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100 N A G I G. BARAKAT
,Contents %
r
Preface v
Dedication vi
Acknowledgements vi
Abbreviations vii
i
Questions 1-10 1
Answers 1-10 10
Questions 11-20 19
Answers 11-20 31
Questions 21-30 41
Answers 21-30 49
-
Questions 31 40 57
Answers 31-40 72
Questions 41-50 81
Answers 41-50 92
Questions 51-60 101
Answers 51-60 112
Questions 61-70 121
Answers 61-70 133
Questions 71-80 141
Answers 71-80 151
Questions 81-90 159
Answers 81-90 171
Questions 91-100 181
Answers 91-100 190
,QUESTIONS 1-10
Case 1
A 13-year-old girl presented to Accident and Emergency ( A&E ) with a
history of lethargy, joint pain and cough. Both of her parents are from
Jamaica . Her problem started 1 month ago , with an upper respiratory
tract infection (URTI). She was seen by her family doctor, and a viral
infection was diagnosed. She had a past history of rashes on her
body, but her family doctor never saw them. On examination, she has
palpable cervical lymph nodes of various sizes, a congested throat,
generalised myalgia and a swollen ankle joint on the left side. Her BP
is 120/75 mmHg, HR 90 b.p.m. and RR 22/min. A urine test showed
protein + with red cells. Other test results are:
Hb 9.7 g/dl
WCC 4 x 109/l with neutropenia and lymphopenia
PLT 100 x 1071
Ret 2.6%
CRP 20
1. Which three other important investigations should be carried
out?
2. What treatments should you prescribe?
3. What are three possible differential diagnoses?
She was admitted for further investigation and on the second night,
her oxygen requirement increased to 3 l/min via a facemaskto
maintain a Sat level above 93%. All cultures were negative.
4. Which single investigation should you carry out?
Her condition got worse, she was transferred to the paediatric
intensive care unit ( PICU), she required ventilation, and other
procedures were carried out. Her blood pressure remained high
( 130/90 mmHg ) and she was treated with nifedipine. A kidney US
scan was reported as normal, as was a hormonal study. She was
treated with antibiotics for 7 days. A viral titre shows IgG for EBV. A
Mantoux test is very weakly positive, although she had never
received a BCG.
5. Which three other investigations may help the diagnosis?
6. What other treatment should be added at this stage?
Case 2
An infant baby girl aged 36 months was seen in A&E with a history of
vomiting and diarrhoea for the previous 3 days. In the last 24 hours,
she became irritable and grew pale. She is not interested in eating
but is still drinking fluids. She was born full term and has no previous
problems. The family lives in a council flat without central heating.
The father is a heavy smoker and the mother is heavily pregnant. The
infant looks pale with a peripheral capillary refill rate of 3 s . Her HR is
, 2 100 Grey Cases in Paediatrics for MRCPCH
/
140 b.p.m., RR 30/min and BP 90/60 mmHg. Her liver is 3 cm below
the right costal margin, the right kidney is palpable and there is no
jaundice. Her urine shows protein +, RBC ++ and no organisms or
leukocytes. All cultures are negative.
1. List four immediate investigations
a ESR
b INR
c Renal US with Doppler
d Urea and electrolytes (U&E )
e Hepatitis B and C serology
f Full blood count (FBC)
g 24-hour urinary protein
h VMA
i Renal biopsy
2. What is the most likely diagnosis?
a Haemolytic uraemic syndrome (HUS)
b UTI
c Gastroenteritis
d Obstructive renal failure
e Right renal artery thrombosis
f Right renal vein thrombosis
/ g Wilms' tumour
h Acute glomerulonephritis
3. Name three steps of management.
Case 3
An 11- year-old boy was referred to A&E with a history of limping si
pain in his right leg. The day before, he was chasing his sister, fell I
and hit the side of the coffee table, and has since been complaining sfl
pain in his right knee. There is no family history of any illnesses s:r
from his aunt, who died 3 years ago with an illness described as s
stroke, after a long time of unspecified illness. -
Systemic and general examinations were reported as normal, excel
for a slight proximal weakness of the right leg.
1. What one test should you carry out?
a ESR
b CRP
c Right and left knee X-ray
d Right knee X-ray
e Right knee US
f Right knee MRI
g Right knee CT
The boy presented 5 days later with more weakness and was seer r
the orthopaedic surgeon, who diagnosed muscle weakness and
referred him to the paediatrician, who would see him in 2 days. T“*l
same night he came back to A&E with more weakness in his right
and a right arm that felt 'heavy'. There is marked weakness of the 1
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100 N A G I G. BARAKAT
,Contents %
r
Preface v
Dedication vi
Acknowledgements vi
Abbreviations vii
i
Questions 1-10 1
Answers 1-10 10
Questions 11-20 19
Answers 11-20 31
Questions 21-30 41
Answers 21-30 49
-
Questions 31 40 57
Answers 31-40 72
Questions 41-50 81
Answers 41-50 92
Questions 51-60 101
Answers 51-60 112
Questions 61-70 121
Answers 61-70 133
Questions 71-80 141
Answers 71-80 151
Questions 81-90 159
Answers 81-90 171
Questions 91-100 181
Answers 91-100 190
,QUESTIONS 1-10
Case 1
A 13-year-old girl presented to Accident and Emergency ( A&E ) with a
history of lethargy, joint pain and cough. Both of her parents are from
Jamaica . Her problem started 1 month ago , with an upper respiratory
tract infection (URTI). She was seen by her family doctor, and a viral
infection was diagnosed. She had a past history of rashes on her
body, but her family doctor never saw them. On examination, she has
palpable cervical lymph nodes of various sizes, a congested throat,
generalised myalgia and a swollen ankle joint on the left side. Her BP
is 120/75 mmHg, HR 90 b.p.m. and RR 22/min. A urine test showed
protein + with red cells. Other test results are:
Hb 9.7 g/dl
WCC 4 x 109/l with neutropenia and lymphopenia
PLT 100 x 1071
Ret 2.6%
CRP 20
1. Which three other important investigations should be carried
out?
2. What treatments should you prescribe?
3. What are three possible differential diagnoses?
She was admitted for further investigation and on the second night,
her oxygen requirement increased to 3 l/min via a facemaskto
maintain a Sat level above 93%. All cultures were negative.
4. Which single investigation should you carry out?
Her condition got worse, she was transferred to the paediatric
intensive care unit ( PICU), she required ventilation, and other
procedures were carried out. Her blood pressure remained high
( 130/90 mmHg ) and she was treated with nifedipine. A kidney US
scan was reported as normal, as was a hormonal study. She was
treated with antibiotics for 7 days. A viral titre shows IgG for EBV. A
Mantoux test is very weakly positive, although she had never
received a BCG.
5. Which three other investigations may help the diagnosis?
6. What other treatment should be added at this stage?
Case 2
An infant baby girl aged 36 months was seen in A&E with a history of
vomiting and diarrhoea for the previous 3 days. In the last 24 hours,
she became irritable and grew pale. She is not interested in eating
but is still drinking fluids. She was born full term and has no previous
problems. The family lives in a council flat without central heating.
The father is a heavy smoker and the mother is heavily pregnant. The
infant looks pale with a peripheral capillary refill rate of 3 s . Her HR is
, 2 100 Grey Cases in Paediatrics for MRCPCH
/
140 b.p.m., RR 30/min and BP 90/60 mmHg. Her liver is 3 cm below
the right costal margin, the right kidney is palpable and there is no
jaundice. Her urine shows protein +, RBC ++ and no organisms or
leukocytes. All cultures are negative.
1. List four immediate investigations
a ESR
b INR
c Renal US with Doppler
d Urea and electrolytes (U&E )
e Hepatitis B and C serology
f Full blood count (FBC)
g 24-hour urinary protein
h VMA
i Renal biopsy
2. What is the most likely diagnosis?
a Haemolytic uraemic syndrome (HUS)
b UTI
c Gastroenteritis
d Obstructive renal failure
e Right renal artery thrombosis
f Right renal vein thrombosis
/ g Wilms' tumour
h Acute glomerulonephritis
3. Name three steps of management.
Case 3
An 11- year-old boy was referred to A&E with a history of limping si
pain in his right leg. The day before, he was chasing his sister, fell I
and hit the side of the coffee table, and has since been complaining sfl
pain in his right knee. There is no family history of any illnesses s:r
from his aunt, who died 3 years ago with an illness described as s
stroke, after a long time of unspecified illness. -
Systemic and general examinations were reported as normal, excel
for a slight proximal weakness of the right leg.
1. What one test should you carry out?
a ESR
b CRP
c Right and left knee X-ray
d Right knee X-ray
e Right knee US
f Right knee MRI
g Right knee CT
The boy presented 5 days later with more weakness and was seer r
the orthopaedic surgeon, who diagnosed muscle weakness and
referred him to the paediatrician, who would see him in 2 days. T“*l
same night he came back to A&E with more weakness in his right
and a right arm that felt 'heavy'. There is marked weakness of the 1
