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Paediatrics finals revision Helena MartinQuestion 1 A 6-week-old infant is referred from the health visitor due to failure to thrive. The infant has fallen from the 50th to 9th centile on growth chart for weight. On further questioning, the parents reveal the infant vomits following each meal, which have on occasions 'hit the wall.' The mother's pregnancy was unremarkable, with normal antenatal scans, and the infant was born by an uncomplicated vaginal delivery. There were no abnormal features noted at the newborn baby examination. What is the most likely diagnosis? A) Intussusception B) Infantile colic C) Cow's milk protein intolerance D) Galactosaemia E) Pyloric stenosisAnswer E Pyloric stenosis typically presents around 2-6 weeks of age. Infants tend to have projectile vomiting following feeds and remain hungry after vomiting. There may be an olive shaped mass in the right upper quadrant due to hypertrophy of the pylorus, and 'waves of peristalsis' may be seen following a test feed. Infantile colic may present at a similar age however it is characterised by paroxysms of crying rather than frequent vomiting. Examination is normal in these infants. Cows milk protein intolerance often presents with diarrhoea preceding vomiting. Galactosaemia is an autosomal recessive metabolic conditions which can present with failure to thrive and vomiting in infancy, however the vomiting is not characterised as 'projectile.' Galactosaemia may be detected by the newborn Guthrie skin-prick test, and 'oil drop' cataracts may be noted on examination.Question 2 A 7-year-old boy is brought in to see you by his mother. He has a diagnosis of asthma which has been treated with salbutamol as and when required. His mother feels that his symptoms have worsened and he now has a night time cough which is keeping him awake and affecting him during exercise at school. The examination is unremarkable. How should you manage this? A) Refer to Paediatrics B) Add an inhaled steroid C) Advise regular salbutamol D) Arrange spirometry E) Add in MontelukastAnswer B In this question, as is currently common in clinical practice, the child is not taking an inhaled corticosteroid. The 2016 British Thoracic Society guidelines recommend all children, and adults, are started on an inhaled corticosteroid at the time of diagnosis. The previous initial 'step 1' of using a short- acting beta agonist by itself has now gone. Therefore, the most appropriate action is to add a 'very low' dose inhaled corticosteroid.Question 3 An 18 month old child attends the paediatric assessment unit with his mother. He has been brought in as he has had a fever, barking cough and difficulty breathing at night. He has been diagnosed with croup and you have been asked to see him to review. After history and assessment you are confident there is no stridor or respiratory distress. What would your next step in management be? A) Give Antibiotics B) Give oxygen C) Full ENT exam D) Give nebulised adrenaline E) Give oral dexamethasoneAnswer E • Croup - A single dose of oral dexamethasone(0.15 mg/kg) is to be taken immediately regardless of severity • This child has mild croup, the severity of croup is based upon; respiratory rate, respiratory distress, heart rate, O2 saturations and exhaustion. Treatment of mild croup is oral dexamethasone 0.15mg/kg single dose and review. Systemic dexamethasone and nebulisedadrenaline 5ml of 1:1000 are used in severe croup, alongside oxygenadministration. Antibiotics shouldnot be given unlessan underlyingbacterial infection is suspected. You shouldnot perform an ENT exam due to the possibility of an epiglottis diagnosis. • Croup: • Caused by Parainfluenza • 6 mo- 3 years • Management:1) single dose of oral dex, 2) high-flow oxygen,3) neb adrenalineQuestion 4 • You review a 4-year-old boy in clinic. He has been diagnosed with asthma after having multiple wheezy episodes over the past 3 years. Around 4 months ago he was admitted with shortness-of-breath and discharge he was given a Clenil (beclometasone dipropionate) inhaler 50mcg bd in addition toior to his salbutamol 100mcg prn via a spacer. His mother reports that he has a persistent night-time cough and is regularly having to use his salbutamol inhaler. Clinical examination of his chest today is normal. What is the most appropriate next step in management? A) Add a long-acting beta agonist B) Add a short-acting muscarinic antagonist (SAMA) C) Add a leukotriene receptor antagonist (Montelukast) D) Add a long-acting muscarinic antagonist E) Switch Clenil to Plumicort (budesonide)Answer C • The correct answer is to adda leukotrienereceptorantagonist. According to the British Thoracic Society (BTS) guidelines, the next step in asthma management for children aged 5 years and under who are not adequately controlled on low-dose inhaled corticosteroids (ICS) like Clenil (beclometasone dipropionate) is to add a leukotriene receptor antagonist, such as montelukast. This helps reduce airway inflammation and improve symptoms. Adda long-actingbetaagonist is not recommended as per BTS guidelines for children aged 5 years and under. Long-acting beta agonists (LABAs), such as salmeterol or formoterol, are typically added to ICS treatment in older children and adults when asthma control is suboptimal. Adda short-actingmuscarinicantagonistwould not be appropriate in this case. Short-acting muscarinic antagonists but are not recommended for routine use in managing chronic asthma symptoms.ilator during acute exacerbations of asthma Adda long-actingmuscarinicantagonistis also not recommended for children aged 5 years and under according to BTS guidelines. Long-acting muscarinic antagonists (LAMAs), such as tiotropium, may be considered in older children and adults with poorly controlled asthma despite optimal therapy; however, they are generally reserved for more severe cases. Lastly, switchClenilto Pulmicort(budesonide) would not be the most appropriate choice. Both Clenil and Pulmicort are ICS medications with similar efficacy profiles. Switching from one ICS drug to another without addressing the inadequate symptom control would not be expected to improve the patient's symptoms. Instead, following the BTS guidelines and adding a leukotriene receptor antagonist would be more appropriate in this case.Question 5 • A 4-year-old girl presents to the GP with a persistent fever and rash for the last 5 days. She is noted to have cracked, dry lips and peeling hands and fingers. Her mother is concerned and has been giving her regular paracetamol which has not helped. What is the most likely diagnosis? A) Kawaski’s disease B) Slapped cheek syndrome C) Viral Urticaria D) Scarlet Fever E) MeaslesAnswer A • High fever lasting >5 days, red palms with desquamation and strawberry tongue are indicative of Kawasaki disease • This question highlights the typical clinical features of Kawasaki's, namely a persistent fever associated with signs of mucocutaneous inflammation. It is important to identify and treat these patients early to reduce the likelihood of developing cardiac sequelae. It is estimated that nearly 1 in 5 people who are not treated early on in the disease with IV immunoglobulins develop coronary artery aneurysms which can lead to myocardial infarction and sudden death.Question 6 A 9-year-old boy is brought to surgery as his asthma has been getting worse over the past 2 days. His mother is concerned that his breathing is getting worse and not responding to inhaled salbutamolas normal. Which one of the following is consistent with a life-threateningasthma attack? A) Quiet breath sounds on auscultation B) SpO2 of 94% C) Heart rate of 120bpm D) Respiratory rate of 30/min E) Peak flow 40% of predictedAnswer A • Quiet breath sounds in a child with asthma is a worrying feature. Children with asthma normally have an obvious bilateral wheeze - the absence of this may suggest a life-threatening asthma attackQuestion 7 A 5-month-old girl presents to the emergency department with a 24-hour history of cough and wheeze, on a background history of one week of mild Observations show:symptoms. She is otherwise well and has no past medical history of note. Respiratory examination identifies generalised wheeze. • Blood pressure 90/50mmHg • Respiratory rate 50/min • Temperature 38.1ºC • Heart rate 122 bpm • Oxygen saturation 97% on room air What is the most appropriate management for this infant? A) Amoxicillin B) Dexamethasone C) Inhaled racemic adrenaline D) Nebulised salbutamol E) Supportive management onlyAnswer E • The correct answer is supportive management only. This child is presenting with cough and wheeze on a background history suggestive of a viral illness; this should raise suspicion of bronchiolitis. Bronchiolitis is a condition characterised by bronchiole inflammation in response to a recent viral illness, most commonly respiratory syncytial virus (RSV). As this patient's Alternatively, if her oxygen saturation was persistently below 92% or her feeding was affected, admission would be considered. may however be used in cases of uncomplicated community-acquired pneumonia and acute otitisantibiotic media. Dexamethasone is incorrect; this is commonly used in the management of croup. This diagnosis is unlikely as it is more likely to present with a barking cough, hoarse voice and inspiratory stridor. Inhaled racemic adrenaline is incorrect; this is commonly used in the management of croup. supportive management only.orrect as this patient is haemodynamically stable and requiresPaediatric Respiratory ConditionsQuestion 8 • A baby is born at term via vaginal delivery with no complications, however he is still not showing signs of breathing at one minute. Heart rate is >100bpm, but he is floppy and cyanosed. What is the most appropriate next step in management? A) Call for anaesthetist to intubate B) 5 mouth-to-mouth rescue breaths C) 5 breaths of air via face mask D) Start chest compressions E) Suction airwaysAnswer C • Airway suction should not be performed unless there is obviously thick meconium causing obstruction, as it can cause reflex bradycardia in babies. Chest compressions are not indicated, as the HR in this case is >100bpm. CPR should only be commenced at a HR < 60bpm. In cases where there are no signs of breathing and this is thought to be due to fluid in the lungs, five breaths should be given via a 250ml bag via face mask. This is a more effective and more hygienic method than using mouth-to-mouth in a hospital setting.Question 9 A 2-year-old child comes to the emergency department with a 2 day history of right knee pain and irritability. She had recently recovered from a viral respiratory tract infection and is apyrexial and asymptomatic now. On examination, the joint is painful to move but not hot or erythematous, and she is able to weight bear. Blood results show the following: What is the likely diagnosis? A) Septic arthritis B) Transient synovitis C) Juvenile idiopathic arthritis D) Psoriatic arthritis E) Osteochondritis dissecansAnswer B Non-weightbearing - 1 point assessthe probabilityof septicarthritis in children using 4 parameters: • Fever >38.5ºC - 1 point • WCC >12 * 10 /L - 1 point • ESR >40mm/hr The probabilitiesare calculatedthus: 0 points= very low risk • 1 point= 3% probabilityof septic arthritis • 2 points= 40% probabilityof septic arthritis • 3 points= 93% probabilityof septic arthritis • 4 points= 99% probabilityof septic arthritis This girl scores 0, and with a historyof recent viral infection,the likely culprit is transientsynovitis. Juvenile idiopathicarthritis (JIA) is more likely to give a polyarticular presentationwith systemicfeatures, including fever and rashes. There is no indicationof psoriasisin the presentation,making psoriaticarthritisunlikely. a moreinsidiousonset.ansoccurs when smallsegmentsof articular cartilageand bone comelooseinto the joint due to reduced bloodsupply. It tends to present in older children withQuestion 10 • A 2 day old baby who was born by a ventouse delivery is noted to have a swelling on the left side of his head in the parietal region. His head appeared normal immediately after delivery. On examination, the baby is well and the swelling does not cross suture lines. The fontanelles and sutures appear normal. What is the most likely diagnosis? A) Subaponeurotic haematoma B) Caput succedneum C) Craniosynostosis D) Skull fracture E) CephalohaematomaAnswer E • A cephalohaematoma appears as a swelling due to bleeding between the periosteum instrumental deliveries. The swelling usually appears 2-3 days following delivery andh does not cross suture lines. It gradually resolves over a number of weeks. Caput succadeneum is commonly seen in newborns immediately after birth. It occurs with prolonged labour and will rapidly resolve over a couple of days.es. It is associated Subaponeurotic haematoma is a rare condition where bleeding occurs that is not bound by the periosteum. It can be life threatening and presents as a fluctuant scalp swelling, which is not limited by suture lines. Craniosynostosis is uncommon and is where there is premature closure of cranial sutures, causing deformity of the skull. It can be evident at birth and may be associated involved. Other clinical features include early closure of the anterior fontanelle and raised ridge along the fused suture.Question 11 A 9-week-old infant is brought to the GP clinic for review by her mother.She is worried about an intermittentfever and wanted to have her daughter checked. There have been no other concerns.On examination,the child looksactiveand well, she is breathing comfortablyand her central capillary refill is less than 2 seconds.She is a normalcolourand has no rashes. Her observationsand growthare noted: • Heart rate 140 beats per minute (NR: 115-180) • Oxygen saturation99% on roomair • Respiratoryrate 42 breaths/min(NR: 25-60) • Temperature38.7ºC • Weight 75th centile • Height 50th centile • Head circumference75th centile • What is the mostappropriate actionto take? A) Keep the infant at the practice for serial observationsover the next 4 hours B) Reassure and review in 24 hrs C) Reassure, give warning signs of when to return, review in 48 hrs D) Refer to the paediatric emergencydepartment E) Urgent referral to a paediatricianAnswer DQuestion 12 A 6-week-old baby boy presents to his GP with symptoms of regurgitation and vomiting after feeding. His mother also reports ongoing issues with diarrhoea. He is generally irritable; his mother has also noticed some dry patches of skin on the insides of his elbows. The mother reports that he is formula-fed. His examination is unremarkable aside from mild eczema of the elbow flexures. Reassuringly, he is an appropriate size and weight for his age. What is the most appropriate next step? A) Preform an oral challenge B) Refer to a paediatrician C) Switch to an amino acid-based formula D) Switch to an extensive hydrolysed formula E) Switch to breastfeedingAnswer D This baby is demonstrating signs of cow's milk protein intolerance/allergy, which occurs in 3-6% of all children, considered a mild-moderate case. As such, it can initially be managed in primary care; the first step would bean be to switch to an extensive hydrolysed formula. reserved for cases where there is significant diagnostic doubt and for determining whether a food allergy has resolved. Referral to a paediatrician is unnecessary at this stage. Given that the symptoms are mild-moderate, the patient can be tried on an extensive hydrolysed formula first. If the initial switch to an extensive hydrolysed formula does not alleviate symptoms at all, a switch to an amino acid-based formula can be tried. It would be inappropriate to advise the mother to switch to breastfeeding. She may not be comfortable in doing so or may be unable to do so. For whatever reason, she has chosen to formula-feed her baby and this decision should be respected. A very small proportion of exclusively-breastfed babies are also cow's milk cow's milk from her own diet.e patients, the mother should be advised to continue breastfeeding and eliminateQuestion 13 • A 6-year-old boy is reviewed in clinic due to nocturnal enuresis. His mother has tried using a star- chart but unfortunately this has not result in any significant improvement. Of the following options, what is the most appropriate initial management strategy? A) Enuresis alarm B) Trial of oral desmopressin C) Trial of imipramine D) Trial of intranasal desmopressin E) Restrict fluids in the afternoon and eveningAnswer A • Enuresis may be defined as the 'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract' before)al enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months Management look for possible underlying causes/triggers • constipation • diabetes mellitus • UTI if recent onset • general advice • fluid intake • toileting patterns: encourage to empty bladder regularlyduring the day and before sleep • lifting and waking • reward systems (e.g. Star charts) • NICE recommend these 'should be given for agreed behaviour rather than dry nights' e.g. Using the toilet to pass urine before sleep • enuresis alarm • generally first-linefor children • have sensorpads that sense wetness • high successrate • desmopressin • particularlyif short-term control is needed (e.g. for sleepovers)or an enuresisalarm has been ineffective/isnot acceptable to the familyQuestion 14 • A 9-month-old boy is taken to the emergency department by his mother due to several hours of inconsolable he draws his knees up. These last for 1-2 minutes at a time and occur every half-hour.n, during which time On examination, he appears unwell. Abdominal examination is difficult due to the pain and irritability, but a sausage-shaped mass is palpable in the right upper quadrant. Some bloodstained, jelly-like stool is noted. What is the investigation of choice, given the underlying diagnosis? A) Colonoscopy B) CT C) MRI D) Ultrasound E) XrayAnswer D Ultrasound is the investigation of choice for intussusception This patient's presentation is suggestive of intussusception - the invagination of a portion of the bowel into the lumen of the adjacent bowel. It typically affects infants between 6-18 months old, more commonly boys. Patients present with episodic, severe abdominal pain and inconsolable crying, sausage-shaped mass in the right upper quadrant is often palpable. Ultrasoundis now considered the. A investigation of choice, with high specificity and sensitivity, and may show a target-like mass. Management involves reduction by air insufflation, or surgery if this fails or the child is peritonitic. CT scanning is normally not appropriate for suspected intussusception. Ultrasound is quicker, highly sensitive and specific, and does not expose the infant to radiation. time-critical scenario. Ultrasound is highly accurate with regard to intussusception.d this is typically a A plain film X-raymay be performed initially if perforation or obstruction is suspected. It has low specificity and sensitivity for the diagnosis of intussusception and so ultrasound is preferred.Question 15 A baby boy born 6 hours ago has an APGAR score of 10. He is not cyanosed, has a pulse of 140, cries on stimulation, his arms and legs resist extension and he has a good cry, He appears jaundiced. What is the most appropriate action? A) Encourage the mother to sit with the baby in sunlight B) Arrange a blood transfusion C) Start phototherapy D) Prescribe IV immunoglobulin E) Measure and record the serum bilirubin level urgentlyAnswer E Measure and record the serum bilirubin level urgently (within 2 hours) in all babies with suspected or obvious jaundice in the first 24 hours of life since this is likely to be pathological rather than physiological jaundice. NICE CG98JAUNDICE • 2 types of jaundice: • Physiological • Pathological Kernicterus: Bilirubin can cross the blood-brainbarrier.Excessive bilirubin causes direct damage to the centralnervoussystem.Kernicterus presents with a less responsive, floppy, drowsy baby with poor feedingQuestion 16 A 1-month baby, born at 39 weeks, presents with being increasingly unsettled around 30-60 minutes after feeds, with frequency regurgitation, ’colic’ episodes, non-bloody diarrhoea. There is no history of fever, urticaria, angioedema or wheezew. He is exclusively formula-fed. The examination is unremarkable aside from some mild eczema in his flexural areas. His weight remains stable between the 50-70 centile. What is the most appropriate next management step for this child? A) amino-acid based formula trial B) Anti-reflux medication trial C) Extensively hydrolysed formula trial D) Refer to paediatrician E) Soya milk trialAnswer CQuestion 17 A 5-week-old baby is brought to ED with vomiting. His father is concerned because he has had three large bouts of vomit. In the last 3 days, after his feeds and especially when being laid down, he has had milky vomits. He continues to breastfeed well otherwise. He has had trouble sleeping, been crying, arching his back and bringing his knees to his chest. His stools have been yellow mustard consistency once a day. There is no signs of infection, such as cough or fever. What is the most appropriate step after examination? A) Abdo US B) Admit and start IV Abx C) Rectal air insufflation D) Stool culture E) Reassure and discharge with infant gavisconAnswer EQuestion 18 A 15-month-old baby is brought to ED because she has had diarrhoea for 3 days and vomiting for 2 days. Her mum says she has had diarrhoea 4 times a day, watery in consistency, with no blood. She also vomiting once yesterday and twice today. Both days the vomit ahs been yellow in colour. In the past 24 hours, she has been refusing all food and not drinking. She has had 2 less nappies today. O/E: the child appears well and is playing. Her skin is pink with no mottling. Her mucous membranes appear dry. Her eyes do not appear sunken. Her RR is 30, sats 99%, HR 110, BP 118/78, CRT 2 centrally, T 37.1 degrees Celsius. Her abdo is soft, non-tender. Urine dip NAD. What is the most appropriate management for this child? A) IV fluids B) Diaralyte oral rehydration C) IV Abx D) Encourage solid foods E) Refer to surgical teamAnswer BQuestion 19 • A 4-day old boy who was born at term haas not passed stool since birth. He has increasing swelling of the abdomen and has been vomiting for the past explosive passage of stool. Bloods are normal. of a gloved finger leads to • Which of the following investigations will most likely confirm the diagnosis? A) Rectal suction biopsy B) CTAP C) Abdomen X-ray D) Flexible sigmoidoscopy with biopsies of sigmoid mucosa E) US AbdomenAnswer AQuestion 20 A 7-year-old presents to Paediatric ED with abdominal pain. His father states his on had a sore throat a few days ago. O/E: he has pain in the RIF, but there is no guarding. Urine dip is NAD. Which is the following most likely diagnosis? A) Mesenteric Adenitis B) Meckel’s diverticulum C) Pyelonephritis D) Appendicitis E) Kidney stoneAnswer AQuestion 21 A 1-year-old girl presents to the ED with intermittent abdominal pain. Her father explains during these episodes she becomes irritable, pale and draws her legs up toward her abdomen. There is no vomiting, but she has refused feeds for the past 2 days. The abdomen is soft. There is a palpable, sausage-shaped mass in the right flank. What is the first line of management after resuscitation? A) Laparotomy B) Hydrostatic enema C) Air enema D) Watch and wait E) Laparoscopic correctionAnswer CQuestion 22 A 14-year-old boy presents to the ED with sudden onset pain in his lower abdomen and scrotum. He had had episodes of pain in his scrotum previously but nothing as bad as this. The pain started two hours ago. O/E: the scrotum is exquisitely tender and swollen, with the left testiscle raised higher in the scortum. What is the most appropriate management? A) start IV Abx B) Contact urology for urgent surgical exploration of the scrotum C) Urgent doppler US testes D) Urgent abdominal XR E) Refer to urology for outpatient follow-upAnswer BQuestion 23 • prolonged jaundice. Her stools are white to pale beige in colour and although she produces plenty wet nappies, her urine is somewhat dark. Initial investigations reveal a conjugated hyperbilirubinaemia. What is the most likely diagnosis? • A) Biliary atresia • B) Galactosaemia • C) Cystic fibrosis • D) Haemolysis • E) Gilbert SyndromeAnswer A • Biliary atresia: rare congenital liver disorder in which bile ducts are stenosed/ blocked or absent, resulting in progressive obstructive jaundice and liver failure. Fatal without early intervention in the form of a Kasai procedure.Question 24 • An 8-year-old previously well girl presents to the ED with a 1-month hx of polyuria and polydipsia and 1 day hx of nausea and vomiting. • Her initial capillary blood gas reveals: Dysfunction of which cells is the most likely cause of her pathology? A) Alpha cells of the pancreatic islets of Langerhans B) Beta cells of the pancreatic islets of Langerhans C) Hepatocytes D) Fat cells E) Neurons of posterior pituitaryAnswer B • She is DKA (glucose > 11, ketones > 3, pH < 7.3).Question 25 • A 3 week-old boy is brought into the ED – he recently has been having problems completing his feeds and today appears SOB. O/E: he has hepatomegaly of 4cm. All bloods are normal. • What is the most likely diagnosis? A– Cardiac failure B – Galactosaemia C – NAI D – GORD E - MeningitisAnswer A • Difficulty competing feeds along with sweats is a good indicator of heart failure in infacy. Hepatomegaly is another sign of cardiac failure. Now important to distinguish between cyanotic v non-cyanotic cardiac conditions.