An 8-year-old boy presents to the emergency department with a 6-hour history of central abdominal pain that has now localised to the right iliac fossa. He has vomited twice and has no appetite. Temperature is 38.1°C, heart rate 110 bpm. Abdominal examination reveals guarding and rebound tenderness in the right iliac fossa. Rovsing's sign is positive. Urine dipstick is normal. Blood tests show WCC 15.2 × 10⁹/L (neutrophils 12.4), CRP 45 mg/L. The surgical team is reviewing him. What is the most appropriate initial imaging investigation if clinical assessment remains equivocal?
Q102
A 3-year-old girl is brought to the GP with a 24-hour history of fever to 38.9°C and pulling at her right ear. She has had coryzal symptoms for 3 days. On examination, she is alert and playful. Temperature is 38.7°C, heart rate 120 bpm. The right tympanic membrane is bulging and erythematous with loss of light reflex. The left ear is normal. There is no discharge, mastoid tenderness, or cervical lymphadenopathy. She has no drug allergies. What is the most appropriate initial management according to current guidance?
Q103
A 2-year-old child presents with a 12-hour history of fever (39.6°C), refusing to walk, and holding the right leg flexed. The parents report she was well until yesterday. On examination, she is febrile and appears uncomfortable. She cries when the right hip is moved. Range of motion is limited in all directions, particularly internal rotation and extension. Left hip examination is normal. There is no overlying erythema or swelling. She is fully immunised. Blood tests show WCC 16.8 × 10⁹/L, CRP 78 mg/L. What is the most important differential diagnosis that must be excluded?
Q104
A 10-month-old infant with bronchiolitis has been admitted for 36 hours. Initial oxygen requirement was 35% via head box to maintain saturations >92%. The infant is now on 28% oxygen with saturations of 93-95%. Respiratory rate has decreased from 68 to 52 breaths/minute. The infant is taking 60% of normal milk feeds orally. Parents are keen to go home. What is the most appropriate management plan?
Q105
A 4-year-old boy with recurrent wheeze is being reviewed in clinic. His mother reports he has had four episodes of wheeze in the past year, each triggered by viral upper respiratory tract infections. Between episodes, he is completely well with no symptoms. He has no history of atopy, no night-time cough, and no exercise-induced symptoms. Examination during the clinic visit is entirely normal. Which management strategy is most appropriate for this child?
Q106
A 14-month-old child is brought to the emergency department with a 3-day history of fever up to 39.8°C, cough, and rapid breathing. The child appears lethargic. On examination, temperature is 39.2°C, respiratory rate 52 breaths/minute, heart rate 165 bpm, oxygen saturation 94% on air, capillary refill time 3 seconds. Chest examination reveals bronchial breathing and crackles in the right lower zone. Chest X-ray shows right lower lobe consolidation. Blood tests show WCC 18.2 × 10⁹/L (neutrophils 14.1), CRP 142 mg/L. What is the most appropriate antibiotic choice?
Q107
A 6-year-old girl with asthma on regular beclometasone 200 micrograms twice daily presents with acute wheeze. She has been given 10 puffs of salbutamol via spacer but remains breathless. On examination, she can speak 3-4 words per breath, respiratory rate 38 breaths/minute, heart rate 128 bpm, oxygen saturation 92% on air. She has bilateral wheeze with reduced air entry in both lung bases. What defines this exacerbation as severe rather than life-threatening?
Q108
A 19-month-old child presents to the emergency department with a 5-day history of fever ranging from 38.5-40.2°C. The parents report the child has been irritable with decreased appetite but no specific symptoms. Examination reveals bilateral non-purulent conjunctivitis, cracked red lips, cervical lymphadenopathy with one node measuring 2.5cm, and a polymorphous rash on the trunk. Hands and feet appear slightly oedematous. Heart sounds are normal with no murmur. What is the most important immediate investigation?
Q109
What is the recommended first-line maintenance inhaled corticosteroid dose adjustment for a child with asthma who continues to have symptoms despite adherence to low-dose inhaled corticosteroid therapy?
Q110
An 11-month-old infant presents with a 2-day history of coryzal symptoms followed by increased work of breathing. The infant was born at term with no significant medical history. On examination, temperature is 37.8°C, respiratory rate 65 breaths/minute, heart rate 155 bpm, oxygen saturation 91% on air. There is subcostal recession, nasal flaring, and fine bilateral inspiratory crackles with scattered wheeze. The infant is taking approximately 50% of normal feeds. What is the most likely diagnosis?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 101: An 8-year-old boy presents to the emergency department with a 6-hour history of central abdominal pain that has now localised to the right iliac fossa. He has vomited twice and has no appetite. Temperature is 38.1°C, heart rate 110 bpm. Abdominal examination reveals guarding and rebound tenderness in the right iliac fossa. Rovsing's sign is positive. Urine dipstick is normal. Blood tests show WCC 15.2 × 10⁹/L (neutrophils 12.4), CRP 45 mg/L. The surgical team is reviewing him. What is the most appropriate initial imaging investigation if clinical assessment remains equivocal?
A. Ultrasound scan of abdomen and pelvis (Correct Answer)
B. CT scan of abdomen and pelvis with intravenous contrast
C. Abdominal X-ray to exclude intestinal obstruction
D. MRI scan of abdomen and pelvis
E. No imaging required - proceed to diagnostic laparoscopy
Explanation: ***Ultrasound scan of abdomen and pelvis***- **Ultrasound (US)** is the initial imaging modality of choice for suspected **acute appendicitis** in children due to its **non-invasive nature** and the absence of **ionizing radiation**.- It is effective in identifying an **inflamed appendix** (e.g., non-compressible, >6mm diameter) and can help rule out other pediatric causes of right iliac fossa pain like **mesenteric adenitis**.*CT scan of abdomen and pelvis with intravenous contrast*- While **CT scans** offer high sensitivity and specificity, they involve significant **radiation exposure**, which is a concern in pediatric patients due to increased lifetime cancer risk.- CT is typically reserved for cases where the **ultrasound is equivocal**, negative despite strong clinical suspicion, or when complications like **perforation** or **abscess** are suspected.*Abdominal X-ray to exclude intestinal obstruction*- **Plain abdominal X-rays** have very limited utility in diagnosing acute appendicitis, as specific findings are often absent or non-specific.- This investigation is more appropriate for suspicion of **bowel obstruction** (e.g., dilated bowel loops, air-fluid levels) or **pneumoperitoneum** (free air indicating perforation).*MRI scan of abdomen and pelvis*- **MRI** is a highly accurate, radiation-free imaging modality but is often limited by its **availability** in emergency settings and longer scan times.- It is generally considered a strong alternative when ultrasound is inconclusive and **CT is contraindicated** (e.g., in pregnant patients or very young children where radiation is a major concern).*No imaging required - proceed to diagnostic laparoscopy*- While appendicitis can be a clinical diagnosis, proceeding directly to surgery in **equivocal cases** significantly increases the **negative appendectomy rate**.- Initial imaging, particularly with ultrasound, is recommended when clinical certainty is not high to avoid unnecessary **surgical risks** and the complications of **general anesthesia**.
Question 102: A 3-year-old girl is brought to the GP with a 24-hour history of fever to 38.9°C and pulling at her right ear. She has had coryzal symptoms for 3 days. On examination, she is alert and playful. Temperature is 38.7°C, heart rate 120 bpm. The right tympanic membrane is bulging and erythematous with loss of light reflex. The left ear is normal. There is no discharge, mastoid tenderness, or cervical lymphadenopathy. She has no drug allergies. What is the most appropriate initial management according to current guidance?
A. Prescribe immediate oral amoxicillin for 5 days
B. Provide safety-netting advice and analgesia, with delayed antibiotic prescription (Correct Answer)
C. Prescribe oral co-amoxiclav due to severity of bulging tympanic membrane
D. Refer urgently to ENT for consideration of myringotomy
E. Prescribe topical antibiotic ear drops and oral analgesia
Explanation: ***Provide safety-netting advice and analgesia, with delayed antibiotic prescription*** - For children older than **2 years** with **unilateral acute otitis media (AOM)** and no otorrhoea, a **no antibiotic** or **delayed antibiotic** strategy is recommended by **NICE guidelines**. - Most cases of AOM are self-limiting and resolve spontaneously within 3 days; management focuses on **symptom control** with paracetamol or ibuprofen.*Prescribe immediate oral amoxicillin for 5 days* - Immediate antibiotics are reserved for children who are **systemically very unwell**, have **otorrhoea**, or are under 2 years old with **bilateral infection**. - Using immediate antibiotics in simple cases does not significantly reduce pain or prevent complications like **mastoiditis**.*Prescribe oral co-amoxiclav due to severity of bulging tympanic membrane* - **Amoxicillin** is the first-line antibiotic for AOM if required; **co-amoxiclav** is only indicated if there is no response to first-line agents or for complications. - **Bulging of the tympanic membrane** is an expected finding in AOM and doesn't automatically necessitate broad-spectrum antibiotic therapy.*Refer urgently to ENT for consideration of myringotomy* - Urgent referral is only indicated for patients with **intra-cranial complications**, facial nerve palsy, or clinical evidence of **acute mastoiditis**. - **Myringotomy** is a surgical intervention not used for initial management of uncomplicated simple AOM in a primary care setting.*Prescribe topical antibiotic ear drops and oral analgesia* - Topical antibiotics are used for **otitis externa** or occasionally for chronic suppurative otitis media with a **perforated eardrum**, but not for intact AOM. - In AOM with an **intact tympanic membrane**, topical medications cannot reach the site of infection in the middle ear.
Question 103: A 2-year-old child presents with a 12-hour history of fever (39.6°C), refusing to walk, and holding the right leg flexed. The parents report she was well until yesterday. On examination, she is febrile and appears uncomfortable. She cries when the right hip is moved. Range of motion is limited in all directions, particularly internal rotation and extension. Left hip examination is normal. There is no overlying erythema or swelling. She is fully immunised. Blood tests show WCC 16.8 × 10⁹/L, CRP 78 mg/L. What is the most important differential diagnosis that must be excluded?
A. Transient synovitis of the hip
B. Septic arthritis of the hip (Correct Answer)
C. Perthes disease
D. Developmental dysplasia of the hip
E. Juvenile idiopathic arthritis
Explanation: ***Septic arthritis of the hip*** - This is a **pediatric emergency** presenting with acute onset of **fever**, **refusal to weight-bear**, and severe pain with **limited range of hip motion**, especially internal rotation and extension. - The child meets several **Kocher criteria** (fever >38.5°C, non-weight bearing, and elevated **WCC/CRP**), which strongly indicates septic arthritis requiring urgent **joint aspiration** to prevent permanent joint damage. *Transient synovitis of the hip* - This is a common, self-limiting condition often following a **viral upper respiratory tract infection**, usually presenting with milder symptoms and less significant systemic inflammation. - While it causes hip pain and limp, the high fever (39.6°C), elevated WCC (16.8), and markedly raised CRP (78 mg/L) in this case are much more suggestive of **septic arthritis**, making transient synovitis a less likely primary diagnosis to be assumed without exclusion of infection. *Perthes disease* - This condition involves **avascular necrosis** of the femoral head and typically presents with a **chronic, insidious limp** and hip pain, rather than an acute febrile illness. - It usually affects children between **4 and 8 years** of age, and would not cause the acute high fever and significantly elevated **WCC and CRP** seen in this 2-year-old. *Developmental dysplasia of the hip* - This is a **congenital condition** that is typically screened for at birth or in infancy via physical examination (**Barlow and Ortolani maneuvers**) or ultrasound. - It presents with features like **leg length discrepancy** or limited abduction, not an acute febrile illness with severe pain and high inflammatory markers in a 2-year-old. *Juvenile idiopathic arthritis* - This is a **chronic autoimmune condition** characterized by joint inflammation lasting for at least **6 weeks**. - The **hyperacute presentation** (12-hour history) with high fever and marked elevation of inflammatory markers is not typical for the initial presentation of JIA, which usually has a more insidious onset.
Question 104: A 10-month-old infant with bronchiolitis has been admitted for 36 hours. Initial oxygen requirement was 35% via head box to maintain saturations >92%. The infant is now on 28% oxygen with saturations of 93-95%. Respiratory rate has decreased from 68 to 52 breaths/minute. The infant is taking 60% of normal milk feeds orally. Parents are keen to go home. What is the most appropriate management plan?
A. Discharge home with safety-netting advice as oxygen requirement is decreasing
B. Continue admission until oxygen saturations are consistently >92% in air for 4 hours (Correct Answer)
C. Discharge home with home oxygen therapy and community respiratory nurse follow-up
D. Continue admission for at least another 24 hours regardless of clinical progress
E. Discharge home once oral intake reaches 75% of normal feeds
Explanation: ***Continue admission until oxygen saturations are consistently >92% in air for 4 hours***
- According to **NICE guidelines**, infants with **bronchiolitis** should only be discharged once they maintain stable oxygen saturations **>92% in room air** for a consistent period, typically 4 hours.
- Although the infant is improving, they still require **28% supplemental oxygen**, making them medically unfit for discharge until they can maintain saturations without support.
*Discharge home with safety-netting advice as oxygen requirement is decreasing*
- While the downward trend in oxygen needs is positive, the infant remains **oxygen-dependent**, which is a primary contraindication for discharge in acute bronchiolitis.
- Discharging a patient who still requires **oxygen therapy** increases the risk of rapid respiratory decompensation at home and subsequent **re-admission**.
*Discharge home with home oxygen therapy and community respiratory nurse follow-up*
- **Home oxygen therapy** is not standard practice for acute bronchiolitis and is generally reserved for children with **chronic lung disease** or extreme prematurity.
- Routine management requires ensuring the infant has reached the **clinical plateau** and can maintain their own oxygenation safely before leaving the hospital.
*Continue admission for at least another 24 hours regardless of clinical progress*
- Discharge decisions should be governed by **physiological stability** and meeting specific safety milestones rather than an arbitrary **time-based threshold**.
- If the infant meets all **discharge criteria** (oxygenation in air and adequate feeding) sooner than 24 hours, keeping them hospitalized unnecessarily increases the risk of **nosocomial infection**.
*Discharge home once oral intake reaches 75% of normal feeds*
- While maintaining **adequate hydration** (usually >50-75% of normal feeds) is a mandatory discharge criterion, it is not the only one.
- In this case, the **respiratory requirement** is the limiting factor; both nutritional stability and **room-air oxygenation** must be achieved simultaneously for a safe discharge.
Question 105: A 4-year-old boy with recurrent wheeze is being reviewed in clinic. His mother reports he has had four episodes of wheeze in the past year, each triggered by viral upper respiratory tract infections. Between episodes, he is completely well with no symptoms. He has no history of atopy, no night-time cough, and no exercise-induced symptoms. Examination during the clinic visit is entirely normal. Which management strategy is most appropriate for this child?
A. Commence regular low-dose inhaled corticosteroid therapy
B. Prescribe salbutamol inhaler with spacer to use as required during viral illnesses (Correct Answer)
C. Prescribe a combined inhaled corticosteroid and long-acting beta-agonist inhaler
D. Commence oral montelukast as regular daily preventive therapy
E. Arrange for allergy testing before deciding on treatment
Explanation: ***Prescribe salbutamol inhaler with spacer to use as required during viral illnesses***- The child's presentation of **recurrent wheeze** strictly associated with **viral upper respiratory tract infections**, with complete wellness between episodes and no signs of atopy or chronic symptoms, defines **episodic viral-induced wheeze**.- For this condition, **short-acting beta-agonists (SABA) like salbutamol** used **as required** during viral illnesses, delivered with a **spacer**, are the recommended first-line management for symptom relief.*Commence regular low-dose inhaled corticosteroid therapy*- **Regular low-dose inhaled corticosteroids (ICS)** are indicated for **multi-trigger wheeze** or persistent asthma, where symptoms occur frequently, at night, or with activity, even without viral triggers.- This child's clear **symptom-free intervals** and lack of atopy or nocturnal/exercise-induced symptoms suggest that daily preventive ICS therapy is not necessary or most appropriate at this stage.*Prescribe a combined inhaled corticosteroid and long-acting beta-agonist inhaler*- **Combined inhaled corticosteroid and long-acting beta-agonist (ICS/LABA) inhalers** are reserved for children with **moderate to severe persistent asthma** that is not adequately controlled with ICS alone.- This child's presentation of **intermittent, viral-triggered wheeze** does not warrant such aggressive or maintenance therapy.*Commence oral montelukast as regular daily preventive therapy*- While **oral montelukast** can be considered for **viral-induced wheeze**, it is generally a second-line option for children with more frequent or severe episodes, or as an alternative if bronchodilators are insufficient.- For a child who is **completely well between episodes** and responds to bronchodilators, regular daily preventive therapy may be an overtreatment as a primary strategy.*Arrange for allergy testing before deciding on treatment*- The clinical history explicitly states **no history of atopy** and that episodes are **triggered by viral infections**, not environmental allergens.- **Allergy testing** is less relevant when the trigger is clearly identified as viral, and it would not change the initial symptomatic management for episodic viral-induced wheeze.
Question 106: A 14-month-old child is brought to the emergency department with a 3-day history of fever up to 39.8°C, cough, and rapid breathing. The child appears lethargic. On examination, temperature is 39.2°C, respiratory rate 52 breaths/minute, heart rate 165 bpm, oxygen saturation 94% on air, capillary refill time 3 seconds. Chest examination reveals bronchial breathing and crackles in the right lower zone. Chest X-ray shows right lower lobe consolidation. Blood tests show WCC 18.2 × 10⁹/L (neutrophils 14.1), CRP 142 mg/L. What is the most appropriate antibiotic choice?
A. Oral amoxicillin 40mg/kg/day divided three times daily (Correct Answer)
B. Intravenous benzylpenicillin and oral clarithromycin
C. Intravenous co-amoxiclav alone
D. Oral co-amoxiclav 40mg/kg/day divided three times daily
E. Intravenous cefotaxime and clarithromycin
Explanation: ***Oral amoxicillin 40mg/kg/day divided three times daily***- **Amoxicillin** is the first-line antibiotic for pediatric **community-acquired pneumonia (CAP)** because it provides excellent coverage against **Streptococcus pneumoniae**, the most common bacterial cause in this age group.- Despite the fever, lethargy, and elevated CRP, the child's oxygen saturation (94% on air) indicates that **oral therapy** is appropriate for this severity, as per **NICE guidelines** for non-severe CAP if the child can tolerate oral intake.*Intravenous benzylpenicillin and oral clarithromycin*- **Intravenous antibiotics** are generally reserved for children with signs of **severe sepsis**, inability to tolerate oral intake, or complicated pneumonia, which is not clearly indicated here.- **Clarithromycin** (a macrolide) is typically added for suspected **atypical pneumonia** (e.g., Mycoplasma), which is less common in toddlers compared to school-aged children, making initial empiric coverage less critical.*Intravenous co-amoxiclav alone*- **Co-amoxiclav** is a broad-spectrum antibiotic and is not recommended as a first-line agent for uncomplicated CAP because the clavulanic acid component does not add benefit against **Streptococcus pneumoniae**.- Using **broad-spectrum intravenous** agents unnecessarily increases the risk of antibiotic resistance, *Clostridioides difficile* infection, and complications associated with IV access.*Oral co-amoxiclav 40mg/kg/day divided three times daily*- Similar to the IV version, **oral co-amoxiclav** is unnecessary for standard pneumonia because **amoxicillin** effectively covers the primary pathogen, **Streptococcus pneumoniae**.- It is typically reserved for second-line treatment, specific cases where **Staphylococcus aureus** or beta-lactamase producing *H. influenzae* is suspected, or in cases of treatment failure.*Intravenous cefotaxime and clarithromycin*- **Cefotaxime** is a third-generation cephalosporin and is reserved for very severe cases of pneumonia, suspected **meningitis**, or when there is concern for highly resistant organisms, none of which are evident.- This combination represents a **broad-spectrum intravenous** approach that is overly aggressive for an initial presentation of localized **lobar consolidation** in a child not requiring intensive care.
Question 107: A 6-year-old girl with asthma on regular beclometasone 200 micrograms twice daily presents with acute wheeze. She has been given 10 puffs of salbutamol via spacer but remains breathless. On examination, she can speak 3-4 words per breath, respiratory rate 38 breaths/minute, heart rate 128 bpm, oxygen saturation 92% on air. She has bilateral wheeze with reduced air entry in both lung bases. What defines this exacerbation as severe rather than life-threatening?
A. Oxygen saturation is ≥92% and she can speak in short phrases (Correct Answer)
B. She has no silent chest and maintains consciousness
C. Her heart rate is <130 bpm and blood pressure is normal
D. Peak flow is likely >33% predicted and pCO2 would be normal
E. She is responding partially to initial bronchodilator therapy
Explanation: ***Oxygen saturation is ≥92% and she can speak in short phrases***
- In children over 5, **severe asthma** is characterized by an oxygen saturation of **92-94%** and the ability to speak in **short phrases/words**, consistent with the patient's 92% SpO2 and speaking 3-4 words per breath.
- Conversely, **life-threatening asthma** typically presents with an SpO2 **<92%** or being too breathless to talk (speaking only single words or unable to speak at all).
*She has no silent chest and maintains consciousness*
- While the absence of a **silent chest**, cyanosis, or **impaired consciousness** indicates the attack is not yet life-threatening, these are signs *not present* rather than the primary positive criteria for classifying an exacerbation as severe.
- These features are ominous signs of **impending respiratory failure**, whose absence is reassuring but does not primarily define the 'severe' category over 'life-threatening' based on quantitative measures.
*Her heart rate is <130 bpm and blood pressure is normal*
- For a 6-year-old, a **heart rate >125 bpm** is a criterion for **severe asthma**. The patient's heart rate of 128 bpm falls into the severe category, meaning the statement "<130 bpm" doesn't adequately differentiate from life-threatening where tachycardia is also common.
- **Normal blood pressure** is an expected finding in severe asthma, as **hypotension** is a late and critical sign of a life-threatening or near-fatal attack.
*Peak flow is likely >33% predicted and pCO2 would be normal*
- A **Peak Expiratory Flow (PEF)** between **33-50%** of best/predicted is consistent with **severe asthma**, though PEF was not measured in this scenario.
- A **normal pCO2** (4.6–6.0 kPa) is often found in severe asthma, but a **rising or elevated pCO2** is a critical indicator of **life-threatening asthma** due to respiratory muscle fatigue and impending respiratory failure.
*She is responding partially to initial bronchodilator therapy*
- The patient
Question 108: A 19-month-old child presents to the emergency department with a 5-day history of fever ranging from 38.5-40.2°C. The parents report the child has been irritable with decreased appetite but no specific symptoms. Examination reveals bilateral non-purulent conjunctivitis, cracked red lips, cervical lymphadenopathy with one node measuring 2.5cm, and a polymorphous rash on the trunk. Hands and feet appear slightly oedematous. Heart sounds are normal with no murmur. What is the most important immediate investigation?
A. Echocardiography to assess for coronary artery abnormalities
B. Blood culture, full blood count, and inflammatory markers (Correct Answer)
C. Throat swab for bacterial culture and rapid antigen test
D. Chest X-ray to exclude pneumonia
E. Lumbar puncture to exclude meningitis
Explanation: ***Blood culture, full blood count, and inflammatory markers***
- Prior to diagnosing **Kawasaki disease**, it is critical to exclude **sepsis** and other bacterial infections, for which **blood cultures** and a **full blood count** are essential.
- Elevated **inflammatory markers** (CRP and ESR) are part of the supporting diagnostic criteria for Kawasaki disease and help establish a baseline for monitoring treatment response with IVIG.
*Echocardiography to assess for coronary artery abnormalities*
- While **echocardiography** is vital for monitoring **coronary artery aneurysms** in Kawasaki disease, it is secondary to stabilizing the patient and excluding immediate life-threatening infections like sepsis.
- A baseline echocardiogram is standard practice once the clinical diagnosis is suspected, but it does not take precedence over **emergency sepsis screening** in a febrile child.
*Throat swab for bacterial culture and rapid antigen test*
- A throat swab is primarily used to identify **Group A Streptococcus** (e.g., in Scarlet fever), which can mimic some Kawasaki symptoms but does not explain the full systemic picture presented.
- This investigation is too narrow and does not address the urgent need to assess for broader **systemic inflammatory** or infectious processes.
*Chest X-ray to exclude pneumonia*
- A **chest X-ray** is not indicated as the most immediate investigation, as there are no specific respiratory signs such as tachypnoea, cough, or focal crackles.
- The child's symptoms of **cervical lymphadenopathy** and **conjunctivitis** point more towards a systemic inflammatory syndrome rather than a primary pulmonary infection.
*Lumbar puncture to exclude meningitis*
- **Lumbar puncture** is unnecessary in this case as the child lacks specific clinical signs of **meningism**, such as neck stiffness, photophobia, or altered level of consciousness.
- Although Kawasaki disease can cause **aseptic meningitis**, it is a diagnosis of exclusion and not the most immediate priority compared to excluding other more common and severe infections.
Question 109: What is the recommended first-line maintenance inhaled corticosteroid dose adjustment for a child with asthma who continues to have symptoms despite adherence to low-dose inhaled corticosteroid therapy?
A. Double the inhaled corticosteroid dose to moderate dose
B. Add a long-acting beta-agonist while maintaining low-dose inhaled corticosteroid (Correct Answer)
C. Switch to a combination inhaler containing formoterol and budesonide
D. Add oral montelukast while maintaining current inhaled corticosteroid dose
E. Increase to high-dose inhaled corticosteroid therapy
Explanation: ***Add a long-acting beta-agonist while maintaining low-dose inhaled corticosteroid***
- For children whose asthma is not controlled on low-dose **inhaled corticosteroids (ICS)**, the recommended first-line step-up in therapy is to add a **long-acting beta-agonist (LABA)**.
- This combination of low-dose ICS and LABA is more effective in improving **lung function** and reducing symptoms than simply increasing the ICS dose, while minimizing steroid exposure.
*Double the inhaled corticosteroid dose to moderate dose*
- While increasing ICS dose is an option, adding a **LABA** to low-dose ICS is generally considered more effective for achieving better asthma control in children.
- Higher doses of ICS, even moderate, carry an increased risk of **systemic side effects**, such as potential impact on **growth velocity** in children.
*Switch to a combination inhaler containing formoterol and budesonide*
- This option introduces a **LABA**, which is correct, but switching directly to a specific **combination inhaler** might imply a specific regimen like **MART (Maintenance and Reliever Therapy)**, which is not universally the first-line *adjustment* over simply adding a LABA to existing ICS.
- The general principle is to add the **LABA component** to the existing low-dose ICS, which can be done with separate inhalers if a suitable combination is not readily available or preferred.
*Add oral montelukast while maintaining current inhaled corticosteroid dose*
- **Oral montelukast (a leukotriene receptor antagonist)** is an alternative add-on therapy but is generally considered **second-line** to a **LABA** in terms of effectiveness for persistent asthma symptoms.
- **LABAs** have demonstrated superior efficacy in improving **forced expiratory volume (FEV1)** and reducing exacerbations compared to **leukotriene modifiers**.
*Increase to high-dose inhaled corticosteroid therapy*
- **High-dose inhaled corticosteroids** are reserved for children with more severe asthma that remains uncontrolled despite **low-dose ICS/LABA combination therapy**.
- Initiating high-dose ICS prematurely increases the risk of significant **systemic side effects**, including **adrenal suppression**, and deviates from the stepwise management approach.
Question 110: An 11-month-old infant presents with a 2-day history of coryzal symptoms followed by increased work of breathing. The infant was born at term with no significant medical history. On examination, temperature is 37.8°C, respiratory rate 65 breaths/minute, heart rate 155 bpm, oxygen saturation 91% on air. There is subcostal recession, nasal flaring, and fine bilateral inspiratory crackles with scattered wheeze. The infant is taking approximately 50% of normal feeds. What is the most likely diagnosis?
A. First episode of viral-induced wheeze
B. Acute bronchiolitis (Correct Answer)
C. Bacterial pneumonia
D. Aspiration pneumonitis
E. Cardiac failure secondary to congenital heart disease
Explanation: ***Acute bronchiolitis***
- This infant presents with a classic clinical triad for bronchiolitis: **age <2 years**, a **coryzal prodrome**, and respiratory distress characterized by **fine crackles** and **wheeze**.
- The moderate severity is indicated by **reduced oral intake (50%)** and oxygen saturations of **91%**, which often require supportive management like fluids and oxygen.
*First episode of viral-induced wheeze*
- Viral-induced wheeze is clinically distinguished by the absence of **fine inspiratory crackles**, which are a hallmark of bronchiolitis.
- This diagnosis is rarely made in infants under **12 months** of age, as the pathophysiology involves airway hyper-responsiveness rather than bronchiolar inflammation.
*Bacterial pneumonia*
- Pneumonia typically presents with a **high-grade fever** (>39°C) and **focal chest signs** (localized crackles or dullness) rather than generalized bilateral crackles and wheeze.
- The preceding 2-day coryzal prodrome and the combination of wheeze and crackles fits the viral etiology of **RSV** over a bacterial cause.
*Aspiration pneumonitis*
- This condition requires a high clinical suspicion based on a history of **choking episodes**, swallowing dysfunction, or **neuromuscular disorders**, none of which are present here.
- Aspiration typically results in localized lung changes, whereas this infant has **bilateral, diffuse** clinical findings.
*Cardiac failure secondary to congenital heart disease*
- While it can cause tachypnea and poor feeding, it is usually associated with **hepatomegaly**, **heart murmurs**, or a history of poor weight gain from birth.
- The acute onset following **coryzal symptoms** strongly points toward an infectious respiratory process rather than a primary cardiac decompensation.
