Paediatrics Flashcards
A 14-year-old girl comes to see you as she has not had her periods yet. You note
that her breasts are stage II and her nipples are set lateral to the mid-clavicular
line. She has no pubic hair. Her weight is on the 50th centile but height is on
the 9th centile. Her parents are both of average height. What is the most likely
diagnosis?
A. Turner’s syndrome
B. Polycystic ovary syndrome
C. Anorexia
D. Constitutional delay
E. Underlying undiagnosed chronic illness
A. Turner’s syndrome
Turner’s syndrome (A) is karyotypically 45XO. There are the classic signs of wide spaced niples, short stature, lack of secondary charecteristics, amenorreha and inferlity. Another classic feature not mentioned here is a webbed neck.
PCOS (B) is unlikely as this girl hasn’t started puberty at all. PCOS tends to lead to secondary amenorehoa or oligomenorehoa.
Her weight is normal, so this isn’t anorexia (C)
Constitutional delay (C) would be a simple isolatted delay in seletal growth, it would not have these syndromic features.
There is nothing here to sugest an underlying chronic illness (E), there is also no evidence of failure to thrive.
A 2-year-old child is referred to you by the GP because he has not started walking.
His mother says that he can stand but cries to be picked up or sits down shortly.
His older sister was walking by 14 months. You note that he is talking well with
short two to three word phrases. He is able to build a tower of six blocks. What is
your management plan?
A. Advise mum to work harder at giving him independence and follow up
in 4 months.
B. Request blood tests including a creatinine kinase
C. Refer for physiotherapy
D. Reassure and discharge as his development is normal
E. Refer to orthopaedics
B. Request blood tests including a creatinine kinase
This child has abdormal developmentisolated to gross motor skills, this is not normal (D), nor is discharge and review an appropriate step (A).
The concern here is that there is a muscular dystrophy, the history of being able to stand but fatiguing quickly is classical. Male gender also makes this possible as these are X-linked recessive conditions. The best screening test here is a CK (B), an abnormal CK would lead to a muscle biopsy to confirm a diagnosis of MD.
Hip dysplasia would be another reason for failure to walk, the first step in that case would be an utrasound, not an orthopaedic referal (E).
Without nowing the cuase of the problem, a referal to physio would be incorrect (C).
You see a boy in outpatients whose parents are concerned he is not talking yet.
You do a developmental assessment and find he is walking well and able to build
a tower of three blocks. He will scribble but does not copy your circle. He is able
to identify his nose, mouth, eyes and ears as well as point to mummy and daddy.
You do not hear him say anything but his parents say he will say a few single
words at home such as mummy, daddy, cup and cat. He is a happy, alert child.
Parents report him to be starting to feed himself with a spoon and they have just
started potty training but he is still in nappies. What is the child’s most likely age?
A. 12 months
B. 15 months
C. 18 months
D. 2 years
E. 2.5 years
C. 18 months
This child achieves the 18 month goals in all four developmental domains.
learn the attached table!
http://medimaps.co.uk/wp-content/uploads/2013/12/Paediatrics_developmental_milestones_Ver_0.2.png
A one-and-a-half-year-old Caucasian child is referred to paediatrics for failure
to thrive. On examination he is a clean, well-dressed child who is quite quiet
and withdrawn. He is pale and looks thin with wasted buttocks. His examination
is otherwise unremarkable. What is the most likely cause of this child’s growth
failure? His growth chart shows good growth along the 50th centile until 6 months followed by weight down to the 9th, height down to 25th and head circumference now starting to falter at 1.5 years.
A. Coeliac disease
B. Neglect
C. Constitutional delay
D. Normal child
E. Beta thalassaemia
A. Coeliac disease
The clue in this case is that the child was normal, until 6 months, when he was presumably weaned onto gluten containing foods. It was only at this stage he began to fail to thrive. The pale description is likely anaemia due to malnutrition, wasted buttocks is a clasic coeliac sign (A).
Neglect (B) is an important consideration in any case of failure to thrive, but it is unlikely as he appears well cared for. His withdrawn nature, in this case, is likey due to chronic illness.
Constitutional delay (C) is an isolated finding of delayed skeletal growth, it is usualy seen at puberty.The failure to gain weight and the other symptoms go against this.
He has moved across the growth and weight curves, he is not a normal child (D).
Beta thalassaemia (E) is extremely rare in a caucasian child, symptoms would have appeared at 6 months (when the fetal Hb is discontinued). He would not have gotten to 1.5 years of age without transfusions and a diagnosis.
A 12-year-old boy presents to his GP with left-sided unilateral breast development
stage III. He is very upset as he is being bullied at school. His mother is worried as
her friend’s sister has just been diagnosed with breast cancer and wants to know
if he could have breast cancer? What is the management?
A. Refer for a breast ultrasound
B. Test sex hormone levels
C. Test alpha fetoprotein
D. Reassure and explain this is a normal part of puberty; it will resolve but
the other breast may enlarge transiently as well
E. Do a fine needle aspirate on his left breast
D. Reassure and explain this is a normal part of puberty; it will resolve but
the other breast may enlarge transiently as well
it is common for adolescent males to transiently undergo breast development. THe correct action here is to reassure and counsel that there may be transient development of the other breast (D).
Investigations (A, B, C, and E) would only be warrented if this did not resolve.
The order of male pubertal development; begins with testicular volume increasing above 4ml, penis enlargement, pubic hair growth, and finally the growth spurt.
You see a baby for the first baby check at 6 weeks. Mum reports no problems
and he is feeding well. On examination you are unable to palpate the testicles
on ether side and do not feel any lumps in the groin area. He has a normal penis
with no hypospadias and the anus is patent. He is otherwise a normal baby on
examination. What is the most important diagnosis to rule out?
A. Klienfelter’s syndrome
B. Congenital adrenal hyperplasia
C. Undescended testicles
D. Virilized female infant
E. Testicular cancer
B. Congenital adrenal hyperplasia
CAH (B) is most commonly casued by 21-hydroxylase deficiency. the presentation is with infants of ambiguous genitalia, or bilateral undescended testes. Because they are at risk of a salt-losing crisis around 1-3 weeks of age it is crucial to investigate this possibility. You would measure U&Es and carry out chromosomal analysis, as well as a pelvic ultrasound to look for the testes. .
This could be a virilised female infant (D), but there would be an underlying reason for this (CAH for example).
Undescended testes (C) is an important diagnosis, as if they persist outside of the scrotom past the age of 2 then there is an increased risk of developing testicular cancer (E). As this is a newborn and not a 2 year old we cannot make this diagnosis.
Klienfelter’s (A) syndrome is karyotypically 47XXY and includes; tall stature, delayed puberty, and mild learning difficultiesbut no link to undescended testicles.
You see an 8-year-old boy in accident and emergency who fell off his bike 3 days
ago and scraped his left calf. The cuts are now angry, red and painful. You note he
is a big boy and plot his growth: his weight is on the 99th centile and height is on
the 75th centile. You note mild gynaecomastia and stretch marks on his abdomen
which are normal skin colour. His past medical history is unremarkable except for
mild asthma. What is the most likely cause of his large size?
A. Cushing’s syndrome secondary to a pituitary adenoma
B. Cushing’s syndrome secondary to becotide inhaler use
C. Obesity
D. His size is within the normal range and is a variant of normal
E. Liver failure
C. Obesity
If this were Cushing’s (A or B) you would expect his growth to be impaired, which is not the case here. In addition the specific mentioning that the striae are normal skin colour goes against Cushings, which is classically purple.
It is also important to be aware that inhaled steroids (B) do not provide enough systemic steroid to cause Cushings syndrome. The child would have to be on high dose oral steroids.
The fact that he is on the 99th centile for weight immediately tells you that this is outside the normal variant range (D), this is confirmed by the mismatch between the centiles of height and weight.
There is nothing in the history sugestive of a severe condition such as liver disease. If the child had liver failure (E) he would be extrememely unwell, and probably not riding his bike.
The gynaecomastia is more likely to be fat deposition due to obesity (C), this child should be encouraged to continue exercise and to eat more healthily. There is not normally a reason to put a child on calorie controlled diets as normal growth should facilitate weight loss.
A 16-year-old boy is brought to the GP by his parents. They are concerned he is the shortest boy in his class. He is otherwise well. His height and weight are on the 9th centile. His father plots on the 75th centile and his mother on the 50th centile for adult height. On examination, his testicular volume is 8 mL, he has some fine pubic and axillary hair. The rest of the physical examination is normal. On further questioning you elicit from his father that he was a late bloomer and did not reach his full height until he was at university. What is the most likely cause of the boy’s short stature?
A. The 9th centile is a normal height and weight so there is nothing wrong
with him
B. Growth hormone deficiency
D. Underlying chronic illness should be sought
E. Anorexia
C. Constitutional delay of growth and puberty
This pattern of late blooming (classically in the male line) is sugestive of constitutional delay (C). A constitutional delay presents as a delay in skeletal growth with no other pathological features.
The boy is progressing through puberty in the normal way, just delayed. The order being increased testicular volume (above 4ml), penis growth, then pubic hair, with the growth spurt being the final stage. This makes a GH deficincy (B) or an underlying chronic illness (D) unlikely.
His height and weight are on the same centile, so this makes anorexia (E) unlikely as you would expect the weight to be much lower than the height.
Given his parent’s height you would expect him to be taller, so this is not normal (A). as an estimate you would expect a child to be the mean of the parental height, plus 7cm in boys, minus 7cm in girls, with a leeway of two standard deviations.
A mother comes to see you with her 2-year-old daughter, Stacey, out of frustration
that her daughter is so ill behaved. She does not know how to make her listen and is worried that she is going to get hurt. Yesterday she ran ahead and did not stop when her mother called to her. She ran into the street and was hit by a cyclist, but fortunately he was OK and Stacey had only had a few cuts and scrapes and seems alright! On questioning you hear other stories of a naughty child. She is active and eats well, feeding herself a lot now, but her mother does say she gets frequent coughs and colds. Her mother says that Stacey only says about 5–10 words and only she can understand what Stacey says. What is the best next management?
A. Ask the health visitor to visit mum for parenting advice and support
B. Order blood tests for full blood count to check for leukaemia as she has
recurrent coughs and colds
C. Give Stacey a tetanus shot to cover her after her fall the day before
D. Refer for a hearing test
E. Tell Stacey that she needs to listen to her mother and not have any
more accidents
D. Refer for a hearing test
There appears to be a speech delay here. The child is feeding herself and running, which is normal for a 2 year old but her speech is closer to that of an 18 month old. The other feature of note is that this vignette suggests that what speech she is producing is abnormal if only the mother (who has grown used to it) can understand.
All of this would raise concern of a hearing problem (D), commonly due to glue ear associated with reccurent coughs and colds.
A child this age would be expected to get around 8 coughs and colds a year, on average, so any referal for a blood cancer (B) would be premature.
Her routine vaccinations would cover for tetanus, so further vaccination would be unecessary (C) unless there was evidence she had missed a scheduled vaccine. Also this answer completely misses the point of the consultation!
(A) and (E), similarly fail to adress the underlying concerning signs.
An older mother books in to see you after attending the health visitor for a weight
check at 2 months for her first child. She and her husband have had a hard time
coming to terms with their daughter’s diagnosis of Down’s syndrome. She is
relieved that the appointment with the cardiologists went well and the heart is
normal. However they have a lot of trouble getting her to take the whole bottle,
she was slow to regain her birth weight and looking at the plotted weight yesterday she is not growing along her birth centile and the mother is worried she is not doing a good enough job. She is not vomiting except for small possets after feeds, is passing urine and opening her bowels. The red book growth chart shows the weight to be falling off centiles. What is the most appropriate management?
A. Contact the cardiologists in light of the poor feeding and slow weight
gain for a second opinion as baby’s with Down’s syndrome are at high
risk of heart problems and they may have missed it
B. Refer to the dietician for nutritional support
C. Replace the growth chart in their red book with a Down’s syndrome
growth chart, reassure mum by re-plotting her growth and explain she
is normal but arrange to review again
D. Tell the mother to try a different milk and come back in 2 weeks
E. Advise the mother to change to a faster flow teat for their bottles so
that she takes her feed faster
C. Replace the growth chart in their red book with a Down’s syndrome
growth chart, reassure mum by re-plotting her growth and explain she
is normal but arrange to review again
It is important to remember that children with Down’s syndrome have different rates of growth and so the stanard growth charts are not appropriate (C). The same goes for other conditions, such as Cystic Fibrosis.
Referal back to cardiology (A) would unduely worry the mother and is rather insulting to the specialists to imply they missed something obvious.
Options (B), (D) and (E) al assume there is a feeding problem of some kind, which in all likelehood is not the case.
Which child should be moved to the resuscitation area for urgent management in
accident and emergency?
A. A miserable 2 year old with a fever and vomiting temperature of 38.5°C, heart
rate of 150, respiratory rate 42, capillary refill time 2–3 seconds who is alert and
clinging on to his father and has just been given paracetamol and started on a
fluid challenge with oral rehydration salts 5 minutes ago by the triage nurse
B. A quiet 4 year old brought in with an asthma attack who is sitting
upright with a respiratory rate of 50, heart rate of 162, capillary refill
time of 3 seconds, subcostal recessions and poor air entry on chest
auscultation following a salbutamol nebulizer
C. An 8 year old, known diabetic, brought in vomiting with her glucose
reader saying HI. She is able to tell you her history and has a heart rate
of 120, respiratory rate of 25, capillary refill time of <2 seconds
D. An alert 3 year old who has had a cough and cold for the past 3 days
which is keeping him up at night and mum noticed a rash on his neck
and face which did not disappear when she pressed a glass tumbler
against it. His temperature is 37.8°C, heart rate is 110, respiratory rate is
30, capillary refill time is <2 seconds
E. A 15 year old, known to social services for a family history of domestic
abuse, brought in to accident and emergency by her best friend after
she admitted to taking 20 paracetamol tablets 4 hours ago. She is alert
but does not make eye contact, her heart rate is 98, respiratory rate is
20, capillary refill <2 seconds
B. A quiet 4 year old brought in with an asthma attack who is sitting
upright with a respiratory rate of 50, heart rate of 162, capillary refill
time of 3 seconds, subcostal recessions and poor air entry on chest
auscultation following a salbutamol nebulizer
The child in (B) is seriously unwell and the sickest child here. She needs to be moved to resus and have a dedicated doctor and nurse managing her. She has deranged observations and signs of circulatory compromise, with the cap refil time being >3 secs, and there has been no responce to the nebuliser.
Child (A) is unwell but has just been given treatment, the pudent course of action is to se if his/her observations improve after the anti-pyretic and fluid challenge.
Child (C) is potentially heading towards a DKA, but at this point in time is alert with no circulatory compromise. She should be closely monitored as there is a risk that she could rapidly deteriorate. Needs a blood gas first and foremost.
Child (D) has a non blanching rash, but is actually pretty well. There are no signs to suggest that he is septic, so this is unlikely to be meningococcal sepsis. He should none the less, be isolated in a side room and be reviewed by a senior clinician.
Child (E) Has the potential to become quite sick, but is stable currently. She needs blood levels of paracetamol measured and would benefit from a private space (a side room) to have a psych consult when medically cleared.
A 4-year-old child has been losing weight recently and has been vomiting for the
past 24 hours, unable to eat anything. His mother has brought him into accident
and emergency out of concern as he seems confused. The triage nurse has taken
him to the resuscitation room and asked for your help. On examination he is
drowsy, has a heart rate of 150, respiratory rate of 60 and a central capillary refill
of 5 seconds. He has subcostal recessions and good air entry bilaterally with no
added sounds. He moans when you examine his abdomen but there are no masses. You put in a canula and take bloods. The venous blood gas shows:
pH 7.12
PCO2 2.3 kPa
PO2 6.7 kPa
HCO3
–15.3 mmol/L
BE –8.6
Glucose 32.4 mmol/L
What is the most likely diagnosis and what is the first management step?
A. Diabetic ketoacidosis, start an insulin infusion
B. Diabetic ketoacidosis, give a fluid bolus
C. Pneumonia, start IV co-amoxiclav
D. Ruptured appendix, give a fluid bolus and book the emergency
operating theatre
E. Gastroenteritis with severe dehydration, give a fluid bolus
B. Diabetic ketoacidosis, give a fluid bolus
It may sound obvious, but remember that diabetic ketoacidosis requires thre components for a diagnosis. There must be evidence of diabetes, as in the glucose reading in this case. There must be acidosis, pH 7.12 in this case. Finally, there must be ketones in the urine, this isn’t mentioned here, but the diagnosis of DKA is most likely. We se other classic signs of DKA, not to be confused with other pathology, the tachypnoeia of metabolic acidosis and the abdominal pain of Ketoacidosis.
The first management if DKA is careful fluid resuscitation (B) and insulin only afteran hour of resuscitation (A). It is importatnt to go slowly with the resuscitation as children are very prone to cerebral oedema, and there is a risk with rapid salt changes of brainstem demyelination. Complete correction should take place over 2 days.
Of ther other options, there is not a respiratory acidosis, so this is not pneumonia (C). With an abnormal glucose any GI pathology is unlikely (D and E).
An 8 year old known asthmatic is brought into accident and emergency by
ambulance as a ‘blue call’. He has been unwell with an upper respiratory tract
infection for the past 2 days. For the past 24 hours his parents have given him
10 puffs of salbutamol every 4 hours, his last dose being 90 minutes ago. The
ambulance staff have given him a nebulizer but he remains agitated with a
heart rate of 155, respiratory rate of 44 and sub/intercostal recessions and on
auscultation there is little air movement heard bilaterally. Saturations in air are 85
per cent. He is started on ‘back to back’ nebulizers with high flow oxygen. How
severe is his asthma exacerbation and what other bedside test would support this?
A. Moderate, venous blood pH 4.4, gas PCO2 = 3.1 kPa
B. Severe, peak flow <33 per cent expected
C. Severe, venous blood pH 4.4, gas PCO2 = 3.1 kPa
D. Life-threatening, peak flow <33 per cent expected
E. Life-threatening, venous blood pH 4.4, gas PCO2 = 3.1 kPa
D. Life-threatening, peak flow <33 per cent expected
The signs of a life-threatening attack here are: Agitation and cyanosis indicating hypoxia, and a silent cheast indicating severely compromised airways. This life threatening atack would be confirmed by a peak flow of <33% of expected (D)
This is more serious attack than suggested by (B)
Blood gases are not used to assess asthma in children, if it were used then a severe or life threatening asthma attack would be shown as a rising CO2 as the lungs would not be effectively exchanging gas. In these examples (A, C, E) there is a hypocapnia indicating hyperventilation.
The accident and emergency triage nurse asks you to look at a 3-year-old child
with a short history of waking up this morning unwell with a cough and fever. She
looks unwell, heart rate is 165, respiratory rate 56, saturations of 96 per cent in
air, temperature of 39.3°C and central capillary refill of 4 seconds. She has a mild
headache but no photophobia or neck stiffness and you notice a faint macular rash on her torso and wonder if one spot is non-blanching. You ask the triage nurse to move her to the resuscitation area and call your senior to review her. Fifteen minutes later your senior arrives and the spot you saw on the abdomen is now non-blanching and there is another spot on her knee. What are the three most important things to give her immediately?
A. High flow oxygen, IV fluid bolus, IV ceftriaxone
B. IV fluid bolus, IV ceftriaxone, IV methylprednisolone
C. High flow oxygen, IV ceftriaxone, IV fresh frozen plasma
D. IV fluid bolus, IV ceftriaxone, IV fresh frozen plasma
E. High flow oxygen, IV ceftriaxone, IV methylprednisolone
A. High flow oxygen, IV fluid bolus, IV ceftriaxone
This child has a classic presentation of meningococcal sepsis and should be treated accordingly.
The prescence of a non-blanching rash indicates that she has disseminated intravascular coagulation and will likely need fresh frozen plama (C and D), but blod tests are needed first, so it is not the first step.
High flow oxygen should always be given to sick children as a first action, it is part of the ‘A’ of the ‘ABCD’ approach. This leaves us with options of answers (A) or (E), of the two, (A) is better as we need to give a fluid bolus (20ml/kg) in a child showing signs of circulatory compromise. The child is also not displaying signs of meningitis at this stage, so the utility of steroids (E) is unclear.
A 9-year-old boy is brought in by ambulance having been hit by a car while
playing football in the street. You have been assigned to do the primary survey in
resus when the ambulance arrives. The patient is receiving oxygen, crying for his
mummy and holding his right arm, but able to move over from the stretcher to the
bed when asked. Which is the correct examination procedure?
A. The trachea is deviated to the right. On auscultation you hear decreased
air entry on the left. Percussion note is hyper-resonant on the left. He is
tachycardic and his heart sounds are muffled, heard loudest at the right
lower sternal edge. You ask for a left-sided thoracocentesis.
B. You introduce yourself and tell him that you will be gentle but need to
check that he is okay. You see his left wrist is deformed and swollen and
check the fingers which are cool and note the capillary refill is 4 seconds.
He is able to feel you touching him and moans when you examine the
wrist. You call for an x-ray to assess the probable fracture in the wrist.
C. You introduce yourself and tell him that you will be gentle but need to
check that he is okay. You listen for equal air entry and think there is
decreased air entry on the left but there is air entry on the right. He is
tachypnoeic and has a pulse which is tachycardic. His capillary refill is
4 seconds. You expose his abdomen and notice bruising and grazes to
the left side. He moans as you palpate in the left upper quandrant and
has guarding. You ask for an IV canula or intraosseous needle and a
20 mL/kg fluid bolus while organizing an urgent CT chest and abdomen.
D. You introduce yourself and tell him that you will be gentle but need
to check that he is okay. He is tachypnoeic. The trachea is deviated
to the right. On auscultation you hear decreased air entry on the left.
Percussion note is hyper-resonant on the left. He is tachycardic and his
heart sounds are muffled, heard loudest at the right lower sternal edge.
You ask for a left-sided thoracocentesis.
E. You listen for equal air entry and think there is decreased air entry on
the left but there is air entry on the right. He is tachypnoeic and has a
pulse which is tachycardic. His capillary refill is 4 seconds. You expose
his abdomen and notice bruising and grazes to the left side. He moans
as you palpate in the left upper quandrant and has guarding. You ask
for an IV canula or intraosseous needle and a 20 mL/kg fluid bolus
while organizing an urgent CT chest and abdomen
D. You introduce yourself and tell him that you will be gentle but need
to check that he is okay. He is tachypnoeic. The trachea is deviated
to the right. On auscultation you hear decreased air entry on the left.
Percussion note is hyper-resonant on the left. He is tachycardic and his
heart sounds are muffled, heard loudest at the right lower sternal edge.
You ask for a left-sided thoracocentesis.
This question is addressing your understading of how to perform an examination and the ATLS framework of the A-B-C-D approach. Options (A) and (E) can be excluded straight away because you have failed to introduce yourself, which is always a crucial step in gaining cooperation and trust from the patient.
Option (B) is an examination of disability and misses all the conditions that might be found during the ‘A’, ‘B’, and ‘C’ stages.
Option (C) recognises the tension pneumothorax but does nothing to address it before continuing the primary survey.
Option (E) is secondarily wrong because, as above, it fails to address the tension pneumothorax after it is discovered.
A 6-year-old boy with a history of anaphylaxis to peanuts is brought in by
ambulance unconscious. He was attending a children’s birthday party. His mother
says there was a bowl full of candy and he may have eaten a Snickers bar but she
is not sure and she did not have his EpiPen with her. His face and lips are swollen and erythematous, he is still breathing but weakly and there is wheeze. His pulse is tachycardic and thready. Which type of shock is this?
A. Hypovolaemic
B. Distributive
C. Septic
D. Cardiac
E. Obstructive
B. Distributive
Shock is the hypoperfusion of tissues, to an extent that is insufficient to meet those tissues metabolic needs. In the case of anaphylaxis there is a shift of fluid to the interstitium due to capiliary leakage, this is a distributive shock (B).
If the leaky capiliaries and distributive shock was in the background of an infection, then this would be septic shock (C).
Blood loss or serious dehydration causes hypovolaemic shock (A). You would expect a pale, cool patient with weak pulses.
Cardiac shock (D) is on the background of cardiac insufficiency, you would expect cardiac symptoms of cheast pain. It is rare in childhod outside of congenital abnormalities or Kawasaki’s disease.
Obstructive shock (E) is due to a mechanical force stopping cardiac output, such as a tamponade or a tension pneumothorax.
A 13 month old is brought in having had a blue floppy episode at home lasting
1 minute. While you are taking a history from the mother, you notice the baby has
gone blue again and seems to be unconscious in her arms. You call for help and
place the baby on the examination table. There is no obvious work of breathing.
The nurses bring the crash trolley and give you a bag valve mask, which they are
connecting to the oxygen. You give two inflation breaths but do not see the chest
rise. You reposition the air way and this time the breaths go in. You feel for a pulse
and there is none. When asked to do CPR the nurse asks for direction on how many breaths and compressions you both need to do.
A. Two inflation breaths per 30 compressions
B. Two inflation breaths per 15 compressions
C. Continuous inflation breaths about 10–12 per minute and compressions
100–120 per minute
D. One inflation breath per five compressions
E. Two inflation breaths per five compressions
B. Two inflation breaths per 15 compressions
As per current guidelines there are 2 inflation breaths per 15 cheast compressions (B).
option (A) is the adult guidelines, primarily because infants are more likely to suffer respiratory arrest than cardiac so the breaths are more important.
Answer (C) is the protocol once the child has been intubated.
Answers (D) and (E) are nothing at all.
A 10-year-old child is brought in by ambulance with seizure activity. His mother
reports it starting 30 minutes ago in his right arm and quickly became generalized
tonic clonic jerking. She gave him his buccal midazolam after the first 5 minutes
and called an ambulance when he did not respond after another 5 minutes.
The ambulance crew gave him rectal diazepam on arrival at 15 minutes into
the seizure. He is receiving high flow oxygen via a face mask and continues to
convulse. The mother tells you that he was weaned from his long-term seizure
medication, phenytoin, 2 weeks ago and that he has had a cold for the past 2 days. What is the next step in management?
A. Gain intravenous or intraosseous access and administer lorazepam
B. Gain intravenous or intraosseous access and administer ceftriaxone
C. Repeat the rectal diazepam
D. Gain intravenous or intraosseous access and start a phenytoin infusion
E. Gain intravenous or intraosseous access and start a phenobarbital
infusion
D. Gain intravenous or intraosseous access and start a phenytoin infusion
The guidelines are that a child in status elepticus (seizure longer than 30 mins) should recieve two dose of benzodiazipines from; Buccal midazolam, Rectal Diazepam and IV Lorazepam. Once two of these have been given to no effect, as in this case, the next stage in management should be started. The next stage here is to give IV Phenytoin (D) to arrest the seizure.
Further use of benzodiazipines (A or C) should be avoided due to risk of respiratory depression
Phenobarbital (E) is the second line drug after phenytoin, it would be given if he was already on phenytoin at the time of the seizure, which he is not.
Ceftriaxone (B) may help if the seizures were due to encephalitits, but this is not first line treatment.
A 3-year-old boy is brought in by ambulance fitting. You are assigned to get
the history from the father. Harry is normally fit and well with no significant
past medical history or allergies. He is up to date with his immunizations and
has been growing and developing normally. His behaviour has been difficult
for the past 2 weeks since the birth of his little sister. Mum has been unwell as
she developed HELLP syndrome and was in hospital for a week following the
delivery. Yesterday, he was quite unwell with a tummy bug, vomiting and had
black diarrhoea. That evening they found a mess he had made in the bathroom
with all of his mum’s things strewn over the floor including her tablets from the
hospital. By that time, Harry was getting better so they did not think anything
of it. Today he has been acting strangely and has been difficult to understand,
he then became lethargic at about 4 pm and started fitting 15 minutes ago. What
is the most likely diagnosis?
A. Paracetamol overdose
B. Aspirin overdose
C. Tricyclic antidepressant overdose
D. Bleach intoxication
E. Iron overdose
E. Iron overdose
The clue that the mother is diagnosed with HELLP syndrome tells you that she has had anaemia, and so will have been prescribed iron supplementation. The classic course of iron overdose (E) is a two stage illness where there is an initial gastric irritation, possibly with haematemesis and malena (as seen here). There is then a period of up to 24hrs where there is improvement, followed by a deterioration with liver failure, drowsiness and coma. The liver failiure can produce can produce the hyoglycaemia and seizures seen here.
Significant Paracetamol overdose (A) is not common in small children, as the tablets are difficult to swallow.You would expect teh liver failure after 3-5 days, there would also not be the malena.
Aspirin overdose (B) would be much quicker, with signs of metabolic acidosis, Symptoms include dizzyness, confusion, nausea, vomiting, tinnitus, abdominal pain and seizures.
Tricyclic overdose (C) would present much quicker with tachycardia, anticholinergic symptoms, shock and then seizures.
Bleach intoxification (D) is possible, but in this age group it is rare as it tastes foul. There tends to be localised lesions of the mucous membranes where the bleach made contact.
A 6-year-old boy with a history of asthma and eczema is brought in to accident
and emergency from a local restaurant. He is on high flow facial oxygen with
significant facial oedema and generalized erythema. On auscultation there is
widespread wheeze for which the ambulance crew gave a salbutamol nebulizer.
What is the next step in management?
A. Insert an IV line and give 10 mg slow intravenous antihistamine
B. Insert an IV line and give 100 mg slow intravenous hydrocortisone
C. Insert an IV line and give 200 μg of 1:10 000 intravenous adrenaline
D. Give intramuscular 1:1000 adrenaline, 250 μg
E. Repeat the salbutamol nebulizer and call for an anaesthetist for
intubation
D. Give intramuscular 1:1000 adrenaline, 250 μg
It is important to recognise that the facial oedema and generalised erythema here is indicating an anyphlactic reaction. The next step in the management is to give IM adrenaline (D) to drive the interstitial fluid back into the vasculature to reduce the airway swelling.
The dosage in (C) is for cardiac arrest, so is not appropriate.
(A) here will also help to block the histamine release which is driving the angioedema. (B) will reduce the inflammation and help to prevent any delayed hypersensitivity (type IV) reaction, which is something that needs to be covered.
You would also be putting in an emergency call for an anaesthetist.
BUT the first thing here is to crack on with the adrenaline.
A newborn baby is born to non-consanguineous parents. She is noted to have
puffy feet on her 1st day check. She weighs 2.0 kg with widely spaced nipples and
absent femoral pulses. You have asked your registrar to review her as you think
she may have Turner’s syndrome. She agrees and asks you to send blood tests for
karyotyping. Which is the chromosomal diagnosis of Turner’s syndrome?
A. 47XXY
B. 45YO
C. 46XY
D. 46XX
E. 45XO
E. 45XO
Turner’s syndrome (E) is the loss of the 46th cromosome leading to femal infants with the syndromic features seen here as well as cardiac abnormalites, horseshoe kidney, coarctation of the aorta, short stature,coeliac, delayed puberty and thyroid disorders,
(A) is Klinefelter’s, they are phenotypically male with tall stature, delayed pubery, and gynaecomastia.
(B) I believe this would be incompatible with life
(C) normal male
(D) normal female
A 15-year-old boy was diagnosed with Down’s syndrome at birth. He is short for
his age, had cardiac surgery as a baby, has treatment for hypothyroidism and now
attends mainstream school with some support. His parents are enquiring now about what complications he faces. Which of these is not a recognized complication of Down’s syndrome?
A. Retinoblastoma
B. Atrioventricular septal defect (AVSD)
C. Type 1 diabetes
D. Leukaemia
E. Alzheimer’s disease
A. Retinoblastoma
Associations of Down’s syndrome:
Cardiac: AVSD, Tetralogy of Fallot
Endocrine: Hypothyroid, Addisons, DM type I
Occular: Cataracts, But NOT retinoblastoma (A)
Malignancy: Leukaemia
GI: Duodenal atresia, Hirschprung’s disease
Musckuloskeletal: Atlanto-axial instability
Neuro: Alzheimer’s disease
A baby is born and you are asked to do the baby check at 6 hours post-natal
age. You go to see the baby and mum states that he has not yet had a feed. You
advise they stay in hospital until the feeding is established. This is the first child of
non-consanguineous parents. On day 4 when you review the baby he has still not
had an adequate intake, has lost over 10 per cent in birth weight and is markedly
hypotonic. Your consultant asks you to request genetic testing for Prader–Will
syndrome. What is the inheritance of Prader–Willi syndrome?
A. X-linked
B. Imprinting
C. Monosomy
D. Microdeletion
E. Trisomy
B. Imprinting
This is because for some of your chromosomes to function correctly, you need a paternal or maternal copy to be intact. In Prader-Willi there is the loss of part of the paternal chromosome 15. The loss of the maternal chromosome 15 leads to Angelman’s syndrome
X-linked (A) conditions include; Duchene’s MD, Fragile X syndrome
Monosomy (C) includes Turner’s syndrome
Microdeletions (D) are seen in DiGeorge’s syndrome and William’s syndrome.
Trisomy (E) conditions include: Down’s (21), Patau’s (13) and Edward’s (18) syndromes.
A 5-day-old baby who is formula fed is on the neonatal unit being treated for sepsis secondary to an Escherichia coli urinary tract infection. He has been on antibiotics for 5 days. He is still unwell and vomiting. The parents are consanguineous and this is their first child. He has had repeat blood and urine cultures taken. Urine reducing substances are positive. What is the most likely underlying diagnosis?
A. Fructose intolerance
B. Galactosaemia
C. Phenylketonuria
D. Lactose intolerance
E. Glycogen storage disease
B. Galactosaemia
Galactosaemia (A) is a deficiency in galactose-1-phosphate uridyl transferase. It manifests with the consumption of lactose-containing milks, with vomiting, cataracts and recurrent episodes of E.coli sepsis.
Fructose intolerance (A) can present similarly but the e.coli sepsis is a giveaway that this is Galactosaemia.
PKU (C) presents as a developmental delay and ‘musty’ smelling urine. It doesn’t present as acute sepsis, it is also screened for in the guthrie test.
A 10-year-old boy is brought to the GP with tall stature. He is taller than his peers at school. His arm span is greater than his height, he has long, thin fingers, scoliosis and pectus excavatum. He is also concerned that he gets short of breath at school during PE lessons. You refer him for an echocardiogram and chest x-ray. You make a clinical diagnosis of Marfan’s syndrome. What is the inheritance of Marfan’s syndrome?
A. X-linked recessive
B. Autosomal recessive
C. Sporadic
D. X-linked dominant
E. Autosomal dominant
E. Autosomal dominant
Marfan’s is an autosomal dominant connective tissue disorder affecting the fibrillin gene.
A. X-linked recessive - Duchenne’s and Becker’s muscular dystrophy
B. Autosomal recessive - Homocysteinuria (similar phenotype but with thromboembolic tendancy)
C. Sporadic - Klinefelter’s
D. X-linked dominant - Hypophosphataemic rickets
A pregnant woman seeks advice from you regarding her condition and its impact
on the pregnancy and risk to the baby. She has phenylketonuria (PKU) and has
been on a phenylalanine-free diet for life. She was told that it was very important
during her pregnancy to be compliant with this diet. She would like to know
how the baby will be tested for the condition as she is aware that is an inherited
condition. What is the initial investigation you will advise?
A. Serum tyrosine levels
B. Genetic screening
C. Serum phenylalanine levels
D. Urine phenylketones
E. Newborn blood spot screening
E. Newborn blood spot screening
PKU is a autosomal recessive metbolic condition leading to a defect in the phenylalanie hydroxylase enzyme. This enzyme converts phenylalanie to tyrosine, unrecognised PKU can lead to seizures, musty urine and eventually microcephaly and learning difficulties. PKU is one of the six inherited metabolic disorders already on the UK newborn screening test (E).
Options (A), (C) and (D) would all be useful for monitoring the disease, but are not diagnostic.
(B) is not used for PKU
You see an 18-year-old boy who is the first child of his African parents and was
born in Kenya before moving to the UK 1 year ago. He has white skin and pink
irises. He was diagnosed with oculocutaneous albinism at birth. He has difficulty
with his sight but has recently developed a skin lesion on his face. His mother has
brought him to his GP as it has recently started to increase in size. On examination
you note is an elevated, 3 cm diameter lump on the left of his nose. It has irregular
edges, is firm and immobile and pigmented in areas. What is the likely diagnosis?
A. Benign naevus
B. Scar from a healing wound
C. Malignant tumour
D. Abscess
E. Wart
C. Malignant tumour
His background of albinism means that he has problems synthesising melanin, this makes him more at risk of solar induced genetic damage. Malignancy shouldalways be considered in these patients, especially as he has lived at an equitorial latitude for 17 years. The description of a lump that is increasing in size, with irregular edges, with multiple colours and is solid, are all alarming for malignancy (C). This certainly does not sound like a benign naevus (A)!
There is nothing in this history that suggests trauma (B) or infection (D).
A wart (E) due to HPV infection would be possible, but the location on the face goes against this, and makes malignancy more likely.
A 20-month-old boy has been referred due to delayed walking. On further
questioning you establish he has no difficulty feeding, had head control at 3
months of age, and sat up by 8 months. He has been crawling for the last 8
months, but he does not pull to stand or walk with support. He has no dysmorphic
features. There is no known family history of muscle problems. His mother has no
myotonia. His mother is very concerned and asks you what is wrong. What is the
most likely diagnosis?
A. Myotonic dystrophy
B. Duchenne’s muscular dystrophy
C. Down’s syndrome
D. Myasthenia gravis
E. Becker’s muscular dystrophy
B. Duchenne’s muscular dystrophy
Of these conditions (B) s the most common, with Becker’s (E) being a a similar but more mild presentation. Both are X-linked conditions.
Myotonic Dystrophy (A) is autosomal dominant, so it would also be present in the mother.
Down’s (C) has a variety of syndromic features; Facies (low set ears, epicanthic folds, protruding tounge, flattened nasal bridge), single palmar crease, sandal gap toes.
Myasthenia Gravis (D) can present with delayed walking, but the key finding is fatigability, which isn’t demonstrated here.
You are asked to see a 3-day-old baby on the post-natal ward. The baby was born
at term and is the first child of consanguineous parents. The baby is drowsy and
vomiting, with no fever, rash or diarrhoea. On examination, the baby is noted to
have ambiguous genitalia. You do some blood tests: white cell count 5 × 109/L,
C-reactive protein 2 mg/L, Na+ 125 mmol/L, K+ 8 mmol/L, glucose 1.7 mmol/L.
17-OH level progesterone is low. You make a diagnosis of congenital adrenal
hyperplasia. What is the best initial management plan?
A. IV hydrocortisone
B. IV dextrose
C. IV dextrose and IV hydrocortisone
D. IV 0.9 per cent saline
E. IV 3 per cent saline and IV hydrocortisone
C. IV dextrose and IV hydrocortisone
Congenital adrenal hyperplasia is a deficiency in the enzymes which convert testosterone to cortisol. This accumulates and leads to the virilisation in female infants, and the abnormal male genitalia.
This lack of cortisol leads to a salt-losing crisis, as seen here, with hypoglaceima and vomiting. Replacement of the steroids and the correction of the glucose (C) is the first line management here. Either option in isolation, (A) or (B), is not enough.
Correction of the Hyponatremia needs to be gradual (over 2 days) in order to avoid central pontine demyelination, (E) is far too dangerous. Normal saline (D) will not really do anything for this child.
A 10-year-old boy is brought to the paediatric outpatient department for a review
of his height. He was found to be on the 0.4th centile and his mid-parental
height is the 98th centile. He also has widely spaced nipples, wide carrying angle,
hypogonadism, pulmonary stenosis and developmental delay. What is the most
likely diagnosis?
A. Angelman’s syndrome
B. Williams’s syndrome
C. Turner’s syndrome
D. Prader–Willi syndrome
E. Noonan’s syndrome
E. Noonan’s syndrome
Nonan’s (E) has a similar phenotype to Turner’s (C) but, unlike turners, affects males as well as females.
This case does not present the typical features of the other syndromes given as answer options.
(A) Happy demenour and developmental delay
(B) ‘Elfin’ facial appearance, highly sociable but with developmental delay in other areas, aortic stenosis.
(D) Poor feeding and weight gain in infancy, hyperphagia and obesity in later life.
A 2-week-old baby was referred to the prolonged jaundice clinic by the
community midwife. The pregnancy was unremarkable, and she was born at term
with no antenatal abnormalities on ultrasound (US) scans or blood serology. She
is now 17 days old and has been jaundiced since day 5 of life and never required
phototherapy. She is breastfed and feeds 3-hourly for 20–25 minutes. She is
afebrile and not lethargic. Her mother reports that the stools are pale and she
has dark coloured urine. The bilirubin is 300 μmol/L, and conjugated bilirubin
100 μmol/L. What is the most important diagnosis to exclude?
A. Breast milk jaundice
B. ABO incompatibility
C. Biliary atresia
D. Neonatal hepatitis
E. Hypothyroidism
C. Biliary atresia
Jaundice is an important presenting complaint in neonates. The key to determining the cause is the timing, duration and onset of the jaundice.
Jaundice in the first 24hrs may be due to immune (ABO, or Rhesus factors), or inherited non-immune conditions (Sphereocytosis or G6PD deficiency). The jaundice in these cases is always unconjugated, so option (B) is wrong.
Breast milk jaundice (A) is physiological and appears between 24hrs and 2 weeks, but shouldn’t persist.
Hypothyroidism (E) is important to identify, due to the long term learning difficulties that can arise. It doesn;t present with pale stools, so is unlikely here, and ti should have been detected on the blood spot test.
Neonatal hepatitis (D) can be secondary to congenital infections, or metabolic diseases such as alpa1 anti-trypsin, or cystic fibrosis.
However, the history of dark urine and pale stools s strongly suggestive of biliary atresia (C). This needs to be investigated, as there is a risk of developing cirrhosis.
A 1-day-old baby is on the post-natal ward. You are asked to review her as she is
febrile and lethargic. On examination she is tachycardic, has a capillary refill time
of 3 seconds centrally and reduced urine output. Her blood culture 24 hours later
grows Gram-positive cocci. Which is the most likely causative organism?
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Group B Streptococcus
D. Streptococcus viridans
E. Group A Streptococcus
C. Group B Streptococcus
Group B streptococcus (C), GBS, can colonise the reproductive tract, and is a common congenital infection. Symptoms include; sepsis, pneumonia, meningitis, UTI, and septic arthritis.
All the others can cause sepsis but the three most common congenital infections are; GBS, E.Coli, and Listeria monocytogenes.
A preterm baby is born at 25 + 6 weeks gestation. He is delivered by caesarean section due to maternal pre-eclampsia. He is intubated at birth and given surfactant via the endotracheal tube. He is ventilated and commenced on IV dextrose. After 4 hours of age he has increased work of breathing, with intercostal and subcostal recession and a respiratory rate of 60/min. A chest x-ray shows a ground glass pattern in both lung fields. He has no audible murmur. He is afebrile. You diagnose respiratory distress syndrome. What is the aetiological factor responsible for respiratory distress syndrome?
A. Pneumonitis
B. Lung hypoplasia
C. Surfactant deficiency
D. Immature lung parenchyma
E. Infection with group B Streptococcus
C. Surfactant deficiency
The respiratory distress syndrome here is due to immature type II pneumocytes producing insufficient surfactant (C). This baby is vulnerable to this because of it’s prematurity. The description of ‘ground glass’ pattern is charecteristic of respiratory distress syndrome
of the other options presented here, (A) is present in meconium aspiration syndrome due to irritation of teh lungs by the compounds in the meconium.
(B) is due to a develpmental issue with the lung, secondary to renal issues or diaphragmatic hernia.
(D) isn’t an issue as the lungs are structualy immature, but functional
Any infection (E) would present as increase respiratory effort, but would have focal signs on chest radiograph.
A preterm baby is now 25 + 7 weeks corrected gestation. He is on the neonatal
unit being cared for while his mother recovers on ITU after he was born secondary
to an eclamptic seizure. He has been receiving formula milk as the parents have
not consented to donor breast milk. He has been having bilious aspirates from
his nasogastric tube and today his abdomen in very distended and tense. He has
had one episode of bloody stools. You are going to treat him for nectrotizing
enterocolitis (NEC). What is the best initial management plan?
A. Conservative management, observe and reassess
B. Nil by mouth (NBM), IV antibiotics and emergency exploratory
laparotomy
C. IV fluids, emergency laparotomy and bowel resection
D. IV fluids and IV antibiotics
E. NBM, IV fluids, abdominal X-ray and surgical review
E. NBM, IV fluids, abdominal X-ray and surgical review
NEC is a complex disease with a multitude of risk factors, we see here some of the risks; formula feeding, prematurity and (possibly) ischaemia at birth. This child is showing signs of bowel pathology and so the (already high) suspiscion of NEC is supported.
Active management of this condition is called for, option (A) is not the correct management here.
As with all surgial pathology, the patient should be made NBM and given IV fluids. Option (D) doesn’t account for the need of NBM here.
Options (B) and (C) completely bypass the step of acually imaging the patient and getting a surgical opinion prior to undergoing surgery. Without first gaining a surgical review, I’m not sure who will be carring out this surgery… The F1?
A 3-day-old baby is seen by the midwife for a routine post-natal review. She
notices that he is very floppy and his mother has raised concerns about his poor
feeding. He has a protruding tongue, epicanthic folds, low set ears and sandal gap
toes. She explains to the parents she thinks he may have Down’s syndrome and
refers him to the paediatrician. What is the diagnostic test for Down’s syndrome?
A. Serum alpha fetoprotein, beta human chorionic gonadotrophin,
oestriol, inhibin
B. Gene mutation analysis
C. Clinical diagnosis
D. Karyotype
E. FISH
D. Karyotype
Down’s syndrome is due to trisomy 21 so a karyotype test (D) is all that is needed to identify the additional chromosome.
Screening for Down’s during pregnancy uses the combined test, utilising serum markers and an ultrasound scan. The markers used are as in (A).
It is a trisomy anomolity so there is no gene mutation to find (B). That would be used for a condition such as cystic fibrosis.
Although syndromic conditions can be identified on the clinical picture (C) a true diagnosis needs something more objective!
Fluorescence in situ hybridisation (E) is used to identify micro deletions, as in Digeorge’s or Cri du Chat.
A baby is born by emergency caesarean section due to fetal tachycardia. His delivery was uneventful and you are asked to see him 5 hours later on the post-natal ward. He has just taken his first feed and has been coughing and spluttering since. He had an episode with blue lips transiently and this has now improved; his oxygen saturations are 97 per cent in air and he is apyrexial. On examination, you note other features including vertebral and limb abnormalities, imperforate anus,
pansystolic murmur at the lower left sternal edge and renal anomalies noted on
antenatal scans. What is the most likely cause for his coughing episode?
A. Cleft palate
B. Tracheoesophageal fistula
C. Choanal atresia
D. Incoordinated swallowing reflex
E. Pneumonia
B. Tracheoesophageal fistula
All of the answers offered here can result in a coughing baby , but in this case there are a constellation of symptoms consistent with one overiding syndrome; VACTERAL. This stands for Vertebral, anal imperforation, cardiac, tracheo-(o)esophageal fistula, renal and limb abnormalities. With this in mind (B) is the correct answer here.
Cleft palate (A) is often seen in DiGeorge’s or Down’s syndrome.
Choanl atresia (C) is associated with CHARGE (coloboma, heart defects, atresia choanae,retardation of growth and development, genitourinary abnormalities and ear anomolies) syndrome.
An incoordinated swallow (D) would be expected if there was an underlying neurological or neuromuscular pathology. There is nothing in this history to suggest that.
The child is afebrile so a pneumonia (E) is unlikely to be the cause of thier problems.
A term baby is awaiting his discharge check when you are called to see him at
10 hours of age. His mother reports that he has turned a dusky colour and is not
as alert as he has been. On examination he has central cyanosis, pulse 150 bpm
regular, and both brachial and femoral pulses are palpable. He has normal heart
sounds with no murmur. His oxygen saturations are 65 per cent in air. What is the
most likely underlying diagnosis?
A. Transposition of the great vessels
B. Ventricular septal defect (VSD)
C. Tetralogy of Fallot
D. Aortic stenosis
E. Coartation of the aorta
A. Transposition of the great vessels
This baby is presenting with a cyanotic defect, of the answers here only (A) and Tetralogy of Fallot (C) are cyanotic heart conditions. The Tetralogy of Fallot includes; right ventricular outflow obstruction, Ventral-septal defect, overiding aorta and right ventricular hypertrophy
The differentiator here is that Tetralogy presents more commonly around 6 months of age, not immediately post birth. Transposition of the great vessels (A), where the aorta is connected to the right ventricle and the pulmonary artery is connected to teh left ventricle, is more likely to present at birth. The only thing keeping this child alive at this point is a left-right shunt, such as a VSD, ASD, or his patent ductus arteriosus (which will be closing). He needs a prostaglandin infusion to keep it patent and urgent surgical correction.
All the other options here, (B) (D) and (E), would not cause cyanotic disease.
A 12-hour-old baby on the post-natal ward has just had a seizure lasting
2 minutes. It resolved spontaneously and was generalized in nature. Her mother
had gestational diabetes and poor glucose control in pregnancy. The baby’s birth
weight was 5 kg. There were no abnormalities noted on antenatal US scans or
maternal serology. On examination she has no dysmorphic features and handles
well. What initial blood tests would you do for the baby?
A. Liver function tests
B. Boehringer Mannheim (BM) glucose
C. Full blood count, C-reactive protein
D. Electrolytes
E. Calcium, magnesium
B. Boehringer Mannheim (BM) glucose
This is an infant of a diabetic mother, she is displaying signs that the poor control in pregnancy has had an adverse effect, she is macrosomic at 5kg.
Poor control of glucose at the time of conception predisposes the fetus to congenital malformations, and macrosomia and hypoglycaemia post-natally.
This baby has been exposed to a hyperglycaemic enviroment during pregnancy and this has led to an increased baseline insulin level in the child. With the birth this has now suddenly changed and that high insulin is innappropriate, she has become profoundly hypoglycaemic and has started seizing. A BM test (B) is needed to confirm.
Infection can lead to seizures and (C) would be your test, electrolyte disturbances (A, D, E) would also cause seizures, but all of these are less likely than hypoglycaemia given the history of this case. In the event of a normal blood sugar in the infant then, of course, you would proceed to these tests.
A pregnant woman is admitted to the labour ward for an elective caesarean
section at 38 weeks for her baby who had an antenatal diagnosis of gastroschisis.
The paediatric team are called to attend the delivery. The baby is born in good
condition with no resuscitation required. He is taken to the neonatal unit for
further care. Which of these is a complication of gastroschisis?
A. Dehydration
B. Hyperthermia
C. Necrotizing enterocolitis (NEC)
D. Fluid overload
E. Hypernatraemia
A. Dehydration
Gastroschisis is a condition where the bowel herniates throught eh anterior abdominal wall during fetal development. The bowel is not covered in a membrane, as in the similar condion of exomphalos, and so this can lead to fluid, electrolyte and heat losses.
Gastroschisis is rarely associated with other conditions. the baby will require fluid replacement and the strict monitoring of fluid balance, they will also need to be in a heated incubator and have regular electrolyte monitoring.
Dehydration (A) is a major concern in these patients, there is no increased risk of overload (D). As discussed above hypothermia is a risk, not hyperthermia (B). Loss of electrolytes makes hyponatraemia likely, but not hypernataemia (E).
Finally NEC (C) is no more common in this group than others.
You are called to see a baby who has just been born at 39 weeks’ gestation, as
the midwife thinks he is small and should be admitted to the neonatal unit for his
care. You review the baby. His weight is 1.8 kg, below the 0.4th centile and his
head circumference is 35 cm – 50th centile. He has no dysmorphic features. Which is the most likely cause of this IUGR?
A. Chromosomal anomaly
B. Maternal smoking
C. Congenital infection
D. Maternal alcohol use
E. Placental insufficiency
E. Placental insufficiency
Placental insufficiency (E) classically presents as asymetrical IUGR, we see this here with the disparity between the centiles of the infants head and weight. common causes of placental insufficiency include vascular compromise in the placenta on a background of maternal diabetes or pre-eclampsia.
This is because the placenta is able to supply the fetus’ needs up to a point, and in the later stages of the pregnancy can no longer sufficiently perfuse the fetus. This accounts for the fact that the head circumfirence is less affected by the growth restriction.
all of the other conditions here would be expected to result in symetrical growth restriction as the situation would arise in early pregnancy and endure. It is possible to see this picture of asymetric growth restriction due to smoking (B), but it is not the most likely case.
A mother brings her 4-week-old baby to see you for the third time. He was born at
term by normal vaginal delivery with no complications. You started him on antireflux medicine last week but it has not helped. He is now vomiting his whole feeds and is becoming lethargic and passing less urine and stool. His mother says he is hungry even after he vomits. The practice nurse has weighed him and he has lost 200 g since last week. His mother was breastfeeding him while waiting to be seen and as you go to examine him, the baby has a large milky vomit, which cascades over the clinic floor. What is the most likely diagnosis?
A. Gastroenteritis
B. Volvulus
C. Necrotizing enterocolitis (NEC)
D. Intussusception
E. Pyloric stenosis
E. Pyloric stenosis
This is a classic presentation of pyloric stenosis (E). It presents at 1 month with projectile vomiting, more common in males. The cause is hypertrophy of the pyloric muscle at the gastric outflow, this leads to delayed emptying and increasing vomiting. The description of being still hungry is also typical of the condition.
Volvulus (B) and intussesception (D) would both present as a surgical abdomen, with tenderness, distention and generally being an irritable baby.
NEC (C) is generally a disease of the premature infant, with formula feeding another risk (the case her specifies breastfed). Other signs of NEC are that theh infant will have bile stained gastric aspirates and abdominal distention. It generally presents in term infants who have had a history of birth asphyxia or severe growth restriction.
Gastroenteritiis (A) can occur in young infants, the risk here is in parents who don’t sterilise their bottles. The presentation is a shorter history of vomiting and diarrhoea.
A 15-month-old girl has come to see you with her father. The family are worried
that she has had diarrhoea for more than a month, occasional vomiting and is
losing weight. She used to be a happy interactive baby but now seems lethargic
and miserable most of the time. She has no significant past medical history, the
rest of the family are well and there is no history of travel. Her mother has well controlled type 1 diabetes. The child’s weight at 6 months in the personal child
health record (‘red book’) was on the 50th centile but she is now just below the
9th. What is the most likely diagnosis?
A. Crohn’s disease
B. Ulcerative colitis
C. Coeliac disease
D. Irritable bowel syndrome
E. Giardiasi
C. Coeliac disease
The history of autoimmunity in the mother gives you a cule here. The problems here have only started after weaning so that also gives you a clue that this is dietary induced. The answer here is Coelic (C), it is an anutoimmune condition resulting in sensitiity to dietary gluten, leading to atrophy of the small intestinal villi. Children present with abdominal bloating, diarrhoea, failure to thrive and wasting (classically affecting the gluteal muscles).
Inflammatory bowel disease (A) and (B) are rare in younger children, they tend to start in teenagers.
IBS (D) is rare in a very young child as it tends to have a degree of stress involved in it’s onset. It is a diagnosis of exclusion, and the weight loss is less likely in IBS.
Giardiasis (E) would present like this, but it would be unlikely without a travel history to an endemic area. This is made more unlikely by the fact that noone else in the family is unwell.
A 13-year-boy is brought to see you as he has recently been complaining of
abdominal pain and is increasingly tired. On examination you note some early
clubbing and erythematous palms. His conjunctivae look pale. He has one or
two spider naevi on his chest. His abdomen is soft with mild tenderness in the
epigastrium and right upper quadrant. The liver is palpable at 1 cm and you feel the splenic tip. He has normal bowel sounds and no bruits. On slit lamp examination of his eyes, an amber ring is noted around the cornea. What is the most likely diagnosis?
A. Abdominal tuberculosis
B. Cystic fibrosis
C. Wilson’s disease
D. Acute hepatitis A
E. Glandular fever
C. Wilson’s disease
This child is showing signs of chronic liver failure, he has clubbing, palmar erythema and non-significant spider naevi (5+ is significant).
The slit lamp examination has demonstrated Kayser-Fleischer rings, these are copper deposits around the cornea, and are pathognomic for Wilson’s disease (C).
Wilson’s is an autosomal recessive condition caused by a defect in the metabolism of coper, this leads to copper being deposited in the tssues and leads to liver failure with cirrhosis, neurological problems, as well as renal and cardiac problems. There is also an association with heamolytic anaemias due to cper being deposited in teh red cell membranes. .
Abdominal Turberculosis (A) would not cause the rampant liver failure we see in this case.
Cystic Fibrosis (B) would cause the clbbing we see here, but there is no information of pulmonary findings.
Hep A (D) would not cause this chronic liver failure, the splenic enlargement also doesn’t fit, and there is no jaundice here.
Glandular fever (E), or Epstein Barr virus, would not show signs of chronic liver failure.
The overiding factor here are the finding of the Kayser-Fleischer rings, these are only present in Wilson’s Disease.
An 8-year-old girl is brought to see you, having not opened her bowels in 8 days. She complains of hard painful stools and recurrent abdominal pain for the past 6 months but no vomiting. Her mother thinks that she is avoiding going to the toilet and reports that she has always been a bit irregular opening her bowels, averaging about twice a week. In her past medical history, she passed meconium on day 1 of life and has had no significant medical problems. On examination she is a well-looking, normally grown child. Her abdomen is soft with a palpable indentable mass in the left iliac fossa. The anus is normal, as are her lower limbs. What is the first step in management?
A. Encourage her to increase her fluid intake, dietary fibre and exercise
B. Introduce scheduled toileting with a positive reward scheme such as a
star chart
C. Refer for bowel disimpaction under anaesthesia
D. Start polyethylene glycol with electrolytes such as Movicol
E. Start a stimulant laxative such as senna
A. Encourage her to increase her fluid intake, dietary fibre and exercise
This is a typical presentation of constipation, and the indentable mass in the L.Iliac fossa is impacted faeces. The abscence of, growth failure, delayed meconium passage, distended abdomen and vomiting, neuro signs or anal pathology, are all reassuring that this is not serious pathology.
The correct first line management here is (A) as she is impacted at this stage and needs some help to soften the stool. Once this has been achieved we can look at behavioural changes (B) to prevent recurrence of this situation.
If the lifestyle changes do not produce softer stols, then a non stimulant laxitive (D) may be needed to medicaly disimpact the bowel.
Stimulant laxitives (E) on a background of impacted faeces are likelt to casue more abdominal pain, so should be avoided as there is also a risk of bowel perforation and dependance forming.
Surgical disimpaction (C) would be the absolute last step after all conservative and medical options had failed. It would also be necessary to rule out all potential underlying causes of constipation first.
A 2-week-old baby is brought to accident and emergency by his parents because he has been intermittently inconsolable for the past 12 hours. He does not want to breastfeed and has vomited. The parents think his tummy is upset as he keeps drawing up his legs. He was born at term by normal vaginal delivery with no problems. On examination the abdomen is distended and tense. He is crying and there is a firm swelling in the right groin area. You can hear active bowel sounds. What is the most likely diagnosis?
A. Appendicitis
B. Right inguinal hernia
C. Gastroenteritis
D. NEC
E. Sepsis
B. Right inguinal hernia
the examination findings of a groin swelling and a tense abdomen give you an indication of the likely pathology here. The baby is also vomiting, but you hear bowel sounds, this tells you that there is a partial bowel obstruction. Putting the picture together we see that this must be an incarcerated Inguinal hernia (B). He need to be seen by the surgeons and this needs correcting before it becomes a strangulated hernia.
Appendicitis (A) is common in the ages of 11-20, but very unlikely in an infant as the relative size of the appendix inlet compared to the rest of the bowel lumen doesn’t predispose it to obstruction.
Gastroenteritis (C) can occur in infants, usually if the parents are not sterilising the bottles and water for the feeds correctly. The history here is a bit more substantial, and the groin swelling goes against this.
NEC (D) is usually seen in premature babies, or those who have suffered birth hypoxia or severe growth restriction. Abdominal distention and bile stained gastric aspirates are the hallmarks of NEC.
If this was a more ambigious history and lacking in abdominal signs then you may well treat with IV antibiotics for a neonatal sepsis (E).
Of note here; any inguinal hernia mandates a surgical review, c.f. umbilical hernias will self resolve without surgical intervention.
A 5-year-old girl is brought to accident and emergency with a 24-hour history of
vomiting and diarrhoea and now her eyes and skin have gone very yellow. She has been taking oral rehydration salts and is still passing urine. She is normally healthy and there is no family history of jaundice. On examination her heart rate is 130 and respiratory rate is 26. She is alert, warm and well perfused. The chest is clear, heart sounds are normal and the abdomen is soft with a 2 cm liver edge. What should the management be?
A. Reassure and discharge home, to return if not keeping fluids down
B. Take bloods to test for liver function, hepatitis, and urea and
electrolytes; inform the Health Protection Agency and discharge home
with follow-up to review results
C. Take bloods to test for liver function, hepatitis screen and urea and
electrolytes and admit for IV fluids
D. Take bloods to test for liver function, hepatitis screen and urea and
electrolytes and admit for observation with continued oral rehydration
salts
E. Take bloods to check liver function and urea and electrolytes. If they
are normal, discharge home with reassurance but to return if not
keeping fluids down
B. Take bloods to test for liver function, hepatitis, and urea and
electrolytes; inform the Health Protection Agency and discharge home
with follow-up to review results
The most likely cause of this childs jaundice is hepititis A, it is important to know that Hep A is a notifiable disease. There are a lot of them and they can be found here:
https://www.gov.uk/notifiable-diseases-and-causative-organisms-how-to-report
Essentially they are all contagious and serious diseases, the helath professional has a statutory duty to notify the proper authority on suspicion of one of these diseases (you are not to wait for laboratory confirmation).
Knowing this we can straight away exclude all of the answers except (B).
Even without knowing that, the child has a palpable liver and is jaundiced, so investigation is needed, This excludes (A). She is drinking and remaining hydrated, so IV fluids are not needed (C).
(E) doesn’t actually perform a hepatitis screen
(D) admits the patient, which is an infection risk, and doesn’t inform the HPA.
A 15 year old with well-controlled type 1 diabetes presents with frank
haematemesis. Her blood tests in accident and emergency show: pH 7.37, glucose
18.3 mmol/L, haemoglobin 12.3 g/dL, white cell count 5.3×109/L, neutrophils
2.1×109/L, platelets 165×109/L, Na+ 135 mmol/L, K+ 3.5 mmol/L, urea 5.0 mmol/L,
creatinine 83 μmol/L, alanine transaminase 740 IU/l, bilirubin 96 μmol/L, alkaline
phosphatase 102 IU/l, and albumin 25 g/L. Further investigations once she is
stable on the ward show hepatitis B surface antigen negative, anti-hepatitis C virus
negative, anti-nuclear antibody (ANA) 1:320 and anti-smooth muscle antibodies
are positive. What is the most likely diagnosis?
A. Autoimmune hepatitis with varices
B. Metabolic ketoacidosis
C. Gastroenteritis with a Mallory–Weiss tear
D. Pregnancy with hyperemesis and a Mallory–Weiss tear
E. Systemic lupus erythematosus (SLE)
A. Autoimmune hepatitis with varices
It is important here to recognise that type I diabetics can also suffer from other autoimmune conditions. The most commonly occuring with diabetes are Grave’s disease and Coeliac disease, these are screened for on a yealy basis.
Autoimmune Hepatitis (A) is more comon to be found in females and typically presents between 10 and 30, as either a chronic liver failure or an acute hepatitis. The ANA will be positive in around 80% of cases and the Anti-smooth muscle will be positive in 70%.
Ketoacidosis (B) is incorrect as we can see her pH is normal. The raised glucose is a stress responce.
There is no history of diarrhoea, and there are normal amounts of white cells so this makes gastroenteritis (C) unlikely. You would probably still isolate her in a side room to be prudent.
Although there is nothing to suggest pregnancy (D) in the history, it wis always wise to test any woman of childbearing age who has abdominal pathology.
SLE (E) would have a positive ANA, but it would not have a positive anti-smooth muscle. There is nothing else in this history consistent with SLE.
An 18-month-old child is brought into accident and emergency with a 2-day
history of vomiting, abdominal pain and fever. Which of the following is an
unlikely cause of this clinical picture?
A. Lower lobe pneumonia with pain referred to the abdomen
B. Mesenteric adenitis
C. Diabetic ketoacidosis
D. Pyelonephritis
E. NEC
E. NEC
NEC (E) (necrotising enterocolitis) classically affects premature infants, or those with severe birth hypoxia or severe growth restriction. It has an onset in the neonatal period, not in an 18-month old child.
A lower lobe pneumonia (A) may present with abdominal pain and fever, any respiratory tract infection in the young can present with vomiting. The infalamed airways cause a gag reflex, and the increased work of breathing increased the intra-abdominal pressure.
Mesenteric adenitis (B) has this presentation, and is the likely pathology here. It is, however, a diagnosis of exclusion. it is caused by an inflammation of the mesenteric lymph nodes, it can be mistaken for appendicitis.
Diabetes (C) is extremely rare, but not impossible, in a child this young. An illness could cause the condition to manifest for the first time with an episode of ketoacidosis. vomiting would be a typical presenting symptom.
Pyelonephritis (D) is always one to rule out in a child with fever and vomiting.
A 13 month old is referred up to her local district general accident and emergency
by a GP who is concerned she has intussusception following an 18-hour historyof fever, vomiting and intermittent colicky screaming. A kind radiologist agreed
to do an urgent ultrasound which shows an area of invaginated bowel in the right
side of the colon. What is the most appropriate management?
A. Ask the radiologist to attempt a reduction by rectal air insufflation and
if this fails make nil by mouth (NBM) and transfer to a local paediatric
surgical unit
B. Make NBM and start intravenous fluids while waiting for transfer to a
paediatric surgical unit
C. Move to theatre for an attempt of rectal air insufflation reduction and if
this fails move to surgery in the local hospital as the patient will be too
unstable for transfer
D. Make NBM, start IV fluids and admit for observation
E. Make NBM and start intravenous fluids, and book him onto the
emergency theatre list as he is too unstable for transfer to a local
paediatric surgical unit
B. Make NBM and start intravenous fluids while waiting for transfer to a
paediatric surgical unit
Although up to 75% of cases of intussuception can be corrected by insufflation, those that fail carry a risk of perforation. It is for this reasont that it should not be attempted without suitably equiped paediatric surgical facilities available. We see here that you have been specifically told that you are at a district general hospital, so the author wants you to recognise that you will not have the facilities for surgery on a 13-month old infant.
As such the only option here is to transfer to a more specialised hospital (B), taking care to manage the patient with NBM and fluids.
Which of the following is not a cause of PR bleeding?
A. Constipation with an anal fissure
B. Intussusception
C. Meckel’s diverticulum
D. Bacterial gastroenteritis
E. Abdominal migraine
E. Abdominal migraine
Often the first symptom of a migraine in children is with abdominal pain. This would be higher on the list of differentials if there was a family history of migraines.
If there was PR bleeding then it stands to reason that a diagnosis of migraine (E) becomes dificult to support, and bowel pathology should be sought.
The most common cause of PR bleeding in children is constipation with an anal fissure (A). You would expect bright red streaks of blood on the tissue or the surface of the stool.
Interssusception (B) presents with ‘redcurrant jely’ stool as an uncommon late stage symptom. It is due to the distal segment of bowel becoming necrotic and this is a mix of blood and mucus. There is a severe risk of perforation during insufflation at this late stage. It really should have been picked up before this.
A Meckel’s diverticulum (C) is fond in 2% of the population. It is an ileal remnant of the embryological yolk stalk, which can lead to ulceration and perforation, which then leads to severe dark red rectal haemorrhage.
A bacterial gastroenteritis (D) caused by Salmonella or Shigella may produce blood and /or pus mixed with the stool.
A mother brings her 2 year old to see you. She is very worried that he always
has diarrhoea or loose stools. He eats a normal diet, and no particular foods seem
to upset him but he often still has bits of vegetables or food he has eaten visible
in the stool. She thinks he is losing weight and he is starting to potty train, so
she is concerned this will affect his ability to anticipate needing the toilet. On
examination he is an alert and well-looking child with a normal capillary refill, heart
and respiratory rate. His abdomen is soft with no masses, there is no evidence of
wasting and his weight and height are following the 50th centile. What is the most
appropriate management?
A. Reassure the mother, explaining this is toddler’s diarrhoea and he will
grow out of it
B. Start loperamide as toddler’s diarrhoea is affecting his toilet training
C. Refer for endoscopy and biopsy to rule out coeliac disease
D. Refer for a colonoscopy and biopsy for inflammatory bowel disease
E. Order a blood test for thyroid function to rule out hyperthyroidism
A. Reassure the mother, explaining this is toddler’s diarrhoea and he will
grow out of it
Todler’s diarrhoea is a common cause of loose stool in children of pre-school age, it normally requires no treatment (A). The symptoms are linked to immature development of intestinal motility, and will usually resolve around 5 years of age.
There is a case for intervention if the symptoms are socially disruptive, if the can’t start school for example, in that case loperamide (B) would be indicated.
He is only just started to potty train, so this needs time to be implemented.
He is growing well and his weight and height are in line with each other and are in normal ranges, There is also no mention of any wasting, so coeliac disease (C) is unlikely. Of note, the first investigation for celiac is a blood test for anti-endomesial antibodies, not an invasive test like an endoscopy.
There is no sign of growth failure, bloody stools or the passage of mucus, making an inflammatory bowel disease (D) unlikely. The age of presentation for IBD is more commonly the late teens or early 20’s.
Although diarrhoea is a common symptom of hyperthyroid (E), it is a conditon more common in female teenagers or in the neonatal period in infants of Grave’s disease mothers. He has no other features consistent with hyperthyroidism; restlessness, increased appetite, tachycardia, or sweating.
A 10-year-old boy presents with recurrent mouth ulcers, abdominal pain,
distension and frequent episodes of diarrhoea with mucus. He has been losing
weight. On examination he is slim and plotting his growth shows a fall in weight
from the 50th centile to below the 9th. His abdomen is soft with generalized
discomfort on deep palpation but no masses are present. What is the most likely
diagnosis?
A. Ulcerative colitis
B. Crohn’s disease
C. Coeliac disease
D. Gastroenteritis
E. NEC
B. Crohn’s disease
The salient points here that give the diagnosis of Crohn’s disease (B) are:
Mouth ucers -Crohn’s is charecterised by skip lesions that can affect the entire digestive tract, from vermillion border to the anus. Distinguishes this case from Ulcerative Colitis (A)
Abdominal pain and distention - Gives an indication that this is serious pathology.
Frequent diarrhoea with mucus - This is a halmark of inflamatory bowel disease, the prescence of mucus goes against Coeliac (C) and Gastroenteritis (D).
Falling weight crossing the curves - again, gives an indication of serious pathology, and it tells you that this is a chronic illness. It is not Gastroenteritis (D).
In sumary the age of presentation (10 years old) excludes NEC (E), a disease of the newborn, and you would expect Coeliac to be a serious problem soon after weaning. That just leaves the inflamatory bowel disease, often the two are hard to distinguish in a clinical setting. In this case the mouth ulcers are your only discriminator, UC (A) is a disease of the rectum with a proximal spread, whereas Crohn’s is a multi site condition that is also more likely in younger patients.
A 15-year-old boy comes to see you, complaining of recurrent abdominal and back
passage pain relieved by passage of diarrhoea. He is also complaining of low back
and knee pain and last week there was blood mixed into his stool. He has been
losing weight recently. On examination he is slim and looks pale. His abdomen
is soft but tender in the left iliac fossa with no masses. What is the most likely
diagnosis?
A. Ulcerative colitis
B. Crohn’s disease
C. Coeliac disease
D. Gastroenteritis
E. NEC
A. Ulcerative colitis
Ulcerative colitis (A) can affect any age, but it is significantly more prevalent in the teenage years and early 20’s. It is a reccurent and chronic inflammatory disease of the rectum, which spreads proximally. It ‘never’ crosses the illieo-caecal valve
It has extra-intestinal symptoms, some of which can be seen in this case; sero-negative arthritis, spondylitis, pyoderma gangrenosum, erythema nodusum.
Crohn’s (C) is difficult to distiguish, but the history of back and joint pain is your clue here that it is UC.
Coeliac (C) would usually present at a younger age, it is charecterised by malnutrition, wasting and abdominal bloating. In the rare cases of coeliac that there is blood in the stool, it would be digested blood, not frank.
Gastroenteritis (D) is unlikely as this is a very chronic picture of disease, and the joint/spine involment doesn’t fit.
NEC (E) is an illness of the newborn, presenting with abdominal distention and bile stained aspirates.
Ninety-nine per cent of healthy term infants will pass meconium within the first
24 hours of life and all should do so within 48 hours. Which of the following is
not a cause of delayed meconium passage?
A. Hirschsprung’s disease
B. Cystic fibrosis with a meconium ileus
C. Choanal atresia
D. Imperforate anus
E. Meconium plug syndrome
C. Choanal atresia
Choanal atresia (C), despite the name, has nothing to do with the anus. It is a congenital blockage of the nasal airway. This leaves the infant in respiratory distress as they are obligate nose breathers.
Hirschprung’s (A) affects around 1 in 4000 and is the abscence of ganglion cells in the mesenteric and submucosal plexi in the rectum or colon. It leads to a norrowed section of bowel where it is denervated. The lack of movement in this section of bowel causes the delay in meconium passage. It is managed by a surgical resection of the denervated bowel section.
Cystic Fibrosis (B) results in inspissated (thickened) meconium which then has difficulty being passed. It will result in meconium ileus in around 20% of cases of cystic fibrosis.
An imporforate anus (D) is rarer than Hischprung’s and will need surgical intervention.
Meconium plug syndrome (E) is the commonest cause of delayed meconium passage. It results from a transient immaturity of the gut, it is managed with anal stimulation using a glycerine chip.
A 3-month-old baby is brought to accident and emergency because he has been
vomiting and having diarrhoea for the past month. His mother breastfed him until
he was 8 weeks old and he is now taking formula milk, 4–5 oz every 4 hours. On
examination he is alert but fussy and looks thin. He has eczema on his face, neck
and torso and the mother says this is new. The abdomen is soft, the genitalia are
normal with a significant nappy rash and the anal margin is erythematous. You
plot his growth in his red book and find that he was born on the 50th centile and
was following that but now he is on the 25th centile for weight. What is the most
likely diagnosis?
A. Cow’s milk protein intolerance
B. Lactose intolerance
C. Gastroenteritis
D. Hyper IgE syndrome
E. Wiskott–Aldrich syndrome
A. Cow’s milk protein intolerance
The onset of eczema since ending breastfeeding, the nappy rash, and the anal inflammation, all point towards a Cow’s milk protein intolerance (A).
This is an allergic reaction to the protiens within the cow’s milk, and is distict from lactose intolerance (B). This intolerance to cow’s milk protein usually presents with exposure in infancy, although if the intolerance is particularly severe the small amount of protein from a dairy consuming mother that is found in breastmilk is enough to cause problems.
The infant presents with worsening skin inflammation (eczema), Diarrhoea (potentially bloody), vomiting, failure to thrive, colic and irritability.
Lactose intolerance (B) is a deficiency in acose dehydrogenase, the build up of lactose in the gut creats an osmotic draw, leading to diarrhoea and dehydration. The intolerance is usually acquired following an episode of acute gastritis, but it can be congenital. The non-GI symptoms here are not consistent.
The history is too long for gastroenteritis (C) and the other symptoms are not consistent.
Hyper IgE syndrome (D), or Job’s syndrome, is an autosomal dominant immunodeficiency (you would think a parent having the condition would be mentioned) which leads to skin boils and severe eczema, but no gastrointestinal manefestations.
Wiskott-Aldrich syndrome (E) is also associated with eczema, as well as thrombocytopenia, and lymphopenia, but no gastrointestinal symptoms. It is an x-linked recessive disorder.
A 15-year-old Asian girl with Down’s syndrome came to accident and emergency with a prolonged fever. She has severe learning difficulties and was difficult to assess. Her parents think she is more unsettled than usual and not eating and drinking properly for the last 3 weeks. She is admitted as you cannot confidently find the source of the infection, but she has no cough, rash, vomiting, diarrhoea or meningism. The next day she complains of a headache and starts to vomit. She has a CT scan which is normal and then a lumbar puncture (LP). White cell count (WCC) 150×109/L (20 per cent neutrophils), red blood count 0, protein 2 g/L, glucose 1.2 mmol/L (serum glucose 6.0 mmol/L). What is the most likely cause of this meningitis?
A. Mycobacterium tuberculosis
B. Herpes simplex virus (HSV)
C. Streptococcus pneumoniae
D. Cryptococcus neoformans
E. Neisseria meningitidis
A. Mycobacterium tuberculosis
This is a very slow and indolent history of meningitis, it’s cetainly not consistent with the main bacterial causes of meningitis in the UK; S.pneumoniae (C) and N.Meningitidis (E).
Cryptococcus (D) is seen more in the immunosuppressed patients, such as those with untreated HIV infection.
HSV (B) results in encephalitis which is clinically difficult to distinguish from meningitis so should be empirically treated until laboratory confirmation. In this case we are told that this is meningitis, not encephalitis.
You are on elective in Uganda and spending the day on the paediatric ward. You
are told that it is the rainy season and malaria is now becoming increasingly
problematic. Almost all the children on the ward are suffering with the effects of
malaria. The first child is a 5-year-old boy with a cyclical fever, abdominal pain
and a 4 cm splenomegaly. He has 2 per cent parasitaemia on blood film. You are
asked how you would treat this child. What is the best initial management step?
A. IM quinine
B. IV fluids and IV quinine
C. IV fluids and prophylactic splenectomy
D. Emergency splenectomy
E. Oral atovaquone
B. IV fluids and IV quinine
This child has a moderate parasitaemia at 2%, a level above 5% would be considered severe. He needs IV antimalarial treatment and fluids is prudent here (B).
The splenomegaly here is secondary to acute haemolysis, unles there are clinical signs of a splenic rupture he shouldn’t undergo a splenectomy (C) or (D).
When this child is improving he could be switched ot oral anti-malarials (E)
A 3-year-old girl presents to accident and emergency with a 6-day history of fever
and she is over 38°C when measured by her mother with a tympanic thermometer.
She has become very miserable for the last few days. She has developed a rash on her trunk, which is blanching, erythematous and confluent. On examination, you
also note bilateral non-purulent conjunctivitis, cervical lymphadenopathy, and a
red tongue with lip cracking. Her extremities are also erythematous but not peeling. WCC 14×109/L, C-reactive protein 200 mg/L, and erythrocyte sedimentation rate 60 mm/hour. Blood culture is pending. What is the diagnosis?
A. Staphylococcal scalded skin
B. Toxic shock syndrome
C. Scarlet fever
D. Kawasaki’s disease
E. Measles
D. Kawasaki’s disease
Kawasaki’s (D) is an inflammatory disease of unknown origin, this girl has all of the features. All of the other conditions do share some symptoms with Kawasaki’s though. The serious complication that can arise is that there can be coronary artery aneurysms. The distinct feature in this case in the bilateral non-purulent conjunctivitis and the almost pathognomic ‘very misearble child’.
Of the other options here; Staph scalded skin (A) causes fever with peeling skin.
Toxic shock (B) presents as a red macular rash, fever and normally diarrhoea. There would be expected to be some route of intoxication with bacterial toxins (prolonged tampon use being the usual route), as this girl is 3 she lacks the risk factors.
Scarlet fever (C) has a ‘sandpaper’ rash and erythematous mucous membranes.
Measles (E) is now extremely rare, but thanks to anti-vaccinators is making a comeback, as such it should be kept in mind. It causes a febrile child with an erythemotous macular rash.
A 3-year-old boy presents with a right swollen eyelid. He has had a cold for the
last week but his eyelid started swelling yesterday. He has had no injury or broken
skin around the eye. On examination, his right eye is swollen and red, there is no
discharge, he is now unable to open his right eye and he has proptosis. You are
concerned about the complications of this infection. Within the last hour he has
become more drowsy and started to vomit. His observations are all normal. What
is the concerning complication in this case?
A. Visual loss
B. Abscess
C. Septicaemia
D. Orbital cellulitis
E. Meningitis
E. Meningitis
All of the answers here can be complications of orbital celulitis, the alarming feature here is the reduced level of conscious and the vomiting, both of which point to neurological pathology.
If there was focal neurology then it would make an abcess (B) more likely, this level of global neurological impairment is more charecteristic of meningitis (E). The route of infection here is likely to be the cellulitis spreading to the CSF surrounding the optic nerve.
The other possibility here is that septicaemia (C) has lead to shock and this hypoperfusion is causing the symptoms we see, but there isn’t anything to go on here to sugest that specifically.
(A), (B) and (D) all need investigating with a CT head and an opthalmology review.
A 14-year-old girl presented to the GP with an enlarged lymph node in her neck.
She first noticed it 3 weeks ago and it is increasing in size. She has also had a
dry cough, fevers, night sweats and weight loss. She has had a poor appetite over
the last 2 weeks, which her mother blames for her weight loss. There is no history
of foreign travel or tuberculosis (TB) contacts. A chest x-ray shows a mediastinal
mass. What is the most likely diagnosis?
A. Lymphoma
B. Pneumonia
C. TB
D. Lung tumour
E. Leukaemia
A. Lymphoma
Here we have a girl with a prolonged history of fever, this raises the possibility of a non-infectious cause.
We have been told that there are no TB contacts and the CXR shows a mediastinal mass, which is not typical of TB (C) or a pneumonia (B).
A primary Lung tumour (D) is very rare in children, so this is unlikely.
With the lymphadenopathy lymphoma and Leukaemia (E) are potenitals, a lymph node biopsy and a blood film and bone marrow aspirate is neded. Given that she has a mediastinal mass causing a dry cough and the ‘B’ symptoms Lymphoma is more likely.
A 6-year-old girl presents to accident and emergency with a fever. She has no
history of cough, cold, vomiting, diarrhoea, rash, headache or joint pain. On
examination, she is tachycardic at 150 bpm and there are two petechial spots on
her right ankle. Her capillary refill time is 4 seconds and she has cold feet. All
her other observations are normal. What is the most appropriate course of action?
A. Inform the consultant about child protection concerns
B. IV ceftriaxone
C. IV fluid bolus and IV ceftriaxone
D. Admit to the ward for observation
E. Discharge home and advise to return if the rash spreads
C. IV fluid bolus and IV ceftriaxone
This girl has subtle, but distinctive signs of meningococcal sepsis. The prescence of petechial spots, with a fever, and clinical signs of shock means that antibiotics must be comenced straight away (B and C). The tachycardia, and slow capillary refil time indicate early shock, so a fluid bolus is needed (C).
Any bruising should make you think of non accidental injury, but in this case there is a rather obvious pathology at work so (A) is incorrect.
She needs urgent treatment so (D) is incorrect, and (E) is just plain negligent.
A 3-year-old boy was brought to accident and emergency with his mother. She says he has been limping for a day now and refusing to walk for the last 2 hours. He has had a fever to 39°C which can be brought down with paracetamol. He has had no vomiting, diarrhoea, rash, cough, coryza or injury. He lives with his mother and is her only child. She is currently unemployed and has a background of depression. On examination of the right leg he has a swollen thigh and cries inconsolably when it is touched. It is red and tender. He refuses to allow movement of the hip either passive or active. The left leg is unremarkable on examination. What is the most likely diagnosis?
A. Perthes’ disease
B. Septic arthritis
C. Fractured femur due to accidental injury
D. Juvenile idiopathic arthritis
E. Fractured femur due to non-accidental injury
B. Septic arthritis
This child is presenting with fever and a limp, he also has a reduced range of movement and signs of acute inflammation over the hip joint. All of this makes a septic arthritis (B) affecting the right hip the most likely diagnosis here.
Perthe’s disease (A) usually affect older children, those older than 5, it results from an avascular necrosis of the femoral head. The pathology of which is unclear. You wouldn’t expect the child to be febrile with localised inflammation.
Without a reported history of trauma we can exclude accidental injury (C), non-accidental injury (E) must always remain in mind. This is particularly true given the social background of deprivation and depression, but it isn’t the most likely diagnosis here.
Juvenile idiopathic arthritis (D) is diagnised after 6 weeks of joint pain and swelling that is unexplained after other diagnoses have been excluded.
A pregnant woman attends her booking appointment at the antenatal clinic and
has her routine blood tests done. She is now 13 weeks pregnant with her first child
and you have a positive result for cytomegalovirus (CMV) IgM. You need to discuss
the implications of CMV infection on her unborn child. Which of the following are
not features of congenital CMV infection?
A. Deafness
B. Intrauterine growth retardation
C. Hydrocephalus
D. Thrombocytopenia
E. Congenital cardiac defects
E. Congenital cardiac defects
All of the features here are possible sequale of congenital CMV infection, apart from congenital cardiac defects (E), which are seen in other conditions such as congenital rubella.
Mothers are screened for CMV during pregnancy as standard, along with CMV they are also screened for Hep B, rubella, Syphilis, and HIV.
This is different to the newborn screening test, the TORCH screening which looks for;
toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and HIV
A 5-year-old girl was admitted to the ward after she presented to her local accident and emergency with diarrhoea. She was passing 7–8 loose, watery stools per day for the last 4 days and had been vomiting for 1 day prior to this. There was blood in the stools and this had worried her mother. You ask about foreign travel and her mother reveals they had been in India until 2 weeks ago, staying with family and drinking tap water. She had no vaccines prior to travelling. On examination, she now has abdominal pain, swinging pyrexias, right upper quadrant tenderness but no rebound or guarding. You notice a pale pink (rose) spot on her trunk. What is the most likely infecting organism?
A. Rotavirus
B. Shigella spp.
C. Vibrio cholerae
D. Salmonella typhi
E. Escherichia coli 0157
D. Salmonella typhi
Of the organisms on this list, Rotavirus (A) is by far the most common cause of gastroenteritis in the world, it accounts for over 50% of cases. In this case, however, there are some unusual features which would make you suspect another cause, the distictive rose spot and the blood in the stols.
A 10-month-old baby is brought to accident and emergency by ambulance having
had a seizure. His mother reports that he went floppy suddenly and then his right
arm and leg started shaking and he was not crying. It lasted less than 5 minutes
and he was sleepy afterwards. He has had a fever and runny nose for the last
2 days and is off his food. Why is this not a febrile seizure?
A. He is too young
B. He has had a focal seizure
C. He has recently had a viral illness
D. The seizure lasted too long
E. The fever was not high enough
B. He has had a focal seizure
Febrile seizures are common in children aged 6 months to 6 years, this makes (A) an incorrect answer. It is believed that they occur due a rapid rise in body temprature at the start of a febrile illness. This is particularly the case for viral illnesses., so (C) is spurious.
There is no agreed range of tempratures that put children at risk for a febrile seizure, so (E) is oncorrect.
Any seizure lasting less than 5 minutes that is self resolving is classified as a simle seizure, so (D) is not correct.
The answer to this question is that the focal nature (B) of the seizure excludes the possibility of this being a febrile seizure. Focal neurology points to focal pathology, this child needs a head CT and antibiotic cover for a potential bacterial meningitis or abcess, as well as antivirals for herpes simplex virus (potentially this is caused by meningoencephalitis).
A 4-year-old boy has been brought into accident and emergency with breathing
problems. He is assessed by the paediatric team and found to have inspiratory and expiratory stridor, audible wheeze, lip and tongue swelling, and an urticarial rash on his trunk and abdomen. His heart rate is 167 bpm and his respiratory rate is 40, BP 90/45 mmHg. What is the single most important management step?
A. Do not examine his throat as this may distress him
B. Give a normal saline fluid bolus
C. Give IV adrenaline 0.1 mg/kg of 1:10 000
D. Give IM adrenaline 0.01 mg/kg of 1:1000
E. Mobilize the paediatric anaesthetist as his airway is compromised
D. Give IM adrenaline 0.01 mg/kg of 1:1000
It’s vital here that you recognise this as an anyphlactic reaction, there are cardiac and respiratory involvement with signs of systemic shock (tachycardic and hypotensive).
A fluid bolus (B) is needed here due to the distributive shock, but it doesn’t solve the root cause of the shock, so is not the most important step.
In order to stop the capilliary leakage and the swelling you need to give adrenaline, in anaphylaxis the adrenaline needs to be given IM not IV (C), IV adrenaline is used in the cardiac arrest protocol.
A paediatric anaesthetist (E) will be needed to assess the airway, and that should be called for but not before giving the adrenaline as it will slow further airway compromise.
It is important to be aware that there is a biphasic reaction, and the child may have another reaction in 6-12 hours despite no further contact with the allergen, long after the adrenaline has worn off. This is why steroid and antihistamine cover is the normal procedure.
(A) is a consideration in bacterial induced airway obstruction, seen in epiglotitis or bacterial tracheitis.
John is a 2-year-old boy whose mother has been concerned about a cough for the
last 2 weeks which started out of the blue. He has been previously fit and well
with no respiratory or cardiac problems from birth. There is no family history of
illness. He is thriving and eating as normal, but has a persistent cough, recently
productive of yellow and slight blood stained sputum. You suspect that John may
have a pneumonia and lung collapse secondary to an inhaled foreign body. Which
is the most likely location of this boy’s foreign body?
A. Left lower lobe
B. Right upper lobe
C. Right middle lobe
D. Left upper lobe
E. Right lower lobe
C. Right middle lobe
The right main brochus is the most vertical and it’s the shortest, as such it is the site for the majority of inhaled foreign bodies.
Of the three lobes, it is the middle lobe (C) that has the most direct parth in terms of it’s bronchi, so it is the most likely location for this inhaled object.
See the attached image.
A 2 year old is brought in by ambulance after pulling a pot of boiling water off
the stove down on top of himself. He has significant burns to the whole of his face,
chest and right arm. Estimate the percentage body surface area affected.
A. 20 per cent
B. 30 per cent
C. 40 per cent
D. 50 per cent
E. 60 per cent
With paediatric burns, it is useful to remember the rule of 9’s
Each arm is 9%, the chest is 2x9% (18%) and the back us another 18%
The head is another 18%
The remaining 28% is the legs (doesn’t really fit with the rule, sorry).
Using this rule in this case; 9% for the face, 18% for the chest, and 9% for the right arm = 36% which is closest to (C)
A burn of 50% (D) or 60% (E) would be very extensive.
