Australian Family Physician
Australian Family Physician


Volume 44, Issue 12, December 2015

Clinical Challenge

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Case 1

Judy brings her son Henry, aged eight weeks, to see you as he has a swelling in his left groin. Henry was born at 39 weeks gestation after the spontaneous onset of labour and by normal vaginal delivery. The antenatal course was uneventful and obstetric ultrasonography for fetal development was reported as normal. He has been well since birth. You suspect that Henry has an inguinal hernia and you explain to Judy that inguinal hernias are very common.

Question 1

What is the prevalence of inguinal hernias in full-term infants?

  1. 1–2%
  2. 3–5%
  3. 6–8%
  4. 9–10%
  5. 11–15%

Question 2

Given Henry’s age, what is the recommended referral time frame for him regarding the inguinal hernia?

  1. 0–2 weeks
  2. 2–4 weeks
  3. 1–3 months
  4. 3–6 months

Judy asks you whether Henry needs an ultrasound to investigate the inguinal hernia. You explain to her that this particular condition does not require a diagnostic ultrasound.

Question 3

In which one of the following conditions is a diagnostic ultrasound likely to be included as part of the routine workup?

  1. Testicular maldescent
  2. Epigastric hernia
  3. Hydrocele
  4. Varicocele
  5. Umbilical hernia

Judy then asks you about Henry’s sister Helen, who is two years of age. Judy has noticed recently that Helen has a firm, pea-shaped, midline lump 1 cm above her umbilicus. It is prominent when Helen stands up but cannot be seen when she lies down. Helen is thriving and Judy has no other concerns about her.

Question 4

What is the most likely diagnosis given this history?

  1. Epigastric hernia
  2. Divarication of the recti
  3. Umbilical hernia
  4. Inguinal hernia

Question 5

What is the most appropriate management for Helen?

  1. Urgent referral written today
  2. Non-urgent referral written today
  3. Defer referral until after Helen is three years of age
  4. Advise that referral is never required for this condition

Case 2

Joan, one of your regular patients, makes an appointment because she is concerned about her daughter Clare’s sleeping patterns. Clare is a healthy child, aged two years, whom you know well. You explain to Joan that there are many interventions that can improve a child’s sleep, including establishing good sleep hygiene.

Question 6

Which of the following is NOT part of establishing good sleep hygiene?

  1. Setting a regular bedtime
  2. Keeping the bedroom quiet
  3. Keeping the bedroom well lit
  4. Avoiding caffeine-containing foods and drinks after 3.00 pm
  5. Ensuring a regular morning wake time

You discuss other management strategies designed to improve to sleep. Joan is especially interested in the idea of ‘extinction’.

Question 7

Which one of the following is the most correct definition of ‘extinction’ in the context of sleep problems?

  1. Parents settle the child in the cot or bed by patting or stroking them until they are quiet but not asleep, and then leave the room.
  2. Parents place a chair or camp bed next to their child’s cot or bed; initially the parents stay with them as they fall asleep at the start of the night, then gradually withdraw their presence from the child’s room.
  3. Parents allow the child to have a ‘pass out’ at bedtime for one acceptable request but once the pass is used, parents do not respond to further requests.
  4. Parents systematically ignore inappropriate behaviours when the child is placed in bed.

Clare has a brother, Harry, aged 14 years. Joan tells you she is also concerned about Harry’s sleep. Harry has difficulty falling asleep until very late at night. When he goes to bed at a time he chooses, he can usually fall asleep easily. He is otherwise well and has no medical or psychological conditions.

Question 8

What is the most likely cause for Harry’s sleep problems?

  1. Delayed sleep phase disorder
  2. Anxiety-related insomnia
  3. Limit-setting disorder
  4. Physiological insomnia

Question 9

You suggest ‘bedtime fading’ to improve Harry’s sleep.

Which of the following techniques is most useful to supplement ‘bedtime fading’?

  1. Vary the morning wake time.
  2. Encourage daytime naps.
  3. Avoid the use of technology with screens before bed.
  4. Increase natural light exposure in the evening.

Case 3

Ying, aged three years, is brought to see you by her father David. He tells you that the family is struggling to manage some of Ying’s behaviour at present. You explore the idea that every parent finds their children difficult to manage from time to time.

Question 10

What is described as the most common normal challenging behaviour in children at the age of three years, affecting over 90% of children?

  1. Resisting going to bed
  2. Constantly seeking attention
  3. Whining and nagging
  4. Wetting the bed at night
  5. Being stubborn

Question 11

David tells you he knows he should ignore low-priority negative behaviour and take disciplinary action for high-priority negative behaviour.

Which of the following is an example of high-priority negative behaviour?

  1. Tantrums
  2. Noisiness
  3. Defiance
  4. Hyperactivity
  5. Swearing

Question 12

Given Ying’s age, what is the most appropriate disciplinary consequence for high-priority negative behaviour?

  1. Timeout alone
  2. Timeout and withdrawal of privileges
  3. Withdrawal of privileges alone
  4. Dispute mediation

Case 4

Alice, one of your regular patients, comes to see you with her 3-week old baby, Quentin, who was born at 36 weeks and is being breastfed. Alice has some questions about breastfeeding.

Question 13

Which one of the following statements about breastfeeding is most correct?

  1. It is normal for newborns to take one hour to finish breastfeeding on one side.
  2. Assessing the adequacy of an infant’s intake from breast milk is always simple to do.
  3. The usual fluid intake for newborns is 140–180 ml/kg per day.
  4. Infants usually have 5–7 feeds per day initially.

Question 14

At what age should you stop correcting Quentin’s growth measurements for prematurity?

  1. 6 months
  2. 12 months
  3. 18 months
  4. 24 months
  5. 30 months

Alice has heard that reflux is very common in infants. She also knows that not all vomiting in babies is due to reflux.

Question 15

Which one of the following is the LEAST concerning feature related to vomiting in infants?

  1. Frequent regurgitation of 1–2 tablespoons of milk
  2. Poor growth
  3. Vomiting several times during the one feed
  4. Respiratory symptoms during feeding
  5. Vomit containing brown flecks

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