Development and Vaccines PDF

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Work Smart Session - MRCPCH Part 1 A / DCH

Question: 100 of 100 Time taken: 01:39:23
Session Analysis
Which of the following developmental attainments is/are appropriate for a child of 10 months?
True / False
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n Crawls symmetrically by dragging his extended legs behind, using his forearms Incorrect answer
selected
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n Has a symmetrical forward parachute reaction Correct
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n Has good finger-thumb opposition with the left hand but uses a mild palmar grasp on the right
Correct
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n Is mobile by shuffling along on his bottom in a sitting position Correct
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n Responds to noise but cannot localise the source Correct
By 10 months the child should

Score:
Have pincer grasp
Pull to stand Total Answered:
Be able to crawl
Have a parachute reaction
Localise sound.
Tag Question
He is not usually walking, but can be bottom shuffling.
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Session Analysis
Which of the following are true of childhood obesity?
True / False
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n It can lead to overestimation of the dose of intravenous fluids when these are required Correct
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n It is more common in families in Social Class I than in Social Class V Incorrect answer selected
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n It is unlikely to lead to adult obesity Correct
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n It is usually associated with above average height before puberty Correct
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n It is usually associated with hypogonadism Correct
Obesity in children causes an elevated body mass index (BMI) on age-reference centile charts. For the
RCPCH this is set out at those above the 91st centile.
Score:
Although hypogonadism may be a feature of disorders such as Prader-Willi syndrome, hypothalamic pituitary
testicular function is usually unimpaired in childhood obesity. Total Answered:
Obese children frequently go on to become obese adults with increased prevalence amongst the lower social
classes. Tag Question
It may lead to overestimation of the dose of an intravenous drug as the doses are based on body weight
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assuming a substantial proportion of that is lean tissue (hydrous) as opposed to fat (anhydrous).
As a consequence of the metabolic activity of the fat tissue, above average height before puberty is a feature. Remove question
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Session Analysis
A 2-year-old child should be able to
True / False
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n name three colours correctly Incorrect answer selected
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n use plurals Incorrect answer selected
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n build a tower of five blocks Correct
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n kick a ball on request Correct
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n hop on one foot Incorrect answer selected
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:
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Session Analysis
Inability to do which of the following in a 20 month child is cause for concern?
True / False
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n Speak in clear two to three word phrases Incorrect answer selected
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n Walk unaided Correct
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n Kick a ball Incorrect answer selected
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n Build a tower of 8 blocks Incorrect answer selected
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n cooperate with dressing Correct
A and C should be present by 2 years. Walking unaided by 18 months. D should be present at 30 months. Helping to
dress should be present by this age.
Score:
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Total Answered:
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Session Analysis
The following are true for errors of morphogenesis (congenital abnormalities):
True / False
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n Teratogens can cause abnormalities by interfering with organogenesis. Correct
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n Malformations and deformations are synonymous. Correct
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n 30% of babies born to mothers with insulin dependent diabetes mellitus present at birth with multiple
congenital abnormalities. Incorrect answer selected
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n Single gene defects account for the majority of congenital heart defects. Incorrect answer selected
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n In the newborn with multiple congenital abnormalities chromosomal aberrations are always found.
Incorrect answer selected
Malformations include any structural, functional or biochemical abnormality determined genetically or induced during
gestation and not due to birthing events. Deformation is a specific developmental anomaly of one organ or tissue. The
Score:
incidence of birth defects is approximately 1%. Teratogens, maternal infections such as rubella may be the cause of
multiple congenital abnormalities without any chromosomal abnormalities. Total Answered:
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Session Analysis
A 2-month-old baby boy weighs 3.6 kg. His birth weight was 3.1 kg. When he presents to OPD is he taking 60
ml of full strength cows' milk formula five times a day.
True / False
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n He is taking an adequate amount of food for normal growth Correct
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n He may have congenital heart disease Correct
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n Measurement of length and head circumference is a useful procedure to facilitate diagnosis Correct
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n Congenital hypothyroidism should be considered Correct
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n The milk should be changed to another formula Correct
140-160 ml/kg/d is the recommended intake in this age group. This child is only taking 5 x 60 = 300 ml/day,
which is inadequate. Score:
Associated medical disorders such as congenital heart disease and congenital hypothyroidism may be Total Answered:
manifested by feeding difficulties.
Over time nutritional deficits affect weight, head circumference and length, with weight effects being seen first. Tag Question
Growth charts are an essential part of the diagnostic process.
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Session Analysis
Regarding dental health in young children:
True / False
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n Periodontal disease is now more common than dental caries. Incorrect answer selected
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n Regular dental visits are effective in reducing the incidence of dental caries. Correct
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n There is wide geographical variation in the incidence of dental caries. Correct
Prolonged breast or bottle feeding beyond the age of one year is thought to increase the risk of tooth
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decay. Correct
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n Only 65% of the UK population receive fluoridated water. Correct
Dental caries remains the most common dental disease in childhood with almost half of under 5's experiencing the
disease. This compares with periodontal (gum disease) which affects just over a quarter of 5-year-olds. Regular dental
check ups are effective in reducing its incidence, though there remains a wide geographical and socio-economic variation. Score:
Sugars are the most important dietary factor, along with prolonged breast or bottle feeding beyond the age of 1 year. One
Total Answered:
part per million of fluoride in the water has been shown to be the most effective way of reducing tooth decay, but only
15% of the UK population currently receive this.
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Session Analysis
Regarding language impairment:
True / False
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n It is 4 times more common in girls Correct
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n It is commoner in large families Incorrect answer selected
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n It is usually caused by middle ear disease Incorrect answer selected
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n It may be associated with motor impairment Correct
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n It is highly associated with socio-economic deprivation Correct
The following are associated with language impairment:
Sex: 4 times commoner in males

Score:
Family history
Motor/developmental problems Total Answered:
Social: large family size, and socio-economic deprivation.
There is seldom any abnormality in perinatal history, and though middle ear disease may be important for
Tag Question
individual children, it is not responsible for the majority of cases of language impairment.
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Session Analysis
A boy of 2 ½ years has congenital adrenal hyperplasia (21 hydroxylase deficiency) and is being treated with
Cortisone Acetate and Fludrocortisone:
True / False
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n A greater than expected growth rate points to inadequate treatment with cortisone. Correct
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n After 3 years of age there will be no need to continue Fludrocortisone Correct
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n There is no risk to any later born female children Correct
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n The ideal method of control is to regularly measure plasma 17 hydroxyprogesterone Correct
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n Even though control is satisfactory throughout childhood he is still likely to end up shorter than expected
Correct
In poorly controlled or untreated patients, increased androgen production leads to the early appearance of
Score:
pubic hair, phallic enlargement, increased muscular development, rapid growth and skeletal maturation.
Total Answered:
Classical CAH causes impaired cortisol and aldosterone synthesis. Fludrocortisone is required to prevent salt
losing crisis. The disease is inherited in an autosomal recessive fashion. Impaired cortisol synthesis leads to a
feedback increase in ACTH, which increases the production of cortisol precursors and androgen precursors
Tag Question
proximal to the block including serum 17 hydroxyprogesterone, androstenedione, and testosterone.
The striking elevation of 17 hydroxy progesterone is a distinguishing feature of the condition. Long term follow Remove Tag
up studies on the effects of glucocorticoid and mineralocorticoid replacement indicate that the mean adult
height of males and females is less than that of unaffected siblings and less than normal mean adult height. Remove question

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Session Analysis
Which of the following drugs are teratogenic?
True / False
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n Warfarin Correct
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n Oral contraceptive Incorrect answer selected
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n Metformin Incorrect answer selected
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n Simvastatin Incorrect answer selected
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n Ranitidine Correct
There is no evidence that ranitidine, metformin or the OCP are teratogenic; and although it was once believed
that aspirin and the OCP were, studies indicate otherwise.
Score:
Similarly, metformin is often used in PCOs to induce fertility through reduction in insulin resistance.
Total Answered:
Warfarin is associated with CNS and skeletal abnormalities if fetal exposure occurs in the first trimester, plus
fetal haemorrhage is more likely.
Tag Question
Statins also are associated with teratogenicity.
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Session Analysis
Which of the following drugs are excreted in breast milk in sufficient quantities to cause harm to the infant?
True / False
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n Cyclosporin Correct
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n Digoxin Correct
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n Fluoxetine Correct
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n Tetracycline Correct
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n Warfarin Correct
Drugs that are excreted in breast milk include
Cyclosporin
Score:
Tetracycline
Antimalarials like mefloquine Total Answered:
Phenindione (but not warfarin which is safe) and
Chemotherapeutic agents such as methotrexate.
Digoxin and the selective serotonin reuptake inhibitors (SSRIs) are probably safe as SSRIs generally cause Tag Question
little side effects in adults even in overdose.

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As usual, following thalidomide, manufacturers recommend avoidance of all drugs wherever possible.
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Session Analysis
Approaches to prevent accidental drug poisoning include
True / False
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n Safely disposing of discarded medicines Correct
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n Never letting a child see an adult taking a medication Correct
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n Using child-proof locks on drug containers Correct
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n Storing medicines in the kitchen Correct
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n Telling the child that all medication will be locked away Correct
Accidental poisoning may be prevented by storing all medicines away safely out of the reach of children.
Storing in a kitchen or fridge would suggest food to the child. Child proof locks are effective. Similarly children
imitate adults and it is best not to let a child see adults taking tablets. Telling the child that it is dangerous to Score:
take tablets unless they are given to the child is appropriate but telling them that the tablets will be locked away
Total Answered:
will generate a searching interest.
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Session Analysis
Criteria for the diagnosis of Kawasaki disease include:
True / False
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n Chest pain Correct
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o
Temperature above 39 C Incorrect answer selected
i
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n Redness of the oral mucous membranes Correct
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n Cervical lymphadenopathy Correct
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n Desquamative rash of fingers and toes Correct
Diagnostic criteria for Kawasaki disease
fever 5 days or more and

Score:
1. bilateral non-purulent conjunctivitis 90 % 2. changes of lips and oral cavity 90 % 3. changes of peripheral extremities
Total Answered:
90 % 4. polymorphous exanthema 90 % 5. cervical adenopathy 75 %
Typical: fever 5 days or more + 4 criteria

Tag Question
Atypical: fever 5 days or more + 3 or less criteria + coronary artery disease - aneurysms
Kawasaki Disease Remove Tag
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Session Analysis
In birth trauma
True / False
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n Lower motor neurone facial nerve palsy results in complete ptosis Correct
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n Klumpke's palsy invloves nerves C7,8 and T1. Correct
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n Erb's palsy involves Cervical nerves 6 and 7 Incorrect answer selected
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n Phrenic nerve injury can result in respiratory distress Correct
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n Radial nerve injury results in a claw hand deformity Incorrect answer selected
Erb palsy (C5-C6) is most common of the nerve injuries and is associated with lack of shoulder motion. The involved
extremity lies adducted, prone, and internally rotated. Moro, biceps, and radial reflexes are absent on the affected side.
Phrenic nerve injury can occur and is associated with diaphragmatic paralysis/weakness with resultant respiratory
Score:
distress. Klumpke paralysis (C7-8, T1) is rare, resulting in weakness of the intrinsic muscles of the hand; grasp reflex is
absent. If cervical sympathetic fibers of the first thoracic spinal nerve are involved, Horner syndrome is present. Radial Total Answered:
nerve injury results in wrist drop, unlike claw hand which is ulnar nerve lesion.
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Session Analysis
A mother is concerned because her one-year-old girl was in contact with measles 2 days previously. Is it true to
say that:
True / False
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n Nothing can be done to affect the course of the disease Correct
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n Gamma globulin intramuscularly will be effective if given within the next two days Correct
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n Immunisation with the live attenuated virus will give life long immunity if given immediately Correct
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n Measles is a benign condition without having any side-effects Correct
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n She should anticipate the rash appearing in the next five days. Correct
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 Score:
effective within 6 days of exposure. One third of those afflicted with measles can expect a complication. These
Total Answered:
include pneumonia, otitis media and diarrhoea. A serious complication is the development of sub acute
sclerosing pan-encephalitis. The initial symptoms of measles are corysal symptoms. Several days after the
appearance of corysal symptoms a rash develops.
Tag Question
In the UK the single vaccine is unavailable for routine use. It is given as part of the primary immunisation
schedule as part of the MMR vaccine. Remove Tag
According to Kumar and Clarke's textbook of medicine, the incubation is 8 - 14 days, but in the author's
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experience, it is about twelve. Prodromal period they say lasts 2 days, but again more commonly four.
Therefore 10 days has to be the absolute bare minimum time from exposure to rash.
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Session Analysis
Which of the following pairs are appropriate?
True / False
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n Bronchiectasis – hypergammaglobulinaemia Correct
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n Coeliac disease – wheat protein Correct
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n H. influenzae - epiglottis Correct
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n Shingles – varicella Correct
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n Strep. viridans type 12 - acute glomerulonephritis Incorrect answer selected
Haemophilus influenzae causes acute epiglottitis, the frequency of which is declining in view of vaccination.
Viridans streptococci cause acute glomerulonephritis and infective endocarditis.

Score:
Bronchiectasis is associated with hypogammaglobulinaemia. Total Answered:
Shingles occurs in people who have previously been infected with varicella zoster.
Coeliac disease is associated with gluten sensitivity, i.e. intolerance of wheat, rye and barley. Tag Question
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Session Analysis
In chicken pox:
True / False
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n The commonest part of the CNS to be involved is the cerebellum Correct
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n Pneumonia is more common in adults than children Incorrect answer selected
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n Occurring in an immunosuppressed patient, the prognosis is worse than herpes zoster Correct
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n Congenital infection has the greatest mortality if the mother is infected in the first trimester Incorrect
answer selected
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n Secondary infection of skin lesions is most commonly due to streptococci Correct
The commonest part of the CNS to be affected is the cerebellum , meningitis can also occur. Pneumonia is
more common in adults. The prognosis of chicken pox is invariably worse in patients who are
Score:
immunosuppressed. Secondary infection of skin lesions is commonly due to staphylococci.
Total Answered:
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Session Analysis
Concerning immunisation:
True / False
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n It is unnecessary to tuberculin test a newborn before BCG vaccination Correct
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n Un-immunised children over 10 years need not receive diphtheria vaccination Correct
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n The recommended age for haemophilus influenza type B vaccination is one year Correct
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n Rubella vaccination may be contraindicated in children known to be hypersensitive to rabbits Incorrect
answer selected
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n Polio vaccination is normally offered to school leavers Incorrect answer selected
The current guidelines for the United Kingdom recommend tuberculin testing before BCG vaccination in all
children older than 3 months although the evidence base is unclear.
Score:
Un-immunised children over the age of 10 years are still at risk of catching diphtheria through contact with a
Total Answered:
carrier, therefore immunisation is recommended.
The recommended age for the first haemophilus influenza b vaccination is 2 months. Live viral vaccines are
often grown in human fetal cell lines or animal cell lines, which include rabbits. Tag Question
Polio vaccination is offered at 8 weeks, 12 weeks, 16 weeks, 3-5 years and school leavers. Remove Tag
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Question: 61 of 100 Time taken: 55:46
Session Analysis
The following drugs should not be used in breast-feeding mothers:
True / False
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n Bromocriptine Incorrect answer selected
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n Digoxin Incorrect answer selected
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n Warfarin Correct
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n Propranolol Incorrect answer selected
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n Tetracycline Incorrect answer selected
Bromocriptine, a dopamine agonist, inhibits prolactin secretion and is used in the treatment of galactorrhoea. Propranolol,
Digoxin and warfarin are secreted in too small amounts to be harmful to the baby. Tetracycline is secreted in breast milk
and will discolour teeth.
Score:
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Session Analysis
Adenovirus infection may cause
True / False
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n Kawasaki disease Correct
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n Pneumonia Correct
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n Otitis media Correct
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n Meningitis Correct
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n Gastroenteritis Correct
Adenovirus may cause the following childhood illnesses:
Upper respiratory tract infection

Otitis media Score:
Acute bronchiolitis Total Answered:
Obliterative bronchiolitis
Pneumonia
Diarrhoea
Tag Question
Meningitis
Encephalitis
Hepatitis Remove Tag
Urinary tract infection
Non-specific febrile illness Remove question
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Session Analysis
A 3-year-old girl presents with her first febrile convulsion. The following is appropriate information for her parents:
True / False
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n Febrile convulsions occur in 5% of children Correct
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n There is a 10% chance of developing epilepsy Correct
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n There is a 25% chance of having a further febrile convulsion. Correct
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n Carbamazepine is the drug of choice to prevent further seizures Correct
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n Pre-school booster vaccinations should not be administered Correct
Febrile convulsions are relatively common (5%) between the ages of 6 months and 5 years; Most children (75%) will have
only one seizure and the most important factor in predicting whether a child will develop further seizures is a strong family
history of febrile seizures. Convulsions are usually tonic-clonic in nature and studies reveal that idiopathic epilepsy
Score:
develops in approximately 2% of infants. No treatment is required after the first seizure with recommendation that the
temperature is controlled with paracetamol. Total Answered:
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Session Analysis
The following are recognised features of Turner's syndrome:
True / False
j
k
l
m
n i
j
k
l
m
n Low birth weight Incorrect answer selected
j
k
l
m
n i
j
k
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n Ovarian cysts Correct
j
k
l
m
n i
j
k
l
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n Elevated LH to FSH ratio Correct
i
j
k
l
m
n j
k
l
m
n Bicuspid aortic valve Correct
i
j
k
l
m
n j
k
l
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n Lymphoedema Correct
Features of Turner's syndrome include Low birth weight, short stature, webbed neck, high arched palate,
hypoplastic nails, cubitus valgus, coarctation and atrial septal defects with bicuspid aortic valves, Streak
ovaries with high LH and FSH. Score:
Total Answered:
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Session Analysis
These epidemiological terms are correct:
True / False
i
j
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n j
k
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m
n Incidence is the number of new cases occurring in a specified period Correct
i
j
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n j
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n A very low birth-weight baby has a birth weight of less than 1500g Correct
i
j
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n j
k
l
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n Standardised mortality rate (SMR) compares a mortality that occurred in a designated group with that of a
standard population Correct
i
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n j
k
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n Validity is a measure of the capacity of a test to give a true positive Incorrect answer selected
i
j
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n j
k
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n Secondary attack rate is the number of new cases of a disease arising within one incubation period after the
primary case(s). Correct
SMR equals observed deaths divided by expected deaths multiplied by 100. validity is a measure of the capacity of a test
to give a true result. Secondary attack rate is equal to the number of derived infections divided by the number of
Score:
susceptible persons in the group at risk.
Total Answered:
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Session Analysis
According to the 1989 Children Act the following principals and provisions are applicable if child abuse is suspected:
True / False
i
j
k
l
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n j
k
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n The welfare of the child is paramount Correct
j
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n i
j
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n An emergency protection order lasts for one month Correct
j
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n i
j
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n The length of an emergency protection order cannot be extended Correct
i
j
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n j
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n A child assessment order allows a child to be taken into local authority care Incorrect answer
selected
i
j
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n j
k
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n A child assessment order can be granted by a local authority Incorrect answer selected
The 1989 Children Act states that the welfare of the child is paramount. An emergency protection order allows a child to
be taken into care and lasts for 8 days. It may be extended at the discretion of the court for a further 7 days. After 3 days
the parent or the child may challenge the order. A child assessment order allows medical or psychiatric examination to Score:
be carried out. A full court order is necessary. If the parents or carers do not co-operate, the assessment order may be
Total Answered:
converted to an emergency protection order.
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Session Analysis
The following would strengthen your suspicion that a 6 month old infant with multiple bruises is a case of "child
abuse" (non-accidental injury):
True / False
j
k
l
m
n i
j
k
l
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n Subperiosteal haemorrhages of the thighs and poorly calcified lower femoral epiphyses on X-ray
Correct
j
k
l
m
n i
j
k
l
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n Prolongation of the thromboplastin generation test Correct
i
j
k
l
m
n j
k
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n Emotional deprivation of the parents when they were children Correct
i
j
k
l
m
n j
k
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n Knowledge that the infant was premature Correct
j
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n i
j
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n Prolonged bleeding time Correct
Any baby of 6 months presenting with multiple bruises should raise serious concern. Generally speaking
Score:
"babies that don't cruise rarely bruise". It is always vital to take a detailed history as well as performing a
thorough examination as there may be a plausible reason for a non ambulatory baby sustaining bruising. A Total Answered:
baby presenting with such bruising needs careful evaluation, and as well as careful examination including
fundoscopy, the child should also undergo blood tests. These include a full blood count to exclude a
thrombocytopaenia, and a coagulation profile to exclude a clotting disorders (suggested in b and e). Scurvy is Tag Question
suggested by subperiosteal haemorrhage and poor long-bone calcification. This patient will also need a full
skeletal survey and a CT head scan to exclude the possibility of occult bony or cerebral injury. Remove Tag
A suspicion of child physical abuse would be strengthened with other factors such as previous social concerns
Remove question
in the family (c.), a parental history of mental health disorders including a history of drug and alcohol misuse,
teenage parents, as well as knowledge that the child was born prematurely(d.) Other factors which would raise
suspicion include a delay in seeking appropriate medical advice, an inadequate or inconsistent explanation for Rate this question
the injuries as well as the accompanying adult being someone other than the parent with no reason why the
parent is not present. Leave question feedback
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Session Analysis
Child battering (non accidental injury) is to be considered in a child presenting with:
True / False
j
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n i
j
k
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n Pica Correct
i
j
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n j
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n Frequent visits to the local casualty department Correct
j
k
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n i
j
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n Blue sclerae Correct
i
j
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n j
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n Unexplained limb fracture Correct
i
j
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n j
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n Bilateral orbital haematomata (black eyes) Correct
Child physical abuse is to be considered in any child repeatedly presenting to the local casualty department
with injuries. A history of a child or siblings presenting to various surgeries and specialists with a variety of
symptoms should also raise alarm bells. This may be an indicator of factitious illness with stories of illness being Score:
invented by the perpetrator. Any unexplained injury such as a fracture should raise the possibility of non-
Total Answered:
accidental injury. Relevant details of history pointing towards a diagnosis of NAI include an inadequate,
unrealistic or inconsistent explanation of the injury. For example a 2 month old sustaining a spiral fracture of
the tibia from 'rolling' in his cot. A child presenting with bilateral periorbital haematomata needs to be carefully
Tag Question
assessed, as this may be the result of physical abuse. A careful history and examination needs to be carried
out. Pica is the term used to describe the ingestion of non-food substances, such as mud and soil. This may be
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present in children with emotional and behavioural difficulties as well as in children with developmental delay
and learning difficulties. Clearly many of these problems co-exist and it is important to consider all factors
Remove question
present. Blue sclerae are seen in children with connective tissue problems such as Osteogenesis Imperfecta
and Ehrlos Danlos syndrome. It is therefore an important physical sign to look for in a child presenting with
repeated fractures. Rate this question
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Session Analysis
The diagnosis of non-accidental injury in a child is more likely if:
True / False
i
j
k
l
m
n j
k
l
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n The presentation of a child with significant injuries to a health professional is delayed Correct
i
j
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n j
k
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n The history of injury given by the father is consistent with that given by the mother Incorrect answer
selected
j
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n i
j
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n The child is 3 years old and has bruising to the shin Correct
j
k
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n i
j
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n There is extensive bruising and thrombocytopenia Correct
i
j
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n j
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n He/she is 6 months old and has a torn labial frenulum Correct
Abused children may present in many different ways and recognition is very rarely straight forward.
As always, it is very important to document the injuries clearly and accurately. It is also essential to take a Score:
detailed history of how the injuries were sustained, preferably from more than one person.
Total Answered:
Social background and family circumstances are important factors to ask about in the history. Other relevant
details which may point to a diagnosis of non-accidental injury include the following:
Tag Question
1. A delay in seeking advice from health professionals.
2. An inadequate, inconsistent or unrealistic explanation.
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3. Indifferent, or inappropriate concern of the carer.
4. Parent unwilling for the child to be examined.
5. Child or siblings on the child protection register. Remove question
A child of 3 years is very likely to have bruising to the shins as a result of accidental minor injury. If a child with
Rate this question
extensive bruising is found to have a thrombocytopaenia, the child will need further haematological
investigations.
It is, however important to emphasise that children with other medical conditions may also be the victims of child
abuse and therefore it is important to take all factors into account.
The final stem relates to a 6-month-old baby presenting with a torn frenulum. This scenario should raise
serious suspicion of the baby either being force fed or having other objects thrust into his/her mouth. A mobile Related Articles (BMJ)
child can tear the labial frenulum as a result of an accidental fall, however this is not the case in non-
ambulatory children.
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Session Analysis
A child separated from his parents for hospital admission is more likely to have difficulties on return home if:
True / False
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j
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n j
k
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n Aged between 7 months and 4 years Correct
i
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n j
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n Previous recent traumatic separation Correct
i
j
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n j
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n An unhappy home Correct
i
j
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n j
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n Regressive behaviour is punished Correct
j
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n i
j
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n Frequent visits from parents Correct
A child admitted to hospital should be adequately prepared for the procedure to be carried out. If possible the
child should attend prior to the appointment to see the lay out of the ward and to meet the staff. Plenty of
opportunity should be given for the child to ask any questions he or she may have. In most cases, parents are Score:
allowed to stay with the child on the ward and this is of considerable benefit to the child's emotional well being.
Total Answered:
In cases where it is not possible for either parent to stay the child will benefit from frequent visits. Most children
wards have open visiting (although the nature of the condition/procedure/operation) will need to be taken into
account. Children are more likely to have problems following admission to hospital if there are other adverse
Tag Question
social factors. These may include previous traumatic separation or an unhappy home (E.g. Marital
disharmony). The pre-school child is more likely to experience separation anxiety than a child of school age
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and therefore needs careful preparation with stories, visits to the hospital play room etc. Regressive behaviour
should never be punished, instead the focus needs to be on positive praise and a reward system for the good
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behaviours.

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Session Analysis
A general practitioner is likely to have, in his practice of 2500, at least one individual (age range 0 – 15 years) with:
True / False
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n j
k
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n Severe mental handicap Correct
i
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n j
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n Spina bifida Correct
i
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n j
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n Cystic fibrosis Correct
j
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n i
j
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n Muscular dystrophy Correct
i
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n A chromosomal anomaly Correct
This question basically assesses the knowledge of incidence of disorders in a typical population. 1:2500 is the figure for
CF (gene frequency 1:25, therefore chances of two heterozygotes meeting 1 in 625 and the chances of having an affected
child is 1 in 4, giving the incidence of 1 in 2500. Similar incidences occur for spina bifida (1 in every 1000 live births) and
Score:
accumulated chromosomal abnormalities.
Total Answered:
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Session Analysis
Groin swelling in a 5-year-old child may be due to:
True / False
i
j
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n j
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n Acute leukaemia Correct
i
j
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n j
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n Transient synovitis of the hip Correct
j
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n i
j
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n Rheumatoid arthritis Incorrect answer selected
j
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n i
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n Osgood-Schlatter’s disease Correct
i
j
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n j
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n Factor VIII deficiency Correct
Acute leukaemia often presents with lymphadenopathy. Transient synovitis often occurs secondary to an URTI and
lymphadenopathy. Rheumatoid arthritis is a condition characterised by inflammation of the joints as well as rheumatoid
nodules. Osgood Schlatters is an apophysitis of the tibial tubercle and often presents with pain, tenderness and a
Score:
swelling at the insertion of the patellar tendon. Factor 8 deficiency is also known as haemophilia. The hallmark of this
condition is haemarthroses or spontaneous bleeding into the joints resulting in swelling. Total Answered:
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Session Analysis
Vaginal discharge in children may be caused by:
True / False
i
j
k
l
m
n j
k
l
m
n Foreign bodies Correct
i
j
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l
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n j
k
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n Vulvovaginitis Correct
i
j
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n j
k
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n Worms Correct
i
j
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n j
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n Sexual abuse Correct
i
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n j
k
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n Precocious puberty Correct
Vaginal discharge in children may be physiological or pathological. In the former, approximately 6 - 12 months
prior to menarche there is an increase in vaginal secretions and girls often complain of staining of under
clothes. This is normal and the patient should be reassured. Vaginal discharge is a common presenting Score:
complaint to the paediatrician. There may be associated symptoms of dysuria, pruritis, frequency of micturition
Total Answered:
and enuresis. A careful history and examination needs to be carried out. All the above are causes of vaginal
discharge. The most common cause of vaginal discharge in young girls is a non-specific vulvovaginitis.
Treatment focuses on the avoidance of soaps and bubble baths general hygiene and topical oestrogen creams
Tag Question
can also be useful. In cases where there is the possibility of a foreign body a joint assessment may be needed
with a paediatrician and a gynaecologist being present. In cases of suspected sexual abuse, the child needs to
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be examined preferably with the aid of a colposcope and social services need to be involved as part of the
overall investigation.
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Session Analysis
The side effects of phenytoin include which of the following?
True / False
i
j
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n j
k
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n Ataxia Correct
j
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n i
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n Cataract Correct
i
j
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n j
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n Gingival hyperplasia Correct
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n j
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n Hirsutism Correct
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n j
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n Hypochromic, microcytic anaemia Incorrect answer selected
Gingival hypertrophy and

Tenderness
Score:
as well as
Total Answered:
Coarse facial features and
Hirsutism
may occur. Tag Question
Haematological side effects include

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Megaloblastic anaemia
Aplastic anaemia Remove question
Thrombocytopenia and
Granulocytosis.
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Neurological side effects include
Peripheral neuropathy
Ataxia
and rarely
1. Nystagmus and Related Articles (BMJ)

2. Dyskinesias.
Eye involvement may occur in cases of overdosages, these include
Blurred vision and

Nystagmus.
Cataracts are not associated with phenytoin use.
Most common side effects of Phenytoin...
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Session Analysis
Which of the following is/are true, regarding breath holding attacks?
True / False
j
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n i
j
k
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n Are commoner over the age of 3 ½ years Correct
j
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n i
j
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n Are fatal in approximately 5% of cases Correct
i
j
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n j
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n Can be confused with a generalised convulsion Correct
i
j
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n j
k
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n May be precipitated by a minor injury Correct
j
k
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n i
j
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n Should be treated with sedatives Correct
Breath holding attacks are common and typically occur in the pre-school child.
They may start as early as six months of age; there is a peak incidence at two years, and they should have
Score:
stopped by five years of age.
Total Answered:
Typically they follow a noxious stimulus such as a minor injury, or they may follow a temper tantrum. The child
gives a brief shrill cry and this is followed by forced expiration and apnoea. There may be cyanosis and loss of
consciousness. Tag Question
These episodes may be confused with ictal events as the loss of consciousness may be associated with tonic
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clonic jerks and opisthotonus.
No treatment is required, and advice to parents should be reassurance. These episodes resolve Remove question
spontaneously.
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Session Analysis
The following signs may be abnormal in mild dehydration in an infant:
True / False
i
j
k
l
m
n j
k
l
m
n Intra-ocular pressure Incorrect answer selected
i
j
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n j
k
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n Capillary refill time Incorrect answer selected
i
j
k
l
m
n j
k
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n Anterior fontanelle tension Incorrect answer selected
i
j
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n j
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n Systemic blood pressure Incorrect answer selected
i
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n j
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n Serum sodium concentration Incorrect answer selected
Dehydration can be classified in two ways:
1. Tonicity
Score:
2. Natraemic state Total Answered:
Severity of dehydration is usually based on % body weight loss as mild (5%), moderate (5-9%) and severe
(10%). From the history, frequency of micturition is very relevant. Clinical signs of dehydration include: Mild -
Tag Question
Restlessness, slightly dry mucous membranes and normal skin elasticity, oliguria; Moderate - Sunken eyes,
depressed fontanelle, decreased skin turgor and dry mucous membranes; Severe - Drowsy, irritable with signs
Remove Tag
of circulatory collapse, (e.g. rapid and weak pulses, delayed capillary refill time (CRT) and low blood pressure),
sunken eyes and decreased skin turgor.
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Certain indices are more reliable than others. Weight loss is useful, and palpation of the anterior fontanelle is
also reliable. Sodium concentration is important as dehydration may be hypotonic, isotonic or hypertonic with
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low, normal or high concentrations of sodium respectively. High sodium is associated with 'doughy' skin turgor
and the risk of cerebral oedema with over-rapid rehydration.
Note that a normal CRT is < 2 seconds.
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Session Analysis
Most children with Down's syndrome:
True / False
i
j
k
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m
n j
k
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n Require institutional care Incorrect answer selected
i
j
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n j
k
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n Require assistance with schooling Correct
j
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m
n i
j
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n Have associated epilepsy Correct
j
k
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m
n i
j
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n Cannot be trained to live independently Incorrect answer selected
j
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n i
j
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n Develop autistic symptoms Correct
Most children with Down's syndrome can be brought up at home, however due to the high frequency of mental
retardation they require considerable assistance with schooling and cannot live independently in adulthood.
Epilepsy risk is not greater in these individuals. Autism occurs in about 10% of cases. Score:
Total Answered:
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Session Analysis
The following are characteristic features of infantile autism:
True / False
i
j
k
l
m
n j
k
l
m
n Failure to develop social relationships. Correct
i
j
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n j
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n Presence of echolalia. Correct
j
k
l
m
n i
j
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n Normal intelligence. Correct
j
k
l
m
n i
j
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n Ritualistic or compulsive phenomena. Incorrect answer selected
j
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n i
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n More common in girls. Correct
Autism is characterised by failure of communication, interaction, repetitive or ritualistic behaviour and developmental
delays and learning disabilities. The ratio of males: females affected is 3-4:1.
Score:
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Total Answered:
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Session Analysis
Cognitive deficit is found in:
True / False
j
k
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n i
j
k
l
m
n alkaptonuria Correct
j
k
l
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n i
j
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m
n maple syrup urine disease Incorrect answer selected
j
k
l
m
n i
j
k
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n homocystinuria Incorrect answer selected
j
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m
n i
j
k
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m
n galactosaemia Incorrect answer selected
i
j
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n j
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n Wilson’s disease Incorrect answer selected
1.Symptomless in childhood, produces homogentisic aciduria. An Autosomal Recessive condition, ochronosis develops
later in life with or without arthritis. 2.Neurological disturbances appear soon after birth. There are increased amounts of
valine, isoleucine, and leucine in blood and urine, due to a defect in the metabolism of these branched chain amino-acids.
Score:
3.Mental retardation, fair hair, lens dislocation. 4.Causes irreversible brain damage if the diagnosis is not made early, and
the child is not placed on a lactose free diet. 5.Neurological impairment is associated with involvement of the basal Total Answered:
ganglia, and cognitive deficit is not normally observed.
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Session Analysis
Regarding immunisation:
True / False
j
k
l
m
n i
j
k
l
m
n In premature babies timing of the first course should be postponed until 3 months from expected date of
delivery Correct
j
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n i
j
k
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n Immunisation is contraindicated in a baby with Down syndrome and congenital heart disease Correct
i
j
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n j
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n Oral polio vaccine is contraindicated in a baby with diarrhoea and vomiting Correct
j
k
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n i
j
k
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n Oral polio vaccine may be given to siblings of immunosuppressed children Correct
j
k
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n i
j
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n MMR vaccine may be given within 3 weeks of oral poliomyelitis Correct
The immunisation schedule should proceed normally. Immunisation is not contraindicated in cases of
congenital heart disease.
Score:
Oral polio vaccine is contraindicated if vomiting is present. Oral polio vaccine consists of live virus, some of
Total Answered:
which may be excreted in the faeces and hence spread to immunosuppressed children.
"Avoid administration of live vaccines (except MMR and BCG) to siblings of immunocompromised patients."
RCPCH Best Practice Statement. Tag Question
MMR is given at 12 months, which is 8 months after the last dose of oral polio. MMR is the best example of Remove Tag
simultaneous administration of multiple live attenuated viral vaccines. Here, the combination is known not to
reduce the protective effect of each component, as the combined vaccine is as effective as spaced injections of Remove question
individual components.
The main objection to administering live vaccines close together is the risk of systemic symptoms, and the Rate this question
possibility of reduced immune response.
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Session Analysis
Which of the following statements are true:
True / False
i
j
k
l
m
n j
k
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m
n Sulphonamides can cause kernicterus in neonates Correct
i
j
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m
n j
k
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n Amphetamine causes bronchiolar constriction Incorrect answer selected
j
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n i
j
k
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n In general, children require less of a drug per unit of body weight than adults Correct
i
j
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n j
k
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n Drugs such as Erythromycin are more likely to be found in high concentrations in breast milk Incorrect
answer selected
i
j
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n j
k
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n Tetracycline is a less suitable antibiotic in pregnancy than Ampicillin Correct
Sulphonamides may cause liver damage and therefore kernicterus in neonates. Amphetamines such as
dexamphetamine and methyl phenidate may be used in the treatment of certain behavioural problems such as
Score:
ADHD. They are associated with many side effects, e.g. restlessness, excitability, palpitations, tachycardia and
hypertension. Bronchiolar constriction is not one of the side effects. In general children require a higher dose Total Answered:
of drug per kilo.of body weight than adults. Ampicillin is safer in pregnancy than tetracycline which is associated
with bone and dental abnormalities in the offspring. Its use is therefore contraindicated in pregnancy.
Erythromycin can be used in pregnancy and by nursing mothers as only small amounts are excreted in to Tag Question
breast milk.
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Consult BNF for further details if necessary.
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Session Analysis
A normal healthy three-year-old is able to:
True / False
j
k
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n i
j
k
l
m
n Ride a tricycle Incorrect answer selected
i
j
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n j
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n Speak in sentences Correct
j
k
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m
n i
j
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n Demonstrate a positive Gower's sign Correct
j
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n i
j
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n Write his full name Correct
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n j
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n Recognise and name three primary colours Correct
At 3 years a normal child:
GROSS MOTOR: Is able to hop on one foot (42 months).

Score:
FINE MOTOR/VISION: Manipulates small objects well, and by 4 years can draw a man of 3 parts. By 4 years
he can copy a cross. Total Answered:
LANGUAGE/HEARING: Able to give his first and last name and to recognise colours.
SOCIAL: Can name a friend, can wash his hands and brush his teeth with help, can eat with a knife and
fork, has vivid make-believe play, and will play independently with other children present, and may show
Tag Question
sympathy to an injured child. Likes hearing and telling stories.
A Gower's sign is positive in Duchenne muscular dystrophy. Any children who cannot write their names when Remove Tag
they begin school at the age of 5.
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Copyright © 2002 Dr Colin Melville
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Session Analysis
The following would be expected at a one year surveillance review:
True / False
i
j
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n j
k
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n Walks with one hand held Correct
j
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n i
j
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n Good pincer grip Incorrect answer selected
j
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l
m
n i
j
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n Drinks from a cup Incorrect answer selected
j
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n i
j
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n Happy to go to strangers Correct
i
j
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n j
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n Understands simple commands Correct
At the one year review, expected findings are:
GROSS MOTOR: Walks with furniture (9 months), and walks with one hand at 12 months, taking a few
Score:
steps unassisted.
FINE MOTOR/VISION: Good pincer grip from 10.5 months with no squint on observation or parental report. Total Answered:
LANGUAGE/HEARING: Understands simple commands, says "mama" or "dada", and one or two appropriate
words by 13 months. No parental concerns about hearing.
SOCIAL: Drinks from a cup, feeds using a spoon or fingers. Wary of strangers, but socially responsive.
Tag Question
Waves "bye bye" at 8 months.
Copyright © 2002 Dr Colin Melville Remove Tag
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Session Analysis
The following are among the five most common causes of death under five years in the United Kingdom:
True / False
i
j
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l
m
n j
k
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n Cot death Correct
i
j
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n j
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n Non-accidental injury Incorrect answer selected
i
j
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n j
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n Congenital heart disease Correct
i
j
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n j
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n Malignant disease Incorrect answer selected
i
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n j
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n Meningitis Incorrect answer selected
Accidents are the main cause of death between the ages of 1 and 14 years and account for approximately 800
deaths per year.
Score:
In the under 5 age group the causes of deaths can be subdivided into the following.
Total Answered:
4 weeks-1 year:
Conditions arising in the perinatal period(46%)

Congenital anomalies(16%) Tag Question
1-4 years: Remove Tag
Accidents(21%)
Congenital anomalies(20%) Remove question
In the 5-14 year age group the two most leading causes of death include Accidents (35%) and cancer (20%)
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respectively.

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Session Analysis
Cow's milk protein intolerance may cause:
True / False
j
k
l
m
n i
j
k
l
m
n stridor Incorrect answer selected
i
j
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l
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n j
k
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n bloody diarrhoea Correct
i
j
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n j
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n flat jejunal villi Correct
i
j
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n j
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n soya protein intolerance Incorrect answer selected
j
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n i
j
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n acrodermatitis enteropathica Correct
Cow's milk intolerance may cause anaphylactic responses but is more traditionally associated with GI effects
and malabsorption.
Score:
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Total Answered:
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Session Analysis
The respiratory syncytial virus (RSV):
True / False
i
j
k
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n j
k
l
m
n Is the most common cause of pneumonia in the 1st year of life Correct
i
j
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n j
k
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n Wheeze is frequently encountered during acute bronchiolitis Correct
j
k
l
m
n i
j
k
l
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n Is a common cause of oral cold sores Correct
j
k
l
m
n i
j
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n Causes epiglottitis Correct
j
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n i
j
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n Is associated with the development of chronic asthma Incorrect answer selected
RSV is the most common cause of pneumonia in infancy. Babies with RSV acute bronchiolitis typically have
tachypnoea, intercostal recession and hyperinflation and on auscultation of the chest, fine crackles with or
without wheeze. Diagnosis of RSV infection can be rapidly confirmed by detection of viral antigens in nasal Score:
secretion by immunofluorescent techniques. This is over 90% sensitive and specific compared with tissue
Total Answered:
culture techniques. Follow-up studies on babies admitted to hospital with acute bronchiolitis suggest that a
large number (50-80%) subsequently develop recurrent episodes of coughing and wheezing. The organism
responsible for obliterative bronchiolitis is usually adenovirus.
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Session Analysis
The following are recognised features or complications of Rubella:
True / False
j
k
l
m
n i
j
k
l
m
n Koplik's spots Correct
j
k
l
m
n i
j
k
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n conjunctivitis Incorrect answer selected
i
j
k
l
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n j
k
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n suboccipital lymphnode enlargement Correct
j
k
l
m
n i
j
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n thrombocytopenia Incorrect answer selected
i
j
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l
m
n j
k
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n rashes on the 5th day of illness Correct
a-seen in measles on the buccal mucosa - Forchheimer spots (petechiae on the soft palate) may be seen in Rubella but
are non-specific. b-characteristic. c-characteristically suboccipital, postauricular and posterior cervical and may persist
long after the rash has faded. d-very rare. Commoner complication is arthritis resembling rheumatoid. Encephalitis also
Score:
rare. e-The rash has a similar distribution (face and behind ears spreading to trunk) as measles but is paler. RASH +
INFECTION (MNEMONIC) Very Sick People Must Take Early Retirement varicella day 1 scarlet fever 2 pox (small) 3 Total Answered:
measles 4 typhus 5 enteric fever (typhoid) 6 rubella 1-7 (Thanks to Dr PM Dubey -
http://www.geocites.com/Athens/Oracle/1632/medical/useful.htm)
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Session Analysis
Complications of measles include:
True / False
j
k
l
m
n i
j
k
l
m
n Cancrum oris Incorrect answer selected
i
j
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n j
k
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n Common occurrence of severe corneal ulceration Incorrect answer selected
j
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n i
j
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n Higher incidence of acute appendicitis Incorrect answer selected
j
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n i
j
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n Post-measles encephalopathy one month later Correct
i
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n j
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n Subacute sclerosing panencephalitis (SSPE) occurs years after an attack of measles Correct
Corneal ulceration is rarely associated with measles but cancrum oris is a feature.
The associated lymphadenopathy may cause a presentation with acute appendicitis.

Score:
Measles encephalopathy occurs one to 14 days after the onset of infection, but SSPE - in which measles is Total Answered:
implicated - is a particularly rare disease and may occur many years after the initial attack of measles.
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Session Analysis
Whooping cough (pertussis) in children:
True / False
i
j
k
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m
n j
k
l
m
n Was responsible for over 300 deaths in children in 1986 Correct
i
j
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n j
k
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n Is infectious for at least two months after the termination of the coughing Incorrect answer selected
i
j
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n j
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n Is associated with an increase in the total lymphocyte count Correct
i
j
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n j
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n Is usually diagnosed by growing the organism from a cough plate Incorrect answer selected
i
j
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n j
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n Is invariably associated with an inspiratory whoop Incorrect answer selected
A relatively high number of deaths occurred in 1986 , possibly due to falling vaccination rates following concerns regarding
safety. The annual death rate is around 30 per year. The disease is often not associated with an inspiratory whoop after
coughing but apnoeic episodes can occur. The disease is most infectious in the first 7-14 days of the illness termed the
Score:
catarrhal phase. The disease is characterised by lymphocytosis. The organism is examined in nasal secretions.
Total Answered:
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Session Analysis
The Haemophilus influenzae type B vaccine (Hib) vaccine:
True / False
j
k
l
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n i
j
k
l
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n Is a live attenuated vaccine Correct
i
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n j
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n Is recommended for children aged between 2 months and 10 years Correct
i
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n j
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n Needs to be given as three doses in all children Incorrect answer selected
i
j
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n j
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n Is very effective Correct
i
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n j
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n Is contraindicated if there is a history of egg allergy in the family Incorrect answer selected
Hib is a capsular conjugated polysaccharide vaccine. It is generally given in a course of three doses at monthly intervals
at 2, 3 and 4 months with the other routine vaccinations. Over 13 months of age a single dose is effective. As the risk of
invasive Haemophilus falls rapidly after 10 years, it is only given after this age to those children considered to be at
Score:
increased risk of invasive Haemophilus disease (sickle cell disease, antineoplastic therapy, an absent spleen). It is
known to be highly effective but vaccination failures have been reported. Hypersensitivity to egg contraindicates influenza Total Answered:
vaccines. Evidence of previous anaphylactic reaction contraindicates the use of the MMR and yellow fever vaccines.
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Session Analysis
The following conditions are contraindications to MMR vaccine:
True / False
j
k
l
m
n i
j
k
l
m
n congenital heart disease Correct
j
k
l
m
n i
j
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n a history of anaphylaxis to peanuts Correct
j
k
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n i
j
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n a history of convulsions Correct
j
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m
n i
j
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n cystic fibrosis Correct
j
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n i
j
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n Down’s syndrome Correct
There are very few absolute contraindications to MMR vaccinations. These include: allergy to neomycin or kanamycin
(very rare), a severe reaction to previous MMR, untreated cancer or diseases of the immune system, and children
receiving immunosuppressive therapy or high dose steroids. Reasons to postpone vaccination include: an acute febrile
Score:
illness, administration of another live vaccine within three weeks of proposed MMR vaccination, or the administration of
immunoglobulins within three months of the proposed MMR vaccine. More in the CBNF Total Answered:
http://bnfc.org/bnfc/bnfc/2005/6498.htm
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Session Analysis
Fever in a child
True / False
i
j
k
l
m
n j
k
l
m
n Is not always found in neonates with sepsis Correct
i
j
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n j
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n Is best treated by cold water sponging Incorrect answer selected
j
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n i
j
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n Is more effectively treated by oral Acetylsalicylate than Paracetamol in recommended dosage Correct
j
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n i
j
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n Due to heat stroke is best treated by an anti-pyretic Correct
j
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n i
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n In Kawasaki disease is usually best treated with oral Paracetamol Correct
Due to an immature immunological system neonates with sepsis may not present with fever. Clinical
manifestations are highly variable, ranging from asymptomatic to severe fulminant presentations, acute to
chronic, and one or multiple organs being affected. Symptoms and signs are so non-specific that a neonate Score:
usually requires a full septic screen.
Total Answered:
The presence of fever requires the source of infection to be identified. In most cases in children fever is the
result of a viral infection. Antipyretics such as paracetamol are effective . Cold sponging is not. Option c. is
incorrect. Children are NOT usually treated with aspirin due to the serious complications and side effects Tag Question
including Reyes syndrome.
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The febrile phase of Kawasaki disease is treated intravenously with gamma globulin as well as aspirin (with
careful monitoring) to minimise the risk of coronary artery aneurysms.
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Session Analysis
A 4-year-old child who appears well and is just below the third centile for height:
True / False
j
k
l
m
n i
j
k
l
m
n Is likely to have an underlying organic disease Correct
j
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n i
j
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n Is approximately one standard deviation below the mean normal height for that age Correct
j
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m
n i
j
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n Is likely to be just below the third centile for weight Incorrect answer selected
j
k
l
m
n i
j
k
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m
n Is likely to be have been about the 3rd centile for height when 2 years of age Incorrect answer
selected
j
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n i
j
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n Is likely to reach puberty at least a year later than a child who is on the 50th centile for height Correct
3% of normal children are on or below the third centile, which is about 2SD below the mean. Weight and height are often
closely correlated. Most correction to genetic growth after birth takes place in the first 6 months, so the child is likely to
have been on a similar centile at 2 years. Obese children enter puberty early, but the reverse does not necessarily apply. Score:
Short stature is broadly divided into 4 groups. Total Answered:
1. Familial
2. Constitutional delay of growth
Tag Question
3. Chronic systemic disorders.
4. Endocrine abnormalities
Remove Tag
During the assessment it is important therefore to establish which is the case for this child. Examination needs
to assess for any signs of chronic illness eg murmurs, chest deformity, clubbing dysmorphic features etc. If Remove question
these features were absent it is quite probable that the cause is either familial or constitutional. In either case it
is not correct to say that the above options are likely. The child would need to be measured on more than 1
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occasion and a height velocity calculated. It would also be useful to measure both parents and calculate a mid-
parental height.
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By 10 months the child should

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The following are associated with language impairment:

Sex: 4 times commoner in males

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