Miscellaneous Questions Flashcards
A 4 year old presents with 2 week history of increasing oedema with scrotal swelling and now periorbital swelling. He has proteinuria 4+, his BP and renal function are normal. The most likely diagnosis is:
- Henoch-Schonlein Purpura
- SLE
- Angioneurotic-oedema
- Glomerulonephritis resulting in nephrotic syndrome
- Post streptococcal glomerulonephritis
Answer: 4. Glomerulonephritis resulting in nephrotic syndrome.
The presentation is of nephrosis, which has many causes so the generic answer is 4. (It could be caused by 1, 2 or 5 but there is not enough info in the question to say this).
This 2 year old has a 6 day history of a fever; very irritable, no cough or runny nose; there are >1cm cervical lymph nodes and non-purulent conjunctivitis. No improvement with broad spectrum antibiotics. Platelets are 1,150,000 and ESR 120. What is the most likely diagnosis?
- Measles
- Rheumatic fever
- Scarlet fever
- Kawasaki’s disease
- Staphyloccocal toxic shock syndrome (TSS)
Answer: 4. Kawasaki’s disease
The features alongside a very high platelet count makes Kawasaki’s most likely.
Scarlet fever usually responds to antibiotics, measles presents with a cough/ URTI.
A 5 year old, just emigrated from Australia 10 days ago has a 1 week history of high grade fevers and a cough, with no response to iv cefuroxime. The most likely organism is?
- Haemophilus
- Strep pneumoniae
- Moxarella
- Staph. aureus
- Mycobacterium TB
Answer: Staph. aureus
Australia has one of the lowest incidences int he world for TB- so very unlikely to be TB.
Which is the most appropriate treatment for an acutely wheezy, alert 18 month old in A&E: RR 40/min, HR 120/min, Sats 90% on 100% oxygen?
- 6 puffs of salbutamol via a turbohaler
- 10 puffs of salbutamol via an MDI + aerochamber
- 6 puffs of salbutamol via an MDI
- 5mg of salbutamol via nebuliser
- 2.5mg of salbutamol via nebuliser
Answer: 2
10 puffs of salbutamol via an MDI and spacer
A nebuliser is reserved for life threatening wheeze or failure to tolerate spacer; even if the child requires oxygen (in non life threatening wheeze), remove the nebuliser temporarily to give salbutamol via spacer.
2 year old child had his first febrile convulsion, which was a very prolonged one resulting in intubation. For the next febrile illness, the parents are best advised to:
- Give prophylactic neurofen and paracetamol to reduce risk of a convulsion
- Tepid sponge and place in a warm (not cold) bath
- Apply a cool fan to the child
- Give rectal diazepam if he starts fitting and call 999
- Always seek medical attention to have the child examined
Answer: 4
Give rectal diazepam and call 999 if he starts fitting
There is no evidence that prophylactic neurofen and paracetamol will work to prevent febrile convulsions (Option 1). Options 2 and 3 are not advisable and there is no need to always have the child examined for a fever alone.
A 5 year old has a sudden onset painful left testes for the past 3 hours. No reported trauma. On examination the testis is swollen and tender. What should the first line management be?
- Ultrasound of the scrotum
- Admission for further assessment
- IV antibiotics
- Discharge with NSAIDs and review in 24 hours
- Arrange for an immediate exploration in theatre
Answer: 5
Arrange for immediate exploration in theatre.
Time is paramount if this is testicular torsion - do not waste time by doing other investigations.
An 8 month old with a mild infantile eczema has a 24 hour history of red, vesicular rash with crusting and exudates. Which treatment option is the most appropriate?
- IV aciclovir
- IV aciclovir and IV flucloxacillin
- IV benzyl penicillin and flucloxacillin
- Oral acyclovir, penicillin V and flucloxacillin
- Topical fucidin, antiseptic baths and emollients
Answer: 2
IV acyclovir and IV flucloxacillin
With this vesicular rash with crusting and exudates, one has to consider both Staph aureus and Herpes simplex. Flucloxacillin covers Staph aureus and Aciclovir covers Herpes simplex.
The rash is actually eczema herpeticum with secondary staph infection. Do not use topical antibiotics for infected eczema.
NB: There is a widespread myth that using penicillin to treat Strep, plus flucloxacillin to treat Staph is good practice. In fact, flucloxacillin is a semi-synthetic penicilin and when given in appropriate doses iv is just as effective at treating Strep as penicillin. It is unnecessary to duplicate the cover, and simply costs more in terms of nursing time, and may reduce the half life of peripheral cannulae by doubling the number of drug doses given intravenously.
A 10 month old baby had a mild allergic reaction to egg and developed a rash subsequently. What should happen with his MMR vaccination?
- Admit for MMR under hospital observation
- Do not give him the MMR vaccine
- Single jabs in community setting
- Single jabs under hospital observation
- MMR in community setting
Answer: 5
MMR in community setting
The MMR vaccine is cultured in fibroblasts derived from chick embryos and not on egg, therefore the amount of egg protein is negligible. Studies on large number of egg-allergic children show there is no increased risk of severe allergic reaction to the MMR vaccine. The Immunisation Against Infectious Diseases (Green book) advises that all children with egg allergy should receive the MMR vaccine as a routine procedure in primary and there is no need to admit for hospital admission.
You never ever give single MMR jabs!!
What is the most appropriate management strategy for an alert, well oxygenated 3 year old with a 24 hour history of barking cough, increasing (moderate) stridor and fever >40 degrees and riggers. No drooling. She is being given oxygen.
- Adrenaline nebuliser stat and call ENT and anaesthetic teams
- Oral dexamethasone and lateral neck X-ray
- IV cefuoxime and flucloxacillin after blood cultures
- Budesonide nebuliser
- Oral dexamethasone, IV cefuroxime and flucloxacillin after blood cultures and review.
Answer: 3
IV cefuroxime and flucloxacillin (after taking blood cultures)
Whilst the history suggests viral croup, the high grade fever with riggers also suggest the possibility of bacterial tracheitis, for which antibiotics are required.
In this case, adrenaline is not yet needed unless she deteriorates, at which you would need to call ENT and anaesthetists.
Never perform a lateral neck X-ray.
Oral dexamethasone is first line for viral croup, although you can give budesonide nebuliser instead.
A 14 month old child presents with a 2 weeks history of increased bruising and a few nose bleeds; no recent history except MMR 2 weeks ago. No family history, examination was normal (no lymph nodes, no enlargement of the liver or spleen), lots of bruises over contact points.
FBC shows Hb 11.9, WCC 7.8 with normal differentials, Plts 8,000 and blood film normal. What is the most likely diagnosis?
- Acute lymphoblastic leukaemia
- Idiopathic thrombocytopenia purport
- Henoch Schonlein Purpura
- MMR associated thrombocytopenia
- Aplastic anaemia
Answer: 4
MMR associated thrombocytopenia
This child most likely has an immune thrombocytopenia so 2 or 4 is correct, but given the MMR history, 4 is the best answer.
A bright 9 year old presents with primary nocturnal enuresis. Parents tried pad and alarm, which have failed. They have also tried lots of self-help remedies to no avail. Which is the most useful first line approach?
- Start DDAVP tablets for 3 months and review
- Give imipramine for 3 months as a trial
- Encourage lifting at midnight and reduction in oral fluids at night
- Commence behavioural approach
- Do nothing, just reassure
Answer: 4
Commence behavioural approach
Medications have a very limited role (short term use of DDAVP occasionally use to support behavioural approach or for sleepovers); Imipramine is almost never used nowadays. Lifting at night will delay continence; doing nothing is not an option at this age!
An 8 year old with asthma has persistent cough and wheeze at night and on exertion. She is requiring regular salbutamol. What is the next step to optimise her asthma management?
- Montelukast 5mg orally once daily
- Low dose inhaled steroids via turbohaler
- Lowe dose inhaled steroids via MDI
- Salmeterol and low dose steroid combination via MDI and spacer
- Low dose inhaled steroids via MDI and aerochamber
Answer: 5
Low dose inhaled corticosteroid via MDI and spacer
A trial of Montelukast is indicated if child is <5 years.
Inhaled corticosteroid via MDI must be used with a spacer!!
What would be the most appropriate immediate response in a situation where a child with severe acute asthma is being removed from the ED by their carers prior to treatment?
- Accept parental wishes
- Prevent child from leaving, by force if necessary
- Ask security to intercept and rescue the child
- Call social services and ask them to of to court for an emergency protection order
- Call the police
Answer: 5
Call the police
The only correct immediate option is 5, so that you can get the child back to start immediate treatment. This can be done without parental consent in the best interests of the child. Meanwhile you will then pursue 4 (calling social services).
Security cannot use force as this would be assault.
A 15 year old takes an overdose of tricyclic antidepressants and is comatose, GCS 6. The most appropriate first line management is?
- Ipecac forced emesis
- Activated charcoal via an NG tube
- Gastric washout, then activated charcoal via an NG tube
- Oxygen, suction and intubation
- Contact psychiatrist
Answer: 4
The only safe option is 4 as she has an unsafe airway, then you would consider 3 followed by 5.
There is no role for forced emesis!
Which of the following statements about the Swine influenza A/H1N1, 2009 is correct?
- This novel virus was the result of a genetic shift, combining pig, avian and human viral characteristics
- The first wave was associated with higher paediatric mortality than normal seasonal influenza
- There was good evidence from RCTs that oseltamivir (Tamiflu) reduced mortality and morbidity in children
- RSV was not a co-factor in more severe illness phenotype
- Schools were not advised to close during a school outbreak, during the initial national containment phase.
Answer: 1
This novel virus was the result of a genetic shift, combining pig, avian and human viral characteristics.
The first wave had very low mortality rates compared to seasonal flu.
There are no RCTS on tamiflu (oseltamivir); RSV can certainly worsen the clinical picture.
The containment phase was the phase when all attempts to stop spread of disease occurred including shutting schools during outbreaks. This all stopped in July 09 once disease was widespread and the containment phase ended.
A healthy 18 month old, has a 3 month history of writhing movements of her thighs whilst strapped in the high chair or car seat. She is always alert and happy throughout these, and the episodes can be stopped by parents. Normal development milestones. Normal neuro examination. Video confirms the above history. What would you do?
- Arrange baseline EEG and MRI
- Refer to the paediatric neurologist
- Arrange an ECG, ECHO and 24 hr holter tape
- Admit for observation
- Reassure this is likely to be normal toddler masturbation
Answer: 5
All the clues point to 5; it is normal and there is nothing to worry about.
In a 6 month old with a 2 week history of persisting diarrhoea (watery, no blood, 6-8 times a day) after an initial bout of vomiting and fever; with no travel or drug history, the most appropriate management would be:
- 24 hours of diarolyte instead of all other fluids
- Perform a coeliac screen, stool cultures and refer to a paediatric gastroenterologist
- Send stool cultures and start ciprofloxacin
- Stop all dairy products and substitute with a hydrolysed formula; also send stool cultures
- Send stool cultures and start metronidazole
Answer: 4
Please see “Diarrhoea and vomiting in under 5’s”, (nice.org.uk); Approach is 4.
If giardia was found, Rx with metronidazole can be considered but there are very few other indications to use antibiotics in children with infective gastroenteritis (other than with possible sepsis)
A 6 wk old breast fed infant with a 2 week history of worsening vomiting after feeds, with poor weight gain and constipation. The chloride is 90 mmol/L.
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
Answer: A. pyloric stenosis
Poor weight gain as the infant is vomiting all the feed. Low chloride due to vomiting up gastric acid (HCl)
A 1 week old with vomiting, lethargy, increasing jaundice and on exam a 3 cm liver is felt and cataracts are noted.
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
Answer: E - Galactosaemia
3 yr old with acute onset abdominal pain for 4 hrs (3 similar episodes in the past, all self resolved), but this time with bile stained vomiting
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
Answer: J. Malrotation
6 month old breast fed infant, vomiting since early on, not resolved with anti-reflux medication; also has eczema hard to control and constipation
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
Answer: K
Cow’s milk protein intolerance
NB: CMP intolerance can occur in breast fed infants as small amounts of CMP fragments may be found in the breast milk of mothers who have not excluded milk from their own diet.
2 week old boy with frequent vomiting, lethargy, no fevers. The abdomen is soft and non tender. U&E’s show Na 122, K+ 6.4
A. Pyloric Stenosis B. GORD C. UTI D. Meningitis E. Galactosaemia F. Encephalitis G. Congenital adrenal hyperplasia H. Lactose intolerance I. Malrotation J. Cow’s milk protein intolerance
Answer: G
Congenital adrenal hyperplasia
A 5 yr old with 1 week of severe left sided headaches, analgesic unresponsive. Having high fevers, vomiting, and earache, on oral amoxicillin for otitis media. Aside from a red left TM, nothing to find on examination.
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
Answer: C Intracranial abscess
Acute onset severe right sided headaches in 7 yr old, with left sided weakness lasting an hour then full recovery. Several similar episodes in the past but getting worse; weakness is taking longer to resolve each time and more severe.
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
Answer: I. Arterio-venous malformation
3 yr old with 2 week history of waking with headaches and vomiting; becoming unsteady on feet and presents with a sudden squint of left eye, with diplopia on looking to the left.
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
Answer: B. Posterior fossa tumour
9 yr old with 6-12 months of continuous daily frontal and vertex headaches; unresponsive to analgesia; does not wake from sleep; no interruption with ADL’s. No other symptoms. Examination was normal, including normal BP and fundi.
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
Answer: A. Tension type headaches
14 yr old girl, 6 weeks worsening headaches, early morning with vomiting; grossly blurred fundi, CT scan normal
A. Tension type headaches B. Posterior fossa tumour C. Intracranial abscess D. Migraine E. Idiopathic intracranial hypertension F. Hypertension G. Mastoiditis H. Chronic sinusitis I. Arterio-venous malformation J. Right hemispheric tumour
Answer: E. Idiopathic intracranial hypertension
5 yr old recently returned Nigeria; has had 3 day history of swinging high fevers, also urine is noted to be dark red. On exam has enlarged liver, otherwise nil else. Dipstick positive for blood +++.
A. UTI B. Hereditary spherocytosis C. Schistosomiasis D. Malaria E. G6PD deficiency F. Wilm’s tumour G. Nephrotic Syndrome H. Acute glomerulonephritis I. Polycystic kidneys J. Von Willebrand’s
Answer: D. Malaria
2 year old with frank haematuria, some abdominal pain, rigors. Urine nitrite and blood +++.
A. UTI B. Hereditary spherocytosis C. Schistosomiasis D. Malaria E. G6PD deficiency F. Wilm’s tumour G. Nephrotic Syndrome H. Acute glomerulonephritis I. Polycystic kidneys J. Von Willebrand’s
Answer: A. UTI
6 month old brought in by parents as they noted blood in the nappy; well infant; history of constipation last 6 weeks; exam, right sided abdominal mass palpable; urine blood ++++.
A. UTI B. Hereditary spherocytosis C. Schistosomiasis D. Malaria E. G6PD deficiency F. Wilm’s tumour G. Nephrotic Syndrome H. Acute glomerulonephritis I. Polycystic kidneys J. Von Willebrand’s
Answer: F. Wilm’s tumour
A 3 yr old with urine noted to be very dark by parents; Has had puffy eyes and been generally unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. BP 110/65.
A. UTI B. Hereditary spherocytosis C. Schistosomiasis D. Malaria E. G6PD deficiency F. Wilm’s tumour G. Nephrotic Syndrome H. Acute glomerulonephritis I. Polycystic kidneys J. Von Willebrand’s
Answer: H. Acute glomerulonephritis
A 6 yr old male, UK born, of Iraqi parents, develops sudden onset very dark red urine, no pain. He has a current viral infection. On exam, slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice.
A. UTI B. Hereditary spherocytosis C. Schistosomiasis D. Malaria E. G6PD deficiency F. Wilm’s tumour G. Nephrotic Syndrome H. Acute glomerulonephritis I. Polycystic kidneys J. Von Willebrand’s
Answer: E. G6PD deficiency
A 5-year-old girl is brought to A+E after school by her mother and school teacher with central abdominal pain.
The best history is likely to be obtained by talking to:
a. Her mother
b. Her mother and her school teacher
c. Her school teacher
d. The A+E triage nurse
e. The girl herself and her mother
Answer: E. The girl herself and her mother
The girl is the one experiencing the pain. The mum can provide details of her PMH and birth/ antenatal history.
A two-year-old boy is seen in Paediatric Outpatients with a 6 month history of diarrhoea and parental concern about his nutritional status. The best way to assess these concerns would be to:
a. Assess his weight for height
b. Calculate his Body Mass Index (BMI)
c. Measure his height and weight in clinic
d. Measure his upper arm circumference
e. Review and plot serial weights and heights
Answer: E. Review and plot serial weights and heights
A previously healthy 2-year-old child presents with a 24 hour history of diarrhoea and vomiting. Which of the following is the single, most accurate method for assessing the degree of dehydration?
a. Assess skin turgor
b. Assess the fontanelle
c. Calculate the difference between the current weight and the predicted weight from the child’s growth records
d. Examine the mucous membranes
e. Measure the heart rate and blood pressure
Answer: C. Calculate the difference between the current weight and the predicted weight from the child’s growth records
A 3-year-old boy attends the Paediatric A+E Department because he has developed an itchy rash whilst at a birthday party. Of the following features, which requires immediate treatment with 0.01 ml/kg of 1:1000 adrenaline i.m.?
a. Blood pressure of 88/50
b. Generalised urticaria
c. Lip swelling
d. Respiratory rate of 22/minute
e. Wheeze on auscultation
Answer: E. Wheeze on auscultation
A 3-year-old boy has just started fitting in A+E. You are the F1 doctor. The nurses are all busy with other children. Of the following actions which should you do first?:
a. Administer rectal diazepam
b. Gain iv access
c. Give him high-flow oxygen
d. Measure his blood sugar
e. Do a blood gas
Answer: C. Give him high-flow oxygen
One evening a 4-month-old boy is brought into A+E by his step-father because of a prolonged nose bleed. This has now stopped. The examination is normal apart from some irregular bruising on his abdomen and small, well circumscribed marks on his back. The next most appropriate step from the options below would be to:
a. Admit him and arrange a full skeletal survey, clinical photographs and clotting studies
b. Check his full blood count and clotting studies, and discharge him if they are normal for follow up in OPD
c. Discharge him and discuss the case the next day with the child protection team
d. Discuss the case with the child protection team now
e. Reassure the step-father that since the nose bleed has stopped, no further treatment is required
Answer: D. Discuss the case with the child protection team now.
A 2-month-old, ex-26 week gestation boy establishing feeding on the neonatal unit has developed a distended abdomen and bile-stained vomiting, and has an increasing oxygen requirement. The most likely diagnosis is:
a. Appendicitis
b. Gastro-oesophageal reflux
c. Hirschsprung’s disease
d. Intussusception
e. Necrotising enterocolitis
Answer: E. Necrotising enterocolitis
Risk factor: prematurity
A 5-month-old boy has been brought to A+E 2 hours previously with a 12 hour history of very high fever and vomiting. Examination does not reveal a clear source of infection so a blood culture is taken and lumbar puncture is performed. Of the following options, which method reflects current clinical practice when an urgent urine sample is required prior to starting antibiotics?
a. Fixing a sterile bag and waiting for a sample
b. Performing an in-out urinary catheterisation with aseptic technique
c. Placing a sterile pad in the nappy and waiting for a sample
d. Placing and leaving a urinary catheter in situ
e. Waiting for the parents to ‘catch’ a mid-stream urine sample in a bowl
Answer: B. Performing an in-out urinary catheterisation with aseptic technique
A 2-week-old boy is brought to A+E by his mother who has noticed that he has become increasingly jaundiced. She reported that he had not been breast-feeding as well as previously, and also commented that his stools looked like “off-white chewing gum”. The most likely diagnosis is:
a. Breast-milk jaundice
b. Congenital gall stones
c. Extra-hepatic biliary atresia
d. Glucose 6-phosphate dehydrogenase deficiency
e. Rhesus incompatibility
Answer: C. Extra-hepatic biliary atresia
A 4-month-old girl is brought into A+E Resus by paramedics with a widespread, progressing, non-blanching purpuric rash on both lower limbs. She has cold peripheries with a capillary refill time of 5 seconds, has a heart rate of 180/min and her blood pressure is unrecordable. The most likely diagnosis is:
a. Anaphylaxis
b. Erythema infectiosum
c. Group B streptococcal infection
d. Henoch-Schonlein purpura (HSP)
e. Neisseria meningitidis infection
Answer: E. Neisseria meningitidis infection
She has signs of septicaemia and shock (prolonged capillary refill time, tachycardia and hypotension).
