paeds last week

Question 1

A 3 year old boy is brought to A&E by his mum with vomiting and lethargy.
Two days ago, he got a fever and developed red spots that turned into little blisters all over his body. He was eating and drinking a bit less than normal, but reasonably well. His mum gave him some aspirin this morning (she had run out of paracetamol that she normally gives him for fevers), and a few hours later he started vomiting and became really tired. He is normally well and takes no regular medicines and has no known allergies. His vaccines are up to date. He does not have a rash, headache or neck stiffness.
On inspection, he appears unwell and is slurring his words. He is tachypnoeic and saturations are 100% in air, heart rate 110, capillary refill 2 seconds and temperature 38.0. His liver is palpable 1cm below the costal margin.
Which of the following investigations would confirm the most likely diagnosis in this case?

Answer 1

This child, with a rash and fever consistent with chickenpox and vomiting, lethargy, slurred speech and hepatomegaly after taking aspirin, most likely has a diagnosis of Reye’s syndrome. Reye’s syndrome causes liver failure and subsequent encephalopathy after aspirin treatment for viral infections in children. The diagnosis can be confirmed with hepatocyte microvesicular steatosis on liver biopsy

Question 2

Ewing’s sarcoma vs osteosarcoma findings

Answer 2

Ewing’s sarcoma typically presented with the lamellated (onion skinning) periosteal reaction which is visible on x-ray. MRI typically shows a large mass with evidence of necrosis and on histology small blue round cells are visible with clear cytoplasms on haematoxylin and eosin staining

Osteosarcoma presents with pain and swelling with a prolonged onset. The x-ray findings of new bony growth and a periosteal reaction causing a sunburnt appearance are typical of osteosarcoma

Question 3

DDH test

Answer 3

Galeazzi’s test is used to indicate whether the shortening is femoral or tibial

Question 4

PKU avoid

Answer 4

aspartame, eg fizzy drinks

Question 5

A 4-year-old boy presents to the GP with multiple, small bruises on both his arms. His mother is concerned, as he seems more tired in the last few months and has had to repeatedly miss school due to being unwell.
On examination, a soft systolic murmur is heard on the left sternal edge.
Which of the following additional features would support the underlying diagnosis?

Answer 5

This patient is showing signs of bone marrow failure, such as anaemia, causing lethargy, fatigue and a soft systolic murmur, neutropenia causing more frequent infections and thrombocytopenia, causing bruising. In young children, these symptoms are red-flag features for acute lymphocytic leukaemia. Acute lymphocytic leukaemia is the most common cancer in children. It is caused by abnormal proliferation of lymphoid progenitor cells. Splenomegaly occurs in acute lymphocytic leukaemia due to the infiltration of lymphocytes into the spleen.

Question 6

ectopic gastric mucosa

Answer 6

meckel’s diverticulum

Question 7

Perthes

Answer 7

Perthes disease describes avascular necrosis of the femoral head in children aged 4-8

Question 8

A 6 week old baby boy is referred to A&E due to jaundice.
He has appeared progressively more yellow over the last 3 weeks. His stools have become pale and his urine has also darkened. He has been breastfeeding well and is growing appropriately along the centiles. He was born at 39+6 weeks by spontaneous vaginal delivery. Antenatal screening and scans showed no abnormalities.
On examination, the baby appears well. His abdomen is soft and a liver edge is palpable 2cm below the costal margin. Blood tests show a raised ALT, ALP and bilirubin (predominantly conjugated).
What is the most likely underlying cause?

Answer 8

Fibrosis of biliary tree
This infant with prolonged jaundice, dark urine, chalky-white stool and conjugated hyperbilirubinaemia is suspicious for an obstructive cause of jaundice. The results of the hepatic scintigraphy radioisotope scan (highlights the liver and not the bowel) is suspicious for biliary atresia. Biliary atresia is characterized by progressive fibrosis and destruction of the biliary tree
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Question 9

A 6-month-old exclusively breastfed infant presents with bruising, bleeding from gums and nose, and blood in the diaper.
What is the most likely cause of his symptoms?

Answer 9

vitamin k deficiency

Breast milk has low levels of vitamin K, which is essential for the production of coagulation factors. Infants who are exclusively breastfed may have a deficiency of vitamin K, which can lead to bleeding tendencies. The symptoms in this case presentation are indicative of a coagulopathy caused by vitamin K deficiency.

Question 10

A six-year old girl presents to ED with her mother, who is worried. Over the last week and a half the child has had a fever with a headache. In the last two days, the child has developed diarrhoea and a red rash covering her cheeks that spares the nasolabial folds. She is also complaining of pain in her knees. The child has been otherwise well, and has completed her vaccines.
What is the most likely diagnosis?

Answer 10

Parvovirus B19 infection
This is a very typical presentation of parvovirus B19 infection. It is a DNA virus spread predominantly through respiratory secretions. In children it causes fifth disease. The ‘slapped cheek’ rash is typical, and shows sparing periorally and on the forehead. It causes an initial viral prodrome. In patients with disorders of the red blood cells it can cause an aplastic crisis

Question 11

A 54 year old woman presents to her GP with an acute presentation of a symmetrical polyarthralgia affecting her proximal interphalangeal and metacarpophalangeal joints for the last few days. She is concerned as her youngest child who has sickle cell disease, is very ill in hospital at the moment with an aplastic crisis. She is a teacher in a nursery where she reports that an outbreak of some sort has broken out. She has no family history of rheumatological conditions and no skin rash.
Given the history, what is the most likely diagnosis?

Answer 11

parvovirus B19

common to have arthralgia

Question 12

Ewings vs osteosarcoma presentation

Answer 12

Ewings is the second most common malignant tumour in children. However, it is more likely to present like an infection, often accompanied by fever and it most commonly affects the diaphysis of long bones

In an adolescent, localised pain of several months duration with no traumatic event or associated injury and an associated mass on examination is highly suggestive of osteosarcoma.
Osteosarcoma is a primary malignant bone tumour where the malignant bone cells produce immature bone. This is the most common primary malignancy of bone in children and adolescents and most commonly affects the distal femur and proximal tibia

Question 13

A 3-year-old girl is brought to the GP by her parents. For the past four days she has had a fever, runny nose, cough and non-bloody diarrhoea. Last night, her parents noticed that she had developed a pink rash on her legs and arms. She is normally fit and well and is up to date with all her vaccinations. On examination, a pink lace-like rash is visible on all four of her limbs, along with erythematous patches on her cheeks which feel hot to touch.
Which of the following is the most likely pathogen causing her symptoms?

Answer 13

This child has presented with a prodrome of fever, coryzal symptoms and diarrhoea, followed by the onset of a diffuse ‘lace-like’ rash across the body and characteristic bright red cheeks. This presentation makes parvovirus B19, aka slapped-cheek syndrome, the most likely diagnosis

Question 14

Pierre Robin sequence

Answer 14

Cleft palate, retracted tongue and small lower jaw
This makes feeding infants difficult. Specialised feeding equipment is used before surgical repair

Question 15

perthes management

Answer 15

Bed rest and analgesia
Perthes disease, especially when diagnosed early, often has a good prognosis and can usually be managed with supportive care - bed rest, analgesia, physiotherapy and avoiding high impact physical activities. Severe cases may require surgery but this is less common.

Question 16

13-year-old girl is brought to the GP by her parents for a 2-month history of intermittent worsening groin and knee pain bilaterally, particularly when walking. There has not been any history of trauma and she does not suffer from any diagnosed health conditions, although she has a low exercise tolerance due to obesity.
Her observations are all within normal range, and chest and abdominal examinations are normal. On examination of the lower limbs, she is suffering from pain in both knees, and has silghtly reduced flexion of the hip on both active and passive flexion.
What is the most likely diagnosis?

Answer 16

Slipped capital femoral epiphysis
Bilateral lower limb pain in an adolescent with a high BMI should raise a flag for slipped capital femoral epiphysis, the most common hip disorder in adolescents. The knee pain is referred from the hip. The “slip” occurs due to mechanical pressure on a weakened proximal femoral growth plate, allowing the displacement of the epiphysis. Obesity is the most common risk factor, but endocrine disorders (hypothyroidism, growth hormone deficiency, hypopituitarism and renal failure osteodystrophy) are also significant risk factors.

Question 17

Causes of hydrops fatalis

Answer 17

CMV, parvovirus, syphillis haemolytic anaemia from rhesus, chromosomal abnormalities, heart and lung defect, lymphatic abnormalities

Question 18

measles incubation and infectivity

Answer 18

measles incubation 7-21 days, usually 11-12, infectious 4 days before and after the rash appears

Question 19

chicken pox incubation and infectivity

Answer 19

chickenpox, incubation 10-21 days, usually 2 weeks, contagious for 1-2 days before the rash appears until after the blisters have dried and scabbed over (around 5-7 days)

Question 20

hep b incubation and infectivity

Answer 20

hep b incubation 60-150 days (avg 90), contagious as long as virus active

Question 21

hep A incubation and infectivity

Answer 21

and hep a incubation and infectivity- incubation 28 days (15-50), maximum infectivity second half of incubation, no longer infectious after first week of jaundice

Question 22

things to look at before exam

Answer 22

trust guidelines on nephrotic syndrome, developmental red flags

Question 23

tonsillitis vs scarlet fever treatment

Answer 23

tonsillitis treat for 5 days, scarlett fever treat for 10 days with Pen V - phenoxymethylpenicilllin

Question 24

which fever stops abruptly with rash -

Answer 24

roseola infantum herpes 6/7

Question 25

parvovirus B19/slapped cheek can lead to

Answer 25

hydrops fetalis

Question 26

measles long term complication-

Answer 26

subacute sclerosis pan encephalitis

Question 27

coxsackie A16 can cause

Answer 27

pericarditis and myocarditis

Question 28

live attenuated vaccines

Answer 28

influenza, rotavirus, MMR, shigella, chickenpox, BCG -

Question 29

chronic wet cough in child that won’t go away with Abx differential -

Answer 29

protracted bacterial bronchitis . give abx for 4-6wks

Question 30

epilepsy EEG

Answer 30

EEG 3 hz spike and wave for absence, hypsarrthymia for infantile spasms (west syndrome)

Question 31

sickle cell child needs what extra vaccine

Answer 31

meningococcal conjugate

Question 32

ALL cytogenetic abnormality

Answer 32

t(12:21)

Question 33

Where is damage in CP

Answer 33

UMN pyramidal pathway

Question 34

coeliac exclusion

Answer 34

gluten- wheat, barley and rye

Question 35

squint and Hirschprungs

Answer 35

fragile X

Question 36

neonatal resus protocol

Answer 36

try inflation breaths first then suction in failure

Question 37

whooping cough presentation in baby

Answer 37

This unvaccinated baby with coughing to the point of vomiting followed by a strange sound on inspiration has a history suspicious for whooping cough. Paroxysmal cough to the point of vomiting is a red flag suggestive of whooping cough. Whooping cough is caused by Bordetella pertussis infection, and is diagnosed with a pernasal swab

Question 38

A 5-year-old boy is seen in the General Paediatric clinic with his parents after being referred by his GP for a 2 year history of constipation unresponsive to laxatives. He passes stool once every 4-5 days with difficulty. Despite struggling to pass stool he soils his underwear daily. His mother states that he did not pass meconium until three days after birth.
On abdominal examination, the abdomen is distended and a faecal mass is palpable in the left iliac fossa. Digital examination reveals an empty rectum and tight anal sphincter.
Which of the following investigations is most likely to confirm the diagnosis?

Answer 38

Rectal Suction Biopsy
This is the correct answer. Definitive diagnosis of Hirschsprung’s disease is established histologically by taking a biopsy at least 1.5 cm above the pectinate line, to demonstrate acetylcholinesterase positive nerve excess and the absence of ganglion cells

Question 39

scan for Meckel’s

Answer 39

technetium-99, will highlight ectopic gastric mucosa in a symptomatic Meckels’ diverticulum. This is the commonest cause of per rectal bleeding in a child

Question 40

pyloric stenosis investigation

Answer 40

abdominal USS

Question 41

management of child with pyloric stenosis very unwell

Answer 41

resus first

correct electrolyte abnormalities before surgery (pyloromyotomy)

Question 42

Neisseria men. sepsis complication

Answer 42

When this is associated with massive adrenal haemorrhage and septic shock, the presentation is known as Waterhouse-Friderichsen syndrome

Question 42

Intussusception USS and examination

Answer 42

Target sign on the ultrasound (sausage shape mass felt)

Question 43

sepsis child take to hospital from GP especially if

Answer 43

high lactate

Question 44

bacterial sepsis marker

Answer 44

Procalcitonin

Question 45

coeliac disease risk factor for what cancer

Answer 45

lymphoma

Question 46

This baby with bilious green vomiting a few days after birth has a history suspicious for ….

Answer 46

malrotation. An upper GI contrast study should be performed urgently to confirm the diagnosis. This baby will require surgery to correct the malrotation and resulting obstruction

Question 47

meconium ileum typical presentation and investigations

Answer 47

Meconium ileus typically presents in the first few days of life as a delay in passing meconium (> 48 hours) and features of bowel obstruction (bilious vomiting). Diagnosis is confirmed with abdominal x-ray which shows characteristic findings of a ‘bubbly’ appearance of the intestines and lack of air-fluid levels

Question 48

DMD inheritance

Answer 48

X linked recessive

Question 49

anti depressant for kids

Answer 49

Fluoxetine

Question 50

This teenager, with a first presentation of seizure with no personal or family history of seizures, is very concerning for a space-occupying lesion (SOL). The description of a frontal mass on CT that crosses the midline (connecting the right and left frontal lobes via the corpus callosum) is most likely to be a

Answer 50

grade 4 astrocytoma, known as glioblastoma multiforme

Question 51

chickenpox incubation period

Answer 51

21 days

Question 52

branchial cyst typical presentation

Answer 52

This is most likely a branchial cyst due to the typical location (anterior to the sternocleidomastoid muscle), the presentation in late adolescence and the lack of movement on swallowing. An ultrasound of a branchial cyst will show an anechoic mass.

Question 53

A 3-day-old girl is brought to the GP by her mother who is worried about her vomiting since she was born. The vomit is yellow and has never contained blood. The mother says her daughter has not passed any stool since they left the hospital but did have a bowel movement whilst there. On examination, the girl has a single palmar crease on both hands and there is evidence of brachycephaly with a flat occiput. Her abdomen appears quite sunken. She has an abdominal x-ray which shows a ‘double bubble’ sign.
Given the likely diagnosis, what is the definitive treatment?

Answer 53

Duodenoduodenostomy
Correct. Duodenal atresia typically presents with vomiting in the first week of life which has been ongoing since birth. The absence of passing stool is also typical of duodenal atresia. Duodenoduodenostomy is the definitive corrective treatment in duodenal atresia. The surgery may be completed laparoscopically or via an open procedure

Question 54

roseola infantum causes

Answer 54

seizures

Question 55

A 13-year-old female with a known diagnosis of coeliac disease presents to her GP. She is concerned about the future complications of her condition.
What is the most likely complication commonly seen?

Answer 55

Enteropathy-associated T-cell lymphoma (EATL)
This is a rare form of non-Hodgkin lymphoma that can occur poorly controlled coeliac disease. The risk of developing this condition is linked to how adherent the patient is to a gluten-free diet. The worse the adherence, the more likely the patient is to get EATL.

Question 56

kawasaki rare complication

Answer 56

coronary artery aneurysm- give echo

Question 57

paeds life support

Answer 57

15:2, give rescue breaths before calling for help

Question 58

A 3-week-old baby presents with bilious vomiting and abdominal distension. The baby had normal bowel movements initially but developed constipation. An abdominal X-ray shows multiple air-fluid levels and absence of gas in the rectum.
What is the most likely diagnosis?

Answer 58

Malrotation
The presentation is suggestive of malrotation with volvulus which can lead to the obstruction of the small bowel, bilious vomiting, and distension. An X-ray showing multiple air-fluid levels and an absence of gas in the rectum indicates a small bowel obstruction. Prompt diagnosis is important to prevent intestinal ischemia and necrosis.

Question 59

A 5-year-old girl presents with a rash that started on her face and spread to her trunk. She also has a low-grade fever and swollen lymph nodes behind her ears.
Which of the following viruses is most likely causing her symptoms?

Answer 59

rubella

Question 60

A 1-day-old newborn girl is brought to the Emergency Department with significant vomiting. The vomiting came on at the same time as significant discomfort and crying, and had a green appearance. The pregnancy and delivery were uneventful.
On examination, she is alert, and appears to be in severe discomfort, with a heart rate of 180 bpm, respiratory rate of 50 breaths per minute, oxygen saturations of 96% on room air, and a temperature of 37C. The chest examination is normal and the abdomen is non-distended and non-tender, with normal bowel sounds.
FBC, U&Es and CRP are all normal. Plain film x-ray radiograph of the abdomen is also normal.
What is the most likely treatment of the underlying condition?

Answer 60

Urgent laparotomy
The most likely underlying diagnosis here is intestinal malrotation. The radiograph is normal because it is likely an intermittent or partial volvulus, which would not cause dilated bowel loops and a dilated stomach. However, there are still significant signs of obstruction and therefore the patient is likely to require surgery the next day, rather than the same day for a fully obstructed patient or a patient with bowel ischaemia.