This chapter contains 50 questions in the style and format of the MRCPCH AKP examination. A single exam paper would contain 60 questions and take 150 minutes (2½ hours) to complete. These 50 questions would therefore take 125 mins to complete if you choose to run the questions as a practice exam.
A 14-year-old male was brought to the emergency department by his mother who found him collapsed in his bedroom. He had admitted to taking a large quantity of his mother’s antidepressant medication in the morning with the intention of taking his life.
Which of the following features in a history would indicate an increased risk of later successful suicide? (Select one answer only).
diagnosis of depression
early morning timing
finding a letter explaining reasons
recent death of father
recent parental separation
A 9-year-old boy was referred by his GP following parental concerns about his behaviour. He was described as aggressive at times and prone to temper tantrums. He would often leave things behind at school and then suggest that this was due to instructions from his teacher. His teachers described him as intelligent and although easily distracted, he could be absorbed in some of his work. His mother acted as a single parent as his father was in prison for armed robbery. He was born at 34 weeks’ gestation but required no intensive neonatal interventions.
His height and weight followed the 75 th centile and there were no abnormal findings on examination.
What is the most likely explanation for his presenting problems? (Select one answer only)
attention deficit disorder
autism spectrum disorder
disruptive domestic circumstances
oppositional defiant disorder
The 19-year-old mother and her 1-year-old daughter attend paediatric outpatients’ clinic following a referral for advice about a family condition. The brother of the mother is now 18 years old and requires full support at home having been diagnosed with Wiskott-Aldrich syndrome. Mother is well without any health issues.
What is the chance of the 1-year-old daughter inheriting Wiskott-Aldrich syndrome? (Select one answer only)
1 in 2 chance of inheriting
1 in 4 chance of inheriting
2 in 3 chance of inheriting
No chance of inheriting
Unable to say as mother of baby needs assessment
A 14-month-old boy was referred from the emergency department with a 3-day history of vomiting and constipation. Concerns were also raised about his growth. His parents were asylum seekers having recently arrived in the UK. He was born at term, weighed approximately 3 kg and appeared normal at that time. He had never been able to weight bear or walk but his speech, vision and hearing were thought to be normal. His parents were first cousins and they had three children alive and well but two others had died when under 2 years old with vomiting illnesses.
On examination, his weight and length were below the <0.4 centile and head circumference was on the 50th centre. He was extremely wasted and dehydrated and had swelling of the wrists and bowing of the lower limbs. He had reduced tone but no focal neurological signs. Rest of examination was normal.
The initial results show:
Urine in pH 6; protein plus; glucose trace
What is the most likely explanation for these findings? (Select one answer only)
A 3-year-old boy was brought to the emergency department following the development of a rash on his face, trunk and limbs. His family was originally from the Egypt and he had recently eaten a cracker with tahini (sesame) and immediately felt an itching sensation on his tongue. A rash had developed within 30 minutes but there were no associated difficulties with his breathing. He responded to chlorphenamine. He had previously been diagnosed with eczema and mild hay fever but there was no family history of atopy.
On examination he had a widespread urticarial rash.
Which investigation is the most appropriate to identify the cause of his presentation? (Select one answer only)
C1 esterase inhibitor levels
Food challenge test with sesame
Serum IgE levels
Serum tryptase levels
Skin prick testing with sesame
A 14-year-old boy has had a second relapse of his osteosarcoma and has developed pulmonary metastases. Following discussions with him and his parents it is agreed that further curative treatment will not be offered and active management of his palliative needs will be introduced. He currently an in-patient whilst the plan for his pain management is established.
His current symptom is that of bone pain and this requires oral morphine at a dose of 5 mg every 4 hours.
What would be the appropriate next step to improve his pain control should the current regime fail? (Select one answer only)
Convert to a fentanyl patch at an adjusted higher dose
Increase frequency to every 2–3 hourly
Increase morphine dose but continue at every 4 hours
Start intravenous diamorphine as patient-controlled analgesia
Start subcutaneous diamorphine infusion
A 3-year-old boy was brought to the emergency department by his father. He had been with his grandmother for the day and she had reported that he had not been ‘his usual self’ for about an hour before his father picked him up. Over the following 2 hours at home, he became agitated and then increasingly drowsy. His father noted he had some jerking movements whilst being brought to hospital.
On examination in hospital, his observations are pulse 124/minute, respiratory rate 24/minute and temperature 37.3 o C. His oxygen saturations are 98% with face mask oxygen. He has normal volume pulses, normal heart sounds and a capillary refill of <2 seconds. His chest is clear and there is no increased respiratory effort. Examination of the abdomen is normal. He opens his eyes to painful stimuli and has some abnormal flexion movements. He is only making mumbling sounds.
What is the next most important response? (Select one answer only)
Administer IV ceftriaxone
Administer IV mannitol
Arrange urgent CT scan of head
Collect urine for toxicology
Intubation and ventilation
You are a junior doctor who has started working on the oncology ward in the last week. You are asked by the new registrar to prescribe an intrathecal methotrexate dose for a patient who is due to receive the dose whilst under anaesthesia for the insertion of a central venous line.
What is the most appropriate response? (Select one answer only)
Advise delay administration of dose until next anaesthesia
Check protocol to confirm dose and timing of methotrexate
Discuss with oncology pharmacist
Indicate that you are unable to prescribe the dose
Prescribe the intrathecal dose
You will be presented with a list of ECG findings and three scenarios.
Which of the following ECG abnormalities is the most likely cause of the presentations described? (One answer only for each scenario).
axis deviated to right
P wave peaked
Prolonged PR interval
QRS complex widened
QT interval prolonged
QT interval shortened
T wave flattened
T wave inverted in V6
T wave upright in V1
A 6-week-old boy presented with cardiac failure and echocardiogram showed a partial atrioventricular septal defect.
A 7-year-old girl had started chemotherapy having been diagnosed with high white count acute lymphoblastic leukaemia. Examination undertaken at 12 hours after starting treatment described her as ‘twitchy’ and revealed positive Chvostek and Trousseau signs.
A 2-year-old girl was found to have a cardiac murmur during examination for a chest infection. Further examination revealed a carotid thrill and a 4/6 ejection systolic murmur in the upper right sternal edge.
A 15-year-old girl was referred to out-patients and attended with her mother. Her father had been diagnosed with Huntington disease and was advising all his family to be tested for the condition. The girl was well without any symptoms and both she and her mother were requesting that she was ‘tested for the gene’ for Huntington disease.
Which is the most appropriate action for managing this request? (Select one answer only)
Advise waiting until she is over 18 before undertaking any testing
Arrange testing for the Huntington disease gene
Obtain more details of the results of the father
Reassure her that females cannot develop Huntington disease
Refer to genetics for counselling
A 2-year-old girl was referred to out-patients for review of recurrent coughs, temperatures and poor speech. She was born at term but spent 3 days in the neonatal unit due to an oxygen requirement and was discharged home without need for respiratory support. Throughout her first year of life, she had recurrent chest infections that were treated with antibiotics. She failed a routine screening test for hearing at 12 months but was not brought for further investigation until she was 18 months old when bilateral grommets were inserted and her hearing improved considerably. Height and weight were following the 2 nd centile.
Examination identified tachypnoea, hyperinflation of the chest, Harrison’s sulci and bilateral coarse crepitations in both lung fields. The chest x-ray taken in clinic is shown below ( Figure 35.1 ).
Which of the following investigations will identify the underlying cause for this presentation? (Select one answer only)
High resolution CT chest
Nasal brush biopsy
A 4-year-old girl was brought to the emergency department by her grandparents who had been looking after her for the day. She had been found collapsed in the house whilst out of their sight for only a few minutes. She had been perfectly well before wandering into the kitchen on her own. There was no suggestion of trauma or a fall. The grandparents were worried that she may have eaten peanuts as these were found scattered on the floor. She was known to have asthma and eczema and the child’s parents were concerned that she may have food allergies.
Examination found her to be pale and floppy, responding poorly to stimuli. Her pulse was 160/minute, capillary refill was 5 seconds, systolic blood pressure was 75mmHg. Oxygen saturation was 90% in air.
What is the next most important step in her management? (Select one answer only)
Give 0.9% saline bolus 20 ml/kg
Give adrenaline 1:1000 150 mcg IM
Give adrenaline 1:1000 150 mcg IV
Give adrenaline 1:1000 300 mcg IM
Give hydrocortisone 100 mg IV
A 7-year-old girl was referred with concerns about adult sweat odour, acne and pubic hair. Her mother was worried that this was early puberty and that she would start her periods very soon. There was no obvious history of growth acceleration and she was otherwise well with no significant past medical or drug history. Her mother had had gestational diabetes in all three of her pregnancies and her paternal grandfather and his sister had type 2 diabetes. Her mother started her periods at 11 years and her father’s voice broke at about 15 years.
On examination her height is on the 75 th centile which is tall for family size with the mid-parental centile 25 th –50 th . Her weight is on 99.6 th and her calculated BMI >99.6 th centile for age. Breast development is difficult to score due to her body habitus but is assessed as B1. Examination of the perineum shows sparse long pubic hair confined to the vulva and is otherwise normal. The remainder of the examination is unremarkable.
What is the most likely diagnosis? (Select one answer only)
Androgen secreting ovarian tumour
Congenital adrenal hyperplasia
Gonadotrophin dependent sexual precocity
A 6-year-old boy was seen in the emergency department with pyrexia and lethargy. He was recently diagnosed with asthma and was started on inhaled budesonide the week before this attendance. His mother had gestational diabetes whilst his maternal grandma was on metformin.
On examination, his height and weight are on the 9 th centile. He is apyrexial, clinically well and no abnormalities are found on examination.
|Random blood sugar||8.8 mmol/l||3.0–6.0 mmol/l|
|HbA1c||54 mmol/mmol||20–42 mmol/mol|
|Fasting blood sugar||6.7 mmol/l||3.0–6.0 mmol/l|
What is the most likely cause for his glycosuria? (Select one answer only)
Steroid induced glycosuria
Type 2 diabetes
Urinary tract infection
A 3-week-old boy was admitted with vomiting up to 4 times daily for the last 2 days. The vomiting was not related to feeding and was not projectile. His bowel frequency had reduced but the stools were normal. He was born at term and was discharged home the following day. His birth weight was 3.6 kg.
On examination the baby weighed 3.7 kg and is clinically undernourished with redundant skin folds. He is drowsy, clinically dehydrated with cool peripheries and he has a sunken fontanelle. His temperature is 37.8 o C, pulse 176/minute and BP 75/30. The remainder of the examination was unremarkable.
Which investigation is most likely to lead to the underlying diagnosis? (Select one answer only)
A 3-year-old girl is seen in the emergency department with her grandmother who was concerned about bruising to her buttocks. The grandmother explains that the child had been left with her that morning by the boyfriend of the child’s mother who had gone to work. The bruising was discovered when grandmother went to change the child’s clothing. The new boyfriend of the mother appears in the emergency department.
Examination records a distressed child with bruises to her buttocks, arms and backs of thighs.
The paediatric registrar requests blood tests.
Who is able to give legally accepted permission for the blood tests? (Select one answer only)
Boyfriend of mother
Duty Social Worker
A 14-year-old female was admitted to hospital with parental concerns about food intake and her severe underweight. She was diagnosed with anorexia nervosa about 18 months previously and had been under the care of the eating disorders team. Her parents expressed concerns about recent changes in her diet with nothing consumed for the preceding 4 days.
Examination identified that she was cachectic but more detailed assessment was limited as she refused further examination.
|Creatinine||75 μmol /l||(40–90)|
What is the next most appropriate action required in view of these results? (Select one answer only)
Give IV bolus 10% glucose
Pause reintroduction of calories for 24 hours
Start oral phosphate supplementation
Start oral potassium supplementation
A 6-year-old boy weighing 20 kg was admitted with acute abdominal pain and a diagnosis of appendicitis with peritonitis was made. He was taken to theatre where a perforated appendix was identified and resected.
There were no immediate postoperative problems although he remained nil by mouth and received intravenous dextrose/saline 4%/0.18% at a rate of 75 mls/hr. On the second day after surgery, he had a short, generalised convulsion of 2 minutes duration.
What is the most appropriate next step in his management? (Select one answer only)
Administer slow IV sodium chloride infusion (40 mmol over 30 minutes)
Restrict IV fluids to 65% maintenance using 0.9% saline
Restrict IV fluids to 65% maintenance using dextrose/saline 4%/0.18%
Restrict IV fluids to 65% maintenance using dextrose/saline 5%/0.45%
Start oral sodium chloride supplements (2 mmol/kg/day)
A 4-year-old boy was referred for assessment of chronic diarrhoea and recent poor weight gain over the last 6 months. He would pass soft, occasionally liquid, stool on 2 to 3 occasions per day although there was no report of blood in the stool. His appetite was generally good and he was usually active. He was born at 30 weeks’ gestation and required ventilatory support for 7 days. He developed necrotising enterocolitis at that time and was managed with antibiotics, parenteral feeding and bowel rest and made a full recovery.
On examination his height is on the 9 th centile whilst his weight is on the 0.4 centile. His temperature is 37.3 o C, pulse 100/minute, capillary refill 3 seconds, blood pressure 95/75. His abdomen is soft and there are no palpable masses or organomegaly. Examination of both respiratory and neurological systems shows no abnormalities. A range of investigations were undertaken and the results are shown below.
|White cell count||4.8 x 10 9 /l||(3.0–10.0 x 10 9 /l)|
|Neutrophils||2.1 x 10 9 /l||(2.0–6.0 x 10 9 /l)|
|Lymphocytes||0.7 x 10 9 /l||(1.5–9.5 x 10 9 /l)|
|Platelets||167 x 10 9 /l||(150–400 x 10 9 /l)|
|ESR||16 mm/hr||(< 20)|
|Urea & creatinine||Normal|
|Liver function tests||Normal|
|Stool culture||no ova, cysts or parasites|
What is the most likely diagnosis? (Select one answer only)
Chronic giardia lamblia infection
Inflammatory bowel disease
Short bowel syndrome
A 2-year-old child had been assessed in the ED after a reported fall down the stairs. The ED team were concerned that the injuries may be nonaccidental.
Which of the following observations support the explanation of an accidental fall? (Select one answer only)
Bruising over the abdomen with liver laceration
Fractures to both humerus and femur
Single transverse femur fracture
Single fracture to the tibia
Vertebral fracture at T11
A practice nurse contacts the on-call registrar for advice on immunisation. She plans to administer the routine MMR vaccine to a 15-month-old boy but has been told by the mother that the child has an egg allergy. A widespread rash developed after eating a boiled egg when he was 7 months old. There is a strong family history of atopy.
What is the most appropriate advice to give to the practice nurse? (Select one answer only)
Administer separate mumps, measles and rubella vaccine
Admit to the Day Care Unit and give MMR
Give MMR at GP practice
Refer to OP for further review
A 3-year-old girl with Down syndrome attends the out-patients department for her annual review.
Which of the following screening investigations should be undertaken at this visit? (Select one answer only)
Growth hormone assay
A 14-year-old boy who is known to have sickle cell disease, presented to the emergency department with fever, breathing difficulties and pains in his limbs and back.
On examination, he is pale and finds it difficult to be comfortable. His temperature was 38.2 o C, pulse 160/minute, systolic blood pressure 110/65, but cardiac auscultation finds no abnormalities. His respiratory rate was 40, O 2 saturations 91% in air, no recession evident and breath sounds were normal and equal. Examination of the abdomen identified a 3 cm liver edge. Remaining examination was normal.
|White cell count||8.3 x 10 9 /l||(5.0–12.0)|
|Platelets||320 x 10 9 /l||(150–400)|
What is the next most important step in his management? (Select one answer only)
Blood sample for culture
IV dextrose saline maintenance fluids
A 5-week-old baby boy was referred by the GP with episodes of ‘twitching’ and a temperature of 38.3 o C despite being given a dose of paracetamol. There is a history of penicillin allergy in the mother.
On presentation in hospital, he is miserable and only wakes when stimulated. His pulse is 166/minute, respiratory rate 54/minute, capillary refill time 2 seconds and temperature of 37.9 o C. He has dry mucous membranes but good skin turgor and his fontanelle is flat. There are no abnormal findings from the rest of the systems.
|White cell count||4.1 x 10 9 /l||(6.0–15.0)|
|Platelets||375 x 10 9 /l||(150–450)|
|CRP||34 mg/l||(< 5)|
Urine dip negative, microscopy awaited.
|WCC||50 x 10 6 /l||(0–30)|
|Lymphocytes||45 x 10 6 /l||(<30)|
|Neutrophils||15 x 10 6 /l||(0)|
Which of the following IV treatments is most appropriate for this baby? (Select one answer only)
benzylpenicillin and gentamicin
benzylpenicillin, gentamicin and acyclovir
cefotaxime and amoxicillin
cefotaxime, amoxicillin and acyclovir
A 12-year-old boy presented to the emergency department with three episodes of rapid heartbeat that had occurred over the previous four weeks. The episodes were of sudden onset, lasted about 5 minutes and terminated spontaneously. He was anxious, lightheaded and slightly breathless during these episodes. He was otherwise well. There was nothing of relevance in the past medical or family history.
Examination was normal. His ECG is shown below ( Figure 35.2 ).
What is the most likely cause of his episodes of fast heartbeat? (Select one answer only)
First degree heart block
Right bundle branch block
Short QT syndrome
A 3-month-old boy is one of nonidentical twins and has recently been diagnosed with severe combined immunodeficiency. Neither of the twins have yet received any of their planned immunisations. The parents ask for advice on immunisation of the child and other family members.
Which of the following is appropriate advice for this family? (Select one answer only)
4-year-old sibling can have preschool immunisations
8-year-old sibling can receive intranasal influenza vaccination
13-year-old sibling can receive her HPV vaccine
the nonidentical twin can have all first-year vaccines
the patient can receive all first-year vaccines
A 9-year-old boy presented with pallor, bruising and temperatures. There was nothing abnormal in the past medical or family history.
Examination found him to be pale with obvious ecchymoses on his trunk and limbs and with widespread lymphadenopathy. His temperature was 39.3 o C, pulse 120/minute, blood pressure was 70/55. Examination of the abdomen revealed a 3 cm liver and a 2 cm spleen. Remaining examination was normal.
|White cell count||346 x 10 9 /l||(5.0–12.0)|
|Platelets||12 x 10 9 /l||(150–400)|
Which two actions must be undertaken immediately? (Select two answers only)
administer bolus 0.9% saline at 10 ml/kg
administer platelet transfusion
administer red cell transfusion
commence fluids—0.9% saline with potassium
commence IV antibiotics
IV calcium gluconate
An 18-month-old girl attended the emergency department following a generalised seizure which lasted 3 minutes. She had been unwell with a coryzal illness over the previous 48 hours and had refused her morning milk. The family were asylum seekers from a war-torn area and had recently moved to the UK. There was no relevant past medical or family history.
Examination revealed her to be drowsy with limited response to stimuli. Her temperature was 37.2 o C, pulse 120/minute, capillary refill was 3 seconds, blood pressure was 95/65. Abdomen was soft with no organomegaly and there were no focal abnormalities identified on examination of her neurological system. Rest of the examination was normal.
|Full blood count|
|Bilirubin||12 μmol/l||(< 17)|
|Base excess||-7 mmol/l||(-2 to +2)|