Acute Paediatrics — MCQs
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A 5-month-old infant is brought to the emergency department with a 12-hour history of fever to 38.6°C and refusing feeds. She has taken only 50ml of her usual 150ml per feed over the past 12 hours. She was born at 38 weeks gestation following an uncomplicated pregnancy and delivery. On examination, she is irritable, has dry mucous membranes, heart rate 160 bpm, respiratory rate 50/min, temperature 38.4°C, and capillary refill time 3 seconds centrally. There are no focal signs of infection. Urine dipstick shows leucocytes ++, nitrites positive, protein +, blood negative. What is the most appropriate management?
A 3-year-old girl with recurrent wheeze is reviewed in the outpatient clinic. Her mother reports that she experiences episodes of wheeze approximately every 6-8 weeks, typically triggered by viral upper respiratory tract infections. Between episodes, she is completely asymptomatic with no wheeze, cough, or activity limitation. She has had four episodes requiring salbutamol in the past year but has never required hospital admission. Her father has asthma. According to current BTS/SIGN guidelines, what is the most appropriate management strategy?
A 14-month-old child presents to the emergency department following a brief generalised tonic-clonic seizure at home lasting 3 minutes. The parents report she has had fever to 39.5°C for the past 8 hours. The seizure stopped spontaneously before arrival. On examination, she is now alert and interactive with temperature 38.8°C following paracetamol. She has erythematous tonsils with white exudate but no other focal signs. Neurological examination is normal. This is her first seizure. What is the most appropriate immediate management after initial assessment and stabilisation?
An 18-month-old child with recurrent viral-induced wheeze is brought to the emergency department with increased work of breathing following 2 days of coryzal symptoms. On examination, she has moderate subcostal recession, respiratory rate 48/min, heart rate 140 bpm, oxygen saturation 94% on air, and widespread expiratory wheeze. She received salbutamol via spacer 2 hours ago at home with minimal improvement. What distinguishes this presentation from bronchiolitis and supports a diagnosis of viral-induced wheeze?
A 2-year-old boy is brought to the emergency department with a 24-hour history of fever to 38.8°C, pulling at his right ear, and being more clingy than usual. He has had coryzal symptoms for 3 days. Examination reveals a red, bulging right tympanic membrane with loss of light reflex. He is otherwise well with no respiratory distress. His observations show: heart rate 130 bpm, respiratory rate 30/min, temperature 38.6°C, and oxygen saturation 98% on air. There is no mastoid tenderness or swelling. What is the most appropriate management?
A 4-month-old infant is brought to the emergency department with a 6-hour history of fever to 39.2°C and reduced feeding. She was born at term with no complications and is up to date with vaccinations. On examination, she appears irritable but consolable, has no rash, fontanelle is flat, cardiovascular and respiratory examinations are normal, and there are no focal signs of infection. Her observations show: heart rate 165 bpm, respiratory rate 45/min, temperature 38.9°C, and capillary refill time 2 seconds centrally. What is the most appropriate management?
A 10-year-old girl with known asthma presents to the emergency department with wheeze and breathlessness that started 4 hours ago. She uses her salbutamol inhaler 4-6 times per week and beclometasone 200 micrograms twice daily. On examination, she can speak in full sentences, has mild intercostal recession, respiratory rate 28/min, heart rate 110 bpm, oxygen saturation 96% on air, and peak flow 65% of her best. Chest auscultation reveals widespread polyphonic wheeze. Following administration of nebulised salbutamol, her peak flow improves to 80% predicted and she has no recession. What is the most appropriate next step in management?
What is the recommended definition of fever in a child under 5 years of age according to NICE guidelines for assessment of febrile illness in children?
A 20-month-old girl presents with a 5-day history of fever ranging from 38.5°C to 40.1°C. She has been irritable but has no focal symptoms. Examination reveals bilateral non-exudative conjunctival injection, erythematous cracked lips, cervical lymphadenopathy with nodes measuring 2cm, and a polymorphous rash on the trunk. Her hands and feet appear oedematous. Blood results show: Hb 105 g/L, WCC 16.8 × 10⁹/L, platelets 485 × 10⁹/L, CRP 128 mg/L, ESR 72 mm/hr. What is the most appropriate initial management?
A 7-year-old boy with known asthma is brought to the emergency department by ambulance. He is sitting forward, using accessory muscles, and speaking in single words. His observations show: heart rate 145 bpm, respiratory rate 38/min, oxygen saturation 89% on air, and peak expiratory flow rate 35% of predicted. Auscultation reveals silent chest bilaterally. What is the most appropriate immediate management?
Acute Paediatrics UK Medical PG Practice Questions and MCQs
Question 41: A 5-month-old infant is brought to the emergency department with a 12-hour history of fever to 38.6°C and refusing feeds. She has taken only 50ml of her usual 150ml per feed over the past 12 hours. She was born at 38 weeks gestation following an uncomplicated pregnancy and delivery. On examination, she is irritable, has dry mucous membranes, heart rate 160 bpm, respiratory rate 50/min, temperature 38.4°C, and capillary refill time 3 seconds centrally. There are no focal signs of infection. Urine dipstick shows leucocytes ++, nitrites positive, protein +, blood negative. What is the most appropriate management?
- A. Admit for observation, encourage oral fluids, send urine for culture, and start antibiotics if culture confirms infection
- B. Send urine for microscopy and culture, commence oral antibiotics, and arrange review within 24 hours
- C. Admit for intravenous antibiotics after sending urine and blood cultures, and provide intravenous fluids for dehydration (Correct Answer)
- D. Send urine for culture, obtain blood tests including inflammatory markers, give intramuscular ceftriaxone, and review in 24 hours
- E. Perform full septic screen including lumbar puncture, commence intravenous ceftriaxone and amoxicillin immediately
Explanation: ***Admit for intravenous antibiotics after sending urine and blood cultures, and provide intravenous fluids for dehydration***- This infant has a **Urinary Tract Infection (UTI)** (nitrite and leukocyte positive) with systemic features and **dehydration** (reduced intake, tachycardia, and 3s capillary refill).- According to **NICE guidelines**, infants over 3 months with signs of **dehydration** or an inability to tolerate oral fluids require **hospital admission** and **intravenous antibiotics**.*Admit for observation, encourage oral fluids, send urine for culture, and start antibiotics if culture confirms infection*- Delaying treatment until culture results are available is dangerous in a febrile, **dehydrated infant** who likely has pyelonephritis.- Encouraging oral fluids is insufficient when the infant is already **refusing feeds** and showing clinical signs of dehydration.*Send urine for microscopy and culture, commence oral antibiotics, and arrange review within 24 hours*- **Oral antibiotics** are inappropriate here because the child is significantly unwell and may not absorb or tolerate the medication.- Outpatient management is unsafe given the **systemic involvement** and necessity for **fluid resuscitation**.*Send urine for culture, obtain blood tests including inflammatory markers, give intramuscular ceftriaxone, and review in 24 hours*- **Intramuscular antibiotics** do not address the urgent need for **rehydration** via the intravenous route.- A 24-hour review is too late for an irritable infant with a prolonged **capillary refill time** and significant feed refusal.*Perform full septic screen including lumbar puncture, commence intravenous ceftriaxone and amoxicillin immediately*- While a septic screen is considered in young infants, a **lumbar puncture** is not routinely indicated for a clear source like a UTI unless **meningitis** is clinically suspected.- Dual therapy with **amoxicillin** is typically reserved for infants under 3 months to cover *Listeria*, which is less relevant in this 5-month-old.
Question 42: A 3-year-old girl with recurrent wheeze is reviewed in the outpatient clinic. Her mother reports that she experiences episodes of wheeze approximately every 6-8 weeks, typically triggered by viral upper respiratory tract infections. Between episodes, she is completely asymptomatic with no wheeze, cough, or activity limitation. She has had four episodes requiring salbutamol in the past year but has never required hospital admission. Her father has asthma. According to current BTS/SIGN guidelines, what is the most appropriate management strategy?
- A. Prescribe salbutamol inhaler via spacer to use as needed during symptomatic episodes only (Correct Answer)
- B. Commence regular inhaled corticosteroid (beclometasone 100 micrograms twice daily) as preventer therapy
- C. Prescribe salbutamol inhaler for acute symptoms and add leukotriene receptor antagonist as regular preventer
- D. Prescribe salbutamol inhaler and commence regular low-dose inhaled corticosteroid during viral illnesses only
- E. Commence regular preventer therapy with long-acting beta-2 agonist plus inhaled corticosteroid combination inhaler
Explanation: ***Prescribe salbutamol inhaler via spacer to use as needed during symptomatic episodes only*** - The child presents with **episodic viral wheeze**, characterized by symptoms occurring only during viral infections and being **completely asymptomatic** between episodes. - According to **BTS/SIGN guidelines**, the first-line management for episodic viral wheeze is a **short-acting beta-2 agonist (SABA)** used only when symptomatic. *Commence regular inhaled corticosteroid (beclometasone 100 micrograms twice daily) as preventer therapy* - **Inhaled corticosteroids (ICS)** are indicated for **multi-trigger wheeze** or asthma, where symptoms occur between viral infections (e.g., during exercise or at night). - Regular ICS provides **no significant benefit** in children with purely episodic viral wheeze who have no interval symptoms. *Prescribe salbutamol inhaler for acute symptoms and add leukotriene receptor antagonist as regular preventer* - **Leukotriene receptor antagonists (LTRAs)** are generally reserved as a second-line option if SABA alone fails to control symptoms in episodic viral wheeze. - This child’s episodes are relatively infrequent (every 6-8 weeks) and non-severe, making **regular preventer** therapy unnecessary at this stage. *Prescribe salbutamol inhaler and commence regular low-dose inhaled corticosteroid during viral illnesses only* - **Intermittent use of ICS** solely during viral illnesses is not the standard recommendation for managing episodic viral wheeze in this age group. - Starting and stopping ICS frequently lacks a strong evidence base for improving outcomes compared to **as-needed SABA therapy**. *Commence regular preventer therapy with long-acting beta-2 agonist plus inhaled corticosteroid combination inhaler* - **Combination inhalers (ICS/LABA)** are used in older children with persistent asthma that is poorly controlled on moderate doses of ICS alone. - **Long-acting beta-2 agonists (LABA)** are contraindicated as monotherapy and are inappropriate for a child with infrequent, infection-triggered symptoms.
Question 43: A 14-month-old child presents to the emergency department following a brief generalised tonic-clonic seizure at home lasting 3 minutes. The parents report she has had fever to 39.5°C for the past 8 hours. The seizure stopped spontaneously before arrival. On examination, she is now alert and interactive with temperature 38.8°C following paracetamol. She has erythematous tonsils with white exudate but no other focal signs. Neurological examination is normal. This is her first seizure. What is the most appropriate immediate management after initial assessment and stabilisation?
- A. Arrange urgent CT head to exclude intracranial pathology and then perform lumbar puncture
- B. Examine for source of fever, treat the underlying infection, provide parental education about febrile seizures, and safety-netting advice (Correct Answer)
- C. Commence prophylactic anticonvulsant therapy with sodium valproate and arrange paediatric neurology follow-up
- D. Perform septic screen including lumbar puncture to exclude meningitis given seizure and fever
- E. Admit for 24-hour observation, perform EEG, and commence antibiotics pending blood culture results
Explanation: ***Examine for source of fever, treat the underlying infection, provide parental education about febrile seizures, and safety-netting advice*** - The child's presentation, including age (14 months), **generalized tonic-clonic seizure** lasting 3 minutes, fever, and rapid return to normal neurological state, is characteristic of a **simple febrile seizure**. - Management involves identifying and treating the source of fever (tonsillitis in this case), providing **reassurance** and comprehensive **parental education** about the benign nature of febrile seizures, and safety-netting advice for future episodes. *Arrange urgent CT head to exclude intracranial pathology and then perform lumbar puncture* - Neuroimaging like a **CT head** is not indicated in **simple febrile seizures** where the child is neurologically normal post-ictally and has no signs of raised intracranial pressure or focal deficits. - A **lumbar puncture** is not routinely recommended for simple febrile seizures, especially when the child is alert, interactive, and has a clear extracranial source of infection, as the risk of meningitis is low. *Commence prophylactic anticonvulsant therapy with sodium valproate and arrange paediatric neurology follow-up* - **Prophylactic anticonvulsants** are not recommended for febrile seizures due to the significant risk of side effects outweighing the benefits for a condition with a benign prognosis and minimal risk of epilepsy. - Routine **paediatric neurology follow-up** is not required for a first-time simple febrile seizure as it does not indicate an increased risk of developing epilepsy compared to the general population. *Perform septic screen including lumbar puncture to exclude meningitis given seizure and fever* - A full **septic screen** and **lumbar puncture** are usually reserved for children who appear toxically unwell, have meningeal signs, or when no obvious source of fever is identified. - In this case, the child is alert, interactive, has normal neurological examination, and a clear source of infection (exudative tonsillitis), making meningitis an unlikely diagnosis. *Admit for 24-hour observation, perform EEG, and commence antibiotics pending blood culture results* - An **EEG** is not recommended for simple febrile seizures as it does not predict the recurrence of seizures or the future development of epilepsy. - Admission for 24-hour observation and empiric **antibiotics** are generally not necessary for a stable child with a simple febrile seizure and a clear, treatable source of fever, such as tonsillitis, which is often viral or can be managed without immediate IV antibiotics.
Question 44: An 18-month-old child with recurrent viral-induced wheeze is brought to the emergency department with increased work of breathing following 2 days of coryzal symptoms. On examination, she has moderate subcostal recession, respiratory rate 48/min, heart rate 140 bpm, oxygen saturation 94% on air, and widespread expiratory wheeze. She received salbutamol via spacer 2 hours ago at home with minimal improvement. What distinguishes this presentation from bronchiolitis and supports a diagnosis of viral-induced wheeze?
- A. The presence of previous similar episodes and response to bronchodilator therapy (Correct Answer)
- B. The age of the child being over 12 months at presentation
- C. The absence of fine inspiratory crackles on chest auscultation
- D. The history of coryzal prodrome preceding respiratory symptoms
- E. The presence of family history of atopy or asthma
Explanation: ***The presence of previous similar episodes and response to bronchodilator therapy***- **Recurrent episodes** of wheezing associated with viral infections are a hallmark of viral-induced wheeze, distinguishing it from bronchiolitis, which is typically a child's first or second episode.- A **response to bronchodilators**, even if partial, is characteristic of viral-induced wheeze, while bronchiolitis is generally unresponsive to these medications.*The age of the child being over 12 months at presentation*- While **bronchiolitis** commonly affects infants under 12 months, it can occur in children up to **24 months of age**.- Therefore, age alone in this range is not a definitive differentiator between the two conditions.*The absence of fine inspiratory crackles on chest auscultation*- **Fine inspiratory crackles** are a common finding in bronchiolitis, along with wheezing, whereas viral-induced wheeze often presents predominantly with **expiratory wheeze**.- However, auscultatory findings can overlap, and the absence of crackles is less specific than the history of recurrence or bronchodilator response for differentiation.*The history of coryzal prodrome preceding respiratory symptoms*- A **coryzal prodrome** (runny nose, cough, low-grade fever) is a typical precursor to both **bronchiolitis** and **viral-induced wheeze**.- Since this feature is common to both conditions, it does not serve as a distinguishing factor.*The presence of family history of atopy or asthma*- A **family history of atopy or asthma** is a risk factor for developing viral-induced wheeze and later asthma, indicating a predisposition.- However, its presence does not definitively differentiate an acute episode from bronchiolitis, as it's a predisposing factor rather than a specific diagnostic criterion for the current illness.
Question 45: A 2-year-old boy is brought to the emergency department with a 24-hour history of fever to 38.8°C, pulling at his right ear, and being more clingy than usual. He has had coryzal symptoms for 3 days. Examination reveals a red, bulging right tympanic membrane with loss of light reflex. He is otherwise well with no respiratory distress. His observations show: heart rate 130 bpm, respiratory rate 30/min, temperature 38.6°C, and oxygen saturation 98% on air. There is no mastoid tenderness or swelling. What is the most appropriate management?
- A. Prescribe amoxicillin for 5 days and advise regular paracetamol for pain relief
- B. Advise regular analgesia with paracetamol or ibuprofen, provide safety-netting advice, and review in 48-72 hours if not improving (Correct Answer)
- C. Prescribe co-amoxiclav for 7 days given the severity of bulging tympanic membrane
- D. Prescribe amoxicillin for 5 days and arrange follow-up with audiology in 6 weeks
- E. Take ear swab for microscopy and culture, prescribe topical antibiotics, and arrange ENT review
Explanation: ***Advise regular analgesia with paracetamol or ibuprofen, provide safety-netting advice, and review in 48-72 hours if not improving***- In children over 2 years with **unilateral acute otitis media (AOM)** who are systemically well, **NICE guidelines** recommend a watchful waiting approach as most cases are self-limiting.- Management focuses on **pain relief** with analgesia and providing clear **safety-netting advice** regarding worsening symptoms or lack of improvement.*Prescribe amoxicillin for 5 days and advise regular paracetamol for pain relief*- Immediate antibiotics are not indicated here because the child is **systemically well**, over 2 years old, and has **unilateral** disease without otorrhoea.- Routine use of **amoxicillin** for uncomplicated AOM contributes to antibiotic resistance and typically only provides a marginal reduction in symptom duration.*Prescribe co-amoxiclav for 7 days given the severity of bulging tympanic membrane*- **Co-amoxiclav** is not first-line for AOM; it is generally reserved for second-line treatment if symptoms fail to respond to amoxicillin.- A **bulging tympanic membrane** is a classic diagnostic feature of AOM but does not, on its own, mandate immediate broad-spectrum antibiotic therapy.*Prescribe amoxicillin for 5 days and arrange follow-up with audiology in 6 weeks*- Immediate antibiotics are inappropriate for this stable child, and **audiology follow-up** is not routinely required after a single acute episode of uncomplicated AOM.- Audiology referral is typically reserved for children with persistent **Otitis Media with Effusion (OME)** or significant hearing concerns following resolution of the acute infection.*Take ear swab for microscopy and culture, prescribe topical antibiotics, and arrange ENT review*- **Ear swabs** and **topical antibiotics** are treatments for **Otitis Externa**, not for AOM where the infection is located behind an intact tympanic membrane.- An **ENT review** is not indicated for simple AOM unless there are complications like **mastoiditis** or frequently recurrent episodes.
Question 46: A 4-month-old infant is brought to the emergency department with a 6-hour history of fever to 39.2°C and reduced feeding. She was born at term with no complications and is up to date with vaccinations. On examination, she appears irritable but consolable, has no rash, fontanelle is flat, cardiovascular and respiratory examinations are normal, and there are no focal signs of infection. Her observations show: heart rate 165 bpm, respiratory rate 45/min, temperature 38.9°C, and capillary refill time 2 seconds centrally. What is the most appropriate management?
- A. Perform full septic screen including blood cultures, urine culture, lumbar puncture, and commence intravenous antibiotics (Correct Answer)
- B. Obtain blood cultures and urine sample, give intravenous ceftriaxone, and observe for 4 hours before deciding on lumbar puncture
- C. Perform blood tests and urine culture, give oral antibiotics if urinary tract infection confirmed, and arrange review in 24 hours
- D. Administer paracetamol, provide safety-netting advice, and arrange GP follow-up within 24 hours
- E. Obtain blood cultures, commence intravenous antibiotics, and perform lumbar puncture once antibiotics have been administered
Explanation: ***Perform full septic screen including blood cultures, urine culture, lumbar puncture, and commence intravenous antibiotics***- In an infant presenting with **high fever (>39°C)**, irritability, and reduced feeding, a **full septic screen** is essential to exclude serious bacterial infections like **meningitis** and **septicaemia**.- According to **NICE guidelines**, infants with concerning features or those who appear unwell require urgent **lumbar puncture** and empirical **intravenous antibiotics** to prevent rapid clinical deterioration.*Obtain blood cultures and urine sample, give intravenous ceftriaxone, and observe for 4 hours before deciding on lumbar puncture*- Delaying a **lumbar puncture** for observation is unsafe in a febrile, irritable infant, as it may delay the diagnosis of **bacterial meningitis**.- Antibiotics should ideally be administered after the **lumbar puncture** is performed to ensure accurate CSF culture results, unless the child is in **septic shock**.*Perform blood tests and urine culture, give oral antibiotics if urinary tract infection confirmed, and arrange review in 24 hours*- **Oral antibiotics** are insufficient for an infant in this age group showing signs of **systemic illness** such as irritability and high fever.- A **24-hour review** is an inappropriate delay for a child who potentially has a **serious bacterial infection** requiring inpatient management.*Administer paracetamol, provide safety-netting advice, and arrange GP follow-up within 24 hours*- **Safety-netting** alone is inappropriate for an infant with a fever of **39.2°C** and reduced feeding, as these are "red flag" or **high-risk** clinical features.- Using **antipyretics** like paracetamol may mask signs of worsening infection and does not address the underlying **pathogen**.*Obtain blood cultures, commence intravenous antibiotics, and perform lumbar puncture once antibiotics have been administered*- Performing a **lumbar puncture** after antibiotics have been started can **sterilize the CSF**, making it difficult to identify the causative organism and tailor treatment.- Unless the patient is **hemodynamically unstable** or showing signs of raised **intracranial pressure**, the LP should precede the first dose of antibiotics.
Question 47: A 10-year-old girl with known asthma presents to the emergency department with wheeze and breathlessness that started 4 hours ago. She uses her salbutamol inhaler 4-6 times per week and beclometasone 200 micrograms twice daily. On examination, she can speak in full sentences, has mild intercostal recession, respiratory rate 28/min, heart rate 110 bpm, oxygen saturation 96% on air, and peak flow 65% of her best. Chest auscultation reveals widespread polyphonic wheeze. Following administration of nebulised salbutamol, her peak flow improves to 80% predicted and she has no recession. What is the most appropriate next step in management?
- A. Discharge home with a 3-day course of oral prednisolone, advice to continue regular preventer, and arrange GP follow-up within 2 days (Correct Answer)
- B. Admit for observation overnight with regular salbutamol nebulisers and commence oral prednisolone
- C. Discharge immediately with advice to use salbutamol inhaler as needed and return if symptoms worsen
- D. Administer ipratropium bromide nebuliser and observe for a further hour before making discharge decision
- E. Commence oral prednisolone and observe in the emergency department for 4 hours before reassessment
Explanation: ***Discharge home with a 3-day course of oral prednisolone, advice to continue regular preventer, and arrange GP follow-up within 2 days*** - The patient presented with **moderate acute asthma** (PEFR 65%, able to speak sentences) and demonstrated a **good response** to initial salbutamol, with PEFR improving to 80% and recession resolving. - For a good responder, discharge is appropriate with a short course of **oral corticosteroids** (e.g., prednisolone for 3-5 days) to reduce inflammation and prevent relapse, along with mandatory **GP follow-up within 2 days** to review control and address frequent reliever use. *Admit for observation overnight with regular salbutamol nebulisers and commence oral prednisolone* - **Admission** is not indicated here as the patient demonstrated a **good clinical response** to initial treatment, achieving a PEFR >75% and resolution of mild respiratory distress signs. - Overnight observation and regular nebulisers are typically reserved for patients with **severe acute asthma**, those with a **poor response** to initial treatment, or individuals at high risk of deterioration. *Discharge immediately with advice to use salbutamol inhaler as needed and return if symptoms worsen* - Discharging without a course of **oral corticosteroids** (like prednisolone) is inappropriate, as they are crucial for resolving underlying airway inflammation and preventing **early relapse** after an acute exacerbation. - Safe discharge requires a structured **asthma action plan**, specific advice on regular preventer use, and **scheduled follow-up**, rather than just general advice to return if symptoms worsen. *Administer ipratropium bromide nebuliser and observe for a further hour before making discharge decision* - **Ipratropium bromide** is an anticholinergic bronchodilator usually reserved for **severe or life-threatening asthma exacerbations** or when there is an inadequate response to **beta-agonists** alone. - Since the patient had a **good response** to salbutamol (PEFR 80%, no recession), adding ipratropium bromide is not necessary and would unnecessarily prolong the emergency department stay. *Commence oral prednisolone and observe in the emergency department for 4 hours before reassessment* - While commencing oral prednisolone is correct, a mandatory **4-hour observation** in the emergency department is generally not required for patients who have shown a **good and sustained response** to initial treatment and are clinically stable. - Guidelines suggest that children can be discharged once stable with adequate PEFR and oxygen saturations, and can manage **4-hourly inhaled bronchodilators** at home, indicating prolonged observation after starting steroids isn't routine for well-responding moderate cases.
Question 48: What is the recommended definition of fever in a child under 5 years of age according to NICE guidelines for assessment of febrile illness in children?
- A. Temperature of 38°C or above (Correct Answer)
- B. Temperature of 37.5°C or above
- C. Temperature of 38.5°C or above
- D. Temperature of 37.8°C or above measured axillary
- E. Temperature more than 1°C above the child's normal baseline
Explanation: ***Temperature of 38°C or above*** - According to **NICE guideline [NG143/CG160]**, fever in children under 5 years is clinically defined as a temperature of **38°C (100.4°F)** or higher. - This threshold is critical for the **Traffic Light System** used to risk-stratify children for serious illness, particularly for infants under 3 months who are considered **high risk (red)** at this level. *Temperature of 37.5°C or above* - While 37.5°C is often considered the upper limit of **normal body temperature**, it does not meet the formal diagnostic criteria for fever according to NICE. - Using this lower threshold would lead to **over-diagnosis** and potentially unnecessary **clinical investigation** for serious bacterial infections. *Temperature of 38.5°C or above* - A temperature of 38.5°C is a significantly high reading but is not the **baseline definition** for the onset of fever according to NICE. - Setting the definition this high would delay the identification of **febrile illness** and potentially miss infants requiring urgent assessment. *Temperature of 37.8°C or above measured axillary* - **Axillary measurements** are recommended for infants and young children, but the numerical threshold for fever remains **38°C** regardless of the site. - NICE specifically advises against using 37.8°C as a definitive cutoff, as it does not align with the validated risk **stratification tools**. *Temperature more than 1°C above the child's normal baseline* - Although a rise from **baseline temperature** indicates a change in health, NICE requires an **absolute numerical value** for standardized assessment. - Subjective parent reports or relative changes are not sufficient to trigger the **fever management pathways** without a documented reading of 38°C.
Question 49: A 20-month-old girl presents with a 5-day history of fever ranging from 38.5°C to 40.1°C. She has been irritable but has no focal symptoms. Examination reveals bilateral non-exudative conjunctival injection, erythematous cracked lips, cervical lymphadenopathy with nodes measuring 2cm, and a polymorphous rash on the trunk. Her hands and feet appear oedematous. Blood results show: Hb 105 g/L, WCC 16.8 × 10⁹/L, platelets 485 × 10⁹/L, CRP 128 mg/L, ESR 72 mm/hr. What is the most appropriate initial management?
- A. Arrange urgent echocardiography and commence intravenous immunoglobulin and high-dose aspirin (Correct Answer)
- B. Commence broad-spectrum intravenous antibiotics after blood cultures and perform lumbar puncture
- C. Administer oral prednisolone and arrange outpatient rheumatology follow-up within one week
- D. Perform viral throat swab, commence supportive treatment, and arrange follow-up in 48 hours
- E. Administer intravenous ceftriaxone and arrange urgent ophthalmology review for uveitis screening
Explanation: ***Arrange urgent echocardiography and commence intravenous immunoglobulin and high-dose aspirin*** - The patient's presentation with persistent fever, bilateral non-exudative conjunctival injection, erythematous cracked lips, cervical lymphadenopathy, polymorphous rash, and oedematous extremities fulfills the diagnostic criteria for **Kawasaki disease**. - **Intravenous immunoglobulin (IVIG)** is crucial to reduce the risk of **coronary artery aneurysms**, and **high-dose aspirin** is used for its anti-inflammatory effects in the acute phase, alongside an **echocardiogram** to assess cardiac involvement. *Commence broad-spectrum intravenous antibiotics after blood cultures and perform lumbar puncture* - This approach is geared towards severe bacterial infections like **sepsis** or **meningitis**, which is less consistent with the specific mucocutaneous findings and extremity changes seen in this child. - Delaying specific treatment for Kawasaki disease, such as **IVIG**, significantly increases the risk of **coronary artery complications**. *Administer oral prednisolone and arrange outpatient rheumatology follow-up within one week* - While **corticosteroids** may be used in IVIG-refractory Kawasaki disease or in conjunction with IVIG in high-risk cases, they are not the primary initial monotherapy. - **Outpatient follow-up** is inadequate for acute Kawasaki disease, which requires urgent inpatient management due to the risk of acute cardiac complications like **myocardial infarction**. *Perform viral throat swab, commence supportive treatment, and arrange follow-up in 48 hours* - The constellation of symptoms, significantly elevated **inflammatory markers (CRP, ESR)**, and **thrombocytosis** strongly indicates a systemic inflammatory process, not a benign viral illness amenable to supportive care and delayed follow-up. - This approach would miss the critical window for intervention, leading to potential irreversible **coronary artery damage**. *Administer intravenous ceftriaxone and arrange urgent ophthalmology review for uveitis screening* - **Ceftriaxone** is an antibiotic and is ineffective for the inflammatory vasculitis of Kawasaki disease. - While **uveitis** can be a feature, the primary life-threatening complication in Kawasaki disease is **coronary artery involvement**, making a general ophthalmology review not the most urgent or appropriate initial step in management.
Question 50: A 7-year-old boy with known asthma is brought to the emergency department by ambulance. He is sitting forward, using accessory muscles, and speaking in single words. His observations show: heart rate 145 bpm, respiratory rate 38/min, oxygen saturation 89% on air, and peak expiratory flow rate 35% of predicted. Auscultation reveals silent chest bilaterally. What is the most appropriate immediate management?
- A. Administer high-flow oxygen, nebulised salbutamol and ipratropium, oral prednisolone, and inform senior clinician urgently (Correct Answer)
- B. Administer high-flow oxygen, intravenous salbutamol, intravenous aminophylline, and prepare for intubation
- C. Administer oxygen to maintain saturations 94-98%, nebulised salbutamol via spacer device, and oral prednisolone
- D. Administer intravenous magnesium sulphate, high-flow oxygen, and continuous nebulised salbutamol
- E. Obtain urgent arterial blood gas, give high-flow oxygen, and commence intravenous hydrocortisone
Explanation: ***Administer high-flow oxygen, nebulised salbutamol and ipratropium, oral prednisolone, and inform senior clinician urgently*** - The patient exhibits features of **life-threatening asthma**, including a **silent chest**, severe **hypoxia** (SpO2 89%), and inability to speak in full sentences. - Immediate management for **life-threatening asthma** requires **high-flow oxygen**, dual **nebulised bronchodilators** (salbutamol and ipratropium), systemic **corticosteroids** (oral prednisolone), and urgent **escalation to senior clinicians**. *Administer high-flow oxygen, intravenous salbutamol, intravenous aminophylline, and prepare for intubation* - **Intravenous bronchodilators** and **aminophylline** are typically second-line treatments for patients who are refractory to initial **nebulised therapy**, not the immediate first-line choice. - While critical, **intubation** is a last resort; the immediate priority is aggressive medical management to improve respiratory function and avoid mechanical ventilation. *Administer oxygen to maintain saturations 94-98%, nebulised salbutamol via spacer device, and oral prednisolone* - Maintaining saturations 94-98% is too conservative for a patient with **life-threatening asthma** and severe hypoxia (SpO2 89%); **high-flow oxygen** is needed to achieve higher saturations quickly. - A **spacer device** is inappropriate for **life-threatening asthma**; oxygen-driven **nebulisers** are required to deliver high-dose bronchodilators effectively in this severe presentation. *Administer intravenous magnesium sulphate, high-flow oxygen, and continuous nebulised salbutamol* - **Intravenous magnesium sulphate** is an important adjunct for severe cases but is usually considered after initial dual **nebulised bronchodilators** and **steroids** have been given. - This option misses the crucial addition of **ipratropium bromide** alongside salbutamol, which is a standard component of initial management for **life-threatening asthma**, and the systemic **corticosteroids**. *Obtain urgent arterial blood gas, give high-flow oxygen, and commence intravenous hydrocortisone* - An **arterial blood gas (ABG)** is an invasive and painful procedure that can cause distress and worsen bronchospasm; it should **not delay** the immediate administration of life-saving medical treatment. - While **high-flow oxygen** and systemic **corticosteroids** are appropriate, this option crucially omits the immediate and essential administration of **nebulised bronchodilators** to relieve severe airway obstruction.
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