Acute Paediatrics — MCQs

A 6-month-old infant is brought to the emergency department with a 3-day history of coryzal symptoms followed by increased work of breathing. On examination, respiratory rate is 65/min, temperature 37.8°C, oxygen saturation 91% in air. There is subcostal recession, nasal flaring, and bilateral expiratory wheeze with fine inspiratory crackles. The child is able to feed but takes smaller volumes. What is the most likely diagnosis?

Q152

A 3-year-old girl presents to the emergency department with fever of 39.2°C for 48 hours. Her mother reports she has been miserable, refusing to eat, and has developed a rash today. On examination, she has bilateral non-purulent conjunctivitis, cracked red lips, a strawberry tongue, and a polymorphous maculopapular rash over her trunk. Her cervical lymph nodes are enlarged. What is the most appropriate initial management?

Acute Paediatrics UK Medical PG Practice Questions and MCQs

Question 151: A 6-month-old infant is brought to the emergency department with a 3-day history of coryzal symptoms followed by increased work of breathing. On examination, respiratory rate is 65/min, temperature 37.8°C, oxygen saturation 91% in air. There is subcostal recession, nasal flaring, and bilateral expiratory wheeze with fine inspiratory crackles. The child is able to feed but takes smaller volumes. What is the most likely diagnosis?

A. Bronchiolitis (Correct Answer)
B. Viral-induced wheeze
C. Pneumonia
D. First presentation of asthma
E. Aspirated foreign body

Explanation: **Bronchiolitis** - This presentation is classic for **bronchiolitis**, typically caused by **Respiratory Syncytial Virus (RSV)** in infants under 12 months following a viral **coryzal prodrome**. - The clinical hallmarks are **increased work of breathing** (recessions, tachypnea) and the characteristic combination of **bilateral expiratory wheeze** and **fine inspiratory crackles**. *Viral-induced wheeze* - This typically occurs in children **over 1 year of age** and is characterized by **recurrent episodes** of wheezing without the fine crackles seen in bronchiolitis. - It is a diagnosis often made in older toddlers who respond to **bronchodilators**, which are generally ineffective in acute bronchiolitis. *Pneumonia* - Bacterial pneumonia usually presents with a **high-grade fever** (>38.5°C), toxic appearance, and **focal (unilateral) crackles** rather than generalized wheezing. - Unlike bronchiolitis, pneumonia often lacks the initial **coryzal phase** and presents with dullness to percussion or decreased breath sounds over a specific lobe. *First presentation of asthma* - Asthma is **rarely diagnosed** in infants under 12 months, as the airways are physiologically different and the pathology of bronchiolitis (inflammation and mucus) predominates. - A diagnosis of asthma requires evidence of **reversibility** and often a strong personal or family history of **atopy**, which is not the primary suspect in this acute setting. *Aspirated foreign body* - This typically involves a **sudden onset** of choking or coughing in a child who was previously well, rather than a 3-day **viral prodrome**. - Examination usually reveals **unilateral** localized wheeze or reduced breath sounds, as opposed to the **bilateral** chest signs observed in this infant.

Question 152: A 3-year-old girl presents to the emergency department with fever of 39.2°C for 48 hours. Her mother reports she has been miserable, refusing to eat, and has developed a rash today. On examination, she has bilateral non-purulent conjunctivitis, cracked red lips, a strawberry tongue, and a polymorphous maculopapular rash over her trunk. Her cervical lymph nodes are enlarged. What is the most appropriate initial management?

A. Admit for intravenous immunoglobulin and high-dose aspirin (Correct Answer)
B. Prescribe oral antibiotics and arrange follow-up in 48 hours
C. Perform lumbar puncture and start intravenous ceftriaxone
D. Arrange urgent echocardiogram and discharge if normal
E. Prescribe oral steroids and arrange paediatric outpatient review

Explanation: ***Admit for intravenous immunoglobulin and high-dose aspirin*** - The patient meets the diagnostic criteria for **Kawasaki disease**, presenting with fever, **strawberry tongue**, **conjunctivitis**, polymorphous rash, and cervical lymphadenopathy. - Immediate management with **IVIG** and **high-dose aspirin** is crucial to reduce the risk of **coronary artery aneurysms**, which can occur in up to 25% of untreated children. *Prescribe oral antibiotics and arrange follow-up in 48 hours* - Kawasaki disease is a **vasculitis**, not a bacterial infection, and oral antibiotics will not address the underlying inflammation or prevent cardiac complications. - Delaying treatment while awaiting follow-up increases the risk of serious **vascular sequelae** and ignores the clinical signs of a systemic emergency. *Perform lumbar puncture and start intravenous ceftriaxone* - While fever and irritability can occur in **meningitis**, the presence of pathognomonic secondary signs like **cracked lips** and **strawberry tongue** points specifically toward Kawasaki disease. - **Lumbar puncture** is an invasive procedure and is not indicated when the clinical presentation strongly conforms to the **American Heart Association** criteria for Kawasaki disease. *Arrange urgent echocardiogram and discharge if normal* - Although an **echocardiogram** is essential to monitor for coronary artery involvement, a normal initial scan does not rule out the need for urgent treatment. - Patients with suspected Kawasaki disease must be **admitted** for therapy regardless of the initial echo results to prevent future **aneurysm formation**. *Prescribe oral steroids and arrange paediatric outpatient review* - While steroids may be used in IVIG-resistant cases, they are not the **first-line therapy** for initial stabilization of Kawasaki disease. - Outpatient review is inappropriate because the patient requires **continuous monitoring** and rapid administration of IVIG to control systemic **vasculitis**.

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