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This is the fourth approach to child fever.  Have another crack and, as ever, beware the strawberry tongue … 

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child fever 4

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Question 1

Stem 1 of 8

During the winter, a 12 year-old male presents to his GP with a sore throat. On examination, he has pharyngeal exudate and pharyngitis visibly. He has a tender anterior cervical lymphadenopathy and a high temperature. He is complaining of nausea associated with a headache.

Which criteria should be clinically used as a pre-testing aid to aetiology?
A
Centor
B
Janeway
C
Murphy
D
Osler
E
Ramshead
Question 1 Explanation: 
The centor criteria ≥3 suggests administration of antibiotics is prudent in those with an acute sore throat.
Question 2

Stem 2 of 8

The patient does not have Koplik spots on examination. For which condition is this pathognomic?
A
Measles
B
Mumps
C
Roseola infantum
D
Rubella
E
Scarlet fever
Question 2 Explanation: 
The viral exanthema are also numbered. Measles is the first of six diseases, so can also be heard to be described as “first disease”. Scarlet fever is the second disease and so on. You can remember the top features of measles by remembering the “K’s” - Konjunctivitis, Kough, Koplik spots with massive rash.
Question 3

Stem 3 of 8

Which point-of-care test is indicated next?
A
Culture throat swab for GAS
B
Culture throat swab for gonococcal
C
PCR for GAS
D
Rapid antigen test for GAS
E
Rapid antigen test for gonococcal
Question 3 Explanation: 
A RAT for group A streptococcus pyogenes is a pertinent test once the feverPAIN/Centor criteria has suggested a pretest probability for bacterial acute pharyngitis. The administration of antibiotics should now be considered to prevent complications such as rheumatic heart disease.
Question 4

Stem 4 of 8

What is the first line antimicrobial management for this patient (NICE, 2021)?
A
Amoxicillin
B
Flucloxacillin
C
Fluoroquinolone
D
Gentamicin
E
Phenoxymethylpenicillin
Question 4 Explanation: 
NICE (CKS Acute Sore Throat) recommends phenoxymethylpenicillin as the first line agent in the non-penicillin allergic patient.
Question 5

Stem 5 of 8

Which of the following would be an acceptable threshold for the prescribing of antibiotics in sore throat? Select all which may apply.
A
Centor score 4
B
feverPAIN score 5
C
History of rheumatic fever
D
Rapid-antigen positive GAS
E
Throat culture positive GAS
Question 5 Explanation: 
“If group A streptococcus (GAS) has been confirmed as the cause of sore throat by rapid antigen testing, or is strongly suspected after applying a FeverPAIN score (score 4 or 5) or Centor score of 3 or 4, and the results of throat cultures are pending, consider prescribing antibiotics: Studies have shown that use of antibiotics for streptococcal sore throat decrease symptom duration by less than 1 day. The threshold for prescribing antibiotics should be lower in people at risk of rheumatic fever (such as people with a previous history of rheumatic fever and those living in South Africa, Australian indigenous communities, Maori communities of New Zealand, the Philippines, and many developing countries), and vulnerable groups of people who are being managed in primary care, (such as infants, very old people, and those who are immunosuppressed or immunocompromised).” - quoted directly from: NG 2021 (CKS Sore Throat “Management”)
Question 6

Stem 6 of 8

You wish to prescribe this patient some paracetamol. What is incorrect about this drug chart?
A
Drug name
B
Route of administration
C
Dose
D
Maximum frequency
E
Max doses per day
Question 6 Explanation: 
According to the CBNF (Aug, 2021), PO paracetamol can be given for pyrexia and discomfort 480–750 mg every 4–6 hours; maximum 4 doses per day. As such the drug name and dose is correct - though the units are grams, not milligrams, the maximum frequency is too often, the maximum doses are too many and the route is IV not PO. Dr Churchill made some errors.
Question 7

Stem 7 of 8

What is “fifth’s disease”?
A
Duke’s disease
B
Measles
C
Mumps
D
Rubella
E
Slapped cheek syndrome
Question 8

Stem 8 of 8

Which of the following features would suggest an acute sore throat was viral not bacterial?
A
7 years of age
B
Cervical lymphadenopathy
C
High pyrexia
D
Productive cough
E
Tonsillar exudate
Question 8 Explanation: 
All of the listed features suggest a bacterial infection on the CENTOR criteria with the exception of expectoration. In fact a productive cough, or cough of any kind, is indicative of a viral upper respiratory tract infection, over a bacterial. Be confident with either CENTOR or feverPAIN in time for finals.
Question 9

Stem 1 of 4

Three days earlier, a 14 year-old female was tackled rather nastily whilst playing football on a muddy pitch. A stud hit her knee, with a puncture wound and some bleeding. Like a good player, she got back up as soon as the red card was issued to the offender. However, the next day she has a hot, swollen L knee joint at the site of the puncture wound with generalised reduction of functional movement. She presents to ED limping.

What is the most likely diagnosis at this point?
A
Osteomyelitis
B
Patella fracture
C
Septic arthritis
D
Tibial dislocation
E
Transient synovitis
Question 10

Stem 2 of 4

Given the answer above, what is the next best step?
A
Intra-articular ceftriaxone
B
Intravenous macrolide
C
Joint aspirate for culture, crystals and cells
D
Joint washout in theatre
E
Per oral fluoroquinolone and metronidazole
Question 10 Explanation: 
All acute hot swollen joints should be aspirated urgently for cells, cultures and crystals. Empirical antibiotics should not be delayed for culture results in the ?septic patient. Admit the patient for antibiotics and joint drainage.
Question 11

Stem 3 of 4

The tap reveals a neutrophilic leukocytosis, cellular debris, absence of crystals and cultures pending. Which empiric therapy is recommended?
A
Clindamycin
B
Colchicine
C
Flucloxacilllin
D
Gentamicin
E
Joint washout
Question 11 Explanation: 
The patient needs to have the joint aspirated for cells, cultures and crystals (all acutely hot, swollen joints require this). Then we enter the local trust sepsis pathway. Immediate empirical antibiotics should be commenced, a penicillin (flucloxacillin) is recommended first line, with a macrolide should the patient have a penicillin allergy. This IV management needs to be accompanied with admission and joint drainage under the surgical team. After two weeks, the patient can be switched to PO antibiotics, earlier if there is notable clinical improvement. Local policy may suggest addition of gentamicin with flucloxacillin first line dependent on guidelines.
Question 12

Stem 4 of 4

How can we monitor the response to treatment?
A
Check ESR/CRP every 24hr
B
Check weekly procalcitonin
C
Hepatorenal function every 24hr
D
Repeat joint aspiration and culture
E
Withdraw antibiotics periodically
Question 12 Explanation: 
Acute phase proteins should be taken every day, or every other day, to monitor the progression of disease and response to therapy non-specifically.
Question 13

Stem 1 of 5

A 3 year-old female presents to her GP with a high fever that has lasted the week. On examination she has a widespread rash (maculopapular) with some palmar skin peeling. Her tongue is bright red with large papillae present and her lips look dry. She has red eye and tender cervical lymphadenopathy bilaterally.

What is the best-matched differential?
A
Acute drug reaction
B
Kawasaki’s disease
C
Measles
D
Reye’s syndrome
E
Slapped-cheek syndrome
Question 13 Explanation: 
Kawasaki disease is a medium-vessel vasculitis predominantly affecting those of Asian lineage before the age of five. Of idiopathic pathology, important findings can be remembered with the classic mnemonic of “CRASH and Burn” - conjunctivitis, rash (maculopapular), adenopathy (tender), strawberry tongue, hand/feet desquamation and burn (prolonged high fever >39ºC for >5 days).
Question 14

Stem 2 of 5

What is the first line therapy?
A
Aciclovir
B
Amoxicillin
C
Aspirin
D
Gentamicin
E
IV immunoglobulin
Question 14 Explanation: 
Start the patient with the Kawasaki picture on anti-thrombosis (aspirin, high dose) under specialist care, with IV immunoglobulins to reduce the damage to vasculature.
Question 15

Stem 3 of 5

What type of conjunctivitis is this patient most likely to present with?
A
Bilateral conjunctivitis
B
Hyperacute conjunctivitis
C
No conjunctivitis present
D
Suppurative conjunctivitis
E
Viral conjunctivitis
Question 15 Explanation: 
This is a bilateral conjunctivitis that is both noninfective and nonsuppurative.
Question 16

Stem 4 of 5

Which of the following complications are linked to this differential classically?
A
Cataract
B
Coronary artery aneurysm
C
Epidural haemorrhage
D
Gaiter venous ulcer
E
Subdural haemorrhage
Question 16 Explanation: 
These patients may benefit from an echocardiogram to assess for coronary artery pathology. This is a good examiner question.
Question 17

Stem 5 of 5

Which is the most useful inflammatory marker in this disease?
A
APP
B
CRP
C
ESR
D
LDH
E
Procalcitonin
Question 17 Explanation: 
ESR is the classic acute phase protein elevated in vasculitis diseases - of which Kawasaki is no exception.
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