is brought to A+E by his parents with a history of 6 days of high fever. On clinical examination the child is irritable, has cervical lymphadenopathy, red swollen palms, red eyes and a rash. What would be the most appropriate treatment?

A. Ibuprofen

B. IVIG

C. IV penicillin

D. Steroids

E. Supportive Treatment

Answer 26

B. IVIG

This is describing Kawasaki’s disease. The diagnosis is clinical: fever >5 days + 4 other features of:
• conjunctival injection,
• red mucous membranes,
• cervical lymphadenopathy,
• rash,
• red and oedematous palms and soles or peeling of fingers and toes.
Treatment is:
• IVIG (to reduce risk of coronary artery aneurysms)
• Aspirin (to reduce risk of thrombosis, but aspirin is not an option in this question)

Question 27

A 2 year old boy presents to Paediatric Accident and Emergency with a four day history of fever, malaise and lymphadenopathy. He saw his GP two days ago and was prescribed amoxicillin. He has since developed a widespread maculopapular rash covering 70% of his body. What is the most likely pathogen causing this presentation?

A. Cytomegalovirus

B. Epstein-Barr Virus

C. Measles

D. Human Herpes Virus-6

E. Rubella

Answer 27

B. Epstein-Barr Virus

Although all of the above can cause fever, Epstein-Barr Virus is the correct answer. When prescribed amoxicillin or ampicillin, children with EBV infection will sometimes develop a morbilliform rash, not too dissimilar to that seen in measles. The constellation of fever, malaise, lymphadenopathy in the light of this amoxicillin-associated rash should point towards a diagnosis of EBV. Always remember Kawasaki’s Disease should be considered in the differential diagnosis

Question 28

A 4-year-old girl presents to the accident-and-emergency department with a five day history of high fever and a rash. On examination, he is miserable, with a non-purulent conjunctivitis, an erythematous patchy rash and marked cervical lymphadenopathy. What is the most appropriate treatment for this girl’s condition?

A. Intravenous ceftriaxone

B. Intravenous dexamethasone

C. Intravenous diphenhydramine

D. Intravenous flucloxacillin

E. Intravenous immunoglobulin

Answer 28

E. Intravenous immunoglobulin

The answer is E – this child has Kawasaki’s disease.

Question 29

A 10 month old boy presents with a two day history of worsening difficulty in breathing and wheeze. Prior to this he was experiencing coryzal symptoms. His 4 year old sister has recently had an upper respiratory tract infection after attending nursery. On examination there is a respiratory rate of 58, nasal flaring, tracheal tug and subcostal and intercostal recession. There is a widespread polyphonic wheeze on auscultation. Pulse oximetry reveals an oxygen saturation of 91% in room air. What is the most likely diagnosis?

A. Aspiration

B. Bronchiolitis

C. Foreign Body inhalation

D. Pneumonia

E. Pneumothorax

Answer 29

B. Bronchiolitis

Correct Answer: B: Bronchiolitis This is unlikely to be pneumonia as might expect focal signs such as an area of consolidation. A pneumothorax is unlikely as there is no evidence of hyper-resonant percussion notes, decreased breath sounds or asymmetrical chest expansion. With foreign body inhalation, one would expect a more sudden onset of symptoms. There is no history to suggest aspiration as cause of this respiratory distress A widespread polyphonic wheeze and increased work of breathing, with a history of coryzal illness and close contacts with viral URTIs is a typical presentation of acute viral bronchiolitis.

Question 30

A 10 month old boy presents to accident and emergency with a three day history of worsening difficulty in breathing. The boys parents report a fever of 38.5oC measured at home during this time. On examination the child is tachypnoeic and there is slightly reduced chest expansion on the right. On auscultation there is reduced air entry at the right lower zone, and also some crepitations at the right base. You also notice the child is grunting during expiration. Pulse oximetry reveals an oxygen saturation of 91% in room air. What is the most likely diagnosis?

A. Aspiration

B. Bronchiolitis

C. Foreign Body inhalation

D. Pneumonia

E. Pneumothorax

Answer 30

D. Pneumonia

Correct Answer: D: Pneumonia This is most likely to be pneumonia as there are focal signs suggestive of pneumonia. Also end expiratory grunting is often indicative of pneumonia or a lower respiratory tract infection. The grunting is due to glottal closure, which produces a positive end expiratory pressure and helps keep the lower airways patent. Grunting is also seen in infants who are acidotic.

Question 31

The nurses have noted that a 2-day-old neonate is turning blue. He was born at term via C-Section. When you examine the baby, he is pale with grey lips, nasal flaring and intercostal recession. The infant is placed on 100% oxygen, but his saturation remains at 82% after 10 minutes. Of the following treatment options what is the most important next step?

A. IV ceftriaxone

B. IV prostaglandin

C. Nebulised Salbutamol

D. Oral dexamethasone

E. Surfactant therapy

Answer 31

B. IV prostaglandin

IV prostaglandin – failure to improve oxygen saturation in 100% oxygen suggests a cardiac rather than a respiratory problem. The neonate in the vignette most likely has cyanotic congenital heart disease. These infants need immediate treatment with IV prostaglandin to keep the ductus arteriosus patent until definitive treatment can be instituted. Some examples of cyanotic heart disease that present in the neonatal period are: transposition of the great vessels, hypoplastic left heart syndrome and truncus arteriosus. The other treatments are more likely to be useful in treating respiratory disorders (surfactant therapy is specifically useful for hyaline membrane disease).

Question 32

During the first day baby check the SHO notices that the baby looks blue. There is nothing on examination of note. No murmur. ABG reveals PaO2 of 2. ECG is normal. Echo shows abnormal arterial connections. What is the best overall management?

A. Blalock-Taussig Shunt

B. Oxygen and morphine

C. Prostaglandin infusion

D. Prostaglandin infusion and surgical correction

E. Surgery at 6-9 months

Answer 32

D. Prostaglandin infusion and surgical correction

Correct Answer: D: Prostaglandin infusion and surgical correction Cyanotic CHD with abnormal arterial connections is most likely to be transposition of the great arteries. The treatment for this is to improve the mixing of saturated and desaturated blood and to maintain the patency of ductus arteriosus. This is done by giving a Prostaglandin infusion. Surgical arterial switch procedure is then performed in the first few days of life.

Question 33

A 12 hour old 36 week infant, with an uncomplicated pregnancy is on the postnatal ward. It is suddenly noted by the mother that the baby is blue. On examination the infant is centrally cyanosed with a respiratory rate of 70 and marked subcostal and intercostal recession. There is no audible murmur, but a single second heart sound is heard. What is the most likely diagnosis?

A. Meconium Aspiration

B. Respiratory Distress Syndrome

C. Tetralogy of Fallot

D. Transient Tachypnoea of the Newborn

E. Transposition of the Great Arteries

Answer 33

E. Transposition of the Great Arteries

Correct Answer: E: Transposition of the Great Arteries Respiratory distress is seen in neonates less than 34 weeks gestation. Respiratory Distress Syndrome, Transient Tachypnoea of the Newborn and meconium aspiration would most likely present immediately or soon after birth, and not with a sudden onset of cyanosis at 12hrs. Tetralogy of Fallot classically presents with a loud murmur and not cyanosis in early life. Transposition of the Great Arteries has a duct-dependent circulation and usually presents on the 1st/2nd day of life with cyanosis due to ductal closure.

Question 34

A 2 year old Caucasian boy presents with a six month history of poor growth and irritability along with foul-smelling, non-bloody diarrhoea. He has had no recent travel history and sweat test was negative. Select the most appropriate step in management from the following options.

A. Commence antibiotic therapy

B. Commence gluten-free diet

C. Steroid therapy

D. Substitute cow’s milk for soya milk

E. Sulfasalazine

Answer 34

B. Commence gluten-free diet

Correct Answer: B: Commence gluten-free diet Coeliac disease classically presents with poor weight gain in the 1st 2 years of life, foul smelling chronic diarrhoea, anorexia and abdominal distension. It is managed with lifelong gluten-free diet. Nothing in the history indicates either an infective cause/need for antibiotics, or a relationship to milk intake. Sulfasalazine can be used to treat inflammatory bowel disease.

Question 35

A 12 year old girl presents to out-patients with a 6 month history of epigastric pain, 3 inches above the umbilicus, which wakes her up at night. She recently moved to a new secondary school as a result of her parents’ divorce. She has missed 6 weeks of school due to the pain. What is the most appropriate next step in the management of this child?

A. Discharge with prophylactic pizotifen

B. Reassure that the pain is non-organic and discharge

C. Reassure that the pain is non-organic and review with an
attendance chart for school

D. Trial of treatment with Clarithromycin + Metronidazole +
Omeprazole

E. USS Kidneys

Answer 35

D. Trial of treatment with Clarithromycin + Metronidazole + Omeprazole

Correct Answer: D: Trial of treatment with Clarithromycin + Metronidazole + Omeprazole Remember Apley’s criteria: If recurrent abdominal pain is peri-umbilical, lasts no more than a few hours, doesn’t wake the child at night and has not been present for a considerable period of time, no investigation is necessary and a non-organic cause is likely. This child has epigastric pain that wakes her at night pointing to possible peptic ulcer disease; therefore a trial of treatment is the most appropriate plan. Other features in the history that suggest a diagnosis of peptic ulcer disease are the two major stressors: moving school and her parent’s divorce. The pain does not sound renal in origin therefore renal imaging is not indicated, Pizotifen can be used to treat abdominal migraine.

Question 36

A four month old baby girl presents with a 3 day history of vomiting, fever and poor feeding. This is the second such episode in the last month. Examination is unremarkable with no focal signs except prolonged capillary refill time: RR 35; HR 150. What is the most likely diagnosis?

A. Meningitis

B. Otitis media

C. Pneumonia

D. Septicaemia

E. UTI

Answer 36

E. UTI

UTIs are common in female infants, and lead to dehydration, vomiting, fever and poor feeding. The recurrence is also suggestive of a UTI. Other options would have had more clinical signs: Meningitis – photophobia, neck stiffness, maybe a non-blanching rash Pneumonia – RR is very important as part of the assessment and isn’t even mentioned in the question OM – ear symptoms, maybe diarrhoea Septicaemia – systemic rash, more severe shock

Question 37

Which of the following would be diagnostic of a UTI in a 5 year old presenting with fever, rigors and dysuria?

A. Bacterial culture of >105 cfu of E.coli from absorbent
pads in a nappy

B. Bacterial culture of >106 cfu of mixed organisms from a clean catch

C. Bacterial culture of >103 cfu of Pseudomonas from a clean catch

D. Bacterial culture of >104 cfu of Proteus sp from a suprapubic aspirate

E. Proteinuria +++ on urine dipstick from clean catch

Answer 37

D. Bacterial culture of >104 cfu of Proteus sp from a suprapubic aspirate

Answer D is correct as a suprapubic aspirate sample is far less likely to be contaminated than either a clean catch or a sample obtained from an absorbable nappy. Proteinuria is a non-specific sign. Nitrites on urine dipstick would be more indicative of UTI.

Question 38

A five year old boy was admitted to the paediatric ward after presenting to A+E with a two day history of sore knees and a purpuric rash over the buttocks and back of his legs. A full blood count is normal. Of the following options, what is the most appropriate next investigation?

A. Blood clotting studies

B. Blood cultures

C. Joint aspirate of knees

D. Lumbar puncture

E. Urine dipstick

Answer 38

E. Urine dipstick

The most likely diagnosis in this case is Henoch-Schönlein Purpura (HSP). Henoch-Schönlein purpura is an immune-mediated vasculitis. It can include:
48
• Palpable purpura on buttocks & extensor surfaces of limbs
• Arthralgia & periarticular oedema
• Abdominal pain
• Glomerulonephritis  haematuria
>80% of children with HSP have micro- or macroscopic haematuria or mild proteinuria. This is the best next step as it is a simple non-invasive bedside test.

Question 39

You are asked to see 3 year old boy who has bilateral leg, ankle and scrotal oedema. You also notice some facial oedema, which the parents report has subsided slightly since the morning. What is the next investigation you will perform?

A. Anti-streptolysin O Titre

B. Hepatitis B Serology

C. Full Blood Count

D. Urea and Electrolytes

E. Urine Dipstick

Answer 39

E. Urine Dipstick

Urine dipstick is the only test from these options you can perform at the bedside and is therefore an appropriate next step, as it will be of diagnostic benefit in what sounds like the nephrotic syndrome. ASOT would be a useful test as post-streptococcal glomerulonephritis may be a cause of the nephrotic syndrome. This arises as immune-complexes containing streptococcal antigens are deposited in the glomerular basement membrane, resulting in an acute proliferative glomerulonephritis. Test for Hepatitis B antigen and antibodies may be of use as HBV-associated glomerulonephritis can also be a cause of the nephrotic syndrome. This occurs as the result of cryoglobulinaemia sometimes associated with HBV. These cryoglobulins precipitate in the glomerular basement membrane, resulting in a membranous glomerulonephritis.

Question 40

A 7-year-old boy attends the GP with his parents. He has just started a new school and his parents report that he has started wetting the bed. A urine dipstick is negative or nitrites and leukocytes. How should the GP proceed at this point?

A. Prescribe Amitriptyline

B. Prescribe Desmopressin

C. Suggest an enuresis alarm

D. Explore school-related issues

E. Prescribe Fluoxetine

Answer 40

D. Explore school-related issues

The answer is D – this child has secondary enuresis most likely as a result of a school-related problem. The GP needs to delineate exactly what is happening before proceeding to suggest medical and non-medical management

Question 41

A 14-year-old girl presents to the GP with her mother. She gives a five-week-history of recurrent headache associated with nausea, vomiting and abdominal pain. She is on no regular medications. Her mother also had similar episodes at her age. What is the most likely diagnosis?

A. Benign Intracranial Hypertension

B. Migraine

C. Cluster headache

D. Posterior Fossa Tumor

E. Tension Headache

Answer 41

B. Migraine

Migraine – is typically associated with nausea, vomiting, and abdominal pain. There is often a positive family history in migraine.

Question 42

A worried mother brings her 9-year-old son to the GP. He suffered from a discrete episode of visual changes, staggering and falling yesterday. He subsequently developed a headache. This is the third time it has happened in three months. He is afebrile and cranial nerve examination is normal at the GP. What is the most likely diagnosis?

A. Atonic epileptic seizure

B. Benign paroxysmal vertigo

C. Migraine

D. Reflex anoxic seizures

E. Syncope

Answer 42

C. Migraine

Child is too old for R.A.S – this is usually in infants or toddlers and follows a trigger such as cold food, head trauma, a sudden fright or a fever. BPV is associated with nystagmus and viral labyrinthitis, neither of which are mentioned. Epileptic seizure would have more details of post-ictal state and temperature would be higher. There is no mentioned trigger for syncope Best option is migraine for which this child is in the typical age range, there are also visual and abdominal symptoms and recurrence – characteristic of a migraine.

Question 43

A 15 year old girl with a BMI of 29 presents with a one month history of frontal headache which is unresponsive to analgesia. The pain worsens on coughing and sneezing and is associated with nausea. A thorough history reveals she is struggling at school and has a family history of glaucoma. The most likely diagnosis is?

A. Benign intracranial hypertension

B. Migraine without aura

C. Refractive error

D. Sinusitis

E. Space-occupying lesion

Answer 43

A. Benign intracranial hypertension

BIH shows the signs of an ICP but is ‘benign’ in that there is no space-occupying lesion; it is a diagnosis of exclusion and is more common in over-weight females.

Question 44

Sophie, a 6 year old known epileptic, comes to A+E having been seizing for the last 35 minutes. The on-call registrar has administered one dose of rectal diazepam. However, Sophie is still seizing. IV access has been gained. Select the next most appropriate treatment.

A. Lorazepam (iv)

B. Midazolam (oral)

C. Paraldehyde (pr)

D. Phenobarbital (infusion)

E. Phenytoin (iv)

Answer 44

A. Lorazepam (iv)

Once intravenous access has been gained, Lorazepam is preferential to rectal diazepam or buccal midazolam. Paraldehyde, phenytoin and phenobarbital are considered next if the child is not responding to benzodiazepines.

Question 45

You are the on-call pediatric registrar in the accident-and-emergency department. A mother brings her 6-year-old son in with severe shortness-of-breath. There is some improvement in his status following administration of nebulized salbutamol and oxygen. However, the child is a known asthmatic and you feel he requires admission. The mother doesn’t wish to stay in hospital and leaves the department with the child. What is the appropriate next step?

A. Contact the consultant on-call

B. Call hospital security

C. Call the police

D. Call social services

E. Respect the mother’s decision and document this in the notes

Answer 45

C. Call the police

Except for choice E (respect the mother’s decision and document this in the notes) all of the above choices should be instituted. However, as the most appropriate next step is C – call the police. This is due to the fact that the mother has left the premises and the child is still at significant risk of harm. If the mother were threatening to leave the hospital, it would be appropriate to call hospital security.

Question 46

A mother brings her 5-month-old infant into the accident-and-emergency department with coryzal symptoms. His weight and length are less than the fifth centile. His birth weight was 4.1kg and he is 3.6kg when the nurses weight him today. He takes an unknown amount of cows-milk-based formula per day and porridge. What is the most likely cause of his weight loss?

A. Cows-milk-protein allergy

B. Non-organic failure to thrive

C. Celiac disease

D. Inflammatory bowel disease

E. Weight loss secondary to reflux

Answer 46

B. Non-organic failure to thrive

Non-organic failure to thrive – this is often seen when a child isn’t fed a sufficient amount of calories to sustain growth and development. This may occur when there is insufficient parental knowledge about feeding, substance abuse, poverty or underlying social and emotional disturbance. Presentation is variable – the child is often thin, with prominence of the bones, wasting of the buttocks (much like celiac disease) and is often developmentally delayed. There may also be evidence of physical abuse, such as a torn frenulum, burns or unusual bruises. Social services should be informed to assess the home situation and it is often necessary to hospitalize the child for nutritional assessment and unlimited feedings.