SBAs

Question 1

A 4 yr old presents with 2 week history of increasing oedema with scrotal swelling and now periorbital swelling; He has proteinuria 4+. His BP and renal function are normal. The most likely diagnosis is

1. Henoch-Schonlein Purpura
2. SLE
3. Angioneurotic-edema
4. Glomerulonephritis resulting in nephrotic syndrome
5. Post streptococcal glomerulonephritis

Answer 1

4. Could be 1,2 or 5 but not enough in the q to say this; the presentation is of nephrosis, many causes so generic answer is 4.

Question 2

This 5 year old, just emigrated from Australia 10 days ago has a 1 week of high fevers and cough; no response to IV cefuroxime; The most likely organism is…

1. Haemophilus
2. Strep Pneumonia
3. Moxarella
4. Staph Aureus
5. Mycobacterium TB

Answer 2

Staph aureus; there are small pneumatocoeles. Also if you thought about TB, Australia has one of the lowest incidences in the world so very unlikely

Question 3

Which is the most appropriate treatment for an acutely wheezy, alert 18 month old in ED, RR 40/min; HR 120/min sats 90% (100% in oxygen)

1. 6 puffs salbutamol via a turbohaler
2. 10 puffs salbutamol via an MDI + aerochamber
3. 6 puffs salbutamol via an MDI
4. 5mg salbutamol via nebuliser
5. 2.5 mg salbutamol via nebuliser

Answer 3

Answer is 2; whilst one can use a nebuliser, this is now reserved for life threatening wheeze or failure to tolerate spacer; even if needing oxygen (in non life threatening wheeze), remove this temporarily to give spacer

Question 4

A 2 yr old child had their first febrile convulsion, which was a very prolonged one resulting in intubation. For the next febrile illness, the parents are best advised:

1. To give prophylactic nurofen and paracetamol to reduce risk of a convulsion
2. Tepid sponge and place in a warm (not cold) bath
3. Apply a cool fan to the child
4. Give the child rectal diazepam if they start fitting and call 999
5. Always seek medical attention to have the child examined

Answer 4

No evidence 1 works; 2 and 3 should not be advised; 4 is correct; no need to always have the child examined just because the child has a fever and a previous convulsion

Question 5

Answer 5

2

This is a case with evidence of multiple similar sized circular lesions (some vesicles) and also crusting + exudates; one has to consider both staph aureus and herpes; this was eczema herpeticum and secondary staph infection. Do not use topical antibiotics for infected eczema.

Note added by Dr Gareth Tudor-Williams: there is a widespread myth that using penicillin to treat Strep, plus flucloxacillin to treat Staph is good practice. In fact, flucloxacillin is a semi-synthetic penicilin and when given in appropriate doses iv is just as effective at treating Strep as penicillin. It is unnecessary to duplicate the cover, and simply costs more in terms of nursing time, and may reduce the half life of peripheral cannulae by doubling the number of drug doses given intravenously

Question 6

A 10 month old baby had a mild allergic reaction to egg (rash); What should happen with MMR

1. Admit for MMR under hospital observation
2. No MMR
3. Single jabs in community setting
4. Single jabs under hospital observation
5. MMR in community setting

Answer 6

V easy here – only 1 answer which is 5. NO need to admit for observation, and never single jabs, ever!

Question 7

What is the most appropriate management strategy for an alert, well oxygenated 3 yr old with 24 hr history of barking cough, increasing (moderate) stridor and fever >40 + rigors. No drooling. She is being given oxygen.

1. Adrenaline nebuliser stat and call ENT and anaesthetic teams
2. Oral dexamethasone and lateral neck X-Ray
3. IV cefuroxime + flucloxacillin (after blood cultures)
4. Budesonide nebuliser
5. Oral dexamethasone, IV cefuroxime + flucloxacillin (after blood cultures) and review

Answer 7

History suggests viral croup but also possible bacterial tracheitis raised. Adrenaline not needed at this stage unless deteriorates (when ENT/anaesthetics should be called). Never do lateral neck xrays; oral dex is first line although you can give a budesonide neb instead; but in this case, advisable to also give broad spectrum antibiotics too, hence 5 is most appropriate answer.

Question 8

A 14 month old child presents with 2 weeks of increased bruising, and a few nose bleeds; no recent history except MMR 2 weeks ago; No family history; Exam normal, no Lymph nodes, no enlarged liver or spleen; lots of bruises over contact points; FBC shows Hb 11.9; WCC 7.8 (Normal diff); Plats 8,000; Blood film normal. Most likely diagnosis is..

1. Acute lymphoblastic leukemia
2. Idiopathic thrombocytopenic purpura
3. Henoch Schonlein Purpura
4. MMR associated thrombocytopenia
5. Aplastic Anaemia

Answer 8

Most likely is an immune thrombocytopneia – so 2 or 4 but given the MMR history, seems 4 more likely

Question 9

A bright 9 yr old presents with primary nocturnal enuresis. Parents tried pad and alarm, failed; have tried lots of self-help remedies to no avail. Which is the most useful first line approach?

1. Start DDAVP tablets for 3 months and review
2. Give imipramine for 3 months trial
3. Encourage lifting at midnight and reduction in oral fluids at night
4. Commence behavioural approach
5. Do nothing, just reassure

Answer 9

The best approach is 4, meds have v limited role (short term use of DDAVP occasionally used to support behavioural approach; sleepovers etc); imipramine almost never nowadays; lifting at night will delay continence; doing nothing not an option at this age.

Question 10

In asthma in an 8 yr old, with persisting cough/wheeze at night and exertion, who is needing regular salbutamol, the next step is

1. Montelukast 5mg orally once daily
2. Low dose inhaled steroids via turbohaler
3. Low dose inhaled steroids via MDI
4. Salmeterol and low dose steroid combination via MDI and spacer
5. Low dose inhaled steroids via MDI and aerochamber

Answer 10

Option 5

Question 11

What would be the most appropriate immediate response in a situation where a child with severe acute asthma is being removed from the ED by their carers prior to treatment

1. Accept parental wishes
2. Prevent child from leaving, by force if necessary
3. Ask security to intercept and rescue the child
4. Call social services and ask them to go to Court for an emergency protection order
5. Call the police

Answer 11

The only immediate option is 5, so that you can get the child back to start immediate treatment (able to do this without parental consent, in best interests of the child; Meanwhile you will then pursue point 4. Security cannot use force = assault.

Question 12

A 15 yr old takes an overdose or tricyclic antidepressants and is comatose, GCS 6; The most appropriate first line management is

1. Ipecac forced emesis
2. Activated charcoal via an NG tube
3. Gastric washout, then activated charcoal via an NG tube
4. Oxygen, suction and intubation
5. Contact psychiatrists

Answer 12

Easy as the only safe option is 4 as she has an unsafe airway; then consider 3 and of course 5; No role ever now for forced emesis.

Question 13

In a 6 month old with a 2 week history of persisting diarrhoea (watery, no blood, 6-8 x a day) after an initial bout of vomiting and fever; with no travel or drug history, the most appropriate management would be

1. 24 hours of diarolyte instead of all other fluids
2. Perform a coeliac screen, stool cultures and refer to a paediatric gastroenterologist
3. Send stool cultures and start ciprofloxacin
4. Stop all dairy products and substitute with a hydrolysed formula; also send stool cultures
5. Send stool cultures and start metronidazole

Answer 13

Please see “Diarrhoea and vomiting in under 5’s”, (nice.org.uk); Approach is 4; If giardia was found, Rx with metronidazole can be considered but there are very few other indications to use antibiotics in children with infective gastroenteritis (other than with possible sepsis)

Question 14

1. A 6 wk old breast fed infant with a 2 week history of worsening vomiting after feeds, with poor weight gain and constipation. The Chloride is 90 mmols/L.
2. A 1 week old with vomiting, lethargy, increasing jaundice and on exam a 3 cm liver is felt and cataracts are noted
3. 3 yr old with acute onset abdominal pain for 4 hrs (3 similar episodes in the past, all self resolved), but this time with bile stained vomiting
4. 6 month old breast fed infant, vomiting since early on, not resolved with anti-reflux medication; also has eczema hard to control and constipation
5. 2 week old boy with frequent vomiting, lethargy, no fevers. The abdomen is soft and non tender. U&E’s show Na 122, K+ 6.4.

Answer 14

1. Pyloric stenosis
2. Galactosaemia
3. Malrotation
4. Cow’s milk protein intolerance - NB CMP intolerance can occur in breast fed infants, as small amounts of cow’s milk protein fragments may be found in the breast milk of mothers who have not excluded milk from their own diet
5. CAH

Question 15

1. A 5 yr old with 1 week of severe left sided headaches, analgesic unresponsive. Having high fevers, vomiting, and earache, on oral amoxicillin for otitis media. Aside from a red left TM, nothing to find on examination.
2. Acute onset severe right sided headaches in 7 yr old, with left sided weakness lasting an hour then full recovery. Several similar episodes in the past but getting worse; weakness is taking longer to resolve each time and more severe.
3. 3 yr old with 2 week history of waking with headaches and vomiting; becoming unsteady on feet and presents with a sudden squint of left eye, with diplopia on looking to the left.
4. 9 yr old with 6-12 months of continuous daily frontal and vertex headaches; unresponsive to analgesia; does not wake from sleep; no interruption with ADL’s. No other symptoms. Exam N, inc BP and fundi
5. 14 yr old girl, 6 weeks worsening headaches, early morning with vomiting; grossly blurred fundi, CT scan normal

Answer 15

1. Intracranial abscess
2. Arterio-venous malformation
3. Posterior fossa tumour
4. Tension type headache
5. Idiopathic intracranial hypertension

Question 16

1. 5 yr old recently returned Nigeria; has had 3 day history of swinging high fevers, also urine is noted to be dark red. On exam has enlarged liver, otherwise nil else. Dipstick positive for blood +++.
2. 2 year old with frank haematuria, some abdominal pain, rigors. Urine nitrite and blood +++.
3. 6 month old brought in by parents as they noted blood in the nappy; well infant; history of constipation last 6 weeks; exam, right sided abdominal mass palpable; urine blood ++++.
4. A 3 yr old with urine noted to be very dark by parents; Has had puffy eyes and been generally unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. BP 110/65.
5. 6 yr old male, UK born, of Iraqi parents, develops sudden onset very dark red urine, no pain. He has a current viral infection. On exam, slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice.

Answer 16

1. Malaria
2. UTI
3. Wilm’s tumour
4. Acute glomerulonephritis
5. G6PD deficiency

Question 17

A previously healthy 2-year-old child presents with a 24 hour history of diarrhoea and vomiting. Which of the following is the single, most accurate method for assessing the degree of dehydration?

a. Assess skin turgor
b. Assess the fontanelle
c. Calculate the difference between the current weight and the predicted weight from the child’s growth records
d. Examine the mucous membranes
e. Measure the heart rate and blood pressure

Answer 17

c

Question 18

A 3-year-old boy attends the Paediatric A+E Department because he has developed an itchy rash whilst at a birthday party. Of the following features, which requires immediate treatment with 0.01 ml/kg of 1:1000 adrenaline i.m.?

a. Blood pressure of 88/50
b. Generalised urticaria
c. Lip swelling
d. Respiratory rate of 22/minute
e. Wheeze on auscultation

Answer 18

e

Question 19

A 15-month-old girl presents with a 3-day history of intermittent fevers and vomiting and poor feeding. On examination her temperature is 38.6 C but there are no localising signs. What is the most likely cause?

a. Bronchiolitis
b. Encephalitis
c. Meningitis
d. Pyloric stenosis
e. Urinary tract infection

Answer 19

e

Question 20

A 6 yr old male born in the UK to Iraqi parents, develops sudden onset very dark red urine with no dysuria. He has a intercurrent viral infection. On examination; slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice. Which investigation is most likely to reveal the underlying diagnosis?

a. Blood film
b. G6PD level, now and in one month’s time
c. Hb electrophoresis
d. Liver function tests
e. Urine M,C&S

Answer 20

b

Question 21

A twelve year old boy has had seven episodes of spontaneous lip swelling and bilateral periorbital oedema in the last three years. His father also had similar episodes in childhood. What is the most likely immunological mediator?

a. C1 esterase inhibitor
b. Complement C4
c. Eosinophils
d. Histamine
e. IgE antibodies

Answer 21

a

Question 22

A term baby is born normally at 38 weeks gestation at 2.3 kg. Labour was difficult with prolonged rupture of membranes. At 35 minutes of age the infant was noted to have an increasing oxygen requirement with grunting and respiratory distress. On examination he was floppy with an oxygen saturation of 95% in 2L/min of oxygen. A CXR showed reticulonodular shadowing. What is the most likely diagnosis?

a. Bacterial pneumonia
b. Bronchiolitis
c. Chronic lung disease
d. Persistent pulmonary hypertension
e. Respiratory distress syndrome

Answer 22

a

Question 23

A 5-year-old girl who never received MMR was exposed to chicken pox last week at school. She now presents with a 12 hour history of rash and abdominal pain and is reluctant to walk. On examination, she is unwell with cold hands and feet, and a widespread blanching maculopapular rash with spots of different sizes sparing the head and neck. What is the most likely diagnosis?

a. Chicken pox (Varicella zoster)
b. Measles
c. Meningococcal sepsis
d. Roseola infantum
e. Rubella

Answer 23

c

Question 24

A 10 year old girl with known sickle cell disease presents to her GP on Monday morning complaining of weakness in her right leg. She says she had a fall on Saturday afternoon and has not felt right since. She has not been febrile and is not in pain. What is the most likely diagnosis?

a. Acute bone marrow aplasia
b. Cerebral infarction
c. Osteomyelitis of the right femur
d. Parvovirus B19 infection
e. Sickle cell crisis

Answer 24

b

Question 25

A four year old, known epileptic is admitted to the ward for observation as he has been vomiting. He is on regular levetiracetam (Keppra). You are called urgently to the ward to see him. An hour ago, he had his regular levetiracetam but vomited soon afterwards. He is now having a seizure and has been fitting for about six minutes. A fingerprick blood glucose is 4.7 mmol/l. What is the most appropriate initial action? ## Footnote a. Give an anti-emetic b. Give buccal midazolam c. Give IV dextrose d. Give IV phenytoin e. Start a levetiracetam ivinfusion

Answer 25

b

Question 26

A 3 year old girl's parents have noted that her urine has gone very dark and she has had puffy eyes. She has been unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. but the rest of the dipstick results are normal. BP 110/65 (greater than 95th centile for age/height). Which investigation is most likely to indicate the underlying diagnosis? a. 24-hour urine protein quantification b. Blood culture c. Complement C3 and C4 levels d. Ultrasound scan of the abdomen e. Urine M,C&S

Answer 26

c

Question 27

A 15-month-old girl presents with a 3-day history of intermittent fevers and vomiting and poor feeding. On examination her temperature is 38.6 C but there are no localising signs. What is the most likely cause? a. Bronchiolitis b. Encephalitis c. Meningitis d. Pyloric stenosis e. Urinary tract infection

Answer 27

e

Question 28

A 6 yr old male born in the UK to Iraqi parents, develops sudden onset very dark red urine with no dysuria. He has a intercurrent viral infection. On examination; slightly jaundiced, no liver or spleen; urine – blood ++++. There was a history of prolonged neonatal jaundice. Which investigation is most likely to reveal the underlying diagnosis? a. Blood film b. G6PD level, now and in one month's time c. Hb electrophoresis d. Liver function tests e. Urine M,C&S

Answer 28

a

Question 29

A twelve year old boy has had seven episodes of spontaneous lip swelling and bilateral periorbital oedema in the last three years. His father also had similar episodes in childhood. What is the most likely immunological mediator? a. C1 esterase inhibitor b. Complement C4 c. Eosinophils d. Histamine e. IgE antibodies

Answer 29

a

Question 30

A term baby is born normally at 38 weeks gestation at 2.3 kg. Labour was difficult with prolonged rupture of membranes. At 35 minutes of age the infant was noted to have an increasing oxygen requirement with grunting and respiratory distress. On examination he was floppy with an oxygen saturation of 95% in 2L/min of oxygen. A CXR showed reticulonodular shadowing. What is the most likely diagnosis? ## Footnote a. Bacterial pneumonia b. Bronchiolitis c. Chronic lung disease d. Persistent pulmonary hypertension e. Respiratory distress syndrome

Answer 30

a

Question 31

A 5-year-old girl who never received MMR was exposed to chicken pox last week at school. She now presents with a 12 hour history of rash and abdominal pain and is reluctant to walk. On examination, she is unwell with cold hands and feet, and a widespread blanching maculopapular rash with spots of different sizes sparing the head and neck. What is the most likely diagnosis? a. Chicken pox (Varicella zoster) b. Measles c. Meningococcal sepsis d. Roseola infantum e. Rubella

Answer 31

c

Question 32

A 10 year old girl with known sickle cell disease presents to her GP on Monday morning complaining of weakness in her right leg. She says she had a fall on Saturday afternoon and has not felt right since. She has not been febrile and is not in pain. What is the most likely diagnosis? a. Acute bone marrow aplasia b. Cerebral infarction c. Osteomyelitis of the right femur d. Parvovirus B19 infection e. Sickle cell crisis

Answer 32

b

Question 33

A four year old, known epileptic is admitted to the ward for observation as he has been vomiting. He is on regular levetiracetam (Keppra). You are called urgently to the ward to see him. An hour ago, he had his regular levetiracetam but vomited soon afterwards. He is now having a seizure and has been fitting for about six minutes. A fingerprick blood glucose is 4.7 mmol/l. What is the most appropriate initial action? a. Give an anti-emetic b. Give buccal midazolam c. Give IV dextrose d. Give IV phenytoin e. Start a levetiracetam ivinfusion

Answer 33

b

Question 34

A 3 year old girl's parents have noted that her urine has gone very dark and she has had puffy eyes. She has been unwell recently with a fever and sore throat. Urine shows blood ++++, protein +++. but the rest of the dipstick results are normal. BP 110/65 (greater than 95th centile for age/height). Which investigation is most likely to indicate the underlying diagnosis? a. 24-hour urine protein quantification b. Blood culture c. Complement C3 and C4 levels d. Ultrasound scan of the abdomen e. Urine M,C&S

Answer 34

c

Question 35

A 15-month-old Muslim girl is not meeting her gross motor developmental milestones and is generally very irritable. She was growing on the 50th centile, but is now on the 25th. She has 2-hourly breast feeds and consumes minimal solids with no additional dairy products. What is the most likely diagnosis? ## Footnote a. Failure to thrive b. Iron Deficiency c. Nutritional Rickets d. Phosphate deficiency e. Vitamin A deficiency

Answer 35

c

Question 36

A three year old girl is brought into A+E by her parents. She is usually fit and well. Her mum says that half an hour ago she ran into a table and banged her head on the corner. She went pale and fell to the floor, and then had two or three twitching movements before starting to cry. She is now back to her normal self and is running round A+E. Clinical examination is normal. What is the most appropriate action? a. Organise an ECG b. Organise an EEG c. Organise neuro-imaging d. Reassure the parents e. Teach parents how to give buccal midazolam if this recurs

Answer 36

d

Question 37

A 3-year-old boy with diarrhoea and vomiting was given metoclopromide and loperamide. He presents to A&E with torticollis and an intermittent convergent squint and upward deviation of both eyes. What is the most appropriate treatment? a. Atropine b. Bromocriptine c. Buccal midazolam d. No treatment - admit for observation e. Procyclidine

Answer 37

e

Question 38

A 13-year-old boy presents to his GP for a routine physical prior to participation in competitive sports. He has had no recent illnesses and no past medical history of note. His height and weight are on the 75th centile for his age. Cardiovascular examination reveals a grade 2/6 ejection systolic murmur heard loudest at the left lower sternal border. It is low pitched and musical but does not radiate. Which of the following is the most likely diagnosis? a. Atrial septal defect b. Mitral stenosis c. Tricuspid regurgitation d. Ventricular septal defect e. Vibratory innocent murmur

Answer 38

e

Question 39

A five week old girl presents with a history of recurrent coughing and choking during and after feeds. Pregnancy was complicated by polyhydramnios. What is the most likely diagnosis? ## Footnote a. Epiglottis b. Gastro-oesophageal reflux c. Laryngomalacia d. Tongue-tie e. Tracheoesophageal fistula

Answer 39

e

Question 40

An 8-week-old exclusively breastfed baby boy was born at 38 weeks gestation after an uneventful pregnancy. Which of the following findings would require a prompt referral to a paediatric surgeon? ## Footnote a. A right testis which can be manipulated to the base of the scrotal sac b. An acute episode of balanitis c. An irreducible firm lump which extends from the inguinal canal to the scrotum d. Bilateral nontender scrotal swellings which transilluminate e. Glandular hypospadias

Answer 40

c

Question 41

An infant of 31 weeks gestation was born via an emergency section because of foetal decelerations noted on CTG. The birth weight was 1100g and the infant required intubation but was difficult to ventilate. A CXR shows diffuse whiteout of both lungs with air bronchograms. What is the most likely diagnosis? a. Bacterial pneumonia b. Chronic lung disease c. Meconium aspiration d. Respiratory distress syndrome e. Transient tachypnoea of the newborn

Answer 41

d

Question 42

A healthy 4-year-old girl develops acute onset of petechiae and epistaxis. Laboratory findings include haemoglobin = 12g/dL; white cell count = 5.5 with normal differential; and platelet count = 15. Of the following investigations, which would you do next? a. Blood film b. Bone marrow aspirate c. Check the bleeding time d. Clotting studies e. Platelet antibody tests

Answer 42

a

Question 43

A 2-week-old boy is brought to A+E by his mother who has noticed that he has become increasingly jaundiced. She reported that he had not been breast-feeding as well as previously, and also commented that his stools looked like “off-white chewing gum”. The most likely diagnosis is: a. Breast-milk jaundice b. Congenital gall stones c. Extra-hepatic biliary atresia d. Glucose 6-phosphate dehydrogenase deficiency e. Rhesus incompatibility

Answer 43

c

Question 44

A 2-week-old boy is admitted with a 3-day history of vomiting and increasing lethargy. Physical examination is normal except for increased pigmentation of the areolar and nipples bilaterally. Laboratory findings include plasma sodium = 126 mmol/L; plasma potassium = 6.8 mmol/L; and plasma glucose = 5.9 mmol/ L. What is the most likely diagnosis? a. Congenital adrenal hyperplasia b. Gastroenteritis c. Hyperaldosteronism d. Panhyperpituitarism e. Pyloric stenosis

Answer 44

a

Question 45

A 14 year old girl with known sickle cell disease presents to the A+E department with severe pain in her right leg. What should your first step be in managing her case? a. Take a full history b. Examine her fully c. Ensure she has adequate analgesia d. Start IV fluids e. Give IV antibiotics

Answer 45

c

Question 46

Two unrelated infants are born at 36 weeks’ gestation. One infant weighs 2600g at birth and the second infant weighs 1600g. Which of the following conditions is the second baby more likely to have? a. Congenital malformations b. Hyperglycaemia c. Low haematocrit d. Occipito-frontal (head) circumference that is small compared to body weight e. Surfactant deficiency

Answer 46

a

Question 47

A 3-month-old breast-fed girl presents with a 3 day history of increasing breathlessness and difficulty with feeding. On examination she is tachypnoeic and hypoxic with no crepitations or wheeze and no abnormal upper airway signs. Her mother declined antenatal blood tests. What is the most likely underlying cause of this child’s respiratory illness? ## Footnote a. Group B streptococcal infection b. HIV infection c. Influenza virus d. Respiratory syncitial virus e. Viral meningitis

Answer 47

b

Question 48

A ten-year-old girl presents with recurrent abdominal pain. Of the following symptoms, which is most suggestive of an organic aetiology? a. Periumbilical location b. She has lost touch with her friends at school c. She wakes from sleep with pain at night d. The pain has persisted intermittently for more than three months e. The pain is so severe that she cannot attend school

Answer 48

c

Question 49

A one week old term baby presents to A+E. He is tachypnoeic, tachycardic and has an enlarged liver. Feeding and weight gain have been poor. On examination the infant is acyanotic with a quiet systolic murmur best heard at the upper left sternal edge. The second heart sound is widely split, the split not varying with respiration. What is the most likely diagnosis? ## Footnote a. Aortic stenosis b. Atrial septal defect c. Interruption of the aortic arch d. Patent ductus arteriosus e. Pulmonary stenosis

Answer 49

b