The “3-Minute MRCPCH Practice”

CORRECT ANSWER:

Safeguarding documentation constitutes a legal record and is pivotal for child protection proceedings. According to professional guidelines from bodies like the GMC and RCPCH, all entries must be factual, objective, and contemporaneous. This means recording precise observations and events as they happen, avoiding subjective interpretation or speculation.

Factual accuracy and objectivity ensure the information is reliable for multi-agency assessment and potential court use. Contemporaneous notes, written at the time of the event or as soon as possible thereafter, are more accurate and credible than those written from memory at a later time. This core principle underpins all medical record-keeping but carries particular weight in a safeguarding context where a child's welfare is at stake.

WRONG ANSWER ANALYSIS:

Option A (Use medical abbreviations to save time) is incorrect because safeguarding entries must be clear and unambiguous to all professionals involved, many of whom may be non-medical.

Option B (Write the entry at the end of your shift) is incorrect as this delay compromises the accuracy and contemporaneous nature of the legal record.

Option D (Write your opinion about the parents clearly) is incorrect because while professional opinion is important, it must be evidence-based and clearly distinguished from factual observations, not stated as a subjective belief.

Option E (Only document findings confirmed by the consultant) is incorrect as all members of the clinical team have an independent professional responsibility to document their own findings and concerns in a timely manner.

CORRECT ANSWER:

High-frequency, low-impact collisions. A newly ambulant toddler has a high centre of gravity, an unsteady, wide-based gait, and poor motor coordination. This combination leads to frequent falls, typically forwards.

Consequently, the most prominent bony surfaces such as the shins, knees, and forehead make primary contact with hard surfaces like floors and furniture. These repeated, low-velocity impacts are sufficient to rupture small subcutaneous capillaries, resulting in the classic pattern of "toddler bruising". This distribution is a hallmark of normal accidental injury in this age group and is consistent with the history of clumsiness associated with developing mobility.

Option A (Low-velocity, high-pressure grip marks) is incorrect as these would typically present as patterned bruising on the torso or limbs, suggestive of non-accidental injury.

Option C (A failure of the intrinsic coagulation pathway) is less likely as this would typically cause more extensive, spontaneous bruising or bleeding disproportionate to the degree of trauma.

Option D (Spontaneous capillary rupture due to low platelets) is incorrect because thrombocytopenia usually presents with petechiae, purpura, and mucosal bleeding, not solely bruises over bony prominences.

Option E (A Type III hypersensitivity reaction) is incorrect as vasculitis characteristically presents as a palpable purpuric rash, which is clinically distinct from bruising.

CORRECT ANSWER:

The infant presents with a normal anion gap metabolic acidosis, also known as hyperchloraemic metabolic acidosis. This is evident from the low pH (7.25) and low bicarbonate (14 mmol/L), with a calculated anion gap of 12.

The key to the diagnosis lies in the urinary pH. In the presence of significant systemic acidaemia, the kidneys should be maximally excreting acid, resulting in a urinary pH of less than 5.5. The inappropriately high urine pH of 6.5 indicates a failure of the distal tubules to secrete hydrogen ions. This specific impairment in urinary acidification is the defining feature of Distal Renal Tubular Acidosis (Type 1). Failure to thrive is a classic presentation in infancy due to the chronic acidosis.

WRONG ANSWER ANALYSIS:

Option B (Proximal Renal Tubular Acidosis) is incorrect because although it causes a normal anion gap acidosis, the distal acidification mechanism is intact, meaning the urine pH would be appropriately low (<5.5) in the context of systemic acidosis. Option C (Lactic acidosis) is incorrect as it would cause a high anion gap metabolic acidosis. Option D (Salicylate poisoning) is less likely as it typically presents with a mixed picture of respiratory alkalosis and a high anion gap metabolic acidosis. Option E (Diabetic Ketoacidosis) is incorrect because it is characterised by a high anion gap metabolic acidosis due to ketone production.