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Work Smart Session - MRCPCH Part 1 A / DCH

Question: 64 of 64 Time taken: 01:10:44
Session Analysis
Which one of the following tasks should a 2-year-old child be able to perform?
(Please select 1 option)
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n Build a tower of five blocks Correct
j
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n hop on one foot
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n Dress themselves
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n Name three colours correctly
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n Use phrases of up to 8 words
A 2-year-old child would be able to build a tower of 6-7 blocks and kick a ball without losing balance and organise
phrases of 2-3 words. Naming of three colours would be expected by aged 5, amd use plurals would be expected by age
3. Hop on one foot should be achieved by aged 4.
Score:
Finish Total Answered:
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Session Analysis
A 16 month old boy was is brought to clinic by his mother who is concerned regrading slow development. Which one of the
following tasks would suggest delayed development?
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n He does not scribble spontaneously with pencil on paper.
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n He does not walk alone Incorrect answer selected
j
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n "Ma" and "Dada" are the only words which are clearly recognizable.
j
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n He is unable to build a tower of 5 cubes.
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n He is unable to throw an object. This is the correct answer
A scribbling occurs usually by the age of 18 months and he should be able to build a tower of 5 blocks by two years.
However, he should be able to throw an object by this age.
Score:
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Session Analysis
A 2.5-year-old boy is referred with behaviour problems and poor speech. He speaks very seldom, and is
unable to sustain a conversation. He always prefers to play on his own, lining up his Thomas the Tank engine
set repetitively, ignoring his older and younger siblings. He throws tantrums when his routine is disturned. He
was born at 37+3/40 weighing 3.51kg and there were no neonatal problems. Pregnancy had been
uncomplicated.
On examination he is apyrexial, and there are no specific abnormalities to find.
What is the most likely diagnosis?
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n Autism This is the correct answer
j
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n Global developmental delay
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n Impaired hearing Score:
i
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n Pervasive developmental disorder Incorrect answer selected Total Answered:
j
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n Speech delay, isolated
Tag Question
The history is of poor speech development, ritualistic behaviour and lack of reciprocal social interaction. The
most likely diagnosis is Autism, which starts before 30 months of age and is characterised by a qualitative
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impairment in verbal and nonverbal communication, in imaginative activity, and in reciprocal social interactions.
It is part of the wider spectrum of pervasive developmental disorders. This includes: autism, Aspergers,
childhood disintegrative disorder, and Rett's syndrome. Remove question
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Session Analysis
A 3-year-old child is suspected to have whooping cough infection. Which one of the following statements correctly applies to his
condition:
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n The child is maximally infectious 2 months after termination of symptoms.
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n A cough plate examination is the usual mode of diagnosis
j
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n An inspiratory whoop would invariably be present
i
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n Neutrophil leukocytosis is expected Incorrect answer selected
j
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n The annual death rate from pertussis is less than 100 per year in the UK. This is the correct answer
The child is maximally infectious in the first 7-14 days of the illness termed the catarrhal phase. The organism attaches
to ciliated epithelium, so it is spread by coughing and in nasal secretions. However, it is difficult to culture, and mostly
Score:
the diagnosis is clinical. A whoop may not be present, but apnoeic episodes can occur. Lymphocytosis is often
observed. The annual death rate in the UK is very low. Pertussis epidemiology. Total Answered:
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Session Analysis
Which one of the following statements is correct concerning the oral polio vaccination?
i
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n It Is a live attenuated strain Correct
j
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n It is given by subcutaneous injection
j
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n It should be given initially at six months of age
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n It is inactivated by gastric acid secretions
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n It gives protection for life
Sabin is the live virus administered orally and Salk is the killed partly inactivated virus. The live virus is an oral vaccine
whilst the inactivated virus is administered subcutaneously. The first dose of polio vaccine is at 2months. It is not
inactivated by gastric secretions and live viruses can proceed down the GI tract into the faeces. The polio vaccine given at
Score:
8 weeks, 12 weeks, 16 weeks and 3-5 years does not invariably confer lifelong immunity therefore school leaving children
require re-administration. Total Answered:
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Session Analysis
Which one of the following statements correctly applies to immunisation of children in the United kingdom.
j
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n The first Diptheria, pertussis and tetanus innoculation should be given at one year.
j
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n BCG vaccinaton should not be performed in the neonatal period
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n Immunity to polio after the three initial SC/IM doses is lifelong
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n Polio vaccine is given by intradermal injection
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n HIV positive children should receive the measles/mumps/rubella and IM polio vaccines Correct
The national guidelines state that the first diphtheria, pertussis and tetanus inoculation should be given at eight weeks
with IM polio, Hib and meningococcal C. BCG can be administered at birth to high risk neonates soon after birth. The
guidelines recommend that school leavers are administered IM polio vaccine, diptheria and tetanus as the initial injections
Score:
may not confer lifelong immunity. Polio vaccine can be given as an oral preparation which contains the live virus or as a
subcutaneous injection of the inactivated virus. HIV positive children should receive MMR and all the appropriate killed Total Answered:
vaccines as well as pneumococcal vaccination. BCG and live oral polio vaccines are contraindicated.
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Session Analysis
A mother is concerned because her one-year-old girl was in contact with measles 2 days previously. Which one of the following
statements is correct?
j
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n Nothing can be done to affect the course of the disease.
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n Gamma globulin can be administered up to 14 days after exposure. Incorrect answer selected
j
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n If she were to become infected then complications would be extremely rare.
j
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n Immunisation with the live attenuated virus will give long immunity if given immediately This is the correct
answer
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n She should anticipate the rash occurring in the next 5 days.
If the person is within 72 hours of exposure measles vaccine is the treatment of choice as it will confer life long immunity.
In persons in whom the vaccine is contraindicated immune globulin can be given. Immune globulin is effective within 6 Score:
days of exposure. One third of those afflicted with measles can expect a complication. These include pneumonia, otitis
media, diarrhoea. A serious complication is the development of sub acute sclerosing, pan-encephalitis. The initial Total Answered:
symptoms of measles are corysal symptoms. Several days after the appearance of corysal symptoms a rash appears.
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Session Analysis
Which one of the following statements correctly applies to Pertussis Infection in children?
j
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n It rarely affects infants under 6 months of age
j
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n Is infectious for at least 2 months after the termination of the coughing
i
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n Is associated with an increase in the total lymphocyte count Correct
j
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n Is usually diagnosed by growing the organism from a cough plate
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n Is invariably associated with an inspiratory whoop
The disease is maximally infectious in the first 7-14 days of the illness, termed the catarrhal phase. There is an
associated lymphocytosis. The organism is diagnosed by isolating the organism from nasal secretions. An inspiratory
whoop may not be present, but complete apnoeic episodes can occur.
Score:
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Session Analysis
A 3-year-old by presents with a 2d history of coryza and cough, particularly at night. On examination he has
Harrison's sulci and is on the 3rd centile for weight and height. Chest auscultation reveals scattered wheeze.
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n Asthma This is the correct answer
j
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n Cystic fibrosis
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n Gastroesophageal reflux Incorrect answer selected
j
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n Sinusitis
j
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n Virus-induced wheeze
Score:
The examination findings suggest chronic undertreated asthma. If he does not respond rapidly to asthma therapy a sweat
test may be indicated to exclude CF. It is likely that he will respond to regular inhaled low-dose steroids. Total Answered:
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Question: 42 of 64 Time taken: 59:03
Session Analysis
At what age are children allowed to drink alcohol in public unaccompanied?
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n 16 years
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n 17 years
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n 18 years This is the correct answer
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n 19 years
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n 21 years Incorrect answer selected
UK legislation aims to reduce the exposure to alcohol and the effects of alcohol. In general, children below 18 years are
not allowed to enter pubs unless accompanied by a responsible adult, and may not consume alcohol.
Score:
In fact, many children younger than this consume alcohol, frequently to excess. The problem of binge drinking is rising
both in boys and girls, and may be accompanied by other risk taking behaviour, such as drug taking and underage Total Answered:
sex.Licencing Act 2003
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Session Analysis
A well boy presents at 3 months postnatal age to the routine outpatient clinic. Parents report no active problems. He was born at
30 weeks gestation weighing 1.7kg. He was given surfactant and ventilated for 72 hours, but was out of oxygen by day 6. Apart
from mild jaundice and one top-up transfusion he required no medical intervention. He was discharge home on day 37 taking
Prematil, Folic acid, Iron and Abidec.
How long would you continue his haematinics?
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n Stop them now
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n Until 4 months
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n Until on stage one baby dinners
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n Until on stage two baby dinners
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n Until on mixed family diet Correct Score:
Total Answered:
These days some preterm formulae are complete (eg Nutriprem II), and no supplements are needed.
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Session Analysis
A father requests access to his 15-year-old son's medical records. He is in the process of separating from his
son's mother, and they have been married for twenty-five years.
What is the most appropriate action in this case?
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n Disclose the complete record with permission of the mother
j
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n Disclose the complete records to the father
j
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n Disclose the record, omitting third party information about the mother
j
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n Seek consent from the son, and if he is competent, disclose the entire record to the son, his mother, and father
i
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n Seek consent from the son, and if he is competent, disclose only information that is not prejudicial to a third party
with his consent Correct
Score:
A 15-year-old adolescent should generally be consulted regarding a request for disclosure of their confidential
Total Answered:
medical record. The maturity of an adolescent may vary, but if they are considered to be 'Gillick' competent,
then a practitioner can respect their decision to disclose or withhold disclosure of their medical record.
It is important that a practitioner consider carefully any third party information contained within the record, and Tag Question
any information which may be considered to cause serious harm to an individual's physical or mental health.
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This information may be withheld under the provisions of the Data Protection Act 1998.
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Session Analysis
Features of Down's syndrome include all of the following except:
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n A third fontanelle. Incorrect answer selected
j
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n Duodenal atresia.
j
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n Ataxic gait. This is the correct answer
j
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n Increased incidence of hypothyroidism.
j
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n Susceptibility to acute leukaemia
Cerebellar dysfunction is not a feature of Down's syndrome, however an Alzheimer's like syndrome of memory
loss and cognitive decline develops when patients reach the mid thirties.
Score:
Down's syndrome
Total Answered:
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Session Analysis
Which one of the following statements is true of Munchausen's syndrome by proxy?
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n The carer genuinely belives the child to be ill
i
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n The child's life is not usually in immediate danger Incorrect answer selected
j
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n The carer is likely to have a schizophrenia
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n It is a cause of sudden infant death This is the correct answer
j
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n The person responsible is more likely to be the father
Munchausen's Syndrome by Proxy is a parenting disorder where parents, usually the mother, fabricate symptoms in their
children, thus subjecting the child to unnecessary medical tests and/or surgical procedures. In some cases, the parents
also inflict injury and can kill their children in the process.
Score:
eMedicine - Munchausen Syndrome By Proxy Total Answered:
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Session Analysis
A 16-year-old boy attends his general practitioner after acquiring an open wound on his left leg whilst playing rugby. Examination
of the wound reveals a dirty 6 cm wound containing soil. With regard to tetanus vaccination, which of the following is the most
appropriate treatment for this patient?
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n If the immunisation status is unclear, he should receive tetanus toxoid only
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n If he previously received three doses of tetanus vaccine, no immunisation for tetanus is required
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n If his immunisation status is uncertain he should receive tetanus immunoglobulin This is the correct answer
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n If the last booster dose of tetanus was within the last 10 years then he should receive a further booster Incorrect
answer selected
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n If he has received three doses of tetanus toxoid and the last booster was more than 10 years ago he should receive
a further 3 dose course tetanus vaccine
With regard to tetanus vaccination, if an individual who has received a full 5 course of tetanus vaccine suffers a tetanus Score:
prone wound, then no further doses of vaccine are recommended.
Total Answered:
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Session Analysis
A 15-year-old boy is referred by his GP with a two-week history of general malaise, fatigue and pharyngitis. On
examination, multiple small lymph nodes were palpable in the neck, axillae and groins.
Investigations revealed:
Haemoglobin 12.5g/dl (13.0-18.0)
WBC 16.0 x 109/l (4-11)

9
Platelets 160 x 10 /l (150-400)
Blood film Lymphocytosis noted
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n Acute lymphoblastic leukaemia
Score:
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n Cytomegalovirus infection
Total Answered:
i
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n Epstein-Barr virus infection Correct
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n Hodgkin's disease
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j
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n Toxoplasmosis
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Acute EBV typically presents with a history of 1-2 weeks of fatigue and malaise, fever, pharyngitis, and
symmetrical, bilateral lymphadenopathy. Heterophil antibody tests are usually positive. Mild transient
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thrombocytopaenia is not uncommon in EBV infectious mononucleosis.
CMV mononucleosis has a lower incidence of pharyngitis and cervical adenopathy. Rate this question
Primary toxoplasmosis is acquired via ingestion of undercooked meat containing toxoplasma cysts, or ingestion
of fresh food contaminated by toxoplasma excreted in cats' faeces. The infection is asymptomatic in 80-90% of Leave question feedback
immunocompetent patients.
Highly characteristic of toxoplasmosis is asymmetrical lymphadenopathy limited to an isolated lymph node

group. Patients with toxoplasmosis have little or no fever, fatigue, or pharyngitis.
CMV infectious mononucleosis may be indistinguishable in clinical presentation from EBV but is usually not
accompanied by posterior cervical adenopathy; non-exudative pharyngitis is minimal or absent.
The diagnosis of ALL and HD is made by a combination of blood film examination, bone marrow aspiration and
biopsy and lymph node biopsy.
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Session Analysis
A 15-year-old female is a close contact of a student who has developed meningitis C. The last contact she had
with her friend was two days ago when her friend developed headache. She has not received any previous
vaccination for meningitis. What is the most appropriate action for this girl?
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n No treatment is required and the girl can be reassured
i
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n Treat with rifampicin only Incorrect answer selected
j
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n She should receive the meningococcal A and C vaccination only
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n She should receive meningococcal immunoglobulin only
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n She should receive the meningococcal A and C vaccination plus rifampicin This is the correct answer
This girl runs a reasonably high risk of developing meningitis and should receive Meningitis C vaccination Score:
together with rifampicin. Antibiotics used for chemoprophylaxis are rifampicin, minocycline, spiramycin,
Total Answered:
ciprofloxacin and ceftriaxone. More here
Guidelines and Advice – Meningococcal
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Session Analysis
A 10 month old boy is brought to clinic as his parents are concerned after he came into contact with another
child with mumps 2 days previously. What is the most appropriate strategy for this child?
j
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n Do nothing now but give MMR at the appropriate age This is the correct answer
j
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n He should receive mumps immunoglobulin now
i
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n He should receive the MMR now Incorrect answer selected
j
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n He should receive MMR plus mumps immunoglobulin now.
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n He should have his mumps serology assessed now
There is little that can be done as the development of immunity following mumps vaccination is too slow to be of
any value. Thus he should receive the appropriate vaccination strategy as usual. Score:
Total Answered:
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Session Analysis
Theme: Obesity
A Type 1 diabetes
B Pseudohypoparathyroidism
C Persistent hyperinsulinaemic hypoglycaemia of infancy
D Asthma treated with fluticasone
E Simple obesity
F Prader-Willi syndrome
G Type 2 diabetes
H Hypothalamic tumour
I Cerebral palsy
J Hypothyroidism
For each of the following patients, choose the most likely cause for their obesity.
Score:
A 13-year-old girl presents with height and weight above the 99.6th centile. She has some abdominal striae and
Total Answered:
has oligomenorrhoea. The rest of the family are not overweight.
Hypothalamic tumour 6
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Incorrect - The correct answer is Simple obesity
Pathology is unlikely as the height has been unaffected. Abdominal striae may occur in simple obesity, not just Remove Tag
Cushing's disease.
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A 12-year-old boy with no significant past medical history presents with both his height and weight well above
th
the 99.6 centile. On examination, there were no abnormal findings and he has completed puberty. His parents Rate this question
th
are both overweight with heights close to the 50 centile.
Simple obesity 6
Correct
Simple obesity is associated with tall stature (thought to be secondary to hyperinsulinism), and tall stature is
reassuring in that pathology is unlikely. There is often a family history of simple obesity reflecting lifestyle Related Articles (BMJ)
issues within the family.
A 7-year-old girl with Down syndrome is seen because of excessive weight gain over the last year, however
assessment by a community dietician reveals a healthy diet and reasonable calorie intake for her age. Her
height has also plateaued.
Her teacher has noticed that she seems less alert than when she initially came into school and her
concentration is poor. Her hearing has been checked and found to be satisfactory. On examination there are
no abnormal findings except for rather cool peripheries and being overweight.
Hypothyroidism 6
Correct
Down syndrome is associated with autoimmune hypothyroidism, and should be screened for in these
individuals. Clinical findings of hypothyroidism include dry skin and cool peripheries and being overweight.
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Session Analysis
A 15-year-old girl presents to casualty with mild gastrointestinal upset. She had recently returned from holiday
where she had been swimming in the hotel pool.
What is the most likely causative organism?
j
k
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n Campylobacter jejuni
j
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n Cryptosporidium parvum This is the correct answer
i
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n Salmonella enteridis Incorrect answer selected
j
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n Shigella flexneri
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n Staphylococcus aureus
Score:
Human cryptosporidiosis causes self-limited diarrhoeal illness in healthy individuals, mostly children; and
severe prolonged diarrhoea in patients with AIDS. Total Answered:
Transmission is via human-to-human fecal-oral contamination. Animals are the major reservoir and outbreaks
have been associated with water supplies and public swimming pools.
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Session Analysis
Theme: Drugs to be avoided during breastfeeding
A Amiodarone
B Aspirin
C Benzodiazepine
D Chloramphenicol
E Heparin
F Haloperidol
G Lithium
H Sulfasalazine
I Sulphonamides
J Warfarin
Which of the above drugs when prescribed to the mother is associated with the following abnormalities in the breast-fed infant:
Score:
May result in neonatal hypothyroidism.
Total Answered:
Amiodarone 6
Correct
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May result in drowsiness and failure to thrive.
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Sulphonamides 6
Incorrect - The correct answer is Benzodiazepine Remove question
Associated with risk to developing nervous system in animal studies. Rate this question
Haloperidol 6
Correct
Administration of certain drugs to breast feeding mums may result in toxicity in the infants if the drug enters the
milk in pharmacologically significant quantities. Some drugs also inhibit the babies sucking reflex. Other drugs
inhibit lactation. Related Articles (BMJ)
Amiodarone needs to be avoided as it may result in neonatal thyroid abnormalities as there is a theoretical risk
from the release of Iodine.
Benzodiazepine may render the infant drowsy resulting in poor growth.
Antipsychotics, such as haloperidol, may adversely affect the developing brain, as shown in animal studies.
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Session Analysis
Theme: Drugs to be avoided during breastfeeding
A Amiodarone
B Aspirin
C Benzodiazepine
D Chloramphenicol
E Heparin
F Lactulose
G Lithium
H Sulfasalazine
I Sulphonamides
J Warfarin
Which of the above drugs, when prescribed to the mother, is associated with the following abnormalities in the
Score:
breast-fed infant?
Total Answered:
May result in hypotonia and cyanosis.
Benzodiazepine 6
Incorrect - The correct answer is Lithium Tag Question
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May result in prolonged jaundice.
Chloramphenicol 6 Remove question

Incorrect - The correct answer is Sulphonamides
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May result in platelet dysfunction.
Aspirin 6 Leave question feedback
Correct
Administration of certain drugs to breast-feeding mums may result in toxicity in the infants if the drug enters the
milk in pharmacologically significant quantities. Related Articles (BMJ)
Some drugs also inhibit the baby's sucking reflex. Other drugs inhibit lactation.
Lithium is also to be avoided as it may result in reduced tone and cyanotic episodes.
Aspirin may result in a possible risk of Reyes syndrome; regular use may impair platelet function, as well as
producing a hypoprothrombinaemia, especially if the infant is low in Vitamin K stores.
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Session Analysis
Theme: Contra-indications to Vaccines
A BCG
B Diphtheria Tetanus Polio
C Hepatitis B
D Haemophilus influenzae B
E Influenza
F Measles Mumps Rubella
G Polio
H Rubella
I Tetanus
J Tuberculin
Which of the vaccines listed above would be contra-indicated in the following scenarios:
Score:
Contra-indication if known to have a hypersensitive reaction to egg.
Total Answered:
Influenza 6
Correct
Tag Question
relates to hypersensitivity to egg, which contra-indicates the Influenza vaccine as there is residual egg protein present.
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Contra-indication if known to have an allergy to gelatin.
Measles Mumps Rubella 6 Remove question
Correct
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refers to contra-indications to MMR, which include children with allergies to Gelatin, Neomycin or kanamycin as well as
children with untreated malignant disease or altered immunity. Those receiving immuno-suppressive drugs or radiotherapy
are also contraindicated. Children who have received another live vaccine by injection within 3 weeks should not be given Leave question feedback
MMR vaccine. MMR should also not be given within 3 months of receiving an Immunoglobulin injection.
Contra-indication if known to have an allergy to kanamycin.
Measles Mumps Rubella 6 Related Articles (BMJ)

Correct
refers to contra-indications to MMR, which include children with allergies to Gelatin, Neomycin or kanamycin as well as
children with untreated malignant disease or altered immunity. Those receiving immuno-suppressive drugs or radiotherapy
are also contraindicated. Children who have received another live vaccine by injection within 3 weeks should not be given
MMR vaccine. MMR should also not be given within 3 months of receiving an Immunoglobulin injection.
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Session Analysis
The parents of a 7-year-old child are concerned that he has started bed wetting as for the last three years he has been dry at
night. What is the most appropriate action for this child?
j
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n Reassure that bedwetting would be expected at this age
j
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n Investigate for secondary causes This is the correct answer
i
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n Suggest a star chart for this child Incorrect answer selected
j
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n Prescribe DDAVP
j
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n Suggest a pre-bed routine and avoid drinks before going to bed.
Bed wetting would not be expected if the child has been dry for a considerable length of time and so requires the
exclusion of other causes such as psychological effects (commonest), urine tract infections and diabetes.
Score:
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Session Analysis
An otherwise healthy 10 month old baby is brought to clinic by her concerned parents who state that 2 days ago she had
come into close contact with another child who has measles. The most appropriate approach is:
j
k
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n She should receive the MMR vaccination now This is the correct answer
i
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n Nothing need be done now but she should receive her MMR vaccination at the usual time of approximately 12
months. Incorrect answer selected
j
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n She should receive the MMR vaccine now together with measles immunoglobulin
j
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n She should receive measles immunoglobulin now
j
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n She should have her measles serology checked now.
The child should receive the MMR vaccination now but the parents should be informed that she may well develop
measles. It is best to reassure the parents that if she develops measles it is most likely to be self limiting and is treated Score:
appropriately. There is no point in assessing serology or giving immunoglobulin.<p>Single vaccines are not available on
the NHS and the child is not immune to mumps or rubella. Total Answered:
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Session Analysis
Theme: Differential Diagnosis of Non-Accidental Injury
A Acute myeloid leukaemia

B Haemophilia A
C Henoch-Schönlein purpura
D Immune thrombocytopaenic purpura
E Mongolian blue spot
F Neglect
G Osteogenesis imperfecta
H Physical abuse
I Thalassaemia major
J Thalassaemia minor
For each of the scenarios below, choose the single most likely diagnosis from the above list of options.
Score:
A midwife carries out a post-natal examination on a 5-day-old Chinese baby, there is a 3 cm, bluish, and non-
Total Answered:
tender lesion over the base of his spine.
Mongolian blue spot 6
Correct Tag Question
Mongolian blue spots are pigmented lesions found in babies of Asian, Chinese, and Mediterranean origin although they
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occur in 10% of white children. They are often found over the base of the spine and are often mistaken for bruises.
Histologically these are dermal melanocytic naevi.
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A 12-month-old baby falls whilst walking in the garden. He is taken to the Emergency Department and an x ray
reveals a fractured right clavicle and humerus. On close inspection the baby's sclerae are thought to appear Rate this question
blue.
Osteogenesis imperfecta 6
Correct
Osteogenesis imperfecta is an inherited condition resulting in osteopaenia, of which at least four types have
been described. They are characterised by: Related Articles (BMJ)
excessive bone fragility
recurrent fractures
hearing impairment and
blue sclerae.
An 11-year-old girl living with her mother and stepfather is not attending school. She is found to be underweight
and has severe dental caries.
Neglect 6
Correct
Persistently failing to meet a child's needs constitutes neglect, for example failing to provide food and shelter as well as
failure to seek appropriate medical care for a child.
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Session Analysis
Theme: Vaginal discharge.
A Allergic
B Bacterial vaginosis
C Child sex abuse
D Foreign body
E Pinworms
F Rectovaginal fistula
G Tumour
H Vulvovaginitis, infectious
I Vulvovaginitis, non-specific
For each scenario choose the most likely diagnosis:
A 4-year-old girl presents with persistent scratching of her anus. Perineal examination is unremarkable. Score:
Pinworms 6 Total Answered:
Correct
Perianal itching is usually due to pinworms (threadworms). This can be confirmed by a sellotape test, where a strip of
Tag Question
sellotape is placed at the anal margin on waking and examined for worms.
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A 4-year-old girl presents with vaginal irritation and scanty discharge. On examination she has minimal perineal
redness.
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Child sex abuse 6
Incorrect - The correct answer is Vulvovaginitis, non-specific Rate this question
Vaginal irritation with redness is common as girls learn to wipe themselves after defaecation and as the skin is thin and
sensitive at this age. Avoidance of occlusion (eg plastic pants), irritants (eg bubble bath) and keeping the perineum dry Leave question feedback
usually results in rapid resolution.
A 9-year-old girl presents with vaginal irritation and offensive discharge. On examination a mucopurulent
discharge is seen.
Vulvovaginitis, non-specific 6
Incorrect - The correct answer is Vulvovaginitis, infectious
Offensive mucopurulent discharge suggests a significant infection, such as chlamydia or gonorrhoea. Swabs should be
taken, including for these organisms. If positive then child sex abuse has been confirmed.
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Session Analysis
Theme: Children with asthma
A Antibiotics
B Antihistamines
C Inhaled steroid 800 mcg/day equivalent
D Inhaled steroid 200mcg/day equivalent
E Leukotriene receptor antagonist
F Long acting b2 agonist
G Nebulised steroid
H Non steroidal anti inflammatory
I Oral steroids
J Short acting b2 agonist
Select the most appropriate next step in the management of the following patients diagnosed with asthma:
Score:
A 2-year-old boy with recurrent nocturnal cough, not responding to salbutamol prn.
Total Answered:
Inhaled steroid 200mcg/day equivalent 6
Correct
Tag Question
A 7-year-old boy receiving fluticasone 100 mcg twice daily and still symptomatic
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Long acting b2 agonist 6
Correct Remove question
A 12-year-old girl receiving fluticasone 200 mcg Bd, and long acting beta agonist, but complains that the latter Rate this question
has had no effect on his symptoms.
Leukotriene receptor antagonist 6 Leave question feedback
Correct
The new British Thoracic Society (BTS) asthma guidelines (2003) are a stepwise guide to management., and are divided
according to patients age. Related Articles (BMJ)
In children age 5-12

Step 1 Inhaled short acting b2 agonist as required
Step 2 Add inhaled steroid 200-400 mcg/day
Step 3 Add long acting b2 agonist (LABA)then assess control. If good response to LABA, continue. If benefit from LABA
but control still iadequate, continue LABA and increase steroid up to 400 mcg/day if not already on this dose. If no
response to LABA, stop and try other therapieseg. Leukotriene receptor antagonist or SR theophylline.
Step 4 Persistent poor control- increase steroid up to 800 mcg/day
Step 5 Daily oral steroid
In children under 5
Step 1 b2 agonist
Step 2 Inhaled steroid 200-400mcg/day
Step 3 In children age 2-5, try leukotriene receptor antagonist, in children under 2, go to step 4
Step 4 Refer to respiratory paediatrician
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Session Analysis
Theme: Investigation of Non Accidental Injury
A CT head
B FBC and Coagulation profile
C Look for blue sclera
D MSU cytology and culture
E No Investigations
F Serial height and weight measurment
G Skeletal survey
For each case of suspected non-accidental injury choose the single best investigation strategy from the list of options.
Score:
A child has just started living with her foster mother and was found have a weight in the 3rd centile. The child
appears well and no abnormalities found on examination. Total Answered:
No Investigations 6
Incorrect - The correct answer is Serial height and weight measurment Tag Question
This child may have a troubled background which explains her poor physical development. She has now been placed in
foster care and it is important to ensure that she thrives. Another possible option here is 'No Investigations' but she Remove Tag
clearly needs monitoring. Also screening for a chronic disease such as recurrent urinary tract infection with an MSU
should be considered. Why not select MSU as the answer you ask? Well all such children with failure to thrive should Remove question
have serial monitoring but only a small number of them would have a chronic infection. The scenario also suggests that
this child, having been fostered, would have been worked up in the past.
Rate this question
A child with bleeding from the mouth was found to have torn lingual frenum.
FBC and Coagulation profile 6
Incorrect - The correct answer is No Investigations
A torn lingual frenum is not an uncommon injury in a small child learning to walk. It is an indicator of abuse but there is
no clear evidence of its sensitivity or specificity as a clinical sign. It could, for example, be the result of forced feeding. A Related Articles (BMJ)
detailed history needs to be taken to explore the circumstances of the injury but the finding of a torn frenum is not enough
to warrant investigations. It is not a sign of a coagulopathy so a coagulation screen is not required.
A child brought with complaints of sudden stoppage of breath. Opthalmoscopy shows multiple retinal
haemorrhages.
CT head 6
Correct
The combination of apnoea and retinal haemorrhage on ophthalmoscopy is supicious of neurotrauma in a child (Shaken
baby syndrome). A CT brain scan is indicated to look for evidence of subdural haematoma or oedema. The Royal College
of Ophthalmologists have published an update on inflicted which provides useful further reading. Again the FBC and
coagulation screen is a distractor for this question since you may consider a bleeding disorder because of the presence
of retinal haemorrhage. The best answer though is a CT brain. This is also a better option than skeletal survey since we
are considering neurotrauma. Another possible explanation is an attempted strangulation of the child. The option of
looking for signs of neck trauma is not given but this should be performed in such a case.
An 18-month-baby brought to Accident & Emergency with bronchiolitis and is found to have 6 posterior rib
healing fractures.
Skeletal survey 6
Correct
The 6 rib fractures have been discovered opportunistically in a young child presenting with an upper respiratory illness.
This is suspicious of non-accidental injury and investigations should look for other healing fractures - if any are found their
dates can be estimated and checked against the parents' recall of any possible trauma. Posterior rib fractures, along with
metaphyseal lesions, scapular fractures, spinous process fractures and sternal fractures have a high specificity for non-
accidental injury. A is indicated.
An 8-year-old boy sustained a wrist fracture following a fall in rugby match. He has a history of 6 fractures in
previous 3 years. His father is deaf
Skeletal survey 6
Incorrect - The correct answer is Look for blue sclera
The history of multiple fractures (suggesting bone fragility) and the family history of deafness all point to a possible
diagnosis of osteogenesis imperfecta. It is important to remember that osteogenesis imperfecta, although hereditary,
presents differently in different people. The father is reported as deaf but no history of multiple fractures is given; this does
not put us off the possibility of osteogenesis imperfecta.
A child presents with multiple bruises on her body. The parents fail to explain the cause.
FBC and Coagulation profile 6
Correct
Although multiple unexplained bruises may suggest non-accidental injury it is also likely that this may be the first
presentation of a bleeding disorder so a coagulation screen and platelet level needs to be checked.
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Session Analysis
A 15-year-old female comes to you requesting a termination of pregnancy. She tells you that her boyfriend is
17-years-old.
Having asked a number of questions about the relationship you do not have reason to suspect that it is
abusive. The patient seems to be mature for her age, understands what you are telling her about her options
and appears capable of deciding for herself what she wants to do. You cannot persuade her to inform her
parents that she is pregnant.
The girl's mother makes an appointment the following day and tells you that she knows her daughter has been
to see you. She says that she is worried about her daughter, and asks you to tell her whether you have given
her daughter any family planning advice.
Which of the following is the most appropriate action under these circumstances?
(Please select 1 option) Score:
j
k
l
m
n Do not give information to any of the above. This is the correct answer Total Answered:
j
k
l
m
n Inform the police because underage sex is against the law. Do not tell the patient or her mother that you are doing
so.
Reassure her mother that you have provided her daughter with family planning advice but do not tell her that the Tag Question
j
k
l
m
n
daughter is pregnant.
i
j
k
l
m
n Tell the mother that the daughter is pregnant on the basis that you believe that doing so is in the girl’s best Remove Tag
interests. Incorrect answer selected
j
k
l
m
n Tell the social services. Remove question
At 15, your patient is not yet legally an adult but if you judge that she has the capacity to make a decision Rate this question
about disclosure of information she is entitled to confidentiality in her own right.

The capacity of a person under the age of 16 to give or withhold consent is known as Gillick (Fraser)
competence after the case of Gillick vs West Norfolk and Wisbech AHA that was considered by the Law Lords.
Their lordships held that in certain circumstances a child under 16 can give valid consent without parental
knowledge or agreement.
There is no duty to report a crime. However, if you feel that disclosure is necessary to protect a patient from
risk of serious harm, for example if you suspect that she has been abused, you should take action. It would be
helpful to discuss matters with a suitably experienced colleague, for example your child protection lead. It would
also be advisable to discuss difficult cases with your medical defence organisation.
Doctors may be called upon to justify having disclosed or withheld information, and it is important to keep a
clear record of the reasons behind your decision.
Question supplied by the Medical Defence Union.
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