🤔 MEDIUM

I’ve had enough.  This is the final time I write some questions about kids with toilet issues.  Here is part three of three … good luck! 

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paed CBH 3

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Question 1

Stem 1 of 3

A 5 month-old female presents with vomiting, irritability and bright-red blood per rectum. This has occurred secondary to a recent viral upper respiratory tract infection.
Which is the best-matched diagnosis?
A
Duodenal atresia
B
Gastroenteritis
C
Intussusception
D
Pyloric stenosis
E
Sigmoid volvulus
Question 1 Explanation: 
Intussusception is classically seen (especially in MCQs/SBAs) as a paediatric obstructive bowel picture secondarily, and acutely, linked to a prodrome of a viral infection. There is haematochezia “currant jelly” if there is ischaemia in the later-stage.
Question 2

Stem 2 of 3

Which of the following is a suitable set of investigations to order? Select all which may apply.  
A
Abdominal ultrasound scan
B
Abdominal X-ray
C
Abdominal CT non-contrast
D
Abdominal CT contrast
E
Diagnostic enema
Question 2 Explanation: 
Classically, intussusception benefits from plain radiography, ultrasound (at the bedside) and a diagnostic enema - the latter of which can be converted to a treatment as air is blown into the lumen of the colon.
Question 3

Stem 3 of 3

What is the first-line approach to management?
A
Fluids and conservative waiting
B
Hartmann’s procedure
C
Interventional radiology stenting
D
Therapeutic air enema
E
Whipple procedure
Question 4

Stem 1 of 4

A three week old male presents with repeat episodes of vomiting (non-green in colour). There is notable dehydration and an olive-shaped mass in the RUQ on exam.
Hypertrophy of which region is causing the palpable mass?
A
Adventitia
B
Mucosa
C
Muscularis propria
D
Serosa
E
Submucosa
Question 4 Explanation: 
The pyloric stenosis is due to hypertrophy of the muscularis propria of the gastrointestinal tract’s wall in the gastric pylorus.
Question 5

Stem 2 of 4

An ABG is performed. Which finding best-matches the more likely result?
A
Euchloremic metabolic acidosis
B
Hyperchloremic metabolic acidosis
C
Hyperchloremic metabolic alkalosis
D
Hypochloremic metabolic acidosis
E
Hypochloremic metabolic alkalosis
Question 5 Explanation: 
The vomiting +++ second to the stenosis leads to loss of chloride and protons (H+) from the gastric mucosa (literally stomach acid, HCl) … this results in a dual state of alkalosis and a hypochloraemia. Its a bit more complicated than this, but its a nice way to remember the examinable ABG findings.
Question 6

Stem 3 of 4

What is the key investigative step to confirm the diagnosis?
A
Abdominal CT scan with contrast
B
Abdominal MR angiography
C
Abdominal plain X-ray
D
Abdominal ultrasound scan
E
Pelvic ultrasound scan
Question 6 Explanation: 
First line for pyloric stenosis, after a characteristic examination is to probe (USS) the region to confirm the hypertrophic muscle.
Question 7

Stem 4 of 4

Which eponymously-named surgery is performed in this patient?
A
Ramhorn’s procedure
B
Ramstedt’s procedure
C
Reynauld’s procedure
D
Rigley’s procedure
E
Rorshack’s procedure
Question 7 Explanation: 
Randstad’s pyloromyotomy literally shears away the hypertrophied musculature to increase the aperture for the emptying of gastric fluids into the proximal (first) portion of the duodenum. Specific details of operations, beyond outlines, are the remit of the surgeons, not the medics. Thankfully 😛
Question 8

Stem 1 of 4

A 17 year-old female presents to their GP with complaints of fatigue and chronic constipation. They state that they have been struggling to regulate general anxiety for the last year. They have no medical history of note, and deny substance abuse. They say they feel constantly nervous, are exhausted and subsequently cannot concentrate in class.
Which validated questionnaire could be used in the primary care setting?
A
GAD1
B
GAD3
C
GAD5
D
GAD7
E
GAD11
Question 8 Explanation: 
The GAD7 questionnaire is the one recommended by NICE CKS, though others are available. Often its Trust-dependent based on what has been financed. Source: NICE CKS, 2021 “Anxiety”.
Question 9

Stem 2 of 4

The patient is offered low-intensity psychological intervention via individual guided self-help. How many sessions, according to NICE, can this patient expect to receive over the telephone?
A
1
B
5
C
10
D
15
E
20
Question 9 Explanation: 
The typical low-intensity therapy ordered first line for moderate anxiety/depression consists of 5-7 sessions over the telephone. This is increased to more sessions, in person with severity of diagnosis. Source: NICE CKS, 2021 “Anxiety”.
Question 10

Stem 3 of 4

What would be the first line therapy prescribed to this patient if CBT required this adjunct?
A
Clonazepam
B
Duloxetine
C
Risperidone
D
Sertraline
E
Venlafaxine
Question 10 Explanation: 
Prescribe an SSRI first line, usually sertraline (Source: NICE CKS, 2021 “Anxiety”).
Question 11

Stem 4 of 4

What is the maximum dose of the first-line medication offered above? (Consult the BNF, 2021)
A
25mg
B
50mg
C
100mg
D
200mg
E
250mg
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