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PGIM MD Paediatrics study materials
PGIM MD Paediatrics study resources

PGIM MD Paediatrics practice questions

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Question 1Paediatrics

A 3-week-old exclusively breastfed infant is brought for a routine review. Which single vitamin supplement is recommended for all infants in this age group in the UK?

  1. Iron 2 mg/kg daily
  2. Vitamin K 1 mg daily
  3. Vitamin A 200 micrograms daily
  4. Vitamin D 8.5–10 micrograms daily Correct answer.

Explanation

UK guidance advises a daily supplement of vitamin D (8.5–10 micrograms) for all infants from birth, including exclusively breastfed babies, because breast milk does not supply adequate amounts and maternal stores are often low. This prevents nutritional rickets and hypocalcaemic seizures.

Question 2Paediatrics

A 4-year-old presents with a 3-day history of fever, sore throat, and a fine red rash that started on the neck and flexures and feels like sandpaper. The tongue is red with prominent papillae. What is the most likely diagnosis?

  1. Measles
  2. Scarlet fever Correct answer.
  3. Kawasaki disease
  4. Stevens–Johnson syndrome

Explanation

Scarlet fever is caused by group A streptococcal toxin and classically produces fever, sore throat, a sandpapery flexural rash with circumoral pallor, and a strawberry tongue. Prompt penicillin treatment reduces the risk of rheumatic fever and invasive complications.

Question 3Paediatrics

A 6-month-old is brought in with a 2-day history of coryza, cough and mild fever, and today has fast breathing with subcostal recession. Which virus is the most common cause of bronchiolitis in this age group?

  1. Respiratory syncytial virus Correct answer.
  2. Rhinovirus
  3. Influenza A
  4. Adenovirus

Explanation

Respiratory syncytial virus (RSV) accounts for the majority of bronchiolitis cases in infants, typically presenting in winter with coryza, cough, tachypnoea, wheeze and recessions. Management is supportive, with oxygen and feeding support as needed.

Question 4Paediatrics

A newborn is noted to have a soft systolic murmur and weak femoral pulses at the 6-week check. Which congenital cardiac lesion is most consistent with this finding?

  1. Coarctation of the aorta Correct answer.
  2. Atrial septal defect
  3. Ventricular septal defect
  4. Patent ductus arteriosus

Explanation

Coarctation of the aorta classically produces weak or absent femoral pulses with a blood pressure gradient between upper and lower limbs, often with a systolic murmur. It can present in the newborn period with collapse when the duct closes.

Question 5Paediatrics

A 2-year-old is brought in with a 1-day history of profuse watery diarrhoea and vomiting. Which sign is the most reliable indicator of moderate dehydration in a young child?

  1. Dry mucous membranes
  2. Prolonged capillary refill time
  3. Reduced skin turgor Correct answer.
  4. Sunken eyes

Explanation

Reduced skin turgor is one of the most specific clinical signs of significant dehydration in children, reflecting loss of interstitial fluid. It should be interpreted alongside other signs such as lethargy, sunken eyes and delayed capillary refill.

Question 6Paediatrics

A 5-year-old is brought in with a 2-day history of fever and a rash that started on the face and spread downwards. Which feature is most characteristic of measles?

  1. Circumoral pallor
  2. Koplik spots on the buccal mucosa Correct answer.
  3. Vesicles on the palate
  4. Slapped cheek appearance

Explanation

Koplik spots are small white lesions on the buccal mucosa that appear before the rash and are pathognomonic of measles. The rash then spreads from the face downwards and is associated with coryza, cough and conjunctivitis.

Question 7Paediatrics

A 10-year-old with known asthma is prescribed a short course of oral prednisolone for an acute exacerbation. Which adverse effect should be specifically discussed with the family?

  1. Increased appetite and mood changes Correct answer.
  2. Permanent growth suppression
  3. Immediate adrenal suppression
  4. Nephrotoxicity

Explanation

Short courses of oral corticosteroids commonly cause increased appetite, mood lability and sleep disturbance, which are usually transient. Families should be warned about these effects and about the need to seek review if symptoms worsen.

Question 8Paediatrics

A 3-year-old is brought in with a 2-day history of fever, ear pain and irritability. Otoscopy shows a bulging, red tympanic membrane. What is the most appropriate first-line antibiotic in a child without penicillin allergy?

  1. Ceftriaxone
  2. Clarithromycin
  3. Amoxicillin Correct answer.
  4. Co-amoxiclav

Explanation

Amoxicillin is the recommended first-line antibiotic for acute otitis media in children without penicillin allergy, covering the common pathogens Streptococcus pneumoniae and Haemophilus influenzae. Analgesia should also be given.

Question 9Paediatrics

A 2-year-old presents with a 1-day history of barking cough and inspiratory stridor that is worse at night. What is the most appropriate initial management?

  1. Oral dexamethasone Correct answer.
  2. Intravenous antibiotics
  3. Nebulised salbutamol
  4. Nebulised adrenaline alone

Explanation

Croup is treated with a single dose of oral dexamethasone, which reduces airway oedema and symptom severity. Nebulised adrenaline is reserved for severe stridor at rest or impending airway obstruction.

Question 10Paediatrics

A 6-week-old presents with projectile non-bilious vomiting after feeds and a palpable olive-shaped mass in the right upper quadrant. Which electrolyte disturbance is most likely?

  1. Metabolic acidosis with hyperkalaemia
  2. Hypernatraemic dehydration
  3. Hypochloraemic hypokalaemic metabolic alkalosis Correct answer.
  4. Hyperkalaemia and acidosis

Explanation

Pyloric stenosis causes loss of gastric hydrochloric acid and potassium, producing a hypochloraemic hypokalaemic metabolic alkalosis. Correction of the electrolyte disturbance is required before surgical pyloromyotomy.

Question 11Paediatrics

A 7-year-old presents with a 3-week history of polyuria, polydipsia and weight loss. Capillary blood glucose is 22 mmol/L and ketones are present in the urine. What is the most appropriate initial fluid management?

  1. Slow rehydration with isotonic saline over 48 hours Correct answer.
  2. Free access to oral fluids only
  3. Immediate insulin bolus followed by infusion
  4. Rapid correction of dehydration with 0.9% saline boluses

Explanation

In diabetic ketoacidosis, fluid and electrolyte correction must be gradual, typically with isotonic saline over 48 hours, to avoid rapid shifts that precipitate cerebral oedema. Insulin is started as an infusion after initial resuscitation, not as a bolus.

Question 12Paediatrics

A 4-year-old presents with fever, petechiae and pallor. Full blood count shows haemoglobin 65 g/L, platelets 18 × 10⁹/L and white cell count 45 × 10⁹/L with blast cells. What is the most likely diagnosis?

  1. Immune thrombocytopenic purpura
  2. Acute lymphoblastic leukaemia Correct answer.
  3. Haemolytic uraemic syndrome
  4. Aplastic anaemia

Explanation

Pancytopenia with circulating blast cells in a child with fever and petechiae strongly suggests acute leukaemia, most commonly acute lymphoblastic leukaemia in this age group. Urgent referral to a paediatric oncology centre is required.

Question 13Paediatrics

A 2-year-old presents with a 3-day history of fever, and today has a generalised tonic-clonic seizure lasting 4 minutes. He has had a previous similar episode with fever. What is the most appropriate immediate management?

  1. Oral paracetamol alone
  2. Intravenous phenytoin
  3. Rectal or buccal benzodiazepine Correct answer.
  4. Lumbar puncture

Explanation

A febrile seizure lasting more than 5 minutes or recurring requires termination with a benzodiazepine given rectally or buccally if intravenous access is unavailable. Antipyretics do not prevent recurrence, and lumbar puncture is reserved for suspected meningitis.

Question 14Paediatrics

A 9-year-old with nephrotic syndrome has been treated with prednisolone for 2 weeks. Which monitoring is most important during this treatment?

  1. Serum calcium every 48 hours
  2. Blood pressure and blood glucose Correct answer.
  3. Monthly chest radiograph
  4. Routine electrocardiogram

Explanation

Corticosteroid therapy in nephrotic syndrome can cause hypertension and hyperglycaemia, so blood pressure and blood glucose should be monitored regularly. Parents should also be warned about infection risk and behavioural changes.

Question 15Paediatrics

A 2-year-old presents with a 2-day history of fever, refusal to weight-bear and a painful hip. Which investigation is most appropriate to exclude septic arthritis?

  1. Magnetic resonance imaging
  2. Plain radiograph of the pelvis
  3. Hip ultrasound and joint aspiration Correct answer.
  4. Bone scan

Explanation

Septic arthritis of the hip is a surgical emergency requiring urgent joint aspiration, which is often performed under ultrasound guidance to confirm the diagnosis and obtain fluid for culture. Delay risks avascular necrosis of the femoral head.

Question 16Paediatrics

A newborn at 24 hours of age develops jaundice. Which feature would suggest a pathological rather than physiological cause?

  1. Peak bilirubin at day 4
  2. Jaundice appearing within the first 24 hours Correct answer.
  3. Mild jaundice in a breastfed baby
  4. Resolution by day 10

Explanation

Jaundice within the first 24 hours of life is always pathological and requires urgent investigation for haemolysis, sepsis or congenital infection. Physiological jaundice typically appears after 24 hours and peaks around days 3 to 5.

Question 17Paediatrics

A 5-year-old presents with a 1-day history of a purpuric rash on the buttocks and lower limbs, abdominal pain and swollen knees. Urinalysis shows microscopic haematuria. What is the most likely diagnosis?

  1. Meningococcal septicaemia
  2. Idiopathic thrombocytopenic purpura
  3. Kawasaki disease
  4. Henoch–Schönlein purpura Correct answer.

Explanation

Henoch–Schönlein purpura (IgA vasculitis) classically causes a palpable purpuric rash over the buttocks and extensor surfaces, abdominal pain, arthritis and renal involvement. Blood pressure and urinalysis should be monitored for nephritis.

Question 18Paediatrics

A 15-year-old presents with a 2-week history of lethargy, weight loss and a neck swelling. Examination reveals a smooth, non-tender goitre. Which initial investigation is most appropriate?

  1. Radioiodine uptake scan
  2. Serum thyroglobulin
  3. Thyroid function tests Correct answer.
  4. Fine-needle aspiration

Explanation

Thyroid function tests are the first-line investigation for suspected thyroid disease, determining whether the patient is hyperthyroid, hypothyroid or euthyroid. Further imaging or biopsy is guided by the results.

Question 19Paediatrics

A 3-year-old presents with a 1-day history of drooling, muffled voice and a high fever. He is sitting forward and refuses to lie down. What is the most appropriate immediate action?

  1. Urgent senior anaesthetic and ENT review without distressing the child Correct answer.
  2. Inspect the throat with a tongue depressor
  3. Give oral antibiotics and discharge
  4. Obtain a lateral neck radiograph

Explanation

The child has signs of acute epiglottitis with impending airway obstruction. The airway must be secured by a senior anaesthetist with ENT support, and the child should not be distressed or examined with instruments, which can precipitate complete obstruction.

Question 20Paediatrics

A 2-year-old is brought in with a 1-day history of a generalised rash, fever and irritability. He has been treated with amoxicillin for otitis media. Examination shows mucosal erosions and skin detachment. What is the most appropriate initial management?

  1. Stop the drug and refer urgently to a burns or dermatology unit Correct answer.
  2. Continue amoxicillin and observe
  3. Give antihistamines and review in a week
  4. Apply topical corticosteroids and discharge

Explanation

This picture suggests Stevens–Johnson syndrome or toxic epidermal necrolysis, which requires immediate withdrawal of the suspected drug and urgent specialist care in a burns or dermatology unit. Supportive care and fluid management are critical.

Question 21Paediatrics

A 2-year-old with a known ventricular septal defect develops a fever and refuses to feed. Which investigation is most important to exclude infective endocarditis?

  1. Chest radiograph
  2. Erythrocyte sedimentation rate alone
  3. Blood cultures Correct answer.
  4. Repeat echocardiogram only

Explanation

Blood cultures are essential to identify the causative organism in suspected infective endocarditis and should be taken before antibiotics are started. Echocardiography supports the diagnosis but does not replace cultures.

Question 22Paediatrics

A 4-year-old is brought in with a 2-day history of fever, sore throat and a swollen neck. Examination shows bilateral tender cervical lymphadenopathy and exudative tonsillitis. Which complication should be specifically considered?

  1. Retropharyngeal abscess Correct answer.
  2. Peritonsillar abscess
  3. Otitis externa
  4. Epiglottitis

Explanation

Retropharyngeal abscess can complicate upper respiratory infection in young children, presenting with fever, neck stiffness, torticollis and difficulty swallowing. Urgent imaging and specialist ENT assessment are required.

Question 23Paediatrics

A 10-year-old with sickle cell disease presents with a 1-day history of fever, cough and chest pain. Oxygen saturation is 92% on air. What is the most appropriate initial management?

  1. Inhaled salbutamol alone
  2. Await chest radiograph before starting treatment
  3. Intravenous antibiotics, oxygen and urgent admission Correct answer.
  4. Oral antibiotics and outpatient review

Explanation

Acute chest syndrome in sickle cell disease is a medical emergency requiring prompt intravenous antibiotics, oxygen to maintain saturations, analgesia and often transfusion. Delay in treatment increases mortality.

Question 24Paediatrics

A 3-day-old term infant is noted to be jaundiced with a bilirubin of 320 micromol/L and is lethargic. Which factor most increases the risk of bilirubin encephalopathy?

  1. Breastfeeding
  2. Haemolysis and prematurity Correct answer.
  3. Delayed cord clamping
  4. Cephalohaematoma alone

Explanation

The risk of bilirubin encephalopathy is increased by haemolysis, prematurity, sepsis, acidosis and hypoalbuminaemia, all of which raise free bilirubin or reduce binding capacity. Such infants require urgent phototherapy and possibly exchange transfusion.

Question 25Paediatrics

A 12-year-old presents with a 3-week history of weight loss, polyuria and a capillary glucose of 25 mmol/L. Blood gas shows pH 7.15 and bicarbonate 10 mmol/L. Which factor most strongly predicts the development of cerebral oedema during treatment?

  1. Hourly capillary glucose monitoring
  2. Early potassium replacement
  3. Use of isotonic saline
  4. Rapid fluid administration and a fall in serum osmolality Correct answer.

Explanation

Cerebral oedema in paediatric diabetic ketoacidosis is associated with rapid fluid administration and a rapid fall in serum osmolality, which drives water into brain cells. Slow, isotonic rehydration and gradual correction of hyperglycaemia reduce the risk.

Question 26Paediatrics

A 3-year-old is brought to the emergency department with a 2-hour history of profuse watery diarrhoea and vomiting. He is lethargic, has sunken eyes, a capillary refill of 4 seconds and no tears. What is the most appropriate initial fluid management?

  1. Give 5 mL/kg of 0.45% sodium chloride intravenously over one hour
  2. Give an oral rehydration solution slowly by nasogastric tube
  3. Withhold all fluids until the serum sodium result is available
  4. Give a 20 mL/kg bolus of 0.9% sodium chloride intravenously Correct answer.

Explanation

Sunken eyes, delayed capillary refill, lethargy and absent tears indicate severe dehydration with shock, which requires immediate intravascular volume expansion. The standard is an isotonic crystalloid bolus of 20 mL/kg of 0.9% sodium chloride, reassessed after each bolus. Oral or nasogastric rehydration is reserved for children without shock who can tolerate enteral fluids.

Question 27Paediatrics

A 4-year-old is diagnosed with community-acquired pneumonia and is well enough for oral treatment. Which antibiotic is recommended as first-line therapy in the UK for a child of this age without allergy?

  1. Clarithromycin
  2. Trimethoprim
  3. Amoxicillin Correct answer.
  4. Co-amoxiclav

Explanation

Amoxicillin is the first-line oral antibiotic for uncomplicated community-acquired pneumonia in children, because Streptococcus pneumoniae is the commonest causative organism and amoxicillin covers it well. Macrolides are reserved for atypical infection or penicillin allergy. Co-amoxiclav is broader than needed and reserved for treatment failure or specific indications.

Question 28Paediatrics

A 2-year-old is brought in with a 1-day history of fever, sore throat and a hoarse voice. He is drooling and sitting forward, and there is no cough. Which is the most appropriate immediate action?

  1. Send the child for a lateral neck radiograph before any treatment
  2. Inspect the throat with a tongue depressor to look for exudate
  3. Give oral amoxicillin and discharge with safety-netting advice
  4. Alert senior staff and anaesthetics while keeping the child calm Correct answer.

Explanation

Drooling, a hoarse voice, absence of cough and a sitting-forward posture suggest epiglottitis, which can cause sudden complete airway obstruction. The child must be kept calm and undisturbed while senior staff and anaesthetists are summoned for controlled airway management. Any attempt to examine the throat or move the child may precipitate obstruction.

Question 29Paediatrics

A term newborn is examined on the second day of life. Which finding on routine examination most strongly suggests developmental dysplasia of the hip and warrants ultrasound referral?

  1. Asymmetry of the gluteal skin creases
  2. Restriction of hip abduction to 60 degrees
  3. A palpable clunk with Ortolani manoeuvre Correct answer.
  4. A click felt during abduction of the hip

Explanation

A clunk on the Ortolani manoeuvre represents actual subluxation of a dislocated femoral head back into the acetabulum and is a genuine sign of developmental dysplasia of the hip. Isolated clicks are usually benign soft-tissue noises. Ultrasound is indicated for positive Ortolani or Barlow signs, risk factors or persisting limitation of abduction.

Question 30Paediatrics

A 6-year-old with a known peanut allergy develops urticaria, wheeze and hypotension within minutes of eating a biscuit at school. Which is the first drug that should be given?

  1. Intramuscular adrenaline into the anterolateral thigh Correct answer.
  2. Oral chlorphenamine
  3. Nebulised salbutamol
  4. Intravenous hydrocortisone

Explanation

This is anaphylaxis, and intramuscular adrenaline into the anterolateral thigh is the first-line treatment because it reverses bronchospasm and vasodilatation rapidly. Antihistamines, bronchodilators and steroids are adjuncts and do not treat the underlying airway and circulatory compromise. Adrenaline should be given without delay, before any other drug.

Question 31Paediatrics

A 10-year-old boy is brought in because of daytime wetting and recurrent urinary tract infections. Examination shows a normal spine and normal neurology. Which is the most common structural cause to consider in a child with recurrent urinary tract infections?

  1. Neurogenic bladder
  2. Vesicoureteric reflux Correct answer.
  3. Urethral stricture
  4. Posterior urethral valves

Explanation

Vesicoureteric reflux is the commonest structural abnormality associated with recurrent urinary tract infections in children and predisposes to pyelonephritis and renal scarring. Posterior urethral valves affect boys and usually present in infancy with poor stream or retention. Neurogenic bladder and stricture are much rarer.

Question 32Paediatrics

A 7-year-old with a history of recurrent wheeze is assessed in clinic. Which finding best supports a diagnosis of asthma rather than recurrent viral-induced wheeze?

  1. A history of eczema in the first year of life
  2. Wheeze that begins after the age of 2 years
  3. Wheeze occurring only during the winter months
  4. Symptoms that improve with a bronchodilator Correct answer.

Explanation

Demonstrable reversibility of symptoms with a short-acting beta-2 agonist supports an asthma diagnosis, since it shows variable airflow obstruction. Viral-induced wheeze occurs with colds and does not reliably respond to bronchodilators. Atopy and age of onset are supportive but less specific features.

Question 33Paediatrics

A 5-year-old is diagnosed with acute otitis media and has no allergies. Which management is most appropriate according to current UK guidance?

  1. Analgesia with paracetamol or ibuprofen and review if not improving Correct answer.
  2. Topical antibiotic ear drops
  3. Oral antihistamine and decongestant combination
  4. Immediate oral amoxicillin for 5 days

Explanation

Most children with acute otitis media recover without antibiotics, so analgesia and observation with safety-netting is first-line unless the child is systemically unwell, has bilateral infection under 2 years, or has otorrhoea. Paracetamol or ibuprofen provides effective pain relief. Antibiotics are reserved for those who fail to improve or have specific risk features.

Question 34Paediatrics

A 3-year-old with known sickle cell disease presents with a 1-day history of fever and cough. Which is the most important initial step in management?

  1. Start intravenous antibiotics promptly after cultures Correct answer.
  2. Arrange a chest radiograph before any treatment
  3. Give a blood transfusion immediately
  4. Give oral penicillin and review in 24 hours

Explanation

Children with sickle cell disease are functionally asplenic and at high risk of overwhelming sepsis, so fever must be treated as an emergency. Blood cultures should be taken and intravenous antibiotics started promptly, within an hour. Transfusion and imaging follow but must not delay antibiotics.

Question 35Paediatrics

A 4-year-old presents with a 2-day history of fever and a rash that began on the trunk and spread to the limbs, with small vesicles and crusts at different stages. Which is the most likely diagnosis?

  1. Chickenpox Correct answer.
  2. Hand, foot and mouth disease
  3. Scarlet fever
  4. Measles

Explanation

Chickenpox produces crops of lesions in different stages of evolution, from macules to vesicles to crusts, typically starting on the trunk and spreading outwards. Measles gives a descending maculopapular rash with Koplik spots, and scarlet fever gives a sandpaper rash with circumoral pallor. Hand, foot and mouth disease affects the mouth and extremities.

Question 36Paediatrics

A 12-year-old girl presents with a 3-month history of weight loss, heat intolerance and palpitations. Examination shows a diffuse goitre, tremor and a heart rate of 120 beats/min. Which is the most likely underlying diagnosis?

  1. Subacute thyroiditis
  2. Graves disease Correct answer.
  3. Hashimoto thyroiditis
  4. Thyroid adenoma

Explanation

Weight loss, heat intolerance, a diffuse goitre, tremor and tachycardia in an adolescent point to Graves disease, the commonest cause of thyrotoxicosis in children. It is caused by TSH-receptor stimulating antibodies. Hashimoto thyroiditis usually causes hypothyroidism, and subacute thyroiditis is painful and self-limiting.

Question 37Paediatrics

A 2-year-old presents with a 1-day history of fever and refusal to walk, and the left knee is hot and swollen. Joint aspiration is planned. Which organism is the most likely causative agent in a fully immunised child of this age?

  1. Staphylococcus aureus Correct answer.
  2. Streptococcus pneumoniae
  3. Salmonella species
  4. Neisseria meningitidis

Explanation

Staphylococcus aureus is the commonest cause of septic arthritis in children beyond the neonatal period, followed by Streptococcus pyogenes and Kingella kingae. Neonates are more likely to be infected with group B streptococci or Gram-negative organisms. Empirical antibiotics should cover staphylococci until cultures are available.

Question 38Paediatrics

A 9-year-old with asthma is started on a new inhaler. Which device is most appropriate for a child of this age who can coordinate inhalation?

  1. A dry powder inhaler Correct answer.
  2. A pressurised metered-dose inhaler used without a spacer
  3. A pressurised metered-dose inhaler with a spacer and mask
  4. A nebuliser for routine daily therapy

Explanation

Children over about 8 years who can generate sufficient inspiratory flow and coordinate actuation can use a dry powder inhaler effectively. Spacers are recommended for younger children or those unable to coordinate a metered-dose inhaler. Nebulisers are reserved for acute severe exacerbations, not routine maintenance.

Question 39Paediatrics

A 6-month-old presents with a 2-day history of cough, coryza and fast breathing. Examination shows subcostal recession and a respiratory rate of 60 breaths/min, with oxygen saturation of 94% in air. Which is the most appropriate management setting?

  1. Immediate intubation and ventilation
  2. Outpatient follow-up in one week
  3. Admission for oxygen and supportive care Correct answer.
  4. Discharge home with oral antibiotics

Explanation

This infant has bronchiolitis with increased work of breathing and borderline hypoxia, which warrants admission for oxygen and supportive care. Antibiotics are not indicated because most cases are viral. Intubation is reserved for respiratory failure with exhaustion or worsening hypoxia.

Question 40Paediatrics

A 3-year-old presents with a 2-week history of periorbital oedema that is worse in the morning, and the urine is frothy. Urinalysis shows 3+ protein and no blood. Which is the most likely diagnosis?

  1. Nephrotic syndrome Correct answer.
  2. Urinary tract infection
  3. Renal vein thrombosis
  4. Acute glomerulonephritis

Explanation

The combination of periorbital oedema, heavy proteinuria without haematuria and a frothy appearance to the urine is typical of nephrotic syndrome, most commonly minimal change disease in this age group. Acute glomerulonephritis usually presents with haematuria, hypertension and cola-coloured urine.

Question 41Paediatrics

A 14-year-old girl is brought in with a 2-month history of weight loss despite eating well, and she has been vomiting after meals. Examination shows dental enamel erosion and calluses on the knuckles. Which is the most likely diagnosis?

  1. Bulimia nervosa Correct answer.
  2. Anorexia nervosa
  3. Hyperthyroidism
  4. Coeliac disease

Explanation

Weight loss with self-induced vomiting, dental enamel erosion from gastric acid and Russell's sign (knuckle calluses) is characteristic of bulimia nervosa. Unlike anorexia nervosa, body weight is often normal or near normal. Coeliac disease and hyperthyroidism cause weight loss but not these behavioural and physical signs.

Question 42Paediatrics

A 10-year-old is brought in with a 1-day history of a swollen, painful knee after a fall. He is otherwise well and afebrile. Which feature would most suggest a septic joint rather than a traumatic effusion?

  1. A history of a twisting injury
  2. A small effusion with full range of movement
  3. Immediate swelling after the fall
  4. Severe pain on passive movement with fever Correct answer.

Explanation

Fever with severe pain on passive movement and reluctance to bear weight suggests septic arthritis, which is an emergency requiring aspiration and antibiotics. Traumatic effusions may swell immediately but are not associated with fever. The history of injury alone does not exclude sepsis.

Question 43Paediatrics

A 4-year-old is brought in with a 3-day history of fever and a rash. Examination shows a generalised erythematous rash with desquamation of the fingertips, red cracked lips, strawberry tongue and non-purulent conjunctivitis. Which is the most likely diagnosis?

  1. Scarlet fever
  2. Measles
  3. Toxic shock syndrome
  4. Kawasaki disease Correct answer.

Explanation

The combination of prolonged fever, mucocutaneous changes (cracked lips, strawberry tongue, conjunctivitis), rash and peripheral desquamation is diagnostic of Kawasaki disease. Early treatment with intravenous immunoglobulin and aspirin reduces the risk of coronary artery aneurysms. Scarlet fever has a sandpaper rash but no conjunctivitis or lip cracking.

Question 44Paediatrics

A 2-year-old is brought in with a 1-day history of a generalised rash and fever. He has been treated with amoxicillin for 3 days. Examination shows a diffuse maculopapular rash and cervical lymphadenopathy. Which diagnosis should be considered?

  1. Rubella
  2. Infectious mononucleosis Correct answer.
  3. Scarlet fever
  4. Measles

Explanation

A maculopapular rash developing during amoxicillin treatment is a classic presentation of infectious mononucleosis, which is associated with Epstein-Barr virus. The rash reflects a drug-virus interaction. Measles and rubella are vaccine-preventable and would have a different exposure history and prodrome.

Question 45Paediatrics

A 6-week-old presents with a 3-day history of poor feeding, irritability and a bulging fontanelle. Which is the most appropriate initial investigation?

  1. Blood film for malaria
  2. Lumbar puncture after stabilisation Correct answer.
  3. Cranial ultrasound
  4. Skull radiograph

Explanation

A bulging fontanelle with poor feeding and irritability in a young infant suggests bacterial meningitis, and lumbar puncture after stabilisation is the key investigation to identify the organism and guide antibiotics. Cranial imaging may be needed if there are focal signs or raised intracranial pressure, but it does not replace CSF analysis.

Question 46Paediatrics

A 15-year-old boy presents with a 2-week history of a painless testicular swelling. Examination shows a firm, non-tender mass. Which is the most appropriate next step?

  1. Reassurance and review in 6 weeks
  2. Empirical antibiotics for epididymitis
  3. Immediate needle aspiration in clinic
  4. Urgent urology referral with scrotal ultrasound Correct answer.

Explanation

A painless, firm testicular mass in an adolescent raises suspicion of testicular germ cell tumour and requires urgent urology referral with scrotal ultrasound. Testicular tumours are the commonest solid tumour in young men. Antibiotics are inappropriate without signs of infection, and aspiration risks tumour seeding.

Question 47Paediatrics

A 3-year-old is brought in with a 2-day history of fever, irritability and a stiff neck. Which finding on examination most strongly supports a diagnosis of bacterial meningitis?

  1. Photophobia
  2. Kernig sign Correct answer.
  3. Bulging fontanelle
  4. Neck stiffness alone

Explanation

Kernig sign, like Brudzinski sign, is a specific meningeal irritation sign that supports bacterial meningitis more strongly than isolated neck stiffness or photophobia, which are common in viral illness. Clinical signs are often absent in young children, so a low threshold for lumbar puncture is needed.

Question 48Paediatrics

A 5-year-old with newly diagnosed type 1 diabetes is started on a basal-bolus insulin regimen. Which statement about insulin administration is correct?

  1. Rapid-acting insulin should be given 15 to 30 minutes before meals Correct answer.
  2. Long-acting insulin is given with each meal
  3. Rapid-acting insulin is given only when glucose exceeds 15 mmol/L
  4. Insulin should be stored in the freezer

Explanation

Rapid-acting insulin analogues are given 15 to 30 minutes before meals to match postprandial glucose peaks. Long-acting basal insulin is given once or twice daily, not with meals. Insulin must not be frozen, and rapid-acting insulin is given with meals regardless of the glucose level.

Question 49Paediatrics

A 12-year-old presents with a 4-week history of fatigue and a rash over the cheeks and bridge of the nose after sun exposure. Which is the most likely diagnosis?

  1. Juvenile idiopathic arthritis
  2. Systemic lupus erythematosus Correct answer.
  3. Psoriasis
  4. Dermatomyositis

Explanation

A photosensitive malar rash sparing the nasolabial folds, with systemic symptoms in an adolescent girl, is characteristic of systemic lupus erythematosus. Dermatomyositis causes a heliotrope rash and Gottron papules rather than a malar rash. Juvenile idiopathic arthritis does not typically cause this rash.

Question 50Paediatrics

A 7-year-old with cystic fibrosis presents with a 2-day history of increased cough and sputum production, and a fall in forced expiratory volume. Which is the most appropriate management?

  1. A course of oral antibiotics guided by previous sputum cultures Correct answer.
  2. Inhaled bronchodilators alone
  3. Observation with review in 2 weeks
  4. Routine chest physiotherapy alone

Explanation

A pulmonary exacerbation in cystic fibrosis is defined by increased cough and sputum with a decline in lung function and is treated with antibiotics chosen according to previous sputum microbiology. Physiotherapy and bronchodilators are adjuncts but do not treat infection. Early treatment preserves lung function.