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So here we go with the third child fever quiz. There are so many causes of this presentation that, truthfully, it would be a bit risky to not know the differential cold for your finals.  Have a go at another set of 11 questions – good luck as ever!

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Child fever 3

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Question 1

Stem 1 of 7

A 15 year-old female presents to her GP with a sore throat and persistent, dry cough. She complains of feeling “hot and sweaty”, with objective fever of 39ºC. On examination she has cervical lymphadenopathy and is clearly fatigued. Her throat is inflamed with petechiae on the soft palate. She has a painful LUQ (immediately inferior to the subcostal margin) on palpation.

Which organ is most likely enlarged?
A
Left kidney
B
Liver
C
Right kidney
D
Spleen
E
Stomach
Question 1 Explanation: 
The spleen sits in the left upper quadrant. It is an intraperitoneal structure between the 9th and 11th ribs on the left-hand side. Ordinarily, the spleen is not palpable, but in cases of splenomegaly can be palpated as far as the right LOWER quadrant. This unique surface anatomy makes for good exam fodder.
Question 2

Stem 2 of 7

Based on this latter finding, what is the most likely causative organism?
A
EBV
B
Hepatitis A virus (HAV)
C
HIV
D
IM
E
Syphilis
Question 2 Explanation: 
Epstein–Barr virus (EBV) is a double stranded virus, very common in humans, causing infectious mononucleosis. In the UK, this is commonly called “glandular fever”, and in the USA its termed “mono” for short. It is a key differential for a sore throat that you should be familiar with.
Question 3

Stem 3 of 7

The physician undertakes the Centor criteria. For which reason was this performed?
A
To assess hospital risk of DVT
B
To rule out a bacterial infection
C
To rule out a fungal infection
D
To rule out a protozoan infection
E
To rule out a viral infection
Question 3 Explanation: 
This is a method used, similar to feverPAIN score, for rapidly identifying the risk of the patient having a bacterial pharyngitis. The one that we are usually concerned about is a group A streptococcus pneumoniae infection that is known to be linked to cause rheumatic heart disease.
Question 4

Stem 4 of 7

Calculate the Centor criteria using the information below. Based on your result, what is the next best step for this patient?
A
0
B
1
C
2
D
3
E
4
Question 4 Explanation: 
The Centor criteria is one that is best memorised for exams, but best outsourced to applications (eg MDCalc - no affiliation) on the wards. The patient receives one point for age (3-14), exudate, tender LAN of the anterior cervical chain, >38ºC temperature, absence of cough. If a patient scores >3 the likelihood of strep throat is 50% and antibiotics should be commenced, a score of 2-3 indicates culturing and - if positive - antibiotics. A score lower is okay for supportive management only. The patient is more likely than not to NOT have a bacterial cause of her sore throat based on the above screen.
Question 5

Stem 5 of 7

Which of the following is the best-matched management?
A
Amoxicillin
B
Fluids, simple analgesia
C
Nebulised salbutamol
D
Oral rehydration therapy
E
Oxygen therapy
Question 5 Explanation: 
The patient is showing a classic case of glandular fever (aka IM as described in answers above). As this is a viral cause, the management is mostly supportive and self-limiting. Ensure safety netting for splenomegaly, avoidance of alcohol and contact sports.
Question 6

Stem 6 of 7

In antibody testing for viral capsid antigens (VCAs), which of the following findings indicate an acute viral infection?
A
IgD
B
IgA
C
IgM
D
IgG
E
IgE
Question 6 Explanation: 
IgM spikes in acute infection, IgG is usually a chronic sign of long-standing immunity due to prior infection.
Question 7

Stem 7 of 7

Previously the patient was prescribed an “antibiotic” to manage a similar complaint of a sore throat. After this prescription, she developed a drug reaction of urticaria. Which medication was most likely prescribed?
A
Amoxicillin
B
Ampicillin
C
Benzylpenicillin
D
Carbapenem
E
Flucloxacillin
Question 8

Stem 7 of 7

Previously the patient was prescribed an “antibiotic” to manage a similar complaint of a sore throat. After this prescription, she developed a drug reaction of urticaria. Which medication was most likely prescribed?
A
Amoxicillin
B
Ampicillin
C
Benzylpenicillin
D
Carbapenem
E
Flucloxacillin
Question 8 Explanation: 
A classic first line agent for strep throat is amoxicillin. Patients can report a rash drug-reaction to this beta-lactam penicillin - especially when non-judiciously used in non-bacterial sore throats. Watch out for the new-onset urticaria in a patient prescribed penicillin for a sore throat.
Question 9

Stem 1 of 4

A 1 year-old female infant presents to ED with persistent cough for two days. This cough is sometimes “wet”. She has an elevated respiratory rate, and an audible wheeze. She has peripheral cyanosis, with nasal flaring and scalene recruitment.

What is the current best-matched differential?
A
Alpha-1-antitrypsin deficiency
B
Asthma
C
Bronchiolitis
D
Bronchopulmonary dysplasia
E
Community acquired pneumonia
Question 9 Explanation: 
This is a very common viral lower respiratory tract infection in this patient population. The most common causative agent is RSV (respiratory syncytial virus) Patients who are significantly immunocompromised can be prescribed palivizumab to provide some passive immunity.
Question 10

Stem 2 of 4

What are the mechanisms of palivizumab?
A
Binds to C protein of RSV
B
Binds to D protein of EBV
C
Binds to D protein of HAV
D
Binds to F protein of EBV
E
Binds to F protein of RSV
Question 10 Explanation: 
This prophylaxis therapy “a passive immunity vaccine” can be given to those at risk patients in winter seasons when RSV circulating rates are highest. The monoclonal antibody binds to the F protein of the respiratory syncytial virus which leads to an inhibition of viral replication.
Question 11

Stem 3 of 4

Which of the following is a first line investigation in this patient?
A
Chest CT
B
ELISA rapid antigen testing
C
Pulmonary function test
D
Pulse saturation
E
Arterial blood gas
Question 11 Explanation: 
In the common presentation of bronchiolitis, the diagnosis is made clinically. Pulse saturations are ordered to track severity of disease and suggest stepping up supportive management options. Commonly serology, imaging are not undertaken.
Question 12

Stem 4 of 4

Although not first line therapy, which of the following steroids could be offered as adjunct to support care?
A
Dexamethasone
B
Fludrocortisone
C
Hydrocortisone
D
Prednisolone
E
Prednisone
Question 12 Explanation: 
Often dexamethasone is prescribed as a single dose to improve outcomes and the symptoms of the patient. As the management is “supportive with the option of a dexa adjunct”, it's a good drug to remember associated with bronchiolitis.
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