Q 1:
You are evaluating a 12-year-old boy in the emergency department who presents with fever,
chills, malaise, and blood in his urine. On physical examination, he appears comfortable and alert
and has a temperature of 102.7°F (39.3°C), a blood pressure of 110/40 mm Hg, no rashes, and
clear breath sounds. He has a diastolic murmur heard best in the sitting position (Item Q133).
You elicit no abdominal or flank tenderness.
Of the following, the BEST next step in the management of this patient is
A. administration of broad-spectrum antibiotics
B. blood cultures
C. renal ultrasonography
D. transesophageal echocardiography
E. urine culture
Answer
B
Answer
B
The patient described in the vignette has history and physical examination findings that are
highly suggestive of infective endocarditis. These include symptoms of chills and malaise; a
history of fever; and the findings of hematuria, a new murmur, and fever. Typically, the diagnosis
is confirmed by isolation of the offending organism from blood cultures. Blood cultures from three
to five sites should be obtained prior to initiation of antibiotic therapy. Because the bacterial
shedding is constant, the practitioner should not wait until the patient is febrile to obtain blood
cultures. Viridans streptococci (eg, S bovis, S mitis) as well as Staphylococcus aureus are the
most common bacterial pathogens causing endocarditis in children. However, clinicians must be
concerned about organisms such as Enterococcus, coagulase-negative Staphylococcus, fungi,
and a group of bacteria referred to as the HACEK organisms (Haemophilus sp, Actinobacillus
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae).
The HACEK organisms are gram-negative oral and pharyngeal flora that are fastidious and slow growing,
often requiring growth factors and carbon dioxide to be isolated in cultures.
Treatment of endocarditis depends on the isolated organism. In general, long-term antibiotic
treatment (4 to 6 weeks) is undertaken in an effort to eradicate completely the bacteria that have
been sequestered in a nonvascular vegetation. Surgery is reserved for patients who develop
severe congestive heart failure from severe valve regurgitation or deterioration.
The boy in the vignette requires intravenous antibiotic treatment, but blood cultures should
be obtained before therapy is begun. He also should undergo echocardiography, which may be
performed from the transesophageal approach to improve the sensitivity, but similar to renal
ultrasonography, such a study is performed after blood cultures have been obtained. The
absence of vegetation at the time of echocardiography does not rule out a diagnosis of infective
endocarditis. Patients who have infective endocarditis may exhibit hematuria from the deposition
of immune complexes resulting in glomerulonephritis. Although fever and hematuria may be
associated with urinary tract infection, the presence of a diastolic murmur and absence of
urinary symptoms make such a diagnosis unlikely.
------
Q2:
A 5-year-old full term male infant was severely cyanotic at birth. Prostaglandin E was administered
initially and later balloon atrial septostomy was done which showed improvement in oxygenation. The most
likely diagnosis of this infant is:
a. Tetralogy of Fallot
b. Transposition of great vessels
c. Truncus arteriosis
d. Tricuspid atresia
e. PDA
Answer
B
Q 3:
Which one of the following CHD has cyanosis without cardiomegaly and/or CCF?
a. TGV
b. TOF
c. Congenital MR
d. Congenital PS
Answer
B
Q 4:
One-year-old child with PDA; which is true:
a. Symptoms are similar to aortopulmonary window
b. Chances of spontaneous closure is high
c. Indomethacin may help in closure
d. Endocarditis is rare
Answer
A
Q5:
An 8-yr-old male child is admitted with a diagnosis of rheumatic fever with arthritis, carditis and CCF, with
reference to this case, consider the following as initial lines of management:
a. Eradication of remnant streptococcal infection
b. Administration of an anti-inflammatory drug
c. Institution of decongestive therapy
d. Institution of graded and gradually increasing exercise
Answer
C
Q6:
A young boy had developed CCF, found to have membraneous VSD. He showed spontaneous improvement. This is most likely due to:
a. Perimembraneous closure of VSD
b. Development of AR
c. Pulmonary vascular changes
d. Infective endocarditis
Answer
C
---------------------------
Q 7
A full-term newborn develops cyanosis a few hours after birth. Oxygen administration does
not improve color or oxygen saturations. Which of the following is the most likely diagnosis?
(A) atrial septal defect
(B) ventricular septal defect
(C) patent ductus arteriosus
(D) aortic stenosis
(E) pulmonary stenosis
highly suggestive of infective endocarditis. These include symptoms of chills and malaise; a
history of fever; and the findings of hematuria, a new murmur, and fever. Typically, the diagnosis
is confirmed by isolation of the offending organism from blood cultures. Blood cultures from three
to five sites should be obtained prior to initiation of antibiotic therapy. Because the bacterial
shedding is constant, the practitioner should not wait until the patient is febrile to obtain blood
cultures. Viridans streptococci (eg, S bovis, S mitis) as well as Staphylococcus aureus are the
most common bacterial pathogens causing endocarditis in children. However, clinicians must be
concerned about organisms such as Enterococcus, coagulase-negative Staphylococcus, fungi,
and a group of bacteria referred to as the HACEK organisms (Haemophilus sp, Actinobacillus
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae).
The HACEK organisms are gram-negative oral and pharyngeal flora that are fastidious and slow growing,
often requiring growth factors and carbon dioxide to be isolated in cultures.
Treatment of endocarditis depends on the isolated organism. In general, long-term antibiotic
treatment (4 to 6 weeks) is undertaken in an effort to eradicate completely the bacteria that have
been sequestered in a nonvascular vegetation. Surgery is reserved for patients who develop
severe congestive heart failure from severe valve regurgitation or deterioration.
The boy in the vignette requires intravenous antibiotic treatment, but blood cultures should
be obtained before therapy is begun. He also should undergo echocardiography, which may be
performed from the transesophageal approach to improve the sensitivity, but similar to renal
ultrasonography, such a study is performed after blood cultures have been obtained. The
absence of vegetation at the time of echocardiography does not rule out a diagnosis of infective
endocarditis. Patients who have infective endocarditis may exhibit hematuria from the deposition
of immune complexes resulting in glomerulonephritis. Although fever and hematuria may be
associated with urinary tract infection, the presence of a diastolic murmur and absence of
urinary symptoms make such a diagnosis unlikely.
------
Q2:
A 5-year-old full term male infant was severely cyanotic at birth. Prostaglandin E was administered
initially and later balloon atrial septostomy was done which showed improvement in oxygenation. The most
likely diagnosis of this infant is:
a. Tetralogy of Fallot
b. Transposition of great vessels
c. Truncus arteriosis
d. Tricuspid atresia
e. PDA
Answer
B
Q 3:
Which one of the following CHD has cyanosis without cardiomegaly and/or CCF?
a. TGV
b. TOF
c. Congenital MR
d. Congenital PS
Answer
B
Q 4:
One-year-old child with PDA; which is true:
a. Symptoms are similar to aortopulmonary window
b. Chances of spontaneous closure is high
c. Indomethacin may help in closure
d. Endocarditis is rare
Answer
A
Q5:
An 8-yr-old male child is admitted with a diagnosis of rheumatic fever with arthritis, carditis and CCF, with
reference to this case, consider the following as initial lines of management:
a. Eradication of remnant streptococcal infection
b. Administration of an anti-inflammatory drug
c. Institution of decongestive therapy
d. Institution of graded and gradually increasing exercise
Answer
C
Q6:
A young boy had developed CCF, found to have membraneous VSD. He showed spontaneous improvement. This is most likely due to:
a. Perimembraneous closure of VSD
b. Development of AR
c. Pulmonary vascular changes
d. Infective endocarditis
Answer
C
---------------------------
Q 7
A full-term newborn develops cyanosis a few hours after birth. Oxygen administration does
not improve color or oxygen saturations. Which of the following is the most likely diagnosis?
(A) atrial septal defect
(B) ventricular septal defect
(C) patent ductus arteriosus
(D) aortic stenosis
(E) pulmonary stenosis
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