Chronic Paediatric Conditions — MCQs
On this page
A 13-year-old girl with type 1 diabetes presents with an HbA1c of 82 mmol/mol despite good reported adherence to her insulin regimen. Review of her blood glucose diary shows consistently well-controlled readings between 4-8 mmol/L. Her download data from the glucose meter indicates readings were taken on only 15% of days in the last 3 months. She appears anxious during consultation. Her mother is present and very concerned about diabetes control. What is the most likely explanation for the discrepancy?
Which of the following insulin types has the longest duration of action when used in paediatric type 1 diabetes management?
A 15-year-old boy with type 1 diabetes mellitus for 8 years attends for annual screening. His HbA1c is 68 mmol/mol. Urine albumin:creatinine ratio is 4.5 mg/mmol on two separate occasions. Blood pressure is 118/72 mmHg. Fundoscopy is normal. What is the most appropriate next step in management?
A 6-year-old girl with newly diagnosed childhood absence epilepsy requires anti-epileptic drug therapy. She has typical absence seizures occurring 10-20 times daily with 3 Hz spike-and-wave activity on EEG. Her mother had similar seizures as a child. There is no history of learning difficulties. Which anti-epileptic medication is first-line treatment?
A 10-year-old boy with type 1 diabetes presents with a 3-day history of polyuria, polydipsia, and weight loss of 2 kg. Blood tests show: glucose 25 mmol/L, pH 7.38, bicarbonate 22 mmol/L, ketones 1.5 mmol/L. He is alert and well-perfused. Which condition best describes his presentation?
A 4-year-old girl has a 2-minute episode of blank staring with lip-smacking movements. She is unresponsive during the episode and afterwards appears confused for 3 minutes. Her developmental history is normal. Which type of seizure has she most likely experienced?
A 14-year-old boy with type 1 diabetes is admitted with his third episode of diabetic ketoacidosis in 6 months. Each admission has occurred when his parents were away. His HbA1c is 95 mmol/mol. During the admission, the nursing staff note that he disconnects his insulin pump for prolonged periods and appears disinterested in his diabetes management. He lives with his parents and younger sister. What is the most important immediate action?
A 12-year-old girl with a 6-month history of absence seizures is commenced on ethosuximide. Her EEG shows typical 3 Hz spike-and-wave discharges. After 4 weeks of treatment at an appropriate dose, her mother reports that the absence seizures have stopped but she has now had two generalized tonic-clonic seizures. What is the most likely explanation for this development?
A 9-year-old boy with type 1 diabetes for 3 years attends clinic for routine review. His HbA1c has increased from 58 mmol/mol to 75 mmol/mol over the past 6 months. He is currently on a basal-bolus insulin regimen with insulin detemir twice daily and insulin aspart before meals. His total daily dose is 0.9 units/kg/day. Blood glucose monitoring shows fasting levels of 12-15 mmol/L and post-prandial levels of 8-12 mmol/L. What is the most appropriate adjustment to his insulin regimen?
A 5-year-old girl is witnessed having a generalized tonic-clonic seizure at school lasting 8 minutes. On arrival of the ambulance crew, the seizure continues. She has no previous history of seizures. Which medication should be administered first?
Chronic Paediatric Conditions UK Medical PG Practice Questions and MCQs
Question 151: A 13-year-old girl with type 1 diabetes presents with an HbA1c of 82 mmol/mol despite good reported adherence to her insulin regimen. Review of her blood glucose diary shows consistently well-controlled readings between 4-8 mmol/L. Her download data from the glucose meter indicates readings were taken on only 15% of days in the last 3 months. She appears anxious during consultation. Her mother is present and very concerned about diabetes control. What is the most likely explanation for the discrepancy?
- A. She has developed haemoglobinopathy affecting HbA1c measurement
- B. Her insulin has been stored incorrectly and has lost potency
- C. The HbA1c result is spurious and should be repeated
- D. She is fabricating blood glucose results to avoid parental conflict (Correct Answer)
- E. She has undiagnosed coeliac disease causing erratic glucose absorption
Explanation: ***She is fabricating blood glucose results to avoid parental conflict*** - The marked discrepancy between a high **HbA1c (82 mmol/mol)** and a "perfect" manual logbook (4-8 mmol/L), paired with a **glucose meter download** showing data for only 15% of days, confirms the diary is inaccurate. - This behavior, often seen in **adolescent patients**, is frequently a coping mechanism to manage **parental pressure** or anxiety regarding disease control without actual adherence.*She has developed haemoglobinopathy affecting HbA1c measurement* - **Haemoglobinopathies** can interfere with HbA1c readings, but they do not explain the lack of physical data on the **meter download** or the fabricated diary. - A false HbA1c due to haemoglobinopathy would typically occur in an asymptomatic patient with stable, non-discordant actual meter readings.*Her insulin has been stored incorrectly and has lost potency* - Loss of **insulin potency** would lead to persistently high blood glucose levels on the meter, matching the high HbA1c, contradicting the reported normal readings. - This explanation fails to account for the critical finding that the **glucose meter hardware** reflects minimal testing activity over the past three months.*The HbA1c result is spurious and should be repeated* - While lab errors can occur, the objective evidence from the **glucose meter download** (data for only 15% of days) strongly suggests that the reported blood glucose levels are not real. - The clinical context of **anxiety** and parental concern points more towards a behavioral issue rather than a laboratory error.*She has undiagnosed coeliac disease causing erratic glucose absorption* - **Coeliac disease**, while common in Type 1 Diabetes, typically causes **erratic blood sugars** (hypo- or hyperglycemia) due to malabsorption, not consistently
Question 152: Which of the following insulin types has the longest duration of action when used in paediatric type 1 diabetes management?
- A. Insulin aspart
- B. Insulin detemir
- C. Insulin glargine U300 (Correct Answer)
- D. Insulin lispro
- E. Neutral protamine Hagedorn (NPH) insulin
Explanation: ***Insulin glargine U300*** - **Insulin glargine U300** is an ultra-long-acting basal insulin analogue with a duration of action typically extending up to **30-36 hours**. - Its more concentrated formulation allows for a **flatter pharmacological profile** and a longer duration compared to standard U100 basal insulins. *Insulin aspart* - This is a **rapid-acting insulin** analogue with a very short duration of action, typically only **3-5 hours**. - It is used for **prandial (mealtime)** bolus coverage rather than basal glucose control. *Insulin detemir* - This is a long-acting insulin with a duration of action ranging from **18-24 hours**, which is significantly shorter than U300 glargine. - In many children, its effective duration necessitates **twice-daily dosing** to maintain stable basal insulin levels. *Insulin lispro* - Like aspart, lispro is a **rapid-acting insulin** analogue used to manage postprandial glucose spikes with a duration of **3-5 hours**. - It lacks the sustained release mechanism required for **24-hour basal** management. *Neutral protamine Hagedorn (NPH) insulin* - This is an **intermediate-acting insulin** with a duration of action usually lasting between **12-18 hours**. - It has a distinct **peak of action**, making it less stable as a basal insulin than modern long-acting analogues.
Question 153: A 15-year-old boy with type 1 diabetes mellitus for 8 years attends for annual screening. His HbA1c is 68 mmol/mol. Urine albumin:creatinine ratio is 4.5 mg/mmol on two separate occasions. Blood pressure is 118/72 mmHg. Fundoscopy is normal. What is the most appropriate next step in management?
- A. Reassure that this is normal and continue annual screening
- B. Commence an ACE inhibitor (Correct Answer)
- C. Repeat testing in 3 months before making any changes
- D. Refer to paediatric nephrology urgently
- E. Increase the frequency of screening to 6-monthly
Explanation: ***Commence an ACE inhibitor*** - This patient has **confirmed microalbuminuria**, defined by an **albumin:creatinine ratio (ACR) of 4.5 mg/mmol** on two separate occasions, indicating early **diabetic nephropathy**. - In Type 1 Diabetes, **ACE inhibitors** are the recommended first-line treatment for **microalbuminuria** to provide **renoprotection** and slow the progression of kidney disease, even with **normal blood pressure**. *Reassure that this is normal and continue annual screening* - An **ACR of 4.5 mg/mmol** falls within the range for **microalbuminuria (3-30 mg/mmol)**, which is an abnormal finding and a marker of early kidney damage in diabetes. - Reassurance would be inappropriate as it delays necessary intervention to prevent further **renal deterioration**. *Repeat testing in 3 months before making any changes* - The diagnosis of **microalbuminuria** requires an elevated ACR on **two out of three samples** within a 3-6 month period, which has already been met in this case by
Question 154: A 6-year-old girl with newly diagnosed childhood absence epilepsy requires anti-epileptic drug therapy. She has typical absence seizures occurring 10-20 times daily with 3 Hz spike-and-wave activity on EEG. Her mother had similar seizures as a child. There is no history of learning difficulties. Which anti-epileptic medication is first-line treatment?
- A. Sodium valproate
- B. Ethosuximide (Correct Answer)
- C. Lamotrigine
- D. Levetiracetam
- E. Carbamazepine
Explanation: ***Ethosuximide***- **Ethosuximide** is the first-line treatment for **childhood absence epilepsy** (CAE) when absence seizures are the only seizure type due to its high efficacy and favorable safety profile.- It specifically targets **T-type calcium channels** in the thalamus, which are responsible for the characteristic **3 Hz spike-and-wave** discharges seen on EEG.*Sodium valproate*- While highly effective, it is no longer first-line for females of childbearing potential due to significant risks of **teratogenicity** and neurodevelopmental delays, making ethosuximide a safer initial choice.- It is generally reserved for cases where ethosuximide is ineffective or if there are concurrent **generalized tonic-clonic seizures**.*Lamotrigine*- This is considered a **second-line** option if ethosuximide or sodium valproate are either not tolerated or fail to control seizures.- It carries a risk of **Stevens-Johnson syndrome** and is generally less effective than ethosuximide for controlling absence seizures.*Levetiracetam*- Although widely used for focal and generalized seizures, it is not established as first-line therapy for **isolated absence epilepsy**.- Clinical trials have shown it to be less effective than ethosuximide and valproate in maintaining **seizure freedom** for this specific syndrome.*Carbamazepine*- This medication is **contraindicated** in generalized epilepsies such as CAE because it can worsen or precipitate **absence seizures** and myoclonus.- Its mechanism of action on **sodium channels** is effective for focal seizures but exacerbates the thalamocortical rhythms of absence epilepsy.
Question 155: A 10-year-old boy with type 1 diabetes presents with a 3-day history of polyuria, polydipsia, and weight loss of 2 kg. Blood tests show: glucose 25 mmol/L, pH 7.38, bicarbonate 22 mmol/L, ketones 1.5 mmol/L. He is alert and well-perfused. Which condition best describes his presentation?
- A. Diabetic ketoacidosis
- B. Hyperglycaemic hyperosmolar state
- C. Hyperglycaemia with ketonaemia (Correct Answer)
- D. Hyperosmolar hyperglycaemic state with ketosis
- E. Compensated metabolic acidosis
Explanation: ***Hyperglycaemia with ketonaemia*** - The patient exhibits **hyperglycaemia** (25 mmol/L) and elevated **blood ketones** (1.5 mmol/L) but lacks the biochemical criteria for **diabetic ketoacidosis** (DKA). - Since the **pH** is normal (7.38) and the **bicarbonate** is within the reference range (22 mmol/L), the patient is in a state of metabolic decompensation that has not yet progressed to acidosis. *Diabetic ketoacidosis* - DKA requires a triad of hyperglycaemia, ketonaemia (**>3.0 mmol/L**), and **acidosis** defined by a **pH <7.3** or **bicarbonate <15 mmol/L**. - This patient is alert and well-perfused with a normal pH, failing to meet the mandatory **acidotic criteria** for this diagnosis. *Hyperglycaemic hyperosmolar state* - This condition is rare in **Type 1 Diabetes** and typically presents with extreme hyperglycaemia (often **>30 mmol/L**) and profound dehydration. - It is characterized by high **serum osmolality** and a lack of significant ketonaemia, which contradicts the presence of ketones in this boy. *Hyperosmolar hyperglycaemic state with ketosis* - This is a mixed presentation usually seen in Type 2 Diabetes where **hyperosmolarity** is the dominant feature alongside modest ketone production. - The clinical picture here is a straightforward insulin deficiency in **Type 1 Diabetes**, lacking the extreme glucose levels and dehydration associated with hyperosmolar states. *Compensated metabolic acidosis* - Compensated metabolic acidosis would present with a **low bicarbonate** and a low **pCO2** to maintain a near-normal pH. - In this case, the **bicarbonate** is completely normal (22 mmol/L), indicating that no significant metabolic acid load has been generated yet.
Question 156: A 4-year-old girl has a 2-minute episode of blank staring with lip-smacking movements. She is unresponsive during the episode and afterwards appears confused for 3 minutes. Her developmental history is normal. Which type of seizure has she most likely experienced?
- A. Absence seizure
- B. Focal seizure with impaired awareness (Correct Answer)
- C. Atonic seizure
- D. Focal aware seizure
- E. Myoclonic seizure
Explanation: ***Focal seizure with impaired awareness*** - The duration of **2 minutes**, coupled with **blank staring**, **lip-smacking automatisms**, and **unresponsiveness** during the episode, are classic features of a focal seizure with impaired awareness (formerly complex partial seizure). - The subsequent **3 minutes of confusion** (post-ictal confusion) is a key indicator, as it commonly follows this type of seizure, reflecting the brain's recovery phase. *Absence seizure* - Absence seizures are typically very brief (**5-20 seconds**), involve staring, but usually lack prominent complex automatisms like lip-smacking and are not followed by significant **post-ictal confusion**. - The patient typically returns to full baseline awareness almost immediately after the episode, unlike the prolonged confusion described here. *Atonic seizure* - Atonic seizures are characterized by a sudden, brief **loss of muscle tone**, leading to **"drop attacks"** or head drops. - The clinical presentation does not describe a loss of muscle tone or falling, making this diagnosis unlikely. *Focal aware seizure* - In a focal aware seizure (formerly simple partial seizure), the individual retains **full consciousness** and awareness throughout the event and can typically recall what happened. - The patient's **unresponsiveness** during the episode and subsequent **confusion** clearly rule out a focal aware seizure. *Myoclonic seizure* - Myoclonic seizures present as sudden, **brief, shock-like muscle jerks** without loss of consciousness or a significant post-ictal state. - The described symptoms of prolonged staring, lip-smacking, unresponsiveness, and post-ictal confusion are inconsistent with a myoclonic seizure.
Question 157: A 14-year-old boy with type 1 diabetes is admitted with his third episode of diabetic ketoacidosis in 6 months. Each admission has occurred when his parents were away. His HbA1c is 95 mmol/mol. During the admission, the nursing staff note that he disconnects his insulin pump for prolonged periods and appears disinterested in his diabetes management. He lives with his parents and younger sister. What is the most important immediate action?
- A. Refer to child and adolescent mental health services for assessment of depression
- B. Arrange a safeguarding meeting to assess risk of neglect (Correct Answer)
- C. Switch from insulin pump therapy to multiple daily injections
- D. Refer to the diabetes psychology team for assessment and support
- E. Arrange for district nursing support for insulin administration
Explanation: ***Arrange a safeguarding meeting to assess risk of neglect*** - Recurrent **diabetic ketoacidosis (DKA)**, especially when associated with parental absence, intentional non-adherence (disconnecting insulin pump), and poor glycemic control (**HbA1c 95 mmol/mol**), are major **red flags** for medical neglect. - A **safeguarding meeting** is the most important immediate action to protect the child from further harm and formally evaluate whether the lack of supervision or engagement constitutes a **child protection** concern. *Refer to child and adolescent mental health services for assessment of depression* - While **depression** can contribute to poor self-care in adolescents with chronic conditions, the immediate concern here is the life-threatening physical risk posed by recurrent **DKA**. - Assessment for depression, though important, should follow once the **immediate safety** and safeguarding protocols have been initiated to prevent acute medical emergencies. *Switch from insulin pump therapy to multiple daily injections* - Changing the **insulin delivery method** does not address the underlying issue of intentional non-adherence or the suspected **medical neglect** and lack of parental supervision. - If the child is deliberately disconnecting the pump, they are likely to continue poor adherence with multiple daily injections, keeping them at high risk for **DKA**. *Refer to the diabetes psychology team for assessment and support* - Psychology input is crucial for long-term management of **chronic conditions** and adherence issues, but it is not the immediate priority when a **safeguarding** concern involving life-threatening events is identified. - Formal safeguarding processes must take precedence to ensure the patient's immediate **safety** and involve multi-agency oversight. *Arrange for district nursing support for insulin administration* - This approach might provide a temporary solution for insulin administration but fails to address the critical issues of **parental supervision**, the child's disinterest, and the potential **medical neglect**. - It shifts responsibility without addressing the root causes of non-adherence and the high risk for recurrent **DKA**.
Question 158: A 12-year-old girl with a 6-month history of absence seizures is commenced on ethosuximide. Her EEG shows typical 3 Hz spike-and-wave discharges. After 4 weeks of treatment at an appropriate dose, her mother reports that the absence seizures have stopped but she has now had two generalized tonic-clonic seizures. What is the most likely explanation for this development?
- A. The absence seizures were misdiagnosed and she actually has juvenile myoclonic epilepsy
- B. Ethosuximide has unmasked underlying generalized tonic-clonic seizures that were not previously apparent (Correct Answer)
- C. The ethosuximide dose is too low and seizure control is inadequate
- D. She has developed juvenile absence epilepsy which has naturally progressed
- E. She has developed drug-induced seizures as a side effect of ethosuximide
Explanation: ***Ethosuximide has unmasked underlying generalized tonic-clonic seizures that were not previously apparent*** - **Ethosuximide** is highly effective for treating **absence seizures** but provides no protection against **generalized tonic-clonic seizures (GTCS)**. - Approximately 40% of patients with **childhood absence epilepsy** also have a predisposition to GTCS, which may only become clinically evident once the absence seizures are controlled. *The absence seizures were misdiagnosed and she actually has juvenile myoclonic epilepsy* - The **3 Hz spike-and-wave discharges** are pathognomonic for **childhood absence epilepsy**, whereas JME typically shows faster 4-6 Hz polyspike-and-wave patterns. - **Juvenile myoclonic epilepsy** usually presents in a slightly older age group and is characterized primarily by early morning **myoclonic jerks**. *The ethosuximide dose is too low and seizure control is inadequate* - The patient's **absence seizures have stopped**, which indicates that the ethosuximide dose is pharmacologically **adequate** for its intended target. - Increasing the dose of **ethosuximide** would not prevent GTCS, as the drug lacks the mechanism of action required to stabilize generalized motor seizures. *She has developed juvenile absence epilepsy which has naturally progressed* - While some patients with **juvenile absence epilepsy** develop GTCS, the prompt appearance of these seizures exactly at 4 weeks suggests **unmasking** rather than natural progression. - **Childhood absence epilepsy** (the likely diagnosis at age 12) and JAE are separate clinical syndromes; the timing here strongly correlates with the initiation of specific therapy. *She has developed drug-induced seizures as a side effect of ethosuximide* - **Ethosuximide** does not typically possess **pro-convulsant** properties that trigger new seizure types as a direct side effect. - The onset of GTCS is a reflection of the drug's **narrow spectrum** of activity rather than a toxic or idiosyncratic drug reaction.
Question 159: A 9-year-old boy with type 1 diabetes for 3 years attends clinic for routine review. His HbA1c has increased from 58 mmol/mol to 75 mmol/mol over the past 6 months. He is currently on a basal-bolus insulin regimen with insulin detemir twice daily and insulin aspart before meals. His total daily dose is 0.9 units/kg/day. Blood glucose monitoring shows fasting levels of 12-15 mmol/L and post-prandial levels of 8-12 mmol/L. What is the most appropriate adjustment to his insulin regimen?
- A. Increase the insulin aspart doses by 10%
- B. Increase the morning insulin detemir dose by 10%
- C. Increase the evening insulin detemir dose by 10% (Correct Answer)
- D. Switch from insulin detemir to insulin glargine
- E. Add metformin to improve insulin sensitivity
Explanation: ***Increase the evening insulin detemir dose by 10%*** - The patient's **fasting blood glucose** levels (12-15 mmol/L) are significantly elevated, while post-prandial levels (8-12 mmol/L) are relatively closer to target, indicating inadequate **overnight basal insulin** coverage. - In a twice-daily insulin detemir regimen, the **evening dose** is responsible for controlling hepatic glucose production and maintaining stable glucose levels throughout the night, directly impacting the **fasting glucose** reading. *Increase the insulin aspart doses by 10%* - **Insulin aspart** is a rapid-acting insulin used to manage post-meal glucose excursions. The patient's **post-prandial levels** are relatively controlled (8-12 mmol/L). - Increasing rapid-acting insulin when post-prandial levels are not the main issue could lead to **hypoglycemia** after meals, without addressing the primary problem of **fasting hyperglycemia**. *Increase the morning insulin detemir dose by 10%* - The **morning dose of insulin detemir** provides basal insulin coverage for the daytime hours, primarily affecting glucose levels before lunch and dinner. - This adjustment would not effectively correct the **elevated fasting glucose** observed in the morning, which points to insufficient overnight basal support. *Switch from insulin detemir to insulin glargine* - Both **insulin detemir** and **insulin glargine** are long-acting basal insulins. There is no indication that detemir itself is ineffective, but rather that its current dose is suboptimal. - The initial approach should be to **titrate the current regimen** based on blood glucose patterns before considering a change in insulin type. *Add metformin to improve insulin sensitivity* - **Metformin** is primarily used in **Type 2 Diabetes** to reduce hepatic glucose production and improve insulin sensitivity. - It is not a standard treatment for **Type 1 Diabetes** in children, where the fundamental problem is absolute insulin deficiency requiring exogenous insulin replacement.
Question 160: A 5-year-old girl is witnessed having a generalized tonic-clonic seizure at school lasting 8 minutes. On arrival of the ambulance crew, the seizure continues. She has no previous history of seizures. Which medication should be administered first?
- A. Intravenous lorazepam 0.1 mg/kg
- B. Buccal midazolam 10 mg (Correct Answer)
- C. Rectal diazepam 5 mg
- D. Intravenous phenytoin 20 mg/kg
- E. Intramuscular paraldehyde 0.4 mL/kg
Explanation: ***Buccal midazolam 10 mg***- In a **pre-hospital setting** or when **intravenous access** is not established, **buccal midazolam** is the first-line treatment for a prolonged seizure (status epilepticus).- It is preferred over other routes due to its ease of administration, rapid absorption through the **buccal mucosa**, and greater **social acceptability**.*Intravenous lorazepam 0.1 mg/kg*- While **IV lorazepam** is the gold standard for hospital-based management, it requires **intravenous access**, which is typically not available immediately upon the ambulance crew's arrival.- Establishing IV access in a convulsing child is technically difficult and can cause unnecessary delays in delivering **anti-epileptics**.*Rectal diazepam 5 mg*- **Rectal diazepam** was previously the standard pre-hospital treatment but has been largely replaced by **buccal midazolam** in clinical guidelines.- It has a slower onset of action compared to buccal routes and is considered less **socially acceptable** in public or school environments.*Intravenous phenytoin 20 mg/kg*- **Phenytoin** is a **second-line** agent used in the management of status epilepticus after the failure of two doses of **benzodiazepines**.- It requires cardiac monitoring during administration due to the risk of **arrhythmias** and hypotension, making it unsuitable as an initial treatment.*Intramuscular paraldehyde 0.4 mL/kg*- **Paraldehyde** is rarely used in modern emergency protocols and is generally reserved for refractory cases when other **benzodiazepines** have failed.- It must be administered using a **glass syringe** as it reacts with plastic, making it impractical for rapid first-line use by emergency crews.
Practice by Chapter
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free