Paeds wk 5

Question 1

Maculopapular rash and fever?

Answer 1

Measles, look for Koplik’s spots on buccal mucosa and conjunctivitis

Question 2

Hand foot and mouth disease

Answer 2

Blisters around hands and feet, lesions on mouth

Question 3

Monophonic wheeze initial assessment and Mx

Answer 3

CXR, then rigid bronchoscopy

Question 4

Immune thrombocytopenic purpurin Mx

Answer 4

No treatment, post viral will resolve in 3-6 months

Question 5

Minimal change disease not responding to steroids?

Answer 5

Cyclosporin given instead

Question 6

Henoch Schonlein Purpura (HSP) Ix

Answer 6

Urine dip

Question 7

A 6 year old boy presents to the GP with his mother. Over the last 48 hours he has developed a sore throat, headache and fever. In the last 24 hours he has developed a coarse, erythematous rash over his face and torso and his mother reports that his tongue appears bright red.

Answer 7

Strep pyogenes, Scarlett fever

Question 8

HFMD serious complications

Answer 8

According to NICE guidelines, any child with HFMD who presents with a severe headache or neurological symptoms should be urgently referred to A&E

Question 9

Most common complication of measles

Answer 9

Otitis media

Question 10

A 14-year-old, 50kg male presents to A&E with nausea and vomiting. He started feeling really unwell 2 days ago. He has also had generalised abdominal pain and complained of polyuria. Over the last few months, his parents noticed some weight loss and increased fatigue.
On examination, he has sweet smelling breath and his breathing is deep and rapid. He is administered IV fluids on arrival.
From the choices below, what is the next most appropriate initial management?

Answer 10

Infuse 50 units of actrapid in 50ml of 0.9% NaCl at a rate of 5 units/hour

Question 11

HFMD cause

Answer 11

Coxsackie virus A16

Question 12

Impetigo school rules

Answer 12

48 hours after treatment or when crusted over they can go back

Question 13

Slapped cheek syndrome cause

Answer 13

Parvovirus B19

Question 14

A 2-year-old girl presents to her GP with a new rash. Her parents mention that she had a high fever, reaching 39.5 °C 4 days ago. She has been lethargic and less active since the fevers began. She has had no similar episodes in the past and has no recorded allergies.
On examination, she is haemodynamically stable with no evidence of fever. She has pink–red macules and papules that are across her neck, trunk and have spread to the extremities.
What is the most appropriate management?

Answer 14

Roseola infantum is a common childhood rash. The natural history of the condition is a high temperature and fatigue followed by a rose–pink macular rash. The fever precedes the rash and usually resolves by the time the rash appears. It is caused by human herpes virus (HHV) 6, and occasionally by HHV 7. It is managed supportively.

Question 15

TTP presentation

Answer 15

TTP often presents with neurological symptoms such as headaches, visual changes and kidney failure. TTP can be life-threatening if not treated promptly, as the blood clots can lead to organ failure.

Question 16

HSP presentation

Answer 16

Correct. Henoch-Schonlein purpura is the most common vasculitis of childhood and affects the small vessels. The condition presents with a tetrad of rash, abdominal pain, arthralgia and glomerulonephritis

Question 17

A 2 year old girl has been brought in by her parents to the GP as she is complaining of pain on passing urine. This is her third episode of a urinary tract infection (UTI) in last few weeks. Both previous infections were cleared within 48 hours. The GP prescribes a course of antibiotics and sends off a sample for a midstream urine sample (MSU).
The child does not have any renal angle tenderness and is eating and drinking well. The child responds within 48 hours and the MSU grows E.coli. The child is alert and active.
What is the most appropriate management?

Answer 17

Request an ultrasound scan within 6 weeks and a DMSA scan 4-6 months later
This is the advice according to NICE guidelines. An ultrasound scan at 6 weeks will look for any urinary tract pathology and a DMSA will look for renal scarring. An MCUG is not necessary at this age as reflux nephropathy (diagnosed on MCUG) is more likely to have already presented by 6 months

Question 18

Apgar

Answer 18

The Apgar score is based on a total score of 1 to 10, with up to 2 points each for Appearance, Pulse, Grimace, Activity, Respiration - blue extremities are very common immediately after birth and gives a score of 1 for “Appearance”.

Question 19

Precocious puberty prevents to GP

Answer 19

Refer to paediatrics

Question 20

Tuberous sclerosis presentation

Answer 20

Seizures, you would expect the MRI head to show evidence of benign tubers in the cerebral hemispheres. The hypo pigmented macules described (ash leaf spots) and angiofibromas of the nose are all characteristic of tuberous sclerosis. Tuberous sclerosis is also associated with epilepsy.

Question 21

Sickle cell acute chest crisis

Answer 21

Oxygen and then pain relief

Question 22

A previously-well 12-year-old male from Greece presents to A&E with shortness of breath and exhaustion. His symptoms began 5 days ago when he was started with ciprofloxacin for a urinary-tract infection by his GP. He informs you that the burning sensation has stopped, but he now has very dark urine. He has not had similar episodes before and is up to date with his vaccinations. His mother has been diagnosed with a blood condition in the past.
On examination, there is scleral icterus.
Blood examinations demonstrate a reduced haemoglobin and an elevated urea and bilirubin, alongside deranged liver function tests.
What feature will be seen on the blood film?

Answer 22

Red-cell fragments and Heinz bodies
This child has glucose-6-phosphate dehydrogenase (G6PD) deficiency, an X-linked enzyme deficiency common among people from Mediterranean origin. Patients affected with G6PD deficiency are susceptible to the development of haemolytic anaemia. Medications such as sulphonylureas, ciprofloxacin and nitrofurantoin can trigger haemolysis. On a blood film, haemolysis is demonstrated by the appearnce of red-cell fragments and Heinz bodies.

Question 23

Slapped cheek syndrome Infectivity

Answer 23

Once rash appears, no longer infective

Question 24

hypotonia, macroglossia, an umbilical hernia, reduced feeding and constipation (mild soft abdominal distention)

Answer 24

Congenital hypothyroidism, picked up on newborn heel prick test

Question 25

Hypothyroidism increases your risk of

Answer 25

Children with auto-immune thyroiditis are at higher risk of developing other auto-immune mediated conditions, such as type 1 diabetes, rheumatoid arthritis and vitiligo.

Question 26

A 32 year old woman has just given birth to a term baby who had an APGAR score of 4, due to respiratory distress. Her symphysis fundal height at 40 weeks was found to be 34cm.
The baby is noted to have clubbed feet, low set ears, dry loose skin and the chest X-ray shows smaller lung fields.
What is the most common cause of this presentation?

Answer 26

Bilateral renal agenesis causing Potters

Question 27

Roseola infantum common complication

Answer 27

febrile convulsions. This child has roseola infantum, a common disease in children characterised by an initial high fever followed by a maculopapular rash. It is caused by human herpes virus 6. Febrile convulsions occur in up to 15% of children with the disease

Question 28

Herpes virus 4 and 6

Answer 28

4 = EBV
6 = roseola infantum

Question 29

VUR most common long term complication

Answer 29

Renal scarring

Question 30

Leukocoria assymetric red reflex

Answer 30

Unilateral retinoblastoma

Question 31

Absent red reflex with central opacity

Answer 31

Congenital cataract - think Downs or galactoseamia

Question 32

A 19-year-old girl is seen in the GP, complaining of a dark rash in her axillae and around her neck. The rash has been present for several months. She also complains of tiredness, lethargy, increased thirst and frequent passage of urine, which is more during the nights recently. She denies dysuria and haematuria. She attained menarche at the age of 12 years, with regular periods since then.
On examination, her body mass index (BMI) is 36 and all other vital signs are within the normal range. Abdominal examination is unremarkable. Which one of the following tests is most likely to establish the diagnosis?

Answer 32

The combination of clinical features with a rash suggestive of acanthosis nigricans provides a clue to insulin resistance and perhaps type 2 diabetes mellitus. Fasting blood glucose, out of the options given, would be the most appropriate initial investigation.

Question 33

After noticing an abnormality of the aorta and ventricles on ultrasound scans, a boy is delivered electively at a specialist unit. An echocardiogram confirms his aorta is interrupted with his descending aorta connecting to his pulmonary trunk via his ductus arteriosus. A pan-systolic is heard on auscultation. Additionally, he is noted to have a cleft palate.
What genetic/chromosomal abnormality is this patient most likely to have?

Answer 33

22q11.2 deletion
The phenotype described is that of DiGeorge syndrome. The cardiac involvement in people with DiGeorge syndrome is an inturrupted aortic arch. They usually have a ventricular septal defect too. Their underlying genetic mutation is a deletion on the q arm of chromosome 22

Question 34

UTIs in children need

Answer 34

Urine microbiology

Question 35

Causes of transient proteinuria

Answer 35

Transient proteinuria is common, benign and tends to recede as the precipitant is removed. Precipitants include seizures, strong infections, pregnancy and heavy exercise. It is likely if the urine dip were to be repeated in 24 hours, the protein would either be undetectable or at trace levels

Question 36

Discoid eczema

Answer 36

Very pruritic, psoriasis usually is not as much

Question 37

Impetigo infective period

Answer 37

48hrs after Abx can go back to school

Question 38

First line for nappy rash

Answer 38

Regular washing and exposure to air

Question 39

DKA fluids

Answer 39

This child with DKA is in shock, as indicated by their hypotension and tachycardia. New guidance on managing DKA in children recommends an initial 10 ml/kg of 0.9% sodium chloride as a bolus (NICE), to children in shock with DKA.

Question 40

Minimal change disease histology

Answer 40

Podocyte fusion or normal

Question 41

HSP feature not in ITP

Answer 41

Proteinuria

Question 42

Scarlett fever Infectivity

Answer 42

Can return to school 24hrs after first dose of Abx

Question 43

Severe measles risk factor

Answer 43

Vitamin A deficiency

Question 44

Measles Infectivity

Answer 44

Infectious until 4-5 days after the rash appears

Question 45

Erythema infectiosum, also known as ‘

Answer 45

Slapped Cheek Syndrome’ or ‘fifth disease,’

Question 46

Most common anaemia deficiency in babies

Answer 46

Infants that drink too much cows milk, and babies that drink cows milk before the age of one are at risk of developing iron deficiency anaemia. Iron deficiency anaemia can present as irritability, fatigue, developmental delay and poor cognition. Conjunctival pallor and glossitis are also clinical features of iron deficiency anaemia

Question 47

Live vaccines

Answer 47

Influenza, rotavirus, MMR, BCG, shingles, chicken pox

Question 48

A 14-year-old girl presents to the GP with her mother, as she is concerned about a rash that has developed on her chest. Last week she was seen by another GP for a sore throat, lymphadenopathy, abdominal pain and fever. She was diagnosed with bacterial tonsillitis and started on Amoxicillin. The rash developed on day 5 of treatment. On inspection, an erythematous maculopapular rash and excoriations are noted across her trunk and upper arms.
Which of the following is the most likely cause of the rash?

Answer 48

Morbilliform Eruption
This is the correct answer. A morbilliform eruption is characterised by a generalised maculopapular rash. This child presented with lymphadenopathy, fever, abdominal pain and sore throat most likely as a result of infectious mononucleosis, not bacterial tonsillitis. Morbilliform reactions are extremely common in patients with infectious mononucleosis taking Amoxicillin

Question 49

Sickle cell susceptible infection

Answer 49

This patient has sickle cell disease, and is susceptible to Salmonella osteomyelitis

Question 50

CAH enzyme deficiency

Answer 50

21 hydroxylase

Question 51

A boy is born at term requiring ventilatory support shortly after delivery. He has low set ears, downward slanting eyes and noticeably appears to have a ‘twisted’ posture and extremities. An ultrasound reveals multicystic, dysplatic kidneys.
Which of the following findings would be expected in the antenatal notes?

Answer 51

Oligohydramnios
The phenotype is classical of Potter sequence. It arises from a common sequence of events caused by oligohydramnios. The lack of amniotic fluid means there is a lack of ‘cushioning’ of the foetus, resulting in it getting squashed by the surrounding maternal organs - resulting in their characteristic appearance

Question 52

A 9-year-old female presents to the GP with a rash. The mother informs you that she has been unwell for the last few days with a high temperature and sore throat for 1-2 days prior to the rash.
On examination, you notice a diffuse erythematous maculopapular rash on the face, trunk and limbs. There is also facial flushing extending across the nose, perioral and periorbital regions.
Given the likely diagnosis, what is the correct management for this patient?

Answer 52

Oral phenoxymethylpenicillin
The child has presented with scarlet fever, typically characterised by an initial subclinical phase of rash preceded by fever, sore throat, myalgia, vomiting for 1-2 days prior to the rash. The rash is commonly noted as a diffuse erythematous maculopapular rash of sandpaper texture, starting on the chest and abdomen before spreading. The rash usually spares the face, however there can be flushing/erythema around the face and cheeks, which is blanching. Other associated symptoms include strawberry tongue and lymphadenopathy. It is a notifiable disease and should be treated with a 10-day course of phenoxymethylpenicillin. Note: This presentation is different to slapped cheek syndrome (SCS) as in SCS, the rash spares the nose, perioral and periorbital region and the rash in SCS appears a few days after the fever resolves.

Question 53

A 14-year-old boy presents to the GP Clinic worried about his short stature. He is otherwise normal and does not have any other medical conditions diagnosed since birth. His parents and siblings are of average height.
On examination, his weight is 44 kg (1st–3rd percentile), height is 140 cm (<1st percentile) and blood pressure is 100/60 mm Hg. Both testes are 3 ml in size, and his genitals and pubic hair correspond to Tanner classification stage 1. Estimation of his bone age corresponds to 12 years.
What is the most appropriate investigation to diagnose the condition?

Answer 53

Testosterone and gonadotrophin levels
This boy has delayed puberty, resulting in short stature. The prepubertal genitalia, lack of pubic hair and delayed bone age confirm this diagnosis. Testosterone and gonadotrophin levels will help in identifying the pubertal state.

GH deficiency is very unlikely, as his weight and height are proportionate, and moreover, delayed puberty suggests that GH is not the problem.

Question 54

UTI in neonate needs

Answer 54

US

Question 55

A baby girl has just been born by emergency caesarean section. On assessment, she is blue peripherally but pink centrally; her heart rate is 120 beats/min; she cries in response to stimulation; her limbs are somewhat flexed but do not resist extension, and she has a strong cry.

What is APGAR and why

Answer 55

This baby scores: 1 for being blue peripherally but pink centrally; 2 for heart rate > 100 beats/min; 2 for crying on stimulation; 1 for some flexion in the limbs that do not resist extension, and 2 for a strong cry. This gives a total score of 8. The maximum score for each category is 2.

Question 56

DM causes

Answer 56

Secondary enuresis

Question 57

Most common extra renal manifestation of ADPCKD

Answer 57

Hepatic cyst

Question 58

Abdo pain and bloody diarrhoea and purpurin rash

Answer 58

HSP

Question 59

Sickle cell in children most common complication

Answer 59

Vaso occlusive crisis

Question 60

Acute chest syndrome management

Answer 60

Oxygen, analgesia, Abx

Question 61

HSP mx

Answer 61

NSAIDS