Paeds Flashcards
Liam Hogan is a 12 year old boy who presents with a persistent dry cough, worse at night. He reports coughing fits which he finds it hard to catch his breath from and reports a multiple episodes of coughing until he vomits. You perform a nasopharyngeal swab and PCR is positive for pertussis. How long must Liam be excluded from school?
For 14 days after the onset of cough
For 28 days after the onset of cough
Until the child has received antibiotics for 24 hours
Until the child has received antibiotics for 48 hours
Until the child has received antibiotics for 5 days
He must be excluded from school for 21 days after the onset of the cough or until he has completed 5 days of antibiotics.
Australian Government Department of Health. Pertussis CDNA National Guidelines for Public Health Units. Updated 2015.
Ruby is a 7 year old girl who is brought in by her Mum Sarah. Ruby is still needing to wear a pull up nappy at night due to bed wetting. Ruby is continent of urine during the day, but has never been dry overnight. Sarah says she always thought Ruby would just ‘grow out of it’, but this does not seem to be happening. Ruby has a school camp early next year where she is going to have to sleep a night away from home. She wants to be out of pull ups by the time she goes away on camp. Which management strategy for nocturnal enuresis has the best evidence for long term efficacy?
Desmopressin
Education about enuresis and the high rate of spontaneous resolution
Enuresis alarm
Fluid restriction
Motivational therapy (eg star chart)
Enuresis alarms have the most evidence for long term efficacy in nocturnal enuresis. Desmopressin is more effective in the short term, but has a higher relapse rate.
Lina brings her 2 month old child, Ruby, to see you. She says that Ruby has noisy breathing, which she thinks has been present since not long after her birth. Lina notices it when she is breathing in and Ruby doesn’t seem distressed by it. Sometimes though she will get upset during breast feeding, and has been taking formula by bottle for more of her feeds recently. On examination, you note a high-pitched cog-wheel inspiratory stridor. Ruby is seen by a paediatrician and diagnosed with larynogomalacia.
Lina asks when this condition will likely resolve. Which of the following is correct? Choose one (1) option.
1 - 2 years of age
6 months of age
4 months of age
3 - 4 years of age
5 years of age
The correct response is: 1 - 2 years of age
As stated in eTG:
“Some children present with a chronic ‘cog-wheel’ high-pitched inspiratory stridor that has been present from birth or the first few days or weeks of life. The most common cause is laryngomalacia. The stridor resolves spontaneously at 1 to 2 years of age. Alternatively, inspiratory stridor that develops for the first time at 6 to 8 weeks of life, worsens and becomes biphasic (present in both inspiration and expiration) may be due to a subglottic haemangioma. Most cases of chronic stridor in infants need referral.”
Leo Walker is a six year old boy who presents with a two day history of left hip pain. He denies any trauma to the hip. On examination his temperature is 38.2 degrees Celsius. Any movement of the left leg causes him pain and he cannot weight bear. What is the important diagnosis to consider in Leo?
Bone cyst
Fractured hip
Idiopathic chondrolysis of the hip
Transient synovitis
Juvenile idiopathic arthritis
Malignancy
Muscular strain
Osteoid osteoma
Osteomyelitis
Perthes disease
Septic arthritis of the hip joint
Slipped femoral epiphysis
Any child presenting with acute onset joint pain with reduced movement, refusal to weight bear and fever has septic arthritis until proven otherwise.
Royal Children’s Hospital Melbourne. Clinical Practice Guidelines. Osteomyelitis and septic arthritis. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Osteomyelitis_and_Septic_Arthritis/ (Accessed Jan 2020)
Sharon Frost is a long term patient of yours, and at the end of her consult she asks if you think she should bring her 12 year old daughter in for review. Sharon is worried that her daughter has not had her first period yet, whereas all of her friends around her age have. Sharon reports that her daughter does have some breast bud development and pubertal hair growth.
At what age should a girl be evaluated for primary amenorrhoea if her menses have not occurred in the presence of normal growth and secondary sexual characteristics?
10 years old
11 years old
13 years old
15 years old
17 years old
Primary amenorrhoea is defined as the absence of menses at age 15 in the presence of normal growth and secondary sexual characteristics, or if menarche does not occur within 3 years of breast development.
Jimmy is a three month of baby brought in by his parents to discuss the large birthmark on his face. They were advised by the obstetrician at birth to see you to discuss management of the lesion. Jimmy was born at term via normal vaginal delivery after an uncomplicated pregnancy. He has no medical conditions and takes no regular medications. He has no known allergies.
On examination, you note a large erythematous area over Jimmy’s left eye and cheek as pictured below.
port wine stain
What do you advise Jimmy’s parents in terms of management of the lesion?
Advise that the lesion will likely self-resolve over the next few years
Advise referral for consideration of a trial of oral propranolol under specialist guidance
Advise that the lesion will not self-resolve but is likely to become smaller and lighter with time
Advise referral for further investigation of possible associated neurological and ophthalmological abnormalities
Advise treatment with laser therapy for cosmetic reasons
The correct response is: Advise referral for further investigation of possible associated neurological and ophthalmological abnormalities.
Jimmy has a port wine stain (neavus flammeus) which is a capillary vascular malformation. They occur in approximately 0.3% of newborns and they tend to become darker and thicker over time. Port wine stains do not self-resolve. As Jimmy’s port wine stain affects the V1 & V2 distribution on his face, he will require further investigation including an ophthalmological examination and possible neuro-imaging to exclude associated abnormalities.
Kelly is a 15 year old girl who has been brought in by her concerned mother because she has recently become interested in animal rights and has become vegan. Her mother is concerned about Kelly getting enough essential nutrients in her diet. Regarding dietary sources of essential nutrients, which of these is TRUE?
It is not necessary to fortify a vegan diet with calcium
Non-haem iron is found in eggs and plant foods
Vitamin B12 is found in both animal and plant products
The absorption of non-haem iron is better than haem iron.
Vitamin C reduces the absorption of haem iron
The correct answer is: Non-haem iron is found in eggs and plant foods
The absorption of haem iron (animal foods including red meats, fish and poultry) is better than non haem iron.
As a vegan diet does not include dairy products, it is important to fortify the diet with other calcium-rich foods or calcium supplements.
Vitamin B12 is essential for healthy blood cells and neurological function. It is only found naturally in animal products.
Vitamin C enhances the absorption of iron.
Dynan N. Helping to meet the nutritional needs of patients on a vegan diet. RACGP NewsGP. 2018
https://www1.racgp.org.au/newsGP/Clinical/Helping-to-meet-the-nutritional-needs-of-patients
You are interrupted by the midwife during your morning ward round of your 16 bed rural hospital, which is 400km from the nearest tertiary hospital, and which provides maternity services. She has noticed that Yolanda Ling, the term baby you helped deliver yesterday evening via emergency caesarean seems jaundiced. Yolanda is otherwise well and breastfeeding normally. The mother, who already has two children, had not had any antenatal care. You organise urgent blood tests, transfer to a neonatal service, and commence phototherapy whilst awaiting transfer.
What is the most likely diagnosis to consider in this case? Choose one (1) option.
Sepsis
Physiological jaundice
Red cell haemolysis
Breast milk jaundice
Biliary atresia
The correct response is: Red cell haemolysis
Jaundice is a sign of elevated bilirubin levels in the blood, which occurs when there is an imbalance between bilirubin production, conjugation and elimination. It is very common in newborns, affecting 60% of term babies and 80% of preterm babies in the first week of life. Severe hyperbilirubinaemia can be a sign of a serious underlying disease, and it can also cause brain damage. Jaundice visible at less than 24 hours is always a medical emergency. The most likely causes of early onset jaundice are haemolysis (e.g. rhesus disease, ABO incompatibility, and red cell enzyme defects such as G6PD deficiency) and sepsis. However, you are told that Yolanda seems otherwise well and is breast feeding normally, so red cell haemolysis is more likely the cause of the jaundice in this clinical scenario than sepsis.
Shaun Watson is a 22 year old man who presents with significant fatigue and sore throat that has been present for 7 days. He reports that he has also suffered with headaches, nausea and generalised body aches. He is a professional Australian Rules football player and has already missed one full week of football.
On examination, he is mildly jaundiced, his throat is congested with palatal petechiae, his tonsils are enlarged and covered with exudate, and he has cervical lymphadenopathy and splenomegaly. There is no airway compromise on examination.
Given your expected diagnosis what is the most appropriate management for Shaun? Please select one (1) answer from the following.
Oral phenoxymethylpenicillin 500mg twice per day for 10 days
Oral aciclovir 800mg five times per day for 5 days
Referral to a haematologist for further investigation of splenomegaly and lymphadenopathy
Avoid physical activity for another 2 weeks
Oral prednisolone 50mg daily for 4 days
The most likely diagnosis in this case is Infectious Mononucleosis (IM). This syndrome is caused by Epstein Barre Virus and most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae. Symptomatic relief is the mainstay of treatment. Glucocorticoids and antivirals do not reduce the length or severity of illness. Splenic rupture is an uncommon complication of IM. Because physical activity within the first three weeks of illness may increase the risk of splenic rupture, athletic participation is not recommended during this time. Children are at the highest risk of airway obstruction, which is the most common cause of hospitalization from IM.
Jordan is a 17 year old male who is brought to your clinic by his mother with a rash. Jordan has been unwell recently with fevers, a very sore throat, reduced appetite and generalised abdominal discomfort. He saw another GP a week ago and was started on antibiotics for tonsillitis. This morning he has developed an intensely itchy maculopapular rash. Jordan has no significant past medical history and takes no regular medications. He has no known allergies.
On examination, Jordan appears well and his temperature is 36.5°C. He is well hydrated and non-distressed. He has a widespread blanching maculopapular rash. He has small pustules on bilateral enlarged tonsils and tender cervical lymphadenopathy. His abdominal examination is unremarkable.
What advice do you give Jordan?
Strictly avoid penicillins in the future
The rash will self-resolve without treatment
Apply topical betamethasone 0.05% ointment until the rash resolves
Commence oral prednisolone 25mg daily for three days
Strictly avoid penicillins and cephalosporins in the future
The correct response is: The rash will self-resolve without treatment.
This case describes a teenager with clinical features consistent with Ebstein-Barr virus. When amoxicillin, ampicillin or cephalosporins are given during the course of infectious mononucleosis (often incorrectly prescribed for presumed streptococcal tonsillitis), patients may experience an intensely itchy maculopupular or morbilliform rash seven to ten days later. This rash is not a sign of a true allergy to the antibiotic but is rather considered a ‘hypersensitivity reaction’.
Josh, a 18 month old boy, is brought to you because his mother is worried about his development. Josh was born at term without complication and has no significant past medical history. You perform a developmental assessment.
What would you expect Josh to be able to do at this age? Choose one (1) option.
Point to body parts when asked
Undress himself
Jump on the spot
Able to name 5 body parts
Shows clear hand preference
The correct answer is: Point to body parts when asked.
See the reference below for a useful list of childhood developmental milestones.
Brenda presents with her 13 month old daughter Chloe worried that Chloe is developmentally delayed. Brenda has a 3 year old son and says that he was ‘much more advanced’ at this age. Chloe is currently cruising around the consulting room holding onto her mother and the furniture but Brenda says she is concerned that she is not walking as yet as her son could at 10 months.
Which one of the following tasks would you expect Chloe to be able to do?
Turns pages in a book
Combine 2-3 clear words
Stack 2-3 blocks in a tower
Use a spoon
Wave goodbye
By twelve months a baby should be able to wave goodbye. The other developmental stages are more appropriate for an 18-24 month old child.
A mother brings in her 8 year old girl with a troublesome cough for some months. It seems to be worse at night and particularly when she is playing netball. Her mother has noticed a ‘wheezing’ sound as well at those times. You suspect asthma.
What is the minimum recommended age at which spirometry can be used?
5 years old
6 years old
7 years old
8 years old
9 years old
Generally, spirometry cannot be performed to acceptable standards in children younger than 4–5 years.
The Australian Asthma Handbook recommends spirometry to be performed to support the diagnosis of asthma in children aged 6 years and over.
Caroline brings in her 15 month old baby girl Georgia with an episode of choking earlier in the day after Caroline left her briefly to go to the toilet. Caroline reports that Georgia has been ok since then but she is concerned about the episode and wonders if Georgia choked on a small toy. Georgia has been well recently with no upper respiratory tract infections. She has no past medical history and takes no regular medications. Your examination of Georgia’s vital signs, ENT and respiratory systems is unremarkable.
Which of the following statements about paediatric airway foreign bodies is correct?
A chest x-ray can exclude an airway foreign body
The peak incidence of inhaled foreign bodies is children aged under 12 months
50% of children with an airway foreign body will present with no symptoms
Most children with an airway foreign body will have no history of choking or aspiration
Airway foreign bodies do not result in permanent pulmonary tissue damage
The correct response is: “50% of children with an airway foreign body will present with no symptoms.”
More than 80% of foreign bodies lodge in the bronchial tree, with the right main bronchus being the most common site. The peak incidence of inhaled foreign bodies is in children aged between 1 and 2 years of age. While 50% of children with present asymptomatically, more than 90% will have a history of choking or aspiration which emphasises the importance of an in-depth history from the parent / caregiver. Delays in diagnosis can result in permanent damage to pulmonary tissue and bronchiectasis. If there is a clinical suspicion of an inhaled foreign body, all children should be referred for a tertiary otolaryngology service. It is important to note that normal diagnostic imaging cannot rule out the presence of an airway foreign body.
Harry Williams is a four year old boy brought to your clinic by his mother. Harry was climbing on the couch at home one hour ago and fell onto the tiled floor. The fall was witnessed and he hit his head and had a brief loss of consciousness. Harry’s mother reports he has vomited three times since then and has been complaining of a headache.
On examination, you note that Harry is alert and orientated but miserable and crying intermittently while sitting on his mother’s lap. You note a small haematoma on the occipital region of his scalp. His pupils are equal and reactive to light. He has no neck tenderness and is moving his neck freely. He is moving all four limbs normally and can walk normally when encouraged. He is responding appropriately to your questions and has not vomited since being at your clinic. You do not note any other abnormalities on examination.
What do you advise Harry’s mother in terms of management?
You advise Harry’s mother that he has had a minor head injury and it is safe for him to go home
You advise Harry’s mother that he needs to attend the emergency department for monitoring for up to six hours from the time of his injury
You advise Harry’s mother that he requires an urgent head CT scan and that you will review him with the results later today
You advise Harry’s mother that she can take Harry home but she will need to wake him up every hour throughout the night
You advise Harry’s mother that he needs to attend the emergency department for monitoring for twenty four hours from the time of his injury
The correct response is: You advise Harry’s mother that he needs to attend the emergency department for monitoring for up to six hours from the time of his injury.
According to the guidelines from the Royal Children’s Hospital, Harry has sustained a mild head injury/concussion and will require observation in an emergency department for a period of up to six hours from the time of his injury which will include 30 minutely neurological observations.
A mother brings her three children, aged 1, 3 and 6, to see you to discuss the annual influenza vaccination. They have never been vaccinated against the flu before, but this year she thinks she would like to get the whole family immunised. She wants to know if it is recommended for her children to receive the annual influenza vaccination.
Which of the following statements regarding influenza vaccination in children is correct? Choose one (1) option.
2 doses 4 weeks apart are recommended for children aged 6 months to < 9 years who are receiving the influenza vaccine for the first time
3 doses 4 weeks apart are recommended for children aged 6 months to < 8 years who are receiving the influenza vaccine for the first time
Only children aged over 12 months with medical risk factors should be encouraged to have the annual influenza vaccine
Only children aged over 5 years with medical risk factors should be encouraged to have the annual influenza vaccine
Children aged over 6 months only require one dose of influenza vaccine each year, including in their first year of receiving the vaccine
The correct response is: 2 doses 4 weeks apart are recommended for children aged 6 months to < 9 years who are receiving the influenza vaccine for the first time.
All people aged 6 months or over are strongly encouraged to receive the influenza vaccine each year (unless there are contraindications).
A 12 year old boy presents with a painful penis.
On examination he is uncircumcised and the foreskin covering the glans is hot, red and tender. There is some discharge at the opening of the foreskin.
Which one of the following is the MOST likely diagnosis?
Balanitis
Smegma collection
Dermatitis
Paraphimosis
Phimosis
Minor redness and/or soreness of the tip of the foreskin is common and can be managed with reassurance and avoidance of chemical/physical triggers. More extensive inflammation of the glans penis +/- foreskin is termed balanitis. Causes include:
Chemical irritation: urine trapping, soiled nappies, soap residue.
Physical trauma: forcible retraction.
Candida nappy rash in infants
A four year old girl is brought in by her mother complaining of dysuria and urinary frequency. Urine dipstick reveals positive nitrites and leucocytes. You suspect a urinary tract infection.
Which organism is the most common cause of urinary tract infections in children? Choose one (1) option.
Enterococcus
Escherichia coli
Klebsiella
Proteus
Staphylococcus saprophyticus
The correct response is: Escherichia coli
Escherichia coli is the most common cause of urinary tract infections and accounts for more than 75% of cases.
Reference:
Desai D, Gilbert B and McBride C. Paediatric urinary tract infections: Diagnosis and treatment. Aust Fam Physician 2016; 45(8):558-563
https://www.racgp.org.au/afp/2016/august/paediatric-urinary-tract-infections-diagnosis-and-treatment/
Herbert Zu, aged 4 years, presents with his mother to your GP clinic after recently moving from Canada to Australia. His mother brings his Canadian vaccination book and wants to know what immunisations Herbert requires. His last scheduled immunisations in Canada were at 18 months for diphtheria, tetanus, pertussis, poliomyelitis and haemophilus influenzae type B (as per the Canadian schedule). You notice that he has only had one measles, mumps, rubella, varicella dose at 12 months and no birth dose of hepatitis B. The remaining administered schedule matches the current Australian immunisation schedule. Herbert has no significant past medical history.
Based on the Australian Immunisation Handbook and schedule, what immunisations would you administer for Herbert today? Select one (1) option.
Herbert requires a booster of measles, mumps and rubella vaccine
Herbert requires a booster of measles, mumps, rubella and varicella, in addition to diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B and haemophilus influenzae type B vaccines
Herbert requires diphtheria, tetanus, pertussis and poliomyelitis vaccine
Herbert requires a booster of measles, mumps and rubella, in addition to diphtheria, tetanus, pertussis and poliomyelitis vaccines
Herbert requires diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B and haemophilus influenzae type B vaccines
The correct answer is “Herbert requires a booster of measles, mumps and rubella, in addition to diphtheria, tetanus, pertussis and poliomyelitis vaccines.”
This question reflects a common scenario of children requiring catch-up immunisations. In this scenario candidates need to be aware that there is a need for 2 doses of measles, mumps, rubella vaccine. The current guidelines in Australia are for 1 dose of varicella at 18 months, however a second dose has been shown to increase immunity. The second dose is not currently funded by the National Immunisation Program.
There is no need to catch up a missed birth dose of hepatitis B, provided a full course (i.e. 3 doses) of Hepatitis B vaccine have been provided in the first 12 months from 6 weeks of age.
Abby Reeves is a 12 year old girl who is brought in by her Mum with a troublesome cough for some months. It seems to be worse at night and particularly when she is playing netball. Her mother has noticed a ‘wheezing’ sound as well at those times. You suspect asthma and arrange spirometry. Which of the following criteria demonstrate reversibility on spirometry?
Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 10% higher than baseline
Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 12% higher than baseline
Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 15% higher than baseline
Baseline FEV1<1.7L and post-bronchodilator FEV1 at least 100mL higher than baseline
Baseline FEV1>1.7L and post-bronchodilator FEV1 at least 200mL higher than baseline
Reversibility is demonstrated by either baseline FEV1>1.7L AND post-bronchodilator FEV1 at least 12% higher than baseline
OR baseline FEV1 less than or equal to 1.7L AND post-bronchodilator FEV1 at least 200mL higher than baseline.
Kylie, a five year old who has recently started school, is brought in by her mother after complaining of an ‘itchy bottom’ for the last few nights. It has caused her distress through the night but she has been asymptomatic throughout the day. You suspect a threadworm infection.
How would you manage Kylie’s infection? Choose the optimum treatment approach below - choose one (1) option.
7 day course of metronidazole
Reassurance - these infections are common and rarely cause morbidity
Single dose of mebendazole (Vermox)
Treat all members of the family with pyrantel (Combantrin), with repeat dosing 2 weeks later
Treat all members of the family with single dose of pyrantel (Combantrin)
The correct response is: Treat all members of the family with pyrantel (Combantrin), with repeat dosing 2 weeks later
Threadworm (or pinworm) infections (Enterobius vermicularis) respond to various antihelminthic drugs, including single dose mebendazole, pyrantel or albendazole. However, it is recommended that treatment is repeated after 2 weeks, including for household contacts and carers, due to the frequency of reinfection and autoinfection. eTG also recommends the following advice for patients:
“Provide advice on hygiene measures to reduce the risk of reinfection and spread of infection: wash hands regularly, avoid scratching around the anus, keep fingernails short, take a shower or bath daily, and wash clothing, towels and bed linen in hot water.”
A 14 year old boy presents with left hip pain. His pain is poorly localised and there is no history of trauma. He is systemically well.
On examination, the boy is overweight and he appears to have a limp when walking. His left leg is slightly externally rotated and hip pain is elicited with passive internal rotation. His knee examination is unremarkable.
What is the most likely diagnosis? Choose one (1) option.
Juvenile rheumatoid arthritis
Baker’s cyst
Iliotibial band syndrome
Medial meniscal injury
Osgood Schlatter disease
Osteoarthritis
Osteochrondritis dissecans
Patellar tendonitis
Patellofemoral pain syndrome
Perthes disease
Pes anserinus tendinitis
Septic arthritis
Slipped capital femoral epiphysis
Transient synovitis/irritable hip
The correct response is: Slipped capital femoral epiphysis
Slipped capital femoral epiphysis (SCFE) typically occurs in late childhood / adolescence and in those > 90th percentile for weight. It can present with pain in the knee or hip and with an associated limp. Sometimes the pain is bilateral. On examination, the hip typically appears shortened and externally rotated. There is usually restricted movement, especially internal rotation.
Janine has come to see you to get a form signed so that her 6 month old child, Caleb, doesn’t have to get immunised. She is a bit upset because her Centrelink payments have been ceased, and she cannot enrol Caleb in child care as they won’t accept an unvaccinated child without medical approval. You take a thorough history in order to determine if Caleb has a valid medical contraindication to vaccination.
Which of the following is a valid medical contraindication to vaccination?
Anaphylaxis following any component of the relevant vaccine
Mother has a history of a anaphylaxis following vaccination
Caleb has a past medical history which includes chronic medical conditions: asthma and epilepsy
Caleb has a past medical history of egg allergy
Caleb is currently unwell with an upper respiratory tract infection and has a temperature of 38.0 degree Celsius
The correct response is: Anaphylaxis following any component of the relevant vaccine.
See the Australian Immunisation Handbook for detailed information about medical contraindications to vaccination.
The medical basis for vaccine exemption is to be based on guidance in The Australian Immunisation Handbook. Medical contraindications include:
anaphylaxis following a previous dose of the relevant vaccine anaphylaxis following any component of the relevant vaccine significant immunocompromise (for live attenuated vaccines only). A comprehensive list of false contraindications to vaccination is provided in The Australian Immunisation Handbook.
Egg allergy, even severe, is not necessarily a valid exemption for any vaccine routinely recommended for children.
Presence of a chronic underlying medical condition (apart from significant immunocompromise) is not a valid vaccine exemption.
Family history of any adverse events following immunisation is not a valid vaccine exemption.
While vaccination should be deferred in persons with acute febrile illness (current T ≥38.5°C) or other self-limiting acute systemic illness, this would usually be for short periods only and not require completion of the Immunisation medical exemption form.
References:
Australian Government Department of Human Services. Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011). Available from: https://www.humanservices.gov.au/organisations/health-professionals/forms/im011 (Accessed August 2020).
Australian Government Department of Health. Australian Immunisation Handbook: Preparing for vaccination. Available from: https://immunisationhandbook.health.gov.au/vaccination-procedures/preparing-for-vaccination (Accessed August 2020).
Sally is a 4 year old girl, brought in by her mother because she is concerned about Sally’s seeming lack of energy. She used to spend most of her time outside, but over the last 2 months has been increasing inactive, lying down to watch television, or even going to her room for naps in the middle of the day.
On examination, Sally appears very pale, but otherwise normal. You arrange blood tests which reveal a microcytic, hypochromic anaemia, with other blood picture parameters within normal range. Which of the following are the most likely iron study results in this patient? Choose one (1) option.
Elevated Ferritin, low serum iron, low transferrin, high transferrin saturation
Low ferritin, low serum iron, low transferrin, high transferrin saturation
Normal ferritin, low serum iron, low transferrin, low transferrin saturation
Low ferritin, low serum iron, normal transferrin, low transferrin saturation
Normal ferritin, normal serum iron, normal transferrin, low transferrin saturation
The correct response is: Low ferritin, low serum iron, normal transferrin, low transferrin saturation
Iron deficiency is the commonest cause of anaemia in children, and will be evident by a low ferritin and serum iron, with low transferrin saturation. Differentials for microcytic anaemia, that are less common, include thalassaemia, or aplastic anaemias, including from malignancy such as leukaemia. Thalassaemia will generally present with a normal ferritin level. Aplastic anaemia will often be accompanied by abnormal white cell or platelet counts.
Max is a 2 year old boy brought in to your GP clinic by his parents with a hoarse voice and barking cough over the past 48 hours which seems to be worse at night. There is no significant past medical history and no family history of asthma.
On examination, Max’s temperature is 37.7C and his respiratory rate is 22/minute and heart rate is 110/minute. His oxygen saturations are 98% on room air. He appears non-toxic, alert, interactive and well perfused. There is audible stridor when he is active playing with the toys in your room but there is no stridor when he is resting on his father’s lap. On chest auscultation you note a slight wheeze but no focal crepitations. There is no increased work of breathing. You note a ‘barking’ cough and some rhinorrhoea.
What would be your next step in managing Max? Choose one (1) option.
Provide a prescription for oral prednisolone 2mg/kg for one night
Provide a prescription for oral prednisolone 1mg/kg and a second dose for the next evening
Provide a prescription for dexamethasone 0.3mg/kg for the next two nights
Reassure Max’s parents that no treatment is required at this stage but they should present to the emergency department if he develops stridor at rest
Provide a prescription for dexamethasone 0.2mg/kg for the next three nights
The correct response is: Provide a prescription for oral prednisolone 1mg/kg and a second dose for the next evening
This is a typical presentation of mild croup (laryngotracheobronchitis). Note that oral dexamethasone suspension 0.15mg/kg (single dose) can be given as an alternative to oral prednisolone but dexamethasone suspension is not available from community pharmacies (only hospital pharmacies).
All parents should be advised when to urgently seek review for their child. The management of croup is outlined in the Royal Children’s Hospital clinical guidelines.
Hugo McDonald, a 4 year old boy, presents with his mother reporting he has only opened his bowels once in the past week with a lumpy, hard stool which was painful to pass. There is no previous history of constipation and no developmental issues. He was day-time toilet trained at 3 years of age. Hugo is otherwise well. He recently started attending pre-school five days a week.
On examination, his abdomen is soft, but you can palpate what you believe are faeces in the left lower quadrant.
Which of the following statements regarding the management of constipation in children is correct? Choose one (1) option.
Commence docusate sodium 50mg daily.
Encourage toileting prior to meals, when the colon is most active.
Stool softeners should not be utilised in children under 5 years of age, unless they have a diagnosis of chronic constipation.
Encourage children to undertake a distraction activity while toileting, such as reading a book.
Encourage good toileting behaviour, aiming for sitting on the toilet two to three times a day after meals.
The correct answer is: Encourage good toileting behaviour, aiming for sitting on the toilet two to three times a day after meals.
Constipation is a common presentation in children. This question assesses a candidate’s knowledge of the key principles of paediatric constipation management, which is to soften the stool so as to empty the rectum, soften the stool to minimise pain and finally to encourage good toileting habits. Toileting should ideally be performed for 5 minutes 2 – 3 times per day after meals and should not be associated with distractions such as books or iPads which can prolong toileting. Toileting should be praised even when no stool is passed. A simple stool softener, such as macrogol (Movicol) is acceptable, whereas a stool stimulant, such as docusate sodium (Coloxyl) should not be used first-line. Abdominal x-rays should not be routinely performed in general practice to investigate constipation.
References:
eTG complete by Therapeutic Guidelines [Internet]. West Melbourne, VIC (Australia): Therapeutic Guidelines Ltd; 2019. Functional Gastrointestinal Disorders – Functional Constipation in Children; March 2016. https://tgldcdp.tg.org.au/viewTopic?topicfile=functional-gastrointestinal-disorders&guidelineName=Gastrointestinal#toc_d1e756
Waterham M, Kaufman J, Gibb S. Childhood constipation. Australian Family Physician. 2017 Dec;46(12):908. https://www.racgp.org.au/download/Documents/AFP/2017/December/AFP-2017-12-Focus-Constipation.pdf
Jake is a 7 year old boy brought to your rural emergency department by his parents with widespread bruising, abdominal pain and leg pain. He had a ‘cold’ recently but has otherwise been well and has not suffered any trauma or injuries. Jake has had no fevers, vomiting, cough, diarrhoea, urinary symptoms or weight loss. He has no significant past medical history and takes no regular medications. His mother is not able to recall any family history of bleeding disorders.
On examination, Jake’s temperature is 37.3OC, heart rate 80 / minute, respiratory rate 20 / minute, blood pressure 130/90 mmHg and oxygen saturations 98% on room air. He appears uncomfortable but is alert, orientated, non-toxic and well hydrated. He has palpable purpura on bilateral buttocks and legs. His cardiovascular, respiratory and ENT examinations are unremarkable. He has generalised mild abdominal tenderness with no signs of peritonism. Jake has tender bilateral hips and knees but there is no swelling or increased warmth on palpation. His urine dipstick is positive for blood and protein.
What is the most likely diagnosis?
Leukaemia
Meningococcal septicaemia
Idiopathic thrombocytopenia
Henoch-schonlein purpura
Haemophilia
The correct response is: Henoch-schonlein purpura
The key diagnostic features in this presentation include palpable purpura over bilateral buttocks and legs, abdominal pain, arthralgia, haematuria, proteinuria and hypertension.
Reference:
Royal Children’s Hospital. Clinical Practice Guidelines: Henoch-schonlein purpura. https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/ (Accessed April 2020).
Kelly brings her 2 year old daughter Sally to see you regarding some skin lesions she has noticed on Sally’s legs over the past 3 months. Sally has a history of eczema and is otherwise well and healthy. She uses topical steroid ointments as needed but otherwise takes no regular medications. Sally has no drug allergies. Her immunisations are up-to-date.
You note about 10 pearly papules with central umbilication around Sally’s knees and thighs bilaterally and diagnose her with molluscum contagiosum. Kelly is keen to learn more about this condition. Which of the following pieces of advice and education do you provide Kelly, choose one (1) option.
The condition can be spread by children sharing baths and towels
Molluscum is caused by a bacterial infection and can be effectively treated with topical antibiotics
Children with this condition need to be excluded from daycare and school
The papules normally resolve within a few weeks
Molluscum will not cause a flare of Sally’s eczema
The correct response is: “molluscum can be spread by children sharing baths and towels”. Most of the time molluscum do not require any treatment and is not a reason for school or daycare exclusion. Molluscum can cause a flare of eczema. It may take more than a year for the papules to self-resolve.
The Royal Children’s Hospital Melbourne. Kids Health Info Fact Sheets: Molluscum. 2018 https://www.rch.org.au/kidsinfo/fact_sheets/Molluscum/ (accessed Dec 2019).
Luke is a 19 year old university student who presents with a 2 week history of lethargy associated with mild fever and sore throat. He has been otherwise well with no significant past history and is on no regular medications. He denies previous illicit drug use or recent excessive alcohol intake. One month ago he went on a one week holiday to Bali. On examination, he is afebrile, has diffuse cervical lymphadenopathy and is tender over the liver margin with no organomegaly. Which one of the following is the MOST likely diagnosis?
Hepatitis A infection
Influenza
Chronic fatigue syndrome
Streptococcal throat infection
Infectious mononucleosis
Infectious mononucleosis is a common condition which typically starts with fevers, sore throat and swollen cervical lymphadenopathy. Hepatosplenomegaly occurs in approximately 10-15% of cases.
Therapeutic Guidelines eTG complete. Antibiotic: Epstein-Barr virus infection 2019
https://tgldcdp.tg.org.au/viewTopic?topicfile=epstein-barr-virus&guidelineName=Antibiotic#toc_d1e47
Charles P. Infectious Mononucleosis. Aust Fam Physician 2003;32:785-788. https://www.racgp.org.au/afp/200310/17633
A mother brings her four year old son to see you regarding concerns about his behaviour. She is concerned that he may be displaying features of autism spectrum disorder.
Which of the following is a feature suggestive of autism spectrum disorder? Choose one (1) option.
Deliberately annoying others
Echolalia
Heightened response to pain
Advanced capabilities for imaginative play at a young age
Intense attention to social stimuli
The correct response is: Echolalia
Stereotyped and repetitive use of language such as echolalia is commonly seen in autism spectrum disorder.
Deliberately annoying others is a symptom of oppositional defiant disorder.
Children with autism spectrum disorder often have lack of response to pain, and self injurious behaviour is a common feature.
Children with autism spectrum disorder will usually engage in repetitive play that lacks imagination. Older children may engage in what appears to be imaginative play, but it is usually repetition of learned activities/behaviour.
Early developmental differences include failing to have an anticipatory posture, such as reaching out to be picked up, and absent or reduced visual attention to social stimuli, smiling in response to others, vocalisation and exploration of objects.
Reference:
Tonge B, Brereton A. Autism spectrum disorders. Aust Fam Physician 2011;40:672-677.
https://www.racgp.org.au/afp/2011/september/autism-spectrum-disorders/
Jenny brings in her four month old baby, George, to your clinic because she is concerned about the appearance of his scalp. She has noticed yellow greasy scales on his scalp which started about six weeks ago. He has been otherwise well. George was born at term and has no significant past medical history. He takes no medications and has no known allergies.
You examine George’s scalp and notice yellow flaky crusts mostly over the frontal region. The underlying skin does not appear to be red or inflamed. What management advice do you give to Jenny?
Source: DermNet NZ
Advise skin scrapings to confirm the diagnosis
Advise application of an emollient and then removal of the scales with a soft brush/comb
Advise application of topical mupirocin 2% ointment 8 hourly for 5 days
Advise application of topical ketoconazole 2% for 1-2 weeks
Advise application of topical hydrocortisone 1% cream for 1-2 weeks
The correct response is: advise application of an emollient or gentle baby shampoo and then removal of the scales with a soft brush/comb.
This is a classic case of mild cradle cap which is very common in infants under the age of 12 months and parents should be reassured about the benign nature of the condition. Most mild cases can be treated with application of gentle baby shampoo, liquid paraffin or an emollient. Parents can then remove the scales with a soft toothbrush or comb. Only more extensive cases require the use of low-potency topical treatments such as 1% hydrocortisone or ketoconazole 2%.
DermNet NZ. Cradle cap. https://www.dermnetnz.org/topics/cradle-cap (Accessed June 2018).
Su J. Common rashes in neonates. Aust Fam Physician 2012; 41(5): 280 – 286. https://www.racgp.org.au/afp/2012/may/common-rashes-in-neonates/
Rory is a 4 year old boy who you are reviewing today. Rory has been seen at your practice twice this week already as his Mum is very concerned. He has been having high fevers for the last 5 days. He is off his food and is drinking only small amounts. You note his lips appear dry and cracked and his tongue is very red. His eyes are both red and injected, but there is no discharge. He has large tender cervical lymph nodes and the palms of his hands and soles of his feet are red and swollen.
From the following list what is the most important diagnosis to consider in this case? Choose one (1) option.
Roseola infantum
Kawasaki Disease
Rubella
Henoch-Schonlein purpura
Molluscum contagiosum
Hand foot and mouth disease
Primary Herpes Simplex infection
Measles
Erythema infectiosum
Scarlet fever
Meningococcal infection
Chicken pox
Impetigo
The correct response is: Kawasaki disease
The diagnostic criteria for Kawasaki disease are: fever for 5 days or more, plus 4 out of 5 of:
· polymorphous rash
· bilateral (non-purulent) conjunctival injection
· mucous membrane changes (e.g. reddened or dry cracked lips, strawberry tongue, diffuse redness of oral or pharyngeal mucosa)
· peripheral changes (e.g. erythema of the palms or soles, oedema of the hands or feet, and in convalescence desquamation)
· cervical lymphadenopathy (at least one node > 15 mm diameter, usually unilateral, single, non-purulent and painful)
It is the most important diagnosis to consider because patients with diagnosed or suspected Kawasaki disease should be admitted to hospital and require ongoing follow-up due to the possible sequele associated with this disease including coronary aneurysms.
Reference:
The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines: Kawasaki Disease. Updated August 2017.
https://www.rch.org.au/clinicalguide/guideline_index/Kawasaki_disease/
Correct answers is:
Kawasaki Disease
Mary Su, presents with her 25 month old son Jason, after picking him up from day care. She has noticed when talking to the other parents that perhaps Jason is behind in certain aspects of his development compared with his peers.
Which of the following would be considered a red flag for Jason? Choose one (1) option.
Difficulty in understanding his peer’s emotions
Speech occasionally difficult to understand
Difficulty walking up and down stairs
A vocabulary of 15 words
Unable to run well
The correct response is: A vocabulary of 15 words
A child of 2 years of age should have a vocabulary of at least 50 words. It is important that GPs are aware of developmental milestones in children. The RACGP Red Book provides a useful ‘Red flag’ early intervention referral guide on page 41.
Reference:
RACGP. Red Book – Guidelines for Preventative Activities in General Practice. 9th Ed. 2016. https://www.racgp.org.au/download/Documents/Guidelines/Redbook9/17048-Red-Book-9th-Edition.pdf (Accessed April 2020)
A mother brings in her 18 month old son to see you for his routine vaccinations. The child is currently well with no significant past medical history, he was born at term and is not of Aboriginal or Torres Strait Islander descent. He tolerated his previous vaccinations without any adverse reactions, has no known contraindications to any immunisations, and has no known allergies.
Which of the following vaccination combinations would you recommend for this child according to the National Immunisation Program schedule? Choose one (1) option.
Measles, Mumps, Rubella (MMR) and Diptheria, Tetanus, Pertussis (DTPa)
Measles, Mumps, Rubella, Varicella (MMRV)
Measles, Mumps, Rubella (MMR) and Haemophilus influenza b (Hib), Meningococcal ACWY
Measles, Mumps, Rubella, Varicella (MMRV) and Diptheria, Tetanus, Pertussis (DTPa) and Haemophilus influenzae type b (Hib)
Measles, Mumps, Rubella, Varicella (MMRV) and Diptheria, Tetanus, Pertussis, Polio (DTPa/IPV)
The correct response is: Measles, Mumps, Rubella, Varicella (MMRV) and Diptheria, Tetanus, Pertussis (DTPa) and Haemophilus influenzae type b (Hib)
See the National Immunisation Program schedule referenced below for details of recommended vaccinations.
A mother is concerned that her 6 month old daughter Neve is not putting on weight appropriately. She has been unwell in the last 2 months with a bout of gastroenteritis and an episode of bronchiolitis. Neither illness required hospitalisation. Neve was 3.2kg at birth and currently weighs 6kg.
In assessing Neve further for possible poor growth, which of the following would be considered a red flag?
A family history of coeliac disease
A history of breast feeding difficulties
Signs of poor attachment between Neve and her mother
Weight < 5th percentile when plotted on a growth chart
Neve is not showing interest in solid foods when they have been offered to her
Poor growth generally describes a child whose current weight, or rate of weight gain, is significantly below that expected of similar children of the same age and sex. Adequacy of growth is best evaluated by plotting serial measurements on a centile weight chart.Serial measurements are needed to assess a child’s growth. One-off measurements show a child’s size but not their growth. Many healthy children grow on centile lines at the top or bottom of the growth chart and many healthy children have small “dips” above or below a particular centile line or growth curve. Birth weight is not necessarily representative of the genetic potential for future growth. Eg. there is no cause for concern if a baby is healthy and gaining weight but tracking along a lower centile than that of the birth weight.
As per the Royal Children’s Hospital Clinical Guidelines, if one or more of the following red flags are identified, involvement of a multidisciplinary team is essential. Admission to hospital should also be considered if any of the following red flags are present.
Signs of abuse or neglect
Poor carer understanding e.g. non-English speaking, intellectual disability
Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support
Signs of poor attachment
Parental mental health issues
Already/previously case managed by child protection services
Did not attend or cancelled previous appointment/s
Signs of dehydration
Signs of malnutrition or significant illness
Jordan is a 17 year old male who is brought to your clinic by his mother with a rash. Jordan has been unwell recently with fevers, a very sore throat, reduced appetite and generalised abdominal discomfort. He saw another GP a week ago and was started on antibiotics for tonsillitis. This morning he has developed an intensely itchy maculopapular rash. Jordan has no significant past medical history and takes no regular medications. He has no known allergies.
On examination, Jordan appears well and his temperature is 36.5°C. He is well hydrated and non-distressed. He has a widespread blanching maculopapular rash. He has small pustules on bilateral enlarged tonsils and tender cervical lymphadenopathy. His abdominal examination is unremarkable.
What advice do you give Jordan?
Strictly avoid penicillins in the future
The rash will self-resolve without treatment
Apply topical betamethasone 0.05% ointment until the rash resolves
Commence oral prednisolone 25mg daily for three days
Strictly avoid penicillins and cephalosporins in the future
The correct response is: The rash will self-resolve without treatment.
This case describes a teenager with clinical features consistent with Ebstein-Barr virus. When amoxicillin, ampicillin or cephalosporins are given during the course of infectious mononucleosis (often incorrectly prescribed for presumed streptococcal tonsillitis), patients may experience an intensely itchy maculopupular or morbilliform rash seven to ten days later. This rash is not a sign of a true allergy to the antibiotic but is rather considered a ‘hypersensitivity reaction’.
Lina brings her 2 month old child, Ruby, to see you. She says that Ruby has noisy breathing, which she thinks has been present since not long after her birth. Lina notices it when she is breathing in and Ruby doesn’t seem distressed by it. Sometimes though she will get upset during breast feeding, and has been taking formula by bottle for more of her feeds recently. On examination, you note a high-pitched cog-wheel inspiratory stridor. Ruby is seen by a paediatrician and diagnosed with larynogomalacia.
Lina asks when this condition will likely resolve. Which of the following is correct? Choose one (1) option.
1 - 2 years of age
6 months of age
4 months of age
3 - 4 years of age
5 years of age
he correct response is: 1 - 2 years of age
As stated in eTG:
“Some children present with a chronic ‘cog-wheel’ high-pitched inspiratory stridor that has been present from birth or the first few days or weeks of life. The most common cause is laryngomalacia. The stridor resolves spontaneously at 1 to 2 years of age. Alternatively, inspiratory stridor that develops for the first time at 6 to 8 weeks of life, worsens and becomes biphasic (present in both inspiration and expiration) may be due to a subglottic haemangioma. Most cases of chronic stridor in infants need referral.”
Shaun Watson is a 22 year old man who presents with significant fatigue and sore throat that has been present for 7 days. He reports that he has also suffered with headaches, nausea and generalised body aches. He is a professional Australian Rules football player and has already missed one full week of football.
On examination, he is mildly jaundiced, his throat is congested with palatal petechiae, his tonsils are enlarged and covered with exudate, and he has cervical lymphadenopathy and splenomegaly. There is no airway compromise on examination.
Given your expected diagnosis what is the most appropriate management for Shaun? Please select one (1) answer from the following.
Oral phenoxymethylpenicillin 500mg twice per day for 10 days
Oral aciclovir 800mg five times per day for 5 days
Referral to a haematologist for further investigation of splenomegaly and lymphadenopathy
Avoid physical activity for another 2 weeks
Oral prednisolone 50mg daily for 4 days
The most likely diagnosis in this case is Infectious Mononucleosis (IM). This syndrome is caused by Epstein Barre Virus and most commonly occurs between 15 and 24 years of age. It should be suspected in patients presenting with sore throat, fever, tonsillar enlargement, fatigue, lymphadenopathy, pharyngeal inflammation, and palatal petechiae. Symptomatic relief is the mainstay of treatment. Glucocorticoids and antivirals do not reduce the length or severity of illness. Splenic rupture is an uncommon complication of IM. Because physical activity within the first three weeks of illness may increase the risk of splenic rupture, athletic participation is not recommended during this time. Children are at the highest risk of airway obstruction, which is the most common cause of hospitalization from IM.
Womack, J. Jimenez. Common Questions about Infectious Mononucleosis. Am Fam Physician. 2015 Mar 15;91(6):372-376. Available from: https://www.aafp.org/afp/2015/0315/p372.html (Accessed June 2020).
Therapeutic Guidlines. Etg complete. Epstein Barre Virus infection. 2020. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=epstein-barr-virus#toc_d1e47 (Accessed June 2020)
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Correct answers is:
Avoid physical activity for another 2 weeks
