Ex Dx ped P101 to 148

A 7 year old with a 3-day history of upper respiratory tract infection is brought to accident and emergency by his mother because he suddenly went pale and sweaty and seems to be working hard to breath.The triage nurse calls you to see him urgently because his heart rate is 200 beats per minute.You take him round to the resuscitation area, give him oxygen and connect him to the cardiac monitor. The electrocardiogram (ECG) shows a narrow complex tachycardia with a rate of 180 beats per minute.He remains alert, with a respiratory rate of 40. What is the most appropriate initial diagnosis?

102. A 2-year-old child is referred to hospital by the GP after his third visit that week; he now has a rash and the GP is worried he has meningitis.He has had a fever for 5 days up to 39.5°C or above every day and is not eating or drinking well. On examination, he has a temperature of 38.5°C, heart rate of 150, and respiratory rate of 30 and is miserable.He has a blanching macular rash on his torso, swollen hands and feet, red eyes, red cracked lips, large tonsils with no pus, and a left-sided 2 cmx 3 cm cervical lymph node which is mobile.There is no photophobia or neck stiffness.His chest is clear with normal heart sounds and his abdomen is soft with a palpable liver edge.You note his BCG scar is inflamed. What is the most likely diagnosis?

103. A 14-year-old refugee from Afghanistan who has lived in the UK for 2 years comes to see you complaining of increasing fatigue and breathlessness on exertion. On examination she appears cyanosed and has bilateral basal fine crepitations and a soft pansystolic murmur with a displaced apex beat.She has never been in hospital and has no surgical scars.You urgently refer her for a cardiology review.What is the most likely diagnosis?

104. A 5-year-old child was admitted overnight awaiting surgical repair of a broken right ankle and was noted to have a raised blood pressure consistently above 130/90 mmHg despite adequate analgesia. On examination he has a plaster on his right foot and appears comfortable at rest. On auscultation there is a soft systolic murmur heard at the right upper sternal edge.His femoral pulse is difficult to fmd, but present bilaterally. When felt with the radial pulse, the impulse in the femoral pulse occurs slightly later.His abdomen is soft and there are no bruits heard.The blood pressure done in the right arm is 136/92 mmHg but the left arm gives a reading of 124/80. What is the most likely diagnosis?

105. Forty per cent of children with trisomy 21have congenital heart defects.Which of the following is not associated with Down 's syndrome?

106. A 14-year-old girl was seen in accident and emergency following her third collapse this year and referred to cardiology for review of a low rumbling murmur heard at the left upper sternal edge.Her ECG in accident and emergency was normal. Her blood sugar was 5.3 mmol/L. Urea and electrolytes were normal. The most recent collapse occurred at school while waiting for exam results to be given out.Previously they occurred while watching a parade all afternoon standing in a crowded street, and at a party. On all three occasions she felt dizzy beforehand, was unconscious for less than 10 seconds and fully alert following the episode, but did feel nauseous.Her echocardiogram today is normal. What is the most likely diagnosis?

107. James is an 8-year-old boy who recently attended accident and emergency with a swollen left ankle.He had an x-ray and was discharged home and told there was no fracture.He has now developed a dark purple rash on his legs, which does not disappear with a glass pressed on. He was brought back to the department today vomiting, with abdominal pain. His observations and urine dipstick are all within normal limits.What is the most likely diagnosis?

108. A 7-year-old boy presented to accident and emergency with diarrhoea and vomiting for the past week. He had no history of foreign travel and but had been to a zoo recently on a school trip.He was discharged home, after providing a stool sample, with rehydration advice as he was less than 5 per cent dehydrated and tolerating oral fluids. The stool had grown 'Escherichia coli 0157' which was phoned from the microbiology laboratory to the on-call doctor 48 hours later. What is the most serious complication?

109. A 5-year-old girl was brought to hospital at midnight by her mother with 5 per cent partial thickness burns to her chest and abdomen.Her mother states that she pulled on the kettle at 2 pm and the boiling water scalded her. On examination she is tachycardic, and drowsy with cool peripheries.Her initial blood tests: sodium 150 mmol/L, potassium 7.8 mmol/L, urea 10.2 mmol/L, creatinine 104 μmol/L, haemoglobin 14 g/dL.What is the most likely aetiological factor to account for these results?

110. An 11-year-old girl presents to the out of hours GP while on holiday in England with abdominal pain. She tells you she bas polycystic kidney disease which was diagnosed early in life.She has bilateral palpable kidneys and hepatosplenomegaly, with visible distended veins on the abdomen and ascites.Abdominal ultrasound shows liver fibrosis.What is the inheritance of this condition?

111. A 1-month-old baby attends accident and emergency with a 2-day history of fever to 38.8°C measured at the GP surgery. He has been vomiting, with no diarrhoea, rash, cough or coryza. A clean catch urine has leukocytes +++ and ketones, no nitrites, blood or protein.An urgent microscopy shows >200 cells/ μL white cells.What is the most appropriate course of action?

112. A 5-year-old boy presents to his GP with a 3-day history of puffy eyes.He has been unwell with a coryzal illness for the last week. His mother states he has had no new medications and no hayfever, allergies or asthma. On further examination he has generalized oedema and scrotal oedema.He is tachycardiac and has cool peripheries, no skin rashes or erythema.What is the most likely diagnosis?

113. A 12-year-old girl presents to her GP with a UTI. She has no past medical history of note and is not taking any medication. On testing her routine observations, her blood pressure was 140/90 mmHg with a manual sphygmomanometer.You are concerned this may be high for her age. She has no headaches, visual disturbance, vomiting, chest pain, dyspnoea or neurological signs. What is your next course of action?

114. A 6-year-old girl presents to hospital with a large right-sided abdominal mass.It does not cross the midline.On further questioning she has had macroscopic haematuria and weight loss of 4kg over the last 4 months. She has reduced appetite and lethargy. Her blood pressure is 125/73 mmHg, heart rate 120 bpm. Which of the following is not a complication of this malignancy?

115. A 20-year-old man presents to the infectious diseases department with a large 7 cmx 8 cm swollen painful lump in the left anterior triangle of his neck.He has night sweats, 10 kg weight loss and a dry cough for the last month.He was treated with surgery and radiotherapy for a high grade astrocytoma when he was 8 years old. Which of the following is not a recognized complication of his childhood condition and its treatment?

116. A 12-year-old girl has been seeing her GP for the last year with heavy periods and had suffered with bleeding gums when she was younger. She is otherwise well and lives with her adoptive parents who now have parental responsibility. Her coagulation tests reveal normal prothrombin time (PT) and activated partial thromboplastin time (APTT), low factor VIII, low von Willibrand factor (vWF), and abnormal platelet aggregation and increased bleeding time. What is the likely inheritance of her condition?

117. A 4-year-old girl has just returned from holiday in France where she visited a petting farm. She has had diarrhoea for 2 days, and her mother noticed fresh red blood mixed with the stools. She has also been vomiting.On admission to hospital her blood tests showed: Hb 5 g/dL, wee 15 x 109/L, platelets 55 xt09/L, urea 19 mmol/L, creatinine 110 μmol/L. Her stool culture is pending.What is the most likely diagnosis?

118. A 9-month-old boy presented to his GP with lethargy and a prominen t forehead. He is pale on examination and has yellow sclerae.He is the first child of his non-consanguineous parents. His haemoglobin is 6.5g/dL, wee 5.0 x109/L, platelets 300 x 109/L. His blood film shows evidence of haemolysis, no spherocytes, no sickle cells and a good reticulocyte count.Direct antiglobulin test (DAT) is negative.What is the most likely diagnosis?

119. A 4-year-old boy is brought to accident and emergency with a limp for 1day. He was unhappy to weight bear on his right leg.He had been with his grandparents all day and his mother brought him to hospital when she returned from work that evening.He was afebrile with a heart rate of llObpm but had had a cold last week.Mum reports no history of trauma. What is the most important diagnosis to exclude?

120. A 14-year-old girl went to her GP with a sore throat and cervical lymphadenopathy. She had a blood test done and you are called later that day with results.Haemoglobin 6.0 g/dL, wee 230 x109/L, neutrophils 0.9 x109/L, platelets 77 x109/L; blood film showed blasts and Auer rods. What is the most important management priority for this child in the first 24 hours from diagnosis?

121. A 4-year-old is brought into accident and emergency by very anxious parents.She has had a bad cough which makes her vomit and a fever for 2 days.She has now developed a rash on her face which does not pass the 'glass test', in that the spots are still visible when a glass is pressed against the skin.On examination she is alert and comfortable at rest, with fine petechiae on her cheeks and neck which are non-blanching.She has red, enlarged tonsils without pus and the chest is clear. What is the most likely cause of her rash?

122. A 2 year old was seen in accident and emergency by the senior house officer with a short history of fever, malaise and now vomiting. She had a blanching rash on her arms and abdomen. She looked unwell but had no clear focus for her fever.She was tachypnoeic but her chest was clear.A urine sample was requested which showed a trace of leukocytes and two plus of ketones. Forty-five minutes later the paediatric registrar came to review the child who appears lethargic with a capillary refill centrally of 6 seconds and the rash on her abdomen is now non-blanching. What is the most likely diagnosis?

123. A 2 year old is brought in by ambulance after pulling a pot of boiling water off the stove down on top of himself. He has significant burns to the whole of his face, torso and right arm. Estimate the percentage body surface area affected

124. A 3 year old is brought to see the GP with multiple pearly raised papules with central umbilications.They have been there for more than a month on his torso and upper legs.His mother is worried he has warts.What is the most likely diagnosis?

125. On a newborn baby check of an Asian, 36-hour-old baby you note a large bruise coloured area on the buttocks and lower back which seems non-tender .The mother does not know how it got there.He is handling well and the rest of the baby check is unremarkable.What is the most likely explanation?

126. A 5-day-old baby is brought to see the GP because she has had a rash for the past 3 days which started on her chest, is spreading to her face and getting worse. On examination she handles well and is alert.There is an erythematous rash on her face, torso and right arm with little pustules.What is the most likely diagnosis?

127. A 3-year-old is brought into accident and emergency on a Monday morning because she has developed several bruises on her buttocks, left leg and right arm.She is seen with her nanny who reports finding the bruises when she was getting her dressed this morning.Recently the girl has not been herself. She has had several colds over the past 2 months and has been more lethargic lately. The nanny is worried she is losing weight. On exami nation she appears withdrawn, pale and has a bruise on the left buttock which is 5 cm x 8 cm.She has three other bruises on her left leg and right arm which are of varying colours.She also has some fine petechiae on her neck and cheeks. She has a runny nose and a cough but the chest is clear.What is the most likely diagnosis?

128. A 3 year old is brought to accident and emergency by his parents because he has not been walking for the past day and refuses to stand.He is normally fit and healthy but he did have antibiotics for tonsillitis 2 weeks ago.They do not think he has had any injuries but he attends daycare and something could have happened there.He is up to date with his immunizations and his parents have no concerns with his development.On examination he looks well, is apyrexial, with a heart rate of 120 and respiratory rate of 26 with no bruising.His knees are normal on examination and the hips have a full range of movement except he cries on external rotation of the right hip.There are no deformities seen on x-ray of the hips and knees.After some paracetamol he manages to stand and take a few antalgic steps with encouragement, limping on the right leg.What is the most likely diagnosis?

129. A 6-year-old girl is taken to see her GP because she is complaining of knee and elbow pains frequently.Her mother thinks it is worst after her ballet classes and when she gets home from school.She denies stiffness or pain in the mornings.Her mother has been administrating paracetamol several times a week and is worried that this is too much to be giving a child. On examination, the child looks well and has full range of movement of her joints with evidence of hyperextension. There are no swollen joints or effusions present and she is non-tender on examination.What is the most likely diagnosis?

130. A 2-year-old boy is brought to accident and emergency for the sixth time and is found to have a right-sided non-displaced transverse fracture of his tibia. His parents state that he was running in the living room and tripped landing on a toy truck. He has broken his other leg twice, several fingers and his right arm previously. He appears healthy, is well dressed and his growth is normal.His mother is very upset, she is 5 months pregnant with their second child and her anomaly scan yesterday suggested the baby has a broken leg. What is the most likely explanation for these fractures?

131. A 4 year old is brought to accident and emergency acutely unwell and refusing to walk for the past 2 days.Her parents are not aware of any recent injuries. On examination, she is pyrexial (T = 39.2°C), capillary refill 3 seconds centrally, heart rate 150 beats per minute, respiratory rate 40 breaths per minute.Her right thigh is swollen and slightly erythematous but too tender to examine fully. An x-ray of the hip and femur shows soft tissue swelling surrounding the proximal femur but the bones look normal. An urgent MRI shows a periosteal reaction in the proximal femur with extensive inflammati on in the surrounding soft tissues. What is the most likely diagnosis?

132. A 5-year-old is referred to paediatrics due to concerns initially raised by his school teacher that he is weak and clumsy. On examination he has wasting of his quadriceps and walks in a waddling gait.His blood creatine kinase is 1600 mmoVL (normal is 24-190). What is the most likely diagnosis?

133. A 10-year-old girl was diagnosed with diabetes 1year ago.She has been compliant with her insulin regimen and her HBAlc is 6 per cent.She is attending her annual diabetic review and has been asking about why she has diabetes.What is the aetiology of type 1diabetes?

134. A 2-year-old girl was brought by her mother to accident and emergency after 4 days of vomiting and abdominal pain.She had brought her in 2 days ago after developing a cold and was discharged home and diagnosed with a 'tummy bug'. On examination, she was drowsy, had dry mucous membranes, deep heavy breathing, cool peripheries and tachycardia. Her mother reports a 1-month history of weight loss, excessive drinking and passing large volumes of urine prior to this episode.Her urine dipstick has ketones and glucose.Her blood gas shows the following:pH 7.10, PC02 kPa 2.1, P02 kPa 10.0, BE -12, HC0-3 mmoVL 18.What is the most likely diagnosis?

135. A 3-week-old baby is brought to the 'prolonged ja undice clinic'. His mother reports he has poor feeding, is not gaining weight appropriately and is more sleepy compared to her previous child. He opens his bowel once a day and is being mix breast and bottle fed. He is floppy, jaundic ed, has a large, protruding tongue and a hoarse cry. He had a newborn blood spot screening test done at birth which was normal and he has no dysmorphic features.What is the most likely diagnosis of this child?

136. A 13-year-old girl has presented to her GP with her mother with concerns that she is the shortest in her class at school.She has always been 'on the small side' according to her mother, despite eating well. When you examin e her you find she is hypertensive but has no cardiac murmur.Respiratory and abdominal systems are normal. She has no signs of pubertal development and you notice she has widely spaced nipples and a low hair line.You are considering the diagnosis of Turner's syndrome.What is the most appropriate diagnostic investigation?

137. You are asked to examine a tall 15-year-old boy.His height is above the 98th centile for his age and he has other concerns about the development of breast tissue.He was told this was normal as he develops through puberty but his father states he has no facial or underarm hair. Jake allows a brief examination of his genitalia and you note he has a small penis and testicular volume.He has no arachnodactyly or visual problems.What is the most likely diagnosis?

138. A 16-year-old boy attends your GP clinic for the first time with his father.He has recently moved to the area.His father is concerned that he is shorter than his peers at school and he frequently complains about being bullied. On further questioning there is no evidence of chronic illness or familial illness and he eats a balanced diet.His weight is on the 25th centile and his height is on the 10th centile.On examination he has no evidence of facial, axillary or pubic hair his testes are both descended and are <4ml, volume.What is the most likely cause of his delayed puberty?,

139. A 6-year-old girl has presented to her GP with a rapid increase in growth.Her mother is also concerned that she seems to have developed pubic and axillary hair and breast development prior to this but thought it would go away. She has no history of trauma and has reported problems with her vision.Her levels of gonadotrophin-releasing hormone (GnRH), folliclestimulating hormone (FSH), luteinizing hormone (LH) and oestrogen are high. You are concerned that she may have a pituitary tumour.What is the likely visual field defect?

140. A 7 year old is referred to neurology due to frequent episodes of day-dreaming at school where she is unresponsive.She is falling behind in her work because of this.An electroencephalograph (EEG) shows three spike waves per second activity in all leads.What is the most likely diagnosis?

141. A mother brings her 2-year-old daughter to the GP on a Monday morning.Over the weekend she became very upset on being told 'no'. She was screaming and then held her breath, went blue and fainted. She woke up quickly and seemed okay afterwards.However, it hasjust happened again this morning when she found some scissors and her mother took them away. On this occasion she had a brief generalized convulsion lasting about 10 seconds.What is the most likely explanation?

142. A mother with known placenta praevia with heavy vaginal bleeding was rushed into the labour ward and delivered by emergency caesarean section at 35 weeks' gestation. Pre-delivery the fetus was bradycardic and after birth APGARs were three at 1minute, five at 5 minutes and nine at 10 minutes.Thirty-six hours later on the special care baby unit the baby is irritable and requiring nasogastric tube feeds as he is not sucking well.The tone in his upper limbs is reduced and an EEG showed seizure activity which has been controlled by intravenous phenobarbitone. His cranial ultrasound is normal.His blood sugar monitoring is between 3.5 and 5 mmol/L, Creactive protein (CRP) was less than 5 mg/L and is 7 mg/L today.He is apyrexial. What is the most likely diagnosis?

143. A 15-year-old girl comes to accident and emergency complaining of sudden right arm weakness and double vision.Last week she was incontinent of urine twice.She is normally fit and well.On examination she has a left-sided 6th nerve palsy and four out of five power in her right arm.The examination is otherwise unremarkable.An MRI head shows multiple hyperintense, inflammatory, white matter lesions.What is the most likely diagnosis?

144. A 10-year-old girl with sickle cell disease presents to her GP on Monday morning complaining of weakness in her right leg. She says she collapsed on Saturday afternoon and has not felt right since.What is the most likely diagnosis?

145. A 6-year-old boy is taken to see the GP by his mother because he has been getting severe abdominal pains, sometimes with vomiting and yesterday with a headache as well. He has no diarrhoea or constipation. His growth and examination are normal.He has no significant past medical history.In his family history, his maternal grandfather recently died of gastric cancer and mum's migraines have been worse since his death. She is worried her son is getting gastric cancer too.What is the most likely diagnosis

146. A 13-year-old Somali girl presents to accident and emergency with a 1-month history of headaches, weight loss and night sweats.Her father is concerned that she seems confused and is more unwell with her headache despite paracetamol. She was born in the UK and has had all her immunizations.She travelled to Somalia 6 months ago.The rest of the family is well although dad has a cough. On examination she is thin and looks unwell but is neurologically intact with no abnormal findings on clinical examination. Which diagnosis needs to be ruled out first?

147. A 4-month-old baby being investigated for infantile spasms is noted to have an ash leaf macule on his back u nder Wood 's light. His EEG shows hypsarrythmia. The report of his MRI brain states there are subependymal nodules.What is the diagnosis?

148. A 3 month old is brought into accident and emergency with a generalized tonic clonic seizure.She is apyrexial and the seizure stopped after 15 mi nutes with rectal diazepam given by the ambulance crew. Her heart rate is 130, respiratory rate of 36 and capillary refill is less than 2 seconds. On examination she is drowsy, has a port wine stain on her forehead but is otherwise normal on examination. What is the most likely cause of her seizure?