Acute Paediatrics — MCQs
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A 4-year-old girl presents with acute wheeze and breathlessness. She has had two previous similar episodes, both triggered by viral illnesses. Between episodes, she is completely well with no symptoms. Her mother has eczema and her father has hay fever. Examination shows widespread polyphonic wheeze. Which factor would most strongly support a diagnosis of asthma rather than viral-induced wheeze?
A 3-year-old boy presents with a 36-hour history of fever (39.1°C) and reduced activity. His parents report he has not urinated for 8 hours. On examination, he has a capillary refill time of 3 seconds centrally, heart rate 155/min, respiratory rate 35/min, and blood pressure 85/50 mmHg. He has cool peripheries and decreased skin turgor. What degree of dehydration does this clinical picture most likely represent?
What is the mechanism of action of ipratropium bromide when used in acute asthma exacerbations in children?
A 6-year-old girl with asthma presents with an acute exacerbation. She has received three doses of nebulised salbutamol and ipratropium bromide, oral prednisolone, and oxygen. Her respiratory rate remains 40/min, oxygen saturations 93% on 15L oxygen, and she has a silent chest with minimal wheeze. What is the most appropriate next step in management?
A 14-month-old boy presents with a 5-day history of persistent fever (maximum 39.5°C daily). He has bilateral non-purulent conjunctivitis, cracked lips, a polymorphous rash on his trunk, and cervical lymphadenopathy with one node measuring 2cm. His hands and feet appear erythematous and slightly swollen. Blood tests show: WCC 18 × 10⁹/L, CRP 145 mg/L, platelets 520 × 10⁹/L, albumin 28 g/L. What is the most likely diagnosis?
A 2-year-old girl presents with a 2-day history of coryzal symptoms and barking cough, worse at night. She has mild chest recession and occasional stridor at rest. Her respiratory rate is 35/min, heart rate 110/min, temperature 37.8°C, and oxygen saturations 98% on air. She is taking fluids normally. What is the most appropriate treatment?
A 5-year-old boy with asthma presents to the emergency department with an acute exacerbation. He has received 10 puffs of salbutamol via spacer and oral prednisolone 20mg. His respiratory rate is 45/min, heart rate 130/min, oxygen saturations 92% on air. He can speak in short phrases and has widespread wheeze with good air entry bilaterally. What severity classification best describes this presentation?
A 7-month-old infant presents with a 12-hour history of fever (38.5°C) and irritability. On examination, she cries when handled but stops when left alone. There is no rash, and respiratory and abdominal examinations are normal. Urine dipstick shows leucocytes 2+ and nitrites negative. What is the most appropriate next step in management?
What is the correct definition of a complex febrile seizure?
Which of the following features is consistent with a diagnosis of viral-induced wheeze rather than asthma in a preschool child?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 131: A 4-year-old girl presents with acute wheeze and breathlessness. She has had two previous similar episodes, both triggered by viral illnesses. Between episodes, she is completely well with no symptoms. Her mother has eczema and her father has hay fever. Examination shows widespread polyphonic wheeze. Which factor would most strongly support a diagnosis of asthma rather than viral-induced wheeze?
- A. Age of 4 years at presentation
- B. Personal history of eczema
- C. Episodes triggered by viral infections
- D. Interval symptoms between viral infections with exercise or night-time cough (Correct Answer)
- E. Family history of atopy
Explanation: ***Interval symptoms between viral infections with exercise or night-time cough*** - The presence of **symptoms between viral episodes**, such as wheeze, cough, or breathlessness triggered by non-viral factors like **exercise**, **cold air**, or occurring at **night**, is a key distinguishing feature of **asthma**. - **Viral-induced wheeze** typically presents with symptoms *only* during acute viral respiratory infections, with complete asymptomatic periods in between episodes. *Age of 4 years at presentation* - Preschool wheeze is a broad term encompassing both **viral-induced wheeze** and early-onset **asthma**, making age alone an unreliable differentiator. - While a proportion of children with **viral-induced wheeze** outgrow their symptoms, a significant number of children diagnosed with asthma also present at this age, often with viral triggers initially. *Personal history of eczema* - A personal history of **eczema** is a strong indicator of **atopy**, which is a significant risk factor for developing asthma. - However, many children who experience **viral-induced wheeze** also have atopic tendencies or a family history of atopy, meaning this factor does not definitively rule out viral-induced wheeze. *Episodes triggered by viral infections* - Both **asthma exacerbations** and **viral-induced wheeze** in young children are very commonly triggered by **viral respiratory infections**. - Therefore, the mere fact that episodes are triggered by viral infections does not help differentiate between the two conditions; the pattern of symptoms *outside* of these infections is more critical. *Family history of atopy* - A **family history of atopy** (e.g., mother has eczema, father has hay fever) is a known risk factor for asthma. - However, like personal atopy, it indicates a predisposition but does not provide the specific symptom pattern needed to distinguish asthma from **viral-induced wheeze** where viral triggers are predominant and symptoms are absent between episodes.
Question 132: A 3-year-old boy presents with a 36-hour history of fever (39.1°C) and reduced activity. His parents report he has not urinated for 8 hours. On examination, he has a capillary refill time of 3 seconds centrally, heart rate 155/min, respiratory rate 35/min, and blood pressure 85/50 mmHg. He has cool peripheries and decreased skin turgor. What degree of dehydration does this clinical picture most likely represent?
- A. No clinically detectable dehydration (<5%)
- B. Mild dehydration (5%)
- C. Moderate dehydration (5-10%)
- D. Severe dehydration (>10%) (Correct Answer)
- E. Hypovolaemic shock (>15%)
Explanation: ***Severe dehydration (>10%)*** - The presence of **marked tachycardia** (155 bpm), **decreased skin turgor**, and a **delayed capillary refill time** (3 seconds) strongly indicates significant intravascular volume depletion, consistent with >10% dehydration. - Clinical features such as **oliguria** (8 hours without urination) and **cool peripheries** are critical signs used to classify dehydration as severe due to compensatory mechanisms failing to maintain adequate perfusion. *No clinically detectable dehydration (<5%)* - This stage typically presents with **no clinical signs**, normal vital signs, and an **immediate capillary refill time (<2 seconds)**. - The child's pronounced symptoms, including **tachycardia**, **delayed CRT**, and **cool peripheries**, clearly rule out minimal dehydration. *Mild dehydration (5%)* - Characterized by **increased thirst** and slightly **dry mucous membranes**, but **normal heart rate** and **capillary refill** are typically maintained. - The patient's signs, such as **cool peripheries** and **marked tachycardia**, are far more severe than those expected in mild dehydration. *Moderate dehydration (5-10%)* - Features often include **sunken eyes** and decreased skin turgor, but **capillary refill** is usually 2-3 seconds and vital signs are less dramatically deranged. - The combination of **marked tachycardia**, **cool peripheries**, and significant **oliguria** indicates a fluid deficit beyond the moderate classification. *Hypovolaemic shock (>15%)* - This is characterized by profound **hypotension** (decompensated shock) and a significantly **altered level of consciousness**, representing a critical failure of compensatory mechanisms. - While severely dehydrated, the child's **blood pressure** (85/50 mmHg) is at the lower end of normal, indicating he is in **compensated shock** rather than full decompensated shock.
Question 133: What is the mechanism of action of ipratropium bromide when used in acute asthma exacerbations in children?
- A. Stimulation of beta-2 adrenergic receptors causing bronchodilation
- B. Inhibition of phosphodiesterase leading to smooth muscle relaxation
- C. Competitive antagonism of muscarinic receptors reducing bronchoconstriction (Correct Answer)
- D. Direct relaxation of bronchial smooth muscle through calcium channel blockade
- E. Reduction of airway inflammation through inhibition of leukotriene synthesis
Explanation: ***Competitive antagonism of muscarinic receptors reducing bronchoconstriction*** - **Ipratropium bromide** is a short-acting muscarinic antagonist (**SAMA**) that blocks **M3 muscarinic receptors** on bronchial smooth muscle cells. - By preventing **acetylcholine** from binding to these receptors, it inhibits parasympathetic-mediated **bronchoconstriction** and reduces glandular mucus secretion, leading to bronchodilation. *Stimulation of beta-2 adrenergic receptors causing bronchodilation* - This mechanism describes **short-acting beta-agonists (SABAs)** like **albuterol** (salbutamol), which activate beta-2 receptors, leading to increased cAMP and bronchial smooth muscle relaxation. - While SABAs are primary bronchodilators in asthma, ipratropium acts via a different, anticholinergic pathway. *Inhibition of phosphodiesterase leading to smooth muscle relaxation* - This is the mechanism of action for **methylxanthines**, such as **theophylline**, which inhibit phosphodiesterase enzymes, thereby increasing intracellular cAMP levels and promoting bronchodilation. - Methylxanthines have a narrow therapeutic index and are not first-line agents for acute asthma exacerbations in children, unlike ipratropium. *Direct relaxation of bronchial smooth muscle through calcium channel blockade* - While calcium is essential for smooth muscle contraction, **calcium channel blockers** are not used for bronchodilation in acute asthma exacerbations. - The primary pathways for bronchodilation in asthma involve G-protein coupled receptors rather than direct calcium channel blockade. *Reduction of airway inflammation through inhibition of leukotriene synthesis* - This mechanism describes **leukotriene modifiers** (e.g., **montelukast**), which either inhibit leukotriene synthesis or block leukotriene receptors. - These drugs are primarily used for **long-term asthma control** and prevention, not for the rapid reversal of **acute bronchoconstriction** in an exacerbation.
Question 134: A 6-year-old girl with asthma presents with an acute exacerbation. She has received three doses of nebulised salbutamol and ipratropium bromide, oral prednisolone, and oxygen. Her respiratory rate remains 40/min, oxygen saturations 93% on 15L oxygen, and she has a silent chest with minimal wheeze. What is the most appropriate next step in management?
- A. Continue nebulisers and reassess in 30 minutes
- B. Commence intravenous magnesium sulphate
- C. Arrange urgent transfer to intensive care and consider intravenous salbutamol (Correct Answer)
- D. Commence intravenous aminophylline infusion
- E. Administer intramuscular adrenaline
Explanation: ***Arrange urgent transfer to intensive care and consider intravenous salbutamol***- The presence of a **silent chest**, **persistent hypoxia** (SpO2 93% on 15L oxygen), and failure to respond to multiple initial treatments indicates **life-threatening asthma** and impending respiratory failure.- Urgent **PICU/ICU involvement** is critical as the child is at high risk of **respiratory arrest** and may require intubation and advanced intravenous therapies like **IV salbutamol** or other bronchodilators. *Continue nebulisers and reassess in 30 minutes*- This approach is dangerous as the child has already failed to respond to initial intensive therapies and shows signs of **impending respiratory arrest**.- Delaying escalation of care in the presence of a **silent chest** significantly increases the risk of **fatal hypoxia** and respiratory collapse. *Commence intravenous magnesium sulphate*- While **IV magnesium sulphate** is a standard treatment for severe or life-threatening asthma, this child’s **silent chest** signals a need for a higher level of care, including potential mechanical ventilation, rather than just adding another drug.- Magnesium can still be given, but the priority is to secure a setting for **advanced respiratory support** and continuous monitoring. *Commence intravenous aminophylline infusion*- **IV aminophylline** is a second-line or third-line therapy for refractory asthma due to its narrow therapeutic index and significant side effects such as **arrhythmias** and seizures.- It requires intensive **cardiac monitoring** and should only be initiated after consulting senior clinicians and intensive care specialists, not as the immediate next step for a patient this critical. *Administer intramuscular adrenaline*- **Intramuscular adrenaline** is the first-line treatment for **anaphylaxis**, not typically for acute exacerbations of asthma, unless anaphylaxis is also suspected.- While adrenaline has bronchodilator effects, it is not the standard or most appropriate next step for severe asthma exacerbation compared to escalating to intensive care with IV bronchodilators.
Question 135: A 14-month-old boy presents with a 5-day history of persistent fever (maximum 39.5°C daily). He has bilateral non-purulent conjunctivitis, cracked lips, a polymorphous rash on his trunk, and cervical lymphadenopathy with one node measuring 2cm. His hands and feet appear erythematous and slightly swollen. Blood tests show: WCC 18 × 10⁹/L, CRP 145 mg/L, platelets 520 × 10⁹/L, albumin 28 g/L. What is the most likely diagnosis?
- A. Scarlet fever
- B. Kawasaki disease (Correct Answer)
- C. Measles
- D. Staphylococcal toxic shock syndrome
- E. Juvenile idiopathic arthritis
Explanation: ***Kawasaki disease*** - This patient meets the diagnostic criteria for **Kawasaki disease**, which requires a persistent fever for at least **5 days** plus four out of five clinical features: conjunctivitis, oral changes (cracked lips), rash, extremity changes (erythema/swelling of hands/feet), and lymphadenopathy. - Lab findings such as **elevated CRP**, **leucocytosis**, **thrombocytosis** (often later in the course), and **hypoalbuminaemia** further support this diagnosis of systemic inflammation and vasculitis. *Scarlet fever* - While it presents with fever and a rash, the **rash has a characteristic sandpaper texture** and conjunctivitis is typically absent. - It is caused by **Group A Streptococcus** and does not usually involve the degree of extremity swelling or prominent cracked lips seen in this case. *Measles* - Presentations usually include a **prodrome of cough, coryza, and conjunctivitis**, along with pathognomonic **Koplik spots** on the buccal mucosa. - The rash in measles typically follows a **cephalocaudal progression** (starting from the head and moving down), rather than being a polymorphous trunk rash. *Staphylococcal toxic shock syndrome* - This is an acute toxin-mediated illness characterized by **rapid-onset hypotension** and multiple organ system failure, which is not described here. - While it involves fever and rash, the patient's stability and the specific involvement of the **cervical lymph nodes and non-purulent conjunctivitis** favor Kawasaki disease. *Juvenile idiopathic arthritis* - **Systemic JIA** involves a daily spiking fever and an evanescent rash, but it lacks the **mucocutaneous constellation** of cracked lips and bilateral non-purulent conjunctivitis. - JIA typically features **objective arthritis** in one or more joints, whereas this child presents with generalized extremity erythema and edema without clear arthritis.
Question 136: A 2-year-old girl presents with a 2-day history of coryzal symptoms and barking cough, worse at night. She has mild chest recession and occasional stridor at rest. Her respiratory rate is 35/min, heart rate 110/min, temperature 37.8°C, and oxygen saturations 98% on air. She is taking fluids normally. What is the most appropriate treatment?
- A. Oral dexamethasone 0.15 mg/kg as a single dose (Correct Answer)
- B. Nebulised budesonide 2mg
- C. Nebulised adrenaline and oral dexamethasone
- D. Reassurance and safety netting advice only
- E. Oral prednisolone 1-2 mg/kg daily for 3 days
Explanation: ***Oral dexamethasone 0.15 mg/kg as a single dose*** - This patient exhibits signs of **moderate croup**, characterized by a **barking cough** and **stridor at rest**; current guidelines recommend a single dose of oral dexamethasone for all children with croup. - **Dexamethasone** is the preferred corticosteroid due to its longer half-life and clinical evidence showing it reduces the need for hospitalization and additional treatments. *Nebulised budesonide 2mg* - While effective, **nebulised budesonide** is typically reserved for children who are vomiting or unable to tolerate anything **orally**. - It is more distressing for the child than oral administration and has not been shown to be superior to **oral dexamethasone**. *Nebulised adrenaline and oral dexamethasone* - **Nebulised adrenaline** is specifically indicated for **severe croup** involving significant respiratory distress, cyanosis, or impending respiratory failure. - This patient’s normal saturations and mild recession indicate they do not yet require the temporary, rapid-acting reduction in **airway edema** provided by adrenaline. *Reassurance and safety netting advice only* - Although many cases of croup are mild, the presence of **stridor at rest** requires medical intervention beyond simple observation. - Standard of care mandates that even mild cases should receive **corticosteroids** to prevent progression and minimize symptom duration. *Oral prednisolone 1-2 mg/kg daily for 3 days* - **Oral prednisolone** is the standard treatment for **asthma exacerbations**, not the primary choice for managing acute croup. - Studies show **dexamethasone** is more effective in the context of croup due to its higher potency and better **volume-to-dose ratio** for pediatric patients.
Question 137: A 5-year-old boy with asthma presents to the emergency department with an acute exacerbation. He has received 10 puffs of salbutamol via spacer and oral prednisolone 20mg. His respiratory rate is 45/min, heart rate 130/min, oxygen saturations 92% on air. He can speak in short phrases and has widespread wheeze with good air entry bilaterally. What severity classification best describes this presentation?
- A. Mild asthma exacerbation
- B. Moderate asthma exacerbation
- C. Acute severe asthma (Correct Answer)
- D. Life-threatening asthma
- E. Near-fatal asthma
Explanation: ***Acute severe asthma***- In children aged 2–5 years, **acute severe asthma** is defined by a **respiratory rate >40/min** or a **heart rate >130/min**, both of which are present in this patient.- An **SpO2 ≥92%** combined with the inability to complete sentences in one breath (speaking in **short phrases**) confirms this severity level according to BTS guidelines.*Mild asthma exacerbation*- **Mild asthma** typically presents with minimal symptoms and relatively normal physiological parameters for the child's age.- It lacks the significant **tachypnea** and **tachycardia** observed in this clinical scenario.*Moderate asthma exacerbation*- While **moderate asthma** features an **SpO2 ≥92%**, it does not meet the higher thresholds for respiratory or heart rates seen here.- Stable patients who can **speak reasonably well** and show no severe physiological distress are classified in this category.*Life-threatening asthma*- This classification requires clinical red flags such as **SpO2 <92%**, a **silent chest**, cyanosis, or **exhaustion/altered consciousness**.- This patient maintains **good air entry** and a saturation of 92%, excluding life-threatening status at this time.*Near-fatal asthma*- **Near-fatal asthma** is characterized by a **raised PaCO2** and/or the requirement for **mechanical ventilation**.- This patient is still conscious, talking in phrases, and showing **bilateral air entry**, which does not meet these critical criteria.
Question 138: A 7-month-old infant presents with a 12-hour history of fever (38.5°C) and irritability. On examination, she cries when handled but stops when left alone. There is no rash, and respiratory and abdominal examinations are normal. Urine dipstick shows leucocytes 2+ and nitrites negative. What is the most appropriate next step in management?
- A. Treat as urinary tract infection with oral trimethoprim
- B. Perform lumbar puncture to exclude meningitis
- C. Send urine for microscopy, culture and sensitivity before starting antibiotics (Correct Answer)
- D. Reassure parents and arrange review in 24 hours
- E. Commence empirical intravenous antibiotics for possible sepsis
Explanation: ***Send urine for microscopy, culture and sensitivity before starting antibiotics*** - In a 7-month-old with **fever without a clear source** and a positive dipstick for **leucocytes**, confirming a **Urinary Tract Infection (UTI)** via culture is essential before initiating treatment. - Because the infant is over 3 months old and clinically stable (only 38.5°C, settles when left alone), there is time to obtain a **clean catch** or **catheter specimen** for accurate diagnosis, crucial for guiding appropriate antibiotic therapy. *Treat as urinary tract infection with oral trimethoprim* - Initiating antibiotics solely based on **isolated leucocytes** on a dipstick is premature, especially with negative nitrites, as leucocytes can be seen in other febrile states or contamination. - A **confirmatory urine culture** is required in infants to precisely identify the causative organism and its sensitivity, preventing empirical overtreatment or inadequate therapy. *Perform lumbar puncture to exclude meningitis* - While the infant is irritable, the absence of other specific signs like a **bulging fontanelle**, neck stiffness, or severe toxicity makes **meningitis** less likely than a UTI given the urine findings. - **Lumbar puncture** is an invasive procedure generally reserved for infants under 3 months with fever, or older infants with clear clinical signs of meningeal irritation or high suspicion of serious bacterial infection. *Reassure parents and arrange review in 24 hours* - Reassurance is inappropriate because the presence of **2+ leucocytes** in the urine of a febrile infant indicates a high probability of infection that warrants immediate investigation. - Failing to investigate a potential **Urinary Tract Infection (UTI)** in an infant can lead to delayed diagnosis, progression of infection, and increased risk of long-term **renal scarring**. *Commence empirical intravenous antibiotics for possible sepsis* - **Empirical intravenous antibiotics** are indicated for infants who appear toxic, are under 3 months with fever, or show signs of **hemodynamic instability** or severe sepsis. - This infant is clinically stable (fever 38.5°C, settles when left alone) and does not exhibit the classic features requiring immediate broad-spectrum IV antibiotic coverage for presumptive **sepsis** at this stage.
Question 139: What is the correct definition of a complex febrile seizure?
- A. A generalised tonic-clonic seizure lasting more than 15 minutes, or focal features, or recurrence within 24 hours, or incomplete recovery within 1 hour (Correct Answer)
- B. Any seizure occurring in a child with fever regardless of duration or characteristics
- C. A generalised seizure lasting less than 15 minutes in a child aged between 6 months and 6 years
- D. Any seizure associated with fever above 39°C in a child with underlying neurological abnormality
- E. Recurrent febrile seizures occurring in different febrile illnesses separated by weeks or months
Explanation: ***A generalised tonic-clonic seizure lasting more than 15 minutes, or focal features, or recurrence within 24 hours, or incomplete recovery within 1 hour***- A **complex febrile seizure** is defined by one or more specific criteria: duration **longer than 15 minutes**, **focal features** at onset or post-ictally, **recurrence** within the same illness period (24 hours), or delayed recovery.- These seizures are associated with a slightly higher risk of developing **epilepsy** (approximately 2-10%) compared to the general population.*Any seizure occurring in a child with fever regardless of duration or characteristics*- This is a broad description of any **febrile seizure**, but it fails to distinguish between the **simple** and **complex** subtypes.- Clinical management and prognosis significantly differ based on whether the seizure meets the specific **complex** criteria.*A generalised seizure lasting less than 15 minutes in a child aged between 6 months and 6 years*- This describes a **simple febrile seizure**, which is the most common type and generally carries a benign prognosis.- Simple seizures must also be **non-focal** and not recur within the same **24-hour** febrile episode.*Any seizure associated with fever above 39°C in a child with underlying neurological abnormality*- The presence of an **underlying neurological abnormality** may increase the risk of seizures but is not a defining characteristic of a **complex febrile seizure**.- Complex seizures are defined by the **nature and timing** of the seizure event itself, rather than the baseline neurological state or the specific height of the fever.*Recurrent febrile seizures occurring in different febrile illnesses separated by weeks or months*- This scenario describes **recurrent febrile seizures**, which predicts a higher risk of future febrile seizures but does not make the individual episode **complex**.- For a seizure to be complex due to recurrence, the repeat event must happen within the **same 24-hour period** or same febrile illness.
Question 140: Which of the following features is consistent with a diagnosis of viral-induced wheeze rather than asthma in a preschool child?
- A. Wheeze occurring only during viral upper respiratory tract infections with symptom-free intervals between episodes (Correct Answer)
- B. Nocturnal cough and wheeze occurring independently of viral infections
- C. Daily symptoms requiring regular preventer medication
- D. Exercise-induced wheeze in the absence of viral infection
- E. Strong family history of atopy with elevated IgE and positive skin prick tests
Explanation: ***Wheeze occurring only during viral upper respiratory tract infections with symptom-free intervals between episodes*** - This pattern is the hallmark of **episodic viral wheeze**, where respiratory symptoms are triggered strictly by **viral pathogens** and resolve completely between events. - Unlike asthma, there are **no interval symptoms** (such as night cough or exercise triggers) when the child does not have a cold. *Nocturnal cough and wheeze occurring independently of viral infections* - Symptoms occurring at **night** in the absence of a viral trigger are highly suggestive of **asthma** or multi-trigger wheeze. - This indicates **ongoing airway inflammation** rather than a reactive process limited to acute viral infections. *Daily symptoms requiring regular preventer medication* - **Viral-induced wheeze** is typically managed with **intermittent bronchodilators** as needed, rather than daily controller therapy. - Persistent daily symptoms necessitate **inhaled corticosteroids**, which is progressive toward a management strategy for **early-onset asthma**. *Exercise-induced wheeze in the absence of viral infection* - Wheezing triggered by **physical activity**, laughter, or cold air suggests **bronchial hyper-responsiveness** characteristic of asthma. - In pure viral-induced wheeze, exercise does not typically act as an **independent trigger** outside of the acute illness phase. *Strong family history of atopy with elevated IgE and positive skin prick tests* - These findings indicate an **atopic phenotype**, which significantly increases the probability that the child's wheezing will transition into **chronic asthma**. - Viral-induced wheeze often occurs in children without a strong **personal or family history** of allergic disease or atopy.
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