Paediatrics Sample EMQs Asthma treatment A. Oral bronchodilator B. Inhaled bronchodilator C. Inhaled steroids D. Oral long acting bronchodilator E. IM Adrenaline F. Nebulized bronchodilator G. IV Aminophylline H. Nebulized steroids I. Inhaled sodium cromoglycate J. Pre-exercise bronchodilator K. Desensitization Ipratropium bromide For each of the patient described below choose the single most likely management from the above list of options. Each option may be used once, more than once or not at all. 101. A 12 yr old boy comes to medical OP with complaints of shortness of breath and wheezing whenever he plays football in his school. He is otherwise normal when he is not playing. 102. A 10 yr old known asthmatic on regular once daily inhaled bronchodilator comes to review OP with complaints that his symptoms are not under control and that he needs to use inhaled bronchodilator twice a day. His parents are not willing to use any medication that contains steroids. 103. A 13 yr old known asthmatic child is brought to A&E with complaints with severe shortness of breath not controlled by inhaled bronchodilator. 104. A 16 yr old boy complains of shortness of breath. On examination his pulse is 110 and BP 80/60 mmHg. He apparently ate a sandwich that was 3 days old.105. A 15 yr old chronic asthmatic comes with acute exacerbation of symptoms that are not relieved by Nebulized salbutamol. ANSWERS 101.J 102.I 103.F 104.E 105.H Investigation of fever in children Options A. EEG B. Blood culture C. Lumbar puncture D. Urine microscopy and culture E. Joint aspiration F. Stool microscopy and culture G. Chest x-ray H. Sputum culture I. ESR J. Throat swab K. CT scan head L. Upper GI Endoscopy Instructions For each of the patient described below choose the single most likely investigation from the above list of options. Each option may be used once, more than once or not at all. 106. An anxious mother brings her 3 yr old child with complaints of high fever and vomiting since 2 days. She says that the child has been drowsy and irritable. 107. An 11 yr old boy is brought to A&E with high fever and cough for last 4 days. The cough is productive with foul smelling sputum. 108. A 7 yr old girl is brought with complaints of profuse diarrhea and high fever. 109. A 10 yr old is brought to A&E with complaints of high fever and rapidly appearing rash on his limbs. On examination you find neck stiffness. 110. A 14 yr old girl is brought with complaints of swollen right knee and low-grade fever. On examination the right knee is warm, swollen and tender. Answers 106.B 107.H 108.F 109.C 110.E Theme: Cerebral Palsy Options: A. Diplegic cerebral palsy B. Hemiplegic cerebral palsy C. Quadriplegic cerebral palsy D. Ataxic cerebral palsy E. Dyskinetic cerebral palsy F. Mixed cerebral palsy (ataxic diplegia) Lead-in: For each child with cerebral palsy, select the correct diagnostic category. Stems: 1. A two year old boy has been walking for three months. He was born at 26 weeks gestation weighing 950g. His walking remains precarious and unsteady. He can say ten words and points to his nose when asked. He was born prematurely at 26 weeks. On examination he stands with hips and knees flexed, taking his weight on his toes. His legs tend to cross when walking. He has limited abduction of his hips and downpointing feet. He has brisk reflexes in his legs but tone, power, co-ordination and reflexes are normal. 2. An 18 month old girl has just started to take her first steps, and is noted to be unable to straighten her right leg or put her right foot flat on the ground. Her birth and perinatal history were normal. It has also been observed that she is left handed, and tends to hold her right arm flexed at the elbow with her right hand clenched. Examination reveals decreased power, increased tone and brisk reflexes in the right arm and leg. 3. A 12 month old girl has had feeding problems since birth, and intermittently requires nasogastric feeding. She was born at term weighing 3500g but developed hypoxic-ischaemic encephalopathy following birth asphyxia. She is unable to sit or crawl and makes only unintelligible sounds. Examination reveals microcephaly, impaired swallowing and spasticity and hypereflexia in all four limbs. 4. The parents of a 20 month old boy are concerned that he is clumsy and unsteady, particularly when sitting and reaching for objects. Birth history was normal. He cannot yet walk independently but with support walks with a wide-based gait. He can say a few words but his speech is unclear. On examination, his head circumference is above the 97th centile. Tone and reflexes are normal in all four limbs, but he is unable to grasp a small toy placed in front of him. 5. A ten month old boy was previously noted to have generalised hypotonia with few voluntary movements, but now has episode where he is rarely still, making writhing movements with his limbs and trunk. He was born at 32 weeks gestation weighing 1400g. He developed jaundice, with a peak serum bilirubin of 400μmol/l at day four. He has subsequently had recurrent feeding problems, with vomiting and regurgitation. On examination, his resting muscle tone and reflexes appeared normal, although any handling provoked an increase in tone. 6. A 12 month old girl was noted to have generalised hypotonia until the age of three months, after which her legs became stiff. She was born at 28 weeks and developed hydrocephalus following an intraventricular haemorrhage. Her balance now seems very poor and she is unable to stand or sit unsupported. On examination she has poor coordination in her upper limbs with an obvious intention tremor when reaching for objects. Tone and reflexes are normal in her upper limbs but her lower limbs are hypertonic and hypereflexic, and she has bilateral equinovarus. Answers ABCDEF Theme Delayed walking in young children A. Developmental dysplasia of the Hip B. Diplegic cerebral palsy C. Normal child D. Global developmental delay E. Quadraplegic cerebral palsy F. Duchenne muscular dystrophy G. Hemiplegic cerebral palsy H. Spinal cord tumour I Spinal muscular atrophy type 1 Lead in: The following histories all describe 18 month old children who are not walking. What is the most likely diagnosis for each one? 1. Jack has never walked but has crawled everywhere since the age of 1 year. He loves building towers of bricks and is saying 4-5 words. On examination he has equal skin creases at his hips, and a normal range of movement in his lower limbs. He hates being examined so power and reflexes are difficult to assess but appear normal and equal bilaterally in all four limbs. 2. Richard has just started to crawl. He is saying mama and dada and plays peek-aboo. He grasps objects and likes putting things in his mouth but is not yet feeding himself. On examination he has reduced muscle tone but a normal range of movement at his hips. Reflexes and power are normal on examination. 3. Petra has never walked but bottom shuffles quickly around the room. She loves making animal noises and can say about 20 words. She can build a tower of 3 bricks and mum says that she likes to help with the housework. On examination she has equal skin creases at his hips, and a normal range of movement in his lower limbs. Power and reflexes appears normal and equal bilaterally in all four limbs. 4. James was born prematurely at 26 weeks. He was discharged at 3 months of age and his mother feels that he has been progressing well since then. He has just started to “bottom shuffle” and is messily feeding himself and drinking from a cup. He can say 10 words and points to his nose when asked. On examination he has equal skin creases at his hips but the range of movement of his lower limbs is reduced. He has brisk reflexes in his legs but his arms appear normal. 5. Jody started to crawl 4 months ago. She likes playing with bricks and her mother comments proudly that she is going to be left handed like her father. She is saying about 20 words and enjoys feeding herself at mealtimes. She had a normal examination of all her limbs and hips, although she has brisker reflexes in her right arm and leg when compared to the left. 6. Fred is crawling, is able to cruise around the furniture but is not yet walking. He can build a tower of 3 bricks and is saying 15-20 words. He can hold a spoon and feeds himself at mealtimes. On examination he has unequal skin creases at his hips, and a reduced abduction of his right hip. Power and reflexes appears normal and equal bilaterally in all four limbs. 7. Andrew is not yet crawling. He started to sit unsupported a few months ago and likes to roll around the floor. He will reach out for objects but finds it difficult to grab hold of them. He says mama and points at his drink is when is thirsty. He cannot feed himself and is dribbling a great deal. On examination he has equal skin creases at his hips, but his legs appear “stiff” and it is difficult to abduct his legs at his hips. Reflexes are brisk in all four limbs.