MISCELLANEOUS FACTS FROM PASSMED

Question 1

Which one of the following is least likely to cause snoring in children?

Hypertrophic nasal turbinates

Tonsillitis

Obesity

Kallman’s syndrome

Down’s syndrome

Answer 1

Kallman’s syndrome - a cause of delayed puberty secondary to hypogonadotrophic hypogonadism. It is not associated with snoring

Question 2

What are some of the causes of snoring in children?

Answer 2

Obesity

Nasal problems: polyps, deviated septum, hypertrophic

Nasal turbinates

Recurrent tonsillitis

Down’s syndrome

Hypothyroidism

Question 3

What is the first sign of puberty in girls?

Development of pubic hair

Menstrual bleeding

Development of axillary hair

Breast development

Height spurt

Answer 3

Breast development

Question 4

Which one of the following statements regarding the MMR vaccine is incorrect?

Malaise, fever and rash may occur after around one week

Allergy to neomycin is a contraindication

The second dose is given at 3-4 years

MMR is a live attenuated vaccine

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

Answer 4

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

Must leave a gap of more than 4 weeks

Question 5

Which one of the following statements regarding retinoblastoma is true?

The most common presenting symptom is strabismus

70% of cases are hereditary

All cases require enucleation

The average age at diagnosis is 3 months

More than 90% of children survive to adulthood

Answer 5

More than 90% of children survive to adulthood

Most common diagnosis is through loss of red reflex

10% are hereditary

Alternatives to enucleation include external beam radiation therapy, chemotherapy and photocoagulation.

The average age of diagnosis is 18 months.

Question 6

A 2-year-old child with a history of atopic eczema is brought to the local GP surgery. Her eczema is usually well controlled with emollients but her parents are concerned as the facial eczema has got significantly worse overnight. She now has painful clustered blisters on both cheeks, around her mouth on her neck. Her temperature is 37.9ºC. What is the most appropriate management?

Advise paracetamol + emollients and reassure

Admit to hospital

Add hydrocortisone 1%

Oral flucloxacillin

Topical fusidic acid

Answer 6

Admit to hospital - Eczema herpeticum is a serious condition that requires IV antivirals

Question 7

Which one of the following examination findings is abnormal?

Respiratory rate of 40 / min in a 2-year-old

Heart rate of 140 bpm in a 6-month-old

Respiratory rate of 24 / min in a 10-year-old

Heart rate of 120 bpm in a 18-month-old

Heart rate of 110 bpm in a 7-year-old

Answer 7

Respiratory rate of 40 / min in a 2-year-old

Question 8

What are the normal ranges for heart rate and resp rate in an infant (under 1 year old)?

Answer 8

HR – 110-160

RR – 30-40

Question 9

What are the normal ranges for heart rate and resp rate in a child aged 1-2 years old?

Answer 9

HR – 100-150

RR – 25-35

Question 10

What are the normal ranges for heart rate and resp rate in a child aged 2-5 years old?

Answer 10

HR – 90-140

RR – 25-30

Question 11

What are the normal ranges for heart rate and resp rate in a child aged 5-12 years old?

Answer 11

HR – 80-120

RR – 20-25

Question 12

What are the normal ranges for heart rate and resp rate in a child who is older than 12 years old?

Answer 12

HR – 60-100

RR – 15-20

Question 13

What is the most common presenting feature of Wilms tumour?

Recurrent urinary tract infections

Abdominal mass

Fever

Loin pain

Haematuria

Answer 13

Abdominal mass

Question 14

Which one of the following is least recognised as a side-effect of carbamazepine?

Headache

Hirsutism

Diplopia

Ataxia

Transient erythematous rash

Answer 14

Hirsutism is associated with phenytoin

Side effects of carbamazepine:

• P450 enzyme inducer
• dizziness and ataxia
• drowsiness
• headache
• visual disturbances (especially diplopia)
• Steven-Johnson syndrome
• leucopenia and agranulocytosis
• syndrome of inappropriate ADH secretion

Question 15

You are in a genetics clinic and explaining to a mother and father the reasoning why their son has Prader-Willi syndrome. What is the term we use to describe the mode of inheritance for Prader-Willi syndrome?

Autosomal recessive

Autosomal dominant

Imprinting

Pleiotropy

Variable expressivity

Answer 15

Imprinting - Prader-Willi is an example of imprinting. For this disease to occur, the patient does not receive the gene from their father. The mother’s gene may be normal, but that does not prevent the phenotype occurring. The phenotype consists of learning difficulties, hypotonia, obesity and the urge to eat.

• Prader-Willi syndrome if gene deleted from father
• Angelman syndrome if gene deleted from mother

Question 16

You see a 6 week-old baby boy for his routine baby check and note a small, soft, umbilical hernia on examination. What should you do?

Advise parents to tape a coin over the area

Refer for surgery

Refer for ultrasound

Watch and wait

Arrange emergency admission

Answer 16

Watch and wait

Small umbilical hernias are common in babies and tend to resolve by 12 months of age. Parents should be reassured no treatment is usually required but to be aware of the signs of obstruction or strangulation such as vomiting, pain and being unable to push the hernia in - this is rare in infants. Advise the parents to present the child at around 2 years of age if the hernia is still present to arrange referral to a surgeon. Attempts to treat the hernia by strapping or taping things over the area are not helpful and can irritate the skin.

Question 17

An 8-year-old child is brought into the emergency department after have 5 episodes of bloody diarrhoea. Her parents say that the diarrhoea begun 3 days ago after a barbecue at a friends house but did not turn bloody till today. On examination the child is pyrexial at 38 degrees with diffuse abdominal pain. Blood test are taken which show a thrombocytopenia, raised urea, creatinine and lactate dehydrogenase.

Which of the following organisms has most likely caused this infection?

Escherichia coli

Campylobacter jejuni

Listeria monocytogenes

Norovirus

Giardia lamblia

Answer 17

Escherichia coli

The child is not just showing signs of food poisoning but also early signs of haemolytic uraemic syndrome.

Question 18

You deliver a baby on the maternity ward. At 2 minutes, the baby’s heart rate is 110bpm, the baby is crying loudly with stimulation and moving all four limbs. The baby is pink but hands and feet are slightly blue and feel cold to the touch. What is the APGAR score?

5

7

8

9

10

Answer 18

In this case, the baby scores a 9 as the only point he/she misses is the fact his extremities are blue and cold to the touch. This is not unusual in babies

Question 19

A 5-year-old girl is brought in to see her GP by her mother complaining of increased frequency of passing urine and dysuria. This has never happened before and she is otherwise well. The GP asks for a urine sample to be given before starting antibiotics. Pending culture results, he decides to prescribe a 3-day course of antibiotics. Which antibiotic would be most appropriate in this case?

Trimethoprim

Amoxicillin

Cefalexin

Nitrofurantoin

Clarithromycin

Answer 19

Trimethoprim

Nitrofurantoin is not licensed for a 3-day course. Amoxicillin resistance is common so it should ideally only be used if the culture and sensitivities show that the organism is sensitive. Cephalosporins should be avoided if more narrow-spectrum antibiotics would work due to the increased risk of MRSA, Clostridium difficile and resistant UTIs.

Question 20

Which one of the following statements regarding childhood squints is correct?

Amblyopia is a sign of a paralytic squint

Divergent squints are more common than convergent squints

The corneal light reflection test is a suitable screening test

Management of the majority of childhood squints should be done in primary care

A child with a non-paralytic squint would have a degree of double vision

Answer 20

The corneal light reflection test is a suitable screening test

Question 21

A 7-year-old boy is diagnosed with Attention Deficit Hyperactivity Disorder. What is the most appropriate dietary advice to give to his parents?

Eat a normal balanced diet + avoid artificial colourings

Eat a normal balanced diet + avoid all sugar containing products

Eat a normal balanced diet

Eat a normal balanced diet + take a fatty acid supplement unless having three portion of oily fish per week

Eat a normal balanced diet + take a multivitamin tablet

Answer 21

Eat a normal balanced diet

Unless a food diary has shown a link between diet and behaviour there is no basis for recommending the avoidance of artificial colourings or the use of fatty acid supplements

Question 22

A 4-year-old boy is brought to the GP by his mother who states that she has noted a ‘barking’ cough a few times every day for the last two days. There has been no change to his appetite and his behaviour has not changed. The GP does not find any abnormalities on examination. Given the likely diagnosis of mild croup, what would be the first-line treatment?

Nebulised adrenaline

Oral benzylpenicillin

Oral dexamethasone

Oral prednisolone

Oral ibuprofen

Answer 22

Oral dexamethasone

CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity

Question 23

A 10-month-old boy is brought to surgery. Around 4 days ago he developed a fever after being irritable the previous day. The fever settled after around 3 days but following this he developed a rash, which prompted his mother to bring him to surgery. He is taking around 75% of his normal feeds, is producing wet nappies and has had two episodes of loose stools. On examination he is alert, temperature is 37.0ºC, chest is clear, ears/throat unremarkable. There are a number of blanching, rose pink macules present on his trunk. What is the most likely diagnosis?

Rubella

Chickenpox

Roseola infantum

Pityriasis rosea

Measles

Answer 23

Roseola infantum

Fever followed later by rash

Question 24

A 3-year-old child is brought to surgery as her mother has noticed that she is ‘cross-eyed’. The corneal light reflection test confirms this. What is the most appropriate management?

Advise that referral to secondary care should be delayed until 5 years of age, when surgery may be contemplated

Refer to ophthalmology

Refer to paediatric physiotherapy for eye movement exercises

Reassure mother that the majority of squints improve with age

Advise the mother to restrict the amount of television she watches

Answer 24

Refer children with a squint immediately to ophthalmology

Question 25

You see a worried mum with her 6 month old baby boy. She is concerned that his skull shape is not normal. His development and birth have been normal and there are no conditions in the family. On examination his head circumference is at the 40th centile with his height and weight at the 30th centile. His occiput is flattened on the left, his left ear mildly protruding forward and his left forehead more prominent than the right. No other abnormality is detected. What is the most appropriate management?

Urgent referral to neurosurgery

Suggest buying an infant helmet

Arrange an MRI scan

Routine referral to community child health clinic

Reassurance

Answer 25

Reassurance

Plagiocephaly is more common since there have been campaigns to encourage babies to sleep on their back to reduce the risk of sudden infant death syndrome (SIDS). Plagiocephaly is a skull deformity producing unilateral occipital flattening, which pushes the ipsilateral forehead ear forwards producing a ‘parrallelogram’ appearance. The vast majority improve by age 3-5 due to the adoption of a more upright posture. Turning the cot around may help the child look the other way and take the pressure off the one side. Other simple methods include giving the baby time on their tummy during the day, supervised supported sitting during the day, and moving toys/ mobiles around in the cot to change the focus of attention. Ensure all advice is in line with prevention of SIDS.

Question 26

A 4-year-old boy was discharged from the hospital six weeks ago after an episode of viral gastroenteritis. He now has 4-5 loose stools each day which has been present for the past four weeks.

What is the most likely diagnosis?

Coeliac disease

Inflammatory bowel disease

Secondary bacterial infection

Lactose intolerance

Clostridium difficile infection

Answer 26

Lactose intolerance

Transient lactose intolerance is a common complication of viral gastroenteritis. Removal of lactose from the diet for a few months followed by a gradual reintroduction usually resolves the problem.

Question 27

You are reviewing a 6-month-old child with suspected bronchiolitis. Which one of the following should prompt a referral to hospital?

Oxygen saturations of 96%

Lethargy

Feeding two-thirds of normal amount

Respiratory rate 54 / min

Crackles on auscultation

Answer 27

Lethargy

SIGN suggested the following criteria for referral to hospital:

• Poor feeding ( 70/min
• Nasal flaring or grunting
• Severe chest wall recession
• Cyanosis
• Oxygen saturation

Question 28

A 2-year-old boy with meningococcal septicaemia arrests on the ward. You are the first person to attend. After confirming cardiac arrest and following paediatric BLS protocol, what is the rate you should perform chest compressions at?

140-160 compressions per minute

160-180 compressions per minute

120-140 compressions per minute

100-120 compressions per minute

80-100 compressions per minute

Answer 28

100-120 compressions per minute

The UK Resuscitation Council’s Paediatric Basic Life Support guideline states that chest compressions for children of all ages must be performed at a rate of 100-120 per minute. Compressions should depress the sternum by at least a third of the depth of the chest.

Question 29

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

At birth

On first day of life

On fourth day of life

Between fifth and ninth day of life

Any time in first month of life

Answer 29

Between fifth and ninth day of life

Question 30

At what age do the majority of children achieve day and night time urinary continence?

2-3 years old

3-4 years old

4-5 years old

5-6 years old

6-7 years old

Answer 30

3-4 years old

Question 31

A 12-year-old girl presents with a two-day history of an itchy rash over her whole body associated with a low-grade pyrexia and is diagnosed with chickenpox. Which one of the following complications is least likely to occur?

Disseminated haemorrhagic chickenpox

Secondary bacterial infection

Encephalitis

Dilated cardiomyopathy

Pneumonia

Answer 31

Dilated cardiomyopathy is not an established complication of chickenpox, unlike the other four options.

Question 32

A 2-month-old baby presents with gradually worsening noisy breathing which is especially noticeable when she eats. She is on a lower centile for weight gain and has poor food intake. What is the most likely diagnosis?

Congenital subglottic stenosis

Laryngomalacia

Congenital vocal cord paralysis

Croup

Adenotonsillar hypertrophy

Answer 32

Laryngomalacia

Laryngomalacia is the most common cause of stridor in infants. It occurs due to a floppy epiglottis which folds into the airway on inspiration. This is normally a self-limiting condition, but if the stridor becomes severe with signs of respiratory distress, or if there is failure to thrive (due to poor feeding), then surgery is recommended to improve the airway.

Question 33

A 8-year-old girl presents to the GP with her mother. She has been experiencing nausea for the last few days with dysuria and increased frequency. Her mother is concerned she may have a urinary tract infection. On examination the girl appears well and observations are stable. Abdominal examination is unremarkable. A clean catch sample is obtained and is positive for leucocytes and nitrites. What is the next step in management?

5 day course antibiotics as per local policy

10 day course co-amoxiclav

3 day course antibiotics as per local policy

7 day course antibiotics as per local policy

Reassure illness should resolve within 72 hours

Answer 33

3 day course antibiotics as per local policy

Question 34

A 9-day-old pre-term neonate stops tolerating his cow’s milk feeds given by the nurses in the special care baby unit. He vomited after the most recent feed and the nurse noticed bile in the vomit. Stools are normal consistency but the last stool contained fresh red blood. On examination he is well hydrated but his abdomen is grossly distended and an urgent abdominal x-ray is requested. X-ray shows distended loops of bowel with thickening of the bowel wall. What is the next best step in management?

Continue oral feeds, switching to breast milk

Commence broad spectrum antibiotics

Commence IV fluids

Commence IV hydrocortisone

Commence erythromycin

Answer 34

Commence broad spectrum antibiotics

This scenario describes a case of necrotising enterocolitis. Given the history and examination along with the age and prematurity of the infant, bacterial necrotising enterocolitis is the most likely diagnosis. Due to the seriousness of this, broad spectrum antibiotics must be commenced immediately.

Although necrotising enterocolitis is seen more often in bottle fed infants, changing feeds at this stage is futile.

Question 35

A 9-year-old boy presents to the GP with his father. He has had diarrhoea for the past 3 days with no signs of improvement. He describes the stools as watery but there is no blood or mucus present. The boy also states he has been passing stools around 6 times a day since it began. Other than the diarrhoea, the boy has been clinically well. He is still eating and drinking normally and does not appear dehydrated. His bowel pattern has been regular up until this began. His father mentions a few children in the boy’s class have been off with a stomach bug in the last week and wonders if this might be the cause. What is the next step in management in this case?

Reassure this should settle within 1-2 weeks and advise to maintain normal oral intake

Prescribe loperamide

Obtain stool for culture

Reassure this should settle within 24 hours and advise to maintain a normal oral intake

Prescribe oral broad spectrum antibiotics

Answer 35

Reassure this should settle within 1-2 weeks and advise to maintain normal oral intake

Viral gastroenteritis is usually self limiting and should settle within 1-2 weeks. It is also crucial to encourage normal oral intake.

Question 36

A 4-year-old girl presents to the emergency department at 2pm with her pre-school teacher. While having lunch at 12pm, she began to develop urticaria on her arms and neck and has some facial swelling. Her teacher is concerned because the child beside her was eating a peanut butter sandwich. On examination, the child appears well. She has some swelling below her eyes but the airway is patent. Breathing is normal and there is no audible wheeze. Urticaria is present on the right side of the neck and on the forearms. You decide the most likely explanation is a peanut allergy. What is the next best step in management?

IM chlorphenamine

IM adrenaline 1:1000

IM adrenaline 1:10,000

Oral chlorphenamine

IM hydrocortisone

Answer 36

Oral chlorphenamine

The child in this scenario is most likely experiencing an allergic reaction to peanuts. She has urticaria and some facial swelling but is otherwise stable with a patent airway. Given her stability and the length of time she has been experiencing this reaction, it is an allergic reaction rather than anaphylaxis.

Question 37

Meera brings her 5 year old daughter Reena to the surgery who is being treated for acute lymphoblastic leukaemia (ALL) for review as Reena’s classmate has been sent home from school with chickenpox. Reena is asymptomatic currently. Meera is unclear if Reena has suffered with chicken pox previously. What would be the correct management?

Admit urgently

Send home and come back if symptomatic

Prescribe aciclovir

Prescribe varicella zoster immunoglobulin

Urgent bloods for varicella zoster antibodies

Answer 37

Urgent bloods for varicella zoster antibodies

‘People who have had a significant exposure to chickenpox and who are immunocompromised should be tested for varicella-zoster antibody, regardless of their history of chickenpox. Test for varicella-zoster immunoglobulin G (IgG) antibodies in primary care if test results can be available within 2 working days of first exposure. If this is not possible, urgently seek specialist advice because testing in secondary care and/or varicella-zoster immunoglobulin prophylaxis may be needed.’

Question 38

Which one of the following conditions is not associated with obesity in children?

Down’s syndrome

Hypothyroidism

Cushing’s syndrome

Prader-Willi syndrome

Growth hormone excess

Answer 38

Growth hormone excess

Cause of obesity in children:

• Growth hormone deficiency
• Hypothyroidism
• Down’s syndrome
• Cushing’s syndrome
• Prader-Willi syndrome

Question 39

You are asked to see a baby on the post-natal ward 10 hours post vaginal delivery. The midwife informs you that the mother was positive for group B streptococcus. On examination you note a yellow discolouration to the skin. What is the next most appropriate action to take?

Measure serum bilirubin within 2 hours

Measure serum bilirubin within 6 hours

Measure bilirubin via transcutaneous bilirubinometer

Start empirical phototherapy

Reassess after 24 hours of age

Answer 39

Measure serum bilirubin within 2 hours

Question 40

Which one of the following statements regarding infantile spasms is incorrect?

EEG shows hypsarrhythmia in the majority of children

Carries a good prognosis

More common in male children

Typically presents in the first 4 to 8 months

Causes characteristic ‘salaam’ attacks

Answer 40

Carries a good prognosis